PARTNERS HEALTH PLANS
Updated 9/2000

These data reflect the most commonly purchased benefits package for each of the health plans in the year 2000.

HMO General Information
Background Information	PARTNERS Health Plans received its HMO license from the NC Department of Insurance and began operations on October 30, 1986. It is a for-profit corporation, owned by Novant Health Inc., a North Carolina corporation.
Type of HMO	PARTNERS operates an IPA/network model HMO. That means that it contracts directly with physicians in the community or with networks of physicians.
Type of Products	PARTNERS most commonly purchased HMO plan is a "gatekeeper" product. In a gatekeeper system, you must choose a primary care provider who is responsible for managing all your care. For example, your primary care provider would be required to refer you to a specialist, or authorize a non-emergency admission to the hospital. PARTNERS also offers a point-of-service option, called "Select Care" and a Direct Access product in which members can access participating providers without a referral.
Accreditation	PARTNERS received a commendable accreditation from the National Committee for Quality Assurance (NCQA). NCQA looks at five categories in its accreditation process access and services, qualified providers, staying healthy, getting better, and living with illness. An HMO seeking accreditation is evaluated on how well it meets NCQA’s standards in each of these areas. HMOs that fully meet NCQA’s standards receive a Commendable status. Those that meet most of NCQA standards receive an Accredited status. Provisional accreditation may be given for plans that meet some, but not all, of NCQA standards. Health plans that fail to meet NCQA’s requirements during the review will have their accreditation request Denied. A health plan’s accreditation status gives an idea of the quality of care provided by the plan as a whole. However, NCQA’s accreditation does not guarantee the quality of care provided to any individual member.
Enrollees	PARTNERS offers HMO coverage to both large and small employer groups. It does not offer coverage to individuals ("non-group" coverage) or Medicaid recipients. PARTNERS Health Plans does offer Medicare HMO coverage in the following counties: Alamance, Alexander, Alleghany, Ashe, Cabarrus, Davidson, Davie, Forsyth, Gaston, Guilford, Iredell, Mecklenburg, Orange, Rockingham, Rowan, Stokes, Surry, Wilkes, and Yadkin.
Counties in which HMO has an Active Presence	PARTNERS has at least 25 commercial (group) HMO members at the end of 1999 in the following North Carolina counties: Alamance, Alexander, Alleghany, Anson, Ashe, Brunswick, Buncombe, Burke, Cabarrus, Caldwell, Carteret, Caswell, Catawba, Chatham, Cleveland, Cumberland, Davidson, Davie, Durham, Orange, Person, Pitt, Randolph, Rockingham, Rowan, Rutherford, Stanly, Stokes, Surry, Union, Vance, Wake, Watauga, Wilkes and Yadkin.
Customer Service Number	1-800-942-5695
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services	Covers: Semi-private room and board. Meals and special diets. Operating room, intensive care unit and related facilities. Medications, biologicals, chemotherapy. Administration of whole blood plasma. General nursing care. Intensive and cardiac care units and services. Drugs, medications and biologicals Anesthesia and oxygen. Administration of whole blood and blood plasma. Limits: All services must be arranged by a participating provider, received in an emergency situation or be prior approved by the plan. Services of a non-participating hospital may be covered when medically necessary and approved in advance by the plan or for certain emergency situations.
Outpatient Services	Covers: Same services as inpatient coverage, including radiation therapy, dialysis, chemotherapy, outpatient surgery, and ambulatory surgery center services.
Emergency Care	Covers: Emergency services within service area: Needed to screen and stabilize the member. Members are encouraged to call their PCP if experiencing an emergency medical condition. If member cannot contact PCP, member should go to the nearest participating emergency facility. Emergency services in non-participating facilities: to be used only if a prudent lay person would have believed use of a participating facility would cause a delay that would worsen the member’s condition or because of circumstances beyond the member’s control. Resulting hospitalizations at non-participating facilities are covered until the member can be safely transferred. Emergency services outside service area: Covered only if the member could not reasonably have anticipated the need for care before leaving the service area, or if the delay in going to a participating provider would prove hazardous to the member’s health or life. Covers dependents living outside service area as full-time student for services necessary to stabilize and treat acute medical conditions resulting from emergencies and requiring immediate attention. Notification Requirements: The member should notify the PCP or plan as soon as possible following emergency services. Follow-up care must be provided or arranged by PCP. Follow-up care will not be authorized unless member notifies PCP or plan within a reasonable time after receipt of emergency care. Excludes: Emergency care outside the service area that could have been anticipated, such as maternity and delivery care.
Urgent Care	Covers: Services at an urgent care center will be covered if medically necessary. Limits: Members should contact their PCP, who will instruct them to do one of the following: Go to the PCP’s office, Go to a specific physician’s office, Go to an emergency room of a participating hospital, or Go to a participating urgent care center.
Ambulance	Covers: Ambulance services in an emergency to nearest medical facility. Limits: Non-emergency, inter-facility ambulance transfers are covered with prior approval by the plan.
Care for Students Outside of Service Area	Covers: Services necessary to stabilize and treat acute medical conditions resulting from emergencies and requiring immediate attention.
Non-Urgent Care Outside of Service Area	Excluded.
Professional Services
Professional Services (general)	Covers: Primary care services provided by a PCP, including health maintenance and preventive care. Specialty care services with PCP referral and/or prior authorization by Partners. Professional services provided by a physician at the office, hospital, house call or surgery for diagnosis and treatment of a disease, injury, or congenital defects for children.
OB/GYN	Covers: Services of OB/GYN. Referral not required for services provided by participating obstetrician/gynecologist for evaluation and treatment of reproductive system.
Diagnostic Procedures	Covers: X-ray, laboratory and other diagnostic tests.
Therapeutic Treatment Services	Covers: Radiation, Chemo-therapy, Respiratory Therapy.
Allergy Testing and Treatment	Covers: Allergy testing, serum and injections (excluding court- ordered tests) provided by a Board certified allergist with referral from PCP. Excludes: Certain types of allergy tests including skin titration (RINKEL Method); cytotoxicity testing (Bryan’s Test); MAST testing; urine autoinjections; subcutaneous or sublingual provaocative and neutralization testing for allergies.
Preventive Services
Annual Physicals (well-baby, well-child)	Covers: Well-child care and physical examinations according to plan-prescribed frequency guidelines. The number of covered well-child visits and physical examinations varies by age. Also includes vision and hearing screening by PCP up to age 18. Excludes: Physical examinations required by third parties such as insurers, schools, employers, camps, athletic teams or judicial bodies. Also excludes examinations required to travel abroad.
Immunizations	Covers: Immunizations for pediatrics if recommended by the American Academy of Pediatrics and the Centers for Disease Control. Covers adult immunizations as indicated by medically recognized risk factors. Excludes: Immunizations for employment or foreign travel.
Preventive Clinical Services	Covers: Pap smears, mammograms and PSA tests (as required by state law).
Other Health Promotion/Disease Prevention Activities	Covers: Nutritional counseling when ordered by PCP and approved by the plan. Limits: Nutritional counseling limited to 3 visits per 12 consecutive months for services following a newly diagnosed condition or significant worsening of a chronic condition. Excludes: Printed health education materials.
Diabetic Treatment	Covers: Self-management training and educational services, equipment, supplies, medications and laboratory procedures used to treat diabetes. Limits: Medications for members without a prescription rider are limited to a 30-day supply. In addition, individuals with prescription benefits through another plan are subject to coordination of benefits. Cost Sharing: Members without a prescription rider are subject to a copayment equal to the copayment required for an office visit. DME copayment or coinsurance applies to all equipment and supplies. Excludes: Experimental equipment and supplies, such as implantable insulin pumps. Portable external subcutaneous insulin pumps are covered with prior approval by plan.
Conception Services
Prenatal Care and Obstetrical Services	Covers: Prenatal care and obstetrical services. Also covers complications of pregnancy for dependent children (miscarriages, tubal pregnancies and non-elective cesarean sections). Excludes: Routine prenatal care for dependent children, including term and premature labor and delivery, elective cesarean sections, routine prenatal and post-natal services. Also excludes services provided at birth centers.
Family Planning	Covers: Voluntary sterilization (tubal ligation and vasectomy). Excludes: Other contraceptive devices/fittings, supplies or treatment including (unless included in a rider) diaphragms, IUDs, Norplant, and Depo Provera unless covered by prescription drug rider.
Abortion	Covered, unless considered illegal under state law. Limits: Elective abortions (including such abortions for dependent children) are limited to a maximum of one procedure per lifetime of member.
Infertility Services	Covers: Diagnostic and treatment for problems of fertility and infertility. Excludes: Artificial conception procedures, including but not limited to, artificial insemination and in-vitro fertilization, reversal of voluntary sterilization.
Mental Health and Substance Abuse Services
Mental Health Inpatient	Excluded: Unless covered by a supplemental rider. With purchase of a supplemental rider covers: Inpatient and Partial hospital services for acute care. Limits: All services, except for emergencies, must be prior approved by the Plan’s designated mental health provider. Benefits are limited to 30 days of care per member per contract year for inpatient services. One inpatient day may be exchanged for two partial hospital therapy visits. Prior approval by the plan’s designated mental health provider is required in order to exchange inpatient benefits for partial hospitalization benefits. Cost Sharing: Copays apply Excludes: Treatment of learning disabilities and developmental and learning disorders. Long-term rehabilitation, treatment of chronic conditions, and treatment of conditions not subject to favorable modification according to generally accepted standards of psychiatric care are also excluded. Partners excludes vocational rehabilitation, or employment, religious, adoption, pastoral, psychic and other counseling for relationships not attributable to a mental disorder. Services needed for involuntary commitments, police detentions or other arrangements are also excluded unless medically necessary. Partners excludes services for patients who are deliberately non-compliant with their recommended treatment, when such non-compliance is not a direct result of psychiatric illness.
Mental Health Outpatient	Excluded, unless covered by a supplemental rider. With purchase of a supplemental rider covers: Outpatient therapy for acute care is covered, including individual therapy, intensive outpatient therapy, and group therapy. Outpatient medication checks are also covered, as well as treatment of Attention Deficit/Hyperactivity Disorder (ADHD). ADHD treatment includes evaluation, psycho-educational treatment. Limits: All services, except for emergencies, must be prior approved by the Plan’s designated mental health provider. Benefits are limited to a total of 20 outpatient therapy visits per member per contract year, regardless of which kind or combination of kinds of therapies received (individual, intensive or group). One outpatient visit may be exchanged for 2 medication check visits. Prior approval by the plan’s designated mental health provider is required in order to exchange inpatient benefits for partial hospitalization benefits. ADHD medication is covered only with the purchase of a prescription drug supplemental policy. Cost Sharing: Copayments apply Excludes: Treatment of learning disabilities and developmental and learning disorders. Long-term rehabilitation, treatment of chronic conditions, and treatment of conditions not subject to favorable modification according to generally accepted standards of psychiatric care are also excluded. Partners excludes vocational rehabilitation, or employment, religious, adoption, pastoral, psychic and other counseling for relationships not attributable to a mental disorder. Services needed for involuntary commitments, police detentions or other arrangements are also excluded unless medically necessary. Partners excludes services for patients who are deliberately non-compliant with their recommended treatment, when such non-compliance is not a direct result of psychiatric illness.
Substance Abuse Inpatient	Excluded, unless covered by a supplemental rider. With purchase of a supplemental rider covers: Inpatient and Partial Hospital Services for short-term evaluation or crisis treatment of alcohol or substance abuse. Limits: All services except for emergencies must be approved in advance by plan’s designated chemical dependency providers. Maximum benefit per member per contract year of $8,000; maximum lifetime benefit per member of $16,000. Cost Sharing: Copayments apply Excludes: Treatment of chronic, non-acute conditions, long-term rehabilitation, vocational rehabilitation, and employment, religious, pastoral and psychic counseling.
Substance Abuse Outpatient	Excluded, unless covered by a supplemental rider. With purchase of a supplemental rider covers: Outpatient therapy and medication check for short-term evaluation or crisis treatment of alcohol or substance abuse. Includes individual therapy, intensive outpatient therapy and group therapy. Covers methadone treatment when treatment of heroin addiction is covered by the supplemental policy. Limits: All services except for emergencies must be approved in advance by plan’s designated chemical dependency providers. Maximum benefit per member per contract year of $8,000; maximum lifetime benefit per member of $16,000. Cost Sharing: Copayments apply Excludes: Treatment of chronic, non-acute conditions, long-term rehabilitation, vocational rehabilitation, and employment, religious, pastoral and psychic counseling.
Prescription Drugs and Medical Supplies
Prescription drugs	Covers: Prescriptions during inpatient care, or for treatment of diabetes (subject to copayment and limited to a 30-day supply). Excludes: Outpatient prescriptions and non-prescription medications unless purchased separately under a supplemental rider. With purchase of a supplemental rider covers: Prescriptions filled by a participating pharmacy. Covers Legend drugs; compouded drugs for which at least one ingredient is a prescription drug; and injectable insulin and disposable syringes and needles for diabetic use. Limits: Prescription drugs will be supplied as specified in the PARTNERS formulary. Drugs in the plan’s formulary are covered only at the generic reimbursement level for the brand name drugs with an FDA rate generic available. If the brand name is purchased, whether due to the provider or the member requesting the brand name, the member will be responsible for the copayment plus the cost difference between the brand name drug and the generic reimbursement level for the generic drug. Prescription size is limited to a 30-day supply, unless otherwise specified by the plan. Certain maintenance medications are available for a 90 day supply. Infertility drugs require prior approval from plan and the courses of treatment covered are limited. Partners limits drug coverage to a maximum amount each year (the amount varies depending on the policy purchased). Contraceptives, oral or other, medication or contraceptive device prescribed for birth control. Some drugs, as indicated on the formulary, have quantity limitations per copayment. Some drugs, as indicated on the formulary, require prior authorization to be met in order to be covered. Cost Sharing: Copayments apply Excludes: Over the counter drugs. Charges for the administration or injection of any drug. Experimental and investigational drugs. Prescription drugs for treating impotence and anorgasmia, unless covered by a special rider. Prescription drugs for the purpose of or related to artificial conception procedures. Prescription drugs administered for cosmetic purposes. Prescription drugs for purposes of reducing or controlling weight and/or treatment of obesity. Prescription drugs for the purpose of smoking cessation unless covered by a special rider.
Blood	Covers: Blood donated by a member before an elective procedure or surgery for use during the procedure ("autologous donation"); administration and processing fees of blood and blood plasma. The process of separating blood into components ("apheresis") and separation of the cellular elements from the plasma (" plasmapheresisare" covered under certain conditions when approved in advance by plan. Excludes: Blood and blood plasma. Blood and blood plasma will be covered if not available for free or through replacement.
Medical Supplies	Covers: Selected, medically necessary supplies. Limits: Supplies must be prescribed and arranged by PCP and authorized in advance by plan. Plan maintains a list of covered supplies and the conditions under which they are covered.
Insulin and Diabetic Supplies	Covers: Supplies and medications used to treat diabetes. Limits: Medications for members without a prescription rider are limited to a 30-day supply and subject to a copayment equal to the copayment required for an office visit. In addition, individuals with prescription benefits through another plan are subject to coordination of benefits. Cost Sharing: DME copayment or coinsurance applies to all equipment and supplies. Excludes: Experimental equipment and supplies, such as implantable insulin pumps.
Smoking Cessation	Excluded, except when purchased separately through a supplemental rider.
Growth Hormones	Covers: Growth hormones with prior approval.
Durable Medical Equipment, Prosthetics, and Orthotics
Durable Medical Equipment (DME)	Covers: Selected, medically necessary DME. Covers maintenance, repair and replacement (due to physical changes in member) and other reasons, such as wear and tear. Limits: DME must be prescribed and arranged by PCP and authorized in advance by plan. Partners maintains a list of covered DME and the conditions under which they are covered. Partners reserves right to select source from which DME is purchased or leased, as well as the model or style. Benefits limited for the following: $1,200 for manual wheelchair; $3,000 for motorized wheelchair. Excludes: Replacement of lost, stolen or improperly used equipment.. Cost Sharing: Coinsurance applies to most DME, except wheelchairs.
Prosthetic Devices	Covers: Selected, medically necessary prosthetics, when prescribed and arranged by PCP and authorized in advance by plan. Plan maintains a list of covered prosthetics and the conditions under which they are covered. Covers maintenance, repair and replacement (due to physical changes in member) and because of wear and tear. Limits: Prosthetics must be authorized by plan. Partners reserves right to select source from which prosthetic is purchased or leased, as well as the model or style. Penile prosthesis benefit limited to $3,400 and not subject to scheduled DME coinsurance.
Orthotic Devices	Covers: Orthotic shoe inserts prescribed by a participating podiatrist or orthopedic surgeon to treat a specific medical condition that must be worn during all daily activities and authorized in advance by plan. Includes one pair of inserts at time of initial purchase, and replacement pair once every 12 months. Limits: Maximum benefit payable per pair of orthotics is $250. After initial purchase, coverage is provided ($250) for one replacement pair every 12 months.
Rehabilitative and Habilitative Services
Physical Therapy	Covers: Inpatient and outpatient, short-term physical therapy for treatment expected by Partners to result in significant improvement of member’s condition. Limits: Limited to 24 visits per spell of illness for acute conditions. (Acute defined as medical condition resulting from a sudden onset of disease or injury.) Coverage may also include up to 12 visits (as part of maximum of 24) per calendar year for patients with developmental abnormalities (e.g. cerebral palsy), primarily for parental instruction and monitoring. Excludes: Therapy for chronic conditions, long-term physical therapy.
Occupational Therapy	Same as physical therapy
Speech Therapy	Covers: Speech therapy for accident, disease, or medical condition and when significant improvement is expected within a predicted time. Limits: Limited to 24 sessions per calendar year. Requires prior approval by plan. Will only be approved for children if under the age of 3, and does not cover therapy for children when therapy is available through the public school system.
Pulmonary Therapy	Covers: Necessary pulmonary rehabilitation when prior approved by plan.. Limits: Limited to one course of treatment for 3 consecutive months per lifetime when approved by plan. Note: Limit does not apply to patients who have undergone a lung transplant. Covers inpatient rehabilitation therapy if under supervision of physician and supported by plan-approved treatment plan.
Chiropractic	Covers: Chiropractic services. Limits: Must have PCP referral and prior approval by and be medically necessary as determined by Chiropractic Network. Limited to 12 visits per calendar year.
Cardiac Rehabilitation	Covered with prior approval by plan. Cost Sharing: Copayment applies for certain services.
Other Therapy Services	Covers: Sclerotherapy if used in conjunction with a related surgical procedure, or when medically necessary for the treatment of esophageal varices. Excludes: Sclerotherapy for the treatment of varicose veins (unless part of a medically necessary surgical procedure.)
Skilled Nursing Facility	Covers: Skilled nursing facility. Coverage includes room and board in semiprivate accommodations and prescribed therapeutic drugs. Limits: Coverage limited to 100 days per spell of illness for SNF and home health services combined if approved in advance by the plan. Must be provided by a licensed participating provider. Coverage should lead to an increased ability to function. Services are limited to those which cannot be safely, effectively or appropriately provided in a home setting or in an intermediate care facility. Excludes: Custodial services.
Home-Based Services
Home Health	Covers: Home health services including those provided by RNs, LPNs, respiratory therapists, home health aides and/or supplies. Limits: Coverage limited to 100 days per spell of illness for SNF and home health services combined if approved in advance by the plan. Coverage limited to members who are confined to home. Physical and speech therapy services are subject to limitations previously listed. Excludes: Custodial and respite care.
Private Duty Nursing	Excluded.
Hospice	Covers: Hospice for members with a prognosis of 6 months or less to live. Limits: Requires physician direction and advance approval by plan. Limited to 210 days, once per lifetime. Cost Sharing: Copayments apply. Excludes: bereavement, pastoral, financial or legal counseling; funeral arrangements; homemaker or caretaker services; respite care.
Transplants and Dialysis
Transplants	Covers: Heart, heart/lung, cornea, pediatric and neonatal heart, kidney, bone marrow, liver, lung, and pancreas transplants. Coverage includes: preoperative care (including prophylactic dental care), transplant care, facility and professional fees, organ procurement fees (including organ donor fees), and post transplant care (including immunosuppressant when included in outpatient prescription rider). Expenses for the member’s reasonable travel, meals and lodging are covered with prior approval for transplants outside of the plan’s service area at a plan-designated facility. Limits: Transplants must be approved in advance by the plan. Partners reserves the right to choose the transplant center. Excludes: Combined kidney and liver transplants, and transplants which are determined by the plan to be experimental or investigational.
Dialysis	Covered.
Other Services
Dental	Covers: Treatment of malignant and premalignant lesions, tumors and cysts. Repairs to sound, natural teeth as a result of accidental injury necessary to restore the level of dental function prior to injury. This includes dental procedures, surgery or orthodontic treatment and installation of crowns, dentures or bridgework. Root canal therapy if root damage a result of accidental injury. TMJ covered if caused by congenital defect or anomaly, disease or traumatic injury and prevents normal functioning. Limits: Anesthesia for dental procedures is covered only when hospitalization is necessary due to a medical condition unrelated to the dental procedure. Examples include severe asthma or bleeding disorder. Age or anxiety does not constitute a medical condition in this circumstance. Anesthesia and hospital or facility charges for dental procedures for children below the age of nine years. Excludes: All other dental services, including treatment of natural cysts of dental root origin.
Vision	Covers: Vision screening by PCP to determine vision loss during periodic health maintenance examinations up to age 18. Contact lenses are covered following cataract surgery or when natural lens is missing due to congenital absence. Also covers contact lenses used in treatment of acute or chronic corneal pathology. Excludes: Vision care, including: refraction; eyeglass frames; eye exercises; visual training; orthoptics; all types of contact or corrective lenses unless covered by a supplemental policy; treatment or diagnostic testing related to visual processing disorders.
Hearing	Covers: Screening by PCP to determine hearing loss during periodic health maintenance examinations up to age 18. Excludes: Hearing aids, cochlear implants, services, treatment or diagnostic testing related to auditory processing disorders.
Foot Care	Excluded.
Weight Loss	Covers: Nutritional counseling for morbid obesity when ordered by a PCP and approved in advance by Partners. Limits: Limited to 3 visits per 12 consecutive months. Excludes: All other weight loss services.
Alternative Therapies	Covers: Biofeedback and acupuncture. Limits: Biofeedback limited to 60 day period of treatment per illness and prior approval by plan. Acupuncture must be performed by plan-approved physician and approved in advance by Partners. Excludes: Naturopathy; homeopathy; hypnotherapy; massage therapy; maintenance biofeedback; nutritional supplements; thermography; recreational, educational and sleep therapy.
Reconstructive/Cosmetic Surgery	Covers: Reconstructive surgery to correct results of disease or injury needed to correct a functional impairment. Covers post-mastectomy breast surgery. Limits: Requires prior approval. Excludes: Surgeries done primarily to improve appearance.
Non-Emergency Transportation	Excluded, except with prior approval in the case of transplants performed outside of the service area.
Excluded Services
Experimental or Investigational Services	Excluded.
Services Not Considered Medically Necessary	Excluded.
Non-Emergency Services Rendered in the Emergency Room	Excluded.
Commonly Excluded Services	See List of Common Exclusions
Definitions
Medically Necessary	Meets statutory definition
Experimental or Investigational	Medical, surgical, psychiatric and other health care services, supplies, treatments, procedures, drug therapies, or devices that are determined by the plan to be either: Not generally accepted or endorsed by health care professionals in the general medical community as safe and effective in treating the condition, illness or diagnosis for which their use is proposed. Not proven by scientific evidence to be safe and effective in treating the condition, illness or diagnosis for which their use is proposed.
Emergency	Uses statutory definition of emergency.
Urgent Care	Not specifically defined by the plan.
Primary Cary Providers, Referrals and Pre-Authorization Requirements
Types of Providers Who Can Serve as Primary Care Provider	Family Practitioners, Internists, Pediatricians, OB/GYN and Nephrologists and Oncologists with prior plan approval.
What Happens if Member Fails to Choose a PCP?	Until PCP is selected, benefits limited to coverage of emergency. If a PCP is not selected, Partners will select one.
Process to Change PCP	Requests to change PCP are made to Partner’s customer service department. A PCP change will become effective the first day of the month following receipt of notification by plan. Limits: Members may change their PCP up to 4 times per contract year. A change of PCP cannot be made if the member is confined as an inpatient at a medical facility or is being treated by a participating physician.
Referrals to Specialists	Referrals to participating providers: Referrals are made by the member’s PCP. referrals by the PCP for non-covered services do not mean that the services are covered. Referrals to non-participating providers: Covered only when services are medically necessary and participating providers are not available to treat the member without an unreasonable delay. Prior approval must be obtained by the PCP from the plan. Written authorization for such services can only be issued by the plan. Note: To be sure that the services will be covered, it is the member’s responsibility to be sure that the appropriate referral has been obtained. Referrals are not needed for female health services by a participating OB/GYN or covered services by participating opthamologists or optometrists.
Can Specialists Serve as PCP?	Yes, with prior plan approval.
Non-Emergency Hospital Preauthorization Requirements	Hospital services must be arranged by a participating provider, received in an emergency situation or be prior- approved by plan if in-patient. Note: Services of a non-participating hospital may be covered when medically necessary. However, prior approval by plan is required.
Appeal and Grievance Procedures
First Level Non-Certification Appeal Provisions	Follows statutory definition. Note: Members or their representatives must submit first level appeal to PARTNERS within 60 days of the date of their claims decision. Members will receive a response from PARTNERS within 30 days of PARTNERS’ receipt of the review request.
First Level Expedited Appeals	Follows statutory definition. Note: Responses to expedited appeals will be received within 4 days of the receipt of all necessary information.
First Level Grievance Hearings	Follows statutory definition. Note: Members or their representatives must request a first-level grievance hearing within 60 days of the date of the notice of the action affecting the member. PARTNERS’ will make a decision on the grievance within 30 days of the receipt of the grievance.
Second-Level Grievance Hearings (Covers Second-Level Appeals and Grievances)	Follows statutory definition. Note: Requests for second-level grievance hearings must be made within 60 days of the date of notice of the first-level grievance decision. The second-level review meeting will be held within 30 days of PARTNERS’ receipt of a request for a second-level grievance review. Member will be notified of the decision within 7 business days of the review meeting.
Second Level Expedited Appeals	Follows statutory definition. Note: Responses to expedited appeals will be received within 4 days of the receipt of all necessary information.
Other Avenues of Appeal	Members can obtain independent information about the appeals process and seek assistance from the N.C. Department of Insurance and the Office of Commissioner. Call 1-800-662-7777.
Notes	Limitations Formal Appeal and Grievance Process: The appeal and grievance process does not apply to denials rendered solely on the basis that Partners does not provide coverage for the health care service performed or being requested, as outlined in the Evidence of Coverage.
Enrollment Trends
Enrollment on December 31, 1999 (Financial Report, # 10)	306,573
Member Months (1999) (Financial Report, #11)	2,915,711
Average 1999 Monthly Enrollment (Member Months/12)	242,976
Percentage of Change in Average Monthly Enrollment between 1998-1999	16.0%
Percentage of Groups that Disenrolled (December 31, 1998-December 31, 1999)	12%
Percentage of Members that Disenrolled (December 31, 1998-December 31, 1999)	17%
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1998 — Dec. 31, 1999)	4%
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1998 — Dec. 31, 1999)	0.1%
Utilization Review Information
Number of Reviews Requested, 1999	35,839
Review Rate per 1,000 Members, 1999	213
Percentage of Noncertifications, 1999	8.22%
Noncertification Rate per 1,000 Members, 1999	17.50
Appeal Rate per 1,000 Noncertifications	68.93
Percentage of Appeals Decided for the Members, 1999	60.78%
Financial Data
Total 1999 Revenues (Financial Report, #6)	$488,591,882
Average Premium per member per month (1999) (Financial Report, #5 / #11)	$166.36
Five-year Premium per member per month Trends	1999: $166.36 1998: $153.98 1997: $144.89 1996: $138.82 1995: $130.34
Medical/Hospital Expenses per member per month (Financial Report, #7 / #11), 1999	$148.82
Medical Loss Ratio (% Premiums Spent on Medical/Hospital expenses) (Financial Report, #15), 1999	89.5%
Five-year medical loss ratio Trends	1999: 89.5% 1998: 87.4% 1997: 87.0% 1996: 84.8% 1995: 81.0%
Operating profit margin (Financial Report, #9 / #6)	2.5%
Five-year Operating Profit Margin Trends	1999: 2.5% 1998: 3.8% 1997: 5.0% 1996: (6.9%) 1995: (9.7%)
Sources of Information
Source of Information	Partners National Health Plan of North Carolina, Inc., Certificate of Coverage, GRPCERT-99; 1998 Annual Financial Report; NC DOI Managed Care and Health Benefits Division, "HMOs in North Carolina Status Reports: Analysis of 1995 Activity" January 1997; NC DOI, "1999 Managed Care Plan Handbook: A Comparison Guide for North Carolina Consumers." Data on Utilization Review and Appeals and Grievances from NC DOI. 2000 Amendments to the COC and 2001 Amendments to the COC.

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