The hospital will agree to provide services to all HealthPlus members at the same level, scope, and quality of care provided to any other patient. The hospital must not discriminate against a member based on, but not limited to, the following:
- marital status
- national origin
- health status
- frequency or extent of covered services needed
- benefit carrier assignment
Licensing and Accreditation
The hospital will be duly licensed by the State of Michigan and accredited by The Joint Commission [formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)], the American Osteopathic Association (AOA) and/or the Det Norske Veritas (DNV), National Integrated Accreditation for Healthcare Organizations (NIAHO), to render covered services to members. The hospital and its affiliates will maintain such licensure and accreditation and will notify HealthPlus within 5 days of loss of any such licensure or accreditation.
The hospital will require any employee or agent who renders services to HealthPlus members to be appropriately supervised and have the appropriate license and/or certification to render such services. All personnel, facilities, equipment and support services must meet all appropriate licensure and certification requirements.
HealthPlus encourages hospitals to participate in patient safety activities and reporting through local and national organizations such as Leapfrog, the Michigan Health and Safety Committee, National Quality Forum and Michigan Health and Hospital Association .
Participating hospitals must accept HealthPlus members as patients. Elective and urgent admissions will be made only upon the appropriate referral of the member by a participating HealthPlus physician.
The hospital is required to notify HealthPlus within 24 hours after learning a member’s identity following an emergency situation.
Required Member Information
At the time of admission, the hospital will obtain the following information from the member:
- Possession of a valid HealthPlus subscriber card
- Disclosure of duplicate coverage, including policy numbers, where applicable
- Eligibility of coverage under any private or governmental program
- Execution of a Release of Information form
Hospitals will provide HealthPlus a daily written census of inpatient members.
In order to receive compensation for the rendering of covered hospital services, the hospital must obtain a complete billing number from HealthPlus. HealthPlus will issue a complete billing number if:
- The hospital notified HealthPlus within 24 hours in the case of an emergency admission.
- The hospital notified HealthPlus of an elective or urgent admission pursuant to HealthPlus’ Case Management Program.
- The medical care provided was deemed medically necessary according to HealthPlus’ utilization criteria.
Neither HealthPlus nor a member will be responsible for compensating the hospital for covered hospital services rendered without proper HealthPlus issuance of a billing number. For services rendered with a HealthPlus billing number, for which the member was eligible on the date of service and was subsequently retroactively disenrolled from HealthPlus, the hospital will pursue payment for services from the member or appropriate collateral sources.
Behavioral Health Services
Except in the case of an emergency, the hospital must obtain an authorization from HealthPlus prior to rendering inpatient or outpatient behavioral services (mental health or substance abuse) in accordance with HealthPlus’ behavioral health policies and procedures.
Except in the case of an emergency, in the event a member presents himself or herself for service(s) without the necessary prior authorization and approval, the hospital must obtain the approval of HealthPlus prior to treatment. To authorize services, contact the Customer Service Department at: 1-800-332-9161.
Submission of Invoices
The hospital must submit claims for covered services to HealthPlus, according to the contracted timeframe.
Claims received after the designated period of time has elapsed will not be paid. The hospital may not bill or collect payment from a subscriber.
The hospital must separate invoices for outpatient services from other hospital services and must identify those invoices associated with outpatient service.
The hospital may seek compensation from HealthPlus for services rendered to a member only when HealthPlus’ Subscriber Contract covers such services. The hospital may not bill, charge, collect a deposit from, seek compensation or remuneration from, assess surcharges, or have any recourse against a member or persons acting on behalf of a member (other than HealthPlus), except to the extent that copays are specified in an HealthPlus Subscriber Contract, or as permitted under principles of coordination of benefits.