About PHCS

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About PHCS
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About PHCS

• National leader in health care cost management
• Corporate office in Waltham, MA
• 350 customers with over 16 million members
• Direct agreements with nearly 450,000 providers
  and 4,200 facilities NO LEASED NETWORKS
• PHCS is the first and only national PPO to earn
  four endorsements of quality from National
  Committee for Quality Assurance (NCQA) and URAC
• PHCS Care Management is the second largest
  independent utilization review firm

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A Historical View of PHCS

• In 1985, we were established as a partnership by
  15 insurance companies
• In 1992, we incorporated and began selling
  services to a diverse customer base
• In 1993, our Health Utilization Management
  services became URAC accredited, with subsequent
  reaccreditation every two years
• In 2001, we successfully reorganized our
  corporate governance and capital structure
• We became the first and only healthcare
  management company to earn four endorsements of
  quality from two independent, nationally-recognize
  d quality assurance organizations, the National
  Committee for Quality Assurance (NCQA) and URAC
• In 2002, we created a new approach to care
  management, enabling health plans to better
  address rapidly rising costs
• Now in 2004 our unprecedented growth and
  expansion of market share continues, solidifying
  our position as a national leader with 28
  consecutive quarters of profitability

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Commitment to Networks
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National Access with the Best Savings

• In addition to providing broad national access to
  a quality-based provider network, we have helped
  our customers achieve the best savings in the
  industry
• Average inpatient discount 40.0
• Average outpatient discount 27.5
• Average physician discount 34.7
• Average ancillary discount 47.1
• Currently have nearly 450,000 providers and 4,200
  acute care facilities in 50 States, all
  agreements are direct
• NCQA Certification for Credentialing and
  Re-credentialing
• URAC accreditation for Health Network and
  Credentialing

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Network Staff

• The PHCS Network staff is highly experienced at
  negotiating contracts with providers and
  facilities
• We have offices in 15 locations nationwide

Seattle, WA
Waltham, MA (Corporate Headquarters)
Syracuse, NY
Chicago, IL
Saddle Brook, NJ
Kansas City, MO
Washington, DC
Nashville, TN
Irvine, CA
Phoenix, AZ

Atlanta, GA
Jackson, MS
Dallas, TX
Orlando, FL
New Orleans, LA
HI
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Kaiser ColoradoDisruption Savings
AnalysisResults
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Results of PHCS Analysis for KPIC 2004 Claims
Activity

• Facility Disruption 89
• Percentage of Facility Claims 91
• Physician Disruption 83
• Percentage of Physician Claim Dollars 84
• Outside Colorado, Percentage of all Claim
  Dollars 89

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PHCS Provider Numbers in Kaiser Areas

• Zip Code Hosp PCPs Specialists
• 800 7 524 1483
• 801 4 632 1783
• 802 9 1324 3527
• 803 1 164 509
• 804 5 103 290
• 805 4 653 1069
• 806 2 183 534
• 808 3 46 67
• 809 4 374 903
• 810 7 155 232
• 812 3 36 49
• Totals 49 4194 10446

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To access PHCS Search for a Provider go to
www.phcs.com and select Search for a Provider.
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What Is PHCS Search for a Provider?

• PHCS Search for a Provider is our online provider
  directory that enables you to
• Search for a provider based on distance from
  address
• Get directions to health care providers offices
• Specify gender and language when searching for a
  health care provider
• View a list of up to 150 providers who meet
  specific criteria
• See where a physician attended medical school
• Access a help function from every field within
  the site
• Import the providers contact information into an
  MS Outlook address book

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On-Line Provider Nomination
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If your provider does not participate in the PHCS
Network, you can refer him or her by using our
online provider referral system in the Health
Plan Members section of www.phcs.com . Click on
Provider Referral System.
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On the Provider Referral System page, click on
Online Provider Referral System.
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Choose Refer a Provider to the PHCS Network.
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Fill in the information requested.
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Once you complete the form

• We send you an e-mail confirming we have received
  your request
• We contact the provider to determine if he/she is
  interested
• While we make every effort to complete the
  recruitment process as quickly as possible, it
  may take 90-180 days to finish the process
• You can check the status of your referral at
  anytime

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Commitment to Quality
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Quality

NCQA Certification for Credentialing and
Re-credentialing URAC accreditation for Health
Network and Credentialing NCQA certification
for Utilization Management URAC accreditation
for Utilization Management

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Our Credentialing/Recredentialing Process

• When credentialing providers we establish a
  quality baseline for provider networks with
  primary source verification of
• State licensure, including any actions against
  the provider
• National Practitioner Data Bank (NPDB), including
  malpractice claims payment history
• Medicare/Medicaid sanctions
• Board Certification/Training
• DEA license
• PHCS meets NCQA and URAC standards for
  credentialing by
• Collecting provider attestation for
• Review of hospital privileges
• Malpractice coverage
• Professional questionnaire
• Recredentialing providers every three years
• Continuous monitoring between recredentialing
  events

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PHCS Helps You Protect Your Members

• Our base agreement includes the following member
  protections
• Providers are forbidden to balance bill for
  covered services
• Providers cannot bill or collect payment from the
  member until the explanation of benefit is issued
• Providers must continue care after termination of
  the agreement
• Providers must comply with the payors
  utilization review (UR) policies and procedures
• Our network access and availability standards
  help ensure members have adequate access to care
• We are committed to safety
• PHCS Corporate Quality Management (CQM) Program
• Continual physician monitoring
• We are HIPAA compliant with patient security and
  confidentiality regulations

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