VIRGINIA HEALTH NETWORK, INC. Report for Participating Physicians and Hospitals October 1, 2017

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1 VIRGINIA HEALTH NETWORK, INC. Report for Participating Physicians and Hospitals October, 207 PLEASE NOTE SHADED AREAS REPRESENT ADDITIONS OR CHANGES SINCE LAST REPORT ACCORDING TO MCHIP REGULATIONS, ROUTINE APPOINTMENTS FOR NON-EMERGENCY OR NON-URGENT CARE SHALL BE MADE AVAILABLE WITHIN TWO WEEKS OF THE ENROLLEES REQUEST AND PREVENTIVE CARE APPOINTMENTS, INCLUDING PHYSICAL EXAMS, SHALL BE MADE AVAILABLE WITHIN 60 DAYS OF THE ENROLLEE S REQUEST. MCHIP REGULATIONS ALSO REQUIRE PPO PARTICIPATING PROVIDERS TO ENSURE THAT ENROLLEES HAVE TELEPHONE ACCESS TO A KNOWLEDGEABLE HEALTH CARE PRACTITIONER 24 HOURS A DAY, 7 DAYS A WEEK. # Area Advanced Electronic Services 5090 Statewide VHN Office Visit Co-Pay: $25 (PCP);$50 (Spec.) Deductible: $750/person; $,500/family Out-of-pocket max: $6,350/person, $2,700/family Effective: //4 AEC Narrows of Virginia Effective: 9/23/4 AEC Health/Custom Manufacturing Services Effective: 9//205 Air Power Effective: 7// Statewide VHN Benefit Assistance Corporation 708 and Statewide VHN Benefit Assistance Corp. P.O. Box 790 Ripley, WV 2527 Statewide VHN Payer ID Basic Plan Office Visit Co-Pay: $35 (PCP); $55 (Spec.) Deductible: $900/person; $2,700/family Out-of-pocket max: $3,800/person; $9,500/family Office Visit Co-Pay: $30 (PCP); $45 (Spec.) Deductible: $450/person; $,350/family Out-of-pocket max: $2,500/person; $6,250/family PLAN A Deductible: $2,000/person; $4,000/family PLAN B Deductible: $2,000/person; $4,000/family Coinsurance: 30% PLAN C Deductible: $5,000/person; $0,000/family Coinsurance: 00% Traditional Option Copays: $25(PCP); $50(Spec); $300(ER) Deductible: $,500/person; $3,000/family Out-of-pocket-max: $4,500/person; $9,000/family over this outline. VHN Matrix 207

2 2 # Area Albemarle Regional Library Effective: 7//5 Alleghany County (N.C.) M09 Statewide VHN M045 Statewide VHN Office Visit Co-pay: $20(PCP); $40(Spec) E.R. Copay: $ Office Visit Co-pay: $20(PCP); $40(Spec) E.R. Copay: $50/Coinsurance/Deductible Effective: 7//6 Ammar s Effective: 3//6 American Healthcare Alliance Benefit Assistance Corporation Varies by Group AMMARS Statewide VHN Benefit Assistance Corp. P.O. Box 790 Ripley, WV 2527 Varies by Group Statewide EXCEPT Winchester VHN Payer ID American Healthcare Alliance 9229 Ward Parkway, Suite 300 Kansas City, MO Plan A: Office Visit Co-pay: $25 (PCP); $40(Spec) Deductible: $2,500/person; $5,000/family Plan B: Office Visit Co-pay: $25 (PCP); $40 (Spec) Deductible: $5,000/person; $0,000/family Plan C: Deductible: $6,450/person; $2,900/family Coinsurance: 00% Plan D: Office Visit Co-pay: $20 (PCP); $50 (Spec) Coinsurance: 00% Refer to ID Card Refer to ID Card Varies by Group - Refer to ID card Payer ID 066 AmeriCorps VISTA & AmeriCorps NCCC (Through Choice Care / Humana Asheville Specialty Hospital Effective: //7 Seven Corners VS Statewide VHN Seven Corners Attn: Claims P. O. Box 3430 Carmel, IN Payer ID H0 Statewide VHN Please Payor Refer to plan benefits listed on ID card over this outline. VHN Matrix 207

3 3 # Area Audiotronics Effective: 9//5 Auto-Owners Insurance Effective: //6 Automotive Fasteners C09 Statewide VHN Prairie States ACT Statewide VHN Prairie States Enterprises P.O. Box 23 Sheboygan, WI (Eff. 9//3) (Prev. ACS Benefit Services) 4040 (previously 083) Payer ID Statewide VHN Virginia Health Deductible: $2,000/person; $5,200/family Coinsurance: 00% after deductible Multiple Plan Designs Please contact Payor Office Visit Co-Pay: $25 Deductible: $,000/person; $2,000/family Out-of-pocket max: $5,000/person; $0,000/family Bacon Enterprises Effective: 7//5 Termed: 6/30/7 Bailey s Jewelry Effective: 5//5 Billy Graham C03 Statewide VHN Aultra KA00005 Statewide VHN Virginia Health 735 Statewide VHN $5,000 Deductible Option $30 Copay (PCP) Deductible: $5,000/person; $0,000/family Coinsurance: 00% (after deductible) HDHP Option Deductible: $2,600/person; $5,200/family 00% after Satisfying Deductible Please Payor Refer to plan benefits listed on ID card. Effective: //5 over this outline. VHN Matrix 207

4 4 # Area Blue Ridge Best Foods Effective: 4//6 C039 Statewide VHN $5,000 Deductible Option $30 Copay (PCP) Deductible: $5,000/person; $0,000/family Coinsurance: 00% (after deductible) HDHP Option Deductible: $2,600/person; $5,200/family 00% after Satisfying Deductible Botetourt County Employees Effective: 2// Statewide VHN Office Visit Co-Pay: $20 (PCP); 30% coinsurance (Spec) Deductible: 0 Coinsurance: 30% Out-of-pocket max: #3,000/person; $6,000/family Box Board Products, inc Statewide VHN Office Visit Co-Pay: $25 (PCP); $75 (Spec) Deductible: $,500/person; $3,000/family Coinsurance: 40% Out-of-pocket max: $5,500/person; $,000/family Effective: 7//4 Brady Trane Service, Inc Statewide VHN Deductible: $,500/person; $3,000/family Coinsurance: 40% Coinsurance Max: $2,000/person; $3,000/family Out-of-pocket max: $3,500/person; $6,000/family Effective: 3//4 Carilion Clinic Employees (Only in specific counties, see service area) Effective: 7// Aetna Augusta, Bath, Highland and Page Counties; Cities of Buena Vista, Galax, Lexington, Staunton, Waynesboro VHN Aetna P. O. Box 9806 El Paso, TX Payer ID Aetna Select (Must choose a PCP & have referrals to specialists) Office Visit Co-Pay: $5 (PCP), $50 (Spec) Deductible: $0 Classic Care POS II Plan Deductible $2,000/person; $4,000/family Choice POS II Plan Office Visit Co-Pay: $20 (PCP), $50 (Spec) Deductible: $0 over this outline. VHN Matrix 207

5 5 # Area Carolina Narrow Fabric, Inc. Effective: 9//4 Benefit Plan Services, Inc. 072 Statewide VHN Virginia Health Office Visit Copay: $25 (PCP) Urgent Care Copay: $25 Deductible: $,500/person; $3,000/family Out-of-pocket: $2,500/person; $5,000/family CarolinaEast Health System 7050 Statewide VHN Refer to plan benefits listed on ID card. Effective: //6 Carolinas Healthcare System 300 Statewide VHN Refer to plan benefits listed on ID card. Effective: 3//7 Carteret Health Care Effective: 7// Statewide VHN Refer to plan benefits listed on ID card. City of Oxford Effective: 7//4 M256 Statewide VHN Office Visit Co-Pay: $30 (PCP); $40 (Spec) Deductible: $500/Person; $,000/Family Out-of-pocket max: $6,350/Person; $2,700/Family CMC Supply, Inc. Effective: 2//5 C025 Statewide VHN Refer to plan benefits listed on ID card over this outline. VHN Matrix 207

6 6 # Area Coastal AgroBusiness, Inc. Effective: 2//2 Interactive Medical Systems IMS580 Statewide VHN (Eff. 3//5) Virginia Health Office Visit Co-Pay: $25 (PCP); $50 (Spec.) Deductible: $2,500/person; $5,000/family Out-of-pocket max: $3,000/person; $6,000/family Cole Chevrolet- Cadillac Effective: 2//7 Benefit Assistance Corp. COLE Statewide VHN Benefit Assistance Corp. P.O. Box 790 Ripley, WV 2527 Payer ID Office Visit Co-Pay: $35 (PCP); $50 (Spec.) Deductible: $6,850/person; $3,700/family Coinsurance: 00% Out-of-Pocket max: $4,925/person; $9,850/family Conn-Weld Industries, Inc. Effective: 6//5 Benefit Assistance Corp Statewide VHN Benefit Assistance Corp. P.O. Box 790 Ripley, WV 2527 Payer ID Deductible: $400/person; $800/family Coinsurance: 0% Out-of-Pocket max: $,900/person; $3,800/family Copland Fabrics Effective: 3//2 Maestro Health (Previously with ACS Benefit Services) 2840 (prev. 36) Statewide VHN Virginia Health Deductible: $575/person; $,725/family Coinsuracnce: 20% Out-of-pocket max: $4,600/person Cornerstone Health Care Effective: 7//4 500 Statewide VHN Payer ID Refer to plan benefits listed on ID card. County of Camden Effective: 7//3 M969 Statewide VHN Virginia Health Office Visit Co-Pay: $5 (PCP); 30 (Spec.) Deductible: $2,000/ person; $6,000/family Out-of-Pocket max: $3,000/person; $9,000/family County of Dare 705 Statewide VHN Refer to plan benefits listed on ID card. Effective: 7//5 Payer ID 5662 over this outline. VHN Matrix 207

7 7 # Area Danville Orthopedic (Spectrum Medical) CO Statewide VHN GATEWAY Deductible: $2,600/person; $5,200/family Coinsurance (after deductible): 00% Out-of-pocket max: $2,600/person; $5,200/family Effective: 4//5 Davidson Healthcare 5370 Statewide VHN Office Visit Co-Pay: $30 (PCP), $40 (Spec.) Deductible: $300/person; $600/family Coinsurance: 30% Out-of-pocket max: $4,200/person; $5,900/family Effective: 2//4 DuPont Community Credit Union 7052 Statewide VHN Refer to plan benefits listed on ID card Effective: //6 Eagle Physicians and Associates 690 Statewide VHN Refer to ID card for Co-pay and Coinsurance information Effective: 7//7 East Carolina Behavioral Health Elizabeth City Housing Authority Effective: 7//3 Flow Automotive Effective: //6 PLEASE REFER TO TRILLIUM HEALTH RESOURCES FOR INFORMATION M830 Statewide VHN 7082 and 7083 Virginia Health Statewide VHN Office Visit Co-Pay: $20 (PCP); $30 (Spec.) Deductible: $400/person: $800/family Coinsurance: 5% Out-of-pocket max: $,500/person; $3,000/family Refer to plan benefits listed on ID card over this outline. VHN Matrix 207

8 8 # Area George Nice & Sons C05 Statewide VHN Refer to plan benefits listed on ID card Effective: 2//6 Goad s Body Shop Effective: 2//5 Graves Mountain Lodge Effective: 2//5 C033 Statewide VHN C03 Statewide VHN Refer to plan benefits listed on ID card Refer to plan benefits listed on ID card Gregory Poole Equipment Co. WEB-TPA 202GP Statewide VHN (Eff. //6) WEB-TPA P. O. Box Grapevine, TX Please contact Payor Effective: 6//2 Guy C. Lee Manufacturing Co. Interactive Medical Systems IMS350 Statewide VHN (Eff. 3//5) EDI Address 7526 Virginia Health, Inc Deductible: $,220 Out-of-pocket max: $3,660/person; $9,760/family Effective: 0//4 Heating, Piping & Refrigeration Medical Fund Benefits Administration Corp W32E Statewide VHN Benefit Administration Corp. Leasing P.O. Box El Paso, TX Please Payor Effective: //0 Hertford County M07 Statewide VHN Payor ID Physicians: SB690 Facilities: Office Visit Co-pay: $20(PCP); $40(Spec) E.R. Copay: $300 Effective: 7//5 over this outline. VHN Matrix 207

9 9 # Area Hertford County ABC Board Effective : 7//5 Termed: 0//7 M02 Statewide VHN Office Visit Co-pay: $20(PCP); $40(Spec) E.R. Copay: $300 Hillco Hillco, Ltd Statewide VHN (Eff. 3//5) Virginia Health Please Payor Effective: //0 Hometown Grocery Effective: //7 Hospice and Palliative Care Center Benefit Assistance Corporation Hometown Statewide VHN Benefit Assistance Corporation P,O, Box 950 Hurricane, WV Statewide VHN Payor ID Option A: O. V. Copay: $30 (PCP); $50 (spec.) Deductible: $2,000/person; $4,000/family Out-of-Pocket max: $3,500/person; $7,000/family Option B: O. V. Copay: $30 (PCP); $50 (spec) Deductible: $5,000/person; $0,000/family Out-of-pocket max: $6,600/person; $3,200/family Option C: Deductible: $2,000/person; $4,000/family Coinsurance: 50% Out-of-pocket max: $6,600/person; $3,200/family Refer to ID Card Effective: 6//6 over this outline. VHN Matrix 207

10 0 # Area Howell s Motor Freight Effective: 8//5 Medcost C05 Statewide VHN HDHP Option: Deductible: $2,600/person; $5,200/family Coinsurance: 00% after deductible ER Co-Pay: $300 Co-Pay AFTER deductible Co-Pay Option: Office Visit Co-Pay: $30 (PCP) Deductible: $3,000/person; $6,000/family Huffman Oil Effective: 9//3 532 Statewide VHN Virginia Health Office Visit Copay: $20 (PCP) Deductible: $500/person; $,500/family Out-of-pocket max: $3,500/person; $7,000/family Humana Employers Health Ins. Co. thru ChoiceCare Effective: //05 accessing VHN statewide Humana Employers Health Ins. Co. Varies by group Statewide VHN Humana Employers Health 00 Employers Boulevard Green Bay, WI Payer ID Varies by plan idertools.asp James River Air Conditioning C02 Statewide VHN Refer to ID Card Effective: 0//5 Jones Apparel Group Aetna US Healthcare Statewide VHN Virginia Health, Inc PPO Plan - Office Visit Co-Pay: $5 Deductible: $200/person; $450/Family Out-of-pocket max: $2,000/person; $4,000/family Preventative Care: $5 Co-Pay PPO Plan 2 - Office Visit Co-Pay: $0 Deductible: $00/person; $250/Family Coinsurance: 0% Out-of-pocket max: $,000/person; $2,000/family Preventative Care: $0 Co-Pay over this outline. VHN Matrix 207

11 # Area Kevin Powell Enterprises Benefit Plan Services 083 Statewide VHN Virginia Health Unavailable at time of printing Effective //6 Lynch Construction The Employee Benefit Service Center LCI0405 Statewide VHN The Employee Benefit Service Center 4430 Kanawha Turnpike South Charleston, WV Office Visit Co-pay: $5 Deductible: $500/person; $,000/family Out-of-packet max: $2,000/person; $4,000/family Effective: 4//7 Macado s Inc. Effective: 9//5 Maryfield, Inc. C07 Statewide VHN 275 Statewide VHN $,000 Deductible Option: Office Visit Co-Pay: $30 (PCP) Deductible: $,000/person; $2,000/family ER Copay: $300 Co-Pay, AFTER deductible Out-of-pocket max: $3,500/person; $7,000/family $5,000 Deductible Option Office Visit Co-Pay: $30 (PCP) Deductible: $5,000/person; $0,000/family Coinsurance: 00% after deductible ER Co-Pay: $300 Co-Pay, AFTER deductible Out-of-pocket max: $6,350/person; $2,700/family Refer to ID Card Effective: 5//7 Mattern and Craig C04 Satewide VHN HDHP: $2,600 Deductible PCP: 00% after deductible Spec: 00% after deductible ER: Deductible, then $300 Effective: 6//6 over this outline. VHN Matrix 207

12 2 # Area MB Contractors C043 Statewide VHN Refer to patient s ID card Effective: 9//6 Mission Hospital System 9200 Statewide VHN Refer to patient s ID card Effective://7 Mountain Area Health Education Center 325 Statewide VHN Office Visit Co-Pay: $30 (PCP); $50 (Spec) Deductible: $350/person; $,050/family Out-of-pocket max: $3,000/person; $9,000/family Effective: 6//4 MSC, Inc. Effective: 4//3 The Nottingham Co. Effective: 4//5 (Formerly ACS Benefit Services) 6096 (Formerly 070) Statewide VHN Payer ID Statewide VHN Office Visit Copay: $20 (PCP); $40 (Specialist) Deductible: $750/person; $,500/family Out-of-pocket max: $3,000/person; $6,000/family Refer to patient s ID card Effective: 8//6 Northampton County Effective: 7//3 M997 Statewide VHN Payer ID 5662 Virginia Health Office Visit Co-Pay: $5 (PCP); $30 (SPEC) Deductible: $500/person; $,500/family Coinsurance: 0% Out-of-pocket max: $2,500/person; $7,500/family over this outline. VHN Matrix 207

13 3 # Area Northern Eagle (Previously known as Proud Eagle, Inc. And Mountain Eagle) Benefit Assistance Corp. NORTH EAGLE Statewide VHN Benefit Assistance Corporation P. O. Box 950 Hurricane, WV Payer ID Office Visit Co-Pay: $0 (PCP); $20 (Spec) Deductible: $500/person; $,000/family Out-of-pocket max: $,500/person; $3,000/family Effective: // Novanet Varies by Group Varies by Group Statewide EXCEPT Winchester VHN Refer to ID Card Refer to ID Card Refer to ID Card Varies by Product Orders Construction Company Benefit Assistance Corp Statewide VHN Benefit Assistance Corp. P.O. Box 790 Ripley, WV Deductible: $,000/person; $2,000/family Out-of-pocket max: $3,500/person; $7,000/family Effective: 6//5 Payer ID Peace Corps (through Choice Care / Humana) Seven Corners? Statewide VHN Peace Corps - Attn. Claims P. O. Box 2270 Carmel, IN Payer ID Please Payor PHCS (Private Healthcare Systems) (Tidewater & Charlottesville) Varies by Group Varies Hampton Rds Charlottesville Only VHN Refer to ID Card Refer to ID Card Refer to ID Card PHCS utilizes VHN s network in the Hampton Roads and Charlottesville service areas and is an optional network. Providers in these areas who wish to participate with PHCS must accept the PHCS exhibit. Physicians to Children Effective: //6 C028 Statewide VHN Payer ID Refer to plan of benefits found on ID card over this outline. VHN Matrix 207

14 4 # Area Piedmont Community Health Plan (PCHP) or Piedmont Community Healthcare Piedmont Triad Regional Council Piedmont Community Health Plans Varies by Client Statewide VHN Piedmont Community Health Plans P. O. Box 4408 Cincinnati, OH Statewide VHN Payer ID Varies by client. PCHP members who reside outside PCHP s service area are set up to use VHN s network. VHN will be on the member s ID Card and on the EOB. PCHP membes who reside within PCHP s service area may access VHN providers located outside of PCHP s s service area only with a referral Refer to plan of benefits located on ID card. Effective: 7//6 The Price Company Brookneal Chips Prime Health Services Effective: 5//09 Benefit Support (prev. AdminOne) 8658C (Prev PC 06) Varies by Group Varies Statewide EXCEPT Winchester Statewide VHN Virginia Health VHN Refer to ID Card Refer to ID Card Office Visit Co-Pay: $25 Deductible: $,000/person; $3,000/family Out-of-pocket max: $3,000/person; $9,000/family Refer to ID Card Varies by Product Procon, Inc Effective: 0// Statewide VHN Payer ID Refer to ID Card QHM (Quality Health Management) QHM Varies Statewide VHN Quality Health Management 5280 NW 79 th Court, Suite 00 Miami Lakes, FL Varies by Plan over this outline. VHN Matrix 207

15 5 # Area REI Consultants Effective: 9//0 Eff. 7// Benefit Assistance Corp. (Formerly Benefit Plan Administrators, Inc.) REIC (Formerly G9200) Statewide VHN Benefit Assistance Corporation P. O. Box 790 Ripley, WV 2527 Payer ID Office Visit Co-Pay: $20 (PCP) $40 (Spec) Deductible: $750/person; $,500/family Out-of-pocket mac: $2,000/person; $4,000/family Renaissance Contract Lighting and Furnishings, Inc. C053 Statewide VHN Deductible: $5,000/person; $0,000/family Coinsurance: 00% after Deductible Out-of-pocket: $6,350/person; $2,700/family Effective: 6//7 Replacements, LTD 4090 Statewide Office Visit Co-Pay: $25 (PCP); $50 (Spec) Deductible: $,000/person; $2,000/family Out-of pocket max: $4,000/person; $8,000/family Effective: //4 Robinson, Bradshaw, and Hinson 8585 Statewide VHN Office Visit Co-Pay: $20 Deductible: $300/person; $600/family Coinsurance: 0% Out-of-pocket: $6,350/person; $2,700/family Effective: 9//5 Samaritan s Purse Effective //4 Sandhu Group 200 Statewide VHN C045 Statewide VHN Office Visit Co-Pay: $20 (PCP) Deductible: $500/person; $,000/family Out-of-pocket: $,750/person; $3,500/family Refer to Patient s ID Card Effective: //6 over this outline. VHN Matrix 207

16 6 # Area Scott County School Board Effective: 7//2 Shenandoah Landscape Services Inc. 50 Statewide VHN 7097 Statewide VHN Virginia Health, Inc Office Visit Co-Pay: $20 (PCP) $40 (Spec) Deductible: $0 Coinsurance: 30% Out-of-pocket max: $3,000/person; $6, Refer to Patient s ID Card Effective: 4//7 Shoe Show, Inc. Effective: //4 Smyth Companies, (Piedmont Label) 920 Statewide VHN Preferred One PKA Virginia Health, Inc. Statewide VHN Virginia Health Office Visit Copay: $25 (PCP), $35 (Spec) Deductible: $600/Person; $2,400/family Out of Pocket: $2,000/person; $24,000/family Please Payor Stanly Health Services 580 Statewide VHN Office Visit: $20 or $30 (PCP) $40 or $50 (Spec) Deductible: $300 or $500/person $600 or $,000/family Coinsurance: 0% or 20% Out-of-pocket: $2,000 or $3,000/person $4,000 or $6,000/family Sterling Transport Co Statewide VHN Refer to ID card for co-pay and coinsurance information. Effective: 8//6 over this outline. VHN Matrix 207

17 7 # Area Stokes County Effective: 7//3 Storr Office Environments, Inc M993 Statewide VHN 707 Statewide VHN Virginia Health Office Visit Co-Pay: $40 (PCP) $75 (Spec) Deductible: $,500/person; 3,000/family Out-of-pocket max: $5,000/person; $5,000/family Refer to ID card for co-pay and coinsurance information. Effective: //6 Swing Transport Effective 2//2 Medcost 7370 Statewide VHN Virginia Health Office Visit Co-Pay: $50 Deductible: $,200/person Out-of-pocket max: $3,600/person; $7,200/family Terry, Inc. C008 Statewide VHN Refer to ID card for co-pay and coinsurance information. Effective: //5 Theodore Alexander, USA Benefit Plan Services 085 Statewide VHN Virginia Health Refer to ID card for co-pay and coinsurance information. Effective: 6/26/7 Town of Kill Devil Hills Effective: 7//3 M758 Statewide VHN Virginia Health, Inc Office Visit Co-Pay: $20 (PCP); $30 (Spec.) Deductible: $2,000/person; $4,000/family Coinsurance: 5% Out-of-pocket max: $3,500/person; $7,000/family over this outline. VHN Matrix 207

18 8 # Area Town of Nags Head Effective: 7//3 Triad Freightliners, Inc M659 Statewide VHN Virginia Health 7068 Statewide VHN Office Visit Co-Pay: $30 (PCP); $40 (Spec.) Deductible: $,000/person; $2,000/family Coinsurance: 30% Out-of-pocket max: $3,000/person; $6,000/family Refer to plan of benefits located on ID card Effective: //6 Trillium Health Resources (Formerly East Carolina Behavioral Health) Interactive Medical Systems IMS500 Statewide VHN Virginia Health Office Visit Co-Pay: $30 (PCP); $40 (Spec.) Deductible: $660/person: $,980/family Coinsurance: 0% Out-of-pocket max: $3,800/person; $,400/family Effective: 7//2 Union Corrugating Co. Effective: // Statewide VHN Office Visit Copay: $25 (PCP); $50 (Spec.) Deductible: Base Option: $2,000/person; $4,000/Family Buy-up Option: $,000/person; $2,000/Family Coinsurance: Base Option: 20% Buy-up Option: 0% or 20% Out-of-pocket max: Base Option: $4,000/person; $8,000/family Buy-up Option: $2,000/person; $4,000/family over this outline. VHN Matrix 207

19 9 # Area United Chemi Con Effective: 4//4 65 Statewide VHN Payor ID Office Visit Co pay: $20 (PCP) Deductible: $500/person; $,000/family Coinsurance: 5% Out-of-pocket max: $2,250/person; $4,500/family UVA Employees (Only in specific counties, see service area) Effective: // Aetna Staunton, Waynesboro, Accomack, Augusta Northampton and Page Counties VHN Aetna P. O. Box 9806 El Paso, TX Payer ID High Premium Plan Office Visit Co-Pay: $20 (PCP); $40 (Spec.) Urgent Care: $40 Co-Pay ER Visit: $25 Co-Pay I/P Hospital: $300 per confinement O/P Hospital: $25 per visit Deductible: $00/person: $200/family Coinsurance: 0% Out-of-pocket max: $2,500/person; $5,000/family Low Premium Plan Office Visit Co-Pay: $20 (PCP); $40 (Spec) Urgent Care: $40 Co-Pay Deductible: $350/person: $700/family ER Visit: Deductible; 20% coinsurance I/P Hospital: Deductible; 20% coinsurance O/P Hospital: Deductible; 20% coinsurance Out-of-pocket max: $3,500/person; $7,000/family Value Added Distributors C048 Statewide VHN Refer to benefits listed on ID card Effective: //7 over this outline. VHN Matrix 207

20 20 # Area Vance County (NC) M053 Satewide VHN Refer to ID Card Effective: 8//6 Vidant Health Effective: // Statewide VHN Office Visit: $20 (PCP); $40 (Spec) Deductible:: (Basic Option): $800/person; $,600/family (Premium Option): $600/person; $,200/family Coinsurance: (Basic Option): 30% (Premium Option): 20% Out of pocket max: (Basic Option): $3,850/person; $7,700/family (Premium Option): $3,00/person; $6,200/family VIIAD (Contract Analysis System Varies by Group Statewide VHN Refer to ID Card Refer to ID Card Refer to ID Card Varies by Group Village Realty Medcost 7073 Statewide VHN Office Visit Co-pay: $25 (PCP); $50 (Spec) Deductible: $,500/person; $3,000/family Out-of-pocket max: $3,000/person; $6,000/family Effective: 3//6 Virginia Air Distributors C049 Statewide VHN Refer to benefits listed on ID card Effective: //7 over this outline. VHN Matrix 207

21 2 # Area Wake Emergency Physicians, PA Statewide VHN Office Visit Copay: $20 (PCP); $40 (Spec) Deductible: $500/person; $,000/Family Coinsurance: 0% Out-of-pocket: $2,000/person; $4,000/Family Effective: 0//4 Wake Forest Baptist Medical Center 3372 Statewide VHN Refer to benefits listed on ID card Effective: //7 Westminster Canterbury on Chesapeake Bay Effective: 0//2 Whitescarver Engineering Co Statewide VHN C023 Statewide VHN Virginia Health Base Plan: Office Visit Co-Pay: $5 (PCP); $35 (Spec) Coinsurance: Varies Out-of-pocket max: $2,000 person/ $4,000 family Optional Plan: Office Visit Co-Pay: $25 (PCP); $50 (Spec) Coinsurance:30% Out-of-pocket max: $2,500 person/ $5,000 family Extended : Office Visit Co-Pay: $5 (PCP); $35 (Spec) Coinsurance: 30% Out-of-pocket max: $2,000 person/ $4,000 family Refer to ID Car Effective: 0//5 over this outline. VHN Matrix 207

22 VIRGINIA HEALTH NETWORK, INC. Preferred Provider Arrangements for Workers' Compensation PPO October, 207 Focus Healthcare Management,, VIIAD (Contract Analysis Systems), Novanet, Corvel, Procura (Effective 3//5) and Prime Health Services are broker model organizations which have contracted with VHN and the following payor groups so that such payors can utilize the VHN Workers' Compensation. The Workers' Compensation PPO (WC-PPO) is an optional network to the providers currently participating with Virginia Health and applies only to those providers who have chosen to participate. The list of payors is based on information VHN has received from the contracting networks and may not include all payors. Payor Name Acordia Adam s Mark Hotel Advanced Auto AG Employer Advantage Alaska National Alpha AM FED AMF Bowling Center American Interstate Insurance Company Amerisys Aramark Atlantic Mutual Best Buy Bunch & Associates Bunch & Associates Cambridge Integrated Services Chase Staffing CNA Insurance Comp IQ Corporation Comp IQ DMI Comp IQ / Intermed / CIGA Comp IQ / Starr Comprehensive Solutions Companion Property & Casualty Continuum / Amtrak - EDI Corvel Costco Crawford & Company Crawford & Company Cumis Insurance Company Rockport HealthCare Group Corvel

23 Payor Name Dollar General Eagle Claims Management ESIS / Ace Everest National / WRO / Everest F. A. Richard F. A. Richard / Mandeville Bridge Fair Isaac and Company Fair Isaac Corporation Federated Insurance FHM Insurance Company Forte Managed Care Friendly Ice Cream GAB Business Services Gallagher Bassett Services, Inc Golden Corral Guard Insurance Heartland Express Highlands Insurance Home Properties Hoover / Penn National Ingenix ASP / Alpha Corporation Ingenix ASP / MES Solutions Ingenix / ICM Ingenix Rising Medical Solutions Integrity Insurance Intracorp. Jasons Deli Kimberly Clark LWP Claims Solutions Lowes Marriott Hotels MCMC MCMC - Atlanta MCMC - Continuum Medata, Medata / Medical Bill Plus Medata Medicore Managed Term Record Rockport HealthCare Group Rockport HealthCare Group

24 Payor Name Medata Transportation Claims, MedRisk Merchants Mutual Insurance Company Mitchell Medical Morgan Tire & Aito Motorists Mutual Insurance Company Municipal Risk Management Murphy & Beane North American Risk Papa Johns Peninsula Insurance Company Penn Line Service, Premier Comp. Solutions Prime Health Services Procura Program Risk Management Claims Services Providence Property & Casualty Public Service Mutual Med Med Reny Company Ringling Brothers Barnum & Bailey Company Rising Medical Solutions, Safeco Salvation Army Seabright Insurance Company Sedgwick CMS Selective Insurance Company of America Shorman Solutions Signal Administrators Sisco Startech Startech / Medivest Benefit Advisors StrataCare / Casenet Managed Care StrataCare / CBI StrataCare / Colen & Lee StrataCare, & Care Solutions Rockport HealthCare Group Prime Health Services Procura Rockport HealthCare Group

25 Payor Name StrataCare Insurance Company of the West StrataCare / PacBlu StrataCare Wal-Mart StrataCare / Wal-Mart SUA Sunz Insurance Target - Sedgwick The Branch Group The Gap Tyson Foods United Fire & Casualty USIS VanLiners Insurance Company VIIAD (Contract Analysis Systems) Victoria Insurance Group Zurich Services Corporation Viiad (Contract Analysis Systems) 7 - Eleven 84 Lumber

26 VIRGINIA HEALTH NETWORK, INC. Preferred Provider Arrangements VHN LINK PPO October, 207 EXPLANATION OF VHN LINK (EXHIBIT J) PROVISIONS This Exhibit links you to payors such as secondary network or wrap payors. This network is known as VHN LINK. In return for discounting your billed charges, VHN LINK provides you with the opportunity for more volume and reasonably prompt payment. Participation in this additional network is optional. The secondary or wrap payor aspect of the VHN LINK network is designed to expand member access to providers who have agreed to accept a percentage of charges for services rendered outside the payor s primary network program. Most commercial healthcare and third party payors offering PPO or other plans experience significant charge volume outside their primary networks. Providers who fall outside the payor s directed network are often faced with unpredictable reimbursement methodologies such as payment only to U&C levels, reimbursement directly to member, retrospective claim review and negotiation and less timely payments as well as the potential for high dollar account receivables for which a patient may ultimately be responsible. When a secondary or wrap network offering such as VHN LINK is in place, claims processed as out-of-network use the discounts agreed upon by the secondary network and its participating providers. Consequently, claims are paid more rapidly and providers have assured reimbursement, avoiding the time, cost and uncertainty of fee negotiations or U&C adjustments. Payment will be made within thirty (30) days of the payor's receipt of a clean claim and VHN LINK or the payor/network accessing VHN will be identified on the EOB. The following payors are utilizing the VHN LINK network for their secondary and wrap business. Payor/ Name Service Area VHN on ID Cards Customer Service Numbers Beech Street/Viant Richmond Hampton Roads Charlottesville / Augusta Fredericksburg No Fax Number: Complete Claims Solutions, INC. Statewide Not on card, but VHN LINK is referenced on EOBs Refer to ID Card FedMed Statewide No Refer to ID Card HRGi (HealthRisk Resource Group, LLC) Statewide Not on card, but VHN LINK is referenced on EOBs Refer to ID Card MultiPlan (MPI) MPI Direct Contract Supercedes the VHN LINK Contract agreement Richmond Hampton Roads Charlottesville/Augusta Fredericksburg No Please visit the VHN document library for access to the MultiPlan Professional Handbook or visit: Prime Health Statewide Not on card, but VHN LINK is referenced on EOBs

27 27 VIRGINIA HEALTH NETWORK, INC. Preferred Provider Arrangements Automobile Medical PPO October, 207 The Automobile Medical PPO (Auto Med) Exhibit modifies the Virginia Health, Inc. Participating Provider, Hospital or Physician Agreement. The Auto Med PPO is optional and applies only to those providers who have chosen to participate. Automobile Medical Program is defined to include First Party Automobile Medical Liability and First Party General Liability. First Parties are those persons in a direct contractual relationship with their own insurance company, i.e. the insured. Access to the Automobile Medical Program will be clearly identified on the Explanation of Benefits (EOB) accompanying the payment to Participating Provider of the Code of Virginia (Liability Insurance Policies Chapter) provides a mechanism by which health care providers may seek a valid assignment of medical expense benefits (AOB) provided under a motor vehicle insurance policy in cases where the injury being treated arises out of the ownership, operation, or use of a motor vehicle. It is the responsibility of the Participating Provider to obtain a valid AOB pursuant to this law. The following payors are utilizing the VHN Automedical Program (Auto Med): Payor/ Name Service Area VHN on ID Cards Customer Service Numbers CorVel Effective: 8/4/5 Statewide Not on card, but VHN should be referenced on EOB s For a complete Client list, please contact Sheron Campbell: scampbell@vhn.com Prime Health Effective: 9//4 Statewide Not on card, but VHN should be referenced on EOB s For a complete Client list, please visit Prime Health Services website at or contact Sheron Campbell: scampbell@vhn.com Procura Effective: 3//5 Statewide Not on card, but VHN should be referenced on EOB s For a complete Client list, please visit Procura s website at or contact Sheron Campbell: scampbell@vhn.com