1 GATEWAY AT A GLANCE for Medicare Assured SM Providers Gateway Health Medicare Assured SM 444 Liberty Avenue, Suite 2100 Pittsburgh, PA YOUR PROVIDER NUMBERS: Group Provider Number : Individual Provider Numbers (used for billing) : Practitioner : Provider Number : Practitioner : Provider Number : Practitioner : Provider Number : 3/2015
2 Gateway Health Medicare Assured SM offers options designed to provide More Than Healthcare for those who qualify. Medicare Assured SM offers medical and prescription drug coverage, and all the benefits of Original Medicare, PLUS more benefits. Healthcare Options Dual Eligible Special Needs Plans (D-SNP) Medicare Assured Diamond SM (HMO SNP) and Medicare Assured Ruby SM (HMO SNP): For people who have BOTH Medicare (Part A and B) and Medical Assistance or assistance from the State. Those eligible can enroll in a new plan any time throughout the year. Chronic Condition Special Needs Plans (C-SNP) Medicare Assured Gold SM (HMO SNP) and Medicare Assured Platinum SM (HMO SNP): For people who have BOTH Medicare (Part A and B) and at least one of the following chronic conditions: diabetes, cardiovascular disorder or chronic heart failure. There are no income requirements for the chronic condition Special Needs Plans. As a SNP, Gateway is required by the Centers for Medicare and Medicaid Services (CMS) to administer a Model of Care Plan. The SNP Model of Care Plan is the architecture for care management policy, procedures and operational systems. Refer to the Model of Care section in the Gateway Health Medicare Assured SM Provider Policy and Procedure Manual for our SNP Model of Care Elements. MAPD Plans (HMO) - Additional Healthcare Options offered outside Pennsylvania are Medicare Assured Choice SM, Medicare Assured Prime SM and Medicare Assured Select SM (HMO): The only requirement is to be entitled to Medicare Part A, enrolled in Medicare Part B and live in the non-pennsylvania Gateway service area. There are NO Medicaid or Chronic Condition requirements for these plans. Frequently Asked Questions Do Gateway Health Medicare Assured SM members have any out of pocket expense? A member s out of pocket expense or cost sharing will vary depending upon the level of assistance they may be receiving from the State, Medicare, as well as which Medicare Assured SM plan they have chosen to join. For more benefit information a copy of the Summary of Benefits for all Medicare Assured SM plans is included with the 2015 Gateway Health Medicare Assured SM Provider Policy & Procedure Manual available at For your convenience co-pays* for frequently used services are provided below: Dual Eligible Special Needs Plans (D-SNP) Chronic Condition Special Needs Plans (C-SNP) Gateway Health Medicare Diamond SM (HMO SNP): PCP-$0, SCP-$0, ER-$0** Gateway Health Medicare Gold SM (HMO SNP): PCP-$20, SCP-$40, ER-$65** Gateway Health Medicare Ruby SM (HMO SNP): PCP-$0 or $15, SCP-$0 or $30, ER-$65** Gateway Health Medicare Platinum SM (HMO SNP): PCP-$15, SCP-$30, ER-$65** *This list does not represent every service covered or every applicable co-pay. **Not covered outside the U.S. except under limited circumstances. Do Gateway Health Medicare Assured SM members have to use plan providers? Members of Gateway Health Medicare Assured SM, with a few exceptions, must use plan providers to get covered services. At the time of enrollment, members must choose a Primary Care Physician (PCP) to provide basic medical care and coordinate the covered services received outside of the PCP s office. Are referrals required for services outside of the PCP s office? Services outside of the PCP s office should be arranged or coordinated by the member s PCP. PCPs are not required to use a specific Referral Form for submission to the specialist or Gateway. Certain types of covered services or supplies require prior-authorization. Prior-authorization is required for any services to a non-plan specialist. Refer to the Authorization Quick Reference Guide that is included for more information on which services require an authorization. Claims Submission Guidelines: Timely filing criteria for initial bills is 365 days from the date of service. Corrected claims or requests for review are considered if information is received within the 180-day follow-up period from the date of the initial remittance advice. Practitioners must bill within 180 days from date of an Explanation of Benefits (EOB) from the primary carrier when Gateway is secondary. Electronic claims must include NPI number. Correct/current practitioner information identified as the Gateway Provider ID Number (Legacy Number) must be entered on all paper claims. Gateway Provider ID numbers are 5 or 7 digits. EDI claims submitted without an NPI will be rejected. Correct/Current member information, including Gateway Member ID Number, must be entered on all claims. Gateway cannot accept verbal requests to retract claim(s) overpayments. Providers must complete and submit a Refund Form (available in the Forms and Reference Material section under Providers on our website) or a letter that contains all of the information requested on this form. This form, together with all supporting materials relevant to the claim(s) reversal request being made, including but not limited to EOB from other insurance carriers and your refund check should be mailed to: PNC BANK, c/o GATEWAY HEALTH PAYMENTS/REFUNDS, Lock Box #645171, 500 1st Avenue, Pittsburgh, PA CPID PAYER NAME PAYER ID CLAIM TYPE 2298 Gateway Health Medicare Assured SM (PA) Professional 2912 Gateway Health Medicare Assured SM (KY, NC, OH) Institutional All of a patient s applicable diagnosis codes that support their Hierarchical Condition Category (HCC) must be reported at least once per year to CMS. CMS guidelines state that Physicians should code all documented conditions that co-exist at the time of the encounter/visit, and require or affect patient care treatment or management.
3 Gateway Health Medicare Assured SM Important Phone Numbers Call to Inquire About: Provider Services Claims Inquiry KY: M-F 8:00am to 4:30pm NC: OH: PA: Utilization Management Authorization KY: M-F 8:30am-4:30pm Medical & Behavioral Health NC: Calls received during non-business hours are OH: referred to PA: DIVA Member Eigibility Line Member Eligibility hours a day, 7 days a week Pharmacy Requests for Non-Formulary KY: M-F 8:30am-4:30pm Drugs and Prior Authorizations NC: OH: PA: FA: Our searchable drug formulary and prior authorization forms are available at Part D Prescriber Appeals Expedited Voice mail box monitored 24 hours a redetermination day, 7 days a week for requests and status of redetermination requests. Care Management/ Care Management KY: M-F 8:30am-4:30pm Complex Case Management NC: OH: PA: (option 1) Gateway to Lifestyle Management SM KY: M-F 8:30am-4:30pm Cardiac Program NC: COPD Program OH: Diabetes Program PA: Mom Matters Fax OBNAF to MedicareAssured.com Preventive Health Preventive Health KY: M-F 8:30am-4:30pm Services/Member NC: Outreach OH: PA: (option 1) FA: Member Services Member Complaints/ KY: M-F 8:00am - 8:00pm Concerns/Inquiries NC: OH: PA: Fraud and Abuse Concerns/Inquiries (412) or 24 hours a day, 7 days a week and Compliance Helpful Telephone Numbers: AT&T Language Line Services Provides qualified medical interpretation services Gateway Health SM Assistance with hearing impaired 711 or TTY/TDD KY: NC: OH: PA: Mailing Address for Medical and Behavioral Health Claim Forms: PA: Gateway Health Medicare Assured SM P.O. Box Birmingham, AL KY, NC & OH: Gateway Health Medicare Assured SM P.O. Box Birmingham, AL Visit us online at All Other Correspondence: Gateway Health SM 444 Liberty Avenue, Suite 2100 Pittsburgh, PA Correspondence Type Claims Reviews Provider Appeals Practice Change Information Attention: Claims Review Dept. Appeals Department Provider Relations Gateway Health SM offices will be closed to observe the following holidays: New Years Day, Martin Luther King Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day (and day immediately following), Christmas Eve Day, and Christmas Day. Operations will resume the following business day.
4 Gateway Health Medicare Assured SM AU T H O R I Z AT I O N Q U I C K R E F E R E N C E G U I D E Gateway AUTH SCRIPT AMBULANCE (Non emergent only) AMBULATORY SURGICAL SERVICES No auth required for outpatient surgeries (except those listed under SPU &/or SURGICAL Services) No auth required for lab services provided in an ASC lab BONE DENSITOMETRY (Bone Mass Measurement) CT SCANS CHIROPRACTIC SERVICES DIALYSIS DME (Medical Supplies, Prosthetics, and Orthotics) Items paid at $500 and over $500 ELECTIVE ADMISSIONS (Medical and Behavioral Health) GENETIC TESTING HOME HEALTH VISITS HOME INFUSION (*Gateway Pharmacy Authorization May Be Required) INPATIENT ACUTE CARE (Including transplants and medical detox) INPATIENT PSYCHIATRIC OR MENTAL HEALTH CARE INPATIENT MEDICAL REHAB INPATIENT REHAB SUBSTANCE ABUSE CARE LONG TERM ACUTE CARE (LTAC) HOSPITAL MRI/MRA NON-PAR PROVIDERS NUCLEAR CARDIOLOGY OUTPATIENT PSYCHIATRIC PARTIAL HOSPITALIZATION OUTPATIENT ECT TREATMENT OUTPATIENT THERAPY (Physical, Speech & Language, Occupational, Cardiac) PET SCANS SKILLED NURSING FACILITY (SNF) CARE SPU &/or SURGICAL SERVICES (except those listed below) Bariatric Surgery/Stapling, Blepharoplasty, Breast Reduction, Carpal Tunnel, Surgery, Genital Reconstruction, Hysterectomy, Panniculectomy, Removal of Breast Implant, Rhinoplasty, TMJ Surgery, Transplants/Implants, Varicose Vein Authorizations are the responsibility of the ordering provider. Cosmetic or investigational/experimental procedures are not covered. Please contact Provider Services at (KY), (NC), (OH) or (PA). for further explanation of what services require an authorization.
5 Member Eligibility Newly enrolled members receive an Evidence of Coverage (EOC) and Gateway Health Medicare Assured SM Identification Card. The card itself does NOT guarantee that a person is currently enrolled in one of the Gateway Health Medicare Assured SM plans. Because of possible changes in a member s eligibility, each participating provider is responsible for verifying a member s eligibility with Gateway before providing services. This can be done by reviewing monthly panel reports, on-line verification through NaviNet or calling Gateway s telephonic eligibility system (DIVA), please dial and follow the prompts (also listed below). To Verify Eligibility using DIVA Call PRESS 1 to verify eligibility Member Identification Number? Using your telephone keypad, enter the member s 8-digit Gateway ID followed by #. If you make a mistake, press * to start over. To return to the main menu, press #. To verify coverage or PCP assignment for today s date of service, press 1. To enter a different date, press 2. Please enter the 8-digit date of service using the following format: If you make a mistake, press * to start over. If you need help, just press #. Additional Instructions: For more information, press 1. To have this verification faxed to you, press 2. To check a different date, press 3. To check a different member, press 4. If you would like to return to the main menu, press #. If this completes your call, you may hang up now.
6 444 Liberty Avenue, Suite 2100 Pittsburgh, PA PR-003_2015_MC
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