GLANCE GATEWAY AT A. for Medicaid Providers. GATEWAY HEALTH SM 444 Liberty Avenue, Suite 2100 Pittsburgh, PA

Transcription

1 GATEWAY AT A GLANCE for Medicaid Providers GATEWAY HEALTH SM 444 Liberty Avenue, Suite 2100 Pittsburgh, PA YOUR PROVIDER NUMBERS: Group Provider Number (used for referrals) : Individual Provider Numbers (used for billing) : Practitioner : Provider Number : Practitioner : Provider Number : Practitioner : Provider Number : 3/2015

2 TO VERIFY OR REVIEW A REFERRAL To verify or review a referral? PRESS 3 If you are a PCP, PRESS 1. If you are a specialist, PRESS 2. Using your telephone keypad, please enter your 7-digit provider ID. Please enter the member s 8 digit ID number excluding the *01, located on their card. Using your telephone keypad, please enter the 10 digit fax number, including the area code. If you make a mistake, PRESS * to start over. To use the fax number ending in <last4faxnum>, PRESS 1. To enter a different number, PRESS 2. To cancel this fax and return to the previous menu, PRESS 3. Claims Submission Guidelines Timely filing criteria for initial bills is 180-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 60 days from the date of an Explanation of Benefits (EOB) from the primary carrier when Gateway is secondary. Correct/Current practitioner information, including NPI Number on electronic claims. Correct/Current member information, including Gateway Member ID Number, must be entered on all claims. Gateway accepts electronic claims through Emdeon and RelayHealth. To submit claims to Gateway, please refer to the following grid for Emdeon Payer IDs and RelayHealth CPIDs: CPID PAYER NAME PAYER ID CLAIM TYPE 8472 Gateway Health SM - Medicaid Professional 4569 Gateway Health SM - Medicaid Institutional Member Eligibility Newly enrolled members receive a Member Handbook and Gateway Identification Card. The card itself does NOT guarantee that a person is currently enrolled in Gateway. 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 Eligibility line (DIVA) at This is important because members have the ability to change plans every 30 days. Self-Referred Services Members may refer themselves for the following types of care: routine dental emergency services routine eye examination family planning mental health/substance abuse OB/GYN services chiropractic services mammograms

3 Gateway Health SM Important Phone Numbers Call to Inquire About: Provider Services Claims Inquiry M-F 8:30am to 4:30pm Medical Management Authorization M-F 8:30am-4:30pm (Calls received during non-business hours are referred to ) Member Eligibility and Member Eligibility/Generate hours a day, 7 days a week DIVA Phone Line and Retrieve Referrals National Imaging Authorization for MRI/MRA, PA Medicaid M-F 8:00 AM to 8:00 PM Associates (NIA) CT/CTA, CCTA, PET Scan, Nuclear Cardiology/MPI, Muga Scan, and Stress Echocardiography Pharmacy Request Non-Formulary Drug M-F 8:30am-4:30pm and Prior Authorization FA: or Special Needs Care Management Care Management ; Option 1 M-F 8:30am-4:30pm Gateway to Lifestyle Management SM ; Option 3 M-F 8:30am-4:30pm Asthma Program Cardiac Program COPD Program Diabetes Program Mom Matters ; Option 2 M-F 8:30am-4:30pm FA: OBNAF to Preventive Health Preventive Health ; Option 4 M-F 8:30am-4:30pm Services/EPSDT/Member Fax: Outreach Member Services Member Complaints/Inquiries M-F 8:00am 6:00pm Helpful Telephone Numbers: Adagio Health, Inc. Authorizations for Family Planning Services (formerly Family Health Council) AT&T Language Line Services Provides qualified medical interpretation services Community Care Mental Health and Substance Abuse Services for members who Behavioral Health reside in Allegheny, Adams, Berks, Cameron, Clarion, Clearfield, Elk, Erie, Forest, Huntington, Jefferson, Potter, Warren, and York Magellan Behavioral Health Mental Health and Substance Abuse Services for members who Care of Pennsylvania reside in Lehigh and Northampton counties. Pennsylvania Third-party administrator of enrollment process for MA recipients Enrollment Services Perform Care Mental Health and Substance Abuse Services for members who reside in Bedford, Cumberland, Dauphin, Franklin, Fulton, Lancaster, Lebanon, Perry, and Somerset Counties TTY/TDD Assistance with hearing impaired 711 or ( ) Value Behavioral Health Mental Health and Substance Abuse Services for members who reside in Armstrong, Beaver, Butler, Cambria, Crawford, Fayette, Greene, Indiana, Lawrence, Mercer, Venango, Washington, and Westmoreland Counties Claims and Referral Forms Mailing: Gateway Health SM PO Box Birmingham, AL 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 Visit us online at 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 SM Quick Reference Guide AU T H O R I Z AT I O N S V S. R E F E R R A L S This listing of procedures should not be considered all inclusive. ALLERGY VISITS ANGIOGRAMS BONE DENSITOMETRY BONE SCAN CT/CTA and CCTA CHEMOTHERAPY (Hospital and Physician Office) CHIROPRACTIC SERVICES DIALYSIS DME (see categories below) Covered items under $500 (purchase or rental) & Items on MA fee schedule Items paid at $500 and over $500 Items not on Medical Assistance fee schedule ELECTIVE ADMISSIONS FETAL NON-STRESS TESTS HEARING AIDS, EAR MOLDS, DISPENSING FEES as well as HEARING AID REPAIR SERVICES (members under 21) HEART CATHETERIZATIONS (Performed in Lab) HOME HEALTH VISITS/HOSPICE INPATIENT REHAB IV THERAPY (see categories below) GATEWAY NIA REFERRAL AUTH AUTH SCRIPT In-Home (Drugs may require authorization by Gateway's Pharmacy Department - - refer to drug formulary) See notes to left OP Hospital Dr's office (Must be authorized by Gateway s Pharmacy Department) - See notes to left Remicade (Must be authorized by Gateway's Pharmacy Department when - dispensed in a Dr's office) See notes to left LABORATORY TESTING (see categories below) Member's Designated Laboratory Non-Designated Laboratory MAMMOGRAMS (all types) MRI/MRA NERVE CONDUCTION TESTING NON-PAR PROVIDERS NUCLEAR CARDIOLOGY/MPI PAIN MANAGEMENT (see categories below) Performed in Physician office or as an Outpatient Consult to Pain Clinic PET SCANS RADIATION (see categories below) Radiation Therapy Radiology Services-Standard Plain Film Radiology Services-Invasive Radiology & Nuclear Medicine RESPIRATORY THERAPY SERVICES - Including Atrial Blood Gases, Pulmonary Function Test, and Pulse Oximetry SKILLED NURSING FACILITY SLEEP STUDY 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, Rhinoploasty, Spinal Neuro Stimulator Services, TMJ Surgery, Transplant/Implant, Tubal Ligations, Varicose Vein Any Service provided in a Lab or OP Facility* STRESS ECHOCARDIOGRAGHY THERAPY SERVICES (Occupational, Physicial and Speech) ULTRASOUND (All types) Authorizations are the responsibility of the ordering provider. Reimbursement for services requires that they are billed with valid covered codes included on Gateway's fee schedules. Please contact Provider Services at for further explanation of what services require a referral or authorization. Family planning services such as post-partum tubal ligations require prior authorization by Adagio Health, Inc.

5 DIVA Telephone Eligibility & Referral System TO VERIFY ELIGIBILITY 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 #. TO ENTER A REFERRAL TO A SPECIALIST OR HOSPITAL (PCPS & OB/GYNS ONLY) Enter a Referral? PRESS 2 Using your telephone keypad, please enter your 7-digit provider ID. If you make a mistake, PRESS * to start over. Please enter the member s 8-digit ID excluding the *01, located on their card. Please enter the 7-digit provider ID for the specialist or hospital. When you are finished, PRESS *. To create a general referral for 3 visits within the next 90 days, PRESS 1. To create a referral for 9 visits w/in the next 90 days for allergy or pain management services, PRESS 2. Please enter the beginning date for this referral. (Referrals can be back-dated up to 30 calendar days, and can be no more than 90 calendar days into the future.) Please enter the 8-digit date of service using the following format: To save this referral PRESS 1. ~If successful entry you will receive the following message: This referral has been saved. The referral ID number is <>. To discard it and start over with a new referral, PRESS 2. 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. Additional Instructions: To hear this authorization again, PRESS 1. To enter a new referral for the same PCP PRESS 2. To enter a new referral for a different PCP PRESS 3. To fax this referral PRESS 4. To return to the main menu PRESS #. If you need to speak with someone, PRESS 0.

6 444 Liberty Avenue, Suite 2100 Pittsburgh, PA PR