ProHealth Provider Update

Transcription

1 ProHealth Provider Update May 2010 Correction *This is a correction to the May, 2010 newsletter* Please note that the May, 2010 ProHealth Update included updated Behavioral Care fees. Only the ProHealth HMO fees were included. We failed to include the ProHealth PPO fees. Please find both attached! We are sorry for any inconvenience this may have caused our providers. Published by ProHealth Provider Relations, (317) Judy Bourquin, Director [email protected] Provider Relations Coordinators: Kim Tibbets, [email protected] Carol Tucker, [email protected] April Woodruff, [email protected] Manager of Medicaid Services Salena Woodson, [email protected] Credentialing and Contracting: Beverly Casper, [email protected] Credentialing and Contracting Mid-Levels: Jenny Bouck, [email protected] Recredentialing: Sue Bolner, [email protected] Behavioral Care Services Credentialing: Sherry Mueller, [email protected] Data Analyst: Hollie Putzback, [email protected] ProHealth Provider U 1

2 The following Behavioral Health fees have been updated for both the ProHealth HMO and PPO Fee Schedules, effective July 1, 2010 ProHealth HMO Fees CPT Codes HMO MD Fee HMO PHD Fee (Modifier AH) HMO SW Fee (Modifier AJ) HMO NP/CNS N/A N/A N/A N/A N/A - N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ProHealth Provider U 2

3 CPT Codes HMO MD Fee HMO PHD Fee (Modifier AH) HMO SW Fee (Modifier AJ) HMO NP/CNS N/A N/A N/A N/A N/A % 80% 80% 80% N/A N/A N/A ProHealth Provider U 3

4 ProHealth PPO Fees CPT Codes PPO MD Fee PPO PHD Fee (Modifier AH) PPO SW Fee (Modifier AJ) PPO NP/CNS N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ProHealth Provider U 4

5 CPT Codes PPO PHD Fee (Modifier PPO SW Fee AH) (Modifier AJ) PPO MD Fee PPO NP/CNS N/A N/A N/A N/A N/A N/A N/A % 80% 80% 80% N/A N/A N/A ProHealth Provider U 5

6 ProHealth Provider Update May 2010 CONTRACTING AND CREDENTIALING CORNER Providers Joining ProHealth We would like to welcome the following providers to the ProHealth Network effective June 1, Hospital affiliations will be listed with each provider. Hasan, Syed, M.D., Psychiatry & Neurology, SpecPrime, Gallahue Psych Associate/Serenity Medical Associates, CHE, CHN Pushpala, Shekar, M.D., Family Medicine, Prime SCP, MedCheck, CHE, CHN, CHS Stevens, Caroline, D.O., Psychiatry & Neurology, Prime SCP, Central Indiana Neurology, CHA Bohn, Karen, NP, Women s Health, Prime SCP MidLevel, Integrative Health Solutions Horan-Toll, Sandra, NP, Adult Health, Prime PCP MidLevel, Community Primary Care, CHE, CHN Mickler, Barbara, NP, Adult Health, Prime SCP MidLevel, Life s Journey Choices in Care Wettrick, Alicia, NP, Women s Health, Prime OBG MidLevel, Castleton OB/GYN, CHE, CHN Credentialing con t. Hines, Gregory, LCSW, Behavioral Health, SpecPrime, Gallahue Hojnacki, Jason, LCSW, Behavioral Health, SpecPrime, Gallahue Pennington, Bobbie Jo, LCSW, Behavioral Health, SpecPrime, Community Psych Associates Heimann, Julie, PA, Physician Assistant, Prime SCP MidLevel, Premier Surgical, CHS The following Nurse Anesthetists are Prime SCP MidLevels with Community Group CRNA s Baker, Raymond, CRNA Freeland, John, CRNA Henry, Angela, CRNA Melvin, Julie, CRNA White, Michael, CRNA TABLE OF CONTENTS 1 New Providers 3 ProHealth Fee Schedule Changes ProHealth Provider U 1

7 Sagamore Plus Fee Schedules Employed Providers It has come to the attention of ProHealth that Sagamore has not been loading some of our employed/llc providers to the correct fee schedule due to a contract issue. Moving forward, Sagamore will be loading our employed/llc s accordingly, so you may see your reimbursement for E & M codes change in the next month. If you need further clarification please contact ProHealth Provider Relations at If you were contracted with Sagamore Select in addition to Sagamore Plus, the move to the employed fee schedule will terminate participation in the Sagamore Select network, effective 6/1/2010. The Following Providers Will No Longer Be Participating with ProHealth Shobashalini Chokkalingam, M.D. effective 7/1/2010 Norissa Howard, M.D. eff 7/27/2010 Mary Scamardo, M.D. eff 7/1/2010 Olive Soriero, M.D. eff 6/7/2010 The following are MedCheck Providers Mark Freije, M.D.- eff 7/1/2010 James Gaither, M.D. eff 7/31/2010 Eric Jones, M.D. eff 7/1/2010 James Jordan, M.D. eff 7/31/2010 PROHEALTH DISCUSSION GROUPS Discussion Group East, Thursday, July 8, 2010, Community Hospital East, Medical Staff Conference Room Discussion Group North, Wednesday, July 7, 2010, at ProHealth, 8180 Clearvista Parkway, Ste. 230, Conf. Room 1,2,3 Anderson Discussion Group, Thursday, July 15, 2010, Community Hospital Anderson Education Center Discussion Group South, Wednesday, July 14, 2010, at Indiana Internal Medicine Consultants Conference Room, 701 E. County Line Rd., Ste All groups meet from 11:30 a.m. to 1:00 p.m. You may FAX your topics for discussion to Provider Relations at (317) If you will be attending one of these Discussion Groups, please RSVP by calling (317) Bring your lunch and join us! Published by ProHealth Provider Relations, (317) Judy Bourquin, Director [email protected] Provider Relations Coordinators: Kim Tibbets, [email protected] Carol Tucker, [email protected] April Woodruff, [email protected] Manager of Medicaid Services Salena Woodson, [email protected] Credentialing and Contracting: Beverly Casper, [email protected] Credentialing and Contracting Mid-Levels: Jenny Bouck, [email protected] Recredentialing: Sue Bolner, [email protected] Behavioral Care Services Credentialing: Sherry Mueller, [email protected] Data Analyst: Hollie Putzback, [email protected] ProHealth Provider U 2

8 Credentialing of Providers Completing Their Residency Program It is that time of year when physicians are finishing up their residency programs. Please keep in mind that ProHealth must obtain verification of Completion of Residency prior to presenting a physician to the credentialing committee. If a physician completes his residency on June 30 th, the chances are very slim that verification of residency will be obtained by the next credentialing committee slated for July 2 nd. Therefore, this physician cannot be presented to the credentialing committee until the first week in August, provided the verification has been obtained. The ProHealth effective date with the payers will then be September 1. This is very important to remember when setting start dates for new physicians in your practice. Have You Checked Your NPI Lately? Just a reminder to update your NPI Registry and verify that your provider is included on the PECOS file? You may do First Health Contract and Coventry Background: A few years ago, COVENTRY bought First Health. At that time, and currently, ProHealth held a contract with First Health for our ProHealth providers to participate in its group health networks for First Health payer clients only and MailHandlers. At one time, ProHealth providers were also contracted with First Health Workers Compensation networks, but that contract for our providers terminated a couple of years ago. COVENTRY also has payer clients for group health and work comp with whom ProHealth did not hold a contract. The New Contract: Effective with dates of service on or after June 1, 2010, those providers who are currently participating in First Health/MailHandlers will continue as participating providers in First Health for its payer clients and MailHandlers, and will also be participating providers for payer clients of COVENTRY. The new contract also includes the workers compensation network for COVENTRY which includes First Health and FOCUS/Aetna Workers Comp networks. These networks are rolled into one network called FOCUS/First Health. This will also be effective June 1, Providers who are currently participating in ProHealth s Workers Compensation Network for USA/MCO and CorVel will automatically be enrolled in the FOCUS/First Health Workers Compensation network. Reimbursement Fee Schedule Changes CPT code J7302 (Mirena IUD) has been increased as follows: HMO fee schedule, $ effective 6/1/2010 PPO fee schedule, $ effective 7/15/2010 Attached you will also find new fees for Behavioral Health codes. Group Health: COVENTRY, First Health and MailHandlers will reimburse on the ProHealth PPO fee schedule, which is how providers are currently reimbursed for First Health/ MailHandlers. Workers Compensation: Reimbursement will be based on the ProHealth Workers Compensation fee schedule with one exception. For providers who have a direct contract with FOCUS/Aetna and the patient is an employee of a FOCUS/Aetna client, reimbursement will be based on that providers FOCUS/Aetna contract. ProHealth Provider U 3

9 The following Behavioral Health fees have been updated for both the ProHealth HMO and PPO Fee Schedules, effective July 1, 2010 CPT Codes HMO MD Fee HMO PHD Fee (Modifier AH) HMO SW Fee (Modifier AJ) HMO NP/CNS N/A N/A N/A N/A N/A - N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ProHealth Provider U 4

10 N/A N/A N/A N/A N/A % 80% 80% 80% N/A N/A N/A ProHealth Provider U 5