Directory of Services

Transcription

1 Business Communications... 2 Case Management... 2 Claims and Correspondence es... 2 Contract Management... 4 Credentialing... 4 Department of Managed Health Care... 5 EDI... 6 Grievance and Appeals Management... 6 Health Care Informatics... 6 Health Improvement Programs... 7 Medical Policy and Technology... 7 Network Education, Training and Development... 7 Network Relations and Service... 7 Pharmacy Management... 8 Preventive Health Services... 8 Provider Care... 9 Provider Database Operations... 9 Quality Improvement...10 Quality Operations (PMG Delegation Oversight, Including Credentialing and Utilization Management)...10 Senior Secure...10 Utilization Management...11 Web site Address...11 Blue Cross HMO and Senior Secure Operations Manual March 2006 Directory of Services: Page 1

2 Business Communications Business Communications writes and distributes the Blue Cross HMO and Senior Secure Operations Manual. Direct any manual layout questions or comments to: Fax Business Communications P.O. Box 4358 Woodland Hills, CA (818) Case Management Area Out-of-Area Admissions (888) Attn: Case Management Fax P.O. Box 4307 (800) Woodland Hills, CA Area (Senior Secure) Senior Secure Case (888) / Management Blue Cross Senior Secure Anne Richter, Director (818) P.O. Box 4307 Woodland Hills, CA Linda Wade-Bickel, (818) Supervisor Claims and Correspondence es Type of Plan Service Unit Number Blue Cross HMO (CaliforniaCare) Customer Service (800) Blue Cross HMO Preferred (HMO POS) Blue Cross POS (Blue Cross PLUS) Blue Cross PPO (Prudent Buyer Plan) Large Group Members Customer Service (800) Customer Service (800) Customer Service Use the Customer Service telephone number on the member s identification card. Blue Cross Individual Customer Service (800) Blue Cross Small Group Customer Service (800) Blue Cross Federal Employees Program (FEP) Customer Service (800) Blue Cross HMO and Senior Secure Operations Manual March 2006 Directory of Services: Page 2

3 Type of Plan Service Unit Number BlueCard (Out-of-Area (800) 676-BLUE or Eligibility Line Blue Cross and Blue Shield (800) members) Claim Status (800) EDI Claims Submission Customer Service (800) Healthy Families and Medi-Cal Senior Secure Plans Workers Comp Managed Care Services (WCMCS) Health Care Professional/ Member Services Anita Dominick, Senior Regulatory Specialist (800) (805) Bill Review Service (800) In an effort to make medical claims submission faster and easier, (Blue Cross) uses the following mailing addresses for claims and claims-related correspondence: Service Area All claims and claims-related correspondence, except for Federal Employee Programs, Stop Loss, Pharmacy and Third-Party Administrator Professional All claims and claims-related correspondence for Federal Employee Programs Claims and correspondence via Federal Express, registered or certified mail, etc. All Workers Compensation-related correspondence Senior Secure claims and claims-related correspondence P.O. Box Los Angeles, CA FEP P.O. Box Van Nuys, CA /name of product Oxnard Street Woodland Hills, CA Workers Compensation Managed Care Services 2170 Towne Center Drive, Suite 320 Anaheim, CA / Blue Cross Senior Secure Blue Cross Senior Secure Claims P.O. Box Los Angeles, CA Blue Cross HMO and Senior Secure Operations Manual March 2006 Directory of Services: Page 3

4 Contract Management Blue Cross assigns a contract manager to act as a liaison between the medical group or IPA and Blue Cross. The contract manager is responsible for: 1. Renegotiating the Blue Cross HMO Medical Services Agreement as necessary. 2. Negotiating and annually renegotiating the Blue Cross Senior Secure Medicare Advantage Medical Services Agreement (for Noncap)/Blue Cross Senior Secure Medicare Advantage Professional Services Agreement (for Dual Risk)*. 3. Arranging status meetings with a medical group s administrator and/or staff to resolve any outstanding contract-related (excluding claims adjudication for Senior Secure) issues. 4. Identifying new network expansion sites and managing negotiations to recruit prospective physician groups. 5. Monitoring existing physician/medical groups membership limits and negotiating with physician/medical groups for additional availability or other alternatives for ensuring adequate physician coverage. 6. Working with Quality Management Operations to monitor the physician/medical group s quality management programs. 7. Keeping abreast of new physician/group enrollment and any issues that may impact Health Care Management. 8. Working with Blue Cross Network Relations department and/or Blue Cross Health Care Management staff regarding outside contract matters, hospital discounts, or other issues raised by any of the hospital associations. 9. Coordinating activities related to contract disputes and other legal matters with the Blue Cross Legal department and associated medical providers. Credentialing Area Blue Cross Credentials Committee Richard Lehrfeld, MD, JD, Staff Vice President, Medical Director, Chairperson Karla Enrequez, Manager, Credentialing (for delegated Credentialing, see Quality Operations below) (818) (818) Blue Cross HMO and Senior Secure Operations Manual March 2006 Directory of Services: Page 4

5 Customer Service Customer Service associates are available to medical group offices and other health care staff to answer both written and telephone inquiries on a variety of topics, including: Benefit questions and explanations Eligibility verification and research, medical group eligibility, and effective dates Professional services, billing and claims status Hospital services, billing and claims status Prescription drug benefits, eligibility and claims process Requests for removal of members for disciplinary actions Conflict resolution regarding benefit interpretation Member removal at physician request Area HMO Customer Service Department for providers only (800) Customer Service Department for Members Only Use the telephone number on the member s ID card Direct Senior Secure-related medical group, hospital and other ancillary health care professional inquiries to Blue Cross Senior Secure s Customer Service department. Use the Customer Service telephone number on the member s ID card. If that information is not available, use the following number: Area Blue Cross Senior Secure Customer Service (888) Department of Managed Health Care Area Area The California Department of Managed Health Care (DMHC) is responsible for regulating health care service plans. For more information on grievance procedures, see the Grievance and Appeals Management section in this manual. Service Health Plans Division Complaints Health Plans Division California Relay Service The DMHC s Web site (online complaint forms and instructions) Contact : (888) HMO-2219 or (888) Fax: (916) : (877) (TDD) Blue Cross HMO and Senior Secure Operations Manual March 2006 Directory of Services: Page 5

6 Service Department of Managed Health Care California HMO Help Center 980 Ninth Street, Suite 500 Sacramento, CA Contact EDI Electronic Claims Submission (800) Encounter Data Submission (818) Rose Hutchinson, Senior EDI Account Manager EDI LivePerson Live Chat If you have Internet access in your office, offers LivePerson. For help with eligibility inquiries, sending and receiving claims, settlement of claim payments or other Electronic Data Interchange (EDI) services, doctors and other health care professionals can simply connect to the Web site, navigate to the EDI page and click on the button labeled Live Help. The LivePerson tool can also be accessed by the following path: Grievance and Appeals Management HMO Medical Grievance and Appeals (818) Theresa Peterson, Manager Medical Grievance and Appeals Management (818) Ron McGinnis, Director Grievance and Appeals Management Specialists (800) Fax (818) Attn: Grievance and Appeals Management P.O. Box 4310 Woodland Hills, CA TTD/TTY line: (877) Health Care Informatics Contact Peter Lee, Director (818) Blue Cross HMO and Senior Secure Operations Manual March 2006 Directory of Services: Page 6

7 Health Improvement Programs Enrollment for Health Improvement Programs (800) Health Improvement Programs Attn: Health Improvement Programs P.O. Box 4413 Woodland Hills, CA Medical Policy and Technology Medical Policy and Review Alan Rosenberg, MD, Vice President, Medical Director (312) Network Education, Training and Development Network Education, Training and Development delivers and supports formal ongoing administrative and procedural education workshops for medical group office staff. Examples of workshops include, but are not limited to: office managers, claims processors, medical management personnel, and front office staff. Workshops are also offered to staff from hospitals, physician offices and ancillary providers. Fax (818) (818) wellpoint.com For ancillary, Network Relations and Service Network Relations is the liaison between (Blue Cross) and participating medical groups, hospitals and physicians. Network Relations associates are available to assist you with contract interpretation questions, requests for educational workshops or on-site visits, and issue resolutions that requires escalation, (i.e., normal channels for resolving issues have been exhausted). You can reach the Network Relations department by telephone Monday through Friday, 9 a.m. to 4 p.m. PST, at (800) If you are calling from a participating medical group, select option #3, then option #1. Blue Cross HMO and Senior Secure Operations Manual March 2006 Directory of Services: Page 7

8 You can also Network Relations at Please include the following information to expedite our response to you: Provider s tax identification number(s) The nine-digit Tax ID number of the medical group, physician and institution Institutions should also provide their six-digit Medicare ID number Provider s name and address Complete contact name (company name, if not the same as provider) and phone number, including extension Patient s name (when applicable) Patient s Health Care Identification (HCID) number Dates of Service Total charges Network Relations can respond to questions or complaints regarding Blue Cross operations and policies including, but not limited to, noncapitated claims reporting, noncapitated performance settlements, encounter reporting, capitation payments, eligibility and enrollment protection claims. To forward correspondence via Federal Express, or registered or certified mail, etc.: Attn: [Name of Product, Specific Department] Oxnard Street Woodland Hills, CA Pharmacy Management WellPoint Pharmacy Management Formulary Request WellPoint Pharmacy Management Customer Service WellPoint Pharmacy Management Prior Authorization of Pharmacy Benefits (PAB) Program Center /Fax Number (800) (800) : (888) Fax: (888) Preventive Health Services Preventive Health Services Kimberly Higgins-Mays, Director (925) Blue Cross HMO and Senior Secure Operations Manual March 2006 Directory of Services: Page 8

9 Provider Care The Provider Care department assists hospitals and medical groups with a variety of administrative issues, including: 1. Eligibility verification and research 2. Benefits questions and explanations 3. Claims status and claims adjustment inquiries Department Number Provider Care (800) The hours of operation for Provider Care Customer Service are: Monday through Thursday Friday Saturday, Sunday, and Holidays Provider Database Operations 8:00 a.m. to 5:00 p.m. 8:30 a.m. to 5:00 p.m. Closed The Provider Database Operations area updates addresses, telephone numbers, tax identification numbers, and directory listings for medical groups, physicians and other health care professionals that are contracted with the Blue Cross HMO and Senior Secure networks. Using your own letterhead, fax changes to the following numbers: Practice Location Fax Number Northern California Counties (818) Southern California Counties (818) Note: All changes must be signed by the physician. The Provider Database Operations department can also assist with the following situations: 1. Health care professional s checks mailed to incorrect address 2. A physician has been added to the practice 3. Changes to a health care professional s hospital staff privileges Note: To check on the status of an application, call the Credentialing Status Inquiry Line at (877) or via at providerdatabase-bcc@wellpoint.com. Blue Cross HMO and Senior Secure Operations Manual March 2006 Directory of Services: Page 9

10 Quality Improvement The Quality Improvement Program strives to support, not interfere with, the patient-physician relationship that ultimately drives all quality improvement. Contact Number Address Quality Management Program (877) Mary Spitzer, Director, Quality Improvement Colleen Patania, Manager, Quality Improvement (818) (925) Quality Improvement Department Oxnard Street AC-12G Woodland Hills, CA Quality Operations (PMG Delegation Oversight, Including Credentialing and Utilization Management) Quality Operations Julie Theodore, Director Quality Management Suzanne Zelazny, Manager (805) (818) If you need to speak to a Quality Management Audit Nurse (QMAN), contact Suzanne Zelazny and she will direct you to the appropriate QMAN. Senior Secure Member Services Information for Blue Cross Senior Secure Department Number Blue Cross Senior Secure Member Services (888) The hours of operation are: Monday through Thursday Friday Saturday and Sunday 8:00 a.m. to 6:00 p.m. 8:00 a.m. to 3:00 p.m. Closed Blue Cross HMO and Senior Secure Operations Manual March 2006 Directory of Services: Page 10

11 Utilization Management Medical Policy and Review Alan Rosenberg, MD, Vice President, (312) Medical Director Utilization Management, Medical Review and Preferred Provider HMO Networks (818) Zeinab Dabbah, MD, Medical Director Provider Line, Utilization Management (800) Web site Address The Blue Cross Web site is (featuring ProviderAccess, pharmacy information, medical policy, and more). Blue Cross HMO and Senior Secure Operations Manual March 2006 Directory of Services: Page 11