WellCare of Kentucky Provider Update
|
|
|
- Alexina Dickerson
- 8 years ago
- Views:
Transcription
1 2008 WellCare Health Plans Inc.. All rights reserved. WellCare of Kentucky Provider Update Summer 2013
2 WellCare of Kentucky Offices Lexington Office Louisville Office Ashland Office Owensboro Office Hazard Office Bowling Green Office We have six offices throughout the Commonwealth staffed with Provider Relations Representatives and Case/Disease Managers that live in those communities to service the needs of members and providers. Confidential and Proprietary WellCare Health Plans, Inc. 7/16/2013 2:33 PM p 1
3 WellCare of Kentucky Claims, Authorizations and Appeals Claim Submission Metrics Nov. 1, 2011 Dec. 31, 2012 Pharmacy Claims Received and Paid 3.6M Electronic (EDI) Claims - Non-Pharmacy 4.0M Clean EDI Claims Ready For Processing 3.4M Claim Acceptance Rate 96.0% % of Claims Received Electronically 86.0% % of Claims Received in Paper Form 14.0% Service Authorization Requests Nov. 1, 2011 Dec. 31, 2012 Authorization Requests All Providers 189,186 Authorizations Approved 178,730 Authorizations Denied 12,480 Avg. Auth. Approvals per Month 12,766 Avg. Auth. Denials per Month 891 % of Authorization Requests Denied 6.50% Claim Payment Metrics (Non-Pharmacy) Nov. 1, 2011 Dec. 31, 2012 Claims Paid (EDI & Paper) 3,422,820 Claims Denied (EDI & Paper) 624,363 Total Dollars Paid to Providers (Non-Pharmacy) $592,616,304 Avg. Days for Provider to Send Claim 28.7 Avg. Days for WellCare to Pay Claim 14.9 Claims Paid Within 30 Days 96.6% Provider Appeals Nov. 1, 2011 Dec. 31, 2012 Number of Provider / Member Appeals 3,195 % of Non Pharmacy Claims Appealed <1% Number of Fair Hearings Requested 131 % of Claims Requiring Fair Hearings <1% Number of Claims Received 7.6M Confidential and Proprietary WellCare Health Plans, Inc. 7/16/2013 2:33 PM p 2
4 Top Reasons Claims are Denied 70.5% Are Avoidable 70.5% of all claim line denials are due to six avoidable reasons. Top Denial Reasons Include Duplicate Claim Submission, Not Obtaining Authorization, and Kentucky Medicaid Not Being The Primary Insurer. All other denial code reasons accounted for just 7.6% of all claim lines billed. Rank Reason For Claim Denial % Of All Denials % of Total Claim Lines 1 Duplicate Claim Billed: Exact Duplicate of Another Claim 32% 5.58% 2 Prior Authorization Required but Not Obtained 16% 2.74% 3 Payment Included In The Allowance For Another Previously Billed Service 9% 1.57% 4 Medicare Is Responsible - Must submit an EOB from Medicare 5% 0.91% 5 Other Commercial Coverage - Must submit an EOB from the Primary Insurance Carrier 5% 0.82% 6 Medicare Primary Payment Equals or Exceeds Medicaid Liability 4% 0.75% Subtotal 70.5% 12.4% All Other 29.5% 7.6% TOTAL 100.0% 20.0% Confidential and Proprietary WellCare Health Plans, Inc. 7/16/2013 2:33 PM p 3
5 WellCare of Kentucky Avg. Time To Receive and Pay Claims Provider Responsibility How long does it take for a Provider to send the claim to WellCare? WellCare Responsibility How long does it take WellCare to pay the claim? 28.7 Days 14.9 Days Avg. Days For Avg. Days For MCO Time Period Paid Claim Lines Provider To Send Claim To Pay The Claim December , March , June , July , August , September , October , Q4 Avg November , Days 9.7 December , Total Q4 Avg. 9.5 Days Confidential and Proprietary WellCare Health Plans, Inc. 7/16/2013 2:33 PM p 4
6 WELLCARE RESOURCES 2008 WellCare Health Plans Inc.. All rights reserved.
7 WellCare Resources Provider Manual Quick Reference Guide Online Authorization Online Eligibility and Claims Submission Online Forms and Documents including PDL Clinical Coverage & Clinical Practice Guidelines Provider and Pharmacy Lookup Provider Newsletters Fax Blasts Notifications Provider Relations Visits Regions 1, 2 & 4 Contact Information: Bill Watson Director of Network Management (216) Julie Crousore Provider Relations Manager, Regions 1, 2 & 4 (502) Amber Henderson Provider Relations Rep (270) Jonathan Milliner Sr. Provider Relations Rep (270) Melanie Poole Sr. Provider Relations Rep (270) Pam Cline Sr. Provider Relations Rep (270) Confidential and Proprietary WellCare Health Plans, Inc. 7/16/2013 2:33 PM p 6
8 Online Resources (Medicaid) Quick Reference Guides: Full of Helpful Information You and your staff will have secure Web access to a variety of easy-touse tools created to streamline your day-to-day administrative tasks with the plan. Confidential and Proprietary WellCare Health Plans, Inc. 7/16/2013 2:33 PM p 7
9 p 8 AUTHORIZATIONS
10 p 9 Online Authorization Information Do you even NEED an authorization? Check our online Authorization Lookup Tool to know for sure
11 p 10 Online Authorization Information As an alternative to fax or phone, you can also submit and track status on authorizations on our Secure Portal
12 p 11 SUBMITTING CLAIMS
13 p 12 Claims Submission Use Emdeon? Please contact our EDI-Master who can assist. Mail Paper Claim Submissions to: WellCare of Kentucky Health Plans, Inc. Claims Department PO Box Tampa FL
14 VENDORS: Optometry & Ophthalmology: Avesis. (855) and Dental: Avesis: (855) and Audiology: Max Specialty. Providers can reach them by contacting Dru Coleman CareCore National for Advanced Imaging, Diagnostic Cardiac Nuclear Studies, Sleep Studies and Pain Management Authorizations On line at By phone at (888) By fax at (866) Confidential and Proprietary WellCare Health Plans, Inc. 7/16/2013 2:33 PM p 13
15 Behavioral Health Services WellCare s Behavioral Health Services are managed in-house. No outside vendor is used. Behavioral Health Providers are held to the same standard and processes included in WellCare s Provider Resources, unless otherwise noted. Interqual criteria is used for assessing level of care criteria. Authorization request forms can be found on the Forms and Documents page of our website, including fax numbers and phone numbers for urgent authorization requests. Confidential and Proprietary WellCare Health Plans, Inc. 7/16/2013 2:33 PM p 14
16 p 15 APPEALS
17 p 16 Appeal Rights & Process - Payment
18 p 17 Appeal Rights & Process - Medical Providers may seek an appeal through the Appeals department within thirty (30) calendar days of a claims denial for lack of prior authorization, services exceeding the authorization, insufficient documentation or late notification. Mail or fax medical appeals with supporting documentation to: WellCare of Kentucky Health Plans Inc. Attn: Appeals Department PO Box Louisville, KY Fax
19 p 18 PHARMACY
20 p 19 Pharmacy Information WellCare s Preferred Drug List is available on the unsecured portion of our Website
21 p 20 ENHANCED MEMBER BENEFITS
22 p 21 Enhanced Member Benefits Pre-Natal Care Rewards Program Partnering with Providers
23 p 22 Enhanced Member Benefits
24 p 23 Enhanced Member Benefits In-Home Case Management Weekly Face-to-Face visits with licensed personnel in the home with feedback provided to the PCP. Upon request, accompany the member to the MD visit and facilitate compliance with PCP recommendations. Empower the member to participate in their plan of care. Coordination of Community Resources
Managed Care Organization and Provider Forum Region 3 June 24, 2013
Managed Care Organization and Provider Forum Region 3 June 24, 2013 Humana Headquartered in Kentucky Fortune 100 company Leading national healthcare company 12 million medical members 8 million specialty
WellCare Post-Implementation Teleconference Question and Answers
WellCare Post-Implementation Teleconference and s Introduction On the KMA hosted a teleconference with WellCare Kentucky Health Plan. The Medical Director for WellCare Kentucky, Cheryl Shafer, MD reminded
NEW JERSEY MEDICARE FAQs FREQUENTLY ASKED QUESTIONS FROM PROVIDERS
NEW JERSEY MEDICARE FAQs To help answer some of the most frequently asked questions we receive from providers and members, please see below. If you have a question that isn't listed here, or if you need
Submitting Special Batch Claims and Claim Appeals
Submitting Special Batch Claims and Claim Appeals Nevada Medicaid and Nevada Check Up August 2013 2012 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without
Medicaid Managed Care Questions and Answers
Medicaid Managed Care Questions and Answers WellCare The KMA has presented each of the three new Managed Care Organizations hired by the state to administer the Medicaid program in Kentucky with a list
Presentation prepared for: Vision Providers & Staff
Presentation prepared for: Vision Providers & Staff Avesis is National Executive Offices in Baltimore, MD Operations located in Phoenix, AZ Phone: (800) 828-9341 Eligibility Claims Member Services Southeast
CLAIM FORM REQUIREMENTS
CLAIM FORM REQUIREMENTS When billing for services, please pay attention to the following points: Submit claims on a current CMS 1500 or UB04 form. Please include the following information: 1. Patient s
Managed Care Enrollment Expansion
www.horizonnjhealth.com Managed Care Enrollment Expansion George Ingram Director of Contracting and Strategy Phase I ABD and DYFS with Medicaid only 40,000 People Plan self selection ending July 18 with
Third Quarter Updates Q3 2014
Third Quarter Updates Q3 2014 0714.PR.P.PP. 2014 Agenda Claim Process Reminders and Updates Top Rejections Top Denials IHCP Updates Resources Claim Process Electronic submission MHS accepts TPL information
How To Participate In The Well Sense Health Plan
Well Sense Health Plan How We Do Business with Providers New Hampshire Health Protection Program August 2014 Agenda Working with Well Sense and our members Our partners Provider responsibilities Resources
General Information Key Contact Information. Overview of Managed Care & Medicaid Changes 1
General Information Key Contact Information Overview of Managed Care & Medicaid Changes 1 IDs and Checking Eligibility Amerigroup Identification Amerigroup ID, IA Health Link ID, Name and phone number
Your Guide to Anthem HealthKeepers Plus Web Updates and Other Changes
Your Guide to Anthem HealthKeepers Plus Web Updates and Other Changes Effective November 1, 2013, we have made some great changes to our provider website and a few of our tools. Recently, we announced
EXTERNAL REVIEW CONSUMER GUIDE
EXTERNAL REVIEW CONSUMER GUIDE STATE OF CONNECTICUT INSURANCE DEPARTMENT Rev. 7-11 CONNECTICUT INSURANCE DEPARTMENT EXTERNAL REVIEW CONSUMER GUIDE OVERVIEW Connecticut Public Act 11-58 gives you the right
Date Posted: Nov. 27, 2012. Overview:
Landon State Office Building Phone: 785-296-3981 900 SW Jackson Street, Room 900-N Fax: 785-296-4813 Topeka, KS 66612 www.kdheks.gov/hcf/ Robert Moser, MD, Secretary Kari Bruffett, Director Sam Brownback,
Chapter 82-60 WAC All Payer Claims Database
Chapter 82-60 WAC All Payer Claims Database WAC 82-60-010 Purpose (1) Chapter 43.371 RCW establishes the framework for the creation and administration of a statewide all-payer health care claims database.
New York. UnitedHealthcare Community Plan Claims System Migration Provider Quick Reference Guide. Complete Claims. Our Claims Process
Our Claims Process Here are a few steps to ensure you receive prompt payment: 1 Review and copy both sides of the member s ID card. members receive an ID card containing information that helps you process
REVENUE CYCLE CLARITY. Streamlined Solutions for Hospitals and Physicians
REVENUE CYCLE CLARITY Streamlined Solutions for Hospitals and Physicians SOLUTIONS for Hospitals and Large Physician Groups ClaimLogic offers a full suite of advanced claims and payment processing systems
Frequently Asked Questions About Your Hospital Bills
Frequently Asked Questions About Your Hospital Bills The Registration Process Why do I have to verify my address each time? Though address and telephone numbers remain constant for approximately 70% of
Provider Claims Billing
Provider Claims Billing Objective At the end of this session, you should be able to recognize the importance of using Harvard Pilgrim s online tools and resources to manage the revenue cycle: Multiple
IHCP 3 rd Quarter Workshop Hoosier Healthwise/HIP. MDwise Claims HHW HIPP0264 (6/13) Exclusively serving Indiana families since 1994.
IHCP 3 rd Quarter Workshop Hoosier Healthwise/HIP MDwise Claims HHW HIPP0264 (6/13) Exclusively serving Indiana families since 1994. Agenda 1. Provider Enrollment 2. Claim submission for MDwise Hoosier
DENTAL COLORADO MEDICAID EDI UPDATE
220 Burnham Street South Windsor CT 06074 Vox 888-255-7293 Fax 860-289-0055 DENTAL COLORADO MEDICAID EDI UPDATE PAYER ID NUMBER CKCO1 ELECTRONIC REGISTRATIONS Agreements Required PROVIDER ENROLLMENT FORM
CLAIMS AND BILLING INSTRUCTIONAL MANUAL
CLAIMS AND BILLING INSTRUCTIONAL MANUAL 2007 TABLE OF ONTENTS Paper Claims and Block Grant Submission Requirements... 3 State Requirements for Claims Turnaround Time... 12 Claims Appeal Process... 13 Third
Molina Healthcare of Puerto Rico (MHPR) Non-Participating Provider Information
Molina Healthcare of Puerto Rico (MHPR) Non-Participating Provider Information Please refer to Carta Normativa 15-0326 Re Transicion for details regarding the ASES-established Transition of Care and Reimbursement
Dental Orientation. Molina Healthcare
Dental Orientation Molina Healthcare Scion Provider Web Portal The Scion Electronic Outreach Team is calling all providers offices to provide information and help with registration. Some offices may receive
ARChoices. HPE Fiscal Agent for the Arkansas Division of Medical Services. September 2016
ARChoices HPE Fiscal Agent for the Arkansas Division of Medical Services September 2016 Topics for Today Provider Training Provider Manuals Submitting Claims Claim Adjustments and Voids Current CPT Codes
Proposed Adoption of Workers Compensation Rules
May 19, 2014 Proposed Adoption of Workers Compensation Rules The Workers Compensation Division proposes to adopt new rules to establish standards for electronic medical billing, OAR 436-008. Please review
MyCare Ohio Skilled Nursing Facility Orientation
MyCare Ohio Skilled Nursing Facility Orientation Demonstration/Pilot Area Demonstration/Pilot Area 2 Health Plan Options Northwest Southwest West Central Central East Central Northeast Central Northeast
2016 Evidence of Coverage for Passport Advantage
2016 Evidence of Coverage for Passport Advantage EVIDENCE OF COVERAGE January 1, 2016 - December 31, 2016 Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Passport
IMPORTANT BILLING GUIDELINES
IMPORTANT BILLING GUIDELINES The guidelines contained herein are meant to assist GHP Family Participating Providers in billing appropriately for medically necessary services rendered to GHP Family Members.
REPORT 9: DENTAL CLAIMS GLOBAL ANALYSIS ANALYSES OF CLAIMS SUBMITTED BY DENTAL PROVIDERS TO GEORGIA CARE MANAGEMENT ORGANIZATIONS SEPTEMBER 4, 2009
GEORGIA FAMILIES PROGRAM REPORT 9: DENTAL CLAIMS GLOBAL ANALYSIS ANALYSES OF CLAIMS SUBMITTED BY DENTAL PROVIDERS TO GEORGIA CARE MANAGEMENT ORGANIZATIONS SEPTEMBER 4, 2009 TABLE OF CONTENTS Table of Contents...
Radiology Prior Authorization Program Frequently Asked Questions for the UnitedHealthcare Community Plan
Radiology Prior Authorization Program Frequently Asked Questions for the UnitedHealthcare Community Plan 1. What is the UnitedHealthcare Radiology Prior Authorization Program? Acting on behalf of our Medicaid
Physician Health Care Provider. Quick Reference. CIGNA HealthCare 2006
& Physician Health Care Provider Quick Reference CIGNA HealthCare 2006 1 Contents Provider Value Proposition 3 Overview 4 Electronic Services 6 Working with Us 17 Contact Information 21 2 Confidential,
27. Will the plan pay for radiology done in the provider s office?... 10 28. How do providers request assistance with care management issues?...
Provider Q&A Contents 1. Who is Florida True Health?... 3 2. What is the new product name?... 3 3. Does the plan have a website?... 3 4. How will physicians be paid? (FFS or capitation)... 3 5. What clearing
Behavioral Health Provider Training: Substance Abuse Treatment Updates
Behavioral Health Provider Training: Substance Abuse Treatment Updates Agenda Laboratory Services Behavioral Health Claims Submission Process Targeted Case Management Utilization Management eservices Claims
! Claims and Billing Guidelines
! Claims and Billing Guidelines Electronic Claims Clearinghouses and Vendors 16.1 Electronic Billing 16.2 Institutional Claims and Billing Guidelines 16.3 Professional Claims and Billing Guidelines 16.4
WellCare of Kentucky, Inc. July 2013. 2008 WellCare Health Plans Inc. All rights reserved.
WellCare of Kentucky, Inc. July 2013 2008 WellCare Health Plans Inc. All rights reserved. WellCare of Kentucky Region 3 2 Region 1/Paducah: 7 Region 2/Owensboro: 13 Region 3/Louisville: 58 Region 4/Bowling
Clinical Headquarters. Cardiologist CV. Vaughn W. Payne, PharmD, MD, MBA, FACP, FACC, CCDS, CPE. States Covered: KY, IN
CV Vaughn W. Payne, PharmD, MD, MBA, FACP, FACC, CCDS, CPE & Medical Director, Kentucky - Humana/CareSource Louisville, KY States Covered: KY, IN After more than 20 years practicing clinical cardiology
Florida Medicaid Provider Resource Guide
Florida Medicaid Provider Resource Guide Staywell Health Plan of Florida, Inc., (WellCare) understands that having access to the right tools can help you and your staff streamline day-to-day administrative
How to read the paper remittance advice. How to review claim and adjustment information How to correct overpayments and underpayments
How to read the paper remittance advice How to review claim and adjustment information How to correct overpayments and underpayments Overview DMAP mails the paper Remittance Advice (RA) weekly. It tells
Electronic Claims Submission (EDI) Training
Electronic Claims Submission (EDI) Training Part 1 How to completed CMS1500 form Contact Information EDI@ActivHealthCare.com 866-374-9558 770-455-0040 Two parts of Training Part 1: How to complete CMS1500
Claims and Billing Process. AHCCCS Provider Identification Number and NPI Number
Claims and Billing Process AHCCCS Provider Identification Number and NPI Number All United Healthcare Community Plan providers requesting reimbursement for services must be properly registered with AHCCCS
CHAPTER 7 (E) DENTAL PROGRAM CLAIMS FILING CHAPTER CONTENTS
CHAPTER 7 (E) DENTAL PROGRAM CHAPTER CONTENTS 7.0 CLAIMS SUBMISSION AND PROCESSING...1 7.1 ELECTRONIC MEDIA CLAIMS (EMC) FILING...1 7.2 CLAIMS DOCUMENTATION...2 7.3 THIRD PARTY LIABILITY (TPL)...2 7.4
Medical and Rx Claims Procedures
This section of the Stryker Benefits Summary describes the procedures for filing a claim for medical and prescription drug benefits and how to appeal denied claims. Medical and Rx Benefits In-Network Providers
Evidence of Coverage:
January 1 December 31, 2015 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Health Net Ruby (HMO) This booklet gives you the details about
MyCare Ohio Assisted Living Provider Orientation & Training
MyCare Ohio Assisted Living Provider Orientation & Training Opt IN Enrollees - Full duals with Buckeye Medicare and Medicaid benefits through Buckeye Medicare option to change plans monthly If member selects
Handbook for Home Health Agencies. Chapter R-200 Policy and Procedures For Home Health Agencies
Handbook for Home Health Agencies Chapter R-200 Policy and Procedures For Home Health Agencies Illinois Department of Healthcare and Family Services Issued February 2011 Chapter R-200 Home Health Agency
SECTION E Molina Healthcare CLAIMS
SECTION E Molina Healthcare CLAIMS CLAIMS CLAIM SUBMISSION (Refer to Section J, Claims, in the 2007 Provider Manual for detailed information) Professional Fees Claims must be submitted on a CMS (Centers
Sunflower State Health Plan
Sunflower State Health Plan 1 Comprehensive Provider Network Doctors & Clinics Sunflower State has a large and growing network of Providers throughout the State including: Hospitals, Health Clinics, Primary
Home Health Agency Manual (Revisions to Billing Instructions for Claims for Members with Commercial Health Insurance in Addition to MassHealth)
Commonwealth of Massachusetts Executive Office of Health and Human Services 600 Washington Street Boston, MA 02111 www.mass.gov/dma MASSHEALTH TO: FROM: RE: Home Health Agencies Participating in MassHealth
Unpaid Claims Management
Unpaid Claims Management National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD 20814 301-347-0400 301-347-0459 FAX www.nachc.com AGENDA Introduction Clean
1. Long Term Care Facility
Table of Contents 1.... 1 1.1. Introduction... 1 1.1.1. General Policy... 1 1.1.2. Advance Directives... 1 1.1.3. Customary Fees... 1 1.1.4. Covered Services... 1 1.1.5. Swing Bed General Policy... 2 1.2.
2014 Tennessee Healthcare Financial Management Conference
2014 Tennessee Healthcare Financial Management Conference Agenda UnitedHealthcare and UnitedHealthcare of the River Valley (Commercial) UnitedHealthcare Community Plan and Dual Complete Preferred Medicare
2016 Updates and Refresher Course CHPW PRESENTATION
2016 Updates and Refresher Course CHPW PRESENTATION 1 About CHPW In 1992, Washington s local Community Health Centers voted to create a notfor-profit managed care company Community Health Plan of Washington.
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://eoc.anthem.com/eocdps/aso or by calling 1-888-650-4047.
Children s Long Term Support (CLTS) Waiver Third Party Administration (TPA) Claims Processing
Children s Long Term Support (CLTS) Waiver Third Party Administration (TPA) Claims Processing Wisconsin Department of Health Services Division of Long Term Care Bureau of Long-Term Support 1 Third Party
Provider Adjustment, Time limit & Medicare Override Job Aid
Provider Adjustment, Time limit & Medicare Override Job Aid Contents Overview... 1 Medicaid Resolution Inquiry Form... 1 Medicare Overrides... 3 Time Limit Overrides... 3 Adjusting a Claim through the
Molina Dual Options MyCare Ohio Medicare-Medicaid Plan FAQ s
Molina Dual Options MyCare Ohio Medicare-Medicaid Plan FAQ s Coverage and Benefits Q: What is the Molina Dual Options MyCare Ohio Medicare-Medicaid Plan? A: Molina Dual Options is a health plan that contracts
Section 9. Claims Claim Submission Molina Healthcare PO Box 22815 Long Beach, CA 90801
Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your
MEDICAID BASICS BOOK Third Party Liability
Healthy Connections Visual MEDICAID BASICS BOOK Third Party Liability An illustrated companion to the interactive courses at: MedicaideLearning.com. This topic includes content from the exclusive Third
FAX and Address Reference Guide for Providers. Commercial Addresses
FAX and Address Reference Guide for Providers Name of Link: FAX and Address Reference Guide Introduction: Utilize the chart below to determine the correct address or fax number to submit a claim or correspondence
****************************************** **************ATTENTION************** ******************************************
4/4/2006 Cover Page 1 PAYER ID: SKNJ0 SUBMITTER: 9902201 NEW JERSEY MEDICAID MEDICAL **************ATTENTION************** THIS PAYER EDI AGREEMENT MUST BE PROCESSED THROUGH EMDEON S PAYER ENROLLMENT DEPARTMENT.
Managed Care Program
Summit Workers Compensation Managed Care Program KENTUCKY How to obtain medical care for a work-related injury or illness. Welcome Summit s workers compensation managed-care organization (Summit MCO) is
Behavioral Health Provider Training: Program Overview & Helpful Information
Behavioral Health Provider Training: Program Overview & Helpful Information Overview The Passport Behavioral Health Program provides members with access to a full continuum of recovery and resiliency focused
Appeals: Eligibility & Health Plan Decisions in the Health Insurance Marketplace
Appeals: Eligibility & Health Plan Decisions in the Health Insurance Marketplace There are 2 kinds of appeals you can make once you ve applied and enrolled in coverage through the Health Insurance Marketplace:
PROVIDER TRAINING APRIL 7, 2015
PROVIDER TRAINING APRIL 7, 2015 Melanie Hodoh As the New third party administrator (TPA) for the CMSP Governing Board, Advanced Medical Management, Inc. (AMM) would like to thank you for partnering with
Billing Guidelines Manual for Contracted Professional HMO Claims Submission
Billing Guidelines Manual for Contracted Professional HMO Claims Submission The Centers for Medicare and Medicaid Services (CMS) 1500 claim form is the acceptable standard for paper billing of professional
UnitedHealthcare Injectable Chemotherapy Prior Authorization (PA) Program Frequently Asked Questions
UnitedHealthcare Injectable Chemotherapy Prior Authorization (PA) Program Frequently Asked Questions Q1. What members are impacted by the UnitedHealthcare Injectable Chemotherapy PA Program? A. Beginning
HUSKY Health Program and Charter Oak Health Plan Radiology Benefits Management Program
HUSKY Health Program and Charter Oak Health Plan Radiology Benefits Management Program Training Agenda Presentation Overview Introduction of Presenters Radiology Benefits Management Program Overview Prior
Community HealthEssentials. 2014 Guide
Community HealthEssentials 2014 Guide Community HealthEssentials - Summary Community HealthEssentials is the new name for Community Health Plan of Washington s (CHPW) individual commercial products offered
October 2013 IHCP Annual Workshop Hoosier Healthwise/HIP
HHW-HIPP0311 (9/13) October 2013 IHCP Annual Workshop Hoosier Healthwise/HIP MDwise UB-04 for Hoosier Healthwise and HIP: A guide for claim adjudication Exclusively serving Indiana families since 1994.
Coventry receives claims in two ways:
Coventry receives claims in two ways: Paper Claims Providers send claims to the specific Coventry PO Box, which are keyed by our vendor and sent via an EDI file for upload into IDX. Electronic Claims -
Member Rights, Complaints and Appeals/Grievances 5.0
Member Rights, Complaints and Appeals/Grievances 5.0 5.1 Referring Members for Assistance The Member Services Department has representatives to assist with calls for: General verification of member eligibility
COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE HEALTHCHOICES EXAMINATION GUIDE
COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE HEALTHCHOICES EXAMINATION GUIDE SUPPLEMENTAL GUIDANCE PHYSICAL HEALTH FINANCIAL SCHEDULES AND EXAMINATION REPORTS DECEMBER 2013 DEPARTMENT OF PUBLIC
ATTENTION PRACTICE MANAGERS
Volume VI; June 2013 ATTENTION PRACTICE MANAGERS MUST USE Easier to Read Asterisks detailing required information New telephonic team working to give you timely status updates AZPCP Prior Authorization
HOW TO COMPLETE THIS FORM
HOW TO COMPLETE THIS FORM For your convenience, Sharp Health plan makes this reimbursement form available for your use. All requests for reimbursement received in writing shall be processed. 1. The Member
Please type provider information on the form for ease of processing at MD On-Line.
COLORADO MEDICAID EDI CONTRACT INSTRUCTIONS (SKCO0) Please MAIL the completed and signed agreement to: MD On-Line ATTN: Enrollment 6 CENTURY DR 2ND FL PARSIPPANY, NJ 07054 Do not fax the agreement to MD
Utilization Review Annual Summary. Utilization review annual summary for 2014.
Department of Consumer and Business Services Insurance Division 2 P.O. Box 14480 Salem, Oregon 97309-0405 Phone: 503-947-7268 Fax: 503-378-4351 350 Winter St. NE, Salem, Oregon www.insurance.oregon.gov
Directory Of Resources Downloads/Bulletins Downloads/Forms
Directory Of Resources Information is listed by webpage name; a link has been included to automatically open each page of the Medicaid Portal. If the page location of an item or topic is not known, type
PATIENT FINANCIAL POLICIES Effective Date: June 1, 2015
Cardiovascular Specialists of Central Maryland A Community Specialty Practice of Johns Hopkins Medicine 10710 Charter Drive, Suite 400 Columbia MD 21044 PATIENT FINANCIAL POLICIES Effective Date: June
Qtr 2. 2011 Provider Update Bulletin
West Virginia Medicaid WEST VIRGINIA Department of Health & Human Resources Qtr 2. 2011 Provider Update Bulletin West Virginia Medicaid Provider Update Bulletin Qtr. 2, 2011 Volume 1 Inside This Issue:
GLANCE GATEWAY. Providers AT A. for Medicare Assured SM. Gateway Health Medicare Assured SM 444 Liberty Avenue, Suite 2100 Pittsburgh, PA 15222-1222
GATEWAY AT A GLANCE for Medicare Assured SM Providers Gateway Health Medicare Assured SM 444 Liberty Avenue, Suite 2100 Pittsburgh, PA 15222-1222 YOUR PROVIDER NUMBERS: Group Provider Number : Individual
Title 40. Labor and Employment. Part 1. Workers' Compensation Administration
Title 40 Labor and Employment Part 1. Workers' Compensation Administration Chapter 3. Electronic Billing 301. Purpose The purpose of this Rule is to provide a legal framework for electronic billing, processing,
2015 HMO Evidence of Coverage
hap.org/medicare 2015 HMO Evidence of Coverage HAP Senior Plus (hmo)-henry Ford Individual Plan 006 Option 1 Your Medicare Health Benefits and Services as a Member of HAP Senior Plus (hmo)-henry Ford.
Copayment: The amount you must pay for each medical visit to a participating doctor or other healthcare provider, usually at this time service.
Basic Terms How to calculate Out of Pocket Costs on a Hospital Stay: If you have a $2000 deductible and 30% coinsurance health insurance plan. If you have a $10,000 emergency room or hospital stay your
A Consumer s Guide to Appealing Health Insurance Denials
STATE OF CONNECTICUT Insurance Department Appeals & External Review Guide RIGHTS GUIDANCE APPEAL ASSISTANCE October 2013 A Consumer s Guide to Appealing Health Insurance Denials Introduction This guide
VOLUME 4: MEDICAL SERVICES
VOLUME 4: MEDICAL SERVICES Effective Date: 12/2003 CHAPTER 34 Revision Date: 05/2015 4.34.2 UTILIZATION MANAGEMENT MEDICAL SERVICES REVIEW PROCEDURE Attachments: Yes No I. PROCEDURE OVERVIEW The purpose
How To Contact Americigroup
Mental Health Rehabilitative Services and Mental Health Targeted Case Management TXPEC-0870-14 1 Agenda Key contacts Eligibility Mental Health Rehabilitative services (MHR) and Mental Health Targeted (TCM)
A Consumer s Guide to Appealing Health Insurance Denials
STATE OF CONNECTICUT Insurance Department Appeals & External Review Guide RIGHTS GUIDANCE APPEAL ASSISTANCE October 2013 A Consumer s Guide to Appealing Health Insurance Denials Introduction How do I appeal
Third Party Liability. HP Provider Relations/October 2014
Third Party Liability HP Provider Relations/October 2014 Agenda Objectives Define Third Party Liability (TPL) TPL Program Responsibilities TPL Resources Cost Avoidance Medicare Buy-in Program Claims Processing
Connecticut Department of Social Services Medical Assistance Program Provider Bulletin. PB 2008-36 June 2008
Connecticut Department of Social Services Medical Assistance Program Provider Bulletin PB 2008-36 June 2008 TO: SUBJECT: Professional Claim Submitters Change to National Drug Code Requirements on Professional
Optum Intelligent EDI. Achieve higher first-pass payment rates and help your organization get paid quickly and accurately.
Optum Intelligent EDI Achieve higher first-pass payment rates and help your organization get paid quickly and accurately. The new benchmark for EDI performance Health care has outgrown commoditized EDI,
Billing Clinic (STAR, STAR Health, CHIP and STAR+PLUS (non-nf residents)
Billing Clinic (STAR, STAR Health, CHIP and STAR+PLUS (non-nf residents) Provider Training SHP_2014624 Introductions & Agenda Verifying Eligibility Authorization Process Establishing Medical Necessity
North and South Florida Regions. Administrative. Manual
North and South Florida Regions Administrative Manual Inside Front Cover Table of Contents Key Contact Information... 2 Online Account Management SM Useful Tools for Plan Administration... 3 Access Online
Chapter 16 Restricted Recipient Program
Chapter 16 Restricted Recipient Program Program Overview The Restricted Recipient Program (RRP) is a program developed by the Minnesota Department of Human Services for recipients who have failed to comply
Quick Reference Guide
Ohio Non-Participating Provider 2014 Physician, Health Care Professional, Facility and Ancillary Quick Reference Guide UHCCommunityPlan.com Important Phone Numbers Provider Services Department 800-600-9007
FUNDING & REIMBURSEMENT
FUNDING & REIMBURSEMENT Access & manage your reimbursement funds Inside You ll learn how to use your extend health online account. which documents you should save for use. how to submit claims for reimbursement.
Radiology Prior Authorization Program Frequently Asked Questions (FAQ) For AmeriChoice by UnitedHealthcare, Tennessee
Radiology Prior Authorization Program Frequently Asked Questions (FAQ) For AmeriChoice by UnitedHealthcare, Tennessee 1. What is the AmeriChoice Radiology Prior Authorization Program? Acting on behalf
Basics of the Healthcare Professional s Revenue Cycle
Basics of the Healthcare Professional s Revenue Cycle Payer View of the Claim and Payment Workflow Brenda Fielder, Cigna May 1, 2012 Objective Explain the claim workflow from the initial interaction through
Medicaid EHR Incentive Program Updates ehealth Services and Support September 24, 2014
Medicaid EHR Incentive Program Updates ehealth Services and Support September 24, 2014 Today s presenter: Nicole Bennett, Provider Enrollment and Verification Manager Goals and Objectives Goals of today
State and School Employees Life and Health Insurance Plan Frequently Asked Questions
State and School Employees Life and Health Insurance Plan Frequently Asked Questions Medical Plan Q. What is included in the AHS State Network (Network)? A. You can receive the maximum benefits available