HEALTHAMERICA PROVIDER MANUAL

Transcription

1 HEALTHAMERICA PROVIDER MANUAL October 2013

2 CONTENTS Chapter 1. General Health Plan Information 1.1 Introduction 1.2 Coventry 1.3 HealthAmerica 1.4 HealthAmerica Mission Statement 1.5 Scope of Coventry Products 1.6 [Page Deleted] 1.7 Pennsylvania Regions by County 1.8 Participating Hospital Listing by Region 1.9 Contact Information Quick Reference Guide WPA Quick Reference Guide NWPA Quick Reference Guide EPA Quick Reference Guide Chapter 2. Products and Member Rights and Responsibilities 2.1 Products Descriptions 2.2 Sample Identification Cards 2.3 Member Rights and Responsibilities Commercial Member Rights and Responsibilities Medicare Advantage Member Rights and Responsibilities 2.4 Member Confidentiality and Release of Information Chapter 3. Advantra 3.1 What is Medicare? What is Advantra HMO? What is Advantra PPO? 3.2 Medicare Advantage s Member Rights and Responsibilities 3.3 Member Identification 3.4 Unique Services Emergent/Urgent Care/Renal Dialysis Services/Clinical Trials 3.5 Referrals/Prior Authorization Mental Health/Substance Abuse Services Prior Authorizations 3.6 Member Input in Treatment Plan 3.7 Advance Directives 3.8 Authorized Representatives for an Advantra Member 3.9 Important Information 3.10 Provider Appeals Process 3.11 Member Grievance or Medicare Appeals Process for Medical Coverage Notice of Discharge and Medicare Appeal Rights 3.12 Quality Improvement Organization Review 3.13 Claims and Encounter Submission 3.14 Medicare Advantage (MA) Risk Adjustment 3.15 Special Status Medicare Members 3.16 Privacy of Medical Records 3.17 CMS Requirements

3 3.18 Medicare Part D 3.19 Medicare Provider Training and Education Chapter 4. Communications and Electronic Services 4.1 Directprovider.com How Do I Customize My Favorite Provider List? Online Authorization Requests Attaching Files in Directprovider.com Secure Messaging New Function for HRA Plans on Directprovider.com Mail Handlers Benefit Plan Information on Directprovider.com Medical Criteria Search Functionality on Directprovider.com 4.2 Provider Literature and Publications 4.3 Member Literature and Publications Chapter 5. General Provider Information 5.1 Information for All Provider Types 5.2 Hospitals 5.3 Physicians Office Visits HMO, PPO, POS, and Advantra After Hours Emergency Care Physician Request to Transfer Member Policy Members with Disabilities Public Accommodations and Services at Participating Primary Care Physician Offices for Members with Disabilities Locum Tenens Outpatient Lab Policies Radiology Services I-CORE Provider Administered Drug Program Top 10 Reasons to Call Your Provider Relations Representative 5.4 Ancillary Providers Chiropractic Services Physical Therapy Facility Based Providers Anesthesiologists Emergency Medicine Physicians Pathologists Radiologists Outpatient Laboratory Policy NWPA WPA EPA Durable Medical Equipment (DME) & Home Health Services Free Standing Radiology Dialysis Ambulatory Surgery Centers (ASCs) Medical Transportation Providers Skilled Nursing Facilities Urgent Care Centers 5.5 Network Administrators and Health Plan Programs Vision Programs

4 5.5.2 Behavioral Health Services/Mental Health/Substance Abuse RX Health Care (Home Care Providers Including DME) Radiology Benefit Management Program (NIA) NIA Privileging NIA Claim Resolution Matrix NIA Cardiology Checklist I-CORE Provider Administered Drug Program Chapter 6. Credentialing 6.1 Hospital and Ancillary Credentialing Standards 6.2 Physician & Licensed Independent Practitioner Credentialing Standards 6.3 Recredentialing Cycle Chapter 7. Medical Management 7.1 Utilization Review 7.2 Prospective Review/Precertification 7.3 Concurrent Review 7.4 Retrospective Review 7.5 Member/Patient Facility Denials 7.6 Coordination of Benefits 7.7 Reconsideration Process 7.8 Medical/Clinical Criteria 7.9 Complex Case Management 7.10 Referral Policy/Authorization 7.11 Global Notification for Prenatal Care 7.12 Gynecological Services (All Products) Chapter 8. Billing and Reimbursement 8.1 Claim Submission Paper Claim Electronic Claims Submission (EDI) EDI Specifications Coventry Specific Payer Edits at Emdeon 8.2 Professional EDI Claim Submission Information Provider Information Patient Information Special Data Items Data Not Used 8.3 Institutional (UB) Claim Submission Information Provider Information Patient Information Recommended Information Data Not Used 8.4 EDI Acknowledgement and Reject Reports 8.5 Common Rejection Reasons 8.6 EDI Assistance 8.7 Electronic Fund Transfer (EFT) 8.8 Clean Claims 8.9 Submitting NPI and Coventry Proprietary Numbers (PIN/UPIN) Sample HCFA

5 8.10 Other Requirements (UB 04 Field Requirements) Sample UB Pended Claims 8.12 Denied Claims 8.13 Claims Inquiry My Voice Services My Voice Services Features and Functions of Menu Options My Voice Services Helpful Hints 8.14 Resubmission Guidelines 8.15 Claim Submission Helpful Hints Claim Addresses Timely Filing Denial Appeal Policy Coordination of Benefits (COB) Coventry Consumer Choice (SM) Products Remittance Advice Information Remittance Advice Example Posting a Remittance Advice Collection Advice Summary Collection Advice Summary Example Recoveries Unit Chapter 9. Commercial Pharmacy Benefits 9.1 General 9.2 Formulary 9.3 Co-payments/Generic Policy 9.4 Deductibles/Benefits Maximums 9.5 Mail Order 9.6 Lifestyle Discount 9.7 Prior Authorization Including Step Therapy 9.8 Specialty Drugs/Self Administered Injectable Drugs 9.9 Quantity Limits 9.10 Transition Benefits 9.11 Co-pay Waiver Program 9.12 Formulary Exceptions 9.13 Where to Call for Information and Assistance Chapter 10. Chapter 11. Quality Initiatives (Quality Initiatives is located in a separate companion manual. A link to that manual is provided.) Appendix Supporting Documents and Links to Respective Information

6 1. GENERAL HEALTH PLAN INFORMATION 1.1 INTRODUCTION The purpose of this Provider Manual is to give general information to assist HealthAmerica providers and their staff in understanding the managed care products offered or administered by HealthAmerica and its affiliates. Please note the provider manual for the Network Access, Workers Compensation and Auto products can be found at This manual is intended as a reference tool only and does not alter the terms of your Participating Provider Agreement with HealthAmerica. Please feel free to contact us at any time should you have any questions. As of the date of this manual, all provider manuals have been combined and any references in provider contracts to Manuals (facility, physician, provider, etc.) shall refer to this document. 1.2 COVENTRY Coventry Health Care ( is a diversified national managed healthcare company based in Bethesda, Maryland, operating health plans, insurance companies, network rental and workers compensation services companies. Coventry provides a full range of risk and fee-based managed care products and services to a broad cross section of individuals, employer and government-funded groups, government agencies, and other insurance carriers and administrators in all 50 states as well as the District of Columbia and Puerto Rico. Coventry provides a full range of products and services, including group and individual health insurance, Medicare and Medicaid programs, and coverage for specialty services such as workers compensation, auto and behavioral health care. Click here to review the scope of Coventry products or go to Section 1.5.

7 1.3 HEALTHAMERICA With over 35 years of providing health care benefits, HealthAmerica has earned a reputation as one of the most trusted and experienced health insurers in Pennsylvania. The company ranks 14th in the nation for HMO and POS plans by the National Committee for Quality Assurance, and its Medicare plan ranks 28th nationally. It has ranked among the top health plans by NCQA for six consecutive years. HealthAmerica provides a range of traditional and consumer-directed health insurance products, including self-funded, Medicare, Medicaid, indemnity, nongroup, and pharmacy plans. It currently has "Excellent" accreditation by the National Committee for Quality Assurance for its commercial HMO, POS, and Medicare plans. HealthAmerica s corporate offices are in Harrisburg, Philadelphia, and Pittsburgh, Pennsylvania. HealthAmerica serves 11,000 businesses and over 468,000 Members in Pennsylvania and 11 counties in eastern Ohio and offers progressive medical management, innovative wellness programs, and statewide and national provider networks. HealthAmerica is a subsidiary of Coventry Health Care, Inc., one of the country s largest health care companies providing a full range of risk and fee-based health care products and services in all 50 states. Coventry Health Care directly administers coverage for over 4.6 million Members including over 34,000 employer group customers. Because of its strong bottom line and consistent financial performance, Coventry is ranked on the list of top performers by Forbes Platinum 400, Fortune 500, Fortune 40, Barron s 500, and The Wall Street Journal. For more information, visit HealthAmerica s website at HEALTHAMERICA MISSION STATEMENT We are driven to ensure that every person and organization we serve receives the greatest possible value for their health care investment. We do this by bringing together Members, employers, and providers; making available the best possible information; and together devising solutions that help people enjoy optimal health.

8 1.5 SCOPE OF COVENTRY PRODUCTS The Breadth and Depth of Coventry Health Care Medicaid National in scope, yet local in focus. Coventry s Medicaid expertise helps communities around the nation support their Medicaid recipients and gain control over their health challenges. A national health care company providing health insurance and administrative services to a broad array of commercial and government accounts. Workers Compensation Coventry Workers Comp Services offers a suite of client solutions designed to help drive industry-leading medical outcomes and identify appropriate cost savings at every step of an injured worker s recovery. Medicare Various health plans offer Medicare Advantage coverage. The company offers Advantra Plans as well as Advantra RX and First Health Part D plans through the Medicare Prescription Drug (Part D) Program. Commercial Both fully-insured and selfinsured coverage options are offered through health plans and insurance companies. Carrier and TPA Through Network Rental agreements, our Coventry National Network or First Health Network is made available to third party administrators and other carriers. Auto Coventry Auto Solutions offers cost containment solutions to assist with the rising medical costs associated with first party medical payments and Personal Injury Protection. Coventry National Accounts (formerly known as First Health Group Corp.) provides ASO coverage to national employers, including the Federal Employees Health Benefits (FEHB) Program and Mail Handlers.

9 1.7 PENNSYLVANIA REGIONS BY COUNTY Western Pennsylvania Region Counties Allegheny Armstrong Beaver Bedford Butler Cambria Fayette Greene Indiana Lawrence Somerset Washington Westmoreland Northwestern Pennsylvania Region - Counties Cameron Clarion Clearfield Crawford Elk Erie Forest Jefferson McKean Mercer Venango Warren Chautauqua (NY) Cattaraugus (NY) Eastern Ohio Region Counties Handled By: Handled By: Belmont WPA PR Geauga NWPA PR Columbiana WPA PR Lake NWPA PR Harrison WPA PR Mahoning NWPA PR Jefferson WPA PR Medina NWPA PR Ashtabula NWPA PR Trumbull NWPA PR Cuyahoga NWPA PR Eastern Pennsylvania Region Counties Adams Franklin Monroe Berks Fulton Montour Blair Huntington Northampton Bradford Lackawanna Northumberland Carbon Lancaster Schuylkill Centre Lebanon Susquehanna Clinton Lehigh Tioga Columbia Luzerne Union Cumberland Lycoming Wayne Dauphin Mifflin Wyoming York Southeastern Pennsylvania Region Counties Bucks Chester Delaware Montgomery Philadelphia

10 1.8 PARTICIPATING HOSPITAL LISTING BY REGION * The proceeding lists of participating hospitals are subject to change. Please visit our website or call your provider representative for any updates. Western Pennsylvania Region - Hospitals Advanced Surgical Hospital Allegheny General Hospital Allegheny Valley Hospital Armstrong County Memorial Hospital Butler Memorial Hospital Canonsburg General Hospital Children s Home of Pittsburgh Children s Hospital of Pittsburgh of UPMC The Children s Institute of Pittsburgh Conemaugh Memorial Medical Center Ellwood City Hospital Forbes Regional Hospital Frick Hospital HealthSouth Hamarville Rehabilitation Hospital HealthSouth of Sewickley Heritage Valley Beaver Heritage Valley Sewickley Highlands Hospital Indiana Regional Medical Center Jameson Regional Medical Center North Jefferson Regional Medical Center South Latrobe Regional Hospital LifeCare Hospitals of Pittsbugh Alle-Kiski LifeCare Hospitals of Pittsburgh (Main) LifeCare Hospitals of Pittsbugh Monroeville LifeCare Hospitals of Pittsburgh Suburban Magee-Women s Hospital of UPMC Meyersdale Medical Center Miners Medical Center Monongahela Valley Hospital Ohio Valley General Hospital Select Specialty Hospital Pittsburgh/UPMC Select Specialty Hospital Laurel Highlands Select Specialty Hospital Johnstown Select Specialty Hospital McKeesport Somerset Hospital Southwest Regional Medical Center St. Clair Memorial Hospital Transitional Care Center at LifeCare Hospitals of Pittsburgh Uniontown Hospital UPMC Bedford Memorial UPMC East UPMC McKeesport UPMC Mercy UPMC Montefiore UPMC Passavant UPMC Passavant Cranberry UPMC Presbyterian UPMC Shadyside UPMC St. Margaret Washington Health System/Washington Hospital West Penn Hospital Westmoreland Regional Hospital Windber Hospital Northwestern Pennsylvania Region - Hospitals Bradford Regional Medical Center Brookville Hospital Charles Cole Memorial Hospital Clarion Hospital Clearfield Hospital Corry Memorial Hospital DuBois Regional Medical Center Edgewood Surgical Hospital Elk Regional Health Center Grove City Medical Center HealthSouth Rehabilitation Hospital of Erie Jones Memorial Hospital (NY) Kane Community Hospital Meadville Medical Center Millcreek Community Hospital Olean General Hospital (NY) Punxsutawney Area Hospital Saint Vincent Health Center Erie Select Specialty Hospital Erie Sharon Regional Health System Titusville Area Hospital UPMC Hamot UPMC Horizon UPMC Northwest Warren General Hospital Westfield Memorial Hospital (NY) Womans Christian Association Hospital (NY) 11 of 223

11 Eastern Ohio Region Hospitals Barnesville Hospital Belmont Community Hospital +Children s Hospital Medical Center of Akron Cleveland Clinic Main Campus East Liverpool City Hospital East Ohio Regional Hospital *Euclid Hospital (Cleveland Clinic) *Fairview Hospital (Cleveland Clinic) Harrison Community Hospital *Hillcrest Hospital (Cleveland Clinic) Hillside Rehabilitation Hospital *Huron Hospital (Cleveland Clinic) *Lakewood Hospital (Cleveland Clinic) *Lutheran Hospital (Cleveland Clinic) *Marymount Hospital (Cleveland Clinic) *Medina General Hospital (Cleveland Clinic) Northside Medical Center *Parma Community General Hospital Salem Community Hospital Select Specialty Hospital Youngstown St. Elizabeth's Boardman Health Center St. Elizabeth's Health Center St. Joseph's Health Center *South Pointe Hospital (Cleveland Clinic) *Southwest General Health Center The Surgical Hospital at Southwoods Trinity East Medical Center Trinity West Medical Center TriPoint Medical Center Trumbull Memorial Hospital *UH Ahuja Medical Center *UH Bedford Medical Center *UH Case Medical Center *UH Conneaut Medical Center *UH Geauga Medical Center *UH Geneva Medical Center *UH Richmond Medical Center West Medical Center + This facility is only participating with commercial products at this time. * This facility is only participating with Medicare products at this time. Eastern Pennsylvania Region Hospitals Barnes-Kasson County Hospital Berwick Hospital Bon Secours-Holy Family Hospital (Altoona Regional Health System) Bucktail Medical Center Carlisle Regional Medical Center Chambersburg Hospital (Summit Health) Corning Hospital Corning, NY Divine Providence Hospital (Susquehanna Health System) Easton Hospital Endless Mountains Health System Ephrata Community Hospital Evangelical Community Hospital Fulton County Medical Center Geisinger Bloomsburg Hospital Geisinger Community Medical Center Geisinger Shamokin Area Community Hospital Geisinger Wyoming Valley Medical Center Gettysburg Hospital Gnaden Huetten Memorial Hospital Good Samaritan Hospital Lebanon Hanover Hospital Memorial Hospital Towanda Memorial Hospital York Mercy Hospital Scranton Mid-Valley Hospital Milton S. Hershey Medical Center Moses Taylor Hospital Mount Nittany Medical Center Muncy Valley Hospital (Susquehanna Health System) Nason Hospital Nesbitt Memorial Hospital (Wyoming Valley Health Care System) Palmerton Hospital Pinnacle Health Hospitals Pocono Medical Center Reading Hospital & Medical Center Robert Packer Memorial Hospital Schuylkill Medical Center East Norwegian St. Schuylkill Medical Center South Jackson St Sacred Heart Hospital Select Specialty Hospital, Inc. Camp Hill Select Specialty Hospital, Inc. Danville Select Specialty Hospital, Inc. Harrisburg 12 of 223

12 Hazleton General Hospital (Greater Hazleton Health Alliance) HealthSouth Rehabilitation Hospital of Altoona Heart of Lancaster Regional Medical Center Holy Spirit Hospital JC Blair Memorial Hospital Jersey Shore Hospital Lancaster General Hospital Lancaster Regional Medical Center Lehigh Valley Hospital Lehigh Valley Muhlenberg Hospital Lewistown Hospital LifeCare Hospitals of Pittsburgh Chester County LifeCare Hospitals of Pittsburgh - Mechanicsburg Lock Haven Hospital Marian Community Hospital Select Specialty Hospital, Inc. York Soldiers and Sailors Memorial Hospital St. Joseph Medical Center Reading St. Luke s Hospital Allentown Campus St. Luke s Hospital Bethlehem Campus St. Luke s Miners Memorial Hospital Sunbury Community Hospital Troy Community Hospital Tyler Memorial Hospital Tyrone Hospital UPMC Altoona Waynesboro Hospital (Summit Health) Wilkes Barre General Hospital (Wyoming Valley Health Care System) Williamsport Hospital & Medical Center (Susquehana Health System) York Hospital Southeastern Pennsylvania Region Hospitals Abington Memorial Hospital Lankenau Hospital Albert Einstein Medical Center Lansdale Hospital Aria Health Bucks Campus Lower Bucks Hospital Aria Health Frankford Campus Mercy Fitzgerald Hospital Aria Health Torresdale Campus Mercy Hospital of Philadelphia Brandywine Hospital Mercy Suburban Hospital Bryn Mawr Hospital Nazareth Hospital Chester County Hospital Paoli Hospital Chestnut Hill Hospital Pennsylvania Hospital Children s Hospital of Philadelphia Phoenixville Hospital Crozer Chester Medical Center Pottstown Memorial Medical Center Crozer Chester Medical Center Springfield Riddle Memorial Hospital Hospital Roxborough Memorial Hospital Crozer Chester Medical Center Taylor Hospital St. Christopher s Hospital for Children Delaware County Memorial Hospital St. Lukes Quakertown Hospital Doylestown Hospital St. Mary Medical Center Einstein Medical Center Montgomery St. Joseph s Hospital Girard Medical Center Temple University Hospital Grand View Hospital Thomas Jefferson University Hospital Hahnemann University Hospital Thomas Jefferson University Hospital Methodist Hospital of the University of Pennsylvania Hospital (TJUH) Jeanes Hospital University of Pennsylvania Medical Center Jennersville Regional Hospital Presbyterian 13 of 223

13 1.9 CONTACT INFORMATION QUICK REFERENCE GUIDES WPA Contact Information Quick Reference Guide Claims Filing for: HealthAmerica Advantra Carelink/Carelink Medicaid HealthAmerica PO Box 7088 London KY EDI Payor Number Advantra PO Box 7087 London KY EDI Payor ID Carelink/Carelink Medicaid PO Box 7373 London KY Payor Number Payor Number (Medicaid) Claims Filing For: HealthAmerica One Coventry One (product for individuals) HealthAmerica One Attn: Claims P.O. Box 7142 London, KY EDI Payor ID Coventry One Attn: Claims P.O. Box 7704 London, KY EDI Payor ID Claim Status Check For: HealthAmerica Advantra HealthAmerica Interactive Voice Response (IVR) Or Directprovider.com Advantra Interactive Voice Response (IVR) Or Directprovider.com Carelink/Carelink Medicaid Interactive Voice Response (IVR) Or Directprovider.com Resubmission/Corrected Claims For: HealthAmerica Advantra Carelink/Carelink Medicaid HealthAmerica PO Box 7088 London KY HealthAmerica Advantra PO Box 7087 London KY Carelink/Carelink Medicaid P.O. Box 7373 London KY Check Returns For: HealthAmerica Advantra Carelink/Carelink Medicaid HealthAmerica 120 East Kensinger Drive Cranberry Twp PA Attention: Recoveries Dept Advantra 120 East Kensinger Drive Cranberry Twp PA Attention: Recoveries Dept Carelink Carelink Medicaid 120 East Kensinger Drive Cranberry Twp PA Attention: Recoveries Dept Check Refunds For: HealthAmerica Advantra Carelink/Carelink Medicaid HealthAmerica Attention: Recoveries Dept PO Box Philadelphia,PA Advantra Attention: Recoveries Dept PO Box Philadelphia,PA Carelink Carelink Medicaid Attention: Recoveries Dept PO Box Columbus, Ohio Website care.com

14 Pharmacy Department Fax: Hours: M-F 8:30am 5pm Fax: Hours: M-F 8:30am 5pm Fax: Behavioral Health MHNet Behavioral Health MHNet Behavioral Health Mental Health Network Health Education or Hours: 8:00am 5:00pm Eyemed Vision Care eyemedvisioncare.com or Hours: 8:00am 5:00pm N/A N/A N/A Authorizations HealthAmerica Advantra Carelink/Carelink Medicaid HealthAmerica Pharmacy request option #1 Claims/Benefits option #2 Employee pre-cert option #3 Provider reconsideration option #4 All other pre-cert press #0 Fax: Advantra Pharmacy request option #1 Claims/Benefits option #2 Employee pre-cert option #3 Provider reconsideration option #4 All other pre-cert press #0 Fax: Carelink Carelink Medicaid Fax: Provider Inquiry: Member Eligibility MBR Benefits Claims Questions HealthAmerica Advantra Carelink/Carelink Medicaid WPA Provider Relations Department:

15 1.9.2 NWPA Contact Information Quick Reference Guide Revised /NWPA NWPA ADVANTRA GENERAL ELECTRIC CARELINK HealthAmericaOne CoventryCares from HealthAmerica Claims Filing HealthAmerica PO Box 7088 London KY HealthAmerica Advantra PO Box 7087 London KY HealthAmerica PO Box 7129 London KY Carelink PO Box 7373 London KY HealthAssurance Attn: Claims PO Box 7142 London KY CoventryCares Attn: Claims PO Box 7803 London KY Claims Status Check HealthAmerica Interactive Voice Response (IVR) HealthAmerica Advantra Interactive Voice Response (IVR) HealthAmerica Interactive Voice Response (IVR) Carelink Interactive Voice Response (IVR) HealthAmericaOne CoventryCares Interactive Voice Response (IVR) Resubmission of Corrected Claims HealthAmerica PO Box 7088 London KY HealthAmerica Advantra PO Box 7087 London KY HealthAmerica PO Box 7129 London KY Carelink PO Box 7373 London KY HealthAssurance Attn: Claims PO Box 7142 London KY CoventryCares Attn: Claims PO Box 7803 London KY Check Returns HealthAmerica Attn: Recoveries Dept. 120 E Kensinger Dr Cranberry Twp PA HealthAmerica Advantra Attn: Recoveries Dept. 120 E Kensinger Dr Cranberry Twp PA HealthAmerica Attn: Recoveries Dept. 120 E Kensinger Dr Cranberry Twp PA Carelink Attn: Recoveries Dept. 120 E Kensinger Dr Cranberry Twp PA HealthAmericaOne Attn: Recoveries Dept. 120 E Kensinger Dr Cranberry Twp PA CoventryCares Attn: Recoveries Dept. 120 E Kensinger Dr Cranberry Twp PA Check Refunds HealthAmerica Attn: Recoveries Dept. PO Box Philadelphia PA HealthAmerica Advantra Attn: Recoveries Dept. 120 E Kensinger Dr Cranberry Twp PA HealthAmerica Attn: Recoveries Dept. PO Box Philadelphia PA Carelink Attn: Recoveries Dept. PO Box Columbus OH HealthAmerica Attn: Recoveries Dept. PO Box Philadelphia PA CoventryCares Attn: Recoveries Dept. PO Box Philadelphia PA EDI Claims Submission Payor Number: Payor Number: Payor Number: Payor Number: Payor Number: Payor Number: Appeals HealthAmerica Attn: Appeals PO Box 7088 London KY HealthAmerica Advantra Attn: Medicare Medical Appeals & Grievances PO Box 7776 London KY HealthAmerica Attn: GE Team 120 E Kensinger Dr Cranberry Twp PA Carelink Health Plans, Inc. Attn: Appeals Coordinator PO Box 1711 Charleston WV HealthAmericaOne Attn: Appeals PO Box 7142 London KY CoventryCares Attn: Appeals Dept. PO Box Harrisburg PA

16 Website NWPA ADVANTRA GENERAL ELECTRIC CARELINK HealthAmericaOne CoventryCares from HealthAmerica ealthcare.com althcare.com yhealthcare.com althcare.com pennsylvania.coventryhealthcare.c om/advantra-pennsylvania om Pharmacy Department Fax: Hours: M-F 8:30am 5:00pm Managed by MEDCO Managed by MEDCO Preauth: Fax: Fax: Hours: M-F 8:30am 5:00pm Managed by MEDCO Behavioral Health MHNet Behavioral Health MHNet Behavioral Health Managed by CIGNA BEHAVIORAL HEALTH Mental Health Network Coventry National Network Covered by the state & managed by each county Health Education or Hours: M-F 8:00am 5:00pm or Hours: M-F 8:00am 5:00pm or Hours: M-F 8:00am 5:00pm N/A or Hours: M-F 8:00am 5:00pm N/A Vision (if applicable) Cole Vision Cole Vision Managed by DAVIS VISION N/A N/A Block Vision Authorizations Pharmacy = option #1 Claims/Benefits = option #2 Employee pre-auth = option #3 Provider reconsid = opt #4 All other pre-auth = option #0 Fax: Pharmacy = option #1 Claims/Benefits = option #2 Employee pre-auth = option #3 Provider reconsid = opt #4 All other pre-auth = option #0 Fax: Pharmacy = option #1 Claims/Benefits = option #2 Employee pre-auth = option #3 Provider reconsid = opt #4 All other pre-auth = option #0 Fax: Fax: Pharmacy = opt #1 Customer Serv = opt #2 Special Needs = opt #3 Provider reconsid = opt #4 Outpt rad = opt#5 All other pre-auth = opt#0 Fax: High-Tech Imaging Services NIA NIA N/A No prior auth required for hightech imaging N/A HealthAmericaOne NIA Provider Inquiry, Member Eligibility, Benefits, Claims Questions HealthAmerica HealthAmerica Advantra General Electric Dedicated Unit Carelink HealthAmericaOne CoventryCares

17 1.9.3 EPA Contact Information Quick Reference Guide Coventry Health Care Quick Reference Guide Authorizations Fax: Behavioral Health HealthAmerica Advantra Coventry Health Care of Delaware Inc (Adams, Lancaster and York counties, and the Philadelphia region) MHNet Claims PR ext 4784 Hours: M-F 8:00 5: Fax: MHNet Claims PR ext 4784 Hours: M-F 8:00 5: or MHNet Claims PR ext 4784 Hours: M-F 8:00 5:00 Check Refunds HealthAmerica PO Box Philadelphia PA Attention: Recoveries Dept Advantra PO Box Philadelphia PA Attention: Recoveries Dept First Union Bank PO Box Philadelphia PA Vision EyeMed Vision Care EyeMed Vision Care EyeMed Vision Care Check Returns HealthAmerica 120 East Kensinger Drive Cranberry Twp PA Attention: Recoveries Dept Advantra 120 East Kensinger Drive Cranberry Twp PA Attention: Recoveries Dept Coventry Health Care Inc 120 East Kensinger Drive Cranberry Twp PA Attention: Recoveries Dept Claims Submissions HealthAmerica PO Box 7089 London KY Advantra PO Box 7087 London KY Coventry Health Care of DE Inc. PO Box 7713 London KY Claim Status Check HealthAmerica Interactive Voice Response (IVR) Option 2,#2 DirectProvider.com Direct Provider.com Customer Service Eligibility/Benefits EDI Claim Submission Payor Number Payor Number Payor Number 25133

18 Formal Appeals Pharmacy Department HealthAmerica 3721 TecPort Drive PO Box Harrisburg, PA Attention: Appeals Dept Option 1 or Fax or Hours: M-F 8:30 am 5pm Advantra 3721 TecPort Drive PO Box Harrisburg, PA Attention: Appeals Dept Option 1 or Fax or Hours: M-F 8:30 am 5pm Coventry of Delaware 750 Prides Crossing, Ste 300 Newark, DE Attention: Appeals Dept Caremark Reimbursement Per provider agreement Per provider agreement Per provider agreement Resubmission of Corrected Claims HealthAmerica PO Box 7089 London KY Payor #25133 NOTE: For paper submissions, Corrected Claim must be noted on the HCFA. Corrected or resubmitted claims can be sent electronically. Use the Claim Frequency Type Code (CLM05-3) value equal to "7" to indicate a replacement claim. The Claim Type Frequency Code (code set 235) may be used for other resubmitted claim types as well. Advantra PO Box 7087 London KY Payor #25133 NOTE: For paper submissions, Corrected Claim must be noted on the HCFA. Corrected or resubmitted claims can be sent electronically. Use the Claim Frequency Type Code (CLM05-3) value equal to "7" to indicate a replacement claim. The Claim Type Frequency Code (code set 235) may be used for other resubmitted claim types as well. Coventry Health Care of DE, Inc PO Box 7713 London KY NOTE: For paper submissions, Corrected Claim must be noted on the HCFA. Corrected or resubmitted claims can be sent electronically. Use the Claim Frequency Type Code (CLM05-3) value equal to "7" to indicate a replacement claim. The Claim Type Frequency Code (code set 235) may be used for other resubmitted claim types as well. Website EPA Provider Relations Department:

19 2. PRODUCTS AND MEMBER RIGHTS & RESPONSIBILITIES This section is designed to assist providers and their staff in understanding the various managed health care products administered by HealthAmerica. This guide has been assembled to serve as a comprehensive resource for information. Please feel free to contact us at anytime should you have any questions. Note: Benefits, co-payments, deductibles and coinsurance vary according to individuals specific coverage. Participating Provider is a health care provider, including, but not limited to a physician, home health agency, laboratory or other professional, facility, supplier, or vendor that has entered into a direct or indirect written agreement with HealthAmerica or a Coventry Health Care entity to provide Covered Services to Members. Non Participating Provider is any health care provider that has not entered into a direct or indirect written agreement with HealthAmerica or a Coventry Health Care entity to provide Covered Services to Members. 2.1 PRODUCT DESCRIPTIONS Click here for the links to the commercial and Medicare Advantage sample ID cards or go to section 2.2. COMMERCIAL INSURED/SELF-INSURED PRODUCT The Commercial Insured/Self-Insured Product (ASO) includes health maintenance organization (HMO) products, point-of-service (POS) products, and preferred provider organization (PPO) products offered or administered by HealthAmerica, HealthAssurance, Coventry Health and Life Insurance Company or other Member Company or a Payor. From time to time Coventry and/or Payors may designate only certain Participating Providers to take part in the provider delivery network for a particular Product benefit plan(s). MEDICARE ADVANTAGE: Medicare ADVANTRA [HMO] [PPO] [POS] PRODUCT The Medicare Advantage Product includes the Medicare health benefit plan(s) administered directly by Coventry or a Coventry Company (Health Plan), currently referred to as the HealthAmerica Advantra Program. From time to time HealthAmerica and/or Payors may designate only certain Participating Providers to take part in the provider delivery network for a particular Product benefit plan(s). Click here to be directed to the HealthAmerica Advantra section of the manual or go to section 3.

20 MEDICAID The Medicaid product includes the Medicaid health benefit plan(s) administered directly by Coventry or a Coventry Company. In Pennsylvania, this product is called CoventryCares from HealthAmerica and is open to Medical Assistance recipients. CoventryCares is an HMO product and requires Members to select a PCP. Based on certain eligibility information, new Members will be assigned to one of six HMO plan designs. Medical Assistance recipients can choose among the health plans available in their area. If they do not actively enroll, they are enrolled in a plan selected by HealthChoices. This is known as auto-assignment. For specific information about the CoventryCares Medicaid PA Product, you can visit that product s website at To view the provider directory specific to the CoventryCares Medicaid PA Product, visit NETWORK ACCESS (First Health) The Network Access Product includes third party administrators (TPAs), employers, or other insurance carriers, union trusts, business coalitions, or other associations who are interested in securing access to our networks. Coventry has entered into network lease and/or rental agreements with these entities. Coventry does not assume the financial liability for any claim or fee for health care services provided to Members participating in the Network Access Product. The provider manual for the Network Access product can be located by visiting: You may also contact us at COVENTRY HEALTH CARE WORKERS COMPENSATION SERVICES Workers Compensation Program The Workers Compensation Program product includes network access and other services to Payors, including but not limited to workers compensation insurance carriers, third party administrators and other entities and corporations for work related injury or illness and subject to state workers compensation regulations as required. The provider manual for the Workers Compensation Product can be located by visiting: You may also contact us at