GATEWAY AT A GLANCE for Medicare Assured SM Providers

GATEWAY AT A GLANCE for Medicare Assured SM Providers

Gateway Health Medicare Assured SM offers options designed to provide more than healthcare for those who qualify. Medicare Assured SM offers medical and prescription drug coverage, and all the benefits of Original Medicare, PLUS more benefits. Healthcare Options Dual Eligible Special Needs Plans (DSNP) Medicare Assured Diamond SM (HMO SNP) and Medicare Assured Ruby SM (HMO SNP) are for people who have BOTH Medicare (Part A and B) and Medical Assistance or assistance from the State. Those eligible can enroll in a new plan any time throughout the year. Chronic Condition Special Needs Plans (CSNP) Medicare Assured Gold SM (HMO SNP) and Medicare Assured Platinum SM (HMO SNP) are for people who have BOTH Medicare (Part A and B) and at least one of the following chronic conditions: diabetes, cardiovascular disorder or chronic heart failure. There are no income requirements for the chronic condition Special Needs Plans. As a SNP, Gateway is required by the Centers for Medicare and Medicaid Services (CMS) to administer a Model of Care Plan. The SNP Model of Care Plan is the architecture for care management policy, procedures and operational systems. Refer to the Model of Care section in the Gateway Health Medicare Assured SM Provider Policy and Procedure Manual for our SNP Model of Care elements. MAPD Plans (HMO) Additional healthcare options offered outside Pennsylvania are Medicare Assured Prime SM and Medicare Assured Select SM (HMO). The only requirement is to be entitled to Medicare Part A, enrolled in Medicare Part B and live in the non-pennsylvania Gateway service area. There are NO Medicaid or chronic condition requirements for these plans. Frequently Asked Questions Do Gateway Health Medicare Assured SM members have any out of pocket expense? A member s out of pocket expense or cost sharing will vary depending upon the level of assistance they may be receiving from the State and Medicare, as well as which Medicare Assured SM plan they have chosen to join. For more benefit information, a copy of the Summary of Benefits for all Medicare Assured SM plans is available at www.medicareassured.com. For your convenience, co-pays* for frequently used services are provided below: Dual Eligible Special Needs Plans (D-SNP) Gateway Health Medicare Diamond SM (HMO SNP): PCP-$0, SCP-$0, ER-$0** Gateway Health Medicare Ruby SM (HMO SNP): PCP-$0 or $15, SCP-$0 or $35, ER-$0 or $75** Chronic Condition Special Needs Plans (C-SNP) Gateway Health Medicare Gold SM (HMO SNP): PCP-$20, SCP-$45, ER-$75** Gateway Health Medicare Platinum SM (HMO SNP): PCP-$15, SCP-$35, ER-$75** *This list does not represent every service covered or every applicable co-pay. **Not covered outside the US. except under limited circumstances.

Do Gateway Health Medicare Assured SM members have to use plan providers? Members of Gateway Health Medicare Assured SM, with a few exceptions, must use plan providers to get covered services. At the time of enrollment, members must choose a Primary Care Physician (PCP) to provide basic medical care and coordinate the covered services received outside of the PCP s office. Are referrals required for services outside of the PCP s office? Referrals are not required. However, all Gateway Health members are encouraged to coordinate care with their PCP. Claims Submission Guidelines Timely filing criteria for initial bills is 365 days from the date of service. Corrected claims or requests for review are considered if information is received within the 180-day followup period from the date of the initial remittance advice. Practitioners must bill within 180 days from date of an Explanation of Benefits (EOB) from the primary carrier when Gateway is secondary. Paper and EDI claims must be submitted with the required NPI numbers. Claims submitted without the required NPI number will not be loaded and returned to the provider s EDI clearinghouse or billing address on the claim form. Correct/current member information, including Gateway member ID number, must be entered on all claims. Handwritten claims are not accepted. Gateway can not accept verbal requests to retract claim(s) overpayments. Providers must complete and submit a Refund Form (available in the Forms and Reference Material section under Providers on our website) or a letter that contains all of the information requested on this form. This form, together with all supporting materials relevant to the claim(s) reversal request being made, including but not limited to EOB from other insurance carriers and your refund check, should be mailed to: PNC BANK, c/o GATEWAY HEALTH PAYMENTS/REFUNDS, Lock Box #645171, 500 1st Avenue, Pittsburgh, PA 15219. CPID PAYER NAME PAYER ID CLAIM TYPE 2298 Gateway Health Medicare Assured SM 60550 (PA), 91741 (KY, NC, OH) Professional 2912 Gateway Health Medicare Assured SM 60550 (PA), 91741 (KY, NC, OH) Institutional * All of a patient s applicable diagnosis codes that support their Hierarchical Condition Category (HCC) must be reported at least once per year to CMS. CMS guidelines state that Physicians should code all documented conditions that co-exist at the time of the encounter/visit, and require or affect patient care treatment or management.

Gateway Health Medicare Assured SM Important Phone Numbers Call to Inquire About: Claims Inquiry Provider Services KY: 1-855-847-6381 NC: 1-855-847-6431 OH: 1-888-447-4370 PA: 1-800-685-5205 Authorization Medical and Behavioral Health Requests for Admissions to Inpatient Rehab (IRF), Long-Term Acute Care (LTAC) or Skilled Nursing Facilities (SNF) Member Eligibility Requests for Non- Formulary Drugs and Prior Authorizations Expedited Redetermination Care Management Asthma, Cardiac, COPD, Diabetes and Mom Matters Programs Preventive Health Services and Member Outreach Member Complaints, Concerns and Inquiries Concerns and Inquiries Utilization Management navihealth (PA only) KY: 1-855-847-6383 NC: 1-855-847-6433 OH: 1-888-447-4375 PA: 1-800-392-1146 For urgent requests: 1-855-692-6140 Providers can submit authorization requests via toll-free fax. General Prospective Review: 1-844-496-7226 Continued Stay Review for IRF, LTAC or SNF: 1-855-796-7177 Therapy Treatments or Visits Submitted to navihealth: 1-888-242-3495 DIVA Member Eligibility Line Pharmacy KY: 1-855-847-6382 NC: 1-855-847-6432 OH: 1-888-447-4507 PA: 1-800-685-5215 FA: 1-888-447-4369 8 a.m. to 4:30 p.m. (Calls received during nonbusiness hours are referred to 1-800-685-5209) 8 a.m. to 5 p.m 1-800-642-3515 24 hours a day, 7 days a week Our searchable drug formulary and prior authorization forms are available at www.gatewayhealthplan.com. Part D Prescriber Appeals Care Management and Complex Case Management 1-800-213-7083 Voice mail box monitored 24 hours a day, 7 days a week for requests and status of redetermination requests KY: 1-855-847-6384 NC: 1-855-847-6429 OH: 1-888-447-450 PA: 1-800-685-5212 (option 1) Gateway to Lifestyle KY: 1-855-847-6384 Management SM NC: 1-855-847-6429 OH: 1-888-447-4506 PA: 1-800-685-5212 Fax OBNAF to 1-888-225-2360 Preventive Health KY: 1-855-847-6384 NC: 1-855-847-6429 OH: 1-888-447-4506 PA: 1-800-685-5212 (option 1) FA: 1-888-225-2360 Member Services KY: 1-855-847-6380 NC: 1-855-847-6430 OH: 1-888-447-4505 PA: 1-800-685-5209 Fraud and Abuse and Compliance 8 a.m. to 8 p.m. (412) 255-4340 or 1-800-685-5235 24 hours a day, 7 days a week medicarecomplianceofficer@gatewayhealthplan.com

Helpful Telephone Numbers AT&T Language Line Services Provides qualified medical interpretation services 1-800-874-9426 TTY/TDD Assistance with hearing impaired 711 or KY: 1-800-648-6056 NC: 1-800-735-2962 OH: 1-800-750-0750 PA: 1-800-654-5988 Practice Change Information Fax: 1-855-451-6680 Mailing Address for Medical and Behavioral Health Claim Forms PA: Gateway Health Medicare Assured SM PO Box 830430 Birmingham, AL 35283-0430 KY, NC & OH: Gateway Health Medicare Assured SM P.O. Box 830500 Birmingham, AL 35283-0500 Appeals & Grievances P.O. Box 22278 Pittsburgh, PA 15222 All Other Correspondence Gateway Health SM 444 Liberty Avenue, Suite 2100 Pittsburgh, PA 15222-1222 Correspondence Type Claims Reviews Practice Change Information Attention: Claims Review Dept. Visit us online at www.medicareassured.com 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 and Christmas Day. Operations will resume the following business day.

Gateway Health Medicare Assured SM Authorization Quick Reference Guide Pennsylvania Gateway Health Medicaid and Medicare Assured participating providers have the ability to submit authorization requests electronically via NaviNet for the following services: Home Health Visit, Home Health Therapy, Inpatient Maternity, Medical care (both inpatient and outpatient), Behavioral health care, Private duty nursing services, Skilled Nursing Facility (SNF) Admission, Medicaid Only (Please note that SNF prior authorization must be obtained for Medicare Assured members through navihealth), Radiology services which require authorization through National Imaging (NIA). A training guide including detailed instructions is available on our website www.gatewayhealthplan.com under Provider Updates and Forms and Reference Materials. GATEWAY AUTH NAVIHEALTH AUTH (PA ONLY) SCRIPT AMBULANCE (Non emergent only) AMBULATORY SURGICAL SERVICES No auth required for outpatient surgeries (except chose listed under SPU &/or SURGICAL Services) * No auth required for lab services provided in an ASC lab BONE DENSITOMETRY (Bone Mass Measurement) CT SCANS CHIROPRACTIC SERVICES DIALYSIS DME (Medical Supplies, Prosthetics and Orthotics) Items paid at $500 and over $500 (except for those listed below) Oxygen Concentrator, Stationary Liquid Oxygen, Cough Stimulating Device, Respiratory Assistance Device, Hospital Bed Total Electric, Hospital Bed Heavy Duty Extra Wide, and Powered Air Flotation Bed ELECTIVE ADMISSIONS (Medical and Behavioral Health) GENETIC TESTING HOME HEALTH VISITS HOME INFUSION (*Gateway Pharmacy Authorization May Be Required) INPATIENT ACUTE CARE (Including Transplants and Medical Detox) INPATIENT PSYCHIATRIC OR MENTAL HEAITH CARE INPATIENT REHAB FACILITY INPATIENT REHAB SUBSTANCE ABUSE CARE LONG TERM ACUTE CARE (LTAC) HOSPITAL MRI/MRA NON-PAR PROVIDERS NUCLEAR CARDIOLOGY OUTPATIENT PSYCHIATRIC PARTIAL HOSPITALIZATION OUTPATIENT ECT TREATMENT OUTPATIENT THERAPY (Physical, Speech and Language Occupational, and Cardiac) PET SCANS SKILLED NURSING FACILITY (SNF) CARE SPU and/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, TMJ Surgery, Transplant/Implants, Varicose Vein Authorizations are the responsibility of the ordering provider. Cosmetic or investigational/experimental procedures are not covered.

Member Eligibilty Newly enrolled members receive an Evidence of Coverage (EOC) and Gateway Health Medicare Assured SM ID Card. The card itself does NOT guarantee that a person is currently enrolled in one of the Gateway Health Medicare Assured SM plans. 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, online verification through NaviNet or calling Gateway s telephonic eligibility system (DIVA). Please dial 1-800-642-3515 and follow the prompts (also listed below). To Verify Eligibility Using DIVA Call 1-800-642-3515 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 : 11.11.1111. 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. If you make a mistake, press * to start over. If you need help, PRESS #.

Four Gateway Center 444 Liberty Avenue, Suite 2100 Pittsburgh, PA 15222-1222 www.gatewayhealthplan.com PR003-2016_MC