You have the right to an explanation from us about any bills you may get for drugs not covered by our Plan. provider must already be participating in PHCS Network, which is certified for credentialing by NCQA. If you do, please call Member Services. Answer 5. Female members may directly access a women's health care specialist within the network for the following routine and preventive health care services provided as basic benefits: Annual mammography screening (age restrictions apply) See preauthorization list for DME that requires pre-authorization. What can you doif you think you have been treated unfairly or your rights arent being respected? Member satisfaction with ConnectiCare is very important. Influenza and pneumococcal vaccinations Once submitted, ConnectiCare will verify the eligibility of the member with the Centers for Medicare & Medicaid Services (CMS) as they are the sole arbiter of eligibility for Medicare. Your providers must explain things in a way that you can understand. ConnectiCare requires that sufficient notice be given to all of your patients affected by a change in your practice. How do I know if I qualify for PHCS insurance? Discounts on frames, lenses, and contact lenses: 25% discount for items costing $250 or less; 30% discount for items over $250. If you need help with communication, such as help from a language interpreter, please call Medicare Member Services. You can reference your plan document for the complete list. To get any of this information, call Member Services. To verify or determine patient eligibility, call 1-800-222-APWU (2798). ConnectiCare cannot reverse CMS' determination. If you need more information, please call our Member Services. Your right to get information in other formats When in the service area, members are expected to seek routine services, except for certain self-referred services, from their PCP. You have the right to find out from us how we pay our doctors. We hope that our members are satisfied and decide to stay with ConnectiCare; however, should you learn that a member plans to disenroll, you may avoid payment delays by: 1. faq. Notify ConnectiCare within twenty-four (24) hours after an emergency admission at 888-261-2273. If you refuse treatment, you accept responsibility for what happens as a result of your refusing treatment. Your right to see plan providers, get covered services, and get your prescriptions filled within a reasonable period of time plan. In-office procedures are restricted to a specific list of tests that relate to the specialty of the physician. 410 Capitol Avenue Submit a Coverage Information Form. ConnectiCare will maintain such health information and make it available to CMS upon request, as necessary. Blue Cross Providers: 800 . Preferred Provider Organization Questions? However, the majority of PHCS plans offer members . Transition of Care allows new members and/or members whose plan has experienced a recent provider network change to continue to receive services for specified medical and behavioral conditions, with health care professionals that are not participating in the plans designated provider network, until the safe transfer of care to a participating provider and/or facility can be arranged. Although not a provider of health insurance, PHCS is a provider of PPO (Preferred Provider Organization) networks. You have the right to ask someone such as a family member or friend to help you with decisions about your health care. You may also search online at www.multiplan.com: If you are currently seeing a doctor or other healthcare professional who does not participate in the PHCS Network,you may use the Online Provider Referral System in the Patients section of www.multiplan.com, which allows you tonominate the provider in just minutes using an online form. MRI/MRA (all examinations) Requests may be made by either the physician or the member. Referrals must be signed in to ConnectiCaresProvider Connection. Eligibility Claims Eligibility Fields marked with * are required. PHCS (Private Healthcare Systems, Inc.) - PPO. The right to know how information about race, language, ethnicity, gender orientation, and sexual identity are collected and used. There are different types of advance directives and different names for them. (SeeOther Benefit Information). Notify ConnectiCare within twenty-four (24) hours after an emergency admission at 888-261-2273. To obtain a copy of the privacy notice, visit our website atconnecticare.com, or call Provider Services at the number below. Prospective members must properly complete and sign an enrollment application and submit it to ConnectiCare. In addition, the following guidelines apply: The following are covered preventive care services: Please note there are designated frequencies and age limitations. This information is not used in contracting or credentialing decisions or for any discriminatory purpose. UHSM is always eager and ready to assist. Physicians are required to make referrals to participating specialty physicians, including chiropractic physicians. This feature is meant to assist members who need additional copies of their ID card. You may want to give copies to close friends or family members as well. Treatment Programs we offer and in which you may participate. allergenic extracts (or RAST allergen specific testing); 2.) Minimal hold time Fast Claim Processing and Payment Clear Explanation of Benefits Clear Benefit Descriptions Be treated with respect and recognition of your dignity and right to privacy. PHC's Member Services Department is available Monday - Friday, 8 a.m. - 5 p.m. You can call us at 800 863-4155. In addition, some of the ConnectiCare plans include Part D, prescription drug coverage. The Evidence of Coverage (EOC) will instruct them to call their PCP. Your rights include knowing about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. The plan contract is terminated. Colorectal screening (age restrictions apply) Dominion Tower 999 Waterside Suite 2600 Norfolk, VA 23510. To inquire about an existing authorization - (phone) 800-562-6833 All providers shall comply with Title VI of the Civil Rights Act of 1964, as implemented by regulations at 45 C.F.R. All genetic testing requires preauthorization, with the exception of the following: Routine chromosomal analysis (e.g., peripheral blood, tissue culture, chorionic villous sampling, amniocentesis) - CPT 83890 - 83914, billed withModifier 8A or ICD-9 diagnosis codes V77.6 or V83.81, DNA testing for cystic fibrosis - CPT 88271 - 88275; 88291, billed withModifier 2A - 2Z or ICD-9 codes V10.6x or V10.7x, FISH (fluorescent in situ hybridization) for the diagnosis of lymphoma or leukemia - CPT 88230 - 88269; 88280 - 88289; 88291; 88299. Note: These procedures are covered procedures, but do not require preauthorization in network. ConnectiCare enrolls individual members into the ConnectiCare plan. If you dont know the member's ID number, contact Provider Services during regular business hours to verify eligibility and benefits. The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. Please check the privacy statement of the website where this link takes you. According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. Choose "Click here if you do not have an account" for self-registration options. If you have signed an advance directive, and you believe that a doctor or hospital hasnt followed the instructions in it, you may file a complaint with: Connecticut Department of Health 410 Capitol Avenue, P.O. For emergency care received outside the U.S. there is a $100,000 limit. For concerns or problems related to your Medicare rights and protections described in this section, you may call our Member Services. The provider must agree to accept network rates for the defined period of time. Without preauthorization, these services and procedures may not be covered or may be covered at a reduced rate. PCPs:Advise your patients to contact ConnectiCare's Member Services at 800-224-2273 to designate a new PCP, even if your practice is being assumed by another physician. How to get more information about your rights MedAvant, an online transaction system available to ConnectiCare participating providers, also offers a secure means for entering and verifying referrals. If you want to, you can use a special form to give someone the legal authority to make decisions for you if you ever become unable to make decisions for yourself. Wondering how member-to-member health sharing works in a Christian medical health share program? Testing that exceeds this maximum is the members responsibility. If you have difficulty obtaining information from your plan based on language or a disability, call 1-800-MEDICARE (800-633-4227). When performed out of network, these procedures do require preauthorization. You have the right to an explanation from us about any prescription drugs or Part C medical care or service not covered by our plan. Such information includes, but is not limited to, quality and performance indicators for plan benefits regarding disenrollment rates, enrollee satisfaction, and health outcomes. Your right to get information about our plan No prior authorization requirements. If your plan does not meet the requirements below, Primary PPO Complementary PPO Specialty Networks Network Management Analytics-Based Solutions: Negotiation Services Medical Reimbursement This would also include chronic ventilator care. Emergency care and out-of-area urgently needed services are covered under the Prime and Custom Plans, anytime, anywhere (worldwide). Some plans cover preventive dental services: Receive information about us, our services, our participating providers, and "Members Rights and Responsibilities.". PHCS is the leading PPO provider network and the largest in the nation. (214) 436 8882 Medicare providers under their ConnectiCare contract are required to see all ConnectiCare VIP Medicare Plan members including those who are dual eligible for Medicare and Medicaid. Choice - Broad access to nearly 4,400 hospitals, 79,000 ancillaries and more than 700,000 healthcareprofessionals. High Deductible Health Plan (Health Savings Account [HSA] Compatible). You also have the right to this explanation even if you obtain the prescription drug, or Part C medical care or service from a pharmacy and/or provider not affiliated with our organization. It is not medical advice and should not be substituted for regular consultation with your health care provider. Your Registration Code is the Alternate ID number on your ID card plus a suffix of 01 for the subscriber, 02, 03, 04, 05, etc for spouse and/or dependents. You are now leavinga ConnectiCare website. Your right to the privacy of your medical records and personal health information. Your right to get information about our plan, plan providers, drugs, health care coverage, and costs. No referrals needed for network specialists. Monitoring includes member satisfaction with physicians. Simply call (888) 371-7427 Monday through Friday from 8 a.m. to 8 p.m. (Eastern Standard Time) and identify yourself as a health plan participant accessing PHCS Network for Limited Benefit plans. Our plan must have individuals and translation services available to answer questions from non-English speaking beneficiaries, and must provide information about our benefits that is accessible and appropriate for persons eligible for Medicare because of disability. PROVIDER PORTAL LOGIN REGISTER NOW Electronic Options: EDI # 59355 Eligibility (270/271) Bill Status (276) Bill Submission (837) For technical assistance with EDI transactions, please contact Change Healthcare at 1-800-845-6592. Clinical Review Prior Authorization Request Form. Oops, there was an error sending your message. All oral medication requests must go through members' pharmacy benefits. Some plans may have a copayment requirement for radiology services. Please note that your benefits and out of pocket expenses may vary when using PHCS providers. A voluntary termination initiated by a practitioner should be communicated to ConnectiCare verbally or in writing, in accordance with the terms set forth in the contract, but no less than sixty (60) days before the effective date. Members who develop ESRD after enrollment may remain with a ConnectiCare plan. Follow the plans and instructions for care that they have agreed on with practitioners. Remember you will only need your registration code this one time to set up your account. This includes information about our financial condition and about our network pharmacies. Accessing PHCS Savility PHCS Savility is available to insurers and benefit plan administrators meeting certain benefit design Members have the responsibility to: Members rights and our obligations are limited to our ability to make a good faith effort in regard to: Each time a member receives services, you should confirm eligibility. No out-of-network coverage unless preauthorized in writing by ConnectiCare. Providers are also reminded that dual eligible members who are designated as Qualified Medicare Beneficiaries (QMB or QMB+) cannot be billed for any Medicare cost-share. Life Insurance *. Member Services can also help if you need to file a complaint about access (such as wheel chair access). PCP name and telephone number You and your administrative staff can quickly and easily access member eligibility and claims status information anytime, on demand. You have the right to get your questions answered. Benefit Type* Subscriber SSN or Card ID* Subscriber Group #* Patient First Name Patient Gender* Male Female Patient Date of Birth* Provider TIN or SSN*(used in billing) No referrals needed for network specialists. What should I do if I get a bill from a healthcare provider? For the PHCS Network, 1-800-922-4362 For PHCS Healthy Directions, 1-800-678-7427 For the MultiPlan Network, 1-888-342-7427 For the HealthEOS Network, 1-800-279-9776 For language assistance, please call 1-866-981-7427 For TTY/TTD service, please call 1-866-918-7427 Search for a provider > Letting us know if you have any questions, concerns, problems, or suggestions. For a specific listing of services and procedures that require preauthorization please refer to the preauthorization lists found within this manual. Please also be sure to follow any preauthorization procedures required by your plan(usually a telephone number on your ID card). Questions regarding the confidentiality of member information may be directed to Provider Services at 877-224-8230. You have the right under law to have a written/binding advance coverage determination made for the service, even if you obtain this service from a provider not affiliated with our organization. Not condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive. If you are a PCP, please discuss your provisions for after-hours care with your patients, especially for in-area, urgent care. Virtual colonoscopy for diagnostic purposes only, as determined by medical necessity criteria (CPT code 0067T). Please call Member Services if you have any questions. Get coverage information. The bill of service for these members must be submitted to Medicaid for reimbursement. What does Transition of Care and Continuity of Care mean? Prior Authorizations are for professional and institutional services only. You have the right to timely access to your providers and to see specialists when care from a specialist is needed. Refuse treatment and to receive information regarding the consequences of such action. My rep did an awesome job. According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. Emergency care is covered. It is important to sign this form and keep a copy at home. Box 450978 Westlake, OH 44145. Please note: MultiPlan, Inc. and its subsidiaries are not insurance companies, do not pay claims and do not guaranteehealth benefit coverage. As of January 1, 2023, the Transparency in Coverage Rule mandates member access to a healthcare price comparison tool. What to do if you think you have been treated unfairly or your rights are not being respected? Optional Life Insurance *. It is critical that the members eligibility be checked at each visit. For benefit-related questions, call Provider Services at 877-224-8230. Question 2. Your benefits, claims and/or eligibility are available 24/7 via our member portal. ConnectiCare's policies must show evidence of respecting the implementation of their rights, including a clear and precise statement of limitation if ConnectiCare and its network of participating providers cannot implement an advance directive as a matter of conscience. All oral medication requests must go through members' pharmacy benefits. Eligibility Claims Eligibility Fields marked with * are required. precertification on certain services. Coverage for medical emergencies without preauthorization. Occasionally, these complaints relate to the quality of care or quality of service members receive from their PCP, specialist, or the office staff. Member race, language, ethnicity, gender orientation, and sexual identity cannot be used to perform underwriting, rate setting, and benefit determinations (specifically denial of coverage and benefits), and cannot be disclosed to unauthorized users. Performance Health at Go > Document in a prominent part of the individual's current medical record whether or not the individual has executed an advance directive; and Ask to see the member's ConnectiCare member identification (ID) card. When performed out-of-network, these procedures do require preauthorization. Be considerate of our providers, and their staff and property, and respect the rights of other patients. Your responsibilities include the following: Getting familiar with your coverage and the rules you must follow to get care as a member. It is important to note that not all of the Sutter Health network . You have the right to make a complaint if you have concerns or problems related to your coverage or care. P.O. Following is the statement in its entirety. It is important to sign this form and keep a copy at home. Hartford, CT 06134-0308 ConnectiCare, in coordination with participating providers, will maintain and monitor the network of participating providers to ensure that members have adequate access to PCPs, specialists, hospitals, and other health care providers, and that through the network of providers their care needs may be met. For a specific listing of services and procedures that require pre-authorization refer to the Appendices within this manual. The admitting physician is responsible for pre-authorizing elective admissions five (5) working days in advance. Provider Portal - Claims & Eligibility Note: Refractions (CPT 92015) are considered part of the office visit and are not separately reimbursed.
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