Clinical Review Prior Authorization Request Form. Answer 3. Our goal is to be the best healthcare sharing program on the planet and to provide. Customer Service at 800-337-4973 Regardless of where you get this form, keep in mind that it is a legal document. The plan will release your information, including your prescription drug event data, to Medicare, which may release it for research and other purposes that follow all applicable Federal statutes and regulations. Some preventive services are covered at 100% and are exempt from the deductible requirement. You must apply for Transition of Care no later than 30 days after the date your coverage becomes effective or after the effective date of the network change using the request form below. Member satisfaction with ConnectiCare is very important. allergenic extracts (or RAST allergen specific testing); 2.) CT scans (all diagnostic exams) No specialist-to-specialist referrals permitted, except OB/GYNs may make referrals. This video explains it. Were here to help! To get any of this information, call Member Services. Refractions are not covered by ConnectiCare Medicare Advantage plans. A complete list of Sutter Health Hospitals and Medical Groups accepting this health plan. Balance Bill defense is available for all members with a Reference Based Pricing Plan. Refuse treatment and to receive information regarding the consequences of such action. ConnectiCare members must continue to pay the Medicare Part B premium directly to the Medicare program. Savings - Negotiated discounts that result in significant cost savings when you visit in-network providers,helping to maximize your benefits. The service area includes all counties in Connecticut. You can easily: Verify member eligibility status; . Coverage follows Original Medicare guidelines. 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. Prospective members must properly complete and sign an enrollment application and submit it to ConnectiCare. . Refer members to the ConnectiCare Member Services at 800-224-2273 if they need information on disenrollment. Letting us know if you have additional health insurance coverage. Identify the state legal authority permitting such objection; Choice - Broad access to nearly 4,400 hospitals, 79,000 ancillaries and more than 700,000 healthcareprofessionals. If you have any questions please review your formulary website or call Member Services. Virtual colonoscopy for diagnostic purposes only, as determined by medical necessity criteria (CPT code 0067T). Examples of covered medical conditions can be found below. (214) 436 8882 All requests to initiate or extend a mental health or substance abuse authorization should be directed to our Behavioral Health Program at 800-349-5365. Some plans cover preventive dental services: Receive information about us, our services, our participating providers, and "Members Rights and Responsibilities.". Members who do not have an ID card should not be denied medical services without contacting ConnectiCare first to determine the member's enrollment status. Members pay a copayment as cost-share for most covered health services at the time services are rendered. 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) Portal Training for Provider Groups Provider Portal SeeAutomated and Online Featuresfor additional information. ConnectiCare cannot reverse CMS' determination. For a specific listing of services and procedures that require pre-authorization refer to the Appendices within this manual. Each members enrollment is generally in effect as long as the member chooses to stay in ConnectiCare. Referrals must be signed in to ConnectiCaresProvider Connection. For plans where coverage applies, one routine eye exam per year covered at 100% after copayment (no referral required). Generally, we must get written permission from you (or from someone you have given legal power to make decisions for you) before we can give your health information to anyone who isnt providing your care or paying for your care. ConnectiCare involuntary disenrollment Note: Some plans may have different benefits/limits; refer members to Member Services for verification at 800-251-7722. TTY users should call 877-486-2048, or visit www.medicare.govto view or download the publication Your Medicare Rights & Protections. Under Search Tools, select find a Medicare Publication. If you have any questions whether our plan will pay for a service, including inpatient hospital services, and including services obtained from providers not affiliated with our plan, you have the right under law to have a written/binding advance coverage determination made for the service. Bone mass measurement PHCS Health Insurance - Health Insurance Providers You have the right to get your questions answered. After the deductible is met, benefits will be covered according to the Plan. Members of PHCS health insurance plans have mental health benefits, which vary based on the plan under which they're enrolled. Its affordable, alternative health care. Your benefits, claims and/or eligibility are available 24/7 via our member portal. You must pay for services that arent covered. Visit Performance Health HealthworksWellness Portal. We will make sure that unauthorized people dont see or change your records. Nuclear cardiology 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. Note: Refractions (CPT 92015) are considered part of the office visit and are not separately reimbursed. You will now leave the AvMed web site once you click the "I agree" button. If there are unusual and extraordinary circumstances, or the enrollees PCP is unavailable or inaccessible, the enrollee may seek urgent care treatment at the nearest facility. ConnectiCare will communicate to your patients how they may select a new PCP. Testing that exceeds this maximum is the members responsibility. PHCS (Private Healthcare Systems, Inc.) - Sutter Health Your right to the privacy of your medical records and personal health information. If you need assistance If you encounter issues when scheduling appointments with PHCS Network providers, call us at 866-685-7427. 2. You can also get free help and information from CHOICES - your SHIP. Enrollee satisfaction with ConnectiCare is very important. 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. MRI/MRA (all examinations) See the preauthorization section for a listing of DME that requires preauthorization. Copyright 2022 Unite Health Share Ministries. The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. Initial mental health consultation Call us and tell us you would like a decision if the service or item will be covered. You and your administrative staff can quickly and easily access member eligibility and claims status information anytime, on demand. Eligibility Claims Eligibility Fields marked with * are required. The plan cannot and will not disenroll a member because of the amount or cost of services used. Blue Cross Providers: 800 . Provider Portal Eligibility inquiry Claims inquiry. 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. ConnectiCare encourages members to actively participate in decision making with regard to managing their health care. This arrangement will be allowed until the safe transfer of care to a participating provider and/or facility can be arranged. To determine copayment requirement, call ConnectiCare's Eligibility & Referral Line at 800-562-6834. Eligibility Claims Eligibility Fields marked with * are required. 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. Land or air ambulance/medical transportation that is not due to an emergency requires pre-authorization. DME, orthotics & prosthetics must be obtained from a participating commercial DME vendor unless otherwise authorized by ConnectiCare and preauthorization must be obtained through ConnectiCare. (More information appears later in this section.). Member eligibility Medicaid managed care and Medicare Advantage plan effective dates Note: MultiPlan does not have access to payment records and does not make determinations with respect to ben-efits or eligibility. * ConnectiCare reserves the right to use third-party vendors to administer some benefits, including utilization management services. Members > MultiPlan You may want to give copies to close friends or family members as well. ConnectiCare takes all complaints from members seriously. 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 After the deductible has been met, coinsurance will apply to the covered benefits. PHCS Network | AvMed Remember you will only need your registration code this one time to set up your account. Voice complaints or appeals/grievances about us or the care you are provided. Employer group enrollment will be the result of employers electing to offer benefits to retirees through ConnectiCare. You can reference your plan document for the complete list. In addition, some of the ConnectiCare plans include Part D, prescription drug coverage. You can sometimes get advance directive forms from organizations that give people information about Medicare. In addition, the following guidelines apply: The following are covered preventive care services: Please note there are designated frequencies and age limitations. Use your member subscriber ID to access the pricing tool using the link below. 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 > To inquire about an existing authorization - (phone) 800-562-6833 Box 450978 Westlake, OH 44145. To request a continuation of an authorization forhome health careorIV therapyfax 860-409-2437, All infertility services that are subject to the mandate must be preauthorized, including: a) injectible infertility drugs for the purpose of ovulation induction, b) intrauterine insemination with or without the use of oral or injected medications for ovulation induction, and c) all ART procedures. Check Claims & Eligibility Verify patient eligibility and check the status of submitted claims through our online services below. Home health services are coordinated by ConnectiCare's Health Services: To verify benefits and eligibility - (phone) 800-828-3407 HPI | Provider Resources | Patient Benefits & Eligibility Go > This information, reprinted in its entirety, is taken from the planEvidence of Coverage. However, the majority of PHCS plans offer members . If you need more information, please call Member Services. Screening pap test. 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. ConnectiCare provides each member with a statement of member rights and responsibilities. They will be clearly distinguishable by their ID cards. (SeeOther Benefit Information). Be considerate of our providers, and their staff and property, and respect the rights of other patients. Monitoring includes member satisfaction with physicians. This means the PHCS Savility network offers the same quality for which PHCS Network has been recognized since 2001. Occasionally, these complaints relate to the quality of care or quality of service members receive from their PCP, specialist, or the office staff. Questions regarding the confidentiality of member information may be directed to Provider Services at 860-674-5850 or 800-828-3407. What does Transition of Care and Continuity of Care mean? info@healthdepotassociation.com, Copyright © 2023 Health Depot Association, All Rights Reserved, Supplemental Accident and/or Critical Illness, Follow the prompts to enter your search criteria. Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible. Pelvic exam PDF PHCS Savility - MultiPlan You can also get help from CHOICES - your State Health Insurance Assistance Program, or SHIP. Benefits - Penn Medicine Princeton Health If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You must apply for Continuity of Care within 30 days of your health care providers termination date (this is the date your provider is leaving the network) using the request form below. 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 LimitedBenefit plans. We conduct routine, focused surveys to monitor satisfaction using the Consumer Assessment of Health Plan Satisfaction (CAHPS) survey and implement quality improvement activities when opportunities are identified. ConnectiCare will also notify members of the change thirty (30) days prior to the effective date of the change, or as soon as possible after we become aware of the change. You have the right to an explanation from us about any bills you may get for drugs not covered by our Plan. Note: Some services require preauthorization. 860-509-8000, (TTY) 860-509-7191. All Practitioners:Please notify ConnectiCare in advance prior to taking any action to remove a specific member from your practice for any reason. You have the right to be told about any risks involved in your care. We must investigate and try to resolve all complaints. Services or supplies that are new or recently emerged uses of existing services and supplies, are not covered benefits unless and until we determine to cover them. Check with our Customer Service Team to find out if your plan accesses Health Coaching. We are equally committed to you, our PHCS PPO Network, and your overall satisfaction. ConnectiCare Medicare Advantage plans include a number of Medicare Advantage Plans. Routine hearing tests covered up to 1 every year, Routine eye exams covered up to 1 every year, Discounts are available on lenses, contacts and frames. Read the Membership Agreement, Evidence of Coverage, or other Plan document that describes the Plans benefits and rules. You have the right to receive a detailed explanation from us if you believe that a provider has denied care that you believe you were entitled to receive or care you believe you should continue to receive. Please note: MultiPlan, Inc. and its subsidiaries are not insurance companies, do not pay claims and do not guaranteehealth benefit coverage. Timely access means that you can get appointments and services within a reasonable amount of time. As always, confirm benefits by contacting Provider Services at 877-224-8230. See preauthorization list for DME that requires pre-authorization. Providers | Gmr If you are calling to verify your patient's benefits*, please have a copy If you have difficulty obtaining information from your plan based on language or a disability, call 1-800-MEDICARE (800-633-4227). You have the right to make a complaint if you have concerns or problems related to your coverage or care. ConnectiCare will communicate to your patients how they may select a new PCP. Members are required to see participating providers, except in emergencies. You have the right to get information from us about our plan. Coverage is provided for temporomandibular joint (TMJ) surgery or orthognathic procedures with preauthorization, when medical necessity is established. Provider Portal 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) How to get more information about your rights PHCS / Multiplan Provider Search for CommunityCare Life & Health PPO I'm a Broker. The provider must agree to accept network rates for the defined period of time. You may also search online at www.multiplan.com: Click on the Search for a Doctor or Facility button To find a participating provider outside of Oklahoma, follow the steps listed below. Your right to get information about our plan and our network pharmacies Since you have Medicare, you have certain rights to help protect you. Bone Mineral Density exams ordered more frequently than every twenty-three (23) months View sample member ID cards forcopayandhigh-deductibleplans for details. What should I do if I get a bill from a healthcare provider? To get any of this information, call Member Services. You have the right to ask someone such as a family member or friend to help you with decisions about your health care. Get coverage information. No referrals needed for network specialists. If you want a paper copy of this information, you may contact Provider Services at 877-224-8230. ConnectiCare, in compliance with advance directives regulations, must maintain written policies and procedures concerning advance directives with respect to all adult individuals receiving medical care. Your right to be treated with dignity, respect and fairness Accessing PHCS Savility PHCS Savility is available to insurers and benefit plan administrators meeting certain benefit design The PHCS Network is designed to be used with limited benefit plans that offer a higher level of coverage. SISCO's provider portal allows you to submit claims, check status, see benefits breakdowns, and get support, anytime. We dont discriminate based on a persons race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age, or national origin. To get any of this information, call Member Services. PPM/10.16 Overview of Plans Overview of products Answer 1. Additional term life coverage can be elected in increments of $10,000 to a maximum of $500,000 or 5 times your salary, whichever is less; paid for through payroll deductions. You have the right to refuse treatment. Be sure to ask your doctors and other providers if you have any questions and have them explain your treatment in a way you can understand. 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. New members may use a copy of the enrollment form as a temporary identification card until they receive their ID card. Members are no longer eligible for coverage after their 40th birthday. I called in with several medical bills to go over and their staff was extremely helpful. Optional Life Insurance *. 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. Colorectal screening (age restrictions apply) Coverage for medical emergencies without preauthorization. That goes for you, our providers, as much as it does for our members. This feature is meant to assist members who need additional copies of their ID card. If transport is required from one facility to another on a weekend or holiday, transport must be provided by a participating service. With discounts averaging 42% for physicians and specialiststhe types of services most typically used with these plansHealth Depot members get more value for their benefit dollars. part 91; other laws applicable to recipients of federal funds; and all other applicable laws and rules, are required by applicable laws or regulations. The right to know how information about race, language, ethnicity, gender orientation, and sexual identity are collected and used. Provider Quick Reference Guide - MultiPlan Simplifying the benefits experience, so you can focus on patient care. Note: To ensure accurate billing for plans with deductibles, bill ConnectiCare prior to taking any payment from members. New Century Health - Medical Oncology Policies, Provider resource: 2020 changes to Medicare Advantage plans, Dual special needs plan member information available through provider website, Reminders about caring for our Medicare Advantage members, Changes to claims payment for Medicare Advantage inpatient stays, Update on Medicare Beneficiary Identifiers (MBIs), Clinical Review Prior Authorization Request Form. Your right to get information about your drug coverage and costs From www.myperformancehlth.com, go to My Plan, Web Access Login, Register & Enroll, Select Member, Complete the Registration form. Performance Health at Emergency care is covered. ConnectiCare enrolls individual members into the ConnectiCare plan. Preferred Provider Organization Questions? UHSM medical sharing eligibility extends to qualifying costs at the more than 1.2 million doctors, hospitals, and specialists in this network. While you may contact us by telephone, you will be asked to place your concerns in writing. UHSM Providers - PHCS PPO Network View the video below for additional information on the MyMedicalShopper pricing tool: The Member Resource Document includes details for your reference on: You can reference your plan document for the complete list. Coverage for skilled nursing facility (SNF) admissions with preauthorization. They should be informed of any health care needs that require follow-up, as well as self-care training. Prostate cancer screening (age restrictions apply) Below are the additional benefits covered by ConnectiCare. Contact us. If you want a paper copy of this information, you may contact Provider Services at 860-674-5850 or 800-828-3407. We protect your personal health information under these laws. 1-1/2 times your annual salary paid to your beneficiary in the event of your death. ConnectiCare distributes its privacy notice to members annually, and to new members upon enrollment in the plan. This includes information about our financial condition, and how our Plan compares to other health plans.