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2014 Provider Orientation Manual
2014 Coventry Health Care of Illinois, Inc. Provider Orientation Manual Table of Contents I. Contact Information A. Important Contact Information B. Quick Links II. Prior A. B. C. D. III. Claims A. Submission of Claims B. Claim Inquiries C. Electronic Services IV. Provider Search A. How to Search for a Provider B. How to Create a Directory V. Disease Management Programs VI. Reference Materials Directprovider.com Quick Guide Members Rights and Responsibilities Disease Management/Case Management Referral Form Authorization Prior Authorization List (Medical Services) Medical Injection Prior Authorization List How to Decrease Call Time to Pre-Authorize Medical Services Peer to Peer Review Coventry Health Care of Illinois, Inc. 2 2014.v1 I - Contact Information A. Coventry Health Care of Illinois, Inc. - Important Contact Information Department Phone Toll Free Website Fax Accredo n/a 877-881-9047 www.accredo.com 877-481-1061 Caremark Therapeutic Service (for injectables) n/a 877-834-8657 www.caremark.com 877-834-8658 Coventry Medicare Advantra Customer Service n/a 866-784-4916 www.chcillinoismedicare.com n/a New Century Health (NCH) n/a 877-624-8601 #5 - Intake my.newcenturyhealth.com Coventry Pharmacy Service Center n/a 877-215-4098 www.chcillinois.com 877-554-9139 Customer Service (for fully insured members) 217-366-1226 800-431-1211 www.chcillinois.com n/a Customer Service (for self funded (ASO) members) n/a 866-557-8751 www.chcillinois.com 701-250-5394 Directprovider.com n/a 866-629-3975 www.directprovider.com n/a ICORE Mental Health Network MH Net (inpatient and outpatient mental health) National Imaging Associates (NIA) Pre Authorization Department 8:00 am – 5:00 pm CST; M-F Provider Relations n/a 800-424-4157 www.ICOREHealthcare.com n/a n/a 800-423-8070 www.mhnet.com n/a n/a 800-642-7835 www.RadMD.com n/a 217-373-3998 866-557-8748 www.chcillinois.com 800-224-2009 217-366-1226 800-562-5792 www.chcillinois.com 800-698-2043 n/a 888-584-8742 Triad Healthcare www.triadhealthcareinc.com 877-624-8602 888-229-5680 B. Coventry Health Care of Illinois, Inc. - Quick Links Category Website Location Pre-Authorization http://chcillinois.coventryhealthcare.com/services-andsupport/providers/pre-authorizations/index.htm Pharmacy http://chcillinois.coventryhealthcare.com/health-caresolutions/prescription-coverage/index.htm Provider Manual and Policies http://chcillinois.coventryhealthcare.com/services-andsupport/providers/document-library/index.htm Preventive Health and Practice Guidelines http://chcillinois.coventryhealthcare.com/services-andsupport/providers/practice-guidelines Hospital List Disease Management Brochure http://chcillinois.coventryhealthcare.com/services-andsupport/providers/document-library/index.htm http://chcillinois.coventryhealthcare.com/web/groups/pu blic/@cvty_regional_chcil/documents/document/c08065 6.pdf Coventry Health Care of Illinois, Inc. 3 Description Prior Authorization Lists Prior Authorization Form Authorization requirements by code Formulary, Pre Authorization, Step Therapy & Quantity limits Self-Administered Injectable Formulary Forms Policies Quality Improvement Program Preventive health guidelines (Pediatric/Teens/Adults) Practice Guidelines List of participating hospitals Disease Management Program Information 2014.v1 A. Prior Authorization (Medical) List (effective 08/01/14) HMO, POS, PPO, Medicare Advantra, CH&L PPO, Carelink & TotalCare *Please verify ASO plan requirements by calling 866-557-8751 Pre-authorization Department Phone: 866-557-8748 Fax: 800-224-2009 www.directprovider.com Inpatient care: Skilled Nursing Observation stays Transplants – includes initial evaluation All admissions (including maternity admissions) Acute inpatient Acute rehabilitation Outpatient care: Advanced Radiology Services (See NIA below): Medication given IV, IM, or sub-Q (See ICORE below and -All cardiac stress imaging -Cardiac nuclear scans -PET scans refer to website for listing of medications & forms) -CT scans -MRI/MRA -Stress echocardiogram Chemotherapeutic Drugs and supportive agents (See New Century Health below and refer to website for listing of medications & forms) Diagnosis/treatment of Autism spectrum disorders/Habilitative services Neuropsychological Testing Pain management injections (See Triad below) (including epidural and facets) Physical Therapy in custodial care setting Prosthetic/Orthotic devices – over $500 Durable medical equipment purchase over $500 and all rental equipment (oxygen, TENS, CPM and Bili Light units not Radiation Therapy Services (See MSI below for the included) following treatments: Brachytherapy, Intensity Modulated Radiation Therapy (IMRT), Proton Beam Therapy, Stereotactic Radiation Therapy) Experimental/Investigational services Sleep Studies (Sleep lab or outpatient facility) Genetic testing Surgical/other Outpatient procedures (outpatient hospital or ambulatory surgery center) refer to website for list Hyperbaric treatments of procedure codes requiring prior authorization) Infertility services Coventry Pharmacy www.chcillinois.com Prior Authorization: 877-215-4098 MHNET www.MHNET.com Prior Authorization: 800-423-8070 Self administered injectable medications Mental Health/Substance abuse IP & OP services Prior Authorization Contacts Applies to fully insured membership including Medicare Advantra business. Excludes Carelink, Self funded and Total Care membership ICORE www.icorehealthcare.com National Imaging Associates (NIA) Prior Authorization: 800-424-4157 www.RadMD.com Prior Authorization: 800-642-7835 Physician office and Facility locations Actemra J3262 Botox J0585 Gel-One J7326 Nplate J2796 Remicade J1745 Synvisc J7325 Acthar Euflexxa Myobloc Orthovisc Supartz/Hyalgan Tysabri Advanced Radiology Services: J0800 J7323 J0587 J7324 J7321 J2323 All cardiac stress imaging Cardiac nuclear scans Stress echocardiogram CT scans MRI/MRA PET scans New Century Health my.newcenturyhealth.com Prior Authorization: 877-624-8601 MedSolutions (MSI) www.medsolutions.com Physician office and Facility locations Prior Authorization: 877-624-8601 Chemotherapeutic drugs and supportive agents Radiation Therapy Services 2D and 3D conformal IMRT Proton Beam Therapy TRIAD Healthcare www.triadhealthcareinc.com Brachytherapy Neutron Beam Therapy SRS/SBRT Prior Authorization: 888-584-8742 Pain Management Services Prior authorization is the process for authorizing the non-emergency use of facilities, diagnostic testing, and other health services before care is provided. Coventry Health Care of Illinois, Inc. 4 2014.v1 B. Medical Injection Prior Authorization List (effective 08/01/2014) HMO/POS/PPO, Medicare Advantra Phone: 800-546-4603 Fax 866-603-5536 www.directprovider.com All new drugs require prior authorization Alphabetical by drug name Numerical by drug code Drug Name Code Code Drug Name 8-Mop** J8999 90283 Immune globulin (IgIV) Abraxane J9264 90378 Synagis Actemra* J3262 C9257 Avastin* Acthar* J0800 C9278 Xeomin Adalimumab J0135 C9281 Krystexxa Adcentris (brentuximab vendotin)** J9042 C9284 Yervoy Adriamycin** J9000 C9286 Nulojix Adrucil** J9190 C9291 Aflibercept Advate J7192 C9292 Perjeta Aflibercept C9291 C9297 Synribo** Alkeran** J8600 J0129 Orencia Alkeran** J9245 J0135 Adalimumab Aloxi** J2469 J0178 Eylea Alpha 1 Proteinase Inhibitor (Human) J0257 J0180 Fabrazyme Alphanate J7186 J0207 Ethyol** AlphaNine SD J7193 J0215 Amevive Amevive J0215 J0220 Myozime Anti-Inhibitor J7198 J0221 Lumizyme Antithrombin Recombinant J7196 J0256 Prolastin Aranesp** J0881 J0256 Zemira Aredia (pamidronate) J2430 J0257 Alpha 1 Proteinase Inhibitor (Human) Arixtra** J1652 J0490 Benlysta (belimumab) Arranon** J9261 J0585 Botox* Arzerra (ofatumumab) J9302 J0586 Dysport Avastin* C9257 J0587 Myobloc* Avastin** J9035 J0588 Etanercept Bebulin VH J7194 J0594 Busulfex** Belnoxane** J9040 J0597 C-1 Esterase Inhibitor (human) Benefix J7195 J0598 Cinryze (esterase) Benlysta (belimumab) J0490 J0638 Canakinumab Bexxar** J9999 J0640 Leucovorin** Bicnu** J9050 J0641 Fulsilev** Bioclate J7192 J0718 Certolizumab Pegol Bivigam** J3590 J0725 Ovidrel (chorionic gonadotropin) Boniva J1740 J0725 Pregnyl (chorionic gonadotropin) Coventry Health Care of Illinois, Inc. 5 2014.v1 Botox* J0585 J0725 Profasi (chorionic gonadotropin) Busulfex** J0594 J0775 Xiaflex C-1 Esterase Inhibitor (human) J0597 J0800 Acthar* Cabazitaxel J9043 J0800 H.P. Acthar Gel Campath** J9010 J0881 Aranesp** Camptosar** J9206 J0882 Darbepoetin Alfa Canakinumab Carimune (immune globulin lyophilized) Ceenu** J0638 J0885 Epogen/Procrit* J1566 J0894 Dacogen J8999 J0897 Prolia Cerezyme J1786 J0897 Xgeva Certolizumab Pegol J0718 J1190 Zinecard** Cinryze (esterase) J0598 J1290 Kalbitor Clolar J9027 J1300 Soliris Cosmegen** J9120 J1325 Flolan (veletri) Cytostar-U** J9100 J1438 Enbrel Cytoxan** J8530 J1442 Neupogen** Cytoxan** J9070 J1453 Emend** Dacogen J0894 J1458 Naglazyme Darbepoetin Alfa J0882 J1459 Privigen Daunorubicin** J9150 J1460 Immune Globulin Daunoxome** J9151 J1557 Gammaplex Depocyt** J9098 J1559 Immune globulin (IgIV) Doxil** J9002 J1560 Immune Globulin Doxil** Q2050 J1561 Gamunex Dtic-Dome** J9130 J1562 Dysport J0586 J1566 Elaprase J1743 J1568 Immune globulin (Vivaglobin) Carimune (immune globulin lyophilized) Octagam Elitek** J2783 J1569 Gammagard Ellence** J9178 J1572 Flebogamma Eloxatin** J9263 J1595 Glatiramer Acetate Emcyt** J8999 J1599 Immune globulin (IgIV) Emend** J1453 J1602 Simponi (golimumab) Emend** J8501 J1652 Arixtra** Enbrel J1438 J1675 Epogen/Procrit* J0885 J1725 Erbitux J9055 J1740 Histrelin Acetate Makena (hydroxyprogesterone caproate) Boniva Erwinaze J9020 J1743 Elaprase Erwinaze** J9019 J1745 Remicade* Etanercept J0588 J1786 Cerezyme Ethyol** J0207 J1826 Interferon Beta-1A Euflexxa* J7323 J1830 Interferon Beta-1B Eulexin** J8999 J1930 Somatuline Coventry Health Care of Illinois, Inc. 6 2014.v1 Eylea J0178 J1950 Lupron Depot Fabrazyme J0180 J2020 Zyvox (linezolid) Factor VIII J7191 J2170 Mecasermin** Factor XIII J7180 J2315 Vivitrol Fareston** J8999 J2323 Tysabri* Faslodex** J9395 J2353 Sandostatin LAR Firmagon** J9155 J2354 Octreotide Flebogamma J1572 J2355 Neumega Flolan (veletri) J1325 J2357 Xolair Fludara** J9185 J2358 Olanzapine Folotyn (pralatrexate) J9307 J2425 Kepivance** Fudr** J9200 J2430 Aredia (pamidronate) Fulsilev** J0641 J2469 Aloxi** Gammagard J1569 J2503 Macugen Gammaplex J1557 J2505 Neulasta** Gamunex J1561 J2507 Pegloticase Gel-One* J7326 J2562 Mozobil (perixafor) Gemzar** J9201 J2778 Lucentis Glatiramer Acetate J1595 J2783 Elitek** Goserelin J9202 J2793 Rilonacept H.P. Acthar Gel J0800 J2796 Nplate* Halaven (eribulin mesylate) J9179 J2820 Leukine** Halotestin** J8999 J2941 Somatropin Helixate FS J7192 J3110 Teriparatide Hematide (peginesatide) Q2047 J3240 Thyrogen Hemofil-M Hemophilia clotting factor not otherwise classified Herceptin** J7190 J3262 Actemra* J7199 J3285 Remodulin (Treprostinil) J9355 J3315 Trelstar Hexalen** J8999 J3357 Stelara Histrelin J9225 J3385 VPRIV (velaglucerase alfa) Histrelin Acetate J1675 J3396 Visudyne (verteporfin) Human Fibrinogen Q2045 J3487 Zometa Humate-P J7187 J3488 Reclast Hyalgan* J7321 J3489 Reclast Hyaluronate J7326 J3489 Zometa Hydrea** J8999 J3490 Voraxaze** Idamycin** J9211 J3590 Bivigam** Ifex** J9208 J7180 Immune Globulin J1460 J7183 Immune Globulin J1560 J7185 Factor XIII Von Willebrand factor complex (human) Xyntha (factor VIII) Immune globulin (IgIV) 90283 J7186 Immune globulin (IgIV) J1559 J7186 Coventry Health Care of Illinois, Inc. 7 Alphanate Von Willebrand factor complex (human) 2014.v1 Immune globulin (IgIV) J1599 J7187 Immune globulin (Vivaglobin) J1562 J7187 Interferon Alfa-2A J9213 J7189 Humate-P Von Willebrand factor complex (human) Novoseven Interferon Alfa-2B J9214 J7190 Hemofil-M Interferon Alfa-N3 J9215 J7190 Koate-DVI/HP Interferon Beta-1A J1826 J7190 Monarc-M Interferon Beta-1B J1830 J7190 Monoclate-P Interferon Gamma J9216 J7191 Factor VIII Istodax (romidepsin) J9315 J7192 Advate Ixempra J9207 J7192 Bioclate Kalbitor J1290 J7192 Helixate FS Kepivance** J2425 J7192 Kogenate/FS Koate-DVI/HP J7190 J7192 Recombinate/Refacto Kogenate/FS J7192 J7193 AlphaNine SD Konyne-80 J7194 J7193 Mononine Krystexxa C9281 J7194 Bebulin VH Kyprolis** J9047 J7194 Konyne-80 Leucovorin** J0640 J7194 Profilnine SD Leucovorin** J8999 J7194 Proplex T Leukeran** J8999 J7195 Benefix Leukine** J2820 J7196 Antithrombin Recombinant Leustatin** J9065 J7197 Thrombate III (antithrombin III) Lipodox** Q2049 J7198 Lucentis J2778 J7199 Lumizyme J0221 J7321 Anti-Inhibitor Hemophilia clotting factor not otherwise classified Hyalgan* Lupron J9217 J7321 Supartz* Lupron J9218 J7323 Euflexxa* Lupron Depot J1950 J7324 Orthovisc* Lysodren** J8999 J7325 Synvisc* Macugen J2503 J7326 Gel-One* Makena Makena (hydroxyprogesterone caproate) Marqibo** Q2042 J7326 Hyaluronate J1725 J7686 Treprostinil J9999 J8501 Emend** Matulane** J8999 J8510 Myleran** Mecasermin** J2170 J8530 Cytoxan** Mesnex** J9209 J8600 Alkeran** Methotrexate** J9250 J8700 Temodar Methotrexate** J9260 J8705 Topotecan oral Monarc-M J7190 J8999 8-Mop** Monoclate-P J7190 J8999 Ceenu** Mononine J7193 J8999 Emcyt** Mozobil (perixafor) J2562 J8999 Eulexin** Coventry Health Care of Illinois, Inc. 8 2014.v1 Mustargen** J9230 J8999 Fareston** Mutamycin** J9280 J8999 Halotestin** Myleran** J8510 J8999 Hexalen** Mylotarg** J9300 J8999 Hydrea** Myobloc* J0587 J8999 Leucovorin** Myozime J0220 J8999 Leukeran** Naglazyme J1458 J8999 Lysodren** Navelbine** J9390 J8999 Matulane** Neulasta** J2505 J8999 Nilandron** Neumega J2355 J8999 Purinethol** Neupogen** J1442 J8999 Sprycel** Nilandron** J8999 J8999 Stivarga** Nipent** J9268 J8999 Tafinalar** Novantrone** J9293 J8999 Targretin** Novoseven J7189 J8999 Tretinoin/Vesanoid** Nplate* J2796 J9000 Adriamycin** Nulojix C9286 J9002 Doxil** Octagam J1568 J9010 Campath** Octreotide J2354 J9015 Proleukin** Olanzapine J2358 J9019 Erwinaze** Oncaspar** J9266 J9020 Erwinaze Oncovin** J9370 J9025 Vidaza Ontak** J9160 J9027 Clolar Orencia J0129 J9031 Tice/Theracys** Orthovisc* J7324 J9033 Treanda** Ovidrel (chorionic gonadotropin) J0725 J9035 Avastin** Paraplatin** J9045 J9040 Belnoxane** Pegloticase J2507 J9041 Velcade Pegylated Interferon Alfa-2A S0145 J9042 Adcentris (brentuximab vendotin)** Pegylated Interferon Alfa-2B S0148 J9043 Cabazitaxel Pemetrexed J9305 J9045 Paraplatin** Perjeta C9292 J9047 Kyprolis** Photofrin** J9600 J9050 Bicnu** Platinol** J9060 J9055 Erbitux Pregnyl (chorionic gonadotropin) J0725 J9060 Platinol** Privigen J1459 J9065 Leustatin** Profasi (chorionic gonadotropin) J0725 J9070 Cytoxan** Profilnine SD J7194 J9098 Depocyt** Prolastin J0256 J9100 Cytostar-U** Proleukin** J9015 J9120 Cosmegen** Prolia J0897 J9130 Dtic-Dome** Proplex T J7194 J9150 Daunorubicin** Provenge Q2043 J9151 Daunoxome** Coventry Health Care of Illinois, Inc. 9 2014.v1 Purinethol** J8999 J9155 Firmagon** Reclast J3488 J9160 Ontak** Reclast J3489 J9171 Taxotere** Recombinate/Refacto J7192 J9178 Ellence** Remicade* J1745 J9179 Halaven (eribulin mesylate) Remodulin (Treprostinil) J3285 J9181 Vepesid** Rilonacept J2793 J9185 Fludara** Rituxan J9310 J9190 Adrucil** Sandostatin LAR J2353 J9200 Fudr** Sermorelin Acetate Q0515 J9201 Gemzar** Simponi (golimumab) J1602 J9202 Goserelin Soliris J1300 J9202 Zoladex Somatropin J2941 J9206 Camptosar** Somatuline J1930 J9207 Ixempra Sprycel** J8999 J9208 Ifex** Stelara J3357 J9209 Mesnex** Stivarga** J8999 J9211 Idamycin** Supartz* J7321 J9213 Interferon Alfa-2A Supprelin LA (histrelin implant) J9226 J9214 Interferon Alfa-2B Synagis 90378 J9215 Interferon Alfa-N3 Synribo** C9297 J9216 Interferon Gamma Synvisc* J7325 J9217 Lupron Tafinalar** J8999 J9218 Lupron Targretin** J8999 J9219 Viadur** Taxol** J9265 J9225 Histrelin Taxotere** J9171 J9226 Supprelin LA (histrelin implant) Temodar J8700 J9228 Yervay (ipilimumab) Temozolomide J9328 J9230 Mustargen** Teriparatide J3110 J9245 Alkeran** Testopel S0189 J9250 Methotrexate** Thioplex** J9340 J9260 Methotrexate** Thrombate III (antithrombin III) J7197 J9261 Arranon** Thyrogen J3240 J9263 Eloxatin** Tice/Theracys** J9031 J9264 Abraxane Topotecan J9351 J9265 Taxol** Topotecan oral J8705 J9266 Oncaspar** Torisel (temsirolimus) J9330 J9268 Nipent** Treanda** J9033 J9280 Mutamycin** Trelstar J3315 J9293 Novantrone** Treprostinil J7686 J9300 Mylotarg** Tretinoin/Vesanoid** J8999 J9302 Arzerra (ofatumumab) Tysabri* J2323 J9303 Vectibix Uvadex** J9999 J9305 Pemetrexed Coventry Health Care of Illinois, Inc. 10 2014.v1 Valstar** J9357 J9307 Folotyn (pralatrexate) Vectibix J9303 J9310 Rituxan Velban** J9360 J9315 Istodax (romidepsin) Velcade J9041 J9320 Zanosar** Vepesid** J9181 J9328 Temozolomide Viadur** J9219 J9330 Torisel (temsirolimus) Vidaza J9025 J9340 Thioplex** Visudyne (verteporfin) J3396 J9351 Topotecan Vivitrol Von Willebrand factor complex (human) Von Willebrand factor complex (human) Von Willebrand factor complex (human) Voraxaze** J2315 J9355 Herceptin** J7183 J9357 Valstar** J7186 J9360 Velban** J7187 J9370 Oncovin** J3490 J9390 Navelbine** VPRIV (velaglucerase alfa) J3385 J9395 Faslodex** Vumon** Q2017 J9400 Zaltrap** Xeomin C9278 J9600 Photofrin** Xgeva J0897 J9999 Bexxar** Xiaflex J0775 J9999 Marqibo** Xolair J2357 J9999 Uvadex** Xyntha (factor VIII) J7185 J9999 Yondelis** Yervay (ipilimumab) J9228 Q0515 Sermorelin Acetate Yervoy C9284 Q2017 Vumon** Yondelis** J9999 Q2042 Makena Zaltrap** J9400 Q2043 Provenge Zanosar** J9320 Q2045 Human Fibrinogen Zemira J0256 Q2047 Hematide (peginesatide) Zinecard** J1190 Q2049 Lipodox** Zoladex J9202 Q2050 Doxil** Zometa J3487 S0145 Pegylated Interferon Alfa-2A Zometa J3489 S0148 Pegylated Interferon Alfa-2B Zyvox (linezolid) J2020 S0189 Testopel For a listing of pharmacy injectables/SAI's that require prior authorization, please visit our websites at www.chcillinois.com www.chcmissouri.com www.chcillinoismedicare.com www.chcmissourimedicare.com Coventry Health Care of Illinois, Inc. 11 2014.v1 C. How to Decrease Call Time to Pre-Authorize Medical Services Call and hold time to pre-authorize services will be decreased if all provider offices have some basic information available to them when they place a call to the Pre-Authorization Department at 866-557-8748 or 217-373-3998. We will need the following information: 1. Your name, the office you are calling from and a call back number 2. Member name 3. Member ID number 4. Test or Procedure requested (CPT code) 5. Diagnosis (ICD-9 code) 6. Requested place of service 7. Anticipated date of service 8. Current patient symptoms or suspected disorder 9. Findings on physical exam (PCP or specialist) 10. Medical/surgical history related to this request 11. Current medications related to this request (including failed medication therapy as appropriate) 12. Results of previous imaging studies related to this request 13. Results of lab testing related to this request 14. Results from the use of assistive devices (i.e. can crutches and or walker related to this request) Prior Authorization Phone Queue Dial 866-557-8748 and see below for menu choices to help direct your prior authorization calls and reduce wait times: Be prepared to report the member’s coverage type (e.g., HMO, PPO, Advantra or ASO (self-funded)), as numeric options are based on this information. For questions about claims or benefits, press 2. For pharmacy oral medication authorizations or self-administered injectables, press 3. To check the status of a request for authorization, press 4. For ASO (self-funded employer groups) authorizations, press 5. For authorizations of services applicable to the outpatient imaging program National Imaging Associates (NIA), press 6 for commercial or Medicare Advantra members. For authorizations of services applicable to the outpatient pain management program Triad, press 7 for commercial or Medicare Advantra members. For all other prior authorizations for commercial membership or Medicare Advantra members, press 8. To hear the menu again, press 9. Additionally, directprovider.com is available. Data is readily available to providers to help accelerate claims processing and information flow. If you have not already registered, please do so to review available information. Common uses of the site include: Verification of whether or not a service requires prior authorization by CPT code Submission of online requests for prior authorization Viewing status of an authorization request Please note that you need a user name and password to use directprovider.com. For more information about how to access directprovider.com, contact your local Provider Relations representative at 800-562-5792. D. Peer to Peer Review If a provider disagrees with a decision made by one of Coventry’s medical directors, he/she may speak with that medical director in a peer-to-peer discussion at 314-506-1708. Peer-to-peer discussions should occur within one business day of the adverse decision. III - Claims A. Submission of Claims Paper claim submission Paper claims must be submitted to Coventry Health Care of Illinois, Inc. on CMS-1500 or UB-04 forms. The provider is responsible for ensuring data being submitted is accurate and complete. Be sure to use valid and complete diagnosis codes on your claims. All information should be printed on the forms within the specified boxes. Coventry Health Care of Illinois, Inc. 12 2014.v1 Medical Claim Mailing Address: Coventry Health Care, P.O. Box 7141, London, KY 40742 Electronic medical claim submission Coventry Health Care of Illinois, Inc. encourages physicians and facilities to submit claims electronically. Electronic claim submissions can have significant, positive impact on the productivity and cash flow for your practice. Electronic claim submissions will be routed through Emdeon who will review and validate the claims for HIPAA compliance and forward them directly to Coventry. The Emdeon Payer ID for Coventry Health Care of Illinois, Inc. is 25133. Contact your practice management system vendor or clearinghouse to initiate the process. Providers should call (800) 215-4730 for information on direct submission to Emdeon. B. Claim Inquiries DirectProvider Directprovider.com and Emdeon have an online claims adjustment process that many providers find very useful. For more information, please see the Quick Guide for directprovider.com located in the back of this manual. C. Electronic Services Coventry Health Care of Illinois, Inc. offers providers various electronic services to assist with claims payment and posting. Electronic Fund Transfer (EFT) Any provider that participates with Coventry Health Care, Inc. is eligible to receive EFT. Providers receive claim payments more quickly and the payments are directly deposited into the provider’s bank account. For additional information, please visit our website www.chcillinois.com or www.coventryil.com and review the information under the Electronic Solutions section. To begin the process of receiving EFT, you must complete the EFT form. It is located on our website at www.chcillinois.com or www.coventryil.com under Providers, click on Document Library, then under the Forms section, you will see the EFT form. Please note that when you sign up for EFT you will no longer receive paper remittances advices in the mail. Electronic Remittance Advice (ERA) Electronic Remittance Advices allow providers to post payments quickly and efficiently. ERA’s have many benefits for provider offices and hospitals. It allows for increased accuracy of posting and increased billing office productivity. For more information on ERA’s, go to our website, www.chcillinois.com or www.coventryil.com, click on Provider, then Electronic Solutions, then EDI Documentation. IV - Provider Search A. How to Search for a Provider at www.chcillinois.com, www.coventryil.com, or www.chcillinoismedicare.com Coventry Health Care of Illinois Inc.’s online provider search makes finding a network provider even easier. The provider search is used to find a doctor, hospital or other type of providers based on specific search criteria. The following instructions will help you find the type of provider (doctor, hospital, behavioral health/substance abuse provider or ancillary service provider) you select. 1. Go to www.chcillinois.com, www.coventryil.com, or www.chcillinoismedicare.com and select Providers. Then click on “Locate a Provider” on the top of the page. 2. Click on the blue box labeled “Provider Search”. Select a plan Search by zip code, name, facility, county, specialty or condition 3. Based upon your search criteria, you can select more options to narrow your search. Click on the left and right arrows. 4. You also have the option to print a directory or sort by distance. 5. At anytime, you can start a new search by clicking on Start a new search located at the upper right of the screen. B. How to Create a Directory at www.chcillinois.com, www.coventryil.com, www.chcillinoismedicare.com Coventry Health Care of Illinois, Inc. 13 2014.v1 Coventry Health Care of Illinois Inc.’s online provider search makes finding a network provider even easier. The provider search is used to find a doctor, hospital or other type of providers based on specific search criteria. The following instructions will help you find the type of provider (doctor, hospital, behavioral health/substance abuse provider or ancillary service provider) you select. 1. Go to www.chcillinois.com, www.coventryil.com, or www.chcillinoismedicare.com and select Providers. Then click on “Locate a Provider” on the top of the page. 2. Click on the blue box labeled “Provider Search”. Select a plan, Search by zip code, name, facility, county, specialty or condition 3. Based upon your search criteria, you can select more options to narrow your search. Click on the left and right arrows. 4. You also have the option to print a directory or sort by distance. 5. At anytime, you can start a new search by clicking on Start a new search located at the upper right of the screen. V - Disease Management Programs COVENTRY HEALTH CARE DISEASE MANAGEMENT PROGRAMS The following Disease Management Programs are offered by Coventry Health Care of Illinois, Inc. Condition Asthma Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Coronary Artery Disease (CAD) Diabetes Age Requirement Age 5 & older Age 18 & older Age 18 & older Age 18 & older Age 5 & older Clinical Practice Guidelines: All of the disease management programs are based on clinical practice guidelines from nationally recognized organizations. Our member education is based on the recommended care outlined in these clinical practice guidelines. Program Clinical Practice Website Guidelines American Lung and National Asthma Heart, Lung and Blood Institute Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Coronary Artery Disease (CAD) Diabetes Global Initiative for Chronic Obstructive Lung Disease – World Health Organization, National Heart, Lung and Blood Institute and the American Lung Association American College of Cardiology and the American Heart Association American College of Cardiology and the American Heart Association http://www.nhlbi.nih.gov/guidelines/asthma http://www.goldcopd.com/ http://www.acc.org/qualityandscience/clincal/statements.htm http://www.acc.org/qualityandscience/clincal/statements.htm American Diabetes Association http://diabetes.org/for-health-professionals-andscientists/cpr.jsp Program Enrollment: System Referrals: Members identified with Asthma, COPD, CHF, CAD and Diabetes is enrolled into the disease management programs. Members are referred to the program through the utilization review process and through the use Coventry Health Care of Illinois, Inc. 14 2014.v1 of Coventry Health Care’s disease management system that utilizes medical and pharmacy claims to identify members who may benefit from the programs. Members are provided with information on how to Opt-Out of the programs, if they prefer not to participate. Self Referrals: Members may self-refer to any of the disease management programs by contacting the customer service number on the back of their insurance card. Provider Referrals: Providers may refer a member by contacting the customer service number on the back of the member’s insurance card OR by faxing the attached provider referral form to 866-603-5400. Coventry Health Care of Illinois, Inc. 15 2014.v1 Risk Stratification and Interventions: Members identified for Disease Management Programs are stratified into three risk groups – Low, Medium and High. Product Commercial Membership (Fully-Insured, ASO) Low Risk Welcome Kit Outreach Call – Disease Management (DM) Call Center – to review treatment goals and recommended services Advantra & Total Care Moderate Risk Welcome Kit & Outreach Call Targeted Mailing for members missing one or more recommended service for their condition Targeted Outreach Call from DM Call Center staff to review the importance of the missing service(s). Welcome Kit Quarterly Disease Specific Mailings High Risk Welcome Kit & Outreach Call Targeted Mailings & Targeted Outreach Call Referral for Case Management Evaluation and ongoing Case Management services, if needed Welcome Kit Quarterly Mailings Targeted Reminders Welcome Kit Quarterly Mailings Targeted Mailings Referral for Case Management Evaluation and ongoing Case Management services, if needed. Program interventions are based on the Risk Stratification of the member. Members are re-stratified every 6 months. Disease Management Program Interventions are based on the Risk Stratification. VI - Reference Materials A. B. C. D. E. DirectProvider Quick Guide Authorization Form Provider Request for Review Form Members Rights and Responsibilities Disease Management/Case Management Referral Form Coventry Health Care of Illinois, Inc. 16 2014.v1 If your Tax ID has not already Provider Offices do not require “permission” to access their information associated with their tax IDs. been registered 1. 2. Identify who the account administrator will be. The account administrator is responsible for adding and deleting users and giving privileges to certain functions within the site. 2. Decide if you prefer to have a single administrator who is responsible for setting up other users throughout the organization, or an administrator for each site. 3. Each user will set up those Tax IDs, plans, and providers they wish to see in their individual drop-down boxes. All providers associated with a Tax ID will be available for selection to include in your drop-down box. Click on the Login/Register link on the Provider Channel at www.chcillinois.com or www.coventryil.com 3. Click the Register link on the home page 4. Fill out the online form, remembering to fill in all required fields (designated with an asterisk *). Tax ID and Coventry Health Care of Illinois, Inc. provider ID will be required, along with a designated account administrator and their email address. If you do not have your provider ID number, you can obtain it from your Coventry Provider Representative. 5. You will be asked to identify what password you wish. 6. Your user ID will be emailed within a day to the email account as designated on the setup form. The information on your setup form will be validated. If the information CANNOT be validated, you will be instructed via email to contact Net Support at 866-629-3975. Users who have multiple tax IDs will be required to sign up under a single tax ID. User’s have the ability to add additional tax IDs after they have logged in. A letter will be sent to the primary address we have on file for that Coventry Health Care of Illinois, Inc. provider ID notifying the site that someone has registered to use directprovider.com. For Large Provider Groups and Billing Offices with Multiple Tax IDs and Providers 1. During registration you will need to determine which provider “type” you wish to sign up as. To set up new users under an existing Tax ID New users are required to contact their administrators in order to register for a user ID and password. New users will be set up under the Tax ID(s) of the administrator who sets them up. If a new user is unsure who their administrator is, they can contact Net Support at 866-629-3975. Administrators will need to complete the enrollment form online. 1. Complete the online form, remembering to fill-in all required fields (designated with an asterisk *). Administrators will set up the user ID. 2. Set up the user’s online privileges. Administrators have the power to restrict a user’s access to certain functionality and times they can access those functions. 3. Verify the information online. 4. The Administrator will forward the user ID to the new user. 5. A temporary password will be emailed to the new user or to the administrator if no email is available for the user. Users will have the ability to change their password after they log in. Please note: emails to new users and administrators will include a link to the User’s Guide. User IDs and passwords will never appear in the same email for security reason. Billing Provider Type—This is a separate entity that is contracted with the provider to do billing for them. Providers who own individual Tax IDs will be contacted and will need to give the billing offices permission to access their information. Provider Office Type—This is a provider who does not contract with an outside organization for billing services. Coventry Health Care of Illinois, Inc. 17 2014.v1 Coventry Commercial Products (HMO,PPO,POS) Member Rights and Responsibilities As a CoventryMember, you have the right to: · Receive information about Coventry, its services, its practitioners and providers and member rights and Responsibilities · Be treated with respect and recognition of your dignity and right to privacy · Participate with practitioners in making decisions about your health care · A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage · Voice complaints or appeals about Coventry or the care it provides · Make recommendations regarding Coventry’s member rights and responsibilities policy As a CoventryMember, you have the responsibility to: · Supply information (to the extent possible) that Coventry and its practitioners and providers need in order to provide care · Follow plans and instructions for care that you have agreed to with your practitioners · Understand your health problems and participate in developing mutually agreed-upon goals, to the degree possible Coventry Health Care of Illinois, Inc. 18 2014.v1 Plan Member Rights and Responsibilities The health plan preserves and protects the rights of its members to obtain the health care they require. In addition, members are responsible for working with their plan and providers to promote their well-being. A. Members have the right to be treated as a partner when choosing the appropriate care. This right is often asserted in the following ways: 1. Each member may designate their own primary care physician under their plan’s network requirements. 2. Members may see most types of participating specialty care physicians without a referral from a primary care physician regardless of their plans (e.g. HMO, POS, or PPO). For female members, this includes a women’s principal health care provider, such as a participating physician specializing in obstetrics and gynecology. 3. All members are entitled to all of the information necessary to manage their health care needs. They may also seek a second opinion if they so choose. 4. Members and providers may discuss the appropriateness or medical necessity of treatment options for the conditions at hand, regardless of cost or benefit coverage. The health plan does not ask health care providers to withhold information about treatments that may not be covered. B. Members have the right to receive information that enables them to maximize their plan’s benefits. We are available to answer any and all questions regarding health benefits. We also provide members with the following information on our secure website: 1. Evidence of Coverage: Outlines benefits in depth, including what the member will pay for the services he or she receives 2. Plan Member Identification Card: Helps others recognize them as a plan member. 3. Provider Directory: Lists doctors, hospitals and other care providers within a member’s network. 4. Member Rights and Responsibilities: Describes how to obtain a printed copy of this statement and explains any policy changes through our plan’s member publication Living Well. Printed copies of any web-based materials may be obtained by calling the toll-free Customer Service number on the back of the member ID card. C. Members have the right to be treated with dignity and respect. The health plan honors members’ rights by: 1. Respecting their privacy. We treat nonpublic personal information with the utmost respect. We have instated policies and procedures to protect members’ information against unlawful use or disclosure. 2. Treating members as we would like to be treated. 3. Valuing members’ personal dignity and preferences. D. Members have the right to voice their concerns or problems with the plan or the care they receive. We encourage unsatisfied members to voice their opinions in the following ways: 1. Call the Customer Service department at the number on the back of the plan member ID card. 2. Send a letter to our Customer Service department at 2110 Fox Drive, Suite A, Champaign, Illinois 61820. 3. Write to the Illinois Department of Insurance (Attention: Consumer Services) at 320 W. Washington, Springfield, Illinois 62767. E. Members have the right to make recommendations regarding our rights and responsibilities statement. This statement was reviewed by our Consumer Advisory committee, which is composed of plan members. Please write the Quality Improvement department at 2110 Fox Dr. Suite A, Champaign, IL 61820 in order to do so. F. Members must assist their health plan and doctors in the following ways: 1. Remain polite and respectful. 2. Present their member identification card at the time of service. 3. Allow no one else to use identification card. 4. Provide true and complete details regarding their previous and present state of health. 5. Refrain from divulging false details that may mislead care providers or limit their ability to administer proper medical care. 6. Gain a full understanding of health problems and participate in the development of treatment goals. 7. Follow the treatment plan discussed between the member and provider, and communicate any concerns. 8. Pay premiums on time. 9. Pay copayments/coinsurance amounts required by the plan and provider. 10. Provide the plan with requested information, including medical records, as well as physician statements regarding physical conditions, care and treatment. Coventry Health Care of Illinois, Inc. 19 2014.v1 Coventry Health Care of Illinois, Inc. Disease Management ● Case Management Referral Form Providers: Fax Completed form to 1-866-603-5400 Member Name: Member’s Coventry ID number: Member Phone Number (daytime): Member DOB: Referring Physician Name: PCP Name: Referring Physician Phone Number: Referring Physician Fax Number: Disease Management Program referral – Please check Asthma COPD CHF Coronary Artery Disease Diabetes Case Management Program referral Diagnosis: Brief description explaining reason for referral : Person Completing Form: Coventry Health Care of Illinois, Inc. Date: 20 2014.v1
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