phcs eligibility and benefits

Mail Paper HCFAs or UBs: Medi-Share You have the right to go to a womens health specialist (such as a gynecologist) without a referral. These services are covered under the Option Plan nationwide. You must be told in advance if any proposed medical care or treatment is part of a research experiment, and be given the choice of refusing experimental treatments. We must investigate and try to resolve all complaints. Voice complaints or appeals/grievances about us or the care you are provided. Out of network benefits will apply when receiving care from non-participating providers. We must tell you in writing why we will not pay for or approve a service, and how you can file an appeal to ask us to change this decision. Emergency care and out-of-area urgently needed services are covered under the Prime and Custom Plans, anytime, anywhere (worldwide). For a specific listing of services and procedures that require preauthorization please refer to the preauthorization lists found within this manual. Additionally, ConnectiCaremaydisenroll a member if: Premiums are not paid on a timely basis. If you want a paper copy of this information, you may contact Provider Services at 860-674-5850 or 800-828-3407. Such information includes, but is not limited to, quality and performance indicators for plan benefits regarding disenrollment rates, enrollee satisfaction, and health outcomes. Customer Service number: 877-585-8480. . Follow the plans and instructions for care that they have agreed on with practitioners. 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. The right to know how information about race, language, ethnicity, gender orientation, and sexual identity are collected and used. ConnectiCare cannot reverse CMS' determination. The PHCS Network is designed to be used with limited benefit plans that offer a higher level of coverage. If you want to receive Medicare publications on your rights, you may call and request them at 1-800-MEDICARE (800-633-4227). See preauthorization list for DME that requires pre-authorization. PPM/10.16 Overview of Plans Overview of products Limited to a maximum of $315 every two (2) calendar years for: 1.) Providers are also required to contact ConnectiCares Notification Line at 888-261-2273 to advise ConnectiCare of the transport. I'm a Broker. Refer members to the ConnectiCare Member Services at 800-224-2273 if they need information on disenrollment. If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital. You will be contacted by Insurance Benefit Administrators regarding final pricing for the claims submitted in the weeks following submission. Specialists:Provide continuity and coordination of care by sending a written report to the member's PCP regarding any treatment or consultation provided to the member. CT scans (all diagnostic exams) 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. UHSM is NOT an insurance company nor is the membership offered through an insurance company. Eligibility and Referral Line After the Plan deductible is met, benefits will be covered according to the Plan. ConnectiCare offers both employer-sponsored plans and individual insurance plans. PDF PHCS Network Bringing Greater Choice and Savings to the Employees If you have difficulty obtaining information from your plan based on language or a disability, call 1-800-MEDICARE (800-633-4227). You must pay for services that arent covered. For Medicaid managed TTY users should call 877-486-2048. Healthcare Provider FAQs > MultiPlan ConnectiCare takes all complaints from members seriously. 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. (More information appears later in this section.). Members have an in-network deductible for some covered services. Prostate cancer screening (age restrictions apply) plan. For additional details on using ConnectiCare's Eligibility & Referral Line or Medavant, refer toAutomated & Online Features. This includes the right to know about the different Medication Management. To begin the precertification process, your provider(s) should contact Coverage for skilled nursing facility (SNF) admissions with preauthorization. If you need assistance If you encounter issues when scheduling appointments with PHCS Network providers, call us at 866-685-7427. Best of all, it's free- no downloads required or software to install. When performed out of network, these procedures do require preauthorization. If you do, please call Member Services. The member provides fraudulent information on the application or permits abuse of an enrollment card. We must tell you in writing why we will not pay for or approve a prescription drug or Part C medical care or service, and how you can file an appeal to ask us to change this decision. PDF PHCS Network and Limited Benefit Plans - MultiPlan 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. You also have the right to receive an explanation from us about any utilization-management requirements, such as step therapy or prior authorization, which may apply to your plan. Eligibility Claims Eligibility Fields marked with * are required. You will get most or all of your care from plan providers, that is, from doctors and other health providers who are part of our plan. 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. Oops, there was an error sending your message. The following is a description of all product types offered by ConnectiCare, Inc. and its affiliates. SeeGlossaryfor definitions of emergency and urgent care. Access to any Medicare-approved doctor or hospital in the United States. Copyright 2022 Unite Health Share Ministries. We are equally committed to you, our PHCS PPO Network, and your overall satisfaction. In these cases, you must request an initial decision called an organization determination or a coverage determination. 877-585-8480. 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. ConnectiCare encourages members to actively participate in decision making with regard to managing their health care. 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. If you dont know the member's ID number, contact Provider Services during regular business hours to verify eligibility and benefits. I called in with several medical bills to go over and their staff was extremely helpful. PHCS Health Insurance is Private HealthCare Systems, and was recently acquired by MultiPlan. PDF PHCS Network and Limited Benefit Plans - MultiPlan Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. Any treatment for which there is insufficient evidence of therapeutic value for the use for which it is being prescribed is also not covered. This includes information about our financial condition, and how our Plan compares to other health plans. These extra benefits include, but are not limited to, preventive services including routine annual physicals, routine vision exams and routine hearing exams. P.O. This would also include chronic ventilator care. What can you doif you think you have been treated unfairly or your rights arent being respected? MRI/MRA (all examinations) Reference the below Performance Health Open Negotiation Notice for details on the process your provider must follow for disputing the allowable rate used on your claim. 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. Notify ConnectiCare within twenty-four (24) hours after an emergency admission at 888-261-2273. Delays and failures to render services due to a major disaster or epidemic affecting our facilities or personnel. Members under 12 years of age call PHC's Care Coordination Department at (800) 809- 1350. What to do if you think you have been treated unfairly or your rights are not being respected? You can also visit www.medicare.gov on the Web to view or download the publication Your Medicare Rights & Protections. Under Search Tools, select Find a Medicare Publication. Or, call 1-800-MEDICARE (800-633-4227). ConnectiCare involuntary disenrollment precertification on certain services. Please call Member Services if you have any questions. Box 340308 In addition, information is protected by information systems security, and authentication and authorization procedures, such as but not limited to: password-protected files; storage, data disposal, and reuse of media and devices; and transmission and physical security requirements using company-protected equipment including access to devices and media that contain individual-level data. You have the right to be treated with dignity, respect, and fairness at all times. Can be provided safely by persons who are not medically skilled, with a reasonable amount of instruction, including, but not limited to, supervision in taking medication, homemaking, supervision of the patient who is unsafe to be left alone, and maintenance of bladder catheters, tracheotomies, colostomies/ileostomies and intravenous infusions (such as TPN) and oral or nasal suctioning. New members may use a copy of their enrollment form. For a specific listing of services and procedures that require pre-authorization refer to the Appendices within this manual. Member Services can also help if you need to file a complaint about access (such as wheel chair access). A complete list of Sutter Health Hospitals and Medical Groups accepting this health plan. If a member tells you that he/she has disenrolled from ConnectiCare, ask where the bill should be sent. The Evidence of Coverage (EOC) will instruct them to call their PCP. You may also call the Office for Civil Rights at 800-368-1019 or TTY:800-537-7697, or your local Office for Civil Rights. How to get more information about your rights Benefit Type* Subscriber SSN or Card ID* Patient First Name Patient Gender* Male Female Patient Date of Birth* Provider TIN or SSN*(used in billing) PHCS is the leading PPO provider network and the largest in the nation. PHCS Network | AvMed No prior authorization requirements. ConnectiCare also makes available to members printable, temporary ID cards via our website. Contact us. It is important to sign this form and keep a copy at home. In-office procedures are restricted to a specific list of tests that relate to the specialty of the physician. SISCO's provider portal allows you to submit claims, check status, see benefits breakdowns, and get support, anytime. For non-portal inquiries, please call 1-800-950-7040 . You will now leave the AvMed web site once you click the "I agree" button. High Deductible Health Plan (Health Savings Account [HSA] Compatible). Your right to use advance directives (such as a living will or a power of attorney) Some applicable copayments Life Insurance *. Customer Service at 800-337-4973 If you have questions or concerns about your rights and protections, please call Member Services. (SeeOther Benefit Information). Your right to get information about our plan UHSM is not insurance. Virtual colonoscopy for diagnostic purposes only, as determined by medical necessity criteria (CPT code 0067T). Note: The list of covered DME and disposable supplies is reviewed periodically and subject to change at the sole discretion of ConnectiCare. To get any of this information, call Member Services. part 84; the Americans with Disabilities Act; the Age Discrimination Act of 1975, as implemented by regulations at 45 C.F.R. As a member of a ConnectiCare plan, each individual enjoys certain rights and benefits. PHCS is a large health insurance company with a wide range of plan types, therefore the amount of coverage ranges. However, ConnectiCare must terminate members for the following: The member has a change of address outside the service area. By contracting with this network, our members benefit from pre-negotiated rates and payment processes that lead to a much smoother . We also cover additional benefits beyond Original Medicare alone. If you have any concerns about your health, please contact your health care provider's office. It is important to note that not all of the Sutter Health network . Savings - Negotiated discounts that result in significant cost savings when you visit in-network providers,helping to maximize your benefits. Balance Bill defense is available for all members with a Reference Based Pricing Plan. Remember you will only need your registration code this one time to set up your account. PHCS PPO Network - WeShare Healthcare ConnectiCare enrolls individual members into the ConnectiCare plan. The following is a description of all plan types offered by ConnectiCare, Inc. and its affiliates. Examples of qualifying medical conditions can be found below. If you need more information, please call our Member Services. You are now leavinga ConnectiCare website. To obtain a copy of the privacy notice, visit our website atconnecticare.com, or call Provider Services at the number below. Box 340308, Hartford, CT 06134-0308, 860-509-8000, TTY: 860-509-7191. Three simple steps and a couple minutes of your time is all it takes to obtain preauthorization from UHSM. Use your member subscriber ID to access the pricing tool using the link below. 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. Lifetime maximums apply to certain services. MultiPlan uses technology-enabled provider network, negotiation, claim pricing and payment accuracy services as building blocks for medical payors to customize the healthcare cost management programs that work best for them. What should I do if I get a bill from a healthcare provider? Giving your doctor and other providers the information they need to care for you, and following the treatment plans and instructions that you and your doctors agree upon. Go > Provider Portal - 90 Degree Benefits If you admit a member to a SNF on a weekend or holiday, ConnectiCare will automatically authorize payment for SNF services from the day of admission through the next business day. On a customer service rating I would give her 5 golden stars for the assistance I received. Really good service. Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). Notifying providers when seeking care (unless it is an emergency) that you are enrolled in our plan and you must present your plan enrollment card to the provider. 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. 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. You can sometimes get advance directive forms from organizations that give people information about Medicare. You have the right to choose a plan provider (we will tell you which doctors are accepting new patients). Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. Monitoring includes member satisfaction with physicians. If a complaint about you or your office staff is received, ConnectiCare will contact you and request information relating to the complaint. Question 1. Answer 2. 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. HPI | Provider Resources | Patient Benefits & Eligibility The following information was provided by the Connecticut Office of Attorney General for the Department of Public Health and Addiction Services and the Department of Social Services. In-office procedures are restricted to a specific list of tests that relate to the specialty of the physician. Asking at the time of each visit if he/she is still enrolled in a ConnectiCare plan. Your right to get information about our plan and our network pharmacies Provider Quick Reference Guide - MultiPlan The admitting physician is responsible for pre-authorizing elective admissions five (5) working days in advance. 1-1/2 times your annual salary paid to your beneficiary in the event of your death. 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. According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. To verify or determine patient eligibility, call 1-800-222-APWU (2798). Your right to get information about your prescription drugs, Part C medical care or services, and costs Note: Some services require preauthorization. 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. For emergency care received outside the U.S. there is a $100,000 limit. This includes information about our financial condition and about our network pharmacies. Home health services are coordinated by ConnectiCare's Health Services: To verify benefits and eligibility - (phone) 800-828-3407 Submit a Coverage Information Form. You also have the right to get information from us about our plan. Go to the Client Portal > Provider directories Create a customized listing of facilities and/or practitioners participating in the network services offered by MultiPlan. Members must reside in the service area. Supporting evidence, which may be required includes: 1.) The rental and/or purchase of CPAP and BI-PAP machines must be done through our preferred vendors. UHSM Health Share and WeShare All rights reserved. A complaint can be called a grievance, an organization determination, or a coverage determination depending on the situation. ConnectiCare will communicate to your patients how they may select a new PCP. All routine laboratory services must be obtained from participating laboratories.
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