I really appreciate the service I received from UHSM. You may want to give copies to close friends or family members as well. These plans, sometimes called "Part C," provide all of a member's Part A (hospital coverage) and Part B (medical coverage) and may offer extra benefits too. Answer 3. Requests may be made by either the physician or the member. part 84; the Americans with Disabilities Act; the Age Discrimination Act of 1975, as implemented by regulations at 45 C.F.R. 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 information from us about 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. You have the right to go to a womens health specialist (such as a gynecologist) without a referral. 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. Some plans may have deductible and coinsurance requirements. 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. If you want a paper copy of this information, you may contact Provider Services at 877-224-8230. Coverage is provided for temporomandibular joint (TMJ) surgery or orthognathic procedures with preauthorization, when medical necessity is established. Question 4. You can easily: Verify member eligibility status; . 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. For plans where coverage applies, one routine eye exam per year covered at 100% after copayment (no referral required). To get any of this information, call Member Services. For benefit-related questions, call Provider Services at 877-224-8230. You also have the right to give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. For a specific listing of services and procedures that require preauthorization please refer to the preauthorization lists found within this manual. Occasionally, these complaints relate to the quality of care or quality of service members receive from their PCP, specialist, or the office staff. After the Plan deductible is met, benefits will be covered according to the Plan. If you need assistance If you encounter issues when scheduling appointments with PHCS Network providers, call us at 866-685-7427. 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. To begin the precertification process, your provider(s) should contact, Transition and Continuity of Care - Information and Request Form, Performance Health Open Negotiation Notice. What should I do if I get a bill from a healthcare provider? This includes information about our financial condition and about our network pharmacies. UHSM is NOT an insurance company nor is the membership offered through an insurance company. Question 5. 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. Examples of covered medical conditions can be found below. For preauthorization of the following radiological services, call 877-607-2363 or request online atradmd.com/. The following is a description of all product types offered by ConnectiCare, Inc. and its affiliates. Lifetime maximums apply to certain services. Medicare and Medicaid eligible members designated as Qualified Medicare Beneficiary. A sample of the ConnectiCare ID cards appear below. Long Term Care Insurance. However, the majority of PHCS plans offer members . I called in with several medical bills to go over and their staff was extremely helpful. All oral medication requests must go through members' pharmacy benefits. Members are encouraged to actively participate in decision-making with regard to managing their health care. 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. Be considerate of our providers, and their staff and property, and respect the rights of other patients. 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 receive out-of-network level of benefits when they see non-participating providers. Performance Health at Coverage for skilled nursing facility (SNF) admissions with preauthorization. MultiPlan can help you find the provider of your choice. 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. Some applicable copayments Members are required to see participating providers, except in emergencies. Make recommendations regarding our members rights and responsibilities policies. You can also get help from CHOICES - your State Health Insurance Assistance Program, or SHIP. Provider Quick Reference Guide - MultiPlan Acting in a way that supports the care given to other patients and helps the smooth running of your doctors office, hospitals, and other offices. No referrals needed for network specialists. ConnectiCare eligible members shall not be discriminated against with respect to the availability or provision of health services based on an enrollee's race, sex, age, religion, place of residence, HIV status, source of payment, ConnectiCare membership, color, sexual orientation, marital status, or any factor related to an enrollee's health status. Do I have any Out of Network benefits and what happens when doctor says we do not take your insurance? You can sometimes get advance directive forms from organizations that give people information about Medicare. Below are the additional benefits covered by ConnectiCare. 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. For non-portal inquiries, please call 1-800-950-7040. The Members Rights and Responsibilities Statement, reprinted below in its entirety, summarizes ConnectiCares position: Introduction to your rights and protections CT scans (all diagnostic exams) The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. Not condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive. This video explains it. By contracting with this network, our members benefit from pre-negotiated rates and payment processes that lead to a much smoother . You also have the right to give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. At a minimum, this statement must: Clarify any differences between institution-wide conscientious objections and those that may be raised by the individual physician; PHC's Member Services Department is available Monday - Friday, 8 a.m. - 5 p.m. You can call us at 800 863-4155. New members may use a copy of their enrollment form. In addition, some of the ConnectiCare plans include Part D, prescription drug coverage. Product and plan details are outlined in the product and coverage section on this page. In order to maintain permanent residence, a member must not move or continuously reside outside the service area for more than 6 consecutive months. To contact our office for any eligibility, benefits and claims assistance: Performance Health Claims Administrator P.O. ConnectiCare members will receive an identification (ID) card when they enroll in the plan. Yes, PHCS provides coverage for therapy services. 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. You may also search online at www.multiplan.com: Click on the Search for a Doctor or Facility button 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. Minimal hold time Fast Claim Processing and Payment Clear Explanation of Benefits Clear Benefit Descriptions faq. DME, orthotics & prosthetics must be obtained from a participating commercial DME vendor unless otherwise authorized by ConnectiCare and preauthorization must be obtained through ConnectiCare. ConnectiCare enrolls individual members into the ConnectiCare plan. Providers - INSURANCE BENEFIT ADMINISTRATORS UHSM Providers - PHCS PPO Network A complete list of Sutter Health Hospitals and Medical Groups accepting this health plan. You have the right to make a complaint if you have concerns or problems related to your coverage or care. 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 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. Refuse treatment and to receive information regarding the consequences of such action. Provider - SisCo Document in a prominent part of the individual's current medical record whether or not the individual has executed an advance directive; and How to get more information about your rights Payors > MultiPlan Eligibility and Benefits | ConnectiCare Refer to the annually updated Summary of Benefits section on this page and list of Exclusions and Limitations for more details. ConnectiCare also makes available to members printable, temporary ID cards via our website. It is generally available between 7 a.m. and 9:30 p.m., Monday through Friday, and from 7 a.m. to 2 p.m. on Saturday. Your responsibilities include the following: Getting familiar with your coverage and the rules you must follow to get care as a member. ConnectiCare will maintain such health information and make it available to CMS upon request, as necessary. ConnectiCare cannot reverse CMS' determination. ConnectiCare encourages members to actively participate in decision making with regard to managing their health care. Members receive in-network level of benefits when they see participating providers. Submit a Coverage Information Form. The legal documents that you can use to give your directions in advance in these situations are called "advance directives." Your right to make complaints Medical claims can be sent to: Insurance Benefit Administrators, c/o Zelis, Box 247, Alpharetta, GA, 30009-0247; EDI Payor ID: 07689. The PHCS Network includes nearly 4,400 hospitals, 79,000 ancillary care facilities and more than 700,000 healthcare professionals nationwide. The admitting physician is responsible for pre-authorizing elective admissions five (5) working days in advance. UHSM is excellent, friendly, and very competent. Phcs Insurance Provider Phone Number | TheWebster Miami 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. Pelvic exam You also have the right to get information from us about our plan. You may want to give copies to close friends or family members as well. If you need help with communication, such as help from a language interpreter, please call Medicare Member Services. These services are covered under the Option Plan nationwide. 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. Get coverage information. We request your cooperation in investigating and resolving these complaints. Note: These procedures are covered procedures, but do not require preauthorization when performed by in-network providers. Examples of qualifying medical conditions can be found below. The plan contract is terminated. Monitoring includes member satisfaction with physicians. According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. Hartford, CT 06134-0308 In-office procedures are restricted to a specific list of tests that relate to the specialty of the physician. PHCS / Multiplan Provider Search for CommunityCare Life & Health PPO If you think you have been treated unfairly or your rights have not been respected, you may call Member Services or: If you think you have been treated unfairly due to your race, color, national origin, disability, age, or religion, you can call the Office for Civil Rights at 800-368-1019 or TTY 800-537-7697, or call your local Office for Civil Rights. When you complete the form, MultiPlan will contact yournominee to determine whether the provider is interested in joining. You also have the right to ask us to make additions or corrections to your medical records (if you ask us to do this, we will review your request and figure out whether the changes are appropriate).
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