phcs eligibility and benefits
provider must already be participating in PHCS Network, which is certified for credentialing by NCQA. No specialist-to-specialist referrals permitted, except OB/GYNs may make referrals. 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. Members have the right to: While enjoying specific rights of membership, each ConnectiCare member also assumes the following responsibilities. There are different types of advance directives and different names for them. Welcome to the MultiPlan Provider PortalThe portal lets you view and update your network-related information, manage tasks such as credentialing and track your customer service case history. ConnectiCare encourages members to actively participate in decision making with regard to managing their health care. To inquire about an existing authorization - (phone) 800-562-6833 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. You may want to give copies to close friends or family members as well. Members pay a copayment cost-share for most covered health services at the time the services are rendered. The rental and/or purchase of CPAP and BI-PAP machines must be done through our preferred vendors. If you need more information, please call Member Services. Such information includes, but is not limited to, quality and performance indicators for plan benefits regarding disenrollment rates, enrollee satisfaction, and health outcomes. Our contract with you for participation in the ConnectiCare program requires you to provide coverage 24-hours, seven days a week, including weekends and holidays. Your right to get information about your prescription drugs, Part C medical care or services, and costs Refuse treatment and to receive information regarding the consequences of such action. Providers are responsible for seeking reimbursement from members who have terminated if the services provided occurred after the member's termination date. The Evidence of Coverage (EOC) will instruct them to call their PCP. ConnectiCare distributes its privacy notice to members annually, and to new members upon enrollment in the plan. What to do if you think you have been treated unfairly or your rights are not being respected? part 84; the Americans with Disabilities Act; the Age Discrimination Act of 1975, as implemented by regulations at 45 C.F.R. ConnectiCare members will receive an identification (ID) card when they enroll in the plan. 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. Your rights include knowing about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. Eligibility Claims Eligibility Fields marked with * are required. Coverage for medical emergencies without preauthorization. To pre-notify or to check member or service eligibility, use our provider portal. Choice - Broad access to nearly 4,400 hospitals, 79,000 ancillaries and more than 700,000 healthcareprofessionals. The PHCS Network is designed to be used with limited benefit plans that offer a higher level of coverage. If you need more information, please call our Member Services. Documents called "living will" and "power of attorney for health care" are examples of advance directives. PHCS is the leading PPO provider network and the largest in the nation. 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 Information is protected as outlined in ConnectiCare's policies. Below are the additional benefits covered by ConnectiCare. If you have questions or concerns about privacy of your personal information and medical records, please call Member Services. ConnectiCare Medicare Advantage plans include a number of Medicare Advantage Plans. In addition, some of the ConnectiCare plans include Part D, prescription drug coverage. The Members Rights and Responsibilities Statement, reprinted below in its entirety, summarizes ConnectiCares position: Introduction to your rights and protections For benefit-related questions, call Provider Services at 877-224-8230. This system requires that you have a touch-tone phone and know your ConnectiCare provider ID number, as well as the member's identification number, to verify eligibility. 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. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. (SeeOther Benefit Information). Once you have completed the Registration form you will be emailed a link to confirm your Registration. SeeGlossaryfor definitions of emergency and urgent care. UHSM serves as a connector, we administer the cost-sharing program and help health share members support each otherits AWESOME! ConnectiCare offers both employer-sponsored plans and individual insurance plans. See the preauthorization section for a listing of DME that requires preauthorization. They will be clearly distinguishable by their ID cards. It is your responsibility to confirm your provider or facilitys continued participation in the PHCS Network and accessibilityunder your benefit plan. 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. Popular Questions. Your right to get information in other formats 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). Christian Health Sharing State Specific Notices. Asking at the time of each visit if he/she is still enrolled in a ConnectiCare plan. For Medicaid managed Letting us know if you have any questions, concerns, problems, or suggestions. The admitting physician is responsible for preauthorizing elective admissions five (5) working days in advance. Network providers and practitioners are also contractually obligated to protect the confidentiality of members information. TTY users should call 877-486-2048. faq. Click Here to go to the PHCS / Multiplan Provider Search. Oops, there was an error sending your message. 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. Pleasant and provided correct information in a timely manner. We protect your personal health information under these laws. Answer 3. The provider must agree to accept network rates for the defined period of time. Product and plan details are outlined in the product and coverage section on this page. While other insurance companies and TPAs make you go through numerous frustrating prompts and then hold for an extensive period, our approach is to take the call as soon as possible so that you can move on with your day. (A 12-month waiting period may apply for members in individual [ConnectiCare SOLO] plans.). Following is the statement in its entirety. Please note that your benefits and out of pocket expenses may vary when using PHCS providers. You should consider having a lawyer help you prepare it. ConnectiCare will communicate to your patients how they may select a new PCP. (SeeOther Benefit Information). This includes the right to stop taking your medication. United Faith Ministries, Inc. is a 501(c)(3) nonprofit corporation, dba Unite Health Share Ministries or UHSM Health Share, that facilitates member-to-member sharing of medical bills. Virtual colonoscopy for diagnostic purposes only, as determined by medical necessity criteria (CPT code 0067T). Your Explanation of Payment (EOP) will specify member responsibility. You must call ConnectiCares Notification Line at 860-674-5870 or 888-261-2273 to advise ConnectiCare of the admission. Coverage for skilled nursing facility (SNF) admissions with preauthorization. How to manage the front desk when they ask who you are insured with? However, the majority of PHCS plans offer members . The provider must agree to accept network rates for the defined period of time. Please note: The benefit information provided is not a comprehensive list and is subject to change. Contact us. Medicare members who elect to become members of ConnectiCare must meet the following qualifications: Members must be eligible for Medicare Part A and be enrolled in and continue to pay for Medicare Part B. Regardless of where you get this form, keep in mind that it is a legal document. Coverage follows Original Medicare guidelines. Follow the rules of this Plan, and assume financial responsibility for not following the rules. Call Automated Phone Specialists between 8 a.m. and 4:30 p.m. (CST) Monday through Fridays at 800-650-6497. Examples of covered medical conditions can be found below. Physicians are required to make referrals to participating specialty physicians, including chiropractic physicians. 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. Long Term Care Insurance. 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) Members who develop ESRD after enrollment may remain with a ConnectiCare plan. 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. All routine laboratory services must be obtained from participating laboratories. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you cant. The following are samples of each type of ID card that ConnectiCare issues to members. We also cover additional benefits beyond Original Medicare alone. You have the right to ask someone such as a family member or friend to help you with decisions about your health care. Its affordable, alternative health care. Members have an in-network deductible for some covered services. 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. If you make a complaint, we must treat you fairly (i.e., not retaliate against you) because you made a complaint. part 91; other laws applicable to recipients of federal funds; and all other applicable laws and rules, are required by applicable laws or regulations. Medicare providers under their ConnectiCare contract are required to see all ConnectiCare VIP Medicare Plan members including those who are dual eligible for Medicare and Medicaid. Were here to help! After the deductible is met, benefits will be covered according to the Plan. 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. If a member tells you that he/she has disenrolled from ConnectiCare, ask where the bill should be sent. To contact our office for any eligibility, benefits and claims assistance: Performance Health Claims Administrator P.O. Circumstances beyond our control such as complete or partial destruction of facilities, war, or riot. On a customer service rating I would give her 5 golden stars for the assistance I received. (214) 436 8882 Question 3. Medicare Advantage or Medicaid call 1-866-971-7427. The service area includes all counties in Connecticut. Note: Presentation of a member ID card is not a guarantee of a member's eligibility. Some preventive services are covered at 100% and are exempt from the deductible requirement. 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. including benefit designs and Sutter provider participation in your provider network. Each members enrollment is generally in effect as long as the member chooses to stay in ConnectiCare. 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. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under yourplan. UHSM is always eager and ready to assist. Ask to see the member's ConnectiCare member identification (ID) card. Remember you will only need your registration code this one time to set up your account. Some plans cover preventive dental services: Receive information about us, our services, our participating providers, and "Members Rights and Responsibilities.". These extra benefits include, but are not limited to, preventive services including routine annual physicals, routine vision exams and routine hearing exams. If authorization is not obtained, payment for the service may be denied. Documents called a "living will" and "power of attorney for health care" are examples of advance directives. The member provides fraudulent information on the application or permits abuse of an enrollment card. Box 340308, Hartford, CT 06134-0308, 860-509-8000, TTY: 860-509-7191. Provider. A complaint can be called a grievance, an organization determination, or a coverage determination depending on the situation. These services are covered under the Option Plan nationwide. Note: Some plans may vary. A candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage. Life Insurance *. Your right to make complaints To get this information, call Member Services. 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. There are different types of advance directives and different names for them. The plan contract is terminated. A new web site will open up in a new window. Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible. Copyright 2022 Unite Health Share Ministries. You have the right to an explanation from us about any bills you may get for drugs not covered by our Plan. ConnectiCare distributes its privacy notice to members annually, and to new members upon enrollment in the plan. In addition, the ID card also includes emergency instructions and a toll-free telephone number for out-of-area and after-hours notifications, the Member Services phone number, and the claims submission address. (SeeOther Benefit Information). ConnectiCare Medicare Advantage plans provide all Part A and Part B benefits covered by Original Medicare. You have the right to get information from us about our plan. ConnectiCare will maintain such health information and make it available to CMS upon request, as necessary. For preauthorization of the following radiological services, call 877-607-2363 or request online atradmd.com/. PHC's Member Services Department is available Monday - Friday, 8 a.m. - 5 p.m. You can call us at 800 863-4155. These extra benefits include, but are not limited to, vision, dental, hearing, and preventive services, like annual physicals. I'm a Broker. Answer 1. Members under 12 years of age call PHC's Care Coordination Department at (800) 809- 1350. You have the right to be treated with dignity, respect, and fairness at all times. There are federal and state laws that protect the privacy of your medical records and personal health information. This would also include chronic ventilator care. 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. We may enroll employer group members as well. Your responsibilities include the following: Getting familiar with your coverage and the rules you must follow to get care as a member. Quality - MultiPlan applies rigorous criteria when credentialing providers for participation in the PHCSNetwork, so you can be assured you are choosing your healthcare provider from a high-quality network. * ConnectiCare reserves the right to use third-party vendors to administer some benefits, including utilization management 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. ConnectiCare reserves the right to terminate coverage for members who repeatedly fail to make the required copayments, coinsurance or deductibles, subject to the terms outlined in the applicableMember Agreement, Evidence of Coverage, or other governing contract. allergenic extracts (or RAST allergen specific testing); 2.) Examples of qualifying medical conditions can be found below. Not condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive. The bill of service for these members must be submitted to Medicaid for reimbursement. Clinical Review Prior Authorization Request Form. Refractions are not covered by ConnectiCare Medicare Advantage plans. 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. 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. The member loses entitlement to Medicare Parts A and/or B. Members must meet an in-network Plan deductible that applies to most covered health services, including prescription drug coverage, before coverage of those benefits apply. Refer to the annually updated Summary of Benefits section on this page and list of Exclusions and Limitations for more details. PCP name and telephone number Pharmacy cost-share, if applicable. Box 450978 Westlake, OH 44145. 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. You have the right to get your questions answered. Three simple steps and a couple minutes of your time is all it takes to obtain preauthorization from UHSM. If you do not inform ConnectiCare according to these guidelines, the SNF may not receive payment for any additional days of the member's stay. 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. Information is protected as stated in ConnectiCares policies. They are collected via enrollment information, self-disclosure, and the member portal. Your right to get information about our network pharmacies and/or providers UHSM is excellent, friendly, and very competent. Submit a Coverage Information Form. In-office procedures are restricted to a specific list of tests that relate to the specialty of the provider. Document in a prominent part of the individual's current medical record whether or not the individual has executed an advance directive; and No referrals needed for network specialists. The following is a description of all product types offered by ConnectiCare, Inc. and its affiliates. You have the right to refuse treatment. You have chosen PHCS (Private Healthcare Systems, Inc.). 2. Please note: MultiPlan, Inc. and its subsidiaries are not insurance companies, do not pay claims and do not guaranteehealth benefit coverage. (More information appears later in this section.). You also have the right to this explanation even if you obtain the prescription drug, or Part C medical care or service from a pharmacy and/or provider not affiliated with our organization. It is 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. plan. We must investigate and try to resolve all complaints. You have the right to make a complaint if you have concerns or problems related to your coverage or care. Our goal is to be the best healthcare sharing program on the planet and to provide. Contact the pre-notification line at 866-317-5273. Provide, to the extent possible, information providers need to render care. To get any of this information, call Member Services. You can sometimes get advance directive forms from organizations that give people information about Medicare. In-office procedures are restricted to a specific list of tests that relate to the specialty of the physician. Covered at participating urgent care providers. ConnectiCare involuntary disenrollment Monitoring includes member satisfaction with physicians. We request your cooperation in investigating and resolving these complaints. 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. Three simple steps and a couple minutes of your time is all it takes to obtain preauthorization from UHSM. Postoperative physical therapy for TMJ surgery is limited to ninety (90) days from the date of surgery when pre-authorized as part of surgical procedure. Be treated with respect and recognition of your dignity and right to privacy. When you complete the form, MultiPlan will contact yournominee to determine whether the provider is interested in joining. ConnectiCare requires that sufficient notice be given to all of your patients affected by a change in your practice. ConnectiCare cannot reverse CMS' determination. MultiPlan can help you find the provider of your choice. 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). Member satisfaction with ConnectiCare is very important. Answer 4. Preferred Provider Organization Questions? This means the PHCS Savility network offers the same quality for which PHCS Network has been recognized since 2001. abnormal MRI; and 2.) Prostate cancer screening (age restrictions apply) What should I do if I get a bill from a healthcare provider? Your right to get information about our plan and our network pharmacies Actual copayment information and other benefit information will vary. It is important to sign this form and keep a copy at home. Dominion Tower 999 Waterside Suite 2600 Norfolk, VA 23510. This feature is meant to assist members who need additional copies of their ID card. Discounts on frames, lenses, and contact lenses: 25% discount for items costing $250 or less; 30% discount for items over $250. You also have the right to get information from us about our plan. Prior Authorizations are for professional and institutional services only. In addition, the following guidelines apply: The following are covered preventive care services: Please note there are designated frequencies and age limitations. Members receive in-network level of benefits when they see participating providers. Occasionally, these complaints relate to the quality of care or quality of service members receive from their PCP, specialist, or the office staff. Call us and tell us you would like a decision if the service or item will be covered. No prior authorization requirements. This arrangement will be allowed until the safe transfer of care to a participating provider and/or facility can be arranged. 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. To verify eligibility for services, request to see the member's current ID card. We are a caring community dedicated to keeping our members healthy, happy, and in control of their well-being. Solutions. Member Services can also help if you need to file a complaint about access (such as wheel chair access). Requests may be made by either the physician or the member. From www.myperformancehlth.com, go to My Plan, Web Access Login, Register & Enroll, Select Member, Complete the Registration form. By contracting with this network, our members benefit from pre-negotiated rates and payment processes that lead to a much smoother . Members are encouraged to actively participate in decision-making with regard to managing their health care. 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. Accessing PHCS Savility PHCS Savility is available to insurers and benefit plan administrators meeting certain benefit design Providers are also reminded that dual eligible members who are designated as Qualified Medicare Beneficiaries (QMB or QMB+) cannot be billed for any Medicare cost-share. Please also be sure to follow any preauthorization procedures required by your plan(usually a telephone number on your ID card). They are used to assess health care disparities, design intervention programs, and design and direct outreach materials, and they inform health care practitioners and providers about individuals needs. This line is available twenty-four (24) hours a day, seven days a week. Covered according to Massachusetts state mandate. Pay applicable copayments, deductibles or coinsurance. It is important to sign this form and keep a copy at home. ConnectiCare enrolls individual members into the ConnectiCare plan. Your responsibilities as a member of our plan. You and your administrative staff can quickly and easily access member eligibility and claims status information anytime, on demand. 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) Get coverage information. Please review our formulary website or call Member Services for more information. A voluntary termination initiated by a practitioner should be communicated to ConnectiCare verbally or in writing, in accordance with the terms set forth in the contract, but no less than sixty (60) days before the effective date.
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