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. Information is protected as stated in ConnectiCares policies. Be considerate of our providers, and their staff and property, and respect the rights of other patients. Box 340308 Member Services can also help if you need to file a complaint about access (such as wheel chair access). part 84; the Americans with Disabilities Act; the Age Discrimination Act of 1975, as implemented by regulations at 45 C.F.R. (A 12-month waiting period may apply for members in individual [ConnectiCare SOLO] plans.). 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. Your responsibilities include the following: Getting familiar with your coverage and the rules you must follow to get care as a member. PHCS is a large health insurance company with a wide range of plan types, therefore the amount of coverage ranges. Refractions are not covered by ConnectiCare Medicare Advantage plans. Virtual colonoscopy for diagnostic purposes only, as determined by medical necessity criteria (CPT code 0067T). Examples of covered medical conditions can be found below. 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. Initial mental health consultation ConnectiCare will communicate to your patients how they may select a new PCP. Influenza and pneumococcal vaccinations For a specific listing of services and procedures that require preauthorization please refer to the preauthorization lists found within this manual. Your right to get information about our plan, plan providers, drugs, health care coverage, and costs. After the Plan deductible is met, benefits will be covered according to the Plan. PROVIDER PORTAL LOGIN REGISTER NOW Electronic Options: EDI # 59355 Eligibility (270/271) Bill Status (276) Bill Submission (837) For technical assistance with EDI transactions, please contact Change Healthcare at 1-800-845-6592. Once submitted, ConnectiCare will verify the eligibility of the member with the Centers for Medicare & Medicaid Services (CMS) as they are the sole arbiter of eligibility for Medicare. How do I know if I qualify for PHCS insurance? Browse the list to see where your plan is accepted. You may also use the ConnectiCare Eligibility and Referral Line. Prior Authorizations are for professional and institutional services only. The member provides fraudulent information on the application or permits abuse of an enrollment card. Pelvic exam Coverage for skilled nursing facility (SNF) admissions with preauthorization. Your right to get information about our plan and our network pharmacies You must call ConnectiCares Notification Line at 860-674-5870 or 888-261-2273 to advise ConnectiCare of the admission. To pre-notify or to check member or service eligibility, use our provider portal. TTY users should call 877-486-2048, or visit www.medicare.govto view or download the publication Your Medicare Rights & Protections. Under Search Tools, select find a Medicare Publication. If you have any questions whether our plan will pay for a service, including inpatient hospital services, and including services obtained from providers not affiliated with our plan, you have the right under law to have a written/binding advance coverage determination made for the service. New members may use a copy of the enrollment form as a temporary identification card until they receive their ID card. Medical claims can be sent to: Insurance Benefit Administrators, c/o Zelis, Box 247, Alpharetta, GA, 30009-0247; EDI Payor ID: 07689. 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. abnormal arthrogram. CommunityCare Life and Health Insurance Company provides an in-network level of benefits for services delivered outside of Oklahoma through a national PPO network, PHCS. Although not a provider of health insurance, PHCS is a provider of PPO (Preferred Provider Organization) networks. 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. Your providers must explain things in a way that you can understand. What services are available to me that could save me money? Members have the right to: While enjoying specific rights of membership, each ConnectiCare member also assumes the following responsibilities. Your benefits, claims and/or eligibility are available 24/7 via our member portal. You have the right to choose a plan provider (we will tell you which doctors are accepting new patients). You have the right to get information from us about our network pharmacies, providers and their qualifications and how we pay our doctors. Follow the rules of this Plan, and assume financial responsibility for not following the rules. Circumstances beyond our control such as complete or partial destruction of facilities, war, or riot. 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 member loses entitlement to Medicare Parts A and/or B. New members may use a copy of their enrollment form. Make recommendations regarding our members rights and responsibilities policies. PCP name and telephone number 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. Go to the Client Portal > Provider directories Create a customized listing of facilities and/or practitioners participating in the network services offered by MultiPlan. Physicians may make referrals to participating specialists without entering them into the telephonic referral system. The service area includes all counties in Connecticut. If you have any concerns about your health, please contact your health care provider's office. Monitoring includes member satisfaction with physicians. faq. 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. 877-585-8480. Members receive in-network level of benefits when they see participating providers. Use your member subscriber ID to access the pricing tool using the link below. Note: Refractions (CPT 92015) are considered part of the office visit and are not separately reimbursed. Note: These procedures are covered procedures, but do not require preauthorization when performed by in-network providers. Member receive in-network level of benefits when they see PHCS Healthy Direction Providers. 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. These members may have a different copayment and/or benefit package. Delays and failures to render services due to a major disaster or epidemic affecting our facilities or personnel. Clinical Review Prior Authorization Request Form. Screening pap test. PHCS (Private Healthcare Systems, Inc.) - PPO. Premier Health Solutions, LLC operates as a Third-Party Administrator in the state of California under the name PHSI Administrators, LLC and does business under the name PremierHS, LLC in Kentucky, Ohio, Pennsylvania, South Carolina and Utah. Click Here to go to the PHCS / Multiplan Provider Search. Please check the privacy statement of the website where this link takes you. Voice complaints or appeals/grievances about us or the care you are provided. Note: To ensure accurate billing for plans with deductibles, bill ConnectiCare prior to taking any payment from members. 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. 1-1/2 times your annual salary paid to your beneficiary in the event of your death. 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. 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) UHSM medical sharing eligibility extends to qualifying costs at the more than 1.2 million doctors, hospitals, and specialists in this network. What should I do if I get a bill from a healthcare provider? The following is a description of all product types offered by ConnectiCare, Inc. and its affiliates. New users to the Provider Portal can create an account by selecting the Provider Access Link on the portal login page. Three simple steps and a couple minutes of your time is all it takes to obtain preauthorization from UHSM. Documents called a "living will" and "power of attorney for health care" are examples of advance directives. Use our online Provider Portal or call 1-800-950-7040. To get any of this information, call Member Services. 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. Your right to see plan providers, get covered services, and get your prescriptions filled within a reasonable period of time The provider must agree to accept network rates for the defined period of time. abnormal MRI; and 2.) 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. PCPs:Advise your patients to contact ConnectiCare's Member Services at 800-224-2273 to designate a new PCP, even if your practice is being assumed by another physician. Some applicable copayments Pay applicable copayments, deductibles or coinsurance. Read the Membership Agreement, Evidence of Coverage, or other Plan document that describes the Plans benefits and rules. Occasionally, these complaints relate to the quality of care or quality of service members receive from their PCP, specialist, or the office staff. 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). Dominion Tower 999 Waterside Suite 2600 Norfolk, VA 23510. The plan cannot and will not disenroll a member because of the amount or cost of services used. Your Registration Code is the Alternate ID number on your ID card plus a suffix of 01 for the subscriber, 02, 03, 04, 05, etc for spouse and/or dependents. To verify eligibility for services, request to see the member's current ID card. All participating providers agree to certify that all information submitted to ConnectiCare is accurate, complete, truthful, and shall comply with applicable CMS standards. You may also search online at www.multiplan.com: Click on the Search for a Doctor or Facility button CT scans (all diagnostic exams) Remember you will only need your registration code this one time to set up your account. Members pay a copayment as cost-share for most covered health services at the time services are rendered. Timely access means that you can get appointments and services within a reasonable amount of time. Below are the additional benefits covered by ConnectiCare. Discounts on frames, lenses, and contact lenses: 25% discount for items costing $250 or less; 30% discount for items over $250. Your right to know your treatment options and participate in decisions about your health care However, ConnectiCare must terminate members for the following: The member has a change of address outside the service area. Providers shall not discriminate against an enrollee based on whether or not the enrollee has executed an advance directive. There are different types of advance directives and different names for them. 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. Claims or Benefits questions will not be answered here. Regardless of where you get this form, keep in mind that it is a legal document. Some plans may have a copayment requirement for radiology services. I'm a Broker. When performed out-of-network, these procedures do require preauthorization. Such information includes, but is not limited to, quality and performance indicators for plan benefits regarding disenrollment rates, enrollee satisfaction, and health outcomes. Simply call (888) 371-7427 Monday through Friday from 8 a.m.to 8 p.m. (Eastern Standard Time) and identify yourself as a health plan participant accessing PHCS Network for LimitedBenefit plans. Life Insurance *. In addition, to ensure proper handling of your claim, always present yourcurrent benefits ID card upon arrival at your appointment. You have the right to timely access to your providers and to see specialists when care from a specialist is needed. Colorectal screening (age restrictions apply) In these cases, you must request an initial decision called an organization determination or a coverage determination. If a complaint about you or your office staff is received, ConnectiCare will contact you and request information relating to the complaint. Eligibility, Benefits & Claims Assistance, If you dont see the network listed on your ID card please contact our Customer Service at, Please be sure to verify your providers network access with your provider's office directly prior to receiving services. Your right to get information about our plan No prior authorization requirements. Your responsibilities as a member of our plan. Your Explanation of Payment (EOP) will specify member responsibility. This arrangement will be allowed until the safe transfer of care to a participating provider and/or facility can be arranged. All oral medication requests must go through members' pharmacy benefits. Examples of qualifying medical conditions can be found below. You have 24/7 access to all of the tools needed to answer your questions, whenever it's convenient for you. PHCS is the leading PPO provider network and the largest in the nation. To contact our office for any eligibility, benefits and claims assistance: Performance Health Claims Administrator P.O. ConnectiCare takes all complaints from members seriously. If you have any questions regarding a member's eligibility, call Provider Services at 877-224-8230. The following are samples of each type of ID card that ConnectiCare issues to members. Go > Check provider status Research practitioners and facilities to view their participation status in our provider networks. For additional details on using ConnectiCare's Eligibility & Referral Line or Medavant, refer toAutomated & Online Features.
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