Anthem Blue Cross. CCHCA Physician Handbook (7 th Edition)

Transcription

1 Part II Section B Introduction 1 Verifying Member Eligibility and Benefits 1 Sample Member ID Card 2 Eligibility Certification Form 3 CCHCA Physician Handbook (7 th Edition)

2 INTRODUCTION, created in 1986 to provide high quality medical care that is personalized, affordable and accessible, has rapidly grown into one of the largest and most recognized health maintenance organizations (HMO) in California. CCHCA is also a participating medical group under. The addition of Anthem Blue Cross to the existing CCHCA programs will further enhance the access of bilingual providers and quality health care in a culturally sensitive setting to our community. CCHCA utilizes Primary Care Physicians (PCP) for the Program. The same utilization protocol is used as in our other CCHCA programs. Members who have chosen CCHCA as their medical group must use CCHCA plan physicians for services. Referral physicians must also be from within the medical group. Exceptions require prior authorization from the Utilization Management Department. All claims, and authorizations for members enrolled under the CCHCA medical group will be processed by the Health Plans Office. Refer to Part I, Section 7 for the mailing address for paper and electronic claims. (Do not submit claims to. This will only cause delay in payment of your claims, as the claims will be returned to our office for processing. ) The program also utilizes a co-payment system. The amount to be collected varies for each plan, and should be collected from the patient at the time of service. Some of the member ID cards will carry the amount of the office visit co-payment. Verifying Member Eligibility and Benefits Eligibility and benefits can be obtained through the website at If you have any questions concerning patient eligibility, benefits or co-payments, please call directly at CCHCA Physician Handbook, Part II, Section B - 1 -

3 Identification cards generally provide the following information: 1. Member, spouse, domestic partner or covered dependent name 2. Certificate number 3. Employer group number (for group coverage only) 4. plan code 5. Coverage code 6. Medical group name, address and phone number (if HMO or POS) 7. Subscriber s effective date with the medical group (if HMO or POS) 8. Additional benefits rider (where applicable) 9. Claims mailing address(es) and Customer Service telephone number(s) for the medical program and any supplemental benefits 10. Instructions regarding carrying and using the identification card 11. Guidelines for obtaining services and reporting emergencies (if HMO or POS) 12. Telephone number for preauthorization or pre-service review (if PPO), this information is not available on the Medicare Advantage ID card CCHCA Physician Handbook, Part II, Section B - 2 -

4 MEMBER ELIGIBILITY members enrolled under the CCHCA medical group seeking medical attention and representing themselves as eligible, but do not possess a valid ID card, should be verified by calling. Eligibility can also be obtained from the website at Newly enrolled members may also show a copy of their enrollment form or a temporary ID card to signify that they are eligible. If eligibility cannot be verified, the member in question should be instructed to sign an eligibility certification form (see next page) before receiving any medical services. CCHCA Physician Handbook, Part II, Section B - 3 -

5 CCHCA Physician Handbook, Part II, Section B - 4 -