Provider Orientation 2009
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- Ethel Murphy
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1 Provider Orientation
2 This orientation will cover the following topics: Who is Coventry Health Care? Products and Networks Product and Network Basics How to Identify the Members Useful References Contact Information 2
3 Coventry Health Care Overview Managed Health Care company based in Bethesda, Maryland Began Operations in 1987 Locally-run health plans located in 16+ markets w/ 2.5 million members Products include, HMO, POS, PPO, Network Rental, Workers Compensation, Medicare, Medicaid & Individual Products 3
4 The First Health Acquisition Coventry purchased First Health/CCN in January 2005 The acquisition of First Health allowed Coventry to tackle markets nation wide Georgia began consolidating provider agreements to include First Health/CCN in 2006 First Health consolidated CCN into their existing network effective ; retiring the CCN logo forever. 4
5 Two Leased Networks? The acquisition of First Health left Coventry with two leased networks: Coventry began consolidating the two networks in The SouthCare network was rolled into the First Health Network. The SouthCare logo retired effective
6 Products and Networks With our consolidation we were able to take our logo s from this: HEALTHCARE PREFERRED GEHA 6
7 Products and Networks 7
8 Logo Changes Old Logo New Logo No changes as a result of network consolidation for Coventry Health Care of Georgia, Inc. *This name is being retired effective Clients are moving to the Coventry Health Care National Network. *The First Health Network will remain the same. *SouthCare will become the First Health Network effective *CCN is being retired as of Clients are being moved to the First Health Network effective
9 Coventry Health Care of Georgia HMO/POS Network Product Contract/ Fee Schedule Pre-Authorization Labs Mental Health Sample ID Card Coventry Health Care of Georgia HMO/POS network Open Access HMO/POS/QHDHP Coventry Health Care of Georgia HMO/POS contract Standard Coventry Preauthorization List Must use Quest Diagnostics except for In Office List Mental Health Network 9
10 Member ID Cards Look for the Coventry Health Care of Georgia Logo. When you see this logo, you know that the member is accessing the HMO/POS network. 10
11 Labs Our contracted lab vendor is Quest Diagnostics. All lab work should be sent to Quest. Please pay close attention to where you send the labs for our members. In-office STAT lab list , 85007, is allowed for Hematology/Oncology providers only. You can also bill for the following when sending lab work out to Quest. G Please be aware that Specimen Handling is not reimbursed. 11
12 Individual Product CoventryOne is a fully insured POS product sold by Coventry. Coventry has also partnered with Assurant who also offers a individual product. Individual products accesses our Coventry Health Care of Georgia Network (HMO/POS/Individual rates). Look for these logos along with the standard Coventry Health Care of Georgia logo This product is designed for the uninsured population who is self employed, full time student, employed part-time etc. Benefit plans may include high deductibles. Member records may be reviewed to determine if pre-existing conditions qualify for coverage. If a condition has been flagged as pre-ex there is a 12 month window of no coverage for services related to the condition. 12
13 Important Addresses and Phone Numbers Claims Address: Coventry Health Care of Georgia, Inc P.O. Box 7711 London, KY Electronic Claims Payor Number Customer Service for all CHC Members: Coventry Health Services: ext (fax) 13
14 Coventry Health Care National Network (formerly First Health Direct) Network Product Contract/ Fee Schedule Pre-Authorization Labs Claims/Customer Service Recognizable Logos Coventry Health Care National Network formerly known as First Health Direct National Network for large multi-site employers. This network consists of customers that Coventry prices claims for and in many instances actually adjudicates the claim. Coventry Health Care of GA contract. See Exhibit B of contract for Direct Business rates Plan specific Participating labs Refer to member Identification cards 14
15 Coventry Health Care National Network Sample Id Cards Old Cards New Cards Look for the Coventry Health Care National Network to denote the network. 15
16 Medicare Advantage Plans Coventry Advantra Coventry Health Care of Georgia currently offers a Medicare Advantage Plan in Metro Atlanta area. Benefit plan to include: Open Access plan. Members are required to select PCP but DO NOT require referrals to see specialists. Member responsible for copay if treated by in network provider. Coinsurance applies to out of network visits. Claims processed by Coventry Health Care usually resulting in faster turn around. Direct access to view claims, member eligibility, and initiate appeals online via directprovider.com 16
17 Advantra- Medicare Advantage Plans Network Product Contract/ Fee Schedule Pre-Authorization Labs Timely Filing Sample ID Card Coventry Health Care of Georgia Advantra Medicare Network Advantra Gold & Silver Point of Service (POS) Medicare Advantage Plans with integrated pharmacy benefit (Part D). PCP is required but open access to specialists. Coventry Health Care of Georgia Medicare Amendment with corresponding rates Standard Coventry Medicare Preauthorization List Must use Quest Diagnostics except for In Office List Same as Participating Physician Agreement. Not standard Medicare time period. 17
18 Important Addresses and Phone Numbers Claims Address: Coventry Advantra Gold/Silver P.O. Box 7156 London, KY Electronic Claims Payor Number Customer Service for all Advantra Gold/Silver Members: Coventry Advantra Gold/Silver Health Services: ext (fax) Coventry Advantra Gold/Silver Provider Relations: Ext Ext (Fax) 18
19 Advantra Freedom PFFS What makes it different? Advantra Freedom is a private fee for service (PFFS) Medicare Product. Members are not limited to seeing providers in a select network. No contracts. Providers choose on a case by case basis if they wish to see member. If provider accepts Medicare they can accept Advantra Freedom Member. Reimbursements and benefits are the same as standard Medicare. Member benefits are identical to standard Medicare. No Utilization Management performed by Coventry. 19
20 Important Addresses and Phone Numbers Claims Address: Advantra Freedom P.O. Box 7154 London, KY Electronic Claims Payor Number Customer Service for Advantra Freedom Members: Coventry Advantra Freedom Health Services: NA Coventry Advantra Freedom Provider Relations:
21 FREEdom to go direct Our electronic solution is Real-time Information - Direct Information is as accurate as our current system. 24/7 access to Customer Service No Fees with directprovider.com - FREE! Faster access to more & better information Including benefits accumulators Medical content Quick Access to Forms, Manual, SmartSheets Better information for Authorizations More accurate billing Time and money saved! Available on Directprovider.com 21
22 Potential Cost Savings to You: Based on 2006 Milliman Study $12.00 $10.00 Manual Cost Electronic Cost $8.00 $6.00 $4.00 $2.00 $0.00 Claim Submission Eligibility Verification Referral Certification Preauthorization Payment Posting Claim Status Savings $3.73 $2.95 $6.22 $8.71 $1.49 $
23 Online Auth Submission 4 Simple Steps To Request an Authorization: Users will find a NEW tab for Request Authorization Select the type of service and location Select a patient Select a provider Define the service No more time on the phone holding or faxing the authorizations. 23
24 Update Authorizations Tracking numbers are available for all updates/requests 24
25 Check Eligibility Online The Batch Inquiry tab allows the user to create a batch of multiple inquiries. The user can submit the batch immediately for eligibility response or can save the batch, submit, and view the batch on the Manage Batch Response tab. 25
26 Request Claim Adjustments Adjustments Not available for.. Claim already submitted for dispute. Adjustment/Dispute is Open or in Pending status An Original claim in which an associated Backout or Replacement claim exists A Backout claim in which an associated Replacement claim exists A Replacement claim where a more recent Replacement claim exists Claims in a Rejected status Option will not be available if Adjustment not permitted 26
27 Online Claim Adjustments Provide Reason for Adjustment Attach supporting files Up to 5 mg total A secure will be sent to Customer Service and a tracking number will be provided to you. 27
28 Directprovider.com Resources Registration Training Webcasts User s Guide Face-to-face Support Directprovider.com Questions/Issues Net Support (866) ERA Questions/Issues ERAQuestions@cvty.com Claim Submission Questions/Issues Emdeon EDI support - (800) Coventry EDI support - (302)
29 Network Lease Network Product Contract/ Fee Schedule Pre- Authorization Labs Claims / Customer Service Mental Health Recognizable Logos First Health Network, SouthCare PPO(retired), CCN (retired) Leased PPO network where the clients pay and reprice own claims. Coventry Health Care of GA contract. See Exhibit B of contract for Network Lease rates Payor specific Participating providers Refer to Member Identification Card Use Network Providers GEHA 29
30 Worker s Compensation First Health is one of the largest Worker s Compensation carriers in the country. Please be aware that the members will not have an identification card. Please check with their carrier to determine the network that they access. Reimbursement is based on a percentage off the State Worker s Compensation fee schedule. 30
31 Where can I find out more? Check our website, for provider info such as: Pre Auth lists Provider Manuals RX Formulary Directprovider.com and much much more. 31
32 Coventry Provider Relations Ext Ext (Fax) Monday - Friday 8:00am - 5:00pm 1100 Circle 75 Parkway,Suite 1400 Atlanta, GA
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