You have the right to get full information from your providers when you go for medical care, and the right to participate fully in decisions about your health care. We believe there is no such thing as a standard cost management approach. Members can print temporary ID cards by visiting the secure portion of our member website. Provider Portal Eligibility inquiry Claims inquiry. You should consider having a lawyer help you prepare it. We also cover additional benefits beyond Original Medicare alone. For a specific listing of services and procedures that require pre-authorization refer to the Appendices within this manual. The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. Refer to the annually updated Summary of Benefits section on this page and list of Exclusions and Limitations for more details. Members have the right to: While enjoying specific rights of membership, each ConnectiCare member also assumes the following responsibilities. We request your cooperation in investigating and resolving these complaints. part 91; other laws applicable to recipients of federal funds; and all other applicable laws and rules, are required by applicable laws or regulations. Eligibility and Referral Line You have the right to find out from us how we pay our doctors. 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. ConnectiCare's service area includes all counties. Medical claims can be sent to: Insurance Benefit Administrators, c/o Zelis, Box 247, Alpharetta, GA, 30009-0247; EDI Payor ID: 07689. Billing and Claims Eligibility and Benefits Commercial Medicare Product & Coverage Information Overview of Plan Types Overview of plan types The following is a description of all plan types offered by ConnectiCare, Inc. and its affiliates. 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 providean AWESOME*experience, every time! Reminding the patient to notify ConnectiCare; and Eligibility Claims Eligibility Fields marked with * are required. Answer 1. Enrollee satisfaction with ConnectiCare is very important. Oops, there was an error sending your message. If you have questions or concerns about privacy of your personal information and medical records, please call Member Services. You have the right to know how your health information has been given out and used for non-routine purposes. MRI/MRA (all examinations) Balance Bill defense is available for all members with a Reference Based Pricing Plan. What should I do if I get a bill from a healthcare provider? If you want to receive Medicare publications on your rights, you may call and request them at 1-800-MEDICARE (800-633-4227). If you have any concerns about your health, please contact your health care provider's office. 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. A 3-day covered hospital stay is not required prior to being admitted. Provide, to the extent possible, information providers need to render care. UHSM Health Share and WeShare All rights reserved. The admitting physician is responsible for preauthorizing elective admissions five (5) working days in advance. As of January 1, 2023, the Transparency in Coverage Rule mandates member access to a healthcare price comparison tool. In this section, we explain your Medicare rights and protections as a member of our plan and, we explain what you can do if you think you are being treated unfairly or your rights are not being respected. (SeeOther Benefit Information). I really appreciate the service I received from UHSM. See the preauthorization section for a listing of DME that requires preauthorization. Covered at participating urgent care providers. 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. You have the right to an explanation from us about any bills you may get for drugs not covered by our Plan. Its affordable, alternative health care. Please note: The benefit information provided is not a comprehensive list and is subject to change. 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. If you dont know the member's ID number, contact Provider Services during regular business hours to verify eligibility and benefits. If you have any questions please review your formulary website or call Member Services. Performance Health at 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. Your right to the privacy of your medical records and personal health information. This would also include chronic ventilator care. We conduct routine, focused surveys to monitor satisfaction using the Consumer Assessment of Health Plan Satisfaction (CAHPS) survey and implement quality improvement activities when opportunities are identified. Choice - Broad access to nearly 4,400 hospitals, 79,000 ancillaries and more than 700,000 healthcareprofessionals. The Evidence of Coverage (EOC) will instruct them to call their PCP. In addition, some of the ConnectiCare plans include Part D, prescription drug coverage. The legal documents that you can use to give your directions in advance in these situations are called "advance directives." Click on the link and you will then have immediate access to the Member portal. Note: Presentation of a member ID card is not a guarantee of a member's eligibility. There are different types of advance directives and different names for them. Emergency care and out-of-area urgently needed services are covered under the Prime and Custom Plans, anytime, anywhere (worldwide). If you have any questions regarding a member's eligibility, call Provider Services at 877-224-8230. Discounts on frames, lenses, and contact lenses: 25% discount for items costing $250 or less; 30% discount for items over $250. Asking at the time of each visit if he/she is still enrolled in a ConnectiCare plan. These services are covered under the Option Plan nationwide. Please review the member's ID card to confirm the appropriate phone number. Bone Mineral Density exams ordered more frequently than every twenty-three (23) months New members may use a copy of the enrollment form as a temporary identification card until they receive their ID card. Visit www.uhsm.com/preauth Download and print the PDF form Fax the preauth form to (888) 317-9602 GET PREAUTH FORM member-to-member health sharing How Healthshare Works with UHSM, it's Awesome! Your right to get information about your prescription drugs, Part C medical care or services, and costs Note: These procedures are covered procedures, but do not require preauthorization when performed by in-network providers. In-office procedures are restricted to a specific list of tests that relate to the specialty of the provider. If you are calling to verify your patient's benefits*, please have a copy Note: Refractions (CPT 92015) are considered part of the office visit and are not separately reimbursed. Please review our formulary website or call Member Services for more information. Question 1. First, try the Eligibility and Referral Line, If unable to verify, then call Provider Services, (You must participate with Medavant to utilize services). If you need help with communication, such as help from a language interpreter, please call Medicare Member Services. View sample member ID cards forcopayandhigh-deductibleplans for details. They should be informed of any health care needs that require follow-up, as well as self-care training. 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. For non-portal inquiries, please call 1-800-950-7040 . To determine copayment requirement, call ConnectiCare's Eligibility & Referral Line at 800-562-6834. Claims or Benefits questions will not be answered here. You can easily: Verify member eligibility status; . After the Plan deductible is met, benefits will be covered according to the Plan. 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. ConnectiCare cannot reverse CMS' determination. What does Transition of Care and Continuity of Care mean? Members are no longer eligible for coverage after their 40th birthday. ConnectiCare Medicare Advantage plans include a number of Medicare Advantage Plans. Members have an in-network deductible for some covered services before coverage for the benefits will apply. In addition, some of the ConnectiCare plans include Part D, prescription drug coverage. Examples of qualifying medical conditions can be found below. ConnectiCare requires that sufficient notice be given to all of your patients affected by a change in your practice. Participate with practitioners in decision-making regarding your health care. What can you doif you think you have been treated unfairly or your rights arent being respected? Make recommendations regarding our members rights and responsibilities policies. You may want to give copies to close friends or family members as well. 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. 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. 877-585-8480. Your responsibilities as a member of our plan. Go > There are federal and state laws that protect the privacy of your medical records and personal health information. If so, they will follow up to recruit the provider. Access to any Medicare-approved doctor or hospital in the United States. If there are unusual and extraordinary circumstances, or the enrollees PCP is unavailable or inaccessible, the enrollee may seek urgent care treatment at the nearest facility. However, the majority of PHCS plans offer members . We will make sure that unauthorized people dont see or change your records. (800) 557-5471. To get any of this information, call Member Services. We are equally committed to you, our PHCS PPO Network, and your overall satisfaction. Please check the privacy statement of the website where this link takes you. ConnectiCare, in coordination with participating providers, will maintain and monitor the network of participating providers to ensure that members have adequate access to PCPs, specialists, hospitals, and other health care providers, and that through the network of providers their care needs may be met. It is important to sign this form and keep a copy at home. To verify eligibility for services, request to see the member's current ID card. Call us and tell us you would like a decision if the service or item will be covered. ConnectiCare will disclose to the Centers of Medicare & Medicaid Services (CMS) all information that is necessary to evaluate and administer our Medicare Advantage plans, and to establish and facilitate a process for current and prospective members to exercise choice in obtaining Medicare services. All requests to initiate or extend a mental health or substance abuse authorization should be directed to our Behavioral Health Program at 800-349-5365. The admitting physician is responsible for pre-authorizing elective admissions five (5) working days in advance. Answer 2. The ConnectiCare Medicare Advantage network. Members under 12 years of age call PHC's Care Coordination Department at (800) 809- 1350. Follow the plans and instructions for care that they have agreed on with practitioners. CT scans (all diagnostic exams) According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. Occasionally, these complaints relate to the quality of care or quality of service members receive from their PCP, specialist, or the office staff. 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 Member Services. Member Services can also help if you need to file a complaint about access (such as wheel chair access). Members receive in-network level of benefits when they see participating providers. 1-1/2 times your annual salary paid to your beneficiary in the event of your death. All oral medication requests must go through members' pharmacy benefits. You can sometimes get advance directive forms from organizations that give people information about Medicare. What to do if you think you have been treated unfairly or your rights are not being respected? including benefit designs and Sutter provider participation in your provider network. 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. To get any of this information, call Member Services. We are equally committed to you, our PHCS PPO Network, and your overall satisfaction. To verify or determine patient eligibility, call 1-800-222-APWU (2798). 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. SISCO's provider portal allows you to submit claims, check status, see benefits breakdowns, and get support, anytime. Wondering how member-to-member health sharing works in a Christian medical health share program? Note: These procedures are covered procedures, but do not require preauthorization in network. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. 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. 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. High Deductible Health Plan (Health Savings Account [HSA] Compatible). Copyright 2022 Unite Health Share Ministries. ConnectiCare enrolls individual members into the 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. Nuclear cardiology If transport is required from one facility to another on a weekend or holiday, transport must be provided by a participating service. You and your administrative staff can quickly and easily access member eligibility and claims status information anytime, on demand. A complaint can be called a grievance, an organization determination, or a coverage determination depending on the situation. Members pay a copayment as cost-share for most covered health services at the time services are rendered. 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. Some applicable copayments Members receive out-of-network level of benefits when they see non-participating providers. 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. Documents called a "living will" and "power of attorney for health care" are examples of advance directives. We must investigate and try to resolve all complaints. In-office procedures are restricted to a specific list of tests that relate to the specialty of the physician. Yes, PHCS provides coverage for therapy services. Solutions. SeeMedical Management. If you have difficulty obtaining information from your plan based on language or a disability, call 1-800-MEDICARE (800-633-4227). We have partnered with TALON to bring you access to MyMedicalShopper; which provides you the ability to shop for healthcare services based on price, quality, and location. We are a caring community dedicated to keeping our members healthy, happy, and in control of their well-being. PHCS (Private Healthcare Systems, Inc.) - PPO. No referrals needed for network specialists. ConnectiCare, in compliance with advance directives regulations, must maintain written policies and procedures concerning advance directives with respect to all adult individuals receiving medical care. Pelvic exam Any information provided on this Website is for informational purposes only. provider must already be participating in PHCS Network, which is certified for credentialing by NCQA. This includes the right to know about the different Medication Management. The ID card lists the following information: ConnectiCare member ID number No specialist-to-specialist referrals permitted, except OB/GYNs may make referrals. Refuse treatment and to receive information regarding the consequences of such action. Just like we shop for everything else! 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. Savings - Negotiated discounts that result in significant cost savings when you visit in-network providers,helping to maximize your benefits. Out of network benefits will apply when receiving care from non-participating providers. ConnectiCare distributes its privacy notice to members annually, and to new members upon enrollment in the plan. However, ConnectiCare must terminate members for the following: The member has a change of address outside the service area. We request your cooperation in investigating and resolving these complaints. If you admit a member to a SNF on a weekend or holiday, ConnectiCare will automatically authorize payment for SNF services from the day of admission through the next business day. 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. (A 12-month waiting period may apply for members in individual [ConnectiCare SOLO] plans.). It is your responsibility to confirm your provider or facilitys continued participation in the PHCS Network and accessibilityunder your benefit plan. Members of PHCS health insurance plans have mental health benefits, which vary based on the plan under which they're enrolled. (SeeOther Benefit Information). This information, reprinted in its entirety, is taken from the planEvidence of Coverage. Prior Authorizations are for professional and institutional services only. Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible. SeeAutomated and Online Featuresfor additional information. ConnectiCare offers both employer-sponsored plans and individual insurance plans. Answer 4. If you are relocating out of ConnectiCare's network or retiring, please notify your patients at least ten (10) days in advance, in writing, in addition to notifying ConnectiCare and, if applicable, your contracted PHO/IPA in writing sixty (60) days in advance. Use the My Plan tab on the main website page to register for online access to your claims, plan document, EOBs and additional items. ConnectiCare members must continue to pay the Medicare Part B premium directly to the Medicare program. Their services are offered to health care plans, not individuals, as they do not sell insurance or offer any medical services. Christian Health Sharing State Specific Notices. Be treated with respect and recognition of your dignity and right to privacy. Paying your co-payments/coinsurance for your covered services. You have the right to an explanation from us about any bills you may get for services not covered by our plan. They will be clearly distinguishable by their ID cards. Regardless of where you get this form, keep in mind that it is a legal document. While you may contact us by telephone, you will be asked to place your concerns in writing. Your right to get information in other formats If you want a paper copy of this information, you may contact Provider Services at 877-224-8230. In-office procedures are restricted to a specific list of tests that relate to the specialty of the physician. 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. You have the right to refuse treatment. 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) abnormal arthrogram. Physicians may make referrals to participating specialists without entering them into the telephonic referral system. To contact our office for any eligibility, benefits and claims assistance: Performance Health Claims Administrator P.O. Visit Performance Health HealthworksWellness Portal. Describe the range or medical conditions or procedures affected by the conscience objection; Benefits Administration and Member Support for The Health Depot Association is provided byPremier Health Solutions. (SeeOther Benefit Information). You have the right to get information from us about our plan. Since you have Medicare, you have certain rights to help protect you. If you have questions or concerns about your rights and protections, please call Member Services. 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. Continuity of Care allows members the option to apply to receive services at in-network coverage levels for specified medical and behavioral conditions, from their current health care provider if the provider is or is soon to be out-of-network. We conduct routine, focused surveys to monitor satisfaction using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and implement quality improvement activities when opportunities are identified. Letting us know if you have any questions, concerns, problems, or suggestions. We dont discriminate based on a persons race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age, or national origin. Customer Service at 800-337-4973 You can sometimes get advance directive forms from organizations that give people information about Medicare. 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. This arrangement will be allowed until the safe transfer of care to a participating provider and/or facility can be arranged. If you do, please call Member Services. your current benefits ID card upon arrival at your appointment. 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. 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. Members pay a copayment cost-share for most covered health services at the time the services are rendered.
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