For Providers: Updated 6/10/09, Clinical Information Regarding H1N1 Flu
July 2007
Resolving Claims issues for Health Choice Generations Providers
If you are a Health Choice Generations Contracted Provider
Under Chapter 13 Section 70.1 of the Medicare Managed Care Manual, contracted providers do not have appeal rights. Appeals for non-payment of services would have to be filed by the beneficiary. However, Health Choice Generations would like to assist you in resolving your claims issues.
If a Claim is denied or you disagree with a payment:
Please call Claims Customer Service (CSRT) at (480) 968-6866 OR 1-800-322-8670. The CSR will review the claim issue with you and send a referral sheet if an adjustment is required. This referral will be routed to the HC Generations Claims Team lead for research and determination.
- Claim in question must be timely (1-year from date of service or 60-days from date of last adverse action).
- If the claim is paid correctly and no adjustment is necessary, a new line will be entered under the same claim # and a note is entered detailing the findings of the research.
- If the claim is paid/processed incorrectly, an adjusted line is added to the claim for each line that is paid incorrectly, and a note will be added to the claim detailing the adjustment, noting if an additional payment will be made or if a recoupment for an over, payment is needed.
- If you require a call back from the adjuster regarding the determination, please indicate so when speaking with the CSR so it may be noted on the referral.
If you are NOT a Health Choice Generations Contracted Provider
Under Chapter 13 Section 60.1.4 of the Medicare Managed Care Manual, a non-contracted provider on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the provider completes a Waiver of Liability Statement (WOL), which provides that the provider will not bill the enrollee regardless of the outcome of the appeal. The WOL Statement is available by calling Health Choice Generations Medicare Operations at 480-317-3328 or 1-800-322-8670 X 3328. A Standard Appeal may be filed by utilizing the following steps.
- A Provider may request a standard reconsideration by filing a signed, written request with Health Choice Generations within 60 calendar days from the date of denial. This request must be accompanied by a WOL Statement. (If the WOL Statement is not provided, every effort will be made by Health Choice Generations to secure that statement. If not received within the 60 calendar days, then the request for reconsideration will be forwarded to the IRE with request for dismissal). Mail requests to:
- Health Choice Generations
- Attn: Provider Appeals
- 410 N. 44th Street, Ste. 900
- Phoenix, AZ 85008
- Once the request for standard reconsideration is received and logged, the physician may be contacted to provide additional information in order to review the case.
- Health Choice Generations will make its reconsideration determination no later than 60 calendar days from the date Health Choice Generations receives the request.
- If upon reconsideration, Health Choice Generations overturns its adverse organization determination denying a request for payment, then Health Choice Generations will issue its reconsidered determination and send payment for the service no later than 60 calendar days from the date it received the request for a standard reconsideration.
- If Health Choice Generations affirms, in whole or in part, its adverse organization determination, a written explanation and case file will be prepared and sent to the Independent Review Entity contracted by CMS.
- If the IRE reverses, the original determination then payment will be made within 30 calendar days from the date Health Choice Generations receives the notice of the reversal.
- If the IRE affirms the original determination, and the amount remaining in controversy meets the appropriate threshold requirement ($120 in 2007) then the provider or beneficiary has a right to a hearing before an Administrative Law Judge (ALJ).
- The Request for Hearing must be in writing and must be filed with the entity specified in the IRE's reconsideration notice within 60 days of receiving the adverse determination.
December 2006
Health Choice Generations Medicare Advantage Special Needs Plan Prior Authorization Form-Last updated 12/6/2006
Health Choice Generations Medicare Advantage Special Needs Plan Behavioral Health Medication Prior Authorization Form
Effective Monday, January 1, 2007, Health Choice Arizona will no longer provide a "STAT" (24-hour turn around) time frame on prior authorization requests. AHCCCS plans are required to execute the following time frame standards for addressing prior authorization requirements that State AHCCCS (via the Balanced Budget Act of 1997) regulators have put in place:
"Standard" Authorization - A request for which Health Choice Arizona must provide a decision no later than 14 calendar days following the receipt of the authorization request, with a possible extension of up to 14 calendar days if the member or provider requests an extension or if Health Choice Arizona justifies a need for additional information and the decision interruption is in the enrollee's best interest.
"Expedited" Authorization - A request for which healthcare providers indicate or Health Choice Arizona determines that using the standard timeframe could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function. Health Choice Arizona must make an expedited authorization decision and provide notice as expeditiously as the member's health condition requires, but no later than three working days following the receipt of the authorization request. An extension of up to 14 days is possible, if the member or provider requests an extension or if Health Choice Arizona justifies a need for additional information and the interruption is in the enrollee's best interest.
During the 2005-6 AHCCCS Operational and Financial Review audit, it was noted that Health Choice Arizona was not following "standard" guidelines by providing the additional option of "STAT" to our providers. Ensuing AHCCCS remarks regarding this finding, coupled with ongoing provider misuse and/or abuse of the HCA "STAT" category (originally put in place to help our providers and members hasten turn around on highly sensitive requests), has led Health Choice Arizona to discontinue its use indefinitely.
New HCA PA forms will only contain options for either "Standard" or "Expedited." Expedited, as written above, is to only be utilized when it is determined that the member's health is at risk if the service is not provided within 72 hours. HCA has developed new Medical and Behavioral Health Prior Authorization Request forms for the Health Choice (Medicaid - AHCCCS) and HC Generations (Medicare Advantage Prescription Drug) health plans, which have been posted above and on the Commonly Used Forms page for your use. Again, these forms go into effect Monday, January 1, 2007.
If you should have any questions, please call your Network Services representative. If you are not sure who your representative is, please refer to the listing of the Network Services staff.
November 2006
Synagis© Guidelines 2006-2007
The RSV season is almost here and Health Choice Generations would like to make you aware of our guidelines for administration of Synagis© (palivizumab) during the 2006-2007 RSV season.
HC Generations has based our practice guidelines for RSV immunoprophylaxis from the most current American Academy of Pediatrics and CDC guidelines. HC Generations has determined the beginning of the RSV season for medication delivery and subsequent administration as Wednesday, November 1, 2006 and will later determine the end of RSV season in the various geographical service areas covered through communication with regional reference labs and positive culture rates.
The following link is the 2006-2007 Eligibility Assessment form to be used with all prior authorization requests for Synagis®. (Click here to download PDF Form )
All prior authorization requests should be submitted on the Synagis? Eligibility Assessment form. Prior authorization requests should be submitted directly to the designated HC Generations Synagis? providers listed in the table below.
Additional assistance can be attained from Priscilla Holly, at 480-333-4541.
Maricopa County and Tucson Metropolitan:
Los Ninos Synagis® Program
Attn: Davena Ballard
Fax: 602-424-2149
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Once approved for Synagis® administration, all members residing in Maricopa
County and in the Tucson Metropolitan area will receive this immunization through
Los Ninos Synagis® Program
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All other Cities and Counties:
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Accredo Health Group, Inc.
Attn: Shaunte Winfrey
Fax: 877-369-3447
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Once approved for Synagis® administration all members residing in other
cities and counties will have their immunizations shipped directly to their ordering
PCP and/or Specialist from Accredo Health Group, Inc. and may
then administer in the office setting.
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Providers who receive drop shipped orders from Accredo Health Group, Inc. should
follow these Billing Guidelines.
Report services, using appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes,
Revenue codes, and/or ICD-9 diagnostic codes.
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Use CPT code 90772 from billing
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October 2006
Direct EDI notice
Flu and Pneumonia information
Flu season vaccine program information
September 2006
ESRD Claims Medicare Overpayment Recoupment
July 2006
Web site registration
Members
