All oral medication requests must go through members' pharmacy benefits. How to manage the front desk when they ask who you are insured with? For a specific listing of services and procedures that require pre-authorization refer to the Appendices within this manual. Provide, to the extent possible, information providers need to render care. 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. Nutritionist and social worker visit 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. For additional details on using ConnectiCare's Eligibility & Referral Line or Medavant, refer toAutomated & Online Features. If you want a paper copy of this information, you may contact Provider Services at 860-674-5850 or 800-828-3407. Go to the Client Portal > Provider directories Create a customized listing of facilities and/or practitioners participating in the network services offered by MultiPlan. Go > Browse the list to see where your plan is accepted. Emergency care and out-of-area urgently needed services are covered under the Prime and Custom Plans, anytime, anywhere (worldwide). How do I contact PHCS? (SeeOther Benefit Information). Our goal is to be the best healthcare sharing program on the planet and to provide. Any personal information that you give us when you enroll in this plan is protected. Physicians may make referrals to participating specialists without entering them into the telephonic referral system. What to do if you think you have been treated unfairly or your rights are not being respected? Your right to get information about our plan We are a caring community dedicated to keeping our members healthy, happy, and in control of their well-being. Services or supplies that are new or recently emerged uses of existing services and supplies, are not covered benefits, unless and until we determine to cover them. All providers shall comply with Title VI of the Civil Rights Act of 1964, as implemented by regulations at 45 C.F.R. You also have the right to ask us to make additions or corrections to your medical records (if you ask us to do this, we will review your request and figure out whether the changes are appropriate). To pre-notify or to check member or service eligibility, use our provider portal. 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. This information, reprinted in its entirety, is taken from the planEvidence of Coverage. Reminding the patient to notify ConnectiCare; and Click Here to go to the PHCS / Multiplan Provider Search. Medicare members may disenroll from the plan when the guidelines, as set forth bythe Centers for Medicare & Medicaid Services (CMS), are met. If a complaint about you or your office staff is received, ConnectiCare will contact you and request information relating to the complaint. Notify ConnectiCare within twenty-four (24) hours after an emergency admission at 888-261-2273. 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. Supporting evidence, which may be required includes: 1.) To get this information, call Member Services. Just like we shop for everything else! Prior Authorizations are for professional and institutional services only. If you want to receive Medicare publications on your rights, you may call and request them at 1-800-MEDICARE (800-633-4227). Question 5. You also have the right to give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. They should be informed of any health care needs that require follow-up, as well as self-care training. Identify the state legal authority permitting such objection; The temporary card is a valid form of ConnectiCare member identification. To verify eligibility for services, request to see the member's current ID card. We must tell you in writing why we will not pay for or approve a service, and how you can file an appeal to ask us to change this decision. Best of all, it's free- no downloads required or software to install. You must call ConnectiCares Notification Line at 860-674-5870 or 888-261-2273 to advise ConnectiCare of the admission. 877-585-8480. (SeeOther Benefit Information). Access to any Medicare-approved doctor or hospital in the United States. Can be provided safely by persons who are not medically skilled, with a reasonable amount of instruction, including, but not limited to, supervision in taking medication, homemaking, supervision of the patient who is unsafe to be left alone, and maintenance of bladder catheters, tracheotomies, colostomies/ileostomies and intravenous infusions (such as TPN) and oral or nasal suctioning. Medicare members who elect to become members of ConnectiCare must meet the following qualifications: Members must be eligible for Medicare Part A and be enrolled in and continue to pay for Medicare Part B. Dominion Tower 999 Waterside Suite 2600 Norfolk, VA 23510. If you are a PCP, please discuss your provisions for after-hours care with your patients, especially for in-area, urgent care. SeeGlossaryfor definitions of emergency and urgent care. MultiPlan can help you find the provider of your choice. P.O. Our plan must obey laws that protect you from discrimination or unfair treatment. You may also use the ConnectiCare Eligibility and Referral Line. This report is sent to all PCPs upon request, and it lists each member who has selected or has been assigned to that PCP. The PHCS Network includes nearly 4,400 hospitals, 79,000 ancillary care facilities and more than 700,000 healthcare professionals nationwide. Follow the rules of this Plan, and assume financial responsibility for not following the rules. The following information was provided by the Connecticut Office of Attorney General for the Department of Public Health and Addiction Services and the Department of Social Services. The plan contract is terminated. You can sometimes get advance directive forms from organizations that give people information about Medicare. To begin the precertification process, your provider(s) should contact, Transition and Continuity of Care - Information and Request Form, Performance Health Open Negotiation Notice. Answer 4. (SeeOther Benefit Information). Circumstances beyond our control such as complete or partial destruction of facilities, war, or riot. You may also search online at www.multiplan.com: If you are currently seeing a doctor or other healthcare professional who does not participate in the PHCS Network,you may use the Online Provider Referral System in the Patients section of www.multiplan.com, which allows you tonominate the provider in just minutes using an online form. Since you have Medicare, you have certain rights to help protect you. New users to the Provider Portal can create an account by selecting the Provider Access Link on the portal login page. Refractions are not covered by ConnectiCare Medicare Advantage plans. allergenic extracts (or RAST allergen specific testing); 2.) 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. 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. 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. Requests may be made by either the physician or the member. PCP name and telephone number The admitting physician is responsible for pre-authorizing elective admissions five (5) working days in advance. This feature is meant to assist members who need additional copies of their ID card. TTY users should call 877-486-2048. Please review our formulary website or call Member Services for more information. For a specific listing of services and procedures that require preauthorization please refer to the preauthorization lists found within this manual. Your providers must explain things in a way that you can understand. While we strive to keep this list up to date, it's always best to check with your health plan to determine the specific details of your coverage, including benefit designs and Sutter provider participation in your provider network. Box 340308, Hartford, CT 06134-0308, 860-509-8000, TTY: 860-509-7191. For example, you have the right to look at medical records held at the plan, and to get a copy of your records. This includes information about our financial condition, and how our Plan compares to other health plans. Product and plan details are outlined in the product and coverage section on this page. ConnectiCare provides each member with a statement of member rights and responsibilities. Out of network benefits will apply when receiving care from non-participating providers. Simplifying the benefits experience, so you can focus on patient care. If you have any questions regarding a member's eligibility, call Provider Services at 877-224-8230. You should consider having a lawyer help you prepare it. You must pay for services that arent covered. UHSM is always eager and ready to assist. For plans where coverage applies, one routine eye exam per year covered at 100% after copayment (no referral required). 2. 1-1/2 times your annual salary paid to your beneficiary in the event of your death. Your benefits, claims and/or eligibility are available 24/7 via our member portal. If you need help with communication, such as help from a language interpreter, please call Medicare Member Services. 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. You have the right to an explanation from us about any bills you may get for drugs not covered by our Plan. Oops, there was an error sending your message. We are equally committed to you, our PHCS PPO Network, and your overall satisfaction. According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. Do I have any Out of Network benefits and what happens when doctor says we do not take your insurance? For concerns or problems related to your Medicare rights and protections described in this section, you may call our Member Services. To get any of this information, call Member Services. After the Plan deductible is met, benefits will be covered according to the Plan. Specialists:Provide continuity and coordination of care by sending a written report to the member's PCP regarding any treatment or consultation provided to the member. Our plan must have individuals and translation services available to answer questions from non-English speaking beneficiaries, and must provide information about our benefits that is accessible and appropriate for persons eligible for Medicare because of disability. Providers are also required to contact ConnectiCares Notification Line at 888-261-2273 to advise ConnectiCare of the transport. Land or air ambulance/medical transportation that is not due to an emergency requires pre-authorization. MRI/MRA (all examinations) In addition, some of the ConnectiCare plans include Part D, prescription drug coverage. 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. Question 1. In-office procedures are restricted to a specific list of tests that relate to the specialty of the physician. We will make sure that unauthorized people dont see or change your records. MedAvant, an online transaction system available to ConnectiCare participating providers, also offers a secure means for entering and verifying referrals. All routine laboratory services must be obtained from participating laboratories. Coverage for skilled nursing facility (SNF) admissions with preauthorization. Document in a prominent part of the individual's current medical record whether or not the individual has executed an advance directive; and To obtain a copy of the privacy notice, visit our website atconnecticare.com, or call Provider Services at the number below. Network providers and practitioners are also contractually obligated to protect the confidentiality of members information. Members with End Stage Renal Disease (ESRD) will not qualify, except if they are currently covered by a ConnectiCare benefit plan through an employer or self pay (a commercial member). You may want to give copies to close friends or family members as well. Pharmacy cost-share, if applicable. TTY users should call 877-486-2048. Use the My Plan tab on the main website page to register for online access to your claims, plan document, EOBs and additional items. Influenza and pneumococcal vaccinations Notifying providers when seeking care (unless it is an emergency) that you are enrolled in our plan and you must present your plan enrollment card to the provider. We may enroll employer group members as well. ConnectiCare limits and terminates access to information by employees who are not or no longer authorized to have access. Please call Member Services if you have any questions. According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. What can you doif you think you have been treated unfairly or your rights arent being respected? To inquire about an existing authorization - (phone) 800-562-6833 Members are required to see participating providers, except in emergencies. Without preauthorization, these services and procedures may not be covered or may be covered at a reduced rate. To determine copayment requirement, call ConnectiCare's Eligibility & Referral Line at 800-562-6834. Members under 12 years of age call PHC's Care Coordination Department at (800) 809- 1350. You can reference your plan document for the complete list. The Members Rights and Responsibilities Statement, reprinted below in its entirety, summarizes ConnectiCares position: Introduction to your rights and protections Answer 5. By contracting with this network, our members benefit from pre-negotiated rates and payment processes that lead to a much smoother . ConnectiCare requires that sufficient notice be given to all of your patients affected by a change in your practice. It is generally available between 7 a.m. and 9:30 p.m., Monday through Friday, and from 7 a.m. to 2 p.m. on Saturday. Minimal hold time Fast Claim Processing and Payment Clear Explanation of Benefits Clear Benefit Descriptions We are equally committed to you, our PHCS PPO Network, and your overall satisfaction. Your right to get information about our plan and our network pharmacies 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). If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you. Copyright 2022 Unite Health Share Ministries. Letting us know if you have any questions, concerns, problems, or suggestions. Note: Refractions (CPT 92015) are considered part of the office visit and are not separately reimbursed. 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. Question 2. You have chosen PHCS (Private Healthcare Systems, Inc.). For emergency care received outside the U.S. there is a $100,000 limit. Monitoring includes member satisfaction with physicians. To find a participating provider outside of Oklahoma, follow the steps listed below. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. Discounts on frames, lenses, and contact lenses: 25% discount for items costing $250 or less; 30% discount for items over $250. If transport is required from one facility to another on a weekend or holiday, transport must be provided by a participating service. Member race, language, ethnicity, gender orientation, and sexual identity cannot be used to perform underwriting, rate setting, and benefit determinations (specifically denial of coverage and benefits), and cannot be disclosed to unauthorized users. It is important to note that not all of the Sutter Health network . Documents called a "living will" and "power of attorney for health care" are examples of advance directives. This would also include chronic ventilator care. PCPs:Advise your patients to contact ConnectiCare's Member Services at 860-674-5757 or 800-251-7722 to designate a new PCP, even if your practice is being assumed by another physician. Glaucoma screening Please review the member's ID card to confirm the appropriate phone number. ConnectiCare distributes its privacy notice to members annually, and to new members upon enrollment in the plan. Some plans cover preventive dental services: Receive information about us, our services, our participating providers, and "Members Rights and Responsibilities.". Benefits Administration and Member Support for The Health Depot Association is provided byPremier Health Solutions. provider must already be participating in PHCS Network, which is certified for credentialing by NCQA. Reference the below Performance Health Open Negotiation Notice for details on the process your provider must follow for disputing the allowable rate used on your claim. The provider must agree to accept network rates for the defined period of time. You can also visit www.medicare.gov on the Web to view or download the publication Your Medicare Rights & Protections. Under Search Tools, select Find a Medicare Publication. Or, call 1-800-MEDICARE (800-633-4227). 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. ConnectiCare members will receive an identification (ID) card when they enroll in the plan. Admission to a SNF for rehabilitation, in the absence of a hospitalization or acute episode of illness, requires preauthorization and is subject to medical necessity review. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. The legal documents that you can use to give your directions in advance in these situations are called "advance directives." ConnectiCare also makes available to members printable, temporary ID cards via our website. In addition, some of the ConnectiCare plans include Part D, prescription drug coverage. 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. Paying your co-payments/coinsurance for your covered services. If you have questions or concerns about your rights and protections, please call Member Services. 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. The rental and/or purchase of CPAP and BI-PAP machines must be done through our preferred vendors. Your responsibilities include the following: Getting familiar with your coverage and the rules you must follow to get care as a member. If you have any other kind of concern or problem related to your Medicare rights and protections described in this section, you can also get help from CHOICES. In addition, information is protected by information systems security, and authentication and authorization procedures, such as but not limited to: password-protected files; storage, data disposal, and reuse of media and devices; and transmission and physical security requirements using company-protected equipment including access to devices and media that contain individual-level data. Wondering how member-to-member health sharing works in a Christian medical health share program? Answer 1. Providers shall not discriminate against an enrollee based on whether or not the enrollee has executed an advance directive. If you have difficulty obtaining information from your plan based on language or a disability, call 1-800-MEDICARE (800-633-4227). Covered according to Massachusetts state mandate. Some preventive services are covered at 100% and are exempt from the deductible requirement. Blue Cross Providers: 800 . DME, orthotics & prosthetics must be obtained from a participating commercial DME vendor unless otherwise authorized by ConnectiCare and preauthorization must be obtained through ConnectiCare. For non-portal inquiries, please call 1-800-950-7040 . These extra benefits include, but are not limited to, preventive services including routine annual physicals, routine vision exams and routine hearing exams. You have the right to choose a plan provider (we will tell you which doctors are accepting new patients). Please check the privacy statement of the website where this link takes you. Member satisfaction information is updated and posted annually and is made available on our website atconnecticare.com. If you have any concerns about your health, please contact your health care provider's office. Use your member subscriber ID to access the pricing tool using the link below. Describe the range or medical conditions or procedures affected by the conscience objection; What services are available to me that could save me money? With the PHCS Network in your cost management strategy, you give your health plan participants the choice of over 4,100 hospitals, 70,000 ancillary care facilities and 630,000 healthcare professionals nationwide, whether they seek care in their home town or across the country. We must tell you in writing why we will not pay for a drug, and how you can file an appeal to ask us to change this decision. These services are covered under the Option Plan nationwide. A 3-day covered hospital stay is not required prior to being admitted. New members may use a copy of the enrollment form as a temporary identification card until they receive their ID card. In addition, the ID card also includes emergency instructions and a toll-free telephone number for out-of-area and after-hours notifications, the Member Services phone number, and the claims submission address. Balance Bill defense is available for all members with a Reference Based Pricing Plan. SeeMedical Management. Coverage is provided for temporomandibular joint (TMJ) surgery or orthognathic procedures with preauthorization, when medical necessity is established. A complete list of Sutter Health Hospitals and Medical Groups accepting this health plan. First, try the Eligibility and Referral Line, If unable to verify, then call Provider Services, (You must participate with Medavant to utilize services). Routine hearing tests covered up to 1 every year, Routine eye exams covered up to 1 every year, Discounts are available on lenses, contacts and frames. Call Automated Phone Specialists between 8 a.m. and 4:30 p.m. (CST) Monday through Fridays at 800-650-6497. Please note: The benefit information provided is not a comprehensive list and is subject to change. You have the right to get information from us about our network pharmacies, providers and their qualifications and how we pay our doctors. When performed out of network, these procedures do require preauthorization. SISCO's provider portal allows you to submit claims, check status, see benefits breakdowns, and get support, anytime. Voice complaints or appeals/grievances about us or the care you are provided. This system requires that you have a touch-tone phone and know your ConnectiCare provider ID number, as well as the member's identification number, to verify eligibility. Question 4. Hartford, CT 06134-0308 You have the right under law to have a written/binding advance coverage determination made for the service, even if you obtain this service from a provider not affiliated with our organization. ConnectiCare Medicare Advantage plans include a number of Medicare Advantage Plans. In-office procedures are restricted to a specific list of tests that relate to the specialty of the provider. drug, biological or venom sensitivity. 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. Regardless of where you get this form, keep in mind that it is a legal document. ConnectiCare requires all of its participating practitioners and providers to treat member medical records and other protected health information as confidential and to assure that the use, maintenance, and disclosure of such protected health information complies with all applicable state and federal laws governing the security and privacy of medical records and other protected health information. These members may have a different copayment and/or benefit package. At a minimum, this statement must: Clarify any differences between institution-wide conscientious objections and those that may be raised by the individual physician; When in the service area, members are expected to seek routine services, except for certain self-referred services, from their PCP. You also have the right to get information from us about our plan. If you want a paper copy of this information, you may contact Provider Services at 877-224-8230. Delays and failures to render services due to a major disaster or epidemic affecting our facilities or personnel. They will be clearly distinguishable by their ID cards. You have the right to refuse treatment. Life Insurance *. Choice - Broad access to nearly 4,400 hospitals, 79,000 ancillaries and more than 700,000 healthcareprofessionals. Lifetime maximums apply to certain services. However, the majority of PHCS plans offer members . Point-of-Service High Deductible Health Plans have an additional Plan deductible requirement for services rendered by non-participating providers. Any information provided on this Website is for informational purposes only. Members receive out-of-network level of benefits when they see non-participating providers. Your Explanation of Payment (EOP) will specify member responsibility. Note: These procedures are covered procedures, but do not require preauthorization in network. part 84; the Americans with Disabilities Act; the Age Discrimination Act of 1975, as implemented by regulations at 45 C.F.R. Prostate cancer screening (age restrictions apply) 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. 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. This line is available twenty-four (24) hours a day, seven days a week. If you refuse treatment, you accept responsibility for what happens as a result of your refusing treatment. 410 Capitol Avenue Optional Life Insurance *. To get any of this information, call Member Services. I really appreciate the service I received from UHSM. Member satisfaction with ConnectiCare is very important. Members have an in-network deductible for some covered services before coverage for the benefits will apply. It is critical that the members eligibility be checked at each visit. If your plan does not meet the requirements below, Primary PPO Complementary PPO Specialty Networks Network Management Analytics-Based Solutions: Negotiation Services Medical Reimbursement Eligibility Claims Eligibility Fields marked with * are required. Such information includes, but is not limited to, quality and performance indicators for plan benefits regarding disenrollment rates, enrollee satisfaction, and health outcomes. Letting us know if you have additional health insurance coverage. If you are a primary care provider (PCP), you may also check your most recentMembership by PCPreport. When performed out-of-network, these procedures do require preauthorization.
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