Any information provided on this Website is for informational purposes only. Transition of Care allows new members and/or members whose plan has experienced a recent provider network change to continue to receive services for specified medical and behavioral conditions, with health care professionals that are not participating in the plans designated provider network, until the safe transfer of care to a participating provider and/or facility can be arranged. 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) 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. Pay applicable copayments, deductibles or coinsurance. New users to the Provider Portal can create an account by selecting the Provider Access Link on the portal login page. PDF PHCS Savility - MultiPlan These members may have a different copayment and/or benefit package. Prostate cancer screening (age restrictions apply) Really good service. ConnectiCare must provide written information to those individuals, including their rights under the law of the State to make decisions concerning their medical care, such as the right to accept or refuse medical or surgical treatment and the right to formulate advance directives. Timely access means that you can get appointments and services within a reasonable amount of time. Answer 5. For concerns or problems related to your Medicare rights and protections described in this section, you may call our Member Services. If you need more information, please call Member Services. What insurance carrier is PHCS? - InsuredAndMore.com Monitoring includes member satisfaction with physicians. Refer to the annually updated Summary of Benefits section on this page and list of Exclusions and Limitations for more details. Your right to be treated with dignity, respect and fairness Initial mental health consultation Long Term Care Insurance. Occasionally, these complaints relate to the quality of care or quality of service members receive from their PCP, specialist, or the office staff. Note: These procedures are covered procedures, but do not require preauthorization in network. Treatment Programs we offer and in which you may participate. Most plans exclude purely dental services, including oral surgery, but benefits vary by employer. Medical claims can be sent to: Insurance Benefit Administrators, c/o Zelis, Box 247, Alpharetta, GA, 30009-0247; EDI Payor ID: 07689. If you have questions about your benefits or the status of claims, please call Group Benefit Services, Inc. Provider Quick Reference Guide - MultiPlan You also have the right to receive an explanation from us of any utilization management requirements, such as step therapy or prior authorization that may apply to your plan. Your rights include knowing about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. A candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage. Follow the plans and instructions for care that they have agreed on with practitioners. See preauthorization list for DME that requires pre-authorization. (More information appears later in this section.). The following are samples of each type of ID card that ConnectiCare issues to members. The plan cannot and will not disenroll a member because of the amount or cost of services used. 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. You can sometimes get advance directive forms from organizations that give people information about Medicare. This includes information about our financial condition, about our plan health care providers and their qualifications, about information on our network pharmacies, and how our plan compares to other health plans. They will be clearly distinguishable by their ID cards. ConnectiCare takes all complaints from members seriously. What should I do if I get a bill from a healthcare provider? ConnectiCare Medicare Advantage plans provide all Part A and Part B benefits covered by Original Medicare. It includes services and supplies furnished to a member who has a medical condition that is chronic or non-acute and which, at our discretion, either: Are furnished primarily to assist the patient in maintaining activities of daily living, whether or not the member is disabled, including, but not limited to, bathing, dressing, walking, eating, toileting and maintaining personal hygiene or. This information, reprinted in its entirety, is taken from the planEvidence of Coverage. Please review our formulary website or call Member Services for more information. 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). Best of all, it's free- no downloads required or software to install. Members of PHCS health insurance plans have mental health benefits, which vary based on the plan under which they're enrolled. PET scans 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. Members can print temporary ID cards by visiting the secure portion of our member website. In addition, MultiPlan is not liable for the payment of services under plans. Regardless of where you get this form, keep in mind that it is a legal document. PHCS (Private Healthcare Systems, Inc.) - Sutter Health The admitting physician is responsible for preauthorizing elective admissions five (5) working days in advance. Enrollee satisfaction with ConnectiCare is very important. Balance Bill defense is available for all members with a Reference Based Pricing Plan. Please Note: When searching for providers, the results presented are for reference only; as participating physicians, hospitals, and/or healthcare providers may have changed since the online directory was last updated. You can also get help from CHOICES - your State Health Insurance Assistance Program, or SHIP. Minimal hold time Fast Claim Processing and Payment Clear Explanation of Benefits Clear Benefit Descriptions This includes information about our financial condition and about our network pharmacies. ConnectiCare Medicare Advantage plans include a number of Medicare Advantage Plans. If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital. In-office procedures are restricted to a specific list of tests that relate to the specialty of the provider. All oral medication requests must go through members' pharmacy benefits. 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. 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. Provider. 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. Members have an in-network deductible for some covered services. What can you doif you think you have been treated unfairly or your rights arent being respected? You should consider having a lawyer help you prepare it. Be treated with respect and recognition of your dignity and right to privacy. Limited to a maximum of $315 every two (2) calendar years for: 1.) If a complaint about you or your office staff is received, ConnectiCare will contact you and request information relating to the complaint. You may also call the Office for Civil Rights at 800-368-1019 or TTY:800-537-7697, or your local Office for Civil Rights. Discounts on frames, lenses, and contact lenses: 25% discount for items costing $250 or less; 30% discount for items over $250. You will get most or all of your care from plan providers, that is, from doctors and other health providers who are part of our plan. When in the service area, members are expected to seek routine services, except for certain self-referred services, from their PCP. If you have any questions regarding a member's eligibility, call Provider Services at 877-224-8230. Always confirm network participation and provide your UHSM Member ID card prior to scheduling an appointment and before services are rendered. You have the right to know how your health information has been given out and used for non-routine purposes. Member Services can also help if you need to file a complaint about access (such as wheel chair access). That goes for you, our providers, as much as it does for our members. To obtain a copy of the privacy notice, visit our website atconnecticare.com, or call Provider Services at the number below. No referrals needed for network specialists. You must pay for services that arent covered. Read the Membership Agreement, Evidence of Coverage, or other Plan document that describes the Plans benefits and rules. abnormal arthrogram. 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. The bill of service for these members must be submitted to Medicaid for reimbursement. Actual copayment information and other benefit information will vary. Network providers and practitioners are also contractually obligated to protect the confidentiality of members information. Covered at participating urgent care providers. 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. Your benefits, claims and/or eligibility are available 24/7 via our member portal. We must investigate and try to resolve all complaints. How to get more information about your rights Members have the responsibility to: Members rights and our obligations are limited to our ability to make a good faith effort in regard to: Each time a member receives services, you should confirm eligibility. Question 2. Make recommendations regarding our members rights and responsibilities policies. Access to any Medicare-approved doctor or hospital in the United States. View sample member ID cards forcopayandhigh-deductibleplans for details. PDF PHCS Network and Limited Benefit Plans - MultiPlan Question 3. To contact our office for any eligibility, benefits and claims assistance: Performance Health Claims Administrator P.O. Register for an account For No Surprises Act First time visitor? 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. ConnectiCare distributes its privacy notice to members annually, and to new members upon enrollment in the plan. Medicare and Medicaid eligible members designated as Qualified Medicare Beneficiary. Note: Some services require preauthorization. If you want a paper copy of this information, you may contact Provider Services at 877-224-8230. 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. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. No referrals needed for network specialists. ConnectiCare involuntary disenrollment Performance Health at For preauthorization of the following radiological services, call 877-607-2363 or request online atradmd.com/. You and your administrative staff can quickly and easily access member eligibility and claims status information anytime, on demand. Refer members to the ConnectiCare Member Services at 800-224-2273 if they need information on disenrollment. 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. You have the right to choose a plan provider (we will tell you which doctors are accepting new patients). Choose "Click here if you do not have an account" for self-registration options. Savings - Negotiated discounts that result in significant cost savings when you visit in-network providers,helping to maximize your benefits. If you make a complaint, we must treat you fairly (i.e., not retaliate against you) because you made a complaint. After the Plan deductible is met, benefits will be covered according to the Plan. You have the right to refuse treatment. Provide, to the extent possible, information providers need to render care. You have the right to make a complaint if you have concerns or problems related to your coverage or care. Providers shall not discriminate against an enrollee based on whether or not the enrollee has executed an advance directive. 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. Use our online Provider Portal or call 1-800-950-7040. (A 12-month waiting period may apply for members in individual [ConnectiCare SOLO] plans.). Female members may directly access a women's health care specialist within the network for the following routine and preventive health care services provided as basic benefits: Annual mammography screening (age restrictions apply) These services are covered under the Option Plan nationwide. That goes for you, our providers, as much as it does for our members. The legal documents that you can use to give your directions in advance in these situations are called "advance directives." You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you cant. UHSM serves as a connector, we administer the cost-sharing program and help health share members support each otherits AWESOME! Out of network benefits will apply when receiving care from non-participating providers. In addition, some of the ConnectiCare plans include Part D, prescription drug coverage. Acting in a way that supports the care given to other patients and helps the smooth running of your doctors office, hospitals, and other offices. Circumstances beyond our control such as complete or partial destruction of facilities, war, or riot. However, ConnectiCare must terminate members for the following: The member has a change of address outside the service area. In addition, to ensure proper handling of your claim, always present yourcurrent benefits ID card upon arrival at your appointment. Follow the rules of this Plan, and assume financial responsibility for not following the rules. UHSM medical sharing eligibility extends to qualifying costs at the more than 1.2 million doctors, hospitals, and specialists in this network. 2. Members must reside in the service area. Prospective members must properly complete and sign an enrollment application and submit it to ConnectiCare. How do I know if I qualify for PHCS insurance? PHC's Member Services Department is available Monday - Friday, 8 a.m. - 5 p.m. You can call us at 800 863-4155. Provider Portal Provider Portal - Claims & Eligibility 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. Call us and tell us you would like a decision if the service or item will be covered. HPI | Provider Resources | Patient Benefits & Eligibility Glaucoma screening Visit Performance Health HealthworksWellness Portal. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under yourplan. 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. Bone mass measurement Click on the link and you will then have immediate access to the Member portal. Advance directives are written instructions, such as living will, durable power of attorney for health care, health care proxy, or do not resuscitate (DNR) request, recognized under state law and relating to the provision of health care when the individual is incapacitated and unable to communicate his/her desires. 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. If you need assistance If you encounter issues when scheduling appointments with PHCS Network providers, call us at 866-685-7427. My rep did an awesome job. 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. Influenza and pneumococcal vaccinations PHCS Health Insurance - Health Insurance Providers Answer 2. After the deductible has been met, coinsurance will apply to the covered benefits. It is your responsibility to confirm your provider or facilitys continued participation in the PHCS Network and accessibilityunder your benefit plan. Requests may be made by either the physician or the member. Blue Cross Providers: 800 . (SeeOther Benefit Information). CT scans (all diagnostic exams) A complaint can be called a grievance, an organization determination, or a coverage determination depending on the situation. Members receive out-of-network level of benefits when they see non-participating providers. Member receive in-network level of benefits when they see PHCS Healthy Direction Providers. This information is not used in contracting or credentialing decisions or for any discriminatory purpose. Prior Authorizations are for professional and institutional services only. MRI/MRA (all examinations) (800) 557-5471. Submit a Coverage Information Form. Referrals must be signed in to ConnectiCaresProvider Connection. If you are a PCP, please discuss your provisions for after-hours care with your patients, especially for in-area, urgent care. Please note: The benefit information provided is not a comprehensive list and is subject to change. PHCS Health Insurance is Private HealthCare Systems, and was recently acquired by MultiPlan. 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 may enroll employer group members as well. All oral medication requests must go through members' pharmacy benefits. Three simple steps and a couple minutes of your time is all it takes to obtain preauthorization from UHSM. If you need more information, please call our Member Services. Questions regarding the confidentiality of member information may be directed to Provider Services at 877-224-8230. Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible. Click Here to go to the PHCS / Multiplan Provider Search. If so, they will follow up to recruit the provider. You have the right to be told about any risks involved in your care. Your right to use advance directives (such as a living will or a power of attorney) For a specific listing of services and procedures that require preauthorization please refer to the preauthorization lists found within this manual. 410 Capitol Avenue From www.myperformancehlth.com, go to My Plan, Web Access Login, Register & Enroll, Select Member, Complete the Registration form. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. While other insurance companies and TPAs make you go through numerous frustrating prompts and then hold for an extensive period, our approach is to take the call as soon as possible so that you can move on with your day. 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. A sample of the ConnectiCare ID cards appear below. UHSM Health Share and WeShare All rights reserved. Stress echocardiograms Once your account has been created you will only need your login and password. Coverage for skilled nursing facility (SNF) admissions with preauthorization. At a minimum, this statement must: Clarify any differences between institution-wide conscientious objections and those that may be raised by the individual physician; drug, biological or venom sensitivity. It is important to note that not all of the Sutter Health network . Popular Questions. Examples of covered medical conditions can be found below. 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. For additional details on using ConnectiCare's Eligibility & Referral Line or Medavant, refer toAutomated & Online Features. Giving your doctor and other providers the information they need to care for you, and following the treatment plans and instructions that you and your doctors agree upon. Claims or Benefits questions will not be answered here. You have the right to get information from us about our network pharmacies, providers and their qualifications and how we pay our doctors. ConnectiCare encourages members to actively participate in decision making with regard to managing their health care. This includes the right to stop taking your medication. 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. 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. Pelvic exam The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. 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! In-office procedures are restricted to a specific list of tests that relate to the specialty of the physician. 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. The plan contract is terminated. Asking at the time of each visit if he/she is still enrolled in a ConnectiCare plan. Examples of qualifying medical conditions can be found below. You have the right to an explanation from us about any bills you may get for services not covered by our plan. What to do if you think you have been treated unfairly or your rights are not being respected? 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. Its affordable, alternative health care. If you have signed an advance directive, and you believe that a doctor or hospital hasnt followed the instructions in it, you may file a complaint with: Connecticut Department of Health Delays and failures to render services due to a major disaster or epidemic affecting our facilities or personnel. Check with our Customer Service Team to find out if your plan accesses Health Coaching. Note: Some plans may vary. Life Insurance *. Please note: MultiPlan, Inc. and its subsidiaries are not insurance companies, do not pay claims and do not guaranteehealth benefit coverage. Prior Authorizations are for professional and institutional services only. It is not medical advice and should not be substituted for regular consultation with your health care provider. These plans, sometimes called "Part C," provide all of a member's Part A (hospital coverage) and Part B (medical coverage) and may offer extra benefits too. ConnectiCare members are entitled to an initial assessment of their health care status within ninety (90) days of enrollment in the Plan. The member engages in disruptive behavior. Notify ConnectiCare within twenty-four (24) hours after an emergency admission at 888-261-2273. When performed out-of-network, these procedures do require preauthorization. In order to maintain permanent residence, a member must not move or continuously reside outside the service area for more than 6 consecutive months. To verify benefits and eligibility - (phone) 800-828-3407, To inquire about an existing authorization -800-562-6833, To request a continuation of authorization for home health care or IV therapy (seeForms, to obtain a copy of the applicable form) - fax 860-409-2437. Your right to know your treatment options and participate in decisions about your health care 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. Prior Authorizations are for professional and institutional services only. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage. Members must meet an in-network Plan deductible that applies to most covered health services, including prescription drug coverage, before coverage of those benefits apply. Use your member subscriber ID to access the pricing tool using the link below. I called in with several medical bills to go over and their staff was extremely helpful.