February 2015
ADVANTAGE HEALTH
SOLUTIONS
Special points of interest:
Area Network Offerings:
ADV 360, Commercial PHO Networks and MEDICARE ADVANTAGE

Medicare Plan Update

Medicare Remits
online

ADVANTAGE 360:

Medicare Wellness Codes

Medicare Retro Auths

Indiana Statewide
Direct Provider Contracts
www.advantageplan.com to view claims and eligibility


MEDICARE PPO:
Medicare Provider Appeals
2015 Prior Advantage
Risk Auth requirements
SHO Claims transition
2015 Advantage web
tools

PR contacts

Web resources
Coming soon: Access to online claims and Eligibility
47 Indiana counties participate in Medicare PPO
Commercial PHO Networks:
CHA 360
Community Prohealth
St. Francis Health Network
SHO
FRANCISCAN ALLIANCE
Select Health Network
St. Vincent CMO
Medicare ADVANTAGE Plan Update
EFFECTIVE June 1, 2014
ALL MEDICARE ADVANTAGE claims should be
submitted to the following:
New EDI Payor ID: 35219
or
PO Box 502030 Indianapolis, IN 46250
Please contact Medicare ADVANTAGE provider services for any questions
regarding the claims address/payor ID change at 1.877.660.6258
Page 2
Access Medicare Provider Remits online at:
www.cmcs-indy.com/services/eservices
1.
Once on the website, Provider will select the “PROVIDER” button on the left side.
2.
After selecting the “PROVIDER” button, the provider will login if they have an account. If the provider
does not have an account the provider will need to select “Register New User’ below the login area.
3.
Once they have created the account and logged in, the provider will be able to see claims information.
4.
If the provider needs assistance on the website they can call 1-888-504-5556.
Coming soon: Access to Medicare online claims and eligibility @ www.advantageplan.com
Medicare Provider Appeal Process
………..rising
above the
service you
expect”

Provider letterhead or individual appeal form

Deadlines
Submit—60 days from date of Remittance Advice
Decision—60 days of Receipt
ADVANTAGE Health Solutions, Inc. SM
ATTN: Medicare Provider Appeals
Provider Relations
9045 N. River Road, Suite 200
Indianapolis, IN 46240
Wellness Codes
EFFECTIVE January 1, 2015
In order to remain consistent with CMS, all claims submitted with CPT Codes 99381 – 99397 for
Medicare Advantage Members covered by ADVANTAGE Health Solutions, Inc. will be denied as
non-covered services & members should be held harmless.
EDI Payor ID: 35219
or
PO Box 502030 Indianapolis, IN 46250
Please contact Medicare Advantage provider services for any questions regarding the processing
of provider claims at 1.877.660.6258
Page 3
Dear Provider Partner:
Advantage Health Solutions, Inc. is implementing a new Retrospective authorization policy effective
November 1, 2014. Providers must provide all relevant information necessary to authorize a service
within the following timeframe:
 Within 3 business days for an emergency
 No later than 2 business days before service if non-emergent
Retrospective authorizations after services have begun or have been completed will be considered by
Advantage Health Solutions for medically necessary services only under the following circumstances:
The provider followed appropriate procedures but received invalid information.
For example, documentation of authorization from an incorrectly identified payor source.
The provider's documentation confirms checking eligibility but was provided erroneous information.
The provider's records document that the recipient refused or was physically unable to provide
the recipient identification information.
All authorization requests delayed due to the three circumstances above must be submitted within 30
calendar days from identifying the member’s eligibility or member’s confirmation of insurance coverage. The request must be accompanied by evidence of the provider’s failed attempts to confirm eligibility (i.e. screen shots). If a claim is submitted for services that require authorization but is not obtained, the claim will be processed as a payment denial. The Explanation of Benefit (EOB) will include
the applicable reference to denial for no authorization and includes contact information on submitting
a provider dispute.
If you have any questions regarding this new policy please contact Provider Relations
Thank you,
Provider Relations
Page 4
ADVANTAGE RISK 2015 PRIOR AUTH REQUIREMENTS
Provider MUST obtain prior auth through ADVANTAGE
auto authorization system

Inpatient hospitalization

Advanced imaging: PET/SPECT & MRI’s

Outpatient Surgery, excluding colonoscopies
and endoscopies

Durable Medical Equipment > than $750

Home Health Care

Home IV Therapy

Hospice Care

Skilled Nursing Facility

Dialysis

Chemotherapy/radiation

Cardiac & Pulmonary Rehab

Physical Therapy (after 8 visits)

Occupational Therapy (after 8 visits)

Speech Therapy

Corrective Appliances/Prosthesis

Biotech Drugs*(See Below)

Wound Treatment

Sleep Study

Pain Management

Transplants

Tertiary/ Out of Network Services
Behavioral Health Prior Authorizations:
“Prior
Authorization
does not
guarantee
payment.
Payment is
subject to
eligibility and
benefits at the
time of service.”

Behavior Health (Call phone number on back of card for
Prior Authorizations)

Authorization is required for following services:

All inpatient services,

Intensive Outpatient Programs

Electroconvulsive Therapy

Partial Hospitalizations
Specialty Pharmacy Prior Authorizations:
*Biotech medication requests will be completed by
Visit www.advantageplan.com for a
complete listing of specialty
pharmacy drugs.

Envison Specialty Pharmacy:

Prior Authorization Phone:
877.684.0021

Prior Authorization Fax:
330.405.8081
The product will then be delivered per the direction of the
ordering physician*
Page 5
TO: SHO PHO and St. Vincent CMO Providers
RE: Transition of ADVANTAGE Claims & Medical Management to Cooperative Managed Care Services (CMCS)
Suburban Health Organization (SHO) is moving the administration of Advantage Health Solution claims and
medical management administration from ProHealth to CMCS effective 1/1/2015.
PLEASE READ BELOW CAREFULLY.
Providers will remain in their SHO PHO network and/or St. Vincent CMO; only claims processing and
medical management administration will move to CMCS.
The following information will need to be shared with your office and billing staff and your records updated in order
to receive reimbursements:
CMCS Electronic Claims Submission: may be submitted as early as 12/15/14
EDI Payer ID: EMDEON
35199
Paper Claims: may be submitted as early as 12/15/14
Suburban Health Organization P.O. Box 50830 Indianapolis, IN 46250
Claims Inquiries & Customer Service
Information
Ph: 1- 866-873-4516 or 1-317-596-5929 Fax: 1-317-570-6822
Medical Management (including all authorizations and precertification-related calls):
Ph: 1-317-570-9999 or 1-866-482-5254 Fax: 800-747-3693
Please note: Member Services at Advantage & Credentialing at Suburban Health Organization will not change.
ADVANTAGE member services phone number is 800-553-8933 or 317-573-6228.
If you have any questions please contact our Provider Relations Department at ADVANTAGE Health Solutions 1-877-901-2237
or by visiting www.advantageplan.com.
Page 6
Volume 1, Issue 1
ADVANTAGE Web Tools
ADVANTAGE-connect features:

Online Service Request & Provider Demographic Changes

View Network Authorization & Precert Requirements

Verify Member Benefits & Eligibility

View Claim Status

Access to Other Health Plan Websites

Access to Health Guidelines & Preventative Health Information

Access to ADVANTAGE Announcements
Allows providers the ability to check medical claims and current eligibility status
Automated Prior Auth Tool @ www.advantageplan.com
This tool has been built to reduce the time and resources it takes provider offices to request authorizations from ADVANTAGE.
The Automated Prior Auth
Tool is available 24/7
including weekends
and holidays.
*Retro
authorizations can
not be completed on
line.
The tool is available 24 hours a day and 7 days a week including weekends and
holidays.
Interactive Voice Response
Allows providers the ability to check medical claims and current eligibility status
for members and dependents.
1. Providers may select an automated interactive voice response and/or a
faxed copy of the interactive voice response.
2. To access the IVR system, providers can call 800-553-8933 or 317-573-6228
and select option 1.
3. Be sure to have the following information handy when calling: Provider fax
number, TIN, Member ID, DOB & DOS.
The IVR is available by
calling 1-800-553-8933
or 317-573-6228.
QUICK REFERENCE GUIDE
Page 7
www.adantageplan.com
Providers Log on to ADVANTAGE-connect and see all of the time saving
tools that are available to you!
ADVANTAGE-connect
LOGGING
IN
TO
THE
PROVIDER
PORTAL

Click on “Provider”

Click on “ADVANTAGE-connect Login”

Click on “Sig-Up” as a new user or use your existing username and password

Click on “Agree” to register as a new use and complete Steps 1-5

Click on "Finish” to complete registration
PROVIDER
SERVICES

Click on “FAQs” to review most frequently asked questions and their answers

Click on “In-Network Provider Directories” to view a listing of in network providers

Click on “ADV 360 Provider Manuals” to view ADV 360 provider policies, ID cards, etc.

Click on “Provider Authorizations Requests” to obtain a listing of patient services requiring prior authorization

Click on “Provider Directory” to review network providers

Click on “Provider Notification Form” to submit demographic changes online

Click on “Request EOP” to request an EOP online

Click on “Claims Submission Address” to identify members network claim information



(Select the “Eligibility and Benefits Inquiry” Service and follow the directions indicated)
Click on “View ID Card/Network Affiliation” for directions to identify members network claim information
(Select the “Eligibility and Benefits Inquiry” Service and follow the directions indicated)

Click on “Care-Advantage/Disease Management/Wellness” to learn of Advantage wellness opportunities

Click on “Pharmacy/Authorization” to view medication requiring authorization by network

Click on “Formulary” for directions to identify member formulary

(Select the “Eligibility and Benefits Inquiry” Service and follow the directions indicated)

Click, on “Provider Newsletter” to view the latest provider newsletter written by different networks

Click on “Medical Records Confidentiality Guidelines” to view medical record guidelines

Click on “Provider Interactive Voice Response System” to learn how to retrieve claims and eligibility information from our
automated IVR system

Click on “Contact Us” to directly connect to the Provider Relations Department by phone or online
PROVIDER

INQUIRIES
Click on “Claims and EOPS/EOBs” (Provider have three search options: Dates of Service, Patient Search
or Claim Number

Click on “Eligibility and Benefits Inquiry” (Providers have two search options: Member ID Search
or Patient Name Search)
Page 8
ADVANTAGE has a team of dedicated Provider Relations staff available to assist you with
questions about our products and services.
Contact Us:
877
877-901
901-2237 Fax: 317
317-663
663-1895
Sandy Thorne
– Director, Operations Strategy and Provider Relations
Lisa Fennig
– Provider Relations Supervisor
Candy Ervin
– Provider Relations Specialist
Kathrina Settle
– Provider Relations Specialist
Katherine Shull
- Provider Relations Specialist
Laura Berry
– Provider Relations Trainer/Auditor
Erica Hankerson
– Provider Relations Coordinator
Margaret Cobb
- Provider Relations Coordinator
Rebecca Nulliner
- Provider Relations Coordinator
Jacque Driver
– Provider Relations Credentialing Coordinator
Kevin Goodwin
– Provider Relations Database Coordinator Assistant
Shannon Sellars
– Provider Relations Project Assistant
Page 9
Important Website Resources:
Resources
Preventive Guidelines
Individual Immunization Schedules – Birth-18
Individual Immunization Schedules – Adult
ChooseMyPlate.gov
Women’s Preventive Services
Member Appeal Rights
Glossary of Health Coverage and Medical Terms
Member Quick Reference Guide
Rx Savings Card Brochure
Tobacco Cessation
Caregiver Tips
Alcohol and Diabetes
Alcohol and Cardiovascular Disease
ADVANTAGE Care Select Member Services: (800) 784-3981
For the hearing impaired: (866) 859-7812
Director of Network Development Contracts
Kelvin Orr (317) 573-6572
Provider Relations/Contracting Specialist
Dan Green (317) 816-6760
Provider Relations Specialist
Katie Shull (317) 573-2795
Page 10
Prior Authorization Submission by Mail:
Written requests for PA are submitted, (using an Indiana Prior Review and Authorization Request form), to
one of the following address’s listed below based on the program the member is associated to, which can be
determined by the eligibility verification obtained on the member.
ADVANTAGE Health Solutions – FFS
Prior Authorization Department
P.O. Box 40789
Indianapolis, IN 46240
ADVANTAGE Health Solutions Care Select
Prior Authorization Department
P.O. Box 80068
Indianapolis, IN 46280
ADVANTAGE Health Solutions
MRO Prior Authorization
Prior Authorization Department
P.O. Box 40789
Indianapolis, IN 46240
Prior Authorization Submission by Phone or Fax:
 By Fax – Providers may fax ADVANTAGE Health Solutions – FFS and ADVANTAGE Health Solutions
– Care Select PA requests (using an Indiana Prior Review and Authorization Request form) to:
1-800-689-2759.
 By Fax – Providers may fax ADVANTAGE Health Solutions – MRO Prior Authorization requests (using
an Indiana Prior Review and Authorization Request form) to: 1-866-541-3977.
 Please send them on a daily basis. Please do not send large weekly batches of PA requests
 By Phone – The following PA department telephone numbers are as follows:
 ADVANTAGE – FFS & MRO: (800) 269-5720
 ADVANTAGE – Care Select: (800) 784-3981
The Web Interchange application on the IHCP website allows providers to submit non-pharmacy PA requests
and to inquire on request via Web Interchange.
Indiana Prior Review and Authorization Request Forms are available at:
The IHCP website at: www.indianamedicaid.com
List of Prior Authorization Request Forms