Provider Guide - the Culinary Health Fund
Provider Guide - the Culinary Health Fund
Provider Guide - the Culinary Health Fund
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<strong>Provider</strong><br />
<strong>Guide</strong><br />
Administrative Services, LLC<br />
October 2012
Table of Contents<br />
Introduction<br />
Who We Are<br />
Participant ID Cards<br />
Benefits At A Glance<br />
Prescription Benefits<br />
October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Programs<br />
• <strong>Health</strong>y Pregnancy Program<br />
• Diabetes Program<br />
• Immediate Cardiac Evaluation Program (ICEP)<br />
• <strong>Culinary</strong> Care Assistance Program<br />
• Dr. Tomorrow<br />
• Hospitalist Program for Acute Facilities<br />
• Radiology Management Program<br />
Prior Authorization/Utilization<br />
AHH & <strong>Health</strong>Help<br />
Claims Processing <strong>Guide</strong>lines<br />
Contract Information<br />
Credentialing<br />
Resources<br />
Information Update<br />
FAQ’s<br />
PPO Quick <strong>Guide</strong><br />
<strong>Provider</strong> Address Information Form<br />
Allowable Amount Request Form<br />
Group Add Request Form<br />
<strong>Culinary</strong> <strong>Provider</strong> Reconsiderations Form<br />
<strong>Health</strong>y Pregnancy Program Certification Form<br />
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47
<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Introduction<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> is a multi-employer Taft-Hartley <strong>Health</strong> and Welfare Trust<br />
governed by a Board of Trustees representing both labor and management. It is<br />
funded by employer contributions negotiated in Collective Bargaining Agreements.<br />
Contracts for <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> plan providers are maintained through <strong>the</strong> <strong>Culinary</strong><br />
<strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC.<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> is one of <strong>the</strong> largest health plans in Nevada, covering<br />
approximately 120,000 lives.<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> has developed this guide in order for providers and <strong>the</strong>ir office<br />
staff to navigate through <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> plan simply and easily.<br />
This guide provides helpful information regarding claims submission and payment, prior<br />
authorization, and benefits.<br />
Information in this guide will be updated regularly. Updates are available via facsimile and/<br />
or mail to your office and can also be found on <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>’s website at<br />
www.culinaryhealthfund.org.<br />
Additional copies of this <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> <strong>Provider</strong> <strong>Guide</strong> can be requested by<br />
contacting <strong>Provider</strong> Services at 702-892-7313 or downloaded from our website at<br />
www.culinaryhealthfund.org.<br />
4 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC
Who we are
<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Who We Are<br />
Leadership Team<br />
Kathy Silver<br />
President, Las Vegas<br />
kathys@culinaryhealthfund.org<br />
Maria Martinez-Riach<br />
Senior Director of Finance<br />
maria@culinaryhealthfund.org<br />
Kim Voss<br />
Senior Director, <strong>Health</strong>care<br />
Networks & Advocacy<br />
kim@culinaryhealthfund.org<br />
Dr. Kelly Van Wagner<br />
Medical Director<br />
kvanwagner@culinaryhealthfund.org<br />
Sylvia Vazquez<br />
Director of Advocacy,<br />
Outreach & Communications<br />
sylvia@culinaryhealthfund.org<br />
Nancy Nikolski, BSN, RN<br />
Senior Director,<br />
Medical Management<br />
nancy@culinaryhealthfund.org<br />
Nevada <strong>Health</strong> Care Policy Group<br />
Bobbette Bond<br />
Executive Director of<br />
Nevada Public Policy<br />
bobbette@culinaryhealthfund.org<br />
6 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC
October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Who We Are<br />
<strong>Health</strong>care Network<br />
Cindy Pearson<br />
Senior Manager of<br />
<strong>Health</strong>care Networks<br />
cindy@culinaryhealthfund.org<br />
Kimberly Esau<br />
Manager of <strong>Health</strong>care Services<br />
kesau@culinaryhealthfund.org<br />
Debra Manchester<br />
Contracts Manager<br />
debra@culinaryhealthfund.org<br />
Andrea Schwartzman<br />
<strong>Provider</strong> Network Supervisor<br />
andrea@culinaryhealthfund.org<br />
Mary McGill, MBA<br />
<strong>Health</strong>care Services<br />
Associate II<br />
mary@culinaryhealthfund.org<br />
Michael Barton<br />
<strong>Provider</strong> Services Representative<br />
michael@culinaryhealthfund.org<br />
Melanie Hildebrand<br />
<strong>Health</strong>care Services Associate I<br />
melanie@culinaryhealthfund.org<br />
Jessica Wesley<br />
<strong>Provider</strong> Network<br />
Data Coordinator<br />
jessica@culinaryhealthfund.org<br />
Lucia James<br />
<strong>Health</strong>care Services Associate I<br />
lucia@culinaryhealthfund.org<br />
Jeanie Jenkins<br />
Credentialing Specialist<br />
jeanie@culinaryhealthfund.org<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
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<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Who We Are<br />
Care Management Team<br />
Lori Rogers RN, BAN, CCM<br />
Senior Manager,<br />
<strong>Health</strong>care Management<br />
Lrogers@culinaryhealthfund.org<br />
Ava High, RN, CCM<br />
Case Manager<br />
ava@culinaryhealthfund.org<br />
Eric Dinulos, BSN, RN<br />
Hospital Care Manager<br />
eric@culinaryhealthfund.org<br />
Susan Rotman, BSN, RN<br />
Hospital Care Manager<br />
susan@culinaryhealthfund.org<br />
Yolanda Short, RN<br />
Case Manager<br />
yolanda@culinaryhealthfund.org<br />
Rosemary Villaquiran, BSN, RN<br />
Hospital Care Manager<br />
rosemary@culinaryhealthfund.org<br />
Lynn Jones, BSN, RN<br />
Case Manager<br />
lynn@culinaryhealthfund.org<br />
Carol Neely, RN<br />
Hospital Care Manager<br />
carol@culinaryhealthfund.org<br />
Rolanda Chapman<br />
Care Coordinator<br />
rolanda@culinaryhealthfund.org<br />
Cindy Foley, RN<br />
Case Manager<br />
cindyf@culinaryhealthfund.org<br />
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October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Who We Are<br />
Care Management Team (continued)<br />
Lynn Wiegand, RN, CCM<br />
Case Manager<br />
lynnw@culinaryhealthfund.org<br />
Kathy Leon, RN<br />
Case Manager<br />
kathy@culinaryhealthfund.org<br />
Lesley Knudson, RN<br />
Case Manager<br />
lesley@culinaryhealthfund.org<br />
Claudia Swift, RN<br />
Case Manager<br />
claudia@culinaryhealthfund.org<br />
Zohar Mizrahi, BSN, RN<br />
Case Manager<br />
zohar@culinaryhealthfund.org<br />
Transitional Management Team<br />
Ramon Barajas<br />
Transitional Management<br />
Supervisor<br />
ramon@culinaryhealthfund.org<br />
Christie Barton<br />
Transitional Care Coordinator<br />
christie@culinaryhealthfund.org<br />
Lawrence Chubbs<br />
Transitional Care Coordinator<br />
lawrence@culinaryhealthfund.org<br />
Alicia Estrada<br />
Transitional Care Coordinator<br />
alicia@culinaryhealthfund.org<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
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<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Who We Are<br />
Transitional Management Team (continued)<br />
Sandra Schneider<br />
Transitional Care Coordinator<br />
sandra@culinaryhealthfund.org<br />
Celene Ochoa<br />
Transitional Care Coordinator<br />
celene@culinaryhealthfund.org<br />
Participant Advocacy<br />
Tiffany Ellis<br />
Manager of Member Advocacy<br />
tiffanye@culinaryhealthfund.org<br />
Shannon Avila<br />
Wellness & <strong>Health</strong><br />
Promotions Manager<br />
shannon@culinaryhealthfund.org<br />
Myrna Mendoza<br />
Member Advocate<br />
myrna@culinaryhealthfund.org<br />
Martin Gamboa<br />
Senior Member Advocate<br />
martin@culinaryhealthfund.org<br />
Gina Kramer<br />
Senior Benefits Specialist<br />
gina@culinaryhealthfund.org<br />
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October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Participant ID Cards<br />
TM<br />
John Q Sample<br />
ID: Use Primary SSN<br />
Coverage: Family<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong><br />
UNITE HERE <strong>Health</strong><br />
Medical / Prescription Card - Group<br />
150<br />
THIS CARD IS FOR IDENTIFICATION PURPOSES ONLY<br />
Possession of this card does not guarantee eligibility for benefits.<br />
ESTA TARJETA ES PARA INDENTIFICACIÓN SOLAMENTE<br />
La posesión de esta tarjeta no garantiza elegibilidad de beneficios.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong><br />
Medical Prescription Card<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Medical/Prescription ID<br />
card will assist you in identifying <strong>Culinary</strong> <strong>Health</strong><br />
<strong>Fund</strong> participants. It is strongly encouraged that<br />
you request photo identification in addition to <strong>the</strong><br />
participant’s ID card.<br />
• The name of <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> covered participant is <strong>the</strong> only name listed on <strong>the</strong> ID card.<br />
• The Social Security Number is not listed on <strong>the</strong> ID card. You will need to request <strong>the</strong> Social<br />
Security Number of <strong>the</strong> covered employee for your records and billing purposes.<br />
• Possession of a <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> ID card does not automatically certify eligibility for benefits.<br />
• Services should not be denied if a <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> participant does not have an ID card;<br />
however, <strong>the</strong> participant should be required to show photo ID prior to services being rendered.<br />
<strong>Provider</strong>s should always verify participant eligibility at <strong>the</strong> time services are rendered.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
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<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Benefits at a Glance<br />
Below is a summary of <strong>the</strong> benefits provided to <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> participants. Some services are PPO<br />
only. For additional information, visit our website at www.culinaryhealthfund.org.<br />
Benefits at a Glance: PPO vs Non-PPO<br />
BENEFIT PPO PLAN NON-PPO PLAN<br />
IS APPROVAL<br />
(PRIOR AUTHORIZATION)<br />
NEEDED?<br />
Addiction Treatment YES NO YES<br />
Ambulance Benefit YES YES NO<br />
Birthing Center YES YES NO<br />
Chiropractic Care YES NO NO<br />
Dental YES YES SOME<br />
Durable Medical Equipment YES NO SOME<br />
Emergency Room YES YES NO<br />
<strong>Health</strong>y Pregnancy Program YES NO Certificate required<br />
Hearing Aids YES YES NO<br />
Home <strong>Health</strong> Care/Infusion YES NO YES<br />
Hospice Care YES NO NO<br />
Hospital (Inpatient) YES YES YES<br />
Hospital (Outpatient) YES SOME SOME<br />
Hospital Room & Board YES YES YES<br />
Inpatient Rehabilitation YES NO YES<br />
MRI/CAT/PET Scans YES NO YES<br />
Medical Supplies YES NO SOME<br />
Mental <strong>Health</strong> (Inpatient) YES NO YES<br />
Mental <strong>Health</strong> (Outpatient) YES NO YES<br />
O<strong>the</strong>r Outpatient Services YES SOME SOME<br />
Physician Services YES YES SOME<br />
Pregnancy/Delivery YES YES UR required for delivery<br />
Prescriptions YES NO SOME<br />
Surgery/Anes<strong>the</strong>sia YES YES YES<br />
Surgery (Outpatient) YES NO SOME<br />
Therapy (Outpatient) YES NO NO<br />
Vision YES NO NO<br />
X-Ray (Outpatient) YES YES SOME<br />
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October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Prescription Benefits<br />
Catalyst Rx is <strong>the</strong> Pharmacy Benefit Manager for <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>. You can get<br />
more information about Catalyst Rx at www.catalystrx.com or by calling 866-611-5960.<br />
Prescriptions are covered on three co-pay tiers, as outlined below.<br />
Three-Tier Co-pay Prescription Program<br />
<strong>Culinary</strong> Pharmacy Medications<br />
FREE<br />
Tier 1 All Generics $5.00<br />
Tier 2 Formulary Medications $15.00<br />
Tier 3 O<strong>the</strong>r Non Formulary Medications $30.00<br />
FREE<br />
$10.00<br />
$20.00<br />
$35.00<br />
Starting<br />
Jan. 1, 2013<br />
Please Note: If <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> participant receives a brand-name medication<br />
when a generic equivalent is possible, <strong>the</strong> participant will pay <strong>the</strong> difference in cost<br />
between <strong>the</strong> brand-name and <strong>the</strong> generic medication.<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> uses two formularies:<br />
• One for <strong>the</strong> three-tier prescription plan.<br />
• One for <strong>the</strong> prescriptions available without a co-pay from <strong>the</strong> <strong>Culinary</strong> Pharmacy.<br />
Copies of both formularies are available on our website at<br />
www.culinaryhealthfund.org. You can also call <strong>Provider</strong> Services at 702-892-7313 to<br />
request additional formularies.<br />
<strong>Culinary</strong> Pharmacy<br />
• The <strong>Culinary</strong> Pharmacy offers a 60-day supply for most maintenance medications.<br />
• If you prescribe medications that are available at <strong>the</strong> <strong>Culinary</strong> Pharmacy, <strong>Culinary</strong><br />
<strong>Health</strong> <strong>Fund</strong> participants do not have a co-pay. The <strong>Culinary</strong> Pharmacy offers over<br />
300 prescription medications, including most diabetic supplies.<br />
The <strong>Culinary</strong> Pharmacy is located at:<br />
1945 Las Vegas Blvd. South<br />
(Inside <strong>the</strong> St. Louis Square adjacent to <strong>the</strong><br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Customer Service Office )<br />
Monday through Friday from 8am to 6pm & Saturday from 10am to 2pm<br />
excluding national holidays<br />
Prescriptions can be called in at 702-650-4417 or faxed to 702-369-5940.<br />
E-prescriptions are also accepted at <strong>the</strong> <strong>Culinary</strong> Pharmacy - Please use ID 2990124.<br />
Please visit our website at www.culinaryhealthfund.org for more information<br />
on additional services offered at <strong>the</strong> <strong>Culinary</strong> Pharmacy.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
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<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Prescription Benefits<br />
Generic Medications<br />
Generics are safe, effective and FDA approved.<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> works hard to control rising prescription costs and protect our participants’<br />
health benefits. We urge you to help by prescribing generic medications when appropriate.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> participants pay no co-pay at <strong>the</strong> <strong>Culinary</strong> Pharmacy if <strong>the</strong> generic medication is<br />
available.<br />
Effective July 1, 2012, <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> implemented a clinical prior authorization program for all Oral<br />
Specialty Medications. Walgreens Specialty Pharmacy will fill prescriptions for <strong>the</strong> oral specialty products,<br />
and deliver <strong>the</strong>m to <strong>the</strong> plan participant preferred location. All specialty prescriptions will be limited to a<br />
30-day supply.<br />
Mail Service Pharmacy (Catalyst Mail)<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> offers a mail order prescription program through Catalyst Mail. <strong>Culinary</strong> <strong>Health</strong><br />
<strong>Fund</strong> participants can take advantage of up to a 60-day supply of <strong>the</strong>ir medications for only one co-pay.<br />
A sample of <strong>the</strong> mail order form and brochure is on <strong>the</strong> website at www.culinaryhealthfund.org. To contact<br />
Catalyst Mail directly, please call 866-834-0449.<br />
E-Prescriptions<br />
The <strong>Culinary</strong> Pharmacy accepts e-prescriptions. <strong>Provider</strong>s can submit prescriptions electronically<br />
to reduce <strong>the</strong> risk of medication errors due to illegible handwriting and manual data entry. Using<br />
e-prescriptions saves you and <strong>the</strong> participant’s time by reducing <strong>the</strong> number of phone calls related to<br />
faxes not being received by <strong>the</strong> pharmacy. Please use ID 2990124.<br />
Formulary Advantage<br />
Program (FAP)<br />
The FAP is a formulary management program that<br />
targets medications within 17 drug classes and<br />
encourages <strong>the</strong> selection of clinically effective, lower<br />
cost medications that support patient’s treatment<br />
adherence by lowering out-of-pocket prescription<br />
costs. Under this program, <strong>Culinary</strong> participants<br />
must try a preferred alternative before a nonpreferred<br />
brand-name medication will be covered<br />
by <strong>the</strong>ir prescription drug plan under <strong>the</strong> targeted<br />
drug classes (listed at right). For a complete list of<br />
preferred and non-preferred medications, please<br />
contact Catalyst Rx at 866-611-5960 or visit our<br />
website at www.culinaryhealthfund.org.<br />
Albuterol Inhalers<br />
Androgens<br />
Atypical<br />
Antipsychotics<br />
Blood Pressure<br />
Fenofibrates/<br />
Triglycerides<br />
Growth Hormones<br />
Drug Class<br />
Interferons for HEPC<br />
Intranasal Steroids<br />
Multiple Sclerosis<br />
Ophthalmic Prostaglandins<br />
(Glaucoma)<br />
Osteoporosis<br />
Proton Pump<br />
Inhibitors Ulcers<br />
SSRIs/Antidepressants<br />
Triptans<br />
Hepatitis C Antivirals<br />
Hypnotics/Sleep Aids<br />
TNF Inhibitors (Rheumatoid Arthritis)<br />
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<strong>Provider</strong> <strong>Guide</strong><br />
Prescription Benefits<br />
Medication Prior Authorization<br />
Prior authorization is required for certain medications (see <strong>the</strong> list below). This list may be updated<br />
from time to time. <strong>Provider</strong>s may call Catalyst Rx at 866-611-5960 for updates to this list, or call<br />
<strong>Provider</strong> Services at 702-892-7313.<br />
Medications Requiring Prior Authorization:<br />
• Acne Products for participants over <strong>the</strong> age of 24<br />
• ADD/ADHD for participants over <strong>the</strong> age of 18<br />
• Contraceptives: Authorization is required for dependent children under <strong>the</strong> age of 19.<br />
• Growth Hormone<br />
• Injectables except for insulin or Injectable Migraine Medications<br />
• New Medications to <strong>the</strong> Market<br />
• Nutritional Supplements for PKU (all o<strong>the</strong>r Nutritional Supplements are excluded)<br />
• Nuvigil/Provigil<br />
• Oral Specialty (Cancer, MS, etc.)<br />
• Sexual Dysfunction Medications<br />
• Singular: Participants over <strong>the</strong> age of 12 for diagnoses o<strong>the</strong>r than asthma<br />
• Tazorac<br />
• Thyrogen (all o<strong>the</strong>r Diagnostics/Biologicals are excluded)<br />
• Weight Loss Medications<br />
Narcotic Medications<br />
The medications listed in Table A will be covered only when prescribed by a PPO physician.<br />
Table A<br />
Avinza Methadone MS Contin<br />
Duragesic Methadose Opana ER<br />
Fentanyl Lozenges Morphine Sulfate CR Opana<br />
Fentanyl Transdermal Patches Morphine Sulfate ER Oramorph SR<br />
Kadian<br />
Morphine Sulfate SA<br />
The medications listed in Table B will be covered only when prescribed by a PPO oncologist<br />
or pain management specialist.<br />
Table B<br />
Oxycontin Abstral Butrans<br />
Oxycodone ER Actiq Oxecta<br />
Oxycodone CR Fentora Lazanda<br />
Oxycodone SA Marinol Nucynta ER<br />
Levorphanol Onsolis Subsys Spray<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
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<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Programs<br />
<strong>Health</strong>y Pregnancy Program<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>’s <strong>Health</strong>y Pregnancy Program strongly encourages<br />
<strong>Culinary</strong> participants, <strong>the</strong>ir spouses and/or eligible female domestic partners<br />
to seek prenatal healthcare within <strong>the</strong> first trimester, and to continue with<br />
regularly scheduled antepartum visits. As a part of our efforts to promote<br />
healthier pregnancies, a benefit payment of $100 will be paid to participants<br />
and <strong>the</strong>ir managing physician who participate in <strong>the</strong> <strong>Health</strong>y Pregnancy<br />
Program and complete <strong>the</strong> requirements.<br />
For physicians to receive <strong>the</strong>ir additional $100 reimbursement, please submit<br />
<strong>the</strong> <strong>Health</strong>y Pregnancy Program Certification Form located in <strong>the</strong> back of<br />
this book or on our website at www.culinaryhealthfund.org, along with <strong>the</strong><br />
<strong>Culinary</strong> patients’ antepartum records and visit summary to:<br />
1901 Las Vegas Blvd. South, Suite 107<br />
Las Vegas, NV 89104<br />
Fax (702) 892-7326<br />
If you have any fur<strong>the</strong>r questions regarding <strong>the</strong> additional reimbursement,<br />
please contact <strong>Provider</strong> Services at 702-892-7313.<br />
<strong>Culinary</strong> Diabetes Program<br />
The <strong>Culinary</strong> Diabetes Program was developed to provide assistance with <strong>the</strong><br />
management of diabetes among <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> participants, spouses<br />
and/or eligible domestic partners, and dependents.<br />
This program offers:<br />
• FREE meters<br />
• FREE Diabetic Education<br />
• FREE lancets, test strips, syringes and o<strong>the</strong>r diabetic supplies at <strong>the</strong><br />
<strong>Culinary</strong> Pharmacy.<br />
• Insulin pumps: Required prior authorization through American <strong>Health</strong><br />
Holding, Inc. (AHH).<br />
• Diabetic Shoe benefit: Eligible members can have two pairs per Calendar<br />
• Year (January 1 – December 31) with a $55 per pair co-pay.<br />
For a complete list of Diabetic Education classes locations, please visit <strong>the</strong><br />
website at www.culinaryhealthfund.org.<br />
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<strong>Provider</strong> <strong>Guide</strong><br />
Programs<br />
Immediate Cardiac Evaluation Program (ICEP)<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> introduced a cardiology initiative that provides participants with an alternative<br />
to waiting long hours in emergency rooms for low-level cardiac symptoms. This Program was developed<br />
to provide physicians with <strong>the</strong> necessary resources to facilitate direct access to participating cardiology<br />
offices for immediate evaluation of patients with cardiac symptoms.<br />
The following is a list of cardiology offices (Immediate Cardiac Evaluation Centers, or ICEC) that have<br />
committed to provide timely cardiac evaluations <strong>the</strong> same or next day, for your patients with chest pain,<br />
palpitations, new onset atrial fibrillation, etc.<br />
1) Advanced Cardiovascular Specialists<br />
3201 S. Maryland Pkwy. #502<br />
Contact: Myrna<br />
Phone: 702-733-8600<br />
Fax: 702-733-0374<br />
2) Keith G Boman MD, FACC<br />
601 S. Rancho Dr. #D28<br />
Contact: Shannon<br />
Phone: 702-383-0677<br />
Fax: 702-383-0688<br />
3) Siena Cardiology<br />
2641 W. Horizon Ridge Pkwy. #120<br />
Contact: Gerri<br />
Phone: 702-616-0091<br />
Fax: 702-616-2329<br />
4) Hearth Center Of Nevada<br />
1815 E. Lake Mead Blvd. #110<br />
4275 S. Burnham Ave. #370<br />
6850 N. Durango Dr. #210<br />
700 Shadow Lane #240<br />
866 Seven Hills Dr. #102<br />
Contact: Jessica/Carina<br />
(Any Issues: Susan Levine)<br />
Phone: 702-384-0022<br />
Fax: 702-384-0529<br />
5) Nevada Cardiology Associates<br />
3121 S. Maryland Pkwy. #512<br />
3150 N. Tenaya Way #460<br />
Contact: Petra<br />
Phone: 702-233-4733<br />
Fax: 702-233-1001<br />
The <strong>Fund</strong> encourages providers to utilize <strong>the</strong> ICEP as a resource that will improve access for your patients<br />
requiring timely cardiac evaluations and help avoid defaulting to <strong>the</strong> emergency room. If <strong>the</strong> first office<br />
contacted is unable to accommodate your requested time/location, or should you have any addition<br />
questions regarding this program, please contact <strong>the</strong> <strong>Provider</strong> Service Line at (702) 892-7313.<br />
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17
<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Programs<br />
<strong>Culinary</strong> Care Assistance Program/<br />
Harmony <strong>Health</strong>care<br />
This confidential program is provided to all <strong>Culinary</strong> <strong>Health</strong><br />
<strong>Fund</strong> participants and <strong>the</strong>ir eligible dependents for FREE.<br />
Harmony <strong>Health</strong>care is here to help participant address<br />
any problem that may arise; no matter how big or small <strong>the</strong><br />
problem is before it gets worse.<br />
Harmony <strong>Health</strong>care can help participants in areas such as:<br />
• Marriage & Family<br />
• Work Pressure<br />
• Emotional Stress<br />
• Substance Abuse<br />
• Grief & Loss<br />
• Gambling<br />
• Financial Difficulties<br />
• Crisis Intervention<br />
Five free counseling visits are allowed per episode, per<br />
Calendar Year (January 1- December 31) with a <strong>the</strong>rapist.<br />
Harmony <strong>Health</strong>care will help participants get additional<br />
treatment if more than five counseling visits are necessary,<br />
after which co-pay will be required.<br />
Harmony <strong>Health</strong>care has a staff of Psychologists, Therapists<br />
and Psychiatrists available to help.<br />
Bilingual services are available, in addition to services for <strong>the</strong><br />
physically challenged (including visual and hearing impaired).<br />
24 hours a day, 7 days a week services at 702-251-8000 or<br />
800-363-4874. Counseling Services are available in English<br />
and Spanish.<br />
Rapid Response<br />
The Rapid Response team is a group of licensed, trained<br />
counselors that will promptly respond to any crisis in an<br />
emergency room, doctor’s office, or workplace. The Rapid<br />
Response team will provide clinical face-to-face assessments<br />
in conjunction with <strong>the</strong> <strong>Culinary</strong> participants’ physician to<br />
initiate required treatment 24 hours a day, 7 days a week. You<br />
can contact Rapid Response directly at 702-788-9875.<br />
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October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Programs<br />
®<br />
Dr. Tomorrow is an alternative emergency room or urgent care option to provide participants a phone<br />
number to call for same or next day appointments with a primary care provider. We have partnered with<br />
PPO providers to provide participants with appointments at <strong>the</strong> physician’s office.<br />
Participants can contact <strong>the</strong> Dr. Tomorrow phone line 24 hours a day, 7 days a week at 702 691-5656.<br />
Hospitalist Program for Acute Facilities<br />
The mandatory Hospitalist Program is a team approach to inpatient healthcare, with participants’ care<br />
managed by <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> UR nurses, case managers and <strong>the</strong> hospitalist plan providers. Under <strong>the</strong><br />
Hospitalist Program, all inpatient rounding for adult, non-obstetrical <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> patients will be<br />
managed by <strong>the</strong> assigned hospitalist plan provider for <strong>the</strong> facility to which <strong>the</strong>y have been admitted for<br />
services. All acute facilities are inclusive in this program.<br />
Admitting Primary Care Physicians (PCPs) may choose to visit <strong>the</strong>ir own established patients, but <strong>the</strong><br />
management of <strong>the</strong> case will be assigned to <strong>the</strong> designated hospitalist provider. Admitting specialists who<br />
require internal medicine services must utilize <strong>the</strong> assigned hospitalist plan provider for each facility to<br />
assist in <strong>the</strong> management of <strong>the</strong> participant’s inpatient care.<br />
The following hospitalist groups are <strong>the</strong> exclusive plan providers under <strong>the</strong> Hospitalist Program:<br />
• Pioneer Hospitalist Group (702-388-9777) – Sou<strong>the</strong>rn Hills Hospital, Spring Valley Hospital, Sunrise<br />
Hospital and Summerlin Hospital Medical Center<br />
• Inpatient Consultants of Nevada-IPC (702-380-1992) – Desert Springs Hospital, North Vista Hospital, St.<br />
Rose Hospital – Siena Campus and St. Rose – De Lima Campus<br />
• Nevada Hospitalist Group-NHG (702-450-1717) – Centennial Hills Hospital, Mountain View Hospital and<br />
St. Rose Hospital – San Martin Campus<br />
• Internal Medicine Specialists of Las Vegas (702-588-7373) – Valley Hospital<br />
• Hospitalist Management Group-HMG (702-207-8263) – University Medical Center<br />
Radiology Management Program<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC has implemented a Radiology Management Program<br />
to evaluate <strong>the</strong> quality of imaging services provided within <strong>the</strong> network. <strong>Provider</strong>s who offer diagnostic<br />
services must contact <strong>Provider</strong> Services at 702-892-7313 to enroll in <strong>the</strong> program. In order to be eligible<br />
for reimbursement for <strong>the</strong>se services, you must have successfully completed <strong>the</strong> program.<br />
Please Note: Under <strong>the</strong> Radiology Management Program, services provided by mobile imaging vendors<br />
will not be reimbursed.<br />
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19
<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Prior Authorization/Utilization<br />
Prior Authorization/Utilization Criteria<br />
Services requiring prior authorization include both outpatient and inpatient services. Please refer to page<br />
21 or <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>’s website at www.culinaryhealthfund.org for a list of services that require<br />
prior authorization. This list will be updated from time to time and it is <strong>the</strong> provider’s responsibility to<br />
check <strong>the</strong> website for updates or contract <strong>Provider</strong> Services at 702-892-7313.<br />
Approval does not guarantee that benefits will be paid. Payment will depend on whe<strong>the</strong>r <strong>the</strong> service is a<br />
covered benefit; <strong>the</strong> service is within <strong>the</strong> scope of your <strong>Provider</strong> Agreement and whe<strong>the</strong>r <strong>the</strong> participant is<br />
eligible at <strong>the</strong> time of service.<br />
American <strong>Health</strong> Holding Inc., (AHH)<br />
American <strong>Health</strong> Holding Inc. is <strong>the</strong> utilization/case management provider for <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>.<br />
They conduct prior authorizations, concurrent and retrospective reviews.<br />
You may call American <strong>Health</strong> Holding authorization number at 1-866-330-2307 Monday through<br />
Friday from 8am to 8pm EST, or you can use <strong>the</strong> online form at http://culinaryhealthfund.ahhinc.com/<br />
to initiate a review. A staff person will record all of <strong>the</strong> demographics of <strong>the</strong> case, and if all <strong>the</strong> medical<br />
information iIs available, <strong>the</strong> information will be given to a nurse for review.<br />
<strong>Health</strong>Help<br />
Effective August 1, 2012, <strong>the</strong> following requests will now be authorized by <strong>Health</strong>Help:<br />
• Diagnostic Imaging: CT, CTA, MRI, MRA, PET and cardiac nuclear medicine scans.<br />
• Medical Oncology treatments: chemo<strong>the</strong>rapy, hormone <strong>the</strong>rapy, biologics, supportive care medications.<br />
• Radiation Oncology treatments: two-dimensional (2D) and three-dimensional (3D) conformal radiation,<br />
intensity-modulated radiation <strong>the</strong>rapy (IMRT), brachy<strong>the</strong>rapy, stereotactic radiation <strong>the</strong>rapy and<br />
proton-beam procedures.<br />
You may call <strong>the</strong> <strong>Health</strong>Help authorization number at 1-800-519-9935, fax <strong>the</strong> prior authorization request<br />
to 1-800-592-9050 or you can use <strong>the</strong> website at http://www.healthhelp.com/culinary to request <strong>the</strong><br />
prior authorization.<br />
These changes will NOT affect emergency department (ED) services or radiology services ordered while a<br />
member is hospitalized.<br />
Behavioral <strong>Health</strong> Authorization<br />
All behavioral health, mental health, and chemical dependency services require prior authorization through<br />
Harmony <strong>Health</strong>care at 702-251-8000 or 800-363-4874. Harmony <strong>Health</strong>care is available 24 hours a day, 7<br />
days a week..<br />
Medication Authorization<br />
Catalyst Rx performs drug authorizations for specific medications. This list may be updated from time to<br />
time. It is <strong>the</strong> provider’s responsibility to contact Catalyst Rx at 866-611-5960 for updates.<br />
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October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Prior Authorization/Utilization<br />
Services Requiring Prior Authorization:<br />
HIGH TECH DIAGNOSTIC SERVICE REVIEW<br />
OB Ultrasounds<br />
All MRI/MRAs<br />
All CT/CTA Scans<br />
Fetal Biophysical Profiles<br />
All PET Scans & cardiac nuclear medicine scans<br />
Sleep Screenings through Bennett Medical Services<br />
Sleep Studies (must be ordered by a Neurologist,<br />
Pulmonologist or ENT)<br />
Discography<br />
MEDICAL / RADIATION ONCOLOGY TREATMENTS<br />
Chemo<strong>the</strong>rapy Intensity-modulated radiation <strong>the</strong>rapy (IMRT)<br />
Hormone Therapy<br />
Brachy<strong>the</strong>rapy<br />
Biologics<br />
Stereotactic radiation <strong>the</strong>rapy & proton-beam procedures<br />
Supportive care medications related to a cancer<br />
diagnosis<br />
AMBULATORY SURGERY REVIEW<br />
Blepharoplasty<br />
Varicose Vein Stripping/Ligation<br />
Orthotripsy for Plantar Fasciitis<br />
Surgical Treatment of Sleep Apnea<br />
Two-dimensional (2D)/three-dimensional (3D) conformal<br />
radiation<br />
Septoplasty<br />
Breast Reduction<br />
Ventral Hernia Repair > 18 years<br />
Orthoses (or Orthotics)<br />
ADDITIONAL SERVICES REQUIRING PRIOR AUTHORIZATION<br />
All hospital admissions including elective admissions<br />
and those resulting from ER or observation stay<br />
All TMJ procedures<br />
Skilled Nursing Facility<br />
Inpatient Rehabilitation<br />
Long Term Acute Care<br />
Insulin Pumps<br />
All Hysterectomies (Inpatient or Outpatient)<br />
Custom Compression Stockings<br />
Cochlear Implants<br />
Mandibular/Oral/Orthognathic Surgery<br />
Gastric Neurostimulators<br />
Durable Medical Equipment items that are over $500<br />
(whe<strong>the</strong>r it is rental or purchase to include oxygen<br />
equipment over $500, i.e. oxygen concentrators)<br />
Dialysis<br />
Home <strong>Health</strong> and Infusion Therapy<br />
Orthoses (or Orthotics)<br />
Pros<strong>the</strong>tic Appliances<br />
Outpatient Chemo/Radiation Therapy<br />
Back Surgeries (Inpatient or Outpatient Services)<br />
Genetic Testing<br />
Implantable Hormone Therapy<br />
Stereotactic Radiosurgery<br />
EECP<br />
Skin Substitutes/ Grafts<br />
Please Note: Services requiring prior authorization include outpatient and inpatient services. As of this printing,<br />
<strong>the</strong> services listed above require prior authorization. This list may be updated from time to time. It is <strong>the</strong> provider’s<br />
responsibility to check for updates. If <strong>the</strong> procedure billed is not <strong>the</strong> procedure approved by American <strong>Health</strong><br />
Holding, Inc or <strong>Health</strong>Help, <strong>the</strong>re may be no payment and <strong>the</strong> patient is not liable. Please call American <strong>Health</strong><br />
Holding, Inc at 866-330-2307 or <strong>Health</strong>Help at (800) 519-9935 for more information.<br />
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<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Claims Processing <strong>Guide</strong>lines<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> uses a Third Party Administrator, Zenith<br />
American Solutions to process all claims.<br />
Claims Submission<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> accepts claims via electronic submission.<br />
<strong>Provider</strong>s interested in submitting claims electronically should<br />
contact one of <strong>the</strong> following clearinghouses to set up an account:<br />
Capario (ProxyMed) 800-586-6938<br />
The SSI Group, Inc. 800-880-3032<br />
HCRNet 702-735-5525<br />
Emdeon 800-845-6592<br />
Our Electronic ID is 59140<br />
Paper claims should be submitted to:<br />
Zenith American Solutions<br />
P.O. Box 94469<br />
Seattle WA 98124<br />
All claims submitted to Zenith American Solutions go through<br />
an Optical Character Recognition process, which turns <strong>the</strong> paper<br />
claim into a scanned image. This process allows Zenith American<br />
Solutions to process claims faster. In order to ensure that this<br />
process can take place, please be sure to follow <strong>the</strong> guidelines<br />
below:<br />
• Claims submitted should be <strong>the</strong> finest quality, using <strong>the</strong><br />
standardized Red CMS 1500 (08/05) forms.<br />
• All information should be typed, as handwritten forms cannot be<br />
Scanned into this system.<br />
• The ink should be dark (if it is too light it will not be processed).<br />
Information must be properly aligned on <strong>the</strong> claims form.<br />
Electronic <strong>Fund</strong>s Transfer<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> has teamed up with Pay Span <strong>Health</strong> and offers <strong>the</strong> providers Electronic <strong>Fund</strong><br />
Transfers (EFTs). This service enables online presentation of Explanation of Payment (EOP), direct deposit<br />
into a designated bank account and straightforward reconciliation of payments to empower our providers<br />
to reduce costs, speed secondary billings, improve cash flow and help <strong>the</strong> environment by reducing paper<br />
usage.<br />
To find out more information on how to become registered for this new service, please contact<br />
Pay Span <strong>Health</strong> at 877-331-7154.<br />
22 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC
October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Claims Processing <strong>Guide</strong>lines<br />
Allowable Requests<br />
Requests for allowables should be faxed to <strong>Provider</strong> Services at 702-892-7326.<br />
<strong>Provider</strong>s may also refer to <strong>the</strong> reimbursement page of <strong>the</strong>ir current provider agreement to obtain<br />
payment methodology for reimbursement rates.<br />
Timely Filing<br />
There is a 90-day filing limit to submit new claims to <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>. It is <strong>the</strong> provider’s<br />
responsibility to ensure claims are received within <strong>the</strong> 90-day filing limit. Secondary claims must be<br />
submitted within 90 days of <strong>the</strong> primary EOB.<br />
Claims Status<br />
Please allow at least 30 days from <strong>the</strong> date of submission before inquiring about claims status. Claims<br />
status can be checked on <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>’s website at www.culinaryhealthfund.org, or by utilizing<br />
<strong>the</strong> IVR telephone system at 702-733-9938, option 1, or by contacting <strong>the</strong> Customer Service Office at<br />
702-733-9938.<br />
• From time to time, claims are pended for additional information such as accident/injury inquiries and<br />
coordination of benefit information. In <strong>the</strong>se cases, in order to ensure claims are not delayed, it is<br />
important to send any relevant information regarding <strong>the</strong> claim, such as <strong>the</strong> chart notes or injury forms.<br />
• Injury/subrogation and coordination of benefit forms can be requested from <strong>the</strong> Customer Service<br />
Office at 702-733-9938 or printed from our website at www.culinaryhealthfund.org.<br />
<strong>Provider</strong> Reconsiderations<br />
In an effort to expedite <strong>the</strong> administrative process for providers seeking to appeal a decision on a claim,<br />
<strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> has established a <strong>Provider</strong> Reconsiderations Department. You may contact<br />
<strong>Provider</strong> Reconsiderations at 702-691-5625 / FAX: 702-216-9525 or mail your reconsiderations directly to<br />
<strong>the</strong> following address:<br />
<strong>Provider</strong> Reconsiderations<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong><br />
P. O. Box 44216<br />
Las Vegas, NV 89116<br />
To submit a corrected claim, please clearly indicate on <strong>the</strong> claim that it is a corrected claim. This will<br />
avoid <strong>the</strong> claim being denied as a duplicate. If you feel <strong>the</strong> claim was submitted correctly and you wish to<br />
appeal, please send a copy of <strong>the</strong> EOB and an appeal letter, or a <strong>Provider</strong> Reconsiderations Form. You can<br />
find a copy of <strong>the</strong> <strong>Provider</strong> Reconsiderations Form in <strong>the</strong> back of this guide or on our website at<br />
www.culinaryhealthfund.org. Please allow 60 days from date of submission for review.<br />
Please Note: First level provider reconsiderations must be received within 180 days of <strong>the</strong> date on <strong>the</strong><br />
initial explanation of payment. Second level reconsiderations must be received within 30 days of <strong>the</strong><br />
processing date of <strong>the</strong> first level appeal, which can be found on <strong>the</strong> explanation of payment.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
23
<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Claims Processing <strong>Guide</strong>lines<br />
TEXT<br />
Box 1a<br />
Should<br />
always have<br />
<strong>the</strong> <strong>Culinary</strong><br />
participant’s ID<br />
number<br />
Box 10<br />
Should have<br />
sections a, b<br />
and c filled in<br />
Box 33<br />
Should list<br />
<strong>the</strong> provider’s<br />
billing address,<br />
especially if<br />
different from<br />
<strong>the</strong> service<br />
address<br />
Box 31<br />
Should have<br />
provider’s<br />
name listed<br />
24 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC
October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Contract Information<br />
All Primary Care Physicians (PCPs) and specialty physician groups are contracted directly with <strong>Culinary</strong><br />
<strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC. Please contact <strong>Provider</strong> Services at 702-892-7313, option 1 with<br />
any questions regarding a physician/group provider contract. Forms in <strong>the</strong> back of this book have been<br />
provided to assist in requesting a new contract, updating your practice information or requesting contract<br />
allowables. You may also find printable forms on our website at www.culinaryhealthfund.org.<br />
Ancillary providers are those providers of services such as skilled nursing, home health, durable medical<br />
equipment, outpatient rehabilitation, as well as facility-based services such as ambulatory surgery, dialysis,<br />
laboratory and diagnostic testing. Please contact <strong>Provider</strong> Services at 702-892-7313, option 3, with any<br />
questions regarding your ancillary contract.<br />
Remember <strong>the</strong> following requirements per your agreement with <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>:<br />
• Referrals: Participants and <strong>the</strong>ir eligible dependents must be referred to <strong>Culinary</strong> PPO providers.<br />
The referring physician will be financially responsible for referrals to non-PPO providers when a PPO<br />
<strong>Provider</strong> is available.<br />
• Co-pays/Coinsurance/Deductibles: <strong>Culinary</strong> participants are responsible only for applicable co-pays,<br />
coinsurance, and/or deductibles for covered services. All o<strong>the</strong>r charges for covered services are not <strong>the</strong><br />
responsibility of <strong>the</strong> participant, and <strong>the</strong> participant cannot be balanced-billed.<br />
• Prior Authorization: The provider is responsible for obtaining prior authorization from American <strong>Health</strong><br />
Holding, Inc. (AHH), for all services that require prior authorization, including, but not limited to:<br />
1) Non-emergency inpatient services.<br />
2) Outpatient covered services.<br />
3) All referrals to non-PPO providers.<br />
4) Outpatient chemo/radiation <strong>the</strong>rapy.<br />
• <strong>Health</strong>Help: Effective August 1, 2012, <strong>the</strong> following requests will now be authorized by <strong>Health</strong>Help:<br />
• Diagnostic Imaging: CT, CTA, MRI, MRA, PET and cardiac nuclear medicine scans.<br />
• Medical Oncology treatments: Chemo<strong>the</strong>rapy, hormone <strong>the</strong>rapy, biologics, supportive care<br />
medications related to a cancer diagnosis.<br />
• Radiation Oncology treatments: two-dimensional (2D) and three-dimensional (3D) conformal<br />
radiation, intensity-modulated radiation <strong>the</strong>rapy (IMRT), brachy<strong>the</strong>rapy, stereotactic radiation <strong>the</strong>rapy<br />
and proton-beam procedures.<br />
• Out of Area: Before referring a patient out of <strong>the</strong> area for any specialized services, please contact<br />
American <strong>Health</strong> Holding, Inc. (AHH) at 866-330-2307. New technologies and services are evolving<br />
all <strong>the</strong> time and we at <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> want to assist you with <strong>the</strong> proper access for <strong>the</strong>se<br />
services.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
25
<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Credentialing<br />
The purposes of credentialing and recredentialing is to review and validate a practitioners’ qualifications to<br />
provide health care services for <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> participants. This process ensures that practitioners’<br />
are credentialed and recredentialed consistently and in a non-discriminatory manner, in compliance with<br />
accrediting bodies, state and federals laws, rules and regulations.<br />
All providers must successfully complete our credentialing process prior to being added to our provider<br />
network. Once a provider has been added to <strong>the</strong> network, recredentialing is generally conducted every<br />
three years to assess and validate <strong>the</strong> practioner’s qualifications.<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC uses <strong>the</strong> state of Nevada mandated credentialing<br />
and recredentialing applications which can be found on <strong>the</strong> website at www.culinaryhealthfund.org. All<br />
elements in <strong>the</strong> application must be completed and/or acknowledged. If you feel a section does not apply,<br />
you must insert “N/A”, as no section can be left blank. For your convenience, if you have an up-to-date<br />
state of Nevada application already completed, you may re-sign and re-date that application and submit<br />
it to <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC, in-lieu of completing <strong>the</strong> new one we have<br />
provided to you.<br />
Copies of <strong>the</strong> following items must also be returned with your completed application:<br />
1) Current license to practice<br />
2) Certificate of Insurance (Malpractice Face Sheet)<br />
3) DEA Registration (or Prescription Plan Designation) and CDS certificate, when applicable<br />
4) <strong>Health</strong> Status Form and/or Designation of Credentialing Agent Form, as applicable<br />
Please return your completed application along with all o<strong>the</strong>r materials to <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong><br />
Administrative Services, LLC at:<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
Attn: Credentialing Department<br />
1901 Las Vegas Blvd. South, Suite 101<br />
Las Vegas, NV 89104<br />
Or, for more timely processing you may fax your application to:<br />
FAX: 702-892-7365<br />
(Please always keep a copy of all <strong>the</strong> information you submit to us for review.)<br />
If you have any questions or concerns regarding <strong>the</strong> credentialing process, please contact <strong>Provider</strong><br />
Services at 702-892-7313, option 1.<br />
26 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC
October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Resources<br />
TEXT<br />
Website<br />
Some information can be accessed on <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>’s website at www.culinaryhealthfund.org.<br />
Some services on <strong>the</strong> website require registration with a username and password. Simply click on<br />
“<strong>Provider</strong> log-in and sign-up” and follow <strong>the</strong> prompts to establish an account.<br />
• Claim status can be checked online with a username and password. By using <strong>the</strong> participant’s ID<br />
number and <strong>the</strong> date of service, it can be determined whe<strong>the</strong>r <strong>the</strong> claim has been paid, pended, or<br />
denied. Please allow at least 30 days from <strong>the</strong> date of submission before checking claims status. You<br />
can also view benefit information and updates online.<br />
• Online <strong>Provider</strong> Directory: The online <strong>Provider</strong> Directory is updated weekly. Use this directory<br />
when referring to participants and <strong>the</strong>ir eligible dependents to specialists or to verify that practice<br />
information is correct. If practice information is incorrect, please contact <strong>Provider</strong> Services at<br />
702-892-7313.<br />
• Participant eligibility can also be checked online with a username and password. The website is secure,<br />
and all participant and provider information is confidential. In most cases eligibility is given for a 2<br />
month period.<br />
• <strong>Provider</strong> updates are also available on <strong>the</strong> website. Communication sent to <strong>the</strong> network regarding<br />
updates to policies and/or procedures will be posted online for your reference.<br />
Please Note: Only one password is issued for all practices, even those with more than one office location.<br />
If you become locked out or need a new password, please contact your office account administrator.<br />
Fast and easy to use.<br />
Don’t have time to hold?<br />
www.culinaryhealthfund.org<br />
Visit our website 24 hours a day, 7 days a week to find<br />
all <strong>the</strong> updated information you need under our provider section.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
27
<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Resources<br />
IVR<br />
IVR, <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>’s automated telephone system, can be used to check participant eligibility<br />
and claims status.<br />
• Call 702-733-9938 and select option 1.<br />
• Services are available 24 hours a day, 7 days a week.<br />
• In most cases eligibility is given for a 2-month period.<br />
Vision IVR<br />
This is a dedicated IVR for ophthalmology and optometry providers, and can be used to check participant<br />
eligibility and hardware benefits status.<br />
• Call 702-216-1298.<br />
• Services are available 24 hours a day, 7 days a week.<br />
• In most cases eligibility is given for a 2-month period.<br />
Customer Service Office<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>’s Customer Service Office can be reached Monday through Friday from<br />
8am to 6pm at 702-733-9938 to answer any questions you may have.<br />
<strong>Provider</strong> Services<br />
To reach <strong>Provider</strong> Services, please call 702-892-7313 or fax 702-892-7326.<br />
<strong>Provider</strong> Reconsiderations<br />
To reach <strong>Provider</strong> Reconsiderations, please call 702-691-5625 or fax 702-216-9525.<br />
28 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC
October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Information Update<br />
<strong>Provider</strong>s<br />
Changes in address and/or contact information can be submitted using <strong>the</strong> <strong>Provider</strong> Address Information<br />
Form, located in <strong>the</strong> back of this book or on <strong>the</strong> website.<br />
When a new provider is added to a practice, <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC must be<br />
notified immediately so that credentialing can be completed.<br />
Please Note: <strong>Provider</strong>s must pass credentialing and receive an effective date under <strong>the</strong> current provider<br />
agreement in order to see <strong>Culinary</strong> patients as a PPO provider. Some updates, including staff changes<br />
within a practice, may require additional information (i.e. a credentialing application). <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong><br />
Administrative Services, LLC will notify you once <strong>the</strong> physician is credentialed and when <strong>the</strong>y will become<br />
a PPO provider with <strong>the</strong> <strong>Culinary</strong> Network. Information on <strong>the</strong> addition of providers to your practice can<br />
be submitted on our Group Add Request Form, located in <strong>the</strong> back of this book or on our website. Please<br />
complete <strong>the</strong> form and submit to <strong>the</strong> fax number listed on <strong>the</strong> form.<br />
Please remember that a provider should not see <strong>Culinary</strong> participants until <strong>the</strong>y have been credentialed<br />
and added to your provider agreement.<br />
Additionally, if a provider leaves a practice, this information should be communicated to us in writing.<br />
Letters can be faxed to <strong>the</strong> attention of <strong>Provider</strong> Services at 702-892-7365.<br />
Practice information can be verified by contacting <strong>Provider</strong> Services at 702-892-7313 or by checking <strong>the</strong><br />
online <strong>Provider</strong> Directory at www.culinaryhealthfund.org.<br />
Ancillary <strong>Provider</strong>s<br />
Keep information up to date by submitting any changes in names, facility locations, phone numbers, and<br />
tax identification numbers to <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> <strong>Provider</strong> Services at <strong>the</strong> address listed below:<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong><br />
Attn: <strong>Provider</strong> Services<br />
1901 Las Vegas Blvd. South, Suite 101<br />
Las Vegas, NV 89104<br />
Phone: 702-892-7313<br />
Fax: 702-892-7365<br />
Information regarding a facility can be verified by checking <strong>the</strong> online <strong>Provider</strong> Directory at<br />
www.culinaryhealthfund.org or by contacting <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>’s Customer Service Office at<br />
702-733-9938.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
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<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Frequently Asked Questions<br />
Q: Does <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> reimburse for mobile imaging services?<br />
AA:<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> does not reimburse for mobile imaging services. In order to provide<br />
imaging services to <strong>Culinary</strong> participants, providers must successfully complete <strong>the</strong> Radiology<br />
Management Program referenced on page 22.<br />
Q: What are <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC guidelines for<br />
office visit re-coding?<br />
AA:<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> payment guidelines follow national coding standards when re-coding.<br />
PCP providers and designated specialties who submit elevated E&M codes will be required to<br />
submit medical records to support <strong>the</strong> level of care. Claims that are submitted with elevated E&M<br />
codes without medical records will be denied with a request for supporting documentation. The<br />
<strong>Fund</strong> has established criteria to identify providers with low instances of re-coding. <strong>Provider</strong>s can<br />
be waived from this process once <strong>the</strong> established criteria is met.<br />
Q: What are <strong>the</strong> age limits for screening mammograms?<br />
AA:<br />
One baseline mammogram is covered for participants between <strong>the</strong> ages of 35-39, followed by<br />
yearly mammograms for women ages 40 and over.<br />
Q: What are <strong>the</strong> timelines and limitations on adult and pediatric well care visits?<br />
A:<br />
Adults: One preventative routine physical exam is covered every 12 months.<br />
Children: Exams are covered in accordance with <strong>the</strong> guidelines of <strong>the</strong> American Academy<br />
of Pediatrics.<br />
Q: What are <strong>the</strong> time frames for claims processing?<br />
AA:<br />
Clean claims are normally processed within 30 working days of receipt.<br />
Claims requiring additional information may take longer to resolve.<br />
Q: What is <strong>the</strong> process for appealing a claim decision?<br />
AA:<br />
Please submit a copy of <strong>the</strong> EOB and a letter outlining <strong>the</strong> basis for your reconsideration request<br />
to:<br />
<strong>Provider</strong> Reconsiderations, <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>, P.O. Box 44216, Las Vegas, NV 89116<br />
Please allow 60 days from <strong>the</strong> date of submission for review. You may contact <strong>Provider</strong><br />
Reconsiderations at 702-691-5625 or fax 702-216-9525.<br />
30 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC
October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Frequently Asked Questions<br />
Q: How are assistant surgeons reimbursed?<br />
AA:<br />
Assistant surgeons are reimbursed at 16% of <strong>the</strong> surgical allowable. If <strong>the</strong> assistant surgeon is a<br />
physician’s assistant, <strong>the</strong> reimbursement is 14% of <strong>the</strong> surgical allowable (80% of <strong>the</strong> 16% for a<br />
medical doctor).<br />
Q: What is <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC policy on<br />
Physician Extenders?<br />
AA:<br />
All Physician Assistants (PA/PAC) and Advanced Practice Nurses (APN), including Certified Nurse<br />
Midwives (CNM), Clinical Nurse Specialists (CNS) and Certified Registered Nurse Anes<strong>the</strong>tists<br />
(CRNA) must successfully complete credentialing. In addition, <strong>the</strong>se providers must be added<br />
under <strong>the</strong> <strong>Culinary</strong> Preferred <strong>Provider</strong> Agreement in order for claims submitted under <strong>the</strong>ir name<br />
to be processed and paid at PPO rates.<br />
Q: How does <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> reimburse for immunization<br />
administrations?<br />
AA:<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> does not recognize CPT codes 90460 and 90461 and requires that<br />
providers use CPT codes 90471 – 90474 for immunization administration reimbursement.<br />
Q: What immunizations are covered by <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>?<br />
AA:<br />
A list of immunizations that are covered by <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> and <strong>the</strong> corresponding<br />
allowables are listed below. The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> establishes reimbursement for<br />
immunizations based on Center for Disease Control (CDC) allowables. If your office participates<br />
in <strong>the</strong> Delegation of Authority Program offered by <strong>the</strong> Nevada State <strong>Health</strong> Division you may<br />
choose to administer vaccines that do not have allowables set by <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> in<br />
your office. Administration codes will be reimbursable on all currently recommended childhood<br />
immunizations; however, <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> has only set allowables for <strong>the</strong> vaccinations<br />
outlined below.<br />
Vaccine<br />
Allowable<br />
Hepatitis A $35.00<br />
Hepatitis A $61.01<br />
HPV (Quadrivalent) Female &<br />
Male<br />
$130.00<br />
HPV (Bivalent) $128.25<br />
Pneumococcal (7 valent) $83.88<br />
Pneumococcal (13 valent) $120.95<br />
Rotavirus (Rotateq) $73.00<br />
Rotarix $106.57<br />
Meningococcal $106.49<br />
If your office does not participate in <strong>the</strong> Delegation of Authority Program, you can refer your<br />
patients to <strong>the</strong> Sou<strong>the</strong>rn Nevada <strong>Health</strong> District for all <strong>the</strong>ir immunizations. Please call Sou<strong>the</strong>rn<br />
Nevada <strong>Health</strong> District at 702-759-0850 for hours and locations.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
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<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
Frequently Asked Questions<br />
Q: If <strong>Culinary</strong> is <strong>the</strong> secondary payor on a claim, what is <strong>the</strong> timely filing<br />
deadline for <strong>the</strong> secondary claims submission?<br />
AA:<br />
If <strong>Culinary</strong> is <strong>the</strong> secondary payor, claims must be received within 90 days of <strong>the</strong> date on<br />
<strong>the</strong> explanation of payment from <strong>the</strong> primary payor.<br />
Q: What services are included in a routine vision exam and what is <strong>the</strong><br />
co-pay?<br />
AA:<br />
The participant is responsible for $20 co-pay for a routine vision exam. A routine vision<br />
exam includes tests and procedures related to case history, eye muscle, visual acuity, eye<br />
health, refraction and disposition. Contact lens fittings are eligible for reimbursement in<br />
addition to a routine vision exam or on a separate date of service.<br />
Please Note: Participants receiving contact lens fittings during a routine vision exam will<br />
not be responsible for any additional co-pays.<br />
Q: How do I add a new provider to our group?<br />
AA:<br />
Please fill out a Group Add Request Form (copy in <strong>the</strong> back of this book) and mail to:<br />
1901 Las Vegas Blvd. South, Suite 101, Las Vegas, NV 89104<br />
or via fax to 702-892-7365<br />
Q: How do I appeal a timely filing denial?<br />
AA:<br />
Please submit a copy of <strong>the</strong> EOB and proof of timely filing to:<br />
<strong>Provider</strong> Reconsiderations, <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>, P.O. Box 44216, Las Vegas, NV 89116<br />
Proof of timely filing should include a screen print or electronic transmission receipt that<br />
clearly shows <strong>the</strong> date of submission and payor name that <strong>the</strong> claim was submitted to.<br />
Q: I have a patient that I would like to send to a specialist outside of Las<br />
Vegas. What is your process for this type of referral?<br />
AA:<br />
If you have a <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> participant who requires services that cannot be<br />
performed in Las Vegas, please contact American <strong>Health</strong> Holding, Inc. (AHH) ei<strong>the</strong>r via<br />
telephone at 866-330-2307 or <strong>the</strong> website at http://culinaryhealthfund.ahhinc.com to<br />
initiate a pre-certification. The request will be assigned to a nurse for review. Please be<br />
prepared to supply information as to why <strong>the</strong> services cannot be performed by an<br />
in-network provider within <strong>the</strong> Las Vegas area.<br />
Please Note: Pre-Certification is required for services to be performed at UCLA.<br />
Q: I have patients that need diagnostic imaging services; do I still contact<br />
AHH to obtain prior authorization<br />
AA:<br />
No, effective August 1, 2012, <strong>Health</strong>Help is <strong>the</strong> Utilization Review vendor for diagnostic<br />
imaging services.<br />
They can be reached by phone at 800-519-9935, by fax at 800-592-9050 or by <strong>the</strong> web at<br />
www.healthhelp.com/culinary<br />
32 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC
October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
Frequently Asked Questions<br />
Q: I am a primary care provider. How does <strong>the</strong> Hospitalist Program affect me?<br />
AA:<br />
The <strong>Fund</strong>’s Hospitalist Program was established to promote a team approach to <strong>Culinary</strong><br />
participants’ care while in an acute hospital setting. As such, <strong>the</strong> <strong>Fund</strong> requires all<br />
admissions be assigned to a hospitalist plan provider for continuity of care. In support<br />
of this goal, <strong>the</strong> <strong>Fund</strong> encourages primary care physicians to remain engaged and<br />
informed about <strong>the</strong>ir patients’ care while in an inpatient setting. If you choose to visit your<br />
established patients in <strong>the</strong> hospital, please submit CPT code 99231 for reimbursement.<br />
Please Note: Obstetrical and pediatric patients are excluded from <strong>the</strong> Hospitalist Program.<br />
If <strong>the</strong>re is concern with a hospitalist provider, or <strong>the</strong> care your patients are receiving, please<br />
contact <strong>Provider</strong> Services at 702-892-7313 and a call with <strong>the</strong> <strong>Fund</strong> Medical Director will be<br />
coordinated.<br />
Below is <strong>the</strong> list of hospitalist groups that are under <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Hospitalist<br />
Program:<br />
• Pioneer Hospitalist Group (702-388-9777) - Sou<strong>the</strong>rn Hills Hospital, Spring Valley<br />
Hospital, Sunrise Hospital and Summerlin Hospital Medical Center<br />
• Inpatient Consultants of Nevada-IPC (702-380-1992) - Desert Springs Hospital, North<br />
Vista Hospital, St. Rose Hospital – Siena Campus and St. Rose – De Lima Campus<br />
• Nevada Hospitalist Group-NHG (702-450-1717) – Centennial Hills Hospital, Mountain<br />
View Hospital and St. Rose Hospital – San Martín Campus<br />
• Internal Medicine Specialists of Las Vegas (702-588-7373) -Valley Hospital<br />
• Hospitalist Management Group-HMG (702-207-8263) - University Medical Center<br />
Q: We have moved our office to a new location. How do we notify you?<br />
AA:<br />
Please fill out a <strong>Provider</strong> Address Form (copy in <strong>the</strong> back of this book) and mail to:<br />
1901 Las Vegas Blvd. South, Suite 101, Las Vegas, NV 89104<br />
or via fax to 702-892-7365<br />
Q: Why are my radiology claims being denied?<br />
AA:<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> requires all providers that perform imaging services in <strong>the</strong>ir office<br />
to enroll in our mandatory Radiology Management Program. In order to be eligible for<br />
reimbursement for <strong>the</strong>se services, you must have successfully completed this program. For<br />
questions regarding participation in this program, please contact <strong>Provider</strong> Services at<br />
702-892-7313.<br />
Q: How do I know what diagnostic/radiology imaging services needs to be<br />
authorized?<br />
AA:<br />
A complete list of procedures with CPT codes can be found on <strong>Health</strong>Help website.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
33
CULINARY HEALTH FUND ADMINISTRATIVE SERVICES LLC<br />
PROVIDER ADDRESS INFORMATION<br />
TAX IDENTIFICATION NUMBER:<br />
SITE LOCATION ADDRESS:<br />
[3] ADDRESS<br />
PRACTICE NAME: CORRESPONDENCE MAILING ADDRESS: [1] ADDRESS<br />
ADDRESS PHONE CONTACT/E-MAIL<br />
PHONE FAX<br />
CONTACT/E-MAIL FAX BILLING ADDRESS:<br />
ADDRESS [2] ADDRESS<br />
PHONE CONTACT/E-MAIL<br />
PHONE FAX<br />
CONTACT/E-MAIL FAX CREDENTIALING ADDRESS:<br />
ADDRESS PHONE FAX PHONE CONTACT/E-MAIL<br />
FAX<br />
please attach If more than 3 sites complete roster including site/providers.<br />
CONTACT/E-MAIL Site roster attached.<br />
Effective Date:_____________________________________<br />
PROVIDER NAME SPECIALTY LOCATION NO. Ex.: [2] or all.<br />
If more providers please attach complete roster including site/providers. Site roster attached<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong><br />
1901 Las Vegas Blvd. South, Suite 101<br />
Las Vegas, Nevada 89104<br />
Or<br />
Via Fax at: 702-735-1649<br />
PPO Quick <strong>Guide</strong><br />
Important Telephone Numbers<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> www.culinaryhealthfund.org<br />
Customer Service Office 702-733-9938<br />
Mon-Fri 8am to 6pm<br />
<strong>Provider</strong> Services 702-892-7313<br />
<strong>Culinary</strong> Pharmacy 702-650-4417<br />
Case Management 702-892-7313, #4<br />
<strong>Provider</strong> Reconsiderations 702-691-5625<br />
American <strong>Health</strong> Holding, Inc. (AHH)<br />
www.americanhealthholding.com<br />
Mon - Fri, 7:30am to 8pm EST 866-330-2307<br />
<strong>Health</strong>Help<br />
www.healthhelp.com/culinary<br />
Mon - Fri, 7am to 7pm CST<br />
Diagnostic Imaging:<br />
• CT, CTA, MRI, MRA, PET and cardiac nuclear medicine<br />
scans.<br />
Medical Oncology Treatments:<br />
• Chemo<strong>the</strong>rapy, hormone <strong>the</strong>rapy, biologics, supportive<br />
care medications related to a cancer diagnosis.<br />
Radiation Oncology Treatments:<br />
• Two-dimensional (2D) and three-dimensional (3D)<br />
conformal radiation, intensity-modulated radiation<br />
<strong>the</strong>rapy (IMRT), brachy<strong>the</strong>rapy, stereotactic radiation<br />
<strong>the</strong>rapy and proton-beam procedures.<br />
Phone: 800-519-9935 /Fax: 800-592-9050<br />
Harmony <strong>Health</strong>care www.harmonyhc.com<br />
Behavioral <strong>Health</strong> Benefits, including:<br />
• Addiction Treatment • Grief and Loss Counseling<br />
• Marriage & Family<br />
• Crisis Intervention<br />
Counseling<br />
24 hours a day/7 days a week 702-251-8000<br />
Rapid Response 702-788-9875<br />
Catalyst Rx Prescription Services<br />
www.catalystrx.com<br />
Prescription Benefits and Drug Prior Authorization<br />
24 hours a day/ 7 days a week 866-611-5960<br />
Catalyst Mail Order 866-834-0449<br />
LabCorp<br />
www.labcorp.com<br />
Test Results, Ordering Supplies, Customer Service<br />
24 hours a day/ 7 days a week 888-522-2677<br />
Quest Diagnostics www.questdiagnostics.com<br />
Test Results, Ordering Supplies, Customer Service<br />
24 hours a day/ 7 days a week 888-522-2677<br />
Clinical Pathology Laboratories (CPL)<br />
www.cpllabs.com 800-595-1275<br />
SERVICE DESCRIPTION<br />
CO-PAYS<br />
Urgent Care Visit<br />
Primary Office Visit<br />
Specialist Office Visit<br />
Chiropractic Office Visit<br />
Injections<br />
Allergy Testing<br />
IV Treatment<br />
Pulmonary Treatment<br />
X-ray<br />
Lab (*Only if tests are processed<br />
at contracted lab facilities)<br />
All o<strong>the</strong>r Physician Office procedures:<br />
Examples: Chemo<strong>the</strong>rapy,<br />
Radiation Therapy<br />
$20 per visit<br />
$14 per visit<br />
Cooperative Association of Chiropractic Physicians (CACP)<br />
Mon- Fri, 8:30am to 5pm 702-365-5981<br />
Nevada Dental Benefits<br />
Mon – Fri, 8am to 5:30pm 702-478-2014<br />
Administrative Services, LLC<br />
Vision Eligibility Express Line<br />
24 hours a day / 7 days a week 702-216-1298 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> - Revised October 2012<br />
(Replaces Quick <strong>Guide</strong> dated July 2011)<br />
HIGH TECH DIAGNOSTIC SERVICE REVIEW<br />
$20 per visit<br />
OB Ultrasounds Fetal Biophysical Profiles<br />
All MRI/MRAs All PET Scans & cardiac nuclear medicine scans<br />
All CT/CTA Scans Sleep Screenings through Bennett Medical Services<br />
Sleep Studies (must be ordered by a Neurologist,<br />
Discography<br />
Pulmonologist or ENT)<br />
$14 per visit<br />
$6 per procedure<br />
$7 per test type<br />
$7 per visit<br />
MEDICAL / RADIATION ONCOLOGY TREATMENTS<br />
$5 per procedure<br />
Chemo<strong>the</strong>rapy Intensity-modulated radiation <strong>the</strong>rapy (IMRT)<br />
$12 per procedure<br />
Hormone Therapy Brachy<strong>the</strong>rapy<br />
Biologics Stereotactic radiation <strong>the</strong>rapy & proton-beam procedures<br />
$5 per visit<br />
$7 per visit<br />
Tier 1 - Generic $5<br />
Tier 2 - Formulary Drugs $15<br />
Tier 3 - Non-Formulary Drugs $25<br />
True Emergency Visit<br />
Inpatient Hospital<br />
MRI - Outpatient Services<br />
CAT Scan - Outpatient Services<br />
PET Scan - Outpatient Services<br />
Ambulatory Surgery - Outpatient<br />
Services<br />
Outpatient Hospital Services:<br />
Examples: Chemo<strong>the</strong>rapy,<br />
Sleep Studies<br />
Compression Stockings<br />
Orthotic Shoe Insert<br />
Diabetic Shoes<br />
Mastectomy Bra<br />
Supportive care medications related to a cancer diagnosis Two-dimensional (2D)/three-dimensional (3D) conformal radiation<br />
AMBULATORY SURGERY REVIEW<br />
Services Requiring Prior Authorization:<br />
Blepharoplasty Septoplasty<br />
Varicose Vein Stripping/Ligation Breast Reduction<br />
$150 per visit<br />
$250 deductible<br />
$55 per visit<br />
$55 per visit<br />
$155 per visit<br />
$77 per visit<br />
$75 deductible with a<br />
20% coinsurance<br />
5 pairs per Calendar<br />
Year with $22 per<br />
pair copay<br />
3 pairs per lifetime<br />
with $10 per pair<br />
copay<br />
2 pairs per Calendar<br />
Year with $55 per<br />
pair copay<br />
$12 per item<br />
PPO Quick<br />
Orthotripsy for Plantar Fasciitis Ventral Hernia Repair > 18 years<br />
Surgical Treatment of Sleep Apnea Orthoses (or Orthotics)<br />
Durable Medical Equipment items that are over $500 (whe<strong>the</strong>r it is<br />
All hospital admissions including elective admissions and those<br />
rental or purchase to include oxygen equipment over $500, i.e. oxygen<br />
resulting from ER or observation stay<br />
concentrators)<br />
ADDITIONAL SERVICES REQUIRING PRIOR AUTHORIZATION<br />
All TMJ procedures Dialysis<br />
Skilled Nursing Facility Home <strong>Health</strong> and Infusion Therapy<br />
Inpatient Rehabilitation Orthoses (or Orthotics)<br />
Long Term Acute Care Pros<strong>the</strong>tic Appliances<br />
Insulin Pumps Outpatient Chemo/Radiation Therapy<br />
All Hysterectomies (Inpatient or Outpatient) Back Surgeries (Inpatient or Outpatient Services)<br />
Custom Compression Stockings Genetic Testing<br />
Cochlear Implants Implantable Hormone Therapy<br />
Mandibular/Oral/Orthognathic Surgery Stereotactic Radiosurgery<br />
Gastric Neurostimulators EECP<br />
Skin Substitutes/ Grafts<br />
Please Note: Services requiring prior authorization include outpatient and inpatient services. As of this printing, <strong>the</strong> services listed above re<br />
prior authorization. This list may be updated from time to time. It is <strong>the</strong> provider’s responsibility to check for updates. If <strong>the</strong> procedure bi<br />
not <strong>the</strong> procedure approved by American <strong>Health</strong> Holding, Inc or <strong>Health</strong>Help, <strong>the</strong>re may be no payment and <strong>the</strong> patient is not liable. Plea<br />
American <strong>Health</strong> Holding, Inc at 866-330-2307 or <strong>Health</strong>Help at (800) 519-9935 for more information.<br />
<strong>Culinary</strong> Pharmacy<br />
• There are more than 300 drugs, including most diabetic and several over-<strong>the</strong>-counter medications, available at <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> Fu<br />
Pharmacy, which are FREE to all <strong>Culinary</strong> participants. Prescriptions can be called in at: 702-650-4417 or faxed to 702-369-5940.<br />
Don’t forget! The <strong>Culinary</strong> Pharmacy is accepting E-prescriptions! The ID code is: 2990124<br />
Please call <strong>the</strong> Customer Service Office to request an updated <strong>Culinary</strong> Pharmacy List or visit our website at www.culinaryhealthfu<br />
Diabetes Program offered to your <strong>Culinary</strong> Patients<br />
• Free Diabetic Educations! Please call our <strong>Provider</strong> Services at 702-892-7313 or go to our website at www.culinaryhealthfund.org f<br />
locations.<br />
• Free Diabetic Meters<br />
• Most diabetic medications are available at <strong>the</strong> <strong>Culinary</strong> Pharmacy. Please call <strong>the</strong> <strong>Culinary</strong> Pharmacy at 702-650-4417 for more<br />
Eligibility and Claims:<br />
• To verify your <strong>Culinary</strong> patient’s eligibility, please call <strong>the</strong> Customer Service Office at 702-733-9938, <strong>the</strong>n press 1 for <strong>the</strong> autom<br />
verification and claims status telephone line.<br />
• The Customer Service Office is open Mon - Fri from 7:30am to 6pm and <strong>the</strong> telephone line is available Mon - Fri from 8am to<br />
You can mail claims to:<br />
You can mail provider appeals to:<br />
P.O Box 94469<br />
<strong>Provider</strong> Reconsiderations<br />
Seattle, WA 98124<br />
P.O Box 42216<br />
EDI Payor ID# 59140<br />
Las Vegas, NV 89116<br />
For more Benefit Information and Updates, visit <strong>the</strong> website at www.culinaryhealthfund.<br />
This is only a guide to <strong>Culinary</strong> PPO participant benefits and does not provide you with all of <strong>the</strong> benefits available through t<br />
For fur<strong>the</strong>r information about o<strong>the</strong>r available programs and benefits, please call <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Customer Service Offi<br />
<strong>Guide</strong> & Forms<br />
1901 Las Vegas Blvd. So.<br />
Suite 101<br />
Las Vegas, Nevada 89104-1309<br />
(702) 892-7313<br />
www.culinaryhealthfund.org<br />
ALLOWABLE AMOUNT REQUEST FORM<br />
Section<br />
<strong>Provider</strong> Name TIN<br />
Please enter CPT procedure codes in each cell and fax your request to <strong>Provider</strong> Services<br />
(702) 892-7326. Please include your contact information and fax number on <strong>the</strong> cover<br />
page.<br />
GROUP ADD REQUEST<br />
Name of Group:<br />
Tax ID #<br />
Name of <strong>Provider</strong><br />
being added:<br />
Specialty of <strong>Provider</strong><br />
being added:<br />
Effective Date:<br />
Hospital-Based<br />
<strong>Provider</strong>? (Please<br />
circle one) Yes No<br />
Practice Location(s)<br />
(attach separate<br />
Sheet if necessary)<br />
Contact Name:<br />
Phone:<br />
1901 Las Vegas Blvd. So.<br />
Suite 101<br />
Las Vegas, Nevada 89104-1309<br />
(702) 892-7313<br />
www.culinaryhealthfund.org<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong><br />
<strong>Health</strong>y Pregnancy Program Certification<br />
To ensure proper reimbursement, please submit this certificate<br />
and patient’s antepartum records with your billing to:<br />
UNITE HERE HEALTH<br />
ATTN: Claims Payment<br />
1901 Las Vegas Blvd. South, Suite 107<br />
Las Vegas, NV 89104<br />
702-733-993<br />
Fax: 702-892-7326<br />
NOTE: Antepartum records must be attached.<br />
NAME OF ELIGIBLE EMPLOYEE: SS#:<br />
NAME OF MOTHER (if different): SS#:<br />
ADDRESS (Street, City, State, Zip):<br />
DATE OF DELIVERY:<br />
I certify that this patient: Did Did Not Complete all recommended ante partum care during her<br />
pregnancy.<br />
MD NAME: T.I.N:<br />
SIGNATURE: DATE:<br />
Fax:<br />
The allowables requested are not a guarantee of payment. <strong>Provider</strong> shall be reimbursed<br />
according to <strong>the</strong> terms of <strong>the</strong>ir contract. Any reimbursement shall be subject to applicable<br />
modifier reductions, co-pays, deductibles, co-insurance, plan limitations, exclusions and<br />
nationally accepted coding initiatives.<br />
Email:<br />
Please fax back to: 702-892-7365 Attention: Jessica Wesley<br />
Or e-mail to jwesley@culinaryhealthfund.org
<strong>Provider</strong> <strong>Guide</strong> October 2012<br />
PPO Quick <strong>Guide</strong><br />
Important Telephone Numbers<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> www.culinaryhealthfund.org<br />
Customer Service Office 702-733-9938<br />
Mon-Fri 8am to 6pm<br />
<strong>Provider</strong> Services 702-892-7313<br />
<strong>Culinary</strong> Pharmacy 702-650-4417<br />
Case Management 702-892-7313, #4<br />
<strong>Provider</strong> Reconsiderations 702-691-5625<br />
American <strong>Health</strong> Holding, Inc. (AHH)<br />
www.americanhealthholding.com<br />
Mon - Fri, 7:30am to 8pm EST 866-330-2307<br />
<strong>Health</strong>Help<br />
www.healthhelp.com/culinary<br />
Mon - Fri, 7am to 7pm CST<br />
Diagnostic Imaging:<br />
• CT, CTA, MRI, MRA, PET and cardiac nuclear medicine<br />
scans.<br />
Medical Oncology Treatments:<br />
• Chemo<strong>the</strong>rapy, hormone <strong>the</strong>rapy, biologics, supportive<br />
care medications related to a cancer diagnosis.<br />
Radiation Oncology Treatments:<br />
• Two-dimensional (2D) and three-dimensional (3D)<br />
conformal radiation, intensity-modulated radiation<br />
<strong>the</strong>rapy (IMRT), brachy<strong>the</strong>rapy, stereotactic radiation<br />
<strong>the</strong>rapy and proton-beam procedures.<br />
Phone: 800-519-9935 /Fax: 800-592-9050<br />
Harmony <strong>Health</strong>care www.harmonyhc.com<br />
Behavioral <strong>Health</strong> Benefits, including:<br />
• Addiction Treatment<br />
• Marriage & Family<br />
• Grief and Loss Counseling<br />
• Crisis Intervention<br />
Counseling<br />
24 hours a day/7 days a week 702-251-8000<br />
Rapid Response 702-788-9875<br />
Catalyst Rx Prescription Services<br />
www.catalystrx.com<br />
Prescription Benefits and Drug Prior Authorization<br />
24 hours a day/ 7 days a week 866-611-5960<br />
Catalyst Mail Order 866-834-0449<br />
LabCorp<br />
www.labcorp.com<br />
Test Results, Ordering Supplies, Customer Service<br />
24 hours a day/ 7 days a week 888-522-2677<br />
Quest Diagnostics www.questdiagnostics.com<br />
Test Results, Ordering Supplies, Customer Service<br />
24 hours a day/ 7 days a week 888-522-2677<br />
800-433-2750<br />
Clinical Pathology Laboratories (CPL)<br />
www.cpllabs.com 800-595-1275<br />
Cooperative Association of Chiropractic Physicians (CACP)<br />
Mon- Fri, 8:30am to 5pm 702-365-5981<br />
Nevada Dental Benefits<br />
Mon – Fri, 8am to 5:30pm 702-478-2014<br />
Administrative Services, LLC<br />
Vision Eligibility Express Line<br />
24 hours a day / 7 days a week 702-216-1298 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> - Revised October 2012<br />
(Replaces Quick <strong>Guide</strong> dated July 2011)<br />
36 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
SERVICE DESCRIPTION<br />
Urgent Care Visit<br />
Primary Office Visit<br />
Specialist Office Visit<br />
Chiropractic Office Visit<br />
Injections<br />
Allergy Testing<br />
IV Treatment<br />
Pulmonary Treatment<br />
X-ray<br />
Lab (*Only if tests are processed<br />
at contracted lab facilities)<br />
CO-PAYS<br />
$20 per visit<br />
$14 per visit<br />
$20 per visit<br />
$14 per visit<br />
$6 per procedure<br />
$7 per test type<br />
$7 per visit<br />
$5 per procedure<br />
$12 per procedure<br />
$5 per visit<br />
All o<strong>the</strong>r Physician Office procedures:<br />
Examples: Chemo<strong>the</strong>rapy,<br />
$7 per visit<br />
Radiation Therapy<br />
Tier 1 - Generic $5<br />
Tier 2 - Formulary Drugs $15<br />
Tier 3 - Non-Formulary Drugs $25<br />
True Emergency Visit<br />
$150 per visit<br />
Inpatient Hospital<br />
$250 deductible<br />
MRI - Outpatient Services<br />
$55 per visit<br />
CAT Scan - Outpatient Services<br />
$55 per visit<br />
PET Scan - Outpatient Services<br />
$155 per visit<br />
Ambulatory Surgery - Outpatient<br />
Services<br />
$77 per visit<br />
Outpatient Hospital Services:<br />
Examples: Chemo<strong>the</strong>rapy,<br />
Sleep Studies<br />
Compression Stockings<br />
Orthotic Shoe Insert<br />
Diabetic Shoes<br />
Mastectomy Bra<br />
$75 deductible with a<br />
20% coinsurance<br />
5 pairs per Calendar<br />
Year with $22 per<br />
pair copay<br />
3 pairs per lifetime<br />
with $10 per pair<br />
copay<br />
2 pairs per Calendar<br />
Year with $55 per<br />
pair copay<br />
$12 per item
HIGH TECH DIAGNOSTIC SERVICE REVIEW<br />
OB Ultrasounds<br />
All MRI/MRAs<br />
All CT/CTA Scans<br />
Sleep Studies (must be ordered by a Neurologist,<br />
Pulmonologist or ENT)<br />
MEDICAL / RADIATION ONCOLOGY TREATMENTS<br />
Fetal Biophysical Profiles<br />
All PET Scans & cardiac nuclear medicine scans<br />
Sleep Screenings through Bennett Medical Services<br />
Discography<br />
Chemo<strong>the</strong>rapy Intensity-modulated radiation <strong>the</strong>rapy (IMRT)<br />
Hormone Therapy<br />
Biologics<br />
Supportive care medications related to a cancer diagnosis<br />
AMBULATORY SURGERY REVIEW<br />
Blepharoplasty<br />
Varicose Vein Stripping/Ligation<br />
Orthotripsy for Plantar Fasciitis<br />
Brachy<strong>the</strong>rapy<br />
Stereotactic radiation <strong>the</strong>rapy & proton-beam procedures<br />
Two-dimensional (2D)/three-dimensional (3D) conformal radiation<br />
Septoplasty<br />
Breast Reduction<br />
Ventral Hernia Repair > 18 years<br />
Surgical Treatment of Sleep Apnea<br />
Orthoses (or Orthotics)<br />
ADDITIONAL SERVICES REQUIRING PRIOR AUTHORIZATION<br />
All hospital admissions including elective admissions and those<br />
resulting from ER or observation stay<br />
All TMJ procedures<br />
Skilled Nursing Facility<br />
Inpatient Rehabilitation<br />
Long Term Acute Care<br />
Insulin Pumps<br />
All Hysterectomies (Inpatient or Outpatient)<br />
Custom Compression Stockings<br />
Cochlear Implants<br />
Mandibular/Oral/Orthognathic Surgery<br />
Gastric Neurostimulators<br />
October 2012<br />
Services Requiring Prior Authorization:<br />
Durable Medical Equipment items that are over $500 (whe<strong>the</strong>r it is<br />
rental or purchase to include oxygen equipment over $500, i.e. oxygen<br />
concentrators)<br />
Dialysis<br />
Home <strong>Health</strong> and Infusion Therapy<br />
Orthoses (or Orthotics)<br />
Pros<strong>the</strong>tic Appliances<br />
Outpatient Chemo/Radiation Therapy<br />
Back Surgeries (Inpatient or Outpatient Services)<br />
Genetic Testing<br />
Implantable Hormone Therapy<br />
Stereotactic Radiosurgery<br />
EECP<br />
Skin Substitutes/ Grafts<br />
Please Note: Services requiring prior authorization include outpatient and inpatient services. As of this printing, <strong>the</strong> services listed above require<br />
prior authorization. This list may be updated from time to time. It is <strong>the</strong> provider’s responsibility to check for updates. If <strong>the</strong> procedure billed is<br />
not <strong>the</strong> procedure approved by American <strong>Health</strong> Holding, Inc or <strong>Health</strong>Help, <strong>the</strong>re may be no payment and <strong>the</strong> patient is not liable. Please call<br />
American <strong>Health</strong> Holding, Inc at 866-330-2307 or <strong>Health</strong>Help at (800) 519-9935 for more information.<br />
<strong>Culinary</strong> Pharmacy<br />
• There are more than 300 drugs, including most diabetic and several over-<strong>the</strong>-counter medications, available at <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong><br />
Pharmacy, which are FREE to all <strong>Culinary</strong> participants. Prescriptions can be called in at: 702-650-4417 or faxed to 702-369-5940.<br />
Don’t forget! The <strong>Culinary</strong> Pharmacy is accepting E-prescriptions! The ID code is: 2990124<br />
Please call <strong>the</strong> Customer Service Office to request an updated <strong>Culinary</strong> Pharmacy List or visit our website at www.culinaryhealthfund.org.<br />
Diabetes Program offered to your <strong>Culinary</strong> Patients<br />
• Free Diabetic Educations! Please call our <strong>Provider</strong> Services at 702-892-7313 or go to our website at www.culinaryhealthfund.org for a list of<br />
locations.<br />
• Free Diabetic Meters<br />
• Most diabetic medications are available at <strong>the</strong> <strong>Culinary</strong> Pharmacy. Please call <strong>the</strong> <strong>Culinary</strong> Pharmacy at 702-650-4417 for more information..<br />
Eligibility and Claims:<br />
• To verify your <strong>Culinary</strong> patient’s eligibility, please call <strong>the</strong> Customer Service Office at 702-733-9938, <strong>the</strong>n press 1 for <strong>the</strong> automated eligibility<br />
verification and claims status telephone line.<br />
• The Customer Service Office is open Mon - Fri from 7:30am to 6pm and <strong>the</strong> telephone line is available Mon - Fri from 8am to 6pm.<br />
You can mail claims to:<br />
P.O Box 94469<br />
Seattle, WA 98124<br />
EDI Payor ID# 59140<br />
You can mail provider appeals to:<br />
<strong>Provider</strong> Reconsiderations<br />
P.O Box 42216<br />
Las Vegas, NV 89116<br />
<strong>Provider</strong> <strong>Guide</strong><br />
For more Benefit Information and Updates, visit <strong>the</strong> website at www.culinaryhealthfund.org<br />
This is only a guide to <strong>Culinary</strong> PPO participant benefits and does not provide you with all of <strong>the</strong> benefits available through <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>.<br />
For fur<strong>the</strong>r information about o<strong>the</strong>r available programs and benefits, please call <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Customer Service Office at 702-733-9938.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
37
CULINARY HEALTH FUND ADMINISTRATIVE SERVICES LLC<br />
PROVIDER ADDRESS INFORMATION<br />
PRACTICE NAME: TAX IDENTIFICATION NUMBER:<br />
CORRESPONDENCE MAILING ADDRESS: SITE LOCATION ADDRESS:<br />
ADDRESS [1] ADDRESS<br />
PHONE FAX PHONE FAX<br />
CONTACT/E-MAIL CONTACT/E-MAIL<br />
BILLING ADDRESS:<br />
ADDRESS [2] ADDRESS<br />
PHONE FAX PHONE FAX<br />
CONTACT/E-MAIL CONTACT/E-MAIL<br />
CREDENTIALING ADDRESS:<br />
ADDRESS [3] ADDRESS<br />
PHONE FAX PHONE FAX<br />
CONTACT/E-MAIL CONTACT/E-MAIL<br />
If more than 3 sites please attach complete roster including site/providers.<br />
Site roster attached.<br />
PROVIDER NAME SPECIALTY LOCATION NO. Ex.: [2] or all.<br />
Effective Date:_____________________________________<br />
If more providers please attach complete roster including site/providers. Site roster attached<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong><br />
1901 Las Vegas Blvd. South, Suite 101<br />
Las Vegas, Nevada 89104<br />
Or<br />
Via Fax at: 702-735-1649
1901 Las Vegas Blvd. So.<br />
Suite 101<br />
Las Vegas, Nevada 89104-1309<br />
(702) 892-7313<br />
www.culinaryhealthfund.org<br />
ALLOWABLE AMOUNT REQUEST FORM<br />
<strong>Provider</strong> Name<br />
TIN<br />
Please enter CPT procedure codes in each cell and fax your request to <strong>Provider</strong> Services<br />
(702) 892-7326. Please include your contact information and fax number on <strong>the</strong> cover<br />
page.<br />
The allowables requested are not a guarantee of payment. <strong>Provider</strong> shall be reimbursed<br />
according to <strong>the</strong> terms of <strong>the</strong>ir contract. Any reimbursement shall be subject to applicable<br />
modifier reductions, co-pays, deductibles, co-insurance, plan limitations, exclusions and<br />
nationally accepted coding initiatives.
1901 Las Vegas Blvd. So.<br />
Suite 101<br />
Las Vegas, Nevada 89104-1309<br />
(702) 892-7313<br />
www.culinaryhealthfund.org<br />
GROUP ADD REQUEST<br />
Name of Group:<br />
Tax ID #<br />
Name of <strong>Provider</strong><br />
being added:<br />
Specialty of <strong>Provider</strong><br />
being added:<br />
Effective Date:<br />
Hospital-Based<br />
<strong>Provider</strong>? (Please<br />
circle one) Yes No<br />
Practice Location(s)<br />
(attach separate<br />
Sheet if necessary)<br />
Contact Name:<br />
Phone:<br />
Fax:<br />
Email:<br />
Please fax back to: 702-892-7365 Attention: Jessica Wesley<br />
Or e-mail to jwesley@culinaryhealthfund.org
CULINARY PROVIDER RECONSIDERATIONS FORM<br />
DATE:<br />
CLAIM #:<br />
PATIENT NAME:<br />
DATE OF SERVICE:<br />
________________________________<br />
________________________________<br />
________________________________<br />
________________________________<br />
CPT/HCPCS CODE (S) REQUIRING REVIEW:<br />
__________________<br />
________________________________________________________<br />
PROVIDER TIN:<br />
PROVIDER NAME:<br />
CONTACT PERSON:<br />
PHONE NUMBER:<br />
________________________________<br />
________________________________<br />
________________________________<br />
________________________________<br />
REASON FOR REQUEST (brief description of <strong>the</strong> issue (s))<br />
_________________________________________________________________<br />
_________________________________________________________________<br />
_________________________________________________________________<br />
_________________________________________________________________<br />
_________________________________________________________________<br />
_________________________________________________________________<br />
ATTACHMENTS: Check all that apply<br />
Copy of Claim Operative Report Medical Records<br />
CCI guidelines<br />
Contract Language<br />
O<strong>the</strong>r _________________________________________________________<br />
<strong>Provider</strong> Reconsiderations Department<br />
P.O. Box 44216<br />
Las Vegas, NV 89116
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong><br />
<strong>Health</strong>y Pregnancy Program Certification<br />
To ensure proper reimbursement, please submit this certificate<br />
and patient’s antepartum records with your billing to:<br />
UNITE HERE HEALTH<br />
ATTN: Claims Payment<br />
1901 Las Vegas Blvd. South, Suite 107<br />
Las Vegas, NV 89104<br />
702-733-993<br />
Fax: 702-892-7326<br />
NOTE: Antepartum records must be attached.<br />
NAME OF ELIGIBLE EMPLOYEE: SS#:<br />
NAME OF MOTHER (if different): SS#:<br />
ADDRESS (Street, City, State, Zip):<br />
DATE OF DELIVERY:<br />
I certify that this patient: Did Did Not Complete all recommended ante partum care during her<br />
pregnancy.<br />
MD NAME: T.I.N:<br />
SIGNATURE: DATE:
October 2012<br />
<strong>Provider</strong> <strong>Guide</strong><br />
We want to hear<br />
from you!<br />
The <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> is always looking<br />
for new ideas to ensure <strong>the</strong> quality of care<br />
for our participants. If you have any ideas<br />
or programs that you think would be of<br />
interest to <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>, please<br />
contact <strong>Provider</strong> Services at 702-892-7313<br />
or email us at<br />
providerservices@culinaryhealthfund.org.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
49
YOUR HEALTH. YOUR PLAN.<br />
<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC<br />
1901 Las Vegas Blvd. South, Suite 101<br />
Las Vegas, NV 89104<br />
702-892-7313<br />
www.culinaryhealthfund.org