Provider Guide - the Culinary Health Fund

Provider
Guide
Administrative Services, LLC
October 2012

Table of Contents
Introduction
Who We Are
Participant ID Cards
Benefits At A Glance
Prescription Benefits
October 2012
Provider Guide
Programs
• Healthy Pregnancy Program
• Diabetes Program
• Immediate Cardiac Evaluation Program (ICEP)
• Culinary Care Assistance Program
• Dr. Tomorrow
• Hospitalist Program for Acute Facilities
• Radiology Management Program
Prior Authorization/Utilization
AHH & HealthHelp
Claims Processing Guidelines
Contract Information
Credentialing
Resources
Information Update
FAQ’s
PPO Quick Guide
Provider Address Information Form
Allowable Amount Request Form
Group Add Request Form
Culinary Provider Reconsiderations Form
Healthy Pregnancy Program Certification Form
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Provider Guide October 2012
Introduction
The Culinary Health Fund is a multi-employer Taft-Hartley Health and Welfare Trust
governed by a Board of Trustees representing both labor and management. It is
funded by employer contributions negotiated in Collective Bargaining Agreements.
Contracts for Culinary Health Fund plan providers are maintained through the Culinary
Health Fund Administrative Services, LLC.
The Culinary Health Fund is one of the largest health plans in Nevada, covering
approximately 120,000 lives.
The Culinary Health Fund has developed this guide in order for providers and their office
staff to navigate through the Culinary Health Fund plan simply and easily.
This guide provides helpful information regarding claims submission and payment, prior
authorization, and benefits.
Information in this guide will be updated regularly. Updates are available via facsimile and/
or mail to your office and can also be found on the Culinary Health Fund’s website at
www.culinaryhealthfund.org.
Additional copies of this Culinary Health Fund Provider Guide can be requested by
contacting Provider Services at 702-892-7313 or downloaded from our website at
www.culinaryhealthfund.org.
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Who we are

Provider Guide October 2012
Who We Are
Leadership Team
Kathy Silver
President, Las Vegas
kathys@culinaryhealthfund.org
Maria Martinez-Riach
Senior Director of Finance
maria@culinaryhealthfund.org
Kim Voss
Senior Director, Healthcare
Networks & Advocacy
kim@culinaryhealthfund.org
Dr. Kelly Van Wagner
Medical Director
kvanwagner@culinaryhealthfund.org
Sylvia Vazquez
Director of Advocacy,
Outreach & Communications
sylvia@culinaryhealthfund.org
Nancy Nikolski, BSN, RN
Senior Director,
Medical Management
nancy@culinaryhealthfund.org
Nevada Health Care Policy Group
Bobbette Bond
Executive Director of
Nevada Public Policy
bobbette@culinaryhealthfund.org
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October 2012
Provider Guide
Who We Are
Healthcare Network
Cindy Pearson
Senior Manager of
Healthcare Networks
cindy@culinaryhealthfund.org
Kimberly Esau
Manager of Healthcare Services
kesau@culinaryhealthfund.org
Debra Manchester
Contracts Manager
debra@culinaryhealthfund.org
Andrea Schwartzman
Provider Network Supervisor
andrea@culinaryhealthfund.org
Mary McGill, MBA
Healthcare Services
Associate II
mary@culinaryhealthfund.org
Michael Barton
Provider Services Representative
michael@culinaryhealthfund.org
Melanie Hildebrand
Healthcare Services Associate I
melanie@culinaryhealthfund.org
Jessica Wesley
Provider Network
Data Coordinator
jessica@culinaryhealthfund.org
Lucia James
Healthcare Services Associate I
lucia@culinaryhealthfund.org
Jeanie Jenkins
Credentialing Specialist
jeanie@culinaryhealthfund.org
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Provider Guide October 2012
Who We Are
Care Management Team
Lori Rogers RN, BAN, CCM
Senior Manager,
Healthcare Management
Lrogers@culinaryhealthfund.org
Ava High, RN, CCM
Case Manager
ava@culinaryhealthfund.org
Eric Dinulos, BSN, RN
Hospital Care Manager
eric@culinaryhealthfund.org
Susan Rotman, BSN, RN
Hospital Care Manager
susan@culinaryhealthfund.org
Yolanda Short, RN
Case Manager
yolanda@culinaryhealthfund.org
Rosemary Villaquiran, BSN, RN
Hospital Care Manager
rosemary@culinaryhealthfund.org
Lynn Jones, BSN, RN
Case Manager
lynn@culinaryhealthfund.org
Carol Neely, RN
Hospital Care Manager
carol@culinaryhealthfund.org
Rolanda Chapman
Care Coordinator
rolanda@culinaryhealthfund.org
Cindy Foley, RN
Case Manager
cindyf@culinaryhealthfund.org
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October 2012
Provider Guide
Who We Are
Care Management Team (continued)
Lynn Wiegand, RN, CCM
Case Manager
lynnw@culinaryhealthfund.org
Kathy Leon, RN
Case Manager
kathy@culinaryhealthfund.org
Lesley Knudson, RN
Case Manager
lesley@culinaryhealthfund.org
Claudia Swift, RN
Case Manager
claudia@culinaryhealthfund.org
Zohar Mizrahi, BSN, RN
Case Manager
zohar@culinaryhealthfund.org
Transitional Management Team
Ramon Barajas
Transitional Management
Supervisor
ramon@culinaryhealthfund.org
Christie Barton
Transitional Care Coordinator
christie@culinaryhealthfund.org
Lawrence Chubbs
Transitional Care Coordinator
lawrence@culinaryhealthfund.org
Alicia Estrada
Transitional Care Coordinator
alicia@culinaryhealthfund.org
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Provider Guide October 2012
Who We Are
Transitional Management Team (continued)
Sandra Schneider
Transitional Care Coordinator
sandra@culinaryhealthfund.org
Celene Ochoa
Transitional Care Coordinator
celene@culinaryhealthfund.org
Participant Advocacy
Tiffany Ellis
Manager of Member Advocacy
tiffanye@culinaryhealthfund.org
Shannon Avila
Wellness & Health
Promotions Manager
shannon@culinaryhealthfund.org
Myrna Mendoza
Member Advocate
myrna@culinaryhealthfund.org
Martin Gamboa
Senior Member Advocate
martin@culinaryhealthfund.org
Gina Kramer
Senior Benefits Specialist
gina@culinaryhealthfund.org
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October 2012
Provider Guide
Participant ID Cards
TM
John Q Sample
ID: Use Primary SSN
Coverage: Family
Culinary Health Fund
UNITE HERE Health
Medical / Prescription Card - Group
150
THIS CARD IS FOR IDENTIFICATION PURPOSES ONLY
Possession of this card does not guarantee eligibility for benefits.
ESTA TARJETA ES PARA INDENTIFICACIÓN SOLAMENTE
La posesión de esta tarjeta no garantiza elegibilidad de beneficios.
Culinary Health Fund
Medical Prescription Card
The Culinary Health Fund Medical/Prescription ID
card will assist you in identifying Culinary Health
Fund participants. It is strongly encouraged that
you request photo identification in addition to the
participant’s ID card.
• The name of the Culinary Health Fund covered participant is the only name listed on the ID card.
• The Social Security Number is not listed on the ID card. You will need to request the Social
Security Number of the covered employee for your records and billing purposes.
• Possession of a Culinary Health Fund ID card does not automatically certify eligibility for benefits.
• Services should not be denied if a Culinary Health Fund participant does not have an ID card;
however, the participant should be required to show photo ID prior to services being rendered.
Providers should always verify participant eligibility at the time services are rendered.
Culinary Health Fund Administrative Services, LLC
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Provider Guide October 2012
Benefits at a Glance
Below is a summary of the benefits provided to Culinary Health Fund participants. Some services are PPO
only. For additional information, visit our website at www.culinaryhealthfund.org.
Benefits at a Glance: PPO vs Non-PPO
BENEFIT PPO PLAN NON-PPO PLAN
IS APPROVAL
(PRIOR AUTHORIZATION)
NEEDED?
Addiction Treatment YES NO YES
Ambulance Benefit YES YES NO
Birthing Center YES YES NO
Chiropractic Care YES NO NO
Dental YES YES SOME
Durable Medical Equipment YES NO SOME
Emergency Room YES YES NO
Healthy Pregnancy Program YES NO Certificate required
Hearing Aids YES YES NO
Home Health Care/Infusion YES NO YES
Hospice Care YES NO NO
Hospital (Inpatient) YES YES YES
Hospital (Outpatient) YES SOME SOME
Hospital Room & Board YES YES YES
Inpatient Rehabilitation YES NO YES
MRI/CAT/PET Scans YES NO YES
Medical Supplies YES NO SOME
Mental Health (Inpatient) YES NO YES
Mental Health (Outpatient) YES NO YES
Other Outpatient Services YES SOME SOME
Physician Services YES YES SOME
Pregnancy/Delivery YES YES UR required for delivery
Prescriptions YES NO SOME
Surgery/Anesthesia YES YES YES
Surgery (Outpatient) YES NO SOME
Therapy (Outpatient) YES NO NO
Vision YES NO NO
X-Ray (Outpatient) YES YES SOME
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October 2012
Provider Guide
Prescription Benefits
Catalyst Rx is the Pharmacy Benefit Manager for the Culinary Health Fund. You can get
more information about Catalyst Rx at www.catalystrx.com or by calling 866-611-5960.
Prescriptions are covered on three co-pay tiers, as outlined below.
Three-Tier Co-pay Prescription Program
Culinary Pharmacy Medications
FREE
Tier 1 All Generics $5.00
Tier 2 Formulary Medications $15.00
Tier 3 Other Non Formulary Medications $30.00
FREE
$10.00
$20.00
$35.00
Starting
Jan. 1, 2013
Please Note: If the Culinary Health Fund participant receives a brand-name medication
when a generic equivalent is possible, the participant will pay the difference in cost
between the brand-name and the generic medication.
The Culinary Health Fund uses two formularies:
• One for the three-tier prescription plan.
• One for the prescriptions available without a co-pay from the Culinary Pharmacy.
Copies of both formularies are available on our website at
www.culinaryhealthfund.org. You can also call Provider Services at 702-892-7313 to
request additional formularies.
Culinary Pharmacy
• The Culinary Pharmacy offers a 60-day supply for most maintenance medications.
• If you prescribe medications that are available at the Culinary Pharmacy, Culinary
Health Fund participants do not have a co-pay. The Culinary Pharmacy offers over
300 prescription medications, including most diabetic supplies.
The Culinary Pharmacy is located at:
1945 Las Vegas Blvd. South
(Inside the St. Louis Square adjacent to the
Culinary Health Fund Customer Service Office )
Monday through Friday from 8am to 6pm & Saturday from 10am to 2pm
excluding national holidays
Prescriptions can be called in at 702-650-4417 or faxed to 702-369-5940.
E-prescriptions are also accepted at the Culinary Pharmacy - Please use ID 2990124.
Please visit our website at www.culinaryhealthfund.org for more information
on additional services offered at the Culinary Pharmacy.
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Provider Guide October 2012
Prescription Benefits
Generic Medications
Generics are safe, effective and FDA approved.
The Culinary Health Fund works hard to control rising prescription costs and protect our participants’
health benefits. We urge you to help by prescribing generic medications when appropriate.
Culinary Health Fund participants pay no co-pay at the Culinary Pharmacy if the generic medication is
available.
Effective July 1, 2012, Culinary Health Fund implemented a clinical prior authorization program for all Oral
Specialty Medications. Walgreens Specialty Pharmacy will fill prescriptions for the oral specialty products,
and deliver them to the plan participant preferred location. All specialty prescriptions will be limited to a
30-day supply.
Mail Service Pharmacy (Catalyst Mail)
The Culinary Health Fund offers a mail order prescription program through Catalyst Mail. Culinary Health
Fund participants can take advantage of up to a 60-day supply of their medications for only one co-pay.
A sample of the mail order form and brochure is on the website at www.culinaryhealthfund.org. To contact
Catalyst Mail directly, please call 866-834-0449.
E-Prescriptions
The Culinary Pharmacy accepts e-prescriptions. Providers can submit prescriptions electronically
to reduce the risk of medication errors due to illegible handwriting and manual data entry. Using
e-prescriptions saves you and the participant’s time by reducing the number of phone calls related to
faxes not being received by the pharmacy. Please use ID 2990124.
Formulary Advantage
Program (FAP)
The FAP is a formulary management program that
targets medications within 17 drug classes and
encourages the selection of clinically effective, lower
cost medications that support patient’s treatment
adherence by lowering out-of-pocket prescription
costs. Under this program, Culinary participants
must try a preferred alternative before a nonpreferred
brand-name medication will be covered
by their prescription drug plan under the targeted
drug classes (listed at right). For a complete list of
preferred and non-preferred medications, please
contact Catalyst Rx at 866-611-5960 or visit our
website at www.culinaryhealthfund.org.
Albuterol Inhalers
Androgens
Atypical
Antipsychotics
Blood Pressure
Fenofibrates/
Triglycerides
Growth Hormones
Drug Class
Interferons for HEPC
Intranasal Steroids
Multiple Sclerosis
Ophthalmic Prostaglandins
(Glaucoma)
Osteoporosis
Proton Pump
Inhibitors Ulcers
SSRIs/Antidepressants
Triptans
Hepatitis C Antivirals
Hypnotics/Sleep Aids
TNF Inhibitors (Rheumatoid Arthritis)
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October 2012
Provider Guide
Prescription Benefits
Medication Prior Authorization
Prior authorization is required for certain medications (see the list below). This list may be updated
from time to time. Providers may call Catalyst Rx at 866-611-5960 for updates to this list, or call
Provider Services at 702-892-7313.
Medications Requiring Prior Authorization:
• Acne Products for participants over the age of 24
• ADD/ADHD for participants over the age of 18
• Contraceptives: Authorization is required for dependent children under the age of 19.
• Growth Hormone
• Injectables except for insulin or Injectable Migraine Medications
• New Medications to the Market
• Nutritional Supplements for PKU (all other Nutritional Supplements are excluded)
• Nuvigil/Provigil
• Oral Specialty (Cancer, MS, etc.)
• Sexual Dysfunction Medications
• Singular: Participants over the age of 12 for diagnoses other than asthma
• Tazorac
• Thyrogen (all other Diagnostics/Biologicals are excluded)
• Weight Loss Medications
Narcotic Medications
The medications listed in Table A will be covered only when prescribed by a PPO physician.
Table A
Avinza Methadone MS Contin
Duragesic Methadose Opana ER
Fentanyl Lozenges Morphine Sulfate CR Opana
Fentanyl Transdermal Patches Morphine Sulfate ER Oramorph SR
Kadian
Morphine Sulfate SA
The medications listed in Table B will be covered only when prescribed by a PPO oncologist
or pain management specialist.
Table B
Oxycontin Abstral Butrans
Oxycodone ER Actiq Oxecta
Oxycodone CR Fentora Lazanda
Oxycodone SA Marinol Nucynta ER
Levorphanol Onsolis Subsys Spray
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Provider Guide October 2012
Programs
Healthy Pregnancy Program
The Culinary Health Fund’s Healthy Pregnancy Program strongly encourages
Culinary participants, their spouses and/or eligible female domestic partners
to seek prenatal healthcare within the first trimester, and to continue with
regularly scheduled antepartum visits. As a part of our efforts to promote
healthier pregnancies, a benefit payment of $100 will be paid to participants
and their managing physician who participate in the Healthy Pregnancy
Program and complete the requirements.
For physicians to receive their additional $100 reimbursement, please submit
the Healthy Pregnancy Program Certification Form located in the back of
this book or on our website at www.culinaryhealthfund.org, along with the
Culinary patients’ antepartum records and visit summary to:
1901 Las Vegas Blvd. South, Suite 107
Las Vegas, NV 89104
Fax (702) 892-7326
If you have any further questions regarding the additional reimbursement,
please contact Provider Services at 702-892-7313.
Culinary Diabetes Program
The Culinary Diabetes Program was developed to provide assistance with the
management of diabetes among Culinary Health Fund participants, spouses
and/or eligible domestic partners, and dependents.
This program offers:
• FREE meters
• FREE Diabetic Education
• FREE lancets, test strips, syringes and other diabetic supplies at the
Culinary Pharmacy.
• Insulin pumps: Required prior authorization through American Health
Holding, Inc. (AHH).
• Diabetic Shoe benefit: Eligible members can have two pairs per Calendar
• Year (January 1 – December 31) with a $55 per pair co-pay.
For a complete list of Diabetic Education classes locations, please visit the
website at www.culinaryhealthfund.org.
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October 2012
Provider Guide
Programs
Immediate Cardiac Evaluation Program (ICEP)
The Culinary Health Fund introduced a cardiology initiative that provides participants with an alternative
to waiting long hours in emergency rooms for low-level cardiac symptoms. This Program was developed
to provide physicians with the necessary resources to facilitate direct access to participating cardiology
offices for immediate evaluation of patients with cardiac symptoms.
The following is a list of cardiology offices (Immediate Cardiac Evaluation Centers, or ICEC) that have
committed to provide timely cardiac evaluations the same or next day, for your patients with chest pain,
palpitations, new onset atrial fibrillation, etc.
1) Advanced Cardiovascular Specialists
3201 S. Maryland Pkwy. #502
Contact: Myrna
Phone: 702-733-8600
Fax: 702-733-0374
2) Keith G Boman MD, FACC
601 S. Rancho Dr. #D28
Contact: Shannon
Phone: 702-383-0677
Fax: 702-383-0688
3) Siena Cardiology
2641 W. Horizon Ridge Pkwy. #120
Contact: Gerri
Phone: 702-616-0091
Fax: 702-616-2329
4) Hearth Center Of Nevada
1815 E. Lake Mead Blvd. #110
4275 S. Burnham Ave. #370
6850 N. Durango Dr. #210
700 Shadow Lane #240
866 Seven Hills Dr. #102
Contact: Jessica/Carina
(Any Issues: Susan Levine)
Phone: 702-384-0022
Fax: 702-384-0529
5) Nevada Cardiology Associates
3121 S. Maryland Pkwy. #512
3150 N. Tenaya Way #460
Contact: Petra
Phone: 702-233-4733
Fax: 702-233-1001
The Fund encourages providers to utilize the ICEP as a resource that will improve access for your patients
requiring timely cardiac evaluations and help avoid defaulting to the emergency room. If the first office
contacted is unable to accommodate your requested time/location, or should you have any addition
questions regarding this program, please contact the Provider Service Line at (702) 892-7313.
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Provider Guide October 2012
Programs
Culinary Care Assistance Program/
Harmony Healthcare
This confidential program is provided to all Culinary Health
Fund participants and their eligible dependents for FREE.
Harmony Healthcare is here to help participant address
any problem that may arise; no matter how big or small the
problem is before it gets worse.
Harmony Healthcare can help participants in areas such as:
• Marriage & Family
• Work Pressure
• Emotional Stress
• Substance Abuse
• Grief & Loss
• Gambling
• Financial Difficulties
• Crisis Intervention
Five free counseling visits are allowed per episode, per
Calendar Year (January 1- December 31) with a therapist.
Harmony Healthcare will help participants get additional
treatment if more than five counseling visits are necessary,
after which co-pay will be required.
Harmony Healthcare has a staff of Psychologists, Therapists
and Psychiatrists available to help.
Bilingual services are available, in addition to services for the
physically challenged (including visual and hearing impaired).
24 hours a day, 7 days a week services at 702-251-8000 or
800-363-4874. Counseling Services are available in English
and Spanish.
Rapid Response
The Rapid Response team is a group of licensed, trained
counselors that will promptly respond to any crisis in an
emergency room, doctor’s office, or workplace. The Rapid
Response team will provide clinical face-to-face assessments
in conjunction with the Culinary participants’ physician to
initiate required treatment 24 hours a day, 7 days a week. You
can contact Rapid Response directly at 702-788-9875.
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October 2012
Provider Guide
Programs
®
Dr. Tomorrow is an alternative emergency room or urgent care option to provide participants a phone
number to call for same or next day appointments with a primary care provider. We have partnered with
PPO providers to provide participants with appointments at the physician’s office.
Participants can contact the Dr. Tomorrow phone line 24 hours a day, 7 days a week at 702 691-5656.
Hospitalist Program for Acute Facilities
The mandatory Hospitalist Program is a team approach to inpatient healthcare, with participants’ care
managed by Culinary Health Fund UR nurses, case managers and the hospitalist plan providers. Under the
Hospitalist Program, all inpatient rounding for adult, non-obstetrical Culinary Health Fund patients will be
managed by the assigned hospitalist plan provider for the facility to which they have been admitted for
services. All acute facilities are inclusive in this program.
Admitting Primary Care Physicians (PCPs) may choose to visit their own established patients, but the
management of the case will be assigned to the designated hospitalist provider. Admitting specialists who
require internal medicine services must utilize the assigned hospitalist plan provider for each facility to
assist in the management of the participant’s inpatient care.
The following hospitalist groups are the exclusive plan providers under the Hospitalist Program:
• Pioneer Hospitalist Group (702-388-9777) – Southern Hills Hospital, Spring Valley Hospital, Sunrise
Hospital and Summerlin Hospital Medical Center
• Inpatient Consultants of Nevada-IPC (702-380-1992) – Desert Springs Hospital, North Vista Hospital, St.
Rose Hospital – Siena Campus and St. Rose – De Lima Campus
• Nevada Hospitalist Group-NHG (702-450-1717) – Centennial Hills Hospital, Mountain View Hospital and
St. Rose Hospital – San Martin Campus
• Internal Medicine Specialists of Las Vegas (702-588-7373) – Valley Hospital
• Hospitalist Management Group-HMG (702-207-8263) – University Medical Center
Radiology Management Program
Culinary Health Fund Administrative Services, LLC has implemented a Radiology Management Program
to evaluate the quality of imaging services provided within the network. Providers who offer diagnostic
services must contact Provider Services at 702-892-7313 to enroll in the program. In order to be eligible
for reimbursement for these services, you must have successfully completed the program.
Please Note: Under the Radiology Management Program, services provided by mobile imaging vendors
will not be reimbursed.
Culinary Health Fund Administrative Services, LLC
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Provider Guide October 2012
Prior Authorization/Utilization
Prior Authorization/Utilization Criteria
Services requiring prior authorization include both outpatient and inpatient services. Please refer to page
21 or the Culinary Health Fund’s website at www.culinaryhealthfund.org for a list of services that require
prior authorization. This list will be updated from time to time and it is the provider’s responsibility to
check the website for updates or contract Provider Services at 702-892-7313.
Approval does not guarantee that benefits will be paid. Payment will depend on whether the service is a
covered benefit; the service is within the scope of your Provider Agreement and whether the participant is
eligible at the time of service.
American Health Holding Inc., (AHH)
American Health Holding Inc. is the utilization/case management provider for the Culinary Health Fund.
They conduct prior authorizations, concurrent and retrospective reviews.
You may call American Health Holding authorization number at 1-866-330-2307 Monday through
Friday from 8am to 8pm EST, or you can use the online form at http://culinaryhealthfund.ahhinc.com/
to initiate a review. A staff person will record all of the demographics of the case, and if all the medical
information iIs available, the information will be given to a nurse for review.
HealthHelp
Effective August 1, 2012, the following requests will now be authorized by HealthHelp:
• Diagnostic Imaging: CT, CTA, MRI, MRA, PET and cardiac nuclear medicine scans.
• Medical Oncology treatments: chemotherapy, hormone therapy, biologics, supportive care medications.
• Radiation Oncology treatments: two-dimensional (2D) and three-dimensional (3D) conformal radiation,
intensity-modulated radiation therapy (IMRT), brachytherapy, stereotactic radiation therapy and
proton-beam procedures.
You may call the HealthHelp authorization number at 1-800-519-9935, fax the prior authorization request
to 1-800-592-9050 or you can use the website at http://www.healthhelp.com/culinary to request the
prior authorization.
These changes will NOT affect emergency department (ED) services or radiology services ordered while a
member is hospitalized.
Behavioral Health Authorization
All behavioral health, mental health, and chemical dependency services require prior authorization through
Harmony Healthcare at 702-251-8000 or 800-363-4874. Harmony Healthcare is available 24 hours a day, 7
days a week..
Medication Authorization
Catalyst Rx performs drug authorizations for specific medications. This list may be updated from time to
time. It is the provider’s responsibility to contact Catalyst Rx at 866-611-5960 for updates.
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October 2012
Provider Guide
Prior Authorization/Utilization
Services Requiring Prior Authorization:
HIGH TECH DIAGNOSTIC SERVICE REVIEW
OB Ultrasounds
All MRI/MRAs
All CT/CTA Scans
Fetal Biophysical Profiles
All PET Scans & cardiac nuclear medicine scans
Sleep Screenings through Bennett Medical Services
Sleep Studies (must be ordered by a Neurologist,
Pulmonologist or ENT)
Discography
MEDICAL / RADIATION ONCOLOGY TREATMENTS
Chemotherapy Intensity-modulated radiation therapy (IMRT)
Hormone Therapy
Brachytherapy
Biologics
Stereotactic radiation therapy & proton-beam procedures
Supportive care medications related to a cancer
diagnosis
AMBULATORY SURGERY REVIEW
Blepharoplasty
Varicose Vein Stripping/Ligation
Orthotripsy for Plantar Fasciitis
Surgical Treatment of Sleep Apnea
Two-dimensional (2D)/three-dimensional (3D) conformal
radiation
Septoplasty
Breast Reduction
Ventral Hernia Repair > 18 years
Orthoses (or Orthotics)
ADDITIONAL SERVICES REQUIRING PRIOR AUTHORIZATION
All hospital admissions including elective admissions
and those resulting from ER or observation stay
All TMJ procedures
Skilled Nursing Facility
Inpatient Rehabilitation
Long Term Acute Care
Insulin Pumps
All Hysterectomies (Inpatient or Outpatient)
Custom Compression Stockings
Cochlear Implants
Mandibular/Oral/Orthognathic Surgery
Gastric Neurostimulators
Durable Medical Equipment items that are over $500
(whether it is rental or purchase to include oxygen
equipment over $500, i.e. oxygen concentrators)
Dialysis
Home Health and Infusion Therapy
Orthoses (or Orthotics)
Prosthetic Appliances
Outpatient Chemo/Radiation Therapy
Back Surgeries (Inpatient or Outpatient Services)
Genetic Testing
Implantable Hormone Therapy
Stereotactic Radiosurgery
EECP
Skin Substitutes/ Grafts
Please Note: Services requiring prior authorization include outpatient and inpatient services. As of this printing,
the services listed above require prior authorization. This list may be updated from time to time. It is the provider’s
responsibility to check for updates. If the procedure billed is not the procedure approved by American Health
Holding, Inc or HealthHelp, there may be no payment and the patient is not liable. Please call American Health
Holding, Inc at 866-330-2307 or HealthHelp at (800) 519-9935 for more information.
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Provider Guide October 2012
Claims Processing Guidelines
The Culinary Health Fund uses a Third Party Administrator, Zenith
American Solutions to process all claims.
Claims Submission
The Culinary Health Fund accepts claims via electronic submission.
Providers interested in submitting claims electronically should
contact one of the following clearinghouses to set up an account:
Capario (ProxyMed) 800-586-6938
The SSI Group, Inc. 800-880-3032
HCRNet 702-735-5525
Emdeon 800-845-6592
Our Electronic ID is 59140
Paper claims should be submitted to:
Zenith American Solutions
P.O. Box 94469
Seattle WA 98124
All claims submitted to Zenith American Solutions go through
an Optical Character Recognition process, which turns the paper
claim into a scanned image. This process allows Zenith American
Solutions to process claims faster. In order to ensure that this
process can take place, please be sure to follow the guidelines
below:
• Claims submitted should be the finest quality, using the
standardized Red CMS 1500 (08/05) forms.
• All information should be typed, as handwritten forms cannot be
Scanned into this system.
• The ink should be dark (if it is too light it will not be processed).
Information must be properly aligned on the claims form.
Electronic Funds Transfer
The Culinary Health Fund has teamed up with Pay Span Health and offers the providers Electronic Fund
Transfers (EFTs). This service enables online presentation of Explanation of Payment (EOP), direct deposit
into a designated bank account and straightforward reconciliation of payments to empower our providers
to reduce costs, speed secondary billings, improve cash flow and help the environment by reducing paper
usage.
To find out more information on how to become registered for this new service, please contact
Pay Span Health at 877-331-7154.
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October 2012
Provider Guide
Claims Processing Guidelines
Allowable Requests
Requests for allowables should be faxed to Provider Services at 702-892-7326.
Providers may also refer to the reimbursement page of their current provider agreement to obtain
payment methodology for reimbursement rates.
Timely Filing
There is a 90-day filing limit to submit new claims to the Culinary Health Fund. It is the provider’s
responsibility to ensure claims are received within the 90-day filing limit. Secondary claims must be
submitted within 90 days of the primary EOB.
Claims Status
Please allow at least 30 days from the date of submission before inquiring about claims status. Claims
status can be checked on the Culinary Health Fund’s website at www.culinaryhealthfund.org, or by utilizing
the IVR telephone system at 702-733-9938, option 1, or by contacting the Customer Service Office at
702-733-9938.
• From time to time, claims are pended for additional information such as accident/injury inquiries and
coordination of benefit information. In these cases, in order to ensure claims are not delayed, it is
important to send any relevant information regarding the claim, such as the chart notes or injury forms.
• Injury/subrogation and coordination of benefit forms can be requested from the Customer Service
Office at 702-733-9938 or printed from our website at www.culinaryhealthfund.org.
Provider Reconsiderations
In an effort to expedite the administrative process for providers seeking to appeal a decision on a claim,
the Culinary Health Fund has established a Provider Reconsiderations Department. You may contact
Provider Reconsiderations at 702-691-5625 / FAX: 702-216-9525 or mail your reconsiderations directly to
the following address:
Provider Reconsiderations
Culinary Health Fund
P. O. Box 44216
Las Vegas, NV 89116
To submit a corrected claim, please clearly indicate on the claim that it is a corrected claim. This will
avoid the claim being denied as a duplicate. If you feel the claim was submitted correctly and you wish to
appeal, please send a copy of the EOB and an appeal letter, or a Provider Reconsiderations Form. You can
find a copy of the Provider Reconsiderations Form in the back of this guide or on our website at
www.culinaryhealthfund.org. Please allow 60 days from date of submission for review.
Please Note: First level provider reconsiderations must be received within 180 days of the date on the
initial explanation of payment. Second level reconsiderations must be received within 30 days of the
processing date of the first level appeal, which can be found on the explanation of payment.
Culinary Health Fund Administrative Services, LLC
23

Provider Guide October 2012
Claims Processing Guidelines
TEXT
Box 1a
Should
always have
the Culinary
participant’s ID
number
Box 10
Should have
sections a, b
and c filled in
Box 33
Should list
the provider’s
billing address,
especially if
different from
the service
address
Box 31
Should have
provider’s
name listed
24 Culinary Health Fund Administrative Services, LLC

October 2012
Provider Guide
Contract Information
All Primary Care Physicians (PCPs) and specialty physician groups are contracted directly with Culinary
Health Fund Administrative Services, LLC. Please contact Provider Services at 702-892-7313, option 1 with
any questions regarding a physician/group provider contract. Forms in the back of this book have been
provided to assist in requesting a new contract, updating your practice information or requesting contract
allowables. You may also find printable forms on our website at www.culinaryhealthfund.org.
Ancillary providers are those providers of services such as skilled nursing, home health, durable medical
equipment, outpatient rehabilitation, as well as facility-based services such as ambulatory surgery, dialysis,
laboratory and diagnostic testing. Please contact Provider Services at 702-892-7313, option 3, with any
questions regarding your ancillary contract.
Remember the following requirements per your agreement with the Culinary Health Fund:
• Referrals: Participants and their eligible dependents must be referred to Culinary PPO providers.
The referring physician will be financially responsible for referrals to non-PPO providers when a PPO
Provider is available.
• Co-pays/Coinsurance/Deductibles: Culinary participants are responsible only for applicable co-pays,
coinsurance, and/or deductibles for covered services. All other charges for covered services are not the
responsibility of the participant, and the participant cannot be balanced-billed.
• Prior Authorization: The provider is responsible for obtaining prior authorization from American Health
Holding, Inc. (AHH), for all services that require prior authorization, including, but not limited to:
1) Non-emergency inpatient services.
2) Outpatient covered services.
3) All referrals to non-PPO providers.
4) Outpatient chemo/radiation therapy.
• HealthHelp: Effective August 1, 2012, the following requests will now be authorized by HealthHelp:
• Diagnostic Imaging: CT, CTA, MRI, MRA, PET and cardiac nuclear medicine scans.
• Medical Oncology treatments: Chemotherapy, hormone therapy, biologics, supportive care
medications related to a cancer diagnosis.
• Radiation Oncology treatments: two-dimensional (2D) and three-dimensional (3D) conformal
radiation, intensity-modulated radiation therapy (IMRT), brachytherapy, stereotactic radiation therapy
and proton-beam procedures.
• Out of Area: Before referring a patient out of the area for any specialized services, please contact
American Health Holding, Inc. (AHH) at 866-330-2307. New technologies and services are evolving
all the time and we at the Culinary Health Fund want to assist you with the proper access for these
services.
Culinary Health Fund Administrative Services, LLC
25

Provider Guide October 2012
Credentialing
The purposes of credentialing and recredentialing is to review and validate a practitioners’ qualifications to
provide health care services for Culinary Health Fund participants. This process ensures that practitioners’
are credentialed and recredentialed consistently and in a non-discriminatory manner, in compliance with
accrediting bodies, state and federals laws, rules and regulations.
All providers must successfully complete our credentialing process prior to being added to our provider
network. Once a provider has been added to the network, recredentialing is generally conducted every
three years to assess and validate the practioner’s qualifications.
The Culinary Health Fund Administrative Services, LLC uses the state of Nevada mandated credentialing
and recredentialing applications which can be found on the website at www.culinaryhealthfund.org. All
elements in the application must be completed and/or acknowledged. If you feel a section does not apply,
you must insert “N/A”, as no section can be left blank. For your convenience, if you have an up-to-date
state of Nevada application already completed, you may re-sign and re-date that application and submit
it to the Culinary Health Fund Administrative Services, LLC, in-lieu of completing the new one we have
provided to you.
Copies of the following items must also be returned with your completed application:
1) Current license to practice
2) Certificate of Insurance (Malpractice Face Sheet)
3) DEA Registration (or Prescription Plan Designation) and CDS certificate, when applicable
4) Health Status Form and/or Designation of Credentialing Agent Form, as applicable
Please return your completed application along with all other materials to the Culinary Health Fund
Administrative Services, LLC at:
Culinary Health Fund Administrative Services, LLC
Attn: Credentialing Department
1901 Las Vegas Blvd. South, Suite 101
Las Vegas, NV 89104
Or, for more timely processing you may fax your application to:
FAX: 702-892-7365
(Please always keep a copy of all the information you submit to us for review.)
If you have any questions or concerns regarding the credentialing process, please contact Provider
Services at 702-892-7313, option 1.
26 Culinary Health Fund Administrative Services, LLC

October 2012
Provider Guide
Resources
TEXT
Website
Some information can be accessed on the Culinary Health Fund’s website at www.culinaryhealthfund.org.
Some services on the website require registration with a username and password. Simply click on
“Provider log-in and sign-up” and follow the prompts to establish an account.
• Claim status can be checked online with a username and password. By using the participant’s ID
number and the date of service, it can be determined whether the claim has been paid, pended, or
denied. Please allow at least 30 days from the date of submission before checking claims status. You
can also view benefit information and updates online.
• Online Provider Directory: The online Provider Directory is updated weekly. Use this directory
when referring to participants and their eligible dependents to specialists or to verify that practice
information is correct. If practice information is incorrect, please contact Provider Services at
702-892-7313.
• Participant eligibility can also be checked online with a username and password. The website is secure,
and all participant and provider information is confidential. In most cases eligibility is given for a 2
month period.
• Provider updates are also available on the website. Communication sent to the network regarding
updates to policies and/or procedures will be posted online for your reference.
Please Note: Only one password is issued for all practices, even those with more than one office location.
If you become locked out or need a new password, please contact your office account administrator.
Fast and easy to use.
Don’t have time to hold?
www.culinaryhealthfund.org
Visit our website 24 hours a day, 7 days a week to find
all the updated information you need under our provider section.
Culinary Health Fund Administrative Services, LLC
27

Provider Guide October 2012
Resources
IVR
IVR, the Culinary Health Fund’s automated telephone system, can be used to check participant eligibility
and claims status.
• Call 702-733-9938 and select option 1.
• Services are available 24 hours a day, 7 days a week.
• In most cases eligibility is given for a 2-month period.
Vision IVR
This is a dedicated IVR for ophthalmology and optometry providers, and can be used to check participant
eligibility and hardware benefits status.
• Call 702-216-1298.
• Services are available 24 hours a day, 7 days a week.
• In most cases eligibility is given for a 2-month period.
Customer Service Office
The Culinary Health Fund’s Customer Service Office can be reached Monday through Friday from
8am to 6pm at 702-733-9938 to answer any questions you may have.
Provider Services
To reach Provider Services, please call 702-892-7313 or fax 702-892-7326.
Provider Reconsiderations
To reach Provider Reconsiderations, please call 702-691-5625 or fax 702-216-9525.
28 Culinary Health Fund Administrative Services, LLC

October 2012
Provider Guide
Information Update
Providers
Changes in address and/or contact information can be submitted using the Provider Address Information
Form, located in the back of this book or on the website.
When a new provider is added to a practice, Culinary Health Fund Administrative Services, LLC must be
notified immediately so that credentialing can be completed.
Please Note: Providers must pass credentialing and receive an effective date under the current provider
agreement in order to see Culinary patients as a PPO provider. Some updates, including staff changes
within a practice, may require additional information (i.e. a credentialing application). Culinary Health Fund
Administrative Services, LLC will notify you once the physician is credentialed and when they will become
a PPO provider with the Culinary Network. Information on the addition of providers to your practice can
be submitted on our Group Add Request Form, located in the back of this book or on our website. Please
complete the form and submit to the fax number listed on the form.
Please remember that a provider should not see Culinary participants until they have been credentialed
and added to your provider agreement.
Additionally, if a provider leaves a practice, this information should be communicated to us in writing.
Letters can be faxed to the attention of Provider Services at 702-892-7365.
Practice information can be verified by contacting Provider Services at 702-892-7313 or by checking the
online Provider Directory at www.culinaryhealthfund.org.
Ancillary Providers
Keep information up to date by submitting any changes in names, facility locations, phone numbers, and
tax identification numbers to Culinary Health Fund Provider Services at the address listed below:
Culinary Health Fund
Attn: Provider Services
1901 Las Vegas Blvd. South, Suite 101
Las Vegas, NV 89104
Phone: 702-892-7313
Fax: 702-892-7365
Information regarding a facility can be verified by checking the online Provider Directory at
www.culinaryhealthfund.org or by contacting the Culinary Health Fund’s Customer Service Office at
702-733-9938.
Culinary Health Fund Administrative Services, LLC
29

Provider Guide October 2012
Frequently Asked Questions
Q: Does the Culinary Health Fund reimburse for mobile imaging services?
AA:
The Culinary Health Fund does not reimburse for mobile imaging services. In order to provide
imaging services to Culinary participants, providers must successfully complete the Radiology
Management Program referenced on page 22.
Q: What are Culinary Health Fund Administrative Services, LLC guidelines for
office visit re-coding?
AA:
The Culinary Health Fund payment guidelines follow national coding standards when re-coding.
PCP providers and designated specialties who submit elevated E&M codes will be required to
submit medical records to support the level of care. Claims that are submitted with elevated E&M
codes without medical records will be denied with a request for supporting documentation. The
Fund has established criteria to identify providers with low instances of re-coding. Providers can
be waived from this process once the established criteria is met.
Q: What are the age limits for screening mammograms?
AA:
One baseline mammogram is covered for participants between the ages of 35-39, followed by
yearly mammograms for women ages 40 and over.
Q: What are the timelines and limitations on adult and pediatric well care visits?
A:
Adults: One preventative routine physical exam is covered every 12 months.
Children: Exams are covered in accordance with the guidelines of the American Academy
of Pediatrics.
Q: What are the time frames for claims processing?
AA:
Clean claims are normally processed within 30 working days of receipt.
Claims requiring additional information may take longer to resolve.
Q: What is the process for appealing a claim decision?
AA:
Please submit a copy of the EOB and a letter outlining the basis for your reconsideration request
to:
Provider Reconsiderations, Culinary Health Fund, P.O. Box 44216, Las Vegas, NV 89116
Please allow 60 days from the date of submission for review. You may contact Provider
Reconsiderations at 702-691-5625 or fax 702-216-9525.
30 Culinary Health Fund Administrative Services, LLC

October 2012
Provider Guide
Frequently Asked Questions
Q: How are assistant surgeons reimbursed?
AA:
Assistant surgeons are reimbursed at 16% of the surgical allowable. If the assistant surgeon is a
physician’s assistant, the reimbursement is 14% of the surgical allowable (80% of the 16% for a
medical doctor).
Q: What is Culinary Health Fund Administrative Services, LLC policy on
Physician Extenders?
AA:
All Physician Assistants (PA/PAC) and Advanced Practice Nurses (APN), including Certified Nurse
Midwives (CNM), Clinical Nurse Specialists (CNS) and Certified Registered Nurse Anesthetists
(CRNA) must successfully complete credentialing. In addition, these providers must be added
under the Culinary Preferred Provider Agreement in order for claims submitted under their name
to be processed and paid at PPO rates.
Q: How does Culinary Health Fund reimburse for immunization
administrations?
AA:
The Culinary Health Fund does not recognize CPT codes 90460 and 90461 and requires that
providers use CPT codes 90471 – 90474 for immunization administration reimbursement.
Q: What immunizations are covered by the Culinary Health Fund?
AA:
A list of immunizations that are covered by the Culinary Health Fund and the corresponding
allowables are listed below. The Culinary Health Fund establishes reimbursement for
immunizations based on Center for Disease Control (CDC) allowables. If your office participates
in the Delegation of Authority Program offered by the Nevada State Health Division you may
choose to administer vaccines that do not have allowables set by the Culinary Health Fund in
your office. Administration codes will be reimbursable on all currently recommended childhood
immunizations; however, the Culinary Health Fund has only set allowables for the vaccinations
outlined below.
Vaccine
Allowable
Hepatitis A $35.00
Hepatitis A $61.01
HPV (Quadrivalent) Female &
Male
$130.00
HPV (Bivalent) $128.25
Pneumococcal (7 valent) $83.88
Pneumococcal (13 valent) $120.95
Rotavirus (Rotateq) $73.00
Rotarix $106.57
Meningococcal $106.49
If your office does not participate in the Delegation of Authority Program, you can refer your
patients to the Southern Nevada Health District for all their immunizations. Please call Southern
Nevada Health District at 702-759-0850 for hours and locations.
Culinary Health Fund Administrative Services, LLC
31

Provider Guide October 2012
Frequently Asked Questions
Q: If Culinary is the secondary payor on a claim, what is the timely filing
deadline for the secondary claims submission?
AA:
If Culinary is the secondary payor, claims must be received within 90 days of the date on
the explanation of payment from the primary payor.
Q: What services are included in a routine vision exam and what is the
co-pay?
AA:
The participant is responsible for $20 co-pay for a routine vision exam. A routine vision
exam includes tests and procedures related to case history, eye muscle, visual acuity, eye
health, refraction and disposition. Contact lens fittings are eligible for reimbursement in
addition to a routine vision exam or on a separate date of service.
Please Note: Participants receiving contact lens fittings during a routine vision exam will
not be responsible for any additional co-pays.
Q: How do I add a new provider to our group?
AA:
Please fill out a Group Add Request Form (copy in the back of this book) and mail to:
1901 Las Vegas Blvd. South, Suite 101, Las Vegas, NV 89104
or via fax to 702-892-7365
Q: How do I appeal a timely filing denial?
AA:
Please submit a copy of the EOB and proof of timely filing to:
Provider Reconsiderations, Culinary Health Fund, P.O. Box 44216, Las Vegas, NV 89116
Proof of timely filing should include a screen print or electronic transmission receipt that
clearly shows the date of submission and payor name that the claim was submitted to.
Q: I have a patient that I would like to send to a specialist outside of Las
Vegas. What is your process for this type of referral?
AA:
If you have a Culinary Health Fund participant who requires services that cannot be
performed in Las Vegas, please contact American Health Holding, Inc. (AHH) either via
telephone at 866-330-2307 or the website at http://culinaryhealthfund.ahhinc.com to
initiate a pre-certification. The request will be assigned to a nurse for review. Please be
prepared to supply information as to why the services cannot be performed by an
in-network provider within the Las Vegas area.
Please Note: Pre-Certification is required for services to be performed at UCLA.
Q: I have patients that need diagnostic imaging services; do I still contact
AHH to obtain prior authorization
AA:
No, effective August 1, 2012, HealthHelp is the Utilization Review vendor for diagnostic
imaging services.
They can be reached by phone at 800-519-9935, by fax at 800-592-9050 or by the web at
www.healthhelp.com/culinary
32 Culinary Health Fund Administrative Services, LLC

October 2012
Provider Guide
Frequently Asked Questions
Q: I am a primary care provider. How does the Hospitalist Program affect me?
AA:
The Fund’s Hospitalist Program was established to promote a team approach to Culinary
participants’ care while in an acute hospital setting. As such, the Fund requires all
admissions be assigned to a hospitalist plan provider for continuity of care. In support
of this goal, the Fund encourages primary care physicians to remain engaged and
informed about their patients’ care while in an inpatient setting. If you choose to visit your
established patients in the hospital, please submit CPT code 99231 for reimbursement.
Please Note: Obstetrical and pediatric patients are excluded from the Hospitalist Program.
If there is concern with a hospitalist provider, or the care your patients are receiving, please
contact Provider Services at 702-892-7313 and a call with the Fund Medical Director will be
coordinated.
Below is the list of hospitalist groups that are under the Culinary Health Fund Hospitalist
Program:
• Pioneer Hospitalist Group (702-388-9777) - Southern Hills Hospital, Spring Valley
Hospital, Sunrise Hospital and Summerlin Hospital Medical Center
• Inpatient Consultants of Nevada-IPC (702-380-1992) - Desert Springs Hospital, North
Vista Hospital, St. Rose Hospital – Siena Campus and St. Rose – De Lima Campus
• Nevada Hospitalist Group-NHG (702-450-1717) – Centennial Hills Hospital, Mountain
View Hospital and St. Rose Hospital – San Martín Campus
• Internal Medicine Specialists of Las Vegas (702-588-7373) -Valley Hospital
• Hospitalist Management Group-HMG (702-207-8263) - University Medical Center
Q: We have moved our office to a new location. How do we notify you?
AA:
Please fill out a Provider Address Form (copy in the back of this book) and mail to:
1901 Las Vegas Blvd. South, Suite 101, Las Vegas, NV 89104
or via fax to 702-892-7365
Q: Why are my radiology claims being denied?
AA:
The Culinary Health Fund requires all providers that perform imaging services in their office
to enroll in our mandatory Radiology Management Program. In order to be eligible for
reimbursement for these services, you must have successfully completed this program. For
questions regarding participation in this program, please contact Provider Services at
702-892-7313.
Q: How do I know what diagnostic/radiology imaging services needs to be
authorized?
AA:
A complete list of procedures with CPT codes can be found on HealthHelp website.
Culinary Health Fund Administrative Services, LLC
33

CULINARY HEALTH FUND ADMINISTRATIVE SERVICES LLC
PROVIDER ADDRESS INFORMATION
TAX IDENTIFICATION NUMBER:
SITE LOCATION ADDRESS:
[3] ADDRESS
PRACTICE NAME: CORRESPONDENCE MAILING ADDRESS: [1] ADDRESS
ADDRESS PHONE CONTACT/E-MAIL
PHONE FAX
CONTACT/E-MAIL FAX BILLING ADDRESS:
ADDRESS [2] ADDRESS
PHONE CONTACT/E-MAIL
PHONE FAX
CONTACT/E-MAIL FAX CREDENTIALING ADDRESS:
ADDRESS PHONE FAX PHONE CONTACT/E-MAIL
FAX
please attach If more than 3 sites complete roster including site/providers.
CONTACT/E-MAIL  Site roster attached.
Effective Date:_____________________________________
PROVIDER NAME SPECIALTY LOCATION NO. Ex.: [2] or all.
If more providers please attach complete roster including site/providers.  Site roster attached
Culinary Health Fund
1901 Las Vegas Blvd. South, Suite 101
Las Vegas, Nevada 89104
Or
Via Fax at: 702-735-1649
PPO Quick Guide
Important Telephone Numbers
Culinary Health Fund www.culinaryhealthfund.org
Customer Service Office 702-733-9938
Mon-Fri 8am to 6pm
Provider Services 702-892-7313
Culinary Pharmacy 702-650-4417
Case Management 702-892-7313, #4
Provider Reconsiderations 702-691-5625
American Health Holding, Inc. (AHH)
www.americanhealthholding.com
Mon - Fri, 7:30am to 8pm EST 866-330-2307
HealthHelp
www.healthhelp.com/culinary
Mon - Fri, 7am to 7pm CST
Diagnostic Imaging:
• CT, CTA, MRI, MRA, PET and cardiac nuclear medicine
scans.
Medical Oncology Treatments:
• Chemotherapy, hormone therapy, biologics, supportive
care medications related to a cancer diagnosis.
Radiation Oncology Treatments:
• Two-dimensional (2D) and three-dimensional (3D)
conformal radiation, intensity-modulated radiation
therapy (IMRT), brachytherapy, stereotactic radiation
therapy and proton-beam procedures.
Phone: 800-519-9935 /Fax: 800-592-9050
Harmony Healthcare www.harmonyhc.com
Behavioral Health Benefits, including:
• Addiction Treatment • Grief and Loss Counseling
• Marriage & Family
• Crisis Intervention
Counseling
24 hours a day/7 days a week 702-251-8000
Rapid Response 702-788-9875
Catalyst Rx Prescription Services
www.catalystrx.com
Prescription Benefits and Drug Prior Authorization
24 hours a day/ 7 days a week 866-611-5960
Catalyst Mail Order 866-834-0449
LabCorp
www.labcorp.com
Test Results, Ordering Supplies, Customer Service
24 hours a day/ 7 days a week 888-522-2677
Quest Diagnostics www.questdiagnostics.com
Test Results, Ordering Supplies, Customer Service
24 hours a day/ 7 days a week 888-522-2677
Clinical Pathology Laboratories (CPL)
www.cpllabs.com 800-595-1275
SERVICE DESCRIPTION
CO-PAYS
Urgent Care Visit
Primary Office Visit
Specialist Office Visit
Chiropractic Office Visit
Injections
Allergy Testing
IV Treatment
Pulmonary Treatment
X-ray
Lab (*Only if tests are processed
at contracted lab facilities)
All other Physician Office procedures:
Examples: Chemotherapy,
Radiation Therapy
$20 per visit
$14 per visit
Cooperative Association of Chiropractic Physicians (CACP)
Mon- Fri, 8:30am to 5pm 702-365-5981
Nevada Dental Benefits
Mon – Fri, 8am to 5:30pm 702-478-2014
Administrative Services, LLC
Vision Eligibility Express Line
24 hours a day / 7 days a week 702-216-1298 Culinary Health Fund - Revised October 2012
(Replaces Quick Guide dated July 2011)
HIGH TECH DIAGNOSTIC SERVICE REVIEW
$20 per visit
OB Ultrasounds Fetal Biophysical Profiles
All MRI/MRAs All PET Scans & cardiac nuclear medicine scans
All CT/CTA Scans Sleep Screenings through Bennett Medical Services
Sleep Studies (must be ordered by a Neurologist,
Discography
Pulmonologist or ENT)
$14 per visit
$6 per procedure
$7 per test type
$7 per visit
MEDICAL / RADIATION ONCOLOGY TREATMENTS
$5 per procedure
Chemotherapy Intensity-modulated radiation therapy (IMRT)
$12 per procedure
Hormone Therapy Brachytherapy
Biologics Stereotactic radiation therapy & proton-beam procedures
$5 per visit
$7 per visit
Tier 1 - Generic $5
Tier 2 - Formulary Drugs $15
Tier 3 - Non-Formulary Drugs $25
True Emergency Visit
Inpatient Hospital
MRI - Outpatient Services
CAT Scan - Outpatient Services
PET Scan - Outpatient Services
Ambulatory Surgery - Outpatient
Services
Outpatient Hospital Services:
Examples: Chemotherapy,
Sleep Studies
Compression Stockings
Orthotic Shoe Insert
Diabetic Shoes
Mastectomy Bra
Supportive care medications related to a cancer diagnosis Two-dimensional (2D)/three-dimensional (3D) conformal radiation
AMBULATORY SURGERY REVIEW
Services Requiring Prior Authorization:
Blepharoplasty Septoplasty
Varicose Vein Stripping/Ligation Breast Reduction
$150 per visit
$250 deductible
$55 per visit
$55 per visit
$155 per visit
$77 per visit
$75 deductible with a
20% coinsurance
5 pairs per Calendar
Year with $22 per
pair copay
3 pairs per lifetime
with $10 per pair
copay
2 pairs per Calendar
Year with $55 per
pair copay
$12 per item
PPO Quick
Orthotripsy for Plantar Fasciitis Ventral Hernia Repair > 18 years
Surgical Treatment of Sleep Apnea Orthoses (or Orthotics)
Durable Medical Equipment items that are over $500 (whether it is
All hospital admissions including elective admissions and those
rental or purchase to include oxygen equipment over $500, i.e. oxygen
resulting from ER or observation stay
concentrators)
ADDITIONAL SERVICES REQUIRING PRIOR AUTHORIZATION
All TMJ procedures Dialysis
Skilled Nursing Facility Home Health and Infusion Therapy
Inpatient Rehabilitation Orthoses (or Orthotics)
Long Term Acute Care Prosthetic Appliances
Insulin Pumps Outpatient Chemo/Radiation Therapy
All Hysterectomies (Inpatient or Outpatient) Back Surgeries (Inpatient or Outpatient Services)
Custom Compression Stockings Genetic Testing
Cochlear Implants Implantable Hormone Therapy
Mandibular/Oral/Orthognathic Surgery Stereotactic Radiosurgery
Gastric Neurostimulators EECP
Skin Substitutes/ Grafts
Please Note: Services requiring prior authorization include outpatient and inpatient services. As of this printing, the services listed above re
prior authorization. This list may be updated from time to time. It is the provider’s responsibility to check for updates. If the procedure bi
not the procedure approved by American Health Holding, Inc or HealthHelp, there may be no payment and the patient is not liable. Plea
American Health Holding, Inc at 866-330-2307 or HealthHelp at (800) 519-9935 for more information.
Culinary Pharmacy
• There are more than 300 drugs, including most diabetic and several over-the-counter medications, available at the Culinary Health Fu
Pharmacy, which are FREE to all Culinary participants. Prescriptions can be called in at: 702-650-4417 or faxed to 702-369-5940.
Don’t forget! The Culinary Pharmacy is accepting E-prescriptions! The ID code is: 2990124
Please call the Customer Service Office to request an updated Culinary Pharmacy List or visit our website at www.culinaryhealthfu
Diabetes Program offered to your Culinary Patients
• Free Diabetic Educations! Please call our Provider Services at 702-892-7313 or go to our website at www.culinaryhealthfund.org f
locations.
• Free Diabetic Meters
• Most diabetic medications are available at the Culinary Pharmacy. Please call the Culinary Pharmacy at 702-650-4417 for more
Eligibility and Claims:
• To verify your Culinary patient’s eligibility, please call the Customer Service Office at 702-733-9938, then press 1 for the autom
verification and claims status telephone line.
• The Customer Service Office is open Mon - Fri from 7:30am to 6pm and the telephone line is available Mon - Fri from 8am to
You can mail claims to:
You can mail provider appeals to:
P.O Box 94469
Provider Reconsiderations
Seattle, WA 98124
P.O Box 42216
EDI Payor ID# 59140
Las Vegas, NV 89116
For more Benefit Information and Updates, visit the website at www.culinaryhealthfund.
This is only a guide to Culinary PPO participant benefits and does not provide you with all of the benefits available through t
For further information about other available programs and benefits, please call Culinary Health Fund Customer Service Offi
Guide & Forms
1901 Las Vegas Blvd. So.
Suite 101
Las Vegas, Nevada 89104-1309
(702) 892-7313
www.culinaryhealthfund.org
ALLOWABLE AMOUNT REQUEST FORM
Section
Provider Name TIN
Please enter CPT procedure codes in each cell and fax your request to Provider Services
(702) 892-7326. Please include your contact information and fax number on the cover
page.
GROUP ADD REQUEST
Name of Group:
Tax ID #
Name of Provider
being added:
Specialty of Provider
being added:
Effective Date:
Hospital-Based
Provider? (Please
circle one) Yes No
Practice Location(s)
(attach separate
Sheet if necessary)
Contact Name:
Phone:
1901 Las Vegas Blvd. So.
Suite 101
Las Vegas, Nevada 89104-1309
(702) 892-7313
www.culinaryhealthfund.org
Culinary Health Fund
Healthy Pregnancy Program Certification
To ensure proper reimbursement, please submit this certificate
and patient’s antepartum records with your billing to:
UNITE HERE HEALTH
ATTN: Claims Payment
1901 Las Vegas Blvd. South, Suite 107
Las Vegas, NV 89104
702-733-993
Fax: 702-892-7326
NOTE: Antepartum records must be attached.
NAME OF ELIGIBLE EMPLOYEE: SS#:
NAME OF MOTHER (if different): SS#:
ADDRESS (Street, City, State, Zip):
DATE OF DELIVERY:
I certify that this patient: Did Did Not Complete all recommended ante partum care during her
pregnancy.
MD NAME: T.I.N:
SIGNATURE: DATE:
Fax:
The allowables requested are not a guarantee of payment. Provider shall be reimbursed
according to the terms of their contract. Any reimbursement shall be subject to applicable
modifier reductions, co-pays, deductibles, co-insurance, plan limitations, exclusions and
nationally accepted coding initiatives.
Email:
Please fax back to: 702-892-7365 Attention: Jessica Wesley
Or e-mail to jwesley@culinaryhealthfund.org

Provider Guide October 2012
PPO Quick Guide
Important Telephone Numbers
Culinary Health Fund www.culinaryhealthfund.org
Customer Service Office 702-733-9938
Mon-Fri 8am to 6pm
Provider Services 702-892-7313
Culinary Pharmacy 702-650-4417
Case Management 702-892-7313, #4
Provider Reconsiderations 702-691-5625
American Health Holding, Inc. (AHH)
www.americanhealthholding.com
Mon - Fri, 7:30am to 8pm EST 866-330-2307
HealthHelp
www.healthhelp.com/culinary
Mon - Fri, 7am to 7pm CST
Diagnostic Imaging:
• CT, CTA, MRI, MRA, PET and cardiac nuclear medicine
scans.
Medical Oncology Treatments:
• Chemotherapy, hormone therapy, biologics, supportive
care medications related to a cancer diagnosis.
Radiation Oncology Treatments:
• Two-dimensional (2D) and three-dimensional (3D)
conformal radiation, intensity-modulated radiation
therapy (IMRT), brachytherapy, stereotactic radiation
therapy and proton-beam procedures.
Phone: 800-519-9935 /Fax: 800-592-9050
Harmony Healthcare www.harmonyhc.com
Behavioral Health Benefits, including:
• Addiction Treatment
• Marriage & Family
• Grief and Loss Counseling
• Crisis Intervention
Counseling
24 hours a day/7 days a week 702-251-8000
Rapid Response 702-788-9875
Catalyst Rx Prescription Services
www.catalystrx.com
Prescription Benefits and Drug Prior Authorization
24 hours a day/ 7 days a week 866-611-5960
Catalyst Mail Order 866-834-0449
LabCorp
www.labcorp.com
Test Results, Ordering Supplies, Customer Service
24 hours a day/ 7 days a week 888-522-2677
Quest Diagnostics www.questdiagnostics.com
Test Results, Ordering Supplies, Customer Service
24 hours a day/ 7 days a week 888-522-2677
800-433-2750
Clinical Pathology Laboratories (CPL)
www.cpllabs.com 800-595-1275
Cooperative Association of Chiropractic Physicians (CACP)
Mon- Fri, 8:30am to 5pm 702-365-5981
Nevada Dental Benefits
Mon – Fri, 8am to 5:30pm 702-478-2014
Administrative Services, LLC
Vision Eligibility Express Line
24 hours a day / 7 days a week 702-216-1298 Culinary Health Fund - Revised October 2012
(Replaces Quick Guide dated July 2011)
36 Culinary Health Fund Administrative Services, LLC
SERVICE DESCRIPTION
Urgent Care Visit
Primary Office Visit
Specialist Office Visit
Chiropractic Office Visit
Injections
Allergy Testing
IV Treatment
Pulmonary Treatment
X-ray
Lab (*Only if tests are processed
at contracted lab facilities)
CO-PAYS
$20 per visit
$14 per visit
$20 per visit
$14 per visit
$6 per procedure
$7 per test type
$7 per visit
$5 per procedure
$12 per procedure
$5 per visit
All other Physician Office procedures:
Examples: Chemotherapy,
$7 per visit
Radiation Therapy
Tier 1 - Generic $5
Tier 2 - Formulary Drugs $15
Tier 3 - Non-Formulary Drugs $25
True Emergency Visit
$150 per visit
Inpatient Hospital
$250 deductible
MRI - Outpatient Services
$55 per visit
CAT Scan - Outpatient Services
$55 per visit
PET Scan - Outpatient Services
$155 per visit
Ambulatory Surgery - Outpatient
Services
$77 per visit
Outpatient Hospital Services:
Examples: Chemotherapy,
Sleep Studies
Compression Stockings
Orthotic Shoe Insert
Diabetic Shoes
Mastectomy Bra
$75 deductible with a
20% coinsurance
5 pairs per Calendar
Year with $22 per
pair copay
3 pairs per lifetime
with $10 per pair
copay
2 pairs per Calendar
Year with $55 per
pair copay
$12 per item

HIGH TECH DIAGNOSTIC SERVICE REVIEW
OB Ultrasounds
All MRI/MRAs
All CT/CTA Scans
Sleep Studies (must be ordered by a Neurologist,
Pulmonologist or ENT)
MEDICAL / RADIATION ONCOLOGY TREATMENTS
Fetal Biophysical Profiles
All PET Scans & cardiac nuclear medicine scans
Sleep Screenings through Bennett Medical Services
Discography
Chemotherapy Intensity-modulated radiation therapy (IMRT)
Hormone Therapy
Biologics
Supportive care medications related to a cancer diagnosis
AMBULATORY SURGERY REVIEW
Blepharoplasty
Varicose Vein Stripping/Ligation
Orthotripsy for Plantar Fasciitis
Brachytherapy
Stereotactic radiation therapy & proton-beam procedures
Two-dimensional (2D)/three-dimensional (3D) conformal radiation
Septoplasty
Breast Reduction
Ventral Hernia Repair > 18 years
Surgical Treatment of Sleep Apnea
Orthoses (or Orthotics)
ADDITIONAL SERVICES REQUIRING PRIOR AUTHORIZATION
All hospital admissions including elective admissions and those
resulting from ER or observation stay
All TMJ procedures
Skilled Nursing Facility
Inpatient Rehabilitation
Long Term Acute Care
Insulin Pumps
All Hysterectomies (Inpatient or Outpatient)
Custom Compression Stockings
Cochlear Implants
Mandibular/Oral/Orthognathic Surgery
Gastric Neurostimulators
October 2012
Services Requiring Prior Authorization:
Durable Medical Equipment items that are over $500 (whether it is
rental or purchase to include oxygen equipment over $500, i.e. oxygen
concentrators)
Dialysis
Home Health and Infusion Therapy
Orthoses (or Orthotics)
Prosthetic Appliances
Outpatient Chemo/Radiation Therapy
Back Surgeries (Inpatient or Outpatient Services)
Genetic Testing
Implantable Hormone Therapy
Stereotactic Radiosurgery
EECP
Skin Substitutes/ Grafts
Please Note: Services requiring prior authorization include outpatient and inpatient services. As of this printing, the services listed above require
prior authorization. This list may be updated from time to time. It is the provider’s responsibility to check for updates. If the procedure billed is
not the procedure approved by American Health Holding, Inc or HealthHelp, there may be no payment and the patient is not liable. Please call
American Health Holding, Inc at 866-330-2307 or HealthHelp at (800) 519-9935 for more information.
Culinary Pharmacy
• There are more than 300 drugs, including most diabetic and several over-the-counter medications, available at the Culinary Health Fund
Pharmacy, which are FREE to all Culinary participants. Prescriptions can be called in at: 702-650-4417 or faxed to 702-369-5940.
Don’t forget! The Culinary Pharmacy is accepting E-prescriptions! The ID code is: 2990124
Please call the Customer Service Office to request an updated Culinary Pharmacy List or visit our website at www.culinaryhealthfund.org.
Diabetes Program offered to your Culinary Patients
• Free Diabetic Educations! Please call our Provider Services at 702-892-7313 or go to our website at www.culinaryhealthfund.org for a list of
locations.
• Free Diabetic Meters
• Most diabetic medications are available at the Culinary Pharmacy. Please call the Culinary Pharmacy at 702-650-4417 for more information..
Eligibility and Claims:
• To verify your Culinary patient’s eligibility, please call the Customer Service Office at 702-733-9938, then press 1 for the automated eligibility
verification and claims status telephone line.
• The Customer Service Office is open Mon - Fri from 7:30am to 6pm and the telephone line is available Mon - Fri from 8am to 6pm.
You can mail claims to:
P.O Box 94469
Seattle, WA 98124
EDI Payor ID# 59140
You can mail provider appeals to:
Provider Reconsiderations
P.O Box 42216
Las Vegas, NV 89116
Provider Guide
For more Benefit Information and Updates, visit the website at www.culinaryhealthfund.org
This is only a guide to Culinary PPO participant benefits and does not provide you with all of the benefits available through the Culinary Health Fund.
For further information about other available programs and benefits, please call Culinary Health Fund Customer Service Office at 702-733-9938.
Culinary Health Fund Administrative Services, LLC
37

CULINARY HEALTH FUND ADMINISTRATIVE SERVICES LLC
PROVIDER ADDRESS INFORMATION
PRACTICE NAME: TAX IDENTIFICATION NUMBER:
CORRESPONDENCE MAILING ADDRESS: SITE LOCATION ADDRESS:
ADDRESS [1] ADDRESS
PHONE FAX PHONE FAX
CONTACT/E-MAIL CONTACT/E-MAIL
BILLING ADDRESS:
ADDRESS [2] ADDRESS
PHONE FAX PHONE FAX
CONTACT/E-MAIL CONTACT/E-MAIL
CREDENTIALING ADDRESS:
ADDRESS [3] ADDRESS
PHONE FAX PHONE FAX
CONTACT/E-MAIL CONTACT/E-MAIL
If more than 3 sites please attach complete roster including site/providers.
 Site roster attached.
PROVIDER NAME SPECIALTY LOCATION NO. Ex.: [2] or all.
Effective Date:_____________________________________
If more providers please attach complete roster including site/providers.  Site roster attached
Culinary Health Fund
1901 Las Vegas Blvd. South, Suite 101
Las Vegas, Nevada 89104
Or
Via Fax at: 702-735-1649

1901 Las Vegas Blvd. So.
Suite 101
Las Vegas, Nevada 89104-1309
(702) 892-7313
www.culinaryhealthfund.org
ALLOWABLE AMOUNT REQUEST FORM
Provider Name
TIN
Please enter CPT procedure codes in each cell and fax your request to Provider Services
(702) 892-7326. Please include your contact information and fax number on the cover
page.
The allowables requested are not a guarantee of payment. Provider shall be reimbursed
according to the terms of their contract. Any reimbursement shall be subject to applicable
modifier reductions, co-pays, deductibles, co-insurance, plan limitations, exclusions and
nationally accepted coding initiatives.

1901 Las Vegas Blvd. So.
Suite 101
Las Vegas, Nevada 89104-1309
(702) 892-7313
www.culinaryhealthfund.org
GROUP ADD REQUEST
Name of Group:
Tax ID #
Name of Provider
being added:
Specialty of Provider
being added:
Effective Date:
Hospital-Based
Provider? (Please
circle one) Yes No
Practice Location(s)
(attach separate
Sheet if necessary)
Contact Name:
Phone:
Fax:
Email:
Please fax back to: 702-892-7365 Attention: Jessica Wesley
Or e-mail to jwesley@culinaryhealthfund.org

CULINARY PROVIDER RECONSIDERATIONS FORM
DATE:
CLAIM #:
PATIENT NAME:
DATE OF SERVICE:
________________________________
________________________________
________________________________
________________________________
CPT/HCPCS CODE (S) REQUIRING REVIEW:
__________________
________________________________________________________
PROVIDER TIN:
PROVIDER NAME:
CONTACT PERSON:
PHONE NUMBER:
________________________________
________________________________
________________________________
________________________________
REASON FOR REQUEST (brief description of the issue (s))
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
ATTACHMENTS: Check all that apply
Copy of Claim Operative Report Medical Records
CCI guidelines
Contract Language
Other _________________________________________________________
Provider Reconsiderations Department
P.O. Box 44216
Las Vegas, NV 89116

Culinary Health Fund
Healthy Pregnancy Program Certification
To ensure proper reimbursement, please submit this certificate
and patient’s antepartum records with your billing to:
UNITE HERE HEALTH
ATTN: Claims Payment
1901 Las Vegas Blvd. South, Suite 107
Las Vegas, NV 89104
702-733-993
Fax: 702-892-7326
NOTE: Antepartum records must be attached.
NAME OF ELIGIBLE EMPLOYEE: SS#:
NAME OF MOTHER (if different): SS#:
ADDRESS (Street, City, State, Zip):
DATE OF DELIVERY:
I certify that this patient: Did Did Not Complete all recommended ante partum care during her
pregnancy.
MD NAME: T.I.N:
SIGNATURE: DATE:

October 2012
Provider Guide
We want to hear
from you!
The Culinary Health Fund is always looking
for new ideas to ensure the quality of care
for our participants. If you have any ideas
or programs that you think would be of
interest to the Culinary Health Fund, please
contact Provider Services at 702-892-7313
or email us at
providerservices@culinaryhealthfund.org.
Culinary Health Fund Administrative Services, LLC
49

YOUR HEALTH. YOUR PLAN.
Culinary Health Fund Administrative Services, LLC
1901 Las Vegas Blvd. South, Suite 101
Las Vegas, NV 89104
702-892-7313
www.culinaryhealthfund.org