Provider Guide - the Culinary Health Fund

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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. 20 Culinary Health Fund Administrative Services, LLC
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. Culinary Health Fund Administrative Services, LLC 21
Page 1: Provider Guide Administrative Servi
Page 4 and 5: Provider Guide October 2012 Introdu
Page 6 and 7: Provider Guide October 2012 Who We
Page 12 and 13: Provider Guide October 2012 Benefit
Page 14 and 15: Provider Guide October 2012 Prescri
Page 16 and 17: Provider Guide October 2012 Program
Page 18 and 19: Provider Guide October 2012 Program
Page 22 and 23: Provider Guide October 2012 Claims
Page 24 and 25: Provider Guide October 2012 Claims
Page 26 and 27: Provider Guide October 2012 Credent
Page 28 and 29: Provider Guide October 2012 Resourc
Page 30 and 31: Provider Guide October 2012 Frequen
Page 32 and 33: Provider Guide October 2012 Frequen
Page 35 and 36: CULINARY HEALTH FUND ADMINISTRATIVE
Page 37: HIGH TECH DIAGNOSTIC SERVICE REVIEW
Page 41: 1901 Las Vegas Blvd. So. Suite 101
Page 45: CULINARY PROVIDER RECONSIDERATIONS
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Provider Guide - the Culinary Health Fund

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