<strong>Provider</strong> <strong>Guide</strong> October 2012 Claims Processing <strong>Guide</strong>lines TEXT Box 1a Should always have <strong>the</strong> <strong>Culinary</strong> participant’s ID number Box 10 Should have sections a, b and c filled in Box 33 Should list <strong>the</strong> provider’s billing address, especially if different from <strong>the</strong> service address Box 31 Should have provider’s name listed 24 <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC
October 2012 <strong>Provider</strong> <strong>Guide</strong> Contract Information All Primary Care Physicians (PCPs) and specialty physician groups are contracted directly with <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC. Please contact <strong>Provider</strong> Services at 702-892-7313, option 1 with any questions regarding a physician/group provider contract. Forms in <strong>the</strong> 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 <strong>Provider</strong> Services at 702-892-7313, option 3, with any questions regarding your ancillary contract. Remember <strong>the</strong> following requirements per your agreement with <strong>the</strong> <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong>: • Referrals: Participants and <strong>the</strong>ir eligible dependents must be referred to <strong>Culinary</strong> PPO providers. The referring physician will be financially responsible for referrals to non-PPO providers when a PPO <strong>Provider</strong> is available. • Co-pays/Coinsurance/Deductibles: <strong>Culinary</strong> participants are responsible only for applicable co-pays, coinsurance, and/or deductibles for covered services. All o<strong>the</strong>r charges for covered services are not <strong>the</strong> responsibility of <strong>the</strong> participant, and <strong>the</strong> participant cannot be balanced-billed. • Prior Authorization: The provider is responsible for obtaining prior authorization from American <strong>Health</strong> 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 <strong>the</strong>rapy. • <strong>Health</strong>Help: Effective August 1, 2012, <strong>the</strong> following requests will now be authorized by <strong>Health</strong>Help: • Diagnostic Imaging: CT, CTA, MRI, MRA, PET and cardiac nuclear medicine scans. • Medical Oncology treatments: Chemo<strong>the</strong>rapy, hormone <strong>the</strong>rapy, biologics, supportive care medications related to a cancer diagnosis. • Radiation Oncology treatments: two-dimensional (2D) and three-dimensional (3D) conformal radiation, intensity-modulated radiation <strong>the</strong>rapy (IMRT), brachy<strong>the</strong>rapy, stereotactic radiation <strong>the</strong>rapy and proton-beam procedures. • Out of Area: Before referring a patient out of <strong>the</strong> area for any specialized services, please contact American <strong>Health</strong> Holding, Inc. (AHH) at 866-330-2307. New technologies and services are evolving 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 services. <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Administrative Services, LLC 25
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