Provider Guide - the Culinary Health Fund

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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
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
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Page 20 and 21: Provider Guide October 2012 Prior A
Page 22 and 23: Provider Guide October 2012 Claims
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Page 26 and 27: Provider Guide October 2012 Credent
Page 28 and 29: Provider Guide October 2012 Resourc
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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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