Provider Guide - the Culinary Health Fund

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