AvMed Physician

avmed.org

AvMed Physician

AvMed Physician

Orientation Manual


Dear Physician,

Welcome to a 35-year-old tradition of medical excellence. We are

pleased you’ve chosen the AvMed network as a partner in providing

quality health care to Floridians of all ages and walks of life.

The enclosed materials will help you work effortlessly with AvMed to

ensure fast service and prompt payment. If you or your staff have any

questions about our forms, policies or procedures, please call your

Physician Service Representative or contact the Provider Service

Center at 1-800-452-8633.

Visit www.avmed.org to find several useful documents and tools.

Accessing AvMed online can give you and your staff quick answers and

easy access to important information. You are also invited to join our

Quality Improvement Program and be part of our continuing efforts

to provide you and your patients with the best service possible.

On behalf of all of us at AvMed, we look forward to providing you with

unparalleled service and peace of mind.

Sincerely,

Barry Wagner

Vice President of Network

AvMed Health Plans


Physician

Orientation

Manual

Table of Contents

Physician Support /Responsibilities ............................................................................................................ 04

Claims ................................................................................................................................................. 05

Electronic Claims Submission

Claims Entry Online

Paper Claims Submission

Benefit Coordination .............................................................................................................................. 06

Benefit Coordination Team

Authorizations

Utilization Management .......................................................................................................................... 08

Utilization Review

Discharge Planning

Clinical Pharmacy Management

Care Management Programs

Member Benefits & Eligibility .....................................................................................................................10

Co-payments/Care Coordination

Eligibility Listings

Pharmacy Benefits/Drug Formulary

Important Resources .............................................................................................................................. 12

Credentialing ........................................................................................................................................ 13

Quality Activity .......................................................................................................................................14

AvMed’s Quality Improvement Program

Physician Assessment Audits

Clinical Guidelines ................................................................................................................................... 15


Physician

Support /

Responsibilities

AvMed makes sure that you receive all the support and information you need.

You will be assigned a personal Physician Service

Representative responsible for introducing you to

AvMed Health Plans and to troubleshoot problems,

explain responsibilities, offer assistance and to visit you

and your staff. Our goal is to make your participation as

rewarding as possible.

The Provider Service Center is your chief link to AvMed

Health Plans. The staff at the Center can help you with

any questions about policies and procedures, to report

or request a change in your panel status, address/phone,

covering physician, hospital privileges, Tax ID and

Licensure or any other service issue. You may contact the

Provider Service Center weekdays between 8:30 am and

5:00 pm at 1-800-452-8633.

Physician Services

Important Contact Information

Provider Service Center:

PO Box 569004

Miami, FL 33256-9004

1-800-452-8633 (Option 3)

Fax: 305-671-6149

Toll Free: 1-877-231-7695

E-mail: Providers@avmed.org

In addition to your Physician Service Representative and

the Provider Service Center, the Physician Reference

Guide is an excellent support tool full of information.

The Physician Reference Guide can be found on the

AvMed Web Site at www.avmed.org.

Additional Information

found at www.avmed.org.

Refer to Chapter 1 of the

Physician Reference Guide for:

Physician responsibilities

■ In-office laboratory guidelines

■ When to call the Provider

Service Center

■ Basic agreement highlights

4 • AvMed Physician Orientation Manual


Claims

Ninety-eight percent of AvMed claims are processed within 10 days.

AvMed requires that all claims be submitted within 180

days from the date of service. In addition, all requests

for review or appeal have to be received within 150

days from the date on which the explanation of

payment was printed.

Electronic Claims Submission

AvMed receives claims electronically from the following

clearinghouses: Emdeon, ProxyMed, ENS, ZirMed, Office

Ally, Availity, SSI and eHDL.

Claims Entry Online

Please go to AvMed’s Web Site at www.avmed.org and

click on Physicians & Care Providers. Then select the

Provider Services Online section to learn more about

submitting claims online.

Paper Claims Submission

Physicians should always bill their usual and customary

fees. AvMed will pay the lesser of your contractual

agreement or the Medicare allowance for Medicare

members. When billing commercial member claims,

AvMed will pay at your contractual agreement rates.

Claims

Important Contact Information

To submit claims:

PO Box 569000

Miami, FL 33256-9000

To query claims status:

PO Box 569004

Miami, FL 33256-9004

1-800-452-8633 (Option 2)

Fax: 1-800-452-5182

To request claims

review/appeal:

PO Box 569004

Miami, FL 33256-9004

1-800-452-8633 (Option 2)

Fax: 1-800-452-3847

Additional Information

found at www.avmed.org.

Refer to Chapter 2 of the

Physician Reference Guide for:

■ Claims related information

■ Adjustments

■ Coordination of Benefits

■ Reimbursements

AvMed Physician Orientation Manual • 5


Benefit

Coordination

Ninety-eight percent of AvMed physicians find it easy to obtain referrals and authorizations.

Benefit Coordination Team

Each regional office is comprehensively supported by the Benefit

Coordination Team, a highly trained clinical and administrative staff.

When a request is submitted for authorization, an AvMed Medical

Director and the Benefit Coordination Team will provide consistent

application of internal procedures/guidelines, nationally recognized

criteria and administration of benefit limitations. These initiatives

can be best accomplished by coordinating your clinical expertise

with the clinical and cost management know-how of the AvMed

Medical Directors and Benefit Coordination Team.

AvMed’s authorization process has been designed to achieve and

sustain coordinated and efficient service for AvMed members.

This process also allows AvMed to identify and enroll members in

pre-planned discharge planning (Speedy Recovery) and specialized

programs, such as Disease and Case Management.

The Benefit Coordination Team constantly strives to enhance

the partnership with your office via a commitment to enhanced

teamwork, effective communication and first-class customer

service. Their goal is to provide you and AvMed Members — your

patients — with high-quality and cost-effective care.

Authorizations

Authorizations for simple referrals/consultations to participating

specialists, as well as for most services provided in a

participating physician’s office, are not required; however, a

referral is required by select plans. AvMed values the role of the

Primary Care Physician (PCP) and requires that most members

select a PCP. We expect that the PCP will continue to play the same

integral role with our members by coordinating their medical care

with specialists and other health care providers.

6 • AvMed Physician Orientation Manual


For services requiring an authorization from AvMed, the

prescribing physician should submit an Authorization

Request Form via fax to 1-800-552-8633. If the service

is deemed emergent or urgent, contact the Authorization

Team directly by calling 1-800-816-5465.

Primary Care Physicians and Specialists are encouraged

to utilize the AvMed Link line and Web authorization

modules to obtain select automated authorizations and to

check member benefits and eligibility. AvMed’s automated

authorization process is easy and fast. You and your staff can

access AvMed Link by calling 1-800-816-LINK (5465). It’s

as fast as the average credit card authorization. Additional

information on authorizations can be found in the Quick Tips

tab of this kit.

The Service Plus department works closely with the Benefits

Coordination Team and is responsible for admissions to an

inpatient facility on an emergent/urgent basis either from the

physician’s office or an emergency room.

Benefits Coordination

Important Contact Information

Hours of Operation: 6:00 am – 10:00 pm

Automated system is available seven days a

week for simple referrals and authorization

confirmation 8:30 am – 5:00 pm,

Monday through Friday for

coordinator-assisted authorizations

Provider Authorizations

Requests/confirmations:

AvMed Link

1-800-816-LINK

(1-800-816-5465)

Pre-Auth Fax: 1-800-55AVMED

(1-800-552-8633)

Service Plus: 7 days, 24 hours

1-888-ER-AVMED (1-888-372-8633)

Weekend Discharge Planner:

1-888-372-8633 (Option 4)

For Eye Care Referral:

Primary Plus/CompBenefits, Inc.:

1-800-393-2873

For Mental Health Referral:

Psychcare, LLC - North (Gainesville,

Jacksonville, Orlando and Tampa):

1-800-305-5886

UMBH - South (Miami-Dade, Broward, Palm

Beach and Southwest):

1-800-294-8642

Additional Information

found at www.avmed.org.

Refer to Chapter 3 of the

Physician Reference Guide for:

■ Authorization requirements

■ Services requiring authorization

■ Services not requiring authorization

■ How to obtain an authorization

AvMed Physician Physicians Orientation Manual • 00 • 7


Utilization

Management

AvMed provides the resources you need to give your patients the best care.

Utilization Review

In addition to daily authorizations by the Benefits Coordination

Team, AvMed’s Utilization Management department examines the

overall frequency of procedures by a doctor. Utilization Management

(UM) approvals are handled by clinical personnel, all of whom

have unrestricted licenses in the State of Florida, at the regional

office level. Concurrent reviews are conducted both on site and by

telephone. Doctors are invited to contact their regional office or

Medical Director to discuss any UM denial decision.

Discharge Planning

Discharge planning is performed at each regional office. Discharge

planners (RNs/LPNs) are licensed by the State of Florida and the

Discharge Coordinators (non-clinical) work with the Utilization

Management Coordinators in the facilitation of member’s access to

benefits for discharge arrangements.

AvMed recognizes that health care doesn’t stop after 5:00 pm.

Service Plus performs Discharge Planning after normal business

hours and weekends. The Service Plus program provides several

24/7 services to help make things easier for you and your patients.

Clinical Pharmacy Management

The Clinical Pharmacy Management Department is located in

Gainesville and administers the Prescription Drug Plan statewide.

Pharmacists supervise clinical decision-making. Under the

supervision of the Director of Clinical Pharmacy, non-clinical staff

provides technical support.

If you or your staff have any questions on dispensing limits and

coverage guidelines you can access the latest information in the

Coverage and Dispensing Limits Guide section at www.avmed.org,

by clicking on the Useful Shortcuts and selecting Drug List.

8 • AvMed Physician Orientation Manual


Care Management Programs

AvMed’s Care Management and Disease Management

programs are administered at both the regional offices

and centralized locations. Interested AvMed members

will discuss their eligibility and enrollment with you.

Each eligible member is assigned a Registered Nurse,

called a Care Coordinator, who works closely with you,

medical directors and ancillary services to monitor and

control their condition. If you are interested in enrolling

a member, you should contact Disease Management at

1-800-972-8633 and the Care Coordinator will contact

you to discuss the referral. The programs are free and

member participation is voluntary.

Care Management Programs include:

■ Complex Case

■ Cancer Care

■ Chronic Kidney Disease and Transplant

Disease Management Programs include:

■ Congestive Heart Failure

■ Asthma/Chronic Obstructive Pulmonary Disease

■ Wound Care

■ Diabetes

■ High Risk Pregnancy

■ Coronary Artery Disease

Utilization Management

Important Contact Information

Disease Management:

1-800-972-8633

Discharge Planning:

1-888-372-8633

Pharmacy:

1-800-237-1255, ext. 40665

Plan Medical Directors

Broward: 954-462-2520

Fax: 954-627-6280

Miami-Dade: 305-671-0126

Fax: 305-671-4770

Gainesville: 352-337-8860

Fax: 352-337-8870

Jacksonville: 904 858-1311

Fax: 904-858-1358

Orlando: 1-800-227-4848

Fax: 407-975-1634

Tampa: 1-800-257-2273

Fax: 1-800-572-6252

Additional Information

found at www.avmed.org.

Refer to Chapter 3 of the

Physician Reference Guide for:

■ Utilization Management

■ Access to Utilization Management staff

AvMed’s Nurse On Call

AvMed Physician Physicians Orientation Manual • 00 • 9


Member

Benefits

& Eligibility

AvMed provides quick and easy access to eligibility listings at www.avmed.org.

Co-payments/Care Coordination

AvMed offers many benefit plans and riders. Most

plans have varying co-payments, deductible and/or

co-insurance, limitations and exclusions. Please be aware

that the co-payment associated with various services may

differ from plan to plan, and while not all plans require

the member to select a Primary Care Physician (PCP),

we emphasize the importance of coordination of care.

Eligibility Listings

Primary Care Physicians should receive a monthly

“eligibility list” around the first day of each month for

all members whose plan requires them to select a PCP.

You can also view current eligibility listings via the web

at www.avmed.org.

Pharmacy Benefits/Drug Formulary

Most members have a prescription rider for

prescription medications coverage, which varies in terms

of covered medications, co-payments and quarterly

maximum benefit dollar amounts. All prescriptions must

be filled at a participating pharmacy. In addition to the

contracted independently owned pharmacies, AvMed’s

pharmacy network includes: CVS, Winn Dixie, Long’s

Drugs, Walgreens, Publix, Target, Navarro and Sedanos.

We encourage the use of cost-effective prescribing

habits. Use the AvMed Health Plans Two-Tier and Three-

Tier Preferred Drug Lists, found on our Web site, for

the most updated information available. If a physician

or a member requests a brand name medication when a

10 • AvMed Physician Orientation Manual


generic equivalent is available, most members will have

to pay the cost difference between the brand and generic

products plus their applicable co-payment, which is

determined by the member’s prescription benefit.

The Coverage and Dispensing Limit Guide is a reference

that is used in addition to the Preferred Drug Lists.

You can access the lists at www.avmed.org.

This reference provides additional information about a

member’s benefits including:

■ Drugs requiring Prior Authorization

■ Drug-Specific Quantity Limits

■ Exclusion to the Prescription Drug Benefit

This reference is provided as a tool for medication

therapy selection. The final choice of medication selection

for an AvMed member rests with the prescriber and

the member. Situations may arise in which non-covered

medications are medically warranted. If that occurs, you

must complete and fax a Medication Exception Request

Form to the Clinical Pharmacy Management Department,

with supporting documentation to 1-800-552-8633.

Member Benefit/Eligibility

Important Contact Information

Member Benefit/Eligibility:

Member Services:

1-800-882-8633

Provider Service Center:

1-800-452-8633 (Option 1)

AvMed LINK Line:

1-800-816-LINK

North Fax: 352-337-8612

South Fax: 305-671-4936

AvMed Web Site: www.avmed.org

Additional Information

found at www.avmed.org.

Refer to Chapter 4 of the

Physician Reference Guide for:

■ Member benefits

■ Eligibility

■ Product information

AvMed Physician Orientation Manual • 11


Important

Resources

24/7 access to AvMed Service Plus for your administrative, home care and patient needs.

For general questions and to

request supplies:

Provider Service Center

P.O. Box 569004,

Miami FL 33256-9004

1-800-452-8633, Fax: 305-671-6149

or Fax: 1-877-231-7695

E-mail to: Providers@avmed.org

To obtain authorizations, confirm

authorizations and verify

member eligibility:

Pre-Authorization Call Center/(AvMed Link):

1-800-452-8633, Fax: 1-800-552-8633

(for all faxed requests)

Confirm authorization online at our Web site,

under Physicians & Care Providers

To submit claims:

Claims (Statewide)

P.O. Box 569000

Miami, FL 33256-9000

To query claims status and request

reviews/appeals:

Claims & Reviews/Appeals Phone: 1-800-452-8633 (Option 2)

Claims Status Fax: 1-800-452-5182

Claims Review/Appeals Fax: 1-800-452-3847

Review status claims online at our Web site, under

Physicians & Care Providers

For eye care referrals:

Primary Plus/CompBenefits, Inc.

(Jacksonville, Southwest, Orlando, Tampa,

Miami-Dade, Broward & West Palm Beach):

1-800-393-2873

For questions regarding member benefits:

Member Services – North

(Gainesville, Jacksonville, Orlando,

Tampa & Tallahassee):

1-800-882-8633, Fax: 352-337-8612

Member Services - South

(Miami-Dade, Broward,

West Palm Beach & Southwest):

1-800-882-8633, Fax: 305-671-4736

Verify member eligibility/benefits at our

Web site, under Physicians & Care Providers

For Mental Health/Behavioral Health:

South - University of Miami

Behavioral Health (UMBH)

(Miami-Dade, Broward and West Palm Beach):

1-800-294-8642

North – Psychcare, LLC.

(Gainesville, Jacksonville, Orlando,

Tampa and SW Florida):

1-800-305-5886

To refer suspect issues, anonymously

if preferred:

Audit Services & Investigation Unit:

1-877-286-3889

For authorizations that originate in the ER

or direct admits from the doctor’s office:

Service Plus 24/7:

1-888-372-8633

For disease management:

Disease Management:

1-800-972-8633

12 • AvMed Physician Orientation Manual


Credentialing

AvMed wants you to become part of a 35-year tradition of quality health care.

An important component of AvMed Health Plans’ Quality

Improvement process is the Credentialing Program. The

Credentialing Program is designed to ensure that participating

practitioners possess the practice experience, licenses,

certifications, privileges, professional liability coverage, education

and other professional qualifications to provide a level of

professionally recognized care. When selecting providers, AvMed

does not discriminate against sex, race, religion, creed, color, age

and/or national origin.

Composed of multi-disciplinary representation of participating

community physicians, the Credentialing Committee reviews

applications and credentials of each practitioner upon credentialing

and re-credentialing. In the event that a practitioner is denied recredentialing,

the practitioner will be given the right to a hearing.

Credentialing

Important Contact Information

AvMed’s Credentialing

Department:

Contact your Physician

Service Representative

Council for Affordable Quality Health

care (CAQH):

1-888-599-1771

You will be notified of the Credentialing Committee’s decision within 30

days following the monthly committee meeting. Physicians also have the

right, upon request, to be informed of the status of their application.

All practitioners may review information submitted in support of their

credentialing applications. This information is limited to data that is

not peer-review protected and can be obtained by the practitioner

from the same primary sources utilized by AvMed.

All practitioners have the right to correct erroneous information

submitted to AvMed by another party. In the event that any

information obtained during the credentialing process varies

substantially from the information provided to AvMed by the

practitioner, the practitioner will be notified in writing and asked

to submit written clarification. All information obtained in the

credentialing process is maintained in a confidential manner.

There is no appeal mechanism available to a practitioner who is

denied initial credentialing into AvMed’s Network.

To start your credentialing process, please contact your

Physician Service Representative.

Additional Information

found at www.avmed.org.

Refer to Chapter 6 of the

Physician Reference Guide for:

■ Credentialing

■ Re-credentialing

■ Ambulatory Site Standards

AvMed Physician Orientation Manual • 13


Quality Activity

The Quality Improvement program lets you impact the future of AvMed health care.

AvMed’s Quality Improvement Program

The policies, procedure and activities of the AvMed Health Plans

Quality Improvement (QI) Department are integrated into a

single Quality Improvement Program. AvMed’s Board of Directors

oversees the program to ensure that QI functions are timely,

consistent and effective. The following are audits performed by

AvMed as part of our QI initiatives.

Physician Assessment Audits

Medical Record Audits: Primary Care Physicians may receive an

annual medical record review audit within their outpatient offices.

A corrective action plan will be requested when your score is below

AvMed’s minimum compliance level.

Quality Activity

Important Contact Information

Quality Improvement:

Contact your Physician Service

Representative

Risk Management:

1-800-346-0231

Fax: 352-337-8526

Accessibility and Availability: Primary Care Physicians may

be assessed annually to ensure their compliance with making

appointments for members within the recommended AvMed

guidelines. A corrective action plan will be requested when your

score is below AvMed’s minimum compliance level.

After Hours Accessibility: Primary Care Physicians are assessed

annually for member’s ability to reach their PCP after hours. According

to the PCP contract, you or a designee must be available to members

24 hours a day, 7 days a week.

Member Satisfaction with their PCP: AvMed conducts surveys

to determine member satisfaction with their PCP. These surveys

are conducted and the results are tabulated for AvMed by an NCQA

certified market research firm. When appropriate, results are

calculated and forwarded to each PCP for review and action.

Additional Information

found at www.avmed.org.

Refer to Chapter 7 of the

Physician Reference Guide for:

■ Quality Activities

■ Advance Directives

■ Disrobing Guidelines

■ Risk Management

■ A sample Membership

Satisfaction Survey

14 • AvMed Physician Orientation Manual


Clinical

Guidelines

The NCQA* rates AvMed’s clinical performance “Excellent.”

AvMed’s comprehensive and informative Clinical Guidelines range

from Asthma to Postpartum Care. These guidelines have been

drawn from the National Institutes for Health and other leading

health organizations such as the American Diabetes Association

and the March of Dimes.

It’s the physician’s responsibility to periodically check for

updates to these guidelines, which can be found under Quality

Improvements at www.avmed.org, or in the Physician Reference

Guide set of PDFs.

*The National Committee for Quality Assurance

Additional Information

found at www.avmed.org.

Refer to Chapter 8 of the

Physician Reference Guide for:

■ Clinical Guidelines

■ Behavioral Health

Clinical Practice

■ Pediatric Preventive Care

■ Adult Preventive Care

Recommendations

AvMed Physician Orientation Physicians Manual • 00 15


www.avmed.org

AvMed Health Plans

Regional Offices

Miami

Ft. Lauderdale

Tampa Bay

Orlando

Jacksonville

Gainesville

MP-0000 (00/06)

AVM-EMKFR01ER

AvMed Health Plans (health benefit plan) is the brand name used for products

and services provided by AvMed, Inc. Plans contain limitations and exclusions.


Authorization Request Form

Link Line: 1-800-816-5465

Fax: 1-800-552-8633

For Urgent/Emergent requests, contact AvMed’s PreAuthorization Department at this number:

1-800-816-5465

NOTICE: Failure to complete this form in its entirety may result in delayed processing or an adverse determination due to

insufficient information.

Existing Authorization Number:

Date(s) of Service:

Member Information

Name: (first and last)

AvMed ID#:

A ___ ___ ___ ___ ___ ___ ___ ___ - ___ ___

Type of Request

Outpatient Surgery

Inpatient Admission

Transplant

Outpatient Drug / Chemotherapy

Speedy Recovery

Date Change only – DOS ______/ ______/ ______

Wound Care

Predetermination

Non Par Request

Home Health

Date of Birth: ______/ ______/ ______

Nuclear Cardiology (i.e. Thallium Scan)

Complex Radiological Procedures

i.e. CT/CT Angiogram, MRI, MRA, Pet Scans and

includes in-office, DTF or outpatient settings

Requesting Physician (PCP or Specialist) Referred to: Facility Hospital Physician

Name:

Name:

AvMed Provider#:

Telephone #: (

) _____________________________

AvMed Provider#:

Additional information as indicated:

Fax#: ( ) _____________________________

Contact Person:

Diagnosis and Procedure Information

ICD9 Diagnosis Code(s):

Diagnosis Description:

CPT4 Procédure / DME Code(s):

Procedure Description:

NOTE: This request cannot be processed without Supporting Clinical Documentation, e.g. office visit note(s); pertinent

laboratory results; prior treatment(s) note(s).

MP-1437 (7/2007)


Please fax completed form to AvMed Claims Department: FAX: 1-305-671-6121

Dear Member:

Your AvMed contract provides for benefits to be coordinated with other medical insurance by which you may

be covered. The primary carrier pays first when there is more than one insurance company or health care

provider. In order to expedite your claim(s) process, please complete the following information:

NOTE: If the reason for your medical care was not due to an accident related injury, do not complete Section I

of the questionnaire. You should complete Section I and III only when applicable.

Patient Member ID Number _______________________

Patient Name ______________________________

Provider Name _________________________

Date of Service ________________________

SECTION I

Is the reason for your visit to your doctor due to an injury caused by an accident?

Yes _____ No _____

If so, please indicate:

Auto _______ Home _______ School _______ Other ___________________________________________

Date of Accident ________________ How and where accident happened:

__________________________________________________________________________________________

__________________________________________________________________________________________

Was a third party responsible for the injury? Yes ____ No ____

If so, provide the following:

Name of individual or company: _______________________________________________________________

Name and address of attorney representing third party insurance company or party responsible:

__________________________________________________________________________________________

________________________________________________________________________________________

SECTION II

Full name of your spouse: _________________________________________________________________

Spouse’s Birth date: ____________________ Social Security Number: ____________________________

Spouse’s Employer: _______________________________________________________________________

Employer’s Address: ______________________________________________________________________

________________________________________________ Telephone Number: _____________________

Is your spouse covered by any other Health Insurance Company: _____Yes ______No

If YES, give name, address and telephone number of Health Insurance Company:

_________________________________________________________________________________________

________________________________________________ Telephone Number: _______________________

Policy Number: ______________________________ Effective Date: _____________________________

Type of Coverage: ______ Family ______Couple ______ Single

Do you have Medicare coverage?

Part A ____ Effective Date ______________

Part B ____ Effective Date ______________

SECTION III (Information to be filled out only if auto accident)

Were you in your own or someone else’s vehicle? _____________________________________________

Name of your insurance company: __________________________________________________________

Amount of PIP coverage: _________________________ Amount of Deductible: ___________________

If represented by an attorney, please provide the following: Attorney name, address and telephone #:

__________________________________________________________________________________________

________________________________________________________________________________________

Subscriber/Member Signature______________________________________ Date _____________________

MP-1488 Revised 5/17/06


AvMed Directory Information Change Form

Please complete this form and return as soon as possible to have your directory changes

reflected on the AvMed website and in the printed directories.

Fax to 305-671-6149

or email to: providers@avmed.org

or mail to:

AvMed Health Plans

Provider Service Center

9400 Dadeland Blvd, Ste 420

Miami, FL 33156

1. Please fill in ALL information in this section. Make Address corrections on next page.

Provider Name

(As it should appear in the directory. Use middle initial if desired)

Provider AvMed # Provider Tax ID #

Specialty

(Heading in the directory under which your name should appear)

Contact Name

Phone#

Person authorized to make these changes

2. Fill in ONLY the information that should be changed.

Fill in the parentheses as follows: (A) for Addition (D) for Deletion (C) for Change

( ) Panel Comments

(Age restrictions and/or other panel comments)

( ) Board Certified (Year)

(Attach a copy of certificate)

( ) Group Practice Name

(Please abbreviate. Field is limited to 24 characters)

( ) Group Practice Name

( ) Languages

Your comments


AvMed Directory Information Change Form - continued

Fill in ONLY the information that should be changed.

Fill in the parentheses as follows: (A) for Addition (D) for Deletion (C) for Change

First Location:

County

( ) Provider Address ( ) Suite

( ) City ( ) State ( ) Zip

( ) Phone ( ) Fax ( ) Email

( ) Office Hours

Second Location:

County

( ) Provider Address ( ) Suite

( ) City ( ) State ( ) Zip

( ) Phone ( ) Fax ( ) Email

( ) Office Hours

Third Location:

County

( ) Provider Address ( ) Suite

( ) City ( ) State ( ) Zip

( ) Phone ( ) Fax ( ) Email

( ) Office Hours

Fourth Location:

County

( ) Provider Address ( ) Suite

( ) City ( ) State ( ) Zip

( ) Phone ( ) Fax ( ) Email

( ) Office Hours


AVMED VERIFICATION FORM

Dear AvMed Patient:

Our records show you are not on our AVMED eligibility list. You will receive services today with the understanding that

you may be billed and held financially responsible in the unlikely event that your coverage is not effective for one of the

following reasons:

- Your membership has lapsed

- The services are not a covered benefit

- You have selected a different Primary Care Physician this month

- Your enrollment application is still being processed, has not been received or cannot be verified by

AVMED

I HAVE READ THE ABOVE AND UNDERSTAND MY POSSIBLE FINANCIAL RESPONSIBILITY TO

DOCTOR ___________________________________.

I HEREBY AFFIX MY SIGNATURE AS AN ACKNOWLEDGEMENT OF THIS UNDERSTANDING. I

AUTHORIZE AVMED TO DESIGNATE THIS PHYSICIAN AS MY PRIMARY CARE PHYSICIAN AS OF

TODAY’S DATE.

_____________________________

Patient’s Signature/Date

_____________________________

Patient’s Name (Please Print)

_____________________________

AVMED/ID Number

(If not sure, use *Subscriber’s SS#)

_____________________________

Office Staff Signature/Date

_____________________________

Employer/Group Name (If Applicable)

_____________________________

AVMED Provider Number

*SUBSCRIBER IS THE PERSON WHO WORKS FOR THE EMPLOYER WHO OFFERS AVMED COVERAGE.

TO PHYSICIAN’S OFFICE: AVMED members who are required to select a PCP and are not on your eligibility list should

sign this form. Mail forms to AVMED so that your eligibility listing can be updated.

Send to the following address:

AvMed Health Plans

P.O. Box 823

Gainesville, FL 32602-0823

Attn: Member Services

Fax: (352) 337-8612


MP-3160 (10/07)

Contact Numbers

Phone: 800-452-8633

Fax: 800-835-6132

Medication Exception Request Form

RETAIL PHARMACY AND IN OFFICE MEDICATIONS

Please note, if your patient is on AvMed Medicare, this form cannot be used to request:

• Medicare Part D excluded drugs, including but not limited to, barbiturates, benzodiazepines, fertility

drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs, or

prescription vitamins (except prenatal vitamins and fluoride preparations).

Please specify delivery requested:

In Office (Supplied & Administered)

Retail Pharmacy Pick-Up

CuraScript Specialty Pharmacy

Delivered to office

Delivered to patient for self-injection

Delivered to patient for Home Health to administer

Facility (i.e. out-patient)

Date of this request:

Type of request:

New

Update

Name:

Member Information

Name:

Prescriber Information

AvMed ID: Vendor #:

DOB: Sex: M F Phone: Fax:

Current Weight:

Contact:

Diagnosis:

Diagnosis and Medication Information

Diagnosis Code(s):

Medication:

Strength: Route: Frequency:

Expected length of therapy:

*Procedure Codes:

This request cannot be processed without SUPPORTING DOCUMENTATION such as:

• Office visit notes

• Current lab results

• Alternative therapies or treatments contraindicated/previously tried and failed

(including dose, length of therapy, and adverse outcome)

Please fax all URGENT/EMERGENT REQUESTS to AvMed Health Plans at 352-337-8737.

(*ONLY REQUIRED FOR IN-OFFICE SUPPLY AND ADMINISTRATION.)


AvMed Health Plans

Order Form

Please complete this form and return as soon as possible.

Fax: 305-671-6149

Toll-free Fax: 1-877-231-7695

or mail to: AvMed Health Plans

Provider Service Center

9400 Dadeland Blvd, Ste 420

Miami, FL 33156

1. Please fill in all information in this section.

Person Requesting

Phone Number

Best time to call

Provider AvMed # Provider Tax ID #

Provider Name

Mailing Address

Suite

City State Zip

2. Please fill in quantities requested if applicable.

Network Directory

Physicians Reference Guide

Office Orientation

MP-1445 Advance Directives Member Pamphlet

GP-1062 Allergy Stickers - For outside your Medical Record

MP-1437 Authorization Request Form

MP-1538 AvMed Link Referral Sheet (Pad)

MP-1056 Envelopes - Attn: Claims Dept. (yellow)

MP-1058 Envelopes - Attn: Claims Review & Appeal Dept. (pink)

MP-1435 Lead Screening Labels - For Medical Records Documentation

MP- 3160 Medication Exception Request Form

MP- 2118 Prenatal Care Assessment Stickers

MP-1843 Problems and Medication Summary (Pad) - For Medical Records Documentation

MP- 2105 Request For Claims Review/Appeal

MP- 2106 Request For Claims Status


Fax completed referral RX form to Priority Healthcare:

PHONE# 877-634-8555 FAX# 866-877-1342

Physician Name: ______________________________________ Office Contact/RN Name: ________________

Phone Number: ________________________________ Fax Number: __________________________________

Address: ___________________________________ City: ___________________ State: _____ Zip: _________

DEA #: ______________________

Patient Information

Patient Name: _____________________________________ DOB: ___________ Member #: ________________

Address: ___________________________________ City: ____________________ State: _____ Zip: _________

Home Phone: ________________________________ Daytime Phone: __________________________________

Allergies:__________________________________________________ Height: __________Weight: _________

Primary Diagnosis: __________________________________________________Dx Code:__________________

Insurance Information

Primary Policy: Patient Spouse Parent

Primary Insurance: AvMed Health Plans

Insurance Phone: 1-800-816-5465

Policy Holder's Name: _________________________

Group Number: ______________________________

Drug Delivery Information

* If drug requires Prior Authorization send

appropriate documents (i.e.: notes, test results, etc.).

In-Office Delivery

Just in Time Program*

Drug Replacement Program*

Home Delivery

Other (ex: delivery to work): ________________

*Program requires physician enrollment with AvMed

Prescription

Prescription: (select, stamp or write below) New Patient Refill Request

Medication Strength Directions Quantity

Date: ______________________ Physician’s Signature: _________________________________

Date Needed: ___________________________ (Please allow 48 hours for delivery)

IMPORTANT NOTICE: This facsimile is intended to be delivered to the named addressee and may contain material that is confidential, privileged, proprietary or

exempt from disclosure under applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address

and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or retained by other than

the named addressee, except by express authority of the sender to the named addressee.


REQUEST FOR CLAIM: REVIEW APPEAL

INSTRUCTIONS FOR COMPLETING FORM

1. Submit legible copies of CMS 1500 or UB92 form to process your request accordingly.

2. Check the most appropriate box below for type of review requested.

3. Use only one form per review type/per member. You may attach more than one claim per review type.

PLEASE PRINT

MEMBER IDENTIFICATION NUMBER

MEMBER NAME

Date of Request:

-

FIRST:

_________________________________________________________________

LAST:

_________________________________________________________________

DATE OF

SERVICE:

CLAIM #

_________/_________/___________________

_______________________________________

Fax Your Request To:

(800) 452-3847

OR

FROM: CONTACT PERSON PHONE FAX

________________________________________________________________________________________________________________________________

PROVIDER NAME

PROVIDER NUMBER

________________________________________________________________________________________________________________________________

ADDRESS

Mail To: (Statewide)

AvMed Health Plans

P O Box 569004

Miami, FL 33256-9004

________________________________________________________________________________________________________________________________

CITY STATE ZIP

________________________________________________________________________________________________________________________________

TAX ID#

Corrected Claim

A corrected claim is enclosed for:

Units

Service Code (CPT / HCPCS / REVENUE CODE)

Member ID Number

Other Correction (please describe below)

Implant / Prosthetic Device

(Invoice or purchase order enclosed)

Cost: $ + % = $ expected

__________ _______ ____________ reimbursement

Claim Paid Incorrectly

Units Paid Incorrectly

Payment Sent To Wrong Address

Payment Made To Wrong Provider

Payment Not Correct According To Contract

DME: Purchase Authorized, Rental Paid

Other: (Describe request in detail)

Authorization Denial

Claim denied for “no auth” but services do not

require an authorization

Services were authorized, please review

Authorization # ________________________

Specific services were not authorized, but were

medically necessary

(See enclosed appeal letter and supporting documentation

describing the situation)

Other Denial

Consult Report Not Received

(See enclosed consult report)

Member Is Not Assigned To Your Panel

(Proof of member assignment dates enclosed)

Member Not Eligible At Time Of Service

(See enclosed eligibility documentation)

Untimely Filing

(See enclosed appeal letter describing the situation)

Lack Of COB Information

(COB form signed by member is enclosed)

Service Covered Under Capitation

NOTE: Your contract allows a specified time period to request a review. This date is calculated from the date of the original notice of payment or denial

on the explanation of payment report. Late claim reviews or appeals cannot be considered.

TO REORDER ADDITIONAL FORMS CALL THE PROVIDER SERVICE CENTER AT 1-800-452-8633.

MP-2105 (11/06)


REQUEST FOR CLAIM STATUS

INSTRUCTIONS FOR COMPLETING FORM

• Submit legible copies of CMS 1500 or UB92 form to process your request accordingly, or

• Please enter the claims information on this form.

Please Print

FROM: CONTACT PERSON PHONE FAX

Date of Request:

______________________________________________________________________________________________________________________________________________

PROVIDER NAME PROVIDER NUMBER

______________________________________________________________________________________________________________________________________________

ADDRESS

_____________________________________________________________________________________________________________________________________________

CITY STATE ZIP

Fax Your Request To: Mail To:

(800) 452-5182 OR P O Box 569004

Miami, FL 33256-9004

For AvMed Use Only

Member

ID #

Member

Name

DOS

Amount

Billed

Paid Amount or

Denial Code Description

Check

Number

Check

Date

Comments:

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

REMINDER: Your contract allows a specified time period to request a review. This date is calculated from the date of the original notice of payment or denial on the

explanation of payment report. Late claim reviews or appeals cannot be considered.

Claims Service Rep: ________

TO REORDER ADDITIONAL FORMS CALL THE PROVIDER SERVICE CENTER AT 1-800-452-8633.

MP-2106 (12/04)


AvMed Risk Management

Incident Report

COVER SHEET

Complete your identification in the “From” section.

Transmit both sides of the completed Risk Management Incident Report within 24 hours

of the occurrence and promptly mail original report to address at top of form.

For assistance call AvMed Corporate Director of Risk Management at 1-800-346-0231

Confidentiality: This transmission is a privileged communication and is

protected by Florida Law.

Date:

To:

AvMed Corporate Director, Risk Management

Fax: 1-352-337-8526

Phone: 1-800-346-0231

From:

(Provider)

(Fax, Phone)

(Address)

(City, Sate, Zip)

Number of Pages, Including Cover Sheet ______

Confidentiality Note:

The information contained in this facsimile message may be legally privileged and confidential

information intended only for the use of the individual or entity named above. If the reader of this

message is not the intended recipient, you are hereby notified that any dissemination, distribution, or

copying of this telecopy is strictly prohibited. If you have received this telecopy in error, please

immediately notify us by telephone and return the original message to us at the address above by the

United States Postal Service. Thank you.

HARD COPY WILL FOLLOW BY MAIL


Get a quick payment estimate!

AvMed’s Cost Share Calculator allows

you to quickly estimate the payment due

from an AvMed member with a deductible

or co-insurance benefit plan.* This Web

tool is easy to access and can be used

right at the time of service to determine

the member’s responsibility. It can also

be used to check deductible totals or

co-insurance values.

To access the Cost Share Calculator, log on to AvMed’s Web Site at www.avmed.org. Click on Physicians & Care

Providers and then Provider Services Online. Once you enter your provider and PIN number, you will see the

link to Cost Share Calculator under the left menu bar.

To get an estimate of the member’s responsibility through the Cost Share Calculator, please follow these steps:

1. Specify your county, the fee schedule your contract stipulates, along with the reimbursement percentage, then click Next.

2. Enter member information including member number, deductible remaining and applicable co-insurance.

Note: you can view deductible totals and co-insurance values from a link where the member information is entered.

3. Enter CPT4 code information.

4. Click Submit to display the estimated results for member responsibility.

If you would like more information or if you need to confirm your provider or

PIN number, please contact AvMed’s Provider Service Center at 1-800-452-8633.

* Please note that this tool only supplies an estimate of the final costs for which the member is responsible. The actual value will not be determined until the claim

is adjudicated.


AvMed ePay

AvMed ePay

AvMed ePay allows you to receive fast direct deposit payment,

review patient eligibility and instantly check claim status, all

through your e-mail. Your Explanation of Payment (EOP)

can be delivered in the HIPAA 835 transaction format or as

an interactive PDF attachment that has several convenient

functions including downloading your claim to Excel,

retrieving past EOPs and making a claim adjustment. You

will need Adobe Acrobat Reader 6.0 or higher installed on your

computer in order to enroll and use the EOP interactive PDF.

AvMed ePay Advantages

Using AvMed ePay gives you several advantages:

■ Secure and private correspondence

■ Simplified claims reconciliations for improved cash flow

■ Payments electronically transferred into your bank

account within minutes

■ Access from your e-mail 24 hours a day, 7 days a week

■ Reducing or eliminating costs and time associated with

manual process

Required Information

Before enrolling in AvMed ePay, you will need to gather

the following information:

■ Provider Information

• Provider Name

• Provider Tax ID number

■ Billing Information

• E-mail address of recipient(s) to receive EOPs

• Billing address

• Contact name and telephone number

■ Bank Account Information

• Bank Routing Number

• Bank Account Number

• Bank Account Name

• Type of account (savings, checking)

• Bank’s name and address

Enrollment

If you belong to a group practice, only the group should

enroll for AvMed ePay. Allow up to 10 days for AvMed

to process your enrollment after you have submitted the

appropriate forms. You can easily enroll in AvMed ePay

through these simple steps:

1) Visit www.avmed.org and log on to Provider Services

Online using your Provider ID and PIN.

2) Click as directed to begin the enrollment process, fill out

your Federal Tax ID number and click Next.

3) On the next page enter your Provider or Group number

and name, and a contact name and an email address

to receive the enrollment invitation. You can specify a

unique password to open the enrollment invitation or

the password will default to your AvMed Payee number.

Click the Enroll button in the “Action” section.

4) AvMed will send you an invitation to the ePay program

to authorize your Electronic Funds Transfer (EFT). You

must open the secure PDF form attachment using the

password you specified in Step 3 above. Fill out the

required bank and billing information. Provide a password

to protect and open your future EOPs, then click Submit

to see a printable version. Print, sign and then fax or mail

the document with a voided check to AvMed. Adobe

Acrobat Reader is required for this step.

Using the E-EOP

Electronic funds transfers for approved claims are made once

a week, and the e-mail containing your EOP attachment will

be sent at that time. You will need your password to open the

interactive PDF. The e-mail will include the hint that you chose

during enrollment to help you remember your password. The

functioning buttons of the EOP include:

■ Overpayment Advice – Jumps to the page of the

Overpayment Advice included with your EOP

■ Request Previous EOP – Jumps to the page that allows

you to obtain a copy of an earlier EOP for reference

■ View FAQ – Opens a page of the AvMed Web Site

containing ePay questions and answers

■ Download Excel – Opens a new Excel document

with the details of the claims

■ Claim Adjustment – Allows you to submit an

adjustment request and explanation online

If you would like more information about AvMed ePay,

please contact the AvMed Provider Service Center

at 1-800-452-8633.

MP-4088 (05/08)


Products

AvMed Products at a Glance

PRODUCT

AvMed

Choice

AvMed

Open

Access

AvMed

Consumer

AvMed

HSA-Compatible

HDHPs

AvMed

Classic

AvMed

Open

Access POS

AvMed

Classic POS

Medicare

Premier Care

Medicare

Preferred PPO

DESCRIPTION

Allows a member to use any doctor, any hospital, anywhere in the United States, all referral

free. The member’s co-payments, deductible and co-insurance will vary depending on the

network the member selects.

A plan that allows members to freely see any AvMed physician without a referral. With AvMed

Open Access, members are not required to designate a Primary Care Physician (PCP) upon

enrollment. However, AvMed encourages members to visit a PCP for routine and preventive

care. Members agree to use an AvMed network doctor or hospital in order to have expenses

covered, except for emergency care or in special situations when authorized by AvMed.

AvMed’s consumer-directed (CDHP) product line allows employers to design plans for

their employees by pairing the AvMed products with funding mechanisms such as Health

Reimbursement Arrangements (HRAs and HSAs). The plans encourage preventive care and

generally have higher deductibles and co-insurance. They are designed to lower premiums

for employers while engaging consumers in all aspects of their health care.

Specialized consumer-directed health plans (CDHPs) generally have lower premiums and can

be paired with Health Savings Accounts (HSAs). The HSA-compatible High-Deductible Health

Plans (HDHPs) are designed to actively engage consumers in using and choosing their health

benefits, while providing them access to a tax-free account that can serve as a long-term

savings mechanism for health care expenses.

A plan that allows for fully coordinated health care within the AvMed network. With AvMed

Classic, members choose a Primary Care Physician (PCP) for routine and preventive care. A PCP

coordinates visits to specialists. Members agree to use a network doctor or hospital to have

expenses covered. Various co-payments, co-insurance and deductible options are available.

A POS plan that allows members referral-free office visits for any AvMed physician and the

freedom to go outside the AvMed network at any time for most services. With AvMed Open

Access POS, members are not required to designate a Primary Care Physician (PCP) upon

enrollment. However, AvMed encourages members to visit a PCP for routine and preventive care.

A POS plan that allows for coordinated health care through a Primary Care Physician (PCP)

within the AvMed network, and offers a member the freedom to seek care outside the

network at any time for most services.

A Medicare Advantage HMO plan that uses a full network of AvMed participating Primary Care

Physicians, Specialists, Hospitals and other providers located in Miami-Dade and Broward

counties. A member can use any provider who is part of the AvMed Premier Care Network.

A Medicare Advantage PPO plan that uses a full network of AvMed participating Primary Care

Physicians, Specialists, Hospitals and other providers located in Miami-Dade and Broward

counties. A member can use any provider who is part of the AvMed Medicare Preferred

PPO Network or providers who accept Medicare but do not participate in AvMed’s Medicare

Preferred PPO Network at a nonparticipating provider rate.

MP-4089 (05/08)


Authorizations

Authorization Tips

Services Requiring An Authorization

■ Inpatient Hospitalizations (Acute, Observation, Skilled

Nursing, Vent and Rehabilitation admissions Mental

Health must be rendered through our capitated providers

■ Outpatient Surgery in an Ambulatory Surgery Center

or Hospital Setting* (Includes cardiac catherization and

PTCA but excludes specific CPT4 codes that can be found

on our Web Site at www.avmed.org)

■ Complex Radiology Procedures performed In-Office,

Outpatient Diagnostic Testing Facility, or Outpatient

Hospital Setting* (Defined as CT, CT-Angiography, MRI,

MRA, PET Scans, Myocardial Perfusion Imaging [MPI] and

Cardiac Blood Pool Imaging Services)

■ Hemodialysis

■ Transplants

■ Home Health Care* (Any service rendered by Home

Health Care Agency, including therapy and drug

administration/infusion services

■ Outpatient Drug Infusion Services and Injection Therapy*

(Defined as infusion/administration performed outside of

a physician office not billed with a location 11)

■ In-Office “Select” Drug Administration

(Codes: See list of codes under Quick Tips)

■ ALL Non-Participating Providers*

* These services do not require authorization for Members who are covered

by our Choice product, or our POS product while using the POS benefit for

non-participating providers.

Quick Tips

■ Simple referrals no longer require authorization, however

a referral from the PCP for select plans is required.

■ WEB/VRU are available for quick entry authorizations,

no faxing required. (excludes Complex Radiology, Home

Health, Inpatient Admissions/Hemodialysis/Transplant

Services/Outpatient Drug Therapy)

■ Labs should still be sent to our contracted providers

for processing unless they are listed on the In-Office

Laboratory Guidelines and billed per guideline or member

has out-of-network benefits. (Quest Diagnostics for

Miami, Ft. Lauderdale, Southwest, Palm Beach, Tampa,

Orlando and Gainesville Plan Areas and Consolidated

Laboratory for Jacksonville Plan Area)

■ Services rendered In-Office not outlined specifically under

Services Requiring an Authorization will no longer require

prior authorization. In-Office is defined as a physician

office not contracted by AvMed as a facility and billed in

a location 11.

■ If you are unsure how your office is set up with AvMed

please contact your Physician Service Representative for

further explanation.

■ Services such as outpatient therapy in any setting,

except therapy delivered in the Home setting, no longer

requires authorization, as they are not noted in the above

Authorization Requirements.

■ No authorization is required for specific CPT4 Codes

that are done in a participating providers office or

outpatient surgical facility or hospital.

■ The following codes require authorization in the

physician office setting (location 11):

Q0136 Procrit/Epogen J1440 Neupogen

Q4055 Procrit/Epogen J1441 Neupogen

J2505 Neulasta J2820 Leukine

J0880 Aranesp J9999 Misc

J1563 IVIG J3490 Misc

J1745 Remicade C9003 Synagis

J0215 Amevive

■ Drug administration and infusion services delivered in any

setting, excluding In-Office setting, require authorization

(see specific drugs requiring authorization above)

■ For more detailed information regarding Authorization

Requirements, please refer to Chapter 3, Benefits

Coordination/Utilization Management, of the Physician

Reference Guide.

■ The following are not covered benefits

when supplied In-Office:

• Oral Medications

• Inhaled Medications

• Nebulized Medications

(except Albuterol and Ipratroptium/Atrovent)

• Self-injectables (some exceptions are made

for Medicare Members)

■ For the most current Authorization Request Fax Form,

please refer to Forms on the Web.

Continued on other side

MP-4090 (05/08)


IN-OFFICE LABORATORY GUIDELINES

The tests below are on the approved physician in-office lab list and will be considered routine.

No chief complaint or sick diagnosis is required to receive payment.

CODE

DESCRIPTION

82270 BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES

86580 SKIN TEST; TUBERCULOSIS, INTRADERMAL

87210 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS

87220 TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR

The tests listed below are payable when services are rendered in the physician’s office and only

when the member is treated for a chief complaint or sick diagnosis. If the visit is a well or preventive

medicine visit, please send all specimens to your local AvMed contracted laboratory provider.

CODE

DESCRIPTION

81000 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE

81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE

81002 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE

81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE

81015 URINALYSIS; MICROSCOPIC ONLY

81025 URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS

82247 BILIRUBIN, TOTAL

82465 CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL

82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3

82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)

82948 GLUCOSE; BLOOD, REAGENT STRIP

82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA

83014 HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY

85004 BLOOD COUNT, AUTOMATED DIFFERENTIAL WBC COUNT

85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL

85013 BLOOD COUNT; SPUN MICROHEMATOCRIT

85014 BLOOD COUNT; HEMATOCRIT (HCT)

85018 BLOOD COUNT; HEMOGLOBIN (HGB)

85025 BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET

85610 PROTHROMBIN TIME

85651 SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED

86308 HETEROPHILE ANTIBODIES; SCREENING

87081 CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING

87086 CULTURE, BACTERIAL; QUANTITATIVE COLONLY COUNTY, URINE

87430 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE

87880 INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL

If you have any

questions regarding

the information

to the left,

please contact

the Provider

Service Center at

1-800-452-8633.

All lab work

should be sent

to the following

AvMed contracted

Laboratories:

Jacksonville

Plan Area –

Consolidated

Laboratory

Miami, Ft. Lauderdale,

Southwest, Palm

Beach, Tampa,

Orlando, Gainesville

Plan Areas –

Quest Diagnostics


Web Site

AvMed Web Site Guide

www.avmed.org

REQUIREMENTS

AvMed Provider number and PIN. (Same numbers utilized

when requesting authorization via the link)

WELCOME PAGE

Take an online tour and maximize the benefits of your

online experience. Designed for use by all providers, the

tour takes you through each of AvMed’s services for

providers, explaining each page in detail. No Provider

number or PIN required for tour.

■ Click on Physicians & Care Providers

(upper right hand circle)

■ Click on Provider Services Online

■ Insert AvMed Provider ID

(AvMed six digit provider number)

■ Insert PIN

■ Click on Log In button

PROVIDER SERVICES ONLINE

Choose from the following menu options:

■ Important Communications

■ Authorization Requirements

■ Claim Entry

■ Claim Inquiries

■ Clear Claim Connection

■ Cost Share Calculator

■ Medicare Benefits References

■ Member Eligibility

■ Mini Health Record (printable)

■ Provider References

■ Referral Entry

■ Referral Inquiries

■ Chan ge My PIN

■ Update My E-mail Options

Important Communications

Recent important communications that have been mailed

or faxed to providers can be found here.

Authorization requirements

A detailed description of services requiring authorization,

quick tips and quick links to the following:

■ In-Office Laboratory Guidelines

■ Current list of Specific CPT4 Codes that do not require

authorization

■ Chapter 3 (Benefits Coordination/Utilization

Management) of the Physician Reference Guide

■ Current Authorization Request Fax Form

Claim Entry

This allows you to submit CMS1500 claims directly to AvMed via

our Web Site. To enter a claim online, follow the steps below:

1) Type the Patient/Insured’s last name and ID# and click

on the Patient Lookup button. You will be taken to

the CMS 1500 Form. The patient’s information will

automatically be populated.

2) Enter your Tax ID# and click the Lookup button. For

multiple providers with the same Tax ID#, a drop

down list will appear in order to select the treating

physician. The provider information will automatically

be populated.

3) Enter all required claim information into the CMS 1500

form and click the Submit button.

4) Once you click Submit, you will receive a confirmation

number. Please make a note of it for your records. Click

New Claim to continue, or End Session to end your

claims entry session.

Helpful Tips:

If a provider is not in our claim entry database, click on the

link at the top of the CMS 1500 form: “click here to enter

or modify provider data.”

The member information can be changed once it is

populated on the CMS 1500 form. If a patient is not found,

click on the New Patient Click Below button. You will be

able to status your claims within 24-48 hours.

Reporting Options

■ View Claims Log Sheet – This button will allow you to

view a spreadsheet of all claims done for the date of

entry you specify.

■ View Claim – This button will allow you to view a

spreadsheet of claims by one of the following options:

• Member ID and Date of Service

• Confirmation #

• User Name and Date of Service

Claim Inquiries – Search by:

■ Authorization Number

■ Claim Number

■ Member ID

■ Patient Account Number

■ Rejected Claims (EDI claims only)

■ Reports

• Provider claims received report

• Denied claims report

For detailed claim information, click on the highlighted

claim number.

Continued on other side

MP-4091 (05/08)


Web Site (continued)

Clear Claim Connection

You can view how AvMed’s code auditing software

evaluates code combinations during the adjudication of a

claim by entering certain claim data elements.

To run a claim through Clear Claim Connection,

follow these steps:

1) Click one of the gender buttons

2) Enter the member’s date of birth

3) Enter the procedure codes and

modifier (if applicable)

4) Enter the date of service

5) Enter the place of service

6) Click Review Claim Audit Results

The results will be shown with a recommended value of

“Allow, Disallow or Review.” A Clinical Edit Clarification will

be provided for claims with a recommendation value of

“Disallowed or Review.” To view a Clinical Edit Clarification,

double-click on the procedure line, and then click Review

Clinical Edit Clarification.

Cost Share Calculator

This allows you to calculate an estimate of the patient’s

responsibility at the time of service for AvMed members

with a deductible and/or co-insurance benefit plan.

Please note that this tool supplies an estimate of the final

cost for which the member is responsible. The actual value

will not be determined until the claim is adjudicated.

To get an estimate of the member’s responsibility through

the Cost Share Calculator, follow these steps:

1) Specify your county, the fee schedule your

contract stipulates, along with the reimbursement

percentage, then click Next

2) Enter member information including member

number, deductible remaining and applicable

co-insurance. Note: you can view deductible totals

and co-insurance values from a link where the

member information is entered

3) Enter CPT4 code information

4) Click Submit to display the estimated results for

member responsibility

MEdicare benefits references

This provides you with the current years Medicare Benefits

by Plan and County.

Member Eligibility – Search by:

■ Member ID

■ Member’s Name

■ Search your panel

■ List Your Panel (Individual or Group)

For detailed member information (including benefits),

click on the highlighted member number.

Mini Health record

Allows you to print a Mini Health Record for AvMed

members/patients prior to a visit or whenever the

information is required. The printable record shows the

last 90 days of medical claims, pharmacy claims and

authorizations.

Provider References – To obtain:

■ Medication List

■ Decision Support Center

■ Clinical Guidelines (Adobe Acrobat Required)

■ Orientation Documents

■ Provider Directory

Physician Reference Guide (Adobe Acrobat Required)

Referral Entry

To obtain authorization for simple referrals:

■ Enter Member ID number, referred to provider

number, diagnosis code, CPT code

■ Click the Request Authorization button on referral

entry screen

■ Authorization number with details will be displayed.

This information can be printed.

Note: At this time, referral entry is limited to those services

that are currently authorized automatically via AvMed Link

Referral Inquiries – Search by:

■ Inpatient Admission

■ Referred from provider

■ Referred to Provider

■ Inpatient by Tax ID Number

■ Request by Tax ID Number

For detailed authorization information, click on the

highlighted Authorization Number. Authorization

information can be printed.

In addition, from the AvMed Homepage via Useful

Shortcuts, the following can be accessed:

Continued on next page


Web Site (continued)

■ Urgent Care Centers

■ Medication List (If no Internet access please contact Provider

Services for a hard copy)

■ Contact Provider Services (allows you to e-mail AvMed’s

Provider Service Center)

change my pin

Allows you to change your current PIN. Please be aware that if

you choose to change your PIN, it will be necessary for you to

notify all internal and external users who will be conducting

business utilizing your PIN.

Update My E-mail Options

You can provide an e-mail address for communications.

Additional Web Site Resources

■ Online Provider Directory

■ Forms

■ Emergency Preparedness Resources

■ Electronic Data Interchange (EDI)

■ Provider Publications

■ Quality Improvement

■ Fraud, Waste and Abuse

■ Frequently Asked Questions

If you do not have either a Provider ID Number

or PIN Number, please contact the

Provider Service Center at 1-800-452-8633


OB/GYN

AvMed OB/GYN Guidelines

These guidelines are for AvMed’s Obstetrician’s,

Gynecologists, Midwives and their staff. They should answer

most questions regarding procedures for AvMed members.

OBSTETRICAL GUIDELINES

As an obstetrician, you become the member’s primary

care physician for the duration of the pregnancy. As such,

members whose plan requires PCP assignment must be

assigned to your panel of members. On or about the

1 st of each month, you will receive a monthly eligibility

listing. You can also obtain a current eligibility list on our

Web site at www.avmed.org. Please check this listing

when AvMed members present for services. If a member

whose plan requires PCP assignment is not on your

panel, please have the member contact Member Services

for re-assignment to your panel for the duration of her

pregnancy. Fetal non-stress tests performed in the office do

not require authorization. OB ultrasounds do not require

authorization. Please notify AvMed if the delivery does

not occur in a hospital.

AvMed’s global payment is inclusive of the delivery,

antepartum and postpartum care, as well as all hospital

and office services provided throughout the member’s

pregnancy. When billing with the appropriate industry

standard CPT code for the initial OB visit, the physician

will be paid $100. This amount is prepaid and deducted

from the global delivery fee and payment is contingent

upon care being provided throughout the pregnancy

(antepartum, delivery and postpartum). An additional

amount of $100 will be withheld when billing for global

OB care and will be reimbursed when postpartum care is

provided 21-56 days following delivery and accompanied

with CPT code 59430.

Note: In order to receive your full contract rate for complete

OB care, you must bill the initial OB visit and the postpartum

visits as indicated above.

Non-maternity related admissions are reimbursed on

a fee for service basis with authorization from AvMed’s

Pre-Authorization Department. Non-maternity office

visits submitted with a non-maternity diagnosis code are

also payable fee for service. The member’s co-payment/coinsurance

for each maternity visit is deducted from the

global maternity care payment. If AvMed does not receive

an itemized claim, a standard of 10 visit co-payments will

be deducted.

NOTE: If additional day of confinement falls on a weekend

or holiday, the physician may call for authorization on the

next working day.

Circumcisions performed in the hospital setting are

reimbursable under the authorization number for the

delivery. Circumcisions performed in office are covered up

to 12 months after birth, and authorization is not required.

In the event care is transferred or terminated during the

maternity care period, AvMed will pay antepartum care

using industry standard CPT codes. Billing guidelines for

antepartum care are as follows:

1-3 visits – bill appropriate Evaluation & Management CPT

codes (1 co-payment per visit will be deducted)

4-6 visits – bill using CPT code 59425 (6 co-payments will

be deducted from this code)

7 or more visits – bill using CPT code 59426

(10 co-payments will be deducted from this code).

HIGH-RISK GUIDELINES

AvMed Health Plans will continue to reimburse

additionally for pregnancies that are confirmed high risk

by the AvMed Medical Department. It is no longer a

requirement to bill the AvMed homegrown code for either

moderate or extreme high-risk pregnancies in order to

be reimbursed correctly. Once the provider has received

authorization approval for the high-risk pregnancy, the

provider will only bill for the appropriate global delivery

code, vaginal or C-section.

Continued on other side

MP-4092 (2/07)


When the claim is submitted and processed, the system

will reimburse based on the authorization in the system.

If two OB/GYN physicians, from separate practices, are

involved in the care of a member during an identified

high-risk pregnancy, the additional payment will be

divided between the two physicians.

Midwives are not eligible for reimbursement

of high-risk pregnancies.

Requesting authorization for high-risk:

When submitting an authorization request for a

pregnancy that is considered high-risk, indicate in the

Additional Information section of the authorization

form “Requesting High Risk Payment”. This will flag the

medical department to review for consideration. Be sure

to enter the Diagnosis Code for High-risk OB and attach

all necessary clinical documentation.

General Medical Criteria for High Risk Pregnancy

■ Multiple Gestation

■ Gestational diabetes or pre-gestational IDDM

■ Chronic hypertension on anti-hypertensive

medication or PIH prior to 37 weeks

■ Intrauterine growth retardation (IUGR) confirmed

by ultrasound

■ Preterm labor requiring tocolytic agents prior

to 37 weeks

■ Incompetent cervix

■ Uterine Fibroids (symptomatic during pregnancy)

■ Overweight when BMI equal to or > 30,

Underweight when BMI is equal to or < 19

■ Hemoglobinopathies including sickle cell disease,

excludes sickle cell trait

■ NYHA Class II, III and IV or cardiac history

(excludes MVP)

■ Chronic Renal Disease

■ Lupus

■ HIV Disease

■ Miscellaneous high-risk patients (Refer to

Medical Director)

GYNECOLOGY GUIDELINES

AvMed members may self refer for one annual

gynecological (well woman) exam per calendar year. Use

industry standard CPT codes with Dx. V72.31 when billing

for this service. Reminder, all lab specimens must be sent

to the AvMed contracted lab.

Authorization is not required when medically necessary

care is needed during the annual gynecological exam or

follow-up care afterwards. All gynecological surgeries

require authorization. Please do not schedule the surgery

until you have received written confirmation that it has

been authorized. This will avoid unnecessary delays in

the event additional information is needed to process the

authorization request.

FAMILY PLANNING

Family Planning is an AvMed covered benefit. Diaphragm

fitting with instructions and insertion of an IUD are payable.

Routinely, IUD supplies are not a covered benefit; please

contact Member Services for benefit verification.

Sterilization, both elective and for medical necessity,

is a covered service with authorization. Elective sterilization

may require a co-payment/co-insurance. Please contact

Member Services to verify the benefit and co-payment/

co-insurance amount. If sterilization is planned through

tubal ligation, authorization is not required. If sterilization

is planned through hysterectomy, authorization is required.

Contraception for birth control is a covered benefit

for members with a group RX benefit that includes

contraceptives. Please contact Member Services to

confirm whether a member has an RX plan that

includes contraceptives.

Depo Provera, when used as a contraceptive, is a covered

service if the member has the contraceptive rider on their

policy. No authorization is required for this service.

When used as a contraceptive, the member will have a

co-payment/co-insurance. Depo Provera, as a

contraceptive, can be administered two ways:

■ You may write a prescription for the drug. The pharmacy

would collect the co-payment/co-insurance, when the

member picks up the Depo. If the member returns to

your office for the injection and you bill for an office visit,

you may collect an office visit co-payment if applicable.

■ The office can supply the drug and collect the

co-payment/co-insurance. If you are billing an office

visit in addition to the Depo injection, an office visit

co-payment should be collected in addition to the

drug co-payment.

If Depo Provera is to be administered for medically

necessary reasons other than birth control, no

authorization is required. Co-payments are applicable

for medically necessary injectable contraceptives.

Termination of pregnancy procedures require

authorization, for groups with said benefit. Please

contact Member Services for benefit verification.


Q

A

Q

A

Q

A

Q

A

Q

A

Frequently Asked Questions

Do I file with the Tax ID or provider number?

You file with both your Federal Tax Number

and your AvMed provider number.

Why am I receiving rejects for member

information?

Verify that your Practice Management System

is submitting the patient’s full 11-digit AvMed

Member ID number and that it is being

submitted at the HIPAA patient level loop.

Must I bill with a modifier on EDI Claims?

The same rules apply as paper claims.

What is a Pin Number?

A Pin Number is an AvMed assigned and

secured number that is used to grant access to

our Web site and our Link Line. It is not part of

the EDI Claims submission.

How do I contact your EDI department?

AvMed does not have a separate EDI

department. Contact AvMed’s Provider Service

Center at 800-452-8633 with your questions.

Benefits of EDI

✔ Increased billing and data

entry accuracy

✔ Reduced adjudication and

payment cycle time

✔ Reduced operating cost

If you have questions, contact

AvMed’s Provider Service Center

at 800-452-8633 or write us an

e-mail at providers@avmed.org.

AvMed’s Provider Service Center

Online Portal is an excellent tool

for improving office efficiency.

Visit us at

www.avmed.org.

Electronic Data Interchange

for providers

E-Z

EDI

Steps


Provider Select:MD

A Comprehensive Cost Reduction Program for Physician Offices and Group Practices

Provider Select, an operations-improvement company focused on

the non-acute care market, is a unit of Premier, Inc., one of the

nation’s largest healthcare alliances. Provider Select is setting a new

standard in supply procurement, distribution and operating cost

reduction through an outstanding portfolio of products and services.

To remain competitive in an expanding and ever-changing marketplace,

physician offices and group practices must identify and

maximize cost-efficiencies while delivering quality patient care.

Our programs and services have demonstrated success at helping

physicians:

• Reduce costs in many areas of their operations,

• Better manage their purchasing, and

• Improve administrative functions.

• A comprehensive portfolio of high-quality products and services tailored

for the physician market.

• Savings on medical and non-medical products, equipment, and services.

• Medical supply distribution and supply management through one source –

McKesson Medical-Surgical – a proven leader in the physician market.

PROVIDER SELECT: MD’S COMMITTED DISTRIBUTOR

As a member of Provider Select: MD physicians and physician

clinics can access favorable pricing from a broad range of leading

healthcare manufacturers. Through our exclusive distribution

agreement with McKesson Medical-Surgical, part of the nation’s

largest multi-market distributor of pharmaceutical and medical

supplies, Provider Select manages the entire supply chain function

– from negotiating and contracting to inventory management and

Streamlining practice operations can help physicians increase their

competitiveness and create more time for quality assurance and

delivering patient care. Through our exclusive physician program

Provider Select: MD we offer measurable savings and unprecedented

opportunity for the physician to control and reduce supplyprocurement

costs and related operating expenses. Provider Select

combines the national purchasing power of Premier’s group

purchasing operations with a non-acute care-focused contracting

approach to address the diverse and unique needs of the physician

market. The comprehensive program encompasses medical supplies,

services, office products, capital, equipment, pharmaceuticals and

distribution.

PROVIDER SELECT: MD BENEFITS

Typical group purchasing organizations offer portfolios that do not

adequately cover products used by physicians. The comprehensive

Provider Select: MD portfolio includes medical and pharmaceutical

products as well as an extensive range of service agreements.

Provider Select: MD also offers:

• Simple participation requirements.

• Access to highly competitive pricing from market-leading manufacturers

and service companies.


superior distribution services. By providing valuable cost

reductions to physicians and group practices coupled with

competitive pricing, McKesson Medical-Surgical has partnered

with Provider Select to focus on lowering costs, improving

productivity and enhancing the quality of patient care.

The Primary Care Division of McKesson Medical-Surgical has a

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market while collaborating with practices to achieve cost

reductions and supply chain improvements. McKesson Medical-

Surgical is committed to delivering superior healthcare supply

chain management services by providing:

• A nationwide network of over 45 state-of-the-art service centers offering

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• The most extensive product lines in the industry, including more than 3,000

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In addition, Provider Select: MD customers have access to

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CLIA, and Medicare reimbursement.

PARTICIPATION REQUIREMENTS

In return for these outstanding benefits, Provider Select: MD

members agree to purchase at least 80 percent of their medical

supplies through McKesson Medical-Surgical. Provider Select: MD

is open to all physicians and group practices sponsored by a

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For more information about the rewards and benefits of

Provider Select: MD, call 877 777 1552.

For more information on McKesson Medical-Surgical,

call 888 234 7717, ext. 4456.

ABOUT PREMIER

Premier, Inc., is a strategic alliance in U.S. healthcare, entirely

owned by nearly 200 of the nation’s leading hospital and healthcare

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ABOUT MCKESSON CORPORATION

McKesson has provided healthcare products for more than

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premierinc.com

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