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 


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 





■ 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 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. 


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 


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 





■ 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. 


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 


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 





■ 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 


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 


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 





■ Member benefits 

■ Eligibility 

■ Product information 


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 


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 


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. 





■ Credentialing 

■ Re-credentialing 

■ Ambulatory Site Standards 


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 


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. 





■ Quality Activities 

■ Advance Directives 

■ Disrobing Guidelines 

■ Risk Management 

■ A sample Membership 

Satisfaction Survey 


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 





■ 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: 



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 





Third Location: 

County 





Fourth Location: 

County 




( ) 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: 


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.)


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 


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) 


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 


Open 

Access 


Consumer 


HSA-Compatible 

HDHPs 


Classic 


Open 

Access POS 


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)


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 




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. 


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. 


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 

long history of servicing physician practices. Field-sales account 

managers respond to the specialized needs of the primary care 

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 

the most flexible distribution programs to meet the individual needs of each 

customer 

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

manufacturers and over 135,000 line items of product inventory 

• Experienced primary-care account managers to support inventory 

management using sophisticated information systems, customized order 

forms, and detailed product usage reports 

• Assistance with inventory levels, product standardization and Provider 

Select: MD contract utilization 

In addition, Provider Select: MD customers have access to 

educational programs to address industry issues and product 

information. These materials, including newsletters, videos and 

training manuals, inform customers on topics such as OSHA, 

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 

Premier acute care facility. 

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 

systems. These systems operate or are affiliated with nearly 1,500 

hospital facilities in 50 states and hundreds of other care sites. 

Premier provides an array of resources supporting health services 

delivery, including group purchasing of $17 billion annually in 

supplies and equipment. Other resources offered by Premier are 

insurance programs and performance improvement services of 

many kinds. Premier is headquartered in San Diego, CA, with 

other major facilities in Chicago, IL, and Charlotte, NC. Advocacy 

and policy offices are located in Washington, DC. For more 

information, please visit www.premierinc.com. 

ABOUT MCKESSON CORPORATION 

McKesson has provided healthcare products for more than 

165 years. A publicly traded Fortune 40 company, McKesson has 

become the largest multi-market distributor of pharmaceutical 

and medical/surgical supplies while exceeding industry-leading 

standards for availability, accuracy, and efficiency. McKesson is 

committed to being the leader in healthcare supply management 

by providing tools, technologies and logistics programs such as 

Optima, SupplyNET, and ROBOT-Rx to help its customers exceed 

their goals for cost control and quality improvement. 

premierinc.com

AvMed Physician

Create successful ePaper yourself

Delete template?

Save as template?