AvMed Physician

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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
Page 1 and 2: AvMed Physician Orientation Manual
Page 4 and 5: Physician Orientation Manual Table
Page 6 and 7: Claims Ninety-eight percent of AvMe
Page 8 and 9: For services requiring an authoriza
Page 10 and 11: Care Management Programs AvMed’s
Page 12 and 13: generic equivalent is available, mo
Page 14 and 15: Credentialing AvMed wants you to be
Page 16 and 17: Clinical Guidelines The NCQA* rates
Page 18 and 19: Authorization Request Form Link Lin
Page 20 and 21: AvMed Directory Information Change
Page 22 and 23: AVMED VERIFICATION FORM Dear AvMed
Page 24 and 25: AvMed Health Plans Order Form Pleas
Page 26 and 27: REQUEST FOR CLAIM: REVIEW APPEAL IN
Page 28: AvMed Risk Management Incident Repo
Page 32 and 33: AvMed ePay AvMed ePay AvMed ePay al
Page 34 and 35: Authorizations Authorization Tips S
Page 38 and 39: Web Site (continued) ■ Urgent Car
Page 40: When the claim is submitted and pro
Page 45 and 46: Provider Select:MD A Comprehensive

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