What are the names of the different CHA Health networks and how are they different from each other?
How do I get a list of participating providers and hospitals?
What criteria does CHA Health utilize to make medically necessary determinations?
Can I obtain a copy of the coverage criteria that CHA Health uses for making medical necessity determinations?
What are CHA Health's disease management programs?
What is HEDIS?
Please explain CHA Health's Prescription Drug Program.
Who is MedImpact? What do they do?
What is the MedPreferred program?
How do I verify a member's eligibility?
Can I submit claims electronically to CHA Health, and if so, what is CHA Health's electronic payor number?
What fields are required for submission of claims?
How do I check on the status of a claim?
What is CodeReview®?
How does CHA Health acknowledge claim payment?
What services are excluded from coverage by CHA Health?
What is the process for adding providers to CHA Health's network?
How often does CHA Health recredential practitioners?
What are CHA Health's access standards for appointments?
Can providers bill members for services?
What are the names of the different CHA Health networks and how are they different from each other?
CHA Health has three separate networks. They include:
1) Prime Network
CHA Health's Prime Network covers CHA Health's fully insured products, which include:
- PrimeCare Gold: HMO
- PrimeCare Platinum: Point-of-Service (POS)
- PrimeCare Silver: Preferred Provider Organization (PPO)
- State Employees: HMO, POS, PPO, EPO
2) Commonwealth Network
CHA Health's Commonwealth Network is for self-funded employers and is administered by Commonwealth Administrators. Questions regarding benefits, eligibility and claims should be directed to Commonwealth Administrators at 859-226-1500.
3) Preferred Network
Licensed Third Party Administrators (TPA) may lease our Preferred Network for a self-funded employer. Plans are designed by the employer. Questions regarding benefits, eligibility and claims should be directed to the TPA. Please see the back of the ID card for contact numbers and claim submission addresses.
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How do I get a list of participating providers and hospitals?
MyCHAinfo has the most up-to-date listing of providers. Additionally, CHA Health publishes an annual provider directory for each provider network: Prime, Commonwealth and Preferred. A copy can be requested by calling Member Services at 859-232-8686 or 800-457-5683. Please specify the name of the network when requesting a directory.
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What criteria does CHA Health utilize to make medically necessary determinations?
CHA Health has adopted InterQual® rule-based criteria for the determination of appropriateness of hospitalizations and most procedures requiring PPA. In addition, CHA Health has developed internal criteria (Technology Assessments/Coverage Guidelines) for some procedures and services requiring PPA. These criteria are objectively applied, utilizing clinical information provided by the member's physician or facility. All these criteria were developed by physicians based on published medical literature and current medical knowledge. Criteria utilized by CHA Health has been reviewed by physicians practicing in the relevant specialties, approved by the Peer Review/Utilization Management Committee (PR/UM) and adopted for use by CHA Health. The PR/UM Committee is made up of physicians who practice in Kentucky and participate in the CHA Health physician network.
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Can I obtain a copy of the coverage criteria that CHA Health uses for making medical necessity determinations?
Requests for copies of specific coverage criteria may be made by contacting Medical Management at 859-232-8686 or 800-457-5683.
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What are CHA Health's disease management programs?
In addition to CHA Health's Nurse411™ service which provides our members with toll-free access to registered nurses 24 hours a day, seven days a week, CHA Health has three disease management programs.
1) Healthy Heart
CHA Health, together with QMed Interactive Heart Management Corp. (IHMC), provides an innovative program for managing coronary artery disease (CAD). The Healthy Heart program, with focus on early detection and improved treatment for CAD, is designed to strengthen the relationship between the patient and their physician, where the physician facilitates treatment to promote coronary wellness and improve clinical outcomes. Our goal is to provide patient education and improve the treatment of CAD in an effort to help members lead a long, healthy life. For more information, contact your Provider Relations Representative at 859-232-8686 or 800-457-5683 or the IHMC Account Manager at 888-925-0474. To refer a patient, please contact the Program Manager/CVD Services at 859-232-8623 or 800-457-5683, ext. 8623.
2) Healthy Horizons
Healthy Horizons, CHA Health's cancer disease management program, is administered by Quality Oncology, Inc. Quality Oncology provides a comprehensive cancer care program that facilitates, monitors and coordinates the cancer care of patients from tissue diagnosis through active treatment and into follow-up. It is our goal to have Quality Oncology involved as early as possible to ensure that our members are receiving advice and support throughout their treatments. For more information, contact your Provider Relations Representative at 859-232-8686 or 800-457-5683. To refer a patient or to contact Quality Oncology directly, please call 800-229-8073.
3) Healthy Beginnings
Designed to give mothers and their babies a healthy start together, Healthy Beginnings encourages appropriate prenatal care, provides early and ongoing education to pregnant women, and identifies those with the potential for developing complications, such as pre-term labor. To refer a patient for enrollment, please contact the Member Services department at 859-232-8686 or 800-457-5683.
4) Healthy Airways
Especially for CHA Health members with asthma and COPD (Chronic Obstructive Pulmonary Disease), Healthy Airways is a wellness program that seeks to improve the health and life of those with chronic respiratory disease. The program focuses on self-care, prevention and intervention, education, support, quality of life improvements and reducing complications. Real results can be measured in quality of life improvements such as reduced days of missed school and work, and a reduction in nighttime awakenings, emergency room visits, and hospital admissions.
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What is HEDIS?
HEDIS (Health Plan Employer Data and Information Set) is a set of 60 standardized performance measures designed to give employers and members information to reliably compare the performance of managed care organizations. HEDIS measures target areas such as effectiveness of care, access and availability of care, and satisfaction with the experience of care.
HEDIS was developed by the National Committee for Quality Assurance (NCQA), an independent, not-for-profit organization whose mission is to improve the quality of health care. The NCQA HEDIS Compliance Audit™ indicates whether a managed care organization has adequate and sound capabilities for processing medical, member and provider information as a foundation for accurate and automated performance measurement, including HEDIS reporting.
A representative may contact you to request an appointment for medical record review.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
NCQA HEDIS Compliance Audit™ is a trademark of the National Committee for Quality Assurance (NCQA).
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Please explain CHA Health's Prescription Drug Program.
CHA Health's three-tier drug program helps physicians choose appropriate drug therapy while controlling pharmacy expenses for the member. Physicians may assist members in managing out-of-pocket expenses by prescribing generic and preferred brand medications when appropriate.
Our prescription drug program includes generic, preferred and non-preferred medications. Generic drugs are the most affordable way to obtain quality medications at the lowest cost. Preferred brands have no generic equivalent and are covered at a higher cost. Non-preferred brands have either an equally effective and less costly generic equivalent, or one or more preferred brand options. Most benefit plans cover non-preferred brands at the highest cost. Complete information about CHA Health's Prescription Drug Program is available in your Provider Office Manual or on the home page of the web site www.cha-health.com.
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Who is MedImpact? What do they do?
MedImpact is CHA Health's Pharmacy Benefits Manager. They contract with pharmacies to provide prescription services to eligible members of CHA Health. MedImpact provides prescription claim processing, payment, eligibility verification and processes prior authorization requests. The Pharmacy Help Desk at 800-788-2949 can answer questions from patients, providers or pharmacists.
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What is the MedPreferred program?
MedPreferred is a program administered by MedImpact on behalf of CHA Health that notifies physicians regarding the availability of lower cost prescriptions for our members based on CHA Health's formulary. When a physician prescribes a non-preferred medication, a fax is sent to the physician detailing generic and preferred brand alternatives. The physician is free to decide if a change in medicine is right for the patient. The change may be faxed back to MedImpact and will serve as the patient's new prescription.
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How do I verify a member's eligibility?
The easiest way to verify eligibility is to log onto myCHAinfo. CHA Health also makes eligibility data available electronically using point of sale devices via MediFAX at www. medifax.com and Medicheck at www.medicheck.com. Eligibility information may also be obtained by or by calling Member Services at 859-232-8686 or 800-457-5683.
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Can I submit claims electronically to CHA Health, and if so, what is CHA Health's electronic payor number?
CHA Health accepts electronic claim submission through ENVOY/WebMD. The CHA Health Submitter ID # is 23171. If you have questions about claims specifications for electronic submission, please contact our ENVOY/WebMD representative at 800-845-6592.
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What fields are required for submission of claims?
Filing clean and accurate claims to CHA Health will ensure prompt processing and payment. Kentucky Revised Statutes 304.17A - 700 (3) defines a 'clean claim' as a properly completed billing instrument that does not involve:
- Coordination of benefits for third-party liability;
- Pre-existing condition investigations; or
- Subrogration
Clean claims must include all information necessary to process the claim, including any CHA Health required attachments. Claims filed to CHA Health without the appropriate attachments will not be considered clean, and may result in delayed processing and payment to your office.
Required attachments:
- Emergency Room Notes must be attached to the institutional bill for hospitals without an ER case rate.
- Itemized statements are required to be attached to all outpatient physical, speech and occupational therapy claims.
- Itemized statements are required for hospitals with a percent billed reimbursement contract.
- Invoices detailing provider cost must be attached to the institutional bill for all claims involving implants, represented by Revenue Code 278 if required.
- Medical records supporting the use and authorization of Air Ambulance Services (to be included with the Air Ambulance claim).
- Explanations of benefit from third party payors for members with primary coverage other than CHA Health must be attached to all professional and institutional claims, as applicable.
On occasion, claims submitted to CHA Health may require additional review and may request additional clinical or administrative documentation.
All claims for professional services must be filed using the National HCFA-1500 form, or its electronic equivalent. All professional claims must:
- Comply with contractually established timely filing limits
- Include appropriate member information such as: insured's ID number, patient name, patient date of birth, patient sex, patient address, patient relationship to insured and insured's policy group number.
- Utilize current CPT-4 procedure codes and or ICD-9 diagnosis codes
- ·Include all applicable modifiers
- Specify date, place, and type of service rendered, as well as charges.
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How do I check on the status of a claim?
Claims status can be obtained by logging onto myCHAinfo. Claims status can also be verified by calling Member Services at 859-232-8686 or 800-457-5683, option 5.
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What is CodeReview®?
CodeReview® is an expert system designed to objectively evaluate medical billing information and CPT-4 coding for accuracy. The CodeReview® program assists in the review of claims processing by providing accuracy and consistency to the claims payment process.
CodeReview® contains a comprehensive set of rules, or criteria, for all clinical areas of medicine, surgery, laboratory, pathology, radiology and anesthesiology. These criteria address coding inaccuracies that result from unbundling, fragmentation, upcoding, duplicate coding, invalid codes and mutually exclusive procedures.
CodeReview® is applied by CHA Health to each individual claim, and also on a historical basis. Historical CodeReview® allows for the review of multiple claims submitted for an individual member within a specified time frame, and will address coding inaccuracies across claims history.
Questions or concerns regarding CodeReview® denials or adjustments should be addressed in writing to: CHA Health, Attention: CodeReview® , P.O. Box 23468, Lexington, KY 40523
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How does CHA Health acknowledge claim payment?
All reimbursement checks to providers are accompanied by a Remittance Advice. See your Provider Manual for a sample Remittance Advice.
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What services are excluded from coverage by CHA Health?
Please refer to your Provider Manual for a complete list of exclusions. If you have additional questions, you may contact Member Services at 859-232-8686 or 800-457-5683.
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What is the process for adding providers to CHA Health's network?
Providers requesting to participate with CHA Health must sign the standard CHA Health Participating Provider Agreement and complete a credentialing application. The credentialing process takes 60 to 90 days. Providers must be credentialed before they provide services to members under the terms of the provider agreement.
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How often does CHA Health recredential practitioners?
CHA Health formally recredentials its practitioners every three years. As part of this process, CHA Health re-verifies the credentialing information that is subject to change over time. The intent of this process is to identify any changes in the practitioner's ability to perform contracted services. In addition, CHA Health checks patterns of practice compared to their peers.
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What are CHA Health's access standards for appointments?
CHA Health has established the following access standards for appointments.
- Medical Emergency Care: immediate service on request
- Medical Urgent Care Appointments: same day or next day
- Medical Routine Primary Care Appointments: within one week
- Medical Ongoing Follow-up: within 2 weeks
- Medical Preventive Care Appointments: within 4 weeks
- Medical After-Hours Calls: returned based on the urgency of the member's complaint
- Behavioral Life-Threatening Emergency Care: immediate service on request
- Behavioral Non-Life Threatening Emergency Care: within 6 hours
- Behavioral Urgent Care: within 48 hours
- Behavioral Routine Office Visit: within 10 working days
Additionally, Primary Care Physicians are required to have 24-hour access for CHA Health members. It is the provider's responsibility to maintain these standards when scheduling appointments for CHA Health members.
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Can providers bill members for services?
Providers may collect any applicable copayments, deductibles, or co-insurance from a member, but may not bill, charge or try to collect any other amounts from a member for a covered service or a denial based on medical necessity or failure to obtain Plan authorization (PPA).
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