PROVIDER INFORMATION - Your Benefits At Work™ - Allegiance

PROVIDER INFORMATION

FOR THE STATE OF MONTANA EMPLOYEE BENEFIT PLAN

Table of Contents

I. State of Montana Employee Benefit Plan ? 2016 Updated Third Party Administrative (TPA) Services ? ID cards ? Verification of Benefits

II. Pre-notification III. Air Ambulance Services

? In-Network Air Ambulance Providers IV. Claim submission and payment

? Claim submission ? Sample Explanation of Benefits V. Provider Online Resources VI. Contact Information

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State of Montana Employee Benefit Plan

STATE OF MONTANA EMPLOYEE BENEFIT PLAN

? Effective January 1, 2016 the State of Montana Employee Benefit Plan (SoMT) will have new ID cards which will have a new group number: 3000900 and members will have new ID numbers

? Allegiance Provider Direct currently serves as the provider network for the (SoMT) and will continue to serve as the provider network in 2016

? Services you provide on or after January 1, 2016, will be processed by Allegiance. Payment for services you provide on or before December 31, 2015, will be processed by Cigna

? Providers will continue to submit all medical and vision claims to the Allegiance Payer ID 81040, PO Box 3018, Missoula, MT 59806-3018. For services provided prior to January 1, 2016 Allegiance will price the claim and send to Cigna for processing

? Members will receive a new health ID card in the mail prior to January 1, 2016 with updated group and identification numbers and contact information

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State of Montana Employee Benefit Plan

UPDATED ID CARDS ? EFFECTIVE 1/1/2016

? Effective January 1, 2016, Allegiance Benefit Plan Management (ABPM) will serve as the Third Party Administrator (TPA) for the SoMT

? Providers will need to update their systems with the updated information located on the patient ID cards for all services rendered on or after 1/1/2016

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State of Montana Employee Benefit Plan

VERIFICATION OF BENEFITS

? Online verification of benefits to estimate benefit levels and coverage ?

? To verify health plan specifics, contact customer service at (855) 999-1057 ? 24-hour Faxback Verification of Coverage:

(855) 999-1057 or (406) 523-3199

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