Provider Manual

[Pages:31]Provider Manual

Revised 12/22/2010

Revisions will be noted in bold and italics.

Table of Contents

Chapter One ? First Choice Health Information

1

? Introduction

1

? General Information

1

? How to contact us

2

? Business profile

2

Chapter Two ? Web Page

4

? Provider Web Pages

4

? Payor / Employer Group Search

5

? Publications

6

? Reference materials

6

? Contracted Network Providers

6

? Priced Claims Status Inquiry

6

? Claims Activity Reports

7

Chapter Three ? Claims and Billing

8

? Claim form

8

? Anesthesia claims

9

? Modifiers

9

? NPI

9

? Where to send claims

9

? Payment of claims

9

? Priced Claims Status (secure)

10

? Sample ID cards

10

? Eligibility and Benefits

10

? Prior Authorization

10

? Claims appeals

10

? Coordination of Benefits (COB)

11

? Collecting money at time of service

11

Chapter Four ? Payment Overview

12

? Anesthesia claims

12

? Modifiers

12

? Code editing software

14

? Supplies for Immunization Injections

15

? Supplied Vaccine Program

15

Chapter Five ? Payor Information

16

? Eligibility and Benefits

16

? ID cards

16

? Explanation of payment (EOP/EOB)

17

Chapter Six ? Credentialing

18

? Credentialing and Re-credentialing

18

? Provider Effective Date Assignment

18

? Rules for Retroactive Assignment Date

19

? Locum Tenens

19

? Providers' Right to Review

19

? Criteria for Denial of Credentialing or Re-credentialing Application or Termination

20

? Termination

22

? Appeals Process

23

? Level One Appeal

23

? Level Two Appeals

23

Chapter Seven ? Quality

26

Chapter Eight ? Frequently Asked Questions

27

Chapter One: PPO Network

Introduction

Welcome to the First Choice Health PPO Network! The purpose of this manual is to provide you with the basic information that you and your office staff need when seeing our PPO Network patients. This manual provides you with direction and clarification regarding your obligations as a PPO Network provider. This information is also available on our web site at: . Please check the web site periodically to ensure that your manual information is up-to-date. Notifications of manual updates are published in our quarterly newsletter.

General Information

First Choice Health is a Seattle-based, physician and hospital owned company that has served Washington and the Northwest since 1985. We now serve well over one million people with our array of products and services. First Choice Health's Preferred Provider Organization (PPO Network) is recognized as the leading independent PPO Network in Washington State and has a growing regional presence in Oregon, Idaho, Montana and Alaska. Our network offers over 42,000 directly contracted and credentialed providers and 220 hospitals used by a wide variety of insurance companies, third party administrators, and plan sponsors. In addition to our PPO Network, First Choice Health offers Medical Management Services, an Employee Assistance Program (EAP), a Physician Assistance Program (PAP), and Third Party Administration (TPA).

First Choice Health | One Union Square | 600 University Street, Suite 1400 | Seattle, WA 98101

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How to Contact us

Provider Relations can be contacted directly at (800) 231-6935 extension 2103. We can also be contacted via email at ProviderRelations@. Any information that a provider needs about working with First Choice Health Network can be found on the provider web page at .

Business Profile

Management

Kenneth A. Hamm, President & CEO

Curtis Taylor, V.P. & Chief Marketing Officer

Jacque Brainard, V.P. of Operations

Jeff Robertson, M.D., V.P. & Chief Medical Officer

Sara Kasper, V.P. of TPA Operations

Warren Maxwell, V.P. of Finance

Board of Directors

Kathryn D. Beattie, M.D. CEO Valley Medical Center

Diane E. Cecchettini, R.N., CEO MultiCare System

Gerald A. Cufley, M.D., Board Vice Chairman

Paul M. Elliott, Board Chairman

John V. Fletcher, V.P. Providence Health System

William Gilbert, CEO, Deaconess Medical Center

Dan Greening, Consultant

Craig Hendrickson, CEO Overlake Hospital Medical Center

William F. Johnston, M.D., Northwest Hospital

Shareholder Hospitals

Evergreen Health System, Kirkland Good Samaritan Community Healthcare, Puyallup MultiCare Health System, Tacoma Northwest Hospital, Seattle Overlake Hospital Medical Center, Bellevue Providence Health System, Seattle Spokane Washington Hospital Co., LLC Spokane Stevens Healthcare, Edmonds Swedish Health Services, Seattle Valley Medical Center, Renton University of Washington Medical Center, Seattle

Shareholder Physicians

Associated Emergency Physicians, Inc.

Colville Medical Center, P. S.

Covington Primary Care

Eastside Gastroenterology Consultants

First Choice Health | One Union Square | 600 University Street, Suite 1400 | Seattle, WA 98101

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Calvin K. Knight, CEO, Swedish Health Services

Scott F. Kronlund, M.D., Physician Consultant

Barbara L. Mitchell, Employer Representative

Erica V. Peavy, M.D., The Everett Clinic

Richard A. McGee, M.D., US Oncology

Richard E. Rust, M.D., Emeritus

Peter Rutherford, M.D. Board Chair Wenatchee Valley Clinic

Johnese Spisso, COO, University of WA Medicine

Clyde D. Walker, Sr. V.P., Continental Mills

Mitchell B. Weinberg, M.D., Evergreen Healthcare

Book of Business by Class

Edmonds Emergency Medicine Evergreen Medical Group Minor & James Medical, P.L.L.C. North Seattle Women's Group Northwest Emergency Physicians Proliance Surgeons, Inc. P. S. Puget Sound Family Physicians Summit View Clinic Tacoma Emergency Care Physicians Tacoma Radiology Associates The Everett Clinic

35% Insurance Companies

Valley Anesthesia Associates

18% Union Trusts

Valley Internal Medicine

28% Self-Insured Groups/TPA's

Valley Radiologists, Inc.

15% National Networks

Washington Sports Medicine

3% Employer

Wenatchee Valley Medical Center

1% Other

Western Radiology Associates

PPO Network Membership - Total eligible employees and dependents: 970,000

First Choice Health | One Union Square | 600 University Street, Suite 1400 | Seattle, WA 98101

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Chapter two: Web Page

Provider Web pages

The Provider Web pages have been substantially updated in order to serve as a functional tool and help our providers understand the First Choice Health Network business model and how to operate within it. Several new areas of the web have been added over the past year. To get to the provider web pages, follow this link:

The navigational bar on the left lists out the tools available to all Providers. The following tools are the most frequently used.

First Choice Health | One Union Square | 600 University Street, Suite 1400 | Seattle, WA 98101

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Payor / Employer Group Search:

This is a "real time" search tool where Providers have access to view the most current First Choice Health Network payor and employer group information. Providers can search by Payor Name, Employer/Group Name or Employer/Group Number.

Providers can also upload the most current copy of our List of Payors (Yellow Pages) in this section. The Employer Group List (Blue Pages) can be found in this section as well. This file is run on a monthly basis as a pdf file, however, and may not have the most current information. Your preferred tool should be the "real time" Payor and Employer Group Search.

First Choice Health | One Union Square | 600 University Street, Suite 1400 | Seattle, WA 98101

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