november 2017 prohealth provider relations update 2017 prohealth provider relations update ......
TRANSCRIPT
1
November 2017
P r o H e a l t h P r o v i d e r R e l a t i o n s
U p d a t e
I N S I D E T H I S I S S U E :
1 ePower
1 New Provider Credentialing
1 2018 - New & Termed Payors
2 Updates on PA Requests
2 MRIs of the Spine
2 PAs Medicaid Eligible 8/1/2017
3-4 New Providers, effective
11/1/2017
5 Termed Providers
5-6 CareSource Medicare Terming
7 Better Doctor, Inc. Validation
8 VHG - Healthcare & Business
Consulting
ePower
ProHealth’s ePower (Provider Portal) is now available on our
website at:
https://www.ecommunity.com/community-prohealth/
provider-relations
Providers may login and use ePower to check claim status,
eligibility and more.
Credentialing of New Providers:
*PLEASE NOTE*
Credentialing through ProHealth for ALL new providers can take anywhere from 90-120 days from notification to completion.
The Credentialing fee has increased to $200 for ALL new providers wishing to join the Community/ProHealth network, effective 11/1/2016.
ProHealth Credentialing/Enrollment Supervisor:
Jenna White
Phone#: (317)621-9312
New Payors for CHNw Employed/CPN providers, effective 1/1/2018:
AllWell (MHS Medicare) - ALL CHNw Employed/CPN providers
Community Health Direct - ALL Tier 1 providers (Basic PPO Plan)
Humana Military - ALL CHNw Employed/CPN providers
Payors Terming for CHNw Employed/CPN providers, effective 12/31/2017:
CareSource Medicare
MDWise Marketplace
Anthem Pathway (Marketplace plan)
Anthem PathwayX (Marketplace plan)
2
Update on Prior Authorization Requests:
Due to regulatory and legal issues, ProHealth will no longer allow providers to withdraw prior authorization requests that list incorrect tests or procedures. Any request submitted with incorrect information will result in a denial of the request, and the provider and member will be notified by mail. A new prior authorization request must then be submitted with the correct test or procedure for review.
MRIs of the Spine:
In order to clarify the criteria used for reviews of MRIs of the spine in adults, the following must be submitted within the clinical information:
1) Rule out syringomyelia, transverse myelitis or demyelinating condition
2) Suspected post-operative spinal complication or known trauma
3) Acute onset of back pain where no red flag symptoms are present will require documentation of a minimum of 6 weeks of conservative management, that includes two of these three treatments:
A. NSAIDs or acetaminophen/analgesics and/or oral steroids for > 3 weeks (Unless contraindicat-ed or not tolerated)
B. Physical therapy and/or a home exercise program for ≥ 6 weeks
C. Activity modification for ≥ 6 weeks
4) Red flag symptoms associated with back pain
A. Unexplained weight loss
B. Unexplained fever
C. Immunosuppression
D. History of cancer
E. Bowel or bladder incontinence
F. Severe nighttime pain
G. Saddle anesthesia
H. Prolonged use of corticosteroids, osteoporosis
I. Age > 70
Physician Assistants Now Eligible for Medicaid:
*PLEASE NOTE*
Effective 8/1/2017, Physician Assistants (PAs) are now eligible to be enrolled in Indiana Medicaid. If you are an inde-
pendent provider who has signed a contract with Community ProHealth to be enrolled in CHNw MDwise (HIP &
HHW) and wish to have your PAs enrolled in these plans, please contact your ProHealth Provider Relations Analyst so
they can start the process.
Dawn Widgery, Provider Relations Analyst Carol Boyd, Provider Relations Analyst
Phone#: (317)621-7462 Phone#: (317)621-7923
3
Contract ing and Credentia l ing Corner Providers Joining ProHealth
We would like to welcome the following providers to the ProHealth Network effective November 1, 2017.
Hospital affiliations will be listed with each provider.
Prime SCP
Chapman LCSW, Peppi A. - Behavioral Health
Gallahue Mental Health Services (Employed)
Drew LMFT, Jennifer - Behavioral Health
Gallahue Mental Health Services (Employed)
Elsinger MD, Swapna - Otolaryngology
Otolaryngology Associates, LLC - CHE/CHN, CHV, CHS
Haynes LCSW, Elwanda - Behavioral Health
Gallahue Mental Health Services (Employed)
Hussey MD, Richard W. - Pediatric Neurology
Josephson Wallack Munshower Neurology, P.C. - CHE/CHN, CHV, CHS
Leising LCSW, Kathryn S. - Behavioral Health
Gallahue Mental Health Services (Employed)
Lin MD, David - Orthopedic Surgery
CPN, Orthopedic Specialty Care - Anderson (Employed) - CHA
Majors LCSW, Danielle L. - Behavioral Health
Gallahue Mental Health Services (Employed)
Maloy MD, Kelsey M. - Anesthesiology
Community Anesthesia Associates, P.C. - CHE/CHN, CHV
Moore CGC, Jennifer - Genetic Counseling
Maternal-Fetal Medicine Comprehensive Care (Employed)
Morrow MD, PhD, Jay T. - Vascular & Interventional Radiology
Summit Radiology, PC - CHRH, CHSH
Motashaw DO, Veera - Hospice & Palliative Medicine
Palliative Care Services (Employed) - CHE/CHN, CHV
Okwechime MD, Josephine - Dermatology
Suburban Dermatology - CHRH
Pabon MD, Sheila - Opthalmology
Corneal Consultants of Indiana - CHE/CHN, CHV
Peragallo LCSW, Lianna - Behavioral Health
Gallahue Mental Health Services (Employed)
Power MD, Megan E. - Anesthesiology
Southeast Anesthesiologists, PC - CHS, CSC-S
Robbins LMHC, Andrew - Behavioral Health
Gallahue Mental Health Services (Employed)
Roussey LCSW, Kyle T. - Behavioral Health
Community Howard Behavioral Health (Employed)
Vincent MD, Robert - Gastroenterology
Indianapolis Gastroenterology & Hepatology - CHS
Watts LCSW, Angela - Behavioral Health
Gallahue Mental Health Services (Employed)
4
Prime SCP Advanced Practice Practitioners
Byrum NP, Kimberly - Nurse Practitioner
Community Physician Network, Orthopedic Specialty Care (Employed)
Caress PA, Serena - Physician Assistant
Radiology of Indiana
Davis NP, Caitlin E. - Nurse Practitioner
St. Francis Medical Group / IIMC
Fish NP, Michelle S. - Nurse Practitioner
Gastroenterology Care (Employed) - CHE/CHN, CHV
Fuss NP, Joyce A. - Nurse Practitioner
St. Francis Medical Group / IIMC
Greenwalt MP, Mary L. - Nurse Practitioner
Community Physician Network, Heart and Vascular Care (Employed)
Grubb NP, Emily - Nurse Practitioner
JWM Neurology
Hamilton PA, Nicole - Physician Assistant
Indianapolis Gastroenterology & Hepatology
Hubbard NP, Laurel A. - Nurse Practitioner
Community Physician Network, Heart and Vascular Care (Employed)
Marquez NP, Linda - Nurse Practitioner
Community Physician Network, Heart and Vascular Care (Employed)
Morris NP, Angela D. - Nurse Practitioner
Family Medicine, Pediatric and Ob/Gyn Care, CLMP (Employed)
Randall NP, Andrea - Nurse Practitioner
JWM Neurology
Rominger NP, Helen C. - Nurse Practitioner
Damien Cares
Scherschel PA, Matthew - Physician Assistant
Community Physician Network, Heart and Vascular Care (Employed)
Prime PCP
Bergfeld MD, Sara B. - Pediatrics
Community Pediatric Hospitalists (Employed) - CHE/CHN, CHV
Morad MD, Mohamed H. - Internal Medicine
St. Francis Medical Group / IIMC - CHS
Prime PCP Advanced Practice Practitioners
Oakley NP, Lisa - Nurse Practitioner
Community Physician Network, Family Medicine Care (Employed)
Stephenson NP, Kathryne W. - Nurse Practitioner
Northpoint Pediatrics
Contract ing and Credentia l ing Corner Providers Joining ProHealth
We would like to welcome the following providers to the ProHealth Network effective November 1, 2017.
Hospital affiliations will be listed with each provider.
5
Termed Providers
The following providers will no longer be participating with ProHealth:
Brinson PA, Kyle - Physician Assistant, termed 10/1/2017.
Community Physician Network, Heart and Vascular Care (Employed)
Choi DO, Peter Y. - Family Medicine, termed 10/1/2017.
Community Physician Network, Family Medicine Care (Employed)
Daugherty LCSW, Deborah L. - Licensed Clinical Social Worker, termed 10/17/2017.
Anderson Psychiatric Clinic, LLC
Fuller-Nave NP, Mary K. - Nurse Practitioner, termed 10/1/2017.
Community Physician Network, Heart and Vascular Care (Employed)
Lawson NP, Terri L. - Nurse Practitioner, termed 10/1/2017.
Community Physician Network, MedCheck (Employed)
Nichols DO, James T. - Family Medicine, termed 10/1/2017.
Community Physician Network, Family Medicine Care (Employed)
Torres MD, Michelle - Internal Medicine, termed 10/1/2017.
Community Physician Network, Internal Medicine Care (Employed)
Ullah MD, Asad - Neurology, termed 10/31/2017.
Albert C Lee, M.D. P.C.
Attention Community-Employed Practices: CareSource Medicare Advantage Indiana Exit Announced:
Effective January 1, 2018, CareSource Medicare Advantage product will no longer be sold in Indiana
and Kentucky areas. The CareSource Medicare plan has mailed letters to their members as well as providers
impacted by this change. Community Health Network employed practices, please remember: Medicare open
enrollment starts October 15, 2017 and runs through December 7, 2017. During open enrollment, CareSource
Medicare patients will have the opportunity to choose another plan for the January 2018 coverage year. These
members will maintain their CareSource Medicare coverage until 12/31/17. Please direct all member ques-
tions to CareSource Medicare at 1-855-202-0557.
Community Health Network is contracted with various Medicare Advantage plans. For a list of those plans or
questions of what plans do we accept, please call ProHealth Provider Relations at 317-621-7581.
6
7
BETTER DOCTOR, INC. VALIDATION - Employed Providers :
Many Community employed practices have received phone calls or faxes from a company by the name of Better Doctor,
Inc. This organization is a third party vendor that seeks contracts with many of the Medicare Advantage (MA) plans to
verify provider data on a quarterly basis. CMS has required all MA companies to verify data on a quarterly
basis. Community Health Network has contracts in place with several of the MA companies. ProHealth transmits
provider demographic data to these organizations on a bi-weekly basis. Please do not verify provider data either via fax
or phone with Better Doctor, Inc. at the practice level. The provider data is shared by ProHealth to the MA companies
bi-weekly on your behalf. We have reached out to the MA plans and Better Doctor, Inc. to assist in streamlining their
process and ask that they do not contact our offices for this project. It has been communicated to Better Doctor, Inc. that
we do not verify provider data at the practice level.
If you have further questions or concerns, please contact Lori White, Medicare Program Manager, ProHealth
[email protected] or 317-621-7461.
8
Visionary Health Group veicorp.com/consulting Are you an independent practice that needs consulting/financial help? ...
Integrated physician consulting services
A division of VEI since 1987, Visionary Health Group (VHG), formerly known as Indianapolis Medical Management
(IMM), has provided physician practice management and consulting services for more than 20 years. VHG prides itself
in providing comprehensive, tailor-made services that meet and exceed the needs of its physician clients. VHG’s con-
sulting and evaluation services have been designed to objectively evaluate every aspect of a medical practice and to
provide realistic solutions to the challenges faced by physicians today. VHG offers a diverse team of skilled individuals
to assist you with your various practice needs.
*Complimentary business assessment available upon request*
Consulting and practice operations
Business healthcare consulting
Revenue cycle management
Documentation and coding experts
Financial consulting and reporting
Payer credentialing and enrollment
Practice/business start-up
Full suite of human resource services
OSHA/HIPAA compliance
Project management
Process improvement
Development of policy and procedures
Please Contact: Tara Rieman
Director, Provider Operations Ph#: (317)621-7066
Pat Schmitter, CPC, CPC-I Senior Healthcare Consultant
Ph#: (317)621-7187 [email protected]
Joni A. Reed, MBA, BSBA, ASB, CMA Jamie L. McAllister, MA Business Consultant - Physician Services Business Consultant
Ph#: (317)621-1539 Ph#: (317)621-7521 [email protected] [email protected]
Anita Huse, RN, CAPPM Pam Cawood, CPPM
Business Consultant - Physician Services Business Consultant - Physician Services Ph#: (317)621-4090 Ph#: (317)621-1537
9
Department Staff
Manager Provider Relations:
Jenny Bouck, [email protected]
Business Information Coordinator
Hollie Putzback, [email protected]
Provider Relations Analysts:
Carol Boyd, [email protected]
Dawn Widgery, [email protected]
Amanda Bobo, [email protected]
Governmental Programs Manager (Medicare):
Lori White, [email protected]
Governmental Programs Manager (Medicaid): Salena Woodson, [email protected]
Supervisor Provider Credentialing: Jenna White, [email protected]
Credentialing Coordinators:
Kim Tibbets, [email protected]
Julia Chumbley, [email protected]
Julie Starr, [email protected]
Aletha Burnett, [email protected]
April Woodruff, [email protected]
Adrianne Stocks, [email protected]
Provider Credentialing Assistants:
Amy Walls, [email protected]
Denise Smith, [email protected]
Dianne Castillo, [email protected]
Sharon Harlan, [email protected]
Lori Jones, [email protected]
Melissa Scharfenberg, [email protected]
Provider Relations Department
6626 E. 75th St, #500
Indianapolis, IN 46250
Phone: 317-621-7581
www.ecommunity.com/prohealth