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January 2019
Prov i de r Re l a t ions Ne wsl e t t e r
I N S I D E T H I S I S S U E :
1 NEW Community Health Direct
website
1 ePower
1 New Provider Credentialing
1 New Providers, effective
1/1/2019
1 Termed Providers
2 ProHealth name change
3 EncoreCombined - Tier 2
4 2019 Access90 Program
4 MDwise CHN terming
5-7 Payor Highlights
8 CHD 2019 PA Quick Ref Guide
9 CHD Peer to Peer Review
10 Provider Relations Staff
Directory
Credentialing of New Providers:
*PLEASE NOTE*
Credentialing through Community Health Direct 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.
Community Health Direct
Provider Relations Manager:
Jenny Bouck
Phone#: (317)621-7547
ePower Provider Portal:
Look up member claims, eligibility and more on
Community Health Direct’s ePower (Provider Portal) at:
https://www.ecommunity.com/community-health-direct/
providers/community-gold-and-silver-plans
Community Health Direct has a NEW and improved web-
site with valuable info for members & providers! Visit us
at: https://www.ecommunity.com/community-health-direct
Contracting and Credentialing Corner:
NEW Providers Joining ProHealth - Click HERE
TERMED ProHealth Providers - Click HERE
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New name. New look. Same great product.
ProHealth, the network that administers health insurance to thousands of
Community Health Network employees and their families, is getting a
facelift. Effective January 1, 2019, the product will be renamed
Community Health Direct and will feature a new logo design along with
targeted marketing support and strategic consumer education. These
enhancements reflect our efforts to improve support to our partners in an
evolving healthcare environment.
The reimagining of ProHealth will not impact the provider network for the Gold and Silver
plans. Those providers will continue to participate as part of the Community Health Direct
brand. However, all references to ProHealth will be replaced with Community Health Direct
on all print and digital communications. Likewise, Gold and Silver insurance cards issued for
2019 will feature the new Community Health Direct logo.
The emergence of direct-to-employer health insurance management arrangements has
changed the spirit of what it truly means to provide exceptional service to customers.
Likewise, the ProHealth network of high quality, high demand products and services has
expanded beyond Community Health Network into entities and organizations such as the
City of Fishers, Primaria and Encore. In 2019, continuing to offer our very best products,
services and support to our partners is our top priority.
What does this mean for you, your providers and staff?
The rebranding of ProHealth will not impact the provider network for the Gold and Silver plans. Those providers will continue to participate as part of the Community Health Direct brand.
The Epic payer/plan that you use for ProHealth will be updated, effective January 1, 2019.
Community Gold and Silver Plans
There will be a new website in 2019 for Community Health Direct. It will be located at www.ecommunity.com/community-health-direct
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Community Health DIrect Tier2 Changes for Community Gold & Silver Plans:
Beginning 1/1/2019, Encore Combined will become the Tier 2 network for the Community Gold and Silver Plans (see chart below).
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Changes to the MDWise Community Health Network Plans:
MDwise Community Health Network HIP & HHW (Medicaid) plans will be terming, effective
12/31/2018. MDwise is moving away from the delivery system model, and will be transitioning
these into the MDwise Excel and MDwise Excel HIP programs.
If you have any questions regarding these changes, please feel free to reach out to
Governmental Program Manager Salena Woodson at [email protected] or by
phone at (317)621-7593.
Community Health Direct - Health Plan Pharmacy Benefit Update 2019
Mandatory 90 supply fill for maintenance medications (Access90 Program)
As of January 1, 2019 Community Health Network, in partnership with Walgreens pharmacies and Express Scripts Home Delivery, is implementing the Access90 Maintenance Medication Program.
Applies only to maintenance mediations
— List will be available at: www.ecommunity.com/community-health-direct under Member
Area, Gold and Silver Plan, Pharmacy
This is a mandatory program for both Community Gold and Silver members
Members must fill a 90 day supply of their maintenance medications at Walgreens or Express
Scripts Home Delivery.
— Members currently on a maintenance medications that are included in the Access90
program:
Members can get up to 2 courtesy fills of 30 day supplies at a 30 day copay if
needed, then must fill a 90 day supply.
— When a member is started on a new maintenance medication or new dosage and the
medication is included in the Access90 program:
The member should fill 1-2 (30day supply) fills to make sure they can tolerate the
new prescription and then fill a 90 day supply
Members will only pay 2.5 times the copay instead of 3 copays for a 3 month supply
Walgreens will still have the preferred copays for 90 day fills
If you have any additional questions visit: www.ecommunity.com/community-health-direct under Member Area, Gold and Silver Plan, Pharmacy or call Community Health Direct at (317)621-7575 option 2 then option 2.
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PAYOR H IGHL IGHTS
Encore/Encircle Name Change: October 1, 2018 Encircle was rebranded to be called EncoreCombined and has significant enhancements to its provider participation and value for Indiana Employers. Encore Health Network has been gradually expanding the provider participation of Encircle to include most of Indiana. EncoreCombined will include 95% of the providers in the Encore Health Network service area. Hospitals participating in the EncoreCombined product agree to offer top tier pricing in an open access product. Significant pricing upgrades have been made with many of the Hospitals in the EncoreCombined product.
United Healthcare Navigate plan: Navigate is a gated product and care is managed by the member selected PCP.
The UnitedHealthcare logo, Navigate product name and PCP are listed on the front of the health care ID card, bottom right hand corner.
Plan benefits should be verified before provision of care to ensure the PCP and address match UHC rec-ords.
Referrals are required for members to be seen by specialty physicians.
All referrals must be generated via Link and referral submissions do not require submission of medical documentation.
Referrals are not necessary for other providers with the same TIN as the PCP.
UHC’s authorization requirements are in addition to specialist referrals.
General information: https://www.uhcprovider.com/en/health-plans-by-state/indiana-health-plans/in-commercial-plans.html, select UnitedHealthcare Navigate FAQ: https://www.uhcprovider.com/content/dam/provider/docs/public/health-plans/Navigate-Frequently-Asked-Questions.pdf Navigate QRG: https://www.uhcprovider.com/content/dam/provider/docs/public/health-plans/Navigate-Quick-Reference-Guide.pdf Referral submission QRG: https://www.uhcprovider.com/content/dam/provider/morgue/referral/Referral-Guide.pdf
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PAYOR H IGHL IGHTS
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PAYOR H IGHL IGHTS
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Community Health Direct supports the concept of the PCP as the “medical home” for its members. Services from Tier II and Tier III providers will only be considered for coverage at the Tier I level if those services are unavailable with a Tier I provider.
Please submit requests as soon as possible to allow time for review. Routine requests for authorizations are processed within 3 business days after receipt of all needed clinical information.
Contact information Medical Management: 317‐621‐7575 Medical Management Fax: 317‐621‐7984 Provider Relations: 317‐621‐7581 Benefits/ Eligibility: 317‐621‐7565
Authorizations Required No Authorization Required
Standard Authorization Requests
Fax your request; include CPT and ICD‐10 codes and clinical documentation with authorization request.
Requests for Tier II and Tier III services at Tier I coverage:*
Any requests for services not provided by the Community Health Network or Tier I providers as listed in directory
Durable Medical Equipment
Durable medical purchases over $500 –this includes wheel‐chairs, CPAP (initial rental/purchase ONLY), hospital beds, insulin pump (initial purchase ONLY)
Prosthetics Custom Orthotics
Inpatient Notification
All inpatient admissions, including clinical updates for con‐tinued stay
Rehabilitation facility admissions Skilled nursing home facilities
Outpatient
Cosmetic/Aesthetic Procedures Transplant Requests Genetic testing (Excludes prenatal tests outlined in the
American College of Obstetricians /Gynecologists (ACOG) guidelines, and surgical specimen testing)
Routine labs/genetics tests performed by non-Tier I labora‐tories
Endoscopy services Colonoscopies for patients under the age of 50 Investigational and experimental procedures
Infertility Surgeries of the neck and back Rhinoplasties and Septoplasties
Radiology
MRI‐ Spine (includes cervical) Non‐oncology related PET Scans
Behavioral Health
All inpatient admissions for behavioral health treatment –this includes inpatient hospital and partial hospitalizations (PHP) for mental health and substance abuse
Intensive outpatient (IOP) for mental health and substance abuse
Urgent Care at Urgent Care Centers, such as Med Check and Community Clinic at Walgreens
Laboratory
Genetic pre‐natal tests outlined in the American College of Obstetricians /Gynecologists (ACOG) guidelines, and surgi‐cal specimen testing
Durable Medical Equipment
Medical purchases less than $500 Bilirubin blankets for newborns Nebulizers CPAP supplies after initial authorization Insulin pump supplies after initial authorization Catheters Other disposable supplies after initial authorization
Outpatient
Colonoscopies for patients aged 50 or older Dialysis and Epogen administration with Dialysis
Home Health Care
Home Health Services Hospice Care (Outpatient and Inpatient) Total Parental Nutrition (TPN) Home oxygen
Radiology
All radiology services except MRI(s) Spine (includes cervical)
Miscellaneous Services
Sleep studies performed at in-network sleep labs Sleep studies performed in home under the direction of an
in-network sleep lab
Behavioral Health
Neuropsychological testing Applied Behavior Analysis (ABA)
Only these services that are unavailable in-network are cov-ered at Tier 1 without a prior authorization**
Office visits and office based testing:
Pediatric neurosurgery < 15 years old Pediatric endocrinology < 16 years old
Members < 18 years old - pediatric hematology/oncology, pediatric ophthalmology, pediatric pulmonology, pediatric
urology, pediatric cardiology
Community Health Direct HRA Gold, HSA Silver Health Plans
2019 Authorization Quick Reference Guide
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Peer-to-Peer Process for Community Health Direct Gold and Silver Plans:
Effective June 8, 2018 Community Health Direct changed the peer to peer process to expedite
the turnaround time on adverse determinations. The changes include:
Providers can call (317-621-7575, option 2) and schedule a peer to peer discussion as long
as a prior authorization form with associated clinical records has previously been
submitted; however once the denial letter is sent, Community Health Direct Medical
Directors cannot overturn an adverse determination.
Community Health Direct Utilization Management nurses will provide a potential verbal
denial on requests that do not meet medical necessity. In addition, the prior authorization
form that was submitted to Community Health Direct will be faxed back to the provider’s
office noting the reason criteria was not met on the form. Call back numbers will be
supplied with both the potential verbal denial and the faxed prior authorization form to
schedule a peer to peer discussion.
Providers will have until 5pm the following business day to schedule a peer to peer
discussion to provide additional information.
If no response is received by 5pm the following business day, a denial letter will be sent to
both the provider and the member.
Once the denial letter is sent, reconsideration will require that the member appeal the
denial (please note that members may designate their provider to appeal on their behalf).
If you have any questions, please contact your local Provider Relations Analyst:
Carol Boyd Dawn Widgery
Community Health Direct Community Health Direct
Provider Relations Analyst Provider Relations Analyst
Phone#: (317)621-7923 Phone#: (317)621-7462
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Department Staff
Manager Provider Relations:
Jenny Bouck, [email protected]
Business Information Coordinator:
Hollie Putzback, [email protected]
Provider Relations Analysts:
Amanda Bobo, [email protected]
Carol Boyd, [email protected]
Dawn Widgery, [email protected]
Governmental Programs Manager:
Lori White, [email protected]
Salena Woodson, [email protected]
Supervisor Provider Credentialing:
Jenna White, [email protected]
Credentialing Coordinators:
Aletha Burnett, [email protected]
April Woodruff, [email protected]
Adrianne Stocks, [email protected]
Amy Walls, [email protected]
Denise Smith, [email protected]
Dianne Castillo, [email protected]
Jerrilyn Dixon, [email protected]
Kim Tibbets, [email protected]
Lori Jones, [email protected]
Melissa Baldwin, [email protected]
Michael Starks, [email protected]
Provider Relations Department 6626 E. 75th St, #500 Indianapolis, IN 46250 Phone: 317-621-7581 https://www.ecommunity.com/community-health-direct
