Billing TrainingUpdated March 2018

Great Plains Medicare Advantage Plan is a Medicare Advantage Plan offering a product designed to improve care for residents. The product offered by Great Plains Medicare Advantage Plan is:

• Institutional/Institutional Equivalent Special Needs Plan(ISNP)– designed for residents who functionally and medically meet a nursing facility level of care

We are a plan with strong local roots and a commitment to the residents, families, and communities we serve.

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Capitation Rates – Per Member Per Month

Plan Per State Part A SNF CapPart B

Therapy CapSkill in Place

Per Diem

GPMA - Nebraska $ 334.00 $ 137.00 $ 290.00

GPMA - South Dakota $ 334.00 $ 137.00 $ 290.00

GPMA - North Dakota (Bismarck Area) $ 334.00 $ 137.00 $ 350.00

GPMA - North Dakota (Grand Forks Area) $ 334.00 $ 137.00 $ 290.00

Capitation Checks cut last business day of the month and mailed directly to participating facilities. Member Count based on 15th of the month membership.

Supplemental Benefits• 6 routine foot care visits per year• 1 Routine Eye Exam and glaucoma test (annually) with Plan

paying up to $275 annually for eyewear• Hearing Exams – 1 routine exam and hearing aid fitting annually.

Hearing Aids up to $2,000 every 2 years• Dental -- Preventative services such as oral exam, cleaning

and x-rays. Plan also pays up to $1,500 every 2 years• Non-Emergency Transportation – 24 one-way trips annually

Claims submitted by performing provider to the Plan using paper claims, Provider Portal via EZNet or EDI.

Non-Emergency Transportation

Plan covers 24 one-way non-emergency transports per year under following 3 categories:

• Non-Emergency - No Wheelchair/Ambulatory (A0120): $35.00 +$2.00 per mile (A0380) (each way)

• Non-Emergency - Wheelchair: (A0130) $55.00 + $2.00 per mile (A0380) (each way)

• Non-Emergency - Stretcher: T2005 @ $112.50 + $2.00 per mile (A0380) (each way)

Claims submitted by performing provider to the Plan using paper claims, EZNet or EDI.

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• Great Plains Medicare Advantage Plan follows all Medicare guidelines in regard to timely filing requirement (12 months from date of service)

• Cannot bill future dates of service• Bill Great Plains Medicare Advantage Plan as you would bill

Medicare in 30 day increments

• Acceptable claim forms:• CMS 1500 for Professional Claims• UB04 for Facility Claims

• Claims can be submitted via paper, Provider Portal via EZNet or EDI

• Paper Claims Mailing Address:

Great Plains Medicare Advantage Plan PO Box 908Addison, TX 75001-0908

Provider Portal Access and Training• EZNet Functionality:

• Member Eligibility Lookup• Authorization/Referral Submittal & Inquiry• Claims Submittal & Inquiry

• User Guide & Training Video available on home page: https://planprovportal.align-360.com/EZ-NET60/ConfigFiles/EZ-NET%20User%20Guide.docx

• Monthly provider trainings offered on the last Friday of each month at 12:30 PM EST

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• Reduce the cost of sharing information—reduced faxes, voicemail, and telephone tag

• Improve the accuracy of informationpresentation—eliminate the incidence of human error

• Provide secure, controlled access to information 24 hours a day, 7 days a week

• Enhance communication between us and our network providers

• Compatible with the popular Microsoft® Internet Explorer 9.0 and >

EZ-NET Benefits to Business Partners1. Search for network providers2. Submit authorizations requests and claims into the

EZ-CAP system3. Inquire on authorization status4. Verify health plan eligibility5. View member authorization history6. Check status of claim/encounter information7. PCPs can access and print assigned member lists8. Look up procedure codes, diagnosis codes, and

other general reference information9. Provide a contact list of key office personnel for

problem resolution

Payment Schedule• Claims can be submitted directly through our

clearinghouse or through your current system. You can also receive payments electronically, but you need to sign up! Here is how:

• EDI Customer Support: 1-888-635-0009, Option 2• Website: http://exchangeedi.com/quick-links• Obtain Companion Guide from the Great Plains Medicare

Advantage websiteEDI Routing• Great Plains Medicare Advantage ND – GPND1• Great Plains Medicare Advantage SD – GPSD1• Great Plains Medicare Advantage NE – GPNE1

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Claims Require the AuthorizationUM Department can be reached at:

• Phone: 1-844-637-4760 (Option 3)• Fax: 800-541-9048• Email:

UMInquiryRequest@GreatPlainsMedicareAdvantage.com

For help, Great Plains Medicare Advantage Provider Services Representatives can be reached at:

• 1-844-637-4760Helpful provider information is always available on the Great Plains Medicare Advantage website: www.greatplainsmedicareadvantage.com

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Authorization Quick Guide• Optometry- No preauthorization required. No preauthorization

required for glasses ($275 benefit every year) but encourage provider to verify benefits with provider services (844-637-4760) to ensure that benefit has not been used.

• Audiologist- Requires preauthorization. Plan does cover hearing aids up to $2000 every 2 years.

• Dental- Requires preauthorization. Plan does cover dentures up to$1500 every 2 years.

• Podiatry- No preauthorization is required as long as visit is done at facility. If member has to go to an office visit, referral from PCP/NP is required and Request for Authorization form needs to be submitted.

• Psychiatrist-Requires PCP/NP referral and copy of order must be included with Request for Authorization form.

• Psychologist/LCSW visits-Requires PCP/NP referral and copy of order must be included in the Request for Authorization form.

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Authorization Quick Guide• Specialist- Requires PCP/NP referral and preauthorization. Please

check provider directory for in network physicians or contact your Member Advocate for assistance. Examples include cardiologist, orthopedic, ENT, etc.

• Wound Management/DME-Requires preauthorization and PCP/NP referral along with clinical documentation.

• Labs-No preauthorization is required. If member has to go out of facility, PCP/NP referral is required along with Request for Authorization form. If services are emergent, no preauthorization is required.

• X-rays-No preauthorization is required. If member has to go out of facility, PCP/NP referral is required along with Request for Authorization form. If services are emergent, no preauthorization is required.

• Transportation-Requires preauthorization for Ambulance. This can be included on the same Request for Authorization form as the Hospitalization. The transport for the supplemental benefit for non-emergency transport does not require an authorization.

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Thank You!

Billing TrainingUpdated: March 2018