7. Clarification of contract.
8. Request fee schedule information.
9. Electronic Solutions: To sign up for Electronic Fund Transfers (EFT) and /or Electronic Remittance Advice (ERA).
10. How to sign up for directprovider.com to check eligibility, claims status or request authorizations on line.
Note: please continue to call the Customer Service Organization
for claims, eligibility & benefit questions at WPA, NWPA and Ohio 1-800-735-4404
EPA 1-800-788-5448
* Click here for the link to the Provider Information Form or refer to Chapter 11 Appendix.
5.4 ANCILLARY PROVIDERS 5.4.1 Chiropractic Services
Chiropractors are licensed practitioners that treat bodily disorders by the manipulation of the spine and other areas of the body.
Credentialing requirements: Chiropractors do not need to be credentialed.
Authorization Requirements: No prior authorization is required for chiropractic services.
General Billing Requirements: Chiropractors should bill using a 1500 form. For more billing information click here to be directed to that portion of the manual or refer to section 8.2.
Please refer to your Provider contract for specific coding/billing guidelines.
Advantra coverage is limited to Chiropractic Manipulative Treatment using CPT codes 98940, 98941, and 98942.
Please contact the Customer Service Organization to confirm Member’s benefits. Members may self-refer to Chiropractors.
5.4.2 Physical Therapy
Credentialing Requirements: Physical Therapy providers require credentialing at the group level. Practitioners do not require credentialing individually.
Authorization Requirements: Providers should contact the Pre-authorization number on members’ ID cards to determine authorization requirements for each member.
General Billing Requirements: Physical Therapists should bill using a 1500 form. For more billing information click here to be directed to that portion of the manual or refer to section 8.2.
Please refer to your Provider Contract for coding/billing guidelines
5.4.3 Facility Based Providers
Facility-based providers practice exclusively within a network facility and provide care for HealthAmerica Members only as a result of Members being directed to that facility. This would include: radiologist, anesthesiologist, pathologists and emergency medicine physicians. Types of facilities where these providers may provide care include: inpatient facilities, freestanding radiology centers, urgent care centers, surgery centers.
The above providers do not require credentialing with HealthAmerica, with the exception of Anesthesiologist when practicing as a pain management specialist.
Claims should be submitted on the CMS 1500 form under the group name.
5.4.4 Anesthesiologists
Credentialing Requirements: For anesthesiologists providing only timed anesthesia services and related non-timed procedures in a hospital or ambulatory surgery center setting contracting is done at the group level. No credentialing of the individual doctors is required.
For anesthesiologists with a pain management specialty providing pain management services in an outpatient (office) setting in addition to providing timed anesthesia services credentialing is required. An anesthesiologist providing pain management service should not see HealthAmerica Members until credentialing and contracting have been completed.
For physicians only providing pain management services in an outpatient setting, refer to the Physician portion of this manual in section 5.3 or click here to be directed to that section.
General Billing Requirements: Anesthesiology providers should bill on the HCFA 1500 or equivalent. For more billing information click here to be directed to that section of the manual or refer to section 8.2.
If you are a participating provider that has had a change in your business such as a change in address, additional service locations, or change in services provided, please click on the following link to complete an updated Provider Information Form, also located in Chapter 11 Appendix, and fax it to Network Development at 1-866-341-8017. Anesthesia Provider Information Form
5.4.5 Emergency Medicine Physicians
Credentialing Requirements: Contracting is done at the group level. No credentialing of the individual doctors is required.
General Billing Requirements: Emergency Medicine providers should bill on the HCFA 1500 or equivalent. For more billing information click here to be directed to that section of the manual or refer to section 8.2.
If you are a participating provider that has had a change in your business such as a change in address, additional service locations, or change in services provided, please click on the following link to complete an updated Provider Information Form, also located in Chapter 11 Appendix, and fax it to Network Development at 1-866-341-8017. Hospital Based Physician Group Provider Information Form
5.4.6 Pathologists
Credentialing Requirements: Contracting is done at the group level. No credentialing of the individual doctors is required.
General Billing Requirements: Pathology providers should bill on the HCFA 1500 or
equivalent. For more billing information click here to be directed to that section of the manual
If you are a participating provider that has had a change in your business such as a change in address, additional service locations, or change in services provided, please click on the following link to complete an updated Provider Information Form, also located in Chapter 11 Appendix, and fax it to Network Development at 1-866-341-8017. Hospital Based Physician Group Provider Information Form
5.4.7 Radiologists
Credentialing Requirements: Contracting is done at the group level. No credentialing of the individual doctors is required.
General Billing Requirements: Radiology providers should bill on the HCFA 1500 or
equivalent. For more billing information click here to be directed to that section of the manual or refer to section 8.2.
If you are a participating provider that has had a change in your business such as a change in address, additional service locations, or change in services provided, please click on the following link to complete an updated Provider Information Form, also located in Chapter 11 Appendix, and fax it to Network Development at 1-866-341-8017. Hospital Based Physician Group Provider Information Form
5.4.8 Outpatient Laboratory Policy
The Outpatient Laboratory Policy varies by region. Be sure to refer to the policy applicable to your region