Medicare Advantage Provider Manual

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Medicare

Advantage

Provider Manual

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Section 1:

HealthSpan Integrated Care

Medicare Advantage Provider Manual

Medical Care Program

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Welcome

It is our pleasure to welcome you as a Plan Provider with HealthSpan Medicare Advantage, offered in 31 counties throughout the State of Ohio by HealthSpan Integrated Care, hereafter identified as HealthSpan. As a valued Plan Provider, we want this business relationship to work well for you, your medical support staff, and HealthSpan Members.

The HealthSpan Network Development and Performance (Provider Relations) Department is committed to providing support to you and your staff. This includes responding to your operational inquiries and providing education regarding new products and plans. If, at any time, you have a question or concern about the information outlined in this Manual, you can reach our Provider Relations Department by calling 800-441-9742, option 1.

Introduction

This Provider Manual (“Manual”) is referenced in your Agreement

(“Agreement”) with a HealthSpan entity. The information in this Manual is proprietary and may not be used, circulated, reproduced, copied or disclosed in any manner whatsoever, except as specified in your Agreement, or with prior written permission from HealthSpan.

The HealthSpan Medicare Advantage Provider Manual is posted on the

Providers website at healthspan.org/providers/north-coast. Updates, changes and additions to the information contained herein are posted on this website and made part of this Manual as of the date posted thereon, unless otherwise required by your Agreement or applicable Law. If there is a conflict between this Manual and your Agreement, the terms of your Agreement will control. All defined terms in Section 11 of this HealthSpan Medicare Advantage Provider Manual are capitalized throughout this Manual. Capitalized terms that are used in this Manual, but not defined, will have the meanings given to them in your Agreement.

Provider Support

For your convenience, HealthSpan has established a phone system that allows Plan Providers to call one phone number to address most issues or questions regarding HealthSpan Plan protocols or Members. Representatives are

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Option 1: This option will connect you with a representative in the Customer Relations Department who can assist with any of the following inquiries:

• Member Eligibility and Covered Benefits verification.

• Claims payment inquiries (that is, to check on the status of Claim payment, an over or under claim payment, a denial or partial denial of Services, or Coordination of Benefits).

• Claims submission questions.

• Obtain current Plan Provider directories.

• Electronic Data Interchange Clearinghouse information. Option 2: If a HealthSpan Member needs to be admitted to a hospital, select

option 2. Option 2 will connect you with a representative in the HealthSpan Repatriation Department.

Option 3: To initiate an urgent or emergent request for Services requiring Referral or Precertification, select option 3. Option 3 will connect you with a representative in the HealthSpan Referrals Management and Clinical Review Department (866-433-1333 [toll-free]). To initiate a new Referral request for routine Services requiring Authorization, fax your request to the HealthSpan Referrals Management and Clinical Review Department at 866-422-5940 (toll-free).

For the following inquiries, contact your designated Provider Relations Department in Cleveland or Cincinnati:

• Add or delete a Practitioner in the practice.

• Confirm or change the open or closed status of a Practitioner’s practice with HealthSpan.

• Provide demographic updates.

• Agreement questions.

If a Member has a question about Covered Benefits, desires to change his/her Primary Care Physician, would like to file a compliment or Complaint, or appeal an Adverse Determination, refer the Member to the HealthSpan Customer Relations Department,

8 a.m. – 8 p.m. daily, 800-493-6004. The hearing/speech impaired may call 711 (toll free TTY).

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Section 1:

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Section 1: HealthSpan Medical Care Program

1.1 History

HealthSpan Partners is a non-religious, supporting organization of Mercy Health, formerly Catholic Health Partners. Mercy Health is the largest health system in Ohio and operates more than 250 health facilities, including 24 hospitals, 15 senior living communities, five hospice programs, eight home health agencies and a health insurance plan.

1.1.1 HealthSpan Mission Statement

HealthSpan delivers compassionate, high-quality, affordable health care to improve the health of our communities with emphasis on people who are poor and underserved.

1.1.2 HealthSpan Values

HealthSpan demonstrates behaviors reflecting our core values of compassion, excellence, human dignity, justice, sacredness of life and service.

1.2 Organizational Structure

1.2.1 HealthSpan Physicians, LLC

Health Span Physicians, LLC, is a medical group practice that delivers

integrated care through its multispecialty medical group that serves Members in Northeast Ohio.

1.2.2 HealthSpan Integrated Care

Working in partnership with HealthSpan Physicians, LLC, HealthSpan Integrated Care is a non-profit organization that offers Traditional Health Maintenance Organization, Point-of-Service and Medicare Plans in

northeastern Ohio. 1.2.3 HealthSpan, Inc.

HealthSpan, Inc. offers an array of self-insured, individual, commercial, Medicare and Medicaid Plans throughout the State of Ohio.

1.3 HealthSpan Medicare Advantage Service Area

Following is a map of the HealthSpan Medicare Advantage Service Area. To find a Plan participating Provider, including ancillary Providers, access the

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code, select a search radius and choose the way you prefer to search. If you prefer a paper directory, contact the HealthSpan Customer Relations

Department at 800-441-9742, option 1.

1.3.1 HealthSpan Service Area Map See the following page.

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Section 1:

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Medicare Advantage Provider Manual

Medicare

Advantage

Provider Manual

Section 1:

HealthSpan Integrated Care

Medicare Advantage Provider Manual

Medical Care Program

Table of Contents

Welcome

Introduction

Section 1: HealthSpan Medical Care Program

1.1 History

1.2 Organizational Structure

1.3 HealthSpan Medicare Advantage Service Area