2014
Coventry Health Care of Illinois, Inc.
Provider
Orientation
Manual
Table of Contents
I.
Contact Information
A.
Important Contact Information
B.
Quick Links
II.
Prior
A.
B.
C.
D.
III.
Claims
A.
Submission of Claims
B.
Claim Inquiries
C.
Electronic Services
IV.
Provider Search
A.
How to Search for a Provider
B.
How to Create a Directory
V.
Disease Management Programs
VI.
Reference Materials
Directprovider.com Quick Guide
Members Rights and Responsibilities
Disease Management/Case Management Referral Form
Authorization
Prior Authorization List (Medical Services)
Medical Injection Prior Authorization List
How to Decrease Call Time to Pre-Authorize Medical Services
Peer to Peer Review
Coventry Health Care of Illinois, Inc.
2
2014.v1
I - Contact Information
A. Coventry Health Care of Illinois, Inc. - Important Contact Information
Department
Phone
Toll Free
Website
Fax
Accredo
n/a
877-881-9047
www.accredo.com
877-481-1061
Caremark Therapeutic
Service (for injectables)
n/a
877-834-8657
www.caremark.com
877-834-8658
Coventry Medicare Advantra
Customer Service
n/a
866-784-4916
www.chcillinoismedicare.com
n/a
New Century Health (NCH)
n/a
877-624-8601
#5 - Intake
my.newcenturyhealth.com
Coventry Pharmacy Service
Center
n/a
877-215-4098
www.chcillinois.com
877-554-9139
Customer Service (for fully
insured members)
217-366-1226
800-431-1211
www.chcillinois.com
n/a
Customer Service (for self
funded (ASO) members)
n/a
866-557-8751
www.chcillinois.com
701-250-5394
Directprovider.com
n/a
866-629-3975
www.directprovider.com
n/a
ICORE
Mental Health Network MH Net (inpatient and
outpatient mental health)
National Imaging Associates
(NIA)
Pre Authorization Department
8:00 am – 5:00 pm CST; M-F
Provider Relations
n/a
800-424-4157
www.ICOREHealthcare.com
n/a
n/a
800-423-8070
www.mhnet.com
n/a
n/a
800-642-7835
www.RadMD.com
n/a
217-373-3998
866-557-8748
www.chcillinois.com
800-224-2009
217-366-1226
800-562-5792
www.chcillinois.com
800-698-2043
n/a
888-584-8742
Triad Healthcare
www.triadhealthcareinc.com
877-624-8602
888-229-5680
B. Coventry Health Care of Illinois, Inc. - Quick Links
Category
Website Location
Pre-Authorization
http://chcillinois.coventryhealthcare.com/services-andsupport/providers/pre-authorizations/index.htm
Pharmacy
http://chcillinois.coventryhealthcare.com/health-caresolutions/prescription-coverage/index.htm
Provider Manual
and Policies
http://chcillinois.coventryhealthcare.com/services-andsupport/providers/document-library/index.htm
Preventive Health
and Practice
Guidelines
http://chcillinois.coventryhealthcare.com/services-andsupport/providers/practice-guidelines
Hospital List
Disease
Management
Brochure
http://chcillinois.coventryhealthcare.com/services-andsupport/providers/document-library/index.htm
http://chcillinois.coventryhealthcare.com/web/groups/pu
blic/@cvty_regional_chcil/documents/document/c08065
6.pdf
Coventry Health Care of Illinois, Inc.
3
Description
Prior Authorization Lists Prior
Authorization Form Authorization
requirements by code
Formulary, Pre Authorization, Step
Therapy & Quantity limits
Self-Administered Injectable
Formulary
Forms
Policies
Quality Improvement Program
Preventive health guidelines
(Pediatric/Teens/Adults)
Practice Guidelines
List of participating hospitals
Disease Management Program
Information
2014.v1
A. Prior Authorization (Medical) List (effective 08/01/14)
HMO, POS, PPO, Medicare Advantra, CH&L PPO, Carelink & TotalCare
*Please verify ASO plan requirements by calling 866-557-8751
Pre-authorization Department
Phone: 866-557-8748
Fax: 800-224-2009
www.directprovider.com
Inpatient care:
Skilled Nursing
Observation stays
Transplants – includes initial evaluation
All admissions (including maternity admissions)
Acute inpatient
Acute rehabilitation
Outpatient care:
Advanced Radiology Services (See NIA below):
Medication given IV, IM, or sub-Q (See ICORE below and
-All cardiac stress imaging
-Cardiac nuclear scans
-PET scans
refer to website for listing of medications & forms)
-CT scans
-MRI/MRA
-Stress echocardiogram
Chemotherapeutic Drugs and supportive agents (See
New Century Health below and refer to website for listing of
medications & forms)
Diagnosis/treatment of Autism spectrum
disorders/Habilitative services
Neuropsychological Testing
Pain management injections (See Triad below) (including
epidural and facets)
Physical Therapy in custodial care setting
Prosthetic/Orthotic devices – over $500
Durable medical equipment purchase over $500 and all
rental equipment (oxygen, TENS, CPM and Bili Light units not
Radiation Therapy Services (See MSI below for the
included)
following treatments: Brachytherapy, Intensity Modulated Radiation
Therapy (IMRT), Proton Beam Therapy, Stereotactic Radiation
Therapy)
Experimental/Investigational services
Sleep Studies (Sleep lab or outpatient facility)
Genetic testing
Surgical/other Outpatient procedures (outpatient
hospital or ambulatory surgery center) refer to website for list
Hyperbaric treatments
of procedure codes requiring prior authorization)
Infertility services
Coventry Pharmacy www.chcillinois.com
Prior Authorization: 877-215-4098
MHNET www.MHNET.com
Prior Authorization: 800-423-8070
Self administered injectable medications
Mental Health/Substance abuse IP & OP services
Prior Authorization Contacts
Applies to fully insured membership including Medicare Advantra business. Excludes Carelink, Self funded and Total Care membership
ICORE www.icorehealthcare.com
National Imaging Associates (NIA)
Prior Authorization: 800-424-4157
www.RadMD.com
Prior Authorization: 800-642-7835
Physician office and Facility locations
Actemra
J3262
Botox
J0585
Gel-One
J7326
Nplate
J2796
Remicade J1745
Synvisc
J7325
Acthar
Euflexxa
Myobloc
Orthovisc
Supartz/Hyalgan
Tysabri
Advanced Radiology Services:
J0800
J7323
J0587
J7324
J7321
J2323
All cardiac stress imaging
Cardiac nuclear scans
Stress echocardiogram
CT scans
MRI/MRA
PET scans
New Century Health my.newcenturyhealth.com
Prior Authorization: 877-624-8601
MedSolutions (MSI) www.medsolutions.com
Physician office and Facility locations
Prior Authorization: 877-624-8601
Chemotherapeutic drugs and supportive agents
Radiation Therapy Services
2D and 3D conformal
IMRT
Proton Beam Therapy
TRIAD Healthcare www.triadhealthcareinc.com
Brachytherapy
Neutron Beam Therapy
SRS/SBRT
Prior Authorization: 888-584-8742
Pain Management Services
Prior authorization is the process for authorizing the non-emergency use of facilities, diagnostic testing, and other health services before care
is provided.
Coventry Health Care of Illinois, Inc.
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2014.v1
B. Medical Injection Prior Authorization List (effective 08/01/2014)
HMO/POS/PPO, Medicare Advantra
Phone: 800-546-4603
Fax 866-603-5536
www.directprovider.com
All new drugs require prior authorization
Alphabetical by drug name
Numerical by drug code
Drug Name
Code
Code
Drug Name
8-Mop**
J8999
90283
Immune globulin (IgIV)
Abraxane
J9264
90378
Synagis
Actemra*
J3262
C9257
Avastin*
Acthar*
J0800
C9278
Xeomin
Adalimumab
J0135
C9281
Krystexxa
Adcentris (brentuximab vendotin)**
J9042
C9284
Yervoy
Adriamycin**
J9000
C9286
Nulojix
Adrucil**
J9190
C9291
Aflibercept
Advate
J7192
C9292
Perjeta
Aflibercept
C9291
C9297
Synribo**
Alkeran**
J8600
J0129
Orencia
Alkeran**
J9245
J0135
Adalimumab
Aloxi**
J2469
J0178
Eylea
Alpha 1 Proteinase Inhibitor (Human)
J0257
J0180
Fabrazyme
Alphanate
J7186
J0207
Ethyol**
AlphaNine SD
J7193
J0215
Amevive
Amevive
J0215
J0220
Myozime
Anti-Inhibitor
J7198
J0221
Lumizyme
Antithrombin Recombinant
J7196
J0256
Prolastin
Aranesp**
J0881
J0256
Zemira
Aredia (pamidronate)
J2430
J0257
Alpha 1 Proteinase Inhibitor (Human)
Arixtra**
J1652
J0490
Benlysta (belimumab)
Arranon**
J9261
J0585
Botox*
Arzerra (ofatumumab)
J9302
J0586
Dysport
Avastin*
C9257
J0587
Myobloc*
Avastin**
J9035
J0588
Etanercept
Bebulin VH
J7194
J0594
Busulfex**
Belnoxane**
J9040
J0597
C-1 Esterase Inhibitor (human)
Benefix
J7195
J0598
Cinryze (esterase)
Benlysta (belimumab)
J0490
J0638
Canakinumab
Bexxar**
J9999
J0640
Leucovorin**
Bicnu**
J9050
J0641
Fulsilev**
Bioclate
J7192
J0718
Certolizumab Pegol
Bivigam**
J3590
J0725
Ovidrel (chorionic gonadotropin)
Boniva
J1740
J0725
Pregnyl (chorionic gonadotropin)
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2014.v1
Botox*
J0585
J0725
Profasi (chorionic gonadotropin)
Busulfex**
J0594
J0775
Xiaflex
C-1 Esterase Inhibitor (human)
J0597
J0800
Acthar*
Cabazitaxel
J9043
J0800
H.P. Acthar Gel
Campath**
J9010
J0881
Aranesp**
Camptosar**
J9206
J0882
Darbepoetin Alfa
Canakinumab
Carimune (immune globulin
lyophilized)
Ceenu**
J0638
J0885
Epogen/Procrit*
J1566
J0894
Dacogen
J8999
J0897
Prolia
Cerezyme
J1786
J0897
Xgeva
Certolizumab Pegol
J0718
J1190
Zinecard**
Cinryze (esterase)
J0598
J1290
Kalbitor
Clolar
J9027
J1300
Soliris
Cosmegen**
J9120
J1325
Flolan (veletri)
Cytostar-U**
J9100
J1438
Enbrel
Cytoxan**
J8530
J1442
Neupogen**
Cytoxan**
J9070
J1453
Emend**
Dacogen
J0894
J1458
Naglazyme
Darbepoetin Alfa
J0882
J1459
Privigen
Daunorubicin**
J9150
J1460
Immune Globulin
Daunoxome**
J9151
J1557
Gammaplex
Depocyt**
J9098
J1559
Immune globulin (IgIV)
Doxil**
J9002
J1560
Immune Globulin
Doxil**
Q2050
J1561
Gamunex
Dtic-Dome**
J9130
J1562
Dysport
J0586
J1566
Elaprase
J1743
J1568
Immune globulin (Vivaglobin)
Carimune (immune globulin
lyophilized)
Octagam
Elitek**
J2783
J1569
Gammagard
Ellence**
J9178
J1572
Flebogamma
Eloxatin**
J9263
J1595
Glatiramer Acetate
Emcyt**
J8999
J1599
Immune globulin (IgIV)
Emend**
J1453
J1602
Simponi (golimumab)
Emend**
J8501
J1652
Arixtra**
Enbrel
J1438
J1675
Epogen/Procrit*
J0885
J1725
Erbitux
J9055
J1740
Histrelin Acetate
Makena (hydroxyprogesterone
caproate)
Boniva
Erwinaze
J9020
J1743
Elaprase
Erwinaze**
J9019
J1745
Remicade*
Etanercept
J0588
J1786
Cerezyme
Ethyol**
J0207
J1826
Interferon Beta-1A
Euflexxa*
J7323
J1830
Interferon Beta-1B
Eulexin**
J8999
J1930
Somatuline
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Eylea
J0178
J1950
Lupron Depot
Fabrazyme
J0180
J2020
Zyvox (linezolid)
Factor VIII
J7191
J2170
Mecasermin**
Factor XIII
J7180
J2315
Vivitrol
Fareston**
J8999
J2323
Tysabri*
Faslodex**
J9395
J2353
Sandostatin LAR
Firmagon**
J9155
J2354
Octreotide
Flebogamma
J1572
J2355
Neumega
Flolan (veletri)
J1325
J2357
Xolair
Fludara**
J9185
J2358
Olanzapine
Folotyn (pralatrexate)
J9307
J2425
Kepivance**
Fudr**
J9200
J2430
Aredia (pamidronate)
Fulsilev**
J0641
J2469
Aloxi**
Gammagard
J1569
J2503
Macugen
Gammaplex
J1557
J2505
Neulasta**
Gamunex
J1561
J2507
Pegloticase
Gel-One*
J7326
J2562
Mozobil (perixafor)
Gemzar**
J9201
J2778
Lucentis
Glatiramer Acetate
J1595
J2783
Elitek**
Goserelin
J9202
J2793
Rilonacept
H.P. Acthar Gel
J0800
J2796
Nplate*
Halaven (eribulin mesylate)
J9179
J2820
Leukine**
Halotestin**
J8999
J2941
Somatropin
Helixate FS
J7192
J3110
Teriparatide
Hematide (peginesatide)
Q2047
J3240
Thyrogen
Hemofil-M
Hemophilia clotting factor not
otherwise classified
Herceptin**
J7190
J3262
Actemra*
J7199
J3285
Remodulin (Treprostinil)
J9355
J3315
Trelstar
Hexalen**
J8999
J3357
Stelara
Histrelin
J9225
J3385
VPRIV (velaglucerase alfa)
Histrelin Acetate
J1675
J3396
Visudyne (verteporfin)
Human Fibrinogen
Q2045
J3487
Zometa
Humate-P
J7187
J3488
Reclast
Hyalgan*
J7321
J3489
Reclast
Hyaluronate
J7326
J3489
Zometa
Hydrea**
J8999
J3490
Voraxaze**
Idamycin**
J9211
J3590
Bivigam**
Ifex**
J9208
J7180
Immune Globulin
J1460
J7183
Immune Globulin
J1560
J7185
Factor XIII
Von Willebrand factor complex
(human)
Xyntha (factor VIII)
Immune globulin (IgIV)
90283
J7186
Immune globulin (IgIV)
J1559
J7186
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Alphanate
Von Willebrand factor complex
(human)
2014.v1
Immune globulin (IgIV)
J1599
J7187
Immune globulin (Vivaglobin)
J1562
J7187
Interferon Alfa-2A
J9213
J7189
Humate-P
Von Willebrand factor complex
(human)
Novoseven
Interferon Alfa-2B
J9214
J7190
Hemofil-M
Interferon Alfa-N3
J9215
J7190
Koate-DVI/HP
Interferon Beta-1A
J1826
J7190
Monarc-M
Interferon Beta-1B
J1830
J7190
Monoclate-P
Interferon Gamma
J9216
J7191
Factor VIII
Istodax (romidepsin)
J9315
J7192
Advate
Ixempra
J9207
J7192
Bioclate
Kalbitor
J1290
J7192
Helixate FS
Kepivance**
J2425
J7192
Kogenate/FS
Koate-DVI/HP
J7190
J7192
Recombinate/Refacto
Kogenate/FS
J7192
J7193
AlphaNine SD
Konyne-80
J7194
J7193
Mononine
Krystexxa
C9281
J7194
Bebulin VH
Kyprolis**
J9047
J7194
Konyne-80
Leucovorin**
J0640
J7194
Profilnine SD
Leucovorin**
J8999
J7194
Proplex T
Leukeran**
J8999
J7195
Benefix
Leukine**
J2820
J7196
Antithrombin Recombinant
Leustatin**
J9065
J7197
Thrombate III (antithrombin III)
Lipodox**
Q2049
J7198
Lucentis
J2778
J7199
Lumizyme
J0221
J7321
Anti-Inhibitor
Hemophilia clotting factor not
otherwise classified
Hyalgan*
Lupron
J9217
J7321
Supartz*
Lupron
J9218
J7323
Euflexxa*
Lupron Depot
J1950
J7324
Orthovisc*
Lysodren**
J8999
J7325
Synvisc*
Macugen
J2503
J7326
Gel-One*
Makena
Makena (hydroxyprogesterone
caproate)
Marqibo**
Q2042
J7326
Hyaluronate
J1725
J7686
Treprostinil
J9999
J8501
Emend**
Matulane**
J8999
J8510
Myleran**
Mecasermin**
J2170
J8530
Cytoxan**
Mesnex**
J9209
J8600
Alkeran**
Methotrexate**
J9250
J8700
Temodar
Methotrexate**
J9260
J8705
Topotecan oral
Monarc-M
J7190
J8999
8-Mop**
Monoclate-P
J7190
J8999
Ceenu**
Mononine
J7193
J8999
Emcyt**
Mozobil (perixafor)
J2562
J8999
Eulexin**
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2014.v1
Mustargen**
J9230
J8999
Fareston**
Mutamycin**
J9280
J8999
Halotestin**
Myleran**
J8510
J8999
Hexalen**
Mylotarg**
J9300
J8999
Hydrea**
Myobloc*
J0587
J8999
Leucovorin**
Myozime
J0220
J8999
Leukeran**
Naglazyme
J1458
J8999
Lysodren**
Navelbine**
J9390
J8999
Matulane**
Neulasta**
J2505
J8999
Nilandron**
Neumega
J2355
J8999
Purinethol**
Neupogen**
J1442
J8999
Sprycel**
Nilandron**
J8999
J8999
Stivarga**
Nipent**
J9268
J8999
Tafinalar**
Novantrone**
J9293
J8999
Targretin**
Novoseven
J7189
J8999
Tretinoin/Vesanoid**
Nplate*
J2796
J9000
Adriamycin**
Nulojix
C9286
J9002
Doxil**
Octagam
J1568
J9010
Campath**
Octreotide
J2354
J9015
Proleukin**
Olanzapine
J2358
J9019
Erwinaze**
Oncaspar**
J9266
J9020
Erwinaze
Oncovin**
J9370
J9025
Vidaza
Ontak**
J9160
J9027
Clolar
Orencia
J0129
J9031
Tice/Theracys**
Orthovisc*
J7324
J9033
Treanda**
Ovidrel (chorionic gonadotropin)
J0725
J9035
Avastin**
Paraplatin**
J9045
J9040
Belnoxane**
Pegloticase
J2507
J9041
Velcade
Pegylated Interferon Alfa-2A
S0145
J9042
Adcentris (brentuximab vendotin)**
Pegylated Interferon Alfa-2B
S0148
J9043
Cabazitaxel
Pemetrexed
J9305
J9045
Paraplatin**
Perjeta
C9292
J9047
Kyprolis**
Photofrin**
J9600
J9050
Bicnu**
Platinol**
J9060
J9055
Erbitux
Pregnyl (chorionic gonadotropin)
J0725
J9060
Platinol**
Privigen
J1459
J9065
Leustatin**
Profasi (chorionic gonadotropin)
J0725
J9070
Cytoxan**
Profilnine SD
J7194
J9098
Depocyt**
Prolastin
J0256
J9100
Cytostar-U**
Proleukin**
J9015
J9120
Cosmegen**
Prolia
J0897
J9130
Dtic-Dome**
Proplex T
J7194
J9150
Daunorubicin**
Provenge
Q2043
J9151
Daunoxome**
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Purinethol**
J8999
J9155
Firmagon**
Reclast
J3488
J9160
Ontak**
Reclast
J3489
J9171
Taxotere**
Recombinate/Refacto
J7192
J9178
Ellence**
Remicade*
J1745
J9179
Halaven (eribulin mesylate)
Remodulin (Treprostinil)
J3285
J9181
Vepesid**
Rilonacept
J2793
J9185
Fludara**
Rituxan
J9310
J9190
Adrucil**
Sandostatin LAR
J2353
J9200
Fudr**
Sermorelin Acetate
Q0515
J9201
Gemzar**
Simponi (golimumab)
J1602
J9202
Goserelin
Soliris
J1300
J9202
Zoladex
Somatropin
J2941
J9206
Camptosar**
Somatuline
J1930
J9207
Ixempra
Sprycel**
J8999
J9208
Ifex**
Stelara
J3357
J9209
Mesnex**
Stivarga**
J8999
J9211
Idamycin**
Supartz*
J7321
J9213
Interferon Alfa-2A
Supprelin LA (histrelin implant)
J9226
J9214
Interferon Alfa-2B
Synagis
90378
J9215
Interferon Alfa-N3
Synribo**
C9297
J9216
Interferon Gamma
Synvisc*
J7325
J9217
Lupron
Tafinalar**
J8999
J9218
Lupron
Targretin**
J8999
J9219
Viadur**
Taxol**
J9265
J9225
Histrelin
Taxotere**
J9171
J9226
Supprelin LA (histrelin implant)
Temodar
J8700
J9228
Yervay (ipilimumab)
Temozolomide
J9328
J9230
Mustargen**
Teriparatide
J3110
J9245
Alkeran**
Testopel
S0189
J9250
Methotrexate**
Thioplex**
J9340
J9260
Methotrexate**
Thrombate III (antithrombin III)
J7197
J9261
Arranon**
Thyrogen
J3240
J9263
Eloxatin**
Tice/Theracys**
J9031
J9264
Abraxane
Topotecan
J9351
J9265
Taxol**
Topotecan oral
J8705
J9266
Oncaspar**
Torisel (temsirolimus)
J9330
J9268
Nipent**
Treanda**
J9033
J9280
Mutamycin**
Trelstar
J3315
J9293
Novantrone**
Treprostinil
J7686
J9300
Mylotarg**
Tretinoin/Vesanoid**
J8999
J9302
Arzerra (ofatumumab)
Tysabri*
J2323
J9303
Vectibix
Uvadex**
J9999
J9305
Pemetrexed
Coventry Health Care of Illinois, Inc.
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Valstar**
J9357
J9307
Folotyn (pralatrexate)
Vectibix
J9303
J9310
Rituxan
Velban**
J9360
J9315
Istodax (romidepsin)
Velcade
J9041
J9320
Zanosar**
Vepesid**
J9181
J9328
Temozolomide
Viadur**
J9219
J9330
Torisel (temsirolimus)
Vidaza
J9025
J9340
Thioplex**
Visudyne (verteporfin)
J3396
J9351
Topotecan
Vivitrol
Von Willebrand factor complex
(human)
Von Willebrand factor complex
(human)
Von Willebrand factor complex
(human)
Voraxaze**
J2315
J9355
Herceptin**
J7183
J9357
Valstar**
J7186
J9360
Velban**
J7187
J9370
Oncovin**
J3490
J9390
Navelbine**
VPRIV (velaglucerase alfa)
J3385
J9395
Faslodex**
Vumon**
Q2017
J9400
Zaltrap**
Xeomin
C9278
J9600
Photofrin**
Xgeva
J0897
J9999
Bexxar**
Xiaflex
J0775
J9999
Marqibo**
Xolair
J2357
J9999
Uvadex**
Xyntha (factor VIII)
J7185
J9999
Yondelis**
Yervay (ipilimumab)
J9228
Q0515
Sermorelin Acetate
Yervoy
C9284
Q2017
Vumon**
Yondelis**
J9999
Q2042
Makena
Zaltrap**
J9400
Q2043
Provenge
Zanosar**
J9320
Q2045
Human Fibrinogen
Zemira
J0256
Q2047
Hematide (peginesatide)
Zinecard**
J1190
Q2049
Lipodox**
Zoladex
J9202
Q2050
Doxil**
Zometa
J3487
S0145
Pegylated Interferon Alfa-2A
Zometa
J3489
S0148
Pegylated Interferon Alfa-2B
Zyvox (linezolid)
J2020
S0189
Testopel
For a listing of pharmacy injectables/SAI's that require prior authorization, please visit our websites at
www.chcillinois.com
www.chcmissouri.com
www.chcillinoismedicare.com
www.chcmissourimedicare.com
Coventry Health Care of Illinois, Inc.
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C. How to Decrease Call Time to Pre-Authorize Medical Services
Call and hold time to pre-authorize services will be decreased if all provider offices have some basic information available
to them when they place a call to the Pre-Authorization Department at 866-557-8748 or 217-373-3998.
We will need the following information:
1.
Your name, the office you are calling from and a call back number
2.
Member name
3.
Member ID number
4.
Test or Procedure requested (CPT code)
5.
Diagnosis (ICD-9 code)
6.
Requested place of service
7.
Anticipated date of service
8.
Current patient symptoms or suspected disorder
9.
Findings on physical exam (PCP or specialist)
10.
Medical/surgical history related to this request
11.
Current medications related to this request (including failed medication therapy as appropriate)
12.
Results of previous imaging studies related to this request
13.
Results of lab testing related to this request
14.
Results from the use of assistive devices (i.e. can crutches and or walker related to this request)
Prior Authorization Phone Queue
Dial 866-557-8748 and see below for menu choices to help direct your prior authorization calls and reduce wait times:
Be prepared to report the member’s coverage type (e.g., HMO, PPO, Advantra or ASO (self-funded)), as
numeric options are based on this information.
For questions about claims or benefits, press 2.
For pharmacy oral medication authorizations or self-administered injectables, press
3. To check the status of a request for authorization, press 4.
For ASO (self-funded employer groups) authorizations, press 5.
For authorizations of services applicable to the outpatient imaging program National Imaging Associates (NIA),
press 6 for commercial or Medicare Advantra members.
For authorizations of services applicable to the outpatient pain management program Triad, press 7 for
commercial or Medicare Advantra members.
For all other prior authorizations for commercial membership or Medicare Advantra members, press
8. To hear the menu again, press 9.
Additionally, directprovider.com is available. Data is readily available to providers to help accelerate claims processing and
information flow. If you have not already registered, please do so to review available information. Common uses of the
site include:
Verification of whether or not a service requires prior authorization by CPT code
Submission of online requests for prior authorization
Viewing status of an authorization request
Please note that you need a user name and password to use directprovider.com. For more information about how to
access directprovider.com, contact your local Provider Relations representative at 800-562-5792.
D. Peer to Peer Review
If a provider disagrees with a decision made by one of Coventry’s medical directors, he/she may speak with that medical
director in a peer-to-peer discussion at 314-506-1708. Peer-to-peer discussions should occur within one business day
of the adverse decision.
III - Claims
A. Submission of Claims
Paper claim submission
Paper claims must be submitted to Coventry Health Care of Illinois, Inc. on CMS-1500 or UB-04 forms. The provider is
responsible for ensuring data being submitted is accurate and complete. Be sure to use valid and complete
diagnosis codes on your claims. All information should be printed on the forms within the specified boxes.
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Medical Claim Mailing Address: Coventry Health Care, P.O. Box 7141, London, KY 40742
Electronic medical claim submission
Coventry Health Care of Illinois, Inc. encourages physicians and facilities to submit claims electronically. Electronic claim
submissions can have significant, positive impact on the productivity and cash flow for your practice. Electronic
claim submissions will be routed through Emdeon who will review and validate the claims for HIPAA compliance and
forward them directly to Coventry. The Emdeon Payer ID for Coventry Health Care of Illinois, Inc. is 25133.
Contact your practice management system vendor or clearinghouse to initiate the process. Providers should call
(800) 215-4730 for information on direct submission to Emdeon.
B. Claim Inquiries
DirectProvider
Directprovider.com and Emdeon have an online claims adjustment process that many providers find very
useful. For more information, please see the Quick Guide for directprovider.com located in the back of this
manual.
C. Electronic Services
Coventry Health Care of Illinois, Inc. offers providers various electronic services to assist with claims payment and posting.
Electronic Fund Transfer (EFT)
Any provider that participates with Coventry Health Care, Inc. is eligible to receive EFT. Providers receive claim payments
more quickly and the payments are directly deposited into the provider’s bank account. For additional information, please
visit our website www.chcillinois.com or www.coventryil.com and review the information under the Electronic Solutions
section.
To begin the process of receiving EFT, you must complete the EFT form. It is located on our website at
www.chcillinois.com or www.coventryil.com under Providers, click on Document Library, then under the Forms section,
you will see the EFT form. Please note that when you sign up for EFT you will no longer receive paper remittances
advices in the mail.
Electronic Remittance Advice (ERA)
Electronic Remittance Advices allow providers to post payments quickly and efficiently. ERA’s have many benefits for
provider offices and hospitals. It allows for increased accuracy of posting and increased billing office productivity.
For more information on ERA’s, go to our website, www.chcillinois.com or www.coventryil.com, click on Provider, then
Electronic Solutions, then EDI Documentation.
IV - Provider Search
A. How to Search for a Provider at www.chcillinois.com, www.coventryil.com,
or www.chcillinoismedicare.com
Coventry Health Care of Illinois Inc.’s online provider search makes finding a network provider even easier. The provider
search is used to find a doctor, hospital or other type of providers based on specific search criteria.
The following instructions will help you find the type of provider (doctor, hospital, behavioral health/substance abuse
provider or ancillary service provider) you select.
1. Go to www.chcillinois.com, www.coventryil.com, or www.chcillinoismedicare.com and select Providers. Then click on
“Locate a Provider” on the top of the page.
2. Click on the blue box labeled “Provider Search”.
Select a plan
Search by zip code, name, facility, county, specialty or condition
3. Based upon your search criteria, you can select more options to narrow your search.
Click on the left and right arrows.
4. You also have the option to print a directory or sort by distance.
5. At anytime, you can start a new search by clicking on Start a new search located at the upper right of the screen.
B. How to Create a Directory at www.chcillinois.com, www.coventryil.com,
www.chcillinoismedicare.com
Coventry Health Care of Illinois, Inc.
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Coventry Health Care of Illinois Inc.’s online provider search makes finding a network provider even easier. The provider
search is used to find a doctor, hospital or other type of providers based on specific search criteria.
The following instructions will help you find the type of provider (doctor, hospital, behavioral health/substance abuse
provider or ancillary service provider) you select.
1. Go to www.chcillinois.com, www.coventryil.com, or www.chcillinoismedicare.com and select Providers. Then click on
“Locate a Provider” on the top of the page.
2. Click on the blue box labeled “Provider Search”.
Select a plan, Search by zip code, name, facility, county, specialty or condition
3. Based upon your search criteria, you can select more options to narrow your
search. Click on the left and right arrows.
4. You also have the option to print a directory or sort by distance.
5. At anytime, you can start a new search by clicking on Start a new search located at the upper right of the screen.
V - Disease Management Programs
COVENTRY HEALTH CARE DISEASE MANAGEMENT PROGRAMS
The following Disease Management Programs are offered by Coventry Health Care of Illinois, Inc.
Condition
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure (CHF)
Coronary Artery Disease (CAD)
Diabetes
Age Requirement
Age 5 & older
Age 18 & older
Age 18 & older
Age 18 & older
Age 5 & older
Clinical Practice Guidelines:
All of the disease management programs are based on clinical practice guidelines from nationally recognized
organizations. Our member education is based on the recommended care outlined in these clinical practice guidelines.
Program
Clinical Practice
Website
Guidelines
American Lung and National
Asthma
Heart, Lung and Blood Institute
Chronic
Obstructive
Pulmonary
Disease
(COPD)
Congestive Heart
Failure (CHF)
Coronary Artery
Disease (CAD)
Diabetes
Global Initiative for Chronic
Obstructive Lung Disease –
World Health Organization,
National Heart, Lung and
Blood Institute and the
American Lung Association
American College of
Cardiology and the American
Heart Association
American College of
Cardiology and the American
Heart Association
http://www.nhlbi.nih.gov/guidelines/asthma
http://www.goldcopd.com/
http://www.acc.org/qualityandscience/clincal/statements.htm
http://www.acc.org/qualityandscience/clincal/statements.htm
American Diabetes
Association
http://diabetes.org/for-health-professionals-andscientists/cpr.jsp
Program Enrollment:
System Referrals: Members identified with Asthma, COPD, CHF, CAD and Diabetes is enrolled into the disease
management programs. Members are referred to the program through the utilization review process and through the use
Coventry Health Care of Illinois, Inc.
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of Coventry Health Care’s disease management system that utilizes medical and pharmacy claims to identify members
who may benefit from the programs. Members are provided with information on how to Opt-Out of the programs, if they
prefer not to participate.
Self Referrals: Members may self-refer to any of the disease management programs by contacting the customer service
number on the back of their insurance card.
Provider Referrals: Providers may refer a member by contacting the customer service number on the back of the
member’s insurance card OR by faxing the attached provider referral form to 866-603-5400.
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Risk Stratification and Interventions:
Members identified for Disease Management Programs are stratified into three risk groups – Low, Medium and High.
Product
Commercial
Membership
(Fully-Insured, ASO)
Low Risk
Welcome Kit
Outreach Call –
Disease
Management (DM)
Call Center – to
review treatment
goals and
recommended
services
Advantra & Total Care
Moderate Risk
Welcome Kit &
Outreach Call
Targeted Mailing for
members missing
one or more
recommended
service for their
condition
Targeted Outreach
Call from DM Call
Center staff to review
the importance of the
missing service(s).
Welcome Kit
Quarterly Disease
Specific Mailings
High Risk
Welcome Kit &
Outreach Call
Targeted Mailings &
Targeted Outreach
Call
Referral for Case
Management
Evaluation and
ongoing Case
Management
services, if needed
Welcome Kit
Quarterly Mailings
Targeted Reminders
Welcome Kit
Quarterly Mailings
Targeted Mailings
Referral for Case
Management
Evaluation and
ongoing Case
Management
services, if needed.
Program interventions are based on the Risk Stratification of the member. Members are re-stratified every 6 months.
Disease Management Program Interventions are based on the Risk Stratification.
VI - Reference Materials
A.
B.
C.
D.
E.
DirectProvider Quick Guide
Authorization Form
Provider Request for Review Form
Members Rights and Responsibilities
Disease Management/Case Management Referral Form
Coventry Health Care of Illinois, Inc.
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If your Tax ID has not already
Provider Offices do not require “permission” to access their
information associated with their tax IDs.
been registered
1.
2.
Identify who the account administrator will be. The
account administrator is responsible for adding and
deleting users and giving privileges to certain functions
within the site.
2.
Decide if you prefer to have a single administrator who is
responsible for setting up other users throughout the
organization, or an administrator for each site.
3.
Each user will set up those Tax IDs, plans, and providers
they wish to see in their individual drop-down boxes. All
providers associated with a Tax ID will be available for
selection to include in your drop-down box.
Click on the Login/Register link on the Provider Channel at
www.chcillinois.com or www.coventryil.com
3.
Click the Register link on the home page
4.
Fill out the online form, remembering to fill in all required
fields (designated with an asterisk *). Tax ID and
Coventry Health Care of Illinois, Inc. provider ID will be
required, along with a designated account administrator
and their email address. If you do not have your provider
ID number, you can obtain it from your Coventry Provider
Representative.
5.
You will be asked to identify what password you wish.
6.
Your user ID will be emailed within a day to the email
account as designated on the setup form.
The information on your setup form will be validated. If the
information CANNOT be validated, you will be instructed via
email to contact Net Support at 866-629-3975.
Users who have multiple tax IDs will be required to sign up
under a single tax ID. User’s have the ability to add additional
tax IDs after they have logged in.
A letter will be sent to the primary address we have on file for
that Coventry Health Care of Illinois, Inc. provider ID notifying
the site that someone has registered to use
directprovider.com.
For Large Provider Groups and Billing Offices with
Multiple Tax IDs and Providers
1.
During registration you will need to determine which
provider “type” you wish to sign up as.
To set up new users under an
existing Tax ID
New users are required to contact their administrators in order to
register for a user ID and password.
New users will be set up under the Tax ID(s) of the administrator
who sets them up.
If a new user is unsure who their administrator is, they can contact
Net Support at 866-629-3975.
Administrators will need to complete the enrollment form online.
1.
Complete the online form, remembering to fill-in all required
fields (designated with an asterisk *). Administrators will set
up the user ID.
2.
Set up the user’s online privileges. Administrators have the
power to restrict a user’s access to certain functionality and
times they can access those functions.
3.
Verify the information online.
4.
The Administrator will forward the user ID to the new user.
5.
A temporary password will be emailed to the new user or to
the administrator if no email is available for the user. Users
will have the ability to change their password after they log in.
Please note: emails to new users and administrators will include a
link to the User’s Guide. User IDs and passwords will never
appear in the same email for security reason.
Billing Provider Type—This is a separate entity that
is contracted with the provider to do billing for them.
Providers who own individual Tax IDs will be
contacted and will need to give the billing offices
permission to access their information.
Provider Office Type—This is a provider who does
not contract with an outside organization for billing
services.
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Coventry Commercial Products (HMO,PPO,POS)
Member Rights and Responsibilities
As a CoventryMember, you have the right to:
· Receive information about Coventry, its services, its practitioners and providers and member rights and
Responsibilities
· Be treated with respect and recognition of your dignity and right to privacy
· Participate with practitioners in making decisions about your health care
· A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless
of cost or benefit coverage
· Voice complaints or appeals about Coventry or the care it provides
· Make recommendations regarding Coventry’s member rights and responsibilities policy
As a CoventryMember, you have the responsibility to:
· Supply information (to the extent possible) that Coventry and its practitioners and providers need in order
to provide care
· Follow plans and instructions for care that you have agreed to with your practitioners
· Understand your health problems and participate in developing mutually agreed-upon goals, to the degree
possible
Coventry Health Care of Illinois, Inc.
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Plan Member Rights and Responsibilities
The health plan preserves and protects the rights of its members to obtain the health care they require. In addition,
members are responsible for working with their plan and providers to promote their well-being.
A. Members have the right to be treated as a partner when choosing the appropriate care. This right is often
asserted in the following ways:
1. Each member may designate their own primary care physician under their plan’s network requirements.
2. Members may see most types of participating specialty care physicians without a referral from a primary care
physician regardless of their plans (e.g. HMO, POS, or PPO). For female members, this includes a women’s
principal health care provider, such as a participating physician specializing in obstetrics and gynecology.
3. All members are entitled to all of the information necessary to manage their health care needs. They may also
seek a second opinion if they so choose.
4. Members and providers may discuss the appropriateness or medical necessity of treatment options for the
conditions at hand, regardless of cost or benefit coverage. The health plan does not ask health care providers
to withhold information about treatments that may not be covered.
B. Members have the right to receive information that enables them to maximize their plan’s benefits. We are
available to answer any and all questions regarding health benefits. We also provide members with the
following information on our secure website:
1. Evidence of Coverage: Outlines benefits in depth, including what the member will pay for the services he or she
receives
2. Plan Member Identification Card: Helps others recognize them as a plan member.
3. Provider Directory: Lists doctors, hospitals and other care providers within a member’s network.
4. Member Rights and Responsibilities: Describes how to obtain a printed copy of this statement and explains any
policy changes through our plan’s member publication Living Well.
Printed copies of any web-based materials may be obtained by calling the toll-free Customer Service number on
the back of the member ID card.
C. Members have the right to be treated with dignity and respect. The health plan honors members’ rights by:
1. Respecting their privacy. We treat nonpublic personal information with the utmost respect. We have instated
policies and procedures to protect members’ information against unlawful use or disclosure.
2. Treating members as we would like to be treated.
3. Valuing members’ personal dignity and preferences.
D. Members have the right to voice their concerns or problems with the plan or the care they receive. We
encourage unsatisfied members to voice their opinions in the following ways:
1. Call the Customer Service department at the number on the back of the plan member ID card.
2. Send a letter to our Customer Service department at 2110 Fox Drive, Suite A, Champaign, Illinois 61820.
3. Write to the Illinois Department of Insurance (Attention: Consumer Services) at 320 W. Washington,
Springfield, Illinois 62767.
E. Members have the right to make recommendations regarding our rights and responsibilities statement.
This statement was reviewed by our Consumer Advisory committee, which is composed of plan members.
Please write the Quality Improvement department at 2110 Fox Dr. Suite A, Champaign, IL 61820 in order to
do so.
F. Members must assist their health plan and doctors in the following ways:
1. Remain polite and respectful.
2. Present their member identification card at the time of service.
3. Allow no one else to use identification card.
4. Provide true and complete details regarding their previous and present state of health.
5. Refrain from divulging false details that may mislead care providers or limit their ability to administer proper
medical care.
6. Gain a full understanding of health problems and participate in the development of treatment goals.
7. Follow the treatment plan discussed between the member and provider, and communicate any concerns.
8. Pay premiums on time.
9. Pay copayments/coinsurance amounts required by the plan and provider.
10. Provide the plan with requested information, including medical records, as well as physician statements
regarding physical conditions, care and treatment.
Coventry Health Care of Illinois, Inc.
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Coventry Health Care of Illinois, Inc.
Disease Management ● Case Management Referral Form
Providers: Fax Completed form to 1-866-603-5400
Member Name:
Member’s Coventry ID number:
Member Phone Number (daytime):
Member DOB:
Referring Physician Name:
PCP Name:
Referring Physician Phone Number:
Referring Physician Fax Number:
Disease Management Program referral – Please check
Asthma
COPD
CHF
Coronary Artery Disease
Diabetes
Case Management Program referral
Diagnosis:
Brief description explaining reason for referral :
Person Completing Form:
Coventry Health Care of Illinois, Inc.
Date:
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