| Applies To* |
All MCO Credentialed Faculty**
EXCEPT: Transplant Services
**For further clarification of "All MCO Credentialed Faculty" refer to Table of Contents.
|
| PCP Services |
- PPO network agreement does not require members selection of a PCP.
|
| Laboratory Services |
Includes services performed at:
|
| Radiology Services |
Includes services performed at:
- Algur H. Meadows Diagnostic Imaging Center
- Aston Radiology
- Mary Nell & Ralph B. Rogers MRI Center
- PET Center
A radiology benefit management company will begin
administering radiology services for Humana members
January 1, 2006. Any MRI, CT, CTA, MRA or PET
procedure you need for a Humana insured patient
should be ordered through the RadConsult Call Center
at (866) 825-1550. Fax RadConsult Clinical Information
Form sheet to (888) 863-4464 and a coordinator will
contact you regarding the test that is being ordered.
|
| Participating Facilities |
- Children’s Medical Center
- Parkland Health and Hospital System
- St. Paul Medical Center
- Zale Lipshy University Hospital
- UT Southwestern Clinical Procedure Clinic (CPC)/Ambulatory Surgery Center (ASC)
- Moncrief Radiation Oncology Center (MROC)
|
| Referral Requirements |
Referral forms are not applicable for this PPO contract agreement; however, the UT provider should refer the patient to other participating Choice Care providers.
For information on ChoiceCare Transplant members,
please refer to Choice Care National Transplant Network
|
| Authorization Requirements |
For authorization call the Integrated Voice Response (IVR) system at (800) 523-0023 and for EHI (Employers Health Insurance) call 800-647-4477. Refer to the Humana IVR Instructions for additional information.
Services requiring authorization include, but may not be limited to, the following:
- All inpatient hospitalizations
- Adenoidectomy & Tonsillectomy (T&A or individually)
- Arthroscopy (All Joints)
- Carpel Tunnel
- Cesarean Section, first or repeat
- Cholecystectomy (Laparoscopic or Open)
- Coronary Artery Bypass Surgery
- Colonoscopy
- Hysterectomy
- Laminectomy Discectomy with or without Fusion
- Myringotomy with or without insertion of ventilating tubes
- MRI/MRA
- Tonsillectomy
- Tympanostomy (Myringotomy) with or without tubes
Fax written authorization requests to (800) 921-7751.
Services requiring written authorization include, but may not be limited to, the following:
- Blepharoplasty
- BIPAP
- Continuous Positive Airway Pressure (CPAP)
- Breast Reconstruction, Reduction Mammoplasty, Subcutaneous or Prophylactic Mastectomy (including Gynecomastia)
- Cosmetic Procedures
- Durable Medical Equipment
- Gastric Bypass Surgery or Gastroplasty
- High Tech biosynthetic Drugs: Betaseron, Protropin or Pulmozyme
- Nasal Surgery-Rhinoplasty and/or Septoplasty with or without Submucousal Resection
- Penile Implants and/or Revascularization
- Scar Revisions
- Speech Therapy
- TMJ/TMD surgery and/or splint therapy (including Mandibular or Maxillary Osteotomy)
- Uvulopalatopharyngoplasty (UPPP)
|
| Managed Care Plan*** |
-Choice Care PPO
-Choice Care PPO - ASO
-National POS - Open Access
-Humana Preferred
-Humana Preferred - ASO
-Humana Preferred POS - Open Access
Please note that we are not contracted and do NOT
accept :
-Humana Gold Plus Medicare HMO or
-Humana Choice Medicare PPO
Sample ID Cards for Medicare products UT DOES NOT ACCEPT
|
|
Identification Cards
|
Humana Health Care Plans - See ID Card
ChoiceCare - See ID Card
PPO Smart Net/Humana Preferred - See ID Card
|
| FSC |
268-Humana PPO/Choice Care
-Choice Care PPO
-Choice Care PPO - ASO
-National POS - Open Access
367- ChoiceCare PPO-CPC Facility Billing
285-ChoiceCare Advantage Network/PPO Smart Net
-Humana Preferred
-Humana Preferred - ASO
-Humana Preferred POS - Open Access
368-ChoiceCare Advantage CPC Facility Billing
|
| Contract Date(s) |
July 1, 1999 - All Faculty
(Implementation date August 1, 1999)
March 1, 2004-Choice Care Advantage Network
|
| Eligibility |
|
| Claims Mailing Address |
- Varies by Plan- see member's ID card which includes but not limited to:
Louisville Service Center
Humana Claims Office
P.O. Box 14601
Lexington, KY 40512-4601
Jacksonville Service Center
Humana Claims Office
P.O. Box 14602
Lexington, KY 40512-4602
San Antonio Service Center
Humana Claims Office
P.O. Box 14603
Lexington, KY 40512-4603
Green Bay Service Center (Kansas City)
Humana Claims Office
P.O. Box 14604
Lexington, KY 40512-4604
Green Bay Service Center (Self-Funded Groups)
Humana Claims Office
P.O. Box 14609
Lexington, KY 40512-4609
Green Bay Service Center (Fully Insured)
Humana Claims Office
P.O. Box 14610
Lexington, KY 40512-4610
|
| Deductible/Co-Payment |
- Varies by Plan-see member’s ID card
|
| Claims Submission |
-
File electronically or use a HCFA 1500 claim form.
-
UTSWMC has 95 days from the date-of-service to file a claim with the payor.
-
Payor ID# 61101 is the identifier for electronically submitted claims to Humana/ChoiceCare payor.
- Humana Clean Claim Requirements
|
| Claims Payment |
- All clean electronically billed claims will be
reimbursed by the payor, within 30 days of receipt
by payor.
- All clean non-electronic claims will be reimbursed,
by the payor, within 45 days of receipt by payor.
|
| Appeals |
Appeal request must be submitted to payor within 180 days of the processing date on the EOB or the date of the denial letter. |
| Provider Relations |
Choice Care Network
Attention: Provider Relations
P.O. Box 19013
Green Bay, WI 54307-9013
800-626-2741 or fax to 800-626-1686
www.choicecarenetwork.com
|
| Comments |
Behavioral Health Services-varies by group. UTSW mental health providers are participating in the ChoiceCare Network. UTSW will be considered in network ONLY if employer groups are accessing the ChoiceCare Network for their mental health benefits.
|
