6 - Benefits and Eligibility Verification - Health Plan of Nevada

2010 Dental Provider Summary Guide
6 - Benefits and Eligibility Verification
6.1 Enrollee Benefits
Health Plan of Nevada, Inc. (HPN), Sierra Health & Life Insurance Company, Inc. (SHL)
and Sierra Health-Care Options, Inc. (SHO), offer a variety of dental benefit plans that
are made available to eligible employees and their eligible family members of employer
groups.
Health Plan of Nevada (HPN) also provides dental services to Medicaid participants and
Nevada Check Up members enrolled with HPN. Dental benefits are based upon
Nevada Medicaid’s dental benefits outlined in the Medicaid Services Manual, Chapter
1000 at http://dhcfp.state.nv.us.
Effective March 1, 2005, HPN provided Senior Dimensions’ members with an added
value dental benefit, allowing Senior Dimensions members to receive contracted rates
when accessing HPN’s expansive network of participating dental providers.
If you have questions regarding dental benefits including exclusions and limitations,
please contact the Member Services Department at the following numbers:
Health Plan of Nevada (702) 242-7300
Toll free (800) 777-1840
TDD (702) 242-9214
TDD Toll free (800) 349-3538
HPN SmartChoice/Nevada CheckUp (702) 242-7317
NorthernChoice/Northern Nevada Check Up
Toll free (800) 962-8074
Senior Dimensions (702) 242-7301
TDD Toll free (800) 349-3538
Toll free (800) 650-6232
Sierra Health & Life (702) 242-7700
Toll free (800) 888-2264
TDD (702) 242-6281
TDD Toll free (800) 349-3538
Fax (702) 240-6281
Business Hours: Mon. – Fri., 8 a.m. – 5 p.m.
Interactive Voice Response System (24 hours 7 days a week)
SHL (702) 242-7393
HPN/Senior Dimensions (702) 242-7724
Toll free (800) 768-2808
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Sierra Health-Care Options
Dental Plans are administered through the following Third Party Administrators
(TPA’s):
The Loomis Company (800) 498-6237
(City of Henderson) (Clark County Self-Funded) (Palms)
Benefit Planners (866) 868-9787
(Station Casinos)
6.2 Eligibility and Plan Coverage Verification
The Member Services Department has a staff of representatives and specialists who can
assist you with the following:
• Eligibility
• Plan coverage
• ID card questions
• Member concerns
• Claim status
A member’s eligibility needs to be determined before services are rendered. Every
member and dependent is issued an identification card. All information on the card
serves as identification; however, it does not guarantee eligibility. Medicaid participants
and Nevada Check Up members are issued an identification card by First Health the
administrator for the Division of Health Care Financing and Policy (DHCFP) and may
present to your office with this card. @YourService will allow you to search by Medicaid
ID number to verify eligibility and benefits. For more information regarding
@YourService please see section 6.3.
Please remember any payment for covered services is subject to the member’s
eligibility at the time of service, compliance with the managed care program, contractual
limitations/exclusions and coordination of benefits as set forth in the Evidence of
Coverage (EOC) or Certificate of Coverage (COC).
6.3 @YourService
@YourService is your online provider information center for HPN, Senior Dimensions,
SHL, HPN- SmartChoice, and HPN Nevada Check Up member eligibility, top 20 copay
amounts, benefits, claims status, and prior authorization status. @YourService is
accessed through an Internet connection on the personal computers (PC’s) in your
office. This service is available 24-hours-a-day, 7-days-a-week. This feature is part of
our continuing effort to improve service to our providers.
@YourService is a “real time” application; (i.e. it is updated as our member eligibility,
claims information and prior authorization information is entered or changed in our
computer system). @YourService will allow you to search for information by member
name, partial name and date of birth, health plan member identification number or
Medicaid ID number. The member’s claim information is tied to your provider tax
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identification number, which means that only patients connected to that Tax ID number
are available for viewing. @YourService can help reduce and for some providers even
eliminate the amount of time spent on the telephone with the Member Services
Department.
@YourService also allows providers to submit electronic prior authorization requests for
medical procedures and for site and anesthesia for dental procedures; Thus, replacing
the current paper-based process that relies on hand-written forms. @YourService uses
technology to capture and route authorization data to increase efficiency and accuracy
and improve overall satisfaction. The information entered is routed through an interface
engine and workflow process to determine status (pre-approvals and pend for review)
and automatically populates in the health plan’s Utilization Management system. Please
note: Dental pre-determinations must still be submitted through the Claims department.
If you currently have Internet services in your office, and are not yet connected to
@YourService, please complete the enclosed access request form to request an
account. An @YourService user guide is located on the HPN and SHL websites. Dental
Provider Services is also available to answer specific questions you may have regarding
the application.
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HPN@Your Service and SHL@Your Service
Administrator Account Request Form
To better track account activity within the @YourService application, group TIN profiles will no
longer be issued. All new and existing accounts are to be set up with an individual login per
employee. Please complete this form with the information for the individual your office has
designated to be an Account Administrator.
The Account Administrator will be responsible for creating profiles, editing profiles, and
password reset of the individual accounts associated with their provider TIN.
Billing offices must go through their physician office for access. NO EXCEPTIONS
Please complete and fax to (702) 242-9124 Attn: Provider Services
ALL REQUESTED INFORMATION IS REQUIRED.
First & Last Name:
Requestor DOB:
Requestor Job Title:
Office Name:
Office Address:
TIN:
E-Mail:
Phone Number:
Fax Number:
As an authorized user of the HPN/SHL @YourService application, the above named organization will be given access to
private and confidential patient and health plan member data for the exclusive purpose of performing their professional
responsibilities. The following rules will govern usage of the system named above at all times:
‣ Usernames and passwords are to be safeguarded. Disclosing the username and password information to anyone
for any reason with the exception of authorized personnel of the entity providing access to the HPN/SHL
@YourService application is STRICTLY PROHIBITED.
‣ The private and confidential data within the HPN/SHL @YourService application is to be safeguarded at all times.
The HPN/SHL @YourService application contains information that is confidential and protected from disclosure by
law (except for specific legal exception or with the individual authorization). The Privacy Act of 1974, the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), and the Federal Privacy Rule all protect the
confidentiality of all individually identifiable health information.
‣ Use of the HPN/SHL @YourService application is monitored and subject to audit review. Access to private and
confidential data within the HPN/SHL @YourService application is to be limited to only such data as is required to
carry out professional responsibilities. Improper disclosure or access to private and confidential information
(obtained through the computer or otherwise) may result in immediate termination of system access privileges and
possible legal action.
HPN/SHL expressly reserves the right to make any and all determinations concerning violation of the rules stated herein.
Any determination made by us will be final and not subject to any formal review or appeal process
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6.4 Interactive Voice Response System
When calling the Member Services Department with eligibility questions, a new, userfriendly
menu designed especially for providers will greet you. By depressing a number
on the phone pad, your call will be routed to a trained representative who will help
answer your questions -- including prior authorization requests and contractual issues.
The phone system will let you know if there are calls ahead of yours.
Another enhancement is the “Interactive Voice Response System.” This will enable
you to obtain eligibility, benefits, and claims status at the touch of a button. This service
is available 24-hours-a-day, 7-days-a-week. This feature is part of our continuing effort
to improve service to our providers. We have also initiated an Interactive Voice
Response (IVR) direct number that will allow access directly to this system.
INTELLIGENT
CALL QUEUE
If you are waiting to speak with a representative, we will tell you if
there is a significant wait time. If you do not wish to wait, PRESS
1, we will keep your place and call you back when you are first in
line.
If you would like to leave a message in the
Member Services mailbox, PRESS 2.
Interactive
Voice
Response
Eligibility
&
Benefits
If you would prefer to continue to hold for the first available
representative, please remain on the line.
If you pressed 1, please enter the
telephone number where you would like
to be called back. If you are calling
outside the Las Vegas area, please
include your area code first.
Please enter the 11-digit member number.
When your place in the queue arrives,
we will call you at the telephone
number you entered.
IVR DIRECT
HPN (702) 242-7724
SHL (702) 242-7393
MEMBER SERVICES:
HPN, SmartChoice/Nevada Check Up,
Senior Dimensions
(702) 242-7317
Toll free (800) 962-8074
SHL (702) 242-7700
Toll free (800) 888-2264
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Den tal E & B
Inte rVoice
8/26 /02
Draf t 1
Eng lehart
DENTAL ELIGIBILITY & BENEFITS IVR APPLICATION
(PROVIDERS)
Direct to IVR 242-7724 (HPN).....242-7393 (SHL)
En ter Fax #
(including area code)
3
Vo ice On ly - 1
Fax Only - 2
Voice & Fax - 3
2
En ter Fax #
(including area code)
1
If fax requested
A fax document
has been created
and will be sent
to fax # entered.
yes
Enter 11-digit Member #
Enter D. O.B. (2-digit month, 2-digi t day, 4-digit year)
Effective today's date, pr ess #
For previous date, enter 2-digit month, day of service, year of service
(Member effective?)
no
Ter m date is_________
Enter di fferent date - 1
Enter di fferent mbr # - 9
Speak w/Rep - 0
if fax & voice requested
yes
Effective date
Calendar year maximum benefit & accumulator
Plan and/or Non-plan deductible for insured & accumul ator
Plan and/or Non-plan deductible for family & accumulator
(pl ays only when member has plan & non-plan benefits)
PLAN BENEFI TS
Product plan code
Waiting period (if applicable)
1
Benefits using plan providers - 1
Benefits using non-plan providers - 2
Benefits for both plan & non-plan provi ders - 3
2
NON-PLAN BENEFI TS
Product plan code
Waiting period (if applicable)
TYPE I
Routine Exams
Cleanings
Bite-wing x-rays
Flourides & Sealants
Complete X-ray series/Panorex
TYPE II
Per iodontal scaling
Root planing
Fil lings
Root canals
Extractions
TYPE III
Crowns
Bri dges
Dentures
Orthodo ntia
TYPE I
Routine Exams
Cleanings
Bite-win g x-rays
Flourides & Sealants
Complete X-ray series/Panorex
TYPE II
Periodontal scaling
Root planing
Fil lings
Root canals
Extractio ns
TYPE III
Crowns
Bri dges
Dentures
Orthodontia
******* Press 9 to skip to next type of benefits
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6.5 Sample ID Cards
Copies of identification cards are provided to better identify our members. The front of
the card contains information pertaining to the member and their benefits. Included in
this information are the following:
Employer Name:
Member Name:
Member Number:
Group Number:
Benefits:
Code:
Effective Date:
Copays:
The employer name may be included on the card
Name of member, can be dependent, spouse or insured
Unique 9 digit number identifying each member
Employer Group Number
Medical, Pharmacy, Vision, Dental
For each benefit a patient is eligible for, a corresponding code will
be listed
Effective dates will be displayed for each benefit code the member
is eligible for
Copays will be listed for Office Visits and other benefits if
applicable
@YourService, IVR or Member Services can provide additional copay information.
Based upon the benefits the member has, the information on the back of the card may
contain some of the following information:
Disclaimer:
Emergency:
Claims Address:
Benefit Questions:
Mental Health:
Web Site:
Instructions for the member and providers regarding eligibility &
prior authorizations
Members are to call 911 or go to the nearest hospital in case of an
emergency and contact Member Services as soon as reasonably
possible
Where to send claims
Phone number to contact Member Services
If the member has Mental Health Benefits through HPN, the name
and number of the Mental Health Provider
Web Site address information
Sample ID Cards, for many of the dental plans that you may come in contact with, have
been included for your review.
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Please note: Members who are enrolled in a SHO Dental plan (i.e. City of Henderson,
Clark County Self-Funded and Station Casinos) are issued member ID cards by the
applicable TPA.
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