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