Plan Provider Summary Guide - Sierra Health and Life

Plan Provider Summary GuideSierra Optima offers Medicare Advantage Private Fee-for-Service plans that allow members toaccess care with any eligible provider that is considered to be a participating provider throughthe deeming process. There are no networks or contracts in place. Providers will have theoption of deeming themselves participating providers and therefore able to render services toSierra Optima members and receive reimbursement for the services rendered. A provider mayelect not to become a participating provider. In which case they should not render services to aSierra Optima member.Eligible ProviderSierra Optima by Sierra Health and LifeA provider is eligible to become a participating provider if: They are licensed by the state. They have a Medicare billing number or are eligible to obtain one. They have not been sanctioned or have opted out of Medicare. They are not a federal health care provider.

Deemed ProviderA provider is deemed to be a Sierra Optima participating provider if: They had knowledge of the member’s enrollment in Sierra Optima. They had knowledge or had reasonable access to Sierra Optima’s Terms and Conditions. They provided services to a Sierra Optima member.Deemed ProcessUpon enrollment, Sierra Optima members will be given a membership card. When a memberattempts to access services at a provider’s office, they will present the membership card to theprovider. The card will direct the provider to www.sierraoptima.com and/or the Member ServicesDepartment to obtain information regarding Sierra Optima’s Terms and Conditions. If, afterhaving knowledge of the member’s enrollment in the plan and the plan’s Terms and Conditions,the provider agrees to render services to the member, they are deemed to be a Sierra Optimaparticipating provider and will be subject to Sierra Optima’s Terms and Conditions. If the providerdoes not agree to Sierra Optima’s Terms and Conditions, they may not render services to themember.Sample Membership CardPlan WebsiteSierra Optima’s Web site is a valuable tool for providers and their office staff. By visiting theWeb site and selecting the “Provider Terms and Conditions” option, providers will gain access to: Plan Terms and Conditions Plan Payment Guide Plan Summary of BenefitsThe Sierra Optima Web site is www.sierraoptima.com.Eligibility and BenefitsEligibility and plan information can be obtained by calling Sierra Optima’s Member ServicesDepartment at 888-274-2207.

The Member Services Department has a staff of representatives and specialists who can assistyou with the following: Eligibility Plan coverage ID card questions Member concerns Plan Terms and ConditionsClaimsProviders should submit their completed HCFA 1500 or UB-92 forms to:Sierra Health and Life Insurance CompanyP.O. Box 15645Las Vegas, NV 89114-5645Sierra Health and Life Insurance Company is able to receive HIPAA-compliant electronic claimsfrom the following clearinghouses:HCRnet WebMd Envoy ENS2310 Paseo Del Prado, #208 One Century Plaza 7899 Lexington Drive, #203Las Vegas, NV 89102 26 Century Blvd, #601 Colorado Springs, CO 80920(702) 735-5525 Nashville, TN 37214 (800) 341-6141(615) 885-3700For electronic claims submissions, please use Payor ID 76342.Timely Filing PeriodClaims for covered services shall be submitted within ninety (90) calendar days of the date ofservice. If a claim is submitted more than 90 calendar days after the date of service, it will not behonored for payment.ReimbursementServices will be reimbursed based on the Medicare allowable amounts and are subject toMedicare guidelines. For further information regarding plan reimbursement, please referencethe “Plan Payment Guide.” Sierra Optima participating providers agree to accept the Medicareallowable minus the member’s cost-share amount as payment in full for services regardless ofwhether they accept Medicare assignment or not.For information regarding the member’s cost-share amount, please reference the Sierra OptimaSummary of Benefits.Under no circumstances should members be billed any amount over their cost-share amount.Claims Reconsideration Process/Dispute ResolutionIf a provider disagrees with the adjudication of a claim reflected on their Explanation of Payment(EOP), he/she can file a written appeal within sixty (60) days of the receipt of the initial EOP. Thereconsideration request should include the EOP, reasons for requesting the reconsideration, andany pertinent information.

Requests for reconsideration should be submitted to:Sierra Health and Life Insurance CompanyAttention: Claims ReconsiderationP.O. Box 15645Las Vegas, NV 89114-5645Sierra Health and Life Insurance Company will respond, in writing, to all provider appeals withinsixty (60) days.Appeals ProcessIf a provider disagrees with a determination of non-coverage reflected on his/her EOP, they canfile a written appeal within sixty (60) days of the receipt of the initial EOP. The appeal shouldinclude the EOP, reasons for requesting the appeal, and any substantiating medical records orpertinent information.Appeals should be submitted to:Sierra Health and Life Insurance CompanyAttention: Customer Response and ResolutionP.O. Box 15645Las Vegas, NV 89114-5645Sierra Health and Life Insurance Company will respond, in writing, to all provider appeals withinsixty (60) days.Referral and/or Prior Authorization RequirementsThere are no referral or prior authorization guidelines for this plan. Sierra Optima does followMedicare guidelines regarding coverage determinations.Hospital Admission NotificationSierra Optima requests admission notification when a plan provider is admitting a member into ahospital.For hospital admit notifications, please call 800-365-9687.Hospital admission notification is not a requirement and will not impact claims processing.Sierra Optima is a product of Sierra Health and Life Insurance Company, Inc. with a Medicare contract to offer MedicareAdvantage Private Fee-For-Service plans available to anyone enrolled in both Medicare Parts A and B through age or disability.Benefits and premiums vary by state and county.Last revision: 03/200841NVSHL06858