4 - Provider Services - Sierra Health and Life
4 - Provider Services - Sierra Health and Life
4 - Provider Services - Sierra Health and Life
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2008 SHL <strong>Provider</strong> Summary Guide4 - <strong>Provider</strong> <strong>Services</strong>Under one department, <strong>Provider</strong> <strong>Services</strong> <strong>and</strong> Network Development <strong>and</strong> Contracts worktogether to accomplish provider contracting, re-contracting, resolve network issues, conductprovider orientation, <strong>and</strong> provide continuing education to our network of providers. Both entitiesof this department are described in greater detail below.4.1 Department Overview<strong>Provider</strong> <strong>Services</strong> is responsible for the orientation <strong>and</strong> continuing education of providers <strong>and</strong>their office staff, translation of benefit design, provider policies, <strong>and</strong> timely <strong>and</strong> effectivecoordination of problem resolution between the provider offices <strong>and</strong> various departments within<strong>Sierra</strong> <strong>Health</strong> <strong>and</strong> <strong>Life</strong>.<strong>Provider</strong> <strong>Services</strong> representatives are available for initial staff orientations, ongoing assistance,education <strong>and</strong> support. Our representatives make regular site visits to providers <strong>and</strong> their officestaff to provide current, updated information, educational materials, <strong>and</strong> assist with problemresolution, including claims payment <strong>and</strong> status.Network Development <strong>and</strong> Contracts is responsible for the initial contracting of providers, aswell as for recontracting, contract amendments <strong>and</strong> updates. The Network Development <strong>and</strong>Contracts Department processes all provider changes, including routing new <strong>and</strong> updatedinformation throughout <strong>Sierra</strong> <strong>Health</strong> <strong>Services</strong>’ internal departments, <strong>and</strong> producing the providernetwork directories for all <strong>Sierra</strong> products.Contracted providers may at any time request information regarding SHL’s reimbursementlevels by submitting a Request for Allowables form. This form can be found in Section 21.1, <strong>and</strong>is also available on SHL’s website at www.sierrahealth<strong>and</strong>life.com.For more information regarding the <strong>Provider</strong> <strong>Services</strong> Department, please call:Telephone Numbers:Las Vegas area (702) 242-7088Toll free (800) 745-7065Fax Numbers:Las Vegas area (702) 242-9124Hours of Operation: Monday - Friday 8:00 a.m. - 5:00 p.m. Pacific St<strong>and</strong>ard TimeSHL 2008 Section 4 <strong>Provider</strong> <strong>Services</strong> 1
2008 SHL <strong>Provider</strong> Summary GuideSHL@YourService also allows providers to submit electronic prior authorization requestsreplacing the current paper-based process that relies on h<strong>and</strong>-written forms.SHL@YourService uses technology to capture <strong>and</strong> route authorization data to increaseefficiency <strong>and</strong> accuracy <strong>and</strong> improve overall satisfaction. The information entered is routedthrough an interface engine <strong>and</strong> workflow process to determine status (pre-approvals <strong>and</strong> pendfor review) <strong>and</strong> automatically populates in SHL’s Utilization Management system.If you currently have internet services in your office, <strong>and</strong> are not yet connected toSHL@YourService, Please refer to Section 21.2 for the SHL @YourService Request Form. An@YourService user guide is located on the SHL website <strong>and</strong> <strong>Provider</strong> <strong>Services</strong> is available toanswer any specific questions you may have regarding the application.4.3 National <strong>Provider</strong> Identifier-(NPI)The National <strong>Provider</strong> Identifier (NPI) is a <strong>Health</strong> Insurance Portability <strong>and</strong> Accountability Act(HIPAA) Administrative Simplification St<strong>and</strong>ard. The NPI is a unique identification number forcovered health care providers. Covered health care providers <strong>and</strong> all health plans <strong>and</strong> healthcare clearinghouses will use the NPIs in the administrative <strong>and</strong> financial transactions adoptedunder HIPAA.What is the NPI – National <strong>Provider</strong> Identifier?• The NPI is a 10-digit, intelligence free numeric identifier (10 digit number). Intelligencefree means that the numbers do not carry information about health care providers, suchas the state they practice or their provider type or specialization.• The NPI will replace health care provider identifiers in use today in HIPPA transactions.Those numbers include Medicare legacy IDs (UPIN, OSCAR, PIN <strong>and</strong> National SupplierClearinghouse or NSC).• The provider’s NPI will not change <strong>and</strong> will remain with the provider regardless of job orlocation.For more information regarding NPI you can contact CMS at (800) 465-3203, <strong>Provider</strong> <strong>Services</strong>at (702)-242-7088, or information is available on a CMS web page.http://www.cms.hhs.gov/NationalProvIdentSt<strong>and</strong>/4.4 <strong>Provider</strong> Additions, Changes <strong>and</strong> TerminationsIt is important to notify <strong>Sierra</strong> <strong>Health</strong> <strong>and</strong> <strong>Life</strong> as soon as possible of any of the following events:• Adding a new provider to a group practice• <strong>Provider</strong>s leaving a group practice• Changes in Tax ID Numbers• Office or billing address changes.For provider additions, please complete form 21.3 in Section 21 <strong>and</strong> fax it back to SHL at(702) 242-9124.For all other additions, changes, or terminations, please fax notification to SHL at (702)242-9124.Timely notification of these changes will help to avoid delays in the processing of claims, theremittance of payments, <strong>and</strong> important provider notifications.SHL 2008 Section 4 <strong>Provider</strong> <strong>Services</strong> 3
2008 SHL <strong>Provider</strong> Summary Guide4.5 Explanation of Payment (EOP) RequestsExplanations of Payments (EOP’s) are generated each time a claim is processed by the <strong>Health</strong>Plan. EOP’s contain detailed information such as claim adjudication, processed date <strong>and</strong> checknumbers.An electronic copy of how a claim was processed may be obtained through SHL@YourService,which offers providers the opportunity to view on line, the same detailed claim informationavailable on the “hard copy” EOP. For more information regarding SHL@YourService see Section6.4.A duplicate hard copy of an Explanation of Payment can be requested through the <strong>Provider</strong><strong>Services</strong> department at:• Phone (702) 242-7088 or (800) 745-7065• Fax (702) 242-9124.Or submit your request in writing to:<strong>Sierra</strong> <strong>Health</strong> <strong>and</strong> <strong>Life</strong>Attention: <strong>Provider</strong> <strong>Services</strong>P.O. Box 15645Las Vegas, NV 89114-5645When requesting a duplicate hard copy of an Explanation of Payment please provide thefollowing information:• Tax Identification number• Member Name• Date of Service• Billed Charges4.6 Divorce of Patient CareSHL recognizes that there may be extenuating circumstances when it becomes necessary for aphysician to divorce patient care <strong>and</strong> terminate the physician-patient relationship. Divorce ofpatient care is something that SHL takes very seriously <strong>and</strong> should be a last resort. To divorcepatient care please follow the steps outlined below:• Provide the patient with written notification via certified mail of your intent to divorce care• Copy the health plan on all divorce of care correspondence• Allow the patient thirty (30) days to find alternative careCopy of the Divorce of Patient Care letter should be mailed or faxed to the <strong>Provider</strong> <strong>Services</strong>Department at:SHL <strong>Provider</strong> <strong>Services</strong>Attention: <strong>Provider</strong> <strong>Services</strong> RepresentativeP.O. Box 15645Las Vegas, NV 89114-5645Fax (702) 242-9124SHL 2008 Section 4 <strong>Provider</strong> <strong>Services</strong> 4
2008 SHL <strong>Provider</strong> Summary GuideIf you have questions regarding Divorce of Patient Care please contact the <strong>Provider</strong> <strong>Services</strong>Department at (702) 242-7088 or (800) 745-7065.SHL 2008 Section 4 <strong>Provider</strong> <strong>Services</strong> 5