4 - Provider Services - Sierra Health and Life

2008 SHL Provider Summary Guide4 - Provider ServicesUnder one department, Provider Services and Network Development and Contracts worktogether to accomplish provider contracting, re-contracting, resolve network issues, conductprovider orientation, and provide continuing education to our network of providers. Both entitiesof this department are described in greater detail below.4.1 Department OverviewProvider Services is responsible for the orientation and continuing education of providers andtheir office staff, translation of benefit design, provider policies, and timely and effectivecoordination of problem resolution between the provider offices and various departments withinSierra Health and Life.Provider Services representatives are available for initial staff orientations, ongoing assistance,education and support. Our representatives make regular site visits to providers and their officestaff to provide current, updated information, educational materials, and assist with problemresolution, including claims payment and status.Network Development and Contracts is responsible for the initial contracting of providers, aswell as for recontracting, contract amendments and updates. The Network Development andContracts Department processes all provider changes, including routing new and updatedinformation throughout Sierra Health Services’ internal departments, and producing the providernetwork directories for all Sierra 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, andis also available on SHL’s website at www.sierrahealthandlife.com.For more information regarding the Provider Services 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 Standard TimeSHL 2008 Section 4 Provider Services 1

2008 SHL Provider Summary GuideSHL@YourService also allows providers to submit electronic prior authorization requestsreplacing the current paper-based process that relies on hand-written forms.SHL@YourService uses technology to capture and route authorization data to increaseefficiency and accuracy and improve overall satisfaction. The information entered is routedthrough an interface engine and workflow process to determine status (pre-approvals and pendfor review) and automatically populates in SHL’s Utilization Management system.If you currently have internet services in your office, and 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 and Provider Services is available toanswer any specific questions you may have regarding the application.4.3 National Provider Identifier-(NPI)The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act(HIPAA) Administrative Simplification Standard. The NPI is a unique identification number forcovered health care providers. Covered health care providers and all health plans and healthcare clearinghouses will use the NPIs in the administrative and financial transactions adoptedunder HIPAA.What is the NPI – National Provider 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 and National SupplierClearinghouse or NSC).• The provider’s NPI will not change and will remain with the provider regardless of job orlocation.For more information regarding NPI you can contact CMS at (800) 465-3203, Provider Servicesat (702)-242-7088, or information is available on a CMS web page.http://www.cms.hhs.gov/NationalProvIdentStand/4.4 Provider Additions, Changes and TerminationsIt is important to notify Sierra Health and Life as soon as possible of any of the following events:• Adding a new provider to a group practice• Providers 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 and 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, and important provider notifications.SHL 2008 Section 4 Provider Services 3

2008 SHL Provider Summary Guide4.5 Explanation of Payment (EOP) RequestsExplanations of Payments (EOP’s) are generated each time a claim is processed by the HealthPlan. EOP’s contain detailed information such as claim adjudication, processed date and 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 ProviderServices department at:• Phone (702) 242-7088 or (800) 745-7065• Fax (702) 242-9124.Or submit your request in writing to:Sierra Health and LifeAttention: Provider ServicesP.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 and terminate the physician-patient relationship. Divorce ofpatient care is something that SHL takes very seriously and 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 Provider ServicesDepartment at:SHL Provider ServicesAttention: Provider Services RepresentativeP.O. Box 15645Las Vegas, NV 89114-5645Fax (702) 242-9124SHL 2008 Section 4 Provider Services 4

2008 SHL Provider Summary GuideIf you have questions regarding Divorce of Patient Care please contact the Provider ServicesDepartment at (702) 242-7088 or (800) 745-7065.SHL 2008 Section 4 Provider Services 5