2022 PPO Plans Rated

5 out of 5 Stars
Source: Medicare.gov >

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How to verify Eligibility & Benefits:

  • Provider Support Benefits & Eligibility Team: 844-806-8217 (Option 1)
  • Email: [email protected]

EFT/ACH Enrollment Changes:

It is important to note that in order to continue receiving EFT payments from Care N’ Care Insurance Company of North Carolina, Inc., it is required that you enroll with RedCard. Failure to enroll will mean future payments will be issued by paper check.

It’s important to note that in order to continue receiving EFT payments from Care N’ Care Insurance Company of North Carolina, Inc., it is required that you enroll with Zelis. Failure to enroll will mean payments will be issued by paper check. You may still register without the letter, by enrolling here *.

*All new enrollments require account confirmation to finalize enrollment. A test deposit will be sent to your account on file. Once the test deposit is received, be sure to login to Zelis to record and verify this test deposit amount.*

All provider services for Zelis are handled exclusively by Zelis. If you need assistance, please use the contact information below:
To enroll: http://enroll.ach835.com/new
To login: https://enroll.ach835.com/login
Email: [email protected]
Zelis Provider Service Center: (844) 292-4066

How to submit Pre-Authorization requests:

How to Register for Acuity Connect Web Portal.

In-network providers are able to request access to the Acuity Connect Portal. Unfortunately, we are unable to accept out-of-network provider requests for portal access at this time.

Follow the instructions below to register for access:

Step 1: Complete the below form.

Step 2: Once the form is submitted, it is reviewed by provider concierge. If you are an in network provider, you will be sent a link to a training module.

Step 3: Complete the training module and required credentials. Once completed, you will receive an email invitation within 2-5 business days.

Step 4: You will receive an email invitation to the Acuity Connect Portal. Once you complete the new login process, you will have access to the portal.

 

  • * Indicates required fields

2021 Prior Authorization List:

The list below outlines services and medications for which prior authorization in 2021 is required for HealthTeam Advantage members. Please review the key information at the top of the list for important information before submitting a prior authorization request.

2021 Prior Authorization List (PPO)

2021 Prior Authorization List (Diabetes & Heart Care HMO)

2021 Prior Authorization Forms:

If you do not have access to the portal, please print and complete the applicable prior authorization form found below. Important reminder: the form must be complete and include clinicals to support medical necessity. If you have any questions or to verify if a procedure requires prior authorization, please contact our intake team at: 844-873-2905 8 AM to 5 PM M-F and 336-604-1589 after 5 PM.

Please allow eight to ten (8-10) days turn-around time for processing. Note, per CMS the standard turn-around time is fourteen (14) days.

2022 Prior Authorization List:

The list below outlines services and medications for which prior authorization in 2021 is required for HealthTeam Advantage members. Please review the key information at the top of the list for important information before submitting a prior authorization request.

2022 Prior Authorization List (PPO)

2022 Prior Authorization List (Diabetes & Heart Care HMO)

2022 Prior Authorization Forms:

If you do not have access to the portal, please print and complete the applicable prior authorization form found below. Important reminder: the form must be complete and include clinicals to support medical necessity. If you have any questions or to verify if a procedure requires prior authorization, please contact our intake team at: 844-873-2905 8 AM to 5 PM M-F and 336-604-1589 after 5 PM.

Please allow eight to ten (8-10) days turn-around time for processing. Note, per CMS the standard turn-around time is fourteen (14) days.

How to Submit Claims:

Providers are to submit claims electronically or by mail.

  1. Electronically:
    HealthTeam Advantage PPO Plan I and Plan II Electronic Payer ID #: 88250
    HealthTeam Advantage HMO Diabetes and Heartcare Plan Electronic Payer ID #: 88350
  2. Mail: Claims Mailing Address 
    HealthTeam Advantage
    P.O. Box 94270
    Lubbock, TX 79493

How to Check Claim Status:

How to Submit a Claim Dispute:

Send dispute letter to include the following:

  • Member Name
  • ID Number
  • Claim Number
  • Detailed explanation of the dispute and supporting documentation

2021 Dispute Mailing Address:

HealthTeam Advantage Claims Department
P.O. Box 94270
Lubbock, TX 79493

Faxed Requests are Not Accepted

How do I submit a claim?

See “Claims Information” in the above section for directions on easily submitting claims.

How do I check claims status?

Visit the Provider Portal or Call 844-806-8217 (Option 2)

How do I submit a change in my demographic information? (Address, NPI, TIN, etc.)

Changes must be submitted in writing along with an updated W9 (online) Provider Update Form

What is the phone number and fax number for the Prior Authorization Department?

Phone: 844-873-2905
Fax: 844-873-3163

How do I verify benefits and eligibility?

You can verify member benefits and eligibility by phone, 844-806-8217 (Option 1), online, Provider Portal, or by email, [email protected]

How do I check if we are a contracted provider?

You can check your status by searching our online provider directory or by calling 855-218-3334.

The Member ID card has a separate number for dental and vision.  Is that the number I call for those benefits?

Yes! For 2021, our dental benefit is administered by Delta Dental.  In addition to the embedded routine dental benefits, our members have the option to enroll in a rider plan with extended dental benefits at an additional monthly premium.

For 2021, our routine vision benefit is administered by VSP.  There is no rider for the routine benefit as all available benefits are embedded in the member’s plan at no additional cost.

Who do I contact if I have questions about my contract or need a copy of my contract?

Contact your Provider Concierge at 855-218-3334 or [email protected]

What is the HealthTeam Advantage Diabetes & Heart Care HMO CSNP?

The HealthTeam Advantage Diabetes & Heart Care HMO CSNP is a Health Maintenance Organization (HMO) Chronic Special Needs Plan (CSNP) available to Medicare beneficiaries who reside in Guilford county. The beneficiaries must have diabetes and/or congestive heart failure (CHF) that is verified by an HTA network provider to enroll in the plan. To complete the enrollment in the CSNP, your patients must confirm they have a qualifying condition of diabetes or congestive heart failure by having YOU complete this verification form. HealthTeam Advantage will need to obtain the attestation verbally or written within the enrollee’s first 30 days of coverage to remain enrolled in the Chronic Special Needs Plan. To assist your patients in completing the enrollment process, HealthTeam Advantage will be calling to verify the chronic disease or faxing an attestation form to your office to complete and return to HealthTeam Advantage. If we are unable to obtain the attestation verbally or written within 30 days of the effective date of coverage, a dis-enrollment from the plan will occur.

When your office receives attestation forms, act immediately to keep your patients enrolled in the HTA Diabetes & Heart Care HMO CSNP

Email your Provider Concierge or call 855-218-3334 for more information about this plan. To keep your patients enrolled, please complete the verification form.

Dispute vs. Appeals: What’s the Difference?

Dispute: A dispute occurs when a contract provider disagrees with payment from the plan. It involves issues that have occurred after services have been rendered. This can include a review of the claim allowed amounts, the amount paid, denials, etc. The dispute is the only option available to contracted providers.

Appeal: An appeal is a formal request from a non- contracted provider requesting a review of a previous claim decision resulting in a denial by the plan that results in zero payment made to the non-contracted provider. The denial can happen on the entire claim, or on a line item. Appeal rights are only available to non-contracted providers. For more information on this process, click here.

Who Can Submit a Dispute?

  • Contracted providers
  • A contracted provider with HealthTeam Advantage/Teal Premier has the right to dispute claims processing and payments
  • All disputes must be filed with 120 days from the claims adjudication date on the Explanation of Payment (EOP) to submit a dispute

When Should You Submit a  Dispute?
You should submit a dispute when you believe a claim was paid incorrectly. The situation for reprocessing includes, but is not limited to:

  • Amount paid is different than what the provider expected
  • The claim was filed in a timely manner and the provider has proof
  • The claim was denied for no authorization when the provider has an authorization number
  • All supporting documentation such as medical records and provider statement support claims payment

How to Submit a Dispute
Send a dispute letter that includes the following:

  • Member Name
  • ID Number
  • Provider Name
  • Provider Tax ID
  • Ticket Number
  • Claim Number
  • Date of Service
  • Amount Billed
  • A detailed explanation of the dispute and supporting documentation
  • Expected Outcome
  • Multiple “LIKE” claims complete a spreadsheet

Online Dispute Resolution Request

Where to Submit Your Dispute
HealthTeam Advantage Claims Department
P.O. Box 94270
Lubbock, TX 79493

Email: [email protected]

Introducing the Optum In-Office Assessment Program

Beginning August 10, 2020, we have partnered with Optum in their in-office assessment (IOA) program.

What is the Optum in-office assessment program?

The Optum® in-office assessment program promotes early detection and ongoing assessment of chronic conditions for our health plans’ Medicare Advantage members. The assessment should be used prospectively at the point of care. The goal of the in-office assessment program is to help ensure that these patients receive a comprehensive annual exam and to support a variety of quality programs, including The Healthcare Effectiveness Data and Information Set (HEDIS®) and the Five-Star Quality Rating System.

The in-office assessment program provides historical information about patients to the provider. This health information may include:

  • PCP, specialists, and hospitalization history
  • Prescription history
  • Information on previously diagnosed conditions
  • Potential gaps in preventive screenings or recommended chronic illness treatment

The in-office assessment program allows for identification and accurate reporting of chronic conditions. Optum will work with you to determine which delivery method is most suitable for your practice.

Why is the in-office assessment program important to providers?

Routine exams and screenings can help identify and detect chronic conditions, often before your high-risk patients have any symptoms. These annual exams are an important part of maintaining the quality of care and quality of life of your patients.

The in-office assessment and reimbursement

When you accurately complete and submit your provider assessment form (PAF) and supporting medical record documentation, you may be eligible for reimbursement.

A sample copy of the assessment form can be viewed here: Optum-Healthcare-Quality-Patient-Assessment-2020

Your practice is eligible for $125 if the PAF form is turned in at or before the 60th day from date of service.

Your practice is eligible for $75 if the PAF form is returned after the 60th day from the date of service.

How will we be reimbursed for completed PAFs?

Reimbursement for eligible forms will only be made via EFT.  Enrollment is required.

To ensure accurate and timely reimbursement, the following is required:

  1. Submit a copy of your W-9 to Optum.
  2. Return a completed Account Setup Form (provided by Optum). Download a copy here: Optum-InOffice-Assessment-Form

The “Pay to” TIN on the Account Setup Form must match the TIN on your W-9.

Your completed Account Setup Form and your W-9 must be submitted prior to submission of a completed assessment to ensure that your reimbursement account setup has been completed by Optum.

Account Setup Forms (ASFs) and W-9s are required to qualify for any eligible assessment reimbursements. Reimbursements for eligible assessments will be paid monthly for all assessments made the PRIOR Failure to timely submit your ASF and W-9 acts as a waiver of any and all claims for the program year reimbursement.

Refund/Overpayment Requests

HealthTeam Advantage works diligently to process and make payments correctly to your claims the first time. Unfortunately, a processing error can happen, and an overpayment occurs. When we identify an overpayment, the refund request process begins. We are unable to process “recoupments” or “take-backs” at this time but are working to add this option soon.

The refund process is as follows:

  • A letter is mailed to the provider requesting a refund.
  • The letter will contain information regarding the claim that has an overpayment and what the reason is for the overpayment.
  • We will provide you with the member ID, name, and date of services.
  • If there are multiple refund requests for the same reason, we will provide a spreadsheet with each member’s information, dates of services, and overpayment amount.
  • If the refund is not received within 30 days, we will send you another letter. Three letters will be sent over 90 days to collect. Failure to submit the requested monies could result in collection action.

All refunds are to be mailed directly to the Plan:

HealthTeam Advantage
Attn: Refunds
7800 McCloud Road, Suite 100
Greensboro, NC 27409

Should you have any questions regarding a refund request letters you received, please call your provider concierge for HealthTeam Advantage at 844-806-8217 (option 2).

Drug Coverage: Part B Drugs vs. Part D Drugs

HealthTeam Advantage follows Medicare Part B and D guidelines when processing and paying for prescription drugs.

When is a drug covered by Part B?

Part B covers drugs that usually aren’t self-administered. These drugs are given in an office setting and are part of their service.

When is a drug covered by Part D?

Part D covers outpatient drugs when a physician writes a prescription and it is filled at a pharmacy.

 Note: There a few drugs that can be covered by Part B or Part D depending on the circumstances; please call your Provider Concierge for assistance.

Here are a few examples of types of drugs covered by Part B that can be submitted to HTA for payment by physician practices:

  • Drugs used with an item of durable medical equipment (DME)
  • Certain types of injectables
  • Infused drugs
  • Vaccinations: Flu shots, Pneumococcal shots, and Hepatitis B shots (when disease-specific criteria are met), and Tetanus when being treated for accident/injury.

Here are a few  examples of types of drugs covered by Part D and processed under the  prescription benefit:

  • Vaccine: Shingles, Hepatitis B, and Tetanus (for routine immunization)
  • Self-Administered Injectables
  • Self-administered drugs

HealthTeam Advantage is always here to assist you if you have questions regarding Part B and Part D drugs. You can call your HealthTeam Advantage Provider Concierge at 844-806-8217 (option 2).

You may also use this link to look up covered medications.