Provider Informational Guide Booklet

transcript

(Updated 7-25-16)

TABLE OF CONTENTS Vendor List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-16

Aetna ……………………………………………………………………………………………………... 3 Blue Cross Blue Shield ….………………………………………………………………………….…. 4 CIGNA-HealthSpring ………………………………….………………………………………….…. 5-6 County Care ………………………………………………….………………………….…. 7 FHN / CCAI ……………………………………………………….…………………….…. 8-9 Harmony ……………………………………………………….…………………….…. 10 Health Alliance ……………………………………………………….…………………….…. 11 Humana ……………………………………………………….…………………….…. 12 Illini Care ………………………………………………………….………………….…. 13-14 Meridian ………………………………………………………….………………….…. 15 Molina Healthcare ………………………………………………………….………………….…. 16 NextLevel Health ………………………………………………………….………………….…. 17

Provider Relations Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18-35

Aetna ……………………………………………………………………………..…. 18 Blue Cross Blue Shield ………………………………………………………………………….…..… 19-20 CIGNA-HealthSpring ………………………………………………………………………….….…. 21-22 County Care ………………………………………………………………………….….…. 23 FHN / CCAI ……………………………………………………………………….…….…. 24 Harmony ……………………………………………………………………….…….…. 25 Health Alliance ……………………………………………………………………….….….… 26 Humana ………………………………………………………………………….….…. 27 Illini Care …………………………………………………………………………….….. 28 Meridian ……………………………………………………………………………..…. 29-32 Molina Healthcare …………………………………………………………………………….….. 33-34 NextLevel Health …………………………………………………………………………….….. 35

CAQH Education Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36-38 ICD-10 Links . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Prior Authorization Links . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Provider Manual Links . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Vendor List - Aetna Better Health of Illinois

Behavioral Health Contact information for point of contact (internal or external) Name Sue Strange Karen White Terriana Clark Phone Number 312-821-0514 312-821-0680 630-737-6462 Email Address StangeS@aetna.com WhiteK1@aetna.com ClarkT9@aetna.com Dental Contact information for point of contact (internal or external) Name Betty Irving David Thielemier Phone Number 312-821-6503 314-221-2394 Email Address IrvingB@aetna.com David.Thielemier@dentaquest.com Long Term Care Contact information for point of contact (internal or external) Name Nicole Sunder Magali Dure Phone Number 312-821-0487 312-821-0633 Email Address SunderN@aetna.com DureM@aetna.com Pharmaceuticals Contact information for point of contact (internal or external) FHP & ICP Name Alisha Sellers, Pharm D Bruce Himelstein, MD Phone Number 602-616-1277 312-928-3094 Email Address SellersA@aetna.com HimelsteinB@aetna.com For MMAI DUALS Pharmacy Name Kathy Lojkovic Phone Number 224-281-2690 Email address Lojkovick@aetna.com Transportation Contact information for point of contact (internal or external) Name Betty Irving Henry Graham Phone Number 312-821-6503 314-662-0880 Email Address IrvingB@aetna.com Hgraham@mtm-inc.net Vision Contact information for point of contact (internal or external) Name Betty Irving Heather Ragusa Phone Number 312-821-6503 888-493-4070 x2455 Email Address IrvingB@aetna.com hragusa@marchvisioncare.com

Vendor List - BlueCross BlueShield of Illinois Behavioral Health If there is a concern should the provider contact the health plan or the vendor? BlueCross BlueShield of Illinois (no vendor)

Derek Punzalan 312.653.6916 derek_punzalan@bcbsil.com

Dental If there is a concern should the provider contact the health plan or the vendor? Dentaquest

Suzanne Echeverria 262.834.3701 suzanne.echeverria@DentaQuest.com

Long Term Care If there is a concern should the provider contact the health plan or the vendor? BlueCross BlueShield of Illinois (no vendor)

Sherry Heise 312-653-7652 heises@bcbsil.com

Pharmaceuticals If there is a concern should the provider contact the health plan or the vendor? Prime Therapeutics John Everett 972-906-7142 JEverett@primetherapeutics.com Pharmacies should call: Transportation If there is a concern should the provider contact the health plan or the vendor? MTM

Henry Graham 636.695.5652 www.mtm-inc.net

Vision If there is a concern should the provider contact the health plan or the vendor? Davis Vision

Garry Denk 224.545.0618 gdenk@davisvision.com

Vendor List - Cigna-HealthSpring

Behavioral Health The provider should contact the health plan. Behavioral Health Hotline: 866-780-8546

Contracting Questions: Maggie Domaradzki 312-548-2011 Magdalena.domaradzki@healthspring.com

Clinical Questions: Suzie Kamp

615-291-7021 Suzanne.kamp@healthspring.com

Dental The provider should contact DentaQuest. DentaQuest: Carol Leonard – Account Executive 262-290-1678

Carol.leonard@dentaquest.com Cigna-HealthSpring Primary: Angela Stevens 860-902-0786 Angela.stevens@healthspring.com

Cigna-HealthSpring Secondary: Maren Hill 615-695-1287 Maren.hill@healthspring.com

Long Term Care The provider should contact the health plan.

General LTC Questions: IL_NursingHome_Requests@healthspring.com

Contracting Questions: Kirsten Keeley Kirsten.keeley@healthspring.com 312-548-2045 Clinical LTC Questions: Maureen Drumm Maureen.drumm@healthspring.com 312-547-2186

Non-Clinical Questions: Maggie Domaradzki Magdalena.domaradzki@healthspring.com 312-548-2011

Pharmaceuticals The provider should contact the health plan.

Joel Hahn 860-787-7869 Joel.hahn@healthspring.com

Transportation The provider should contact the health plan.

Cigna-HealthSpring: Leonard VanSlyke 312-548-2035 Leonard.vanslyke@healthspring.com

Vision The provider should contact the vendor.

Superior Vision: Adrian Bennett, MBA Vice President, Quality and Account Management 443-451-1026 800-243-1401 x 1026 abennett@superiorvision.com Cigna-HealthSpring: Primary: Angela Stevens

860-902-0786 Angela.stevens@healthspring.com

Secondary: Maren Hill 615-695-1287 Maren.hill@healthspring.com

Vendor List - CountyCare Health Plan Behavioral Health If there is a concern should the provider contact the health plan or the vendor? Name Alicia Searcy Phone Number 866.329.4701 x 47829 Email Address asearcy@cenpatico.com Dental If there is a concern should the provider contact the health plan or the vendor? Name Carol Leonard Phone Number 262-834-3543 Email Address carol.leonard@dentaquest.com Long Term Care If there is a concern should the provider contact the health plan or the vendor? Name #1 – Kristin Murphy Phone Number - 630-655-7876 Email Address - KRMURPHY@illinicare.com Name #2 – Andrea McGlynn Phone Number – 312-864-0915 Email Address – amcglynn@cookcountyhhs.org Pharmaceuticals If there is a concern should the provider contact the health plan or the vendor? Name- Elmer Abbo, MD Phone Number 312-864-1156 Email Address eabbo@cookcountyhhs.org Transportation If there is a concern should the provider contact the health plan or the vendor? Name Tasha Reese Phone Number Tel: (630) 873-1356 Email Address tasha.reece@firstgroup.com Vision If there is a concern should the provider contact the health plan or the vendor? Name Tracy Mills Phone Number (252) 544-9264 Email Address tmills@Opticare.net

Vendor List- Family Health Network & Community Care Alliance Ancillary Services (Home Health, DME, Med Supplies, etc.) Contracting inquiries: FHNProviderRequest@myfhn.com Marleen Severino, Manager, Ancillary Services- MSeverino@myfhn.com - 312-561-2542 Behavioral Health If there is a concern should the provider contact the health plan or the vendor? Health Plan Contracting inquiries: Scott Krugel, Network Management Specialist – SKrugel@myfhn.com – 312-605-9828 Authorizations: Health Integrated at 888-211-6851 Claims Disputes, Appeals, and Inquiry MCPID@myfhn.com Contracting Contracting inquiries: FHNProviderRequest@myfhn.com Marcia Moore, Senior Manager, Contracting - MMoore@myfhn.com - 312-605-9851 Credentialing Annette Allen, Manager, Credentialing - AAllen@myfhn.com - 312-605-9877 Dental If there is a concern should the provider contact the health plan or the vendor? Health Plan DentaQuest Customer Service: 888-286-2447, Provider Relations: 888-281-2076 Marleen Severino- Manager, Ancillary Services- MSeverino@myfhn.com - 312-561-2542 Long Term Care If there is a concern should the provider contact the health plan or the vendor? Health Plan Amy Edders, Director, LTSS – AEdders@ccaillinois.com – 312-605-9822 Marleen Severino, Manager, Ancillary Services - MSeverino@myfhn.com - 312-561-2542 Pharmaceuticals If there is a concern should the provider contact the health plan or the vendor? Health Plan CVS Caremark Customer Care: 855-248-3446, TDD: 800-231-4403 Luenetta Jackson, Director, Pharmacy Services - LJackson@ccaillinois.com - 312-605-9826 Quality and Case Management Sally Szumlas, Vice President, Quality Improvement– SSzumlas@myfhn.com – 312-995-1899 Dr. Connie L. Zak, Vice President, Healthcare Management- CZak@ccaillinois.com - 312-880-1696 Transportation If there is a concern should the provider contact the health plan or the vendor? Health Plan First Transit: 877-725-0569 Chris Zaruszak, Vice President, Operations - CZaruszak@myfhn.com - 312-995-1289

Vendor List- Family Health Network & Community Care Alliance (Continued)

Utilization Management (UM) FHN Referrals and Authorizations Authorization guidelines for covered services and procedures: www.fhnchicago.com/providers Lourdes Reyes, Vice President, UM and Care Transition– LReyes@myfhn.com – 312-995-1881 Vision If there is a concern should the provider contact the health plan or the vendor? Health Plan EyeQuest- 888-696-9551 - eyequestproviderservices@dentaquest.com Marleen Severino, Manager, Ancillary Services- MSeverino@myfhn.com - 312-561-2542

Vendor List - Harmony

Behavioral Health If there is a concern should the provider contact the health plan or the vendor? – Health Plan Name – Dr. Traci Powell Phone Number - 312-516-4906 Email Address – traci.powell@wellcare.com Dental If there is a concern should the provider contact the health plan or the vendor? - Vendor Name – Liberty Dental Plan Phone Number – 1-888-352-0215 Long Term Care If there is a concern should the provider contact the health plan or the vendor? – Health Plan Name – Barb Alexander Phone Number 312-516-5835 Email Address – Barbara.Alexander@WellCare.com Pharmaceuticals If there is a concern should the provider contact the health plan or the vendor? – Health Plan Palak Desai Pharmacy Director, Harmony / WellCare Palak.Desai@wellcare.com Transportation If there is a concern should the provider contact the health plan or the vendor? – Vendor (Non Emergent); Health Plan (Emergent) Local Provider Rep - 312-658-3100 Name – Greg Irby - Medical Transportation Management Phone Number – 1-877-248-1338 Email Address - girby@mtm-inc.net Vision If there is a concern should the provider contact the health plan or the vendor? - Vendor Name – Premier Eye Care Phone Number – 1-855-865-9723

Vendor List - Health Alliance Refer to: Maxine Wallner

maxine.wallner@healthalliance.org Sinead Rice Madigan sinead.madigan@healthalliance.org

Vendor List - Humana

Behavioral Health If there is a concern should the provider contact the health plan or the vendor? Health Plan Ashley Thornberry (502)580-4295 athornberry@humana.com Dental If there is a concern should the provider contact the health plan or the vendor? Health Plan Kammy Schneider (262)408-4697 kschneider@humana.com Long Term Care If there is a concern should the provider contact the health plan or the vendor? Health Plan Lisa M. Smith (630)794-5954 lsmith73@humana.com Pharmaceuticals If there is a concern should the provider contact the health plan or the vendor? Health Plan Mark Malone (502)476-1151 mmalone1@humana.com Transportation If there is a concern should the provider contact the health plan or the vendor? Health Plan Lee Havey (502)476-5927 lhavey@humana.com Vision If there is a concern should the provider contact the health plan or the vendor? Health Plan Kelli Moody 813.829.9145 kmoody4@Humana.com

Vendor List - IlliniCare Health

IlliniCare Health Contact: Tiffany Lewis Phone Number: 312-260-5747 Email: Tilewis@illinicare.com

Behavioral Health

Internal Name: Emily Cassidy, Senior Manager, Case Management Phone Number: 630-655-7855 Email Address: ecassidy@illinicare.com

External Name: Cenpatico – Wendy Verner Phone Number: 512-406-7200 ext. 67401 Email Address: wverner@centene.com

Dental

Internal Name: Eric Forster, Clinical Manager Phone Number: 630-655-7833 E-mail Address: eforster@illinicarehealth.com External Name: Dental Health & Wellness – Tara Price Phone Number: 252-452-9771 Email Address: tprice@dentalhw.com

Long Term Care

Internal Name: Connie Sherman, Senior Manager, Case Management Phone Number: 630-655-7858 Email Address: csherman@illinicare.com

Pharmaceuticals

Internal Name: Steven Sproat, Director of Pharmacy Phone Number: 630-655-7952 Email Address: ssproat@illinicare.com External Name: US Script – Phil Doveikis Phone Number: 314-445-0738 Email Address: pdoveikis@usscript.com

Transportation

Internal Name: Emily Cassidy, Senior Manager, Case Management Phone Number: 630-655-7855 Email Address: ecassidy@illinicare.com External Name: MTM – Allison Tussey Phone Number: 636-695-5569 Email Address: atussey@mtm-inc.net

Vision

Internal Name: Dan Byars, Clinical Manager Phone Number: 312-260-5347 Email Address: dbyars@illinicare.com External Name: Opti-Care – Tracey Simpson Phone Number: 252-544-9263 Email Address: tracey.simpson@opticare.net

Vendor List - Meridian Health Plan

Behavioral Health If there is a concern should the provider contact the health plan or the vendor? Sara Mathews 312-508-7994 Sara.mathews@mhplan.com Dental If there is a concern should the provider contact the health plan or the vendor? Sean Kendall (313) 324-3793 Sean.kendall@mhplan.com

Long Term Care If there is a concern should the provider contact the health plan or the vendor? Michael Scholl 312-980-2357 Michael.scholl@mhplan.com Pharmaceuticals If there is a concern should the provider contact the health plan or the vendor? Andrew Miller Vice President of Operations – MRx 313-324-1805 Andrew.miller@mhplan.com Transportation If there is a concern should the provider contact the health plan or the vendor? Sean Kendall (313) 324-3793 Sean.kendall@mhplan.com

Vision If there is a concern should the provider contact the health plan or the vendor? Sean Kendall (313) 324-3793 Sean.kendall@mhplan.com

Vendor List - Molina Healthcare

Behavioral Health If there is a concern should the provider contact the health plan or the vendor? Kathleen Jones 309-265-8473 Kathleen.Jones@MolinaHealthcare.com Dental If there is a concern should the provider contact the health plan or the vendor? Amber Wilkins 888-562-5442 Ext 163964 Amber.Wilkins@MolinaHealthcare.com Long Term Care If there is a concern should the provider contact the health plan or the vendor? Jared Fritz 217-260-7674 Jared.Fritz@MolinaHealthcare.com Pharmaceuticals If there is a concern should the provider contact the health plan or the vendor? Vinay Bhargava 855-866-5462 prompt for language – prompt for pharmacy Vinay.Bhargava@MolinaHealthcare.com Transportation If there is a concern should the provider contact the health plan or the vendor? Amber Wilkins 888-562-5442 Ext 163964 Amber.Wilkins@MolinaHealthcare.com Vision If there is a concern should the provider contact the health plan or the vendor? Amber Wilkins 888-562-5442 Ext 163964 Amber.Wilkins@MolinaHealthcare.com

Vendor List - NextLevel Health

Behavioral Health If there is a concern should the provider contact the health plan or the vendor? Health Plan Name Provider Services Phone Number 844-807-9734 Email Address provider.services@nlhpartners.com Dental If there is a concern should the provider contact the health plan or the vendor? Health Plan Name Provider Services Phone Number 844-807-9734 Email Address provider.services@nlhpartners.com Long Term Care If there is a concern should the provider contact the health plan or the vendor? Health Plan Name Provider Services Phone Number 844-807-9734 Email Address provider.services@nlhpartners.com Pharmaceuticals If there is a concern should the provider contact the health plan or the vendor? Vendor Name Meridian Rx – James Cowhy Phone Number 313-324-3700x1669 Email Address james.cowhy@meridianrx.com Transportation If there is a concern should the provider contact the health plan or the vendor? Health Plan Name Provider Services Phone Number 844-807-9734 Email Address provider.services@nlhpartners.com Vision If there is a concern should the provider contact the health plan or the vendor? Vendor Name Opticare Phone Number 844-302-9211

Provider Relations Contacts - Aetna Better Health of IL

General Provider Relations: 1-866-212-2851

Hospitals Lawrence Underwood 630-737-6464 UnderwoodL2@aetna.com

Physicians Jocelyn Carroll Lawrence Underwood 630-737-6519 630-737-6464 CarrollJ2@aetna.com UnderwoodL2@aetna.com

LTC-Waiver providers William Henderson Lawrence Underwood 312-821-0629 630-737-6464 HendersonW2@aetna.com UnderwoodL2@aetna.com

LTC- Skilled Nursing Facilities Magali Dure Lawrence Underwood 312-821-0633 630-737-6464 DureM@aetna.com UnderwoodL2@aetna.com

LTC- Supported Living Facilities William Henderson Lawrence Underwood 312-821-0629 630-737-6464 HendersonW2@aetna.com UnderwoodL2@aetna.com

Mental Health Terriana Clark Lawrence Underwood 630-737-6462 630-737-6464 ClarkT9@aetna.com UnderwoodL2@aetna.com

Substance Use Disorder Terriana Clark Lawrence Underwood 630-737-6462 630-737-6464 ClarkT9@aetna.com UnderwoodL2@aetna.com

Hospice Magali Dure Lawrence Underwood 312-821-0633 630-737-6464 DureM@aetna.com UnderwoodL2@aetna.com

Home Health Juanita Harris Lawrence Underwood 312-821-0513 630-737-6464 HarrisJ5e19f@aetna.com UnderwoodL2@aetna.com

DME Juanita Harris Lawrence Underwood 312-821-0513 630-737-6464 HarrisJ5e19f@aetna.com UnderwoodL2@aetna.com

FQHCs Terriana Clark Lawrence Underwood 630-737-6462 630-737-6464 ClarkT9@aetna.com UnderwoodL2@aetna.com

Transportation Betty Irving Henry Graham 312-821-6503 314-662-0880 IrvingB@aetna.com Hgraham@mtm-inc.net

Dentists Betty Irving Suzanne Echeverria 312-821-6503 262-834-3701 IrvingB@aetna.com Suzanne.Echeverria@dentaquest.com

Public Health Dept’s Jocelyn Carroll, MPA Lawrence Underwood 630-737-6519 630-737-6464 CarrollJ2@Aetna.com UnderwoodL2@aetna.com

Pharmacy Kathy Lojkovic Brian Davis Pharmacy Director Medicare Director 224-281-2690 314-506-2046

lojkovicK@aetna.com davisB4@aetna.com

Provider Relations Contacts - BlueCross BlueShield of Illinois

877/723-7702 govproviders@bcbsil.com Hospitals John M. Evans, (312) 653-8279 evansj1@bcbsil.com Physicians Joanne O’brien 312-653-2413 joanne_obrien@bcbsil.com Tishika Townsend Office: (312) 653-4915 tishika_townsend@bcbsil.com LTC-Waiver providers Derek Punzalan 312.653.6916 derek_punzalan@bcbsil.com LTC- Skilled Nursing Facilities Sherry Heise, 312-653-7652 heises@bcbsil.com LTC- Supported Living Facilities Sherry Heise, 312-653-7652 heises@bcbsil.com Mental Health Derek Punzalan 312.653.6916 derek_punzalan@bcbsil.com Substance Use Disorder Derek Punzalan 312.653.6916 derek_punzalan@bcbsil.com Hospice/Home Health Sherry Heise, 312-653-7652 heises@bcbsil.com DME Sherry Heise, 312-653-7652 heises@bcbsil.com

FQHCs Tishika Townsend 312-653-4915 tishika_townsend@bcbsil.com Ratna Soni 312-653-2317 Ratna_Soni@bcbsil.com Transportation Henry Graham 636.695.5652 www.mtm-inc.net Dentists Suzanne Echeverria 262.834.3701 suzanne.echeverria@DentaQuest.com

Provider Relations Contacts - Cigna-HealthSpring Structure of Provider Rep Assignments Shelina Kassam 175 W Jackson Blvd ste 1750 Chicago, IL 60604 shelina.kassam@healthspring.com (312) 548-2061 Sheetal Rami 9701 W Higgings Rd ste. 360 Rosemont, IL 60018 sheetal.rami@healthspring.com (312) 548-2028 Leaonard VanSlyke 175 W Jackson Blvd ste 1750 Chicago, IL 60604 leonard.vanslyke@healthspring.com (312) 548-2035 Anna Volberg 175 W Jackson Blvd ste 1750 Chicago, IL 60604 anna.volberg@healthspring.com N/A Structure of Provider Rep Assignments (Behavioral Health) Magdalena Domaradzki 175 W Jackson Blvd ste 1750 Chicago, IL 60604 magdalena.domaradzki@healthspring.com (312) 548-2011 Structure of Provider Rep Assignments (Professional) All Previous Contacts Director, Provider Contracting Kirsten Keeley 175 W Jackson Blvd ste 1750 Chicago, IL 60604 kirsten.keeley@healthspring.com N/A Director, Provider Relations N/A Director of Operations N/A Director of Claims Kim Stuart 2900 N Loop West ste. 1300 Houston, TX 77092 kimberly.stuart@healthspring.com (443) 573-1620 Director of Utilization/Medical Management Dan Chambers 2208 N Hwy 121 Ste. 210 Bedford, TX 76021 mark.chambers@healthspring.com 817-554-5760

Director of Credentialling Lori Pegler 530 Great Circle Rd. Nashville, TN 37228 ri.pegler@healthspring.com (615) 234-2171 Vice President of Operations Robyn Leland 2208 N Hwy 121 Ste. 210 Bedford, TX 76021 robyn.leland@healthspring.com (817) 554-5553 Vice President of Network Management Melissa Dannenberg 175 W. Jackson ste 1750 Chicago, IL 60604 melissa.dannenberg@healthspring.com (312) 548-2009 External Vendor Liaison (i.e. pysch, dental, transportation) Vonda Kinney 1225 N Loop West ste 127 Houston, TX 77008 vonda.kinney@healthspring.com (770) 261-7751

Provider Relations Contacts - CountyCare Health Plan

ALL Provider Relations issues should be directed to: 1st option CountyCare 312-864-8200 2nd option Tina Barksdale Director of Business Development/Provider Relations 312-864-0920 tbarksdale@cookcountyhhs.org Jeanne Klein 312-864-0947 jklein2@cookcountyhhs.org

Provider Relations Contacts - Family Health Network & Community Care Alliance of Illinois

Family Health Network Provider Services: 1-888-FHN-4YOU (346-4968) www.fhnchicago.com Community Care Alliance of Illinois Provider Services: 1-866-871- 2305 https://www.ccaillinois.com

Provider Relations Contacts - Harmony Health Plan of Illinois A WellCare Company

Provider Services: (800) 504-2766 Provider Relations issues should be directed to:

Local Provider Rep – (312) 658-3100 Escalated Issues: Ron Damasauskas

(312) 658-3136 ronald.damasauskas@wellcare.com

Provider Relations Contacts - Health Alliance

1-800-851-3379, extension 4668 PSC@healthalliance.org (217) 365-7492 Provider Relations issues should be directed to the following:

Maxine Wallner Maxine.wallner@healthalliance.org Denise Grussing Denise.grussing@healthalliance.org

Provider Relations Contacts -Humana Hospitals

Humana Provider Relations: 800-626-2741 Casandra Montgomery: 312.441.5989; cmontgomery@humana.com

Physicians

LTC-Waiver providers

Independent Living Systems Provider Relations: 855-661-2029 IllinoisProviders@ilshealth.com Kathryn Schmit: 305-262-1292 x5010; kschmit@ilshealth.com

LTC- Skilled Nursing Facilities

LTC- Supported Living Facilities

Mental Health

Beacon Health Strategies Provider Relations: 855-481-7044 prelations@beaconhs.com John Sellers: 630-382-5250; john.sellers@beaconhs.com

Substance Use Disorder

Beacon Health Strategies Provider Relations: 855-481-7044 prelations@beaconhs.com John Sellers: 630-382-5250; john.sellers@beaconhs.com

Hospice/Home Health

FQHCs Humana Provider Relations: 800-626-2741 Casandra Montgomery: 312.441.5989; cmontgomery@humana.com

Transportation

Logisticare ICP: 855-253-6865 Logisticare MMP: 855-253-6867

Dentists

DentaQuest: 855-343-7400 Casandra Montgomery: 312.441.5989; cmontgomery@humana.com

Provider Relations Contacts - IlliniCare Health Hospitals Mariam Jafri – 312-995-0123 – mjarfi@illinicare.com Jerome Salter – 708-793-0677 – jesalter@illinicare.com Physicians Shatina Jackson – 312-497-7996 – shatjackson@illinicare.com Christine Fox – 708-625-7612 – chrifox@illinicare.com LTC-Waiver providers Chris Waskiewicz – 312-519-9280 – cwaskiewicz@illinicare.com Tahniyat Patel – 312-590-5703 – tpatel@illinicare.com LTC- Skilled Nursing Facilities Chris Waskiewicz – 312-519-9280 – cwaskiewicz@illinicare.com Tahniyat Patel – 312-590-5703 – tpatel@illinicare.com LTC- Supported Living Facilities Chris Waskiewicz – 312-519-9280 – cwaskiewicz@illinicare.com Tahniyat Patel – 312-590-5703 – tpatel@illinicare.com Mental Health Claudia Phillips – 630-655-7968 – clphillips@cenpatico.com Alicia Searcy - 866-329-4701 ext. 47829 – asearcu@cenpatico.com Substance Use Disorder Claudia Phillips – 630-655-7968 – clphillips@cenpatico.com Alicia Searcy - 866-329-4701 ext. 47829 – asearcu@cenpatico.com Hospice/Home Health Angelic Williams – 312-465-0390 – angwilliams@illinicare.com Christine Fox – 708-625-7612 – chrifox@illinicare.com DME Chris Waskiewicz - 312-519-9280 – cwaskiewicz@illinicare.com Tahniyat Patel – 312-590-5703 – tpatel@illinicare.com FQHCs Mariam Jafri – 312-995-0123 – mjafri@illinicare.com Jerome Salter – 708-793-0677 – jesalter@illinicare.com Transportation Chris Waskiewicz – 312-519-9280 – cwaskiewicz@illinicare.com Tahniyat Patel – 312-590-5703 – tpatel@illinicare.com Dentists Catherine Cameron – 331-305-9468 - cacameron@dentalw.com

Provider Relations Contacts - Meridian Health Plan

ALL Provider Relations issues should be directed to:

Sean Kendall (313) 324-3793Sean.kendall@mhplan.com

Provider Network Development Representative Coverage Map

LakeStephenson

Whiteside

Rock Island

MercerHenry Bureau La Salle

Kendall

Grundy

Kankakee

Livingston

MarshallKnox

Warren

Hancock McDonough Fulton

Peoria Woodford

McLean Ford

ChampaignDe Witt

Tazewell

AdamsBrown

ScottPike

Calhoun Greene

Morgan

Schuyler

CassMenard

Franklin

DeKalb Kane DuPage

Winnebago Boone McHenry

Jo Daviess

Carroll

StarkPutnam

Iroquois

Vermilion

Christian

Sangamon

Macoupin

Jersey

Madison

St. Clair

Monroe

Randolph Perry

Washington

Clinton

Montgomery

Fayette

Marion

Je�erson

HamiltonWhite

Saline Gallatin

WayneEdward

Wabash

RichlandClay

E�ngham Jasper

Shelby

MoultrieDouglas

Cumberland

Crawford

Lawrence

Hardin

Jackson

Alexander

Pulaski Massac

PopeJohnson

Williamson

Chicago

6064660645 60626

6063160666

60656 60634

60630 60625

60659 60660

6061360657

606226065160610 60611

60602606036060460605

6060160606

6066160644 60624 60612

60623 60608 60616

60638 60629

60609 6065360615

60621 6063760649

60652 60620 60619

6061760642

60655 60643 60628

John Heintz 312-805-8723

Director of Network Development

Michelle Roan, Manager

Kimberly French

Courtney Gast

Fred Remmert

Antwone Young

Representative TBD*

312-343-5290

312-835-4153

312-415-7170

309-620-0974

312-718-5530

Southern IL Network

Crystal Klier, Manager

Nighat Ali

Taylor Guthrie

Dawn Schutt

Alexandria Walton

Erin Wilson

312-415-7170

312-718-5557

312-550-2417

309-235-7910

312-505-6840

312-447-1923

Northern IL Network

Stephanie Huston 312-505-0614

Behavioral Health (State of IL)

Ben Salentine 312-350-2849

LTSS Network (State of IL)

*Please contact Provider Services directly at 866-606-3700

Chicago

ParkRidge

Maywood

Oak BrookOak Park

Berwyn

Skokie

WilmetteEvanston

Evergreen Park

Burbank

Oak Lawn

Orland Park Oak

Forest

TinleyPark

Harvey

Blue IslandDolton

LansingSouth Holland

Cook County

Ho�man Estates

Bartlett

StreamwoodHanover Park

PalatineWheeling

NorthbrookMount ProspectArlington

Heights

Barrington

Clinic Address Phone Provider Network

Development Representative

Advocate Christ Medical Center 4440 W 95th StOak Lawn, IL 60453 708-684-8000 Taylor Guthrie

Illinois Masonic Medical Center 836 W Wellington AveChicago, IL 60657 773-975-1600 Taylor Guthrie

Advocate Lutheran General Hospital 1775 Dempster StPark Ridge, IL 6068 847-723-2210 Taylor Guthrie

Advocate South Suburban Hospital 17800 Kedzie AveHazel Crest, IL 60429 708-799-8000 Taylor Guthrie

Advocate Medical Group Trinity 2320 E 93rd StChicago, IL 60617 773-967-2000 Taylor Guthrie

Alexian Brothers Behavioral Health 1650 Moon Lake BlvdHoffman Estates, IL 60169 847-882-1600 Taylor Guthrie

Alexian Brothers Medical Center 800 Biesterfield RdElk Grove Village, IL 60007 847-882-1600 Taylor Guthrie

Ann and Robert H. Lurie Children's Hospital of Chicago

225 E Chicago AveChicago, IL 60611 312-227-4000 Taylor Guthrie

Presence Holy Family Medical Center 100 N River RdDes Plaines, IL 60016 847-297-1800 Taylor Guthrie

Presence Our Lady of Resurrection Medical Center

5645 W Addison StChicago, IL 60634 773-282-7000 Taylor Guthrie

Presence Resurrection Medical Center 7435 W Talcott AveChicago, IL 60631 773-774-8000 Taylor Guthrie

St. Francis Hospital 355 Ridge AveEvanston, IL 60202 847-316-4000 Taylor Guthrie

Presence Saint Joseph Hospital-Chicago 2900 N Lake Shore DrChicago, IL 60657 773-665-3000 Taylor Guthrie

Presence Saints Mary and Elizabeth Medical Center

2233 W Division StChicago, IL 60622 312-770-2000 Taylor Guthrie

St Alexius Medical Center 1555 Barrington RdHoffman Estates, IL 60169 847-843-2000 Taylor Guthrie

Chicago Behavioral Hospital 555 Wilson LnDes Plaines, IL 60016 847-768-5430 Stephanie Huston

Aries Health Care of Illinois 8311 Roosevelt RdForest Park, IL 60130 708-771-7000 Stephanie Huston

Adventist Paulson Rehab, La Grange 5101 Willow Springs RdLa Grange, IL 60525 708-245-7900 Kim French

Holy Cross Hospital 2701 W 68th StChicago, IL 60629 773-884-9000 Kim French

The Ingalls Memorial Hospital 1 Ingalls DrHarvey, IL 60426 708-333-2300 Kim French

Jackson Park Hospital Foundation 7531 S Stony Island AveChicago, IL 60649 773-947-7500 Kim French

www.mhplan.comFLYPS53 IL

Cook County Hospital Assignments

Clinic Address Phone Provider Network

Development Representative

Mount Sinai Hospital Medical Center 1501 S California AveChicago, IL 60608 773-542-2000 Kim French

Schwab Rehabilitation Hospital 1401 S California AveChicago, IL 60608 773-257-1783 Kim French

Shriners Hospitals for Children 2211 N Oak Park AveChicago, IL 60707 773-622-5400 Kim French

South Shore Hospital 8012 S Crandon AveChicago, IL 60617 773-356-5000 Kim French

RML Chicago 3435 W Van Buren StChicago, IL 60624 773-826-6300 Erin Wilson/Central

Methodist Hospital of Chicago 5025 N Paulina StChicago, IL 60640 773-989-7357 Central - TBD

Provident Hospital of Cook County 55 E 51st StChicago, IL 60615 312-572-1200 Central - TBD

Roseland Community Hospital 45 W 111th StChicago, IL 60628 773-995-3000 Central - TBD

John H Stroger Jr. Hospital of Cook County 1901 W Harrison StChicago, IL 60612 312-864-6000 Antwone Young/

Alexandria Walton

La Rabida Children's Hospital E 65th St at Lake MichiganChicago, IL 60649 773-363-6700 Antwone Young

Norwegian American Hospital 1044 N Francisco AveChicago, IL 60622 773-292-8200 Antwone Young

Palos Community Hospital 12251 S 80th AvePalos Heights, IL 60463 708-226-2623 Antwone Young

St Anthony Hospital 2875 W 19th StChicago, IL 60623 773-484-1000 Antwone Young

Swedish Covenant Hospital 5145 N California AveChicago, IL 60625 773-878-8200 Antwone Young

Thorek Memorial Hospital 850 W Irving Park RdChicago, IL 60613 312-791-2670 Antwone Young

University of Illinois Hospital 1740 W Taylor StChicago, IL 60612 866-600-2273 Antwone Young

Aurora Chicago Lakeshore Hospital 4840 N Marine DrChicago, IL 60640 773-878-9700 Alex Walton

Loretto Hospital 645 S Central AveChicago, IL 60644 773-626-4300 Alex Walton

Northshore University 2650 Ridge AveEvanston, IL 60201 847-570-2000 Alex Walton

Northwest Community Hospital 800 W Central RdArlington Heights, IL 60005 847-618-1000 Alex Walton

www.mhplan.comFLYPS53 IL

Cook County Hospital Assignments

Contracted providers are an essential part of delivering quality care to our members. Molina Healthcare of Illinois values our provider partnerships and supports the doctor-patient relationship our members share with you.

As our partner, superior customer service and provider relations are one of our highest priorities. We welcome your feedback and look forward to assisting all your efforts to provide quality care.

If you have questions or concerns, please call Molina Healthcare Provider Services at (855) 866-5462.

Provider Services Department

• Director, Provider Serviceso Manages and oversees Provider Services Department

• Manager, Provider Serviceso Manages and oversees Provider Service Representativeso Ensures Provider Issues and Needs are timely addressed and resolved

• Provider Services Representativeo Liaison for Providers in assigned territoryo Monthly PCP Visitso Meets with Hospitals, Specialists, LTSS and Behavioral Health Providerso Conducts Orientations, Continued Education and Training

New Provider Orientations Provides on-site training and/or webinars Troubleshoots Web Portal questions and issues

o Facilitates Joint Operating Committee (JOCs) Meetingso Coordinates Team Visits with Quality Departmento Responds to Provider inquiries via phone and email within 24-48 Business Hourso Assist Providers with Claims Dispute Resolution

Provider Relations Contacts - Molina Healthcare ALL Provider Relations Questions or Concerns should be directed to:

Jared Fritz - Manager, Provider Services (Central/Metro East) jared.fritz@molinahealthcare.com (217) 260-7674 Gary Colucci - Manager, Provider Services (Cook County) gary.calucci@molinahealthcare.com (630)664-3132

ALL Contracting Questions or Concerns should be directed to:

Kim Gallaher - Manager, Provider Contracts kimberly.gallaher@molinahealthcare.com (331)229-9034

Escalated Issues:

Tracy Pacheco - Director, Provider Contracts tracy.pacheco@molinahealthcare.com (630)203-3949

Provider Relations Contacts - NextLevel Health General Provider Relations: 1-844-807-9734 provider.relations@nlhpartners.com Hospitals 1-844-807-9734 provider.relations@nlhpartners.com Physicians 1-844-807-9734 provider.relations@nlhpartners.com LTC-Waiver providers 1-844-807-9734 provider.relations@nlhpartners.com LTC- Skilled Nursing Facilities 1-844-807-9734 provider.relations@nlhpartners.com LTC- Supported Living Facilities 1-844-807-9734 provider.relations@nlhpartners.com Mental Health 1-844-807-9734 provider.relations@nlhpartners.com Substance Use Disorder 1-844-807-9734 provider.relations@nlhpartners.com Hospice 1-844-807-9734 provider.relations@nlhpartners.com Home Health 1-844-807-9734 provider.relations@nlhpartners.com DME 1-844-807-9734 provider.relations@nlhpartners.com FQHCs 1-844-807-9734 provider.relations@nlhpartners.com Transportation 1-844-807-9734 provider.relations@nlhpartners.com Dentists 1-844-807-9734 provider.relations@nlhpartners.com

CAQH Education Guide

Question Answer 1. What is CAQH? CAQH ProView – previously known as CAQH Universal Provider Datasource – is an

online provider data-collection solution. It streamlines provider data collection by using a standard electronic form that meets the needs of nearly every health plan, hospital and other healthcare organization. CAQH ProView enables physicians and other healthcare professionals in all 50 states and the District of Columbia to enter information free-of-charge into a secure central database and authorize healthcare organizations to access that information. CAQH ProView eliminates redundant paperwork and reduces administrative burden. CAQH, a non-profit alliance, is the leader in creating shared initiatives to streamline the business of healthcare. Through collaboration and innovation, CAQH accelerates the transformation of business processes, delivering value to providers, patients and health plans. For more information, please visit www.CAQH.org.

2. What business challenge does CAQH ProView help solve?

By streamlining data collection electronically, CAQH ProView reduces duplicative paperwork and saves millions of dollars of annual administrative costs. This benefits both the 1.2 million healthcare providers and more than 700 participating health plans, hospitals and other healthcare organizations that use CAQH ProView.

3. What administrative processes does CAQH ProView help simplify?

CAQH ProView is the trusted source and industry standard for collecting provider data used in credentialing. In the future, this data can also be used for claims processing, quality assurance, emergency response, member services and more.

4. Why is administrative simplification for credentialing an important issue?

Administrative simplification of the credentialing process helps providers increase their compliance with an organization’s requirements. The paperwork associated with credentialing is a time-consuming task facing physicians, other health care providers, practice managers and healthcare organizations. A typical healthcare provider contracts with 10 - 20 healthcare organizations, each requiring the provider to complete an extensive credentialing application. CAQH ProView simplifies the process by enabling providers to submit one standard credentialing application to a single source, the CAQH ProView credentialing application database, to satisfy the credentialing requirements of participating health plans. This significantly reduces the administrative requirements associated with the credentialing application process.

5. Where can I get additional information about this solution?

Please visit https://proview.caqh.org/po for more information on CAQH ProView.

6. How do physicians and other healthcare professionals complete the CAQH ProView data collection process?

Completing the online form requires five steps: 1. Register with CAQH ProView, https://proview.caqh.org/pr 2. Complete the online application and review the data. 3. Authorize access to the information. 4. Verify the data and/or attest to it. 5. Upload and submit supporting documents.

7. Why does CAQH ProView ask for such detailed provider and practice information?

Detailed practice information helps ensure that CAQH ProView participating health plans, hospitals, and other healthcare organizations can obtain all the information they need without having to conduct any follow up with physicians or other healthcare providers. The form's broad scope also ensures that participating organizations can better maintain and improve provider directories and data systems.

8. Do providers need to complete their entire profile?

Yes. Providers must complete all profile questions; however, the system is designed to allow you to complete your profile over time. The CAQH ProView profile will present questions that are relevant to a particular specialty, provider type and practice location(s). You can stop any time, save what you have completed, and return later to finish the process. The entire profile must be completed prior to your verification of its accuracy, and before the participating health plans you have authorized can access it.

9. Can any organization access a provider’s data?

No. The provider controls which organizations have access to the information. When completing the CAQH ProView profile, providers indicate which healthcare organizations and health plans are authorized to access the data.

10. Do physicians and other healthcare professionals need to notify CAQH ProView participating organizations that they have completed their CAQH ProView profile?

No. Organizations authorized to view completed data will automatically be notified.

11. Which departments within a participating organization are affected by CAQH ProView?

As CAQH ProView continues to add new functionality, credentialing, quality assurance, claims, member services departments and others will be able to benefit from the rich provider data in CAQH ProView.

12. Is Primary Source Verification included as part of CAQH ProView?

No, Primary Source Verification is not currently part of CAQH ProView. This solution currently addresses only the data collection part of the credentialing process. Health plans and other related organizations independently perform primary source verification on certain data that is collected, as well as make their own decisions about whether a provider meets that organization's standards for participation.

13. Are all physicians and other healthcare professionals required to use CAQH ProView?

No. Participation in CAQH ProView is completely voluntary. All health plans and healthcare organizations may use and benefit from using CAQH ProView but are not required to do so. Some health plans and other healthcare organizations have requested that their network providers use CAQH ProView starting with their next re-credentialing event. Click here for a list of CAQH ProView-participating organizations or call the CAQH ProView Support Desk at 1-888-599-1771. Provider relations staff can also provide this information.

14. How much does it cost to access CAQH ProView?

There is no cost for physicians and other health care providers to use CAQH ProView. Health plans and other healthcare organizations using CAQH ProView pay administrative fees and an annual fee per provider to access the database. For more information contact CAQH at 1-202-517-0384 or email Ask.ProView@caqh.org.

15. Who do I contact for administrative support questions when utilizing the system?

Contact the CAQH Help Desk: Providers: Email providerhelp@proview.caqh.org or call: 888-599-1771. Participating Organizations: Email accounthelp@proview.caqh.org or call: 888-600-9802. Help Desk hours are: Monday – Thursday: 7 AM – 9 PM (ET) Friday: 7 AM – 7 PM (ET)

ICD-10 Links Aetna: http://www.aetnabetterhealth.com/illinois/assets/pdf/providers/FAQ_Aetna_Medicaid_Providers.pdf Blue Cross Blue Shield: http://www.bcbsil.com/pdf/standards/icd_faqs_il.pdf CCAI/FHN: https://www.ccaillinois.com/files/ICD-10_Provider_Notice.pdf http://www.fhnchicago.com/providers/icd-10-resources Cigna-HealthSpring: http://www.careplanil.com/DownFile.Aspx?fileid=4223 County Care: http://www.countycarehealth.com/for-providers/icd-10-overview/ Harmony/WellCare: https://www.wellcare.com/en/Illinois/Providers/ICD10-Compliance/FAQ Health Alliance: http://medicaid.healthalliance.org/. Click on "I'm a Provider", then ICD-10 FAQ pdf Humana: https://www.humana.com/provider/medical-providers/education/claims/icd-10/ IlliniCare: http://www.illinicare.com/files/2011/01/IL_Provider_ICD-10_Booklet.pdf Meridian: http://www.mhplan.com/content/pdf/shared/providers/bulletins/ICD10_FAQs.pdf Molina: http://www.molinahealthcare.com/providers/il/Medicaid/Pages/home.aspx NextLevel Health:

Prior Authorization Links

Aetna: http://www.aetnabetterhealth.com/illinois/providers/resources/priorauth BlueCross BlueShield of Illinois: http://www.bcbsil.com/pdf/network/benefit_preauth_gov_programs.pdf CCAI: https://www.ccaillinois.com/medicaid/files/Provider%20Materials/ICP/C1621_0815_AuthorizationList_eng-4.pdf Cigna HealthSpring: http://www.careplanil.com/DownFile.Aspx?fileid=3944 CountyCare: http://www.countycarehealth.com/for-providers/pre-auth-needed/prior-authorization-requirements/ FHN: Covered Procedures: http://www.fhnchicago.com/files/providers/F1501_0415_ProcedureAuthList.pdf Covered Services: http://www.fhnchicago.com/files/providers/F1302_1114_FHPACACoveredServicesList.pdf Harmony/Wellcare: https://www.wellcare.com/Illinois/Providers/Authorization-Lookup Health Alliance: http://medicaid.healthalliance.org/providers Humana: ICP http://apps.humana.com/marketing/documents.asp?file=2502734 MMAI http://apps.humana.com/marketing/documents.asp?file=2502721 Illinicare: http://www.illinicare.com/for-providers/pre-auth-needed/prior-authorization-requirements/ Meridian: http://www.mhplan.com/content/pdf/il/providers/tools/Prior_Auth_Overview.pdf Molina: http://www.molinahealthcare.com/providers/il/PDF/Medicaid/PA-codification.pdf NextLevel Health:

Provider Manual Links

Aetna: Our provider manual may be accessed via: http://www.aetnabetterhealth.com/illinois/assets/pdf/providers/IL_Provider_Handbook14b.pdf Blue Cross Blue Shield: Blue Cross Community Options: http://www.bcbsil.com/provider/network/bc_community.html CIGNA HealthSpring: http://specialcareil.com/DownFile.Aspx?fileid=4044 for ICP Medicaid http://careplanofil.com/DownFile.Aspx?fileid=4179 for MMP Dual Demonstration CountyCare: http://www.countycarehealth.com/files/2014/06/cc_provider_manual_FHP.pdf FHN / CCAI: http://www.fhnchicago.com/providers https://www.ccaillinois.com/medicaid/providers/medicaid-provider-resources Harmony: www.harmonyhpi.com/provider/resources Health Alliance: http://medicaid.healthalliance.org/. Click on “I’m a Provider”. Humana https://www.humana.com/provider/support/publications/ Illinicare http://www.illinicare.com/for-providers/resources/ Meridian http://www.mhplan.com/il/providers/index.php?location=provider&page=home Molina Healthcare Medicaid: http://www.molinahealthcare.com/providers/il/medicaid/manual/Pages/home.aspx MMP: http://www.molinahealthcare.com/providers/il/duals/manual/Pages/manual.aspx NextLevel Health:

Provider Informational Guide Booklet

Documents