How to Become A 3 rd Party Provider Addressing: Preparation for enrolling with a 3 rd PartyPreparation for enrolling with a 3 rd Party Contact information.

How to Become AHow to Become A33rdrd Party Provider Party Provider

Addressing:Addressing:•Preparation for enrolling with a 3Preparation for enrolling with a 3rdrd PartyParty• Contact information for 3Contact information for 3rdrd Parties in Parties in NebraskaNebraska

DisclaimersDisclaimers

This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD.

To the best of his knowledge, it was current and accurate at the time it was prepared. It is not guaranteed to be error or omission free.

It was prepared as general information to assist doctors and staff, and is not intended to grant rights or impose obligations.

DisclaimerDisclaimer

• The ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services.• The Nebraska Optometric Association, and its presenters, agents, consultants and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free or omission-free, and will bear no responsibility or liability for the results or consequences of the information contained herein.

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Enrolling as a ProviderEnrolling as a ProviderMultiple page application forms with Multiple page application forms with

considerable documentation: copies ofconsiderable documentation: copies of

•NPI (National NPI (National Provider Identifier) Provider Identifier) •Optometry DiplomaOptometry Diploma•State License State License

•DEA Registration (need it)DEA Registration (need it)•Proof of Malpractice Proof of Malpractice InsuranceInsurance•Photo IDPhoto ID……plus more in some casesplus more in some cases

•Turn-around timeTurn-around time: weeks to months: weeks to months

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NPI (National Provider Identifier)NPI (National Provider Identifier) Need before enrolling as any providerNeed before enrolling as any provider Need a separate NPI for Need a separate NPI for

– Each doctor (only one NPI for any doctor), Each doctor (only one NPI for any doctor), – Each office location, Each office location, – Each separate business entity (optical Each separate business entity (optical

dispensary may need separate NPI if has a dispensary may need separate NPI if has a separate tax ID number)separate tax ID number)

• http://www.cms.hhs.gov/NationalProvIdentStand/01_Overview.asp#TopOfPagehttp://www.cms.hhs.gov/NationalProvIdentStand/01_Overview.asp#TopOfPage

Enrolling as a ProviderEnrolling as a Provider

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NPI (National Provider Identifier)NPI (National Provider Identifier) Exception: Sole Proprietor (Not a PC or Exception: Sole Proprietor (Not a PC or

partnership, etc.)…partnership, etc.)…– Only one NPI total (represents both doctor and Only one NPI total (represents both doctor and

her/his practice). her/his practice). – Get specifics at Get specifics at

http://www.cms.hhs.gov/NationalProvIdentStand/01_Overview.asp#TopOfPagehttp://www.cms.hhs.gov/NationalProvIdentStand/01_Overview.asp#TopOfPage

Enrolling as a ProviderEnrolling as a Provider

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Enrolling as a ProviderEnrolling as a Provider

NPI enrollment information found atNPI enrollment information found at•National Plan and Provider National Plan and Provider Enumeration SystemEnumeration System ( (NPPESNPPES))

https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do

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NPI (National Provider Identifier)NPI (National Provider Identifier)• Information on NPI application must match Information on NPI application must match

information oninformation on– Medicare B application (855i and 855b)Medicare B application (855i and 855b)– Medicare DME application (855s)Medicare DME application (855s)– IRS information (Employer ID number, etc)IRS information (Employer ID number, etc)

Enrolling as a ProviderEnrolling as a Provider

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Contacts to Become a Contacts to Become a ProviderProvider

Routine CareRoutine Care (July 2011)(July 2011)

– AvesisAvesis http://http://www.avesis.com/provider_benefits.htmlwww.avesis.com/provider_benefits.html

– EyeMed (Eyecare Plan of America)EyeMed (Eyecare Plan of America) http://portal.eyemedvisioncare.com/wps/portal/emweb/prhttp://portal.eyemedvisioncare.com/wps/portal/emweb/providers/become_a_provideroviders/become_a_provider

– Optum (Spectera)Optum (Spectera)

https://www.optumhealthvision.com/providers/OH_Vision_Provider.jsphttps://www.optumhealthvision.com/providers/OH_Vision_Provider.jsp

– Vision Service Plan (VSP)Vision Service Plan (VSP) https://www.vsp.com/cms/provider/provider-home.htmlhttps://www.vsp.com/cms/provider/provider-home.html

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Contacts to Become a Contacts to Become a ProviderProvider

Standard MedicaidStandard Medicaid • Via Nebraska Dept. of Health & Human Via Nebraska Dept. of Health & Human

Services Services • Both Routine & Medical Both Routine & Medical • Patients age 65+ &/or in nursing homePatients age 65+ &/or in nursing home

http://www.hhs.state.ne.us/med/providerenrollment.htmhttp://www.hhs.state.ne.us/med/providerenrollment.htm

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Contacts to Become a Contacts to Become a ProviderProvider

Medicaid Managed Care Organizations Medicaid Managed Care Organizations (MCOs)(MCOs)

– MCOs cover all Medicaid patients that are MCOs cover all Medicaid patients that are not also covered by Medicare. MCOs covernot also covered by Medicare. MCOs cover

Medical DiagnosesMedical Diagnoses

Routine Care (sub-contracted)Routine Care (sub-contracted)

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Contacts to Become a Contacts to Become a ProviderProvider

Medicaid Managed Care Organizations (MCOs)Medicaid Managed Care Organizations (MCOs)

– State divided into two parts, each having two MCOsState divided into two parts, each having two MCOs

MCOs for MCOs for Eastern 10 counties:Eastern 10 counties: – UnitedHealthCare Community Plan (United HealthCare)UnitedHealthCare Community Plan (United HealthCare)– Coventry Nebraska (Coventry)Coventry Nebraska (Coventry)

MCOs for MCOs for Other 83 Counties: Other 83 Counties: (starting July 1, 2012)(starting July 1, 2012)– Coventry Cares (Coventry)Coventry Cares (Coventry)– Arbor Health (AmeriHealth Nebraska via BCBS)Arbor Health (AmeriHealth Nebraska via BCBS)

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Contacts to Become a Contacts to Become a ProviderProvider

Medicaid Managed Care Organizations (MCOs)Medicaid Managed Care Organizations (MCOs)

MCOs for MCOs for Eastern 10 counties Eastern 10 counties : : – UnitedHealthCare Community Plan UnitedHealthCare Community Plan (United (United

HealthCare)HealthCare)

– Coventry Nebraska (Coventry)Coventry Nebraska (Coventry)

Eastern 10 Counties include Eastern 10 Counties include

• Seward• Washington

• Otoe• Sarpy• Saunders

• Cass• Dodge

• Douglas• Gage• Lancaster

• Cass• Dodge

• Douglas• Gage• Lancaster

• Otoe• Sarpy• Saunders

• Cass• Dodge

• Douglas• Gage• Lancaster

• Seward• Washington

• Otoe• Sarpy• Saunders

• Cass• Dodge

• Douglas• Gage• Lancaster

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Contacts to Become a Contacts to Become a ProviderProvider

Eastern 10 countyEastern 10 county Medicaid MCO Contact Info Medicaid MCO Contact Info::

UnitedHealthCare Community Plan (United HealthCare)

Routine CareRoutine Care (Block Vision subcontractor) (Block Vision subcontractor)– Call Adrienne Bennett, VP, Operations at 800-243-1401

x1067; Email [email protected] .

Medical CareMedical Care (United HealthCare) (United HealthCare)– Contact: Jeremy Sand, at 402-445-5587, or

[email protected].

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Contacts to Become a Contacts to Become a ProviderProvider

Eastern 10 countyEastern 10 county Medicaid MCO Contact Info: Medicaid MCO Contact Info:

Coventry Of Nebraska, Inc.(Coventry Health Care)• Routine CareRoutine Care (Block Vision subcontractor) (Block Vision subcontractor)

– Call Adrienne Bennett, VP, Operations at 800-243-1401 x1067; Email [email protected] .

Medical CareMedical Care ( (Coventry of Nebraska))– Coventry of Nebraska’s “contracting area” call 800-471-0240

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Contacts to Become a Contacts to Become a ProviderProvider

Medicaid Managed Care Organizations (MCOs)Medicaid Managed Care Organizations (MCOs)

– State divided into two parts, each having two MCOsState divided into two parts, each having two MCOs

MCOs for MCOs for Eastern 10 counties:Eastern 10 counties: – Share Advantage (United HealthCare)Share Advantage (United HealthCare)– Coventry Nebraska (Coventry)Coventry Nebraska (Coventry)

MCOs for MCOs for Other 83 Counties: Other 83 Counties: (starting July 1, 2012)(starting July 1, 2012)– Coventry Cares (Coventry)Coventry Cares (Coventry)– Arbor Health (AmeriHealth Nebraska via BCBS)Arbor Health (AmeriHealth Nebraska via BCBS)

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Contacts to Become a Contacts to Become a ProviderProvider

Western 83 CountyWestern 83 County Medicaid MCO Contact Medicaid MCO Contact Info:Info:

Coventry Cares (Coventry) Routine CareRoutine Care (Block Vision subcontractor) (Block Vision subcontractor)

– Monica Jenifer- Sr. Network Development Specialist– 1-800-243-1401 x 1067– [email protected] – Teresa Moragne El- Sr. Network Development Specialist– 1-800-243-1401 x 1067– [email protected]  

Medical CareMedical Care (Coventry) (Coventry)– Scott Davis– Manager, Network Development– 402-995-7174– (800) 471-0240 Ext. 7174– [email protected]– 15950 West Dodge Road– Omaha, NE 68118 .

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Contacts to Become a Contacts to Become a ProviderProvider

Western 83 CountyWestern 83 County Medicaid MCO Contact Info: Medicaid MCO Contact Info:

Arbor Health (AmeriHealth Nebraska via BCBS) Routine Care and Medical CareRoutine Care and Medical Care (Avesis subcontractor) (Avesis subcontractor)

– Eilene Fennelly Contracting SpecialistContracting Specialist Phone: (800) 643-1132, ext. 116Phone: (800) 643-1132, ext. 116 Email: Email: [email protected]@avesis.com

– Cheryl BeyenkaCheryl Beyenka Contracting Specialist Contracting Specialist

Phone: (800) 643-1132, ext. 141Phone: (800) 643-1132, ext. 141 Email: Email: [email protected]@avesis.com

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Contacts to Become a Contacts to Become a Provider Provider

Medical Coverage Blue Cross Blue Shield of Nebraska

http://www.bcbsne.com/Providers/Library/Credentialing.aspxApparently BCBS will pay claims retroactive to the date of Apparently BCBS will pay claims retroactive to the date of

applicationapplicationfor enrollment, but only when their special form is completed.for enrollment, but only when their special form is completed.

Midlands Choice http://www.midlandschoice.com/Provider/Credentialing/Index.html

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Contacts to Become a Contacts to Become a Provider Provider

Medical Coverage Coventry 800 865-2673, press 6 for credentialing

United HealthCare, , 877/842-3210, then using a fake tax ID # 877/842-3210, then using a fake tax ID # 471234567, follow their phone voice response. 471234567, follow their phone voice response. When given the choice, sayWhen given the choice, say

First choice, Press 5 or say “…Other”First choice, Press 5 or say “…Other” Next choice Press 1 or say “Credentialing”Next choice Press 1 or say “Credentialing” Next choice Press 2 say “Medical”Next choice Press 2 say “Medical” Next choice Press 2 or say “Join network”Next choice Press 2 or say “Join network”

UHC convoluted web site found at: UHC convoluted web site found at: http://www.uhc.com/physicians/join_our_network.htmhttp://www.uhc.com/physicians/join_our_network.htm

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Contacts to Become a Contacts to Become a Provider Provider

Medical CoverageMedical Coverage

Medicare Medicare – Medicare Part B Medicare Part B

http://www.wpsmedicare.com/j5macpartb/departments/enrollment/http://www.wpsmedicare.com/j5macpartb/departments/enrollment/

– Rail RoadRail Road Medicare Part B 877/288-7600 Medicare Part B 877/288-7600• http://www.palmettogba.com/palmetto/Providers.nsf/docsCat/http://www.palmettogba.com/palmetto/Providers.nsf/docsCat/

Providers~Railroad%20Medicare~Resources~Provider%20Enrollment?openProviders~Railroad%20Medicare~Resources~Provider%20Enrollment?open

– Medicare Durable Medical EquipmentMedicare Durable Medical Equipment• Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

(DMEPOS) Brochure [PDF,87KB](DMEPOS) Brochure [PDF,87KB]

https://www.noridianmedicare.com/dme/enroll/https://www.noridianmedicare.com/dme/enroll/

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Becoming a ProviderBecoming a Provider

Once Approved you will be given…Once Approved you will be given…– Provider number Provider number – Manuals &/or other (Web) resourcesManuals &/or other (Web) resources

Claim requirementsClaim requirements Explanation of various plansExplanation of various plans Other important dataOther important data

– Be sure to read these resources…ignorance is Be sure to read these resources…ignorance is not an excuse for incorrect claims! not an excuse for incorrect claims!

– Fraudulent filing is a Federal crime.Fraudulent filing is a Federal crime.

Thank You for ListeningThank You for Listening

We hope this information has been We hope this information has been helpful.helpful.

Thank you for listening!Thank you for listening!

See our NOA Website for more 3See our NOA Website for more 3rdrd Party Educational Videos.Party Educational Videos.

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Nebraska Optometric AssociationNebraska Optometric Association