<div>Provider Call Quiz</div> <div> </div>

Participating Hematology specialist Colin Sieff, is calling to dispute the paid amount for two office visits on 2/7/21 and 2/8/21. He states he has a copy of his contract and he should have been paid $900. What would you offer as solutions?

The provider may contact the Provider Engagement consultant by phone or email to review the contract.

The provider may send another bill is the charge amount as $900 for each date of service.

The provider may send a copy of his contract to the Provider Services Fax, 617-897-0884 so that our Claims department manager can update the rate on the claim.

Plastic Surgeon Bradley Meland, NPI 1932275088 has called in to inform his name and billing address is incorrect. The address should be listed as 70325 East Cochise Road Scottsdale, AZ 85253.

Inform the provider that the update to the name and address will be completed today. Update the information using the Practitioner Tool in Facets.

Inform the provider to send an email to the Provider Engagement mailbox and inform it will take 3-7 business days.

Inform the provider to submit a Change Form with the correct information and send it to Provider Enrollment by fax.

How does a provider start the process to become participating with our plan?

By submitting a Non-Participating Provider Activation Form and copy of the W-9 form.

By emailing their Provider Engagement Rep letting them know they want to join

By submitting a Letter of Interest Request Form, and a copy of the W-9 form.

Where does a non-par provider, seeing a NH Medicaid Well Sense member, mail their registration form?

NHProvider.Enrollment@Wellsense.org

NHProviderInfo@Wellsense.org

Provider.Info2@Wellsense.org

What is Prior Authorization?

It is a formal request for coverage of anything you deem necessary for your wellbeing that can be placed by calling the Customer Service Department

It is a formal request for coverage of a service or medication from a medical provider to the Plan containing clinical information to support such request.

It is a formal request for coverage of a service or medication from the member to the Plan containing a letter explaining why such service/medication is needed.

It is an informal request from the member to the Plan asking for something to be covered.

What is a referral?

It is a recommendation from the member to the Plan to include a service or an item to the covered service list.

It is a recommendation from the member’s specialist provider to have a service covered.

It is a recommendation from the member’s primary care provider to have a service covered.

It is a recommendation from one of the member’s providers to receive care from another provider who may specialize in a specific area of care.

During a provider call, how can you first determine if a service requires prior authorization?

By calling the TA line.

By researching the procedures code the provider will bill with.

By a previous claim denial.

I am not the medical professional here, the provider should know.

Who is responsible for submitting the medical prior authorization request ?

The member

The Participating provider or Non-participating provider

Customer Service Rep

Prior Authorization Rep

Who handles prior authorization requests high-tech imaging?

Express Scripts

Cornerstone Health Solutions

Evicore

Wellsense Internal PA

If a Peer-to-Peer is requested for a denied wheelchair, who would the caller need to speak with?

Medical Prior Authorization Team

Northwood

Evicore

ESI

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