Download Washoe County Department of Social Services Health Care

Washoe County Department of Social Services
Health Care Assistance Program
The Health Care Assistance Program (HCAP) reimburses medical and institutional facilities for eligible participants
who do not qualify for Federal, State or community programs.
Washoe County HCAP Approved Providers
Renown Regional Medical Center-Tax ID #: 88-0213754
Renown South Meadows Hospital-Tax ID #:46-0517825
Saint Mary’s Regional Medical Center-Tax ID #:45-4989022
Northern Nevada Medical Center-Tax ID #:88-0159958
Outpatient Clinic
Renown Health Care Center- Tax ID #: 88-0213754
Medical Miscellaneous Providers
Remsa-Tax ID # 88-0175774
See Addendum A for complete list
Acadian Rehab Inc-Tax ID # 88-0254192
Accellence Home Health-Tax ID # 94-3325112
Better Breathing-Nevada, LLC-Tax ID # 90-0197492
KCI USA Inc-Tax ID # 74-2152396
Lincare-Tax ID # 59-2852900 & 59-3493196
Neurodevelopmental Neurodiagnostic/
Sleep Disorder Center-Tax ID # 88-0200884
Preferred Home Care-Tax ID # 86-0898663
Renown Home Care-Tax ID # 88-0213754
St. Mary’s Home Care-Tax ID # 45-4989022
Hospitals
Eligible Services
Service
Ambulance
Hospital Inpatient Care
(Includes Inpatient Rehab)
Outpatient Care
Outpatient Facility Charges including:
Coverage Notes
Transports to facility from private residence or public site.
Transports from:
 Healthcare Center to hospital
 Jail infirmary to hospital
 NNAMHS to hospital
 Triage Center to hospital
Note: Transports from acute facility to acute facility are not
covered. Example: Renown Regional Medical Center to
Renown South Meadows would not be covered. (See
Definitions)
Medicaid bed day rates paid for the admission timeframe
minus the discharge date.
 Cardiac Rehab-Phase I & Phase II (See Definitions)
 Cardiac Stress Test
 Chemotherapy / Radiation Therapy
 Diabetic Shoes
 Durable Medical Equipment (See Definitions)
 Emergency Room Facility (emergent only)
 Home Health Care (See Definitions)
 Hospice Care
 Hyperbaric Chamber Oxygen Treatment
 Influenza Vaccinations
 Infusion Therapy
 Laboratory Testing (pathology professional fees are a
non-covered service)
 Mammogram – Diagnostic Only (See Prior
Authorization section)
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

Non-Formulary Drugs (See Prior Authorization section)
Occupational Therapy (24 in a calendar year, 25th visit
requires Prior Authorization)
 Observation (first 48 hours only)
 Oxygen – 8 canisters per month (See Prior
Authorization section)
 Physical Therapy (24 in a calendar year, 25th visit
requires Prior Authorization)
 Pneumonia Vaccinations
 Prescriptions dispensed by an approved hospital clinic
or facility.
 Radiology Services- (See Prior Authorizations section)
 Same-Day-Surgery
 Sleep Studies/CPAP Titrating (See Definitions)
 Speech Therapy (24 in a calendar year, 25th visit
requires Prior Authorization)
 Substance Abuse Treatment (See Prior Authorization
section)
 Treatment received in an approved hospital clinic or
facility
 Wound Therapy (24 in a calendar year, 25th visit
requires Prior Authorization)
Prior Authorization Requirements
Unless expressly stated otherwise, all services requiring
Prior Authorization must meet Nevada Medicaid requirements
Service
Cardiac Rehabilitation
Authorization Information
Phase I & Phase II (See Definitions)
Note: Phase III is not covered.
Cardiac Stress Test
Durable Medical Equipment All Prosthetics
Home Health Care
Hospice Care
Hyperbaric Chamber Oxygen Treatment
Mammogram-Diagnostic Only
Non-Formulary Drugs
Oxygen
Physical/Occupational/Speech Therapy
Radiology Services
Rehabilitation Inpatient Facility
Sleep Studies / CPAP Titrating
Substance Abuse Treatment (outpatient)
Wound Therapy
Charges greater than $1000. Items available through local
non-profit organizations (Care Chest) are not eligible.
Charges greater than $1000
Women – Diagnostic only and must meet the following
criteria:
• Provide proof of denial from Access to Healthcare
Network (AHN) for Medicaid Breast and Cervical
Cancer Program and Susan G. Komen grant funds.
Men - No authorization required.
Prior Authorization Request may only be sent if drug was
prescribed by a Specialist and the Pharmacist has signed
off that there is not an equivalent available on the HCAP
Formulary. Prior Authorization Requests should be sent to
the Washoe County HCAP Program Coordinator.
Up to 8 canisters per month
In excess of 24 visits in a calendar year
PET Scans / CT Scans / MRI / MRA
Services must be approved by WCSS as an exception
In excess of 24 visits in a calendar year
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Exclusions- Non-Covered Services
1. Alcohol and/or detoxification.
2. Ambulance transports from acute facility to acute facility. Example: Renown Regional Medical Center to
Renown South Meadows Hospital.
3. Any medication not included on the Health Care Assistance Program Formulary without prior authorization.
4. Clients with private insurance, Medi-Cal, Medicaid, or other State/Federal medical programs if the program
pays for the cost of medical treatment in Washoe County.
5. Behavioral Health/Mental Health
6. Dental, Vision or Audiology Services.
7. Dialysis-outpatient services covered under Emergency Medicaid for individuals with End Stage Renal
Disease.
8. Experimental surgery. Experimental surgery is any surgical procedure not funded by Medicare or Medicaid.
9. Family Planning services which may include education, counseling, physical examinations; or birth control
devices, supplies or surgeries.
10. Hyperactive disorders of children.
11. Immunizations with the exception of pneumonia or influenza vaccinations.
12. Medical Care for eligible veterans.
13. Medical examinations or evaluations not related to specific complaints of illness including examinations for
sports, employment and health screening.
14. Out-of-State care without prior authorization.
15. Over the counter items.
16. Pre natal services.
17. Preventative/Routine Services.
18. Private Physicians and/or Professional Fees.
19. Psychiatric care including sedative, hypnotic, psychotropic medications or other psychiatric medications; and
inpatient or outpatient psychotherapy.
20. Tests or treatment for sexually transmitted diseases provided by the Washoe County Health Department.
Emergency Medicaid Requirement
Section 9406 of P.L. 99-509 authorizes Medicaid in emergency situations to non-citizens. Emergency Medicaid only
coverage is for non-citizens who meet eligibility requirements for Temporary Assistance for Needy Families or
Medicaid with the exception of citizenship status.
The Health Care Assistance Program will not pay emergency room visits for persons who could be eligible for
Emergency Medicaid. Ambulance transports or inpatient hospital admissions require proof of denial from
Emergency Medicaid for non-emergent service prior to HCAP payment.
The Health Care Assistance Program will not pay for outpatient dialysis for individuals with End Stage Renal
Disease who could be eligible for Emergency Medicaid for citizens or non-citizens.
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DEFINITIONS
Ambulance: Professional ground or air ambulance service: (1) when necessary to transport a Covered Person
from the place where he/she is injured or stricken by a Sickness to the nearest Hospital where treatment can be
given, (2) from Nevada Adult Mental Health Services facility to nearest Hospital where treatment can be given (3)
from incarceration facility to nearest Hospital where treatment can be given.
Ambulatory Surgical Center (Same Day Surgery): Any public or private establishment which complies with all
licensing and other legal requirements and is operating lawfully in the jurisdiction where it is located; has an
organized medical staff of Physicians, with permanent facilities that are equipped and operated primarily for the
purpose of performing surgical procedures; provides continuous Physician services and registered professional
nursing services whenever a patient is in the facility; and does not provide services or other accommodations for
patients to stay overnight.
Cardiac Rehab: A monitored exercise program directed at restoring both physiological and psychological wellbeing to individuals with heart disease and only for patients who have one of the following:
documented diagnosis of acute myocardial infarction within the preceding 12 months
had coronary bypass surgery
have stable angina pectoris
had heart valve repair/replacement
had percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting
had a heart or heart-lung transplant
Note: Phase I and II are considered medically necessary. Phase I refers to inpatient cardiac rehabilitation services.
Phase II, cardiac rehabilitation, is a comprehensive, long-term program including medical evaluation, prescribed
exercise, cardiac risk factor modification, education and counseling. Phase II refers to outpatient, medicallysupervised programs that are typically initiated one to three weeks after hospital discharge and provide appropriate
electrocardiographic monitoring. Phase III refers to maintenance programs without physician supervision and
monitoring and does not meet criteria for coverage.
Chemotherapy/Radiation Therapy: Services performed in hospital setting only. Supplies related to the
administration of chemical agents in the treatment or control of a sickness.
Covered Recipient: In accordance with federal and state regulations, eligibility of the individual is dependent upon
the approval of the Washoe County Social Services Health Care Assistance Program. The following is a list of CDS
benefit plans and benefit codes:
Plan/Benefit Code
MEDA/WA- Approved for services and reimbursement under the Washoe County Social Services Health Care
Assistance Program (HCAP)
MEDP/WP-Approved for services under HCAP, but denied for reimbursement due to pending Medicaid
MEXA/XA-Approved for services and reimbursement under HCAP for a specific, identified service and timeframe
MEXP/XP-Approved for service under HCAP for a specific, identified service and timeframe, but denied for
reimbursement due to pending Medicaid
MEEM/WM-Approved for service and reimbursement under HCAP for services other than Emergency Medicaid
MEDD/WD-Denied for services and reimbursement under HCAP due to Medicaid eligibility.
NOCOV/XX-No coverage under HCAP, Medicaid, or other Government Entity
Covered Provider: Any practitioner of the healing arts who:
is licensed and regulated by a state or federal agency and is acting within the scope of his or her
license; or
in the absence of licensing requirements, is certified by the appropriate regulatory agency
or professional association;
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DEFINITIONS, continued
including, but not limited to a/an:
Certified Registered Nurse Anesthetist (CRNA)
Licensed Practical Nurse (LPN)
Occupational Therapist (OTR)
Physical Therapist (PT or RPT)
Registered Nurse (RN)
Respiratory Therapist
Speech Pathologist
A "Covered Provider" will also include the following when appropriately-licensed and providing services which are
covered by the Plan:
facilities as are defined herein including, but not limited to, Hospitals, Ambulatory Surgical Facilities,
hemodialysis and Outpatient clinics under the direction of a Physician (MD);
ambulance companies.
Dialysis: Covered under Emergency Medicaid for individuals with End Stage Renal Disease.
Diabetic Shoes: Diabetic shoes, fitting, and Modification (HCPC A5500 – A5507, A5512 – A5513)
Durable Medical Equipment: Rental of durable medical equipment (but not to exceed the fair market purchase
price) or purchase of such equipment where only purchase is permitted or where purchase is more cost-effective
due to a long-term need for the equipment. Such equipment must be prescribed by a Physician and required for
therapeutic use in treatment of an active Sickness or Accidental Injury. The decision to rent or purchase equipment
shall be at the discretion of Washoe County Social Services. Excess charges for deluxe equipment or devices will
not be covered. Repair of purchased equipment will be covered when necessary to maintain its usability.
Replacement of durable medical equipment will be covered only if: (1) needed due to a change in the patient’s
physical condition, or (2), it is likely to cost less to buy a replacement than to repair existing equipment or rent like
equipment. Durable Medical equipment includes, but it not limited to oxygen, nebulizers, and concentrators.
Emergency Room Care: “Emergency medical condition” or “emergency” is defined as a medical condition
manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a lay person, with an
average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to
result in:
Serious jeopardy to the health of the individual or, the case of a pregnant woman, the health of the
woman or her unborn child,
Serious impairment to bodily functions; or
Serious dysfunction of any bodily organ or part.
Home Health Care: Services provided by a Registered Nurse, Speech Therapist , Occupational Therapist or
Physical Therapist Services and supplies which are furnished to an eligible Person who is confined at home and is
under the active medical supervision of the Physician ordering home health care and who is treating the condition
for which that care is needed. Home health care services and supplies must be consistent with the patient’s health
condition, degree of disability and medical needs. Home health care services and/or supplies must be provided and
billed by a Home Health Care Agency. Covered home health care services and supplies include:
Services of physical, occupational and speech therapists;
Necessary medical supplies provided by the Home Health Care Agency.
Services of a registered nurse (RN)
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DEFINITIONS, continued
Hospice Care Services: Nursing services, physician services, and drugs and biologicals must be routinely
available on a 24-hour basis; all other covered services must be available on a 24-hour basis to the extent
necessary to meet the needs of individuals for care that is reasonable and necessary for the palliation and
management of terminal illness and related conditions and provide these services in a manner consistent with
accepted standards of practice. Bereavement counseling must be provided. The following services are included in
the hospice reimbursement when consistent with the plan of care. The services must be provided in accordance
with recognized professional standards of practice.
a. Nursing Services
b. Medical Social Services
c. Physician Services
d. Counseling Services
e. Medical Appliances, Supplies and Pharmaceutical
f. Home Health Aide, Personal Care Aide and Homemaker Services
g. Physical Therapy, Occupational Therapy, Respiratory Therapy and Speech-Language Pathology Services
Level of Care (LOC)
a. Routine Home Care
b. Continuous Home Care
c. Inpatient Care (Respite or General):
Hyperbaric Oxygen Therapy (HBOT): Therapy in which a recipient breathes 100% oxygen intermittently while the
pressure of the treatment chamber is increased to a point higher than sea level pressure (i.e.,>1 atm abs.).
Breathing 100% oxygen at 1 atm of pressure or exposing isolated parts of the body does not constitute HBOT; the
recipient must receive the oxygen by inhalation within a pressurized chamber.
Mammogram: Diagnostic mammograms for men and women are not restricted to age. Women over the age of 40
and who possess a valid social security number must provide proof of denial for services from Access to Healthcare
Network (AHN). Programs available through AHN include Women’s Health Connection (WHC) and the Medicaid
Breast and Cervical Program.
Medical Supplies: Medical supplies such as ostomy, catheter, wound, surgical dressings, and related supplies.
Occupational Therapy: Short-term active, progressive Occupational Therapy performed by a licensed or duly
qualified therapist as ordered by a Physician. Services that are restorative in nature and designed to significantly
improve, develop or restore physical functions lost or impaired as a result of a disease, or injury and only if there is a
reasonable expectation that occupational therapy will achieve measurable improvement in the patient’s condition in
a reasonable and predictable amount of time.
Over-the-Counter Items: Supplies that can be obtained without a Physician’s prescription are not covered.
Physical Therapy: Short-term active, progressive Physical Therapy performed by a licensed or duly qualified
therapist as ordered by a Physician. Services that are related to an injury, illness, or disease and the diagnosis are
consistent with physical therapy treatment. There must be reasonable expectation that the services will produce
significant improvement in the patient’s condition. Documentation, when requested, must support physical therapy
services that contain progress reports, a diagnosis to support the level of care provided, medical necessity of the
care provided, the patient’s progress toward meeting the goals of the therapy and the results achieved during the
physical therapy services.
Prescription Drugs: Drugs and medicines which are dispensed and administered to a Covered Person. Coverage
for pharmacy purchases is provided through Catalyst RX. See the Prescription Drugs section for additional
information.
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DEFINITIONS, continued
Radiology Services: Services that are considered to be reasonable and necessary for the diagnosis and treatment
of a specific illness, symptom, complaint, or injury or to improve the functioning of a malformed body part. Magnetic
Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Magnetic Resonance Spectroscopy (MRS),
or Positron Emission Tomography (PET) scans. Always use other modalities or less expensive tests such as CT,
Ultrasound,or standard X-ray, etc., when they will achieve the required results.
Rehabilitation Inpatient Facility: Inpatient hospital services are services ordinarily furnished in a hospital for the
care and treatment of an inpatient under the direction of a physician.
Sleep Studies, Polysomnography, multiple sleep latency test (MSLT)-Medically necessary testing in a certified
sleep disorder clinic. These facilities in which certain conditions are diagnosed through the study of sleep are either
affiliated with a hospital or are under the direction and control of physicians. Coverage will be based upon the
following:
a licensed physician or other licensed professionals working within the scope of their practice must request the
appropriate test.
the need for diagnostic testing is confirmed by medical evidence, e.g., patient history, physician examination and
other laboratory type tests.
diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results
are still pertinent is not covered.
diagnostic Testing Facilities for Sleep Disorders may be covered even in the absence of direct supervision by a
physician, however, a trained qualified attendant must be present to assess and monitor the patient. A licensed
physician must review and sign reports.
Diagnostic testing is covered only if the recipient has symptoms or complaints of one of the conditions:
Morbid obesity
Pickwickian Syndrome
Cataplexy and narcolepsy
Various Insomnia’s
Obstructive Sleep Apnea (OSA) requires documentation of at least 30 episodes of apnea, each lasting a minimum
of 10 seconds, and hypopnea with oxygen saturation levels below 85% during 6-7 hours of recorded sleep.
Polysomnography is distinguished from sleep studies by the inclusion of sleep staging. The following are included:
EEG;
Electro-oculography (EOG); and
EMG
Additional parameters of sleep which may be monitored include:
EKG;
Airflow;
Ventilation and respiratory effort;
Gas exchange by oximetry, transcutaneour monitoring, or end tidal gas analysis;
Extremity muscle activity, motor activity-movement;
Extended EEG monitoring;
Penile tumescence;
Gastro esophageal reflux;
Continuous blood pressure monitoring;
Snoring; and
Body positions, etc.
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DEFINITIONS, continued
For a study to be reported as a polysomnogram, sleep must be recorded and staged. Adult testing includes a half
night with continuous positive airway pressure (CPAP). Testing for children (0-12) must be reviewed and scored by
physician to determine need for follow-up with CPAP. Prior authorization may be included for this age group in the
initial authorization. Multiple Sleep Latency studies are covered only if the symptoms or complaints suggest a
diagnosis for Narcolepsy.
Speech Therapy: Short-term active, progressive Speech Therapy performed by a licensed or duly qualified
therapist as ordered by a Physician. Speech Therapy to restore speech to a person who has lost existing speech
function as a result of disease, injury or surgery, such as seizure disorder, CVA or stroke, otitis media, brain injury,
hearing loss, Parkinson’s disease and paralysis of the vocal cord or larynx, carcinoma of the larynx, trachea,
pharynx, lip, head, neck, and dysphasia.
NOTE: Speech Therapy is not covered for non-organic/functional speech and language disorders such as lisping,
stuttering and stammering, or speech and language problems that result from non-curable developmental disorders
such as, developmental delay, mental retardation, Down’s Syndrome. Maintenance therapy is not covered.
Maintenance therapy begins when the therapeutic goals of a treatment plan have been met and no further functional
progress is expected.
Substance Abuse Treatment:Substance abuse treatment (methadone and suboxone opioid therapy) as approved
by the Washoe County Department of Social Services Health Care Assistance Program. Services include oral
medication, evaluation and management, lab drug and TB tests, and diagnostic psychiatric evaluation.
Wound Therapy: Restore or ameliorate functional limitations that are the result of an illness or injury which can
respond or improve as a result of the prescribed therapy treatment plan in a reasonable, predictable period of time.
It must be rendered according to the written orders of the physician, physician’s assistant or an advanced
practitioner of nursing (APN) and be directly related to the active treatment regimen designed by the therapist and
approved by the professional who wrote the order.
PRESCRIPTION DRUG PROGRAM
The Prescription Drug Program is provided through a separate agreement with Catamaran Rx, a Pharmacy Benefit
Manager (PBM). Catamaran RX administers Point of Service (POS) claims This section provides a summary of the
prescription drug coverage through Catamaran Rx.
Catamaran Rx
(888) 869-4600
www.catalystrx.com
There is a 30 day supply limit on prescriptions. Currently the rules for refills at the Renown Health Care Clinic
(HCC) Pharmacy are:
1. If the refill is within the thirty (30) days of the last dispensing date, there is a two (2) day rule for a
controlled substance (i.e. the 30 day limit is on a Sunday the client may refill on the Friday before or
2 days early)
2. Five (5) days for a non-controlled substance (i.e. the 30 day limit is on a Sunday, so the script would
not be eligible for refill until Wednesday of the following week).
3. The date of the refill reverts to the dispensing date or the clock starts ticking on the refill date for the
next 30 days.
Claims must be billed within six (6) months from the date of service (dispensing) or ninety (90) days from the
authorization date.
To obtain updated information regarding the Formulary list, covered and non covered drugs, and helpful information
on generic equivalent drugs, contact Catamaran RX Customer Service at (888) 869-4600.
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.ELIGIBILITY
Washoe County Department of Social Services Health Care Assistance Program (HCAP) determines recipient
eligibility. Eligibility is determined on a month to month basis. Providers must always verify recipient
eligibility prior to providing services.
VERIFYING ELIGIBILITY
Eligible Recipients will be identified by the following benefit plan and benefit codes:
Plan/Benefit Code
MEDA/WA- Approved for services and reimbursement under the Washoe County Social Services Health Care
Assistance Program (HCAP)
MEDP/WP-Approved for services under HCAP, but denied for reimbursement due to pending Medicaid
MEXA/XA-Approved for services and reimbursement under HCAP for a specific, identified service and timeframe
MEXP/XP-Approved for service under HCAP for a specific, identified service and timeframe, but denied for
reimbursement due to pending Medicaid
MEEM/WM-Approved for service and reimbursement under HCAP for services other than Emergency Medicaid
MEDD/WD-Denied for services and reimbursement under HCAP due to Medicaid eligibility.
NOCOV/XX-No coverage under HCAP, Medicaid, or other Government Entity
It is important to verify a recipient’s eligibility before providing services. Eligibility can be verified through the CDS
web portal at https://secure.cdsgrouphealth.com/. You may log on 24 hours a day, 7 days a week using any
Internet-ready computer.
To obtain access, new users must register on the Provider Web Portal at https://secure.cdsgrouphealth.com/. CDS
will verify you are authorized for access. Once this is complete, you will be notified via mail or email with your
password to begin using the system.
For questions or assistance, contact CDS’ Customer Service Department at (775) 352-6900 or (800) 455-4236
Monday thru Friday 8:00 am to 5:00 pm Pacific Standard Time.
Or by email at [email protected]
PRIOR AUTHORIZATIONS
Prior Authorization is required for most services. For a list of services refer to the Prior Authorization Requirements
section.
For prior authorization questions, forms, or requirements, contact:
CDS Group Health
Customer Service Department
(775) 352-6900 or (800) 455-4236
Ways to request prior authorization
Paper Requests: Services can be requested by obtaining the Prior Authorization Request form, which can be found
on the CDS website @ www.cdsgrouphealth.com under the ‘Member/Provider’ section.
Requests may be faxed or mailed and must include documentation supporting medical necessity.
The prior authorization fax number for all services is: (775) 352-6992.
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PRIOR AUTHORIZATIONS, continued
The mailing address is:
CDS Group Health
PO Box 50190
Sparks, NV 89435-0190
Attn: Medical Management
Prior Authorization Turnaround Time Requirements:
Pre Service
Urgent – 72 hours
Non Urgent–15 Calendar Days
Post Service
30 Calendar Days
Review / Notification completion times from receipt of request
Incomplete Requests: If additional information is necessary to make a determination notification will be sent by
fax. You have five (5) business days to submit the requested information or the request will be denied for
insufficient information.
Requests for Modification: All requests to modify a previously approved request must be submitted in writing (e.g.
CPT code, date of service, number of units). Any modifications must be approved before the scheduled service
date.
Approved Requests: When a request has been approved, CDS Medical Management department will provide
written confirmation, sent via fax to the provider(s). Approved requests are assigned an 11-digit authorization
number, CPT/HCPCS code, and a service date range. Approved requests are only valid for specific service(s), and
date(s) shown.
CLAIMS AND APPEALS PROCEDURES
Filing a Claim: Claims may be submitted electronically to CDS Group Health for processing by utilizing:
Payer ID Number: 88022
Timely Filing: Claims must be received within one hundred eighty (180) days from the date of service(s) or ninety
(90) days from the date of Medicaid eligibility denial.
Inaccurate, Illegible or Incomplete Claims: If a claim is denied or returned (e.g., illegible or incomplete claims),
you are not given an additional 180 or 90 days to resubmit. Timely filing is always based on date of service or date
of eligibility denial.
Claim Appeals: Providers have the right to appeal an adverse determination. Appeals must be post marked no later
than thirty (30) calendar days from the date of the original decision. If the appeal is rejected for incomplete
information, there is no extension to the original 30 calendar days.
How to File: All appeals must be submitted in writing and include the following information:
•
•
•
•
•
•
•
•
A cover letter or statement indicating the reason for the appeal
Reason for the appeal
Provider name and Tax ID #
Recipient name and ID #
Date(s) of service
Procedure code(s)
Contact Information for the individual filing the appeal
Documentation to support the issue, e.g., prior authorization, physician’s notes, ER reports
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•
A copy of the original Explanation of Benefits (EOB) showing the denial
CLAIMS AND APPEALS PROCEDURES, continued
Mailing Address:
CDS Group Health
Attention: Appeals
P.O. Box 50190
Sparks, NV 89435-0190
Or Via Fax: (775) 352-7266
Determination: CDS Group Health will render a decision within sixty (60) days of receipt of the appeal and will
notify, in writing, of the findings. Washoe County Social Services Health Care Assistance Program has one (1) level
of Appeal.
HIPAA
The HIPAA Privacy Rule (Standards for Privacy of Individually Identifiable Health Information) (3) provides the first
national standards for protecting the privacy of health information. The Privacy Rule regulates how certain entities,
called covered entities, use and disclose certain individually identifiable health information, called protected health
information (PHI). PHI is individually identifiable health information that is transmitted or maintained in any form or
medium (e.g., electronic, paper, or oral), but excludes certain educational records and employment records
Protected Health Information
The Privacy Rule protects certain information that covered entities use and disclose. This information is called
protected health information (PHI), which is generally individually identifiable health information that is transmitted
by, or maintained in, electronic media or any other form or medium. This information must relate to 1) the past,
present, or future physical or mental health, or condition of an individual; 2) provision of health care to an individual;
or 3) payment for the provision of health care to an individual. If the information identifies or provides a reasonable
basis to believe it can be used to identify an individual, it is considered individually identifiable health information.
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Addendum A
PROVIDER LIST FOR WASHOE COUNTY SOCIAL SERVICES
HEALTH CARE ASSISTANCE PROGRAM
TAX ID # 88-0213754
Renown Regional Medical Center
850 Harvard Way N12
Reno NV 89502
TAX ID # 59-2852900 & 59-3493196
Lincare
PO Box 22950
Tucson AZ 85734
TAX ID # 45-4989022
Prime Health (aka: Saint Mary's Regional)
235 West 6th Street
Reno NV 89503-4548
TAX ID # 88-0200884
Washoe Sleep Disorder Center
75 Pringle Way Ste 701
Reno NV 89502-1472
TAX ID # 23-2537015
Northern Nevada Medical Center
2375 E Prater Way
Sparks NV 89434
TAX ID # 86-0898663
Preferred Home Care
PO Box 40700
Mesa AZ 85274-0700
TAX ID # 46-0517825
Renown South Meadows
10101 Double R Blvd
Reno NV 89521
TAX ID # 88-0213754
Renown Home Care
780 Kuenzli Ste 200
Reno NV 89502
TAX ID # 94-3325112
Accellence Home Medical
35 North Edison Way #37
Reno NV 89502
TAX ID # 45-4989022
Saint Mary’s Home Care Services
18653 Wedge Parkway
Reno NV 89511
TAX ID # 90-0197492
Better Breathing-Nevada, LLC
434 South Rock Blvd
Sparks NV 89431
TAX ID # 45-4717291
Ability Prosthetics & Orthotics
309 Kirman Ave Ste A
Reno NV 89502
TAX ID # 74-2152396
KCI USA Inc
PO Box 203084
Houston TX 77216-3084
TAX ID # 88-0175774
Remsa
450 Edison Way
Reno NV 89502
TAX ID # 88-0254192
Acadian Rehab Inc
175 South Park St
Reno NV 89502
TAX ID # 88-0113741
Reno Radiological Associates
PO Box 39000 Dept 34548
San Francisco CA 94139
TAX ID # 26-3558729
Davita (Sparks Dialysis, So Meadows Dialysis,
Reno Dialysis, Sierra Rose Dialysis)
PO Box 8500-8326
Philadelphia, PA 19178-8326
TAX ID # 88-0113741
Renown Vista
910 Vista Blvd
Sparks NV 89502
775-982-5585
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TAX ID # 26-1565558
Millenium Laboratories, Inc
16981 Via Tazon
San Diego, CA 92127
TAX ID # 65-0127483
DVA Laboratory Services
PO Box 281226
Atlanta, GA 30384-1226
TAX ID # 59-3205549
Total Renal Laboratories
Lock Box 100244
Atlanta, GA 30384-0244
TAX ID # 94-6004062-001
Incline Village Community Hospital
PO Box 60901
Truckee, CA 96160-9001
TAX ID # 86-0808230
Vista Care Hospice
a Gentiva Co.
PO Box 847949
Dallas, TX 75284
TAX ID # 95-2667855
Hanger Prosthetics & Orthotics
961 Matley Lane
Reno, NV 89502-2100
TAX ID #88-0291454
Continuum Rehab Agency
3700 Grant Drive
Reno, NV 89509
TAX ID # 88-0402361
Life Change Center
1755 Sullivan Lane
Sparks, NV 89431
13 of 13
Effective 9/1/13