Download CONTRACT SUMMARY for HUMANA I. PLAN INFORMATION II

CONTRACT SUMMARY
for
HUMANA
I. PLAN INFORMATION
Name:
Humana d.b.a. ChoiceCare Network
Plan Type:
PPO
Effective Date:
Entities included in Contract:
July 1, 2000 for ChoiceHealth Affiliated Specialists. All other entities April 19,
2000.
One (1) year contract with automatic annual renewal. Termination without
cause by either party with 90 days prior written notice.
ChoiceHealth
Credentialing
Non-Delegated, ChoiceCare’s responsibility
Contract Terms:
II. FINANCIAL INFORMATION
Reimbursement:
See Unblinded Fee Schedule
Co-Pay:
Refer to ID Card
Deductible:
Refer to ID Card
Coverage for Physician
Assistants & Nurse
Practitioners:
Benefit Summary:
Services are covered when billed under the supervising physician.
Varies by benefit plan.
III. VISIT GUIDELINES
Annual Exams/Preventive
Care Visit:
Obstetrical Guideline:
CPT coding guidelines
Laboratory:
Lab may be billed by either participating physician’s office or in-network lab.
Radiology:
May be performed and billed through the participating physician’s office. For
services not available in the office, must refer the patient to a in-network
imaging facility and/or ChoiceCare network participating facility.
ChoiceHealth
Refer to the 1-(800) on back of card.
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Humana
CONTRACT SUMMARY
for
HUMANA
Formulary:
The following drugs require prior-authorization:
Accutane (isotretinoin) Lamisil (terbinafine) Actos (pioglitazone) Miacalcin
(calcitonin) Arava (leflunomide) Mobic (meloxicam) Avandia (rosiglitazone)
Penlac (ciclopirox) Celebrex (celecoxib) Proscar (finasteride) Fosamax
(alendronate sodium) Sporanox (itraconazole) Injectable medications **
Vioxx (rofecoxib)
**See plan exclusions for status of injectable coverage.
For medications requiring prior authorization, additional information may be
required for approval. Prior authorization requests can only be made by your
physician in order to be considered. Please have your physician contact the
Humana Clinical Hotline at the numbers below.
Humana Clinical Hotline
Phone: 800-555-CLIN (2546)
Fax: 888-480-5056
IV. REFERRAL, PRE-CERTIFICATION AND AUTHORIZATION INFORMATION
Referral Network:
Pre-Certification(Referral):
ChoiceCare Network participating physician. ChoiceHealth
preferred.
Visits to providers outside of the ChoiceCare network will result in reduced
benefit level penalties incurred by the patient.
N/A
Pre-Authorizations:
Required for inpatient admissions and outpatient surgical procedures.
Claims Submission &
Payment Guidelines:
Clean claims will be paid within thirty (30) days of receipt. If claim is not
paid within 30 days, provider will be reimbursed 100% of billed
charges.
Physician offices have 120 days from date of service to file claims.
Facilities have 180 days from discharge to file claims.
Referral Process:
Claims to be submitted on HCFA-1500(professional) or UB92(facility) forms
to:
See Back of ID Card
Electronic claim submission is available.
V. QUALITY ASSURANCE/UTILIZATION MANAGEMENT
Refer to back of ID card.
Policy:
Resolution:
Refer to back of ID card.
Reconsideration & Appeals
Procedures:
Medical Records:
Contact Plan.
Provide upon written request.
VI. Key Contacts
ChoiceHealth
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Humana
CONTRACT SUMMARY
for
HUMANA
Medical Director:
Mayo Gibson, MD
Plan Website:
www.humana.com
Plan Address:
Provider Representative:
Talatha Vaughters, Large Practice and Ancillary Contracting Executive
6100 Fairview Road, Suite 750, Charlotte, NC 28210
Phone: (704) 643-0400 ext. 1030354
Email: [email protected]
ChoiceHealth Contacts:
For day to day business and medical issues, contact:
Charlotte Area:
LaTonya Dalton (p) 704-384-7296 or [email protected]
Lisa Stratton (p) 704-384-7261 or [email protected]
Andrea Philbeck (p) 704-384-4975 or [email protected]
Winston-Salem Area:
Suzanne Jones (p) 336-277-1144 or [email protected]
Susan Hobbs (p) 336-277-1461 or [email protected]
Novant Health Contact:
ChoiceHealth
Carol Barron, Account Executive
Business Development & Sales
Phone: (336) 277-1133
Email: [email protected]
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Humana