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  Managed HealthCare Northwest, Inc. 
      A Company of Legacy Health System and Adventist Medical Center

 

 

 

 

 

 

 

 

 

 

 

 

 

 





      
   


CareMark / MHN PPO

   
   

Contract Analysis Available Free From MHN
We can help you look before you leap.
It is hard to differentiate the ultimate financial result for you of the various managed care plans in which you participate.  It is not enough to compare fee schedules only on the conversion factor, since the fees are also greatly affected by which RVU’s the conversion factor is applied to, as well as other payment practices of each payor.  If the managed care contract puts you at financial risk for losses in a plan, if low fees are further reduced by risk withholding, and if you don’t get your risk withhold back, what had looked like a good deal may turn out to be very bad business for you.

A couple of payors that have worked with MHN PPO, developed their own managed care networks in the last few years.  They imposed lower fees on you, and put you at financial risk.  Because these plans pay providers less than you would be paid under MHN PPO, some employers chose to move their group plan from a plan using MHN PPO to the same payor’s proprietary network.  It was easy for them to make that decision, because many of you participate in both the MHN PPO network as well as the payor’s own new network. This undermines MHN’s efforts to obtain fair and reasonable reimbursement for you.

MHN staff is happy to review any managed care contracts presented to you by any other company and provide you with an objective comparison of reimbursement and other contract terms to help you make an informed decision about which networks you wish to participate in.  We will provide you with a thorough explanation of the differences in the fee schedule between contracts and cite specific contract provisions to allow you to validate for yourself the accuracy of MHN’s conclusions about differences between contracts.  There is no cost to you for this service.  Please call (503) 413-5800 if you wish to take advantage of this service.

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Referrals
Most CareMark/MHN PPO members do not require referrals from the primary care physician.  A few of the Payors using the CareMark/MHN PPO have plans which include a gatekeeper component and may require referrals to specialists in order for the service to be covered or for the member to obtain a better benefit rate.  If the name of a primary care physician is printed on the member ID Card, it is likely that the plan may require a referral.  If you are ever unsure about referrals, contact the Payor for eligibility and benefit information. 

Providers must refer CareMark/MHN PPO enrolled members to Participating Physicians, Providers and Facilities.

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Precertification

CareMark PPO
Precertification by MHN is Required

  • Inpatient Hospital Stays

  • Most Outpatient Hospital Procedures

  • Angiogram

  • Arteriogram

  • Cystectomy

  • Cystourethroscopy

  • Discogram

  • Epidural Steroid Injection

  • Inpatient Chemotherapy

  • Laproscopic Cholecystectomy

  • Myelogram

  • Sleep Studies

Please click below for the precertification form:
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CareMark PPO Precertification Form

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MHN PPO
 
MHN does not carry out precertification.  Precertification may be carried out by the Health Plan, by a Medical Review Company, or none may be required. Please refer to the Member ID Card for precertification requirements.


Claims Processing Tips
Physician Extenders

Not all Payors using Managed Care Organizations (MCOs) are based in Oregon.  Therefore, they may not recognize nurse practitioners and physician assistants as eligible providers.  We advise you to use the name of the participating contracted physician as well as the name of the nurse practitioner or physician assistant on these claims for CareMark PPO and MHN PPO members.

Group Name/Group Numbers
MHN works with almost eighty different payors, including insurance companies, third-party administrators, and self-insured groups.  In order to allow MHN to process your claims in a timely manner, please make sure that each form includes completed information on group name, and group number and employer.   At minimum, MHN needs to have payor name, group name or group number in order to process.  Claim forms without this minimum information will be returned to your office to complete and resubmit. 

Call-Share for Non-Participating Physicians & Providers  
Non-participating providers may share call and receive payment at the participating rate when covering for participating CareMark PPO and MHN PPO providers.  In order to ensure the claim is processed at the participating rate, both the non-participating provider and participating provider’s names must appear on the bill.  Box 31 or 33 of the HCFA 1500 form should indicate:

   
1. Name of non-participating provider rendering services
    2. “Covering for Dr. (participating provider name)” or 
        “On-Call for Dr. (participating provider name)”

You can increase patient satisfaction and reduce the incidence of re-billing by following this simple procedure.  On-call providers are obligated to the same billing and compensation conditions as participating providers (accepting allowed rate as payment in full, billing claims for members, etc.).  If you need further information, please refer to your CareMark PPO and MHN PPO Administrative Manual, Page 3, Section 1.04 “On-Call Coverage” or call MHN Provider Relations Department at (503) 413-5800.   

Please note:  This policy only applies to the CareMark PPO and MHN PPO Plans and does not apply to other lines of business offered by MHN.

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Chart Notes
There is no charge to MHN or the Payor for obtaining a patient’s medical record data to complete the Utilization Management or Quality Management review process or to pay claims. If your office bills for chart notes or uses a copy service that bills for these records, please ask them to note that MHN and our payors are not to be charged.

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Fee Schedule
Did you know that you can request fee schedules for up to 20 CPT Codes at a time?  Please send a list of those codes on your letterhead to Managed Healthcare Northwest or FAX Attn: Provider Relations at (503) 413-5801 or email MHN Provider Updates.

Limit of 20 CPT Codes per each request. No HCPC codes or obsolete codes, please. If requesting DXL Codes Diagnostics, X-ray, Laboratory) please specify global or professional fees (modifier 26). 

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Beech Street Payors On-Line
MHN has a reciprocity agreement with Beech Street, a national PPO network, to provide our PPO panel for their members living in Oregon and Southwest Washington.  Like MHN, Beech Street works with numerous Payors around the country.  Now a list of these Payors and their benefits and eligibility phone numbers are available on the Internet at:

https://www.beechstreetas400.com/nationalpayerlist/paya.html

For Beech Street's provider search please click on the following link:

http://beechplus.beechstreet.com/IPLU/

Note - MHN does not have contracts through Beech Street for Auto or Workers' Compensation Coverage.

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Newsletters for CareMark and MHN PPO
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CareMark and MHN PPO
Newsletters

   
   
   

 

 

 

 

 

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