MHN PPO

MHN PPO

Referrals
Most MHN PPO members do not require referrals from the primary care physician. A few of the Payors using the 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.
Precertification
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 MHN PPO members.

Group Name/Group Numbers

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 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 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 MHN PPO Plan and does not apply to other lines of business offered by MHN.
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.
Newsletters for CareMark MHN and MHN PPO