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Compliance Fraud, Waste and Abuse (FWA)
Important Medicare Compliance Requirement – Train Every Employee!
Advance Directive Information
In 1991, the federal government passed the Patient Self-Determination Act (PSDA), guaranteeing individuals the right to make health care decisions and indicate preferences regar
All pharmacy submissions can be made electronically through our pharmacy benefit manager (PBM), Express Scripts.
The Health Plan provides the ability for a practitioner/facility to submit a file for eligibility information and benefits for our members through their designated clearinghouse or directly to their office as instructed. You can also access our billing and EDO authorization form.
The Health Plan has a certified staff of professionals who continuously monitor trends and industry standards. Our staff includes registered nurses (RN) and certified coders. We over percent of our claims reviewed manually and an auto-adjudication rate of only nine percent.
The Health Plan utilizes established guidelines provided by governing bodies of the federal and state levels of government to process medical claims.
The Health Plan provides the HIPAA 835 transaction set for electronic vouchers.
Physician Case Management Referral
The Health Plan has registered nurses that are certified case managers to coordinate health care services for members with catastrophic illnesses, injuries, or behavioral health problems.