National Provider Identifier (NPI)

Authorizations/Referrals

Billing and Payment

Materials

Miscellaneous Benefits

What is a referral?

An approval by the member's PCP (or the covering physician designated by the member's PCP), an OB/GYN that is a participating physician, or for mental health and alcohol and substance abuse care, our Behavioral Health Program, that is provided prior to the member's receipt of health care services from participating specialist physicians and other participating providers.

What services require a referral?

The following services require a referral for Personal Care Plan members (REFERRAL REQUIRED on the ID card): Medical and surgical specialty visits; podiatric services. chiropractic services; non-routine vision services.

What is pre-authorization or pre-authorized?

The authorization, based on medical necessity, is needed in advance of the member’s receipt of certain specified health services that are obtained from us, or in the case of mental health and alcohol and substance abuse services, from our Behavioral Health Program. Pre-authorization also includes the written authorization, from us, or in the case of mental health and alcohol and substance abuse services, from our Behavioral Health Program, needed in advance of the member’s receipt of Health Services from a non-participating provider. Physician & Provider Manual

What is pre-certification or pre-certified?

The registration and approval process, based on medical necessity, needed in advance of the member’s partial hospitalization or inpatient admission to a hospital, hospice, residential treatment facility, rehabilitation facility or skilled nursing facility (with the exception of emergency services) that is obtained from us, or in the case of mental health and alcohol and substance abuse services, from our Behavioral Health Program. Physician & Provider Manual

Can I file my claims electronically?

All members of the health care community - health care providers, patients and insurance carriers - realize numerous benefits with electronic claims filing. Not only is electronic data transmitted faster and more accurately, saving processing and response time, but per transaction costs are ultimately reduced. Click here to receive more information regarding Electronic Data Interchange (EDI).

What is the filing limit for in-plan claims?

The filing limit for in-plan claims is 180 days.

What do I need to do to change my payment and/or office address with ConnectiCare?

Payment and office addresses must be communicated to ConnectiCare in writing. Please submit a letter requesting the change on your new letterhead to ConnectiCare via fax or mail. Always include your tax ID number and ConnectiCare provider ID number.

How can I assure that my payment will go to the appropriate office?

Our general policy is to maintain one payment address for each provider. If a physician participates under multiple tax ID numbers, he or she should submit claims with the appropriate 6-digit provider ID number and 4-digit site number.

When can I request an adjustment to a claim?

An adjustment should be requested if all the data elements on the originally submitted claim are correct, but the claim has not been paid for all reimbursable services or has been denied inappropriately. For additional details, visit our Physician & Provider Manual online.

Under what circumstances do I need to resubmit a claim?

A claim should only be resubmitted if the claim data on the originally submitted claim was incorrect or missing information. For additional details, visit our Physician & Provider Manual online.

How do I request an appeal on a claim that was denied?

Requests for appeal may be made in writing to ConnectiCare. For additional details, visit our Physician & Provider Manual online.

When does ConnectiCare pay it's Providers?

See our check run calendar. Calendar is subject to change. Please allow 5-10 business days for mail time.

How can I get a Physician Manual?

Much of the Physician & Provider Manual exists on this website. To obtain a hard copy of the Manual, email our Provider Service Associates at ProviderQuestions@ConnectiCare.com.

How can I order additional forms, stickers, and/or labels?

You may request these provider supplies by visiting our Online Forms resource and choosing Reorder Form for providers. This form must be printed out, completed and mailed to ConnectiCare.

How is genetic testing and/or genetic counseling covered?

Genetic analysis and testing are excluded as follows:

• Genetic analysis of the products of conception;
• Genetic analysis of a stillbirth other than chromosome analysis;
• Deoxyribonucleic acid (DNA) banking;
• Paternity testing;
• Genetic testing for the following carrier status: carrier screening for breast cancer, ovarian cancer, colon cancer, Factor V (Leiden) deficiency, and cystic fibrosis; or
• Y-chromosome DNA assay for microdeletions.

What is the NPI?

The National Provider Identifier (NPI) is a unique 10 digit identification number assigned to health care providers for use in transmitting standard health care transactions electronically (e.g., electronic claims and eligibility verification) through the National Provider System (NPS).

This identifier, which fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), must be used by health plans and health care clearinghouses in HIPAA standard electronic transactions by May 23, 2007.

NPIs will replace other provider identifiers previously used by health care providers (and assigned by payers).

NPIs will not replace tax identification number (TINs) used for tax reporting on HIPAA electronic transactions.

How will ConnectiCare test NPI submissions with health care providers?

ConnectiCare will test NPI-related changes to HIPAA transactions with EDI vendors, clearinghouses, and direct submitters of these transactions. We will not test NPI submissions directly with health care providers. Providers should contact their clearinghouse or practice management system software vendor for more information and to ensure accurate submissions and reporting.

When will ConnectiCare begin accepting the NPI?

By May 23, 2007, ConnectiCare will be able to accept the NPI on all HIPAA standard electronic transactions.

We will notify providers when they can begin submitting the NPI on their claim transactions via a letter that will be included with the Explanation of Payment (EOP).

For electronic claim submissions, the provider's taxpayer identification number (TIN) will still be required to complete the transaction. The provider's adoption of an NPI will not change any reporting requirements for other data elements, such as TIN, billing name, or billing address.

When will ConnectiCare begin returning the NPI on the 835 ERA transaction?

By May 23, 2007, ConnectiCare will begin returning NPIs on the Electronic Remittance Advice transaction.

How and when should I report my NPI to ConnectiCare?

ConnectiCare is currently in the process of collecting provider NPIs. Please click on the following link to access the internet-based form that will allow you to submit your NPI to ConnectiCare.  http://www.connecticare.com/Provider/npicollection/

How should I include NPI in my electronic transactions with ConnectiCare?

Your EDI clearinghouse or practice management system software vendor can give you detailed information about how to submit the NPI in your HIPAA transactions.