| Provider support and information | ||
|---|---|---|
Department/Vendor |
Services |
Telephone |
Behavioral health program |
Coordinates and manages behavioral health and substance abuse services for members of most plans. |
|
Coordination of benefits |
Determines order of payment responsibility when a member is covered by more than one health plan or insurer. |
|
Credentialing |
Reviews and assesses the qualifications of practitioners/providers applying for participation in our network, and periodically thereafter. Certain changes in a practitioner’s status may require review by the Credentialing Department, for example, completely moving into a new service area or a specialty change. Inquiries about the status of an application should be directed to this unit. |
Credentialing: Recredentialing: |
Electronic online office support |
Provides a standardized approach to receive member eligibility verification, claim submission, claim status, and referrals using Internet technology via the PNT Data. |
PNT Data |
Eligibility line |
Provides touch-tone phone access to verify member benefits and eligibility. |
|
Total Population Health |
Offers innovative programs to support members with specific conditions, including members with asthma, chronic obstructive pulmonary disease, diabetes, heart failure, coronary artery disease and other complex conditions. |
|
IPA/PHO |
The medical directors of participating IPAs and PHOs may consult with practitioners for the first line of appeal for any clinical decisions. Please consult your IPA or PHO. |
|
Member and Provider Services |
Responds to your telephone, mail, or facsimile inquiries regarding claim submissions, status of checks, benefits, eligibility and policies. When you are not certain where to direct your call, start here. Also responds to inquiries from members who require more information. |
Providers: CT & MA Members: |
Notification Line |
Provides a voice message system for physicians and other providers who need to notify us of a hospital admission, skilled nursing facility admission, or that occurred on a weekend or holiday. SNF admissions on weekends or holidays will be automatically approved through the next business day following the admission. However, admission to a SNF for rehabilitation, in the absence of a hospitalization or acute episode of illness, requires pre-authorization and is subject to medical necessity review. |
|
Pharmacy Services |
Manages ConnectiCare’s pharmacy benefit, prior authorization program, and drug list. Available 8:30 a.m. to 5 p.m., Monday – Thursday, 9 a.m. to 5 p.m. on Friday. |
Fax: 1-860-674-2851 E-mail: pharmacy@connecticare.com |
Pre-authorization Program |
Coordinates pre-authorization of those services and procedures that require prior review by ConnectiCare. Use to initiate an authorization or pre-certification for a member. |
|
Provider File |
Maintains provider records in ConnectiCare’s automated claims payment system and makes necessary changes to provider information, such as address, Tax ID Number, etc. We require that you submit your changes in writing to attention Network Operations, 175 Scott Swamp Road, Farmington, CT 06032-3124. Please include the effective date of the change. Please contact provider services. |
|
Radiology Preauthorization Program |
Administers pre-authorization of imaging services and radiation oncology services, as appropriate, for all for all product lines. Go online to view clinical guidelines, begin the authorization process, track pended pre-authorization requests, or verify authorizations at http://www.radmd.com/. |
|
Manage Spine Surgery and Interventional Pain Management Program |
Administers authorization of the following medical and surgical services for our members so they receive clinically appropriate care:
|
|
Special Investigative Unit |
A confidential and anonymous hotline for reporting suspected fraudulent or abusive billing activities. The line is available 24 hours a day to members, providers, employees, and government officials. |
1-888-4KO-FRAUD |
Switchboard |
Assists you in reaching a department or specific employee within ConnectiCare. |
|
Utilization management |
Nurse case managers, in consultation with medical directors, work with physicians and members to obtain information necessary to help make benefit determinations about the appropriateness and medical necessity of certain health care procedures and services. Case managers are available for other management questions, 8 a.m. – 5 p.m., Monday – Friday (after hours, please leave a voicemail message). |
Fax: |
Website |
Provides useful information on such topics as community wellness programs, products, health management programs and more. |
Fax: |
PPM/10.16
