Liability for Cost Sharing for Recipients Enrolled in Medical Assistance
Medical Assistance Bulletin regarding liability for cost sharing for recipients enrolled in Medical Assistance through Fee for Service or Managed Care and a private third party insurer.
Third Party Medical Resources (TPR) - Excerpt from Act 62 regarding third party medical resources:
§ 1101.64. Third-party medical resources (TPR)
(a) General. Other private or governmental health insurance benefits shall be utilized before billing the MA Program. Providers shall make reasonable efforts to secure from the recipient sufficient information regarding the primary coverages necessary to bill the insurers or programs. The medical resources which are primary third parties to MA include Medicare; CHAMPUS (Civilian Health and Medical Programs of the Uniformed Services); Blue Cross, Blue Shield or other commercial insurance; VA benefits; Workman’s Compensation; and the like. The information needed to bill third parties includes the insurer’s name and address, policy or group I.D. number, and the patient’s or the patient’s employer’s address. When the total amount of payment by the third-party resource is less than the Department’s fee or rate for the same service, the provider may bill the Department for the difference by submitting an invoice with a copy of the third party’s statement of payments attached. If a third-party resource refuses payment to the provider based on coverage exclusions or other reasons, the provider may bill the Department by submitting an invoice with a copy of the third party’s refusal advisory attached.
What Providers Should be Doing Now
Instructions for providers to follow with regards to changes in autism services and billing under Act 62.
Insurance Related Information
Autism Insurance Coverage Form
Providers can use this form to determine if the child's insurance is subject to Act 62.
Information from private health insurers for autism service providers on Act 62.
Significa Insurance Group, Inc.
Kris Danz, Credentialing Manager, (717) 735-7760, ext. 141.
Coventry Health and Life Insurance Company
HealthAmerica Pennsylvania, Inc.
HealthAssurance Pennsylvania, Inc.
Rafael Pinero, Provider Relations Dept., 866-369-8362
United Healthcare Insurance Company
National Credentialing Center Phone: 1-877-842-3210
Behavioral Health Providers
Physical Therapists, Occupational Therapists and Speech Therapists Phone: (800) 873-4575.
The UBH Network Manager for Western and Southeastern PA (Erie are and south, Philadelphia are) is Ken Ridge, 215-231-3110 or 877-474-2685.
UniCare Life and Health Insurance Company
Ms. Alisha Davis
Manager, Provider Relations-InterGroup
P: 800-537-9389 ext.137
Pan-American Life Insurance Company
Inter-County Health Plan, Inc. Inter-County Hospitalization Plan, Inc.
Cigna Healthcare of PA, Inc. Connecticut General Life Insurance Company
Provider Advocate Department at 800-274-7603
For particular circumstances or questions: Susan Knutson
CIGNA Behavioral Health Provider Contracting
Phone: (952) 996-2548
Geisinger Health Plan, Inc.
Geisinger Quality Options, Inc
Phone: (570) 214-9749
Teachers Protective Mutual Life Insurance Company
Quest Behavioral Health
Brian Beyer, Director of Operations
Phone: (717) 851-1464
Highmark, Inc. Keystone Health Plan West, Inc.
Providers who wish to participate in a Highmark network may contact Highmark in a variety of ways as described below:
Aetna Health Inc.
Aetna Health Insurance Company
Aetna Life Insurance Company
Providers interested in becoming part of Aetna's network can go to Aetna.com, then click on "Healthcare Professionals" and then "Join Aetna's Network".
The phone # for Credentialing Customer Service is 800-353-1232.
Please see additional information from Aetna.com
Contact Numbers for Providers:
American Heritage Life Insurance Company
The company uses the PHCS Network through MultiPlan, Inc. Providers wishing to participate with MultiPlan (MPI) may contact MPI’s Service Operations department and request an application for participation. Providers may also go to www.multiplan.com and complete the online request for participation.
MMA Insurance Company
Phone:(574) 533-9511 or (800) 348-7468 ext. 427.
First Priority Life Insurance Company
HMO of Northeastern Pennsylvania, Inc.
Jeanine Rivera, Provider Relations Consultant
Phone: (570) 200-4669.
Secondary Contact: Jeanne Wisnewski, Director Provider Relations
Phone: (570) 200-4679.
Trustmark Life Insurance Company
Phone: 330-729-6517, X26517
HM Life Insurance Company
Independence Blue Cross
Keystone Health Plan East
QCC Insurance Company
Amerihealth HMO, Inc.
In June 2009, the Companies will post a news alert on their provider Web site.
Psychiatric, psychological or rehabilitative services providers can contact Magellan's interested provider line at 800-866-4108 option #I and identify themselves as a provider interested in treating individuals with autism spectrum disorders. An appropriate Magellan staff person will follow up with the interested provider.
Capital Advantage Insurance Company
Capital Blue Cross
Keystone Health Plan Central Inc.
UPMC Health Benefits, Inc.
UPMC Health Network, Inc.
UPMC Health Plan, Inc.
To join the network, go to www.upmchealthplan.com, select "For Providers" and click on "Network Participation Request."
For other concerns, please call 412-454-5264.
BCS Insurance Company
Planned Administrators, Inc.
8906 Two Notch Road, Ste 200
Columbia SC 29223
Phone: (803) 462-3139
Principal Life Insurance Company
Principal Life Insurance Company uses the PHCS Network through MultiPlan, Inc. Providers wishing to participate with MultiPlan (MPI) may contact MPI’s Service Operations department at 800-422-0294 and request an application for participation.
Providers may also go to www.multiplan.com and complete the online request for participation.
Principal Life Insurance Company also uses Devon Health Services.
Providers wishing to participating in Devon may contact Devon at 800-431-2273.
Providers wishing to participate in PPHN may contact:
Phone: 717-560-9290 Ext. 135
Guardian Life Insurance Company of America
Ms. Lori Gordon
Mr. Ken Ridge
Phone: 877-474-2685 or 215-231-3110
Or Log online www.ubhonline.com "quick links"
Providers may also contact Mark Kowaleski at 212-598-8775, and he will connect them with the appropriate network contact.
Community Care Behavioral Health
Behavioral Health Providers
Contact UPMC Health Plan
Or phone Network Management at 412-454-5264