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1199SEIU Benefit and Pension Funds 330 West 42nd Street New york, NY 10036-6977
Non-Profit U.S. Postage PAID New York, NY Permit No. 3700
1199SEIU PROVIDER
Connections
Your Key to the 1199SEIU Benefit Funds
Fall 2010
ADDRESS SERVICE REQUESTED
Reminder: Message from the
Executive Director
COMING SOON: Personalized Patient, Coverage and Claims Information at the Click of a Button In just a few months, 1199SEIU providers will have access to a new, online system that will provide the detailed, personalized information you need from the Funds.You will be able to check your 1199SEIU patients’ eligibility and benefit coverage, as well as claims status, remittance statements and Explanations of Payment with the click of a button. This service will be provided through Navinet, a system that many of our 1199SEIU Benefit Funds’ providers already use for other payers. If you already have a Navinet account, you won’t need to make any changes at all. A single log-in will allow you to access information from all your contracted payers, including the Funds.
Utilization Review for Radiology Services The Benefit Funds have contracted with a new vendor, Care to Care, to provide utilization review for our members’ non-emergent, outpatient MRA, MRI, PET and CAT scans beginning January 1, 2011. Care to Care will add an extra level of review to ensure that our members receive the highest quality and most appropriate radiology services. If your 1199SEIU patients need any of these services, please continue to call (888) 910-1199 to request prior authorization. MedFocus remains our preferred radiology provider network, so you can still refer our members to the same imaging sites and providers.
We know that in order for you to continue providing highquality care to our members, you need accurate, up-to-date information on our 1199SEIU Benefit Funds’ coverage and policies. In this issue of Provider Connections, we let you know about several important changes. First, under the new healthcare reform law, we will extend coverage of dependents to age 26 and eliminate lifetime and newborn benefit maximums beginning January 1, 2011.We have also made several updates to our prescription benefit program that may require some changes in the way your 1199SEIU patients access certain medications. And we have included information about an exciting new service that we will soon be providing to you – an online provider portal that will give you electronic access to detailed eligibility and claims information whenever you need it. As always, we value our ongoing relationship with you and hope you find the information in this newsletter helpful. If you have any questions or concerns, we encourage you to speak to your Provider Representative, or contact our Provider Relations Department at (646) 473-7160.
Keep an eye out for more details! Mitra Behroozi
No Separate Facility Charge for Office-Based Surgeries If your 1199SEIU patient undergoes a surgical procedure at an office-based surgery center, the Benefit Funds will reimburse the practitioner at the full office-based rate but will not pay a separate facility charge. Any facility charges billed on a CMS 15 or UB04 form will be denied. If you have any questions about our reimbursement policies, please contact our Provider Representatives at (646) 473-7160.
Remember: LabCorp and Quest Are the Funds’ Preferred Labs When you need to refer your 1199SEIU patients for any lab services, we want to remind you to be sure to use only our preferred labs – LabCorp and Quest Diagnostics. Referring our members to the Funds’ preferred labs helps them get the quality care they’ve earned with no unnecessary out-of-pocket costs. Of course, for specialized lab tests, be sure to first contact the Funds at (646) 473-7160 to determine if prior authorization is required.
Pre-Authorization Now Required for Certain Oral and Spinal Surgeries Beginning in 2011, our list of ambulatory surgical procedures that require pre-certification will be expanded to include certain oral surgeries and certain spinal surgeries. If your 1199SEIU patient requires such a procedure, you or the member must call CareAllies at (800) 227-9360 to receive pre-authorization. Please watch for further announcements.