Contact Information

• Benefits
• Claim Status
• Determine member's primary care physician
• Member eligibility

• Basic provider network inquiries
• Benefit questions
• Claims questions or projects not answered through the Provider Access Line
• Claims statuses
• Explanation of Payment (EOP) questions including negative balance reasons and explanations
• Member eligibility

• Address changes
• Ancillary and hospital issues not related to claims
• Assist with any ongoing provider services issues
• Contract clarification or questions
• Explain new policies or procedures
• Fee schedule inquiries
• General training and large group presentations
• Orientations for new office staff, newly contracted physicians, ancillary and hospital staff
• Physician requests for discharge of members
• Discrepancies of participation status
• Provider set up issues
• Tax ID changes
• Visit physician offices to answer questions/concerns

• Admissions
• Diagnostic procedures
• Emergency/Urgent
• Out-of-plan providers
• Outpatient services
• Outpatient surgery
• Plan approval
• Reconsideration
• Referral
• Specialty services

Our program helps ensure members living with illness get medically necessary and appropriate health care by working together with the member, primary care physician and other health resources.

Case Management for Members

Health education and disease management programs:

• Asthma
• Cardiac
• Depression
• Diabetes
• Quit Tobacco
• Women and children's initiatives
• Immunizations
• Weight Management

Confidential and anonymous tool to help promote early detection and intervention.

View the Depression and Alcohol Screening Tool

Utilization Management criteria are available upon request.

Please note that the treating physician may contact the physician reviewer to discuss the denial decision and alternate care options upon notification of a denied service. Please call (877) 442-1181 and one of our Care Choices UM/UR nurses will be happy to coordinate the discussion.

Pharmacy issues that are clinical in nature.