• Do I need to obtain authorization from Health Plus for in-network referrals?
• If I am both a primary care physician (PCP) and a specialist, do I need to call Health Plus for an authorization?
• What should I do if a member presents a Health Plus ID card which has "Unassigned" for the PCP?
• Why don't new members show up on my roster?
• Is there a faster way for members to join Health Plus besides Maximus?
• How can I increase my member panel?
• If I want to add a lab to my practice, what is the procedure?
• How long does it take to become credentialed with Health Plus?
• Can I bill for emergency room or urgent care visits?
• What procedures can I perform in my office? Can I bill fee-for-service?
• If I am covering for a colleague and see one of his/her members, can I bill fee-for-service?
• If I bill only for fee-for-service care on a HCFA 1500, will I be paid the $1.50 for submitting the form?
• If a member is re-assigned to a different primary care physician (PCP) mid-month, which provider is entitled to the capitation, the new PCP or the previous one?
• Is vaccine administration considered part of the capitation payment?
• If I am eligible for an incentive payment, will it be included in my capitation check or sent separately?
• What is the timeframe for submitting claims?
• What is the advantage of submitting claims electronically?
• What is the turnaround time for payment of submitted claims?
• How do I appeal a denied claim?

Q: Do I need to obtain authorization from Health Plus for in-network referrals?
A:

Yes.  Effective March 1, 2005, Health Plus requires prior authorization for all MRIs and specialist visits. Prior authorization for specialist visits must be obtained by the member's primary care physician (PCP).  For MRIs, prior authorization can be obtained by any participating provider. 

The only specialty services that do not require prior authorization from Health Plus include: OB/GYN and family planning, HIV testing, dental care, optometry, audiology, initial mental health/substance abuse visit (one per year), and routine diagnostic services (i.e. chest X-ray, sonogram, basic labwork, etc.). 

PCPs can obtain authorization for specialist visits quickly and efficiently by using the INFO PLUS Online or Automated Telephone Service. For more information, please go to the Referral Info & Forms page under Providers and click on the document entitled  How to Refer a Member for Specialty Care.

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Q: If I am both a primary care physician (PCP) and a specialist, do I need to call Health Plus for an authorization?
A: You don't need to call Health Plus for consultations, but you do need to get an authorization from us if you're planning to do invasive procedures.

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Q: What should I do if a member presents a Health Plus ID card which has "Unassigned" for the PCP?
A:

The term "unassigned" means that the member has not yet selected a PCP.  If possible, the member should dial the Health Plus Member Services Department immediately at 1-800-300-8181 and notify the plan that he/she has selected you as their PCP. Members who do not select a PCP within 30 days of enrollment are assigned to a participating provider in their area by Health Plus.

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Q: Why don't new members show up on my roster?
A: Newly enrolled members have 30 days to select a PCP and may not appear on a PCP roster until the third month of enrollment. If the member selects you as their PCP you will receive a retroactive capitation payment.

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Q: Is there a faster way for members to join Health Plus besides Maximus?
A: Yes. Members can go directly to any Health Plus office and enroll in one of our three benefit programs: Child Health Plus, Family Health Plus, or Health Care Plus (Medicaid Managed Care).

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Q: How can I increase my member panel?
A: Speak to your Provider Relations Associate, who can provide ideas and suggestions and put you in touch with Health Plus staff who specialize in member enrollment.

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Q: If I want to add a lab to my practice, what is the procedure?
A: You will need to obtain a CLIA certificate and give your Provider Relations Associate a copy of it.  He or she will then make the necessary arrangements.

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Q: How long does it take to become credentialed with Health Plus?
A: The credentialing process usually takes 30-45 days once we receive a complete application with all supporting documentation.

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Q: Can I bill for emergency room or urgent care visits?
A: You can bill for emergency room visits. Urgent care visits are covered under your capitation unless the member receives care at a recognized Urgent Care Center. Only the Urgent Care Center can bill for these services.

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Q: What procedures can I perform in my office? Can I bill fee-for-service?
A:

Your Provider Relations Associate (PRA) will provide you with a list of procedures and services covered under capitation. If the services you wish to provide are not on the list, please speak to your PRA, who will advise you on authorization and billing.

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Q: If I am covering for a colleague and see one of his/her members, can I bill fee-for-service?
A: Yes, but only for services NOT covered under capitation. The office visit is included in the capitation payment.

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Q: If I bill only for fee-for-service care on a HCFA 1500, will I be paid the $1.50 for submitting the form?
A: No. The $1.50 is paid only for HCFA 1500 forms submitted for capitated services.

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Q: If a member is re-assigned to a different primary care physician (PCP) mid-month, which provider is entitled to the capitation, the new PCP or the previous one?
A: If the member sees his/her previous PCP within the month, then that doctor is eligible for the capitation payment. If not, then the payment goes to the new PCP.

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Q: Is vaccine administration considered part of the capitation payment?
A: No, vaccine administration should be billed fee-for-service. Check the Health Plus fee schedule for applicable rates.

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Q: If I am eligible for an incentive payment, will it be included in my capitation check or sent separately?
A: Incentive payments are sent separately once per quarter.

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Q: What is the timeframe for submitting claims?
A: In order to avoid denial for late billing, claims must be submitted within 120 days of the date of service.

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Q: What is the advantage of submitting claims electronically?
A: Electronic claims submission has many advantages-- elimination of paperwork and lost claims, greater security and confidentiality of your data, streamlined business transactions and reduced administrative costs.

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Q: What is the turnaround time for payment of submitted claims?
A: Clean claims (with all of the required information entered correctly) are paid 30-45 days after submission.  Please wait at least 30 days to check the status of a claim.

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Q: How do I appeal a denied claim?
A: Please do NOT resubmit the claim.  If you do, Health Plus will have to process it as a duplicate, resulting in a denial. Send us a letter explaining the decision(s) you are appealing along with a copy of the Remittance Advice (Explanation of Payment) and any supporting data.  Letters should be sent no later than sixty (60) days after receiving the denial decision to: Health Plus Claims Appeals Unit, 241 37th Street, Suite 412, Brooklyn, NY 11232.   

Letters of appeal for medical necessity denials should be sent within 60 days of the denial decision to: Health Plus, Health Services Department,  335 Adams Street, Suite 2600, Brooklyn, NY 11201 Attn: Medical Appeals Unit.

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