FAQ's

• 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?
• Is it faster to submit claims electronically?
• What is the turnaround time for payment of submitted paper claims?
• How do I appeal a denied claim?

Q: Do I need to obtain authorization from Health Plus for in-network referrals?
A: No.  Health Plus no longer requires prior authorization for referrals to our participating specialists. You only need authorization if you are referring a patient to an out-of-network specialist.

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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: If the member has not yet called Health Plus to select a PCP, have the member call Health Plus Member Services right away at 1-800-300-8181.

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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: Speak with your Provider Relations Associate for a copy of procedures that are not covered under capitation and can thus be billed fee-for-service.

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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: This varies by contract. Generally, Health Plus requests that claims be submitted within 120 days of the date of service.

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Q: Is it faster to submit claims electronically?
A: You bet! Electronic claims submitted with all of the required information are processed within 2 days.

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Q: What is the turnaround time for payment of submitted paper claims?
A: Claims that are complete and require no further Health Plus inquiry are processed within 21 days.

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Q: How do I appeal a denied claim?
A: Send us a letter of appeal with a copy of the Remittance Advice and any supporting data.  Letters should be sent to: Health Plus Claims Appeals, 241 37th Street, Brooklyn, NY 11232.

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