TIMELINE FOR IMPLEMENTATION

Community Health Choices will be phased in across the state over the next three years using the five geographic health choices zones.

MCOs in each zone

  • Amerihealth Caritas
  • PA Health and Wellness
  • UPMC Community Health Choices

Managed Care Organization

What is MCO?

  • Managed Care Organization
  • A managed care organization (MCO) is a group of health industry companies and professionals that work together to provide health care at affordable rates and at the same time control the costs of providing these services.
  • Some of the goal of an MCO are to deliver high quality health care when it is medically necessary and to render the services by the most appropriate health care professional.
  • MCOs oversee how health care professionals are reimbursed for their services.

3 Major MCO’s in Pennsylvania

  • Amerihealth Caritas
  • PA Health and Wellness
  • UPMC Community Health Choice

PA Health and Wellness

  • Is also an MCO and subsidiary of Centene Corporation
  • Is existing to improve the health of its beneficiaries through focused, compassionate and coordinated care.
  • Will serve participants in the CHC program.
  • CHC provider should verify participants eligibility before every service rendered.

Recipients

  • CHC participants who nare eligible and 21 yrs and older
  • Who are dual eligible for Medicaid and Medicare
  • Who are qualified for LTSS

Steps of Verifying Eligibility

  1. Log on to provider portal at PAHealth and Wellness.com search by DOS, Patient Name, and DOB or MA ID.
  2. Call automated participants eligibilty IVR system. Call 1-844-626-6813 and give the patient MA ID and month of service.
  3. Call PA Health and Wellness Provider Services at toll free number 1-844-626-6813. Give the ff. information of patient MA ID, DOB, Name of patient.

Prior Authorization

  • Prior Authorization is not required for DME Supplies.

Fee Schedule

  • 100% of PA Medicaid

Clearing Houses

  • APEX
  • AVAILITY
  • ClaimMD
  • ClaimRemedi
  • Claim Source
  • EDI 360
  • ELIGIBLEAPI
  • ChangeHealthcare
  • ENCODA
  • Experian
  • First Healthcare
  • Mckesson
  • MD Online

Filing Method

Electronic Claim

  • Thru Provider Portal

Paper Claim

Use CMS-1500 form and sent to
P.O Box 5070
Farmington, MO 63640

Deadline of Claim Filing

  • Original Claim is 180 days from Date of Service
  • Claim Resubmissions
    • Contracted and Non – contracted providers: For claims resubmissions, including a response to an invalid or incomplete claim submission and or a claim re-submission with previously missing claim information, submitters have 365 days from the date of service to file a timely re-submission request via EDI or to the following address:

Medicaid Claims Reconsideration Department
Pennsylvania Health and Wellness
P.O Box 5040
Farmington, MO 6340

  • Claim Adjustments – For Claim Adjustments that include a correction to a billing error in the initial claim submission or to request claim reprocessing due to a previously partially paid claim.
  • Contracted Providers: Submitters have 90 calendar days from the last timely processed of claim (as confirmed by the EOP) to request processing of a claim adjustment via EDI or to the address below.
  • Non-Contracted Providers: Submitters have 365 calendar days from the date of service to request processing of a claim adjustment via EDI or to the address below:

Medicaid Claims Reconsideration
Pennsylvania Health and Wellness
P.O Box 5040
Farmingtong, MO 6340

Appeal Rights

  • Providers and vendors contracted with Pennsylvania Health and Wellness (PHW) have the right to file an appeal on their own behalf. The appeal request must be submitted to PHW within 180 calendar days from the date of PHW’s denial decision. PHW’s staff is available to guide providers and vendors through the process and to work with the provider or vendor to structure a formal letter of appeal.
  • The appeal must be submitted in writing to Pennsylania Health & Wellness at:

Medicaid Claims Reconsideration
Pennsylvania Health and Wellness
P.O Box 5040
Farmington, MO 6340

The appeal request must include the following:

  1. Participant name and identification number
  2. Claim number or authorization number
  3. Provider name
  4. Service denied
  5. Issue or reason for the appeal
  6. A copy of the original billing document (CMS1500-UB, etc) and remittance advice, which clearly identifies each line to be appealed, and includes a narrative explanation of why Provider or Vendor does not agree with the payment decision.

A decision will be made and appropriate notification of the decision must be received by the provider within 45 days of Health and Wellness’ receipt of appeal.

EMILY GODFREY
PHONE: 717-551-8046(8097046)
EMAIL: Emily.R.Godfrey@pahealthwellness.com
PROVIDER: 844-626-6813
EMAIL: information@pahealthwellness.com
FAX: 844-706-7719

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