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New York Network Management, LLC
Billing Guide


www.nynmonline.com (888) 511-5208
NYNM Providers have access to the new Claims Channel 360 portal for free. If you have not signed up yet and you are a NYNM provider, please sign up today by visiting www.claimschannel360.com today.
Please be aware that as of May 1st, 2012, Health Plus was aquired by Amerigroup; NYNM providers will need to bill NYNM for Health Plus members. Please call urgently to confirm if you are to send claims to NYNM or not.
To avoid denials, always use your
dedicated nynm provider id number
call nynm to obtain



Payor Plan Info Eligibility
and
Referral Process
Authorization,

Use only NYNM Provider ID No.

Radiology Behavioral Health
and
Substance Abuse
Billing Process
Amerigroup Community (Formerly carePlus) (800) 454-3730 www.amerigroupcorp.com Medicaid (including FHP & CHP) and medicare managed care Organization (MCO)/Health Plan Call 1-800-454-3730 for Referral and Eligibility Request. All specialist visits including lab and radiology services require an authorized referral from the patient's PCP. Except for free access services such as family planning, vision care, HIV counseling and testing as part of the visit, Parental care, OB/GYN visits 2x a year for routine care. Referral and authorization forms are available by visiting: www.amerigroupcorp.com Call (800) 454-3730 for preauthorization's. Fax request to 1-800-964-3627. Fax request for Maternity Deliveries only to 1-800-964-3627. Also refer to the Amerigroup Quick refernece card available at: www.amerigroupcorp.com for pre-certification and notification guidelines for specific service. DME, PT, OT, OBS, etc. require pre-certification. Precertification is required for coverage of Psychological Testing.
Referral/Authorization forms are available via the website.

*Important* Must use your PIN - "Provider ID number" assigned by AGP/NYNM
No preauthorization is required for coverage of routine X rays, EKGs and ultrasounds performed in a network physician's office or a network facility or tests performed in conjunction with an inpatient stay.
No preauthorization is required by the ordering physician for coverage of OB diagnostic testing for ultrasounds, Biophysical Profile (BPP) and Non-Stress Tests (NST).
Preauthorization is required for coverage of MRA, MRI, CAT scans, nuclear cardiac, PET scans and sleep studies.
Preauthorization is required for coverage of amniocentesis based on high-risk OB diagnosis.
Primary mental healthcare may be furnished by the member’s PCP. Preauthorization is required for coverage of inpatient admission, partial hospitalization and residential treatment. Coverage of initial outpatienttreatment requires notification for initial 10 therapy sessions and medication management. Treatment plan completion is required for ongoing therapy sessions. Coordination of physical and behavioral healthcare is essential.

Electronic Claims

Claims Submissions on or after December 5, 2011 should be directed to CCN through direct electronic submission via www.nynmonline.com billing tab or directly at www.claimschannel360.com

Clearing House and Paper Claims:

CareCore National will initially also accept electronic claims from Emdeon clearing house with the existing NYNM Payor ID 11334 and paper claims from a dedicated new PO Box address. Send Paper Claims to:

NYNM IPA - Paper Claims
PO BOX 620 Lake Katrine, NY 12449

All Appeals and supporting documents:
CareCore National will accept appeals and supporting documents for these 3 payors and should also be sent to a new dedicated PO Box:

NYNM - Appeals and COB
PO Box 640 Lake Katrine, NY 12449

Beech Street - A Viant Network
www.beechstreet.com
PPO (Preferred Provider Organization) Benefits designs, eligibility payor information vary by plan and must be verified with the appropriate party as identified on the patient identification card/insurance materials. you may also go online at www.beechstreet.com to obtain benefits office information. For referrals Participating Providers facilities, call 1-800-877-1444 for a list of participating providers. Precertification requirements are different for most benefits plans and can be obtained by contacting the pair directly. Precertification is NOT required for ER visits or Physician office visits. All other Healthcare services are subject to Precertification requirements. Refer to Patient’s insurance card for telephone number to obtain Precertification or go online at www.beechstreet.com to submit a request. Participating providers must refer patients to Participating laboratory providers for non-office based services. A list of participating laboratory providers can be found in the online provider directory at www.beechstreet.com This is covered benefit. Call the telephone number on the back of the patient’s insurance card to ascertain the extent of benefits and to obtain a list of participating providers.

Claims for services must be submitted along with a copy of the patient’s insurance id card within 30 days to NEW YORK NETWORK MANAGEMENT(NYNM).Hamilton Financial Center, 9201 4th Avenue, 4th Floor, Brooklyn, NY 11209 718-748-7316. Refer to attached sample Beechstreet completed 1500 form to ensure proper claims submission and timely payments. Shaded areas must be accurately and completely filled in.


*Important*
NYNM requires a copy of front and back of insurance card.

 

Consumer Health Network (CHN)
(800) 225-4246
www.chn.com
PPO (Preferred Provider Organization) Eligibility must be verified with group or health plan identified on patient’s insurance card. For specialist visits , eligible person should be referred to another participating CHN provider listed on the CHN website.Referral forms are not required. If a network provider is not available contact CHN’s Customer service dept at 800-225-4CHN Prior to the referral, for assistance. For Precertification Please call the phone no. on the patient’s id card for the requirements necessary to obtain precertification. Call (800) 225-4246 for participating radiology groups contracted with CHN. Call the telephone number on the back of the patient group insurance card to ascertain the extent of covered benefits, eligibiligy and participating Providers.

Claims for services must be submitted along with a copy of the patient's insurance id card within 30 days to NEW YORK NETWORK MANAGEMENT (NYNM). Hamilton Financial Center, 9201 4th Ave, 4th Floor, Brooklyn, NY 11209 718-748-7316.


*Important*
NYNM requires a copy of front and back of insurance card
Coventry Health Care
(First Health Care)
PPO/PPS/HMO For eligibility and benefits determination please call the number listed on the patient's ID card. Provider Services main number: (800) 937-6824 fax number: (916) 374-4638. For precertification; please call the phone number on the patient's ID card for the requirements necessary to obtain precertification. For radiology; please refer to patient's ID card for benefits information. For behavioral Health and Substance Abuse, please refer to patient's ID Card for benefits information and contact number. Claims for services must be submitted along with a copy of the patient's insurance ID card within 30 days to NEW YORK NETWORK MANAGEMENT (NYNM). Hamilton Financial Center, 9201 4th Ave, 4th Floor, Brooklyn, NY 11209 (718) 748-7316.
Devon Health Services Inc
(800) 431-2273
or
(866)498-4773
www.devonhealth.com
PPO (Preferred Provider Organization) Referral requirements vary based on individual insurance payor. Refer to the back of the patient's ID card for the telephone number of the individual payor for the information. Call the number to verify referral requirements and eligibility. Provider should call the number that appears on the back of the patient's insurance card to determine authorization guidelines and requirements. Refer to the individual payor on the back of the insurance card to get information on local participating providers and to obtain authorization when necessary. Each plan in the PPO has its own guidelines. Call the number on the back of the patient's ID card to ascertain extent of benefits. Claims for services must be submitted along with a copy of the patient's insurance ID card within 30 days to NEW YORK NETWORK MANAGEMENT (NYNM). Hamilton Financial Center, 9201 4th Ave, 4th Floor, Brooklyn, NY 11209 (718) 748-7316.
Evolution Healthcare Systems (Guardian Resources, inc.)
(800) 881-4474
PPO (Preferred Provider Organization) Referral Requirements vary based on individual insurance payor. Refer to the back of the patient's insurance ID card for the telephone number of the individual payor for information. Call the number to verify referral requirements and eligibility. Provider should call the number that appears on the back of the patient's insurance ID card to determine authorization guidelines and requirements. Refer to the individual payor on the back of the insurance card to get information on local participating providers and to obtain authorization when necessary. Refer to the individual insurance payor found on the back of the insurance card to ascertain extent of this benefits and requirement Claims for services must be submitted along with a copy of the patient's insurance ID card within 30 days to NEW YORK NETWORK MANAGEMENT (NYNM). Hamilton Financial Center, 9201 4th Ave, 4th Floor, Brooklyn, NY 11209 (718) 748-7316.
Fidelis Care of NY
1-888-343-3547
www.fideliscare.org
Medicaid (including FHP and CHP) and Medicare Managed Care Organiztion (MCO)/Health Plan To verify eligibility cal 1-888-fidelis or go to the provider portal at www.fideliscare.org. Paper referrals are not required for specialist services. For Dentist referrals, please contact Doral at 1-800-719-9874. For Vision referrals please contact Davis Vision at 1-800-328-4728. Referrals to the Fidelis provider directory for all other participating providers in your region. *Please refer to the Fidelis Care of New York authorization grid for services that requires authorizations. This information may be found at www.fidelis.org. Under the provider icon or call 1-888-343-3547 for pre-authorization.
*Important*
Must use your PIN "Provider ID Number" assigned by Fidelis/NYNM
Participating labs is located at www.fideliscare.org under the provider icon. The provider or memeber may contact Fidelis Behavioral Health Department through the toll free number: 1-888-FIDELIS (1-888-343-3547). Follow the voice prompts to connect directly to the Behavioral Health Department. Covered service are outlined in the provider manual and the member hand book.

Electronic Claims

Claims Submissions on or after December 5, 2011 should be directed to CCN through direct electronic submission via www.nynmonline.com billing tab or directly at www.claimschannel360.com

Clearing House and Paper Claims:

CareCore National will initially also accept electronic claims from Emdeon clearing house with the existing NYNM Payor ID 11334 and paper claims from a dedicated new PO Box address. Send Paper Claims to:

NYNM IPA - Paper Claims
PO BOX 620 Lake Katrine, NY 12449

All Appeals and supporting documents:
CareCore National will accept appeals and supporting documents for these 3 payors and should also be sent to a new dedicated PO Box:

NYNM - Appeals and COB
PO Box 640 Lake Katrine, NY 12449

Galaxy Health Network
Formerly Managed Care, inc.
PPO (Preferred Provider Organization) Refer to the member insurance ID card for health plan eligibility authorization requirements, covered service. Refer to the member insurance ID card for health plan eligibility authorization requirements, covered service. Confimation is required for non emergency hospital procedures. Refer to individual insurance payor on the back of the insurance card to get insurance information on local participating radiology providers. Consult plan benefits for Mental Health/Behavioral Health benefits for covered services and guidelines. Claims for services must be submitted along with a copy of the patient's insurance ID Card within 30 days to NEW YORK NETWORK MANAGEMENT (NYNM). Hamilton Financial Center, 9201 4th Ave, 4th Floor, Brooklyn, NY 11209 (718) 748-7316.
Health Plus PHSP
(Prepaid Health Services Plan)
(800) 300-8181
(800) 450-8753
Medicaid (including FHP & CHP) and Medicare Managed Care Organization (MCO)/Health Plan

Authorized Referral from PCP required for all specialist visits. Call Health Services at (718) 630-0123 option 1 Health Services, or (800) 450-8753 option 2 for referrals and authorization. Option 3 Behavioral Health.
Visit

www.healthplus-ny.org
and click "Providers"

Pre-authorization is no longer required for visits to participating specialists.
Pre-auth is still required from Health Plus for Physical, Occupational and Speech Therapies, as well as MRI, PET scans, Home Health Care and Behavioral Health after the first visit.
Please refer to the healthcare provider manual for a complete listing of other visits that continue to require prior authorization.
Call (800) 450-8753
Providers can refer members for routine radiology and diagnostic imaging services without prior authorization from HP. Members can receive mammography screening services without a referral or prior HP approval. MRI and PET scan services require prior authorization. A current listing of radiology providers can be found online at www.healthplus-ny.org (click find a provider). Call the HP behavioral health dept at 1-800-450-8753 to obtain authorization for behavioral and mental health services. Members may self refer to any per provider for one mental health and one alcohol/substance abuse asessment per calendar year. Only one visit per par BH provider is allowed without prior HP auth. Initial mental health or alcohol/substance abuse assessment per provider or ER services by a per or non per provider do not require prior auth.

Electronic Claims

Claims Submissions on or after December 5, 2011 should be directed to CCN through direct electronic submission via www.nynmonline.com billing tab or directly at www.claimschannel360.com

Clearing House and Paper Claims:

CareCore National will initially also accept electronic claims from Emdeon clearing house with the existing NYNM Payor ID 11334 and paper claims from a dedicated new PO Box address. Send Paper Claims to:

NYNM IPA - Paper Claims
PO BOX 620 Lake Katrine, NY 12449

All Appeals and supporting documents:
CareCore National will accept appeals and supporting documents for these 3 payors and should also be sent to a new dedicated PO Box:

NYNM - Appeals and COB
PO Box 640 Lake Katrine, NY 12449

Multiplan (PHCS)
1-800-950-7040 or
1-800-546-3887
www.multiplan.com
PPO (Preferred Provider Organization) Refer to the patient's health plan to obtain eligibility information and confirm pre certification and utilization management requirements. The number to call can be found on the back of the patient's insurance ID card. Contact Multiplan at 800-950-7040 or use the provider search feature on the Multiplan website when referring patients to other providers or facilites. Refer to the patient's health plan to confirm precertification's and or pre authorizations and utilizations managements requirements. Call 1-800-950-7040 or (800) 546-3887 or visit the Multiplan website to obtain a list of local participating radiologists. Call the telephone number that appears on the back of the patients insurance ID card to ascertain benefits of the individual. Claims for services must be submitted along with a copy of the patient's insurance ID card within 30 days to NEW YORK NETWORK MANAGEMENT (NYNM). Hamilton Financial Center, 9201 4th Ave, 4th Floor, Brooklyn, NY 11209 (718) 748-7316.
Wellcare
www.wellcare.com
1-800-278-5155
Medicare and MEDICAID AS OF MAY 1st, 2012. Managed Care Organization (MCO)/Health Plan Eligibiligy verification, Utilization Mgmt. Call 800-278-5155 or visit Wellcare.com click show eligibility Co-pay. For only urgent Auth. requests call 800-278-5155
Visit www.Wellcare.com for auth guidelines
For radiology prior auth. call Carecore National or visit: Carecorenational.com Contact Magellan for all mental health and substance abuse services including in patient hospitalization and out patient counseling. Auth is not required for first out patient visit.
Prior Approval is required for continued services.
Contact Magellan: (800) 241-1103
www.magellanhealth.com/provider

Electronic Claims

Claims Submissions on or after December 5, 2011 should be directed to CCN through direct electronic submission via www.nynmonline.com billing tab or directly at www.claimschannel360.com

Clearing House and Paper Claims:

CareCore National will initially also accept electronic claims from Emdeon clearing house with the existing NYNM Payor ID 11334 and paper claims from a dedicated new PO Box address. Send Paper Claims to:

NYNM IPA - Paper Claims
PO BOX 620 Lake Katrine, NY 12449

All Appeals and supporting documents:
CareCore National will accept appeals and supporting documents for these 3 payors and should also be sent to a new dedicated PO Box:

NYNM - Appeals and COB
PO Box 640 Lake Katrine, NY 12449