|
Reimbursement and Credentialing Information
|
|
|
KENTUCKY ARNP CREDENTIALING & REIMBURSEMENT INFORMATION
Please let us know if any of this information is incorrect.
CAQH (Council for Affordable Quality Health Care) is an online universal
credentialing datasource
that contracts with multiple health insurers
for credentialing of providers. Registering your data
with CAQH may save
you hours of filling out individual applications.
https://caqh.geoaccess.com/oas, choose "Registration"
1-888-599-1771 for help desk; Fax: 1-866-293-0414
National Provider Identifier (NPI)- The NPI will be the single provider
identifier by 2007,
replacing the different provider identifiers nurse
practitioners currently use for each health
plan with which he/she does
business. It will also be used in place of the DEA# on prescriptions.
https://nppes.cms.hhs.gov
1-800-465-3203 or TTY 1-800-692-2326
AETNA US HEALTHCARE
1-800-353-1232
www.aetna.com. Choose "doctors & hospitals", then "provider application requests".
Or
request application by mail at: Initial Application Processing, Aetna
Credentialing,
151 Farmington Ave-MC38H, Hartford CT 06156-7182.
Do credential ARNPs. Reimburse at 85%.
  Reimbursement:
- NPs are recognized as PCPs in states where the state
laws say NPs are PCPs. So for KY, AETNA should recognize NPs as PCP.
- Independent practice owners are reimbursed at 85% of
the physician rate.
- AETNA will directly reimburse NPs
- Aetna will credential NPs as PCP and pay at 85% of
physician rate if you are an employee of a practice.
Referrrals:
- NPmust be credentialed as a PCP with AETNA and be
reimbursed at 85% to be able to make referrals within the AETNA
system.
- If the NP is not credentialed as a PCP, Aetna will not
allow NP to refer. So, that means if you are billing under the
collaborating physician's # to get 100% reimbursement, you cannot make a
referral. It will have to be the physician with whom you work.
In-office procedures:
- AETNA reimburses NP services at 85%.This includes
in-office procedures such as cryotherapy, I&D, suturing,
etc.
AETNA reimburses (as does
Medicare) surgery assistants at 12%.
ANTHEM BLUE CROSS AND BLUE SHIELD OF KENTUCKY (Also includes Indiana and Ohio)
Provider Relations - 1-800-205-5870, Ext. 5642; 9901 Linn Station Rd, Louisville, KY 40223
Or www.anthem.com; Choose "providers", "KY", "enter", "streamlined credentialing process"
Fax: 502-327-5311
Do credential ARNPs. Reimburse @ 85%.
BLUEGRASS FAMILY HEALTH
Provider Relations - 1-800-787-2680; 651 Perimeter Dr, Suite 300, Lexington, KY 40517
www.BGFH.com; Choose "providers", "provider homepage", "request a participation application"
Do credential ARNPs. Reimburse at 80%.
CHA
1-800-457-5683, P.O.Box 23468, Lexington, KY 40523.
www.CHAHEALTH.com, choose "for providers", "provider forms", "provider pre-application"
Do credential ARNPs. Reimburse at 75%.
CIGNA (CONNECTICUT GENERAL LIFE INSURANCE CO)
www.cigna.com, Search for "credentialing"; choose "credentialing & recredentialing"
Provider Relations: 1-800-882-4462
Do credential ARNPs. There is a $200 application fee, short enrollment period which is only
in February each year.
GEHA PPO (Government Employees Hospital Assn)
Insure all federal employees.
Provider Relations: 1-800-821-6136, x5257.
Call Private Health Care System to request application - 1-800-950-7040 x4258
Do credential ARNPs. Reimburse at 100%.
HUMANA
Central Provider # - 1-800-448-6262
Do
contract with ARNPs, but require that MD provider # be on claim if ARNP
in group practice
with MD. Will fully credential ARNPs if practicing
independently.
Reimburse at 80%.
INTERNATIONAL UNION OF OPERATING ENGINEERS-Locals 181, 320, TVA
Health and Welfare Trust, 700 Elm Street, P.O.Box 1179, Henderson KY 42419 270-826-6750
Credential ARNPs. Reimburse at 100%
MEDICARE
Carrier in Kentucky is ADMINASTAR Federal, Inc.
www.cms.hhs.gov/home/medicare.
Under "provider enrollment & certification", choose
"Medicare
provider-supplier enrollment", on left side of page choose "enrollment
applications",
then "CMS 8551"
Provider Enrollment: 1-502-329-8591
Do credential ARNPs. Reimburse at 85%.
MEDICAID
www.chfs.ky.gov/dms/provider+enrollment
Do credential ARNPs. Reimburse at 75%.
TRICARE
In Kentucky, and several northern states, managed by Health Net Federal Services
If enrolling as non-network provider, may obtain application online at www.mytricare.com
If
enrolling as network provider, call Health Net Federal Services at
1-877-874-2273, choose 1,
then 3 to be connected to customer service.
Ask for provider services to request application.
Do credential ARNPs. Reimburse at 100%.
UNITED HEALTH CARE of KENTUCKY
Provider Services - Lexington - 800-495-5285;
Northeast KY 1-800-328-8835;
Northern KY & Grant County - 1-800-752-7106
Do credential ARNPs. Reimburse at 100%
PREFERRED PROVIDER ORGANIZATIONS (PPO) AND THIRD PARTY ADMINISTRATORS
The
following companies contract as third-party administrators for health
insurers or maintain
provider networks for self-insured plans. Several
of them manage workman's comp claims. They
do not sell health insurance,
but they may credential ARNPs for the insurance industry.
BLUEGRASS HEALTH NETWORK
Handle workers comp claims for a group of self-insured companies.
502-245-8012; Fax: 502-426-7426; 1700 Eastpoint Parkway, Louisville, KY 40223
Do not credential ARNPs. Submit claim in MD name.
CENTER CARE
Provider Relations - 800-972-7038 or 270-745-1517; 1225 Fairway St., Bowling Green, KY 42103
Do credential ARNPs. Reimburse at 70%.
CONCENTRA MANAGED CARE
Manage Workman's Comp cases for many companies.
Sue Lee, 1-800 465-6054 or 502-423-0002, 320 Whittington Pkwy, Suite 116, Louisville KY 40222
Do credential ARNPs. MD must sign off on chart. Reimbursement based on Workman's
Comp fee schedule.
CUMBERLAND HEALTHCARE INC
Provider Relations - 888-893-2264, x100
Do credential ARNPs. Claim must also include MD identification number, if possible.
Reimburse at 100%.
DIRECT CARE AMERICA
Provider Relations - 800-266-5896; 4301 Darrow Rd, Stow, Ohio 44224
Do credential ARNPs. Reimburse at 100%.
FIRST HEALTH or CCN (COMMUNITY CARE NETWORK)
www.firsthealth.com, choose "doctor or hospital", "join the network"
1-800-937-6824
Do credential ARNPs. Reimburse at 100%
OMCA (OCCUPATIONAL MANAGED CARE ALLIANCE)
Manage workman's comp claims.
Provider Relations: 1-800-633-5960; P. O. Box 20908, Louisville, KY 40250
Do credential ARNPs. Reimburse at 100%.
PHCS (PRIVATE HEALTH CARE SYSTEMS)
www.phcs.com, choose "join the network"
Provider Relations - 800-950-7040
Do credential ARNPs. Reimburse at lower rate than MD, except in cases where claim is submitted
under office group #.
ARNP must have hospital admitting privileges.
PLAN VISTA SOLUTIONS or MEDAVANT HEALTH
www.medavanthealth.com
Provider Enrollment: 800-792-5256, choose option 1
Do credential ARNPs. Reimburse at 100%.
PPO NEXT
www.pponext.com, choose "provider", "join the PPO NEXT network"
Provider Relations - 800-860-6381; 8625 King George Dr., Suite 300, Dallas, TX 75235
Do credential ARNPs. Reimburse at 100%.
PURCHASE PHYSICIAN ORGANIZATION/PURCHASE HEALTH PARTNERS
Manage provider network in Western KY for several health insurers.
www.php-ppo.com
Provider Relations - 270-575-2955
Do credential ARNPs. Reimburse at rate dictated by insurance plan, which is often lower than MD.
$150 annual network fee.
|
|
|
|
Received Central District Medical Services Award from the Ky Association of Health Care Facilities