September 2016 ProHealth Provider Relations Update I T2016/09/10 · Hart LMHC, LCAC, Margo S....

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September 2016

P r o H e a l t h P r o v i d e r R e l a t i o n s

U p d a t e

I N S I D E T H I S I S S U E :

1 e-Power 1 Gold & Silver ID cards - 2017 1 Credentialing New Providers

2-4 New Providers, effective

10/1/2016

5 Termed Providers

6 VHG

7-9 2017 PMCC Registration info

10-12 CORE EFT Enrollment

Instructions & Form

13-15 CORE ERA Enrollment

Instructions

16 Provider Relations Staff

Directory

Gold & Silver Plan ID Cards for 2017:

*Please Note*

Gold and Silver Plans for 2017 will NOT have a PCP listed

on members’ ID cards.

The Gold Plan is a PPO plan and Silver Plan is an HSA plan,

so neither require a PCP on the card. Both enrollment

materials and ID card inserts will note that members are

strongly encouraged to pick a PCP to help guide their

care. Members will still be instructed to call ProHealth

customer service in order to update their PCP in our system,

it just will no longer be stated on the ID cards at this time.

ePower

ProHealth’s ePower (Provider Portal) is now available on our

website at:

https://www.ecommunity.com/community-prohealth/provider-relations

Providers may login and use ePower to check claim status,

eligibility and more.

Credentialing of New Providers:

*Please Note*

Credentialing through ProHealth for ALL new providers can take anywhere from 90-120 days from notification to completion.

The Credentialing fee has increased to $200 for ALL new providers wishing to join the Community/ProHealth network, effective 11/1/2016.

ProHealth Credentialing/Enrollment Supervisor:

Jenna White

[email protected]

Phone#: (317)621-9312



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Contract ing and Credentia l ing Corner Providers Joining ProHealth

We would like to welcome the following providers to the ProHealth Network effective October 1, 2016.

Hospital affiliations will be listed with each provider.

Prime SCP

Anthony LCSW, Tammy L. - Behavioral Health

Gallahue Mental Health Services (Employed)

Chitra MD, Natalie - Allergy and Immunology

Allergy Partners of Central Indiana, PC - CHE/CHN, CHW, CHV

Christophel-Lichti LCSW, Jennifer - Behavioral Health

Community Behavioral Professionals (Employed)

Del Castillo MD, Marco - Anesthesiology

Community Anesthesia Associates, P.C. - CHE/CHN, CHW, CHV

El Hoyek MD, George - Internal Medicine

Touchpoint Senior Living (Employed) - CHE/CHN, CHW, CHV

Endsley MD, Whitney A. - Internal Medicine

Community Bariatric Surgeons, South (Employed) - CHE/CHN, CHV, CHS

Funk MD, Robert D. - Pain Management

Indiana Spine Group, P.C. - CHE/CHN, CHW, CHV, CHRH

Gaebler LCSW, Douglas - Behavioral Health


Gentry MD, Matthew G. - Neurophysiology

JWM Neurology, P.C. - CHE/CHN, CHW, CHV

Gill LCSW, Melissa D. - Behavioral Health

Community Behavioral Professionals Inpatient (Employed)

Gulyancis DO, Debra - Emergency Medicine

MedCheck (Employed) - CHE/CHN, CHW, CHV

Lajiness MD, Brian - Anesthesiology


Lutz MD, Michael L. - Diagnostic Radiology

Radiology of Indiana, P.C. - CHE/CHN, CHV, CHS

Mandigo LCSW, Danielle - Behavioral Health


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Prime SCP (continued)

Matharu MD, Tarvinder - Nephrology

Kidney and Hypertension Consultants - CHS

McFall LMHC, Melissa - Behavioral Health

Gallahue Mental Health Services

Rice MD, Camille - Anesthesiology


Shurtz MD, Austin F. - Anesthesiology

Community Anesthesia Associates, P.C. - CHE/CHN, CHV, CHC-N

Sturgill DO, Mark E. - Neuroradiology

Summit Radiology, P.C. - CHRH

Walsh LCSW, Molly M. - Behavioral Health


Wasik LCSW, Lindsay M. - Behavioral Health


Prime SCP Advanced Practice Providers

Bell NP, Kristen - Nurse Practitioner

Community Quick Care (Employed)

Burke NP, Cayla - Nurse Practitioner

Josephson Wallack Munshower Neurology, P.C.

Burns PA, Andrew - Physician Assistant

Dermatology, P.C. - CHE/CHN, CHV, CHW

Copple PA, Stacie K. - Physician Assistant

Pulmonary and Critical Care (Employed)

Giesler NP, Ashlee - Nurse Practitioner

Urology of Indiana, LLC

Huynh NP, Maria - Nurse Practitioner


Luessow NP, Angela V. - Nurse Practitioner





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Prime SCP Advanced Practice Providers (continued)

Mann NP, Denise L. - Nurse Practitioner

Indiana Nephrology & Internal Medicine - CHE/CHN, CHV, CHW

Mozzone NP, Rebekah - Nurse practitioner

Urology of Indiana, LLC - CHE/CHN, CHV, CHW

Neidigh PA, Kimberly B. - Physician Assistant


Peterson PA, Ana C. - Physician Assistant


Potts NP, Jean A. - Nurse Practitioner

Community Quick Care (Employed)

Roberts NP, Lorinda - Nurse Practitioner

Lorinda Roberts, NP

Savko NP, Megan A. - Nurse Practitioner

Neurosurgical Care (Employed)

Prime PCP

Ahmad MD, Usman - Internal Medicine

Gastroenterology Care, Anderson (Employed) - CHA

Barker MD, John - Family Medicine

Arlington Family Medicine - CHE/CHN, CHW, CHV

Booms MD, Stephanie - Pediatrics

Northpoint Pediatrics - CHE/CHN, CHW, CHV

Davisson MD, John L. - Internal Medicine

Internal Medicine Care, Noblesville (Employed) - CHE/CHN, CHW, CHV, CHS

Frechette MD, Nickolas R. - Internal Medicine

St. Francis Medical Group / IIMC - CHS

Serafin MD, Mateusz - Internal Medicine

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Termed Providers The following providers will no longer be participating with ProHealth:

Davis DO, Thomas M. - Osteopathic Medicine, termed 9/14/2016

Thomas M. Davis, D.O., LLC

Eastman III MD, Joseph R. - Pathology, termed 9/30/2016

Ameripath Indianapolis, PC

Hart LMHC, LCAC, Margo S. - Licensed Mental Health Counselor, termed 9/30/2016

Community Hospitals of IN, Inc. / Gallahue Mental Health Services (Employed)

Hartman MD, Eric P. - Family Medicine, termed 9/30/2016

St. Francis Medical Group / IIMC

Hittle MD, John B. - Internal Medicine, termed 9/30/2016

Hancock Physician Network, LLC

Jones MD, W. Terry - Urology, termed 9/30/2016


Klinestiver MD, Robert M. - Critical Care Medicine, termed 9/30/2016

Hancock Physician Network, LLC

Moto NP, Mercy TsiTsi - Nurse Practitioner, termed 9/30/2016

Community Physicians of IN, Inc / Touchpoint Senior Living (Employed)

Power PA, Kasie N. - Physician Assistant, 9/2/2016

Central Indiana Orthopedics

Ramsey MD, Megan P. - Internal Medicine, termed 9/30/2016

St. Francis Medical Group / IIMC

Schutzman MD, Stephen J. - Internal Medicine, termed 9/30/2016

Community Howard Regional Health Hospitalists (Employed)

Sloffer PA, Constantina K. - Physician Assistant, termed 9/30/2016

Community Physicians of IN, Inc / MedCheck (Employed)

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Visionary Health Group

Are you an independent practice that needs consulting/financial help? ...

Integrated physician consulting services

A division of VEI since 1987, Visionary Health Group (VHG), formerly known as Indianapolis Medical Management

(IMM), has provided physician practice management and consulting services for more than 20 years. VHG prides itself

in providing comprehensive, tailor-made services that meet and exceed the needs of its physician clients. VHG’s con-

sulting and evaluation services have been designed to objectively evaluate every aspect of a medical practice and to

provide realistic solutions to the challenges faced by physicians today. VHG offers a diverse team of skilled individuals

to assist you with your various practice needs.

*Complimentary business assessment available upon request*

Consulting and practice operations

Revenue cycle management

Documentation and coding experts

Financial consulting and reporting

Payer credentialing and enrollment Practice/business start-up

Full suite of human resource services

OSHA/HIPAA compliance

Project management

Process improvement

Development of policy and procedures

Please Contact: Joni A. Reed, MBA, BSBA, ASB, CMA Business Consultant Physician Services Ph#: (317)621-1539 [email protected] Anita Huse, RN, CAPPM Business Consultant Physician Services PH#: (317)621-4090 [email protected] Jamie L. McAllister, MA Account Coordinator Ph#: (317)621-7521 Fx#: (317)957-2794 [email protected] Stracy Faulkner Billing/Coding Team Manager - Practice Management Ph#: (317)621-1537 [email protected]

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Community ProHealth

CORE EFT Enrollment Instructions

Instructions for Completing the EFT Enrollment Form

Please type or print legibly.

Use only blue or black ink to complete paper form.

Please allow 1 week for the enrollment process.

(o) – Optional

Please fax completed form to 317.355.6084

For questions about the paper or electronic enrollment process, please call 317-621-7580, or email

Michele Dowd at [email protected].

Provider Information – Please complete all

Provider Name – Enter Complete legal name of institution, corporate entity, practice, or individual provider

Provider Street Address – Enter Number and Street name associated with Provider listed

City – Enter City associated with provider address field

State – Enter Two Character code associated with the State

Zip Code – Enter Postal zip code

Provider Identifiers

Provider Federal Tax Identification Number (TIN) – Enter Federal Tax Identification Number, also known

as an Employer Identification Number (EIN), or 10 digit National Provider Identifier (NPI).

Provider Contact Information

Provider Contact Name –Enter Name of a contact in provider office for handling EFT issues

Telephone Number – Enter telephone number of contact person

Email address – Enter email address of contact person

Fax Number – Enter Fax number for contact person.

Financial Institution Information

Financial Institution Name- Enter name of the provider’s financial institution.

Financial Institution Routing Number – Enter the 9-digit identifier of the provider’s financial institution

which payments are to be deposited

Type of Account at Financial Institution – Select the type of account the provider will use to receive EFT

payments (e.g., Checking, Savings).

Provider Account Number with Financial Institution – Enter the Provider’s account number at the Financial

Institution where EFT payments are to be deposited.

Account Number Linkage to Provider Identifier – Provider preference for grouping claim payments must

match preference for v5010x12 835 remittance advice.

Providers Tax Identification Number (TIN)

National Provider Identifier (NPI)

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Community ProHealth

CORE EFT Enrollment Instructions (continued)

Reason for Submission: Must select one from below

New Enrollment

Change Enrollment

Cancel Enrollment

Include with Submission: Must select one from below

Voided check -

Bank Letter

*Note that a copy of a voided check is needed if checking account is being used*

Clearinghouse Information Clearinghouse Name – Official Name of the provider’s clearinghouse

Telephone Number – Telephone number of contact

Email Address – An electronic mail address at which the health plan may contact the provider’s clearing-

house.

Reason for Submission

New Enrollment

Change Enrollment

Cancel Enrollment

Authorized Signature – Signature of an individual authorized by the provider or its agent to initiate, modi-

fy, or terminate an enrollment. May be used with electronic or manual enrollment.

Electronic Signature of Person Submitting Enrollment – Enter the electronic name of the person authorized

to submit enrollment.

Written Signature of Person Submitting Enrollment – The cursive name of the person authorized to submit

enrollment.

Printed Title of Person Submitting Enrollment – The printed title of the person signing the form. May be

used with electronic or manual enrollment.

Submission Date – The date that the enrollment is submitted.

Requested ERA Effective Date – Date the provider wishes to begin ERA per Phase III CORE Health Care

Claim Payment/Advice (835) Infrastructure Rule Version 3.0.0.

Fax the completed paper form to: 317.355.6084

Researching Missing/Late Files

ERA files that have not been received after 4 business days of receipt of the corresponding EFT file can be

researched by calling Joanna Haehl at 317.621.7408 or via email at [email protected].

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Community ProHealth

CORE ERA Enrollment Instructions

Instructions for Completing the ERA Enrollment Form

Please type or print legibly.

Use only blue or black ink to complete paper form.

Please allow 1 week for the enrollment process.

(o) – Optional

Fax completed form to 317.355.6084

For questions about the paper or electronic enrollment process, please call the EDI team at 317-621-

7580, or email Michele Dowd at [email protected].

**Providers enrolling in 835 transaction will no longer receive a paper remittance advice. **

Provider Information – Please complete all

Provider Name – Enter the Complete legal name of institution, corporate entity, practice, or individual provider

Provider Address Street – Enter the Provider Street Address

City – Enter the City associated with Provider address field

State – Enter the Two Character code associated with the Provider State

Zip Code – Enter the Postal zip code

Provider Identifiers

Provider Federal Tax Identification Number (TIN) – Enter either the Federal Tax Identification Number, also

known as an Employer Identification Number (EIN), used to identify a business entity. Or the National Pro-

vider Identifier (NPI) – A Health Insurance Portability and Accountability Act (HIPAA) Administrative Sim-

plification Standard. The NPI is a unique 10-digit identification number for covered healthcare providers.

Other Identifiers

Assigning Authority – Organization that issues and assigns the additional identifier request on the form (e.g.,

Medicare, Medicaid).

Trading Partner ID – The providers submitter ID assigned by the health plan or the provider’s clearinghouse

or vendor.

Provider Contact Information

Provider Contact Name –Enter the name and title of the person who can answer questions about the infor-

mation submitted on this request.

Telephone Number – Enter the contact person’s telephone number.

Email address – Enter the contact person’s email address.

Fax Number – Enter the contact person’s fax number.

Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier): Pro-

vider preference for grouping claim payments – must match EFT payments

Must fill out one of the two options below

Providers Tax Identification Number (TIN)

National Provider Identifier (NPI)

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Community ProHealth

CORE ERA Enrollment Instructions (continued)

Method of Retrieval – Method in which provider will receive the ERA from the health plan (e.g., download

from the health plan website, clearinghouse, etc.,)

Clearinghouse Information

Clearinghouse Name – Enter the name of the provider’s clearinghouse

Telephone Number – Enter telephone number of the provider’s clearinghouse

Email Address – Enter email address of provider’s clearinghouse.

Reason for Submission

New Enrollment

Change Enrollment

Cancel Enrollment

Authorized Signature – The Authorized Signature may be either Electronic or Written.

Electronic Signature of Person Submitting Enrollment – If the Authorized Signature is electronic, enter your

name in the designated field.

Written Signature of Person Submitting Enrollment – If the Authorized Signature is Manual, please write

your name in the designated field.

Printed Title of Person Submitting Enrollment – Enter the title of the person signing the form. May be used

with electronic or manual enrollment.

Submission Date – Enter the date that the enrollment is submitted.

Requested ERA Effective Date – Enter the date the provider wishes to begin ERA per Phase III CORE Health

Care Claim Payment/Advice (835) Infrastructure Rule Version 3.0.0.

Fax the completed paper form to: 317.355.6084

Researching Missing/Late Files

ERA files that have not been received after 4 business days of receipt of the corresponding EFT file can be

researched by calling Joanna Haehl at 317.621.7408 or online at [email protected].

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Department Staff

Jenny Bouck, Provider Relations Manager

[email protected]

Business Information Coordinator

Hollie Putzback, [email protected]

Provider Relations Coordinators:

Carol Boyd, [email protected]

Dawn Widgery, [email protected]

Amanda Bobo, [email protected]

Medicaid Program Manager:

Salena Woodson, [email protected]

Medicare Program Manager:

Lori White, [email protected]

Credentialing Enrollment Supervisor: Jenna White, [email protected]

Credentialing Coordinators:

Julia Chumbley, [email protected]

Julie Starr, [email protected]

Kim Tibbets, [email protected]

Credentialing Specialist:

Adrianne Stocks, [email protected]

Provider Enrollment Coordinators:

Aletha Burnett, [email protected]

Amy Walls, [email protected]

Denise Smith, [email protected]

Dianne Castillo, [email protected]

Jessie Eskew, [email protected]

Sharon Harlan, [email protected]

Provider Relations Department

6626 E. 75th St, #500

Indianapolis, IN 46250

Phone: 317-621-7581

www.ecommunity.com/prohealth

mailto:[email protected]









September 2016 ProHealth Provider Relations Update I T2016/09/10 · Hart LMHC, LCAC, Margo S....

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