FAQs

Resources

Do members of Physicians Health Choice require a referral to see a specialist?

Members do need a written referral from their PCP to visit a specialist. We highly recommend that the PCP is aware of the medical needs and making specialty recommendations accordingly. Members must see providers that are contracted with the Plan.

My name/office is not listed on the ID card. Can I still see the patient?

Verify the member’s PCP in our secure provider portal, ePRG, or call Customer Service at 1-866-550-4736 (TTY: 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, for assistance. The member could be carrying an outdated ID card, or if the member is present and can consent, a PCP change can possibly be made.

What do I do if I have a complaint?

We make every attempt to address concerns locally. If you have a dispute, we encourage you to contact your local Network Representative. In the rare event that they cannot resolve the issue to your satisfaction, please fill out a Provider Dispute Resolution Form available through your local Network Representative or the Help tab on the Provider Portal. All disputes are handled within 30 business days. Please note the Provider Dispute Resolution process is not applicable to provider medical necessity appeals which will be adjudicated using the processes mandated by CMS. Please reference instructions provided with an adverse determination or claim denial.

What is RAPS?

RAPS stands for the Risk Adjusted Processing System, an acronym used to describe the coding system the federal government utilizes to establish rates of reimbursement to Medicare Advantage Plans for their members. Certain key ICD-9 diagnostic codes are triggers for a change in the reimbursement level for the member (such as codes for diabetes with nephropathy, aortic atherosclerosis, old MI, etc). These diagnoses must be addressed by the Physician (or mid-level extender) with the patient in a face-to-face encounter at least once per calendar year. This encounter must include an assessment and plan for each diagnosis, and be documented appropriately in the patient’s chart. RAPS is important to all of us because it has a direct impact on the health care dollars coming in to provide benefits to your patients and allows us to provide above Medicare reimbursement to your practice. Where RAPS coding is not addressed appropriately there is a real chance of lower CMS funding, which reduces member benefits and the overall reimbursement to our PCPs. We provide annual nurse reviews of all your PHC patient charts to help point out appropriate ICD-9 codes (but it is still up to the provider to clinically determine which diagnoses truly affect the patient). We also provide ongoing education for physicians and their staff. For more information, contact your local Provider Relations Representative or visit the DataRAP Quick Reference guide located in the Help section of the Provider Portal.)

What are the Access Standards Physicians Health Choice uses?

  • Emergency Care……. Immediate
  • Urgent Care …………..24 Hours
  • Routine Primary Care……. 7 Calendar Days
  • Routine Specialty Care…….10 Calendar Days
  • Preventative Care or Periodic Health Evaluation..30 Calendar Days
  • Office Visit Wait Time……. 30-45 Minutes

My name/TIN/address/fax or telephone number/call covering physician/etc. has changed. How do I notify you?

Please fill out a Provider Information Change (PIC) form located in the Help section of the Provider Portal. Email, fax or mail the form back to the address on the form.

How can I find out if a procedure requires pre-authorization?

You may call the Physicians Health Choice Utilization Management Department at 1-877-299-7213, (TTY: 711), 8:00 a.m. – 5:00 p.m., Central Time, Monday – Friday, or refer to the Prior Authorization Tools located in the Help section of the Provider Portal.

What is the timely filing deadline?

Contracted providers must submit their claims within 90 days of the date of service. Non-contracted providers have 12 months from the date of service.

Where do I submit a corrected W9?

Please fill out a Provider Information Change (PIC) form located in the Help section of the Provider Portal. Email, fax or mail the form back to the address on the form.

What is the appeal’s filing deadline?

The appeals filing deadline is 90 days from the original claim processing date. All appeals will be considered and responded to within 45 days.

Why is the claim pending?

In our provider portal, a claim may reflect a pending status when additional information is needed to process the claim. Hold status indicates receipt of the claim and is in the initial stage of processing.

Why do you need medical records?

We will request medical records on certain out-of-network claims and procedures that require authorization.

I am a non-contracted provider and would like to dispute the amount you paid on a claim. What is the process?

Non-contracted providers who disagree with the amount paid by Physicians Health Choice may dispute the payment by submitting a formal written request within 90 days of the initial determination date. These requests should be sent to:

Physicians Health Choice
Claims Department
Attn: Appeals
PO Box 29429
San Antonio, TX 78229-9998