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Provider Medicare Manual
To help serve you better, we have collected information related to our Medicare processes, policies and procedures into one reference page.If you have any questions about the information provided, please call our Medicare customer service department at 800-378-5234, Monday through Friday, 8 a.m. to 8 p.m. (TTY 800-947-3529).
Authorization Information
2021 Medicare PPO Prior Authorization List
2021 Medicare HMO Prior Authorization List
Authorization Request Timelines Guideline
iExchange and eviCore Healthcare Authorization Requests
Services Requiring Authorization
2020 Medicare PPO Prior Authorization List
2020 Medicare HMO Prior Authorization List
For the most up-to-date Experimental or Investigational Authorization List for Medicare members, please contact us at 800-378-5234, Monday through Friday from 8 a.m. to 8 p.m.
Care Management Staff Accessibility to Members and Practitioners
Clinical Criteria for Utilization Decisions
Notice of Medicare Non-Coverage Form (Home Health Care)
Notice of Medicare Non-Coverage Form (Skilled Nursing Facility)
Grievance and Appeals Resolution Policy and Procedure for Medicare Advantage Plans Part D
Grievance and Appeals Resolution Policy and Procedure for Medicare Advantage Plans Part C
Home Telemonitoring Agency List
Claims Resources
Medicare and Commercial Claims ResourcesInvestigation Timeline for Medical Record Request and Review policy
Recoupment Request Form
Medicare Fraud, Waste and Abuse Program Plan
Involuntary Disenrollment for Fraud, Waste and Abuse
Provider Line for Claims Issues
This line is designed to specifically help Medicare providers with complex claims issues.
855-580-9935 or 920-720-1460
Credentialing
Credentialing Process
Recredentialing Process
Medicare Opt Out
Practitioners Communication, Advice to Patients
General Policies
Business Information Protection
Diverse Population-Cultural and Linguistic Needs
No Member Discrimination in Delivery of Health Care
Privacy and Confidentiality of Member Information and Records
Prohibition of Health Screening Prior to Enrollment
Medicare Required Disclosure of Information to Beneficiaries
Pharmacy Information
Visit the Pharmacy Information page in the provider resources section.
Safe Use of Opioid Pain Medication
The Centers for Medicare and Medicaid Services (CMS) has published guidance to help prescribers and pharmacists dispense opioid medications according to new Medicare drug policies.
2019 Medicare Part D Opioid Policies: Information for Pharmacies
2019 Medicare Part D Opioid Policies: Information for Prescribers
Authorization Drug Lists
ESI Care Continuum Prior Authorization Drug List
June 2021
Medicare Plan Materials
View the plan documents below to learn more about Medicare member benefits.
2021 Plan Materials
2021 Benefits at a Glance - Medicare Advantage Benefits for Providers
2020 Plan Materials
2020 Benefits at a Glance - Medicare Advantage Benefits for Providers
Training
Network Cares (PPO SNP) Medicare Model of Care Training
2020 Medicare and Individual and Family Plans Benefit Training
2020 Medicare and Individual and Family Plans Benefit Training FAQ
