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

2023 Medicare PPO/EGWP Prior Authorization List
Authorization Request Timelines Guideline
iExchange and eviCore Healthcare Authorization Requests
Services Requiring Authorization

 

2022 Medicare PPO Prior Authorization List
2022 Medicare HMO Prior Authorization List
2021 Medicare PPO Prior Authorization List
2021 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.

Authorization Request Form

Activity Level of Care Form (ALOC – SNF Facility)

Care Management Staff Accessibility to Members and Practitioners
Clinical Criteria for Utilization Decisions

Medicare Appeal Request Form

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

 

Claims Resources

Medicare and Commercial Claims Resources
Investigation 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

 

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
January 2023
March 2023

 

Medicare Plan Materials

View the plan documents below to learn more about Medicare member benefits. 

2023 Plan Materials
2023 Benefits at a Glance - Medicare Advantage Benefits for Providers
2022 Plan Materials
2022 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