Providers

Provider Information

Welcome to Health Choice Generations’ Provider Portal!

The HCG Provider Portal has been designed with you in mind. Our goal for the site is twofold.

We want to assist you with reducing administrative burdens by streamlining processes and providing a one-stop-“resource shop” saving you time and money.

We want to provide you with the tools you need so you can make the best decisions for your patients.

Included in this site, and accessed through a secure portal, is patient data such as claims history and prior authorizations. In addition, you will find forms, newsletters, the HCG Provider Manual, continuing education information and links to other medical and dental information.

Provider Portal Login Manual

Provider Portal

 

Problems? Questions? Comments? Suggestions?
Please contact the Provider Portal Coordinator at 480-760-4651 or providerportal@iasishealthcare.com

HCGenerations.com Account Holders

In an ongoing effort to improve Health Choice’s on-line web-based services, we have designed and built a brand new “single sign on” secure Provider Portal that allows access to both our Medicare (Health Choice Generations – HCG) and Medicaid (Health Choice Arizona – HCA) lines of business.

Currently registered HCG Account Holders will not need to re-register to use the new system; however, providers that were also account holders on our Medicaid website (or dual contracted Providers) will need to follow the on screen prompts within the Provider Portal to register to view our Medicaid information. We apologize for this inconvenience, and assure you this is a one time requirement.

We hope that you enjoy the improvements we have made to our on-line services, and invite your comments and feedback.

Health Choice Generations Provider Escalation 

Health Choice Generations is committed to ensuring that you have an open line of communication with us at all times. Should you ever feel the need to escalate an issue, your Provider Representative’s supervisor is: 

Dania Wales
DWales@iasishealthcare.com 
602-829-3380

To see the updated contact information, view the Provider Escalation Process.

April 2017 Notice Regarding Changes to Dental Covered Code Set
Updates on Claims Processes for Dental Providers
Provider Forum Notice

April Tips and Tricks: Nutrition and BMI

Prior Authorization Update FAQs

Notice Regarding Prior Authorization Update Clarification

Additional Upgrades to Health Choice Provider Portal
March 2017  Updated Prior Authorization Grids Effective 4/1/2017
February 2017

Improvements to Health Choice Provider Portal
Notice on Health Choice Payment Processing Documentation
AHCCCS Request for Information
February Tips and Tricks: History & Status

December 2016

Notice Regarding Change in Contracted Labs
December 2016 Tips and Tricks: Avoiding Penalties
Prior Authorization Grid Updates Effective 1/1/17

November 2016 Notice Regarding Paths for Provider Escalation at Health Choice
October 2016  October 2016 Tips and Tricks: Definitive Diagnoses vs Signs & Symptoms
September 2016

Changes to Supplemental Benefits in 2017
Changes to Prior Authorization Guidelines
Provider Newsletter
September 21, 2016 Provider Forum Reminder
September 2016 Tips & Tricks: Flu Vaccinations

August 2016 August 2016 Tips and Tricks: Total OB
July 2016 July 2016 Tips and Tricks: Cerebrovascular Accident (CVA)
May 2016 May 2016 Tips and Tricks: Nutrition & BMI
March 2016 March 2016 Tips and Tricks: Cardiology
February 2016 February 2016 Tips and Tricks: Chronic Kidney Disease
January 2016 January 2016 Tips and Tricks: COPD
Provider Newsletter
Supplemental Submissions For Performance and Quality Reporting
2016 Covered Code Set (Dental)
2016 Covered Code Set (Hearing & Vision)
December 2015 December 2015 Tips and Tricks: Depression
November 2015 November 2015 Tips and Tricks: Diabetes
September 2015 ICD-10 Transition
August 2015 Updates to Benefit Authorization Requirements Effective August 18, 2015
July 2015 Important Prior Authorization Update
Prior Authorization Guidelines for 2015
May 2015 Facet Injections Billing Update
EM Coding Guidelines
April 2015 Important Hospice Notice
Annual Podiatry Services
March 2015 Podiatry Routine Foot Care Visits
Flouride Varnish Billing
February 2015 Electronic Prior Authorization System Is Now Available Through The Health Choice Provider Portal!
January 2015 CMS New Modifier Update
Flu Notification
How to bill radiology modifiers

Prior Authorization Guidelines

Prior Authorization Guidelines effective for dates of service 4/1/2017
Prior Authorization Guidelines effective for dates of service 1/1/2017-3/31/2017
Medical Services Prior Authorization Form

Clinical Guidelines and Recommendations

Centers for Medicare and Medicaid Services – Medicare Coverage Database

Annual Medicare Model of Care Training

Health Choice Generations utilizes:

  • Inter-Qual
  • UpToDate

Adult Hypertention Management Guidelines (NHLBI)

Adult Obesity Management Guidelines (NHLBI and NIDDKD)

Asthma & COPD Management Guidelines (NHLBI)

Cardiac and CVA Care Management (ACC/AACE)

Chironic Pain Management Guidelines (American Pain Society)

Diabetes Management Guidelines (ADA)

General Infections Disease Management Guidelines (IDSA)

HIV Management Guidelines

Pediatric Obesity Management Guidelines (NHLBI and NIDDKD

Smoking Cessation Guidelines (NIH)

Claim Submissions and Coordination of Benefits

Where should Plan Providers send their Claims?

Medical Claims
Health Choice Generations
410 N. 44th Street, Ste. 510
Phoenix, AZ 85008

Which Provider ID # should be used on the Claim Form for Health Choice Generations

Providers may use their Medicare/UPIN number in Box 33 or continue to use the AHCCCS Provider ID as currently used when billing Health Choice.

Effective January 1, 2007, Health Choice will allow the option to submit claims using the National Provider Identifier (NPI), however, effective May 23, 2007, all claims are required to submitted with the NPI. More information on NPI is available at http://www.cms.gov/NationalProvIdentStand.

Providers currently contracted with Health Choice may mail or fax written notification of their NPI number to the Network Services.

Health Choice Arizona Attention:
Network Services
410 N. 44th Street, Ste. 900
Phoenix, AZ 85008

Maricopa and Pinal Counties Fax: 480-303-4433
Pima County Fax: 520-322-5784
Apache/Navajo/Coconino Counties Fax: 928-532-0824

How may I check Claims Status or Claims Inquiry?

Providers can visit the Health Choice Generations Web site to review claims and check member eligibility. Providers must pre-register on-line prior to having access to this confidential information. After you have registered, you will be able to view only your member’s claim information. Should you have difficulty registering you may refer to the Log-in Tutorial.

Providers may also call Health Choice Generations Claims Customer Service or Member Services for eligibility at 1-800-322-8670.

Who is the Primary payor: Health Choice Generations or Health Choice Arizona?

Health Choice Generations (Medicare) is the primary payor and submits the encounter directly to Health Choice Arizona (Medicaid) for processing of the secondary payment. Providers do not have to submit two claims to each Plan. However, Providers will receive two explanation of Benefits (EOB), one EOB reflects the Medicare allowable and the second EOB will show processing of any secondary amount under the Medicaid (AHCCCS) program. If Health Choice Arizona is not the secondary payor, then the primary EOB must be submitted to the secondary payor by the Provider.

Provider Accounts Receivable

Health Choice does not reconcile accounts receivable for provider offices. It is the responsibility of the provider office to ensure that payments are properly posted and that claims are resubmitted with proper/requested information in a timely manner. Enclosed is a Health Choice Generations denial glossary to assist you in reconciling your receivables.

Current Year Supplemental Benefits

Supplemental Benefits – 2017
Supplemental Code Set – Dental – 2017 (as of 5/20/17)
Supplemental Code Set – Non-Dental – 2017

Certain benefits under the Health Choice Generations plan require a referral or prior authorization. PCPs are required to coordinate the member’s care by sending the member to a contracted Health Choice Generations specialist. If a member receives healthcare services from any physician, hospital or other healthcare provider without getting a referral or authorization in advance, the member may have to pay for these services. Please click on the “Find a Doctor” link for a complete listing of Health Choice Generations providers.

The Health Choice Generations Summary of Benefits and Evidence of Coverage list the benefits which are covered by our plan. Section four in the Evidence of Coverage lists covered services that need prior authorization.

There are many services a member may obtain on their own, without prior approval from a provider or Health Choice Generations.

The following services are covered as Preventive Care and do not require prior authorization.

  • Colorectal Screenings
  • Mammography screenings
  • Pap Smears, Pelvic Exams and Clinical Breast Exam
  • Prostate Cancer Screening exams
  • Cardiovascular Disease Testing
  • Physical exams
  • Outpatient substance abuse services
  • Emergency services
  • Urgently needed care
  • Physician services, including doctor office visits
  • Flu shots and pneumonia vaccinations
  • Renal dialysis services that are obtained when a member is temporarily outside the plan’s service area and for the first Renal Dialysis visit so the Health Choice Case Management department is aware of the member’s dialysis needs and can coordinate follow-up care (along with the provider). Ongoing dialysis treatment does not require additional authorization(s).

In addition to any exclusions or limitations described in the HC Generations Evidence of Coverage and Summary of Benefits, the following items in the list below are NOT covered except as indicated by Health Choice Generations.

They include but are not limited to:

  • Services that are not covered under Original Medicare, unless such services are specifically listed as covered in Section 4.
  • Services that you get from non-plan providers, except for care for a medical emergency and urgently needed care, renal (kidney) dialysis services that you get when you are temporarily outside the plan’s service area, and care from non-plan providers that is arranged or approved by a plan provider. See other parts of this booklet (especially Sections 2 and 3) for information about using plan providers and the exceptions that apply.
  • Services that you get without a referral from your PCP, when a referral from your PCP is required for getting that service.
  • Services that you get without prior authorization, when prior authorization is required for getting that service. (Section 4 gives a definition of prior authorization and tells which services require prior authorization.)
  • Services that is not reasonable and necessary according to the standards of original Medicare unless these services are otherwise listed by Health Choice Generations as a covered service. As noted in Section 4, we provide all covered services according to Medicare guidelines.
  • Emergency facility services for non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency. (See Section 3 for more information about getting care for a medical emergency).
  • Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by Original Medicare or unless services covered under an approved clinical trial. Experimental procedures and items are those items and procedures determined by Health Choice and Original Medicare that are not generally accepted by the medical community. See Section 7 for information about participation in clinical trials while you are a member of Health Choice Generations.
  • Surgical treatment of morbid obesity unless medically necessary and covered under Original Medicare.
  • Private room in a hospital, unless medically necessary.
  • Private duty nurses.
  • Personal convenience items, such as a telephone or television in your room at a hospital or skilled nursing facility.
  • Nursing care on a full-time basis in your home.
  • Custodial care is not covered by Health Choice Generations unless it is provided in conjunction with skilled nursing care and/or skilled rehabilitation services. “Custodial care” includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, and using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered.
  • Homemaker services.
  • Charges imposed by immediate relatives or members of your household.
  • Meals delivered to your home.
  • Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance unless medically necessary
  • Cosmetic surgery or procedures, unless it is needed because of accidental injury or to improve the function of a malformed part of the body. Breast surgery is covered for all stages of reconstruction for the breast on which a mastectomy was performed and, to produce a symmetrical appearance, surgery and reconstruction of the unaffected breast.
  • Routine dental care (such as cleanings, fillings, or dentures) or other dental services. Certain dental services that you get when you are in the hospital will be covered.
  • Chiropractic care is generally not covered under the plan, (with the exception of manual manipulation of the spine, as outlined in Section 4) and is limited according to Medicare guidelines.
  • Routine foot care is generally not covered under the plan and is limited according to Medicare guidelines.
  • Orthopedic shoes unless they are part of a leg brace and are included in the cost of the leg brace. There is an exception: Orthopedic or therapeutic shoes are covered for people with diabetic foot disease (as shown in Section 4, in the Benefits Chart under “Outpatient Medical Services”).
  • Supportive devices for the feet. There is an exception: orthopedic or therapeutic shoes are covered for people with diabetic foot disease (as shown in Section 4, in the Benefits Chart under “Outpatient Medical Services”).
  • Hearing aids and routine hearing examinations.
  • Routine eye examinations and eyeglasses (except after cataract surgery), radial keratotomy, LASIK surgery, vision therapy and other low vision aids and services.
  • Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.
  • Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies and devices. (Medically necessary services for infertility are covered according to Original Medicare guidelines.)
  • Acupuncture.
  • Naturopath services.
  • Services provided to veterans in Veteran’s Affairs (VA) facilities. However, in the case of emergency services received at a VA hospital, if the VA cost sharing is more than the cost sharing required under Health Choice Generations, we will reimburse veterans for the difference. Members are still responsible for the Health Choice Generations cost sharing amount.

Please see the Health Choice Generations Prior Authorization list for more information on what services are covered and not covered by the Health Choice Generations plan.

This is not all-inclusive therefore Providers must verify both eligibility and covered benefits prior to rendering services at (480) 968-6866 and (800) 322-8670.


You are now leaving Health Choice Generations

Health Choice Generations provides links to web sites of other organizations in order to provide visitors with certain information. Once you link to another web site not maintained by Health Choice Generations, you are subject to the terms and conditions of that web site, including but not limited to its privacy policy.

You will be redirected to

Click the link above to continue or CANCEL

Attention:

Health Choice is currently experiencing difficulties with our toll-free phone systems.

We appreciate your patience as we work to resolve this issue.

In the meantime, our Member Services team can still be reached on our local lines: 480-968-6866 (Maricopa County) and 520-322-5564 (Pima County).