1 Provider Manual mayo Clinic Health Solutions CHAPTER 1 - INTRODUCTION. mayo Clinic Health Solutions ( MMSI) is a third-party administrator (TPA) and health benefits management company focused on providing outstanding member care. Based in Rochester, MN, mayo Clinic Health Solutions serves millions of households through our plan administration services and wellness products and programs. mayo Clinic Health Solutions processes claims, provides customer service support, manages Provider networks and performs other administrative functions. A team of specialists provide medical management services to assure plan participants receive quality care at a reasonable cost along with appropriate and effective utilization of health care resources for positive clinical and financial outcomes. mayo Clinic Health Solutions has developed this Provider Manual for use by participating health care providers and their business office staff.
2 This Manual provides information about our commercial claims filing procedures, payment, Provider agreements, managed care requirements, communications, and other topics that affect patient accounts and patient relations. As our policies and procedures change, this Provider Manual will be revised and you will be notified through: The quarterly eUpdate for Providers online newsletter The mayo Clinic Health Solutions Online Service for Providers Web site at Important Note: Commercial as used in this Provider Manual , refers to all mayo Clinic Health Solutions medical products that are not Medicare, Medicaid, or other governmental products. In the event of a conflict or inconsistency between your contract and this Manual , the provisions of your contract with mayo Clinic Health Solutions will control. Information for the South Country Health Alliance (SCHA) governmental products can be found in the SCHA Provider Manual , EUPDATE FOR PROVIDERS NEWSLETTER.
3 The eUpdate for Providers newsletter is published quarterly and emailed to the Office Manager's attention at mayo Clinic Health Solutions-contracted sites. Please notify us if you need to update the designated contact person's email address or add a new contact person to receive the newsletter. Email your request and include your tax identification number to 1. mayo Clinic HEALTH SOLUTIONS RESOURCES. CUSTOMER SERVICE. Representatives are available to assist you Monday through Friday, 7:00 to 7:00 CT. Please refer to the back of the member's member ID card for the Customer Service phone number for their specific plan. Customer Service phone numbers are also listed in the Quick Reference Guide, available when you sign in to your account at When you call, please have your National Provider Identification (NPI) number and tax identification number, and the member's membership number and the claim number available to expedite your call.
4 HEALTH SERVICES. Please refer to the following information to contact Health Services: Phone 1-800-645-6296. Fax 1-888-889-7822. PHARMACY BENEFIT SERVICES. Please contact Pharmacy Benefit Services by fax: 507-538-5767 or 507-538-5222. PHYSICAL ADDRESSES. mayo Clinic Health Solutions 4001 41st Street NW. Rochester, MN 55901. ONLINE SERVICES FOR PROVIDERS mayo Clinic Health Solutions Online Services for Providers includes tools that give providers access to plan and administrative information. Through the Web site, you have access to: Member claims information Member eligibility information Member health plan documents In order to access these tools, you must be registered as a Super User or as an End User. To register as a Super User, please complete a Super User Request fax form, available at in the Online Services for Providers under Provider Forms.
5 There is only one Super User assigned per health care facility. 2. To register as an End User, please contact the designated Super User at your health care facility. CLAIMS ADDRESS. All participating providers with electronic capabilities for claim submission are required to electronically submit all claims. Refer to the back of the membership card for the correct claims mailing address and the correct electronic Payor ID. The mayo Clinic Health Solution electronic Payer ID is 41154. MEMBER ID CARDS. Your patient's member ID card contains information that is essential for claims processing. We recommend that you review the patient's member ID card at every visit and have a current copy of the front and back of the card on file. Sample member ID cards are listed in the Quick Reference Guide, available when you sign in to your account at The following information is found on the member ID card: Name of the plan Member number, including alpha prefix Member's name and group number Prescription coverage information Claims submission information Customer Service contact information CHANGES TO DEMOGRAPHIC INFORMATION.
6 Your contract with mayo Clinic Health Solutions requires you to contact us with demographic changes, including facility location updates. Without proper notification, new facility locations may be considered out-of-network, or your contract may become null and void. Please complete the Facility Change Update form, located at in the Online Services for Providers section under Provider Forms and fax a copy to us at 1-507-266-0619. 3. CHAPTER 2 - PARTICIPATING Provider POLICIES AND. PROCEDURES. Participating Providers are those providers who have entered into a written contract with mayo Clinic Health Solutions in order to establish an independent contractor relationship between the parties for the purpose of engaging the Provider to supply medical services to our clients and members. RESPONSIBILITIES OF PARTICIPATING PROVIDERS.
7 The responsibilities of participating providers include: Electronic submission of all claims (if the Provider has electronic capabilities). Participation in the mayo Clinic Health Solutions credentialing process. Submission of prior notifications or prior authorizations, when required. Referral of patients to other participating providers, whenever necessary. Acceptance of payment provisions outlined in the Provider Agreement. Provision of services within the scope of their registration, license, and training and consistent with community standards for quality and utilization. Maintenance and provision of records and documents to mayo Clinic Health Solutions at no charge, as required by applicable laws, regulations and program requirements. Cooperation with mayo Clinic Health Solutions to facilitate the information and records exchanges necessary for quality management, utilization management, peer review or other programs required for operations.
8 Compliance with applicable state and federal laws, regulations and plan requirements. Cooperation with mayo Clinic Health Solutions in the implementation of Member Grievance procedures and assistance in taking appropriate action. Maintaining insurance coverage on behalf of themselves, and, if applicable, each of their participating providers. Compliance with all mayo Clinic Health Solutions Provider policies and procedures, which may be enacted and revised from time to time. 4. SITE REVIEWS. As stated in your contract, mayo Clinic Health Solutions may conduct site reviews to ensure that network facilities and medical records meet our quality standards, and as may be required by applicable law. If findings from the site review show deficiencies, an action plan will be developed to ensure the network facility will be brought up to our standards.
9 This plan should be completed within a reasonable amount of time or the contract may be terminated, according to contract terms. NON-DISCRIMINATION. Except as medically appropriate, participating providers shall not differentiate or discriminate in the treatment of any member because of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age, health status or source of payment. CULTURALLY COMPETENT CARE. Participating providers must demonstrate cultural competence in their treatment of plan members. This practice ensures that all Clinic and non-clinical services are accessible to all members and are provided in a culturally competent manner, including members with limited English proficiency or low reading levels, and those with diverse cultural and ethnic backgrounds. ADVANCE DIRECTIVES.
10 Participating providers are required to inform all adult patients about their right to accept or refuse medical treatment, as well as the right to execute an advance directive. Providers must document in the medical record whether or not an individual has executed an advance directive. In addition, providers have the responsibility to inform patients of the right to file a complaint with their State's Health Department regarding noncompliance with advance directive requirements. CONFIDENTIALITY. Participating providers must comply with HIPAA privacy requirements and all applicable state and federal privacy laws and regulations. All Provider Agreement terms and conditions must remain strictly confidential. 5. HOW TO APPLY TO BECOME A PARTICIPATING Provider . To learn more about how to become a participating Provider , go to Online Services for Providers at and click on Join our Network in the left hand navigation.