PROVIDER QUICK REFERENCE GUIDE - 1199SEIU Funds

1 1199 SEIUPROVIDER QUICK REFERENCE GUIDE1199 SEIU Benefit FundsProvider Relations Department330 West 42nd StreetNew York, NY 10036-6977(646) 2017 QUICK REFERENCE GUIDEFOR ALL PROVIDER INQUIRIES (INCLUDING PROVIDER PARTICIPATION STATUS): 1199 SEIU Benefit Funds PROVIDER Relations Department 330 West 42nd StreetNew York, NY 10036-6977(646) 473-7160 | Interactive Voice Response (IVR) System is available to you 24 hours a day to check claim status and member eligibility. Just call (888) 819-1199. Claim status and eligibility information is also available through NaviNet at To sign in, click the Login icon that appears at the upper right corner of the REQUEST A PROVIDER APPLICATION PACKAGEC omplete the PROVIDER Recruitment Form on our website at Fax it to (646) 473-7213, or call (646) 473-7160 for more Funds TRANSFER (EFT) ENROLLMENT For information on EFT enrollment, call Change Healthcare (formerly Emdeon) at (866) 506-2830 (Option 1).

2 To enroll online, visit To enroll via fax or mail, download the enrollment form at Then fax the completed form to (615) 238-9615, or mail it to:Change Healthcare EFT Enrollment Request 3055 Lebanon Pike Ste. 100 Nashville, TN 37214TO SUBMIT PROVIDER INFORMATION CHANGESC omplete the PROVIDER Demographic Information Change Request Form on our website at Fax it to (646) 473-7229. Be sure to include your Form W-9 as notify us at least 60 days prior to the effective date for all SUBMISSION To submit electronic claims, use Payer ID #13162:Change Healthcare (formerly Emdeon and Capario) (866) 742-4355 ABILITY Network(formerly MD On-Line) (888) (866) 735-2963 To submit paper claims:Medical Claims:1199 SEIU Benefit FundsMedical ClaimsPO Box 1007 New York, NY 10108-1007 Hospital Inpatient Admissions, ER and Ambulatory Surgery Claims.

3 1199 SEIU Benefit FundsPO Box 933 New York, NY 10108-0933 For reconsideration of a medical claim, complete the Claim Reconsideration Request Form on our website at You can submit via email to via fax to (646) 473-7088 or via mail to Medical Claims Reconsideration, PO Box 717, New York, NY , LABORATORY SERVICES, RADIOLOGY, RADIATION THERAPY, MEDICAL ONCOLOGY AND THE 1199 SEIU MEDICAL REVIEW PROGRAMP rescriptions For general information, call Express Scripts at (800) 818 6720. For prior authorization, call Express Scripts at (800) 753-2851, or submit electronically at Specialty drugs delivered on an outpatient basis and billed through the medical benefit require prior authorization. Call Care Continuum at (877) 273-2122, fax to (877) 814-4047 or visit Services1199 SEIU Benefit Funds participating labs: Quest Diagnostics (866) 697-8378 Laboratory Corporation of America (LabCorp) (800) 788-9091 For a list of lab services that can be done in-office, visit Medical Review ProgramPrior authorization is required for high-tech radiology and nuclear cardiology scans, radiation therapy, medical oncology treatments and certain outpatient molecular and genomic laboratory services.

4 To request prior authorization, call the 1199 SEIU Medical Review Program, which is managed by eviCore healthcare, at (888) 910-1199. For a directory of participating radiology facilities, call One Call Care Management (formerly MedFocus Radiology Network) at (800) 398-8999, or visit our website at AUTHORIZATIONCall (646) 473-7446 to request prior authorization for the following outpatient services: Home health care Non-emergency ambulance service Hyperbaric oxygen therapy (HBOT) and negative pressure wound therapy (NPWT) BiPAP/Ventilators Oxygen services Prosthetics Certain outpatient testing and procedures, including sleep studies and pulmonary and cardiac rehabilitation Certain durable medical equipment (DME)Hospital Care and Other ServicesCall 1199 SEIU CareReview at (800) 227-9360 for prior authorization of.

5 Certain ambulatory surgery/outpatient surgical procedures Chiropractic services beyond 12 visits All evaluations for consideration of potential transplant Hospital care: Call before a hospital admission or within two days of an emergency admission Behavioral health: Mental health and alcohol/substance abuse treatment Inpatient treatment: Call 1199 SEIU CareReview at (800) 227-9360 Outpatient treatment (including PHP and IOP): Call the Member Assistance Program at (646) 473-6900 For a comprehensive list of services requiring prior authorization, visit BENEFIT FUND MEMBER PROGRAMS For Care Management, call (646) 473-7160, Option 2. For the Wellness Member Assistance Program, call (646) 473-6900. For the Prenatal Program, call (646) 473-8962. For Vital Decisions (healthcare counseling), call (800) 301-3984.

6 For Teladoc (telehealth service), call (800) 835-2362 or visit : Using in-network providers, labs and facilities will help ensure that your 1199 SEIU patients do not incur a balance.