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Elderplan 2016 Provider ManualNetwork: the collective group of physicians, facilities,hospitals, agencies, and ancillary providers contractedwith Elderplan.Participating Provider: a licensed healthcareprofessional, facility, hospital, or agency who orwhich has entered into a contractual agreement eitherdirectly or indirectly with Elderplan to provide servicesto Elderplan members. Some non-participatingprovider services may be provided to members in casesof Elderplan prior-authorization.Non-Participating Provider: a licensed healthcareprofessional, facility, hospital, or agency who or whichhas NOT entered into a contractual agreement eitherdirectly or indirectly with Elderplan to provide servicesto Elderplan members.Primary Care Physician (PCP): a primary carephysician is a participating provider contractedwith Elderplan the member selects from a list ofparticipating physicians in Internal Medicine, Familyor General Practice, and Pediatrics. The PCP rendersgeneral medical care to the member and coordinatesspecialty care as needed.All Primary Care and Specialty Care Physicians mustverify a member’s eligibility and product participationat the time of service. To verify membership eligibility,call Elderplan Customer Service at (718) 921-7979or use the Elderplan web portal. To sign up for theProvider Portal, simply go to: http://elderplan.org/forproviders/ and choose the option “CLICK HERE toregister for the Physician Web Portal today.” To verifyproduct participation, please refer to the lower lefthand corner of the member ID card or call ElderplanCustomer Service at (718) 921-7979.It is the provider’s responsibility to request themember’s membership card at the time of service.Elderplan does not retrieve membership cards frommembers when they disenroll or lose coverage;therefore presentation of a membership card is NOT aguarantee of eligibility.Though capitated Primary Care Physicians can consulttheir membership roster of the present month toensure the member appears on their list, verificationof eligibility through Elderplan Customer Service orweb is always recommended. If the member is on thecapitation list, the provider has received the monthlycapitation payment for that member and can thusprovide services during that month.Specialty Care Provider (SCP): a physician specialistwho is board eligible or board certified in the specialtyhe/she has declared on the Elderplan participationapplication.Service Area: the counties of New York under whichElderplan has received NYS approval to enrollmembers, recruit a provider network, and providecoverage.PROVIDER NETWORK OPERATIONSAND SERVICESImportant DefinitionsNetwork Operations and Planning: the departmentdesignation given to the group of Elderplan staffdedicated to complete provider recruitment andcontracting, field service, and managing provider files.Provider Services Representative: field individualsemployed by Elderplan to service providers.Provider Contract: a legal agreement betweenElderplan and participating professionals, facilities,hospitals, agencies that binds the participants toprovide covered services to Elderplan members at amutually agreed upon rate.7

Elderplan 2016 Provider ManualProvider ServiceField RepresentativesElderplan Web SiteElderplan assigns Field Representatives by region.Each new participating provider will be visited byan Elderplan Provider Services Representative for anorientation on our plan, products, and procedures.Your Provider Services Representative will then visityour office periodically in order to ensure the serviceElderplan is providing you is efficient and the servicesyou provide to Elderplan members conforms with thecontractual agreement and policies and proceduresoutlined herein.Providers and their office staff are encouraged tovisit our web site at www.elderplan.org. On thissite, providers can find participating providers andancillary providers, using the Provider directory. Thewebsite also includes new policies and proceduresenacted by Elderplan, as well as other providerreference materials.We have also introduced the provider web portal. ForElderplan’s participating providers, some of the mostcommon inquiries—including member eligibility,claims details, and authorization status—now canbe done with the click of a mouse 24 hours a day, 7days a week. While the Web portal uses sophisticatedtechnology, it is easy to use.You should become familiar with your FieldRepresentative as they can provide assistance inmaking your Elderplan network participation a verypositive experience.ROLES AND RESPONSIBILITIESElderplan has paid close attention to feedback fromproviders. In addition to eligibility and claims details,the portal offers important resources such as:PCP and Specialist Roles and ResponsibilitiesAll Elderplan participating professionals, hospitals,facilities, agencies, and ancillary providers agree to: Formulary Participating providers Steps for filing an appeal Summary of benefits for each member planTo learn more about the Web portal, contact ElderplanCustomer service at (718) 921-7979. To sign up forthe Provider Portal, simply go to: http://elderplan.org/for-providers/ and choose the option “CLICK HEREto register for the Physician Web Portal today.”Contractual Requirements: provider must complywith all contractual, administrative, medicalmanagement, quality management, appeals &grievances, and reimbursement policies as outlined inthe Elderplan provider contract, Provider Manual, andcirculated updates. Failure to adhere or comply withall contractual/regulatory requirements may result intermination of your contract.The provider is expected to coordinate referrals forElderplan members who require care outside thescope of the provider’s practice to appropriate innetwork specialists, participating ancillary providers,or facilities for medical care or services. A full list ofparticipating providers can be found on the ElderplanWeb site at www.elderplan.org/find-a-provider/.Note: An Elderplan PCP who has training in a subspecialty may be credentialed in that specialty and alsoparticipate as a specialist in Elderplans network. Suchproviders are called “Dual Providers”. Out-of-networkreferrals require prior authorization.Please input your information and finalize the requestby pressing the “Confirm and Submit” button.Elderplan will approve your request as promptly aspossible by validating your information. You will needto keep your login information on hand in order toaccess the valuable data housed in the portal 24 hoursa day, 7 days a week.Customer ServiceIf you have question about a claim, pre-authorization,or other questions, please call (718) 921-7979.Avoid busy call volume times by using Elderplan’sweb site – www.elderplan.org8

Elderplan 2016 Provider Manual Accessibility of doctors’ offices, clinics and other healthcare providers is essential in providing medical careto people with disabilities. Medical care providersare required to make their services available in anaccessible manner. This standard includes physicalaccess, non-discrimination in policies and proceduresand communication. Accessibility needs should be notedin the member’s chart so the provider is prepared toaccommodate the member on future visits. Physical accessibility is not limited to entry to a providerAt provider sites where participating providers aresite (including accessibility along public transportationsharing office space with non-participating providers, aroutes and/or availability of parking with adequate numberparticipating provider must treat Elderplan members.of accessible parking spaces and path of travel from thedisability-accessible parking space to the facility entranceNon-Discrimination, ADA Compliance andthat does not require the use of stairs), but also meansAccessibility:access to services within a site, such as: Provider must not differentiate or discriminate in—accessible exam tables,accepting and treating patients on the basis of race,—accessible stretcher or gurney, or a patient lift,ethnicity, national origin, religion, sex, age, mental—trained staff available to assist the memberor physical disability or medical condition, sexualwith transfers,orientation, claims experience, medical history, evidence—accessible medical equipment.of insurability (including conditions arising out of actsof domestic violence), disability, genetic information, orProvider site physical accessibility is verified duringsource of payment.Elderplan credentialing process. When a memberis unable to sufficiently access a provider location, Elderplan and its contracted providers shall ensurealternative treatment locations will be made available.compliance with Title VI of the Civil Rights Act, the AgeFor more information on important accessibilityDiscrimination Act of 1975, the Americans with DisabilitiesAct, and other laws applicable to recipients of Federal Funds. requirements click here.Title II of the Americans With Disabilities Act (ADA) and Communications Access: Communications withSection 504 of the Rehabilitation Act of 1973 (Section 504)individuals with disabilities are required to be as effectiveprovides that no qualified individual with a disability shall,as communication with others, including membersby reason of such disability, be excluded from participationwith hearing, vision, or speech impairment. Providersin or denied access to the benefits of services, programs orare encouraged to utilize the TTY (teletypewriter lines)activities of a public entity, or be subject to discrimination byat 711. Member materials are made available in ansuch an entity. Further, Section 504 of the Rehabilitation Actalternate format such as Braille, larger print, or audio.of 1973 requires providers (e.g., facilities, clinics, individualElderplan Member Service should be contacted atproviders) who receive payments, directly or indirectly, from(718) 921-7979 for additional information.Medicaid or Medicare ensure individuals with disabilitieshave an equal opportunity to receive services by way ofaccessible health care services. Under the ADA, Title III,public entities, such as private doctors’ offices, hospitals andclinics are required to make reasonable accommodationsfor individuals with disabilities irrespective of the receipt offederal funds.A referral should be made only when, in yourprofessional opinion, you believe it is medicallyappropriate and necessary. If you have never seen thepatient before, you have the right to ask the patientto come in for an examination and diagnosis beforeissuing a referral. If you do not examine the patient onthe day you issue a referral, you may not charge for anyevaluation and management service at that time. Forcomplete details log on to Elderplan.org9

Elderplan 2016 Provider ManualCultural Competency Elderplan Provider Web Portal (to register for the ProviderWeb Portal please Click Here) One-on-one in-service training sessions facilitated byProvider Services Representative onsite.Elderplan Provider Services Department will maintaina record of provider participation in the CulturalCompetency training. The provider is required toattest to taking the Cultural Competency Course andoffering it to the practice/facility staff by filling outan Attestation form available via the provider portal.Provider may either utilize Cultural Competencytutorial available on Elderplan web portal or attest totaking the equivalent course as training requirementsmay be met by demonstrating completion of CulturalCompetency certificate program or another New YorkState FIDA Plans equivalent Cultural Competencytraining program. Examples of proof of trainingcompletion may include copies of course certifications,pre/post test, and knowledge check results and aresubject to random audits by Elderplan ProviderServices team.Elderplan takes pride in serving an incrediblyculturally diverse member population. Rooted in thelong tradition of caring for New York elderly anddisabled of various ethnic and cultural backgrounds,Elderplan strives to meet the individual needs of thepopulation it serves through recognizing the diversityand providing appropriate support to the memberswith unique linguistic and communication needsas well as to the provider community treating thispopulation.The required Elderplan Cultural Competency traininghelps medical, behavioral, community-based andfa

prior- authorization. Emergency care does not require prior-authorization. Emergency admissions require notification within 24 hours of admission. VERIFYING ELIGIBILITY Verifying eligibility and product participation is extremely important in the care and payment process. Eligibility and product participation determines ones