Providers

Our Network Management Department understands the importance of developing and maintaining strong relationships with our contracting providers, while eliminating the barriers that people must overcome to access their quality health care services.

Credentialing/Re-credentialing of Providers

Contracted providers are adequately trained and appropriately licensed by governing agencies. Coastal Care Services mirrors NCQA standards to evaluate our providers in the network. This critical process assesses the providers’ training, experience, and licensing and/or sanctions.

For Providers Seeking to Partner with Us

Coastal Care Services, Inc. requires providers to be licensed and reputable with a desire to provide collaborative care and a successful track record. Providers seeking to partner with us are to be quality-focused, willing to participate in quality ratings and customer satisfaction programs.

To learn more or submit the below application forms call or email us at 1-855-481-0505, ProviderRelations@ccsi.care

IMPORTANT NOTIFICATIONS

Hurricane Michael

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October 22 – Disaster Grace Period Update

The Agency is extending the “disaster grace period” for Hurricane Michael from October 22 through November 9, 2018 for the following twelve counties that the Federal Emergency Management Agency (FEMA) has designated as a major disaster area: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Leon, Liberty, Taylor, Wakulla, and Washington.

Members in these counties can continue to receive inpatient and outpatient services without prior authorization, regard for service limitations, or whether the member has temporarily relocated to another region or state. Providers can check the Hurricane Michael Emergent Claims Processing page for specific details.

The state of emergency and 30-day emergency prescription refills continue in all 35 counties listed below.

October 08 – Hurricane Michael update

Important information about Hurricane Michael

Effective October 08, 2018, Governor Rick Scott has declared a state of emergency in 35 Florida counties due to the potential impact of Hurricane Michael.  At this point in time this includes Escambia, Santa Rosa, Okaloosa, Walton, Holmes, Washington, Bay, Jackson, Calhoun, Gulf, Gadsden, Liberty, Franklin, Leon, Wakulla, Jefferson, Madison, Taylor, Hamilton, Suwannee, Lafayette, Dixie, Columbia, Gilchrist, Levy, Citrus, Bradford, Pasco, Hernando, Pinellas, Hillsborough, Manatee, Alachua, Union and Baker counties.

This means that members in these 35 counties may refill their regular prescriptions earlier than usual to ensure a sufficient supply. Members may receive up to a 30-day emergency prescription refill of maintenance medication until December 7, 2018.

If you’re a member, please visit your pharmacy to receive up to a 30-day emergency prescription refill. If you have any questions, please contact Member Services at 1-855-355-9800 (TDD/TTY 1-855-358-5856).

If you’re a provider, we thank you for serving our members every day. If you have any questions regarding the state of emergency or prior authorizations, please call Provider Services at 1-800-617-5727.

Hurricane Provider Reimbursement

Important Provider Information Regarding Reimbursement for Services Rendered to Prestige Members Impacted by Hurricane Michael

October 22 – Disaster Grace Period Update

The Agency is extending the disaster grace period for Hurricane Michael from October 22 through November 9, 2018 for the following twelve counties that the Federal Emergency Management Agency (FEMA) has designated as a major disaster area: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Leon, Liberty, Taylor, Wakulla, and Washington.

Disaster Grace Period: Extended to November 9, 2018 for the 12 counties listed above (October 7, 2018 through October 21, 2018 for all other counties under state of emergency.)

  • No prior authorizations are required for any inpatient or outpatient services.
  • Payment will be provided to both participating and non-participating providers for services provided to Prestige members during this period.
  • Services will be provided whether or not the enrollee has temporarily relocated to a different region or state.
  • Usual service limitations will not be applied during this period.
  • Payment will be provided to mobile pharmacies in FEMA designated counties when all the requirements stated in the Department of Health Emergency Order 18-276 are met and when the mobile pharmacy is one of the following:
    • A participating pharmacy network provider and is known to Florida Medicaid.
    • A non-participating provider but is currently a Medicare participating provider and is provisionally enrolled in the Florida Medicaid program.
  • In order to be reimbursed for eligible Prestige members for dates of service within this period, providers not already enrolled in Florida Medicaid (out-of-state or in-state) must complete a provisional (temporary) enrollment application. The process for provisional provider enrollment is located at the Agency for Health Care Administration (AHCA) Hurricane Michael information page.  Please refer to the Provisional Provider Enrollment section below for additional information

Starting November 10, 2018, prior authorizations will be reinstated for inpatient and outpatient services for the 12 counties listed above. Prior authorizations have been reinstated for all other counties as of October 22, 2018.

For the 12 counties listed above, starting with date of service Nov 10, 2018, new authorization requests for durable medical equipment (DME) and home health services will be reviewed as part of an expedited authorization process until further notice.  This expedited authorization process will be completed within forty-eight (48) hours after receipt of the request for service. Prestige may extend the timeframe for expedited authorization decisions by up to two (2) business days if the member or the provider requests an extension or if additional information is needed to process the request, and the extension is in the member’s best interest.

Outside of the Disaster Grace Period (Beginning November 10, 2018, until further notice, for the 12 counties listed above. This period begins October 22, 2018  for all other counties under the state of emergency.)

In those instances where a provider and/or member could not comply with policy requirements because of ongoing storm-related impact, Prestige will continue to reimburse for:

  • Services furnished after the disaster grace period without prior authorization and without regard to service limitations
  • Services provided by a current Medicaid enrolled provider in those instances where the provider and/or member could not comply with policy requirements because of ongoing storm-related impacts

Providers must have rendered services in good faith to maintain the member’s health and safety. Examples of such instances include:

  • Provider still does not have access to the Internet or phone services as a result of continued power outages, therefore could not request prior authorization timely
  • The member continues to be displaced and must receive services in a different region of the state or out of state
  • The member’s assigned PCP or specialist’s office remains closed due to the storm and urgent care is rendered at another provider’s location without prior authorization
  • In order to be reimbursed for eligible Prestige members for dates of service within this period, providers not already enrolled in Florida Medicaid (out-of-state or in-state) must complete a provisional (temporary) enrollment application. The process for provisional provider enrollment is located at the Agency for Health Care Administration (AHCA) Hurricane Michael information page. This process should be completed PRIOR to submitting your claim to the Prestige Claims Payment Exception Process

Provider Provisional Enrollment

If a Provider and Billing Group DOES NOT Have a Florida Medicaid Number, you MUST FIRST apply for a Florida Medicaid ID.

To Apply for your Florida Medicaid Number:

For Medicaid providers within the State of Florida that are not enrolled with Florida Medicaid, along with out-of-state providers who are providing services to displaced Florida residents, Florida Medicaid is waiving the requirements to submit documentation showing the nature of the treatment, as well as other normally-required information. Until further notice, Florida Medicaid will only require the following:

  • A fully completed claim form containing the provider’s active National Provider Identifier (NPI), along with the provider’s SSN/FEIN; (this claims will not be reimbursed by AHCA, it is being used by AHCA as part of their provider provisional enrollment process only; after you receive your provisional provider number you will need to resubmit this claim to Prestige for claims processing and reimbursement)
  • A signed Florida Medicaid Provider Agreement (MPA);

If you are an Institutional Provider, please complete the Institutional Medicaid Provider Agreement.

If you are a Non-institutional Provider, please complete the Non-institutional Medicaid Provider Agreement.

  • A copy of the provider’s professional license; and
  • An optional signed Electronic Funds Transfer (EFT) Authorization Agreement, if providers choose to receive payment electronically.

After obtaining your Provider and/or group Florida Medicaid ID number from the state of Florida, you will then need to complete the Prestige Health Choice provider registration form.  This registration form will assist Prestige in setting you up in the Prestige claim’s payment system so that we can process your claims appropriately.

Once you have completed this form, please fax the completed form to 1-844-518-2552 or email to PHCPNORequests@prestigehealthchoice.com.  In addition to this form Prestige will also need the following documentation:

  • A complete and signed W9
  • A copy of your AHCA letter indicating your Florida Medicaid provider and group Medicaid IDs
  • A copy of 1 claim for provider setup purposes (this claim will not be forwarded to claims)

 

Prestige Claims Payment Exception Process

Prestige will reimburse for a medically necessary service that were provided to an impacted Prestige member DURING the designated disaster grace period (10/7/2018 through 10/21/2018) for the following:

  • The service(s) would have required a prior authorization
  • The service(s) was rendered by a non-participating provider
  • The service(s) exceeded normal policy limits for the service(s)

During this designated disaster grace period, providers should follow the usual Prestige claims submission process.

For medically necessary service(s) that were provided to an impacted Prestige member OUTSIDE of the designated disaster grace period (beginning 10/22/2018 and until further notice) to be considered for reimbursement by the Plan, the provider MUST submit the following information:

  • A completed Prestige Claims Exception Form
  • A contact name, telephone number and email address for the provider/provider office
  • A copy of the Agency’s letter reflecting your Medicaid provisional enrollment number.
  • A paper provider claim to ensure proper processing

Please note that for this claims payment exceptions process, Prestige’s process will include the waiver of non-applicable provider credentialing requirements.

Please provide all documentation in hard copy.  All information should be sent to:

Prestige Health Choice

Claims Exception Process-Hurricane Michael

11631 Kew Gardens Avenue, Suite 200

Palm Beach Gardens, FL  33410

For any questions regarding the claims payment exception process for Hurricane Michael, please call 1-888-599-1476 or email your question to HurricaneClaimExceptionProcess@prestigehealthchoice.com .