Q. |
How do physicians become a part
of the Delaware Physician's Care Network?
|
Q. |
Where do providers send a claim? |
Q. |
Who do providers call with questions
about a claim payment or claim status? |
Q. |
How do providers order a current Provider
Manual or Directory? |
Q. |
How do I find out who my provider
representative is? |
Q. |
How do providers obtain authorizations
from Delaware Physicians Care? |
Q. |
How do providers verify enrollment
of a patient? |
Q. |
What services are covered under Delaware Physicians Care |
Q. |
Do members enrolled in the Delaware
Healthy Children Program receive different benefits? |
Q. |
Are there benefits available to members of Delaware Physicians Care, but
covered directly by the Delaware Medical Assistance Program? |
Q. |
Does Delaware Physicians Care offer
a perinatal program? |
Q. |
Does Delaware Physicians Care offer
any disease management programs? |
Q. |
Are the providers able to bill under the mother's ID number for newborns? |
Q. |
Are providers able to bill bilateral procedures on one line or two? |
Q. |
With multiple modifiers are the providers to bill with a "99"? How are they to
bill with multiple modifiers? |
Q. |
If a member is in the hospital and they become eligible for DPCI,
who pays for the entire inpatient stay? |
Q. |
Can CMS 1500 claims be submitted with date spans? |
Q. |
Should providers bill with the Delaware taxonomy codes? |
Q. |
How should hospitals bill for outpatient late charges? |
Q. |
How should providers submit claims for new drugs on the market? |
Q. |
If a non-contracted primary care physician refers to a contracted specialist can the specialist see
the member and receive payment? |
Q. |
Will DPCI reimburse providers for completed EPSDT forms? |
Q. |
If a member presents to a primary care physician (PCP) office with a dental related issue,
will DPCI reimburse the provider for services with a dental diagnosis code? |
Q. |
How does DPCI reimburse if the member has other primary insurance? |
Q. |
Is Human Papillomavirus (HPV) screening a covered service for women? |
Q. |
Is the meningitis vaccine covered for members over the age of 18? |
Q. |
Do lab tests sent to contracted hospitals require prior authorization? |
Q. |
Which cardiac testing procedures require prior authorization? |
Q. |
Do allergy injections given in the PCP's office as ordered by an Allergist require
prior authorization? |
Q. |
When requesting authorization for elective hospital admissions, is the provider
required to submit the "end" date of the admission? |
Q. |
If a dentist refers a member to a maxiollofacial surgeon, does the surgeon need a referral? |
Q. |
If a member is referred to a specialist and DPCI is the second party
to be billed, in order to submit a claim, does a provider need to receive a referral or obtain a prior
authorization to submit the secondary claim to DPCI? |
Q. |
Does DPCI have a specific Behavioral Health release of information form? |
Q. |
If a member requests a change in their primary care physician,
when will the change be effective? |
Q. |
Will there be a suffix number on the Member ID numbers in addition to the DMAP number? |
Q. |
DPCI accepts claims electronically from which vendors? |
Q. |
What is DPCI's electronic payer ID? |
| |
|
Q. |
How do physicians become a part of the Delaware Physician's Care Network?
|
A. |
Please contact our Provider Relations department for an application.
Delaware Physicians Care, Incorporated
Attn. Provider Relations
252 Chapman Rd., Suite 250
Newark, DE 19702-5406
1-800-287-9860
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|
Q. |
Where do providers send a claim? |
A. |
Delaware Physicians Care
Claims Submission
P.O. Box 61145
Phoenix, AZ 85082-1145
Resubmissions, along with all attachments, should be sent to the same address,
marked as resubmissions on the envelope.
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|
Q. |
Who do providers call with questions about a claim
payment or claim status? |
A. |
Providers should contact the Claim Research/Claim Inquiry
Unit in our Claims department at 1-866-543-2167.
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|
Q. |
How do providers order a current
Provider Manual or Directory? |
A. |
Providers may call the Provider Relations department at 1-800-287-9860
or contact their assigned provider representative.
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|
Q. |
How do I find out who my provider
representative is? |
A. |
Delaware Physicians Care assigns every network provider a representative.
Provider representatives are in regular contact with providers and/or
office staff. Providers may confirm the name and phone number of their
provider representative by calling the Provider Relations department
at 1-800-287-9860.
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|
Q. |
How do providers obtain authorizations from Delaware Physicians Care? |
A. |
Providers may contact the Prior Authorization Unit seven days a week,
24 hours a day by calling 1-866-543-2167. Providers may also fax requests
for authorizations to Delaware Physicians Care at 1-866-543-2184. Behavioral
Health requests should be faxed to 1-866-543-2384.
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|
Q. |
How do providers verify enrollment of a patient? |
A. |
Providers can verify eligibility by registering on the Delaware Physicians
Care Web site or calling the Member Services department at 1-866-543-2167.
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|
Q. |
What services are covered under Delaware Physicians Care |
A. |
- Inpatient and outpatient hospital care
- Doctor office visits, including specialist visits
- Routine checkups and sick visits
- Health risk assessments and screenings
- Baby and child care for regular checkups and immunizations (shots)
- Well woman visits – Pap test, mammograms
- Lab visits and X-rays
- Durable medical equipment and supplies like wheelchairs or walkers
- Emergency care 24 hours a day
- Care to stabilize you after an emergency
- Home health services
- Nursing home – up to 30 days a year
when ordered by your PCP
- Rehabilitation services, including occupational, speech and physical
therapy
- Routine immunizations (shots)
- Maternity care (prenatal, labor and delivery, postpartum)
- Routine eye care and glasses for members under the age of 21
- Family planning services
- Hospice
- Behavioral health/substance abuse services
- Emergency transportation
- Private duty nursing – up to 28 hours
per week
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|
Q. |
Do members enrolled in the Delaware
Healthy Children Program receive different benefits? |
A. |
Basic benefits listed in Question 8 are the same, plus you get case management
and care coordination services. Dental services and non-emergency transportation
for medical care are not covered for kids in the Healthy Children’s program.
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|
Q. |
Are there benefits available to members of Delaware Physicians Care, but
covered directly by the Delaware Medical Assistance Program? |
A. |
Yes. The following benefits are available to Delaware
Physician Care members, but are covered directly by the Delaware Medical
Assistance Program:
- Prescription Drugs
- Behavioral health services that continue longer than
the benefits covered by Delaware Physicians Care.
- Extended nursing facility services
after the 30 days covered by Delaware Physicians Care.
- Non-emergency transportation
- Dental services for members under age 21
- Benefits for children such
as Preschool Developmental Diagnostic Nursery, Pediatric Extended
Care and DPSDT/CSCRP, etc.
To find out more about these services, including transportation,
please call the Delaware Division of Social Services at 1-800-372-2022.
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|
Q. |
Does Delaware Physicians Care offer a perinatal
program? |
A. |
Yes. Specifically designed to offer pregnant members the best maternity
and post partum care available, Delaware Physicians Care has taken
a collaborative approach with the State of Delaware by folding the
existing state’s “Smart Start Program” into our own
perinatal program. Health professionals are encouraged to use both
programs to support the care of expectant mothers. The objective of
our perinatal program is to
- Have every pregnant member begin perinatal care as early as possible
- Conduct a health risk assessment on every identified pregnant member
and then to coordinate and provide case management services specific
to the member’s needs
If you would like to make a referral for any of your pregnant members, please
contact the perinatal case management staff at (302) 894-6740, or use the Case
Management Request form found on this
Web site.
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|
Q. |
Does Delaware Physicians Care
offer any disease management programs? |
A. |
Yes. Disease management programs for asthma, diabetes, COPD and congestive
heart failure are available to members of Delaware Physicians Care, as
well as other chronic illnesses. If you would like to make a referral
for any of your members, please contact the case management staff at
(302) 894-6740, or use the Case Management Request
form found on this
web site.
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|
Q. |
Are the providers able to bill
under the mother's ID number for newborns?
|
A. |
No, newborns will be assigned their own identification numbers and claims will need
to be billed with the newborn's Medicaid identification number.
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|
Q. |
Are providers able to bill bilateral procedures on one line or two?
|
A. |
Providers are to bill bilateral procedures not inherently bilateral on two claim lines,
one unit on each line and modifier 50 reported on the second line.
Example:
CPT 69210 is for removal of impacted cerumen, one or both ears. CPT 69210 is inherently bilateral,
therefore the code should be submitted on one line only with units = 1. CPT code 29830 is for a diagnostic
arthroscopy of the elbow.
CPT 29830 is not inherently bilateral, therefore, if this procedure was performed on both the left
and right elbows, the code should be submitted on two lines, one unit reported for each lined and modifier 50
reported on the second line.
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|
Q. |
With multiple modifiers are the providers to bill with a "99"? How are they to
bill with multiple modifiers?
|
A. |
If there are multiple modifiers on a single line, they should bill the modifiers together (i.e. 5159, please
to not place a space between the modifiers)
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|
Q. |
If a member is in the hospital and they become eligible for DPCI,
who pays for the entire inpatient stay?
|
A. |
Should a member become eligible for DPCI while admitted as an inpatient, the admitting carrier is responsible for the entire
inpatient admission reimbursement. The physician fees will become the responsibility of DPCI on the effective date of
the member going forward.
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|
Q. |
Can CMS 1500 claims be submitted with date spans?
|
A. |
DPCI does not accept CMS 1500 claims submitted with date spans.
Exception: Date spans may be billed if the dates of service are consecutive.
Example: DOS 7/1/04-7/2/04; 99233; 2 units
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|
Q. |
Should providers bill with the Delaware taxonomy codes?
|
A. |
It is not necessary to bill DPCI utilizing Delaware taxonomy codes. However,
providers should bill with their Medicaid Identification or State assigned number in
Box 33 of the CMS 1500. Please contact Delaware Health & Social Services Provider Registration
or the DPCI Provider Service Department.
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|
Q. |
How should hospitals bill for outpatient late charges?
|
A. |
The entire claim should be re-billed with the late charges included and clearly marked as a resubmission.
DPCI will reverse the original claim and repay the new claim to include the late charges
to avoid duplicate denials.
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|
Q. |
How should providers submit claims for new drugs on the market?
|
A. |
The provider should submit the claim using the appropriate HCPCS code including a copy
of the drug invoice that includes the NDC number and cost of the drug.
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|
Q. |
If a non-contracted primary care physician refers to a contracted specialist can
the specialist see the member and receive payment?
|
A. |
The contracted specialist will be reimbursed for services provided as along as the specialist
is contracted and appropriate authorization of services is obtained. The specialist is to notify
DPCI of these occurrences to allow DPCI to contact the member and provide education regarding the
use of PCP and assignment.
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|
Q. |
Will DPCI reimburse providers for completed EPSDT forms?
|
A. |
DPCI contracted providers are required to provide EPSDT services utilizing the appropriate CPT
evaluation and management codes using the CMS 1500 form. Providers will be reimbursed according to
CPT codes billed at the contracted rate. DPCI does not reimburse providers based on completed EPSDT forms.
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|
Q. |
If a member presents to a primary care physician (PCP) office with a dental related issue,
will DPCI reimburse the provider for services with a dental diagnosis code?
|
A. |
Dental services are a covered benefit through DMAP. The PCP should bill dental services to DMAP.
Dental services are covered by DMAP for those members aged 21 and under for Medicaid and
the Healthy Children's Program.
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|
Q. |
How does DPCI reimburse if the member has other primary insurance?
|
A. |
DPCI shall consider for payment deductibles, coinsurance and other cost-sharing obligations up to the eligible reimbursable amount.
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|
Q. |
Is Human Papillomavirus (HPV) screening a covered service for women?
|
A. |
Yes, this is a covered service; providers should follow ACOG guidelines for this screening.
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|
Q. |
Is the meningitis vaccine covered for members over the age of 18?
|
A. |
Yes, meningitis vaccine is covered.
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|
Q. |
Do lab tests sent to contracted hospitals require prior authorization?
|
A. |
No, laboratory tests may be sent to contracted hospitals for processing. DPCI encourages providers to
send these lab tests to the DPCI contracted clinical laboratory.
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|
Q. |
Which cardiac testing procedures require prior authorization?
|
A. |
The following cardiac testing requires prior authorization:
Intracardiac Electrophysiological procedures; Echocardiography; Cardiac Catheterizations; Angiographic procedures;
and Cardiac Stent procedures.
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|
Q. |
Do allergy injections given in the PCP's office as ordered by an Allergist
require prior authorization?
|
A. |
Allergy injections given by the PCP in the PCP's office do not require prior authorization.
Allergy injections given in an allergist's office for members over the age of 21 require authorization.
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|
Q. |
When requesting authorization for elective hospital admissions, is the provider
required to submit the "end" date of the admission?
|
A. |
No, the provider only needs to submit the date of the surgery (the beginning date of the admission).
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|
Q. |
If a dentist refers a member to a maxiollofacial surgeon,
does the surgeon need a referral?
|
A. |
A dentist may refer a member to a maxiollofacial surgeon for a consultation who will
be reimbursed by DPCI for appropriate services. The maxillofacial surgeon is required
to obtain prior authorization for any type of services, orthotic, or procedures.
The maxillofacial surgeon is also required to inform the dentist and the member's PCP of services provided.
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|
Q. |
If a member is referred to a specialist and DPCI is the second party
to be billed, in order to submit a claim, does a provider need to receive a referral or obtain a prior
authorization to submit the secondary claim to DPCI?
|
A. |
If the primary carrier accepts a claim with or without a prior authorization or a referral,
DPCI will coordinate services and reimburse accordingly.
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|
Q. |
Does DPCI have a specific Behavioral Health release of information form?
|
A. |
Behavioral health providers may utilize their own release of information form.
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|
Q. |
If a member requests a change in their primary care physician,
when will the change be effective?
|
A. |
If a member requests a change in their primary care physician, the change to the
requested primary care physician will not be come effective until the first of the following month.
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|
Q. |
Will there be a suffix number on the Member ID numbers in addition to the DMAP number?
|
A. |
There is no suffix number to be added to a DPCI member ID number,
providers are to bill using the member's Medicaid ID number.
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|
Q. |
DPCI accepts claims electronically from which vendors?
|
A. |
NDC, NEIC, Proxy Med and WebMD
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|
Q. |
What is DPCI's electronic payer ID?
|
A. |
27009
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