Hospital Orientation
May 2014
Conducted by: Yvonne Flores
The information in this document is confidential and should not be disclosed outside of Prestige Health Choice. It may not be reproduced in whole,
or in part, nor may any of the information contained therein be disclosed without the prior consent of the directors of Prestige Health Choice.
Prestige Health Choice
Who we are
At Prestige Health Choice, we don’t just want to build a better health plan – we want to make getting
care a priority. We believe that every person deserves respect and quality care. That’s our promise –
and we’re working to deliver on that promise every day.
What makes us different
Prestige is owned in part by Community Health Centers (Federally Qualified Health Centers – FQHCs).
These non-profit health centers and their doctors share our mission to improve the health of our
members. Many of these centers have served their communities for over forty years, giving care to
patients who need it the most. Our doctor-owners serve over 350,000 Floridians – most of whom have
no insurance.
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Medicaid Overview
Prestige serves both adults and children eligible to participate in Florida’s Medicaid Program.
In addition to traditional Medicaid coverage, additional coverage* includes:
 Adult Dental Services
 Adult Vision Services
 Adult Hearing Services
 Over-the-Counter Vitamins, Medicines and Health Supplies
*Coverage is subject to change
No Co-Payments, Coinsurance or Deductibles.
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Member Identification and Eligibility Verification
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Prestige Health Choice member eligibility varies by month. Therefore, each participating provider is
responsible for verifying member eligibility with Prestige before providing services. Eligibility may be
verified by visiting the Provider Portal of Prestige Health Choice’s website at
www.prestigehealthchoice.com, via the Availity Portal at www.availity.net or by calling Provider Services at
1-800-617-5727.
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If you have questions or need assistance you can contact the Availity support team at 1-800-282-4548 or
you may email them at support@availity.com
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Please note that the presentation of a Prestige Health Choice ID card is not sole proof that a person is
currently enrolled in Prestige. For example, when a member becomes ineligible for Medicaid, the member
does not return the Prestige Health Choice membership card. Providers should request a picture ID to verify
that the person presenting is the person named on the ID card. Services may be delayed being rendered, if
the provider suspects the presenting person is not the card owner and no other ID can be provided, except
for emergent situations. If providers suspect a non-eligible person is using a member’s ID card, please
report the occurrence to Prestige Health Choice’s Fraud and Abuse Hotline at 1-866-833-9718.
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Claims Overview
Prestige Health Choice will reimburse providers for the delivery of covered services as follows:
1. Claims are considered received on the date the claims are received by Prestige.
2. Providers must mail or electronically transfer (submit) the claim to Prestige Health Choice within the time
frame allowed by their contract.
Electronic Claims Submission
Providers have the option of submitting claims electronically through Electronic Data Interchange (EDI). The
advantages of electronic claims submission are as follows:
• Facilitated, expedient claims payment
• Acknowledged receipt of claims electronically (through EMDEON -formerly known as WebMD and
ProxyMed)
• Improved claims tracking
• Improved claims status reporting
• Improved turnaround time for timely reimbursement
• Eliminated paper
• Improved cost effectiveness
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Claim Submission Protocol
Prestige Health Choice monitors encounter data submissions for accuracy, timeliness and
completeness through claims processing edits and through network provider profiling activities.
Encounters can be rejected or denied for inaccurate, untimely and incomplete information. Network
providers will be notified of the rejection via a remittance advice and are expected to resubmit
corrected information to Prestige in the allowed timeframe listed in the providers’ contract. Network
providers may also be subject to sanctioning by Prestige for failure to submit accurate Encounter data
in a timely manner.
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Verification that all required fields are completed on the UB-04 forms or its successor.
Verification that all Diagnosis and Procedure Codes are valid for the date of service.
Verification of member eligibility for services under Prestige during the time period in which
services were provided.
Verification that the services were provided by a participating provider or that the “out of
plan” provider has received authorization to provide services to the eligible member.
Verify service being performed is a covered service and that member has not exhausted
their benefits.
Verification that the provider is eligible to participate with the Medicaid Program at the
time of service.
Verification that an authorization has been given for services that require prior
authorization by PHC.
Verification of whether there is Medicare coverage or any other third-party resources and, if
so, verification that PHC is the payer of last resort” on all claims submitted to PHC.
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Provider Portal
Prestige is pleased to offer a number of online services to our providers through Availity at
www.prestigehealthchoice.com.
This self-service site requires registration.
How to register:
You will need to click on: http://www.availity.com/providers/registration-details/
Click on:
“Start Registration.”
1. Complete the registration process using this sign-up process
2. Availity will provide Security verification and assign your user name
3. You will be asked to crate a password
Once you've completed the registration process, you will be able utilize the website. If you need assistance,
please call 1-800-Availity.
Services Available:
• Eligibility and Benefits
• Claim Status
• Authorization Submission and Inquiry
• Report Inquiry
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Utilization Management Overview
Prior Authorization
The most up to date listing of services requiring Prior Authorization will be maintained in the Provider Portal
at www.prestigehealthchoice.com. You may also request a listing by contacting Provider Services at
1-800-617-5727.
Providers may request Prior Authorization by contacting Utilization Management at 1-855-371-8074 or by
sending a fax request for authorization to 1-855-236-9285.
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Notification of Admission
Facilities should fax the member demographic sheet and their contact information to 305-994-0059 to notify
Prestige of an inpatient admission. The case will be pended for clinical review and all clinical information is to
be faxed to our Utilization Management line at 305-994-0060.
**Please note faxing clinical information does not constitute as notification and we must have the business
office notification in order to process.
Please be advised that elective admissions for pre-certification must be previously approved through our
Prior Authorization department at 1-855-371-8074 or fax 1-855-236-9285.
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Provider Appeals/Provider Complaint
Provider Complaint System 1-800-617-5727
You may dispute Prestige Health Choice’s policies, procedures, or any aspects of Prestige Health Choice
administrative functions, including proposed actions, claims, billing disputes, and service authorizations.
You may contact Prestige Health Choice via telephone, email, regular mail or may request an in- person
meeting using the contact methods listed below.
Please call Provider Services at 1-800-617-5727, or send a written complaint to:
Prestige Health Choice
Attn: Provider Complaints Coordinator
P.O. Box 7366
London, KY 40742
Fax 1-855-358-5853
You may file a written complaint within forty-five (45) calendar days for issues not related to claims. Within
three (3) business days of receipt, Prestige Health Choice will notify you (either verbally or in writing) that the
complaint was received and provide an expected date of resolution.
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Provider Appeals/Provider Complaint – Cont.
Prestige will thoroughly investigate the complaint and keep you informed of any delays in resolution with an
update at least every fifteen (15) calendar days. All complaints will be resolved within ninety (90) calendar
days. Once a resolution has been determined, Prestige will notify you of the resolution within three (3)
business days of the resolution.
Because Prestige Health Choice takes your concerns seriously, all complaints are tracked and presented biannually to the Quality of Service Committee, in addition to being reported to the Agency, as required.
Appeals on Behalf of the Member
“An appeal may be filed orally or in writing within thirty (30) calendar days of the enrollee’s receipt of
the notice of action.
To file an appeal on behalf of the member, please send to Prestige Health Choice Appeal and Grievance
Department at:
Prestige Health Choice
Appeal and Grievance Department
P.O. Box 7368
London, KY 40742
Fax: 1-855-358-5847
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Questions?
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Yvonne Flores
Regional Manager, Hospital Contracting
Tampa Gulf, Central & North Florida
Cell 786-473-8402
Email: yaflores@prestigehealthchoice.com
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Thank you for your participation!
We look forward to working with you!
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