NEW PROVIDER
ORIENTATION
WELCOME TO NEW PROVIDER ORIENTATION
Congratulations on becoming a patient of the CareCentrix family!
Our role in Provider Operations is to be your advocate as you work with CareCentrix. Please
feel free to contact your Provider Operations team should you have additional questions after
reviewing this new provider orientation!
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AGENDA
Who is CareCentrix and how does CareCentrix benefit providers?
Review the home care benefits management workflow
Review the steps of the referral process and getting authorizations/pre-certifications
Review the requirements of meeting start of care (SOC)
Review the steps of the claim submission process and getting paid
Review CareCentrix contact information
Review provider performance metrics
Questions?
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CARECENTRIX
CARECENTRIX
Who is CareCentrix?
Nation’s leading home care network
A healthcare delivery system that performs utilization management functions for ancillary care
and specialty pharmacy services for commercial, and managed Medicare and Medicaid plans
Privately owned since 2008, founded in 1996
Network: Over 8,000 credentialed provider locations of home health, durable medical
equipment, infusion and behavioral health
Accreditation: Full URAC accreditation in health utilization management
Customers: CIGNA/CIGNA West, Health Net, Florida Blue, Horizon Blue Cross Blue Shield of New
Jersey, Aetna and Cofinity
National footprint: 24/7 service in all 50 states
How does CareCentrix benefit the provider?
Single Point-of Contact: CareCentrix integrates the full spectrum of services - network
management, referrals, care coordination, utilization management, and reimbursement
consolidation
Focus on relieving provider from the burden of collecting patient cost share
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HOME CARE BENEFITS
MANAGEMENT
WORKFLOW
HOMECARE BENEFITS MANAGEMENT WORKFLOW
Physicians
Hospital
Discharge
Planners
Case
Managers
CareCentrix
Home
Health
Provider
CCX
Providers

Infusion Provider &
Ambulatory Infusion
Suites
DME/OP
Provider
Claims Billing
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AUTHORIZATIONS/
PRE-CERTIFICATIONS
The Referral Process &
Getting an Authorization
Requests for service, whether for the initial start of care or
reauthorization for continued care, must be requested
prior to the service being provided. If a provider fails to
request an authorization/pre-certification prior to
providing services, the services performed may not be
reimbursable and are not billable to the patient.
THE REFERRAL PROCESS: SERVICE SPECIFIC TIPS
THH – Home Health
DME/O&P
Infusion
Required to be
Homebound?
Varies by plan/product type.
N/A
N/A
Initial Auth Required?
Yes for non-BlueCard services*
Yes for non-BlueCard services*
Yes for non-BlueCard services*
Re-auth Required?
Plan Dependent
Plan Dependent
Plan Dependent
Start of Care (SOC)
Changes
Provider must make CareCentrix
aware & update on
www.carecentrixportal.com
Provider must make CareCentrix
aware & update on
www.carecentrixportal.com
Provider must make CareCentrix
aware & update on
www.carecentrixportal.com
Miscellaneous
Lab tests must be taken to the lab
specified by the patient’s plan
Routine supplies are included in
the cost of visit
If additional supplies are needed,
CareCentrix will authorize.
Oxygen
Provide height, weight,
allergies, type of venous access,
and next scheduled dose
Infusion providers must accept
case “full-service” which
includes drug, skilled nursing
and supplies (per diem)
•Liter flow
•O2 saturation w/ date
CPAP
•Sleep study or letter of medical
necessity
•MD order required for
upgraded unit
- Please note these are service specific tips, however all providers should reference the provider manual, the provider
agreement and the health plan policies for guidance on the referral process.
* BlueCard requirements for precert vary by HomePlan. Please refer to BlueCard training.
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SAMPLE REFERRAL INSTRUCTION SHEET
Read your fax
coversheet. It will tell
you the patient ’s plan
type, including how to
check eligibility and
benefits and whether
reauthorization is
needed.
Identifies the lab of choice
per the health plan
Notifies you if PTA and OTA are
allowed by patient ’s health plan
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IMPORTANT AUTHORIZATION INFORMATION
Coordination of Benefits (COB)
Please click the PDF to the right for an overview of COB
Authorizations of services is NOT a guarantee of payment
Payment of services rendered is subject to the patient’s eligibility and coverage on the date of
service, the medical necessity of the services rendered, the applicable payer’s payment policies,
including but not limited to, applicable the payer’s claim coding and bundling rules, and
compliance with the Provider’s contract with CareCentrix. Refer to the Provider Manual for more
information regarding authorizations.
Provider is ultimately responsible for eligibility benefit and payer source verification.
Providers must in every instance, whether receiving a referral from CareCentrix or a primary referral
source, verify eligibility and benefits with the patient’s Health Plan prior to providing any service,
equipment or supply item.
Providers should maintain documentation to evidence this verification of eligibility and benefits.
CareCentrix does not conduct electronic eligibility and benefit verification transactions, but our
health plan customers do.
Eligibility and benefit verification and service authorization are not a guarantee of payment for
services such as, but not limited to, items provided when the patient is not eligible or there is no
available benefit. Providers are responsible for ensuring that they maintain, and have available
upon request, all documentation necessary to support the services rendered, including but not
limited to, the medical necessity of such services.
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ELIGIBILITY TIPS
Health Plan
Website
Patient Plan Type
Contact Phone
Aetna
Navinet
www.navinet.com
PPO patient
HMO patient
(888) 632-3862
(800) 624-0756
Cigna
Cigna Web Portal
www.cignaforhcp.com
Florida Blue
Blue Card
Availity
www.availity.com
State, Local and FEP
BlueCard
(877) 352-2583
(800) 676-BLUE(2583)
Horizon NJ
Navinet
www.navinet.com
General/Medicare
Advantage/SHBP
(800) 624-1110
FEP
(800) 624-5078
Pfizer
(888) 340-5001
Merck
(877) 663-7258
Labor Funds
(888) 456-7910
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START OF CARE
Missed starts of care (MSOC) can create
dissatisfaction, put patients at risk, and can
result in readmissions or delayed discharges
START OF CARE (SOC)
A start of care (SOC) date is set by the ordering physician or discharge planner.
When accepting a case, consider your ability to service the patient and meet their needs.
Notify CareCentrix immediately if you must delay the start of care or if you are unable to
continue the case. Refer to page 26 of the Provider Manual for start of care delays and
referral turn backs.
Changes to the patient’s start of care date must be approved by the referring physician.
You are required to obtain the orders needed to prevent a delay in the start of care.
For most items and services, the CareCentrix Service Validation team will confirm
that the care was provided by the SOC via an outbound phone call to the patient.
Provider performance is measured on various metrics, including compliance with
SOC date and number of missed starts of care.
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CLAIM SUBMISSION
AND PAYMENT
Clean claims must be submitted
electronically within 60 days of the date of
service (or, as determined by applicable law)
and must include the CareCentrix HCPCS
Code & Modifiers.
CLAIM SUBMISSION AND PAYMENT
The Referral Process
(Getting an Authorization)
Visit the Patient
The Claim Submission Process
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THE CLAIMS SUBMISSION PROCESS
Timely filing
60 days from time service was rendered (or, as determined by applicable law or plan mandate)
Providers must submit a clean claim within timely filing period, non clean claims submitted
within the timely filing period therefore reject
Substitution of Services
Example: If a provider is granted auth for RN visits, an LPN may be used but providers must bill
CCX for LPN not RN. The same applies for the substitution of PTAs and OTAs.
*Important Note Horizon does not allow for PTA or OTA/COTA. Providers should always bill the
services that were rendered at the appropriate contracted rate.
Providers may NOT disclose contracted pricing
Providers do not collect copays/deductibles from patients. CareCentrix will collect the copays
and deductibles from the patient.
Click here to review the provider manual for clean claim submission requirements.
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THE CLAIM SUBMISSION PROCESS
CareCentrix offers a billing crosswalk to identify the CareCentrix internal service code to the
HCPC code on the provider’s fee schedule. Current billing cross walk can be found at
www.carecentrixportal.com
To use the billing crosswalk, locate the CareCentrix service code and UOM (unit of measure) as
shown on your Service Authorization Form (SAF) and match to the above crosswalk to determine
the correct HCPCS/Modifier combination you must bill.
Claims must include the following:
Description of the service
ICD9 and/or ICD-10 Code(beginning on 10/1/2015)
Taxonomy number (provider’s and referring physician)
NPI number
If billed with HCPCS and modifiers not consistent with the HCPCS and modifiers on the SAF the
claim could be denied
Refer to the Provider Manual for a complete list of clean claim submission requirements.
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REJECTED CLAIM
If your claim was rejected
(You received a rejection letter from CareCentrix)
Correct the claim for the issue(s) identified and resubmit the claim as an
Original Claim via an 837 submission or on a CMS1500/UB04 form.
(Do not submit the claim as a Corrected Claim, Claim Reconsideration,
or Claim Appeal)
Please resubmit the claim to CareCentrix as quickly as possible; claims must still be
received within 60 days* from the date of service (or as indicated by State law) to be
timely.
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DENIED CLAIM
If your claim was denied
(You received and explanation of payment (EOP) from
CareCentrix)
And you agree with the denial reason given by CareCentrix, correct the claim for the
issue(s) identified and resubmit the claim as a Corrected Claim.
(Do not submit the claim as a Claim Reconsideration or Claim Appeal).
“Corrected” marking must be clearly visible in large font and cannot obstruct any data
elements on claim
Please resubmit the claim timely to expedite the payment process. Claims can be
submitted electronically or sent to: PO Box 7779 London, KY 40742
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DENIED CLAIM
If your claim was denied
(You received and explanation of payment (EOP) from
CareCentrix)
And you disagree with the denial reason given by CareCentrix, complete the Claim
Reconsideration Form
(CLICK HERE FOR CLAIM RECONSIDERATION FORM) and mail it to the address on the
form.
(Do not make changes to the original claim. Claim Reconsideration Forms should only
be used if you believe your initial claim was 100% accurate)
Claim Reconsideration Forms must be received within 45 days of the date of an EOP, or
as required by law, if longer.
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CLAIM APPEALS
If your Claim Reconsideration
request was denied you may submit a claim appeal
Complete the Claim Appeal Form
(CLICK HERE FOR CLAIM APPEAL FORM) and mail it to the address on the form.
(Do not make any changes to the original claim. Claim Appeals should only be used if
you have received an EOP from a Claim Reconsideration)
Claim Appeal Forms must be received within 30 days of the date of a Claim
Reconsideration EOP
Note: Corrected claims, reconsiderations, and appeals can be submitted electronically
for claims processed through our Claims 2.0 platform.
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WHAT IS CLAIMS 2.0?
We listened to your feedback! The 2.0 platform includes several new features that
came from provider requests.
These enhancements include:
• More detailed claim status updates via the Provider Portal
• Improved technology that checks your claim for completeness
• Claims reconciliation tools that provide you with detailed claims reporting
information
• The Claims 2.0 training can be found under the Education Center on the
CareCentrix Provider Portal :
www.carecentrixportal.com/ProviderPortal/homePage.do
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CONTACT US
Know where to go
CONTACT US
Register for Portal Access & EDI Claims Submission
Register for Portal Access
Register for EDI Claims Submission
Support
Portal Support
EDI Support
Authorizations
Initial Authorization Requests
Re-Authorization Requests
Add-on Requests
Authorization Status
Edit an Authorization
Authorization Contact Numbers
Claims
Claims Status
Claims Questions
Appeal Status
Claims Support Team
Contract/Network Management
Provider Manual
Patient Financial Responsibility
Patient Services Team
www.CareCentrixPortal.com
Portalinfo@CareCentrix.com
EDISupport@CareCentrix.com
www.CareCentrixPortal.com
Aetna FL: 888-999-9641
BCBS FL: 877-561-9910 –Inquiries FLBlueAuthInquiry@carecentrix.com
All Other Plans: 877-466-0164
www.CareCentrixPortal.com
Phone: 877-725-6525
www.CareCentrixPortal.com
Phone: 800-808-1902
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THINGS TO REMEMBER
THINGS TO REMEMBER
Provider Performance Metrics
100% portal compliance
100% EDI compliance
Claim denial rate of 7% or less
No quality of care concerns
Case acceptance rate, no turn-backs
Monitor these to avoid becoming non-compliant.
Providers may NOT use the CareCentrix name in any media without prior approval.
Timely filing
60 days from time service was rendered (or, as determined by State law)
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THANK YOU