Become Part of Our Provider Network

By participating in Elderwood Health Plan, you’re helping us provide high-quality, accessible long-term care services. You are one of the most critical components of our care management team, as we work together to help our members retain their independence and remain comfortably in their homes and communities.

Our dedicated Provider Relations Department works with you to understand your business, meet your needs and process claims in an efficient and timely manner. Care managers help coordinate services, ensure patients arrive to their appointments on time and follow your instructions. Don’t forget, Elderwood Health Plan members DO NOT have a co-pay.

To become a participating provider, please contact our Provider Relations Department at 1-866-THE-PLAN (1-866-843-7526).

For more detailed information on member eligibility, claims, authorizations and more, please view the Provider Manual.

 

Requesting Authorization

Providers can submit a request to add new or modify existing services within the member’s care plan outside of basic podiatry, ophthalmology, dentistry or audiology care. Expedited authorization is available if any delay in decision could jeopardize their health.

Authorization for services, revised authorizations and authorization terminations are faxed to the provider. Contact your patient’s care manager to make arrangements.

 

Verifying Membership

All providers must verify the member’s eligibility at time of service. All members are instructed to present their membership card each time they obtain medical services that are covered by the plan. However, this is NOT a guarantee of eligibility because we cannot always retrieve cards from those who have disenrolled or lose coverage. Failure to verify member eligibility could result in denial of payment for services.

To verify membership eligibility, call our Provider Relations Department at 1-866-THE-PLAN (1-866-843-7526).

 

Submitting a Claim

We accept electronic and paper claim submissions; however, electronic forms are preferred for faster processing. Only clean claims are accepted, so we can process them without obtaining additional information. Providers must inform the Provider Relations Department of any changes in tax ID number, corporate name or addresses as soon as they are known. Please allow 30 days for updating.

SUBMISSION GUIDELINES

  • All claims must be submitted within 120 days from the date of service, or within 120 days from the date an explanation of payment was issued from a primary payor.
  • Claims for services partially covered by Medicare or another primary payor must be accompanied by a Medicare or other primary payor EOB.
  • Elderwood may pay claims denied for untimely filing when the provider can demonstrate that a claim submitted after 120 days of the date of service resulted from an unusual occurrence and the provider has a pattern of timely claims submissions.
  • Claims submitted beyond 120 days will be paid at a discount up to 25%.
  • Claims for dates of service beyond 365 days will not be considered for payment.
  • Clean electronic claims will be paid within 30 days and clean paper claims will be paid in 45 days if the claims contain a prior authorization number and are pursuant to the Elderwood Utilization Management process.
  • If applicable, providers on a capitation basis will be paid according to the time period specified in the provider agreement.

 

Provider Resources