How do I become a provider for Saint Mary’s Health Plans?

Send a letter of intent, by FAX or mail to the attention of “Contracting”, stating your interest in becoming a contracted provider. Please include your name, specialty, location and when you would first be available to see patients. Also, specify which products you would like to be considered for. Once approved, provider information is then forwarded to our Quality Improvement Department to begin the credentialing process.

Saint Mary’s Health Plans
1510 Meadow Wood Lane
Reno, NV 89502
Attn: Contracting

FAX: (775) 770-3823


How are prescriptions covered?

If HealthFirst provides your prescription benefit, you must have a participating pharmacy fill your prescriptions to receive the best rates (refer to your Provider Directory).


How can I replace my lost HealthFirst membership card?

To request a new membership card, call our Member Services Department at (775) 770-6060 or (800) 863-7515. HealthFirst will send a replacement card to your home address within five working days of your request.


I will be moving soon. How do I notify HealthFirst of my new address?

To ensure continuous healthcare coverage, HealthFirst must have your correct address and telephone number. We notify members about any referrals, program or physician changes, and claims status by mail. Also, we want to make sure you receive each issue of our quarterly member newsletter.

Please fill out a HealthFirst Enrollment Application/Membership Change Form at your Human Resources Department, call our Member Services Department before you move, or mail us a change of address card (available at your local post office).


What is the role of my Primary Care Physician?

Your Primary Care Physician’s primary responsibility is to provide, arrange and coordinate all aspects of your healthcare.


Can my spouse and children have a different Primary Care Physician than I have?

Yes. Each member may have his or her own PCP. A general or family practitioner, internist, or pediatrician may serve as a PCP. Women may select an OB/GYN as a secondary PCP.


What is the time frame for becoming a provider on your health plans?

The entire process, from the letter of intent through credentialing and contracting, can take 90-120 days or longer depending on individual circumstances. It is advisable to notify us of your intent to become a provider as far in advance as possible.


Why does Health Plans need to credential providers in addition to Saint Mary’s Regional Medical Center?

Each Health care entity is required to demonstrate compliance to applicable regulatory standards for their respective organizations (i.e. Joint Committee on Accreditation of HealthCare Organizations, National Committee for Quality Assurance, etc.). Saint Mary’s Health Plans credentials practitioners (i.e. physicians, allied health professionals, etc.) and providers (i.e. facilities, hospitals, etc.) to National Committee for Quality Assurance (NCQA) standards. Primary Source Verification (PSV) is required for specific elements in the credentialing and recredentialing process. Health care entities are unable to share PSV information. Therefore, the processing of all credentialing information is required of each health care entity, respectively.

Nevada has implemented the Nevada Standardized Initial Application; a statewide credentialing application utilized by approximately 30 entities throughout Nevada. Practitioners complete this application once and distribute copies to each entity they are applying to. In addition, Northern Nevada has also implemented a standardized community recredentialing cycle, allowing practitioners to be recredentialed at the same time by a number of health care entities.

For additional information regarding Saint Mary’s Health Plans credentialing and recredentialing, please contact our Quality Improvement department at (775) 770-6172.


If I have my A.P.N. or P.A. contracted and credentialed, how do I bill for their services?

Services provided by physician extenders who have completed the credentialing and contracting process can be billed on a HCFA-1500 under their name as the Provider of Service (box 31) as long as the Tax Identification Number (TIN) for which they were contracted is also provided in box 25.


How can I verify which products I’m contracted for and my effective date?

Please contact the Provider Relations department at (775) 770-6278.


How can I verify what my contracted allowable is for a particular code.

The Provider Relations Staff can provide you with this information and, if necessary, send you a copy of your contract.


As a contracted provider, how do I open or close my practice to new patients?

Mail or FAX a brief letter to the attention of “Provider Relations” stating your desire to open or close your practice to new members, which product the change applies to and the effective date of the change.


How do I notify Health Plans of changes in my address, phone or Taxpayer Identification Number?

We ask that changes be communicated in writing with the effective date of the change. These can be sent by mail or FAX to the attention of “Provider Relations”. With regards to address changes, please be specific if your mailing and or billing address is different from your physical address. Be aware that we cannot change a taxpayer Identification Number without an updated IRS W-9 form. If you don’t have one available, they can be downloaded at http://www.starbuilders.org/blulotus/w9/w9form.html or the Provider Relations staff will be happy to send you one by fax or mail.


Can I find out eligibility and benefit information on-line?

This is not currently available although it is under development. Benefit and eligibility information can be obtained through our Member Services Department for HealthFirst and HealthChoice members. For patients accessing Preferred Health Care Network, please call the number listed on the patient’s insurance card or refer to the Preferred Health Care Client List.


Do you accept claims electronically?

Yes, We currently offer electronic claims submission through our contracted clearinghouse Emedeon. Visit www.transact.emdeon.com to begin submitting claims electronically.


What should I do if I believe my claim has not been paid correctly?

Many claim payment issues can be resolved by our Member Services Department. Our Provider Relations staff is also available to assist you with claims issues as well as any questions or concerns you may have.


How can I get RBRVS/Medicare Provider Fee Schedule information

This information can be downloaded directly from the Medicare web site at:
http://cms.hhs.gov/medicare/



How often are your Provider Directories updated?

Provider Directories are updated each month and are available on this web site or by contacting the Provider Relations Department.