Forms and Documents

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Code Editing/Bundling Issues

Code Audit Rules
PDF | 50 KB
This document provides details regarding code auditing guidelines
Coding Guidelines
PDF | 64 KB
This presentation describes our prospective approach to risk adjustment and accurate documentation and coding
Coding Overview
PDF | 25 KB
This document provides an overview of coding procedures
Common Coding Questions
PDF | 8 KB
This document provides a list of common coding questions and answers


Coding Guidelines

Avoiding Medicare and Medicaid Fraud and Abuse
PDF | 7 MB
This publication from the US Department of Health and Human Services outlines steps to take to avoid Medicare and Medicaid fraud and abuse
Coding for Cancer
PDF | 72KB
This flyer provides tips on appropriate coding for cancer-related services
Coding for Circulatory Disorders
PDF | 108 KB
This flyer provides tips on appropriate coding for circulatory disorder services
Coding for the Heart
PDF | 25.2 KB
This flyer provides tips on appropriate coding for heart-related services
Coding Guidelines for Modifier 25 and 59
PDF | 62.3 KB

This flyer provides tips on appropriate coding for Modifers 25 and 59

Diagnosis Coding for Deep Vein Thrombosis
PDF | 7 KB
This flyer provides tips on appropriate coding for deep vein thrombosis-related services
Medical Record Documentation
PDF | 95 KB
This document provides specific documentation guidelines to follow to promote compliance with CMS data validation.
National Coverage Determinations
PDF | 171 KB
This document provides information on national coverage determinations
National Coverage Determinations 2013
PDF | 51.1 KB
This document provider additional information on national coverage determinations.


Documents

Coventry Health Care of Missouri, Inc., HEDIS® 2012 Results
PDF | 38 KB
This document provides a summary of our results for the most recent HEDIS rates for Coventry Health Plan. Inc.
2013 Formulary Changes
PDF | 24 KB
This flyer lists the changes to the formulary for 2013.
How to Read Your Explanation of Payment
PDF | 288 KB
This brochure demonstrates the components of your EOP and provides explanations.
Medicare Advantage Product Offerings
PDF | 27 KB
This benefit grid outlines the Medicare Advantage plans available
Medicare Compliance Attestation
PDF | 61.7 KB
This document explains the Medicare Compliance program requirements established by the Centers for Medicare & Medicaid Services (CMS).
Medicare Provider Training and Education
PDF | 18 KB
This document describes your requirements as a contracted first tier or related entity.
Model of Care Training Certificate of Completion
PDF | 49 KB
This document is a certificate of completion for the Model of Care traing that you can fill to prove completion.
Quality Improvement Program
PDF | 131 KB
This document provides a description of our quality improvement program.
Provider SNP Model of Care Training Document
PDF | 288 KB
This document provides a description of our SNP model of Care.
Utilization Management Programs and Criteria Guidelines
PDF | 67.5 KB
This document describes the Utilization Management Programs and Criteria Guidelines
Utilization Management Program
PDF | 97 KB
This document describes the 2012 utilization management program.


Electronic Payor Information

Electronic Payor ID Grid
PDF | 357 KB
This grid lists electronic payor ID information for Coventry plans in the region.


Forms

Aetna Specialty Pharmacy Medication Request Form
PDF | 172 KB
This form is to obtain medication from Aetna Specialty Pharmacy.
Case and Disease Management Referral form
PDF | 72 KB
Use this form to refer your patient to one of our disease management or case management programs
Commercial Authorization - Non-Covered Services
PDF |  57 KB
Use this form to obtain authorization from your Commercial patient to perform non-covered services
Coventry 2013 Quality Improvement Form
PDF | 15 KB
Demographic Update Form
PDF | 123 KB
Illinois Authorized Representative Form
PDF | 36 KB
Complete this form to serve as an authorized representative for an Illinois patient regarding an appeal
Illinois IRO Physician Certification Form
PDF | 71 KB
Complete this form as a supplement to the Request for External Review form when an Illinois patient has been denied a health care service or course of treatment
Illinois Request for External Review Form
PDF | 60 KB
Use this form to request an external review when an Illinois patient has been denied a health care service or course of treatment
Medicare Data and Quality Incentive (MDQI) Program (PEP Program)
PDF | 35 KB
This document is instructions for using the Medicare Data and Quality Incentive (MDQI) Program.
Medicare Notice - Non-Coverage - IL - Home Health
PDF | 78 KB
This document is used to notify Illinois Medicare Advantage patients that their coverage for home health care services will end
Medicare Notice - Non-Coverage - IL - SNF
PDF | 14 KB
This document is used to notify Illinois Medicare Advantage patients that their coverage for Skilled Nursing Facility services will end
Medicare Notice - Non-Coverage - MO - Home Health
PDF | 14 KB
This document is used to notify Missouri Medicare Advantage patients that their coverage for home health care services will end
Medicare Notice - Non-Coverage - MO - SNF
PDF | 14 KB
This document is used to notify Missouri Medicare Advantage patients that their coverage for Skilled Nursing Facility services will end
Medicare Specialist Referral Form
PDF | 110 KB
Use this form to submit a request for authorization to refer your Medicare Advantage patient to a specialist
Medicare Member Request Form
PDF | 19 KB
Provide this form to your members when Coventry Health Care makes organizational determinations
Member Rights and Responsibilities
PDF | 17.5 KB
To ensure that our members are treated fairly, we have provided a list of member rights and responsibilities below. We encourage you to become familiar with them.
Pain Management Member Release form
PDF | 124 KB
This form is used to obtain acknowledgement from patients of financial liability when obtaining pain management services at a facility-based setting
Prior Authorization Form for Bariatric Surgery
PDF | 7.12 KB
This form should be completed for bariatric surgery requests
Prior Authorization Form for Generic Office Procedure
PDF | 26KB
Use this form to submit a request for authorization for an office procedure
Prior Authorization Form for Global OB
PDF | 30 KB
Use this form to request authorization to provide global OB services for your patient
Prior Authorization Form for Pain Management
PDF | 147 KB
Use this form to submit a request for authorization for your patient to obtain pain management injections
Provider Participation Request Form
PDF | 232 KB
Use this form to submit a request to participate in our network.
Provider Request for Review
PDF | 50 KB
Utilize this form to request review of a denied claim
Provider Responsibilities
PDF | 56 KB
As a Coventry provider you have the following responsibilities to Coventry and our members.
RA Paperless Request form
PDF | 20 KB
Use this form to request electronic remittance advice through directprovider.com
SNP Certificate of Completion
 PDF | 49 KB
Certificate of Completion to be printed and filled out once you have completed the SNP Model of Care Training.
SNP Model of Care Training
PDF | 288 KB
Annual training to be completed by providers with members participating in the Dual Eligible Special Needs Plan. (DE-SNP)


Timely Filing

Timely Filing Guidelines
PDF | 31 KB
This document describes our policies regarding timely filing guidelines
Timely Filing Reconsideration form
PDF | 20 KB
Use this form to request reconsideration of claim payment due to timely filing


Workers' Compensation

Workers' Compensation FAQ
PDF | 86 KB
This document describes frequently asked questions regarding Coventry Health Care’s acquisition of Concentra’s Workers’ Compensation Managed Care Services

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