If you are interested in contracting with us, please contact the Provider Relations Representative associated within the area where you are located. They will work with you on getting an application and a contract.

Kathy Ripley-Hake, Director of Provider Relations	816-559-9442
Juanita Prieto, Manager of Provider Relations	816-559-9447
Lesa Castillo, Provider Relations Representative	816-559-9444	Bourbon, Cherokee, Crawford
Cindy Edwards, Provider Relations Representative	816-559-9448	Allen, Coffey, Labette, Lyon, Neosho, Osage
Christina Gault, Provider Relations Representative	816-559-9450	Atchison, Brown, Clay, Cloud, Doniphan, Jackson, Leavenworth, Marshall, Nemaha, Ottawa, Pottawatomie, Republic, Washington
Marie Goelz, Provider Relations Representative	316-788-5505	Barber, Comanche, Cowley, Harper, Kingman, Kiowa, Pratt, Sedgwick, Sumner
Kyla Krull, Provider Relations Representative	620-665-0034	Barton, Edwards, Ellis, Ellsworth, Jewell, Lincoln, Mitchell, Osborne, Pawnee, Phillips, Reno, Rice, Rooks, Rush, Russell, Saline, Smith, Stafford
Derrick Richardson, Provider Relations Representative	816-559-9446	Johnson, Wyandotte
Lynette Scheid, Provider Relations Representative	316-239-6239	Butler, Chase, Chatauqua, Dickinson, Elk, Greenwood, Harvey, Marion, McPherson, Montgomery, Morris, Sedgwick, Wilson, Woodson
Rose Williams, Provider Relations Representative	816-559-9449	Douglas, Geary, Jefferson, Riley, Shawnee, Wabaunsee
Nancy Zirpolo, Provider Relations Representative	816-559-9445	Anderson, Franklin, Johnson, Linn, Miami

Children's Mercy Family Health Partners will accept the CAQH application or the State of Kansas Standard application. Once applications and contracts are received by Children's Mercy Family Health Partners, the applications are screened for completeness. If something is missing, we will contact your office for the necessary information. When we have received the complete information, then we begin the credentialing process. Typically our turn around time to credential a provider is 90 days. Once the credentialing process is completed, you will receive a letter from Children's Mercy Family Health Partners notifying you of your approval or denial. Approvals will include your effective date as well as a fully executed contract for your files.

If you have questions about the status of your application or questions about the credentialing process, you may contact our Credentialing Department at 816-559-9443.

Our provider contracts indicate the provider must file a claim with us within 90 days from the date of service. However, you should be aware that we do not deny claims as untimely until 180 days from the date of service. Further, it is important to clarify the initial date for the timely filing requirement does not begin until the provider has all the information necessary to submit the claim. For example, your office/facility is informed by the patient that he or she has commercial insurance, but in fact it is determined (after receipt by your office/facility of the remit from the commercial insurer) that the patient is covered by Children's Mercy Family Health Partners. The timely filing deadline for Children's Mercy Family Health Partners would not begin until you (using reasonable effort) were able to determine the correct claim submission information to submit the claim to us.

Also, in recognition of special circumstances with regard to obstetrical services, we provide an exception to the timely filing requirement for physician claims for prenatal care and delivery. These claims must be submitted within 12 months from the date of service. This payment guideline is included within our Provider Administration Manual.

Children's Mercy Family Health Partners does not require written referrals to in network providers. PCPs may verbally refer a member to a specialist within the Children's Mercy Family Health Partners network and document in the member's chart that this has been done. Referrals to an out of network provider require prior authorization. Contact our Health Services Department at 888-691-4874, option 1 for an out of network authorization.

We have an excellent track record for claims payment. 70% of our HealthWave claims are processed electronically and the balance are scanned into our system upon receipt for automated processing. We work with a number of clearinghouse providers including: ASK/EDI Midwest, Gateway EDI, EMDEON and SSI. Our 1st quarter average to pay HealthWave claims was 23 days. We are still assisting providers who may have claim submission issues. It is important that providers include their 6-digit CMFHP provider number on every claim submission.

We process and pay all of our claims in our local Kansas City office. We do not use any offsite service centers. Because we pay claims in-house, individual claims issues can be resolved in a single phone call. Our Customer Service and Provider Relations staff works directly with you for fast resolution of issues. Call us at 1-877-347-9363 for help.

When you have a question about a claim, you can call Customer Service at 1-877-347-9363. Customer Service can look up the claim to determine if it has been received, in process, paid, denied or pending. If a provider feels a claim was not processed correctly, a Customer Service or Provider Relations Representative will review the claim for accuracy. Because our claims are processed in-house, needed corrections can be made to a claim in a timely fashion.

Since Children's Mercy Family Health Partners is the payer of last resort we first look for other payment resources. We are provided information from the State concerning COB information. We also get information from providers when an EOB is submitted with a claim. If you have other insurance information without an EOB, include the information on the claim submission. COB information should be available on the website within the next few months.

The mailing for claims is as follows:
Children's Mercy Family Health Partners (CMFHP)
P.O. Box 411806
Kansas City, MO 64141-1806

For electronic claim filings, we use the EDI vendors listed below.

Vendor	CMFHP Payer ID No.
ASK/EDI	31472
GateWay	31472
SSI	31472
Emdeon/WebMD	31472

Once you are set-up as an authorized user, you will follow the easy steps below to check your claims status:

• Login using your assigned user id and password.
• Go to the Office Manager menu item and then:
  • Claims
  • Inquiry
• Member Information
  • Fill in the fields with the appropriate information, member name or id number.
• Claim Information
  • Claim Type, you'll need to select the appropriate claim you're searching for either HCFA or UB92 claim.
  • From and To dates, enter a date range
• Search for Claims

To look up another claim, click on Inquiry as you did before and follow the same steps.

Since this is a secured area, you will need to contact your Provider Relations Representative to get access to view this information. Your Provider Relations Representative will provide you with password and login identification. Please remember to notify your Provider Relations Representative of changes in your staffing that may affect access, such as an employee leaving.

Eligibility information is updated daily.

Claims information is live data.

You can view the list of representatives here (opens in a new window).

Members may change HealthWave health plans for any reason at any time. They can call the Managed Care Enrollment Center at 1-866-305-5147 for help in changing health plans. The change may be effective the first of the next month.

Click here to view the HealthWave Provider Administration Manual.

On occasion members may be confused and seek care from a provider that is not their designated PCP. This may occur with another physician within a group practice or with a provider in an entirely different practice. We understand this happens and we want you to know how we handle these circumstances. First, we would not deny payment for any claim solely based on the member having received services from a provider other than his/her designated PCP. As long as the provider is in our network, whether the member's designated PCP or not, and the member was otherwise eligible for coverage, we would process the claim for payment. This is also the case for services provided by a participating referral specialist. We encourage members to use their designated PCP for the coordination of all services; however, as a practical matter we do not have a formal referral process and therefore would not deny payment for the services of any participating referral provider solely based on no referral from the PCP.

If you are unable to establish a working relationship with a member and need to dismiss him/her from your practice, you must notify the member and Children's Mercy Family Health Partners in writing of this request. The member must be given 30 days notice of this change and still be treated by your office for emergent and urgent medical conditions. If the request for dismissal is due to potential fraud or abuse by the member, please contact the Compliance Officer at 816-234-3946.

All members are sent ID cards with their welcome packet upon assignment to the plan that includes a member handbook, provider directory, health risk assessment and a postcard to request a PCP change. Members will have the opportunity to change PCP's by calling Customer Service at 1-877-347-9363, going to our website at www.fhp.org or mailing the post card back to us. HealthWave 19 members will continue to receive the monthly paper ID card from the State.

Claims received without the CMFHP provider number or NPI, or an incorrect CMFHP provider number or NPI, must be researched manually. Claims received without a CMFHP provider number or NPI will be returned to the provider. Claims with incorrect CMFHP provider number or NPI may cause an incorrect payment. This is the biggest delay in processing a provider's claim.

CMFHP highest denial is for duplicate filing of claims already received. Claims should not be resubmitted in less than 30 days of the original claim submission. Always check the CMFHP website to check the status of the original claim.

Code Review is a software program that checks for correct CPT procedural coding on CMS1500 claims. The software reviews claims and claim history for unbundling, fragmented, up-coding, duplicate coding, invalid coding, mutually exclusive procedures and global periods of procedural coding. Code denials for these reasons will be displayed on the CMFHP remittance advice as 99 - Code Review; IC - Incidental

If your office files claims under a group name for services provided by a Nurse Practitioner or Physician Assistant, you may have received a CMFHP provider number to use. This allows for the proper KS Medicaid reimbursement for ARNP and PA mid level providers. If your office files claims without the appropriate provider number, the incorrect provider reimbursement is dispensed and a refund should be generated for the overpayments. If you are not sure if your office is filing with the correct provider number, please contact your CMFHP Provider Relations Representative.

CMFHP follows AMA and CMS guidelines to determine which CPT codes are to be identified for a payment reduction following multiple surgery guidelines. All services should be submitted on the same CMS1500 claim form. The highest relative value procedure will be paid at 100% of the allowable. Subsequent procedures should be billed with a 51 modifier. Subsequent procedures will be reduced, if applicable, following the multiple surgery guidelines outlined in your Provider Administration Manual. Bilateral procedures should be billed on one line with the 50 modifier. It is not correct to bill multiple units to signify a bilateral procedure.

Both surgeons must be of different specialties in order to meet the AMA guidelines describing a team surgery. Both providers must bill the procedures with a 62 modifier to describe their services. The procedure must be recognized by the AMA as a potential team surgical procedure. If the different specialty requirement is not met, then one surgeon should be the primary and assistant surgeon services identified using the 80 modifier.

Newborns of eligible plan members will be covered for expenses submitted under the mother's Beneficiary number for the first 45 days. The case where the mother is uninsured, the newborn's permanent Beneficiary number would have to be received before payment is rendered.

If the service is for a RHC qualified service, you must bill with your CMFHP RHC group provider ID #/NPI # in order for you to be reimbursed correctly by CMFHP and the State. CMFHP uses this provider number to pull encounter data to the State for them to process your wrap payment for Title 19 members. For services provided that do not qualify as RHC, these services should be billed under the individual provider ID #/NPI #. For specialist's services within your RHC, you should also bill with their individual CMFHP provider ID#/NPI#. If the Primary Care Provider provides a non RHC services, you will need to bill using their individual provider ID#/NPI#.

You must bill with the emergency room revenue code of 450 with the appropriate evaluation and management code along with the ET modifier.

You must bill with the observation room revenue code of 762 with the evaluation and management code 99218 along with the ET modifier.

Contact your provider relations representative to inform them of the provider you are adding and they will send you the application.

If you have a few, contact Customer Service and let them know which are duplicate payments and whether or not you want a letter sent or if we can recoup the duplicate payment on a future check. If you have more than a few, contact your provider relations representation who will work with you.

Our IT Department has created a new system generated refund letter that our Claims Department just started using. We apologize for the delay but wanted to be sure we had a good process in place to handle these requests.

If it is regarding membership, please contact Customer Services Department and they will look into the problem. All other issues, please contact your provider relations representative.

If the message you receive is that your password has expired, contact Customer Service and they will re-active it for you. Any other issues, please contact your provider relations representative.

When we started receiving all the applications last fall, we were allowed to do "provisional" credentialing since we already had a contract with the State. We received no less than 3 thousand applications and have been working very hard to get them caught up. Any of those that we had received prior to April 1st are in the provisional status. Any applications that we received after April 1st, we are handling as they come in. We had a temporary person helping out this summer and was able to get more providers through credentialing than normal. As those providers in the provisional status finish the credentialing process, a Welcome Letter is sent at that time so that you know that the credentialing process is completed.

You must use your VFC stock as they are medicaid members.

Yes, you should use your VFC stock for both.

If the primary insurance carrier covers immunizations then you need to use your private stock. However, if the immunizations are not covered by the primary carrier or will be applied to their deductible by the primary carrier, then use your VFC stock.

Medications included in the Children's Mercy Family Health Partners Preferred Drug List are chosen by an advisory committee called the Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is responsible for developing, managing, updating, and administering the PDL. The P&T Committee is comprised of primary care providers, specialty providers and pharmacists. Members are from both the Children's Mercy organization and our provider network. To ensure integrity in the decision-making process, all current and potential P&T members must disclose any potential conflicts of interest that may interfere with that individual's ability to evaluate therapeutic classes of medication in an unbiased manner.

It is true that a good Preferred Drug List will evolve as new evidence and products become available on the market. Currently, the most up to date version of the PDL is available on the Children's Mercy Family Health Partners HealthWave website. Click here to view it.

In June 2007, Children's Mercy Family Health Partners will also have its PDL accessible through Epocrates^TM. If you are a current user of Epocrates^TM, you will receive notification from Epocrates^TM when the Children's Mercy Family Health Partners PDL is available for your use. Each time the PDL is revised, the updated version will be available through both of these web-based tools. Updates and PDL changes will also continue to be communicated in pharmacy and provider newsletters that are distributed on a routine basis.

A medication exception form is required when you wish to have a medication for your patient that is not included in the PDL. The medication exception form is posted on the Children's Mercy Family Health Partners HealthWave website. You can find it here.

A prior authorization is required for a medication that is included in the PDL but is only approved for a patient that presents with specific clinical characteristics. For example, Sporonox capsules are listed in the PDL but require prior authorization before prescriptions for the capsules can be filled. Copies of the prior authorization criteria sets are posted on the Children's Mercy Family Health Partners HealthWave website in the Provider Resources section. Once you have responded to the questions on the prior authorization form, fax the form to Caremark for their review at 1-952-820-3513. If Caremark is unable to determine whether the prior authorization request should be approved, the request will be forwarded to Children's Mercy Family Health Partners for the final determination.

Historically, Children's Mercy Family Health Partners has printed a hard copy of its PDL once per year. In 2007, the latest version of the PDL became available March 1, 2007. If you are a physician and have not received a copy of the PDL yet, please contact your Provider Relations Representative and he/she will be happy to provide you with one or more copies for your office. Hard copies of the PDL were mailed to each pharmacy in the Children's Mercy Family Health Partners pharmacy network in April 2007.

Pharmacy related questions can be directed either to the Children's Mercy Family Health Partners Prior Authorization staff or to Ma'ata Touslee. To speak with a Prior Authorization staff member, please contact 1-888-691-4874 between the hours of 8am and 5pm CST. To contact the pharmacy department directly, please contact Ma'ata Touslee at 1-816-559-9300 between the hours of 8:30am and 5:00pm CST.