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Provider Portal
User Guide
Provider Web Portal
www.PHCcares.com
Table of Contents
Did you know…? ........................................................................................................................... 1
Register........................................................................................................................................ 2
Logging In..................................................................................................................................... 5
Home ........................................................................................................................................... 6
Member Inquiry>Search Members ............................................................................................. 6
Member Inquiry>Search Requests .............................................................................................. 7
Member Inquiry>Search Claims .................................................................................................. 8
Member Inquiry>Medical............................................................................................................ 8
Member Inquiry>Medical>Provider List...................................................................................... 9
Member Inquiry>Medical>Vitals ................................................................................................. 9
Member Inquiry>Medical>Diagnosis .......................................................................................... 9
Member Inquiry>Medical>Allergies .......................................................................................... 10
Member Inquiry>Medical>Medications.................................................................................... 10
Member Inquiry>Medical>Labs................................................................................................. 11
Member Inquiry>Medical>Immunizations................................................................................ 11
Member Inquiry>Insurance>Member....................................................................................... 12
Member Inquiry>Insurance>Eligibility ...................................................................................... 12
Member Inquiry>Insurance>Claims .......................................................................................... 13
Referral & Prior Authorization Guidelines................................................................................. 14
Definitions ................................................................................................................................. 14
Referral Guidelines .................................................................................................................... 15
Referral to Specialist.................................................................................................................. 16
Specialist Guidelines .................................................................................................................. 18
Member Inquiry>Insurance>Prior Authorization ...................................................................... 18
Entering a Prior Authorization Request..................................................................................... 19
Place of Service codes ............................................................................................................... 21
Authorization Type codes.......................................................................................................... 22
Auth Guidelines ......................................................................................................................... 23
Member Inquiry> Insurance>View Pending .............................................................................. 23
Member Inquiry> Insurance> View Approved .......................................................................... 24
Member Inquiry> DM (Disease Management).......................................................................... 25
Member Inquiry> Attestation.................................................................................................... 26
Pharmacy ................................................................................................................................... 27
eTools ........................................................................................................................................ 29
Help............................................................................................................................................ 30
Help>Contact Us ........................................................................................................................ 30
Help>Provider Resources .......................................................................................................... 31
Administration........................................................................................................................... 31
Physicians Health Choice Provider Web Portal Training Guide January 2011
1
Provider Web Portal
www.PHCcares.com
Did you Physicians Health Choice offers an interactive website specifically for our
know…? contracted providers! Our website allows you to:
Verify eligibility and effective date of coverage
Verify benefits for most common services
View claim status
View authorization status
Access member medical information such as
o Hospital visits
o Medications
o Lab results…and more!
Submit referrals to Disease Management
Browse our Formulary
Print screens for your records!
Our provider portal was developed with you in mind. It promotes
convenience by:
Being available 24/7‐ log on for patient information when you want,
not only when Customer Service is available
Retrieving eligibility instantly‐ rather than waiting for a Customer
Service Representative to gather the information.
Toll‐free technical support available
In addition, the following resources are available to everyone when visiting
www.PHCcares.com‐ no registration or log‐on required!
Summary of Benefits for all plans
Formularies for each plan
Provider Directories
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Register To begin looking up member accounts online, you must first register with the
Physicians Health Choice website. Online registration is quick and easy:
Point your browser to
www.PHCcares.com.
Select I am a Doctor.
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Select Login from the
menu on the left.
Select Login once more.
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Now that you’ve arrived
at the Provider Portal,
select Create a new
account to register.
Review the HIPAA
statement, check the
box indicating your
agreement and click
Next.
On the next screen, you will establish a username and answer some security
questions.
In a few minutes, you will receive an email from NewUser‐
NOREPLY@phccares.com. It will include further log‐on instructions.
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Logging In Now that you’ve registered, you are ready to log on. Simply go through the
steps listed on pages two and three, using the username and password
provided in the email. Sign in and select Login.
Note: At this time, you will have an opportunity to change the default password
that was provided.
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Home The first screen you will see upon logging in is the Home tab. This area will be
used to alert you of important information, new features of the portal, house
the most recent Provider Manual and present/past issues of our provider
newsletter, Physician News.
Note: The Quick Links menu is static and will remain on every page. These links
take you to the most commonly‐visited areas of the Portal.
Member To begin looking up members, you will click on the Member Inquiry tab.
Inquiry>Search Here, you can search for members, authorization requests or claims that
Members have been submitted.
When searching for a member, enter the member ID number, as indicated
on their Physicians Health Choice ID card.
If you do not have the member ID number, you may conduct your lookup by
using the member’s name and date of birth.
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The Recent
button will
reveal the
last 25
member
accounts that
were
accessed.
Enter the member’s ID number (from their
Verify the correct member was retrieved Physicians Health Choice ID card). No need to
and open the account by clicking on the enter the preceding zeros, however the suffix
member’s name. (01) is required. Click Search.
Member To search for a Prior Authorization request, you must enter a combination of
Inquiry>Search date range and either a provider name or a “Web ID.”
Requests
A “Web ID” is a
unique number
assigned to each
referral request.
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Member To search by claim, you must enter a combination of date range and a
Inquiry>Search provider name or a check number.
Claims
Note: only claims from the previous 12 months are accessible online.
Member Once a member’s account is accessed, the screen below will appear. Here,
Inquiry>Medical you can verify:
□ Plan
□ PCP and effective date of PCP
□ DOB, address, phone #
□ Member ID #
□ Benefits at a glance
From here, you have visibility to the Medical tab. This will display
information such as clinical information and provider utilization.
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Member Inquiry> Lists providers the member has seen through received claims. Click on a
Medical> provider’s name to display the provider’s demographics.
Provider List
DR. JANE DOE 123-456-7890 123-456-7890 ###
DR. JOHN DOE
234-567-8901 234-567-8901 ###
DR. MARY DOE
DR. FRANK DOE 345-678-9012 345-678-9012 ###
DR. JACK DOE 456-789-0123 456-789-0123 ###
DR. JILL DOE 678-901-2345 678-901-2345 ###
Member Inquiry> Here, you can view vitals collected and entered into the website. To enter
Medical>Vitals a new vital, click on the Add New Vital, fill out the form, and press Add
New.
Member In this section, diagnosis collected from claims data is listed.
Inquiry>Medical>
Diagnosis
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Member Inquiry> Here, you can review known allergies that have been documented on the
Medical>Allergies website. To enter a new allergy, click on the Add New Allergy Record, fill
out the form, and press Add New
Member Inquiry> Lists prescription medications prescribed to the member while on the
Medical> Physicians Health Choice plan.
Medications
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Member Inquiry> Lab work that the member has had done is listed here.
Medical>Labs
Member Inquiry> Immunizations administered to the member.
Medical> To enter a new allergy, click on the Add New Immunization, fill out the DOS
Immunizations and CPT code, and press Add New.
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Member Inquiry> You have now arrived at the Insurance area of the Member Inquiry tab.
Insurance> This provides useful information such as:
Member Insurance company and plan name
Current PCP
Start date with current PCP
Co‐pays for common benefits:
o PCP office visit
o Specialist office visit
o Hospitalization
o Emergency room
o Ambulance
o Outpatient surgery
o Durable medical equipment
o Radiology
Member Inquiry> Shows original effective date, name of plan the member is/has been on,
Insurance> and PCP assignment. Click on a row to display benefits for that timeframe.
Eligibility
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Member Inquiry> Displays the previous 12 months worth of claims, along with their status.
Insurance>Claims For more processing information‐such as denial reason‐ click on the row of
the claim and refer to the comments at the bottom of the screen.
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Referral & Prior Before we discuss entering Prior Authorizations into the Provider Web
Authorization Portal, it is important to understand the Physicians Health Choice Medical
Guidelines Management guidelines.
Beginning January 1, 2011, members of the Corpus Christi Total
HMO plan will follow a referral process and a slightly different
Prior Authorization process.
When you are serving members of all other Physicians Health Choice plans,
please follow the “business as usual” process – no referral required for in‐
network specialty visits. Prior Authorization is still required for all services
listed on the Prior Authorization list, regardless of the provider type.
In order to easily distinguish which information pertains to the referral and
Prior Authorization process for the Corpus Christi Total HMO plan, relevant
sections will be noted with this symbol:
CC
Guidelines that apply to all other Physicians Health Choice plans outside of
the Corpus Christi Total HMO will be noted with this symbol:
Definitions A referral is the process of sending the patient from one
practitioner to another for health care services.
CC
A Prior Authorization is a formal process where a provider must obtain
authorization from the health plan before a specific procedure, treatment or
service on the PA list is rendered.
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Referral It is important to note that there are two different types of referrals‐
Guidelines Evaluate and Evaluate & Manage.
EVALUATE EVALUATE & MANAGE
Can only be requested by the PCP and • Can only be requested by the PCP
must be submitted via the Provider Web and must be submitted via the
Portal at www.PHCcares.com Provider Web Portal at
• PCP selects option for Evaluation Only www.PHCcares.com
• Evaluation only covers office visit and • PCP selects option for Evaluation
limited associated codes by specialty & Management
• Specialists cannot request services on • Referral authorizes all services not
CC the Prior Authorization list without an on the Prior Authorization list
Evaluate & Manage referral • This allows the specialist to
• Specialist cannot refer member to other request services on the Prior
specialties Authorization list
• If the specialist feels additional services • Specialist cannot refer member to
are necessary, they should contact and other specialties
discuss with PCP
SERVICES ALLOWED UNDER “EVALUATE” ONLY REFERRAL
Office E & M • Venipuncture • Glucose Injections • EKG • Fecal occult blood
Protime CRIT/CBC • U/A Supplies • Plain films • Introduce needle/IV catheter
Injectable Methylprednisoslone •Injectable Triamciniolone
Injectable Betamethasone
Specialty types that do not require a referral: OB/GYN, Hematology, Oncology,
Radiology, Pathology and Anesthesiology (pain management will require a referral).
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Referral to Requesting a referral is easy. Refer to the guidance below.
Specialist
(continued)
DR. JOHN DOE
987-654-3210 987-654-3211
1
DR. JANE DOE
2,3
CC 987-654-3213 987-654-3212
4
5
6
7
Step Action
1 Select the Specialty from the drop‐down menu.
2 Search for the desired specialist by clicking Select to the left of
the Name drop‐down menu. A separate window will open (make
sure your pop‐up blocker is disabled). From here, you can search
for physicians by specialist type.
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Referral to
Specialist Step Action
(continued) 3 Select a specialist by clicking on the check mark next to
specialist’s name. The specialists telephone and fax number will
auto‐populate.
CC
4 Select Evaluation Only or Evaluation & Management.
5 Select the number of requested visits and enter the date span in
which the member needs to be seen. For Evaluate referrals, up
to three visits may be requested. For Evaluate & Manage
referrals, up to 12 visits may be requested. The default for both
types of referrals is three.
6 Enter the member’s diagnosis (by code or description). Once it is
retrieved, highlight it and click on the red arrow to bring it to the
Selected box. Up to three diagnoses may be added. To DELETE,
highlight the selection and click “X” to remove.
7 Click Save to enter your request.
If you select a Specialty type that does not require a referral, the following
message will appear:
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Specialist By clicking here, the Prior Authorization and Referral List for Corpus Christi
Guidelines Total HMO members will be displayed.
CC
Member This area allows you to request Prior Authorizations without having to call
Inquiry> Medical Management. Refer to the following pages for a detailed description
Insurance>Prior on how to enter a new request.
Authorization
1 2
3
Dr. John Health Dr. John Health
876-543-2109 876-543-2108 876-543-2107 876-543-2106
CC Dr. John Q
876-543-2109 876-543-2109
4
5
6
7
8
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Entering a Prior Step Action
Authorization 1 This field allows a choice of two turnaround times:
Request Routine 14 days
Expedited* 72 hours
*Expedited authorizations require a call to the Medical
Management team for prompt attention. They can be reached at
1‐877‐299‐7213.
2 Enter the desired date of service (DOS).
3 In the Provider the patient is being referred to section, search for
CC the desired specialist by clicking Select to the left of the Name
drop‐down menu. From here, you can search for physicians by
specialist type.
Phone and fax numbers will automatically populate when you
choose a provider. Otherwise, enter the required information.
4 Select the appropriate Service Type from the drop‐down menu:
• Observation/ER
• Inpatient
• Outpatient
• Other
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Entering a Prior
Authorization Step Action
Request 5 Place of Service (POS) and Authorization Type vary by the Service Type
(continued) selected. Refer to the next page for a list of all POS and Authorization
types.
6 Enter the member’s Diagnosis (by code or description). Once it is
retrieved, highlight the appropriate diagnosis and click on the red
arrow to bring the diagnosis to the Selected box. Up to three diagnoses
may be added. To DELETE, highlight the selection and click the “X” to
remove.
CC 7 Search for the desired Procedure by CPT or description and click Filter.
Once retrieved, and click on the red arrow to bring the procedure code
to the Selected box and specify the number of visits associated with
that code. Up to three codes may be added. To DELETE, click the “X”
next to the selection.
8 Select up to three Service Groups by clicking the arrow to move the
service group to the Selected box. To DELETE highlight the selection
and click the “X” to remove.
9 Add any necessary free‐text notes, upload any related documents and
click Save. Cancel will delete the request.
10 For those services requested that do not require an authorization, a
message box will pop up advising that authorization is not required.
Please reference the Prior Authorization List in the Auth Guidelines section of
this menu.
If a specialist has an Evaluate Only referral and attempts to submit a Prior
CC Authorization in the Provider Web Portal, the following message will be
displayed. The specialist will need to contact the member’s PCP.
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Place of Service
codes Place of Service (POS)
01‐ Pharmacy 34‐ Hospice
03‐ School 35‐40‐ Unassigned
04‐ Homeless Shelter 41‐ Ambulance (Land)
05‐ Indian Health Svc (OP Fac) 42‐ Ambulance (Water/Air)
06‐ Indian Health Svc (IP/OP) 49‐ Independent Clinic
07‐ 638 Indian Health Svc (OP Fac) 50‐ Federally Qualified Health Ctr
08‐ 638 Indian Health Svc (IP/OP) 51‐ Inpatient Psychiatric Facility
09‐ Prison/Correctional Fac 52‐ Psychiatric Facility (Partial Hosp)
11‐ Office 53‐ Community Mental Health Ctr
12‐ Patient’s Home 54‐ Int Care Fac/Mentally Retarded
13‐ Assisted Living Facility 55‐ Res Substance Abuse Treat Ctr
14‐ Group Home 56‐ Psychiatric Res Treatment Ctr
15‐ Mobile Health Service Unit 57‐ Non‐Res Subst Abuse Treatm Fac
16‐ Temporary Lodging 60‐ Mass Immunization Center
20‐ Urgent Care Facility 61‐ Comprehensive Inpt Rehab Fac
21‐ Inpatient Hospital 62‐ Comprehensive Outpt Rehab Fac
22‐ Outpatient Hospital 63‐64‐ Unassigned
23‐ Emergency Room (Hospital) 65‐ ESRD Treatment Facility
24‐ Ambulatory Surgery Center 66‐70‐ Unassigned
25‐ Birthing Center 71‐ Public Health Clinic
26‐ Military Treatment Facility 72‐ Rural Health Clinic
27‐30‐ Unassigned 73‐80‐ Unassigned
31‐ Skilled Nursing Facility 81‐ Independent Laboratory
32‐ Nursing Facility 82‐98‐ Unassigned
33‐ Custodial Care Facility 99‐ Other
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Authorization Authorization Type
Type codes Diagnostic Lab Occupational Therapy
Diagnostic Medical Oncology
Diagnostic X‐ray Otological Exam
Donor Procedures Periodontics
Durable Medical Equipment Purch Physical Therapy
Emergency Services Podiatry‐ Office Visits
Endodontics Radiation Oncology
Family Planning Rehabilitation‐Inpatient
Hearing Aids Rehabilitation‐Outpatient
Hospital‐Outpatient Restorative
Immunizations Second Surgical Opinion
Inhalation Therapy Speech Therapy
Maxillofacial Prosthetics Third Surgical Opinion
Medical Care Well Baby Care
MRI/CAT/PET Scan
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Auth Guidelines By clicking here, the appropriate Prior Authorization List for the member you have
selected will be displayed.
Member Inquiry> View Pending allows you to view, print and edit all Prior Authorization requests
Insurance>View entered for that member.
Pending
123-456-7885 123-456-7890 DR. JAN DOE
DR. JIM DOE
234-567-8986 234-567-8901
DR. JEB DOE
345-678-9087 345-678-9012
DR. JOY DOE
678-901-2388 678-901-2345
DR. JED DOE
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Member Inquiry> Processed Prior Authorizations can be viewed here. Click on the desired request
Insurance> View to view details including the outcome and any notes from the Medical
Approved Management department.
Type of Referral that was
requested/approved
E= Evaluate only
CC EM= Evaluate &
Manage
DR. JOHN DOE
987-654-3210
Provider that is being
referred to/authorized
Authorized service DR JANE HEALTH DR JOHN DOE
987-654-1111 987-654-7777
987-654-3210 987-654-3209
Notes from Medical
Management
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Member Inquiry> Do you have a patient that has a chronic condition? Would you like the
DM (Disease nurse case managers to assist you in managing this patient’s condition? If
Management) so, we encourage you to make an online referral for the member for our
Disease Management program. All of our members are eligible to
participate in this free program. Qualifying diseases:
Chronic Obstructive Pulmonary Disease (COPD)/Asthma
Congestive Heart Failure (CHF)
Diabetes Mellitus (DM)
Ischemic Heart Disease (IHD)
You can view information
regarding current or past
participation in Disease
Management programs, or
make recommendations to
refer members to
additional Disease
Management programs.
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Member Inquiry> This area of the portal allows you to view outstanding Attestations by
Attestation member for DataRAPS purposes. You can download the PDF and view.
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Pharmacy The Pharmacy tab allows you to look up drugs covered by the plan. You will
be taken to the unauthenticated PHC website to view all pharmacy‐related
information including the formulary.
Interactive search
Download full
formulary
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Pharmacy You may search the full PDF formulary or use our interactive online search.
(continued)
To begin your drug search using our interactive online search, click Search.
When conducting this type of search, you may search by Category or Tier, or
by name of the drug.
Category Used when searching for a type of
drug, when exact name is unavailable
Tier Can be used to locate the lowest‐cost
drug
OR
Name Partial name search is permissible
Search by
drug or
therapeutic
class.
If you prefer to view the entire formulary, a PDF is available by clicking the
desired language in the Download & Search Prescription Formulary
area.
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eTools The eTools section allows you to run various reports, with an emphasis on
DataRAPS:
o RAPS‐ can download Attestation Summaries, Plan of Care
samples, Member Lists and multiple Attestation reports
o Member List‐ download your patients by selecting your market
and provider name
o DM Provider Report‐ download list of member that’s enrolled
in the Disease Management program
o Physician Package‐ download your performance against the
Quality Metrics, view patients as they pertain to Quality
Metrics, etc.
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Help The Help section allows you to contact Physicians Health Choice and serves
as a library of helpful resources and forms.
Help>Contact Us Use this area to provide feedback about the Provider Portal.
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Help>Provider The Provider Resources section allows you to view phone number lists,
Resources Prior Authorization lists, the Provider Manual, information change forms
and more.
Administration You may change your password or log out anytime during the session. This
can be accomplished by selecting the desired action from the upper right‐
hand corner of the screen, as long as you are logged in.
Please be advised that not all information provided on this website is real‐time. Some
database changes may not be reflected until the next business day.
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