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Referral-only agreements.
Encore has referral-only agreements with Welborn Health Plans and M-Plan. Like Encore, M-Plan is owned by The HealthCare Group, LLC.
Welborn Health Plans
Encore Health Network has agreed to an exclusive statewide arrangement with Welborn Health Plans (located in Evansville, Indiana) and USA Managed Care Organization (USA MCO). Deaconess Health Plan participating providers are not included in this arrangement.
Encore Health Network will offer referral-only healthcare services to members of Welborn HMO for out-of-area in-network services or for those members who seek specialized care not available through Welborn. USA MCO is the national network and claims repricer for the Welborn HMO arrangement.
How does this arrangement affect participating providers?
Members of Welborn HMO will be referred to Indiana Encore providers through the use of their Primary Care Physician (PCP). It will be the member’s responsibility to obtain the referral from their PCP from Welborn before contacting your office. Welborn members must have a referral from their PCP prior to seeing an Encore participating provider. If your office has not received a referral by the time of the patient visit, Encore asks that you provide services and ask the member to sign a statement of financial responsibility.
Who will be the payor and where should claims be submitted?
Encore providers will continue to be reimbursed according to your contracted Encore reimbursement schedule. Welborn is the payor and will adjudicate all claims.
Encore providers will submit claims to USA MCO for repricing to the address on the member’s ID card. USA MCO also accepts electronic claims. Claims will then be forwarded to Welborn for payment.
How will this arrangement be represented on the ID card?
Encore’s logo must be on the ID card as providing services on a referral basis only.
Encore’s logo will appear on the EOB.
Welborn Health Plans will be on the ID card along with one of the following product names and their corresponding claim address and phone number: Welborn Health Plans or Health Care Solutions.
USA MCO’s logo will be on the ID card as the national network providing services outside of Indiana.
Who do I call for information?
Customer Service is available as noted on the ID card. All claims questions will be answered through Welborn HMO as noted on the ID card.
M-Plan
Encore Health Network provides statewide access for M-Plan, effective Jan. 1, 2004. M-Plan HMO members are eligible for access to Encore PPO providers for emergencies or covered services when referred by their M-Plan PCP.
How does this arrangement affect participating providers?
Encore Providers will participate, as contract parameters will be compliant with Provider Agreements.
Encore’s logo will be on the ID card stating Encore services will be provided on an emergent or a referral basis only.
Encore will appear on the EOB identifying the PPO discount.
M-Plan’s logo will be on the ID card, along with the typical information about authorizations and eligibility verification.
Access to Encore for M-Plan members does not mean that you are a participating provider with M-Plan.
What about the referral process?
Members of M-Plan HMO must call their selected PCP prior to visiting an Encore PPO provider to receive authorized in-network benefits. Encore providers have no responsibility for the referral process and are not to act in a gatekeeper capacity. M-Plan members accessing Encore providers without authorization will be financially responsible.
Reimbursement and Claims Submission
Encore providers will continue to be reimbursed according to your contracted Encore reimbursement arrangement.
You should collect the appropriate co-payment listed on the M-Plan member’s identification card.
Submit claims to the network name and address on the M-Plan member’s identification card.
For claims inquiries, call toll free (800) 675-2605.
How will this arrangement be represented on the ID card?
The member’s identification card will identify Encore for emergency services or services authorized by the M-Plan PCP.
What if I am also a participating M-Plan provider?
If you are a M-Plan participating provider, your M-Plan network contract will supersede your Encore agreement. The member is an M-Plan HMO member when visiting your office and all M-Plan administrative guidelines apply.
Who do I call for more information?
Call Encore Provider Relations toll free at (888) 574-8180 for contract or administrative questions. All claims questions should go to the claims phone number on the member ID card.