- What type of information is available online?
- What is a POD?
- What is the address to submit professional or facility claims?
- Do you accept electronic claims?
- Who do I talk to if a claim has been rejected electronically?
- What is "Usual and Customary" rates?
- If I need electronic benefit, eligibility or provider information, can I obtain specialist information via the Renaissance website?
- Who is responsible for getting an authorization for a patient?
- How do I get more IPA referral forms?
- What is the fax number for the authorization utilization department?
- Do outpatient procedures need authorization from Renaissance?
- Can an authorization be extended if they still have visits left?
- Can the Physical Therapy provider call to request additional visits?
- When do I receive my cap check?
- If a member is listed on my capitation detail report, does that mean they are eligible?
- Can the member be billed directly for any services rendered in the office or the hospital?
- What if the member requests care which falls outside of the Schedule of Benefits, or is deemed medically unnecessary by the IPA's Medical Director?
1. What type of information is available online?
A: Online directories that include information such
as:
Primary Care Physicians (PCP's)
Specialists
Customer Service Contacts
Important phone numbers and website addresses.
Map showing the Renaissance Physicians Organization service area.
2. What is a POD?
A: Physicians Organized Delivery System
PODS are groups of physicians (PCPs and Specialists) geographically
centered around a hospital whose referral patterns usually remain within the same
geographic physician community.
3. What is the address to submit professional or facility claims?
A: RPO Claims
P.O.Box 922001
Houston, TX 77092
4. Do you accept electronic claims?
A: Please contact the Provider Relations Department for payor ID information at 832-553-3300.
5. Who do I talk to if a claim has been rejected electronically?
A: Contact Customer Service at 832.553.3333 for assistance.
6. What is "Usual and Customary" rates?
A: They are customary rates based on a national recognized
authoritative database.
7. If I need electronic benefit, eligibility or provider information, can I obtain specialist information via the Renaissance website?
A: All participating providers can access this information by signing onto My Quest
8. Who is responsible for getting an authorization for a patient?
A:
Initial authorization comes from the referring physician (PCP or specialist) The treating physician completes any additional authorizations. The treating physician does not need to contact the referring physician for an additional authorization.
9. How do I get more IPA referral forms?
A: Contact your Provider Relations Representative at 832.553.3300
10. What is the fax number for the authorization utilization
department?
A: Fax all authorization request to 832.553.3420
11. Do outpatient procedures need authorization from Renaissance?
A: Outpatient procedures need authorization from Renaissance for the professional charges. They also need authorization from the healthplan for the facility charges.
12. Can an authorization be extended if they still have visits left?
A: Yes, if the eligibility if still active and member has the same PCP. However, you need to contact your referral coordinator to have the authorization extended.
13. Can the Physical Therapy provider call to request additional visits?
A: No, the request must come from the requesting physician.
14. When do I receive my cap check?
A: Renaissance distributes cap on or before the 22nd of each
month.
15. If a member is listed on my capitation detail report, does that mean they are eligible?
A: The capitation detail report is NOT proof of eligibility. You must call the healthplan of the member to get the most up-to-date eligibility information. The IPA information includes some retroactivity and should not be used for proof of payment. Please sign onto My Quest for the latest eligibility information.
16. Can the member be billed directly for any services rendered in the office or the hospital?
A: Members cannot be billed if the services are a covered benefit under the health plan. The physician must look solely to the IPA for payment of these services. Only the copayment may be billed to the member when services are included in the individuals benefit package. In the event that a member self-directs to a physician for care without authorization, the member may be billed.
17. What if the member requests care which falls outside of the Schedule of Benefits, or is
deemed medically unnecessary by the IPA's Medical Director?
A: The member should be informed that these services are not covered benefits and will be billed directly to the member.
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