Provider FAQs



Administrative & Credentialing
Billing & Claims
Eligibility & Referrals
CeltiCare Member Benefits
5010 Migration Frequently Asked Questions (PDF)

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Administrative & Credentialing


How can I become a provider of CeltiCare Health Plan?

Contact your Provider Relations Specialist. You can call (866) 895-1786, Monday through Friday, 8am-5pm, to obtain the name and phone number of the Provider Relations Specialist in your area.

What is the turnaround time to credential a new provider?

There is a 30 day turnaround time from the receipt date that a clean and complete credentialing application is received until a provider is fully credentialed. Prior to receiving the letter from CeltiCare that credentialing has been completed a provider should not see a CeltiCare member without prior authorization from the Plan.

How do I notify CeltiCare Health Plan of an address change?

Please send the address change notification to:


CeltiCare Health Plan of Massachusetts
Attn: Provider Relations Department
1380 Soldiers Field Road, Suite 300
Brighton, MA 02135

How can I change my role from a PCP to a Specialist?

Please send the address change notification to:

CeltiCare Health Plan of Massachusetts
Attn: Provider Relations Department
1380 Soldiers Field Road, Suite 300
Brighton, MA 02135

If you are contracted with CeltiCare through an IPA, Medical Group or PHO, a letter on the organization’s letterhead must be sent by the administrator of the contracting entity requesting that your status be changed. The letter should be mailed to:

CeltiCare Health Plan of Massachusetts
Attn: Provider Relations Department
1380 Soldiers Field Road, Suite 300
Brighton, MA 02135

There may be additional credentialing requirements that must be completed before the change can be made. If you are contracted with CeltiCare individually please send your written request on your letterhead to:

CeltiCare Health Plan of Massachusetts
Attn: Provider Relations Department
1380 Soldiers Field Road, Suite 300
Brighton, MA 02135

There may be additional credentialing requirements that must be completed before the change can be made.

When does my contract become effective?

Your contract will become effective on the first day of the month following the notice that all credentialing requirements have been completed. You must have prior authorization from CeltiCare to see CeltiCare members prior to the date that your contract is effective.

What types of providers need to fill out a facility credentialing application?

Community Health Centers, Hospitals, Surgery Centers, Rehab Centers, Radiology Imaging Centers, Skilled Nursing Facilities, Adult Living Facilities, Durable Medical Equipment, Home health Agencies and Assisted Long-Term Care Facilities. If you have a question about this or any other credentialing requirement please call your Professional Relations Specialist at (866) 895-1786, Monday through Friday, 8am-5pm.

How do I check the status of my provider application?

Contact the CeltiCare Health Plan Provider Relations department at (866) 895-1786, Monday through Friday, 8am-5pm.

How do I submit a request to change a member's PCP?

Click here to access CeltiCare’s PCP Change Request Form. Please fax a copy of this form, with a copy of the member ID card, if available, to CeltiCare Member Services Department at (866) 614-1953. PCP change requests take 24 hours to process.

Does Find a Doctor list imaging centers?

CeltiCare’s Find a Doctor does not include the imaging centers at this time.

Do I need Prior Authorization for imaging?

Yes. For details on Prior Authorizations please go to our Prior Authorization page here.

 

Billing and Claims

Are claim disputes and claim adjustments the same thing?

No. A claim adjustment is a claim that has previously processed but needs something changed to it (such as CPT code, ICD-9 diagnosis, member name, sex, DOB or date of service). All new and adjusted claims should be sent to:

CeltiCare Health Plan of Massachusetts
Attn: Claims
PO Box 3080
Farmington, MO 63640-3824

A claim dispute is a provider request for a high level review of a claim that denied or did not pay as expected because of CeltiCare’s administrative policies (such as a code auditing software edit, filing limit, authorization edit, etc.). Please see the Provider Billing Guide on our Documents and Forms page under the General Information section for a successful submission of a Claim Dispute. Please click here.


Should I use the group NPI or the individual NPI when billing?

The servicing/rendering physician’s NPI should be is box 24J. The Business entities NPI’s number should be in 33A. In some cases the same number could be the same.

What is our turnaround time regarding clean claims?

Clean claims will be adjudicated (finalized as paid or denied) within thirty (30) business days of the receipt of the claim.

How much time does CeltiCare have to respond to a dispute request? How soon does the acknowledgment letter get sent out?

An acknowledgement letter will be sent within 5 days of receipt of a provider dispute. CeltiCare will review all dispute requests within 45 days of receipt.

Does CeltiCare follow the MassHealth guidelines in regards to consult codes?

Claims billed to CeltiCare with consultation codes 99241-99245 and 99251-99255 will not be reimbursed.

Do we follow MassHealth guidelines in regards to the use of Modifiers?

CeltiCare follows a comprehensive set of billing requirements for modifiers; including but not limited to, AMA, CMS, MassHealth, etc. Please see our Provider Billing Guide on our Documents and Forms page under the General Information section click here for helpful modifier placement.

Is prior authorization required when billing injectables outpatient on a UB?

Many biopharmaceutical and injectable drugs require prior authorization. Some exceptions apply for certain providers. Please see the Prior Authorization page for more information.

When do I have to send CeltiCare a refund and where do I send refunds?

If you have received an overpayment or misdirected payment, please send the money back to CeltiCare using the address below.

Please send your refund to:

CeltiCare Health Plan of Massachusetts
16900 Collections Center Drive
Chicago, IL 60693

What encounter data fields are required to be a completed for a claim to be processed?

All CeltiCare claims must have complete Encounter and HIPAA data fields complete before they can be processed. For the complete listing of required data fields, see the notices for Encounter Data Fields and HIPAA Data Fields.

 

 

Eligibility & Referrals

How do I check member eligibility?

There are several ways to obtain the eligibility information. You can call (866) 895-1786, Monday through Friday, 8am-5pm, and follow the prompts or you can obtain the information by logging in to the CeltiCare web portal and clicking on the Eligibility tab.

How often should I check member eligibility?

Eligibility should be checked when scheduling an appointment and prior to every member appointment. Member eligibility can change on a daily basis so it is important to validate eligibility especially if there has been a long time between when the appointment was scheduled and the date of service.

How can I obtain a report of the individuals that have selected me as their PCP?

The CeltiCare web portal has this functionality. You can log-in to the portal and run this report as needed. To access the secure provider portal, go to https://portal.centenesecure.com/portal/public/celticare/provider and follow the instructions given. If you need assistance on how to complete this specific request in the portal please contact your CeltiCare Provider Relations Specialist.

How can a member select me as their PCP?

Have the member fill out a PCP Change Form found on our Documents and Forms page under the Other Forms and Applications section click here. For assistance with further questions please contact Provider Services at: (866) 895-1786.

If a member self refers to a specialist, is it mandatory to notify the members PCP?

Although is it not mandatory, it is for the best interest of the patient that all services provided to the member be communicated back to the members PCP for continuity of care.

Does CeltiCare cap provider panels?

No.

Can you back date a referral/authorization when a patient is seen at a non-contracted facility?

Celticare does not ‘back date’ or provide retrospective authorization or reviews.

What is the turn around time for an authorization that needs to be reviewed by Medical Management?

The turn around time is 2 business days of obtaining all necessary information to effect a determination.

Do you need an authorization for inpatient admission / surgery?


• Authorization is required for all impatient admissions/surgeries.
• Emergency Room does not require Prior Authorization.
• Observation stays in participating facilities do not require Prior Authorization.
• Outpatient services at a participating facility would not require authorization.

Is it stated on the CeltiCare website or in the Provider Manual what the turn around time is for a Prior Authorization?

It is noted on the Prior Authorization fax request form that determination for standard requests will be made within two business days of receiving all necessary information. For urgent requests, please follow the instructions on the fax form.

 

 

CeltiCare Member Benefits

Is the CentAccount Program renewed annually?

Yes it is renewed annually.

What do I do if a member needs eye care?

CeltiCare partners with OptiCare to provide some, but not all, eye services. In addition, the Member should always check their benefit plan as not all services may be covered by all plan designs.

How can I become contracted to provide vision services for CeltiCare Members?

To provide the full scope of eye services a provider must be contracted with both OptiCare and CeltiCare. Please call Provider Services at (866) 895-1786, Monday through Friday, 8 a.m.-5 p.m., for more information regarding obtaining a contract to provide these services.

What do I do if a member needs behavioral health services?

CeltiCare partners with Cenpatico to provider behavioral services. If a member’s need for behavioral health services is an emergency, please refer the member to the nearest emergency room or Emergency Service Provider (ESP). If you would like to contract with Cenpatico to provider behavioral services to a member on an ongoing basis please contact Cenpatico at (866) 896-5053.

Does CeltiCare require a Sterilization Consent Form be completed?

CeltiCare does not require a Sterilization Consent Form.

What services require plan authorization for payment to be considered?

A list of services and medications requiring prior authorization can be found on our Documents and Forms page in the Prior Authorization section. Please click here for the Documents and Forms page. Please note, this list is not exhaustive and you should contact CeltiCare Medical Management Department at (866) 895-1786, Monday through Friday, 8am-5pm for confirmation.

Who may order services for the treatment of autism spectrum disorder?

Per MA General Law Chapter 176 G Section 4V for members covered under a Commercial plan the treatment of autism spectrum disorders, includes the following care prescribed, provided or ordered for an individual diagnosed with one of the autism spectrum disorders by a licensed physician or a licensed psychologist: habilitative or rehabilitative care; pharmacy care; psychiatric care; psychological care; and therapeutic care.

Is there a listing of drugs or types of drugs that require Prior Authorization?

The best way to determine if Prior Authorization is required is by consulting our Prior Authorization page please click here.