Administrative & Credentialing

Billing & Claims

Eligibility & Referrals

CeltiCare Member Benefits

5010 Migration Frequently Asked Questions

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Administrative & Credentialing

How can I become a provider of CeltiCare Health Plan?

Contact your Provider Relations Specialist. You can call 1-866-895-1786, 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?

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 1-866-895-1786, Monday through Friday, 8am-5pm.

How do I check the status of my provider application?

Contact the CeltiCare Health Plan Provider Relations department at 1-866-895-1786, 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.

Billing & Claims

Are claim appeals 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 appeal is a provider request for written reconsideration of a claim that denied or did not pay as expected because of CeltiCare’s administrative policies (such as claim extend, filing limit, authorization requirements, medical necessity, etc.). All claims appeals should be sent to:

CeltiCare Health Plan of Massachusetts
Attn: Claims Appeals
PO Box 3000
Farmington, MO 63640-3824

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 turn around 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 an appeals request?  How soon does the acknowledgment letter get sent out?

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

E&M code & procedure billed same day – Do we pay both services?

CeltiCare will pay both the E&M code and the procedure when billed the same day.

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

CeltiCare follows the mass health guidelines in regards to the use of Modifiers.

Does prior authorization process apply when billing injectiables outpatient on a UB or is that covered under the pape rate?

PA is not required for injectiables when the service is done outpatient hospital setting and billed on a UB.  The reimbursement would be included in the pape rate.

Eligibility & Referrals

How do I check member eligibility?

There are several ways to obtain the eligibility information. You can call 1-866-895-1786, 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.

Can I see a member that has not selected me as their PCP?

If you are not listed as the PCP of record but you provide primary care services and the member wishes to select you as their PCP, have the member complete the PCP change form located on the CeltiCare website (under Provider), or have the member contact CeltiCare member services to have the PCP information updated. This can happen quickly and easily even if the member has an appointment that day.

If you are not the PCP of record, but you are covering for the member’s PCP and you are a credentialed CeltiCare provider in good standing, you are billing per your contract requirements and the services that you are providing do not require an authorization, the claims that you submit for services provided under these circumstances will pay according to the terms of your CeltiCare contract.

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 authorize retroactive authorizations.

What is the turn around time for an authorization that needs to be reviewed by “core”?

The turn around time is 2 business days of obtaining all necessary information.

Do you need an authorization for inpatient admission / surgery?

Authorization is required for all impatient admissions/surgeries.  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 PA?

It is noted on the PA fax request form that determination for standard requests will be made within two working 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?

The only CentAccount incentive that is renewed annually is the annual wellness visit, which can occur 270 days after the member’s previous annual wellness visit.

What do I do if a member needs eye care?

CeltiCare partners with OptiCare to provide some, but not all, eye services. To provide the full scope of eye services a provider must be contracted with both OptiCare and CeltiCare. Please call Professional Relations at 1-866-895-1786, Monday through Friday, 8am-5pm, for more information regarding obtaining a contract to provide these services. Always check a member’s benefit before providing any eye service as not all services may be covered by all plan designs.

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 1-866-896-5053.

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 website at http://www.celticarehealthplan.com/providers/. Please note, this list is not exhaustive and you should contact CeltiCare case management at 1-866-895-1786, 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 PA?

The best way to determine if PA is required is by consulting our website at http://www.celticarehealthplan.com/current-members/preferred-drug-lists/.

Do we need a prior authorization for cataract surgery?

 

Prior Authorization is not required for cataract Surgery.