Policies for Non-Contracted Providers

Welcome to the Non-Contracted Provider Policy Resource Center for Hometown Health and Senior Care Plus. The following policies and procedures outline the guidelines and responsibilities for non-contracted providers when delivering services to our members.

1. Referral from Contracted Providers for Medicare Advantage Membership – Senior Care Plus

Member Liability: Senior Care Plus members will not be held financially liable for services rendered by a non-contracted provider when referred by a contracted provider.
Authorization Requirement: All services that require prior authorization under Senior Care Plus policies must be authorized in advance, regardless of referral source, including the authorization to see an out of network provider. Failure to obtain authorization will result in denial of payment.
Provider Responsibility: In cases where required authorization is not obtained, the non-contracted provider assumes full financial liability for the cost of services. The member and the health plan must be held harmless.

Referral from Contracted Providers for Commercial Membership

Member Liability: Members may be held financially liable for services rendered by a non-contracted provider when referred by a contracted provider.
Authorization Requirement: All services that require prior authorization under Hometown Health policies must be authorized in advance, regardless of referral source, including the authorization to see an out of network provider for any member on an HMO or EPO plan. Failure to obtain authorization will result in denial of payment.

2. Prior Authorization Requirements

Mandatory Prior Authorization: All out-of-network services (excluding emergency services) require prior authorization. Non-contracted providers must submit prior authorization requests for all services.
Submission Process: Authorization requests should be submitted by fax to 775-982.3774. The Medical Prior Authorization Form can be found here or by creating an account on our EpicCare Link online portal.

3. Submitting Claims

Hometown Health allows 180 days from the date of service to submit a claim for payment unless otherwise required by law. If the payer is the secondary payer, Hometown Health allows 365 days from the date of service to submit a claim for payment.
For all claims submissions, but particularly paper claims, please pay particular attention to the following items:
Member’s name and enrollee identification number exactly as they appear on the member’s identification card
Member’s birth date
Provider’s Taxpayer Identification Number – Do not use a signature stamp that in any way obscures the Tax Identification Number (TIN)
Accurate coding of all diagnoses and services in accordance with national coding guidelines
Provider’s National Provider Identifier and/or servicing provider’s National Provider Identifier (NPI) on the CMS-1500

Complete claims requirements include:

Member’s name (enter exactly as it appears on the member’s ID card)
Member’s ID number 35 Effective 01/01/2025
Member’s address
Member’s gender
Member’s date of birth (mm/dd/yyyy)
Member’s relationship to subscriber
Subscriber’s name (enter exactly as it appears on the member’s ID card)
Subscriber’s ID number
Subscriber’s employer group name
Subscriber’s employer group number
Rendering physician, health care professional, ancillary provider, or facility name
Rendering physician, health care professional, ancillary provider, or facility representative’s signature
Address where services were rendered
Physician, health care professional, ancillary provider, or facility “remit to” address
Phone number of Physician, health care professional, ancillary provider, or facility performing the service (provide this information in a manner consistent with how that information is presented in your agreement with us)
Physician, health care professional, ancillary provider, or facility NPI and federal TIN
Referring physician’s name and TIN (if applicable)
Date of service(s)
Place of service(s)
Number of services (days/units) rendered
Current CPT-4 and HCPCS procedure codes, with modifiers where appropriate
Current ICD-10 diagnostic codes by specific service code to the highest level of specificity (it is essential to communicate the primary diagnosis for the service performed, especially if more than one diagnosis is related to a line item)
Charges per service and total charges
Detailed information about other insurance coverage
Information regarding job-related, auto or accident information, if available
Retail purchase cost (or a cumulative retail rental cost) greater than $1000 for DME
Current National Drug Code (NDC) 11-digit number for all claims submitted with drug codes. The NDC number must be entered in the 24D field of the CMS-1500 Form or the LIN03 segment of the HIPPA 837 Professional electronic form. 36 Effective 01/01/2025

Additional information needed for a complete CMS-1450 (UB-04) form:

Date and hour of admission
Discharge date and hour of discharge
Member status-at-discharge code
Type of bill code (4 digits)
Type of admission (e.g., emergency, urgent, elective, newborn)
Current 4-digit revenue code(s)
Current principal diagnosis code (highest level of specificity), with the applicable present on admission (POA) indicator on hospital impatient claims per CMS guidelines
Current other diagnosis codes, if applicable (highest level of specificity), with the applicable present on admission (POA) indicator on hospital inpatient claims per CMS guidelines
Current ICD-10 procedure codes for inpatient procedures
Attending physician ID
For outpatient procedures, provide the appropriate revenue and CPT or HCPCS codes
For outpatient services, providers specific CPT or HCPCS codes and appropriate revenue code(s) (e.g., laboratory, radiology, diagnostic or therapeutic)
Complete box 45 for physical, occupational or speech therapy services (revenue codes 0420-0449)
Submit claims according to any special billing instructions that may be indicated in your agreement with us
On an inpatient hospital bill type of 011x, the admission date and time should always reflect the actual time the member was admitted to inpatient status

4. Appeals Process for Denied Claims

All reconsiderations, including appeals, must be submitted within 90 days from the date of explanation of payment unless otherwise regulated by law.
Right to Appeal: Non-contracted providers have the right to appeal claim denials, including those related to medical necessity.
Waiver of Liability: When submitting an appeal, non-contracted providers must sign a waiver of liability, agreeing not to hold the member responsible for denied services.
If you believe that Hometown Health has not processed your claim correctly for any reason including timely filing or denial for needed medical records, you should submit a provider reconsideration. Reconsiderations must be submitted with the following information:
Claim number
Member Name
Date of Service
Clear explanation as to why you disagree with the initial determination
Submission Details: Appeals should be submitted in writing to:
Hometown Health Attn: Provider Reconsiderations
10315 Professional Circle
Reno, NV 89521

5. Reimbursement Policies

Payment Guidelines: Reimbursement for services rendered by non-contracted providers will be processed in accordance with all applicable laws and regulations. When not regulated by federal or state law, Hometown Health and Senior Care Plus’ established rates and policy edits will apply.
Balance Billing: Non-contracted providers are prohibited from balance billing members for any amount beyond the health plan’s payment, except as allowed by law.
Emergent services for Commercial members provided in Nevada will be paid as outlined in NRS 439B. Dispute Resolution for these services falls under NRS 439B.754.

6. Member Rights and Protections

No Surprises Act Compliance: In accordance with the No Surprises Act, members are protected from unexpected medical bills for emergency services and certain out-of-network care received at in-network facilities.
Hold Harmless: Non-contracted providers must agree to hold members harmless in situations where services are denied due to lack of prior authorization or other policy violations.