PROVIDER INFORMATION

Our Partnership Program Provider Directory outlines our broad network of qualified doctors, clinics, hospitals, and other providers to offer health care services to our members. We try to ensure the Provider Directory is up-to-date and accurate. However, because of additions, resignations, and changes in practice arrangements, we cannot guarantee that providers listed in the directory will always be available.

The Provider Manual is developed as a tool for Plan Providers to use when serving Members. It defines the Partnership Program, policies and procedures and the Quality Improvement (QI) program and initiatives required by the State of Wisconsin Department of Health and Family Services (DHFS) and the Partnership Program.

It’s recommended you refer to our website for the most current, electronic document of the Provider Directory and Provider Manual. Printed copies of the Directory and Manual can be obtained by calling the Provider Relations Department at 715-838-1607. We cannot guarantee continued affiliation with any provider that is listed in the Directory.

Community Health Partnership, a Program of Partnership Health Plan, Inc. (PHP), is the payer of medical and long-term support services for Partnership Members enrolled in the program. The following information will be helpful for you to know when you submit a claim for processing: PHP Provider Billing Procedures.

Our Clinical Practice Guidelines have been gathered from medical literature and opinion. Please note: these guidelines are not a substitute for a provider’s judgment.

The CHP Formulary is designed to promote rational drug therapy through products that have been selected based on both therapeutic efficacy and cost.

IMPORTANT INFORMATION & FORMS

The form documents below are Portable Document Format (PDF) files. This format requires the free Adobe® Acrobat® Reader® software to open the file. It you do not have it installed on your computer, you can visit Adobe.com and download Adobe Acrobat Reader.

• Retroactive Rate Adjustments for Wisconsin Skilled Nursing Facilities Medicaid RUGs Stays
• Physician Request for Coverage Determination Form

Additional Appeals and Grievance information is available from the Centers for Medicare and Medicaid Services (CMS) website. (see links below)

• Medicare Managed Care Appeals and Grievances
• Medicare Prescription Drug Appeals and Grievances
• Fee-For-Service Appeals

Best Available Evidence (BAE)

Federal regulations specify the requirements of Part D sponsors in the administration of the low-income subsidy program - including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, the Center for Medicare and Medicaid Services (CMS) has inaccurate information about a person's low-income subsidy status. This means that CHP may not have the correct information to determine a member's subsidy.

To address these situations, CMS created the Best Available Evidence (BAE) Policy. This policy requires CHP to establish the appropriate cost-sharing for low-income members when presented with evidence the member's information is not accurate.