Polk HealthCare Plan Providers
Your role as a provider in the Polk HealthCare Plan network is essential to the health of our members. We are committed to providing you with resources and updates that will support our partnership and your efforts to serve plan members. We’re glad to have you in the network. Interested in becoming a Provider in the Polk HealthCare Plan network?
Eligibility and Benefit Verification
Eligibility must be verified by calling Customer Service (863)533-1111 and benefits and claims information must be verified by calling Meritain Health, Inc. at (888) 850-8222. PHP members should provide their medical enrollment card at the time of their visit.
For eligibility and benefit information, when you call you will need to:
- Identify the Polk HealthCare Plan
- Provide the member ID number(s) available
Gain convenient online access to patient eligibility, claim information and assistance in completing administrative tasks within your office, by registering as a provider at https://www.meritain.com/resources-for-providers-meritain-health-provider-portal/
Note: Meritain can only quote visits already accumulated toward the 20 visit limit based on claims received and processed.
Provider Quick Reference
| Service(s) | Visit Limits Per Plan Year | Approvals |
|---|---|---|
| Primary Care | Unlimited | No Pre-Cert Required |
| Specialist | 20 Visit Limit (does not refer to procedures) | PCP Referral Required |
| CT Scans | 4 Visit Limit | No Pre-Cert Required |
| MRI/MRA* | 3 Visit Limit Combined Max | No Pre-Cert Required |
| PET Scan | 2 Visit Limit | No Pre-Cert Required |
| Ultrasound | 6 Visit Limit | No Pre-Cert Required |
| Physical Therapy, Occupational Therapy and Speech Therapy | 36 Visit Limit Combined Max | No Pre-Cert Required |
*Visit Limit Combined Maximum refers to a grouping of services or therapies, in which the number of total visits for each service or therapy should NOT exceed the number of combined visit limits.
Referrals and Precertification
All member referrals MUST be to a provider or specialist within the Polk HealthCare Plan provider network. Referral forms are not required for diagnostic treatment, such as X-rays, MRIs, Ultrasounds, etc., or occupational, physical or speech therapies. A prescription from the referring provider is all that is required.
Refer to a network provider group, rather than a specific provider within the group. If referring the member to a specific provider, the member may only see the specified provider.
Only one referral per member per plan year (October 1 to September 30) is needed.
Referrals should be submitted prior to claim submission. Do not submit referrals with the claim.
Specialist Referring Specialist
If a Specialist refers to a Specialist, the referring Specialist must provide the Specialty Referral form.
The Provider/Specialist who receives the patient referral must submit the completed Specialty Referral form to: Meritain Health, Inc. via fax at (602) 789-9369 or submit via email at group_precert-referrals@meritain.com in order for claims to be paid.
To obtain a Provider Directory or Specialist Directory please contact Provider Services (863) 534-5377.
Primary Care Provider Specialist Referral
Referrals to Specialists must come from the member’s Primary Care Provider (PCP). The referring PCP must submit the Specialty Referral Form to the specialist’s office for the member to see a specialist.
Precertification
All items listed on the precertification list must be authorized prior to service delivery.
Precertification requests should be faxed to American Health Holding (AHH) at (844) 241-9075 and questions about requests should be directed to AHH at (866) 353-6506.
Claims
Claim Submission
Claims may either be mailed Meritain Health, P.O. Box 853921, Richardson, TX 75085-3921 or submitted electronically to EDI: WebMD/Emdeon 41124 or McKesson/Relay Health 1761.
Claims Appeals
Please mail all claims appeals to: Meritain Health, Appeals Department, P.O. Box 41980, Plymouth, MN 55441-0970
Polk HealthCare Plan Provider Directories
Please notify PHP Provider Services at (863) 534-5377 regarding changes in office location, phone, fax, or provider additions and eliminations. If the correct information is not on file, claims will be denied.
Lab Services
All blood work must go through Laboratory Corporation of America only. All pathology must go to Laboratory Corporation of America or Micro Path Labs only.
X-Rays
Simple bone and joint X-rays may be done in your office if available. If not available at your office, the member must go to one of our contracted radiology groups.