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What services does First Health provide to its clients?

What type of clients does First Health service?

How do I identify payers whose members have access to The First Health® Network?

For patients with access to The First Health® Network, whom do I contact for:
  • Eligibility questions
  • Benefit information
  • Utilization management questions
  • Pre-certification guidelines and to initiate review
  • Verifying compensability status on workers' compensation situations
What are the referral requirements for patients accessing The First Health® Network?

Where do I send claims for quickest turnaround?

Can we send First Health claims electronically?

Whom do I call for Claims follow-up?

How does First Health identify claims that are rendered by a First Health® Network Participating Provider?

Where should correspondence be sent?

Is there someone at First Health I may call with questions?

What are the Provider Relations Department hours of operations?

What is Provider Relations' fax number?

Is there anything different I need to do if the patient's injury is workers' compensation related?

What information is typically provided on the patient's benefit card?

What is the purpose of the First Health Comprehensive Client List?

How do I obtain a current First Health Comprehensive Client List?

What is the purpose of the Provider Referral Directory?

How do I obtain a current Provider Referral Directory?

What is First Health's E-mail address?

 

What services does First Health provide to its clients?

First Health provides both regional and national payers one or more of the following services:

  • Access to a network of preferred hospitals and outpatient care providers
  • Utilization management:  pre-certification and case management services
  • Workers' compensation bill review services (known as OUCH Systems)
  • Claims administration services
  • Pharmacy Benefit Management Services

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What type of clients does First Health service?

First Health's clients include multi-sited payers who fall into one of the following categories:

  • Corporate clients
  • Insurance carriers
  • Unions
  • Third-party Administrators
  • Federal Employees Health Benefits Program Plans

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How do I identify payers whose members have access to The First Health® Network?

Group Health and Auto Managed Care Services:

Payers using The First Health® Network for group health or auto managed care services distribute benefit cards to members.  The payer's name and The First Health® Network logo (or the historic AFFORDABLE or HealthCare COMPARE logo) will be indicated on the front or back of this card.  During the initial visit and at least once a year, be sure to make a copy of BOTH sides of the patient's benefit card for their file.

Payers whose members have access to The First Health® Network are also listed on the First Health Comprehensive Client List.  The type of network in place for each payer is noted under the heading "plan type".  Plan types include:

G = Group Health
W = Workers' Compensation
D = Auto Managed Care

The EOB/EOR is another way to identify payers using The First Health® Network.  The EOB/EOR will note that the payer is reducing payment in accordance with The First Health® Network contract allowable.

Workers' Compensation Services:

For workers' compensation services, contact the patient's employer regarding network access.

Workers' compensation payers whose members have access to The First Health® Network are also listed on the First Health Comprehensive Client List.  The type of network in place for each payer is noted with a code listed under the heading "plan type".  Plan types include:

G = Group Health
W = Workers' Compensation
D = Auto Managed Care

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For patients with access to The First Health® Network, whom do I contact for:

Eligibility questions
Benefit information
Utilization management questions
Pre-certification guidelines and to initiate review
Verifying compensability status on workers' compensation situations

Contact information varies by payer

Group Health and Auto Managed Care Patients:

Check the patient's benefit card for eligibility and pre-certification telephone numbers.  If no card is available, check the First Health Comprehensive Client List to verify that the patient's payer is listed and then use the contact information listed under the appropriate heading.

Workers' Compensation Patients:

As part of standard industry practice, patients are typically asked if their injuries are work-related.  A benefit card is not used for identification in workers' compensation situations.  Contact the patient's employer or check the First Health Comprehensive Client List for contact information.

The EOB/EOR will note that the payer is reducing payment in accordance with The First Health® Network contract allowable.

Workers' compensation payers whose members have access to The First Health® Network are also listed on the First Health Comprehensive Client List.  The type of network in place for each payer is noted with a code listed under the heading "plan type".  Plan types include:

 

G = Group Health
W = Workers' Compensation
D = Auto Managed Care

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What are the referral requirements for patients accessing The First Health® Network?

Referral requirements vary by payer.  Patients referred in-network will maximize their benefit coverage.  Check the benefit card for referral instructions or contact the patient's payer for specific referral details.  Contact information can be obtained on the benefit card or the First Health Comprehensive Client List.

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 Where do I send claims for quickest turnaround?

Remember to verify the patient's "non-hospital" or "other" claims address.  First Health pays claims for many but not all payers.  Submitting claims to incorrect addresses will delay payment.

Group Health and Auto Managed Care Patients:

Use the patient's benefit card to identify the appropriate "non-hospital" or "other" claims submission address, or check the First Health Comprehensive Client List for payer-specific claims information.

Workers' Compensation Patients:

Call the patient's employer or check the First Health Comprehensive Client List for claims submission addresses.

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Can we send First Health claims electronically?

Verify electronic capability with the individual payer and be sure to use the appropriate electronic identifiers for timely turnaround.

For more information on electronic claims submission, contact the First Health EDI Department at (800) 813-0397.

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Whom do I call for Claims follow-up?

No payment after 45 days:

  • Call the payer-specific telephone number listed on the patient's benefit card or the First Health Comprehensive Client List

Questions on benefit payment (co-insurance/deductibles):

  • After receiving EOB/EOR, call the payer-specific billing telephone number on the patient's benefit card or the First Health Comprehensive Client List

Questions on applied contract allowable:

  • Call First Health Provider Relations Department at (800) 937-6824

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How does First Health identify claims that are rendered by a First Health® Network Participating Provider?

To ensure claims are priced correctly and patient benefits are appropriately applied, First Health considers three demographic variables when identifying network versus non-network providers.  Because provider address and Federal Tax Identification Numbers (FTIN) change and many names are similar, the process of identifying network providers becomes very complex.  Therefore, First Health has developed a series of reviews which match the submitting provider's FTIN, name and/or address against our participating provider database.  The matching process is a "step-wise" procedure which seeks to match on as many variables as possible.  Ultimately, however, the key variable in the matching process is FTIN.

As this description of the First Health provider matching process implies, billing under an FTIN other than that in your First Health record can create significant issues for you and your First Health patients.  If your FTIN does change, please be sure to notify our Provider Relations staff at (800) 937-6824.

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Where should correspondence be sent?

Use the First Health Comprehensive Client List or the patient's benefit card to determine where claims should be sent.

Mail all First Health contract allowable appeals to :

First Health
Claim Appeal Unit
P.O. Box 348412
Sacramento, CA 95834-8412

Include letter of request for appeal; copy of original claim and attachments; copy of EOB or EOR; and copy of operative report.

Mail all other correspondence to:

First Health
Provider Relations
P.O. Box 348300
Sacramento, CA 95834-8300

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Is there someone at First Health I may call with questions?

Contact First Health Provider Relations at (800) 937-6824 for the following:

  • Contract questions
  • A change in physician information (name, address, telephone, FTIN)
  • Sample list of CPT codes (20 code maximum per request)
  • Preferred Provider Directory (network physicians, outpatient facilities, ancillary providers and hospitals)
  • Claim appeals (send documentation to: P.O. Box 348412, Sacramento, CA 95834-8412)
  • Billing follow-up when:
  • Payer's claim administrator does not have the claim after 30 days

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What are the Provider Relations Department hours of operations?

Provider Relations specialists are available to answer your phone calls Monday through Friday from 8 a.m. to 7 p.m., Central Standard Time.  You may leave a voice mail message during non-office hours.

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What is Provider Relations' fax number?

Provider Relations fax number is (916) 374-4638.

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Is there anything different I need to do if the patient's injury is workers' compensation related?

It is the physician's responsibility to be aware of the state regulations for workers' compensation services.  Refer to The First Health® Network Reference Manual or the Workers' Compensation section of this website for more information on return-to-work and other workers' compensation details.

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What information is typically provided on the patient's benefit card?

  • Identifies the payer name (also labeled as group name or employer)
  • Contains addresses for claims submission
  • Provides telephone numbers for:

Eligibility
Benefit Coverage
Billing Follow-up
Utilization Review

Group health payers distribute benefit cards imprinted with The First Health® logo (historic AFFORDABLE or HealthCare COMPARE logo may appear on some cards and should be recognized as First Health).

Workers' compensation payers do not distribute benefit cards.  Contact the employer to verify patient compensability status.

Some auto payers may distribute auto cards.  If you are given an auto ID card, these cards should be imprinted with First Health® logo.

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What is the purpose of the First Health Comprehensive Client List

This report summarizes key contact information for payers whose members are accessing The First Health® Network.

  • Contains claims submission addresses
  • Provides telephone numbers for:

    Eligibility
    Benefit Coverage
    Billing Follow-up and Utilization Review
    Pre-certification

  • Identifies participating group health, auto managed care and workers' compensation payers

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How do I obtain a current First Health Comprehensive Client List?

Visit the Comprehensive Client List section of this web site.

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What is the purpose of the Provider Referral Directory?

The Preferred Provider Directory lists physician and ancillary providers participating in The First Health® Network.  These providers are listed alphabetically by specialty for each county.  Medical laboratory, radiology facility and ambulatory surgery center information follows the provider listings.

Patients with access to The First Health® Network should be referred within network whenever possible.

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How do I obtain a current Provider Referral Directory?

A First Health Provider Referral Directory may be obtained by completing the Provider Referral Request form.

The directory includes group health, auto managed care and workers' compensation network hospitals, physicians and ancillary care providers.

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What is First Health's E-mail address?

The following address should only be used to obtain provider specific materials or if you are having difficulties with any online resources.

healthprofessionals@firsthealth.com

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