Provider Resources

• Provider Education
• Tools and Resources
• Payer IDs and Electronic Remittance Advice

Claims submission Address:

Saint Mary's ATRIO Health Plans
338 Jericho Turnpike #135
Syosset, NY 11791

Please send REFUND CHECKS to:

Saint Mary's ATRIO Health Plans
2965 Ryan Drive SE
Salem, OR 97301

Provider Updates

• QTR 4 Provider Newsletter
• Provider Newsletter
• American Specialty Health (ASH) Contracting Letter
• Annual Wellness Visit vs. Annual Physical Exam
• QTR 3 Provider Training

Provider Education

• Provider Manual (effective 1/1/2023)
• Issuing an Advanced Written Notice of Non-Coverage
• Fraud, Waste and Abuse Compliance Training
• CAHPS Information
• Clinical Practice Guidelines (CPG)
• Quick Reference Guide

US Inflation Reduction Act (IRA): 2023 Medicare Prescription Drug Changes

Drug Cost Inflation Increase Limits

Beneficiaries pay less for some drugs covered under Medicare Part B and nearly all Part D covered drugs, if the drug cost increases faster than the US inflation rate (Part B 20% coinsurance is based on the lower-adjusted price)

Insulin Products

Beneficiaries may not pay more than $35 for a 30-day supply of Part D insulin products even if they have not met their deductible(s) or have entered the Part D Coverage Gap. Effective July 1, 2023, insulin covered by Part B (applicable when administered using an insulin pump) also may not cost more than $35 for a 30-day supply

• Saint Mary’s ATRIO Health Plan members pay $0 copay for covered Part D insulin until the coverage gap, during which they will pay $35 for a 30-day supply (see “Formulary Insulins” table)
• Saint Mary’s ATRIO Health Plan members pay 20% coinsurance for Part B insulin up to $35 for a 30-day supply

NOTE: Between January 1^st and January 18^th, 2023, Saint Mary’s ATRIO members may have been charged more than $35 for Part D insulin if they were in the Coverage Gap or if they received a non-formulary insulin product (e.g., Lantus) during a transition fill(s)

• What should members do?
  • Members can call Saint Mary’s ATRIO Customer Service at 1-877-672-8620 (TTY: 711) and request reimbursement
• What can prescribers do?
  • Switch your Saint Mary’s ATRIO members to a formulary insulin, if clinically appropriate

Vaccines

Beneficiaries must not have cost-sharing for all vaccines recommended for adults by the Center for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP), such as the shingles vaccine; this change brings Part D vaccine coverage more in line with Part B for other approved vaccines (including the flu and COVID-19)

NOTE: Following the end of the US Public Health Emergency (PHE) on May 11, 2023, cost-sharing may begin to apply for approved Part B COVID treatments

Tools and Resources

• Provider Appeal Form - Electronic Submission
• Provider Appeal Form - Fillable PDF
• Provider Claim Dispute Form - Electronic Submission
  • Provider Payment Dispute: Providers disputing the way a claim was paid.
  • Par Provider Reconsideration: A contracted provider may file when a claim or claim line is denied. This is not a CMS requirement, but a service provided by ATRIO to contracted providers.
• Provider Claim Dispute Form - Downloadable PDF (Print and Fax)
• Medical Record Audit Response Form - Electronic Submission

• To submit claims directly to American Specialty Health please use below link:

  https://www.ashlink.com/ASH/WCMGenerated/ClaimsSubmission031517_tcm17-126962.pdf

• PCP Attestation Form
• Medicare Advantage Formulary Information
• Medicare Advantage Plans Benefit Information
• Medicare Advantage Provider Directory
• Notice of Medicare Non-Coverage (NOMNC)
• Notice of Medicare Non-Coverage (NOMNC) - Instructions
• Notice of Medicare Non-Coverage (NOMNC) - SNF Checklist
• Waiver of Liability Form
• Protected Health Information Disclosure Form
• Appointment of Representative Form (CMS - 1696) (For Medicare Appeals, Grievances, and Coverage Requests only)
• Provider Policy Listing

Medicare Star Rating Resources

View Saint Mary's ATRIO's Star Ratings Program page for measure descriptions and resource materials. For questions on the Star Ratings Program, please click here to contact Saint Mary's ATRIO Quality Improvement.

Opioid Information for Prescribers

Opioid drugs (“opioids”) have serious risks such as addiction, overdose, and death. CMS is very concerned about the opioid epidemic and its effect on our communities, and is committed to a complete strategy to combat this public health emergency. Several drug management programs are in place to prevent and combat opioid overuse.

Click here to see the formulary-level opioid safety edits at the point of sale, as recommended by CMS.

Medicare Part D Prescription Opioid Policies

Payer IDs