Providers

Frequently Asked Questions

WellHealth Quality Care

Who is WellHealth and what is their role with the Teachers Health Trust?

WellHealth is a healthcare delivery system, which links Payors (insurance companies), Providers (Networks), and Members (the patients) together to facilitate and create better access to care while improving the healthcare experience for all parties. Teachers Health Trust has chosen to partner with WellHealth in several ways, including the management of the existing THT Medical Provider Network. For more information on WellHealth, visit www.wellhealthqc.com.

Who is TRISTAR® and what is their role with the Teachers Health Trust?

TRISTAR® is the Trust’s chosen Third Party Administrator. Founded in 1987, TRISTAR® is the largest privately held third party administrator in the nation, with more than 30 locations throughout the United States. TRISTAR® provides a wide range of claims services, including group health claims administration, absence management, managed care, medical management, and property and casualty claims administration. They provide the Trust with consistent expertise and reliable technology for proper claims management and adjudication. TRISTAR® is also responsible for the administration of the Trust’s Member Services, Case Management, and Prior Authorization. For more information on TRISTAR®, visit http://www.tbahealth.com.

As a Provider, who should I contact?

For all Medical Providers, WellHealth Network Relations can be reached by calling (702) 728-5880, or by email at networkrelations@wellhealthqc.com.

For all Vision, Hospital, Facility, and Dental Providers (including oral surgeons), THT Provider Relations can be reached by calling (702) 866-6160 or by email at providerrelations@teacherhealthtrust.org.

WellHealth Provider Credentialing can be reached at (702) 545-6108, or by email at credentialing@wellhealthqc.com.

Authorizations can be reached by calling (702) 832-4658, or by email at THTpreauth@tristargroup.net.

Information regarding Member Benefits & Eligibility can all be found on the Provider Portal. For further questions regarding a member's eligibility, providers may also use the automated system by calling (702) 866-6160. WellHealth Chief Medical Officer, Keith Boman MD, FACC can be reached at (702) 205-7752, or by email at CMO@wellhealthqc.com.

Claims & Prior Authorization

How can I see or access my claims history, explanation of payments (EOPs), and/or check current claims statuses?

For the majority of claims submitted on or after 4/1/2016*, claims information including current claim statuses and payment details can be found by using TRISTAR’s Provider Portal. This portal will allow you to have 24/7, 365 days a year access to instantly view the information that is most pertinent for you and your staff.

As providers, you will be able to login to your office account and retrieve answers in a matter of minutes rather than call the Trust for answers. We encourage all provider groups to register online through the new provider portal in order to have quick, easy access to the information you most commonly request.

Please note, because this portal is associated with the TRISTAR’s claims system which went live in April of 2016, all providers/groups must create a new account to access the system. Old login and passwords will not be recognized by the new portal as they are associated with the previous Trust claims system. For quicker answers, we encourage all providers to utilize the provider portals for information. Again, information is available 24/7, 365 days a year with no hold wait times.

* For claims submitted prior to April 1, 2016, providers can log in to the previous Provider Portal by utilizing your old login and password information.

When will my prior-authorization request be approved?

Prior Authorization requests are typically processed within 36 hours or within 24 hours for STAT Prior Auth requests. If you have concerns regarding the timeliness of your prior-auth status, please email THTpreauth@tristargroup.net or contact Network Relations at networkrelations@wellhealthqc.com with details, including when and how your request was submitted.

An online system should be available sometime next year allowing providers to check the status of their authorization requests through the Trust's Third Party Administrator, TRISTAR.

Member Services

How do I verify a Member's current eligibility, co-pay, and/or deductible information?

Member eligibility can be verified by logging in to the Provider Portal. For further questions regarding a member's eligibility, providers may also use the automated system by calling (702) 866-6160.

Provider Portal Information

Helpful Tips & Practices

A new provider portal associated with the new claims system is now live. This portal will allow you to have 24/7, 365 days a year access to instantly view the information that is most pertinent for you and your staff, including:

  • Claims Data & Statuses for claims submitted on or after 4/1/2016*
  • Explanation of Benefits (EOBs)
  • Payment Check Issue Dates
  • Member Eligibility
  • Current Member Deductibles

Because this portal is associated with the TRISTAR’s claims system which went live in April of 2016, all providers/groups must create a new account to access the system. Old login and passwords will not be recognized by the new portal as they are associated with the previous Trust claims system.

To create a new account, follow these simple steps:

  1. Go to www.teachershealthtrust.org
  2. On the PROVIDERS drop down menu, Select Portal
  3. This will link you to the Portal Login Website
  4. Click I'm a new Provider
  5. Complete the Provider Registration Form

Please keep track of login information in a secure place, including password information and answers to security questions. Multiple accounts can be created per TIN, however, to minimize confusion, please create a single account for your group rather than per staff member. High turnover in office staff has previously lead to complications in password and account reset when troubleshooting.

* For information regarding claims submitted prior to 4/1/2016, the previous provider portal may still be accessed by using your old login and password. Simply follow the link provided on the portal login webpage to access that portal.

Network Contracting

How can I join the THT WellHealth Network?

For providers wishing to join the THT WellHealth Network, you will need to first submit a Letter of Interest (LOI), W-9, and rate proposal to networkrelations@wellhealthqc.com. A committee will review all LOIs and approve or decline based on network adequacy among other criteria. If you are approved to join the network, you will need to complete the contracting and NCQA credentialing process PRIOR to seeing patients and being considered an in-network provider.

For more detailed information about joining the THT WellHealth Network, please visit www.wellhealthqc.com/doctors.

Is there a way to find out my current contracted rate with the Teachers Health Trust?

For all medical providers seeking information regarding your current contracted rate with the Teachers Health Trust, please contact a WellHealth Provider Advocate by calling (702) 728-5880.

All Dental, Vision, and Hospital facilities, please continue to call (702) 866-6160 for support.

I would like to explore other contracting options. Who do I speak to?

WellHealth is continually working with providers to enhance and improve the THT Provider Network and is always open to exploring any number of value-based pricing arrangements with their doctors. If you would like to discuss your contracting options, please email networkrelations@wellhealthqc.com for more information.

Referrals, par8o, & the PCMH Model

What is par8o, and why do I need it?

par8o (pronounced pär/āt/o) is a simple electronic program that allows providers to send referrals directly to other providers on behalf of members. par8o is THT's chosen referral management system designed to promote communication and coordination between PCMH providers and Specialists, while simultaneously reducing both patient inaction and network leakage. par8o is designed to ensure that patients always gain access to the care that they need and are never lost to follow up.

With par8o, decision support including network participation, plan design, provider clinical preferences, and appointment availability is visible to referring providers and staff right at the point of referral. par8o integrates directly with your EMR workflow and makes managing your provider network and patient referrals a standardized process across your enterprise.

Ultimately, the use of referrals has meaningful influence on the cost, quality, and volume of care for both providers and members alike. Although one out of every three patients are referred to a specialist each year, only 25% of those patients actually schedule an appointment with their referred provider. par8o is designed to close that gap in an effort to improve patient care and costs as well as increase provider appointments and quality metrics.

For more information regarding par8o and/or to schedule a training, please contact WellHealth Network Relations at (702) 728-5880 or email at support@par8o.com.

I don't have access to par8o. How should I send a referral for a member?

All providers in the WellHealth network should be utilizing par8o by the beginning of 2017. If you need to be trained on the par8o product, please contact WellHealth's local par8o expert at stacey@par8o.com.

Providers who do not have access to par8o may send referrals through their traditional means – whether it be written, email, fax, or phone – until they are able to be fully trained on the par8o system.

Is the Performance Plus Plan an HMO?

No, the Performance Plus Plan is a Patient Centered Medical Home Model, which encourages members and providers to develop better relationships and promote open communication. Unlike an HMO, specialist visits without a referral will NOT be denied. Members are incentivized to utilize referrals, which results in minimal out of network leakage and greatly improved utilization metrics and data.

In addition, retro-active referrals can be submitted for emergent visits as well as ER Specialist follow up visits. For more information about referrals, please reference the June Apple TidBits, Issue 2, Volume 1.

Why are referrals required?

Referrals are not required, however, members will be charged a higher benefit level without a referral and will ultimately incur more charges. Please verify prior to scheduling appointments as to whether or not the member has obtained a referral from their chosen PCMH provider.

A member does not have a referral to see me. What do I do?

Members scheduled to see a specialist without a referral should not be turned away. Some members may choose to see a specialist without first obtaining a referral from their PCMH provider. This is allowed by the THT Performance Plus Plan, however, the member will be subject to a 20% coinsurance after their deductible has been met.

Under certain circumstances, a retroactive referral can be arranged. The specialist's office should, however, always verify that members have a referral when confirming/scheduling appointments and/or help the member obtain a referral from their chosen PCMH provider. Offices should remind members that without a referral, 100% of the charges will be at the member's expense until they meet their deductible.

A member has not chosen me as their PCMH provider but is scheduled to see me.

The Performance Plus Plan requires members to choose an in-network PCMH provider, which only includes Internal Medicine, General Family Practice, and/or Pediatrics. In some cases, members were auto-assigned a provider and sent communication from the THT notifying them of their assigned provider.

Members are allowed to change their chosen PCMH provider only once per quarter, unless the following applies:

  • Their chosen PCMH provider's panel has closed,
  • Their chosen PCMH provider cannot see them in a reasonable amount of time, and/or
  • The member has filed a grievance against their chosen PCMH provider.

Please educate your office schedulers to verify a member's PCMH provider PRIOR to scheduling an appointment. Seeing a member who has not selected you or your practice will result in higher co-pays and lower co-insurance AFTER their deductible has been met.

If you are scheduled to see a member who has not chosen you, please confirm with the member to verify if they are aware of the additional cost of continuing with the appointment.

How do I verify if a member has chosen me as their PCMH provider?

To verify if you are a member's chosen PCMH provider, you can easily utilize the par8o system to confirm a provider's member attribution when scheduling an appointment. You can also call (702) 728-5880 to verify. Please do not wait until the day of the appointment to verify, however, as the member may be subject to higher costs.

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