Provider Quick Reference Guide

All Provider Inquiries (including Provider Participation Status)

Visit the NaviNet provider portal to access the Benefit Funds’ eligibility and benefits information, including services with visit maximums and confirmation of visits remaining, claim status, claim adjudication details and print copies of Explanation of Payments, where available.

Call our Interactive Voice Response system at (888) 819-1199, 24 hours a day, to check claim status and member eligibility.

Request to Join the 1199SEIU Benefit Funds Network

Download the Provider Recruitment Form and submit the completed form by fax to (646) 473-7213 or by email to [email protected]. For more information, call our Provider Relations Call Center at (646) 473-7160.

Electronic Funds Transfer (EFT) Enrollment

To enroll online via the Benefit Funds Zelis ePayment Center, visit the 1199SEIU ePayment Center Portal. For information on EFT enrollment, call Zelis at (833) 306-0337.

Provider Practice Change Submission

Download the Provider Demographic Information Change Request Form and submit the completed form by fax to (646) 473-7229 or email to [email protected]. Be sure to include your Form W-9. Please notify us at least 60 days before the effective date for all demographic and billing changes.

Claims Submission

To submit electronic claims, use Payer ID #13162. To enroll in electronic claims submission, call Inovalon at (800) 548-2890, or complete and submit an intake form and an Inovalon provider representative will contact you. For reconsideration of a medical claim, download the Medical Claim Reconsideration Request Form and submit the completed form using one of the methods listed below:

• Fax to (646) 473-7088;
• Email to [email protected]; or
• Mail to 1199SEIU Benefit Funds, Medical Claims Reconsideration, PO Box 717, New York, NY 10108-0717.

Hospital Claims Reconsideration requests must be mailed to PO Box 345, New York, NY 10108-0345.

Reconsideration requests of denied claims must be submitted within 180 days of the date of denial.

Benefit Funds reconsideration requests: Outpatient services/procedures, durable medical equipment, home care services and intensive outpatient program/partial hospitalization program appeals must be filed with the Benefit Funds.

Vendor reconsideration requests: Reconsideration requests for specialty drugs (clinical and claim reviews) radiology, radiation therapy, laboratory and molecular pathology and medical oncology (clinical and claim reviews) must be filed with EviCore by email, [email protected]; or by phone, (800) 792-8744, ext. 49100, or (800) 918-8924, ext. 49100.

Prescriptions, Laboratory Services and Additional 1199SEIU Medical Review Program

Prescriptions

Submit prescriptions for acute and maintenance drugs in the Benefit Funds’ The 90-Day Rx Solution and for specialty drugs to CVS Caremark by calling CVS Caremark at (833) 250-3273.

Review the 1199SEIU Preferred Drug List in an online searchable version or printer-friendly version or call CVS Caremark at (833) 250-3273.

If you have any questions, call the CVS Pharmacy Help Desk at (800) 364-6331.

Specialty drugs delivered on an outpatient basis and billed through the medical benefit require prior authorization.

For oncology or non-oncology drugs, submit electronically at www.EviCore.com, call EviCore at (888) 910-1199; or fax to (800) 540-2406.

Laboratory Services

1199SEIU Benefit Funds participating labs:

For a list of lab services that can be done in providers’ offices, visit the Benefit Funds Laboratory Tests web page.

1199SEIU Medical Review Program

Prior authorization is required for high-tech radiology and nuclear cardiology scans, radiation therapy, medical oncology treatments, medical specialty drugs and certain outpatient molecular and genomic laboratory services.

To request prior authorization, call the 1199SEIU Medical Review Program, which is managed by EviCore, at (888) 910-1199. For a directory of participating radiology facilities, call One Call Care Management at (800) 398-8999, or visit our radiology services web page.

Other Outpatient Services

Call (646) 473-7446 to request prior authorization for the following outpatient services:

• Home healthcare
• Non-emergency ambulance service
• BiPAP/ventilators
• Oxygen services
• Prosthetics
• Hyperbaric oxygen therapy and negative pressure wound therapy
• Certain outpatient testing and procedures, including sleep studies and pulmonary and cardiac rehabilitation
• Certain durable medical equipment

Hospital Care Services

Call 1199SEIU CareReview at (800) 227-9360 to request prior authorization for:

• Certain ambulatory surgery/outpatient surgical procedures
• Chiropractic services beyond 12 visits
• All evaluations for consideration of potential transplant
• Hospital care: call before a hospital admission or within two days of an emergency admission
• Behavioral health: mental health and alcohol/substance use disorder treatment
• Inpatient treatment: call 1199SEIU CareReview at (800) 227-9360
• Outpatient treatment (including PHP and IOP): call the Wellness Member Assistance Program at (646) 473-6900

For a comprehensive list of services requiring prior authorization, visit our Prior Authorization web page.

Benefit Funds Member Programs

Wellness Member Assistance Program: (646) 473-6900

Prenatal Program: (646) 473-8962

Remember: Using in-network labs, providers and facilities will help ensure that your 1199SEIU patients do not incur a balance.