How to Work with Us

We’re committed to offering our Medicare and Medicaid dual-eligible, and Medicaid Managed Long Term Care, members in the greater New York City area access to quality providers in their communities, and we want you to join us!

Interested in joining the Senior Whole Health of New York provider network? Contact our Provider Relations department at 1-877-353-9819 for more information or contact us by email SWHProviderRelationsNY@magellanhealth.com.

Senior Whole Health Medicaid Managed Long Term Care Plan eligibility

Individuals are eligible to join Senior Whole Health Medicaid Managed Long Term Care Plan if they:

  • Are 21 or older
  • Are Medicaid eligible
  • Live in our New York City service area:
    • Bronx
    • Kings
    • New York County
    • Queens
    • Westchester County
  • Their health care needs can be safely met in their home and/or community
  • Assessed as requiring at least one (1) of the following long-term care services and care management for more than 120 days from the date of enrollment:
    • Nursing services in the home
    • Therapies in the home
    • Home health aide services
    • Adult day health care
    • Personal care services in the home
    • Private duty nursing
    • Consumer-Directed Personal Assistance Services
Senior Whole Health Medicaid Managed Long Term Care Plan benefits

Care at home starts with:

  • A comprehensive in-home assessment
  • Help with activities of daily living (ADL)
  • Home delivered meals
  • Help with housekeeping
  • Physical therapy
  • Transportation to and from medical appointments
  • Home health aides
  • Medical supplies and equipment
  • Adult day health care
  • Dental care
  • Nursing home care, if needed
  • Podiatry
  • Speech therapy
  • Vision care
  • And more!

All with no copays or premiums for any covered service.

Plus, they get access to an entire Care Management team so they get the attention they deserve.

We work as a team which includes your patient (and a caregiver or family member, if desired), their care manager, and their provider. They can also help them access medical, behavioral, social, educational, financial and other services that support your care plan.

Senior Whole Health of New York NHC eligibility

Individuals are eligible to join Senior Whole Health of New York NHC (HMO SNP) if they:

  • Are 65 or older
  • Eligible for both Medicaid and Medicare*
  • Live in our service area:
    • Bronx
    • Kings
    • Nassau
    • New York County
    • Queens
    • Westchester County
  • Have health care needs that can be safely met in their home and/or community
  • Are eligible for nursing home level of care at the time of enrollment
  • Are assessed as requiring at least one (1) of the following long term care services and care management for more than 120 days from the effective date of enrollment:
    • Nursing services in the home
    • Therapies in the home
    • Home health aide services
    • Adult day health care
    • Personal care services in the home
    • Private duty nursing
    • Consumer Directed Personal Assistance Services
Senior Whole Health of New York NHC benefits

Senior Whole Health of New York NHC includes the benefits, services and personalized care your patients need to keep them safe and healthy in the comfort of their home and in their community, plus:

  • No copays or premiums for any covered services
  • $80 per month toward certain health-related items
  • Help with activities of daily living (ADL)
  • Durable medical equipment
  • Physical therapy
  • Transportation for medical appointments
  • Home health aides
  • Adult day health care
  • Dental care
  • Nursing home care
  • Certain behavioral health care*
  • And more!

We work as a team which includes your patient (and a caregiver or family member, if desired), their care manager, and their provider. They can also help them access medical, behavioral, social, educational, financial and other services that support your care plan.

*Some services not covered by MAP, including certain behavioral health services, may be covered under your traditional fee-for-services (FFS) Medicaid benefit.

Model of Care

The Centers for Medicare & Medicaid Services (CMS) requires Special Needs Plans (SNPs) to provide initial and annual Model of Care (MOC) training to our network providers and all out-of-network providers seen by our members routinely. This training ensures providers have knowledge of the Senior Whole Health of New York NHC population and our Model of Care.

Please complete the 2020 training by October 31, 2020. Click here to complete your 2020 attestation.

2020 Model of Care Training

 

Step Therapy Algorithms

In some cases, Senior Whole Health of New York NHC requires members to first try certain drugs to treat their medical condition before we will cover another drug for that condition.

2020 Step Therapy Algorithm

Submitting Claims

You can submit medical claims one of two ways:

  • Submit claims electronically through Ability
  • Submit claims electronically through Emdeon

It is important to remember that an Electronic Data Interchange (EDI) submission is the recommended method for all claims. Claims Submitted via EDI are received and processed in a more efficient manner. Senior Whole Health works with Emdeon for all EDI transactions. When submitting your 837 (I & P) files, please use our Payer ID: 83035.

If the need arises to submit claims in paper format, send claims to:

Senior Whole Health Claims Department

PO Box 956

Elk Grove Village, IL 60009-0956

More information on claims can be found in the Provider Manual. If you have questions or need assistance, please contact the Senior Whole Health Claims Department at 1-866-233-4773 Monday through Friday from 9 a.m. to 5 p.m.

Appeals and Grievances

Senior Whole Health of New York NHC service authorizations, actions and complaints

Senior Whole Health of New York NHC members have Medicare and get assistance from Medicaid. There is an integrated appeals process for these members. For more information, please refer to the service authorization, action and complaint section of our website here. Information can also be found in the Senior Whole Health of New York NHC EOC.

2020 SWH of NY EOC

Senior Whole Health of New York MLTC appeals and complaints

For more information, please refer to the Senior Whole Health of New York MLTC complaint and appeal section of our website here.

Fraud, Waste and Abuse

Health care fraud, waste and abuse is a serious problem and it affects everyone.

 

What is fraud?

Fraud is when someone intentionally lies to a health insurance company, Medicaid or Medicare to get a benefit or money. Fraud is intentional with knowledge that the information is false.

What is waste?

Waste is when someone overuses health services carelessly. Waste isn’t always intentional

What is abuse?

Abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed.

Examples of fraud, waste and abuse

Providers

  • Providing medical services that are not needed
  • “Up-coding” – charging for a more complex or expensive service than was given
  • Billing for services that were not provided
  • Lying about a patient’s diagnosis so they can get tests, surgeries or other procedures that aren’t needed
  • Billing for rented medical equipment after it has been returned
  • Billing twice for the same service
  • Billing for more services than can be performed in one day
  • Asking for, offering or getting money or something of value in exchange for referrals (e.g. a doctor paying a patient to refer other Medicaid members, or to get services that are not needed)

Members

  • Using another person’s name to get Medicaid services
  • Sharing a member ID card or using another person’s member ID card
  • Visiting several doctors to get multiple prescriptions
  • Lying to a care coordinator or someone else to try and get a service you don’t need
  • Paying a doctor cash for a prescription that is not needed
  • Making false documents by changing:
    • The date of service
    • Prescriptions
    • Medical records
    • Referral forms

How do I report fraud, waste and abuse?

Reporting suspected fraud, waste and abuse is easy— and it’s important.

Senior Whole Health of New York’s Fraud Hotline
1-800-341-4915

Magellan Health’s Anonymous Compliance Hotline
1-800-915-2108

Other ways to report suspected fraud:

Office of Inspector General (OIG)
To report suspected cases of fraud, waste, or abuse in Federal Health and Human Services (HHS) programs, you may fill out the online OIG Hotline form. You can also call, mail or fax using the information below:

Office of Inspector General
U.S. Department of Health & Human Services
ATTN: HOTLINE
PO Box 23489
Washington, DC 20026

Phone: 1-800-HHS-TIPS (8477)
TTY: 1-800-377-4950
Fax: 1-800-223-8164

Centers for Medicare and Medicaid Services 
1-800-MEDICARE (1-800-633-4227)

Senior Whole Health of New York’s Civil Rights Coordinator

Civil Rights Coordinator, Corporate Compliance Department
8621 Robert Fulton Drive
Columbia MD 21046

Phone: 1-800-424-7721
Email: compliance@magellanhealth.com

Magellan’s Fraud, Waste and Abuse Policy

Prior Authorizations

As a Senior Whole Health of New York provider, you may need to prescribe necessary therapy for a member. Some of these services and/or providers require prior authorization. Please refer to your Provider Manual for the Senior Whole Health of New York MLTC Member Handbook or Senior Whole Health of New York NHC EOC to determine if a particular service requires authorization.

To obtain Prior Authorization, complete all sections of the Standard Prior Authorization Request Form at fax it to 1-855-818-4871.

After the authorization is approved, Senior Whole Health of New York will send written confirmation to the specialist or facility in writing via mail or fax. Nonparticipating specialists or facilities can check the status of a referral or authorization or request a copy of a referral by calling Senior Whole Health of New York at 1-877-635-3101.

Pharmacy Authorizations

A small number of drugs require prior authorization. Other exceptions to the standard formulary require specific documentation. Please refer to the pharmacy section for additional information.

Referrals

A referral is a communication by a member’s primary care provider (PCP) for the need for services from a specialty provider. Senior Whole Health of New York does not require referrals for network specialists. Please refer to the Senior Whole Health of New York Provider Directory.

Referrals to non-participating providers require an authorization. Please complete the Senior Whole Health of New York Standard Prior Authorization Request Form and fax it to 1-855-818-4871.

After the referral or authorization is approved, Senior Whole Health of New York will send written confirmation to the specialist or facility in writing via mail or fax. Nonparticipating specialists or facilities can check the status of a referral or authorization or request a copy of a referral by calling Senior Whole Health of New York at 1-877-635-3101.

Pharmacy

Senior Whole Health of New York covers medications in four categories:

  1. Medicare Part D: The Part D drug list, or Formulary, includes an extensive list of medications commonly prescribed to treat certain conditions. We review and update this list on an ongoing basis.
  2. Over the Counter (OTC): Our drug list includes many OTC drugs. With a written prescription from a network provider, we cover these drugs for our members.
  3. Medicare Part B: Specialty medications administered in a provider’s office are considered Part B drugs. These should be billed to the appropriate codes. If using a miscellaneous code, J3490 for example, include the NDC number, quantity and drug name. Providers may also get Part B drugs directly from our Specialty Pharmacy vendor, Accredo, by calling 1-866-848-9870. Then you may bill SWH for only the administration of the drug. Some Part B drugs require prior authorization. To find out more, refer to the list of Drugs Requiring Prior Authorization.
  4. New York Medicaid: Many drugs not covered by Medicare may be covered by Senior Whole Health of New York through a member’s New York Medicaid benefits. These drugs are included in the Senior Whole Health of New York Formulary.

Senior Whole Health does not cover medicines not covered by Medicare or New York Medicaid. There may be technical or regulatory reasons why a drug is not covered.

Senior Whole Health of New York Formulary

We have a formulary that lists all of the drugs that we cover. Senior Whole Health of New York generally covers all the drugs listed in our formulary as long as the drug is medically necessary. Prescriptions are filled at a network pharmacy or through our network mail order pharmacy service. For certain prescription drugs we have additional requirements for coverage or limits on our coverage.

The drugs on the formulary are selected by our plan with the help of a team of health care providers. We select the prescription therapies believed to be a necessary part of a quality treatment program, and both brand name drugs and generic drugs are included on the formulary.

Download the 2020 Formulary

Formulary Change Chart