You Have Questions. We Have Answers.

Frequently Asked Questions

PROVIDER PORTAL:

The Provider Portal has been implemented to assist our Provider Partners with easy access to verify eligibility and claim status. To register, please contact us.

After an unsuccessful attempting to reset your password online, please contact us, and a representative will promptly help you.

PROVIDERS/CREDENTIALING/OFFICE UPDATES:

The Health Plans credentialing timeframes may vary and range from 60 -180 days. Currently, the Networks are not delegated for credentialing and must adhere to the Health Plans credentialing documentation process/timeframe. We appreciate your cooperation and patience as we work with the Health Plans to get your paperwork processed. Should we need any additional information, we will contact your office.

You may begin treating members once you have been credentialed by the Health Plan, linked to the Network contract, and have received a Welcome Letter from the Network. The Welcome Letters will include the respective health plan, line of business, and effective date indicating when you can begin treating members.

Yes. Although this may speed up the credentialing process, the Provider still needs to be linked to the Network, and that Health Plan process could take from 30-60 days.

Yes, the Network requires all Physician Extenders to submit credentialing documentation. However, some Health Plans may not require Physician Extenders to be credentialed.

No. The Network contracts are designed in a way that Provider partners can elect which Health Plans/line of business they would like to participate.

The Network contracts are evergreen and will automatically renew in the absence of contrary notice by one of the parties.

You may begin treating members once you have received a Welcome Letter from the Network. The Welcome Letters will include the respective health plan, line of business, and effective date.

We are thrilled to help you through this process as you expand your practice. To add new physicians or physician extenders, please contact us.

Please reach out to your In-House Coordinator and submit a request on letterhead. If you have any trouble identifying your In-House Coordinator, please contact us.

CLAIM SUBMISSION/EFT:

Yes, the Network wants to ensure your claims are paid seamlessly. Our payer ID is 43056. For any questions, please contact your dedicated Servicing or In-House Coordinator directly or email info@pns-mgmt.com

We will promptly pay your clean claims within the specified line of business timeframes below:

  •   Medicare claims – 30 days electronic and paper claims
  •   Medicaid & Healthy Kids claims – 20 days electronic claims and 30 days paper claims
  •   Commercial claims – 20 days electronic claims and 30 days paper claims

Yes, the Networks wants to ensure your services are paid seamlessly. To set up your account for Electronic Funds Transfer, you must complete and submit the EFT Form to your dedicated Servicing or In-House Coordinator directly.

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For services covered by the members’ benefits, which are not part of the Health Plan/Network agreement, you must bill the Health Plan directly for reimbursement. Please refer to the Claims Submission Guidelines in the Provider Manual for specified non-covered services.

REFERRALS:

Each health plan referral process differs. Please refer to the:

  • DNS Provider manual, page 22
  • PNS Provider manual, page 17
  • ONS Provider manual, page 15
  • PCS Provider manual, pages 14-17

Provider Manuals may be obtained via your Provider Portal account, your dedicated Servicing, or In-House Coordinator.

Provider Manuals may be obtained via your Provider Portal account, your dedicated Servicing, or In-House Coordinator.

NETWORKS COVERED TERRITORIES:

Each health plan network coverage differs. Please refer to the:

  • DNS Provider manual, pages 25-26
  • PNS Provider manual, pages 21-22
  • ONS Provider manual, page 20
  • PCS Provider manual, page 19

Provider Manuals may be obtained via your Provider Portal account, your dedicated Servicing or In-House Coordinator.

UTILIZATION MANAGEMENT:

Please send an email request to portalsupport@pns-mgmt.com. This email should include your desired account email, which will be your assigned username, the PCPs in your practice, and the primary Tax ID number (TIN). You will receive an email with access and the next steps for utilizing your account.

Please fill out and fax the Offline Referral Request to ReferralSupport@pns-mgmt.com. The fax number is (305) 667-8860. 

You may find pertinent information in the network specialty Provider Manual, or you can contact the Utilization Management department at (305) 667-8787 / Toll-Free 1-844-222-3535.

For information relating to benefit coverage or reimbursement, please contact Customer Service at (305)284-7484 extension 8020.

The Utilization Management department has a five-day turn-around timeframe on decision-making for Standard (non-urgent) prior-authorization cases. For Expedited (urgent) cases, the Utilization Management department observes and adheres to the Centers for Medicare & Medicaid Services (CMS) 72-hour timeframe and 24-hour timeframe for Part B drugs. 

The networks are not member delegated. Please refer members directly to the health plan for all inquiries.

We are not delegated Utilization Management by these health plan partners. Therefore we cannot review these cases. Please contact the respective health plans authorizations department.

We only require authorization on MOHS surgery for AvMed members.

Yes, we cover Photodynamic Therapy (PDT) treatment for AvMed and Florida Blue members only.

**Please see Pages 11 and 12 of the Provider Manual for applicable “J” codes that are covered for this treatment.**

For services being performed in an office setting (POS 11), no authorization is required by the network. If the member is being treated at an inpatient facility (POS 21), you are required to obtain an authorization directly with the member’s health plan as the network can not authorize these services and the place of service. 

*This is listed in the manual under Provider Responsibilities. DNS: Page 8, Point #13, PNS: Page 8, Point #13, ONS: Page 8, Point #13.*