FREQUENTLY ASKED QUESTIONS

Why are you transitioning from a Medical Home Network to a Managed Care Organization?

Consistent with the recommendations of SCDHHS, PPC is transforming into a South Carolina Managed Care Organization (MCO). This conversion from an MHN to an MCO is a transformation we must implement as part of SC DHHS’ vision for the Medicaid program.

Is it too late for me to contract with Advicare?

No. We ask you to join our network by executing a Provider Agreement. You may request a Provider Agreement by contacting Advicare Provider Contracting at (888) 781-4371 or by email at [email protected].

What are some advantages of joining Advicare as a participating provider?

  • Potential for Gain Share / Shared Savings and Case Management Fees
  • Limited prior authorization
  • Integrated case and disease management programs
  • Local, accessible and dedicated provider relations personnel
  • EFT/Direct Deposit

Can a specialist refer a member to a sub specialist without going through the PCP?

Yes for the plan. However there are some specialists that their own internal practice requires a referral.

What are the Prior Authorization guidelines for therapies? (Speech/Occupational/Physical)

Provider must obtain prior Auth through showing medical necessity once for each modality needed and then member’s benefit is opened to the state required limit. If exhausted must request additional visits by proving MN

What is the turnaround time for prior authorization?

Standard Auth decisions will be turned around in 7 business days. Expedited Auth decisions no later than 3 business days after receipt of request.

Do you have a list of procedures that require prior authorization?

Our prior authorization list is listed in our provider manual and can be found on our website, www.advicarehealth.com.

What is your claims turnaround time?

Advicare will pay ninety percent (90%) of all Clean Claims from practitioners, either in individual or group practice or who practice in shared health facilities, within thirty (30) days of the date of receipt. Advicare will pay ninety-nine percent (99%) of all Clean Claims from practitioners, either in individual or group practice or who practice in shared health facilities, within ninety (90) days of the date of receipt. The date of receipt is the date Advicare receives the claim, as indicated by its data stamp on the claim. The date of payment is the date of the check or other form of payment.

What is a clean claim?

Claims that can be processed without obtaining additional information from the Provider of the service or from a third party.

Who is your pharmacy vendor?

CVS Caremark.

Does Advicare have a preferred drug list?

Yes. This list can be found on our website, www.advicarehealth.com.

What medications require pre-authorization?

There are some medications that require prior authorization. The prior authorization list can be found on our website and the medications that require are clearly indicated. If you have any questions, please call  our Customer Service Department   at (888) 781-4371