Forms & Documents
Documents and forms are intended ONLY for current contracted PHP Network Providers.
Our goal is to provide you with what you need so you can focus on providing the best care possible to our members.
Provider Support
Eligibility
If you need information regarding a Polk HealthCare Plan member’s eligibility, please contact customer service at (863) 533-1111.
Claims/Benefits
Meritain is the third-party administrator for claims and medical management. Should you need access to claims or benefit information, please visit their portal.
Meritain Portal
Claim Submission
Claims may either be mailed to
P.O. Box 853921
Richardson, TX
75085-3921
or submitted electronically to EDI: WebMD/Emdeon 41124 or McKesson/Relay Health 1761.
Claims Appeals
Please mail all claims appeals to:
P.O. Box 41980
Plymouth, MN 55441-0970
Provider Services
Should you have a need that is not eligibility, claim or benefit related, please contact the Polk County Indigent Health Care Provider Services office at (863) 519-2003.
Go to PortalQuick Reference Chart
| Services | Visit Limits Per plan Year (October 1- September 30) | Approvals |
|---|---|---|
| Primary Care | Unlimited | No Pre-Cert Required |
| Specialist | 20 Visit Limit (does not refer to procedures) | No Pre-Cert Required |
| CT Scans | 4 Visit Limit | No Pre-Cert Required |
| MRI/MRA* | 3 Visit Limit Combined Max | No Pre-Cert Required |
| PET Scan | 2 Visit Limit | No Pre-Cert Required |
| Ultrasound | 6 Visit Limit | No Pre-Cert Required |
| Physical Therapy, occupational Therapy and Speech Therapy | 36 Visit Limit Combined Max | No Pre-Cert Required |
*Visit Limit Combined Maximum refers to a grouping of services or therapies, in which the number of total visits for each service or therapy should NOT exceed the number of combined visit limits.
Lab Services
All blood work must go through Laboratory Corporation of America only. All pathology must go to Laboratory Corporation of America or Micro Path Labs only.
X-Rays
Simple bone and joint X-rays may be done in your office if available. If not available at your office, the member must go to one of our contracted radiology groups.
Referrals & Precertification
Referrals
A referral form is required when a member’s PCP is referring them to a Specialist or when a Specialist is referring to another Specialist within the Polk HealthCare Plan Provider Network. You may only refer members to network providers.
The provider receiving the patient referral must submit the completed Specialty Referral form to: Meritain Health, Inc. via fax at (602) 789-9369 or submit via email at [email protected].
Referrals should be submitted prior to claim submission.
Refer to a network provider group, rather than a specific provider within the group. If referring the member to a specific provider, the member may only see the specified provider.
Only one referral per member per plan year (October 1 to September 30) is needed.
Precertification
The following items require precertification and must be authorized prior to service delivery:
Inpatient Admissions
- Acute Inpatient medical and surgical admissions only
Outpatient – Surgery
- Abdominoplasty
- Autologous chondrocyte implantation, Caritcel
- Back Surgeries
- Blepharoplasty
- Cervicoplasty (neck lift)
- Facial skin lesions (MOHS, Photo therapy, laser therapy)
- Hysterectomy (including prophylactic)
- IDET (Thermal Intradiscal Procedures)
- Liposuction/lipectomy
- Mammoplasty, augmentation and reduction (includes removal of implant)
- Mastectomy, gynecomastia and prophylactic
- Orthognathic procedures (ex: Genioplasty, LeFort osteotomy, Mandibular ORIF, TMJ)
- Osteochondral Allograft, knee
- Otoplasty
- Palatopharyngoplasty (UPPP for snoring)
- Panniculectomy
- Rhinoplasty
- Rhytidectomy
- Scar revisions
- Septoplasty
- Varicose vein surgery/sclerotherapy
Pre-certification requests should be faxed to American Health Holding (AHH) at (844) 241-9075 and questions about requests should be directed to AHH at (866) 353-6506.
Provider Referral Directory
Polk HealthCare Plan Members must have a referral from a network plan provider, if they do not they could be responsible for the cost of care. If you are referring a member to a specialty care provider please use the Specialty Referral Form.
| Provider | Group/Organization | Area of Care | Location | Contact |
|---|