Quick Reference

• Important Phone Number
• Important Addresses
• Mental Health/Substance Abuse Contact Information
• Fraud and Abuse
• Medical/Utilization Management

Mental Health/Substance Abuse Contact Information

Please note that these numbers are for members to call.  Practices do not need to send a referral or authorize mental health/substance abuse services.

Gateway Health Plan^® has a comprehensive policy for handling the prevention, detection and reporting of fraud and abuse. A Gateway Vice President is designated as the compliance officer. It is Gateway’s policy to investigate any action by members, employees or practitioners that affects the integrity of Gateway and/or the Medical Assistance Program.

As a participating practitioner with Gateway, the contract that is signed requires compliance with Gateway’s policies and procedures for the detection and prevention of fraud and abuse. Such compliance may include referral of information regarding suspected or confirmed fraud or abuse to Gateway and submission of statistical and narrative reports regarding fraud and abuse detection activities.

If fraud or abuse is suspected, whether it is by a member, employee or practitioner, it is your responsibility to immediately notify Gateway at (412) 255-4340.  In cooperation with the Department of Public Welfare, Gateway maintains a Recipient Restriction Program, which restricts members who mis-utilize medical services or pharmacy benefits.  Gateway enforces and monitors these restrictions.

It is Gateway’s policy to discharge any employee, terminate any practitioner or recommend any member be withdrawn from the Medical Assistance Program who, upon investigation and referral to the Department of Public Welfare, has been identified as being involved in fraudulent or abusive activities.

The Department of Public Welfare has established a Medical Assistance Provider Compliance Hotline, 1-866-DPW-TIPS (1-866-379-8477), to report suspected fraud and abuse committed by any entity providing services to Medical Assistance recipients. The hotline operates between the hours of 8:30 AM and 3:30 PM, Monday through Friday. Voicemail is available at all other times. Callers may remain anonymous and may call after hours and leave a voicemail if they prefer.

Some common examples of fraud and abuse are:

• Billing or charging Medical Assistance recipients for covered services
• Billing more than once for the same service
• Dispensing generic drugs and billing for brand name drugs
• Falsifying records
• Performing inappropriate or unnecessary services

Suspected fraud and abuse may also be reported via the Department of Public Welfare website at: http://www.dpw.state/oa/us/omap or emailed to omaptips@state.pa.us . Information reported via the website or email can also be done anonymously. The website contains additional information on reporting fraud and abuse.

The Department of Public Welfare has a protocol available to practitioners/providers to voluntarily come forward and disclose overpayments and improper payments of Medical Assistance funds.  Gateway and the Department of Public Welfare encourage practitioners and providers to utilize the Pennsylvania Medical Assistance Provider Self-Audit Protocol when concerns over payment compliance arise.   The protocol, which includes options for conducting self-audit and examples of inappropriate payments that may constitute a self-audit, can be found at www.dpw.state.pa.us/omap/omapprotocol.asp or by contacting Gateway’s Finance Department.

Practitioners or their representatives that have questions regarding this protocol may also contact the Department of Public Welfare’s Bureau of Program Integrity at (717) 772-4606 for additional information.

The Utilization Management Department is open from 8:30 AM to 4:30 PM Monday through Friday.  The best time to call the Utilization Management Department is between the hours of 8:30 AM and 11:30 AM.  For urgent authorizations stay on the line to have your call serviced.  Please do not leave multiple voicemail messages for the same authorization request on the same day, for this may delay decision time.  You can reach the Utilization Management Department by calling 1-800-392-1146.  The following options can be used to reach Gateway’s Utilization Management Department for specific information:

If faxing information, speak with a Utilization Management Representative first and when requested, fax the information to the Utilization Management Representative’s attention.  The Representative will inform you of the name and fax number.

Information needed for an authorization request includes:

• Member ’s name, Gateway Identification Number and Birth Date
• Diagnosis (ICD-9 or precise terminology)
• Procedure Code (CPT4, HCPCS, or MA Coding)
• DME Codes and Cost of Item(s)
• Treatment Plan
• Date of Service
• Name of Admitting/Treating Practitioner
• Name of the Practitioner Requesting the Service
• The Practitioner’s Gateway Identification Number
• History of the Current Illness and Treatment