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Quick Reference


Important Phone Numbers
Call to Inquire About: Telephone Number Hours of Operation
Davis Vision - Provider Servicing 1-800-773-2847 Monday-Friday
8:00 AM to 6:00 PM
Dental Benefit Providers 1-800-822-5353;
Option 2
Monday-Thursday,
8:30 AM to 8:00 PM;
Friday 9:00 AM to 8:00 PM
Digital Voice Assistant (DIVA) (Eligibility Check/Generate and Review Referrals) 1-800-642-3515 24 hours a day/7 days a week
Eligibility Verification System (EVS) 1-800-766-5EVS (5387)  
Adagio Health (Authorization/Family Planning) 1-800-532-9465  
MA Provider Compliance Hotline (Fraud and Abuse Reporting) (412) 255-4340
1-866-DPW-TIPS
(1-866-379-8477)
Monday-Friday
8:30 AM to 4:30 PM
Credentialing Department Gateway Health Plan® (412) 255-4320 Monday-Friday
8:30 AM to 4:30 PM
Gateway Health Plan®
Medical Management (Utilization Management)
1-800-392-1146 Monday-Friday
8:30 AM to 4:30 PM (Voicemail during off hours.  The call will be returned the next business day.)  Please do not leave multiple voicemail messages or call for the same authorization request on the same day.
Gateway Health Plan® Member Services   1-800-392-1147 24 hours a day/7 days a week
Gateway Health Plan® Pharmacy
(Request Non-Formulary and Prior Authorization)
1-800-528-6738 Monday-Friday
8:30 AM to 4:15 PM
Gateway Health Plan® Preventive Health  1-800-642-3550
Option 1—Special Needs/Case Management
Option 2—Maternity/MOM Matters®
Option 3—Congestive Heart Failure/Asthma
Option 4—Preventive Health Services/
EPSDT/Outreach
Monday-Friday
8:30 AM to 4:30 PM
Gateway Health Plan®
Provider Servicing (Claims Inquiries and Supplies)
1-800-392-1145 Monday-Friday
8:30 AM to 4:30 PM
Gateway Health Plan®
Regulatory Affairs (Provider and Member Appeals)
1-800-392-1145 Monday-Friday
8:30 AM to 4:30 PM
Health Management Corporation (Diabetes Disease Management Program) 1-866-366-3415 24 hours a day/7 days a week
National Imaging Associates (NIA) (Authorization for CT, MRI/MRA, Nuclear Cardiology, Bone Densitometry and PET Scans) 1-888-879-5922 Monday-Friday
8:00 AM to 8:00 PM

 

Important Addresses
Gateway Health Plan® US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219
Claims Office: Gateway Health Plan®
Claims Processing Center
P.O. Box 11-718
Albany, NY 12211-0718

Reason for Mailing Address
Claims and Referral Forms Gateway Health Plan® Claims Processing Department
P.O. Box 11-718
Albany, NY 12211-0718
Claims Inquiries, Provider and Member Appeals, and other correspondence Gateway Health Plan® Attention: Provider Servicing
US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219
Initial Applications for Credentialing Gateway Health Plan® Attention: Network Development
US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219
Recredentialing Applications Gateway Health Plan® Attention: Credentialing
US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219
Practice Change Information Gateway Health Plan® Attention: Provider Relations
US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219
Dental Claims Dental Benefit Providers P.O. Box 30752
Salt Lake City, UT 84130-0752
Vision Claims Davis Vision Attention: Vision Card Processing Unit
P.O. Box 1525
Latham, NY 12110

 

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.

COUNTY AGENCY/AREA TELEPHONE NUMBER
Adams Community Care Behavioral Health 1-866-738-9849
Allegheny Community Care Behavioral Health 1-800-553-7499
Armstrong Value Behavioral Health 1-877-688-5977
Beaver Value Behavioral Health 1-877-688-5977
Berks Community Care Behavioral Health 1-866-292-7886
Blair Mental Health and Substance Abuse Services 1-800-540-4690
Butler Value Behavioral Health 1-877-688-5977
Cambria Johnstown 1-800-331-0911
Ebensberg 1-814-472-4400; or 1-800-331-0911
24 Hours a Day 1-814-535-8531
Carbon Carbon County-Mental Health 1-610-377-0773
Substance Abuse-Carbon, Monroe, and Pike Drug and Alcohol Commission 1-610-377-5177
Clarion Mental Health and Substance Abuse Services 1-814-226-1080
Columbia Mental Health and Substance Abuse Services 1-570-387-6741
Cumberland Community Behavioral Healthcare Network of Pennsylvania 1-888-722-8646
Dauphin Community Behavioral Healthcare Network of Pennsylvania 1-888-722-8646
Erie Adult Mental Health 1-814-878-3440
Children’s Mental Health 1-814-878-3430
Mental Health-24 Hours a Day 1-800-300-9558; or 1-814-456-2014
Substance Abuse 1-814-451-6877; or 1-800-862-3743
Fayette Value Behavioral Health 1-877-688-5977
Franklin Mental Health and Substance Abuse-Franklin and Fulton Counties 1-717-264-2184; or 1-800-994-2555
Fulton
Greene Value Behavioral Health 1-877-688-5977
Indiana
Jefferson Dubois-Mental Health and Substance Abuse 1-814-371-1100
Brookville-Mental Health 1-814-849-8842
Clearfield-Mental Health 1-814-765-5337
Punxsatawny-Mental Health 1-814-938-8817
County-wide 24-hour Mental Health and Substance Abuse 1-814-371-1105; or 1-800-699-2642
Falls Creek-Substance Abuse 1-814-371-9002
Lackawanna Scranton-Mental Health 1-570-346-5741
Scranton-Substance Abuse 1-570-963-6820
Lancaster Community Behavioral Healthcare Network of Pennsylvania 1-888-722-8646
Lawrence Value Behavioral Health 1-877-688-5975
Lebanon Community Behavioral Healthcare Network of Pennsylvania 1-888-722-8646
Lehigh Magellan Behavioral Health of PA 1-866-238-2311
Luzerne Luzerne and Wyoming Counties 1-800-432-8007
Mercer Mental Health and Substance Abuse 1-724-662-1550
Monroe Monroe County Mental Health 1-570-421-2901
Carbon, Monroe, and Pike Drug and Alcohol Commission-Substance Abuse 1-270-421-3669
Montour Mental Health and Substance Abuse 1-570-387-6741
Northampton Magellan Behavioral Health of PA 1-866-238-2312
Northumberland Mental Health Services 1-570-495-2040
Substance Abuse Services 1-570-495-2154
Perry Community Behavioral Health Network of Pennsylvania 1-888-772-8646
Pike Mental Health Services 1-570-296-6484
Carbon, Monroe, and Pike Drug and Alcohol Commission-Substance Abuse 1-570-296-7255
Schuylkill Mental Health-16 Hours per Day Walk-in 1-570-628-1180
Mental Health-16 Hours per Day by Phone 1-570-472-2688
Mental Health-24 Hours a Day Service 1-800-334-8094
Substance Abuse Service 1-570-621-2890
Substance Abuse- 24 Hours a Day Service 1-800-334-8094
Somerset Mental Health and Substance Abuse 1-814-443-6440
Mental Health Services-8 AM to 4 PM 1-814-445-6440
Mental Health 1-814-443-3639; or 1-800-452-0218
Substance Abuse Service 1-814-445-9789
Substance Abuse-24 Hours a Day Service 1-800-452-0218
Susquehanna Tri-County Human Services Center 1-570-346-5741
Substance Abuse-Susquehanna Drug and Alcohol Commission 1-570-278-1000
Washington Value Behavioral Health 1-877-688-5977
Wayne Mental Health-Tri-County Human Services Center 1-570-346-5741
Substance Abuse-Carbon, Monroe and Pike Drug and Alcohol Commission 1-570-253-5099
Wayne County Drug and Alcohol Commission 1-570-253-6022
Westmoreland Value Behavioral Health 1-877-688-5977
Wyoming Mental Health-Luzerne and Wyoming Counties 1-800-432-8007
York Community Care Behavioral Health 1-866-542-0299

Fraud and Abuse

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.

Medical/Utilization Management

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:

Reason for Call Number/Option
Calls for DME, Therapy, or Chiropractic Services Option 3
Calls for Emergency Inpatient Admissions,Concurrent Review, Home Health Updates or IV Infusion Option 4

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
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Gateway to Physician Excellence
Last Updated: 1/28/2010