
GATEWAY HEALTH Plan® AT A GLANCE
Gateway at a Glance PDF Download
Gateway Health Plan Medicare AssuredSM Important Phone Numbers
Additional Helpful Telephone Numbers
Mailing Addresses
Frequently Asked Questions
What is Gateway Health Plan Medicare AssuredSM?
Do Gateway Health Plan Medicare AssuredSM members have any out-of-pocket expense?
Do Gateway Health Plan Medicare AssuredSM members have to use "plan" providers?
Are referrals required for services outside of the PCP's office?
Self-Referred Services
Claims Submission Guidelines
Sample Gateway Health Plan Medicare AssuredSM Card - Pennsylvania
Sample Gateway Health Plan Medicare AssuredSM Card - Ohio
Authorization Quick Reference Guide
Member Eligibility
| Gateway Health Plan Medicare AssuredSM Important Phone Numbers |
| Call to Inquire About: |
| Provider Services |
Claims Inquiry/Supplies |
1-800-685-5205 |
M-F 8:30am to 4:30 pm |
| Utilization Management |
Authorization |
1-800-685-5207 (PA)
1-800-447-4375 (OH) |
M-F 8:30am-
4:30pm |
| |
Calls received during non-business hours are referred to
1-800-685-5209 (PA) or 1-888-447-4505 (OH). |
| DIVA Member Eligibility Line |
Member Eligibility |
1-800-642-3515 |
24 hours a day, 7 days a week |
| Pharmacy |
Requests for Non-Preferred Drugs and Prior Authorizations |
1-800-685-5215 (PA)
1-888-447-4507 (OH)
FAX: 1-888-245-2049 |
M-F 8:30am-
4:30pm |
| Case Management |
Case Management |
1-800-685-5212 (PA)
1-888-447-4506 (OH)
Option 1 |
M-F 8:30am-
4:30pm |
| Disease Management |
Maternity |
1-800-685-5212 (PA)
1-888-447-4506 (OH)
Option 2 |
M-F 8:30am-
4:30pm |
| Congestive Heart Failure |
Option 3 |
| Asthma |
Option 3 |
| Healthy Returns Diabetes Program |
1-866-366-9415 |
| Preventive Health |
Preventive Health Services/Member Outreach |
1-800-685-5212 (PA)
1-888-447-4506 (OH)
Option 4
FAX: 1-888-225-2360 |
M-F 8:30am-
4:30pm |
| Member Services |
Member Complaints/Concerns/
Inquiries |
1-800-685-5209 (PA)
1-888-447-4505 (OH) |
M-F 7:00am-8:00pm
S-S 8:00am-8:00pm |
| Additional Helpful Telephone Numbers |
| National Imaging Associates (NIA) |
Authorizations for CT, MRI/MRA, Nuclear Cardiology, Bone Densitometry, and PET Scans |
1-888-879-5922 |
| Community Behavioral Healthcare Network of Pennsylvania (CBHNP) |
Authorizations for Behavioral Health Services |
1-866-755-7299 (PA)
1-866-341-7022 (OH) |
Mailing Address for Medical and Behavioral Health Claim Forms:
FOR PENNSYLVANIA
Gateway Health Plan®
Claims Processing Center
P.O. Box 11-560
Albany, NY 12211-0560
FOR OHIO
Gateway Helath Plan®
Claims Processing Center
P.O. Box 11-725
Albany, NY 12211-0725
ALL OTHER CORRESPONDENCE
Gateway Health Plan®
US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219-2704
Frequently Asked Questions
What is Gateway Health Plan Medicare AssuredSM?
Gateway Health Plan Medicare AssuredSM is offered by Gateway Health Plan, and is a Medicare Advantage HMO Special Needs Plan for people with Medicare Part A, Medicare Part B and full Medicaid coverage.
Do Gateway Health Plan Medicare AssuredSMmembers have any out-of-pocket expense?
Depending on a member’s Medicaid benefit, they may not have to pay out-of-pocket costs for premiums, deductibles, co-payments and coinsurances. These costs may be covered by Medicaid, as long as the member qualifies for Medicaid benefits and the provider accepts Medicaid. The only exception is that members are responsible for Part D prescription drug co-payments and their Medicaid co-payments, if applicable.
Do Gateway Health Plan Medicare AssuredSMmembers have to use “plan” providers?
Members of Gateway Health Plan Medicare AssuredSM, with a few exceptions, must use plan providers to get covered services. At the time of enrollment members must choose a Primary Care Physician (PCP) to provide basic medical care and coordinate the covered services received outside of the PCP’s office.
Are referrals required for services outside of the PCP’s office?
Services outside of the PCP’s office should be arranged or coordinated by the member’s PCP. PCPs are not required to use a specific Referral Form for submission to the specialist or Gateway. Certain types of covered services or supplies require prior-authorization. Prior-authorization is required for any services to a “non-plan” specialist, except emergency room services and renal dialysis services. Refer to the Authorization Quick Reference Guide that is included for more information on which services require an authorization.
Self-Referred Services
Members may refer themselves for the following types of care:
- Routine Women’s Health Care
- Pap Smears
- Pelvic Exams
- Mammograms
- Flu Shots
- Pneumonia Vaccinations
- Specialists Visits
- Prostate Screening
- Colorectal Screening
- Bone Mass Measurements (Bone densitometry requires authorization by NIA)
- Diabetes Monitoring Training
- Vision Exams
- Hearing Exams
Claims Submission Guidelines
- Timely filing criteria for initial bills is 365 days from the date of service.
- Corrected claims or requests for review are considered if information is received within the 120-day follow-up period from the date of the remittance advice.
- Practitioners must bill within 365 days from the date of an Explanation of Benefits (EOB) from the primary carrier when Gateway is secondary.
- Correct/Current practitioner information, including Gateway Provider ID Number must be entered on all claims.
- Correct/Current member information, including Gateway Member ID Number, must be entered on all claims.
- Gateway accepts electronic claims through Emdeon (formerly WebMD). To submit claims to Gateway please note the Pennsylvania Payer ID Number is 60550 and the Ohio Payer ID Number is 91741.
Sample Gateway Health Plan Medicare AssuredSM Card (Pennsylvania)

Sample Gateway Health Plan Medicare AssuredSM Card (Ohio)

GATEWAY HEALTH PLAN MEDICARE ASSUREDSM
AUTHORIZATION QUICK REFERENCE GUIDE
*This listing of procedures should not be considered all-inclusive and various copayments and limits may apply.
|
Gateway
AUTH |
NIA
AUTH |
CBHNP
AUTH |
AMBULANCE |
X (Non emergent only) |
|
|
AMBULATORY SURGICAL SERVICES |
|
|
|
- If services provided in ambulatory surgery center
|
X |
|
|
- No auth required for lab services provided in an ASC lab
|
|
|
|
BONE DENSITOMETRY (Bone Mass Measurement) |
|
X |
|
CT SCANS |
|
X |
|
CHIROPRACTIC SERVICES |
X |
|
|
DIABETIC SHOES |
X |
|
|
DME (Medical Supplies, Prosthetics, and Orthotics) |
|
|
|
Items paid at $500 and over $500 |
X |
|
|
ELECTIVE ADMISSIONS (Medical and Behavioral Health) |
X |
|
X (BH Admissions) |
HOME HEALTH VISITS |
X |
|
|
HOME INFUSION (*Gateway Pharmacy Authorization Required) |
X* |
|
|
INPATIENT ACUTE CARE (Including transplants and substance abuse care) |
X |
|
|
INPATIENT PSYCHIATRIC OR MENTAL HEALTH CARE |
|
|
X |
INPATIENT MEDICAL REHAB |
X |
|
|
INPATIENT REHAB SUBSTANCE ABUSE CARE |
|
|
X |
LONG TERM CARE (LTC) ACUTE HOSPITAL |
X |
|
|
MRI/MRA |
|
X |
|
NON-PAR PROVIDERS |
X |
|
X (BH Services) |
NUCLEAR CARDIOLOGY |
|
X |
|
OUTPATIENT HOSPITAL SHORT PROCEDURE (SPU) |
X |
|
|
OUTPATIENT PSYCHIATRIC PARTIAL HOSPITALIZATION |
|
|
X |
OUTPATIENT SUBSTANCE ABUSE |
|
|
X |
OUTPATIENT THERAPY (Physical, Speech & Language, Occupational, Cardiac) |
X |
|
|
PET SCANS |
|
X |
|
SKILLED NURSING FACILITY (SNF) CARE |
X |
|
|
- Authorizations are the responsibility of the ordering provider.
- Please contact Provider Services at 1-800-685-5205 for further explanation of what services require an authorization.
- NIA can be reached for authorization at 1-888-879-5922
- CBHNP can be reached for authorization at 1-866-755-7299 in Pennsylvania or 1-866-341-7022 in Ohio.
Note: Depending on a member’s Medicaid benefit, they may not have to pay out-of-pocket costs for premiums, deductibles, co-payments and coinsurances. These costs may be covered by Medicaid, as long as the member qualifies for Medicaid benefits and the provider accepts Medicaid. The only exception is that members are responsible for Part D prescription drug co-payments and their Medicaid co-payments, if applicable.
Member Eligibility
- Newly enrolled members receive an Evidence of Coverage (EOC) and Gateway Health Plan Medicare AssuredSM Identification Card. The card itself does NOT guarantee that a person is currently enrolled in Gateway Health Plan’s Medicare AssuredSM plan.
- Because of possible changes in a member’s eligibility, each participating provider is responsible for verifying a member’s eligibility with Gateway before providing services. This can be done by reviewing monthly panel reports or calling Gateway’s telephonic eligibility system (DIVA), please dial 1-800-642-3515 and follow the prompts (also listed below).
Press 1 If calling for a member who resides in Pennsylvania
Press 2 If calling for a member who resides in Ohio
Press 1 To verify eligibility
Member Identification Number?
Press 1 To verify eligibility using the patient’s social security number, when prompted enter the patient’s 9-digit social security number
Press 2 To verify eligibility using the patient’s Gateway member identification number, when prompted enter the patient’s 8-digit Gateway Health Plan Medicare AssuredSM identification number
Press 3 To verify eligibility using the patient’s Medical Assistance recipient identification number, when prompted enter the patient’s Medical Assistance recipient number (Note: This option can not be used for Gateway Health Plan Medicare AssuredSM members.)
Press 4 To verify eligibility using the patient’s Medicare Health Insurance Claim (HIC) number, when prompted enter the patient’s HIC number, followed by the # sign.
Press 0 To speak to a Provider Services Representative
Press 9 To repeat the menu
Verification of Date?
Press 1 To verify whether the patient is eligible TODAY
Press 2 To verify whether the patient is eligible on a specific date (enter date)
Press 9 To listen to the instructions again
Press 0 To speak to a Provider Services Representative
Additional Instructions:
Press 1 To receive additional information about the patient/member
Press 2 To receive the patient’s Primary Care Practitioner name and telephone number
Press 3 To fax information regarding the patient whose eligibility is being verified
Press 4 To verify eligibility for another patient/member
Press 5 To exit
Press 0 To speak to a Provider Services Representative
PR-001-1106-MC
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