GATEWAY HEALTH Plan^® AT A GLANCE

Gateway at a Glance PDF Download

Gateway Health Plan Medicare Assured^SM Important Phone Numbers

Additional Helpful Telephone Numbers

Mailing Addresses

Frequently Asked Questions

What is Gateway Health Plan  Medicare Assured^SM?

Do Gateway Health Plan  Medicare Assured^SM members have any out-of-pocket expense?

Do Gateway Health Plan  Medicare Assured^SM 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 Assured^SM Card - Pennsylvania

Sample Gateway Health Plan  Medicare Assured^SM Card - Ohio

Authorization Quick Reference Guide

Member Eligibility

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 Assured^SM?

Gateway Health Plan Medicare Assured^SM 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 Assured^SMmembers 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 Assured^SMmembers have to use “plan” providers?

Members of Gateway Health Plan Medicare Assured^SM, 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 Assured^SM Card (Pennsylvania)

Sample Gateway Health Plan Medicare Assured^SM Card (Ohio)

GATEWAY HEALTH PLAN MEDICARE ASSURED^SM

AUTHORIZATION QUICK REFERENCE GUIDE

*This listing of procedures should not be considered all-inclusive and various copayments and limits may apply.

• 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 Assured^SM Identification Card.  The card itself does NOT guarantee that a person is currently enrolled in Gateway Health Plan’s Medicare Assured^SM 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 Assured^SM 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 Assured^SM 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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