 kanawha quick reference guide
PPO/EPO/POS Quick Reference Guide for Chiropractic
General Information
Do not send claims directly to Kanawha Healthcare!
Ignore the claims billing address on the member ID card or given to you on the telephone when verifying benefits. You are under contract through CNC and our instructions for filing claims override information given to you by Kanawha
Kanawha Healthcare Solutions, Inc. offers members three products; EPO, POS, and PPO. Look for the Kanawha Healthcare Solutions, Inc name or logo to identify members of this PPO, EPO, or POS. Chiropractic benefits vary by employer group; ask for specific information on Chiropractic benefits. The POS and EPO plan require a referral from a primary care physician. The PPO plan is a direct member access plan requiring no referral. Confirm the plan type under which the member is covered when verifying benefits. Look for the Kanawha HealthCare Solutions, Inc. name and/or logo to identify members of this PPO, EPO or POS.
If you are unsure where to send the claim when you receive the member’s insurance card, please fax a copy of the card along with the CNC Fax Inquiry Form to CNC. We will gladly fax you back your answer!
PPO (Preferred Provider Organization plans)
EPO (Exclusive Provider Organization plans)
POS (Point of Service plans)
Waiving Co-payments, Deductibles and Coinsurance
It is unlawful to waive co-payments, deductibles, coinsurances, or other patient responsibility
payments and is specifically prohibited by our contracted managed care partners.
This includes accepting a "lower" co-payment amount than the amount indicated on the member's subscriber ID card, waiving co-payments including for services deemed “professional courtesy” and TWIP (take what insurance pays).
Absent true financial hardship (with complete, current, supporting, documented evidence of such hardship maintained in the patient’s health record), the full amount of the co-pay as well as ALL co-payments, deductibles and coinsurance due and owed must be collected by all network providers.
For CNC Contracts:
Failure to consistently comply for individuals covered by a CNC contracted payor is in violation of the policies of our contracted payors and may result in the termination of your status as a CNC participating provider.
For Medicare:
Failure to comply for individuals covered by Medicare is a violation of the Federal False Claims Act,
Federal Anti-Kickback Statute, and the Federal and State Insurance Fraud Laws. Failure to comply may
result in civil money penalties in accordance with the new provision section 1128 A(a)(5) of the Health
Insurance Portability and Accountability Act of 1996 [section 231(h) (HIPAA).
 Benefits/Eligibility
- Telephone: Refer to the number on the member’s identification card.
- Chiropractic benefits may vary by employer group; ask for specific information on Chiropractic benefits. The POS and EPO plans may require a referral from the primary care physician. The PPO plan is a direct member access plan requiring no referral. Confirm the plan type under which the member is covered when you call to verify benefits!
- Always ask if a referral from the PCP is required.
Referral System
- Kanawha HealthCare Solutions, Inc., EPO and POS plans require a referral from the primary care physician.
- Kanawha HealthCare Solutions, Inc. PPO plan is a direct access plan and no referral from a PCP is needed.
Co-payment/Co-insurance Collection
- No money is collected at the time of service unless there is a co-payment amount stated on the ID card. We recommend that you always ask whether the member’s plan has a co-payment or deductible when verifying benefits.
- Some payors only require a co-payment, while others may have a deductible and co-insurance.
- Upon receipt of the notification of payment or remittance summary, provider may bill for any deductible or co-insurance up to Kanawha’s allowed amount.
- Provider may not balance bill for the discount amount.
Claims Submission
Submit all claims to:
CNC
PO Box 2368
Cornelius, NC 28031
Ignore the address on the member ID card or any address given to you when verifying benefits and SEND ALL CLAIMS DIRECTLY TO CNC.
Please refer to the CNC Billing Instructions for complete information on claims submission.
- Group or policy number must be in box 11.
- Employer name must be in box 11B.
- Kanawha must be in box 11C
- The claim must be identified as a Kanawha claim in the address section at the top of the HCFA form (CNC/Kanawha is an acceptable format). Be sure that you put the CNC address here.)
Example:
CNC/Kanawha
PO Box 2368
Cornelius, NC 28031
- If filing Kanawha as secondary, always attach copy of the primary EOB from the payor, and submit this, together with a new HCFA 1500 direct to CNC.
Claims Inquiries
- For tracing overdue claims (after 60 days from your billing date), complete the CNC Fax Form and fax to CNC. We will gladly trace the claim for you and will respond back to you within 5 business days.
- Resubmit lost/missing claims through CNC.
- If submitting a corrected claim, you must STAPLE the appropriate EOB to the HCFA 1500 and send to CNC. Please mark “corrected” claim on the HCFA 1500.
- For questions relating to payment of a claim, contact the payor shown on the notification of payment.
- Refer to your CNC/Kanawha fee schedule to confirm allowable amounts.
Provider Relations
Questions relating to your participation in these MedCost products should be directed to CNC
at 704-895-8117, EXT. 2.
IMPORTANT NOTE:
Kanawha Healthcare Solutions has plans that participate in the MedCost Program. If the ID card has the MedCost logo, it is still a MedCost claim and must be identified as a Medcost claim at the top of the HCFA 1500. If it does not have the Medcost name, the member is part of one of the contracts listed above and claims still come to CNC. If you are uncertain, please use your CNC Fax Inquiry Form and a fax copy of the ID card to CNC. We will review the card and fax back the correct information.
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