 primary physician care quick reference guide for chiropractic
Primary Physician Care Quick Reference Guide For Chiropractic
General Information
Do not send claims directly to Primary Physician Care!
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 Primary Physician Care!
Primary Physician Care is an administrative company providing network and claims payment services for self-funded employer groups. Each ID card contains information specific to the subscriber. Look for the Primary Physician Care name and/or logo on the top right corner of the card to identify members of this PPO and send all such claims directly to CNC.
All claims for COVERED SERVICES provided to a beneficiary of a CNC contracted payor MUST be submitted to CNC. Participating providers who fail to submit all such claims to CNC may lose thier status as a Network Provider. (This includes all self-funded groups who utilize a CNC contracted payor as a third party administrator.)
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 or call (800) 446-5439 between the hours of 8:00 AM and 5:00 PM.
- Chiropractic benefits may vary by employer group; ask for specific information on Chiropractic benefits.
Referral System
- Primary Physician Care is a PPO offering direct access to members. No referral from a PCP is needed.
- When necessary to refer to another health provider, referrals within the network are strongly recommended
- No referral form 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 or in the physician reference guide. We recommend that you always ask whether the member’s plan has a co-payment of deductible when verifying benefits.
- Some payors only require a co-payment, while others may have a deductible and co-insurance.
- Upon receipt of the EOB or remittance summary, provider may bill for any deductible or co-insurance up to Primary Physician Care’s allowed amount on the CNC/Primary Physician Care Schedule.
- Provider may not balance bill for the discount amount on covered services.
- Non-covered services may be billed at the provider’s normal charges.
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 to CNC.
Please refer to the CNC Billing Guidelines for complete information on claims submission.
- Group or policy number must be in box 11.
- Employer name must be in box 11B.
- Primary Physician Care PPO must be in box 11C.
- The claim must be identified as a PPC claim in the address section at the top of the HCFA form (CNC/PPC is an acceptable format). Be sure that you put the CNC address here.)
Example:
CNC/PPC
PO Box 2368
Cornelius, NC 28031
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. We will fax the results 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/PPC fee schedule to confirm allowable amounts.
Provider Relations
Questions relating to your participation in Primary Physician Care should be directed to CNC
at 704-895-8117, EXT. 2.
IMPORTANT NOTE:
Primary Physicians Health Plan 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 (rather than PPC) at the top of the HCFA 1500. If it does not have the MedCost name, the member is part of the Primary Physician Care PPO. In that case, PPC should appear at the top of the HCFA 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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