Effective January 1, 2020

Quick Reference Guide 2020

PRIOR AUTHORIZATIONPhone: (702) 570-5420

Fax: (702) 570-5419Portal: EZ NET

CARE MANAGEMENTPhone: (702) 570-5582

Fax: (702) 570-5519E-mail: caremanagement@p3hp.org

PHARMACY PRIOR AUTHORIZATIONMED IMPACT

Phone: (800) 788-2949Fax: (858) 790-7100

24 hours a day / 7 days a week

CLAIM/ENCOUNTER SUBMISSIONP3 Health Partners - Nevada

PO Box 211083Eagan, MN 55121

ELECTRONIC CLAIMS SUBMISSION EDI Payer ID: P3HNV

EDI Payer Name: Hometown Health Plan MA HMO (P3 Health Partners Nevada)

Professional, Institutional and Hospital Claims

CLAIMS STATUS Call to check claims status if claim has not been processed

within 30 days of the initial submission.Phone: (702) 570-5119

E-mail: claims@p3hp.orgMON - FRI | 8:00 A.M. - 5:00 P.M.

CLAIMS STATUS / CORRESPONDENCE Requests for review must be submitted within 180 days of the

Remittance Advice for denials, underpayment, etc.P3 Health Partners - Nevada

PO Box 211083Eagan, MN 55121

TRANSPORTATION Phone: (702) 444-0408

MON - FRI | 7:15 A.M. - 5:00 P.M.

MEMBER SERVICESFor any questions related to claims,

benefits, eligibility or any patient related question, provide this

number to the patient.Phone: (702) 914-0863

Download the printable Provider Directory at

https://p3hp.org/nevada/brokers-agents/printable-

provider-directory/

ANY QUESTIONS? CONTACT P3 PROVIDER RELATIONS

Phone: (702) 444-0412

Email: P3Networksolutions@P3HP.org

Effective January 1, 2020

2020Overview

H1994

009 - HMO

Clark, Nye

P3 Network

Contract

Plan ID

Service Area

Network

Effective January 1, 2020

Benefits

Hospitals and Urgent Care

In-Network Copay/ Cost Sharing

Inpatient Hospital $0 / all daysEmergency Care $120

Urgently Needed Services

$10 - Preferred facility$40 - Non-preferred facility

$0 - Teledoc

Outpatient Facility Services

In-Network Copay/Cost Sharing

Medical Deductible $0Pharmacy Deductible $0

MOOP $1,900 (does not include prescription drugs)

OP Surgery $0ASC $0

Diagnostic Colonoscopy $0IV Infusion Therapy N/A

Sleep Studies $75Other Covered Services $20 - Pulmonary function

Chiropractic Services $0Home Health $0Renal Dialysis 20%

Doctor’s Office Visits In-Network Copay/Cost Sharing

PCP $0SCP $0

Preventative Care $0

Transportation In-Network Copay/ Cost Sharing

Ambulance $180 / Ground$295 / Air

Transportation $0 / up to 24 one-way trips

In-Clinic Procedures In-Network Copay/ Cost Sharing

Non-Nuclear Cardiac Stress Tests

$15 - EKG$50 - Treadmill stress test

EKGs $15Spirometry $20

Diagnostic Services In-Network Copay/ Cost Sharing

Diagnostic radiology services (such as MRIs,

CT Scans)

$50 - CT$200 - MRI, PET, Nuclear

MedicineDiagnostic Tests &

Procedures$0-$80

$80 - Specialty tissue cultures, Genetic testing, oncology screening, INR test strips

Lab Services $0-$80 $0 - Routine blood work

Outpatient X-Rays $0Therapeutic Radiology 20%

Outpatient Rehabilitation

In-Network Copay/Cost Sharing

Physical and Speech Therapy

$0

Occupational Therapy $0Cardiac Rehab $0

Pulmonary Rehab $0Ambulance $200

Podiatry/Foot Care $0 / up to 4 visits

Outpatient Care In-Network Copay/ Cost Sharing

OP Substance Abuse Office

$40 - Individual therapy$30 - Group therapy

OP Substance Abuse Facility

$40 - Individual therapy$30 - Group therapy

Hospice $0Wound Care N/A

Nurse Hotline N/ACare Management N/A

Wellness Programs In-Network Copay/Cost Sharing

Wellness Programs Silver&Fit Healthy Aging Program Fitness membership

Chiropractic Services $0

Treatment Programs In-Network Copay/Cost Sharing

Opioid Treatment Program

$40 per visit

Effective January 1, 2020

Benefits

Pharmacy In-Network Copay/Cost Sharing

Part B Drugs 20%OTC $50/quarter

Rx Coverage in the Gap $2 / $8 / $0 (Tiers 1, 2, 6)Rx - Deductible No Deductible

Rx - Preferred Generic [1] $2 (30-day) / ($0 mail)Rx -Non-Preferred

Generic [2]$8 (30-day)

Rx - Preferred Brand [3] $47 (30-day)Rx - Non-Preferred

Brand [4]$100 (30-day)

Rx- Speciality 33% coinsuranceRx - Select Drug $0 (30-day)

Rx - 90-day Retrail/ Rx-90-day Mail

2.5 times 30-day / 2 times 30-day

Vision Services In-Network Copay/Cost Sharing

Exam to diagnose and treat diseases and

conditions of the eye

$0

Routine and non-routine eye exams

$0

Vision Test (Refraction) Not CoveredEyeglasses or contact lenses after cataract

surgery

$0

Vision Hardware MandatoryFrames $150 - Either eyeglasses or

contactsLenses $150 - Either eyeglasses or

contactsContacts $150 - Either eyeglasses or

contactsMedical Equipment &

SuppliesIn-Network Copay/

Cost SharingDME 20%

Medical Supplies - Other 20%Prosthetics 20%

Diabetes Monitoring Supplies

20%

Diabetes Self-Management Training

$0

Therapeutic Shoes 20%Meals Not Covered

Accupuncture Not Covered

Dental Services - Medicare Covered

In-Network Copay/Cost Sharing

Preventative Dental MandatoryDeductible $0

Plan Max N/AOral Examinations $0 - 2 Exams

X-Rays $0 - 2 Sets of BitewingsComprehensive Dental $30 - Optional

Deductible $100Plan Max $1,000

Basic 20%Major 50%

Periodintal Exam $0Orthodontics Not Covered

Mental Health Services In-Network Copay/Cost Sharing

Inpatient Mental Health $0Outpatient Group

Therapy$30

Outpatient Individual Therapy

$40

Partial Hospitalization for Mental health

$55

Skilled Nursing Facility $0 / days 1-20$125 / days 21-40$0 / days 41-100

Hearing Services In-Network Copay/Cost Sharing

Medicare Covered Hearing

$0

Routine Hearing $0Hearing Exam/

Hearing Aids$0 per exam (yearly)

2 TruHearing Flyte hearing ads per year

$299 / $599

Effective January 1, 2020

Ancillary Vendors

Laboratory CPLRadiology Desert Radiology

Home Health Physician’s Choice Home Health;Dynamic Health Care

Hospice Nathan Adelson or AviantTransportation Lyft (Med) to coordinate

(702) 444-0408

Preferred Glucometer Freestyle, Precision Xtra

Health & Fitness Partner Silver and Fit(855) 626-4667

MON - FRI | 5:00 A.M. - 6:00 P.M.www.silverandfit.com

Eye Exam, Glasses and Contacts

(866) 723-0513

Over-the-Counter Medication

Fieldtex(855) 383-4231

Hearing Aids Tru Hearing(844) 341-9614

Mail Order Pharmacy Costco Mail Order Pharmacy(800) 607-6861

Postal Prescription Services(800) 552-6694

Nurse Health Hotline (775) 982-5757Durable Medical Equipment

(DME)Preferred Home Care

(702) 951-6900Gable Distributes LLC

(702) 489-2288

Medication Therapy Management ProgramProgram that helps you and your doctor evaluate the effectiveness of your medications.

Criteria to participate:3 specific chronic conditions or diseases, and

Take at least 8 covered Part D drugs, andLikely to have a covered drug costs greater than $4,044

Participation is voluntary and does not impact your drug coverage

Effective January 1, 2020

Urgent Care

1 | Blue Diamond Quick Care Center(702) 383-2300

4760 Blue Diamond Rd. #110Las Vegas, NV 89139

2 | Centennial Quick Care Center

(702) 383-62705785 Centennial Center Blvd. #190

Las Vegas, NV 89149

3 | Enterprise Quick Care Center(702) 646-0298

1700 Wheeler Peak St.Las Vegas, NV 89106

4 | Nellis Quick Care Center(702) 383-6240

61 North Nellis BlvdLas Vegas, NV 89110

5 | Peccole Quick Care Center(702) 383-3850

9320 West Sahara Ave.Las Vegas, NV 89117

6 | Rancho Quick Care Center(702) 383-3800

4321 North Rancho Rd.Las Vegas, NV 89130

7 | Spring Valley Quick Care Center(702) 383-3645

8 | Summerlin Quick Care Center(702) 383-3750

2031 North Buffalo Dr.Las Vegas, NV 89128

9 | Sunset Quick Care Center(702) 383-2610525 Marks St.

Henderson, NV 89014

10 | Advanced Urgent Care (702) 361-2273

9975 South Eastern Ave. #110Henderson, NV 89183

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