members

WELCOME PRIMETIME HEALTH PLAN 

PrimeTime Health Plan has a number of plan designs for you to choose from. Our number one goal is to provide you with an affordable health plan designed to enhance your Medicare coverage. Have a doctor or a pharmacy that you prefer? We have more than 4,800 highly-skilled and dedicated physicians in our network and more than 30,000 pharmacies serving our PrimeTime Health Plan members!

Please click a button below for more information:

• EVIDENCE OF COVERAGE▼
  
  To access your Evidence of Coverage forms, click here and select your plan.* 
  
  The Evidence of Coverage includes information on:
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  · Enrollee rights & responsibilities
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  · Benefit restrictions outside of the network
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  · How to submit a claim for covered services
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  · How to obtain language/interpreter services
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  · Pharmacy Management Program information
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  · How and when to submit an appeal or complaint, including the independent appeals process
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  · Obtaining a Primary Care Physician (PCP), specialist, behavioral healthcare services and hospital services
  
  · Services included and excluded from your coverage, including copayments and other charges for which members   are responsible
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  · Emergency/urgent care services in or out of the network and during or after normal business hours, including an   inpatient admittance  
  
  *If you are enrolled in an employer-sponsored plan, you will need to log into your online account to access your Summary of Benefits/Evidence of Coverage.
  
• GENERAL HEALTH PLAN INFORMATION▼
  
  As a valuable PrimeTime Health Plan member, you have access to information regarding your health plan. Listed below, you will find information available to you throughout the PrimeTime Health Plan website.
  
  Extensive Health Library, Interactive Self-Management Tools, Silver&Fit. Find health and wellness information on our website by clicking here.
  
  Explanation of Benefits. Find out how we paid your claims including your out-of-pocket cost, and if claims have been received and are waiting to be processed. This information is only available by logging into your online account. Click here to login to your account.
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  Summary of Benefits. An overview of your benefits is available on our website. Click here to learn more.
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  Referral, Prior-Authorization, and Pre-Certification Guidelines. This includes information on how to submit a request for coverage and what services require pre-certification or prior-authorization. Click here and select “Grievances, Coverage Determinations & Appeals.”        
  
  Web-Based Searchable Provider Directory. Our searchable provider directories include information about our network healthcare professionals. You can search by network, specialty, name, hospital affiliation, languages spoken, gender, zip code, county, and whether or not they are accepting new patients. Click here to visit our provider directory.
  
  Pharmacy Information. You have access to the pharmacy directory, formularies, recall information, and prior-authorization/step therapy/quantity limit information. Click here to find this information.
  
  Forms. Enrollment forms, HIPAA release of information form, forms for submitting coverage determinations, and prescription mail order forms are available by clicking here.  
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  Quality Program Outcomes. You can see health plan performance outcomes on clinical and consumer satisfaction metrics, information on the health plan’s accreditation and a year-end quality evaluation summary. Click here to find this information.
  
  Notice of Privacy Policies. Click here to find this information.
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  National Coverage Determinations. Throughout the year, the Centers for Medicare & Medicaid Services (CMS) may issue notifications of additional services covered by the Medicare program or clarifications of existing covered services. These notifications are called National Coverage Determinations (NCDs). Click here to find this information.
  
  Contact Information. Information on how to email or contact PrimeTime Health Plan is available by clicking here. Hearing impaired and language assistance contact information can also be found online.  
  
  
• CARE COORDINATION PROGRAMS/ POPULATION HEALTH MANAGEMENT
  PROGRAMS & SERVICES▼
  
  
  Did you know we have Population Health Management programs available at no additional cost to you? Population Health Management programs help you maintain or begin a healthy lifestyle and manage any chronic or complex conditions you may have. Through these programs and outreach, we encourage you to visit your doctor for an annual physical exam and recommended check-ups. These are just a few of the programs we offer to you at no additional cost:
  
  • One-on-one health coaching with a registered nurse, including evidence based educational materials
  
  • Interactive programs including:
  
  Congestive Heart Failure Program- A tele-monitoring program for members with Congestive Heart Failure (CHF) that allows one of our Care Coordinators to monitor your daily weight readings and symptoms and communicate with your provider and you to report issues and prevent hospital admissions.
  
  Diabetic Program- A tele-monitoring program for members with diabetes that allows one of our Care Coordinators to monitor your daily blood sugar readings and symptoms and communicate with you and your provider to report issues and prevent hospital admissions.
  
  COPD Program- A tele-monitoring program for members with COPD that allows one of our Care Coordinators to monitor your pulse ox readings and symptoms and communicate with you and your provider to report issues and prevent hospital admissions.
  
  Behavioral Health Education- A program that provides education, resources and support through outreach to members with behavioral health diagnoses with the goal to improve your self-management or mental health and improve overall outcomes and utilization of services.
  
  Stroke Prevention Program- A program to assist you with a high risk for stroke by providing health coaching and education to help identify symptoms, knowing when to seek medical attention, preventing hospital and ED utilization, and statin medication compliance.
  
  Diabetes Prevention Education- Provides monthly educational materials on how to help lower the risk of becoming diabetic. The materials incorporate tips for healthy eating and exercise and helps individuals understand factors that may trigger unhealthy habits. The first 6 months of the program focuses on decreasing weight/BMI by 5-7% and encouraging participation in an exercise program with physician approval. Fitness goals include working towards 150 minutes of weekly activity. The second 6 months focuses on education to help maintain weight loss and motivation.
  
  Case Management- A program that offers Case Management services to help assist with both complex and basic needs to navigate through the healthcare continuum.
  
  Population Health Management Program- Focuses on providing patient-centered, accessible, comprehensive, and coordinated care. Population Health Management nurses connect with members over the phone or face-to-face for as long as needed. Education is offered to those dealing with chronic and acute conditions along with additional information and resources to ensure members’ needs are met. They offer education on the importance of age and gender preventive screenings, appropriate utilization of services, and education on how to navigate the healthcare system. The Population Health Management team of nurses are available on-site at many Primary Care Provider offices and serve as the link between members, providers, and the health plan.
  
  Smoking Cessation Assistance- Assist by listening, giving advice and tips, and motivating you to kick the habit. To reach the Wellness Smoking Cessation Coach, please call 330-363-3281 or for The Ohio Tobacco Quit Line counseling services call 1-800-QUIT-NOW. To learn more about these programs, visit our webpage dedicated to these services by clicking here.
  
  
• FRAUD, WASTE, AND ABUSE▼
  
  PrimeTime Health Plan encourages anyone with knowledge of suspected instances of non-compliance and/or fraud, waste, and abuse to report this information. Please know this information can be reported anonymously and without fear of retaliation. Every effort is made to maintain confidentiality. To report unethical behavior, policy violations, suspected fraud, waste, or abuse anonymously and confidentially, contact our Compliance/FWA hotline toll-free at 1-866-307-3528 or log onto: https://aultcarepthp.alertline.com
  MAKING DECISIONS ABOUT COVERAGE FOR NEW MEDICAL SERVICES ▼
  
  PrimeTime Health Plan investigates all requests for coverage of new technology using a medical technology assessment company as a guideline. If additional information is needed, we utilize sources including, but not limited to Medicare and Medicaid policies and Food and Drug Administration releases of any current medical peer review literature.
  
  This information is reviewed and evaluated by our medical director and other physician advisors in order to determine if a new technology is appropriate for coverage under your plan. Members may request a certain new technology be investigated for coverage by contacting Utilization Management or Pharmacy.
  
• ACCESSING UTILIZATION MANAGEMENT & APPROPRIATE DECISION-MAKING▼
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  PrimeTime Health Plan communicates your appeal rights in many ways to ensure each member understands their rights. Your plan documents, your Explanation of Benefits, and a benefit denial letter describe your appeal rights as a PrimeTime Health Plan member. Every member is granted the same first level of appeal rights or internal review. If you initiate a first-level appeal and we uphold our original decision, your resolution letter will outline your additional appeal rights, which may include external review rights. Your rights vary depending on state and federal laws.
  
  PrimeTime Health Plan has Care Coordination programs available at no additional cost to our members. Care Coordination programs help you maintain or begin a healthy lifestyle and help manage your chronic or complex conditions.
  
  • You have access to speak with Utilization Management staff members Monday through Friday from 8:00 am to
  4:30 pm.
  
  • Staff members are able to receive inbound communication regarding Utilization Management issues after normal business hours via voicemail or fax.
  
  • Utilization Management staff typically send outbound communication regarding Utilization Management inquiries and requests during normal business hours.
  
  • Utilization Management staff members will identify themselves by name, title, & organization when initiating or returning calls regarding Utilization Management issues.
  
  • TTY/Hearing impaired and language assistance is available for members or providers who require these services.
  
  Utilization Management decisions are based on the appropriateness of care and services as well as eligibility and coverage of requested services. PrimeTime Health Plan does not reward practitioners or other individuals for issuing denials of coverage or service of care and there are no financial incentives for Utilization Management decision makers that result in underutilization. The specific criteria used in decisions are available to you at no cost by contacting Utilization Management and a physician, nurse, or pharmacist reviewer is available to discuss Utilization Management denial decisions.
  
  
  For more information on your appeal rights, you can review your plan document, Explanation of Benefits, benefit denial letter, appeal resolution letter or contact PrimeTime Health Plan customer service for a copy of your appeal procedure at 330-363-7407 or toll-free 1-800-577-5084
  
  
• CONTACT INFORMATION▼
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  Customer Service
  Monday – Friday | 8:00 am – 8:00 pm (October 1-March 31, also available Saturday and Sunday)
  330-363-7407 | 1-800-577-5084 | (TTY 711)*
  Claim status, benefits, eligibility, status of referrals/pre-certifications/prior authorizations 
  
  Utilization Management
  Monday – Friday | 8:00 am – 4:30 pm
  330-363-6360 | 1-800-344-8858
  Request referrals/prior authorizations/pre-certifications 
  
  Pharmacy
  Monday – Friday | 8:00 am – 4:30 pm
  330-363-6360 | 1-800-344-8858
  Request prior authorizations or exceptions 
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  Case Management
  Monday – Friday | 7:30 am – 4:30 pm
  330-363-6360 | 1-800-344-8858
  Inquiries and referrals to Case Management programs 
  
  Disease Management
  Monday – Friday | 7:30 am – 4:30 pm
  330-363-2421
  Inquiries and referrals to Disease Management programs
  
  Too busy to call us?
  
  You may also email us 24 hours a day 7 days a week at www.pthp.com by clicking on >"I am looking for" > "An Answer to my question (Contact Us)" link at the top of the website homepage. You will receive a response within 1 business day of your inquiry.
  
  * We understand that some of our members have special communication needs. We will provide a translator or hearing impaired services (TTY) to those members who are in need. If you require these services, please contact our service center at the numbers provided and we will gladly assist you (for hearing impaired members, please use the TTY number indicated for Customer Service).