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STANFORD HEALTH CARE ALLIANCE
2021 PROVIDER OPERATIONS GUIDE
www.StanfordHealthCareAlliance.org
StanfordHealth
©2020-2021 Stanford Health Care
Care.Alliance 2021Reserved.
All Rights External Provider Operations Guide Page 1
Revised Date 12/14/2020
INTRODUCTION
Welcome to Stanford Health Care Alliance! Stanford Health Care Alliance (SHC Alliance) is an
Accountable Care Organization (ACO) plan that provides a custom narrow network to self-funded
employer groups. SHC Alliance plans may vary in the benefit design offered to each employer and
resemble a narrow network Exclusive Provider Organization (EPO) or Point of Service (POS) plan.
SHC Alliance is a custom network and providers must be selected to participate in each specific
employers’ custom ACO plan. The core provider network for SHC Alliance plans is the Stanford
Medicine and Stanford affiliated network of hospitals, facilities and physicians, and the onsite
Employer-Based Clinics (EBCs). To ensure network adequacy, the SHC Alliance provider network
also includes supplemental non-Stanford providers contracted through a national health plan
(e.g., Aetna or Anthem) that “wrap” around the core Stanford network. It is important to
understand the wrap network for each employer group as it may vary significantly. Check the
specific network directory for each employer group starting on page 16 or call provider services to
confirm provider status with the SHC Alliance network. Most benefit plans do not include an
out of network option so enrollees who are incorrectly referred to a non-SHC Alliance
network provider (out of network) may be held financially liable for charges incurred.
The Stanford Health Care Alliance 2021 Provider Operations guide is a summary of policies,
resources, and operating procedures for in-network Stanford Health Care Alliance
providers. This guide will assist providers and office administrators with:
• Highlights of important 2021 plan changes
• Identifying members in the SHC Alliance plans
• Medical Home Model Plans – PCP requirements and specialist referrals
• Precertification and prior authorization
• Referral management requirements
• Filing claims
• Who to contact with questions
SHC Alliance plans are offered to members of the following plan sponsors (employers):
• Stanford Employer Groups: • Cisco Systems, Inc. (Cisco)
- Lucile Packard Children’s Hospital (LPCH) • Google, Inc (Google)
- Packard Children’s Health Alliance (PCHA) • Intel Corporation (Intel)
- Stanford Health Care (SHC)
- Stanford Health Care – ValleyCare (VC)
- Stanford University Faculty & Staff (SU)
- Stanford University Postdoctoral Scholars (Post
Docs)
- University HealthCare Alliance (UHA)
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 2
Revised Date 12/16/2020
IMPORTANT 2021 PLAN CHANGES
New Medical Home Model PCP Plan Design Changes
For 2021, the following SHC Alliance employer groups have elected to adopt a medical home
model plan with specific managed care features and requirements:
• Stanford University Faculty & Staff
• Stanford Health Care
• Lucile Packard Children’s Hospital
Members enrolled in these plans are required to designate a Primary Care Physician
(PCP). The designated PCP is responsible for coordinating the member’s care including
referrals for specialty care. In most cases, members cannot self-refer to a specialist. A
referral must be submitted by the designated PCP prior to any specialist visit occurring or
being scheduled or the member will be held liable for charges. This is a plan requirement for
enrollees in the employer groups listed above.
New TPA for Intel’s Connected Care Plan
Beginning January 1, 2021, Intel’s Connected Care plan will be administered by a new third-
party administrator (TPA), HealthComp. Right Choice will no longer administer this plan. The
current plan design will not change.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 3
Revised Date 12/16/2020
TABLE OF CONTENTS
Medical Home Model Plan Requirements .......................................................... 5
PCP Requirements ..................................................................................................5
Referral Requirements ...........................................................................................5
How to Identify Members in SHCA Plans ........................................................... 9
SHC Alliance Medical Home Model Plans ..............................................................9
SHC Alliance Non-Medical Home Model Plans ....................................................10
Precertification and Prior Authorization ........................................................ 13
Precertification for Advanced Imaging............................................................ 14
At-A-Glance Summary ................................................................................... 16
SHC Alliance Stanford Employer Plans ................................................................16
SHC Alliance Technology Clients ..........................................................................18
Network Summary ....................................................................................... 20
Prescription Drug and Pharmacy Benefits Manager (PBM) Program .................. 24
Claims Submission, Disputes and Appeals ...................................................... 25
Case Management ........................................................................................ 27
EHR Systems and Interoperability ................................................................. 27
Contact Information ..................................................................................... 28
Appendix A: 2021 SHC Alliance Medical Home Model Referral FAQ .................... 29
Appendix B: Intel Connected Care Provider Reference Guide ............................ 31
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 4
Revised Date 12/16/2020
MEDICAL HOME MODEL PLAN REQUIREMENTS
The medical home model plan design now includes certain managed care features and
requirements. These plans apply to the following SHC Alliance employer groups only:
• Lucile Packard Children’s Hospital
• Stanford Health Care
• Stanford University Faculty & Staff
PCP REQUIREMENTS
Members enrolled in the SHC Alliance Medical Home Model plan are required to
select a primary care physician (PCP). Members who do not elect a PCP will be
auto-assigned an SHC Alliance network primary care physician based on their
care history and/or location. Members can change their PCP at any time by calling Member
Care Services. Members are required to seek care from their designated PCP or another PCP
within the same practice.
REFERRAL REQUIREMENTS
Medical home model plans require the member’s PCP to coordinate the member’s
health care and issue referrals for specialist care. The PCP must issue a referral
prior to the member seeking treatment from a network specialist. If the PCP is unable to
submit a referral prior to the specialist visit, the plan will allow a 21-day grace period.
Plan guidelines for patient referrals allow for the following referral types:
• Consult and Treat referrals
Referrals submitted with CPT code 99499. In most cases, consult and treat (C&T)
referrals do not need to include the specialist’s procedures. Aetna will pay specialists
for performing associated covered services in an office setting per the current claim
processing guidelines.
• Exact procedure code referrals
These are referrals submitted with code(s) other than CPT code 99499. Primary care
physicians should use this referral type when a member needs care for a specific
health reason. Aetna will only reimburse for the procedure code(s) that matches the
code(s) on the referral.
A referral submitted without a procedure code will default to C&T referral (CPT code 99499).
Authorized procedures are subject to the number of visits on the referral. Referrals are valid
for 1 year from the date issue and must be renewed if ongoing care is needed.
Referrals must include a specific provider using his or her national provider identifier (NPI) or
specialty type using a taxonomy code found here: https://taxonomy.nucc.org/.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 5
Revised Date 12/16/2020
How to Submit a Referral
For Stanford Health Care and University HealthCare Alliance Epic Users
A referral is required in Epic. Once a referral is submitted in Epic, an automated workflow will
route the referral to Aetna.
For non-Epic Users
PCPs can submit referrals electronically using Aetna’s provider portal on Availity. Paper
referrals can be faxed to Aetna at 1-859-455-8650.
• Login at www.Availity.com, select Patient Registration from the navigation Menu.
• Select Authorizations & Referrals, then Referrals.
NOTE: The referral and precertification processes are separate. Any referrals received with
procedure codes for services that require precertification will not be accepted.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 6
Revised Date 12/16/2020
2021 SHCA Direct Access List (No PCP Referral Required)
Applicable to SHCA Medical Home Model Plans
(SHCA enrollees of Stanford University Faculty & Staff, SHC, and LPCH)
SERVICE DETAILS
No referral required for services done in an ambulatory surgery facility, clinic, (e.g.
ABORTION
Planned Parenthood), outpatient hospital, in-network provider’s office
ACUPUNCTURE, Plan allows direct access to in-network acupuncture or chiropractic care providers
CHIROPRACTIC CARE with no referral requirement.
Advance Practice Providers (Physician Assistant, Nurse Practitioner, etc.) that are
ADVANCE PRACTICE
practicing in Primary Care and designated as a PCP by the health plan can enter
PROVIDERS
referral orders on behalf of the PCP.
No referral required for behavioral health providers, including psychologists,
psychiatrists and psychotherapy providers.
BEHAVIORAL HEALTH
Neuropsychology testing that is part of Behavioral Health does not require a
referral. Note: Prior authorization rules may still apply.
DIABETES MANAGEMENT Plan allows direct access to in-network outpatient diabetes education programs for
EDUCATION individual counseling (code G01018) and group counseling (G0109)
DME rentals and sales that are not included on the Aetna Precertification List do
DME not need a PCP referral. If on the Aetna Precertification list, prior auth is required
but no referral is required.
Referrals are not required for ER services; however, members are required to
EMERGENCY ROOM obtain a referral from their PCP if subsequent specialist services or visits are
needed.
Express Care clinics are accessible to all SHCA members, regardless of their
assigned PCP. If member’s designated PCP is part of SHC, Express Care can make
STANFORD EXPRESS CARE specialty referrals on behalf of the member. If member’s designated PCP is outside
of SHC, member must be directed back to their designated PCP to request a
specialist referral.
No PCP referral required for OB/GYN services provided by an OB/GYN provider. Lab
GYNECOLOGY AND and ultrasound services provided in conjunction with OB/GYN services do not
OBSTETRICS CARE require a referral. Genetic testing does not require a referral however genetic
counseling does require a referral from the designated PCP.
HOME HEALTH CARE No PCP referral required for in-network Home Health Care services.
No PCP referral required for outpatient hospital radiology and lab services.
HOSPITAL OUTPATIENT LAB
Services not billed by an outpatient hospital will require a specialist referral from
AND RADIOLOGY SERVICES
the designated PCP.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 7
Revised Date 12/16/2020
SERVICE DETAILS
No additional PCP referral is needed for services and diagnostics rendered in a
hospital or in the treating specialist’s office.
INFUSION &
Please note: a PCP referral is required for the patient’s consultation and treatment
CHEMOTHERAPY
with the specialist. For example, a referral to oncology must exist in order for the
related infusion to not require a separate referral.
LACTATION Plan allows direct access to in-network lactation consultants with no referral
CONSULTATIONS requirement.
No PCP referral is required for immunizations/vaccines administered outside the
PREVENTIVE CARE –
PCP’s office when administered without an office visit. A PCP referral is required
VACCINES/IMMUNIZATIONS
when provided in conjunction with an office visit by a participating specialist.
X-ray/lab services which are performed in the specialist’s office when patients are
seen for visits and evaluations as a result of Aetna’s direct access or when
authorized by a referral from their primary care physician does not require a
referral. These services may be performed even if the procedure itself was not
RADIOLOGY PATHOLOGY &
specifically indicated on the referral. These are in general, procedures which are
LAB
integral to the evaluation of the problem which led to the referral to the specialist.
Enhanced Clinical Review and Pre-Authorization takes precedence.
For example: Cardiologist who performs an EKC/ECG in the office.
RX DRUGS COVERED UNDER No PCP referral required for medical injectable drugs for RX pharmacy provider
MEDICAL types only.
SEXUAL ASSAULT VICTIMS PCP referrals are not required for services rendered with a sexual assault diagnosis.
SHORT TERM REHAB Customized within plan to allow direct access to short term rehab providers with
(PT/OT/ST) no referral requirement.
PCP referrals are not required for in-network Urgent Care providers. If member
URGENT CARE requires subsequent specialty care, referral must be obtained by designated PCP
for needed specialty care.
Referrals are not required for in-network providers for a routine eye exam i.e.
VISION Optometrist. Note: routine vision is likely covered by a different vendor specific to
vision benefit coverage.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 8
Revised Date 12/16/2020
HOW TO IDENTIFY MEMBERS IN SHC ALLIANCE PLANS
SAMPLE ID CARDS
Below is a quick guide to help identify members of the SHC Alliance plans. This section also
describes the requirements associated with the various employer groups.
Medical Home Model Plans - these plans require a PCP and referrals for specialist visits
Lucile Packard Children’s Hospital, Stanford Health Care, Stanford University Faculty &
Staff
PCP Required Referral Required Out-of-Network Benefits
Yes Yes No
.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 9
Revised Date 12/16/2020
Non-Medical Home Model Plans – these plans do not require a PCP or specialist referral
• Stanford University Postdoctoral • University Health Care Alliance
Scholars • Cisco – Life Connections
• Packard Children’s Health Alliance • Google – gHIP Select
• Stanford Health Care – ValleyCare • Intel Connected Care California
Stanford University Postdoctoral Scholars
PCP Required Referral Required Out-of-Network Benefits
No No Yes
Packard Children’s Health Alliance, Stanford Health Care-ValleyCare,
University Healthcare Alliance
PCP Required Referral Required Out-of-Network Benefits
No No No
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 10
Revised Date 12/16/2020Cisco – Life Connections
PCP Required Referral Required Out-of-Network Benefits
Encouraged No No
Google – gHIP Select
PCP Required Referral Required Out-of-Network Benefits
No No No
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 11
Revised Date 12/16/2020Intel Connected Care
PCP Required Referral Required Out-of-Network Benefits
Encouraged No Yes
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 12
Revised Date 12/16/2020PRECERTIFICATION AND PRIOR AUTHORIZATION
Cisco, Google and Stanford SHC Alliance Plans – Prior Authorizations
The SHC Alliance plans for Cisco, Google and Stanford utilize the Aetna National
Precertification List (“Aetna NPL”). The current Aetna NPL can be located at the following
link, and is routinely updated on a quarterly basis:
https://www.aetna.com/content/dam/aetna/pdfs/health-care-professionals/2021-precert-
list.pdf
Providers can submit authorizations for Stanford, Google or Cisco members to SHC Alliance
through the Aetna Provider Portal or by calling Aetna at 1-888-632-3862. Providers can
determine if a CPT code is required for precertification by entering one or more 5-ditgit CPT
codes via:
https://www.aetna.com/health-care-professionals/precertification/precertification-lists.html
Providers can also review the Behavioral Health Precertification List via:
http://www.aetna.com/healthcare-professionals/assets/documents/bh_precert_list.pdf
Special programs requiring Contact Information and Website
precertification
BRCA genetic testing Aetna Provider Portal or by phone: 1-877-794-8720
Gender Reassignment Surgery Aetna’s Provider Service Center: 1-888-632-3862
High-tech radiology MedSolutions (dba eviCore healthcare):
(Stanford University Faculty & Staff 1-888-693-3211 Website: www.eviCore.com
and Google members only)
Infertility Program National Infertility Unit (NIU): 1-800-575-5999
Google: Progyny: 1-888-461-5062 (Provider line); 1-888-461-
4997 (Patient Care Advocate line)
Infertility Program: Injectables Stanford - Aetna Specialty Pharmacy: 1-800-237-2767
Cisco - CVS Caremark Pharmacy: 1-800-294-5979
https://eforms.com/prior-authorization/cvscaremark/
Mental Health or Substance Abuse Aetna’s Provider Service Center: 1-888-632-3862
Services Precertification
Note: Includes Autism Spectrum
Disorders (ABA Therapy only)
Transplant Aetna’s Provider Service Center: 1-888-632-3862
Note: All related codes requested as
part of a Pre-Transplant Evaluation,
Transplant, or Post-Transplant
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 13
Revised Date 12/16/2020Intel Connected Care California – Prior Authorizations Intel does not use a standard national precertification list and requires medical necessity review only for inpatient services at non-Stanford owned hospitals. For details on the Intel authorization process, contact Connected Care Concierge at 1-800-971-4153. The in-network non-Stanford owned hospitals that require prior authorization include: • Good Samaritan Hospital • St. Louise Regional Hospital • El Camino Hospital – Mountain View • St. Rose Hospital • El Camino Hospital – Los Gatos • UCSF Benioff Children’s Hospital • O’Connor Hospital Oakland • Regional Medical Center of San Jose • Sequoia Hospital • Seton Medical Center Sutter facilities and providers are all out of network for the Connected Care plan. Members will incur very high out of pocket coinsurance if Sutter is used. All in-network providers can be found on the on the Connected Care California website: https://connectedcareproviders.com/provider/search In the event a member may require medical services from an out-of-network provider , the referring provider will be required to submit a referral request and should contact the Connected Care Concierge Center at 1-800-971-4153 for additional instructions. PRECERTIFICATION FOR ADVANCED IMAGING (applicable to Stanford University Faculty & Staff and Google SHCA members only) Precertification is required for the following advanced (high cost) radiology services for Stanford University Faculty & Staff and Google members. • CT, CTA (Computed Tomography, Computed Tomography Angiography) • MRI, MRA (Magnetic Resonance Imaging, Magnetic Resonance Angiography) • PET (Positron Emission Tomography) eviCore Prior Authorization Resources (applicable to Stanford University Faculty & Staff and Google SHCA enrollees only) The 2021 eviCore Prior Authorization CPT Code List includes services that require submission to eviCore for advanced clinical review and authorization prior to services being rendered, including advanced (high-cost) imaging, cardiology imaging, interventional pain management, large joint services, and sleep diagnostic services. Stanford Health Care Alliance 2021 External Provider Operations Guide Page 14 Revised Date 12/16/2020
For more information about eviCore healthcare, please visit eviCore Clinical Resources website. For services other than high cost imaging, please refer to https://www.aetna.com/health-care-professionals/precertification/precertification-lists.html How to Submit a Precertification For Stanford Health Care and University HealthCare Alliance Epic Users An authorization request is required in Epic. Once an authorization request is submitted in Epic, an automated workflow will route the inquiry to Aetna. For non-Epic Users Providers can submit a precertification electronically using Aetna’s provider portal on Availity or by phone at 1-888-632-3862. Enhanced Clinical Review update for MR and CT authorizations Beginning January 1, 2021, Aetna’s claim system will require an exact CPT code match between the submitted claims and eviCore Healthcare’s authorizations for CT and MR studies. In addition to the specific type of imaging study, eviCore Healthcare will be making medical necessity determinations about the correct use of contrast for MR and CT procedures. Other recommendations will be offered for requests that are not appropriate based on the contrast component of the imaging procedure. Aetna will deny claims billed with CPT codes that do not match the ones that were authorized. Providers can access policies related to contrast through our Coverage Policy Bulletins (CPB) at https://www.aetna.com/health-care-professionals/clinical-policy-bulletins/medical-clinical- policy-bulletins.html#. Stanford Health Care Alliance 2021 External Provider Operations Guide Page 15 Revised Date 12/16/2020
AT-A-GLANCE SUMMARY
SCH Alliance Stanford Employer Groups
Topics Medical Home Model Plans Non-Medical Home Model Plans
(PCP required, specialist referrals required)
• Lucile Packard Children’s Hospital • Packard Children’s Health Alliance
SHC Alliance Employer Group • Stanford Health Care • Stanford Health Care - ValleyCare
• Stanford University Faculty & Staff • Stanford University Postdoctoral Scholars
• University HealthCare Alliance
Member Eligibility SHC and UHA users: verify eligibility in Epic under “Coverages”
Others: Aetna’s provider portal www.Availity.com or contact Provider Services at 1-888-632-3862.
PCP Selection Required Yes No
Network Directory www.StanfordHealthCareAlliance.org
Referral Required Yes No
Yes, for CPT codes, drugs and injectables on Aetna’s
National Precertification List.
Yes, for CPT codes, drugs and injectables included in
Advanced (high cost) imaging requires prior Aetna’s National Precertification List.
authorization by Aetna for Stanford University
Authorization Required Faculty & Staff members. Providers can search by CPT code:
https://www.aetna.com/health-care-
Providers can search by CPT code: professionals/precertification/precertification-lists.html
https://www.aetna.com/health-care-
professionals/precertification/precertification-
lists.html
Electronic claim submission:
https://www.aetna.com/health-care-professionals/claims-payment-reimbursement/electronic-claims.html
EDI Vendor #60054
Claim Submission
Paper claim submissions (CMS-1500 or UB-04):
P.O. Box 14079
Lexington, KY 40512-4079
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 16
Revised Date 12/16/2020Topics Medical Home Model Plans Non-Medical Home Model Plans
(PCP required, specialist referrals required)
LabCorp, Quest Diagnostics, and Stanford Health Care laboratories are in-network; see member benefits for
Preferred Laboratories
member cost share which can vary by place of service or facility.
RadNet (Valley Radiology Medical Associates and RadNet (Valley Radiology Medical Associates and NorCal
NorCal Imaging), SimonMed Health Diagnostics Imaging), SimonMed Health Diagnostics facilities, and
facilities, and Stanford facilities are in-network. For a Stanford facilities are in-network. For a complete list, refer
complete list, refer to to www.StanfordHealthCareAlliance.org
www.StanfordHealthCareAlliance.org
Stanford Health Care - ValleyCare and Packard Children’s
Stanford Health Care and Lucile Packard Children’s Health Alliance: Coinsurance does not apply to Tier 1
Preferred Radiology and Hospital: Coinsurance does not apply to Tier 1 facilities (Stanford Hospital, Lucile Packard Children’s
Imaging Services facilities (Stanford Hospital, Lucile Packard Hospital and Stanford Health Care – ValleyCare)
Children’s Hospital and Stanford Health Care –
ValleyCare)
NOTE: Pre-certification is required for Advanced
(high cost) imaging by Aetna for Stanford University
Faculty & Staff members.
Network includes Stanford and Aetna behavioral Network includes Stanford and Aetna behavioral health
health providers. For a complete list, refer to the providers. For a complete list, refer to the network
network directory website. directory website.
Behavioral Health For Teladoc Behavioral Health, please visit: For Teladoc Behavioral Health, please visit:
https://member.teladoc.com/aetna. https://member.teladoc.com/aetna.
For Meru Health, please visit:
https://www.meruhealth.com/lpch-shc.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 17
Revised Date 12/16/2020SHC Alliance Technology Clients
Topics Cisco Google Intel
Check eligibility in Connected Care’s
provider portal at
SHC and UHA users: verify eligibility in Epic under “Coverages” https://secure.healthx.com/connect
Member Eligibility
Others: Aetna’s provider portal www.Availity.com or contact Provider Services at edcareprovideraccess or contact
1-888-632-3862. the Concierge Team at 1-800-971-
4153.
PCP Selection Required Encouraged No Encouraged
https://tinyurl.com/2021Cisco-directory https://tinyurl.com/2021Google-directory https://connectedcareproviders.co
Network Directory
m/provider/search
Referral Required No No No
Yes, for CPT codes, drugs and injectables Yes, for CPT codes, drugs and injectables Limited to hospitalizations.
on Aetna’s National Precertification List. on Aetna’s National Precertification List.
Providers can search by CPT code: Providers can search by CPT code: Authorization is not required for
Authorization Required https://www.aetna.com/health-care- https://www.aetna.com/health-care- Stanford facilities (Lucille Packard
professionals/precertification/precertifica professionals/precertification/precertifica Children's Hospital, Stanford
tion-lists.html tion-lists.html Hospital and Stanford Health Care –
ValleyCare).
Electronic claim submission: Electronic claim submission:
https://www.aetna.com/health-care-professionals/claims-payment- Payer ID 47198
reimbursement/electronic-claims.html
EDI Vendor #60054 New for 2021:
Claim Submission Paper claim submissions:
Paper claim submissions (CMS-1500 or UB-04): Group #: L00841M001 Plan: 040
P.O. Box 14079 Anthem Blue Cross
Lexington, KY 40512-4079 P.O. Box 60007
Los Angeles, CA 90060-0007
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 18
Revised Date 12/16/2020Topics Cisco Google Intel
LifeConnections Health Center Various Google Wellness Centers Stanford Santa Clara Primary Care
3571 North First St. Mountain View, CA: 2518 Mission College Blvd
Campus Building Q • 1600 Amphitheatre Pkwy, Building 40 San Jose, CA 95054
2nd Floor • 1010 Joaquin Rd, Building 48 1-408-688-9720
Near Site San Jose, CA 95134 • 2037 Landings Dr, Building LMK6
Clinics (in 1-408-424-2000 • 468 Ellis St, Building QD3 Stanford Express Care San Jose
proximity to • 1310 Shorebird Way, Building 1310 52 Skytop St., Suite 10
employer) Crossover Health @ SOMA Sunnyvale, CA: San Jose, CA 95134
49 Stevenson St, 14th Floor • 1170 Bordeaux Dr, Building MP3 1-669-294-8888
San Francisco, CA 94105 • 803 11th Ave, Building TC1
1-415-963-0573
For a full listing, please visit:
https://tinyurl.com/2021Google-directory
LabCorp and Quest Diagnostics; Stanford Health Care Laboratories are also in-network, but LabCorp and Quest Diagnostics are preferred
Preferred
member cost share may be impacted laboratories; Stanford Health Care
Laboratories
laboratories are also in-network, but member
cost share may be impacted
RadNet (Valley Radiology Medical Associates RadNet (Valley Radiology Medical Associates and RadNet (Valley Radiology Medical Associates
and NorCal Imaging) and SimonMed Health NorCal Imaging) and SimonMed Health and NorCal Imaging), Health Diagnostics, and
Preferred Diagnostics are preferred providers; Diagnostics are preferred providers; Stanford and other facilities are preferred. Stanford
Radiology Stanford and other facilities are additionally other facilities are additionally in-network, but facilities are additionally in-network, but
and Imaging in-network, but member cost share may be member cost share may be impacted. For a member cost share may be impacted. For a
Services impacted. For a complete list, refer to complete list, refer to Google’s network directory. complete list, refer to Intel’s network
Cisco’s network directory. directory.
NOTE: Precertification is required for high-tech
radiology.
Behavioral For a full listing of Behavioral Health For a full listing of Behavioral Health providers, For a full listing of Behavioral Health
Health providers, please refer to the Cisco network please refer to the Google network directory providers, please refer to the Intel network
directory: https://tinyurl.com/2021Cisco- website: https://tinyurl.com/2021Google- directory website:
directory directory https://connectedcareproviders.com/provide
r/search
For Teladoc Behavioral Health, please visit: For Teladoc Behavioral Health, please visit:
https://member.teladoc.com/aetna https://member.teladoc.com/aetna All Sutter providers and facilities are
excluded from the network.
All Sutter providers and facilities are excluded
from network
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 19
Revised Date 12/16/2020NETWORK SUMMARY – this section provides an overview and highlights of each employers’ network. For a complete list of network
providers by employer group, please consult the network directory specific to that employer or contact Provider Services.
SHC Alliance Employer Key Hospitals Other Providers and Ancillaries
- Stanford University Network Hospitals Stanford Health Care Alliance Network Providers:
Faculty & Staff • Lucile Packard Children’s Hospital • All Stanford providers including Stanford Health Care
- Stanford • Stanford Hospital (SHC) and SHC – ValleyCare (VC), University HealthCare
Postdoctoral • Stanford Health Care - ValleyCare Alliance (UHA), Packard Children’s Health Alliance (PHCA),
Scholars • Select Aetna contracted hospitals within the service area Lucile Packard Children’s Hospital (LPCH)
- University (e.g., El Camino, Good Samaritan, Washington Hospital, • Select Aetna supplemental contracted providers including
HealthCare Alliance California Pacific Medical Center) Affinity Medical Group, and ancillary providers (e.g., DME,
acupuncture, chiropractors, behavioral health)
Note: Only two Sutter hospitals are included in the network: (1) • Select Brown & Toland physicians primarily located in San
Alta Bates Summit Medical Center (ABSMC) hospital only, Francisco and San Mateo counties
physicians at ABSMC are not in-network, and (2) California Pacific • Washington Township Medical Foundation physicians
Medical Center (CPMC) – hospital and physicians. All other Sutter • Sutter Pacific Medical Foundation physicians located in
hospitals and facilities are excluded. San Francisco
Out-of-Network Providers:
For the complete network directory:
Plans for these employer groups do not include out of network
www.StanfordHealthCareAlliance.org
benefits:
• Stanford University Faculty & Staff
• University HealthCare Alliance
For Stanford University Postdoctoral Scholars, Aetna Choice POS
II Network outside of the 5 counties:
• Out-of-network benefit level
Palo Alto Medical Foundation (PAMF) physicians are out-of-network
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 20
Revised Date 12/16/2020SHC Alliance Employer Key Hospitals Other Providers and Ancillaries
- Lucile Packard Network Hospitals Stanford Health Care Alliance Network Providers:
Children’s Hospital
- Packard Children’s Tier 1 Benefit Level: • All Stanford providers including Stanford Health Care
Health Alliance • Lucile Packard Children’s Hospital (SHC) and SHC – ValleyCare (VC), University HealthCare
- Stanford Health Care • Stanford Hospital Alliance (UHA), Packard Children’s Health Alliance (PHCA),
- Stanford Health Care • Stanford health Care - ValleyCare Lucile Packard Children’s Hospital (LPCH)
– ValleyCare Tier 2 Benefit Level: • Select Aetna supplemental contracted providers including
• Select Aetna contracted hospitals within the service area Affinity Medical Group, and ancillary providers (e.g., DME,
(e.g., El Camino, Good Samaritan, Washington Hospital, acupuncture, chiropractors, behavioral health)
Alta Bates Summit Medical Center (ABSMC), California • Select Brown & Toland physicians primarily located in San
Pacific Medical Center (CPMC)) Francisco and San Mateo counties
• Washington Township Medical Foundation physicians
Note: • Sutter Pacific Medical Foundation physicians located in
1. Only two Sutter hospitals are included in the network: San Francisco
(1) Alta Bates Summit Medical Center (ABSMC), and (2) • Meru Health (non-CRONA SHC and non-CRONA LPCH
California Pacific Medical Center (CPMC). All other Sutter members only)
hospitals and facilities are excluded.
2. El Camino and Sequoia hospital charges for delivery and Out-of-Network Providers: Plans for these employer groups do not
newborn services only is covered at Tier 1 Benefit Level include out of network benefits.
(except CRONA members); all other non-maternity
Palo Alto Medical Foundation (PAMF) physicians are out-of-network
services would apply to the Tier 2
For the complete network see:
www.StanfordHealthCareAlliance.org
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 21
Revised Date 12/16/2020SHC Alliance Employer Key Hospitals Other Providers and Ancillaries
Cisco * Network Hospitals Stanford Health Care Alliance Network Providers:
• Lucile Packard Children’s Hospital • LifeConnections Health Center (LCHC): Stanford manages
• Stanford Hospital and staffs the Cisco onsite LCHC clinic, which is the
• Stanford Health Care – ValleyCare preferred provider for primary care and core to the Cisco
• Select Aetna contracted hospitals within the service area health plans
(e.g., El Camino, Good Samaritan, Washington Hospital) • Crossover Health @ SOMA located in San Francisco
• All Stanford providers including Stanford Health Care
Note: Only California Pacific Medical Center (CPMC) is included (SHC) and SHC – ValleyCare (VC), University HealthCare
in the network. All other Sutter hospitals and facilities are Alliance (UHA), Packard Children’s Health Alliance (PHCA),
excluded. Lucile Packard Children’s Hospital (LPCH)
• Select Aetna supplemental contracted providers including
For the complete network see: Affinity Medical Group, and ancillary providers (e.g., DME,
acupuncture, chiropractors, behavioral health)
https://tinyurl.com/2021Cisco-directory • Select Brown & Toland physicians primarily located in San
Francisco and San Mateo counties
• Washington Township Medical Foundation physicians
• Sutter Pacific Medical Foundation physicians located in
San Francisco
• Teladoc for Behavioral Health
Out-of-Network Providers: This employer group does not include
out of network benefits.
Palo Alto Medical Foundation (PAMF) physicians are out-of-network
* The Cisco employer has an Out of Area (OOA) plan for eligible dependents who live out of area. Members can contact Member Care Services to determine if their
dependents are eligible.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 22
Revised Date 12/16/2020SHC Alliance Employer Key Hospitals Other Providers and Ancillaries
Google Network Hospitals Stanford Health Care Alliance Network Providers:
• Lucile Packard Children’s Hospital • All Stanford providers including SHC, VC, UHA, PHCA,
• Stanford Hospital LPCH
• Stanford Health Care – ValleyCare • Select Aetna supplemental contracted providers including
• Select Aetna contracted hospitals within the service area Affinity Medical Group, and ancillary providers (e.g., DME,
(e.g., El Camino, Good Samaritan, Washington Hospital) acupuncture, chiropractors, behavioral health)
• Washington Township Medical Foundation providers
Note: All Sutter hospitals are excluded
Google Onsite Wellness Centers
For the complete network see: • Onsite clinics managed by One Medical Group
https://tinyurl.com/2021Google-directory
Out-of-Network Providers: This employer group does not include
out of network benefits.
All Sutter providers (e.g., PAMF) are out-of-network
Intel • Lucile Packard Children’s Hospital In-Network Tiers (5% coinsurance)
• Stanford Hospital Primary Network (“Medical Neighborhood”)
• Stanford Health Care – ValleyCare • All Stanford providers and specifically designated
(Note: these hospitals do not require prior authorization) Anthem’s wrap providers within the service area (including
Affinity Medical Group and Washington Township Medical
The hospitals listed below require prior authorization Foundation)
• El Camino Hospital (Mountain View and Los Gatos)
• Good Samaritan Hospital Anthem’s PPO network outside of the service area
• O’Connor Hospital • Anthem’s PPO network of providers primarily for out-of-
• Regional Medical Center of San Jose area dependents and members who travel
• St. Rose Hospital • First Health national network for out of state
• St. Louise Regional Hospital
• Sequoia Hospital Out-of-Network Tiers (40% coinsurance)
• Seton Medical Center Anthem’s PPO network within the service area (providers who are
• UCSF Benioff Children’s Hospital Oakland not in the Primary Network, but are contracted with Anthem PPO)
• Washington Hospital • Out-of-network benefit level at Anthem contracted rates
Out-of-Network Providers (not contracted with Anthem)
Note: All Sutter hospitals are excluded. • Out-of-network, no contract rates
All Sutter providers are Tier 4 and considered out of network.
For the complete network see: Members will incur high out of pocket charges associated with
https://connectedcareproviders.com/provider/search visits to Sutter facilities and providers.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 23
Revised Date 12/16/2020PRESCRIPTION DRUG AND PHARMACY BENEFITS MANAGER
(PBM) PROGRAM
SHC Alliance PBM Provider Contact Information
Employer
Stanford Employers Aetna Pharmacy 1-800-AETNA RX (1-800-238-6279)
Network MD Rx line: 1-800-641-6444
Fax: 1-877-270-3317
Cisco CVS Caremark Mail Order: 1-877-864-7744; Fax: 1-800-378-0323
Specialty: 1-800-237-2767; Fax: 1-800-323-2445
Prior Authorization: 1-800-294-5979; Fax: 1-888-836-0730
Appeals: Fax: 1-866-443-1172
Cisco Customer Care: 1-877-411-8164
Google CVS Caremark Mail Order: 1-877-864-7744; Fax: 1-800-378-0323
Specialty: 1-800-237-2767; Fax: 1-800-323-2445
Prior Authorization: 1-800-294-5979; Fax: 1-888-836-0730
Appeals: Fax: 1-866-443-1172
Google Customer Care: 1-844-387-1441
Intel Express Scripts 1-800-922-1557
(Accredo for MD Specialty Rx Line: 1-800-987-4904
Specialty Rx) Coverage/Prior Authorization Reviews: 1-800-753-2851
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 24
Revised Date 12/16/2020CLAIMS SUMISSION, DISPUTES AND APPEALS
CLAIM SUBMISSION
Claims must be submitted within 120 days from date of service. Providers should submit
claims for SHC Alliance members directly to the TPA in accordance with the applicable
existing claims submission procedures of the TPA designated in the At-A-Glance Table of this
guide.
Electronic claim submission is the preferred method for submitting claims. Reimbursement
and claims processing procedures are subject to the terms of your existing TPA provider
service agreement. For further questions about claims related processing or reimbursement
matters, contact the appropriate TPA claims administrator via the contact information
provided on page 28.
DISPUTES AND APPEALS
Employer Group Medical Disputes Prescription Drug Disputes
Provider Resolution Team
P.O. Box 14020
Stanford
Lexington, KY 40512
Fax: 1-859-455-8650
Provider Resolution Team Prescription Claim Appeals MC 109 – CVS Caremark
P.O. Box 14020 P.O. Box 52084
Cisco Lexington, KY 40512 Phoenix, AZ 85072
Fax: 1-859-455-8650 Fax: 1-866-443-1172
CVS Caremark 1-877-411-8164
Provider Resolution Team Prescription Claim Appeals MC 109 – CVS Caremark
P.O. Box 14020 P.O. Box 52084
Google Lexington, KY 40512 Phoenix, AZ 85072
Fax: 1-859-455-8650 Fax: 1-866-443-1172
CVS Caremark 1-844-387-1441
Connected Care Provider
Grievance & Appeal Department
Intel P.O. Box 2900
Milwaukee WI 53201-2900
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 25
Revised Date 12/16/2020For Stanford, Cisco and Google
To file an appeal on the member’s behalf, Aetna must receive a completed Authorized
Representative Request form signed by the member. This form and the appeal request must
be submitted to:
Aetna
Attention: National Account CRT
P.O. Box 14463
Lexington, KY 40512
or Fax: 1-859-425-3379
Cisco and/or Google Rx
CVS Caremark Appeals, MC109
P.O. Box 52084
Phoenix, AZ 85072-2084
or Fax: 1-866-443-1172
To be eligible for consideration, requests for adjustment or reconsideration of a claim should
be submitted 365 days from the most recent date of action on the issue. All claim appeals
will be reviewed and outcomes communicated to the provider office via the EOP or letter.
For Intel Connected Care California
Connected Care will acknowledge receipt of all letters and respond with the resolution or
action undertaken to resolve the matter. The resolution letter will follow within 30 calendar
days after receipt of the grievance or appeal. The TPA will be copied on the correspondence
and provide necessary information confirming the contract amount if a claim adjustment is
warranted.
Participating providers are offered two levels of internal review. If a participating provider
remains dissatisfied with the resolution of the issue and has additional relevant information
to present, the participating provider may initiate a second level review request and include
any additional relevant information. Refer to the process outlined above. The second level
review determination is final and binding with respect to the contract amount.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 26
Revised Date 12/16/2020CARE MANAGEMENT
SHC Alliance Care Managers provide clinical care coordination to manage
members’ optimal health. SHC Alliance Care Managers are Registered Nurses
with hands-on experience in hospital care as well as other areas of clinical practice. When
needed, Care Managers partner with providers as a participant of the member’s care team in
developing a plan of care specifically tailored to the member’s needs. Care Managers monitor
progress of the case and focus on closing care gaps by performing telephonic clinical
assessments and coordinating with multiple entities including providers, family, caregivers
and vendors to address and close care gaps. Once mutual goals are achieved, the case is
closed. SHC Alliance Care Management can be reached via fax at 1-650-497-6927 for
physicians referring patients for care management services, to send clinical notes related to
the care management referral, and to receive the appropriate Care Management Referral
Form.
EHR SYSTEMS AND INTEROPERABILITY
Stanford Epic System Naming Conventions
If you are a Stanford Health Care (SHC) or University HealthCare Alliance (UHA)
provider and currently use the Epic Electronic Health Record system, continue
to follow the existing process for verifying member eligibility and placing orders through Epic.
All SHC Alliance plan (coverage) names in Epic, including the Tapestry module, include
“SHCA”, the name or acronym of the employer group, the TPA, and if the plan is a COBRA
account. There are numerous Stanford operating divisions and the divisions will be specified
by their account numbers. More information and tables listing Epic plan names are available
to SHC and UHA users on the SCH Connect intranet.
Epic CareEverywhere
Providers that do not utilize the Stanford Health Care Epic system and are utilizing a different
instance of Epic, can connect to the SHC Epic instance via CareEverywhere. Additionally,
hospital health care systems can access CareEverywhere to exchange referral information.
Epic Prism Portal for Community Providers
Providers who do not have access to Epic or CareEverywhere may sign up for the Prism Portal
for “read-only” privileges to the member’s Stanford Epic Medical Record. Providers can also
utilize this portal to submit referrals directly into the Stanford physician community. For
information on how to sign up for the Epic Prism Portal, see:
https://prism.stanfordhealthcare.org
If you have further questions regarding access to Prism, contact a the PRISM Navigation Line
for assistance at 1-650-724-1314.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 27
Revised Date 12/16/2020CONTACT INFORMATION
Employer Groups Stanford Cisco Google Intel
Member Care 1-855-345-7422 1-844-845-8078 1-650-725-0274 1-800-971-4153
Services/Concierge
Center
Pharmacy Member 1-888-792-3862 1-877-411-8164 1-844-387-1441 1-855-315-4523
Services
Nurse Line 1-800-556-1555 (available 1-800-556-1555 (available 1-800-556-1555 (available 1-800-971-4153 (available
24 hours) 24 hours) 24 hours) only outside of normal
business hours)
Provider Services 1-888-632-3862 1-888-632-3862 1-888-632-3862 1-800-971-4153
Provider Portal www.Availity.com www.Availity.com www.Availity.com https://secure.healthx.com/c
onnectedcareprovideraccess
This operations guide and other SHC Alliance resources can be found at www.stanfordhealthcarealliance.org/for-providers.
For any additional information or questions, please contact the SHC Alliance Network Operations team at
SHCAnetwork@StanfordHealthCare.org.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 28
Revised Date 12/16/20202021 SHCA Plan Changes – Applicable to Medical Home Model Plans
Referral Administration – Important Information and Frequently Asked Questions
Background
Certain employer groups have elected to adopt a medical home model plan design for 2021. This plan design change applies
to the following SHCA employer groups only:
- Stanford University Faculty & Staff - Stanford Health Care - Lucile Packard Children’s Hospital Stanford
These SHCA plans, administered by Aetna, require all members to designate a Primary Care Physician (PCP). The
designated PCP is responsible for coordinating patient care and directing referrals to in-network specialists. Most
specialist visits will require a referral from the designated PCP. This change does not apply to other SHCA employers such
as University Healthcare Alliance, SHC-ValleyCare, PCHA, Cisco, Google, or Intel.
All SHCA plans (with the exception of Intel) will continue to use the Aetna National Precertification list. Please note that a
referral is not a substitute for a service that requires precertification. Aetna is responsible for prior authorizations and
precertification for all SHCA plans.
Applicable to Stanford University Faculty & Staff ONLY - the following services also require pre-certification, effective January
1, 2020:
• CT, CTA (Computed Tomography, Computed Tomography Angiography)
• MRI, MRA (Magnetic Resonance Imaging, Magnetic Resonance Angiography)
• PET (Positron Emission Tomography)
Specialty Visit Referrals Required – Stanford University Faculty & Staff, SHC, and LPCH SHCA enrollees
Specialist visits for all members (including new and existing patients) require a referral from the member’s designated PCP.
This includes specialist visits in a hospital clinic setting. Referrals are not required for direct access services, such as routine
eye care and Ob/Gyn services. See the Direct Access list for more information.
Stanford Health Care and University Healthcare Alliance Epic Users: Submitting A Referral in Epic
A referral order to the specialist is required in Epic. Once the referral order is in Epic, an automated workflow will route the
referral submission to Aetna, SHCA’s plan administrator.
Non-Epic and other Users: Submitting A Referral to Aetna
PCPs can submit a referral in real-time directly to Aetna’s provider portal, Availity (www.availity.com). Paper referrals can
be faxed directly to Aetna to 1-858-455-8650.
Tips for Submitting a Referral through Availity – Taxonomy code
Referrals may be issued to either a specific provider, using his or her national provider identifier (NPI) or to specialty type,
using a taxonomy code. Services can be rendered by any in-network SHCA provider under that taxonomy code. For
example, a referral can be submitted to Dr. Jones (cardiologist) using her specific NPI or using the taxonomy code for
cardiology, 207RC0000X. Taxonomy codes can be found here: https://taxonomy.nucc.org/
Aetna’s guidelines for submitting patient referrals under the Aetna Select product are as follows:
• Consult & Treat referrals – Referrals submitted with CPT code 99499. In most areas, consult and treat referrals do not
need to include the specialists’ procedures. Aetna will pay specialists for performing associated covered services in an
office setting per the current claim processing guidelines. This is the recommended referral type.
• Exact procedure code referrals – Referrals submitted with code(s) other than 99499. Primary care physicians (PCPs)
should use these referrals when a member needs care for a specific health reason. Aetna will only reimburse for the
procedure code(s) that matches the code(s) on the referral. Note: Referrals submitted without a procedure code will
default to C&T referral (99499). Referrals are valid for one year from date of issue.
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 29
Revised Date 12/16/2020Frequently Asked Questions
1. Who is considered a PCP?
• Internal Medicine • Family Medicine
• General Practice • OB/GYN (only if designated as a PCP)
• Pediatrician
Note: Providers who are not designated as a PCP by Aetna for the SHCA network may not submit referrals. Advanced
Practice Providers (APP) such as Physician Assistants within Primary Care Clinics can also submit PCP referral orders.
2. When should a PCP submit the referral to the specialist?
Ideally, the PCP should submit the referral prior to the specialist visit occurring or being scheduled. However, if the PCP
cannot enter the referral into the system the same day, the system allows a 21-day grace period to electronically submit
a retro-referral.
3. Can any PCP “on call” within the same practice enter referrals on behalf of the designated PCP?
Any in-network PCP within the same TIN as the member’s designated PCP can submit a referral to a specialist. The claim
will be handled as if the PCP of record provided the service and made the referral to the specialist.
4. What if a member needs to change their assigned PCP?
Members can change their PCP any time during the year by calling SHCA Member Care Services at 1-855-345-7422.
5. Can members who have existing/ongoing relationships with their specialist continue to see them without a PCP
referral?
No. Aetna requires a referral from the member’s PCP to continue seeing the specialist; therefore, the member must
request a referral from their PCP. Referrals are required for new and existing patients.
6. Can Emergency Department (ED) providers refer ED patients directly to specialists?
Only if within the facility during that specific ED encounter; otherwise, the ED would have to refer the patient back to
their PCP who would refer specialty care for follow up visits. After an Emergency Department (ED) visit, a patient (or
family members on behalf of the patient), should be directed by the ED to follow up with their PCP for referrals for
follow-up care with specialists.
7. Are specialist to specialist referrals permitted?
No, specialist to specialist referrals are not permitted under this new plan design. If a referral is needed for a different
specialty service, the assigned PCP must submit a separate referral to that specialty. For example, an oncologist cannot
make a referral directly to the cardiologist. The member or the oncologist would need to work with the designated PCP
to submit a referral for cardiology.
8. If a specialist wants to refer members for physical or occupational therapy, is a referral from the PCP required?
Rehab therapy does not require a PCP referral. Members can be directed to physical and occupational therapy by their
specialist.
9. Does a service that requires a prior authorization also require a referral?
In cases where a procedure requires an authorization, a PCP referral to the specialty is required to cover any pre/post
procedure specialty visits.
For any additional information or questions, please review SHCA’s Provider Operations Guide or contact the SHCA
Network Operations team at SHCAnetwork@stanfordhealthcare.org
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 30
Revised Date 12/16/2020Intel Connected Care California
2021 Provider Quick Reference
Stanford Health Care Alliance (SHCA) is an Accountable Care Organization plan that
serves as a Delivery Service Provider (DSP) for Intel’s innovative Connected Care
Overview healthcare benefit to provide an integrated care experience to their Bay Area
employees.
As of January 1, 2021, HealthComp will become the new third-party administrator
New for 2021 (TPA) for Intel Connected Care. RightCHOICE will no longer administer this plan.
The current plan design will not change.
PCP Selection PCP selection is encouraged, but not required. Self-referrals are allowed.
Network Directory https://connectedcareproviders.com/provider/search
For eligibility, claims status and provider network:
Provider Portal
https://secure.healthx.com/connectedcareprovideraccess
Preferred Network (member deductible and 5% coinsurance applies)
Primary Network (referred to by Intel as “Neighborhood”) including all preferred
providers detailed on the Network Directory Website. SHCA network providers are
included in the Preferred Network.
Preferred Provider Non-Preferred Network (member deductible and 40% coinsurance applies)
Network Custom Anthem PPO in state and First Health network out of state. All Sutter
providers and facilities are excluded from the Connected Care network and are
considered out of network.
Providers: If you don’t know if your referral is within the network, please contact
the Concierge Center at 1-800-971-4153 for assistance.
Prior authorization is not required for Stanford Hospital, Lucille Packard Children's
Inpatient Prior Hospital, and Stanford Health Care - ValleyCare Hospital
Authorizations For non-Stanford facilities call 1-800-971-4153.
For electronic submission: For paper submissions:
Group #: L00841M001 Plan: 040
Claim Submission Payer ID 47198 Anthem Blue Cross
P.O. Box 60007
Los Angeles, CA 90060-0007
Stanford Santa Clara Primary Care Stanford Express Care San Jose
Near Site Clinics
2518 Mission College Blvd. 52 Skytop St., Suite 10
(in proximity to Intel
San Jose, CA 95054 San Jose, CA 95134
offices)
Phone: 1-408-688-9720 Phone: 1-669-294-8888
Preferred labs are LabCorp and Quest Diagnostics; Stanford laboratories are in-
Preferred Laboratories network, but member cost share may be impacted.
Preferred providers are RadNet (Valley Radiology Medical Associates and NorCal
Preferred Radiology and Imaging), Health Diagnostics, and other facilities; Stanford facilities are in-network
Imaging Services but member cost share may be impacted; call Connected Care Concierge Center
(provider/member services) for facility information: 1-800-971-4153.
Prescription Drug Express Scripts (ESI) network pharmacy call: 1-800-922-1557
Program and Provider Specialty pharmacy (Accredo) call: 1-800-987-4904
Services Coverage reviews call: 1-800-753-2851
Stanford Health Care Alliance 2021 External Provider Operations Guide Page 31
Revised Date 12/16/2020You can also read
