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Medicare Advantage HMO

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Healthcare Resources NW (HRNW) provides medical management services and medical claims processing for Medicare Advantage HMO members who have selected a Primary Care Provider (PCP) who participates in the MyChoice NW network.

MyChoice NW provides a network of providers in the Multnomah, Clackamas, Washington and Clark counties. This broader network includes primary care providers and specialists (including Skilled Nursing Facilities and Durable Medical Equipment).

Current Medicare Advantage HMO health plans accessing our network of providers include:

  • AARP® Medicare Complete® insured through UnitedHealthcare® (HMO)
  • Humana Gold Plus® (HMO and HMO-POS)

AARP® Medicare Complete® insured through UnitedHealthcare® (HMO)
Adventist Medical Center and Tuality Healthcare are the in-network providers for procedures, labs and radiology. Adventist Medical Center and Tuality Community Hospital are the in-network facility for inpatient admissions. Any services that occur outside of Adventist Medical Center or Tuality Healthcare will require an authorization from the primary care provider (PCP) before the service is performed.

To view a list of participating providers, click on any of the following directories. To search for a specific provider by name, type in either the first or last name in the search field.

Disclaimer: Healthcare Resources NW makes every effort to provide accurate information. The information presented is for reference only and may have changed since this online directory was last updated. Please confirm with Healthcare Resources NW if a provider is participating.

Humana Gold Plus® (HMO)
Adventist Medical Center, Tuality Healthcare and Oregon Health & Science University (OHSU) are the in-network providers for procedures, labs and radiology. Adventist Medical Center, Tuality Community Hospital and OHSU are the in-network facilities for inpatient admissions. Any services that occur outside of Adventist Medical Center, Tuality Healthcare or OHSU will require an authorization from the primary care provider (PCP) before the service is performed.

To view a list of participating providers, click on any of the following directories. To search for a specific provider by name, type in either the first or last name in the search field.

Disclaimer: Healthcare Resources NW makes every effort to provide accurate information. The information presented is for reference only and may have changed since this online directory was last updated. Please confirm with Healthcare Resources NW if a provider is participating.

Care Management (Referral/Authorization)
If you are a participating provider, view the Quick-Reference-Referrals (PDF).

HRNW-Policy-700-Authorization

HRNW-Policy-729-Durable-Medical-Equipment

Care Management Decisions
Care Management (CM) decision making is based only on appropriateness of care and service, and existence of coverage. HRNW does not specifically reward practitioners, providers or other individuals conducting care review for issuing denials of coverage or service care. There are no financial incentives for CM decision makers to encourage decisions that result in under-utilization.

A physician peer to peer reviewer is available to discuss medical necessity denials. Physician may utilize an appeal process for unresolved differences of option by contacting HRNW.

Claims
HRNW Medicare Advantage HMO plans’ claims are processed by HRNW.

Customer Service: 503-251-6890 ext 3
Fax: 503-261-6020

Electronic payor ID: 56731

Address:
PO Box 33470
Portland OR 97292

To Avoid a Retroactive Claim

  1. Contact the PCP’s office for an authorization before seeing any HRNW member. When an auth has expired, contact the PCP’s office for a new authorization for additional visits.
  2. For members who need to be seen on an urgent or same day basis, call the PCP office the same day to request a referral.

Retro Claim Review
Retrospective claims review will require the Service Provider/Specialist office to send supporting documentation of medical necessity, with the claim, to HRNW Claims. HRNW Claims fax number is 503.261-6020. The following correspondence must support consideration for a retro authorization:

  • Primary care provider authorized services per HRNW guidelines. Submitted office or clinical notes must support PCP intent to refer).
  • Primary care provider felt there were extenuating circumstances (e.g. urgency, access issue) and such circumstances were documented.

Should supporting documentation not be received, the claim will be denied and Provider will be required to submit a Provider Dispute Resolution (PDR) directly to the Member’s respective Health Plan. HRNW is no longer permitted to make retrospective determinations after a claim has been denied.