Provider FAQ

Is there a Quick Reference Guide for providers?
Yes, the Quick Reference Guide is designed to assist you in providing services to eligible persons and to receive prompt claims payment. Please click here to download the Quick Reference Guide in PDF format.

How are ppoNEXT providers reimbursed?
ppoNEXT providers are reimbursed using Medicare's Resource-Based Relative Value Schedule (RBRVS) and other fee schedules. We are transitioning all fee schedules to an RBRVS methodology for ease of administration. All provider contracts contain a fee schedule and a default discount to ensure maximum savings for our clients. Our hospital reimbursement methodology uses a per diem and case rate model. ppoNEXT makes every effort to avoid percent discount contracts, which make medical costs unpredictable for our clients. Global per diem rates are in effect for all members of our Community Partners network.

How do I file a claim?
You mail the claim to the address listed on the patient's benefit card. If you don't have a copy of the card, contact the patient's insurance company or his or her employer's Human Resources or Benefits office for the address or phone number.

How do I appeal the way a claim was paid or denied?
You should contact the patient's insurance company or claims payor directly for information about appeals. That number is provided on the ID card. Or you can contact the patient's Human Resources or Benefits office. If you don't have a copy of the card, contact the patient's insurance company or his or her employer's Human Resources or Benefits office for the address or phone number.

How do I get a directory?
You may visit the Find a Doctor section to access our database of providers or to print a custom directory. Or you can contact our Customer Care Center at 800.860.6381 between 8 a.m. and 5 p.m. Central Time, Monday through Friday for assistance.

How are patients directed to participating providers?
There are several ways members are directed to ppoNEXT providers. They can contact our Customer Care Center at 800.860.6381 between 8 a.m. and 5 p.m. Central Time, Monday through Friday or visit the Find a Doctor section 24 hours a day.

What is ppoNEXT's policy regarding balance-billing of patients?
ppoNEXT contracts contain stringent language prohibiting participating providers from balance-billing patients for the contracted discount. Patient responsibility is limited to non-covered services and any deductibles, coinsurance or copayments outlined in the patient's medical plan.

Is there a provider nomination mechanism in place?
Yes. A nomination form is available to our clients and patients. Once the completed form is received and a determination of additional partners in the area made, a member of our Provider Contracting department will contact the provider within 30 days to discuss network participation.