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Eligibility

The following information is in this section:

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Member Enrollment Procedure and Effective dates

To enroll for membership an applicant must complete and sign a member enrollment form called an Individual Election Form. They can also enroll online. If an individual assists the member in completing the election form he/she must also sign the form and indicate the relationship to the beneficiary.

Generally, the effective date will be as early as the first of the following month. The member's true effective date will be in the acknowledgment of receipt letter which will be mailed to the member within 10 calendar days after the plan receives the completed enrollment request. Coverage begins at 12:00 a.m. Pacific time on the effective date.

The member's effective date may be delayed if the election form does not contain all necessary documentation of proof of entitlement to Medicare Parts A and B; or if the election form is incomplete. Desert Canyon Community Care will work with the potential member to resolve any outstanding issues with the election form to complete the enrollment process.

We will issue membership identification cards within 10 days of the member's effective date.

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Eligibility Verification Process

The primary care physician office must verify eligibility each time a member is present for services. Verification is critical to determine if a member's enrollment status has changed as the member may have been disenrolled from our plan. Please note:

  • The Individual Election Form does not guarantee eligibility,
  • A membership card does not guarantee eligibility;
  • The member may have enrolled late in the previous month;

Each Primary Care Provider is provided monthly with an Eligibility List of all your assigned members. The list contains the following information:

  • Member Name
  • Status – Active or Terminated
  • Member I.D. Number
  • Date of Birth
  • Gender – Male or Female
  • PCP Effective Date
  • Termination Date (if applicable)
  • Plan Effective Date

Note: We may provide eligibility information through electronic means such as tape media or file transfer. We will coordinate initiation of electronic eligibility with your software vendor, if applicable. Please contact your Provider Relations Representative for more information on electronic eligibility.

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Online Eligibility Verification with the Arcadian Online System (AOS)

The Arcadian Online System (AOS) is a secure web-based system built for our Providers to have easy access to the tools they need. This service provides easy access to eligibility information 24 hours a day, 7 days a week.

Your Provider Relations Representative will provide you with your AOS ID# and Password and assist with any questions or problems you encounter. Upon initial access to this service you will register for your password.

The AOS (Arcadian Online System) provides an eligibility confirmation number and basic member eligibility data including:

  • Member Name
  • Date of Birth
  • Gender
  • Member I.D. Number
  • Medical I.D. Number ( Medicare Number)
  • Effective Date
  • Termination Date (if applicable)
  • PCP Name
  • PCP Effective Date
  • Demographic Information of Member (address/Phone)
  • Type of Plan
  • PCP Co-Payment Information
  • Specialist Co-Payment Information
  • Health Plan Name
  • Medicaid Information (if applicable)

Contact Arcadian Management Services Link out if you are part of a large Provider group or Hospital Network and would like to receive more information about the AOS system.

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New Member Verification Procedure

When a member is present for services, follow the steps below:

  1. Verify eligibility through AOS; or
  2. Contact Member Services at 1-800-597-8597, TTY/TDD 1-866-573-8591, 7 days a week, 8 a.m. to 8 p.m., except holidays.

Note: The member's eligibility information should appear in the AOS within one week of enrollment and on the eligibility list within 30-60 days.

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Retroactive Terminations

If the eligibility list indicates a retroactive termination of a member the provider should seek reimbursement for any services provided outside the member's eligibility by billing Medicare fee-for-service, or another plan that the member may have enrolled in. Please contact the member for that information, or the CMS Working File.

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Reimbursement Procedure

If the provider determines a member is ineligible, he/she may seek reimbursement by submitting the claims to Medicare for fee-for-service reimbursement, or another plan the member may have enrolled in. Please contact the member for that information, or the CMS working file.

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Referrals and Authorizations

The following information is in this section:

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Referral Authorization Process

The Member's primary care physician is responsible for initiating the referral authorization request when referring a member to another provider.

Primary Care Physicians are required to submit notification or authorization/referral requests via the Arcadian Online System (AOS) for all services that need to be referred outside of the PCP's office setting.

Online notification has many benefits to both members and providers:

  • Verifies member eligibility
  • Ensures member is being referred to a network provider
  • Provides notification to specialist that member is not "self referring" and prevents claim issues
  • Pre-screening for benefit coverage
  • Provides member and provider with written approval of referral

The Medical Management Department provides verification of all referral notification requests. The Medical Management Department reviews and authorizes, pends or denies all referral requests according to the CMS Guidelines. The process works very smoothly and the usage of the online system significantly reduces the amount of time the providers spend on the phone and dealing with faxes.

Please contact a Provider Relations Representative to obtain a password and instructions for the AOS system.

If the AOS system is not available please fax your forms as follows. The Desert Canyon Community Care Referral Authorization Form must be used for all faxed referral authorization requests.

  • Fax Referral authorization requests to 877-676-0751.
  • Fax Pharmacy Authorization Exception Requests to 1-866-258-2828.

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Direct Access Services

Members may directly access services from a contracting physician for the following medical services.

Women's Health Specialists

Members can see a Gynecologist for well-woman exams and routine gynecological services such as pap tests, pelvic exams and mammograms (if recommended). A Certified nurse midwife or another qualified health care provider may also be recommended.

Annual Screening Mammography

Members may self-refer within the contracted Provider network for an annual screening mammography. Members are provided annually with a list of contracted mammography facilities.

Flu and Pneumonia Vaccine

Members have direct access to a contracted physician for an annual flu and pneumonia vaccine. The member's primary care physician should educate members about annual flu shot clinics and the availability of flu and pneumonia shots through their office.

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Authorization Notification

Our Medical Management Department will securely provide copies of the authorization determination to the following people:

  • Member's Primary Care Physician
  • Referred to provider(s)
  • Member

Possible authorization determinations include:

  • Authorized as requested – no changes
  • Authorized as modified – referral approved, but the requested provider or treatment plan was modified
  • Delayed – need additional information, will include specific information required
  • Denied – will include the reason for denial and a suggested alternative treatment plan.

If the member requests a specific treatment when the primary care physician has suggested an alternative treatment plan, the physician must submit the referral request to us. This will provide the member formal documentation of the adverse determination and notify the member of his/her appeal rights in case of a modification or denial.

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Claims

To check claims status using our automated system call: 1-800-775-6490. Our Electronic Claims Payor ID is 77045. We have relationships with the following clearinghouses: Emdeon, Capario, Office Ally and the SSI Group.

Our claims address is:

Desert Canyon Community Care
Claims Department
P.O. Box 4946
Covina, CA 91723

AOS (Arcadian Online System) Access and Use

Our contracted providers may use Arcadian Online System (AOS) to verify claims status.