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Welcome Providers!

At MediGold, we take pride in our network of physicians and ancillary providers who provide our members with quality care and services.

This page is to be used as a resource for physicians and other providers who participate in the MediGold Provider Network or are interested in participation. From this page you can gain access to a variety of helpful links, documents and forms.

Credentialing

For information about Credentialing, please click here.


Provider Portal

For access to MediGold's provider portal, with access to claims, remit and eligibility information, please complete the Portal Set Up form. A Provider Relations Specialist will complete your set up and return your login information.

If you have been assigned a password, access the Portal here


FDR Administrative Manual

The FDR Administrative Manual found at the link below provides a summary of MediGold's Compliance Program requirements.  These requirements apply to MediGold's First Tier, Downstream, and Related Entities.  Please review the manual and complete and return the attestation below to confirm your receipt and compliance with these requirements.

Return the completed attestation to MediGold's Compliance Officer by email or fax:

Email: jcalder@mchs.com
Fax: 614-546-3146

2014 FDR Administrative Manual

FDR Manual Attestation

Annual Fraud, Waste and Abuse and Compliance Training Requirements

The Centers for Medicare & Medicaid Services (CMS) requires all First Tier, Downstream or Related Entities (FDRs), providers and staff who provide services to a Medicare Advantage plan or Medicare prescription drug plan to complete Fraud, Waste and Abuse (FWA) Training and Compliance Training annually. Please review the MediGold FWA Training and MediGold Compliance Training documents and complete and return the Attestation below by no later than December 31, 2014.  

Please return the completed Attestation by mail, e-mail or fax to MediGold’s Compliance Officer:

Jennifer Calder, RN, CPHQ
6150 East Broad Street, Suite EE320
Columbus, OH 43213-1574
614-546-3146 – fax
jcalder@mchs.com – e-mail 

Important Facts about Fraud, Waste and Abuse Training and Compliance Training

  • It is the responsibility of all first tier, downstream or related entities (FDRs), contracted providers, facilities, hospitals, and ancillary providers such as durable medical equipment suppliers, to complete this mandatory training no later than December 31, 2014, and annually thereafter.
  • In an effort to reduce the burden on providers, if providers and their staff have already completed Fraud, Waste and Abuse Training and/or Compliance Training provided by another Medicare Advantage plan or through CMS, attestation of the training will be accepted by MediGold.
  • Physicians within a group practice as well as staff within each organization must complete the training.
  • Training provided by MediGold is free of charge.
  • Providers must attest to both physicians and staff completing the training.
  • Ancillary providers must also attest that all staff have completed training.
  • For additional assistance or to receive a hard copy of materials, please contact Provider Relations.

FWA and Compliance Training Documents and Forms

Annual Compliance Training and FWA Training Attestation Form

MediGold Compliance Training 2014

MediGold FWA Training 2014

FWA & Compliance Training FAQs

Prior Authorization Requirements

Effective July 1, 2011, referring physicians are required to obtain prior authorization from Care to Care for the following outpatient diagnostic imaging studies (unless provided in an emergency room or observation setting):

  • MRI 
  • MRA
  • CT
  • CTA
  • PET
  • PET/CT
  • Nuclear Cardiology

ALERT:  Please Submit Online Prior Authorizations for High-Tech Radiology Procedures through Care to Care’s Upgraded CARE Portal @ https://medigold.careportal.com/, as the portal URL has changed.

For direct access to Care to Care's website, click here. To obtain a Care to Care Prior Authorization form for MediGold members, click here. For a list of outpatient advanced imaging services that require prior authorization, click here.

To obtain a prior authorization form for a MediGold member for services other than outpatient advanced imaging services, please refer to the Frequently Used Documents and Forms section below to obtain an authorization form.


Last Updated 10/30/2014 9:36:35 AM

Frequently Used Documents and Forms

Claims guidelines and forms

Electronic Payment Form

Integrated Denial Notice 1.24.14

Claims guidelines

Corrected Claims Form

Request for Claims Review Form & Instructions

Claims Status Inquiry Fax Request Form

Coding Guideline

Prior Authorization Request Form 

2014 Prior Authorization List

Central Prior Authorization Request Form

Southeast Prior Authorization Request Form

2014 POV Questionnaire with Prior Authorization Request Form (by region)

 2014 POV Questionnaire w/Central Prior Authorization Request Form

 2014 POV Questionnaire w/SE Prior Authorization Request Form

MediGold Customized Certificate of Medical Necessity for Power Mobility Devices

Part D Formulary Exception Request Form

Part D Prior Authorization Forms

Miscellaneous

2014 HEDIS Coding Guide

2013-2014 Flu Vaccine Information

Medicare Preventive Services Quick Reference Guide

Provider Information Change Form

PCP Information Change Form

Post-Cataract Lens Reimbursement Form

Materials Request Form

Provider Remit Appeal Review Rights

Non-plan providers interested in disputing the payment amount should fax a "Claim Request for Review" form to MediGold's Audit department.  Instructions for completing this form are located at this link.

The Claim Request for Review process does not apply to cases when a claim is denied; those cases should be forwarded under MediGold's standard appeal process.

Non-plan Provider Appeal & Waiver of Payment Statement Form

Frequently used links

Last Updated 10/1/2014 8:28:58 AM