2008 HEALTH NET MEDICARE PART D SAMPLE ID CARDS

2008 HEALTH NET MEDICARE PART D SAMPLE ID CARDS
SAMPLE - PDP ID CARD
Health Net Orange
Member questions call 1-800-806-8811
(TTY/TDD: 1-800-929-9955)
A Medicare Prescription Drug Plan
ID:
R00000000-00
Name: FIRST MI LAST
Effective: 2008
HN Group ID: 123456A
Rx Claims Processor: Caremark
RxBIN: 004336
RxPCN: ADV
RxGrp: RX6270
Issuer: (80840)
Material ID: S5678_2007_85 CMS Approved 09/07
CMS_S5678 XXX
For Provider Inquiries, Call 1-888-949-4200
For Pharmacist Inquiries, Call 1-888-865-6567
Submit Part D Prescription Drug Claims to:
Health Net
Attn: Claims
10540 White Rock Rd., Ste. 280
Rancho Cordova, CA 95670
SAMPLE - PFFS ID CARD
Member questions call 1-800-977-8221
(TTY/TDD: 1-800-929-9955)
Health Net Pearl
A Medicare Advantage Private Fee for Service Plan
Name: FIRST MI LAST
ID:
R00000000-00
Group ID: 123456A
Specialist Copay: $###
Effective: 01-01-2008
Issuer:
(80840)
Office Visit Copay: $###
Emergency Room Copay: $###
Part D Claims Processor: Caremark
RxBIN: 004336
RxPCN: ADV
RxGrp: RX6270
Providers: Do not bill Original Medicare. Health Net Pearl is a Medicare
Advantage Private Fee-For-Service Plan. For terms and conditions of
payment, go to www.healthnet.com or call 1-800-977-8221.
For Pharmacist Inquiries, Call 1-888-865-6567
Submit Medical and
Part B Drug Claims to:
P.O Box 2226
Augusta, GA 30903-2226
Submit Part D Drug Claims to:
Health Net - Claims
10540 White Rock Rd., Ste 280
Rancho Cordova, CA 95670
Decision PowerSM –To access a Health Coach (24 hours a day, 7
days a week) call: 1-800-893-5597 (TTY/TDD: 1-800-276-3821)
Material ID M0004-PFFS-07-081 CMS Approved: 09/07
CMS_H5996-H5721 XXX
Electronic Claims Submission to:
Professional Payer ID: SX185 Institutional Payer ID: 12X48
SAMPLE - HNAZ MAPD ID CARD
This card is for identification purposes only and does not guarantee eligibility
Card Issuer ID: 80840
Contract: H0351-014
Subscriber: SAMPLE MEMBER
ID#: HN0000000 01
Plan: RUBY OPTION 1
PCP:$0
Specialist:$35
Group#: AZ0007
Urgent Care:$35
ER:$50
RxClaims Processor: Caremark
RxBIN: 004336
RxPCN: ADV
RxGROUP: RX6270
Important Member Phone Numbers:
Customer Contact Ctr: 1-800-977-7522 TTY: 1-800-977-6757
Hours of operation Monday-Friday, 8am - 8pm
Decision Power:
1-800-893-5597 TTY: 1-800-276-3821
Hours of operation 24 hours/day, 7 days/ week
Hospitals and Physicians: 1-800 289-2818
Prior Authorization:
1-800 977-7518
Behavioral Health:
1-800-977-0281 TTY: 1-866-726-1785
MEDICAL CLAIMS: To submit claims, complete a current original CMS-1500 or
UB92. Include the Health Net ID # and the member’s two-digit billing code which
appears on the front of this card. Mail claims to Health Net, P.O. Box 14225,
Lexington, KY 40512-4225. Electronic claims: Contact our EDI Dept. at
1-866-334-4638 or 1-866-EDI-HNET.
Pharmacies Call: 1-800-410-6565
Caremark:1-888-865-6567
PHARMACY CLAIMS: Mail claims to Health Net, Attn: Pharmacy, 950 N.
Finance Center Drive, Tucson, AZ 85710
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SAMPLE - HNCA MAPD ID CARD
FRONT OF CARD
You have selected the following medical group for your care.
All medical services, with the exception of emergency,
urgently needed services, or out of the area renal dialysis for
ESRD members, as defined in your Evidence of Coverage,
must be provided or arranged by:
Group/Physician Name:
HILL PHYSICIANS - ABSMC
JANE Q. PROVIDER
1234 Main Street
SACRAMENTO CA 00000
PPG Eff. Date:
01-01-08
PPG #: 0000
PCP Copay: $10 copayment
Group Phone:
1-925-820-8300 (TTY/TDD: 1-877-735-2929)
Physician Phone: 1-800-555-1234 (TTY/TDD: 1-877-735-2929)
Health Net
Medicare Advantage HMO
Subscriber Name:
JOHN DOE
Subscriber #: R0000000
RxProcessor: Caremark
RxBIN #: 004336
RxPCN #: ADV
RxGroup: RX6270
Group # 00000F
Issuer: (80840)
CMS Contract H0562 068
Plan: 2T6 WITH PHARMACY RUBY
BACK OF CARD
For questions or concerns, call the Member Services Department at
1-800-275-4737 (TTY/TDD: 1-800-929-9955) 8:00 a.m to 8:00
p.m., 7 days a week.
For Provider inquiries, call 1-800-929-9224.
Medical Claims:
Health Net Medicare Advantage Claims
P.O. Box 14702
Lexington, KY 40512
Pharmacists call 1-888-865-6567.
For mental health benefits, call MHN at 1-800-646-5610
(TTY/TDD: 1-800-327-0801)
Pharmacy Claims:
Health Net of California
Attn: Pharmacy
P.O. Box 9103
Van Nuys, CA 91409-9103
To contact a Decision Power Health Coach, call 1-800-893-5597
(TTY/TDD: 1-800-276-3821) 24 hours a day, 7 days a week
If an emergency arises: Call 911 or go to the nearest hospital or
emergency care facility. If you are unsure of the seriousness of
your condition, you may call your physician for assistance.
Material ID# H0562-07-0145
CMS Approval (10/07)
SAMPLE - HNNE MAPD ID CARD
This card is for identification purposes only and does not guarantee eligibility
Card Issuer ID: 80840
Contract: CT0755-022
Subscriber: SAMPLE MEMBER
ID#: HN0000000 01
Plan:
Group#: 006453
PCP:$15 Specialist:$30 Urgent Care:$30 ER:$50
RxClaims Processor: Caremark
RxBIN: 004336
RxPCN: ADV
RxGroup: RX6270
Important Member Phone Numbers:
Customer Contact Ctr: 1-800-547-8734 TTY: 1-888-747-2424
Hours of operation Monday-Friday, 8am - 8pm EST
Hospitals and Physicians: 1-800-438-7886
Healthy Lifestyles:
1-888-747-9444 TTY: 1-888-747-2424
Behavioral Health:
1-800-627-7715 TTY: 1-800-855-2881
MEDICAL CLAIMS: To submit claims, complete a current original CMS-1500 or
UB92. Include the Health Net ID # and the member’s two-digit billing code which
appears on the front of this card. Mail claims to Health Net, P.O. Box 14700,
Lexington, KY 40512-4225. Electronic -Payer ID 06108, EDI Dept.
1-866-334-4638.
Pharmacy Help Desk:
1-888-865-6567
PHARMACY CLAIMS: Mail claims to Health Net of the Northeast, Attn:
Pharmacy Mgmt.- Medicare Part D, P.O. Box 904, Shelton, CT 06484-9831
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SAMPLE - HNOR MAPD ID CARD
FRONT OF CARD
Health Net
Medicare Advantage PPO
Health Net Medicare Advantage PPO
Office Visit
Emergency Room
Urgent Care Facility
Hospital
In Network
$15
20%
$25
20% per day (Days 1-10)
Website: www.healthnet.com
Out-of-Network
30%
20%
$50
30% per day (Days 1-10)
Subscriber Name:
MIKE A. SMITH (SAMPLE)
Subscriber #: R00000000
In Network
Acupuncture, Chiropractic,
Naturopathy Medicine
Chiropractic (Medicare Covered)
Massage Therapy
Out-of-Network
$15
$15
$25
$15
$50
$25
Medical Plan: SAGE
Group ID: MO210A
RX Claim Processor: Caremark
Rx BIN #: 004336
Rx PCN:
ADV
Rx Group: RX6270
CMS Contract: H5520 007
Issuer:
80840
BACK OF CARD
Treatment Review
Send Medical Claims to:
Health Net Medicare Advantage
P.O. BOX 14130
Lexington, KY 40512
Send Pharmacy Claims to:
Health Net Pharmacy Claims Dept.
13221 SW 68th Parkway
Tigard, OR 97223
If you have questions regarding prior authorization requirements, please
refer to your benefits information or contact Health Net’s Member
Services at the number on this card.
Providers:
If you have any questions regarding this Medicare
Advantage PPO, please contact Health Net Member
Services at 1-888-445-8913 (prompt #3), Monday-Friday,
8 a.m.-5 p.m., except holidays or go to
www.healthnet.com
Pharmacists:
For billing assistance, call the Pharmacy help line at
1-888-865-6567
Member Services: 1-888-445-8913 (prompt #2), TTY: 1-800-929-9955
8am-8pm, seven days a week. www.healthnet.com
_________________________________________________
Complementary Care Benefits call ASH: 1-800-678-9133
Decision Power - to access a Health Coach (24 hours a day, 7 days a week)
call: 1-800-893-5597 (TTY: 1-800-276-3821)
If an emergency arises: Call 911 or go to the nearest hospital or
emergency care facility. If you are unsure of the seriousness of your
condition, you may call your physician for assistance.
Material ID# H5520-07-0043
CMS Approval (10/07)
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