Resources

How to verify Eligibility & Benefits:

  • Provider Support Benefits & Eligibility Team: 844-806-8217 (Option 1)
  • Email: [email protected]

It’s important to note that in order to receive EFT payments from Care N’ Care Insurance Company of North Carolina, Inc., it is required that you enroll with Zelis Payments. Failure to enroll will mean payments will be issued by paper check.

All provider services for Zelis Payments are handled exclusively by Zelis. If you need assistance, please use the contact information below:

Phone (Enrollment): 855-496-1571
Phone (Support): 844-292-4066

How to submit Prior Authorization requests:

  • Fax: 844-873-3163
  • Call: 844-806-8217 option 3
  • Submission Option via Provider Portal: Coming Soon

2023 Prior Authorization List:

The list below outlines services and medications for which prior authorization in 2023 is required for HealthTeam Advantage members. Please review the key information at the top of the list for important information before submitting a prior authorization request.

2023 Prior Authorization List (PPO)

2023 Prior Authorization List (Diabetes & Heart Care HMO)

2023 Prior Authorization Forms:

Please print and complete the applicable prior authorization form found below.
Important reminder: the form must be complete and include clinicals to support medical necessity. If you have any questions or to verify if a procedure requires prior authorization, please contact our intake team at: 844-806-8217 option 3 from 8 AM to 5 PM M-F and 336-604-1589 after 5 PM.

Please allow eight to ten (8-10) days turn-around time for processing. Note, per CMS the standard turn-around time is fourteen (14) days.

2022 Prior Authorization List:

The list below outlines services and medications for which prior authorization in 2021 is required for HealthTeam Advantage members. Please review the key information at the top of the list for important information before submitting a prior authorization request.

2022 Prior Authorization List (PPO)

2022 Prior Authorization List (Diabetes & Heart Care HMO)

2022 Prior Authorization Forms:

If you do not have access to the portal, please print and complete the applicable prior authorization form found below. Important reminder: the form must be complete and include clinicals to support medical necessity. If you have any questions or to verify if a procedure requires prior authorization, please contact our intake team at: 844-873-2905 8 AM to 5 PM M-F and 336-604-1589 after 5 PM.

Please allow eight to ten (8-10) days turn-around time for processing. Note, per CMS the standard turn-around time is fourteen (14) days.

How to Submit Claims:
Providers are to submit claims electronically or by mail.

1. Electronically:
HealthTeam Advantage Electronic Payer ID #: 88250

2. Mail:
Claims Mailing Address:
HealthTeam Advantage
P.O. Box 652
Southborough, MA 01772

How to Check Claim Status:
Provider Portal
Phone: 844-806-8217 (Option 2)
Email: [email protected]

Timely Filing Limits:
Initial Claims: 180 calendar days from the date of service to submit
Secondary Payer: 180 days from the date of the primary payers’ Explanation of Benefit (EOB) decision to file
Corrected Claims: 180 calendar days from the original date of service to correct

How to Submit a Claim Dispute:
Send dispute letter to include the following:

  • Member Name
  • ID Number
  • Claim Number
  • Detailed explanation of the dispute and supporting documentation

Dispute Mailing Address:
HealthTeam Advantage
Attn: Claims Dispute
P.O. Box 652
Southborough, MA 01772

Faxed Requests are Not Accepted

Dispute vs. Appeals: What’s the Difference?

Dispute: A dispute occurs when a contracted provider disagrees with payment from the plan. It involves issues that have occurred after services have been rendered. This can include a review of the claim allowed amounts, the amount paid, denials, etc. The dispute is the only option available to contracted providers.

Appeal: An appeal is a formal request from a non-contracted provider requesting a review of a previous claim decision. This decision can be a denial by the plan that results in zero payment made to the non-contracted provider or where the claim was paid but the non-contracted provider disagrees with the amount that was allowed. Appeal rights are only available to non-contracted providers. For more information on this process, click here.

Who Can Submit a Dispute?

  • Contracted providers

When Should You Submit a Dispute?

All disputes must be filed within 120 days from the claims adjudication date on the Explanation of Payment (EOP).

You should submit a dispute when you believe a claim was paid incorrectly. The situation for reprocessing includes, but is not limited to:

  • Amount paid is different than what the provider expected
  • The claim was filed in a timely manner and the provider has proof
  • The claim was denied for no authorization when the provider has an authorization number
  • All supporting documentation such as medical records and provider statement support claims payment

How to Submit a Dispute
Send a dispute letter that includes the following:

  • Member Name
  • ID Number
  • Provider Name
  • Provider Tax ID
  • Ticket Number
  • Claim Number
  • Date of Service
  • Amount Billed
  • A detailed explanation of the dispute and supporting documentation
  • Expected Outcome
  • Multiple “LIKE” claims complete a spreadsheet

Online Dispute Resolution Request

Where to Submit Your Dispute
HealthTeam Advantage Claims Department
P.O. Box 652
Southborough, MA 01772

Email: [email protected]

HealthTeam Advantage makes every attempt to identify claim overpayments and issue provider notices for an overpayment refund request within 30 days, but in no case more than 12 months after the date of the original payment.

Should an overpayment occur, HealthTeam Advantage will send a claim overpayment refund request letter with detailed claim information about the payment error and request a return of the overpayment to be returned to the plan within 30 days. If payment is not received within 30 days, a second refund request letter will be issued. The maximum written request for refunds will not exceed three (3) within ninety (90) days.

New for 2023:  HealthTeam Advantage reserves the right to pursue additional overpayment recovery efforts if monies are not received. This means if no dispute is filed against the refund request, and the monies are not returned as requested, after 100 days, we will recoup/deduct the amount owed from future payments owed to you through claim activity.

If a provider receives an overpayment refund request letter from HealthTeam Advantage, the provider should follow the instructions promptly, as outlined in the letter for returning the overpayment or disputing the request. If a provider independently identifies an overpayment from HealthTeam Advantage, the following steps should be taken:

Return a check made payable to HealthTeam Advantage to:
Attn: Claim Overpayments
HealthTeam Advantage
PO Box 744676
Atlanta, GA 30374-4676

Include a copy of the Explanation of Payment that accompanied the overpayment to expedite HealthTeam Advantage’s adjustment of the provider’s account. If the Explanation of Payment is not available, the following information must be provided:

• HealthTeam Advantage member name and ID number;

• Date of service;

• Payment amount;

• Vendor or provider name and number;

• Provider Tax Id number; and,

• Reason for the overpayment refund.

Drug Coverage: Part B Drugs vs. Part D Drugs

HealthTeam Advantage follows Medicare Part B and D guidelines when processing and paying for prescription drugs.

When is a drug covered by Part B?

Part B covers drugs that usually aren’t self-administered. These drugs are given in an office setting and are part of their service.

When is a drug covered by Part D?

Part D covers outpatient drugs when a physician writes a prescription and it is filled at a pharmacy.

 Note: There a few drugs that can be covered by Part B or Part D depending on the circumstances; please call your Provider Concierge for assistance.

Here are a few examples of types of drugs covered by Part B that can be submitted to HTA for payment by physician practices:

  • Drugs used with an item of durable medical equipment (DME)
  • Certain types of injectables
  • Infused drugs
  • Vaccinations: Flu shots, Pneumococcal shots, and Hepatitis B shots (when disease-specific criteria are met), and Tetanus when being treated for accident/injury.

Here are a few  examples of types of drugs covered by Part D and processed under the  prescription benefit:

  • Vaccine: Shingles, Hepatitis B, and Tetanus (for routine immunization)
  • Self-Administered Injectables
  • Self-administered drugs

HealthTeam Advantage is always here to assist you if you have questions regarding Part B and Part D drugs. You can call your HealthTeam Advantage Provider Concierge at 844-806-8217 (option 2).

You may also use this link to look up covered medications.