Providers and Partners

Georgia Health Advantage firmly believes that our success as a health plan hinges on our participating Providers. And we are committed to simplifying the administration of health insurance so our Providers can devote their attention to providing high-quality health care. We are always available if questions arise, and we collaborate with our Providers to help facilitate the efficient delivery of quality care to our Members.

For Prescribers and Pharmacies

Georgia Health Advantage provides Medicare Part D prescription drug coverage through our partner Elixir Solutions. Elixir Solutions is a full-service pharmacy benefit management company committed to lowering drug costs, improving health, and providing superior customer service in a manner that instills trust and confidence.

For Prescribers:

    • Access Formulary and Prior Authorization Forms at https://elixirsolutions.promptpa.com
      • Select “Prescribers” and click on “Prior Authorization”
      • Enter your NPI number and State to access the prescriber portal
    • EnvisionRxOptions Pharmacy Helpdesk
      • Phone number: 1-833-665-5420
      • TTY phone number: 711
    • Refer to the Prescription Drug Benefit page for formulary, prior authorization criteria, and step therapy criteria

For Pharmacies:

    • Access payer sheets and other information at https://elixirsolutions.promptpa.com
      • Select “Pharmacies” and click “Pharmacies Login”
      • Enter your NPI number and NCPDP number to access the pharmacy portal
    • EnvisionRxOptions Pharmacy Helpdesk
      • Phone number: 1-833-665-5420
      • TTY phone number: 711
    • Refer to the Prescription Drug Benefit page for formulary, prior authorization criteria, and step therapy criteria

Institutional Special Needs Plan Model of Care and Training

At Georgia Health Advantage, we specialize in improving health care and advancing a truly unique philosophy of care to meet the complex needs of the institutional Medicare beneficiary population, while simultaneously streamlining administrative functions for our Providers. The Georgia Health Advantage Model of Care focuses on providing a unique level of customized clinical care and services for residents in nursing facilities or individuals living in the community or a contracted assisted living facility (ALF) but require an institutional level of care (LOC) As we help extend your care, our care model concentrates on addressing each Member’s full range of medical, functional, and behavioral health care needs in a coordinated and Member-centric manner. This means putting the Member’s preferences at the center of the care planning process and leveraging Provider resources to ensure every Member receives the services necessary to achieve their short-term and long-term care goals. Our model organizes best practices and industry innovations including:

    • The Advanced Nurse Practitioner (ANP) and primary care physician (PCP)/NFist (a PCP specializing in the care of nursing home patients) care team providing onsite, facility-based PCP support;
    • A risk-assessment tool designed for a senior, nursing facility patient population;
    • A comprehensive history and physical assessment that generates an Individualized Care Plan (ICP);
    • A care management platform that helps identify needed preventive health/HEDIS services, ensures the use of evidence-based clinical guidelines, and facilitates care team communications for care coordination; and
    • Frequent face-to-face Member and caregiver/family member interactions that identify Member care preferences and allow time for important care decision discussions and counseling.

It is important that all of our Providers are properly trained and informed about the Georgia Health Advantage Model of Care. Our top priority is making sure all of the providers in the Georgia Health Advantage network meet the training and education needs of our institutional Medicare beneficiary population. The purpose of the Model of Care Training is to comply with the statutory requirement of the Centers for Medicare and Medicaid Services (CMS), that all Special Needs Plans provide a general understanding of the requirements of the Model of Care. In addition, this will also help you to seamlessly serve Georgia Health Advantage Members, your patients.

Model of Care Training

  • Click on each ‘+’ below to review material.
  • Complete Attestation
  • Centers for Medicare and Medicaid Services (CMS) requires all Medicare Advantage Special Needs Plans (SNPs) to have a Model of Care (MOC)
  • CMS requires all SNPs to conduct initial and annual training that reviews the major elements of the MOC for providers and staff
  • Purpose of this training is to comply with the statutory requirements of CMS that all SNPs provide a general understanding of the requirements of the MOC

I-SNPs are Medicare Advantage Prescription Drug Plans that restrict enrollment to Medicare eligible individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a:

    • Skilled nursing facility (SNF)
    • LTC nursing facility (NF)
    • Intermediate care facility for the intellectually disabled (ICF/ID)
    • Inpatient psychiatric facility
      OR
    • Individuals living in the community or a contracted assisted living facility (ALF) but require an institutional level of care (LOC)*.

*As determined by a state assessment tool and evaluation. The tool is the same as that used for individuals residing in an institution.

  • Entitled to Medicare Part A (Hospital Insurance)
  • Enrolled in Medicare Part B (Medical Insurance)
  • Live in Plan service area
  • Must reside, or be expected to reside, in a participating I-SNP nursing facility for greater than 90 days at the time of enrollment, individuals living in the community or a contracted assisted living facility (ALF) but require an institutional level of care (LOC)

Model of Care – Element 1
Special Needs Plan (SNP) Population

  • General Population
  • Vulnerable Subpopulations

Model of Care – Element 2
Care Coordination

  • I-SNP Staff Structure
  • Health Risk Assessment (HRA)
  • Individualized Care Plan (ICP)
  • Interdisciplinary Care Team (ICT)
  • Care Transition Protocols

Model of Care – Element 3
Provider Network

  • Specialized Expertise
  • Use of Clinical Practice Guidelines
  • Model of Care Training

Model of Care – Element 4
Quality Measurement and Performance Improvement

  • Model of Care Performance Improvement
  • Measurable Goals and Health Outcomes for the Model of Care
  • SNP Member Satisfaction
  • Evaluation of the Model of Care
  • Dissemination of SNP Quality Performance Related to the Model of Care
  • Institutionalized in a Long-Term Care (LTC) Facility or in the community and need institutional type of care usually provided in a long-term care facility
  • Frail/vulnerable
  • More likely to be Female
  • Average age is 75 years old
  • Clinical Risk Factors
    • Diabetes
    • Heart failure
    • Pressure injury
    • Respiratory conditions
    • Psychosis
    • Falls
    • Pressure ulcers
    • Urinary tract infections
    • Incontinence

SNP Staff Structure

  • The I-SNP has a care coordination team in place that includes an Advanced Practice Provider, Case Manager, Member Advocate, Clinical Pharmacist, and other providers

Health Risk Assessment (HRA):

  • HRA is conducted to identify medical, psychosocial, cognitive, functional and mental health needs and risks
  • Initial HRA is completed within 90 days of enrollment and annually thereafter; findings are integrated into the member’s care plan
  • Stratification level dictates Advanced Practice Provider and Case Manager’s intervention schedule

Individualized Care Plan (ICP):

  • Includes goals that are member specific driven from clinical information obtained from HRAs and other Plan data

Interdisciplinary Care Team (ICT):

  • The Interdisciplinary Care Team reviews and approves the ICP
  • Composition varies and is dependent on each member’s unique goals and member preferences
  • Includes the member and any designated representative(s)

Care Transitions:

  • Advanced Practice Provider conducts a care transition assessment, including comprehensive medication review post discharge. The Case Manager updates the ICP and communicates with ICT, as relevant

Specialized Expertise

  • Comprehensive network of providers that collaborate with the I-SNP’s ICP and ICT
  • Comprehensive network of providers that meet CMS adequacy standards
  • All contracted providers are credentialed

Clinical Practice Guidelines:

  • Nationally developed and approved; reviewed minimally every two years, or significant change
  • Available for provider reference

MOC Training is required for:

  • Health Plan Staff
  • Contracted Providers and Vendors
  • Long Term Care Facility Staff

Quality Measurement & Performance Improvement:

  • Continuous improvement and monitoring of medical care, patient safety, and delivery of services
  • Data analysis and standard reporting is used in the Annual Quality Improvement Work Plan

Measurable Goals and Health Outcomes for the Model of Care

  • Processes and procedures to determine health outcomes are met

Member Satisfaction:

  • Assessed annually

Model of Care Evaluation:

  • Data is collected, analyzed and evaluated on a monthly, quarterly, and annual basis from each Model of Care domain to monitor performance, identify areas for improvement, and to ensure program goals have been meet

Dissemination of SNP Quality Performance Results

  • Results shared within the organization and provider network

    Did you complete the Model of Care Training?

    Do you understand the Model of Care Training material presented?

    Your Details:

    or

    Person Completing Attestation:

    Become a Network Provider

    Georgia Health Advantage contracts with physicians, facilities and other allied providers to ensure we have an adequate Provider network which is essential for the delivery of health care services to our members. All Providers must be credentialed before they can be added to our network as a participating Provider. Why Partner with Georgia Health Advantage:

      • From the beginning, physicians discover that Georgia Health Advantage isn’t just another Medicare Advantage health plan.
      • We have a different philosophy, attitude and approach to caring for our Members.
      • Our emphasis is on encouraging proactive health care and offering programs and services that can make a difference in our Members/your patients’ quality of life.
      • We strive to provide our Members exceptional benefits and an abundance of attention.
      • And we believe Georgia Health Advantage Providers deserve the same.

    For more information on becoming a Georgia Health Advantage contracted Provider, please contact Network Operations at 1-844-917-0645; TTY 711 or via email at networkservices@amhealthplans.com.

    Last Updated on October 8, 2021

    Need a referral to a specialist?

    CALL UM Department: 1-844-917-0645
    FAX UM Department: 1-844-917-0644

    Provider Search

    Search for Georgia Health Advantage network providers.

    Want more information about Georgia Health Advantage?

    Call us at 1-844-917-0645; TTY 711.
    Our trained member service representatives are available from 8:00 a.m. to 8:00 p.m., or fill out this Information Request Form to have us call you.

    START TYPING AND PRESS ENTER TO SEARCH