Providers

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We take great pride in our network of physicians and related professionals who serve our members with the highest level of quality care and service. We are absolutely committed to making sure our providers receive the best possible and latest information, technology and tools available to ensure their success and their ability to provide for clients.

At Coventry, we focus on operational excellence, constantly striving to eliminate redundancy and streamline processes for the benefit and value of all of our partners. Learn why providers have chosen to join us as their partners in managed health care.

  • Easy and simple experience
  • Operational excellence
  • Financial discipline
  • Empowering environment

Online Solutions

We value the doctors, hospitals and all health care professionals who participate in our networks, and we are dedicated to meeting your needs for ease and convenience. With that goal in mind, we have expanded our online services with a unique electronic solution. Coventry’s directprovider.com simplifies the historic paper process and accelerates claims processing and information flow management so  data is readily available to providers as soon as they need it.

Grievances and Appeals

Grievances and Appeals policies are in place to ensure that we have effective procedures for addressing, documenting and resolving complaints or appeals.

The grievance procedure is designed to provide prompt, meaningful and confidential resolution of member concerns regarding quality of care, physician behavior, office waiting times, claims payment, coverage of services and other similar matters.

The appeals process gives members the opportunity to ask us to review any matter related to:

  • Issues about the scope of coverage for health care services
  • Medical necessity of services requested
  • Denial of care/services/claim
  • Other adverse benefit determinations
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Grievances and Appeals instructions can be found here.  The form can be found here
For more information on your Grievance and Appeals rights please call the customer service phone number that appears on your member ID card.

Financial Compensation - Doctors Make the Decisions

People sometimes do not understand Utilization Management (UM) programs.  At Coventry Health Care, UM is a system for reviewing the care that has been provided toour members.

Our policy about payment for services is to make sure that decisions are made because they are what our policies say we will do.  There are no financial incentives in the review process.

  • UM decision-making is based only on appropriateness of care and service and existence of coverage.
  • The organization does note specifically reward practitioners or other individuals for issuing denials of coverage.
  • Financial incentives for UM decision makers do not encourage decisions that result in under utilization.

How We Evaluate New Technology

Doctors and health care manufacturers are constantly developing new technologies.  They can include anything from a new way to perform a procedure to a new use of a a piece of equipment.  So Coventry Health Care, Inc. established a system to review and evaluate new technologies. 

When a new technology is presented to Coventry, we do a thorough review of existing literature.  The opinion of experts in the field may be requested.  They may also contact the accrediting body of the appropriate medical specialty. 

Coventry compares the information against established criteria.  Then we decide whether to provide coverage.  All of our decision are based on making sure our members have the appropriate care and services.  We continue to focus on providing our members with quality health care products.

Member Rights and Responsibilities

To ensure that our members are treated fairly, we have a list of member rights and responsibilities.  We encourage you to become familiar with them.

Our Member's Privacy Matters

Coventry Health Care works hard to keep our members' personal and health information secure and private.  We need information about our members to manage their health benefits.  We collect information from many sources, and keeping our members' personal information safe is one of our most important jobs.  We make sure that only people that need to you their information have access to it.  We may use and share your information for:

Treatment
Payment
Health care operations

These uses are covered under state and federal laws.  Our policies will reflect the most protective laws that apply to our members.  We encourage you to view our Notice of Privacy and Practices.

Coventry's Quality Improvement Program

Coventry is committed to providing members with access to quality care and delivering programs and services that help them enjoy optimal health. The Coventry Quality Improvement (QI) program supports this commitment by ensuring that all of our services meet high standards of quality and safety and that each member has the best health plan experience possible. 

Through the QI program, Coventry identifies opportunities of improvements and implements solutions that reinforce our commitment to quality, safety and service excellence.  Our four primary areas of focus are:

  • Member Satisfaction
  • Safety of care
  • Healthplan services
  • Access and availability to network providers

One tool we use to identify opportunities for improvement is the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.  CAHPS is a program of the U.S. Agency for Healthcare Research and Quality that collects information on members' experiences with the health care system.   The survey questions focus on a member's overall satisfaction with:
  • the health plan
  • their doctor and specialists
  • the medical care they've received

Each year, a third party vendor, sends the CAHPS survey to a random sample of our member population.  We use the results of the survey to help develop goals for the Quality Improvement program and implement initiatives to achieve these objectives. View the 2013 CAHPS results here.

Provider Services

Our physicians and ancillary health care providers are key to the quality plans and service we promise clients. At Coventry, we believe in putting exceptional people in an empowering environment where individuals are accountable for their efforts. As a team we strive to support each other and exceed expectations.

Network Participation

Our network includes more than 4,800 hospitals, 555,000 professional providers and 68,000 pharmacies. Our ever-expanding network speaks to our client satisfaction. We are proud of our track record of success and aggressive growth supported by exceptional service.

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Secure Provider Portal

Coventry’s free online provider portal, directprovider.com, allows you to access critical information wherever and whenever you need it. This innovative and secure tool is available with all Coventry Health Care plans and provides direct connection to data management for up-to-date information.

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