- Create Provider Directory
- Document Library
- Frequently Asked Questions
- Claims Information
- HIPAA 5010 and ICD10
- Provider Inquiries
- ELECTRONIC SOLUTIONS
- Secure Provider Portal
- EDI Documentation
- User Support & Training
- NETWORK PARTICIPATION
- Provider Nomination
- Credentialing Criteria
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
DirectProvider.com - Your Online Solution
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 including: A superior online tool, directprovider.com is designed and maintained to the highest standards, promising accurate information and faster access to the information you need, when you need it.
The prior-authorization process is also quick and easy with directprovider.com. Providers can submit, look-up, or edit authorizations online, at their convenience. And, with our exclusive Adjustment Reconsideration function, providers have the opportunity to request a review/reconsideration of an authorization and submit the documentation online in support of that request.
Coventry prides itself on the EDI tools it has available for its providers and with directprovider.com, Coventry can boast one of the most multi-functional payer websites available to its providers in the health care industry.
Webcast training is offered quarterly on our DirectProvider.com application and its functionalities. Please review the training opportunities via the links offered below and follow the registration instructions contained within each PDF.
> DirectProvider.com - All Functionalities
A superior online tool, directprovider.com is designed and maintained to the highest standards, promising accurate information and faster access to the information you need, when you need it.It allows providers the ability to verify Eligibility benefit information before services are rendered. The Claim Inquiry section provides the ability to view claims by status (Paid, Pended, Denied, Rejected, etc.), and search for claims by member, claim number, or date range, for any 30-day period, with up to 3 years worth of claims history available. Claims disposition codes are easy to understand and each claim clearly displays member responsibility. You can see pre-existing conditions, authorization numbers, and line level detail for each claim, as well as, the date we received the claim and how and when it was transmitted through our system. The Online Claims Adjustment Reconsideration function evens allows a provider the opportunity to request a review/reconsideration of a claim that they feel did not properly adjudicate, even at the claim line level, and submit documentation online in support of that request.
For provider support questions pertaining to the Coventry Health Care, Inc. business, please refer to the following contact and support information available below:
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
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.
Members have access to case management—a collaborative process between the Plan, the member and the provider. Our case management programs are designed to assess, plan, implement and evaluate services and resources required to meet the member’s health care needs. The process aims to efficiently produce the highest quality outcomes and manage health care costs.
The program is staffed by registered nurses to advocate for the member in the case management process. The Plan’s nurses are educated in health care management and service delivery and help our members smoothly navigate their health care by connecting them with resources and support within their respective communities. Our health plan nurses embrace cultural diversity and are well-suited to assist members of any background. We require that the Plan nurses continue to expand their expertise through professional development including certification, seminars and classes for continuing education and case management credits.
Our Utilization Management Policy
Our utilization management program helps our members get medically necessary health care services in the most cost-effective setting under their benefit package. We work with members and physicians to evaluate services for medical appropriateness, timeliness and cost.
- Our decisions are based entirely on appropriateness of care and service and the existence of coverage, using nationally recognized guidelines and resources.
- We do not pay or reward practitioners, employees or other individuals for denying coverage or care.
- Financial incentives do not encourage our staff to make denials of coverage. In fact, our utilization review staff is trained to focus on the risks of members not adequately using certain services.
- We do not encourage utilization decisions that result in underutilization.
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.
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:
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.
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.
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.
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.
Manage all your Coventry health plan needs at our secure, one-stop, multi-functional provider portal.