Providers

Provider Directory and Formulary

Find a Provider 2020 SEARCH
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Find a Network Pharmacy 2020 SEARCH
Find a Network Pharmacy 2021 – SEARCH
Check the comprehensive 2020 Formulary SEARCH
Check the comprehensive 2021 Formulary – SEARCH
2021 (HMO) Comprehensive Formulary List of Drugs (Gold Formulary) – SEARCH
2021 (HMO-SNP) Comprehensive Formulary List of Drugs (Bronze Formulary) – SEARCH

Prior Authorization

• Prior Authorization List
• Prior Authorization Form
• Coverage Determination Form (OPTUM RX)

Contract Provider Appeal Rights

• Providers may appeal decision on denied claims such as denial of a service related to medical necessity and appropriateness.

Fraud and Abuse

If you suspect fraud, waste, or abuse, contact us at 1-833-610-0005

Fraud, Waste, Abuse and Compliance Training

Reliance Medicare Advantage requires annual training to detect, prevent, and correct fraud, waste and abuse. All providers and their employees, contractors, governing bodies and downstream entities who partner with Medicare Advantage and Part D prescription drug plans are required to take the training.

Records of the training, including participant names, must be retained and available for inspection upon request for 10 years after the end date of the provider’s contract with Reliance Medicare Advantage.

Providers may use the CMS training modules available on the Medicare Learning Network (MLN), or providers may use their own training programs with similar content.

To complete the training using MLN, follow these steps:

1. Select Medicare Learning Network® (MLN) Learning Management System
2. Log in or create an account
3. Complete these training modules:
   1. Medicare Parts C and D general compliance training
   2. Combating Medicare Parts C and D Fraud, Waste and Abuse
4. Save a certificate for each module

Providers who use their own training programs can incorporate the content from the Medicare Parts C and D, fraud, waste and abuse training (PDF) and the Medicare Parts C and D general compliance training (PDF) modules into their training materials. Regardless of the option you choose, certificates of completion must be kept on file for 10 years.

www.lighthouse-services.com/reliancehmo – 833-610-0005

D-SNP Provider Model of Care Training

The Centers for Medicare & Medicaid Services (CMS) requires all contracted medical providers and staff receive basic training about the Special Needs Plans (SNPs) Model of Care. This training and completion of an attestation are required for new providers and annually thereafter. The SNPs Model of Care is the plan for delivering coordinated care and care management to special needs members. This course will describe how Reliance and their contracted providers can work together to successfully deliver the SNPs Model of Care.

Download D-SNP Model of Care Training.