- Senior Whole Health – MA - https://www.seniorwholehealthma.com -

Working with us

We’re committed to offering our Senior Whole Health (HMO SNP), Senior Whole Health NHC (HMO SNP) and SCO members access to quality providers in their communities, and we want you to join us!

Checking member eligibility

Individuals are eligible for Senior Whole Health plans if they:

  • Are 65 years old or older
  • Have Medicare & MassHealth Standard (dual eligible) or have MassHealth Standard
  • Live in our service area

To check member eligibility: 

Please log onto our provider portal:

Follow these instructions to register on the provider portal.

Link to PDF on how to register for provider portal

The most efficient way to check member eligibility is through one of the following online tools:

  • NewMMIS, formerly known as REVS
    • Log in to Provider Online Service Center (POSC)*
      • Click Manage Members/Eligibility, and look up patient by SSN or name and DOB
      • In the List of Managed Care Data (for MCO) section, choose Senior Whole Health
    • Registration is free for MassHealth Providers
    • For registration and other information, visit Mass.gov/masshealth* or call
      1-800-841-2900 (this number may also be used to access the IVR system)
  • NEHEN, New England Healthcare EDI Network
    • Log in to
      • Under Payer, select Medicaid
      • In the Additional/Alternate Payer section, choose Senior Whole Health under Managed Care Coordinator
    • Available at no cost to NEHEN members
    • For information, visit NEHENNet.org* or call 781-290-1290

Advantages to using these online tools:

  • Prompt, 24/7 access
  • Unlimited number of inquiries
  • Ability to confirm single dates of service and date ranges
  • Easily print eligibility confirmation for your records

You can also call SWH Eligibility at 1-855-838-8002 for assistance.

*By clicking this link you will be leaving the Senior Whole Health website.

Member Benefit Information

We cover benefits provided by network providers without referrals.

For a complete list of member benefits, limitations and requirements, please refer to the Senior Whole Health Evidence of Coverage and Summary of Benefits

For medical services requiring prior authorization, complete the Standard Prior Authorization Request Form and fax it to our confidential Clinical Department fax line at 617-494-5554 or 508-823-6375. We will give you’re a decision within 14 calendar days unless we need additional information.

All inpatient authorization requests must include clinical information. You may call in the clinical information to 617-252-6357.

To get prior authorization for prescription drugs, you may request coverage:

More information on concurrent and retroactive authorizations is available in the Provider manual.

You may use the means above to request Formulary exceptions, including asking for a drug not listed on the formulary or to waive a restriction such as quantity limits, prior authorizations and step therapy.

Submitting appeals on behalf of your patients

Provider may file appeals and/or grievances on behalf of a Senior Whole Health member with the member’s written consent.

To file an appeal or grievance:

  • Call us at 1-88-794-7268
  • Fax your request to 1-855-838-7998
  • Write to us at:

Senior Whole Health
Attn: Member Services
1075 Main Street, Suite 400
Waltham, Massachusetts  02451

We will make our appeal decision and send to you in writing within 30 days of receipt of the request. Expedited appeals will be resolved within 72 hours.

A grievance on behalf of a SWH member must be filed within 60 days of the event. Grievances regarding quality of care (QOC) may be made up to 180 days after the even. We resolve routing complaints immediately. However, we may need to ask you to submit additional information. In that case, you will have 14 days to get us the information. QOC grievances will be investigated by the quality department. We will notify the member and/or the representative within 30 days of the grievance filing or 44 days if an extension was granted.

Submitting Claims

Senior Whole Health pays clean claims submitted for covered services provided to eligible members. In most cases, we pay clean claims within 30 days.

We recommend that you submit claims through the Electronic Data Interchange (EDI) for efficient processing and payment. We work with Change Healthcare for all EDI transations.

When submitting your 837 (I & P) files, please use our Payer ID: 83035.

Learn more about EDI

To submit paper claims, please mail to:

Senior Whole Health
P.O. BOX 956
ELK GROVE VILLAGE, IL 60009-0956

If you have question, contact Senior Whole Health Claims Operations at 1-866-233-4773.


EDI Technical Assistance: If you are currently submitting via Change Healthcare you should have a login for ON24/7 website. ON24/7 is a web-based system that allows Change Healthcare customers to submit service requests and check on the status of those requests 24 hours a day, 7 days a week. Please contact Change Healthcare directly at 1-866-506-2830 or Visit the ON24/7 website

For more information on submitting claims, refer to Chapter 5 of the
Senior Whole Health Provider Manual 

Utilization management (UM)

We use evidence-based clinical practice guidelines when making decision about members’ care.

Clinical practice guidelines address preventive, acute or chronic and behavioral health services. These guidelines are reviewed at least every two years and updated as necessary. When this happens, we notify all network practitioners.

When determining the medical appropriateness of a service, we apply these criteria while taking into account individual circumstances and the local delivery system.

Clinical and UM staff make decisions based solely on appropriateness of care and existence of coverage. We do not reward staff for issuing denials of coverage. We do not encourage under utilization by providing financial incentives to deny coverage.

View our Clinical Practice Guidelines.

Reporting Fraud, Waste and Abuse

Senior Whole Health encourages providers to report fraud or suspected fraud by calling the Molina AlertLine: Call: 1-866-606-3889 TTY: 711 (for the hearing impaired) Online: https://molinahealthcare.alertline.com.Read our Fraud, Waste and Abuse policy here 

Submitting provider rosters and other changes to provider information

How to submit provider rosters and roster updates

Please read the following rules and guidelines for submitting rosters and roster updates.

  • All provider rosters submitted for processing must include a complete listing of par providers associated with:
    • Participating group practices of 5 or more providers
    • IPAs
    • Hospitals and hospital systems
    • PHOs, IDNs and other contractual relationships that include multiple providers (practitioners and/or facilities)
  • To comply with CMS and state Medicaid regulatory requirements, providers should submit full roster updates on a quarterly basis (once every 3 months)
  • Interim roster updates/changes can be submitted on a monthly basis and must contain a minimum of 5 affiliated providers.

Updates submitted for fewer than 5 providers will not be accepted. Please see the section titled How to submit provider maintenance tasks for updates to individually contracted providers and groups of fewer than 5.

  • All provider rosters and provider roster updates must be submitted using the Excel spreadsheet template below and include all the required data elements.

Senior Whole Health Roster Template

  • Any roster, roster update or provider data maintenance request that does not contain all required data elements will be returned to the contracted provider entity (submitter) to append the missing information.
  • Completed requests should be saved using the following file naming conventions: <provider name_date>.xls

Example file names:
Group Practice: ABCPediatrics_01012020
Health System, IPA, PHO: BaptistHealthSystem_01012020

  • Email completed rosters, roster updates and provider data maintenance files/forms to swhdelegation@seniorwholehealth.com.
  • All provider rosters, roster updates and data maintenance tasks including the required data elements will be processed within 30 calendar days from the date of receipt (via email). Upon completion, an email confirmation will be sent to the address provided on the original request.

 

How to submit provider maintenance tasks

Individually contracted providers (solo practitioners/facilities) and group practices with fewer than 5 providers can update their demographic information by submitting a provider maintenance task.

  • Provider maintenance tasks can be submitted each month (as needed) by downloading and completing the following Excel spreadsheet template.

Senior Whole Health Roster Template

  • Provider data maintenance tasks that do not contain all required data elements will be returned to the contracted provider entity (submitter) to append the missing information.
  • Completed requests should be saved using the following file naming conventions.

Example file names:
Individual Provider: JohnSmith_01012020
Small Group Practice: ABCPediatrics_01012020

Please note groups must be less than 5 providers

  • Email provider data maintenance files/forms to providerrelations@seniorwholehealth.com.
  • All provider data maintenance forms will be completed within 30 calendar days from the date of receipt (via email). Upon completion, an email confirmation will be sent to the address provided on the original request.