Skip to main content

Select Health Medicare

Select Health Medicare plans for Medicare Advantage beneficiaries are available to residents in select regions in Nevada, Utah, and Colorado.

Effective January 1, 2027, the following service areas will offer Select Health Medicare plans:

A regional map illustrates the Select Health Medicare 2017 plan service area across multiple counties. Counties are shaded in purple and red to distinguish different plan offerings, while non-covered areas remain light gray. A legend in the lower left explains the color coding for Select Health Medicare plans and out-of-area regions. The map focuses on county-level boundaries and coverage distinctions rather than geographic terrain.

Networks

Effective January 1, 2027, Select Health Medicare Advantage members will access care through one of two provider networks: the Mountain West Network or the Desert Network. 

Mountain West Network

The Mountain West Network is for Utah and Colorado Medicare Advantage members and includes all Medicare providers. Claims and prior authorizations are handled through Select Health.

Image of a Select Health Medicare Mountain West Network member identification card shown front and back. The front side displays member name, ID number, contact phone numbers, website, mailing address, and plan year 2027 details. The back side lists Select Health Medicare Essential (HMO) 001 in-network medical benefits, pharmacy benefits, copay amounts, and tier information. A QR code and barcodes appear alongside Rx BIN 016484, Rx PCN 7463, and GRP SHP 000. The word SAMPLE is diagonally overlaid across both sides of the card.

Desert Network

The Desert Network is for Nevada Medicare Advantage members only. Claims and prior authorizations are handled through Intermountain Health Nevada. Participating providers include:

  • Nevada providers: Providers practicing in Nevada who participate in Select Health Medicare plans and are approved to provide care within the applicable Select Health network.

  • Southern Utah providers: Providers practicing in Iron, Garfield, or Washington counties. If a practice operates statewide, only its locations within these designated counties will be in-network.  

  • Intermountain providers: Any Utah-based Intermountain Health location.

  • Additional Utah provider groups: A few select statewide Utah-based ancillary and affiliate providers.

Digital image of a Select Health Medicare insurance identification card shown front and back. The front side displays the plan name MEDICARE DESERT NETWORK, a placeholder Member Name, and ID number 800000000. It lists contact numbers for member services, doctor search, provider questions, and prior authorization, along with a MedicareRx mark and plan year 2027. The back side details Select Health Medicare Essential (HMO) 012 benefits, including copays for primary care, specialist visits, urgent care, virtual visits, and emergency room, plus pharmacy tiers and a QR code. The card also shows addresses in Eagan, MN 55121 and Murray, UT 84123, and includes sample indicators.

Standards and regulations

Physicians and other healthcare professionals who participate on Select Health Medicare agree to comply with the standards and regulations set forth by the Centers for Medicare & Medicaid Services (CMS). The standards below address preauthorization, balance billing, requests needing documentation, general compliance, fraud/waste/abuse regulations and guidance, Medicare Advantage marketing by providers, and Medicare Star ratings.

Learn about and access Select Health's online preauthorization tool, CareAffiliate.

Access preauthorization forms.

Providers participating on Select Health Medicare have agreed to accept our established fee schedule rates for services rendered to Medicare members. CMS and Select Health do not allow providers to "balance bill" members for covered services beyond these rates. Providers not participating on the Select Health Medicare network who render services to Medicare beneficiaries agree to accept the Medicare allowed amounts and also to not balance bill beneficiaries.

Please note:

  • Members cannot be held financially responsible for more than the Select Health Medicare cost-sharing amount for services rendered by a participating provider.
  • Some services (e.g., cosmetic procedures) deemed medically unnecessary may not be covered. In such cases, the member must be informed before the service is rendered that he or she is responsible to pay in full.
  • Member Services whether a service is covered and if a preservice denial or service is documented as never covered in the Evidence of Coverage (EOC). Provider Services can be reached at 800-222-6358.

Preservice Denials: Getting Paid for Non-Covered Services

Contrary to original Medicare, CMS does not permit the use of Advance Beneficiary Notices (ABNs), or waiver of liability, for members of any Medicare Advantage plan, such as Select Health Medicare.

As an alternative to issuing an ABN, you can use a “preservice denial” to bill a member for non-covered services instead of an ABN or similar form, which are subject to CMS audit and corrective action. A preservice denial ensures all parties are informed of the noncovered service, makes the member aware of their appeal rights, and supports accurate reporting.

To obtain a preservice denial, be sure to use:

  • The usual preauthorization process: Call provider services for details - 800-222-6358
  • The preservice denial form and not the standard prior authorization form.
  • A – GA modifier when billing for noncovered services that have received a preservice denial. If the preservice denial is not received or the claim is not billed with a – GA modifier, the provider will be financially responsible for the cost of any non-covered services rendered.

Providers will receive a copy of the denial notice when the preservice is approved or denied.

For more information, access the following CMS resources:

Some services require additional information from the provider before we can review and process the claim appropriately. Our documentation process for a Select Health Medicare request requires that we may:

  • “Pend” a request received without the necessary documentation for 15 days and request the needed information from the provider.
  • Review requests based on available information at the end of the stipulated time if the requested documentation has not been received. This may result in a denial.

To expedite original request processing, please include missing documentation with the requesting letter instead of with a new request. This will avoid having your request mistakenly entered as a corrected or duplicate request.

Any provider and organization that contracts with Select Health to participate in the Select Health Medicare provider or pharmacy network is considered a “first-tier entity, downstream, and related entity” (FDR) under the Centers for Medicare & Medicaid Services (CMS) guidelines.

View FDR definitions.

Select Health providers, FDRs, employees who perform services related to the Select Health Medicare product or enrollees are required to:

  1. Implement a compliance program that includes:
    • Adoption of policies and procedures to prevent FWA, promote ethical conduct, and ensure compliance with Federal and State laws, regulations, and other requirements relating to the Medicare program
    • A code of conduct.
    • Exclusion screening (Department of Health and Human Services Office of Inspector General [OIG] List of Excluded Entities and Individuals [LEIE] and the General Services Administration System for Award Management [SAM]). See details below.
    • Program for maintaining reporting and communication channels.
    • Downstream entities audit and monitoring for compliance with CMS requirements.
    • Ten-year records retention (Examples of proof of training may include copies of sign-in sheets, employee attestations, and electronic certifications from the employees taking and completing the training.) Select Health or CMS may request this documentation as part of a compliance audit.
  2. Annually train employees and contractors supporting Select Health Medicare plans on compliance policies and FWA. Key parameters of recommended training include:
    • FDR providers should conduct Compliance/FWA training within 90 days of contract/hire; and annually thereafter. If the FDR does not have their own training, they may request a copy from Select Health. See Combating Medicare Parts C & D Fraud, Waste, & Abuse (cms.gov) for more detail.
    • The content of the training is at the discretion of your FDR; however, it should incorporate the elements found in No. 1 above.
  3. Attest to compliance with Select Health requirements. Complete the online attestation; records of this training may be reviewed by CMS during compliance audit proceedings.

Code of Conduct

Your organization's code of conduct must be distributed annually. If your organization does not have its own code of conduct, share the Intermountain Health/Select Health Code of Conduct with your employees.

Reporting FWA: Anonymous reporting and interpretation services are available. To report potential fraud, waste, and abuse, call the Compliance Hotline at 800-442-4845.

To speak to someone or ask questions about plan benefits or coverage, call Member Services at 800-538-5038 (TTY: 711). Learn more by accessing the CMS Fraud Prevention Toolkit by calling 800-Medicare (800-633-4227). TTY/TDD users should call 877-486-2048. A Medicare Customer Service representative can answer your questions 24 hours a day, 7 days a week. For additional information, please see the Medicare Compliance Program website. 

Regulations governing the MA program are found at 42 CFR Part 422 and Part 423. Review the Code of Federal Regulations (CFR).

CMS provides additional guidance through the CMS Internet-Only Manuals as follows:

  • For MA plans in the Medicare Managed Care Manual: (Publication #100-16)
  • For Prescription Drug Plans in the Medicare Prescription Drug Benefit Manual (Publication #100-18)

CMS requires MA plans and their FDRs to check the OIG List of Excluded Individuals and Entities (LEIE) and GSA System for Award Management (SAM) lists each month for those who have been excluded or precluded from participation in federal programs.

Note that: In addition, the CMS Preclusion List includes providers (individuals and entities) who are currently precluded from receiving payment from the Medicare plan.

Download guidance: Skilled Nursing Facilities (SNFs) & Home Health Providers: Notices of Medicare Non-Coverage Required for Select Health Medicare

 

Select Health strives to provide the same superior service to patients that they provide to providers. If providers have a patient who has questions or concerns about Medicare Advantage plans, or just general questions, have them call Select Health at 800-538-5038.

For more information about CMS marketing guidelines please contact CMS directly. 

Each year, CMS measures the quality and value of certified health plans like Select Health Medicare. Medicare-certified health plans, both Part C (Medicare Advantage) and Part D (Prescription Drug), are rated on a star scale. The scale ranges from one to five stars, with five stars representing the highest quality. Medicare Advantage plans, like Select Health Medicare, with prescription drug coverage contracts are rated on up to 42 unique quality and performance measures. Some examples of the categories include:

  • Staying healthy: How well the plan covers and helps its members receive recommended health screenings, vaccinations, and other check-ups, including programs that encourage wellness and help members stay healthy
  • Managing chronic conditions: How often members with different chronic conditions receive certain tests and treatments that help them manage their condition
  • Member experience: How members rate their satisfaction with plan benefits (e.g., coverage, copays, and customer service)
  • Member complaints and plan performance: How often CMS and Medicare members find problems with the plan, including how well the plan handles member appeals and new enrollment requests

CMS Star ratings can help members compare different plans’ quality and performance when they evaluate their current plans each year during the annual election period (October 15 to December 7). This is the best time for members to make sure their plan will meet their healthcare needs for the coming year and make any necessary adjustments.

Ultimately, star ratings result in added benefits like exercise plans, vision, dental, lower premiums, and lower copayments for the members. Any revenue bonus the plan receives for these ratings must be reinvested back to the member.

To determine overall performance ratings, Medicare uses:

  • Information from provider, plan, and member surveys, such as the Health Outcomes Survey discussed below
  • Reviews of claims and other information that plans submit to Medicare
  • Results from Medicare’s regular monitoring and auditing activities

The Health Outcomes Survey (HOS) is administered annually by a CMS-approved vendor and is mandatory for MA plans. Each year, a random sample is drawn from the MA plan and selected to participate. The HOS queries Medicare Advantage plan members about their health status and the discussions they have with their providers that occur during a clinic visit or an annual wellness visit. CMS uses the results of this survey to monitor health plan performance and drive quality improvement, and results impact annual CMS Star ratings.

Learn more about the Health Outcomes Survey.