Physician Self-Service Center
A 100% web-based application that enables clinic staff and physicians to verify patient eligibility, claims status and referral status for the Seton employee plans (EPN and Expanded EPN); Seton Health Plan CHIP; MAP (CBRACKFQ Group); SETONCare Plus and Charity. To ensure secure, safe and confidential transactions, you must become a registered user.You will need the free Acrobat Reader, a browser plug- in to view or print some of the documents below.
Reference Center
Seton Employee Health Plan Benefit Comparison Grid 81 KB pdf
Provider Inservices
Provider In-service Plan Year 2011 472 KB pdf
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Provider Directories
For EPN and Expanded EPN (SPHN providers) please utilize the online "Provider Search" above.
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Diagnostics and Therapeutics Locations/Services/Hours
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Referral and Authorization Procedures
Referral Form EPN-EPNX-MAP-Seton Care Plus-Charity for 2012
Seton Employees, Seton Promise, SETONCare Plus, MAP, CCHC and Charity 60 KB pdf CHIP-STAR
Referral Form 2012 62 KB pdf Prior Authorization Grid
EPN-EPNX-STAR-CHIP 201252 KB xls Prior Authorization Grid
for MAP-Seton Care Plus-Charity for 201274 KB xls
Seton Employees, Seton Promise, SETONCare Plus, MAP, CCHC and Charity 60 KB pdf CHIP-STAR
Referral Form 2012 62 KB pdf Prior Authorization Grid
EPN-EPNX-STAR-CHIP 201252 KB xls Prior Authorization Grid
for MAP-Seton Care Plus-Charity for 201274 KB xls
Listing of procedures/services that require prior authorization
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Prescription Drug Benefit Guides
Listing of self administered oral and injectable prescription medications that require authorization
Seton Employee Plan: Self administered Medications Requiring Authorization 35 KB pdf Seton Employee Plan: Prescription Medication Prior Authorization Process 17 KB pdf
Authorization form for self administered oral prescription medications.
Seton Employee Plan: Oral Medication Authorization Form 22 KB pdf
Authorization form for self administered injectable medications (excludes insulin)
Seton Employee Plan: Injectable Medication Authorization Form 47 KB pdf
Listing of formulary medications
Seton Employee Plan: Formulary 76 KB pdf SETON/Care Plus: Formulary/ By Alpha Order/Drug Class 287 KB pdf
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CHIP Benefit Documents
CHIP Evidence of Coverage and Scope of Benefits 105 KB pdf CHIP Member Enrollment Issue 35 KB pdf At or Below 100% FPL 133 KB pdf 101% to 150% of FPL 135 KB pdf 151% to 185% of FPL 135 KB pdf 186% to 200% of FPL 133 KB pdf Native American 133 KB pdf
Copayment Schedule 9 KB pdf CHIP Provider Manual 448 KB pdf
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Copayment Schedule 9 KB pdf CHIP Provider Manual 448 KB pdf
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