Contact Us

Our hours of operation are Monday-Friday 8:00am-8:00pm local time.

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Provider Portal

Web Address: https://planprovportal.align-360.com/EZ-NET60PHP
Mailing Address: PruittHealth Premier
PO Box 2190
Glen Allen, VA 23058-2190

Claims Helpdesk

Phone:
1-855-855-0668 (TTY 711), option 4
1-855-855-0759 (TTY 711), option 4
1-855-855-0759 (TTY 711), option 4
Mailing Address: PruittHealth Premier
Attn: Claims Dept
PO Box 2190
Glen Allen, VA 23058-5850

Utilization Management

Phone:
1-855-855-0668 (TTY 711), option 3
1-855-855-0759 (TTY 711), option 3
1-855-855-0759 (TTY 711), option 3
Fax: 1-833-610-2399
Call to start an authorization, check the status of an authorization, provide clinical information over the phone, or get referrals for specialists

Navitus Pharmacy Helpdesk

Web Address: www.navitus.com
Phone: 1-866-270-3877 (TTY 711)

EZ-Net Support/Provider Services

Phone:
1-855-855-0668 (TTY 711), option 4
1-855-855-0759 (TTY 711), option 4
1-855-855-0759 (TTY 711), option 4
Email: [email protected]

Network Support

Phone:
1-855-855-0668 (TTY 711), option 4
1-855-855-0759 (TTY 711), option 4
1-855-855-0759 (TTY 711), option 4
Email: [email protected]

SSI Claimsnet Customer Support

Phone: 1-800-356-0092
Email: [email protected]

Enrollment Services

Phone:
1-855-855-0668 (TTY 711), option 1
1-855-855-0759 (TTY 711), option 1
1-855-855-0759 (TTY 711), option 1
Fax: 1-833-610-2390
Email: [email protected]
Mailing Address: PruittHealth Premier
Po Box 2190
Glen Allen, VA 23058-2190

Compliance Hotline

Phone: 1-844-317-9059, TTY 711 (toll free)
Fax: 1-833-572-2367
Email: [email protected]
Mailing Address: PruittHealth Premier
PO Box 2190
Glen Allen, VA 23058-2190

Compliance Officer

Name: Rich Gardner
Email: [email protected]
Mailing Address: PruittHealth Plan
Attn: Rich Gardner
1626 Jeurgens Court
Norcross, GA 30093

Appeals and Grievances

Phone:
1-855-855-0668 (TTY 711), option 6
1-855-855-0759 (TTY 711), option 6
1-855-855-0759 (TTY 711), option 6
Fax: 1-833-610-2380
Call to submit or check on an authorization request, or ask about authorization denials.

Medicare

URL: www.medicare.gov
Phone: 1-800-MEDICARE (1-800-633-4277)

Privacy or HIPAA

Phone:
1-855-855-0668 (TTY 711)
1-855-855-0759 (TTY 711)
1-855-855-0759 (TTY 711)
Email: [email protected]
Mailing Address: PruittHealth Premier
Attn: Compliance Department
PO Box 2190
Glen Allen, VA 23058-2190

Speak With an Agent

Complete the boxes below to have a plan representative contact you.

How to fill out the enrollment form

Who can use this form?

People with Medicare who want to join a Medicare Advantage Plan

To join a plan, you must:

Be a United States citizen or be lawfully present in the U.S.
Live in the plan’s service area

Important: To join a Medicare Advantage Plan, you must also have both:

Medicare Part A (Hospital Insurance)
Medicare Part B (Medical Insurance)

When do I use this form?

You can join plan:

Between October 15–December 7 each year (for coverage starting January 1)
Within 3 months of first getting Medicare
In certain situations where you’re allowed to join or switch plans

Visit Medicare.gov to learn more about when you can sign up for a plan.

What do I need to complete this form?

Your Medicare Number (the number on your red, white, and blue Medicare card)
Your permanent address and phone number

Note: You must complete all items in Section 1. The items in Section 2 are optional — you can’t be denied coverage because you don’t fill them out.

Reminders:

If you want to join a plan during fall open enrollment (October 15–December 7), the plan must get your completed form by December 7.
Your plan will send you a bill for the plan’s premium. You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit.

What happens next?

Once they process your request to join, they’ll contact you

How do I get help with this form?

Call PruittHealth Premier at 1-855-855-0668 (TTY 711) 1-855-855-0759 (TTY 711) 1-855-855-0759 (TTY 711).

Or, call Medicare at 1-800-MEDICARE (1-800-633- 4227). TTY users can call 1-877-486-2048.

En español: Llame a PruittHealth Premier al 1-855-855-0668 (TTY 711) 1-855-855-0759 (TTY 711) 1-855-855-0759 (TTY 711) o a Medicare gratis al 1-800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time required to complete this information is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data need- ed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or sugges- tions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

IMPORTANT Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept, reviewed, or forwarded to the plan. See “What happens next?” on this page to send your completed form to the plan.