Provider Resources

Our mission is to take the administrative burden off of your plate, so you can spend more time focusing on what’s important, your patients.

You will be able to find valuable resources here or on your provider portal.

Access Your Provider Portal
provider

Provider Manual

Our online Provider Manual hosts the most up-to-date information on eternalHealth’s
products, programs, policies, and procedures.

Jump to what you are looking for:

Quick Reference Guide

Quick links, phone numbers,
and information you need.

Member Eligibility & Covered Benefits

Identification & eligibility of
members, service areas,

referrals, covered benefits,

coordination of benefits, and

subrogation.

Provider Responsibilities

Standards of participation, standards, member referrals, access to medical records, non-adherent members, provider collection data, compliance.

Claims & Billing

Claim submission information and program integrity.

Payment Disputes

Payment dispute information.

Fraud, Waste, & Abuse

State and federal laws, and
eternalHealth policies and

procedures.

Provider Termination

Circumstance for termination,
non-renewal of contract, and

continuity of care

Provider Credentialing &
Rights

Provider rights and tools.

View Resources >>

Provider and Pharmacy Directory

Online look-up tools

Find a provider or specialist and look up a pharmacy closest to you!

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Available for download

The following documents may not contain the most up to date information. Please utilize the on-line look-up tools to search our directories in real time.

Other Resources

Prior-Authorization Form

File a Request on Behalf of Your Patient.

Referral Form

If your patient needs to see a specialist, fill out this form!

Request for Medicare Prescription Drug Coverage Determination

This form will help your patient determine their coverage of a prescription drug.

Request For Redetermination Of Medicare Prescription Drug Denial

Your patient may appeal a coverage determination about a prescription drug with this form.

Request for Redetermination of Medical Services and Products

Your patient may appeal a coverage determination about medical services or products with this form.

Medicare Advantage Prior Authorization List

This is a list of products and services that require prior authorization before they are provided/administered.

Medicare Advantage Part B Prior Authorization List

This is a list of medications that require prior authorization before they are provided/administered.

Provider Portal Enrollment

If you are looking to get access to the provider portal, please fill out this form and your credentials will be emailed to you.

Provider Portal Fact Sheet

Please use this as a reference, as it shows you the functionality available on the provider portal.

Provider Quick References

This document will give you a high-level summary of the eternalHealth Provider Manual!

Can’t Find What You Are Looking For?

Our team is available and happy to help.

Provider forms
Page Last Updated On: December 5, 2022

The Inflation Reduction Act

There are many implications from the Inflation Reduction Act (IRA) of 2022 which impacts Medicare and are aimed at improving access to affordable treatments.

The 2 important take-aways effective January 1, 2023 are:

  • The cost of a month’s supply of insulin is capped at $35 for all covered insulins and Part D deductibles won’t apply to covered insulin products.
  • Adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), including the shingles vaccine, will be available to your Medicare patients at no cost.

For a list of covered insulin and Part D vaccines please refer to the eternalHealth 2023 formulary available at our Prescription Drugs & Pharmacy Information page.

More information about IRA Medicare impacts is available at the Centers for Medicare & Medicaid Services (CMS)’s Inflation Reduction Act Factsheet

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Tom Cunniffe

Director of Operations 

Tom Cunniffe comes to eternalHealth with over 20 years of healthcare operations’ experience, having held leadership positions in Call Center, Enrollment, Credentialing, UAT and Reimbursement teams. Tom has worked with Medicaid, Commercial and Medicare lines of business and has consistently built teams who are metrics driven with proven successful outcomes. Making sure our business strives for an efficient, best-in-class customer experience is at the center of Tom’s philosophy.

Tom has a bachelor’s degree from Fordham University and a master’s in business administration from University of Massachusetts at Amherst.

Tom Lawless

Chief Financial Officer

Tom Lawless has spent the past 20+ years building, sustaining, and growing new healthcare-related programs that balance fiscal responsibility & prudence with creativity & innovation, focusing on models of care that are novel, person-centered, and improve the social welfare of those who are served. He is very excited to continue doing so in his role as the Chief Financial Officer of eternalHealth.

Tom comes to eternalHealth from a not-for-profit, member-centric, health insurance cooperative. He helped the company continuously strive toward its dual goals of thriving financially, while keeping members at the very epicenter of its mission and service model. While there, Tom also spearheaded the creation of a brand new private, charitable foundation, which will be meaningfully giving back to those in need in the surrounding communities for years to come. Previously, Tom worked in the finance department of a successful hospice that provided high-quality care to persons experiencing their unique and poignant end-of-life journeys, assuring that the appropriate financing was always available. Tom’s career began as a civil servant in the Wisconsin Medicaid program, where he helped to create a program that expanded the institutional entitlement to care into home and community-based settings. Starting with only a blueprint in hand, the program now serves more than 57,000 frail elders and disabled adults and is considered a national model. Growing into a senior leadership role, Tom was a key architect of an innovative financing model, through which the public and private sectors successfully collaborated to better the lives of persons in great need.

Tom holds undergraduate and graduate degrees from the University of Chicago, with additional graduate work in economics completed at the University Wisconsin-Madison.

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