Fidelis SecureCare of North Carolina Provider Manual

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Use of Evidence Based Clinical Practice Guidelines (CPGs) • Fidelis encourages the use of CPGs for prevention, diagnosis and management of medical and behavioral health conditions. • These CPGs correspond to nationally recognized standards of care and clinical treatments for specific conditions. • Goal is to support quality of care and consistency in healthcare delivery to FSC members Fidelis Clinical Practice Guidelines Adult Preventive Care • Immunizations Centers for Disease Control and Prevention Adult Immunization Schedule (over 18 years old) http://www.cdc.gov/vaccines/schedules/index.html • American Cancer Society Guidelines for the Early Detection of Cancer o Breast cancer o Colorectal cancer and polyps o Cervical cancer o Endometrial (uterine) cancer o Prostate cancer http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/america n-cancer-society-guidelines-for-the-early-detection-of-cancer Asthma • National Asthma Education and Prevention Program Expert Panel Report 3 – PDF File http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf Behavioral Health • Depression American Psychiatric Association Practice Guideline for the Treatment of Patients With Major Depressive Disorder - Third Edition http://psychiatryonline.org/guidelines.aspx • Substance Abuse U.S. Department of Health & Human Services – Agency for Healthcare Research and Quality Screening, diagnosis and referral for substance use disorders http://www.guideline.gov/content.aspx?id=34790
• Psychotropic Medication Management U.S. Department of Health & Human Services – Agency for Healthcare Research and Quality The Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations http://www.ahrq.gov/clinic/schzrec1.htm Practice guideline for the treatment of patients with schizophrenia http://www.guideline.gov/content.aspx?id=5217&search=medi cation+management+for+psychiatric+patients Chronic Kidney Disease (CKD) • Guidelines and Commentaries National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI) http://www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm Chronic Obstructive Pulmonary Disease (COPD) • Global Initiative For Chronic Obstructive Lung Disease http://www.goldcopd.org Congestive Heart Failure (CHF) American College of Cardiology Foundation • ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult—Summary Articlehttp://content.onlinejacc.org/article.aspx?articleid=1136917 J Am Coll Cardiol. 2005;46(6):1116-1143. doi:10.1016/j.jacc.2005.08.023 American Heart Association • Task Force on Practice Guidelines http://circ.ahajournals. org/content/119/14/197 7.full.pd
Page 1 and 2: Provider Manual North Carolina
Page 3 and 4: Utilization Management Affirmative
Page 5 and 6: Fraud, Waste and Abuse Provider and
Page 7 and 8: Regulations and Responsibilities Co
Page 9 and 10: • Contracted providers agree to r
Page 11 and 12: Physician Responsibilities Primary
Page 13 and 14: Access to Care Fidelis has adopted
Page 15: The Care Management team is compris
Page 19 and 20: Credentialing Credentialing Program
Page 21 and 22: SecureCare members only as a result
Page 23 and 24: • Have no significant utilization
Page 25 and 26: Medical/treatment record keeping re
Page 27 and 28: Eligibility You may verify the elig
Page 29 and 30: You can receive your username and p
Page 31 and 32: Quality Program Purpose The purpose
Page 33 and 34: Referral and Prior Authorization Pr
Page 35 and 36: Referrals to Non-Participating Prov
Page 37 and 38: Criteria for Authorizing Part A Ski
Page 39 and 40: Fidelis SecureCare Criteria for Aut
Page 41 and 42: OUTPATIENT CARE COORDINATION PHONE:
Page 43 and 44: Remittance Advice (RA) Payments rec
Page 45 and 46: Claims Look-Up Once logged in, you
Page 47 and 48: Claim Disputes and Appeals Appealin
Page 49 and 50: Fidelis will reimburse the facility

Fidelis SecureCare of North Carolina Provider Manual

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