Peach State Provider Office Manual - Peach State Health Plan ...

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EXPEDITED ADMINISTRATIVE REVIEWIf a decision on an Administrative Review is required immediately due to the member’s healthneeds, an expedited Administrative Review may be requested. Peach State’s decision will beprovided within 72 hours of Peach State’s receipt of the request for the review, subject to anauthorized extension of up to 14 days.ASSISTANCE AND CONTACTING PEACH STATEPeach State’s Appeals and Grievance Coordinator is available to assist members who need helpin filing a grievance or request for Administrative Review or in completing any element in thegrievance or Administrative Review process. Members may seek assistance or initiate agrievance or request for Administrative Review by calling 1-800-704-1484 (or TDD/TTY 1-800-659-7487).MEMBERS RIGHT TO AN ADMINISTRATIVE LAW HEARINGThe State will maintain an independent Administrative Law Hearing process as defined in theGeorgia Administrative Procedure Act (0.C.G.A Title 50, Chapter 13) and as required by federallaw, 42 CFR 431.200 et seq. The Administrative Law Hearing process shall provide MedicaidMembers an opportunity for a hearing before an Administrative Law Judge.A member, member’s authorized representative, or legal representative of a deceased member’sestate, upon receipt of an adverse determination regarding an administrative review, has the rightto request an Administrative Law Hearing. The Peach State Grievance and Administrative Reviewprocesses must be exhausted prior to requesting an Administrative Law Hearing. The requestmust be in writing and received by the Plan within 30 calendar days of Peach State mailing theNotice of Adverse Action.The parties to the Administrative Law Hearing shall include Peach State, the member ormember’s authorized representative, or legal representative of a deceased member’s estate. Aprovider cannot request an Administrative Law Hearing on behalf of a member. The request forthe Administrative Law Hearing should be mailed to the following address:Department of Community HealthLegal Services SectionDivision of Medical AssistanceTwo Peachtree Street, NW, 40 th FloorAtlanta, GA 30303-3159Information regarding the date, time, and place of the hearing is sent by the Office of StateAdministrative Hearings. An Administrative Law Judge will preside over the hearing. Themember has the right to present evidence, obtain representation for him or herself during thehearing, and have access to the case files.During the Administrative Law Hearing process, the member may request a continuation ofbenefits. The request must be in writing and received by the Plan within 10 calendar days ofreceipt of the notice advising that Peach State will not cover or pay for a service. Peach Statemust continue coverage until:• Ten calendar days have elapsed from the date the Plan’s initial adverse decisionwas mailed to the member, unless within the 10 calendar day timeframe themember submits a request for an Administrative Law Hearing with Continuationof Benefits until a decision is rendered by the Administrative Law Judge.• Benefit limitations are met or the authorization expires.• The Administrative Law Hearing request is withdrawn by the member.Provider Services1-866-874-063302/22/2011115
• An Administrative Law Hearing decision is rendered unfavorable to the member.If the decision rendered is unfavorable for the member, he or she may be responsible for the costof any continued benefits. If the decision is favorable for the member, Peach State will authorizeand cover the previously denied service.Medicaid /Peach Care for Kids members may obtain assistance with or initiate a grievance,Administrative Review, Administrative Law Hearing or State Formal Grievance by contacting thePeach State Appeals and Grievance Coordinator at 1-8010-704-1484 (or TDD/TTY 1-800-659-7487).Peach Care for Kids (PCK) members do not have access to the Medicaid Administrative LawHearing process. If a Peach Care for Kids member or parent of a member is dissatisfied with aNotice of Adverse Action issued through a Peach State Administrative Review, the member orparent of the member may submit a written request for a review of the decision by the StateManagement Review Committee. The request should be mailed to:Department of Community HealthPeachCare for Kids2 Peachtree Street, NWAtlanta, GA 30303-3159The member or parent of the member has the opportunity to represent themselves or designate arepresentative in the process at the Formal Grievance level. The member or parent of themember has the right to review the files related to the case and fully participate in the reviewprocess. The State Formal Grievance Committee will inform the member or parent of the memberof the appeal process timeframes upon receipt of the request for a Formal Grievance Appeal.The State Formal Appeals Committee will review the Plan’s decision. No further recourse will beavailable to the member or parents of the member after the State Formal Appeals Committeereviews and renders a decision.SPECIAL SERVICES TO ASSIST WITH MEMBERSPeach State has designed its programs and trained its staff to ensure that each member's culturalneeds are considered in carrying out Peach State operations. Providers should remain cognizantof the diverse Peach State population. Members’ needs may vary depending on their gender,ethnicity, age, beliefs, etc. We ask that you recognize these needs in serving your members.Peach State is always available to assist your office in providing the best care possible to themembers.There are several services that are also available to the members to assist with their everydayneeds. Please see the description below.TRANSPORTATION SERVICESTo arrange transportation for a Peach Care for Kids member that may reside in the Atlanta,Central, and Southwest region, please call Southeastrans at 1-800-657-9965. For non-emergenttransportation for Medicaid members, please contact Southeastrans at 1-866-991-6701 (Central)and 404-209-4000 (Atlanta). For Medicaid members in the Southwest region, please contactProvider Services1-866-874-063302/22/2011116
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CHRONIC AND COMPLEX CONDITIONS.....
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Description of GeorgiaFamiliesGeorg
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have any questions about Peach Stat
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Provider ResponsibilitiesPRIMARY CA
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Planning for Healthy BabiesWaiver P
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Tubal Ligation(Sterilization)• St
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Additional InformationProviders see
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83655 Lead Effective: 11/2010 Submi
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PROVIDER VISIT - WAITING TIMES• S
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Medical Management/Case Management1
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• Notification of all newborn del
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PROVIDER ASSISTANCE WITH PUBLIC HEA
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competency begins with self-awarene
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• Unresolved problems from previo
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• Member’s name, ID number• P
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Peach State may shorten the period
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Provider Services1-866-874-063302/2
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Notification is required to track i
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Members, a member’s representativ
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• HIV / AIDS• Children with Spe
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the member. The Peach State Medical
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Provider Services1-866-874-063302/2
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• A plan physician with privilege
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• In order to reimburse providers
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• Influence a member to choose on
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Covered Services andBenefits for Pe
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If you have any questions about the
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HEALTH CHECKGEORGIA HEALTH CHECK SE
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Health Check (EPSDT) Billing Requir
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Vaccine Codes must be billed with m
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Interperiodic Vision Only and Heari
Page 65 and 66: BLOOD LEAD SCREENINGPhysicians are
Page 67 and 68: General BillingInformation and Guid
Page 69 and 70: Peach State dental claims should be
Page 71 and 72: IMAGING REQUIREMENTSPeach State use
Page 73 and 74: PROCEDURES FOR FILING A CLAIM/ENCOU
Page 75 and 76: medical necessity. Peach State may
Page 77 and 78: Example: CPT 42820 submitted for a
Page 79 and 80: Procedure 99213 is submitted within
Page 81 and 82: Example: CPT 69436 billed with a 50
Page 83 and 84: BILLING CODESIt is important that p
Page 85 and 86: -Charge information and units• Se
Page 87 and 88: UB 04 CLAIM INSTRUCTIONSPeach State
Page 89 and 90: EMERGENCY DEPARTMENT HOSPITAL CLAIM
Page 91 and 92: Peach State Health PlanATTN: Peach
Page 93 and 94: Inquiry, Claims Adjustmentsand Prov
Page 95 and 96: selected, unless the plan and the p
Page 97 and 98: As accountable and fiscally respons
Page 99 and 100: CredentialingCREDENTIALING REQUIREM
Page 101 and 102: CREDENTIALING OF HEALTH DELIVERY OR
Page 103 and 104: Quality ImprovementTHE PEACH STATE
Page 105 and 106: PROVIDER REVIEWThe Peach State Qual
Page 107 and 108: AUTHORITY AND RESPONSIBILITYThe Pea
Page 109 and 110: Provider Services1-866-874-063302/2
Page 111 and 112: Member ServicesPeach State is commi
Page 113 and 114: • Income• Health Status• Arre
Page 115: • To keep all your appointments.
Page 119 and 120: The staff often answers questions a
Page 121 and 122: PharmacyThe Peach State preferred d
Page 123 and 124: • Experimental drugs• Nutrition
Page 125 and 126: The member or provider, acting with
Page 127 and 128: Pharmacy ProgramPeach State Health
Page 129 and 130: Gender LimitsSome medications on th
Page 131 and 132: Cyclosporine, Digoxin, Disopyramide
Page 133 and 134: SPECIALTY MEDICATIONPRIOR AUTHORIZA
Page 135 and 136: Common Brand Name(s) Product Descri
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Common Brand Name(s) Product Descri
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