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

More documents

Recommendations

Info

PCP AVAILABILITY AND ACCESSIBILITYEach participating physician shall maintain sufficient facilities and personnel to provide coveredphysician services and shall ensure that such services are available as needed twenty-four (24)hours a day, 365 days a year. All participating providers shall offer hours of operation that are noless than the hours of operation offered to commercial and fee-for-service members. Peach Stateencourages PCPs to offer services after hours and on the weekends.Peach State will monitor physicians’ offices through scheduled and un-scheduled visits throughour Provider Relations staff.PCP COVERAGEThe participating physician shall arrange for coverage with a physician who must have executeda contractual agreement with Peach State. If the participating physician is capitated forprofessional services, compensation for the covering physician is considered to be included in thecapitation payment. If the participating physician is on a fee-for-service agreement with PeachState, the covering physician is compensated in accordance with the fee schedule in his/heragreement.APPOINTMENT AVAILABILITYThe following schedule should be followed regarding appointment availability:• PCP (routine visits) not to exceed fourteen (14) calendar days• PCP (adult sick visit) not to exceed twenty-four (24) hours• PCP (pediatric sick visit) not to exceed twenty-four (24) hours• Specialist visits not to exceed (30) calendar days• Urgent Care Provider not to exceed twenty-four (24) hours• Emergency care services rendered immediately and available twenty-four (24) hours aday, seven (7) days a week and without prior authorization• Dental Provider (routine visits) should not exceed 21 calendar days.• Dental Provider (urgent care) not to exceed 48 hours• Non-emergency hospital stays should be provided within thirty (30) calendar days• Behavioral Health visits should be provided immediately for emergency services, withintwenty-four (24) hours of the request for urgent care, and within fourteen (14) calendardays of the request for routine care• Mental Health Provider visits should be provided within fourteen (14) calendar days.• OB (initial pregnancy visit) appointment should be provided within fourteen (14) days ofthe request.The participating physician shall provide adequate capacity for initial visits for pregnant womenwithin fourteen (14) calendar days and visits for Health Check eligible children within ninety (90)calendar days of the members’ enrollment in Peach State.Peach State will monitor appointment and after-hours availability on an on-going basis through itsQuality Improvement Program.Provider Services1-866-874-063302/22/201117
PROVIDER VISIT - WAITING TIMES• Scheduled Appointments: Wait times shall not exceed 60 minutes. After 30 minutes,patient must be given an update on the wait time with an option of waiting or reschedulingthe appointment.• Work-In or Walk-In Appointments: Wait times shall not exceed 90 minutes. After 45minutes, patient must be given an update on the wait time with an option of waiting orrescheduling the appointment.PROVIDER RESPONSE TIME FOR AFTER HOUR CALLS• Urgent Calls: Shall not exceed 20 minutes.• Other Calls: Shall not exceed one hour.TELEPHONE ARRANGEMENTSProviders are required to develop and use telephone protocol for all of the following situations:• Answering the members telephone inquiries on a timely basis• Prioritizing appointments• Scheduling a series of appointments and follow-up appointments as needed by amember• Identifying and rescheduling broken and no-show appointments• Identifying special member needs while scheduling an appointment (e.g., wheelchair andinterpretive linguistic needs, or for non-compliant individuals or those people withcognitive impairments)• Response time for telephone call-back waiting times:o after hours telephone care for non-emergent, symptomatic issues within thirty(30) to forty-five (45) minuteso same day for non-symptomatic concernso crisis situations within fifteen (15) minutes• Scheduling continuous availability and accessibility of professional, allied, and supportivepersonnel to provide covered services within normal working hours; Protocols shall be inplace to provide coverage in the event of a provider’s absence• After-hour calls should be documented in a written format in either an after-hour call logor some other method, and then transferred to the member’s medical recordNote: If after-hour urgent care or emergent care is needed, the PCP or his/her designee shouldcontact the urgent care center or emergency department in order to notify the facility. Notificationis not required prior to member receiving urgent or emergent care.Peach State will monitor appointment and after-hours availability on an on-going basis through itsQuality Improvement Program.Provider Services1-866-874-063302/22/201118
Page 3 and 4: CHRONIC AND COMPLEX CONDITIONS.....
Page 5 and 6: Description of GeorgiaFamiliesGeorg
Page 7 and 8: have any questions about Peach Stat
Page 9 and 10: Provider ResponsibilitiesPRIMARY CA
Page 11 and 12: Planning for Healthy BabiesWaiver P
Page 13 and 14: Tubal Ligation(Sterilization)• St
Page 15 and 16: Additional InformationProviders see
Page 17: 83655 Lead Effective: 11/2010 Submi
Page 21 and 22: Medical Management/Case Management1
Page 23 and 24: • Notification of all newborn del
Page 25 and 26: PROVIDER ASSISTANCE WITH PUBLIC HEA
Page 27 and 28: competency begins with self-awarene
Page 29 and 30: • Unresolved problems from previo
Page 31 and 32: • Member’s name, ID number• P
Page 33 and 34: Peach State may shorten the period
Page 35 and 36: Provider Services1-866-874-063302/2
Page 37 and 38: Notification is required to track i
Page 39 and 40: Members, a member’s representativ
Page 41 and 42: • HIV / AIDS• Children with Spe
Page 43 and 44: the member. The Peach State Medical
Page 45 and 46: Provider Services1-866-874-063302/2
Page 47 and 48: • A plan physician with privilege
Page 49 and 50: • In order to reimburse providers
Page 51 and 52: • Influence a member to choose on
Page 53 and 54: Covered Services andBenefits for Pe
Page 55 and 56: If you have any questions about the
Page 57 and 58: HEALTH CHECKGEORGIA HEALTH CHECK SE
Page 59 and 60: Health Check (EPSDT) Billing Requir
Page 61 and 62: Vaccine Codes must be billed with m
Page 63 and 64: 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 and 116:
• To keep all your appointments.
Page 117 and 118:
• An Administrative Law Hearing d
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
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?