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

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Medical RecordsPeach State providers must keep accurate and complete medical records. Such records willenable providers to render the highest quality healthcare service to members. They will alsoenable Peach State to review the quality and appropriateness of the services rendered. Toensure the member’s privacy, medical records should be kept in a secure location. Peach Staterequires providers to maintain all records for members for at least seven (7) years.REQUIRED INFORMATIONMedical records means the complete, comprehensive records of a member including, but notlimited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of themember’s participating primary care physician or provider, that document all medical servicesreceived by the member, including inpatient, ambulatory, ancillary, and emergency care,prepared in accordance with all applicable DCH rules and regulations, and signed by the medicalprofessional rendering the services.Providers must maintain complete medical records for members in accordance with the followingstandards:• Member’s name, and/or medical record number on all chart pages.• Personal/biographical data is present (i.e. spouse, home telephone number, employer etc.).• All entries must be legible.• All entries must be dated and signed, or dictated by the provider rendering the care.• *Significant illnesses and/or medical conditions are documented on the problem list.• *Medication, allergies, and adverse reactions are prominently documented in a uniformlocation in the medical record; if no known allergies, NKA or NKDA are documented.• An immunization record is established for pediatric members or an appropriate history ismade in chart for adults.• Evidence that preventive screening and services are offered in accordance with PSHP’practice guidelines.• *Appropriate subjective and objective information pertinent to the member’s presentingcomplaints is documented in the history and physical.• *Past medical history (for members seen three or more times) is easily identified andincludes any serious accidents, operations and/or illnesses, discharge summaries, andER encounters; for children and adolescents (18 years and younger) past medical historyrelating to prenatal care, birth, any operations and/or childhood illnesses.• *Working diagnosis is consistent with findings.• *Treatment plan is consistent with diagnosis.Provider Services1-866-874-063302/22/201127
• Unresolved problems from previous visits are addressed in subsequent visits.• Laboratory and other studies ordered as appropriate.• Abnormal lab and imaging study results have explicit notations in the record for follow upplans; all entries should be initialed by the ordering practitioner to signify review.• Referrals to specialists and ancillary providers are documented, including follow-up ofoutcomes and summaries of treatment rendered elsewhere.• Health teaching and/or counseling is documented.• For members ten (10) years and over, appropriate notations concerning use of tobacco,alcohol and substance use (for members seen three or more times substance abusehistory should be queried).• Documentation of failure to keep an appointment.• Encounter forms or notes have a notation, when indicated, regarding follow up care callsor visits. The specific time of return should be noted as weeks, months or as needed.• Evidence that the member is not placed at inappropriate risk by a diagnostic ortherapeutic problem.• Confidentiality of member information and records are protected.• Evidence that an advance directive has been offered to adults 18 years of age and older.• Records are organized and easily accessible each visit and kept in a secure location.* Denotes NCQA core elements and require 100% compliance.MEDICAL RECORDS RELEASEAll medical records of members shall be confidential and shall not be released without the writtenauthorization of covered person or a responsible covered person’s legal guardian. When therelease of medical records is appropriate, the extent of that release should be based uponmedical necessity or on a need to know basis.Written authorization is required for the transmission of the medical record information of acurrent Peach State member or former Peach State member to any physician not connected withPeach State.MEDICAL RECORDS TRANSFER FOR NEW MEMBERSAll PCPs are required to document, in the member’s medical record, attempts to obtain oldmedical records for all new Peach State members. If the member or member’s guardian is unableto remember where they obtained medical care, or are unable to provide an appropriate address,then this should also be noted in the medical record.MEDICAL RECORDS AUDITSMedical records may be audited to determine compliance with Peach State’s standards fordocumentation. The coordination of care and services provided to members, including over/underutilization of specialists, as well as the outcome of such services may also be assessed during amedical record audit.Provider Services1-866-874-063302/22/201128
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 and 18: 83655 Lead Effective: 11/2010 Submi
Page 19 and 20: PROVIDER VISIT - WAITING TIMES• S
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: competency begins with self-awarene
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
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Procedure 99213 is submitted within
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Example: CPT 69436 billed with a 50
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BILLING CODESIt is important that p
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-Charge information and units• Se
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UB 04 CLAIM INSTRUCTIONSPeach State
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EMERGENCY DEPARTMENT HOSPITAL CLAIM
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Peach State Health PlanATTN: Peach
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Inquiry, Claims Adjustmentsand Prov
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selected, unless the plan and the p
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As accountable and fiscally respons
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CredentialingCREDENTIALING REQUIREM
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CREDENTIALING OF HEALTH DELIVERY OR
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Quality ImprovementTHE PEACH STATE
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PROVIDER REVIEWThe Peach State Qual
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AUTHORITY AND RESPONSIBILITYThe Pea
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Provider Services1-866-874-063302/2
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Member ServicesPeach State is commi
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• Income• Health Status• Arre
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• To keep all your appointments.
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• An Administrative Law Hearing d
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The staff often answers questions a
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PharmacyThe Peach State preferred d
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• Experimental drugs• Nutrition
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The member or provider, acting with
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Pharmacy ProgramPeach State Health
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Gender LimitsSome medications on th
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Cyclosporine, Digoxin, Disopyramide
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SPECIALTY MEDICATIONPRIOR AUTHORIZA
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Common Brand Name(s) Product Descri
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