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

Other disease case management programs will be developed based on the Georgia DCHrequirements.Providers are asked to contact a Peach State Case Manager to refer a member identified in needof case management intervention:Medical Management/Case Management1-800-504-8573Web address: www.pshp.comPRACTICE GUIDELINES AND PROTOCOLS, INCLUDING CHRONIC CAREPeach State clinical practice guidelines are based on the health needs and opportunities forimprovement identified as part of the Quality Assurance Program Improvement (QAPI) program.The guidelines are based on valid and reliable clinical evidence formulated by nationallyrecognized professional organizations or government institutions, such as the NIH or aconsensus of health care professionals in the applicable field. The guidelines consider the needsof the Members, are adopted in consultation with network providers; and are reviewed andupdated periodically as appropriate. The following Peach State clinical practice guidelines aremailed to providers and are available on the website: Routine Ante partum Care, Lead ToxicityScreening, Preventive Health Maintenance of Sickle Cell Patients, General Diabetes Care,Prevention and Management of Diabetes Complications, and Special ManagementConsiderations in Gestational Diabetes. For a complete listing, please access our website,www.pshp.com. The guidelines are available on request to members and providers.Peach State utilization management, member education, coverage of services, and other areasto which the guidelines apply are consistent with these guidelines. These guidelines are used forboth preventive services as well as for the management of chronic diseases.Chronic disease guidelines include:• NIH Asthma Guidelines• American Diabetes Association Standards of Care for Diabetes Guidelines• National Kidney Foundation guidelines for screening and detecting chronic kidneydisease.NEW TECHNOLOGYPeach State evaluates the inclusion of new technology and the new application of existingtechnology for coverage determination. This may include medical procedures, drugs and/ordevices. The Medical Director and or Medical Management staff may identify relevant topics forreview pertinent to Peach State population. The Clinical Policy Committee (CPC) reviews allrequests for coverage and makes a determination regarding any benefit changes that areindicated.In the instance where the request is made for coverage for new technology, which has not beenreviewed by the CPC, the Peach State Medical Director will review all information and make aone-time determination within two (2) business days of receipt of all information. This newtechnology request will then be reviewed at the next regular meeting of the CPC. If you need anew technology benefit determination or have an individual case review for new technology,please contact the Medical Management Department at 1-800-704-1483.The DCH will be notified in writing thirty (30) days following any material change to the MedicalManagement Program.Provider Services1-866-874-063302/22/201143