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

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THIRD PARTY LIABILITY AND ............................................................................................................. 90COORDINATION OF BENEFITS (COB) GUIDELINES.............................................................................. 90INQUIRY, CLAIMS ADJUSTMENT, ADMINISTRATIVE REVIEW, AND PROVIDER APPEALS ............................. 92RESUBMITTED CLAIMS ..................................................................................................................... 92CLAIM PAYMENT AUDITS .................................................................................................................. 95POST PROCESSING CLAIMS AUDIT.................................................................................................... 95MEDICAL MANAGEMENT ADMINISTRATIVE REVIEW............................................................................. 97CREDENTIALING REQUIREMENTS ...................................................................................................... 98CREDENTIALING COMMITTEE ............................................................................................................ 99RECREDENTIALING .......................................................................................................................... 99MIDLEVEL PRACTITIONER CREDENTIALING........................................................................................ 99CREDENTIALING OF HEALTH DELIVERY ORGANIZATIONS .................................................................. 100RIGHT TO REVIEW AND CORRECT INFORMATION.............................................................................. 101THE PEACH STATE QUALITY IMPROVEMENT PROGRAM .................................................................... 102HEALTH MANAGEMENT PROGRAM NEEDS ANALYSIS........................................................................ 102PERFORMANCE IMPROVEMENT PROCESS........................................................................................ 103PROVIDER REVIEW......................................................................................................................... 104FEEDBACK ON PHYSICIAN SPECIFIC PERFORMANCE ........................................................................ 104FEEDBACK AFTER FOCUSED STUDIES ............................................................................................. 104FEEDBACK OF AGGREGATE RESULTS.............................................................................................. 104QUALITY OVERSIGHT COMMITTEES................................................................................................. 105WASTE ABUSE AND FRAUD (WAF) SYSTEM .................................................................................... 105AUTHORITY AND RESPONSIBILITY.................................................................................................... 106CONNECTIONS PROGRAM............................................................................................................... 110MEMBER MATERIALS...................................................................................................................... 111MEMBER RIGHTS & RESPONSIBILITIES ............................................................................................ 111MEMBER GRIEVANCES ................................................................................................................... 114ADMINISTRATIVE REVIEW................................................................................................................ 114EXPEDITED ADMINISTRATIVE REVIEW............................................................................................... 115ASSISTANCE AND CONTACTING PEACH STATE................................................................................. 115MEMBERS RIGHT TO AN ADMINISTRATIVE LAW HEARING .................................................................. 115SPECIAL SERVICES TO ASSIST WITH MEMBERS................................................................................ 116TRANSPORTATION SERVICES.......................................................................................................... 116INTERPRETER/TRANSLATION SERVICES........................................................................................... 117NURSEWISE .................................................................................................................................. 117PROVIDER RELATIONS DEPARTMENT .............................................................................................. 119GRANDFATHERING ......................................................................................................................... 120INJECTABLES ................................................................................................................................. 120NON-COVERED DRUGS .................................................................................................................. 120PRIOR AUTHORIZATION .................................................................................................................. 122PHARMACY LOCK-IN PROGRAM ...................................................................................................... 123
Description of GeorgiaFamiliesGeorgia Department of Community Health (DCH) has implemented Georgia Families (GF). GF isa statewide, full-risk care management system for certain Medicaid adults, children, andPeachCare for Kids. The GF program is designed to:• Improve the Health Care status of the member population• Establish a “Provider Home” for members through its use of assigned Primary CareProviders (PCP’s)• Slow the rate of expenditure in the Medicaid Program• Expand and strengthen a case of member responsibility that leads to more appropriateutilization of the healthcare systemPEACH STATE HEALTH PLANPeach State Health Plan, Inc. (Peach State) is a care management organization (CMO)contracted with the Georgia Department of Community Health (DCH) to serve Medicaid and othergovernment services program members. Peach State has developed the expertise to work withMedicaid members to improve their health status and quality of life. Our number one priority is thepromotion of healthy lifestyles through preventive healthcare. Peach State works to accomplishthis goal by partnering with the primary care providers (PCP) who oversee the healthcare ofPeach State members.Effective June 1, 2006, Centene Corporation ® (Centene) began providing Medicaid managedcare services to members in the designated regions of Georgia as Peach State Health Plan.Centene and its wholly owned health plans have a long and successful track record offeringMedicaid managed care services. For more than 20 years, Centene has provided comprehensivemanaged care services to the Medicaid population and currently operates health plans inGeorgia, Florida, Indiana, Massachusetts, Mississippi, New Jersey, Ohio, South Carolina, Texas,and Wisconsin. Peach State will serve our Georgia members consistent with our core philosophythat quality healthcare is best delivered locally. Peach State is a physician-driven organizationthat is committed to building interactive partnerships with providers.Peach State has been designed to achieve the following goals:• Ensure access to primary and preventive care services• Improve access to all necessary healthcare services• Encourage quality, continuity, and appropriateness of medical care• Provide medical coverage in a cost-effective mannerWe at Peach State strive to provide members with an improved health status. Peach Statecontinually seeks to improve member and provider satisfaction.All of our programs, policies and procedures are designed with these goals in mind. We hopethat you will assist Peach State in reaching these goals.Provider Services1-866-874-063302/22/20114
Page 3: CHRONIC AND COMPLEX CONDITIONS.....
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 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
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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
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BLOOD LEAD SCREENINGPhysicians are
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General BillingInformation and Guid
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Peach State dental claims should be
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IMAGING REQUIREMENTSPeach State use
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PROCEDURES FOR FILING A CLAIM/ENCOU
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medical necessity. Peach State may
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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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