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

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92553 EP 99 Interperiodic Hearing *screening both ears, puretone audiometry (threshold); air and bone92555 EP 99 Interperiodic Hearing *screening both ears, speechaudiometry threshold92556 EP 99 Interperiodic Hearing *screening both ears, speechaudiometry threshold with speech recognitionEPSDT LEAD AND TB SCREENSHIPAAProcedureCodeHIPAAModifierPOSCodesProcedure Code Description86580 EP 99 TB Skin Test36415 EP 99 Blood Lead TestEPSDT REFERRAL CODESIn compliance with HIPAA Guidelines, CMS requires documentation of EPSDT Referral Codeswhen submitting Health Check Screening Code Claims. EPSDT Referral Codes must bedocumented on all screening (EPSDT screens, EPSDT interperiodic screens, interperiodic visionand interperiodic hearing) claims. CMS (Centers for Medicare and Medicaid Services) defines aHealth Check (EPSDT) referral as members scheduled for another appointment with the HealthCheck (EPSDT) Provider or a referral to another provider for further needed diagnostic andtreatment services as a result of at least one health problem identified during the Health Checkscreen.Condition Indicator: Health Check Referral? Document: Y (Yes) or N (No)AVNUS2STCondition Codes are requiredAvailable – Not The patient refused the referralUsedMust be used when the providerNot Useddocuments no referralPatient is currently under treatmentUnder Treatment for referred diagnostic or correctivehealth problemReferral to another provider fordiagnostic or corrective treatment orNew Servicescheduled for another appointmentRequestedwith screening provider fordiagnostic or corrective treatmentNote:Enter condition codesin Box 19 on the CMS1500 form. Filing thruthe Web Portal,condition codes shouldbe entered in theinformation field.Provider Services1-866-874-063302/22/201159
Vaccine Codes must be billed with modifier EP and POS 99 when provided to a memberunder age 18 as the EPSDT program.Shown below are vaccine codes covered for members ages 18 and under:36415 9071686580 9072390633 9073290647 9073490655 9074490657 9074890658 9068090669 9071090700 9071590702 9070790713 9071390714 9071690718(limited to age 7+)Shown below are other vaccine codes covered for members’ age 0-18when provided by physicians:90585905869063390675907159072590733 (limited to age 1+)9073590747Shown below are other vaccines covered for member age 19-21:86580 9071290585 9071390586 9071590634 9071690645 9071890658 9072590675 9073290707- 90710 9073390712 9073590713 9074690715 9074790716 9074890718 9072590732Provider Services1-866-874-063302/22/201160
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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
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 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: Health Check (EPSDT) Billing Requir
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
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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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Peach State Provider Office Manual - Peach State Health Plan ...

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