2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

ii2014 Practitioner and Provider Manual - Ver. 3

IntroductionUsing Your 2014 Provider ManualThis 2014 Practitioner and Provider Manual is both a resource for essential information aboutPresbyterian policies and procedures and an extension of your service agreement.For your reference, this manual and many other communications from Presbyterian Health Plan,Inc., and Presbyterian Insurance Company, Inc., will refer to both entities as “Presbyterian” onsecond reference.Presbyterian mails updated manuals to all contracted practitioners and providers on an annualbasis. The digital version of the manual is updated quarterly or as needed and is posted athttps://www.phs.org/providers/clinicians-resources. Providers can also request a paper copy ofthe manual be mailed to them at no charge. The 2014 Centennial Care Practitioner andProvider Manual located at https://www.phs.org/providers/centennial-care can also bereferenced for detailed information on Presbyterian’s Centennial Care program.Presbyterian updates and news will also be communicated periodically through the “NetworkConnection” newsletter and on the provider communications page located athttps://www.phs.org/providers/news-communications.You can also receive newsletters and updates from Presbyterian by signing up to receive emailsfrom Provider Network Management at https://www.phs.org/providers/newscommunications/Pages/enews-registration.aspx.How the Term “Provider” Is Used in this ManualWe acknowledge that the National Committee for Quality Assurance (NCQA) distinguishesbetween a practitioner (person) and a provider (facility). We make this distinction on thismanual’s cover, but to simplify the text within the manual we have chosen to use the term“provider” as an umbrella term that includes facilities as well as physicians, practitioners, andany other staff who are directly or indirectly contracted to provide service to Presbyterianmembers.We Want To Hear From YouWe encourage you to provide us with feedback on this manual. Please forward any corrections,questions, and comments to us at providercomm@phs.org.iii2014 Practitioner and Provider Manual - Ver. 3

iv2014 Practitioner and Provider Manual - Ver. 3

Revision HistoryVersion Date Change DescriptionA March 1,2014 Initial document releaseB March 17, 2014 Update to CMS-1500 Reference – additional information added (18-3)C June 9, 2014 Added Payor Identification Numbers to table on page 17-7D June 19, 2014Updated American Sign Language translation services vendor and contactinformation on page 19-12v2014 Practitioner and Provider Manual - Ver. 3

vi2014 Practitioner and Provider Manual - Ver. 3

Table of Contents1. Presbyterian Healthcare Services ............................................................................................................... 1-1Purpose Statement .................................................................................................................................. 1-1Presbyterian Healthcare Services ............................................................................................................ 1-1Commercial Products .............................................................................................................................. 1-2Medicare Advantage: Presbyterian Senior Care (HMO)........................................................................... 1-2Presbyterian Centennial Care .................................................................................................................. 1-2Alternative Benefit Package ..................................................................................................................... 1-2Covered Services and Authorization:....................................................................................................... 1-3Regulatory Agency Websites ................................................................................................................... 1-32. Provider Network Management .................................................................................................................. 2-1What We Do ............................................................................................................................................ 2-1Keep Us Updated: Provider Change Notification Form ............................................................................ 2-1Expanding Contracted Services ............................................................................................................... 2-1Network Training and Education .............................................................................................................. 2-2Presbyterian’s Annual Conference for Health Care Professionals, Providers, and Staff ........................... 2-2Network Communications ........................................................................................................................ 2-2Provider Satisfaction Survey .................................................................................................................... 2-33. Primary Care Providers .............................................................................................................................. 3-1The Role and Responsibilities of the PCP ............................................................................................... 3-1Coverage Requirements and After Hours Care ........................................................................................ 3-2Requirement to Use Contracted Providers ............................................................................................... 3-2Laboratory Services ................................................................................................................................ 3-3Durable Medical Equipment (DME) Services ........................................................................................... 3-34. Specialists .................................................................................................................................................. 4-1The Role and Responsibilities of the Specialty Care Provider .................................................................. 4-1Requirement to Use Contracted Providers ............................................................................................... 4-2Laboratory Services ................................................................................................................................ 4-2Durable Medical Equipment Services ...................................................................................................... 4-2Specialty Care Provider Termination ....................................................................................................... 4-2Other Information for PCPs and Specialists ............................................................................................. 4-3Accessibility of Services Standards ......................................................................................................... 4-35. Preventive Health Care Guidelines ............................................................................................................. 5-1vii2014 Practitioner and Provider Manual - Ver. 3

Nurse Advice Line ................................................................................................................................... 5-1Nurse Advice Line Telephone Numbers .................................................................................................. 5-1Preventive Health Care Guidelines and Screening .................................................................................. 5-1Presbyterian’s Preventive Health Care Guidelines ................................................................................... 5-2Measurement Activities ............................................................................................................................ 5-2Personal Health Assessments ................................................................................................................. 5-3Health Risk Assessments (For Centennial Care members) ..................................................................... 5-3Screening for Alcohol and Drug Abuse .................................................................................................... 5-3Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program ........................................... 5-3Immunizations ......................................................................................................................................... 5-4Vaccines for Children ............................................................................................................................... 5-46. Care Coordination ...................................................................................................................................... 6-1Coordinating Care: Prior Authorization Referrals ..................................................................................... 6-1Prior Authorization Process ..................................................................................................................... 6-2Authorizations of Coverage...................................................................................................................... 6-2Requesting a Prior Authorization ............................................................................................................. 6-3Urgent and Expedited Requests .............................................................................................................. 6-3Verify a Member’s Eligibility and Benefits ................................................................................................ 6-4Inpatient Admission ................................................................................................................................. 6-4Hours of Operation .................................................................................................................................. 6-4Appeals ................................................................................................................................................... 6-4Prior Authorization for Radiology/Advanced Imaging ............................................................................... 6-4Care Plan Development – Centennial Care ............................................................................................. 6-6Interdisciplinary Care Plan Team ............................................................................................................. 6-7Ongoing Care Coordination ..................................................................................................................... 6-8Disease Management .............................................................................................................................. 6-9Improve Health Outcomes ..................................................................................................................... 6-10Clinical Practice Guidelines and Tools ................................................................................................... 6-10Predictive Modeling ............................................................................................................................... 6-12Medical Records and Confidentiality Assurance .................................................................................... 6-13Provider Profiles .................................................................................................................................... 6-13Under- and Overutilization Analysis ....................................................................................................... 6-14Technology Assessment ........................................................................................................................ 6-14Medical Policy Development and Dissemination .................................................................................... 6-14Continuity of Care .................................................................................................................................. 6-15Family Planning (Presbyterian Centennial Care Only) ........................................................................... 6-15Dental Care (Presbyterian Centennial Care Only) ................................................................................. 6-16Vision Services (Presbyterian Centennial Care only) ............................................................................. 6-16viii2014 Practitioner and Provider Manual - Ver. 3

Medicare Notices ................................................................................................................................... 6-17Important Message to Medicare Beneficiaries ....................................................................................... 6-17Detailed Notice of Discharge ................................................................................................................. 6-17Notice of Medicare Non-Coverage ........................................................................................................ 6-17Home Skilled Nursing Facility (SNF) Rule Under Medicare.................................................................... 6-17Special Populations ............................................................................................................................... 6-18Appeals ................................................................................................................................................. 6-18Specialists as PCPs for Members with Special Health Care Needs ....................................................... 6-19Behavioral Health Care Coordination ..................................................................................................... 6-19Medical Record Reviews ....................................................................................................................... 6-20Presbyterian Access to Medical Records ............................................................................................... 6-20Minimum Medical Record Standards ..................................................................................................... 6-211. Confidentiality .................................................................................................................................... 6-212. Legibility and Provider Identification .................................................................................................. 6-213. Entries ............................................................................................................................................... 6-214. Organization/Patient Identification ..................................................................................................... 6-215. Personal Biographical Data ............................................................................................................... 6-226. Allergies ............................................................................................................................................ 6-227. Documentation of Tobacco, Alcohol, and Substance Abuse .............................................................. 6-228. Problem List (as appropriate for practitioner/practice type) ................................................................ 6-229. Medication List and History (as appropriate for practitioner/practice type) ......................................... 6-2210. Periodic Health Examinations (Physical Health Only) ...................................................................... 6-2211. Prevention Screening, Patient Education and Counseling (Physical Health Only) ........................... 6-2312. Durable Power of Attorney/Advance Directives (Physical Health Only) ........................................... 6-2313. Patient Notification of Abnormal Diagnostic Test Results (Physical Health Only) ............................. 6-2314. Consultations/Referrals ................................................................................................................... 6-2315. X-Ray, Lab, and Imaging Reports, Referrals, and Diagnostic Information (Physical Health Only) ... 6-2416. Past Medical History (as appropriate for practitioner/practice type) ................................................. 6-2417. Medically Appropriate Care (as appropriate for practitioner/practice type) ....................................... 6-2418. Hospital and Outside Clinical Records (as appropriate for practitioner/practice type) ...................... 6-2419. Immunization Status (Physical Health Only) .................................................................................... 6-24Individual Clinical Encounters ................................................................................................................ 6-24Behavioral Health Practitioners .............................................................................................................. 6-25Risk Stratification and Predictive Modeling ............................................................................................ 6-25Member Awareness ............................................................................................................................... 6-25Referral Requests/Prior Authorization .................................................................................................... 6-26Home Health Services ........................................................................................................................... 6-26Laboratory Services ............................................................................................................................... 6-26ix2014 Practitioner and Provider Manual - Ver. 3

Pharmacy Benefits ................................................................................................................................ 6-27Contacts for Other Information ............................................................................................................... 6-277. Laboratory Services .................................................................................................................................... 7-1Using Contracted Laboratory Services ....................................................................................................... 18. Pharmacy ................................................................................................................................................... 8-1Provider Guidelines ................................................................................................................................. 8-1ASKRX .................................................................................................................................................... 8-1National Drug Code ................................................................................................................................. 8-1Benefit Guidelines ................................................................................................................................... 8-1Pharmacy Benefits .................................................................................................................................. 8-2Centennial Care Prescription Benefit ....................................................................................................... 8-2Co-payments ........................................................................................................................................... 8-3Pharmacy Lock-Ins .................................................................................................................................. 8-3Over-The-Counter ................................................................................................................................... 8-3Commercial Prescription Drug Benefit ..................................................................................................... 8-3Mail Order for Commercial and PPO ....................................................................................................... 8-4Retail for Commercial and PPO ............................................................................................................... 8-4Maximum Dosing Quantity for 30-day Supply .......................................................................................... 8-5Medicare Prescription Drug Benefit ......................................................................................................... 8-5Medicare Stages of Coverage ................................................................................................................. 8-5Presbyterian Senior Care (HMO) and Presbyterian MediCare PPO ......................................................... 8-6Mandatory Generic Substitution Requirement.......................................................................................... 8-6Specific Limitations and Exclusions ......................................................................................................... 8-6Medicare Formulary Requirements .......................................................................................................... 8-6Mail Order for Medicare Plan ................................................................................................................... 8-7Medication Therapy Management............................................................................................................ 8-7Maximum Dosing Quantity for 30-day Supply .......................................................................................... 8-7Specialty Pharmaceuticals (Tier 5 medications obtained through the pharmacy benefit) ......................... 8-7Exclusions ............................................................................................................................................... 8-8Experimental Drugs ................................................................................................................................. 8-9Pharmacy and Therapeutics Committee Organization, Scope, and Function ........................................... 8-9Purpose of the P&T Committee ............................................................................................................... 8-9Review and Approval of Requests for Formulary Changes .................................................................... 8-10Pharmacy Prior Authorization Process................................................................................................... 8-11Revised Requests ................................................................................................................................. 8-12Processing of Approved Pharmacy Prior Authorization Requests .......................................................... 8-12Processing of Pended Pharmacy Prior Authorization Requests............................................................. 8-12Processing of Denied Pharmacy Prior Authorization Requests.............................................................. 8-12x2014 Practitioner and Provider Manual - Ver. 3

Expedited Pharmacy Prior Authorization Requests ............................................................................... 8-12Appeals Process ................................................................................................................................... 8-139. Behavioral Health ....................................................................................................................................... 9-1Presbyterian Behavioral Health Provider Participation ............................................................................. 9-1Presbyterian Behavioral Health Providers ................................................................................................ 9-1Types of Behavioral Health Providers ...................................................................................................... 9-2Individual Provider ................................................................................................................................... 9-2Group Practice ........................................................................................................................................ 9-2Organization ............................................................................................................................................ 9-2Core Service Agencies ............................................................................................................................ 9-3Credentialing ........................................................................................................................................... 9-3Provider Credentialing Application Process ............................................................................................. 9-3Recredentialing ........................................................................................................................................ 9-4Appealing Credentialing Decisions .......................................................................................................... 9-4Reporting Changes in Clinical Status ....................................................................................................... 9-4Contracting with Presbyterian .................................................................................................................. 9-4Updating Information ............................................................................................................................... 9-4Expectations of the Medicaid Provider ..................................................................................................... 9-5Expectations of Medicaid Members and Their Families ........................................................................... 9-5Care Coordination Communication Requirements (for Commercial and Medicare) ................................. 9-5Care Coordination (for Centennial Care Members) .................................................................................. 9-6Member Referrals .................................................................................................................................... 9-8After-Hours Coverage for Member Emergencies ..................................................................................... 9-8Crisis/Emergency Room Usage ............................................................................................................... 9-8Emergency/Disaster Planning .................................................................................................................. 9-9Authorization of Services ......................................................................................................................... 9-9Cultural Competency ............................................................................................................................... 9-9Access Standards .................................................................................................................................. 9-10Additional Access Requirements ........................................................................................................... 9-10Ambulatory Follow-up ............................................................................................................................ 9-10Timely and Confidential Exchange of Information .................................................................................. 9-10Timely Access and Follow-up for Medication Evaluation and Management ........................................... 9-10Claims Submission Procedures ............................................................................................................. 9-11Submitting Electronic Transactions/Claims ............................................................................................ 9-11Benefits of Filing Electronically .............................................................................................................. 9-11Claims Courier ....................................................................................................................................... 9-11Direct Submit ......................................................................................................................................... 9-11Paper Claims ......................................................................................................................................... 9-12xi2014 Practitioner and Provider Manual - Ver. 3

Clearinghouses ...................................................................................................................................... 9-12Payer ID for Clearinghouse Services (Centennial Care) ........................................................................ 9-12Clearinghouse Contact Information (Magellan) ...................................................................................... 9-12Clearinghouse Contact Information for Presbyterian Behavioral Health (Medicare and Commercial)can be found in Appendix? .................................................................................................................... 9-1310. Long-Term Care ..................................................................................................................................... 10-1Patient Eligibility .................................................................................................................................... 10-1General Eligibility................................................................................................................................... 10-1Native American Member Eligibility ....................................................................................................... 10-1Community Benefit ................................................................................................................................ 10-2Nursing Facility Level of Care Assessment for Long-Term Care Beneficiaries ....................................... 10-2Comprehensive Needs Assessment ...................................................................................................... 10-3Member Choice ..................................................................................................................................... 10-3Agency-Based Community Benefit ........................................................................................................ 10-3Self-Directed Community Benefit ........................................................................................................... 10-4Termination from the Self-Directed Community Benefit ......................................................................... 10-6Family Members Serving as Providers .................................................................................................. 10-7Utilization Management and Prior Authorization .................................................................................... 10-7Care Review Process ............................................................................................................................ 10-8Review Criteria ...................................................................................................................................... 10-8Supporting Integration and Coordination of Physical Health, Behavioral Health, and Long-Term CareServices................................................................................................................................................. 10-8Care Coordination ................................................................................................................................. 10-9Risk Stratification and Comprehensive Needs Assessment ................................................................... 10-9Interdisciplinary Care Plan Team ........................................................................................................... 10-9Delivery of Coordinated and Integrated Services ................................................................................. 10-10Member Engagement and Self-Care Management .............................................................................. 10-10Monitoring and Evaluation ................................................................................................................... 10-10Identification and Referral for Behavioral Health Services ................................................................... 10-10Community Health Workers and Community Health Representatives .................................................. 10-10Nursing Facility Level of Care: Care Plan Development ....................................................................... 10-11Transitions of Care .............................................................................................................................. 10-12Communication .................................................................................................................................... 10-12Care Management System .................................................................................................................. 10-13Provider Portal .................................................................................................................................... 10-13Credentialing ....................................................................................................................................... 10-13Individual Providers and Groups .......................................................................................................... 10-13Organizations ...................................................................................................................................... 10-14Other Provider Requirements .............................................................................................................. 10-14xii2014 Practitioner and Provider Manual - Ver. 3

Electronic Visit Verification................................................................................................................... 10-14Long-Term Care Claims Submission ................................................................................................... 10-1411. Home Health........................................................................................................................................... 11-1The Synagis Program ............................................................................................................................ 11-1Agency Recredentialing Policy .............................................................................................................. 11-1Agency Contracting Policy and Process ................................................................................................ 11-2New Agency Orientation ........................................................................................................................ 11-2Patient Eligibility .................................................................................................................................... 11-2Qualifying Home Care Criteria Policy ..................................................................................................... 11-2Qualifying Home Care Criteria Policy – Medicaid ................................................................................... 11-3Presbyterian Medicaid Early and Periodic Screening, Diagnosis, and Treatment Services .................... 11-4Medically Fragile Home and Community-Based Services ...................................................................... 11-4Personal Care Services ......................................................................................................................... 11-4Prior Authorization Processes ................................................................................................................ 11-5Initial Prior Authorization........................................................................................................................ 11-5Prior Authorization for Additional/Concurrent Services .......................................................................... 11-5Prior Authorization – Presbyterian Medicaid/EPSDT Medically Fragile Home and Community-Services ................................................................................................................................................ 11-5Personal Care Services ......................................................................................................................... 11-5Retroactive Authorizations ..................................................................................................................... 11-6Co-payments, Co-insurance, and Deductibles ....................................................................................... 11-6Transition of Care .................................................................................................................................. 11-6Denials .................................................................................................................................................. 11-7Appeals ................................................................................................................................................. 11-8Utilization Management ......................................................................................................................... 11-8Reporting Requirements ........................................................................................................................ 11-9Patient Care Conferences ................................................................................................................... 11-10Claims Processing ............................................................................................................................... 11-10Home Care Agency Contract Termination Policy ................................................................................. 11-1112. Quality Improvement Program ................................................................................................................ 12-1National Committee for Quality Assurance ............................................................................................ 12-2Focus on Excellence.............................................................................................................................. 12-2QI Program Activities ............................................................................................................................. 12-31. Availability of Providers ................................................................................................................ 12-32. Accessibility of Services (Appointment Availability) ...................................................................... 12-3Data Collection ............................................................................................................................. 12-33. Credentialing and Recredentialing ................................................................................................ 12-3Delegation .................................................................................................................................... 12-3xiii2014 Practitioner and Provider Manual - Ver. 3

Site Visits ..................................................................................................................................... 12-3Ongoing Monitoring ...................................................................................................................... 12-44. Quality of Clinical Care ................................................................................................................. 12-45. Peer Review ................................................................................................................................. 12-46. Continuity and Care Coordination ................................................................................................. 12-57. Standards of Care ........................................................................................................................ 12-58. Service Quality Concerns ............................................................................................................. 12-59. Clinical Practice Guidelines .......................................................................................................... 12-510. Preventive Health Care Guidelines ............................................................................................... 12-511. Member Medical Records ............................................................................................................. 12-512. Integrated Care Management Program ........................................................................................ 12-613. Continuum of Care ....................................................................................................................... 12-614. Special Populations ...................................................................................................................... 12-615. Early and Periodic Screening, Diagnosis, and Treatment ............................................................. 12-716. Health Risk Assessment and Personal Health Assessments ........................................................ 12-717. Culturally Appropriate Services .................................................................................................... 12-718. Oversight of Delegated, Subcontracted, and High-Volume or Single-Source Functions ............... 12-819. Nurse Advice Line ........................................................................................................................ 12-920. Utilization Management Program ................................................................................................. 12-921. Web Resources .......................................................................................................................... 12-1022. Voice of the Customer ................................................................................................................ 12-10Survey Data ............................................................................................................................... 12-10Complaint and Inquiry Data ........................................................................................................ 12-10Qualitative Research .................................................................................................................. 12-10Service Quality Committee and Delegated Teams ..................................................................... 12-11Member and Provider Satisfaction Prioritization Processes ........................................................ 12-1123. Patient Safety Program .............................................................................................................. 12-11Objectives of the Patient Safety Program ................................................................................... 12-11Focus ......................................................................................................................................... 12-11QI Program: HEDIS ® Medical Record Data Abstraction .............................................................. 12-11Where does HEDIS data come from? ......................................................................................... 12-12How does HEDIS reporting impact the practice setting? ............................................................. 12-13How does Presbyterian use the HEDIS reporting system? ......................................................... 12-1313. Health Insurance Portability and Accountability Act ................................................................................ 13-1What Requires Your Particular Attention? .............................................................................................. 13-1Who is Legally Responsible for HIPAA Compliance?............................................................................. 13-1Which Providers Must Be HIPAA Compliant? ........................................................................................ 13-2xiv2014 Practitioner and Provider Manual - Ver. 3

Key HIPAA Definitions ........................................................................................................................... 13-2HIPAA ................................................................................................................................................... 13-2HITECH Act ........................................................................................................................................... 13-3HIPAA Final Omnibus Rule .................................................................................................................... 13-3HIPAA Information Resources ............................................................................................................... 13-314. Legal ...................................................................................................................................................... 14-1Cooperation with Presbyterian’s Programs ............................................................................................ 14-1Presbyterian Centennial Care Contracting Requirements ...................................................................... 14-2Provider Responsibilities ....................................................................................................................... 14-2Selection of or Assignment to a PCP ..................................................................................................... 14-2Provider Disclosure of Current or Previous Affiliation with Excluded Providers ...................................... 14-3Hold Harmless ....................................................................................................................................... 14-3Delegation (if applicable) ....................................................................................................................... 14-4Cooperation with Medicaid Program Integrity ........................................................................................ 14-4Employee Education .............................................................................................................................. 14-4Credentialing Requirements .................................................................................................................. 14-5Review Requirements ............................................................................................................................ 14-5No Debarment ....................................................................................................................................... 14-5False Claims .......................................................................................................................................... 14-6Provider Termination ............................................................................................................................. 14-6Other Important Provisions .................................................................................................................... 14-7Exclusion from Federal Health Care Programs ...................................................................................... 14-8Provider Communications ...................................................................................................................... 14-8Background Checks............................................................................................................................... 14-9Conflict of Interest Certification .............................................................................................................. 14-9Indemnity ............................................................................................................................................... 14-9Medicare Contracting Requirements ...................................................................................................... 14-9Definitions: ............................................................................................................................................ 14-9Nondiscrimination .................................................................................................................................. 14-9Privacy of Medical Records ................................................................................................................... 14-9Communication with MA Plan Enrollees .............................................................................................. 14-10Indemnity ............................................................................................................................................. 14-10MA Plan Enrollee Hold Harmless ......................................................................................................... 14-10Continuation of Services Beyond Termination ..................................................................................... 14-11Federal Funds Used ............................................................................................................................ 14-11Access to Books and Records ............................................................................................................. 14-11Exclusion From Federal Health Care Programs ................................................................................... 14-11Subcontractors and Participating Pharmacies Adequate Network Coverage ....................................... 14-12xv2014 Practitioner and Provider Manual - Ver. 3

Monitoring ............................................................................................................................................ 14-12Credentialing ....................................................................................................................................... 14-12Standard of Conduct ............................................................................................................................ 14-12Fraud Waste and Abuse Control Compliance Program ........................................................................ 14-12Provider Training and Education .......................................................................................................... 14-13Provider Communications .................................................................................................................... 14-13Reasonable Assurances ...................................................................................................................... 14-13Revocation of Delegation or Termination of Agreement ....................................................................... 14-13Prompt Pay by Presbyterian ................................................................................................................ 14-14By SXC Health Solutions Corporation ................................................................................................... 14-14Subcontractor Certification of Data Accuracy, Completeness, and Truthfulness .................................. 14-14Office of the Inspector General Exclusion Certification ........................................................................ 14-14Conflict of Interest Certification ............................................................................................................ 14-14Offshore Contracting............................................................................................................................ 14-1515. Fraud, Waste, and Abuse ....................................................................................................................... 15-1Regulatory Definitions ............................................................................................................................ 15-1How to Report Fraud, Waste, and Abuse ............................................................................................... 15-2Medical Record Documentation ............................................................................................................. 15-2Physical Health Provider Medical Record Documentation ..................................................................... 15-2Behavioral Health Provider Medical Record Documentation .................................................................. 15-2Documenting Timed CPT Codes ........................................................................................................... 15-2Claims Validation Audits ........................................................................................................................ 15-3Medical Identity Theft and Identity Misrepresentation Prevention .......................................................... 15-5Federal Register (FR) and the Code of Federal Regulations (CFR)....................................................... 15-7Government Initiatives ........................................................................................................................... 15-7Federal and State False Claims Acts ..................................................................................................... 15-7Federal False Claims Act ...................................................................................................................... 15-7New Mexico False Claims Act (Dual Eligible) ........................................................................................ 15-8New Mexico Fraud Against Taxpayers Act ............................................................................................ 15-8Whistleblower Acts ................................................................................................................................ 15-8How Whistleblowers are Protected ........................................................................................................ 15-8New Mexico Whistleblower Protection Act ............................................................................................. 15-9Deficit Reduction Act of 2005 ................................................................................................................. 15-9Anti-Kickback Laws ............................................................................................................................. 15-10Anti-Kickback Safe Harbors ................................................................................................................. 15-10Self-Referral Laws ............................................................................................................................... 15-10Beneficiary Inducement Civil Monetary Penalty Law ............................................................................ 15-11Program Exclusion Lists ...................................................................................................................... 15-11xvi2014 Practitioner and Provider Manual - Ver. 3

myPRES Training and Support.............................................................................................................. 17-3Interactive Voice Response ................................................................................................................... 17-4Electronic Claims Transmission ............................................................................................................. 17-4Electronic Data Interchange Remittance Advice .................................................................................... 17-4Electronic Coordination of Benefits (eCOB) ® ......................................................................................... 17-4InstaMed ................................................................................................................................................ 17-4Sign Up for this Free Service ................................................................................................................. 17-5HealthXnet ® ........................................................................................................................................... 17-5ePocrates ® ............................................................................................................................................. 17-5Making Prescribing Easier ..................................................................................................................... 17-5Sign Up for This Free Service ............................................................................................................... 17-5Provider Network Management Website ................................................................................................ 17-6Medical Policy Information ..................................................................................................................... 17-6Appeals and Grievances ........................................................................................................................ 17-618. Claims and Payment ............................................................................................................................... 18-1Electronic Claims Transmission ............................................................................................................. 18-1Benefits of Filing Electronically .............................................................................................................. 18-1Requirements ........................................................................................................................................ 18-2How to Begin Filing Electronically .......................................................................................................... 18-2If You Encounter Problems .................................................................................................................... 18-3Paper Claims Submission Process ........................................................................................................ 18-3CMS 1500 ............................................................................................................................................. 18-3UB-04 .................................................................................................................................................... 18-4National Provider Identifier .................................................................................................................... 18-4Interim Billing Process for Institutional Services .................................................................................... 18-4Submitting Late Charges and Replacement Claims for Institutional Services ........................................ 18-4Submitting Corrections on a CMS 1500 (02-12) form ............................................................................ 18-5Submitting Unlisted/Unclassified Codes ................................................................................................ 18-5Guidelines for Submitting Hemoglobin A1c Claims and Test Results ..................................................... 18-5Requirement for 837 Professional ......................................................................................................... 18-5Requirement for 837 Institutional, Excluding Availity ® ............................................................................ 18-6Requirement for 837 Institutional for Availity ® ........................................................................................ 18-6For Paper Claims ................................................................................................................................... 18-6For CMS 1500 (02-12) Claims ............................................................................................................... 18-6For UB-04 Paper Claims ....................................................................................................................... 18-6Understanding the National Drug Code ................................................................................................. 18-6Obstetrical Services ............................................................................................................................... 18-7Pregnancy Termination for Centennial Care Members .......................................................................... 18-8xviii2014 Practitioner and Provider Manual - Ver. 3

Federally Funded Terminations ............................................................................................................. 18-8Physician Certification of Medical Necessity for Pregnancy Termination ............................................... 18-8State-Funded Terminations ................................................................................................................... 18-9Sterilization Consent Forms for Centennial Care Members.................................................................... 18-9Submitting Hospice Care Services for Medicare Advantage Members ................................................ 18-10Medicare Part D Description Drug Coverage ....................................................................................... 18-11Filing Claims with Coordination of Benefits (COB) ............................................................................... 18-11Adjustment Requests Involving COB ................................................................................................... 18-11Centennial Care COB .......................................................................................................................... 18-12Centennial Care Third-Party Liability ................................................................................................... 18-12Requesting an Adjustment .................................................................................................................. 18-13Recovery of Claim Overpayments ....................................................................................................... 18-13Timely Submission Guidelines ............................................................................................................. 18-14Guidelines for Original Claim Submissions .......................................................................................... 18-14Guidelines for Claim Resubmissions, Corrected Claims, and Adjustment Requests for AdditionalPayment .............................................................................................................................................. 18-14“Clean” Claims .................................................................................................................................... 18-15“Unclean” Claims ................................................................................................................................. 18-15Encounter Reporting ........................................................................................................................... 18-16Correct Coding Standards ................................................................................................................... 18-16National Correct Coding Initiative......................................................................................................... 18-17Interest Payment ................................................................................................................................. 18-17Claims and Payment Resources .......................................................................................................... 18-18myPRES ............................................................................................................................................. 18-18Provider CARE Unit ............................................................................................................................. 18-18Mailing Address for Claims, Corrected Claims, and Claims Resubmissions ........................................ 18-18Other Contact Information ................................................................................................................... 18-1819. Presbyterian Customer Service Center ................................................................................................... 19-1Member Contacts for Customer Service ................................................................................................ 19-1Member Communication and Welcome Packets .................................................................................... 19-1Identification Cards ................................................................................................................................ 19-1Choosing a Primary Care Provider ........................................................................................................ 19-2Specialist Assigned as a Primary Care Provider .................................................................................... 19-2Primary Care Provider Changes ............................................................................................................ 19-2Removing Members from Your Panel .................................................................................................... 19-3Centennial Care Member Eligibility and Enrollment ............................................................................... 19-3Transportation Services for Centennial Care members .......................................................................... 19-3Medicare Annual Notification of Change Meetings ................................................................................. 19-4xix2014 Practitioner and Provider Manual - Ver. 3

Medicare Advantage Plans New Member Education, Verification, and Welcome Calls .......................... 19-4Medicare Member Appreciation Events ................................................................................................. 19-4Additional Medicare Benefits Medicare Social Service Coordinators ..................................................... 19-4SilverSneakers ® Fitness Program .......................................................................................................... 19-4Members’ Rights and Responsibilities ................................................................................................... 19-5Members have the right to ..................................................................................................................... 19-5Members have the responsibility to: ....................................................................................................... 19-7Confidentiality ........................................................................................................................................ 19-7Member Health Information Rights ........................................................................................................ 19-8Legal Authority to Make Health Care Decisions for Minors or Others .................................................... 19-8Right to See and Get a Copy of Health Information ............................................................................... 19-8Right to Amend Incorrect or Incomplete Health Information ................................................................... 19-8Right to Request Restrictions of Health Information .............................................................................. 19-8Right to Request Confidential Communications of Health Information ................................................... 19-8Right to Request an Accounting of Disclosures ..................................................................................... 19-8Right to Receive a Paper Copy of Privacy Notice .................................................................................. 19-9Use of Consents and Authorizations to Obtain Protected Health Information ........................................ 19-9Members Who are Unable to Give Consent or Authorization ................................................................. 19-9Member Access to Protected Health Information Contained in Plan Records ...................................... 19-10Safeguarding Oral, Written, and Electronic Protected Health Information Across Presbyterian ............ 19-10myPRES/Website Internet Information ................................................................................................ 19-10Protection of Information Disclosed to Plan Sponsors, Employers, or Government Agencies .............. 19-11Cultural Competency ........................................................................................................................... 19-11Translation Services ............................................................................................................................ 19-11Advance Directive ................................................................................................................................ 19-12Provider CARE Unit ............................................................................................................................. 19-13Self-Help Options ................................................................................................................................ 19-13Web-based Inquiries ........................................................................................................................... 19-13Helpful Tips ......................................................................................................................................... 19-14Contacting the Provider CARE Unit ..................................................................................................... 19-14Telephone Inquiries ............................................................................................................................. 19-1420. Appeals and Grievances ......................................................................................................................... 20-1Provider Appeals and Grievance Process .............................................................................................. 20-1Standard Appeal ................................................................................................................................... 20-1Formal Grievances ................................................................................................................................ 20-2Circumstances Giving Rise to a Provider Fair Hearing .......................................................................... 20-2Initiation of an Appeal Hearing............................................................................................................... 20-2Member Appeals and Grievances .......................................................................................................... 20-3xx2014 Practitioner and Provider Manual - Ver. 3

Appendix A. Acronyms .................................................................................................................................. A-1Appendix B. Definitions.................................................................................................................................. B-1Appendix C. Websites ................................................................................................................................... C-1Appendix D. Phone Numbers ........................................................................................................................ D-1Appendix E. Business Associate Agreement ................................................................................................. E-1Appendix F. Prior Authorization Guide ............................................................................................................ F-1Appendix G. Alternative Benefits Package Covered Services ........................................................................ G-1List of TablesAlternative Benefits Package Details .............................................................................................................. 1-4Regulatory Agency Websites .......................................................................................................................... 1-5Clinical Practice Guidelines and Tools .......................................................................................................... 6-10Contacts for Other Information Providers May Need ..................................................................................... 6-28TriCore Contact Information ........................................................................................................................... 7-2Types of Pharmacy Prior Authorization Requests ......................................................................................... 8-12General Processing Routine Pharmacy Prior Authorization Requests by Fax, Mail, or Online ...................... 8-12Claims Processing Revenue Codes............................................................................................................ 11-10Clearinghouse Contact Information .............................................................................................................. 17-7Physician Certification of Medical Necessity for Pregnancy Termination .................................................... 18-10Presbyterian Customer Service Center Hours of Operation for Members ..................................................... 19-1xxi2014 Practitioner and Provider Manual - Ver. 3

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1. Presbyterian Healthcare Services1. Presbyterian HealthcareServicesPurpose StatementPresbyterian exists to improve the health of thepatients, members, and communities we serve.Presbyterian Health Plan, Inc., and PresbyterianInsurance Company, Inc. (Presbyterian), are part ofPresbyterian Healthcare Services, New Mexico’slargest, locally-owned integrated health caresystem. Established on October 24, 1908, as theSouthwest Presbyterian Sanatorium, Presbyterianbegan as a treatment center and refuge fortuberculosis patients. Through the years,Presbyterian grew and expanded into the statewideintegrated health care system it is today. A few keyservices includeEight not-for-profit Presbyterian-operated hospitals,located in Albuquerque, Clovis, Espanola, RioRancho, Ruidoso, Socorro, and Tucumcari.The Presbyterian Medical Group, consisting ofmore than 500 physicians and practitionersproviding medical care throughout New Mexico.Presbyterian, New Mexico’s largest managed careorganization, providing commercial healthinsurance, Medicaid, and Medicare products.Presbyterian Healthcare ServicesPresbyterian offers a statewide health care deliverysystem that provides your patients and ourmembers with a comprehensive provider network, aquality medical management program, and costeffective,consumer-driven managed health careservices. We are committed to providingexceptional customer service to our providers andmembers. In all that we do, Presbyterian strives toensure members can access primary and specialtycare services as needed and receive quality healthcare services in the most cost-effective setting.Unlike most managed care organizations, whichare accountable to shareholders, Presbyterian isultimately accountable to a board of directorscomprised of volunteers from our communities.Presbyterian’s enduring purpose is to improve thehealth of the patients, members, and communitieswe serve.Our statewide network exists because of thepartnerships and relationships we build with you,our physical health, behavioral health, and longtermcare providers. Presbyterian’s statewidenetwork comprisesThirty-six general acute-care hospitals (eight ofthese are currently owned, leased, or managed byPresbyterian Healthcare Services)More than 10,000 practitionersMore than 300 retail pharmacies composed oflocally owned stores and most major chainsPresbyterian offers a range of health careinsurance products and programs to members,including commercial products, Presbyterian1-12014 Practitioner and Provider Manual - Ver. 3

Presbyterian Healthcare ServicesCentennial Care, Presbyterian Senior Care (HMO),and Presbyterian MediCare Preferred ProviderOrganization (PPO).Commercial ProductsPresbyterian offers a portfolio of products foremployers, including Health MaintenanceOrganization, Point-of-Service, and AdministrativeService Only products. Presbyterian InsuranceCompany offers a PPO product for groups andindividuals.Medicare Advantage: Presbyterian Senior Care(HMO) and Presbyterian MediCare PPOPresbyterian Senior Care (HMO) and PresbyterianMediCare PPO are Medicare Advantage programsfor seniors and other Medicare-eligiblebeneficiaries. The programs are designed to meetthe special health care and financial needs ofMedicare beneficiaries who live in our service areaof Bernalillo, Valencia, Sandoval, and Torrancecounties, along with parts of Cibola and Santa Fecounties. Presbyterian’s individual and employergroup benefit plans offer more benefits than originalMedicare and include prevention and wellnessbenefits.Presbyterian offers a network of providers with awide range of specialties to fit the unique needs ofMedicare beneficiaries. Presbyterian Senior Care(HMO) has plans available that include MedicarePart D prescription drug coverage.Members can use doctors, hospitals, and providersoutside the Presbyterian network for an additionalcost.Presbyterian Centennial CarePresbyterian Centennial Care is New Mexico’s newMedicaid program, replacing the former Salud!program, State Coverage Insurance, andCoordination of Long Term Care Services.Presbyterian Centennial Care is a single,comprehensive delivery system through fourmanaged care plans, allowing for greateradministrative simplicity. It emphasizes carecoordination so that recipients receive the rightcare, in the right place, at the right time, leading tobetter health outcomes. The 2014 Centennial CarePractitioner and Provider manual located athttps://www.phs.org/providers/centennial-care canalso be referenced for detailed information onPresbyterian’s Centennial Care program.Alternative Benefit PackageMedicaid expansion services, also known as theAlternative Benefit Package (ABP), are provided toqualified enrollees through the PresbyterianCentennial Care program. Before Centennial Care,Medicaid was primarily available to children,pregnant women, very low income mothers, andpeople with disabilities.Beginning January 2014, eligible recipients includemany adults who have never qualified for Medicaidbefore. Network providers will be required toprovide ABP-covered services under the terms ofthe Presbyterian Centennial Care ServiceAgreement.The ABP offers low-cost health care coverage tolow-income adults who meet ABP eligibilitystandards under the Human Services Department’s1-22014 Practitioner and Provider Manual - Ver. 3

Presbyterian Healthcare Services(HSD’s) Category of Eligibility 100. Eligibility isbased on income, rather than the multiple eligibilitycategories that were used before. To be eligible forABP, enrollees must be adults between the ages of19 and 64 who are at or below 138% of the FederalPoverty Level (FPL).Qualifying adults will receive ABP services throughPresbyterian Centennial Care. Native Americanswho are eligible through the expansion may enrollin Centennial Care or receive services through feefor service.ABP members will be assessed co-paymentsbased on income level for outpatient and inpatientservices and may be subject to additional copaymentsfor unnecessary services.Covered Services and Authorization:Refer to the Alternative Benefits Package Detailstable for a list of services included under theCentennial Care Alternative Benefit Package.Please note the covered services and authorizationrequirements may differ from regular CentennialCare.Please refer to Appendix G for a list of ABPcoveredservices.Regulatory Agency WebsitesThis Presbyterian 2014 Provider Manualincorporates information from regulatory agenciesabout requirements for Presbyterian’s product lines.For more information about regulatoryrequirements, please visit the websites listed in theRegulatory Agencies Website table.1-32014 Practitioner and Provider Manual - Ver. 3

Presbyterian Healthcare ServicesAlternative Benefits Package DetailsRecipient Income Level Services Co-paymentsABP recipients at or below100% of FPL or ABP-exemptCo-payments only apply for unnecessary use of a brand-name drug and unnecessaryuse of an emergency room (ER). See unnecessary services below.ABP recipients between101% and 138% of FPLABP-exempt individualsPharmacy ServicesPractitionerServicesHospital ServicesUnnecessaryServices$3 per drug item; does not apply if the co-payment for unnecessary brand-name drugutilization is assessed.$8 for outpatient visit to physician or other practitioner, dental visit, rehabilitativeor habilitative session. The co-pay does not apply to ER facility or ER professionalcharges. Note: Does apply to outpatient hospital clinic visits and urgent care visits, but isapplied to the professional service, not the facility charge.$25 for inpatient admission. Not applied when the hospital is receiving the member asa transfer from another hospital.A co-payment of $8 will be applied for non-emergent use of the ER or for a brandnamedrug when there is a less expensive equivalent drug, unless the prescriberdetermines the alternative drug is less effective or has greater adverse reactions.Psychotropic drug items are exempt from the brand-name co-payment (only the regularpharmacy co-payment applies).The following individuals are ABP-exempt and may voluntarily opt out of the ABP:Individuals who qualify for medical assistance on the basis of being blind or disabledIndividuals who are terminally ill and are receiving benefits for hospice carePregnant womenIndividuals who are medically frail including those with• A disabling mental disorder, including individuals up to age 21 with seriousemotional disturbances and adults with serious mental illness• A chronic substance use disorder• A serious and complex medical condition as defined by HSD• A physical, intellectual, or developmental disability that significantly impairsthe member’s ability to perform one or more activities of dialing living• A disability determination based on Social Security criteriaExempt individuals are identified with a “disability code type” of ME or PH in the eligibilityfile. Co-payments only apply to these recipients for unnecessary services, which includeuse of a brand-name drug or non-emergent use of the ER. These individuals will beidentified by Presbyterian, or members can self-identify by contacting their PresbyterianCare Coordinator. Exempt individuals will use their standard Medicaid benefit package.1-42014 Practitioner and Provider Manual - Ver. 3

Presbyterian Healthcare ServicesRegulatory Agency WebsitesAgencyNew Mexico Human Services Department Medical Assistance DivisionCenters for Medicare and Medicaid ServicesState of New Mexico Regulations & Licensing DepartmentNational Provider Identifier (NPI)Website Locationhttp://www.hsd.state.nm.us/mad/http://www.cms.gov/http://www.rld.state.nm.us/https://nppes.cms.hhs.gov/1-52014 Practitioner and Provider Manual - Ver. 3

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Presbyterian Healthcare Services2. Provider Network Management2. Provider Network ManagementPresbyterian has an internal Provider NetworkManagement (PNM) team that is dedicated toworking with our network of practitioners andproviders. The department is committed todelivering an exceptional provider experiencethrough relationship management andengagement, timely and informativecommunications, modern resources and services,and good customer service. We develop and shareprograms, tools, and communications that provideour network with critical information, managedcare-relatedtraining and education, facilitation, andsupport. As part of the Health Plan, we areconstantly evaluating new services and tools thatmay increase efficiency, add value, and lower costsfor our network and all other stakeholders.What We DoPNM team members provide their expertise andservice to the following areas: practitioner andprovider relationship management andtraining/education, credentials verification,practitioner and provider e-business resources,network communications, and business analysis.Each practitioner or provider within thePresbyterian network has a designated PNMrelationship executive who is available as youradvocate within the health plan. Our relationshipexecutives are reaching out to their assignedpractitioners and providers through in-person visits,phone calls, and emails. They are your first anddedicated resource for questions and supportrelating to Presbyterian products, services, andinitiatives.Keep Us Updated: Provider Change NotificationFormThe PNM team is dedicated to maintaining andproviding up-to-date information aboutPresbyterian’s network of practitioners andproviders. Help us maintain accurate practitionerand provider data and keep automated processesrunning smoothly by providing us with up-to-dateinformation about your office.Your contract with Presbyterian requires you tosubmit changes to your relationship executive inwriting. This includes any changes related to yourpractice, such as an address change, taxpayeridentification number change, panel status, andcontract status. This information is used inelectronic and paper provider directories, and forregulatory reporting purposes. An electronicnetwork change form can be submitted athttps://www.phs.org/providers/trainingreference/Pages/update-provider-directory.aspx.Expanding Contracted ServicesAll practitioners and providers interested incontracting for an additional location, services, orspecialty must comply with the applicable2-12014 Practitioner and Provider Manual - Ver. 3

Provider Network ManagementPresbyterian policies and procedures for networkdevelopment. Therefore, before adding any newlocations, services, or specialties, please contactyour PNM relationship executive.The addition of practitioners and or providers of thesame specialty does not require formal compliancewith the Presbyterian network developmentprocess. However, you must notify Presbyterianbefore allowing any new practitioner or provider toprovide services to a Presbyterian member until thecredentialing process has been completed, ifapplicable.Network Training and EducationIf you are new to the Presbyterian network, or coulduse an update on one of our resources, programs,or initiatives, please contact your PNM relationshipexecutive. They can provide training andinformation about billing, coding, appeals andgrievances, PresOnline, and many other topics.They will serve as your guide and advocate inconnecting you with other Health Plan personnel asnecessary.Presbyterian’s Annual Conference for HealthCare Professionals, Providers, and StaffIn addition to the ongoing training provided by yourPNM relationship executive, Presbyterian hosts aconference and webinar for all health careprofessionals and providers, including physicalhealth, behavioral health, and long-term careservices for all lines of business. During theconference and webinar, we distribute new,updated, and important regulatory information toour contracted health care professionals andproviders. The purpose of the conference is to giveour network the most current regulatory informationas it relates to Presbyterian, and other keyinformation to ensure a successful partnership foryour patients and our members. For the CentennialCare program, the PNM team will be hosting fourtraining conferences throughout the year in differentlocations throughout the state.Network CommunicationsPresbyterian uses a variety of publications andcommunication methods to provide the networkwith accurate, timely, relevant, and engaginginformation about changes and initiatives at thehealth plan and other news affecting the network.Communication topics include notification ofinternal process changes, notification of regulatoryrequirements and changes, clarification of codingissues, education regarding utilization of the healthmanagement programs available to our members,and information about product-line specific policiesand procedures as required by the specificregulatory agencies (such as the New MexicoHuman Services Department, the Centers forMedicare and Medicaid Services, and the Office ofSuperintendent of Government).Presbyterian publishes a bi-monthly practitionerand provider communications program newslettertitled Network Connection. The practitioner andprovider newsletter contains articles about newresources and programs at Presbyterian, importantbusiness updates and changes, and regulatoryupdates and requirements. The newsletter is alsoposted in the “For Providers” section ofhttps://www.phs.org, along with updated copies of2-22014 Practitioner and Provider Manual - Ver. 3

Provider Network Managementthis manual and an archive of recent faxed andmailed letters. Please keep your PNM relationshipexecutive updated with any changes in your contactinformation.Provider Satisfaction SurveyProvider Network Management contracts with athird-party independent health care survey group toadminister an annual provider and practitionersatisfaction survey.2-32014 Practitioner and Provider Manual - Ver. 3

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Centennial Care Overview3. Primary Care Providers3. Primary Care ProvidersPrimary care providers (PCPs) are contractedphysical health providers who meet certainobjective criteria established by Presbyterian. PCPsmust accept the responsibility for rendering primaryphysical health care 24 hours a day, seven days aweek (24/7) and coordinate referrals.Presbyterian’s network of PCPs specializes infamily practice, general practice, internal medicine,pediatrics, obstetrics, gynecology, and otherspecializations as approved by Presbyterian.Presbyterian’s PCP network also includes certifiedphysician assistants, certified nurse practitioners,and other specialists who are credentialed andelect to perform the role of a PCP. Providers canaccess help by calling the Presbyterian Provider E-Help Desk at 505-923-5590 or 1-866-861-7444 andchoosing option three.The Role and Responsibilities of the PCPPCPs play an integral role in providing care tomembers. They focus on the total well-being of themember and provide a “medical home” where themember can readily access preventive health careservices and treatment rather than episodic or crisishealth care treatment. Members are encouraged tobe involved in their health care decisions and tobuild a healthy lifestyle. The PCP is responsible forteaching members how to use the available healthservices appropriately. It is important to educatemembers to seek PCP services first, except inemergent or urgent health care situations.The PCP is responsible forProviding or arranging for the provision ofcovered services and telephone consultationsduring normal office hours, and on anemergency basis 24/7Providing appropriate preventive healthservices in accordance with programrequirements, medical policies, and the Earlyand Periodic Screening, Diagnosis, andTreatment (EPSDT) guidelines as applicableVaccinating members during PCP visitsinstead of writing a referral for immunizationsCoordinating with other contract providers toensure continuity of care for all coveredservices, including behavioral health and longtermcare servicesReferring a member for behavioral services,as applicable (see Behavioral Health chapter)Participating in the Interdisciplinary Care PlanTeam (for Centennial Care members)Maintaining current medical records that meetestablished Presbyterian standardsMaking referrals to contracted specialty careproviders, when appropriate3-12014 Practitioner and Provider Manual - Ver. 3

Primary Care ProvidersMonitoring the member’s progress andfacilitating the member’s return to the PCPwhen medically appropriateDocumenting communication with specialtycare providers in the medical recordEducating members and their families abouttheir health issuesFollowing established utilization managementand quality management guidelinesAdhering to Presbyterian’s administrativepolicies and proceduresMeeting Presbyterian’s credentialing and recredentialingrequirementsNotifying Presbyterian of changes in address,license, liability insurance, contracting status,or any other issue that could affect theprovider’s ability to effectively render coveredservicesAdvising patients of their right to know aboutall treatment options related to their conditionor disease, regardless of whether or not it is acovered benefit under their insurance plan;the Presbyterian Customer Service Center isavailable to assist with confirming coveredbenefitsReporting any misappropriation of property,abuse, or neglect of a child or vulnerable adultthat is revealed or suspected to the properregulatory authorities using the appropriatethe statewide central reporting intake number• Adult Protective Services: 1-866-654-3219• Children, Youth, and FamiliesDepartment: 1-800-797-3260• Department of Health/Division of HealthImprovement (DOH/DHI): 1-800-445-6242Further information regarding state reportingrequirements for suspected abuse, neglect, ormisappropriation of property of children andvulnerable adults can be obtained from the NewMexico DOH/DHI.The PCP is also responsible for contactingPresbyterian to verify member eligibility and priorauthorizations for covered services. You canquickly and easily verify member eligibility throughmyPRES, the provider online service located athttp://www.phs.org (locate the myPRES Loginbox) or through our Interactive Voice Responsesystem by calling 505-923-5757 or 1-888-923-5757. You can also request prior authorization ofcovered services through myPRES.Coverage Requirements and After Hours CarePCPs must be available to members 24/7. Whenthe PCP is unavailable, coverage should bearranged through a participating Presbyterianprovider, or with an on-call health care professionalwho has signed a coverage arrangement with aparticipating PCP.Requirement to Use Contracted ProvidersPCPs are required to use Presbyterian’s contractedproviders, laboratories, durable medical equipment(DME), and other services for referrals in an effortto minimize member inconvenience and billingissues. If you need to verify whether services areavailable in-network, you can call the Provider3-22014 Practitioner and Provider Manual - Ver. 3

Primary Care ProvidersClaims Activity Review and Evaluation Unit at 505-923-5757 or 1-888-923-5757 for assistance.Laboratory ServicesPCPs are responsible for sending members toPresbyterian’s preferred laboratory provider,TriCore Reference Laboratories, unless clinicalcircumstances require the use of a differentlaboratory. If you need to refer to a differentlaboratory, you should immediately seek a priorauthorization as outlined in the Care Coordinationchapter of this manual. For a list of laboratorylocations, please visithttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00078812.pdf.Durable Medical Equipment (DME) ServicesPCPs are responsible for referring members tocontracted DME providers. For a complete listing ofcontracted DME providers, please visit our websiteat http://www.phs.org and click Find A Doctor at thetop of the page and search by specialty. If you donot comply with these requirements, Presbyterianreserves the right to hold you responsible for up to150% of eitherThe difference between the amount thatPresbyterian would have paid if a contractedprovider had been used and the total amountactually paid by Presbyterian to the noncontractedprovider, orThe entire cost of such servicesIf Presbyterian elects to utilize this right, theseamounts are withheld automatically and offsetagainst any future claims payments owed byPresbyterian to you.3-32014 Practitioner and Provider Manual - Ver. 3

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Primary Care Providers4. Specialists4. SpecialistsSpecialists are contracted physical and behavioralhealth practitioners not identified as primary careproviders (PCPs). Specialists agree to acceptreferrals from other contracted providers.The Role and Responsibilities of the SpecialtyCare ProviderThe specialist accepts referrals from othercontracted providers to provide more specializedservices for the member. The specialty careprovider is responsible forProviding medically necessary services tomembers who have been referred by one or moreof the following:• Their PCP• Another contracted provider• Self-referral, when appropriate, forspecified treatments or diagnosesReferring members to other providers as needed,including laboratory services and durable medicalequipment (DME) providersAdvising patients of their right to know about alltreatment options related to their condition ordisease, regardless of whether or not it is a coveredbenefit under their insurance plan. ThePresbyterian Customer Service Center is availableto assist with confirming covered benefits.Communicating with the member’s PCP or otherproviders about services rendered, treatmentresults, reports, and recommendations to ensurecontinuity of careDocumenting communication with the PCP or othercontracted providers in the medical recordObtaining prior authorization from Presbyterian’sHealth Services department for non-emergencyinpatient and outpatient services in accordance withthe member’s benefits package and Presbyterian’sutilization management policiesFollowing utilization and quality managementguidelinesAdhering to Presbyterian’s administrative policiesand proceduresMeeting Presbyterian’s credentialing and recredentialingrequirementsNotifying Presbyterian of changes in address,license, liability insurance, contract status, or anyother issue that could affect the provider’s ability toeffectively render covered services.Participating in the Interdisciplinary Care PlanTeam (for Centennial Care members)Specialty care providers are also responsible forreporting any misappropriation of property, abuse,or neglect of a child or vulnerable adult that isrevealed or suspected to proper regulatoryauthorities pursuant to state law using theappropriate the statewide central reporting intakenumber:4-12014 Practitioner and Provider Manual - Ver. 3

SpecialistsAdult Protective Services: 1-866-654-3219Children, Youth, and Families Department: 1-800-797-3260Department of Health/Division of HealthImprovement (DOH/DHI): 1-800-445-6242Further information regarding state reportingrequirements for suspected abuse, neglect, ormisappropriation of property of children andvulnerable adults can be obtained from the NewMexico DOH/DHI.In addition, specialty care providers are responsiblefor verifying member eligibility before renderingservices. This can be easily and quickly donethrough myPRES athttps://mypres.phs.org/Pages/default.aspx orthrough Presbyterian’s Interactive Voice Responsesystem by calling 505-923-5757 or 1-888-923-5757. Specialists can also request priorauthorization of covered services through myPRESat https://mypres.phs.org/Pages/default.aspx.Requirement to Use Contracted ProvidersSpecialty care providers are required to usePresbyterian’s contracted providers, includinglaboratory services, DME, and other services, in aneffort to minimize member inconvenience andbilling issues. To verify if services are available innetwork, you can call the Provider Claims ActivityReview and Evaluation Unit at 505-923-5757 or 1-888-923-5757 for assistance.Laboratory ServicesSpecialists are responsible for sending members toPresbyterian’s preferred laboratory servicesprovider, TriCore Reference Laboratories, unlessclinical circumstances require the use of a differentlaboratory. If you need to refer to a differentlaboratory, immediately seek a prior authorizationas outlined in the Care Coordination chapter of thismanual. For a list of laboratory locations, pleasevisithttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00078812.pdf.Durable Medical Equipment ServicesSpecialists are responsible for referring members tocontracted DME providers. For a complete listing ofDME providers, please visit our website athttp://www.phs.org and click “Find a Doctor” at thetop of the page and search by specialty.If you do not comply with these requirements,Presbyterian reserves the right to hold youresponsible for up to 150% of eitherThe difference between the amount thatPresbyterian would have paid if a contractedprovider had been used and the total amountactually paid by Presbyterian to the non-contractedprovider, orThe entire cost of such servicesIf Presbyterian elects to utilize this right, theseamounts are withheld automatically and offsetagainst any future claims payments owed byPresbyterian to you.Specialty Care Provider TerminationPlease refer to your service agreement withPresbyterian for specific time frames andobligations regarding terminations.4-22014 Practitioner and Provider Manual - Ver. 3

SpecialistsOther Information for PCPs and SpecialistsPractitioners are able to freely communicate withpatients about treatment options available to them,including medication treatment options, regardlessof benefit coverage limitations.Accessibility of Services StandardsAs required by our regulators and the NationalCommittee for Quality Assurance, Presbyterian isrequired to provide and maintain appropriateaccess to primary care, specialty care, andbehavioral health care services. Presbyterian’spolicy is to communicate our accessibility ofservices standards to our network and monitorcompliance with these standards.Presbyterian’s accessibility of services standardsare consistent with regulatory requirements andexist to ensure that our members receivereasonable, appropriate, and timely access to carefrom contracted providers. Specialists can accessPresbyterian’s Accessibility of Services andGeographic Availability Standards at the followingwebsites:http://docs.phs.org/resources/documents/accessibility.pdfhttp://docs.phs.org/idc/groups/public/documents/phscontent/wcmdev1001078.pdf4-32014 Practitioner and Provider Manual - Ver. 3

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Specialists5. Preventive Health Care Guidelines5. Preventive HealthCare GuidelinesPresbyterian encourages members to accesspreventive health care services through thedevelopment and distribution of preventive healthcare guidelines. Health education information isdistributed to our members in a variety of ways,including at health fairs and community meetingsand in member newsletters and handbooks.Presbyterian also offers a provider manual on theprovision of Early and Periodic Screening,Diagnosis, and Treatment (EPSDT) programservices including recommended childhoodimmunization schedules. The manual can belocated athttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001063.pdf.Nurse Advice LineAll Presbyterian members and Presbyterianemployees have access to a Nurse Advice Linethrough NurseAdvice SM New Mexico that isavailable 24 hours a day, seven days a week, toanswer their health care questions. The nurses donot take the place of practitioners, but providehelpful information on how to feel better and stayhealthy or when it is appropriate to go to theemergency department.Nurse Advice Line Telephone NumbersPresbyterian Centennial Care members maycontact the Nurse Advice Line at 505-923-5677 or 1-888-730-2300.Presbyterian Senior Care (HMO) andMediCare Preferred Provider Organization(PPO) members may contact the NurseAdvice Line at 1-800-887-9917.Presbyterian commercial members maycontact the Nurse Advice Line at 1-866-221-9679.Presbyterian employees and their dependentsmay contact the Nurse Advice Line at 1-800-905-3282.Preventive Health Care Guidelines andScreeningPreventive health care guidelines aresystematically developed statements designed togive members and providers current informationabout preventive health care screenings,counseling, and immunizations for all age groups.Presbyterian adopts preventive health careguidelines that are relevant to the enrolledpopulation and are based on reasonable medicalevidence. The Presbyterian preventive health careguidelines are based on a variety of resources,including but not limited to:U.S. Preventive Services Task ForceCenters for Disease Control and Prevention(CDC)American Academy of Pediatrics (AAP)5-12014 Practitioner and Provider Manual - Ver. 3

Preventive Health Care GuidelinesAmerican Academy of Family Physicians(AAFP)American Congress of Obstetricians andGynecologistsNational Cancer InstitutePresbyterian expects that providers provide thefollowing preventive screenings for allasymptomatic members within six months ofenrollment or within six months of a change inscreening standards, as necessary:Screening for breast cancerScreening for cervical cancerScreening for colorectal cancerBlood pressure measurementSerum cholesterol measurementScreening for obesityScreening for elevated lead levelsScreening for tuberculosisScreening for rubellaScreening for chlamydiaScreening for Type 2 diabetesPrenatal screeningNewborn screeningTot-to-Teen health checksPresbyterian has adopted immunization guidelinesapproved by the AAP, the Advisory Committee onImmunization Practices, and the AAFP. ThePreventive Healthcare Guidelines for Children,published by the AAP, were adopted byPresbyterian for members from birth through age20. All preventive health care guidelines arereviewed at least every two years and are updatedwhen clinically appropriate.All member households receive preventive healthcare guidelines as part of their member handbooks,which are available online. The guidelines are alsodistributed annually in the member newsletters.Presbyterian’s Preventive Health CareGuidelinesPresbyterian also informs providers of updates tothe preventive health care guidelines through theNetwork Connection provider newsletter. Writtencopies of the preventive health care guidelines areavailable upon request. For more information,please seehttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001475.pdf.Measurement ActivitiesPresbyterian conducts measurement activities atleast annually based on the National Committee forQuality Assurance (NCQA) HealthcareEffectiveness Data and Information Set (HEDIS ® ),and other clinically based measurement rules.Measures are collected from claims and other datasources made available to Presbyterian, such aslab results and medical record reviews.This data provides feedback on the preventivehealth and health maintenance services membersreceive. Presbyterian uses these measurementresults to identify members with or at risk forspecific health problems, and to inform theirproviders that prevention and treatment servicesmay be needed. For selected measures,5-22014 Practitioner and Provider Manual - Ver. 3

Preventive Health Care GuidelinesPresbyterian provides individual scores to providerswho act as primary care providers (PCPs).Along with the scores, Presbyterian includes lists ofmembers who might not be receiving the careneeded according to these clinical guidelines.Providers are encouraged to use these lists toengage members in their care and to providePresbyterian with updated information that maycorrect the data reported, such as lab results or aqualifying event.Personal Health AssessmentsPresbyterian encourages members to participate inPersonal Health Assessment (PHA) surveys. ThePHA includes a series of questions designed toidentify potential health risks and determine if newmembers require focused care coordination forphysical or behavioral health issues, or if theywould benefit from one of Presbyterian’s health ordisease management programs.Health Risk Assessments (For Centennial Caremembers)All members receive a telephonic Health RiskAssessment (HRA) to determine the level of carecoordination the member requires. The HRAincludes a series of questions designed to identifypotential health risks and determine if newmembers require focused care coordination forphysical or behavioral health or if they wouldbenefit from one of Presbyterian’s health or diseasemanagement programs. The surveys are also usedto identify special populations.Screening for Alcohol and Drug AbusePCPs are requested to use a standardized alcoholand drug abuse screening tool for high-riskmembers. The frequency of screening isdetermined by the results of the first screening andother clinical indicators. PCPs may use the CAGE(cut, annoy, guilty, eye opener) or any otherstandardized tool for an alcohol and drug abusescreening test.Presbyterian has adopted the CAGE standardizedalcohol and another drug abuse screening tooldeveloped by Brown and Rounds. The CAGEquestions can be used in the clinical setting in aninformal manner.It has been demonstrated that the questions aremost effective when used as part of a generalhealth history and should not be preceded byquestions about how frequently the patient drinks oruses illegal drugs. Responses on the CAGEscreening tool are scored at either 0 or 1, with ahigher score indicating possible alcohol or drugabuse problems. A total score of 2 or greater isconsidered clinically significant.Early and Periodic Screening, Diagnosis, andTreatment (EPSDT) ProgramChildren experience numerous health anddevelopmental milestones that should be assessedin a timely manner. Early detection and treatmentcan avoid or minimize the effects of manychildhood conditions.The federally mandated EPSDT programemphasizes early discovery of illness and the needfor comprehensive care. One component of the5-32014 Practitioner and Provider Manual - Ver. 3

Preventive Health Care GuidelinesEPSDT program is complete and timelyimmunizations (see the Vaccines for Childreninformation below). Presbyterian supports providersin coordinating these services.EPSDT benefits include comprehensive medicaland behavioral screening and treatment servicesavailable to all Presbyterian Centennial Carechildren from birth through age 21. The EPSDTWell-Child Checkups are also referred to as Tot-to-Teen health checks.EPSDT training for providers is available throughthe Provider Network Management department.ImmunizationsAll Presbyterian contracted PCPs are requested toprovide and document all immunizations accordingto the accepted immunization schedule. Theschedule can be accessed on the PresbyterianHealthcare Services website athttps://www.phs.org/providers/cliniciansresources/Pages/health-services.aspx.See thepreventive health care section on the webpage forimmunization information.The New Mexico Medicaid Managed Care programin the New Mexico Administrative Code8.305.6.12.A (5) requires PCPs contracted withPresbyterian Centennial Care to vaccinatemembers in their offices and not refer memberselsewhere for immunizations.Vaccines for ChildrenPresbyterian participates in the federal Vaccines forChildren (VFC) Program and supports the programgoals toImprove vaccine availability nationwide byproviding vaccines free of charge to VFCeligiblechildren through public and privateprovidersEnsure that no VFC-eligible child contracts avaccine-preventable disease because of his orher parent’s inability to pay for the vaccine orits administrationVFC-eligible children are those children from birththrough 18 years who meet one of the followingcriteria:Are eligible for MedicaidHave no health insuranceAre American Indian/Alaska NativeHave health insurance, but it does not coverimmunizations, and they go to a FederallyQualified Health CenterUnder the VFC program, New Mexico iscategorized as a Universal State, which is definedas a state that offers all vaccines as recommendedby the Advisory Committee on ImmunizationPractices to all health care providers to serve allchildren, including those who are fully insured.Presbyterian does not reimburse providers forvaccines that are available through the VFCprogram when they are given to Centennial Caremembers.Information regarding the VFC program may beobtained from the program director at 505-827-2898 or the immunization hotline at 1-888-231-2367. Additional VFC information is availablein the Presbyterian EPSDT Provider Manual, whichcan be accessed on the Presbyterian Healthcare5-42014 Practitioner and Provider Manual - Ver. 3

Preventive Health Care GuidelinesServices website athttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001063.pdf.For a printed copy of the EPSDT Provider Manual,contact your provider network managementrelationship executive.To visit the New Mexico Department of Health siteregarding children’s vaccines, go toContact UsFor additional information about health educationand preventive health care services that areavailable to Presbyterian Centennial Caremembers, call the Quality and Population HealthManagement Resource Line at 505-923-5017 or 1-866-634-2617. (This is a message phone only.)http://www.immunizenm.org/Provider/vacchild.shtml.To learn more about VFC, go tohttp://www.cdc.gov/vaccines/programs/vfc/index.html.5-52014 Practitioner and Provider Manual - Ver. 3

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Care Coordination6. Care Coordination6. Care CoordinationCare coordination exists to support you and yourPresbyterian patients. We are here to assist youwith coordination of care and services for yourpatients with chronic or catastrophic illnesses andinjuries and in promoting healthy lifestyles.Care coordination also serves to provide you andyour Presbyterian patients with proactive tools andresources to help them improve their health, stayhealthy, and live with chronic disease byAssisting providers and members to preventor reduce the burden of diseaseAssisting individual members with accessingmedical and behavioral health careIdentifying health needs and risksImproving the health of member populationswith selected health conditionsAssisting members to obtain appropriatemedicationsPredicting and managing health care costsFacilitating appropriate and cost-effective careEnsuring privacy and confidentiality of medicalinformationPresbyterian’s Utilization Management (UM)program includes care coordination for theevaluation of the appropriateness, medical need,and efficiency of health care services proceduresand facilities, according to established criteria andguidelines. Care coordination UM processescomprise a comprehensive set of integratedcomponents including prior authorization,concurrent review, continued stay review,retrospective review, discharge planning, andindividual medical case management as required todetermine medical necessity.The National Committee for Quality Assurance(NCQA) affirmative statement about incentives forUM decision making requires that “The organizationdistributes a statement to all members and to allpractitioners, providers, and employees who makeUM decisions, affirming the following:1. UM decision making is based only onappropriateness of care and service andexistence of coverage.2. The organization does not specifically rewardpractitioners or other individuals for issuingdenials of coverage.3. Financial incentives for UM decision makers donot encourage decisions that result inunderutilization.”Coordinating Care: Prior AuthorizationReferralsFor Commercial, Presbyterian Senior Care HealthMaintenance Organization, and selectAdministrative Service Only (ASO) plans, the modelis “no referral required” for most care rendered bycontracted specialists. This includes referrals from6-12014 Practitioner and Provider Manual - Ver. 3

Care Coordinationone contracted specialist to another contractedspecialist. Refer to specific plans for any specialrequirements.For ASO plans not participating in the open accessmodel and for Presbyterian Centennial Care,members need to continue to see their primary careproviders (PCPs) for a specialist referral. PCPs,however, are not required to get referralauthorization numbers from Presbyterian. The formof communication between the PCP and specialist(prescription, phone call, or note in medical record)is at the discretion of the PCP and the specialist.For all plans, members may self-refer foremergency care, urgent care, and contractedwomen’s health care. Presbyterian Centennial Carehas additional benefits for self-referral for women’shealth care, which are explained in another sectionof this chapter.Prior Authorization ProcessPresbyterian wants your patients to get the bestcare, in the right place, at the right time. One of theprocesses we use to help our members get thebest care is called prior authorization.Authorizations of CoverageServices requiring prior authorization are publishedin our Provider Manual, the member handbooks,and Presbyterian’s website. Extensive detail isincluded in provider orientations and ongoingtraining. This ensures that the provider andmember know if services are covered.The UM team reviews cases for medical necessity,appropriate setting, history of medical conditionsand treatments, special circumstances,socioeconomic issues, support issues, complexityof health status, clinical quality considerations, andavailability of local health resources. Individualpatient situations, risk factors, service availability,and patient safety are also considered whenrelevant and known. Consequently, completedocumentation by the referring provider todemonstrate medical necessity is critical.Presbyterian encourages its providers to addressthe following issues when requesting authorizationfor a service:Recommendation of treating physicianAgeCo-morbiditiesComplicationsMental statusActivities of daily livingInstrumental activities of daily livingFinancial statusPoly-pharmacyProgress of treatmentPsychosocial and cultural situationHome environmentAvailability of less restrictive treatmentmodalities to address the member’s needsAvailability of services including, but notlimited to, skilled nursing facilities or homecare in the member’s area to support themember after discharge6-22014 Practitioner and Provider Manual - Ver. 3

Care CoordinationPresbyterian’s coverage of benefits for skillednursing facilities, sub-acute care facilities, orhome careAbility of local hospitals to provide allrecommended services within the estimatedlength of stayRequesting a Prior AuthorizationTo serve our providers, Presbyterian has adedicated prior authorization line. Call HealthServices at 505-923-5757 or 1-888-923-5757(Option 4). For home health care requests, call505-559-1151 or 1-877-606-1151 (Option 4).When a need is identified for a service that requiresa clinical review, Presbyterian offers a variety ofuser-friendly tools for providers to submitauthorization requests online through myPRES athttp://www.phs.org. Using myPRES to submitreferral requests or prior authorizations is theeasiest, least intrusive method for the provider’soffice or facility. If the provider is unable to submitthe request online, it may be submitted by fax,email, or telephone or through a care coordinator. Ifapplicable, the provider should submit supportingdocumentation to demonstrate the medicalnecessity for the request. Prior authorizations,including auto-generated approvals for specificservices, may be obtained through myPRES athttp://www.phs.org. The provider may also accessthe status of prior authorization requests, claims,and eligibility information through myPRES 24hours a day, seven days a week. For moreinformation about myPRES, see the e-Businesschapter of this manual. You may also contact usthrough the following waysInpatient prior authorization requests may befaxed to 505-213-0181 or 1-888-923-5990Outpatient services and durable medicalequipment (DME) requests may be faxed to505-213-0246University of New Mexico prior authorizationsmay be faxed to 505-213-0149Long-term care prior authorizations may befaxed to 505-213-0240Mail to Health Services:Presbyterian Prior Authorization TeamP.O. Box 27489Albuquerque, NM 87125-7489Urgent and Expedited RequestsFollowing are the criteria for requests that require aquick decision (urgent and expedited) fromPresbyterian.The life, health, or safety of a covered personwould be seriously jeopardized because of themember’s psychological state.In the opinion of a practitioner with knowledgeof the member’s medical or behavioral healthcondition, the member would be subjected toadverse health consequences without thecare or treatment requested.The covered person’s ability to regainmaximum function would be jeopardized.The medical exigencies of the case require anexpedited decision.When you have a situation that meets the definitionof an urgent or expedited determination, we6-32014 Practitioner and Provider Manual - Ver. 3

Care Coordinationsuggest that you call Health Services at 505-923-5757 or 1-888-923-5757, Option 4.What this means for the provider’s office is that allurgent and expedited prior authorization requeststhat the provider sends should meet one or more ofthe criteria listed above. If the request does notmeet the urgent and expedited criteria, it may beprocessed as a routine prior authorization request.Verify a Member’s Eligibility and BenefitsEligibility can be checked easily and quicklythrough myPRES at https://mypres.phs.org or bycalling 505-923-5757 or 1-888-923-5757, Option 1.Inpatient AdmissionFor elective or emergency admissions, usemyPRES for all prior authorization requests andnotification of deliveries. If necessary, the providermay also obtain prior authorization for an inpatientconcurrent review or inpatient hospital admissionby calling 505-923-5757 or 1-888-923-5757, Option4. The provider needs to either fax the request tothe number designated in the message for the typeof request or leave a message.Hours of OperationPresbyterian’s UM team of nurses, pharmacists,behavioral health specialists, therapists, andmedical directors are available 24-hours a day,seven days a week to assist providers withauthorizations or verification of benefits.AppealsIf a request is not authorized, the provider or facilitymay appeal this decision. The provider is notprohibited from advocating on behalf of themember, but must have the member’s writtenconsent. The criteria used to make thisdetermination are made available to the provider ifrequested. In addition, the provider may speakdirectly to Presbyterian’s medical director. Refer tothe Appeals and Grievances chapter of this manualfor information on filing appeals.Prior Authorization for Radiology/AdvancedImagingSince 2007, Presbyterian has been using anadvanced imaging ordering program for outpatientsthrough HealthHelp ® . The program applies to allPresbyterian members who have medical benefitsfor in-plan radiology facilities (some employergroups may decide not to participate). The programis designed to improve health care, patient safety,utilization, and cost by applying clinical criteriawhen ordering Computed Tomography (CT),Magnetic Resonance Imaging/Angiography (MR),and Positron Emission Tomography (PET).When ordering CT, CT angiography, MR, or PETscans, the provider or office staff must submitpatient demographics, diagnosis, patient history(such as prior treatment and associatedsymptoms), and procedure codes to HealthHelp ®through a web-based ordering system, bytelephone, or by fax. HealthHelp ® reviews therequest against published guidelines and, ifappropriate, issues an authorization number, whichthen becomes the Presbyterian prior authorizationnumber. A direct link to the HealthHelp ® web-basedprogram is available through myPRES. Noadditional sign-on or password is needed to access6-42014 Practitioner and Provider Manual - Ver. 3

Care Coordinationthe program. If the provider is a radiology facility orhospital, or these procedures are provided in theprovider’s office, the provider should confirm thatHealthHelp ® has processed and approved therequest before scheduling an appointment. Thisensures payment of the claims submitted.Detailed instructions and reference guides areavailable on Presbyterian’s website athttps://www.phs.org/providers/clinicians-resourcesand includeScopeCurrent list of procedure codes thatHealthHelp ® managesProcess steps and contract informationFrequently asked questions, which includeroutine, expedited, retroactive, and emergentrequestsClinical information/fax formA demonstration of the HealthHelp ® webbasedprocessPresbyterian’s care coordination model facilitatesthe integration of physical health and behavioralhealth services into a seamless and coordinatedsystem of care. Our care coordination modelprovides our members with timely, appropriateservices in the least restrictive and most costeffectivesetting possible. This care coordinationmodel assists and supports providers and membersto improve the continuity of care. It is designed toenhance access to services and achieve optimalhealth and quality outcomes throughMember-centric care coordination thatencourages personal responsibility andmember engagementPopulation-based, predictive modeling thatincorporates claims, lab, and pharmacy datato identify care opportunities and to identifymembers who are at risk for future adverseevents that can benefit from care coordinationinterventionsHealth Risk Assessments (HRAs) forCentennial Care members are completedduring a new member’s onboarding that aredesigned to identify members in need of carecoordinationA Comprehensive Needs Assessment (CNA)designed to identify each Centennial Caremember’s holistic needsComprehensive care plans that addressphysical, psychosocial, behavioral, andfunctional needsInterdisciplinary Care Planning Teams (ICPTs)that work together and collaborate to meet thediverse and holistic needs of members acrossdomains of health careEvidence-based best practice guidelines andclinical pathwaysTechnology solutions and clinical decisionsupport toolsCare coordination, disease management, transitionof care, and utilization management are integralcomponents of our overall integrated care model forour Presbyterian members. Activities andinterventions are based on the needs of each6-52014 Practitioner and Provider Manual - Ver. 3

Care Coordinationmember across this integrated care continuum. ThePresbyterian care coordination team includes ouremployed staff and those of our experiencedbehavioral health partner, Magellan, for theCentennial Care Behavioral Health network. Somecare coordination team members have extensivebehavioral health and long-term care experience.They are available to be primary care coordinatorsor to consult with other providers of care formembers with co-morbid medical and behavioralhealth conditions and functional needs. The carecoordination team works under the leadership ofour senior medical director to bring an array ofclinical experience and cultural/linguisticcapabilities to the care coordination process.Our model leverages the experience andcapabilities of its provider partners along with localcommunity resources to ensure comprehensiveand culturally appropriate care coordination formembers. Presbyterian encourages care beingprovided through qualified Patient-CenteredMedical Homes and future health homes includingcare coordination services. Through thesearrangements, Presbyterian provides overarchingcare coordination services, technical assistance,and systematic monitoring to assure carecoordinators at these provider sites have access toPHP systems, resources, tools, utilization data, andencounter data required for effective carecoordination.Members are matched with an appropriate carecoordinator based on their clinical needs,geographic location, language, culturalpreferences, and history of established providerrelationships. To find out who your patient’sassigned care coordinator is, you may contact thecare coordination unit atPhone: 1-866-672-1242 or 505-923-8858Fax: 505-213-0063For Centennial Care members, based on theresults of the CNA, an individualized care plan isdeveloped for members assigned to a specific carecoordination level of care. The care plan aligns amember’s needs and preferences with appropriateservices and interventions, which include thesupport the member needs to stabilize or improvehis or her health, safety, and well-being. The careplan includes all Medicaid services, value-addedservices, and other supports or services identifiedfor the member.Care Plan Development – Centennial CareBased on the results of the CNA, an individualizedcare plan is developed for members assigned tocare coordination Level 2 or 3. The care plan alignsa member’s needs and preferences withappropriate services and interventions, whichinclude the support the member needs to stabilizeor improve his or her health, safety, and well-being.The care plan includes all Medicaid services, valueaddedservices, and other supports or servicesidentified for the member.This customized care plan allows the member tounderstand what services are available and createsa foundation for discussions about his or her healthamong the member, the member’s caregivers, carecoordinator, and providers. The assigned carecoordinator works with the member and his or her6-62014 Practitioner and Provider Manual - Ver. 3

Care Coordinationdesignated family members, caregivers, orauthorized representatives, the member’s primarycare provider (PCP), other providers, and the ICPTto develop an individualized care plan that ismember-driven and addresses issues and needsidentified in the CNA. The member’s assigned carecoordinator is accountable for the development andimplementation of the member’s care plan, servesas the primary point of contact, and directs all carecoordination activities for the member. Themember’s PCP, other providers, and other ICPTmembers provide assistance as appropriate fortheir areas of expertise. The care coordinator worksin collaboration with the provider and the memberto identify measurable physical, behavioral,functional, and social support goals, and to developinterventions to address the member’s goals. Keyelements of the care plan includeContact information, preferred language, andpreferred method(s) of contactMember-identified support persons orcaregiversCurrent health status and stabilityThe member’s understanding of his or herhealth status, health trajectory, and self-carecapacityIdentified current active providers and gaps(e.g., assessed need for behavioral health)with scheduled follow-up appointmentsIdentified clinical, behavioral health,functional, environmental, and social supportneedsRecommended benefits and services neededto meet the member’s individual needs,including value-added benefits and services, ifindicatedWhat medication reconciliation is needed andan evaluation of medication adherenceTransportation needs and preferencesSpecific, mutually agreed-upon, prioritizedgoals, interventions, and time frames basedon the member’s stated health and caredesires and recognized potential barriersBackup plan to address any service gaps formembers receiving community benefitsSelf-directed care plan and annual budget formembers that elect the Self-DirectedCommunity BenefitOutcome measures to evaluate the success ofmeeting stated goals, as well as follow-upintervals for reassessmentIdentified early signs of clinical deteriorationand appropriate responses to these signs, andany other urgent or emergent situationsInterdisciplinary Care Plan TeamBased on the CNA and the individualized care plan,an appropriate ICPT is established. The ICPTaddresses the member’s specific needs and is acentral component of the care coordination model.Members of the ICPT are based on the member’sindividual needs, preferences, and situation. Atminimum, the ICPT consists of the carecoordinator, the member, and the member’s PCP.In addition, as appropriate and with the member’sinput and consent, additional members of the ICPTmay include6-72014 Practitioner and Provider Manual - Ver. 3

Care CoordinationFamily members or other persons withsignificant involvement in the member’s carePeer/family support specialistsCommunity health workers or communityhealth representativesPharmacistsPresbyterian’s medical directorBehavioral health (mental health andsubstance abuse treatment) cliniciansSpecialty providersClinical staff from nursing homes and assistedliving facilities where members live are alsoincluded as integral participants in the member’sICPT. Residential care staff employees areinstrumental participants in the member’s careteam, and play a central role in alerting carecoordinators to a change in a member’s conditionor status that, if acted upon in a timely andappropriate fashion, may prevent unnecessaryhospitalizations.Members are encouraged to actively participate inthe care planning process, and are provided withtools and resources that allow them to takepersonal responsibility for their care management.The care plan is reviewed, modified if necessary,and approved by the member.ICPT communication may occur through in-personcase conferences, by telephone, or electronicallythrough the care management system. Themember’s assigned care coordinator works with theprovider to ensure that the provider’s input andrecommendations are incorporated into the careplan where appropriate.Ongoing Care CoordinationThe assigned care coordinator is responsible formanaging ongoing care coordination and ensuringthat documentation of care coordination activities ismaintained in the member’s care managementsystem record. These activities are conducted inaccordance with the care plan, and include, at aminimum, the responsibility toDevelop and update the care plan as neededProvide disease management interventionsand health education related to chronicconditionsMonitor treatment and coordinate with theprovider to encourage best practice as itrelates to tests, appointment frequency, andadherence to clinical practice guidelines andcondition-specific protocolsAs appropriate, educate the member and themember’s caregivers about advancedirectives and psychiatric advance directives,and document the member’s decision in thecare management system recordMonitor the member’s participation in careplan activities and recommended servicesMaintain ongoing communication withcommunity and natural supports to monitorand support ongoing participation in themember’s careIdentify non-covered services needed topromote the member’s health, safety, andwell-being, and enlist communityorganizations to provide those services andsupports6-82014 Practitioner and Provider Manual - Ver. 3

Care CoordinationFacilitate access to physical and behavioralhealth services as neededMonitor and ensure the provision of coveredservices and ensure that they meet themember’s needsFacilitate coordination and communicationbetween the member’s service providers toensure a comprehensive, holistic, membercenteredapproachDisease ManagementPresbyterian’s innovative disease managementprogram, called Healthy Solutions, supportsproviders in their management of chronic illnesses.The Care Continuum Alliance defines diseasemanagement as a system of coordinated healthcare interventions and communications forpopulations with conditions in which patient selfcareefforts are significant. More information aboutthe Care Continuum Alliance is available on itswebsite at http://www.carecontinuumalliance.org/.To provide resources for providers in their carecoordination for members with chronic conditions,Presbyterian offers comprehensive diseasemanagement programs for diabetes, chronicobstructive pulmonary disease, coronary arterydisease, congestive heart failure, and asthma.These programs include distribution of bloodglucose meters for all members with diabetes, peakflow meters for members with asthma, andeducational materials for members and providers.Presbyterian provides comprehensive care to ourmembers statewide through our network ofservices. This comprehensive Healthy Solutionsdisease management programSupports the provider/patient relationship andplan of careEmphasizes prevention of exacerbations andcomplications by using evidence-basedpractice guidelines and patient empowermentstrategies for self-management of chronicdiseaseEvaluates clinical, humanistic, and economicoutcomes on an ongoing basis with the goal ofimproving overall healthThrough this disease management program,PresbyterianStrives to identify a member’s problemsbefore the problems occur. We proactivelywork to identify members potentially in need ofthese services through medical andpharmaceutical data available through thePresbyterian claims data systems.Stratifies members by risk criteria using apredictive modeling tool to identify members’risk level. Using these criteria for initialstratification, a member’s needs are matchedto an appropriate level of intervention.Provides meaningful interventions throughcare coordination and Healthy Solutionsphone-based health coaching.Care Coordinators manage members with thehighest risk score who need moreintensive/multisystem medical or nursinginterventions.6-92014 Practitioner and Provider Manual - Ver. 3

Care CoordinationMembers with moderate risk scores are managedby our Healthy Solutions team. They providephone-based health coaching, which is differentfrom the traditional educational model that identifiesand focuses on members who already meet thecriteria of “readiness to change.” Through healthcoaching, we provide the member the one-on-onesupport he or she needs to reach the stage of“readiness to change.” This behavioral changemethodology ensures we focus our efforts ondeveloping a personalized health improvement planfor members. In turn, the staff provides support andeducation for the member’s health-relatedbehavioral change.Healthy Solutions offers a member-focusedprogram to meet the medical, behavioral, andeducational health care needs for all of ourmembers. Health coaches work with individuals onbehavioral issues for those with a moderate riskscore.Improve Health OutcomesPresbyterian understands the importance ofimproving health outcomes. By tailoring thefrequency and intensity of outreach to the membersbased on risk and severity of disease, as well as totheir readiness to change, our staff is moreeffective with interventions. Members with chronicillness learn to manage their health to lead moreproductive lives. Members are also more willing toparticipate if their provider discusses the programwith them and recommends their participation in theprogram. Members who are considered at risk learnto minimize problems with ongoing education.Utilization of health care resources becomes moreappropriate and effective. You may refer yourPresbyterian patients to the Presbyterian HealthySolutions disease management program atPhone: 1-800-841-9705Email: PHPreferral@phs.orgClinical Practice Guidelines and ToolsClinical Practice Guidelines are systematicallydeveloped statements designed to give providersthe most current, nationally recognizedrecommendations regarding the care of specificclinical circumstances. Presbyterian adopts clinicalpractice guidelines that are relevant to the enrolledpopulation and are based on reasonable scientificevidence. All clinical practice guidelines arereviewed at least every two years and are updatedwhen clinically appropriate.You may contact the Presbyterian Quality andPopulation Health Management team by phone at505-923-5017 or 1-866-634-2617 (these aremessage phones only). You may also contact themby e-mail at PopulationHlthMgt@phs.org.Clinical Practice Guidelines and ToolsGuidelines and ToolsAmerican Psychiatric Association (APA) and theAmerican Academy of Pediatrics (AAP) BehavioralHealth Clinical Practice Guidelines and ToolsWebsite LocationAPA Bipolar Disorderhttp://psychiatryonline.org/content.aspx?bookid=28&sectionid=1669577APA Major Depression6-102014 Practitioner and Provider Manual - Ver. 3

Care CoordinationClinical Practice Guidelines and ToolsGuidelines and ToolsWebsite Locationhttp://psychiatryonline.org/guidelines.aspxAPA Schizophreniahttp://psychiatryonline.org/content.aspx?bookid=28&sectionid=1665359AAP Attention Deficit Hyperactivity Disorder (ADHD)http://pediatrics.aappublications.org/content/105/5/1158.full.pdf+html?sid=f4a99748-b682-4ec4-a4f3-8d545eb204a6AsthmaGuidelines for the Diagnosis and Management of Asthma Full Report (NationalAsthma Education and Prevention Program, National Heart, Lung, and BloodInstitute)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1029224.pdfGuidelines for the Diagnosis and Management of Asthma Summary Report(National Asthma Education and Prevention Program, National Heart, Lung, andBlood Institute)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1000916.pdfGuidelines for the Diagnosis and Management of Asthma – Full Report ChangePage (National Heart, Lung, and Blood Institute)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031055.pdfAttention Deficit/Hyperactivity Disorder (ADHD)ADHD Diagnosis and Evaluation Guidelineshttp://pediatrics.aappublications.org/content/105/5/1158.full.pdf+html?sid=f4a99748-b682-4ec4-a4f3-8d545eb204a6Treatment of School-Aged Children with ADHDhttp://pediatrics.aappublications.org/content/108/4/1033.full.pdf+htmlADHD Quick Reference Guidehttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/wcmdev1000899.pdfCoronary Artery DiseaseAHA/ACC Secondary Prevention for Patients with Coronary and Other VascularDisease: 2006 Update (American College of Cardiology and the American HeartAssociation)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00052254.pdfCoronary Artery Disease Clinical Practice Guidelines (American College ofCardiology and the American Heart Association)http://docs.phs.org/idc/groups/public/@phs/@marketing/documents/phscontent/wcmdev1000934.pdfCoronary Artery Disease Clinical Recommendations for Prevention of HeartDisease in Women (American Heart Association)http://docs.phs.org/idc/groups/public/@phs/@marketing/documents/phscontent/wcmdev1000935.pdf6-112014 Practitioner and Provider Manual - Ver. 3

Care CoordinationClinical Practice Guidelines and ToolsGuidelines and ToolsDepressionWebsite LocationDepression Guidelines for Primary Care Practitioners Treating Adult Patientswith Depressionhttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/wcmdev1001004.pdfDiabetesObesityDiabetes Clinical Practice Guidelines for Providers–Non-Pregnant Adulthttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001010.pdfGetting in Balance Worksheet to Identify Overall Weight-Related Health Risk(Clinical prevention Initiative)http://www.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031069.pdfOverweight & Obesity in Primary Care (Clinical Prevention Initiative)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1030683.pdfQuick Discussion Guide for Adult Weight Counseling in Primary Care (ClinicalPrevention Initiative)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031068.pdfGetting in Balance Worksheet to Identify Overall Weight-Related Health Risk(Clinical prevention Initiative)http://www.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031069.pdfQuick Discussion Guide for Adult Weight Counseling in Primary Care (ClinicalPrevention Initiative)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031068.pdfAs guidelines are updated, Presbyterian notifiesproviders in a subsequent issue of the “NetworkConnection” provider newsletter. In addition,updates are posted on the Presbyterian website athttps://www.phs.org/providers/cliniciansresources/Pages/health-services.aspx.If you godirectly to the phs.org website, you can access theguidelines by following this pathway:Go to www.phs.orgSelect “For Providers” from the top menuSelect “Clinicians’ Resources”Select “Health Services Resources” from themenu on the leftScroll down to “Clinical Practice Guidelines”and select desired guideline.Predictive ModelingPredictive modeling is a tool that applies riskfactors to claims, utilization patterns, andpharmaceutical and lab data using a mathematical6-122014 Practitioner and Provider Manual - Ver. 3

Care Coordinationformula, which is then used to predict future risk ofcosts and utilization. Using this tool, we are able tooffer your patients proactive intense carecoordination interventions and assistance withnavigation of the health care system. Predictivemodeling is also useful in member stratification fordisease management interventions.Medical Records and Confidentiality AssuranceThere may be instances where records from youroffice or facility are requested to ensure that correctand timely coverage decisions are rendered, toreview records for a special utilization/quality study,or as required by regulatory agencies such as:HealthInsight New Mexico. Presbyterian iscommitted to requesting the minimum amount ofinformation required and assisting with either onsitereview or telephone discussions to minimizeadministrative burdens. We currently reimburseproviders $30.00 for the first 15 pages and $0.15per page after the first 15 pages (based on the NewMexico Administrative Code [NMAC], Title 16,Chapter 10.17.8).Presbyterian ensures that Health InsurancePortability and Accountability Act (HIPAA)requirements are met and maintains confidentialrecords files. All information and medical recordsobtained during the course of review activities shallbe treated as confidential, in compliance with allapplicable state and federal regulations.Presbyterian uses reasonable diligence to preventinappropriate disclosure. This obligation excludesdisclosure of information that is required by state orfederal law or is in the public domain.Provider ProfilesPresbyterian is committed to working with providersto improve the quality of care provided to ourmembers. Part of this commitment includessending a Physician Performance Assessment(PPA) to providers. The PPA is based on the datasubmitted on claims processed and paid byPresbyterian and goes to PCPs who have largeenough panels and claims activity to make a PPAreport statistically meaningful. The data adjusts forseverity of illness of the members on a provider’spanel and reports on quality measures associatedwith prioritized initiatives.Data is processed through clinical informaticssoftware to analyze utilization, costs, and clinicalindicators and includes case mix index andcomparative peer data.Presbyterian also sends lists of members who maybe due for health maintenance testing,immunizations, preventive health care screenings(such as mammograms), or pharmaceuticals. ThePPAs and member lists are intended to be tools forthe provider to aid in the improvement of the healthof patients. We encourage feedback from theprovider on the information contained in the PPAsand member lists so that we can continue toimprove these tools and the data contained inthem. For questions regarding a PPA or a memberlist, providers may call the number in the coverletter included with the provider’s packet. Atpresent, PPAs and member lists are available forPCPs only.6-132014 Practitioner and Provider Manual - Ver. 3

Care CoordinationUnder- and Overutilization AnalysisAnnually, Presbyterian chooses relevant types ofutilization data to monitor for each product line todetect potential under- and overutilization ofservices. Examples might include emergency roomvisits, hospital days, certain procedures, behavioralhealth admissions, and community benefits.Presbyterian monitors these data elements,compares them to national benchmarks, and tracksthem over time to identify trends. If under- oroverutilization problems are identified, Presbyteriantakes action to address causes of the trend andinform providers as appropriate.Technology AssessmentThe Technology Assessment Committee (TAC)provides a process for reviewing all technologyrecommendations, and new medical, experimental,investigational, or behavioral therapies orprocedures.Following a formal application process, the TACevaluation includes a literature search, review ofgovernmental and regulatory publications, andexpert opinion. The TAC also recommends clinicalpolicies and procedures. This includes procedures,drugs, and devices. The TAC is chaired by aPresbyterian senior medical director.Medical Policy Development and DisseminationCoverage decisions are based onEligibilityMember’s contractual benefitsPresbyterian Health Plan, Inc., Medical PolicyManualIndividual, community, and/or local deliveryconsiderations.If there is a conflict between the member’s contractand the Medical Policy Manual, the contract willgovern.Presbyterian uses nationally recognized medicalreview criteria to assist in certifying benefitcoverage. Medical policies are reviewed bypracticing New Mexico practitioners and must beapproved by the Presbyterian Clinical QualityCommittee, consisting of local providers as well asPresbyterian clinical staff.Review criteria may includeHayes, Inc. (a nationally recognized andindependent health technology assessmentcompany)Centers for Medicare and Medicaid Services(CMS) Medical Policy GuidelinesThe CMS Durable Medical EquipmentMedicare Administrative Contractor (DMEMAC), Jurisdiction CLocal Medical Review Board Medical PoliciesMilliman Care Guidelines (a nationallyrecognized company specializing in bestpractice continuum of care recommendations)New Mexico Medical Assistance DivisionProgram GuidelinesOregon Outpatient Therapy Guidelines forChildren with Special Healthcare NeedsApollo Guidelines for ManagingPhysical/Occupational/Speech Therapy andRehabilitation Care6-142014 Practitioner and Provider Manual - Ver. 3

Care CoordinationAmerican Psychiatric Association Levels ofCareAmerican Academy of Child and AdolescentPsychiatry Levels of CareAmerican Society of Addiction MedicineLevels of CareHealth Plan’s Uniform Level of CareGuidelinesPresbyterian Health Plan, Inc., Medical PolicyManualPresbyterian encourages providers and membersto contact us for information about the medicalpolicies or for copies of the medical policies usedfor specific coverage determinations. The MedicalPolicy Manual is available athttps://www.phs.org/providers/cliniciansresources/medical-policymanual/Pages/default.aspx.Continuity of CareHealth Services staff assists members wheneverpossible in making a smooth transition betweenproviders when necessary; for example, ifA new member enrolls from a previous insurerto PresbyterianA member’s health care provider leaves or isterminated from Presbyterian’s networkA member voluntarily switches or is switchedto another health planA member’s coverage ends or benefits areexhaustedThe transitional period is administered inaccordance with all applicable law, rules, andregulations. Currently, the period continues for aperiod of time that is sufficient to permit coordinatedtransition planning consistent with the member’scondition and needs relating to the continuity of thecase. The period is less than 30 days but may beextended for a period of active treatment or up to90 days, whichever is shorter, or as otherwisemandated by contract or regulation.Transition of care is covered for women in theirsecond or third trimester of pregnancy and fortransplant patients.Providers or members may call the PresbyterianCustomer Service Center for assistance withcontinuity of care issues.Family Planning (Presbyterian Centennial CareOnly)Presbyterian Centennial Care must allow membersthe freedom of choice, and the methods ofaccessing family planning services, withoutrequiring a referral from the PCP.Clinics and providers, including those funded byTitle X of the Public Health Service Act, shall bereimbursed by Presbyterian Centennial Care for allfamily planning services regardless of whether theyare participating or non-participating providers.Unless otherwise negotiated, PresbyterianCentennial Care shall reimburse providers of familyplanning services at the Presbyterian CentennialCare fee schedule.Family planning services are defined asHealth education and counseling necessary tomake informed choices and understandcontraceptive methods6-152014 Practitioner and Provider Manual - Ver. 3

Care CoordinationLimited history and physical examinationLaboratory tests, if medically indicated, as partof the decision-making process for choice ofcontraceptive methodsDiagnosis and treatment of sexuallytransmitted diseases, if medically indicatedScreening, testing, and counseling of at-riskindividuals for human immunodeficiency virusand referral for treatmentFollow-up care for complications associatedwith contraceptive methods issued by thefamily planning providerProvision of, but not payment for,contraceptive pills (refer to formulary)Provision of devices/suppliesTubal ligationVasectomiesPregnancy testing and counselingPresbyterian Centennial Care is not required underany Human Services Department (HSD)-initiatedobligation to reimburse non-participating familyplanning providers for non-emergent servicesoutside the scope of these defined services.For guidelines about sterilization and termination ofpregnancy, please see the The following isinformation regarding global maternity billing (bycovered providers such as primary careobstetricians and specialists).If the delivery of the newborn is greater than threemonths past the mother’s eligibility date,Presbyterian pays the global feeIf the delivery is within three months of the mother’seligibility, a breakdown of services (prenatal visits,delivery, and postpartum visits) from the first day ofeligibility is needed from the providerThe following procedure must be followed whensubmitting fragmented, non-global obstetrics (OB)delivery claims to Presbyterian:Use generic Evaluation and Management or OBvisit codes to report prenatal visitsThe beginning date of service is equal to the initialprenatal visitThe number of units equals the total number ofprenatal visitsThe appropriate charge should be entered into thecharge columnPregnancy Termination and Physician Certificationof Medical Necessity for Pregnancy Terminationsections of the Claims and Payment chapter of thismanual.Dental Care (Presbyterian Centennial CareOnly)Routine dental exams and prophylaxis (cleanings)do not require a referral. Members may access inplandental providers without obtaining a referral orprior authorization from Presbyterian CentennialCare. Providers may contact Presbyterian’spartner, DentaQuest, at 1-855-390-6424. Membersmay call the Presbyterian Customer Service Centerfor information about in-plan dental providers.Vision Services (Presbyterian Centennial Careonly)Routine vision services do not require a referral.Members may access in-plan vision providers6-162014 Practitioner and Provider Manual - Ver. 3

Care Coordinationwithout obtaining a referral or prior authorizationfrom Presbyterian Centennial Care. Providers maycontact Presbyterian’s partner, VSP, at 1-800-852‐7600. Members may call the PresbyterianCustomer Service Center for information about inplanvision providers.Medicare NoticesImportant Message to Medicare BeneficiariesUpon admission to a contracted or non-contractedacute care hospital, the hospital will provideMedicare Advantage members with the Centers forMedicare and Medicaid Services (CMS) documententitled “An Important Message to MedicareBeneficiaries.” This document explains theMedicare Advantage member’s appeal rights whenreceiving care in an acute hospital setting.Once the Medicare Advantage member has signedthe document, the hospital must deliver a follow-upcopy as far in advance of discharge as possible butnot more than two calendar days before theplanned date of discharge except when the originalImportant Message from Medicare was deliveredwithin two calendar days of discharge.Detailed Notice of DischargePresbyterian will communicate in an expeditiousmanner with the Quality Improvement Organization(QIO) in order to facilitate appeals. When a QIOnotifies Presbyterian that a member has requestedan immediate review, Presbyterian will directly orby delegation deliver a “Detailed Notice ofDischarge” to the member. This document providesa detailed explanation of why acute care hospitalservices are no longer covered.Notice of Medicare Non-CoveragePresbyterian Medicare Advantage beneficiaries andMedicare recipients receiving home health care orthose in a Skilled Nursing Facility (SNF) must begiven a CMS-approved written notice informingthem that their covered home health care or SNFservices are ending. The notice must be given twodays in advance of services ending. If services areexpected to be less than two days, the notice mustbe given upon admission to the provider (facility).In a non-institutional setting, if the span of timebetween services exceeds two days, the providershould deliver the notice no later than the next tolast time that services are furnished. The noticeincludes the date the enrollee’s financial liability forcontinued services begins and a description of themember’s right to an expedited appeal to a QIO.Care Coordination will ensure that providers havethe appropriate CMS approved forms to give tomembers.Home Skilled Nursing Facility (SNF) Rule UnderMedicareThe “Home SNF Rule” refers to provisions affectingthe choices Medicare Advantage members havewhen needing SNF care, following discharge from ahospital stay. The rule allows a hospitalizedMedicare Advantage member who requires skillednursing care and is ready for discharge to elect oneof the following three options:The member can return to the SNF fromwhich they came.They may go to the SNF where their spouseis.6-172014 Practitioner and Provider Manual - Ver. 3

Care CoordinationThey may go back to their Continuing CareRetirement Community SNF, if applicable.If the “Home SNF” is a non-participating provider(facility), Presbyterian Medicare Advantagebeneficiaries or the delegated entity must attemptto contract with the non-participating provider.Special PopulationsSpecial populations require a broad range ofprimary specialized medical, behavioral health, andrelated services. Presbyterian follows HSDguidelines for determining special populations. Wecurrently define adult special populations asAge 18 years and olderHaving ongoing physical, mental,neurobiological, emotional, and/or behavioralhealth conditionsRequiring health care and related servicesthat are different from the services required bymost individualsHaving functional limitationsPresbyterian currently defines child specialpopulations asAge up to 18 yearsHaving or at an increased risk for an ongoingphysical, developmental, neurobiological,mental, or behavioral/emotional healthconditionRequiring health care and related servicesthat are different from the services required bymost childrenChildren identified in the Department of HealthTitle V Children’s Medical Services ProgramChildren receiving foster care or adoptionassistance support through Title IV EOther children in foster care or out-of-homeplacementChildren who are eligible for services throughthe Individuals with Disabilities Education ActOther children whose clinical assessmentshows that they have special health careneedsProviders are encouraged to help educatemembers, their families, and their caregiversregarding special considerations and needs fortheir care, including care coordination, specialtransportation needs, therapy services, DME, andcoordination of emergency inpatient and outpatientambulatory surgery services with facilities andhospitalists.AppealsIf we are unable to prior authorize/certify a request,the provider or facility may appeal this decision.The provider is not prohibited from advocating onbehalf of the member. The criteria used to makethis determination will be made available to theprovider. In addition, the provider may speakdirectly to the medical director. Refer to theAppeals and Grievances chapter of this manual forinformation on filing appeals.Children who are eligible for SupplementalSecurity Income as disabled under Title XVI6-182014 Practitioner and Provider Manual - Ver. 3

Care CoordinationSpecialists as PCPs for Members with SpecialHealth Care NeedsOn an individual basis, specialists treatingmembers with disabilities or chronic/complexconditions may serve in the capacity of PCP. Thespecialist is credentialed as a PCP/Specialist andperforms all PCP duties within the scope of theparticipating specialist’s certification.Contact your provider network managementrelationship executive listed in the Provider NetworkRelations Contact Guide athttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf.Behavioral Health Care CoordinationMembers may access the Behavioral Healthnetwork of contracted providers without a referral orprior authorization. They do not need a referral formost outpatient services. Behavioral HealthServices for Centennial Care members areadministered through Magellan. For assistance infinding behavioral health providers, you or yourpatients may contact the following:For Commercial, Presbyterian Senior Care (HMO)and MediCare PPO members: 505-923-5221 or 1-866-593-7431.For Centennial Care members: 505-923-8858 or 1-866-672-1242.Presbyterian encourages PCPs and behavioralhealth practitioners to communicate with oneanother regarding individual cases.Members may access Centennial Care contractedbehavioral health providers without a referral orprior authorization. Referrals are not needed formost outpatient services.For Presbyterian Centennial Care patients, theprovider can make a direct referral for BehavioralServices based on the following indicators:1. Suicidal/homicidal ideation or behavior;2. At-risk of hospitalization due to a BehavioralHealth condition;3. Children or adolescents at imminent riskof out-of-home placement in a psychiatricacute care hospital or residential treatmentfacility;4. Trauma victims;5. Serious threat of physical or sexual abuseor risk to life or health due to impairedmental status and judgment, mentalretardation, or other developmentaldisabilities;6. Request by Member or Representative forBehavioral Health services;7. Clinical status that suggests the need forBehavioral Health services;8. Identified psychosocial stressors andprecipitants;9. Treatment compliance complicated bybehavioral characteristics;10. Behavioral and psychiatric factorsinfluencing medical condition;11. Victims or perpetrators of Abuse and/orneglect and Members suspected of beingsubject to Abuse and/or neglect;12. Non-medical management of substanceabuse;13. Follow-up to medical detoxification;6-192014 Practitioner and Provider Manual - Ver. 3

Care Coordination14. An initial PCP contact or routine physicalexamination indicates a substance abuseproblem;15. A prenatal visit indicates substance abuseproblems;16. Positive response to questions indicatessubstance abuse, observation of clinicalindicators or laboratory values that indicatesubstance abuse;17. A pattern of inappropriate use of medical,surgical, trauma or emergency roomservices that could be related to substanceabuse or other Behavioral Health conditions;and/or18. The persistence of serious functionalimpairment.For additional detail on procedures for authorizationof behavioral health services, please refer to theBehavioral Health chapter of this manual.Medical Record ReviewsMedical record reviews are performed for primarycare practitioners, OB/GYN practitioners, and highvolumebehavioral health specialists. The followingcriteria apply:A passing score of 85 percent is required.If the medical record review score is less than85 percent, Presbyterian may choose to doany or all of the following:• Identify deficiencies and send a letter tothe provider that identifies complianceissues• Suggest an action plan for improvement,and send an example education form• Publish best practices for medical recorddocumentation in the provider newsletter• Coordinate with Provider Services formedical record review follow-upPresbyterian Access to Medical RecordsPresbyterian has adopted the following medicalrecord access standards from Title 8 and Title 13 ofthe NMAC, the Medicare Managed Care Manual,and the HIPAA Standards for Privacy of IndividuallyIdentifiable Health Information. Providers agree tocomply with the following:The primary care practitioner must maintain aprimary medical record for each member thatcontains sufficient medical information from allproviders involved in the member’s care toensure continuity of care.All providers involved in the member’s careshall have access to the member’s primarymedical record.Providers shall request information from othertreating practitioners, with a signed consentfrom the member, as necessary to ensurecontinuity of care.Medical records shall be available to providersfor each clinical encounter. Each specialtycare practitioner shall forward a record to themember’s primary care practitioner of theservices provided.Providers shall ensure the confidential transfer ofmedical, dental, or behavioral health information toanother primary medical, dental, or behavioralhealth provider when a primary medical, dental, orbehavioral health practitioner leaves Presbyterian6-202014 Practitioner and Provider Manual - Ver. 3

Care Coordinationor when the member changes primary medical,dental, or behavioral health practitioners. Theinformation forwarded shall include but is notlimited to the following:A list of the member’s principal physical andbehavioral health problems, as applicableA list of the member’s current medications,dosage amounts, and frequencyThe member’s preventive health serviceshistoryEarly and Periodic Screening, Diagnosis, andTreatment (EPSDT) screening results (forPresbyterian Centennial Care members underage 21)Other information necessary to ensurecontinuity of carePractitioners shall ensure that they have policies orplans in place for medical record authorized accessand coordination in the event that they areincapacitated in some way.Practitioners and providers shall make any and allmember medical records available to PHP,Presbyterian Insurance Company, Inc., the NewMexico Superintendent of Insurance, the CMS, theNew Mexico Human Services Department (HSD),and other state and federal regulatory agencies ortheir agents, for the purpose of quality review,annual NCQA HEDIS ® audits, and for investigationof member grievances or complaints.Minimum Medical Record StandardsPresbyterian has adopted medical recordsstandards from the NCQA, the NMAC, Title 8,Section 305.8.17, and the Medicare Managed CareManual. The following standards apply to bothphysical and behavioral health unless otherwisenoted:1. ConfidentialityPatient records must be maintained and managedin a confidential manner in accordance with allapplicable state and federal laws, including, but notlimited to, the privacy and security rules asprovided for under HIPAA.2. Legibility and Provider IdentificationPatient records must be maintained in atimely, legible, current, detailed, andorganized manner to permit effective andconfidential patient care and quality review.The patient record must be legible to personsother than the writer.3. EntriesAll entries must be dated and include date of entryand date of encounter. The entries, includingdictation, must be identified by the author andauthenticated by his or her entry. Authenticationmay include signature or initials verifying that thereport is complete and accurate. Patient recordnotes generated or stored electronically bycomputer are considered authenticated if there is ademonstrated password-protected entry with atime-limited edit capability.4. Organization/Patient IdentificationPatient records must be organized systematicallyand uniformly. Paper documentation must be firmlysecured or attached in the patient record/medical6-212014 Practitioner and Provider Manual - Ver. 3

Care Coordinationrecord. Patient identification information must bepresent on each page or electronic file.Individual patient records are recommended asopposed to family records. If family records areused, each patient’s component of the record mustbe clearly distinguishable and organized. Eachpage in the patient’s record must contain patientname or patient identification number.5. Personal Biographical DataThis may include age, sex, date of birth, address,employer, school, home and work telephonenumbers, names and telephone numbers ofemergency contacts, marital status, consent forms,and guardianship information.6. AllergiesAllergies must be documented in a uniformlocation on the patient record.Adverse reactions must be listed, if present.Document no known allergies (NKA), ifapplicable.7. Documentation of Tobacco, Alcohol, andSubstance AbuseNotations must be made concerning tobacco,alcohol, or recreational/illicit substance use (allpatients over 12 years of age).8. Problem List (as appropriate forpractitioner/practice type)Identification of current problems, significant illness,and medical conditions are documented on theproblem list. If the patient has no known medicalillness or condition, the medical record must includea flow sheet for health maintenance.9. Medication List and History (as appropriate forpractitioner/practice type)Reflects current medications and medicationhistory, including what has and what has not beeneffective.10. Periodic Health Examinations (Physical HealthOnly)Required examination elements are includedin the Presbyterian Health Plan, Inc.,Preventive Healthcare Guidelines athttps://www.phs.org/better-health/access-your-care/Pages/preventive-care-guidelines.aspx.Examinations for Presbyterian CentennialCare children under the age of 21 must meetthe guidelines for the EPSDT Programservices for New Mexico Medicaid.The Presbyterian EPSDT Program ProviderManual contains links to the New MexicoMedical Assistance Division’s PreventiveHealth Guidelines and anticipatory guidanceschedules. The Presbyterian EPSDT ProgramManual is available athttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001063.pdf or• Go to www.phs.org• Select “For Providers” from the top menu• Scroll down to “Health ServicesResources”• Select EPSDT Provider Training Manualfrom list under Forms and Documents6-222014 Practitioner and Provider Manual - Ver. 3

Care Coordination11. Prevention Screening, Patient Education andCounseling (Physical Health Only)Documentation is present as applicable forproblems and current diagnosis. For Medicaidrecipients, the status of preventive services, or atleast those specified by the NMHSD, must besummarized on a single sheet in the medical recordwithin six months of enrollment. Lifestylemanagement and preventive health careinformation must be documented and includes butis not limited to the information in the list below. Acomprehensive list of screening and counselingtopics is available in the Presbyterian PreventiveHealthcare Guidelines for practitioners athttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001475.pdf.Family planningCancer prevention and detection (such as sunexposure and breast, cervical, testicular, andcolon cancer screenings, as appropriate)Injury prevention – at least one of thefollowing:• Vehicle safety belts• Occupational hazards• Home safetySmoke alarmsPromotion of preventive health care screeningand counselingHIV infection and other sexually transmitteddiseasesTobacco useAlcohol and substance use/abuseOsteoporosis and heart disease inmenopausal womenMotor vehicle injuriesHousehold and recreational injuriesDental and periodontal diseaseUnintended or mistimed pregnanciesObesityPhysical activityHealthy diet12. Durable Power of Attorney/Advance Directives(Physical Health Only)Documentation must be present in the medicalrecord that each adult patient was offeredinformation on durable power of attorney/advancedirectives. The documentation should be signedand dated by the patient and the practitioner and bemaintained in the patient medical record. Anadvance directive form is available on thePresbyterian website athttps://www.phs.org/providers/cliniciansresources/Pages/health-services.aspxunderMedical Record Standards and Requirements.13. Patient Notification of Abnormal Diagnostic TestResults (Physical Health Only)Patients must be notified of abnormal diagnostictest results and the scheduled follow-up visit, plans,and/or directions.14. Consultations/ReferralsDocumentation must be present in themedical record regarding medical care,services, and results for consultations.6-232014 Practitioner and Provider Manual - Ver. 3

Care CoordinationReferral Information. The patient’s pastmedical or surgical history and results ofprevious diagnostic tests must be recorded inthe medical record. Documentation must bepresent in the patient record indicating thatpertinent medical or behavioral information iscommunicated from the specialist to theprimary care practitioner.15. X-Ray, Lab, and Imaging Reports, Referrals,and Diagnostic Information (Physical Health Only)Reports must be filed in the medical recordand initialed by the PCP signifying review.Consultation and abnormal lab imaging studyresults should have an explicit notation in themedical record for follow-up plans.Referrals, past medical records, hospitalrecords (such as operative and pathologyreports, admission and discharge summaries,consultations, and emergency room reports)should be filed in the medical record.16. Past Medical History (as appropriate forpractitioner/practice type)Past medical history must be obtained on firstvisit for patients under age 21 and for patientsage 21 or older when the patient is seen twoor more times.Past medical history should be easilyidentifiable and include serious accidents,operations, illnesses, and familial or hereditarydisease or mental illness.17. Medically Appropriate Care (as appropriate forpractitioner/practice type)Diagnosis and treatment plans must bedocumented and medically appropriate.18. Hospital and Outside Clinical Records (asappropriate for practitioner/practice type)Pertinent documents must be present in order tofacilitate continuity of care for hospital, ambulatorysurgical facility, behavioral health facility,emergency room visits, etc.19. Immunization Status (Physical Health Only)Appropriate immunizations for children,adolescents, and adults must be noted.Individual Clinical EncountersAt a minimum, the patient’s record must include thefollowing detail as appropriate forpractitioner/practice type:History and physical examination for thepresenting complaint, including relevantpsychological and social conditions affectingthe patient’s medical and psychiatric statusSubjective patient information and objectivephysical findingsWorking diagnosis consistent with findings(practitioner’s medical impression)Documentation of plan of action and treatmentconsistent with diagnosesDiagnostic tests and/or resultsDrugs prescribed including the strength,amount, and directions for use and refillsTherapies and other prescribed regimes orresults6-242014 Practitioner and Provider Manual - Ver. 3

Care CoordinationFollow-up plans or directions such as time forreturn visit or symptoms that should prompt areturn visitConsultations and referrals and resultsPatient compliance/non-compliance (such ascanceled or missed appointments, no-show,or other indications of patient non-compliance)Documented patient follow-upCounseling session start and stop time(behavioral health only)Any other significant aspects of patient careBehavioral Health PractitionersFor patients who receive three or more serviceswithin a 12-month period, the following must bedocumented in the behavioral health record:A mental status evaluation which documentsaffect, speech, mood, thought content,judgment, insight, concentration, memory, andimpulse controlDSM-IV diagnosis consistent with the history,mental status examination, or otherassessment dataA treatment plan consistent with diagnosis,which has objective and measurable goalsand time frames for goal attainment orproblem resolutionDocumentation of progress toward attainmentof the goalPreventive services such as relapseprevention and stress managementRisk Stratification and Predictive ModelingOur risk stratification process includes gatheringand analyzing available member eligibility andenrollment data, claims information, historicalutilization data, and care plan and serviceauthorization information to create an initial profilefor each member. This information is loaded intoour predictive modeling system and flags aregenerated identifying high cost, complex conditions,or other indicators. Presbyterian Centennial Careuses the results of the HRA combined withpredictive modeling flags to preliminarily classifymembers into Care Coordination Levels 1, 2, or 3.We are then able to offer our providers’ patientsproactive care coordination, interventions, andassistance in navigating the health care system.Member AwarenessMembers receive the Member Handbook, whichdescribes services that are available to them.Medically necessary services or supplies may beauthorized for up to one year. Member handbooksand explanation of benefits are available online onthe Member Download Library web page athttps://www.phs.org/insurance-plans/memberdownload-library/Pages/default.aspxby selectingindividual plans from the dropdown.Member Medical SummaryMembers may need to access services fromproviders who may not be familiar with their history.Presbyterian includes a medical summary form inthe Member Handbook to assist members inproviding their medical histories. Members are6-252014 Practitioner and Provider Manual - Ver. 3

Care Coordinationasked to update their records by one of thefollowing methods:Regularly update this medical summary andcarry it with them at all times so they canpresent it when accessing care.Enter updates into MyChart(https://www.phs.org/better-health/accessyour-care/Pages/access-your-healthinformation.aspx).Presbyterian's MyChartgives members secure online access to theirmedical records and helps them keep track ofall their medical information.Call the Presbyterian Customer ServiceCenter at 505-923-5200 or 1-888-977-2333.Referral Requests/Prior AuthorizationMembers need to see their PCPs for referrals forservices and specialty care. In most cases, thePCP is required to submit a referral request for aservice, such as a specialist visit or a specifictherapy. The PCP either gets an authorizationnumber or a notice that a service requires priorauthorization. PCPs or other providers submittingreferral requests are encouraged to submit themonline so they get immediate notification of theaction, authorization number, or notice that thereferral request has been received and is in theprior authorization process. The referring providershould notify the treating provider of theauthorization number to be submitted on a claim.Members may self-refer and do not need priorauthorization for emergency care, urgent care,behavioral health, and women’s health care.In addition, benefits with limitations may alsorequire a prior authorization.For a complete list of services that require a referralrequest or prior authorization, please referenceAppendix F.Home Health ServicesPresbyterian Centennial Care home care servicesare managed through the Presbyterian HomeHealthcare Statewide Network (PHHSN).PHHSN provides utilization management throughreview of prior authorization requests for home careservices. The review is to ensure that the rightservices are provided at the right frequency,duration, and level needed. Please refer to theHome Health chapter of this manual for detailedauthorization requirements and guidelines.Laboratory ServicesPresbyterian requires providers to refer theirpatients to an in-network laboratory servicewhenever possible. TriCore Reference Laboratoriesis the only laboratory service within the network atthis time.Presbyterian uses the Clinical LaboratoryImprovement Amendments Waive Test list. The listapplies to all Presbyterian product lines, and iseffective for dates of service on or after January 1,2014.Please refer to the Laboratory Services chapter ofthis manual for more information.6-262014 Practitioner and Provider Manual - Ver. 3

Care CoordinationPharmacy BenefitsProviders are required to comply withPresbyterian’s formulary requirements formedications. Some medications on the formularymay require prior authorization. The priorauthorization process is available once a memberhas tried and failed all formulary agents and it isdeemed medically necessary to have access to anon-formulary agent. (Please see the Pharmacychapter for detailed information.) The formularies,pharmacy prior authorization forms, specialtypharmaceuticals listing, and specialty drug requestform are available on the pharmacy page athttps://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.Providers may obtain a copy of the formularies bydownloading them from http://www.epocrates.com.Contacts for Other InformationThe following table includes contacts for otherinformation you may need.6-272014 Practitioner and Provider Manual - Ver. 3

Care CoordinationContacts for Other Information Providers May NeedRequestMember Eligibility VerificationPrior Authorization Guide forCommercial and Medicare PlansmyPRES at https://mypres.phs.org.Contact InformationInteractive Voice Response numbers: 505-923-5757 or 1-888-923-5757, Option 1http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001400.pdfMost Outpatient RequestsInpatient AdmissionsmyPRES at https://mypres.phs.orgPhone: 505-923-5757 or 1-888-923-5757, Option 4Fax: 505213-0246myPRES at https://mypres.phs.orgPhone: 505-923-5757 or 1-888-923-5757, Option 4Fax: 505-213-0181 or 1-888-923-5990Behavioral Health Requests Phone: 505-923-5221 or 1-866-593-7431Dental Requests (DentaQuest)Fax: 505-213-0169www.dentaquestgov.comPhone: 1-800-233-1468Fax: 1-262-241-7150myPRES at https://mypres.phs.org/Pages/default.aspxHome Health Requests Phone: 505-559-1151 or 1-877-606-115124/7 phone: 505-559-1000Local Fax: 505-559-1150Toll-Free Fax: 1-877-606-1155myPRES at https://mypres.phs.orgPharmacy Requests Phone: 505-923-5757, Option 3 or 1-888-923-5757, Option 3Radiology/Diagnostic ImagingRequests (through HealthHelp ® )Phone: 1-888-318-0280Fax: 1-888-717-9655Non-emergency medical transportation (Superior Medical Transport) for Centennial Care members only:505-923-6300 and toll-free 1-(855)-774-7737.Transportation Requests Air Transportation: Phone: 505-923-5757 or 1-888923-5757, Option 46-282014 Practitioner and Provider Manual - Ver. 3

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Care Coordination7. Laboratory Services7. Laboratory ServicesPresbyterian uses the Clinical LaboratoryImprovement Amendments (CLIA) waive test list forlaboratory services. The list applies to allPresbyterian product lines, and is effective fordates of service on or after January 1, 2014.Reimbursement for these pathology/laboratoryservices is based on Presbyterian’s Clinical Lab feeschedule, unless your contract states otherwise.Please note that certain Current ProceduralTerminology codes are restricted to specificspecialties.The CLIA waive test list can be located athttp://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf.The list includes pathology/laboratory services thatmay be performed in the physician’s office. The listincludes a description identifying codes along withany limitations for each service. It is theresponsibility of the provider to establishappropriate CLIA waive test certification, or to applyfor a CLIA waive test certificate, if the choice ismade to perform any of these services.Reimbursement for these services remains at thecurrent Presbyterian fee schedule and payment issubject to the member’s eligibility, benefit plan, andbenefit limitations.Mexico. TriCore is the only laboratory service withinthe Presbyterian network at this time. Using orreferring to another laboratory service could resultin unnecessary additional expenses for yourpatients and violate the terms of your Agreementwith Presbyterian. Please be advised thatPresbyterian is monitoring all non-contractedlaboratory use.Please be aware that non-contracted laboratoriesmay solicit health care professionals belonging toour network with the assertion that they can accept“Presbyterian insurance.” Presbyterian willcommunicate with you to keep you informed of anyfuture network changes.A complete list of TriCore locations and contactinformation is available athttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00078812.pdf.If you have issues or questions, please contactyour provider network management relationshipexecutive athttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf.Using Contracted Laboratory ServicesTriCore Reference Laboratories is Presbyterian’sexclusive, independent contracted laboratory andprovides laboratory services throughout New7-12014 Practitioner and Provider Manual - Ver. 3

Laboratory ServicesTriCore Contact InformationDepartmentContact InformationClient Services (test results, TriCore locations, specimenrequirements, general information)505-938-8922 (24 hours)1-800-245-3296 (24 hours)Client SuppliesFor phone or fax orders:505-938-8957 (phone)1-800-245-3296 ext. 8957 (phone)505-938-8472 (fax)Logistics/Couriers 505-938-89581-800-532-2649505-954-3780 (Santa Fe)For online supply orders, call the Supply Order Desk:505-938-8957 or 1-800-245-3296, ext. 8957IS Help Desk (printer, TriCore Express, TriCore Direct, andcomputer-interface assistance)505-938-8974 or 1-800-245-3296, ext. 8974Sales and Service 505-938-8917 or 1-800-245-3296, ext. 8917Billing/Business Office 505-938-8910 or 1-800-541-9557505-938-8640 (fax)Main Numbers505-938-8888 (24 hours)1-800-245-3296 (24 hours)7-22014 Practitioner and Provider Manual - Ver. 3

Pharmacy8. Pharmacy8. PharmacyProvider GuidelinesThe Presbyterian pharmacy benefit is an essentialelement in providing Presbyterian patients themedication they need while appropriately managingcosts. As the patient’s provider, you are the key tothe appropriate use of pharmaceuticals, whichincludesChoosing the best, most cost-effective drugand dosage form to treat the patient’scondition and complying with Presbyterian’sformulary requirementsMaking sure each patient clearly understandsthe use of the drug, the correct dose, andpossible side effectsLooking for key drug interactions anddiscontinuing ineffective drugsReviewing each patient’s medication list anddosages at every visitCarefully monitoring therapeutic drug levels asnecessaryPlease take time to become familiar with thePresbyterian prescription program and thePresbyterian formularies. These are helpful tools tomanage both quality and cost for our members.Providers may obtain a copy of the formularies bydownloading them from http://www.epocrates.com/or by visiting the pharmacy page athttps://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.You may also call us for additional assistance.Following is a list of phone numbers to expediteservice:Pharmacy Services Helpdesk Phone Number505-923-5500 or Toll Free 1-888-923-5757Pharmacy Services Fax Number505-923-5540 or Toll Free 1-877-640-5814ASKRXASKRX@phs.org is an email box we have createdto better serve providers. Any questions orconcerns can be emailed directly to this box, whichis monitored hourly by one of our clinicalpharmacists. Any email sent to ASKRX is answeredwithin one business day.National Drug CodeAs a reminder, you must bill with National DrugCodes (NDCs). For more information about thisrequirement, please see the NDC ProcedureManual, located athttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00079542.pdf.Benefit GuidelinesThe following describes the general administrationof the Presbyterian pharmacy benefit. All productlines vary in structure. For example, some follow aclosed, generics-based formulary while others use8-12014 Practitioner and Provider Manual - Ver. 3

Pharmacya multi-tier formulary structure. However, they allfollow the same basic limitations.Generic substitution is mandatory for drugs thathave generic Food and Drug Administration (FDA)AB-rated equivalents available. All drugs aresubject to generic substitution when an approvedgeneric becomes available.The formularies apply only to prescriptionmedications obtained by outpatients through aparticipating retail pharmacy. The formularies donot apply to inpatient medications. Not all dosageforms and strengths of a medication may becovered (for example, sustained release,micronized, enteric coated). Please see thecomment section of the formularies for moreinformation.Drugs are constantly being developed and newversions released or made available in generic orother forms. As a result, please obtain copies ofPresbyterian’s complete and most up-to-date drugformularies by visiting the pharmacy page athttps://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.Pharmacy BenefitsSome medications on the formulary may requireprior authorization. The prior authorization processis available once a member has tried and failed allformulary agents and it is deemed medicallynecessary to have access to a non-formularyagent. (Please see the Prior Authorization Processchapter for more information.) The formularies,pharmacy prior authorization forms, specialtypharmaceuticals listing, and specialty drug requestform are available on the pharmacy page athttps://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.You may also call Presbyterian’s PharmacyServices Department directly for assistance at 505-923-5500 or outside Albuquerque at 1-888-923-5757, using the “Pharmacy” option.Specialty pharmaceuticals must be obtainedthrough our designated specialty pharmacy vendor,except when administered in an inpatient hospitalsetting when medically necessary. These productsmay require a prior authorization. Please note thatspecialty pharmaceuticals are not available throughmail order or retail pharmacies, and must beobtained through our specialty pharmaceuticalvendor.Centennial Care Prescription BenefitAll membership under Presbyterian CentennialCare continues to follow a closed generics-basedformulary. In this formulary the use of generic drugsis promoted as the drug of choice except whenclinically contraindicated, with the exception ofpsychotropic medications. Presbyterian’s formularyincludes all medications that fall into thepsychotropic class.Adherence to the formulary is required, but thepharmacy prior authorization process (see thePharmacy Prior Authorization Process section ofthis chapter) is available for members who have adocumented trial and failure of formularyalternatives. The formulary covers all medicallynecessary treatments and includes medications inall therapeutic categories.8-22014 Practitioner and Provider Manual - Ver. 3

PharmacyPresbyterian Centennial Care covers brand namedrugs and drug items not generally on the formularywhen determined to be medically necessary byPresbyterian, through the prior authorizationprocess.The Presbyterian Centennial Care Formulary isavailable on the pharmacy page athttps://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspxor maybe downloaded through the ePocrates ® Rxsoftware.Co-paymentsIn accordance with federal regulations,Presbyterian imposes a nominal co-payment forindividuals over 100% of the federal poverty levelon any prescription for a legend drug when atherapeutically equivalent generic drug is available.This co-payment does not apply to legend drugsthat are classified as psychotropic drugs for thetreatment of behavioral health conditions.Presbyterian has a co-payment exception process(prior authorization process) in place for otherlegend drugs where such drugs are not tolerated bymembers. At no time does Presbyterian denyservices for a member’s failure to pay the copaymentamounts. No co-payments are imposedon Native American members.Pharmacy Lock-InsPresbyterian requires a member to visit a certainpharmacy provider or obtain prescriptions from onespecific prescriber when member non-complianceor drug-seeking behavior is suspected. Beforeplacing the member on pharmacy lock-in,Presbyterian informs the member or theirrepresentative of the intent to lock in.Presbyterian’s grievance process is made availableto the member being designated for pharmacy lockin.The pharmacy lock-in is reviewed anddocumented by Presbyterian and reported to theHuman Services Department (HSD) every quarter.The member is removed from the lock-in whenPresbyterian determines that the non-complianceor drug-seeking behavior has been resolved andthe recurrence of the problem is judged to beimprobable. HSD is notified of all lock-ins and theirremovals.Over-The-CounterCoverage of over-the-counter products is restrictedto instances for which a provider has written aprescription and for which the item is aneconomical or preferred therapeutic alternative tothe prescribed item.NOTE: For Presbyterian Centennial Care, NativeAmerican members accessing the pharmacybenefit at Indian Health Services/Tribal 638facilities/urban Indian clinics are exempt fromPresbyterian’s formulary and the prior authorizationprocess.Commercial Prescription Drug BenefitPresbyterian offers numerous pharmacy benefit copaystructures for our members under theCommercial and preferred provider organization(PPO) plans. Most commercial groups utilize amulti-tier (4-Tier) benefit formulary that increasesaccess and eliminates restrictions on most8-32014 Practitioner and Provider Manual - Ver. 3

Pharmacymedications. This multi-tier structure offers ourmembers a greater number of options.The member’s out-of-pocket expenses are lowestwhen they fill prescriptions for preferred genericmedications (Tier 1) and preferred brand-namedrugs (Tier 2). They are highest when prescriptionsfor non-preferred drugs (Tier 3) are obtained.Specialty pharmaceuticals (Tier 4) are specializedmedications that may be required to be obtainedthrough the designated specialty pharmacy vendor.Some medications on the formulary may requireprior authorization. The prior authorization processis available once a member has tried and failed allformulary agents and it is deemed medicallynecessary to have access to a non-formularyagent. (See Pharmacy Prior Authorization Processin this chapter.) The formularies, pharmacy priorauthorization forms, specialty pharmaceuticalslisting, and specialty drug request form areavailable on the pharmacy page athttps://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.You may also call the Pharmacy ServicesDepartment directly at 505-923-5500 or outsideAlbuquerque at 1-888-923-5757, and select the“Pharmacy” option.For each prescription drug purchased at aPresbyterian participating retail pharmacy,applicable co-pays will apply. The co-paymentrequired for each type of prescription or refill,whether it is an oral tablet, capsule, liquid,ointment, cream, or lotion, will be one applicableco-payment per 30-day supply, not to exceed themanufacturer’s prescribing recommendation.Specialty pharmaceuticals, obtained through ourdesignated specialty pharmacy vendor, require coinsuranceup to a maximum dollar amount for mostplans, except when administered in an inpatienthospital setting when medically necessary. Theseproducts may require a prior authorization.Please note that specialty pharmaceuticals are notavailable through mail order or retail pharmacies,and must be obtained through our specialtypharmaceutical vendor.Mail Order for Commercial and PPOUnder the Mail Order Pharmacy Benefit,maintenance medications can be obtained throughthe mail service pharmacy identified byPresbyterian. Co-payments vary, depending onwhich benefit structure a member falls under.Under the multi-tier drug listing structure, membersusually pay 2 times the retail co-payment for Tier 1,2.5 times the retail co-payment for Tier 2, and 3times the retail co-payment for Tier 3. Tier 4 drugsare not available through mail order; they must beprovided by our specialty vendor, and are limited toa 30-day supply.Retail for Commercial and PPOFor convenience, members have the option to pickup a 90-day supply of their maintenancemedications at a local participating pharmacy.Members will be charged three retail co-paymentsfor a 90-day supply up to the manufacturer’s usualmaximum recommended dosing for the medication.8-42014 Practitioner and Provider Manual - Ver. 3

PharmacyMaximum Dosing Quantity for 30-day SupplyUnder this pharmacy benefit enhancement, amember’s 30-day prescription supply will be filled,up to the maximum dosing recommended by themanufacturer, without charging any additional copayments.The prescription will still be subject toone of the three (preferred generic, preferredbrand, non-preferred) applicable co-payments.Medicare Prescription Drug BenefitThe Medicare Modernization Act of 2003established the new voluntary outpatientprescription drug benefit program (Medicare PartD). The Medicare Part D prescription drug benefitbecame available to beneficiaries beginning onJanuary 1, 2006. The Medicare Part D prescriptiondrug benefit will allow all Medicare beneficiaries toenroll in drug coverage through a prescription drugplan or Medicare Advantage Plan, with Medicarepaying approximately 75 percent of the premium onaverage (more for qualifying, low-incomebeneficiaries). The Medicare Part D drug benefitincludes beneficiary protections intended to ensurethat all beneficiaries have coverage for medicallynecessary drugs through nearby pharmacies. Drugplans are subject to many of the existingbeneficiary protections that are available inMedicare, including requirements to meet strictpharmacy access standards to give beneficiariesaccess to retail pharmacies and needed drugs.In 2006, Presbyterian launched prescription drugplans for our Medicare-eligible beneficiaries. Theseplans are also known as Medicare Part D. Thisprescription drug coverage is available to anyindividual who is Medicare-eligible. Some of theemployer group plans also have Medicare Part Dcoverage already built in. Presbyterian offers bothHealth Maintenance Organization (HMO) andPreferred Provider Organization (PPO) plans withprescription drug coverage.Please verify the information on the member’sidentification card at the time of service. If themember’s coverage and plan includes prescriptiondrug coverage, it will be noted on the member’s IDcard.Medicare Stages of CoverageMedicare plans consist of the following stages ofcoverage:Annual deductible: The amount thebeneficiary will pay out of pocket for theirprescriptions each year before the initialcoverage begins. There are currently nodeductibles for Presbyterian’s MedicareAdvantage plans.Initial Coverage: Initial coverage begins whenthe first prescription (in the contract year) isfilled. Presbyterian covers the cost of themedications after the member has met theirco-payment requirement.Coverage gap (donut hole): After the benefitspaid out by both Presbyterian and the memberreaches a yearly specified amount, themember is fully responsible for a portion of thecosts (dependent on the Centers for Medicareand Medicaid Services [CMS] gap coveragerules) until their true out-of-pocket costreaches the catastrophic stage.8-52014 Practitioner and Provider Manual - Ver. 3

PharmacyCatastrophic coverage: Coverage begins afterthe beneficiary expends the CMS set amount(specified yearly) of their own money. Thebeneficiary will then pay reduced co-pays orco-insurance until the end of the contract year.Additional assistance is available for qualifyingbeneficiaries with low incomes and limited assets.Assistance is based on income limits. Beneficiariesmay contact the Presbyterian Customer ServiceCenter at 505-923-6060 or 1-800797-5343 forinformation and forms.Presbyterian Senior Care (HMO) andPresbyterian MediCare (PPO)The following is Presbyterian’s Medicareprescription co-pay structure:Tier 1: Preferred Generic DrugsTier 2: Non-Preferred GenericsTier 3: Preferred Brand-Name DrugsTier 4: Non-Preferred Brand/Generic DrugsTier 5: Specialty PharmaceuticalsThe beneficiary’s out-of-pocket expenses arelowest when filling prescriptions for preferredgeneric drugs (Tier 1) and preferred brand namedrugs (Tier 3). They are highest when prescriptionsfor non-preferred (Tier 2 and Tier 4) drugs areobtained. Specialty pharmaceuticals (Tier 5) arespecialized medications and may be required to beobtained through our designated specialtypharmacy vendor. Some medications may requireprior authorization. The complete Formulary,Pharmacy Prior Authorization forms, SpecialtyPharmaceutical Listing, and Specialty DrugRequest forms are available on the pharmacy pageat https://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.Specialty pharmaceuticals are not available throughmail order and must be obtained through ourspecialty pharmaceutical vendor.Mandatory Generic Substitution RequirementSubstitution of generic products is mandatory whenan FDA-AB rated generic is available.Specific Limitations and ExclusionsQuantity limitations as well as specific exclusionsapply. Examples of exclusions are medicationsused for cosmetic purposes. Please refer tomember-specific materials for a listing of limitationsand exclusions.Medicare Formulary RequirementsFormularies must be approved by the CMS.Formularies must be developed by the Pharmacyand Therapeutics (P&T) Committee.Drugs may be added to or deleted from theformulary at any time during the plan year.Members and practitioners are notified if drugs areremoved from the formulary, if tier placementchanges, or if the criteria change.Beneficiaries are allowed to obtain a transitionsupply of their current non-formulary drug whenthey enroll in a Part D plan or move from one PartD plan to another. This transition fill allows newbeneficiaries sufficient time to establish with thenew practitioner to switch to a formulary alternativeor initiate the prior authorization process.8-62014 Practitioner and Provider Manual - Ver. 3

PharmacyMail Order for Medicare PlanMail order is available to all of our Medicare Part DMembers. (Specialty medications must be obtainedthrough our specialty vendor.)Medication Therapy ManagementThe Medication Therapy Management (MTM)program is designed to improve care, enhancecommunication among patients and providers,improve collaboration among providers, andoptimize medication use that leads to improvedpatient outcomes. The patient meets with aPresbyterian pharmacist for a comprehensivemedication therapy review and has additional visitswith the pharmacist throughout the year to addressongoing medication monitoring issues and eventbasedmedication therapy problems. The programis available for all members but specifically assistspeople in one of these categories:Those who take multiple prescription drugsThose who have chronic illnessesThose who expect to spend a significantamount of money on prescription drugs eachyearMTM helps to identify potential errors and gaps incare by assisting with the following:Reducing the risk of medication errors,especially for members who have chronicconditions, take several medications, or seemultiple providersProviding current information on provenmedical practices to help members and theirproviders determine the most effectivetreatmentHelping the members understand theirconditions and medications, so they can takean active role in managing their healthMTM includes five core components:Medication therapy reviewA personal medication recordA medication action planIntervention and referralDocumentation and follow-upMaximum Dosing Quantity for 30-day SupplyUnder this pharmacy benefit, a member’s 30-dayprescription supply is filled, up to the maximumdosing recommended by the manufacturer.Specialty Pharmaceuticals (Tier 5 medicationsobtained through the pharmacy benefit)Specialty pharmaceuticals are defined as high-cost(greater than $600 per 30-day supply) injectable,infused, oral, or inhaled drugs that generally requirecomplex care and supervision. These medicationsinvolve unique distribution and are usually providedby a specialty pharmacy vendor.Specialty pharmaceuticals are used to treat seriouschronic, often rare diseases. Specialtypharmaceuticals are self-administered, meaningthey are administered by the patient or to thepatient by a family member or caregiver. Somespecialty pharmaceuticals may require priorauthorization before they can be obtained. For acomplete list of specialty pharmaceuticals todetermine which require prior authorization and8-72014 Practitioner and Provider Manual - Ver. 3

Pharmacywhich drugs are mandated through our specialtyvendor, please see the Presbyterian SpecialtyPharmaceuticals and Medical Drugs list athttp://ucmprod.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00052739.pdf..Specialty medications are not available through themail order vendor. They must be obtained throughthe specialty pharmacy vendor and are limited to30-day supplies. Medical Drugs (medicationsobtained through the medical benefit)Medical drugs are defined as medicationsadministered in the office or facility that require ahealth care professional to administer. Thesemedications include but are not limited to injectable,infused, oral, or inhaled drugs. They may involveunique distribution and may be required to beobtained from our specialty pharmacy vendor.Some medical drugs may require priorauthorization before they can be obtained.The term “office administered” applies to alloutpatient settings including, but not limited to,physician’s offices, emergency rooms, urgent carefacilities, and outpatient surgery facilities. For acomplete list of medical drugs to determine whichrequire prior authorization and which drugs aremandated through Presbyterian’s specialtypharmacy, please seehttp://ucmprod.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00052739.pdf.All information regarding formularies and otherhelpful pharmacy information can be found onhttps://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.You may also call Presbyterian’s PharmacyServices Department directly for assistance at 505-923-5500 or outside Albuquerque at 1-888-923-5757, using the “Pharmacy” Option.ExclusionsPresbyterian includes on the formulary all multisourcegeneric drug items with the exception ofItems used for cosmetic purposesItems consisting of more than one therapeuticingredientAnti-obesity itemsItems that are not medical necessaryCough, cold, and allergy medicationsPrescription drugs requiring a pharmacy priorauthorization when prior authorization was notobtainedPrescriptions ordered by a non-participatingprovider or purchased at a non-participatingpharmacy unless required because ofemergent or urgent care encountersOver-the-counter medications and drugs forwhich there is a non-prescription equivalentavailableCompounded prescriptionsMedications (listed as covered in PresbyterianCentennial Care member materials) receivedupon hospital discharge, provided by ahospital pharmacy unless a participatingoutpatient pharmacy is not availableDisposable medical supplies, except whenprovided in a hospital or physician’s office orby a home health professional8-82014 Practitioner and Provider Manual - Ver. 3

PharmacyMedications and treatments for the purpose ofweight reduction or control except formedically necessary treatment for morbidobesityNutritional supplements unless for prenatalcare as prescribed by the attending physicianor as sole source of nutritionInfant formula, unless the need is warrantedas a result of inborn errors of metabolismMedications used for the treatment of sexualdysfunctionNew medications for which the determinationof criteria for coverage has not yet beenestablished by Presbyterian’s P&T CommitteePrior authorization may apply.Experimental DrugsThe experimental nature of drug products or theexperimental use of drug products is determined bythe P&T Committee using current medicalliterature. Any drug product or use of an existingproduct that is determined to be experimental isexcluded from coverage. Criteria include thefollowing:The drug cannot be marketed lawfully withoutapproval of the U.S. FDA and approval formarketing has not been given at the time thedrug is furnished.Reliable evidence shows a consensus ofopinion among experts that further studies ofclinical trials are necessary to determine thedrug’s maximum tolerated dose, its toxicity, itssafety, or its efficacy as compared with thestandard means of treatment or diagnosis.Pharmacy and Therapeutics CommitteeOrganization, Scope, and FunctionThe P&T Committee is composed of primary careand medical specialty providers in order toadequately represent Presbyterian providers. Othermembers include Presbyterian medical directors,Presbyterian’s behavioral health medical director,pharmacy department directors, Presbyterianclinical pharmacists, and retail pharmacyrepresentatives.Purpose of the P&T CommitteeThe committee serves in an advisory capacity tothe Presbyterian panel of medical providers andPresbyterian management in all matters pertainingto the use of drugs.The committee develops formularies accepted foruse by Presbyterian providers and provides forconstant revision of these formularies. ThePresbyterian P&T Committee uses the followingcriteria in the evaluation of product selection:The drug must demonstrate unequivocalsafety for medical use based on sound clinicaldataThe drug must be efficacious and bemedically necessary for the treatment,maintenance, or prophylaxis of the medicalcondition based on sound clinical dataThe drug must demonstrate a positivetherapeutic outcome8-92014 Practitioner and Provider Manual - Ver. 3

PharmacyThe drug must be accepted for use by themedical communityThe drug must provide a cost-effectivealternative for the treatment of the medicalconditionThe drug must not be experimental orinvestigationalRecommendations of national organizations,committees, or specialty societies are stronglyconsideredThe drug is mandated as the result of stateMedicaid mandates or is CMS-mandatedThe committee makes recommendations forchanges to the formularies. The committeedevelops forms to be completed when requestingan addition of a drug to the formularies and definesprocedures and responsibilities for documenting theneed for a formulary addition or replacement.The committee may propose and approve certainmechanisms for approved formulary agents that aredesigned to promote appropriate usage. Thesemechanisms would include but not be limited toPrior authorization by medical criteriaapproved by the committeeStep Edit (a requirement for a trial of anotherappropriate formulary/drug listing agent beforecoverage of the targeted drug)Quantity limits based on manufacturer’srecommended maximum daily dosingThe establishment of suitable educationalprograms for the Presbyterian CentennialCare panel of medical providers andPresbyterian Centennial Care enrollees onmatters relating to drug therapyReview of the use of drugs or drug classes byPresbyterian Centennial Care providers andmembers to detect both underutilization andoverutilization, and recommendations toimprove medically appropriate and costeffectivedrug utilizationReview of adverse drug reactions occurring inthe ambulatory care setting, investigation ofpossible causes, and recommendations tominimize the occurrence of adverse drugreactions, and report of serious adverse drugreactions to the FDA when appropriateParticipation in quality assurance activitiesrelated to the distribution, administration, anduse of medicationsReview and approval of all PresbyterianCentennial Care guidelines and policiesrelated to the use of medicationsReview and Approval of Requests for FormularyChangesAll requests should be documented on the“Request for addition of a drug to the PresbyterianFormulary” form. This is available on thePresbyterian website athttps://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.For assistance, call Presbyterian’s PharmacyServices Department directly at 505-923-5500 oroutside Albuquerque at 1-888-923-5757, using the“Pharmacy” option.8-102014 Practitioner and Provider Manual - Ver. 3

PharmacyOnce the request has been received, a letter is sentto the requesting provider acknowledging receipt ofthe request and stating when it will be reviewed.Additional information may be solicited to supportthe request.Requesting providers may be invited to attend theP&T Committee meeting and present their case forthe addition of a drug, although attendance is notmandatory.A Presbyterian pharmacist reviews all requests andprepares a written review of the drug for the P&TCommittee. Formulary changes and the rationale ofthe changes are communicated to all appropriateparties through memorandum or newsletter.Committee actions regarding deletions take effect60 days following the decision. Additions areeffective 30 days following the decision. Anyremoval of a formulary drug is associated with all ofthe following procedures:Identify members who are currently on theagentNotify the member of the change in benefitwith at least a 60-day noticeEnsure that the affected member hascontinued coverage of the drug during the 60-day notification periodPresbyterian providers may obtain a copy of theformulary by downloading the formulary fromhttp://www.epocrates.com/, or from the pharmacypage at https://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.Formulary changes are communicated to providersfollowing each P&T Committee meeting.Pharmacy Prior Authorization ProcessPresbyterian’s pharmacy prior authorizationprocess includes intake, evaluation, decisionmaking, and response to the requesting provider.An automated prior authorization system is usedwhere providers can submit pharmacy priorauthorization requests online through myPRES orby fax. Protocols with criteria are built into thesystem, so in many instances providers receive thedecision as soon as they finish submitting therequired information. To access myPRES, go tohttps://mypres.phs.org.Providers can also request prior authorization ofcovered services through myPRES. This processensures appropriate and timely services toPresbyterian members.Non-formulary requests are evaluated by thePharmacy Services Department for medications notlisted in the current Presbyterian formularies,requests for drugs for which Presbyterian requiresprior authorization, and for quantities which are inexcess of those defined by the product line benefitdescription documents.Determinations are made on a timely basis asrequired by the urgency of the situation, inaccordance with sound medical principles andregulatory requirements.Our Pharmacy Services Department is under thedirect supervision of at least one full-time clinicalpharmacist who is accountable to a medicaldirector.8-112014 Practitioner and Provider Manual - Ver. 3

PharmacyTypes of Pharmacy Prior Authorization Requests• Medications listed on a formulary that require priorauthorization with application of specific clinical criteria.• Request for an exception to a formulary (non-formularyrequest).• Requests for a quantity or frequency (including vacation)override.General Processing Routine Pharmacy Prior AuthorizationRequests by Fax, Mail, or Online• The provider generates a request for a medication requiringprior authorization, using the pharmacy services priorauthorization form.• All requests are submitted directly into our automated priorauthorization system or manually entered into the system bythe technician if they did not come online or through fax.• Verification of eligibility and benefits, including the verificationof the plan to which the Presbyterian Centennial Caremember belongs and the original effective date is requiredfor all requests and in online submissions. This is anautomated feature.• The Benefit Plan is evaluated to assure the request is for acovered benefit.• All pertinent medical information is gathered, includingmedical documentation.• Requests are evaluated using appropriate criteria, includingmember claim history.Revised RequestsFollowing discussion between the provider and thepharmacy benefit technicians or clinical pharmacist,the request may be changed to a mutually agreeduponalternative medication. All changes aredocumented on the original request.Processing of Approved Pharmacy PriorAuthorization RequestsWhen a request is approved, the provider is notifiedby telephone or fax. If approved, authorization formedication is automatically entered into the onlinesystem for claims processing.Processing of Pended Pharmacy PriorAuthorization RequestsIf the request is pended, the reason (such as theneed for additional medical information) is indicatedin the pharmacy prior authorization request. Ifadditional information is needed to determine ifcriteria for coverage is met, additional information isrequested by phone or fax. A phone call is madeevery 24 hours to the requesting provider to obtainupdated information. If no additional information tosupport the request is received after three businessdays, a denial is issued.Processing of Denied Pharmacy Prior AuthorizationRequestsThe denial form, a copy of the pharmacy priorauthorization request, and all pertinent medicalinformation available are presented to a medicaldirector for review and signature. All requests thatare denied based on medical necessity must bereviewed by the pharmacist and by a medicaldirector. The requesting provider shall be advisedof the denial, rationale, and alternatives available.Under no circumstance may this responsibility bedelegated to non-medical personnel. A denial letteris sent to the member within 24 hours ofdetermination. Copies are also sent to therequesting provider and stored in the Presbyterianautomated system. All denial letters includeappeals rights language to assist the member orprovider in filing an appeal if they choose to do so.Expedited Pharmacy Prior Authorization RequestsA request for an expedited pharmacy priorauthorization is prioritized by the PharmacyDepartment staff for immediate action.Determination is made within 24 hours of receipt ofemergency requests. Pharmacy Department benefittechnicians immediately evaluate and apply theappropriate criteria which, if approved, are8-122014 Practitioner and Provider Manual - Ver. 3

Pharmacyimmediately communicated to the requester byphone or fax and are entered into the system.If the request does not meet the approval criteria,the request is immediately routed to the clinicalpharmacist, who approves the request if justified. Ifnot, the request is routed to the medical director fora determination. If the request is denied, notificationis given to the requester by phone, includingnotification of the availability of the medical directorto discuss the case by phone, and of the right toappeal the decision. A written notice of thepharmacy decision (approved or denied) is alsoissued to the member with a copy sent to theprovider.Appeals ProcessAn appeal may be submitted orally or in writing if amember is not satisfied with the decision to deny apharmacy prior authorization request. The providermay submit an appeal for members with themember’s consent.8-132014 Practitioner and Provider Manual - Ver. 3

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Pharmacy9. Behavioral Health9. Behavioral HealthBehavioral health is the overarching term thatrefers to an array of mental health and substanceabuse clinical management services that combinethe best traditional approaches to health caredelivery with innovative, emerging solutions tosupport members in achieving their recovery goals.In addition to our Commercial and Medicarebehavioral health services, with the creation ofPresbyterian Centennial Care, the New MexicoHuman Services Department now contracts withmanaged care organizations to deliver the fullrange of physical health, behavioral health, andlong-term care in a comprehensive and integratedmanner.As a long-time health plan and health servicedelivery provider across New Mexico, we are wellaware of the need to maintain a trusted networkthat can deliver all covered services to ourmembers in a manner that is geographically,culturally, and linguistically appropriate. We havecontracted with Magellan Health Services tomanage behavioral health services for ourCentennial Care members. Magellan HealthServices’ specialized expertise in coordinating a fullcontinuum of behavioral health services will supportdelivery in the most clinically appropriate, leastrestrictivesettings.Presbyterian Behavioral Health ProviderParticipationContracted behavioral health providers arecredentialed to provide services for eligiblemembers enrolled in Presbyterian’s CentennialCare. Although it is the member’s responsibility tounderstand his or her benefit requirements,Presbyterian is available to provide assistance24 hours a day, seven days a week to membersand providers. Please call the behavioral healthcustomer service line at 505-923-5678 for furtherinformation. The Presbyterian Provider Care Unitalso has a dedicated Centennial Care team that isavailable 24 hours a day, seven days a week, 365days a year at 505-923-5757 or 1-800-923-5757.Presbyterian Behavioral Health ProvidersThe behavioral health component of PresbyterianCentennial Care includes a range of providers andorganizations eligible to provide Medicaid services.These include physicians, physician assistants,psychologists, nurse practitioners, social workers,other master’s-prepared therapists, licensedalcohol and drug counselors, Core ServiceAgencies (CSAs), Federally Qualified HealthCenters (FQHCs), hospitals, and tribalorganizations. Presbyterian actively evaluates thecultural diversity of our behavioral health providersand makes every effort to include professionalswho are able to meet the cultural needs of ourmembers. In addition, Presbyterian’s provider9-12014 Practitioner and Provider Manual - Ver. 3

Behavioral Healthagreements, addenda, and other documents areconsistent with State of New Mexico and Centersfor Medicare and Medicaid Services Medicaidrequirements.In order to receive referrals of Presbyterianmembers, a provider mustBe a New Mexico Medicaid providerHave an active status inPresbyterian/Magellan behavioral healthcredentialing systemHave an executed provider agreement withPresbyterianBe free of any Medicare or Medicaid sanctionsfrom the Office of the Inspector GeneralTypes of Behavioral Health ProvidersPresbyterian Centennial Care behavioral healthproviders includes individual, group, andorganization providers. Organization providersinclude hospitals, clinics, agencies, CSAs, andresidential treatment centers.Individual ProviderAn individual provider is a clinician who suppliesprofessional behavioral health care services directlyto a member and bills under the provider’s owntaxpayer identification number. The individualprovider must be enrolled with Centennial Care andmeet Presbyterian/Magellan credentialing criteria,including, but not limited to, a state license topractice within the scope of the individual’sdiscipline and class of service. In addition, theprovider must hold a current, fully executedPresbyterian Provider Participation Agreement(PPA).Group PracticeA group practice is a collection of individualproviders that supply professional behavioral healthcare services and bill under a single taxpayeridentification number. The group practice may ormay not be incorporated. The group typicallyprovides ambulatory levels of care. Cliniciansaffiliated with the group are credentialed individuallyand must be enrolled with Centennial Care andmeet Presbyterian/Magellan credentialing criteria toprovide services to Centennial Care members. Thegroup practice enters into an agreement withPresbyterian as a single entity, and the group billsas a single entity for the services performed by itsPresbyterian/Magellan-credentialed clinicians.OrganizationAn organization is an entity that is licensed orcertified as required by the state in which itoperates. The organization enters into anagreement with Presbyterian as an entity. It mustbe enrolled with Centennial Care, and must meetPresbyterian/Magellan credentialing criteria fororganizations. Examples of organizations providingbehavioral health services for Centennial Careinclude inpatient facilities, community mental healthcenters, FQHCs, rural health centers, and IndianHealth Service or Tribal 638 facilities that offerbehavioral health services. The organization entersinto an agreement with Presbyterian to provide oneor more levels of care, which may includeoutpatient care. The organization generally hasPresbyterian/Magellan-credentialed physicians or9-22014 Practitioner and Provider Manual - Ver. 3

Behavioral Healthother individual providers on staff or it may contractwith physicians and other individual providers toprovide behavioral health services.Core Service AgenciesCSAs are designated by the state to manage muchof the service delivery of behavioral health services.CSAs also provide prevention, early intervention,treatment, and recovery services related tobehavioral health for members. CSAs arecontracted as organizations and are required toprovideCrisis intervention 24 hours a day, seven daysa weekBehavioral health servicesAccess to psychiatric evaluationsAccess to medication managementBehavioral health out-of-home assessmentand service planningCare coordination to members with seriousmental illness or serious emotionaldisturbanceAccess to a range of other clinical behavioralhealth servicesAccess to comprehensive community supportservicesAll behavioral health providers are expected tohave a current description of the behavioral healthservices they provide on file with Presbyterian forinclusion in our provider directory and to assist withreferrals to our behavioral health providers.CredentialingIn order to be eligible for referrals, Presbyterianbehavioral health providers are required to undergothe credentialing review process before beingaccepted as Presbyterian providers, and periodicrecredentialing thereafter (see the Recredentialingsection in this chapter). Presbyterian has delegatedbehavioral credentialing for the Centennial Careprogram to Magellan. Magellan’s CredentialingVerification Organization department is responsiblefor completing credentialing activities according toNational Committee for Quality Assurancestandards, and the requirements of Presbyterianand the Centennial Care program.Provider Credentialing Application ProcessProvider credentialing is initiated through theprovider application process. Individual providersare asked to submit the following documents, alongwith a fully completed application, to facilitate thecredentialing review:Copies of current licenses and certificationsEducation and training documentationMalpractice insurance informationForm W-9Organization providers are asked to submit thefollowing documents, along with a fully completedapplication, to facilitate the credentialing review:Copies of current licenses (if applicable)Copy of current accreditationsProof of professional liability insurance(minimum amounts of $1 million/$3 million)Proof of general liability insurance9-32014 Practitioner and Provider Manual - Ver. 3

Behavioral HealthForm W-9Staff roster (to be updated as changes inclinical staffing occur)RecredentialingIn addition to the initial review, Presbyterianbehavioral health providers are required to havetheir credentials reviewed periodically through therecredentialing process. In the State of NewMexico, individual, professional, and organizationprovider recredentialing is conducted every threeyears.Recredentialing includes an administrative updateof the provider’s original credentialing documentsas well as a review of Presbyterian’s experiencewith the provider. The registered nurse clinicalcoordinator review evaluation includes thefollowing, but is not limited toAny quality reviewsSatisfaction survey findingsCompliments and complaintsAppealing Credentialing DecisionsIf the credentialing review is not favorable and it isdetermined that Magellan will not continue thecredentialing or recredentialing process,Presbyterian notifies the provider in writing. Thedenial notification letter includes the reason fordenial and contains instructions for initiating anappeal process, if applicable.Reporting Changes in Clinical StatusProviders are required to notifyPresbyterian/Magellan in writing within 10 days ofany changes, additions, or deletions that occurrelated toLicensureAccreditationsCertificationsHospital privilegesInsurance coveragePast or pending malpractice actionsNew or updated credentialing information must bemailed toPresbyterian Behavioral HealthP.O. Box 25926Albuquerque, NM 87125-5926Contracting with PresbyterianIn addition to successfully completing thecredentialing process, providers must have anexecuted Presbyterian PPA and Centennial Careproduct attachment under which the provideragrees to comply with Presbyterian’s andMedicaid’s policies, procedures, and guidelines inorder to receive referrals of, and reimbursement for,services rendered to Centennial Care members.Updating InformationPrompt notification of changes in practiceinformation helps us maintain an efficient andeffective referral process, and present accurate andtimely information in Presbyterian publications. Theprovider should notify Presbyterian Centennial Carepromptly when any of the following practicechanges occur:Medicaid enrollmentAddress9-42014 Practitioner and Provider Manual - Ver. 3

Behavioral HealthTelephone numberStatus (including changes in the numbers ofservice slots available)Services provided (with updated programdescriptions)Ability to accept Centennial Care referralsTaxpayer identification numberGroup practice membershipStaff rostersProviders may submit new or updated informationonline or by mail, phone, or fax using the contactinformation below.Presbyterian Behavioral HealthP.O. Box 25926Albuquerque, NM 87125-5926Phone: 505-923-5678Expectations of the Medicaid ProviderCentennial Care behavioral health providers agreetoBe available to accept referrals of CentennialCare members within the scope of theprovider’s practiceDeliver services in accordance with the termsof New Mexico Medicaid regulations, thePresbyterian PPA, and policies andprocedures outlined in this manualRender all services in the provider’s office, orin facilities or locations that are mutuallyagreed upon under the terms of thePresbyterian PPAInitiate authorizations as required byPresbyterianExpectations of Medicaid Members and TheirFamiliesAs an organization, Presbyterian strongly endorsesconsumer empowerment and family involvement.Experience shows that when members arevoluntarily engaged in the management of theirbehavioral health services, they are generally morecompliant with treatment and medications. Thiscompliance in turn leads to more positiveoutcomes.Presbyterian not only encourages members andtheir families to become active participants intreatment, we believe that members and familieshave a responsibility to do so. Providers arerequired to document member and familyinvolvement in all treatment records, and todemonstrate compliance with this requirementduring site visits and audits.Care Coordination CommunicationRequirements (for Commercial and Medicare)We require that communication take place betweenthe behavioral health practitioner and the managedcare member’s primary care provider (PCP), withinseven days of admission to a behavioral healthservice, upon any significant change in themember’s behavioral health status, and upondischarge from services. Documentation of thiscommunication must be evident in the managedcare member’s medical record. Presbyterian haspolicies and procedures in place to help with suchcommunication, such as the Coordination of Careform. If used, Presbyterian’s Coordination of Careform meets the documentation requirements andcan be accessed through the provider web page at9-52014 Practitioner and Provider Manual - Ver. 3

Behavioral Healthhttps://www.phs.org/providers/cliniciansresources/Pages/behavioral-health.aspx.The formis a valuable tool, not only for practitioner-to-practitioner communication, but also forpractitioner-patient discussion of the benefits ofcare coordination. The reasons for coordinatingcare should be explained to patients, so that theytake an active role in managing their care andsharing critical information. If the patient prefers notto release information, the form allows the providerto document this and remain in compliance with thestandard. Presbyterian will audit compliance relatedto this communication periodically as well as at thetime of recredentialing. The managed caremember’s PCP is responsible for reciprocalcommunication with the behavioral healthprofessional.Care Coordination (for Centennial CareMembers)Presbyterian makes every attempt to perform aHealth Risk Assessment for each Centennial Caremember. Members who are identified as requiringbehavioral health intervention are categorized byneed using Levels 1, 2, or 3, with Level 3 as thehighest need. Those members who are identifiedas having potential Level 2 or 3 needs receive aComprehensive Needs Assessment (CNA).Members with Level 2 or Level 3 needs areassigned a care coordinator. The care coordinatorhas oversight of the member’s treatment objectivesand requires provider input to meet the memberobjectives. Presbyterian care coordinators who arebehavioral health specialists are available to beprimary care coordinators for members withextensive behavioral health needs. These carecoordinators have the ability to consult with othercare coordinators for members who have co-morbidbehavioral health and medical conditions.Behavioral health providers play a crucial role in theoverall care coordination plan for the member. Thecare coordinator works with the member’s currentbehavioral health provider or offers referrals forservices to the member based on service need,geographical location, and level of care, as well asthe member’s preferences. Care coordination isrequired to ensure that service needs are met andnot duplicated. The care coordinator develops acomprehensive care plan for the member to meetidentified objectives. This care plan is developedwith input from the providers as well as anycommunity supports. The plan is then shared withthe treating providers electronically or by mail toensure coordination and avoid duplication ofservices.Care coordination is designed to assist memberswho have extensive health care needs and whomay be receiving services from other sources. Thefollowing are examples of scenarios in whichcoordination is required between behavioral healthservices provided through Centennial Care andservices provided by another institution or provider:Need to coordinate Centennial Carebehavioral health services with servicesprovided by school-based health centers.These centers are outpatient clinics on schoolcampuses that provide onsite primary,preventive, and behavioral health services tostudents in order to reduce lost school time,9-62014 Practitioner and Provider Manual - Ver. 3

Behavioral Healthremove barriers to care, and promote familyinvolvement. School-based providers arerequired to coordinate with the member’sassigned care coordinator as well as otherproviders.Need to coordinate Centennial Carebehavioral health services with non-Medicaidservices. Many times members benefit fromcommunity services that are not part of thebenefits they receive from Centennial Care.Communication and coordination by theprovider with these services increasecompliance with the members’ overalltreatment objective.Need to coordinate Centennial Carebehavioral health services with a provider inthe planning of institutional care for themember.Need to coordinate Centennial Carebehavioral health services with the member’sassigned PCP and the behavioral healthprovider.Need to coordinate Centennial Carebehavioral health services with CSAs whenthe CNA is being performed.Need to coordinate Centennial Carebehavioral health services with servicesprovided by the Children, Youth, and FamiliesDepartment (CYFD).Need to coordinate Centennial Carebehavioral health services provided to childrenin tribal custody or under tribal supervision.Presbyterian Centennial Care PCPs are required torefer members for behavioral health services whenthey identify one or more of the following:Suicidal or homicidal ideation or behaviorRisk of hospitalization because of a behavioralhealth conditionChildren or adolescents at imminent risk ofout-of-home placement in a psychiatric acutecare hospital or residential treatment facilityThe member is a victim of traumaThere is serious threat of physical or sexualabuse or risk to the member’s life or healthbecause of the member’s impaired mentalstatus and judgment, mental retardation, orother developmental disabilitiesRequest by a member or representative forbehavioral health servicesClinical status that suggests the need forbehavioral health servicesIdentified psychosocial stressors andprecipitantsTreatment compliance complicated bybehavioral characteristicsBehavioral and psychiatric factors influencingmedical conditionVictims or perpetrators of abuse or neglectand members suspected of being subject toabuse or neglectNon-medical management of substanceabuseFollow-up to medical detoxification9-72014 Practitioner and Provider Manual - Ver. 3

Behavioral HealthAn initial PCP contact or routine physicalexamination indicating a substance abuseproblemA prenatal visit indicating substance abuseproblemsPositive response to questions indicatingsubstance abuse problemsObservation of clinical indicators or laboratoryvalues indicating substance abuse problemsA pattern of inappropriate use of medical,surgical, trauma, or emergency room servicesthat could be related to substance abuseproblems or other behavioral health conditionsThe persistence of serious functionalimpairmentWhen a member is involved or at risk of becominginvolved with the CYFD, it is an indicator of thepossible need for more intensive care coordinationactivities. Providers should be prepared toparticipate in care coordination and CYFDprotocols, staffing, discharge planning, or otherrequirements.Children in tribal custody or under tribal supervisionpursuant to a Tribal Court order (as such term isdefined in New Mexico Statutes Annotated [NMSA]1978 § 32A-1-4) must receive a behavioral healthscreening within 24 hours of a referral to abehavioral health contract provider and receive abehavioral health assessment, any medicallynecessary covered services, and care coordinationas appropriate.Member ReferralsMembers may refer themselves to providers ofcovered services without contacting Presbyterian orobtaining a referral from their PCP. Regardless ofwhether the member is self-referred, referred byPresbyterian, or referred by a PCP, providers arerequired to authorize services in accordance withPresbyterian’s requirements in the PriorAuthorization section of this chapter.After-Hours Coverage for Member EmergenciesBehavioral health providers must have or arrangefor on-call and after-hours coverage to supportmembers who are experiencing behavioral healthcrises or emergencies. Such coverage must beavailable 24 hours a day, seven days a week.Providers must inform members about hours ofoperation and provide instruction for contacting oncallstaff after hours. When unavailable to provideon-call support, providers must arrange foralternative coverage with another participatingclinician.Crisis/Emergency Room UsagePresbyterian strives to provide the appropriatebehavioral health services in a timely manner for allmembers. For members requiring intervention froma crisis or an emergency room service provider,coordination with the member’s care coordinator isrequired. The care coordinator can assist withidentifying and referring the member to theappropriate level of care.9-82014 Practitioner and Provider Manual - Ver. 3

Behavioral HealthNote that advising a member to call 911 is not anacceptable form of crisis intervention for aCentennial Care behavioral health provider.Emergency/Disaster PlanningIn the event of a federally declared disaster,Presbyterian Centennial Care coordinates with thestate’s interagency Behavioral Health PurchasingCollaborative to locate providers to participate incrisis counseling implemented by the FederalEmergency Management Agency and supportedthrough an interagency agreement with theSubstance Abuse and Mental Health ServicesAdministration’s Center for Mental Health Services.Supplemental funding for crisis counseling isavailable to state mental health authorities throughtwo grant mechanisms: the Immediate ServicesProgram, which provides funds for up to 60 days ofservices immediately following a disasterdeclaration, and the Regular Services Program,which provides funds for up to nine monthsfollowing a disaster declaration.Authorization of ServicesAppendix F provides a detailed description of theauthorization requirements for all services,including behavioral health services. It is theprovider’s responsibility to assure that all servicesare authorized in accordance with thoserequirements.Cultural CompetencyPresbyterian is committed to embracing the richdiversity of the people we serve. We believe inproviding high-quality care to culturally,linguistically, and ethnically diverse populations, aswell as to those who are visually and hearingimpaired. We are committed to ensuring that allmembers provided with behavioral health servicesreceive equitable and effective treatment in arespectful manner that recognizes individualspoken language, gender differences, and the roleculture plays in a person’s health and well-being.In order to refer members to providers appropriateto their needs and preferences, Presbyterian’s staffis trained in cultural diversity and sensitivity.Providers with myPRES access have theopportunity to complete cultural competencytraining through their portal. Magellan HealthServices also provides cultural competencytraining, technical assistance, and online resourcesathttps://www.magellanprovider.com/MHS/MGL/education/culturalcompetency/index.asp to helpproviders enhance their provision of high-quality,culturally appropriate services. Presbyteriancontinually monitors and assesses providerdiversity and sensitivity, and at the same timeactively recruits, develops, and works to retain adiverse array of behavioral health providerscompatible with our member population.It is the provider’s responsibility to includeinformation on the provider’s credentialingapplication about language services the provideroffers and about any specialty services theprovider’s practice offers.9-92014 Practitioner and Provider Manual - Ver. 3

Behavioral HealthAccess StandardsMembers must have timely access to appropriatemental health and substance abuse services froman in-network provider 24 hours a day, seven daysa week.Our access standards enable members to obtainbehavioral health services by an in-networkprovider within a time frame appropriate for theclinical urgency of their situation.Timely access to services is an essential first stepin meeting the needs of our members. Memberaccess to providers is regularly monitored againstestablished standards as a core care coordinationactivity. Centennial Care behavioral healthproviders are responsible for providing memberswith immediate emergency services whennecessary to evaluate or stabilize a potentially lifethreateningsituation.It is the provider’s responsibility toProvide access to services 24 hours a day,seven days a weekEnsure that members know what to do if theyneed services after business hoursArrange for alternative coverage with anotherparticipating clinician when the provider is notavailable, including, but not limited to, ananswering service with emergency contactinformationRespond to telephone messages in a timelymannerProvide face-to-face services within two hoursin a crisis evaluationProvide services within 24 hours in an urgentclinical situationSet an appointment within 14 calendar days ofrequest for routine clinical situations, unlessthe member requests a later dateProvide services within seven days of amember’s discharge after an inpatient stayFor continuing care, continually assess theurgency of member situations and provideservices within the time frame that meets theclinical urgencyAdditional Access RequirementsAmbulatory Follow-upMembers being discharged from an inpatient staymust have a follow-up appointment scheduledbefore they are discharged. The appointment mustoccur within seven days of discharge.Timely and Confidential Exchange of InformationWith written authorization from the member, theprovider must communicate key clinical informationin a timely manner to all other health care providersparticipating in a member’s care, including themember’s PCP.Timely Access and Follow-up for MedicationEvaluation and ManagementMembers must receive timely access and regularfollow-ups for medication management.Provide immediate emergency services whennecessary to evaluate or stabilize a potentiallylife-threatening situation9-102014 Practitioner and Provider Manual - Ver. 3

Behavioral HealthClaims Submission ProceduresPresbyterian maintains the primary responsibilityfor all behavior health care claims adjudication andpayments for Medicare and Commercial members.Claims from Centennial Care behavioral healthproviders relating to mental health or substanceabuse services may be submitted to Magellandirectly if that is more convenient for the provider,but be assured that all behavioral health claims –even as part of a mixed service – may always besubmitted directly to Presbyterian and we willreroute the behavioral claims to Magellan foradjudication and payment.Submitting Electronic Transactions/ClaimsPresbyterian and Magellan encourage providers totake advantage of our electronic claimstransmission (ECT) process. ECT has become thepreferred method of claims submission for themajority of our network.Benefits of Filing ElectronicallyPresbyterian generally processes electronicallysubmitted claims in an average of seven days,whereas hard copy claims are generally processedin an average of 14 days. Electronic submissionsaves postage and paper and also gives theproviderQuicker confirmation of claims receipt andintegrity of the dataA higher percentage of claims accuracy,resulting in faster paymentClaims data already formatted into the HealthInsurance Portability and Accountability Act(HIPAA)-required ANSI-X12 837 claims formatClaims CourierAccessible through the Magellan provider websiteat www.magellanprovider.com, Claims Courier is adata entry application for Centennial Care providerssubmitting professional claims on a claim-at-a-timebasis. Providers can gain access to Claims Courierby signing onto the Magellan website with their username and password and following the instructionsunder “Submit a Claim Online.” Claims Courierstreamlines the claims process by eliminating theclaims middleman, and there is no charge to theprovider for using the service. The provider simplyenters the claims information data into the onlineClaims Courier application. Note that Magellanmust be the designated payer in order to processthe submitted claims.On the main Claims Courier (Submit a Claim) page,the provider canCreate a new, blank claimCreate a new claim from a copy of apreviously submitted claimComplete a claim the provider savedpreviouslyView the submitted claimsDirect SubmitThrough the Magellan application Direct Submit,HIPAA-compliant electronic data interchange (EDI)837 files can be sent directly to Magellan in bulk,without accompanying claim data entry or theinvolvement of a clearinghouse. Direct Submit isavailable to all Presbyterian Centennial Careproviders regardless of claims submission volume.9-112014 Practitioner and Provider Manual - Ver. 3

Behavioral HealthThere is no charge to the provider for using theservice. To get started on the process, the providercan visit Magellan’s Electronic Data Interchange(EDI) Testing Center website atwww.edi.magellanprovider.com. The center offersan easy-to-follow, six-step process toindependently validate the provider’s EDI test files(837 Professional and Institutional) for HIPAAcompliance rules and codes. The provider isassigned an information technology analyst toguide them through the process and address anyquestions. The process includes creating a uniqueuser ID and password, downloading EDI guidelinedocumentation (companion guides), uploading andtesting EDI files, and obtaining immediate feedbackregarding the results of the validation test. Once theprovider has completed the six-step process, theyare able to exchange production-ready EDI fileswith Magellan.The provider can register to submit EDI claims toMagellan by sending an e-mail toEDISupport@MagellanHealth.com or by contactingMagellan EDI Support at 1-800-450-7281,extension 75890.Paper ClaimsPresbyterian and Magellan encourage electronicclaims submissions and offer technical assistanceto providers to address any difficulties withaccessing or using our electronic submission tools.Paper claims can be submitted to the address orfax number below.Presbyterian Behavioral HealthP.O. Box 25926Albuquerque, NM 87125-5926505-923-5400 (Fax)ClearinghousesExternal EDI clearinghouses act as a middlemanbetween the provider and Presbyterian and/orMagellan, and can transform non-HIPAA-compliantformats to compliant 837s. Both Presbyterian andMagellan accept 837 transactions from a number ofclearinghouses. Note that there may be chargesfrom the clearinghouses.Payer ID for Clearinghouse Services(Centennial Care)When using the services of a clearinghouse, it iscritical that the proper payer ID is used so the EDIclaims are sent to Magellan. The following payerIDs are required for all clearinghouses forMagellan, with the exception of Emdeon.837P Professional: 01260837I Institutional: 01260The following unique payer IDs are for Emdeononly:837P Professional: 01260837I Institutional: 12X27Clearinghouse Contact Information (Magellan)Payerpath (formerly Mysis and also known asAllscripts)9030 Stony Point PkwySuite 440Richmond, VA 232351-877-623-5706www.payerpath.com9-122014 Practitioner and Provider Manual - Ver. 3

Behavioral HealthCapario (formerly MedAvant and ProxyMed)1901 E. Alton Ave, Suite 100Santa Ana, CA 927051-800-586-6938PayerAdvocacy@Capario.comAvaility ® (formerly THIN)PO Box 550857Jacksonville, FL 32255-08571-800-AVAILITY (282-4548)www.availity.comEmdeon Business Services (formerlyWebMD ® )One Century Place26 Century Blvd, Suite 601Nashville, TN 372141-877-469-3263 orhttp://www.emdeon.comGateway EDIOne Financial Plaza501 North Broadway 3rd FloorSt. Louis, MO 631021-800-969-3666www.gatewayedi.comRelayHealth (also known as McKesson)700 Locust StreetSuite 500Dubuque, IA 520011-800-527-8133, Option 2www.relayhealth.comOffice AllyPO Box 872020Vancouver, WA 986871-866-575-4120Fax: 1--896-2151www.officeally.comHealthEC371 Hoes LanePiscataway, NJ 068541-877-444-7194http://www.healthec.com/Clearinghouse Contact Information forPresbyterian Behavioral Health (Medicare andCommercial) can be found in Appendix D.Availity ® (formerly THIN)PO Box 550857Jacksonville, FL 32255-08571-800-AVAILITY (282-4548)www.availity.comPayer ID: PREHP (Commercial)Payer ID: PRESA (Medicare)Emdeon Business Services (formerlyWebMD ® )One Century Place26 Century Blvd, Suite 601Nashville, TN 372141-877-469-3263 orhttp://www.emdeon.comPayer ID: 05003 (all lines of business)HealthXnet ®7471 Pan American Freeway NEAlbuquerque, NM 87109505-346-0290 orhttp://www.healthxnet.comPayer ID: Z0003 (Commercial)MedAssets100 North Point Cetnere EastSuite 200Alpharetta, GA 300221-888-883-6332Payer ID: 23456 (all lines of business)Claim.MD (Fast Claim)PO Box 1177Pecos, NM 87552505-757-6060http://www.claim.mdPayer ID: PRESB (all lines of business)InstaMed1880 John F. Kennedy Blvd.12th FloorPhiladelphia, PA 191031-866-945-7990 orsupport@instamed.com9-132014 Practitioner and Provider Manual - Ver. 3

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Behavioral Health10. Long-Term Care10. Long-Term CareLong-term care is the overarching term that refersto the Community Benefit, the services of a nursingfacility, and the services of an institutional facility.With the creation of Centennial Care, the NewMexico Human Services Department (HSD) nowcontracts with four Managed Care Organizations(MCOs) including Presbyterian to deliver the fullrange of physical health, behavioral health, andlong-term care in a comprehensive and integratedmanner.Presbyterian Centennial Care’s goal is to provideeach of our members with access to the servicesand support necessary to maintain the highest levelof function and independence in their community.For members residing in nursing facilities or otherinstitutions, our goal is to ensure quality health careand reduce the number of acute inpatientadmissions through effective care coordination andsuccessful care transitions. Please note that thischapter applies specifically to the Centennial Careprogram.Patient EligibilityGeneral EligibilityThe state determines eligibility for enrollment in aCentennial Care program. Continued eligibility isassessed annually and includes a re-assessmentby the state or its designee. All individualsassessed as Medicaid-eligible are required toparticipate in Centennial Care unless specificallyexcluded by a 1115(a) Waiver.Recipients in the Developmental Disabilities1915(c) Waiver and recipients with developmentaldisabilities in the Mi Via 1915(c) Waiver continue toreceive home- and community-based services(HCBS) through those waivers for a limited periodof time, but are required to enroll in CentennialCare for all non-HCBS. Recipients in the MedicallyFragile 1915(c) Waiver continue to receive HCBSthrough that waiver unless and until such servicesare transitioned to Centennial Care. Recipients inthe Medically Fragile 1915(c) Waiver are requiredto enroll in a Centennial Care MCO for all non-HCBS.Native American Member EligibilityNative American members may self-refer to anIndian Health Service (IHS) or Tribal Health Centerfor long-term care services. PresbyterianCentennial Care allows members who are NativeAmerican to seek care from any IHS or tribalprovider defined in the Indian Health CareImprovement Act, 25 United States Code (USC)§§1601, et seq., whether or not the providerparticipates in Presbyterian’s provider network. Tofurther promote access for our Native Americanmembers, Presbyterian Centennial Care does notrequire prior authorization for services providedwithin the IHS and Tribal 638 network and accepts10-12014 Practitioner and Provider Manual - Ver. 3

Long-Term Carean individual provider employed by the IHS orTribal 638 facility that holds a current license topractice in the United States or its territories asmeeting licensure requirements.Community BenefitUnder Centennial Care, the state has created onecomprehensive Community Benefit that includesboth personal care and the HCBS previouslyprovided through the Coordination of Long-TermServices 1915(c) Waiver and the Mi Via 1915(c)Waiver. Individuals who are otherwise Medicaideligibleand who meet Nursing Facility Level ofCare (NF LOC) eligibility requirements have accessto HCBS and personal care services withoutwaiting for a slot to become available. Those whoare not otherwise Medicaid-eligible (including thoseelecting self-directed services) and who haveincomes below 300% of supplemental securityincome and who meet NF LOC eligibilityrequirements are able to access the CommunityBenefit if a slot is available. The state maintains acentral registry for persons waiting for theCommunity Benefit who are not otherwiseMedicaid-eligible. The central registry is managedon a statewide basis using a standardizedassessment tool and in accordance with criteriaestablished by the state.Nursing Facility Level of Care Assessment forLong-Term Care BeneficiariesA NF LOC eligibility assessment must beperformed for all applicants for whom there is areasonable indication that long-term care servicesmay be needed in the future. Presbyterian conductsthe NF LOC eligibility assessment for individualsenrolled in Presbyterian Centennial Care.Presbyterian uses state-developed LOC criteriaand a state-approved assessment tool fordetermining NF LOC eligibility for all long-term careservices (including facility placement and theCommunity Benefit). Elements of NF LOC eligibilitycriteria used to initially and periodically determinethe individual’s medical eligibility includeMedical risk factors, including but not limitedto medical diagnoses associated with BasicActivities of Daily Living (BADL), InstrumentalActivities of Daily Living (IADL), range ofmotion limitations, need for medicaltreatments, need for clinical monitoring by aregistered nurse, and hospitalization in thelast 90 daysAvailability of support and social resources,such as personal care assistancehousekeeping, home-delivered meals, livingarrangements, homebound status, anddurable medical equipmentEnvironmental conditions, including safety andaccessibility issuesNutritional challenges including eating issuessuch as swallowing problems, tube feeding,special diet, nausea, and tooth or mouthproblemsCommunication and cognition capabilityBehavioral/mental health statusHealth and safety risks, including susceptibilityto falling10-22014 Practitioner and Provider Manual - Ver. 3

Long-Term CareAbility to perform BADL, including bathing andshowering (washing the body), bowel andbladder management (recognizing the need torelieve oneself), dressing, eating (includingchewing and swallowing), feeding (setting upfood and bringing it to the mouth), functionalmobility (moving from one place to anotherwhile performing activities), personal devicecare, personal hygiene and grooming(including washing hair), sexual activity, andtoilet hygiene (completing the act of relievingoneself)Ability to perform IADL, including doinghousework and laundry, preparing meals,taking medications as prescribed, managingmoney, shopping for groceries or clothing,using the telephone or other form ofcommunication, scheduling appointments,using technology (as applicable), and usingtransportation within the communityComprehensive Needs AssessmentPresbyterian conducts a Comprehensive NeedsAssessment (CNA) for everyone meeting NF LOCeligibility criteria to determine the level of need forlong-term care services. The CNA places peopleinto either a low-needs or high-needs group. Thisassessment also applies to eligibility for existingslots. Slots available for those not otherwiseMedicaid-eligible are divided into low-needs slotsand high-needs slots with the respective lowexpenditureand high-expenditure limits.Member ChoiceMembers eligible for the Community Benefit areeducated on and have the option to select eitherthe Agency-Based Community Benefit or the Self-Directed Community Benefit.Agency-Based Community BenefitThe Agency-Based Community Benefit is aconsolidation of HCBS and personal care servicesand is available to members meeting NF LOCeligibility criteria. Members selecting the Agency-Based Community Benefit have the option to selecttheir personal care service provider. PresbyterianCentennial Care makes the following HCBSavailable through the Agency-Based CommunityBenefit:Adult day health careAssisted livingBehavior support consultationCommunity transition servicesEmergency responseEmployment supportEnvironmental modificationsHome health aidePersonal care services (may be self-directed)Private duty nursing for adultsRespiteSkilled maintenance therapy servicesEach Presbyterian Centennial Care memberenrolled in the Agency-Based Community Benefitare assigned a Presbyterian care coordinator. Thiscare coordinator helps the member understand the10-32014 Practitioner and Provider Manual - Ver. 3

Long-Term Careavailable services, and helps the member developand implement an annual care plan that identifiesthe services and support necessary to meet themember’s choices, abilities, and needs. This careplan drives the authorization of Agency-BasedCommunity Benefit services available to eachmember.Self-Directed Community BenefitSelf-direction in Presbyterian Centennial Careaffords members the opportunity to have choiceand control over how Self-Directed CommunityBenefit (SDCB) services are provided, whoprovides the services, and how much providers arepaid for providing care in accordance with a rangeof rates per service established by HSD.Presbyterian supports consumer-directed deliveryof personal care and HCBS. Member self-directionprovides the opportunity for members to personallydirect the purchase of long-term care supports andservices and manage their budgets in a way thatpromotes self-advocacy and independence.The services of a support broker are available toassist members in understanding and using thebenefit as well as developing and managing theirbudget.Support brokers are consultant agencies whocurrently support the State of New Mexico’s Mi Viaprogram (the state’s Medicaid self-directed waiverprogram). Several of these broker agencies havebeen contracted by Presbyterian to provideCentennial Care members who opt for the SDCBwith the expert help they need to develop andmanage their benefit’s details. The support brokersPresbyterian contracts with include the largest,which supports approximately 80% of the currentMi Via participants.Members who opt for the SDCB will receive helpfrom their care coordinators in establishing arelationship with a support broker.Under Presbyterian Centennial Care, the followingHCBS are available for self-direction:Behavior support consultationCustomized community support servicesEmergency responseEmployment supportsEnvironmental modificationsHome health aideHomemaker/personal careNutritional counselingPrivate duty nursing for adultsRelated goodsRespiteSkilled maintenance therapy servicesSpecialized therapiesTransportation (non-medical)Presbyterian provides members who elect theSDCB service delivery option with the informationand assistance necessary to develop a budgetbased on member preferences, assessed need,and the resources available to the member. Thisbudget is developed in coordination with themember’s care plan and takes into account theservices covered, the member’s natural or informalsupports, and living situation. The support brokermakes available the worksheets and other tools10-42014 Practitioner and Provider Manual - Ver. 3

Long-Term Careneeded to assist the member. Our aim is to ensurethat members are effectively encouraged to choosethe services, supports, and goods they believe bestmeet their community living needs.Members who participate in the SDCB chooseeither to serve as the employer of record (EOR) oftheir providers or to designate an EOR orauthorized agent to serve as the EOR on his or herbehalf. Development of the budget begins after themember’s completion of the self-assessmentrequired for the SDCB, identification of an EOR orauthorized agent if applicable, and completion ofthe CNA by Presbyterian’s care coordinator. Thesupport broker and member (and EOR orauthorized agent, when applicable) reviews theresults of the CNA. Based on the results of theCNA, the support broker provides the level ofassistance the member requires, ranging from noassistance to in-depth discussions to identify eachneed and determine how each need can best bemet. The member is also encouraged to identify hisor her short-term and long-term goals, includingneeds related to life goals and any anticipated lifechanges, such as living situation, caregiveravailability, and/or community participation. Thesupport broker obtains the member’s annual budgetallocation amount from the care coordinator and, ifappropriate, calculate the average monthly andweekly amounts for the member’s use.The support broker then guides the memberthrough the budget development process. Thesupport broker helps the member address thefollowing key decisions necessary to develop thewritten budget plan and provide background andadditional information as needed:What services, supports, and goods do youneed each month? Are there any services,supports, and goods you need once duringthe year or just a few times, and, if so, whatare they?Are there any no-cost resources availablefrom other programs, organizations, familymembers, or friends that can be used insteadof a covered service? Do you need helpcontacting these other resources?Are the remaining needed services, supports,and goods covered? Are any prohibited bystate or federal requirements?What types of workers do you need to hire toprovide the identified services, supports, andgoods?How often do you need the services, supports,and goods (daily for how many hours, weekly,other)?What is your budget to purchase services,supports, and goods? How much can youoffer to pay providers for the services,supports, and goods based on the rate rangesprovided by HSD?What is your backup or emergency plan?The Fiscal Management Agency (FMA) is the entitycontracting with the state to provide the fiscaladministration functions for members receiving theSDCB. The FMA must be an entity operating underSection 3504 of the Internal Revenue Service code,Revenue Procedure 70-6, and Notice 2003-70, as10-52014 Practitioner and Provider Manual - Ver. 3

Long-Term Carethe agent to members for the purpose of filingcertain federal tax forms and paying federal incometax withholding, FICA, and FUTA taxes. The FMAalso files state income tax withholding andunemployment insurance tax forms, pays theassociated taxes, and processes payroll based onthe eligible SDCB services authorized andprovided.Presbyterian’s care coordinator ensures adequatesupport for participants who choose the SDCB.Termination from the Self-Directed CommunityBenefitPresbyterian Centennial Care may involuntarilyterminate a member from the SDCB wheneverthe following circumstances occur:The member refuses to follow HSD rulesand regulations after receiving focusedtechnical assistance on multiple occasions,and support from the care coordinator orFMA, which is supported by documentationof the efforts to assist the member.There is an immediate risk to the member’shealth or safety by continued self-direction ofservices, for example, the member is inimminent risk of death or serious bodily injury.Examples include but are not limited to thefollowing: the member (i) refuses to includeand maintain services in his or her care planthat would address health and safety issuesidentified in his or her CNA or challenges theassessment after repeated and focusedtechnical assistance and support fromprogram staff, care coordination, or FMA; (ii) isexperiencing significant health or safety needsand refuses to incorporate the carecoordinator’s recommendations into his or hercare plan; or (iii) exhibits behaviors thatendanger himself, herself, or others.The member misuses his or her SDCBbudget following repeated and focusedtechnical assistance and support from thecare coordinator and/or FMA, which issupported by documentation.The member expends his or her entire SDCBbudget before the end of the care plan year.The member commits Medicaid fraud.Presbyterian Centennial Care will submit to HSDany requests to terminate a member from theSDCB with sufficient documentation regarding therationale for termination. Upon HSD approval,Presbyterian Centennial Care will notify themember regarding termination in accordance withHSD rules and regulations. The member shall havethe right to appeal the determination by requestinga fair hearing.Presbyterian Centennial Care will facilitate aseamless transition from the SDCB to ensure thereare no interruptions or gaps in services. Involuntarytermination of a member from the SDCB shall notaffect a member’s eligibility for covered services orenrollment in Centennial Care.Presbyterian Centennial Care will notify the FMAwithin one business day of processing theoutbound enrollment file when a member isinvoluntarily terminated from SDCB and when amember is disenrolled from Centennial Care. Thenotification should include the effective date oftermination and/or disenrollment, as applicable.10-62014 Practitioner and Provider Manual - Ver. 3

Long-Term CareMembers who have been involuntarily terminatedmay request to be reinstated in the SDCB. Suchrequest may not be made more than once in a 12-month period. The care coordinator will work withthe FMA to ensure that the issues previouslyidentified as reasons for termination have beenadequately addressed before reinstatement. Allmembers shall be required to participate in SDCBtraining programs before re-instatement in theSDCB.Family Members Serving as ProvidersPresbyterian complies with all appropriatecontractual and regulatory requirements regardinglegally responsible individuals (LRIs) serving asproviders. Family members or spouses may serveas providers under extraordinary circumstances inorder to assure the health and welfare of membersand to avoid institutionalization. Presbyterianapproves these instances on a case-by-case basisusing pre-established criteria.The following services provided by an LRIregarding the SDCB are not approved:The service that the LRI is proposed toperform as a provider is a service the LRIwould ordinarily perform in the household forindividuals of the same age who do not have adisability or chronic illnessThe LRI is the member’s EORThe LRI is unable to pass a nationwidecriminal history screening or is listed in theabuse registryWhen Presbyterian considers approval for an LRI, ittakes into account whether attempts have beenmade to find other qualified, suitable providers.Presbyterian believes there are instances when anexception process, with HSD approval, may beused to determine whether a spouse or familymember who does not meet the LRI criteria shouldbe granted approval to serve as the member’s LRI.Our exception review criteria and process are:The member or EOR, with assistance from thesupport broker when requested, provides themember’s care coordinator with a compellingexplanation as to why spouse or familymember provision of the requested services isessential in order for the member to remainsafely at home.The Medical Director, Interdisciplinary CarePlan Team (ICPT), and member or EORjointly determine the spouse or family memberprovision of the requested service(s) is in thebest interest of the member.In the event an impasse is reached,Presbyterian’s medical director shall make thefinal determination.Utilization Management and Prior AuthorizationPresbyterian’s utilization management program isdesigned to reduce overuse, underuse, and misuseof health care resources in order to reduce cost andimprove quality. Utilization managementcomponents include care review (priorauthorization), monitoring for over/underutilization,concurrent review, and retrospective review toensure our members receive the right amount of10-72014 Practitioner and Provider Manual - Ver. 3

Long-Term Carecare at the right time, in the right setting, and in themost cost-effective way.Care Review ProcessPresbyterian’s care review process is administeredin a way that promotes timely care delivery andminimizes administrative burden by streamlining,standardizing, and automating prior authorization.The care review process uses a team-basedapproach to ensure that each individual member’sneeds are met in a holistic way.The member’s care coordinator authorizes amember’s HCBS. Additional authorization isrequired when a member’s assessed need involvesan alternative HCBS service that is a downwardsubstitution of care; that is, the use of services thatareLess restrictive and lower cost than otherwisemight have been providedConsidered clinically acceptableRequired to meet specified objectives outlinedin the member’s plan of treatmentThe alternative HCBS request is reviewed by theUtilization Management department, whichdetermines if these services can be reasonablyexpected to avoid or delay institutionalization.Member consent to downward substitution of careis required.Review CriteriaPresbyterian references nationally recognized,evidence-based standards to develop criteria. Seethe Minimum Medical Records Standards section ofthe Care Coordination chapter for a list ofstandards.Medical policies are reviewed and approved by ourClinical Quality Committee, Pharmacy andTherapeutics Committee, and medical directors toensure they are clinically appropriate. Bothcommittees include local (New Mexico),community-based, actively practicing clinicians. Allmedical policies are available on the web athttps://www.phs.org/providers/cliniciansresources/medical-policy-manual.Supporting Integration and Coordination ofPhysical Health, Behavioral Health, and Long-Term Care ServicesPresbyterian Centennial Care is structured tosupport and foster whole-person care that iscoordinated and integrated across providers anddisciplines. This care includesCoordination of physical health, behavioralhealth, and long-term care services by primarycare providers (PCPs), core service agencies,federally qualified health centers, patientcenteredmedical homes, and health homesParticipation of providers in care planningteamsCommunication and information sharingacross provider systemsWe collaborate with our network providers toenhance care coordination throughComprehensive provider training andeducationClear and simple policies and procedures forcoordination and communication among10-82014 Practitioner and Provider Manual - Ver. 3

Long-Term Carephysical health, behavioral health, and longtermcare providers (a list of policies andprocedures is available athttps://www.phs.org/providers/cliniciansresources/)Data exchange and access to clinicalinformation across systems of care throughtechnology solutions that include• Presbyterian’s web-based caremanagement platform, where providerscan access data regarding claims,authorizations, member risk stratification,and care coordination• Community Connect, an external providerEpic tool for smaller providers withouttheir own electronic health records (EHRs)• Data interfaces with providers’ existingEHRs and our care management platform• Data dashboards with actionable memberinformation that allows providers tomonitor members’ outcomes and theirperformance against specific standardsCare CoordinationPresbyterian’s member-centric care model isdesigned to integrate physical health, behavioralhealth, and long-term care services into a seamlesscare system that provides members withappropriate services at the right time within theleast restrictive and most cost-effective setting. Ourlong-term care providers play a key role in thisprocess by engaging members, participating in careplanning efforts, and ensuring comprehensive,coordinated, and culturally appropriate care foreach unique member. The care model promotescollaboration and supports providers in advancingwellness and promoting independence, resiliency,healthy living, health literacy, and personalresponsibility. A comprehensive understanding ofthis model by our providers is critical. The followingsubsections describe our care model’s corecomponents.Risk Stratification and Comprehensive NeedsAssessmentAll members receive a Health Risk Assessment(HRA), are assigned to a level of care coordination,and are partnered with a dedicated carecoordinator. Members are matched with anappropriate care coordinator based on their clinicalneeds, geography, language, cultural preferences,and history of established relationships with aprovider or community-based service agency. AllLevel 2 and Level 3 members receive an in-personCNA to identify and prioritize their clinical,behavioral, functional, and social support needs.Interdisciplinary Care Plan TeamBased on the results of the CNA, an individualizedcare plan is developed for each member and anappropriate ICPT is established. The ICPT includesthe member and all providers, including PCPs,specialists, and support providers, along with anyadditional resources needed to fulfill the care plan’sgoals, such as a behavioral health provider and/orpharmacist. The care plan is reviewed, approved,and signed by the member. The ICPT is structuredto address the member’s specific needs and is acentral component of the care model. Members areencouraged to actively participate in the care10-92014 Practitioner and Provider Manual - Ver. 3

Long-Term Careplanning process, and they are provided with toolsand resources that allow them to take personalresponsibility for their care management. Clinicalstaff from nursing homes and assisted livingfacilities where members live are included asintegral participants in the member’s ICPT.Residential care staff members are instrumentalparticipants in the member’s IPCT and play acentral role in alerting our care coordinators to achange in condition or status that, if acted upon,may prevent unnecessary hospitalizations.Delivery of Coordinated and Integrated ServicesThe care coordinator works in collaboration with themember, the member’s PCP, and the ICPT toimplement the care plan. The care coordinator alsofacilitates access to care coordination providersand the necessary physical, behavioral, and longtermcare services.Member Engagement and Self-Care ManagementMembers are at the center of our care model. Weprovide appropriate tools and resources, such asStanford’s My Chronic Disease program, to engagethem as active participants in managing their illnessand lifestyle. Members are provided access to theirown Care Plan and a downloadable personal healthrecord through the Presbyterian member portal.The ICPT includes a combination of professionalswith the expertise to address the specific needs ofeach member.Monitoring and EvaluationThe care coordinator is responsible for effectivecommunication across the system, continuous andsystematic monitoring, and regular reassessment toevaluate adherence to the care plan. The carecoordinator also identifies gaps, barriers, andchanges in condition or status. Any change instatus or condition automatically triggers areassessment and potentially a revision to themember’s care plan.Identification and Referral for Behavioral HealthServicesTo ensure that the care and services provided toour Centennial Care members are most effective, itis critical that unmet behavioral health needs areidentified and addressed. As a highly engagedparticipant in a member’s care, long-term careproviders are well positioned to recognizebehavioral health issues that may be interferingwith a member’s ability to live independently in thecommunity or respond to other physical care, longtermcare, or treatment. When a provider suspectsa need for a behavioral health service, that providershould encourage the member to contact his or hercare coordinator, PCP, or Presbyterian’s customerservice representatives at 505-923-5200 or 1-888-977-2333 for assistance in locating a behavioralhealth provider. Providers may also refer membersto Presbyterian’s online interactive web tools onvarious behavioral health conditions and generalinterest topics, and an online depression screeningself-test with automatic scoring and feedback, athttp://www.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001006.pdf.Community Health Workers and CommunityHealth RepresentativesPresbyterian has developed a community healthworker (CHW) network to support our care10-102014 Practitioner and Provider Manual - Ver. 3

Long-Term Carecoordinators and providers in engaging membersand improving health outcomes through increasedhealth literacy and personal responsibility. CHWs,also known as promotoras, are lay health workersand advocates for members who assist individualsand families in obtaining the knowledge and skillsnecessary to achieve optimal health and well-being.Community health representatives (CHRs) play asimilar role in tribal communities. CHWs and CHRsplay a key role inEngaging members, their families, andcaregivers in culturally appropriate,individually tailored health education to ensurethey have the tools needed to activelyparticipate in their careDelivering interdisciplinary care planning,including the completion of CNAs and formalHRAsFacilitating integrated care by helpingmembers access appropriate physical health,behavioral health, and long-term care servicesBuilding relationships with community-basedsocial service organizations across NewMexico to ensure that members can obtainneeded non-medical social support servicessuch as transportation, food, and housingCHWs and CHRs may be part of a member’s ICPTand are a valuable resource for providers forcoordinating and ensuring that a member’s holisticcare needs are met.Nursing Facility Level of Care: Care PlanDevelopmentOnce a member is assessed as eligible for NFLOC, the care coordinator develops a care planwith the member and/or legal guardian orrepresentative, as well as anyone else the memberchooses. The care planning process is based onthe CNA, which incorporates elements of the NewMexico Personal Care Option need determinationand the assessment used for long-term care waiverclients. The care planning process incorporates themember’s medical, functional, behavioral, socialsupport, and community participation needs andpreferences as part of a holistic plan for HCBS.Members who elect to use the SDCB work withtheir support broker (and their EOR or authorizedagent) to identify the needed services within thescope of covered services and the HSD-providedannual allotment. The budget plan is incorporatedinto the member’s care plan.The assessment is used as the basis fordetermining the types and amount and duration ofHCBS the member needs. Based on establishedcriteria for individual need level, the carecoordinator develops an individual HCBS plan asfollows:The member and/or representative identifyspecific HCBS the member desires/needs.The care coordinator educates the member ontheir option to elect the SDCB, and explainsthe self-assessment tool that must becompleted for members electing this option.The care coordinator ensures that the HCBSincluded in the care plan and (for SDCB) the10-112014 Practitioner and Provider Manual - Ver. 3

Long-Term Carebudget plan are sufficient to meet themember's needs. The criteria used to makethis determination include one or more of thefollowing:• The service is essential to enable themember to attain, maintain, or regain hisor her optimal functional capacity.• The service addresses a need related toimproving the member's health, functionaloutcomes, or quality-of-life outcomes.• The service addresses environmentalsafety or a safety-related long-term careneed.• The service enables the member toincrease or maximize his or herindependence.• The service delays or prevents the needfor more expensive institutionalplacement.• The service is not available from anothersource.The care coordinator identifies one or moresources of covered services and supportsavailable to meet identified long-term careneeds, including one or more HCBS primaryproviders and backup providers/plans if theHCBS primary provider becomes unavailable.The care coordinator considers the views andchoices of the member or the member’srepresentative regarding the proposedservices and considers any other relevantinformation from qualified professionals, themember’s HCBS providers, and others whenauthorizing services.A comprehensive individual reassessment of allindividuals receiving HCBS takes place at leastevery six months, incorporating a reassessment ofthe HCBS plan. NF LOC eligibility reassessmenttakes place at least annually and within fivebusiness days of notification to PHP that themember’s functional or medical status has changedin a way that may affect LOC determination.Transitions of CareFor members in out-of-home care or transitioning toa nursing facility, Presbyterian’s care coordinatorparticipates in the facility’s care planning anddischarge planning/transition processes,advocating that the member be managed in theleast restrictive setting and coordinating services tohelp support the member’s transition back to thecommunity as appropriate.CommunicationTo ensure a truly integrated delivery system ofcare, Presbyterian requires and relies on ourproviders to communicate with each other and withthe Presbyterian care coordination staff. Themember’s care coordinator is accountable forfacilitating this communication, sharing the careplan with all providers, and conducting ICPTmeetings and interactions. All providers involved ina member’s care are responsible for participating inthese care coordination efforts, providing updateson the member’s status and progress toward careplan goals, and making referrals andrecommendations as appropriate. PresbyterianCentennial Care offers web-based technologies tosupport our providers and community-based10-122014 Practitioner and Provider Manual - Ver. 3

Long-Term Careorganizations in their work on care coordination andlinking to our ICPTs.Care Management SystemCare management system is Presbyterian’s fullyintegrated care management system. The systemdatabase maintains all information related to eachmember and facilitates communication betweenmembers, providers, and the ICPT. Informationavailable through our care management systemincludes but is not limited to utilizationmanagement, care review, assessments, selectedelements of the EHRs, the ICPT care plan,educational materials accessible through themember portal, predictive modeling information, labresults, pharmacy data, and telehealth data. Ourcare management system allows for bettercommunication across the health care team andensures improved decision making and monitoring,including alerts regarding tasks, quality monitoringreports, the likelihood of hospitalization, and gapsin care.Through web-based access to our caremanagement system, Presbyterian CentennialCare providers can integrate all care coordinationfunctions and programs across the continuum ofcare. Providers who have implemented a modernEHR system can seamlessly consume clinical datafrom our care management system in the form ofstandard continuity of care documents. Our caremanagement system also provides a communityresource database that facilitates access toresources such as housing, meals, and traditionalhealing services.Medical providers and service agencies haveaccess to the Presbyterian care managementsystem either directly through the myPRESProvider Portal or, with patient permission, throughthe Patient Portal, and can request an immediatevisit from a care coordinator or CHW.Provider PortalThe Provider Portal in our care managementsystem provides physicians with access tomembers’ medication lists, collaborative care plans,authorization entry, care coordination records(which document provider interaction with the careteam), and profiles, including lab results and otherclinical data.CredentialingPhysicians, other health care providers, facilities,and hospitals that provide health services toPresbyterian members must be credentialed inaccordance with Presbyterian’s policies andprocedures. Under the State of New Mexicoregulation, the credentialing process and approvalmust be completed before providing care to aPresbyterian member. Recredentialing occursevery three years thereafter for all credentialedentities.Individual Providers and GroupsPresbyterian credentials all providers and groups ofproviders who have an independent relationshipwith the organization. An independent relationshipexists when the organization selects and directs itsmembers to see a specific provider, including allproviders whom members can select as PCPs.10-132014 Practitioner and Provider Manual - Ver. 3

Long-Term CareOrganizationsFor the purposes of credentialing, organizationsinclude hospitals, skilled nursing facilities, freestandingsurgical centers, and skilled home healthagencies.Other Provider RequirementsCertain non-traditional provider types require amodified credentialing process that may involveverification of the following:W-9 FormCurrent Professional/Liability Face Sheets ofeach insurance policyCurrent state licenses and other certificationsCriminal background checkThis shall include, but is not limited to, personalcare option service providers, assisted livingfacilities, adult day health centers, CHWs, andnutritional counselors.Electronic Visit VerificationPresbyterian monitors member receipt and use ofthe Community Benefit. Electronic Visit Verificationincludes the following capabilities to ensuremembers receive appropriate services:Logs the arrival and departure of individualprovider staff personnel or self-directionproviderVerifies in accordance with business rules thatservices are being delivered in the correctlocation (such as the member’s home)Verifies the identity of the individual providerproviding the service to the memberMatches services provided to a member withservices authorized in the member’s care planEnsures that the provider delivering theservice is authorized to deliver such servicesEstablishes a schedule of services for eachmember and ensures adherence to theschedule, identifying the time at which eachservice is needed, as well as the amount,frequency, duration, and scope of eachserviceProvides real-time notification to carecoordinators if a provider does not arrive asscheduled or otherwise deviates from theauthorized schedule; this allows any servicegaps to be immediately identified andaddressed, including the implementation ofbackup plans, as appropriateReconciles paid claims with serviceauthorizationsPresbyterian also monitors and uses informationfrom the Electronic Visit Verification system toverify that services are provided as specified in thecare plan and in accordance with the establishedschedule, including the amount, frequency,duration, and scope of each service, and thatservices are provided by the authorized provider.This system is also used to identify andimmediately address service gaps, including lateand missed visits.Long-Term Care Claims SubmissionAll Centennial Care long-term care claims shall besubmitted directly to Presbyterian except for claimsfor members enrolled in the SDCB, which is paidfor by the FMA.10-142014 Practitioner and Provider Manual - Ver. 3

Long-Term Care11. Home Health11. Home HealthNote that throughout this chapter, home health careagency providers are referred to as agency oragencies.Home care services for Presbyterian are managedthrough the Presbyterian Home HealthcareStatewide Network (PHHSN). PHHSN supports themission of Presbyterian to improve the health ofindividuals, families, and communities throughoutNew Mexico by ensuring the provision of thehighest quality and affordable home care servicesfor patients in their home.PHHSN provides utilization management throughreview of prior authorization requests for home careservices. The review is to ensure that the rightservices are provided at the right frequency,duration, and level needed. PHHSN is alsoaccountable to guide the denial process to thePresbyterian medical director and track all homecare denials.PHHSN also collects data and performs analyseson a monthly, quarterly, and annual basis tomeasure quality outcomes. Additionally, utilizationresults will be reported to the PHHSN QualitySubcommittee.The PHHSN director of finance, businessoperations, decision support and statewide networkand the PHHSN Lead Quality ResourceManagement (QRM) Analyst are available to assistagencies in learning and implementing the policies,procedures, and benefits outlined in this section ofthe manual. To the extent that there are any directconflicts between the provisions of this home healthcare section and any contract with PHHSN, theprovisions of the contract will prevail.The Synagis ProgramThe Synagis (Palivizumab) program is coordinatedfor all Presbyterian eligible children that meetqualifying criteria, statewide through PHHSN.Agency Recredentialing PolicyAccredited and non-accredited home health careagency providers within the State of New Mexico orin surrounding states that are within 100 miles ofthe New Mexico state boundary and that carry aNew Mexico home care license may request tocontract with PHHSN. Presbyterian will, amongother things, confirm that the requesting homehealth care agencyIs in good standing with state and federalregulatory bodiesHas been reviewed and approved by arecognized accrediting bodyWill ensure, at least every three years, thatthe home health care agency providercontinues to be in good standing with stateand federal regulatory bodiesMeets Presbyterian’s credentialing standardsfor home health care.11-12014 Practitioner and Provider Manual - Ver. 3

Home HealthPresbyterian’s credentialing department isresponsible for reviewing the required credentialingdocuments and information as provided by theagency. The credentialing packet is presented tothe Peer Review Credentialing Committee atPresbyterian for approval. Presbyterian maintainsthe security and confidentiality of the credentialingfiles. At least every three years, all contractedagencies need to comply with the Presbyterianrecredentialing process in order to maintainparticipation with PHHSN.For those non-licensed home health care agenciesproviding only hourly care under the Medicaid Earlyand Periodic Screening, Diagnosis, and Treatment(EPSDT) benefit, PHHSN has developed a list ofcriteria to be met in order to qualify as a PHHSNagency provider. Once the required information hasbeen submitted and reviewed, a subcontract mustbe signed before a request for configuration canoccur. All agencies must be configured into thePresbyterian computer system to allow PHHSN tocertify care and for an agency to submit claims toPresbyterian for payment.Agency Contracting Policy and ProcessPHHSN is responsible to ensure statewide homecare coverage by contracting with qualified homecare providers throughout the State of New Mexico.Before any home care services may be provided toPresbyterian members, a written, fully executedcontract developed by Presbyterian’s legaldepartment must be signed by all necessaryparties. Presbyterian maintains the security andconfidentiality of the contract files.New Agency OrientationUpon successful completion of the credentialingand contracting processes, PHHSN’s director offinance and statewide network or lead QRM analystwill schedule orientation with the new agency. Theorientation will include explanation of the priorauthorization process, the appeals and grievanceprocess, reporting requirements, the teamconference process, and completion of the annualself-audit and claims submission process. Eachagency will be provided access to this manualthrough the PHS website address.Patient EligibilityUpon initial receipt of a referral or priorauthorization request, PHHSN will verify patients’eligibility and benefits. When reviewing for ongoingauthorization, a letter indicating non-eligibility willbe sent within 24 hours if PHHSN determines thepatient is no longer a current Presbyterian member.Qualifying Home Care Criteria PolicyThe qualifying home care criteria policy applies toplans that have a home health care benefit,including commercial/Administrative Service Only,Presbyterian Senior Care (HMO), Medicaid andPresbyterian Insurance Company, Inc., plans.Upon receipt of a referral or prior authorizationrequest, PHHSN will review the referral or requestagainst qualifying criteria for home care services,which may include ensuring that a patient ishomebound. At the time this manual was published,“homebound” is defined as a person meeting all ofthe following:11-22014 Practitioner and Provider Manual - Ver. 3

Home HealthThe condition of these patients should besuch that a normal inability to leave homeexists and, consequently, leaving home wouldrequire a considerable and taxing effort.Absences from the home are infrequent or forperiods of relatively short duration, or areattributable to the need to receive health caretreatment, including regular absences for thepurpose of participating in therapeutic,psychosocial, or medical treatment in an adultday care program. Attending a religiousservice shall be deemed to be an absence ofinfrequent or short duration.Occasional absences from the home for nonmedicalpurposes, such as an occasional tripto the barber, a walk around the block, a drive,attendance at a family reunion, funeral,graduation, or another infrequent or uniqueevent would not necessitate a finding that thepatient is not homebound if the absences areon an infrequent basis or are of relatively shortduration and do not indicate that the patienthas the capacity to obtain health care servicesoutside rather than in the home.The patient has a condition because of anillness or injury that restricts the patient’sability to leave their place of residence exceptwith the aid of supportive devices such ascrutches, canes, wheelchairs, or walkers; theuse of special transportation; the assistance ofanother person; or if leaving home ismedically contraindicated.of time. A patient may leave the home morefrequently during a short period when, forexample, the presence of visiting relativesprovides a unique opportunity for suchabsences than is normally the case.So long as the patient’s overall condition andexperience is such that he or she meets thesequalifications, he or she should be consideredconfined to the home.PHHSN may also review the referral or requestagainst the following qualifying criteria for homecare services:Ensuring requests for services are medicallynecessary requiring a skilled service (forexample, nursing, physical therapy,occupational therapy, and speech languagepathology)Ensuring that intermittent part-time serviceswill meet the patient’s needsEnsuring that all care is ordered and under aphysician’s direction through the course ofcareQualifying Home Care Criteria Policy – MedicaidPresbyterian Medicaid Intermittent Skilled Servicesadmission criteria are modeled as follows:Recipient must have documented medicalneed to receive care at homeServices are needed on an intermittent basisAll care must be ordered and under physiciandirection throughout the course of careWhen determining if a patient is homebound,their condition must be reviewed over a period11-32014 Practitioner and Provider Manual - Ver. 3

Home HealthPresbyterian Medicaid members are notrequired to be homebound to be eligible forhome care servicesPresbyterian Medicaid Early and PeriodicScreening, Diagnosis, and Treatment ServicesMedically Fragile Home and Community-BasedServicesThese services are case managed through theUniversity of New Mexico (UNM) CaseManagement Program for children less than 21years of age. Referrals to this program are directedto UNM case managers at 505-272-2910. The casemanager with the interdisciplinary team evaluatesthe child and determines the level of care required.Services include hourly private duty nursing and/orhourly home health aide care. PHHSN priorauthorizes care as directed by UNM casemanagers’ assessment and budget.Personal Care ServicesThe EPSDT, personal care services admissioncriteria are as follows:Recipient must be under 21 years of ageRecipient must have a need for assistancewith at least two physical requirements suchas eating, bathing, dressing or toileting acts,appropriate to his or her agePersonal care services must be medicallynecessary and prescribed by their physicianand included in the plan of treatmentThe need for personal care services isevaluated based upon formal and informalsupport, availability of family members, othercommunity resources, and/or friends who canassist in providing such carePersonal care must have the consent ofrecipient’s parents or guardians if the recipientis under the age of 18 years, and therecipient’s consent if over the age of 18Personal care services that are medicallynecessary are furnished in the recipient’shome or outside the home when medicallynecessary and are not available throughtraditional programsThese services cannot be provided to peoplewho are in a hospital, nursing facility,intermediate care facility, or facility for thementally retarded or an institution for mentaldiseasePersonal care services that are medicallynecessary for attending school are furnishedin partnership with the recipient’s school as analternative to participation in a homeboundprogram, with the services fostering the child’sindependencePersonal care services are furnished basedon approval by the designated utilizationreview agentServices must be provided by a personal careattendant (PCA) who is trained and demonstratescompetency to provide assistance with personalcare. The PCA must be employed by the agencyand work under the supervision of a registerednurse (RN). The supervising RN must have oneyear direct patient care experience and must makehome visits every 62 days or as often as needed toassess the recipient’s progress and the PCA’s11-42014 Practitioner and Provider Manual - Ver. 3

Home Healthperformance, and to update the care plan inconjunction with the recipient’s case manager.A Presbyterian case manager will determine thechild’s eligibility. An assessment of the child’sneeds will be conducted and a level of care andbudget developed. PHHSN will collaborate with thePresbyterian case managers to identify a homehealth care provider. PHHSN will authorize servicesbased on budgetary guidelines.Prior Authorization ProcessesInitial Prior AuthorizationPHHSN will process all referrals for home careservices through a comprehensive review processagainst admission criteria, in conjunction with thereferral sources or agency. The patient’s eligibilityand benefits will be verified. PHHSN may provideprior approval for home care services for admissionand ongoing care for up to two weeks on all initialrequests.Prior Authorization for Additional/ConcurrentServicesPHHSN requires that the requesting agency submitsupporting documentation including physician’sorders with the PHHSN prior authorization requestform for ongoing care. Requests for reauthorizationwill be reviewed before completion ofthe current certification period if requested by theagency.If a service under Intermittent Skilled Services hasbeen ordered by a physician and an agency doesnot provide that service, the agency must letPHHSN know of the order. A PHHSN quality reviewnurse has the option to find an alternative localagency to provide all home health care services orjust the additional services.Prior Authorization – Presbyterian Medicaid/EPSDTMedically Fragile Home and Community-ServicesUpon receipt by PHHSN of recipients’ MedicallyFragile budget, PHHSN reviews the indicatednumber of hours/month and designated home careproviders. PHHSN contacts the designatedagencies to discuss staff availability. PHHSNprovides prior authorization to all providers who willbe providing services. Services may be approvedfor six months and infrequently for up to 12-monthtime periods.Long-hour nursing care is requested in hours, notvisits, as indicated on the PHHSN priorauthorization form. For billing/payment purposes,the discipline authorized must match the disciplineon the claim submission (for example, licensedpractical nurse [LPN] on claim must match LPN oncertification). As LPN and RN availability change,the agency must notify PHHSN so a revision to theauthorization/certification can be processed. Thenumber of hours identified on the EPSDT budget isdeveloped by the Medically Fragile EPSDT casemanager.Personal Care ServicesUpon receipt of a referral from a Presbyterian casemanager, PHHSN will secure a home health careprovider to initiate services as outlined on the casemanager’s assessment and plan of care. Personalcare is requested in hours, not visits, on thePHHSN prior authorization form. Medicaidmembers under 21 years of age only are eligible for11-52014 Practitioner and Provider Manual - Ver. 3

Home Healththese services. Services may be approved for sixmonthtime periods.Retroactive AuthorizationsRetroactive authorizations are not provided as ageneral rule. However, for those medicallynecessary home care visits ordered by a physicianduring normal business hours for a same-day visitor a new referral requiring a same-day visit, a priorauthorization will be provided if the request isreceived on the next business day.Also, in those cases when medically necessary butunscheduled visits are ordered by the physicianafter business hours or on a weekend or holiday, aprior authorization will be issued when requestedby the end of the next business day. Agenciesshould normally request prior authorization forhome health care services before providing theservices.Co-payments, Co-insurance, and DeductiblesThe agency will be informed by PHHSN of anyPresbyterian commercial plan member’s copayments,co-insurance, or deductible or applicableco-payments under Medicaid State Children’sHealth Insurance Program or Working DisabledInsurance. The agency is responsible for informingthe patient of his or her financial responsibilitybefore initiation of home care services. The agencyis responsible for billing the member and collectingall co-payments and deductibles as they relate tohome care services. Co-payments are based uponan agency’s Presbyterian contracted rates, notupon an agency’s charges.Transition of CarePHHSN allows for the transition of Presbyterian ,members who are in need of home care services.This transition may involve members who arechanging from another insurer to PHP for memberswhose home care provider leaves the PHHSNnetwork of agencies. PHHSN will facilitatecontinuity of home care services while memberstransition to or from PHP or if the member changeshome care providers within the plan. Members willbe offered the following transition of care benefits:If the member’s home health care providerleaves the statewide network of home careproviders, PHHSN will permit the member tocontinue an ongoing course of treatment withthe original home care provider for atransitional period.The transitional period will continue for a timethat is sufficient to permit coordinatedtransition planning consistent with themember’s condition and needs relating to thecontinuity of the care. The transition periodmay be extended for a period of up to 90days.PHHSN will not be required to permit themember to continue treatment with a currenthome care provider if the provider is no longeraffiliated with PHHSN because of reasonsrelated to professional behavior or providercompetence.PHHSN will authorize continued care asrequired by applicable law or regulation,currently not less than 30 days. If thetransitional period exceeds 30 days, PHHSN11-62014 Practitioner and Provider Manual - Ver. 3

Home Healthwill authorize continued care only if theprovider agrees to all of the following:• Accept reimbursement from Presbyterianat the rates applicable before the start ofthe transitional period• Adhere to PHHSN’s quality assurancerequirements and provide PHHSN withnecessary medical information related tosuch care• Adhere to PHHSN’s policies andprocedures, including but not limited toprocedures regarding referrals, priorauthorization, treatment approved byPHHSN, cultural competency, andconfidentialityDenialsAll referrals and requests for home health careservices that do not meet treatment requirementsor medical necessity criteria, as determined byPHHSN quality review nurses, will be referred tothe Presbyterian medical director to review for adecision regarding appropriateness of care througha home health care agency. Additionally, allreferrals and requests for services, includingrequests for new technologies, will be reviewed bythe PHHSN quality review nurse.There are several situations that would result in apatient being denied for care by PHHSN. Thefollowing are examples of these situations identifiedthrough an initial screen:Some patients will not be eligible for carebecause our network is not the designatedcontractor for the patient’s payer sources. Theagency may inform the patient that they maychoose to go “out of plan” and pay for servicesprivately; the PHHSN does not need toapprove these casesThe care request is for a service not providedby the networkAdditional situations in which PHHSN quality reviewnurses may perform administrative denials areFailure of a provider or practitioner to providemedical or other individualized informationneeded to establish medical necessityFailure to comply with contract requirementsin non-urgent/non-emergent situationsAll requests that lack physician ordersAll late requests that do not fall within theallowable retroactive authorization policyThe quality review nurse will clearly document thereason for each denial on the Prior AuthorizationRequest Form. When any of the above situationsoccur, the referral source will be notified byPHHSN, as appropriate. Documentation is kept onfile.If a patient refuses services, the agency isresponsible for contacting the physician, who maydiscuss with the patient the rationale for home careservices. If the patient subsequently agrees, thepatient may need to reenter the system throughPHHSN.If the PHHSN quality review nurse questions themedical necessity of the request for authorization,discussion between the PHHSN quality reviewnurse and the agency or referral source will beinitiated. If consensus cannot be reached, a request11-72014 Practitioner and Provider Manual - Ver. 3

Home Healthfor review will be submitted to a Presbyterianmedical director. The PHHSN quality review nursewill inform the agency or referral source as topending status of the request. If the agency,member, or physician disagrees with the decision,they may initiate the appeals process throughPresbyterian.A written notice of action will be issued to themember and the requesting provider for any reviewdecision related to a request for services thatresults in the denial or limited authorization of arequested service (to include a reduction inservices). The notice will include the type of level ofservice or the reduction, suspension, or terminationof a previously authorized service.AppealsFor information on filing an appeal or grievance,please refer to the Appeals and Grievances sectionof this manual.Utilization ManagementThe goal of the quality management and utilizationmanagement program is to ensure that resourcesare appropriately allocated for the provision of highqualityhome care. PHHSN quality review nurseswill ensure that the home care services beingprovided are done in a cost-effective and timeefficientmanner that will enhance the achievementof superior clinical outcomes and improve the carerecipient’s quality of life.The PHHSN quality review nurse will monitor theagency’s adherence to the requirements andcriteria presented in the Medicare conditions ofparticipation and licensing regulations for homehealth care agencies, particularly as interpreted byThe Medicare HIM 11 (a guide that definesregulatory standards), the Medicare homecare interpretive guide, and PresbyterianSenior criteria manualsThe New Mexico Human ServicesDepartment, Medical Assistance Divisionmanual sections on home care and on theEPSDT program for long-hour careThe Presbyterian Commercial plan’s benefitdescriptionsAny addendum related to state lawIn addition, Milliman Care Guidelines will beused as a reference to ensure appropriateutilization is occurring and that access to carefor Presbyterian members is available.All patients, regardless of payer source, will haveaccess to any home care services covered undertheir policy benefit that are appropriate andprovided by the agency and available in theirgeographic area. Services are provided based on acombination of factors, including diagnosis andcurrent clinical status, appropriateness of theservices to meet the patient’s needs, physicianorders, or, in some cases, specific arrangementwith payer sources.Those staff members involved in the formation ofthe policies, protocols, and procedures, and anypatient education materials that are part of theseprograms will have associated relevant experience,training, education, or certification related to theprogram (for example, the practice guidelines for11-82014 Practitioner and Provider Manual - Ver. 3

Home Healththe management of decubitus ulcers for the Agencyfor Healthcare Policy and Research).Data collected by agencies from required reportingand from PHHSN prior authorization analysis willbe used to generate the quality and utilizationsummaries. The utilization and quality managementprogram will be overseen by the quality subcommitteeof the PHHSN. This committee will actas a utilization and quality committee that isresponsible for providing oversight, review, andrecommendations regarding home care practicerelative to utilization benchmarks, credentialing,grievances, and recommendations forimprovements.If a need for improvement is identified for anagency, PHHSN will work with the agency toidentify the root cause and develop a correctiveaction plan. Periodic follow-up reporting will bedone by PHHSN.Outcome measurement will be monitored as itrelates to utilization management. Quarterly andannual reporting of measurements will beconducted through the Presbyterian HomeHealthcare Albuquerque Professional AdvisoryBoard, which will consist of physicians, clinicians,Presbyterian representatives and the PHHSNdirector. The measurements that will be reviewedare as follows:Individual agency’s random annual chart auditresultsPatient satisfaction survey resultsUtilization reports relative to unduplicatedcensus, admits, and visits, which will bebenchmarkedAgency satisfaction with PHHSN surveyresultsDenials/appeals related to medical necessityGrievances and complaints as received byPresbyterian, including disagreement with thedischarge date of service by the care recipientor their authorized representativeReporting RequirementsReporting of statistical data by agencies to PHHSNis required toEffectively identify issues and trends byagenciesComplete root-cause analysis of the trendsSupport the development of an action plan bythe agency to enhance or modify acceptedpractice methodologiesRe-evaluate the data following implementationof changes (to note changes in trends)Reports must be sent to PHHSN within theidentified time frames. Results will be sent out inthe PHHSN newsletter. Each agency must providePHHSN random concurrent review self-audits on ayearly basis.Each agency must complete a monthly audit on allPresbyterian MediCare PPO members to ensurethat the Medicare Notice of Non-Coverage wasprovided to members in accordance with Medicareregulation. The audit results are sent to PHHSNmonthly.11-92014 Practitioner and Provider Manual - Ver. 3

Home HealthPatient Care ConferencesMonthly patient care conferences will be conductedby telephone. PHHSN quality review nurses willidentify those patients who will benefit from a careconference. Identification of these patients is basedupon complexity of the case, need for coordinationwith other health care providers, patients utilizinggreater than 20 visits within a prior authorizationperiod, or patients with recidivism to the hospital orhome care.Participants in the care conferences may be aPHHSN quality review nurse, a member of agencystaff, a physician, or other health care providers.The PHHSN quality review nurse will completedocumentation of care conferences and results onthe case-conference report. The case-conferencereport will be faxed to the agency with a copymaintained in the PHHSN patient’s record andcase-conference review files.Claims ProcessingThe agency should submit all claims on a UB-04form, completing all fields in accordance withstandard home health billing requirements. Pleaserefer to the Claims and Payment chapter of thismanual for detailed information on the claimssubmission processes and policies. The followingrevenue codes should be used:Claims Processing Revenue CodesDescriptionRevenue CodeRN visit 0551Dietitian visit 0581Claims Processing Revenue CodesDescriptionRevenue CodePhysical therapy visit 0421Occupational therapy visit 0431Speech therapy visit 0441Social worker visit 0561Home health aide visit 0571Supplies 0270RN per hour 0550LPN per hour 0580PCA per hour 0590HHA per hour 0570Please keep in mind the following when submittingclaims:Attach an itemized supply list to the UB-04when billing under Revenue Code 0270.Record accurate federal tax identificationnumber on the UB-04 under form Locator #5.Record the prior authorization/benefitcertification number on the UB-04 under formLocator #63; it is not necessary to attach ahard copy of the approval to the claim.Ensure that all claims contain the agency’sNational Provider Identifier number and thecorrect taxonomy code.Ensure that the correct ICD9 Code is used.When billing EPSDT long-hour care, the timemust be billed in 15-minute increments. Whenservices go over or under 15 minutes, the11-102014 Practitioner and Provider Manual - Ver. 3

Home Healthagency is responsible for rounding up orrounding down.All claims are processed as one unit equal to15 minutes.Ensure that an agency employee signs theUB-04 form.Mail paper claims to:Presbyterian Health PlanP.O. Box 27489Albuquerque, NM 87125-7489Complete billing adjustments in accordance withPresbyterian’s adjustment procedures that aredetailed in the Claims and Payment chapter of thismanual. Direct all payment or adjustment questionsto Presbyterian’s Provider Care Unit at 1-888-923-5757.Home Care Agency Contract Termination PolicyAn agency requesting a termination of their contractwill provide written notification to the PHHSNDirector of Finance and Statewide Network aminimum of 120 days before the effectivetermination date as stipulated in their contract withPHHSN. The PHHSN Director of Finance andStatewide Network will notify all appropriate parties.PHHSN will assist with the transition of members toother network agencies if needed.11-112014 Practitioner and Provider Manual - Ver. 3

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12. Quality ImprovementHome Health12. Quality Improvement ProgramProgramThe Presbyterian Quality Improvement (QI)program provides the infrastructure needed forcontinuously improving the quality and safety ofclinical care processes and the quality of servicesoffered to all members through providers. It isdesigned to support the physical health, behavioralhealth, and long-term care services for members ofPresbyterian’s different lines of business.New activities are selected each year to helpimprove the quality and safety of care and servicesPresbyterian offers. The scope of the QI programincludes all operational functions withinPresbyterian, all applicable members, and allproviders contracted with Presbyterian to providecare and services.Contracted services include but are not limited tobehavioral health care, care coordination, casemanagement, diagnostic studies, emergency care,home health care, inpatient and outpatient services,nurse advice and triage for medical care, pharmacyservices, prevention programs, primary medicalcare, school-based health care centers, skillednursing care, specialty medical care, rehabilitationservices, urgent care, and web support resources.A QI program evaluation is conducted annually toassess the overall effectiveness of the QI program.Where the evaluation demonstrates that the QIprogram has not met established targets, goals,and benchmarks, recommendations for change aremade in the subsequent QI program. A report ofsuccess and progress is available to providersupon request by contacting the QualityManagement (QM) Department at 505-923-5516.The success of the QI program and relatedactivities requires the cooperation and support ofthe provider network. Providers are invited toparticipate in QI program activities. Examples ofparticipation include providing input for diseasemanagement activities; clinical, service, and safetyimprovement activities; cooperating with medicalrecord data abstraction; quality of care reviews;participating in satisfaction surveys; serving on adhoc quality improvement teams; and serving as QIcommittee members.Several internal QI committees meet routinely toreview data and discuss and share ideas forimproving health and service to members. Clinicalpractitioners are invited to participate as memberson the following committees:Clinical Quality CommitteePharmacy and Therapeutics CommitteeCredentialing Review CommitteeProfessional Practice Evaluation CommitteeUtilization Management CommitteeFor additional information about the QI program oropportunities for participation, please contact theQuality Management Department at 505-923-5516.12-12014 Practitioner and Provider Manual - Ver. 3

Quality Improvement ProgramNational Committee for Quality AssurancePHP has participated in the National Committee forQuality Assurance (NCQA) accreditation programsince 2000 and Presbyterian Insurance Company,Inc., has participated since 2009. Presbyterian’sgoal is to achieve national excellence by earning an“excellent” NCQA Health Plan status in all HealthMaintenance Organization (HMO) and PreferredProvider Organization (PPO) products. This goalcan only be achieved with the combined efforts ofhealth plan employees, network practitioners, andproviders. In addition, PHP participates in theNCQA Medicare Advantage HMO and PPOdeeming program, which is available for healthplans participating with the Centers for Medicareand Medicaid Services (CMS) regulatoryrequirements.An “excellent” accreditation status is awarded tohealth plans that provide service and clinical qualitythat meets or exceeds rigorous requirements forquality improvement. Evidence shows that healthplans with an excellent NCQA status do more toimprove the health of their members.An NCQA health plan accreditation survey includesa review of quality improvement, utilizationmanagement, credentialing and recredentialing,member rights and responsibilities, and innovativecommunications using the internet. It also includesdelegation activities, improvement in clinicaleffectiveness of care measures, and improvementin member satisfaction. Health plans thatparticipate in NCQA accreditation are re-evaluatedannually to monitor quality care and service.Focus on ExcellencePresbyterian is guided by principles and practicesthat promote the continuous improvement ofbusiness operations, medical care, behavioralhealth care, and all services provided to membersand providers. Quality improvement structures andprocesses are planned, systematic, and clearlydefined. Presbyterian uses the Baldrige HealthCare Criteria for Performance Excellence. We alsoemploy process improvement tools such as thePresbyterian Improvement Model and Lean SixSigma. Using the Baldrige criteria ensures we havea balanced focus on our employees, members, andpartners as we target benchmark performance inclinical, service, and operational excellence.The Improvement Model is a process improvementtool used to gain and apply knowledge. It isdesigned to help employees effectively thinkthrough problems and processes that will ultimatelyresult in improved outcomes. Focusing on theImprovement Model questions accelerates thebuilding of knowledge by emphasizing a frameworkfor learning, using data, and designing effectivetests or trials.The focus of Lean is improved efficiency and thereduction of waste. The focus of Six Sigma isimproved effectiveness. Lean Six Sigma forimprovement follows a disciplined course of actionwith each project. The process most commonlyused is called by its acronym, DMAIC, whereproblem boundaries are identified (Define),opportunities quantified (Measure), root causesdetermined (Analyze), solutions identified and12-22014 Practitioner and Provider Manual - Ver. 3

Quality Improvement Programimplemented (Improve), and process improvementshardwired (Control).QI Program Activities1. Availability of ProvidersAvailability of providers is measured to assesssufficient numbers of primary care and specialtycare practitioners by geographic distribution and inratios of members per provider.Results are compared to established standards toidentify opportunities for improvement. Stateregulations determine the geographic standards forMedicaid.2. Accessibility of Services (AppointmentAvailability)Data CollectionData is collected, including the following:Consumer Assessment of HealthcareProviders and Systems (CAHPS ® ) results forquestions related to accessibility of servicesfor primary care, behavioral health, andspecialty careMystery shopping surveys as supplementaldata to the CAHPS ® results3. Credentialing and RecredentialingPresbyterian credentials and recredentialsindividual practitioners and organizationalproviders. The credentialing program ensurescompliance with credentialing policies andprocedures, NCQA standards, and state andfederal requirements for verification of credentialsincluding but not limited to license, boardcertification, and education.DelegationPresbyterian may delegate to designated entities allor some of the credentialing responsibilities. Theperformance of the entity is monitored on anongoing basis for compliance with Presbyterianrequirements and all applicable regulatory andaccreditation standards. Presbyterian retains theright based on quality issues to approve, suspend,and terminate individual providers in situationswhere it has delegated decision-making.Performance by the delegate is evaluated inaccordance with regulatory requirements andresults are reported to the Credentialing ReviewCommittee.Site VisitsSite visits are included as part of the initialcredentialing for primary care providers (PCPs),obstetrician/gynecologists, and high-volumebehavioral health specialists. Site visits are alsoperformed for organizational providers who havenot been approved by an accrediting body.Initial applicants whose site visit score is below anacceptable threshold are notified that thecredentialing process is discontinued. Applicantsmay contact Presbyterian for information about howto improve their sites and to restart thecredentialing process once the deficiencies havebeen corrected.If a provider receives two or more complaintsregarding their site within a 12-month period, a sitevisit is scheduled. If during the site visit an issue isidentified, the provider must develop a correctiveaction plan to address the deficiencies. A follow-upreview is conducted within six months to determine12-32014 Practitioner and Provider Manual - Ver. 3

Quality Improvement Programcompliance. If the provider fails to submit thecorrective action plan within the specified timeframe, it is considered a breach of contract andmay result in termination from the network.Ongoing MonitoringThe Office of Inspector General ExclusionPrograms database, as well as applicable statelicensing agencies, are monitored monthly forsanctions or licensure limitations. The MedicareOpt Out website is also checked monthly to ensurethat providers contracted for Medicare Advantagehave not opted out of Medicare. Interventions areimplemented as appropriate.4. Quality of Clinical CareThe QM Department investigates and resolves allquality of clinical care complaints and referrals.Investigations include but are not limited toobtaining medical records, provider responses, andsubject matter expert responses.Sources of quality of clinical care referrals areprimarily from the Enterprise Wide ComplaintManagement Department. Where appropriate, theQM Department may also receive direct referralsfrom providers, Presbyterian medical directors,Presbyterian pharmacy, or the Special InvestigativeUnit.The Quality Management Department monitors allproviders monthly for trends in the number andnature of complaints referred to the quality of careprocess. When a provider has three or morecomplaints in a 12-month period, he or she isreferred to the Presbyterian Professional PracticeEvaluation Committee for review for a possiblepattern of conduct or behavior that is contrary togood patient care. Other criteria for reporting acase at the Professional Practice EvaluationCommittee include cases that meet certainoutcome levels or cases identified by aPresbyterian medical director.Any suspected inappropriate practice patternconcern is investigated. A medical record chartaudit is performed, and if it is determined to be aquality of care issue it is reported to theProfessional Practice Evaluation Committee. Allquality of clinical care investigations and resolutionsare referenced as part of the credentialing andrecredentialing process.5. Peer ReviewThe Presbyterian Board of Directors hasdesignated the Professional Practice EvaluationCommittee to serve as a review organization underthe New Mexico Review Organization ImmunityAct, Section 41 9 5. Its membership includespracticing members of the provider panel. Peerreview activities include review of the quality ofclinical care delivered by providers within the samediscipline and area of clinical practice, anddocumentation of the findings in the meetingminutes. The Professional Practice EvaluationCommittee has the authority to act immediately onthe results of any quality of clinical careinvestigation. Where necessary, action taken canbe as simple as continuing to track and trend theprovider or as severe as recommending terminationfrom the network.12-42014 Practitioner and Provider Manual - Ver. 3

Quality Improvement Program6. Continuity and Care CoordinationContinuity and care coordination that membersreceive is monitored to improve communicationacross the Presbyterian’s health care network andbetween medical and behavioral health carepractitioners. Information exchange betweenmedical and behavioral providers must be memberapprovedand be conducted in an effective, timely,and confidential manner. PCPs are encouraged tomake timely referral for treatment of behavioralhealth disorders commonly seen in their practices.Drug use evaluations of psychopharmacologicalmedications are conducted to increase appropriateuse or decrease inappropriate use, and to reducethe incidence of adverse drug reactions. Data iscollected and analyzed to identify opportunities forimprovement. Collaborative interventions areimplemented when opportunities for improvementare identified.7. Standards of CarePresbyterian has processes in place to assure thathealth care services provided to members arerendered under reasonable standards of quality ofcare consistent with prevailing professionallyrecognized standards of medical practice. This ismonitored through the credentialing,recredentialing, and quality of clinical careprocesses.8. Service Quality ConcernsService quality concerns from members,practitioners, and providers are tracked bothindividually and in aggregate to identify potentialproblems with quality of services. Provider networkmanagement investigates service-relatedcomplaints that involve providers. Interventions areidentified, developed, and implemented, asappropriate.9. Clinical Practice GuidelinesClinical practice guidelines for acute and chronicmedical conditions and behavioral health disordershave been adopted using current and evidencebasednationally recognized sources. The clinicalpractice guidelines are reviewed at least every twoyears and are appropriately updated anddisseminated. Practitioners are involved in thereview and approval of all guidelines. The use ofguidelines is measured annually using NCQAHealthcare Effectiveness Data and Information Set(HEDIS ® ), the Physician Performance Assessment(PPA), or by an internally developed methodology.10. Preventive Health Care GuidelinesPresbyterian adopts preventive health careguidelines from nationally recognized, evidencebasedguidelines for all age groups. The use ofguidelines is measured annually using HEDIS ® , thePPA, or an internally developed methodology. (Seethe QI Program: HEDIS ® Medical Record DataAbstraction section at the end of this chapter for athorough discussion of HEDIS ® .)11. Member Medical RecordsTo ensure that the Presbyterian provider networkmeets a minimal set of standards for medicalrecord documentation, individual practitioneradherence to standards is monitored and comparedto performance goals. Presbyterian regularlyassesses compliance with these standards and awritten report is mailed to the practice outlining the12-52014 Practitioner and Provider Manual - Ver. 3

Quality Improvement Programresults of the evaluation. Strengths andopportunities for improvement are reported to theClinical Quality Committee and are shared withproviders along with educational information forareas needing improvement.12. Integrated Care Management ProgramPresbyterian provides an Integrated CareManagement (ICM) program that includes carecoordination, complex case management, anddisease management components. The program isdesigned to assist members with multiple complex,physical, neurological, emotional, or cognitive andbehavioral health care needs.By identifying members with moderate risk andoffering disease management, the intent is to slowor prevent the progression of complications ofchronic conditions. By providing ICM, Presbyterianfacilitates timely access to and use of appropriateservices, thereby reducing unnecessary servicesand the incidence and costs of inappropriateemergent and inpatient care. ICM is a membercentered,family-focused (when appropriate),culturally competent, and strength-based service.The ICM program also supports providers in theirmanagement of members with catastrophic, highcost,high-risk, or complex illnesses, injuries, orconditions.A care coordinator is assigned to complex casemanagement for a member who meets the criteriafor care coordination. This individualized careserves to help and guide members through thehealth care continuum in a coordinated, caring,cost-effective, and quality-oriented manner. Inaddition to measuring member satisfaction, twoclinical measures are identified annually to monitorthe effectiveness of the complex case managementprogram.The incorporation of behavioral health care intoICM facilitates timely and appropriate access tothese services for Presbyterian Centennial Caremembers. This individualized care serves to helpand guide members through the health carecontinuum in a coordinated, timely, caring, costeffective,and quality-oriented manner.13. Continuum of CarePresbyterian believes that providing a member withappropriate, available service is optimal for quality,cost-effective health care. Presbyterian is dedicatedto helping members meet their health care needsacross the continuum of care through programsand services that address the preventive, acute,and chronic care needs of members. Interventionsand tools are developed from evidence-basedguidelines to work with members and to create andimplement plans of care that provide members withthe tools needed to move toward self-management.Staff works collaboratively with members,practitioners, and other health care providers topromote a seamless delivery of health careservices.14. Special PopulationsThe identification of special populations inPresbyterian Centennial Care enables Presbyterianto facilitate timely and appropriate health carethrough effective care coordination. Presbyterianuses guidelines that promote coordination and12-62014 Practitioner and Provider Manual - Ver. 3

Quality Improvement Programaccess to care. Complaints, grievances, andappeals are tracked in aggregate to identify trendsand opportunities for improvement. The aggregatereport is reviewed quarterly by the CareCoordination Management Team. Trends aretracked and addressed. Where indicated, actionplans are developed to address opportunities forboth procedural and individual case activities. Theuse of guidelines is measured annually usingHEDIS ® , the PPA, or an internally developedmethodology.15. Early and Periodic Screening, Diagnosis, andTreatmentThe Early and Periodic Screening, Diagnostic andTreatment (EPSDT) Program for Tot-to-Teen healthchecks (also called Well-Child checkups) is in placefor Presbyterian Centennial Care members asrequired by the New Mexico Human ServicesDepartment (HSD). EPSDT services are measuredannually using HEDIS ® and the PPA.16. Health Risk Assessment and Personal HealthAssessmentsFor Centennial Care: All members who are new toPresbyterian Centennial Care complete an initialHealth Risk Assessment of their physical andbehavioral health needs. Results of theseassessments enable Presbyterian to determine ifnew members would benefit from carecoordination, case management, or diseasemanagement program services.For Medicare: All the Medicare members who arenew to Presbyterian Medicare Advantage productsare encouraged to complete an initial PersonalHealth Assessment (PHA) of their physical andbehavioral health needs. Results of theseassessments enable Presbyterian to determine ifnew members would benefit from carecoordination, case management, or diseasemanagement program services.The employer groups that participate in the HealthyAdvantage Wellness Program have access toWebMD ® for the PHA. The assessment covers awide range of common illnesses and risk factors.Members can use their PHA score to determinewhich tools would be of help to them, includingweb-based interactive consumer health tools,printed educational materials, and public or privateresources related to their specific health needs.They can also receive advice about improvingbehaviors that impact their health. Referrals to carecoordination, case management, and diseasemanagement programs are available for memberswith chronic illnesses and members who need helpobtaining care.17. Culturally Appropriate ServicesPresbyterian supports culturally competent andsensitive services. These services begin with anunderstanding and respect for language, ethnicity,race, age, and gender-based differences. It isessential that these differences are recognized andshared with our staff when interacting withmembers verbally, non-verbally, and in writing.Without effective interactions, members may notunderstand their health care benefits or be able toparticipate fully in the recommended course ofprevention and treatment.At all levels of operations, Presbyterianacknowledges and promotes the importance of and12-72014 Practitioner and Provider Manual - Ver. 3

Quality Improvement Programrespect for culture and language and the traditionsassociated with different people and communities inthe delivery of services. Clinical and non-clinicalservices are accessible to all members and areprovided in a culturally competent manner withsensitivity to the member’s religious beliefs, values,traditions, diverse culture, and ethnic backgroundas well as limitations with English proficiency orreading skills, physical or mental disabilities, andstate of homelessness.Presbyterian’s objectives for serving a culturallyand linguistically diverse membership includeAn annual assessment to describe diversityamong the health plan membershipThe use of customer feedback in the form ofcomplaints and survey data to identifydisparitiesDevelopment of work plan activities toaddress identified opportunities forimprovement. At a minimum, work planactivities include• Maintaining a cultural competency andsensitivity policy to provide direction forPresbyterian services and operations• Maintaining a translation services policy toensure that customer information andservices are available in languages otherthan English• Tracking bias and discrimination issuesthat hinder or prevent culturally sensitiveservices and care in accordance with theAmericans with Disabilities Act and otherapplicable federal and state laws• Conducting an annual assessment oflanguages and cultural background withinthe provider network to determine ifproviders meet the needs andpreferences of members• Developing an annual plan to adjust theprovider network if it does not meet themembers’ language needs and culturalpreferences• Providing annual cultural competencytraining for Presbyterian staff• Providing cultural competency educationalmaterials and training for providersthroughout the year• Assisting members in locating providerswho correspond with their language,cultural, and gender preferences• Developing communication tools andstrategies to address identified race,ethnicity, age, gender, and languageneeds, such as subscriber materials,member handbooks, newsletters,physician directory, educational materials,telephone outreach, TTY assistance, andmultilingual employees18. Oversight of Delegated, Subcontracted, andHigh-Volume or Single-Source FunctionsPresbyterian may delegate to subcontract withthird-party entities for specific administrativefunctions such as credentialing, qualitymanagement, disease management, utilizationmanagement, claims payment functions, nurseadvice line services, and pharmacy benefitinformation. All delegates and subcontractors must12-82014 Practitioner and Provider Manual - Ver. 3

Quality Improvement Programmeet Presbyterian requirements as well asapplicable accreditation and regulatory standardsbefore and during delegation. Delegates aresubject to appropriate oversight activities to ensurethat services are compliant with regulatory,contractual, and accreditation requirements.Delegated, subcontracted, and high-volume orsingle-source provider functions are monitored atleast semiannually to review policies, procedures,operational reports, and activities to ensure thatthey continue to meet Presbyterian requirements aswell as applicable contractual, accreditation, andregulatory standards. Audit findings and applicablecorrective action plans are reported to andmonitored by the appropriate quality committee.19. Nurse Advice LineNurseAdvice SM New Mexico (NANM) providestelephone triage of symptoms, medical advice andinformation and medical and behavioral healthreferrals 24 hours a day, seven days a week.NANM also serves as a community link betweenproviders and patients regarding health information,flu clinics, health alerts, community resourceinformation, links to 911 services, poison control,social services, and behavioral health. NANMemploys registered nurses who are located withinthe State of New Mexico and are knowledgeableabout state and county resources. NANM is alsoable to receive questions and concerns throughtheir website. Although NANM does not have anaudio health library feature, written healthinformation is available to members upon request.Presbyterian offers our Centennial Care membersdirect access to our Presbyterian Customer ServiceCenter to connect with our nurse advice line.Members can call 505-923-5200 for assistance.20. Utilization Management ProgramThe Presbyterian Utilization Management (UM)Program identifies the authority and accountabilityfor all UM activities, including physical health,behavioral health, and pharmacy. The UM programis under the direction of the chief medical officer,and medical directors and UM staff havesubstantial involvement in developing andimplementing the UM program. The annualevaluation of the UM program is contained withinthe annual QI program evaluation. A separate UMprogram description is reviewed annually, updatedas needed, and approved by the UtilizationManagement Committee.Any entities delegated for UM functions must meetall requirements set forth by Presbyterian asoutlined in delegation agreements and service levelagreements. These agreements set forthaccountabilities for pre- and post-auditing andoversight by Presbyterian, as well as provisions forcorrective action plan requirements and delegationconditions.The criteria resources used to determine medicalnecessity, including the method by which criteriaare developed or chosen, and the method by whichcriteria are reviewed, are updated and modified asappropriate. Annual medical director and nurseinter-rater reliability agreement audits areperformed to ensure consistent application ofreview criteria and consistent decisions.12-92014 Practitioner and Provider Manual - Ver. 3

Quality Improvement ProgramPresbyterian continually assesses member andprovider satisfaction with the UM processes toidentify areas needing improvement. Under- andoverutilization of pharmacy, physical, andbehavioral health care services is monitoredquarterly to facilitate the delivery of appropriatecare. Results are compared to establishedthresholds.21. Web ResourcesThe Presbyterian Healthcare Services (PHS)website, http://www.phs.org, has been enhanced toimprove member access to information that can beuseful when making health care decisions.Information about many services is available onPresbyterian’s website, including the following:Information about claims payments, medicalbenefits, and pharmacy benefits. Membersmay request identification cards and canmake PCP changes.The provider directory and hospital directoriesto help current and prospective memberschoose providers, pharmacies, and hospitals.Web technology for members for e-appointments, e-consultations, e-referrals,online personal health information, and forrequesting lab reports.Presbyterian evaluates website functionality toimprove usability. Processes for posting andmaintaining accuracy and currency of content andinformation are monitored.22. Voice of the CustomerPresbyterian understands the importance ofobtaining feedback from our members andproviders. Presbyterian collects feedback frommembers and providers to improve satisfaction andloyalty through improved processes andcommunication. We collect feedback in a variety ofways.Survey DataWe conduct relationship surveys such as theCAHPS ® survey, the annual provider satisfactionsurvey, and the internally developed quarterlymember survey. The reasons for conducting arelationship survey are to trend results over time,compare performance against external benchmarkswhen available, identify drivers of satisfaction andloyalty, and identify opportunities for improvement.In addition, we occasionally conduct transactionalsurveys to evaluate the performance of specificinteractions with Presbyterian such as a postcustomer-servicecall survey or a web survey.Complaint and Inquiry DataWhenever a member contacts the health plan,whether through calls, emails, or letters, thetransaction is logged into the advocate system.Complaints, appeals, and grievances are capturedin a similar manner. This data is aggregated andreported at least annually to identify trends andopportunities for improvement. The data can befiltered in many different ways to perform variousanalyses such as by product type, employer group,inquiry type, and customer type.Qualitative ResearchPresbyterian also uses qualitative researchmethodologies including focus groups, formal andinformal interviews, usability studies, and mystery12-102014 Practitioner and Provider Manual - Ver. 3

Quality Improvement Programshopping, as appropriate. Consumer advisoryboards are also used to evaluate the quality of ourservice and the customer experience.Service Quality Committee and Delegated TeamsThe Service Quality Committee and delegatedteams use the data above to identify opportunitiesfor improvement, make recommendations to theappropriate areas, and create action plans.Member and Provider Satisfaction PrioritizationProcessesPresbyterian conducts a formal prioritizationprocess to select the critical areas for improvementactivities for the following year. This objectiveprocess allows for the “voice of the customer” tohelp determine the areas of greatest concern andthe biggest drivers of satisfaction.23. Patient Safety ProgramThe Patient Safety Program improves the quality ofcare through the identification, analysis, andreduction of risks that could cause or have causedpreventable patient injury or impairment.Objectives of the Patient Safety ProgramIdentify opportunities to improve safetyperformance.Manage identified risk by timely intervention,corrective preventive action, and educationalactivities.Provide information on identified risk toappropriate departments and committees.Analyze adverse events, identify themesacross events, and use themes to drive qualityimprovement priorities.FocusEstablish a non-punitive culture for sharinginformation and lessons learned.The Patient Safety Committee focuses on bothprovider and health plan process-related risks. As ahealth plan, we recognize that our processes cancreate or contribute to medical errors.Performance MonitoringPriority consideration for the implementation ofpatient safety performance improvement strategiesis given toProcesses that affect a large percentage ofmembersProcesses that place members at risk if notperformed well, if performed when notindicated, or if not performed when indicatedProcesses that have been or are likely to beproblem-proneThe quality of clinical care process providesongoing monitoring and identification of trends andpotential sentinel events.QI Program: HEDIS ® Medical Record DataAbstractionHEDIS ® is a standardized set of performancemeasures that was designed to focus on healthcare quality. HEDIS ® data is collected annually andis designed to provide purchasers and consumerswith the information they need to compare theperformance of health plans. HEDIS ® is aregistered trademark of the NCQA and wasestablished by NCQA in 1992. The HEDIS ® reportcould not be prepared without the continuedcooperation and support of the provider community.12-112014 Practitioner and Provider Manual - Ver. 3

Quality Improvement ProgramNCQA originally designed HEDIS ® for privateemployers so that they could compare health planservices before making purchase decisions. Theuse of HEDIS ® data has expanded to include publicpurchasers, regulatory agencies, and consumers.NCQA conducts surveys to assess a health plan’sability to meet specific standards and guidelines forquality improvement, utilization management,credentialing and recredentialing, member rightsand responsibilities, and member communicationsusing the internet.When a health plan is accredited by NCQA, it isrequired to prepare and submit an annual HEDIS ®report as a way of continuously measuring qualityof care. The HSD requires HEDIS ® reporting forhealth plans contracted to provide Medicaidbenefits.What quality performance measures are included inthe reports?Effectiveness of care measures look at clinicalquality of care, such asChildhood immunizationsBreast and cervical cancer screeningChlamydia screeningControl of high blood pressureCholesterol managementDiabetes careUse of appropriate asthma medicationsFollow-up after hospitalization for a mentalillnessAntidepressant medication managementColorectal screeningAccess and availability of care measures look athow members access services from their healthcare system, such asAdults’ access to preventive/ambulatoryservicesChildren’s access to primary care practitionersPrenatal and postpartum careAnnual dental visitsSatisfaction with the experiences of caremeasures look at the members’ experiencewith their health plan, such asRating of all health careRating of the health planRating of personal practitionerRating of specialist seen most oftenClaims processingCustomer serviceGetting care quicklyGetting needed careUse of services measures look at information abouthow health plans manage the care provided to theirmembers, such asFrequency of ongoing prenatal careFrequency of selected proceduresInpatient/outpatient utilizationMental health utilizationWhere does HEDIS data come from?HEDIS ® data is collected from a sample of healthcare claims and encounters, enrollment forms,surveys, and medical records. Most of the dataincludes information from the previous calendar12-122014 Practitioner and Provider Manual - Ver. 3

Quality Improvement Programyear and a few performance measures requirehealth plans to find and report on data for previousyears. The HEDIS ® data requirements are veryspecific and cannot be changed by the health plan.Before submitting the report to NCQA, HSD, andCMS, it is thoroughly reviewed by NCQA-certifiedauditors to ensure that it was prepared correctly.NCQA and regulatory agencies frequently publishHEDIS ® results in public forums so that existingand potential health plan purchasers and memberscan compare results.How does HEDIS reporting impact the practicesetting?Health plans rely on the claims submitted bypractice sites to prepare the HEDIS ® report. Whenclaims are not coded correctly, they cannot be usedfor reporting purposes. When a health plan cannotfind the claims data, a medical record searchbegins by identifying those providers that provideda service to members selected for the HEDIS ®report.These providers are given a list of patient namesand asked to make available the medical recordsfor health plan staff to review or, when this is notpossible, make copies of selected medical recordpages. Because medical records are confidential,many health plans obtain authorization to reviewmedical records when a member signs up forbenefits. Health plans submit the audited HEDIS ®reports to NCQA in June of each year, and typicallybegin preparing at least six months before the Junedeadline. Medical record data collection can beginany time during the first quarter of the calendaryear.How does Presbyterian use the HEDIS reportingsystem?For the past several years, Presbyterian hasintegrated the HEDIS ® performance measures intoits QI program to gauge the success of its clinicaland service activities. For example, HEDIS ®measures are used to determine the success ofPresbyterian’s disease management programs fordiabetes and coronary artery disease. The annualmember satisfaction survey measures, known asCAHPS ® , is used to monitor improvement activitiesin customer service and getting care quickly.Selected HEDIS ® and CAHPS ® measures wereincluded in the Presbyterian QI program to rewardthe provider network for providing quality care.12-132014 Practitioner and Provider Manual - Ver. 3

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13. Health Insurance PortabilityQuality Improvement Program13. Health Insurance Portability and Accountability Actand Accountability ActThis chapter provides a high-level overview of thefollowing critical federal regulations created toaddress key concerns relating to electronic healthinformation:The Health Insurance Portability and AccountabilityAct (HIPAA) of 1996The Health Information Technology for Economicand Clinical Health (HITECH) Act of 2009The HIPAA Final Omnibus Rule of 2013HIPAA regulations are detailed in the Code ofFederal Regulations (CFR) Title 45, whichaddresses public welfare and is administered bythe U.S. Department of Health and HumanServices (DHHS). The specific regulations thataddress HIPAA are 45 CFR Parts 160 and 164,which can be reviewed in their entirety athttp://www.ecfr.gov/cgi-bin/textidx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl.This chapter’s overview includes a brief descriptionof the relevance of these regulations to allproviders, and a list of informational and trainingresources for providers seeking additionalinformation.What Requires Your Particular Attention?Providers are advised to pay particular attention tothe recently enacted (September 23, 2013) HIPAAFinal Omnibus Rule.You can review the Federal Register release of this25/pdf/2013-01073.pdf.The American Medical Association provides anumber of resources for physicians atrule at http://www.gpo.gov/fdsys/pkg/FR-2013-01-http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act.page.These resources include a .pdf titled “HIPAAPrivacy and Security Toolkit: Helping Your PracticeMeet New Compliance Requirements.”Many additional resources posted online by DHHS,trade associations, and commercial entities areavailable to providers seeking to ensure that theyare fully compliant.Who is Legally Responsible for HIPAACompliance?All providers are solely responsible for theircompliance with HIPAA regulations. Presbyteriandoes not assume any responsibility for ensuringthat providers are compliant.The information provided in this chapter should notbe construed as legal advice; providers shouldconsult their own legal counsel for an opinion as tohow these regulations apply to their office or facility.13-12014 Practitioner and Provider Manual - Ver. 3

Health Insurance Portability and Accountability ActWhich Providers Must Be HIPAA Compliant?All providers who handle members’ protectedhealth information (PHI) for treatment purposes arelegally obliged to observe HIPAA regulations.Those providers who perform a service on behalf ofPresbyterian for non-treatment purposes are alsolegally obliged to observe HIPAA regulations. Sucha service might include any function or activityspecified in the definition of business associate in45 CFR §160.103. These activities performedinclude:Claims processing or administrationData analysis, processing, or administrationUtilization reviewQuality assurancePatient safety activitiesBilling, benefit management, practice management,and/or repricingAdditional services such as legal, actuarial,accounting, consulting, data aggregation,management administration, accreditation, orfinancial where the provision of services involvesthe disclosure of PHIKey HIPAA DefinitionsThe three definitions in this section are derivedfrom 45 CFR 160.103. HIPAA definitions can alsobe found in 45 CFR 160.202, 160.401, 160.502,164.103, 164.304, 164.402, and 164.501. (Seehttp://www.ecfr.gov/cgi-bin/textidx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tpl.)Covered entity meansA health planA health care clearinghouseA health care provider who transmits any healthinformation in electronic form in connection with atransaction covered by 45 CFR 160Protected Health Information (PHI) meansindividually identifiable health information that iscreated or received by a health care provider,health plan, or health care clearinghouse relating tothe past, present, or future physical or mentalhealth or condition of an individual or payment forhealth care and is transmitted by electronic media,maintained in electronic media, or transmitted ormaintained in any other form or medium, excludingeducation records or employment records held by acovered entity in its role as employer.Business associate means a person who is not amember of the workforce that creates, receives,maintains, or transmits PHI for a function or activityinvolving the use or disclosure of PHI on behalf of acovered entity. See Appendix E in this manual for acopy of the Business Associate Agreement.HIPAAHIPAA contains several key components:Title I protects a workers’ health insurancecoverage when they lose or change jobsTitle II, which is also known as the AdministrativeSimplification Regulation, mandates that the DHHScreate national regulations to address several keyconcerns relating to the privacy and security ofpatient health information including13-22014 Practitioner and Provider Manual - Ver. 3

Health Insurance Portability and Accountability ActStandardization of electronic health insurancetransactionsSecurity of electronic PHIPrivacy of PHI in any mediumHITECH ActHITECH expands HIPAA privacy and security rules,and increases penalties for HIPAA violations. TheHITECH Act includes regulations thatApply the HIPAA privacy and security directly toany business associates of HIPAA-covered entitiesEstablish mandatory requirements for reportingsecurity breachesCreate privacy requirements for HIPAA-coveredentities and their business associates, includingnew accounting requirements for electronic healthrecords (EHRs)Establish criminal and civil penalties for noncomplianceand enforcement responsibilitiesHIPAA Final Omnibus RuleThis final rule, which is in effect as of September23, 2013, incorporates the federal government’sfinal regulations for implementation of the HITECHAct. In a summary published by the AmericanMedical Association (http://www.amaassn.org/resources/doc/washington/hipaa-omnibusfinal-rule-summary.pdf),the purposes of theOmnibus Final Rule are described as follows:Expand the obligations of physicians and otherhealth care providers to protect patients’ PHIExtend these obligations to a host of otherindividuals and companies who, as “businessassociates,” have access to PHIIncrease the penalties for violations of any of theseobligationsHIPAA Information ResourcesThe resources listed here are just a few of themany online resources available to all providersseeking to ensure that they are fully compliant withall HIPAA regulations, including the recentlyenacted Final Omnibus Rule. As stated earlier inthis chapter, however, Presbyterian advisesproviders to consult their own legal counsel for anopinion as to how these regulations apply to theiroffice or facility.Official HIPAA Information Sources• Department of Health and HumanServiceshttp://www.hhs.gov/ocr/privacy/index.html• Center for Medicare and MedicaidServiceshttp://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/HIPAAGenInfo/index.htmlHIPAA Final Omnibus RuleNote that in addition to the official DHHS siteand various medical association sites, anumber of additional sources of support forproviders are available.• Department of Health and HumanServiceshttp://www.hhs.gov/ocr/privacy/hipaa/administrative/omnibus/index.html• American Medical Association, “TheHealth Insurance Portability and13-32014 Practitioner and Provider Manual - Ver. 3

Health Insurance Portability and Accountability ActAccountability Act (HIPAA) Omnibus FinalRule Summary”http://www.amaassn.org/resources/doc/washington/hipaaomnibus-final-rule-summary.pdf• The American Academy of OrthopaedicSurgeons, “What You Need to Knowabout the HIPAA Omnibus Rule”http://www.aaos.org/news/aaosnow/jul13/managing4.aspHIPAA TrainingDepartment of Health and Human Serviceshttp://www.hhs.gov/ocr/privacy/hipaa/understanding/training/index.htmlTrade OrganizationsProviders should check with their specialtytrade organization, which will have the mostspecific information on HIPAA complianceissues that affect their particular specialty orservice.Workgroup on Electronic Data Interchange (WEDI)WEDI has organized collaborative, industrywideeffort aimed at implementation of healthinformation technology, clinical initiatives, andstandards, including those for security,privacy, electronic data interchangetransactions, code sets, and identifiers.370). Establishes the eligibility criteria andprocesses for documenting and applyingfor EHR incentives for providers.Registration for the Medicare andMedicaid EHR Incentive Program is openand available online athttps://ehrincentives.cms.gov.• DHHS Office of the National Coordinatorfor Health Information Technology, “EHRIncentives and Certification”http://www.healthit.gov/providersprofessionals/faqs/ehr-incentive-paymentschedulePlease note that while most Medicaid EHRIncentive Programs are acceptingregistrations, launch dates will vary by state.Information on when registration will beavailable for Medicaid EHR IncentivePrograms in specific states is posted at:http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/40_MedicaidStateInfo.asphttp://www.wedi.org/http://www.wedi.org/topics/health-recordsmanagement-systems/Electronic Health Record Incentives• Standards for the Electronic HealthRecord Incentive Program (42 CFR 495.2-13-42014 Practitioner and Provider Manual - Ver. 3

Health Insurance Portability and Accountability Act14. Legal14. LegalAs a provider you have signed an agreement todeliver services to Presbyterian members. Bysigning that agreement you have agreed to complywith all of the requirements and responsibilitiesunder Presbyterian. However, we understand that alegal document may not always be easilyaccessible, so the purpose of this chapter is to tryto highlight and summarize some of the keyresponsibilities. If there is any doubt about yourresponsibilities or conflict between the agreementand this provider manual, it is always the languageof the agreement that will apply.The health care environment is both dynamic andheavily regulated. It is necessary for Presbyterianto make sure that our providers are in compliancewith all of requirements in this chapter. As a result,we will update this chapter as regulatoryrequirements are added or changed.Cooperation with Presbyterian’s ProgramsAs a provider, you must use your best efforts tocooperate with Presbyterian’s quality improvementprograms, member grievance systems, medicationtherapy management, and utilization managementprograms to the extent applicable. If you havesubcontractors, you also need to require them tocooperate with these programs. For example, youand your contractors have responsibilities regardingCredentialing and recredentialingQuality assuranceUtilization review and managementMedical records maintenanceClaims payment reviewManagement peer reviewGrievance proceduresAccording to section 13.10.22 of the ManagedHealth Care Plan Compliance of New Mexico,contracts with providers in the state of New Mexicoshall contain a description of the specific holdharmless provision specifying protection of coveredperson set forth as follows: “Health careprofessionals/health care facility agrees that in noevent, including but not limited to nonpayment bythe health insuring corporation, insolvency of thehealth insuring corporation, or breach of thisagreement, shall health care professional/healthcare facility bill, charge, collect a deposit from, seekremuneration or reimbursement from, or have anyrecourse against, a subscriber, enrollee, coveredperson, or person acting on behalf of the coveredperson, for health care services provided pursuantto this agreement. This does not prohibit healthcare professional/health care facility from collectingco-insurance, deductibles, or copayments asspecifically provided in the evidence of coverage, orfees for uncovered health care services deliveredon a fee-for-service basis to persons referenced14-12014 Practitioner and Provider Manual - Ver. 3

Legalabove, nor from any recourse against the healthinsuring corporation or its successor.”Presbyterian Centennial Care ContractingRequirementsIt is important to recognize the difference betweenCentennial Care and the former Medicaid program,which was called Salud! You need to review all ofthe requirements of this new program. Because thisprogram is jointly funded by both the federal andstate governments, Presbyterian Centennial Care isrequired to verify your compliance.You need to comply with all the terms of yourCentennial Care agreement. For example, byparticipating in the Presbyterian Centennial Carenetwork, you have agreed that you or anyone withmore than 5% ownership is not an ExcludedPerson, as specified in Sections 1128 and 1128A ofthe Social Security Act.You also have certain rights, such as the right tothe information specified in 42 Code of FederalRegulations (CFR) § 438.10(g)(1) about thePresbyterian grievance and appeals system.Provider ResponsibilitiesIt is your responsibility to cooperate withPresbyterian to monitor your activities to ensurecompliance with Presbyterian and the state’spolicies. Presbyterian has established mechanismsto ensure that you comply with requirements. Wemonitor regularly to determine compliance, andtake corrective action if there is a failure to comply.Presbyterian will help by providing education aboutspecial populations and their service needs. Workwith Presbyterian to ensure that you successfullyidentify and refer members to specialty providers asmedically necessary.If you are a primary care provider (PCP) you needto ensure coordination and continuity of care withproviders, including all behavioral health and longtermcare providers.You also need to ensure that members receiveprevention services appropriate for their age group.Selection of or Assignment to a PCPPresbyterian has written policies and proceduresgoverning the process of member selection of aPCP and requests for change. You need tocooperate with Presbyterian to help us carry out ourobligations, such as the following:Initial Enrollment. At the time of enrollment,Presbyterian shall ensure that each member hasthe freedom to choose a PCP within a reasonabledistance from the member’s place of residence.The process by which Presbyterian assignsmembers to PCPs shall include at least thefollowing features:Presbyterian shall provide the means forselecting a PCP within five business days ofprocessing the enrollment filePresbyterian shall contact pregnant memberswithin five business days of processing anenrollment file that designates the member aspregnant to assist the member in selecting aPCPPresbyterian shall offer freedom of choice tomembers in making a PCP selection14-22014 Practitioner and Provider Manual - Ver. 3

LegalIf a member does not select a PCP within 15calendar days of enrollment, Presbyterianshall make the assignment and notify themember in writing of his or her PCP’s name,location, and office telephone number, whileproviding the member with an opportunity toselect a different PCP if the member isdissatisfied with the assignmentPresbyterian shall assign a PCP based onfactors such as member age, residence, and,if known, current provider relationshipsSubsequent Change in PCP Initiated by MemberPresbyterian shall allow members to change PCPsat any time, for any reason. The request can bemade in writing or by telephone. If a request ismade on or before the 20th calendar day of amonth, the change shall be effective as of the firstof the following month. If a request is made afterthe 20th calendar day of the month, the changeshall be effective the first calendar day of thesecond month following the request.Subsequent Change in PCP Initiated byPresbyterianYou need to understand that Presbyterian mayinitiate a PCP change for a member only under thefollowing circumstances:The member and Presbyterian agree thatassignment to a different PCP in thePresbyterian provider network is in themember’s best interest, based on themember’s medical conditionA member’s PCP ceases to be a providerA member’s behavior toward the PCP is suchthat it is not feasible to safely or prudentlyprovide medical care, and the PCP has madereasonable efforts to accommodate thememberA member has initiated legal actions againstthe PCPThe PCP is suspended for any reasonIf you are terminating your contract, you mustprovide us with sufficient notice so that we cannotify a member in writing about that terminationwithin 15 calendar days. This allows the member toselect a new PCP.Provider Disclosure of Current or PreviousAffiliation with Excluded ProvidersIf your subcontractor has been excluded or isaffiliated with an excluded provider and you havehad a business transaction with that subcontractortotaling more than $25,000 during the previous 12months, you have certain obligations. You arerequired to submit, within 35 days of the date ofrequest, information about the ownership of thatsubcontractor. Reimbursement for expenditures forservices furnished during the period between thedue date and the date the information was actuallysupplied will be denied.Hold HarmlessBy contracting to provide Presbyterian CentennialCare services, you have agreed to hold harmlessthe state and Presbyterian’s members in the eventthat Presbyterian cannot or shall not pay forservices performed by you. This hold harmlessprovision shall survive the termination of your14-32014 Practitioner and Provider Manual - Ver. 3

Legalagreement with Presbyterian for authorizedservices rendered before it was terminated,regardless of the cause giving rise to termination,and shall be construed to be for the benefit of themembers.Delegation (if applicable)Your written agreement specifies activities,reporting responsibilities, and any delegatedfunctions, including provisions for the revocation ofdelegated functions and for the imposition of othersanctions for inadequate subcontractorperformance. Presbyterian has policies andprocedures to ensure thatA delegated entity meets all standards ofperformance mandated by the state. Theseinclude but are not limited to• Use of appropriately qualified staff• The application of clinical practiceguidelines and utilization management• Reporting capability• Ensuring members’ access to careThere is oversight of the delegated entity’sperformance of the delegated functions,including the frequency of reporting (ifapplicable) and the process by whichPresbyterian evaluates the delegateThere is consistent statewide application of allutilization management criteria whenutilization management is delegatedCooperation with Medicaid Program IntegrityYou need to comply with Presbyterian’scomprehensive internal fraud, waste, and abuseprogram, the Medicare Fraud and Elder AbuseDivision (MFEAD) of the New Mexico AttorneyGeneral’s Office, and other investigatory agenciesin accordance with the provisions of New MexicoStatutes Annotated (NMSA) 1978, 27-11-1 et seq.You also must comply with all federal and staterequirements regarding fraud, waste, and abuse,including but not limited to Sections 1128, 1156,and 1902(a)(68) of the Social Security Act, Section6402(h) of the Patient Protection and AffordableCare Act, the Centers for Medicare and Medicaid(CMS) Medicaid integrity program, and the DeficitReduction Act of 2005.You must cooperate fully in any activity performedby the Human Services Department (HSD),MFEAD, Medicaid Recovery Audit Contractor(RAC), CMS, and/or Payment Error RateManagement and CMS Audit Medicaid IntegrityContractors. You must, upon request, makeavailable to the RAC any and all administrative,financial, and medical records relating to thedelivery of items or services for which state moniesare expended, unless otherwise provided by law. Inaddition, you must provide the RAC with accessduring normal business hours to your place ofbusiness and records.Employee EducationIf you are paid $5 million or more in aggregatedMedicaid payments annually, you must establishwritten policies for all employees, includingmanagement, providing detailed information aboutfalse claims, false statements, and whistleblowerprotections under applicable federal and state fraudand abuse laws. These written policies must14-42014 Practitioner and Provider Manual - Ver. 3

Legalinclude a specific discussion of the applicable lawsand detailed information regarding your policiesand procedures for detecting and preventing fraud,waste, and abuse, as well as the rights ofemployees to be protected as whistleblowers. Youmust also include in any employee handbook aspecific discussion of the laws described in thewritten policies, the rights of employees to beprotected as whistleblowers, and a specificdiscussion of your policies and procedures fordetecting and preventing fraud, waste, and abuse.Credentialing RequirementsYou must assist Presbyterian in complying with thefollowing requirements:Maintaining standards, policies, andprocedures for credentialing and recredentialingphysicians, hospitals, and otherhealth care professionals and facilities thatprovide covered services to members underthe Presbyterian Centennial Care program.The credentialing program shall be maintainedin accordance with the requirements of stateand federal law and the standards ofaccreditation organizations.Enroll with New Mexico Medicaid as required.Upon a change in location, licensure orcertification, or status, use the New MexicoMedicaid’s provider web portal and updateenrollment information/status with theCentennial Care program.Review RequirementsPresbyterian maintains fully executed originals ofall subcontracts, including your agreement withPresbyterian. These will be made accessible to theHSD Medical Assistance Division (MAD) uponrequest.No DebarmentYour agreement with Presbyterian warrants thatneither you nor any of your employees orsubcontractors have beenCharged with a criminal offense in connectionwith obtaining, attempting to obtain, orperforming a public (federal, state, or local)contract or subcontractListed by a federal governmental agency asdebarredProposed for debarment or suspension orotherwise excluded from federal programparticipationBeen convicted of or had a civil judgmentrendered against you or them regardingdishonesty or breach of trust, including but notlimited to the commission of a fraud, includingmail fraud or false representations, violation ofa fiduciary relationship, violation of federal orstate antitrust statutes, securities offenses,embezzlement, theft, forgery, bribery,falsification or destruction of records, makingfalse statements, tax evasion, or receivingstolen propertyWithin a three-year period preceding the dateof this agreement, had one or more public14-52014 Practitioner and Provider Manual - Ver. 3

Legaltransactions (federal, state, or local)terminated for cause or defaultYou must immediately notify Presbyterian if any ofthe above referenced representations change. Anymisrepresentation of or change in your status maybe grounds for immediate termination of youragreement with Presbyterian.False ClaimsYou must have written policies and procedures forall employees, agents, or contractors that providedetailed information regarding the New MexicoFalse Claims Act, NMSA 1978, 27-14-1 et seq., theNew Mexico Fraud Against the Taxpayers Act,NMSA 1978, 44-9-1 et seq., and the Federal FalseClaims Act established under 31 United StatesCode (USC) §§ 3729-3733, administrativeremedies for false claims established under 31USC 3801 et seq., including but not limited topreventing and detecting fraud, waste, and abusein federal health care programs (as defined inSocial Security Act § 1128B(f)). Such policies andprocedures shall articulate Presbyterian’scommitment to compliance with federal and statestandards.You must cooperate with all appropriate state andfederal agencies in investigating fraud, waste, andabuse. Presbyterian has methods for identifying,investigating, and referring suspected fraud casespursuant to 42 CFR §§ 455.1, 455.13, 455.14, and455.21. Report all confirmed, credible, or suspectedfraud and abuse to Presbyterian or HSD andMFEAD as follows:Suspected fraud, waste, and abuse in theadministration of Presbyterian CentennialCare shall be reported to Presbyterian, HSD,and MFEADAll confirmed, credible, or suspected providerfraud, waste, and abuse shall immediately bereported to Presbyterian, HSD, and MFEADand shall include the information provided in42 CFR § 455.17, as applicableAll confirmed or suspected member fraud,waste, and abuse shall be reportedimmediately to PresbyterianProvider TerminationRefer to your service agreement with Presbyterianfor specific time frames and obligations regardingterminations.Presbyterian has the right to suspend, deny, refuseto renew, or terminate any provider agreement inaccordance with the terms of the serviceagreement and applicable statutes and regulations.HSD has the right to direct Presbyterian toterminate or modify this agreement when HSDdetermines it to be in the best interest of the state.In the event of termination of the agreement, youshall immediately make available to HSD or itsdesignated representative in a usable form any orall records, whether medical or financial, related toyour activities undertaken pursuant to theagreement. The provision of such records shall beat no expense to HSD.14-62014 Practitioner and Provider Manual - Ver. 3

LegalOther Important ProvisionsThe following terms and conditions are deemed tobe incorporated into your agreement withPresbyterian Centennial Care:The agreement has been and shall beconsidered to be executed in accordance withall applicable federal and state laws,regulations, policies, procedures, and rulesThe agreement identifies the parties of thecontract and their legal basis of operation inthe State of New MexicoThe agreement includes procedures andspecific criteria for terminating the subcontractThe agreement identifies the services,activities, and reporting responsibilities to beperformed by you and those servicesperformed under any other agreementThe agreement includes provisions describinghow services provided under the terms of theagreement are accessed by membersThe agreement includes the reimbursementrates and risk assumption, if applicable; youshall maintain all records relating to servicesprovided to members for a ten-year periodand shall make all enrollee medical records orother service records available for the purposeof quality review conducted by the state, ortheir designated agents, both during and afterthe contract periodAll member information will be keptconfidential, as defined by federal and statelawAuthorized representatives of the state willhave reasonable access to facilities andrecords for financial and medical auditpurposes both during and after the contractperiodYou shall release to Presbyterian anyinformation necessary for Presbyterian toperform any of its obligations andacknowledge that Presbyterian shall bemonitoring your performance on an ongoingbasis and conducting formal periodic reviewsYou shall accept payment from Presbyterianas payment for all services included in thebenefit package, and you cannot requestpayment from the state for services performedunder your agreement with PresbyterianIf your agreement with Presbyterian includesthe provision of primary care, then theprovisions for compliance with PCPrequirements delineated in the PresbyterianCentennial Care Agreement shall also applyto youYou are required to comply with all applicablestate and federal statutes, rules, andregulationsPresbyterian may institute corrective actionplans if indicated, sanctions, and/ortermination for any violation of applicableHSD/MAD, state, or federal statutes, rules, orregulationsThe agreement with Presbyterian does notprohibit you or your subcontractors or anyone(with the exception of third-partyadministrators) from entering into a14-72014 Practitioner and Provider Manual - Ver. 3

Legalcontractual relationship with another managedcare organizationThe agreement with Presbyterian does notinclude any incentive or disincentive thatencourages you or any other subcontractornot to enter into a contractual relationship withanother contractorThe agreement with Presbyterian does notcontain any gag order provisions that prohibitor otherwise restrict covered healthprofessionals from advising patients abouttheir health status or medical care ortreatment as provided in Section 1932(b)(3) ofthe Social Security Act or in contravention ofNMSA 1978 §§ 59A-57-1 to 59A-57-11, thePatient Protection ActFor pharmacy providers, payments are beingmade consistent with 1978 NMSA § 27-2-16B,unless there is a change in law or regulationYou shall submit electronic claims, unless youhave been granted a hardship extension; theagreement with Presbyterian includes theHSD/MAD contractual provisions related tothe State of New Mexico Executive Order2007-049 concerning subcontractor healthcoverage requirements, as further defined inArticle 37You will comply with the State of NewMexico’s Statewide Immunization InformationSystem initiativeYou have not been restricted fromparticipating in a federal entitlement program(for example, Medicare or Medicaid)Exclusion from Federal Health Care ProgramsBy contracting to provide Presbyterian CentennialCare services, you warrant that neither you or youremployees, agents, or independent contractorshave, to the best of your knowledge, been excludedfrom participation in any federally funded healthcare programs, including but not limited toMedicare and Medicaid.You shall immediately notify Presbyterian if you orany of your servicing employees or subcontractorsare threatened with exclusion or excluded from anysuch program. In the event that you or yoursubcontractor are excluded from participation inany such program, Presbyterian may terminate theagreement as of the effective date of the exclusion.You shall immediately remove the excludedemployee or subcontractor from providing anyservices in connection with the agreement and shallnotify Presbyterian’s compliance officer in writing.In this notification you must state the informationknown regarding the basis for the exclusion and thesteps taken to remove the excluded persons fromproviding any services. If you cannot remove theexcluded employee or subcontractor, Presbyterianshall have the option to terminate your agreementas of the effective date of such exclusion. (Source:42 CFR § 422.752(a)(8).)Provider CommunicationsYou shall report to Presbyterian’s complianceofficer through telephone and follow-up electronicmail communication any suspected or potentialfraud or other misconduct by you, your agent, yoursubcontractor, or any other person or entity ofwhich you become aware.14-82014 Practitioner and Provider Manual - Ver. 3

LegalYou shall also have an internal reporting process toreport suspected or potential fraud to yourcompliance officer.You shall report to Presbyterian any potential fraudor other misconduct by you or a subcontractor. Thisreport shall be made as soon as you becomeaware of the potential fraud or other misconduct.Background ChecksYou will perform criminal background checks for allrequired individuals providing services, as specifiedin 7.1.9 New Mexico Administrative Code,Caregivers Criminal History ScreeningRequirements.Conflict of Interest CertificationYou and your subcontractor’s officers, directors,and managers shall annually sign a statement that(1) the individual has reviewed Presbyterian’s andyour conflict of interest policies; (2) the individualhas disclosed any potential conflicts of interest; and(3) the individual has obtained managementapproval to work despite any conflicts or haseliminated the conflict. (Source: Chapter 9, Section50.2.1.2.)IndemnityYou shall hold Presbyterian harmless of any loss,damage, or costs (including reasonable attorneys’fees) incurred in connection with claims resultingfrom your or your subcontractor’s acts oromissions.Medicare Contracting RequirementsDefinitions:Terms that are used in your contract withPresbyterian (such as downstream entities,related entities, and first tier entities) have thesame meanings as defined by the CMS in 42CFR § 422.2.The term “subcontractor” means alldownstream entities and related entities whichproviders use to perform services.NondiscriminationProviders agree and will require all subcontractorsto agree, not to differentiate or discriminate in thetreatment of Medicare Advantage (MA) planenrollees on the basis of health status or on thebasis of color, race, creed, sex, age, religion, placeof residence, health status, sexual orientation,disability, place of origin, type of illness orcondition, or source of payment, or any other basisprohibited by federal law and to observe, protect,and promote the rights of MA plan enrollees aspatients. (Source: 42 CFR § 422.110.)Privacy of Medical RecordsProvider will treat, and will require allsubcontractors to treat, all MA plan enrollees’medical records or other health and enrollmentinformation as confidential and protected againstunauthorized disclosure so as to comply with allstate and federal laws regarding privacy, security,confidentiality, and disclosure so as to comply withall state and federal laws regarding the privacy,security, confidentiality and disclosure so as to14-92014 Practitioner and Provider Manual - Ver. 3

Legalcomply with all state and federal laws regarding theprivacy, security, confidentiality and disclosure ofMA Plan Enrollees’ health information. The providerwill ensure maintenance of such information in anaccurate and timely manner and ensure thatenrollees may timely access such information uponrequest. (Source: 42 CFR § 422.118.)Cooperation with Presbyterian’s ProgramsProvider shall use their best efforts to cooperatewith and participate in, and to require allSubcontractors to cooperate with and participate in,Presbyterian’s quality improvement programs,member grievance systems, medication therapymanagement, and utilization managementprograms to the extent applicable to the Servicesprovided by Provider, including, but not limited to,credentialing, recredentialing, quality assurance,prospective, concurrent, and retrospective utilizationreview and management, medical recordsmaintenance, claims payment review andmanagement peer review, and provider andmember grievance procedures. Provider shall bebound by the appeal procedures of Presbyterian’sutilization review and quality assurance program.(Source: 42 CFR §§ 422.152, 422.202(c).)Communication with MA Plan EnrolleesPresbyterian encourages the provider, and providershall encourage subcontractors, to freelycommunicate with plan enrollees regardingappropriate treatment alternatives, regardless ofbenefit limitations, in a culturally competent mannerand in compliance with requirements of 42 USC §12101, as amended (otherwise known as the“American with Disabilities Act of 1990”).Presbyterian shall not penalize its employees,contractors, or subcontractors for discussingmedically necessary or appropriate care withenrollees. (Source: 42 CFR § 422.206(a)(1) & (2).)IndemnityProvider shall indemnify, defend and holdPresbyterian responsible for any loss, damage, orcosts (including reasonable attorneys’ fees)incurred in connection with claims arising out of orresulting from provider’s or a subcontractor’s failureto comply with all applicable Medicare Advantagerequirements.MA Plan Enrollee Hold HarmlessProvider hereby agrees, and will require allsubcontractors to agree, to seek payment forcovered prescription drug services only fromPresbyterian. In no event, including, but not limitedto, termination of the Agreement(s) or thisAmendment, non-payment by Presbyterian,Presbyterian’s insolvency or breach of theAgreement(s) or this Amendment, shall a provideror a subcontractor bill, charge, collect a depositfrom; seek compensation, remuneration, orreimbursement from; or have any recourse againstenrollees, their families, or people acting on theirbehalf for covered prescription drug services. Theforegoing sentence shall not prohibit collection byprovider or a Subcontractor of applicable copayments,co-insurance, and cost-sharing chargesfor non-covered services. (Source: 42 CFR §422.504(g)(1)(i) & (i)(3).)14-102014 Practitioner and Provider Manual - Ver. 3

LegalContinuation of Services Beyond TerminationIn the event your agreement with Presbyterian isterminated or you otherwise cease to operate, youand your subcontractors shall continue to provideservices in accordance with the terms of youragreement until the end of the period of time duringwhich Presbyterian is obligated to CMS to providesuch services. This provision shall survive thetermination of your agreement. (Source: 42 CFR §422.504(g)(2).)Federal Funds UsedPayments under your agreement are made fromfederal funds, and subject you and your andsubcontractors to Title VI of the Civil Rights Act of1964, the Age Discrimination Act of 1975, theAmericans with Disabilities Act, all applicableMedicare laws, Medicare Advantage laws,regulations, CMS instructions, and all other lawsapplicable to those who receive federal funds.Providers acknowledge that they and theirsubcontractors may also be subject to anyapplicable civil and criminal laws for fraudperpetrated in the delivery of the MedicareAdvantage benefit. (Source : 42 CFR §422.504(i)(4)(v).)Access to Books and RecordsProvider agrees that it shall provide, and shallrequire Subcontractors to provide Presbyterian, theComptroller General, the U.S. Department of Healthand Human Services, or other regulatoryauthorities with jurisdiction over the subject of theAgreement, or their designees, with access tobooks, contracts, computer or other electronicsystems, including records of claims and medicalrecords, patient care documentation, financial,administrative and other such related claimsrecords that specifically pertain to the transactionsfor enrollees. Provider agrees to maintain suchrecords and provide access to such records asrequired by this paragraph until the later of tenyears following termination of the agreement orcompletion of an audit by CMS, whichever is later.This is true even when your agreement isterminated. (Source: 42 CFR §422.504(i)(2)),423.505(i)(4)(iii).)Exclusion From Federal Health Care ProgramsProvider hereby represents and warrants thatneither it nor, to the best of Practitioner/provider’sknowledge, its employees, agents or independentcontractors involved in the provision of Services toPresbyterian (the “Servicing Employees”) orsubcontractors have been excluded fromparticipation in any federally funded health careprograms, including but not limited to, Medicare andMedicaid.Provider agrees to immediately notify Presbyterianif they or any of their servicing employees orsubcontractors are threatened or excluded from anysuch program. In the event that Provider or asubcontractor is excluded from participation in anysuch program during the term of the agreement(s)or this Amendment, Presbyterian may terminate theagreement(s) or this amendment as of the effectivedate of such exclusion.If any of provider’s servicing employees orsubcontractors are excluded from participation in14-112014 Practitioner and Provider Manual - Ver. 3

Legalany such program during the term of theagreement(s) or this amendment, provider shallimmediately remove such employee orsubcontractor from providing any services inconnection with the agreement(s) or thisAmendment and shall notify Presbyterian’sCompliance Officer in writing, stating theinformation known by provider regarding the basisfor the exclusion and the steps taken to removethem from providing services in connection with theagreement(s) or this Amendment. If providercannot remove such servicing employee orsubcontractor, Presbyterian shall have the option toterminate the agreement and any other agreementswith practitioner/provider as of the effective date ofsuch exclusion. (Source: 42 CFR § 422.752(a)(8)).Subcontractors and Participating PharmaciesAdequate Network CoverageSXC Health Solutions Corporation shall ensure thatall enrollees have adequate access to pharmaciesin compliance with the requirements of 42 CFR §§423.120, 423.124, and any other MedicareAdvantage requirements.MonitoringProvider shall permit Presbyterian to monitor theperformance of provider, and that of participatingpharmacies and subcontractors on an ongoingbasis. (Source: 42 CFR § 422.504(i)(4)(iii.)CredentialingProvider shall, in contracting with participatingpharmacies, credential such pharmacies using aprocess that has been reviewed and approved byPresbyterian, and that shall include but not belimited to ensuring that the pharmacy is licensed tooperate in the state in which it operates and is incompliance with all applicable state or federalrequirements.Provider shall immediately notify Presbyterian inwriting of any changes in their participatingpharmacy credentialing process or procedure.Presbyterian retains the right to suspend orterminate provider’s obligation to contract withparticipating pharmacies if Presbyterian determinesthat the delegation of this network function isadversely affecting Presbyterian’s MedicareAdvantage program. Provider shall notifyPresbyterian and all enrollees of any delegation ofa participating pharmacy from the network at least30 days before the effective date. (Source: 42 CFR§§ 422.204(b)(1), 422.504(i)(4).)Standard of ConductProvider and subcontractors will provide all servicesin a manner consistent with professionallyrecognized standards of health care. For MA Planenrollees, this means standards as prescribed byCMS. (Source: 42 CFR § 422.504(a)(3)(iii).)Fraud Waste and Abuse Control ComplianceProgramIn accordance with Prescription Drug BenefitManual Chapter 9: Part D Program to ControlFraud, Waste and Abuse (“Chapter 9”), providershall establish and maintain a comprehensivecompliance program for the purpose of corporateintegrity, fraud prevention, and detection. Suchprogram shall include all elements set forth in14-122014 Practitioner and Provider Manual - Ver. 3

LegalChapter 9 that are required by a First-Tier Entityproviding the Services set forth in the agreement(s)or this amendment.Provider Training and EducationIn accordance with Chapter 9, provider shallimplement annual compliance training andeducation of all employees, independentcontractors, agents, participating pharmacies, andsubcontractors with any Medicare Advantage orPart D responsibilities on behalf of Presbyterian.Such training shall include, at a minimum, all topicsincluded in Section 50.2.3 of Prescription DrugBenefit Manual Chapter 9. Upon request, providershall report to Presbyterian certified, fact-specificinformation on the training and the provider’seducation compliance. (Source: 42 CFR§§422.503(b)(4)(vi)(C).)Provider CommunicationsProvider shall report to Presbyterian’s ComplianceOfficer through telephone and follow-up electronicmail communication any suspected or potentialfraud or other misconduct by provider (or anemployee, agent of practitioner/provider) or asubcontractor (or an employee or agent of asubcontractor) or any other entity of whichbecomes aware. Provider shall also have aninternal reporting process for provider andsubcontractor employees and agents to reportsuspected or potential fraud to provider’scompliance officer. Provider shall report toPresbyterian any potential fraud or othermisconduct by provider or a subcontractor. Thisreport shall be made as soon as the providerbecomes aware of the potential fraud or othermisconduct.Reasonable AssurancesProvider will, as of the effective date of thisagreement, and thereafter as reasonably requestedby Presbyterian provide reasonable assurances toPresbyterian that provider’s and subcontractors’performance of these fraud, waste, and abuserequirements. Such assurances may include,among other things, providing written certificationthat the subcontractors are in compliance with allMedicare requirements or providing Presbyterianwith copies of provider’s policies and procedures,compliance program, documentation of training,and any other information necessary to providePresbyterian with reasonable assurances ofsubcontractor’s compliance with all applicableMedicare Advantage requirements.Revocation of Delegation or Termination ofAgreementPresbyterian may revoke its delegation of anyMedicare Advantage duties to provider or terminatethe agreement(s) if Presbyterian determines, in itssole discretion after a good faith investigation, thata provider or a subcontractor is not satisfactorilyperforming their Medicare Advantage duties orresponsibilities to the extent that it may cause harmto MA plan enrollees or may cause Presbyterian tobe in non-compliance with any Medicare Advantagerequirements. (Source: 42 CFR §422.504(i)(4)(ii).)14-132014 Practitioner and Provider Manual - Ver. 3

LegalPrompt Pay by PresbyterianPresbyterian shall make payment in full to providerfor clean claims within the time period specifiedunder applicable state law. (Source: 42 CFR §422.520(b).)By SXC Health Solutions CorporationProvider shall pay participating pharmacies for allclean claims for MA plan enrollees no later than thetime required by Medicare Advantage rules, asapplicable. (Source: 42 CFR s 423.50, MedicareManaged Care Manual, Chapter 11, § 100.4.)Reimbursement – Provider shall update thepricing standard used for reimbursement toparticipating pharmacies every seven days.Payment rate –Provider shall establishpayment rates for plan-covered items andservices, reimburse participating pharmacieson a fee-for-service basis, and makeinformation on payment rates available toproviders.Long-term care claims –Provider shall pay longtermcare pharmacy claims consistent with thetime frames established in Section 42 CFR §423.505(b)(20).Subcontractor Certification of Data Accuracy,Completeness, and TruthfulnessTo the extent applicable to the services providedunder the agreement(s) or this amendment,practitioner/provider warrants and represents, andupon request will certify to Presbyterian and toCMS that all data including, without limitation,encounter data, it submitted to Presbyterian isaccurate, complete, and truthful and agrees tosubmit all data necessary to characterize thecontent of purpose of each encounter with MA planenrollees. (Source: 42 CFR §§ 422.310, 422.504.)Office of the Inspector General ExclusionCertificationProvider shall, and shall require all subcontractorsto, review the Office of Inspector General andGeneral Services Administration exclusions listsupon initially hiring and annually thereafter toensure that any employee or manager responsiblefor administering or delivering Part D or MedicareAdvantage benefits is not excluded from federalhealth care programs. Providers andsubcontractors shall immediately remove anyexcluded employee from work related directly orindirectly to all federal health care programs andtake appropriate corrective actions that anemployee responsible for the administration ofdelivery of any Part D or Medicare Advantagebenefits who is on such lists. Providers andsubcontractors shall annually provide Presbyterianwith written certification of compliance with theserequirements. (Source: 422.752(a)(8); Chapter 9,Sec. 50.2.1.2.)Conflict of Interest CertificationProvider and a subcontractors’ officers, directors,and managers shall annually sign a statement,attestation or certification stating that (1) theindividual has reviewed Presbyterian’s conflict ofinterest policies; (2) the individual has disclosedany potential conflict of interests; and (3) theindividual has obtained management approval to14-142014 Practitioner and Provider Manual - Ver. 3

Legalwork despite any conflicts or has eliminated theconflict. (Source: Chapter 9, Sec. 50.2.1.2.)Offshore ContractingProvider will annually submit an offshoresubcontractor attestation to Presbyterian and CMSfor each offshore subcontractor he/she use toperform services. Provider will require allsubcontractors to report such information about anyoffshore subcontractors they use to provider,Presbyterian and CMS. (Source: HPMS Memosdated: 07/23/07, 09/20/07 and 08/26/08.)14-152014 Practitioner and Provider Manual - Ver. 3

Legal15. Fraud, Waste, and Abuse15. Fraud, Waste, and AbuseAs a health plan, Presbyterian is required tocooperate with regulatory and law enforcementagencies in reporting any activity that appears to besuspicious in nature. According to the law, anyinformation that we have concerning such mattersmust be turned over to the appropriategovernmental agencies.By identifying areas of concern relative to fraud,waste, and abuse, and working with physicians andother health care providers to make improvements,Presbyterian is able to dedicate more resources toour goal of improving the health of patients,members, and communities.This chapter of the provider manual is intended toeducate providers on fraud, waste, and abuse andto comply with the Centers for Medicare andMedicaid Services (CMS) mandatory requirementthat providers receive the training.Regulatory DefinitionsFraud is defined as intentional deception ormisrepresentation made by an entity or person,including but not limited to a subcontractor, vendor,provider, member, or other customer with theknowledge that the deception could result in someunauthorized benefit to a person or an entity. Fraudincludes any attempt to obtain, by means of false orfraudulent pretenses, representations, or promises,any of the money or property owned by or underthe custody or control of, any health care benefitprogram. It includes any act that constitutes fraudunder applicable state and federal law. Forexample, fraud may exist when a provider bills forservices not rendered, and the service cannot besubstantiated by documentation.Waste is defined as an act involving payment orthe attempt to obtain payment for items or serviceswhere there was no intent to deceive ormisrepresent, but where the outcome of poor orinefficient methods resulted in unnecessary costs tothe plan.Abuse is defined as incidents or practices that areinconsistent with accepted and sound business,fiscal, or medical administrative practices. Abusemay, directly or indirectly, result in unnecessarycosts to the health plan, improper payment, orpayment for services that fail to meet professionalstandards of care or are medically unnecessary.Abuse consists of payment for items or serviceswhen there is no legal entitlement and the recipienthas knowingly misrepresented the facts to receivethe benefit or payment. Abuse often takes the formof claims for services not medically necessary ornot medically necessary to the extent provided.Abuse also includes practices by subcontractors,providers, members, or customers that result inunnecessary costs to the health plan. For example,abuse may exist when the provider fails toappropriately bill new and established patient officecodes. The provider bills a “new” patient code bothon the initial visit and subsequent visits.15-12014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and AbuseHow to Report Fraud, Waste, and AbuseWhile true fraud involves only a small percentage ofindividuals, the costs associated with it are high.We realize that the majority of providers conducttheir practices in accordance with proper businessstandards. Presbyterian’s Special Investigative Unit(SIU) is responsible for the detection andinvestigation of any suspected fraudulent activitiesor abuse involving any members, subcontractors,providers, brokers, agents, or employer grouprepresentatives.The SIU takes a proactive approach to identifyfraud and abuse by using the claims database forresearch to detect fraudulent activities. The SIUmay contact the provider to assist with theinvestigation of any type of suspicious activity. Areview of medical records for claims validation maybe conducted at the provider’s office or facility.Medical Record DocumentationPresbyterian follows policies and procedures thatgovern the standardization and maintenance ofmedical records by its contracted providers.Presbyterian expects providers to maintain thefollowing medical record information:Physical Health Provider Medical RecordDocumentationDate of serviceType of service (for example, 99212, 99213)Medications/interventionsModalities and frequencies of treatmentfurnished with start and stop timesClinical test results and summaries of any ofthe following: diagnosis, functional status,treatment plan, symptoms, prognosis, andprogress to dateBehavioral Health Provider Medical RecordDocumentationDate of serviceType of service (for example, 90791, 90832)Medications/interventionsModalities and frequencies of treatmentfurnished with start and stop timesClinical test results and summaries of any ofthe following: diagnosis, functional status,treatment plan, symptoms, prognosis, andprogress to dateName and credentials of the provider whorendered the serviceDocumenting Timed CPT CodesHealth care professionals provide a number ofservices that are strictly time-dependent. Foraccurate coding, the provider’s documentation mustreflect the actual face-to-face time spent with thepatient. This chapter provides guidance fordocumenting timed Current Procedure Terminology(CPT) codes for the following services:Physical therapyOccupational therapyChiropractic servicesAcupunctureThese must have proper documentation for thetime or duration of each service performed, as well15-22014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and Abuseas the time of the general session. Documentationof the total therapy time, including untimed codes,is required in accordance with CMS guidelines, theAmerican Medical Association (AMA) CPT Manual,and Presbyterian’s provider manual. Counselingservices and behavioral health services must alsoprovide documentation for the face-to-face timespent with the patient.The CMS Medicare Benefit Policy Manual providesguidelines for physical therapy, occupationaltherapy, acupuncture service, and chiropracticservices (see the CMS Medicare ClaimsProcessing Manual, Chapter 5, Section 20.3,Determining What Time Counts Towards 15-MinuteTimed Codes All Claims). Providers report the codefor the time actually spent in the delivery of themodality requiring constant attendance and therapyservices. Pre- and post-delivery services are not tobe counted in determining the treatment servicetime. In other words, the time counted as “intraservicecare” begins when the therapist orphysician (or an assistant under the supervision ofa physician or therapist) is directly working with thepatient to deliver treatment services. The patientshould already be in the treatment area (such as onthe treatment table or mat or in the gym) andprepared to begin treatment.The time counted is the time the patient is treated.For example, if gait training in a patient with arecent stroke requires both a therapist and anassistant, or even two therapists, to manage in theparallel bars, each 15 minutes the patient is beingtreated can count as only one unit of code 97116.The time the patient spends not being treatedbecause of the need for toileting or resting shouldnot be billed. In addition, the time spent waiting touse a piece of equipment or for other treatment tobegin is not considered treatment time. (See theAmerican Medical Association CPT Manual,Physical Medicine and Rehabilitation, TherapeuticProcedures: Physician or therapist [is] required tohave direct (one-to-one) patient contact.)These services are generally timed. Here is anexample of a CPT code with its guidelines: 97110Therapeutic procedures, 1 or more areas, each 15minutes; therapeutic exercises to develop strengthand endurance, range of motion and flexibility.Claims Validation AuditsUnder your existing contract, Presbyterian reservesthe right to audit our members’ records forpurposes that may include but are not limited toAccuracy of claimsCoverage of servicesAppropriateness of servicesAppropriateness of billingPresbyterian routinely conducts claims validationaudits. To ensure accurate payment, please ensurethat complete and accurate supportingdocumentation exists in the patient’s medicalrecord that includes the following requiredelements:Date of treatment.Identification of each specificintervention/modality provided and billed for,both timed and untimed codes in languagethat can be compared with the billing on the15-32014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and Abuseclaim to verify correct coding. Providersshould record each service provided that isrepresented by a timed code regardless ofwhether or not it is billed, because the unbilledtimed services may impact the billing.Total timed code treatment minutes and totaltreatment time in minutes.Total treatment time including the minutes fortimed code treatment and untimed codetreatment. Total treatment time does notinclude time for services that are not billable(such as rest periods). The billing and the totaltimed code treatment minutes must beconsistent. See Pub. 100-04, Section 20.2 fora description of billing timed codes.Signature and professional identification of thequalified professionals who furnished orsupervised the services and a list of eachperson who contributed to that treatment(such as, the signature of Kathleen Smith,PTA, with notation of phone consultation withJudy Jones, PT supervisor, when permitted bystate and local law).These determine compliance with appropriatebilling practices and ensure appropriate chartingthat must support medical necessity and coveredservices of specific codes billed. Additionally, theseaudits may identify other problematic concernswhere greater understanding and compliance canbe achieved through education. All audits areperformed in accordance with the members’contracts and the existing Presbyterian providercontract.Throughout the auditing process a number of toolsare used to ensure accuracy and consistency. Thetools may include but are not limited toCPT, AMAInternational Classification of Diseases (ICD-9-CM and ICD-10-CM Manuals)CPT Handbook for PsychiatristsHealthcare Common Procedure CodingSystem (HCPCS) Level II code bookBenefit and contract languagePresbyterian Provider ManualPresbyterian Reimbursement GuidelinesMedical director reviewDocumentation from patient charts obtainedduring the auditClaims validation audits may be conducted eitheron site at the provider office or by desk audit andmay be announced or unannounced.For desk audits, the provider office is contacted inwriting with a request to submit the specifiedmedical record information to Presbyterian SIU.The office representative is asked to sign a formthat the records submitted are complete.When an onsite audit is conducted and completed,the auditors briefly meet with the provider or arepresentative to discuss the general findings andimpressions of the audit. The provider orrepresentative is asked to sign a form that all of thedocumentation was in the patient records at thetime of the audit and that the auditors returned thefile to the provider in the same condition that it wasprovided to the auditor.15-42014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and AbuseAll documentation required to justify the billingsmust be present in each file at the time of the audit.The time period selected for medical record reviewmay vary. Additions to the documentation or theproduction of missing chart notes or files at a laterdate cannot be accepted.Upon completion of the data-gathering portion ofthe audit, all of the information obtained isorganized and reviewed. Inquiries as to the resultsof the completed audit cannot be answered until allof the preliminary findings have been thoroughlyreviewed by the Presbyterian medical director andcompiled into a finalized Audit Findings Report. Thereport is sent to the provider through the U.S.Postal Service with a certified return receiptrequest.The report details the claim information such asmember name, date of service, CPT code, amountpaid, amount billed, and amount to be recovered, ifany. The Presbyterian claims or financial recoverydepartments handles all recovery requests.The provider or office representative is requested tosign, date, and indicate agreement or disagreementwith the audit findings within 30 calendar days fromdate of receipt of the certified findings letter. Theprovider options are the following:Agree with the audit.Disagree with the audit and provide additionalinformation/documentation.Disagree with the audit findings and waivehis/her right to an Administrative OfficerReview.Disagree with the audit findings and requestan informal Administrative Officer Review. Ifthe review option is chosen, the provider orrepresentative has the opportunity toparticipate either by attendance orteleconference to present their case. If theprovider waives the right to participate, theReview convenes to review the request andrender a decisionDuring the course of an investigation, many casesare found to be unintentional errors in which theprovider was unaware of the appropriate billingcriteria. In these instances, Presbyterian’s ProviderNetwork Management Department is available toassist the provider in rectifying the error andproviding education to prevent such errors in thefuture.Medical Identity Theft and IdentityMisrepresentation PreventionMedical identity theft occurs when someone uses aperson’s name and sometimes other parts of theiridentity such as insurance information without theperson’s knowledge or consent to obtain medicalservices or goods, or uses the person’s identityinformation to make false claims for medicalservices or goods. Medical identity theft frequentlyresults in erroneous entries being put into existingmedical records, and can involve the creation offictitious medical records in the victim’s name.Identity misrepresentation is the intentional use ofanother’s insurance card or the intentional “loaning”of an insurance card to an individual other than theenrolled member in order to access services.15-52014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and AbuseAccording to the National Health Care Anti-FraudAssociation, approximately 250,000 to 500,000individuals have been victims of medical identitytheft in the United States. A victim of financialidentity theft may also be a victim of medicalidentity theft.Medical identity theft occurs when an individualuses eitherAnother person’s name, which may includethe victim’s insurance information or SocialSecurity number, without the victim’sknowledge or consent to obtain medicalservices or goodsThe victim’s identity to obtain money byfalsifying claims for medical services andfalsifying medical records to support thoseclaimsMedical identify theft is one of the most damagingand potentially dangerous forms of identity theftand is a crime that causes harm to the victimresulting inReceiving the wrong medical treatmentFinding their health insurance benefits havebeen exhausted, and potentially becominguninsurable for both life and health insurancecoverageUnexpectedly failing a physical exam foremployment because a disease or conditionfor which the victim has never been diagnosedor received treatment has been unknowinglydocumented in his or her health recordThe creation of a fictitious medical recordusing the victim’s name or erroneous entriesin the victim’s existing medical recordsLeaving a trail of falsified information inmedical records that can plague victims’medical and financial lives for yearsThe outcomes related to medical identity theftinclude any of the following:Filing false health insurance claims, medicaland pharmaceutical billsDenials of health insurance claims orcoverage, and life insurance claims orcoverageDenied employment because of a falsemedical historyUnnecessary loss of time and expense spentcorrecting false patient records and insurancerecordsIn addition, member-initiated identity theft is alsoincreasing. In this theft type, the health planmember “lends” his or her health plan identificationcard to a friend or relative who does not haveinsurance to obtain unauthorized medical care thatis ultimately billed to the health plan under themember’s name.As a provider, you may help mitigate potentialidentity theft byVerifying that the patient scheduled for theencounter is the correct person with thecorrect insurance information by asking for aphoto identification card or driver’s license, inaddition to the health insurance identificationcard15-62014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and AbuseVerifying that the patient’s name, address,telephone, and date of birth match theidentification providedMaking copies to retain in the patient’s fileincluding but not limited to health planinsurance ID cards, Medicaid cards, anddriver’s licensesAsking the parent or adult accompanying aminor child to the appointment to provide hisor her photo identification and making copiesand retaining all the adult’s forms ofidentification provided in the minor child’smedical record.Federal Register (FR) and the Code of FederalRegulations (CFR)Published by the office of the Federal Register,National Archives and Records Administration, theFR is the official daily publication for rules,proposed rules, and notices of federal agenciesand organizations, as well as executive orders andother presidential documents. It is updated daily by6 a.m. and is published Monday through Friday,excluding federal holidays.The CFR is the codification of the general andpermanent rules published in the FR by theexecutive departments and agencies of the federalgovernment. It is divided into 50 titles that representbroad areas subject to federal regulation. Eachvolume of the CFR is updated once each calendaryear and is issued on a quarterly basis.Government InitiativesThe federal agencies responsible for oversight arethe Department of Health and Human ServicesOffice of Inspector General (DHHS OIG),Department of Justice, and the CMS. Because ofthe identified risks, CMS is responding with intenseoversight and increased funding for the DHHS OIG.Included in this oversight are additional fraud andabuse laws, audits, and investigations, includingmore than 140 assistant US attorneys trained onhealth care fraud.It is important for a provider to review and monitoractivities to determine that its practice is free frompotential fraud, waste, and abuse. Often, if leftunchecked, waste and abuse can become fraud.Federal and State False Claims ActsFederal False Claims ActThe Federal False Claims Act covers fraudinvolving any federally funded contract or program,with the exception of tax fraud.Under the Federal False Claims Act, those whoknowingly submit, or cause another person or entityto submit, false claims for payment of governmentfunds areLiable for three times the damages sufferedby the governmentCivil penalties of $5,500 to $11,000 per falseclaimTrial costsExclusion from Medicare and MedicaidPotential for criminal prosecutionFor example, a false $100 claim submitted forpayment with government funds would result in thefollowing penalties:15-72014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and Abuse1 false claim = $11,000 penaltyTreble damages = 3 × $100 or $300This now equals $11,300 in fines for the $100claim. Add to that any trial costs and thepotential to be excluded from participating inany government health plan.New Mexico False Claims Act (Dual Eligible)Effective May 2004, the act provides forCivil action against the filing of false claimsunder the New Mexico Medicaid programPenalties for three times the amount ofdamages the state sustains as a result of theactProtection rights to an employee whodiscloses information to the New MexicoHuman Services Department (HSD)The NM Medicaid False Claims Act (NMMFCA)signed into law in 2004 is applicable to Medicarebeneficiaries who are also covered under thestate’s Medicaid program (dual eligible). Thepurpose of NMMFCA is to deter persons fromcausing or assisting to cause the state to payMedicaid claims that are false. It provides remediesfor obtaining treble damages and civil recoveries forthe state.The NMMFCA increases the state’s ability to bringa lawsuit for Medicaid fraud and recoup funds. NewMexico’s Attorney General prosecutes Medicaidfraud.The NMMFCA contains a whistleblower provisionthat provides incentives for people who comeforward with knowledge and evidence of falseclaims submitted to Medicaid. Whistleblowers mayreceive up to 25% of the amount recovered.Employee whistleblowers are entitled to all reliefnecessary, including reinstatement, double theamount of back pay, and compensation for anyspecial damages sustained.New Mexico Fraud Against Taxpayers ActThe New Mexico Fraud Against Taxpayers Act waspassed by the New Mexico legislature effectiveJuly 1, 2007. It provides for private civil action onbehalf of the state against a person who makes afalse claim for payment and provides for civil actionby a state agency and state intervention. It alsoprovides for qui tam (whistleblower awards) andprohibits retaliation by employers.Whistleblower ActsIn whistleblower lawsuits (qui tam)An employee or private citizen sues on behalfof the governmentThe plaintiff receives as much as 30% of thetotal award and the remainder goes to thegovernmentHow Whistleblowers are ProtectedEmployers may not retaliate againstemployees who report or help investigatefalse claims.No negative employment consequences areallowed, such as firing, demoting, suspending,or harassing.Remedies against retaliation include jobreinstatement with double back pay and otherspecial damages.15-82014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and AbuseHistorically, most whistleblowers actually reportedtheir concerns to someone in their workplacebefore they went to the government with the issue.Employees and private citizens can file suit onbehalf of the government. It is important for aprovider to be open and listen to complaints whenone of your staff or patients raise a concern. If youdo not take appropriate action, they will, and theycan receive as much as 30% of the total award ifthe government’s prosecution is successful.New Mexico Whistleblower Protection ActUnder the New Mexico Whistleblower ProtectionAct, a private party brings civil action on behalf ofthe government and allows the government to takeover litigation. If the government wins the case anddamages are awarded, the private party and thegovernment share in the recovery of damages.Effective March 1, 2010, a public employer (anydepartment, agency, office, institution, boardcommission committee, branch, or district of stategovernment) is prohibited from taking retaliatoryaction against a public employee whoCommunicates to the public employer or athird party information about an action or afailure to act he or she believes in good faithconstitutes an unlawful or improper actProvides information or testifies before apublic body as part of an investigation,hearing, or inquiry into an unlawful orimproper actObjects or refuses to participate in an activity,policy, or practice that constitutes an unlawfulor improper actThe act provides for qui tam (whistleblower awards)when a public employer violates the provisions ofthe act. The public employer is liable to the publicemployee forActual damagesReinstatement with the same seniority statusthat the employee would have had but for theviolationTwo times the amount of back pay withinterestCompensation for any special damagesustained as a result of the violationThe employee’s litigation costs andreasonable attorney feesThe employee may bring an action pursuant to thissection in any court of competent jurisdiction.Deficit Reduction Act of 2005See Chapter 3, Eliminating Fraud, Waste andAbuse in Medicaid, Section 6032, EmployeeEducation about False Claims Recovery.Effective January 1, 2007, the Deficit Reduction Actamends the Social Security Act to include requiringany entity that receives or makes annual paymentof at least $5,000,000 under the state Medicaidplan toEducate employees, contractors, and agentsregarding the prevention of Medicaid fraudProvide information in policies and proceduresand the employee handbooks regarding• The federal False Claims Act• Federal administrative remedies for falseclaims and statements15-92014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and Abuse• State laws pertaining to civil or criminalpenalties for false claims and statements• Detecting and preventing fraud, waste,and abuse• Rights of employees to be protected aswhistleblowersAnti-Kickback LawsThe anti-kickback laws prohibit anyone fromknowingly and deliberately offering, giving, orreceiving remuneration in exchange for referrals ofhealth care goods or services that are paid for inwhole or in part by Medicare or Medicaid.Penalties include:Criminal: jail time, $25,000 fine, mandatoryexclusion from participation in most federalhealth care programs including Medicare andMedicaidCivil: penalties and fines, permissive exclusionAnti-Kickback Safe HarborsCongress added to the law provisions thatdesignate certain provider activities as “safeharbors,” which are specified as not constitutingviolations of the statute.Safe harbors allow certain activities to take placethat may appear on the surface to be violations ofthe law, but those activities are very restricted andmust take place only when all of the safe harborconditions are met. There are many complicatedsafe harbor exceptions, such asPersonal services contractsPayment based on fair market value ofservices, not value of referralSale of practiceProper discounts and rebatesExamples of these exceptions includeDrug “switching” programs – if structuredincorrectlyDrug rebate programs – if structuredincorrectlyPharmacy paid to “steer” patients to specificPart D planSelf-Referral LawsThe physician self-referral law, commonly referredto as the “Stark Law,” prohibits a physician fromreferring patients for certain designated healthservices to an entity in which the physician (or animmediate family member of that physician) has anownership interest or with which the physician (oran immediate family member of that physician) hasany compensation or other relationship thatinvolves remuneration or other benefit unlesscertain prescriptive requirements are met.If those requirements are not met, the entity maynot bill for any designated health service furnishedpursuant to the prohibited referral. Examples ofdesignated health services are inpatient andoutpatient hospital services, outpatient prescriptiondrugs, home health services, durable medicalequipment and supplies, and clinical laboratoryservices. The assumption underlying the statute isthat allowing such referrals would lead tounnecessary tests and increase costs. The statute15-102014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and Abuseis violated regardless of whether the physician orthe entity providing the designated health servicehas any intent to violate or even knows that thereferral is prohibited. Penalties include$15,000 fine per claim and possible exclusionPotential anti-kickback liability (if intentionalviolation)Beneficiary Inducement Civil Monetary PenaltyLawThe beneficiary inducement law prohibits providersfrom incentivizing a beneficiary who is enrolled in agovernment health care program to see a particularprovider because it could encourage theoverutilization of health care supplies and services.Violations of this law can result in substantialpenalties.Penalties includeFines up to $10,000 per violation plus trebledamagesPotential exclusion from participation ingovernment programsProgram Exclusion ListsThe Federal Exclusion Law allows the DHHS OIGto exclude individuals and organizations fromparticipating in Medicare, Medicaid, and othergovernment programs. Reasons for exclusioninclude violating fraud and abuse laws, licensingboard actions (such as suspended license),defaulting on federal student loans, and controlledsubstances violations, as well as other crimes.Providers and subcontractors who participate inMedicare and Medicaid programs are required toverify that their employees are not on the federalexclusion lists (meaning the individual is prohibitedfrom participating in Medicare- and Medicaidfundedservices).Physicians, non-physician practitioners, andemployees must not be identified on the DHHS OIGor General Services Administration (GSA) lists.Providers may log on to the following OIG/GSAwebsites listed to verify the eligibility of individuals:Department of Health and HumanServices/Office of Inspector General(DHHS/OIG), List of Excluded Individuals andEntitieshttps://oig.hhs.gov/exclusions/exclusions_list.aspGeneral Services Administration’s System forAward Management (GSA SAM)https:www.sam.gov/portal/public/SAM/Insurance companies (sponsors) do not pay fordrugs prescribed or other services provided by aprovider who is excluded by either the DHHS OIGor GSA. Additionally, excluded providers may notcontract with or perform services related to anygovernment contract including the FederalEmployee Benefit Program and Medicare orMedicaid.According to the OIG, pharmacies cannot bill for“services performed by, prescribed by, processedby or involved in any way in filling prescriptions” byindividuals who are excluded from federal and stateprograms to Medicare beneficiaries.The prohibition “also extends to payment foradministrative and management services notdirectly related to patient care, but that are anecessary component of providing items and15-112014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and Abuseservices to federal and state programbeneficiaries.”You may not employ any individual who is listed asbeing excluded or debarred, so it is important tocheck the listings before hiring.Not only will you not receive payment for servicesfurnished by an excluded person but you will alsoface a fine of $10,000 for EACH item or serviceplus three times the amount of actual damages.This is another very good reason to check thelistings on a regular basis.Presbyterian requires that all providers review all oftheir employees and contractors or vendors againstthe GSA and OIG lists at least twice each year.Providers should retain written or hard-copy proofthat this activity has been completed and isaccessible during an audit. In addition, providersshould create a policy and procedure identifying thetimeline for completion, the format, and thehandling of employees identified as excluded.Fraud, Waste, and Abuse PreventionThe OIG has a recommended compliance plan forindividual providers and small groups that can befound at their website at http://oig.hhs.gov/. Whilethis program is a voluntary program, we highlyrecommend providers adopt their own complianceprogram, which should include the following sixelements identified by OIG:Implement written policies and proceduresConduct effective training and educationDevelop effective lines of communicationConduct internal monitoring and auditingEnforce standards through well-publicizeddisciplinary guidelinesImplement corrective actionRecoveries of Centennial Care Overpaymentsand FraudIdentification Process for OverpaymentsProviders are required to report overpayments toPresbyterian Centennial Care by the later ofThe date which is 60 calendar days after thedate on which the overpayment was identified;orThe date any corresponding cost report isdue, if applicable.A provider has identified an overpayment if theprovider has actual knowledge of the existence ofan overpayment or acts in reckless disregard orwith deliberate indifference of the overpayment. Anoverpayment shall be deemed to have been“identified” by a provider when the providerReviews billing or payment records and learnsthat it incorrectly coded certain services orclaimed incorrect quantities of services,resulting in increased reimbursementLearns that a patient death occurred beforethe service date on which a claim that hasbeen submitted for paymentLearns that services were provided by anunlicensed or excluded individual on its behalfPerforms an internal audit and discovers thatan overpayment existsIs informed by a government agency of anaudit that discovered a potential overpayment15-122014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and AbuseIs informed by Presbyterian Centennial Care,HSD, or the Medicaid recovery auditcontractor of an audit that discovered apotential overpaymentExperiences a significant increase in Medicaidrevenue and there is no apparent reason forthe increase, such as a new partner added toa group practice or new focus on a particulararea of medicineHas been notified that the contractor or agovernment agency has received a hotline callor emailHas been notified that PresbyterianCentennial Care or a government agency hasreceived information alleging that a recipienthad not received services or been suppliedgoods for which the provider submitted aclaim for paymentSelf-ReportingProviders are required to report overpayments toPresbyterian Centennial Care by the later ofThe date which is 60 calendar days after thedate on which the overpayment was identified;orThe date any corresponding cost report isdue, if applicable.The provider is required to send an overpaymentreport to Presbyterian Centennial Care and HSDwhich must include at a minimum the followinginformation:Provider’s nameProvider’s tax identification number andnational provider numberHow the overpayment was discoveredThe reason for the overpaymentThe health insurance claim number, asappropriateDate(s) of serviceMedicaid claim control number, as appropriateDescription of a corrective action plan toensure the overpayment does not occur againWhether the provider has a corporate integrityagreement with the DHHS OIG or is under theOIG self-disclosure protocol;The specific dates (or time span) within whichthe problem existed that caused theoverpaymentsIf a statistical sample was used to determinethe overpayment amount, a description of thestatistically valid methodology used todetermine the overpaymentThe refund amountRefundsAll self-reported refunds for overpayments shall bemade by the provider to Presbyterian CentennialCare as an intermediary and are property ofPresbyterian Centennial Care unlessHSD, the recovery audit contractor, orMedicaid Fraud and Elder Abuse Division(MFEAD) independently notified the providerthat an overpayment existed15-132014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and AbusePresbyterian Centennial Care fails to initiaterecovery within 12 months from the date thecontractor first paid the claimPresbyterian Centennial Care fails tocomplete the recovery within 15 months fromthe date Presbyterian Centennial Care firstpaid the claimThe provider may request that PresbyterianCentennial Care permit installment payments of therefund. Such request shall be agreed to byPresbyterian Centennial Care and the provider.In cases where HSD, the Recovery AuditContractor, or MFEAD identifies the overpayment,HSD shall seek recovery of the overpayment inaccordance with New Mexico Administrative Code§8.351.2.13.Failure to Self-Report and/or Refund OverpaymentsOverpayments that have been identified by aprovider and not self-reported within the 60-calendar-day time frame are presumed to be falseclaims and are subject to referrals as credibleallegations of fraud.Fraud, Waste, and Abuse ReportingYou can assist Presbyterian prevent fraud, waste,and abuse by reporting any suspicious activity thatappears to be potential fraud, waste, and abuse.Report all confirmed, credible, or suspected fraud,waste, and abuse immediately in accordance withthe following:For all confirmed, credible, or suspectedprovider fraud, waste, and abuse, report toPresbyterian, HSD, and MFEAD and includethe information provided in 42 CFR Section455.17, as applicableFor all confirmed, credible, or suspectedmember fraud, waste, and abuse, report toPresbyterianPlease contact us to report suspicious activity usingthe contact numbers below.The SIU confidential hotline phone numbers are:505-923-5959 (local)1-800-239-3147 (toll-free)Email address: PHPFrau@phs.orgOr, you may file a suspected fraud and abusereport online athttps://www.phs.org/insurance-plans/all-abouthealth-care/faqs/fraud-abuse/Pages/default.aspx.Contact information for reporting abuse, neglectand exploitation of members:Adult Protective Services: 1-866-654-3219Children, Youth, and Families Department: 1-800-797-3260Department of Health/Division of HealthImprovement (DOH/DHI): 1-800-445-6242For suspected fraud, waste, and abuse in theadministration of Centennial Care, report toPresbyterian, HSD, and MFEAD15-142014 Practitioner and Provider Manual - Ver. 3

Fraud, Waste, and Abuse16. Credentialing and Recredentialing16. Credentialing andRecredentialingPresbyterian credentials both individualpractitioners and organizational providers. Thecredentialing process focuses on verifyingadequate training, experience, licensure, andcompetence by accessing data and informationcollected to determine if a provider is qualified torender quality care to our members. See theBehavioral Health chapter of this manual forcredentialing and recredentialing of behavioralhealth providers.Program ScopeThe Presbyterian credentialing program applies tohealth care providers that are contracted withPresbyterian to provide health care services to itsmembers. The following contractual relationshipsrequire providers to be credentialed beforerendering services to Presbyterian members:Providers who have an independentrelationship with Presbyterian. Anindependent relationship exists whenPresbyterian selects and directs its membersto see a specific practitioner or group ofpractitioners, including all practitioners whommembers can select as primary carepractitioners. This is not the same as anindependent contract.Practitioners who see members in anoutpatient setting.Practitioners who are hospital-based but seePresbyterian members as a result of theirindependent relationship with Presbyterian.Examples include but are not limited toanesthesiologists with pain managementpractices, hospital-based cardiologists, andhospital-based university faculty.Dentists who provide care underPresbyterian’s medical benefits. Examples ofthis type of provider include but are not limitedto endodontists, oral surgeons, andperiodontists.Non-physician providers who have anindependent relationship with Presbyterian, asdefined above, and provide care underPresbyterian’s medical benefits.Credentialing and Recredentialing ProcessesThe following is information related to credentialingand recredentialing processes:Ensure that all information on the applicationis complete and correct. Any unexplainedgaps, missing information, or incompleteinformation delay the application processing.Include the beginning and ending month andyear for each work experience under workhistory and explain any gaps exceeding sixmonths.Include a written explanation for any “yes”answer to the professional practice questions.16-12014 Practitioner and Provider Manual - Ver. 3

Credentialing and RecredentialingIf office staff completes the application, ensurethat the answers are correct.Ensure that all required documents aresubmitted with the completed and signedapplication and attestation.Practitioners can obtain an application at anytime by contacting their provider networkmanagement relationship executive(https://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00140718.pdf) or credentialing examiner at the healthplan. Once a request is made fromPresbyterian to the Council for AffordableQuality Healthcare, the practitioner may alsogo to https://upd.caqh.org/oas/ and submit anapplication online. It is important to notify yourrelationship executive if you are joining anexisting group. A practitioner who is notcurrently an in-network provider but would liketo become one must submit a letter of intent.A letter of intent form can be accessed athttps://www.phs.org/providers/Pages/becomecontracted-provider.aspx.Ensure timely completion of the application.After three requests for an application with noresponse, Presbyterian places the applicationrequest on hold. For recredentialingapplications, the practitioner or provider is atrisk for termination.Organizational providers receive their applicationdirectly from Presbyterian.Credentialing Review CommitteeThe Presbyterian Credentialing Review Committeeis a subcommittee of the Presbyterian QualityImprovement Committee and serves as acredentialing review body. The CredentialingReview Committee was established to provideexpertise about current credentialing practices inthe medical and behavioral health community,provide advice on modifying criteria, and maintain areview process for credentialing andrecredentialing.The committee is able to evaluate and improve thequality of health care services rendered by healthcare practitioners and providers and review thenature, quality, and cost of health care servicesprovided to enrollees or members of Presbyterian.The committee makes recommendations toPresbyterian regarding whether individual healthcare practitioners should be included inPresbyterian’s provider panel. The committee alsoprovides input into the corrective action planprocess, and reviews and makes determinations onthe appropriateness of the responses to requestsfor corrective action while providing oversight onwhether the practitioner’s or provider’s membershipon the Presbyterian provider panel should belimited, suspended, or revoked.ConfidentialityPresbyterian maintains the confidentiality of allinformation obtained about the practitioners andproviders it credentials and recredentials, asrequired by state law, federal law, and accreditationstandards.16-22014 Practitioner and Provider Manual - Ver. 3

Credentialing and RecredentialingProvider RightsCredentialing Right to Review InformationEvaluation of the credentialing application includesinformation obtained from any outside source (suchas, malpractice insurance carriers, state licensingboards), with the exception of references,recommendations, or other peer-review protectedinformation.Right to Correct Erroneous InformationPresbyterian notifies practitioners whencredentialing information obtained from othersources varies substantially from that provided bythe practitioner. Presbyterian provides thefollowing:The time frame for changesThe format for submitting correctionsThe person to whom corrections must besubmittedDocumentation of receipt of the correctionsRight to Be Informed of Application StatusAll applicants have the right to be informed of theirapplication status. Application status inquiriesshould be directed to the appropriate credentialingstaff.Right to Be Notified of These Rights DelegationPresbyterian may delegate to designated entities allor some of the credentialing responsibilities. Theperformance of the entity is monitored on anongoing basis for compliance with Presbyterian’srequirements and all applicable regulatory andaccreditation standards. Presbyterian retains theright, based on quality issues, to approve, suspend,or terminate individual practitioners and providerseven in situations where it has delegatedcredentialing responsibilities.Standard Eligibility CriteriaPractitionersPractitioners must meet the following standardeligibility criteria, which includes but is not limited toA current unrestricted license to practicewithin the states where services are provided;temporary licenses are not acceptable to fulfillthis requirement for behavioral health ormedical practitionersAppropriate training within the area of practiceAbsence of felony convictionsProvision of quality, appropriate, and timelycareConfirmation of the primary care practitioner’sability to meet applicable required access andavailability standardsNo sanctions, suspensions, or terminationsimposed by Medicare, Medicaid, or otherdesignated federal/regulatory bodiesWhen contracted to see Medicare or Medicaidpatients, has not opted out of the Medicare orMedicaid programPractitioners who serve Medicare membersmust be Medicare-approvedValid Drug Enforcement Agency (DEA)certificate and applicable state pharmacyregistration for controlled substances16-32014 Practitioner and Provider Manual - Ver. 3

Credentialing and RecredentialingCurrent malpractice insurance coverage in therequired amount (as described in greaterdetail later in this chapter)Acceptable office practices and a safe officeenvironment that requires a minimum score of90 percent on the initial site visitWork history that reflects a consistent patternof professional activity in good standing for thepast five yearsAbsence of evidence that the applicant mightbe unable to perform the contracted dutiesAbsence of suspension, restriction, ortermination of hospital privilegesNational Provider IdentifierOrganizational ProvidersOrganizational providers must meet the followingstandardized criteria, which includes but is notlimited toCurrent good standing with state and federalregulatory bodies and certified by theappropriate state certification agency, asapplicableHas been reviewed and accredited by arecognized accrediting body or, if notapproved by an accrediting body, meetsPresbyterian’s standards of participationCurrent applicable state license or certificationNo sanctions, suspensions, or terminationsimposed by Medicare, Medicaid, otherdesignated federal/regulatory bodies, or thestate where services are renderedWhen contracted to see Medicare or Medicaidpatients, has not opted out of the Medicare orMedicaid programProviders who serve Medicare members mustbe Medicare-approvedCurrent malpractice insurance coverage in therequired amount (as described in greaterdetail later in this chapter)Acceptable malpractice history within the twoyearperiod immediately preceding the date ofapplicationValid DEA certificate and applicable statepharmacy registration for controlledsubstancesMalpractice Insurance RequirementsProviders are required to maintain, at their sole costand expense and at all times, both comprehensivegeneral liability insurance and professional liabilityinsurance. This insurance must contain provisionsand be written by companies reasonablyacceptable to Presbyterian. Providers mustdemonstrate compliance with this requirement byproviding Presbyterian with certificates evidencingdates that this insurance is in effect, as well asamounts. Notwithstanding these guidelines,Presbyterian reserves the right, on a case-by-casebasis, to require either higher or lower limits, orother terms and conditions depending uponcircumstances or other facts that Presbyterian, inits sole discretion, deems necessary to meet itslegal and regulatory obligations. Currently,Presbyterian requires the following amounts ofcoverage:16-42014 Practitioner and Provider Manual - Ver. 3

Credentialing and RecredentialingNew Mexico Practitioners and ProvidersFor practitioners and providers that arequalified under the New Mexico MedicalMalpractice Act, Presbyterian requires that thepractitioner and provider maintain professionalliability insurance in the amounts required bythe act, currently $200,000 per occurrenceand $600,000 aggregate.For those practitioners and providers that areNOT qualified under the New Mexico MedicalMalpractice Act, Presbyterian requires that thepractitioner or provider maintain professionalliability insurance in the following amounts: $1million each occurrence and $3 millionaggregate.Any obstetrician/gynecologists and otherprimary care practitioners who practice in NewMexico and who deliver babies as a part oftheir practice must also carry limits of $1million per occurrence and $3 millionaggregate, regardless of insurance coveragewith the New Mexico Medical Malpractice Act.Practitioners and Providers Outside of New MexicoFor those practitioners and providers locatedoutside of New Mexico, we accept insurance in theamounts and types required by the law of thejurisdiction in which the practitioner or provider islocated, or in the absence of a legal requirement,the following amounts: $1 million per occurrenceand $3 million aggregate.Site VisitSite visits are included as part of the initialcredentialing process for primary care practitioners,obstetrics and gynecology practitioners, and highvolumebehavioral health specialists. In addition tothe initial site visit, a site visit is conducted on anyprovider that receives two or more complaintswithin 12 months regarding their office or practice.Initial applicants who fail a site visit are notified thatthe credentialing process has been discontinued.The applicant may contact Presbyterian forinformation about how to improve their site and torestart the credentialing process once thedeficiencies have been corrected.Any provider that receives two or more complaintsregarding their office or practice within 12 monthshas a site visit scheduled immediately. Should theprovider’s office fail the site visit, they are notifiedand the practitioner or provider must develop acorrective action plan within 30 days to address thedeficiencies. A follow-up review is conducted withinsix months to determine compliance. If thepractitioner or provider fails to submit the correctiveaction plan within the specified time frame, it isconsidered a breach of contract and may result intermination from the network.Ongoing MonitoringThe Office of Inspector General’s List of ExcludedIndividuals and Entities Exclusion Program and theGeneral Services Administration’s System forAward Management (previously Excluded PartiesLists System), and applicable state licensingagencies are monitored monthly for sanctions orlicensure limitations.Investigations are conducted on all quality of careand service complaints. For quality of clinical care16-52014 Practitioner and Provider Manual - Ver. 3

Credentialing and Recredentialingcomplaints, appropriate clinical staff, includingPresbyterian medical directors, are consulted inconjunction with the review of the complaint, andmay include a review of relevant medical records.Upon completion of the initial investigation, thefindings may be reported to the appropriate medicaldirector, the credentialing review committee, andthe provider network management director.Corrective action plans are developed in situationswhere there is an identified need for improvementin quality of care or service. Presbyterian offers aformal appeal process and reports the action asappropriate whenever a practitioner or provider isterminated or suspended for quality of careconcerns.Fair HearingIn the course of the credentialing decision-makingprocess, applicants are given the opportunity toprovide additional information that may addressconcerns raised by the committee that may lead todenial of the application.Practitioners and providers that are deniedmembership at credentialing or recredentialing, orare terminated for cause, have the right to appealthe decision through either the initial denial reviewprocess or fair hearing process.Practitioners and providers should submit thecompleted application and all required documentsto:Presbyterian Health Plan and PresbyterianInsurance CompanyProvider Network Management CredentialingDepartmentP.O. Box 27489Albuquerque, NM 87125-7489Individual practitioners can also submit theapplication online at http://www.caqh.org/.16-62014 Practitioner and Provider Manual - Ver. 3

Credentialing and Recredentialing17. e-Business17. e-BusinessCurrent e-Business ResourcesPresbyterian defines e-business as any tool orresource that allows information to be stored,displayed, or transmitted electronically. We strive tooffer online resources that save time and energy,and that provide our network with improvedefficiency resulting from immediate access tocurrent and accurate information. The following is alist of current and planned e-business toolsavailable to the network:myPRES: A password-protected portal(website) that allows your office to access avariety of Presbyterian resources, as well asmember, benefit, authorization, and claiminformationInteractive Voice Response (IVR) System:This system complements myPRES byproviding you access to member eligibility, copayment,and primary care practitionerinformation over the phoneElectronic Claims Transmission (ECT): Youcan save time and money by sending yourclaims electronically to Presbyterian throughone of our five contracted clearinghouses; alist of these clearinghouses can be found laterin this chapterElectronic Remittance Advice (ERA):InstaMed enables providers to receiveelectronic explanation of payments (EOPs)and fully reconciled remittances electronicallyand access a secure portal to view and printremittances at no costElectronic Funds Transfer (EFT): This enablesyou to receive and accelerate payments withEFT directly deposited into your existing bankaccount at no cost to you through InstaMedInstaMed: A third-party vendor of Presbyterianthat provides you with an ERA/EFT system forelectronic transactions through a secure portalat no cost to providersHealthXnet ® : A third-party vendor ofPresbyterian that provides you with access toa variety of information and functions over theinternet related to eligibility verificationOnline Provider Directory: For theconvenience of you and your patients,Presbyterian has improved its online providerdirectory by including information about ournetwork of primary care providers, specialists,and other providersePocrates ® : A web platform that allows theuser to access current Presbyterian formularyinformationThe Provider Webpage: The Presbyterianprovider web page includes recentcommunications, benefit and criteriainformation, appeals and grievances, onlinesubmissions, and the online provider directory17-12014 Practitioner and Provider Manual - Ver. 3

e-BusinessHealth Insurance Portability and AccountabilityAct (HIPAA) of 1996 Regulations and e-BusinessClaims status, member eligibility, and benefit andpharmacy certification requests are some of thetransactions covered under the HIPAA regulations.Conducting these transactions through the internetqualifies as conducting these transactions“electronically” according to HIPAA, and maytherefore cause you to qualify as a covered entitysubject to the HIPAA regulations.If you are not already considered a covered entityunder the HIPAA regulations, you may want toconsider carefully before initiating thesetransactions over the web. Any provider that wantsto determine whether they are a covered entityunder HIPAA can use the Center for Medicare andMedicaid Service tool at the following link:Simplification/HIPAAGenInfo/index.html?redirect=/HIPAAGenInfo/.myPRESIt is our goal to make myPRES your first choicewhen accessing information from Presbyterian.This web platform provides free online access tocurrent claims status, member eligibility and priorauthorization information, and much more.myPRES also enables you to submit onlineauthorization requests and to email the ProviderClaims Activity Review and Evaluation (CARE) unitfor more complex issues that require research.In direct response to network feedback, myPRESnow has the capability to auto review the followinghttp://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-prior authorizations requests for participatingproviders:Specialty wheelchair evaluationGynecomastia surgery – maleBreast repair and reconstruction for breastcancerEpiduralsDiapersPrior AuthorizationPresbyterian’s Prior Authorization Guide providesprior authorization, referral, and other utilizationmanagement requirements and procedures. Themost updated version of this guide is available onour website athttps://www.phs.org/providers/cliniciansresources/Pages/health-services.aspx.You canalso access our prior authorization request formsfrom the same link.How to Register for myPRESObtain a user ID and password by entering this linkinto the internet address bar:https://mypres.phs.org.You can also follow the steps below:Go to http://www.phs.orgClick “For Providers” on the top of thewebpageClick “myPRES login” located on the top rightcorner of the webpageClick the Providers registration link in themiddle of the page under the “New tomyPres?” section17-22014 Practitioner and Provider Manual - Ver. 3

e-BusinessFill out the form on the page to request accessThis allows you to request user IDs and passwordsfor multiple users. Fill out the application and clickthe submit button at the end of the application.Remember that your user ID and password arecase-sensitive.Each employee in your office who utilizes myPRESmust have their own individual user ID andpassword. Under no circumstances should yourmyPRES user ID and password be shared. It isyour responsibility to contact the PresbyterianCustomer Service Center to terminate access ofemployees who are no longer employed or who nolonger require access to myPRES.Accessing myPRESGo to http://www.phs.org and locate the myPRESlog-in box on the right side of our website, click onlog-in box, and enter your user ID and password tolog on to myPRES.If you have problems locating or completing theenrollment form, you may contact the PresbyterianProvider E-Help Desk byPhone at 505-923-5590 or toll-free at 1-866-861-7444, Monday Friday from 8 a.m. to 5p.m. (MST)Email at ehelpdesk@phs.orgResetting Your myPRES PasswordUser IDs and passwords are easily reset online. Atthe log in screen, simply click on “Forgot/ResetPassword” or “Forgot User ID.” Then follow theeasy steps to get your user ID or password reset.Should this fail to work, please email the E-Helpdesk at ehelpdesk@phs.org or call 505-923-5590or toll free at 1-866-861-7444 for further assistance.Computer and Software Requirements for myPRESIn order to take full advantage of myPRES’scapabilities, you need:A PC or Macintosh computer capable ofrunning either Internet Explorer 5.5 (or higher)or Netscape Navigator 6.2Macromedia Flash PlayerAn internet service provider connectionmyPRES Hours of AvailabilitymyPRES offers continuous availability 24 hours aday, seven days a week, including holidays. As withany internet platform, problems with availability mayarise because of heavy internet traffic.Information UpdatesThe information available through myPRES isupdated in real time and is connected to our claimsprocessing system.Reporting an Information DiscrepancyPlease direct these types of issues to the ProviderCARE Unit web form located athttps://www.phs.org/providers/trainingreference/Pages/request-for-information.aspx.For questions concerning prior authorizationinformation, please call the provider line at 505-923-5757 or 1-888-923-5757, and select the HealthServices option from the menu.myPRES Training and SupportOnline help is available at the touch of a buttononce you are in the application. The Presbyterian17-32014 Practitioner and Provider Manual - Ver. 3

e-BusinessE-Help desk also provides phone support Mondaythrough Friday, 8 a.m. to 5 p.m. The ProviderNetwork Management department is also availableto assist you.Interactive Voice ResponseOur IVR system complements myPRES and allowsyou to check member eligibility as well as obtainco-payment and primary care practitionerinformation over the telephone. Access the IVRsystem by calling 505-923-5757 or 1-888-923-5757and choosing Option 1. Transactions done throughthe IVR system are not covered under HIPAAregulations. Use of the IVR system does not qualifyproviders as conducting HIPAA electronictransactions and use of the IVR system does notqualify providers as covered providers subject toHIPAA regulations.Electronic Claims TransmissionWe encourage you to take advantage ofPresbyterian’s ECT system and capitalize on thetime and savings realized from a paperless system.To submit electronic claims directly to PHP, we nowoffer our Fast Claim direct entry portal. Fast Claimis designed to accommodate lower-volume claimsubmitting practices that would like to submit claimselectronically directly to PHP at no cost. If you areinterested in learning more about ECT or FastClaim, please contact the Provider NetworkManagement e-business Analyst at 505-923-6154.A list of clearinghouses is also available inAppendix ?. Since October 16, 2003, electronicallytransmitted claims must meet the HIPAATransaction Standards with regard to format andcontent. Corrected claims should not be submittedelectronically.Electronic Data Interchange Remittance AdviceProviders using the ECT system may be eligible totake advantage of EDI-RA. By using EDI-RA, youreceive EOP data and payment funds fasterbecause EOP data is sent electronically to youroffice and payment funds are directly deposited toyour bank account. If you are currently submittingclaims electronically and are interested in usingEDI-RA, please contact your provider networkmanagement relationship executive to checkavailability.Electronic Coordination of Benefits (eCOB) ®eCOB ® enables your patients to receive benefitsfrom all health insurance plans they are coveredunder, while ensuring that the total combinedpayment from all sources is not more than the totalcharge for the services provided.If you are interested in submitting eCOB ® , pleaseverify with your practice management softwarevendor that your billing program has the capacity todo so.InstaMedInstaMed offers a payments management solutionto eliminate paper checks and explanation ofpayments, accelerate payments with EFT directlydeposited in your existing bank account, andreceive fully reconciled remittances electronically.17-42014 Practitioner and Provider Manual - Ver. 3

e-BusinessSign Up for this Free ServiceInstaMed will manage the enrollment process. Toget started and access the features availablethrough our provider payments managementsolution, please visitwww.phs.org/providers/training-reference/claims/ todownload our enrollment form. Fax your form andbank documentation to InstaMed at 1-877-755-3392 or register online atwww.instamed.com/presbyterian-health-plan-payerpayments/.If you have any questions about this service,contact InstaMed at 1-866-945-7990 orsupport@instamed.com.HealthXnet ®HealthXnet ® allows you to check member eligibility,claims, and benefit certification status, and tosubmit claims online. For more information, visitHealthXnet ® at http://info.healthxnet.com/index.htmlor contact them by phone, fax, or email as followsfor User Administration and Help Desk (login ID,password, and technical assistance):Local: 505-346-0290Toll Free: 1-866-676-0290Fax: 505-346-0278Email: healthxnet@nmhsc.comePocrates ®Presbyterian is the first New Mexico health plan tointegrate its product-specific formularies with theePocrates ® Rx drug reference information forapplication on your handheld device. This freeservice offers a convenient way to access currentformulary information whenever and wherever youneed it. With ePocrates ® Rx, you can use yourhandheld device to quickly determine which drugsPresbyterian covers before writing a prescription.As a result, you can prescribe more efficiently whilecontinuing to provide quality care for your patients.Making Prescribing EasierThe ePocrates ® Rx software also providesinformation about adult and pediatric dosing, druginteractions, adverse reactions, contraindications,tables, and regimens for more than 3,300 of themost commonly prescribed medications.ePocrates ® updates their references at leastweekly. With this information at your fingertips, youcan help your patients avoid complications thatcould result from inappropriate drug combinations.This tool also allows your patients to leave youroffice knowing the coverage status for theirprescriptions, eliminating problems for them at thepharmacy.Sign Up for This Free ServicePresbyterian’s partnership with ePocrates ® is justanother way Presbyterian makes it easier for you tofocus on patient care. To use ePocrates ® Rx youneed a smartphone, tablet, palm or pocket PChandheld device, or a computer and an internetconnection of any speed. Visit ePocrates ® athttp://www.epocrates.com/ to obtain specific deviceand system requirements and to download the freeclinical and formulary application.If you already have the ePocrates ® Rx orePocrates ® ID software, you can easily add thePresbyterian formularies to your handheld devices.17-52014 Practitioner and Provider Manual - Ver. 3

e-BusinessSimply visit the ePocrates ® web page, click on“EPOCRATES ONLINE” at the top of the page,sign in, and add formularies.Provider Network Management WebsiteVisit the provider page athttps://www.phs.org/providers/Pages/default.aspxto access useful information, documents, andforms, as well as to send online requests toPresbyterian.To access the provider pageGo to http://www.phs.orgSelect “For Providers” at the top of the screenMedical Policy InformationPresbyterian’s Medical Policy Committee (MPC)has the responsibility for creating, revising,interpreting, and disseminating benefit informationin a uniform and organized manner for use byPresbyterian employees and service partners. Aspart of this process, the MPC has created theMedical Policy Manual to assist in administeringplan benefits.The Medical Policy Manual is available on thePresbyterian website and is updated when new orrevised pages are approved by the MPC or theClinical Quality Committee. Not every Presbyterianplan contains the same benefits; therefore, themember’s contract must be reviewed before usingthe Medical Policy Manual to determine if a specificbenefit is available to a member.Information contained in the Medical Policy Manualdoes not replace the member’s Group SubscriberAgreement, Summary Plan Description, orEvidence of Coverage.To access the Medical Policy Manual, visithttps://www.phs.org/providers/cliniciansresources/medical-policymanual/Pages/default.aspx.Appeals and GrievancesPresbyterian has implemented a verycomprehensive process, in conjunction with ourregulatory agencies, to ensure that our membersand providers have a simple method to exercisetheir appeal and grievance rights. In order to makethis process as simple and effective as possible,you are able to file an appeal or report a grievanceby using our website. Should you wish to file anappeal or report a grievance, you may do so onlineat https://www.phs.org/providers/cliniciansresources/appeals-grievances/Pages/default.aspx.Click on the “Appeals and Grievances form” link. Ifyou are interested in learning more about appealsand grievances, please refer to the Appeals andGrievances chapter of this manual.17-62014 Practitioner and Provider Manual - Ver. 3

e-BusinessClearinghouse Contact InformationCompany Contact Information Payor Identification NumberAvaility ®P.O. Box 550857Jacksonville, Florida32255-0857MedAssets100 North Point CenterEast, Suite 200Alpharetta, GA 30022HealthXnet7471 Pan American Freeway NEAlbuquerque, NM 87109EmdeonCorporate Office3055 Lebanon PikeNashville, TN 37214ClaimMDP.O. Box 1177Pecos, NM 87552Clearinghouse Contact Information(800) AVAILITY (282-4548)Website: http://www.availity.com/Main Office: (678) 323-2500Product Information: (888) 883-6332Tech Support: (866) 658-1629Website: http://medassets.come-mail: solutions@medassets.com(866) 676-0290 or (505) 346-0290Website: http://info.healthxnet.com/index.html(877) 469-3263, or (615) 932-3000Website: http://www.emdeon.com/(505) 757-6060Website: http://www.claim.md/PREHP (Commercial)PRESA (Centennial Care)PRESA (Medicare)23456Z0003 (Commercial)Z0077 (Centennial Care)05003 (all lines of business)PRESB (all lines of business)17-72014 Practitioner and Provider Manual - Ver. 3

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e-Business18. Claims and Payment18. Claims and PaymentPresbyterian’s Claims Department ensures thatclaims submitted by our providers are processedaccurately and in a timely manner. The primaryreimbursement tools used in this process areThe application of correct coding guidelines inaccordance with the standards set by the Centersfor Medicare and Medicaid Services (CMS) and theAmerican Medical Association (AMA)Individual provider contractual arrangementsThe application of specific member benefitsThe requirements in this chapter of the ProviderManual can help you ensure that your claims aresubmitted correctly.Requirements for the Health Insurance Portabilityand Accountability Act (HIPAA) of 1996, as weunderstand them today, are included. Periodicupdates are sent to your office as necessarythroughout the year.You are required to submit claims for all servicesrendered, whether they are capitated or fee-forservice.For assistance with claim submissions,please contact your provider network managementrelationship executive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf),who can arrange for helpful technical assistanceand training sessions.Electronic Claims TransmissionElectronic claims are claims that are transmittedelectronically to Presbyterian using a clearinghouseor a web application such as Presbyterian’selectronic claims transmission (ECT) system. UsingECT can capitalize on the time and savingsrealized from a paperless system. To submitelectronic claims directly to Presbyterian, providerscan use the Fast Claim direct entry portal at(https://www.claim.md/phs.plx).Fast Claim is designed to accommodate lowervolumeclaim submitting practices that would like tosubmit claims electronically directly to PHP at nocost. To learn more about ECT or Fast Claim,please contact the provider network managemente-business analyst at 505-923-8726. A list ofclearinghouses is also available at the end of the e-Business chapter. Since October 16, 2003,electronically transmitted claims must meet theHIPAA transaction standards with regard to formatand content. Corrected claims should not besubmitted electronically.Benefits of Filing ElectronicallyPresbyterian processes electronically submittedclaims faster than hard copy claims. Electronicsubmission saves you postage and paper, andprovides you with the following:18-12014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentQuicker confirmation of claims receipt and integrityof the data, higher percentage of claims accuracy,resulting in faster paymentRequired HIPAA formatting of claims dataANSI-X12 837 claims formatTypically free service for claims submitted toPresbyterianRequirementsYou need:A compatible computer system; check with theclearinghouse technical representative forPC/Macintosh compatibility informationA billing system that can produce the data requiredby the HIPAA compliant claim format (ANSI X12837 version 5010); check with your clearinghousetechnical representative to determine thisA modem or internet connectionTwo important aspects of Presbyterian’srelationship with the clearinghouses are complianceand data protection. New Mexico legislationenacted during 2001 requires stringent approachesto protecting both personal health information andpersonal financial information. HIPAA legislationrequires even more exacting procedures andprocesses to ensure data is protected. Presbyterianand its contracted clearinghouses work to ensurethat all data is appropriately protected as it movesthrough the electronic environment needed to fosterrapid and accurate payment.How to Begin Filing ElectronicallyYou may begin filing electronically by calling one orseveral of the clearinghouses listed at the end ofthe e-Business chapter. Presbyterian hascontracted with these companies to provide youwith the software that enables you to transmitclaims electronically. All of these companies areendorsed by Presbyterian and they help you getstarted and provide timely and accurate processingof your claims.The clearinghouse asks you some questions, morethan likely sends you an informational packet, andmay ask you to fill out and send in a questionnaireto help determine your needs. You may comparethe services available through each clearinghouse.The service is free for claims submitted toPresbyterian. There may be additional services theclearinghouse can provide at an additional cost toyour office, including the submittal of claims toother payers. The clearinghouse evaluates yoursystem, sets up a test, and instructs you in the useof their system. You are up and running quickly,barring any major problems.You do not need to notify Presbyterian to startbilling electronically. However, you do need yourPresbyterian assigned provider number and youmust have a National Provider Identifier (NPI). Youmust also provide your tax identification number tosubmit an electronic claim. For special concerns orbilling issues, first contact your provider networkmanagement relationship executive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf) foradvice. Presbyterian does not pay claims if an NPIis NOT submitted. More information regarding NPIis discussed later in this chapter.You receive either an acceptance or rejectionreport from the clearinghouse within one day of18-22014 Practitioner and Provider Manual - Ver. 3

Claims and Paymentsubmission. Claims listed on the acceptance reportare transmitted to Presbyterian. You then receiveeither an acceptance or rejection report fromPresbyterian through the clearinghouse.If You Encounter ProblemsIssue: An electronic claim is rejected by theclearinghouse as “unclean.”Solution: Call the clearinghouse within 48 hours ofreceipt of the rejection report.Issue: An electronic claim is accepted byPresbyterian but does not show as paid in yoursystem.Solution: Check the claim status online or contactthe Provider Claims Activity Review and Evaluation(CARE) Unit through their online web form within30 days from the date of service.Issue: A claim is rejected by Presbyterian with anerror message that you do not understand.Solution: Contact your clearinghouse or yourprovider network management relationshipexecutive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf)within 48 hours of receipt of the rejection report forthe needed information so that you can submit yourclaim.Issue: You consistently submit claims that are notshowing in Presbyterian’s claims system and thatare not recorded on your error reports that youreceived from your clearinghouse and Presbyterian.Solution: Contact your provider networkmanagement relationship executive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdfhttps://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00140718.pdf) and discussthe issue. If the issue is determined to be atechnical problem, your provider networkmanagement relationship executive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf)coordinates contact with Presbyterian’s InformationServices Department. It is important to check on aregular basis to ensure that the claims are notdenied for lack of timely filing. Also, please be sureto keep detailed records regarding this activity.Paper Claims Submission ProcessPaper claims are printed on a form and mailed toPresbyterian. Presbyterian requires all providers touse one of two forms when billing hard copy paperclaims, the CMS 1500 (02-12) or the UB-04.A complete itemization and medical records arerequired for all claims with billed amounts of$100,000 or greater. Payment will be deniedwithout these documents.CMS 1500The CMS 1500 (02-12) billing form is used whensubmitting claims for all professional services,including ancillary services and professionalservices billed by a hospital. The CMS 1500 (02-12) is available to providers as of January 6, 2014,and is the only acceptable version of this form. Box21 of these forms requires the use of ICD-10 codesand they should be billed in sequential alphabeticalorder. Diagnosis pointer in box 24E should be billedalpha as well.18-32014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentUB-04The UB-04 billing form is used when submittingclaims for hospital inpatient and outpatient services,dialysis services, nursing home room and board,and hospice services.National Provider IdentifierCMS requires that all health care providers acquirean NPI. In order to properly adjudicate and correctlydirect reimbursement, all fields containing providerinformation require an NPI. All providers, with theexception of sole practitioners, must acquire andsubmit the appropriate Type 2 organization NPI inthe appropriate field. Examples are physician grouppractices, hospitals, or durable medical equipmentsuppliers. Additional information on Type 1 andType 2 NPI is available athttps://nppes.cms.hhs.gov/.A provider who does not have an NPI will not beable toSubmit claims for paymentReceive payments from a health planAccess information from a health planYou can apply for an NPI online athttps://nppes.cms.hhs.gov.Interim Billing Process for Institutional ServicesInterim billing is to be used when a patient isconfined in a facility for an extended period of time.Interim billings should be submitted on a monthlybasis.Interim UB (facility) claims are identified by the BillType Frequency and the Patient Status code (30).The appropriate Bill Type Frequencies are asfollows:XX2: Indicates the beginning of the stay.XX3: Indicates the middle of the stay.XX4: Indicates the final bill.Presbyterian encourages the submission of thesemonthly billings within 45 days of the beginning ofthe period for which you are billing.Submitting Late Charges and Replacement Claimsfor Institutional ServicesIn accordance with the CMS, facilities must bill latecharges, corrections, or a replacement claim withthe appropriate bill type and frequency.The appropriate Bill Type Frequencies are asfollows:XX5: Outpatient hospital late charges.XX7: Outpatient hospital replacement charges.XX7: Inpatient hospital late or replacementcharges.Ambulatory Surgical Centers must submit latecharges or replacement charges on a CMS 1500(02-12) form.For outpatient hospital late charges (XX5), submitthe late charges only. Do not include the originalcharges. If the original charges are billed with thelate charges:Clearly indicate that the claim contains late chargesDo not combine late charges with the originalchargesSeparate the late charges so that the charges areeasily identified to avoid a duplicate payment18-42014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentSpecify the original date of serviceSubmit late charges within 12 months of the date ofserviceSubmitting Corrections on a CMS 1500 (02-12)formSubmit all corrections for a CMS 1500 (02-12) formon paper. Clearly indicate that the resubmission isa corrected claim.Submitting Unlisted/Unclassified CodesAn unlisted/unclassified Current ProceduralTerminology (CPT) or Healthcare CommonProcedural Coding System (HCPCS) code may bebilled if no other appropriate code exists or a codehas not been assigned. If a code exists for aservice or procedure you are performing, you mustuse the correct code and not theunlisted/unclassified procedure code. This includesboth CPT and HCPCS Level II (alpha numeric)codes.Unlisted/unclassified CPT/HCPCS codes can beaccepted in the electronic 837 claim format. Whensubmitting an unlisted/unclassified codeelectronically, information may be entered as aservice note or claim level note.When submitting an unlisted/unclassified code on apaper claim, include the description on the claim oras an attachment.If the description is incomplete, Presbyterian mayrequire written documentation with the report andthe invoice for review and pricing.If the description of the unlisted/unclassified code isnot submitted, the service will be denied.Guidelines for Submitting Hemoglobin A1cClaims and Test ResultsPresbyterian requires the reporting of the actualresult of hemoglobin A1c tests (CPT code 83036)so that there is an accurate assessment of thedegree of control of the Presbyterian diabeticmember’s blood glucose. This helps Presbyteriandevelop or maintain diabetes-related qualityimprovement programs.When submitting charges for the A1c test, pleasefollow these guidelines:Report the test result as a three-digit number withno decimal point and a leading zero. For example,a test result of 5.8 is entered as 058.Presbyterian edits for valid values between 3.0 and20.0 (030 and 200). If the result is not within thisrange, the test is invalid.For UB-04 claims, the test date is the service date(field location 45, Service Date). If a service date isnot entered, the test date is the from date (fieldlocation 6, Statement Covers Period).Requirement for 837 ProfessionalThe following information outlines where the A1ctest results need to be reported in the 837professional and institutional electronic claimtransactions. Provide this information to yoursoftware vendors in order to properly configure yourelectronic claims submission software.This information pertains to claims submitted byproviders to the clearinghouse in the 837professional formats.Place the A1C data in the NTE02 segment of the2400 loop with the code qualifier of ADD18-52014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentThe data format is• A1C nnn ccyymmdd – nnn is the testresult and ccyymmdd is the date of thetest• Example: A1C 055 20041028Requirement for 837 Institutional, ExcludingAvaility ®This information pertains to claims submitted byproviders to the clearinghouse in the 837institutional format, excluding Availity ® .• A1C nnn ccyymmdd – nnn is the testresult and ccyymmdd is the date of thetest• Examples:• A1C 055• 20041028 A1C 042• 20041029For Paper ClaimsFor CMS 1500 (02-12) ClaimsPlace the A1C data in the PWK07 segment of the2300 loop with the code qualifier of OZ and PWK02of AAOne test result per PWK segment, which can occurup to 10 timesThe data format is• A1C nnn ccyymmdd – nnn is the testresult and ccyymmdd is the date of thetestFor UB-04 Paper Claims• Example: A1C 055 20041028Requirement for 837 Institutional for Availity ®This information pertains to claims submitted byproviders to Availity ® in the 837 institutionalformats.Place the A1C data in the PWK07 segment of the2300 loop with the code qualifier of OZ and PWK02of AAUp to four test results per PWK segment, which canoccur onceThe data format isUnderstanding the National Drug CodeThe National Drug Code (NDC) is found on thelabel of a prescription drug item and certainsupplies. It must be included on paper andelectronic claim transactions. The NDC is auniversal number that identifies a drug or relateditem. A complete NDC number consists of 11 digitswith hyphens separating the number into threesegments in a 5-4-2 format such as “12345-1234-12.”However, sometimes the NDC as printed on a drugitem omits a leading zero in one of the segments,18-62014 Practitioner and Provider Manual - Ver. 3

Claims and Paymentrequiring a leading zero to be entered on the claimform and the hyphens not to be used. Instead of thedigits and hyphens being in a 5-4-2 format, theNDC may be indicated in a 4-4-1 as in “1234-1234-1,” or in a 5-3-2 format as in “12345-123-12,” orless commonly in a 5-4-1 format as in “12345-1234-1.” A leading zero must be added to make the 5-4-2format. See the following examples:NDC 12345-1234-12 is complete; it is reported as12345123412NDC 1234-1234-12 needs a leading zero in the firstsegment to be in the 5-4-2 digit format; to become01234-1234-12 it is reported as 01234123412NDC 12345-234-12 needs a leading zero in thesecond segment to be in the 5-4-2 digit format; tobecome 12345-0234-12 it is reported as12345023412NDC 12345-1234-1 needs a leading zero in thethird segment to be in the 5-4-2 digit format; tobecome 12345-1234-01 it is reported as12344512301Presbyterian rejects claims with a date of serviceon or after January 1, 2011, that do not indicate avalid NDC for the following HCPCS or CPT codes:Codes in the range J0120–J9999 (variousinjections and chemotherapy)Codes in the range S0012-S0197 and S4990–S5014 (various items)Codes in the range S5550–S5571 (insulininjections)Codes in the range 90281–90399 (immuneglobulins)The same requirement applies to providers’ billingrevenue codes for facility claims. HCPCS or CPTcodes are required whenever the provider bills oneof the following revenue codes and the claim is anoutpatient hospital, emergency room facility,dialysis facility, or other outpatient facility thatsubmits a facility claim. When the reported HCPCSor CPT code is one of the above, the NDC codemust also be reported forPharmacy revenue codes 0250, 0251, 0252, and0254Pharmacy revenue codes 0631, 0632, 0633, 0634,0635, and 0636For complete instructions on where the NDCinformation is to be supplied for a CMS-1500, aUB04, or 837 transactions, please use the followinglink:http://www.hsd.state.nm.us/mad/registers/2010.html. This information is found under the header“Supplements” and it is Supplement Number 10-03.Additionally, you may view the NDC ProcedureManual by accessing the following link:http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00079542.pdf.Obstetrical ServicesThe following is information regarding globalmaternity billing (by covered providers such asprimary care obstetricians and specialists).If the delivery of the newborn is greater than threemonths past the mother’s eligibility date,Presbyterian pays the global feeIf the delivery is within three months of the mother’seligibility, a breakdown of services (prenatal visits,18-72014 Practitioner and Provider Manual - Ver. 3

Claims and Paymentdelivery, and postpartum visits) from the first day ofeligibility is needed from the providerThe following procedure must be followed whensubmitting fragmented, non-global obstetrics (OB)delivery claims to Presbyterian:Use generic Evaluation and Management or OBvisit codes to report prenatal visitsThe beginning date of service is equal to the initialprenatal visitThe number of units equals the total number ofprenatal visitsThe appropriate charge should be entered into thecharge columnPregnancy Termination for Centennial CareMembersCoverage for pregnancy termination includespsychological counseling. Voluntary, informedconsent by an adult or emancipated minor recipientmust be given to the provider before the procedureto terminate pregnancy, exceptIn a medical emergencyIf the recipient is unconscious, incapacitated, orotherwise incapable of giving consentIf pregnancy results from rape or incest or thecontinuation of the pregnancy endangers the life ofthe recipientInformed written consent for a minor who is notemancipated to terminate a pregnancy must beobtained, dated, and signed by a parent, legalguardian, or other acting “in loco parentis” to theminor. An exception is when the minor objects toparental involvement for personal reasons or theparent, guardian, or adult acting “in loco parentis” isnot available. The treating physicians shall note theminor’s objections or the unavailability of the parentin the minor’s chart and meet other regulatoryrequirements as specified at 8 New MexicoAdministrative Code 8.325.7.15.Federally Funded TerminationsFederally funded terminations of pregnancy (thosethat are represented by CPT codes 59840, 59841,59850, 59851, 59852, 59855, 59856, and 59857)are limited to those situations whereThe procedure is necessary to terminate an ectopicpregnancyThe procedure is necessary because thepregnancy aggravates a pre-existing condition,makes treatment of a condition impossible,interferes with or hampers a diagnosis, or has aprofound negative impact upon the physical ormental health of an individualThe procedure is necessary because of rape,incest, or threat to the life of the mother (modifierG7 is required)Physician Certification of Medical Necessity forPregnancy TerminationThe New Mexico Human Services Department(HSD) and Healthcare Services Directory currentlyrequires that Presbyterian receive a hard copy of aphysician certification form before the claim isprocessed, including coordination of benefits (COB)claims where Centennial Care is the secondarypayer. (See the Physician Certification of MedicalNecessity for Pregnancy Termination form.) Thephysician certification may be attached to the claimor faxed to Health Services.18-82014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentPlease note that payment of claims for terminationsof pregnancy under these codes is conditionedupon receipt of a physician’s certification of medicalnecessity.Providers may fax the certification on the date ofservice or submit this certification any time beforesubmitting the claim in one of the following ways:Fax: 505-923-5489Mail: Presbyterian Health ServicesP.O. Box 27489Albuquerque, NM 87125-4789Attention: Medical RecordsState-Funded TerminationsFederally funded terminations of pregnancy (thosethat are represented by CPT codes 59840, 59841,59850, 59851, 59852, 59855, 59856, and 59857)are limited to those situations where:The procedure is necessary to terminate an ectopicpregnancyinterferes with or hampers a diagnosis, or has aprofound negative impact upon the physical ormental health of an individualThe procedure is necessary because of rape,incest, or threat to the life of the mother (modifierG7 is required)Sterilization Consent Forms for Centennial CareMembersIf the provider is performing a sterilizationprocedure, for payment of Medicaid claims aSterilization Consent Form must be completed inaccordance with 42 Code of Federal Regulations441.251. The consent is valid for 30 days from thedate of signature, unless withdrawn by the recipientbefore the procedure. Federal governmentregulators monitor the proper and timely completionof the consent form. Presbyterian Centennial Careis required to ensure proper adherence to therequirements.The procedure is necessary because thepregnancy aggravates a pre-existing condition,makes treatment of a condition impossible,18-92014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentPhysician Certification of Medical Necessity for Pregnancy TerminationPatient Name:Medicaid or Presbyterian Centennial Care Identification Number:After reviewing the patient chart and consulting with the patient, as the treating physician, I certify that, in my best medicaljudgment, pregnancy termination is medically necessary for this patient for the following reason(s):To save the life of the motherThe pregnancy is a result of rape or incestTo terminate an ectopic pregnancyThe pregnancy aggravates a pre-existing conditionThe pregnancy makes treatment of a condition impossibleThe pregnancy interferes with or hampers a diagnosisThe pregnancy has a profound negative impact upon the physical or mental health of an individualPractitioner’s Name:Practitioner’s Signature: _________________________Date:Submitting Hospice Care Services for MedicareAdvantage MembersPresbyterian asks that you file claims for MedicareAdvantage (Presbyterian Senior Care(HMO)/Presbyterian MediCare PPO) members whohave elected hospice coverage to OriginalMedicare, using guidelines published in theMedicare Managed Care Manual by CMS, thefederal agency charged with oversight of theMedicare program.Claims for services covered under OriginalMedicare related to hospice (the member’s terminalcondition) should be filed with the local Medicareintermediary (for Medicare Part A benefits) andcarrier (for Medicare Part B benefits). Please do notfile these claims with Presbyterian, as they will bedenied.Claims for services covered under OriginalMedicare but NOT related to the terminal illnessshould also be filed with the local intermediary andcarrier. Please do not file these claims withPresbyterian, as they will be denied.Once you have received your remittance advicefrom Original Medicare, submit the claim for nonhospicerelated services with the remittance adviceto Presbyterian.18-102014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentPresbyterian is responsible for paying thepractitioner or provider any difference betweenwhat the member’s cost sharing is as a MedicareAdvantage member and the cost sharing underFee-for-Service (FFS) Medicare for non-hospicerelated services. The member’s cost sharing isbased on their Medicare Advantage plan/coverage.Claims for services covered by Presbyterian’sMedicare Advantage Plans, above and beyondthose of Original Medicare, should be filed toMedicare Advantage for processing. Examples ofthese services include routine (not medicallynecessary) eye and vision exams, routine podiatry,and outpatient prescription drug coverage notalready covered under Original Medicare.Medicare Part D Description Drug CoverageMedicare Part D Prescription Drug Coverage isavailable to individual Medicare-eligiblebeneficiaries in two of the three Presbyterian SeniorCare (HMO) plans and two of the three plansoffered by Presbyterian MediCare PPO. Some ofthe Employer Group plans also have Medicare PartD coverage already built in.Please verify the member’s identification card at thetime of service. If the member’s coverage and planincludes prescription drug coverage, it will be notedon the member’s ID card, identified by specific planand benefit coverage as noted above.Filing Claims with Coordination of Benefits(COB)Presbyterian coordinates benefits in accordancewith CMS regulations and National Association ofInsurance Commissioners guidelines.When the member’s primary carrier is notPresbyterian, the primary carrier’s Explanation ofBenefits (EOB) or Explanation of Payment (EOP)must be provided when submitting the claim toPresbyterian for consideration.Presbyterian requires all COB claims be submittedwithin 90 days from the paid date on the primarycarrier’s EOB or EOP.Once you have billed the other carrier and receivedan EOB/EOP, submit the claim and matchingEOB/EOP to Presbyterian. When submitting theclaim electronically, the EOB/EOP may also bebilled electronically in an 837 compliant transaction.When submitting a paper claim, submit thematching EOB/EOP with the claim.The EOB/EOP must be complete in order tounderstand the paid amount or the denial reasonand must match the billed services for the member.Claims submitted without an EOB/EOP will bedenied.Presbyterian providers may bill the member forapplicable co-pays, co-insurance, and deductibles.Adjustment Requests Involving COBReview all explanation codes on your EOP todetermine if the denial was because of insufficientinformation or if the claim was submittedincorrectly. Corrected claims submitted mustinclude all charges to be considered with thecorrections clearly indicated, and must meet timelysubmission guidelines. A copy of the EOP shouldbe included along with your corrected claim.18-112014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentCentennial Care COBPresbyterian Centennial Care is, by law, the payerof last resort for Presbyterian Centennial Caremembers. Therefore, if a Presbyterian CentennialCare member is eligible for benefits under anotherinsurance plan, you must file a claim and obtain anEOB/EOP from the other insurance plan, asrequired by your contract. Coverage requirementsof the other insurance plan must be satisfied.In coordinating benefits between the primaryinsurance carrier and Presbyterian CentennialCare, Presbyterian Centennial Care still acts in thesame capacity that the HSD Medical AssistanceDivision has in the past as the payer of last resort.Presbyterian Centennial Care’s normal priorauthorization guidelines and plan requirementsapply when Presbyterian is acting as the primarycarrier if the other carrier denied the services.Presbyterian Centennial Care does not makepayment for services denied by another carrierwhen the provider or member did not follow therequirements of the primary plan.Presbyterian Centennial Care does not require aprior authorization or referral in the followingcircumstances:When the member’s primary insurance does notinclude a benefit that is covered by PresbyterianCentennial CareWhen the member’s primary insurance hasreached annual plan maximums, or maximums onspecific benefits that are covered by PresbyterianCentennial CareCentennial Care Third-Party LiabilityPresbyterian Centennial Care is responsible foridentification of third-party coverage of membersand coordination of benefits with applicable thirdparties.Presbyterian Centennial Care is required to informHSD within 20 calendar days of receivinginformation regarding any member who has otherhealth coverage and must provide documentationwithin 20 calendar days to the HSD Third PartyLiability Unit, enabling HSD to pursue its right underfederal and state law, regulations, and rules.Presbyterian Centennial Care has the sole right ofcollection to recover from a third-party resource orfrom a provider who has been overpaid because ofa third-party resource for 12 months from the datePresbyterian Centennial Care first pays the claim toinitiate recovery and attempt to recover any thirdpartyresources available to Medicaid members, forall services provided by Presbyterian CentennialCare.Without mitigating any rights the PresbyterianCentennial Care provider has pursuant to federaland state law and regulations, HSD has the soleright ofCollection from a third-party resource whichPresbyterian Centennial Care has failed to identifywithin 12 months from the date PresbyterianCentennial Care first pays the claim.Recovery from Presbyterian Centennial Care or aPresbyterian Centennial Care provider who hasbeen overpaid because of the combined paymentsof Presbyterian Centennial Care and a third-partyresource when Presbyterian Centennial Care has18-122014 Practitioner and Provider Manual - Ver. 3

Claims and Paymentnot made a recovery within 12 months from thedate Presbyterian Centennial Care first pays theclaim.Recovery from a third-party resource, PresbyterianCentennial Care, or a Presbyterian Centennial Careprovider if Presbyterian Centennial Care hasidentified a third-party resource but failed to initiaterecovery within the 12-month periodRecovery from a third-party resource, PresbyterianCentennial Care, or a Presbyterian Centennial Careprovider if Presbyterian Centennial Care hasaccepted the denial of payment or recovery from athird-party resource or when the contractor fails tocomplete the recovery within 15 months from thedate Presbyterian Centennial Care first pays theclaim. HSD may permit payments to be made inaccordance with state regulations.The exception to this 12-month period is for casesin which a capitation has been recouped fromPresbyterian Centennial Care pursuant to Article6.2.4, whereupon Presbyterian Centennial Careshall retain the sole right of recovery for all paidclaims related to members and months that wererecouped.Requesting an AdjustmentIf you believe a claim was processed incorrectly,contact our Provider CARE Unit for an explanation.They will determine if an adjustment is necessaryand request an adjustment on the claim. You maybe advised to resubmit the claim with additionalinformation. Adjustment requests must be madewith a timely manner as defined in the Timely FilingSubmission Guidelines section within thisdocument.Recovery of Claim OverpaymentsPresbyterian accepts all voluntary refunds andpursues the recovery of all claim overpayments thatare identified by the providers. Presbyterianpursues the recovery of claim overpayments whenidentified by Presbyterian or another entity otherthan the provider if the overpayment is identifiedand the provider is notified within the time framesas outlined below.The time frame for recovery is based on thenotification to the provider or their representative byEOP or other communication type (for example,letter, fax, or phone call).Exceptions to these guidelines may occur becauseof government regulations or cases of suspectedfraud and abuse activities. Claim overpayments arerecovered through the EOP process wheneverpossible. This appears as a payment reduction ornegative claim payment on your EOP.The acceptable time frames for recovery ofoverpayments are as follows:Centennial Care: One year from the date ofpayment.Exception: When COB is involved, there is no timeframe for recovery of any overpayments ifPresbyterian has documented verification that theprovider has received payment from the otherinsurance carrier.Exception: For Indian Health Services (IHS)providers, in network and out of network, a twoyearfiling limit applies.Commercial and Administrative Service Only(ASO): One year from the date of payment.18-132014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentException: When COB is involved, there is no timeframe for recovery of any overpayments ifPHP/Presbyterian Insurance Company, Inc., hasdocumented verification that the provider receivedpayment from the other insurance carrier.Medicare Advantage (Presbyterian Senior Care(HMO) and MediCare PPO): Three years from thedate of payment.The acceptable time frames for recovery ofmember retro-terminations are as follows:Centennial Care: One year from the date ofpayment.Exception: When COB is involved, there is no timeframe for recovery of any overpayments.Commercial and ASO: One year from the date ofpayment.Medicare Advantage (Presbyterian Senior Care(HMO) and MediCare PPO): Three years from thedate of payment.The acceptable time frames for recovery ofconfirmed fraud and abuse activity are asfollows:Centennial Care: Four years from the date ofpayment.Commercial and ASO: Six years from the date ofpayment.Medicare Advantage (Presbyterian Senior Care(HMO) and MediCare PPO): No time limit.Timely Submission GuidelinesGuidelines for Original Claim SubmissionsPresbyterian requires that all claims be receivedwithin three months of the date of service. Failureto adhere to the timely submission guidelinesresults in the denial of your claims.If a claim has been submitted to the wrong carrier,submit the claim and denial letter or EOP from theother carrier to Presbyterian within three months ofthe date of the denial letter or EOB/EOP from theother insurance carrier.When billing claims for inpatient facility charges, thethree-month filing limit begins from the date ofdischarge.The provider is responsible for submitting the claimtimely, for tracking the status of the claim, and fordetermining the need to resubmit the claim.Guidelines for Claim Resubmissions, CorrectedClaims, and Adjustment Requests for AdditionalPaymentPresbyterian requires that all claim resubmissions,corrections, and adjustment requests for additionalpayment must be submitted within 12 months of thedate of service. If a resubmission, corrected claim,or adjustment request for additional payment is notreceived within this time frame, the original decisionis upheld. For adjustment requests related to COB,please refer to the Filing Claims with theCoordination of Benefits section of this chapter fortime frames.If your claim is not in the system, please resubmit it.Maintain a record of your resubmission and anycontacts with Presbyterian.If the resubmission is past the three-month filinglimit, include the original filing documentation withyour resubmission.18-142014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentAcceptable documentation includes computerledgers, written logs, and records of calls toPresbyterian (include date and contact name). Theexception report from Presbyterian or the ECTclearinghouse is required for ECT claims.Documentation that is not acceptable includes aregenerated claim.Submitted documentation must be legible andclearly identify the member, the charges inquestion, date of service, and original billed date.Proof of timely filing may be rejected if thesubmitted documentation cannot be clearly linkedto the claim in question. Any proof of timely filingmust be submitted within 12 months of the date ofservice. We encourage you to follow up on thestatus of your requests every 30 to 45 days. If youcontinue to receive no payment or documentationon your claim, contact the Provider CARE Unit.If a member fails to notify the provider that he orshe is covered through Presbyterian at the time ofservice, documentation that attempts were made todetermine the member’s coverage is required.Acceptable documentation includes:A copy of the patient information sheet thatindicates that insurance information was notprovidedWritten communication from the member verifyingthat he or she failed to notify the provider ofcoverage at the time of serviceA change in the provider’s office billing personnel isnot a valid reason to resubmit claims. You areencouraged to contact members regarding pastduepayments if the members do not respond tobilling statements. This helps determine if themember is covered by Presbyterian.“Clean” ClaimsPresbyterian has adopted CMS claims processingguidelines to ensure timely and accurate claimspayment by Presbyterian on behalf of members.The timeliness for processing a claim can be drivenby whether or not the claim is “clean.” Accuracyand completeness of the information provideddetermine if the claim is considered “clean” or“unclean.”A claim is defined as “clean” if it contains all of therequired data elements necessary for accurateadjudication without the need for additionalinformation from a source outside of Presbyterian,and if it has no defect or impropriety, including butnot limited toThe failure of an electronically transmitted claim tomeet HIPAA transaction standards with regard toformat or contentThe lack of required substantiation or particularcircumstances requiring special treatment thatprevents timely payment being made on the claimA claim may be “clean” even though Presbyterianrefers it to a medical specialist within Presbyterianfor examination.“Unclean” ClaimsA claim is defined as “unclean” if additionalsubstantiating documentation (such as medicalrecords, encounter data, emergency room reports,primary insurance explanation of payments, and fullitemization where necessary) is required from asource external to Presbyterian Centennial Care.18-152014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentEncounter ReportingPresbyterian is required by HSD to report allservices rendered to Presbyterian Centennial Caremembers. The reporting of these services, alsoknown as encounter data reporting, is an essentialelement to the success of Presbyterian CentennialCare.HSD uses encounter data reporting to evaluatehealth plan compliance on many vital issues.Regardless of whether the service you provide iscapitated or fee-for-service, claims should besubmitted to Presbyterian within 90 days of thedate of service to accommodate the State of NewMexico’s request for timely encounter data.Presbyterian is required to submit encounter datato the State of New Mexico within 120 days.Providers are required to submit to Presbyteriancomplete encounter data in a form acceptable toand meeting Presbyterian’s standards. Encountersmust be submitted within 90 calendar days of thedate of service for outpatient services or the date ofdischarge for inpatient services in an approvedformat. Presbyterian accepts encounters submittedon CMS 1500 (02-12) and UB claim forms or anequivalent or substitute approved by Presbyterian.Providers identify services rendered to members byusing appropriate diagnosis and procedure codesas defined by the CPT and/or ICD-9-CM orsubsequent editions. In accordance with Section2702 of the Patient Protection and Affordable CareAct (PPACA), Presbyterian has mechanisms inplace to preclude payment to providers for providerpreventableconditions. Providers report providerpreventableconditions through the claimssubmission process. Presbyterian tracks providerpreventableconditions data and reports data toHSD through encounter data.Correct Coding StandardsPresbyterian uses a Correct Coding Standards(CCS) claim editing system to ensure consistentprocessing of professional and facility claims and todecrease manual intervention. This interfaceapplies pattern recognition and intelligent reasoningto identify potential incorrect payments beforeclaims are paid.Presbyterian applies the National Correct CodingInitiative (NCCI) policy manual, McKesson edits,and other edits based on coding industry standardsfor consistency in the processing of certain codepairs. CMS standards require that providers mustcode correctly even if CCS edits do not exist. Thispromotes consistency of claims submission andreimbursement and prevents the use ofinappropriate code combinations.There are times when Presbyterian reviews certainedits and determines that they may not beappropriate to our current purpose:–to improve thehealth of the patients, members, and communitieswe serve. Most of these reviews are the result ofappeals that are received by the Appeals andGrievances Department at Presbyterian.Presbyterian reviews these edits to determine ifthey are clinically appropriate for situations thatmay arise when providing care to our members.If it is determined that a certain edit does notsupport our purpose, Presbyterian either removesthe edit or revises it. Presbyterian is supportive of18-162014 Practitioner and Provider Manual - Ver. 3

Claims and Paymentallowing providers to provide services that areclinically sound and defensible.National Correct Coding InitiativeCMS developed the NCCI to promote nationalcorrect coding methodologies and to eliminateimproper coding. NCCI edits are developed by theNational Correct Coding Council and are based oncoding conventions defined in the AMA CPTManual’s national and local policies and edits,coding guidelines developed by national societies,analyses of standard medical and surgical practice,and reviews of current coding practice.The NCCI is administered through CMS. CMSannually updates its coding policy manual, theNational Correct Coding Initiative Policy Manual forMedicare Services. Presbyterian encourages you toobtain further information regarding this manualand subsequent updates, and to check the CMSwebsite for recent NCCI edits athttp://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd.The NCCI edits and policies do not include allpossible combinations of correct coding edits or alltypes of unbundling that exist.Interest PaymentInterest applies to clean claims only. Interest will bepaid at the current rate, for the period beginning onthe day after the claim-received date and ending onthe date on which payments are made.Administrative Services Only (ASO): Interest doesnot apply to ASO products.Commercial and Medicare Advantage: Interest ispaid on clean claims not paid within 30 calendardays if submitted electronically, or 45 calendar daysif submitted manually (by mail or in person).Interest is paid at the applicable rate as definedunder the New Mexico Insurance Code, or asrequired by applicable state or federal law orregulation.Centennial Care:Interest payments for Centennial Care will begin onthe 31st day from the claim-received date forelectronically submitted claims, and on the 46th dayfrom the claim-received date for manuallysubmitted claims, in accordance with HSDGuidance Memorandum #108, dated May 5, 2003.Interest payments will begin on the 15th day for thefollowing provider types:• IHS providers• Tribal Health providers• Urban Indian providers• Day Activity providers• Assisted Living providers• Nursing Facilities• Home Care Agencies includingCommunity Benefit providersPresbyterian Centennial Care must pay 95 percentof clean claims received from Indian HealthService/Tribal health providers/urban Indianproviders, day activity providers, assisted livingproviders, nursing facilities, and home careagencies including community benefit providerswithin 15 calendar days of receipt. Interest is paid18-172014 Practitioner and Provider Manual - Ver. 3

Claims and Paymentat a rate of 2 percent for each month or portion ofany month on a prorated basis.Claims and Payment ResourcesmyPRESmyPRES is available 24 hours a day, seven days aweek and enables you and your office staff toobtain the following information electronically:If applicable, at-a-glance co-insurance, deductibleand out-of-pocket amounts (the member’sresponsibility and the amounts that have been metto date that are in our system at the time of inquiry)Other insurance information regarding the memberDetailed demographic information on the member’sprimary care providerInformation for finding a doctor, provider, or facilityCheck summaries (listing of EOPs that weremailed, with access to all claims associated withthat remittance including the address of where thecheck was mailed)Provider CARE UnitThe Provider CARE Unit was established to handlecomplex inquiries from providers, including webbasedinquiries, written inquiries, adjustmentrequests and telephone calls that were not resolvedthrough myPRES, Interactive Voice Response,http://www.phs.org, or one of our electronicsubmission vendors. The Provider CARE Unitaccesses myPRES when assisting you with yourinquiries. Please contact 505-923-5757 or 1-888-923-5757 for assistance.Mailing Address for Claims, Corrected Claims, andClaims ResubmissionsIn an ongoing effort to increase the timeliness ofprovider payment and maximum efficiency andresources in provider offices, Presbyterian stronglyencourages the use of electronic claimssubmissions. In the event that it becomesnecessary to submit a paper claim (new, resubmission,or corrected), please direct it to one ofthe following mailing addresses:Medical/Physical Health ClaimsPresbyterian Health PlanP.O. Box 27489Albuquerque, NM 87125-7489Behavioral Health ClaimsPresbyterian Health PlanP.O. Box 25926Albuquerque, NM 87125-25926Other Contact InformationCoding Information and ResourcesAmerican Medical Association (AMA) CPTProducts515 North State StreetChicago, IL 606541-800-621-8335https://commerce.amaassn.org/store/catalog/categoryDetail.jsp?category_id=cat1150004&navAction=jumpCenters for Medicare and Medicaid Services(CMS)http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index.htmlProvider Updateshttp://www.cms.gov/Center/Provider-Type/All-Fee-For-Service-Providers-Center.html?redirect=/center/provider.asphttp://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html18-182014 Practitioner and Provider Manual - Ver. 3

Claims and PaymentNational Correct Coding Initiative (NCCI) Editshttp://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.htmlCMS Carriers Manual and Hospital Manualhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.htmlNovitas Solutions, Inc.https://www.novitas-solutions.com/Palmetto GBA for HCPCS information and theDMERC Manualhttp://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/97NK5W3580?openProvider Compliance Group Interactive Maphttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/providercompliance-interactive-map/index.html(Click thestate of New Mexico on the map.)National Center for Health Statisticshttp://www.cdc.gov/nchs/Classifications of Diseaseshttp://www.cdc.gov/nchs/icd.htmMcKessonhttp://www.mckesson.com18-192014 Practitioner and Provider Manual - Ver. 3

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Claims and Payment19. Presbyterian CustomerService Center19. Presbyterian CustomerService CenterIt is the Presbyterian Customer Service Center’s(PCSC’s) objective to deliver a consistent customerexperience and to provide outstanding service toevery customer, every contact, every time.Presbyterian Customer Service CenterHours of Operation for MembersPresbyterian Commercial, ASO, IBACand PICPresbyterian Medicare AdvantageCentennial Care7 a.m. to 6 p.m. Mondaythrough Friday8 a.m. to 8 p.m. Mondaythrough Sunday24x7x365 includingholidaysMember Contacts for Customer ServiceMembers can contact Customer Serviceelectronically by visiting the “Contact Us” page athttps://www.phs.org/about-us/contact-us/. Memberscan also email Customer Service at info@phs.org.Members are advised to call the number listed onthe back of their ID cards.Providers should call the Provider Claims ActivityReview and Evaluation (CARE) Unit at 505-923-5757 or 1-888-923-5757 for assistance.Member Communication and Welcome PacketsUpon enrollment, new enrollees receive a welcomepacket, including group subscriber agreements,member handbooks, summary of benefits, orevidence of coverage as appropriate. New andexisting members may access and print thisinformation from our website at http://www.phs.orgor they may contact the PCSC to request a printedcopy.Providers may obtain a copy of a memberhandbook, group subscriber agreement, summaryof benefits, or evidence of coverage by contactingyour provider network management relationshipexecutive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf).Identification CardsAfter enrollment with Presbyterian, each member isissued an identification card showing the member’sname, ID number, the selected primary careprovider’s (PCP’s) name and phone number (ifapplicable), and basic benefit information. Membersenrolled in non-Health Maintenance Organization(HMO) plans do not need to select a PCP;therefore a PCP will not be indicated on their IDcard. Members should not be denied service if aPCP is not listed on their card.The member’s ID card should be presented to theprovider’s office each time the member presents forservice; however, services should not be denied ifno card is presented. The ID card does notguarantee that the member is still eligible.Providers should use myPRES or the PCSC toverify eligibility. However, use of these servicesdoes not guarantee payment.19-12014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service CenterProviders are also encouraged to take theprecaution of verifying the identity of the personpresenting the ID card against another form ofidentification, such as a driver’s license or otherphoto identification. This type of verification not onlydeters fraudulent use, but also protects the providerfrom performing a service for which payment maybe denied. The Federal Trade Commission recentlyissued its final ruling regarding identity theft redflags and addressing discrepancies under the Fairand Accurate Credit Transactions Act of 2003.These regulations require applicable businesses toincorporate processes and procedures incompliance with the final ruling. You areencouraged to determine if your business is subjectto these regulations and implement processes toprotect patient identity theft as applicable.To report suspicion of fraud and abuse, pleaserefer to the Fraud, Waste, and Abuse chapter.Choosing a Primary Care ProviderA member of the Presbyterian HMO plan or amember of Presbyterian must select a PCP tomanage his or her health care needs. The PCP willbe able to meet most of these needs. A member ofthe Presbyterian HMO plan may choose anyparticipating PCP with an open panel.If a member does not designate a PCP on his orher enrollment form, PHP may attempt to place anoutbound call to the member to provide assistancewith the selection. If a member does not select aPCP within 15 calendar days of enrollment,Presbyterian automatically selects a PCP for themember. The selection is based on factors such asthe member’s residence and physical ZIP code, themember’s age, and, if known, current providerrelationships. The choice of a PCP may includethose practicing in a variety of areas, such as familypractice, general practice, internal medicine, andpediatrics.Specialist Assigned as a Primary Care ProviderOn an individual basis, Presbyterian may allow aspecialist currently treating a member withdisabilities or chronic or complex conditions toserve in the capacity of a PCP. The networkspecialist must agree to perform all PCP duties andsuch duties must be within the scope of theparticipating specialist’s certification and inaccordance with the program requirements andrelated medical policies.When a member requests that a specialist serve asthe member’s PCP, the PCSC assists the memberby providing them with the Specialist as a PCPform. This form is completed by the member, whoreturns the form to Presbyterian. Upon receipt ofthe completed form, it is reviewed by the HealthServices Department for approval.Primary Care Provider ChangesMembers may request to change their PCP at anytime, for any reason, throughout the month. PCPchanges become effective the following businessday of the receipt of the request or at the daterequested by the member, provided the date is notretroactive.Presbyterian Centennial Care members mayrequest a PCP change at any time, for any reason;19-22014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service Centerhowever, the effective date varies depending onwhen the request was made.If the request was made by the 20th of the month, itbecomes effective on the 1st of the followingmonth. If the request was made after the 20th ofthe month, the change becomes effective the 1st ofthe month after the following month.Removing Members from Your PanelIf a PCP determines it is in the best interest of thepatient and the provider for the member to beremoved from his or her panel because of themember’s non-compliant or disruptive behavior inthe office, the PCP can request the member’sremoval in accordance with our policies andprocedures. The PCP must send the member aletter advising them of the decision to end thepatient/provider relationship.Upon contact by the provider or the member, thePCSC can help reassign the member to a newPCP. The current PCP is responsible for providingcare according to the transition of care policy untilthe member can be reassigned.Centennial Care Member Eligibility andEnrollmentEligibility for Presbyterian Centennial Care isdetermined by the New Mexico Human ServicesDepartment (HSD) Income Support Division.Presbyterian Centennial Care is assigned eligibleparticipants once a month. Presbyterian CentennialCare is notified before the 1st of the month that amember is enrolled. Presbyterian Centennial Careis responsible for managing the member’s care onthe first effective day of the member’s enrollmentuntil the member is disenrolled from PresbyterianCentennial Care or, if hospitalized in an acute caresetting while disenrolled, until discharge to a lowerlevel of care.If the member not yet enrolled with PresbyterianCentennial Care requires health care in the daysbefore the effective date of enrollment, the State ofNew Mexico or the member’s existing managedcare organization is the financially responsibleparty.Transportation Services for Centennial CaremembersPresbyterian covers medically necessarytransportation for Presbyterian Centennial Caremembers; however, limitations and exclusionsapply for certain services.Presbyterian Centennial Care or its contractorarranges transportation for appropriate services.PCSC’s transportation coordinator assists inarrangements and appropriate authorizations.Rides for routine scheduled office visits or medicalservices require 48 to 72 hours advance notice.Presbyterian Centennial Care covers emergencytransportation by ground ambulance, airambulance, or by a specially equipped van whenmedically appropriate. If members need emergencytransportation for a life-threatening situation, theyshould call 911 or the emergency telephonenumber in the area.Same-day transportation is available for urgenthealth care services or urgent referrals made by aPCP. To schedule a ride, contact Superior MedicalTransport directly at 1-877-735-0111 (toll free) or19-32014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service Center505-341-0042, or Customer Service at 505-923-5200 or 1-888-977-2333.Medicare Annual Notification of ChangeMeetingsEach year, before and during the Medicare AnnualEnrollment Period, members and their guests havethe opportunity to attend a Presbyterian MedicarePlans Annual Notification of Change meeting. Themeetings are designed to meet our members’needs by providing information about changes tothe Presbyterian Medicare Advantage plan benefitsand services for the upcoming year. This is also atime when we can address members’ personalquestions regarding the benefit plans. For ourmembers’ convenience, meetings are availablethroughout the Medicare plan service area.Members are encouraged to attend annually.Medicare Advantage Plans New MemberEducation, Verification, and Welcome CallsAn outreach to all new Presbyterian MedicareAdvantage plan members is conducted within 15calendar days of receipt of the member’s requestfor enrollment. The primary purpose of the call is towelcome the new member and to ensure that theyhave an understanding of the product type and planin which they are enrolling. Key plan elements arereviewed and members are provided an opportunityto ask questions about their new PresbyterianMedicare Advantage plans.Medicare Member Appreciation EventsEvery year, Presbyterian invites all PresbyterianMedicare Advantage plan members and theirguests to join us at a Member Appreciation Event.Presbyterian senior leadership takes thisopportunity to thank our members for theirmembership in Presbyterian’s Medicare Advantageplans and to answer members’ questions. Membersare also informed about the latest developments atPresbyterian.Additional Medicare Benefits: My Advocate byAltegra HealthMy Advocate by Altegra Health is a trusted partnerwhose sole service is providing expert coordinatedoutreach services to Presbyterian MedicareAdvantage plan members. My Advocate assistsmembers in learning about and taking advantage ofprograms that provide financial assistance toseniors and disabled individuals with limitedincome. Members appreciate the personal supportMy Advocated provides with enrolling andrecertifying members into the Medicare SavingsPrograms and the Medicare Part D “Extra Help”program, as well as other federal and state financialassistance programs or services.Through these efforts, My Advocate helps toimprove the quality of life for our members who aremost financially at risk. Participation is entirelyvoluntary and provided at no cost to our members.SilverSneakers ® Fitness ProgramPresbyterian Medicare Advantage plan membersare offered the SilverSneakers ® Fitness Program orSilverSneakers ® Steps benefit at no additional cost.With the SilverSneakers ® Fitness Program,members have access to basic fitness centermembership at no additional cost. This membershipincludes access to amenities such as treadmills,19-42014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service Centerweights, a heated pool, and fitness classes.Members can take signature SilverSneakers ®classes designed specifically for older adults andtaught by certified instructors. AdditionalSilverSneakers ® options may be available at selectfitness centers as members’ fitness levels progress.A designated, specifically trained ProgramAdvisor SM assists members along the way withenrollment and getting started. SilverSneakers ®members have access to more than 10,000participating fitness centers, including women-onlyCurves locations. Once members enroll inSilverSneakers ® , they can use any participatinglocation in the nation. The SilverSneakers ® FitnessProgram is available to all eligible members. To finda location you can visit www.silversneakers.com, orcall 1-888-423-4632SilverSneakers ® Steps is a personalized fitnessprogram that fits the lifestyle of members who donot have convenient access to a SilverSneakers ®location (location is 15 miles or more from themember’s home). This self-directed, pedometerbasedphysical activity and walking programprovides the equipment, tools, and motivation formembers to measure, track, and increase theiractivities and achieve a healthier lifestyle. Afterregistering as a Steps member throughwww.silversneakers.com, the member will receivetheir kit at their home address. Members can get fit,have fun, and make friends.Members’ Rights and ResponsibilitiesPresbyterian has written policies and proceduresregarding members’ rights and responsibilities andimplementation of such rights. As a member ofPresbyterian’s network we expect you to respect,support, and recognize these rights andresponsibilities.Members have the right toExercise their patient rights. Understand thatdoing this does not cause Presbyterian and itscontracted providers or HSD to treat them in anegative way.Be treated with respect and recognition oftheir dignity and right to privacy.Be told about the options open to them fortheir treatment. Be told about any otherchoices they can make about their treatment.They should get this information in a way thatis right for their condition. They should be toldin a way that they can understand.Decide on advance directives for their healthcare as allowed by law.Get care that is free from discrimination.Participate with their provider in all decisionsabout their health care, including theirtreatment plan and the right to refusetreatment; family members and/or legalguardians or decision-makers also have thisright, as appropriate.Get health care that is free from any form ofrestraint or seclusion that is used to pressureor punish them.Ask for and get a copy of their medicalrecords.19-52014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service CenterChoose a stand-in decision-maker to beinvolved as appropriate. This person is able tohelp with care decisions.Give informed consent for health careservices.File a grievance or appeal about Presbyterianor the care that they were given without fear ofretaliation (punishment).Choose a provider from the Presbyteriannetwork. A referral or authorization may beneeded to see some providers.Get information about Presbyterian . Thisincludes information about the services, howto access them, their rights andresponsibilities, and the providers available fortheir care.Be free from harassment by Presbyterian orits network providers about contractualdisputes between Presbyterian and itsproviders.Seek family planning services from anyprovider, including providers outside of thePresbyterian network.Self-refer to a women’s health specialist in thePresbyterian network if a female member.This applies to covered care needed forwomen’s routine and preventive health careservices. This is in addition to the care theirPCP provides if he or she is not a women’shealth specialist.Have private medical and financial records.This is in agreement with current law. Theseare the records kept by Presbyterian andPresbyterian’s provider network. Membershave the right to confidential records. Theirrecords are released only with their writtenconsent. Their legal guardian also may giveconsent. Their records may be released asotherwise allowed by law.See their medical and financial records. Thisis in agreement with any laws and regulationsthat apply.Ask that the use or disclosure of theirprotected health information (PHI) berestricted.Get confidential communications of their PHIfrom Presbyterian.Get and inspect a copy of their PHI as allowedby law.Ask for an amendment (addition to) their PHIif, for example, they feel the information isincomplete or wrong.Get an accounting of PHI disclosures.Ask for a paper copy of the official privacynotice from Presbyterian. This is their righteven if they have already agreed to receiveelectronic privacy notices.File a complaint if they believe Presbyterian isnot following the Health Insurance Portabilityand Accountability Act (HIPAA) Standards forPrivacy of Individually Identifiable HealthInformation.Make recommendations about thePresbyterian member rights and responsibilitypolicy.19-62014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service CenterGet any information in a different format incompliance with the Americans withDisabilities Act.Members have the responsibility to:Give their complete health information. Thishelps their provider give them the care theyneed. This includes providing childhoodimmunization (shot) records for members upto age 21.Follow their treatment plans and instructionsfor medications, diet, and exercise as agreedupon by the member and their provider.Keep their appointment. If they cannot keep it,they should call their provider to reschedule orcancel no later than 24 hours before theappointment.Tell the provider if they do not understand hisor her explanation about their care. Ask theprovider questions. Talk to the PCSC aboutany suggestions or problems they may have.Respect providers and other health careemployees. Treat them with courtesy.Act in a way that supports the care otherpatients get. Act in a way that supports thegeneral functioning of the facility.Refuse to let any other person use theirPresbyterian member ID card.Tell Presbyterian right away if they lose theirmember ID card, or if it is stolen.Know what could happen if they givePresbyterian information that is wrong orincomplete.Tell the New Mexico HSD and Presbyterian.when their phone number, address, or familystatus changes.Tell their providers that they havePresbyterian, at the time of service. They mayhave to pay for services if they do not tell theirprovider that they have Presbyteriancoverage.Protect the privacy of their own care and ofother patients’ care.Ask about any arrangements Presbyterian haswith its providers. This applies to monetarypolicies that might limit referrals or treatment.It also applies to policies that might limitmember services.Change their PCP according to the rulesdescribed in the Member Handbook.Note: Members’ rights and responsibilities arealso available on our website athttp://www.phs.org, or a member may call thePCSC to request a printed copy.ConfidentialityPresbyterian is committed to protecting members’PHI and safeguarding confidential medicalinformation through the implementation of thePresbyterian confidentiality policy. For a printedcopy of the policy, please contact your providernetwork management relationship executive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf).Upon enrollment and annually thereafter,Presbyterian provides each member with a JointNotice of Privacy Practices. This notice describes19-72014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service Centerthe privacy practices of PHP and PresbyterianInsurance Company. This notice helps membersunderstand how Presbyterian protects the privacyof their health information and also informsmembers of their health information rights.Member Health Information RightsThe rights described below are subject tolimitations and conditions.Legal Authority to Make Health Care Decisions forMinors or OthersUsually, health information rights may be given to aperson with legal authority to make health caredecisions for a child or other person (for example, aparent or legal guardian). There are exceptions. Forexample, under New Mexico law, there are anumber of circumstances in which minors (peopleunder the age of 18) may consent to receive healthcare services without parental consent, includingthe following:Examination and treatment for sexuallytransmitted diseasesPregnancy, prenatal, delivery, and postnatalcareFamily planning servicesBehavioral health servicesTreatment in a licensed facility for substanceabuseLife sustaining treatmentAnatomical gifts (must be 16)Right to See and Get a Copy of Health InformationMembers have the right to see and get a copy ofmost of their health information. Their request tosee or get a copy of health records must be madein writing.Right to Amend Incorrect or Incomplete HealthInformationMembers have the right to request that we changeincorrect or incomplete health information kept inour records. The member may be required to makethe request in writing. Presbyterian may deny therequest if we believe that the information in ourrecords is correct and complete. If the request isdenied, the member receives written noticeincluding the reason for the denial and how themember may appeal our decision.Right to Request Restrictions of Health InformationMembers have the right to request that healthinformation is not used or shared for certainpurposes. We are not required by law to agree tothe request. For example, we do not agree to limitthe use or sharing of health information during ahealth emergency.Right to Request Confidential Communications ofHealth InformationMembers have the right to request that healthinformation is delivered in a certain way or at acertain location. We must agree to a reasonablerequest. We may deny the request if it is againstthe law or our policies.Right to Request an Accounting of DisclosuresMembers have the right to request an Accountingof Disclosures Report. This report shows when19-82014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service Centerhealth information was shared by us and otherswithout written authorization.Right to Receive a Paper Copy of Privacy NoticeMembers have a right to receive a printed copy ofthe Joint Notice of Privacy Practices upon request.Use of Consents and Authorizations to ObtainProtected Health InformationWhen the member signs a plan enrollment form,they are authorizing Presbyterian (including itsauthorized agents, regulatory agencies, andaffiliates) to obtain limited information about themember for underwriting or enrollment purposes.We do not re-disclose this health informationwithout valid authorization from the member (ortheir legally authorized personal representative)unless required by law or as otherwise described inthe plan’s Joint Notice of Privacy Practices.Presbyterian expects that a provider will makemember records available to the plan inaccordance with federal and state regulations andthe contract that exists between Presbyterian andthe provider.There may be situations in which Presbyterianrequests PHI from the provider for Presbyterian’shealth care operations. In these situations, theprovider agrees to provide the requested PHI ormake a good faith attempt, within a reasonable timeperiod, to obtain a valid authorization from themember, and to provide Presbyterian, uponrequest, with written documentation of suchattempts.Privacy regulations also permit health careproviders to obtain consent from individuals to useor disclose their PHI for purposes of treatment,payment, or health care operations. Please notethat the regulations do not require that providersobtain consent to use or disclose PHI for thesepurposes.If a provider opts to obtain consent as describedabove from the member, the provider agrees toprovide a copy of that consent to Presbyterian aspart of a response to a request for PHI fromPresbyterian.A member may access and print an authorizationform from the website athttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001068.pdf orcontact the PCSC to request a printed copy.Authorization forms are kept in the member’smedical record or enrollment file.Members Who are Unable to Give Consent orAuthorizationFor children and people who are incapacitated andunable to make health decisions for themselves,health information rights are usually given to aperson with legal authority to make health caredecisions on their behalf (such as a custodialparent, legal guardian, or person holding healthcare power of attorney). In these situations, whenauthorization is needed to use or disclose PHI, theauthorization form is signed by a person with legalauthority to make health care decisions for theindividual.Presbyterian Case Management Staff coordinatecases with appropriate agencies, such as Children,Youth, and Families Department (CYFD) for those19-92014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service Centerchildren who are under CYFD jurisdiction, AdultProtective Services with an open case on amember, Juvenile Justice, and any other applicableagency or case manager for any individual who isunable to make decisions because of incapacitationor the inability to give informed consent, consistentwith federal and state laws.Member Access to Protected Health InformationContained in Plan RecordsPHI is kept in a physically secure location withaccess limited to authorized personnel only.Members have the right, with certain exceptions, tosee and obtain a copy of most PHI about them thatis contained in our records. To request access toinspect or obtain a copy of PHI, the member mustsubmit the request in writing toPresbyterian Customer Service CenterP.O. Box 27489Albuquerque, NM 87125-7489Requests for medical records must be made by themember directly to the treating provider.Safeguarding Oral, Written, and ElectronicProtected Health Information AcrossPresbyterianTo ensure internal protection of oral, written, andelectronic PHI across Presbyterian, the followingrules are strictly adhered to:PHI is accessed only if such information isnecessary to the performance of job-relatedtasks.All employees, volunteers, and all externalentities with a business relationship withPresbyterian that involves health informationare held responsible for the proper handling ofPresbyterian’s confidential businessinformation and PHI, and are required to signa confidentiality statement or businessassociate agreement.Violation of the above rules by an employee maybe grounds for immediate dismissal.myPRES/Website Internet InformationPresbyterian enforces security measures to protectPHI that is maintained on our website, network,software, and applications. We collect informationfrom visitors to our website, includingWebsite traffic statisticsWhere visitor traffic comes fromHow traffic flows within the websiteBrowser typeThese statistics help us improve the website andfind out what visitors find interesting and useful.Presbyterian uses personal information to reply toconcerns. We save this information as needed tokeep responsible records and handle inquiries. Wedo not sell, trade, or rent our visitors’ personalinformation to anyone.Regarding myPRES, the security features of theprogram allow only information pertaining to thatparticular member or provider to be accessed.WebsiteThe Presbyterian website (http://www.phs.org)does not contain any PHI, but rather is a source forgeneral policy statements such as member rightsand responsibilities, forms, listings of participatingproviders, and Presbyterian’s notices of privacypractices.19-102014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service CenterProtection of Information Disclosed to PlanSponsors, Employers, or Government AgenciesFederal law limits the information that Presbyterianmay disclose to employers regarding theiremployees to “summary information” and“information regarding enrollment anddisenrollment.” Presbyterian may provide moredetailed PHI regarding employees to plan sponsors(self-insured employer groups) only when theemployer has certified to Presbyterian that theyhave informed employees about this use of theirinformation by making certain amendments to theplan documents or the employee (or their legallyauthorized representative) consents to the releaseof information.Cultural CompetencyThe ability to communicate effectively with patientsand members affects their ability to understandinformation about their health care, complete aprescribed course of treatment, and be involved inhealth care decisions that affect them. Beingculturally competent, sensitive, and aware is key toPresbyterian’s mission to improve the health of thepatients, members, and communities Presbyterianserves.Cultural competency enhances communication andtreatment effectiveness. For health care providers,being culturally competent includes awareness ofthe existence of culturally diverse populations andthe potential for racial and ethnic health caredisparities. All cultures have unique views andpractices in regard to illness and well-being thataffect the health care decisions they make.Presbyterian requires all staff to complete annualcultural competency training to educate staff on theimportance of respecting diversity, including cultureand language preferences.Presbyterian provides information to members in aculturally sensitive manner, including to thoselimited in English language proficiency or readingskills, those with diverse cultural and ethnicbackgrounds, and those with physical or mentaldisabilities. Presbyterian recommends registeringfor online Cultural Sensitivity competencies athttps://www.thinkculturalhealth.hhs.gov/ or by usingthe Cultural Sensitivity Competencies link whenlogging in to myPRES. Supported by the Office ofMinority Health at the United States Department ofHealth and Human Services, and accredited byCiné-Med, the online competencies offered aredesigned to assist health care professionals deliverculturally competent care to an increasingly diversepopulation of members.Translation ServicesParticipating network practitioners and providersare required by contract to provide or coordinatetranslation services for their patients. Our CustomerService Center is also available to assist providerswith translation services for PresbyterianCentennial Care members through CertifiedLanguage International (CLI). CLI, a third-partycontractor, provides translation services in morethan 170 languages including Spanish, Navajo,Vietnamese, Portuguese, and Russian.Practitioners and providers can contact CLI directlyto coordinate translation services for theirCentennial Care members. Practitioners and19-112014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service Centerproviders are financially responsible for languageinterpretation services provided. Direct billingarrangements are available with CLI. CLI isaccessible 24 hours a day, seven days a week bycalling 1-800-225-5254. Presbyterian MedicalGroup (PMG) can contact the Community OutreachProgram for the Deaf (COPD) for American SignLanguage translation services. COPD can bereached at (505) 255-7636.Advance DirectiveMembers have the right to make health caredecisions and to execute advance directives. Theyalso have the right to accept or refuse treatment.An advance directive is a formal document,completed by a member in advance of anincapacitating illness or injury, which indicates themember’s preferences regarding health caretreatment. Once an advance directive is created,both the member and the provider should have acopy. If a member is admitted to a hospital, thehospital should also have a copy.As long as a member can speak for themselves,providers must honor their wishes, except as amatter of conscience. Providers must document ina prominent part of the member’s current medicalrecord whether or not an individual has executedan advance directive.Under the New Mexico Uniform HealthcareDecisions Act, if a health care practitioner orprovider declines to comply with a member’sinstruction or health care decision as a matter ofconscience, the practitioner or provider mustcontinue to provide care to the member until atransfer can be executed. The practitioner orprovider must promptly inform the member, ifpossible, or an agent authorized to make healthcare decisions for the member. Unless the memberor the agent refuse assistance, the practitioner orprovider must immediately make all reasonableefforts to assist in the transfer of the patient toanother health care practitioner or provider that iswilling to comply with the instruction. Presbyteriandoes not impose conditions that bar the providerfrom implementing advance directives as a matterof conscience if they have not filed a conscienceprotection waiver with Centers for Medicare andMedicaid Services. Presbyterian is not required toprovide care that conflicts with an advancedirective. Presbyterian is not required to providecare that conflicts with an advance directive.A member can obtain the brochure MakingHealthcare Decisions from the PCSC, whichprovides information and forms for completing anadvance directive. These are important legaldocuments, however, and members shouldconsider consulting an attorney to assist them inpreparing an advance directive.Types of directives includeLiving will. This lets members detail whichtreatments they want and do not want if theycannot speak for themselves.Durable power of attorney for health care.This lets members appoint a friend or relativeto make medical decisions for them if theycannot do it themselves.19-122014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service CenterDo-not-resuscitate order. This lets membersinform caregivers they do not want to receiveCPR if their heart stops beating.Provider CARE UnitThe Provider CARE Unit is now a part of the PCSCand is designed to handle “complex” inquiries fromthe provider community that cannot be resolvedthrough self-help options.Self-Help OptionsmyPRES is the quick and easy way of accessingreal-time information. This service is available 24hours a day, seven days a week to ensure that theinformation you and your office staff needs is atyour fingertips. This tool is your most efficient wayof getting the information you need when you needit.Each employee in your office that uses myPRESmust have their own individual user name andpassword. Under no circumstances should themyPRES user name and password be shared. It isyour responsibility to contact the PCSC to terminateaccess of employees who are no longer employed.If you have an employee who no longer requiresaccess to myPRES, please contact the PCSC toterminate their access.Violation of the terms and conditions for use ofmyPRES may result in revocation of myPRESaccess.Information available through myPRES includesMember eligibilityMember benefitsCo-payment, coinsurance, deductible, andout-of-pocket amounts (the member’sresponsibility and the amounts that have beenmet to date that are in Presbyterian’s systemat the time of inquiry)Information regarding a member’s otherinsurance (if applicable)PCP verification (including demographicinformation)Member rosters (for PCPs)Information regarding finding a doctor,provider, or facilityClaims status, inquiry, or verificationCheck summaries (listing of Explanation ofPayments that were mailed, with access to allclaims associated with that remittance,including the address of where the check wasmailed)Benefit certification submission and statusPharmacy exception submission and statusAccess to the Provider CARE Unit(electronically)Presbyterian’s Interactive Voice Response systemis available to assist you with member eligibilityverification, benefits, claim status, benefitcertifications, pharmacy exceptions, and behavioralhealth services.Web-based InquiriesPresbyterian may contact Provider NetworkManagement electronically by going tohttp://www.phs.org and selecting “Contact Us” fromthe menu at the bottom of the page, or by going to19-132014 Practitioner and Provider Manual - Ver. 3

Presbyterian Customer Service Centerhttps://www.phs.org/about-us/contactus/Pages/default.aspx.Helpful TipsIn the event that it is necessary to submit a paperclaim (new, resubmission, or corrected) or whensubmitting claims and encounter information,please direct it to the following mailing address:Presbyterian Health PlanP.O. Box 27489Albuquerque, NM 87125-7489The Provider CARE unit will assist you with yourcomplex inquires Monday through Friday between8 a.m. and 5 p.m. The Provider CARE Unit can becontacted by providers at the following numbers:Local: 505-923-5757Toll-free: 1-888-923-5757When calling the Provider CARE Unit, please haveavailable the following information:Your National Provider Identifier (NPI), arequirement for you to provide as of January1, 2008. The Provider CARE Unit will beunable to assist you without this number.The member’s Presbyterian ID number, dateof service, procedure code, billed amounts,and claim number (if known).For reimbursement and coding questions, refer tothe Claims chapter of this manual.For benefit certification, refer to the CareCoordination chapter of this manual.For appeals and grievance, refer to the Appealsand Grievances chapter.For timely submission guidelines, refer to theClaims chapter of this manual.Contacting the Provider CARE UnitPlease contact your provider network managementrelationship executive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf) ifthe issue affects more than 10 claims (for example,incorrect contract payment, or charge for a specificcode is being denied when it should be paying).Telephone InquiriesIf a member needs to request a primary careprovider change or wishes to speak with acustomer service representative, please have themcall the Customer Service phone number on theback of their Presbyterian member ID card.For questionable claim payment or denial, refer tothe Claims chapter of this manual.19-142014 Practitioner and Provider Manual - Ver. 3

Appeals and Grievances20. Appeals and Grievances20. Appeals and GrievancesA provider has the right to file an appeal ifdissatisfied with a decision made by Presbyterian toterminate, suspend, reduce, or not provideapproved services to a member, or to denypayment for services. The provider also has theright to file an appeal if the provider disagrees withany policy or adverse action made by Presbyterian.Additionally, if a provider is dissatisfied with any ofPresbyterian’s general operations, he or she mayfile a grievance. In order to file an appeal orgrievance on behalf of a member, a provider musthave the member’s written consent.If the issue involves a utilization managementdecision, a provider must obtain the written consentof the member to act on his or her behalf during theappeal process, unless the matter is determined tobe an expedited appeal.Provider Appeals and Grievance ProcessAny provider has the right to file a formal grievanceor appeal with Presbyterian. The provider shouldsubmit the grievance or appeal to the Presbyteriangrievance and appeals coordinator within thefollowing time frame:Grievances or appeals challenging a claimdenial, claim adjudication, claim submission,claim resubmission, or claim resubmission notacted upon by Presbyterian must be filedwithin 12 months of the date of service.Appeals and grievances related tooverpayments identified by Presbyterian mustbe filed within 12 months of the date of serviceor 60 days from the notification, whichever isthe later date.Standard AppealPresbyterian encourages providers to file claimscorrectly the first time or, if time allows, resubmitthe claim through the Claims Activity Review andEvaluation (CARE) Unit to resolve an issue. Aprovider is encouraged to contact his or herprovider network management relationshipexecutive(https://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00140718.pdf) to helpclarify any denials or other actions relevant to theclaim and to help with a possible resubmission of aclaim with modifications.Remember, once a claim is initially submitted in atimely manner, a provider has one year (12months) from the date of service to correct anydefects in the initial claim submission and toresubmit the claim for reprocessing. A provider has12 months from the date of service to file an appealregarding a claim denial or the denial is upheld aspast the filing limit for initiating an appeal.Appeals will be resolved within 30 calendar days. Ifthe provider appeal is not resolved within 30calendar days, Presbyterian requests a 14-20-12014 Practitioner and Provider Manual - Ver. 3

Appeals and Grievancescalendar-day extension from the provider. If theprovider requests the extension, the extension isapproved by Presbyterian.When filing an appeal, please remember todocument the reasons for the reconsiderationrequest and attach all supporting documentation forreview of the issue. If the issue involves a claimsdenial appeal, and the claim was previouslysubmitted electronically, please include a hard copyof the claim in question for review of the appeal. Ifthe appeal is related to a claim-coding matter, it ishelpful to include supporting medical records suchas office notes and operative reports, if applicable.Formal GrievancesA grievance may be filed orally or in writing andmust state with particularity the factual and legalbasis and the relief requested, along with anysupporting documents (such as claim, remittance,medical review sheet, medical records, orcorrespondence). Particularity usually means achronology of pertinent events and a statement asto why the provider believes the action byPresbyterian was incorrect. Grievances shall beresolved within 30 calendar days. If the providergrievance is not resolved within 30 calendar days,Presbyterian requests a 14-calendar-day extensionfrom the provider. If the provider requests theextension, the extension is approved byPresbyterian. Presbyterian reviews grievances inaccordance with all federal and state regulatoryguidelines and Presbyterian’s policies andprocedures. For Centennial Care providers, a copyof the Provider Appeals and Grievance policies andprocedures may be provided to contractedproviders. For a list of the applicable regulations,please access the Appeals & Grievances page athttps://www.phs.org/providers/cliniciansresources/appeals-grievances/Pages/default.aspx.Circumstances Giving Rise to a Provider FairHearingProviders may appeal a decision to deny, suspend,or terminate their participation in the Presbyteriannetwork. If the provider disputes any such action,they must submit a written request for a hearing.A provider has the right to a fair hearing uponreceipt of a written notice from Presbyterian, or itsagent, pursuant to the termination, for terminatingthe agreement either immediately or after notice.Presbyterian must give reasonable advance noticeif the agreement is terminated for cause, unless it isfor quality of care issues. The minimum advancenotice is determined by federal and state regulatoryguidelines unless the provider’s contract statesotherwise.Initiation of an Appeal HearingA provider may initiate a fair hearing within 30calendar days of receiving written notice oftermination from Presbyterian, by delivering orsending by certified mail a written request for a fairhearing to Presbyterian or its agent. Failure todeliver a written request by certified mail for a fairhearing within those 30 days constitutes a waiverby the provider of any hearing regarding theirtermination. If a request for a hearing is not filed bythat time, the provider contract ends.20-22014 Practitioner and Provider Manual - Ver. 3

Appeals and GrievancesMember Appeals and GrievancesWith written consent from the member to act astheir representative during the appeal process,providers may appeal a denied benefit certificationor a concurrent review decision to denyauthorization that was made by the medicaldirector. At the time of the decision, a provider ormember may request that Presbyterian reconsiderthe denial by submitting further documentation tosupport medical necessity. Such requests arereferred immediately to a medical director notpreviously involved in the case for resolution andare handled according to the member appealguidelines.If benefit certification or prior authorization forservices for any Presbyterian member is requestedby a provider and denied by Presbyterian, aprovider may act on the member’s behalf and mayfile a request for an expedited appeal if the providerfeels that the member’s health or welfare are inimmediate jeopardy. Presbyterian then determinesif it meets expedited criteria. If the case is deemedexpedited, Presbyterian processes the expeditedappeal within 72 hours of receipt. (Time extensionsmay apply with written consent from the member.)For Presbyterian Centennial Care, unless themember or the provider requests an expeditedresolution, an oral appeal must be followed by awritten appeal that is signed by the member within13 calendar days; failure to file the written appealwithin 13 calendar days constitutes withdrawal ofthe appeal.The Presbyterian member appeals and grievanceprocess is published in the member handbooks.Presbyterian provides a process that ensures allmembers have the right to exercise their right to anappeal and that they receive the decision within theappropriate and proper time frames for resolution oftheir appeals.Any member also has the right to file a grievance ifhe or she is dissatisfied with the services renderedthrough Presbyterian. In respect to grievances, themember is defined as any individual enrolled inPresbyterian or their designated representative. Aprovider may represent a member in a grievance orappeal with written consent from the member.Member grievances may include but are not limitedto dissatisfaction with providers, appropriateness ofservices rendered, timeliness of services rendered,availability of services, delivery of services,reduction or termination of services, disenrollment,or any other performance that is consideredunsatisfactory. The member should submit agrievance to the Presbyterian grievance andappeals coordinator within 30 calendar days of thedate the dissatisfaction occurred.The member should submit an appeal to thegrievance and appeals coordinator within 90 daysfrom the date of denial.Member Fair HearingA member may request a State Fair Hearing if heor she is dissatisfied with an action that has beentaken by Presbyterian, and the member hasexhausted Presbyterian’s internal process, within30 calendar days of the Presbyterian’s finaldecision. A representative of the member or themember’s estate, or a provider acting on behalf of20-32014 Practitioner and Provider Manual - Ver. 3

Appeals and Grievancesthe member, with the member’s consent, mayrequest a State Fair Hearing on behalf of themember.A State Fair Hearing may be requested by callingor writing to:New Mexico Human Services DepartmentFair Hearings BureauPO Box 2348Santa Fe, NM 87504-2348Phone: 505-476-62131-800-432-6217, Option 6Fax: 505-476-6215If a request for a Fair Hearing is received by theHuman Services Department within 10 calendardays, Presbyterian’s final decision will be uphelduntil the outcome of the hearing is decided.However, if the Hearing Officer agrees withPresbyterian’s final decision, the member may haveto pay for the continued services if those serviceswere the reason for the hearing.20-42014 Practitioner and Provider Manual - Ver. 3

Appendix A. AcronymsAppendix A. AcronymsAppendix A. AcronymsA B C D E F G H I J K L MN O P Q R S T U V W X Y ZAAAFPAAPABPADHDADLAMAAPAASOAmerican Academy of Family PhysiciansAmerican Academy of PediatricsAlternative Benefits PackageAttention Deficit and Hyperactivity DisorderActivities of Daily LivingAmerican Medical AssociationAmerican Psychiatric AssociationAdministrative Service OnlyBack to topBBADLBasic Activities of Daily LivingBack to topCCAGECAHPS ®CARECCSCCSSCDCCFRCHRCHWCLICLIACMSCNACPTCSACTCYFDCut, Annoy, Guilty, Eye OpenerConsumer Assessment of Healthcare Providers and SystemsClaims Activity Review and EvaluationCorrect Coding StandardsComprehensive Community Support ServicesCenters for Disease Control and PreventionCode of Federal RegulationsCommunity Health RepresentativeCommunity Health WorkerCertified Language InternationalClinical Laboratory Improvement AmendmentsCenters for Medicare and Medicaid ServicesComprehensive Needs AssessmentCurrent Procedural TerminologyCore Service AgencyComputed TomographyChildren, Youth, and Families DepartmentBack to topA-12014 Practitioner and Provider Manual - Ver. 3

Appendix A. AcronymsDDEADHHSDHIDMEDOHDrug Enforcement AgencyDepartment of Health and Human ServicesDivision of Health ImprovementDurable Medical EquipmentDepartment of HealthBack to topEeCOB ®ECTEDIEFTEHREOBEOPEOREPSDTERERAElectronic Coordination of BenefitsElectronic Claims TransmissionElectronic Data InterchangeElectronic Funds TransferElectronic Health RecordExplanation of BenefitsExplanation of PaymentEmployer of RecordEarly and Periodic Screening, Diagnosis, and TreatmentEmergency RoomElectronic Remittance AdviceBack to topFFDAFICAFMAFPLFQHCFRFUTAFood and Drug AdministrationFederal Insurance Contributions ActFiscal Management AgencyFederal Poverty LevelFederally Qualified Health CenterFederal RegisterFederal Unemployment Tax ActBack to topGGSAGroup Subscriber Agreement; Government Services AdministrationBack to topHHCBSHCPCSHEDIS ®HHAHIPAAHITHITECHHIVHome and Community-Based ServicesHealthcare Common Procedure Coding SystemHealthcare Effectiveness Data and Information SetHome Health AideHealth Insurance Portability and Accountability ActHealth Information TechnologyHealth Information Technology for Economic and Clinical HealthHuman Immunodeficiency VirusBack to topA-22014 Practitioner and Provider Manual - Ver. 3

Appendix A. AcronymsHMOHRAHSDHealth Maintenance OrganizationHealth Risk AssessmentHuman Services DepartmentIIADLICMICPTIHSI/T/UIVRInstrumental Activities of Daily LivingIntegrated Care ManagementInterdisciplinary Care Plan TeamIndian Health ServiceIndian Health Service/Tribal Health Providers/Urban Indian ProvidersInteractive Voice ResponseBack to topLLPNLRILicensed Practical NurseLegally Responsible IndividualBack to topMMAMACMADMCOMFEADMPCMRMTMMedicare AdvantageMedicare Administrative ContractorMedical Assistance DivisionManaged Care OrganizationMedicare Fraud and Elder Abuse DivisionMedical Policy CommitteeMagnetic Resonance Imaging/AngiographyMedication Therapy ManagementBack to topNNANMNCCINCQANDCNF LOCNMACNMMFCANMSANPINurseAdvice SM New MexicoNational Correct Coding InitiativeNational Committee for Quality AssuranceNational Drug CodeNursing Facility Level of CareNew Mexico Administrative CodeNew Mexico Medicare False Claims ActNew Mexico Statutes AnnotatedNational Provider IdentifierBack to topOOIGOffice of Inspector GeneralBack to topA-32014 Practitioner and Provider Manual - Ver. 3

Appendix A. AcronymsPP&TPCAPCPPETPHHSNPHAPHIPHPPHSPNMPPAPPACAPPOPharmacy and TherapeuticsPersonal Care AttendantPrimary Care Provider/PractitionerPositron Emissions TomographyPresbyterian Home Healthcare Statewide NetworkPersonal Health AssessmentProtected Health InformationPresbyterian Health PlanPresbyterian Healthcare ServicesProvider Network ManagementPhysician Performance AssessmentPatient Protection and Affordable Care ActPreferred Provider OrganizationBack to topQQIQIOQMQRMQuality ImprovementQuality Improvement OrganizationQuality ManagementQuality Resource ManagementBack to topRRACRNRecovery Audit ContractorRegistered NurseBack to topSSAMSDCBSIUSNFSystem for Award ManagementSelf-Directed Community BenefitSpecial Investigative UnitSkilled Nursing FacilityBack to topTTACTxTechnology Assessment CommitteeMedical treatmentBack to topUUMUNMUSCUtilization ManagementUniversity of New MexicoUnited States CodeBack to topVVFCVaccines for ChildrenBack to topA-42014 Practitioner and Provider Manual - Ver. 3

Appendix A. AcronymsWWEDIWorkgroup on Electronic Data InterchangeBack to topA-52014 Practitioner and Provider Manual - Ver. 3

Appendix A. AcronymsThis page intentionally left blankA-62014 Practitioner and Provider Manual - Ver. 3

Appendix B: DefinitionsAppendix B. DefinitionsAppendix B. DefinitionsNote that the definitions provided in this list come from a number of sources. The primary sources are listed below. If the definition comes fromanother source, a link to that source is provided.HSD:Care.CMS:NM:PM:Wiki:New Mexico Human Services Department (HSD) in the August 31, 2012, Request for Proposals (RFP# 13-360-8000-001) for Centennialhttp://www.medicaid.govState of New Mexico websiteWithin this Provider ManualWikipediaTerm Definition SourceabuseMeans: (i) Any intentional, knowing or reckless act or failure to act that produces or is likely to HSDproduce physical or great mental or emotional harm, unreasonable confinement, sexualabuse or sexual assault consistent with the Resident Abuse and Neglect Act, NMSA 1978,30-47-1, et seq.; or (ii) provider practices that are inconsistent with sound fiscal, business,medical or service-related practices and result in an unnecessary cost to the Medicaidprogram, or in reimbursement for services that are not medically necessary services or thatfail to meet professionally recognized standards for health care. Abuse also includes memberpractices that result in unnecessary cost to the Medicaid program pursuant to 42 CFR §455.2.actionMeans, for purposes of an appeal: (i) the denial or limited authorization of a requestedHSDservice, including the type or level of service; (ii) the reduction, suspension or termination of apreviously authorized service; (iii) the denial, in whole or in part, of payment for a service; (iv)the failure of the Managed Care Organization (MCO) to provide services in a timely manner,as defined by HSD or its designee; or (v) the failure of the MCO to complete the authorizationrequest within specific timeframes set forth in 42 CFR § 438.408.activities of daily living Means eating, dressing, maintaining oral hygiene, bathing, ensuring mobility, toileting,(ADL)grooming, taking medications, transferring from a bed to a chair and walking, consistent withHSDHuman Services Department (HSD) regulations. See also basic activities of daily living(BADL) and instrumental activities of daily living (IADL).adult Means an individual age 19 or older unless otherwise specified. HSDadvance directiveMeans written instructions (such as an advance health directive, a mental health advance HSDdirective, a psychiatric advance directive, a living will, a durable health care power of attorneyor a durable mental health care power of attorney) recognized under state law (whetherstatutory or as recognized by the courts of the state) relating to the provision of health carewhen an individual is incapacitated. Such written instructions must comply with NMSA 1978,§§ 24-7A-1 through 24-7A-18, and 24-7B-1 through 24-7B-16.adverse determination Means a determination consistent with 42 CFR § 438.408 by the MCO or the MCO’sHSDutilization review agent that the health care services furnished, or proposed to be furnished, toa member are not medically necessary or not appropriate.adverse eventMeans an event that results in unintended harm to the patient by an act of commission oromission rather than by the underlying disease or condition of the patient.agency-based community Means the consolidated benefit of home- and community-based services (HCBS) andbenefitpersonal care services that are available to members meeting the nursing facility level of care.HSDappeal Means a request by a member for review by the MCO of a MCO Action. HSDB-12014 Practitioner and Provider Manual - Ver. 3

Appendix B. DefinitionsTerm Definition SourceBaldrige Health CareCriteria for Performancesee linkExcellencebasic activities of dailyliving (BADL)behavioral healthCriteria provided by the Baldrige Performance Excellence Program that support health careorganizations in their efforts to reach goals, improve results, and become more competitive byaligning plans, processes, decisions, people, actions, and results.http://www.nist.gov/baldrige/publications/hc_about.cfm#Means bathing and showering (washing the body); bowel and bladder management(recognizing the need to relieve oneself); dressing; eating (including chewing and swallowing);feeding (setting up food and bringing it to the mouth); functional mobility (moving from oneplace to another while performing activities); personal device care; personal hygiene andgrooming (including washing hair); sexual activity; and toilet hygiene (completing the act ofrelieving oneself) http://en.wikipedia.org/wiki/Activities_of_daily_living.Umbrella term for mental health (including psychiatric illnesses and emotional disorders) and HSDsubstance abuse (involving addictive and chemical dependency disorders). The term alsorefers to preventing and treating co-occurring mental health and substance abuse disorders.Behavioral Health (BH) Any practitioner licensed/certified as a psychiatrist, psychologist, clinical social worker,High-Volume Practitioners marriage/family/child counselor, nurse, or other licensed health care professional withappropriate training and experience in behavioral health services to treat chemicaldependency and/or mental disorders.business days Means Monday through Friday, except for State of New Mexico holidays. HSDcalendar days Means all seven days of the week, including State of New Mexico holidays. HSDcare coordinationThe management of a member’s services to ensure that needs are met and services are notduplicated by the organizations involved in providing care.http://medical-dictionary.thefreedictionary.com/care+coordinationcare level See levels of care. HSDCentennial Careclaim(the) Collaborativecommunity benefitcommunity healthrepresentative (CHR)community health workers(CHW)confidential InformationMeans the State of New Mexico’s Medicaid program operated under Section 1115(a) of theSocial Security Act waiver authority.Means a bill for services submitted to the MCO manually or electronically, a line item ofservice on a bill, or all services for one member within a bill.Means the Interagency Behavioral Health Purchasing Collaborative, established under NMSA1978, § 9-7-6.4, responsible for planning, designing, and directing a statewide behavioralhealth system.Means both the agency-based community benefit and the self-directed community benefitsubject to an individual’s annual allotment as determined by HSD.Equivalent to community health worker or promotora but in the tribal communities.Also known as promotoras; means lay members of communities who work either for pay or asvolunteers in association with the local health care system in tribal, urban, frontier and ruralareas and usually share ethnicity, language, socioeconomic status and life experiences withthe members they serve. Community health workers include, among others, communityhealth advisors, lay health advocates, promotoras, outreach educators, community healthrepresentatives, peer health promoters, and peer health educators.Means any communication or record – whether oral, written, electronically stored ortransmitted, or in any other form – consisting of: (i) confidential member information, includingHIPAA-defined protected health information; (ii) all non-public budget, expense, payment andother financial information; (iii) all privileged work product; (iv) all information designated byHSD or any other state agency as confidential, and all information designated as confidentialunder the laws of the State of New Mexico; and (v) information utilized, developed, received,or maintained by HSD, the Collaborative, the MCO, or participating state agencies for thepurpose of fulfilling a duty or obligation under this agreement and that has not been disclosedpublicly.see linksee linkHSDHSDHSDHSDPMHSDHSDB-22014 Practitioner and Provider Manual - Ver. 3

Appendix B. DefinitionsTerm Definition Sourcecore service agencies Means multi-service agencies that help to bridge treatment gaps in the child and adultHSD(CSAs)treatment systems, promote the appropriate level of service intensity for members withcomplex behavioral health service needs, ensure that community support services areintegrated into treatment, and develop the capacity for members to have a single point ofaccountability for identifying and coordinating their behavioral health, health, and other socialservices.covered servicescritical incidentcultural competencedesirabledeterminationdual eligible(s)Early and PeriodicScreening, Diagnosis, andTreatment (EPSDT)Means those physical, behavioral health, and long-term care services provided underCentennial Care.Means a reportable incident that may include, but is not limited to:• Abuse, neglect, and exploitation• Abuse is defined as the willful infliction of injury, unreasonable confinement,intimidation, or punishment with resulting physical harm, pain, or mental anguish to aconsumer.• Neglect is defined as the failure to provide goods and services necessary to avoidphysical harm, mental anguish, or mental illness to a consumer.• Exploitation is defined as the deliberate misplacement, exploitation, or wrongful,temporary, or permanent use of a consumer’s belongings or money without theconsumer’s consent.• Death• Unexpected death is a death caused by an accident or an unknown or unanticipatedcause.• Natural/expected death is a death caused by a long-term illness, a diagnosed chronicmedical condition, or other natural/expected conditions resulting in death.• Other reportable incidents• Environmental hazard is defined as an unsafe condition that creates an immediatethreat to life or health of a consumer.• Law enforcement intervention is defined as the arrest or detention of a person by a lawenforcement agency, involvement of law enforcement in an incident or event, orplacement of a person in a correctional facility.• Emergency services refers to the provision of emergency services to a consumer thatresult in medical care that is not anticipated for this consumer, and that would notroutinely be provided by a primary care provider.Means a set of congruent behaviors, attitudes, and policies that come together in a system oragency or among professionals that enables them to work effectively in cross-culturalsituations. Cultural competency involves integrating and transforming knowledge, information,and data about individuals and groups of people into specific clinical standards, serviceapproaches, techniques, and marketing programs that match an individual’s culture toincrease the quality and appropriateness of health care and outcomes.Means “preferred.” The terms “may,” “can,” “should,” “preferably,” or “prefers” identify adesirable or discretionary item or factor (as opposed to “mandatory”).Means the written documentation of a decision by the procurement manager, includingfindings of fact supporting a decision. A determination becomes part of the procurement file.Means individuals who – by reason of age, income and/or disability – qualify for Medicare andfull Medicaid benefits under Section 1902(a)(10)(A) or 1902(a)(10)(C) of the Social SecurityAct, under Section 1902(f) of the Social Security Act, or under any other category of eligibilityfor medical assistance for full benefits.Means the federally required Early and Periodic Screening, Diagnosis and Treatment(EPSDT) program. as defined in Section 1902(r) of the Social Security Act and 42 CFR Part441, Subpart B for members under the age of twenty-one (21). It includes periodiccomprehensive screening and diagnostic services to determine physical and behavioralhealth needs as well as the provision of all medically necessary services listed in Section1905(a) of the Social Security Act even if the service is not available under the state’sMedicaid plan.HSDHSDHSDHSDHSDHSDHSDB-32014 Practitioner and Provider Manual - Ver. 3

Appendix B. DefinitionsTerm Definition Sourceelectronic health record(EHR)HSDemergency medicalconditionemergency servicesencounterencounter datafair hearingfederally qualified healthcenter (FQHC)fiscal management agency(FMA)fraudfrontiergrievancehome and communitybasedservices (HCBS)health educationMeans a record in digital format that is a systematic collection of electronic health information.Electronic health records may contain a range of data, including demographics, medicalhistory, medication and allergies, immunization status, laboratory test results, radiologyimages, vital signs, personal statistics such as age and weight, and billing information.Means a medical or behavioral health condition manifesting itself through acute symptoms ofsufficient severity (including severe pain) such that a prudent layperson with averageknowledge of health and medicine could reasonably expect the absence of immediatemedical attention to result in: (i) placing the members’ health (or, with respect to a pregnantwoman, the health of the woman or her unborn child) in serious jeopardy; (ii) seriousimpairment to bodily functions; (iii) serious dysfunction of any bodily organ or part; or (iv)serious disfigurement to the member.Means covered services that are inpatient or outpatient and are (i) furnished by a provider thatis qualified to furnish these services and (ii) needed to evaluate or stabilize an emergencymedical condition.Means a record of any claim adjudicated by the MCO or any of its subcontractors for amember, including Medicare claims for which there is no Medicaid reimbursement amountand/or a record of any service or administrative activity provided by the MCO or any of itssubcontractors for a member that represents a member-specific service or administrativeactivity, regardless of whether that service was adjudicated as a claim or whether payment forthe service was made.Information about claims adjudicated by the MCO for services rendered to its members. Suchinformation includes whether claims were paid or denied and any capitated and subcapitatedarrangements.Means the administrative decision-making process that requires aggrieved individuals begiven the opportunity to confront the evidence against them and have their evidenceconsidered by an impartial finder of fact in a meaningful time and manner.Means an entity that meets the requirements of, and receives a grant and funding pursuant to,the Public Health Service Act. An FQHC also includes an outpatient health program, a facilityoperated by a tribe or tribal organization under the Indian Self-Determination Act (PL 93-638),and an urban Indian organization receiving funds under Title V of the Indian Health CareImprovement Act, codified at 25 USC 1601 et seq.Means an entity contracting with the state that provides the fiscal administration functions formembers receiving the self-directed community benefit. The FMA must be an entity operatingunder Section 3504 of the IRS code, Revenue Procedure 70-6 and Notice 2003-70, as theagent to members for the purpose of filing certain federal tax forms and paying federal incometax withholding, FICA and FUTA taxes. The FMA also files state income tax withholding andunemployment insurance tax forms, pays the associated taxes, and processes payroll basedon the eligible self-directed community benefit services authorized and provided.Means an intentional deception or misrepresentation by a person or an entity, with theknowledge that the deception could result in some unauthorized benefit to himself or someother person. It includes any act that constitutes fraud under applicable federal or state law.Means the following counties in New Mexico: Catron, Harding, DeBaca, Union, Guadalupe,Hidalgo, Socorro, Mora, Sierra, Lincoln, Torrance, Colfax, Quay, San Miguel, and Cibola.Means an expression of dissatisfaction about any matter or aspect of the MCO or itsoperation.Home and community-based services (HCBS) provide opportunities for Medicaidbeneficiaries to receive services in their own home or community. These programs serve avariety of targeted populations groups, such as people with mental illnesses, intellectualdisabilities, and/or physical disabilities.Means programs, services, or promotions that are designed or intended to inform the MCO’sactual or potential members about issues related to healthy lifestyles, situations that affect orinfluence health status, or methods or modes of medical treatment.HSDHSDHSDHSDHSDHSDHSDHSDHSDHSDCMSHSDB-42014 Practitioner and Provider Manual - Ver. 3

Appendix B. DefinitionsTerm Definition Sourcehealth homeMeans, as defined in Section 2703 of PPACA, an individual provider, team of health careprofessionals, or health team that meets all federal requirements and provides the followingsix services to persons with one or more specified chronic conditions: (i) comprehensive caremanagement; (ii) care coordination and health promotion; (iii) comprehensive transitionalcare/follow-up; (iv) patient and family support; (v) referral to community and social supportservices; and (vi) use of health information technology (HIT) to link services, if applicable.HSDhealth informationtechnology (HIT)health literacyHealthcare EffectivenessData and Information Set(HEDIS) ®high-volume specialty careprovidersMeans the area of information technology involving the design, development, creation, useand maintenance of information systems for the health care industry.Means the degree to which members are able to obtain, process, and understand basichealth information and services needed to make appropriate health decisions.Means the tool used by health plans to measure performance of certain health care criteriadeveloped by the National Community for Quality Assurance (NCQA).Means providers of anesthesia, cardiology, gastroenterology, general surgery, obstetrics andgynecology, oncology, ophthalmology, orthopedics, and radiation oncology. High-volumespecialists are identified as in-plan providers not identified as primary care providers who arepaid the highest amount per year based on claims submitted, encounter data, and theinclusion of health care costs across all product lines.HIPAA Means the Health Insurance Portability and Accountability Act of 1996, 42 USC 160, et seq. HSDHITECH Act Means the Health Information Technology for Economic and Clinical Health Act of 2009; 42USC 17931, et seq.health risk assessment Assessment performed per HSD guidelines and processes for the purpose of (i) introducing(HRA)the MCO to the member, (ii) obtaining basic health and demographic information about themember, (iii) assisting the MCO in determining the level of care coordination needed by themember, and (iv) determining the need for a nursing facility level of care (NF LOC)assessment.Indian Health Service (IHS)Indian Health Service/tribalhealth providers/urbanIndian providers (I/T/U)instrumental activities ofdaily living (IADL)Interagency BehavioralHealth PurchasingCollaborative (aka TheCollaborative)Means the division of the United States Department of Health and Human Servicesresponsible for providing health services to Native Americans.A collective term that references any or all of the three types of providers.Means doing housework; taking medications as prescribed; managing money; shopping forgroceries or clothing; use of telephone or other form of communication; using technology (asapplicable); and using transportation within the community.http://en.wikipedia.org/wiki/Activities_of_daily_livingCollaborative created by Governor Bill Richardson and the New Mexico State Legislatureduring the 2004 Legislative Session (State Statute). The legislation allows several stateagencies and resources involved in behavioral health prevention, treatment, and recovery towork as one in an effort to improve mental health and substance abuse services in NewMexico. This cabinet-level group represents 15 state agencies and the governor’s office.HSDHSDHSDHSDHSDHSDsee linksee linkThe Collaborative consists of the secretaries of aging and long-term services; Indian affairs;human services; health; corrections; children, youth and families; finance and administration;workforce solutions; public education; and transportation. It also consists of the directors ofthe administrative office of the courts; the New Mexico mortgage finance authority; thegovernor's commission on disability; the developmental disabilities planning council; theinstructional support and vocational rehabilitation division of the public education department;and the New Mexico health policy commission; and the governor's health policy coordinator,or their designees. The Collaborative is chaired by the Secretary of Human Services with therespective secretaries of Health (Services) and Children, Youth and Families (CYFD)alternating annually as co-chairs. http://www.bhc.state.nm.us/B-52014 Practitioner and Provider Manual - Ver. 3

Appendix B. DefinitionsTerm Definition SourceLean Six SigmaSix Sigma is a set of tools and techniques/strategies for process improvement. Lean Six see linkSigma focuses on eliminating waste from processes and increasing process speed byfocusing on what customers actually consider quality, and working back from that.http://www.ehow.com/facts_5007027_definition-lean-six-sigma.htmllevels of care The care coordination process addresses three levels of care, Levels 1, 2, and 3.• Level 1. Members assigned to Level 1 care coordination are those members who do notcurrently require a comprehensive needs assessment, and who are not assigned anindividual care coordinator.• Level 2 and Level 3. Members assigned to Level 2 or Level 3 care coordination meetone of the indicators listed below. These members do require a comprehensive needsassessment to determine they should be in Level 2 or Level 3 care coordination.• Is a high-cost user as defined by the MCO• Is in out-of-state medical placements• Is a dependent child in out-of-home placements• Is a transplant patient• Is identified as having a high-risk pregnancy• Has a behavioral health diagnosis including substance abuse that adversely affects themember’s life• Is medically fragile• Is designated as International Classification of Functioning (ICF)/ Mentally Retarded(MR)/Developmentally Disabled (DD)• Has high emergency room use as defined by the MCO• Has an acute or terminal disease• Is readmitted to the hospital within 30 calendar days of discharge• Has other indicators as prior approved by HSDlimited English proficiency Means the restricted ability to read, speak, write, or understand English by individuals who do HSDnot speak English as their primary language.long-term careRefers to the community benefit, the services of a nursing facility, and the services of aninstitutional facility.HSDmanaged care organization(MCO)medical errormedically necessaryservicesmembermember materialsmember satisfactionsurveyMeans an entity that participates in Presbyterian Healthcare Services under contract withHSD to assist the state in meeting the requirements established under NMSA 1978, § 27-2-12.As referenced in this Provider Manual, the MCO is Presbyterian Health Plan.Defined by the Institute of Medicine as “the failure to complete a planned action as intendedor the use of a wrong plan to achieve an aim.”Means clinical and rehabilitative physical, mental, or behavioral health services that: (i) areessential to prevent, diagnose, or treat medical conditions or are essential to enable themember to attain, maintain, or regain the member’s optimal functional capacity; (ii) aredelivered in the amount, duration, scope, and setting that are both sufficient and effective toreasonably achieve their purposes and clinically appropriate to the specific physical andbehavioral health care needs of the member; (iii) are provided within professionally acceptedstandards of practice and national guidelines; and (iv) are required to meet the physical andbehavioral health needs of the member and are not primarily for the convenience of themember, the provider, or the MCO.Means a person who has been determined eligible for Presbyterian Healthcare Services andwho has enrolled in the MCO’s health plan.All materials distributed to members including but not limited to member handbooks, providerdirectories, member newsletters, member identification (ID) cards and, upon request, anyother additional, but not required, materials and information provided to members designed topromote health and/or educate members.Annual survey that shall assess member satisfaction with the quality, availability, andaccessibility of care.HSDHSDHSDHSDHSDB-62014 Practitioner and Provider Manual - Ver. 3

Appendix B. DefinitionsTerm Definition Sourcenear missDefined as “an occurrence with potentially important safety-related effects, which, in the endwas prevented from developing into actual consequences.”non-contract provider Means an individual provider, clinic, group, association, or facility that provides coveredservices and that does not have a contract with the MCO.HSDnon-Medicaid Contractornot otherwise Medicaideligiblenursing facility (NF)otherwise Medicaid eligibleoutreachPatient Protection andAffordable Care Act(PPACA)patient-centered medicalhome (PCMH)post-stabilization servicespharmacy networkPresbyterian improvementmodelprimary care provider(PCP)Means the entity contracting with the Collaborative to provide behavioral health services withthe use of non-Medicaid funds.Refers to individuals not eligible for Medicaid services under New Mexico’s Medicaid StatePlan.Means a licensed Medicare/Medicaid facility certified in accordance with 42 CFR § 483 toprovide inpatient room, board, and nursing services to members who require these serviceson a continuous basis but who do not require hospital care or direct daily care from aphysician.Refers to individuals who are eligible for Medicaid services under New Mexico’s MedicaidState Plan.Means, among other things, educating or informing the MCO’s members about CentennialCare, managed care, and health issues.Means Public Law 111-148 (2010) and the Health Care and Education Reconciliation Act of2010 (Public Law 111-152 (2010).Means a team-based model of care led by a personal physician who provides continuous andcoordinated care throughout a patient's lifetime to maximize health outcomes.Means covered services relating to an emergency medical condition that are provided after amember is stabilized in order to maintain the stabilized condition or, under the circumstancesdescribed in 42 CFR § 438.114(e), to improve or resolve the member’s condition.Includes licensed retail pharmacies, long-term care pharmacies, home infusion, I/T/Uprovider, school-based centers, mail order pharmacy, and specialty pharmacies. The ratio ofproviders in this network to members is determined by state and federal regulations.Provides the foundation for process-driven execution and excellence across our organization.This model guides our ongoing improvement of operational processes and provides acommon quality framework for measuring, monitoring, and communicating the of results ofimprovement initiatives.Means an individual who is a contract provider and has the responsibility for supervising,coordinating, and providing primary health care to members, initiating referrals for specialistcare and maintaining the continuity of the member’s care. Can include family practitioners,general practitioners, general internists, pediatricians, certified physician assistants, andcertified nurse practitioners, as well as other specialists that elect to perform in the role ofprimary care.Project ECHOMeans the Extension for Community Healthcare Outcomes program, conducted by theHSDUniversity of New Mexico School of Medicine. The program works to develop the capacity tosafely and effectively treat chronic, common, and complex diseases in rural and underservedareas and to monitor the outcomes of this treatment.promotorasAlso known as community health workers (CHWs), lay health workers, and advocates for PMmembers who assist individuals and families in obtaining the knowledge and skills necessaryto achieve optimal health and well-being.providerMeans an institution, facility, agency, physician, health care practitioner, or other entity that is HSDlicensed or otherwise authorized to provide any of the covered services in the state in whichthey are furnished. Providers include individuals and vendors providing services to membersthrough the Self-Directed Community Benefit.provider satisfactionAnnual provider satisfaction survey that covers contract providers and follows NCQAsurveyguidelines to the extent applicable.HSDprovider workgroup Means the workgroup consisting of representatives from all of the MCOs, HSD, the HSDHSDHSDHSDHSDHSDHSDHSDHSDPMHSDB-72014 Practitioner and Provider Manual - Ver. 3

Appendix B. DefinitionsTerm Definition SourceCollaborative, and providers who work collaboratively to reduce administrative burdens onproviders by, among other things, standardizing forms and processes.qui tamLatin for "who as well." A lawsuit brought by a private citizen (popularly called a "whistle see linkblower") against a person or company who is believed to have violated the law in theperformance of a contract with the government or in violation of a government regulation,when there is a statute which provides for a penalty for such violations.http://dictionary.law.com/Default.aspx?selected=1709recipientMeans an individual who is eligible for Presbyterian Healthcare Services but has not yet HSDenrolled in a MCO.reportable incident See critical incident. --representativeMeans a person who has the legal right to make decisions regarding a member’s protected HSDhealth information, and includes surrogate decision makers, parents of unemancipatedminors, guardians and treatment guardians, and agents designated pursuant to a power ofattorney for health care.rural Refers to the counties in the State of New Mexico that are not frontier or urban. HSDrural health clinic (RHC)school-based healthcentersself-directed communitybenefitMeans a public or private hospital, clinic, or physician practice designated by the federalgovernment as complying with the Rural Health Clinics Act, Public Law 95-210.Means outpatient clinics on school campuses that provide on-site primary, preventive, andbehavioral health services to students while reducing lost school time, removing barriers tocare, promoting family involvement, and advancing the health and educational success ofschool-age children and adolescents.Means certain home and community-based services that are available to members meetingnursing facility level of care.telehealthMeans the use of electronic information, imaging, and communication technologies (including HSDinteractive audio, video and data communications as well as store-and-forward technologies)to provide and support health care delivery, diagnosis, consultation, treatment, transfer ofmedical data, and education.tribalMeans of denoting an Indian or Alaska Native tribe, band, nation, pueblo, village, orHSDcommunity that the Secretary of the Interior acknowledges to exist as an Indian tribe pursuantto the Federally Recognized Indian Tribe List Act of 1994, 25 USC § 479a located wholly orpartially in the State of New Mexico.tribal 638 facilityMeans a facility operated by a Native American/Indian tribe authorized to provide services HSDpursuant to the Indian Self-Determination and Education Assistance Act, 25 USC 450 et seq.urbanMeans the following counties in New Mexico: Bernalillo, Los Alamos, Santa Fe, and Doña HSDAna.urban Indian Shall have the meaning ascribed to such term in 25 USC § 1603. HSDutilization management(UM)Means a system for reviewing the appropriate and efficient allocation of health care services HSDthat are provided, or proposed to be provided, to a member.value added service Means any service or benefit offered by the MCO that is not a covered service. HSDwaiverWaivers are vehicles that states can use to test new or existing ways to deliver and pay forhealth care services in Medicaid and the Children’s Health Insurance Program (CHIP). Thereare four primary types of waivers and demonstration projects:• Section 1115 Research & Demonstration Projects: States can apply for programflexibility to test new or existing approaches to financing and delivering Medicaid andCHIP.• Section 1915(b) Managed Care Waivers: States can apply for waivers to provideservices through managed care delivery systems or otherwise limit people’s choice ofproviders.• Section 1915(c) Home and Community-Based Services Waivers: States can apply forwaivers to provide long-term care services in home and community settings rather thaninstitutional settings.HSDHSDHSDCMSB-82014 Practitioner and Provider Manual - Ver. 3

Appendix B. DefinitionsTerm Definition Source• Concurrent Section 1915(b) and 1915(c) Waivers: States can apply to simultaneouslyimplement two types of waivers to provide a continuum of services to the elderly andpeople with disabilities, as long as all federal requirements for both programs are met.Waiver 1115New Mexico StateInsurance Coverage-TitleXIX ComponentWaiver 1115New Mexico CoverageInsurance Title XXIComponentWaiver 1115Centennial CareWaiver 1915(b)NM Behavioral HealthWaiverWaiver 1915(b)New Mexico SaludWaiver 1915(c)NM Mi Via-ICF/MR(0448.R01.00)Waiver 1915(c)NM Mi Via NF (0449.R01.00)Waiver 1915(c)NM Medically Fragile(0223.R04.00)According to information provided by the state, this demonstration provides coverage touninsured childless adults with income from 0 up to 200% of the federal poverty level (FPL)who are unemployed, self-employed, or employed by a small employer with fewer than 50employees. Employers and employees are required to contribute to the cost of coverage. Forthe Title XXI component of the State Coverage Insurance Section 1115 demonstration thatprovides coverage to parents up to 200 percent of the FPL, please see the separate listing forthe Title XXI New Mexico State Coverage Insurance Demonstration.According to information provided by the state, this demonstration permits the state to imposea six-month waiting period for the demonstration population, which is composed of uninsuredchildren from birth through age 18, from 185% FPL up to but not including 235% FPL.According to information provided by the state, Centennial Care designed to create acomprehensive managed care delivery system in New Mexico under which contracted healthplans will offer the full array of current Medicaid services, including acute, behavioral health,home and community–based, and long-term institutional care. This proposal would combineexisting section 1915(b), 1915(c), and 1115 waivers under a comprehensive demonstrationproject. Additional waivers and expenditure authorities are requested for variousprogrammatic and financing changes, including increased cost sharing for non-emergent useof the emergency room (ER) and credits for healthy behaviors. The state also seeks tocontinue its financial support for sole community providers, and to use some of the funds tosupport projects proposed by hospitals that will support the growth of the health careinfrastructure of the state.Managed care program which provides comprehensive mental health and substance abuseservices through collaboration and partnership with a single statewide contractor.Salud! was previously the umbrella name for New Mexico's Medicaid managed care program.Salud! Services were provided by contracted MCOs to provide Medicaid services to eligibleand enrolled citizens. Clients enrolled into the Salud! program had until the 25th day of theirthird month in a Salud! MCO to change to another MCO. After the third month with the sameMCO, clients were unable to change for the next nine months. Two months before the end oftheir nine-month enrollment period, clients got a letter that let them change their MCO.Provides consultant/support guidance, customized community supports, employmentsupports, homemaker/direct support services, respite, home health aide services, skilledtherapy for adults, personal plan facilitation, assisted living, behavior support consultation,community direct support, customized in-home living supports, emergency response services,environmental mods, nutritional counseling, private duty nursing for adults, related goods,specialized therapies, transportation for individuals with autism, DD, MR ages 0 – no maxage.Provides consultant/support guidance, customized community supports, employmentsupports, homemaker/direct support services, respite, home health aide services, skilledtherapy for adults, personal plan facilitation, assisted living, behavior support consultation,community direct support, customized in-home living supports, emergency response services,environmental mods, nutritional counseling, private duty nursing for adults, related goods,specialized therapies, transportation for aged individuals ages 65 – no max age and disabledindividuals ages 0 – 64.Provides case management, home health aide, respite, nutritional counseling, skilled therapyfor adults, behavior support consultation, private duty nursing, specialized medical equipmentand supplies for medically fragile individuals ages 0 – no max age.CMSCMSCMSCMSCMSCMSCMSCMSB-92014 Practitioner and Provider Manual - Ver. 3

Appendix B. DefinitionsTerm Definition SourceWaiver 1915(c)NM DD (0173.R05.00)Waiver 1915(c)NM AIDS (0161.R04.00)wasteProvides case management, community integrated employment, customized communitysupports, living supports, personal support, respite, nutritional counseling, occupationaltherapy (OT) for adults, physical therapy (PT) for adults, speech and language therapy foradults, supplemental dental care, assistive technology, behavior support consultation, crisissupport, customized in-home supports, environmental mods, independent living transition,intensive medical living supports, non-medical transportation, personal support technology/onsiteresponse, preliminary risk screening and consultation related to inappropriate sexualbehavior, private duty nursing for adults, socialization and sexuality education for individualswith autism, intellectual disability (ID), DD ages 0 – no maximum age.Provides case management, homemaker/personal care, private duty nursing for individualswith HIV/AIDS ages 0 – no max age.Means an act involving payment or the attempt to obtain payment for items or services wherethere was no intent to deceive or misrepresent, but where the outcome of poor or inefficientmethods resulted in unnecessary costs to the plan.CMSCMSPM-16B-102014 Practitioner and Provider Manual - Ver. 3

Appendix C. WebsitesAppendix C. WebsitesAppendix C. WebsitesWebsitesNameAccess of Service StandardsAmerican Psychiatric Association (APA) and theAmerican Academy of Pediatrics (AAP) Resourcesand GuidanceWebsite Locationhttp://docs.phs.org/resources/documents/accessibility.pdfAPA Bipolar Disorderhttp://psychiatryonline.org/content.aspx?bookid=28&sectionid=1669577APA Major Depressionhttp://psychiatryonline.org/guidelines.aspxAPA Schizophreniahttp://psychiatryonline.org/content.aspx?bookid=28&sectionid=1665359AAP Attention Deficit Hyperactivity Disorder (ADHD)http://pediatrics.aappublications.org/content/105/5/1158.full.pdf+html?sid=f4a99748-b682-4ec4-a4f3-8d545eb204a6Appeals and Grievances WebpageAsthma Resources and Guidancehttps://www.phs.org/providers/clinicians-resources/appealsgrievances/Pages/default.aspxGuidelines for the Diagnosis and Management of Asthma Full Report (NationalAsthma Education and Prevention Program, National Heart, Lung, and BloodInstitute)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1029224.pdfGuidelines for the Diagnosis and Management of Asthma Summary Report(National Asthma Education and Prevention Program, National Heart, Lung, andBlood Institute)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1000916.pdfGuidelines for the Diagnosis and Management of Asthma – Full Report ChangePage (National Heart, Lung, and Blood Institute)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031055.pdfAttention Deficit/Hyperactivity Disorder (ADHD)ResourcesADHD Diagnosis and Evaluation Guidelineshttp://pediatrics.aappublications.org/content/105/5/1158.full.pdf+html?sid=f4a99748-b682-4ec4-a4f3-8d545eb204a6Treatment of School-Aged Children with ADHDhttp://pediatrics.aappublications.org/content/108/4/1033.full.pdf+htmlADHD Quick Reference Guidehttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/wcmdev1000899.pdfAvaility ®www.availity.comC-12014 Practitioner and Provider Manual - Ver. 3

Appendix C. WebsitesWebsitesNameBecome a Contracted Provider Sign Up Page(PHS)Behavioral Health Resources (PHS)Care Continuum AllianceCAQH WebsiteClaim.MDClaim MD Fast Claim EnrollmentClaims Processing Page (PHS)Classification of Diseases, Functioning, andDisabilityCLIA Waived Test ListClinicians Resources (PHS)CMS Carriers Manual and Hospital ManualWebsite Locationhttps://www.phs.org/providers/Pages/become-contracted-provider.aspxhttps://www.phs.org/providers/clinicians-resources/Pages/behavioral-health.aspxhttp://www.carecontinuumalliance.org/http://www.caqh.org/http://www.claim.md/https://www.claim.md/phs.plxwww.phs.org/providers/training-reference/claims/http://www.cdc.gov/nchs/icd.htmhttp://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdfhttps://www.phs.org/providers/clinicians-resources/http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.htmlCMS Provider UpdatesFee-for-Service Provider Updateshttp://www.cms.gov/Center/Provider-Type/All-Fee-For-Service-Providers-Center.html?redirect=/center/provider.aspQuarterly Provider Updateshttp://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.htmlCoding and Reimbursement Store (AMA)Contact Presbyterian Webpage (PHS)https://commerce.amaassn.org/store/catalog/categoryDetail.jsp?category_id=cat1150004&navAction=jumphttps://www.phs.org/about-us/contact-us/Coronary Artery Disease Resources and GuidanceAHA/ACC Secondary Prevention for Patients with Coronary and Other VascularDisease: 2006 Update (American College of Cardiology and the American HeartAssociation)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00052254.pdfCoronary Artery Disease Clinical Practice Guidelines (American College ofCardiology and the American Heart Association)http://docs.phs.org/idc/groups/public/@phs/@marketing/documents/phscontent/wcmdev1000934.pdfCoronary Artery Disease Clinical Recommendations for Prevention of HeartDisease in Women (American Heart Association)http://docs.phs.org/idc/groups/public/@phs/@marketing/documents/phscontent/wcmdev1000935.pdfC-22014 Practitioner and Provider Manual - Ver. 3

Appendix C. WebsitesWebsitesNameCultural Competency Resource KitWebsite Locationhttps://www.magellanprovider.com/MHS/MGL/education/culturalcompetency/index.aspDentaquest Websitewww.dentaquestgov.comDepression Guidelines for Primary CarePractitioners Treating Adult Patients withDepression (PHS)Depression Recognition Tools: PHQ-9 and OtherInformation (PHS)Diabetes Clinical Practice Guidelines forProviders–Non-Pregnant Adult (PHS)Drug Prior Authorization Request Form (PHS)EHR Medicare and Medicaid Incentive Programhttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/wcmdev1001004.pdfhttp://www.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001006.pdfhttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001010.pdfhttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001068.pdfOfficial Web Site for the Medicare and Medicaid Electronic Health Records (EHR)Incentive Programshttp://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/40_MedicaidStateInfo.aspRegistration and Attestation Websitehttps://ehrincentives.cms.govDHHS Office of the National Coordinator for Health Information Technology, “EHRIncentives and Certification”http://www.healthit.gov/providers-professionals/faqs/ehr-incentive-payment-scheduleElectronic Code of Federal RegulationsEmdeon Business ServiceseNews Registration for Providers (PHS)Epocrates ® WebsiteEPSDT Provider Manual (PHS)Fraud and Abuse Information and Reporting Page(PHS)Gateway EDIGeneral Services Administration’s System forAward Management (GSA SAM)Geographic Availability Standards (PHS)http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tplhttp://www.emdeon.comhttps://www.phs.org/providers/news-communications/Pages/enews-registration.aspxhttp://www.epocrates.comhttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001063.pdfhttps://www.phs.org/insurance-plans/all-about-health-care/faqs/fraudabuse/Pages/default.aspxwww.gatewayedi.comhttps:www.sam.gov/portal/public/SAM/http://docs.phs.org/idc/groups/public/documents/phscontent/wcmdev1001078.pdfC-32014 Practitioner and Provider Manual - Ver. 3

Appendix C. WebsitesWebsitesNameHealthECHealth Services Resources and Forms (PHS)HealthXnet ®HIPAA Final Omnibus Rule ResourcesWebsite Locationhttp://www.healthec.com/https://www.phs.org/providers/clinicians-resources/Pages/health-services.aspxhttp://www.healthxnet.comFederal Register Releasehttp://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01073.pdDepartment of Health and Human Serviceshttp://www.hhs.gov/ocr/privacy/hipaa/administrative/omnibus/index.htmlAmerican Medical Association, “The Health Insurance Portability andAccountability Act (HIPAA) Omnibus Final Rule Summary”http://www.ama-assn.org/resources/doc/washington/hipaa-omnibus-final-rulesummary.pdfThe American Academy of Orthopaedic Surgeons, “What You Need to Knowabout the HIPAA Omnibus Rule”http://www.aaos.org/news/aaosnow/jul13/managing4.aspHIPAA ResourcesAmerican Medical Associationhttp://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-yourpractice/coding-billing-insurance/hipaahealth-insurance-portability-accountabilityact.pageDepartment of Health and Human Serviceshttp://www.hhs.gov/ocr/privacy/index.htmlCenter for Medicare and Medicaid Serviceshttp://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/HIPAAGenInfo/index.htmlHIPAA Training MaterialsInstamed Presbyterian Health Plan PayerPaymentsList of Excluded Individuals and Entities,Department of Health and Human Services/Officeof Inspector General (DHHS/OIG)Magellan EDI Testing CenterMagellan Provider WebsiteMcKessonMedAssetsMedical Policy Manual (PHS)http://www.hhs.gov/ocr/privacy/hipaa/understanding/training/index.htmlwww.instamed.com/presbyterian-health-plan-payer-payments/https://oig.hhs.gov/exclusions/exclusions_list.asphttps://www.edi.magellanprovider.com/index.jspwww.magellanprovider.comhttp://www.mckesson.comhttp:/www.medassets.comhttps://www.phs.org/providers/clinicians-resources/medical-policymanual/Pages/default.aspxC-42014 Practitioner and Provider Manual - Ver. 3

Appendix C. WebsitesWebsitesNameMember Download Library (PHS)MLN Store (CMS)MyChart Information Page (PHS)myPRES Sign In Page (PHS)National Center for Health StatisticsNational Committee for Quality Assurance (NCQA)WebsiteNational Correct Coding Initiative EditsNational Drug Code Billing Procedure Manual forProviders (PHS)National Provider Identifier (NPI)New Mexico Human Services Department MedicalAssistance DivisionNew Mexico Immunization Program WebsiteNovitas Solutions, Inc.Obesity ResourcesWebsite Locationhttps://www.phs.org/insurance-plans/member-download-libraryhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index.htmlhttps://www.phs.org/better-health/access-your-care/Pages/access-your-healthinformation.aspxhttps://mypres.phs.org/Pages/default.aspxhttp://www.cdc.gov/nchs/http://www.ncqa.orghttp://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEdhttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00079542.pdfhttps://nppes.cms.hhs.gov/http://www.hsd.state.nm.us/mad/http://www.immunizenm.org/Provider/vacchild.shtmlhttps://www.novitas-solutions.com/Getting in Balance Worksheet to Identify Overall Weight-Related Health Risk(Clinical prevention Initiative)http://www.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031069.pdfOverweight & Obesity in Primary Care (Clinical Prevention Initiative)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1030683.pdfQuick Discussion Guide for Adult Weight Counseling in Primary Care (ClinicalPrevention Initiative)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031068.pdfGetting in Balance Worksheet to Identify Overall Weight-Related Health Risk(Clinical prevention Initiative)http://www.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031069.pdfQuick Discussion Guide for Adult Weight Counseling in Primary Care (ClinicalPrevention Initiative)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031068.pdfC-52014 Practitioner and Provider Manual - Ver. 3

Appendix C. WebsitesWebsitesNameOffice AllyOffice of Inspector General: US Department ofHealth and Human Services WebsitePalmetto GBA for HCPCS information and theDMERC ManualPayerpathPharmacy Resources and FormsPresbyterian Health Services WebsitePreventative Health Care Guidelines forPractitioners (PHS)Preventative Health Care Guidelines WebsitePrior Authorization Guide for Practitioners andProviders (PHS)Provider Compliance Group Interactive MapProvider Homepage (PHS)Provider Network Relations Contact Guide (PHS)Provider Request for Information FormProvider News and Communications (PHS)RelayHealthSilverSneakers ®State of New Mexico Regulations & LicensingDepartmentThink Cultural HealthTricore Laboratory LocationsUpdate Provider Directory Form (PHS)Vaccines for Children Program Information (CDC)Workgroup on Electronic Data Interchange (WEDI)Website Locationwww.officeally.comhttp://oig.hhs.gov/http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/97NK5W3580?openwww.payerpath.comhttps://www.phs.org/providers/clinicians-resources/Pages/pharmacy-resources.aspxhttp://www.phs.orghttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001475.pdfhttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001400.pdfhttps://www.phs.org/better-health/access-your-care/Pages/preventive-careguidelines.aspxhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.htmlhttps://www.phs.org/providers/Pages/default.aspxhttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdfhttps://www.phs.org/providers/training-reference/Pages/request-for-information.aspxhttps://www.phs.org/providers/news-communicationswww.relayhealth.comwww.silversneakers.comhttp://www.rld.state.nm.us/https://www.thinkculturalhealth.hhs.gov/http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00078812.pdfhttps://www.phs.org/providers/training-reference/Pages/update-provider-directory.aspxhttp://www.cdc.gov/vaccines/programs/vfc/index.htmlhttp://www.wedi.org/C-62014 Practitioner and Provider Manual - Ver. 3

Appendix C. WebsitesWebsitesNameWEDI Health Record SystemsWebsite Locationhttp://www.wedi.org/topics/health-records-management-systems/C-72014 Practitioner and Provider Manual - Ver. 3

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Appendix C. WebsitesAppendix D. Phone NumbersAppendix D. Phone NumbersPhone NumbersNamePhone NumberAdult Protective Services 1-866-654-3219Air Transportation Request (PHS) 505-923-5757 or 1-888-923-5757 (Option 4)American Medical Association (AMA) CPT Products 1-800-621-8335Availity ® 1-800-AVAILTY (282-4548)Behavioral Health Care Coordination (PHS) Commercial/ Presbyterian Senior Care (HMO) members: 505-923-5221or 1-866-593-7431Behavioral Health Customer Service (PHS) 505-923-5678Centennial Care members: 505-923-8858 or 1-866-672-1242Behavioral Health Requests (PHS)505-923-5221 or 1-866-593-7431 (phone)505-213-0169 (fax)Capario 1-800-586-6938Care Coordination Unit (PHS)1-866-672-1242 or 505-923-8858 (phone)505-213-0063 (fax)Children, Youth, and Families Department (CYFD) 1-800-797-3260Claim.MD 505-757-6060Department of Health/Division of Health Improvement (DOH/DHI) 1-800-445-6242DentaQuest (Dental Care)Durable Medical Equipment (DME) Requests (PHS)1-855-390-6424 (phone)1-262-241-7150 (fax)505-213-0246 (fax)E-Help Desk (PHS) 505-923-5590 or 1-866-861-7444Emdeon Business Services Customer Support: 1-877-469-3263Corporate Office: 1-615-932-3000Federal Funded Pregnancy Termination Request (fax) 505-923-5489Gateway EDI, Inc. 1-800-969-3666Health Services (PHS) 505-923-5757 or 1-888-923-5757 (option 4)D-12014 Practitioner and Provider Manual - Ver. 3

Appendix D. Phone NumbersPhone NumbersNamePhone NumberHealthy Solutions Disease Management Program (PHS) 1-800-841-9705HealthEC 1-877-444-7194HealthXnet ® User Administration and Help DeskHome Health Care Requests (PHS)505-346-0290 or 1-866-676-0290 (phone)505-346-0278 (fax)505-559-1151 or 1-877-606-1151 (Option 4) (phone)505-559-1000 (24/7 phone)505-559-1150 (local fax)1-877-606-1155 (toll-free fax)Immunization Hotline (PHS) 1-888-231-2367Inpatient Concurrent Review or Inpatient Hospital Admission(PHS)Inpatient Prior Authorization Requests (PHS)505-923-5757 or 1-888-923-5757 (option 4)505-213-0181 or 1-888-923-5990 (fax)505-213-0181 or 1-888-923-5990 (fax)Instamed 1-866-945-79901-877-755-3392 (fax)Interactive Voice Response (IVR) (PHS) 505-923-5757 or 1-888-923-5757 (Option 1)Magellan EDI Support 1-800-450-7281Long-Term Care Prior Authorization Request (PHS) 505-213-01811-888-923-5990 (fax)MedAssets Main Office: 1-678-323-2500Product Information: 1-888-883-6332Tech Support: 1-866-658-1629New Mexico Human Services Department Fair Hearing Bureau 505-476-6213 or 1-800-432-6217 (option 6)505-476-6215 (fax)NurseAdvice ® New Mexico Centennial Care members 505-923-5677 or 1-888-730-2300Presbyterian Senior Care (HMO) and MediCare PPO members 1-800-887-9917Presbyterian Commercial Members 1-866-221-9679Presbyterian Employees and Dependents 1-800-905-3282Office Ally1-866-575-4120 (phone)1-360-896-2151 (fax)Outpatient Services (PHS) 505-923-5757 or 1-888-923-5757 (option 4)505-213-0246 (fax)D-22014 Practitioner and Provider Manual - Ver. 3

Appendix D. Phone NumbersPhone NumbersNamePhone NumberPayerpath 1-877-623-5706Pharmacy Requests (PHS) 505-323-5757 (option 3) or 1-888-923-5757 (option 3)Pharmacy Services Helpdesk (PHS)505-923-5500 or 1-888-923-5757 (phone)1-877-640-5814 (toll free fax)Provider CARE Unit (PHS) 505-923-5757 or 1-888-923-5757Provider Network Management e-Business Analyst (PHS) 505-923-8726Presbyterian Customer Service Center (PCSC) 505-923-5200 or 1-888-977-2333Prior Authorization Line (PHS) 505-923-5757 or 1-888-923-5757 (Option 4)Quality and Population Health Management Resource Line (PHS)505-923-5017 or 1-866-634-2617 (message only)Quality Management Department (PHS) 505-923-5516Radiology/Diagnostic Imaging Requests (HealthHelp ® )1-888-318-0280 (phone)1-888-717-9655 (fax)RelayHealth 1-800-527-8133 (Option 2)SilverSneakers ® Fitness Program 1-888-423-4632Special Investigative Unit (SIU) Confidential Hotline 505-923-5959 or 1-800-239-3147Superior Medical Transport 1-877-735-0111 (toll free) or 505-341-0042University of New Mexico Case Managers 505-272-2910University of New Mexico Prior Authorization Requests505-213-0149 (fax)Vaccines for Children (VFC) Program Director (PHS) 505-827-2898D-32014 Practitioner and Provider Manual - Ver. 3

Appendix D. Phone NumbersPhone NumbersNameTriCore Telephone NumbersPhone NumberMain Numbers505-938-8888 (24 hours)1-800-245-3296 (24 hours)Client Services505-938-8922 or 1-800-245-3296 (24 Hours)Client SuppliesFor phone or fax orders:505-938-8957 (phone)1-800-245-3296 ext. 8957 (phone)505-938-8472 (fax)For online supply orders, call the Supply Order Desk505-938-8957 or 1-800-245-3296, ext. 8957Logistics/Couriers505-938-89581-800-532-2649505-954-3780 (Santa Fe)IS Help Desk (printer, TriCore Express TriCore Direct and computerinterfaceassistance)505-938-8974 or 1-800-245-3296, ext. 8974Sales and Service505-938-8917 or 1-800-245-3296, ext. 8917Billing/Business Office505-938-8910 or 1-800-541-9557505-938-8640 (fax)University of New Mexico (UNM) Case Management Program 505-272-2910Vaccines for Children (VFC) Program Director (PHS) 505-827-2898VSP Vision Services 1-800-852-7600D-42014 Practitioner and Provider Manual - Ver. 3

Appendix B: Business Associate AgreementAppendix E. Business Associate AgreementAppendix E. BusinessAssociate AgreementE-12014 Practitioner and Provider Manual - Ver. 3

Appendix E. Business Associate AgreementE-22014 Practitioner and Provider Manual - Ver. 3

Appendix E. Business Associate AgreementE-32014 Practitioner and Provider Manual - Ver. 3

Appendix E. Business Associate AgreementE-42014 Practitioner and Provider Manual - Ver. 3

Appendix E. Business Associate AgreementE-52014 Practitioner and Provider Manual - Ver. 3

Appendix E. Business Associate AgreementE-62014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideAppendix F. Prior Authorization GuideAppendix F. PriorAuthorization GuideCovered ServicesIs PriorAuthorizationRequired?Exclusions and Limitations*Member must be < 21 years of ageaccredited residentialtreatment center servicesadaptive skills building(autism)adult day health(ABCB service**)adult psychologicalrehabilitation servicesYesYesYesYesNONCOVERED SERVICES: Services furnished in residential treatment centers aresubject to the limitations and coverage restrictions which exist for other Medicaidservices. See 8.301.3 NMAC, General Noncovered Services. Medicaid does not coverthe following specific services for recipients in residential treatment centers:• A. Services not considered medically necessary for the condition of the recipient, asdetermined by PHP• B. Services for which prior approval was not requested• C. Services furnished to ineligible individuals; residential treatment center servicesare covered only for recipients under 21 years of age• D. Services furnished after Medical Assistance Division (MAD) or its designeedetermines that the recipient no longer needs Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) accredited residential treatment center care• E. Formal educational and services which relate to traditional academic subjects orvocational training• F. Experimental or investigational procedures, technologies, or non-drug therapiesand related services• G. Drugs classified as “ineffective” by the FDA drug evaluation• H. Activity therapy, group activities, and other services primarily recreational ordiversional in natureMember must be < 19, unless in high school, in which case benefits can be continued upto age 22. Services received under the federal Individuals with Disabilities EducationImprovement Act of 2004 and related state laws that place responsibility on state andlocal school boards for providing specialized education and related services to children 3to 22 years of age who have autism spectrum disorder are not covered under this plan.Only for those who qualify for Nursing Facility Level of Care and select Agency BasedCommunity Benefits (ABCB). Services must be at least 2 hours per day for one or moredays per week.• A. Adult day health services can be provided only by eligible adult day healthagencies.• B. Adult day health facilities must be licensed by Department of Health (DOH) as anadult day care facility.• C. Adult day health facilities must meet all requirements and regulations set forth byDOH as an adult day care facility.• D. An adult day health care provider agency must comply with the provisions ofTitle II and III of the Americans with Disabilities Act of 1990 (42 U.S.C. Section12101 et seq.).• E. An adult day health care provider agency must comply with all applicable city,county, or state regulations governing transportation services. This service is notprovided to ABCB recipients in Assisted Living facilities.Pending final determination of behavioral health UM criteria.F-12014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered Servicesambulatory surgical centerservicesanesthesia servicesassertive communitytreatment servicesassisted living(ABCB service**)behavior management skillsdevelopment servicesIs PriorAuthorizationRequired?YesYes for selectservicesYesYesYesExclusions and Limitations*NONCOVERED SERVICES: If the surgery is non-covered, the anesthesia is noncovered.• A. Direct payment to physician. Ambulatory surgical centers are not reimbursed byPHP for physician fees. Reimbursement for physician fees is made directly to theprovider of the service.• B. Services furnished to dual-eligible recipients. By federal regulation, the Medicareprogram pays ambulatory surgical centers only for an approved list of specificsurgical procedures. Medicare is the primary payment source for individuals whoare eligible for both Medicare and Medicaid. For these recipients, Medicaid doesnot pay an ambulatory surgical center for a surgical procedure denied by Medicare.Ambulatory surgical centers must refer these recipients to facilities where Medicarepays for the surgical procedure, such as an outpatient hospital.Anesthesia for pain management and dental procedures require prior authorization.Electronic Claims Transmission (ECT) does not require a separate authorization foranesthesia.• A. When a provider performing the medical or surgical procedure also provides alevel of anesthesia lower in intensity than moderate or conscious sedation, such asa local or topical anesthesia, payment for this service is considered to be part of theunderlying medical or surgical service and is not covered in addition to theprocedure.• B. An anesthesia service is not payable if the medical or surgical procedure is not aMedicaid or other health care benefit.• C. Separate payment is not allowed for qualifying circumstances; payment isconsidered bundled into the anesthesia allowance.• D. Separate payment is not allowed for modifiers (modifiers that begin with theletter “P”) that are used to indicate that the anesthesia was complicated by thephysical status of the patient.Pending final determination of behavioral health UM criteria.This benefit is only for those who qualify for Nursing Facility Level of Care and selectagency based community benefits. The following services are not provided to recipientsin assisted living facilities: personal care, respite, environmental modifications,emergency response or adult day health. The assisted living program is responsible forall of these services at the assisted living facility and are included in the cost of room andboard.PHP does not cover the following specific services in conjunction with behaviormanagement services:• A. Formal educational or vocational services related to traditional academicsubjects or vocational training• B. Activities which are not designed to accomplish the objectives delineated incovered services and which are not included in the behavioral managementtreatment plan• C. Residential treatment careELIGIBLE RECIPIENTS:• A. Behavior management services can be furnished only to Medicaid recipientsunder 21 years of age who:• (1) Are at risk for out-of-home placement because of unmanageable behavior athome or within the community• (2) Need behavior management intervention to avoid inpatient hospitalizations orresidential treatment• (3) Require behavior management support following institutional or other out-of-F-22014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered Servicesbehavior supportconsultation(ABCB service**)(SDCB service***)behavioral healthprofessional services:outpatient behavioral healthand substance abuseservicescare coordinationcase managementcommunity transitionservices(ABCB service**)community health workerscomprehensive communitysupport services (CCSS)customized communitysupports (SDCB)day treatment servicesIs PriorAuthorizationRequired?YesNoNoNoLTSSNoYesYesYesExclusions and Limitations*home placement as a transition to maintain the recipient in the home andcommunity• B. To receive services, recipients must meet the level of care for this serviceestablished by PHP.This is only available to members who meet the Nursing Facility Level of Care criteriaand must be included in the member's care plan and approved by the UM review team.• A. Limited to $3,500 per person every five years. To be eligible, a person must havea nursing facility stay of at least 90 days before transition to the community.• B. Only for those who qualify for Nursing Facility Level of Care and select AgencyBased Community BenefitsCCSS may not be filled in conjunction with the following PHP services:• A. Multi-systemic therapy• B. Assertive community treatment• C. Accredited residential treatment• D. Residential treatment• E. Group home services• F. Inpatient hospitalization• G. Partial hospitalization• H. Treatment foster care• A. Provided at least four or more hours per day, one or more days per week andcannot duplicate community direct support services, employment support services,or any other long-term care service.• B. Only for those who qualify for Nursing Facility Level of Care and select Self-Directed Community Benefits.Member must be < 21 years of age. PHP does not cover the following specific daytreatment activities:• A. Educational programs• B. Vocational training which is related to specific employment opportunities, workskills, or work settings• C. Pre-vocational training• D. Any service not identified in the treatment plan• E. Recreation activities not related to the treatment issues• F. Leisure time activities such as watching television, movies, or playing computergames• G. Transportation reimbursement for the therapist who delivers services in thefamily’s home• H. Services for which prior authorization was not obtained• I. Day treatment services cannot be offered at the same time as partial hospitalprogram or any residential programdental services Yes Benefit managed by DentaQuest, which has published criteria.F-32014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered Servicesdiagnostic imaging andtherapeutic radiologyservices (for imaging)dialysis servicesdurable medical equipment(DME) and suppliesIs PriorAuthorizationRequired?Yes for high-costservicesNoYes for selectitemsExclusions and Limitations*Benefit managed by PHP Care Review team using HealthHelp ® , which has publishedcriteria listing exclusions and limitations.Benefit managed by PHP Care Review team using HealthHelp ® , which has publishedcriteria.• A. Special requirements for purchase of wheelchairs: Before billing for a customizedwheelchair, the provider who delivers the wheelchair and seating system to aneligible recipient must make a final evaluation to ensure that the wheelchair andseating system meets the medical, social, and environmental needs of the eligiblerecipient for whom it was authorized.• (1) The provider assumes responsibility for correcting defects or deficiencies inwheelchair and seating systems that make them unsatisfactory for use by theeligible recipient.• (2) The provider is responsible for consulting physical therapists, occupationaltherapists, special education instructors, teachers, parents or guardians, asnecessary, to ensure that the wheelchair meets the eligible recipient’s needs.• (3) Evaluations by a physical therapist or occupational therapist are required whenordering customized wheelchairs and seating systems. These therapists should befamiliar with the brands and categories of wheelchairs and appropriate seatingsystems and work with the eligible recipient and those consultants listed inParagraph (2) of Subsection B of 8.324.5.14 NMAC to assure that the selectedsystem matches physical seating needs. The physical or occupational therapistmay not be a wheelchair vendor or under the employment of a wheelchair vendoror wheelchair manufacturer.• (4) PHP does not pay for special modifications or replacement of customizedwheelchairs after the wheelchairs are furnished to the eligible recipient.• (5) When the equipment is delivered to the eligible recipient and the eligiblerecipient accepts the order, the provider submits the claim for reimbursement.• B. Special requirements for purchase of augmentative and alternativecommunication devices (AACDs):• (1) The purchase of AACDs requires prior authorization. In addition to beingprescribed by a physician, the communication device must also be recommendedby a speech-language pathologist, who has completed a systematic andcomprehensive evaluation. The speech pathologist may not be a vendor ofaugmentative communication systems nor have a financial relationship with avendor.• (2) A trial rental period of up to 60 calendar days is required for all electronicdevices to ensure that the chosen device is the most appropriate device to meetthe eligible recipient’s medical needs. At the end of the trial rental period, ifpurchase of the device is recommended, documentation of the eligible recipient’sability to use the communication device must be provided showing that the eligiblerecipient’s ability to use the device is improving and that the eligible recipient ismotivated to continue to use this device.• (3) PHP does not pay for supplies for AACDs, such as but not limited to paper,printer ribbons, and computer discs.• (4) Prior authorization is required for equipment repairs.• (5) A provider or medical supplier that routinely supplies an item to an eligiblerecipient must document that the order for additional supplies was requested bythe recipient or their personal representative and the provider or supplier mustconfirm that the eligible recipient does not have in excess of a 15-calendar-daysupply of the item before releasing the next supply order to the eligible recipient. Aprovider must keep documentation in their files available for audit that showcompliance with this requirement.F-42014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered Servicesemergency response(ABCB service**)(SDCB service***)emergency services(including ER visits andpsychiatric ER)employment supports(ABCB service**)(SDCB service***)environmentalmodifications(ABCB service**)(SDCB service***)experimental/investigationalprocedures, technology, ornon-drug therapiesearly and periodicscreening, diagnosis, andtreatment (EPSDT)Is PriorAuthorizationRequired?YesNoYesYesYesExclusions and Limitations*• A. member must have a land line phone.• B. Only for those who qualify for Nursing Facility Level of Care.• C. This benefit is not provided to members living in assisted living facilities. Theservice is not provided to recipients in assisted living facilities.• A. Payment shall not be made for incentive payments, subsidies, or unrelatedvocational training expenses.• B. Only for those who qualify for Nursing Facility Level of Care.• A. Environmental Modification services are limited to $5,000 every five years.Additional services may be requested if an eligible recipient’s health and safetyneeds exceed the specified limit. Excluded are those adaptations or improvementsto the home that are of general utility and are not of direct medical or remedialbenefit to the eligible recipient. Adaptations that add to the total square footage ofthe home are excluded from this benefit except when necessary to complete anadaptation.• B. Only for those who qualify for Nursing Facility Level of Care.• C. This benefit is not provided to members living in assisted living facilities.PHP does not cover experimental or investigational medical, surgical, or other healthcare procedures or treatments, including the use of drugs, biological products, otherproducts or devices, except for the following: PHP provides coverage for routine patientcare costs incurred as a result of the patient’s participation in a Phase I, II, III, or IVcancer trial that meets the following criteria. The clinical trials can only be performed inNew Mexico.• A. The cancer clinical trial is being conducted with approval of at least one of thefollowing:• (1) One of the federal National Institutes of Health• (2) A federal National Institutes of Health cooperative group or center; 8.325.6NMAC 1• (3) The federal Department of Defense• (4) The federal Food and Drug Administration in the form of an investigational newdrug application• (5) the federal Department of Veteran Affairs• (6) S qualified research entity that meets the criteria established by the federalnational institutes of health for grant eligibility• B. The clinical trial has been reviewed and approved by an institutional reviewboard that has a multiple project assurance contract approved by the office ofprotection from research risks of the federal National Institutes of Health.No These services are limited to members under the age of 21.These services are limited to members under the age of 21.EPSDT personal careservices(ABCB service**)(SDCB service***)YesNONCOVERED SERVICES:Services that are not covered under the New Mexico Medicaid EPSDT personal careprogram are as follows:• A. Any task that must be provided by a person with professional or technicaltraining, such as but not limited to insertion and irrigation of catheters, nebulizertreatments, irrigation of body cavities, performance of bowel stimulation, applicationof sterile dressings involving prescription medications and aseptic techniques, tubefeedings, and administration of medications;.F-52014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered ServicesEPSDT private duty nursing(ABCB service**)(SDCB service***)EPSDT rehabilitationservices(ABCB service**)(SDCB service***)family planningfamily supportfederally qualified healthcenter serviceshearing aids and relatedevaluationsIs PriorAuthorizationRequired?YesYesNoNoNoYes for hearing aidonly not forevaluationExclusions and Limitations*• B. Services that are not in the recipient’s approved treatment plan and for whichprior approval has not been received;.• C. Services not considered medically necessary by PHP or its designee for thecondition of the recipient.These services are limited to members under the age of 21. Also, private duty nursingservices must be furnished by a registered nurse or a licensed practical nurse in arecipient’s home or in a school setting, if it is medically necessary for school attendance.The goal of the provision of care is to avoid institutionalization and maintain therecipient’s function level in a home setting.• A. EPSDT private duty nursing services” means nursing services for recipientsunder 21 years of age who require more individual and continuous care than can bereceived through the home health program.• B. EPSDT private duty nursing services must be ordered by the recipient’sphysician and must be included in the recipient’s approved treatment plan. Servicesfurnished must be medically necessary and be within the scope of the nursingprofession.NONCOVERED SERVICES: Private duty nursing services are subject to the limitationsand coverage restrictions which exist for other Medicaid services.Medicaid does not cover the following specific services:• A. Services for which prior approval has not been received or which are notincluded in the recipient’s approved treatment plan• B. Services not considered medically necessary by PHP or its designees for thecondition of the recipient• C. Services which are not within the scope of practice of the nursing professionThese services are limited to members under the age of 21.NONCOVERED SERVICES:• A. Services furnished by speech and language pathologists, physical therapists andoccupational therapists are subject to the limitations and coverage restrictions thatexist for other Medicaid services.• B. Medicaid does not cover these specific services:• (1) Services furnished to individuals who are not eligible for EPSDT services• (2) Services for which prior approval has not been received• (3) Services that are not within the scope of practice of the speech and languagepathologist physical therapist or occupational therapist• (4) Services furnished without the order or prescription of a physician or PCP• (5) Services that are primarily educational or vocational in nature• (6) Services related to activities for the general good and welfare of recipients,such as general exercises to promote overall fitness and flexibility and activities toprovide general motivation, are not considered physical or occupational therapy forMedicaid reimbursement purposesHearing aid and related evaluation services are subject to the limitations and coveragerestrictions that exist for other Medicaid services. Medicaid does not pay for “hearing aidchecks” (assessing a hearing aid for functionality). Hearing aid selection and fitting isconsidered included in the hearing aid dispensing fee, and is not reimbursed separately.F-62014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered Serviceshome health aide(ABCB service**)(SDCB service***)home health serviceshomemaker(SDCB service***)hospice serviceshospital inpatient (includingdetoxification services)hospital outpatientIndian Health servicesIP hospitalization infreestanding psychiatrichospitalsIntensive OutpatientProgram (IOP) servicesIs PriorAuthorizationRequired?YesYesYesYesYesNo, but PHPreserves the rightsto implementprocess foroverutilizersNoYesYesExclusions and Limitations*Only for those who qualify for Nursing Facility Level of Care.Home health services are subject to the limitations and coverage restrictions of otherMedicaid services. See Section MAD-602, General Noncovered Services [now 8.301.3NMAC, General Noncovered Services]. PHP does not cover the following home healthagency services:• A. Services beyond the initial evaluation which are furnished without prior approval.• B. Home health services which are not skilled, intermittent, and medicallynecessary.• C. Services furnished to recipients who do not meet the eligibility criteria for homehealth services.• D. Services furnished to recipients in places other than their place of residence.• E. Services furnished to recipients who reside in intermediate care facilities for thementally retarded or nursing facility (NF) residents who require a high NF level ofservice. Physical, occupational, and speech therapy can be furnished to residentsof nursing facilities who require a low level of service.• F. Skilled nursing services which are not supervised by registered nurses.• G. Services not included in written plans of care established by physicians inconsultation with the home health agency staff.• A. An individual may not access assisted living services and homemaker servicesat the same time and this benefit may not be accessed by members under 21 yearsof age. Homemaker services should not take the place of home health aideservices.• B. Only for those who qualify for Nursing Facility Level of Care and select Self-Directed Community Benefits.For a recipient to be eligible for hospice care, a physician must provide a writtencertification that the recipient has a terminal illness. Recipients must elect to receivehospice care for the duration of the election period. Certification statements must includeinformation that is based on the recipient's medical prognosis, and the life expectancy issix months or less if the terminal illness runs its typical course. If a recipient receiveshospice benefits beyond 210 days, the hospice must obtain a written recertificationstatement from the hospice medical director or the physician member of the hospiceinterdisciplinary group before the 210-day period expires.This does not cover inpatient detoxification, which is a medical benefit managed by PHPUtilization Management.The duration of IOP intervention is typically three to six months. The number of weeklyservices per member is directly related to the goals and objectives specified in themember’s treatment or service plan. PHP does not cover the following specific servicesfor an eligible recipient in freestanding psychiatric hospitals:• A. Services not considered medically necessary for the condition of the eligiblerecipient, as determined by PHP• B. Conditions defined only by V codes in the current version of the internationalF-72014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered ServicesIs PriorAuthorizationRequired?Exclusions and Limitations*classification of diseases (ICD) or the current version of diagnostic statistical manual(DSM)• C. Services for which prior authorization was not obtained• D. Services in freestanding psychiatric hospital for eligible recipient 21 years of ageor older• E. Services furnished after the determination by PHP or its designee has beenmade that the eligible recipient no longer needs hospital care• F. Formal educational or vocational services related to traditional academic subjectsor vocational training; PHP only covers non-formal education services if they arepart of an active treatment plan for an eligible recipient under the age of 21 receivinginpatient psychiatric services; see 42 CFR Section 441.13(b)• G. Experimental or investigational procedures, technologies, or non-drug therapiesand related services or treatment• H. Drugs classified as "ineffective" by the FDA drug evaluation• I. Activity therapy, group activities, and other services primarily recreational ordiversional in nature• J. PHP covers “awaiting placement days” in freestanding psychiatric hospitals whenthe PHP utilization review contractor determines that an eligible recipient under 21years of age no longer meets acute care criteria and the children’s mental healthservices review panel determines that the eligible recipient requires a psychosocialresidential level of care which cannot be immediately located• K. Those days during which the eligible recipient is awaiting placement to the lowerlevel of care are termed awaiting placement days• L. Payment to the hospital for awaiting placement days is made at the weightedaverage rate paid by PHP for psychosocial accredited residential services foreligible recipients classified as Level III, IV, or IV+ plus five percent; a separateclaim form must be submitted for awaiting placement daysICF/MR Yes Must meet Nursing Facility Level of Care criteria. member must be 18 years or older.IV OP serviceslab servicesmedical services providersmedication assistedmedical treatment (Tx) foropioid dependencemidwife servicesmulti-systemic therapy(MST) servicesnon-accredited residentialTx centers and grouphomesYesNo except forselect high-costtestsNo, but reserverights to implementprocess foroverutilizersYes formedications only,not for office visitYesYesYes for specificdefined criteriaMedicaid does not cover the following specific services furnished by midwives:• A. Oral medications or medications, such as ointments, creams, suppositories,ophthalmic, and otic preparations which can be appropriately self-administered bythe recipient• B. Services furnished by an apprenticeMST intervention is typically three to six months. Weekly interventions may range fromthree to 20 hours a week. The number might be less as a case nears closure.Member must be under 21 years of age. PHP does not cover the following specificactivities furnished in non-accredited residential treatment centers or group homes:• A. Services not considered medically necessary for the condition of the recipients,as determined by PHP• B. Room and board• C. Services for which prior approval was not obtainedF-82014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered ServicesIs PriorAuthorizationRequired?Exclusions and Limitations*• D. Services furnished after the determination is made by PHP or its designee thatthe recipient no longer needs care• E. Formal educational or vocational services related to traditional academicsubjects or vocational training• F. Experimental or investigations procedures, technologies, or non-drug therapiesand related services• G. drugs classified as “ineffective” by FDA drug evaluations• H. Activity therapy, group activities, and other services which are primarilyrecreational or diversional in naturenursing facility services YesFor custodial care in a skilled nursing facility, member must meet the Nursing FacilityLevel of Care criteria.nutritional counseling(SDCB service***)nutritional servicesobservation in hospitalgreater than 24 hoursoccupational services(therapy)outpatient hospital basedpsychiatric services andpartial hospitalizationoutpatient and partialhospitalization infreestanding psychiatrichospitalOutpatient health careprofessional servicespersonal care services(ABCB service**)pharmacy servicesphysical health servicesphysical therapyYesNoYesYesYes for partialhospitalization, Nofor outpatientYes for partialhospitalization, Nofor outpatientNoYesYesNo, but reserverights to implementprocess foroverutilizersYesThis benefit is only for those who qualify for Nursing Facility Level of Care and selectSelf-Directed Community Benefits.PHP does not cover the following specific services:• A. Services not considered medically necessary for the condition of the recipient asdetermined by PHP• B. Dietary counseling for the sole purpose of weight loss• C. Weight control and weight management programs• D. Commercial dietary supplements or replacement products marketed for theprimary purpose of weight loss and weight management.Authorization does not exceed 48 total hours.• A. These services are not provided 24 hours per day.• B. Only for those who qualify for Nursing Facility Level of Care and select agencybasedcommunity benefits (ABCB).• C. Personal care services do not include those services for tasks the individual isalready receiving from other sources including tasks provided by natural supports.Natural supports are friends, family, and the community (through individuals, clubs,and organizations) that are able and consistently available to provide supports andservices to the consumer. This service is not provided to ABCB recipients inassisted living facilities.F-92014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered Servicesphysician visitspodiatry servicespregnancy terminationprocedurespreventative servicesprivate duty nursing foradults(ABCB service**)(SDCB service***)prosthetics and orthoticspsychosocial rehabilitationservicesIs PriorAuthorizationRequired?Not for PCP visits,but specialtyreferrals mayrequire a referral toobtain anauthorization #Certain servicesrequireauthorizationNoNoYesYesYesExclusions and Limitations*• A. Routine foot care is not covered except as indicated under “covered services” foran eligible recipient with systemic conditions meeting specified class findings.Routine foot care is defined as:• (1) trimming, cutting, clipping, and debriding toenails• (2) cutting or removal of corns, calluses, or hyperkeratosis• (3) other hygienic and preventative maintenance care such as cleaning andsoaking of the feet, application of topical medications, and the use of skin creamsto maintain skin tone in either ambulatory or bedfast patients• (4) any other service performed in the absence of localized illness, injury orsymptoms involving the foot• B. Services directed toward the care or correction of a flat foot condition. “Flat foot”is defined as a condition in which one or more arches of the foot have flattened out.• C. Orthopedic shoes and other supportive devices for the feet are generally notcovered. This exclusion does not apply if the shoe is an integral part of a leg braceor therapeutic shoes furnished to diabetics.• D. Surgical or nonsurgical treatments undertaken for the sole purpose of correctinga subluxated structure in the foot as an isolated condition are not covered.Subluxations of the foot are defined as partial dislocations or displacements of jointsurfaces, tendons, ligaments, or muscles of the foot.• E. Orthotripsy is not a covered service.This benefit is only for those who qualify for Nursing Facility Level of Care. The membermust be 21 years of age or older. All services provided under private duty nursingrequire the skills of a Licensed Registered Nurse or a Licensed Practical Nurse underwritten physician’s order in accordance with the New Mexico Nurse Practice Act, Code ofFederal Regulation for Skilled Nursing.Private duty nursing services are subject to the limitations and coverage restrictionswhich exist for other Medicaid services. See 8.301.3 NMAC, General NoncoveredServices. PHP does not cover the following specific services:• A. Services for which prior approval has not been received or which are notincluded in the recipient’s approved treatment plan• B. Services not considered medically necessary by PHP for the condition of therecipient• C. Services which are not within the scope of practice of the nursing professionNONCOVERED SERVICES:Prosthetic and orthotic services are subject to the limitations andcoverage restrictions that exist for other Medicaid services. See 8.301.3 NMAC, GeneralNoncovered Services [MAD-602]. In addition to the services identified in 8.301.3 NMAC[MAD-602], General Noncovered Services, the following services are not covered:• A. Orthotic supports for the arch or other supportive devices for the foot, unlessthey are integral parts of a leg brace or therapeutic shoes furnished to diabetics• B. Prosthetic devices or implants that are used primarily for cosmetic purposesPHP covers only those psychosocial rehabilitation services which comply with DOHmental health standards as detailed in the psychiatric rehabilitation user’s manual andF-102014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered Servicesradiology facilities(for imaging)rehabilitation optionservicesrehabilitation servicesprovidersrelated goods(SDCB service***)reproductive healthservicesIs PriorAuthorizationRequired?No priorauthorization forthe facility isneeded. Thespecific service tobe provided mayrequire priorauthorization.YesYesYesNoExclusions and Limitations*are medically necessary to meet the individual needs of the recipient, as delineated inthe treatment plan. Medical necessity is based upon the recipient’s level of functioningas affected by the mental disability. The services are limited to goal-orientedpsychosocial rehabilitative services which are individually designed to accommodate thelevel of the recipient’s functioning and which reduce the disability and restore therecipient to his or her best possible level of functioning.Criteria in process of development.PHP does not cover the following rehabilitation services:• A. Services furnished by providers who are not licensed and/or certified to furnishservices• B. Educational programs or vocational training not part of an active treatment planfor residents in an intermediate care facility for the mentally retarded or forrecipients under the age of 21 receiving inpatient psychiatric services [42 CFRSection 441.13 (b)]• C. Services billed separately by home health agencies, independent physicaltherapists, independent occupational therapists, or outpatient rehabilitation centersto recipients in high-level nursing facilities or inpatient hospitals• D. Transportation, for recipients in low-level nursing facilities or other Medicaidrecipients, to travel to outpatient hospital facilities unless there are no home healthagencies, independent physical therapists, or independent occupational therapistsavailable in the area to provide the therapy at the recipient’s residence• E. Services solely for maintenance of the recipient’s general condition; theseservices include repetitive services needed to maintain a recipient’s functional levelthat do not involve complex and sophisticated therapy procedures requiring thejudgment and skill of a therapist; services related to activities for the general goodand welfare of recipients, such as general exercises to promote overall fitness andflexibility and activities to provide general motivation, are not considered physical oroccupational therapy for Medicaid reimbursement purposes.• A. Related goods are limited to $500 per person per year. Related goods do notinclude services, service agreements or insurance.• B. Only for those who qualify for Nursing Facility Level of Care and select Self-Directed Community Benefits.• A. Sterilization services: PHP covers medically necessary sterilizations only underthe following conditions.• (1) Recipients are at least 21 years old at the time consent is obtained.• (2) Recipients are not mentally incompetent. “Mentally incompetent” is adeclaration of incompetency as made by a federal, state, or local court. A recipientcan be declared competent by the court for a specific purpose, including the abilityto consent to sterilization.• (3) Recipients are not institutionalized. For this section, “institutionalized” is definedas:– (a) An individual involuntarily confined or detained under a civil or criminalstatute in a correctional or rehabilitative facility, including a mental hospital or anintermediate care facility for the care and treatment of mental illnessF-112014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered ServicesIs PriorAuthorizationRequired?Exclusions and Limitations*– (b) Confined under a voluntary commitment in a mental hospital or other facilityfor the care and treatment of mental illness• (4) Recipients seeking sterilization must be given information regarding theprocedure and the results before signing a consent form. This explanation mustinclude the fact that sterilization is a final, irreversible procedure. Recipients mustbe informed of the risks and benefits associated with the procedure;.• (5) Recipients seeking sterilization must also be instructed that their consent canbe withdrawn at any time before the performance of the procedure and that theydo not lose any other Medicaid benefits as a result of the decision to have or nothave the procedure.• (6) Recipients voluntarily give informed consent to the sterilization procedure. See42 CFR Section 441.257(a):– (a) The consent to sterilization form is signed by the recipient at least 30 daysbefore performance of the operation, except in the case of premature deliveriesor emergency abdominal surgery when the consent form must be signed notless than 72 hours before the time of the premature delivery.– (b) A consent form is valid for 180 days from the date of signature.– (c) Consent is not valid if obtained during labor or childbirth, while the recipientis under the influence of alcohol or other drugs, or is seeking or obtaining aprocedure to terminate pregnancy.– (d) Providers obtaining the consent for sterilization must certify that to the bestof their knowledge that the recipient is eligible, competent, and voluntarilysigned the informed consent.– (e) Providers must provide an interpreter if needed to ensure that the recipientunderstands the information furnished.– (f) The recipient is given a copy of the completed, signed consent form and theoriginal is placed in the recipient’s medical record.• B. Hysterectomies: Medicaid covers only medically necessary hysterectomies. PHPdoes not cover hysterectomies performed for the sole purpose of sterilization. See42 CFR Section 441.253.• (1) Hysterectomies require a signed, voluntary informed consent whichacknowledges the sterilizing results of the hysterectomy. The form must be signedby recipients before the operation.• (2) Acknowledgement of the sterilizing results of the hysterectomy is not requiredfrom recipients who have been previously sterilized or who are past child-bearingage as defined by the medical community.• (3) An acknowledgement can be signed after the fact if the hysterectomy isperformed in an emergency.• C. Other covered services:• Medicaid covers medically necessary methods, procedures, pharmaceuticalsupplies and devices to prevent unintended pregnancy, or contraception includingoral contraceptives, condoms, intrauterine devices (IUD), depoprovera injections,diaphragms, and foams.NONCOVERED SERVICES: Reproductive health care services are subject to the samelimitations and coverage restrictions which exist for other Medicaid services. See SectionMAD-602, General Noncovered Services [now 8.301.3 NMAC, General NoncoveredServices].In addition, Medicaid does not cover the following specific services:• A. Sterilization reversalsF-122014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered Servicesrespite(ABCB service**)(SDCB service***)rural health clinic (RHC)servicesschool-based servicesskilled maintenance therapyservices(ABCB service**)(SDCB Service***)Is PriorAuthorizationRequired?YesServices providedby RHC havesamerequirements asother providersNoYesExclusions and Limitations*• B. Fertility drugs• C. In vitro fertilization• D. Artificial insemination• E. Elective procedures to terminate pregnancy• F. Hysterectomies performed for the sole purpose of family planning• A. Respite services are limited to a maximum of 100 hours annually per care planyear, provided there is a primary caretaker. Additional hours may be requested if amember’s health and safety needs exceed the specified limit. For members up to21 years of age diagnosed with a serious emotional or behavioral health disorder,respite services are limited to 720 hours a year or 30 days.• B. Respite services are only for those who qualify for Nursing Facility Level of Careor for select behavioral health patients.Services furnished in school settings are subject to the limitations and coveragerestrictions that exist for other Medicaid services. See 8.301.3 NMAC [MAD-602],General Noncovered Services. PHP does not cover the following specific services:• A. Services classified as educational• B. Services to non-Medicaid eligible individuals• C. Services furnished by providers outside their area of expertise• D. Vocational training that is related solely to specific employment opportunities,work skills, or work settings• E. Services that duplicate services furnished outside the school setting, unlessdetermined to be medically necessary, and given prior authorization by the medicalassistance division or its designee• F. Services not identified in the recipient’s Individual Education Program orIndividualized Family Service Plan, and not authorized by the recipient’s PCP• G. Transportation that a recipient would otherwise receive in the course of attendingschool• H. Transportation for a recipient with special education needs under the Individualswith Disabilities Education Act (IDEA), who rides the regular school bus to and fromschool with other non-disabled children• A. A signed therapy referral for treatment must be obtained from the recipient'sprimary care physician. The referral includes frequency, estimated duration oftherapy, and treatment/procedures to be rendered.• B. Only for those who qualify for Nursing Facility Level of Care.• C. Member must be at least 21 years of age.smoking cessation services NoMember must be over the age of 18. Coverage is limited to two 90-day courses oftreatment per calendar year.• A. Experimental or prohibited treatments and goods are excluded. Related goodsspecialized therapiesare limited to $500 per person per care plan year.Yes(SDCB service***)• B. Only for those who qualify for Nursing Facility Level of Care and select Self-Directed Community Benefits.speech and languagetherapyYesThis benefit is only provided to adults with short-term needs because of an acute event.swing bed hospital servicesYestelehealth services(provider telehealth, nothome-based telehealth)NoF-132014 Practitioner and Provider Manual - Ver. 3

Appendix F. Prior Authorization GuideCovered ServicesTot-to-Teen health checkstransplant servicestransportation services(medical)transportation services(non-medical)(SDCB service***)treatment foster caretreatment foster care IIIs PriorAuthorizationRequired?NoYesNo, except for airtransport. Benefitmanaged by avendor.YesYesYesExclusions and Limitations*value added services Yes Varies by benefitPHP does not cover any transplant procedures, treatments, use of drug(s), biologicalproduct(s), product(s), or device(s) which are considered unproven, experimental,investigational, or not effective for the condition for which they are intended or used.• A. Not to be used for transportation to medical appointments, etc., and not to beused for purposes of vacation• B. Only for those who qualify for Nursing Facility Level of Care and select Self-Directed Community BenefitsTreatment foster care services are subject to the limitations and coverage restrictionswhich exist for other Medicaid services. See 8.301.3 NMAC, General NoncoveredServices. PHP does not cover the following services:• A. Room and board• B. Formal educational or vocational services related to traditional academicsubjects or vocational training• C. Respite careTreatment foster care services are subject to the limitations and coverage restrictionswhich exist for other Medicaid services. See 8.301.3 NMAC, General NoncoveredServices. PHP does not cover the following services:• A. Room and board• B. Formal educational or vocational services related to traditional academicsubjects or vocational training• C. Respite carePHP does not cover the following specific vision services:• A. Orthoptic assessment and treatment• B. Photographic procedures, such as fundus or retinal photography and externalocular photography• C. Polycarbonate lenses other than for prescriptions for high acuity• D. Ultraviolet (UV) lenses• E. Trifocalsvision care servicesYes • F. Progressive lenses• G. Tinted or photochromic lenses, except in cases of documented medicalnecessity; see Subsection D of 8.310.6.12 NMAC above• H. Oversize frames and oversize lenses• I. Low-vision aids• J. Eyeglass cases• K. Eyeglass or contact lens insurance• L. Anti-scratch, anti-reflective, or mirror coatingTo be eligible for community benefits (self-directed community benefits and agency-based community benefits), members must meet medicaleligibility (nursing facility level of care) and financial eligibility. The member’s care coordinator completes a comprehensive needs assessment,which forms the basis for the development of an individual plan of care that includes recommended community benefit services based on theneeds of the individual. All recommended community benefits must be reviewed and approved by a PHP secondary review team before theprovision of services.* Presbyterian edits the prior authorization list as updates are needed. Please visithttp://www.phs.org/PHS/healthplans/providers/healthservices/ to check for the most recent version of this list.** ABCB is an agency-based community benefit service.*** SDCB is a self-directed community benefit service.F-142014 Practitioner and Provider Manual - Ver. 3

Appendix G. Alternative BenefitsG. Alternative Benefits Package Covered ServicesPackage Covered ServicesAppendix G. Alternative Benefits Package Covered ServicesCovered Service Description Prior AuthorizationAutism spectrum disorder Limitation: Services are only available to members through age 22. NoBariatric surgeryBehavioral health professionalservicesCancer Clinical TrialsLimitation: One surgery covered per lifetime. Criteria may be applied thatconsiders previous attempts by the member to lose weight, BMI and healthstatus.These include evaluations, therapy, and tests by licensed practitioners.This is a course of treatment provided to a patient for thepurpose of prevention of reoccurrence, early detection or treatment of cancerthat is being provided in New Mexico.YesNoNoCardiac rehabilitation Limitation: 36 hours per cardiac event NoChemotherapyChemotherapy is the use of chemical agents in the treatment or control ofdisease.NoDental services See Page 6-16. Yes, for select servicesand dental proceduresDiabetes treatment, includingdiabetic shoes and suppliesThis covers office visits, diabetes education and diabetic supplies includingdiabetic shoes, Insulin and diabetic oral agents for controlling blood sugar.Diabetic supplies used on an inpatient basis, applied as part of treatment in apractitioner’s office, outpatient hospital, residential facility, or a home healthservice, are covered when separate payment is allowed in these settings.Yes, for select servicesDiagnostic imaging andtherapeutic radiology servicesDialysis servicesDurable Medical Equipment (DME)and suppliesElectroconvulsive therapyCovered services include medically necessary imaging exams and radiologyservices ordered by doctors or other licensed providers. Some examples ofthese services are X-ray, ultrasound, magnetic resonance imaging (MRI),and computerized tomography (CT) scans.Medicaid covers medically necessary dialysis services and supplies furnishedto members receiving dialysis at home as well as services received from acontracted provider.This is equipment that is medically necessary for treatment of an illness oraccidental injury. It might also be needed to prevent further deterioration.DME is designed for repeated use. It includes items like oxygen equipmentand supplies necessary to use equipment wheelchairs, crutches and items toassist with treatment such as casts and splints that are applied by thehealthcare practitioner.ECT is a medical treatment for severe mental illness in which a small,carefully controlled amount of electricity is introduced into the brain, and isused to treat a variety of psychiatric disorders, including severe depression.Yes, for select servicesNoSome services mayrequire priorauthorizationYesEmergency services See Page 9-10. NoG-12014 Practitioner and Provider Manual - Ver. 3

Appendix G. Alternative Benefits Package Covered ServicesCovered Service Description Prior AuthorizationEarly and Periodic Screening,Diagnosis and Treatment (EPSDT)Extended care hospitals (longterm care hospitals)See Page 5-3. Available to members under 21 years old only.Extended care hospitals are not covered. Sometimes these are referred toas long term care hospitals (certified as acute care hospitals but focus oncare for more than 25 days)Nursing Facility long term care stays are not covered by ABP except as atemporary step down level of care following discharge from a hospital prior tobeing discharged to home. Refer to page 1-4 for more information.NoYesFamily planning See Page 6-15. NoHearing aids and relatedevaluationsHome health servicesHospice servicesRoutine hearing screenings and evaluations are covered withoutauthorization. Hearing aids and their accessories and supplies are notcovered. Hearing testing by an audiologist or a hearing aid dealer is notcovered.These cover services that are skilled and medically necessary. Services mustbe ordered by the member’s attending doctor and included in the care planestablished by the member’s attending doctor. The plan of care must bereviewed, signed, and dated by the attending doctor.Limitation: 100 visits per year. A visit cannot exceed four hours.These inpatient and in-home hospice services are designed to keep youcomfortable if you are terminally ill. An approved hospice program mustprovide these services during a hospice benefit period. Hospice servicesrequire prior authorization. You must be a covered member throughout yourhospice benefit period.The hospice benefit period is defined as follows:Beginning on the date your provider certifies that you are terminallyill with a life expectancy of six months or less.Ending six months after it began, unless you require an extensionof the hospice benefit period below, or upon your death.If you need an extension of the hospice benefit period, the hospice mustprovide a new treatment plan. Your provider also must reauthorize yourmedical condition to us. We will not authorize more than one additionalhospice benefit period.NoYesYes, inpatient onlyIf the hospice recipient requires Nursing Facility level of care, the recipientwill have to meet the requirements for receiving Nursing Facility care.Hospital inpatient (includingdetoxification services)Indian Health ServicesHospital stays must be provided under the direction of the member’s PCP ora consulting provider referred to the member by his PCP. All cases andtreatment must be medically necessary. Acute medical detoxification benefitsare covered under inpatient services.Indian Health Services (IHS) is the primary provider of healthcare services forthe tribal nations and pueblos. Members may self-refer to IHS facilities.YesNoG-22014 Practitioner and Provider Manual - Ver. 3

Appendix G. Alternative Benefits Package Covered ServicesCovered Service Description Prior AuthorizationInpatient hospitalization infreestanding psychiatric hospitalsIntravenous (IV) outpatientservicesThese services include necessary evaluations and psychological testing fortreating severe emotional or substance abuse problems. They also includeregularly scheduled structured counseling and therapy sessions. Theseservices are only for individuals under 21 years of age. Inpatient drugrehabilitation services are not covered. Acute inpatient services for “detox”are covered.Hospital outpatient care includes the use of intravenous (IV) infusions,catheter changes, first aid for IV associated injuries, laboratory and radiologyservices, and diagnostic and therapeutic radiation, including radioactiveisotopes. A partial hospitalization in a general hospital psychiatric unit isconsidered an outpatient service.YesNoSome medications mayrequire priorauthorizationLaboratory servicesThese are medically necessary lab services ordered by doctors or otherlicensed providers. They are performed by ordering providers or are doneunder their supervision in an office lab. They also can be performed by aclinical lab.This includes laboratory genetic testing to specific molecular lab tests suchas BRCA1 and BRCA2 and similar tests used to determine appropriatetreatment. Does not include random genetic screening.NoMedication Assisted Treatment(MAT) for opioid dependenceThis service is treatment for addiction that includes the use of medicationalong with counseling and other support.Midwife services See Page F-8. NoYes, for medicationsonly. Not for officevisitsNutritional counselingOccupational therapyDietary evaluation of counseling as medical management of a documenteddisease, including obesity.These promote fine motor skills, coordination, and integration of the senses.They help the member use adaptive equipment or other technology.Limitation: Short-term therapy only for a two-month period from the initialdate of treatment.YesNoOutpatient hospital-basedpsychiatric services and partialhospitalizationThese services are medically necessary for the diagnosis and/or treatment ofa mental illness, as indicated by the member’s condition. Services andstabilization must be for the purpose of diagnostic study or be expected toimprove the member’s condition.No, outpatient servicesprovided in hospitalsettingOutpatient health careprofessional servicesPharmacy services See Page 8-2.These cover outpatient assessments, evaluations, testing, and therapy.Certain over-the-counter drugs are covered, such as prenatal drug items(examples –vitamins, folic acid; iron), low dose aspirin as preventative forcardiac conditions; contraception drugs and devices, and items for treatingdiabetes.Yes, for partialhospitalization andpsychological testing.No, for evaluations andtesting. Sometherapies may requireprior authorization.Yes, for selectmedicationsG-32014 Practitioner and Provider Manual - Ver. 3

Appendix G. Alternative Benefits Package Covered ServicesCovered Service Description Prior AuthorizationPhysical therapy servicesThese services promote gross and fine motor skills, help with independentfunctioning and prevent progressive disabilities.NoLimitation: Short-term therapy only for a two-month period from the initialdate of treatment.Physician visitsThese are provider services required by members to maintain good health.They include but are not limited to periodic exams and office visits providedby licensed providers.NoPodiatry servicesThese are only medically necessary podiatric services given by providers, asrequired by the member’s condition.Covered services includeRoutine foot care when there is evidence of a systemic condition,circulatory distress, or areas of diminished sensation in the feetdemonstrated through physical or clinical examRoutine foot care, non-surgical and surgical correction of asubluxated foot structureTreatment of warts on the feetTreatment of asymptomatic nails with a fungal infection may becoveredOrthopedic shoes and other supportive devices only when the shoe is anintegral part of a leg brace or therapeutic shoes furnished to diabetics.NoPregnancy terminationproceduresSee Page 18-8.Preventive services See Page 6-23. NoNoProsthetics and orthoticsPulmonary rehabilitationProsthetics and orthotics supplied by providers are covered only when certainrequirements or conditions are satisfied. Prosthetic devices are replacementsor substitutes for a body part or organ, such as an artificial limb or eye.Orthotic devices support or brace the body, such as trusses, compressioncustom-made stockings, and braces.Limitation: Foot orthotic, including shoe and arch supports, are only coveredwhen an integral part of a leg brace or diabetic shoes.Limitation: 36 hours per year.YesNoReproductive health services See Pages F-11 and F-12. NoSkilled nursingSkilled nursing is generally provided only through a home health agency.However, it can also be provided through private duty nursing.YesSmoking cessation/ tobaccoservicesThese include diagnostic services, tobacco/smoking cessation counselingand pharmacotherapy. Group counseling, including classes or a telephoneQuit Line, are covered when offered by an in-network provider. Someorganizations, such as the American Cancer Society and the Tobacco UsePrevention and Control (TUPAC), offer group counseling services at nocharge.NoG-42014 Practitioner and Provider Manual - Ver. 3

Appendix G. Alternative Benefits Package Covered ServicesCovered Service Description Prior AuthorizationTobacco/smoking cessation pharmacotherapy is prescriptiondrugs/medications prescribed by your provider for a 30-day supply up to themaximum dose recommended by the manufacturer. These medications can bepurchased at a pharmacy. Coverage is limited to two 90-day courses oftreatment per calendar year.Specialized behavioral healthservices for adultsSpeech and language therapyTelehealth servicesThese include Intensive Outpatient (IOP), Assertive Community Treatment(ACT) and Psychosocial Rehabilitation (PSR).This is a covered benefit for members under the age of 21. The servicesmust be provided by speech and language pathologists, physical therapists,and occupational therapists. Services must be prescribed or ordered by themember’s PCP or other doctor.Limitation: Short-term therapy only for a two-month period from the initialdate of treatment.An interactive telehealth communication system that must include bothinteractive audio and video. It must be delivered on a real-time basis at theoriginal site and distant sites. Providers may use telehealth when it isavailable for the following services:ConsultationsEvaluation and management servicesIndividual psychotherapyPharmacologic managementPsychiatric diagnostic interview examsEnd-stage renal disease-related servicesIndividual medical nutrition servicesNoNoNoTransplant servicesThese include hospital, doctor, laboratory, outpatient surgical, and othercovered services needed to perform a transplant.YesLimitation: 2 per lifetime.Transportation services (medical)Vision servicesPresbyterian covers expenses for transportation and other related expenseswhich are determined as necessary to secure Medicaid-covered medicalexaminations and treatment for eligible recipients in or out of their homecommunity. Travel expenses include the cost of transportation by publictransportation, taxicab, handivan, and ground or air ambulance. Relatedtravel expenses include the cost of meals and lodging made necessary byreceipt of medical care away from the recipient’s home community. Whenmedically necessary, Medicaid covers similar expenses for an attendant whoaccompanies the recipient to the medical examination or treatment.The diagnoses and treatment of eye diseases and the correction of visionproblems.Certain types of glasses are not covered. See the Non-covered Benefits list.Exclusion: Refractions are not covered.Limitation: Eyeglasses and contact lenses are only covered for aphakiafollowing the removal of the lens.NoSome services requireprior authorizationG-52014 Practitioner and Provider Manual - Ver. 3

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Appendix G. Alternative Benefits Package Covered ServicesG-72014 Practitioner and Provider Manual - Ver. 3