2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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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
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Nurse Advice Line .................
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Pharmacy Benefits .................
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Clearinghouses ....................
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Site Visits .......................
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Monitoring ........................
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Federally Funded Terminations .....
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Appendix A. Acronyms ..............
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1. Presbyterian Healthcare Services
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Presbyterian Healthcare Services(HS
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Presbyterian Healthcare ServicesReg
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Presbyterian Healthcare Services2.
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Provider Network Managementthis man
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Centennial Care Overview3. Primary
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Primary Care ProvidersClaims Activi
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Primary Care Providers4. Specialist
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SpecialistsOther Information for PC
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Specialists5. Preventive Health Car
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Preventive Health Care GuidelinesPr
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Preventive Health Care GuidelinesSe
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Care Coordination6. Care Coordinati
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Page 51 and 52: Care Coordinationthe program. If th
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Page 55 and 56: Care CoordinationFacilitate access
Page 57 and 58: Care CoordinationClinical Practice
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Page 61 and 62: Care CoordinationAmerican Psychiatr
Page 63 and 64: Care Coordinationwithout obtaining
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Page 67 and 68: Care Coordinationor when the member
Page 69 and 70: Care Coordination11. Prevention Scr
Page 71 and 72: Care CoordinationFollow-up plans or
Page 73 and 74: Care CoordinationPharmacy BenefitsP
Page 75 and 76: Care CoordinationThis page intentio
Page 77 and 78: Laboratory ServicesTriCore Contact
Page 79 and 80: Pharmacya multi-tier formulary stru
Page 81 and 82: Pharmacymedications. This multi-tie
Page 83 and 84: PharmacyCatastrophic coverage: Cove
Page 85 and 86: Pharmacywhich drugs are mandated th
Page 87 and 88: PharmacyThe drug must be accepted f
Page 89 and 90: PharmacyTypes of Pharmacy Prior Aut
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Page 93 and 94: Behavioral Healthagreements, addend
Page 95 and 96: Behavioral HealthForm W-9Staff rost
Page 97 and 98: Behavioral Healthhttps://www.phs.or
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Page 103 and 104: Behavioral HealthThere is no charge
Page 105 and 106: Behavioral HealthThis page intentio
Page 107 and 108: Long-Term Carean individual provide
Page 109 and 110: Long-Term Careavailable services, a
Page 111 and 112: Long-Term Carethe agent to members
Page 113 and 114: Long-Term Carecare at the right tim
Page 115 and 116: Long-Term Careplanning process, and
Page 117 and 118: Long-Term Carebudget plan are suffi
Page 119 and 120: Long-Term CareOrganizationsFor the
Page 121 and 122: Home HealthPresbyterian’s credent
Page 123 and 124: Home HealthPresbyterian Medicaid me
Page 125 and 126: Home Healththese services. Services
Page 127 and 128: Home Healthfor review will be submi
Page 129 and 130: Home HealthPatient Care Conferences
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Page 133 and 134: Quality Improvement ProgramNational
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Page 137 and 138: Quality Improvement Programresults
Page 139 and 140: Quality Improvement Programrespect
Page 141 and 142: Quality Improvement ProgramPresbyte
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Page 145 and 146: Quality Improvement ProgramThis pag
Page 147 and 148: Health Insurance Portability and Ac
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Legalabove, nor from any recourse a
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Legalagreement with Presbyterian fo
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Legaltransactions (federal, state,
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Legalcontractual relationship with
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Legalcomply with all state and fede
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Legalany such program during the te
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LegalPrompt Pay by PresbyterianPres
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Legal15. Fraud, Waste, and Abuse15.
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Fraud, Waste, and Abuseas the time
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Fraud, Waste, and AbuseAll document
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Fraud, Waste, and AbuseVerifying th
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Fraud, Waste, and AbuseHistorically
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Fraud, Waste, and Abuseis violated
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Fraud, Waste, and AbuseIs informed
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Fraud, Waste, and Abuse16. Credenti
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Credentialing and RecredentialingPr
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Credentialing and RecredentialingNe
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Credentialing and Recredentialing17
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e-BusinessFill out the form on the
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e-BusinessSign Up for this Free Ser
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e-BusinessClearinghouse Contact Inf
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e-Business18. Claims and Payment18.
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Claims and Paymentsubmission. Claim
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Claims and PaymentSpecify the origi
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Claims and Paymentrequiring a leadi
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Claims and PaymentPlease note that
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Claims and PaymentPresbyterian is r
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Claims and Paymentnot made a recove
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Claims and PaymentAcceptable docume
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Claims and Paymentallowing provider
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Claims and PaymentNational Correct
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Claims and Payment19. Presbyterian
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Presbyterian Customer Service Cente
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Appeals and Grievances20. Appeals a
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Appeals and GrievancesMember Appeal
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Appendix A. AcronymsAppendix A. Acr
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Appendix A. AcronymsHMOHRAHSDHealth
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Appendix A. AcronymsWWEDIWorkgroup
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Appendix B: DefinitionsAppendix B.
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Appendix B. DefinitionsTerm Definit
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Appendix C. WebsitesAppendix C. Web
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Appendix C. WebsitesWebsitesNameCul
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Appendix C. WebsitesWebsitesNameMem
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Appendix C. WebsitesWebsitesNameWED
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Appendix C. WebsitesAppendix D. Pho
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Appendix D. Phone NumbersPhone Numb
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Appendix B: Business Associate Agre
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Appendix E. Business Associate Agre
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Appendix E. Business Associate Agre
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Appendix F. Prior Authorization Gui
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Appendix G. Alternative BenefitsG.
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Appendix G. Alternative Benefits Pa
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