2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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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
Behavioral HealthThis page intentionally left blank9-142014 Practitioner and Provider Manual - Ver. 3
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ii2014 Practitioner and Provider Ma
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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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Care CoordinationPresbyterian’s c
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Care Coordinationthe program. If th
Page 53 and 54: Care Coordinationdesignated family
Page 55 and 56: Care CoordinationFacilitate access
Page 57 and 58: Care CoordinationClinical Practice
Page 59 and 60: Care Coordinationformula, which is
Page 61 and 62: Care CoordinationAmerican Psychiatr
Page 63 and 64: Care Coordinationwithout obtaining
Page 65 and 66: Care CoordinationSpecialists as PCP
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
Page 91 and 92: PharmacyThis page intentionally lef
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
Page 99 and 100: Behavioral HealthAn initial PCP con
Page 101 and 102: Behavioral HealthAccess StandardsMe
Page 103: Behavioral HealthThere is no charge
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
Page 131 and 132: Home HealthThis page intentionally
Page 133 and 134: Quality Improvement ProgramNational
Page 135 and 136: Quality Improvement Programcomplian
Page 137 and 138: Quality Improvement Programresults
Page 139 and 140: Quality Improvement Programrespect
Page 141 and 142: Quality Improvement ProgramPresbyte
Page 143 and 144: Quality Improvement ProgramNCQA ori
Page 145 and 146: Quality Improvement ProgramThis pag
Page 147 and 148: Health Insurance Portability and Ac
Page 149 and 150: Health Insurance Portability and Ac
Page 151 and 152: Legalabove, nor from any recourse a
Page 153 and 154: 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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