2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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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
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Page 8 and 9: Nurse Advice Line .................
Page 12 and 13: Clearinghouses ....................
Page 14 and 15: Site Visits .......................
Page 16: Monitoring ........................
Page 19 and 20: Federally Funded Terminations .....
Page 21 and 22: Appendix A. Acronyms ..............
Page 23 and 24: 1. Presbyterian Healthcare Services
Page 25 and 26: Presbyterian Healthcare Services(HS
Page 27 and 28: Presbyterian Healthcare ServicesReg
Page 29 and 30: Presbyterian Healthcare Services2.
Page 31 and 32: Provider Network Managementthis man
Page 33 and 34: Centennial Care Overview3. Primary
Page 35 and 36: Primary Care ProvidersClaims Activi
Page 37 and 38: Primary Care Providers4. Specialist
Page 39 and 40: SpecialistsOther Information for PC
Page 41 and 42: Specialists5. Preventive Health Car
Page 43 and 44: Preventive Health Care GuidelinesPr
Page 45 and 46: Preventive Health Care GuidelinesSe
Page 47 and 48: Care Coordination6. Care Coordinati
Page 49 and 50: Care CoordinationPresbyterian’s c
Page 51 and 52: 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
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Care CoordinationAmerican Psychiatr
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Care Coordinationwithout obtaining
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Care CoordinationSpecialists as PCP
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Care Coordinationor when the member
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Care Coordination11. Prevention Scr
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Care CoordinationFollow-up plans or
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Care CoordinationPharmacy BenefitsP
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Care CoordinationThis page intentio
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Laboratory ServicesTriCore Contact
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Pharmacya multi-tier formulary stru
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Pharmacymedications. This multi-tie
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PharmacyCatastrophic coverage: Cove
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Pharmacywhich drugs are mandated th
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PharmacyThe drug must be accepted f
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PharmacyTypes of Pharmacy Prior Aut
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PharmacyThis page intentionally lef
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Behavioral Healthagreements, addend
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Behavioral HealthForm W-9Staff rost
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Behavioral Healthhttps://www.phs.or
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Behavioral HealthAn initial PCP con
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Behavioral HealthAccess StandardsMe
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Behavioral HealthThere is no charge
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Behavioral HealthThis page intentio
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Long-Term Carean individual provide
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Long-Term Careavailable services, a
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Long-Term Carethe agent to members
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Long-Term Carecare at the right tim
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Long-Term Careplanning process, and
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Long-Term Carebudget plan are suffi
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Long-Term CareOrganizationsFor the
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Home HealthPresbyterian’s credent
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Home HealthPresbyterian Medicaid me
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Home Healththese services. Services
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Home Healthfor review will be submi
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Home HealthPatient Care Conferences
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Home HealthThis page intentionally
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Quality Improvement ProgramNational
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Quality Improvement Programcomplian
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Quality Improvement Programresults
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Quality Improvement Programrespect
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Quality Improvement ProgramPresbyte
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Quality Improvement ProgramNCQA ori
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Quality Improvement ProgramThis pag
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Health Insurance Portability and Ac
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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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