2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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