2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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