2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Long-Term Care11. Home Health11. Home HealthNote that throughout this chapter, home health careagency providers are referred to as agency oragencies.Home care services for Presbyterian are managedthrough the Presbyterian Home HealthcareStatewide Network (PHHSN). PHHSN supports themission of Presbyterian to improve the health ofindividuals, families, and communities throughoutNew Mexico by ensuring the provision of thehighest quality and affordable home care servicesfor patients in their home.PHHSN provides utilization management throughreview of prior authorization requests for home careservices. The review is to ensure that the rightservices are provided at the right frequency,duration, and level needed. PHHSN is alsoaccountable to guide the denial process to thePresbyterian medical director and track all homecare denials.PHHSN also collects data and performs analyseson a monthly, quarterly, and annual basis tomeasure quality outcomes. Additionally, utilizationresults will be reported to the PHHSN QualitySubcommittee.The PHHSN director of finance, businessoperations, decision support and statewide networkand the PHHSN Lead Quality ResourceManagement (QRM) Analyst are available to assistagencies in learning and implementing the policies,procedures, and benefits outlined in this section ofthe manual. To the extent that there are any directconflicts between the provisions of this home healthcare section and any contract with PHHSN, theprovisions of the contract will prevail.The Synagis ProgramThe Synagis (Palivizumab) program is coordinatedfor all Presbyterian eligible children that meetqualifying criteria, statewide through PHHSN.Agency Recredentialing PolicyAccredited and non-accredited home health careagency providers within the State of New Mexico orin surrounding states that are within 100 miles ofthe New Mexico state boundary and that carry aNew Mexico home care license may request tocontract with PHHSN. Presbyterian will, amongother things, confirm that the requesting homehealth care agencyIs in good standing with state and federalregulatory bodiesHas been reviewed and approved by arecognized accrediting bodyWill ensure, at least every three years, thatthe home health care agency providercontinues to be in good standing with stateand federal regulatory bodiesMeets Presbyterian’s credentialing standardsfor home health care.11-12014 Practitioner and Provider Manual - Ver. 3
Home HealthPresbyterian’s credentialing department isresponsible for reviewing the required credentialingdocuments and information as provided by theagency. The credentialing packet is presented tothe Peer Review Credentialing Committee atPresbyterian for approval. Presbyterian maintainsthe security and confidentiality of the credentialingfiles. At least every three years, all contractedagencies need to comply with the Presbyterianrecredentialing process in order to maintainparticipation with PHHSN.For those non-licensed home health care agenciesproviding only hourly care under the Medicaid Earlyand Periodic Screening, Diagnosis, and Treatment(EPSDT) benefit, PHHSN has developed a list ofcriteria to be met in order to qualify as a PHHSNagency provider. Once the required information hasbeen submitted and reviewed, a subcontract mustbe signed before a request for configuration canoccur. All agencies must be configured into thePresbyterian computer system to allow PHHSN tocertify care and for an agency to submit claims toPresbyterian for payment.Agency Contracting Policy and ProcessPHHSN is responsible to ensure statewide homecare coverage by contracting with qualified homecare providers throughout the State of New Mexico.Before any home care services may be provided toPresbyterian members, a written, fully executedcontract developed by Presbyterian’s legaldepartment must be signed by all necessaryparties. Presbyterian maintains the security andconfidentiality of the contract files.New Agency OrientationUpon successful completion of the credentialingand contracting processes, PHHSN’s director offinance and statewide network or lead QRM analystwill schedule orientation with the new agency. Theorientation will include explanation of the priorauthorization process, the appeals and grievanceprocess, reporting requirements, the teamconference process, and completion of the annualself-audit and claims submission process. Eachagency will be provided access to this manualthrough the PHS website address.Patient EligibilityUpon initial receipt of a referral or priorauthorization request, PHHSN will verify patients’eligibility and benefits. When reviewing for ongoingauthorization, a letter indicating non-eligibility willbe sent within 24 hours if PHHSN determines thepatient is no longer a current Presbyterian member.Qualifying Home Care Criteria PolicyThe qualifying home care criteria policy applies toplans that have a home health care benefit,including commercial/Administrative Service Only,Presbyterian Senior Care (HMO), Medicaid andPresbyterian Insurance Company, Inc., plans.Upon receipt of a referral or prior authorizationrequest, PHHSN will review the referral or requestagainst qualifying criteria for home care services,which may include ensuring that a patient ishomebound. At the time this manual was published,“homebound” is defined as a person meeting all ofthe following:11-22014 Practitioner and Provider Manual - Ver. 3
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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
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Care Coordinationdesignated family
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Care CoordinationFacilitate access
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Care CoordinationClinical Practice
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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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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
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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
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Page 103 and 104: Behavioral HealthThere is no charge
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Page 107 and 108: Long-Term Carean individual provide
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Page 111 and 112: Long-Term Carethe agent to members
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Page 115 and 116: Long-Term Careplanning process, and
Page 117 and 118: Long-Term Carebudget plan are suffi
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Page 125 and 126: Home Healththese services. Services
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Page 129 and 130: Home HealthPatient Care Conferences
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Page 133 and 134: Quality Improvement ProgramNational
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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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Page 151 and 152: Legalabove, nor from any recourse a
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Page 165 and 166: Legal15. Fraud, Waste, and Abuse15.
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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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