2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Clearinghouses ...................................................................................................................................... 9-12Payer ID for Clearinghouse Services (Centennial Care) ........................................................................ 9-12Clearinghouse Contact Information (Magellan) ...................................................................................... 9-12Clearinghouse Contact Information for Presbyterian Behavioral Health (Medicare and Commercial)can be found in Appendix? .................................................................................................................... 9-1310. Long-Term Care ..................................................................................................................................... 10-1Patient Eligibility .................................................................................................................................... 10-1General Eligibility................................................................................................................................... 10-1Native American Member Eligibility ....................................................................................................... 10-1Community Benefit ................................................................................................................................ 10-2Nursing Facility Level of Care Assessment for Long-Term Care Beneficiaries ....................................... 10-2Comprehensive Needs Assessment ...................................................................................................... 10-3Member Choice ..................................................................................................................................... 10-3Agency-Based Community Benefit ........................................................................................................ 10-3Self-Directed Community Benefit ........................................................................................................... 10-4Termination from the Self-Directed Community Benefit ......................................................................... 10-6Family Members Serving as Providers .................................................................................................. 10-7Utilization Management and Prior Authorization .................................................................................... 10-7Care Review Process ............................................................................................................................ 10-8Review Criteria ...................................................................................................................................... 10-8Supporting Integration and Coordination of Physical Health, Behavioral Health, and Long-Term CareServices................................................................................................................................................. 10-8Care Coordination ................................................................................................................................. 10-9Risk Stratification and Comprehensive Needs Assessment ................................................................... 10-9Interdisciplinary Care Plan Team ........................................................................................................... 10-9Delivery of Coordinated and Integrated Services ................................................................................. 10-10Member Engagement and Self-Care Management .............................................................................. 10-10Monitoring and Evaluation ................................................................................................................... 10-10Identification and Referral for Behavioral Health Services ................................................................... 10-10Community Health Workers and Community Health Representatives .................................................. 10-10Nursing Facility Level of Care: Care Plan Development ....................................................................... 10-11Transitions of Care .............................................................................................................................. 10-12Communication .................................................................................................................................... 10-12Care Management System .................................................................................................................. 10-13Provider Portal .................................................................................................................................... 10-13Credentialing ....................................................................................................................................... 10-13Individual Providers and Groups .......................................................................................................... 10-13Organizations ...................................................................................................................................... 10-14Other Provider Requirements .............................................................................................................. 10-14xii2014 Practitioner and Provider Manual - Ver. 3
Electronic Visit Verification................................................................................................................... 10-14Long-Term Care Claims Submission ................................................................................................... 10-1411. Home Health........................................................................................................................................... 11-1The Synagis Program ............................................................................................................................ 11-1Agency Recredentialing Policy .............................................................................................................. 11-1Agency Contracting Policy and Process ................................................................................................ 11-2New Agency Orientation ........................................................................................................................ 11-2Patient Eligibility .................................................................................................................................... 11-2Qualifying Home Care Criteria Policy ..................................................................................................... 11-2Qualifying Home Care Criteria Policy – Medicaid ................................................................................... 11-3Presbyterian Medicaid Early and Periodic Screening, Diagnosis, and Treatment Services .................... 11-4Medically Fragile Home and Community-Based Services ...................................................................... 11-4Personal Care Services ......................................................................................................................... 11-4Prior Authorization Processes ................................................................................................................ 11-5Initial Prior Authorization........................................................................................................................ 11-5Prior Authorization for Additional/Concurrent Services .......................................................................... 11-5Prior Authorization – Presbyterian Medicaid/EPSDT Medically Fragile Home and Community-Services ................................................................................................................................................ 11-5Personal Care Services ......................................................................................................................... 11-5Retroactive Authorizations ..................................................................................................................... 11-6Co-payments, Co-insurance, and Deductibles ....................................................................................... 11-6Transition of Care .................................................................................................................................. 11-6Denials .................................................................................................................................................. 11-7Appeals ................................................................................................................................................. 11-8Utilization Management ......................................................................................................................... 11-8Reporting Requirements ........................................................................................................................ 11-9Patient Care Conferences ................................................................................................................... 11-10Claims Processing ............................................................................................................................... 11-10Home Care Agency Contract Termination Policy ................................................................................. 11-1112. Quality Improvement Program ................................................................................................................ 12-1National Committee for Quality Assurance ............................................................................................ 12-2Focus on Excellence.............................................................................................................................. 12-2QI Program Activities ............................................................................................................................. 12-31. Availability of Providers ................................................................................................................ 12-32. Accessibility of Services (Appointment Availability) ...................................................................... 12-3Data Collection ............................................................................................................................. 12-33. Credentialing and Recredentialing ................................................................................................ 12-3Delegation .................................................................................................................................... 12-3xiii2014 Practitioner and Provider Manual - Ver. 3
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Page 8 and 9: Nurse Advice Line .................
Page 10 and 11: Pharmacy Benefits .................
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
Page 61 and 62: 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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