2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Site Visits ..................................................................................................................................... 12-3Ongoing Monitoring ...................................................................................................................... 12-44. Quality of Clinical Care ................................................................................................................. 12-45. Peer Review ................................................................................................................................. 12-46. Continuity and Care Coordination ................................................................................................. 12-57. Standards of Care ........................................................................................................................ 12-58. Service Quality Concerns ............................................................................................................. 12-59. Clinical Practice Guidelines .......................................................................................................... 12-510. Preventive Health Care Guidelines ............................................................................................... 12-511. Member Medical Records ............................................................................................................. 12-512. Integrated Care Management Program ........................................................................................ 12-613. Continuum of Care ....................................................................................................................... 12-614. Special Populations ...................................................................................................................... 12-615. Early and Periodic Screening, Diagnosis, and Treatment ............................................................. 12-716. Health Risk Assessment and Personal Health Assessments ........................................................ 12-717. Culturally Appropriate Services .................................................................................................... 12-718. Oversight of Delegated, Subcontracted, and High-Volume or Single-Source Functions ............... 12-819. Nurse Advice Line ........................................................................................................................ 12-920. Utilization Management Program ................................................................................................. 12-921. Web Resources .......................................................................................................................... 12-1022. Voice of the Customer ................................................................................................................ 12-10Survey Data ............................................................................................................................... 12-10Complaint and Inquiry Data ........................................................................................................ 12-10Qualitative Research .................................................................................................................. 12-10Service Quality Committee and Delegated Teams ..................................................................... 12-11Member and Provider Satisfaction Prioritization Processes ........................................................ 12-1123. Patient Safety Program .............................................................................................................. 12-11Objectives of the Patient Safety Program ................................................................................... 12-11Focus ......................................................................................................................................... 12-11QI Program: HEDIS ® Medical Record Data Abstraction .............................................................. 12-11Where does HEDIS data come from? ......................................................................................... 12-12How does HEDIS reporting impact the practice setting? ............................................................. 12-13How does Presbyterian use the HEDIS reporting system? ......................................................... 12-1313. Health Insurance Portability and Accountability Act ................................................................................ 13-1What Requires Your Particular Attention? .............................................................................................. 13-1Who is Legally Responsible for HIPAA Compliance?............................................................................. 13-1Which Providers Must Be HIPAA Compliant? ........................................................................................ 13-2xiv2014 Practitioner and Provider Manual - Ver. 3
Key HIPAA Definitions ........................................................................................................................... 13-2HIPAA ................................................................................................................................................... 13-2HITECH Act ........................................................................................................................................... 13-3HIPAA Final Omnibus Rule .................................................................................................................... 13-3HIPAA Information Resources ............................................................................................................... 13-314. Legal ...................................................................................................................................................... 14-1Cooperation with Presbyterian’s Programs ............................................................................................ 14-1Presbyterian Centennial Care Contracting Requirements ...................................................................... 14-2Provider Responsibilities ....................................................................................................................... 14-2Selection of or Assignment to a PCP ..................................................................................................... 14-2Provider Disclosure of Current or Previous Affiliation with Excluded Providers ...................................... 14-3Hold Harmless ....................................................................................................................................... 14-3Delegation (if applicable) ....................................................................................................................... 14-4Cooperation with Medicaid Program Integrity ........................................................................................ 14-4Employee Education .............................................................................................................................. 14-4Credentialing Requirements .................................................................................................................. 14-5Review Requirements ............................................................................................................................ 14-5No Debarment ....................................................................................................................................... 14-5False Claims .......................................................................................................................................... 14-6Provider Termination ............................................................................................................................. 14-6Other Important Provisions .................................................................................................................... 14-7Exclusion from Federal Health Care Programs ...................................................................................... 14-8Provider Communications ...................................................................................................................... 14-8Background Checks............................................................................................................................... 14-9Conflict of Interest Certification .............................................................................................................. 14-9Indemnity ............................................................................................................................................... 14-9Medicare Contracting Requirements ...................................................................................................... 14-9Definitions: ............................................................................................................................................ 14-9Nondiscrimination .................................................................................................................................. 14-9Privacy of Medical Records ................................................................................................................... 14-9Communication with MA Plan Enrollees .............................................................................................. 14-10Indemnity ............................................................................................................................................. 14-10MA Plan Enrollee Hold Harmless ......................................................................................................... 14-10Continuation of Services Beyond Termination ..................................................................................... 14-11Federal Funds Used ............................................................................................................................ 14-11Access to Books and Records ............................................................................................................. 14-11Exclusion From Federal Health Care Programs ................................................................................... 14-11Subcontractors and Participating Pharmacies Adequate Network Coverage ....................................... 14-12xv2014 Practitioner and Provider Manual - Ver. 3
Page 2 and 3: ii2014 Practitioner and Provider Ma
Page 4 and 5: iv2014 Practitioner and Provider Ma
Page 6 and 7: vi2014 Practitioner and Provider Ma
Page 8 and 9: Nurse Advice Line .................
Page 10 and 11: Pharmacy Benefits .................
Page 12 and 13: Clearinghouses ....................
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
Page 63 and 64: 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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