2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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LegalYou shall also have an internal reporting process toreport suspected or potential fraud to yourcompliance officer.You shall report to Presbyterian any potential fraudor other misconduct by you or a subcontractor. Thisreport shall be made as soon as you becomeaware of the potential fraud or other misconduct.Background ChecksYou will perform criminal background checks for allrequired individuals providing services, as specifiedin 7.1.9 New Mexico Administrative Code,Caregivers Criminal History ScreeningRequirements.Conflict of Interest CertificationYou and your subcontractor’s officers, directors,and managers shall annually sign a statement that(1) the individual has reviewed Presbyterian’s andyour conflict of interest policies; (2) the individualhas disclosed any potential conflicts of interest; and(3) the individual has obtained managementapproval to work despite any conflicts or haseliminated the conflict. (Source: Chapter 9, Section50.2.1.2.)IndemnityYou shall hold Presbyterian harmless of any loss,damage, or costs (including reasonable attorneys’fees) incurred in connection with claims resultingfrom your or your subcontractor’s acts oromissions.Medicare Contracting RequirementsDefinitions:Terms that are used in your contract withPresbyterian (such as downstream entities,related entities, and first tier entities) have thesame meanings as defined by the CMS in 42CFR § 422.2.The term “subcontractor” means alldownstream entities and related entities whichproviders use to perform services.NondiscriminationProviders agree and will require all subcontractorsto agree, not to differentiate or discriminate in thetreatment of Medicare Advantage (MA) planenrollees on the basis of health status or on thebasis of color, race, creed, sex, age, religion, placeof residence, health status, sexual orientation,disability, place of origin, type of illness orcondition, or source of payment, or any other basisprohibited by federal law and to observe, protect,and promote the rights of MA plan enrollees aspatients. (Source: 42 CFR § 422.110.)Privacy of Medical RecordsProvider will treat, and will require allsubcontractors to treat, all MA plan enrollees’medical records or other health and enrollmentinformation as confidential and protected againstunauthorized disclosure so as to comply with allstate and federal laws regarding privacy, security,confidentiality, and disclosure so as to comply withall state and federal laws regarding the privacy,security, confidentiality and disclosure so as to14-92014 Practitioner and Provider Manual - Ver. 3
Legalcomply with all state and federal laws regarding theprivacy, security, confidentiality and disclosure ofMA Plan Enrollees’ health information. The providerwill ensure maintenance of such information in anaccurate and timely manner and ensure thatenrollees may timely access such information uponrequest. (Source: 42 CFR § 422.118.)Cooperation with Presbyterian’s ProgramsProvider shall use their best efforts to cooperatewith and participate in, and to require allSubcontractors to cooperate with and participate in,Presbyterian’s quality improvement programs,member grievance systems, medication therapymanagement, and utilization managementprograms to the extent applicable to the Servicesprovided by Provider, including, but not limited to,credentialing, recredentialing, quality assurance,prospective, concurrent, and retrospective utilizationreview and management, medical recordsmaintenance, claims payment review andmanagement peer review, and provider andmember grievance procedures. Provider shall bebound by the appeal procedures of Presbyterian’sutilization review and quality assurance program.(Source: 42 CFR §§ 422.152, 422.202(c).)Communication with MA Plan EnrolleesPresbyterian encourages the provider, and providershall encourage subcontractors, to freelycommunicate with plan enrollees regardingappropriate treatment alternatives, regardless ofbenefit limitations, in a culturally competent mannerand in compliance with requirements of 42 USC §12101, as amended (otherwise known as the“American with Disabilities Act of 1990”).Presbyterian shall not penalize its employees,contractors, or subcontractors for discussingmedically necessary or appropriate care withenrollees. (Source: 42 CFR § 422.206(a)(1) & (2).)IndemnityProvider shall indemnify, defend and holdPresbyterian responsible for any loss, damage, orcosts (including reasonable attorneys’ fees)incurred in connection with claims arising out of orresulting from provider’s or a subcontractor’s failureto comply with all applicable Medicare Advantagerequirements.MA Plan Enrollee Hold HarmlessProvider hereby agrees, and will require allsubcontractors to agree, to seek payment forcovered prescription drug services only fromPresbyterian. In no event, including, but not limitedto, termination of the Agreement(s) or thisAmendment, non-payment by Presbyterian,Presbyterian’s insolvency or breach of theAgreement(s) or this Amendment, shall a provideror a subcontractor bill, charge, collect a depositfrom; seek compensation, remuneration, orreimbursement from; or have any recourse againstenrollees, their families, or people acting on theirbehalf for covered prescription drug services. Theforegoing sentence shall not prohibit collection byprovider or a Subcontractor of applicable copayments,co-insurance, and cost-sharing chargesfor non-covered services. (Source: 42 CFR §422.504(g)(1)(i) & (i)(3).)14-102014 Practitioner and Provider Manual - Ver. 3
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Nurse Advice Line .................
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Pharmacy Benefits .................
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Clearinghouses ....................
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Site Visits .......................
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Monitoring ........................
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Federally Funded Terminations .....
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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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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
Page 107 and 108: Long-Term Carean individual provide
Page 109 and 110: Long-Term Careavailable services, a
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
Page 119 and 120: Long-Term CareOrganizationsFor the
Page 121 and 122: Home HealthPresbyterian’s credent
Page 123 and 124: Home HealthPresbyterian Medicaid me
Page 125 and 126: Home Healththese services. Services
Page 127 and 128: Home Healthfor review will be submi
Page 129 and 130: Home HealthPatient Care Conferences
Page 131 and 132: Home HealthThis page intentionally
Page 133 and 134: Quality Improvement ProgramNational
Page 135 and 136: Quality Improvement Programcomplian
Page 137 and 138: Quality Improvement Programresults
Page 139 and 140: Quality Improvement Programrespect
Page 141 and 142: Quality Improvement ProgramPresbyte
Page 143 and 144: Quality Improvement ProgramNCQA ori
Page 145 and 146: Quality Improvement ProgramThis pag
Page 147 and 148: Health Insurance Portability and Ac
Page 149 and 150: Health Insurance Portability and Ac
Page 151 and 152: Legalabove, nor from any recourse a
Page 153 and 154: Legalagreement with Presbyterian fo
Page 155 and 156: Legaltransactions (federal, state,
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Page 161 and 162: Legalany such program during the te
Page 163 and 164: LegalPrompt Pay by PresbyterianPres
Page 165 and 166: Legal15. Fraud, Waste, and Abuse15.
Page 167 and 168: Fraud, Waste, and Abuseas the time
Page 169 and 170: Fraud, Waste, and AbuseAll document
Page 171 and 172: Fraud, Waste, and AbuseVerifying th
Page 173 and 174: Fraud, Waste, and AbuseHistorically
Page 175 and 176: Fraud, Waste, and Abuseis violated
Page 177 and 178: Fraud, Waste, and AbuseIs informed
Page 179 and 180: Fraud, Waste, and Abuse16. Credenti
Page 181 and 182: Credentialing and RecredentialingPr
Page 183 and 184: Credentialing and RecredentialingNe
Page 185 and 186: Credentialing and Recredentialing17
Page 187 and 188: e-BusinessFill out the form on the
Page 189 and 190: e-BusinessSign Up for this Free Ser
Page 191 and 192: e-BusinessClearinghouse Contact Inf
Page 193 and 194: e-Business18. Claims and Payment18.
Page 195 and 196: Claims and Paymentsubmission. Claim
Page 197 and 198: Claims and PaymentSpecify the origi
Page 199 and 200: Claims and Paymentrequiring a leadi
Page 201 and 202: Claims and PaymentPlease note that
Page 203 and 204: Claims and PaymentPresbyterian is r
Page 205 and 206: Claims and Paymentnot made a recove
Page 207 and 208: 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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