2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Monitoring ............................................................................................................................................ 14-12Credentialing ....................................................................................................................................... 14-12Standard of Conduct ............................................................................................................................ 14-12Fraud Waste and Abuse Control Compliance Program ........................................................................ 14-12Provider Training and Education .......................................................................................................... 14-13Provider Communications .................................................................................................................... 14-13Reasonable Assurances ...................................................................................................................... 14-13Revocation of Delegation or Termination of Agreement ....................................................................... 14-13Prompt Pay by Presbyterian ................................................................................................................ 14-14By SXC Health Solutions Corporation ................................................................................................... 14-14Subcontractor Certification of Data Accuracy, Completeness, and Truthfulness .................................. 14-14Office of the Inspector General Exclusion Certification ........................................................................ 14-14Conflict of Interest Certification ............................................................................................................ 14-14Offshore Contracting............................................................................................................................ 14-1515. Fraud, Waste, and Abuse ....................................................................................................................... 15-1Regulatory Definitions ............................................................................................................................ 15-1How to Report Fraud, Waste, and Abuse ............................................................................................... 15-2Medical Record Documentation ............................................................................................................. 15-2Physical Health Provider Medical Record Documentation ..................................................................... 15-2Behavioral Health Provider Medical Record Documentation .................................................................. 15-2Documenting Timed CPT Codes ........................................................................................................... 15-2Claims Validation Audits ........................................................................................................................ 15-3Medical Identity Theft and Identity Misrepresentation Prevention .......................................................... 15-5Federal Register (FR) and the Code of Federal Regulations (CFR)....................................................... 15-7Government Initiatives ........................................................................................................................... 15-7Federal and State False Claims Acts ..................................................................................................... 15-7Federal False Claims Act ...................................................................................................................... 15-7New Mexico False Claims Act (Dual Eligible) ........................................................................................ 15-8New Mexico Fraud Against Taxpayers Act ............................................................................................ 15-8Whistleblower Acts ................................................................................................................................ 15-8How Whistleblowers are Protected ........................................................................................................ 15-8New Mexico Whistleblower Protection Act ............................................................................................. 15-9Deficit Reduction Act of 2005 ................................................................................................................. 15-9Anti-Kickback Laws ............................................................................................................................. 15-10Anti-Kickback Safe Harbors ................................................................................................................. 15-10Self-Referral Laws ............................................................................................................................... 15-10Beneficiary Inducement Civil Monetary Penalty Law ............................................................................ 15-11Program Exclusion Lists ...................................................................................................................... 15-11xvi2014 Practitioner and Provider Manual - Ver. 3
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Page 8 and 9: Nurse Advice Line .................
Page 10 and 11: Pharmacy Benefits .................
Page 12 and 13: Clearinghouses ....................
Page 14 and 15: Site Visits .......................
Page 18 and 19: myPRES Training and Support........
Page 20 and 21: Medicare Advantage Plans New Member
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Page 24 and 25: Presbyterian Healthcare ServicesCen
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Page 30 and 31: Provider Network ManagementPresbyte
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Page 34 and 35: Primary Care ProvidersMonitoring th
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Page 38 and 39: SpecialistsAdult Protective Service
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Page 42 and 43: Preventive Health Care GuidelinesAm
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Page 48 and 49: Care Coordinationone contracted spe
Page 50 and 51: Care Coordinationsuggest that you c
Page 52 and 53: Care Coordinationmember across this
Page 54 and 55: Care CoordinationFamily members or
Page 56 and 57: Care CoordinationMembers with moder
Page 58 and 59: Care CoordinationClinical Practice
Page 60 and 61: Care CoordinationUnder- and Overuti
Page 62 and 63: Care CoordinationLimited history an
Page 64 and 65: Care CoordinationThey may go back t
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Care Coordination14. An initial PCP
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Care Coordinationrecord. Patient id
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Care CoordinationReferral Informati
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Care Coordinationasked to update th
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Care CoordinationContacts for Other
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Care Coordination7. Laboratory Serv
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Pharmacy8. Pharmacy8. PharmacyProvi
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PharmacyPresbyterian Centennial Car
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PharmacyMaximum Dosing Quantity for
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PharmacyMail Order for Medicare Pla
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PharmacyMedications and treatments
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PharmacyOnce the request has been r
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Pharmacyimmediately communicated to
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Pharmacy9. Behavioral Health9. Beha
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Behavioral Healthother individual p
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Behavioral HealthTelephone numberSt
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Behavioral Healthremove barriers to
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Behavioral HealthNote that advising
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Behavioral HealthClaims Submission
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Behavioral HealthCapario (formerly
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Behavioral Health10. Long-Term Care
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Long-Term CareAbility to perform BA
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Long-Term Careneeded to assist the
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Long-Term CareMembers who have been
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Long-Term Carephysical health, beha
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Long-Term Carecoordinators and prov
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Long-Term Careorganizations in thei
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Long-Term Care11. Home Health11. Ho
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Home HealthThe condition of these p
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Home Healthperformance, and to upda
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Home Healthwill authorize continued
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Home Healththe management of decubi
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Home Healthagency is responsible fo
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12. Quality ImprovementHome Health1
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Quality Improvement Programimplemen
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Quality Improvement Program6. Conti
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Quality Improvement Programaccess t
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Quality Improvement Programmeet Pre
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Quality Improvement Programshopping
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Quality Improvement Programyear and
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13. Health Insurance PortabilityQua
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Health Insurance Portability and Ac
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Health Insurance Portability and Ac
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LegalIf a member does not select a
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Legalinclude a specific discussion
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LegalOther Important ProvisionsThe
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LegalYou shall also have an interna
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LegalContinuation of Services Beyon
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LegalChapter 9 that are required by
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Legalwork despite any conflicts or
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Fraud, Waste, and AbuseHow to Repor
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Fraud, Waste, and Abuseclaim to ver
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Fraud, Waste, and AbuseAccording to
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Fraud, Waste, and Abuse1 false clai
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Fraud, Waste, and Abuse• State la
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Fraud, Waste, and Abuseservices to
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Fraud, Waste, and AbusePresbyterian
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Credentialing and RecredentialingIf
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Credentialing and RecredentialingCu
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Credentialing and Recredentialingco
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e-BusinessHealth Insurance Portabil
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e-BusinessE-Help desk also provides
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e-BusinessSimply visit the ePocrate
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e-BusinessThis page intentionally l
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Claims and PaymentQuicker confirmat
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Claims and PaymentUB-04The UB-04 bi
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Claims and PaymentThe data format i
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Claims and Paymentdelivery, and pos
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Claims and PaymentPhysician Certifi
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Claims and PaymentCentennial Care C
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Claims and PaymentException: When C
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Claims and PaymentEncounter Reporti
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Claims and Paymentat a rate of 2 pe
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Claims and PaymentThis page intenti
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Presbyterian Customer Service Cente
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Appeals and Grievancescalendar-day
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Appeals and Grievancesthe member, w
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Appendix A. AcronymsDDEADHHSDHIDMED
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Appendix A. AcronymsPP&TPCAPCPPETPH
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Appendix A. AcronymsThis page inten
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Appendix B. DefinitionsTerm Definit
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Appendix C. WebsitesWebsitesNameBec
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Appendix C. WebsitesWebsitesNameHea
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Appendix C. WebsitesWebsitesNameOff
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Appendix C. WebsitesThis page inten
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Appendix D. Phone NumbersPhone Numb
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Appendix D. Phone NumbersPhone Numb
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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 Benefits Pa
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