2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Legalwork despite any conflicts or has eliminated theconflict. (Source: Chapter 9, Sec. 50.2.1.2.)Offshore ContractingProvider will annually submit an offshoresubcontractor attestation to Presbyterian and CMSfor each offshore subcontractor he/she use toperform services. Provider will require allsubcontractors to report such information about anyoffshore subcontractors they use to provider,Presbyterian and CMS. (Source: HPMS Memosdated: 07/23/07, 09/20/07 and 08/26/08.)14-152014 Practitioner and Provider Manual - Ver. 3
Legal15. Fraud, Waste, and Abuse15. Fraud, Waste, and AbuseAs a health plan, Presbyterian is required tocooperate with regulatory and law enforcementagencies in reporting any activity that appears to besuspicious in nature. According to the law, anyinformation that we have concerning such mattersmust be turned over to the appropriategovernmental agencies.By identifying areas of concern relative to fraud,waste, and abuse, and working with physicians andother health care providers to make improvements,Presbyterian is able to dedicate more resources toour goal of improving the health of patients,members, and communities.This chapter of the provider manual is intended toeducate providers on fraud, waste, and abuse andto comply with the Centers for Medicare andMedicaid Services (CMS) mandatory requirementthat providers receive the training.Regulatory DefinitionsFraud is defined as intentional deception ormisrepresentation made by an entity or person,including but not limited to a subcontractor, vendor,provider, member, or other customer with theknowledge that the deception could result in someunauthorized benefit to a person or an entity. Fraudincludes any attempt to obtain, by means of false orfraudulent pretenses, representations, or promises,any of the money or property owned by or underthe custody or control of, any health care benefitprogram. It includes any act that constitutes fraudunder applicable state and federal law. Forexample, fraud may exist when a provider bills forservices not rendered, and the service cannot besubstantiated by documentation.Waste is defined as an act involving payment orthe attempt to obtain payment for items or serviceswhere there was no intent to deceive ormisrepresent, but where the outcome of poor orinefficient methods resulted in unnecessary costs tothe plan.Abuse is defined as incidents or practices that areinconsistent with accepted and sound business,fiscal, or medical administrative practices. Abusemay, directly or indirectly, result in unnecessarycosts to the health plan, improper payment, orpayment for services that fail to meet professionalstandards of care or are medically unnecessary.Abuse consists of payment for items or serviceswhen there is no legal entitlement and the recipienthas knowingly misrepresented the facts to receivethe benefit or payment. Abuse often takes the formof claims for services not medically necessary ornot medically necessary to the extent provided.Abuse also includes practices by subcontractors,providers, members, or customers that result inunnecessary costs to the health plan. For example,abuse may exist when the provider fails toappropriately bill new and established patient officecodes. The provider bills a “new” patient code bothon the initial visit and subsequent visits.15-12014 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
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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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Page 121 and 122: Home HealthPresbyterian’s credent
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Page 133 and 134: Quality Improvement ProgramNational
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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
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Page 151 and 152: Legalabove, nor from any recourse a
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Page 169 and 170: Fraud, Waste, and AbuseAll document
Page 171 and 172: Fraud, Waste, and AbuseVerifying th
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Page 177 and 178: Fraud, Waste, and AbuseIs informed
Page 179 and 180: Fraud, Waste, and Abuse16. Credenti
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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
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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
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Page 209 and 210: Claims and Paymentallowing provider
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Page 213 and 214: 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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