2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Fraud, Waste, and AbusePresbyterian Centennial Care fails to initiaterecovery within 12 months from the date thecontractor first paid the claimPresbyterian Centennial Care fails tocomplete the recovery within 15 months fromthe date Presbyterian Centennial Care firstpaid the claimThe provider may request that PresbyterianCentennial Care permit installment payments of therefund. Such request shall be agreed to byPresbyterian Centennial Care and the provider.In cases where HSD, the Recovery AuditContractor, or MFEAD identifies the overpayment,HSD shall seek recovery of the overpayment inaccordance with New Mexico Administrative Code§8.351.2.13.Failure to Self-Report and/or Refund OverpaymentsOverpayments that have been identified by aprovider and not self-reported within the 60-calendar-day time frame are presumed to be falseclaims and are subject to referrals as credibleallegations of fraud.Fraud, Waste, and Abuse ReportingYou can assist Presbyterian prevent fraud, waste,and abuse by reporting any suspicious activity thatappears to be potential fraud, waste, and abuse.Report all confirmed, credible, or suspected fraud,waste, and abuse immediately in accordance withthe following:For all confirmed, credible, or suspectedprovider fraud, waste, and abuse, report toPresbyterian, HSD, and MFEAD and includethe information provided in 42 CFR Section455.17, as applicableFor all confirmed, credible, or suspectedmember fraud, waste, and abuse, report toPresbyterianPlease contact us to report suspicious activity usingthe contact numbers below.The SIU confidential hotline phone numbers are:505-923-5959 (local)1-800-239-3147 (toll-free)Email address: PHPFrau@phs.orgOr, you may file a suspected fraud and abusereport online athttps://www.phs.org/insurance-plans/all-abouthealth-care/faqs/fraud-abuse/Pages/default.aspx.Contact information for reporting abuse, neglectand exploitation of members:Adult Protective Services: 1-866-654-3219Children, Youth, and Families Department: 1-800-797-3260Department of Health/Division of HealthImprovement (DOH/DHI): 1-800-445-6242For suspected fraud, waste, and abuse in theadministration of Centennial Care, report toPresbyterian, HSD, and MFEAD15-142014 Practitioner and Provider Manual - Ver. 3
Fraud, Waste, and Abuse16. Credentialing and Recredentialing16. Credentialing andRecredentialingPresbyterian credentials both individualpractitioners and organizational providers. Thecredentialing process focuses on verifyingadequate training, experience, licensure, andcompetence by accessing data and informationcollected to determine if a provider is qualified torender quality care to our members. See theBehavioral Health chapter of this manual forcredentialing and recredentialing of behavioralhealth providers.Program ScopeThe Presbyterian credentialing program applies tohealth care providers that are contracted withPresbyterian to provide health care services to itsmembers. The following contractual relationshipsrequire providers to be credentialed beforerendering services to Presbyterian members:Providers who have an independentrelationship with Presbyterian. Anindependent relationship exists whenPresbyterian selects and directs its membersto see a specific practitioner or group ofpractitioners, including all practitioners whommembers can select as primary carepractitioners. This is not the same as anindependent contract.Practitioners who see members in anoutpatient setting.Practitioners who are hospital-based but seePresbyterian members as a result of theirindependent relationship with Presbyterian.Examples include but are not limited toanesthesiologists with pain managementpractices, hospital-based cardiologists, andhospital-based university faculty.Dentists who provide care underPresbyterian’s medical benefits. Examples ofthis type of provider include but are not limitedto endodontists, oral surgeons, andperiodontists.Non-physician providers who have anindependent relationship with Presbyterian, asdefined above, and provide care underPresbyterian’s medical benefits.Credentialing and Recredentialing ProcessesThe following is information related to credentialingand recredentialing processes:Ensure that all information on the applicationis complete and correct. Any unexplainedgaps, missing information, or incompleteinformation delay the application processing.Include the beginning and ending month andyear for each work experience under workhistory and explain any gaps exceeding sixmonths.Include a written explanation for any “yes”answer to the professional practice questions.16-12014 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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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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Page 133 and 134: Quality Improvement ProgramNational
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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
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Page 155 and 156: Legaltransactions (federal, state,
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Page 159 and 160: Legalcomply with all state and fede
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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: Fraud, Waste, and AbuseIs informed
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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
Page 207 and 208: Claims and PaymentAcceptable docume
Page 209 and 210: Claims and Paymentallowing provider
Page 211 and 212: Claims and PaymentNational Correct
Page 213 and 214: Claims and Payment19. Presbyterian
Page 215 and 216: Presbyterian Customer Service Cente
Page 227 and 228: 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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