2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Federally Funded Terminations ............................................................................................................. 18-8Physician Certification of Medical Necessity for Pregnancy Termination ............................................... 18-8State-Funded Terminations ................................................................................................................... 18-9Sterilization Consent Forms for Centennial Care Members.................................................................... 18-9Submitting Hospice Care Services for Medicare Advantage Members ................................................ 18-10Medicare Part D Description Drug Coverage ....................................................................................... 18-11Filing Claims with Coordination of Benefits (COB) ............................................................................... 18-11Adjustment Requests Involving COB ................................................................................................... 18-11Centennial Care COB .......................................................................................................................... 18-12Centennial Care Third-Party Liability ................................................................................................... 18-12Requesting an Adjustment .................................................................................................................. 18-13Recovery of Claim Overpayments ....................................................................................................... 18-13Timely Submission Guidelines ............................................................................................................. 18-14Guidelines for Original Claim Submissions .......................................................................................... 18-14Guidelines for Claim Resubmissions, Corrected Claims, and Adjustment Requests for AdditionalPayment .............................................................................................................................................. 18-14“Clean” Claims .................................................................................................................................... 18-15“Unclean” Claims ................................................................................................................................. 18-15Encounter Reporting ........................................................................................................................... 18-16Correct Coding Standards ................................................................................................................... 18-16National Correct Coding Initiative......................................................................................................... 18-17Interest Payment ................................................................................................................................. 18-17Claims and Payment Resources .......................................................................................................... 18-18myPRES ............................................................................................................................................. 18-18Provider CARE Unit ............................................................................................................................. 18-18Mailing Address for Claims, Corrected Claims, and Claims Resubmissions ........................................ 18-18Other Contact Information ................................................................................................................... 18-1819. Presbyterian Customer Service Center ................................................................................................... 19-1Member Contacts for Customer Service ................................................................................................ 19-1Member Communication and Welcome Packets .................................................................................... 19-1Identification Cards ................................................................................................................................ 19-1Choosing a Primary Care Provider ........................................................................................................ 19-2Specialist Assigned as a Primary Care Provider .................................................................................... 19-2Primary Care Provider Changes ............................................................................................................ 19-2Removing Members from Your Panel .................................................................................................... 19-3Centennial Care Member Eligibility and Enrollment ............................................................................... 19-3Transportation Services for Centennial Care members .......................................................................... 19-3Medicare Annual Notification of Change Meetings ................................................................................. 19-4xix2014 Practitioner and Provider Manual - Ver. 3