2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Claims and PaymentPhysician Certification of Medical Necessity for Pregnancy TerminationPatient Name:Medicaid or Presbyterian Centennial Care Identification Number:After reviewing the patient chart and consulting with the patient, as the treating physician, I certify that, in my best medicaljudgment, pregnancy termination is medically necessary for this patient for the following reason(s):To save the life of the motherThe pregnancy is a result of rape or incestTo terminate an ectopic pregnancyThe pregnancy aggravates a pre-existing conditionThe pregnancy makes treatment of a condition impossibleThe pregnancy interferes with or hampers a diagnosisThe pregnancy has a profound negative impact upon the physical or mental health of an individualPractitioner’s Name:Practitioner’s Signature: _________________________Date:Submitting Hospice Care Services for MedicareAdvantage MembersPresbyterian asks that you file claims for MedicareAdvantage (Presbyterian Senior Care(HMO)/Presbyterian MediCare PPO) members whohave elected hospice coverage to OriginalMedicare, using guidelines published in theMedicare Managed Care Manual by CMS, thefederal agency charged with oversight of theMedicare program.Claims for services covered under OriginalMedicare related to hospice (the member’s terminalcondition) should be filed with the local Medicareintermediary (for Medicare Part A benefits) andcarrier (for Medicare Part B benefits). Please do notfile these claims with Presbyterian, as they will bedenied.Claims for services covered under OriginalMedicare but NOT related to the terminal illnessshould also be filed with the local intermediary andcarrier. Please do not file these claims withPresbyterian, as they will be denied.Once you have received your remittance advicefrom Original Medicare, submit the claim for nonhospicerelated services with the remittance adviceto Presbyterian.18-102014 Practitioner and Provider Manual - Ver. 3