2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Medicare Advantage Plans New Member Education, Verification, and Welcome Calls .......................... 19-4Medicare Member Appreciation Events ................................................................................................. 19-4Additional Medicare Benefits Medicare Social Service Coordinators ..................................................... 19-4SilverSneakers ® Fitness Program .......................................................................................................... 19-4Members’ Rights and Responsibilities ................................................................................................... 19-5Members have the right to ..................................................................................................................... 19-5Members have the responsibility to: ....................................................................................................... 19-7Confidentiality ........................................................................................................................................ 19-7Member Health Information Rights ........................................................................................................ 19-8Legal Authority to Make Health Care Decisions for Minors or Others .................................................... 19-8Right to See and Get a Copy of Health Information ............................................................................... 19-8Right to Amend Incorrect or Incomplete Health Information ................................................................... 19-8Right to Request Restrictions of Health Information .............................................................................. 19-8Right to Request Confidential Communications of Health Information ................................................... 19-8Right to Request an Accounting of Disclosures ..................................................................................... 19-8Right to Receive a Paper Copy of Privacy Notice .................................................................................. 19-9Use of Consents and Authorizations to Obtain Protected Health Information ........................................ 19-9Members Who are Unable to Give Consent or Authorization ................................................................. 19-9Member Access to Protected Health Information Contained in Plan Records ...................................... 19-10Safeguarding Oral, Written, and Electronic Protected Health Information Across Presbyterian ............ 19-10myPRES/Website Internet Information ................................................................................................ 19-10Protection of Information Disclosed to Plan Sponsors, Employers, or Government Agencies .............. 19-11Cultural Competency ........................................................................................................................... 19-11Translation Services ............................................................................................................................ 19-11Advance Directive ................................................................................................................................ 19-12Provider CARE Unit ............................................................................................................................. 19-13Self-Help Options ................................................................................................................................ 19-13Web-based Inquiries ........................................................................................................................... 19-13Helpful Tips ......................................................................................................................................... 19-14Contacting the Provider CARE Unit ..................................................................................................... 19-14Telephone Inquiries ............................................................................................................................. 19-1420. Appeals and Grievances ......................................................................................................................... 20-1Provider Appeals and Grievance Process .............................................................................................. 20-1Standard Appeal ................................................................................................................................... 20-1Formal Grievances ................................................................................................................................ 20-2Circumstances Giving Rise to a Provider Fair Hearing .......................................................................... 20-2Initiation of an Appeal Hearing............................................................................................................... 20-2Member Appeals and Grievances .......................................................................................................... 20-3xx2014 Practitioner and Provider Manual - Ver. 3
Appendix A. Acronyms .................................................................................................................................. A-1Appendix B. Definitions.................................................................................................................................. B-1Appendix C. Websites ................................................................................................................................... C-1Appendix D. Phone Numbers ........................................................................................................................ D-1Appendix E. Business Associate Agreement ................................................................................................. E-1Appendix F. Prior Authorization Guide ............................................................................................................ F-1Appendix G. Alternative Benefits Package Covered Services ........................................................................ G-1List of TablesAlternative Benefits Package Details .............................................................................................................. 1-4Regulatory Agency Websites .......................................................................................................................... 1-5Clinical Practice Guidelines and Tools .......................................................................................................... 6-10Contacts for Other Information Providers May Need ..................................................................................... 6-28TriCore Contact Information ........................................................................................................................... 7-2Types of Pharmacy Prior Authorization Requests ......................................................................................... 8-12General Processing Routine Pharmacy Prior Authorization Requests by Fax, Mail, or Online ...................... 8-12Claims Processing Revenue Codes............................................................................................................ 11-10Clearinghouse Contact Information .............................................................................................................. 17-7Physician Certification of Medical Necessity for Pregnancy Termination .................................................... 18-10Presbyterian Customer Service Center Hours of Operation for Members ..................................................... 19-1xxi2014 Practitioner and Provider Manual - Ver. 3
Page 2 and 3: ii2014 Practitioner and Provider Ma
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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 16: Monitoring ........................
Page 19: Federally Funded Terminations .....
Page 23 and 24: 1. Presbyterian Healthcare Services
Page 25 and 26: Presbyterian Healthcare Services(HS
Page 27 and 28: Presbyterian Healthcare ServicesReg
Page 29 and 30: Presbyterian Healthcare Services2.
Page 31 and 32: Provider Network Managementthis man
Page 33 and 34: Centennial Care Overview3. Primary
Page 35 and 36: Primary Care ProvidersClaims Activi
Page 37 and 38: Primary Care Providers4. Specialist
Page 39 and 40: SpecialistsOther Information for PC
Page 41 and 42: Specialists5. Preventive Health Car
Page 43 and 44: Preventive Health Care GuidelinesPr
Page 45 and 46: Preventive Health Care GuidelinesSe
Page 47 and 48: Care Coordination6. Care Coordinati
Page 49 and 50: Care CoordinationPresbyterian’s c
Page 51 and 52: Care Coordinationthe program. If th
Page 53 and 54: Care Coordinationdesignated family
Page 55 and 56: Care CoordinationFacilitate access
Page 57 and 58: Care CoordinationClinical Practice
Page 59 and 60: Care Coordinationformula, which is
Page 61 and 62: Care CoordinationAmerican Psychiatr
Page 63 and 64: Care Coordinationwithout obtaining
Page 65 and 66: Care CoordinationSpecialists as PCP
Page 67 and 68: Care Coordinationor when the member
Page 69 and 70: 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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Home Healthfor review will be submi
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Home HealthPatient Care Conferences
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Home HealthThis page intentionally
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Quality Improvement ProgramNational
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Quality Improvement Programcomplian
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Quality Improvement Programresults
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Quality Improvement Programrespect
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Quality Improvement ProgramPresbyte
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Quality Improvement ProgramNCQA ori
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Quality Improvement ProgramThis pag
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Health Insurance Portability and Ac
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Health Insurance Portability and Ac
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Legalabove, nor from any recourse a
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Legalagreement with Presbyterian fo
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Legaltransactions (federal, state,
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Legalcontractual relationship with
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Legalcomply with all state and fede
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Legalany such program during the te
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LegalPrompt Pay by PresbyterianPres
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Legal15. Fraud, Waste, and Abuse15.
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Fraud, Waste, and Abuseas the time
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Fraud, Waste, and AbuseAll document
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Fraud, Waste, and AbuseVerifying th
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Fraud, Waste, and AbuseHistorically
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Fraud, Waste, and Abuseis violated
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Fraud, Waste, and AbuseIs informed
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Fraud, Waste, and Abuse16. Credenti
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Credentialing and RecredentialingPr
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Credentialing and RecredentialingNe
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Credentialing and Recredentialing17
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e-BusinessFill out the form on the
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e-BusinessSign Up for this Free Ser
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e-BusinessClearinghouse Contact Inf
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e-Business18. Claims and Payment18.
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Claims and Paymentsubmission. Claim
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Claims and PaymentSpecify the origi
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Claims and Paymentrequiring a leadi
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Claims and PaymentPlease note that
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Claims and PaymentPresbyterian is r
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Claims and Paymentnot made a recove
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Claims and PaymentAcceptable docume
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Claims and Paymentallowing provider
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Claims and PaymentNational Correct
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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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