2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Presbyterian Customer Service CenterProviders are also encouraged to take theprecaution of verifying the identity of the personpresenting the ID card against another form ofidentification, such as a driver’s license or otherphoto identification. This type of verification not onlydeters fraudulent use, but also protects the providerfrom performing a service for which payment maybe denied. The Federal Trade Commission recentlyissued its final ruling regarding identity theft redflags and addressing discrepancies under the Fairand Accurate Credit Transactions Act of 2003.These regulations require applicable businesses toincorporate processes and procedures incompliance with the final ruling. You areencouraged to determine if your business is subjectto these regulations and implement processes toprotect patient identity theft as applicable.To report suspicion of fraud and abuse, pleaserefer to the Fraud, Waste, and Abuse chapter.Choosing a Primary Care ProviderA member of the Presbyterian HMO plan or amember of Presbyterian must select a PCP tomanage his or her health care needs. The PCP willbe able to meet most of these needs. A member ofthe Presbyterian HMO plan may choose anyparticipating PCP with an open panel.If a member does not designate a PCP on his orher enrollment form, PHP may attempt to place anoutbound call to the member to provide assistancewith the selection. If a member does not select aPCP within 15 calendar days of enrollment,Presbyterian automatically selects a PCP for themember. The selection is based on factors such asthe member’s residence and physical ZIP code, themember’s age, and, if known, current providerrelationships. The choice of a PCP may includethose practicing in a variety of areas, such as familypractice, general practice, internal medicine, andpediatrics.Specialist Assigned as a Primary Care ProviderOn an individual basis, Presbyterian may allow aspecialist currently treating a member withdisabilities or chronic or complex conditions toserve in the capacity of a PCP. The networkspecialist must agree to perform all PCP duties andsuch duties must be within the scope of theparticipating specialist’s certification and inaccordance with the program requirements andrelated medical policies.When a member requests that a specialist serve asthe member’s PCP, the PCSC assists the memberby providing them with the Specialist as a PCPform. This form is completed by the member, whoreturns the form to Presbyterian. Upon receipt ofthe completed form, it is reviewed by the HealthServices Department for approval.Primary Care Provider ChangesMembers may request to change their PCP at anytime, for any reason, throughout the month. PCPchanges become effective the following businessday of the receipt of the request or at the daterequested by the member, provided the date is notretroactive.Presbyterian Centennial Care members mayrequest a PCP change at any time, for any reason;19-22014 Practitioner and Provider Manual - Ver. 3