2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Presbyterian Customer Service Centerhttps://www.phs.org/about-us/contactus/Pages/default.aspx.Helpful TipsIn the event that it is necessary to submit a paperclaim (new, resubmission, or corrected) or whensubmitting claims and encounter information,please direct it to the following mailing address:Presbyterian Health PlanP.O. Box 27489Albuquerque, NM 87125-7489The Provider CARE unit will assist you with yourcomplex inquires Monday through Friday between8 a.m. and 5 p.m. The Provider CARE Unit can becontacted by providers at the following numbers:Local: 505-923-5757Toll-free: 1-888-923-5757When calling the Provider CARE Unit, please haveavailable the following information:Your National Provider Identifier (NPI), arequirement for you to provide as of January1, 2008. The Provider CARE Unit will beunable to assist you without this number.The member’s Presbyterian ID number, dateof service, procedure code, billed amounts,and claim number (if known).For reimbursement and coding questions, refer tothe Claims chapter of this manual.For benefit certification, refer to the CareCoordination chapter of this manual.For appeals and grievance, refer to the Appealsand Grievances chapter.For timely submission guidelines, refer to theClaims chapter of this manual.Contacting the Provider CARE UnitPlease contact your provider network managementrelationship executive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf) ifthe issue affects more than 10 claims (for example,incorrect contract payment, or charge for a specificcode is being denied when it should be paying).Telephone InquiriesIf a member needs to request a primary careprovider change or wishes to speak with acustomer service representative, please have themcall the Customer Service phone number on theback of their Presbyterian member ID card.For questionable claim payment or denial, refer tothe Claims chapter of this manual.19-142014 Practitioner and Provider Manual - Ver. 3
Appeals and Grievances20. Appeals and Grievances20. Appeals and GrievancesA provider has the right to file an appeal ifdissatisfied with a decision made by Presbyterian toterminate, suspend, reduce, or not provideapproved services to a member, or to denypayment for services. The provider also has theright to file an appeal if the provider disagrees withany policy or adverse action made by Presbyterian.Additionally, if a provider is dissatisfied with any ofPresbyterian’s general operations, he or she mayfile a grievance. In order to file an appeal orgrievance on behalf of a member, a provider musthave the member’s written consent.If the issue involves a utilization managementdecision, a provider must obtain the written consentof the member to act on his or her behalf during theappeal process, unless the matter is determined tobe an expedited appeal.Provider Appeals and Grievance ProcessAny provider has the right to file a formal grievanceor appeal with Presbyterian. The provider shouldsubmit the grievance or appeal to the Presbyteriangrievance and appeals coordinator within thefollowing time frame:Grievances or appeals challenging a claimdenial, claim adjudication, claim submission,claim resubmission, or claim resubmission notacted upon by Presbyterian must be filedwithin 12 months of the date of service.Appeals and grievances related tooverpayments identified by Presbyterian mustbe filed within 12 months of the date of serviceor 60 days from the notification, whichever isthe later date.Standard AppealPresbyterian encourages providers to file claimscorrectly the first time or, if time allows, resubmitthe claim through the Claims Activity Review andEvaluation (CARE) Unit to resolve an issue. Aprovider is encouraged to contact his or herprovider network management relationshipexecutive(https://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00140718.pdf) to helpclarify any denials or other actions relevant to theclaim and to help with a possible resubmission of aclaim with modifications.Remember, once a claim is initially submitted in atimely manner, a provider has one year (12months) from the date of service to correct anydefects in the initial claim submission and toresubmit the claim for reprocessing. A provider has12 months from the date of service to file an appealregarding a claim denial or the denial is upheld aspast the filing limit for initiating an appeal.Appeals will be resolved within 30 calendar days. Ifthe provider appeal is not resolved within 30calendar days, Presbyterian requests a 14-20-12014 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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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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Page 177 and 178: Fraud, Waste, and AbuseIs informed
Page 179 and 180: Fraud, Waste, and Abuse16. Credenti
Page 181 and 182: Credentialing and RecredentialingPr
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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
Page 197 and 198: Claims and PaymentSpecify the origi
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 225: Presbyterian Customer Service Cente
Page 229 and 230: Appeals and GrievancesMember Appeal
Page 231 and 232: Appendix A. AcronymsAppendix A. Acr
Page 233 and 234: Appendix A. AcronymsHMOHRAHSDHealth
Page 235 and 236: Appendix A. AcronymsWWEDIWorkgroup
Page 237 and 238: Appendix B: DefinitionsAppendix B.
Page 239 and 240: Appendix B. DefinitionsTerm Definit
Page 247 and 248: Appendix C. WebsitesAppendix C. Web
Page 249 and 250: Appendix C. WebsitesWebsitesNameCul
Page 251 and 252: Appendix C. WebsitesWebsitesNameMem
Page 253 and 254: Appendix C. WebsitesWebsitesNameWED
Page 255 and 256: Appendix C. WebsitesAppendix D. Pho
Page 257 and 258: Appendix D. Phone NumbersPhone Numb
Page 259 and 260: Appendix B: Business Associate Agre
Page 261 and 262: Appendix E. Business Associate Agre
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Page 265 and 266: Appendix F. Prior Authorization Gui
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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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