2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Appeals and Grievancescalendar-day extension from the provider. If theprovider requests the extension, the extension isapproved by Presbyterian.When filing an appeal, please remember todocument the reasons for the reconsiderationrequest and attach all supporting documentation forreview of the issue. If the issue involves a claimsdenial appeal, and the claim was previouslysubmitted electronically, please include a hard copyof the claim in question for review of the appeal. Ifthe appeal is related to a claim-coding matter, it ishelpful to include supporting medical records suchas office notes and operative reports, if applicable.Formal GrievancesA grievance may be filed orally or in writing andmust state with particularity the factual and legalbasis and the relief requested, along with anysupporting documents (such as claim, remittance,medical review sheet, medical records, orcorrespondence). Particularity usually means achronology of pertinent events and a statement asto why the provider believes the action byPresbyterian was incorrect. Grievances shall beresolved within 30 calendar days. If the providergrievance is not resolved within 30 calendar days,Presbyterian requests a 14-calendar-day extensionfrom the provider. If the provider requests theextension, the extension is approved byPresbyterian. Presbyterian reviews grievances inaccordance with all federal and state regulatoryguidelines and Presbyterian’s policies andprocedures. For Centennial Care providers, a copyof the Provider Appeals and Grievance policies andprocedures may be provided to contractedproviders. For a list of the applicable regulations,please access the Appeals & Grievances page athttps://www.phs.org/providers/cliniciansresources/appeals-grievances/Pages/default.aspx.Circumstances Giving Rise to a Provider FairHearingProviders may appeal a decision to deny, suspend,or terminate their participation in the Presbyteriannetwork. If the provider disputes any such action,they must submit a written request for a hearing.A provider has the right to a fair hearing uponreceipt of a written notice from Presbyterian, or itsagent, pursuant to the termination, for terminatingthe agreement either immediately or after notice.Presbyterian must give reasonable advance noticeif the agreement is terminated for cause, unless it isfor quality of care issues. The minimum advancenotice is determined by federal and state regulatoryguidelines unless the provider’s contract statesotherwise.Initiation of an Appeal HearingA provider may initiate a fair hearing within 30calendar days of receiving written notice oftermination from Presbyterian, by delivering orsending by certified mail a written request for a fairhearing to Presbyterian or its agent. Failure todeliver a written request by certified mail for a fairhearing within those 30 days constitutes a waiverby the provider of any hearing regarding theirtermination. If a request for a hearing is not filed bythat time, the provider contract ends.20-22014 Practitioner and Provider Manual - Ver. 3
Appeals and GrievancesMember Appeals and GrievancesWith written consent from the member to act astheir representative during the appeal process,providers may appeal a denied benefit certificationor a concurrent review decision to denyauthorization that was made by the medicaldirector. At the time of the decision, a provider ormember may request that Presbyterian reconsiderthe denial by submitting further documentation tosupport medical necessity. Such requests arereferred immediately to a medical director notpreviously involved in the case for resolution andare handled according to the member appealguidelines.If benefit certification or prior authorization forservices for any Presbyterian member is requestedby a provider and denied by Presbyterian, aprovider may act on the member’s behalf and mayfile a request for an expedited appeal if the providerfeels that the member’s health or welfare are inimmediate jeopardy. Presbyterian then determinesif it meets expedited criteria. If the case is deemedexpedited, Presbyterian processes the expeditedappeal within 72 hours of receipt. (Time extensionsmay apply with written consent from the member.)For Presbyterian Centennial Care, unless themember or the provider requests an expeditedresolution, an oral appeal must be followed by awritten appeal that is signed by the member within13 calendar days; failure to file the written appealwithin 13 calendar days constitutes withdrawal ofthe appeal.The Presbyterian member appeals and grievanceprocess is published in the member handbooks.Presbyterian provides a process that ensures allmembers have the right to exercise their right to anappeal and that they receive the decision within theappropriate and proper time frames for resolution oftheir appeals.Any member also has the right to file a grievance ifhe or she is dissatisfied with the services renderedthrough Presbyterian. In respect to grievances, themember is defined as any individual enrolled inPresbyterian or their designated representative. Aprovider may represent a member in a grievance orappeal with written consent from the member.Member grievances may include but are not limitedto dissatisfaction with providers, appropriateness ofservices rendered, timeliness of services rendered,availability of services, delivery of services,reduction or termination of services, disenrollment,or any other performance that is consideredunsatisfactory. The member should submit agrievance to the Presbyterian grievance andappeals coordinator within 30 calendar days of thedate the dissatisfaction occurred.The member should submit an appeal to thegrievance and appeals coordinator within 90 daysfrom the date of denial.Member Fair HearingA member may request a State Fair Hearing if heor she is dissatisfied with an action that has beentaken by Presbyterian, and the member hasexhausted Presbyterian’s internal process, within30 calendar days of the Presbyterian’s finaldecision. A representative of the member or themember’s estate, or a provider acting on behalf of20-32014 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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Fraud, Waste, and Abuseis violated
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Page 179 and 180: Fraud, Waste, and Abuse16. Credenti
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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 227: Appeals and Grievances20. Appeals a
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.
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Page 247 and 248: Appendix C. WebsitesAppendix C. Web
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Page 255 and 256: Appendix C. WebsitesAppendix D. Pho
Page 257 and 258: Appendix D. Phone NumbersPhone Numb
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Appendix G. Alternative BenefitsG.
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Appendix G. Alternative Benefits Pa
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