2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Appeals and Grievancesthe member, with the member’s consent, mayrequest a State Fair Hearing on behalf of themember.A State Fair Hearing may be requested by callingor writing to:New Mexico Human Services DepartmentFair Hearings BureauPO Box 2348Santa Fe, NM 87504-2348Phone: 505-476-62131-800-432-6217, Option 6Fax: 505-476-6215If a request for a Fair Hearing is received by theHuman Services Department within 10 calendardays, Presbyterian’s final decision will be uphelduntil the outcome of the hearing is decided.However, if the Hearing Officer agrees withPresbyterian’s final decision, the member may haveto pay for the continued services if those serviceswere the reason for the hearing.20-42014 Practitioner and Provider Manual - Ver. 3
Appendix A. AcronymsAppendix A. AcronymsAppendix A. AcronymsA B C D E F G H I J K L MN O P Q R S T U V W X Y ZAAAFPAAPABPADHDADLAMAAPAASOAmerican Academy of Family PhysiciansAmerican Academy of PediatricsAlternative Benefits PackageAttention Deficit and Hyperactivity DisorderActivities of Daily LivingAmerican Medical AssociationAmerican Psychiatric AssociationAdministrative Service OnlyBack to topBBADLBasic Activities of Daily LivingBack to topCCAGECAHPS ®CARECCSCCSSCDCCFRCHRCHWCLICLIACMSCNACPTCSACTCYFDCut, Annoy, Guilty, Eye OpenerConsumer Assessment of Healthcare Providers and SystemsClaims Activity Review and EvaluationCorrect Coding StandardsComprehensive Community Support ServicesCenters for Disease Control and PreventionCode of Federal RegulationsCommunity Health RepresentativeCommunity Health WorkerCertified Language InternationalClinical Laboratory Improvement AmendmentsCenters for Medicare and Medicaid ServicesComprehensive Needs AssessmentCurrent Procedural TerminologyCore Service AgencyComputed TomographyChildren, Youth, and Families DepartmentBack to topA-12014 Practitioner and Provider Manual - Ver. 3
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ii2014 Practitioner and Provider Ma
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iv2014 Practitioner and Provider Ma
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vi2014 Practitioner and Provider Ma
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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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Fraud, Waste, and AbuseIs informed
Page 179 and 180: Fraud, Waste, and Abuse16. Credenti
Page 181 and 182: Credentialing and RecredentialingPr
Page 183 and 184: Credentialing and RecredentialingNe
Page 185 and 186: Credentialing and Recredentialing17
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 and 228: Appeals and Grievances20. Appeals a
Page 229: Appeals and GrievancesMember Appeal
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
Page 263 and 264: Appendix E. Business Associate Agre
Page 265 and 266: Appendix F. Prior Authorization Gui
Page 279 and 280: Appendix G. Alternative BenefitsG.
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Appendix G. Alternative Benefits Pa
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