2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Appendix B. DefinitionsTerm Definition SourceBaldrige Health CareCriteria for Performancesee linkExcellencebasic activities of dailyliving (BADL)behavioral healthCriteria provided by the Baldrige Performance Excellence Program that support health careorganizations in their efforts to reach goals, improve results, and become more competitive byaligning plans, processes, decisions, people, actions, and results.http://www.nist.gov/baldrige/publications/hc_about.cfm#Means bathing and showering (washing the body); bowel and bladder management(recognizing the need to relieve oneself); dressing; eating (including chewing and swallowing);feeding (setting up food and bringing it to the mouth); functional mobility (moving from oneplace to another while performing activities); personal device care; personal hygiene andgrooming (including washing hair); sexual activity; and toilet hygiene (completing the act ofrelieving oneself) http://en.wikipedia.org/wiki/Activities_of_daily_living.Umbrella term for mental health (including psychiatric illnesses and emotional disorders) and HSDsubstance abuse (involving addictive and chemical dependency disorders). The term alsorefers to preventing and treating co-occurring mental health and substance abuse disorders.Behavioral Health (BH) Any practitioner licensed/certified as a psychiatrist, psychologist, clinical social worker,High-Volume Practitioners marriage/family/child counselor, nurse, or other licensed health care professional withappropriate training and experience in behavioral health services to treat chemicaldependency and/or mental disorders.business days Means Monday through Friday, except for State of New Mexico holidays. HSDcalendar days Means all seven days of the week, including State of New Mexico holidays. HSDcare coordinationThe management of a member’s services to ensure that needs are met and services are notduplicated by the organizations involved in providing care.http://medical-dictionary.thefreedictionary.com/care+coordinationcare level See levels of care. HSDCentennial Careclaim(the) Collaborativecommunity benefitcommunity healthrepresentative (CHR)community health workers(CHW)confidential InformationMeans the State of New Mexico’s Medicaid program operated under Section 1115(a) of theSocial Security Act waiver authority.Means a bill for services submitted to the MCO manually or electronically, a line item ofservice on a bill, or all services for one member within a bill.Means the Interagency Behavioral Health Purchasing Collaborative, established under NMSA1978, § 9-7-6.4, responsible for planning, designing, and directing a statewide behavioralhealth system.Means both the agency-based community benefit and the self-directed community benefitsubject to an individual’s annual allotment as determined by HSD.Equivalent to community health worker or promotora but in the tribal communities.Also known as promotoras; means lay members of communities who work either for pay or asvolunteers in association with the local health care system in tribal, urban, frontier and ruralareas and usually share ethnicity, language, socioeconomic status and life experiences withthe members they serve. Community health workers include, among others, communityhealth advisors, lay health advocates, promotoras, outreach educators, community healthrepresentatives, peer health promoters, and peer health educators.Means any communication or record – whether oral, written, electronically stored ortransmitted, or in any other form – consisting of: (i) confidential member information, includingHIPAA-defined protected health information; (ii) all non-public budget, expense, payment andother financial information; (iii) all privileged work product; (iv) all information designated byHSD or any other state agency as confidential, and all information designated as confidentialunder the laws of the State of New Mexico; and (v) information utilized, developed, received,or maintained by HSD, the Collaborative, the MCO, or participating state agencies for thepurpose of fulfilling a duty or obligation under this agreement and that has not been disclosedpublicly.see linksee linkHSDHSDHSDHSDPMHSDHSDB-22014 Practitioner and Provider Manual - Ver. 3
Appendix B. DefinitionsTerm Definition Sourcecore service agencies Means multi-service agencies that help to bridge treatment gaps in the child and adultHSD(CSAs)treatment systems, promote the appropriate level of service intensity for members withcomplex behavioral health service needs, ensure that community support services areintegrated into treatment, and develop the capacity for members to have a single point ofaccountability for identifying and coordinating their behavioral health, health, and other socialservices.covered servicescritical incidentcultural competencedesirabledeterminationdual eligible(s)Early and PeriodicScreening, Diagnosis, andTreatment (EPSDT)Means those physical, behavioral health, and long-term care services provided underCentennial Care.Means a reportable incident that may include, but is not limited to:• Abuse, neglect, and exploitation• Abuse is defined as the willful infliction of injury, unreasonable confinement,intimidation, or punishment with resulting physical harm, pain, or mental anguish to aconsumer.• Neglect is defined as the failure to provide goods and services necessary to avoidphysical harm, mental anguish, or mental illness to a consumer.• Exploitation is defined as the deliberate misplacement, exploitation, or wrongful,temporary, or permanent use of a consumer’s belongings or money without theconsumer’s consent.• Death• Unexpected death is a death caused by an accident or an unknown or unanticipatedcause.• Natural/expected death is a death caused by a long-term illness, a diagnosed chronicmedical condition, or other natural/expected conditions resulting in death.• Other reportable incidents• Environmental hazard is defined as an unsafe condition that creates an immediatethreat to life or health of a consumer.• Law enforcement intervention is defined as the arrest or detention of a person by a lawenforcement agency, involvement of law enforcement in an incident or event, orplacement of a person in a correctional facility.• Emergency services refers to the provision of emergency services to a consumer thatresult in medical care that is not anticipated for this consumer, and that would notroutinely be provided by a primary care provider.Means a set of congruent behaviors, attitudes, and policies that come together in a system oragency or among professionals that enables them to work effectively in cross-culturalsituations. Cultural competency involves integrating and transforming knowledge, information,and data about individuals and groups of people into specific clinical standards, serviceapproaches, techniques, and marketing programs that match an individual’s culture toincrease the quality and appropriateness of health care and outcomes.Means “preferred.” The terms “may,” “can,” “should,” “preferably,” or “prefers” identify adesirable or discretionary item or factor (as opposed to “mandatory”).Means the written documentation of a decision by the procurement manager, includingfindings of fact supporting a decision. A determination becomes part of the procurement file.Means individuals who – by reason of age, income and/or disability – qualify for Medicare andfull Medicaid benefits under Section 1902(a)(10)(A) or 1902(a)(10)(C) of the Social SecurityAct, under Section 1902(f) of the Social Security Act, or under any other category of eligibilityfor medical assistance for full benefits.Means the federally required Early and Periodic Screening, Diagnosis and Treatment(EPSDT) program. as defined in Section 1902(r) of the Social Security Act and 42 CFR Part441, Subpart B for members under the age of twenty-one (21). It includes periodiccomprehensive screening and diagnostic services to determine physical and behavioralhealth needs as well as the provision of all medically necessary services listed in Section1905(a) of the Social Security Act even if the service is not available under the state’sMedicaid plan.HSDHSDHSDHSDHSDHSDHSDB-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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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
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 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: Appendix B: DefinitionsAppendix B.
Page 241 and 242: 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.
Page 281 and 282: Appendix G. Alternative Benefits Pa
Page 283 and 284: Appendix G. Alternative Benefits Pa
Page 285: Appendix G. Alternative Benefits Pa
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