2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Presbyterian Healthcare ServicesCentennial Care, Presbyterian Senior Care (HMO),and Presbyterian MediCare Preferred ProviderOrganization (PPO).Commercial ProductsPresbyterian offers a portfolio of products foremployers, including Health MaintenanceOrganization, Point-of-Service, and AdministrativeService Only products. Presbyterian InsuranceCompany offers a PPO product for groups andindividuals.Medicare Advantage: Presbyterian Senior Care(HMO) and Presbyterian MediCare PPOPresbyterian Senior Care (HMO) and PresbyterianMediCare PPO are Medicare Advantage programsfor seniors and other Medicare-eligiblebeneficiaries. The programs are designed to meetthe special health care and financial needs ofMedicare beneficiaries who live in our service areaof Bernalillo, Valencia, Sandoval, and Torrancecounties, along with parts of Cibola and Santa Fecounties. Presbyterian’s individual and employergroup benefit plans offer more benefits than originalMedicare and include prevention and wellnessbenefits.Presbyterian offers a network of providers with awide range of specialties to fit the unique needs ofMedicare beneficiaries. Presbyterian Senior Care(HMO) has plans available that include MedicarePart D prescription drug coverage.Members can use doctors, hospitals, and providersoutside the Presbyterian network for an additionalcost.Presbyterian Centennial CarePresbyterian Centennial Care is New Mexico’s newMedicaid program, replacing the former Salud!program, State Coverage Insurance, andCoordination of Long Term Care Services.Presbyterian Centennial Care is a single,comprehensive delivery system through fourmanaged care plans, allowing for greateradministrative simplicity. It emphasizes carecoordination so that recipients receive the rightcare, in the right place, at the right time, leading tobetter health outcomes. The 2014 Centennial CarePractitioner and Provider manual located athttps://www.phs.org/providers/centennial-care canalso be referenced for detailed information onPresbyterian’s Centennial Care program.Alternative Benefit PackageMedicaid expansion services, also known as theAlternative Benefit Package (ABP), are provided toqualified enrollees through the PresbyterianCentennial Care program. Before Centennial Care,Medicaid was primarily available to children,pregnant women, very low income mothers, andpeople with disabilities.Beginning January 2014, eligible recipients includemany adults who have never qualified for Medicaidbefore. Network providers will be required toprovide ABP-covered services under the terms ofthe Presbyterian Centennial Care ServiceAgreement.The ABP offers low-cost health care coverage tolow-income adults who meet ABP eligibilitystandards under the Human Services Department’s1-22014 Practitioner and Provider Manual - Ver. 3
Presbyterian Healthcare Services(HSD’s) Category of Eligibility 100. Eligibility isbased on income, rather than the multiple eligibilitycategories that were used before. To be eligible forABP, enrollees must be adults between the ages of19 and 64 who are at or below 138% of the FederalPoverty Level (FPL).Qualifying adults will receive ABP services throughPresbyterian Centennial Care. Native Americanswho are eligible through the expansion may enrollin Centennial Care or receive services through feefor service.ABP members will be assessed co-paymentsbased on income level for outpatient and inpatientservices and may be subject to additional copaymentsfor unnecessary services.Covered Services and Authorization:Refer to the Alternative Benefits Package Detailstable for a list of services included under theCentennial Care Alternative Benefit Package.Please note the covered services and authorizationrequirements may differ from regular CentennialCare.Please refer to Appendix G for a list of ABPcoveredservices.Regulatory Agency WebsitesThis Presbyterian 2014 Provider Manualincorporates information from regulatory agenciesabout requirements for Presbyterian’s product lines.For more information about regulatoryrequirements, please visit the websites listed in theRegulatory Agencies Website table.1-32014 Practitioner and Provider Manual - Ver. 3
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Page 8 and 9: Nurse Advice Line .................
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Page 31 and 32: Provider Network Managementthis man
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Page 35 and 36: Primary Care ProvidersClaims Activi
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Page 39 and 40: SpecialistsOther Information for PC
Page 41 and 42: Specialists5. Preventive Health Car
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Page 47 and 48: Care Coordination6. Care Coordinati
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Page 57 and 58: Care CoordinationClinical Practice
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Page 71 and 72: Care CoordinationFollow-up plans or
Page 73 and 74: 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
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e-BusinessFill out the form on the
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e-BusinessSign Up for this Free Ser
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e-BusinessClearinghouse Contact Inf
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e-Business18. Claims and Payment18.
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Claims and Paymentsubmission. Claim
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Claims and PaymentSpecify the origi
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Claims and Paymentrequiring a leadi
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Claims and PaymentPlease note that
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Claims and PaymentPresbyterian is r
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Claims and Paymentnot made a recove
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Claims and PaymentAcceptable docume
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Claims and Paymentallowing provider
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Claims and PaymentNational Correct
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Claims and Payment19. Presbyterian
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Presbyterian Customer Service Cente
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Appeals and Grievances20. Appeals a
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Appeals and GrievancesMember Appeal
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Appendix A. AcronymsAppendix A. Acr
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Appendix A. AcronymsHMOHRAHSDHealth
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Appendix A. AcronymsWWEDIWorkgroup
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Appendix B: DefinitionsAppendix B.
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Appendix B. DefinitionsTerm Definit
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Appendix C. WebsitesAppendix C. Web
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Appendix C. WebsitesWebsitesNameCul
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Appendix C. WebsitesWebsitesNameMem
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Appendix C. WebsitesWebsitesNameWED
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Appendix C. WebsitesAppendix D. Pho
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Appendix D. Phone NumbersPhone Numb
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Appendix B: Business Associate Agre
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Appendix E. Business Associate Agre
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Appendix E. Business Associate Agre
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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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