2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Appendix C. WebsitesWebsitesNameBecome a Contracted Provider Sign Up Page(PHS)Behavioral Health Resources (PHS)Care Continuum AllianceCAQH WebsiteClaim.MDClaim MD Fast Claim EnrollmentClaims Processing Page (PHS)Classification of Diseases, Functioning, andDisabilityCLIA Waived Test ListClinicians Resources (PHS)CMS Carriers Manual and Hospital ManualWebsite Locationhttps://www.phs.org/providers/Pages/become-contracted-provider.aspxhttps://www.phs.org/providers/clinicians-resources/Pages/behavioral-health.aspxhttp://www.carecontinuumalliance.org/http://www.caqh.org/http://www.claim.md/https://www.claim.md/phs.plxwww.phs.org/providers/training-reference/claims/http://www.cdc.gov/nchs/icd.htmhttp://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdfhttps://www.phs.org/providers/clinicians-resources/http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.htmlCMS Provider UpdatesFee-for-Service Provider Updateshttp://www.cms.gov/Center/Provider-Type/All-Fee-For-Service-Providers-Center.html?redirect=/center/provider.aspQuarterly Provider Updateshttp://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.htmlCoding and Reimbursement Store (AMA)Contact Presbyterian Webpage (PHS)https://commerce.amaassn.org/store/catalog/categoryDetail.jsp?category_id=cat1150004&navAction=jumphttps://www.phs.org/about-us/contact-us/Coronary Artery Disease Resources and GuidanceAHA/ACC Secondary Prevention for Patients with Coronary and Other VascularDisease: 2006 Update (American College of Cardiology and the American HeartAssociation)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00052254.pdfCoronary Artery Disease Clinical Practice Guidelines (American College ofCardiology and the American Heart Association)http://docs.phs.org/idc/groups/public/@phs/@marketing/documents/phscontent/wcmdev1000934.pdfCoronary Artery Disease Clinical Recommendations for Prevention of HeartDisease in Women (American Heart Association)http://docs.phs.org/idc/groups/public/@phs/@marketing/documents/phscontent/wcmdev1000935.pdfC-22014 Practitioner and Provider Manual - Ver. 3
Appendix C. WebsitesWebsitesNameCultural Competency Resource KitWebsite Locationhttps://www.magellanprovider.com/MHS/MGL/education/culturalcompetency/index.aspDentaquest Websitewww.dentaquestgov.comDepression Guidelines for Primary CarePractitioners Treating Adult Patients withDepression (PHS)Depression Recognition Tools: PHQ-9 and OtherInformation (PHS)Diabetes Clinical Practice Guidelines forProviders–Non-Pregnant Adult (PHS)Drug Prior Authorization Request Form (PHS)EHR Medicare and Medicaid Incentive Programhttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/wcmdev1001004.pdfhttp://www.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001006.pdfhttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001010.pdfhttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001068.pdfOfficial Web Site for the Medicare and Medicaid Electronic Health Records (EHR)Incentive Programshttp://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/40_MedicaidStateInfo.aspRegistration and Attestation Websitehttps://ehrincentives.cms.govDHHS Office of the National Coordinator for Health Information Technology, “EHRIncentives and Certification”http://www.healthit.gov/providers-professionals/faqs/ehr-incentive-payment-scheduleElectronic Code of Federal RegulationsEmdeon Business ServiceseNews Registration for Providers (PHS)Epocrates ® WebsiteEPSDT Provider Manual (PHS)Fraud and Abuse Information and Reporting Page(PHS)Gateway EDIGeneral Services Administration’s System forAward Management (GSA SAM)Geographic Availability Standards (PHS)http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr164_main_02.tplhttp://www.emdeon.comhttps://www.phs.org/providers/news-communications/Pages/enews-registration.aspxhttp://www.epocrates.comhttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001063.pdfhttps://www.phs.org/insurance-plans/all-about-health-care/faqs/fraudabuse/Pages/default.aspxwww.gatewayedi.comhttps:www.sam.gov/portal/public/SAM/http://docs.phs.org/idc/groups/public/documents/phscontent/wcmdev1001078.pdfC-32014 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
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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
Page 197 and 198: Claims and PaymentSpecify the origi
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Page 201 and 202: Claims and PaymentPlease note that
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Page 205 and 206: Claims and Paymentnot made a recove
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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 and 238: Appendix B: DefinitionsAppendix B.
Page 239 and 240: Appendix B. DefinitionsTerm Definit
Page 247: Appendix C. WebsitesAppendix C. Web
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
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