2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Appendix D. Phone NumbersPhone NumbersNamePhone NumberHealthy Solutions Disease Management Program (PHS) 1-800-841-9705HealthEC 1-877-444-7194HealthXnet ® User Administration and Help DeskHome Health Care Requests (PHS)505-346-0290 or 1-866-676-0290 (phone)505-346-0278 (fax)505-559-1151 or 1-877-606-1151 (Option 4) (phone)505-559-1000 (24/7 phone)505-559-1150 (local fax)1-877-606-1155 (toll-free fax)Immunization Hotline (PHS) 1-888-231-2367Inpatient Concurrent Review or Inpatient Hospital Admission(PHS)Inpatient Prior Authorization Requests (PHS)505-923-5757 or 1-888-923-5757 (option 4)505-213-0181 or 1-888-923-5990 (fax)505-213-0181 or 1-888-923-5990 (fax)Instamed 1-866-945-79901-877-755-3392 (fax)Interactive Voice Response (IVR) (PHS) 505-923-5757 or 1-888-923-5757 (Option 1)Magellan EDI Support 1-800-450-7281Long-Term Care Prior Authorization Request (PHS) 505-213-01811-888-923-5990 (fax)MedAssets Main Office: 1-678-323-2500Product Information: 1-888-883-6332Tech Support: 1-866-658-1629New Mexico Human Services Department Fair Hearing Bureau 505-476-6213 or 1-800-432-6217 (option 6)505-476-6215 (fax)NurseAdvice ® New Mexico Centennial Care members 505-923-5677 or 1-888-730-2300Presbyterian Senior Care (HMO) and MediCare PPO members 1-800-887-9917Presbyterian Commercial Members 1-866-221-9679Presbyterian Employees and Dependents 1-800-905-3282Office Ally1-866-575-4120 (phone)1-360-896-2151 (fax)Outpatient Services (PHS) 505-923-5757 or 1-888-923-5757 (option 4)505-213-0246 (fax)D-22014 Practitioner and Provider Manual - Ver. 3
Appendix D. Phone NumbersPhone NumbersNamePhone NumberPayerpath 1-877-623-5706Pharmacy Requests (PHS) 505-323-5757 (option 3) or 1-888-923-5757 (option 3)Pharmacy Services Helpdesk (PHS)505-923-5500 or 1-888-923-5757 (phone)1-877-640-5814 (toll free fax)Provider CARE Unit (PHS) 505-923-5757 or 1-888-923-5757Provider Network Management e-Business Analyst (PHS) 505-923-8726Presbyterian Customer Service Center (PCSC) 505-923-5200 or 1-888-977-2333Prior Authorization Line (PHS) 505-923-5757 or 1-888-923-5757 (Option 4)Quality and Population Health Management Resource Line (PHS)505-923-5017 or 1-866-634-2617 (message only)Quality Management Department (PHS) 505-923-5516Radiology/Diagnostic Imaging Requests (HealthHelp ® )1-888-318-0280 (phone)1-888-717-9655 (fax)RelayHealth 1-800-527-8133 (Option 2)SilverSneakers ® Fitness Program 1-888-423-4632Special Investigative Unit (SIU) Confidential Hotline 505-923-5959 or 1-800-239-3147Superior Medical Transport 1-877-735-0111 (toll free) or 505-341-0042University of New Mexico Case Managers 505-272-2910University of New Mexico Prior Authorization Requests505-213-0149 (fax)Vaccines for Children (VFC) Program Director (PHS) 505-827-2898D-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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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
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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
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 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: Appendix C. WebsitesAppendix D. Pho
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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