2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Appendix F. Prior Authorization GuideCovered Servicesambulatory surgical centerservicesanesthesia servicesassertive communitytreatment servicesassisted living(ABCB service**)behavior management skillsdevelopment servicesIs PriorAuthorizationRequired?YesYes for selectservicesYesYesYesExclusions and Limitations*NONCOVERED SERVICES: If the surgery is non-covered, the anesthesia is noncovered.• A. Direct payment to physician. Ambulatory surgical centers are not reimbursed byPHP for physician fees. Reimbursement for physician fees is made directly to theprovider of the service.• B. Services furnished to dual-eligible recipients. By federal regulation, the Medicareprogram pays ambulatory surgical centers only for an approved list of specificsurgical procedures. Medicare is the primary payment source for individuals whoare eligible for both Medicare and Medicaid. For these recipients, Medicaid doesnot pay an ambulatory surgical center for a surgical procedure denied by Medicare.Ambulatory surgical centers must refer these recipients to facilities where Medicarepays for the surgical procedure, such as an outpatient hospital.Anesthesia for pain management and dental procedures require prior authorization.Electronic Claims Transmission (ECT) does not require a separate authorization foranesthesia.• A. When a provider performing the medical or surgical procedure also provides alevel of anesthesia lower in intensity than moderate or conscious sedation, such asa local or topical anesthesia, payment for this service is considered to be part of theunderlying medical or surgical service and is not covered in addition to theprocedure.• B. An anesthesia service is not payable if the medical or surgical procedure is not aMedicaid or other health care benefit.• C. Separate payment is not allowed for qualifying circumstances; payment isconsidered bundled into the anesthesia allowance.• D. Separate payment is not allowed for modifiers (modifiers that begin with theletter “P”) that are used to indicate that the anesthesia was complicated by thephysical status of the patient.Pending final determination of behavioral health UM criteria.This benefit is only for those who qualify for Nursing Facility Level of Care and selectagency based community benefits. The following services are not provided to recipientsin assisted living facilities: personal care, respite, environmental modifications,emergency response or adult day health. The assisted living program is responsible forall of these services at the assisted living facility and are included in the cost of room andboard.PHP does not cover the following specific services in conjunction with behaviormanagement services:• A. Formal educational or vocational services related to traditional academicsubjects or vocational training• B. Activities which are not designed to accomplish the objectives delineated incovered services and which are not included in the behavioral managementtreatment plan• C. Residential treatment careELIGIBLE RECIPIENTS:• A. Behavior management services can be furnished only to Medicaid recipientsunder 21 years of age who:• (1) Are at risk for out-of-home placement because of unmanageable behavior athome or within the community• (2) Need behavior management intervention to avoid inpatient hospitalizations orresidential treatment• (3) Require behavior management support following institutional or other out-of-F-22014 Practitioner and Provider Manual - Ver. 3
Appendix F. Prior Authorization GuideCovered Servicesbehavior supportconsultation(ABCB service**)(SDCB service***)behavioral healthprofessional services:outpatient behavioral healthand substance abuseservicescare coordinationcase managementcommunity transitionservices(ABCB service**)community health workerscomprehensive communitysupport services (CCSS)customized communitysupports (SDCB)day treatment servicesIs PriorAuthorizationRequired?YesNoNoNoLTSSNoYesYesYesExclusions and Limitations*home placement as a transition to maintain the recipient in the home andcommunity• B. To receive services, recipients must meet the level of care for this serviceestablished by PHP.This is only available to members who meet the Nursing Facility Level of Care criteriaand must be included in the member's care plan and approved by the UM review team.• A. Limited to $3,500 per person every five years. To be eligible, a person must havea nursing facility stay of at least 90 days before transition to the community.• B. Only for those who qualify for Nursing Facility Level of Care and select AgencyBased Community BenefitsCCSS may not be filled in conjunction with the following PHP services:• A. Multi-systemic therapy• B. Assertive community treatment• C. Accredited residential treatment• D. Residential treatment• E. Group home services• F. Inpatient hospitalization• G. Partial hospitalization• H. Treatment foster care• A. Provided at least four or more hours per day, one or more days per week andcannot duplicate community direct support services, employment support services,or any other long-term care service.• B. Only for those who qualify for Nursing Facility Level of Care and select Self-Directed Community Benefits.Member must be < 21 years of age. PHP does not cover the following specific daytreatment activities:• A. Educational programs• B. Vocational training which is related to specific employment opportunities, workskills, or work settings• C. Pre-vocational training• D. Any service not identified in the treatment plan• E. Recreation activities not related to the treatment issues• F. Leisure time activities such as watching television, movies, or playing computergames• G. Transportation reimbursement for the therapist who delivers services in thefamily’s home• H. Services for which prior authorization was not obtained• I. Day treatment services cannot be offered at the same time as partial hospitalprogram or any residential programdental services Yes Benefit managed by DentaQuest, which has published criteria.F-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
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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
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.
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Page 247 and 248: Appendix C. WebsitesAppendix C. Web
Page 249 and 250: Appendix C. WebsitesWebsitesNameCul
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Page 255 and 256: Appendix C. WebsitesAppendix D. Pho
Page 257 and 258: Appendix D. Phone NumbersPhone Numb
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Page 261 and 262: Appendix E. Business Associate Agre
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Page 279 and 280: Appendix G. Alternative BenefitsG.
Page 281 and 282: Appendix G. Alternative Benefits Pa
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Page 285: Appendix G. Alternative Benefits Pa
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2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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