2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Appendix F. Prior Authorization GuideCovered Servicesdiagnostic imaging andtherapeutic radiologyservices (for imaging)dialysis servicesdurable medical equipment(DME) and suppliesIs PriorAuthorizationRequired?Yes for high-costservicesNoYes for selectitemsExclusions and Limitations*Benefit managed by PHP Care Review team using HealthHelp ® , which has publishedcriteria listing exclusions and limitations.Benefit managed by PHP Care Review team using HealthHelp ® , which has publishedcriteria.• A. Special requirements for purchase of wheelchairs: Before billing for a customizedwheelchair, the provider who delivers the wheelchair and seating system to aneligible recipient must make a final evaluation to ensure that the wheelchair andseating system meets the medical, social, and environmental needs of the eligiblerecipient for whom it was authorized.• (1) The provider assumes responsibility for correcting defects or deficiencies inwheelchair and seating systems that make them unsatisfactory for use by theeligible recipient.• (2) The provider is responsible for consulting physical therapists, occupationaltherapists, special education instructors, teachers, parents or guardians, asnecessary, to ensure that the wheelchair meets the eligible recipient’s needs.• (3) Evaluations by a physical therapist or occupational therapist are required whenordering customized wheelchairs and seating systems. These therapists should befamiliar with the brands and categories of wheelchairs and appropriate seatingsystems and work with the eligible recipient and those consultants listed inParagraph (2) of Subsection B of 8.324.5.14 NMAC to assure that the selectedsystem matches physical seating needs. The physical or occupational therapistmay not be a wheelchair vendor or under the employment of a wheelchair vendoror wheelchair manufacturer.• (4) PHP does not pay for special modifications or replacement of customizedwheelchairs after the wheelchairs are furnished to the eligible recipient.• (5) When the equipment is delivered to the eligible recipient and the eligiblerecipient accepts the order, the provider submits the claim for reimbursement.• B. Special requirements for purchase of augmentative and alternativecommunication devices (AACDs):• (1) The purchase of AACDs requires prior authorization. In addition to beingprescribed by a physician, the communication device must also be recommendedby a speech-language pathologist, who has completed a systematic andcomprehensive evaluation. The speech pathologist may not be a vendor ofaugmentative communication systems nor have a financial relationship with avendor.• (2) A trial rental period of up to 60 calendar days is required for all electronicdevices to ensure that the chosen device is the most appropriate device to meetthe eligible recipient’s medical needs. At the end of the trial rental period, ifpurchase of the device is recommended, documentation of the eligible recipient’sability to use the communication device must be provided showing that the eligiblerecipient’s ability to use the device is improving and that the eligible recipient ismotivated to continue to use this device.• (3) PHP does not pay for supplies for AACDs, such as but not limited to paper,printer ribbons, and computer discs.• (4) Prior authorization is required for equipment repairs.• (5) A provider or medical supplier that routinely supplies an item to an eligiblerecipient must document that the order for additional supplies was requested bythe recipient or their personal representative and the provider or supplier mustconfirm that the eligible recipient does not have in excess of a 15-calendar-daysupply of the item before releasing the next supply order to the eligible recipient. Aprovider must keep documentation in their files available for audit that showcompliance with this requirement.F-42014 Practitioner and Provider Manual - Ver. 3
Appendix F. Prior Authorization GuideCovered Servicesemergency response(ABCB service**)(SDCB service***)emergency services(including ER visits andpsychiatric ER)employment supports(ABCB service**)(SDCB service***)environmentalmodifications(ABCB service**)(SDCB service***)experimental/investigationalprocedures, technology, ornon-drug therapiesearly and periodicscreening, diagnosis, andtreatment (EPSDT)Is PriorAuthorizationRequired?YesNoYesYesYesExclusions and Limitations*• A. member must have a land line phone.• B. Only for those who qualify for Nursing Facility Level of Care.• C. This benefit is not provided to members living in assisted living facilities. Theservice is not provided to recipients in assisted living facilities.• A. Payment shall not be made for incentive payments, subsidies, or unrelatedvocational training expenses.• B. Only for those who qualify for Nursing Facility Level of Care.• A. Environmental Modification services are limited to $5,000 every five years.Additional services may be requested if an eligible recipient’s health and safetyneeds exceed the specified limit. Excluded are those adaptations or improvementsto the home that are of general utility and are not of direct medical or remedialbenefit to the eligible recipient. Adaptations that add to the total square footage ofthe home are excluded from this benefit except when necessary to complete anadaptation.• B. Only for those who qualify for Nursing Facility Level of Care.• C. This benefit is not provided to members living in assisted living facilities.PHP does not cover experimental or investigational medical, surgical, or other healthcare procedures or treatments, including the use of drugs, biological products, otherproducts or devices, except for the following: PHP provides coverage for routine patientcare costs incurred as a result of the patient’s participation in a Phase I, II, III, or IVcancer trial that meets the following criteria. The clinical trials can only be performed inNew Mexico.• A. The cancer clinical trial is being conducted with approval of at least one of thefollowing:• (1) One of the federal National Institutes of Health• (2) A federal National Institutes of Health cooperative group or center; 8.325.6NMAC 1• (3) The federal Department of Defense• (4) The federal Food and Drug Administration in the form of an investigational newdrug application• (5) the federal Department of Veteran Affairs• (6) S qualified research entity that meets the criteria established by the federalnational institutes of health for grant eligibility• B. The clinical trial has been reviewed and approved by an institutional reviewboard that has a multiple project assurance contract approved by the office ofprotection from research risks of the federal National Institutes of Health.No These services are limited to members under the age of 21.These services are limited to members under the age of 21.EPSDT personal careservices(ABCB service**)(SDCB service***)YesNONCOVERED SERVICES:Services that are not covered under the New Mexico Medicaid EPSDT personal careprogram are as follows:• A. Any task that must be provided by a person with professional or technicaltraining, such as but not limited to insertion and irrigation of catheters, nebulizertreatments, irrigation of body cavities, performance of bowel stimulation, applicationof sterile dressings involving prescription medications and aseptic techniques, tubefeedings, and administration of medications;.F-52014 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
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Presbyterian Customer Service Cente
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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
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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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