2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Presbyterian Healthcare ServicesAlternative Benefits Package DetailsRecipient Income Level Services Co-paymentsABP recipients at or below100% of FPL or ABP-exemptCo-payments only apply for unnecessary use of a brand-name drug and unnecessaryuse of an emergency room (ER). See unnecessary services below.ABP recipients between101% and 138% of FPLABP-exempt individualsPharmacy ServicesPractitionerServicesHospital ServicesUnnecessaryServices$3 per drug item; does not apply if the co-payment for unnecessary brand-name drugutilization is assessed.$8 for outpatient visit to physician or other practitioner, dental visit, rehabilitativeor habilitative session. The co-pay does not apply to ER facility or ER professionalcharges. Note: Does apply to outpatient hospital clinic visits and urgent care visits, but isapplied to the professional service, not the facility charge.$25 for inpatient admission. Not applied when the hospital is receiving the member asa transfer from another hospital.A co-payment of $8 will be applied for non-emergent use of the ER or for a brandnamedrug when there is a less expensive equivalent drug, unless the prescriberdetermines the alternative drug is less effective or has greater adverse reactions.Psychotropic drug items are exempt from the brand-name co-payment (only the regularpharmacy co-payment applies).The following individuals are ABP-exempt and may voluntarily opt out of the ABP:Individuals who qualify for medical assistance on the basis of being blind or disabledIndividuals who are terminally ill and are receiving benefits for hospice carePregnant womenIndividuals who are medically frail including those with• A disabling mental disorder, including individuals up to age 21 with seriousemotional disturbances and adults with serious mental illness• A chronic substance use disorder• A serious and complex medical condition as defined by HSD• A physical, intellectual, or developmental disability that significantly impairsthe member’s ability to perform one or more activities of dialing living• A disability determination based on Social Security criteriaExempt individuals are identified with a “disability code type” of ME or PH in the eligibilityfile. Co-payments only apply to these recipients for unnecessary services, which includeuse of a brand-name drug or non-emergent use of the ER. These individuals will beidentified by Presbyterian, or members can self-identify by contacting their PresbyterianCare Coordinator. Exempt individuals will use their standard Medicaid benefit package.1-42014 Practitioner and Provider Manual - Ver. 3
Presbyterian Healthcare ServicesRegulatory Agency WebsitesAgencyNew Mexico Human Services Department Medical Assistance DivisionCenters for Medicare and Medicaid ServicesState of New Mexico Regulations & Licensing DepartmentNational Provider Identifier (NPI)Website Locationhttp://www.hsd.state.nm.us/mad/http://www.cms.gov/http://www.rld.state.nm.us/https://nppes.cms.hhs.gov/1-52014 Practitioner and Provider Manual - Ver. 3
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Page 8 and 9: Nurse Advice Line .................
Page 10 and 11: Pharmacy Benefits .................
Page 12 and 13: Clearinghouses ....................
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Page 21 and 22: Appendix A. Acronyms ..............
Page 23 and 24: 1. Presbyterian Healthcare Services
Page 25: Presbyterian Healthcare Services(HS
Page 29 and 30: Presbyterian Healthcare Services2.
Page 31 and 32: Provider Network Managementthis man
Page 33 and 34: Centennial Care Overview3. Primary
Page 35 and 36: Primary Care ProvidersClaims Activi
Page 37 and 38: Primary Care Providers4. Specialist
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 51 and 52: Care Coordinationthe program. If th
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Page 55 and 56: Care CoordinationFacilitate access
Page 57 and 58: Care CoordinationClinical Practice
Page 59 and 60: Care Coordinationformula, which is
Page 61 and 62: Care CoordinationAmerican Psychiatr
Page 63 and 64: Care Coordinationwithout obtaining
Page 65 and 66: Care CoordinationSpecialists as PCP
Page 67 and 68: Care Coordinationor when the member
Page 69 and 70: Care Coordination11. Prevention Scr
Page 71 and 72: Care CoordinationFollow-up plans or
Page 73 and 74: Care CoordinationPharmacy BenefitsP
Page 75 and 76: 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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