2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Appendix F. Prior Authorization GuideCovered ServicesIs PriorAuthorizationRequired?Exclusions and Limitations*classification of diseases (ICD) or the current version of diagnostic statistical manual(DSM)• C. Services for which prior authorization was not obtained• D. Services in freestanding psychiatric hospital for eligible recipient 21 years of ageor older• E. Services furnished after the determination by PHP or its designee has beenmade that the eligible recipient no longer needs hospital care• F. Formal educational or vocational services related to traditional academic subjectsor vocational training; PHP only covers non-formal education services if they arepart of an active treatment plan for an eligible recipient under the age of 21 receivinginpatient psychiatric services; see 42 CFR Section 441.13(b)• G. Experimental or investigational procedures, technologies, or non-drug therapiesand related services or treatment• H. Drugs classified as "ineffective" by the FDA drug evaluation• I. Activity therapy, group activities, and other services primarily recreational ordiversional in nature• J. PHP covers “awaiting placement days” in freestanding psychiatric hospitals whenthe PHP utilization review contractor determines that an eligible recipient under 21years of age no longer meets acute care criteria and the children’s mental healthservices review panel determines that the eligible recipient requires a psychosocialresidential level of care which cannot be immediately located• K. Those days during which the eligible recipient is awaiting placement to the lowerlevel of care are termed awaiting placement days• L. Payment to the hospital for awaiting placement days is made at the weightedaverage rate paid by PHP for psychosocial accredited residential services foreligible recipients classified as Level III, IV, or IV+ plus five percent; a separateclaim form must be submitted for awaiting placement daysICF/MR Yes Must meet Nursing Facility Level of Care criteria. member must be 18 years or older.IV OP serviceslab servicesmedical services providersmedication assistedmedical treatment (Tx) foropioid dependencemidwife servicesmulti-systemic therapy(MST) servicesnon-accredited residentialTx centers and grouphomesYesNo except forselect high-costtestsNo, but reserverights to implementprocess foroverutilizersYes formedications only,not for office visitYesYesYes for specificdefined criteriaMedicaid does not cover the following specific services furnished by midwives:• A. Oral medications or medications, such as ointments, creams, suppositories,ophthalmic, and otic preparations which can be appropriately self-administered bythe recipient• B. Services furnished by an apprenticeMST intervention is typically three to six months. Weekly interventions may range fromthree to 20 hours a week. The number might be less as a case nears closure.Member must be under 21 years of age. PHP does not cover the following specificactivities furnished in non-accredited residential treatment centers or group homes:• A. Services not considered medically necessary for the condition of the recipients,as determined by PHP• B. Room and board• C. Services for which prior approval was not obtainedF-82014 Practitioner and Provider Manual - Ver. 3
Appendix F. Prior Authorization GuideCovered ServicesIs PriorAuthorizationRequired?Exclusions and Limitations*• D. Services furnished after the determination is made by PHP or its designee thatthe recipient no longer needs care• E. Formal educational or vocational services related to traditional academicsubjects or vocational training• F. Experimental or investigations procedures, technologies, or non-drug therapiesand related services• G. drugs classified as “ineffective” by FDA drug evaluations• H. Activity therapy, group activities, and other services which are primarilyrecreational or diversional in naturenursing facility services YesFor custodial care in a skilled nursing facility, member must meet the Nursing FacilityLevel of Care criteria.nutritional counseling(SDCB service***)nutritional servicesobservation in hospitalgreater than 24 hoursoccupational services(therapy)outpatient hospital basedpsychiatric services andpartial hospitalizationoutpatient and partialhospitalization infreestanding psychiatrichospitalOutpatient health careprofessional servicespersonal care services(ABCB service**)pharmacy servicesphysical health servicesphysical therapyYesNoYesYesYes for partialhospitalization, Nofor outpatientYes for partialhospitalization, Nofor outpatientNoYesYesNo, but reserverights to implementprocess foroverutilizersYesThis benefit is only for those who qualify for Nursing Facility Level of Care and selectSelf-Directed Community Benefits.PHP does not cover the following specific services:• A. Services not considered medically necessary for the condition of the recipient asdetermined by PHP• B. Dietary counseling for the sole purpose of weight loss• C. Weight control and weight management programs• D. Commercial dietary supplements or replacement products marketed for theprimary purpose of weight loss and weight management.Authorization does not exceed 48 total hours.• A. These services are not provided 24 hours per day.• B. Only for those who qualify for Nursing Facility Level of Care and select agencybasedcommunity benefits (ABCB).• C. Personal care services do not include those services for tasks the individual isalready receiving from other sources including tasks provided by natural supports.Natural supports are friends, family, and the community (through individuals, clubs,and organizations) that are able and consistently available to provide supports andservices to the consumer. This service is not provided to ABCB recipients inassisted living facilities.F-92014 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 221 and 222: 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
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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
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Page 265 and 266: Appendix F. Prior Authorization Gui
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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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