2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Appendix F. Prior Authorization GuideCovered ServicesTot-to-Teen health checkstransplant servicestransportation services(medical)transportation services(non-medical)(SDCB service***)treatment foster caretreatment foster care IIIs PriorAuthorizationRequired?NoYesNo, except for airtransport. Benefitmanaged by avendor.YesYesYesExclusions and Limitations*value added services Yes Varies by benefitPHP does not cover any transplant procedures, treatments, use of drug(s), biologicalproduct(s), product(s), or device(s) which are considered unproven, experimental,investigational, or not effective for the condition for which they are intended or used.• A. Not to be used for transportation to medical appointments, etc., and not to beused for purposes of vacation• B. Only for those who qualify for Nursing Facility Level of Care and select Self-Directed Community BenefitsTreatment foster care services are subject to the limitations and coverage restrictionswhich exist for other Medicaid services. See 8.301.3 NMAC, General NoncoveredServices. PHP does not cover the following services:• A. Room and board• B. Formal educational or vocational services related to traditional academicsubjects or vocational training• C. Respite careTreatment foster care services are subject to the limitations and coverage restrictionswhich exist for other Medicaid services. See 8.301.3 NMAC, General NoncoveredServices. PHP does not cover the following services:• A. Room and board• B. Formal educational or vocational services related to traditional academicsubjects or vocational training• C. Respite carePHP does not cover the following specific vision services:• A. Orthoptic assessment and treatment• B. Photographic procedures, such as fundus or retinal photography and externalocular photography• C. Polycarbonate lenses other than for prescriptions for high acuity• D. Ultraviolet (UV) lenses• E. Trifocalsvision care servicesYes • F. Progressive lenses• G. Tinted or photochromic lenses, except in cases of documented medicalnecessity; see Subsection D of 8.310.6.12 NMAC above• H. Oversize frames and oversize lenses• I. Low-vision aids• J. Eyeglass cases• K. Eyeglass or contact lens insurance• L. Anti-scratch, anti-reflective, or mirror coatingTo be eligible for community benefits (self-directed community benefits and agency-based community benefits), members must meet medicaleligibility (nursing facility level of care) and financial eligibility. The member’s care coordinator completes a comprehensive needs assessment,which forms the basis for the development of an individual plan of care that includes recommended community benefit services based on theneeds of the individual. All recommended community benefits must be reviewed and approved by a PHP secondary review team before theprovision of services.* Presbyterian edits the prior authorization list as updates are needed. Please visithttp://www.phs.org/PHS/healthplans/providers/healthservices/ to check for the most recent version of this list.** ABCB is an agency-based community benefit service.*** SDCB is a self-directed community benefit service.F-142014 Practitioner and Provider Manual - Ver. 3
Appendix G. Alternative BenefitsG. Alternative Benefits Package Covered ServicesPackage Covered ServicesAppendix G. Alternative Benefits Package Covered ServicesCovered Service Description Prior AuthorizationAutism spectrum disorder Limitation: Services are only available to members through age 22. NoBariatric surgeryBehavioral health professionalservicesCancer Clinical TrialsLimitation: One surgery covered per lifetime. Criteria may be applied thatconsiders previous attempts by the member to lose weight, BMI and healthstatus.These include evaluations, therapy, and tests by licensed practitioners.This is a course of treatment provided to a patient for thepurpose of prevention of reoccurrence, early detection or treatment of cancerthat is being provided in New Mexico.YesNoNoCardiac rehabilitation Limitation: 36 hours per cardiac event NoChemotherapyChemotherapy is the use of chemical agents in the treatment or control ofdisease.NoDental services See Page 6-16. Yes, for select servicesand dental proceduresDiabetes treatment, includingdiabetic shoes and suppliesThis covers office visits, diabetes education and diabetic supplies includingdiabetic shoes, Insulin and diabetic oral agents for controlling blood sugar.Diabetic supplies used on an inpatient basis, applied as part of treatment in apractitioner’s office, outpatient hospital, residential facility, or a home healthservice, are covered when separate payment is allowed in these settings.Yes, for select servicesDiagnostic imaging andtherapeutic radiology servicesDialysis servicesDurable Medical Equipment (DME)and suppliesElectroconvulsive therapyCovered services include medically necessary imaging exams and radiologyservices ordered by doctors or other licensed providers. Some examples ofthese services are X-ray, ultrasound, magnetic resonance imaging (MRI),and computerized tomography (CT) scans.Medicaid covers medically necessary dialysis services and supplies furnishedto members receiving dialysis at home as well as services received from acontracted provider.This is equipment that is medically necessary for treatment of an illness oraccidental injury. It might also be needed to prevent further deterioration.DME is designed for repeated use. It includes items like oxygen equipmentand supplies necessary to use equipment wheelchairs, crutches and items toassist with treatment such as casts and splints that are applied by thehealthcare practitioner.ECT is a medical treatment for severe mental illness in which a small,carefully controlled amount of electricity is introduced into the brain, and isused to treat a variety of psychiatric disorders, including severe depression.Yes, for select servicesNoSome services mayrequire priorauthorizationYesEmergency services See Page 9-10. NoG-12014 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
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 257 and 258: Appendix D. Phone NumbersPhone Numb
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Page 281 and 282: Appendix G. Alternative Benefits Pa
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