2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
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Primary Care <strong>Provider</strong>sMonitoring the member’s progress <strong>and</strong>facilitating the member’s return to the PCPwhen medically appropriateDocumenting communication with specialtycare providers in the medical recordEducating members <strong>and</strong> their families abouttheir health issuesFollowing established utilization management<strong>and</strong> quality management guidelinesAdhering to <strong>Presbyterian</strong>’s administrativepolicies <strong>and</strong> proceduresMeeting <strong>Presbyterian</strong>’s credentialing <strong>and</strong> recredentialingrequirementsNotifying <strong>Presbyterian</strong> of changes in address,license, liability insurance, contracting status,or any other issue that could affect theprovider’s ability to effectively render coveredservicesAdvising patients of their right to know aboutall treatment options related to their conditionor disease, regardless of whether or not it is acovered benefit under their insurance plan;the <strong>Presbyterian</strong> Customer Service Center isavailable to assist with confirming coveredbenefitsReporting any misappropriation of property,abuse, or neglect of a child or vulnerable adultthat is revealed or suspected to the properregulatory authorities using the appropriatethe statewide central reporting intake number• Adult Protective Services: 1-866-654-3219• Children, Youth, <strong>and</strong> FamiliesDepartment: 1-800-797-3260• Department of Health/Division of HealthImprovement (DOH/DHI): 1-800-445-6242Further information regarding state reportingrequirements for suspected abuse, neglect, ormisappropriation of property of children <strong>and</strong>vulnerable adults can be obtained from the NewMexico DOH/DHI.The PCP is also responsible for contacting<strong>Presbyterian</strong> to verify member eligibility <strong>and</strong> priorauthorizations for covered services. You canquickly <strong>and</strong> easily verify member eligibility throughmyPRES, the provider online service located athttp://www.phs.org (locate the myPRES Loginbox) or through our Interactive Voice Responsesystem by calling 505-923-5757 or 1-888-923-5757. You can also request prior authorization ofcovered services through myPRES.Coverage Requirements <strong>and</strong> After Hours CarePCPs must be available to members 24/7. Whenthe PCP is unavailable, coverage should bearranged through a participating <strong>Presbyterian</strong>provider, or with an on-call health care professionalwho has signed a coverage arrangement with aparticipating PCP.Requirement to Use Contracted <strong>Provider</strong>sPCPs are required to use <strong>Presbyterian</strong>’s contractedproviders, laboratories, durable medical equipment(DME), <strong>and</strong> other services for referrals in an effortto minimize member inconvenience <strong>and</strong> billingissues. If you need to verify whether services areavailable in-network, you can call the <strong>Provider</strong>3-22014 <strong>Practitioner</strong> <strong>and</strong> <strong>Provider</strong> <strong>Manual</strong> - Ver. 3
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