2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Primary Care Providers4. Specialists4. SpecialistsSpecialists are contracted physical and behavioralhealth practitioners not identified as primary careproviders (PCPs). Specialists agree to acceptreferrals from other contracted providers.The Role and Responsibilities of the SpecialtyCare ProviderThe specialist accepts referrals from othercontracted providers to provide more specializedservices for the member. The specialty careprovider is responsible forProviding medically necessary services tomembers who have been referred by one or moreof the following:• Their PCP• Another contracted provider• Self-referral, when appropriate, forspecified treatments or diagnosesReferring members to other providers as needed,including laboratory services and durable medicalequipment (DME) providersAdvising patients of their right to know about alltreatment options related to their condition ordisease, regardless of whether or not it is a coveredbenefit under their insurance plan. ThePresbyterian Customer Service Center is availableto assist with confirming covered benefits.Communicating with the member’s PCP or otherproviders about services rendered, treatmentresults, reports, and recommendations to ensurecontinuity of careDocumenting communication with the PCP or othercontracted providers in the medical recordObtaining prior authorization from Presbyterian’sHealth Services department for non-emergencyinpatient and outpatient services in accordance withthe member’s benefits package and Presbyterian’sutilization management policiesFollowing utilization and quality managementguidelinesAdhering to Presbyterian’s administrative policiesand proceduresMeeting Presbyterian’s credentialing and recredentialingrequirementsNotifying Presbyterian of changes in address,license, liability insurance, contract status, or anyother issue that could affect the provider’s ability toeffectively render covered services.Participating in the Interdisciplinary Care PlanTeam (for Centennial Care members)Specialty care providers are also responsible forreporting any misappropriation of property, abuse,or neglect of a child or vulnerable adult that isrevealed or suspected to proper regulatoryauthorities pursuant to state law using theappropriate the statewide central reporting intakenumber:4-12014 Practitioner and Provider Manual - Ver. 3