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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SpecialistsAdult Protective Services: 1-866-654-3219Children, Youth, <strong>and</strong> Families Department: 1-800-797-3260Department 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.In addition, specialty care providers are responsiblefor verifying member eligibility before renderingservices. This can be easily <strong>and</strong> quickly donethrough myPRES athttps://mypres.phs.org/Pages/default.aspx orthrough <strong>Presbyterian</strong>’s Interactive Voice Responsesystem by calling 505-923-5757 or 1-888-923-5757. Specialists can also request priorauthorization of covered services through myPRESat https://mypres.phs.org/Pages/default.aspx.Requirement to Use Contracted <strong>Provider</strong>sSpecialty care providers are required to use<strong>Presbyterian</strong>’s contracted providers, includinglaboratory services, DME, <strong>and</strong> other services, in aneffort to minimize member inconvenience <strong>and</strong>billing issues. To verify if services are available innetwork, you can call the <strong>Provider</strong> Claims ActivityReview <strong>and</strong> Evaluation Unit at 505-923-5757 or 1-888-923-5757 for assistance.Laboratory ServicesSpecialists are responsible for sending members to<strong>Presbyterian</strong>’s preferred laboratory servicesprovider, TriCore Reference Laboratories, unlessclinical circumstances require the use of a differentlaboratory. If you need to refer to a differentlaboratory, immediately seek a prior authorizationas outlined in the Care Coordination chapter of thismanual. For a list of laboratory locations, pleasevisithttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00078812.pdf.Durable Medical Equipment ServicesSpecialists are responsible for referring members tocontracted DME providers. For a complete listing ofDME providers, please visit our website athttp://www.phs.org <strong>and</strong> click “Find a Doctor” at thetop of the page <strong>and</strong> search by specialty.If you do not comply with these requirements,<strong>Presbyterian</strong> reserves the right to hold youresponsible for up to 150% of eitherThe difference between the amount that<strong>Presbyterian</strong> would have paid if a contractedprovider had been used <strong>and</strong> the total amountactually paid by <strong>Presbyterian</strong> to the non-contractedprovider, orThe entire cost of such servicesIf <strong>Presbyterian</strong> elects to utilize this right, theseamounts are withheld automatically <strong>and</strong> offsetagainst any future claims payments owed by<strong>Presbyterian</strong> to you.Specialty Care <strong>Provider</strong> TerminationPlease refer to your service agreement with<strong>Presbyterian</strong> for specific time frames <strong>and</strong>obligations regarding terminations.4-22014 <strong>Practitioner</strong> <strong>and</strong> <strong>Provider</strong> <strong>Manual</strong> - Ver. 3
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