2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Care Coordinationone contracted specialist to another contractedspecialist. Refer to specific plans for any specialrequirements.For ASO plans not participating in the open accessmodel and for Presbyterian Centennial Care,members need to continue to see their primary careproviders (PCPs) for a specialist referral. PCPs,however, are not required to get referralauthorization numbers from Presbyterian. The formof communication between the PCP and specialist(prescription, phone call, or note in medical record)is at the discretion of the PCP and the specialist.For all plans, members may self-refer foremergency care, urgent care, and contractedwomen’s health care. Presbyterian Centennial Carehas additional benefits for self-referral for women’shealth care, which are explained in another sectionof this chapter.Prior Authorization ProcessPresbyterian wants your patients to get the bestcare, in the right place, at the right time. One of theprocesses we use to help our members get thebest care is called prior authorization.Authorizations of CoverageServices requiring prior authorization are publishedin our Provider Manual, the member handbooks,and Presbyterian’s website. Extensive detail isincluded in provider orientations and ongoingtraining. This ensures that the provider andmember know if services are covered.The UM team reviews cases for medical necessity,appropriate setting, history of medical conditionsand treatments, special circumstances,socioeconomic issues, support issues, complexityof health status, clinical quality considerations, andavailability of local health resources. Individualpatient situations, risk factors, service availability,and patient safety are also considered whenrelevant and known. Consequently, completedocumentation by the referring provider todemonstrate medical necessity is critical.Presbyterian encourages its providers to addressthe following issues when requesting authorizationfor a service:Recommendation of treating physicianAgeCo-morbiditiesComplicationsMental statusActivities of daily livingInstrumental activities of daily livingFinancial statusPoly-pharmacyProgress of treatmentPsychosocial and cultural situationHome environmentAvailability of less restrictive treatmentmodalities to address the member’s needsAvailability of services including, but notlimited to, skilled nursing facilities or homecare in the member’s area to support themember after discharge6-22014 Practitioner and Provider Manual - Ver. 3