2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Care CoordinationPresbyterian’s coverage of benefits for skillednursing facilities, sub-acute care facilities, orhome careAbility of local hospitals to provide allrecommended services within the estimatedlength of stayRequesting a Prior AuthorizationTo serve our providers, Presbyterian has adedicated prior authorization line. Call HealthServices at 505-923-5757 or 1-888-923-5757(Option 4). For home health care requests, call505-559-1151 or 1-877-606-1151 (Option 4).When a need is identified for a service that requiresa clinical review, Presbyterian offers a variety ofuser-friendly tools for providers to submitauthorization requests online through myPRES athttp://www.phs.org. Using myPRES to submitreferral requests or prior authorizations is theeasiest, least intrusive method for the provider’soffice or facility. If the provider is unable to submitthe request online, it may be submitted by fax,email, or telephone or through a care coordinator. Ifapplicable, the provider should submit supportingdocumentation to demonstrate the medicalnecessity for the request. Prior authorizations,including auto-generated approvals for specificservices, may be obtained through myPRES athttp://www.phs.org. The provider may also accessthe status of prior authorization requests, claims,and eligibility information through myPRES 24hours a day, seven days a week. For moreinformation about myPRES, see the e-Businesschapter of this manual. You may also contact usthrough the following waysInpatient prior authorization requests may befaxed to 505-213-0181 or 1-888-923-5990Outpatient services and durable medicalequipment (DME) requests may be faxed to505-213-0246University of New Mexico prior authorizationsmay be faxed to 505-213-0149Long-term care prior authorizations may befaxed to 505-213-0240Mail to Health Services:Presbyterian Prior Authorization TeamP.O. Box 27489Albuquerque, NM 87125-7489Urgent and Expedited RequestsFollowing are the criteria for requests that require aquick decision (urgent and expedited) fromPresbyterian.The life, health, or safety of a covered personwould be seriously jeopardized because of themember’s psychological state.In the opinion of a practitioner with knowledgeof the member’s medical or behavioral healthcondition, the member would be subjected toadverse health consequences without thecare or treatment requested.The covered person’s ability to regainmaximum function would be jeopardized.The medical exigencies of the case require anexpedited decision.When you have a situation that meets the definitionof an urgent or expedited determination, we6-32014 Practitioner and Provider Manual - Ver. 3