2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Care Coordinationsuggest that you call Health Services at 505-923-5757 or 1-888-923-5757, Option 4.What this means for the provider’s office is that allurgent and expedited prior authorization requeststhat the provider sends should meet one or more ofthe criteria listed above. If the request does notmeet the urgent and expedited criteria, it may beprocessed as a routine prior authorization request.Verify a Member’s Eligibility and BenefitsEligibility can be checked easily and quicklythrough myPRES at https://mypres.phs.org or bycalling 505-923-5757 or 1-888-923-5757, Option 1.Inpatient AdmissionFor elective or emergency admissions, usemyPRES for all prior authorization requests andnotification of deliveries. If necessary, the providermay also obtain prior authorization for an inpatientconcurrent review or inpatient hospital admissionby calling 505-923-5757 or 1-888-923-5757, Option4. The provider needs to either fax the request tothe number designated in the message for the typeof request or leave a message.Hours of OperationPresbyterian’s UM team of nurses, pharmacists,behavioral health specialists, therapists, andmedical directors are available 24-hours a day,seven days a week to assist providers withauthorizations or verification of benefits.AppealsIf a request is not authorized, the provider or facilitymay appeal this decision. The provider is notprohibited from advocating on behalf of themember, but must have the member’s writtenconsent. The criteria used to make thisdetermination are made available to the provider ifrequested. In addition, the provider may speakdirectly to Presbyterian’s medical director. Refer tothe Appeals and Grievances chapter of this manualfor information on filing appeals.Prior Authorization for Radiology/AdvancedImagingSince 2007, Presbyterian has been using anadvanced imaging ordering program for outpatientsthrough HealthHelp ® . The program applies to allPresbyterian members who have medical benefitsfor in-plan radiology facilities (some employergroups may decide not to participate). The programis designed to improve health care, patient safety,utilization, and cost by applying clinical criteriawhen ordering Computed Tomography (CT),Magnetic Resonance Imaging/Angiography (MR),and Positron Emission Tomography (PET).When ordering CT, CT angiography, MR, or PETscans, the provider or office staff must submitpatient demographics, diagnosis, patient history(such as prior treatment and associatedsymptoms), and procedure codes to HealthHelp ®through a web-based ordering system, bytelephone, or by fax. HealthHelp ® reviews therequest against published guidelines and, ifappropriate, issues an authorization number, whichthen becomes the Presbyterian prior authorizationnumber. A direct link to the HealthHelp ® web-basedprogram is available through myPRES. Noadditional sign-on or password is needed to access6-42014 Practitioner and Provider Manual - Ver. 3