2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

More documents

Recommendations

Info

Care CoordinationFamily members or other persons withsignificant involvement in the member’s carePeer/family support specialistsCommunity health workers or communityhealth representativesPharmacistsPresbyterian’s medical directorBehavioral health (mental health andsubstance abuse treatment) cliniciansSpecialty providersClinical staff from nursing homes and assistedliving facilities where members live are alsoincluded as integral participants in the member’sICPT. Residential care staff employees areinstrumental participants in the member’s careteam, and play a central role in alerting carecoordinators to a change in a member’s conditionor status that, if acted upon in a timely andappropriate fashion, may prevent unnecessaryhospitalizations.Members are encouraged to actively participate inthe care planning process, and are provided withtools and resources that allow them to takepersonal responsibility for their care management.The care plan is reviewed, modified if necessary,and approved by the member.ICPT communication may occur through in-personcase conferences, by telephone, or electronicallythrough the care management system. Themember’s assigned care coordinator works with theprovider to ensure that the provider’s input andrecommendations are incorporated into the careplan where appropriate.Ongoing Care CoordinationThe assigned care coordinator is responsible formanaging ongoing care coordination and ensuringthat documentation of care coordination activities ismaintained in the member’s care managementsystem record. These activities are conducted inaccordance with the care plan, and include, at aminimum, the responsibility toDevelop and update the care plan as neededProvide disease management interventionsand health education related to chronicconditionsMonitor treatment and coordinate with theprovider to encourage best practice as itrelates to tests, appointment frequency, andadherence to clinical practice guidelines andcondition-specific protocolsAs appropriate, educate the member and themember’s caregivers about advancedirectives and psychiatric advance directives,and document the member’s decision in thecare management system recordMonitor the member’s participation in careplan activities and recommended servicesMaintain ongoing communication withcommunity and natural supports to monitorand support ongoing participation in themember’s careIdentify non-covered services needed topromote the member’s health, safety, andwell-being, and enlist communityorganizations to provide those services andsupports6-82014 Practitioner and Provider Manual - Ver. 3
Care CoordinationFacilitate access to physical and behavioralhealth services as neededMonitor and ensure the provision of coveredservices and ensure that they meet themember’s needsFacilitate coordination and communicationbetween the member’s service providers toensure a comprehensive, holistic, membercenteredapproachDisease ManagementPresbyterian’s innovative disease managementprogram, called Healthy Solutions, supportsproviders in their management of chronic illnesses.The Care Continuum Alliance defines diseasemanagement as a system of coordinated healthcare interventions and communications forpopulations with conditions in which patient selfcareefforts are significant. More information aboutthe Care Continuum Alliance is available on itswebsite at http://www.carecontinuumalliance.org/.To provide resources for providers in their carecoordination for members with chronic conditions,Presbyterian offers comprehensive diseasemanagement programs for diabetes, chronicobstructive pulmonary disease, coronary arterydisease, congestive heart failure, and asthma.These programs include distribution of bloodglucose meters for all members with diabetes, peakflow meters for members with asthma, andeducational materials for members and providers.Presbyterian provides comprehensive care to ourmembers statewide through our network ofservices. This comprehensive Healthy Solutionsdisease management programSupports the provider/patient relationship andplan of careEmphasizes prevention of exacerbations andcomplications by using evidence-basedpractice guidelines and patient empowermentstrategies for self-management of chronicdiseaseEvaluates clinical, humanistic, and economicoutcomes on an ongoing basis with the goal ofimproving overall healthThrough this disease management program,PresbyterianStrives to identify a member’s problemsbefore the problems occur. We proactivelywork to identify members potentially in need ofthese services through medical andpharmaceutical data available through thePresbyterian claims data systems.Stratifies members by risk criteria using apredictive modeling tool to identify members’risk level. Using these criteria for initialstratification, a member’s needs are matchedto an appropriate level of intervention.Provides meaningful interventions throughcare coordination and Healthy Solutionsphone-based health coaching.Care Coordinators manage members with thehighest risk score who need moreintensive/multisystem medical or nursinginterventions.6-92014 Practitioner and Provider Manual - Ver. 3
Page 2 and 3:
ii2014 Practitioner and Provider Ma
Page 4 and 5: iv2014 Practitioner and Provider Ma
Page 6 and 7: vi2014 Practitioner and Provider Ma
Page 8 and 9: Nurse Advice Line .................
Page 10 and 11: Pharmacy Benefits .................
Page 12 and 13: Clearinghouses ....................
Page 14 and 15: Site Visits .......................
Page 16: Monitoring ........................
Page 19 and 20: Federally Funded Terminations .....
Page 21 and 22: Appendix A. Acronyms ..............
Page 23 and 24: 1. Presbyterian Healthcare Services
Page 25 and 26: Presbyterian Healthcare Services(HS
Page 27 and 28: Presbyterian Healthcare ServicesReg
Page 29 and 30: Presbyterian Healthcare Services2.
Page 31 and 32: Provider Network Managementthis man
Page 33 and 34: Centennial Care Overview3. Primary
Page 35 and 36: Primary Care ProvidersClaims Activi
Page 37 and 38: Primary Care Providers4. Specialist
Page 39 and 40: SpecialistsOther Information for PC
Page 41 and 42: Specialists5. Preventive Health Car
Page 43 and 44: Preventive Health Care GuidelinesPr
Page 45 and 46: Preventive Health Care GuidelinesSe
Page 47 and 48: Care Coordination6. Care Coordinati
Page 49 and 50: Care CoordinationPresbyterian’s c
Page 51 and 52: Care Coordinationthe program. If th
Page 53: Care Coordinationdesignated family
Page 57 and 58: Care CoordinationClinical Practice
Page 59 and 60: Care Coordinationformula, which is
Page 61 and 62: Care CoordinationAmerican Psychiatr
Page 63 and 64: Care Coordinationwithout obtaining
Page 65 and 66: Care CoordinationSpecialists as PCP
Page 67 and 68: Care Coordinationor when the member
Page 69 and 70: Care Coordination11. Prevention Scr
Page 71 and 72: Care CoordinationFollow-up plans or
Page 73 and 74: Care CoordinationPharmacy BenefitsP
Page 75 and 76: Care CoordinationThis page intentio
Page 77 and 78: Laboratory ServicesTriCore Contact
Page 79 and 80: Pharmacya multi-tier formulary stru
Page 81 and 82: Pharmacymedications. This multi-tie
Page 83 and 84: PharmacyCatastrophic coverage: Cove
Page 85 and 86: Pharmacywhich drugs are mandated th
Page 87 and 88: PharmacyThe drug must be accepted f
Page 89 and 90: PharmacyTypes of Pharmacy Prior Aut
Page 91 and 92: PharmacyThis page intentionally lef
Page 93 and 94: Behavioral Healthagreements, addend
Page 95 and 96: Behavioral HealthForm W-9Staff rost
Page 97 and 98: Behavioral Healthhttps://www.phs.or
Page 99 and 100: Behavioral HealthAn initial PCP con
Page 101 and 102: Behavioral HealthAccess StandardsMe
Page 103 and 104: Behavioral HealthThere is no charge
Page 105 and 106:
Behavioral HealthThis page intentio
Page 107 and 108:
Long-Term Carean individual provide
Page 109 and 110:
Long-Term Careavailable services, a
Page 111 and 112:
Long-Term Carethe agent to members
Page 113 and 114:
Long-Term Carecare at the right tim
Page 115 and 116:
Long-Term Careplanning process, and
Page 117 and 118:
Long-Term Carebudget plan are suffi
Page 119 and 120:
Long-Term CareOrganizationsFor the
Page 121 and 122:
Home HealthPresbyterian’s credent
Page 123 and 124:
Home HealthPresbyterian Medicaid me
Page 125 and 126:
Home Healththese services. Services
Page 127 and 128:
Home Healthfor review will be submi
Page 129 and 130:
Home HealthPatient Care Conferences
Page 131 and 132:
Home HealthThis page intentionally
Page 133 and 134:
Quality Improvement ProgramNational
Page 135 and 136:
Quality Improvement Programcomplian
Page 137 and 138:
Quality Improvement Programresults
Page 139 and 140:
Quality Improvement Programrespect
Page 141 and 142:
Quality Improvement ProgramPresbyte
Page 143 and 144:
Quality Improvement ProgramNCQA ori
Page 145 and 146:
Quality Improvement ProgramThis pag
Page 147 and 148:
Health Insurance Portability and Ac
Page 149 and 150:
Health Insurance Portability and Ac
Page 151 and 152:
Legalabove, nor from any recourse a
Page 153 and 154:
Legalagreement with Presbyterian fo
Page 155 and 156:
Legaltransactions (federal, state,
Page 157 and 158:
Legalcontractual relationship with
Page 159 and 160:
Legalcomply with all state and fede
Page 161 and 162:
Legalany such program during the te
Page 163 and 164:
LegalPrompt Pay by PresbyterianPres
Page 165 and 166:
Legal15. Fraud, Waste, and Abuse15.
Page 167 and 168:
Fraud, Waste, and Abuseas the time
Page 169 and 170:
Fraud, Waste, and AbuseAll document
Page 171 and 172:
Fraud, Waste, and AbuseVerifying th
Page 173 and 174:
Fraud, Waste, and AbuseHistorically
Page 175 and 176:
Fraud, Waste, and Abuseis violated
Page 177 and 178:
Fraud, Waste, and AbuseIs informed
Page 179 and 180:
Fraud, Waste, and Abuse16. Credenti
Page 181 and 182:
Credentialing and RecredentialingPr
Page 183 and 184:
Credentialing and RecredentialingNe
Page 185 and 186:
Credentialing and Recredentialing17
Page 187 and 188:
e-BusinessFill out the form on the
Page 189 and 190:
e-BusinessSign Up for this Free Ser
Page 191 and 192:
e-BusinessClearinghouse Contact Inf
Page 193 and 194:
e-Business18. Claims and Payment18.
Page 195 and 196:
Claims and Paymentsubmission. Claim
Page 197 and 198:
Claims and PaymentSpecify the origi
Page 199 and 200:
Claims and Paymentrequiring a leadi
Page 201 and 202:
Claims and PaymentPlease note that
Page 203 and 204:
Claims and PaymentPresbyterian is r
Page 205 and 206:
Claims and Paymentnot made a recove
Page 207 and 208:
Claims and PaymentAcceptable docume
Page 209 and 210:
Claims and Paymentallowing provider
Page 211 and 212:
Claims and PaymentNational Correct
Page 213 and 214:
Claims and Payment19. Presbyterian
Page 215 and 216:
Presbyterian Customer Service Cente
Page 217 and 218:
Page 219 and 220:
Page 221 and 222:
Page 223 and 224:
Page 225 and 226:
Page 227 and 228:
Appeals and Grievances20. Appeals a
Page 229 and 230:
Appeals and GrievancesMember Appeal
Page 231 and 232:
Appendix A. AcronymsAppendix A. Acr
Page 233 and 234:
Appendix A. AcronymsHMOHRAHSDHealth
Page 235 and 236:
Appendix A. AcronymsWWEDIWorkgroup
Page 237 and 238:
Appendix B: DefinitionsAppendix B.
Page 239 and 240:
Appendix B. DefinitionsTerm Definit
Page 241 and 242:
Page 243 and 244:
Page 245 and 246:
Page 247 and 248:
Appendix C. WebsitesAppendix C. Web
Page 249 and 250:
Appendix C. WebsitesWebsitesNameCul
Page 251 and 252:
Appendix C. WebsitesWebsitesNameMem
Page 253 and 254:
Appendix C. WebsitesWebsitesNameWED
Page 255 and 256:
Appendix C. WebsitesAppendix D. Pho
Page 257 and 258:
Appendix D. Phone NumbersPhone Numb
Page 259 and 260:
Appendix B: Business Associate Agre
Page 261 and 262:
Appendix E. Business Associate Agre
Page 263 and 264:
Appendix E. Business Associate Agre
Page 265 and 266:
Appendix F. Prior Authorization Gui
Page 267 and 268:
Page 269 and 270:
Page 271 and 272:
Page 273 and 274:
Page 275 and 276:
Page 277 and 278:
Page 279 and 280:
Appendix G. Alternative BenefitsG.
Page 281 and 282:
Appendix G. Alternative Benefits Pa
Page 283 and 284:
Page 285:
show all

2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Create successful ePaper yourself

Delete template?

Save as template?