2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Care CoordinationMembers with moderate risk scores are managedby our Healthy Solutions team. They providephone-based health coaching, which is differentfrom the traditional educational model that identifiesand focuses on members who already meet thecriteria of “readiness to change.” Through healthcoaching, we provide the member the one-on-onesupport he or she needs to reach the stage of“readiness to change.” This behavioral changemethodology ensures we focus our efforts ondeveloping a personalized health improvement planfor members. In turn, the staff provides support andeducation for the member’s health-relatedbehavioral change.Healthy Solutions offers a member-focusedprogram to meet the medical, behavioral, andeducational health care needs for all of ourmembers. Health coaches work with individuals onbehavioral issues for those with a moderate riskscore.Improve Health OutcomesPresbyterian understands the importance ofimproving health outcomes. By tailoring thefrequency and intensity of outreach to the membersbased on risk and severity of disease, as well as totheir readiness to change, our staff is moreeffective with interventions. Members with chronicillness learn to manage their health to lead moreproductive lives. Members are also more willing toparticipate if their provider discusses the programwith them and recommends their participation in theprogram. Members who are considered at risk learnto minimize problems with ongoing education.Utilization of health care resources becomes moreappropriate and effective. You may refer yourPresbyterian patients to the Presbyterian HealthySolutions disease management program atPhone: 1-800-841-9705Email: PHPreferral@phs.orgClinical Practice Guidelines and ToolsClinical Practice Guidelines are systematicallydeveloped statements designed to give providersthe most current, nationally recognizedrecommendations regarding the care of specificclinical circumstances. Presbyterian adopts clinicalpractice guidelines that are relevant to the enrolledpopulation and are based on reasonable scientificevidence. All clinical practice guidelines arereviewed at least every two years and are updatedwhen clinically appropriate.You may contact the Presbyterian Quality andPopulation Health Management team by phone at505-923-5017 or 1-866-634-2617 (these aremessage phones only). You may also contact themby e-mail at PopulationHlthMgt@phs.org.Clinical Practice Guidelines and ToolsGuidelines and ToolsAmerican Psychiatric Association (APA) and theAmerican Academy of Pediatrics (AAP) BehavioralHealth Clinical Practice Guidelines and ToolsWebsite LocationAPA Bipolar Disorderhttp://psychiatryonline.org/content.aspx?bookid=28&sectionid=1669577APA Major Depression6-102014 Practitioner and Provider Manual - Ver. 3
Care CoordinationClinical Practice Guidelines and ToolsGuidelines and ToolsWebsite Locationhttp://psychiatryonline.org/guidelines.aspxAPA Schizophreniahttp://psychiatryonline.org/content.aspx?bookid=28&sectionid=1665359AAP Attention Deficit Hyperactivity Disorder (ADHD)http://pediatrics.aappublications.org/content/105/5/1158.full.pdf+html?sid=f4a99748-b682-4ec4-a4f3-8d545eb204a6AsthmaGuidelines for the Diagnosis and Management of Asthma Full Report (NationalAsthma Education and Prevention Program, National Heart, Lung, and BloodInstitute)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1029224.pdfGuidelines for the Diagnosis and Management of Asthma Summary Report(National Asthma Education and Prevention Program, National Heart, Lung, andBlood Institute)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1000916.pdfGuidelines for the Diagnosis and Management of Asthma – Full Report ChangePage (National Heart, Lung, and Blood Institute)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031055.pdfAttention Deficit/Hyperactivity Disorder (ADHD)ADHD Diagnosis and Evaluation Guidelineshttp://pediatrics.aappublications.org/content/105/5/1158.full.pdf+html?sid=f4a99748-b682-4ec4-a4f3-8d545eb204a6Treatment of School-Aged Children with ADHDhttp://pediatrics.aappublications.org/content/108/4/1033.full.pdf+htmlADHD Quick Reference Guidehttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/wcmdev1000899.pdfCoronary Artery DiseaseAHA/ACC Secondary Prevention for Patients with Coronary and Other VascularDisease: 2006 Update (American College of Cardiology and the American HeartAssociation)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00052254.pdfCoronary Artery Disease Clinical Practice Guidelines (American College ofCardiology and the American Heart Association)http://docs.phs.org/idc/groups/public/@phs/@marketing/documents/phscontent/wcmdev1000934.pdfCoronary Artery Disease Clinical Recommendations for Prevention of HeartDisease in Women (American Heart Association)http://docs.phs.org/idc/groups/public/@phs/@marketing/documents/phscontent/wcmdev1000935.pdf6-112014 Practitioner and Provider Manual - Ver. 3
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Page 8 and 9: Nurse Advice Line .................
Page 10 and 11: Pharmacy Benefits .................
Page 12 and 13: Clearinghouses ....................
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Page 23 and 24: 1. Presbyterian Healthcare Services
Page 25 and 26: Presbyterian Healthcare Services(HS
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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
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Page 47 and 48: Care Coordination6. Care Coordinati
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Page 51 and 52: Care Coordinationthe program. If th
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Page 55: Care CoordinationFacilitate access
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Page 61 and 62: Care CoordinationAmerican Psychiatr
Page 63 and 64: Care Coordinationwithout obtaining
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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
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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
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Long-Term Carean individual provide
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Long-Term Careavailable services, a
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Long-Term Carethe agent to members
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Long-Term Carecare at the right tim
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Long-Term Careplanning process, and
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Long-Term Carebudget plan are suffi
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Long-Term CareOrganizationsFor the
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Home HealthPresbyterian’s credent
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Home HealthPresbyterian Medicaid me
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Home Healththese services. Services
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Home Healthfor review will be submi
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Home HealthPatient Care Conferences
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Home HealthThis page intentionally
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Quality Improvement ProgramNational
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Quality Improvement Programcomplian
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Quality Improvement Programresults
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Quality Improvement Programrespect
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Quality Improvement ProgramPresbyte
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Quality Improvement ProgramNCQA ori
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Quality Improvement ProgramThis pag
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Health Insurance Portability and Ac
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Health Insurance Portability and Ac
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Legalabove, nor from any recourse a
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Legalagreement with Presbyterian fo
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Legaltransactions (federal, state,
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Legalcontractual relationship with
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Legalcomply with all state and fede
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Legalany such program during the te
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LegalPrompt Pay by PresbyterianPres
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Legal15. Fraud, Waste, and Abuse15.
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Fraud, Waste, and Abuseas the time
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Fraud, Waste, and AbuseAll document
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Fraud, Waste, and AbuseVerifying th
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Fraud, Waste, and AbuseHistorically
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Fraud, Waste, and Abuseis violated
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Fraud, Waste, and AbuseIs informed
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Fraud, Waste, and Abuse16. Credenti
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Credentialing and RecredentialingPr
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Credentialing and RecredentialingNe
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Credentialing and Recredentialing17
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e-BusinessFill out the form on the
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e-BusinessSign Up for this Free Ser
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e-BusinessClearinghouse Contact Inf
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e-Business18. Claims and Payment18.
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Claims and Paymentsubmission. Claim
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Claims and PaymentSpecify the origi
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Claims and Paymentrequiring a leadi
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Claims and PaymentPlease note that
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Claims and PaymentPresbyterian is r
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Claims and Paymentnot made a recove
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Claims and PaymentAcceptable docume
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Claims and Paymentallowing provider
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Claims and PaymentNational Correct
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Claims and Payment19. Presbyterian
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Presbyterian Customer Service Cente
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Appeals and Grievances20. Appeals a
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Appeals and GrievancesMember Appeal
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Appendix A. AcronymsAppendix A. Acr
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Appendix A. AcronymsHMOHRAHSDHealth
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Appendix A. AcronymsWWEDIWorkgroup
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Appendix B: DefinitionsAppendix B.
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Appendix B. DefinitionsTerm Definit
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Appendix C. WebsitesAppendix C. Web
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Appendix C. WebsitesWebsitesNameCul
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Appendix C. WebsitesWebsitesNameMem
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Appendix C. WebsitesWebsitesNameWED
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Appendix C. WebsitesAppendix D. Pho
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Appendix D. Phone NumbersPhone Numb
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Appendix B: Business Associate Agre
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Appendix E. Business Associate Agre
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Appendix E. Business Associate Agre
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Appendix F. Prior Authorization Gui
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Appendix G. Alternative BenefitsG.
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Appendix G. Alternative Benefits Pa
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