2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Care CoordinationClinical Practice Guidelines and ToolsGuidelines and ToolsDepressionWebsite LocationDepression Guidelines for Primary Care Practitioners Treating Adult Patientswith Depressionhttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/wcmdev1001004.pdfDiabetesObesityDiabetes Clinical Practice Guidelines for Providers–Non-Pregnant Adulthttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001010.pdfGetting in Balance Worksheet to Identify Overall Weight-Related Health Risk(Clinical prevention Initiative)http://www.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031069.pdfOverweight & Obesity in Primary Care (Clinical Prevention Initiative)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1030683.pdfQuick Discussion Guide for Adult Weight Counseling in Primary Care (ClinicalPrevention Initiative)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031068.pdfGetting in Balance Worksheet to Identify Overall Weight-Related Health Risk(Clinical prevention Initiative)http://www.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031069.pdfQuick Discussion Guide for Adult Weight Counseling in Primary Care (ClinicalPrevention Initiative)http://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmprod1031068.pdfAs guidelines are updated, Presbyterian notifiesproviders in a subsequent issue of the “NetworkConnection” provider newsletter. In addition,updates are posted on the Presbyterian website athttps://www.phs.org/providers/cliniciansresources/Pages/health-services.aspx.If you godirectly to the phs.org website, you can access theguidelines by following this pathway:Go to www.phs.orgSelect “For Providers” from the top menuSelect “Clinicians’ Resources”Select “Health Services Resources” from themenu on the leftScroll down to “Clinical Practice Guidelines”and select desired guideline.Predictive ModelingPredictive modeling is a tool that applies riskfactors to claims, utilization patterns, andpharmaceutical and lab data using a mathematical6-122014 Practitioner and Provider Manual - Ver. 3
Care Coordinationformula, which is then used to predict future risk ofcosts and utilization. Using this tool, we are able tooffer your patients proactive intense carecoordination interventions and assistance withnavigation of the health care system. Predictivemodeling is also useful in member stratification fordisease management interventions.Medical Records and Confidentiality AssuranceThere may be instances where records from youroffice or facility are requested to ensure that correctand timely coverage decisions are rendered, toreview records for a special utilization/quality study,or as required by regulatory agencies such as:HealthInsight New Mexico. Presbyterian iscommitted to requesting the minimum amount ofinformation required and assisting with either onsitereview or telephone discussions to minimizeadministrative burdens. We currently reimburseproviders $30.00 for the first 15 pages and $0.15per page after the first 15 pages (based on the NewMexico Administrative Code [NMAC], Title 16,Chapter 10.17.8).Presbyterian ensures that Health InsurancePortability and Accountability Act (HIPAA)requirements are met and maintains confidentialrecords files. All information and medical recordsobtained during the course of review activities shallbe treated as confidential, in compliance with allapplicable state and federal regulations.Presbyterian uses reasonable diligence to preventinappropriate disclosure. This obligation excludesdisclosure of information that is required by state orfederal law or is in the public domain.Provider ProfilesPresbyterian is committed to working with providersto improve the quality of care provided to ourmembers. Part of this commitment includessending a Physician Performance Assessment(PPA) to providers. The PPA is based on the datasubmitted on claims processed and paid byPresbyterian and goes to PCPs who have largeenough panels and claims activity to make a PPAreport statistically meaningful. The data adjusts forseverity of illness of the members on a provider’spanel and reports on quality measures associatedwith prioritized initiatives.Data is processed through clinical informaticssoftware to analyze utilization, costs, and clinicalindicators and includes case mix index andcomparative peer data.Presbyterian also sends lists of members who maybe due for health maintenance testing,immunizations, preventive health care screenings(such as mammograms), or pharmaceuticals. ThePPAs and member lists are intended to be tools forthe provider to aid in the improvement of the healthof patients. We encourage feedback from theprovider on the information contained in the PPAsand member lists so that we can continue toimprove these tools and the data contained inthem. For questions regarding a PPA or a memberlist, providers may call the number in the coverletter included with the provider’s packet. Atpresent, PPAs and member lists are available forPCPs only.6-132014 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 ....................
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 and 54: Care Coordinationdesignated family
Page 55 and 56: Care CoordinationFacilitate access
Page 57: Care CoordinationClinical Practice
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
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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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