2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
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Care CoordinationAmerican Psychiatric Association Levels ofCareAmerican Academy of Child <strong>and</strong> AdolescentPsychiatry Levels of CareAmerican Society of Addiction MedicineLevels of CareHealth Plan’s Uniform Level of CareGuidelines<strong>Presbyterian</strong> Health Plan, Inc., Medical Policy<strong>Manual</strong><strong>Presbyterian</strong> encourages providers <strong>and</strong> membersto contact us for information about the medicalpolicies or for copies of the medical policies usedfor specific coverage determinations. The MedicalPolicy <strong>Manual</strong> is available athttps://www.phs.org/providers/cliniciansresources/medical-policymanual/Pages/default.aspx.Continuity of CareHealth Services staff assists members wheneverpossible in making a smooth transition betweenproviders when necessary; for example, ifA new member enrolls from a previous insurerto <strong>Presbyterian</strong>A member’s health care provider leaves or isterminated from <strong>Presbyterian</strong>’s networkA member voluntarily switches or is switchedto another health planA member’s coverage ends or benefits areexhaustedThe transitional period is administered inaccordance with all applicable law, rules, <strong>and</strong>regulations. Currently, the period continues for aperiod of time that is sufficient to permit coordinatedtransition planning consistent with the member’scondition <strong>and</strong> needs relating to the continuity of thecase. The period is less than 30 days but may beextended for a period of active treatment or up to90 days, whichever is shorter, or as otherwisem<strong>and</strong>ated by contract or regulation.Transition of care is covered for women in theirsecond or third trimester of pregnancy <strong>and</strong> fortransplant patients.<strong>Provider</strong>s or members may call the <strong>Presbyterian</strong>Customer Service Center for assistance withcontinuity of care issues.Family Planning (<strong>Presbyterian</strong> Centennial CareOnly)<strong>Presbyterian</strong> Centennial Care must allow membersthe freedom of choice, <strong>and</strong> the methods ofaccessing family planning services, withoutrequiring a referral from the PCP.Clinics <strong>and</strong> providers, including those funded byTitle X of the Public Health Service Act, shall bereimbursed by <strong>Presbyterian</strong> Centennial Care for allfamily planning services regardless of whether theyare participating or non-participating providers.Unless otherwise negotiated, <strong>Presbyterian</strong>Centennial Care shall reimburse providers of familyplanning services at the <strong>Presbyterian</strong> CentennialCare fee schedule.Family planning services are defined asHealth education <strong>and</strong> counseling necessary tomake informed choices <strong>and</strong> underst<strong>and</strong>contraceptive methods6-152014 <strong>Practitioner</strong> <strong>and</strong> <strong>Provider</strong> <strong>Manual</strong> - Ver. 3
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