2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Care CoordinationThey may go back to their Continuing CareRetirement Community SNF, if applicable.If the “Home SNF” is a non-participating provider(facility), Presbyterian Medicare Advantagebeneficiaries or the delegated entity must attemptto contract with the non-participating provider.Special PopulationsSpecial populations require a broad range ofprimary specialized medical, behavioral health, andrelated services. Presbyterian follows HSDguidelines for determining special populations. Wecurrently define adult special populations asAge 18 years and olderHaving ongoing physical, mental,neurobiological, emotional, and/or behavioralhealth conditionsRequiring health care and related servicesthat are different from the services required bymost individualsHaving functional limitationsPresbyterian currently defines child specialpopulations asAge up to 18 yearsHaving or at an increased risk for an ongoingphysical, developmental, neurobiological,mental, or behavioral/emotional healthconditionRequiring health care and related servicesthat are different from the services required bymost childrenChildren identified in the Department of HealthTitle V Children’s Medical Services ProgramChildren receiving foster care or adoptionassistance support through Title IV EOther children in foster care or out-of-homeplacementChildren who are eligible for services throughthe Individuals with Disabilities Education ActOther children whose clinical assessmentshows that they have special health careneedsProviders are encouraged to help educatemembers, their families, and their caregiversregarding special considerations and needs fortheir care, including care coordination, specialtransportation needs, therapy services, DME, andcoordination of emergency inpatient and outpatientambulatory surgery services with facilities andhospitalists.AppealsIf we are unable to prior authorize/certify a request,the provider or facility may appeal this decision.The provider is not prohibited from advocating onbehalf of the member. The criteria used to makethis determination will be made available to theprovider. In addition, the provider may speakdirectly to the medical director. Refer to theAppeals and Grievances chapter of this manual forinformation on filing appeals.Children who are eligible for SupplementalSecurity Income as disabled under Title XVI6-182014 Practitioner and Provider Manual - Ver. 3
Care CoordinationSpecialists as PCPs for Members with SpecialHealth Care NeedsOn an individual basis, specialists treatingmembers with disabilities or chronic/complexconditions may serve in the capacity of PCP. Thespecialist is credentialed as a PCP/Specialist andperforms all PCP duties within the scope of theparticipating specialist’s certification.Contact your provider network managementrelationship executive listed in the Provider NetworkRelations Contact Guide athttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf.Behavioral Health Care CoordinationMembers may access the Behavioral Healthnetwork of contracted providers without a referral orprior authorization. They do not need a referral formost outpatient services. Behavioral HealthServices for Centennial Care members areadministered through Magellan. For assistance infinding behavioral health providers, you or yourpatients may contact the following:For Commercial, Presbyterian Senior Care (HMO)and MediCare PPO members: 505-923-5221 or 1-866-593-7431.For Centennial Care members: 505-923-8858 or 1-866-672-1242.Presbyterian encourages PCPs and behavioralhealth practitioners to communicate with oneanother regarding individual cases.Members may access Centennial Care contractedbehavioral health providers without a referral orprior authorization. Referrals are not needed formost outpatient services.For Presbyterian Centennial Care patients, theprovider can make a direct referral for BehavioralServices based on the following indicators:1. Suicidal/homicidal ideation or behavior;2. At-risk of hospitalization due to a BehavioralHealth condition;3. Children or adolescents at imminent riskof out-of-home placement in a psychiatricacute care hospital or residential treatmentfacility;4. Trauma victims;5. Serious threat of physical or sexual abuseor risk to life or health due to impairedmental status and judgment, mentalretardation, or other developmentaldisabilities;6. Request by Member or Representative forBehavioral Health services;7. Clinical status that suggests the need forBehavioral Health services;8. Identified psychosocial stressors andprecipitants;9. Treatment compliance complicated bybehavioral characteristics;10. Behavioral and psychiatric factorsinfluencing medical condition;11. Victims or perpetrators of Abuse and/orneglect and Members suspected of beingsubject to Abuse and/or neglect;12. Non-medical management of substanceabuse;13. Follow-up to medical detoxification;6-192014 Practitioner and Provider Manual - Ver. 3
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Nurse Advice Line .................
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Page 23 and 24: 1. Presbyterian Healthcare Services
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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
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Page 47 and 48: Care Coordination6. Care Coordinati
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Page 55 and 56: Care CoordinationFacilitate access
Page 57 and 58: Care CoordinationClinical Practice
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Page 61 and 62: Care CoordinationAmerican Psychiatr
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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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Page 107 and 108: Long-Term Carean individual provide
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Page 111 and 112: Long-Term Carethe agent to members
Page 113 and 114: 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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