2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Care Coordinationasked to update their records by one of thefollowing methods:Regularly update this medical summary andcarry it with them at all times so they canpresent it when accessing care.Enter updates into MyChart(https://www.phs.org/better-health/accessyour-care/Pages/access-your-healthinformation.aspx).Presbyterian's MyChartgives members secure online access to theirmedical records and helps them keep track ofall their medical information.Call the Presbyterian Customer ServiceCenter at 505-923-5200 or 1-888-977-2333.Referral Requests/Prior AuthorizationMembers need to see their PCPs for referrals forservices and specialty care. In most cases, thePCP is required to submit a referral request for aservice, such as a specialist visit or a specifictherapy. The PCP either gets an authorizationnumber or a notice that a service requires priorauthorization. PCPs or other providers submittingreferral requests are encouraged to submit themonline so they get immediate notification of theaction, authorization number, or notice that thereferral request has been received and is in theprior authorization process. The referring providershould notify the treating provider of theauthorization number to be submitted on a claim.Members may self-refer and do not need priorauthorization for emergency care, urgent care,behavioral health, and women’s health care.In addition, benefits with limitations may alsorequire a prior authorization.For a complete list of services that require a referralrequest or prior authorization, please referenceAppendix F.Home Health ServicesPresbyterian Centennial Care home care servicesare managed through the Presbyterian HomeHealthcare Statewide Network (PHHSN).PHHSN provides utilization management throughreview of prior authorization requests for home careservices. The review is to ensure that the rightservices are provided at the right frequency,duration, and level needed. Please refer to theHome Health chapter of this manual for detailedauthorization requirements and guidelines.Laboratory ServicesPresbyterian requires providers to refer theirpatients to an in-network laboratory servicewhenever possible. TriCore Reference Laboratoriesis the only laboratory service within the network atthis time.Presbyterian uses the Clinical LaboratoryImprovement Amendments Waive Test list. The listapplies to all Presbyterian product lines, and iseffective for dates of service on or after January 1,2014.Please refer to the Laboratory Services chapter ofthis manual for more information.6-262014 Practitioner and Provider Manual - Ver. 3
Care CoordinationPharmacy BenefitsProviders are required to comply withPresbyterian’s formulary requirements formedications. Some medications on the formularymay require prior authorization. The priorauthorization process is available once a memberhas tried and failed all formulary agents and it isdeemed medically necessary to have access to anon-formulary agent. (Please see the Pharmacychapter for detailed information.) The formularies,pharmacy prior authorization forms, specialtypharmaceuticals listing, and specialty drug requestform are available on the pharmacy page athttps://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.Providers may obtain a copy of the formularies bydownloading them from http://www.epocrates.com.Contacts for Other InformationThe following table includes contacts for otherinformation you may need.6-272014 Practitioner and Provider Manual - Ver. 3
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Nurse Advice Line .................
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Pharmacy Benefits .................
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Clearinghouses ....................
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Site Visits .......................
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Monitoring ........................
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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 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: Care CoordinationFollow-up plans or
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
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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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