2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Care Coordination7. Laboratory Services7. Laboratory ServicesPresbyterian uses the Clinical LaboratoryImprovement Amendments (CLIA) waive test list forlaboratory services. The list applies to allPresbyterian product lines, and is effective fordates of service on or after January 1, 2014.Reimbursement for these pathology/laboratoryservices is based on Presbyterian’s Clinical Lab feeschedule, unless your contract states otherwise.Please note that certain Current ProceduralTerminology codes are restricted to specificspecialties.The CLIA waive test list can be located athttp://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf.The list includes pathology/laboratory services thatmay be performed in the physician’s office. The listincludes a description identifying codes along withany limitations for each service. It is theresponsibility of the provider to establishappropriate CLIA waive test certification, or to applyfor a CLIA waive test certificate, if the choice ismade to perform any of these services.Reimbursement for these services remains at thecurrent Presbyterian fee schedule and payment issubject to the member’s eligibility, benefit plan, andbenefit limitations.Mexico. TriCore is the only laboratory service withinthe Presbyterian network at this time. Using orreferring to another laboratory service could resultin unnecessary additional expenses for yourpatients and violate the terms of your Agreementwith Presbyterian. Please be advised thatPresbyterian is monitoring all non-contractedlaboratory use.Please be aware that non-contracted laboratoriesmay solicit health care professionals belonging toour network with the assertion that they can accept“Presbyterian insurance.” Presbyterian willcommunicate with you to keep you informed of anyfuture network changes.A complete list of TriCore locations and contactinformation is available athttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00078812.pdf.If you have issues or questions, please contactyour provider network management relationshipexecutive athttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf.Using Contracted Laboratory ServicesTriCore Reference Laboratories is Presbyterian’sexclusive, independent contracted laboratory andprovides laboratory services throughout New7-12014 Practitioner and Provider Manual - Ver. 3
Laboratory ServicesTriCore Contact InformationDepartmentContact InformationClient Services (test results, TriCore locations, specimenrequirements, general information)505-938-8922 (24 hours)1-800-245-3296 (24 hours)Client SuppliesFor phone or fax orders:505-938-8957 (phone)1-800-245-3296 ext. 8957 (phone)505-938-8472 (fax)Logistics/Couriers 505-938-89581-800-532-2649505-954-3780 (Santa Fe)For online supply orders, call the Supply Order Desk:505-938-8957 or 1-800-245-3296, ext. 8957IS Help Desk (printer, TriCore Express, TriCore Direct, andcomputer-interface assistance)505-938-8974 or 1-800-245-3296, ext. 8974Sales and Service 505-938-8917 or 1-800-245-3296, ext. 8917Billing/Business Office 505-938-8910 or 1-800-541-9557505-938-8640 (fax)Main Numbers505-938-8888 (24 hours)1-800-245-3296 (24 hours)7-22014 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 .....
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Appendix A. Acronyms ..............
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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
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 and 72: Care CoordinationFollow-up plans or
Page 73 and 74: Care CoordinationPharmacy BenefitsP
Page 75: Care CoordinationThis page intentio
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
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Page 121 and 122: Home HealthPresbyterian’s credent
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Page 125 and 126: 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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