2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Nurse Advice Line ................................................................................................................................... 5-1Nurse Advice Line Telephone Numbers .................................................................................................. 5-1Preventive Health Care Guidelines and Screening .................................................................................. 5-1Presbyterian’s Preventive Health Care Guidelines ................................................................................... 5-2Measurement Activities ............................................................................................................................ 5-2Personal Health Assessments ................................................................................................................. 5-3Health Risk Assessments (For Centennial Care members) ..................................................................... 5-3Screening for Alcohol and Drug Abuse .................................................................................................... 5-3Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program ........................................... 5-3Immunizations ......................................................................................................................................... 5-4Vaccines for Children ............................................................................................................................... 5-46. Care Coordination ...................................................................................................................................... 6-1Coordinating Care: Prior Authorization Referrals ..................................................................................... 6-1Prior Authorization Process ..................................................................................................................... 6-2Authorizations of Coverage...................................................................................................................... 6-2Requesting a Prior Authorization ............................................................................................................. 6-3Urgent and Expedited Requests .............................................................................................................. 6-3Verify a Member’s Eligibility and Benefits ................................................................................................ 6-4Inpatient Admission ................................................................................................................................. 6-4Hours of Operation .................................................................................................................................. 6-4Appeals ................................................................................................................................................... 6-4Prior Authorization for Radiology/Advanced Imaging ............................................................................... 6-4Care Plan Development – Centennial Care ............................................................................................. 6-6Interdisciplinary Care Plan Team ............................................................................................................. 6-7Ongoing Care Coordination ..................................................................................................................... 6-8Disease Management .............................................................................................................................. 6-9Improve Health Outcomes ..................................................................................................................... 6-10Clinical Practice Guidelines and Tools ................................................................................................... 6-10Predictive Modeling ............................................................................................................................... 6-12Medical Records and Confidentiality Assurance .................................................................................... 6-13Provider Profiles .................................................................................................................................... 6-13Under- and Overutilization Analysis ....................................................................................................... 6-14Technology Assessment ........................................................................................................................ 6-14Medical Policy Development and Dissemination .................................................................................... 6-14Continuity of Care .................................................................................................................................. 6-15Family Planning (Presbyterian Centennial Care Only) ........................................................................... 6-15Dental Care (Presbyterian Centennial Care Only) ................................................................................. 6-16Vision Services (Presbyterian Centennial Care only) ............................................................................. 6-16viii2014 Practitioner and Provider Manual - Ver. 3
Medicare Notices ................................................................................................................................... 6-17Important Message to Medicare Beneficiaries ....................................................................................... 6-17Detailed Notice of Discharge ................................................................................................................. 6-17Notice of Medicare Non-Coverage ........................................................................................................ 6-17Home Skilled Nursing Facility (SNF) Rule Under Medicare.................................................................... 6-17Special Populations ............................................................................................................................... 6-18Appeals ................................................................................................................................................. 6-18Specialists as PCPs for Members with Special Health Care Needs ....................................................... 6-19Behavioral Health Care Coordination ..................................................................................................... 6-19Medical Record Reviews ....................................................................................................................... 6-20Presbyterian Access to Medical Records ............................................................................................... 6-20Minimum Medical Record Standards ..................................................................................................... 6-211. Confidentiality .................................................................................................................................... 6-212. Legibility and Provider Identification .................................................................................................. 6-213. Entries ............................................................................................................................................... 6-214. Organization/Patient Identification ..................................................................................................... 6-215. Personal Biographical Data ............................................................................................................... 6-226. Allergies ............................................................................................................................................ 6-227. Documentation of Tobacco, Alcohol, and Substance Abuse .............................................................. 6-228. Problem List (as appropriate for practitioner/practice type) ................................................................ 6-229. Medication List and History (as appropriate for practitioner/practice type) ......................................... 6-2210. Periodic Health Examinations (Physical Health Only) ...................................................................... 6-2211. Prevention Screening, Patient Education and Counseling (Physical Health Only) ........................... 6-2312. Durable Power of Attorney/Advance Directives (Physical Health Only) ........................................... 6-2313. Patient Notification of Abnormal Diagnostic Test Results (Physical Health Only) ............................. 6-2314. Consultations/Referrals ................................................................................................................... 6-2315. X-Ray, Lab, and Imaging Reports, Referrals, and Diagnostic Information (Physical Health Only) ... 6-2416. Past Medical History (as appropriate for practitioner/practice type) ................................................. 6-2417. Medically Appropriate Care (as appropriate for practitioner/practice type) ....................................... 6-2418. Hospital and Outside Clinical Records (as appropriate for practitioner/practice type) ...................... 6-2419. Immunization Status (Physical Health Only) .................................................................................... 6-24Individual Clinical Encounters ................................................................................................................ 6-24Behavioral Health Practitioners .............................................................................................................. 6-25Risk Stratification and Predictive Modeling ............................................................................................ 6-25Member Awareness ............................................................................................................................... 6-25Referral Requests/Prior Authorization .................................................................................................... 6-26Home Health Services ........................................................................................................................... 6-26Laboratory Services ............................................................................................................................... 6-26ix2014 Practitioner and Provider Manual - Ver. 3
Page 2 and 3: ii2014 Practitioner and Provider Ma
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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 and 58: Care CoordinationClinical Practice
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Care Coordinationformula, which is
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Care CoordinationAmerican Psychiatr
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Care Coordinationwithout obtaining
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Care CoordinationSpecialists as PCP
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Care Coordinationor when the member
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Care Coordination11. Prevention Scr
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Care CoordinationFollow-up plans or
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Care CoordinationPharmacy BenefitsP
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Care CoordinationThis page intentio
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Laboratory ServicesTriCore Contact
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Pharmacya multi-tier formulary stru
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Pharmacymedications. This multi-tie
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PharmacyCatastrophic coverage: Cove
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Pharmacywhich drugs are mandated th
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PharmacyThe drug must be accepted f
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PharmacyTypes of Pharmacy Prior Aut
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PharmacyThis page intentionally lef
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Behavioral Healthagreements, addend
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Behavioral HealthForm W-9Staff rost
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Behavioral Healthhttps://www.phs.or
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Behavioral HealthAn initial PCP con
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Behavioral HealthAccess StandardsMe
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Behavioral HealthThere is no charge
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Behavioral HealthThis page intentio
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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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