2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Behavioral Healthagreements, addenda, and other documents areconsistent with State of New Mexico and Centersfor Medicare and Medicaid Services Medicaidrequirements.In order to receive referrals of Presbyterianmembers, a provider mustBe a New Mexico Medicaid providerHave an active status inPresbyterian/Magellan behavioral healthcredentialing systemHave an executed provider agreement withPresbyterianBe free of any Medicare or Medicaid sanctionsfrom the Office of the Inspector GeneralTypes of Behavioral Health ProvidersPresbyterian Centennial Care behavioral healthproviders includes individual, group, andorganization providers. Organization providersinclude hospitals, clinics, agencies, CSAs, andresidential treatment centers.Individual ProviderAn individual provider is a clinician who suppliesprofessional behavioral health care services directlyto a member and bills under the provider’s owntaxpayer identification number. The individualprovider must be enrolled with Centennial Care andmeet Presbyterian/Magellan credentialing criteria,including, but not limited to, a state license topractice within the scope of the individual’sdiscipline and class of service. In addition, theprovider must hold a current, fully executedPresbyterian Provider Participation Agreement(PPA).Group PracticeA group practice is a collection of individualproviders that supply professional behavioral healthcare services and bill under a single taxpayeridentification number. The group practice may ormay not be incorporated. The group typicallyprovides ambulatory levels of care. Cliniciansaffiliated with the group are credentialed individuallyand must be enrolled with Centennial Care andmeet Presbyterian/Magellan credentialing criteria toprovide services to Centennial Care members. Thegroup practice enters into an agreement withPresbyterian as a single entity, and the group billsas a single entity for the services performed by itsPresbyterian/Magellan-credentialed clinicians.OrganizationAn organization is an entity that is licensed orcertified as required by the state in which itoperates. The organization enters into anagreement with Presbyterian as an entity. It mustbe enrolled with Centennial Care, and must meetPresbyterian/Magellan credentialing criteria fororganizations. Examples of organizations providingbehavioral health services for Centennial Careinclude inpatient facilities, community mental healthcenters, FQHCs, rural health centers, and IndianHealth Service or Tribal 638 facilities that offerbehavioral health services. The organization entersinto an agreement with Presbyterian to provide oneor more levels of care, which may includeoutpatient care. The organization generally hasPresbyterian/Magellan-credentialed physicians or9-22014 Practitioner and Provider Manual - Ver. 3