2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Behavioral Healthother individual providers on staff or it may contractwith physicians and other individual providers toprovide behavioral health services.Core Service AgenciesCSAs are designated by the state to manage muchof the service delivery of behavioral health services.CSAs also provide prevention, early intervention,treatment, and recovery services related tobehavioral health for members. CSAs arecontracted as organizations and are required toprovideCrisis intervention 24 hours a day, seven daysa weekBehavioral health servicesAccess to psychiatric evaluationsAccess to medication managementBehavioral health out-of-home assessmentand service planningCare coordination to members with seriousmental illness or serious emotionaldisturbanceAccess to a range of other clinical behavioralhealth servicesAccess to comprehensive community supportservicesAll behavioral health providers are expected tohave a current description of the behavioral healthservices they provide on file with Presbyterian forinclusion in our provider directory and to assist withreferrals to our behavioral health providers.CredentialingIn order to be eligible for referrals, Presbyterianbehavioral health providers are required to undergothe credentialing review process before beingaccepted as Presbyterian providers, and periodicrecredentialing thereafter (see the Recredentialingsection in this chapter). Presbyterian has delegatedbehavioral credentialing for the Centennial Careprogram to Magellan. Magellan’s CredentialingVerification Organization department is responsiblefor completing credentialing activities according toNational Committee for Quality Assurancestandards, and the requirements of Presbyterianand the Centennial Care program.Provider Credentialing Application ProcessProvider credentialing is initiated through theprovider application process. Individual providersare asked to submit the following documents, alongwith a fully completed application, to facilitate thecredentialing review:Copies of current licenses and certificationsEducation and training documentationMalpractice insurance informationForm W-9Organization providers are asked to submit thefollowing documents, along with a fully completedapplication, to facilitate the credentialing review:Copies of current licenses (if applicable)Copy of current accreditationsProof of professional liability insurance(minimum amounts of $1 million/$3 million)Proof of general liability insurance9-32014 Practitioner and Provider Manual - Ver. 3
Behavioral HealthForm W-9Staff roster (to be updated as changes inclinical staffing occur)RecredentialingIn addition to the initial review, Presbyterianbehavioral health providers are required to havetheir credentials reviewed periodically through therecredentialing process. In the State of NewMexico, individual, professional, and organizationprovider recredentialing is conducted every threeyears.Recredentialing includes an administrative updateof the provider’s original credentialing documentsas well as a review of Presbyterian’s experiencewith the provider. The registered nurse clinicalcoordinator review evaluation includes thefollowing, but is not limited toAny quality reviewsSatisfaction survey findingsCompliments and complaintsAppealing Credentialing DecisionsIf the credentialing review is not favorable and it isdetermined that Magellan will not continue thecredentialing or recredentialing process,Presbyterian notifies the provider in writing. Thedenial notification letter includes the reason fordenial and contains instructions for initiating anappeal process, if applicable.Reporting Changes in Clinical StatusProviders are required to notifyPresbyterian/Magellan in writing within 10 days ofany changes, additions, or deletions that occurrelated toLicensureAccreditationsCertificationsHospital privilegesInsurance coveragePast or pending malpractice actionsNew or updated credentialing information must bemailed toPresbyterian Behavioral HealthP.O. Box 25926Albuquerque, NM 87125-5926Contracting with PresbyterianIn addition to successfully completing thecredentialing process, providers must have anexecuted Presbyterian PPA and Centennial Careproduct attachment under which the provideragrees to comply with Presbyterian’s andMedicaid’s policies, procedures, and guidelines inorder to receive referrals of, and reimbursement for,services rendered to Centennial Care members.Updating InformationPrompt notification of changes in practiceinformation helps us maintain an efficient andeffective referral process, and present accurate andtimely information in Presbyterian publications. Theprovider should notify Presbyterian Centennial Carepromptly when any of the following practicechanges occur:Medicaid enrollmentAddress9-42014 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
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Presbyterian Healthcare Services(HS
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Presbyterian Healthcare ServicesReg
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Presbyterian Healthcare Services2.
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Provider Network Managementthis man
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Centennial Care Overview3. Primary
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Primary Care ProvidersClaims Activi
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Primary Care Providers4. Specialist
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SpecialistsOther Information for PC
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Specialists5. Preventive Health Car
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Page 47 and 48: Care Coordination6. Care Coordinati
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Page 51 and 52: Care Coordinationthe program. If th
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Page 55 and 56: Care CoordinationFacilitate access
Page 57 and 58: Care CoordinationClinical Practice
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Page 63 and 64: Care Coordinationwithout obtaining
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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 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: Behavioral Healthagreements, addend
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
Page 109 and 110: Long-Term Careavailable services, a
Page 111 and 112: Long-Term Carethe agent to members
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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
Page 123 and 124: Home HealthPresbyterian Medicaid me
Page 125 and 126: Home Healththese services. Services
Page 127 and 128: Home Healthfor review will be submi
Page 129 and 130: Home HealthPatient Care Conferences
Page 131 and 132: Home HealthThis page intentionally
Page 133 and 134: Quality Improvement ProgramNational
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Page 137 and 138: Quality Improvement Programresults
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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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