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Presbyterian Provider Network Management Staff (.pdf)


Missed our Webinar? (Recovery Of Claim(s) Overpayments Through the Explanation of Payment (EOP))
On December 21, 2011, we held a live webinar that covered how to correctly post the recovery of claim(s) overpayments done through the explanation of payment (EOP).

*Please Note: Sound at the beginning of the recording is very low and is corrected 2 minutes and 42 seconds into the

Presbyterian Senior Care Provider Directory Error
Recently we included an incorrect Provider Directory in the Annual Notice of Changes (ANOC) packet, which was mailed to our Presbyterian Senior Care (PSC) Members. Many physicians, practitioners, and ancillary providers were inadvertently included in the Presbyterian Senior Care 2012 Provider Directory due to an undetected data error.

The error has been corrected and the directory has been updated to reflect Presbyterian’s network of Senior Care providers. We are working diligently to publish and mail updated provider directories for affected members. We anticipate that the updated directories will be mailed beginning October 28, 2011. In addition, we are initiating outbound telephone calls and correspondence as outlined below:

Outbound Telephone Calls: To PSC Members informing them of the error; advising that an updated 2012 HMO provider directory should be in the mail no later than November 10, 2011; and a reminder that members should continue to use the 2011 Presbyterian Senior Care Provider Directory for the remainder of this year.

Letter Correspondence: When the updated HMO provider directory is mailed to PSC Members, the mailing will include a letter informing members of the error and will also include a picture of the incorrect directory to discard with instructions to begin using the updated directory to find practitioners/providers available to members in January 2012.

We regret any inconvenience this error may have caused you or your office staff. If you have any questions about the updated directory, please contact your Provider Network Management Coordinator directly.


Letter of Direction #41 (Correction of Letter of Direction#40) - Coding/Procedure Options for Opioid Addiction Treatment with Suboxone (State of NM Medical Assistance Div. Document)
This document corrects an error previously published in Letter of Direction #40.  Please ensure you use this document (link above) as your most current reference for coding/procedure options for opioid addiction treatment with Suboxone.
2011 Suboxone Communication To Providers (PPC091103)
Suboxone/Subutex Form (PPC091103)

National Drug Code (NDC) Requirements - ALERT!  Your claims will be denied if you don't meet NDC billing requirements!
A 12/14/11 revision of the NDC Manual corrects instructions given with regards to correcting the omission of leading zeros in NDCs being entered on a claim form.
Salud NDC Supplement 11-03 (03/31/2011) (State of NM Medical Assistance Div. Document)
National Drug Code (NDC) Procedure Manual (.pdf) (PPC021104)
Salud NDC Letter to Providers (01/13/2011) (PPC011101)
Salud NDC Letter to Providers (10/29/2010) (PPC101014)
Salud NDC Letter to Providers (08/06/2010) (PPC081003)
Salud NDC Supplement 10-03 (05/15/2010) (State of NM Medical Assistance Div. Document)
Codes Requiring an NDC


New Mexico Medicaid Electronic Health Records Incentive Payment Program
Specifics of the Program for Eligible Professionals (State of NM Medical Assistance Div. Document)


HIPAA Version 5010: Provider Testing and Readiness
The Centers for Medicare & Medicaid Services (CMS) hosted its fifteenth national education call regarding Medicare FFS's implementation of HIPAA Version 5010 and D.0 transaction standards on March 30, 2011. This session focused on provider testing and readiness. Subject matter experts provided testing and readiness instruction, and information to help through the transition to implementation. The information presented is available

Workgroup for Electronic Data Interchange (WEDI™) White Paper
This whitepaper provides information the 5010 testing initiative and is specifically developed to address the provider's perspective.  It includes terminology frequently utilized by the industry, and provides an understanding of the steps Providers must take to initiate and complete testing with trading partners.  This paper builds on previous WEDI work which identified the key business changes in the 5010 transactions.  This paper is not intended to provider specific test transactions, discuss different testing methods currently used, or discuss multiple transaction testing definition and hte interpretation of such testing in the industry.  Please keep in mind that the 5010 version supports data content for the ICD-10.
5010 Testing and Implementation From the Provider Perspective: Is Your Practice Truly Ready? April 29, 2011


Adaptive Skills Building (ASB): New Service Covered by Medicaid
The Human Services Department (HSD), Medical Assistance Division (MAD), is offering Adaptive Skills Building as a new Medicaid covered service.  This very specialized service is for young children, birth up to 5 years of age, diagnosed with an Autism Disorder.  Select the documents below for information and assistance with becoming an OptumHealth New Mexico enrolled ASB provider.


TriCore Reference Laboratories Information
TriCore Reference Laboratories Patient Care Centers Listing (.pdf)
2011 Non-Contracted Laboratory Letter (PPC011104)


IMPORTANT INFORMATION: Coverage of Medicare Annual Wellness Visit Beginning 2011 for your Presbyterian Medicare Advantage Patients
Click here to open the communication.
 

Medicare Providers must have an enrollment record in PECOS to continue to refer or order items or services for Medicare patients.
The Centers for Medicare & Medicaid Services (CMS) has established Internet-based Provider Enrollment, Chain and Ownership System (PECOS) as an alternative to the paper (CMS-855) enrollment process.  PECOS will allow physicians, non-physician practitioners and provider and supplier organizations to enroll, make a change in their Medicare enrollment, view their Medicare enrollment information on file with Medicare, or check on status of a Medicare enrollment application via the Internet.

You should know that if you do not have an enrollment record in PECOS:

  • Your information may not be current and updating your record in PECOS ensures payment accuracy from CMS for the services you provide to Medicare patients.
  • It is possible that you may not be able to receive incentive payments from Medicare for meaningful use of certified electronic health records. These incentive payments are authorized by the American Recovery and Reinvestment Act of 2009. More information on this initiative, also known as HITECH, is available at http://www.cms.gov/Recovery/11_HealthIT.asp on the Centers for Medicare & Medicaid Services (CMS) website.
  • Many physicians and non-physician practitioners order items or services for Medicare beneficiaries. You need an approved enrollment record in PECOS to continue to refer or order items or services for your Medicare patients.

Effective June 28, 2010, CMS established requirements for providers to verify their information in PECOS, or they would begin to experience claim rejections. Additionally, CMS has stipulated that treating facilities will also begin experiencing claim rejections if the referring physician is not current in the PECOS system. For example, if an independent provider refers a patient to a hospital for imaging studies and is not enrolled, the hospital will not get paid for that service. The effective date when claim rejections will begin is January 1, 2011 (extended from July 6 2010).

Medicare contractors (TrailBlazer) mailed a letter to physicians and other providers and suppliers who did not have a record in PECOS, requesting that providers take the necessary steps to establish a record in PECOS and explained how to do so. Please visit the CMS web page to review the letter sent to providers and a list of which providers should complete this process
Note: Internet-based PECOS will be made available for suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) later this year.

When you are ready to enroll or make changes to your enrollment information, visit the CMS provider enrollment web site to access Internet-based PECOS at http://www.cms.hhs.gov/MedicareProviderSupEnroll. In addition, you can download a paper-based Medicare enrollment application, find responses to commonly asked questions, or find telephone and mailing address information for the fee-for-service contractor serving your area.

Other downloadable brochures on the CMS website include

  • Medicare Physician and Non-Physician Practitioners – Protecting Your Privacy
  • Internet-based PECOS -
    • Contact Information for Physicians and Non-Physician Practitioners
    • Getting Started Guide for Physicians and Non-Physician Practitioners
    • Instructions for Viewing Physician and Non-Physician Practitioner Status and Speciality Type
    • Enrollment Example
    • Getting Started Guide for Provider and Supplier Organizations
    • Provider and Supplier Organization Overview
    • Getting Started Guide for DMEPOS Suppliers


Radiation Therapy Benefit Management Program (RadOnc™) Terminated
Prior authorizations are no longer required for radiation therapy services through HealthHelp's RadOnc™ program.  For proton beam therapy follow Presbyterian's standard process for prior authorizations.



2009 Salud Fluoride Varnish Pilot Program - Chaves County Providers Only (PPC060910) (.pdf)
HSD Letter of Direction - Fluoride Varnish May 27, 2009 (.pdf)

2009 Autism Mandate (.pdf)
Autism Network (.pdf)



Medical Record Standards and Requirements
Presbyterian Health Plan Health Services Department

History
As part of regulatory requirements, Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) must ensure that our members’ medical records are complete.  Presbyterian reports information to several regulatory and/or accreditation agencies including the National Committee for Quality Assurance (NCQA), the State of New Mexico Human Services Department (HSD), the Centers for Medicare and Medicaid Services (CMS), and the New Mexico Department of Insurance (DOI).  These agencies require that certain items be documented in every member’s chart.

A recent audit of Pediatrician and Primary Care Practitioner member charts showed opportunities for improvement in the following areas:

  • Documentation of any history of smoking, alcohol use, and substance abuse (for any member over the age of 12)
  • Documentation of past medical history
  • Documentation of medication history including what has been effective, what has not, and why.  This should include consistent documentation of refills, including long-term prescriptions such as asthma inhalers.  The history should also include any follow-up on new prescriptions.

Advance Directives
All adult member charts should have Advance Directive documentation.  This would include documentation that durable Power of Attorney and Advanced Directive information was provided to the adult member, and was signed and dated by both the adult member and the practitioner.  This documentation should also include if the member executed Advanced Directives.  “Adults” include any member age 18 or older.

If you have any questions about documentation standards, contact Jené Breitburg-Moya, RHIT, at (505) 923-5729 or by e-mail at jbreitbu@phs.org.  Additional information regarding chart documentation is available in the Presbyterian Provider Manual (see pp. 71-76).
Presbyterian Provider Manual (.pdf)
Medical Records Standards (.pdf) 
 

Cultural Sensitivity Competencies Offered Online With Up To 9 Hours of Free CEUs
Presbyterian Health Plan, Inc. and Presbyterian Insurance Company, Inc. (Presbyterian) are pleased to offer our network practitioners, providers, and nurse practitioners educational opportunities to become even more culturally competent while earning up to nine hours of free Continuing Education Units (CEU).

“A Physician’s Practical Guide to Culturally Competent Care” and "Culturally Competent Nursing Care: A Cornerstone of Caring" are continuing education activities. Supported by the Office of Minority Health at the United States Department of Health and Human Services, and accredited by Ciné-Med Inc., these online competencies are designed to assist healthcare professionals deliver culturally competent care to an ever increasing diverse population of members.

When you log on to Pres Online, a Cultural Sensitivity Competencies link appears with other link options (Epocrates, HealthHelp, Pres Online), directing you to the registration page for www.ThinkCulturalHealth.hhs.gov.  You can also access the competencies by visiting www.ThinkCulturalHealth.hhs.gov.

During registration, you will choose an appropriate program in which to earn up to nine free CME credits (Physicians and Physician Assistants) or nine contact hours (Nurse Practitioners).

The website provides a Frequently Asked Questions section, which addresses everything from computer requirements to receiving your CEUs.
Since these competencies are made available on the Internet, you can earn free CEUs at your convenience, 24 hours a day, seven days a week. 


Advanced Imaging Ordering Program
Presbyterian uses an outpatient, office-based advanced imaging ordering program through HealthHelp, a radiology benefit management company. The program improves health care, patient safety, utilization, and cost through application of clinical criteria when ordering advanced imaging (CTs, MRs, PETs). HealthHelp also provides evidence-based education and guidelines to assist ordering providers choose the radiology procedure that best meets their clinical needs while considering safety, risks, benefits, and cost.

Details on the program and for submitting requests are available on the Provider Resources Web page under "Advanced Imaging Ordering Program."

Visit the HealthHelp website for more information about the company. 
 

Apply for Pres Online Access
With Pres Online, providers can check patient eligibility, Primary Care Practitioner information, benefit plan details, claims status, request Benefit Certifications and Pharmacy Exceptions, and contact our Customer Service Center.  Please complete the Pres Online for Presbyterian Health Plan Providers application to receive your login and temporary password.
 

Pres Online for Providers Web Training
Pres Online instructional Web demonstrations are available for providers. Broken down by task, you can review what instructions you want, when you want. Click on PHP Provider Training under Quick Links to access the demonstrations.


"NPI Only" As Of September 1, 2007
The Health Insurance Portability and Accountability Act (HIPAA) regulations established the National Provider Identifier (NPI) as the standard unique health provider identifier for healthcare providers and required all covered entities to comply with its provisions by May 23, 2007.  To obtain an NPI, visit the National Plan & Provider Enumeration System (NPPES) website.

As of September 1, 2007, all claims now need to be submitted with the provider's NPI in addition to their federal tax identification number.  All claims submitted without the required information will be returned to the provider.  Effective September 1, 2007, all electronic and paper claims submitted to Presbyterian must be submitted with the provider's NPI and federal tax identification number only. Claims submitted without this information will be returned to the provider in the following ways:

  • Electronic claims will be rejected back to the clearinghouse as not submitted with the required information. Providers will receive a rejection report from their clearinghouse with this information.
  • Paper claims will be returned to the provider with a cover letter informing them of the reason and a request that they resubmit the claim(s) with the appropriate identifiers.