Provider Resources

Provider Resources

These tools will help you work efficiently with Presbyterian Health Plan and reduce the amount of time required for your administrative tasks. If you have questions or problems, please contact the Provider CARE Unit at (505) 923-5757, Monday through Friday, 8:00 a.m. to 5:00 p.m.

• Accessibility of Services Table (.pdf)
• Certified Diabetic Educators Contracted with PHP (.pdf) 
• Diabetes Care -- Best Practices (.pdf)
• EPSDT Provider Training Manual (.pdf)
• Fraud and Abuse
• Geographic Availability Standards Table (.pdf)
• In-office Lab Listing (.pdf)
• Lab Submission Instructions (.pdf)
• Low Income Subsidy Pharmacy Information (.pdf) - This document will help answer questions regarding appropriate deductible(s) and/or prescription drug copayments for members with a Low Income Subsidy Plan
• Micromedex  
  
  Missed our 2008 Provider Education Conference?  Below are select packet materials from the event.  If you would like to receive a packet in its entirety, contact your Provider Services Coordinator.  
       Presentation Slides  
  

       Direct Behavioral Health Referrals   
       Welcome to Presbyterian Coordination of Care Services    
       Coordination of Care Form    
       Case Management Referral Form   
       Benefit Certification Team   
       Benefit Certification Form   
       Member Referrals to Certified Diabetes Educators   
       Salud EPSDT Information   
       Nurse Advice Line  
  

• Practitioner Practice Profiles - A report comparing the performance of you to your peers using risk (case mix) adjusted Episode Treatment Groups.  There are three separate profiles based upon PCP specialty: Family Practice, Internal Medicine, and Pediatrics.  You need to have Adobe Acrobat Reader (it's free) to read the sample file.
            Sample Profile (.pdf)
            Quick Reference Guide (.pdf) - A step by step guide for the sample profile.
• Select Provider Network (SPN)
• Waiver Provider Training
  • EPSDT Provider Training Presentation (.pdf)
  • Waiver Provider Training Packet (.pdf)

Programs and Services

• Pharmacy
• Home Health, Hospice, and Private Duty Care
• Occupational Health 
• Provider Directory 
• Lab Services 
• Radiology

Advanced Imaging Ordering Program
These documents are all Adobe Acrobat .pdf files. 

• View a Web demonstration for submitting an online Advanced Imaging Order request. (Flash, 7 MB) 
• 90-Day Letter to Practitioners 
• Scope    
• HealthHelp's 2008 Procedure Code List  
• Process Steps and Contact Information  
• Frequently Asked Questions - Ordering Offices   
• Frequently Asked Questions - Facilities  
• Clinical Information Form for use as a tool to collect pertinent clinical information and/or as a fax sheet to communicate with HealthHelp  
• Presentation slides

SilverSneakers Fitness Program for Presbyterian Medicare Plans

• Request SilverSneakers material

These forms are all Adobe Acrobat .pdf files

• Making Staying Healthy More Affordable for Medicare Members
• SilverSneakers: Maintaining Health with Chronic Conditions 
• Case Study Cost Savings by SilverSneakers 
• SilverSneakers Program Deliverables 
• SilverSneakers Core Competencies 
• Patient Information Tablet 
• Exercise Your Mind Poster 
• You Are Not Alone Poster 
• Your Independence Poster

Tobacco Cessation Benefits Enhanced

Presbyterian has enhanced its tobacco cessation benefits for members with full medical coverage (members enrolled on prescription coverage only plans are not eligible for participation).

As of November 1, 2006, the Tobacco Quit Line became available to all its members.

Members who enroll in the Quit Line program will receive up to five telephonic counseling sessions with specially trained counselors who will guide them through the quitting process.

As an incentive to enroll in and complete the program, the Quit Line will provide a predetermined supply of nicotine replacement therapy products to members who qualify.

Additional information and documents may be found under the files below. Should you have additional questions, you may call the Presbyterian Tobacco Quit Line at 1-888-840-5445.

Tobacco Cessation
These forms are all Adobe Acrobat .pdf files 

• Tobacco Cessation Patient Information 
• Tobacco Cessation Prescription Pad 
• Tobacco Cessation Fax Referral Form

Regulatory and HIPAA Resources 

• HIPAA: Compliance with Transaction and Code Sets (.pdf) 
• Information for Medicare Providers from Centers for Medicare and Medicaid Services (CMS) 
• PHP Companion Guides with NPI for Professionals (.pdf) 
• PHP Companion Guides with NPI for Institutions (.pdf) 

Find it in the Claims section of the Presbyterian's Provider Manual (.pdf) or go to this CMS website:

• Click on "Web-Based Training Courses," then 
• Under "Office Management Information" 
• Click on "CMS Form 1450" (Form 1450 = UB-04) or "CMS Form 1500" 
• Instructions for filling out the CMS 1500 are also available on the National Uniform Claim Committee website 
• Additionally, you can download the CMS manual for filling out the UB-04 (.pdf)
• PHP's CMS-1500 (08-05) Claim Form Billing Instructions Manual (created June 25, 2007)
• PHP's UB04 Claim Form Billing Instructions Manual.