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Healthcare Professional and Provider Resources
The tools and information you find on this page will help you work more efficiently with Presbyterian 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, between 8 a.m. and 5 p.m., Monday through Friday.
Provider Quick-link Resource Pages and Documents
- Accessibility of Services Table
- Prior Authorization/Benefit Certification Requests and Guide
- EPSDT Provider Manual
- Fraud and Abuse
- Geographic Availability Standards Table
- In-office Lab Listing
- Lab Submission Instructions
- Low Income Subsidy Pharmacy Information
- Select Provider Network
Apply for myPRES Access
Presbyterian Health Plan's free myPRES Service (formally Pres Online) gives you access to updated information about claims, benefit certifications, eligibility, deductibles, exceptions and more. Please complete the myPRES for Presbyterian Health Plan Providers application to receive your username and temporary password.
Intel Connected Care Provider Directory
Please use this provider directory to make referrals for Connected Care members or use the "Find a Doctor" tool and filter for Connected Care.
TriCore Reference Laboratories Information
TriCore Reference Laboratories Patient Care Centers Listing
2011 Non-Contracted Laboratory Letter
Physician Performance Assessments
A Physician Performance Assessment is a report comparing the performance of you to your peers using patient severity risk adjusted Medical Episode Groupers (MEGs). MEGs use age, gender and diagnosis codes to build a timeline of care for patients throughout their conditions.
The assessments also use the three primary care specialties, including family practice, internal medicine and pediatrics, broken out by their topographical urban or rural location. Urban locations include Bernalillo, Valencia, Torrance and Sandoval counties, and rural locations include all remaining counties in New Mexico. The following are sample profiles for your reference:
- Family Practice-Rural
- Internal Medicine-Rural
- Family Practice-Urban
- Internal Medicine-Urban
Advanced Imaging Ordering Program
The documents below provide additional information about the Radiology Utilization and Cost program. If you have questions or concerns about the program, please contact your Provider Network Management Relationship Executive.
- Explanation of HealthHelp Management Program
- HealthHelp ASO Participation Status for Advanced Imaging
- HealthHelp Advanced Imaging Procedure Code List
- Process Steps and Contact Information
- Frequently Asked Questions - Ordering Offices
- Frequently Asked Questions - Facilities
- Clinical Information Form
- Visit the HealthHelp website for information about the company
The SilverSneakers Fitness Program provides your eligible Presbyterian patients with an opportunity to maintain their functional and mental health through physical activity programs. The program includes a free basic membership to a network of fitness centers with access to all amenities and the signatures SilverSneakers group exercise class. Please see the links below for additional information on the program.
- Request SilverSneakers material
- 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
Prebyterian has enhanced its tobacco cessation benefits for members with full medical coverage* by allowing free enrollment in the Tobacco Quit Line.
Your Presbyterian patients who enroll in the Tobacco 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 Tobacco Quit Line will provide a predetermined supply of nicotine replacement therapy products to patients who qualify.
- Tobacco Cessation Patient Information
- Tobacco Cessation Prescription Pad
- Tobacco Cessation Fax Referral Form
If you have any questions about this program, or would like to request additional information, please contact the Presbyterian Tobacco Quit Line at 1-888-840-5445.
*Members enrolled on prescription coverage only plans are not eligible for participation.
Specifics of the Program for Eligible Professionals (State of NM Medical Assistance Div. Document)
The Medical Assistance Division (MAD) of the Human Services Department (HSD) , is offering Adaptive Skills Building (ASB) as a Medicaid covered service through OptumHealth New Mexico. This very specialized service is for children up to 5-years of age that have been diagnosed with an Autism Disorder. See documents below for information and assistance with becoming an OptumHealth New Mexico enrolled ASB provider.
- Salud OptumHealth ASB Overview and Provider Enrollment Information (PPC031109)
- Salud OptumHealth ASB Service Information (PPC031108)
Presbyterian Health Plan, Inc. and Presbyterian Insurance Company, Inc. (Presbyterian) must ensure that all members’ medical records are accurate and complete. Presbyterian reports information to several regulatory and 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.
- 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.
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