Practitioner and 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)
• Prior Authorization/Benefit Certification Requests and Guide
• Certified Diabetic Educators Contracted with PHP (.pdf) 
• EPSDT Provider 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
• Mammogram Facilities
• Micromedex  

Missed our 2011 Provider Education Conference (PEC) Webinar?
This year, we presented information in a Webinar format on Sept. 27th and Oct. 13th.  If you were not able to participate in the Webinar, you can view the recorded Webinar by clicking on the following link: https://www2.gotomeeting.com/register/308624306.  You'll be directed to the GoToMeeting® web site to register to view the recording.  You can also review presentation and handout materials using the links below.
2011 Provider Education Conference Presentation Slides (PPC071108)
Click on the link above to open the presentation slides used in our 2011 PEC Webinars.
2011 Provider Education Conference Handout Materials
Click on the link above to download or print handout materials used in our 2011 PEC Webinars.
 

Physician Performance Assessments - 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 episode of care for all patients across all of their conditions. There are three primary care specialties: Family Practice, Internal Medicine, and Pediatrics.  Each specialty is broken out by Urban and Rural.  Urban includes Bernalillo, Valencia, Torrance, and Sandoval counties.  Rural includes all other counties in New Mexico.  The following are sample profiles:

• Family Practice-Rural
• Internal Medicine-Rural
• Pediatrics-Rural
• Family Practice-Urban
• Internal Medicine-Urban
• Pediatrics-Urban
   

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 
• 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) 
• Scope    
• 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 (for use as a tool to collect pertinent clinical information and/or as a fax sheet to communicate with HealthHelp)  
• Program Overview and Online Entry System Instructions
• Visit the HealthHelp website for information about the company

Radiation Therapy Benefit Management Program (RadOnc™)
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.

• Notice of Termination of RadOnc's Radiation Therapy Benefit Management Program

• 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) 

Need help filling out CMS 1500 and UB-04 claims forms? 

Find instructions in the Claims section of Presbyterian's Provider Manual (.pdf).
In addition, you can view the following instruction manuals.

• PHP's CMS-1500 (08/05) Claim Form Billing Instructions Manual (created June, 2007)
• PHP's UB-04 Claim Form Biling Instructions Manual (created February, 2008)

The Centers for Medicare & Medicaid Services (CMS) Web site offers Web-Based Training Courses as well.

• Click on this CMS Web site link  
• Click on the "Web Based Training (WBT) Courses" link under "Related Links Inside CMS"
  • For the CMS 1500 course,  click on the "CMS Form 1500 (08/05) (July 2008)" link
  • For the UB-04 course, click on the "Uniform Billing (UB)-04 - (July 2008)" link

Also available on the CMS Web site are helpful Fact Sheets that provide definitions, an overview, and images of the claim forms, tips on filling out the forms and links to additional instructions.

• CMS 1500 Fact Sheet
• UB-04 Fact Sheet

Instructions for filling out the CMS 1500 are also available on the National Uniform Claim Committee website.