Health Services

Medical Policies 

• Medical Policy Manual

Prior Authorization/Benefit Certification Requests: Important changes effective April 1, 2011:

Additional auto-generated approvals through Pres Online:

Arthroereisis Subtalar
Meniscal Transplants
Breast Repair and Reconstruction for Breast Cancer
Surgery for Gynecomastia

Services and procedures no longer requiring approval: 

The following services and procedures no longer require a Prior Authorization/Benefit Certification. (Note: All Prior Authorization/Benefit Certification requests are subject to retrospective review to validate medical record evidence of medical necessity):

Knee Arthroscopies
Carticel Transplant
Genioplasty
Sclerotherapy
Vein Ablation
Magnetoencephalography (MEG)
Kyphoplasty/Vertebroplasty
Uvulopalatopharyngoplasty (UPPP)
Vein ligation and Stripping
X-Stop

Prior Authorization/Benefit Certification Guide and Request Form

Prior Authorization/Benefit Certification Guide (.pdf) Updated 7/12/2011
Prior Authorization/Benefit Certification Request Form (.pdf)

Online Benefit Certification Requests (available to Contracted Providers only)

• Complete the PDF form electronically, print, and fax to appropriate number listed on the form.  OR
• Print the form, complete it manually, and fax to appropriate number listed on the form. Prior Authorization/Benefit Certification Request Form (.pdf) 

Other Communications and Information

Notifiable Diseases/Conditions in New Mexico
Oregon Guidelines for Medically-based Outpatient PT and OT
Certified Diabetic Educators Contracted with PHP (.pdf)

Forms (.pdf)

Referral Form: Care Coordination/Case Management/Disease Management (.pdf)
Durable Medical Equipment (DME) Prior Authorization/Benefit Certification Request Form (.pdf)
Inpatient/Outpatient Prior Authorization/Benefit Certification Request Form (.pdf)

Preventive Healthcare Guidelines (.pdfs)

• Presbyterian Health Plan Preventive Healthcare Guidelines
• Recommended "Done By One" Childhood and Adolescent Immunization Schedule-New Mexico

Clinical Practice Guidelines (.pdfs)

Asthma

• Guidelines for Diagnosis and Management of Asthma Summary
• Asthma Guidelines Full Report
• 2008 Asthma Change Page

Coronary Artery Disease

• Coronary Artery Disease Clinical Practice Guidelines 
• Coronary Artery Disease Clinical Practice Guidelines for Women
• ATP III 2004 Update
• Assessing Your Patient's Risk (Framingham Risk Score)
• Secondary Prevention Guidelines for patients with CAD/CVD

Diabetes 

• Diabetes Clinical Practice Guidelines for Providers - Non-Pregnant Adult
• Diabetes Clinical Practice Guidelines for Members - Non-Pregnant Adult

Obesity

• Obesity Clinical Practice Guidelines
• Adult Weight Counseling Discussion Guide
• Weight-Related Health Risk Worksheet