What's New

Presbyterian Provider Services Staff (.pdf)

 

2009 UNM Medical Plan becomes an ASO, effective 7/01/09 (PPC070902) (.pdf)

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. 84-90).
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” is a continuing medical education activity. 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.
IMPORTANT REGISTRATION INFORMATION: 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 “A Physician’s Practical Guide to Culturally Competent Care.” In order to participate, when registering on the website for the program, it is required to create your user name beginning with the letters “phs” and then the underscore symbol. The rest of your user name is unique, created by you (example, phs_upto9freeCEUs).
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 Image Ordering Program 

In May 2007, Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) implemented Phase One of an outpatient, office-based, advanced imaging ordering program with HealthHelp, a Radiology Benefit Management company.  During Phase One, ordering physician offices used HealthHelp to obtain an "R number" (authorization number) as verification of clinical appropriateness for specific CTs, MRs, and PET scans.  Phase One also allowed office and facility staff time to learn how to use the HealthHelp program.

Beginning December 15, 2008, Phase Two goes into effect.  In Phase Two, we will implement an authorization requirement for claims to pay for specific CTs, MRs, and PET scans.  This means that Presbyterian will deny claims payment to facilities for procedures that do not have an "R number" from HealthHelp.

Members are not to be denied such services nor are they responsible for payment of a denial if issued.

Details on 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.

View a Web demonstration for submitting an online Advanced Imaging Order request.   (Flash, 7 MB)
 

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 the Provider CARE Unit.  We're designing an automatice process to assign a secure Pres Online user and password when you meet set criteria, and expect to go live with this enhancement in 2008.  Until that is available, please do not use the "Register now" link in the Pres Online Login box.  Please complete the Pres Online for Presbyterian Health Plan Providers application to receive your login and temporary password within one business day.

 New Pres Online for Providers Web Training

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

New Product Information

As Presbyterian Health Plan and Presbyterian Insurance Company Inc. introduce new products, information for your review will be available on the PHP Provider Training Web page under Quick Links.  

Facets Upgrade in October

Due to a Facets System upgrade, there will be a delay of up to 120 days to bring on any new contracted providers.  We are working diligently to try to minimize any delays and shorten the length of time that you will be waiting for our decision and/or an executed contract.  If you have questions, please send an e-mail to PHPServices@phs.org. We apologize for the inconvenience and thank you for your understanding!

"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.

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.  Therefore, 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.

Presbyterian Provider CARE Unit
P.O. Box 25283
Albuquerque, NM 87125-5283