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 2007 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.
•      Welcome
            Main Presentation
•      Breakout session
            Behavioral Health
            Coding
            Claims
            Credentialing
            Health Services
                 Presentation
                 Care Coordination Packet (Medical & Behavioral Health)
                 Pharmcy
            Reimbursement
•      Other important materials
            Ancillary Services
                 Accessing Ancillary Services
                 Nurse Advice Line
            Appeals/Grievances
            Blood Lead Screening
            Coding Resources
            Cultural Sensitivity
            EPSDT
            Hearing Aids Mandate
            Member Services
            Provider Responsibilities
• 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 Silver Sneakers 
• 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.