What's New

Credentialing/Peer Review Committee
 

Are you interested in serving on the Credentialing/Peer Review Committee?  The Provider Services and Quality Management Teams are seeking new members to serve on the committee that ensures Presbyterian Health Plan’s provider network is of the highest standard.  We are especially in need of representation for Behavioral Health, Cardiology, and Obstetrics/Gynecology specialties.

Committee members are reimbursed $100 per meeting and reimbursed for travel if from outside the Bernalillo County area.  If you cannot travel to Albuquerque, you may also conference into our meetings for active participation after an initial introductory visit to your first meeting.  Meetings are held the second Wednesday of every month from 6:00 p.m. to 8:00 p.m. at the Presbyterian Administrative Center, located at 2501 Buena Vista Drive SE, Albuquerque, NM.  Dinner is provided.

If you're a contracted Presbyterian Health Plan provider and wish to serve on the committee, please submit your letter of interest and curriculum vitae using the Credentialing/Peer Review Committee application.

If you have further questions, please contact Gloria Jett at gjett@phs.org or (505) 923-8276.

Apply for Pres Online Access

With Pres Online, providers can check a patient's eligibility, Primary Care Practitioner information, benefit plan details, and claims status as well as request Benefit Certifications, Pharmacy Exceptions, and contact the Provider CARE Unit.  We are currently designing a process where the system will automatically assign a Pres Online Security (Login 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 provider application (link available below) and you will receive your Login and temporary password within one business day.  Apply for access to Pres Online now.

New Pres Online Web Training

Pres Online Web demonstrations are now available for providers and their staff. The instructional demonstrations are broken down by task, narrated, and most average two minutes, but vary in time from 39 seconds to eleven minutes. Now, you and your staff can review what instructions you want, when you want. Click on PHP Provider Training under Quick Links to access the demonstrations.

New Product Information

Presbyterian Insurance Company Inc. has introduced a new Individual Preferred Provider Organization benefit plan named PresMetro. Click on PHP Provider Training under Quick Links to review plan details.  

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!

Radiology Cost and Utilization

The right procedure at the right time

Presbyterian Health Plan and Presbyterian Insurance Company have partnered with HealthHelp, a radiology benefit management company, to manage the utilization of advanced radiology procedures - CTs, MRs and PETs - for diagnosis of outpatient conditions.

HealthHelp provides ordering practitioners and offices with evidence-based clinical information and support needed to order CT, MR and PET scans with the goal of ordering the right procedure at the right time.

HealthHelp's evidence-based clinical information, the "Medical Imaging Consultant" (MIC) booklet is:

• User-friendly
• Pocket-sized
• Based on current literature and best practice guidelines
• Also available in PDA format for hand-held device
• Conveniently separated into sections for children and adults
• Arranged by symptoms and suspected clinical diagnoses

When the MIC is used to determine the test to order and the request is submitted to HealthHelp online, it can be approved in a few minutes. Requests can also be submitted by phone or fax.

Some complex clinical cases may not be addressed adequately in the MIC guidelines. In these and in any other cases, the practitioner can talk directly to a specialty Radiologist from HealthHelp.

Implementation of the Advanced Imaging Ordering Program started May 1st, 2007. Details on using the MIC and submitting requests are available under Provider Resources under Advanced Imaging Ordering Program.

Visit the website for more information about HealthHelp.

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

"NPI Only" As Of September 1, 2007

As you know, 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 be in compliance with its provisions by May 23, 2007. In May 2007, The Centers for Medicare and Medicaid Services (CMS) announced "a contingency plan" with regards to the implementation of the NPI. CMS stated that "covered entities that have been making a good faith effort to comply with the NPI provisions may, for up to 12 months, implement contingency plans that could include accepting legacy provider numbers on HIPAA transactions in order to maintain operations and cash flows." They went on to say: "Each covered entity will determine the specifics of its contingency plan...the plan may not extend beyond May 23, 2008, but entities may elect to end their contingency plans sooner."

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 claims submitted to Presbyterian (electronic and paper) 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 to resubmit the claim(s) with the appropriate identifiers.

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