Provider Education Conference

Provider Education Conference Presbyterian Health Plan DECEMBER 2017

Agenda Welcome/Introduction Centennial Care Updates Health Plan Updates mypres Provider Portal Demonstration Health Plan Reminders Presbyterian Quality Initiatives Questions Behavioral Health Updates Questions Conclusion 2

Presbyterian Health Plan 3

Provider Network Management Creating an exceptional provider experience 4

How to Contact Us You can find your Relationship Management team at www.phs.org/contactguide. We have specialized 1:1 relationship teams broken out by: Long-term Care Behavioral Health Hospitals Multi-specialty Groups Medical Specialty County Indian Health Services We re here for you! 5

Online Communications All recent communications and updated provider manuals are online at www.phs.org/providers. You can also opt in to receive your communications by email by going online. 6

Health Plan Updates Managed Services Organization New Mexico Medicaid Enrollment In-Network Referrals Credentialing & Recredentialing Claims & Corrected Claims Appeals and Grievance Demographic Updates/CMS Audit 7

Managed Services Organization (MSO) 8

Management Services Organization Update Presbyterian is continuing to move forward with opening a Management Services Organization (MSO). Our first venture is in North Carolina with Provider-Led, Patient- Centered Care LLC (PLPCC) physicians and practice groups. We will work as the administrator of back-office functions for Medicaid benefits similar to those in New Mexico. This will not affect the relationship with providers in New Mexico. 9

New Mexico Medicaid Enrollment 10

NM Medicaid Enrollment Requirement Quick facts for enrollment on the New Mexico Medicaid Portal 1. Both the individual provider and the group must enroll with HSD. 2. Providers must be enrolled with the appropriate provider type(s) or otherwise claims will deny. 3. Enroll with any, or all, of the following: Individual NPI Group NPI Facility NPI 4. Include an effective date. 5. Update your information with HSD (e.g., an address change). 11

Why NM Medicaid Enrollment Is Important Centennial Care Encounter Reporting Presbyterian is required by HSD to report all services rendered to Presbyterian Centennial Care members. Providers must submit claims to Presbyterian within three (3) months from the date of service. If the Provider is not enrolled with HSD, the claim will be rejected or denied. Additional information regarding encounter data reporting can be found in the Claims chapter of the Provider Manual. 12

In-Network Referrals 13

In-Network Laboratory Referrals Presbyterian s preferred reference laboratory is TriCore Reference Laboratories You are contractually obligated to refer your patients and send all specimens and tests to TriCore. 14

Credentialing & Recredentialing 15

Credentialing & Recredentialing Providers must be registered with the Council for Affordable Quality Healthcare, Inc. (CAQH). Initial credentialing can take 30 to 45 days. You cannot see Presbyterian members until credentialing and contracting are both complete. Recredentialing is performed at a minimum of every three years. You will receive notification when you re up for renewal. Site visits are conducted every three years. 16

Claims & Corrected Claims 17

Submitting Claims to Presbyterian You can submit claims to Presbyterian electronically or by paper. Note: For behavioral health electronic claims submissions (ECT), please notify your clearinghouse to update the Payer ID for ECT submissions to add Magellan Payer ID 01260 (Magellan Payer ID for Change Healthcare, which was formally known as Emdeon) 18

Submitting Corrected Claims If the original submission is past the three-month filing limit, original filing documentation must be included with the resubmission. Acceptable documentation includes computer ledgers, written logs, and records of calls to Presbyterian (include date and contact name). The exception report from Presbyterian or the ECT clearinghouse is required for ECT claims. A regenerated claim is not acceptable. Corrected claims must be submitted within one year from the date of service. 19

Submitting Corrected Claims (con t) Claim resubmissions, corrections and adjustment requests must be submitted within 12 months of the date of service. CMS 1500 UB 04 20

*NEW* Electronic Corrected Claims Providers can submit corrected CMS-1500 claims. A corrected claim must include all previously submitted claim information as well as the corrected information. A corrected electronic claim is identified only when field 22 on the claim has a Resubmission Code of seven or eight and the Original Ref No field contains a claim number. 21

Appeals & Grievances 22

Provider Appeals Providers can file an appeal for: Denials of benefit certification Concurrent review decisions Denials they feel may be inappropriate Correct coding Items needed to file an appeal: Supporting documentation that supports coding Documentation support medical necessity Member consent for benefit certification appeal Exception: expedited appeals request 23

Provider Grievances Providers may file a grievance if he or she is dissatisfied or disagrees with: Presbyterian s decision to terminate Presbyterian s decision to suspend Presbyterian s general operations 24

Appeals & Grievances Timeline 12 months from the date of service to challenge a claim denial, claim adjudication, claim submission, or a resubmission not acted upon 30 days from date of receipt to file an appeal challenging a claim denial 12 months to appeal a claim; if you submit an appeal past one year, it will not be reviewed and the denial will be upheld as past the filing limit Note: Corrected claims, proof of timely filing, new claims or adjustment requests need to be submitted to the Provider CARE Unit. 25

Demographic Updates / CMS Audit 26

Demographic Audit The Centers for Medicaid & Medicare Services (CMS) The Centers for Medicare & Medicaid (CMS) began auditing provider demographic data for all managed care organizations. The review is aimed at determining whether the information contained in the online directory is accurate. Presbyterian is required at a minimum to audit provider data quarterly. CMS may take compliance and/or enforcement actions against Presbyterian: Potential loss of Medicare membership for Presbyterian. Potential loss of directory listing with Presbyterian. 27

We need your help to verify your data! Improving the member and patient experience Directory data should be focused on member-facing points. The provider/practitioner name should reflect how the phone is answered and name on the building. Providers panel status should be current and indicate whether their panel is open or closed (i.e., Are they accepting new patients?). Office staff should be knowledgeable on which Medicare plans are accepted. Only list providers at locations that appointments can be made by member. Only current providers should be listed. Provider offices must notify Presbyterian any time a provider leaves your practice. Note: Our number one audit error is for providers who are being listed who are no longer in practice. 28

mypres Portal Overview 29

mypres Provider Portal Overview 30

My Pres Provider Portal Overview Gaps in Care Report - You are able to view a patient list for the Provider Quality Incentive Program and program support such as program details, instructions and frequently asked questions. 31

My Pres Provider Portal Overview Verify Eligibility - Ability to verify eligibility status, members benefits and view members handbook. 32

My Pres Provider Portal Overview Verify Claims - Ability to check claims status, get denial reasons and pull ERA/EOP. 33

My Pres Provider Portal Overview Inquiries - This allow you to submit any questions you may have about the mypres Provider Portal or claims adjustment. 34

My Pres Provider Portal Overview Payment Tracking - Provides access to research claims payment detail by claim number or check number. 35

My Pres Provider Portal Overview Member Roster - Ability to pull together a list of all members where the provider is assigned as the PCP or where one of the providers within a practice or facility is assigned as the member s PCP. 36

My Pres Provider Portal Overview Fast Claim - This quick link takes providers to a service where they can submit electronic claims at no cost to the provider. 37

Provider Demographic Real Time Updates 38

Real-Time Provider Updates 39

Health Plan Reminders Prior Authorizations & Inpatient Notifications NIA Magellan Fraud, Waste & Abuse Presbyterian Members Cultural Sensitivity Centennial Care Overview Critical Incident Management and Reporting Care Coordination 40

Prior Authorizations & Inpatient Notifications 41

Prior Authorizations & Inpatient Notifications The prior authorization guide is a complete list of services that require an authorization or a notification. To submit a request for a prior authorization, you will need to fax the prior authorization form to our Utilization Management department. 42

Prior Authorizations & Inpatient Notifications Check the Prior Authorization Guide for: Pre-planned surgeries/procedures Observation stays greater than 24 hours Inpatient Notifications Presbyterian requires that hospitals notify us of all inpatients stays with in 24 hours* Acute care (medical/surgical) Rehabilitation, skilled nursing, long-term acute care facilities *Reminder: Even though a prior authorization is never required for labor and delivery services, we do require notification within 24 hours of the patient s arrival. 43

NIA Magellan 44

Authorization Programs Presbyterian partners with National Imaging Associate Inc. (NIA), an affiliate of Magellan Healthcare Inc., to manage two prior authorization programs for nonemergent, outpatient procedures performed: Medical Specialty Solutions (MSS) Program Spine Management Program Procedures Requiring Prior Authorization Settings Excluded from Program: MRI/MRA CT/CTA PET CCTA Myocardial perfusion imaging Muga scan Stress echocardiography Inpatient or outpatient lumbar and cervical spine surgery (Effective 1/15/15) Hospital inpatient Observation Emergency room Urgent care Surgery center 45

Patient and Clinical Information Required Information for Authorization General Includes things like: Ordering physician information Member information Rendering provider information Requested examination Etc. Clinical Information Includes clinical information that will justify examination, symptoms, duration of symptoms and physical exam findings. Preliminary procedures already completed (e.g., x-rays, CTs, lab work, ultrasound reports, scoped procedures, referrals to specialist, specialist evaluation). Reason the study is being requested (e.g., further evaluation, rule out a disorder). For more specific information, refer to the Prior Authorization Checklists on the RadMD website, which is a real-time tool offered by NIA Magellan that provides instant access to high-tech imaging authorization and supporting information. 46

Submitting Clinical Information/Medical Records Two ways to submit clinical information: Fax Online at www.radmd.com When submitting clinical information, use the fax cover sheet found on the RadMD website or request one by calling 866-236-8717. 47

Prior Authorization Process Level 1: Intake level Requests are evaluated using our clinical algorithm. Request may: 1. Approve 2. Require additional clinical review. 3. Pend for clinical validation of medical records Level 2: Initial Clinical Review Nurses will review request and may: 1. Approve 2. Send for additional clinical review Level 3: Physician Clinical Review Physicians may: 1. Approve 2. Deny A peer-to-peer discussion is always available! 48

Questions & Contact for NIA s Authorization Programs NIA Provider Relations Manager Name: Kevin Apgar Phone: 800-450-7281 ext. 65080 or 916-859-5080 Email: Kwapgar@magellanhealth.com 49

Fraud, Waste and Abuse 50

Presbyterian Health Plan s Program Integrity Department (PID) 51

Fraud, Waste and Abuse - Provider Types of Provider Fraud, Waste and Abuse: Billing for services never provided Misuse of modifiers to increase payment Upcoding, unbundling and split-billing Excessive and/or unnecessary prescribing, testing, office visits and procedures Submitting false claims Collusion Billing under another provider s Tax Identification Number (TIN) Altering medical records or claims submissions 52

Fraud, Waste and Abuse - Member Types of Member Fraud, Waste and Abuse: Use of another s insurance card for medical care Medical identity theft Falsifying information on an insurance application Not paying copayments or deductibles Forging prescriptions to obtain drugs for use or sale Failure to reveal other health insurance carrier coverage to collect payment from both carriers Collusion (i.e., signing caregiver timesheets when services were not provided) 53

Reporting Fraud Activity to Presbyterian You can report fraud activity to Presbyterian by: Calling Presbyterian s 24-hour fraud and abuse hotline (505) 923-5959 Going online to phs.org: https://www.phs.org/health-plans/understanding-health-insurance/fraud-andabuse/pages/form.aspx Calling the State of New Mexico hotline. 1-800-239-3147 Writing to Presbyterian's Program Integrity Department (PID) Presbyterian Health Plan Special Investigative Unit (SIU) P.O. Box 27489 Albuquerque, NM 87125-7489 54

Presbyterian Members 55

Member Advocates What they can do for providers and members Providers: Advocates can assist by collecting all of the member s pertinent personal information to schedule an appointment. Members: Advocates can assist with locating providers and facilities that can accommodate their request. 56

Member Rights & Responsibilities Presbyterian members are free to exercise their rights and, by doing so, should not affect the care they receive from Presbyterian or its network of providers. Member Rights and Responsibilities can be found in your conference materials and also at the following link: https://www.phs.org/page s/member-rights.aspx 57

Member Appeals & Grievances All members have the right to voice their concerns or problems related to their coverage or care by filing one of the following: 1. Grievance to voice a concern about their experience 2. Appeal to voice a concern about a decision Members can contact a Presbyterian representative by calling the number on the back of their ID card. 58

Second Opinions Members have the right to seek a second opinion. Presbyterian will assist members in locating a provider within their network. Members should contact Presbyterian by using the number on the back of their ID card. 59

Medicare Advantage Member Reminders As required by CMS, providers cannot request a Medicare Advantage member to sign an Advanced Beneficiary Notice (ABN) to assume financial responsibility, because they are part of a Medicare Advantage plan. Prior to referring Medicare Advantage members for services, such as lab tests and advanced diagnostic imaging services, providers must verify that the service is covered by Medicare. If the service is not covered by Medicare, providers should inform members that they will be held financially responsible for that service. Note: All Presbyterian Medicare plans are considered Medicare Advantage plans. 60

Cultural Sensitivity 61

Cultural Sensitivity We want members to fully understand their healthcare benefits and to participate in their treatment or preventive services. Language Ethnicity/race Age Gender Religious beliefs Values Traditions Diverse culture Ethnic backgrounds Limitations with English proficiency or reading skills Physical or mental disabilities State of homelessness 62

Cultural Sensitivity Translation Services If a provider does not offer translation services, the Presbyterian Customer Service Center or your relationship executive can be contacted to help coordinate these services. Note: Providers are financially responsible for language interpretation and translation services provided in their office settings and/or related office visits and practitioner/provider services, except as otherwise provided by applicable law, rule or regulation. 63

Centennial Care Overview 64

Centennial Care Overview Centennial Care focuses on integrated care coordination that combines physical, behavioral and long-term care services. Providers of all types are encouraged to work together to ensure that patients and members receive the right amount of care, at the right time, in the right setting. 65

Centennial Care Covered Services At a glance Preventive services (e.g., immunizations, well-child checks, mammograms and pap tests) Laboratory tests Hospital care Urgent care and emergency care Prescription drugs Behavioral healthcare related services Long-term care services and support, which are called community benefit services Dental services Vision services Transportation services For a complete listing of all covered services, including Alternative Benefit Package (ABP) benefits, please refer to the Centennial Care Provider Manual. 66

Critical Incident Management & Reporting Behavioral Health & Personal Care Service Providers 67

Critical Incident Management & Reporting Behavioral Health & Personal Care Service Providers Who must report incidents? Behavioral health providers and agencies providing home & community-based services Personal care services (PCS) providers, self-directed benefit services and home health services How do I report incidents? Online: http://www.hsd.state.nm.us/pr oviders/critical-incidentreporting.aspx What qualifies as a critical incident? Abuse, neglect and/or exploitation Incidents that involve: Emergency services Death of a member Involvement of law enforcement Environmental hazards that compromise the health/safety of a member Any elopement or missing member Incidents must be reported within 24 hours of knowledge of the incident. 68

Care Coordination 69

What is Care Coordination? Assists with coordinating complex care needs Maximizes health and functionality for members with chronic conditions Facilitates appropriate and cost-effective care Available to all Centennial Care members Promotes integration among providers including but not limited to behavioral health and long-term care 70

Care Coordination Member Centric Model The Heart and Soul of Centennial Care 71

Members with Special Circumstances Centennial Care Members with special circumstances are those whom are under the care of: New Mexico s Children Youth and Families Department (CYFD) New Mexico Corrections Department (NMCD) Tribal Custody How we support these high-risk members: Behavioral health screening within 24 hours of referral Correctional facility-to-community transition planning 72

Presbyterian Quality Initiatives 73

Quality Commitment Ensuring members and patients receive the care and services they need. To Support the Practitioner/Patient Relationship To work with practitioner and provider partners to improve health To be transparent in the work we do To partner with the state Medicaid Program to support mutual success To meet or exceed current accreditation, regulatory and contractual requirements To openly communicate challenges and opportunities To celebrate successes 74

Collaborate with providers to improve health Priority Measures Breast cancer screening Colon cancer screening Diabetes care and control Antidepressant medication adherence Follow-up after hospitalization for mental illness Asthma controller medication management Osteoporosis (i.e., bone density) screening Pregnancy visits (prenatal and postpartum) 75

Provider Quality Incentive Program (PQIP) Goal is to improve the health of the population we serve. Provider groups Providers are given a gaps in care report and a quarterly goal for each measure. Provide bi-directional communications portal (mypres). Performance is evaluated via claims data and medical record documentation. 76

Vendor Partners TriCore Reference Laboratories Assured Imaging: Mobile Mammography and other screenings RAA: Mobile Mammography Vision Quest: eye screenings Eye Associates: eye care 77

Member Engagement to Improve Health Proactive telephone outreach Mailed materials, letters, text messages, Facebook, PHS.org/events emails, birthday cards and use of MyChart Coordination with community health workers and other community partners to reduce barriers to receiving services Leverage member touch points across the system Getting needed screenings / services Health coaching to improve diabetes self-management 78

Diabetes Health Coaching Reward Coaching provided by Presbyterian s Healthy Solutions Team Goal is to improve A1c levels and screening compliance Rewards for completing health coaching goals and recommended diabetes tests and results Includes educational materials and telephonic support Presbyterian Centennial Care members receive a $50 gift card for completing: Diabetes health coaching calls SMART goals to help lower and maintain A1c levels Hemoglobin A1c test Nephropathy screen Eye exam 79

Baby Benefits for Centennial Care Members Prenatal and Postpartum Care Members receive an incentive for completing both their first prenatal visit within the first 12 weeks of pregnancy and a postpartum visit within 21 to 56 days after delivery. www.phs.org/centennialcare Ongoing Prenatal Care Members receive their choice of a car seat, stroller or travel crib for completing a minimum of 10 of 14 recommended prenatal visits. 80

EPSDT Program Early and Periodic Screening Diagnostic Treatment Program The EPSDT Program is Medicaid s comprehensive preventive program for children under the age of 21. The program requires age-specific screenings, including lead testing, to determine physical and behavioral health needs and medically necessary services and immunizations. Presbyterian sends well-child visit reminder letters to parents of children enrolled in Centennial Care. Letters include ageappropriate screenings, vaccinations and other information. Information regarding the EPSDT Program can be found in the Centennial Care provider manual. 81

Medical Record Review What s new in 2017 82

Focused Review: Coordination between Medical & Behavioral Healthcare Behavioral Health medications commonly prescribed by PCPs Antidepressant Medication Management Diagnosis tool for major depression Assessment of substance abuse Current and past suicide/danger risk assessment Communications with behavioral health provider Follow-Up Care for Children Prescribed ADHD Medication Diagnosis tool for ADHD, such as Vanderbilt Assessment Tool Communications with behavioral health provider Along with routine recordkeeping expectations, include Advance Directives acknowledgment 83 83

Reminder Advanced Directives Minimum Medical Record Standards (Pages 6-22 of provider manual) 12. Durable Power of Attorney / Advance Directives In each adult patient s medical record, documentation must be present to indicate that the patient was offered information on durable power of attorney/advance directives. o The documentation should be signed and dated by the patient and the practitioner, and it must be maintained in the patient s medical record. o Information about advance directives is available on Presbyterian s website at https://www.phs.org/providers/resources /reference-guides/pages/medicalrecords.aspx. 84

Guidelines 85

Guidelines Clinical Practice Guidelines Guidelines for adult conditions Guidelines for pediatric and adolescent conditions Guidelines for behavioral health conditions Found at www.phs.org Preventive Health Guidelines One version for providers One version for members Both versions found at www.phs.org Specific recommendations by age group 86

More Information Marcia K. Hladilek, MPH Director, Performance Improvement PHP Quality Department mhladilek@phs.org Office: (505) 923-5727 Ryan Helton Program Manager, PQIP PHP Quality Department rhelton@phs.org Office: (505) 923-5255 87

Questions? 88

Behavioral Health Updates 89

Contact Information To contact a Behavioral Health provider specialist, please contact: 800-424-6035 or phpccbh@magellanhealth.com Name Title BH Assigned by County Direct Phone Email Address Amber Grewal Network Director 505-923-8838 AMGrewal@magellanhealth.com Amy Hallquist Area Contract Manager 505-923-6746 ahallquist@magellanhealth.com Adam Saxton Provider Relations Manager 505-923-6752 masaxton@magellanhealth.com Jessica Urioste Provider Relations Liaison Taos, Colfax, Union, Mora, Harding, San Miguel, Quay, Guadalupe, Curry, De Baca, Roosevelt, Lincoln, Chaves, Eddy, Lea, Grant, Luna 505-923-6753 jurioste@magellanhealth.com Specialty: School-Based Health Nicole Castillo Sr Provider Relations Liaison Bernalillo Organizations/Facilities, Groups 505-923-8838 ncastillo@magellanhealth.com Specialty: ABA Jessica Taylor Provider Relations Liaison San Juan, Rio Arriba, McKinley, Cibola, Catron, Socorro, Sierra, Otero, Hidalgo, Dona Ana, Luna 505-923-8943 jtaylor4@magellanhealth.com Specialty: FQHC Raymond M. Jones Provider Relations Liaison Bernalillo Individuals, Santa Fe, Torrence, Sandoval, Valencia, all out of state 505-923-6754 rmjones@magellanhealth.com Specialty: Magellan Provider Portal

Presbyterian & Presbyterian Behavioral Health The relationship between Presbyterian Health Plan and Magellan Healthcare is united and seamless. Magellan identifies itself as Presbyterian Behavioral Healthcare. All Electronic Funds Transfers (EFTs) and Electronic Remittance Advices (ERAs) are from Magellan Healthcare for all payments processed under behavioral health.

UPDATE: Roster Maintenance It is very important that providers maintain accurate roster for their practice or agency This information assists with monitoring access for our members. Provider counts are submitted to the state on a quarterly basis for Medicaid providers, which are based on the information reported. Inaccurate rosters will have an impact on claims processing. You may receive rejection or denials for roster provider not registered or non-participating provider if there is no record in our system.

UPDATE: Roster Maintenance To update your roster electronically: Sign in on Magellan provider website: www.magellanprovider.com Select Display / Edit Practice from menu Select the Roster Maintenance option to add or remove

Data Attestation on BH Provider Portal In order to be compliant with new CMS regulations regarding data accuracy, you will be asked to attest to specific data field every three months. Below is the message you will see:

Updating Demographic Information It is very important that behavioral health providers update their demographic information in the Presbyterian Behavioral Health database. Helps the plan demonstrate diversity to our members Assists in directing referrals appropriately Some of the items we encourage providers to update are: Language Ethnicity Specialties

Updating Demographic Information To update your Information: Sign in on Magellan provider website: www.magellanprovider.com Select Display/Edit Practice Information from menu. You can update: Mailing, service and financial address W9 Updates Referral supplement to help direct referrals: Language Ages seen Office hours Specialties Termination notice

Credentialing Presbyterian delegated the responsibility of credentialing behavioral health providers to Magellan Behavioral Health for all lines of business. Before Presbyterian can execute a new Behavioral Health Services Agreement, you must successfully complete the credentialing process. Please contact Magellan at 1-800-424-6035 to initiate a credentialing request or for questions about credentialing or recredentialing processes.

Claim Submission Please send paper claims to: Medicare/Commercial Presbyterian Health Plan P.O. Box 2216 Maryland Heights, MO 63043 Centennial Care Presbyterian Behavioral Health P.O. Box 25926 Albuquerque, NM 87125-5926 For Electronic Claims Submissions (ECT), please notify your clearinghouse to update the Payer ID for ECT submissions to add Magellan Payer ID 01260 (Magellan Payer ID for Change Healthcare institutional claims only 12x17)

EDI Resubmission of Claims Resubmitted claims can be sent electronically via an 837 file. There is a specific indicator for an adjusted claim (please consult Magellan s EDI companion guide or call the EDI hotline for assistance at 1-800-450-7281 ext. 75890). Professional Corrected Claims EDI 837P data should be sent in the 2300 Loop, segment CLM05 (with value of 7) along with an addition loop in the 2300 loop, segment REF*F8* with the original claim number for which the corrected claim is being submitted. Institutional Corrected Claims EDI 837I data should be sent in the 2300 Loop, segment CLM05 (with value of 7) along with an addition loop in the 2300 loop, segment REF*F8* with the original claim number for which the corrected claim is being submitted. Please note: If correcting the bill type on a claim, do not use 7 as the 3rd digit. Must send the REF^F8 as the original transaction number or claim number to prevent a denial for duplicate claim.

Presbyterian Physical & Behavioral Health Presbyterian Physical Health Payer ID: PREHP Processes all physical health claims (Centennial, Commercial, Medicare) with the physical health contract (executed by Presbyterian). Processes inpatient detox and all claims not billed with an F category DX. PHP system will look at TIN/NPI, then Taxonomy/Zip Code to determine processing. FQHC claims are processed when billed with rev code 0529, regardless of rendering provider/primary diagnosis. Presbyterian Behavioral Health Payer ID: 01260 Processes all behavioral health claims (Centennial, Commercial, Medicare) with the behavioral health contract (executed by Presbyterian). Processes UB 04 based on DX and/or rev code. Process CMS 1500 based on rendering provider type. FQHC claims are processed by Magellan when billed with rev code 0919, regardless of rendering provider/primary diagnosis.

Requesting Centennial Care Authorizations To request a behavioral health prior authorization, you must utilize the appropriate BH form To find the form go to www.phs.org For Providers tab Authorizations tab Submit by faxing requests to (505) 213-0169 or emailing form to NMCentennialCare@magellanhealth.com Authorizations cannot be seen on the Magellan provider portal

Requesting Commercial/Medicare Authorizations Providers must request prior authorizations telephonically by: Calling the Presbyterian Behavioral Health Utilization Management line at 1-800-424-4657 View prior authorizations on the Magellan provider portal Sign in on Magellan provider website; www.magellanprovider.com and select View Authorizations from menu This will show the provider information, codes, and dates of service that the authorization was completed under

Utilization Management Presbyterian s utilization management includes: List of services that will require prior authorization Higher levels of care and some community based services Will conform to parity requirements prior authorization for behavioral health services will not be more restrictive than a comparable physical health service Review of utilization trends of services not requiring authorization to identify outlier cases or providers and/or to re-evaluate need for prior authorization

Utilization Management Behavioral Health Critical Incident reports for members receiving Home and Community-Based Services (HCBS) are accepted through the HSD Critical Incident Reporting System for Centennial Care members who have any of the allowed categories of eligibility (COE). All other Behavioral Health critical incident reports for Centennial Care members (Non- HCBS), who do not have one of the allowed COE, must be faxed to Presbyterian Health Plan.

Presbyterian Behavioral Health Training In-depth training for our provider portal monthly on the first Friday of every month. (https://www.magellanprovider.com) New Provider Orientation training monthly Quarterly in-person Town Halls with our leadership team You may request 1:1 training on the Magellan provider portal with your provider liaison.

Questions? 106

Thank you! 107