Manuels d'utilisation pour Bravo Marine Heating System BH -0133

Table des matières

• QUICK REFERENCE GUIDE

  4
• MEMBER INFORMATION

  6
• Member Eligibility

  6
• Eligibility Verification

  6
• Member Hold Harmless

  8
• Member Confidentiality

  8
• Member Rights and Responsibilities

  9
• Advance Medical Directives

  13
• Benefits and Services

  13
• PROVIDER INFORMATION

  13
• Role of the Primary Care Physician (PCP)

  13
• Role of the Specialist Physician

  14
• Communication between Providers

  14
• Provider Marketing Guidelines

  14
• PROVIDER CREDENTIALING AND PARTICIPATION

  15
• PROVIDER & ALLIED HEALTH PRACTITIONERS CREDENTIALING CRITERIA

  15
• Required Information

  15
• Credentials Criteria

  16
• Additional Requirements

  19
• Initial Credentialing Office Site Reviews

  19
• Provider Re-Credentialing

  20
• Practitioner’s Rights

  20
• PROVIDERS DESIGNATED AS PRIMARY CARE PHYSICIANS

  21
• CHANGES IN ADMINISTRATIVE, MEDICAL AND/OR REIMBURSEMENT POLICIES

  21
• NOTIFICATION REQUIREMENTS FOR PROVIDERS

  21
• CLOSING PATIENT PANELS

  22
• PROVIDER ACCESS AND AVAILABILITY STANDARDS

  22
• CLAIMS SUBMISSION

  23
• Professional Claims

  23
• Institutional Claims

  24
• Participating Provider Claim Reconsideration Process

  25
• Claim Adjustment Reason Codes

  26
• NATIONAL PROVIDER IDENTIFIER (NPI)

  31
• HIERARCHICAL CONDITION CATEGORIES (HCC)

  33
• SAMPLE EXPLANATION OF BENEFITS (EOB) STATEMENT AND PAYMENT CHECK

  34
• PRIOR AUTHORIZATION

  35
• General Rules

  35
• Authorization Rules by Place of Service

  36
• In Office

  36
• Inpatient

  37
• Outpatient

  38
• Ambulatory Surgery Center

  40
• Home Health Services

  40
• Preventive Care

  41
• Health and Wellness

  42
• Medicines and Injectibles

  43
• Prior Authorization Request Form

  45
• QUALITY IMPROVEMENT

  46
• Quality Improvement Program

  46
• Healthcare Effectiveness Data and Information Set

  47
• ON-SITE ASSESSMENTS

  48
• Office Standards

  48
• Medical Record Review

  48
• HEALTH SERVICES

  50
• Goals

  50
• Clinical Review Guidelines

  50
• Prospective Review Process

  51
• Decision Time Frames

  51
• Concurrent Review

  53
• Retrospective Review

  53
• Referrals to Non- Contracted Providers

  53
• Ambulatory Services

  53
• Discharge Planning

  54
• Case Management

  55
• Skilled Nursing Care

  55
• Emergency Services

  55
• Decision Time Frames

  56
• DENIALS

  56
• Rendering Denials

  56
• Notification of Denials

  56
• CONTINUITY OF CARE

  57
• CLINICAL PRACTICE GUIDELINES

  58
• Congestive Heart Failure

  58
• CHF Pharmacological Treatment Options

  59
• Heart Failure Disease Classification

  60
• Diabetes

  61
• Coronary and Other Vascular Disease

  62
• COPD

  64
• PHARMACEUTICAL MANAGEMENT

  65
• Step Therapy

  65
• Prior Authorization

  66
• ALTERNATIVE DISPUTE RESOLUTION

  67
• ADULT PREVENTION AND SCREENING GUIDELINES

  71