Bravo Marine Heating System BH -0133 사용자 설명서
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PRIOR AUTHORIZATION .............................................................................................................................................................35
General Rules .........................................................................................................................................................................35
Authorization Rules by Place of Service ................................................................................................................................36
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
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
Healthcare Effectiveness Data and Information Set ...............................................................................................................47
ON-SITE ASSESSMENTS ................................................................................................................................................................48
Office Standards .....................................................................................................................................................................48
Medical Record Review .........................................................................................................................................................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
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
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
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
Prior Authorization .................................................................................................................................................................66
ALTERNATIVE DISPUTE RESOLUTION ...................................................................................................................................67
ADULT PREVENTION AND SCREENING GUIDELINES.........................................................................................................71