Provider & Practitioner Manual

For your review, our Provider & Practitioner Manual effective June 20, 2009.

• View the Summary of Changes
• Provider & Practitioner Manual: Download the entire manual
• Updated March 15, 2010: Updated Requirements and Resources for Structured Screening for Developmental Delays and Autism Spectrum Disorder for Medical Assistance Recipients

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	Table of Contents
	Introduction:	About AmeriHealth Mercy, NPI Number, Telephone Numbers, and Definitions
	Section I:	Covered Benefits
	Section II:	Referral & Authorization Requirements
	Section III:	Member Eligiblilty
	Section IV:	Provider Services
	Section V:	Primary Care Provider (PCP) & Specialist Office Standards & Requirements
	Section VI:	Claims & Claims Disputes
	Section VII:	Practitioner/Provider Dispute/Appeal Procedures, Member Complaints, Grievances & Fair Hearings
	Section VIII:	Quality Management, Credentialing, & Utilization Management
	Section IX:	Special Needs & Case Management
	Section X:	Member Rights & Responsiblities
	Section XI:	Regulatory Provisions
	Section XII:	Medical Assistance Manual & MA Regulations - Chapter 1101
	Appendix:
	Supply Request Fax Form Hospital Notification of Emergency Admission Form Obstetrical Needs Assessment EPSDT Physician's Desk Guide PA EPSDT Periodicity Schedule and Coding Matrix 2009 Immunization Table 0 - 6 years 2009 Immunization Table 7 - 18 years 2009 Immunization Catch-Up Schedule Pharmacy Forms Observation Billing Guidelines Provider Reference Guide Provider Change Form Procedures reimbursed above Capitation Enrollee Consent Form for Physicians Filing a Grievance in behalf of a Member Domestic Violence - Resources for Patients