Riverside Physician Network Utilization Management

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Riverside Physician Network Utilization Management"

Transcription

1 Subject: Program Riverside Physician Network Author: Candis Kliewer, RN Department: Product: Commercial, Senior Revised by: Linda McKevitt, RN Approved by: Effective Date January 1997 Revision Date 1/21/15 Pages 10 Date: 1/15/2014 PURPOSE AND SCOPE: The purpose of the Program is to ensure the delivery of medically necessary, optimally achievable, quality patient care through appropriate utilization of resources in a cost effective and timely manner to all members. To ensure this level is achieved and/or surpassed, programs are consistently and systematically monitored and evaluated. The evaluation process is fully documented and when opportunities for improvement are noted, recommendations are provided. The program description includes the scope of the program and the process and information sources used to make determinations of benefit coverage and medical appropriateness. This program will ensure that: A. Services will be provided by Riverside Physician Network contracted providers or health plan (e.g., hospital network) contracted providers unless authorized by the Committee or Medical Director. B. Hospital admissions and length of stay are authorized on the basis of medical appropriateness and appropriate place of care. C. Appropriate care is offered in a timely manner and is quality-oriented. D. Costs of services are monitored and evaluated. E. Riverside Physician Network will maintain compliance with the regulations set for the specific contracted member populations (e.g., Commercial, Medicare). F. Riverside Physician Network considers the needs of the individual such as: age, co-morbidities, complications, progress of treatment, psychosocial situation, and home environment when applying criteria. G. California licensed physicians, licensed nurses, and unlicensed staff carry out the responsibilities designated for their level of expertise. Qualified health professionals assess the clinical information, which is utilized in making utilization management decisions. Appropriately licensed health professionals supervise all review decisions. H. Providers are not restricted from advocating on behalf of the member, or advising a member regarding care. GOALS AND OBJECTIVES: A. To provide ongoing monitoring/evaluation activities which address and correct over/underutilization and inefficient coordination of medical resources. B. To maintain a systematic process for educating practitioners regarding utilization management issues. 1

2 C. To ensure that governmental and other regulatory agency guidelines, standards and criteria are adhered to when applicable. D. To ensure that services rendered are within the guidelines of and are authorized by the member s health plan benefits and delivered by contracted, credentialed providers/practitioners. E. To respond to member and provider/practitioner complaints/appeals after coordinating comprehensive and timely investigations associated with utilization issues. F. To perform peer review in conjunction with the Quality Management Program when it is necessary. G. To ensure that approved services are timely, medically necessary and consistent with the diagnosis and required level of care. H. To facilitate communication and develop positive relationships between members, practitioners, and health plans by providing education related to appropriate utilization. I. To ensure that members with complex health needs are identified for the Ambulatory and Special Needs Case Management Programs to facilitate their access to the most efficient resources for preventing hospitalizations through proactive planning and prevention, and providing a treatment continuum. J. To ensure the development and implementation of effective health education/promotion programs in order to reduce overall healthcare expenditures. Health education programs which are in compliance with all applicable regulations will be available to the members. Provider and member education will be offered, evaluated and improved on a continual basis. K. To implement procedures to prevent the re-occurrence of problematic utilization issues. L. Review criteria based on reasonable medical evidence will be used to make decisions pertaining to the utilization of services. Riverside Physician Network utilizes current (no more than two years old or most current editions published) standard criteria and informational resources to determine the appropriateness of healthcare services to be delivered (e.g., Apollo, Milliman Care Guidelines, Health Plan criteria, Medicare). Riverside Physician Network involves appropriate practitioners in the development and approval of the criteria. All services authorized by the (UM) Staff will be evaluated to determine medical appropriateness based upon approved standard criteria. The criteria are evaluated, updated (as appropriate) and approved on at least an annual basis by the Committee. The criteria are available upon request to all participating providers, members, and the public. This can be arranged through the Department by contacting the UM Supervisor at (951) (See UM P&P, UM Criteria Practitioners & Patients.) M. A designated senior physician has substantial involvement in the implementation of the UM Program. N. Riverside Physician Network considers the local delivery system when making UM decisions. Examples would be availability of Skilled Nursing Facilities (SNF s), home health and psychiatric services. 2

3 O. To evaluate and monitor healthcare services provided by Riverside Physician Network contracted/credentialed providers through tracking and trending data. P. data will be incorporated into the Credentials Department s process of re-credentialing providers. POLICY: Riverside Physician Network s Utilization Program will assure: A. A designated Behavioral Health Care Practitioner has substantial involvement in the implementation of the UM program which can include setting policy, reviewing cases, participating in the UM Committee, and development and adoption of Behavioral Health care standardizing criteria. The designated Behavioral Health Care Practitioner is a member of the UM Committee and participates in behavioral health care aspects of the program such as review of bed day and readmission rates. Behavioral Health referrals are processed according to the member s health plan benefits. B. Riverside Physician Network ensures a Utilization Review physician is available by telephone to discuss determinations based on medical appropriateness. C. A mechanism is present for checking the accuracy and consistency of application of the criteria by physicians and non-physicians. An evaluation of the utilization review decision-making process is conducted on at least an annual basis. D. Criteria used in the determination of medical appropriateness of services will be clearly documented. This information will be available, upon request, to participating providers. E. Documentation for case review and authorization/denial of services demonstrates efforts are made to obtain all necessary information, including pertinent clinical information. 1. Relevant clinical information is obtained when making a determination of coverage based on medical appropriateness and benefit coverage for inpatient and outpatient services. The treating physician is consulted as appropriate. 2. Information that is collected to support the UM decision-making is documented. This documentation shows that relevant clinical information is gathered consistently to support the UM decision-making process. 3. For Medicare Deeming, Riverside Physician Network will ensure it complies with national coverage decisions, general Medicare coverage guidelines and written coverage decisions of local Medicare contractors. 4. Patients legal representatives will be allowed to facilitate care or treatment decisions when they are unable to do so. F. Board certified physician consultants from appropriate specialty areas assist in making medical appropriate determinations. G. A licensed physician (Medical Director or physician designee) reviews all denials, which are based on medical appropriateness and procedures will be followed in accordance with the Denial Review policy. H. Determinations are made in a timely manner. The urgency of the situation always is considered to ensure that the request is processed appropriately and according to approved time frames. 1. Riverside Physician Network approved standards for timeliness of utilization management decision-making are implemented (see ICE and CMS timeliness standards in the Referral/Authorization Process policy and procedure). 2. Timeliness is monitored to ensure that the standards are met. 3

4 3. If the standards are not met, Riverside Physician Network will take action to improve performance. I. Member and Provider grievances will be forwarded to the health plan within 24 hours or the next business day of our receipt. Riverside Physician Network is not delegated to investigate grievances. Information and responses requested from the health plan regarding these grievances will be coordinated from the provider(s) and submitted back to the health plan in a timely manner. J. There are documented mechanisms to evaluate the effects of the UM program and process using member and provider satisfaction data, staff interviews and/or other appropriate methods. 1. Information is gathered at least every year from members and providers regarding their satisfaction with the UM process. 2. Identified sources of dissatisfaction are addressed. K. Utilization tracking and trending data will be submitted on a regular basis to the (UM) Committee. The data will be analyzed by the UM Committee to determine outcomes related to over utilization or under utilization of services. Opportunities for improvement will be identified and the Committee will decide which opportunities to pursue. The Committee will make recommendations for necessary intervention based on the findings. After intervention strategies have been implemented, re-evaluation will be done, and the results will be reviewed by the UM Committee. L. Quality-related issues will be referred to the Quality Management (QM) Committee. The UM and QM Committees will work together to resolve any cross-related issues or problems. M. The UM Program will include continuous quality improvement processes which will be coordinated with quality management activities as appropriate. The role of the UM Program in the Quality Management Program will be described. N. The Program will include the effective processing of prospective, concurrent, on-going ambulatory and retrospective review determinations by qualified medical professionals. The areas of review will include: Inpatient hospitalizations Outpatient surgeries Selected outpatient services Rehabilitative services Selected ancillary services Home healthcare services Selected pharmaceutical services Selected physician office services Out-of-network services O. Provider and member appeals will be handled efficiently according to medical group policy and procedure (which includes compliance with regulatory time frames). P. A viable case management program will exist which clinically and administratively identifies, coordinates, and evaluates the services delivered to those members which require close management of their care. Q. The Committee will meet on a regularly scheduled basis and not less than quarterly. R. The UM Committee will report to the Governing Body at least on a quarterly basis. 4

5 S. The approved annual Plan will be submitted to the contracted health plans. Other reports will be submitted to the health plans according to contractual agreements. T. Contracted health plan surveys which are conducted annually will involve the cooperation of the Riverside Physician Network staff. ORGANIZATIONAL STRUCTURE AND RESPONSIBILITIES OF OVERSIGHT COMMITTEE RESPONSIBILITIES/FUNCTIONS: The organizational chart accurately reflects the Staff and Committee reporting structures. Staff positions and Committee descriptions explain all associated responsibilities and duties. The staff ratios are equivalent to the organization s needs and are accommodated by the Program s budget. Reporting relationships are clearly defined. Performance objectives are included in the staff evaluations. Interdepartmental coordination of managed care utilization of services is clearly delineated in the description of each department. A. Board of Directors Responsibilities include the development and maintenance of the Utilization Management (UM) Program. The responsibility for creating and implementing the UM Program s infrastructure is delegated to the Utilization Management Committee. The Board of Directors oversees all Program activities, therefore, the UM Committee reports to the Board of Directors on at least a quarterly basis. Documented summaries of utilization statistics and focus study results are presented. The Board of Directors may delegate additional responsibilities to the Committee as necessary. B. President Responsibilities include overseeing the organization and management of the Program with a focus on the program s financial viability, the allocation of resources and staffing, and the interdepartmental effectiveness of the program. C. Medical Director The Medical Director has an unrestricted license to practice in the State of California with license verification accomplished at the time of renewal. Responsibilities include implementation of the Program. The Medical Director serves on the Committee and is responsible for performing or designating Chairmanship of the Committee. Also, he/she works with the Committee and health plans, when applicable, in determining the appropriate utilization of services. Performs and/or supervises daily utilization review activities. 5

6 Authorizes specific hospital, SNF, Home Health, Tertiary Referrals, as well as emergency service requests. Denies services requested if medical appropriateness requirements are not met. D. Director of Clinical Operations The Director of Clinical Operations is a RN/LVN with current licensure in the State of California. Responsibilities include the operational execution of the Program under the direction of the President and Medical Director. The Director of Clinical Operations is responsible for managing the UM Staff which may include the following positions: Supervisor Utilization Review Nurse Authorization Coordinators Inpatient Case Managers Inpatient Coordinators Ambulatory Nurse Case Manager Utilization Administrative Support E. Staff Supervisor: An RN/LVN with current licensure in the State of California. Responsible for direct supervision of the Authorization Coordinators. Assists in monitoring and execution of the UM Program and Workplan. Utilization Review Nurse: An RN /LVN with current licensure in the State of California. Responsibilities include overseeing the authorization process by processing precertification referral requests according to medical necessity guidelines and benefit coverage. Authorization Coordinators: Responsibilities include data entry of authorizations requested, verifying benefits/co-pay and obtaining additional medical information as requested by physician reviewers/nurses. In addition, they would complete the approved authorization process; notify the provider of the outcome and input automatic approval authorizations as designated by approved list. Inpatient Case Managers: An RN /LVN with current licensure in the State of California. Responsible for the identification, review and evaluation of all inpatient facility care. Conducts on site and/or telephonic review of all in-area and out-of-area members admitted to hospital, rehabilitation unit or Skilled Nursing facility within 24 hours of notification of the member s admission. Initial and directs discharge planning, focusing on potential transfers to appropriate alternative care settings. 6

7 Ambulatory Nurse Case Manager: An RN/LVN with current licensure in the State of California. Responsibilities include reviewing the clinical aspects of inpatient and outpatient care to ensure the most efficient utilization of resources allocated to health service functions. Specific criteria and standards must be met for all levels of care. The Case Manager utilizes clinical guidelines and team-based knowledge to address the needs of patients along the entire spectrum of care. They are integral to disease management and participate in the identification and follow-up of high-risk members. Inpatient Coordinators: Responsibilities include receiving information from outlying hospitals and data entering the information received. Developing logs to track and trend patients out-of-area. Reporting of information to the Hospitalist, Case Managers and health plans. Tracking and reconciling of bed days with Hospitalist and health plans from data submitted. Utilization Administrative Support: Responsibilities include direct report to the Medical Director. Duties include appropriate letters to providers, health plans and educational letters to members. This would also include administrative support with new policies, revisions, Committee minutes and Corrective Action Plans. F. Frequency and Schedule of Meetings The UM Committee meets at least quarterly and may meet monthly or more frequently if deemed necessary by the Chairperson, the Medical Director (if different), the President, or the Board of Directors. G. The Committee Processes and Activities 1. Responsibilities of the Committee and Subcommittees: The Utilization Management Committee will be established as a standing committee of Riverside Physician Network, which reports to the Board of Directors. The Chairperson of the UM Committee will be a physician and have current licensure by the State of California. The Chairperson will determine the beginning and end of meetings, will facilitate discussion, and ensure all policy and procedures are followed. 2. Responsibilities of the Medical Director: The Medical Director, Chairperson, or designee will review and sign the committee minutes and correspondence. The Medical Director will communicate as necessary appropriate issues to Committee members. The Medical Director will ensure that the Committee reports are forwarded to the Board of Directors, as required by the current policy and procedure. 3. Linkage with the following departments will occur: QM, Contracting, Provider Relations, Member Services, Claims, and IS as appropriate. 4. Term of Membership: The UM Committee members will serve one-year terms with the possibility of reappointment for two terms. 5. Committee Composition: Physician members of the UM Committee will be appointed by the Medical Director with approval of the Board of Directors. The UM Committee physician membership includes the Chairperson, Medical 7

8 Director and a panel of up to five physicians. This would include PCP s and Specialists. Specialists could consist of an Endocrinologist, OB-GYN, Urologist, Nephrologist and a Psychiatrist. Non-physician UM Committee members will be appointed by the Medical Director of Riverside Physician Network. These may include: the Director of Clinical Operations, the UM Supervisor, QM Nurse, Nurse Case Manager, Provider Relations Representative and UM Administrative Support. Representatives including the CEO, Claims, Operations and Contracts may be asked to attend as guests. 6. Physician consultants from appropriate specialty areas of medicine and surgery and/or additional specialty sources/organizations specified are available to review cases pertaining to their specialty. 7. During the period of time between UM Committee meetings, the Medical Director, or designee may function as an interim decision-maker to expedite the referral/authorization process. 8. Voting Rights: Only the physician members of the UM Committee have voting rights. 9. A quorum of 3 physicians must be present at each meeting. 10. Contracted Health Plans may send staff to attend meetings on a pre-approved basis. The health plan staff may attend the part of the meeting that covers members assigned to their health plan. The staff must sign a confidentiality statement prior to each meeting. 11. The Medical Director will manage urgent issues between meetings. In the case of disagreement between the referring physician and the Medical Director in the care of a patient, the case will be coordinated between the Chairperson of the UM Committee and/or QM Committee and the Medical Director. 12. Communications will be provided regarding any changes or new policies having direct impact on practitioners/providers. 13. Data collection will be used to monitor and evaluate care and service in relationship to specific aspects of each department as follows: Provider/Member satisfaction surveys Referral turn-around-time audit UM Reviewer Inter-rater Reliability Surveys 14. Clinical Data Collection: Analysis of inpatient and outpatient data for tracking, trending and education purposes. This will be obtained through Hospitalist data, Claims and UM Reports and will be presented to the UM Committee monthly. Examples: Bed Days/1000 ER Admits/1000 Adverse Outcome Utilization Patterns for over and under Utilization Referral Patterns Retro Authorizations Pharmacy Patterns High Risk/High Volume Procedures/Diagnoses 15. Reporting of activities to all appropriate staff in order to keep them informed of ongoing monitoring, evaluation activities related to 8

9 outcomes is done through weekly staff meetings and memos. 16. members will sign a confidentiality statement annually 17. Problem Resolution: Description of process for identifying, monitoring and evaluating clinical issues, utilizing performance goals. Reports from ancillary departments linked to and impacting the UM Department will be reviewed and monitored. Any UM problems identified by the QM Committee and referred will be addressed. Corrective action when indicated to include intervention, measurement of effectiveness and correction as applicable. Any actions or decisions will be documented in the UM Committee minutes. 18. The Program s plan, policies and procedures will be reviewed and approved, and if necessary, revised on at least an annual basis, 19. The Annual Summary and Evaluation Report of utilization activities will be annually submitted to the UM Committee and Governing Body and any requesting contracted health plan. Upon member/practitioner request, a description of the Quality Management Program and report of the progress made in meeting goals will be provided. 20. Semi-Annual Reports will be reviewed and approved on a semi-annual basis, submitted to the medical group s Governing Body, and any requesting contracted health plan. 21. A Work plan is developed utilizing the most current approved Industry Collaborated Effort (ICE) forms and implemented each year by the Committee. H. Committee Meeting Minutes Will: Be documented contemporaneously, dated, signed by the Committee Chairperson or Medical Director, will be current and available for contracted health plan review. Indicate attendees. De-identify members/practitioners/providers. Include attachments of applicable reviewed items. Be stored in a confidential area with authorized staff access only. Reflect the process Committee decisions, action plan implementation and evaluation/follow-up. Contain results/reports of clinical data/statistics and audits/studies/surveys. Document Inpatient and Outpatient review findings. Reflect review of practitioner UM statistics, Denials/Appeals. Provide evidence feedback to, ongoing education of and communication with practitioners and/or members by Committee. Contain information relevant to any Quality Management issue identified with reports to the Quality Management Committee and any applicable subcommittee(s). Provide review of subcommittee reports (as applicable). 9

10 Minutes will reflect continuity of issues from meeting to meeting, problem identification, action plan, follow-up and re-evaluation. I. Policies and Procedures The systematic process for conducting activities will be referenced in separate policies and procedures which will be revised as needed, and reviewed annually by the Utilization Review Committee. The Utilization Management department will disclose upon request (will be mailed) the utilization management policies, procedures, and criteria used to authorize, modify, or deny healthcare services to the public. [CA Health & Safety Code (b)(5)] J. Studies/Surveys/Audits All Committee (UMC) audit/study/survey results (as well as audits from ancillary departments impacting UMC goals) will be presented to the UMC for analysis, determination of performance goals, thresholds, and applicable corrective action plan implementation made available upon request to the contracted health plan. 10

Functions: The UM Program consists of the following components:

Functions: The UM Program consists of the following components: 1.0 Introduction Alameda County Behavioral Health Care Services (ACBHCS) includes a Utilization Management (UM) Program and Behavioral Health Managed Care Plan (MCP). They are dedicated to delivering cost

More information

A. IEHP Quality Management Program Description

A. IEHP Quality Management Program Description A. IEHP Quality Management Program Description A. Purpose: The purpose of the QM Program is to provide operational direction necessary to monitor and evaluate the quality and appropriateness of care, identify

More information

Utilization Management Program. [January 2016-January 2017]

Utilization Management Program. [January 2016-January 2017] Utilization Management Program [January 2016-January 2017] Table of Contents Program Overview... 5 Program Goals... 6 Scope... 6 UM Committee Structure [UM1A:1 & 3; UM2A:4-5; UM1B; UM1C; UM1D]... 7 Use

More information

CHAPTER 59A-23 WORKERS COMPENSATION MANAGED CARE ARRANGEMENTS 59A-23.001 Scope. 59A-23.002 Definitions. 59A-23.003 Authorization Procedures.

CHAPTER 59A-23 WORKERS COMPENSATION MANAGED CARE ARRANGEMENTS 59A-23.001 Scope. 59A-23.002 Definitions. 59A-23.003 Authorization Procedures. CHAPTER 59A-23 WORKERS COMPENSATION MANAGED CARE ARRANGEMENTS 59A-23.001 Scope. 59A-23.002 Definitions. 59A-23.003 Authorization Procedures. 59A-23.004 Quality Assurance. 59A-23.005 Medical Records and

More information

Exhibit 2.9 Utilization Management Program

Exhibit 2.9 Utilization Management Program Exhibit 2.9 Utilization Management Program Access HealthSource, Inc. Utilization Management Company is licensed as a Utilization Review Agent with the Texas Department of Insurance. The Access HealthSource,

More information

Population Health Management

Population Health Management Population Health Management 1 Population Health Management At a Glance The MedStar Medical Management Department is responsible for managing health care resources for MedStar Select Health Plan. Our goal

More information

Regulatory Compliance Policy No. COMP-RCC 4.52 Title:

Regulatory Compliance Policy No. COMP-RCC 4.52 Title: I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.52 Page: 1 of 19 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2)

More information

AGENCY FOR HEALTH CARE ADMINISTRATION HEALTH QUALITY ASSURANCE BUREAU OF MANAGED HEALTH CARE 2727 Mahan Drive Tallahassee Florida 32308

AGENCY FOR HEALTH CARE ADMINISTRATION HEALTH QUALITY ASSURANCE BUREAU OF MANAGED HEALTH CARE 2727 Mahan Drive Tallahassee Florida 32308 AGENCY FOR HEALTH CARE ADMINISTRATION HEALTH QUALITY ASSURANCE BUREAU OF MANAGED HEALTH CARE 2727 Mahan Drive Tallahassee Florida 32308 WORKERS COMPENSATION MANAGED CARE ARRANGEMENT SURVEY REPORT NAME

More information

Quality Improvement Program Description

Quality Improvement Program Description 2015 Quality Improvement Program Description Approved by the Board of Directors: March 19, 2002; April 22, 2003; April 20, 2004; April 26, 2005, April 25, 2006, February 27, 2007, March 25, 2008, March

More information

Population Health Management

Population Health Management Population Health Management 1 Population Health Management Table of Contents At a Glance..page 2 Procedures Requiring Prior Authorization..page 3 How to Contact or Notify Medical Management..page 4 Utilization

More information

CHAPTER 7: UTILIZATION MANAGEMENT

CHAPTER 7: UTILIZATION MANAGEMENT OVERVIEW The Plan s Utilization Management (UM) program is collaboration with providers to promote and document the appropriate use of health care resources. The program reflects the most current utilization

More information

INTRODUCTION. QM Program Reporting Structure and Accountability

INTRODUCTION. QM Program Reporting Structure and Accountability QUALITY MANAGEMENT PROGRAM INTRODUCTION To assure services are appropriately monitored and continuously improved, ValueOptions has developed and implemented a comprehensive (QMP). The QMP includes strategies

More information

Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Summit Health Plan of Florida

Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Summit Health Plan of Florida Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Summit Health Plan of Florida Medicare Quality Management Program Overview Quality Improvement (QI) Overview At Coventry, we

More information

EQR PROTOCOL 1 ASSESSING MCO COMPLIANCE WITH MEDICAID AND CHIP MANAGED CARE REGULATIONS

EQR PROTOCOL 1 ASSESSING MCO COMPLIANCE WITH MEDICAID AND CHIP MANAGED CARE REGULATIONS EQR PROTOCOL 1 ASSESSING MCO COMPLIANCE WITH MEDICAID AND CHIP MANAGED CARE REGULATIONS Attachment D: The purpose of this Attachment to Protocol 1 is to provide the reviewer(s) with sample review questions

More information

Medical Management. Table of Contents: Procedures Requiring Prior Authorization. How to Contact or Notify Medical Management

Medical Management. Table of Contents: Procedures Requiring Prior Authorization. How to Contact or Notify Medical Management Medical Management Table of Contents: Page 2 Page 2 Page 2 Page 2 Page 3 Page 7 Page 11 Page 11 Page 12 Page 12 At a Glance Procedures Requiring Prior Authorization How to Contact or Notify Medical Management

More information

Provider Manual. Utilization Management

Provider Manual. Utilization Management Provider Manual Utilization Management Utilization Management This section of the Manual was created to help guide you and your staff in working with Kaiser Permanente s Utilization Management (UM) policies

More information

Certain exceptions apply to Hospital Inpatient Confinement for childbirth as described below.

Certain exceptions apply to Hospital Inpatient Confinement for childbirth as described below. Tennessee Applicable Policies PRECERTIFICATION Benefits payable for Hospital Inpatient Confinement Charges and confinement charges for services provided in an inpatient confinement facility will be reduced

More information

Quality and Performance Improvement Program Description 2016

Quality and Performance Improvement Program Description 2016 Quality and Performance Improvement Program Description 2016 Introduction and Purpose Contra Costa Health Plan (CCHP) is a federally qualified, state licensed, county sponsored Health Maintenance Organization

More information

Case Management and Care Coordination:

Case Management and Care Coordination: HEALTH MANAGEMENT CUP recognizes the importance of promoting effective health management and preventive care for conditions that are relevant to our populations, thereby improving health care outcomes.

More information

UTILIZATION MANGEMENT

UTILIZATION MANGEMENT UTILIZATION MANGEMENT The Anthem Health Care Management Division has a singular dynamic focus - to continually improve the system of health care delivery that influences utilization and cost of services

More information

UTILIZATION MANAGEMENT PROGRAM DESCRIPTION MEDICAL ASSOCIATES HEALTH PLANS 2015

UTILIZATION MANAGEMENT PROGRAM DESCRIPTION MEDICAL ASSOCIATES HEALTH PLANS 2015 UTILIZATION MANAGEMENT PROGRAM DESCRIPTION MEDICAL ASSOCIATES HEALTH PLANS 2015 AUTHORITY Medical Associates Health Plan, Inc. and Medical Associates Clinic Health Plan of Wisconsin (collectively doing

More information

211 CMR: DIVISION OF INSURANCE 211 CMR 52.00: MANAGED CARE CONSUMER PROTECTIONS AND ACCREDITATION OF CARRIERS

211 CMR: DIVISION OF INSURANCE 211 CMR 52.00: MANAGED CARE CONSUMER PROTECTIONS AND ACCREDITATION OF CARRIERS 211 CMR: DIVISION OF INSURANCE 211 CMR 52.00: MANAGED CARE CONSUMER PROTECTIONS AND ACCREDITATION OF CARRIERS Section 52.01: Authority 52.02: Applicability 52.03: Definitions 52.04: Accreditation of Carriers

More information

2014 Behavioral Health. Utilization Management. Program Description

2014 Behavioral Health. Utilization Management. Program Description APS Healthcare 2014 Behavioral Health Utilization Management Program Description 2014 APS BH UM Program Description APS Healthcare 2014 Behavioral Health Utilization Management Program Description I. PURPOSE

More information

Section 6. Medical Management Program

Section 6. Medical Management Program Section 6. Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs.

More information

Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Coventry Health and Life Insurance Company Commercial Lines of Business

Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Coventry Health and Life Insurance Company Commercial Lines of Business Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Coventry Health and Life Insurance Company Commercial Lines of Business Quality Management Program 2012 Overview Quality Improvement

More information

Center for Medicaid and State Operations/Survey and Certification Group

Center for Medicaid and State Operations/Survey and Certification Group DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-12-25 Baltimore, Maryland 21244-1850 Center for Medicaid and State Operations/Survey

More information

MEDICAL MANAGEMENT OVERVIEW MEDICAL NECESSITY CRITERIA RESPONSIBILITY FOR UTILIZATION REVIEWS MEDICAL DIRECTOR AVAILABILITY

MEDICAL MANAGEMENT OVERVIEW MEDICAL NECESSITY CRITERIA RESPONSIBILITY FOR UTILIZATION REVIEWS MEDICAL DIRECTOR AVAILABILITY 4 MEDICAL MANAGEMENT OVERVIEW Our medical management philosophy and approach focus on providing both high quality and cost-effective healthcare services to our members. Our Medical Management Department

More information

McLaren Greater Lansing Rules of the Department of Emergency Medicine ARTICLE I. PURPOSE AND ORGANIZATION

McLaren Greater Lansing Rules of the Department of Emergency Medicine ARTICLE I. PURPOSE AND ORGANIZATION McLaren Greater Lansing Rules of the Department of Emergency Medicine ARTICLE I. PURPOSE AND ORGANIZATION 1.1 PURPOSE 1.1.1 The purpose of the Department of Emergency Medicine shall be to perform the organizational

More information

Quality Improvement Program Description

Quality Improvement Program Description ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 1 Appendix A Quality Improvement Program Description ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation

More information

2014 Quality Improvement and Utilization Management Evaluation Summary

2014 Quality Improvement and Utilization Management Evaluation Summary 2014 Quality Improvement and Utilization Management Evaluation Summary INTRODUCTION The Quality Improvement (QI) and Utilization Management (UM) Program Evaluation summarizes the completed and ongoing

More information

VOLUME 4: MEDICAL SERVICES

VOLUME 4: MEDICAL SERVICES VOLUME 4: MEDICAL SERVICES Effective Date: 12/2003 CHAPTER 34 Revision Date: 05/2015 4.34.2 UTILIZATION MANAGEMENT MEDICAL SERVICES REVIEW PROCEDURE Attachments: Yes No I. PROCEDURE OVERVIEW The purpose

More information

HealthCare Partners of Nevada. Heart Failure

HealthCare Partners of Nevada. Heart Failure HealthCare Partners of Nevada Heart Failure Disease Management Program 2010 HF DISEASE MANAGEMENT PROGRAM The HealthCare Partners of Nevada (HCPNV) offers a Disease Management program for members with

More information

Quality Improvement Program

Quality Improvement Program Introduction Molina Healthcare of Michigan serves Michigan members in counties throughout the state since 2000. For all plan members, Molina Healthcare emphasizes personalized care that places the physician

More information

Unit 1 Core Care Management Activities

Unit 1 Core Care Management Activities Unit 1 Core Care Management Activities Healthcare Management Services Healthcare Management Services (HMS) is responsible for all the medical management services provided to Highmark Blue Shield members,

More information

A. Utilization Management Delegation and Monitoring

A. Utilization Management Delegation and Monitoring 14. UTILIZATION MANAGEMENT A. Utilization Management Delegation and Monitoring APPLIES TO: A. This policy applies to all IEHP Medi-Cal Members. POLICY: A. ICD-9 code is required for online submission prior

More information

Departmental Policy. Nurse Credentialing and the Nurse Credentialing Committee

Departmental Policy. Nurse Credentialing and the Nurse Credentialing Committee Page 1 of 6 Nurse Credentialing and the POLICY STATEMENT To describe the procedure for credentialing and privileging of Advanced Practice Nurses (APRNs), nurses in expanded roles, and non-hospital employed

More information

Section Eleven. Referrals and Pre-Authorization REFERRAL PROCESS

Section Eleven. Referrals and Pre-Authorization REFERRAL PROCESS REFERRAL PROCESS Physician Referrals within Plan Network Physicians may refer members to any Specialty Care Physician (Specialist) or ancillary provider within the Fidelis Care network. Except as noted

More information

2014 Quality Improvement Program Description

2014 Quality Improvement Program Description 2014 Quality Improvement Program Description Table of Contents BACKGROUND AND HISTORY 2 MISSION STATEMENT 3 AUTHORITY 3 SCOPE 3 QI ACTIVITES TO FULFILL THE SCOPE 4 PURPOSE 6 GOALS 7 OBJECTIVES 7 DELEGATION

More information

Ryan White Part A. Quality Management

Ryan White Part A. Quality Management Quality Management Case Management (Non-Medical) Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA) The creation of this public document is fully funded by a federal Ryan White CARE Act Part

More information

Regal Medical Group & QUALITY IMPROVEMENT (QI) PROGRAM 2015

Regal Medical Group & QUALITY IMPROVEMENT (QI) PROGRAM 2015 Regal Medical Group & QUALITY IMPROVEMENT (QI) PROGRAM 2015 Approval Signatures: Kenneth Epstein, MD, Committee Chair 1/23/2015 Date: QUALITY IMPROVEMENT (QI) PROGRAM Contents REGAL MEDICAL GROUP & LAKESIDE

More information

Title: FPPE - Peer Review. Section: Administration Number: 104 Pages: 1 of 8. Approval CMO

Title: FPPE - Peer Review. Section: Administration Number: 104 Pages: 1 of 8. Approval CMO Title: FPPE - Peer Review Approval CMO Section: Administration Number: 104 Pages: 1 of 8 Date of Origin: 02/09 Reviewed/Revised Date: 03/12 Next Review Date: 03/14 Purpose: To ensure that the hospital,

More information

The members of the LGB shall act locally for the CDC GB. The decisions of the LGB are subject to review and approval by the CDC GB or its designee.

The members of the LGB shall act locally for the CDC GB. The decisions of the LGB are subject to review and approval by the CDC GB or its designee. 8BCHAPTER 4 6BLocal Governing Body 9BI. LOCAL GOVERNING BODY Where mandated by Title 22 of the California Code of Regulations (CCR), institutions that have a licensed health facility (i.e., General Acute

More information

Utilization Management

Utilization Management Utilization Management Utilization Management (UM) is an organization-wide, interdisciplinary approach to balancing quality, risk, and cost concerns in the provision of patient care. It is the process

More information

BlueAdvantage SM Health Management

BlueAdvantage SM Health Management BlueAdvantage SM Health Management BlueAdvantage member benefits include access to a comprehensive health management program designed to encompass total health needs and promote access to individualized,

More information

POLICY No. 20-049. Prepared by: Judith Kell Effective: December 20, 2002 Compliance Review Supervisor Revised: January 23, 2009

POLICY No. 20-049. Prepared by: Judith Kell Effective: December 20, 2002 Compliance Review Supervisor Revised: January 23, 2009 LAKESHORE BEHAVIORAL HEALTH ALLIANCE Community Mental Health Services of Muskegon County Community Mental Health of Ottawa County Lakeshore Coordinating Council for Substance Abuse Services POLICY Prepared

More information

DOCUMENT TITLE: Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy Outlined in Policy Information Notice 2001-16

DOCUMENT TITLE: Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy Outlined in Policy Information Notice 2001-16 2002-22 DATE: July 10, 2002 DOCUMENT TITLE: Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy Outlined in Policy Information Notice 2001-16 Revision (October 30, 2014):

More information

SECTION 5 1 REFERRAL AND AUTHORIZATION PROCESS

SECTION 5 1 REFERRAL AND AUTHORIZATION PROCESS SECTION 5 1 REFERRAL AND AUTHORIZATION PROCESS Primary Care Physician Referral Process 1 Referral from PCP to Participating Specialists 1 Referral from Participating Specialist to Participating Specialists

More information

Louisiana CMC MAGELLAN HEALTH SERVICES MAGELLAN HEALTH UTILIZATION MANAGEMENT PROGRAM DESCRIPTION FOR MEDICAID MANAGED CARE

Louisiana CMC MAGELLAN HEALTH SERVICES MAGELLAN HEALTH UTILIZATION MANAGEMENT PROGRAM DESCRIPTION FOR MEDICAID MANAGED CARE Louisiana CMC MAGELLAN HEALTH SERVICES MAGELLAN HEALTH UTILIZATION MANAGEMENT PROGRAM DESCRIPTION FOR MEDICAID MANAGED CARE MARCH 1, 2014 FEBRUARY 28, 2015 Table of Contents Section I: Overview of Program

More information

Magellan Healthcare, Inc. Provider Handbook Supplement for US Family Health Plan

Magellan Healthcare, Inc. Provider Handbook Supplement for US Family Health Plan Magellan Healthcare, Inc. Provider Handbook Supplement for US Family Health Plan 2015 Magellan Health, Inc. Table of Contents SECTION 1: INTRODUCTION... 3 Welcome... 3 US Family Health Plan... 3 Covered

More information

Frequently Asked Questions (FAQs) from December 2013 Behavioral Health Utilization Management Webinars

Frequently Asked Questions (FAQs) from December 2013 Behavioral Health Utilization Management Webinars Frequently Asked Questions (FAQs) from December 2013 Behavioral Health Utilization Management Webinars 1. In the past we did precertifications for Residential Treatment Centers (RTC). Will this change

More information

PENINSULA REGIONAL SUPPORT NETWORK Utilization Management Plan FY 2015-2016

PENINSULA REGIONAL SUPPORT NETWORK Utilization Management Plan FY 2015-2016 PENINSULA REGIONAL SUPPORT NETWORK Utilization Management Plan FY 2015-2016 Peninsula RSN Policies and Procedures The Peninsula Regional Support Network (PRSN) Utilization Management (UM) Plan summarizes

More information

FLORIDA HEALTH CARE PLAN S QUALITY PROGRAM 1340 Ridgewood Ave., Holly Hill, FL 32117

FLORIDA HEALTH CARE PLAN S QUALITY PROGRAM 1340 Ridgewood Ave., Holly Hill, FL 32117 FLORIDA HEALTH CARE PLAN S QUALITY PROGRAM 1340 Ridgewood Ave., Holly Hill, FL 32117 POLICY/PURPOSE Florida Health Care Plan, Inc. (FHCP) has been providing health care benefits since 1974 in Volusia and

More information

RULES AND REGULATIONS FOR UTILIZATION REVIEW IN ARKANSAS ARKANSAS DEPARTMENT OF HEALTH

RULES AND REGULATIONS FOR UTILIZATION REVIEW IN ARKANSAS ARKANSAS DEPARTMENT OF HEALTH RULES AND REGULATIONS FOR UTILIZATION REVIEW IN ARKANSAS 2003 ARKANSAS DEPARTMENT OF HEALTH TABLE OF CONTENTS SECTION 1 Authority and Purpose.. 1 SECTION 2 Definitions...2 SECTION 3 Private Review Agents

More information

Medical and Rx Claims Procedures

Medical and Rx Claims Procedures This section of the Stryker Benefits Summary describes the procedures for filing a claim for medical and prescription drug benefits and how to appeal denied claims. Medical and Rx Benefits In-Network Providers

More information

What Happens When Your Health Insurance Carrier Says NO

What Happens When Your Health Insurance Carrier Says NO * What Happens When Your Health Insurance Carrier Says NO Most health carriers today carefully evaluate requests to see a specialist or have certain medical procedures performed. A medical professional

More information

Final. National Health Care Billing Audit Guidelines. as amended by. The American Association of Medical Audit Specialists (AAMAS)

Final. National Health Care Billing Audit Guidelines. as amended by. The American Association of Medical Audit Specialists (AAMAS) Final National Health Care Billing Audit Guidelines as amended by The American Association of Medical Audit Specialists (AAMAS) May 1, 2009 Preface Billing audits serve as a check and balance to help ensure

More information

Utilization Review Annual Summary. Utilization review annual summary for 2014.

Utilization Review Annual Summary. Utilization review annual summary for 2014. Department of Consumer and Business Services Insurance Division 2 P.O. Box 14480 Salem, Oregon 97309-0405 Phone: 503-947-7268 Fax: 503-378-4351 350 Winter St. NE, Salem, Oregon www.insurance.oregon.gov

More information

Making the Grade! A Closer Look at Health Plan Performance

Making the Grade! A Closer Look at Health Plan Performance Primary Care Update August 2011 Making the Grade! A Closer Look at Health Plan Performance HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized measures designed to track

More information

ACCESSIBILITY OF SERVICES

ACCESSIBILITY OF SERVICES ACCESSIBILITY OF SERVICES ACCESSIBILITY TO CARE STANDARDS Molina Healthcare is committed to timely access to care for all members. The Access to Care Standards below are to be observed by all Providers/Practitioners.

More information

POLICY AND PROCEDURE RELATING TO HEALTH UTILIZATION MANAGEMENT STANDARDS

POLICY AND PROCEDURE RELATING TO HEALTH UTILIZATION MANAGEMENT STANDARDS POLICY AND PROCEDURE RELATING TO HEALTH UTILIZATION MANAGEMENT STANDARDS Prepared by The Kansas Insurance Department August 23, 2007 POLICY AND PROCEDURE RELATING TO HEALTH UTILIZATION MANAGEMENT STANDARDS

More information

Standards of Practice & Scope of Services. for Health Care Delivery System Case Management and Transitions of Care (TOC) Professionals

Standards of Practice & Scope of Services. for Health Care Delivery System Case Management and Transitions of Care (TOC) Professionals A M E R I C A N C A S E M A N A G E M E N T A S S O C I A T I O N Standards of Practice & Scope of Services for Health Care Delivery System Case Management and Transitions of Care (TOC) Professionals O

More information

UTILIZATION MANAGEMENT PROGRAM Introduction Health Care Services

UTILIZATION MANAGEMENT PROGRAM Introduction Health Care Services UTILIZATION MANAGEMENT PROGRAM Introduction Health Care Services Call us: 1-888-898-7969, Option 1, then Option 4 Fax us: 1-800-594-7404 Business hours: Monday Friday (excluding holidays), 8:30 a.m. to

More information

MEDICAL STAFF BYLAWS OF PIEDMONT MOUNTAINSIDE HOSPITAL

MEDICAL STAFF BYLAWS OF PIEDMONT MOUNTAINSIDE HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS OF PIEDMONT HEALTHCARE MEDICAL STAFF BYLAWS OF PIEDMONT MOUNTAINSIDE HOSPITAL Adopted by the Medical Staff: April 17, 2013 Approved by the Board:

More information

Exhibit 4. Provider Network

Exhibit 4. Provider Network Exhibit 4 Provider Network Provider Contract Requirements ICS must develop, implement, and maintain a comprehensive provider network that assures access to primary and specialty health related care that

More information

VI. Appeals, Complaints & Grievances

VI. Appeals, Complaints & Grievances A. Definition of Terms In compliance with State requirements, ValueOptions defines the following terms related to Enrollee or Provider concerns with the NorthSTAR program: Administrative Denial: A denial

More information

AMERICAN MEDICAL DIRECTORS ASSOCIATION WHITE PAPER RESOLUTION A-11

AMERICAN MEDICAL DIRECTORS ASSOCIATION WHITE PAPER RESOLUTION A-11 AMERICAN MEDICAL DIRECTORS ASSOCIATION WHITE PAPER RESOLUTION A-11 1 SUBJECT: WHITE PAPER ON THE NURSING HOME MEDICAL DIRECTOR: LEADER AND MANAGER UPDATES RESOLUTION A06 INTRODUCED BY: ROLE OF MEDICAL

More information

NORTH COUNTRY COMMUNITY MENTAL HEALTH NORTHERN AFFILIATION UTILIZATION MANAGEMENT PLAN November 1, 2001. Revised January 2013

NORTH COUNTRY COMMUNITY MENTAL HEALTH NORTHERN AFFILIATION UTILIZATION MANAGEMENT PLAN November 1, 2001. Revised January 2013 NORTH COUNTRY COMMUNITY MENTAL HEALTH NORTHERN AFFILIATION UTILIZATION MANAGEMENT PLAN November 1, 2001 Revised January 2013 I. Mission II. III. IV. Scope Philosophy Authority V. Utilization Management

More information

TIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS

TIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS ADMINISTRATIVE POLICY TIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS Policy Number: ADMINISTRATIVE 088.15 T0 Effective Date: November 1, 2015 Table of Contents APPLICABLE LINES OF

More information

V. Utilization Management (UM) Program

V. Utilization Management (UM) Program V. Utilization Management (UM) Program Overview Better Health Network s Utilization Management (UM) Program is designed to provide quality, cost-effective and medically necessary services while meeting

More information

OUTLINE OF MEDICARE SUPPLEMENT COVERAGE BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD FOR EFFECTIVE DATES ON OR AFTER JUNE 1, 2010

OUTLINE OF MEDICARE SUPPLEMENT COVERAGE BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD FOR EFFECTIVE DATES ON OR AFTER JUNE 1, 2010 A Medicare Supplement Program An independent licensee of the Blue Cross and Blue Shield Association. This chart shows the benefits included in each of the standard Medicare supplement plans. Every company

More information

Harbor s Payment to Providers Policy and Procedures is available on the Harbor website and will be updated annually or as changes are necessary.

Harbor s Payment to Providers Policy and Procedures is available on the Harbor website and will be updated annually or as changes are necessary. Original Approval Date: 01/31/2006 Page 1 of 10 I. SCOPE The scope of this policy involves all Harbor Health Plan, Inc. (Harbor) contracted and non-contracted Practitioners/Providers; Harbor s Contract

More information

PEDIATRIC SURGERY SERVICE RULES AND REGULATIONS

PEDIATRIC SURGERY SERVICE RULES AND REGULATIONS LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL PEDIATRIC SURGERY SERVICE GENERAL PEDIATRIC SURGERY, PEDIATRIC SURGICAL SUBSPECIALITIES; CARDIOVASCULAR/THORACIC SURGERY, ORAL MAXILLOFACIAL SURGERY, HEAD & NECK

More information

OROVILLE HOSPITAL JOB DESCRIPTION. Department: Dept.#: Last Updated:

OROVILLE HOSPITAL JOB DESCRIPTION. Department: Dept.#: Last Updated: OROVILLE HOSPITAL JOB DESCRIPTION Job Description for VICE PRESIDENT OF NURSING Department: Dept.#: Last Updated: Nursing Administration 8720 TITLE: REPORTS TO: VICE PRESIDENT OF NURSING CHIEF EXECUTIVE

More information

HEALTH ALLIANCE MEDICAL PLANS 2015 QUALITY and MEDICAL MANAGEMENT PROGRAM STRUCTURE

HEALTH ALLIANCE MEDICAL PLANS 2015 QUALITY and MEDICAL MANAGEMENT PROGRAM STRUCTURE HEALTH ALLIANCE MEDICAL PLANS 2015 QUALITY and MEDICAL MANAGEMENT PROGRAM STRUCTURE The Quality and Medical Management (QMM) Program integrates the primary functions of Quality, Medical Management and

More information

Behavioral Health (MAPSI) Utilization Management Program Components

Behavioral Health (MAPSI) Utilization Management Program Components Behavioral Health (MAPSI) Utilization Management Program Components Payer Name: Printed Name of Payer Representative: Phone: Is this document applicable to all groups? Yes No If no, please indicate specific

More information

Section 9: Medical Management and Quality Improvement and Accreditation

Section 9: Medical Management and Quality Improvement and Accreditation Section 9: Medical Management and Quality Improvement and Accreditation MEDICAL MANAGEMENT PLAN...171 Philosophy... 171 Mission... 171 Goals... 171 Authority... 172 Structure... 172 Scope... 178 QUALITY

More information

A BILL FOR AN ACT ENTITLED: "AN ACT ADOPTING AND REVISING PROCESSES THAT PROVIDE FOR

A BILL FOR AN ACT ENTITLED: AN ACT ADOPTING AND REVISING PROCESSES THAT PROVIDE FOR HOUSE BILL NO. INTRODUCED BY G. MACLAREN BY REQUEST OF THE STATE AUDITOR 0 A BILL FOR AN ACT ENTITLED: "AN ACT ADOPTING AND REVISING PROCESSES THAT PROVIDE FOR UTILIZATION REVIEW, GRIEVANCE, AND EXTERNAL

More information

URAC Issue Brief: Best Practices in Network Management

URAC Issue Brief: Best Practices in Network Management 1220 L Street, NW, Suite 400 Washington, DC 20005 202.216.9010 Best Practices in Network Management Introduction As consumers enroll in health plans through newly formed Health Insurance Marketplaces,

More information

2015 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc.

2015 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc. 2015 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc. Welcome from Kaiser Permanente It is our pleasure to welcome you as a contracted provider (Provider) participating under

More information

Pages: 9 Date: 03/13/2012 Subject: Credentialing and Recredentialing. Prepared By: MVBCN Clinical Director

Pages: 9 Date: 03/13/2012 Subject: Credentialing and Recredentialing. Prepared By: MVBCN Clinical Director Governing Body: Mid-Valley Behavioral Care Network (MVBCN) Pages: 9 Date: 03/13/2012 Subject: Credentialing and Recredentialing Prepared By: MVBCN Clinical Director Approved By: Oregon Health Authority

More information

UM 5: Timeliness of UM Decisions

UM 5: Timeliness of UM Decisions UM 5: Timeliness of UM Decisions Element E: Timeliness of Pharmacy UM Decision Making Refer to Appendix 1 for points The organization adheres to the following time frames when making pharmacy UM decisions:

More information

MEDICAL STAFF BYLAWS

MEDICAL STAFF BYLAWS MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS OF EMORY JOHNS CREEK HOSPITAL MEDICAL STAFF BYLAWS Revisions Adopted by the Medical Staff: September 2, 2014 Approved by the Board: September 16,

More information

Regulatory Compliance Policy No. COMP-RCC 4.03 Title:

Regulatory Compliance Policy No. COMP-RCC 4.03 Title: I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.03 Page: 1 of 10 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2)

More information

Health Insurance SMART NC

Health Insurance SMART NC Health Insurance SMART NC ANNUAL REPORT ON EXTERNAL REVIEW ACTIVITY 202 North Carolina Department of Insurance Wayne Goodwin, Commissioner A REPORT ON EXTERNAL REVIEW REQUESTS IN NORTH CAROLINA Health

More information

REIMBURSEMENT CODING SERIES

REIMBURSEMENT CODING SERIES REIMBURSEMENT CODING SERIES Occ. Work Prob. Effective Last Code No. Class Title Area Area Period Date Action 4839 Reimbursement Coder 02 445 6 mo. 00/00/00 Rev. 4840 Reimbursement Coding Specialist 02

More information

SNP Model of Care Provider Training

SNP Model of Care Provider Training SNP Model of Care Provider Training The Centers for Medicare and Medicaid Services (CMS) requires all Medicare Advantage Special Needs Plans (SNPs) to have a Model of Care (MOC) All information about the

More information

MAGELLAN HEALTH SERVICES ORGANIZATION SITE - SITE REVIEW PACKET 2011. Behavioral Health Intervention Services (BHIS) ONLY

MAGELLAN HEALTH SERVICES ORGANIZATION SITE - SITE REVIEW PACKET 2011. Behavioral Health Intervention Services (BHIS) ONLY MAGELLAN HEALTH SERVICES ORGANIZATION SITE - SITE REVIEW PACKET 2011 Behavioral Health Intervention Services (BHIS) ONLY Proprietary: Magellan Health Services policies apply to all subsidiaries,including

More information

AMERICAN BURN ASSOCIATION BURN CENTER VERIFICATION REVIEW PROGRAM Verificatoin Criterea EFFECTIVE JANUARY 1, 2015. Criterion. Level (1 or 2) Number

AMERICAN BURN ASSOCIATION BURN CENTER VERIFICATION REVIEW PROGRAM Verificatoin Criterea EFFECTIVE JANUARY 1, 2015. Criterion. Level (1 or 2) Number Criterion AMERICAN BURN ASSOCIATION BURN CENTER VERIFICATION REVIEW PROGRAM Criterion Level (1 or 2) Number Criterion BURN CENTER ADMINISTRATION 1. The burn center hospital is currently accredited by The

More information

POLICY ON RESIDENT SUPERVISION General Psychiatry Residency Program DEPARTMENT OF PSYCHIATRY August 2010

POLICY ON RESIDENT SUPERVISION General Psychiatry Residency Program DEPARTMENT OF PSYCHIATRY August 2010 Department of Psychiatry www.uthscsa.edu/psychiatry POLICY ON RESIDENT SUPERVISION General Psychiatry Residency Program DEPARTMENT OF PSYCHIATRY August 2010 Section I. Introduction Careful supervision

More information

Ratified: June 6, 2013 PROFESSIONAL STAFF BY-LAW

Ratified: June 6, 2013 PROFESSIONAL STAFF BY-LAW Ratified: June 6, 2013 PROFESSIONAL STAFF BY-LAW ARTICLE 1 DEFINITIONS AND INTERPRETATION...4 Section 1.1 Definitions...4 Section 1.2 Interpretation...6 Section 1.3 Delegation of Duties...6 Section 1.4

More information

PENNSYLVANIA DEPARTMENT OF HEALTH BUREAU OF MANAGED CARE Interim APPLICATION FOR CERTIFICATION AS A UTILIZATION REVIEW ENTITY

PENNSYLVANIA DEPARTMENT OF HEALTH BUREAU OF MANAGED CARE Interim APPLICATION FOR CERTIFICATION AS A UTILIZATION REVIEW ENTITY ...in pursuit of good health PENNSYLVANIA DEPARTMENT OF HEALTH BUREAU OF MANAGED CARE Interim APPLICATION FOR CERTIFICATION AS A UTILIZATION REVIEW ENTITY NOTE: Act 68 gives utilization review (UR) entities,

More information

The Collaborative Models of Mental Health Care for Older Iowans. Model Administration. Collaborative Models of Mental Health Care for Older Iowans 97

The Collaborative Models of Mental Health Care for Older Iowans. Model Administration. Collaborative Models of Mental Health Care for Older Iowans 97 6 The Collaborative Models of Mental Health Care for Older Iowans Model Administration Collaborative Models of Mental Health Care for Older Iowans 97 Collaborative Models of Mental Health Care for Older

More information

Below are listed the most significant collaborative activities at the operational, system, training and oversight level.

Below are listed the most significant collaborative activities at the operational, system, training and oversight level. 5(d) Increase collaboration between outpatient and inpatient mental health providers (e.g. create system to give immediate notification to outpatient providers when their clients are hospitalized; The

More information

Quality Management Plan 1

Quality Management Plan 1 BIGHORN VALLEY HEALTH CENTER PRINCIPLES OF PRACTICE Category: Quality Title: C3 Quality Management Plan Quality Management Plan 1 I. STRUCTURE OF THE QUALITY MANAGEMENT PROGRAM A. Definition of Quality

More information

MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORKS HOSPITAL INPATIENT PSYCHIATRIC CARE APPLICATION FOR BCBSM PARTICIPATION GENERAL INFORMATION

MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORKS HOSPITAL INPATIENT PSYCHIATRIC CARE APPLICATION FOR BCBSM PARTICIPATION GENERAL INFORMATION MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORKS HOSPITAL INPATIENT PSYCHIATRIC CARE APPLICATION FOR BCBSM PARTICIPATION GENERAL INFORMATION NOTE: DO NOT USE THIS APPLICATION FOR OWNERSHIP CHANGES.

More information

TORRANCE MEMORIAL MEDICAL CENTER. Vice President

TORRANCE MEMORIAL MEDICAL CENTER. Vice President JOB DESCRIPTION TORRANCE MEMORIAL MEDICAL CENTER Department: Job Title: Approvals: NURSE I Director Vice President POSITION PURPOSE: Under supportive supervision, the level 1 RN Case Manager position is

More information

CHAPTER 535 HEALTH HOMES. Background... 2. Policy... 2. 535.1 Member Eligibility and Enrollment... 2. 535.2 Health Home Required Functions...

CHAPTER 535 HEALTH HOMES. Background... 2. Policy... 2. 535.1 Member Eligibility and Enrollment... 2. 535.2 Health Home Required Functions... TABLE OF CONTENTS SECTION PAGE NUMBER Background... 2 Policy... 2 535.1 Member Eligibility and Enrollment... 2 535.2 Health Home Required Functions... 3 535.3 Health Home Coordination Role... 4 535.4 Health

More information

Magellan Behavioral Care of Iowa, Inc. Provider Handbook Supplement for Iowa Autism Support Program (ASP)

Magellan Behavioral Care of Iowa, Inc. Provider Handbook Supplement for Iowa Autism Support Program (ASP) Magellan Behavioral Care of Iowa, Inc. Provider Handbook Supplement for Iowa Autism Support Program (ASP) 2014 Magellan Health Services Table of Contents SECTION 1: INTRODUCTION... 3 Welcome... 3 Covered

More information

Medical Management Program

Medical Management Program Section 7. Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs.

More information

CARE MANAGEMENT SERIES Part 6 Developing a Staffing Model That Works

CARE MANAGEMENT SERIES Part 6 Developing a Staffing Model That Works CARE MANAGEMENT SERIES Part 6 Developing a Staffing Model That Works We will get to staffing but let s start by reviewing core functions. Care Management As we have discussed previously, Care Management

More information