Business Continuity Plan

Transcription

1 SECTION 21

2 Business Continuity Plan The Health Plan has created a Business Continuity Plan, policy number AD 216 (located in the back of this section) in order to maintain the viability and integrity of the Health Plan should there be a disaster. This policy will be followed to manage any situation that significantly disrupts critical, important, or marginal business functions that have been defined as a disaster. Critical: Health Plan functions are identified as communication with health plan staff, health plan members, contracted providers and. Ensuring members continue to receive immediate medically necessary services through contracted providers, Prior Authorizations, and concurrent review. Ensuring providers have minimal to no disruption of services. Important: Health Plan functions are identified as telephone systems, voice mail, computers and software, safety and security and finance operations. Marginal: Health Plan functions are identified as grievance/appeals, plan changes, network development and claims processing. Command Centers are established under the direction of the Health Plan CEO in response to any disruption in critical, important or marginal functions that have been defined as a disaster. Currently, the Health Plan servers are backed up daily. Each morning the previous nights back up tapes are taken to a secured off sight storage facility. In the event of disaster, the following alternatives will be initiated: Key personnel will perform functions at alternate locations In the event of systems failure, as soon as work can resume, each department will utilize the manual backup system to ensure workflow continues with minimal interruption If required, telephone calls will be re-routed to pre-designated areas If voice mail is not functional, messages will be taken and callers will be provided with alternate numbers (i.e.; cellular or pager numbers) to reach their parties Network Development staff will communicate information and any special arrangements necessary to conduct business with the Provider Network BUSINESS CONTINUITY PLAN 21.0

3 All medically necessary services will be covered without prior authorization until normal business operations are recovered Healthcare Facility Closure/Loss of Provider In the event of an unexpected change that will result in a healthcare facility closure or loss of a major network provider with less than 30 days of notification of the change to UFC, MHP, UCA, MCA, or KidsCare, the health plan will call an urgent meeting of the Contract Status Committee the same day as the notification. A major provider is defined as one of the following: PCP and OB Provider Specialist, Ancillary Provider or Vendor Inpatient Facility The Contract Status Committee will assess the situation, make recommendations and implement interventions to ensure members receive uninterrupted care. Loss of PCP or OB If through facility closure or any other circumstance a provider leaves the network with less than 30-day notice to the Health Plan, The Contract Strategy Committee will have an urgent meeting to assess the impact on member care and the network, communication within the Plan, and short and long term interventions for ensuring continuity of member care and the adequacy of the network. Network Development Department (ND) 1. The provider office will be contacted by the health plan to determine the extent of the loss, providers ability to render care and any plan the provider has for continuation of care with another provider. We will continue to communicate with the office to inform them of the plan to transition members to another provider. Communication with the office will occur in whatever way the office is able to communicate, i.e. phone, fax, site visit, etc. 2. ND will assess the loss. If a provider is leaving a group but is going to remain in the community, we will attempt to obtain contract with him/her at his/her new location. Members would be given the option of retaining the PCP or OB at his/her new location, or choosing another PCP or OB. BUSINESS CONTINUITY PLAN 21.1

4 3. If the provider is not going to continue to see members in the network or it is a loss of an entire group, ND will assess the network in the given area of town. ND will present the Contract Status Committee short and long term recommendations for the network. Recommendations will include member reassignment, possible short-term solutions for member care and long-term solutions for member care and adequacy of the network. 4. If necessary, ND will contact other contracted and non-contracted providers in the service area to discuss reassignment of members to their practice. In the case of non- contracted providers, ND will negotiate either a Letter of Agreement or Contract with the provider. ND will also assist in temporary credentialing of the providers. 5. ND will communicate the loss and interventions with other network providers as necessary. Communication may include but is not limited to bulletins, newsletters, site visits and phone calls. 6. With the assistance of Customer Care Center, ND will ensure that member records are transferred to the new provider. Customer Care Center (CC) 1. CC will be responsible for identification of members assigned to the PCP. 2. CC will notify members of the change. Members will be notified directly via personal letter. 3. CC will assist members in the selection of a new PCP or OB if necessary. 4. CC will assess any special cultural needs of the affected members and ensure the member continues to receive culturally appropriate services. Medical Management (MM), including Maternal Child Health, Behavioral Health, Case Management and Prior Authorization (PA) 1. MM will be responsible for identifying members with open referral to an OB provider. 2. MM will identify any members with special health care needs. MM will ensure that members with special health care needs receive uninterrupted care during the transition period. BUSINESS CONTINUITY PLAN 21.2

5 3. In the case of an OB provider termination, the Maternal Child Health department will ensure, with assistance from CC, that current OB patients are transitioned to another OB provider. Quality Management (QM) QM will be responsible for ensuring that the interventions developed do not interfere with quality of member care or Performance Standards. Loss of Specialist, Ancillary Provider or Vendor If through facility closure or other means a specialist, ancillary provider or vendor leaves the network with less than 30-day notice to the Health Plan, The Contract Strategy Committee will have an urgent meeting to assess the impact on member care and the network, and short and long term interventions for ensuring continuity of member care and an adequate network. Network Development Department (ND) 1. The Health Plan will call an urgent meeting of the ND and Strategy Team upon notification of the loss. 2. The ND and Strategy Team will create the overall plan and strategy for the loss. 3. The office will be contacted by the Health Plan to determine the loss, the providers ability to render care and any plan the provider may have for continuation of care with another provider or vendor. We will continue to communicate with the office to inform them of the plan to transition members to another provider. Communication with the office will occur in whatever way the office is able to communicate, i.e. phone, fax, site visit, etc. 4. ND will assess the loss. If a provider is leaving a group but is going to remain in practice in the community, we will attempt to obtain a contract with the provider. 5. At the new location. The new provider information would be in the provider listings for the member. 6. If the provider is not going to continue to see members in the network or it is a loss of an entire group, ND will assess the network in the given area of town. ND will present the ND and Strategy Team and identify short and long term recommendations for the network. Recommendations will include possible shortterm solutions for member care and long-term solutions for member care and adequacy of the network. BUSINESS CONTINUITY PLAN 21.3

6 7. If necessary, ND will contact other contracted and non-contracted providers in the service area to discuss possible rendering of care to members due to the loss. If it is a single source provider and there are no providers in the community who provide the service, ND will identify other means for member care, i.e. sending a patient to another city for care if the care does not exist in that city. In the case of noncontracted providers, ND will negotiate either a Letter of Agreement or Contract with the provider. ND will also assist in the temporary credentialing of the providers. 8. ND will communicate the loss and interventions with other network providers as necessary. Communication may include but is not limited to bulletins, newsletters, site visits, phone calls, etc. Customer Care Center (CC) 1. CC will identify potential members affected by the change by running claims data for the provider indicating members who have seen the specialist in the past six (6) months. This will only occur if the contracted facility will not be able to continue to care for the members. 2. CC will notify members of the change. Notification will occur as either a general letter to the members or through the Member Newsletter depending on the situation and recommendation of the Network Development and Strategy Team. 3. CC will assist members in obtaining services with another provider if necessary. 4. CC will assess any special cultural needs and ensure members continue to receive culturally appropriate services. Medical Management (MM), including Maternal Child Health, Behavioral Health, Case Management and Prior Authorization (PA) 1. MM will be responsible for identifying members with open referrals to the specialist, ancillary provider or vendor, when a referral is required. 2. MM will also review the member list obtained through claims data to identify members with special health care needs. MM will ensure that known members with special health care needs receive uninterrupted care during the transition period. BUSINESS CONTINUITY PLAN 21.4

7 3. If a member is identified as being in case management, the case manager will ensure, with assistance from MS, that the member is transitioned to another Specialty Care Provider. Quality Management (QM) QM will be responsible for ensuring that the interventions developed do not interfere with quality of member care or Performance Standards. Loss of an Inpatient Facility If through facility closure or other means an inpatient facility leaves the network with less than 30-day notice to the Plan, the Contract Strategy Committee will have an urgent meeting to assess the short and long term interventions for ensuring continuity of member care and an adequate network. Network Development Department (ND) 1. The Health Plan will contact the facility to determine the loss, the providers ability to render care and any plan the provider may have for continuation of care with another provider or vendor, i.e. patient care diversion plans for hospitals. We will continue to communicate with the office to inform them of the plan to transition members to another provider. Communication with the office will occur in whatever way the office is able to communicate, i.e. phone, fax, site visit, etc. 2. ND will assess the loss. ND will determine if it is a short term, long term or complete closure or loss of the facility. 3. If it is a short-term loss, ND, with the assistance of the facility will estimate the length of time the facility will be closed. Short-term interventions will be created to supplement the network until the facility can again render care. Short-term interventions may include diversion of members to another network facility, another facility out of the service area or contracting with other facilities in the services area. ND will consider using Letters of Agreement until a contract can be negotiated with another facility. 4. If it is a long-term loss, ND will first identify the short-term interventions listed above and implement these interventions. Once the short-term interventions are implemented, ND will identify long-term interventions. ND will assess the impact of the facility loss to the network. If the loss is determined to hinder the ability of the Plan to render services to the member, ND will identify facilities that can render the same or similar services. ND will contact these facilities and begin contract negotiations. BUSINESS CONTINUITY PLAN 21.5

8 5. A complete loss or closure will be handled in the same manner as a long-term loss. 6. ND will communicate the loss and interventions with other network providers as necessary. Communication may include but is not limited to bulletins, newsletters, site visits, phone calls, etc. Customer Care Center (CC) 1. CC will notify members of the change. Notification will occur as either a general letter to the members or through the Member Newsletter depending on the situation and recommendation of the Network Development and Strategy Team. 2. CC will assist members in obtaining services with another provider if necessary. 3. CC will assess any special cultural needs and ensure members continue to receive culturally appropriate services. Medical Management (MM), including Maternal Child Health, Behavioral Health, Case Management, Utilization Review (UR) and Prior Authorization (PA) 1. MM will be responsible for identifying inpatient members at the facility through utilization review records and inpatient notifications. 2. The UR nurse will work closely with The Contract Strategy Committee to ensure the members are transferred to another facility and they continue to receive appropriate care. UR nurses will report back to the Team on the status of members and transition of care. Quality Management (QM) QM will be responsible for ensuring that the interventions developed do not interfere with quality of member care or Performance Standards. BUSINESS CONTINUITY PLAN 21.6