Policy No.: PS015_08. Title: Provider Administrative Dispute Resolution (non medical, non claims) PS Policy Review Frequency: Annual

Transcription

1 Title: Provider Administrative Dispute Resolution (non medical, non claims) Previous Title (if applicable): Department Applicability: Provider Services, Credentialing and Grievance Departments Lines of Business: Medi-Cal, Healthy Families, Healthy Kids, Healthy Workers Originating Dept.: Provider Services Originating Dept. Approval: Dept. Approval: CMO/Medical Director: Approval: Policy No.: PS015_08 Supersedes Previous Policy No. (if applicable): PS Policy Review Frequency: Annual Date Originated: February 2001 Date Approved by P&P Committee: Dept. Approval: Revision Date(s): 09/2003, 12/2003, 12/ 2005, 12/2007, 12/ 2008, 12/2009, 12/ 2010, 12/2011, 07/2012, 02/2013 CEO Approval: 1. Policy Statement Santa Clara Family Health Plan (SCFHP) provides a timely, fair and accessible administrative dispute resolution mechanism under which contracted providers may submit administrative disputes. Claims Disputes and Medical Disputes are addressed in separate policies. 2. Purpose The purpose of this policy is to establish guidelines for administrative provider dispute resolution including procedures to verify that providers are informed of the process, to assure timely review and resolution of administrative disputes, initiated by contracted providers, and to comply with federal and state law. 3. Definitions A. Administrative Dispute means disagreements, demands or disputes related to SCFHP application or interpretation of the provisions of the Provider Service Agreement; or policies and procedures that do not involve claims or medical issues. Authority: Social Security Act, 1851; 42 CFR (a)(4) and (f)(3); 28 CCR et seq. Page 1 of 8

2 B. Arbitration means the hearing and determination of a dispute between SCFHP and a provider resolved by a third party. C. Contracted Provider means a provider participating with SCFHP. D. SCFHP means Santa Clara Family Health Plan E. CEO means Chief Executive Officer F. COO means Chief Operating Officer 4. Procedures A. All contracted providers receive training regarding SCFHP s dispute resolution process during the new provider orientation, which is completed within ten (10) days of the provider s effective date. (refer to policy PS025 New Provider Orientation) Training includes: a. Description of the procedures for submitting, processing and resolving disputes. b. Address for submission of disputes. c. Telephone number for obtaining information about the dispute processes or to inquire about a specific dispute 2. A description of the Provider Dispute Process is included in the Provider contract, in the Provider Manual distributed to all contracted providers, and is available on the SCFHP website. B. Contracted Providers may initiate an Administrative Dispute related to the terms and provisions of the Provider contract. C. Providers must initiate an Administrative Dispute in writing by either: 1. Submitting a letter to the Provider Services Department specifying the nature of the administrative dispute and the requested resolution within 365 days after the action or in the case of inaction. The letter must include the following minimum information: a. Provider s Name, Address and Telephone Number b. Member s Name and ID#, if applicable c. Narrative description of the problem with supporting documentation. d. Desired resolution or 2. Providers may complete an on-line form that includes the same information listed above, by using the provider dispute notification Page 2 of 8

3 form available on SCFHP s website. All on-line administrative provider dispute notifications go directly to the Senior Director of Network Management. D. The Provider Services Department sends to the provider a written acknowledgement, within two (2) working days of receipt in the case of an electronically submitted provider dispute or fifteen (15) working days of receipt in the case of a hand delivered or mailed provider dispute. E. The Grievance Review Committee reviews, investigates and formulates a resolution of all administrative provider disputes. The COO must approve the final proposed resolution. F. The Provider Services Department issues written notice of a proposed resolution, via certified mail, within forty-five (45) working days of receipt of a dispute in compliance with state and federal law. G. A reply from the provider indicating acceptance or rejection of the proposed resolution is required within fifteen (15) working days of receipt of the written notice of a proposed resolution. When the provider accepts the proposed resolution, the Provider Services Department immediately implements all final resolution actions. 1. The Administrative Dispute Process is closed: a. Upon receipt of the provider s acceptance, or b. After three (3) attempts by SCFHP via certified mail to contact the provider, if SCFHP does not receive a response. 2. In the event the provider does not accept the proposed resolution and all efforts of the Administrative Dispute Process have been exhausted without establishing a mutually agreeable resolution, then the provider or SCFHP may request that the dispute be submitted to the arbitration process. Such requests will proceed in accordance with SCFHP Initiated Arbitration policy. (refer to Provider Request for Arbitration policy). H. The provider dispute resolution mechanism is deigned to be fair, fast and effective. I. The provider is not required to have legal representation present or handle the provider dispute on behalf of the contracted provider J. If a contracted provider wishes to be represented by legal counsel in the provider dispute, the costs associated with such representation will be the sole responsibility of the provider. Page 3 of 8

4 K. SCFHP may also decide to be represented by legal counsel to protect its interests in any provider dispute. L. SCFHP designates the Senior Director of Network Management as a plan employee who will be responsible for: 1. Reviewing the provider administrative dispute resolution process. 2. Noting any emerging patterns to be able to improve administrative capacity or plan-provider relations. 3. Preparing reports and disclosures as specified by state and federal law. 4. Reporting to the CEO and COO on administrative provider dispute issues, resolutions and emerging patterns. M. The provider is not required to or allowed to waive any rights conferred upon them by law N. In the event of an administrative provider dispute, the following reports are generated by Senior Director of Network Management and are reviewed by the COO: 1. Provider Dispute Log- A report detailing the number, type and categories of disputes received, resolved and outstanding. 2. Unresolved Disputes-Indicating the number of current unresolved disputes. O. The Provider Services Department submits a report to the QI Department and Compliance Department within sixty (60) days of the close of the calendar quarter if a corrective action plan related to a provider administrative dispute has been undertaken over the preceding two quarters 5. Confidentiality of Information In accordance with SCFHP s Confidentiality Policy, and all applicable state and federal laws, any and all information that is required to be kept confidential, shall be kept confidential. 6. Recordkeeping Each department is responsible for retaining and maintaining documents/records/paperwork for a minimum of ten (10) years for their own department (refer to policy LC Record Retention).. Page 4 of 8

5 Provider Administrative Dispute Acknowledgement Letter (Date) Provider Name & Title Provider Address Re: Provider Administrative Dispute-(Date of dispute) Member s Name and ID #, if applicable Dear: (Full name of provider) On (date of dispute) Santa Clara Family Health Plan (SCFHP) received a (telephone call, letter, , visit) from you regarding the following provider administrative dispute: (Give a clear and concise description of the dispute and state provider s desired resolution) SCFHP will investigate your dispute and issue a written notice of the Health Plan s proposed resolution via certified mail within 45 working days from the date of dispute receipt. If you accept the proposed resolution, SCFHP will immediately implement all final resolution actions. In the event you do not accept the proposed resolution and all efforts have been exhausted without establishing a mutually agreeable resolution, you may send a written notification to SCFHP to submit the dispute to arbitration. If you have additional questions or concerns, please contact me at (408) Sincerely, Peggy Periandri Senior Director Network Management cc: Chief Operations Officer Other directors as applicable (identify) Page 5 of 8

6 Provider Administrative Dispute Acknowledgement Letter with Request For Additional Information (Date) Provider Name & Title Provider Address Re: Provider Administrative Dispute-(Date of dispute) Member s Name and ID #, if applicable Tracking Number: (Assigned by Provider Services) Dear: (Full name of provider) Santa Clara Family Health Plan (SCFHP) received the following administrative dispute on (date): (Give a clear and concise description of the dispute) Additional information is required in order that we many review and give a resolution of the dispute. Please provide me with the information indicated below within 30 working days: (List specific item(s) of information needed for dispute) Upon receipt of all information necessary to determine the outcome of the dispute, SCFHP has 45 working days to review and resolve the dispute. Please submit the above requested information and a copy of this letter to the following address: Santa Clara Family Health Plan 210 E Hacienda Avenue Campbell, CA Attention: Peggy Periandri If you require additional information, please contact me at (408) Please use the tracking number to reference the dispute. Sincerely, Peggy Periandri Senior Director Network Management cc: Chief Operations Officer Other directors as applicable (identify) Page 6 of 8

7 Provider Administrative Dispute Closure Letter for Non Receipt of Additional Information (Date) Provider Name & Title Provider Address Re: Provider Administrative Dispute-(Date of dispute) Member s Name and ID #, if applicable Tracking Number: (Assigned by Provider Services) Dear: (Full name of provider) Santa Clara Family Health Plan (SCFHP) received the following administrative dispute on (date): (Give a clear and concise description of the dispute) The additional information indicated below was requested in order to resolve and make a determination on your administrative dispute: (List specific item(s) of information needed for dispute) Please be advised that SCFHP did not receive the additional information within 30 working days. Therefore your dispute is closed. If you require additional information regarding this dispute, please contact me at (408) Please use the tracking number to reference this dispute. Sincerely, Peggy Periandri Senior Director Network Management cc: Chief Operations Officer Other directors as applicable (identify) Page 7 of 8

8 Provider Administrative Dispute Resolution Letter Certified Mail (Date) Provider Name & Title Provider Address Re: Provider Administrative Dispute-(Date of dispute) Member s Name and ID #, if applicable Dear: (Full name of provider) On (date of dispute) Santa Clara Family Health Plan (SCFHP) received a (telephone call, letter, , visit) from you regarding the following provider administrative dispute: (Give a clear and concise description of the dispute and state provider s desired resolution) SCFHP investigated your dispute and learned the following: (Give a clear and concise description of all facts associated with dispute) Based on these findings, SCFHP s proposed resolution is as follows: (Give a clear and concise description of the resolution including dates) Please respond within fifteen (15) working days stating if you accept or reject the written proposed resolution. If you accept the proposed resolution or if SCFHP does not hear from you, SCFHP will immediately implement all final resolution actions. In the event you do not accept the proposed resolution and all efforts have been exhausted without establishing a mutually agreeable resolution, you may send a written notification to SCFHP to submit the dispute to arbitration. If you have additional questions or concerns, please contact me at (408) Sincerely, Peggy Periandri Senior Director Network Management cc: Chief Operations Officer Other directors as applicable (identify) Page 8 of 8