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1 Quality Improvement... 2 Oversight of Contracted Vendors... 3 Guidelines for Treating Tobacco Use and Dependence Asthma Guideline Diabetes Clinical Practice Guideline Guidelines for the Diagnosis and Treatment of Patients with Depression in the Primary Care Setting BCBSIL Clinical Practice Guidelines Shared Decision-Making Guidelines for Primary and Secondary Prevention of Atherosclerotic Cardiovascular Disease Preventive Health Care Guideline Screening Adults for Depression Clinical Practice Guideline Provider Manual ADHD Guideline Depression Guidelines Hypertension Guideline Cardiovascular Disease Guidelines COPD Guidelines A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association BCBSIL Provider Manual Rev 1/15 1

2 Quality Improvement BCBSIL Provider Manual Rev 1/15 2

3 Policy Name: Oversight of Contracted Vendors Policy Number: Quality Improvement - 03 Effective Date: 5/10/01 Revision Date: 3/1/14 Review Date: 3/1/14 Approval Signature: Senior Medical Director DVP Clinical Outcomes Management & Research HMO, BA HMO Approved QI: N/A Approved P&P: 2/13/14 POLICY: The HCM Clinical Outcomes Management and Research is responsible for conducting oversight of services Blue Cross and Blue Shield of Illinois (BCBSIL) delegates to WIN Fertility. These delegated services may include, but are not limited to: Utilization Management/Case Management PURPOSE/OBJECTIVES: To ensure that members are receiving care and service that are performed in accordance with contractual requirements and mutually agreed upon standards, including relevant accreditation standards. GUIDELINES: A dated and signed contract, business associate agreement and delegation agreement clearly defining reporting and performance expectations for both BCBSIL and the Contracted Vendor must be in place before delegated activities are performed. The following are required of a Contracted Vendor: At least annually, the submission of the following in accordance with the delegation agreement: Policies and procedures Reports that document activities and results for delegated activities All Contracted Vendors must present semi-annually at the BCBSIL Quality Improvement Committee meetings. BCBSIL reserves the right to periodically participate in Contracted Vendors Quality Improvement Committee meetings. Activities that are delegated are applicable for oversight. Only those activities that are delegated as defined in the contracted vendor s delegation agreement are applicable for evaluation and scoring. BCBSIL will perform vendor oversight semi-annually using the attached oversight tools. Procedure 1. The HCM Clinical Outcomes Management and Research staff will review the vendor s policies, procedures and all required submissions prior to delegation. 2. The BCBSIL HCM Clinical Outcomes Management and Research staff reviews the required submissions from the Contracted Vendor for compliance with BCBSIL criteria and provides BCBSIL Provider Manual Rev 1/15 3

4 Oversight of Contracted Vendors Page 2 of 21 the Contracted Vendor with the results of the audit. The results of the audit are presented semiannually at the BCBSIL QI Committee for review and approval. 3. The Contracted Vendor is required to respond to areas of deficiency within 30 days. The oversight review tools include mechanisms for corrective action and follow-up requests. 4. Consequences for failure to meet BCBSIL s requirements may include, but are not limited to: development of corrective action plans, additional BCBSIL audits, and/or revocation of the delegation agreement 5. Any follow-up or necessary action that needs to be taken relating to the above items will be documented by the BCBSIL HCM Clinical Outcomes Management and Research staff and reviewed by the BCBSIL QI Committee. * See Attachments 1-3 for audit tools used to evaluate delegated activities of contracted vendors. UM Program Description Evaluation (Annual) Annual Report Review Delegate Submissions Tool (Quarterly) BCBSIL Provider Manual Rev 1/15 4

5 Oversight of Contracted Vendors ATTACHMENT 1 Page 3 of UM Plan Compliance Tool for the HMOs of BCBSIL IPA Name: # of Revisions until Passing: Initial Review Date: Passing Date: Reviewer: BOLDED ITEMS LISTED ARE NEW REQUIREMENTS FOR 2014 UM PROGRAM / PLAN Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 1. The UM Plan is reviewed and revised yearly with acceptance documented in 10, 16, 41 Pg. UM Committee Meeting Minutes a. Must state that the UM Plan is reviewed, revised and approved on an annual basis and approved through the UM Committee as evidenced in UM minutes. b. UM Plan must include case management. c. UM Plan must include behavioral health (which now includes substance use disorder) or submit BH UM Plan from sub-delegate, if applicable. 2. Scope and Goals includes objective and purpose of IPA UM Program Pg. (specific goals must be identified). The UM Program goals must be identified for the year. Must include a goal for the 2014 CCM Program (ex. engagement rate) The scope must include: pre-cert or initial review, concurrent, retrospective, referrals, denials, complaints, corrective action, discharge planning, case management, including complex case management, triage & screening for behavioral health cases, if applicable, and Dx/procedures/services that do not require review based on historical UM Data, if applicable. 3. Description of IPA process for its UM Plan development (including staff involved in review, revision and final approval) and submission to the 10, 16 Pg. HMO by the required date. Include the process for reviewing the UM Plan, who reviews the plan, monthly meetings. 4. Description of UM Committee structures, meeting schedule and physician representation, including specialist representation. 17 Pg. Include a list of membership. Check submitted committee membership for specialties and physician representation. Include submission to the HMO. Submission date required. PCPs are defined as 1) Internal Medicine, Family Practice or GP; 2) Pediatricians; and 3) OB/GYNs. These would not meet the Specialist Requirement. Describe if UM/ QI Committee combined. 5. UM Staff and accountability includes responsibilities of and staff level for 17, 19 a. Medical Director 19 Pg. b. Physician Advisor 20 Pg. c. List of Board Certified Specialist/Consultant 20 Pg. d. BH practitioners (board certified psychiatrist, licensed clinical psychologist, and/or certified addiction medicine specialist) 20 e. UM Coordinator 20 Pg. f. CCM Coordinator (RN, CCM, PA, MD, LCSW, LCPC, pharmacist) 20 Pg. Include BH, include responsibilities specific for each position, board certification for consultants. Must include a licensed review of inpatient, concurrent certifications, including application of criteria. BCBSIL Provider Manual Rev 1/15 5

6 Oversight of Contracted Vendors Page 4 of Description of Services that are delegated including CMF, hospital UM department, Behavioral Health/ Mental Health facility or group 17, 31 Pg. a. Discussion, documentation of approval of delegate s UM Plan annually 17 Pg. b. Description of BH aspects of UM Program (including mental health and substance use disorder) 17, 31 Pg. c. Review, approval, submission of the BH UM Plan to HMOs 17, 31 Pg. 7. Nationally recognized medical criteria (must be current version (specify edition) must be selected by the IPA for medical necessity review and LOS determinations. ASAM criteria also required by IPA or delegated BH. A process must be included for any additional criteria, guidelines, etc a. Document the process for selection, approval, application and annual process for criteria update and review (including BH). b. Describe your process for notifying practitioners of the availability, method of requesting the criteria and format in which it will be provided. Include any additional criteria. A sample of this annual written statement is to be attached. c. Describe your process and information utilized in making medical necessity and benefit determinations d. Describe your process if nationally recognized criteria is not available and additional criteria created by the IPA is utilized e. Board certified specialist, including BH must be available as needed to assist in making determinations and approving criteria. 8. Description of process for UM reviews performed on-site at facilities. If no on-site review is performed, this must be documented. Must include the following: a. Guidelines for identification of IPA staff at the facility (in 18, 20, 21, 42 Pg. Pg. 21 Pg. Pg. Pg. Pg. 18 Pg. 18 Pg. accordance with facility policy) b. Process for scheduling the on-site reviews in advance 18 Pg. c. A process for ensuring that IPA staff follows facility rules 18 Pg. Pg. 9. Hospitalist Program description, if applicable: Pg. a. Specify Level I or Level II Pg. b. Provide process for ensuring PCP coverage Pg. c. Verify core facilities Pg. IPA PHYSICIAN and UM STAFF 10. An annual list of all Medical Directors, Physician Advisors, RNs, LPNs is to be submitted in the UM Plan (include license numbers for physicians and RNs). Page # where requirement is in HMO plan: 17, Physician and Registered Nurse licenses must be submitted to the HMO annually. A copy of the BH Practitioners licenses must be provided to the HMO with the BH UM Plan as part of the submission process. Page # where requirement is in IPA plan: Pg. BCBSIL Provider Manual Rev 1/15 6

7 Oversight of Contracted Vendors Page 5 of Written job descriptions with qualifications for practitioners who review denials, including a behavioral health practitioner job description. 20 Pg. The job description must include the responsibilities for that position. Page 18 of HMO UM plan under Medical Director a), include supervises all UM decision-making and CM activities. Must include a job description for at least one BH (in BH or IPA plan). 12. All physicians participating within an IPA must be currently licensed to practice medicine in the state in which they practice and must be 20 Pg. currently credentialed by BCBSIL. Include this statement in plan. 13. Written procedures for training, orientation and ongoing performance monitoring of clinical and non-clinical utilization staff submitted annually. 20 Pg. Must state somewhere in Plan and be a policy and procedure. Must include performance monitoring. 14. Inter-rater reliability criteria testing annually for UM decision makers (including PA, Medical Directors, and UM staff) 22, 42 Pg. Statement of performing inter-rater annually for all parties listed peer to peer review. Every physician and UM staff member involved in UM decision-making must be included in the testing. UM plan must state 8 files will be reviewed for EACH physician / staff member. If a physician / staff member is not 100% compliant then that person must perform an additional 22 files for a total of 30 files. 15. Affirmation statement distributed to all staff involved in UM decision 30 Pg. making including a statement regarding conflict of interest. Include the statement with all components. Does not need to be signed. Must be distributed annually. Does not need to be distributed to all existing members, as HMO will distribute via a newsletter. Must be distributed to all new members via memo, welcome letter. A general posting in PCP office meets this requirement. BCBSIL Provider Manual Rev 1/15 7

8 Oversight of Contracted Vendors Page 6 of 21 ACCESS TO IPA STAFF Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 16. The IPA must provide the following communications services for practitioners and members: 22 Pg. a) at least 8 hrs a day, during normal bus. hrs, staff must be available 22 for inbound calls regarding UM issues; Pg. b) UM staff must have the ability to receive inbound after business hrs 22 communication regarding UM issues; Pg. a) there must be outbound communication from staff regarding UM 22 inquiries during normal business hours; Pg. b) calls must be returned within one business day of receipt of 22 communication; Pg. c) staff must identify themselves by name, title and organization name 22 when initiating or returning calls; Pg. d) there must be a toll free number or staff that accepts collect calls 22 regarding UM issues; Pg. e) callers must have access to UM staff for questions 22 Pg. f) the IPA offers access to TDD/TTY services to deaf, hard of hearing 22 or speech impaired Members; and Pg. g) the IPA offers language assistance for Members to discuss UM 22 issues (during business hours). Pg. IPA must document inbound and outbound communication process in 22 the annual UM Plan. Method for receiving after hours communication Pg. must be included. Must include all components. Must state if have a toll free number OR accept collect calls. Must describe how members and practitioners are notified: welcome letter, newsletter, memo in PCP offices, voice mail, denial letter. BCBSIL Provider Manual Rev 1/15 8

9 Oversight of Contracted Vendors Page 7 of 21 REQUIREMENTS FOR UM DECISION MAKING: Non-behavioral and Behavioral Health 17. Description of the Prospective/Pre-certification/Pre-Service process including determination of medical necessity and appropriateness of service and site for inpt/outpt services, performed by the UR Coordinator and/or PA using the nationally recognized medical criteria selected by the IPA. IPA may determine procedures that do not require pre-certification via written policy and procedure attached to UM Plan. The policy may include diagnoses, procedures and/or physicians that do not require prior authorization and/or concurrent review based on historical UM data. Pre-certification/Pre-service includes documentation of the following: Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: Pg. a. Sources of relevant clinical information utilized (list sources) 22 Pg. b. estimated length of stay (admission) 23 Pg. c. medical criteria met including criteria code (admission) 23 Pg. d. non-urgent Pre-service determination (approval and denial) and member/provider notification within 5 calendar days of receipt of request, including the collection of all necessary information e. urgent pre-service determination (approval and denial) and member/practitioner notification within 72 hrs of receipt of request, including the collection of all necessary information Pg. Pg. Must include all components. If pre-cert and/ or concurrent are not required in certain instances, this must be documented in policy and procedure. There must be a description in UM Plan of how it was determined that the diagnoses, procedures, physicians, etc would not be reviewed. Describe method of checking if non reviewed admission was discharged in a timely manner. Describe member notification process. 18. For practitioner notification, if initial notification is made by telephone, IPA must: record time and date of call, AND document name of IPA employee who made the call Must include this statement 23 Pg. 19. For all denials, confirmation of the decision must be provided by mail, fax, or Must include this statement CERTIFICATION / INITIAL REVIEW PROCESS: 23 Pg. Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 20. All admissions must be included on admission log. 24 Pg. Must include - Submit sample log with required elements. 21. Emergent Admissions 22 Pg. a. Timeframes for UM decision making, notification to member and 22 Pg. practitioner b. Application of nationally recognized criteria 22 Pg. c. Assigned LOS 22 Pg. d. Discharge Planning and/ or Case Management, if applicable 22 Pg. Must include all components. 22. Certification form meets all of HMO s required Requirements 23 Pg. Check submitted forms for all required elements. Include social, family, home assessment. Confidential BCBSIL Provider Manual Rev 1/15 9

10 Oversight of Contracted Vendors Page 8 of Initial review for precert/pre-service non-urgent (elective) admission may be deferred until ALOS has reached its limit. 23 Pg. Must include checked day before discharge or end of anticipated LOS 24. Written policy and procedure for closure of a case due to insufficient information decision-making must be included with UM Plan submission and must meet time-frames Must be a policy. 25. IPA cannot reverse a certification decision unless it receives new information not available at time of initial determination Must include this statement. 26. Annual review of staff adherence to all time frames for making UM decisions Must include above statement. Every UM staff member must be included in the testing. 24, 42 Pg. 24 Pg. 25 Pg. CONCURRENT REVIEW PROCESS: 27. Describe concurrent review process (including BH). Include sources of relevant clinical information utilized, the criteria used, UM decisions made and practitioner notification within 24 hrs of receipt of request. The case review is performed once the case meets the 7th day for continued stay if case is not in active certification. Additional assigned LOS, and discharge planning/case management needs addressed. PA must review every seven days. Social, family, home assessment must be documented. Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 24 Pg. Document process, include timeframes, include all components. Include reference to checking case before LOS expired or day before discharge. For cases not requiring review as documented in the IPA s policies, after the assigned length of stay is determined and a discharge date is determined, the IPA must check for discharge on the designated discharge date. If the Member has not been discharged and the case reaches the seventh day, concurrent review must begin with brief documentation of the events since admission. The case should be referred to the PA for a long stay review. An initial review form does not need to be completed. 28. Describe process if pre-service, initial review, concurrent stay does not meet nationally recognized medical criteria. Document PA referrals and resulting denials. RETROSPECTIVE REVIEW PROCESS / POST-SERVICE PROCESS 29. Describe process including timeframe for decision making, and member/ practitioner notification. Describe process, check timeframe. 24 Pg. Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 25 Pg. Confidential BCBSIL Provider Manual Rev 1/15 10

11 Oversight of Contracted Vendors Page 9 of 21 CASE MANAGEMENT PROGRAM 30. Written CCM Program description to include clinical structure: a. Physician oversight of the IPA CCM Program is required. Includes discussion of cases at UM Committees documented in minutes. b. A clinician (Certified Case Manager, RN, LCPC, LCSW, PA, or Pharmacist) is required for at least one Member contact monthly. Staff roles must be defined for clinical and nonclinical staff involved in case management. c. Describe the Case Management program that must include a program goal. (example: engagement rate) Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 16,17 Pg. Document processes: a. Identification of Members for CCM meeting 2014 CCM criteria (IPA list posted to portal, referrals from PCP, QI project data, etc.) b. CCM procedures, tools, and resources c. Documentation requirements for CCR, IA and monthly contacts as defined in MSA d. Member engagement 16 Pg. IPA must describe the Case Management team structure and processes. CCM Coordinator to be identified and must be an RN, Certified Case Manager, PA, physician, LCSW, LCPC, or pharmacist Document how IPA communicates the ability to refer to CCM Document the process to perform clinical case review for Members that meet 2014 CCM Criteria Document the process for clinical attestation documentation that must be performed by the clinician who is an RN, Certified Case Manager, PA, physician, LCSW, LCPC, or pharmacist Document the process for completing the initial assessment within 30 calendar days of determination that Member meets criteria for inclusion in the CCM Program (as determined by CCR and Attestation completion and HMO approval for IPA added cases). The initial assessment documentation requirements within a case must be described in the plan. (see page 35 for requirements) The IPA must describe the process to develop a plan of care in collaboration with the Member that includes prioritized goals (at least 2 goals with one being medical or mental health related), a timeframe for goals to be met or revised, and development and communication of self-management plan. Describe the process for member consent and monthly bi-directional contact between CM and Member. 33, 34 Pg. 33 Pg. 34 Pg. 34 Pg Pg. 35 Pg. 35 Pg. 35 Pg. Confidential BCBSIL Provider Manual Rev 1/15 11

12 Oversight of Contracted Vendors Page 10 of 21 Describe monthly contact documentation requirements that include discussion of progress towards goals. 36 Pg. Describe the process for closing CCM cases (criteria) and how member survey will be administered upon case closure. Document requirement for PCP to approve goals and conduct a face-to-face visit every 6 months for Members enrolled in CCM. The IPA must have policies and procedures which address all requirements on page Discharge Planning/ Hospitalization Follow up 36 Pg. 35 Pg Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 31. For Members having one admission in a one year period for a primary diagnosis of asthma, diabetes, COPD, CHF, traumatic 25 Pg. brain injury (TBI), multiple trauma, new paraplegia or quadriplegia, cerebral vascular accident (CVA), subarachnoid hemorrhage, or amyotrophic lateral sclerosis (ALS), as identified by the HMO, the IPA will be required to document the existence of a follow-up office visit via the IPA Portal on a quarterly basis. 32. Describe behavioral health follow-up after hospitalization process. 25 Pg. Describe process. Appointment should be scheduled within 7 days of discharge- best practice is to schedule appointment prior to discharge whenever possible. ILLINOIS DEPT. OF INSURANCE REQUIREMENT 33. Report to HMO if IPA is a registered URO or identify delegated entity. Include plan and timeframe for seeking registration. Proof of current registration/ renewal must be submitted with UM Plan on an annual basis. IPAs delegating to a CMF must also register Describe when approved, submit letter, and submit renewal, if applicable. Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 25 Pg. IPA REFERRAL PROCESS Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 34. Describe process for referrals to specialists, therapies, DME, labs 25, 26 Pg. Compliance with decision making timeframes for all referral types, within 5 calendar day of receipt of request, including any request for additional 25, 26 Pg. information. Include the process for denied referrals by notifying the member and practitioner must be notified in writing or electronically within 5 calendar days. All referrals must follow the timeframes identified by type i.e. preservice, initial, concurrent review and post-service. Include referral inquiry process, if no denials. PCP communication and agreement must be documented. If the PCP does not agree with the denial, a denial cannot be issued. A written denial letter is not required if the Member does NOT receive a referral. Must describe process/requirements. Sample referral forms must be submitted with UM Plan. 26 Pg. 26 Pg. BCBSIL Provider Manual Rev 1/15 12

13 Oversight of Contracted Vendors Page 11 of Describe process for standing referrals (Submit policy and procedure). 26 Pg. Must be policy and procedure. 36. Describe transition of care process 26, 29 Pg. Describe process, must meet UM Plan requirements. 37. Describe the process for Exhaustion of limited benefits (includes rehab therapies, and infertility). 29 Pg. DENIALS 38. Description of process for behavioral health and non-behavioral health determinations and reconsiderations (including medical necessity and benefit.) Process must include: a) Description of referral process to Medical Director and/or PA and decision time-frame and required documentation (psych, doctoral level clinical psychologist, or certified addiction medicine specialist must be responsible for denial of behavioral health care that is based on lack of medical necessity). b) Medical Director/PA/BH Practitioner denial documentation must include one of the following: a. Physicians signature, documentation identify from the physician, or unique electronic identifier on the letter or a signed or initialed note from a UM staff person, co-signed by the physician/bh practitioner. c) Expedited appeals process for all denied cases, within appropriate time frame. d) Relevant clinical information supporting decision and source(s), PCP communication and agreement must be documented e) Notification to practitioners of policy for making reviewer available to discuss UM denial. f) Denial log maintained monthly clearly identifying type, also document on log if none Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 26 Pg. 27 Pg. 27 Pg. 27 Pg. 27 Pg. 27 Pg. 27 Pg. g) Submission to HMO (IPA portal) as outlined, including BH. 28, 43 Pg. Must include all components; meet required timeframes as outlined in pre-service, concurrent review, etc. Must include BH denial requirements, must include submission of logs and files to IPA Portal. Must change dates in UM Plan to 2013 and 2014 as noted on page 27 of HMO UM Plan. WRITTEN DENIAL NOTIFICATION Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 39. Description of behavioral health and non-behavioral health denial decisions process including appropriate timeframes. The HMO 28 Pg. approved letters must be used for denials and include all the required elements. Check to make sure denial letters are exactly like HMO approved and have all the required components. (include the required attachment). Denial language needs to be based on the member s situation. HMO Scope of Benefits cannot be noted or copied as part of the member s denial letter. BCBSIL Provider Manual Rev 1/15 13

14 Oversight of Contracted Vendors Page 12 of 21 IPA APPEAL PROCESS 40. Description of process for explaining all levels of appeal (Standard, Expedited, External Reviews) a. The HMO letter that includes instructions about appeal rights and resources must be used for all denials and for all appeals for which the denial was maintained, including the required attachments. b. there must be procedures for providing the Member access and copies of all documents relevant to the appeal; free of charge and upon request c. an authorized representative must be able to act on the Member s behalf. d. policies for providing notices of the appeals process to members in a culturally and linguistically appropriate manner 41. Expedited appeal: If the Member is hospitalized, the member may continue to receive services with no financial liability until notified of the decision. 42. External appeal: Requests from the Practitioner(s) and/or Member for an external appeal should be directed to the Customer Assistance Unit of HMO Continued coverage must be provided to the Member pending the outcome of an internal appeal for covered services. Page # where requirement is in HMO plan: 11-12, Page # where requirement is in IPA plan: Pg. Pg. Pg. Pg. 11, 29 Pg. 11, 29 Pg. 11, 29 Pg. 43. Describe new and existing medical technology process 12, 29 Pg. Must contact the HMO 44. Describe process for emergency services 12, 30 Pg. Must follow prudent layperson and MSA. 45. Describe process for ensuring appropriate utilization; include tracking at 13, 30 Pg. least four of the outcomes listed noting potential utilization issues when identified. Include a policy for obtaining corrective action from IPA physicians with identified avoidable days. IPA must describe four elements for tracking utilization, including 1 BH. Must be reported in committee minutes at least semi-annually. Include comparison of at least six months of data. Also must describe method of tracking avoidable inpatient days. Include policy on avoidable days and corrective action for physicians with repeat non-compliance issues. Confidential BCBSIL Provider Manual Rev 1/15 14

15 Oversight of Contracted Vendors Page 13 of 21 TRIAGE AND REFERRAL FOR BEHAVIORAL HEALTH Health Care Management Policy and Procedure Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 46. Describe member process for obtaining behavioral health services and coordination of services. Any delegation of BH must be described in the Pg. UM Plan. Describe triage and referral protocols which include: a. addressing level of urgency and appropriate setting Pg. b. protocols based on sound clinical evidence, currently accepted Pg. practices, reviewed and revised annually; c. decisions are made by licensed BH practitioners with appropriate Pg. experience d. staff is supervised by a licensed BH care practitioner with min. Pg. master s degree and 5 yrs post-master s clinical experience e. decision are overseen by a licensed psychiatrist or an appropriately Pg. licensed doctoral / level clinical psychologist Must refer to BH Plan if they delegate. Otherwise describe how members obtain BH services, protocols used, decisions must be made by BH practitioner. If IPA changes contract management firms, the Nurse Liaison and HMO Provider Network Consultant must be notified at least 30 days in advance of the date the new firm will assume the delegation as noted in the HMO UM Plan page BH services must be provided in accordance with HMO access 31 Pg. standards Must state they meet all required access standards or list the access standards as noted in UM plan. 48. Describe process for submitting telephone reports quarterly to the HMO 31, 43 Pg. QI Dept. If they delegate to BH vendor, must state they will submit these to HMO. Any BH organization or IPA providing BH services must submit telephone reports quarterly to the HMO QI Department. PROTECTED HEALTH INFORMATION Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 49. IPA must follow the provisions for the use of Protected Health 31 Pg. Information a. use Protected Health Information to provide or arrange for the provision of medical and BH benefits administration and services Pg. b. provide a description of appropriate safeguards to protect the information from inappropriate use or further disclosure Pg. c. ensure that sub-delegates have similar safeguards Pg. d. provide individuals with access to their Protected Health Information Pg. e. inform the IPA if inappropriate uses of the PHI occur, and Pg. f. ensure that Protected Health Information is returned, destroyed, or protected if the contract ends Pg. Must include all above components in policy and procedure. BCBSIL Provider Manual Rev 1/15 15

16 Oversight of Contracted Vendors Page 14 of 21 PROCESS FOR DELEGATION AND OVERSIGHT OF UM Health Care Management Policy and Procedure Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 50. Mechanisms for oversight must include, but are not limited to: 31 Pg. a. Annual approval of the sub-delegate UM Plan Pg. b. Annual evaluation of sub-delegate against HMO & IPA requirements Pg. c. Review of quarterly submissions and any reports, and Pg. d. Identification of any deficiencies w/corrective action. Pg. Must state all of the above if they delegate. If they do not delegate, refer to #6, do not have to repeat again. IPA UM COMMITTEE MEETING REQUIREMENTS 51. UM Committee meets at least monthly to review and discuss UM activities. Minutes to include date, chairman and members present (including specialist representation), minutes signed by Medical Director/Chair within 5 weeks of meeting. Must include. 52. Committee minutes must consist of the following additional requirements: Annually: Review and approval of the IPA UM Plan/including BH Review and acceptance of medical criteria (including BH and any additional criteria) Evaluation of the UM program and progress in meeting determined goals. Goals for 2014 must include a goal for CCM program. All goals identified for the year must be discussed. Interventions implemented, results of interventions (outcomes), and further opportunities for improvement should be discussed. Review and revision of all UM related policies and procedures (all must be in a format which minimally includes: IPA name, name of policy, effective date, review date and most current revision date, signature of reviewing and approving authority Page # where requirement is in HMO plan: Page # where requirement is in IPA plan: 40, 43 Pg. 41 Pg. 42 Pg. 18, 42 Pg Pg. Confidential BCBSIL Provider Manual Rev 1/15 16

17 Oversight of Contracted Vendors Page 15 of 21 In minutes, state policies and date they were reviewed. A listing of policies may be submitted to the HMO for the annual submissions requirement. The list must include all required policies, the date of review or revision, and the Medical Director s signature. If a policy does not have any revisions, it does not have to be submitted to the HMO. If the policy is new or has been revised, then it needs to be submitted with the UM Plan. Inter-rater reliability testing for criteria utilization (Medical Director, PA 22, 42 Pg. and UM Staff) and decision making timeframes (UM Staff). A summary of the results and number of cases by reviewer must be included in the minutes. Include any corrective action. Each Physician and UM staff member needs to be included in the testing for UM decision making. On an annual basis, the IPA must assess the characteristics and needs of its Member population and relevant subpopulations. Characteristics 13, 42 Pg. to include: race/ethnicity, needs of children and adolescents, individuals with disabilities, and Members with serious and persistent mental health conditions. This analysis should be documented as a part of the UM Program annual evaluation and utilized to revise and update the IPA s complex case management program and resources. Review of annual HMO PCP and Member survey results with specific reference to referrals and interventions if referral question scores < 83% 43 Pg. Review of PCP site visit results that are posted on the IPA Portal with discussion of non-compliance including corrective action. 42 Referral score must be documented for both surveys. If score <83% need to document intervention Semi-Annually a. Identification, analysis, development of interventions for improvement related to utilization stats. IPAs are required to track at 41 Pg. least 4 (including BH), of inpt.days/1000, admits or discharges/1000, BH days/1000, ALOS, rates for types of procedures, and include a comparison of past quarters (at least 6 months of data arrayed in table or graph & included in the minutes). Interventions noted Monthly data for six months or quarterly data for two quarters meets this Requirement. b. Summary/ discussion of six months of avoidable inpatient days and reason for delayed discharge. IPA Physicians identified with 41 Pg. avoidable day practice patterns identified in UM Committee with corrective action according to MG UM policy. c. Discussion of referral statistics (including BH) with a two quarter referral comparison, trending, analysis, and discussion documented 41 Pg. in the minutes (at least 6 months of data arrayed in table or graph). Interventions must be documented for any trends noted. Monthly data for six months or quarterly data for two quarters meets this Requirement. BCBSIL Provider Manual Rev 1/15 17

18 Oversight of Contracted Vendors Page 16 of 21 Quarterly Quarterly review and discussion any complaints received by the group and resolved timely. These may be discussed in summary format using 43 Pg. categories of complaints. A monthly log must be maintained including documentation of no complaints (includes CCM process complaints). Upon notification of posting of a list of Members on the IPA Portal for the BCBSIL HMO Ambulatory Care Sensitive Conditions (ACSC) 43 Pg. Report using AHRQ-based Preventive Quality Indicators (PQI) methodology, clinical review and discussion of no fewer than 10 outpatient records pertaining to these Members. This should focus on the quality and completeness of the outpatient care preceding each admission in question. Quarterly review and discussion of any submissions, reports from subdelegates. 43 Pg. Quarterly discussion of HMO review of IPA denial files, any noncompliance and corrective action, if required. 43 Pg. Monthly Review and discussion of all denied services to include a summary of categories of denials (BH, non-bh, medical necessity, OON etc.), 43 Pg. member in each category, timeframes compliance and resolution. Include number of IPA referrals and the number resulting in denials. Denial logs and files must be submitted through the IPA Portal. A monthly log of complaints must be maintained. The complaints must be resolved within 30 days. 43 Pg. IPA Committee Minutes: IPA UM Committee Meetings with minutes maintained, listing date of meeting and Committee members and 43 Pg. specialist representation. The minutes must include the signature of the Medical Director and/or Chairperson within five weeks of the date of the last UM Committee meeting. Must state committee will communicate in minutes all components above and required timeframes. 53. ADDITIONAL UM REQUIREMENTS / ACTIVITIES Confidentiality policy and procedure 37 Pg. Data security, integrity, and storage of information system and written 37 Pg. disaster recovery plan policy and procedure Maternity Discharge program/process 37 Pg. Substance Use Disorder/ BH managed by IPA or sub-delegate 37 Pg. Infertility program program/process 37 Pg. Organ transplant program/process Pg. Out of area admissions program/process 38 Pg. Out of network program/process 38 Pg. Termination of benefits process description Pg. Must include all components above and required timeframes. Termination of benefits applies to Medical as well as Behavioral Health Admissions. A diagnosis, clinical summary and patient status must be sent to the HMO Nurse Liaison along with the IPA s termination of benefit letter and the written statement from the PCP. Confidential BCBSIL Provider Manual Rev 1/15 18

19 Oversight of Contracted Vendors Page 17 of 21 HMOs of BlueCross and BlueShield of Illinois 2014 UM Plan Required Submissions IPA Name: A. SAMPLE FORM/WORKSHEETS 1. Pre-Certification (Pre-Service), Initial Review/Concurrent Review 2. Referral from Medical Group 3. Physician Advisor Referral Review Worksheet 4. Inter-rater reliability worksheet for medical criteria, UM staff and Physicians 5. Inter-rater reliability worksheet for time frames, UM staff 6. Timeframes worksheet B. SAMPLE LETTERS (HMO DENIAL LETTER WITH APPEAL LANGUAGE MUST BE USED) 1. Denial letter 2. Closure for lack of information letter 3. URO registration/renewal letter 4. Welcome Letter C. POLICY AND PROCEDURES (MUST HAVE REVIEW & REVISION DATES ON POLICIES) 1. UM Staff On-Site Review at Facility, if applicable 2. UM Staff Orientation, Training, and Performance review 3. Diagnoses, Procedures, Physicians Not Requiring Pre-Certification and/or Concurrent Review, if applicable 4. Additional Criteria, Clinical Pathways, Guidelines used for UM Decision-Making and the Process for Development and Approval, and Procedures for Utilization, if applicable 5. Case Closure Due to Insufficient Information 6. Standing Referrals 7. Appeals 8. Protected Health Information 9. Confidentiality 10. Information Systems, Security, Integrity, Storage & Disaster Recovery Plan 11. Tracking Avoidable Days for 1 IPA Physicians and Method for Corrective Action/Non-Compliance 12. PCP Notification to Member of Approved Certification, if applicable 13. Hospitalist policy, if applicable 14. Complex Case Management D. LOGS 1. Admission 2. Case Management 3. Complaint 4. Denial 5. Referral Behavioral Health 6. Referral Inpatient PA 7. Referral - Inquiry 8. Referral OON E. LISTS 1. Committee membership, including professional degree and specialty 2. Board certified specialist, consultant list, including behavioral health 3. Medical Director and Physician Advisors with license number for verification and R.N. license number 4. Photocopy of Behavioral Health Practitioners licenses F. MEMOS 1. Availability of medical criteria (including additional criteria) for IPA physicians 2. UM affirmation statement, including conflict of interest 3. Provider, member notification of access to UM staff 4. Demonstrate method for member and PCP to contact the IPA with potential CM case G. JOB DESCRIPTIONS 1. Practitioners who perform denials 2. Behavioral Health practitioner(s) BCBSIL Provider Manual Rev 1/15 19

20 Oversight of Contracted Vendors Page 18 of 21 ATTACHMENT 2 Vendor: <<Vendor Organization>> QI Workgroup: <<Date>> Reviewer: <<Name>> Date of Review: Date of Annual Report: <<Product>> Delegate Oversight Materials Audit Tool <<Year>> ANNUAL REPORT REVIEW Product: <<Product Specified>> Managed Care QI Committee: <<Date>> Year: <<Year>> Score: Date Annual Report Approved by <<Vendor Organization>> QI Committee: Annual report includes: Quality Improvement Compliant Summary of QI goals annual status (5) Pg. Discussion of barriers to meeting goals (5) Pg. QI goals continued for next year (5) Pg. QI goals discontinued for next year (5) Pg. QI program annual evaluation (5) Pg. Provider satisfaction survey (5) Pg. List delegate study information: QI STUDY (Clinical and Service) PREVIOUS RESULT GOAL RESULT Clinical: Service: Compliant Quality Improvement Opportunities noted: (5) Pg. Interventions noted: (5) Pg. Member Service Member satisfaction survey (5) Pg. Complaint analysis (5) Pg. Level I Appeals analysis (5) Pg. Phone statistics (5) Pg. Member Service Opportunities noted: (5) Pg. Interventions noted: (5) Pg. Confidential BCBSIL Provider Manual Rev 1/15 20

21 Oversight of Contracted Vendors Page 19 of 21 Utilization Management UM statistics and review summary (5) Pg. Inter-rater reliability results (5) Pg. Denials analysis (5) Pg. Under/ Over utilization method developed (5) Pg. Utilization Management Opportunities noted: (5) Pg. Interventions noted: (5) Pg. Pharmacy (Member Connections) QI Process on Accuracy of Information: Website and Telephone (5) Pg. Policy and standard operating procedures (5) Pg. Audit results (5) Pg. Pharmacy Benefit Information-Website: Standard operating procedure (5) Pg. Screenshots of Web site functionality (5) Pg. Pharmacy Benefit Information-Telephone Training modules (5) Pg. Pharmacy Benefit Updates: Web site and Telephone Policy and standard operating procedure (5) Pg. Documentation of Updates (5) Pg. Member Connections Opportunities noted: (5) Pg. Interventions noted: (5) Pg. *Total Score (Maximum Points Possible) (Delegate Score) % Percentage *The total points possible will vary depending on the services delegated to the vendor. Therefore, the delegate score will be divided by the maximum points possible for a final percentage. Comments and follow-up: Reviewed: 3/1/14 BCBSIL Provider Manual Rev 1/15 21

22 Oversight of Contracted Vendors Page 20 of 21 Vendor: <<Vendor Organization>> QI Workgroup: <<Date>> Reviewer: <<Name>> Health Care Management Policy and Procedure Product: <<Product Specified>> Managed Care QI Committee: <<Date> DELEGATE SUBMISSIONS TOOL Document Timeframe Date Received Points Possible REPORTING 1. Quarterly Reports Quarterly 5 Points (awarded at the end of the reporting year if all four quarters are received) First Quarter Report 1ST Second Quarter Report 2ND Third Quarter Report 3RD Fourth Quarter Report (includes Annual) 4TH 2. Presentation to the BCBSIL Managed Care Semi- QI Committee ATTACHMENT 3 Annually First semi-annual report 1ST HALF Second semi-annual report 2ND HALF 5 Points (awarded at the end of the reporting year) Quarter: <<Quarter>> Points Earned CONTRACTUAL 1. Signed contract NA NA 2. Signed delegation agreement NA NA WHERE QUALITY IMPROVEMENT IS DELEGATED: (If not a delegated service, points in this section are not applicable.) 1. QI Program Description-Annual Annually 5 Points 2. QI Workplan-Annual Annually 5 Points 3. QI Committee-Quarterly (meets at least Quarterly 5 Points (awarded at the end of the reporting year if all four quarters are received) quarterly with meeting minutes) First Quarter Report 1ST Second Quarter Report 2ND Third Quarter Report 3RD Fourth Quarter Report (includes Annual) 4TH 4. QI Study Summaries-Annual Annually 5 Points 5. QI Indicators-Quarterly Quarterly First Quarter Report 1ST 5 Points Second Quarter Report 2ND Third Quarter Report 3RD Fourth Quarter Report (includes Annual) 4TH (awarded at the end of the reporting year if all four quarters are received) 6. Provider Satisfaction Survey Results Annually 5 Points WHERE MEMBER RIGHTS AND RESPONSIBILITIES ARE DELEGATED: (If not a delegated service, points in this section are not applicable.) 1. Member satisfaction survey Annually 5 Points 2. Member inquiry, complaint and appeal policies and procedures Annually 5 Points 3. Confidentiality policy and procedure Annually 5 Points 4. Member rights and responsibilities indicators Quarterly Complaints/1000 1ST Number of member appeals by type and 2ND disposition 3RD Number of member complaints by type and action taken 4TH 5 Points (awarded at the end of the reporting year if all four quarters are received) BCBSIL Provider Manual Rev 1/15 22

23 Oversight of Contracted Vendors Page 21 of 21 Vendor: <Vendor Organization> Managed Care QI Committee: <Date> Reviewer: <Name> Product: <Product Specified> QI Workgroup Committee: <Date> Quarter: <<Quarter>> DELEGATE SUBMISSIONS TOOL - CONT'D Document Timeframe Date Points Points Received Possible Earned WHERE UTILIZATION MANAGEMENT IS DELEGATED: (If not a delegated service, points in this section are not applicable.) 1. UM Program Description Annually 5 Points 2. UM Statistics Quarterly ALOS 1ST Days/1000 2ND Admits/1000 3RD Inpatient readmission rate 4TH 3. UM Indicators Quarterly Inter-rater reliability test results 1ST Timeliness of UM decisions 2ND Denials/1000 3RD 4TH 5 Points (awarded at the end of the reporting year if all four quarters are received) 5 Points (awarded at the end of the reporting year if all four quarters are received) WHERE MEMBER CONNECTIONS IS DELEGATED: (If not a delegated service, points in this section are not applicable.) 1. Policy and Standard Operating Procedures and Other Documented Materials: Quality Assurance (Accuracy of Information) Annually 5 Points Pharmacy Benefit Information: Web site 5 Points Screenshots of Web site Functionality 5 Points Telephone Training Modules 5 Points 2. Reporting for QI Process on Accuracy of Information: Web Site Audit Results: Quarterly First Quarter Report 1ST Second Quarter Report 2ND Third Quarter Report 3RD Fourth Quarter Report 4TH Telephone Audit Results: Quarterly First Quarter Report 1ST 5 Points Second Quarter Report 2ND Third Quarter Report 3RD Fourth Quarter Report 4TH 3. Pharmacy Benefit Updates for Web site and Telephone (including but not limited to Annually 5 Points recalls, formulary changes, withdrawals, etc.) Documentation of Updates Total Score (Maximum Points Possible) 5 Points (awarded at the end of the reporting year If all four quarters are received) (awarded at the end of the reporting year if four quarters are received) (Delegate Score) % Percentage *The total points possible will vary depending on the services delegated to the vendor. Therefore, the delegate score will be divided by the maximum points possible for a final percentage. Comments and follow-up: BCBSIL Provider Manual Rev 1/15 23

24 Policy Name: Guidelines for Treating Tobacco Use and Dependence Policy Number: Quality Improvement 06 Effective Date: 11/01/01 Revision Date: 02/01/14 Review Date: 12/01/14 Approved P&P: 11/20/14 Approval Signature Senior Medical Director 12/11/14 Product Line HMOI, BA HMO PPO BlueChoice Blue Precision MMAI MA PPO Exchange Approving Body Policy and Procedure Approving Committee BCBSIL QI Committee Date: Date: Details Policy: Blue Shield of Illinois (BCBSIL) recommends that practitioners follow the BCBSIL Practice Guidelines for Treating Tobacco Use and Dependence. Purpose/Objectives: To provide recommendations for interventions and system changes to promote the assessment and treatment of tobacco use and dependence. This guideline is designed to assist clinicians by providing a framework for evaluation and treatment of patients and is not intended either to replace a clinician s judgment or establish a protocol for all patients with a particular condition. The final decision regarding medical treatment is made by the physician and the patient. Guideline: Treating Tobacco Use and Dependence, which is a U.S. Public Health Service sponsored guideline, should be used to care for adolescents and adults who smoke. Key recommendations for clinicians, which are based on literature review and expert panel opinion, are: 1. Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence. 2. It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting. BCBSIL Provider Manual Rev 1/15 24

25 Guidelines for Treating Tobacco Use and Dependence Page 2 of 4 Health Care Management Policy and Procedure 3. Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this Guideline. 4. Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in this Guideline. 5. Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt: a. Practical counseling (problem solving/skills training) b. Social support delivered as part of treatment 6. Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). c. First-line medications reliably increase long-term smoking abstinence rates. d. Clinicians also should consider the use of certain combinations of medications identified as effective in this Guideline. 7. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication. 8. Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, clinicians and health care delivery systems should both ensure patient access to quitlines and promote quitline use. 9. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in this Guideline to be effective in increasing future quit attempts. Physicians are urged to incorporate the following steps into daily office care of adults and adolescents to increase the likelihood that tobacco- using patients who visit the clinic will quit: The 5 A s model for treating tobacco use and dependence: Ask about tobacco use Identify and document tobacco use status for every patient at every visit. Advise to quit In a clear, strong and personalized manner, urge every tobacco user to quit. Assess willingness to Is the tobacco user willing to make a quit attempt at this time? make a quit attempt Assist in quit attempt For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. Arrange follow-up For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts. For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit. BCBSIL Provider Manual Rev 1/15 25