PROVIDER MANUAL . Yours Dedicated to ONE Community,
Dedicated to ONE Community, Yours. PROVIDER MANUAL Table of Contents Welcome………………………………………………………………………………………...8 Introduction….……….……..………………………………………….....................................9 About Preferred Care Partners...…………….........................................................................9 Mission Statement………………………………………………………………………….. 9 Non-Discrimination………………………………………………………………………… 9 Using This Manual…………………………………………………………………………. 9 Questions or Comments……………………………………………………………………10 Contact & Administrative Information, Section 1………………………....11 Important Contact Information……………………………………………………………..11 Notification/Authorization………………………………………………………………… 11 Claims…………………………………………………………………………………........11 Pharmacy…………………………………………………………………………………...11 Benefits and Eligibility Verification……………………………………………………….11 Additional Contact Information……………………………………………………………...11 Credentialing……………………………………………………………………………….11 Fraud, Waste & Abuse (FWA) Hotline…………………………………………………….11 Grievance & Appeals………………………………………………………………………12 Health Risk Management…………………………………………………………………..12 Member Services…………………………………………………………………………...12 Network Management Services…………………………………………………………… 12 Utilization Management……………………………………………………………………12 Ancillary & Enhanced-Benefit Providers…………………………………………………..13 24-Hour Nurse Hotline……………………………………………………………………..13 Acupuncture………………………………………………………………………………..13 Behavioral Health Services………………………………………………………………...13 Dental………………………………………………………………………………………13 DME, Home Health, Home Infusion………………………………………………………14 Fitness……………………………………………………………………………………...14 Hearing……………………………………………………………………………………. 14 Laboratory……………………………………………………………………………….... 14 Pharmacy Mail Order………………………………………………………………………14 Podiatry…………………………………………………………………………………… 14 Transportation…………………………………………………………………………….. 14 Vision…………………………………………………………………………………….. .15 Provider Services Online……………………………………………………………………..15 Provider Website and Online Services…………………………………………………….15 Office Location…………………………………………………………………………….15 1 Table of Contents Provider Information & Administrative Responsibilities, Section 2.…16 General Administrative Requirements………………………………………………………16 Introduction………………………………………………………………………………...16 Cooperate with Quality Improvement Activities…………………………………………..16 Provider Network Bulletins………………………………………………………………...16 Physician Specific Standards…………………………………………………………………16 Demographic Changes……………………………………………………………………..16 Access Standards…………………………………………………………………………..17 Missed Appointments……………………………………………………………………...17 After-Hours Care…………………………………………………………………………….. 17 Substitute Coverage………………………………………………………………………...17 Providing Official Notice…………………………………………………………………. 18 Confidentiality of Protected Health Information (PHI)……………………………………18 Member Participation in Treatment Options…………………………………………….... 19 Physician Extender Responsibilities………………………………………………………. 19 Common Provider Standards………………………………………………………………..19 Inform Members of Advance Directives…………………………………………………. 19 Access to Medical Records……………………………………………………………….. 20 Provider Forms……………………………………………………………………………. 20 Fraud, Waste & Abuse……………………………………………………………………. 20 Additional Medicare Advantage Requirements……………………………………………21 Credentialing & Recredentialing…………………………………………………………..22 Rights Related to the Credentialing Process…………………………………………….....23 Termination of Contract Agreements………………………………………………………23 Resolving Disputes – Agreement Concern or Complaint………………………………….23 Member Rights & Responsibilities, Section 3………………………..………..24 Introduction…………………………………………………………………………………...24 Federal Patient Self-Determination Act……………………………………………………24 Member Financial Responsibility………………………………………………………….24 The Florida Patient’s Bill of Rights………………………………………………………..24 Quality Improvement, Section 4………………………….………………………..28 Overview………………………………………………………………………………………28 Quality Improvement Committee……………………………………………………………28 Program Activities…………………………………………………………………………….28 Access & Availability………………………………………………………………………28 Behavioral Healthcare Programs…………………………………………………………...29 Clinical & Preventive Health Guidelines…………………………………………………..29 Continuity & Coordination of Care………………………………………………………...29 Member & Physician Satisfaction Surveys………………………………………………...30 2 Table of Contents Patient Safety……………………………………………………………………………… 30 Physician Medical Records / Office Site Audits…………………………………………...30 Delegation Oversight……………………………………………………………………… 30 CMS Programs & Projects…………………………………………………………………31 Quality Improvement Projects (QIP’s)…………………………………………………….31 Preferred Care Partner’s Quality Improvement Program Milestones for 2013………….31 HEDIS ®1…………………………………………………………………………………. 31 Member Satisfaction (CAHPS & Star Ratings)……………………………………………32 Physician Satisfaction……………………………………………………………………...33 Special Needs Plans…………………………………………………………………………...34 Special Needs Plans (SNP) Model of Care (MOC)………………………………………. 34 SNP MOC Structure & Process……………………………………………………………34 Quality Performance Measures………………………………………………………………34 STAR Rating System………………………………………………………………………34 HOS Program………………………………………………………………………………35 CAHPS ®2Program……………………………………………………………………….. 35 HEDIS Measures………………………………………………………………………….. 36 Utilization Management, Section 5…..…….…………………………………..… 37 Introduction……………………………………………………………………………………37 Services NOT Requiring Prior Authorization………………………………………………37 Emergency Services………………………………………………………………………..37 Urgent Care Services……………………………………………………………………….37 Out-of-Area Renal Dialysis……………………………………………………………….. 38 Open Access Providers……………………………………………………………………. 38 Prior Authorization / Notification Requirements for Physicians, Health Care Professionals and Ancillary Providers……………………………………………………………………………38 Authorization Requirements……………………………………………………………….38 General Notification Requirements………………………………………………………..39 Admission Notification Requirements……………………………………………………..39 Why is Authorization / Notification Required……………………………………………..40 How to Request Prior Authorization……………………………………………………….40 Information That Must be Included in the Request for Prior Authorization……………….40 Clinical Coverage Review: Clinical Information…………………………………………..41 Coverage Determination Decisions………………………………………………………...41 Clinical Coverage Review Criteria…………………………………………………………41 Timeframes for Processing Prior Authorization Requests…………………………………42 Prior Authorization Denials………………………………………………………………..42 Peer-to-Peer Clinical Review………………………………………………………………42 1 2 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 3 Table of Contents Additional UM Information………………………………………………………………….42 Members Requiring External Agency Services……………………………………………42 Hospitalist Program for Inpatient Hospital Admissions…………………………………...42 Discharge Planning……………………………………………………………………… 43 Case Management Programs……………………………………………………………….43 Transitional Case Management…………………………………………………………….43 General Condition Management…………………………………………………………...43 Disease Management Programs……………………………………………………………44 Medicare Advantage Hospital Discharge Appeal Rights Protocol………………………...44 Protocol for Facility (SNF, HHA, and CORF) Notice of Medicare Non-Coverage……….44 New Technology…………………………………………………………………………...45 Appeal & Reconsideration Processes……………………………………………………….. 45 Clinical Appeals: Standard & Expedited…………………………………………………..45 How to File an Appeal……………………………………………………………………..45 Medical Records, Section 6………………..…………………………………..…….46 Overview……………………………………………………………………………………….46 Documentation of Care / Confidentiality of Medical Records………………….………….46 Exemption from Release Requirements……………………………………….…………….46 Medical Records Requirements…………………………………………….………………..46 Patient Identifiers……………………………………………………….………………….46 Advance Directives……………………………………………………………………….. 47 Biographical Information…………………………………………………………………..47 Signatures…………………………………………………………………………………..47 Family History…………………………………………………………………………….. 48 Past Medical History……………………………………………………………………….48 Immunization Documentation…………………………………………………………….. 48 Medication List…………………………………………………………………………….48 Referral Documentation……………………………………………………………………48 Chart Organization…………………………………………………………………………48 Preventive Screenings……………………………………………………………………...48 Required Documentation………………………………………………………………….. 48 Medical Record Reviews……………………………………………………………………...49 Healthcare Risk Management, Section 7.……………………………………….50 Agency for Healthcare Administration (AHCA)……………………………………………50 National Quality Forum (NQF)………………………………………………………………50 CMS 2013 Hospital Acquired Conditions (HAC) & Codes………………………………...53 4 Table of Contents Provider Reporting Responsibilities…………………………………………………………54 Practice Standards & Performance Measures, Section 8…………………55 Overview……………………………………………………………………………………….55 Physicians’ Offices…………………………………………………………………………….55 Skilled Nursing & Rehabilitation Facilities……………………………………………….....61 Cardiac Catheterization & Dialysis Centers………………………………………………...68 Rehabilitation / Physical Therapy Facilities…………………………………………………74 Dialysis Centers………………………………………………………………………………..80 Surgical-Ambulatory Care Centers………………………………………………………….87 Pharmacy, Section 9………….…………………………………………………….…..96 Drug Formulary………………………………………………………………………………96 Coverage Limitations…………………………………………………………………………96 Drugs Covered Under Part B………………………………………………………………...97 Drugs Covered Under Part B or Part D……………………………………………………..97 Long Term Care Facilities (Includes Mental Health Facilities)……………………………97 Home Infusion…………………………………………………………………………………97 Vaccines………………………………………………………………………………………..97 Injectable Medications………………………………………………………………………..98 Utilization Management Rules……………………………………………………………….98 Prior Authorization…………………………………………………………………………98 Response Times………………………………………………………………………….... 98 Quantity Limits……………………………………………………………………………. 99 Generic Substitution………………………………………………………………………..99 Step Therapy………………………………………………………………………………. 99 Coverage Determinations…………………………………………………………………..99 Exceptions………………………………………………………………………………….99 Expedited Exception Requests……………………………………………………………100 Transition Policy……………………………………………………………………………..100 Pharmacy Network…………………………………………………………………….. 101 5 Table of Contents Drug Utilization Review………………………………………………………………101 Appeals & Redetermination Processes………………………………………………...102 Part D Appeals: Standard & Expedited…………………………………………………...102 Appeals……………………………………………………………………………………102 Medication Therapy Management (MTM)………………………………………………...103 2014 Pharmacy Benefit Summaries by Plan……………………………………………….104 Documentation & Coding, Section 10………………………………...................106 Guidelines for Success in the Medical Risk Adjustment Model…………………………..106 What is the Purpose of Risk Adjustment…………………………………………………106 Why is Risk Adjustment Important to Physicians & Providers…………………………. 106 What are the Responsibilities of Physicians and Providers……………………………....106 CPT& HCPCS Codes………………………………………………………………………..106 Overpayment Recovery & Audit, Section 11…………………………………107 Overview……………………………………………………………………………………..107 If You Discover an Overpayment…………………………………………………………. 107 If We Discover an Overpayment…………………………………………………………....107 Filing a Claim, Section 12….………………………………………………………..108 Claim Forms…………………………………………………………………………………108 Compensation………………………………………………………………………………..108 Additional Fees for Covered Services……………………………………………………108 Hospice – Medicare Advantage……………………………………………………………..108 Hospice Services………………………………………………………………………… 108 Emdeon Business Services……………………………………………………………..108 About Emdeon……………………………………………………………………………108 Electronic Remittance Options (ePayment)………………………………………………108 Claims Submission…………………………………………………………………….109 Basic Requirements………………………………………………………………………109 National Provider Identifier (NPI)………………………………………………………..110 Encounter Data……………………………………………………………………………110 Diagnosis Codes…………………………………………………………………………..110 Time Limit for Filing……………………………………………………………………..110 Electronic Claims Submission……………………………………………………………111 6 Table of Contents Claims Requiring Attachments…………………………………………………………...111 Paper Claims…………………………………………………………………………….. 111 Date Formatting…………………………………………………………………………..112 Claim Filing Address……………………………………………………………………..112 Completing the CMS-1500 Claim Form………………………………………………….113 Completing the UB-04 Form…………………………………………………………….. 113 Helpful Hints…………………………………………………………………………….. 113 Claims Processing……………………………………………………………………………113 Time Limits……………………………………………………………………………… 113 Claim Status Inquiries…………………………………………………………………… 114 Coordination of Benefits………………………………………………………………… 114 COB & Medicare…………………………………………………………………………….115 Working Aged…………………………………………………………………………… 115 Disability………………………………………………………………………………… 115 End-Stage Renal Disease…………………………………………………………………115 No-Fault Auto Insurance………………………………………………………………… 115 Workers’ Compensation………………………………………………………………… 116 Subrogation……………………………………………………………………………… 116 Claim Review Requests……………………………………………………………………...116 Claim Appeals……………………………………………………………………………117 Requirements……………………………………………………………………………. 117 Appeals Process…………………………………………………………………………..117 Time Limits………………………………………………………………………………117 Overpayments…………………………………………………………………………… 118 Retroactive Reductions………………………………………………………………… 118 7 Welcome We would like to thank you for choosing to participate in Preferred Care Partners’ network. Preferred Care Partners is committed to improving the health of our members through a managed care environment that provides access to quality healthcare services, resulting in better outcomes and general health status. This manual will serve as a key resource for you and your staff in understanding our plans, our policies and procedures, and the responsibilities of our network of healthcare professionals. It is recommended that you and your staff read this manual and refer to it as necessary. Our Network Management Services representatives are available to assist you and your staff in understanding the policies, procedures and information contained in this manual. We can be reached toll-free at: (877) 670-8432. We value your feedback and want to hear from you. We look forward to a long and productive relationship with you and your staff. Thank you again for choosing Preferred Care Partners. Sincerely, Orlando Lopez-Fernandez, Jr., M.D 8 Introduction About Preferred Care Partners Preferred Care Partners (PCP), a wholly owned subsidiary of UnitedHealthcare, is a Medicare Advantage health plan. PCP offers Medicare Advantage plans in 12 counties: Broward, Hernando, Hillsborough, Manatee, Miami-Dade, Orange, Osceola, Pasco, Pinellas, Polk, Seminole, and Volusia. PCP is committed to delivering quality health care services to its members and quality customer service to its providers. Our mission is to provide members with affordable health care choices to meet their health care needs. A key element of choice is helping customers obtain the information they need to make informed choices and to understand the health and financial impact of those decisions. PCP currently offers a full range of Medicare health care coverage choices to our customers. Mission Statement Our primary mission is to improve the health of our members by providing ready access to health care services, choices regarding their health care needs, and simplification of the health care system. To provide the best experience and eliminate unnecessary barriers for our members and providers, we strive to streamline authorization and referral processes and to build our provider networks around the diverse needs of our members. We are committed to providing members with direct, immediate access to knowledgeable customer service representatives who understand their needs and can help them make informed choices. Non-Discrimination You must not discriminate against any patient, with regard to quality of service or accessibility of services, on the basis that the patient is a member of PCP, or on the basis of race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability, disability, genetic information, or source of payment. You must maintain policies and procedures to demonstrate you do not discriminate in delivery of service and accept for treatment any members in need of the services you provide. Using This Manual The 2014 Provider Manual (this “Manual”) applies to covered services you provide to members under a PCP benefit plan insured by UnitedHealthcare. This manual is an extension of your provider agreement. Except when indicated, this Manual is effective on June 1, 2014 for physicians, health care professionals, facilities and ancillary providers currently participating in the PCP network and effective immediately for physicians, healthcare professionals, facilities and ancillary providers who join the PCP network on or after June 1, 2014. Terms used in this Guide include the following: “Member” refers to a person eligible and enrolled to receive coverage from a payer for covered services as defined or referenced in your agreement with us. “You”, “your”, or “provider” refers to any provider subject to this Manual, including physicians, health care professionals, facilities and ancillary providers; except when indicated all items are applicable to all types of providers subject to this Guide. “The Plan,” “our,” “us,” or “we,” refers to PCP. 9 Introduction In the event of a conflict or inconsistency between your agreement with us and this Manual, the provisions of your agreement with us will control. This entire Manual is subject to change. The most recent version of the Manual is available on our provider website, at www.mypreferredprovider.com. Alternatively, you may request a copy of this Manual from Network Management Services (NMS) via toll-free fax, at (888) 659-0619. Questions or Comments Questions or comments about this Manual [email protected], or submitted by mail to: Preferred Care Partners Network Management Services 9100 South Dadeland Blvd. Suite 1250 Miami, FL 33156-6420 10 should be emailed to NMS at Section 1 Contact & Administrative Information Important Contact Information Notifications/Authorizations (800) 995-0480 For notifications, prior authorizations, referrals, admissions, and discharge planning, call our Utilization Management department at the toll-free number listed above, Monday through Friday, 9:00 a.m. to 5:00 p.m. or fax us toll-free at (866) 567-0144. For after-hour or weekend emergencies, notifications or hospital admissions, please call the Plan’s after-hours telephonic answering service, 1-800-WEANSWER at (800) 995-0480 for assistance. Claims (866) 725-9334 For claims, encounters, inquiries, status, or review requests, please call our Claims department at the toll-free number listed above, Monday through Friday, 8:00 a.m. to 5:00 p.m., or fax us toll-free at (866) 725-9337. For questions related to the use of Emdeon’s claim submission network, such as password or technical support issues, call Emdeon toll-free at (800) 845-6592. Pharmacy (800) 591-6144 To verify pharmacy benefits and eligibility, adjudications, or authorizations, contact our Pharmacy department at the toll-free number listed above, Monday through Friday, 9:00 a.m. to 5:00 p.m., or fax us toll-free at (800) 203-1664. For more information see Pharmacy Benefits, Section 9. Benefits and Eligibility Verification (800) 587-5114 To verify eligibility and benefits, please call our Member Services department at the toll-free number listed above. Additional Contact Information Credentialing (800) 963-6495 Call our Credentialing department toll-free Monday through Friday, 9:00 a.m. to 5:00 p.m., at the tollfree number listed above for issues regarding credentialing, re-credentialing, document changes, or recent hires or terminations in your practice or facility. If you prefer, you can fax us toll-free at (866) 567-0144. Fraud, Waste and Abuse (FWA) Hotline (866) 678-8822 Call our FWA Hotline toll-free Monday through Friday, 9:00 a.m. to 5:00 p.m., at the number listed above, or fax us toll-free at (888) 659-0617 to report any suspected fraudulent or abusive activity. If you prefer, you can e-mail us at [email protected], or write to: Preferred Care Partners Special Investigations Unit P.O. Box 56-5748 Miami, FL 33256-5748 11 You can also contact us via www.mypreferredprovider.com. the Fraud Hotline link on Grievances & Appeals our provider website, (888) 291-5721 Contact our Grievance and Appeals department toll-free Monday through Friday, 9:00 a.m. to 5:00 p.m., at the number listed above for questions about filing a grievance or appeal on behalf of a member, status inquiries, or requests for forms. If you prefer, you may send a fax toll-free to (866) 261-1474, or mail documentation to: Preferred Care Partners, Inc. Health Plan Grievance & Appeals Department P. O. Box 56-6420 Miami, FL 33256-6420 Healthcare Risk Management (800) 872-9750 (305) 670-8440 Fax: (305) 671-4087 Member Incident Reporting Report incidents involving members to the Plan’s Risk Manager by faxing the appropriate report form to the number listed above. For more information, refer to Healthcare Risk Management, Section 7. Privacy Incident Reporting Report incidents involving all privacy issues (potential breeches of PHI and/or PII) immediately to the Plan’s Risk Manager at the number listed above. Member Services Member Line (866) 231-7201 TTY: 711 Member Services can assist our members with any questions, help locate specialists, and perform other related functions. This toll-free phone number is also printed on the member’s Plan ID card. Hours are Monday through Friday, 9:00 a.m. to 5:00 p.m. If you prefer you may sent a fax toll-free to (866) 567-0144. Network Management Services (877) 670-8432 Contact Network Management Services toll-free Monday through Friday, 9:00 a.m. to 5:00 p.m., at the number listed above for questions regarding provider agreements, in-servicing and followup/outreaches, demographic changes, informal complaints, and requests for forms or other materials. You may also send an e-mail to [email protected], or fax us at (786) 888-1291. Utilization Management (800) 995-0480 We recommend that you initiate requests for notifications and authorizations electronically. (See Provider Services Online, below) If additional medical information is needed, or the request cannot be completed electronically, call Utilization Management (UM) Monday through Friday, 9:00 a.m. to 5:00 p.m., at the number listed above. You may also fax us toll-free at (866) 567-0144. UM staff is available to answer any of your questions or discuss any UM issue you may have. 12 UM staffs are available to assist with information regarding referrals, prior authorizations, case management, concurrent review, and admission certification / notification. For more information on Utilization Management, see Utilization Management, Section 5. Ancillary and Enhanced-Benefit Providers Certain health care services and other benefits are offered exclusively through specific networks and providers. Members must obtain these services and/or products from the providers listed on the following pages in order for the services or products to be covered. Note that not all benefits are offered in all plans. If you are unsure, you can check benefits on our provider website, or call Member Services at (800) 587-5114 to verify benefits. 24-Hour Nurse Hotline Carenet (866) 523-4728 The toll-free 24-Hour Nurse Hotline is provided through Carenet. Working from the Carenet script, nurses are available to triage callers to emergency or urgent care, or to refer them to their primary care physician. NOTE: This benefit is only available under certain plans; contact Member Services to verify availability. Acupuncture American Specialty Health (877) 670-8432 A list of American Specialty Health acupuncture providers is included in the Provider Directory. Note that this benefit is only available under some plans. To determine if acupuncture is covered for a particular member, contact Member Services. For other assistance with this program, contact Network Management Services Monday through Friday, 9:00 a.m. to 5:00 p.m. at the toll-free number listed above. Behavioral Health Services Psychcare (800) 221-5487 Psychcare, Inc. (Psychcare) is the Managed Behavioral Health Organization (MBHO) to whom the Plan has delegated the provision of behavioral health and substance abuse services for all members. Psychcare has licensed clinicians on call 24 hours a day, 7 days a week for triage and referral of emergent or urgently needed care. For routine outpatient services, Psychcare’s Member Services department is available 8:00 a.m. to 8:00 p.m. Monday through Friday. Call the toll free number listed above for Behavioral Health services. A list of behavioral health practitioners and providers are included in the Provider Directory. Dental Solstice (877) 670-8432 A list of Solstice dental providers is included in the Provider Directory and on our website. For assistance with this program, contact Network Management Services toll-free Monday through Friday, 9:00 a.m. to 5:00 p.m. at the number listed above. 13 DME, Home Health, Home Infusion All-Med Services of Florida (800) 369-1416 DME, home health, home infusion and similar medical supply items are provided by All-Med Services of Florida. Contact All-Med at the number listed above to arrange for these services. Hours of operation are Monday through Friday from 8:30 a.m. to 7:00 p.m. and Saturday from 8:30 a.m. to 5:30 p.m. On Sundays staff members are on call and will respond within 15 minutes of notification. For assistance with this service, contact Utilization Management Monday through Friday, 9:00 a.m. to 5:00 p.m., at (800) 995-0480, or fax us at (866) 567-0144. If you should have additional questions, you may contact Network Management Services at (877) 670-8432 Monday through Friday, 9:00 a.m. to 5:00 p.m. Fitness Silver & Fit® (877) 427-4788 For information on this program, members can log onto the Silver & Fit website at www.silverandfit.com or they can call the toll-free number listed above, Monday through Friday, 8:00 a.m. to 9:00 p.m. Hearing Hear-X/HearUSA (877) 670-8432 For information on this program, contact Network Management Services Monday through Friday, 9:00 a.m. to 5:00 p.m., at the toll-free number shown above. Laboratory Quest Diagnostics (866) 697-8378 Contact Quest Diagnostics at the toll-free number listed above for information on locations, to make an appointment, and to order lab tests and view results. Or you may obtain this information by logging onto www.questdiagnostics.com. Quest Diagnostics will set up an account with your office and make arrangements to pick up specimens when necessary. Pharmacy Mail Order OptumRx (877) 889-6358 Members can obtain mail-order medications by contacting OptumRx at the toll-free number above, or by logging onto www.optumrx.com Podiatry Foot and Ankle Network (877) 670-8432 A list of podiatrists is included in the Provider Directory. For assistance with this program, contact Network Management Services Monday through Friday, 9:00 a.m. to 5:00 p.m. at the number listed above. Transportation (866) 231-7201 For assistance with transportation, contact Member Services Monday through Friday, 9:00 a.m. to 5:00 p.m., at the number listed above. 14 Vision UHC Vision a/k/a Spectera Eyecare Networks (877) 670-8432 A list of vision providers is included in the Provider Directory. For assistance with this service, contact Network Management Services Monday through Friday, 9:00 a.m. to 5:00 p.m. Provider Services Online Provider Website Our provider website, www.mypreferredprovider.com, is an information resource to help you meet the healthcare needs of our members efficiently and effectively. The website has services that are available to the public and members and secure services accessible by participating providers. Public services include, but are not limited to the following: Find a Drug Search the most current version of our Formulary by drug category, tier, or name. A printable, PDF version of the entire Formulary may also be downloaded and printed. Find a Pharmacy Search the most current list of our in-network pharmacies by pharmacy name, location or zip code. You may also view, download, and print the entire list. Find a Provider Search for a provider by name, specialty, language, or location. You may also view, download and print the complete Provider Directory. Provider Online Services The secure services available to registered providers include but are not limited to the following: Verify a member’s eligibility, including plan benefits, deductibles, and information on the member’s primary care provider, as applicable. Submit, search for, and print authorizations for outpatient services or inpatient stays. Search for, view, and check the status of claims. Provider Resources, such as Fraud, Waste and Abuse Training materials, forms, ICD-9-CM codes and clinical and preventive guidelines. Providers must register with us prior to using these services. Should you need help with registration, contact our Network Management Services Department by email at [email protected]. If you are already registered and wish to add a user or need help with an issue, contact Network Management Services at (877) 670-8432 Monday through Friday, 9:00 a.m. to 5:00 p.m. For complete information on registration and use of these services, refer to the Provider Registration User Guide. Office Location: Miami Office 9100 Dadeland Blvd. Suite 1250 Miami, FL 33156 15 Section 2 Provider Information & Administrative Responsibilities General Administrative Requirements Introduction The following requirements are basic guidelines to which you have agreed to follow in your Provider Agreement. You will be updated as necessary regarding regulatory changes that require revisions to these responsibilities. Cooperate with Quality Improvement Activities All participating physicians, healthcare professionals and facilities must cooperate with all of our quality improvement activities. These include, but are not limited to, the following: Timely provision of medical records upon request by us; Cooperation with quality of care investigations including timely response to queries and/or completion of improvement action plans; Participation in quality audits, including site visits and medical record standards reviews, and annual Health Care Effectiveness Data and Information Set (HEDIS®) record review; If we request medical records, provision of copies or access to such records free of charge (or as indicated in your agreement with us) during site visits or via email, secure email, or secure fax; Use of performance data. Provider Network Bulletins Throughout the year, Preferred Care Partners publishes the “Provider Network Bulletin,” a user-friendly newsletter resource, which includes notice to our network physicians and facilities of any protocol, policy, or program updates and changes, as well as an array of other useful and interesting items. It includes information relevant to our Medicare Advantage products. The Provider Network Bulletins are available on our website at www.mypreferredprovider.com, or you may call (877) 670-8432 to receive a copy. Please read the Network Bulletins to view important information on protocol and policy changes, administrative information and clinical resources. Physician Specific Standards Demographic Changes PCP is committed to providing our members with the most accurate and up-to-date information about our network. Report changes to your practice information 30 days prior to the date of the change. Unless otherwise stated below, these demographic changes can be submitted by facsimile to (786) 888-1291. Demographic changes include changes to any of the following: Taxpayer Identification Number, address, service locations, and additions and deletions to practice professional staff. 16 You may submit demographic changes by faxing a completed Provider Demographic Update Form (found at www.mypreferredprovider.com ) or by faxing a written, detailed description of the change and its effective date. Any notice of a change to a Taxpayer Identification Number and any addition of a physician or other healthcare professional must include a completed W-9 form (which can be found at www.IRS.gov). Access Standards PCP establishes standards for appointment access and after-hours care to make sure members have prompt and timely access to medical care and services. PCP audits your performance of these established standards at least annually. Type of Visit Routine, Wellness and Physical Appointment Within four weeks Non-urgent Within one week Urgent Care Within 24 hours Emergency Care Immediately After-Hours Care 24 hours/7days a week for primary care physicians Specialty Referrals Within two weeks* * The member may request appointments for a specific date that may exceed this standard. If so, the request should be documented to demonstrate compliance upon audit. The guidelines listed above are general PCP guidelines; state or federal regulations may require more stringent standards. Patients with scheduled appointments should have a professional evaluation within one hour of the scheduled appointment time. If a delay is unavoidable, the member must be informed and provided with an alternative. Missed Appointments A patient who misses an appointment without notification is considered a “no-show.” Physicians should have a mechanism in place to ensure that the “no-show” is documented and reviewed. Chronic failure to attend appointments should be forwarded to the Plan with supporting documentation. After-Hours Care You must have a method for members to have access care outside regular office hours. In the case of emergency, members should be directed to dial 911 (or its local equivalent) or go to the nearest emergency room. In non-emergent circumstances, members should be directed, as may be appropriate, to: (i) go to an in-network urgent care center, if the member cannot wait to be seen, (ii) stay on the line to be connected with the physician or healthcare professional on call, or (iii) provide contact information for a physician or healthcare professional to call. Substitute Coverage If you are unable to provide care and are arranging for a substitute, you must arrange substitute care with a physician in network with PCP. We encourage you to go to our website at 17 www.mypreferredprovider.com to find the most current directory of our network physicians and health care professionals. If the covering physician is not recognized by the Plan, their claims will be denied. Providing Official Notice You must send notice to us at the address noted in your agreement with us and delivered via the method required, within 10 calendar days of your knowledge of the occurrence of any of the following: Material changes to, cancellation or termination of, liability insurance; Bankruptcy or insolvency; Any indictment, arrest or conviction for a felony or any criminal charge related to your practice or profession; Any suspension, exclusion, debarment or other sanction from a state or federally funded health care program; Loss, suspension, restriction, condition, limitation, or qualification of your license to practice; For physicians, any loss, suspension, restriction, condition, limitation or qualification of staff privileges at any licensed hospital, nursing home, or other facility; Relocation or closing of your practice, and, if applicable, transfer of member records to another physician/facility. Confidentiality of Protected Health Information (PHI) PCP’s UM Program is designed to comply with the policies of UnitedHealth Group (UHG) related to Ethics and Integrity. Through application of the policies related to Privacy, the Program seeks to retain the trust and respect of our members and the public in handling of private information including health, financial, and other personal information in the conduct of our activities. All employees, contracting providers, and delegates of PCP are required to maintain the confidentiality of protected health information (PHI), including member records. All information used for UM activities is maintained as confidential in accordance with federal and state laws and regulations, including HIPAA Privacy and Security requirements. Reasonable efforts are made to limit PHI access to the minimum necessary required to accomplish the intended purpose, in order to conduct health plan operations. All PCP contracted providers must report all privacy issues immediately to Risk Management at (800) 872-975 or locally at (305) 670-8440. Examples of privacy incidents that must be reported include but are not limited to: Reports and correspondence containing PHI or Personally Identifiable Information (PII) sent to the wrong recipient; Member or provider correspondence that includes an incorrect member’s information; Complaint received indicating that PHI or PII may have been misused; Concern about compliance with a privacy or security policy; PHI or PII sent unencrypted outside of your office; Lost or theft of laptops, PDAs, CDs, DVDs, flash/USB drives and other electronic devices; Caller mentions he/she is a regulator (i.e. person is calling from the Office for Civil Rights, Office of E-Health Standards & Services, State Insurance Departments, Attorney General’s Office, Department of Justice), or threatens legal action or contacting the media in relation to a privacy issue; Caller is advising your office of a privacy risk 18 For more information on Confidentiality, refer to Medical Records, Section 6. Member Participation in Treatment Options Members have the right to freely communicate with their physician and participate in the decision making process regarding their health care, regardless of their benefit coverage. Physicians should encourage and provide active member communication and participation in their treatment planning and course of care. This includes the member’s right to withhold resuscitative services or to forgo or withdraw life-sustaining treatment in compliance with federal and state laws. Each member has the right to receive information on available treatment options (including the option of no treatment) or alternative courses of care and other information specified by law, as applicable. Physicians must communication information, regarding the risks, benefits, and consequences of treatment or non-treatment, at a level the member can understand to decide among the treatment options. Competent members have the right to refuse recommended treatment, counsel or procedure. The physician may regard such refusal as incompatible with the continuance of the physician/patient relationship and the provision of proper medical care. If this occurs, and the physician believes that no professionally acceptable alternatives exist, the physician must so inform the member in writing, via certified mail. The physician must give the member 30 calendar days to find another provider. During this time, the physician is responsible for providing continuity of care to the member. For more information, refer to Quality Improvement, Section 4. Physician Extender Responsibilities Physician extenders are state licensed healthcare professionals who may be employed or contracted by physicians to examine and treat Medicare members. Physician extenders are Advanced Registered Nurse Practitioners (ARNP) and Physician Assistants (PA). When care is provided by a physician extender, the following requirements must be met: Physician extenders must be under direct supervision of a physician when providing care. This means that a physician must be present on the premises at all times when the physician extender is seeing patients. The member must be notified of the physician extender’s credentials and the possibility of not being seen by a medical doctor. All progress notes made by the physician extender must be signed by the sponsoring physicians. Physician extenders will provide services as defined by protocol developed and signed (approved) by the sponsoring physician. Common Provider Standards Inform Members of Advance Directives The federal Patient Self-Determination Act (PSDA) gives individuals the legal right to make choices about their medical care in advance of incapacitating illness or injury through an advance directive. Under the federal act, physicians and providers including hospitals, skilled nursing facilities, hospices, home health agencies and others must provide written information to patients on state law about advance treatment directives, about patients’ rights to accept or refuse treatment, and about their own policies regarding advance directives. To comply with this requirement, we also inform members of state laws on advance directives through our members’ benefit material. We encourage these discussions with our members. For more information on Advance Directive refer to Medical Records, Section 6. 19 Access to Medical Records We may request copies of medical records from you in connection with our utilization management/care management, quality assurance and improvement processes, claims payment and other administrative obligations, including reviewing your compliance with the terms and provisions of your agreement with us, and with appropriate billing practice. If we request medical records, you will provide copies of those records free of charge unless your participation agreement provides otherwise. In addition, you must provide access to any medical, financial or administrative records related to the services you provide to our members within 14 calendar days of our request or sooner for cases involving alleged fraud and abuse, a member grievance/appeal, or a regulatory or accreditation agency requirement, unless your participation agreement states otherwise. Medical records must be maintained and protected for confidentiality for a minimum of 10 years to comply with state and federal regulations or longer if there is a government inquiry/investigation. You must provide access to medical records, even after termination of an agreement, for the period in which the agreement was in place. Provider Forms The latest versions of all forms referenced in the Manual are available on our website at www.mypreferredprovider.com, or contact Network Management Services at (877) 670-8432. We recommend that you check our website to ensure that you are using the latest version of any form. Fraud, Waste and Abuse Prevention Detecting and preventing fraud, waste and abuse is the responsibility of everyone, including employees, Plan members, physicians, vendors, subcontractors, hospitals, and other persons who may be subject to federal or state laws relating to fraud waste and abuse. By the terms of your contract with the Plan, you must have and maintain an effective compliance program that provides: a) measures to detect, correct, and prevent fraud, waste and abuse, b) training and education for everyone within your organization, including managers and directors, and c) effective lines of communication with the organization’s compliance officer. Education and Training The Centers for Medicare and Medicaid Services requires that all employees who work or contract with Part C Medicare Advantage Programs and/or Part D Medicare Prescription Drug Programs meet annual compliance and education training requirements with respect to fraud, waste and abuse. The Plan has made training materials available on our website at: www.mypreferredprovider.com. You are responsible for ensuring compliance with CMS training requirements. Please note that, upon request, you must be able to submit records of training logs documenting employee participation in the training. Reporting Fraud, Waste and Abuse Preferred Care Partners has established a Fraud, Waste and Abuse Prevention Plan to objectively and systematically monitor, investigate and report possible insurance fraud for further investigation and prosecution. The Plan has the duty to investigate and report suspected fraudulent activity to the appropriate federal and/or state agency. 20 If you have information regarding fraud, waste and abuse misconduct or potential misconduct, report the information or complaint to the Plan Special Investigative Unit (SIU). All reports are treated confidentially, and you may remain anonymous. You may report fraud, waste or abuse to the Plan via: FWA Hotline: (866) 678-8822 Email: [email protected] Online: www.mypreferredprovider.com You may report suspected cases of Medicare fraud directly to CMS at: (800) MEDICARE You may also report fraud to the Health and Human Services Office of the Inspector General. The address and phone numbers are: Office of the Inspector General Department of Health and Human Services Attn: HOTLINE 330 Independence Ave., SW Washington, DC 20201 Telephone: TTY: 800-HHS-TIPS (800) 447-8477) (800) 377-4950 Additional Medicare Advantage Requirements If you participate in the network for our Medicare Advantage products, you must comply with the following additional requirements for services you provide to our Medicare Advantage members. You may not discriminate against members in any way based on health status. You must allow members to directly access screening mammography and influenza vaccination services. You may not impose cost-sharing on members for the influenza vaccine or pneumococcal vaccine or certain other preventive services. You must provide female members with direct access to a women’s health specialist for routine and preventive health care services. You must make sure that members have adequate access to covered health services. You must make sure that your hours of operation are convenient to members and do not discriminate against members and that medically necessary services are available to members 24 hours a day, 7 days a week. Primary Care Physicians must have backup for absences. You may only make available or distribute plan marketing materials to members in accordance with CMS requirements. You must provide services to members in a culturally competent manner, taking into account limited English proficiency or reading skills, hearing or vision impairment and diverse cultural and ethnic backgrounds. You must cooperate with our procedures to inform members of health care needs that require follow-up and provide necessary training to members in self-care. 21 You must document in a prominent part of the member’s medical record whether the Customer has executed an advance directive. You must provide covered health services in a manner consistent with professionally recognized standards of health care. You must make sure that any payment and incentive arrangements with subcontractors are specified in a written agreement, that such arrangements do not encourage reductions in medically necessary services, and that any physician incentive plans comply with applicable CMS standards. You must cooperate with our processes to disclose to CMS all information necessary for CMS to administer and evaluate the Medicare Advantage Program, and all information determined by CMS to be necessary to assist members in making an informed choice about Medicare coverage. You must cooperate with our processes for notifying members of network participation agreement terminations. You must comply with our Medicare Advantage medical policies, quality improvement programs and medical management procedures. You must cooperate with us in fulfilling our responsibility to disclose to CMS quality, performance and other indicators as specified by CMS. You must cooperate with our procedures for handling grievances, appeals and expedited appeals. Credentialing and Recredentialing We are dedicated to providing our members with access to effective health care and, as such, we credential physicians and other health care professionals who seek to participate in our network and get listed in our provider directory, and then recredential them at least every 36 months thereafter, in order to maintain and improve the quality of care and services delivered to our members. Our credentialing standards are more extensive than (though, fully compliant with) the National Committee for Quality Assurance (NCQA) and Center for Medicare and Medicaid Services (CMS) and State of Florida requirements. You must notify Contract Network Management Services at (877) 670-8432 if you add a new physician, physician assistant, or advanced nurse practitioner to your staff. Note that these practitioners may not see our members until a credentialing approval letter has been received. We accept the Council for Affordable Quality Healthcare (CAQH) credentialing application. The Health Plan is able to use the CAQH Universal Provider Data Source to obtain credentialing and credentialing documentation for providers that participate with CAQH. If the provider is not a CAQH participant, or if the CAQH file is not updated, the Plan will fax the provider’s office a request for current documentation. Providers must maintain an active, Florida Medical License, DEA license and current malpractice insurance. Current documentation must be maintained in the CAQH system or sent directly to the Health Plan. A site audit and medical record review must be conducted at the time of recredentialing. Physicians are expected to cooperate and facilitate scheduling of these activities. Results will be made available to the physician, including any Corrective Action Plan, if needed. 22 Rights Related to the Credentialing Process Physicians and other health care providers applying for network participation have the following rights regarding the credentialing process: • To review the information submitted to support your credentialing application; • To correct erroneous information; and • To be informed of the status of your credentialing or recredentialing application, upon request. Termination of Contract Agreements The Agreement may also be terminated immediately for cause with written notice to the physician by PCP. If your participation agreement terminates for any reason, you may be required to assist in the transition of our members’ care to another physician or health care professional who participates in the PCP network. This may include providing services for a reasonable time at our contracted rate during the continuation period, per your participation agreement and any applicable laws. Our UM staff is available to help you and our members with the transition. We will notify affected members at least 30 calendar days prior to the effective date of termination of your agreement, or as required under applicable laws As a participating physician, the records of the members that were under your care must be made available to the next physician at no cost to that physician or the member, and must be available to the Plan upon request. In the event that a member chooses to change to another healthcare provider in or out of Network, the current provider must supply all the necessary information and documentation to allow for a timely and smooth transition at no cost to the member, recipient physician or the Plan. Resolving Disputes – Agreement Concern or Complaint If you have a concern or a complaint about your relationship with us, send a letter containing the details to the address listed in your Agreement with us. A representative will look into your complaint and try to resolve it through an informal discussion. If our internal process does not resolve the dispute, please refer to your agreement’s dispute resolution section, if applicable, for more information. 23 Section 3 Member Rights & Responsibilities Introduction We inform our members that they have specific rights and responsibilities as outlined in the member materials for Medicare Advantage benefit plans, all of which are intended to help uphold the quality of care and services that they receive from you. The Member Rights and Responsibilities Statement is published each year in the Evidence of Coverage (EOC) available on the PCP website at www.mypreferredcare.com . A copy of the Member Rights and Responsibilities Statement can also be obtained by contacting the Network Management Department at (877) 670-8432. If your patient has questions about his or her rights as a Medicare Advantage member, please refer them to the Member Services phone number on the back of their ID Card. Federal Patient Self-Determination Act of 1990 According to the Federal Patient Self-Determination Act of 1990, every member over the age of 18 enrolled in a health plan has the right to make decisions concerning his or her medical treatment. This law states that members’ rights and personal wishes must be respected even when the member is too sick to make decisions on his/her own. You may find the Patient Self-Determination Act on the PCP website at www.mypreferredcare.com. Member Financial Responsibility Members are responsible for the copayments, deductibles and coinsurance associated with their benefit plan. You should collect copayments at the time of service; however, to determine the exact member responsibility related to benefit plan deductibles and coinsurance, we recommend that you submit claims first and refer to the appropriate Explanation of Benefits (EOB) when billing members for their financial responsibility. If you prefer to collect payment at the time of service, you must make a good faith effort to estimate the member’s responsibility using the tool we make available and collect no more than that amount at the time of services. A tool, Claims & Payments, is available on our website at www.mypreferredprovider.com to help you determine member and health plan responsibility. The Florida Patient’s Bill of Rights Florida law, the Florida Patient’s Bill of Rights and Responsibilities, Florida Statutes, Chapter 381(026) specifies rights and responsibilities that apply to all patients. The entire Bill of Rights is outlined below for your review. A summarized copy of the Patient’s Bill of Rights, suitable for posting in your office, can be found on our website at www.mypreferredcare.com. Florida Patient's Bill of Rights and Responsibilities Florida Statutes Chapter 381(026) (1) SHORT TITLE. This section may be cited as the "Florida Patient's Bill of Rights and Responsibilities." (2) DEFINITIONS. As used in this section, the term: (a) "Health care facility" means a facility licensed under chapter 395. 24 (b) "Health care provider" means a physician licensed under chapter 458, an osteopathic physician licensed under chapter 459, or a podiatrist licensed under chapter 461. (c) "Responsible provider" means a health care provider who is primarily responsible for patient care in a health care facility or provider's office. (3) PURPOSE. It is the purpose of this section to promote the interests and well-being of the patients of health care providers and health care facilities and to promote better communication between the patient and the health care provider. It is the intent of the Legislature that health care providers understand their responsibility to give their patients a general understanding of the procedures to be performed on them and to provide information pertaining to their health care so that they may make decisions in an informed manner after considering the information relating to their condition, the available treatment alternatives, and substantial risks and hazards inherent in the treatments. It is the intent of the Legislature that patients have a general understanding of their responsibilities toward health care providers and health care facilities. It is the intent of the Legislature that the provision of such information to a patient eliminates potential misunderstandings between patients and health care providers. It is a public policy of the state that the interests of patients be recognized in a patient's bill of rights and responsibilities and that a health care facility or health care provider may not require a patient to waive his rights as a condition of treatment. This section shall not be used for any purpose in any civil or administrative action and neither expands nor limits any rights or remedies provided under any other law. (4) RIGHTS OF PATIENTS. Each health care facility or provider shall observe the following standards: (a) Individual dignity. 1. The individual dignity of a patient must be respected at all times and upon all occasions. 2. Every patient who is provided health care services retains certain rights to privacy, which must be respected without regard to the patient's economic status or source of payment for his care. The patient's rights to privacy must be respected to the extent consistent with providing adequate medical care to the patient and with the efficient administration of the health care facility or provider's office. However, this subparagraph does not preclude necessary and discreet discussion of a patient's case or examination by appropriate medical personnel. 3. A patient has the right to a prompt and reasonable response to a question or request. A health care facility shall respond in a reasonable manner to the request of a patient's health care provider for medical services to the patient. The health care facility shall also respond in a reasonable manner to the patient's request for other services customarily rendered by the health care facility to the extent such services do not require the approval of the patient's health care provider or are not inconsistent with the patient's treatment. 4. A patient in a health care facility has the right to retain and use personal clothing or possessions as space permits, unless for him to do so would infringe upon the right of another patient or is medically or programmatically contraindicated for documented medical, safety, or programmatic reasons. (b) Information. 1. A patient has the right to know the name, function, and qualifications of each health care provider who is providing medical services to the patient. A patient 25 may request such information from his responsible provider or the health care facility in which he is receiving medical services. 2. A patient in a health care facility has the right to know what patient support services are available in the facility. 3. A patient has the right to be given by his health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis, unless it is medically inadvisable or impossible to give this information to the patient, in which case the information must be given to the patient's guardian or a person designated as the patient's representative. A patient has the right to refuse this information. 4. A patient has the right to refuse any treatment based on information required by this paragraph, except as otherwise provided by law. The responsible provider shall document any such refusal. 5. A patient in a health care facility has the right to know what facility rules and regulations apply to patient conduct. 6. A patient has the right to express grievances to a health care provider, a health care facility, or the appropriate state licensing agency regarding alleged violations of patients' rights. A patient has the right to know the health care provider's or health care facility's procedures for expressing a grievance. 7. A patient in a health care facility who does not speak English has the right to be provided an interpreter when receiving medical services if the facility does not have a person readily available who can interpret on behalf of the patient. (c) Financial information and disclosure. 1. A patient has the right to be given, upon request, by the responsible provider, his designee, or a representative of the health care facility full information and necessary counseling on the availability of known financial resources for the patient's health care. 2. A health care provider or a health care facility shall, upon request, disclose to each patient who is eligible for Medicare, in advance of treatment, whether the health care provider or the health care facility in which the patient is receiving medical services accepts assignment under Medicare reimbursement as payment in full for medical services and treatment rendered in the health care provider's office or health care facility. 3. A health care provider or a health care facility shall, upon request, furnish a patient, prior to provision of medical services, a reasonable estimate of charges for such services. Such reasonable estimate shall not preclude the health care provider or health care facility from exceeding the estimate or making additional charges based on changes in the patient's condition or treatment needs. 4. A patient has the right to receive a copy of an itemized bill upon request. A patient has a right to be given an explanation of charges upon request. (d) Access to health care. 1. A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap, or source of payment. 26 2. A patient has the right to treatment for any emergency medical condition that shall deteriorate from failure to provide such treatment. (e) Experimental research. In addition to the provisions of Section 766.103, F.S., a patient has the right to know if medical treatment is for purposes of experimental research and to consent prior to participation in such experimental research. For any patient, regardless of ability to pay or source of payment for his care, participation must be a voluntary matter; and a patient has the right to refuse to participate. The patient's consent or refusal must be documented in the patient's care record. (f) Patient's knowledge of rights and responsibilities. In receiving health care, patients have the right to know what their rights and responsibilities are. (5) RESPONSIBILITIES OF PATIENTS. Each patient of a health care provider or health care facility shall respect the health care provider's and health care facility's right to expect behavior on the part of patients which, considering the nature of their illness, is reasonable and responsible. Each patient shall observe the responsibilities described in the following summary. (6) SUMMARY OF RIGHTS AND RESPONSIBILITIES. Any health care provider who treats a patient in an office or any health care facility that admits and treats a patient shall adopt and make public, in writing, a statement of the rights and responsibilities of patients, including: “SUMMARY OF THE FLORIDA PATIENT'S BILL OF RIGHTS AND RESPONSIBILITIES” This Summary is available at the link provided above. 27 Section 4 Quality Improvement Overview PCP is a health care delivery organization that provides comprehensive medical/clinical care and services for Medicare Advantage and Medicaid members through a network of physicians, facilities and other health care professionals. The QI Program is designed to provide oversight and guidance for all PCP Medicare Advantage and Medicaid Plans. Special attention is given to high volume, high risk areas of care and service for each population. Health promotion, health management, and patient safety activities are also an integral part of the QI Program and are specialized according to regulatory requirement, population needs, and available delivery models. The Program is designed to provide oversight and guidance to ensure the Plan’s goals and objectives are met. The Plan conducts quality reviews to ensure that providers are properly addressing member concerns and rights. Areas of review include site audits, medical record reviews, analysis of complaints and grievances, requests for provider changes, and other measurable data. The QI Program identifies planned activities related to program priorities that address the quality and safety of clinical care and services. Our Quality Improvement activities include but are not limited to: Access and Availability; Behavioral Healthcare Programs Preventive and Clinical Practice Guidelines; Continuity and Coordination of Care; Member and Physician Satisfaction; Patient Safety Physician Medical Records / Office Site Audits (see Practice Standards & Performance Measures, Section 8) Delegation Oversight; and CMS Programs and Projects: o Oversight of Special Needs Plans (SNP) Model of Care (MOC); o Oversight of SNP Structure and Process o Chronic Care Improvement Programs (CCIPs) o Quality Improvement Projects (QIPs) Provider contracts include the obligation to participate in the Plan’s Quality Improvement Program. Upon request, the Plan makes the information within the program available to members and providers. Quality Improvement Committee (QIC) The Plan’s QIC is responsible for assuring quality, comprehensive health care and services are provided to Plan members through an ongoing, systematic evaluation and monitoring process that facilitates continuous process improvement. The QIC has distinct goals and objectives to accomplish its primary function of oversight of the clinical and operational systems as they affect care and services provided to members. Specific performance activity outcomes/results are shared with PCP providers through this Manual and/or Provider Newsletters. Program Activities Access and Availability The Plan requires physicians to meet the access and availability standards described in detail in Provider Information & Administrative Responsibilities, Section 2. Access and availability to health care services is 28 a key component of health care quality that ensures each member is heard and has his or her medical needs met in a reasonable and timely manner. Behavioral Healthcare Programs Psychcare is the Managed Behavioral Healthcare Organization (MBHO) to whom the Plan has delegated the provision of behavioral healthcare services for all members. Psychcare is accredited by the National Committee for Quality Assurance (NCQA) and submits regular reports to the Plan for oversight and monitoring. A Senior Behavioral Healthcare Practitioner is actively involved in the key activities of the behavioral healthcare aspects of the UM program. To the extent possible and permissible by current privacy and confidentiality regulations, behavioral health and general medical management is integrated for optimal health outcomes. For more information on how to access the Behavioral Healthcare programs, you may reference Section 2, Contact & Administrative Information or you or your patients may contact a Psychcare representative through the phone number listed on the back of their health care ID card. To promote coordination of care and collaboration between medical and behavioral health care, a Psychcare Medical Director and the VP of Quality Management are voting members of the Plan’s Quality Improvement Committee. Clinical and Preventive Health Guidelines The Plan uses evidence-based clinical and preventive health guidelines from nationally recognized sources to guide our quality and health management programs. We hope you consider this information and use it when it is appropriate for your eligible patients. A list of the current guidelines is available through our website at, www.mypreferredprovider.com. Continuity and Coordination of Care An annual analysis is conducted to review the continuity and coordination of medical care provided to PCP members across settings and / or during transitions of care. The scope of activities includes transitions in care (including changes in management of care among practitioners), changes in settings (including inpatient and ambulatory location), or other changes in which practitioners partner to provide ongoing care for a member. The primary activities may include but are not limited to: Prescription of controlled substances. Member satisfaction with continuity and coordination of medical care. Provider satisfaction with coordination of medical care. Steerage to transplant centers of excellence. Continuity of care between dialysis centers and nephrologists. Continuity of medical and behavioral healthcare. The Plan and Psychcare offer a medical integration program that is available to all members. This program is called Encompass. The focus of Encompass is to treat all aspects for the members who require coordination of care between the medical and behavioral specialists. Referrals to the program may be made by the member, the provider or by the member’s care-giver. Encompass offers care coordination, intensive case management, and several primary and secondary preventive behavioral healthcare programs. These programs include: Alzheimer’s Disease Preventive Health Program Domestic Violence Prevention Program Eating Disorders Prevention Program 29 Stress Management Prevention Program Tobacco Cessation Program These educational, website articles may be printed to assist and educate the member and/or provider in recognizing the illness, managing the symptoms of the disorder, how to prevent relapse, and various treatment options and community resources. You may also call Psychcare at (800) 221-5487 for more information. Member and Physician Satisfaction Surveys A member satisfaction survey is conducted annually by Member Services. The survey measures members’ satisfaction with the Plan’s services through monitoring of complains and appeals, and CAHPS. A physician satisfaction survey is conducted annually by Network Management Services in order to obtain physicians’ satisfaction with the Plan’s services. Opportunities for improvement are identified by analyzing the data and appropriate action(s) are implemented. Patient Safety PCP supports the prevention and elimination of healthcare errors by our commitment to the practice of evidence-based medicine. PCP is committed to helping practitioners and providers improve the safety of their practices. Patient safety is an important aspect and as such incorporated into the initial health risk assessment and periodic reassessments. Patient Safety is also assessed during Practitioner Site Audits and addressed in Member Newsletter(s). The health risk assessment includes a section on enrollee/patient safety that addresses accessibility to emergency services, the enrollee/patient’s physical environment, caregiver availability, and risk for falls. Safety assessments are evaluated for gaps and interventions implemented to meet enrollee/patient needs. Interventions to address pharmacy issues, e.g., Narcotic Report, are conducted at a physician and/or member level to reduce the prescription of inappropriate medications and to increase the prescriptions that are associated with improved outcomes. Physician Medical Records/Office Site Audits The Plan performs physician medical record and office site audits as part of the Quality Improvement Program. Medical record documentation should facilitate communication, coordination, and continuity of care, and promote efficiency and effectiveness of treatment. Through medical record review, the Plan is able to evaluate the quality, timeliness, and appropriateness of the services rendered. Refer to Medical Records, Section 6 for more information on this topic. The office site audits are part of the Plan’s credentialing and re-credentialing requirements. The purpose of the site audits is to evaluate the quality and safety of clinical care and the quality of service provided to our member, to promote continuous improvements and better clinical outcomes for our members. Refer to Physician Practice Standards and Performance Measures, Section 8 for more information on the topic. Delegation Oversight Some functions/activities that the Plan would normally perform, under regulatory and accreditation standards and requirements, may be delegated to another organization/entity. These delegated functions/activities are described in a written, mutually agreed upon contract. The agreement outlines the delegated activities, reporting responsibilities, and remedies for inadequate performance, including revocation of the delegation agreement. Oversight of these delegated functions/activities is required by 30 CMS and the NCQA. PCP conducts ongoing oversight and opportunities for improvement are identified and addressed, as applicable. CMS Programs and Projects Chronic Care Improvement Program (CCIP) as required by CMS, the Plan must implement a CCIP and establish criteria for participation in the program. The CCIP is a clinically focused project made up of 6 disease management elements: Population Identification, Evidenced-Based Guidelines, Collaborative Care, Patient Self-Management, Process and Outcomes Measures, and Routine Reporting. The CCIP must include a methodology for identifying the members with multiple or sufficiently severe chronic conditions who would benefit from participation in the program. Quality Improvement Projects (QIPs) As required by CMS, the Plan must implement QIPs that are designed to address clinical or non-clinical areas of healthcare that promote improvement in the health outcomes of its members. QIPs, whether clinical or non-clinical, must measure and improve performance. For each project, quality indicators are used to assess performance. The quality indicators must be clearly defined and based on current clinical knowledge or health services research and capable of measuring outcomes. Preferred Care Partner’s Quality Improvement Program Medicare Milestones for 2013: The Plan’s QI Program uses a variety of activities to continually measure, evaluate and improve the services provided to its members. Below are summaries of some of these activities and their outcomes/results. HEDIS HEDIS (Healthcare Effectiveness Data Information Sets) is one of the performance measurement indicators PCP uses to measure, and drive, health outcomes. Some of the data is obtained administratively (through claims information, etc.) and some is obtained through in office chart reviews performed by a certified vendor. During the measurement year 2012-2013, PCP improved on nine (9) indicators and remained the same on 7 indicators. Our top 3 performing indicators included: Cholesterol Management for Members with Cardiovascular Conditions Comprehensive Diabetes Care-Medical Attention Diabetic Nephropathy Adult’s Access to Preventive/Ambulatory Health Services Our bottom 3 performing indicators included: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment-Engagement – Total Medication Reconciliation Post-Discharge Comprehensive Diabetes Care-Blood Pressure Controlled <140/90 Overall, PCP was able to maintain a favorable HEDIS rating compared to our Florida competitors. We will continue to focus our initiatives on the HEDIS STARS measures (as defined by CMS) and improving those rates. 31 Member Satisfaction (CAHPS and STAR Ratings) The CAHPS (Consumer Assessment HealthCare Providers and Systems) Survey “is a public-private initiative to develop standardized surveys of patients’ experience with ambulatory and facility-level care” (AHRQ.gov). The annual survey measures members’ experiences with their health plan over a six month period. Certain CAHPS (and HEDIS) scores are given a 1 to 5 star rating by CMS. These ratings are used to provide information to members to help them choose their plans, effect Medicare payments, and help PCP focus on quality improvement initiatives. Ratings are as follows: 5 is considered excellent 4 is above average 3 is average 2 is below average 1 is poor Several of the PCP scores for CAHPS Composite questions are listed below for 2011-2013. The specific questions making up the composite scores are bulleted below each score. To summarize: The composite for Getting Needed Care has remained at a 4 star rating over the past three year measurement period. The composite for Getting Appointments and Care Quickly has declined from a 4 star rating in 2011 to a rating of only 1 for 2013. Getting Needed Care 2011 2012 2013 Score Star Score Star Score Star 2011 Vs 2012 Change 85 4 87 4 86 4 0 2012 Vs 2013 Change 0 In the last 6 months, how often was it easy to get appointments with specialists? In the last 6 months, how often was it easy to get the care, tests, or treatment you needed through your health plan? Getting Appts/Care Quickly 2011 2012 2013 Score Star Score Star Score Star 2011 Vs 2012 Change 75 4 74 3 71 1 -1 2012 Vs 2013 Change -1 In the last 6 months, when you needed care right away, how often did you get care as soon as you thought you needed? In the last 6 months, not counting the times when you needed care right away, how often did you get an appointment for your health care at a doctor's office or clinic as soon as you thought you needed? In the last 6 months, how often did you see the person you came to see within 15 minutes of your appointment time? 32 Physician Satisfaction The annual Physician Satisfaction Survey is conducted by PCP’s Network Management Staff. Responses to questions relevant to obtaining authorization and referral of services are utilized to measure practitioner (Primary Care and Specialist) satisfaction with these processes during the calendar year 2012. The results for specific questions for the 2012 survey are listed below: UM Satisfaction Questions Q5: Interaction with PCP same as or better than interaction with other plans. o Referral turn-around time o Referral process o Authorization process o Authorization turn-around time Overall 83% Primary Care 92% Specialist 72% Q17: Satisfied or very satisfied with their online portal experience. o Submit authorizations o Submit pre-certifications 89% 97% 79% Q18: Satisfied or very satisfied with characteristics of the online portal. o Submitting pre-certification requests quickly 87% 97% 77% Interventions: To improve overall satisfaction with the UM process the following has been implemented: Training was conducted for Patient Care Coordinators related to the additional auto approval codes and other WebPortal enhancements; Enhancements were made to the online WebPortal: o Additional auto approval codes were implemented to promote faster TATS; o Approvals/denials to include specific service lines/units approved/denied for clearer understanding of decision made; o Search capabilities were improved; o Ability for practitioners to reset their password; o Dedicated personnel to assist with WebPortal issues; o Ability to differentiate between the Medicare/Medicaid LOBs; o Offerings for WebPortal training through the use of WebEx. 33 Special Needs Plans Special Needs Plans (SNP) Model of Care (MOC) The MOC is a framework for providing healthcare and healthcare plans designed by theory, evidence-based protocols and accepted standards. The MOC contains specific elements that delineate implementation, analysis and improvement of care. These elements include description of SNP population (including health conditions), Care Coordination, Provider Network and Quality Measurement and Performance Improvement. SNP MOC Structure and Process The structure and processes of the SNP MOC program is based upon six structure and process measures to evaluate the structure, processes, and performance of SNPs. Through these measures, SNPs must demonstrate that they are providing quality health care for the Plan’s members. These measures are: Complex case management; Improving member satisfaction; Clinical quality improvements; Care transitions; I-SNP relationships with facility; and Coordination of Medicare and Medicaid coverage. Quality Performance Measures The Plan’s Quality Improvement (QI) Department continually monitors, analyzes and evaluates the care and services provided to our Members by our contracted network practitioners/providers. In order to do this, the QI Department uses quality tools and measures such as the Centers for Medicare and Medicaid Services (CMS) STAR Rating System, Health Outcome Survey (HOS) Program, Consumer Assessment of Healthcare Providers and Systems (CAHPS) Program, and the NCQA Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. STAR Rating System The CMS STAR Rating System rates Medicare health plans and drug plans on how well they perform on more than 50 items, which are grouped into five (5) and four (4) different categories, respectively. Health plans are rated on: Staying healthy: screening, tests, and vaccines; Managing chronic (long-term) conditions; Member experience with the health plan; Member complaints, problems getting services, and improvement in the health plan’s performance; and Health plan customer service. Drug plans are rated on: Drug plan customer service; Member complaints, problems getting services, and improvement in the drug plan’s performance; 34 Member experience with the drug plan; and Patient safety and accuracy of drug pricing. What the “STAR” ratings mean Medicare health and prescription drug plans get overall and/or summary ratings that summarize all categories and measures into a single “star” rating. The star rating of the plan’s performance makes it easy for you to compare plans. If you’re interested in more detail, you can look at the health or drug plan summary scores, or you can “drill down” to the star ratings category details (like member experience with drug plan) or to individual measures within the categories (like members’ ability to get prescriptions filled easily when using the plan). A plan’s star rating is calculated each year and results are available each fall. Five Stars = “Excellent” Four Stars = “Above Average” Three Stars = “Average” Two Stars = “Below Average” One Star = “Poor” If you are interested in obtaining more information you may visit www.Medicare.gov/find-a-plan. Enter the appropriate information for a general search and once you see the list of plans, you may view the star ratings by selecting the plan name. HOS Program NCQA administers the HEDIS® Medicare HOS in partnership with the CMS. HOS is the first patientbased health outcomes measure for the Medicare managed care population. The goal of the Medicare HOS program is to gather valid and reliable clinically meaningful data that have many uses, such as for targeting quality improvement activities and resources; monitoring health plan performance and rewarding topperforming health plans; helping beneficiaries make informed health care choices; and advancing the science of functional health outcomes measurement. Managed care plans with Medicare Advantage (MA) contracts must participate. CAHPS® Program The CAHPS program is a multi-year initiative of the Agency for Healthcare Research and Quality (AHRQ) to support and promote the assessment of consumers' experiences with health care. The goals of the CAHPS program are twofold: Develop standardized patient questionnaires that can be used to compare results across sponsors and over time. Generate tools and resources that sponsors can use to produce understandable and usable comparative information for both consumers and health care providers. While CAHPS surveys are similar to patient satisfaction surveys, they are not the same. As with satisfaction surveys, CAHPS surveys can include ratings of health plans or providers (such as doctors, hospitals, and nursing homes), but go beyond ratings by asking patients to report on their experiences with health care services. Reports about care are regarded as more specific, actionable, understandable, and objective than general ratings alone. 35 HEDIS® Measures HEDIS is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS is designed to provide purchasers and consumers with the information they need to reliably compare the performance of health care plans. HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 80 measures across 5 domains of care. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis. Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts. HEDIS measures address a broad range of important health issues. Among them are the following: Asthma Medication Use Persistence of Beta-Blocker Treatment after a Heart Attack Controlling High Blood Pressure Comprehensive Diabetes Care Breast Cancer Screening Antidepressant Medication Management Childhood and Adolescent Immunization Status Childhood and Adult Weight/BMI Assessment Preferred Care Partners has implemented a Stars Improvement Department that has a direct focus on Quality Performance Measures and working closely with the QI Department strives to continually improve the Plan’s performance. Many of these performance measures involve you, the provider, and can be positively impacted by the relationship between the Plan and its network providers. Preferred Care Partners, therefore, continually strives for improved lines of communication and exchange of helpful tools and looks forward to receiving provider feedback in order to continually improve the quality of care and services provided to our members. 36 Section 5 Utilization Management Introduction The Plan’s Utilization Management (UM) Program outlines the program structure and accountability, scope, processes and information utilized for clinical decision making. The UM Program is designed to interface with and support the Quality Improvement (QI) Program. The scope of the UM Program covers all clinical aspects of preventive, diagnostic and treatment services in both the inpatient and outpatient settings, which include behavioral health/substance abuse, and case and disease management. UM clinical review is performed by health care professionals utilizing pre-established clinical decision making criteria to assist in decisions regarding requests for health care services that require authorization. Services NOT Requiring Prior Authorization The Plan does not require Prior Authorization for certain services. A listing of these services is provided during new provider orientation and throughout the year, via Fax Blast, when there are revisions in these requirements. The Plan also publishes a CPT listing of healthcare services, the Participating Provider No Authorization Reference Guide (NARG), to assist South Florida (Miami-Dade and Broward Counties) providers in determining if a Prior Authorization is required prior to services being rendered. A listing of these services is provided during new provider orientation and throughout the year, via Fax Blast, when there are revisions in these requirements. Some of the services that do not require Prior Authorization before services are rendered are listed below: Emergency Services Emergency services are covered inpatient and outpatient services that are: Furnished by a provider qualified to furnish emergency services; and Needed to evaluate or treat an emergency medical condition. An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: Serious jeopardy to the health of the individual; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part. Members have been instructed to access care in an emergency through the 911 system or by going to the nearest emergency room. Should you encounter a patient in an emergent health situation, refer them to the nearest emergency room. Urgent Care Services Urgently-needed services are covered services that: Are not emergency services as defined in this section but are medically necessary and immediately required as a result of an unforeseen illness, injury, or condition such as but are not limited to: high fever, animal bites, fractures, complications from respiratory infections or flu; 37 Are provided when the enrollee is temporarily absent from the plan’s service (or, if applicable, continuation) area, or under unusual and extraordinary circumstances, when the enrollee is in the service or continuation area, and the network is temporarily unavailable or inaccessible; and It was not reasonable given the circumstances to wait to obtain the services through the plan network. Out-of- Area Renal Dialysis Prior Authorization for out-of-area renal dialysis services are not required prior to the service being rendered when provided during extenuating, urgent or emergent circumstances. Open Access Providers Open access providers do not require referrals from primary care physicians. They do however need to abide by Medicare Guidelines (i.e., they may only bill for Medicare-covered services.) The following specialties are considered open access providers: Podiatrists Dermatologists The Well-Woman visit to an OB/GYN does not require a referral when done once annually. Prior Authorization/Notification Requirements for Physicians, Healthcare Professionals and Ancillary Providers Authorization Requirements Physicians, health care professionals and ancillary providers are responsible for obtaining prior authorization for all services requiring authorization before these services are scheduled and/or rendered, such as, but not limited to: outpatient services or planned hospital admissions. Prior authorization for outpatient services or planned hospital admissions should be submitted as far in advance of the planned service as possible to allow for coverage review. Prior authorizations are required to be submitted at least seven (7) calendar days prior to the planned date of service. Prior authorizations for home health and home infusion services, durable medical equipment, and medical supply items should be submitted to All-Med Services of Florida at (800) 369-1416. When requesting that a prior authorization be expedited by placing STAT/urgent on the Prior Authorization Form, please note that you should not request an expedited (72 hours) review unless it is determine that waiting for a standard (14 calendar days) review determination could place the member’s life, health, or ability to regain maximum function in serious jeopardy. Prior authorizations are required for referrals to out-of-network specialty or ancillary providers when the member requires a necessary service that cannot be provided within the available PCP network. The referring physician must submit a completed Prior Authorization Form for approval. The Prior Authorization Form is available at our website at www.mypreferredprovider.com. It is important that you and the member are fully aware of coverage decisions before services are rendered. If you provide the service before a coverage decision is rendered, and we determine that the service was not a covered benefit, we may deny the claim and you must not bill the member; by not waiting for the coverage determination decision you made it impossible for the member to decide, with knowledge of the non-coverage determination, whether to receive and pay for the services. 38 General Notification Requirements For any inpatient or ambulatory outpatient service requiring Prior Authorization, the facility must confirm, prior to rendering the service that the coverage approval is on file. The purpose of this protocol is to enable the facility and the member to have an informed pre-service conversation; in cases where it is determined that the service will not be covered; the member can then decide whether to receive and pay for the service Facilities are responsible for admission notification for inpatient services even if the coverage approval is on file. If a member is admitted through the emergency room, notification is required no later than 48 hours from the time the patient is admitted for purposes of concurrent review and follow-up care. If a member receives urgent care services, the provider must notify the Plan within 48 hours of the services being rendered. For after-hour and weekend notifications please call the Plan’s after-hours telephonic answering service, 1-800-WEANSWER at (800) 995-0480 for assistance. Admission Notification Requirements Facilities are responsible for Admission Notification for the following types of inpatient admissions: o All planned/elective admissions for acute care o All unplanned admissions for acute care o All Skilled Nursing Facility (SNF) admissions o All admissions following outpatient surgery o All admissions following observation Unless otherwise indicated, Admission Notification must be received within 24 hours after actual weekday admission (or by 5:00 p.m. local time on the next business day if 24 hour notification would require notification on a weekend or federal holiday). For after-hour, weekend and federal holiday admissions, please call the Plan’s after-hours telephonic answering service, 1-800WEANSWER at (800) 995-0480 for assistance. Admission Notification by the facility is required even if notification was supplied by the physician and a coverage approval is on file. Receipt of an Admission Notification does not guarantee or authorize payment. Payment of covered services is contingent upon coverage within an individual member’s benefit plan, the facility being eligible for payment, any claim processing requirements, and the facility’s participation agreement with PCP. Admission Notifications must contain the following details regarding the admission: o Member name and member health care ID number o Facility name o Admitting/attending physician name o Description for admitting diagnosis or ICD-9-CM (or its successor) diagnosis code o Actual admission date For emergency admissions when a member is unstable and not capable of providing coverage information, the facility should notify PCP as soon as the information is known and communicate the extenuating circumstances. We will not apply any notification-related reimbursement deductions. Failure to comply with the requirements described in this Section may result in claims being denied in whole or in part and, as required under your agreement with us, the member being held harmless. Subject to state regulation and Medicare Advantage policies, receipt of a Notification or a Prior Authorization approval does not guarantee or authorize payment. Payment of covered services is 39 contingent upon coverage within an individual member’s benefit plan, the provider being eligible for payment, any claim processing requirements, and the Provider participation agreement with PCP. Why is Authorization/Notification Required? Information gathered about planned member care/services supports the pre-service clinical coverage review process, where applicable, and the care coordination process, which allows us to support our members throughout their course of treatment, including pre-service planning and coordination of home care and other discharge plans. How to Request Prior Authorization It is recommended that you initiate prior authorization requests electronically via the provider web portal at www.mypreferredprovider.com. Providers must register with us prior to using this service. If you do not have electronic access, you may call us at the number on the back of the members’ health care ID card. For manual prior authorizations, the requesting provider must fill out the Prior Authorization Form, sign it, and fax it to the Utilization Management Department at (866) 567-0144. This form can be used by both primary care physicians and specialists. The Prior Authorization Forms are available on the provider web portal at, www.mypreferredprovider.com, or you may contact UM at (800) 995-0480 to request a copy. Information That Must be Included in the Request for Prior Authorization Prior Authorizations must contain the following information about the planned service: Member Information: Name, DOB, and Membership ID number. Requesting Provider Information: Name, Specialty, Designate Par or Non-Par, Address and Phone and Fax Numbers Primary Care Physician Information, if different from the Requesting Provider: Name, Phone and Fax Numbers. Referral Information: Name of Referral Provider, Designate Par or Non-Par, Address, Phone and Fax Numbers. Diagnosis/Symptoms: Include the Diagnosis Description and the corresponding ICD-9 Code for each diagnosis to the highest specificity. Service(s) Requested: o If the referral is for one or more specific procedures, identify each procedure, and its corresponding CPT code. o In the Additional Comments field, document any pertinent clinical summary information which would be helpful to that specialist or for the UM determination. o Enter the date of service and number of visits requested, and sign where indicated. Where a clinical coverage review is required in the member’s benefit plan, we may request additional information in order to make the necessary determination, as described in more detail in the Clinical Coverage Review: Clinical Information section below. Note: Certain services may not be covered within an individual member’s benefit plan, regardless of whether Prior Authorization is required. In the event of a conflict or inconsistency between applicable regulations and the Advance Notification Requirements in this Manual, the notification process will be administered in accordance with applicable regulations. 40 Clinical Coverage Review: Clinical Information You must cooperate with all PCP requests for information, documents or discussions for purposes of a clinical coverage review including, but not limited to, providing pertinent medical records, imaging studies/reports and appropriate assessments for determining degree of pain or functional impairment. As a network provider, you must return/respond to calls from our UM staff and/or medical director. You must provide complete clinical information as required within 24 hours of the request for additional information. In addition: PCP may also use tools developed by third parties, such as the MCG™ guidelines®, to assist us in administering health benefits and to assist clinicians in making informed decisions in many health care settings. These tools are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. For Medicare Advantage members, we use CMS coverage determinations, the National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) to determine benefit coverage for Medicare members. If other clinical criteria, such as the MCG™ guidelines or any other coverage determination guidelines contradict CMS guidance, then PCP follow the CMS guidance. You may request a copy of the clinical criteria from your Case Reviewer by calling (800) 9950480. Coverage Determination Decisions Coverage determinations for health care services are based upon the member’s benefit documents and applicable federal requirements. PCP’s UM Staff, its delegates, and the physicians making these coverage decisions are not compensated or otherwise rewarded for issuing adverse non-coverage determinations. PCP and its delegates do not offer incentives to physicians to encourage underutilization of services or to encourage barriers to receiving the care and services needed. Coverage decisions are made based on the definition of “reasonable and necessary within Medicare coverage regulations and guidelines”. Hiring, promoting or terminating physicians or other individuals are not based upon the likelihood or the perceived likelihood that the individual will support or tend to support the denial of benefits. Clinical Coverage Review Criteria PCP utilizes established, nationally recognized criteria to determine medical necessity and appropriateness for requested care and services. Medical necessity and appropriateness coverage determinations for inpatient and outpatient care and services are made using clearly written, published criteria which are based on sound medical evidence. These criteria include, but are not limited to: National Coverage Determinations (NCD) Local Coverage Determinations (LCD) InterQual® Intensity/Severity/Discharge Screening & Indications for Surgery and Procedures. MCG™ guidelines (formerly known as Milliman Care Guidelines®) You must cooperate with all PCP requests for information, documents or discussions for purposes of a clinical coverage review including, but not limited to, providing pertinent medical records, imaging studies/reports and appropriate assessments for determining degree of pain or functional impairment. 41 Timeframes for Processing Prior Authorization Requests The Plan makes a determination of your request within 14 calendar days of receipt of request, or within 72 hours for an expedited review request. It is important that you provide all necessary supporting documents and information at the time of the request to help facilitate the decision. Prior Authorization Denials The Plan may deny a prior authorization request for several reasons: Member is not eligible with the plan; Service requested is excluded, not a covered benefit; Member’s benefit has been exhausted; or Service requested is determined not to be medically necessary (based upon clinical criteria guidelines). The Plan must notify you and the member in writing of any adverse decision (partial or complete) within applicable time frames. The notice must state the specific reasons for the decision, and reference to the benefit provision and clinical review criteria used in the decision making process. The Plan provides the clinical criteria used in the review process for making a coverage determination along with the notification of denial. However, if you have additional questions regarding the criteria, you may call UM at (800) 995-0480. Peer-to-Peer Clinical Review PCP physicians conducting clinical review determinations are available, by telephone or in person, to discuss medical necessity review determinations with the member’s physician requesting the service. If a peer-to-peer conversation does not occur prior to an adverse determination/non-certification notification, the requesting physician has the opportunity to discuss the adverse determination/non-certification decision with the PCP physician reviewer making the initial determination. If the initial physician reviewer is not available within one business day of the notification a peer-to-peer may occur with another appropriate physician reviewer. If you would like to discuss the case with one of the Plans physician reviewers, please contact UM at (800) 995-0480. Additional UM Information Members Requiring External Agency Services Some members may require medical, psychological or social services outside the scope of the Plan benefits from external agencies (for example, from Health and Human Services or Social Services). If you encounter a member in this situation, you should either contact your NMS representative, or have the member contact our Member Services Department at (866) 231-7201 for assistance with, and referral to, appropriate external agencies. Hospitalist Program for Inpatient Hospital Admissions The Hospitalist Program is a voluntary program for members. Hospitalists are physicians who specialize in the care of members in an acute inpatient setting (acute care hospitals and skilled nursing facilities). A hospitalist oversees the member’s inpatient admission and coordinates all inpatient care. The hospitalist is required to communicate with the member’s selected physician by providing records and information such as the discharge summary, upon the member’s discharge from the hospital or facility. 42 Discharge Planning Discharge planning is a collaborative effort between the concurrent reviewer, the hospital/facility case manager, the member, and the admitting physician to ensure coordination and quality of medical services through the post-discharge phase of care. The Plan may, but is not required to, assist in identifying health care resources, which may be available in the member’s community following an inpatient stay. Nurse Case Managers conduct onsite and/or telephone reviews to support discharge planning, with a focus on coordinating health care services prior to the discharge. The facility or physician is required to contact the Plan and provide clinical information to support discharge decisions under the following circumstances: An extension of the approval is needed. Contact must be made prior to the expiration of the approved days. The member’s discharge plan indicates that transfer to an alternative level of care is appropriate. The member has a complex plan of treatment that includes home health services, home infusion therapy, total parenteral nutrition and/or multiple or specialized durable medical equipment identified prior to discharge. Case Management Programs At the core of case management is identifying high-cost, complex, at-risk members who can benefit from these services. We partner with members and their physicians or other health care professionals to facilitate health care access and decisions that can have a dramatic impact on the quality and affordability of their health care. Specifically, our programs are designed to assist in ensuring individuals: Receive evidenced-based care Have necessary self-care skills and/or caregiver resources Have the right equipment and supplies to perform self-care Have requisite access to the health care delivery system Are compliant with medications and the physician’s treatment plan. A comprehensive assessment by specially-trained nurses is performed to help determine the appropriate level and frequency of interventions. The highest risk individuals will receive outbound telephone calls to address particular gaps in care. You will be notified when patients are identified for the high-risk program. Our case managers are specially-trained nurses who engage the appropriate internal, external or community-based resources needed to address members’ health care needs. When appropriate, we provide referrals to other internal programs such as disease management and behavioral health. Case management services are voluntary and a Customer can opt out at any time. Transitional Case Management: Transitional Case Management (TCM) is the collaborative process of evaluating and coordinating posthospitalization needs for member identified as being at risk of re-hospitalization or as frequent users of high-cost services. The goal of TCM is to facilitate access to services so that the member receives timely provider and home health services, medications, medical equipment, oxygen, therapies and other support as required. General Condition Management: General Condition Management serves individuals with chronic conditions, those in need of longer-term support, or those who have unmet access, care plan, psycho-social, or knowledge needs. 43 Disease Management Programs We offer disease management programs designed to provide our members with specific conditions assistance in managing their health. Programs and services provided include: Chronic Heart Failure (CHF); and Diabetes. Our programs include: A comprehensive assessment by specially-trained nurses to help determine the appropriate level and frequency of interventions. Screening for depression and helping members access the appropriate resources. Addressing lifestyle-related health issues and referring to programs for weight management, nutrition, smoking cessation, exercise, diabetes education and stress management, as appropriate. Helping members understand and manage their condition and its implications. Education for reducing risk factors, maintaining a healthy lifestyle, and adhering to treatment plans and medication regimens. Members may receive: Educational mailings, newsletters and tools to assist them in tracking their laboratory results, health status and recommended targets or other screenings. Information on gaps in care and encouragement to discuss treatment plans, goals and results with their physician. Outbound calls for the highest risk individuals to address particular gaps in care. You will be notified when patients are identified for the high-risk program. PCP provides Case Management and Disease Management programs to its members that qualify for these services. These programs facilitate the coordination of services through the healthcare continuum. For more information on these programs please call the UM Department at (800) 995-0480. Medicare Advantage Hospital Discharge Appeal Rights Protocol Medicare Advantage members have the statutory right to appeal their hospital discharge to a Quality Improvement Organization (QIO) for immediate review. The QIO for Florida is Florida Medical Quality Assurance, Inc. (FMQAI). The QIO notifies the facility and PCP of an appeal and: PCP facility onsite Concurrent Review Staff completes the Detailed Notice of Discharge (DNOD), and delivers it to the Medicare Advantage member, or his or her representative as soon as possible but no later than 12:00 p.m. local time of the day after the QIO notification of the appeal is received. The facility faxes a copy of the DNOD to the QIO; or When there are not any PCP facility onsite staff, the facility completes the DNOD, and delivers the DNOD to the Medicare Advantage member or his or her representative as soon as possible but no later than 12:00 p.m. local time of the day after the QIO notification of the appeal is received. The facility faxes a copy of the DNOD to the QIO and PCP. Protocol for Facility (SNF, HHA, CORF) Notice of Medicare Non-Coverage (NOMNC) CMS requires SNFs, HHAs and CORFs to deliver the NOMNC required notice to members at least 2 calendar days prior to termination of skilled nursing care, home health care or comprehensive rehabilitation facility services. If the Customer’s services are expected to be fewer than 2 calendar days in duration, the notice should be delivered at the time of admission, or commencement of services in a non- institutional 44 setting. In a non-institutional setting, if the span of time between services exceeds 2 calendar days, the notice should be given no later than the next to last time services are furnished. Delivery of notice is valid only upon signature and date of Customer or Customer’s authorized representative, if the Customer is incompetent. You must use the standard CMS approved notice entitled, “Notice of Medicare Non-coverage” (NOMNC). The standardized form and instructions regarding the NOMNC may be found on the CMS website at http:// www.cms.gov/Medicare/Medicare-GeneralInformation/BNI/MAEDNotices.html or you may contact your Quality Improvement Organization (QIO) for information. There can be no modification of the NOMNC notification text. New Technology The technology assessment process is utilized to evaluate new technologies and new applications of existing technologies. Technology categories include medical procedures, drugs, pharmaceuticals, or devices. This information allows the Plan to make decisions about treatments which best improve member’s health outcomes, efficiently manage utilization of healthcare resources, and make changes in benefit coverage to keep pace with technology changes and to ensure that members have equitable access to safe and effective care. If you have any questions regarding whether a new technology or a new application of existing technologies are a covered benefit for your patient, please contact Utilization Management at (800) 995-0480. Please note that the Centers for Medicare and Medicaid Services (CMS) NCD and LCD takes precedence over the benefit document. Appeal and Reconsideration Processes Clinical Appeals: Standard and Expedited To appeal an adverse decision (a decision by the Plan not to prior authorize a service or procedure because the service is determined not to be medically necessary or appropriate), on behalf of a member, you must submit a formal letter outlining the issues and submit supporting documentation. The denial letter you received provides you with the filing deadlines and the address to use to submit the appeal. In the event a member designates a healthcare professional to appeal the decision on the members’ behalf a copy of the member’s written consent is required and must be submitted with the appeal. When the final decision is made, you will be notified via mail. If the decision is to overturn the original determination, the service will be authorized. If the decision is to uphold the original denial determination, there will be no further action for you to undertake. How to File an Appeal Upon receiving an adverse organization determination, you may appeal the determination on the member’s behalf following the instructions detailed in the denial notification you received from us. To initiate an appeal: 1. 2. 3. 4. Complete the Appeal/Reconsideration Request form, which can be downloaded from our website at www.mypreferredprovider.com. Alternatively, you can provide a letter stating the reason why you want the reconsideration. Ensure that the letter or form is signed by the person requesting the appeal. Assemble all supporting documents for us to review in reconsidering the decision. Send the form or letter and supporting documents to: Preferred Care Partners Grievance & Appeals P. O. Box 56-6420 Miami, FL 33256-6420 45 Upon receipt of the appeal, the appeals coordinator may call you if it is necessary to clarify your request and supporting documents. Section 6 Medical Records Overview Medical record documentation should facilitate communication, coordination, and continuity of care, as well as promote efficiency and effectiveness of treatment. The Plan’s providers are required to keep accurate and complete medical records of Plan members for at least 10 years. Through medical record review, the Plan is able to evaluate the quality, timeliness, and appropriateness of the services rendered. Documentation of Care / Confidentiality of Medical Records Providers are required to maintain records, correspondence and discussions regarding the member in the strictest of confidence and protection. Providers shall maintain a medical records system, which is: a) consistent with professional standards, b) permits prompt retrieval of information, and c) provides legible and timely information that is accurately documented and readily available to appropriate or authorized healthcare practitioners. The patient should sign a Medical Record Release Form as a part of their medical record. The form is available on our website at www.mypreferredprovider.com The following guidelines are applicable: Records that contain medical/clinical, social, financial or other data on a patient is treated as confidential and is protected against loss, tampering, alteration, destruction, or inadvertent disclosure; Release of information from your office requires that you have the patient sign a Medical Record Release Form that is retained in the medical record; Release of records is in accordance with State and Federal laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA); Records containing information on mental health services, substance abuse, or potential chronic medical conditions that may affect the member’s plan benefits are subject to additional specific waivers for release and confidentiality. Exemption from Release Requirements HIPAA regulation 45 CFR § 164.512 (d) specifically permits disclosure of protected health information to government benefit programs for which health information is relevant to beneficiary eligibility, without patient authorization. Medical Records Requirements Providers must ensure that their medical records meet the standards described in the Practice Standards and Performance Measures, Section 8 provided in this section. The following are expanded descriptions of some requirements which may be helpful: Patient Identifiers Should consist of the patient name and a second unique identifier, and should appear on each page of the medical record. 46 Advance Directives We are committed to ensuring that our members are aware of their right to execute advance directives, and that our providers and staff are in compliance with federal and state laws, as well as with the Plan’s accrediting body. For detailed information on advance directives, refer to Provider Information & Administrative Responsibilities, Section 2. It is the provider’s responsibility to provide the member with Advance Directive information, and to encourage the member to place a copy in their office record. This discussion should be documented at least once in the member’s record. Quality Improvement will evaluate the provider’s compliance during the initial site visit and, subsequently, through the medical record review process. If there are indications that the standards are not being met, Quality Improvement will intervene and request corrective action. Every adult has the right to make decisions concerning his or her own health, including the right to choose or refuse medical treatment. To make sure that a person’s choices about health care will still be respected, even when they are no longer able to make such decisions, the Florida legislature enacted Chapter 765, Florida Statutes. By law providers, hospitals, nursing homes, home health agencies, hospices, and HMOs are required to provide their patients with written information. You may download free forms from the State at http://www.floridahealthfinder.gov/reports-guides/advancedirectives.aspx There is also information for your patients from the Robert Wood Foundation, Five Wishes, which also meets the legal requirements for an advance directive in Florida. Five Wishes is a popular, simple, pamphlet which helps each person let their family and doctors know: Who you want to make health care decisions for you when you can't make them. The kind of medical treatment you want or don't want. How comfortable you want to be. How you want people to treat you. What you want your loved ones to know. Five Wishes is available at www.AgingWithDignity.org Biographical Information Each record should contain the patient’s name, date of birth, address, home and work phone numbers, marital status, sex, primary language spoken, name and phone number of emergency contact, appropriate consent forms and guardianship information if relevant. Signatures For paper medical records, all entries should be dated and signed or initialed by the author. Author identification may be a handwritten signature or initials followed by the title (MD, DO, PA, ARNP, RN, LPN, MA or OM). There must be a written policy requiring, and evidence of, physician co-signature for entries made by those other than a licensed practitioner (MD, DO). Electronic signatures are acceptable for electronic medical records. 47 Family History As part of the past medical history, family history should be documented no later than the first visit. Past Medical History Documentation should include a detailed medical, surgical and social history. Immunization Documentation Documentation of immunizations performed by the office should include the date the vaccine was administered, the manufacturer and lot number, and the name and title of the person administering the vaccine. At a minimum, vaccination history must be recorded. Medication List The patient’s current medications should be listed, with start and end dates, if applicable and re-conciliated within 30 days post inpatient admissions. Referral Documentation If a referral was made to a specialist, the consultation report should be filed in the medical record. There should be documentation that the physician has discussed abnormal results with the patient, along with recommendations. Chart Organization Practitioners should maintain a uniform medical record system of clinical recording and reporting with respect to services, which includes separate sections for progress notes and the results of diagnostic tests. Preventive Screenings Participating providers will promote the appropriate use of age/gender specific preventive health services for members in order to achieve a positive impact on the member’s health and better medical outcomes. Required Documentation Every visit must include the following documentation: the date of the visit; chief complaint or purpose of the visit; objective findings for the visit; diagnosis or medical impression of the visit; studies ordered (lab, x-ray, etc.); therapies administered and/or ordered; education provided; disposition, recommendations, instructions to the patient and evidence of whether there was follow-up; and, outcome of services. (Documentation that a written policy regarding followup care and written procedures for recording results of studies and therapies and appropriate follow-up has been adopted must be available.) Physicians/providers must maintain a medical records system that is: a) consistent with professional standards, b) permits prompt retrieval of information, c) provides legible and timely information that is accurately documented and readily available to appropriate or authorized healthcare practitioners, and d) protects the confidentiality of the records. The patient should sign a Medical Record Release Form as a part of his or her medical record. The patient should sign a Refusal Form when declining a preventative screening referral. 48 We also recommend that medical records include copies of care plans whenever home health or skilled nursing services are being provided. We conduct periodic medical record reviews on random samples of medical records. Providers who do not achieve acceptable scores are notified and provided with a Corrective Action Plan as well as tools and information so that they can improve their medical records documentation. Medical Record Reviews The Plan performs reviews of providers’ medical records through the Quality Improvement Program as part of the Plan’s recredentialing requirements, and for HEDIS reporting. Our criteria for these reviews incorporate applicable federal, state and regulatory requirements for medical record documentation. Providers are encouraged to review Practice Standards and Performance Measures, Section 8 provided in this manual in order to assess their readiness for upcoming reviews. The purpose of periodic medical record reviews is to determine compliance with the Plan’s standards for documentation, coordination of care and outcome of such services; to evaluate the quality and appropriateness of the provider’s office medical records documentation; and to promote continuous improvements. These reviews evaluate medical records and do not define standards of care or replace a physician’s judgment. The Plan conducts pre-contractual medical record reviews; thereafter, reviews are done every three years for re-credentialing purposes. All primary care providers and high volume specialists are subject to medical record reviews. At the conclusion of the review, the reviewer will notify the provider of any deficiencies identified during the review. The provider must achieve a score of at least 80% in order to meet the Plan’s standard. Providers who do not meet the standard have up to 30 days to address the items noted and provide a written response, signed by the provider. If applicable, the Plan will issue a Corrective Action Plan, or provide guidance and other tools to assist providers in improving documentation of care. Any provider not meeting the Corrective Action Plan will be reported to the Credentialing Committee for further action. 49 Section 7 Healthcare Risk Management In any industry, risk management addresses liability, both proactively and reactively. Proactive is avoiding/preventing risk. Reactive is minimizing loss or damage after an adverse/bad event.. Risk management in health care considers patient safety, quality assurance and patients’ rights. The potential for risk permeates all aspects of health care, including medical mistakes, electronic record keeping, provider organizations and facility management. Identifying something as an adverse event does not imply "error," "negligence," or poor quality care. It simply indicates that an undesirable clinical outcome resulted from some aspect of diagnosis or therapy, not an underlying disease process. Examples of adverse events in health care are unexpected death, failure to diagnose or treat disease, surgical mistakes or accidents. All of those can interfere with a provider’s delivery of medical care. Some can result in litigation. Agency for Healthcare Administration (AHCA) The Florida Agency for Healthcare Administration (AHCA), as directed under F.S. 641 Parts I, II, III and other applicable state laws, provides oversight and monitoring of health plans operating in the State of Florida as an HMO and their compliance to applicable regulations. This includes implementation of a Risk Management Program (RMP) with the purpose of identifying, investigating, analyzing and evaluating actual or potential risk exposures. The RMP also corrects, reduces and eliminates identifiable risks through instruction and training to staff and providers. Reporting Adverse and Serious Events annually to AHCA is a statutory requirement under F.S.641, Part III. AHCA defined Adverse and Serious Incidents include but are not limited to: Death of a patient; Brain or spinal damage to a patient; Performance of a surgical procedure on the wrong patient; Performance of a wrong site surgical procedure; or Performance of a wrong surgical procedure. National Quality Forum (NQF) The National Quality Forum (NQF) is a nationwide public service organization that reviews, endorses, and recommends use of standardized healthcare performance measures and quality of care. NQF is aligned with the accreditation requirements for the health plan. NQF identified and categorized events that are reportable by health entities. It is required to report these to the plan’s Risk Manager. National Quality Forum (NQF) defined Adverse Events for any injury caused by medical care, include but not limited to: pneumothorax from central venous catheter placement anaphylaxis to penicillin postoperative wound infection hospital-acquired delirium (or "sun-downing") in elderly patients 50 The National Quality Forum (NQF) in 2011, identified 29 events grouped into six (6) categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal. Table. 2011 Never Events The National Quality Forum's Health Care "Never Events" Surgical events Surgery or other invasive procedure performed on the wrong body part Surgery or other invasive procedure performed on the wrong patient Wrong surgical or other invasive procedure performed on a patient Unintended retention of a foreign object in a patient after surgery or other procedure Intraoperative or immediately postoperative/post-procedure death in an American Society of Anesthesiologists Class I patient Product or device events Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used for functions other than as intended Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting Patient protection events Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person Patient death or serious disability associated with patient elopement (disappearance) Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility 51 Care management events Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration) Patient death or serious injury associated with unsafe administration of blood products Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a health care setting Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy Artificial insemination with the wrong donor sperm or wrong egg Patient death or serious injury associated with a fall while being cared for in a health care setting Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a health care facility Patient death or serious disability resulting from the irretrievable loss of an irreplaceable biological specimen Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results Environmental events Patient or staff death or serious disability associated with an electric shock in the course of a patient care process in a health care setting Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a health care setting Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a health care setting 52 Radiologic events Death or serious injury of a patient or staff associated with introduction of a metallic object into the MRI area Criminal events Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider Abduction of a patient/resident of any age Sexual abuse/assault on a patient within or on the grounds of a health care setting Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care setting The Centers for Medicare and Medicaid Services (CMS) 2013 Hospital Acquired Conditions (HACs) and Codes A hospital-acquired condition (HAC) is an undesirable situation or condition that affects a patient arising during a time spent in a hospital or medical facility. It is a designation used by CMS for determining MSDRG reimbursement. HACs Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Stage III and IV Pressure Ulcers Falls and Trauma: Fracture Dislocation Intracranial Injury Crushing Injury Burn Other Injuries Manifestations of Poor Glycemic Control 53 Catheter-Associated Urinary Tract Infection (UTI) Vascular Catheter-Associated Infection Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG) Surgical Site Infection Following Certain Orthopedic Procedures Surgical Site Infection following Bariatric Surgery for Obesity Surgical site Infection following Cardiac Implantable Electronic Device (CIED) Procedure Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures Iatrogenic Pneumothorax with Venous Catheterization Provider Reporting Responsibilities It is the affirmative duty of the Plan’s network providers, as outlined in applicable provider contracts, to report all adverse events as identified by AHCA, the NQF and the Hospital Acquired Conditions, whether actual or potential, to the Plan’s Risk Manager. The Plan provides a Member Incident Report Form for reporting these incidents available on the provider website at: www.mypreferredprovider.com. The Member Incident Report Form must be filed with the Plan’s Risk Manager within three business days of occurrence of any incident that causes injury to an individual, or property damage. All serious incidents must be reported immediately to the Plan’s Risk Manager at (305) 670-8440 or (800) 872-9750 to access the risk and address liability. These incidents must be reported to AHCA within 24 hours of occurrence. Examples of Serious incidents include: Death or serious injury; Brain or spinal Damage; Performance of a surgical procedure on the wrong patient; Performance of a wrong site surgical procedure; Performance of a wrong surgical procedure; Abduction of a patient/resident of any age; or Sexual abuse/assault on a patient within or on the grounds of a health care setting. Note: The Member Incident Report is confidential. It is the objective record that is established at the time of awareness of an actual or potential incident and records ONLY the facts available at the time. Personal opinions or subjective information are not to be included in the incident report. The individual involved in the incident, or any witness who observed or discovered the incident, should complete the incident report. The incident report should not be copied. Providers are prohibited from keeping a copy of the incident report in the member’s medical record and from making a notation in the member’s medical record that an incident report was filed. The Plan’s Risk Manager will review and evaluate each incident report to determine whether it meets the requirements for filing with applicable state agencies. 54 Section 8 Practice Standards & Performance Measures Overview The Plan performs site audits through the Quality Improvement Program as part of the Plan’s initial credentialing and recredentialing requirements. The purpose of the site audit is to evaluate the quality and safety of clinical care and the quality of service provided to our member, and to promote continuous improvements. These audits evaluate specific areas using criteria established through federal, state and regulatory agencies for different types of practices and facilities, and do not define standards of care or replace a physician’s judgment. Providers are encouraged to review the appropriate Practice Standards and Performance Measures guides in this section in order to assess their readiness for upcoming audits. Items in bold identify areas that must meet site audit criteria or be addressed through a Corrective Action Plan (CAP). The Quality Improvement department follows a reasonable audit process, to ensure effectiveness and efficiency, and minimize any disruption to the provider’s activities. Prior to the onsite audit, the provider will be contacted to arrange specific times that will be agreed to by all parties. During the site audit, any findings or potential problems will be discussed immediately with the provider or designated provider representatives. At the conclusion of the audit, the reviewer will notify the provider of any deficiencies identified during the audit. If applicable, the Plan will issue a Corrective Action Plan, or provide guidance and other tools to assist providers in improving these areas. Physicians’ Offices As a provider in the Preferred Care Partners network, your office will be required to meet the standards of state and national regulatory agencies as well as Preferred Care Partners’ standards. Your office will be audited to ensure that your facility and practices are in compliance with these standards. We have provided this booklet as a set of guidelines to prepare the office and your employees for these audits. The table below includes a listing of the standards upon which you will be audited, the source of the standard (usually a regulatory agency), and the indicators that we will use to determine whether your office is in compliance. If you have any questions about compliance or audits, please contact Network Management Services at (877) 670-8432 or [email protected]. Standard Performance Measures General Patient Rights and Responsibilities are posted, along with toll-free numbers for Consumer Assistance (AHCA). Toll free numbers for customer assistance (AHCA) are posted. Occupational licenses or statutory waiver is displayed. DEA certificate is available and current. NPI # is available and current per CMS regulations. All practitioners must post or make available patient rights and responsibilities for Preferred Care Partners members. All practitioners must post or make available AHCA's customer assistance phone number. Occupational license is displayed and visible. DEA needs to be up-to-date and available for reviewer to see. An NPI number is a unique identification number for covered health care providers under HIPAA. NPI are permanently assigned identifiers that do not change and will have to be used in all administrative and financial transactions adopted under HIPAA. 55 Standard Performance Measures Medical license and physician credentials are available and posted. Bilingual educational literature is available. A licensed practitioner, with current certification in CPR, is present when patients are in the facility. Staff is courteous, respectful, and helpful toward patients and visitors. Ample seating is available for patients in waiting area. Medical license is visibly displayed and in public view. Educational literature that is displayed or distributed to patients is available in English and Spanish. Staff should be able to locate and identify practitioner who is available to meet needs of members in an emergency situation. Staff needs to be courteous, respectful and helpful to patients and visitors. Seating in waiting areas is adequate for the practice. Access & Appearance/Handicapped Access Handicapped parking and handicapped access to the building is available. Handicapped access is provided in the bathroom, including grab bars and emergency call light (if applicable). For offices above the first floor, an elevator is available with current inspection certificate. Office/building address is clearly marked. Building’s exterior appearance demonstrates that routine maintenance is performed. Office and exam rooms have adequate space and seating. Housekeeping is performed to keep them clean, neat, and odor-free. There is adequate parking, which is clearly marked. The parking area offers handicapped parking spaces adequate for the practice. Staff is able to describe how they accommodate people with disabilities who require assistance to access an office. For example, an entrance ramp is provided where there are steps. At least one rest room allows access for people with disabilities, and is equipped with grab bars and emergency call light (if applicable). Where patients need to access an office above the ground floor, there is an elevator displaying evidence of a current city/county inspection. There are signs that clearly identify the building location, entrance, and office. Building appears in good repair, with neatly maintained landscaping. The entire facility is clean. Corners and floors should be clear and free from dirt or trash. Trash is not overflowing from waste receptacles. The environment is smoke and odor-free. There is adequate space in exam rooms for patients and equipment. There is sufficient seating to accommodate patients Adequate parking, including handicapped parking spaces, is easily accessible and includes a reasonably short walk from the parking lot. There are signs or markers that clearly identify parking areas and spaces. Safety Exit signs are posted and there is an evacuation map in the office. Fire extinguishers are placed in strategic areas and reflect yearly inspection. “No Smoking” signs are posted inside the building. The office is smoke-free and has smoke detectors throughout. Doors that exit the office are marked by lighted or printed exit signs. An evacuation map is available for inspection. Extinguishers must have current tags documenting annual inspection by qualified fire equipment inspector or receipt showing purchase within one year. “No Smoking” signs should be conspicuously located in the facility. The office is smoke-free. The office has working smoke detectors installed in 56 Standard Performance Measures All hallways are free of obstacles, with handicapped accessibility to patient rooms, bathrooms, and exits. Emergency lighting available in building. Sprinkler system is installed throughout the building. Personnel are aware of procedure to follow in case of emergency. There is a written disaster plan available. strategic areas to raise an alarm in case of fi re. The office is smoke-free. The office has working smoke detectors installed in strategic areas to raise an alarm in case of fi re. In the event of a power outage, the building is equipped with emergency lighting. Building must be equipped with an overhead sprinkler system. Building must be equipped with an overhead sprinkler system. The practice should have an emergency/disaster plan. All staff should be aware of the plan. Medical Records Medical records are filed away from public access. Access to medical records is available within 30 days of a member’s request. A system is in place to dispose of all PHI. There is a written privacy procedure describing who has access to PHI within the office. Allergies or NKA is documented and prominently displayed. Each patient has a unique record with an identifier, which enables staff to produce a record on demand. Name of the Privacy Officer. There is employee training on HIPAA regulations. All paper medical records should be dated and signed or initialed by the author. Electronic signatures are acceptable for electronic medical records. Signature stamp are not accepted. Records are stored in a location that denies unauthorized access. Records are not stored in patient exam rooms unless files are locked during patient care hours. The practice maintains a system of medical record storage/filing that facilitates quick access and retrieval of clinical information. Policies are in place describing the retention of medical records and the procedure to follow when disposing of PHI. Policies and procedures are in place to ensure that access to patient information is restricted to individuals with authorization. Known allergies, adverse reactions, or NKA is documented in a prominent, consistent location in the record. Medical records do not contain information for other patients. Records are easily retrieved by appropriate office staff. The office has a designated Privacy Officer. Staff is able to name the Privacy Officer. All employees should receive training on, and follow policies and procedures on patient confidentiality. Evidence of training may be confidentiality agreements signed by staff. All medical records must be signed by the author, hand written or e-signature. Signature stamps are not acceptable. Laboratory Services CLIA license, waiver, or proof of payment is available and current. Lab specimens are stored separately from medication and food. CLIA documentation available for inspection. CLIA# and expiration date will be recorded for review purposes. If laboratory certification or waiver is required, certificates should be current, appropriate to the type of testing to be performed, and available for review. Multiple office locations must have a certificate or waiver specific to each office site. Lab specimens requiring refrigeration must be stored in a refrigerator/freezer dedicated to that purpose. No foods or medications can be stored in this refrigerator/freezer. 57 Standard Performance Measures Emergency Drugs and Supplies Emergency medications and crash cart are checked regularly for stock and expiration dates. Log is maintained. If applicable, crash cart includes medications, laryngoscope, endotracheal tubes, tracheostomy set, Foley catheter, IV fluids and supplies, oxygen tank tubing and mask, ambubag, defibrillator, suction equipment, and batteries. Policies and procedures are in place for all emergencies. Medication expiration dates are checked routinely, and expired medicines are properly disposed. (Log recommended). Prescription pads, syringes, and needles are stored in a secure manner with limited access. All medications are stored and prepared in a designated secured area and dispensed by licensed staff. Biological products are stored in: a) Refrigerator at 35˚-45˚F. b) Freezer at 2˚-8˚F. c) Daily maintenance log is kept. All medications requiring refrigeration are properly stored. All immunizations are kept on refrigerator shelves. Records are kept of all immunizations given. Staff is able to describe the frequency with which emergency medications are checked for stock and expiration dates and who is responsible for checking. A written log is maintained on or near the crash cart. The crash cart includes all applicable emergency medications and equipment. The equipment is in good working order, is regularly tested, is appropriately sized, and extra batteries are kept. There is a mechanism for staff to assist patients in lifethreatening situations. This includes a process for calling 911, isolation of the patient, provision of CPR, use of crash cart, etc., where applicable. Medications Staff is able to describe the frequency with which drug samples are checked for expiration and who is responsible for checking. Checking samples for expiration should be a routine office procedure, rather than optional or random in nature. At minimum, there should be documentation of quarterly inspection. Syringes and needles are stored in cabinets or other locations that deter unauthorized access by patients. During office hours, prescription pads are stored in a location that denies unauthorized access, such as with the physician or in a cabinet or drawer that is not in a patient care area. Drug samples and other medications utilized in the office are stored in cabinets or other locations that deny unauthorized access by patients (e.g., drugs should not be observed on counter tops or on open shelves in patient care areas). The temperature of the refrigerator or freezer designated for pharmaceuticals and biological materials is monitored daily and recorded. Pharmaceutical products are not refrigerated with food or beverages. All medications requiring refrigeration must be properly stored at the correct temperature (e.g., varicella vaccine must be kept at 5 degrees Fahrenheit or lower). A thermometer is kept in the refrigerator to ensure that temperatures remain between 36 and 46 degrees Fahrenheit. A separate thermometer must be kept in the freezer compartment. Temperatures are monitored and recorded daily. A written log is maintained of all immunizations given. The refrigerator/freezer is not used to store any other type of item (food, drinks, specimens, blood products, infectious agents, etc.). 58 Standard Performance Measures Controlled substances are kept in a separate, double-locked area. A required current dispensing log is kept. Multi-dose vials of medications are properly labeled with date first used, and are discarded after 30 days. Schedule II, III, IV and V narcotics are stored in a separate, double-locked area; access is restricted to a limited number of staff. A periodic count of controlled substances is recorded. Staff is able to describe the steps taken to destroy outdated or unusable narcotics; required documentation of these steps is available. Containers should be labeled with date opened, expiration date, and initials of the person opening the vial. Infection Control – OSHA Regulations Universal precautions are always taken when obtaining and handling body fluids. Food and drinks are kept in separate refrigerators from those used to store blood or infectious agents. Staff is trained in the importance of hand-washing regarding patient and personal care. Signs are posted in restrooms. Spill Kit 1:10 bleach is available to kill HIV/HBV/TB, and is used according to OSHA guidelines. Provisions are made for isolation of any patient suspected of having a communicable disease. Personnel refrain from eating, drinking, and personal care in work area. Federal regulations require facilities to actively use the OSHA Exposure Control Plan (Infection Control) to ensure safety of staff and patients against blood and other bodily fluids. No food or beverages may be stored in the same refrigerator with medications, blood, or infectious agents. Clean running water and soap should be available in the facility to ensure compliance with hand washing/infection control guidelines. For exam rooms without sinks, there must be a waterless bacteriostatic hand cleaner/sanitizer available for use until staff can get to a sink. Reminder signs are posted in rest rooms. Instruments must be totally immersed in the solution according to the manufacturer’s direction for cold sterilization. Containers must be labeled with solution, lot number, and expiration date. Areas that are contaminated with blood and/or infectious products shall be cleaned after contact. Policies should be enforced to deal with patients suspected of having a communicable disease. Staff personnel should maintain a professional environment in the work area. Handling of Biohazard Waste Hazardous materials and waste are properly disposed. Chemicals and supplies (sterilized and non-sterilized) In exam rooms and storage areas are properly labeled and stored. Staff is able to identify the hazardous waste hauler with which the office contracts to remove medical waste or describe disposal by the physician to an appropriate intermediate site such as a hospital. Sharps containers are closable, puncture resistant, leakproof, and color-coded or labeled as bio hazardous. Containers for other contaminated waste are closable, constructed to contain all contents and prevent leakage, and labeled or color-coded. A large volume of full sharps containers or multiple large boxes or bags of other medical waste are not stored in the office; removal of waste should occur regularly. Sharps containers are stored out of immediate or accidental patient reach (i.e., wall mounted, located on counter tops or stored in a closed cabinet). Containers 59 Standard Performance Measures should not be stored on the floor or on exam tables where patients sit or lie. Radiation Safety (OSHA Regulations) Restricted areas are established near radiation sources with warning signs posted. Radiology area prominently displays a warning for pregnant women. Release statement for women is available. X-ray equipment is inspected regularly. Protective lead barriers such as aprons/gloves and screen are provided for patients and staff. Dosimeter badges are worn by employees who operate equipment. Policies for exposed employees are followed A current licensure and inspection certificate are available for the radiology department. Restricted areas near radiation sources are marked to protect patients and staff from unnecessary exposure to radiation. Radiology areas must display warning signs prominently posted in several locations around the area. Warning signs for pregnant women are prominently posted around the radiology area. A written release statement is available for female patients to sign. Radiology equipment requires periodic inspection (annually at minimum) by the state. Inspection and maintenance documents must be available for review. Radiation protective devices, including shields, aprons, gloves, and lead-based walls are available to protect patients and staff from unnecessary exposure to radiation. Radiology staff wears dosimeter badges. There is a procedure in place in the event a staff member receives excessive exposure to radiation. Staff can describe this procedure. Radiology equipment state licensure and inspection certificates are current and available for review. Availability Appointment scheduling practice is clearly defined. Missed appointments are recalled as necessary and are documented in the medical record. (Log recommended.) An after-hours contact or service is used. Waiting time to see physician is under 30 minutes. Patients are provided an alternate appointment if delay is unavoidable. Average response time for emergency calls, after hours are less than 30 minutes. There is 24-hour coverage provided by a participating PCP network provider. Practitioner has established procedures for staff members regarding how to prioritize and process call from patients. Staff is trained or provided a written procedure. Staff is able to verbalize the wait time for appointments for the categories of routine, urgent, and emergency visits. Patients who have an emergency are seen by a practitioner immediately or referred to an appropriate alternative medical facility. To demonstrate pursuit of ongoing treatment plans, follow-up efforts should be made to determine the reason for a no-show, and to determine the patient’s desire to reschedule the appointment. Missed appointments are documented in the patient’s record. A log should also be kept. Practitioner’s office answering machines or answering services are used in conjunction with a pager. Practitioners may not direct all patients who call after office hours to a hospital emergency department. Waiting time is to be under 30 minutes. Office will reschedule appointments for unavoidable delays. Staff interview. Policies and procedures. The practitioner or a designated covering practitioner may be contacted 24 hours a day through an answering 60 Standard Performance Measures service or directly by telephone and/or pager; he or she responds within 30 minutes. Skilled Nursing and Rehabilitation Facilities As a provider in the Preferred Care Partners network, your center will be required to meet the standards of state and national regulatory agencies as well as those of Preferred Care Partners. You will be audited to ensure that your facility and practices are in compliance. We have provided this booklet as a set of guidelines to prepare your center and employees for these audits. The table below includes a listing of the standards upon which you will be audited, and the indicators that we will use to determine whether your facility is in compliance. If you have any questions about compliance or audits, please contact Network Management Services at (877) 670-8432 or at [email protected]. Standard Performance Measures General Patient rights and responsibilities are posted, along with toll-free numbers for Consumer Assistance (AHCA) Full-time RN/LPN supervises health services 7 days a week and is available on all shifts. Medical, occupational, and state licenses (if applicable) and/or statutory waiver are available and current. Pharmacist license displayed. In-service programs provided to staff. There is an executive privacy officer responsible for all the facility’s policies and procedures, and for compliance with federal laws and regulations. Licensed physical therapists, occupational therapists, and speech therapists are present during session hours. The center posts or makes available upon request patient rights and responsibilities for Preferred Care Partners members. Visual inspection and review of policies and procedures show evidence that there is an RN/LPN who supervises health services 7 days a week, and is available on all shifts. Staff is able to identify the designated RN. Medical licenses and/or statutory waiver are displayed and visible. Pharmacy license(s) is/are displayed and visible. Review of training manual and of policies and procedures shows that the facility provides continuing education and/or in-services for nurses and staff. The facility has a designated privacy officer. Staff is able to name the privacy officer. Staff can locate and identify licensed therapists who are available to meet needs of members during session hours. Access & Appearance/Handicapped Access There is handicapped access to parking, building and facility entrances, bathroom facilities, and water fountain. The parking area offers handicapped parking spaces adequate for the center. Staff is able to describe how they accommodate people with disabilities who require assistance to access a facility. For example, an entrance ramp is provided where there are steps. 61 Standard Performance Measures If building is more than one story, elevator is available with current inspection certificate. Business hours are posted outside of the facility. Inside appearance of the center demonstrates housekeeping; areas are neat, clean, and odor-free. Building’s exterior appearance demonstrates that routine maintenance is performed. Address and parking are clearly marked with adequate parking available. Where patients need to access a facility above the ground floor, there is an elevator displaying evidence of a current city/county inspection. Visual Inspection shows that business hours are posted prominently outside of the facility. The entire facility is clean. Corners and floors should be clear and free from dirt or trash, and trash is not overflowing from waste receptacles. The environment is smoke and odor-free. Building appears to be in good repair, with neatly maintained landscaping. Adequate parking, including handicapped parking spaces, is easily accessible and includes a reasonably short walk from the parking lot. There are signs or markers that clearly identify parking areas and spaces. Safety Fire extinguishers are placed in strategic areas and reflect yearly inspection. There is a written disaster plan available. Corridors are equipped with firmly-secured handrails on both sides. Exit signs and maps are posted for emergency evacuation of patients, staff, and visitors. The facility is smoke-free and has smoke detectors/alarms throughout. “No Smoking” signs are posted inside the building. All hallways are free of obstacles and have adequate lighting. Emergency lighting is available in building. Personnel are aware of procedure to follow in case of emergency, fi re, or other crises. The facility has an emergency plan and holds a minimum of one fire drill each quarter. Extinguishers have current tags documenting current annual inspection by qualified fire equipment inspector, or a receipt showing purchase within one year. The facility has an emergency/disaster plan. All staff are aware of the plan and able to describe it. Visual inspection shows that corridors are equipped with firmly-secured handrails. Doors that exit the facility are marked by lighted or printed exit signs. An evacuation map is available for inspection. The facility is smoke-free. The facility has working smoke detectors installed in strategic areas to raise an alarm in case of fi re. “No Smoking” signs are conspicuously located in the facility. Entrances to facility and passageways are well-lit, clear of obstacles and adequate for movement of patients and equipment. Corridors and floors are free from clutter, trash, and/or loose/unsecured electrical cords for patient and staff safety. Supplies stacked such that they cannot fall over or be pulled over on patients. The building is equipped with emergency lighting In case of a power outage. Staff is able to describe an evacuation plan that demonstrates knowledge of the location of emergency exit(s) and provision for movement of patients to safety. Visual inspection of policies and procedures. Staff is able to describe the policy and procedure. Medical Records Medical records are safeguarded against loss, tampering, or use by unauthorized persons. Records are stored in a location that prevents unauthorized access. Records are not stored in rooms 62 Standard Performance Measures The center maintains confidentiality, releasing medical information only by written consent. Advance directives are documented as discussed in a visible place in the record. If executed, the directive is copied on the chart. Documentation of progress notes, history, and physical are available. Allergies or NKA are documented and prominently displayed. All paper medical records should be dated and signed or initialed by the author. Electronic signatures are acceptable for electronic medical records. Signature stamp are not accepted. Each patient has a unique record with an identifier, which enables staff to produce a record on demand. Policies and procedures are written to address collection, storage, and disposal of written and electronic documents. Documentation of primary language and translation needs is maintained. Staff communicates in members’ language of preference. where patients are seen or in main access areas such as common walkways, etc., unless fi les are locked during patient care hours. Review of medical records shows that a signed consent to release medical information has been obtained for each patient. A review of policies and procedures shows policies are in place describing medical record retention and PHI disposal. Medical record review shows that advance directives are documented as discussed in a visible place in the record, and, if executed, the directive is copied on the chart. Review of medical records shows that there is documentation of progress notes, history, and physical are available, but only if there at least one Preferred Care Partner member in the facility at the time. Known allergies, adverse reactions, or NKA are documented in a prominent, consistent location in the medical record. All medical records must be signed by the author, hand written or e-signature. Signature stamps are not acceptable. Medical records contain the correct patient information; they do not contain information for the wrong patient. Records are easily retrieved by appropriate facility staff. There are policies, procedures and training materials on HIPAA compliance. Staff can describe the procedures to be followed. Review of notes and demographic data in medical record shows documentation of primary language and translation needs for each patient. Pain Management Nurses properly document pain assessment, treatment, and reassessment if pain medication is given. Factors that can alter the response to pain medication are documented. Plan of care includes non-pharmacological interventions. Review of medical record shows evidence of a pain scale assessment and follow-up, if needed. Review of medical record shows evidence of documentation regarding factors that can alter the response to pain medication. Review of medical record and staff interview shows evidence that plan of care includes nonpharmacological interventions. Skin Integrity Nursing staff performs and documents skin integrity assessment of patients to identify those at risk for pressure ulcers. Ulcers are identified and treated early. Routine preventive skin care is performed by the nursing staff and documented. Review of medical record shows evidence of a skin integrity assessment to identify those at risk for pressure ulcers, with documentation of any ulcers identified and treatment follow-up. Review of medical record shows that preventive skin care is performed by the nursing staff. 63 Standard Performance Measures Review of medical record shows that the appropriate nutritional approaches are implemented by the dietary and nursing staff. Nutritional approaches are documented and implemented by the dietary and nursing staff. Laboratory Services CLIA license, waiver, or proof of payment is available and current. Lab specimens are stored separately from medication and food. CLIA documentation is available for inspection. CLIA# and expiration date is recorded for review purposes. If laboratory certification or waiver is required, certificates are current, appropriate to the type of testing to be performed, and available for review. Multiple-facility locations have a certificate or waiver specific to each facility. Lab specimens requiring refrigeration are stored in a refrigerator/freezer dedicated to that purpose. No foods or medications are stored in this refrigerator/freezer. Medications Medications, syringes and needles are stored in a secure manner with limited access. Medications are stored and prepared in a designated secured area and are dispensed by licensed staff. The temperature of the refrigerator or freezer designated for pharmaceuticals and biological materials must be kept within a specified temperature range. Storage of biologicals: Medication, syringes and needles are stored in cabinets or other locations that deter unauthorized access by patients. During facility hours, prescription pads are stored in a location that prevents unauthorized access, such as with the physician or in a cabinet or drawer that is not in a patient care area. Drug samples and other medications used in the facility are stored in cabinets or other locations that deny unauthorized access by patients (e.g., drugs should not be observed on counter tops or on open shelves in patient care areas). Pharmaceutical products are not refrigerated with food or beverages. Visual inspection of log shows that temperature has been recorded daily and that log is up-to-date. Refrigerator: 35˚to 45˚ F. Freezer: 2˚ to 8˚ F. Daily maintenance log is kept. Multi-dose vials of medications are properly labeled with date first used, and are discarded after 30 days. Adverse reactions are reported to the physician and are documented and recorded immediately. Controlled substances are kept in a separate, doublelocked area. A required current dispensing log is kept. Medications requiring refrigeration are properly stored. Visual inspection shows that containers are labeled with date opened, expiration date, and initials of the person opening the vial. Medical record and documentation review. Schedule II, III, IV and V narcotics are stored in a separate, double-locked area; access is restricted to a limited number of staff. A periodic count of controlled substances is recorded. Staff is able to describe the steps taken to destroy outdated or unusable narcotics; required documentation of these steps is available. All medications requiring refrigeration are properly stored at the correct temperature (e.g., varicella vaccine must be kept at 5 degrees Fahrenheit or lower). 64 Standard Performance Measures A thermometer is kept in the refrigerator to ensure that temperatures remain between 36 and 46 degrees Fahrenheit. A separate thermometer is kept in the freezer compartment, and temperatures are monitored and recorded daily. The refrigerator/freezer is not used to store any other type of item (food, drinks, specimens, blood products, infectious agents, etc.). Review of written shows that log is maintained of all immunizations given and is up-to-date. Emergency Drugs and Supplies Emergency medications and crash cart are locked. These are checked regularly for stock and expiration dates. Log is maintained. Emergency/crash cart includes medications, laryngoscope, endotracheal tubes, tracheostomy set, Foley catheter, IV fluids and supplies, oxygen tank tubing and mask, ambubag, defibrillator, suction equipment, batteries, and a list of drawer contents on each respective drawer. Portable oxygen tank and nasal cannula mask are available. Log recommended. Policies and procedures are in place for all emergencies. Staff is able to describe how emergency medications are checked for stock and expiration dates and is able to name who is responsible for checking. A written log is maintained on or near the crash cart. The crash cart includes all applicable emergency medications and equipment. The equipment is in good working order, is regularly tested, is appropriately sized, and extra batteries are kept. Inspection of log shows that log is current, with expiration dates clearly noted. Visual inspection shows that a portable oxygen tank and nasal cannula mask are available. Review of inspection log shows that maintenance is performed regularly according to manufacturer’s specifications. Inspection log is updated regularly and is current. There is a mechanism for staff to assist patients in life threatening situations. This includes a procedure for calling 911, isolation of the patient, provision of CPR, use of crash cart, etc., where applicable. Staff can describe these procedures. Infection Control – OSHA Regulations Food and drinks are stored in separate refrigerators from those used to store blood or infectious materials. Spill Kit 1:10 bleach is available to kill HIV/HBV/TB, and is used according to guidelines. Universal precautions are always taken when obtaining and handling body fluids. Provisions are made for isolation of any patient suspected of having a communicable disease. Visual inspection shows that blood products, infectious agents, lab specimens, etc. are not stored in the same refrigerator as food or drinks. Spill Kit is available upon request. Visual inspection reveals that there is a readily available Spill Kit 1:10 bleach. Review of policies and procedures shows that the facility follows Federal regulations requiring active use of the OSHA Exposure Control Plan (Infection Control) to ensure safety of staff and patients from infection due to blood and other bodily fluids. Policies and procedures include evidence of a plan to deal with patients suspected of having a communicable disease. 65 Standard Performance Measures Personnel refrain from eating, drinking, and personal care in work area. The importance of hand-washing in patient and personal care is stressed. Signs are posted in restrooms. There is an active infection control program in practice. Staff interview indicates all staff are aware of and can describe the policy. The facility work area is neat, orderly, organized, and contains only work-related items, (e.g., the work area is free from foods, personal grooming items, etc.) Clean running water and soap is available in the facility, to ensure compliance with hand washing/infection control guidelines. For exam rooms without sinks, there is a waterless bacteriostatic hand cleaner/sanitizer available for use until staff can get to a sink. Reminder signs are posted in rest rooms. Review of policies and procedures shows there is a policy for infection control. Staff can describe this procedure. Handling of Bio-Hazard Waste Hazardous materials and waste are properly disposed. Sterilization supplies and chemicals in exam rooms and storage areas are labeled properly. Contaminated laundry is placed in bags or containers with lids and is labeled. Staff is able to identify the hazardous waste hauler with which the facility contracts to remove medical waste or describe disposal by the designated staff person to an appropriate intermediate site such as a hospital. Sharps containers are closable, puncture resistant, leak-proof, and color-coded or labeled as bio hazardous. Containers for other contaminated waste are closable, constructed to contain all contents and prevent leakage, and labeled or color-coded. A review of policies and procedures indicates that the facility does not store large numbers of full sharps containers or multiple large boxes or bags of other medical waste. Review of policies and procedures shows that removal of waste occurs regularly. Sharps containers are stored out of immediate or accidental patient reach (i.e., wall mounted, located on counter tops or stored in a closed cabinet). Containers are not stored on the floor or on exam tables where patients sit or lie. Staff is able to identify the contractor that removes and launders contaminated laundry or describe the procedure that is undertaken by the designated staff persons to launder contaminated laundry. Visual inspection shows that contaminated laundry is placed in labeled bags or containers with lids. A review of policies and procedures indicates that the facility has a procedure in place to launder contaminated laundry and that this procedure occurs regularly. Dietetic Service Area An emergency drinking water supply with current dates is present, stored at least 6 inches above the floor, and is protected from environmental contaminants. Visual inspection shows that an emergency drinking water supply with current dates is present, stored at least 6 inches above the floor, and is protected from environmental contaminants. Staff is able to say where it is located. 66 Standard Performance Measures Visual inspection shows that there is a one-week supply of non-perishable food and enteral products available. Visual inspection and review of policies and procedures show that storage, refrigeration, preparation, and distribution of food are done under sanitary conditions. Staff is able to describe the policy. Visual inspection show that dining and patient common areas are clean, neat, odor-free, and adequately furnished and sized, with handicapped accessibility. Review of policies and procedures and visual inspection show that accommodations are made for patients in need of assistance with meals. There is a one-week supply of non-perishable food and enteral products available. Storage, refrigeration, preparation, and distribution of food are done under sanitary conditions. Dining and patient common areas are clean, neat, odorfree, and adequately furnished and sized, with handicapped accessibility. Accommodations are made for patients in need of assistance with meals. Falls Plan of care includes an educational program with proactive measure to prevent falls. Personnel identify patients at risk for falls. Names of staff on duty are posted for the benefit of facility residents and public. Facility identifies accident/environment hazards. This could be physical environment hazards such as a floor mat, or member-specific hazards, such as knowing that a member may be at a higher risk for an accident because of a disability. Review of training manuals shows that a plan of care is in place which includes an education program with proactive measures to prevent falls. Review of medical records shows evidence of documentation of a risk assessment for each patient. Visual inspection shows that the center has names of staff on duty displayed prominently where patients can see them. Staff interview. Staff is able to identify potential areas of accident/environment risk. Restraints Staff interview shows evidence that restraints are not used in the facility. Restraints are not used in the facility. Activities Patients, including those unable to leave their rooms, may choose to take part in a variety of activities. The facility has outdoor areas for patients. Staff provides assistance to, and supervision of, patients when outdoors. The facility has an active volunteer program. Group Meetings among patient, family, and staff are held. Staff interview shows evidence that patients, including those unable to leave their rooms, may choose to take part in a variety of activities. Visual inspection and staff interview show that the facility has outdoor areas for patients and that staff provide assistance to, and supervision of patients when outdoors. Staff interview and review of documentation show evidence that the facility has an active volunteer program. Policies and procedures. Vaccinations Documentation of pneumococcal vaccine administration or refusal is maintained. Flu vaccine offered to residents yearly with documentation of receipt or refusal. Review of medical records shows documentation of pneumococcal vaccine administration or refusal. Review of medical records shows documentation of flu vaccine having been offered to residents yearly, 67 Standard Performance Measures with documentation of receipt or refusal. Cardiac Catheterization and Dialysis Centers As a provider in the Preferred Care Partners network, your center will be required to meet the standards of state and national regulatory agencies as well as those of Preferred Care Partners. Your center will be audited to ensure that your facility and practices are in compliance. We have provided this booklet as a set of guidelines to prepare your center and employees for these audits. The table below includes a listing of the standards upon which you will be audited and the indicators that we will use to determine whether your facility is in compliance. If you have any questions about compliance or audits, please contact Network Management Services at (877) 670-8432 or at [email protected]. Standard Performance Measures General Patient rights and responsibilities are posted, along with toll-free numbers for Consumer Assistance (AHCA). The center posts or makes available upon request patient rights and responsibilities for Preferred Care Partners members. Occupational licenses and state license (if applicable) are available and current. Occupational licenses are displayed and visible. All professional licenses (Medical Director, Physician, RN, Surgeon and medical personnel) are current and available upon request. Professional licenses are visibly displayed and in public view. There is an executive privacy officer responsible for all the facility’s policies and procedures, and for compliance with federal laws and regulations. Professional licenses are visibly displayed and in public view. Written policy and procedure for staff training is in place, along with an agreement for unanticipated patient transfer to a hospital if necessary. This includes ambulance service and transfer of medical information. Staff is courteous, respectful, and helpful toward patients and visitors. Review of policies and procedures, training manuals, and orientation materials. Staff demonstrates a courteous, respectful and helpful manner toward patents and visitors. Access & Appearance/Handicapped Access There is handicapped access to parking, building and facility entrances, bathroom facilities, and water fountain. The parking area offers handicapped parking spaces adequate for the center. Staff are able to describe how they accommodate people with disabilities who require assistance to access a facility. For example, an entrance ramp is provided where there are steps. 68 Standard Performance Measures If building is more than one story, elevator is available with current inspection certificate. Where patients need to access a facility above the ground floor, there is an elevator displaying evidence of a current city/county inspection. Address and parking are clearly marked with adequate parking available. Adequate parking, including handicapped parking spaces, is easily accessible and includes a reasonably short walk from the parking lot. There are signs or markers that clearly identify parking areas and spaces. Center has adequate space and seating for patients. There is adequate space in exam rooms for patients and equipment. There is sufficient seating to accommodate patients. Center demonstrates housekeeping; areas are neat, clean, and odor-free. The entire facility is clean. Corners and floors should be clear and free from dirt or trash, and trash is not overflowing from waste receptacles. The environment is smoke and odor-free. Building’s exterior appearance demonstrates that routine maintenance is performed. Building appears to be in good repair, with neatly maintained landscaping. Safety Exit signs and maps are posted for emergency evacuation of patients, staff, and visitors. Doors that exit the facility are marked by lighted or printed exit signs. An evacuation map is available for inspection. Fire extinguishers are placed in strategic areas and reflect yearly inspection. Extinguishers have current tags documenting current annual inspection by qualified fire equipment inspector, or a receipt showing purchase within one year. “No Smoking” signs are posted inside the building. “No Smoking” signs are conspicuously located in the facility. The facility is smoke-free. The facility has working smoke detectors installed in strategic areas to raise an alarm in case of fire. The facility is smoke-free and has smoke detectors/ alarms throughout. All hallways are free of obstacles and have adequate lighting. Entrances to facility and passageways are well-lit, clear of obstacles and adequate for movement of patients and equipment. Corridors and floors are free from clutter, trash, and/or loose/unsecured electrical cords for patient and staff safety. Supplies stacked such that they cannot fall over or be pulled over on patients. Emergency lighting is available in building. The building is equipped with emergency lighting In case of a power outage. The nursing station is located in an area that provides adequate visual surveillance of patients on dialysis machines. Visual inspection of facility. Personnel identify patients at risk for falls. There is documentation in the medical record which shows a fall risk assessment. 69 Standard Performance Measures Personnel are aware of procedure to follow in case of emergency, fire, or other crises. Staff is able to describe an evacuation plan that demonstrates knowledge of the location of emergency exit(s) and provision for movement of patients to safety. There is a written disaster plan available. The facility has an emergency/disaster plan. All staff are aware of the plan and able to describe it. Medical Records Medical records are safeguarded against loss, tampering, or use by unauthorized persons. Records are stored in a location that prevents unauthorized access. Records are not stored in rooms where patients are seen or in main access areas such as common walkways, etc., unless files are locked during patient care hours. The center maintains confidentiality, releasing medical information only by written consent. Review of medical records shows that a signed consent to release medical information has been obtained for each patient. A review of policies and procedures shows policies are in place describing medical record retention and PHI disposal. Allergies or NKA are documented and prominently displayed. Known allergies, adverse reactions, or NKA are documented in a prominent, consistent location in the medical record. Documentation of informed consent, significant medical history, physical exam, pre-op studies, surgical note, pathology report, adverse reactions, and discharge diagnosis is maintained. Review of medical record documentation shows documentation of informed consent, significant medical history, physical exam, pre-op studies, surgical note, pathology report, adverse reactions, and discharge diagnoses. Documentation of primary language and translation needs is maintained. Staff communicates in members’ language of preference. Review of notes and demographic data in medical record shows documentation of primary language and translation needs for each patient. Each patient has a unique record with an identifier, which enables staff to produce a record on demand. Medical records contain the correct patient information; they do not contain information for the wrong patient. Records are easily retrieved by appropriate facility staff. Policies and procedures are written to address collection, storage, and disposal of written and electronic documents. There are policies, procedures and training materials on HIPAA compliance. Staff can describe the procedures to be followed. Laboratory Services CLIA license, waiver, or proof of payment is available and current. CLIA documentation is available for inspection. CLIA# and expiration date is recorded for review purposes. If laboratory certification or waiver is required, certificates are current, appropriate to the type of testing to be performed, and available for review. Multiple-facility locations have a certificate or waiver specific to each facility. 70 Standard Performance Measures Lab specimens requiring refrigeration are stored in a refrigerator/freezer dedicated to that purpose. No foods or medications are stored in this refrigerator/freezer. Lab specimens are stored separately from medication and food. Emergency Drugs and Supplies Emergency medications and crash cart are locked. These are checked regularly for stock and expiration dates. Log is maintained. Staff are able to describe how emergency medications are checked for stock and expiration dates and are able to name who is responsible for checking. A written log is maintained on or near the crash cart. Emergency/crash cart includes medications, laryngoscope, endotracheal tubes, tracheostomy set, Foley catheter, IV fluids and supplies, oxygen tank tubing and mask, ambubag, defibrillator, suction equipment, batteries, and a list of drawer contents on each respective drawer. The crash cart includes all applicable emergency medications and equipment. The equipment is in good working order, is regularly tested, is appropriately sized, and extra batteries are kept. Inspection of log shows that log is current, with expiration dates clearly noted. Policies and procedures are in place for all emergencies. There is a mechanism for staff to assist patients in life threatening situations. This includes a procedure for calling 911, isolation of the patient, provision of CPR, use of crash cart, etc., where applicable. Staff can describe these procedures. Medications Medication expiration dates are checked routinely and expired medicines are properly disposed. (Log is recommended). Staff is able to describe the frequency with which drug samples are checked for expiration and who is responsible for checking. The checking of samples for expiration is a routine facility procedure, rather than optional or random in nature. At a minimum, there is documentation of quarterly inspection. Syringes and needles are stored in a secure manner with limited access. Syringes and needles are stored in cabinets or other locations that deter unauthorized access by patients. During facility hours, prescription pads are stored in a location that prevents unauthorized access, such as with the physician or in a cabinet or drawer that is not in a patient care area. Medications are stored and prepared in a designated secured area and are dispensed by licensed staff. Drug samples and other medications used in the facility are stored in cabinets or other locations that deny unauthorized access by patients (e.g., drugs should not be observed on counter tops or on open shelves in patient care areas). The temperature of the refrigerator or freezer designated for pharmaceuticals and biological materials must be kept within a specified temperature range. Daily maintenance log is kept. Storage of biologicals: Refrigerator: 35˚to 45˚ F. Freezer: 2˚ to 8˚ F. Multi-dose vials of medications are properly labeled with date first used, and are discarded after 30 days. Pharmaceutical products are not refrigerated with food or beverages. Visual inspection of log shows that temperature has been recorded daily and that log is up-to-date. Visual inspection shows that containers are labeled with date opened, expiration date, and initials of the person opening the vial. 71 Standard Performance Measures IV fluids are properly labeled. Controlled substances are kept in a separate, double-locked area. A required current dispensing log is kept. Visual inspection shows that IV fluids are labeled with the patient name, IV drip rate, IV dosage, and the initials of the nurse administering the IV. Schedule II, III, IV and V narcotics are stored in a separate, double-locked area; access is restricted to a limited number of staff. A periodic count of controlled substances is recorded. Staff is able to describe the steps taken to destroy outdated or unusable narcotics; required documentation of these steps is available. Medications requiring refrigeration are properly stored. All medications requiring refrigeration are properly stored at the correct temperature (e.g., varicella vaccine must be kept at 5 degrees Fahrenheit or lower). A thermometer is kept in the refrigerator to ensure that temperatures remain between 36 and 46 degrees Fahrenheit. A separate thermometer is kept in the freezer compartment, and temperatures are monitored and recorded daily. The refrigerator/freezer is not used to store any other type of item (food, drinks, specimens, blood products, infectious agents, etc.). Review of written shows that log is maintained of all immunizations given and is up-to-date. Adverse reactions are reported to the physician and are documented and recorded immediately. Medical record and documentation review. Infection Control – OSHA Regulations Universal precautions are always taken when obtaining and handling body fluids. Review of policies and procedures shows that the facility follows Federal regulations requiring active use of the OSHA Exposure Control Plan (Infection Control) to ensure safety of staff and patients from infection due to blood and other bodily fluids. The importance of hand-washing in patient and personal care is stressed. Signs are posted in rest rooms. Clean running water and soap is available in the facility, to ensure compliance with hand washing/infection control guidelines. For exam rooms without sinks, there is a waterless bacteriostatic hand cleaner/sanitizer available for use until staff can get to a sink. Reminder signs are posted in rest rooms. There is an active infection control program in practice. Review of policies and procedures shows there is a policy for infection control. Staff can describe this procedure. There is proper use, calibration, and regular maintenance of all dialysis equipment according to the manufacturers’ recommendations. This is documented on an inspection log or inspection tags. Review of inspection log or inspection tag shows that maintenance is performed regularly according to manufacturer’s specifications. Inspection log is updated regularly and is current. Spill Kit 1:10 bleach is available to kill HIV/HBV/TB, and is used according to guidelines. Spill Kit is available upon request. Visual inspection reveals that there is a readily available Spill Kit 1:10 bleach. 72 Standard Performance Measures Provisions are made for isolation of any patient suspected of having a communicable disease. Policies and procedures include evidence of a plan to deal with patients suspected of having a communicable disease. Personnel refrain from eating, drinking, and personal care in work area. Staff interview indicates all staff are aware of and can describe the policy. The facility work area is neat, orderly, organized, and contains only work-related items, (e.g., the work area is free from foods, personal grooming items, etc.). Treatment areas and rest rooms are equipped to attend to patients’ needs and safety. Visual inspection shows that appropriate examination equipment is available. Patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. Visual inspection shows that patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. Patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. Visual inspection shows that patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. Handling of Bio-Hazard Waste Hazardous materials and waste are properly disposed. Staff is able to identify the hazardous waste hauler with which the facility contracts to remove medical waste or describe disposal by the designated staff person to an appropriate intermediate site such as a hospital. Sharps containers are closable, puncture resistant, leak-proof, and color-coded or labeled as bio hazardous. Containers for other contaminated waste are closable, constructed to contain all contents and prevent leakage, and labeled or color-coded. A review of policies and procedures indicates that the facility does not store large numbers of full sharps containers or multiple large boxes or bags of other medical waste. Review of policies and procedures shows that removal of waste occurs regularly. Sterilization supplies and chemicals in exam rooms and storage areas are labeled properly. Sharps containers are stored out of immediate or accidental patient reach (i.e., wall mounted, located on counter tops or stored in a closed cabinet). Containers are not stored on the floor or on exam tables where patients sit or lie. Availability There is a clear policy in place for appointment scheduling practices. Staff interview. Staff is able to describe the policy for appointment scheduling. Missed appointments are recalled as necessary and are documented. (Log recommended.) Patient waiting time is under 30 minutes. Facility reschedules appointments for unavoidable delays. Business hours are posted outside of the facility. Visual Inspection shows that business hours are posted 73 Standard Performance Measures prominently outside of the facility. There is one cardiac catheterization lab per license. Visible inspection shows one cardiac catheterization labs per license. An on-call policy exists at the center. Review of policies and staff interview show that appropriate medical personnel may be contacted 24 hours a day through an answering service or directly by telephone. Members are not directed to a hospital emergency department. Medical personnel respond within 30 minutes. Nursing The Registered Nurse documents the patient’s medical record appropriately, according to the treatment plan. Review of medical record documentation shows that a Registered Nurse documents the patient’s medical record appropriately, according to the treatment plan. Director of Nursing is an RN, with a current, valid state license. Visual inspection of documentation shows evidence that the Director of Nursing is an RN with a current, valid state license. Whenever the facility is operational, a Registered Nurse certified in CPR is available for any emergency treatment. Visual inspection shows evidence that there is an RN who is certified in CPR available for emergency treatment. Staff is able to identify the designated RN. Facility provides continuing education and/or in-services for nurses and staff. Review of training manual and of policies and procedures shows that the facility provides continuing education and/or in-services for nurses and staff. Staff licenses are verified on an annual basis. Staff licenses can be provided upon request of reviewer. Sufficient nursing and other personnel are available to provide services. The staff-to-patient ratio is at a maximum 1 nurse to 4 patients (1:4). Nurses properly document pain assessment, treatment, and reassessment if pain medication is given. Review of medical record shows evidence of a pain scale assessment and follow-up, if needed. Rehabilitation/Physical Therapy Facilities As a provider in the Preferred Care Partners network, your center will be required to meet the standards of state and national regulatory agencies as well as those of Preferred Care Partners. You will be audited to ensure that your facility and practices are in compliance. We have provided this booklet as a set of 74 guidelines to prepare your center and employees for these audits. The table below includes a listing of the standards upon which you will be audited and the indicators that we will use to determine whether your facility is in compliance. If you have any questions about compliance or audits, please contact Network Management Services at (877) 670-8432 or at [email protected]. Standard Performance Measures General Patient rights and responsibilities are posted, along with toll-free numbers for Consumer Assistance (AHCA). The center posts or makes available upon request patient rights and responsibilities for Preferred Care Partners members. Occupational license or statutory waiver is displayed. Staff and medical personnel licenses are displayed and visible. Facility provides continuing education and/or in-services for staff. Review of training manual and of policies and procedures shows that the facility provides continuing education and/or in-services for nurses and staff. The facility has a designated Privacy Officer. Staff is able to name the Privacy Officer. There is an executive privacy officer responsible for all the facility’s policies and procedures, and for compliance with federal laws and regulations. Facility has a written quality improvement plan. Facility may have a Quality Improvement Committee. Review of policies and procedures shows that facility has a written quality improvement plan, or a plan along with a Quality Improvement Committee. Staff is able to describe the plan upon request. Licensed physical therapist, occupational therapist, and speech therapists are present during session hours. Staff can locate and identify licensed therapists who are available to meet needs of members during session hours. Access & Appearance/Handicapped Access There is handicapped access to parking, building and facility entrances, bathroom facilities, and water fountain. The parking area offers handicapped parking spaces adequate for the facility. Staff are able to describe how they accommodate people with disabilities who require assistance to access a Facility. For example, an entrance ramp is provided where there are steps. If building is more than one story, elevator is available with current inspection certificate. Where patients need to access a facility above the ground floor, there is an elevator displaying evidence of a current city/county inspection. Business hours are posted outside of the facility. Visual Inspection shows that business hours are posted prominently outside of the facility. Center demonstrates housekeeping; areas are neat, clean, and odor-free. The entire facility is clean. Corners and floors should be clear and free from dirt or trash, and trash is not overflowing from waste receptacles. The environment is smoke and odor-free. 75 Standard Performance Measures Building’s exterior appearance demonstrates that routine maintenance is performed. Building appears to be in good repair, with neatly maintained landscaping. Address and parking are clearly marked with adequate parking available. Adequate parking, including handicapped parking spaces, is easily accessible and includes a reasonably short walk from the parking lot. There are signs or markers that clearly identify parking areas and spaces. Safety Extinguishers have current tags documenting current annual inspection by qualified fire equipment inspector, or a receipt showing purchase within one year. The facility has an emergency/disaster plan. All staff are aware of the plan and able to describe it. Fire extinguishers are placed in strategic areas and reflect yearly inspection. There is a written disaster plan available. Corridors are equipped with firmly-secured handrails on both sides. Visual inspection shows that corridors are equipped with firmly-secured handrails. Exit signs and maps are posted for emergency evacuation of patients and staff. Doors that exit the facility are marked by lighted or printed exit signs. An evacuation map is available for inspection. The facility is smoke-free and has smoke detectors/alarms throughout. The facility is smoke-free. The facility has working smoke detectors installed in strategic areas to raise an alarm in case of fire. “No Smoking” signs are posted inside the building. “No Smoking” signs are conspicuously located in the facility. All hallways are free of obstacles and have adequate lighting. Entrances to facility and passageways are well-lit, clear of obstacles and adequate for movement of patients and equipment. Corridors and floors are free from clutter, trash, and/ or loose/unsecured electrical cords for patient and staff safety. Supplies stacked such that they cannot fall over or be pulled over on patients. Emergency lighting is available in building. The building is equipped with emergency lighting In case of a power outage. Personnel are aware of procedure to follow in case of emergency, fire, or other crises. Staff is able to describe an evacuation plan that demonstrates knowledge of the location of emergency exit(s) and provision for movement of patients to safety. 76 Standard Performance Measures Visual inspection of policies and procedures. Staff is able to describe the policy and procedure. The facility has an emergency plan and holds a minimum of one fire drill each quarter. Medical Records Medical records are safeguarded against loss, tampering, Records are stored in a location that prevents or use by unauthorized persons. unauthorized access. Records are not stored in rooms where patients are seen or in main access areas such as common walkways, etc., unless fi les are locked during patient care hours. The center maintains confidentiality, releasing medical information only by written consent. Review of medical records shows that a signed consent to release medical information has been obtained for each patient. A review of policies and procedures shows policies are in place describing medical record retention and PHI disposal. Documentation of primary language and translation needs is maintained. Staff communicates in members’ language of preference. Review of notes and demographic data in medical record shows documentation of primary language and translation needs for each patient. Allergies or NKA are documented and prominently displayed. Known allergies, adverse reactions, or NKA are documented in a prominent, consistent location in the medical record. Each patient has a unique record with an identifier, which enables staff to produce a record on demand. Medical records contain the correct patient information; they do not contain information for the wrong patient. Records are easily retrieved by appropriate facility staff. Policies and procedures are written to address collection, storage, and disposal of written and electronic documents. There are policies, procedures and training materials on HIPAA compliance. Staff can describe the procedures to be followed. Each record has an individualized care plan that identifies patients’ goals and progress. Review of medical records shows that each record has an individualized care plan that identifies patients’ goals and progress. Nurse or staff document a comprehensive pain assessment, and reassesses for identified pain a minimum of every four hours. Factors that can alter the response to pain medication is documented. Pain Management Review of medical record shows evidence of a pain scale assessment and follow-up, if needed. Factors that can alter the response to pain medication are documented. Review of medical record shows documentation on factors that can alter the response to pain medication. Emergency Drugs and Supplies 77 Standard Performance Measures Emergency medications and crash cart are locked. These are checked regularly for stock and expiration dates. Log is maintained. Staff are able to describe how emergency medications are checked for stock and expiration dates and are able to name who is responsible for checking. A written log is maintained on or near the crash cart. Emergency/crash cart includes medications, laryngoscope, endotracheal tubes, tracheostomy set, Foley catheter, IV fluids and supplies, oxygen tank tubing and mask, ambubag, defibrillator, suction equipment, batteries, and a list of drawer contents on each respective drawer. The crash cart includes all applicable emergency medications and equipment. The equipment is in good working order, is regularly tested, is appropriately sized, and extra batteries are kept. Inspection of log shows that log is current, with expiration dates clearly noted. Portable oxygen tank and nasal cannula mask are available. Log recommended. Visual inspection shows evidence that an oxygen tank and nasal cannula mask are available. Review of log shows that maintenance of equipment is up-todate based on manufacturer’s maintenance recommendations. Policies and procedures are in place for all emergencies. There is a mechanism for staff to assist patients in life threatening situations. This includes a procedure for calling 911, isolation of the patient, provision of CPR, use of crash cart, etc., where applicable. Staff can describe these procedures. Infection Control - OSHA Regulations Food and drinks are stored in separate refrigerators from those used to store blood or infectious materials. Visual inspection shows that blood products, infectious agents, lab specimens, etc. are not stored in the same refrigerator as food or drinks. Spill Kit 1:10 bleach is available to kill HIV/HBV/TB, and is used according to guidelines. Spill Kit is available upon request. Visual inspection reveals that there is a readily available Spill Kit 1:10 bleach. Universal precautions are always taken when obtaining and handling body fluids. Review of policies and procedures shows that the facility follows Federal regulations requiring active use of the OSHA Exposure Control Plan (Infection Control) to ensure safety of staff and patients from infection due to blood and other bodily fluids. Provisions are made for isolation of any patient suspected of having a communicable disease. Policies and procedures include evidence of a plan to deal with patients suspected of having a communicable disease. Personnel refrain from eating, drinking, and personal care in work area. Staff interview indicates all staff are aware of and can describe the policy. The facility work area is neat, orderly, organized, and contains only work-related items, (e.g., the work area is free from foods, personal grooming items, etc.). 78 Standard Performance Measures The importance of hand-washing in patient and personal care is stressed. Signs are posted in rest rooms. Clean running water and soap is available in the facility, to ensure compliance with hand washing/infection control guidelines. For exam rooms without sinks, there is a waterless bacteriostatic hand cleaner/sanitizer available for use until staff can get to a sink. Reminder signs are posted in rest rooms. Toilet and bath area are clean, sanitary, and free of odors, and have provisions for patient privacy and patient safety. An emergency cord is recommended. Visual inspection shows that toilet and bath area are clean. Corners and floors are clear and free from dirt and trash. There is clean running water and soap is available. Visual inspection shows there are handrails and other patient safety features in the bathroom. Visual inspection shows that there is a sign recommending proper hand-washing after using the rest room. Handling of Bio-Hazard Waste Sterilization supplies and chemicals in exam rooms and storage areas are labeled properly. Sharps containers are stored out of immediate or accidental patient reach (i.e., wall mounted, located on counter tops or stored in a closed cabinet). Containers are not stored on the floor or on exam tables where patients sit or lie. Contaminated laundry is placed in bags or containers with lids and is labeled. Staff is able to identify the contractor that removes and launders contaminated laundry or describe the procedure that is undertaken by the designated staff persons to launder contaminated laundry. Visual inspection shows that contaminated laundry is placed in labeled bags or containers with lids. A review of policies and procedures indicates that the facility has a procedure in place to launder contaminated laundry and that this procedure occurs regularly. Staff is able to identify the hazardous waste hauler with which the facility contracts to remove medical waste or describe disposal by the designated staff person to an appropriate intermediate site such as a hospital. Sharps containers are closable, puncture resistant, leak-proof, and color-coded or labeled as bio hazardous. Containers for other contaminated waste are closable, constructed to contain all contents and prevent leakage, and labeled or color-coded. A review of policies and procedures indicates that the facility does not store large numbers of full sharps containers or multiple large boxes or bags of other medical waste. Review of policies and procedures shows that removal of waste occurs regularly. Hazardous materials and waste are properly disposed. Therapy Area There is proper use, calibration, and regular maintenance of all equipment according to the manufacturers’ recommendations. This is documented on an inspection log or inspection tags. Review of inspection log or inspection tag shows that maintenance is performed regularly according to manufacturer’s specifications. Inspection log is updated regularly and is current. 79 Standard Performance Measures Falls Plan of care includes an educational program regarding proactive measures to prevent falls. A review of policies and procedures shows that there is a plan of care that includes an education program regarding proactive measures to prevent falls. Staff is able to describe these procedures. Personnel identify patients at risk for falls. There is documentation in the medical record which shows a fall risk assessment. Names of staff on duty are posted for the benefit of facility residents and public. Visual inspection shows that the facility has names of staff on duty displayed where patients can see them. Facility identifies accident/environment hazards. This could be physical environment hazards such as a floor mat, or member-specific hazards, such as knowing that a member may be at a higher risk for an accident because of a disability. Staff interview. Staff is able to identify potential areas of accident/environment risk. Visual inspection of medical records shows documentation of a risk assessment for each patient. Dialysis Centers As a provider in the Preferred Care Partners network, your center will be required to meet the standards of state and national regulatory agencies as well as those of Preferred Care Partners. You will be audited to ensure that your facility and practices are in compliance. We have provided this booklet as a set of guidelines to prepare your center and employees for these audits. The table below includes a listing of the standards upon which you will be audited, and the indicators that we will use to determine whether your facility is in compliance. If you have any questions about compliance or audits, please contact Network Management Services at (877) 670-8432 or at [email protected]. Standard Performance Measures General Patient rights and responsibilities are posted, along with toll-free numbers for Consumer Assistance (AHCA). The center posts or makes available upon request patient rights and responsibilities for Preferred Care Partners members. Occupational licenses and state license (if applicable) are available and current. Occupational licenses are displayed and visible. All professional licenses (Medical Director, Physician, RN, Surgeon and medical personnel) are current and available upon request. Professional licenses are visibly displayed and in public view. There is an executive privacy officer responsible for all the facility’s policies and procedures, and for compliance with federal laws and regulations. Professional licenses are visibly displayed and in public view. 80 Standard Performance Measures Written policy and procedure for staff training is in place, along with an agreement for unanticipated patient transfer to a hospital if necessary. This includes ambulance service and transfer of medical information. Staff is courteous, respectful, and helpful toward patients and visitors. Review of policies and procedures, training manuals, and orientation materials. Staff demonstrates a courteous, respectful and helpful manner toward patents and visitors. Access & Appearance/Handicapped Access There is handicapped access to parking, building The parking area offers handicapped parking spaces and facility entrances, bathroom facilities, and water adequate for the center. Staff is able to describe how fountain. they accommodate people with disabilities who require assistance to access a facility. For example, an entrance ramp is provided where there are steps. If building is more than one story, elevator is available with current inspection certificate. Where patients need to access a facility above the ground floor, there is an elevator displaying evidence of a current city/county inspection. Address and parking are clearly marked with adequate parking available. Adequate parking, including handicapped parking spaces, is easily accessible and includes a reasonably short walk from the parking lot. There are signs or markers that clearly identify parking areas and spaces. There is adequate space in exam rooms for patients and equipment. There is sufficient seating to accommodate patients. Center has adequate space and seating for patients. Center demonstrates housekeeping; areas are neat, clean, and odor-free. The entire facility is clean. Corners and floors should be clear and free from dirt or trash, and trash is not overflowing from waste receptacles. The environment is smoke and odor-free. Building’s exterior appearance demonstrates that routine maintenance is performed. Building appears to be in good repair, with neatly maintained landscaping. Safety Exit signs and maps are posted for emergency evacuation of patients, staff, and visitors. Doors that exit the facility are marked by lighted or printed exit signs. An evacuation map is available for inspection. Fire extinguishers are placed in strategic areas and reflect yearly inspection. Extinguishers have current tags documenting current annual inspection by qualified fire equipment inspector, or a receipt showing purchase within one year. “No Smoking” signs are posted inside the building. “No Smoking” signs are conspicuously located in the facility. The facility is smoke-free. The facility has working smoke detectors installed in strategic areas to raise an alarm in case of fire. The facility is smoke-free and has smoke detectors/alarms throughout. 81 Standard Performance Measures All hallways are free of obstacles and have adequate lighting. Entrances to facility and passageways are well-lit, clear of obstacles and adequate for movement of patients and equipment. Corridors and floors are free from clutter, trash, and/or loose/unsecured electrical cords for patient and staff safety. Supplies stacked such that they cannot fall over or be pulled over on patients. Emergency lighting is available in building. The building is equipped with emergency lighting In case of a power outage. The nursing station is located in an area that provides adequate visual surveillance of patients on dialysis machines. Visual inspection of facility. Personnel identify patients at risk for falls. There is documentation in the medical record which shows a fall risk assessment. Personnel are aware of procedure to follow in case of emergency, fire, or other crises. Staff is able to describe an evacuation plan that demonstrates knowledge of the location of emergency exit(s) and provision for movement of patients to safety. There is a written disaster plan available. The facility has an emergency/disaster plan. All staff members are aware of the plan and able to describe it. Medical Records Medical records are safeguarded against loss, tampering, or use by unauthorized persons. Records are stored in a location that prevents unauthorized access. Records are not stored in rooms where patients are seen or in main access areas such as common walkways, etc., unless files are locked during patient care hours. The center maintains confidentiality, releasing medical information only by written consent. Review of medical records shows that a signed consent to release medical information has been obtained for each patient. A review of policies and procedures shows policies are in place describing medical record retention and PHI disposal. Allergies or NKA are documented and prominently displayed. Known allergies, adverse reactions, or NKA are documented in a prominent, consistent location in the medical record. Documentation of informed consent, significant medical history, physical exam, pre-op studies, surgical note, pathology report, adverse reactions, and discharge diagnosis is maintained. Review of medical record documentation shows documentation of informed consent, significant medical history, physical exam, pre-op studies, surgical note, pathology report, adverse reactions, and discharge diagnoses. Documentation of primary language and translation needs is maintained. Staff communicates in members’ language of preference. Review of notes and demographic data in medical record shows documentation of primary language and translation needs for each patient. 82 Standard Performance Measures Each patient has a unique record with an identifier, which enables staff to produce a record on demand. Medical records contain the correct patient information; they do not contain information for the wrong patient. Records are easily retrieved by appropriate facility staff. Policies and procedures are written to address collection, storage, and disposal of written and electronic documents. There are policies, procedures and training materials on HIPAA compliance. Staff can describe the procedures to be followed. Laboratory Services CLIA license, waiver, or proof of payment is available and current. CLIA documentation is available for inspection. CLIA# and expiration date is recorded for review purposes. If laboratory certification or waiver is required, certificates are current, appropriate to the type of testing to be performed, and available for review. Multiple-facility locations have a certificate or waiver specific to each facility. Lab specimens are stored separately from medication and food. Lab specimens requiring refrigeration are stored in a refrigerator/freezer dedicated to that purpose. No foods or medications are stored in this refrigerator/freezer. Emergency Services & Supplies Emergency medications and crash cart are locked. These are checked regularly for stock and expiration dates. Log is maintained. Staff is able to describe how emergency medications are checked for stock and expiration dates and are able to name who is responsible for checking. A written log is maintained on or near the crash cart. Emergency/crash cart includes medications, laryngoscope, endotracheal tubes, tracheostomy set, Foley catheter, IV fluids and supplies, oxygen tank tubing and mask, ambubag, defibrillator, suction equipment, batteries, and a list of drawer contents on each respective drawer. The crash cart includes all applicable emergency medications and equipment. The equipment is in good working order, is regularly tested, is appropriately sized, and extra batteries are kept. Inspection of log shows that log is current, with expiration dates clearly noted. Policies and procedures are in place for all emergencies. There is a mechanism for staff to assist patients in life threatening situations. This includes a procedure for calling 911, isolation of the patient, provision of CPR, use of crash cart, etc., where applicable. Staff can describe these procedures. Medications 83 Standard Performance Measures Medication expiration dates are checked routinely and expired medicines are properly disposed. (Log is recommended). Staff is able to describe the frequency with which drug samples are checked for expiration and who is responsible for checking. The checking of samples for expiration is a routine facility procedure, rather than optional or random in nature. At a minimum, there is documentation of quarterly inspection. Syringes and needles are stored in a secure manner with limited access. Syringes and needles are stored in cabinets or other locations that deter unauthorized access by patients. During facility hours, prescription pads are stored in a location that prevents unauthorized access, such as with the physician or in a cabinet or drawer that is not in a patient care area. Medications are stored and prepared in a designated secured area and are dispensed by licensed staff. Drug samples and other medications used in the facility are stored in cabinets or other locations that deny unauthorized access by patients (e.g., drugs should not be observed on counter tops or on open shelves in patient care areas). The temperature of the refrigerator or freezer designated for pharmaceuticals and biological materials must be kept within a specified temperature range. Daily maintenance log is kept. Storage of biologicals: Refrigerator: 35˚to 45˚ F. Freezer: 2˚ to 8˚ F. Multi-dose vials of medications are properly labeled with date first used, and are discarded after 30 days. Pharmaceutical products are not refrigerated with food or beverages. Visual inspection of log shows that temperature has been recorded daily and that log is up-to-date. IV fluids are properly labeled. Controlled substances are kept in a separate, double-locked area. A required current dispensing log is kept. Visual inspection shows that IV fluids are labeled with the patient name, IV drip rate, IV dosage, and the initials of the nurse administering the IV. Visual inspection shows that containers are labeled with date opened, expiration date, and initials of the person opening the vial. Schedule II, III, IV and V narcotics are stored in a separate, double-locked area; access is restricted to a limited number of staff. A periodic count of controlled substances is recorded. Staff is able to describe the steps taken to destroy outdated or unusable narcotics; required documentation of these steps is available. Medications requiring refrigeration are properly stored. All medications requiring refrigeration are properly stored at the correct temperature (e.g., varicella vaccine must be kept at 5 degrees Fahrenheit or lower). A thermometer is kept in the refrigerator to ensure that temperatures remain between 36 and 46 degrees Fahrenheit. A separate thermometer is kept in the freezer compartment, and temperatures are monitored and recorded daily. The refrigerator/freezer is not used to store any other type of item (food, drinks, specimens, blood products, infectious agents, etc.). Review of written shows that log is maintained of all immunizations given and is up-to-date. 84 Standard Performance Measures Adverse reactions are reported to the physician and are documented and recorded immediately. Medical record and documentation review. Infection Control - OSHA Regulations Universal precautions are always taken when obtaining and handling body fluids. Review of policies and procedures shows that the facility follows Federal regulations requiring active use of the OSHA Exposure Control Plan (Infection Control) to ensure safety of staff and patients from infection due to blood and other bodily fluids. The importance of hand-washing in patient and personal care is stressed. Signs are posted in rest rooms. Clean running water and soap is available in the facility, to ensure compliance with hand washing/infection control guidelines. For exam rooms without sinks, there is a waterless bacteriostatic hand cleaner/sanitizer available for use until staff can get to a sink. Reminder signs are posted in rest rooms. There is an active infection control program in practice. Review of policies and procedures shows there is a policy for infection control. Staff can describe this procedure. There is proper use, calibration, and regular maintenance of all dialysis equipment according to the manufacturers’ recommendations. This is documented on an inspection log or inspection tags. Review of inspection log or inspection tag shows that maintenance is performed regularly according to manufacturer’s specifications. Inspection log is updated regularly and is current. Spill Kit 1:10 bleach is available to kill HIV/HBV/TB, and is used according to guidelines. Spill Kit is available upon request. Visual inspection reveals that there is a readily available Spill Kit 1:10 bleach. Policies and procedures include evidence of a plan to deal with patients suspected of having a communicable disease. Provisions are made for isolation of any patient suspected of having a communicable disease. Personnel refrain from eating, drinking, and personal care in work area. Staff interview indicates all staff are aware of and can describe the policy. The facility work area is neat, orderly, organized, and contains only work-related items, (e.g., the work area is free from foods, personal grooming items, etc.). Treatment areas and rest rooms are equipped to attend to patients’ needs and safety. Visual inspection shows that appropriate examination equipment is available. Patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. Visual inspection shows that patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. 85 Standard Performance Measures Patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. Visual inspection shows that patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. Handling of Bio-Hazard Waste Hazardous materials and waste are properly disposed. Staff is able to identify the hazardous waste hauler with which the facility contracts to remove medical waste or describe disposal by the designated staff person to an appropriate intermediate site such as a hospital. Sharps containers are closable, puncture resistant, leak-proof, and color-coded or labeled as bio hazardous. Containers for other contaminated waste are closable, constructed to contain all contents and prevent leakage, and labeled or color-coded. A review of policies and procedures indicates that the facility does not store large numbers of full sharps containers or multiple large boxes or bags of other medical waste. Review of policies and procedures shows that removal of waste occurs regularly. Sterilization supplies and chemicals in exam rooms and storage areas are labeled properly. Sharps containers are stored out of immediate or accidental patient reach (i.e., wall mounted, located on counter tops or stored in a closed cabinet). Containers are not stored on the floor or on exam tables where patients sit or lie. Availability There is a clear policy in place for appointment scheduling practices. Staff interview. Staff is able to describe the policy for appointment scheduling. Missed appointments are recalled as necessary and are documented. (Log recommended.) Patient waiting time is under 30 minutes. Facility reschedules appointments for unavoidable delays. Business hours are posted outside of the facility. Visual Inspection shows that business hours are posted prominently outside of the facility. There is one cardiac catheterization lab per license. Visible inspection shows one cardiac catheterization labs per license. An on-call policy exists at the center. Review of policies and staff interview show that appropriate medical personnel may be contacted 24 hours a day through an answering service or directly by telephone. Members are not directed to a hospital emergency department. Medical personnel respond within 30 minutes. Nursing 86 Standard Performance Measures The Registered Nurse documents the patient’s medical record appropriately, according to the treatment plan. Review of medical record documentation shows that a Registered Nurse documents the patient’s medical record appropriately, according to the treatment plan. Director of Nursing is an RN, with a current, valid state license. Visual inspection of documentation shows evidence that the Director of Nursing is an RN with a current, valid state license. Whenever the facility is operational, a Registered Nurse certified in CPR is available for any emergency treatment. Visual inspection shows evidence that there is an RN who is certified in CPR available for emergency treatment. Staff is able to identify the designated RN. Facility provides continuing education and/or in-services for nurses and staff. Review of training manual and of policies and procedures shows that the facility provides continuing education and/or in-services for nurses and staff. Staff licenses are verified on an annual basis. Staff licenses can be provided upon request of reviewer. Sufficient nursing and other personnel are available to provide services. The staff-to-patient ratio is at a maximum 1 nurse to 4 patients (1:4). Nurses properly document pain assessment, treatment, and reassessment if pain medication is given. Review of medical record shows evidence of a pain scale assessment and follow-up, if needed. Surgical-Ambulatory Care Centers As a provider in the Preferred Care Partners network, your center will be required to meet the standards of state and national regulatory agencies as well as those of Preferred Care Partners. You will be audited to ensure that your facility and practices are in compliance. We have provided this booklet as a set of guidelines to prepare your center and employees for these audits. The table below includes a listing of the standards upon which you will be audited, and the indicators that we will use to determine whether your facility is in compliance. If you have any questions about compliance or audits, please contact Network Management Services at (877) 670-8432 or at [email protected]. 87 Standard Performance Measures General Patient rights and responsibilities are posted, along with tollfree numbers for Consumer Assistance (AHCA). The center posts or makes available upon request patient rights and responsibilities for Preferred Care Partners members. Occupational licenses and state license (if applicable) are available and current. Occupational licenses are displayed and visible. All professional licenses (Medical Director, Physician, RN, Surgeon and medical personnel) are current and available upon request. Professional licenses are visibly displayed and in public view. There is an executive privacy officer responsible for all the facility’s policies and procedures, and for compliance with federal laws and regulations. Professional licenses are visibly displayed and in public view. Written policy and procedure for staff training is in place, along with an agreement for unanticipated patient transfer to a hospital if necessary. This includes ambulance service and transfer of medical information. Review of policies and procedures, training manuals, and orientation materials. Staff is courteous, respectful, and helpful toward patients and visitors. Staff demonstrates a courteous, respectful and helpful manner toward patents and visitors. Access & Appearance/Handicapped Access There is handicapped access to parking, building and facility entrances, bathroom facilities, and water fountain. The parking area offers handicapped parking spaces adequate for the center. Staff are able to describe how they accommodate people with disabilities who require assistance to access a facility. For example, an entrance ramp is provided where there are steps. If building is more than one story, elevator is available with current inspection certificate. Where patients need to access a facility above the ground floor, there is an elevator displaying evidence of a current city/county inspection. Address and parking are clearly marked with adequate parking available. Adequate parking, including handicapped parking spaces, is easily accessible and includes a reasonably short walk from the parking lot. There are signs or markers that clearly identify parking areas and spaces. Center has adequate space and seating for patients. There is adequate space in exam rooms for patients and equipment. There is sufficient seating to accommodate patients. 88 Standard Performance Measures Center demonstrates housekeeping; areas are neat, clean, and odor-free. The entire facility is clean. Corners and floors should be clear and free from dirt or trash, and trash is not overflowing from waste receptacles. The environment is smoke and odor-free. Building’s exterior appearance demonstrates that routine maintenance is performed. Building appears to be in good repair, with neatly maintained landscaping. Safety Exit signs and maps are posted for emergency evacuation of patients, staff, and visitors. Doors that exit the facility are marked by lighted or printed exit signs. An evacuation map is available for inspection. Fire extinguishers are placed in strategic areas and reflect yearly inspection. Extinguishers have current tags documenting current annual inspection by qualified fire equipment inspector, or a receipt showing purchase within one year. “No Smoking” signs are posted inside the building. “No Smoking” signs are conspicuously located in the facility. The facility is smoke-free and has smoke detectors/alarms throughout. The facility is smoke-free. The facility has working smoke detectors installed in strategic areas to raise an alarm in case of fire. All hallways are free of obstacles and have adequate lighting. Entrances to facility and passageways are well-lit, clear of obstacles and adequate for movement of patients and equipment. Corridors and floors are free from clutter, trash, and/or loose/unsecured electrical cords for patient and staff safety. Supplies stacked such that they cannot fall over or be pulled over on patients. Emergency lighting is available in building. The building is equipped with emergency lighting In case of a power outage. The nursing station is located in an area that provides adequate visual surveillance of patients on dialysis machines. Visual inspection of facility. Personnel identify patients at risk for falls. There is documentation in the medical record which shows a fall risk assessment. Personnel are aware of procedure to follow in case of emergency, fire, or other crises. Staff is able to describe an evacuation plan that demonstrates knowledge of the location of emergency exit(s) and provision for movement of patients to safety. There is a written disaster plan available. The facility has an emergency/disaster plan. All staff are aware of the plan and able to describe it. Medical Records 89 Standard Performance Measures Medical records are safeguarded against loss, tampering, or use by unauthorized persons. Records are stored in a location that prevents unauthorized access. Records are not stored in rooms where patients are seen or in main access areas such as common walkways, etc., unless files are locked during patient care hours. The center maintains confidentiality, releasing medical information only by written consent. Review of medical records shows that a signed consent to release medical information has been obtained for each patient. A review of policies and procedures shows policies are in place describing medical record retention and PHI disposal. Allergies or NKA are documented and prominently displayed. Known allergies, adverse reactions, or NKA are documented in a prominent, consistent location in the medical record. Documentation of informed consent, significant medical history, physical exam, pre-op studies, surgical note, pathology report, adverse reactions, and discharge diagnosis is maintained. Review of medical record documentation shows documentation of informed consent, significant medical history, physical exam, pre-op studies, surgical note, pathology report, adverse reactions, and discharge diagnoses. Documentation of primary language and translation needs is maintained. Staff communicates in members’ language of preference. Review of notes and demographic data in medical record shows documentation of primary language and translation needs for each patient. Each patient has a unique record with an identifier, which enables staff to produce a record on demand. Medical records contain the correct patient information; they do not contain information for the wrong patient. Records are easily retrieved by appropriate facility staff. Policies and procedures are written to address collection, storage, and disposal of written and electronic documents. There are policies, procedures and training materials on HIPAA compliance. Staff can describe the procedures to be followed. Laboratory Services CLIA license, waiver, or proof of payment is available and current. CLIA documentation is available for inspection. CLIA# and expiration date is recorded for review purposes. If laboratory certification or waiver is required, certificates are current, appropriate to the type of testing to be performed, and available for review. Multiple-facility locations have a certificate or waiver specific to each facility. Lab specimens are stored separately from medication and food. Lab specimens requiring refrigeration are stored in a refrigerator/freezer dedicated to that purpose. No foods or medications are stored in this refrigerator/freezer. Emergency Drugs & Supplies 90 Standard Performance Measures Emergency medications and crash cart are locked. These are checked regularly for stock and expiration dates. Log is maintained. Staff is able to describe how emergency medications are checked for stock and expiration dates and are able to name who is responsible for checking. A written log is maintained on or near the crash cart. Emergency/crash cart includes medications, laryngoscope, endotracheal tubes, tracheostomy set, Foley catheter, IV fluids and supplies, oxygen tank tubing and mask, ambubag, defibrillator, suction equipment, batteries, and a list of drawer contents on each respective drawer. The crash cart includes all applicable emergency medications and equipment. The equipment is in good working order, is regularly tested, is appropriately sized, and extra batteries are kept. Inspection of log shows that log is current, with expiration dates clearly noted. Policies and procedures are in place for all emergencies. There is a mechanism for staff to assist patients in life threatening situations. This includes a procedure for calling 911, isolation of the patient, provision of CPR, use of crash cart, etc., where applicable. Medications Medication expiration dates are checked routinely and expired medicines are properly disposed. (Log is recommended). Staff is able to describe the frequency with which drug samples are checked for expiration and who is responsible for checking. The checking of samples for expiration is a routine facility procedure, rather than optional or random in nature. At a minimum, there is documentation of quarterly inspection. Syringes and needles are stored in a secure manner with limited access. Syringes and needles are stored in cabinets or other locations that deter unauthorized access by patients. During facility hours, prescription pads are stored in a location that prevents unauthorized access, such as with the physician or in a cabinet or drawer that is not in a patient care area. Medications are stored and prepared in a designated secured area and are dispensed by licensed staff. Drug samples and other medications used in the facility are stored in cabinets or other locations that deny unauthorized access by patients (e.g., drugs should not be observed on counter tops or on open shelves in patient care areas). The temperature of the refrigerator or freezer designated for pharmaceuticals and biological materials must be kept within a specified temperature range. Daily maintenance log is kept. Storage of biologicals: Refrigerator: 35˚to 45˚ F. Freezer: 2˚ to 8˚ F. Pharmaceutical products are not refrigerated with food or beverages. Visual inspection of log shows that temperature has been recorded daily and that log is up-to-date. Multi-dose vials of medications are properly labeled with date first used, and are discarded after 30 days. Visual inspection shows that containers are labeled with date opened, expiration date, and initials of the person opening the vial. IV fluids are properly labeled. Visual inspection shows that IV fluids are labeled with the patient name, IV drip rate, IV dosage, and the initials of the nurse administering the IV. 91 Standard Performance Measures Controlled substances are kept in a separate, double-locked area. A required current dispensing log is kept. Medications requiring refrigeration are properly stored. Adverse reactions are reported to the physician and are documented and recorded immediately. Schedule II, III, IV and V narcotics are stored in a separate, double-locked area; access is restricted to a limited number of staff. A periodic count of controlled substances is recorded. Staff is able to describe the steps taken to destroy outdated or unusable narcotics; required documentation of these steps is available. All medications requiring refrigeration are properly stored at the correct temperature (e.g., varicella vaccine must be kept at 5 degrees Fahrenheit or lower). A thermometer is kept in the refrigerator to ensure that temperatures remain between 36 and 46 degrees Fahrenheit. A separate thermometer is kept in the freezer compartment, and temperatures are monitored and recorded daily. The refrigerator/freezer is not used to store any other type of item (food, drinks, specimens, blood products, infectious agents, etc.). Review of written shows that log is maintained of all immunizations given and is up-to-date. Medical record and documentation review. Infection Control - OSHA Regulations Universal precautions are always taken when obtaining and handling body fluids. Review of policies and procedures shows that the facility follows Federal regulations requiring active use of the OSHA Exposure Control Plan (Infection Control) to ensure safety of staff and patients from infection due to blood and other bodily fluids. The importance of hand-washing in patient and personal care is stressed. Signs are posted in rest rooms. Clean running water and soap is available in the facility, to ensure compliance with hand washing/infection control guidelines. For exam rooms without sinks, there is a waterless bacteriostatic hand cleaner/sanitizer available for use until staff can get to a sink. Reminder signs are posted in rest rooms. There is an active infection control program in practice. Review of policies and procedures shows there is a policy for infection control. Staff can describe this procedure. There is proper use, calibration, and regular maintenance of all dialysis equipment according to the manufacturers’ recommendations. This is documented on an inspection log or inspection tags. Review of inspection log or inspection tag shows that maintenance is performed regularly according to manufacturer’s specifications. Inspection log is updated regularly and is current. Spill Kit 1:10 bleach is available to kill HIV/HBV/TB, and is used according to guidelines. Spill Kit is available upon request. Visual inspection reveals that there is a readily available Spill Kit 1:10 bleach. 92 Standard Performance Measures Provisions are made for isolation of any patient suspected of having a communicable disease. Policies and procedures include evidence of a plan to deal with patients suspected of having a communicable disease. Personnel refrain from eating, drinking, and personal care in work area. Staff interview indicates all staff are aware of and can describe the policy. The facility work area is neat, orderly, organized, and contains only work-related items, (e.g., the work area is free from foods, personal grooming items, etc.). Treatment areas and rest rooms are equipped to attend to patients’ needs and safety. Visual inspection shows that appropriate examination equipment is available. Patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. Visual inspection shows that patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. Patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. Visual inspection shows that patient care areas have comfortable, operational chairs and adequate space for patients’ personal belongings. Handling of Bio-Hazard Waste Hazardous materials and waste are properly disposed. Staff is able to identify the hazardous waste hauler with which the facility contracts to remove medical waste or describe disposal by the designated staff person to an appropriate intermediate site such as a hospital. Sharps containers are closable, puncture resistant, leak-proof, and color-coded or labeled as bio hazardous. Containers for other contaminated waste are closable, constructed to contain all contents and prevent leakage, and labeled or color-coded. A review of policies and procedures indicates that the facility does not store large numbers of full sharps containers or multiple large boxes or bags of other medical waste. Review of policies and procedures shows that removal of waste occurs regularly. Sharps containers are stored out of immediate or accidental patient reach (i.e., wall mounted, located on counter tops or stored in a closed cabinet). Containers are not stored on the floor or on exam tables where patients sit or lie. Sterilization supplies and chemicals in exam rooms and storage areas are labeled properly. Availability There is a clear policy in place for appointment scheduling practices. Staff interview. Staff is able to describe the policy for appointment scheduling. 93 Standard Performance Measures Missed appointments are recalled as necessary and are documented. (Log recommended.) Patient waiting time is under 30 minutes. Facility reschedules appointments for unavoidable delays. Business hours are posted outside of the facility. Visual Inspection shows that business hours are posted prominently outside of the facility. There is one surgical center per license. Visible inspection shows one surgical center per license. An on-call policy exists at the center. Review of policies and staff interview show that appropriate medical personnel may be contacted 24 hours a day through an answering service or directly by telephone. Members are not directed to a hospital emergency department. Medical personnel respond within 30 minutes. Toilet Facilities & Patient Care Areas Exam rooms’ toilet and bath area are clean, sanitary, and free of odors, and have provisions for patient privacy and patient safety. In the toilet/bath area, an emergency cord is recommended. Visual inspection shows that exam rooms, toilet, and /bath area are clean. Corners and floors are clear and free from dirt and trash. There is clean running water and soap is available, and there are handrails and other patient safety features in the bathroom. A comfortable and operational bed, chair, and cabinet are provided to patients. There is adequate space for patients’ personal belongings Visual inspection shows that patient care areas and rooms have comfortable, operational chairs and adequate storage space for patients’ personal belongings. Nursing Nurses document treatment plan and notes related to patient care. Review of medical record documentation shows evidence that treatment plan and patient care notes have been documented by a nurse. Standardized medication tests and skills assessment are performed/taken for all nursing personnel prior to patient contact. Review of training manual shows evidence that standardized medication tests and skills assessment are performed/taken for all nursing personnel prior to patient contact. Visual inspection of documentation shows evidence that the Director of Nursing is an RN with a current, valid state license. Visual inspection shows evidence that there is an RN who is certified in CPR available for emergency treatment. Staff is able to identify the designated RN. Director of Nursing is an RN, with a current, valid state license. Whenever the facility is operational, a Registered Nurse certified in CPR is available for any emergency treatment. Facility provides continuing education and/or in-services for nurses and staff. Review of training manual and of policies and procedures shows that the facility provides continuing education and/or in-services for nurses and staff. Staff licenses are verified on an annual basis. Staff licenses can be provided upon request of Reviewer. 94 Standard Performance Measures Sufficient nursing and other personnel are available to provide services. Review of policies and procedures and staff interview shows that sufficient nursing and other personnel are available to provide services. Nurses properly document pain assessment, treatment, and reassessment if pain medication is given. Review of medical record shows evidence of a pain scale assessment and follow-up, if needed. Surgical Areas Patients are attended to continuously, and vital signs are recorded while patient is sedated (pre-, intra-, and post-op) Visual inspection of documentation and medical record review show evidence that patients are attended to continuously, and vital signs are recorded while patient is sedated (pre-, intra-, and post-op). Protocols for surgical procedures include a list of equipment, materials, and necessary supplies. Visual inspection of documentation and review of policies and procedures show evidence of protocols for surgical procedures and a list of equipment, materials, and necessary supplies. Conscious Sedation Protocol and Log is available. Visual inspection of log and review of policies and procedures show evidence of a Conscious Sedation Protocol. Staff interview. Staff can provide log upon request. The ASC must have a separate recovery room and waiting area. Visual inspection shows that the ASC has a separate recovery room and waiting area Only authorized staff are allowed in the surgical area. Review of policies and procedures shows evidence that only authorized staff are allowed in the surgical area. Staff can describe this policy. A sign is posted in the surgical area stating “Authorized Personnel Only.” Review of policies and procedures shows evidence that patients are transported by stretcher or wheelchair when appropriate to and from the operation room. Staff is able to describe this policy. Patients are transported by stretcher or wheelchair (when appropriate) to and from the operation room. Each operating room is stocked with sterile supplies, packed and labeled appropriately. Visual inspection and review of policies and procedures show that each operating room is stocked with sterile supplies which are packed and labeled appropriately. Surgical personnel use aseptic technique and/or instruments are properly sterilized after each use. Review of policies and procedures shows that surgical personnel use aseptic technique and/or instruments which are properly sterilized after each use. Staff can describe this policy. Visual inspection and review of policies and procedures show that sterilization equipment is easily accessible for routine or rapid use. Sterilization equipment is easily accessible for routine or rapid use. 95 Standard Performance Measures Blood pressure cuffs are available in various sizes. Visual inspection shows that blood pressure cuffs are available in various sizes. Written policies and procedures for decontamination, disinfection, sterilization, and storage of sterile supplies have been established, and are enforced. Visual inspection and review of policies and procedures show that there are procedures in place for decontamination, disinfection, sterilization, and storage of sterile supplies. Staff are able to describe these policies. Section 9 Pharmacy Drug Formulary We offer an extensive drug formulary. Generic prescriptions, when appropriate, are the most cost effective alternatives. Our Formulary includes a complete list of the drugs we cover, generic and brand name, and any requirements, limits, and/or restrictions for each drug, if applicable. Download the Formulary from our website at www.mypreferredprovider.com, or call our Pharmacy department at (800) 591-6144. The Plan’s Formulary offers four drug tiers: Tier 1: Includes generic drugs and some brand-name drugs. Tier 2: Includes some generic drugs and also preferred brand-name drugs. Tier 3: Includes some generic drugs and non-preferred brand-name drugs. Tier 4: Includes brand-name drugs and some generic drugs. You can look up a drug in our Formulary to find out which tier it is in. The Formulary is subject to change. The most current copy of our Formulary is on our website at www.mypreferredprovider.com. If a drug is not on our Formulary, members can possibly be switched to a different drug that we do cover, or you can request a formulary exception. While the exception is being evaluated, we may provide members with a temporary supply. For details, refer to Transition Policy, below. Coverage Limitations The following highlights some of our drug coverage limitations: A maximum quantity of a 90-day supply per prescription when obtained from a pharmacy or from the OptumRx mail order pharmacy. For some drugs we may require authorization before the drug can be prescribed (prior authorization), there may be limits on the quantity that can be prescribed per prescription (quantity limits), or we may require that you prescribe drugs in a sequence (step therapy), trying one drug before another drug. For details, refer to Utilization Management Rule below. 96 An exception process is provided to allow for cases in which the Formulary may not accommodate the unique medical needs of a patient. To make an exception to these restrictions or limits, you must fill out and submit a Coverage Determination Request (CDR) form. The form can be downloaded from our website at www.mypreferredprovider.com Additional information on these requirements is available in our Formulary on our website (www.mypreferredprovider.com), or by calling our Pharmacy department. Drugs Covered Under Part B Drugs covered under Part B are typically administered and obtained at the provider’s office. Some examples are certain cancer drugs, administered by a physician in his/her office; insulin when administered via pump and diabetes test strips. Drugs Covered Under Part B or Part D Some drugs can fall under either Part B or Part D. The determination of coverage as to whether the drug is Part B or Part D is based on several factors such as diagnosis, route of administration and method of administration. For a list of medications in each category, refer to the CMS website at www.cms.gov; choose Medicare -> Prescription Drug Coverage-General Information -> Downloads, and select the appropriate document. Alternatively, you may contact our Pharmacy department. Long Term Care Facilities (Includes Mental Health Facilities) We provide convenient access to network long-term care (LTC) pharmacies for all members residing in LTC and mental health facilities. For a list of network pharmacies covering long term care facilities, refer to the Provider Directory. Home Infusion Our Plan will cover drugs for home infusion therapy if the home infusion services are provided by a home infusion therapy network pharmacy. However, Medicare Part D does not cover the supplies and equipment needed for administration. For information on home infusion therapy, contact our Pharmacy department. Vaccines Most vaccines and the associated administration fees are covered under Part D. Our plan provides coverage of a number of vaccines, some of which are considered to be medical benefits (Part B medications) and others of which are considered to be Part D drugs. Part D covers most preventative vaccines; Part B covers flu, pneumococcal, hepatitis B, and some other vaccines (e.g., rabies) for intermediate or high-risk individuals when directly related to the treatment of an injury or direct exposure to a disease or condition. The rules for coverage of vaccinations are complex and dependent on a number of factors. If you are unsure of how a vaccine will be covered by the Plan, contact the Pharmacy department at (800) 5916144. For a list of vaccines and how they are covered by the Plan, refer to the Plan’s Formulary which is available on our website at www.mypreferredprovider.com. 97 Injectable Medications Injectable medications administrated in the provider’s office and self-administered medications can be obtained from specialty pharmacy suppliers. Prior authorization may be required for these drugs. Refer to the section Prior Authorization below for more information. Injectable medication authorizations should be ordered one to two weeks in advance of the service date to allow for eligibility and coverage review and for shipping. To order injectable medications, complete and submit a Coverage Determination Request (CDR) form to our Pharmacy department. The form is available for download from our website at www.mypreferredprovider.com. Contact our Pharmacy department at (800) 591-6144 for details on the rules governing injectable medications. Utilization Management Rules For certain prescription drugs, the Plan has additional requirements for coverage or limits on coverage. The medications subject to utilization management rules are subject to change. Prior to prescribing medications you should check our Formulary online at www.mypreferredprovider.com or call the Pharmacy department. Certain drugs may require: Prior Authorization - We require prior approval for the drug. Quantity Limits - We limit the amount of the drug that we will cover per prescription or for a defined period of time. Generic Substitution - We recommend and/or provide members with the generic version, unless the provider has told us that the member must take the brand-name drug and we have approved the request. Step Therapy - We require you to first try certain drugs before we will cover another drug for that condition. If a drug is subject to one of the above restrictions or limitations and the restrictions are not followed we will reject the claim. If a drug is subject to one of these restrictions and your patient is not able to meet the additional restriction for medical necessity reasons, you or the member may request an exception. For more information, refer to Exceptions below. Prior Authorization Drugs that require prior authorization are marked PA in our Formulary. You must fill out and submit a Coverage Determination Request (CDR) form available on our website at www.mypreferredprovider.com. We will send you a reply via fax. For additional information contact our Pharmacy department. Response Times For Part D drugs that require prior authorization we will respond within 72 hours for standard requests and 24 hours for expedited requests. For Part B drugs our response time is 14 days for standard requests and 72 hours for expedited requests. 98 Quantity Limits Quantity limits ensure that prescription drug coverage reflects drug manufacturers and FDA dosing guidelines. Medications subject to quantity limits are identified in the Formulary. These limits specify that coverage is allowed for a maximum quantity of prescribed medication, per prescription. You can find out if a drug is subject to these quantity limits by checking our Formulary at www.mypreferredprovider.com/formulary or by calling our Pharmacy department at (800) 5916144. Both retail and mail order pharmacy drugs can be prescribed for up to a 90 day supply for Tiers 1, 2, and 3. Tier 4 drugs are always limited to a 30-day supply per prescription. Generic Substitution When there is a generic version of a brand-name drug available our network pharmacies may recommend and/or provide members with the generic version unless you, the provider, tells us that the member must take the brand-name drug and we have approved this request. Step Therapy Step therapy requires the use of a designated prerequisite drug first, in order for another drug to be covered. Medications subject to the step therapy requirement are identified in our Formulary with an ST. If you determine that the prerequisite drug is medically unacceptable, you must submit a Prior Authorization using our Coverage Determination Request (CDR) form. For more information, refer to Prior Authorization, above. Coverage Determinations A coverage determination is any decision made by the Plan regarding what Part D prescription drugs will or will not be covered by us. The prescribing physician or the member may request a coverage determination. It may be requested orally, in writing, or by fax. Coverage determinations may include, but are not limited to: Deciding whether or not a drug is medically necessary Determining if a drug falls into the benefit exclusion list Determining if a drug meets the established prescribing criteria Quantity limitations (i.e., requesting more than are typically allowed) A coverage determination is a decision we make about benefits and coverage or about the amount we will pay for prescribed drugs. Exceptions We offer a formulary exception process to allow for cases where the Formulary or its restrictions may not accommodate the unique medical needs of members. To request an exception, you must fill out and submit a Coverage Determination Request (CDR) form. If you request an exception, you must also submit a supporting statement explaining why the exception is being requested. 99 Generally, we will only approve your request for an exception if alternative drugs included on the Plan’s formulary, a lower-tiered drug, or additional utilization restrictions would not be as effective in treating the member’s condition and/or would cause the member to have adverse medical effects. New members taking drugs that are not on our Formulary or for which our Plan has restrictions should talk with you to decide if they should switch to another appropriate drug that we do cover, or if you, the provider, should request an exception. In certain cases, we will cover the drug during the member’s first 90 days of membership in the Plan while you and the member determine the desired course of action. How to Request an Exception: 1. Fill out our Coverage Determination Request (CDR) form available on our website at www.mypreferredprovider.com; 2. Write a supporting statement indicating why the exception is necessary; and 3. Fax the form and supporting statement to our Pharmacy department at (800) 203-1664. Note that providers have 72 hours from the date of the initial request to provide us with a supporting statement. If the statement is not received within the allowed timeframe, an adverse coverage determination may be made. 4. We will respond within 72 hours of receipt of your request and supporting statement. Expedited Exception Requests To submit an expedited exception request follow the same steps as you would for a standard request and write “STAT” on the top of the Coverage Determination Request (CDR) form. We will respond within 24 hours of receipt of the request and supporting statement. If we grant your request to cover a drug that is not on our Formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the fourth tier. You may make a verbal request for an exception, but we will request a follow-up in writing. For information please call our Pharmacy department at (800) 591 6144 or go to our website at www.mypreferredprovider.com. NOTE: The physician or member may appeal an adverse decision. For more information refer to Appeals below. Transition Policy Our Transition Policy provides temporary coverage where new members have an immediate need for a drug that is not on the Plan’s Formulary or for drugs that become subject to restrictions or are no longer covered starting with a new Plan year. If your patient is a new member or a current member taking a drug that we remove from our formulary or to which we add a restriction from one Plan year to the next, you can either switch the member to a different drug or request a formulary exception. While you pursue an exception, we may provide the member with a temporary transition supply provided it is a Part D drug purchased at a network pharmacy. 100 IMPORTANT: Only Formulary changes that take effect at the beginning of the year are subject to the Transition Policy. There is a separate process for changes to the formulary that occur mid-Plan. Members subject to formulary changes in the middle of the Plan year receive a 60day notice prior to the change. During that time we will cover the prescribed drug while the member coordinates with the provider to either switch to another drug or have the provider request an exception. The following table summarizes the rules for receiving a transition supply of a drug: Current Member (with the Plan > 90 days) New Member (with the Plan < 90 days) Retail Pharmacy Length of the prescription up to a maximum of 30 days. Length of the prescription up to a maximum of 30 days. (Not in a Long Term Care Facility) One-time supply only. One-time supply only. During first 90 days of plan calendar year only. During first 90 days of plan calendar year only. Long Term Care Facility Pharmacy One-time supply only. Length of the prescription up to a maximum of 34 days. Length of the prescription up to a maximum of 34 days. We will cover refills if necessary. During first 90 days of plan calendar year only. To request a Formulary exception call our Pharmacy department at (800) 591-6144, or fax us at (800) 203-1664. To protect the health information of members we discourage emailing any personal/health information as emails may not be sent in a secure manner. Pharmacy Network Members must go to a network pharmacy to receive covered drugs. Refer to the Plan’s Provider/Pharmacy Directory for a list of participating retail, chain, long-term care, home infusion, and mail-order pharmacies, and other relevant information. This information is available on our website at www.mypreferredprovider.com.Mail Order Physicians must prescribe a 30- to 90- day supply (a 30-day supply with two refills is not the same). Members may obtain the Mail Order form on our website at www.myPreferredCare.com. To download the form: choose Pharmacy > Forms > Mail Order Form. Follow the instructions on the form to order drugs via mail order. Alternatively, you can call Member Services at (866) 231-7201. Drug Utilization Review We conduct drug utilization reviews to make sure members are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. 101 We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews we look for medication problems such as: Possible medication errors; Duplicate drugs that are unnecessary because the member is taking another drug to treat the same medical condition; Drugs that are inappropriate because of age or gender; Possible harmful interactions between drugs; Drug allergies; and/or Drug dosage errors. If we identify any problems that warrant a modification, we will share our findings with you and discuss a possible alternate course of action with respect to how drugs are being prescribed. You may receive calls and/or faxes from our Pharmacy department following up on any findings. If you have any questions, please contact the Pharmacy department. Appeals and Redetermination Processes Part D Appeals: Standard and Expedited To appeal an unfavorable decision on behalf of a member, you must submit a formal letter outlining the issues and submit supporting documentation. The denial letter will provide you with the filing deadlines and the address to use to submit the appeal. In the event a member designates a healthcare professional to appeal the decision on their behalf a copy of the member’s written consent is required and must be submitted with the appeal. When the final decision is made you will be notified via mail. If the decision is to overturn the original determination, the service will be authorized. If the decision is to uphold the original denial determination, there will be no further action for you to undertake. Appeals An appeal is a written request to have the Plan reconsider an unfavorable coverage determination. If you wish to file an appeal on behalf of a member, you must do so within 60 days of an adverse coverage determination. Providers or members may file appeals for Part D drugs. Part D drug appeals are also called “redeterminations.” Note: It is only after we have made a coverage determination that you may request an appeal. To simply ask that an exception be made to our drug policy, you must submit an exception request. For more information, refer to Exceptions above. To request an appeal, you or the member must fax or mail a written request. You may use our standard Provider Appeal Request form or have the member submit an appeal using the Member Appeal Request form, available on our website at www.MyPreferredCare.com. Our address is: Preferred Care Partners Grievance and Appeals P.O Box 56-6420 Miami, FL 33256-6420 You may also call us toll-free at (888) 291-5721 (coverage is provided 24 hours a day, 7 days a week), or fax us toll-free at (866) 261-1474. 102 We must have all necessary supporting documentation before we can begin processing your appeal. We will answer your Part D appeal within seven calendar days of receipt. We will answer your Part B appeal within 30 calendar days of receipt. If we deny your Part D appeal, the member may re-file an appeal to an independent review entity within 60 days of the initial denial; details on how to do so will be provided in our denial letter. Note that only members (not providers) may re-file appeals, unless the provider re-files the appeal acting as the member’s authorized representative. If we deny your Part B appeal, there is no second level review. MTM (Medication Therapy Management) The Medication Therapy Management (MTM) Program is a free service we offer to members. We conduct reviews on members who: Have multiple chronic conditions; Are taking at least 8 unique Part D Drugs; and Incur an annual cost of at least $3,017 for all covered Part D drugs. We use the MTM program to help make sure our members are using appropriate drugs to treat their medical conditions and to identify possible medication errors. We attempt to educate members as to drugs currently on the market, making recommendations for lower-cost and/or generic drugs where applicable. We may relay this information to the provider as well with the option for doctors to change drug therapies, as appropriate. You may receive calls and/or faxes from our Pharmacy department following up on any interventions discussed with your patient. If you have any questions, please contact our Pharmacy department. 103 2014 Pharmacy Benefit Summaries by Plan GROUP NUMBER Service Area Deductible Initial Coverage: Before the total yearly drug costs (paid by both the member and PCP) reach $***, the member pays the following for prescription drugs 30 Day Retail & Out of Network (Tier 1) 30 Day Retail & Out of Network (Tier 2) 30 Day Retail & Out of Network (Tier 3) 30 Day Retail Specialty Drugs (Tier 4) Preferred Choice Dade (HMO-POS) PSO001 Preferred Choice Broward (HMO) PSO005 Preferred Medicare Assist (HMO-POS-SNP) PSO012 Dade No Deduct. Broward No Deduct. Dade & Broward No Deduct. $7,000 $3,250 $2,850 $0 $0 $0 $0 $20 $25 $40 33% Co-Ins 33% Co-Ins $0 Depends on LICS level - refer to 2014 LICS cheat sheet Depends on LICS level - refer to 2014 LICS cheat sheet 90 Day Retail (Tier 1) $0 $0 $0 90 Day Retail (Tier 2) $0 $60 90 Day Retail (Tier 3) 90 Day (Tier 1) Preferred Mail Order Pharmacy 90 Day (Tier 2) Preferred Mail Order Pharmacy 90 Day (Tier 3) Preferred Mail Order Pharmacy 90 Day (Tier 1) Non-Preferred Mail Order Pharmacy 90 Day (Tier 2) Non-Preferred Mail Order Pharmacy 90 Day (Tier 3) Non-Preferred Mail Order Pharmacy $75 $120 $0 Depends on LICS level - refer to 2014 LICS cheat sheet $0 $0 $0 $0 $50 $65 $110 $0 Depends on LICS level - refer to 2014 LICS cheat sheet $0 $0 $0 $0 $60 $75 Formulary Tier 1 Only $0 copay $120 Formulary Tier 1 Only $0 copay $0 Depends on LICS level - refer to 2014 LICS cheat sheet Formulary Tier 1 Only $0 copay Coverage Gap Coverage Catastrophe Coverage: After yearly member out of pocket drug costs reaches $4,550 member pays: Coverage of Benzodiazepines, Barbiturates, & ED Drugs (Enhanced Drugs Drugs covered under Medicare Part B (Original Medicare) ChemoDrugs Part B Out of Pocket Limit (MOOP) $2.55 for Generics or 5% Co$2.55 for Generics or 5% Co-Ins, Ins, whichever is greater; $6.35 whichever is greater; $6.35 for all After out-of-pocket drug costs for all other drugs or 5% Co-Ins, other drugs or 5% Co-Ins, whichever reach $4,550 member pays a $0 whichever is greater is greater Co-pay. Y Member pays 20% of the cost for Part B-covered drugs Member pays $0 to 20% of the cost for Chemo covered drugs N Member pays 20% of the cost for Part B-covered drugs Member pays 20% of the cost for Chemo covered drugs Y Member pays 0% of the cost for Part B-covered drugs. $3,400 $3,400 $3,400 104 $0 copay GROUP NUMBER Service Area Deductible Initial Coverage: Before the total yearly drug costs (paid by both the member and PCP) reach $***, the member pays the following for prescription drugs 30 Day Retail & Out of Network (Tier 1) 30 Day Retail & Out of Network (Tier 2) 30 Day Retail & Out of Network (Tier 3) 30 Day Retail Specialty Drugs (Tier 4) Preferred Complete Care (HMO) PSO016 Preferred Special Care (HMO-SNP) PSO018 Preferred Secure Option (HMO) PSO023 Dade No Deduct. Dade No Deduct. Orlando/Tampa No Deduct. $6,000 $5,000 $2,850 $0 $0 $6 $0 $0 $45 $25 $25 $95 33% Co-Ins 33% Co-Ins 33% Co-Ins 90 Day Retail (Tier 1) $0 $0 $18 90 Day Retail (Tier 2) $0 $0 $135 $75 $75 $285 $0 $0 $12 $0 $0 $125 $65 $65 $275 $0 $0 $18 $0 $0 $135 90 Day Retail (Tier 3) 90 Day (Tier 1) Preferred Mail Order Pharmacy 90 Day (Tier 2) Preferred Mail Order Pharmacy 90 Day (Tier 3) Preferred Mail Order Pharmacy 90 Day (Tier 1) Non-Preferred Mail Order Pharmacy 90 Day (Tier 2) Non-Preferred Mail Order Pharmacy 90 Day (Tier 3) Non-Preferred Mail Order Pharmacy Coverage Gap Coverage Catastrophe Coverage: After yearly member out of pocket drug costs reaches $4,550 member pays: Coverage of Benzodiazepines, Barbiturates, & ED Drugs (Enhanced Drugs Drugs covered under Medicare Part B (Original Medicare) ChemoDrugs Part B Out of Pocket Limit (MOOP) $75 Formulary Tier 1 & Tier 2 Only $0 copay $2.55 for Generics or 5% Co-Ins, whichever is greater; $6.35 for all other drugs or 5% Co-Ins, whichever is greater Y Member pays 0% of the cost for Part B-covered drugs. $75 $285 Formulary Tier 1 Only $0 copay Not Covered $2.55 for Generics or 5% Co-Ins, $2.55 for Generics or 5% Cowhichever is greater; $6.35 for all Ins, whichever is greater; $6.35 other drugs or 5% Co-Ins, for all other drugs or 5% Cowhichever is greater Ins, whichever is greater $0 copay N Member pays 0% of the cost for Part B-covered drugs. Member pays $0 to 20% of the cost for Chemo covered drugs N Member pays 20% of the cost for Part B-covered drugs Member pays 20% of the cost for Chemo covered drugs $3,400 $3,400 $6,700 105 Section 10 Documentation & Coding Guidelines for Success in the Medical Risk Adjustment Model The Plan is committed to providing the resources necessary to assist plan providers in meeting the guidelines for the Centers for Medicare and Medicaid (CMS)-compliant documentation and coding. Our team of certified coders can meet with providers, by request, to ensure success in the CMS Medical Risk Adjustment (MRA) model. What is the Purpose of Risk Adjustment? Risk adjustment strengthens the Medicare program by ensuring that accurate payments are made to Medicare Advantage (MA) organizations based on the health status of their enrolled beneficiaries. Accurate payments to MA organizations help ensure that providers are paid appropriately for the services they provide to MA beneficiaries. Finally, risk adjustment provides MA organizations with incentives to enroll and treat less healthy individuals. Why is Risk Adjustment Important to Physicians and Providers? The risk adjustment model relies on the ICD-9-CM diagnosis codes to prospectively reimburse MA organizations based on the health status of their enrolled beneficiaries. Physicians and providers must focus attention on complete and accurate diagnosis reporting according to the official ICD-9-CM coding guidelines. What are the Responsibilities of Physicians and Providers? Physicians must report the ICD-9-CM diagnosis codes to the highest level of specificity and report these codes accurately. This requires accurate and complete medical record documentation. They are required to alert the MA organization of any erroneous data submitted and to follow the MA organization’s procedures for correcting erroneous data. Finally, they must report claims and encounter information in a timely manner, generally within 30 days of the date of service (or discharge for hospital inpatient facilities). Links to resources for the latest ICD guidelines and MRA resources are available online at www.mypreferredprovider.com. CPT and HCPCS Codes The American Medical Association (AMA) and the CMS update procedure codes quarterly, with the largest volume effective January 1 of each year. CPT and HCPCS codes may be added, deleted, or revised to reflect changes in healthcare and medical practices. If a claim is submitted with an invalid or deleted procedure code, it will be denied or returned; a valid procedure code is required for claims processing. Because of the importance of proper coding, the Plan encourages you to purchase current copies of CPT and HCPCS reference guides. You can access CPT, HCPCS and ICD-9 coding resources and materials at the American Medical Association’s website (www.ama-assn.org), or from another vendor. 106 Section 11 Overpayment Recovery & Audit Overview Whenever possible, Preferred Care Partners works with providers to eliminate incorrect or duplicate claims. As a Preferred Care Partners provider, you are contractually obligated to return any overpayments. The following are examples of overpayments: payment based on a charge that exceeds the Fee Schedule duplicate processing of the same charges/claims (for example, duplicate billing) payment made to incorrect payee payment for non-covered services or medically unnecessary services payment for items/services provided during a period of member non-entitlement claims processed incorrectly by the Plan as the primary payer payment for unauthorized services If You Discover an Overpayment If you discover an overpayment, duplicate payment, or other payment in excess of the member's benefits payable according to the member's benefit plan, remit payment promptly to Preferred Care Partners. The standard overpayment recovery look-back period is 30 months from the time the provider received the payment. Send us a letter including the following information: claim number or reference number member name your patient account number date of service, if available Send the letter to: Preferred Care Partners Audit and Recovery P.O. Box 56-6118 If We Discover an Overpayment If we discover an overpayment, we will send the provider a letter asking for a refund of the overpaid amount. The standard overpayment recovery look-back period is always 30 months from the time the provider received the payment. For questions related to overpayments, call our Audit and Recovery Department at (305) 671-4044. 107 Section 12 Filing a Claim Claim Forms Please note that all claim and other forms are available on our website at www.mypreferredprovider.com. Compensation Additional Fees for Covered Services You may not charge our members fees for covered services beyond copayments, coinsurance or deductibles as described in their benefit plans. You may not charge our members retainer, membership, or administrative fees, voluntary or otherwise. This includes, but is not limited to, concierge/boutique practice fees, as well as fees to cover increases in malpractice insurance and office overhead, any taxes, or fees for services you provide that are denied or otherwise not paid due to your failure to notify us, to file a timely claim, to submit a complete claim, to respond to our request for information, or otherwise comply with our protocols as required by your Agreement with us, or based on our reimbursement policies and methodologies. Please note, CMS does not allow the provider to charge for “missed appointments” unless the provider has previously disclosed that policy to the member. Hospice – Medicare Advantage Hospice Services When a member elects hospice, CMS pays Medicare Certified Hospice providers for all covered services related to the member’s terminal illness. Claims for hospice services should be billed directly to CMS. For services covered under Medicare Part A and Medicare Part B that are not related to the member’s terminal issue, claims must be billed to the applicable Medicare Administrative Contractor. PCP is not financially responsible for these claims; however, PCP may be financially responsible for any additional or optional supplemental benefits under the member’s benefit plan such as eyeglasses and hearing aids. Additional and optional supplemental benefits are not covered by Medicare and are not related to the member’s terminal condition, e.g. eyeglasses, hearing aids. Emdeon Business Services About Emdeon Physicians/providers are encouraged to submit claims electronically through our clearinghouse, Emdeon Business Services, a leading provider of revenue and payment services for healthcare professionals. For more information on electronic submissions, call Emdeon at (800) 845-6592, or visit their website at www.emdeon.com. Electronic Remittance Options (ePayment) If you would like to receive claims and capitation payments electronically, you can sign up for this service through Emdeon. Multiple enrollments for all health care payers are not necessary. Visit www.emdeonepayment.com to learn more about Emdeon ePayment services or to request additional 108 information. For assistance by phone, including service inquiries and enrollment support, call Emdeon toll-free at (866) 506-2830. Claims Submission Basic Requirements Claims are processed in accordance with CMS, AHCA, the Office of Insurance Regulation, and other applicable standards and requirements. The Plan recommends that claims be submitted electronically. For details, refer to Electronic Claims Submission Section below. However, when a claim requires an attachment, or has an issue that precludes electronic submission; it may be submitted via mail using a paper CMS-1500 or UB-04 form. Claims eligible for payment must meet the following requirements: The member is a current member on the date of service The service provided is a covered benefit under the member’s Plan on the date of service Referral and prior authorization processes were followed The patient name and number on the claim form matches the name and number shown on the patient’s member ID card. A Preferred Care Partners member ID number always begins with the letter P followed by 10 digits and it is listed on the front of the card. For a sample of the member ID card refer to the section Our Plans. The Plan has accurate billing information on file for the following: Provider’s name (as noted on his/her current W-9 form) Provider’s nine-digit Medicare Number Provider’s National Provider Identifier (NPI) Physical location address (as noted on current W-9 form) Billing name and address (if different) Tax Identification Number Before we can process a claim, it must be a “clean” or complete claim submission. Failure to submit a clean claim will result in the delay or rejection of the claim. Following are definitions of “clean” and “non-clean” claims: Clean Claim A clean claim is one that can be processed without obtaining additional information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. A clean claim has no defect or impropriety, including lack of required substantiating documentation. Non-Clean Claim A non-clean claim requires further investigation or additional information due to errors or omissions in the submitted claim. We may ask the provider or other external sources to resolve or correct data omitted from the bill, review additional medical records, or request other 109 information to resolve discrepancies. Non-clean claims may also involve issues of medical necessity. The Plan will issue a determination to the provider within 60 calendar days of receipt of the non-clean claim. We will not delay the determination past 60 days, even to wait for medical records or additional information. Payment for service is contingent upon compliance with referral and prior authorization policies and procedures, as well as the guidelines outlined in this manual. Please note that we may provide available information concerning an individual's status, eligibility for benefits, and/or level of benefits. The receipt of such information shall in no event be deemed to be a promise or guarantee of payment, nor shall the receipt of such information be deemed to be a promise or guarantee of eligibility of any such individual to receive benefits. National Provider Identifier (NPI) All claims must be submitted with a provider’s National Provider Identifier (NPI). We require this on all electronic and paper claim submissions. Providers must send a copy of the confirmation letter from the Enumerator to the Preferred Care Partners Credentialing department to ensure that the NPI is loaded correctly into our claims payment database. Providers may register for an NPI at: nppes.cms.hhs.gov/NPPES/ Providers may download forms at: www.cms.hhs.gov/cmsforms/downloads/cms100114.pdf Encounter Data Encounter data is used to evaluate quality and utilization management. The Plan requires capitated providers to submit an encounter (also called a “proxy claim”) or a claim for each service that you render to a Plan member. The information for each member visit must be submitted on a standard CMS-1500 or UB-04 form and completed with a dollar value. This is a requirement of AHCA and the State of Florida. The Plan will monitor provider compliance for submission of encounter data. Diagnosis Codes A valid ICD-9 diagnosis code is required on all claims submissions. The diagnosis must be coded to the highest level of specificity (4th and 5th digits). Claims submitted without the correct diagnosis code will not be processed and the provider will be responsible for the resubmission of the claim. For additional information, refer to Documentation and Coding Guidelines, Section 10. Time Limit for Filing Providers must submit all claims and encounters, electronic and paper, within 180 calendar days of the date of service. Where Preferred Care Partners is the secondary payer, we must receive the claim within 90 days of the date of final determination of the primary payer. 110 Electronic Claims Submission The Plan accepts electronic submission of claims in the HIPAA-compliant formats listed below. Providers are encouraged to submit claims through their electronic claims provider to our clearinghouse, Emdeon Business Services (Emdeon Payer ID #65088). For more information, call (800) 845-6592. Providers that bill electronically are responsible for: filing claims in one of the following HIPAA-compliant formats: 837P, 837I, 837D or X12 Filing claims within the same filing deadlines as providers who file paper claims. Monitoring their error reports and Explanation of Payment statements to ensure all submitted claims and encounters appear on the reports. Correcting any errors and resubmitting the affiliated claims and encounters. NOTE: A claim that requires an attachment (e.g., operative reports, medical or office notes, etc.) may not be filed electronically. Claims Requiring Attachments Situation Evaluation and management services that involve high-complexity components, such as a level-5 office visit (ex., code 99215) an unlisted procedure (ex., code 19499), or an unlisted HCPCS code. Required Claim Attachment Appropriate, detailed documentation explaining the services. Name of drugs, corresponding National Drug Code (NDC) numbers, and the dosage administered to the member. If this is not submitted with the claim, it will be rejected. Preferred Care Partners is not the primary payer (for example, in the case of an auto accident). A copy of the primary carrier EOP (Explanation of Payment). A Tax Identification Number (TIN), group name, or provider’s name has changed. (Note: Contact Network Management Services for these changes.) A copy of the W-9. Paper Claims Follow the guidelines below when submitting paper claims to ensure prompt and accurate processing: Use commercially-available “red form” versions of the CMS-1500 or UB-04 (not black and white copies). The Plan will return all paper claims submitted on black and white forms with a request to submit on red form or in electronic format. Print claim forms on a printer with sharp, legible type, such as a laser printer. Use black ink only. Use a plain, readable font such as Arial 10 point or larger. Each claim form is a complete billing document. Do not carry over totals from one claim form to another. 111 For paper claims, remember that all entries will be electronically scanned in order to get the data into our claims processing system. Be sure that forms are clear and readable so that the information scans correctly. If the form is not legible and entirely. Be sure to verify that patient met eligibility requirements as of the date of service for the claim being submitted. AVOID: faint or broken characters the use of all capital letters decorative, hard-to-read fonts like italics or cursive styles red or blue ink, or any color other than black small, unreadable font sizes dot-matrix impact printers (these have generally been replaced by ink-jet printers) DO NOT SUBMIT a claim form with: changes made in liquid correction fluid data touching the edges of boxes, or overlapping borders of boxes More than 6 service lines (CMS-1500). Use a new claim form for the additional services. Narrative descriptions of procedure, modifier, or diagnosis; use only the appropriate CPT, ICD-9, HCPCS, and/or Revenue codes. (Exception: If the code is unlisted or “not otherwise classified,” include a narrative description. See the following pages for specific instructions.) stickers or rubber stamps, especially for provider’s name and address handwriting punctuation or ditto marks Attachments smaller than 8.5” X 11” (NOTE: Make copies of prescriptions on letter-sized paper.) Date Formatting For date fields, you must enter the date in: 8-digit format: MMDDYYYY or in 6-digit format: MMDDYY The line by line instructions on the following pages indicate which date format to use. Claim Filing Address All paper claims and encounters should be submitted to: Preferred Care Partners Claims Department P. O. Box 56-5790 Miami, FL 33256-5790 112 Completing the CMS-1500 Claim Form Providers must bill with their NPI number in box 24J. We will return claims when billing information does not match the information that is currently in our files. The CMS-1500 Claim Form (version 02/12) and instructions for filling out the form can be found on our website at www.mypreferredprovider.com. Claims missing the requirements in bold on the form will be returned and a notice will be sent to the provider creating payment delays. Such claims are not considered “clean” and therefore, cannot be entered into the system. Each field on the form is described and all required fields are marked. Required fields must be completed legibly and accurately in order to submit a clean claim. Completing the UB-04 Claim Form Claims submitted on the UB-04 form must adhere to the requirements described by the National Uniform Billing Committee (NUBC) in the UB-04 Data Specifications Manual. The UB-04 Claim Form (version 08/10) and instructions for filling out the form can be found on our website at www.mypreferredprovider.com. Each field on the form is described and all required fields are marked. All required fields must be completed legibly and accurately, otherwise the claim will be returned, and a notice will be sent to the provider, creating payment delays. Such claims are not considered “clean” and therefore cannot be entered into the system. Helpful Hints Providers must bill with their NPI number in box 56. We will return claims when billing information does not match the information that is currently in our files. For inpatient hospital services you must bill all procedures provided on the same date of service on a single claim. For all other services, if there is not enough space on the UB-04 to bill all procedures provided on the same date of service, complete a separate billing form for the rest of the procedures. To avoid processing delays, make sure information is left-aligned in the following fields: 4 = Type of Bill 6 = Statement from and through dates 8b = Patient name Use only one prior authorization number in field 63. In field 57, always enter the provider number to which payment should be sent. An invalid or missing provider number could delay your payment, make payment to a wrong provider, or cause denial of your payment. Claims Processing Time Limits The time limit for the Plan to process a claim is 30 calendar days from date of receipt for clean claims, or 60 calendar days from date of receipt for non-clean claims. The time limit is the same whether the claim is electronic or paper. 113 Claim Status Inquiries You can check the status of your claim by visiting our website at www.mypreferredprovider.com. Select “Medicare”, and then click on the Provider Portal link at the top of the page. You may also call Claims at (866) 725-9334. If our Enrollment department notifies us of retroactive eligibility, we reprocess all claims on file for that member. Coordination of Benefits Coordination of Benefits refers to two or more insurance plans covering one individual, coordinating their respective benefits to share the cost of health care. COB rules identify one plan as the primary payer (this plan pays regular contract benefits first) and the other plan as secondary (this plan pays the balance of charges up to the limits of its contact, but never more than what it would have paid if primary). As a participating provider, you must make reasonable efforts to determine the legal liability of third parties to pay for services furnished to the Plan’s members. If you are unsuccessful in obtaining necessary cooperation from a member in identifying potential third party resources, please inform our Claims department that such efforts have been unsuccessful. We will make every effort to work with you to determine liability coverage. The terms of our participation contracts apply whether the member’s policy is their primary or secondary form of coverage. Coinsurance amounts are the lower of the Preferred Care Partners health plan allowance or the provider’s charge. Our payment, when added to other payments, shall not exceed 100% of the amount agreed to be paid for the services under the applicable Preferred Care Partners provider agreement. Follow the steps below to determine what payments are due when a member has two insurance carriers. Note that COB claims should always be filed as paper claims: 1. Verify the primary insurance. i. File the claim to the primary insurance carrier. ii. Include all other insurance carrier information in the appropriate COB fields in blocks iii. 9a-d of the CMS-1500, or 50A-C of the UB-04. 2. File the claim to the secondary insurance carrier. 3. If Preferred Care Partners is the secondary carrier, participating providers should file the claim to Preferred Care Partners once the primary insurance has completed processing. 4. Include all other insurance carrier information in the appropriate COB fields of the electronic form or in blocks 9a-d of the CMS-1500, or field 50A-C of the UB-04 claim form. 5. Attach a copy of the other carrier’s remittance advice. i. Note: If you submit the HIPAA compliant 837 claim format, you can electronically submit COB data on a secondary claim by entering the primary payment information in the COB segment. If you cannot submit the 837 claim format, when billing the secondary plan, always attach a copy of the explanation 114 of benefits form from the primary plan. COB rules may vary by contract and the rules below do not cover every situation. 6. Collect the Preferred Care Partners coinsurance, copayment, and/or non-covered services amount. 7. The terms of Preferred Care Partners’ participation contracts apply whether the member’s policy is their primary or secondary form of coverage. 8. Coinsurance amounts should be based on the lower of the Preferred Care Partners allowance or the provider’s charge. Preferred Care Partners’ payment when added to other payments shall not exceed 100% of the amount agreed to be paid for the services under the applicable Preferred Care Partners provider agreement. 9. Do not balance bill the member. 10. It is recommended that you wait to collect the coinsurance amount from the member until payments from both insurance companies have been received, which will alleviate the need to issue refunds. COB and Medicare Special rules apply to Coordination of Benefits with Medicare. In many cases, group health plans or other insurance will pay before Medicare. Following are some, but not all, instances in which group health plans or other insurance would be the primary payer: Working Aged If the employee has Medicare coverage due to age (65 and older) and is actively employed through an employer with 20 or more employees, or is self-employed and covered by an association group health plan with 100 or more members, the group health insurance through active employment must pay first. Disability Employees who are entitled to Medicare due to a disability other than ESRD, who are actively employed or who are covered as a dependent through an employer that employs 100 or more employees must have their group coverage as the primary payer and Medicare as the secondary payer. End-Stage Renal Disease For employees entitled to Medicare due to ESRD who also have group coverage through current or former employment - active, retiree, or COBRA, the employer group health plan coverage is the primary payer and Medicare is the secondary payer for the first thirty months of entitlement to Medicare. Thereafter, Medicare is the primary payer and group coverage is secondary. No-Fault Auto Insurance In general, no fault auto insurance provides coverage for losses sustained as a result of bodily injury, sickness, disease, or death arising out of the ownership, maintenance, or use of a motor vehicle. Payments for such claims are made by the carrier that provides coverage for the owner or driver of the vehicle in which the injured party was a passenger. Auto insurance provides medical, disability, and death benefits. The auto carrier assumes the responsibility of the primary payer up to policy limits; Preferred Care Partners will pay as secondary to the auto carrier. If the auto carrier denies payment due to exclusion under its contract, the notice of the rejected claim must be submitted with the claim to Preferred Care Partners. A participating physician may not elect to withhold claims for members with Preferred Care Partners insurance coverage in favor of collecting from 115 settlement proceeds for an injury that has third-party liability. To do so, constitutes balance billing, which is a breach of contract for participating providers. Workers’ Compensation In order to avoid delays in claims, providers must determine if the illness or injury being billed for is the result of an accident or a Workers Compensation incident. If it is, Preferred Care Partners can only be billed after the third-party carrier has considered the charges. Workers Compensation is designed to provide cash and medical care benefits for workers who sustain injuries or illness arising out of, or in the course of, employment. Work-related injuries must be billed to the Workers’ Compensation carrier. According to Florida law, payment from a Workers’ Compensation carrier is considered as payment-in-full. Therefore, benefits would not be coordinated with preferred Care Partners for work-related illnesses or injuries. If Preferred Care Partners makes payment in error, we are entitled to seek full restitution. If the Workers Compensation carrier has denied payment, a copy of both the denial and the claim should be submitted for consideration to Preferred Care Partners. Subrogation Subrogation typically occurs when one party is injured as a result of the actions or negligence of another. Examples include slip and fall accidents; assault; and frequently, auto accidents where subrogation applies. Preferred Care Partners has the right to “stand in the shoes” of the insured against a “wrongdoer.” In the event that Preferred Care Partners makes any payment to or on behalf of a member for any claim in connection with or arising from a condition resulting directly or indirectly from an intentional act or from the negligence or fault of any third party or entity, Preferred Care Partners may exercise its subrogation rights to recover the cost of the medical expenses. Subrogation recoveries may not be claimed by a participating physician or other health care provider in lieu of, or in addition to, making a claim for payment pursuant to the terms of and provisions of the provider agreement. Claim Review Requests A provider can make a Claim Review Request if he or she is dissatisfied with a claim determination. Note that a Claim Review Request is different from a claim status inquiry or a claim appeal. For information on how to check claim status, refer to the section Claim Status Inquiries above. To file a claim appeal, follow the instructions in the section Claim Appeals, below. If you wish for a claim to be reviewed, the provider or an office staff member must submit a Claim Review Request Form, or call our Claims department toll-free at (866) 725-9334. A copy of the Claim Review Request Form is located on our website at www.mypreferredprovider.com. Claim inquiries must be submitted within 120 days (4 months) of EOP receipt. The Plan will respond to the claim inquiry within 30 days from date of receipt. The Plan will respond to the provider in writing on all Claim Review Requests that do not result in the readjudication of a claim. Review of the Claim Review Request does not guarantee payment. Send written Claim Review Requests to: Preferred Care Partners Claims Inquiry P.O. Box 56-5790 Miami, FL 33256-5790 IMPORTANT: Submitting a Claim Review Request is not the same as filing a Claim Appeal. You have 120 days from the date of the EOP to file a Claim Appeal. If you file only a 116 Claim Review Request, the 120 days will continue to elapse until you either file a Claim Appeal, or the 120-day timeframe expires. Claim Appeals A claim appeal is a written request for reconsideration of a claim payment reduction or denial. The EOP will provide an explanation as to why the claim was reduced or denied. The provider has the right to appeal a payment decision. A non-contracted physician or other provider who has furnished a service may also file an appeal of a denied claim if he or she completes a Waiver of Liability (WOL) statement, which says he or she will not bill the member regardless of the outcome of the appeal. A claim appeal does not refer to pre-certification, concurrent review, claim status requests, claim review requests, telephone inquiries, or any other type of provider communication. The Plan generally will not overturn claim denials based on the provider’s failure to comply with required procedures and time limits. Commonly appealed claims decisions include payment for services for which preauthorization was not obtained, such as urgently needed services, or payment for health services furnished by a non-contracted provider or facility that you believe should have been reimbursed by Preferred Care Partners. Requirements Provider claim appeals must: Be submitted in writing Be submitted using the Provider Appeal Request form, or clearly marked “Provider Claim Appeal” Have a copy of the EOP attached Include any necessary supporting documentation as attachments, as indicated by the reason for the denial or reduction Be filed within 120 days of the date of the EOP Send all claim appeals to: Preferred Care Partners Claims Appeals P.O. Box 56-6420 Miami, FL 33256-6420 Appeals Process Upon receipt of your appeal, the Appeals Coordinator will document and log your request for processing, and may also call you to clarify information, if necessary. If the appeal is approved, the claim will be forwarded for adjustment and payment. If the appeal is denied, a letter will be sent advising you of the denial. Appeal decisions are final and may not be re-appealed. Providers may not balance bill members for covered services, including disputed amounts. Time Limits We will determine the appeal status within 60 calendar days of the date of your appeal. You will be notified of the final decision via mail. 117 Overpayments If you discover an overpayment, duplicate payment, or other payment in excess of the member's benefits payable according to the member's benefit plan, payment should promptly be remitted to Preferred Care Partners. Retroactive Reductions The Plan can issue a retroactive reduction on either a previously paid claim, or as a retroactive demand for refund of an overpayment. These will be reconciled to the specific claim, unless the parties agree to other reconciliation methods and terms. For more information on policies and procedures regarding overpayments, refer to Overpayment Recovery & Audit, Section 11. 118 Dedicated to ONE Community, Yours. P.O. 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