Medical Group Service Area. The Medical Group Service Area is the geographic area served by the Medical Group’s Participating Providers, including referral providers. The Medical Group Service Area is defined as being within a thirty (30) mile radius of each of the Medical Group Facilities, and includes the facilities and physician offices beyond the thirty mile radius where Referral Services are arranged for by Medical Group. The Medical Group Service Area shall be determined by PacifiCare, based upon the shortest route using public streets and highways. The purpose of the following Grids is to specify the responsibilities of PacifiCare and Medical Group under the Agreement with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management. The Grids set forth the specific activities with respect to (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management, which PacifiCare has delegated to Medical Group and which Medical Group shall perform on behalf of PacifiCare. The Grids also set forth the specific activities with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management, which PacifiCare has not delegated to Medical Group under the Agreement and which PacifiCare shall perform directly utilizing its own personnel. Medical Group is responsible for cooperating, participating and complying with PacifiCare’s performance of such activities. PacifiCare does not formally delegate to its contracting medical groups the responsibility for performing quality management and improvement activities on behalf of PacifiCare. However, PacifiCare does require contracting medical groups to maintain a quality improvement and management program, participate and cooperate in PacifiCare’s quality improvement program, collect data for PacifiCare’s quality improvement activities, and carry out corrective actions as required by PacifiCare. Accordingly, the Grids set forth certain quality improvement activities which PacifiCare has not delegated to Medical Group to perform on behalf of PacifiCare, but which PacifiCare and Medical Group shall perform concurrently under the Agreement. PacifiCare also does not formally delegate to contracting medical groups the responsibility for performing member services. However, PacifiCare does require contracting medical groups under the Agreement to participate, cooperate and comply with PacifiCare’s activities relating to member services, preventive health services, and medical record reviews as required by PacifiCare The Grids also identify (i) the elements and performance measures established by PacifiCare for the Delegated Activities in accordance with the NCQA accreditation standards and State and Federal law and regulatory requirements, (ii) the reports which shall be provided to PacifiCare by Medical Group for each of the Delegated Activities and the frequency of reporting, and (iii) the oversight activities which PacifiCare shall perform with respect to each of the Delegated Activities. Exhibit 2 may be amended from time to time during the term of this Agreement by PacifiCare to reflect changes in delegation standards; delegation status; performance measures; reporting requirements: and other provisions of Exhibit 2. UM Program Structure and Process ý Delegated o Not delegated Development and documentation of program structure and accountability, including. 1. Goals & Objectives, including behavioral health care aspects 2. Committee responsibilities; a) Membership b) Minutes c) Dissemination of information d) Education of staff & providers 3. UM Director & senior physician’s and designated behavioral health care practitioner roles 4. UM Dept interfaces with other depts. 5. Program is evaluated & approved annually For each UM function delegated there must be documentation of: 1. Staff & Physician responsibilities related to each UM function. 2. Adequate staffing mix 3. After-hours UM process defined 4 Interface with PacifiCare appropriately 5. Data elements as required 6. Reporting capability Implementation of corrective action plan for elements of non-compliance. • Annual submission of UM Program and Work Plan and Evaluation. • Submission of corrective action plans as needed. • Initial onsite assessment using approved oversight document • Annual oversight assessment • Annual PacifiCare committee approval of UM Program documents • Identification of corrective action plans for elements of non-compliance. Prior Authorization Professional Institutional ý Delegated o Not delegated ý Delegated o Not delegated For prior authorization the Provider Group (PG) must: • Comply with PacifiCare’s Turn Around Times and notification requirements • Follow nationally recognized medical necessity criteria • Develop and document program to perform prior authorization function of OP care meeting all regulatory and PacifiCare standards • Weekly submission of authorization/denial logs • Monthly submission of encounter data • Participation in census verification process • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function
Appears in 1 contract
Samples: Medical Group/Ipa Services Agreement (Prospect Medical Holdings Inc)
Medical Group Service Area. The Medical Group Service Area is the geographic area served by the Medical Group’s Participating Providers, including referral providers. The Medical Group Service Area is defined as being within a thirty (30) mile radius of each of the Medical Group Facilities, and includes the facilities and physician offices beyond the thirty mile radius where Referral Services are arranged for by Medical Group. The Medical Group Service Area shall be determined by PacifiCare, based upon the shortest route using public streets and highways. The purpose of the following Grids is to specify the responsibilities of PacifiCare and Medical Group under the Agreement with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management. The Grids set forth the specific activities with respect to (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management, which PacifiCare has delegated to Medical Group and which Medical Group shall perform on behalf of PacifiCare. The Grids also set forth the specific activities with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management, which PacifiCare has not delegated to Medical Group under the Agreement and which PacifiCare shall perform directly utilizing its own personnel. Medical Group is responsible for cooperating, participating and complying with PacifiCare’s performance of such activities. PacifiCare does not formally delegate to its contracting medical groups the responsibility for performing quality management and improvement activities on behalf of PacifiCare. However, PacifiCare does require contracting medical groups to maintain a quality improvement and management program, participate and cooperate in PacifiCare’s quality improvement program, collect data for PacifiCare’s quality improvement activities, and carry out corrective actions as required by PacifiCare. Accordingly, the Grids set forth certain quality improvement activities which PacifiCare has not delegated to Medical Group to perform on behalf of PacifiCare, but which PacifiCare and Medical Group shall perform concurrently under the Agreement. PacifiCare also does not formally delegate to contracting medical groups the responsibility for performing member services. However, PacifiCare does require contracting medical groups under the Agreement to participate, cooperate and comply with PacifiCare’s activities relating to member services, preventive health services, and medical record reviews as required by PacifiCare PacifiCare. The Grids also identify (i) the elements and performance measures established by PacifiCare for the Delegated Activities in accordance with the NCQA accreditation standards and State and Federal law and regulatory requirements, (ii) the reports which shall be provided to PacifiCare by Medical Group for each of the Delegated Activities and the frequency of reporting, and (iii) the oversight activities which PacifiCare shall perform with respect to each of the Delegated Activities. Exhibit 2 may be amended from time to time during the term of this Agreement by PacifiCare to reflect changes in delegation standards; delegation status; performance measures; reporting requirements: ; and other provisions of Exhibit 2. UM Program Structure and Process ý Delegated o Not delegated Development and documentation of program structure and accountability, including. 1. ) Goals & Objectives, including behavioral health care aspects 2. ) Committee responsibilities; . a) Membership b) Minutes c) Dissemination of information d) Education of staff & providers 3. 3 UM Director & senior physician’s and designated behavioral health care practitioner roles 4. 4 UM Dept interfaces with other depts. 5. 5 Program is evaluated & approved annually For each UM function delegated there must be documentation of: 1. 1 Staff & Physician responsibilities related to each UM function. 2. function 2 Adequate staffing mix 3. 3 After-hours UM process defined 4 Interface with PacifiCare appropriately 5. 5 Data elements as required 6. 6 Reporting capability Implementation of corrective action plan for elements of non-compliance. • Annual submission of UM Program and Work Plan and Evaluation. Evaluation • Submission of corrective action plans as needed. needed • Initial onsite assessment using approved oversight document • Annual oversight assessment • Annual PacifiCare committee approval of UM Program documents • Identification of corrective action plans for elements of non-compliance. compliance Prior Authorization Professional Institutional ý Delegated o Not delegated o Delegated ý Delegated o Not delegated For prior authorization the Provider Group (PG) must: • Comply with PacifiCare’s Turn Around Times and notification requirements requirements. • Follow nationally recognized medical necessity criteria • Develop and document program to perform prior authorization function of OP care meeting all regulatory and PacifiCare standards • Weekly submission of authorization/authorization denial logs • Monthly submission of encounter data • Participation in census verification process • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function Concurrent Review o Delegated ý Not delegated For concurrent review PG must: • Comply with PacifiCare’s Turn Around Times and notification requirements. • Follow nationally recognized medical necessity criteria • Develop and document programs to perform concurrent review of acute and Skilled Nursing Facility inpatients meeting all regulatory and PacifiCare standards • Daily submission of patient census by admission and discharge and Level of Care • Monthly submission of Bed Days per thousand members per year • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function Discharge Planning o Delegated ý Not delegated Develop and document program to perform discharge planning functions for Acute and Skilled Nursing Facility meeting all regulatory and PacifiCare standards Issue Skilled Nursing Facility Notice of Non-coverage timely and appropriately Reviewed during annual assessment • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function Out Of Area (OOA) o Delegated ý Not delegated If not delegated, report any OOA notifications received by group If delegated, develop and document program to perform OOA concurrent review meeting all regulatory and PacifiCare standards If Group delegated, OOA should be included in weekly authorization/ denial log submission • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function Case Management o Delegated ý Not delegated Develop and document program to perform Case Management function meeting all regulatory and PacifiCare standards If NOT delegated, responsible to coordinate care with PacifiCare Case Managers Monthly submission of Case Management Log • ESRD • Transplants • Catastrophic • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function Transplants ý Not delegated Develop and document Policies and Procedures to support notification to PacifiCare of potential transplant candidates. • Responsible to provide PacifiCare with all necessary information to make medical determination and manage the case. Report cases immediately New Technology ý Not delegated Develop and document Policies and Procedures to support notification to PacifiCare of requests for new technology and coordination of making determinations Ad Hoc NA Retrospective-Review Professional Retrospective Review Institutional ýDelegated o Not delegated o Delegated ý Not delegated For Retroactive-review of services PG must: • Comply with PacifiCare’s Turn Around Times and notification requirements. • Follow PacifiCare’s approved medical necessity criteria • Develop and document program to perform retrospective review function. Weekly submission of authorization/ denial logs • Pre-delegation onsite assessment to determine ability to perform function. • Annual onsite assessment to determine ability to perform function Denials Professional Institutional ýDelegated o Not delegated o Delegated ý Not delegated For Denials of 1 services PG must: • Comply with PacifiCare’s Turn Around Times and notification requirements. • Follow nationally recognized medical necessity criteria • Develop and document of program to perform denial function meeting all regulatory and PacifiCare standards. Weekly submission of denial logs. • Pre-delegation onsite assessment to determine ability to perform function. • Annual onsite assessment to determine ability to perform function. Benefit Interpretations ý Not delegated For Benefit Interpretations PG must: • Comply with PacifiCare’s Turn Around Times and notification requirements • Request PacifiCare interpretation when unable to make clear determination based on resources provided by PacifiCare (e.g., Benefits Manual) • Request PacifiCare determination regarding medical necessity when requested service appears to be of an experimental or investigational nature for a member who has a “life-threatening” or “seriously debilitating” condition as defined inthe California Health & Safety Code (see note below)*. N A • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function Appeals oDelegated ý Not delegated • Develop and document program to support cooperation with PacifiCare in handling appeals • Notify PacifiCare of all member and provider appeals coming through PG PacifiCare will provide the PG a quarterly report to show number of appeals and overturn rate for specific PG. • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function. PacifiCare’s responsibilities relating to Medical Management and those responsibilities, which PacifiCare has delegated to the Provider Group, are outlined above. The Provider Group agrees to be accountable for all responsibilities delegated by PacifiCare and will not further delegate any such responsibilities without the prior written approval by PacifiCare. PacifiCare will perform audits annually and as needed to evaluate the group’s delegated status. In the event there are deficiencies PacifiCare will perform audits annually and as needed to evaluate the group’s delegated status. In the event there are deficiencies identified in the audit, PacifiCare will provide a specific corrective action plan. If the group is not able to comply with the corrective action plan within the specified time frame, PacifiCare may revoke the group’s delegated status.
Appears in 1 contract
Samples: Professional Capitation Medical Group/Ipa Services Agreement (Prospect Medical Holdings Inc)
Medical Group Service Area. The Medical Group Service Area is the geographic area served by the Medical Group’s Participating Providers, including referral providers. The Medical Group Service Area is defined as being within a thirty (30) mile radius of each of the Medical Group Facilities, and includes the facilities and physician offices beyond the thirty mile radius where Referral Services are arranged for by Medical Group. The Medical Group Service Area shall be determined by PacifiCare, based upon the shortest route using public streets and highways. The purpose of the following Grids is to specify the responsibilities of PacifiCare and Medical Group under the Agreement with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management. The Grids set forth the specific activities with respect to (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management, which PacifiCare has delegated to Medical Group and which Medical Group shall perform on behalf of PacifiCare. The Grids also set forth the specific activities with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management, which PacifiCare has not delegated to Medical Group under the Agreement and which PacifiCare shall perform directly utilizing its own personnel. Medical Group is responsible for cooperating, participating and complying with PacifiCare’s performance of such activities. PacifiCare does not formally delegate to its contracting medical groups the responsibility for performing quality management and improvement activities on behalf of PacifiCare. However, PacifiCare does require contracting medical groups to maintain a quality improvement and management program, participate and cooperate in PacifiCare’s quality improvement program, collect data for PacifiCare’s quality improvement activities, and carry out corrective actions as required by PacifiCare. Accordingly, the Grids set forth certain quality improvement activities which PacifiCare has not delegated to Medical Group to perform on behalf of PacifiCare, but which PacifiCare and Medical Group shall perform concurrently under the Agreement. PacifiCare also does not formally delegate to contracting medical groups the responsibility for performing member services. However, PacifiCare does require contracting medical groups under the Agreement to participate, cooperate and comply with PacifiCare’s activities relating to member services, preventive health services, and medical record reviews as required by PacifiCare PacifiCare. The Grids also identify (i) the elements and performance measures established by PacifiCare for the Delegated Activities in accordance with the NCQA accreditation standards and State and Federal law and regulatory requirements, (ii) the reports which shall be provided to PacifiCare by Medical Group for each of the Delegated Activities and the frequency of reporting, and (iii) the oversight activities which PacifiCare shall perform with respect to each of the Delegated Activities. Exhibit 2 may be amended from time to time during the term of this Agreement by PacifiCare to reflect changes in delegation standards; delegation status; performance measures; reporting requirements: ; and other provisions of Exhibit 2. UM Program Structure and Process ý Delegated o Not delegated Development and documentation of program structure and accountability, including. : 1. Goals & Objectives, including behavioral health care aspects 2. Committee responsibilities; a) Membership b) Minutes c) Dissemination of information d) Education of staff & providers 3. UM Director & senior physician’s and designated behavioral health care healthcare practitioner roles 4. UM Dept interfaces with other depts. 5. Program is evaluated & approved annually For each UM function delegated there must be documentation of: 1. Staff & Physician responsibilities related to each UM function. 2. Adequate staffing mix 3. After-hours UM process defined 4 4. Interface with PacifiCare appropriately approximately 5. Data elements as required 6. Reporting capability Implementation of corrective action plan for elements of non-compliance. • Annual submission of UM Program and Work Plan and Evaluation. • Submission of corrective action plans as needed. • Initial onsite assessment using approved oversight document • Annual oversight assessment • Annual PacifiCare committee approval of UM Program documents • Identification of corrective action plans for elements of for non-compliance. Prior Authorization Professional Professional: Institutional ý Delegated o Not delegated ý Delegated o Not delegated For prior authorization the Provider Group (PG) must: • Comply with PacifiCare’s Turn Around Times and notification requirements requirements. • Follow nationally recognized medical necessity criteria • Develop and document program to perform prior authorization function of OP care meeting all regulatory and PacifiCare standards • Weekly submission of authorization/denial logs • Monthly submission of encounter data • Participation in census verification process • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function Concurrent Review ý Delegated o Not delegated For concurrent review PG must: • Comply with PacifiCare’s Turn Around Times and notification requirements. • Follow nationally recognized medical necessity criteria • Develop and document programs to perform concurrent review of acute and Skilled Nursing Facility inpatients meeting all regulatory and PacifiCare standards • Daily submission of patient census by admission and discharge and Level of Care • Monthly submission of Bed Days per thousand members per year • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function Discharge Planning ý Delegated o Not delegated Develop and document program to perform discharge planning functions for Acute and Skilled Nursing Facility meeting all regulatory and PacifiCare standards Issue Skilled Nursing Facility Notice of Non-coverage timely and appropriately. Reviewed during annual assessment. • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function Out Of Area (OOA) o Delegated ý Not delegated If not delegated, report any OOA notifications received by group. If delegated, develop and document program to perform OOA concurrent review meeting all regulatory and PacifiCare standards. If Group delegated, OOA should be included in weekly authorization/denial log submission • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function Case Management ý Delegated o Not delegated Develop and document program to perform Case Management function meeting all regulatory and PacifiCare standards If NOT delegated, responsible to coordinate care with PacifiCare Case Managers Monthly submission of Case Management Log • ESRD • Transplants • Catastrophic • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function Transplants ý Not delegated Develop and document Policies and Procedures to support notification to PacifiCare of potential transplant candidates. • Responsible to provide PacifiCare with all necessary information to make medical determination and manage the case Report cases immediately. New Technology ý Not delegated Develop and document Policies and Procedures to support notification to PacifiCare of requests for new technology and coordination of making determinations. Ad Hoc N/A Retrospective-Review Professional Retrospective Review Institutional ý Delegated o Not delegated o Delegated ý Not delegated For Retroactive-review of services PG must: • Comply with PacifiCare’s Turn Around Times and notification requirements. • Follow PacifiCare’s approved medical necessity criteria • Develop and document program to perform retrospective review function Weekly submission of authorization/denial logs • Pre-delegation onsite assessment to determine ability to perform function. • Annual onsite assessment to determine ability to perform function Denials Professional Institutional (Administrative/Facility Denials) ý Delegated o Not delegated o Delegated ý Not delegated For Denials of 1 services PG must: • Comply with PacifiCare’s Turn Around Times and notification requirements. • Follow nationally recognized medical necessity criteria • Develop and document of program to perform denial function meeting all regulatory and PacifiCare standards. Weekly submission of denial logs. • Pre-delegation onsite assessment to determine ability to perform function. • Annual onsite assessment to determine ability to perform function.
Appears in 1 contract
Samples: Medical Group/Ipa Services Agreement (Prospect Medical Holdings Inc)
Medical Group Service Area. The Medical Group Service Area is the geographic area served by the Medical Group’s Participating Providers, including referral providers. The Medical Group Service Area is defined as being within a thirty (30) mile radius of each of the Medical Group Facilities, and includes excluding the facilities and physician offices beyond the thirty mile radius where Referral Services are arranged for of specialists as approved by Medical GroupPacifiCare in writing. The Medical Group Service Area shall be determined by PacifiCare, based upon the shortest route using public streets and highways. *** Confidential Treatment Requested The purpose of the following Grids is to specify the responsibilities of PacifiCare and Medical Group under the Agreement with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical utilization management. The Grids set forth the specific activities with respect to (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical utilization management, which PacifiCare has delegated to Medical Group and which Medical Group shall perform on behalf of PacifiCare. The Grids also set forth the specific activities with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical utilization management, which PacifiCare has not delegated to Medical Group under the Agreement and which PacifiCare shall perform directly utilizing its own personnel. Medical Group is responsible for cooperating, participating and complying with PacifiCare’s performance of such activities. PacifiCare does not formally delegate to its contracting medical groups the responsibility for performing quality management and improvement activities on behalf of PacifiCare. However, PacifiCare does require contracting medical groups to maintain a quality improvement and management program, participate and cooperate in PacifiCare’s quality improvement program, collect data for PacifiCare’s quality improvement activities, and carry out corrective actions as required by PacifiCare. Accordingly, the Grids set forth certain quality improvement activities which PacifiCare has not delegated to Medical Group to perform on behalf of PacifiCare, but which PacifiCare and Medical Group shall perform concurrently under the Agreement. PacifiCare also does not formally delegate to contracting medical groups the responsibility for performing member services. However, PacifiCare does require contracting medical groups under the Agreement to participate, cooperate and comply with PacifiCare’s activities relating to member services, preventive health services, and medical record reviews as required by PacifiCare PacifiCare. The Grids also identify (i) the elements and performance measures established by PacifiCare for the Delegated Activities in accordance with the NCQA accreditation standards and State and Federal law and regulatory requirements, (ii) the reports *** Confidential Treatment Requested which shall be provided to PacifiCare by Medical Group for each of the Delegated Activities and the frequency of reporting, and (iii) the oversight activities which PacifiCare shall perform with respect to each of the Delegated Activities. Exhibit 2 may be amended from time to time during the term of this Agreement by PacifiCare to reflect changes in delegation standards; delegation status; performance measures; , reporting requirements: ; and other provisions of Exhibit 2. UM Program Structure HCFA Regulations Delegated or Not Delegated Compliance with all HCFA regulations & guidelines for claims processing and Process ý Delegated o Not delegated Development payment including: • Claims payment turnaround times • Appropriate reimbursement for contracted and documentation of program structure and accountability, includingnon-contracted providers • Interest payments • Denials/denial letters • BBA regulations • Provider reporting • Y2K compliance Monthly • Initial onsite assessment utilizing approved oversight tool • Annual oversight assessment utilizing approved oversight tool. 1. Goals & Objectives, including behavioral health care aspects 2. Committee responsibilities; a) Membership b) Minutes c) Dissemination of information d) Education of staff & providers 3. UM Director & senior physician’s and designated behavioral health care practitioner roles 4. UM Dept interfaces with other depts. 5. Program is evaluated & • Additional onsite reviews as warranted by the plan utilizing approved annually For each UM function delegated there must be documentation of: 1. Staff & Physician responsibilities related to each UM function. 2. Adequate staffing mix 3. After-hours UM process defined 4 Interface with PacifiCare appropriately 5. Data elements as required 6. Reporting capability oversight tool • Implementation of corrective action plan Corrective Action Plan(s) for elements of non-compliance. PacifiCare Standards for Commercial Products Delegated or Not Delegated Compliance with PacifiCare’s standards for processing and payment of claims for Commercial Products including: • Claims payment turnaround times • Appropriate reimbursement for contracted and non-contracted providers • Interest payments • Denials/denial letters • Provider reporting • Appropriate IBNR reserves Monthly • Initial onsite assessment utilizing approved oversight tool • Annual submission of UM Program and Work Plan and Evaluationoversight assessment utilizing approved oversight tool. • Submission Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of corrective action plans Corrective Action Plan(s) for elements of non-compliance. State Regulations Delegated or Not Delegated Compliance with State Regulations for claims processing: • COB and TPL review • Compliance with all Medicaid Regulations N/A • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as neededwarranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. OPM Requirements Delegated or Not Delegated Compliance with Office of Personnel Management for Federal Employees requirements for claims processing and payment including: • COB identification • Debarred providers suspended N/A Standards for Employer Performance Guarantees Delegated or Not Delegated Meet Employer performance guarantee measurements for claims processing and payment. As required by employer • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Eligibility and Benefits Not Delegated Medical Group must: Verify eligibility at time of claim review • Update eligibility and benefit information in their system as often as communicated by the plan. N/A • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Financial Accounting Delegated or Not Delegated Meets PacifiCare financial accounting requirements and solvency requirements including those for • Financial statements • IBNR reserves • Processes for expense reduction Annually • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Check Production Processes Delegated or Not Delegated Compliance with timely claims payments and IRS requirements including: • Check production processes • Performing Provider Satisfaction Survey • Process to settle claims in collections • 1099 production processes N/A • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Staffing Delegated or Not Delegated Staffing sufficient to support claims volume and processing timeliness requirements including: • Staffing levels • Customer Service capabilities • Past experience for claims resolution • Staff available to answer claims questions during normal hours of operation N/A • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Audit Reporting Delegated or Not Delegated Appropriate and adequate audit reporting available including: • Reports provided for audit As needed for audits • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Encounter Data Delegated or Not Delegated The Medical Group must have an encounter data submission process with encounter data reported and submitted to PacifiCare monthly Monthly • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Credentialing Policies and Procedures Delegated or Not Delegated Full Compliance with NCQA Standards: • Identify scope • Define criteria and verification of criteria • Describe decision making process, including how advice is received from participating practitioners • Describe extent of any delegated credentialing/recredentialing arrangements • Describe right of practitioner to review information. • Develop process to notify practitioner of discrepancies. • Include practitioner's right to correct erroneous information. • Ensure confidentiality. • Define Medical Director responsibilities and participation. Submit Credentialing Program annually. Revised credentialing policies and procedures submitted quarterly, if applicable. • Initial onsite assessment using approved • Annual oversight document assessment • Annual PacifiCare Committee approval • Evaluate and approve written Credentialing Program • Implementation of Corrective • Action Plan(s) for elements of non-compliance Credentialing Committee Delegated or Not Delegated Full Compliance with NCQA Standards: • The MG designates a credentialing committee or other review body that makes recommendations regarding credentialing decisions Annual credentialing program to include committee structure. • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare Committee approval • Annual Review of Committee minutes • Annual review of membership • Frequency of meetings • Implementation of Corrective Action Plan(s) for elements of non-compliance Primary source verification of credentialing information Delegated or Not Delegated Full Compliance with NCQA Standards regarding verification of information within 180 days of Committee approval date. Meet 90% of all NCQA credentialing standards (exempt from primary source verification of license). Meet 100% of NCQA standards related to primary source verification of licenser. • Primary source verification to include: • License • Clinical privileges • DEA/CDS • Education • Board certification • Work history • Malpractice insurance • Professional liability claims Submit current list of physicians credentialed and recredentialed with quarterly report. • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare Committee approval • Implementation of Corrective Action Plan(s) for elements of non-compliance • Audit conducted of provider credentialing and recredentialing files (5% or 50 credentialing files reviewed, whichever is less, with a minimum of 10 credentialing and 10 recredentialing files reviewed). Application/Attestation Delegated or Not Delegated Full compliance with NCQA Standards. The PMG/IPA application must include a statement regarding • Reasons for any inability to perform. • Lack of present illegal drug use • History of loss of license or felony conviction • History of loss or limitation of Immediate submission of any changes to application. • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare Committee approval. • Annual review of credentialing files (5% or 50 credentialing files reviewed, whichever is less, with a minimum of 10 credentialing and 10 recredentialing files. • Implementation of Corrective Action Plan(s) for elements of Privileges or disciplinary activity • Attestation by applicant of the correctness and completeness of the application • Signed within 180 days of Committee approval date. non-compliance National Practitioner Data Base (NPDB) Information/Sanction Information Delegated or Not Delegated Full compliance with NCQA Standards regarding verification of information within 180 days of Committee Approval date For all Medicare and/or Medicaid sanctions as appropriate: • State Board of Dental Examiners • State Board of Pediatric Examiners • State Board of Medical Examiners • Federation of State Medical Boards or Department of Professional Regulations • State Board of Chiropractic Examiners of the Federation of Chiropractic Licensing Boards NONE • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare committee approval • Implementation of UM Program documents • Identification of corrective action plans Corrective Action Plan(s) for elements of non-compliance. Prior Authorization Professional Institutional ý compliance Initial office visit of all PCPs and OB/GYNs and medical record keeping review Delegated o or Not delegated ý Delegated o Not delegated For prior authorization Full compliance with NCQA Standards regarding Initial site visit/medical record review and subsequent biannual site visit/medical record review Structured review that evaluates the Provider Group (PG) mustoffice site against standards in the following areas: • Comply Physical accessibility • Physical appearance • Adequacy of waiting room and exam room space • Availability of appointments vs expected performance standards • Documentation of an evaluation of medical record keeping practices for conformity with PacifiCare’s Turn Around Times standards • Incorporation of this information into the credentialing process Include list of all initial site reviews completed on an annual basis. • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare Committee approval • Biannual site review • Biannual medical record review • Implementation of Corrective Action Plan(s) for elements of non-compliance • Annual review of audit tool • Verification of all sites completed within 2 years prior to initial credentialing • Review of credential files annually as above to include evidence of initial site review and notification requirements • Follow nationally recognized medical necessity criteria • Develop and document program record keeping review. Recredentialing Primary source verification (PSV) Delegated or Not Delegated Meet 90% of all NCQA Recredentialing standards (except PSV of Licenser). Meet 100% of all NCQA Standards related to PSV of Licenser Recredentialing to include. License, clinical privileges, DEA/CDS, Board Certification, Malpractice Insurance, Professional Liability claims, signed Attestation regarding any inability to perform prior authorization function and lack of OP care meeting present illegal drug use. Include list of all regulatory and PacifiCare standards providers recredentialed on a quarterly basis (with quarterly report) • Weekly submission Annual audit of authorization/denial logs • Monthly submission files of encounter data • Participation in census verification process • Pre-delegation onsite assessment 5% or random sample of 50 to determine ability to perform function represent entire contracted network • Annual onsite assessment Recredentialing National Practitioner Data Base (NPDB) information/Sanction information Delegated or Not Delegated Full compliance with NCQA Recredentialing Standards regarding verification of information within 180 days of Committee approval date Recredentialing conducted biannually by the Provider. Recredentialing must be completed • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare Committee approval • Implementation of Corrective Action Plan(s) for elements of non-compliance • Annual audit of files of 5% or random sample of 50 to determine ability to perform functionrepresent
Appears in 1 contract
Samples: Medical Group/Ipa Services Agreement (Prospect Medical Holdings Inc)
Medical Group Service Area. The Medical Group Service Area is the geographic area served by the Medical Group’s Participating Providers, including referral providers. The Medical Group Service Area is defined as being within a thirty (30) mile radius of each of the Medical Group Facilities, and includes the facilities and physician offices beyond the thirty mile radius where Referral Services are arranged for by Medical Group. The Medical Group Service Area shall be determined by PacifiCare, based upon the shortest route using public streets and highways. The purpose of the following Grids is to specify the responsibilities of PacifiCare and Medical Group under the Agreement with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management. The Grids set forth the specific activities with respect to (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management, which PacifiCare has delegated to Medical Group and which Medical Group shall perform on behalf of PacifiCare. The Grids also set forth the specific activities with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical management, which PacifiCare has not delegated to Medical Group under the Agreement and which PacifiCare shall perform directly utilizing its own personnel. Medical Group is responsible for cooperating, participating and complying with PacifiCare’s performance of such activities. PacifiCare does not formally delegate to its contracting medical groups the responsibility for performing quality management and improvement activities on behalf of PacifiCare. However, PacifiCare does require contracting medical groups to maintain a quality improvement and management program, participate and cooperate in PacifiCare’s quality improvement program, collect data for PacifiCare’s quality improvement activities, and carry out corrective actions as required by PacifiCare. Accordingly, the Grids set forth certain quality improvement activities which PacifiCare has not delegated to Medical Group to perform on behalf of PacifiCare, but which PacifiCare and Medical Group shall perform concurrently under the Agreement. PacifiCare also does not formally delegate to contracting medical groups the responsibility for performing member services. However, PacifiCare does require contracting medical groups under the Agreement to participate, cooperate and comply with PacifiCare’s activities relating to member services, preventive health services, and medical record reviews as required by PacifiCare PacifiCare. The Grids also identify (i) the elements and performance measures established by PacifiCare for the Delegated Activities in accordance with the NCQA accreditation standards and State and Federal law and regulatory requirements, (ii) the reports which shall be provided to PacifiCare by Medical Group for each of the Delegated Activities and the frequency of reporting, and (iii) the oversight activities which PacifiCare shall perform with respect to each of the Delegated Activities. Exhibit 2 may be amended from time to time during the term of this Agreement by PacifiCare to reflect changes in delegation standards; : delegation status; performance measures; reporting requirements: ; and other provisions of Exhibit 2. UM Program Structure and Process ý Delegated o Not delegated Development and documentation of program structure and accountability, including. , 1. Goals & Objectives, including behavioral health care aspects 2. Committee responsibilities; : a) Membership b) Minutes c) Dissemination of information d) Education of staff & providers 3. UM Director & senior physician’s and designated behavioral health care practitioner roles 4. UM Dept interfaces with other depts. 5. Program is evaluated & approved annually For each UM function delegated there must be documentation of: 1. Staff & Physician responsibilities related to each UM function. 2. Adequate staffing mix 3. After-hours UM process defined 4 4. Interface with PacifiCare appropriately 5. Data elements as required 6. Reporting capability Implementation of corrective action plan for elements of non-compliance. • Annual submission of UM Program and Work Plan and Evaluation. • Submission of corrective action plans as needed. • Initial onsite assessment using approved oversight document • Annual oversight assessment • Annual PacifiCare committee approval of UM Program documents • Identification of corrective action plans for elements of non-compliance. compliance Prior Authorization Professional Institutional ý Delegated o Not delegated o Delegated ý Not Delegated o Not delegated For prior authorization the Provider Medical Group (PGMG) must: must • Comply with PacifiCare’s Turn Around Times and notification requirements requirements. • Follow nationally recognized medical necessity criteria • Develop and document program to perform prior authorization function of OP care meeting all regulatory and PacifiCare standards • Weekly submission of authorization/denial logs • Monthly submission of encounter data • Participation in census verification process • Pre-delegation onsite assessment to determine ability to perform function • Annual onsite assessment to determine ability to perform function
Appears in 1 contract
Samples: Medical Group/Ipa Services Agreement (Prospect Medical Holdings Inc)
Medical Group Service Area. The Medical Group Service Area is the geographic area served by the Medical Group’s Participating Providers, including referral providers. The Medical Group Service Area is defined as being within a thirty (30) mile radius of each of the Medical Group Facilities, and includes excluding the facilities and physician offices beyond the thirty mile radius where Referral Services are arranged for of specialists as approved by Medical GroupPacifiCare in writing. The Medical Group Service Area shall be determined by PacifiCare, based upon the shortest route using public streets and highways. *** Confidential Treatment requested The purpose of the following Grids is to specify the responsibilities of PacifiCare and Medical Group under the Agreement with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical utilization management. The Grids set forth the specific activities with respect to (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical utilization management, which PacifiCare has delegated to Medical Group and which Medical Group shall perform on behalf of PacifiCare. The Grids also set forth the specific activities with respect to: (i) claims processing and payment, (ii) credentialing and recredentialing, (iii) medical records, (iv) quality management and improvement and (v) medical utilization management, which PacifiCare has not delegated to Medical Group under the Agreement and which PacifiCare shall perform directly utilizing its own personnel. Medical Group is responsible for cooperating, participating and complying with PacifiCare’s performance of such activities. PacifiCare does not formally delegate to its contracting medical groups the responsibility for performing quality management and improvement activities on behalf of PacifiCare. However, PacifiCare does require contracting medical groups to maintain a quality improvement and management program, participate and cooperate in PacifiCare’s quality improvement program, collect data for PacifiCare’s quality improvement activities, and carry out corrective actions as required by PacifiCare. Accordingly, the Grids set forth certain quality improvement activities which PacifiCare has not delegated to Medical Group to perform on behalf of PacifiCare, but which PacifiCare and Medical Group shall perform concurrently under the Agreement. PacifiCare also does not formally delegate to contracting medical groups the responsibility for performing member services. However, PacifiCare does require contracting medical groups under the Agreement to participate, cooperate and comply with PacifiCare’s activities relating to member services, preventive health services, and medical record reviews as required by PacifiCare PacifiCare. The Grids also identify (i) the elements and performance measures established by PacifiCare for the Delegated Activities in accordance with the NCQA accreditation standards and State and Federal law and regulatory requirements, (ii) the reports which shall be provided to PacifiCare by Medical Group for each of the Delegated Activities and the frequency of reporting, and (iii) the oversight activities which PacifiCare shall perform with respect to each of the Delegated Activities. Exhibit 2 may be amended from time to time during the term of this Agreement by PacifiCare to reflect changes in delegation standards; delegation status; performance measures; reporting requirements: ; and other provisions of Exhibit 2. UM Program Structure HCFA Regulations Delegated Compliance with all HCFA regulations & guidelines for claims processing and payment including: • Claims payment turnaround times • Appropriate reimbursement for contracted and non-contracted providers • Interest payments • Denials/denial letters • BBA regulations • Provider reporting • Y2K compliance Monthly • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. PacifiCare Standards for Commercial Products Delegated Compliance with PacifiCare’s standards for processing and payment of claims for Commercial Products including: • Claims payment turnaround times • Appropriate reimbursement for contracted and non-contracted providers • Interest payments • Denials/denial letters • Provider reporting • Appropriate IBNR reserves Monthly • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. State Regulations Delegated Compliance with State Regulations for claims processing: • COB and TPL review • Compliance with all Medicaid Regulations N/A • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. OPM Requirements Delegated Compliance with Office of Personnel Management for Federal Employees requirements for claims processing and payment including: • COB identification • Debarred providers suspended N/A Standards for Employer Performance Guarantees Delegated Meet Employer performance guarantee measurements for claims processing and payment. As required by employer • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Eligibility and Benefits Not Delegated Medical Group must: Verify Eligibility at time of claim review • Update eligibility and benefit information in their system as often as communicated by the plan. N/A • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Financial Accounting Delegated Meets PacifiCare financial accounting requirements and solvency requirements including those for: • Financial statements • IBNR reserves • Processes for expense reduction Annually • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation or Corrective Action Plan(s) for elements of non-compliance. Check Production Processes Delegated Compliance with timely claims payments and IRS requirements including: • Check production processes • Performing Provider Satisfaction Survey • Process ý to settle claims in collections • 1099 production processes N/A • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Staffing Delegated o Not delegated Development Staffing sufficient to support claims volume and documentation processing timeliness requirements including: • Staffing levels • Customer Services capabilities • Past experience for claims resolution • Staff available to answer claims questions during normal hours of program structure operation N/A • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Audit Reporting Delegated Appropriate and accountability, adequate audit reporting available including: • Reports provided for audit As needed for audits • Initial onsite assessment utilizing approved oversight tool. 1• Annual oversight assessment utilizing approved oversight tool. Goals & Objectives• Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Encounter Data Delegated The Medical Group must have an encounter data submission process with encounter data reported and submitted to PacifiCare monthly Monthly • Initial onsite assessment utilizing approved oversight tool. • Annual oversight assessment utilizing approved oversight tool. • Additional onsite reviews as warranted by the plan utilizing approved oversight tool. • Implementation of Corrective Action Plan(s) for elements of non-compliance. Credentialing Policies and Procedures Delegated Full Compliance with NCQA Standards: • Identify scope • Define criteria and verification of criteria • Describe decision making process, including behavioral health care aspects 2how advice is received from participating practitioners • Describe extent of any delegated credentialing/recredentialing arrangements • Describe right of practitioner to review information. • Develop process to notify practitioner of discrepancies. • Include practitioner’s right to correct erroneous information. • Ensure confidentiality. • Define Medical Director responsibilities and participation. Submit Credentialing Program annually. Revised credentialing policies and procedures submitted quarterly, if applicable. • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare Committee responsibilities; aapproval • Evaluate and approve written Credentialing Program • Implementation of Corrective Action Plan(s) Membership bfor elements of non-compliance. Credentialing Committee Delegated Full Compliance with NCQA Standards: • The MG designates a credentialing committee or other review body that makes recommendations regarding credentialing decisions Annual credentialing program to include committee structure. • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare Committee approval • Annual Review of Committee minutes • Annual review of membership • Frequency of meetings. • Implementation of Corrective Action Plan(s) Minutes c) Dissemination for elements of non-compliance. Primary source verification of credentialing information Delegated Full compliance with NCQA Standards regarding verification of information d) Education within 180 days of staff & providers 3Committee approval date. UM Director & senior physician’s and designated behavioral health care practitioner roles 4Meet 90% of all NCQA credentialing standards (exempt from primary source verification of license). UM Dept interfaces with other depts. 5. Program is evaluated & approved annually For each UM function delegated there must be documentation of: 1. Staff & Physician responsibilities Meet 100% of NCQA standards related to each UM functionprimary source verification of licenser. 2• Primary source verification to include: • License • Clinical privileges • DEA/CDS • Education • Board certification • Work history • Malpractice insurance • Professional liability claims. Adequate staffing mix 3Submit current list of physicians credentialed and recredentialed with quarterly report. After-hours UM process defined 4 Interface with • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare appropriately 5. Data elements as required 6. Reporting capability Committee approval • Implementation of corrective action plan Corrective Action Plan(s) for elements of non-compliance. • Annual Audit conducted of provider credentialing and recredentialing files (5% or 50 credentialing files reviewed, whichever is less, with a minimum of 10 credentialing and 10 recredentialing files reviewed) Application/ Attestation Delegated Full compliance with NCQA Standards. The PMG/IPA application must include a statement regarding: • Reasons for any inability to perform. • Lack of present illegal drug use. • History of loss of license or felony conviction • History of loss or limitation of Immediate submission of UM Program and Work Plan and Evaluation. • Submission of corrective action plans as neededany changes to application. • Initial onsite assessment using approved • Annual oversight document assessment • Annual PacifiCare Committee approval. • Annual review of credentialing files (5% or 50 credentialing files reviewed, whichever is less, with a minimum of 10 credentialing and 10 recredentialing files. • Implementation of Corrective Action Plan(s) for elements of privileges or disciplinary activity. • Attestation by applicant of the correctness and completeness of the application. • Signed within 180 days of Committee approval date. non-compliance. National Practitioner Data Base (NPDB) Information/ Sanction Information Delegated Full compliance with NCQA Standards regarding verification of information within 180 days of Committee Approval date. For all Medicare and/or Medicaid sanctions as appropriate: • State Board of Dental Examiners • State Board of Pediatric Examiners • State Board of Medical Examiners • Federation of State Medical Boards or Department of Professional Regulations • State Board of Chiropractic Examiners of the Federation of Chiropractic Licensing Boards NONE • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare committee approval • Implementation of UM Program documents • Identification of corrective action plans Corrective Action Plan(s) for elements of non-compliancecompliance Initial office visit of all PCPs and OB/GYNs and medical record keeping review Delegated Full compliance with NCQA Standards regarding Initial site visit/medical record review and subsequent biannual site visit/medical record review. Prior Authorization Professional Institutional ý Delegated o Not delegated ý Delegated o Not delegated For prior authorization Structured review that evaluates the Provider Group (PG) mustoffice site against standards in the following areas: • Comply Physical accessibility • Physical appearance • Adequacy of waiting room and exam room space • Availability of appointments vs. expected performance standards • Documentation of an evaluation of medical record keeping practices for conformity with PacifiCare’s Turn Around Times standards • Incorporation of this information into the credentialing process Include list of all initial site reviews completed on an annual basis. • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare Committee approval • Biannual site review • Biannual medical record review • Implementation of Corrective Action Plan(s) for elements of non-compliance • Annual review of audit tool • Verification of all sites completed within 2 years prior to initial credentialing • Review of credential files annually as above to include evidence of initial site review and notification requirements • Follow nationally recognized medical necessity criteria • Develop and document program record keeping review. Recredentialing Primary source verification (PSV) Delegated Meet 90% of all NCQA Recredentialing standards (except PSV of Licenser). Meet 100% of NCQA Standards related to PSV of Licenser. Recredentialing to include: License, clinical privileges, DEA/CDS, Board Certification, Malpractice Insurance, Professional Liability claims, signed Attestation regarding any inability to perform prior authorization function and lack of OP care meeting present illegal drug use. Include list of all regulatory and PacifiCare standards providers recredentiated on a quarterly basis (with quarterly report) • Weekly submission Annual audit of authorization/denial logs • Monthly submission files of encounter data • Participation in census verification process • Pre-delegation onsite assessment 5% or random sample of 50 to determine ability to perform function represent entire contracted network • Annual onsite assessment Recredentialing National Practitioner Data Base (NPDB) information/Sanction information Delegated Full compliance with NCQA Recredentialing Standards regarding verification of information within 180 days of Committee approval date. Recredentialing conducted biannually by the Provider. Recredentialing must be completed. • Initial onsite assessment • Annual oversight assessment • Annual PacifiCare Committee approval • Implementation of Corrective Action Plan(s) for elements of non-compliance • Annual audit of files of 5% or random sample of 50 to determine ability to perform functionrepresent
Appears in 1 contract
Samples: Medical Group/Ipa Services Agreement (Prospect Medical Holdings Inc)
