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. PACIFICARE OF CALIFORNIA MEDICAL GROUP/IPA SERVICES AGREEMENT (PROFESSIONAL CAPITATION) EXHIBIT 2 DELEGATED ACTIVITIES (This Exhibit 2 is an integral part of this Agreement) 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. MEDICAL MANAGEMENT DELEGATION GRID Function Delegation Status Provider Group Responsibility/ Performance Measure Reporting Frequency PacifiCare Oversight 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
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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. PACIFICARE OF CALIFORNIA MEDICAL GROUP/GROUP IPA SERVICES AGREEMENT (PROFESSIONAL CAPITATION) EXHIBIT 2 DELEGATED ACTIVITIES (This Exhibit 2 is an integral part of this Agreement) 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. MEDICAL MANAGEMENT DELEGATION GRID Function Delegation Status Provider Group Responsibility/ Performance Measure Reporting Frequency PacifiCare Oversight 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 Function Delegation Status Provider Group Responsibility/ Performance Measure Reporting Frequency PacifiCare Oversight 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. Function Delegation Status Provider Group Responsibility/ Performance Measure Reporting Frequency PacifiCare Oversight 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.
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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. PACIFICARE OF CALIFORNIA MEDICAL GROUP/IPA SERVICES AGREEMENT (PROFESSIONAL CAPITATION) EXHIBIT 2 DELEGATED ACTIVITIES (This Exhibit 2 is an integral part of this Agreement) 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. MEDICAL MANAGEMENT DELEGATION GRID Function Delegation Status Provider Group Responsibility/ Performance Measure Reporting Frequency PacifiCare Oversight 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 Function Delegation Status Provider Group Responsibility/ Performance Measure Reporting Frequency PacifiCare Oversight 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 MEDICAL MANAGEMENT DELEGATION GRID Function Delegation Status Provider Group Responsibility/ Performance Measure Reporting Frequency Pacific Oversight 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.
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Samples: 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. PACIFICARE OF CALIFORNIA MEDICAL GROUP/IPA SERVICES AGREEMENT (PROFESSIONAL SPLIT CAPITATION) EXHIBIT 2 DELEGATED ACTIVITIES (This Exhibit 2 is an integral part of this Agreement) 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. MEDICAL MANAGEMENT DELEGATION GRID Function Delegation Status Provider Medical Group Responsibility/ Performance Measure Reporting Frequency PacifiCare Oversight 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
