Index Section II. For information about. See page:

Transcription

1 Index Section II For information about See page: Utilization Management Program Responsibilities of the Plan and Provider 1 Blue Cross and Blue Shield of Oklahoma responsibilities Provider responsibilities Medically necessary 2 Definition of medically necessary When services are not medically necessary Precertification 3 What is precertification? When is precertification required? Who is responsible for precertification? How to request precertification Recertification Precertification does not guarantee payment Special Note: Physicians and Ambulatory Surgical Centers Failure to precertify Referrals 5 What is a referral? In-network Out-of-Network When is a referral required? In-network referrals Out-of-network referrals Provider responsibilities Primary Care Physician Specialist physicians and facilities All physicians How to authorize an in-network referral Extending an in-network referral How to request authorization for an out-of-network referral Self Referrals Failure to authorize referrals Case Management 8 What is case management? How does case management work? Cases that may require special care Who can make a referral? How to submit a referral? i

2 Index Section II For information about: See page: Quality Assurance/Quality Improvement Quality Assurance/Quality Improvement 10 Quality improvement (QI) goals Responsibilities of the plan 11 Responsibilities of the provider 11 Monitoring and Evaluation Methods 12 Quality monitoring activities Network practitioner selection Practitioner review and evaluation Member satisfaction Health Management Systems Preventive Health/Health Promotion Disease Management/Wellness Outcome and occurrence reviews Patient Access to Care Blue Cross and Blue Shield of Oklahoma access standards 14 Mental health and substance abuse access standards 14 Provider Standards of Care Medical record-keeping and documentation standards 15 Behavioral Health Medical Record Standards 16 Appeals and Grievance Procedures Types of Appeals 18 Utilization management appeals Contractual inquiries/appeals Quality assurance/quality improvement appeals Network status appeals Types of utilization management appeals 19 Expedited appeals Standard appeals Contractual inquiries/appeals 21 Inquiry/complaint Contractual appeal Executive mediation Binding arbitration ii

3 Index Section II For information about: See page: Quality assurance/quality improvement appeals 23 Policy Definition Procedure Level 1 Level 2 Network status appeals 25 Credentialing (network status) appeals Level 1 Level 2 Other issues Level 1 Level 2 Primary Care Physicians Definition of primary care physician 27 Responsibilities of the PCP 27 Common PCP questions 27 Referral questions 28 Requesting an application 29 PCP credentialing requirements 29 Specialist physician credentialing requirements 30 Hospital-based physicians (ALEX physicians) 32 Claims Adjudication Policy Guidelines What is the purpose of the guidelines? 33 What does the clinical logic address? 33 How are the guidelines used at Blue Cross and Blue Shield of Oklahoma and its subsidiaries? 33 How are the guidelines updated? 34 How does Blue Cross and Blue Shield of Oklahoma implement new versions? 34 How was the software developed? 34 iii

4 Responsibilities of the Plan and Provider Section II Blue Cross and Blue Shield of Oklahoma responsibilities13 1. Provide properly trained, qualified and supervised Utilization Management (UM) staff. 2. Provide a qualified UM Medical Director. 3. Make clinical review decisions based on established clinical review criteria developed with input from actively participating providers. 4. Provide a mechanism for providers to appeal UM denials. Provider responsibilities 1. Supply complete and detailed clinical information to allow Blue Cross and Blue Shield to make an informed decision. 2. Precertify all services as required by contract. 3. Verify a referral authorization for services when appropriate. 4. Request authorization of out-of-network referrals when necessary and appropriate to the member s health care. 5. Re-certify hospital admissions and extend authorized out-of-network referrals when appropriate. 6. Refer members to the Case Management program when appropriate. 7. Provide call coverage for members 24 hours per day, seven days a week. 4

5 Medically Necessary Section II Definition of medically necessary Medically Necessary or Medical Necessity shall mean health care services that a physician, hospital or other provider, exercising prudent clinical judgment, would provide to a Member for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Member s illness, injury or disease; and (c) not primarily for the convenience of the Member, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that Member s illness, injury or disease. For these purposes, generally accepted standards of medical practice means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors. When services are not medically necessary Unless a proper written waiver has been obtained (as described in your participating provider agreement), providers may not collect charges from the member for services that have been determined not medically necessary by Blue Cross and Blue Shield of Oklahoma. 5

6 Precertification Section II What is precertification? Preadmission Certification (precertification) and Admission Certification are processes used to review certain ancillary services, hospital admissions and certain outpatient services to determine that services are medically necessary. When is precertification required? General Requirements Admission certification is required for all emergency and obstetric admissions. Preadmission certification (precertification) is required for all other inpatient admissions. In addition, specific outpatient services require precertification. You can identify members who require precertification by checking the member ID card. The back of the ID card will indicate the appropriate precertification phone number. Ambulatory Surgical Centers (ASC) ASCs are required by contract to precertify certain procedures. ASCs should refer to the appropriate contract attachment for the updated list of services and corresponding CPT-4 codes which require precertification. Blue Plan65 Select and BlueTraditional members Please note that Blue Plan65 Select members only require precertification when their Medicare Part A benefits have been exhausted. BlueTraditional members only require precertification when it is required by their member contract. Who is responsible for precertification? The provider or treating physician bears the primary responsibility for obtaining precertification. Calls will be accepted from the admitting facility or member. For BlueCard members, precertification is the responsibility of the member. How to request precertification To the extent practical, precertification should be obtained at least five (5) days in advance of an admission or certain ancillary services. Please refer to the Quick Reference Guide for the appropriate phone numbers. Precertification must always be obtained prior to the actual admission and/or treatment. Admission certification for obstetric and emergency admission must be obtained within 48 hours of the actual admission or certain ancillary services. After you have completed the request for precertification and all relevant clinical information has been obtained, we will respond by telephone with a determination within the timeframe provided by law. Written notification of the determination will be sent within the timeframe provided by law to the physician, hospital (if applicable) or ancillary provider and the member. 6

7 Precertification Section II Recertification If a precertified admission is expected to extend beyond Blue Cross and Blue Shield of Oklahoma assigned length of stay, the admission is subject to concurrent review and must be recertified. Recertification must be completed on or before the last day of the assigned stay. The recertification process is the same as precertification. Precertification does not guarantee payment for services rendered1313 Precertification will only determine if a service is medically necessary. Precertification does not determine if the member is enrolled or if the service is a benefit for the member. You may call the Provider Inquiry Unit (PIU) to confirm current member enrollment and general benefit coverage. A member s coverage may be subject to waivers, pre-existing conditions, limitations, exclusions and other membership stipulations, or subject to cancellation retroactive to the effective date (e.g., in the event of fraud, misrepresentation or non-payment of dues), even though such coverage may have been previously confirmed in good faith by Blue Cross and Blue Shield of Oklahoma. Special note: physicians and ambulatory surgical centers13 When a patient is sent to an Ambulatory Surgical Center (ASC) for treatment, it is important to provide accurate diagnosis and procedure codes. The ASC relies on the accuracy of these codes. The Blue Cross and Blue Shield of Oklahoma contract with Ambulatory Surgical Centers requires precertification for specific procedures. ASC claims may be reviewed or denied for a discrepancy between the precertified service and the subsequently submitted claim code. Failure to precertify13 Please refer to your contractual agreement(s) with Blue Cross and Blue Shield of Oklahoma for information regarding provider penalties. 7

8 Referrals Section II What is a referral?13 There are two types of referrals in-network and out-of-network. In-Network Some members choose a benefit plan with a primary care physician (PCP) who is responsible for providing and coordinating health care. If the member requires medically necessary services that the PCP is unable to provide, the PCP must authorize an in-network referral. This process is only applicable for members who have a PCP listed on their ID card. Out-of-Network If medically necessary services are not available within the member s network, the provider should request out-of-network referral authorization from the Plan. Out-of-network referrals are only authorized by Blue Cross and Blue Shield of Oklahoma if the services are a covered benefit, medically necessary and if the services are unavailable within the network. When is a referral required?13 You can identify members who require in-network referrals by checking the member ID card. If the member subscribes to BlueChoice with a PCP, the front of the ID card will indicate the designated PCP s name. Members of Custom Group Services that require an in-network referral authorization have referral instructions on the back of the member ID card. In-Network Referrals The member s designated PCP is required to authorize the following services: Any service the PCP does not provide or bill, including lab and x-ray services. Referrals to specialists. Referrals to hospital outpatient departments. All hospital inpatient admissions, including other physicians and health care providers involved in the patient s course of care. 8

9 Referrals Section II Provider responsibilities Primary care physicians The PCP is responsible for authorizing an in-network referral when necessary. The PCP is also responsible for supplying complete information regarding the authorized treatment, procedures, referral specialist, provider, ancillary provider or facility. Specialist physicians, facilities and ancillary providers Payment will be made to the referral specialist, facility or ancillary provider only for the services specified and authorized by Blue Cross and Blue Shield of Oklahoma. The specialist, ancillary provider or facility should coordinate with the member s PCP if additional services are necessary. Please refer to the Quick Reference Guide for the appropriate phone numbers. All physicians (primary care and specialists) For all networks except BlueTraditional, call Blue Cross and Blue Shield of Oklahoma to request authorization for an out-of-network referral. Out-of-network referrals will only be authorized if the service is a covered benefit, is medically necessary and if the service is unavailable within the member s network. How to authorize an in-network referral Refer to the Quick Reference Guide for the appropriate telephone numbers. When you call, you will be required to identify the beginning date of service, ending date of service and the type of service. In addition, the PCP must furnish their 4-digit PCP number and information regarding treatment or diagnostic services to the specialist prior to the referral. Detailed instructions can be found on the Quick Reference: Referral Authorization information sheet. Extending an in-network referral Please refer to the Quick Reference Guide for the appropriate phone numbers. You also may fax a request for an extension. Fax numbers are included in the Quick Reference: Referral Authorization information sheet. You will be required to provide additional clinical information to justify the extension. 9

10 Referrals Section II How to request authorization for an out-of-network referral1313 For any member, call the precertification department and request authorization for an out-ofnetwork referral. Please refer to the Quick Reference Guide for the appropriate phone numbers. Self referral The patient has the right to self-refer. If a member insists on a referral that you believe is inappropriate, you are not obligated to authorize the referral. Advise him or her to call the appropriate customer service number listed on his or her ID card. Failure to authorize referrals Please refer to your contractual agreement with Blue Cross and Blue Shield of Oklahoma for information regarding provider penalties. For services rendered without the proper referral authorization, Blue Cross and Blue Shield of Oklahoma may render payment for such services at the reduced, self-referral benefit level. 10

11 Case Management Section II What is case management? Case management is a program that helps maintain and improve the health and quality of life of our members with catastrophic or chronic illnesses. In this program, case managers (registered nurses) work with providers and members to coordinate care and develop alternative treatment plans to ensure appropriate coverage of medically necessary care and to enhance the treatment of complex or chronic conditions. How does case management work? The case managers review potential cases to determine if case management could have a positive impact on the member. The case managers consider the member s admission history, present diagnosis, comorbidity issues, current setting, any need for multiple providers or services, placement and discharge planning issues and claims history. With the consent of the member, the case manager will work with the member, their family, the treating physician and provider(s) to determine the most appropriate level of care for the patient. A thorough assessment of the patient s health status, knowledge of their condition, living situation, safety issues and cultural needs will be performed to help formulate an individualized case management plan. The case manager will be familiar with benefits available to the member and ensure that services provided make the most effective use of those benefits. Cases that may require special care Conditions that may require case management intervention include, but are not limited to: Cerebrovascular accident requiring long-term rehabilitation Diagnoses requiring hospice care Long-term ventilator-dependent patients Major organ transplants Major trauma Multiple limb amputation Severe burns Severe head/brain injury Spinal cord injury Terminal illnesses Traumatic and degenerative muscular/neurological disorders, i.e., Muscular Dystrophy, Amyotrophic Lateral Sclerosis, Multiple Sclerosis and Guillain-Barre Syndrome 11

12 Case Management Section II Home Health All infusion therapy and nursing visits related to infusion therapy Diagnoses and conditions which require > 7 SNVs Diagnoses and conditions which require QD SNVs or multiple services Who can make a referral? We accept referrals for case management from facilities, providers, members and the member s family. We encourage referral of the member as early as possible, preferably immediately after the initial diagnosis is made. How to submit a referral To make a referral to the Case Management Department, please call the Case Management Department. The phone number is listed in the Quick Reference Guide. 12

13 Quality Assurance/Quality Improvement Section II Quality Improvement (QI) goals The goal of the Quality Assurance/Quality Improvement (QA/QI) Program is to improve and maintain high-quality patient care and services through ongoing monitoring and assessment of the following items: Quality of care and service issues Adequacy of preventive health care services Practitioner satisfaction with Blue Cross and Blue Shield of Oklahoma services Member satisfaction with medical care and services Mechanisms to ensure that cost containment activities do not adversely affect the quality of care provided to members Practitioner compliance with recommended clinical practice guidelines The QA/QI Program also monitors and assesses member and practitioner educational needs which encourage and facilitate their participation in quality improvement activities including disease management/wellness programs. 13

14 Responsibilities of the Plan Section II Responsibilities of Blue Cross and Blue Shield of Oklahoma Qualified staff is properly trained for the Quality Assurance/Quality Improvement (QAQI) program. QA/QI staff is supervised by a licensed physician.. Health care practices are monitored and evaluated for the sole purpose of improving the quality of care and quality of services rendered by participating practitioners. All information obtained by the QA/QI staff is used solely for the purpose of improving member care through quality management. Such information is confidentially maintained and protected. A variety of evaluation methods are used, such as practitioner surveys, member surveys, access studies, medical record reviews and utilization studies. The written Quality Assurance/Quality Improvement program is updated at least annually, including changes in staff responsibilities, new methodologies and approval of revised or new standards. Information is available to practitioners regarding activities of the QA/QI program. We appreciate your willingness to work with us in our Quality Assurance/Quality Improvement program at Blue Cross and Blue Shield of Oklahoma and would be glad to share our annual report with you. This report outlines our goals, processes and outcomes. A copy may be obtained by making a request to: Responsibilities of the provider Paula Root, M.D. Medical Director, Health Care Quality and Policy Blue Cross and Blue Shield of Oklahoma PO Box 3283 Tulsa, OK Supply complete and detailed clinical information to allow Blue Cross and Blue Shield of Oklahoma to make an informed decision Participate in Quality Assurance/Quality Improvement activities, including practitioner surveys and on-site visits. Cooperate with QA/QI staff to provide medical records or other appropriate medical information upon request and in a timely manner. 14

15 Quality monitoring activities Monitoring & Evaluation Methods Section II Monitoring and evaluation are an integral part of the quality program. Ongoing activities monitor and evaluate quality of care, quality of service, member satisfaction and provider satisfaction. Network Practitioner Selection In order to ensure the selection of quality providers, BCBSOK has developed a credentialing and recredentialing process, which includes an appeal procedure for providers who have had a change in network status. The QA department identifies providers who have been found to have quality of care or service issues. These issues are considered at the time of credentialing or recredentialing. Confidentiality is maintained at all times. Practitioner Review and Evaluation Ongoing monitoring and evaluation of practitioners exemplifies the commitment to deliver quality care and services to members. Monitoring and evaluation activities include: Access studies Practitioner profiling and performance evaluation Member satisfaction assessment Preventative health assessment Utilization management studies Focused review studies Practitioner patient safety monitoring Information received and results obtained through these activities are incorporated into the credentialing process. Results of quality improvement studies are shared with providers to facilitate improvement. When deficiencies are identified through monitoring and evaluation activities, a corrective action plan will be implemented. Member Satisfaction Member satisfaction surveys assess satisfaction with services and quality of care. Survey findings are used in the evaluation of the QI program and for identifying practitioner or plan performance issues for improvement or intervention. 15

16 Health management systems Monitoring & Evaluation Methods Section II Preventive Health/Health Promotion Blue Cross and Blue Shield of Oklahoma has a commitment to educating and encouraging its members on preventive health and health promotion. Preventive health issues may be identified through QI monitoring and evaluation studies and member and practitioner surveys. Preventive health standards and guidelines are developed through the Clinical Services committee. Members receive educational material regarding preventive health and are encouraged to use preventive health services and health promotion programs. Health promotion and prevention reminders are included in member newsletters. In addition, members targeted for intervention may receive reminders via letter and/or telephone. Disease Management/Wellness Population based health promotion is a coordinated, proactive and disease-specific approach to patient care that seeks to produce the best clinical outcome and highest member satisfaction in the most efficient manner. Population based programs take a systems approach to care management and span the entire continuum of care, including wellness and prevention, member education, diagnosis and treatment, follow-up care and ongoing health maintenance. Blue Cross and Blue Shield of Oklahoma currently has disease management programs in place for the following: Diabetes Asthma Congestive Heart Failure (CHF) Coronary Artery Disease (CAD) Chronic Obstructive Pulmonary Disease (COPD) Gastro-Esophageal Reflux Disease (GERD) High-Risk Pregnancy Hypertension Migraine Outcome and occurrence reviews Outcome and occurrence review is conducted on an ongoing basis to evaluate potential quality of care concerns involving Blue Cross and Blue Shield of Oklahoma members. Any potential quality of care concern identified throughout the Blue Cross and Blue Shield of Oklahoma network is to be referred to the QA department for evaluation. The QI Coordinators with direction from the Senior Manager of QA/QI and Credentialing and the Senior Supervisor of QA/QI are responsible for performing medical record reviews on all potential quality of care concerns referred to the QA department. Review data is forwarded to the Healthcare Quality and Policy Medical Director for further review. Cases with potential quality of 16

17 care issues are referred to the Peer Review Committee as appropriate. Confidentiality is maintained at all times. 17

18 Patient Access to Care Section II Blue Cross and Blue Shield of Oklahoma access standards1 Routine health evaluation appointments must be available within 30 working days. Sick non-urgent appointments (illness which does not have a sudden onset of symptoms) must be available within five working days. After-hours, physicians are available 24 hours per day, seven days per week with physicians to return patients phone calls within one hour. Urgent appointments (sudden onset of symptoms) must be available within 24 hours, or the patient is referred to urgent care services. After hours, physicians are available 24 hours per day, seven days per week with physicians to return patients phone calls within one hour. In an emergency situation, members should seek care from the nearest facility and call their PCP within 48 hours of the incident to arrange for follow-up care. (Blue Cross and Blue Shield of Oklahoma defines emergency care as treatment for any injury, illness or condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a reasonable and prudent layperson could expect the absence of medical treatment to result in serious jeopardy to the member s health; serious impairment to bodily function; or serious dysfunction of any body organ or part.) (BlueLincs HMO defines emergency care as treatment for any injury, illness or condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a reasonable and prudent layperson could expect the absence of medical treatment to result in serious jeopardy to the member's health; serious impairment to bodily function; or serious dysfunction of any body organ or part) For chronic condition follow-up, an appointment must be available within 30 days. For an initial specialist care referral, an appointment must be available within 14 working days. For an urgent specialist care referral, an appointment must be available within 24 hours. Clinic waiting time should be no longer than one hour. Wait time is measured at the start of the scheduled appointment. Mental health and substance abuse access standards13 Non-urgent appointment (depression and anxiety without profound symptoms) must be available within 5-10 working days. Urgent appointment (affective disorder, which may include homicidal or suicidal ideations) must be available within hours. Immediate treatment must be available in an emergency situation. An emergency situation may be defined as a drug overdose, threat or plan to harm self or others or a psychotic disorder. Non-life threatening emergency treatment must be available within 6 hours. Clinic waiting time should be less than 30 minutes. Wait time is measured at the start of the scheduled appointment time. 18

19 An average of no more than two therapy patients per hour should be treated. Outpatient follow-up after hospitalization within 14 days. 19

20 Provider Standards of Care Section II Medical record-keeping and documentation standards A Provider will ensure that covered services reported on claim forms are supported by documentation in the medial record and adhere to the general principles of medical record documentation including the items listed below: There is an organized medical record filing system. Personal/ biographical data includes the date of birth, sex, marital status, address, employer, and home and work telephone numbers. Every page in the record contains patient s identification. All entries are dated. All entries include author identification (signed or initialed by practitioner). Electronic signatures are acceptable, provided authorization for its use is included in the signature line. Family/social history is noted in the record. The record is legible to the reviewer. Medication allergies, adverse reactions, or no known allergies are prominently noted in the record. For a patient seen three or more times, the past medical history should be noted including serious accidents, operations or illnesses. For members 18 years old or younger, past medical history should include prenatal care, birth, operations and childhood illnesses. A current problem list notes significant illnesses and medical conditions. For patients 12 years and older who have been seen three or more times, the use of cigarettes, alcohol and any substance abuse is noted. Immunization records are current, or a note indicates up-to-date immunizations. A medication list is present. Visit notes include: reason for visit, physical findings, appropriate diagnostic tests and plan of treatment. Notes indicate follow-up care/plans. Unresolved problems are addressed in subsequent visits. Consult, ancillary services, lab, and imaging study reports are initialed by the practitioner. If hospitalized, the record includes operative report (if applicable) and hospital discharge summary. Working diagnoses are consistent with findings. There is evidence of continuity and coordination of care between primary and specialty practitioners. Notes indicate preventive screenings and services that are offered in accordance with Blue Cross and Blue Shield of Oklahoma Preventive Health Guidelines. Physical examination findings. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. 20

21 Provider Standards of Care Section II Behavioral health medical records standards The following standards apply for behavioral health providers: There is an organized medical record and filing system. Personal/biographical data is present and includes the date of birth, sex, marital status, address, employer, home and work telephone numbers. Every page contains patient identification. All entries are dated. Each entry contains author identification (signed or initialed by practitioner). Electronic signatures are acceptable provided authorization for its use is included in the signature line. A family/social history is noted in the record. The medical record is legible to the reviewer. Medication allergies and/or adverse reactions or, if applicable, no known allergies (NKA) are noted. Personal Health History includes complete medical and behavioral health history. Problem list is present and notes significant illnesses and medical conditions. Documentation addresses smoking/etoh/substance abuse of member and family. Medication list is present including initial prescription and refill dates if prescribed by the provider. Visit notes include: history and description of presenting problems, including precipitating factors, mental status evaluation, physical status evaluation if appropriate, psychosocial history including an appropriate developmental history for children and adolescents, risk assessment of severity and possibility of potential harm to self or others accompanied by a referral to a level of care which is appropriate to the level of risk, and appropriate diagnostic tests. Treatment Plan is consistent with diagnoses and includes measurable objectives, estimated time frames and prevention efforts, community resources utilization and current caregivers contacted or involved in treatment (or, if not, so stated in the record). Notes indicate follow-up care/plans including dates of subsequent appointments and when applicable, a complete discharge plan. Unresolved problems are addressed in subsequent visits. Consult, ancillary services, lab, imaging study reports are initialed by the practitioner. If the member is hospitalized, the record will include the hospital discharge summary. Working diagnoses are consistent with findings and appropriate Axis DSM-IV diagnoses are documented. 21

22 Provider Standards of Care Section II There is evidence of continuity and coordination of care between primary and specialty practitioners. Telephone calls are properly documented. No shows for appointments are properly recorded and follow-up rescheduling is initiated by practitioner. There is documented evidence of family member or caregiver involvement in member s treatment. There is documented evidence of family member or caregiver s capacity to care/protect member. 22

23 Types of appeals Appeals and Grievance Procedures Section II Blue Cross and Blue Shield of Oklahoma has established appeals processes to ensure the timely and organized resolution of provider complaints, grievances and appeals. Complaints and grievances are oral expressions of dissatisfaction with utilization review, network status, and/or quality assurance or quality improvement activities. Providers that cannot achieve resolution of a complaint or grievance may file a written appeal. Blue Cross and Blue Shield of Oklahoma has different appeals processes, depending on the type of appeal and how it is generated. 1. Utilization Management Appeals are related to clinical services provided to a Blue Cross and Blue Shield of Oklahoma member. 2. Contractual Inquiries/Appeals are disagreements relating to the provider s contract with Blue Cross and Blue Shield of Oklahoma, which do not fall into one of the other three categories. Appeals in the above categories should be submitted in writing to (unless an expedited appeal, as discussed under paragraph 1B on the following pages): Appeals Coordinator - Customer Service Department Blue Cross and Blue Shield of Oklahoma PO Box 3283 Tulsa, OK Quality Assurance/Quality Improvement Appeals are for pending disciplinary or corrective actions. 4. Network Status Appeals are for a change in network status, network cancellation, or the denial of an application for network participation. These can be for both medical and non-medical reasons. Appeals in the above categories should be submitted in writing to: Paula Root, M.D. Medical Director, Health Care Quality and Policy Blue Cross and Blue Shield of Oklahoma PO Box 3283 Tulsa, OK

24 Appeals and Grievance Procedures Section II 1. Types of Utilization Management appeals There are two types of Utilization Management (UM) appeals available to health care providers serving BlueChoice, BluePreferred or BlueLincs members expedited/urgent care or standard. An appeal is a formal request for review or reconsideration of a determination to reduce or deny a service. Any appeal regarding a medical necessity, experimental or investigational noncertification determination, submitted by a health care provider, will be considered an appeal on behalf of the member. Prior to an appeal, the attending or ordering provider may request a peer-to-peer conversation with the Medical Director, Utilization Management, who made the non-certification decision. The provider may call the Utilization Management Department using the number listed in the Quick Reference Section. The Medical Director, Utilization Management, making the determination or another medical director within the Blue Cross and Blue Shield of Oklahoma family of companies, will be available within one business day to discuss the non-certification decision. If the decision not to certify the requested service is upheld after the conversation, the provider has the option to proceed with an appeal. A. Expedited Appeals An expedited or urgent care appeal is a request, usually by telephone or fax, for an additional review of a determination not to certify a service. The review is conducted by a clinical peer who was not involved in the original decision not to certify and is not the subordinate of the person making the original determination. An expedited appeal applies to urgent care requests. Urgent care requests are defined as any request for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, or in the opinion of a physician with knowledge of the claimant s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. It does not apply to non-urgent or post-service/retrospective requests. Local specialty providers, MCMC and MRI, Inc., are external consultants who may be utilized in the appeal process. A determination will be made within 72 hours of receipt of the request. To initiate an expedited appeal: Call the Utilization Management Department at the number listed in the Quick Reference Section. 24

25 Appeals and Grievance Procedures Section II Have all related clinical information available regarding the denied services including: Patient name Patient ID number Patient reference number if known Date of service Name of facility where services are being rendered, if applicable Name of ordering/attending physician B. Standard Appeals A standard appeal is a request to review a determination not to certify an admission, extension or stay, or other health care service conducted by a peer reviewer who was not involved in any previous non-certification decision nor the subordinate of the peer making the original determination. A standard appeal applies to non-urgent or post-service/retrospective requests. It must be made in writing accompanied by all or applicable parts of the patient s medical record required to perform the review. A statement from the member, attending/ordering physician, or facility is needed to perform the review. Local specialty providers, MCMC and MRI, Inc., are review consultants who may be utilized in the appeal process. Standard appeals may be requested within 180 days from the date of notice of the non-certification determination. A standard appeal request should be submitted to the following address: The written request should include: Appeal Coordinator - Customer Service Department Blue Cross and Blue Shield of Oklahoma P.O. Box 3283 Tulsa, OK Name of the requestor Patient name Patient ID number Patient reference number if known Date of service Name of facility where services are being rendered, if applicable Name of ordering/attending physician Include any documentation, including medical records that you want to become a part of the review file A letter/statement indicating the issue and resolution being sought 25

26 Appeals and Grievance Procedures Section II 2. Contractual inquiries/appeals If a Blue Cross and Blue Shield of Oklahoma participating provider has an inquiry or complaint, which does not fall under one of the other three categories and relates to the provider's contract, an initial attempt should be made to resolve it by communication with the Health Industry Relations Department. If a resolution cannot be reached, a written appeal process is available. A. Inquiry/Complaint An inquiry/complaint is an initial verbal or written communication requesting additional information, confirmation or clarification regarding benefits, pricing, claim adjudication, and/or claims processing guidelines. Responses range from a quick and informal exchange of information to a written response. An inquiry/complaint is not considered an appeal. B. Contractual appeal Contractual appeals can be requested for reconsideration regarding benefits, pricing, claims adjudication, and/or claims processing guidelines. Contractual appeals can be requested for reconsideration regarding benefits, pricing, claims adjudication, and/or claims processing guidelines. All contractual appeals must be submitted in writing. Contractual appeals must be received by Blue Cross and Blue Shield of Oklahoma within one hundred eighty (180) days of the initial claims adjudication date to be considered. The written request should include the following information: Name of the member Member ID number Nature of the complaint Facts upon which the complaint is based Resolution you are seeking Include a CMS 1500 form, copy of the detail of remittance or any documentation (including medical records) that you want to include for consideration. Appeals should be mailed to the Appeals Coordinator at: Appeals Coordinator Customer Service Department Blue Cross and Blue Shield of Oklahoma PO Box 3283 Tulsa, OK

27 Appeals and Grievance Procedures Section II Providers will be notified of a decision for contractual appeals in a timely manner. If the appeal results in additional payment, the provider will be notified on his/her detail of remittance. All other appeal responses will be mailed directly to the provider. C. Executive Mediation If the dispute has not been resolved to the provider s satisfaction, the parties shall attempt in good faith to resolve the dispute by negotiation between executives who have authority to settle the controversy and who are at a higher level of management than the persons with direct responsibility for administration of this Agreement who have not already reviewed the matter. Any party may give the other party written notice of the unresolved dispute. Within fifteen (15) days after delivery of the notice, the receiving party shall submit to the other a written response. The notice and the response shall include (A) a statement of each party s position, and (B) the name and title of the executive who will represent that party and of any other person who will accompany the executive. Within thirty (30) days after delivery of the disputing party s notice, the executives of both parties shall meet at the mutually acceptable time and place, and thereafter as often as they reasonably deem necessary, to attempt to resolve the dispute. All reasonable requests for information made by one party to the other will be honored. All negotiations pursuant to this paragraph are confidential and shall be treated as compromise and settlement negotiations for purposes of applicable rules of evidence. D. Binding Arbitration After exhaustion of the provider contractual complaint inquiries and appeals process and the executive mediation process as outlined above, if the issue has not been resolved to both parties satisfaction, either party may request that the issue be submitted to binding arbitration. Notice of a demand for arbitration shall be sent in writing to the other party no later than six (6) months after conclusion of the executive mediation process above. Failure to send notice within the aforementioned time shall result in the other party being entitled to object to submission of the matter to arbitration. Such binding arbitration shall be conducted in Tulsa, Oklahoma, by a single arbitrator in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration. The arbitrator shall be selected by agreement of the parties from a list of arbitrators provided by the American Health Lawyers Association Alternative Dispute Resolution Service. Unless otherwise determined by the arbitrator, the arbitration fees shall be shared equally by the parties, and each party shall pay its own attorney s fees and other costs associated with the arbitration. 27

28 Appeals and Grievance Procedures Section II To the extent of the subject matter of the arbitration, the determination of the arbitrator shall be binding not only on the parties to this agreement, but also on any other entity controlled by or in control of or under common control with the party, to the extent that such affiliate joins in the arbitration. Judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. 3. Quality Assurance/Quality Improvement appeals Policy Blue Cross and Blue Shield of Oklahoma has established a process to ensure the timely and organized resolution of provider (both individual and institutional) complaints, grievances, and appeals related to Quality Improvement (QI) activities that may result in a change in network status. Definition Blue Cross and Blue Shield of Oklahoma defines a complaint as an oral expression of dissatisfaction with health network services. A grievance is defined as a formal, written expression of dissatisfaction with health network services. Any oral or written expression of a misunderstanding or dissatisfaction regarding a QI activity will follow the complaint/grievance/ appeal process as outlined in this manual. Provider contracts stipulate that a provider may have a change in network status at any time for cause. This network procedure becomes effective when the provider is served with a written notice of the cause prompting the network status change, including termination. The definition of cause includes, but is not limited to: Failure to comply with quality improvement, peer review and/or utilization review procedures, except in medical emergencies; Failure to meet or maintain Blue Cross and Blue Shield of Oklahoma credentialing criteria; Unprofessional conduct as determined by the appropriate state professional licensing agency; Filing false claims; Conviction for any criminal offense; and Conflict of interest between practitioner and Blue Cross and Blue Shield of Oklahoma as determined by Federal and State laws and regulations. 28

29 Appeals and Grievance Procedures Section II Procedure When an oral complaint is received by phone call or written grievance directed to the Medical Director of Health Care Quality and Policy regarding a QI activity that resulted in a recommendation to the Credentialing Committee for provider suspension/cancellation/termination, the provider is informed that Blue Cross and Blue Shield of Oklahoma has an appeals process for clinical quality complaints and grievances. All relevant provider information and QA file will be compiled, and the appeals process will proceed as outlined below: Level 1 Peer Review Committee-East or West review is initiated when a provider appeals the network status change imposed as mentioned above. Providers may request that the relevant files and supporting documentation, including any member personal statements, be reviewed by the Peer Review Committee. Providers are required to submit a written request for Peer Review Committee review. At least one participating provider, not involved with Plan management or a previous review of that case and who is a clinical peer of the provider filing the appeal (if the appeal is clinical in nature), will be involved. If the Peer Review Committee upholds the denial, the provider may request in writing, the appeal be reviewed by the Level Two Committee. Level 2 Peer Review Committee-East or West or Utilization Management Committee is available when the decision of the Level One committee is unacceptable to the provider. Providers may appeal, in writing, directly to the Level Two Review Committee within 30 days from the date of the receipt of the first Peer Review Committee s decision letter. All relevant files and supporting documentation, including any member personal statements, and any new information will be reviewed by the Level Two Committee. At least one participating provider, not involved with Plan management, and who is a clinical peer of the provider filing the appeal (if the appeal is clinical in nature) and not involved with the Level One appeal, will participate in the Level Two process. If the provider requests a personal appearance before the committee, the following guidelines will be utilized: 1. The Chairperson will notify the provider of the time, date and place for his/her appearance before the Committee. The provider will be notified of this meeting by Certified Mail Return Receipt Requested. 2. At the meeting, the Chairperson will take no more than 5 minutes to introduce the provider and give a brief explanation of the appearance. 3. The provider will be given 10 minutes to present his/her appeal. 4. The committee members will be given 10 minutes to ask questions. 29

30 5. After the questioning period is completed, the provider will be dismissed and the committee will discuss the issue, and then make a decision/determination. 6. The provider will be notified by Certified Mail Return Receipt Requested, within 10 working days of the committee s decision. The decision will be final. The appropriate departments involved with the complaint/grievance/appeal will also be notified of the decision. All QA/QI appeals are to be sent to: 4. Network status appeals Paula Root, M.D. Medical Director, Health Care Quality and Policy PO Box 3283 Tulsa, OK Blue Cross and Blue Shield of Oklahoma has developed an appeals process for all providers whose network contract(s) are cancelled for either a medical or non-medical reason. Providers who are denied acceptance in a network by the Credentialing Committee also have access to this appeals process. A. Credentialing (Network Status) Appeals If the Credentialing Committee initiates the network cancellation, or if a provider is denied access in a network, the provider should submit his/her appeal to the Credentialing Committee Chair. The appeal will be processed as follows: Written Appeals All appeals should be made in writing and submitted to the Credentialing Committee Chair within sixty (60) days of receipt of the denial notice. The Credentialing Committee Chair will ask the Credentialing Committee to review its earlier decision. If the original decision is overturned the provider will be notified within sixty (60) days of the decision. Level 1 The Peer Review Committee (East or West) will review the written appeal, all additional submitted information and Credentialing file deficiencies. The Committee may overturn the original Credentialing Committee decision; however, if the denial/cancellation cannot be overturned, the appeal is forwarded to the Peer Review Committee (East or West) for Level Two review. At least one participating provider, not involved with Plan management, and who is a clinical peer of the provider filing the appeal (if the appeal is clinical in nature) and not involved with the Written Appeal, will participate in the Level One process. The Credentialing Committee Chair will notify the provider within thirty (30) days of the Peer Review Committee's decision. 30