MOUNTAIN STATE BLUE CROSS BLUE SHIELD NETWORK CREDENTIALING POLICY & PROCEDURE

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1 TITLE: Ongoing Review and Monitoring of Sanctioning Information, Medicare Opt-Out, Quality Issues and Complaints No: CR-015 Supersedes No: N/A Original Effective Date: 06/20/05 Date Of Last Revision: 07/22/09 Related Policies: CR-013 CR-014 CR-016 QM-023 DRAFT ( ) INTERIM ( ) FINAL ( X ) Networks and Lines of Business: Page 1 of 5 PPO (X) POS (X) POLICY: PURPOSE: PROCEDURES: All applicable medical, dental, and behavioral health practitioners/providers that are 1) debarred or opt-out of or are precluded from government programs (e.g., CMS, FEHBP, OMAP etc.), 2) identified as having sanctions or limitations on their licensure, and/or 3) identified as having quality issues/complaints, are to be addressed by the Plan in accordance with the guidelines set forth by all regulatory/accrediting bodies and applicable Plan policies and procedures. On-going monitoring of sanctions, quality issues, adverse events and complaints ensures that the Plan identifies, and when appropriate, acts on important quality and/or safety issues in a timely manner during the interval between recredentialing cycles to ensure that the integrity and quality of the network is maintained at the highest level and that the plan is in compliance with external regulatory and accrediting requirements. The following procedures will be followed related to the ongoing review and monitoring mechanisms for sanctioning, quality issues, adverse events and complaints information: A. Medicare/Medicaid Sanctioned and Debarred Practitioners/Providers: Debarment refers to exclusion from participation in, and receipt of payment from, government programs due to fraud, abuse, failure to repay loans, etc. The following procedure is to be utilized for debarred practitioners/providers and those practitioners/providers who are identified on the monthly government debarred and reinstated report: 1. On a monthly basis, correspondence relative to debarred practitioners/providers is received from: a). The U.S. Office of Personnel Management/Office of the Inspector General (OPM/OIG), b). Xact Medicare website, c). Office of Medical Assistance, d). Federal Register Correspondence will be obtained by the designated business analyst in the Provider Data Services (PDS) department. 2. The lists/reports will be reviewed within 30 calendar days of publication and compared, by the PDS business analyst, to the practitioners/providers listed in the Highmark Consolidated

2 No: CR-015 Page 2 of 5 Credentialing Component (HC3) database and the CPR provider file. This review is to be completed within five (5) working days of receipt of the information in the PDS department. 3. PDS staff electronically notifies the Manager of Network Credentialing (Attachment A). 4. In the event that a network participating practitioner/provider is identified on the listing: a. The matter will be addressed by the Manager of Network Credentialing with the Director of Health Services and the applicable Medical Director. b. The identified practitioner/provider will be notified in writing by the Medical Director as to his/her immediate termination status (Refer to separate policy titled: Professional Network Provider Denial and Termination Policy ). c. A copy of the corresponding page from the report from the government agency, along with a cover explanatory memo, will be forwarded from the Credentials area to the appropriate Plan internal departments including, but not limited to: Provider Relations, PDS, Provider Claims, Provider Contracts, Medical Directors Vice-President of Health Services, Care/Case Management (when applicable), and Member Service Departments to ensure that the practitioner is terminated in the database or that any contracting activity is discontinued. In addition, it is imperative that claims are not processed for reimbursement to these practitioners/providers. d. A binder/file will be maintained by the Manager of Network Credentialing and/or a designee, which includes a copy of the correspondence noting the debarred practitioner/provider and the correspondence/memo noting the outcome of the review. This binder/file will be kept current and up to date and will be on file in the Credentials Department. (Refer to Attachment A). e. The information relative to network debarred practitioners/providers, and any action taken, will be updated in the CPR database (sanction tab). 5. If no network practitioners/providers are identified on the report the PDS Business Analyst will generate a follow-up memo indicating this information to the file, and any appropriate departments, indicating the source of the listing, that the listing has been reviewed, and that the listing does not indicate that any practitioners/providers have been debarred. This file memo will be signed/initialed by the individual conducting the review, and will reference the review date, the document(s) reviewed and the outcome of the review. B. Government Opt-Out Practitioners/Providers Opt-out refers to practitioners/providers who elect not to participate in any Centers for Medicare and Medicaid Services (CMS) programs. As a result, they are not eligible for reimbursement from CMS. The following procedure is to be utilized for practitioners/providers who opt-out of government programs:

3 No: CR-015 Page 3 of 5 1. Initial Credentialing A query of both the 1) Medicare Xact Website to determine OPT-OUT status and 2) the mail or Internet link to the Superintendent of Documents for the UPIN number or Medicare welcome letter will be made by PDS following completion of the credentialing process and prior to finalization of the contracting process. 2. In-Network Participants On a quarterly basis, PDS will query the Medicare Xact Website for updated information on practitioners who have opted out of the Medicare Program. A PDS analyst compares the names with the CPR Database to determine active participation in Medicare Advantage Networks. Any practitioners identified as active participants in Medicare Advantage Networks will be immediately terminated from network participation for Senior products only by the PDS analyst. A checklist will be completed and forwarded to the Manager of Network Credentialing. 3. Reinstatement to Medicare Government Program If the practitioner/provider has been reinstated with regard to the government programs, he or she may then make application to the applicable network in accordance with the policies outlined in the Highmark Credentials Policy and Procedure Manual. The process is operationalized by PDS, who is fully accountable for compliance with this policy and all applicable CMS regulations. C. Sanctions and Limitations on Licensure The following process will be utilized: 1. Disciplinary Action Report On a monthly basis, an electronic disciplinary action report from the all contiguous states to West Virginia State Licensing Board will be compared to the CPR database by the Provider Data Services staff. A listing of current network participating practitioners identified by that comparison is generated by PDS. That listing will be shared with the Manager of Network Credentialing. All practitioners with disciplinary actions are referred to the Medical Director for appropriate actions, as detailed in separate policies, when indicated. The process is completed within thirty days of the distribution of the report from the state licensing board. All current network practitioners whose licenses are suspended, revoked or surrendered are immediately terminated in CPR by a Internal Provider Relations or PDS staff member. Any practitioner whose license was suspended for longer than a thirty-day period and whose license has been reinstated must reapply to the network as an initial applicant. In the event of a termination the Medical Director will send a letter of termination notification to the practitioner which will include his/her right to appeal. If a practitioner wishes to appeal the current decision, they must submit their appeal in writing within 30 days of receipt of the termination letter. Any practitioner whose license was suspended for less than thirty-days for an infraction that was administrative in nature (i.e., payment of a license fee) and has a current and active license will have the termination date in CPR removed and a sanction flag assigned by a PDS staff member.

4 No: CR-015 Page 4 of 5 This sanction flag will be removed at the discretion of the Network Credentialing Specialist at the time of recredentialing. Any network practitioner identified on the listing for any reason other than the above mentioned license issues requiring a termination will be assigned a credentialing review indicator in CPR by the PDS staff. This flag will be removed at the discretion of the Network Credentialing Specialist at the time of recredentialing. 2. Newspaper Clippings The PDS staff will maintain responsibility for the monitoring of newspaper clippings weekly from the Press Clipping Service and monthly disciplinary action reports from the State Licensing Board. A credentialing review indicator is added in CPR to all network participating practitioners identified in newspaper clippings. PDS staff notifies the Manager of Network Credentialing of the existence of the newspaper article. Clippings are reviewed for network practitioners and referred to the Medical Director when adverse information is reported (i.e., malpractice settlements or actions, arrests, and various sanctions). The Medical Director will initiate further investigation which could lead to a possible termination action as detailed in a separate policy, when applicable. In the event that there is no need for medical director action, the information is maintained in the credentialing file for additional investigation at the time of the recredentialing review. D. Complaints/Quality Issues and/or Adverse Events The Specialists within the Network Credentialing department receive member complaint information electronically on a daily basis. Through a formal process the complaints are further investigated by professional nurses for potential quality of care issues. When indicated, medical records are obtained. When Quality of Care issues are identified, Medical Directors are consulted and appropriate interventions, as referenced in the above policy, are implemented. If a true quality of care complaint is determined to be moderate or severe in nature by a Medical Director, the issue is referred to the Medical Advisory Committee for further review. If the Medical Advisory Committee agrees that there is a true quality of care issue, the practitioner is notified by the Medical Director, which could include Corrective Action. All complaints, whether true quality of care or not quality of care in nature, are entered into the Member Dissatisfaction Tracking (MDT) database for tracking and trending. At the time of recredentialing the Network Credentialing Specialists will review the provider s quality files for complaints or quality referrals from the previous three years. All practitioners with at least one true quality of care case or six or more track and trend cases are reviewed by the Medical Director for possible inclusion on the Credentials Committee exception listing. All practitioners with 20 or more complaints over the previous three years or from the date of the last credentialing will automatically be presented to the Credentials Committee, for review as an exception. The process for incorporation of complaints into the recredentialing process is described in further detail in CR Policy titled: Incorporation of Quality of Care Information and Performance Data into the Recredentialing Process.

5 No: CR-015 Page 5 of 5 E. Implementing Appropriate Interventions where Instances of Poor Quality Identified Each of the sections above identify steps that can be taken when appropriate. When instances of poor quality are identified, the details of the available actions/interventions are described in separate CR policies titled: Professional Network Provider Corrective Action Policy and Professional Network Provider Denial and Termination Policy.

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