Appendix A PC NAME READINESS ASSESSMENT TOOL CONTRACT YEAR ENDING Conducted by:

Transcription

1 Appendix A PC NAME READINESS ASSESSMENT TOOL CONTRACT YEAR ENDING 2007 Conducted by: Division of Health Care Management, Information Services Division, Office of Administrative Legal Services

2 Table of Contents ADMINISTRATION AND MANAGEMENT... 3 BEHAVIORAL HEALTH... 5 CASE MANAGEMENT... 7 DELIVERY SYSTEM MEDICAL MANAGEMENT QUALITY MANAGEMENT MEMBER SERVICES CLAIMS PROCESSING ENCOUNTER REPORTING FINANCIAL REPORTING, INITIAL CAPITALIZATION, PERFORMANCE BOND REQUIREMENTS GRIEVANCE SYSTEM PHYSICAL PLANT MANAGEMENT INFORMATION SYSTEMS

3 ADMINISTRATION AND MANAGEMENT AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Review minimum staffing requirements Plan Administrator/CEO Medical Director Chief Financial Officer QM/UM Coordinator Provider Services Manager Provider Services Staff Case Management Administrator Case Management Staff Claims Administrator Claims Processors Grievance Coordinator Behavioral Health Coordinator Prior Authorization Staff Compliance Officer Concurrent Review Staff Page 3

4 Encounter Processors Clerical Staff Review hiring strategy and plans for staffing orientation Review staffing qualification vs. RFP requirements Review job descriptions of key staff positions Review management reporting functions as it relates to ALTCS Review Program Contractor's organizational chart Review plans for policy development and implementation. Identify required policies. Review PC Website to determine compliance With AHCCCS standards Review marketing plans and policies Review HIPAA compliance program Review compliance with Medicaid Managed Care requirements C=critical D=done P=pending N=no action Page 4

5 BEHAVIORAL HEALTH AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Review policies and procedures related to behavioral health: Behavioral health referral process Coordination of care Quarterly consultations with a Behavioral Health Professional EPSDT Monitoring/Oversight of behavioral health service delivery (QM) Review the behavioral health provider network to assess network sufficiency (related to all settings): Emergency services Children s services Adult services Review the program contractor s plan for training and educating case managers and providers (e.g. PCPs) in the identification of behavioral health needs. Review the program contractor s plan for training and educating case managers and providers (e.g. PCPs) on how to obtain behavioral health services for their members. Page 5

6 Determine that a mechanism is in place to allow the Behavioral Health Coordinator to consult with the Medical Director, psychiatric consultant and contracted behavioral health provider C=critical D=done P=pending N=no action Page 6

7 CASE MANAGEMENT AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Review the Support Structure for Case Management PC timetable for hiring qualified case managers, including minimum number needed. Supervision, including what ratio to CMs will be Support staff Reporting structure Review case management policies and procedures Roles & responsibilities of case managers Initial contact and visit (timeframes) Assignment of new case and/or transfer of case to other CM in same agency Needs assessment & care planning Cost Effectiveness Study Placement/service planning Contingency Planning/Service Gaps Service plan monitoring & reassessment Notices of Action Ventilator dependent Page 7

8 Behavioral Health Transitional Program BH Reinsurance Skilled Nursing Needs EVALUATION ELEMENT C D P N COMMENTS Case file documentation, including uniform system of tracking services Member transitions (use of MCR/PCCR) Service closure Abuse & neglect reporting Review case manager orientation/training plan, materials and schedule (new case managers) General overview of AHCCCS/ALTCS program ALTCS services and settings Contractor s provider network Interface with PCP Person-centered philosophy (choice, dignity, etc.) Most integrated/least restrictive setting Member rights & responsibilities AHCCCS case management policies (AMPM Ch. 1600) Contractor case management procedures Community resources (Non-ALTCS services) Monitoring for and reporting of quality of care/service issues, interaction with Quality Mgmt General social service information (e.g., family dynamics, difficult people, managed risk agreements) General medical information (e.g., conditions and treatments common to ALTCS population) Page 8

9 General behavioral health information (e.g., how to identify BH needs and access services) PASARR EPSDT standards ALTCS management information system (CATS), including timeframes Review case manager training plan/schedule for regular ongoing training (established case managers) Review proposed methods for ongoing training Tentative schedule and topics Caseload Management Review hiring plan for management of case management ratios Plan for assignment of special populations Review Accessibility requirements Availability of staff to members, including system of back-up case managers CM beepers, cell phones, numbers, phone messaging, receptionist for messages, etc. Review case management monitoring plans For new case managers For established case managers Quarterly audits and analysis of aggregated data Plans for continuous process improvement C=critical D=done P=pending N=no action Page 9

10 DELIVERY SYSTEM AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Review plans for orienting new providers to Program Contractor and AHCCCS policies, including fraud and abuse, PCP roles/responsibilities Review the Program Contractor's provider manual and its distribution plan (ensure contact numbers for providers are present) Review Program Contractor strategy to monitor own telephone accessibility to providers Review Program Contractor s transportation policy and procedure Review Program Contractor's policy and procedures to monitor appointment availability, in-office waiting times, and transportation wait times (corrective action plans for non-compliance) Review Program Contractor's proposed network against its actual contracted network (Note: Signed contracts must be reviewed and random phone confirmations made) Review Program Contractor's policies and procedures on: Ongoing Monitoring Site visits/audits Corrective Action Plans Page 10

11 Review Program Contractor's process for provider registration Review minimum GSA-specific network capacity requirements (See attached network assessment tools) Review compliance with subcontract requirements Evaluation of subcontractor s ability Written agreement specifies activities and reporting requirements Program Contractor monitoring Corrective action Termination of delegation Review specialty network to determine if adequate (Note TBI and BH Homes, ALH, ALC, and capacity) Review Program Contractor's network development plan and types of contracts Review gap reporting process Review process for reviewing network gaps Review process for the loss of a major provider C=critical D=done P=pending N=no action Page 11

12 MEDICAL MANAGEMENT AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Contractual agreement between Health Plan and Medical Director or designee meets criteria and defines Medical Director responsibilities. There is no financial incentive to the Medical Director for limiting any services or access to services Medical Director s Curriculum Vitae (CV) or resume demonstrates experience in Long Term Care. Medical Director time allocation is adequate for the plan, and includes after hours availability for consultation as needed. Evaluation of Medical Director role in : Prior Authorization Concurrent Review Utilization Management Policy Development Communication with the provider network, including provider education, in-service training and health plan orientation Provider recruitment Provider profiling Administration of all Medical Management Activities Development and implementation of the Medical Management Plan Oversight of Medical Management committee and data reporting The Health Plan has appointed a designated back-up Medical Director Page 12

13 The Health Plan has an orientation for the Medical Director and back-up Medical Director that is comprehensive and includes all the regulatory and contractual commitments of the Health Plan. The Health Plan has developed a written Medical Management Plan that addresses its plan for monitoring Medical Management activities The Health Plan has policies and procedures for managing transplant and catastrophic cases to AHCCCS. The Health Plan has a process for identifying members who qualify for Catastrophic, Transplant or Inpatient Reinsurance. Care is coordinated for these members to assure quality outcomes and care coordination. The Health Plan has a process for authorization of Transplant services which is in compliance with the AHCCCS policy manual, and reflects an individual caseby-case review of the member s condition The Health Plan has implemented procedures for utilization management program requirements, which are consistent with AHCCCS standards, including reporting activities through the Medical Management Committee. The Health Plan has a process identified for review of utilization data that reports trends, variances, analysis/ evaluation, interventions through the Medical Management Committee. The Health Plan can identify the reports that will be utilized in data review and trending. The Health Plan has a process for monitoring both over and under utilization. The Health Plan has a process for identifying and intervening on member or provider profiling data that demonstrates a variance. The Health Plan has written policies and procedures for utilization management program requirements, which are consistent with AHCCCS standards. The Health Plan has a process for adoption and dissemination of practice guidelines that include the following elements: Are based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field Consider the needs of the Health Plan s members Page 13

14 Are adopted in consultation with contracting health care professionals process for periodic review and updates Provides a basis for utilization decisions and member education and service coverage The process includes a process for updating existing providers as well as any new providers and members upon request The Health Plan has a policy and process for review of new technologies, the application of existing technologies to new uses. The new technology process includes both a mechanism for committee review on a quarterly basis and a process for review based on an immediate request. The Health Plan has a structure and process in place for the prior authorization (PA) of requested medical services The Health Plan has a structure and process in place to monitor/evaluate prior authorization services. The Health Plan has adopted standardized criteria in making prior authorization decisions. The Health Plan has a process for obtaining relevant clinical information when making prior authorization decisions. The Health Plan has a process for consulting with the requesting provider or a qualified health care provider when additional information is required to make a service authorization decision. The Health Plan has developed and implemented policies and procedures regarding prior authorization inter-rater reliability and monitoring processes to evaluate the consistency with which individuals, involved in PA decision making, apply the established criteria The Health Plan has a policy in place for timelines when making the initial prior authorization decision. Page 14

15 The Health Plan policy meets or exceeds the BBA requirement that all standard prior authorization decisions are made within 14 days for a standard request and 3 days for an urgent request and notifies the appropriate parties (requesting provider and member) of the outcome of the decision. The Health Plan has a process for issuing an Extension Notice letter when either the member requests an extension in making a service authorization decision, or if the Health Plan requires further information in order to make a decision, up to 14 additional days (total of 28 days). The Health Plan has a process for providing the member written notice of the reason for the decision to extend the time frame. The Health Plan has a process for providing the member with written notice that for service authorization decisions not reached within 14 days, the authorization shall be considered denied on the date that the time frame expires. The Health Plan has a process to ensure that the individuals who make decisions on grievances and appeals are appropriately qualified and the reviewer was not involved in the initial decision. The Health Plan has mechanisms in place to evaluate the timeliness of the initial PA decision. The Health Plan has a process for taking action when timeframes for making the initial decision are not being met. The Health Plan has a process for providing prior authorization 24 hours/ day, 7 days/week. The Health Plan has a delegated agreement with a Pharmacy Benefit Manager that meets AHCCCS standards. The Health Plan has a process for monitoring the summary information that describes the cost and utilization of pharmacy services to allow the Health Plan to adequately manage its prescription benefit program. Page 15

16 The Health Plan has criteria in place for the review of requests for non-formulary medications along with established timelines for making the initial decision regarding requests for non-formulary medications. The Health Plan has a structure and process to provide members with Notices of Action. The Health Plan s Prior Authorization (PA) Denial policy covers Notices of Action. Member s right to notice of action is accurately described in the Utilization Management Policy. The Health Plan s Notice of Action forms contain all required components. The action taken by the Health Plan The reasons for the action The member s right to file an appeal The procedures for exercising the right to appeal The circumstances under which expedited resolution is available The member s right to have benefits continue, how to request continuation and the circumstances under which the member may be required to pay the cost of services Member s right to file an appeal. Procedures for filing an appeal, requesting a state fair hearing, and expedited appeals Availability of assistance from the Health Plan to file an appeal. The Health Plan s written notice of the extension includes: The reason for the decision to extend the time frame The length of the extension The member s right to file a grievance if the member disagrees with the decision. The Health Plan has a process in place for reviewing the medical necessity of inpatient stays. Page 16

17 The Health Plan has standardized criteria for length of stay determinations. The Health Plan has policies that describe what relevant clinical information is to be obtained when making hospital length of stay decisions. The Health Plan has a process by which the Medical Director or physician designee will be responsible for making hospital stay denial decisions. Mechanisms are identified to evaluate the consistency with which individuals involved in decision making apply the standardized criteria. (Inter-rater reliability for concurrent review staff including the Medical Director). The Health Plan has a mechanism for taking action when criteria are not being applied in a consistent manner. The Health Plan has a process in place to conduct concurrent review on-site or telephonically. The Health Plan has a process by which a Chronic Care/ Disease Management program will be developed. The process includes the following elements: Identification of a condition/ disease based on criteria that either defines the condition as high risk, high utilization or high cost. A method for intervention that includes case management, providers and community resources A method to evaluate intervention efficacy A method to measure outcomes C=critical D=done P=pending N=no action Page 17

18 QUALITY MANAGEMENT AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Review QM/UM Staffing Sufficient staff /positions with appropriate qualifications Review monitoring and evaluation of ALTCS services and sites including specific tools Service Sites Nursing Facilities Assisted Living Centers and Homes Behavioral Health Group Homes Developmental Disabilities Group Homes (if applicable) Services: Transportation services DME/Supply services Home Delivered Meal services Adult Day Health Care services HHC-Nurse-aide services Attendant care, housekeeping, personal care services Page 18

19 Review implementation of actions to improve care including identifying specific types of problems and types of actions Education Follow-up monitoring, evaluation and improvement Changes in processes, structures, forms Informal counseling/termination Review communication plan between QM and other departments, AHCCCS, Contractors, APS/CPS, and/or regulatory boards/agencies Review QM Committee membership QM Committee functions Determine Executive Management involvement in the QM process and any delegation of functions Determine procedures for documenting QM activities Review the Program Contractor's Credentialing, Initial, Provisional, and Recredentialing processes Written policy and procedures Physician credentialing process Allied health professional credentialling process Verification of qualifications & licensure of other providers Review Medical Records policy/procedure and plans for implementation Determine readiness for providing EPSDT services. Staff positions responsible and accountable System activities to monitor EPSDT o o Tracking EPSDT/database/ system Electronic possibilities for data collection Page 19

20 o Provider and member Handbooks Outreach Developmental screenings/oral health Review plan to develop quality performance measures and data collection process---data must reflect the product line specific to ALTCS whether statistically significant or not. HCBS Initiation of Services Performance Measures Diabetes Performance Measures (HbA1c, Retinal, and Lipids) EPSDT Performance Measures C=critical D=done P=pending N=no action Page 20

21 MEMBER SERVICES AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Review role of member service representatives in ALTCS Member's freedom of choice Review PCP Assignment policies and procedures Review PCP Change policy and procedures Review information packet sent to new members Review Program Contractor's policy and procedures for distributing information to its members Review Program Contractor's communication with its members Telephone accessibility (24 hrs) In person accessibility Bilingual staff (if applicable) AHCCCS approved Member Handbook & distribution plan Written communication produced in English & Spanish (if applicable) Review policy and procedures for communicating program changes notification to members Review plans for providing translation/interpreting services to non-english speaking members Page 21

22 Review plans for providing interpreting services to hearing impaired members Review policies/procedures on handling member grievances (complaints) C=critical D=done P=pending N=no action Page 22

23 CLAIMS PROCESSING AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Perform walkthrough of claims processing system from receipt in the mail room to actual payment of claim, as evidenced by check or voucher generated or entry into general ledger system, noting the following during this walkthrough: Claims preparation (opening mail to data entry) Length of processing cycle Internal controls (control number assigned, batched number, log-in) Frequency of processing cycle Data entry Security (passwords) Reference materials Capacity Edits Systems technical support Claims requiring PA Staffing Adjudication Pended claims Disaster recovery plan Override capabilities /security levels Retention Service limits Functions performed manually vs. automated Page 23

24 Review adequacy of staffing of claims processing area, noting the following: Number of claims processors Experience Training Available reference materials (Desk level, etc.). Review claims medical review requirements noting: How these are incorporated into the automated system Length of time needed for med review Capacity for med review Ability to bypass med review if backlogged Standards Outlier Unique scenarios Authorization triggered Procedure/service based Review prior authorization requirements noting: How these are incorporated into the automated system Ability to override Review and determine adequacy of ability to manually adjust claims noting controls over this process. Clean Claim Date Voids Security Claim vs. line Internally/Externally Initiated Audit Trails Review and determine adequacy of process for clearing pended claims noting the following: Overrides Timing Use of claims correction letter Electronic Billing Page 24

25 Review and adequacy of remittance advice noting the following: Reason for denials are indicated and are clear Instructions are indicated for resubmittal Adjustments Timeframes for resubmittal are indicated Payment methodology is clear Internal Retention/Availability Review adequacy of how the various payment strategies are accounted for: Discounts FFS claims Capitated arrangements Outliers Negotiated Rates Grievance Settlements Medicare/TPL Review post processing review of claims, noting at least the following are present: Independent from claims processing Performed timely and regularly Review audit trail and production reports generated from processing claims and determine adequacy. Review adequacy of provider assistance/training with respect to submittal of claims. Review and determine adequacy of plan to adjust capacity to process claims as membership in the Program Contractor grows. Conclude as to the Program Contractors ability to pay claims in a 1-2 page summation of key findings and final assessment. Page 25

26 Reinsurance EVALUATION ELEMENT C D P N COMMENTS Review adequacy of staffing of reinsurance processing area, noting the following: Number of staff Experience Training Available reference materials Communication links to encounters Review tracking procedures and processes Review and determine adequacy of ability to adjust reinsurance associated encounters Review and determine adequacy of process for clearing pended reinsurance associated encounters Review internal procedures and processes intended to ensure timely submission of reinsurance encounters Review tracking and submission processes for catastrophic reinsurance Review tracking and submission process for high cost Behavioral Health/TBI C=critical D=done P=pending N=no action Page 26

27 ENCOUNTER REPORTING AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: STAFFING EVALUATION ELEMENT C D P N COMMENTS Program Contractor has adequate staff and infrastructure to submit new encounters and correct pended encounters within prescribed timelines. Program Contractor has staff person with necessary authority to direct the timely and accurate submission of encounter data and to resolve data quality issues identified by AHCCCS POLICIES/PROCEDURES Program Contractor has written policies and procedures ensuring that all claims are accurately and timely encountered to AHCCCS. Program Contractor has written policies and procedures regarding file and report submission and retrieval. Program Contractor has written policies and procedures regarding timely submission of encounters within 240 days. Program Contractor has written policies and procedures regarding correction of pended encounters. Page 27

28 The Program Contractor s policies and procedures include Encounter Manual and Companion Guide requirements. Policies and procedures are reviewed at least annually and updated as needed. MANAGEMENT REPORTING Program Contractor has summary reports which track: Encounter volume submissions Outcomes (approved encounters, pended encounters; % pends) ENCOUNTER TEST AND PRODUCTION The Program Contractor ha s a timeline for encounter test and production Test plan and timelines will be completed prior to October (test plan includes new day and pend error correction processes) Implementation in production does not occur prior to successful completion of test plan Completion of test plan must be no later than 3 months following the start of the contract year, i.e., December 31st. Therefore, production file submission must begin in January. ENCOUNTER VENDOR CONTRACTS If Program Contractor subcontracts encounter submissions to an outside vendor, contract specifies: Vendor has responsibility for submissions of all encounters for services which occur during contract period, even after termination of contract. Page 28

29 Vendor must adhere to all AHCCCS data submissions, testing and correction requirements. C=critical D=done P=pending N=no action Page 29

30 FINANCIAL REPORTING, INITIAL CAPITALIZATION, PERFORMANCE BOND REQUIREMENTS AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Review support staff requirements Compare to organization chart in the RFP Review of IBNR calculation methods Review of RBUC calculation methods Review of cost allocation methods Review the Program Contractor's financial reporting requirements policy and procedures Determine plans for compliance with Reporting Guide monthly, quarterly reporting; audit, and FY end (assume quarterly for now) Determine plans for monitoring internal viability (solvency) Verify initial capitalization (15 days after contract award) Review status of performance bond Type Source In place by 10/1/00 (15 days after AHCCCS notifies PC of amount) C=critical D=done P=pending N=no action Page 30

31 GRIEVANCE SYSTEM AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Determine if the Program Contractor's grievance system policy and procedures meets AHCCCS and CY 07 RFP requirements Review the following: Documentation Acknowledgement letters Notice of Appeal Resolution/Notice of Decision Logs Communication of: Member grievance rights Member appeal rights Provider claim disputes rights Tracking/Trending/Reporting Review Grievance, Appeals and Claim Dispute language in: Member handbook Provider Manual Provider contracts C=critical D=done P=pending N=no action Page 31

32 PHYSICAL PLANT AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Determine readiness of physical environment Contract/Lease Agreement Staff space requirements Determine office equipment and furniture requirements Copy machine(s) Fax machine Computers (PC) Printers/typewriters Furniture Telephone Systems Telephone lines operative (# of lines) Telephone numbers published & available to Members Providers AHCCCS Review plans to train personnel on the use of telephone systems and computer systems, as pertinent to job responsibilities Page 32

33 Review plan for monitoring or telephone availability C=critical D=done P=pending N=no action Page 33

34 MANAGEMENT INFORMATION SYSTEMS AHCCCS REVIEW TEAM: PROGRAM CONTRACTOR STAFF: DATE OF REVIEW: EVALUATION ELEMENT C D P N COMMENTS Review Support Staff Requirements Review Staff Training Plan Review Procedures to Transmit Data to and From AHCCCS Review Acquisition and Installation Schedule for: Data Lines Equipment Software Determine Outside Service Bureau Readiness Review Service Bureau Contract Review Procedures to Monitor Service Bureau Review Procedures for Roster Update and Member File Maintenance Review MIS Policies and Procedures Determine System Availability and Access Determine Operations Scheduling Review Operations and testing Procedures Page 34

35 Review Ongoing System Support and Operations C=critical D=done P=pending N=no action Page 35