Quality Program

Quality Program

The Quality Program (QP) supports our commitment to ongoing quality care for our members. We have developed standards and performance goals and continue to monitor them to identify improvement opportunities.

Participation in the Quality Program

Participation in our QP activities is required in our agreements with physicians, other health care professionals and facilities. Participation may include:

  • Site visits and record review
  • Adherence to clinical standards
  • Credentialing or re-credentialing
  • Quality of care concerns or complaints
  • Providing evidence of preventive health promotion
  • Providing data for various medical records audits such as the annual Healthcare Effectiveness Data and Information Set (HEDIS®) audit

Providers may be asked to review and provide feedback on proposed or ongoing clinical activities and development of clinical practice guidelines at focus groups or Medical Advisory Committees.

Quality Program scope

The scope of the QP includes developing improvement opportunities and activities throughout our Company that directly impact the experience of our members, physicians, other health care professionals or facilities:

  • Develop focused quality improvement activities (QIAs) including:
    • Clinical QIAs
    • Service QIAs
  • Monitor activities throughout our Company to further the "integration of our processes" including:
    • Access
    • Availability
    • Quality surveys
    • Staff qualifications
    • Advance directives
    • Case Management
    • Member satisfaction
    • Provider satisfaction
    • Inter Rater Reliability
    • Medical record keeping
    • Quality of care concerns
    • Community collaboration
    • Under and over utilization
    • Pharmacy education programs
    • Disease management programs
    • Clinician performance monitoring
    • Coaching and wellness programs
    • Utilization Management: Physical and Behavioral Health
  • Monitor patient safety activities to fulfill our commitment to the safe delivery of care to our members.
  • Support contractual and regulatory compliance.
  • Develop and administer the QP to provide an organizational structure, resources and coordination of quality processes within the Company.

Health Strategies Committee of the Board of Directors

Our Board of Directors has participating providers as directors and on the Health Strategies Committee. This committee meets quarterly to discuss issues surrounding the health care delivery system and provider-related quality improvement activities.

Other tools

Provider quality resources are tools and resources to help providers understand and improve patient care and outcomes, including measures included on CAHPS and HOS surveys.

Accessibility and availability standards

Accessibility and Availability Standards

Provider appointment availability

We work to ensure that number of physicians, other health care professionals and facilities will be appropriate to satisfy our members' health care needs, and are committed to providing our members the necessary information to:

  • Be able to use their health plan benefits
  • Have reasonable access to health services

Please review this information carefully. If your office currently is not meeting these standards, please take the steps necessary to comply with them to ensure that our members—your patients—, have access to quality care. This information and these standards consider the immediacy of patient needs and common waiting times for comparable services in the community. You should have a system in place to evaluate the urgent and emergent needs of members and to determine the appropriate site for care in a timely fashion.

We review compliance with these standards annually.

Appointment availability standards

Physicians and other health care professionals must provide or arrange for the provision of covered services to members on a 24/7 basis. The following standards are the minimum availability requirements for all members:

Primary care providers

  • Emergent care will be assessed, treated or referred immediately.
  • Urgent, acute care appointments will be scheduled within 24 hours.
  • Preventive care examinations will be scheduled within 42 calendar days.
  • Non-urgent, appointments for symptomatic conditions will be scheduled within seven calendar days.
  • Non-urgent, routine appointments for asymptomatic conditions will be scheduled within 30 calendar days.
  • Office wait time for a scheduled appointment will be no more than 30 minutes.

Specialty referral providers

  • Urgent, symptomatic condition appointments will be scheduled within 24 hours.
  • Non-urgent specialty referral appointments will be scheduled within 30 calendar days.

Behavioral health providers

  • Non-life-threatening emergency treatment will occur within six hours, directed to a behavioral health crisis unit, or directed to the nearest emergency room.
  • Urgent care appointments will be scheduled within 48 hours.
  • Routine office visits will be scheduled within 10 business days.

Definitions

Emergency medical conditions
An emergency medical condition means a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson who has an average knowledge of medicine and health would reasonably expect the absence of immediate medical attention at a hospital emergency room to result in any one of the following:

  • Serious impairment to bodily functions
  • Serious dysfunction of any bodily organ or part
  • Placing the member’s health, or with respect to a pregnant member, the member’s health or the health of the unborn child, in serious jeopardy
  • A behavioral health crisis. Behavioral health crisis means a disruption in an individual's mental or emotional stability or functioning resulting in an urgent need for immediate outpatient treatment in an emergency department or admission to a hospital to prevent a serious deterioration in the individual's mental or physical health.

Urgently needed services
Urgent acute care, while not considered life threatening, cannot comfortably be delayed. Practitioners must have a system in place to evaluate the needs of members calling or presenting at the office that enables them to identify conditions requiring urgent and emergent care.

After-hours answering systems

To assist our members in accessing services after their provider’s regular office hours, please instruct your patients about options for after-hours care. This coverage could include:

  • An answering service that can contact the on-call provider or another designated network provider
  • An on-call pager
  • Call forwarding to the provider’s home or other location
  • A recorded phone message with instructions that direct the member to a provider for instruction in after-hours care. Please avoid giving direction to another recording.
  • An after-hours recording on the office phone that instructs members to call 9-1-1 or go to a hospital emergency room for needed emergency services.

Cultural competency

Legislative requirements emphasize the importance of demonstrating cultural competency in the provision of health services. This includes members who may:

  • Be homeless
  • Have physical or mental disabilities
  • Have a diverse cultural or ethnic background
  • Are limited in English proficiency and/or reading skills

Please review the Cultural Competency tab at the top of this page for more information and resources to support you and your staff.

Non-English speaking and hearing-impaired members

  • To ensure accurate interpretation and translation, we strongly encourage utilization of an interpreter service or staff person who is trained in translating medical terminology.
  • Asking family members or friends to act as an interpreter is not appropriate. They may not be familiar with medical terms and translation errors may occur, or information may be overlooked or withheld.

Members with visual impairments

The following information may assist you in providing services to visually impaired patients:

  • Assign a person in your office to assist visually impaired patients. Identify what to do if a patient needs assistance from their vehicle to your office, with form completion, or to and from the restroom or exam room.
  • Braille signs should be posted on restrooms and elevators to meet Americans with Disabilities Act (ADA) requirements.
  • Guide dogs must be permitted to accompany visually impaired patients to all areas of your facility where patients are allowed. An individual with a guide dog may not be segregated from other patients.

Members with physical disabilities

Medical services are accessible to people with physical disabilities. Participating physicians and other health care professionals must ensure the following provisions for access:

  • Wheelchair-accessible offices
  • Clearly identified handicapped parking spaces

Help in identifying handicapped parking spaces can be obtained from the following sources:

  • Signs: Your state's disabilities commission can assist you with obtaining signs designating handicapped (including van-accessible) parking. Signs can also be obtained through other commercial vendors.
  • Striping and stenciling: Parking space painting and stenciling can be arranged through a variety of commercial vendors. Search for "pavement marking" to find a contractor near you.

If your office is unable to serve a particular disabled population or individual, please call our Provider Contact Center so that other arrangements or referrals can be provided.

Advance directives

Advance directives

To ensure our members' wishes are met concerning the provision of health care if the member becomes incapacitated and is unable to make those wishes known please comply with the following:

  • If the office has received a signed advance directive, a copy of the document must be prominently displayed in the patient's chart.
  • The office or facility should have copies of advance directives available for their patients to complete, or advise the patient how to obtain one from the hospital or his or her attorney.
  • If your office or facility is currently not meeting these standards, please take the steps necessary to ensure that members have access to quality care by complying with these standards.
Cultural Competency

Cultural competency

Cultural competency and health literacy
State and federal legislative requirements emphasize the importance of demonstrating cultural competency when providing health care services. This means care should be inclusive of members who may:

  • Be homeless
  • Have physical or mental disabilities
  • Have a diverse cultural or ethnic background
  • Are limited in English proficiency and/or reading skills

We seek providers who speak languages in addition to English and who have an awareness of the social and cul
In addition, see the social determinants of health section below for information about the ICD-10 Z codes to use to capture a more holistic view your patients' health.tural composition of the community. Additionally, we require that Medicare Advantage members have access to information in their primary language, and that primary care provider (PCP) offices have provisions for non-English speaking Medicare Advantage patients.

Review these resources to develop and improve your cultural competency and health literacy as you and your staff provide care for our members.

National standards and essential references

Resources for Integrated Care: These resources present specific strategies for organizations and providers for implementing culturally and linguistically competent programs, including self-assessments and toolkits with actionable steps.

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care: The U.S. Department of Health & Human Services (HHS) published the National CLAS Standards to improve the quality of service to all individuals to help reduce health disparities and achieve health equity.

Improving Cultural Competency for Behavioral Health Professionals: HHS also provides a free training to help behavioral health professionals learn how to better respect and respond to patients with unique needs.

Office of Minority Health: The HHS Office of Minority Health includes population profiles, cultural competency information, and an online library, among other resources.

Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations: The American Psychological Association's (APA) Board of Ethnic Minority Affairs (BEMA) established a Task Force on the Delivery of Services to Ethnic Minority Populations in 1988 in response to the increased awareness about psychological needs associated with ethnic and cultural diversity. The task force developed the guidelines to enlighten all areas of service delivery, not simply clinical or counseling endeavors.

Health Literacy: The Centers for Disease Control and Prevention (CDC) offers seven online courses for health professionals covering culture and communication, health literacy and plain language, some of which are free continuing education opportunities.

Health Literacy Universal Precautions Toolkit, 2nd Edition: Consider Culture, Customs, and Beliefs: Tool #10: The Agency for Healthcare Research and Quality (AHRQ) offers this excerpt from their full Health Literacy Universal Precautions Toolkit. Tool #10 focuses on culture, customs and beliefs and how they can influence how patients understand health concepts, take care of their health and make decisions related to their health.

National Council on Interpreting in Health Care: The National Council on Interpreting in Health Care's mission is to promote and enhance language access in health care in the U.S.

For more information

CME/CEU resources

  • A Physician's Practical Guide to Culturally Competent Care: Think Cultural Health offers continuing education and equips health care professionals with awareness, knowledge and skills to better treat the increasingly diverse U.S. population they serve.
  • Quality Interactions: Quality Interactions offers more than 25 clinical and non-clinical eLearning courses for health care professionals; cultural competency resources; and organizational assessment. The eLearning offerings also include behavioral health-focused options.
  • American Academy of Family Physicians (AAFP): The AAFP offers a variety of AAFP-certified CME courses.

Non-CME/CEU resources

  • National Center for Cultural Competence (NCCC) at Georgetown University: The mission of the NCCC is to increase the capacity of health care and behavioral health care programs to design, implement and evaluate culturally and linguistically competent service delivery systems to address growing diversity and persistent disparities, and to promote health and behavioral health equity.

Implicit bias

  • Implicit Bias Resource Guide: The National Institute for Children's Health Quality produced this guide to help in recognizing and addressing biases as a critical step towards eliminating health disparities and achieving health equity.
  • Project Implicit: Social Attitudes Self-Assessment: Project Implicit is a non-profit organization and international collaboration between researchers who are interested in implicit social cognition, thoughts and feelings outside of conscious awareness and control. The goal of the organization is to educate the public about hidden biases and to provide a virtual laboratory for collecting data.
  • AAFP - The EveryONE Project: The AAFP offers a toolkit to promote diversity and address social determinants of health to advance health equity in all communities. The toolkit offers strategies for use in your practice and community to improve your patients' health and help them thrive.

Language access & services

  • Interagency Working Group on Limited English Proficiency (LEP): Created in 2002, the mission of LEP.gov is to share resources and information to help expand and improve language assistance services for individuals with limited English proficiency, in compliance with federal law
  • Office of Equity & Inclusion: The Oregon Health Authority Office of Equity & Inclusion's provider FAQ regarding the provision of interpreter services to individuals who have vision or auditory limitations are deaf, deaf-blind, hard of hearing or have limited English proficency.
  • Interpreter services: The Washington State Health Care Authority's website information about provider interpreter services requirements including the sign language request process, resources and program updates.

LGBTQ+

  • The Trevor Project: The leading national organization providing crisis intervention and suicide prevention services to lesbian, gay, bisexual, transgender, queer & questioning (LGBTQ+) young people.
  • National LGBTQIA+ Health Education Center: The National LGBTQIA+ Health Education Center provides educational programs, resources, and consultation to health care organizations with the goal of optimizing quality, cost-effective health care for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minority (LGTQIA+) people. Includes over 100 publications, toolkits, training videos, and more, as well as CME options.
  • Center of Excellence LGBTQ+ Behavioral Health Equity: The Center of Excellence on LGBTQ+ Behavioral Health Equity provides behavioral health practitioners with vital information on supporting the population of people identifying as lesbian, gay, bisexual, transgender, queer, questioning, intersex, two-spirit, and other diverse sexual orientations, gender identities and expressions.

Maternal health care

  • CLAS in Maternal Healthcare: This free, two-hour e-learning program from HHS is designed for providers and students seeking knowledge and skills related to cultural competency, cultural humility, person-centered care, and combating implicit bias across the continuum of maternal health care.
  • CDC's Hear Her Campaign - Resources for Healthcare Professionals: The CDC’s Division of Reproductive Health is committed to healthy pregnancies and deliveries for every woman. The Hear Her campaign supports CDC’s efforts to prevent pregnancy-related deaths by sharing potentially life-saving messages about urgent warning signs.

Tribal health care

  • Tribal Training and Technical Assistance Center: The Substance Abuse and Mental Health Services Administration (SAMHSA) provides culturally appropriate training and technical assistance to American Indian and Alaska Native communities to address and prevent mental and substance use disorders and suicide and to promote mental health.
  • Tribal Learning Series: What Non-Tribal Providers Need to Know: Presented by North Sound Accountable Community of Health, an independent nonprofit organization committed to building vibrant,healthy communities.
  • National Indian Health Board: The National Indian Health Board (NIHB) represents tTribal governments—both those that operate their own health care delivery systems through contracting and compacting, and those receiving health care directly from the Indian Health Service (IHS). Located on Capitol Hill in Washington, DC, on Capitol Hill, the NIHB, a non-profit organization, provides a variety of services to tribes, Aarea Hhealth Bboards, tTribal organizations, federal agencies, and private foundations, including: advocacy, policy formation and analysis, legislative and regulatory tracking, direct and timely communication with tribes, research on Indian health issues, program development and assessment, training and technical assistance programs, and project management.
  • Indian Health Service Clinical Support Center: The mission of the Clinical Support Center (CSC) Office of Continuing Education (OCE) is to develop and support continuing professional education activities and meet the needs of Indian health program health care providers throughout the U.nited States. The purpose of these continuing education activities is to improve the health care for all American Indians and Alaskan Natives.

Additional resources

  • Cultural Competency Planning Guide: The Department of Social and Health Services - DSHS is committed to cultural competence through promoting respect and understanding of diverse cultures, social groups, and individuals.
  • Distinction in Multicultural Health Care: The NCQA Distinction in Multicultural Health Care identifies organizations that excel in providing culturally and linguistically sensitive services and work to reduce health care disparities.
  • Find an Interpreter or Translator: The Office of Diversity and Inclusion's vision is that all our access, diversity goals, values and practices are interconnected and interdependent, and we all share the responsibility for equity and inclusion.
  • LearnCQ.com: The Cultural Intelligence Center, an innovative, research-based consulting and training organization that draws upon empirical findings to help executives, companies, universities and government organizations assess and improve cultural intelligence (CQ). The CIC provides engaging, research-based workshops, tools, resources and courses, using effective learning and development strategies.
  • National Alliance on Mental Illness - Identity and Cultural Dimensions: When a mental health professional understands the role that cultural differences play in the diagnosis of a condition, and incorporates cultural needs and differences into a person’s care, it significantly improves outcomes. Mental health care must be tailored to thean individual’s — to their identity, culture and experience. The NAMI describes significant cultural factors around mental health care, including barriers to mental health care and how to seek culturally competent care.
  • Oregon Mandatory Cultural Competency Continuing Education: Oregon requires cultural competency continuing education for health care professionals Under the requirement, Oregon Medical Board licensees must complete cultural competency continuing education as a condition of licensure.
  • Oregon Medical Board - Cultural Competency: The Oregon Medical Board publishes a practical guide to cultural competency for medical professionals.
  • Rural Health Information Hub: The Rural Health Information Hub, formerly the Rural Assistance Center, is funded by the Federal Office of Rural Health Policy to be a national clearinghouse for rural health issues. Find links to individual state guides that provide basic demographics; information about rural health care facilities; and selected social determinants of health for rural areas.
  • Washington Cultural Competency Planning Guide: The Washington Department of Social and Health Services (DSHS) is committed to cultural competence through promoting respect and understanding of diverse cultures, social groups, and individuals.
  • Washington Find an Interpreter or Translator: The Washington Office of Diversity and Inclusion's vision is that all our access, diversity goals, values and practices are interconnected and interdependent, and we all share the responsibility for equity and inclusion.

Social determinants of health
We are working to close health equity gaps to ensure simpler, better and more affordable health care for those we serve—from all backgrounds and walks of life. This includes collecting and tracking social determinants of health (SDoH) information about our members to understand barriers and support equitable access to quality health care and health education.

We encourage you to include the SDoH Z codes in your patients’ medical records. Including these codes will help us identify opportunities to provide support to our members, such as transportation or in-home care, and as well as connections to food banks and other community resources.

View our Social Determinants of Health Z codes flyer (PDF), which includes a list of the codes that make it possible to measure social risk factors and social needs.

Categories of codes

  • Education/literacy
  • Employment and unemployment
  • Occupational exposure to risk factors
  • Physical environment
  • Housing and economic circumstances
  • Social environment
  • Upbringing
  • Primary support group, including family circumstances
  • Psychosocial circumstances
  • Other psychosocial circumstances
  • Lifestyle
  • Life management difficulty
  • Care provider dependency
  • Medical facilities and other health care
  • Personal risk factors, not elsewhere classified

Physician and non-physician providers can document SDoH codes during patient encounters. Non-physician providers include nurses, community health workers, case managers and other clinicians.

HEDIS reporting

HEDIS measurement and reporting

Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) that allows purchasers and consumers to compare quality among health plans.

Regulators also use HEDIS results to evaluate and reward plan performance in various programs. We are required to report HEDIS values annually on our members, making HEDIS a key component of our Quality Program.

Medical and pharmacy claims are the primary administrative data sources for HEDIS measures. Audit-approved "supplemental" data, such as state immunization registries, laboratory results, vision vendor services and specific electronic medical record (EMR) services, are also used.

NCQA-designated measures rely in part or whole on the addition of medical record data, in combination with administrative data, to achieve valid rates.

NCQA requires a statistically valid sample from all members eligible for these measures. If any of your patients are a part of that sample and their claims do not reflect compliance with the measure, we will need to review their records. We will work with you to complete these necessary reviews.

Provider tips for improving HEDIS scores:

  • Provide clinically appropriate preventive screenings, tests and vaccines at established recommended intervals.
  • Monitor chronic conditions according to established disease-specific guidelines.
  • Accurate and timely submission of claims will reduce the number of medical record reviews required for HEDIS rate calculation.
  • Ensure that medical record documentation accurately reflects services billed.
  • Submit claims for all services delivered. Submit all applicable diagnostic, procedure, and CPT level II codes (whenever possible). If services are not billed or are billed inaccurately, they are not included in the HEDIS scores.

Frequently asked questions about the 2021 chart review:

What HEDIS measures will be included in the 2021 review?

We are reviewing 9 measures this year:

  • Cervical cancer screening (CCS)
  • Colorectal cancer screening (COL)
  • Prenatal and postpartum care (PPC)
  • Childhood immunization status (CIS)
  • Comprehensive diabetic care (CDC)
  • Controlling high blood pressure (CBP)
  • Weight assessment and counseling for nutrition and physical activity for children/adolescents (WCC)
  • Immunization for adolescents (IMA)
  • Transitions of care (TRC)

What dates of service are included in the review?

Office medical records are being reviewed for services received in the 2021 calendar year. However, some measures require additional periods of time, especially for exclusions. The specific periods of service for each member will be included with the chart request.

What types of services and information in the medical record will be reviewed?

The types of services reviewed are specific to each HEDIS measure; however, in general, they include:

  • History
  • Lab results
  • Problem list
  • Specialist consultations
  • Chart notes for a specified period

Are we required to participate?

Yes, your provider agreement requires that you participate in quality improvement activities, such as HEDIS. You must provide access to members' records for these purposes at no cost and without requiring a signed release.

What do I need to do?

We have contracted with Inovalon to contact providers to schedule record retrieval and perform the record review. Retrieval can be done by on-site, fax or mail. Instructions for submitting the requested records will be included with the chart request.

Will I be asked to change or resubmit claims?

No.

Will Inovalon protect members' personal health information?

Yes, they will follow Health Insurance portability and Accountability Act (HIPAA) guidelines 45 CFR 164.506(c) (4) while collecting and coding member information, in accordance with our signed business associate agreement.

What can I do to minimize the impact to our office?

Inovalon and our staff will work with your office to identify the most efficient way to obtain the necessary chart information. We recognize that each office is unique and that this review can be time-consuming.

Who do I call if I have additional questions?

  • For questions about scheduling or your specific charts, contact Inovalon directly at the phone or fax number included with the request you received.
  • For other HEDIS-related questions, please contact Brenda Taylor at (208) 798-2042 or by email.

Additional Resources

  • See our site review standards tab for details about adequacy of medical record keeping.
  • Use our Quality Measures Guide (PDF) for related coding and documentation tips
Provider advisory groups

Provider advisory groups

Our Provider Advisory Council (PAC) and our new Behavioral Health Provider Advisory Council (BH-PAC) both serve as communication and advisory forums for participating providers including primary care, medical specialties and behavioral health. PAC and BH-PAC members practice in communities across our service area and provide input for some of our programs and collaborate with us on initiatives to improve care and services to members.

Provider Advisory Council (PAC)

The primary roles and responsibilities of the PAC include:

  • Providing input and feedback on services provided to members
  • Providing input and feedback on Accountable Health program initiatives
  • Through discussion, participate in quantitative and qualitative analyses of Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) results and other quality measures
  • Providing input and make recommendations to the Quality Programs Committee (QPC) about clinical quality and service improvement activities, including:

    • HEDIS results and improvement strategies
    • Members' access to providers and appointment availability
    • Medication prescribing and adherence measurement results
    • Clinical practice, behavioral health and preventive health guidelines
    • Coordination of care between medical and behavioral health care providers

PAC membership

Membership in the PAC represents a broad spectrum of participating primary and specialty care providers, including behavioral health. Appointments are made based on availability and need by specialty type. To learn more about becoming an active member of the PAC, please contact our Director of Quality.

The PAC meets at least semi-annually.

BH-PAC

Primary roles and responsibilities include:

  • Providing input and feedback on services provided to members
  • Providing input and feedback on Regence's behavioral health initiatives
  • Through discussion, participating in quantitative and qualitative analyses of HEDIS and CAHPS results and other quality measures
  • Providing input and making recommendations to the Provider Quality Measurement Oversight Subcommittee of the Quality Programs Committee (QPC) about clinical quality and service improvement activities, including:

    • HEDIS and improvement strategies
    • Behavioral health medical policy review
    • Addressing opioid use disorders and access to care
    • Members' access to providers and appointment availability
    • Operational enhancements to facilitate positive communication
    • Coordination of care between medical and behavioral health care providers

BH-PAC membership

Membership in the BH-PAC represents a broad spectrum of behavioral health providers. Appointments are made based on availability and need by specialty type. To learn more about becoming an active member of the BH-PAC, please contact our Director of Quality.

Provider responsibilities

Provider responsibilities

As a participating provider, you have agreed to:

  • Not discriminate against any member and to treat all members with dignity, respect, and courtesy regardless of race, physical or mental ability, ethnicity, gender, sexual orientation, creed, age, religion or national origin, cultural or education background, economic or health status.
  • Cooperate with our Member Grievance and Appeal Procedures.
  • Abide by our policy guidelines as it pertains to the determination of claims for our members.
  • Bill us directly for covered services. Patients should not be asked to submit claims.
  • Direct patients to physicians, other health care professionals and facilities participating on the network used by the member's plan whenever possible.
  • Accept our Maximum Allowable Fees (depending on which agreements you have signed) as payment in full for covered services for all our members.
  • Ensure that all subcontractors are subject to and comply with the terms of Provider's Participating Provider Agreement and all applicable Federal and State statutes, laws and regulations.
  • Your patients are only responsible for copayment, coinsurance and deductible amounts, and for services not covered by their benefit contract.
  • Provide us with copies of members' records (including X-rays), at no charge, when we request records to make a claim determination. Provider must maintain records necessary to document the services for those claims submitted to us.
  • Provide covered services to our members where such services are necessary and the provider is qualified to provide such services. In providing such services, the provider will meet the same standards of professional care that characterize the providers' services to non-members.
  • You are responsible for your relationship with each patient and are solely responsible for the medical care provided, including the discussion of treatment alternatives. Your Agreement does not limit your right to communicate freely with your patients, including the right to inform them services are appropriate or necessary, even if we determine the services are not covered by their plan.
  • Consideration of privacy concerning care and confidentiality in all communication and medical records.

Contact your Provider Relations team if you have any questions regarding these benefits and responsibilities.

Benefits of Participation

  • Claim payments are made to you directly on a weekly basis.
  • Provider Relations staff are available to help you and your staff.
  • You are listed in the Provider Search tool made available to our members.
  • You may provide input on our policies.
  • Our members have financial incentives to seek care from you because their expenses will be limited to deductible, copayment and coinsurance amounts, and charges for non-covered items. They may also pay a lower deductible, copayment and/or coinsurance if care is provided by a Network provider.
Site review standards

Site review standards

In order to provide a sanitary, comfortable experience, participating physicians, other health care professionals, facilities and agree to adhere to the following site standards. Offices will be regularly reviewed to ensure compliance with these standards.

Physical accessibility

  • Exterior is generally accessible; the office is easy to locate, parking is available, clearly identified and handicap accessible
  • Interior is generally accessible; is handicap accessible, rooms are clearly identified and office hours are communicated clearly

Physical appearance and safety

Exterior

  • Building is generally clean and well-maintained
  • Exterior premises are safe

Interior

  • Interior is generally clean and well-maintained
  • Interior premises are safe
  • Fire extinguish system is available
  • There is adequate hazardous product disposal
  • Narcotics are securely locked

Waiting room adequacy

  • There are educational materials available
  • The waiting room is generally clean with adequate seating for the number of providers in the office

Examination room adequacy

  • The patient's privacy is protected
  • There is an exam table in each room
  • There is educational information available
  • There is hand washing available in each room
  • The rooms are generally clean and of adequate size
  • There is an assistant available as needed

Appropriate equipment available

  • There are Sharps containers
  • There is resuscitation equipment or Cardiopulmonary Resuscitation (CPR)-certified staff
  • If in-office X-rays performed, state certification has been obtained
  • If in-office laboratory work performed, Clinical Laboratory Improvement Amendments (CLIA) certification has been obtained
  • There are examination instruments – for primary care physicians this would include:

    • Stethoscope
    • Blood pressure cuff
    • Otoscope
    • Ophthalmoscope

Adequacy of medical record keeping

Physicians, other health care professionals and facilities must establish the following policies and procedures:

  • Confidentiality policy
  • Release of information policy
  • Medical records must be readily available
  • Medical records must be kept from public access
  • The patient charts must be organized and contents secured
  • Procedures for assessing and improving content, legibility, organization and completeness of medical records

In addition, providers must maintain a medical record-keeping system that:

  • Permits encounter claim review
  • Conforms to professional medical standards
  • Permits an internal and external medical audit
  • Facilitates an adequate system for follow-up treatment

All medical records must be maintained for at least ten years after the date of medical services.

Medical records must contain all the necessary documentation to support the services rendered and billed, as well as the medical necessity of those services. Valid Current Procedural Terminology (CPT®) codes, International Classification of Diseases (ICD) codes and Diagnostic and Statistical Manual of Mental Disorders (DSM) codes must be supported by the patient's medical record. If the appropriate documentation is not included, we may be unable to confirm that payment was made appropriately, which can result in requests for refunds from providers.

Providers must include, at a minimum, the following in medical records:

  • Specific and clear treatment plans
  • Information on advance directives
  • Complete, accurate and legible documentation
  • Complete history, examination and medical decisions
  • Identification of all providers participating in the patient's care
  • Diagnostic testing, laboratory tests and radiology reports and results
  • Prescribed medications, including dosages and dates of initial or refill prescriptions
  • Complete descriptions of the patient's concerns and reason for seeking medical care
  • A problem list, including significant illnesses and medical and psychological conditions
  • Evaluation and assessment of the provider's findings and a complete list of all diagnoses
  • Information on allergies and adverse reactions or a notation that the patient has no allergies or history of adverse reactions

Each entry or page in the medical record must include:

  • Progress notes, any improvement in the patient's condition, changes in the treatment plan and updates to the diagnosis
  • Each page must include the patient's name, date of birth and date of service to verify who the patient is and what date services were provided
  • Each entry must have the rendering provider's signature at the completion of the chart note, medical records, operative report or any other medical document in a patient's file. If an entry spans multiple pages, the signature is required at the end of the entry, but the patient identifiers still need to be on each page.