Policy and Procedures Toolkit

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Tapping Your Untapped Engagement Advantage
Members are increasingly demanding that the interactions they have with their health plans be timely, relevant, and convenient. In response, payers should capitalize on this opportunity by ensuring they are optimizing their existing member communication channels to be as effective as possible. This white paper explores engagement best practices from hyper-personalization to omni-channel communications that members respond to.

BEN-002-POL-Benefit Design for HPA 09-2023
Benefit Design Policy - to ensure that we comply with all requirements of health insurance issuers of both individual and group coverage in the design and provision of our benefit packages. Applies to Commercial lines of business

AlliantHealthPlans_PandP_ERM_LegalDocumentRequest
Alliant Health Plans policy for subpoena requests, outlines the process for responding to legal requests for documents containing member PHI.

AlliantHealthPlans_PandP_ERM_CyberSecurity
Alliant Health Plans policy for CyberSecurity, provides a guide of how to handle and when to report a security incident to the Company's cyber liability insurance carrier.

AlliantHealthPlans_PandP_ERM_CyberSecurityMalware
Alliant Health Plans policy for CyberSecurity, provides a guide of how to handle and when to report a security incident to the Company's cyber liability insurance carrier.

AlliantHealthPlans_PandP_ERM_IncidentResponsePrivacy
Alliant Health Plans policy for Privacy, provides guidance for the implementation of workforce training on all policies, procedures, and regulations for each department who handles PHI. In accordance with HIPAA.

AlliantHealthPlans_PandP_ERM_RiskManagementPrivacy
Alliant Health Plans policy for Privacy, provides guidance for the implementation of workforce training on all policies, procedures, and regulations for each department who handles PHI. In accordance with HIPAA.

AlliantHealthPlans_PandP_ERM_WorkforceSecurity
Alliant Health Plans policy for Privacy, provides guidance for the implementation of workforce training on all policies, procedures, and regulations for each department who handles PHI. In accordance with HIPAA.

AlliantHealthPlans_PandP_ThirdPartyRelationships_BusinessAssociates
Alliant Health Plans policy for contract review, provides guidance regarding the execution of business associate contracts.

AlliantHealthPlans_PandP_ThirdPartyRelationships_ThirdPartySubrogation
Alliant Health Plans policy for third party subrogation, provides guidelines for requesting accident and injury details sustained by a member.

AlliantHealthPlans_PandP_ThirdPartyRelationships_OperationsCommCharter
Alliant Health Plans document for Operations or Business Owner Policy & Procedures, facilitates operational issues from the organization and allows for long-term strategies and policy recommendations to be formulated among directors and vice presidents.

AlliantHealthPlans_PandP_ThirdPartyRelationships_ProviderDirectory
Alliant Health Plans policy for Provider Directory Accuracy, outlines the elements and process for maintaining an online provider directory to assist members in identifying providers participating in-network.

AlliantHealthPlans_PandP_ThirdPartyRelationships_DelegationPolicies
Alliant Health Plans policy for delegated vendor oversight, with emphasis on scope of work elements audited prior and during the contractual agreement process with a vendor entity.

Medical Associates Fraud Waste Abuse
Medical Associates Fraud, Waste and Abuse Compliance Policy

Medical Associates Population Health Registries Database
Medical Associates Health Plans (MAHP), Live360 Health Plan and Health Choices (HC) Population Health Registries (PHR) database allows for complete and accurate record keeping for members participating in any of our population health programs. This tool is the central database utilized by population health staff to continually monitor, manage and assist members/participants throughout their continuum of care.

Medical Associates Disease Management
Medical Associates Disease Management Program Identification and Interventions

Medical Associates Health Coach and Case Management
Medical Associates Health Coach and Case Management Program.

Medical Associates Utilization Management Review
Medical Associates Utilization Management Review Policy: requests for services requiring authorization are reviewed according to member contract or plan documents and established Health Care Services (HCS) Guidelines

Medical Associates Authorization Timeframe and Determinations
Medical Associates Authorization Timeframe and Determinations: Requests for services requiring authorization are viewed according to member contract or plan document and established Medical Associates Health Plans, Health Care Services Guidelines. These Guidelines are reviewed and approved annually.

Medical Associates Continuity and Coordination of Care
Medical Associates Continuity and Coordination of Care: Medical Associates Health Plans (MAHP) and Health Choices (HC) are committed to meeting the medical, surgical, behavioral health and other health care needs and concerns of its enrollees as well as assuring that continuity and coordination of care exists between primary care, specialty care practitioners, as well as health delivery organizations.

Medical Associates Risk Assessment
Medical Associates Risk Assessment: Risk analysis and risk management are recognized as important components of the Medical Associates Health Plans (MAHP)Compliance Program. It is the policy of MAHP to conduct regular assessment of critical risks to the business

Medical Associates Monitoring of HIPAA Standards
Medical Associates Monitoring and Auditing of employee workstations for compliance with HIPAA Privacy Standards.

Medical Associates Compliance Complaints and Hotline
Medical Associates Compliance Complaints and Compliance Hotline Policy.

Medical Associates Notice of Privacy Practice
Medical Associates Notice of Privacy Practice policy: To establish procedures for compliance with all laws and regulations regarding notification of privacy practices, including the Health Insurance Portability and Accountability Act (HIPAA).

Medical Associates Security Incident Response
Medical Associates Information Security Incident Response policy. (Cybersecurity)

Medical Associates Participating Provider Contract Content
Medical Associates Provider Contracting Policy: To ensure that all participating provider contracts include appropriate terms, including terms required by state and/or federal laws, for NCQA accreditation, and for maintaining MAHP standards for quality of care and service provided to members.

Medical Associates Provider Directories
Medical Associates Provider Directory Policy: Medical Associates Health Plans (MAHP) is committed to providing members an accurate listing of participating providers.

Medical Associates Appeal and Grievance Policy
Medical Associates Internal appeal of an Adverse Benefit Determination for Commercial members: To assure a timely, efficient, and compliant response to internal appeal of an Adverse Benefit Determination for members covered by a Large Group or Small Group Subscriber Agreement

Medical Associates Coordination of Benefits
Medical Associates Coordination of Benefits

NetworkHealth_PandP_ProviderDataValidation
Network Health and the Marketplace ensures its demographic data for contacted providers is accurate.

NetworkHealth_PandP_ProviderDirectoryCompliance
To ensure a process for identifying practitioners to be included in the Network Health directories with the purpose of providing members with an updated list of participating practitioners and facilities from which they can seek in-network services.

NetworkHealth_PandP_ProviderDisputes
This reimbursement policy outlines Network Health Plan's process, for all lines of business, when submitting a provider dispute or a provider appeal.

NetworkHealth_PandP_ProviderNetworkAvail
Network Health ensures its network has sufficient number and types of practitioners practicing primary, OB/GYN, behavioral health and specialty care.

NetworkHealth_PandP_PublishedReviewCriteria
Network Health's Utilization Management (UM) Department applies commercially published utilization criteria to medical necessity utilization decisions. This policy ensures annual physician review and approval for Network Health's adoption of these nationally developed medical criteria and standard of care guidelines.

NetworkHealth_PandP_QHPDesign
The Affordable Care Act (ACA) established qualified minimum certification standards that require health plans participating in the Federally-Facilitated Exchange (FFE) to have outlined references included in their policies and procedures and supporting documentation/processes. Network Health Plan/Network Health Insurance Corporation (NHP/NHIC) will comply with all regulatory requirements in its Qualified Health Plan (QHP) design.

NetworkHealth_PandP_QualityImprovementPlans
This policy describes the process for the development and implementation of Quality Improvement Plans required by the Centers for Medicare & Medicaid Services (CMS).

NetworkHealth_PandP_RecordsRetention
This policy ensures necessary records are adequately protected and maintained in compliance with applicable state and federal regulations and to ensure that records are destroyed at the proper time in accordance with the record retention schedule.

NetworkHealth_PandP_RegulatoryComplianceProgram
To ensure all employees have a basic understanding of what the compliance program is and why it has been established; the Code of Conduct; knowing their responsibilities and options for anonymously and confidentially reporting in good faith, violations of the Code of Conduct, potential and/or actual instances of non-compliance, fraud waste and/or unethical or illegal behavior; basic knowledge of the fraud, waste and abuse program; and have knowledge and basic understanding of Health Information Portability and Accountability Act (HIPAA). Network Health is committed to complying with all applicable federal and state laws, rules and regulations for all product lines including commercial, Medicare and Qualified Health Plans (QHP) on the Marketplace. This includes the marketing of all lines of business. Network Health will not employ discriminatory marketing practices for any lines of business.

NetworkHealth_PandP_ReportingConcerns
Network Health will comply with CMS and OCI requirements to have mechanisms and communications for reporting compliance issues or unethical behaviors.

NetworkHealth_PandP_RequiredDisclosures
To ensure Network Health Insurance Corporation (NHIC) compliance with the Medicare Communication and Marketing Guidelines (MCMGs) and the Code of Federal Regulations, the Health Plan will comply with required disclosures of information to its members annually and/or upon request.

NetworkHealth_PandP_SIURecordsRequest
This policy defines the process Network Health Special Investigations Unit (SIU) utilizes during a claims review to determine provider compliance with Medicare coverage, coding and billing rules and the corrective action steps taken, as appropriate, when providers are found to be non-compliant.

NetworkHealth_PandP_Subrogation
This reimbursement policy outlines Network Health's process, for all lines of business, for subrogation related claims.

NetworkHealth_PandP_USERRACoverage
Network Health to comply with The Uniform Services Employment and Re-Employment Rights Act (USERRA) of 1994, requires all employer groups to provide healthcare coverage during all active military leave to current NHP/ NHIC members and their dependents for 2 to 24 months.

NetworkHealth_PandP_WorkersComp
This reimbursement policy outlines Network Health's process, for all lines of business, regarding workers' compensation claims.

AlliantHealthPlans_PandP_Clinical_PHMDescription
Alliant Health Plans document for Transitions of Care, identifies eligible populations for each program/service needed and outlines the program goals, coordination of care, criteria, and focus area.

DenverHealthMedicalPlan_PandP_Claims_AppealsProcess
The process for the receipt, processing, investigation, reporting and communication of all Medicaid and CHP+ appeals filed by the member or the member's representative.

DenverHealthMedicalPlan_PandP_Claims_CommercialAppealProcess
The process for the receipt, processing, investigation, reporting and communication of all Large Group appeals filed by the member or the member's representative.

DenverHealthMedicalPlan_PandP_Claims_IndependentExternalReview
Describes the process for the receipt, processing, and resolution of independent external review requests filed by the member or the member's representative

DenverHealthMedicalPlan_PandP_Claims_PartCReconsiderations
The process for the receipt, processing, investigation, reporting and communication of all Part C appeals filed by the member or the member's representative.

DenverHealthMedicalPlan_PandP_Claims_PartDAppeals
The process for the receipt, processing, investigation, reporting and communication of all Part D appeals filed by the member or the member's representative.

DenverHealthMedicalPlan_PandP_Claims_PharmacyAppealProcess
Describes how the Pharmacy team should send appeals they receive to the Grievance and Appeals team.

DenverHealthMedicalPlan_PandP_Claims_QualityofCareComplaints
The process for the receipt, processing, investigation, reporting and communication of all Quality of Care Complaints filed by the member or the member's representative.

NetworkHealth_PandP_ProdDevandImplementation
To define the process for the smooth implementation of new product launches and existing product refreshes. This process will ensure 1) there is appropriate governance over product changes 2) products are aligned with Network Health's strategy, and 3) all affected departments are aware of the new/refreshed product specifications and implementation timeline. It will also ensure that products are launched by the most effective means to be scalable and easily administered, including the sunsetting of plans and products whose market no longer supports continuation.

NetworkHealth_PandP_ProductPolicyReview
The format, language, and benefits for all product products will be reviewed and updated on an established schedule or sooner for changes based upon regulatory requirements, statutory change or other identified business initiatives.

PCHP.DE.101 Correctly Classify Contracted Entities
PCHP uploads a guideline that helps to identify & classify all delegated entities for the Policy & Procedures toolkit.

AlliantHealthPlans_PandP_Clinical_TransitionOfCare
Alliant Health Plans policy for Transitions of Care, identifies safe alternatives to ensure a quality transition of medically necessary care/services when a member exhaust plan benefit limits.

SIU Workplan
MediGold uploads a guideline surrounding a focused and strategic work plan around the investigational priorities of the Special Investigations Unit (SIU) that addresses the risks associated with the Medicare Part C and D benefits concerning areas at risk for fraud, waste, and abuse (FWA) for the Policy and Procedures toolkit.

Monitoring HPMS Analytics & Investigation
MediGold Policy & Procedures toolkit submission.

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