Policy and Procedures Toolkit

eBook: Improve care gap closure through targeted quality improvement and member engagement
Closing gaps in your member's care improves overall consumer satisfaction in addition to HEDIS and Star Ratings outcomes. But reaching members at the right time with the right message remains one of the greatest challenges for all health plans. In our new eBook, learn how to improve care gap identification and closure with a specific focus on preventive care and overcoming barriers to member engagement.

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_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.

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.

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.

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_ANOC_EOC
Plans must ensure the Centers for Medicare and Medicaid Services (CMS) model Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents are developed for each of its contracted Medicare Advantage plans for distribution to all members within the specific CMS required instructions and timeframes.

NetworkHealth_PandP_AppealsGrievancesComplaints
To describe the policy governing receipt, investigation, tracking, and resolution of all written appeals and grievances as well as verbal complaints received at Network Health from all commercial insured, self-insured, and Marketplace members/participants or their authorized representatives, in accordance with applicable state and federal regulations, and National Committee of Quality Assurance (NCQA) standards.

NetworkHealth_PandP_AuditingMonitoring
Network Health's compliance department will establish and maintain a plan for monitoring, auditing, and regulatory reporting to test and confirm compliance with the Centers for Medicare and Medicaid Service (CMS) and Wisconsin Office of the Commissioner of Insurance (OCI) regulations, sub-regulatory guidance, contractual agreements, and all applicable state and federal laws, as well as internal policies and procedures.

NetworkHealth_PandP_AuditingMonitoringOperations
Network Health will conduct effective auditing and monitoring of operational departments in order to identify risks including non compliance, fraud, waste and abuse to achieve and maintain operational compliance.

NetworkHealth_PandP_AvailabilityofDirectories
Network Health Plan will provide members/participants with provider directories.

NetworkHealth_PandP_BusinessContinuity
Network Health is committed to providing its stakeholders with an operational and administrative business continuity management (BCM) program, including policies, standards, risk mitigation controls, procedures and action plans. The BCM program is designed to ensure that the long-term viability of the enterprise is maintained in the event of an interruption to mission-critical/essential business operations. This document establishes the BCM program policy for Network Health, which is endorsed by Network Health's executive management team.

NetworkHealth_PandP_ClaimsReprocessing
Establish consistent guidelines for reprocessing claims under Network Health.

NetworkHealth_PandP_ClaimsSubmissions
This guideline outlines Network Health's procedure for clean claim submissions, corrected claims, and timely filing.

NetworkHealth_PandP_Coding
This policy provides the resources utilized by Network Health to ensure correct coding is applied to all claims.

NetworkHealth_PandP_CommercialDeductibleMOOP
Network Health ensures consistent application of deductible and/or out of pocket credit to reduce member's cost sharing for the Commercial lines of business (HMO, POS, OPT, IFP and SF) within the same benefit year.

NetworkHealth_PandP_CommercialPreventiveMedicine
This reimbursement policy outlines Network Health's process, for the Commercial (HMO/POS) product, when preventive medicine Evaluation and Management (E&M) services are performed on the same day as problem-oriented E&M services. This policy applies to services provided in a professional setting.

NetworkHealth_PandP_CompliancePolicyandProcedure
The compliance department of Network Health maintains a comprehensive compliance program description. The purpose of the compliance program description is to describe Network Health's commitment to preventing and detecting non-compliance and fraud, waste and abuse (FWA) with federal, state statutory, regulatory, and all other requirements related to the Government and commercial insurance programs. Network Health enhances a culture of compliance through education and open lines of communication in compliance with all Federal and State regulations.

NetworkHealth_PandP_ContinuityContinuedAccess
Network Health uses information at its disposal to facilitate continuity and coordination of member's medical and behavioral health care across its delivery system. Continued access is maintained for members affected by the termination of a practitioner or practice group.

NetworkHealth_PandP_CoordinationofBenefits
This reimbursement policy outlines Network Health's process, for all lines of business, when a member has medical insurance coverage with more than one plan.

NetworkHealth_PandP_CorrectingProviderPayments
This reimbursement policy outlines Network Health's process, for all lines of business, when correcting provider overpayments and/or underpayments related to claims audit findings. This policy is not applicable to the following: -Coordination of benefit (COB) claims -Corrected claims -Provider disputes or appeals -Subrogation claims

NetworkHealth_PandP_DelegationOversight
This policy defines the responsibility of each business owner for oversight of delegated entities as they relate to Network Health 's insurance products in providing or administering health care services for members of, including but not limited to, Medicare Part C, D or Qualified Health Plan benefits.

NetworkHealth_PandP_DisclosingtoLawEnforcement
This policy is established to ensure that Network Health safeguards the privacy of member/participant protected health information (PHI) when reporting or disclosing member/participant PHI to law enforcement officials as required or permitted by law.

NetworkHealth_PandP_DisposalandReuseofMedia
This policy provides guidance for addressing the disposal and potential re-use of data storage devices and media, including fixed and removable disk drives, CD-ROMs, backup tapes, computers, and file storage cabinets.

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.

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.

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

Health First Health Plans_PandP_System Controls
Health First Health Plans Policy on System Controls. Incorporates new NCQA requirements.

Health First Health Plans_PandP_System Control Prior Authorizations
Health First Health Plans Policy on System Controls. Incorporates new NCQA requirements.

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.