Policy and Procedures Toolkit
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NetworkHealth_PandP_NoticeofPrivacyPractices
To establish guidelines for the availability, content, and distribution of the Network Health Notice of Privacy Practice's to comply with two federal privacy laws, the Gramm Leach Bliley Act (GLBA) and Health Insurance Portability and Accountability Act (HIPAA). Both require that Network Health provide members with privacy notices concerning Network Health's privacy practices.
NetworkHealth_PandP_PartDCovDeterminationsExceptions
This policy defines the process used by Network Health Insurance Corporation (NHIC) to maintain an exception process for coverage determinations, as well as for exceptions regarding utilization management and cost- sharing. This policy meets the requirement by CMS that plan sponsors who manage the pharmacy benefit through the use of a tiered formulary and/or utilization management criteria to grant an exception whenever the restricted/limited, nonpreferred or otherwise excluded treatment is determined to be medically necessary upon request of the practitioner. The policy will ensure NHIC administers Coverage Determinations and Exceptions per CMS requirements, be compliant with CMS guidance, and will is reviewed annually.
NetworkHealth_PandP_PolicyFormsRateFilings
Compliance will submit and monitor the filing status and maintain a record of all Network Health Plan (NHP) policy form and rate filings with the Wisconsin Office of the Commissioner of Insurance (OCI).
NetworkHealth_PandP_PopulationAssessment
To assess the characteristic and needs of member/participant populations to inform Quality and population health management strategy, structure, and resources.
NetworkHealth_PandP_PreventiveServices
Network Health is required by the Patient Protection and Affordable Care Act to provide specific preventive services at no cost to members, unless stated differently in individual benefit plans. These services include screenings, immunizations, lab tests and other services that may help identify and prevent potential health problems. The ACA mandates coverage of new guidelines without cost sharing the policy year beginning one year after the date the recommendation or guideline is issued.
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.
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.
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.
DenverHealthMedicalPlan_PandP_Clinical_ClinicalCriteria
Describes how DHMP uses written criteria based on sound clinical evidence to make utilization decisions, and specifies procedures for appropriately applying the criteria.
DenverHealthMedicalPlan_PandP_Clinical_ComplexCaseManagement
This policy outlines the process that the Denver Health Medical Plan Complex Case Management (CCM) Program uses to provide CCM services to all of its assigned members.
DenverHealthMedicalPlan_PandP_Clinical_EPSDT
This policy describes DHMP's Early Periodic Screening, Diagnostic, and Treatment (EPSDT) screening package and methods used to assure screening requirements are met.
DenverHealthMedicalPlan_PandP_Clinical_MemberIdentificationProcess
This policy describes DHMP's procedure to proactively identify members for the program using available data systems.
DenverHealthMedicalPlan_PandP_Clinical_MembersSpecialHealthCare
This policy describes DHMP's procedure to identify, screen, and assess members with special health care needs and the process used to provide and coordinate care to ensure members receive the additional services appropriate to their level of need.
DenverHealthMedicalPlan_PandP_Clinical_PractitionerTerminations
This policy outlines the rules and procedures by which Denver Health Medical Plan, Inc ensures its members receive continuity and coordination of medical care when practitioners terminate their contracts with the plan.
DenverHealthMedicalPlan_PandP_Clinical_TransitionsofCareSNP
The purpose of this policy is to ensure compliance with the Center for Medicare and Medicaid Services' (CMS) Special Needs Plan (SNP) requirements, as well as to outline the process by which Denver Health Medical Plan, Inc. (DHMP) manages planned and unplanned care transitions for its SNP members. Managing member transitions between care settings is essential for member safety and quality of care.
DenverHealthMedicalPlan_PandP_Clinical_TransitiontoOtherCare
Document the procedures by which Denver Health Medical Plan, Inc. (DHMP) ensures its members receive continued access to practitioners for continuity and coordination of medical care for a period of time for circumstances such as when a member is in an active treatment plan with an out of network provider, member received emergent services and follow-up care is needed, and/or member is new with the health plan and receiving active treatment.
DenverHealthMedicalPlan_PandP_Clinical_UtilizationManagementProcess
This policy describes DHMP's procedure to maintain accurate documentation or prior authorization requests at all times. This document provides standard procedures to be followed for receipt and processing of PARs.
DenverHealthMedicalPlan_PandP_Clinical_UtilizationManagementProgram
The UM Program Description identifies the goals and objectives of the UM Program, and describes the Program structure and accountability, including the scope, processes and information utilized for Utilization Management (UM) decisionâ?making. This Description covers the Child Health Plan Plus (CHP+), Commercial (COM), Medicaid (MCD) and Medicare (MCR) lines of business (LOBs).
DenverHealthMedicalPlan_PandP_Clinical_UtilizationReviewDeterminations
How Denver Health Medical Plan makes utilization decisions in a fair, impartial and consistent manner using standardized, measurable criteria based on sound clinical evidence. These criteria are applied based on the needs of the individual members.
DenverHealthMedicalPlan_PandP_FWA_FraudWasteandAbuse
This policy outlines the measures taken by the Denver Health Medical Plan for detecting and preventing fraud, waste and abuse.
DenverHealthMedicalPlan_PandP_FWA_PaymentIntegrityAudits
This policy outlines the measures taken by the Denver Health Medical Plan for auditing providers in order to detect and prevent fraud, waste and abuse
DenverHealthMedicalPlan_PandP_FWA_PaymentIntegrityMonitoring
This policy outlines the measures taken by the Denver Health Medical Plan for detecting and preventing fraud, waste and abuse.
DenverHealthMedicalPlan_PandP_FWA_SIURiskAssessment
This policy outlines the measures taken by the Denver Health Medical Plan for conducting an annual Special Investigation Unit (SIU) Risk Assessment in order to detect and/or prevent fraud, waste, and abuse.
DenverHealthMedicalPlan_PandP_ERM_RecordRetentionandDestruction
This policy ensures that Denver Health Medical plan records and those of its subcontractors and providers are adequately maintained, preserved, retained, and destroyed as required by all applicable legal, contractual, regulatory, accreditation, and/or licensure requirements.
DenverHealthMedicalPlan_PandP_ERM_ContractedEntityOversight
This policy describes how Denver Health Medical Plan (DHMP) conducts oversight of its contracted entities and the activities performed on the DHMP's behalf to ensure compliance with DHMP standards, contractual obligations, and applicable laws, regulation and guidance.
DenverHealthMedicalPlan_PandP_ERM_FDRAttestationsofCompliance
This policy describes how Denver Health Medical Plan (DHMP) obtains evidence from its First Tier, Downstream and Related Entities of compliance with Medicare Compliance Program requirements.
DenverHealthMedicalPlan_PandP_ERM_FDRClassification
This policy describes how Denver Health Medical Plan (DHMP) classifies its vendors as First Tier, Downstream and Related Entities.
DenverHealthMedicalPlan_PandP_ERM_Subrogation
This policy describes the process whereby Denver Health Medical Plan (DHMP) shall pursue subrogation to obtain the reimbursement of claims paid on behalf of its members.
DenverHealthMedicalPlan_PandP_Claims_AppealsProcess
This policy describes Denver Health Medical Plan's process for the receipt, processing, investigation, reporting, and communication of all appeal decisions filed by a member or member's representatives.
DenverHealthMedicalPlan_PandP_Claims_IndependentExternalReview
This policy describes Denver Health Medical Plan's process for the receipt, processing, investigation, reporting, and communication of all External Review decisions filed by a member or member's representatives.
DenverHealthMedicalPlan_PandP_Claims_PartCReconsiderations
This policy describes Denver Health Medical Plan's process for the receipt, processing, investigation, reporting, and communication of all appeal decisions filed by a member or member's representatives.
DenverHealthMedicalPlan_PandP_Claims_PartDAppeals
This policy describes Denver Health Medical Plan's process for the receipt, processing, investigation, reporting, and communication of all appeal decisions filed by a member or member's representatives.
DenverHealthMedicalPlan_PandP_Claims_PharmacyAppealProcess
This policy describes Denver Health Medical Plan's process for the receipt, processing, investigation, reporting, and communication of all appeal decisions filed by a member or member's representatives.
DenverHealthMedicalPlan_PandP_Claims_QualityofCareComplaints
This policy describes Denver Health Medical Plan's process for the receipt, processing, investigation, reporting, and communication of all Quality of Care Complaints filed by a member or member's representatives.
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_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.
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.
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.