| |
Administration
|
| | 917A101: Commercial HMO/POS/QCP - Audit of Claims and Corresponding Medical Records |
| | 917A102: Commercial HMO/POS/QCP - Closed Practice Policy |
| | 917A103: Commercial HMO/POS/QCP - Confidentiality & Accuracy of Records |
| | 917A104: Commercial HMO/POS/QCP - Covering Physician |
| | 917A105: Commercial HMO/POS/QCP - Refusal to Accept/Dismissal of Member |
| | 917A106: Commercial HMO/POS/QCP - Internet Notification |
| | 917A107: Commercial HMO/POS/QCP - Member Access to Practitioner Information |
| | 917A108: Commercial HMO/POS/QCP - Non-Communicating Specialists |
| | 917A109: Commercial HMO/POS/QCP - Non-Compliance Protocols |
| | 917A110: Commercial HMO/POS/QCP - Primary Care Physician Role |
| | 917A111: Commercial HMO/POS/QCP - Inquiry and Appeal Process for Post-Service Claims |
| | 917A112: Commercial HMO/POS/QCP - Appeal Process for Pre-Service Claims |
| | 917A113: Commercial HMO/POS/QCP - Privacy Breach |
| | 917A114: Commercial HMO/POS/QCP - Referral Guide/Provider Directory |
| | 917A115: Commercial HMO/POS/QCP - Service Expectations |
| | 917A116: Commercial HMO/POS/QCP - Specialists Providing Primary Care Services |
| | 917A117: Commercial HMO/POS/QCP - Laboratory Testing |
| | 917A118: Commercial HMO/POS/QCP - Mental Health/Substance Abuse |
| | 917A119: Commercial HMO/POS/QCP - DEXA Scans |
| | 917F102: DEXA Scan Survey |
| | HCM.CMG.279: ESRD Case Management Coordination |
| | QM.CRD.06.01: Site Visits of Practitioner Offices for Member Complaints |
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Credentialing
|
| | QM.CRD.02: Anti-Discrimination |
| | QM.CRD.03: Appeals Committee |
| | QM.CRD.03.01: Appeal Process |
| | QM.CRD.04: Board Certification |
| | QM.CRD.05: Confidentiality of Credentialing Information |
| | QM.CRD.06: Corrective Action of Plan Practitioners |
| | QM.CRD.07: Credentialing Committee |
| | QM.CRD.08: Credentialing of Health Care Delivery Organizations |
| | QM.CRD.08.01: Credentialing Site Visits - Practitioners |
| | QM.CRD.08.02: Ancillary Services & Facility Providers |
| | QM.CRD.09: Delegated Credentialing |
| | QM.CRD.10: Fellowship Verification |
| | QM.CRD.11: Hospital Privileges |
| | QM.CRD.13: Investigation of Conflicting Information |
| | QM.CRD.14: Locum Tenens Credentialing |
| | QM.CRD.15: Ongoing Monitoring of Sanctions and Complaints |
| | QM.CRD.16: Practitioner Initial Credentialing |
| | QM.CRD.17: Practitioner Recredentialing |
| | QM.CRD.18: Practitioner's Right of Review |
| | QM.CRD.19: Practitioner's Right to Correct Errors |
| | QM.CRD.20: Recredentialing Delinquent |
| | QM.CRD.21: Reporting to the NPDB/HIPDB |
| | QM.CRD.23: Updating Credentialing Information |
| | QM.CRD.24: Use of Additional Background Checks |
| | QM.CRD.25: Use of Practitioner Case Reviewers |
| | QM.CRD.26: Professional Malpractice Insurance Coverage |
| | QM.CRD.27: CT and/or MRI Services Policy |
| | QM.CRD.30: Standards in Specialized Pain Management |
| | QM.CRD.31: Clean File Criteria |
| | QM.CRD.32: Provider Information in Member Materials |
| |
Physician Rights and Responsibilities
|
| | 917P101: Commercial HMO/POS/QCP - PCP Rights & Responsibilities |
| | 917P102: Commercial HMO/POS/QCP - Specialist Rights & Responsibilities |
| |
Case Management
|
| | HCM.CMG.024: Travel & Lodging Infertility and Transplant |
| | HCM.CMG.025: Total Parenteral Nutrition |
| | HCM.CMG.041: Infertility Policystic Ovary Disease |
| | HCM.CMG.043: MD Coverage for Skilled Nursing Facility |
| | HCM.CMG.045: Speech Therapy, Occupational Therapy and Physical Therapy for Children |
| | HCM.CMG.060: Sterilization for Catholic Sponsored Plans |
| | HCM.CMG.061: Communication of Clinical Information |
| | HCM.CMG.062: Referral to Associate Medical Director |
| | HCM.CMG.063: Resolution of Conflict in Case Management |
| | HCM.CMG.064: Delegation of Non-Catholic Family Planning and Infertility Rider |
| | HCM.CMG.073: ICD-9 Referral Guidelines |
| | HCM.CMG.074: Case Management |
| | HCM.CMG.081: Healthy Living Survey Risk Categories |
| | HCM.CMG.088: Autism, Pervasive Dev. Disorder and Other Autistic Spectrum Disorders |
| | HCM.CMG.106: Home Health Care Case Management |
| | HCM.CMG.113: Coordination of Infertility Services |
| | HCM.CMG.129: Management of Patients by Specialist |
| | HCM.CMG.153: Endometriosis Infertility |
| | HCM.CMG.169: Autologous Bone Marrow Transplant for Breast Cancer |
| | HCM.CMG.212: Transplants Living Donors |
| | HCM.CMG.213: Care Support Advisor Follow-Up |
| | HCM.CMG.245: Experimental/Investigational Procedure, Services or Supplies |
| | HCM.CMG.246: Transplant |
| | HCM.CMG.268: Tubal Patency - Sub-fertility Post Tubal Ligation |
| | HCM.CMG.269: Infertility Sperm Count - Sub-fertility post |
| | HCM.CMG.286: Complex Case Management Workflow |
| | HCM.CMG.287: Drug Utilization Case Management Program |
| | HCM.CMG.304: Utilization Review Process |
| |
Commercial Administration
|
| | HCM.CML.001: Referral Process |
| | HCM.CML.005: Emergency Room or Urgent Care Claims |
| | HCM.CML.007: Fracture Care Referral |
| | HCM.CML.008: Medical Director Referrals |
| | HCM.CML.017: Sterlization |
| | HCM.CML.018: Written Referral Process |
| | HCM.CML.020: PET (Positron Emission Tomography) Scan |
| | HCM.CML.021: Physical, Occupational and Speech Therapy Services - Pre-requisites |
| | HCM.CML.021.010: Aquatic Therapy |
| | HCM.CML.021.020: CVA Head Injury |
| | HCM.CML.021.030: Lymphedema |
| | HCM.CML.021.040: Vestibular Clinic Vertigo |
| | HCM.CML.023: Orientation and Training Program for HCM |
| | HCM.CML.026: Chiropractic Services - Pre-requisites |
| | HCM.CML.027: PCP and Specialty Services |
| | HCM.CML.028: Enteral Feedings Case Management |
| | HCM.CML.030: Out of Network Referrals |
| | HCM.CML.031: Out of Area Coverage |
| | HCM.CML.039: Avoidable Inpatient Days |
| | HCM.CML.044: Monthly Audit Review for HealthCare Management Coordinators, Specialists and Intake Coordinators |
| | HCM.CML.046: Transition of Services |
| | HCM.CML.047: Workman's Compensation Coverage |
| | HCM.CML.048: Bone Densitometry |
| | HCM.CML.049: Requests for Over-Age Handicap Eligibility |
| | HCM.CML.054: Clinical Criteria for UM Decisions |
| | HCM.CML.066: Confidentiality of UM Information |
| | HCM.CML.067: Preauthorization Process -- Inpatient and Outpatient Surgical Procedures |
| | HCM.CML.068: Preauthorization Process for Inpatient Medical Admissions |
| | HCM.CML.069: Post-Service (Retrospective) Review |
| | HCM.CML.070: UM Program Qualifications |
| | HCM.CML.071: Initial Clinical Review Staff Qualifications |
| | HCM.CML.072: UM Staff Qualifications |
| | HCM.CML.075: Inter-rater Reliability |
| | HCM.CML.077: Transition of Care from Non-contracted Providers to Contracted Providers |
| | HCM.CML.078: Transition of Care After Expiration of Benefits |
| | HCM.CML.082: UM Staff Qualifications for Non Clinical Reviewers |
| | HCM.CML.083: Scope of UM Program |
| | HCM.CML.084a: Timely Completion of Referral Preauth Requests for Non-urgent Preservice Claims |
| | HCM.CML.084b: Timely Coompletion of REferral Preauth Requests for Urgent Preservice Claims |
| | HCM.CML.084c: Timely completion of Referral Preauth Requests for Concurrent Care Decisions |
| | HCM.CML.084d: Changing Claim Status While Under Review |
| | HCM.CML.085: Medical Director Accessible to Discuss Denied PreAuth |
| | HCM.CML.087: Reimbursement for Medical Records |
| | HCM.CML.089: Dermatology Referrals |
| | HCM.CML.089a: Dermatology Referrals - Accutane |
| | HCM.CML.091: Autologous Blood Storage for Surgery |
| | HCM.CML.097: Requesting Information for Preauthorization Completion |
| | HCM.CML.098: Required Information for Referral/Preauth Completion |
| | HCM.CML.099: Referral/Preauth Determination Approval Notification |
| | HCM.CML.100: Referral/Preauth Denial (non auth) Notification |
| | HCM.CML.102: Accessibility and Onsite Department Procedures of HCM Staff |
| | HCM.CML.105: Peer Clinical Review |
| | HCM.CML.108: Medical Director Credentialing |
| | HCM.CML.109: Confidentiality for Members who are Unable to Give Consent |
| | HCM.CML.112: Onsite Review Policy |
| | HCM.CML.115: Rheumatology Care |
| | HCM.CML.116: Physical Therapy for Rectal Incontinence/Pelvic Floor Dysfunction |
| | HCM.CML.119: Pain Management |
| | HCM.CML.120: Allergy Treatment |
| | HCM.CML.121: Diabetic Teaching Dietician and Self Management Training and Education |
| | HCM.CML.123: Foot Strapping |
| | HCM.CML.124: TMJ Evaluation |
| | HCM.CML.127: Perinatologists |
| | HCM.CML.133: Dental Procedures and Hospital Costs Coverage |
| | HCM.CML.134: Coordination of Benefits for Commercial |
| | HCM.CML.135: Podiatry Referral for Onycomycosis |
| | HCM.CML.136: Supervisor Review of Daily Department Workflow |
| | HCM.CML.138: Authorization for Observation vs Inpatient Admission |
| | HCM.CML.145: Physicals |
| | HCM.CML.154: ENT Follow-Up Visits following ear tube insertion |
| | HCM.CML.155: Immunizations |
| | HCM.CML.158: Medicare Primary Referral Preauthorization Completion |
| | HCM.CML.159: Synvisc and Hyalgan Authorization |
| | HCM.CML.160: Timely Completion of Medical Director Reviews |
| | HCM.CML.162: COB Savings Credit Reserve Bank |
| | HCM.CML.163: Genetic Information Privacy Act |
| | HCM.CML.165: Confidentiality Regarding OSFHP Employee Referrals/Preauthorizations |
| | HCM.CML.171: Magnetic Resonance Imaging for the Spine |
| | HCM.CML.174: Computerized Tomography for the Spine |
| | HCM.CML.180: Neuropsychological Testing |
| | HCM.CML.183: Next Review Date Follow Up |
| | HCM.CML.185: Cardiac Rehabilitation |
| | HCM.CML.188: Electronic Notification |
| | HCM.CML.189: Member Correspondence |
| | HCM.CML.203: Specialty Coverage Following Emergency/Urgent Care |
| | HCM.CML.204: Record Request for Selected Surgical Procedures |
| | HCM.CML.211: Daily Denial Audits |
| | HCM.CML.217: Protected Health Information Transmitted and Received by Fax |
| | HCM.CML.219: Hyperbaric Oxygen Treatment |
| | HCM.CML.220: Acupuncture/Acupressure |
| | HCM.CML.223: Genetic Testing for BRCA Gene Mutations |
| | HCM.CML.224: Video Capsule Endoscopy |
| | HCM.CML.229: Platinum Providers |
| | HCM.CML.230: Wound Care Treatment Authorizations |
| | HCM.CML.238: Second/Third Opinions |
| | HCM.CML.239: ASC vs Outpatient Facility Authorization |
| | HCM.CML.239.010: T & A Preauth Guidelines for Children Five and Under |
| | HCM.CML.240: PUVA Treatments |
| | HCM.CML.247: Office Treatment and Procedures |
| | HCM.CML.248: CHF CLinic |
| | HCM.CML.249: Carotid Clinic Referrals |
| | HCM.CML.250: College Students Out of the Area |
| | HCM.CML.251: Hearing Evaluations |
| | HCM.CML.252: Vision Exams/Ophthalmology Referrals |
| | HCM.CML.254: Physician Phone Consults |
| | HCM.CML.256: Dental Expenses |
| | HCM.CML.266: Heart Scan (Coronary Tomography Angiography) |
| | HCM.CML.267: CT (virtual) Colonoscopy |
| | HCM.CML.271: Delegation of Pharmaceutical Management and Formulary/PDL Review |
| | HCM.CML.275: Annual Attestations |
| | HCM.CML.280: Infertility Sperm Count -- Sub-fertility Post Vasectomy Reversal |
| | HCM.CML.293: H. Pylori Breath Testing |
| | HCM.CML.300: Oncotype DX Genetic Testing |
| |
Quality Management
|
| | QM.ADM.01: Policy and Procedure Guidelines |
| | QM.ADM.02: QM Program |
| | QM.CAR.01: Delegation of Quality Activities |
| | QM.CAR.08: Patient Safety |
| | QM.CAR.10: Preventive Healthcare Guidelines |
| | QM.CAR.11: Smoking Cessation Programs and Medications |
| | QM.CAR.12: Continuity & Coordination between Behavioral Healthcare and Medical Care |
| | QM.CAR.13: Health Information System |
| | QM.CAR.14: Medical/Denial Criteria |
| | QM.CAR.15: Monitoring Utilization |
| | QM.CAR.18: Assessing Performance against Access Standards for Routine Care |
| | QM.CAR.19: Assessing Performance against Access Standard for Urgent Care |
| | QM.CAR.20: Consumer Board |
| | QM.CAR.21: Analysis of Complaint Data |
| | QM.CAR.22: Satisfaction Surveys and Corrective Action |
| | QM.CAR.23: Specialist Ratios |
| | QM.CAR.24: Clinical Practice Guideline |
| | QM.CAR.25: Payment Recovery Process |
| | QM.CAR.26: Assessing Performance Against Access Standards for After-Hours Care |
| | QM.COM.02: Communication of QM Information |
| | QM.COM.03: Evaluation of Written Material |
| | QM.COM.04: Geographic Accessibility of PCPs |
| | QM.COM.05: Geographic Accessibility of SPCs |
| | QM.COM.06: Language Assessment |
| | QM.COM.07: Members' Rights & Responsibilities |
| | QM.COM.08: Phone Service in Member Services |
| | QM.COM.09: Release of Physician Compensation Information |
| | QM.COM.10: Health Literacy |
| | QM.HED.03: Outcomes Monitoring |
| | QM.MDR.01: Guidelines for Structure & Content of Medical Record |
| | QM.MDR.02: Medical Record Reviews-Scores/Corrective Action Notification |
| | QM.MDR.03: Record Selection for MMR |
| | QM.MDR.04: Follow Up Review for Practitioners Deficient on Summer Reviews |
| | QM.PCY.01: Drug Alert Letters |
| | QM.TAC.01: Assessing New Medical Technologies |
| | QM.TAC.02: Guest Presenters at TAC |
| | QM.TAC.03: Technology Assessment |
| | QM.UM.01: Release of Utilization Management Data |
| | QM.UM.02: Satisfaction with the UM Process |
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Reimbursment for Covered Services
|
| | 917R101: Commercial HMO/POS/QCP - Administration of Vaccines |
| | 917R102: Commercial HMO/POS/QCP - Coordination of Benefits (COB) |
| | 917R103: Commercial HMO/POS/QCP - Copayment Collection |
| | 917R105: Commercial HMO/POS/QCP - EDI Claim Submission Guidelines |
| | 917R106: Commercial HMO/POS/QCP - 99211 Office Visits |
| | 917R107: Commercial HMO/POS/QCP - Locum Tenens Billing |
| | 917R108: Commercial HMO/POS/QCP - Mid-Level Practitioner Reimbursement |
| | 917R109: Commercial HMO/POS/QCP - Provider Overpayment Recovery – fully insured |
| | 917R111: Commercial HMO/POS/QCP - Timely Filing/Follow-up of Claims |
| | 917R201: Commercial HMO/POS/QCP - Insurance Waiver |
Providers
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