OSF HealthPlans - Policies & Procedures

Commercial PPO Administrative Policies and Procedures

	Credentialing
	QM.CAR.09: Physician Peer Performance Review
	Administration
	917A501: Commercial PPO - Inquiry and Appeal Process for Post-Service Claims
	917A502: Commercial PPO - Appeal Process for Pre-Service Claims
	917A503: Commercial PPO - Confidentiality & Accuracy of Records
	917A504: Commercial PPO - Covering Physician
	917A505: Commercial PPO - Refusal to Accept/Dismissal of Member
	917A506: Commercial PPO - Internet Notification
	917A507: Commercial PPO - Member Access to Practitioner Information
	917A508: Commercial PPO - Non-Compliance Protocols
	917A510: Commercial PPO - Provider Directory
	917A511: Commercial PPO - Service Expectations
	Quality Managment
	QM.ADM.01 (PPO): Policy and Procedure Guidelines
	QM.ADM.02 (PPO): QM Program
	QM.CAR.01 (PPO): Delegation of Quality Activities
	QM.CAR.08 (PPO): Patient Safety
	QM.CAR.09(PPO): Physician Peer Performance Review
	QM.CAR.10(PPO): Preventive Healthcare Guidelines
	QM.CAR.11 (PPO): Smoking Cessation Programs and Medications
	QM.CAR.13(PPO): Health Information System
	QM.CAR.14(PPO): Medical/Denial Criteria
	QM.CAR.21 (PPO): Analysis of Complaint Data
	QM.CAR.23 (PPO): Specialist Ratios
	QM.CAR.25(PPO) : Payment Recovery Process
	QM.COM.02 (PPO): Communication of QM Information
	QM.COM.06 (PPO): Language Assessment
	QM.COM.07 (PPO): Members' Rights & Responsibilities
	QM.COM.08 (PPO): Phone Service in Member Services
	QM.COM.09 (PPO): Release of Physician Compensation Information
	QM.COM.10(PPO): Health Literacy
	QM.MDR.01(PPO): Guidelines for Structure & Content of Medical Record
	QM.PCY.01 (PPO): Drug Alert Letters
	QM.TAC.01 (PPO): Assessing New Medical Technologies
	QM.TAC.02 (PPO): Guest Presenters at TAC
	QM.TAC.03 (PPO): Technology Assessment
	Participating Physician Rights & Responsibilities
	917P501: Commercial PPO - Practitioner Rights & Responsibilities
	Reimbursement for Covered Services
	917R501: Commercial PPO - Coordination of Benefits (COB)
	917R502: Commercial PPO - EDI Claim Submission Guidelines
	917R503: Commercial PPO - Locum Tenens Billing
	917R504: Commercial PPO - Provider Overpayment Recovery – self insured
	917R506: Commercial PPO - Timely Filing/Follow-up of Claims