PROVIDER RESOURCE MANUAL Revised Date:

PROVIDER RESOURCE
MANUAL
A Reference Guide for Network Providers at Group Health Cooperative of
South Central Wisconsin.
Revised Date:
August 4, 2014
Table of Contents
SECTION 1
INTRODUCTION TO GHC-SCW
1.1 About GHC-SCW…………………………………………………………………………………
1.2 History of GHC-SCW…………………………………………………………………………..
1.3 How to use the Provider Manual………………………………………………………..
SECTION 2
PROVIDER RESOURCES
2.1 Key Contact Information……………………………………………………………………
2.2 Provider Resources on GHC-SCW Website (ghcscw.com)…………………..
SECTION 3
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
11
11
11
12
12
12
12
12
ELIBIBILITY VERIFICATION
5.1 Understanding the Member ID Card…………………………………………………..
SECTION 6
10
10
10
COVERED SERVICES
Inpatient Hospital Services…………………………………………………………………
Emergency Care…………………………………………………………………………………
Skilled Nursing Facility Care……………………………………………………………….
Complementary Medicine…………………………………………………………………
Mental Health and Substance Use Disorder Services………………………….
End of Life Services……………………………………………………………………………
Dental Services…………………………………………………………………………………..
Vision Services……………………………………………………………………………………
SECTION 5
6
8
PRODUCT DESCRIPTIONS
3.1 Health Maintenance Organization (HMO) Plan………………………………….
3.2 Point-of-Service (POS) Plan……………………………………………………………….
3.3 Preferred Provider Option (PPO) Plan……………………………………………….
SECTION 4
4
5
5
13
PRIOR AUTHORIZATION GUIDELINES
6.1 Authorization for Services………………………………………………………………….
6.2 Second Opinions………………………………………………………………………………..
1
15
16
SECTION 7
7.1
7.2
7.3
7.4
7.5
7.6
7.7
Filing a Claim……………………………………………………………………………………
Claim Filing Time Frame…………………………………………………………………..
Common Claim Denials and Rejects…………………………………………………
Billing When a Member Has Other Health Insurance Coverage………..
Reconciling Payments………………………………………………………………………
Member Billing Restrictions…………………………………………………………….
Recoupment……………………………………………………………………………………
SECTION 8
8.1
8.2
8.3
8.4
8.5
CLAIMS AND BILLING GUIDELINES
PHARMACY AND PRESCRIBER INFORMATION
Prescription Drug Formulary Information…………………………………………
How the Formulary is Developed…………………………………………………….
Pharmacy Prior Authorization………………………………………………………….
Medication Therapy Management Program……………………………………..
GHC-SCW Pharmacy Network…………………………………………………………..
SECTION 9
25
25
26
26
26
26
MEMBER SERVICES
11.1 Primary Care Provider Selection……………………………………………………..
11.2 Primacy Care Provider Changes……………………………………………………….
11.3 New Member Materials…………………………………………………………………..
11.4 Member Rights and Responsibilities………………………………………………..
SECTION 12
24
CREDENTIALING
10.1 Credentialing Process………………………………………………………………………
10.2 Re-credentialing………………………………………………………………………………
10.3 Provider Rights……………………………………………………………………………….
10.4 Credentialing Confidentiality Policy…………………………………………………
10.5 Provider Changes……………………………………………………………………………..
10.6 Evaluation of Clinic Site……………………………………………………………………
SECTION 11
22
22
22
23
23
CARE MANAGEMENT
9.1 Referring Members for Care Management………………………………………..
SECTION 10
17
18
18
18
19
20
20
28
28
28
29
IMPORTANT FUNCTIONS AND SERVICES
12.1 Clinical Health Education………………………………………………………………….
12.2 Disease Management……………………………………………………………………….
12.3 Health Care Effectiveness Data and Information Set (HEDIS®)…………..
12.4 Wellness and Preventive Services…………………………………………………….
2
31
31
32
33
SECTION 13
PRIMARY CARE PROVIDER RESPONSIBILITIES
13.1 Clinical Practice Guidelines………………………………………………………………
13.2 Access Standards……………………………………………………………………………..
13.3 Encounter Data Submission……………………………………………………………..
13.4 Cultural Competency……………………………………………………………………….
13.5 Interpreter Services…………………………………………………………………………
13.6 Fraud or Abuse - Investigating and Reporting………………………………….
SECTION 14
PROVIDER APPEALS PROCESS
14.1 Appeal /Request for Hearing…………………………………………………………..
14.2 Waiver by Failure to Request a Hearing…………………………………………..
14.3 Notice of Time and Place for Hearing………………………………………………
14.4 Appointment of Hearing Panel…………………………………………………………
14.5 Attendance/Representation…………………………………………………………….
14.6 Rights of Parties……………………………………………………………………………….
14.7 Postponement…………………………………………………………………………………
14.8 Hearing Panel Report……………………………………………………………………….
14.9 Notification of Authorities………………………………………………………………..
SECTION 15
35
36
38
39
39
40
41
41
41
41
42
42
42
42
42
CONFIDENTIALITY
15.1 Privacy within GHC-SCW……………………………………………………………………
43
15.2 How GHC-SCW Will Use and Disclose Patient’s Protected Health Information……44
15.3 When GHC-SCW is Required to Obtain Patient Authorization Prior to Use or Disclosure of PHI
15.4 Safeguarding PHI………………………………………………………………………………
45
15.5 Statement of Patient’s Health Information Rights……………………………..
46
15.6 Internal Protection of Oral, Written, and Electronic PHI Across the Organization..47
15.7 GHC-SCW Website Privacy Protections……………………………………………...
47
15.8 Personal Information vs. Non-Personal Information…………………………..
47
15.9 Sharing Personal Information……………………………………………………………..
48
APPENDIX – A
POLICIES AND PROCEDURES……………………..
3
49
SECTION 1
INTRODUCTION TO GHC-SCW
Welcome to Group Health Cooperative of South Central Wisconsin (GHC-SCW). We are pleased to have
you in our network of providers and look forward to a long, partnership with you.
This manual is intended to be used as a communication tool and reference guide for the network
providers of GHC-SCW. It contains information on our policies and procedures, and our quality
initiatives, as well as how to refer members to specific services. This manual in a way that emphasizes:
• Essential information that providers need to know
• Steps that providers need to take for any prior authorizations for specialty care
• How to obtain more information
The information contained in the manual is as current as the date published. We update individual
subsections of the manual from time to time. In the event of a conflict or inconsistency between the
federal or state regulatory requirements and this manual, the provisions of the regulatory requirements
will prevail.
1.1
About GHC-SCW
Group Health Cooperative of South Central Wisconsin (GHC-SCW) is a non-profit cooperative health
maintenance organization (HMO) representing 75,000 cooperative members. GHC-SCW, as a consumer
sponsored health plan, provides or arranges for the delivery of both primary and specialty health care
and health insurance products to members living or working in South Central Wisconsin. GHC-SCW clinic
services focus on primary care and select specialty care services. One of our Common Values is to
provide for the health and wellness to those in our communities. Community involvement is core to our
non-profit status and Common Values.
Mission: The mission of Group Health Cooperative of South Central Wisconsin (GHC-SCW) is to provide
accessible, comprehensive, high quality health care and outstanding service in an efficient and
personalized manner.
Vision: Group Health Cooperative of South Central Wisconsin (GHC-SCW) will be a leader among health
plans in providing high quality medical care, impeccable service, and competitive benefit levels and
premium rates. GHC-SCW will maintain consistent membership growth and a sound financial return
each year.
Our Common Values: What drives the success of GHC-SCW is our unwavering belief in five Common
Values which shape the way we behave each day in order to deliver the best possible member
experience. These values guide our work:
•
•
•
We are innovative: we create a culture of openness, honesty and the freedom to generate and
express new ideas which provide solutions and enhance services to members.
We are quality- driven: we foster personalized excellence in primary care for members.
We are patient-centered: we encourage member involvement in their care and we devote
ourselves to the health of our members.
4
•
•
We are community involved: we work to cultivate partnerships with our community by
performing good deeds, and contributing to and aiding community organizations.
We are a not-for-profit cooperative: we empower our members to set service standards and to
have “a voice” in their health care while recognizing the unique nature and opportunities of our
non-profit, cooperative governance structure.
Better Together: because we believe in these Common Values, we are able to act according to our brand
promise, “Better Together.” This is a promise we make each day to ourselves and to our key
stakeholders—our members, our group leaders, our agents, our community and each other. The
essence of “Better Together” is the belief that we are stronger together than alone. This belief has been
the guide for our organization since we saw our first patient in 1976 and it will continue to guide us in
the future.
1.2
History of GHC-SCW
GHC-SCW began with the vision of its early founding members who had a novel idea that consumers of
health care should own and govern the way health care is organized and delivered. From that vision,
GHC-SCW was incorporated on March 6, 1972. Almost four years later, on March 1, 1976, GHC-SCW saw
its first patient. GHC-SCW owns and operates six clinics (Hatchery Hill, Sauk Trails, Capitol, Madison
College, East and DeForest) in Dane County. The vision of the founding members has been validated as
GHC-SCW continues to be recognized as one of the highest quality HMOs in the country. The
organization has been recognized by the National Committee for Quality Assurance (NCQA) as they
rated GHC-SCW the top health plan in for eight years in a row.
1.3
How to use the Provider Manual
This manual was drafted in a way so that it is easily searchable and accessible through our website
ghcscw.com. Providers can easily search for particular topics by reviewing the manual’s table of
contents, or by using the Adobe word search feature. The contents of this manual are organized to
highlight important topics, including:
• Covered services
• Eligibility verification
• Prior authorization guidelines
• Claims and billing guidelines
• Pharmacy and prescriber information
We encourage providers to become familiar with contents of the provider manual and to refer to it
frequently. If you have questions or concerns after reading the manual, please discuss them with us. We
welcome and appreciate your ideas for improving our services. Please call the GHC-SCW Provider
Resources Line at (608) 662-4193.
5
SECTION 2
2.1
PROVIDER RESOURCES
Key Contact Information
GHC-SCW Administrative Offices
1265 John Q Hammons Drive
Madison, WI 53717
(608) 251-4156
TTY: (608) 257-7391
ghcscw.com
Department
Care Management
Address
GHC-SCW
1265 John Q Hammons Dr.
Madison, WI 53717
Phone Number
(608) 257-5294
(800) 605-4327, ext.
4514
Compliance
GHC-SCW
1265 John Q Hammons Dr.
Madison, WI 53717
(608) 662-4899
(800) 605-4327
Claims
GHC-SCW
1265 John Q Hammons Dr.
Madison, WI 53717
GHC-SCW
1265 John Q Hammons Dr.
Madison, WI 53717
(608) 251-4526
Fax: (608) 828-4856
Clinical Health
Education
(608) 662-4924
6
Services Provided
- Referral
request/status/extension/reason for
denial
- Home care nursing
assistance/Continuing Care
- All Inpatient Admissions
- All Outpatient services/procedures
- Audit questions or requests
- Privacy or Security Breaches
• Julie Coleman, ext:4237
- Federal or State regulatory inquiries
• David Berry, ext:4873
- Provider inquiries on claims status
- Claims fax number and address
requests
- Register for Disease Management
and Prenatal/Child Classes
-Answer questions about class
offerings
Enrollment
GHC-SCW
1265 John Q Hammons Dr.
Madison, WI 53717
(608) 260-3170
Fax: (608) 662-4837
Eye Care Center
GHC-SCW
3051 Cahill Main
Fitchburg, WI 53711
GHC-SCW
8202 Excelsior Dr.
Madison, WI 53717
(608) 257-7328
Laboratory Services
(608) 250-2005
Fax: (608) 831-9081*
Hours: 7:30 a.m. – 10
p.m. daily seven days a
week
(608) 251-4138
Medical Billing
GHC-SCW
1265 John Q Hammons Dr.
Madison, WI 53717
Medical Imaging
GHC-SCW
3051 Cahill Main
Fitchburg, WI 53711
(608) 661-7248
Medical Records
GHC-SCW
5249 E. Terrace Dr.
Madison, WI 53718
(608) 222-9777,
ext: 3222
Fax: (608) 441-3499
7
- Primary Care Provider (PCP) changes
- Address/demographic changes
- Eligibility status for new or existing
members
- Cobra questions
- Member ID card requests
- Adding or dropping dependents to a
policy
- Adding newborns to a policy
- Employer group requests for
additions/terminations to a group
policy
- Request for Certificate of Creditable
Coverage
* Fax outside orders for your patients
to have their lab draw at any
GHC-SCW lab
- Fee For Service (Member wants to
be seen but is not a GHC Member)
- Copies of payments made for copays and Rx
- Medicare and other insurance
- Workers Comp/Motor Vehicle
Accident Questions
- Billing Statement questions or
payments
- X-ray
- CT Scan
- Ultrasounds
- Mammography
- Bone Mineral Density
- Flourscopy
- Questions about how to obtain
copies of GHC-SCW Medical Records
- Questions about immunizations
given at GHC-SCW (also available via
GHCMyChart)
Member Services
GHC-SCW
1265 John Q Hammons Dr.
Madison, WI 53717
(608) 828-4853,
press 0 and ask for
Member Services or
toll-free at
(800) 605-4327
Mental Health
GHC-SCW
700 Regent St., Ste 302
Madison, WI 53703
(608) 441-3290
Prior Authorization
GHC-SCW
1265 John Q Hammons Dr.
Madison, WI 53717
(608) 257-5294
(800) 605-4327,
ext: 4514
Pharmacy
Administration
GHC-SCW
1265 John Q Hammons Dr.
Madison, WI 53717
(608) 828-4811
(800) 605-4327
Quality
Management
GHC-SCW
1265 John Q Hammons Dr.
Madison, WI 53717
(608) 257-9705
2.2
- Benefit questions/interpretations
- Claims questions from a member
- Compliments/Complaints
- Appeals
- Dental Benefits
- Member eligibility questions from a
provider
- MyChart Password reset
- Questions about mental health
benefits
- Assistance with scheduling an
appointment for the GHC-SCW
mental health department
- Request/status/extension/reason
for denial
- Questions about pharmacy benefits
or drug information
- Pharmacies with questions about
submitting a prescription claim
- Disease management and
preventive outreach
• Chronic conditions
• Letters
• TeleVox calls
- Worksite Wellness calls
- Employee Trust Fund/State Wellness initiative
- NCQA related issues/questions
Provider Resources on GHC-SCW Website
The provider resource page on ghcscw.com is intended to serve as a one-stop hub for providers. The
provider page offers easy access to information on specific services, guidance on completing certain
functions, everyday reference materials (e.g., formulary information, procedures requiring
authorization), and other resources.
EpicLink is a secure, online tool that can be used by all GHC-SCW providers and network provider to
perform administrative tasks, including reviewing:
• Verify insurance coverage
• Review member demographics
• Creating and viewing authorizations
• Summary of Benefits & Coverage
8
Click on the EpicLink button in the right side navigation bar to get started. If you do not have access but
would like access to EpicLink, please contact your Provider Network Coordinator. You will be asked to
sign a Confidentiality Agreement prior to gaining access. If you need assistance, on-site training can be
provided.
After you have returned the required Confidentiality Agreement, your Provider Network Coordinator
will contact you to determine who the administrator account person will be. This person will be provided
access to:
• View Eligibility, Claims, and Benefits
• If needed, Prior Authorization and Remittance
Additionally, you can add users within your facility to allow access to:
• View Eligibility, Claims, and Benefits
• Prior Authorization and Remittance
Forgotten Password/Username:
If you have forgotten your password for EpicLink, simply click on the EpicLink login at ghcscw.com and
enter your username and select Forgot your password. You will be prompted to enter your username
again choose the Email Password. A new password will be emailed to you immediately.
9
SECTION 3
PRODUCT DESCRIPTIONS
GHC-SCW offers several managed health care products for members:
3.1
Health Maintenance Organization (HMO) Plan
GHC-SCW provides a variety of HMO plans, including co-payment, deductible, and co-insurance plans.
Members with an HMO plan must select a PCP and obtain all non-emergent health care services through
a defined network of providers, hospitals, and other medical professionals.
3.2
Point-of-Service (POS) Plan
GHC-SCW’s POS plan pays benefits at two different levels – In-Plan or Out-of-Plan, depending on the
“point” at which the care is accessed.
3.3
Preferred Provider Option (PPO) Plan
GHC-SCW contracts with ChoiceCare and Wisconsin Health Plan as our preferred provider organizations
that make up a national network for our PPO Plan.
10
SECTION 4
COVERED SERVICES
GHC-SCW provides members with coverage for a wide-range of health care services. The covered
services may be subject to cost-sharing (copayments, deductibles, coinsurance, and maximum out-ofpockets) and exceptions/limitations in coverage. For more information about specific benefits, please
consult the GHC-SCW Member Certificate, Benefits Summary, and Summary of Benefits and Coverage
(SBC). The covered services provided by GHC-SCW include, but are not limited to, the following:
4.1
Inpatient Hospital Services
GHC-SCW provides coverage for medically necessary services and supplies furnished to members by a
hospital. Inpatient hospital services covered by GHC-SCW include the hospital room, meals, lab tests,
physical therapy, oxygen, and additional services. Inpatient special duty nursing is available when
medically necessary.
GHC-SCW provides coverage for maternity-related hospital or surgical services, including prenatal and
postnatal care. GHC-SCW covers hospital maternity stays that are 48 hours in duration for vaginal
delivery and 96 hours in duration for Cesarean section. GHC-SCW also provides coverage for obstetrical
services, including lactation services.
4.2
Emergency Care
GHC-SCW provides coverage for services obtained at a hospital emergency room or an emergency room
located at an outpatient facility when the services are necessary to treat an emergency medical
condition. GHC-SCW provides ER coverage for patients both in-network and out-of-network. If a
member is experiencing an emergency medical condition, GHC-SCW instructs them to go to the nearest
emergency room to seek care.
Emergency care also provides coverage for ambulance services when a member is experiencing an
emergency medical condition. This includes both air and ground ambulance services. Air ambulance
services will only be covered when ground transportation would further endanger the member’s health,
or other emergency transportation is not available at that location.
4.3
Skilled Nursing Facility Care
GHC-SCW provides coverage for services that require a qualified nurse or therapist in certain
convalescent/chronic disease facilities. This does not include custodial care or domiciliary services for
chronic conditions. Skilled nursing facility care is typically limited to a certain amount of days in a
plan/benefit year. Information about limits on skilled nursing facility care can be found in the GHC-SCW
Member Certificate, Benefits Summary, and Summary of Benefits and Coverage (SBC).
11
4.4
Complementary Medicine
GHC-SCW provides coverage for complementary medicine services. Complementary medicine
services/treatment include: acupuncture, homeopathy, naturopathy, biofeedback, various types of
manual therapy, various types of massage therapy and energy work, various types of stress reduction
and mind/body medicine, various types of mindfulness therapy, various types of eastern practices, yoga,
movement therapy, wellness classes, and lifestyle change classes. GHC-SCW is proud to be a leader in
the area of complementary medicine. For HMO members, complementary medicine services must be
received from the GHC-SCW Complementary Medicine Department (located at the GHC-SCW Clinics).
4.5
Mental Health and Substance Use Disorder Services
GHC-SCW provides coverage for mental health (MH) and substance use disorder (SUD) services received
on an inpatient, outpatient, and transitional treatment basis. This includes treatment for eating
disorders and other psychiatric conditions.
Inpatient MH/SUD services are covered when received at a GHC-SCW contracted hospital as a bed
patient in that hospital. Outpatient MH/SUD are services provided at a non-residential facility.
Transitional treatment MH/SUD services are typically provided at day treatment programs for adults,
children, and adolescents. All MH/SUD services must be medically necessary and appropriate, as
determined by the GHC-SCW Chief Medical Officer.
4.6
End of Life Services
GHC-SCW provides coverage for supportive and palliative care for terminally ill members whose lifeexpectancy is six months or less. Covered services include nursing care, psychological counseling,
dietary counseling, physical/occupational therapy, medical supplies, prescription medications, and
additional services. This benefit includes an expanded complementary medicine benefit.
4.7
Dental Services
GHC-SCW provides certain dental services under our medical policies. Additionally, GHC-SCW offers a
stand-alone dental policy to employer groups, which offers a more diverse set of dental benefits. Dental
services are provided through our In-Network provider, Dental Health Associates of Madison (DHA).
GHC-SCW medical policies include coverage for accidental injury to teeth, treatment of the
temporomandibular joint (TMJ), and oral surgical procedures. Also, some plans offer preventive dental
(cleanings and fluoride treatment) for children, up to a certain age (typically 12, 15, or 19).
4.8
Vision Services
Some GHC-SCW plans cover vision examinations. Additionally, some plans have an increased vision
benefit that covers eyeglasses for children up to age 19. For HMO members, vision services must be
received from the GHC-SCW Optometry Department (located at the GHC-SCW Hatchery Hill Clinic).
12
SECTION 5
ELIGIBILITY VERIFICATION
Except for emergency services, providers rendering covered services to any GHC-SCW member
should first verify eligibility prior to rendering the service. GHC-SCW does not require a provider to
verify a member’s eligibility prior to rendering emergency services. Verifying the member’s
eligibility is critical to determine whether a member’s enrollment status has changed and to help
ensure payment. A member identification card does not guarantee eligibility.
5.1
Understanding the Member ID Card
All Group Health Cooperative of South Central Wisconsin (GHC-SCW) subscribers or policyholders
receive two individualized member identification cards upon enrollment. The member identification
card (ID card) it is not a proof of member eligibility. It includes the following enrollment related
information:
1. Your Network - The ID card will indicate which network to use to search for providers in Find A
Provider.
2. Plan ID - This is a code for the benefit coverage for the group. You can refer to this information
when calling GHC-SCW Member Services for a more detailed explanation of the member’s benefit
plan coverage.
3. Group Number - The group number identifies the subscriber’s employer group and is usually
the same for all employees and their dependents within that employer group.
4. Prescription (Rx) Information - This information will provide the pharmacy with detailed
information about the plans prescription drug coverage. Within this information there are contact
numbers for prescription drug coverage help and/or questions.
5. Effective Date – This is the date the coverages was effective.
6. Member Name - Each member/dependent is listed under “member name,” along with each
individual member’s PCP name or clinic name and telephone number.
7. Member ID Number - Each member/dependent is identified by a member number. You can
refer to the member number when calling the GHC-SCW.
8. PCP Location - The clinic in which the Primary Care Physician (PCP) selected by each member is
listed along with the clinic phone number. Each member listed on a card may have a different PCP
and/or location. Please Note: This information will not be listed for PPO and POS members.
13
1
2
3
5
8
7
6
4
The back of the ID card includes information for both members and providers. It describes how to obtain
urgent and emergency care. It includes hours and phone numbers for GHC-SCW Member Services.
Please contact GHC-SCW Member Services with questions regarding member benefits.
14
SECTION 6
PRIOR AUTHOIRZATION
GUIDELINES
Prior Authorization (PA) is a process which identifies specific procedures or services which require a
medical necessity and/or medical appropriateness review prior to services being rendered for either
inpatient and/or outpatient services.
6.1
Authorization for Services
GHC-SCW maintains a prior authorization list at ghcscw.com. This list has specific CPT procedure codes
and HCPCs DME/specialty drug codes which require prior authorization. To view the PA list, please see
click here.
GHC-SCW uses the Milliman Care Guidelines® to ensure consistency in utilization practices. The
guidelines span the continuum of patient care and describe best practices for treating common
conditions. The Milliman Care Guidelines® are updated regularly as each new version is published. A
copy of individual guidelines pertaining to a specific case is available for review upon request. To
support prior authorization, concurrent review, and retrospective review decisions, GHC-SCW uses
nationally recognized evidence-based criteria with input from health care providers in active clinical
practice. These criteria are applied on the basis of medical necessity and appropriateness of the
requested service, the individual member’s circumstances, and applicable contract language concerning
the benefits and exclusions. The criteria will not be the sole basis for the decision.
Criteria sets are reviewed annually for appropriateness to GHC-SCW’s needs and changed as applicable
in order to reflect current medical standards. The annual review process involves appropriate providers
in developing, adopting, or reviewing criteria. Providers may obtain a copy of the utilization criteria
upon request.
Prior authorization, concurrent review, and retrospective review requests are presented to the Physician
Reviewer or Chief Medical Officer for review when the request does not clearly meet criteria applied as
defined above. Before making a determination of medical necessity, the reviewing physician may
contact the requester to discuss the case.
The prescribing or treating provider may request a peer review to discuss a medical necessity denial
with a chief medical officer reviewer.
Health care services and items must be medically necessary and provided in an appropriate, effective,
timely, and cost efficient manner. Providers will need to submit by fax or complete the appropriate
authorization online via EpicLink.
The following information is required for prior authorization:
• Current, applicable codes (e.g., Current Procedural Terminology (CPT)/HCPCs codes)
• Member name
• Date of birth
15
•
•
•
•
•
•
•
•
•
•
•
Gender
Member ID #
Primary care or treating provider Tax ID#
Facility name
Facility address
Facility phone and fax number
Signature, if applicable of the referring provider
Problem/diagnosis, must include the ICD-9 code
Reason for the referral
Clinical information such as progress notes, consultation reports, or a letter of medical
necessity, reports of laboratory and imaging studies, and treatment dates, as applicable for the
request.
If DME, indicate rental or purchase
Following the NCQA guidelines, the Care Management Department has up to 15 days to make a
determination; however, if all the clinical information is submitted with the initial PA requests, a
determination is made within 5-7 business days. If additional information is required, the Utilization
Management (UM) staff will contact the provider to inform them what clinical information is needed.
UM staff will contact the provider twice in one week to submit the additional information. If the
information is not received after 5 business days upon receipt of the prior authorization, the PA will be
sent to Physician or Chief Medical Officer to review as is.
When the Care Management Department approves the referral request, a letter is mailed to the
member and the specialist only if provider does not have access to EpicLink. EpicLink will identify PA
approval and/or denials for providers to view. When the member receives the letter of approval, the
member may schedule the appointment to see the specialist. It is helpful for the member to take the
letter of approval to the appointment as it is not always seen by the specialist office in the member’s
electronic medical record. If the member makes an appointment without approval from the GHC-SCW
Care Management Department, they may be responsible for full payment of the services provided.
If the member’s referral request is denied, both the provider and the member will receive a denial letter
in the mail explaining member/provider appeal rights. If the appointment has already been scheduled
for the same day or next day after the denial decision is made, GHC-SCW Care Management Department
will contact the member and the provider of the denial decision.
GHC-SCW approves services or supplies based on the information that is available at the time of the
approval/denial decision. Approval does not guarantee a member’s eligibility or benefits under his/her
health plan. It is the responsibility of the member to know their deductible, Co-payment, or
Co-insurance amounts that apply to Specialty Services.
6.2
Second Opinions
Second opinions are a covered benefit when provided by another GHC-SCW plan provider. Members
should contact their Primary Care Provider for a prior authorization for a second opinion if the request is
for an out of plan provider.
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SECTION 7
7.1
Filing a Claim
CLAIMS AND BILLING
GUIDELINES
The GHC-SCW Claims Department is responsible for the processing of claims for professional,
institutional, and ancillary services rendered to GHC-SCW members. GHC-SCW is committed to meeting
the standard goal of processing claims within 30 days of receipt. In order to meet that goal we have
implemented a workflow system to:
• Eliminate the possibility of misdirected claims
• Retrieve claims and other documentation electronically
• Reduce processing errors through the electronic transfer of claims information
GHC-SCW accepts claims in both electronic and hard copy formats. Please follow the guidelines listed
below to help ensure the GHC-SCW Claims Department can pay the claim in a timely and accurate
manner:
• Submit claims electronically using the standard ASC X12 005010 837 format. Please contact our
EDI administrator Shannon Westman at swestman@ghcscw.com to establish an EDI
submission.
• If you are unable to submit claims electronically, please follow the guidelines below for paper
claims:
o Submit the original claim form individually
o Carbon copies, photocopies, facsimiles, and forms created on laser printers are not
acceptable for claims submission and processing
o Do not staple multiple claims forms together
• Use alpha or numeric characters
o Please use only alphabetical letters or numbers in data entry fields as appropriate.
Symbols such as “$,#, cc, gm” or positive (+) and negative (-) signs may be used when
entering information in the Specific Details/Explanation/Remarks
• Do not write on the claim form with red ink or dark highlighter
o Highlighted areas will appear as a solid black mark, covering the highlighted information
• Use prescribed format when enter dates
o Enter dates in the six-digit format (MMDDYY) without slashes
• Cover corrections
o Do not strike over errors
o Do not use correction fluid
o Do not use correction tape
When submitting a claim please make sure it includes the following data:
• Member name and GHC-SCW member ID #
• Dates of service
• National Provider Identifier (NPI) number
• Service address where services were rendered
• Diagnosis, using current and appropriate ICD-9 codes
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•
•
Services provided, using current and appropriate CPT procedure codes
Charges for each service, using current and appropriate revenue codes
Submit hard copy claims to:
GHC-SCW Administrative Offices
P.O. BOX 44971
Madison, WI 53744-4971
7.2
Claim Filing Time Frames
Providers should file claims within the applicable time frames.
• Providers have one year from the date of service to submit a claim for covered services
rendered on or after January 1, 2014.
Questions regarding the claims submission process should be directed to:
GHC-SCW Claims Department
(608) 251-4526
GHC-SCW Member Services
(608) 828-4853 or (800) 605-4327
7.3
Common Claim Denials and Rejections
The GHC-SCW Claims Department is responsible for processing claims for professional, institutional, and
ancillary services rendered to GHC-SCW members. This section identifies several common reasons that
may cause the GHC-SCW’s Claims Department to deny a claim. When the GHC-SCW Claims Department
identifies a claim that may be contested or denied, the GHC-SCW Claims Department will send a request
for additional information to the provider. If the provider does not respond within 45 calendar days of
the date of the letter requesting the additional information, the claim will be processed based on the
available information. Below you will find the most common reasons for denying claims when providers
do not furnish any additional information.
Description
Duplicate Claim
No Authorization
7.4
Billing Tips
The claim has been denied because an earlier claim was received for
the same member, for the same services, and the same date of
service. The provider should be sure to check the previous payment
record before re-billing the original claim. To inquire on the status of a
claim, the provider can contact the GHC-SCW Claims Department at
(608) 251-4526, Monday through Friday from 8 a.m. to 5 p.m.
The claim has been denied because the service was not authorized.
The provider should refer to ghcscw.com/Pages/Plan-Proivders.aspx
for authorization requirements.
Billing When a Member Has Other Health Insurance Coverage
In general, providers should bill the primary health insurance coverage carrier prior to billing GHC-SCW.
The primary carrier may reimburse the provider at a higher rate than GHC-SCW. If a provider receives
partial payment from the primary carrier, GHC-SCW may be billed for the balance of the
benefit/payment consideration. Below is a more detailed explanation of how to bill GHC-SCW when a
member has other primary health insurance coverage:
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•
•
•
•
•
•
7.5
Bill the primary health coverage carrier first.
Bill GHC-SCW second. Attach the primary coverage carrier’s Explanation of Benefits to the claim
and submit to the GHC-SCW Claims Department.
GHC-SCW may be billed for the balance remaining from other health coverage, including copayments, coinsurance, and deductibles from the primary coverage.
GHC-SCW will pay up to the limitations of member’s specific plan, less the primary coverage
payment amount, if any.
GHC-SCW will not pay the balance of a provider’s bill when the provider has an agreement with
the other health coverage carrier/plan to accept the carrier’s contracted rate as a “payment in
full.”
An Explanation of Benefits or denial letter from the other health coverage must accompany the
GHC-SCW claim.
The amount, if any, paid by the other health coverage carrier for all items listed on the claim
form must be indicated in the appropriate field on the claim. Providers should not reduce the
charge amount or total amount billed because of any other health coverage payment.
Reconciling Payments
It is important that providers account for each claim, so that the provider can conduct any appropriate
follow-up. Providers should also be vigilant in adhering to requirements governing claims submission
timelines.
Tips for reconciliation issues
• Missing Checks
 If a check is missing, please allow 10 calendar days from the release date before making
an inquiry. After 10 days, contact the GHC-SCW Claims Department at (608) 251-4526.
Send the notification to: GHC-SCW Claims Department, P.O. BOX 44971, Madison, WI
53744. Please be sure to include a request for the check to be reissued. GHC-SCW will
initiate a search for the check. If the search finds that the missing check was canceled,
GHC-SCW will send a copy of the front and back of the check to the provider.
 If a provider believes that a check has been stolen, the provider should call the
GHC-SCW Claims Department at (608) 251-4526. Providers should be prepared to
furnish the GHC-SCW claims representative with all of the claims details. Providers
should then submit written notification that a check was stolen. Send the notification to
GHC-SCW Claims Department, P.O. BOX 44971, Madison, WI 53744. GHC-SCW will verify
that the check has not been presented for payment and will place a stop payment order,
if appropriate. A replacement check may be issued by GHC-SCW. Please note that once a
“STOP” is placed on a check, it will not be honored if presented for payment.
•
Returned Checks
 A check may be returned to GHC-SCW by a provider or by the U.S. Postal Service as
undeliverable. The GHC-SCW Claims Department researches undeliverable checks to
locate a correct address. If the check remains undeliverable, the check is re-deposited
into a suspense account, and the claim lines on the check are voided.
 Once a check has been re-deposited and its claim lines have been voided, a provider
must re-bill GHC-SCW to receive payment and advise the GHC-SCW Claims Department
of his or her correct address. The re-submitted claim must be within the timeliness
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guidelines. If the claim is no longer within the timeliness guidelines, the provider may
file a Provider Dispute Resolution (PDR) form with the appropriate documentation
indicating why the claim was submitted late.
 If the check is returned by a provider because of an incorrect payment, the check will be
re-deposited into a suspense account. If there are any correct claims that should be paid
to the provider, the provider must re-bill the claim for reprocessing.
7.6
Member Billing Restrictions
Providers contracted with GHC-SCW cannot bill GHC-SCW members for covered services, except for
applicable co-insurance or co-payment amounts. Furthermore, providers cannot sue a member to
collect sums owed by GHC-SCW. The prohibition on billing of the member includes, but is not limited to
the following:
• Covered services (inclusive of Medicare)
• Covered services provided during a period of retroactive eligibility
• Covered services once the member meets his or her share of cost requirement
• Co-payments, co-insurance, deductible or other cost sharing required under a member’s other
health coverage
• Pending, contested or disputed claims
• Fees for missed, broken, cancelled or same day appointments
• Fees for completing paperwork related to the delivery of care (e.g., immunization cards, WIC
forms, disability forms, and well-child visit forms)
A provider may bill a member only for non-covered services, if:
• The member agrees to the fees in writing prior to the actual delivery of non-covered services;
and
• A copy of the written agreement is provided to the member and placed in his or her medical
record.
7.7
Recoupment
GHC-SCW’s most common method of claim payment correction is the recoupment process. This means
that any amount owed to GHC-SCW will be offset from future payments. All recoupments will be listed
individually and at the end of the remittance advice and will be listed as a negative amount. If an
amount is due to GHC-SCW and there are no claims payments due to a provider during a weekly
payment cycle, an outstanding liability report will print out showing the amount that is still owed to
GHC-SCW.
Example:
A claim was submitted to GHC-SCW and was paid in the amount of $39.43. GHC-SCW then receives
notice that the member terminated coverage. In this case, the full amount of the payment will need to
be recouped from subsequent remittance advices until the amount is repaid.
• The claim is reprocessed and notification that the member was terminated is sent to the
provider on the first payment cycle after the date the claim was reprocessed. On this remittance
advice, there was no payment due to the provider for any other claims. The amount owed to
GHC-SCW on the reprocessed claim will show individually and on the last page of the remittance
advice.
20
•
On the following payment cycle, the check to the provider contained claims payments totaling
$216.00; however, since there is $39.43 listed as an outstanding liability, the check is written for
$176.57. This clears the outstanding liability. Detail of each claim payment amount and the
negative amount is included on the remittance advice.
21
SECTION 8
PHARMACY AND PRESCRIBER
INFORMATION
The following information is provided to help you understand the prescription drug benefit, address
concerns you may have regarding medication coverage, answer benefit-related questions from
members, and work within the GHC-SCW system to ensure the best possible care for our members.
8.1
Prescription Drug Formulary Information
A formulary is a list of medications identifying their level of coverage. It is an important tool to help
GHC-SCW meet its goal of providing coverage for safe and effective medications in an affordable
manner. The Standard GHC-SCW Drug Formulary includes three categories of drugs: Tier 1, Tier 2, and
Specialty drugs. Specialty Tier drugs require prior authorization for coverage and are distributed
through only through selected pharmacies. Some drugs are excluded, including cosmetic treatments,
weight modification medications, medical food, nutritional supplements, most infertility medications,
sexual dysfunction medications, and most over-the-counter medication. The current Formulary is
always posted at https://ghcscw.com/get-care/pharmacy. Questions about drug benefits or
medications listed on the formulary can be directed to GHC-SCW Pharmacy Administration at
(608) 828-4811, or toll free at (800) 605-4327, 8 a.m. – 5 p.m., Monday- Friday.
8.2
How the Drug Formulary is developed
The GHC-SCW Formulary Committee is responsible for creating and maintaining the prescription drug
formulary. This committee is made up of physicians and pharmacists who consider a variety of factors,
such as safety, side effects, drug interactions, how well the drug works, dosing schedule and dose form,
appropriate uses, and cost-effectiveness. The committee obtains the information from a variety of
sources: published clinical trials, data submitted to the FDA for drug approval, recommendations from
local or national treatment guidelines, and input from local experts. GHC-SCW Drug Formulary is subject
to change at any time.
8.3
Pharmacy Prior Authorization
In cases when the GHC-SCW Drug Formulary does not include a specific medication that a physician
believes is medically necessary, the physician may request that GHC-SCW prior authorize that drug for a
specific patient. Requests may be submitted two ways:
1. Complete a PA Request form and fax it to (608) 828-4810. You can find the form on our web site
at ghcscw.com/getcare/pharmacy or by clicking the link below:
https://ghcscw.com/SiteCollectionDocuments/Formulary_Exception_Request.pdf
2. Request a PA by phone; GHC-SCW Pharmacy Administration staff is available at (608) 828-4811,
8 a.m. -5 p.m., Monday through Friday.
Please be sure to include documentation of appropriate clinical information that supports the medical
necessity of the requested item. Please document other drugs tried previously, along with the resulting
clinical outcome. The reviewer may request additional supporting documentation.
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The GHC-SCW Pharmacy Department is responsible for notifying the member and requesting provider of
the decision. Generally, PA Requests will be decided within 3 business days (1 day if urgent). If there is
a denial, members will be notified in writing. Denials will include the reason for denial and an
explanation of the plan’s formal appeals process. A copy of the denial letter will be faxed to the
provider who submitted the PA.
8.4
Medication Therapy Management Program
GHC-SCW’s prescription claims processing interface with local pharmacies includes drug utilization
software that can signal a warning to the pharmacist when certain situations are found, such as
potential duplicate therapy, drug interactions, excessive dose, and more.
8.5
GHC-SCW Pharmacy Network
GHC-SCW uses the national Navitus Pharmacy Network, which includes nearly every pharmacy in
Wisconsin. A list of participating major pharmacy chains is available at https://ghcscw.com/getcare/pharmacy. Providers can also search for pharmacies by zip code or city at
https://prescribers.navitus.com .
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SECTION 9
CARE MANAGEMENT
Care management is the coordination of care and services for members who have experienced a critical
event or chronic diagnosis, or may be a high-risk member. Typically, these members require extensive
use of resources and need help navigating the health care system to facilitate the appropriate delivery
of care and services.
GHC-SCW is committed to providing case management services for our members. We perform a
comprehensive assessment of the member’s condition, determine the available benefits and resources,
develop and implement a case management nursing care plan, establish goals with the member as they
are engaged with the case management program, and continue with monitoring/follow-up contacts
with the member.
The following are guidelines:
• Active chronic diagnoses with two or more co-morbidities
• Two or more hospitalizations in the past three months
• Two or more emergency room visits in the past three months
• Experiences a transition in care or change in health status
• Readmissions within 30 days
9.1
How to Refer a Member for Case Management Services
If a provider identifies a member who would benefit from case management services, the provider
should immediately contact GHC-SCW Care Management Department at (608) 257-5294. Providers
and/or members may self-refer for case management services by completing the CM Self-Referral form.
Please click here for form.
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SECTION 10 CREDENTIALING
Credentialing is an important process GHC-SCW uses to ensure that we offer quality care to our
members. GHC-SCW’s credentialing and re-credentialing processes follow National Committee for
Quality Assurance (NCQA) guidelines for the acceptance, discipline, and termination of providers based
on the provider’s education and history.
10.1
Credentialing Process
Credentialing is an important process GHC-SCW uses to ensure that we offer quality care to our
members and that all providers meet minimum standards relative to licensure, education, malpractice
coverage, etc.
The Credentialing Committee reviews all providers who are in GHC-SCW’s network and make all
credentialing and re-credentialing decisions based solely on the verified information provided on the
provider’s applications. GHC-SCW does not discriminate against an applicant or make credentialing
decisions based on an applicant’s race, ethnic/national identity, gender, age, sexual orientation, or
patient (e.g., Medicaid) in which the provider specializes. The committee reserves the right to
determine which health care providers are eligible to participate in GHC-SCW’s Network. Providers are
required to complete the credentialing process and be approved by the committee prior to treating
GHC-SCW members.
When a new provider joins your facility, please contact your Provider Coordinator to request a
credentialing packet. GHC-SCW’s Medical Staff Administrator will send a packet to the provider within 7
days. If your facility prefers to have the credentialing packet sent to a staff member, please indicate this
to the Provider Coordinator. Typically, the credentialing process will take less than 90 days, but it can
take up to 180 days.
When the Medical Staff Administrator has completed the verification process, the credentials file is
presented to the Credentialing Committee which meets on a monthly basis. The Credentialing
Committee reviews the completed file and either: (a) accepts, (b) accepts with restrictions or conditions,
or (c) denies the application. Within 60 calendar days of the Credentialing Committee’s decision, an
appropriate notification letter is sent to the individual provider or their designee. The Provider
Coordinator will also notify the facility that the provider has been approved and able to see GHC-SCW
members.
10.2
Re-credentialing
Re-credentialing takes place every three years. Providers who are due for re-credentialing will receive
their re-credentialing packet from the GHC-SCW’s Medical Staff Administrator approximately two to
three months in advance. This enables GHC-SCW to complete the process within the required time
frames and will prevent termination of Network participation. The same process that is used for
credentialing is followed for the re-credentialing process.
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10.3
Provider Rights
Providers have the right to review the information submitted in support of their credentialing
application with the exception of references, recommendations or other peer-review protected
information. GHC-SCW’s credentialing staff will notify the provider of any information obtained during
the credentialing process that varies substantially from the information provided to GHC-SCW by the
provider. The practitioner has the right to correct erroneous information and has 30 days to submit
written corrections. The provider also has the right to request application status during the
credentialing or re-credentialing process.
10.4
Credentialing Confidentiality Policy
Information obtained during the credentialing process is confidential. Access to credentialing
information is carefully monitored and the information will not be released to outside parties without
permission of the provider involved, or as permitted by law, including the Health Care Quality
Improvement Act of 1986. Provider credentialing files are accessible only to the Credentialing
Committee, credentialing staff, and GHC-SCW’s Chief Medical Officer
An individual provider may request to review the information contained in his/her file with the
exception of references, recommendations or other peer-review protected information. To request a
review, the provider should contact the Medical Staff Administrator who will schedule an appointment.
10.5
Provider Changes
GHC-SCW requests timely notification of significant changes within your organization so that we can
ensure accurate claims processing, notification to providers and members and continuity of care
processes. Please notify GHC-SCW Medical Staff Administrator as soon as possible of any changes, such
as:
• New practitioner within your facility
• New facility location
• Terminated practitioner
• Terminated location
• Changes in relation to:
o Tax Identification Number
o National Provider Identifier (NPI)
o Phone or Fax number
o Street or Billing address
10.6
Evaluation of Clinic Site
GHC-SCW sets standards for and monitors offices of all practitioners in its network where care is
delivered. GHC-SCW has standards for the quality and safety of office sites, including but not limited to
physical accessibility, physical appearance, adequacy of waiting and examining room space, and
adequacy of medical treatment record-keeping practices.
Member Services reports all complaints about clinic offices to the Medical Staff Administrator. The
Medical Staff Administrator and Clinic Facilities Supervisor will investigate all complaints related to clinic
offices and determine what follow-up is required.
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If two complaints about the same issue for the same office are received within a one-year period, the
Medical Staff Coordinator and/or Clinic Facilities Supervisor conducts a site visit within 60 days of the
second complaint. If a corrective action plan is established for the office site, the Medical Staff
Coordinator and/or Clinic Facilities Supervisor will conduct follow-up site visits until the office site is
compliant with GHC-SCW standards.
GHC-SCW will make every effort to assist the facility to achieve compliance. However, if compliance
cannot be obtained, the Credentialing Committee may take action, up to and including a
recommendation that GHC-SCW terminate its contract with the facility.
An audit may be triggered by member complaints. If a member complaint is made regarding clinic
physical accessibility, appearance or adequacy of waiting room or exam rooms, the Credentialing
Specialist will conduct an on-site audit, using a tool approved by NCQA.
If the clinic is found to be deficient in any area, a corrective action plan will be required. The clinic will
have the opportunity to make corrections and become compliant. The final audit results will be
presented to GHC-SCW’s Credentialing Committee.
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SECTION 11 MEMBER SERVICES
The GHC-SCW Member Services Department responds to the questions and needs of members, as well
as answers questions from providers about their members. Member Services helps members:
• Choose or change a primary care provider (PCP)
• Know how to access care within the managed-care system
• Understand their benefits and how to access care
• Recognize their rights and responsibilities as members
• And more
Contact Member Services, at (608) 828-4853 or toll free at (800) 605-4327, Monday through Friday,
from 8 a.m. to 5 p.m.
11.1
Primary Care Provider Selection
GHC-SCW is committed to ensuring that its members have ample opportunity to select a primary care
provider (PCP) when they join GHC-SCW. The following outlines the major elements of PCP selection
process.
Choice upon Initial Enrollment into GHC-SCW:
• New members have the opportunity to select a GHC-SCW Network. Based on the network
chosen, a PCP is then chosen upon enrollment.
• New members receive a Provider Directory during the GHC-SCW enrollment process, which lists
GHC-SCW’s providers, network clinics, and hospitals.
• New members complete an enrollment form and choose a PCP during the enrollment process.
• If a member does not select a PCP, GHC-SCW will assign the member to a PCP based on the
member’s geographical location. GHC-SCW will notify the member of the assignment, along with
instructions about how to change the PCP.
11.2
Primary Care Provider Changes
Members may choose any of the providers listed in the GHC-SCW Provider Directory as their PCP. If
the PCP is not open to new members, we will ask the member to choose another PCP.
Members may change their PCP and/or network at any time by calling the Member Services
Department at (608) 828-4853 or toll free at (800) 605-4327.
11.3
New Member Materials
Upon enrolling in GHC-SCW, members receive a New Member Welcome Packet. This is sent to
members prior to their effective date of coverage. The packet contains information to help
members access GHC-SCW’s programs and services as well as their GHC-SCW Member ID Card.
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Members also receive an e-newsletter four times a year called HouseCall. The newsletter includes
articles on health education, service and benefit reminders, and information about how to use the
health plan.
11.4
Member Rights and Responsibilities
GHC-SCW stands behind our commitment to provide high-quality, comprehensive and accessible health
care to members in an efficient and personalized manner. To further demonstrate this commitment,
we have established the following patient rights and responsibilities:
Member Rights:
• Receive information about GHC-SCW, its services and its providers, including the right to receive
a copy of the GHC-SCW Patient Rights and Responsibilities.
• Be treated with dignity and respect in a confidential manner
• Participate with your providers in making decisions about your health care
• Participate in a candid discussion of appropriate or medically necessary treatment options for
your conditions, regardless of cost or benefit coverage
• Voice complaints about the service and care you receive without penalty or disenrollment
• Receive notification and a rationale when case management services are changed or no longer
needed
• Receive a certificate outlining the coverage to which you and/or your family members are
entitled, and to whom the benefits are paid
• Ask questions regarding your medical plan coverage, the preauthorization process or claims
payment
• Submit complaints about appeals about GHC-SCW or the care we provide.
• Select a primary care provider and to request a new provider without indicating a reason
• Receive a full explanation of any charges billed to you as a result of care
• Participate in the governance of GHC-SCW. Each member must be at least 18 years of age to be
a voting member of the Cooperative and is encouraged to actively participate in its operation.
• Make recommendations regarding the organization’s member rights and responsibilities
• Receive informed consent, as required by law, prior to procedures or treatments. To the extent
permitted by law, it is your right to refuse the recommended treatment and be informed of the
consequences of this decision
• Receive confidential treatment of all communications and records concerning your care, except
as otherwise provided by law.
• View and receive a copy of your health records and x-rays upon receipt of written authorization.
• Receive a copy of the GHC-SCW Notice of Privacy Practices
Member Responsibilities:
• Be considerate of others.
• Observe safety and smoking regulations in all GHC-SCW facilities
• Treat GHC-SCW employees with consideration and respect
• Provide accurate and complete health care information
• Use facilities and equipment properly
• Read and understand your coverage
• Be on time for appointments and inform the clinic in advance when appointments cannot be
kept
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•
Follow plans and instructions for care as agreed to with your provider
Understand your health problems and participate in developing mutually-agreed-upon
treatment goals
Pay your financial obligations under the benefit plan
Know and confirm your benefits before receiving treatment
Obtain preauthorization for services indicated in your certificate
Notify GHC-SCW of changes in your address, phone number or family status
For more information about member rights and responsibilities, please contact Member Services at
(608) 828-4853 or toll free at (800) 605-4327 and ask for Member Services, Monday through Friday
8 a.m. to 5 p.m. TTD/TTY users can contact us at (608) 257-7391.
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SECTION 12 IMPORTANT FUNCTIONS AND
SERVICES
12.1
Clinical Health Education
Clinical Health Education (CHE) services are an available benefit for members with no co-payment for
many GHC-SCW plans, although co-insurance or deductibles may still apply.
GHC-SCW’s Clinical Health Education specialty areas include but are not limited to:
• Asthma and COPD
• Diabetes Education and Management
• Nutrition Counseling
• Tobacco Cessation
• Genetic Counseling
• Pregnancy, Childbirth, and Infant Feeding
Prior Authorization is not needed to see a CHE provider, although an order from the primary care
provider documenting the need for the visit as part of the member’s plan of care is requested. GHC-SCW
members can schedule individual clinic visits with a CHE provider by calling their clinic. To register for a
CHE class or for more information about these services, contact our Clinical Health Education
Department at (608) 662-4924 or visit ghcscw.com and select “Get Care.”
12.2
Disease Management
GHC-SCW has developed Disease Management Programs to measure and improve the health status and
quality of life of our members. GHC-SCW identifies and automatically enrolls members who are
diagnosed with the following conditions:
• Asthma
• Diabetes
• Cardiovascular Disease
GHC-SCW’s Disease Management Programs are confidential; available to members at no additional cost,
and participation in the programs is voluntary. Each program provides a variety of services for at-risk
members with chronic conditions. The goal is to promote member self-management, assist the primary
care provider in managing the condition and improving the health, well-being, and quality of life for
members.
Member resources and services include:
• An informational brochure about the condition, along with a list of national and local
organizations to contact for additional information
• Condition-specific newsletters
• Reminders about necessary screenings and exams, recommended frequency of practitioner
visits
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•
•
•
•
Annual influenza vaccine reminder
Ongoing educational mailings regarding important health information
Information about the connection between chronic conditions and other co-morbid indications
and when to seek medical assistance
Telephonic follow-up following a visit to the ED or hospital to offer health coaching or potential
referral to case management
Provider resources and services include:
• GHC-SCW's Clinical Practice Guidelines (CPG). Each CPG is developed by an interdisciplinary
group of recognized local leaders and is based on a nationally recognized evidence based
recommended guideline.
• Provider-specific notification on members recently seen in the ED or hospitalized with a
condition-specific diagnosis.
Prior Authorization is not needed to see a health educator. GHC-SCW members can schedule individual
clinic visits with health educators who are certified in diabetes, asthma, and cardiac education. For more
information about the Disease Management Programs, contact our Quality Management Department at
(608) 257-9705.
12.3
Health Care Effectiveness Data and Information Set (HEDIS®)
HEDIS® is a set of standardized measures designed by the National Committee for Quality Assurance
(NCQA) to evaluate performance of health plans and their providers. It allows for assessment based on
quality and performance.
Data that is obtained from HEDIS helps GHC-SCW direct its quality improvement activities, evaluate
performance, and identify further opportunities for improvement. It also helps employers understand
the value a health plan offers and how to hold a health plan accountable for its performance. An
increasing number of employers request HEDIS reports for evaluating cost and quality and for making
comparisons among health plans. Currently, the State of Wisconsin mandates HEDIS reporting for
managed care organizations that provide coverage to State employees. Members and practitioners
periodically receive reminders about missing labs or tests.
Collecting data for HEDIS reports can be challenging. Claims and other pertinent data are collected by
the managed care organization. Such data is not always adequate for complete and accurate reporting,
especially for clinical measurements. Often a review of the medical record is needed to provide accurate
reporting of performance levels.
As a result of measuring health care services, GHC-SCW develops initiatives to improve the health of
members based upon their health care needs. Quality programs serve to increase member awareness
and understanding of preventive health care, health care screenings and appropriate care for specific
conditions. Throughout the HEDIS data collection process, GHC-SCW maintain every member’s
confidentiality at the highest level. No individual results are reported.
32
The seven major areas of performance measured in HEDIS are:
• Effectiveness of Care
• Access and Availability of Care
• Satisfaction with the Experience of Care
• Health Plan Stability
• Use of Services
• Cost of Care
• Health Plan Descriptive Information
If you have questions about the HEDIS measurement process or GHC-SCW’s individual results, please
contact the GHC-SCW Quality Management Department at (608) 257-9705.
To review GHC-SCW’s Quality Improvement Plan please click on link below:
https://ghcscw.com/SiteCollectionDocuments/Quality_Report.pdf
12.4 Wellness and Preventive Services
GHC-SCW provides reminders to members on a variety of preventive health services. Reminders are sent
to members who qualify based on gender, age, claims, laboratory results, and/or pharmacy indicators.
The services for which regular reminders are sent are:
SERVICE OR MEASURE
Childhood Well Check Visits
Health Milestones – reminders of age and gender
appropriate services
Pap and Mammography
Influenza
Diabetes Lab and Screening
PROTOCOL
Annually, to those ages 3 – 21
Female: age 18, 40 and 50
Males: age 50
Females past due
Annually to those considered high risk
Annually (monthly between calls and letters)
Educational topics are available on a variety of topics at ghcscw.com/be well/wellness resources.
Members may participate in a variety of wellness reimbursement options. You may learn more at
ghcscw.com/be well/wellness-reimbursement.
To enroll a member in any of these services, or to learn more, call (608) 828-4853.
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SECTION 13 PRIMARY CARE PROVIDER
RESPONSIBILITIES
The primary care provider (PCP) is the main provider of health care services for GHC-SCW members and
is responsible for the delivery of health care to his or her assigned members. GHC-SCW’s model of care
is built around the PCP, with the PCP at the center of a multidisciplinary team coordinating services
furnished by other physicians or providers to meet the needs of the member.
PCP responsibilities include, but are not limited to, the following:
1. Furnish appropriate care for the health care problems presented by a member, including preventive,
acute and chronic health care, and provide referrals to other practitioners for services.
2. Provide risk assessment, treatment planning, coordination of medically necessary services, referral,
follow-up, and monitoring of appropriate services and resources required to meet a member’s
health care needs. Coordinate medically necessary services that are available to GHC-SCW members
as part of their dual eligibility.
3. Provide basic medical case management to assigned members:
• Ensure continuity of care for the member and an interactive relationship between the PCP and
the member.
• Initiate and maintain in the medical record an individualize care plan (ICP) that addresses areas
identified through the comprehensive assessment.
• Communicate the ICP with providers involved in the member’s care at the point of notification
of a planned or unplanned transition of care.
• Increase member satisfaction.
• Facilitate access to appropriate health services.
• Ensure appropriate use of specialty and hospital services.
• Ensure the appropriate use of the pharmacy and drug benefit including medication
reconciliation.
• Screen health status, monitor, and provide preventive health services.
• Identify and provide appropriate health education to improve a member’s understanding of the
importance of a healthy lifestyle and disease-specific interventions.
4. Assure the provision of the required scope of services to the assigned members.
5. Verify eligibility of the member at the time services are provided.
6. Assure access to care 24 hour per day, seven days per week, including accommodations for urgent
care, performance of procedures, and arrangements for emergency and back-up coverage in the
PCP’s absence.
7. Keep office waiting times to a maximum of 45 minutes.
8. Coordinate and direct appropriate care for members, including scheduling an appointment for high
risk members within 30 calendar days.
9. Provide second opinions as necessary.
10. Consult with a referral specialists (including providing necessary history and clinical data to assist the
specialists in his or her examination of the member).
11. Provide follow-up care to assess results of the primary care treatment regimen and specialist
recommendations
12. Provide special treatment within the framework of integrated, continuous care.
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13. Coordinate the authorization of specialist and non-emergency hospital services for a member, and
ensure that services generated from referrals are initiated within 30 calendar days after the visit at
which the referral was made.
14. Assure the provision of basic clinical services including primary evaluation and treatment of acute
and chronic medical and surgical problems in all systems.
15. Record the following information in the medical record and make records available for review upon
request by GHC-SCW, and applicable federal and state oversight agencies
• Member office visits, emergency visits and hospital admissions)
• A problem list that includes allergies, medications, immunizations, surgeries, procedures and
visits
• Efforts to contact a member
• Treatment, referral, consultation and inpatient stay reports
• Laboratory and radiology results ordered by the PCP
• Individualized Care Plan (ICP)
16. Adhere to the following to ensure that the member’s medical record documentation is accurate:
• The documentation of each encounter includes: reason for encounter and relevant history,
physical examination findings, and prior diagnostic test results, assessment, clinical impression,
or diagnosis, medical plan of care, date and legible identity of the rendering provider
• The current procedural terminology (CPT) and current International Classification of Diseases
(ICD) codes reported on the health insurance claim form or billing statement supported by the
documentation in the medical record
17. Facilitate and ensure quality of care by establishing procedures to contact a member when the
member misses an appointment that requires rescheduling for additional visits, and following up on
referrals to a specialist for care.
18. Assist the member with the GHC-SCW Grievance and Appeals process.
19. Coordinate the transfer of the member and his or her medical records to another provider upon
notification of a planned or unplanned transition of care episode, or upon request by the member.
20. Make all reasonable attempts to communicate with a member in the member’s preferred language,
using interpretation or translation services available through a member’s physician medical group.
21. Preserve the dignity of the member.
13.1
Clinical Practice Guidelines
GHC-SCW encourages its providers to practice evidence-based medicine. GHC-SCW has links to clinical
practice guidelines available to address conditions frequently seen in patients at your practice. All
clinical practice guidelines included have been reviewed and approved by GHC-SCW’s Clinical and
Service Quality Committee (CSQC) and are based on guidelines from national organizations or on a
review of the medical literature. GHC-SCW participates in a stated wide collaborative that meets period
ally to review, develop and approve CPGS. This initiative is led by the University of Wisconsin Center for
Clinical Knowledge and HealthCare.
All guidelines are connected to links that are simple to access and include algorithms for quick
reference. A detailed document accompanies each algorithm. GHC-SCW is confident you will find these
clinical practice guidelines valuable to your daily practice.
35
GHC-SCW’s Quality Management Department reviews the Clinical Practice Guidelines annually and
updates as appropriate to include additional guidelines once approved by the Clinical and Service
Quality Committee.
Notifications regarding updates/changes to the Quality Management provider manual and clinical
practice guidelines are emailed to providers annually. If you would prefer a paper copy of the clinical
practice guidelines or any other part of the provider manual, please contact the GHC-SCW Quality
Management Department at (608) 828-4820.
To view GHC-SCW’s Clinical Practice Guidelines click web site link below:
https://ghcscw.com/Pages/Provider-Resources/Clinical-Practice-Guidelines.aspx
13.2
Access Standards
GHC-SCW is required to adhere to patient care access and availability standards. GHC-SCW has
implemented these standards to ensure that members can get an appointment for care on a timely
basis, can reach the provider over the phone, and can access interpreter services, if necessary.
All GHC-SCW providers and contracted providers are expected to comply with these appointment,
telephone access, practitioner availability and linguistic service standards. GHC-SCW monitors its
providers for compliance with these standards. GHC-SCW will develop a corrective action plan for
providers and health networks that do not meet these standards.
Below is a brief description of the access standards for GHC-SCW members:
Access to Medical Care: Type of Care
Wait Time
Emergency Services
Immediately
Urgent Care
Within 24 hours after request
Non-urgent acute care
Within three calendar days after date of request
Primary care
Within 1 business days after the date of request
Routine physical exams and wellness visits
Within 7 calendar days after the date of request
Specialty care
Within 15 business days of request for appointment
Ancillary services for diagnosis or treatment
Within fifteen 15 business days of request for
appointment
Comprehensive Health Assessments
Within 30 calendar days after enrollment; follow-up
at 30 and 60 calendar days if not returned
In office wait time for appointments
Not to exceed 45 minutes after time of
appointment
Emergency care that is life-threatening
Immediately
36
Emergency care that is not life-threatening
Within six hours after receipt of request
Telephone Access
Wait Times
Telephone wait time during business
hours
A non-recorded voice within 30 seconds and an
abandonment rate of not greater than five percent
Non-emergency and non-urgent
messages during business hours
Practitioner returns the call within 24 hours after the
time of message
Urgent message during business
hours
Practitioner returns the call within 30 minutes after the
time of message
Emergency message during business
hours
Practitioner returns the call within five minutes after the
time of message
Telephone access after business
hours
If recorded message: "If you feel that this is an emergency,
hang up and dial 911 or go to the nearest emergency
room."
If live after-hours attendant and call is an emergency:
• Connect member to the on-call physician; or
• Physician returns the call within five minutes after the
call
Cultural and Linguistic Services
Availability
Verbal interpretation
Verbal interpretation shall be available through an
interpreter in person upon a member's request or by
telephone 24 hours a day and seven days a week.
Written translation
All written materials to members shall be available in
threshold languages as determined by GHC-SCW.
Cultural sensitivity
Practitioners and staff shall encourage members to
express their spiritual beliefs and cultural practices, be
familiar with and respectful of various traditional healing
systems and beliefs and, where appropriate, integrate
these beliefs into treatment plans.
37
Provider Access
Availability
After- hours access
A PCP or designee shall be available 24 hours a
day, seven days a week to respond to afterhours member calls or to a hospital emergency
room practitioner.
Telephone Triage
Telephone triage shall be available 24 hours a
day, seven days a week.
PCP access
90 percent of members shall have a PCP within
10 miles or 30 minutes from the member’s
residence.
PCP availability
Ratio of physician PCPs to members of 1: 2,000
Hospital and ancillary facility access
Within 15 miles or 30 minutes from a
member’s residence or place of business
13.3
Encounter Data Submission
GHC-SCW encourages providers to document patient health information accurately because this
information is permanently a part of the member’s medical record. Below are some important
reminders about data submission:
• Each GHC-SCW provider is responsible for collecting the data and providing it to GHC-SCW.
• To help ensure a complete data encounter accurately, report ICD-9-CM diagnosis codes,
including secondary diagnoses, to the highest level of specificity.
• Maintain accurate and complete medical record documentation (ICD-9 codes submitted should
have proper documentation in the medical record)
• Alert GHC-SCW of any erroneous data that has been submitted.
• Report encounter data within 30 days of the date of service.
• Member risk scores are based on acute, chronic and status conditions documented in the
members’ medical record. In our view, “if it wasn’t documented, it didn’t happen.”
• Every encounter with a patient is an opportunity to assess health and comprehensively
document chronic conditions, co-existing acute conditions, active status conditions, and
pertinent past conditions.
• The most common issues with documentation is that it is not sufficiently thorough. The
following conditions are frequently not documented or documented correctly:
o Major depression (rather than depression)
o Old myocardial infarction
o Renal failure
o Diabetes with complications
o Angina pectoris
o Breast, prostate, colorectal cancers coded as “history of’ rather than active
o Protein calorie malnutrition
o Amputation status
o Drug or alcohol dependency
o Tracheostomy status or respirator dependence
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For more information or additional questions about encounter data, please contact the Coordination of
Benefits Department at (608) 251-4138.
13.4
Cultural Competency
Cultural competency is the ability of individuals, as reflected in personal and organizational
responsiveness, to understand the social, linguistic, moral, intellectual, and behavioral characteristics of
a community or population, and translate this understanding systematically to enhance the
effectiveness of health care delivery to diverse populations.
Members are to receive covered services regardless of: race, ethnicity, national origin, religion, gender,
age, gender identification, mental or physical disability, sexual orientation, genetic information or
medical history, ability to pay, or ability to speak English.
GHC-SCW expects providers to treat all members with dignity and respect as required by federal law.
Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of race, color, and national
origin in programs and activities receiving federal financial assistance, such as Medicaid.
Most importantly, to the extent possible, GHC-SCW strives to meet recipient needs by developing and
maintaining a provider network that mirrors the racial, ethnic and linguistic composition of our
members.
13.5
Interpreter Services
Federal and state regulations require interpreter services to be provided to members with limited
English proficiency. Limited English proficient members include those who do not speak English as their
primary language and who have a limited ability to read, speak, write, or understand English.
Documenting Interpreter Services:
Regulations require that GHC-SCW, and its health network providers to offer free interpreter services to
limited English proficient members, and ensure that the interpreters are professionally trained and are
versed in medical terminology and health care benefits.
Because of these requirements, it is important that providers document when members use or refuse to
use interpreter services. Documenting refusal of interpreter services in the medical record not only
protects the provider and the provider’s practice, it also ensures consistency when medical records are
monitored through site reviews/audits to ensure adequacy of Language Assistance Programs. Below are
some tips on documenting for interpreter services:
1. GHC-SCW recommends using professionally trained interpreters and documenting the use of the
interpreter in the member’s medical record.
2. If the member was offered an interpreter and refused the service, it is important to note that refusal
in the medical record for that visit.
3. Using a family member or friend to interpret should be discouraged. However, if the member insists
on using a family member or friend, it is extremely important to document this in the medical
record, especially if the chosen interpreter is a minor.
39
4. Consider offering a telephonic interpreter in addition to the family member/friend to ensure
accuracy of interpretation.
5. For all limited English proficient members, it is a best practice to document the member’s
preferred language in their electronic medical records.
13.6
Fraud and Abuse – Investigating and Reporting
GHC-SCW takes matters of fraud and abuse very seriously. Strict policies and procedures related to
health care fraud and abuse are in place to ensure that GHC-SCW staff is vigilant in identifying warning
signs and responding appropriately. Examples of health care fraud include:
•
•
•
•
•
A person using someone else’s GHC-SCW Member ID card
A member getting a bill for services not covered by GHC-SCW
A member getting a bill for unnecessary services
A member getting a bill for services not performed
A supply or equipment company sending a bill (e.g., for a wheelchair or diabetic supplies) not
ordered by the provider or incorrectly delivered to the member.
To report suspected or known fraud and abuse, contact the GHC-SCW Compliance Department at
(608) 662-4899 or the Compliance Hotline at (608) 662-4930 or toll free at (800) 605-4327.
40
SECTION 14 PROVIDER APPEAL PROCESS
GHC-SCW is committed to a fair and thorough process for making medical management decisions. To
ensure fair decision-making, GHC-SCW invites providers to discuss such decisions with the chief medical
officer if necessary.
14.1
Appeal / Request for Hearing
Providers have the right to request a hearing and appeal any decision of the GHC-SCW Peer Review
Committee. The providers must request a hearing, in writing, within 30 days from the date the provider
receives the Chief Medical Officer’s final decision and action plan. The request should be sent via
certified mail to the Chair of the Peer Review Committee, 1265 John Q. Hammons Drive, Madison, WI
53717.
14.2
Waiver by Failure to Request a Hearing
A provider who fails to request a hearing within the time and in the manner specified waives his/her
right to any hearing or any appellate review to which he/she might otherwise have been entitled. Such
waiver shall apply only to the matters that were the basis for the initial review.
14.3
Notice of Time and Place for Hearing
Upon receiving a timely and proper request for hearing, the Chief Medical Officer shall then schedule
a hearing. Within fifteen (15) business days of receipt of the request for hearing, the Chief Medical
Officer shall send the provider, via certified mail, notice of the time, place and date of the hearing.
The hearing date shall be within forty-five (45) days of the date the notice of hearing was sent to the
provider.
The notice of hearing must contain a concise statement of the provider’s alleged acts or omissions,
a list of the specific or representative patient records in question, and/or the other reasons or
subject matter forming the basis for the adverse action that is the subject of the hearing.
14.4
Appointment of Hearing Panel
When a hearing has been requested in the manner specified above, the Chief Medical Officer shall
appoint a hearing panel composed of the Chief of Staff, who shall Chair the panel, and no less than three
(3) additional members whose practice is relevant to the issue addressed. This may necessitate the use
of non-employed providers. The hearing panel shall be composed of members of the medical staff who
have not participated actively in consideration of the matter involved at any previous level. Knowledge
of the reasons or subject matter forming the basis for the adverse action or recommendation, which
gave rise to the request for a hearing, shall not preclude a member of the medical staff or other person
from serving as a member of the hearing panel.
41
14.5
Attendance/Representation
The provider may attend the hearing in person or may submit written materials in lieu of their presence.
The practitioner may be accompanied and represented at the hearing by an attorney or by another
person of his/her choice. The provider shall inform the Chief Medical Officer in writing of the name of
that person at least ten days prior to the hearing date. GHC-SCW shall appoint an individual to
represent them. Such individual may be an attorney or any other person designated by the Chief
Medical Officer.
14.6
Rights of Parties
During the hearing, each party shall have the following rights:
a) call and examine witnesses;
b) introduce exhibits;
c) cross-examine any witness on any matter relevant to the issues;
d) rebut any evidence
e) to have a record made of the proceedings, copies of which may be obtained by the
appellant upon payment of reasonable charges for the preparation thereof;
14.7
Postponement
Requests for postponement or continuance of a hearing may be granted by the Chief Medical Officer
only upon a timely showing of good cause.
14.8
Hearing Panel Report
Within twenty (20) days after adjournment of the hearing, the hearing panel shall make a written report
of its findings and recommendations. The report shall contain a summary of the basis of the decision.
The hearing panel shall forward the report along with the record and other documentation to the Chief
Medical Officer. The provider shall also be given a copy of the report.
14.9
Notification of Authorities
As required by the Health Care Quality Improvement Act of 1986, as amended and 45 Code of
Federal Regulations Part 60, the Chief Medical Officer or his/her designee shall report to the State
Medical Examining Board and/or the National Practitioner Data Bank (NPDB) in accordance with the
respective state and federal regulations. Incidents requiring reporting include, but are not limited to:
contract suspension/termination due to quality reasons; involuntary reduction of current clinical
privileges; suspension of clinical privileges; termination of all clinical privileges. All submissions will be
reviewed by corporate council prior to notification to authorities.
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SECTION 15 CONFIDENTIALITY
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal regulation that
requires GHC-SCW and its providers to protect the privacy and security of its members’ Protected Health
Information (PHI). This includes, but is not limited to, ensuring that their right to file a complaint,
amend or restrict the use or disclosure of their PHI is honored in a timely manner. Because patient
information is critical to carrying out treatment, payment, and health care operations, GHC-SCW
supports and encourages the efforts of providers and other staff to work collaboratively to comply with
HIPAA requirements. GHC-SCW Network Providers are encouraged to visit the Office of Civil Rights
website at http://www.hhs.gov/ocr/privacy/index.html to determine whether its privacy practices align
with federal regulations as well as the expectations of GHC-SCW.
Protected health information (PHI) is any individually identifiable health information including but not
limited to a member’s name, address, phone number, social security number, date of birth, medical,
financial, and insurance information.
Privacy protections at GHC-SCW are divided into two distinct components. The first describes the
protections afforded to protected health information (PHI) collected, used, maintained, and disclosed
internally within the organization. The second component addresses privacy protections in place for the
GHC-SCW website, ghcscw.com.
15.1
Privacy within GHC-SCW
Care provided at GHC-SCW is documented and stored in an electronic health record (EHR). This record
contains identification and financial information as well as symptoms, diagnoses, test results, a
description of the patient’s physical examination and a treatment plan. This information is used:
• to plan for care and treatment
• for communication among healthcare providers
• as a legal document describing the care received
• as a way for the insurance company to verify the services provided
• to help GHC-SCW review and improve health care and outcomes
• for other similar activities that allow GHC-SCW to conduct business efficiently and provide the
patient with high quality health care
The GHC-SCW Notice of Privacy Practices (“Notice”) provides the patient with the following important
information:
•
•
•
How we use and disclose protected health information (PHI)
Patient privacy rights with regard to protected health information (PHI)
GHC-SCW’s obligations to our patient’s concerning the use and disclosure of PHI
The terms of the Notice apply to all designated GHC-SCW records containing PHI that are created and
maintained by the organization. The Notice is posted at the entrance to each clinic and is readily
available to our patients in the form of a brochure within our clinical locations and also available by
contacting the GHC-SCW Privacy Officer at (608) 662-4899 or toll free at (800) 605-4327.
43
At any time, the patient may request a copy of the Notice. It is the expectation of GHC-SCW that our
affiliated health care partners maintain, provide and post a copy of their Notice of Privacy Practices in
accordance with the provisions of the HIPAA Privacy Rule. GHC-SCW provides care and administers
health insurance benefits to our patients in partnership with physicians and other health care
professionals and organizations. Our privacy practices are observed by:
•
•
•
Any of our health care professionals who care for patients at any one of our locations (e.g.
nurses, lab technicians, billing staff)
All locations and departments that are part of our organization; and
All members of GHC-SCW’s workforce including employees, students, contractors, interpreters
and interns
GHC-SCW participates in a regional arrangement of health care organizations, who have agreed to work
with each other to facilitate access to health information that may be relevant to their care. As a result
of this sharing, other health care organizations may directly access the PHI of GHC-SCW for the provision
of care and treatment.
15.2
How GHC-SCW Will Use and Disclose Patient’s Protected Health Information
In accordance with the requirements of the HIPAA Privacy Rule, we may use and disclose PHI without
authorization for the following purposes:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
15.3
Treatment, payment and health care operations
Information Provided to the Patient for the Patient
Appointment Reminders
Disclosures Required by Law
Correctional Institutions, law enforcement and victims of abuse, neglect or violence
Public health, public safety and research
Health oversight activities
Judicial and administrative proceedings
Coroners or Medical Examiners and Organ and Tissue Donation
National security
Worker’s compensation
Plan sponsor disclosures (for enrollment and disenrollment purposes only)
Health information marketing functions and disclosure of PHI after death
To those involved with care or payment
When GHC-SCW is required to Obtain Patient Authorization Prior to Use or Disclosure of PHI
Except as described within the Notice of Privacy Practices, GHC-SCW will not use or disclose PHI without
the patient’s written authorization. For example, uses and disclosures made for the purpose of
psychotherapy, marketing, disclosures to plan sponsors and sale of PHI require patient authorization. If
authorization is granted, it may be revoked at any time by contacting the GHC-SCW Privacy Officer at
(608) 662-4899 or toll free at (800) 605-4327.
44
15.4
Safeguarding PHI
PHI in Paper Form
In the Office
PHI located in work areas such as provider’s office, nurse’s stations and
reception desks should be turned upside down at attended desks and in a locked
drawer or file cabinet when unattended.
Paper PHI should never be left in an unattended exam room or patient care area.
Verify fax numbers prior to sending the fax.
Fax
Outgoing faxes must include a fax cover sheet, which contains a confidentiality
disclaimer.
Incoming faxes should not be left unattended on fax machines or common work
areas during non-business hours and retrieved promptly during business hours.
Verify the accuracy of contents to envelope information prior to sending.
Mail
Envelopes or packages must be securely sealed prior to sending.
Envelopes for mailings that contain PHI must contain the name of the GHC-SCW
sender in the return address area.
Paper PHI utilized in remote (e.g. home or travel) locations must be afforded
heightened privacy protections. If unattended, PHI must be properly secured.
Handling PHI Offsite
or a Remote Location
If paper PHI is lost or stolen, it must be reported immediately to the proper
person in authority at that facility.
Loss or theft of paper containing PHI must be evaluated in accordance with the
HIPAA Breach Notification Rule.
Disposal
Documents containing PHI must be properly shredded or destroyed.
45
PHI in Electronic Form
Internal Email: Internal e-mail within the GHC-SCW Network should be used only
for business purposes unrelated to patient care. The electronic health record
(EHR) should be used for such reasons to ensure proper documentation
guidelines are achieved. If use of e-mail within the GHC-SCW Networks is
essential, its content must be limited to the minimum necessary amount of
information required to accomplish the intended task and should not include PHI
in the subject line.
Email
External Email: E-mail sent to external entities may include PHI only if the
sender’s computer has been equipped with a secure encryption function. The
sender’s e-mail must contain a disclaimer to ensure that mis-directed e-mails are
managed appropriately.
Patients may not use e-mail as a means of communicating with their provider(s).
The appropriate tool for patient-provider communication is either GHCMyChart
or telephone.
Portable electronic devices containing PHI, such as laptops, tablets, or cell
phones, must be encrypted and password-protected.
Portable Electronic
Devices
If such devices are lost or stolen, it must be reported immediately to the proper
person in authority at that facility.
Loss or theft of portable devices containing PHI must be evaluated in accordance
with the HIPAA Breach Notification Rule.
Disposal
15.5
PHI in an electronic format must be destroyed or disposed of in a secure manner
in accordance with the requirements of the HIPAA Security Rule.
Statement of Patient’s Health Information Rights
Patients have the right to:
•
•
•
•
•
•
•
•
Inspect and copy health information
Request restrictions
Request confidential communications
Request record amendment
Request an accounting of disclosures
Receive notification of a breach of protected health information
Receive a copy of the Notice of Privacy Practices
File a privacy complaint
46
To exercise any of these rights, the patient may contact the GHC-SCW Privacy Officer directly by:
•
•
•
•
•
15.6
Telephone at: (800) 605-4327 or (608) 662-4899
E-mail to: jcoleman@ghcscw.com
Fax to: (608) 662-4965
Mail to: GHC-SCW Privacy Officer at 1265 John Q. Hammons Drive, Madison, WI 53717
Web: ghcscw.com
Internal Protection of Oral, Written and Electronic PHI across the Organization
GHC-SCW will maintain adequate management controls to ensure appropriate access to PHI regardless
of format or location. Oral, or verbal, access is protected through an ongoing process of education such
as encouraging staff to be aware of their physical surroundings and the use of a moderate voice tone
and volume when in work environments where such discussion may be overheard by those with no
need to know.
Protection of written PHI is assured by providing ongoing education and training to staff and periodic
site audits to evaluate compliance with laws and regulations governing such environments. To ensure
protection of electronic PHI, the organization utilizes role-based access. This process limits employee
access to that PHI specifically required to carry out his/her work functions. For example, a physician
may need access to problem lists and medications while an insurance representative may need only
referral and claims information. Electronic audit trails collect specific information about each keystroke
made into the EHR permitting retrospective review of employee access to confirm appropriateness.
Employees must complete annual HIPAA Privacy Training, including re-signing of the Confidentiality
Agreement. Other activities and publications designed to emphasize expectations for privacy
protections occur throughout the year.
15.7
GHC-SCW Website Privacy Protections
The Website Privacy Statement and the Website Terms and Conditions statements provide detailed
information about GHC-SCW’s efforts to maintain the privacy of information collected, maintained,
used, stored and disclosed on the site. The nature of this information is different than that referenced
in the “privacy within GHC-SCW” portion of this document.
15.8
Personal Information vs. Non-Personal Information
“Personal Information” means information that specifically identifies a user as an individual, such as full
name, telephone number, e-mail address, postal address, or certain account numbers. The website
may include web pages that give the user the opportunity to provide this personal information. A user
does not, however, have to provide the information if they do not wish to do so. GHC-SCW may use
personal information for the following purposes:
• To respond to an e-mail or particular request about the user
• To personalize the website
• To process an application requested by the user
• To administer surveys and promotions
• To provide information that may be useful to the user, such as information about health care
products or services provided by GHC-SCW or other businesses
• To perform analytics and to improve our products, website and advertising
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To comply with applicable laws and regulations
To protect someone’s health, safety or welfare
To protect our rights, the rights of affiliates or third parties, or take appropriate legal action,
such as to enforce our Terms and Conditions
To keep a record of our transactions and communications
As otherwise necessary or useful for us to conduct our business, so long as such use is
permitted by law
“Non-Personal Information” means information that does NOT permit us to specifically identify our
patients by name or similar unique identifying information such as a social security number, member
number, address or telephone number. Non-personal information may be used, unless restricted by law
or by this statement, for the following purposes:
• Customizing the user experience on the website including managing and recording preferences
• Marketing, product development and research purposes
• Tracking resources and data accessed on the website
• Developing reports regarding site usage, activity and statistics
• Assisting users experiencing website problems
• Enabling certain functions and tools on the website
• Tracking paths of visitors to the site and within the site
15.9
Sharing Personal Information
GHC-SCW will only share personal information as outlined in the GHC-SCW Terms and Conditions or this
statement. We do not sell or rent personal information about visitors to this site or customers who use
this site. We may share information in response to a court order, subpoena, search warrant, law or
regulation. We may cooperate with law enforcement in investigating and prosecuting activities that are
illegal, violate our rules, or may be harmful to other visitors. If information is submitted to a chat room,
bulletin board, or similar “chat-related” portions of this website, the information you submit, along with
your screen name, will be visible to other visitors, and such visitors may share with others. We may
share personal information with other companies that we hire to perform services on our behalf or
collaborate with.
48
APPENDIX – A
POLICIES AND PROCEDURES
A.1
HEALTH PLAN INFORMATION
A.2
EPICLINK USER MANUAL
A.3
PHARMAUCEUTICAL MANAGEMENT PROGRAM
A.4
CREDENTIALING AND RE-CREDENTIALING
A.5
PEER REVIEW COMMITTEE
A.6
MEMBER RIGHTS AND RESPONSIBILITIES
A.7
ULTLIZATION MANAGEMENT PROGRAM DESCRIPTION
A.8
COMPLEX CASE MANAGEMENT PROGRAM DESCRIPTION
A.9
ASTHMA DISEASE MANAGEMENT PROGRAM
A.10
DIABETES DISEASE MANAGEMENT PROGRAM
A.11
HEART AND VASCULAR DISEASE MANAGEMENT PROGRAM
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APPENDIX A.1
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GHC-SCW Departments:
Health Education…..……. (608) 662-4924
Care Management……….. (608) 257-5294 or (800) 605-4327, ext. 4514
Quality Management.…… (608) 257-9705
Mental Health……………… (608) 441-3290
Language Assistance:
TTY……………………………. (608) 257-7391
Interpreter Services ……… (608) 828-4853 or
(800) 605-4327, press 0 and ask for Member Services
Gateway Recovery…………………... (608) 278-8200
Group Health Cooperative of South Central Wisconsin
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APPENDIX A.3
_________________________________________
APPROVAL as appropriate:
Board _________Exec Dir _________
Med Dir _________ Other Dir/Mgr _________
_________________________________________
REVIEWED BY LEGAL COUNSEL
Date: x
Yes ___No ___
Name: x
__________________________________________
POLICY STATUS: _x__ Approved ___Pending
Policy and Procedure
Title:
Author:
Volume:
Pharmaceutical Management Program
P. Baum
Div/Dept/Serv Area: Pharmacy
V
Number: CL.PH.BEN.008 Date of Issue:
5/00
Page 1 of 4
Formerly B2b.050 (4/08), PH,033
PURPOSE:
The purpose of this policy is to articulate the Pharmaceutical Management Program of Group Health Cooperative of South
Central Wisconsin (GHC-SCW).
POLICY:
The GHC-SCW Pharmacy promotes and supports rational and cost-effective use of pharmaceuticals in compliance with
NCQA guidelines for pharmaceutical management.
PROCEDURE:
1. Adoption of Policies and Procedures
a. Criteria used to adopt pharmaceutical management procedures.
1) The pharmaceuticals covered will include multiple options for most drug classes that are not excluded by the
insurance contract.
2) The Formulary Committee will evaluate which pharmaceuticals within drug classes will be covered, taking
into account the relative safety, effectiveness, and value of the pharmaceuticals. Other factors that may be
considered in the evaluation include FDA approval: anticipated demand; addressing a medical need; quality
of published studies. The Formulary Committee will also determine criteria for prior authorization for
pharmaceuticals that require it.
3) When coverage limits exist for specific pharmaceuticals, they will be noted within the Formulary document.
4) An exceptions process for obtaining non-covered pharmaceuticals will conform to NCQA standards.
b. Evaluations will use clinical evidence from appropriate external organizations.
1) Information from external organizations is obtained prior to changes in the drug formulary.
2) Information obtained is presented to the Formulary Committee for evaluation.
3) External organizations used include medical and pharmacy literature, University of Wisconsin Center for
Drug Policy, U. S. Food and Drug Administration and its advisory panels, pharmaceutical industry news, and
consultant-specialist recommendations.
Review Date
Revision Date
6/04
9/01
7/13
9/05
9/01
12/13
9/07
9/03
9/09
6/04
9/06
10/08
10/10
7/11
7/12
Policy and Procedure
Title: Pharmaceutical Management Program
Policy Number: CL.PH.BEN.008
Page 2 of 4
c. Procedures will be developed and approved by the Formulary Committee, Medical Director, and appropriate
oversight committees.
1) The Formulary Committee is composed of practitioners and pharmacists. Membership is by appointment of
the Medical Director. The Medical Director retains the right of final approval of Committee actions. The
Pharmacy Services Manager serves as chair of the Committee.
2) Specialist recommendations are sought and made available to Committee members for all new drug
evaluations and for other relevant topics. The Committee Chair may invite a specialist to actively participate
in a given meeting.
d. Availability of pharmaceutical management procedures.
1) The Formulary Committee will review and approve changes to Pharmaceutical Management Procedures
annually, and additionally as needed. The most current Procedures will be posted on the health plan website.
2) New drugs may be added to the drug formulary subsequent to each Formulary Committee meeting. The most
current Procedures will be posted on the health plan website.
3) Members’ financial responsibility will be identified on Formulary documents by Tier category. Members’
plan Benefits Summary information will specify the actual copayment or coinsurance for each Tier.
2. GHC-SCW maintains a list of pharmaceuticals covered under the drug benefit, which includes restrictions, and makes
this information available to members and practitioners.
a. The current drug Formulary will be available on the web, and changes will periodically be published in member
communications.
b. The Formulary will include information on how to use it.
c. The Formulary will include information on restrictions or limits that may apply.
1) Pharmaceuticals on the Formulary are not restricted (beyond the terms of the certificate of insurance) unless
noted within the Formulary. An example would be a quantity limit on a specific drug, as approved by the
Formulary Committee.
2) Drugs listed on the formulary do not require prior authorization unless specifically noted and are subject to
the cost sharing and quantity limits as described in their plan’s certificate of coverage.
3) Exceptions to the quantity limits may be established by the Medical Director and/or the Pharmacy Services
Manager.
4) The GHC-SCW Board of Directors has authority to make changes to the certificate of coverage.
d. Practitioners must provide information to support an exceptions request, establishing that:
1) A reasonable number of similar drugs that are on the formulary have been tried;
2) The formulary drugs were tried with an adequate dose and duration of therapy;
Policy and Procedure
Title: Pharmaceutical Management Program
Policy Number: CL.PH.BEN.008
Page 3 of 4
3) The formulary drugs were not tolerated or were not effective; and
4) The requested drug therapy is evidence-based and generally accepted medical practice.
e. Related processes: generic substitution, therapeutic interchange, and step therapy.
1) Generic substitution is addressed in the Outpatient Prescription Drug Rider, which may provide for a cost
penalty for choosing a brand when an approved generic is available, or identify a copayment tier for branded
versions of generic pharmaceuticals.
2) Therapeutic interchange is not part of the GHC-SCW pharmaceutical management program.
3) Pharmaceuticals on Formulary subject to step-therapy will be identified on Formulary documents.
3. Clinical and Patient Safety Programs
a. GHC-SCW will utilize a prescription claims system that identifies and classifies potential drug interactions. It
will utilize a generally recognized reference source (e.g., Medispan) to identify and classify interactions and
utilize prescriptions in the Claims database, i.e., written by any prescriber and dispensed by any practitioner the
plan is aware of due to on-line prescription claim submissions.
b. GHC-SCW will notify the dispensing practitioner at the point of dispensing of potential interactions by using a
prescription claims system that responds in real-time when a prescription claim is submitted on-line.
c. GHC-SCW will identify patients and prescribers affected by a Class II recall or a voluntary withdrawal from the
market for safety reasons, by query of the central prescriptions claims database. Prescribers will be supplied the
identity of the patients affected by this before communication goes to the patients. This process will be completed
within thirty (30) calendar days of the FDA notification. This procedure does not apply if the recall is issued at
the wholesale-level only.
d. GHC-SCW will identify members and prescribers affected by a Class I drug recall by query of the central
prescription dataset. Notification will be sent to patients and prescribers as quickly as possible, but no later than
seven (7) calendar days of FDA notification
4. Review and Updating pharmaceutical management procedures.
a. The Formulary Committee will review and approve changes to pharmaceutical management procedures annually
and additionally as needed to respond to practitioner, member, or pharmacist requests, or to address new drug
approvals or information.
b. The Formulary Committee will review and revise the list of covered pharmaceuticals at scheduled meetings.
Revisions to the list may occur subsequent to each meeting.
5. Exceptions Process
a. Requests for formulary exceptions may be made by the practitioner or the member by contacting GHC-SCW
Pharmacy Services by telephone or fax. Practitioners who use GHC-SCW’s electronic prescribing system may
Policy and Procedure
Title: Pharmaceutical Management Program
Policy Number: CL.PH.BEN.008
Page 4 of 4
also submit a request by choosing the class of “Prior Auth” when electronically ordering a medication. Members
may use the secure GHC-SCW MyChart website “Ask the Pharmacy” function to submit a request.
b. Formulary exceptions must be based on medical necessity. Any member-generated request will be forwarded to
the member’s practitioner to obtain documentation of medical necessity before evaluation of the request occurs.
c.
(See also Section 2c: “Practitioner provides information supporting the request”.) When the information
submitted to support an exceptions request is insufficient to establish medical necessity, Pharmacy Services will
contact the practitioner to obtain additional information.
d. The request is initially reviewed by Pharmacy Services. If the drug requested has specific written criteria
established and the request includes information supporting that the criteria are met, the request may be approved.
If support is unclear (or for any drugs without specific written criteria), the request is referred to a pharmacist for
review. The pharmacist may consult as necessary with a specialist, Medical Doctor, or other practitioner as
appropriate before making a decision.
e. Exception requests will be handled in a timely manner.
1) Urgent (pre-service) requests will be decided and responded to within one (1) business day of receipt.
(Urgent request are those that could seriously jeopardize the life or health of the member or the member’s
ability to regain maximum function based on a prudent layperson’s judgment, or, in the opinion of a
practitioner with knowledge of the member’s medical condition, would subject the member to severe pain that
cannot be adequately managed without the care or treatment that is the subject of the request.)
2) Non-urgent (pre-service) requests will be decided and responded to within three (3) business days of receipt.
3) If additional information is requested from the practitioner, the request will be pended for an additional five
(5) business days. Lack of response to a request for additional information after the additional period will
result in a denial of that request. If and when additional supporting information is provided, it will be treated
as a new exception request.
f.
Pharmacy Services is responsible for notifying the member and requesting practitioner of the decision. Denials
will further include the reason for denial and an explanation of the plan’s formal appeals process. Approval
notification may be made verbally, electronically, or in writing. Denials to members will be made in writing.
Practitioners will be notified electronically, via fax, or in writing.
APPENDIX A.4
_________________________________________
APPROVAL as appropriate:
Board _________Exec Dir _________
Med Dir _________ Other Dir/Mgr _________
_________________________________________
REVIEWED BY LEGAL COUNSEL
Date: x
Yes ___No ___
Name: x
__________________________________________
POLICY STATUS: _x__ Approved ___Pending
Policy and Procedure
Title:
Author:
Volume:
Credentialing and Re-credentialing/HEDIS Process
M. Ostrov, MD
Div/Dept/Serv Area: Medical Division
7/94
Page 1 of 22
VI
Number: MED.ADM.025 Date of Issue:
Formerly A1a.150 (2/08)/MED.025 (1/12)
PURPOSE:
The purpose of this policy is to document the Credentialing and Re-credentialing /HEDIS Process for Assessment of
Practitioner Board Certification at Group Health Cooperative of South Central Wisconsin (GHC-SCW).
POLICY:
1. In order to promote the highest quality of care for Group Health Cooperative of South Central Wisconsin (GHCSCW) members, GHC-SCW ensures that all employed and contracted practitioners and providers meet minimum
standards relative to licensure, education, and board certification, if applicable. The licensure, educational, and board
certification is verified by the collection of specific credentials on a routine basis.
2. Medical practitioners requiring credentialing are defined as Medical Doctor (MDs), Doctor of Osteopathic Medicine
(Dos), Oral Surgeons, Doctor of Podiatric Medicine (DPMs), Doctor of Chiropractic (DCs), Nurse Practitioners
(NPs), Physician Assistants (PAs), Optometrist (ODs), Physical Therapists (PTs), Occupational Therapists (OT),
Certified Nurse Midwives (CNM) and Speech/Language Therapists. Behavioral Health practitioners requiring
credentialing are defined as physicians and psychiatrists (MD or DO); masters or doctorate level psychologist who are
state licensed (PhD or PsyD); licensed Advanced Practice Nurse Prescribers (APNP); masters or doctorate level
Licensed Clinical Social Workers (LCSW); Licensed Marriage & Family Therapists (LFMT); Licensed Professional
Counselors (LPC); and licensed Clinical Substance Abuse Counselors (CSAC) who are certified to practice
independently.
3. Providers are defined as Hospitals, including Behavioral Health inpatient services; Home Health agencies; Skilled
Nursing facilities; Free Standing Surgical Centers and Behavioral Health Residential and Ambulatory facilities.
4. OVERSIGHT, PRACTITIONER RIGHTS, AND CONFIDENTIALITY
a. OVERSIGHT AND ACCOUNTABILITY
1) As part of the GHC-SCW Quality Improvement Program, GHC-SCW has adopted standards for
credentialing. These standards are described in Policy Items 5a, 5b, and Procedure Item 3 of this Attachment.
2) The GHC-SCW Board of Directors through the Health Services Committee has delegated the responsibility of
practitioner credentialing to the Medical Director. The Medical Director, in turn, delegates the credentialing
process to the GHC-SCW Peer Review/Credentialing Committees. GHC-SCW’s Credentialing Committee is
the same body as the GHC-SCW Peer Review Committee which reviews all credentialing/re-credentialing
applications with or without exceptions (malpractice, sanctions, pending claim, etc) Final approval for
credentialing all practitioners is done by the Medical Director after reviewing recommendations from the
Credentialing Committee and the information obtained during the credentialing process.
Review Date
Revision Date
3/95
1/05
1/97
1/07
5/97
2/08
2/98
1/09
3/99
12/09
2/00
2/11
2/01
1/12
7/02
2/13
7/03
1/04
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 2 of 21
3) The GHC-SCW Medical Director or the Quality Management MD Liaison chairs the Credentialing
Committee which approves the credentialing & re-credentialing of the staff model MDs and DCs, all PCPs in
the Department of Family Medicine and in the UW Health Clinics, direct contract psychiatrists, and all
behavioral health practitioners.
4) GHC-SCW’s Credentialing Committee makes credentialing and re-credentialing decisions based solely on the
verified information provided on the practitioner’s applications. GHC-SCW does not discriminate against an
applicant based on race, ethnic/national identity, gender, age, sexual orientation, or types of procedures or
types of patients (e.g. Medicaid) the practitioner specializes in.
5) GHC-SCW recognizes the need to expedite the approval of clean credential files and may approve clean
credential files outside of the regularly scheduled Credentialing meetings. Clean credential files are defined
as initial or re-credential files whose primary source verification elements (outlined on the GHC-SCW Initial
and Re-Credentialing Checklists) are complete and without questions or concerns and the files meet the
necessary requirements eligible to be approved by the GHC-SCW Credentialing Committee. Clean files may
be approved by the GHC-SCW Medical Director or the Quality Management MD Liaison or designee outside
of the regularly scheduled Credentialing Committee meeting. The Medical Staff Coordinator (MSC) is
responsible for completing the GHC-SCW Initial and/or Re-Credentialing Checklist and will present clean
files to either the Medical Director or the Quality Management MD Liaison or designee for review and
approval. The Medical Director or the Quality Management MD Liaison or designee will sign and date the
GHC-SCW Checklist as indication of approval. A list of the files approved outside of the regularly scheduled
meeting will be presented at the next Credentialing Committee meeting.
6) GHC-SCW’s Credentialing Committee receives and reviews the credentials of all practitioners, including
those who do not meet the organization’s established criteria. GHC-SCW’s Medical Director or Quality
Management MD Liaison monitors for nondiscriminatory credentialing and re-credentialing by reviewing
every file that is denied in the credentialing process to ensure that there has been no discrimination. The
Medical Director or Quality Management MD Liaison performing the review will be the one who did not
chair the Credentialing Committee meeting when the application was denied. GHC-SCW’s Medical Director
or Quality Management MD Liaison will forward the result of their review to the Credentialing Committee,
and the result of his/her review will be documented in the Credentialing Committee minutes.
7) In addition, all applications that are received by the MSC but are not taken to the Credentialing Committee
will be reviewed by the Medical Director or Quality Management MD Liaison. The individual conducting the
review for potential discrimination will be the one not involved in the processing of the application.
8) Annually, all Credentialing Committee members are required to sign an affirmative statement that they will
make decisions in a non-discriminatory manner.
9) GHC-SCW prevents discrimination of credentialing and re-credentialing by maintaining a heterogeneous
credentialing committee and requiring those responsible for credentialing decisions to sign a statement
affirming that they do not discriminate applicants and re-applicants on the basis of race, ethnicity/national
identity, age, gender, sexual orientation, disability status, type of procedures or type of patients.
10) Appropriate documentation for a GHC-SCW credential file must include primary source verification
documentation in one of two ways:
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 3 of 21
a) A detailed, signed/initialed and dated checklist where the checklist contains the name of the source used,
the date of the verification, the signature or initials of the credentialing professional who performed the
primary source verification and the date of the report, if applicable; or
b) Copies of credentialing information and a checklist. GHC-SCW may use an electronic signature or
unique electronic identifier of staff to document verification if it can demonstrate that the electronic
signature or unique identifier can only be entered by the signatory. The system must identify the
individual verifying the information, the date of verification, the source and the report date, if applicable.
11) GHC-SCW will maintain credential and re-credential files for all practitioners that are not delegated for not
less than a six (6) year period to ensure the current credentialing and previous credentialing cycle are
available.
12) The decision making process for initial and re-credentialing of GHC-SCW practitioners and providers is
achieved through the use of a standardized and objective set of criteria set forth in Policy Items 5a and 5b and
Procedure Item 3 below.
b. PRACTITIONER RIGHTS
1) Practitioners have the right to review the information submitted in support of their credentialing applications
with the exception of references, recommendations or other peer-review protected information. Should any
information obtained during the credentialing and re-credentialing process vary substantially from the
information provided by the practitioner, the MSC will notify the practitioners in writing within 10 days of
becoming aware of the discrepancy. The practitioner has the right to correct erroneous information and is
requested to respond, in writing, with additional information to support a correction. Practitioners have up to
30 days to submit written corrections to the MSC. The MSC will respond by telephone, United States Postal
Service or by email to the practitioner within seven (7) calendar days of receiving the corrections.
2) Practitioners have the right, upon request in writing to the MSC, to be informed of the status of their
credentialing or re-credentialing applications. The MSC will respond by telephone, United States Postal
Service or by e-mail to the practitioner within seven (7) calendar days of the status of their credentialing or recredentialing application.
3) In the event an application and attestation must be updated, only the practitioner may attest to the update, a
staff member may not sign on behalf of the practitioner.
4) Practitioners have the right to receive notification of the above rights. GHC-SCW notifies applicants of their
Practitioner Rights at the time of initial and re-application in a statement on the initial application form and in
the letters that accompanies the initial and re-credentialing application.
5) MSC will notify practitioners in writing of credentialing decisions (decisions include acceptance, denial or if
additional information is required to process the application or re-application) within 60 calendar days of the
Credentialing Committee decision.
c. CONFIDENTIALITY OF INFORMATION
1) The information obtained in the credentialing process is confidential. Access to information obtained
throughout the credentialing process will be carefully monitored and will not be released to outside parties
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 4 of 21
without permission of the practitioner involved or by legal responsibility, including the Health Care Quality
Improvement Act of 1986.
2) The credentialing files will only be available to GHC-SCW’s Credentialing Committee, Credentialing Staff
and GHC-SCW’s Medical Director. Credentialing files and minutes will be maintained in a locked, secure
location. The individual practitioner may read information contained in his/her file upon request of a
scheduled appointment. The file review will take place in the presence of GHC-SCW MSC.
5. CREDENTIALING OF STAFF (EMPLOYED) PHYSICIANS, DANE COUNTY PCPs, BEHAVIORAL
HEALTH PRACTITIONERS, CHIROPRACTORS
a. The credentialing verification activities for these practitioners are performed by GHC-SCW.
b. INITIAL CREDENTIALING (See Checklist)
1) The following is a listing of the items that must be present and will be verified. The criteria and the source of
verification is listed below:
2) GHC-SCW requires that the eligible practitioner holds a valid, current, unrestricted license in the State of
Wisconsin. Primary source verification is completed by receipt of written verification directly from the
appropriate state licensing agency or verification via the WI State licensing web page at
http://online.drl.wi.gov/LicenseLookup/LicenseLookup.aspx is acceptable.
3) GHC-SCW requires that the eligible practitioner, if applicable, holds a valid, current DEA in the State of
Wisconsin. Primary source verification of DEA is completed by query of the Drug Enforcement
Administration (DEA) Registration File from NTIS (CD ROM received quarterly) OR by the MSC viewing a
photocopy of the DEA. The DEA must be valid in the state where the practitioner provides care to GHCSCW members. If practitioner type is eligible for a DEA (i.e. MD, DO, DPM, APNP, PA-C or OD) but does
not have a DEA, the practitioner must explain why no DEA AND provide explanation of arrangements for
his/her patients who need prescriptions requiring DEA certification. If a practitioner’s DEA is pending, a
written plan will be documented in the provider’s credential file, which allows a practitioner with a valid
DEA certificate to write all prescriptions requiring a DEA number for the prescribing practitioner until the
practitioner has a valid DEA.
4) GHC-SCWs requirement for completion of education is based on the practitioner type. Primary verification
of highest level of education is outlined by the following provider types:
a) MD and DO
(1) Board Certification is preferred, but not required by GHC-SCW. If the physician is board certified,
primary source verification of board certification satisfies the verification of highest level of
education.
(2) For MDs, GHC-SCW will verify board certification via the American Board of Medical Specialties
(ABMS) thru CeriFACTS on line (password protected). GHC-SCW only recognizes those board
associated with the ABMS. For those ABMS Boards who do no provide an expiration date, GHCSCW will verify the board certification within 180 days of the initial or re-credentialing decision date.
(3) For DOs, GHC-SCW will verify board certification via the American Osteopathic Association (AOA)
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 5 of 21
Board Certification. GHC-SCW will contact the Board, in writing, online, or by phone for primary
source verification.
(4) For practitioners who are not board certified, GHC-SCW requires the physician to complete a
residency program. Acceptable residency programs include only those residency programs that have
been accredited by the Accreditation Council for Graduate Medical Education (ACGME) and the
American Osteopathic Association (AOA) in the United States or by the College of Family
Physicians of Canada (CFPC) or the Royal College of Physicians and Surgeons of Canada. GHCSCW will contact the residency program in writing or by phone for primary source verification OR
verification of licensure from the State of Wisconsin Department of Safety & Professional Services
website satisfies the verification of highest level of education.
(5) For practitioners who did not complete a residency, primary source verification is completed by
contacting the medical school
b) DPM
(1) Board Certification is preferred, but not required by GHC-SCW. If the physician is board certified,
primary verification of board certification satisfies the verification of highest level of education.
Verify via the American Board of Podiatric Surgery Board Certification. GHC-SCW MSC will
contact the Board, in writing for primary source verification
(2) If the physician is not board certified, GHC-SCW requires the physician to complete his/her
education from a podiatry college. Primary source verification is completed by contacting the
Podiatry school OR verification of licensure from the State of Wisconsin Department of Safety &
Professional Services website satisfies the verification of highest level of education.
c) DCs
(1) GHC-SCW requires physician to complete his/her education from a Chiropractic College. Primary
source verification is completed by contacting the Chiropractic College OR verification of licensure
from the State of Wisconsin Department of Safety & Professional Services website satisfies the
verification of highest level of education.
d) NP, PA-C, OD, PT, Speech and Language Therapists and other Credentialed Providers
(1) GHC-SCWs requirement for practitioner education is based on practitioner type.
(2) Professional School –or(3) Primary Source verification is completed by confirmation from the WI Licensing Department, which
performs primary source verification of education for all licensed practitioner types.
(4) If the healthcare professional is board certified, primary source verification from the appropriate
specialty board is completed.
e) Oral Surgeon
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 6 of 21
(1) Board certificated is preferred, but not required by GHC-SCW. If the provider is board certified,
primary verification of board certification is obtained from the appropriate specialty board if the
board performs primary source verification of graduation from a CODA accredited training program.
At least annually, the organization must obtain written confirmation from the specialty board that is
performs primary-source verification of graduation from a CODA accredited training program.
(2) For providers not board certified, verification of completion of a residency training program in Oral
and Maxillofacial Surgery accredited by the Commission on Dental Accreditation (CODA). GHCSCW will contact the residency program in writing or by phone for primary source verification OR
verification of licensure from the State of Wisconsin Department of Safety & Professional Services
website satisfies the verification of highest level of education.
5) Annually, MSC obtains written confirmation from the WI Licensing agency that it performs primary source
verification of education.
6) GHC-SCW requires the applicant to complete an application and attest to its correctness and completeness.
The following questions must be addressed:
a) Physical and mental health status and reasons for inability to perform essential functions of the position,
with or without accommodations
b) Chemical dependency or lack of illegal drug use
c) History of loss of license and/or felony convictions
d) History of loss or limitation of clinical privileges or disciplinary action
e) Work history for the last five years in mm/yy to mm/yy format, and any gaps six (6) months or greater
must be explained, in writing.
f) Malpractice history
g) Current coverage for malpractice insurance, including dates and amounts, even if the coverage amount is
$0.
h) Signature attesting to the correctness and completeness of the application
7) GHC-SCW requires a National Practitioner Data Bank (NPDB) report to be run on all applicants for
verification of malpractice history and initial sanction information. The Committee will review all adverse
NPDB reports. The MSC will obtain a query of the NPDB at https://www.npdb-hipdb.com/login.html.
8) The MSC will enroll all practitioners in the Proactive Disclosure Service (PDS) for NPDB and HIPDB. All
enrolled practitioners are renewed annually.
9) If employment is terminated, the enrollment is canceled 30 days after termination date.
10) Any notifications from the PDS are sent via e-mail to the MSC including malpractice claims, Office of the
Inspector General sanctions, and Department of Regulation and Licensing orders
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 7 of 21
11) Review of Medicare/Medicaid sanctions through the NPDB-HIPDB
12) Review of the Disciplinary Actions by the Medical Examining Board through the NPDB-HIPDB for MD,
DO, Oral Surgeons, non-physician, and behavioral health care professional.
c. For Chiropractors, GHC-SCW requires a query of the disciplinary actions from the National Practitioner Data
Bank. The Committee will review all adverse NPDB-HIPDB reports. The MSC will obtain the query.
d. For Podiatrists, GHC-SCW requires a query of the disciplinary actions through the State Board of Podiatric
Examiners, The Federation of Podiatric Medical Boards, or the National Practitioner Bata Bank. The
Committee will review all adverse reports. The MSC will obtain the query.
e. Verification and completion of all of the above must be within 180 days prior to the date of the initial credentialing
decision.
f. The Credentialing Committee reviews the application and credentialing documents and makes recommendations to
the Medical Director. A practitioner from the specialty of a practitioner being credentialed participates on the
Credentialing Committee.
g. Credentialing process is completed prior to a practitioner providing services to GHC-SCW members.
h. If GHC-SCW terminates a practitioner and later wishes to reinstate the practitioner, GHC-SCW will credential and
re-verify credentialing requirements, if the break in service is 30 days or more. GHC-SCW’s Credentialing
Committee will review all credentials and make a final determination prior to the practitioner’s reinstatement.
6. RE-CREDENTIALING (See Checklist)
a. GHC-SCW employed physicians; Dane County PCPs, Oral Surgeons, NPs, PA-Cs, ODs, PTs, OTs, Speech and
Language Therapists, behavioral health practitioners, DCs and other credentialed providers are re-credentialed
every three years.
b. The following is a listing of the items that must be present and will be verified. The criteria and the source of
verification is listed below:
1) GHC-SCW requires that the eligible practitioner holds a valid, current, unrestricted license in the State of
Wisconsin. Primary source verification by receipt of written verification directly from the appropriate state
licensing agency or verification via the WI State licensing web
page:http://online.drl.wi.gov/LicenseLookup/LicenseLookup.aspx.
2) GHC-SCW requires that the eligible practitioner, if applicable, holds a valid, current DEA in the State of
Wisconsin. Primary source verification of DEA is completed by query of the Drug Enforcement
Administration (DEA) Registration File from NTIS (CD ROM received quarterly) OR by the MSC viewing a
photocopy of the DEA. The DEA must be valid in the state where the practitioner provides care to GHCSCW members. If practitioner type is eligible for a DEA (i.e. MD, DO, DPM, APNP, PA-C or OD) but does
not have a DEA, the practitioner must explain why no DEA AND provide explanation of arrangements for
his/her patients who need prescriptions requiring DEA certification. If a practitioner’s DEA is pending, a
written plan will be documented in the provider’s credential file, which allows a practitioner with a valid
DEA certificate to write all prescriptions requiring a DEA number for the prescribing practitioner until the
practitioner has a valid DEA.
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 8 of 21
3) GHC-SCW does not require board certification; however if a re-applicant is board certified, GHC-SCW must
verify the board certification. Verify via the American Board of Medical Specialties (ABMS) thru
CeriFACTS on line (password protected). GHC-SCW only recognizes those board associated with the
ABMS or the AOA. For those ABMS Boards who do no provide an expiration date, GHC-SCW will verify
the board certification within 180 days of the initial or re-credentialing decision date.
4) GHC-SCW requires continuous monitoring of adverse events through the NPDB/HIPDB and this is
maintained through the PDS.
5) The MSC will maintain continuous enrollment of all practitioners in the Proactive Disclosure Service (PDS)
for NPDB and HPDB.
6) All enrolled practitioners are renewed annually.
7) If employment is terminated, the enrollment is canceled 30 days after termination date.
8) Any notifications from the PDS are sent via e-mail to the MSC including malpractice claims, Office of the
Inspector General sanctions, and Department of Regulation and Licensing orders.
9) Review of Medicare/Medicaid sanctions through the NPDB-HIPDB/PDS
10) Review of the Disciplinary Actions by the Medical Examining Board through the NPDB-HIPDB for MD,
DO, Oral Surgeons, non-physician, and behavioral health care professionals
11) At the time of re-credentialing, GHC-SCW requires re-applicants to submit a current, signed attestation by the
applicant regarding:
a) Physical and mental health status and reasons for inability to perform essential functions of the position,
with or without accommodations
b) Chemical dependency or lack of illegal drug
c) History of loss of licensure since last appointment
d) Any felony convictions since last appointment
e) History of loss or limitation of clinical privileges or disciplinary activity since last appointment
f) Current coverage for malpractice insurance, including dates and amounts, even if the coverage amount is
$0.
g) Signature attesting to the correctness and completeness of the statement
12) GHC-SCW requires a monthly review of the Disciplinary Actions by the State of Wisconsin Medical
Examining Board. The MSC queries the report monthly and presents the report to the Committee.
13) GHC-SCW reviews all Quality of Care and Service complaints for any practitioner being re-credentialed.
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 9 of 21
14) Verification and completion of all of the above must be within 180 days prior to the date of the recredentialing decision.
15) Review of all of the above information by the Credentialing Committee with re-credentialing
recommendations to the Medical Director.
16) If GHC-SCW terminates a practitioner and later wishes to reinstate the practitioner, GHC-SCW will
credential and re-verify credentialing requirements, if the break in service is 30 days or more. GHC-SCW’s
Credentialing Committee will review all credentials and make a final determination prior to the practitioner’s
reinstatement.
7. DELEGATED CREDENTIALING OF PHYSICIANS AND OTHER PRACTITIONERS AT HOSPITALS OR
OTHER ENTITIES
a. GHC-SCW considers delegating to another organization only after performing a pre-delegation audit, which
ensures the delegate candidate is compliant with GHC-SCW’s credentialing and re-credentialing policies
described in this document. The available elements for delegation are described in Procedure Items 1 and 2
below. It is the Medical Director’s responsibility to determine if the delegated entities meet the standards
established by Group Health Cooperative of South Central Wisconsin. The delegation agreement must be in place
before delegated activities are performed.
b. Upon successful completion of a pre-delegation audit, GHC-SCW prepares a written delegation agreement which
includes the following elements:
1) The delegation document is mutually agreed upon
2) The delegation document describes the responsibilities of GHC-SCW and the delegated entity
3) The delegation document describes the delegated activities (as described in Procedure Items 1 and 2 below).
4) The delegation document describes the reporting process, which includes at least semiannual reporting from
the delegated entity. GHC-SCW prefers monthly reports, but requires at least semiannual reports.
5) The delegation document describes the process by which GHC-SCW annually performs an evaluation of the
delegated entity’s performance
6) The delegation document describes remedies to the organization if the delegated entity does not fulfill it’s
obligations, including revocation of the delegation agreement.
7) The delegation agreement includes the use of protected health information (PHI) by the delegated entity and
the following PHI provisions:
a) A list of the allowed uses of PHI
b) A description of delegate safeguards to protect the information from inappropriate use or further
disclosure
c) A stipulation that the delegate will ensure that sub delegates have similar safeguards
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 10 of 21
d) A stipulation that the delegate will provide individuals with access to their PHI
e) A stipulation that the delegate will inform the organization if inappropriate uses of the information occur
f) A stipulation that the delegate will ensure that PHI is returned, destroyed or protected if the delegation
agreement ends
8) Credentialing activity is delegated to University of Wisconsin Medical Foundation (UWMF) and to Dean
Health Plan for practitioners not employed by GHC-SCW who have privileges at area hospitals or are
credentialed by Dean Health Plan.
9) GHC-SCW retains the right to approve, suspend and terminate individual practitioners, providers and sites for
any delegated practitioner, provider and site.
10) GHC-SCW MSC performs annual reviews of credentialing policies and files at the delegated entities. GHCSCW uses the current NCQA credentialing and re-credentialing Data Collection Tools. GHC-SCW is using
NCQA’s 8/30 methodology to review delegate files.
8. INITIAL CREDENTIALING by DELEGATED ENTITY
a. ELEMENTS PERFORMED BY DELEGATED ENTITY:
1) Primary source verification of a valid State of Wisconsin license
2) Primary source verification of a current DEA. The DEA must be valid in the state where the practitioner
provides care to GHC-SCW members. If practitioner type is eligible for a DEA (i.e. MD, DO, DPM, APNP,
PA-C or OD) but does not have a DEA, the practitioner must explain why no DEA AND provide explanation
of arrangements for his/her patients who need prescriptions requiring DEA certification.
3) Primary source verification of the highest level of education (board certification satisfies residency or
professional school) will be completed. For practitioners who are not board certified, primary source
verification is completed by contacting the residency-training program. Acceptable residency programs
include only those residency programs that have been accredited by the Accreditation Council for Graduate
Medical Education (ACGME) and the American Osteopathic Association (AOA) in the United States or by
the College of Family Physicians of Canada (CFPC) or the Royal College of Physicians and Surgeons of
Canada.
4) Review of a completed application, including the following:
a) Physical and mental health status and reasons for inability to perform essential functions of the position,
with or without accommodations
b) Alcohol or chemical dependency and lack of current illegal drug use
c) History of loss of license
d) History of any felony convictions
e) History of loss or limitation of clinical privileges or disciplinary action
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 11 of 21
f) Work history for the last five years in mm/yy to mm/yy format, and any gaps six (6) months or greater
must be explained in writing
g) Malpractice history
h) Current coverage for malpractice insurance, including dates and amounts, even if the coverage amount is
$0.
i)
Signature attesting to the correctness and completeness of the application
5) National Practitioner Data Bank (NPDB-HIPDB) inquiry, to include
a) Professional liability claims history
b) Medicare/Medicaid sanctions
c) Disciplinary Actions by the Medical Examining Board
6) Verification and completion of all of the above must be within 180 days prior to the date of the initial
credentialing decision.
7) The Credentialing Committee of the delegate reviews the application and credentialing documents, and makes
credentialing decisions. A practitioner from the specialty of a practitioner being credentialed participates on
the Credentialing Committee.
8) Credentialing process completed prior to practitioner providing services to GHC-SCW members.
9) Delegates provide to GHC-SCW a monthly report, which includes lists of credentialed practitioners, analysis
of data, and committee meeting minutes.
10) If a delegate terminates a practitioner and later wishes to reinstate the practitioner, the delegate will credential
and re-verify credentialing requirements, if the break in service is 30 days or more. The delegate’s
Credentialing Committee will review all credentials and make a final determination prior to the practitioner’s
reinstatement.
b. ACTIVITIES PERFORMED BY GHC-SCW (in relation to delegated contracts)
1) GHC-SCW performs annual site visit audits at each delegated entity.
2) Review of credentialing policies and practitioner files at each delegated entity, to assure compliance with
GHC-SCW credentialing requirements. GHC-SCW uses NCQA’s 8/30 methodology to review delegate files.
3) Evaluation of the file review by the GHC-SCW Medical Director or Quality Management MD Liaison . If
any deficiencies are noted, a recommendation for an action plan will be sent. Credentialing Staff send the
Audit Report to the delegate and, within 30 days, conduct follow-up with the delegate as indicated in the
corrective action plan.
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 12 of 21
4) Credentialing Staff conduct re-evaluations of the delegate’s performance annually or more frequently if
indicated in a corrective action plan.
9. RE-CREDENTIALING by DELEGATED ENTITY
ELEMENTS PERFORMED BY DELEGATED ENTITY
a. Primary source verification of valid State of Wisconsin license
b. Primary source verification of a current DEA. The DEA must be valid in the state where the practitioner
provides care to GHC-SCW members. If practitioner type is eligible for a DEA (i.e. MD, DO, DPM, APNP, PAC or OD) but does not have a DEA, the practitioner must explain why no DEA AND provide explanation of
arrangements for his/her patients who need prescriptions requiring DEA certification.
c. Primary source verification of the highest level of education (board certification satisfies residency or professional
school) will be completed. For practitioners who are not board certified, primary source verification is completed
by contacting the residency-training program. Acceptable residency programs include only those residency
programs that have been accredited by the Accreditation Council for Graduate Medical Education (ACGME) and
the American Osteopathic Association (AOA) in the United States or by the College of Family Physicians of
Canada (CFPC) or the Royal College of Physicians and Surgeons of Canada.
d. National Practitioner Data Bank inquiry, to include:
1)
Professional liability claim history
2) Review of Medicare/Medicaid sanctions
3) Disciplinary Actions by the Medical Examining Board
e. Current, signed attestation by the applicant regarding:
1) Physical and mental health status and reasons for inability to perform essential functions of the position, with
or without accommodations
2) Alcohol or Chemical dependency and lack of current illegal drug use
3) History of loss of licensure
4) History of any felony convictions
5) History of loss or limitation of clinical privileges or disciplinary activity
6) Current coverage for malpractice insurance, including dates and amounts, even if coverage amount is $0.
7) Signature attesting to the correctness and completeness of the statement
8) Monthly review of member complaints by GHC-SCW for all practitioners.
f.
Verification and completion of all of the above must be within 180 days prior to the date of the re-credentialing
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 13 of 21
decision.
g. The Credentialing Committee of the delegate reviews the application and credentialing documents, and makes
credentialing decisions. A practitioner from the specialty of a practitioner being credentialed participates on the
Credentialing Committee.
h. Delegates provide to GHC-SCW a monthly report, which includes lists of re-credentialed practitioners, analysis
of data, and/or committee meeting minutes.
i.
If a delegate terminates a practitioner and later wishes to reinstate the practitioner, the delegate will credential and
re-verify credentialing requirements, if the break in service is 30 days or more. The delegate’s Credentialing
Committee will review all credentials and make a final determination prior to the practitioner’s reinstate activities
performed by GHC-SCW.
10. CREDENTIALING OF HEALTH CARE DELIVERY ORGANIZATIONS
a. GHC-SCW requires that Health Care and Behavioral Health Care delivery organizations meet requirements of
Federal and state regulatory bodies, and that the appropriate accrediting body for the respective organization
accredits these organizations. These requirements are verified prior to the initial contract being signed by GHCSCW and every three years thereafter.
b. GHC-SCW conducts an on-site visit if the provider organization is not accredited. A non-accredited provider
organization MAY substitute a CMS or State Review in lieu of the required site visit. (GHC-SCW must obtain
the report from the institution to verify that the review has been performed and that the report meets GHC-SCW’s
standards; however, a letter from CMS or the applicable state agency which shows that the facility was reviewed
and indicates that is passed inspection is acceptable in lieu of the survey report if GHC-SCW reviewed and
approved CMS or State criteria as meeting the standard). The CMS or State review may not be greater than three
years old at the time of verification.
c. GHC-SCW requires specific licensure and accreditation as listed below:
1) Hospitals (includes Behavioral Health inpatient services)
a) Medicare certification
b) Medicaid certification (optional)
c) State licensure
d) The Joint Commission (TJC) accreditation
e) If not TJC accredited, GHC-SCW will evaluate through the following methods:
(1) A copy of the hospital’s malpractice liability insurance declaration
(2) Names of the members and by-laws of the governing body or designated person who functions as the
governing body
(3) A copy of the hospital’s Quality Assurance (QA) plan
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 14 of 21
(4) A copy of the Utilization Review (UR) plan
(5) A copy of the hospital’s medical record keeping policies and procedures
(6) A site visit by the GHC-SCW Medical Director or his/her designee to review the above or GHCSCW may accept a CMS or state review in lieu of the required site visit. GHC-SCW must obtain the
report from the institution to verify that the review has been performed and that the report meets
GHC-SCW’s standards; however, a letter from CMS or the applicable state agency which shows that
the facility was reviewed and indicates that it passed inspection is acceptable in lieu of the survey
report if GHC reviewed and approved CMS or state criteria as meeting our standards. The CMS or
State review may not be greater than three years old at the time of verification.
2) Home Health Agencies (HHA)
a) Medicare certification
b) State licensure
c) Care Accreditation Commission (CCAC)
d) If not CCAC or TJC accredited, GHC-SCW will evaluate through the following methods:
(1) A copy of the HHA’s malpractice liability insurance declaration
(2) Names of the members and by-laws of the governing body or designated person who functions as the
governing body
(3) A copy of the HHA’s Quality Assurance (QA) plan
(4) A copy of the Utilization Review (UR) plan
(5) A copy of the HHA’s medical record keeping policies and procedures
(6) A site visit by the GHC-SCW Medical Director or his/her designee to review the above or GHCSCW may accept a CMS or state review in lieu of the required site visit. GHC-SCW must obtain the
report from the institution to verify that the review has been performed and that the report meets
GHC-SCW’s standards; however, a letter from CMS or the applicable state agency which shows that
the facility was reviewed and indicates that it passed inspection is acceptable in lieu of the survey
report if GHC reviewed and approved CMS or state criteria as meeting our standards. The CMS or
State review may not be greater than three years old at the time of verification.
3) Skilled Nursing Facility (SNF)
a) Medicare certification (if accepting Medicare patients)
b) State licensure
c) Medicaid (optional)
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 15 of 21
d) Commission on Accreditation of Rehabilitation Facilities (CARF)
e) If not Commission on Accreditation of Rehabilitation Facilities (CARF) accredited or TJC, GHC-SCW
will evaluate through the following methods:
(1) A copy of the SNF’s malpractice liability insurance declaration
(2) Names of the members and by-laws of the governing body or designated person who functions as the
governing body
(3) A copy of the SNF’s Quality Assurance (QA) plan
(4) A copy of the Utilization Review (UR) plan
(5) A copy of the SNF’s medical record keeping policies and procedures
(6) A site visit by the GHC-SCW Medical Director or his/her designee to review the above or GHCSCW may accept a CMS or state review in lieu of the required site visit. GHC-SCW must obtain the
report from the institution to verify that the review has been performed and that the report meets
GHC-SCW’s standards; however, a letter from CMS or the applicable state agency which shows that
the facility was reviewed and indicates that it passed inspection is acceptable in lieu of the survey
report if GHC reviewed and approved CMS or state criteria as meeting our standards. The CMS or
State review may not be greater than three years old at the time of verification.
4) Free Standing Surgicenter
a) Medicare certification
b) TJC or AAAHC (Accreditation Association for Ambulatory Health Care) accreditation
c) If not AAAHC accredited, GHC-SCW will evaluate through the following methods:
(1) A copy of the ASC’’s malpractice liability insurance declaration
(2) Names of the members and by-laws of the governing body or designated person who functions as the
governing body
(3) A copy of the ASC’’s Quality Assurance (QA) plan
(4) A copy of the Utilization Review (UR) plan
(5) A copy of the ASC’s medical record keeping policies and procedures
(6) A site visit by the GHC-SCW Medical Director or his/her designee to review the above or GHCSCW may accept a CMS or state review in lieu of the required site visit. GHC-SCW must obtain the
report from the institution to verify that the review has been performed and that the report meets
GHC-SCW’s standards; however, a letter from CMS or the applicable state agency which shows that
the facility was reviewed and indicates that it passed inspection is acceptable in lieu of the survey
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 16 of 21
report if GHC reviewed and approved CMS or state criteria as meeting our standards. The CMS or
State review may not be greater than three years old at the time of verification.
5) Behavioral Health Residential and Ambulatory Facilities
a) State licensure
b) TJC accreditation
c) A site visit by the GHC-SCW Medical Director or his/her designee to review the above or GHC-SCW
may accept a CMS or state review in lieu of the required site visit. GHC-SCW must obtain the report
from the institution to verify that the review has been performed and that the report meets GHC-SCW’s
standards; however, a letter from CMS or the applicable state agency which shows that the facility was
reviewed and indicates that it passed inspection is acceptable in lieu of the survey report if GHC reviewed
and approved CMS or state criteria as meeting our standards. The CMS or State review may not be
greater than three years old at the time of verification.
11. INTERNAL NOTIFICATION OF CREDENTIALING DECISION:
a. Upon approval by the GHC-SCW Credentials Committee of initial credentialing the MSC sends notification out
no later than one week after the Credentialing Committee’s decision to GHC-SCW internal departments of:
1) Facilities
2) Enrollment
3) Claims
4) Marketing
5) Member Services
6) Scheduling Coordinator
7) Epic/Cadence Coordinator
8) Clinic Managers
9) Pharmacy
10) Human Resources
11) Coding Department
12) Health Information
13) Compliance
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 17 of 21
14) Care Management
15) Quality Management
16) Mental Health Manager/Coordinators
b. This notification includes the following information for all Staff Model practitioners:
1) Name
2) Credentials
3) Start Date
4) License Number/Expiration Date
5) Board Certification/Expiration Date (if applicable)
6) NPI
7) DEA/Expiration Date (if applicable)
c. For Non-Staff Model practitioners
1) Name
2) Credentials
3) Place of practice
12. ONGOING MONITORING OF SANCTIONS AND COMPLAINTS
GHC-SCW performs ongoing monitoring of sanctions and complaints continuously. If any incident of poor quality
relating to the categories below is identified and requires intervention, the processes outlined in Policy ADM.001
(Attachment 4) govern the intervention process. The information below is reviewed at the Peer Review Committee as
standing agenda items. On a monthly basis, before the Peer Review/Credentialing Committee meeting, the MSC
compiles the following information:
a. Medicare and Medicaid Sanctions
1) Review within 30 days of the release of the quarterly reports from the Office of Inspector General for
Medicare and Medicaid Sanctions web page at oig.hhs.gov/exclusions_list.asp. MSC also receives
notification of Sanctions from the NPDB Proactive Disclosure Service (PDS) of enrolled practitioners as soon
as it is posted.
2) If any GHC-SCW practitioner credentialed by the GHC-SCW Peer Review Committee is listed, the
practitioner is required to submit an explanation. The Peer Review Committee reviews this information and
the pertinent sanctions at the next meeting. If the Committee determines that corrective action or loss of
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 18 of 21
privileges are necessary, this is recommended to the Medical Director who communicates to the practitioner.
The practitioner may appeal this action as outlined in the description of Peer Review Committee actions.
3) If any GHC-SCW practitioner credentialed by a delegate is listed, GHC-SCW will send that information to
the delegate in order for the delegate to take appropriate action.
b. Wisconsin State Licensing and Examining Board
1) Review of monthly disciplinary reports from the State of Wisconsin Department of Safety & Professional
Services web page at online.drl.wi.gov/orders/searchorders.aspx. The MSC also receives notification of
sanctions from the NPDB Proactive Disclosure Service (PDS) of enrolled practitioners as soon as they are
posted.
2) If any GHC-SCW practitioner credentialed by the GHC-SCW Credentialing Committee is listed, the
practitioner is required to submit an explanation. The Peer Review Committee reviews this information and
the pertinent sanctions at the next meeting. If the Committee determines that corrective action or loss of
privileges are necessary, this is recommended to the Medical Director who communicates to the practitioner.
The practitioner may appeal this action as outlined in the description of Peer Review Committee actions.
3) If any GHC-SCW practitioner credentialed by a delegate is listed, GHC-SCW will send that information to
the delegate in order for the delegate to take appropriate action.
c. Member Complaints
1) GHC-SCW maintains a log of member complaints by practitioner. The log lists whether the complaint is
justified after Peer Review Committee and Medical Director review.
2) The GHC-SCW Peer Review Committee reviews the log during their monthly meeting for all GHC-SCW
practitioners credentialed by the GHC-SCW Credentialing Committee. If any practitioner has three or more
quality of care concerns in the previous 12 months, the Peer Review Committee conducts an additional
review of the practitioner. If the Committee determines that corrective action or loss of privileges are
necessary, this is recommended to the Medical Director who communicates to the practitioner. The
practitioner may appeal this action as outlined in the description of Peer Review Committee actions.
3) Site visits at any participating practitioner office including, but not limited to the offices of primary care
physicians and obstetricians/gynecologists for facility review and medical record keeping practices review
will be performed when complaints dictate.
4) If any GHC-SCW practitioner credentialed by a delegate is listed on the complaint log, GHC-SCW will send
that information to the delegate in order for the delegate to take appropriate action.
d. Ongoing Monitoring of Adverse events related to injury (Safety):
1) GHC-SCW collect reports on a monthly basis from Member Services and Care Management Departments on
any adverse events related to injuries that happened while receiving health care services from a practitioner.
GHC-SCW also maintains a log of Malpractice Cases by practitioner prepared by the GHC-SCW Medical
Director. This log lists all active malpractice claims cases. If any GHC-SCW practitioner credentialed by the
GHC-SCW Peer Review Committee is reported, the practitioner is required to submit an explanation. The
Peer Review Committee reviews this information and the pertinent sanctions at the next meeting. If the
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 19 of 21
Committee determines that corrective action or loss/limitation of privileges are necessary, this is
recommended to the Medical Director who communicates to the practitioner. The practitioner may appeal this
action as outlined in the description of Peer Review Committee actions.
2) If any GHC-SCW practitioner credentialed by a delegate has any adverse event, GHC-SCW will send that
information to the delegate in order for the delegate to take appropriate action.
13. GHC-SCW Directories and Membership Materials:
a. The MSC ensures that the information provided in member materials, which include practitioner directories and
website listings is consistent with the information contained in the credentialing file. On a monthly basis the MSC
sends an e-mail to the Marketing Communication Specialist, Member Services Manager, Enrollment Manager,
and Claims Manager, of the newly approved practitioners which includes name, education, training, specialty,
license number, board certification status, DEA number and location. The MSC monitors license, DEA, and
Board Certification status on a monthly basis and would notify the Marketing Communication Specialist of any
changes.
b. Before printing the GHC-SCW’s Provider Directory, the Marketing Communication Specialist contacts the MSC
to review and verify the correctness of all published information about a practitioner based on credentialing and
primary source verification.
14. Initial and Re-credentialing PROCESS for HEDIS:
a. GHC-SCW complies with HEDIS Standards for Board Certification and Practitioner Turnover by utilizing the
credentialing data obtained in the initial and re-credentialing processes explained above in Procedure Items 1 and
2.
b. The MSC maintains a database for all credentialed practitioners. This database is in the MSC’s G:drive.
c. Information from those practitioners credentialed in-house and information from delegates is maintained in the
database.
d. The data in the database can only be modified by the MSC.
e. An overview of the credentialing/re-credentialing process is outlined below:
1) For Initial Credentialing: Application Process is outlined as follows:
a) Application is sent, allowing two weeks for completion by practitioner
b) Two applications and a follow-up phone call will be made in an effort to obtain the initial credentialing
application.
c) Review of the application for completeness, including signature and date. Fax, digital and photocopied
signatures are acceptable.
d) Review of the current signed attestation statement regarding physical and mental health status, limitation
of privileges and status regarding drug or alcohol use is reviewed.
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 20 of 21
e) Primary source verification of Board Certification status is performed as part of the credentialing/recredentialing process outlined in above Procedure Items 1 and 2.
f) Initial applicants are presented to the GHC-SCW Credentialing Committee for approval/denial.
2) For Re-Credentialing: Reapplication Process is outlined as follows:
a) Reapplication is sent, allowing two weeks for completion by practitioner.
b) Two reapplications and a follow-up phone call will be made in an effort to obtain the re-credentialing
application.
c) Review of the reapplication for completeness, including signature and date. Fax, digital and photocopied
signatures are acceptable.
d) Review of the current signed attestation statement regarding physical and mental health status, limitation
of privileges and status regarding drug or alcohol use is reviewed.
e) Primary source verification of Board Certification status is performed as part of the credentialing/recredentialing process outlined in above Procedure Items 1 and 2.
f) Re-applicants are presented to the GHC-SCW Credentialing Committee for approval/suspension/denial.
f.
Board Certification Calculation for HEDIS:
At least annually, the MSC will report the board certification percentage rates of the following practitioners:
1) Primary Care Practitioners (PCP)
2) OB/GYN Practitioners
3) Pediatric Practitioner Specialties
4) Geriatrics
5) All other Practitioner Specialties
6) The MSC manually calculates the board certification status based on information in the credentialing database
and in accordance with the most current HEDIS Guidelines.
g. Practitioner Turnover Calculation for HEDIS:
1) At least annually, the MSC reports the practitioner turnover rate.
2) Termination dates are entered into the database.
3) The MSC manually calculates the practitioner turnover rate based on the credentialed/termination dates in the
credentialing database in accordance with the most current HEDIS Guidelines.
Policy and Procedure
Title: Credentialing and Recredentialing
Policy Number: MED.ADM.025
Page 21 of 21
h. Audit for Accuracy:
1) At least annually, the MSC and Director of Claims provide each other with reports of data in their systems on
the practitioners entered into each system for comparison.
2) The reports must contain the following information:
a) Name
b) Credentials
c) Start Date
d) License Number
e) Board Certification
f) NPI
g) DEA
3) Any discrepancies are identified, researched and resolved in both systems.
APPENDIX A.5
_________________________________________
APPROVAL as appropriate:
Board _________Exec Dir _________
Med Dir _________ Other Dir/Mgr _________
_________________________________________
REVIEWED BY LEGAL COUNSEL
Date: x
Yes ___No ___
Name: x
__________________________________________
POLICY STATUS: _x__ Approved ___Pending
Committee Charter
Title:
Peer Review Committee
Author:
M. Ostrov, MD
Div/Dept/Serv Area: Administration/Committees
Number: ADM.COM.001
Volume: II
Date of Issue: 6/85
Page 1 of 6
Formerly ADM.001 (1/12)
PURPOSE:
The Peer Review Committee of Group Health Cooperative of South Central Wisconsin (GHC-SCW) investigates patient
or practitioner complaints about the quality of clinical care provided by a GHC-SCW practitioner and makes
recommendations for corrective actions. The Committee also reviews sentinel conditions identified as having quality
concerns by Patient Services (Hospital Concurrent Review Nurses). The Committees discussions and documents are
protected by federal and state laws providing confidentiality of health care peer review activities, which are conducted in
good faith. In addition, the Peer Review Committee (PRC) is the committee that makes recommendations regarding
credentialing decisions for practitioners employed by GHC-SCW, Dane county primary care practitioners, chiropractors,
oral surgeons, physician assistants, optometrists, nurse practitioners, physical therapists, and behavioral health
practitioners as well as practitioners who do not have privileges at a hospital affiliated with GHC-SCW.
GOALS:
Peer Review at GHC-SCW is a process designed to improve the quality of health care provided to GHC-SCW members.
Peer Review is based on the following assumptions:
1. The provision of health care is a complex process.
2. Every practitioner has areas in which her/his knowledge is not exhaustive.
3. Every practitioner will make some clinical decisions, which are not optimal.
4. Practitioners may not be aware of their knowledge deficiencies and less than optimal clinical decisions.
5. A managed health care system can provide a framework for allowing practitioners to improve clinical deficiencies in a
supportive environment.
6. Peer Review is an organized system in which practitioners provide educational feedback to each other based on
review of actual clinical care.
Review Date
Revision Date
10/12
10/85
8/91
9/98
11/98
7/09
1/12
Committee Charter
Title: Peer Review Committee
Policy Number: ADM.COM.001
Page 2 of 6
ROSTER








Quality Management MD Liaison (Chair)
Family Physicians (2-3)
Internists (1-2)
Pediatricians (1)
Physician Assistant (1)
Other specialists as needed for case review or credentialing decisions (Dentist, Chiropractor, Psychiatrist)
Concurrent review Nurse
Medical Staff Coordinator
The Medical Director makes appointments to the Committee
MEETING FORMAT AND FREQUENCY
1. The minutes of the previous Committee meeting are reviewed. Cases are prepared outside the committee by an initial
reviewer who presents the case for further review and discussion at the meeting. Corrective actions, if any, are
recommended. Policies concerning confidentiality are followed.
2. Every three years, re-credentialing information for current GHC-SCW staff and certain contracted practitioners is
reviewed prior to re-appointment. Credentials of new staff are presented to the Committee when an employment
contract is being offered.
3. The Committee meets at least quarterly.
CONFIDENTIALITY OF INFORMATION
1. The Peer Review Committee (PRC) is a distinct and separate Committee within GHC-SCW’s Quality Improvement
Program.
2. Peer Review is organized and operated to help improve the quality of health care. Accordingly, no person acting in
good faith who participates in the review or evaluation of services of health care practitioners as part of the GHCSCW Peer Review Committee is liable for any civil damages as a result of any act or omission by such person in the
course of such review or evaluation. This civil immunity, pursuant to law, applies to acts and omissions including,
but not limited to, censuring, reprimanding or taking any other disciplinary action against a health care practitioner.
3. No person who participates in the review or evaluation of the services of health care practitioners as part of the GHCSCW Peer Review Program may disclose any information acquired in connection with such review or evaluation, nor
may any record of the investigation, inquiries, proceedings and conclusions of the Peer Review Committee be
released to any person under Section 804.10(4), Wis. Stats, or otherwise, except as permitted by the exceptions set
forth in Section 146.38(3), Wis. Stats. Any person who testifies during, or participates in the review or evaluation
may testify in any civil action as to matters within his or her knowledge, but may not testify as to information
obtained through her or his participation in the review or evaluation, nor as to any conclusion of such review or
evaluation, as provided in Section 146.38(2), Wis. Stats.
4. Consistent with its goals of helping to improve the quality of health care, the PRC reports its findings to the Medical
Director who in turn, reports general activities of the PRC to the Health Services Committee of the Board of Directors
of GHC-SCW and, ultimately, the full Board of Directors of GHC-SCW.
Committee Charter
Title: Peer Review Committee
Policy Number: ADM.COM.001
Page 3 of 6
COMMITTEE AUTHORITY
The Board of Directors is ultimately responsible for the quality of health care provided to GHC-SCW members. The
Board delegates the responsibility of ensuring a high level of quality of care to the Medical Director who, in turn, charges
the PRC to review all quality concerns referred to it, provide educational feedback to the involved practitioners, to report
findings to the Medical Director, and when appropriate, makes recommendations to the Medical Director for
credentialing, re-credentialing, and reduction, suspension or termination of individual practitioner privileges. The
Medical Director acts in a manner providing for maximum protection for documentation from legal discovery and
protection of the identity of individual practitioners.
SOURCES OF QUALITY OF CARE CONCERNS FOR COMMITTEE REVIEW
Quality of care concerns can be brought to the PRC from several sources, including but not limited to the following:
1. Practitioners
2. Medical Director
3. Members through Member Services complaints or other member generated communications.
4. Utilization Management Department from concurrent hospitalization review and case management activities
5. Other QA/QI committees or teams
6. Medicare / Medicaid Sanctions
7. Licensure Sanctions or Limitations
PROCEDURE:
1. Committee Function
a. The PRC will carefully review the medical care in all situations in which a quality concern has been raised. The
involved GHC-SCW practitioner will be notified of a possible quality concern. The involved practitioner is
notified in writing and asked to present additional verbal or written information for the primary reviewer prior to
the date of the PRC meeting. The Committee will take these practitioner comments into consideration when
reviewing the case.
b. The Committee will evaluate the quality concern related to the medical care and make a determination as to
whether there is sufficient evidence that the involved practitioner failed to provide care within generally accepted
standards.
c. The Committee will communicate a written evaluation of the quality concern to the involved practitioner with a
copy sent to the Medical Director. The practitioner may respond in writing to the Committee or may appear at a
subsequent Committee meeting. If the practitioner’s response prompts a change in the Committee’s findings, this
will be documented in the minutes with the revised opinion forwarded to the practitioner and to the Medical
Director.
Committee Charter
Title: Peer Review Committee
Policy Number: ADM.COM.001
Page 4 of 6
2. Range of Actions
a. The Committee may make a recommendation for an educational activity for the involved practitioner such as
reviewing a text or an article. This is consistent with the overall educational purpose of the Peer Review.
b. If the Committee observes a pattern of quality concerns regarding a single practitioner, a more structured
educational activity may be recommended. The Committee may suggest reduction, limitation, or suspension of
privileges, or contract termination. The Committee will make these preliminary recommendations to the Medical
Director and will so inform the practitioner. The involved practitioner may respond in writing to the Committee
or may appear in person at a Committee meeting. The final Committee recommendation will occur after the
response is received from the practitioner or at the following Committee meeting, if there is no response from the
practitioner.
3. Appeal Process and process for notifying practitioners:
a. The Medical Director will create an action plan after receiving the Committee’s recommendations. The reason
for the action and a summary of the appeal rights will be communicated, in writing, to the involved practitioner
according to the contract with the practitioner or according to GHC-SCW Personnel Policy, whichever applies.
b. The practitioner is informed at that time of his right to appeal this decision. The practitioner may respond in
writing to the Committee or may appear in person at a Committee meeting.
c. After such appeal, the Medical Director will make a decision and carry out the action plan.
d. The practitioner can then appeal the Medical Director’s decision according to the appropriate contract or
Personnel Policy.
e. The Medical Director will make a final decision after hearing this appeal.
4. Appeal Process
a. First level appeal is the first step available to the practitioner:
1) First level appeal provides an opportunity for the practitioner to present additional or amended information to
GHC-SCW’s Peer Review Committee. The practitioner must request the first level appeal in writing within
30 days of receiving notification of the Committee’s initial decision. Failure to do so, or to appear without
good cause at a scheduled first level appeal, will result in the forfeiture of the right to both the first level and
any subsequent appeal rights.
2) The practitioner has the right to review the information upon which the original decision was based and to
correct erroneous information in his/her application file. Peer review minutes and information obtained from
the NPDB may not be given directly to the practitioner. The practitioner may obtain a self-review thru the
NPDB. The practitioner will be provided with a copy of GHC-SCW’s Credentialing & Re-credentialing
Policy, the format for the first level proceeding, and the date of the hearing. Notice of the first level appeal
date must be supplied to the practitioner within 15 business days of GHC-SCW’s receipt of the request for
such appeal and the date of the first appeal.
3) The practitioner will be notified of the result of the first level appeal decision within ten business days from
the date of the first level appeal. If the Committee’s decision is to uphold its original decision, or the decision
Committee Charter
Title: Peer Review Committee
Policy Number: ADM.COM.001
Page 5 of 6
is modified but the decision still affects the practitioner’s ability to care for GHC-SCW members, the
practitioner may then request a second level appeal.
b. Second level Appeal of Peer Review Committee Actions:
1) Practitioners have the right to appeal any decision of the GHC-SCW Peer Review Committee, which affects
their ability to care for GHC-SCW members and which has been upheld by the Peer Review Committee after
the first level informal review. Appeals will be heard by the Peer Review Committee. If the applicant appeals
the decision, a copy of the decision and relevant information will be forwarded to the Peer Review
Committee.
2) The practitioner must request a hearing in writing and the request must be received by GHC-SCW’s Peer
Review Committee [1265 John Q. Hammons Dr. Madison, WI 53717] within 30 days from the date the
applicant receives the Peer Review Committee’s written decision.
c. Notice of Hearing:
1) The Notice of Hearing will be sent to the appellant by certified mail within 15 business days of the receipt of
the request for hearing. The Notice of Hearing will include the date, time and location of the appeal hearing
and a list of witnesses (if any) expected to testify on behalf of the Peer Review Committee.
2) The appeal will be heard within 30 days of the date of the notice of hearing, unless changed by mutual
consent of GHC-SCW and the practitioner.
Committee Charter
Title: Peer Review Committee
Policy Number: ADM.COM.001
Page 6 of 6
d. Conduct of Hearing:
1) The hearing will be held before the Appeals Committee as defined above. The right to a hearing shall be
forfeited, and the original decision of the committee shall become final, if the appellant fails to request such
an appeal hearing within 30 days of the date of receiving notice of the decision based on the informal review
or fails, without good cause, to appear.
2) Appellant’s Rights in the Hearing:
a) To representation by an attorney or other person of their choosing;
b) To have a record made of the proceedings, copies of which may be obtained by the appellant upon
payment of reasonable charges for the preparation thereof;
c) To call, examine or cross-examine witnesses;
d) To present relevant information, regardless of its admissibility in court;
e) To submit a written statement at the end of the hearing; and upon completion of the hearing, to receive the
written decision of the Appeals Committee, including a statement of the basis for the decision.
5. Process for notifying the appropriate authorities
As required by the Health Care Quality Improvement Act of 1986, as amended, and 45 Code of Federal Regulations
Part 60, the Medical Director of his/her designee shall report to the State Medical Examining Board and/or the
National Practitioner Data Bank (NPDB) in accordance with the respective state and federal regulations. The
submission(s) will be reviewed by corporate council prior to submission.
APPENDIX A.6
_________________________________________
APPROVAL as appropriate:
Board _________Exec Dir _________
Med Dir _________ Other Dir/Mgr _________
_________________________________________
REVIEWED BY LEGAL COUNSEL
Date: x
Yes ___No ___
Name: x
__________________________________________
POLICY STATUS: _x__ Approved ___Pending
Policy and Procedure
Title:
Author:
Volume:
Member Rights and Responsibilities
L. Baird
Div/Dept/Serv Area: Marketing/Member Services
III
Number: MS.027
Date of Issue:
6/82
Page 1 of 3
Formerly A2f.005 (7/08)
PURPOSE:
The purpose of this policy is to document the rights and responsibilities of the members of Group Health Cooperative of
South Central Wisconsin (GHC-SCW).
POLICY:
1. GHC-SCW is committed to treating members in a manner that respects their rights as well as the expectations of
members’ responsibilities.
2. Members of GHC-SCW are entitled to the following rights:
a. Members have the right to receive information about GHC-SCW, its services and , its practitioners., and its
practitioners. Further, members have the right to receive information regarding member’s rights and
responsibilities.
b. Members have the right to be treated with respect and recognition of their dignity and right to privacy.
c. Members have a right to participate with practitioners in making decisions regarding their health care.
d. Members have a right to a candid discussion of appropriate or medically necessary treatment options for their
conditions, regardless of cost or benefit coverage.
e. Members have a right to voice complaints or appeals about GHC-SCW or the care provided. Members have a
right to appeal decisions made by GHC-SCW.
f.
Selection of a personal practitioner. Members have the right to change practitioners at any time without having to
state a reason.
g. Members have the right to a full explanation of any charges that may be billed to member as a result of care.
h. Given informed consent, as required by law, prior to procedures or treatments. To the extent permitted by law,
member has the right to refuse the recommended treatment and to be informed of the consequences of that
decision.
i.
Participation in the governance of the organization. Each member who is at least 18 years of age is a voting
member of the Cooperative and is encouraged to be an active participant in its operation.
j.
Members have the right to make recommendations regarding the organization’s members’ rights and
responsibilities policies.
Review Date
Revision Date
12/02
8/90
2/04
8/91
1/09
11/91
11/09
8/97
9/02
12/02
Policy and Procedure
Title: Member Rights and Responsibilities
Policy Number: MS.027
Page 2 of 3
k. Members have the right to receive confidential treatment of all communications and records concerning the
member’s care, except as otherwise provided by law. Upon submitting proper authorization for the disclosure of
information, a member has the right, except as otherwise limited by law, to:
1) View those health care records generated by GHC-SCW pertaining to the member at any time during regular
business hours, upon reasonable notice; and
2) Receive a copy of the member’s health care records, upon payments of GHC-SCW’s costs and upon
reasonable notice; and
3) Receive a copy of GHC-SCW’s x-ray reports pertaining to the member or have the x-rays referred to another
health care practitioner upon payment of GHC-SCW’s costs and upon reasonable notice.
3. Members have the following responsibilities:
a. Each consumer at GHC-SCW has the responsibility to be considerate of others, to observe safety and smoking
regulations in all GHC-SCW facilities, to treat GHC-SCW personnel with consideration and respect, and to
supply accurate and complete medical history information.
b. Members have the responsibility to provide, to the extent possible, information that GHC-SCW and their
practitioners and practitioners need in order to care for them.
c. Members have the responsibility to use facilities and equipment appropriately and to fulfill any financial
obligation they may incur.
d. Members are responsible for being on time for appointments and informing the clinic when an appointment
cannot be kept so someone else may be seen.
e. Members are responsible for reading and understanding their coverage.
f.
Members have a responsibility to follow the plan’s instructions for care agreed upon with their practitioners.
g. Members are responsible for understanding their health problems and participating in the development of
mutually agreed upon treatment goals to the degree possible.
Policy and Procedure
Title: Member Rights and Responsibilities
Policy Number: MS.027
Page 3 of 3
PROCEDURE:
1. GHC-SCW apprises the members of the above rights and responsibilities via the GHC-SCW Member Handbook. The
Member Handbook explains the member’s rights, the member’s responsibilities, and information about the
practitioners available to GHC-SCW members.
2. The new member packet is distributed to all members enrolling with GHC-SCW.
3. The new member packet contains the following items:
a. Member Handbook
b. GHC-SCW Identification Card
c. Primary Clinic Information
4. Practitioners receive this information via the Provideractitioner Handbook.
APPENDIX A.7
GROUP HEALTH COOPERATIVE of South Central Wisconsin
2013 Utilization Management (UM) Program Description
Purpose:
The purposes of the Group Health Cooperative of South Central Wisconsin (GHC-SCW)
Utilization Management (UM) Program are to conduct a series of coordinated and integrated
activities that assist in: 1) maintaining and improving high quality medical and behavioral health
care and services to our members across the full continuum of care, 2) meeting fiduciary
responsibilities, and 3) complying with accreditation and regulatory requirements.
Goals:
The goals of the UM program are to: 1) objectively, consistently, impartially, and fairly promote,
monitor, and evaluate the delivery of high quality, cost effective medical and behavioral health,
Substance Use Disorder (SUD) care services for all members, 2) make UM decisions based on
medical necessity, appropriateness, and availability of resources and benefits, 3) ensure
confidentiality of personal health information, 4) monitor and improve practitioner and member
satisfaction, and 5) provide case management services for members with complex medical
conditions.
Objectives:
A. To participate in the review of consistency of UM decision making,
B. To ensure that medical and behavioral health care and SUD services are medically necessary,
appropriate, and provided in the most cost-effective setting,
C. To facilitate communication and collaboration among members, practitioners/providers and
the organization in an effort to support cooperation and appropriate utilization of health care
benefits,
D. To provide information to practitioners regarding utilization management activities,
E. To identify high utilization of resources and implement appropriate case management
activities,
F. To render timely determinations and issue timely notifications,
G. To initiate process improvement activities to enhance department functions,
H. To assist with discharge planning and transition of care issues.
Organizational Structure and Accountability (UM 1)
The GHC-SCW Board of Directors grants UM authority to the senior management team with the
Medical Director having direct responsibility for UM activities. The Medical Director delegates
the responsibilities of the daily UM operations to the Manager of the Care Management
Department (CM). The Medical Director also delegates behavioral health and substance use
disorders UM activities to the Associate Medical Director for Mental Health , the Clinical and
Developmental Psychologist, and the Behavioral Health Services Manager, pharmacy UM
activities to the Manager of Pharmacy Services, and chiropractic UM activities to the
Chiropractor Chief of Staff.
The Medical Director grants authority to the following persons for making specific denials that
are outlined later in this document: 1) Associate Medical Director for Mental Health, 2) the
Clinical and Developmental Psychologist 3) Manager of Pharmacy Services, 4) Chiropractor
Chief of Staff, and 5) Manager of Care Management. An annual review is conducted to evaluate
the effectiveness of the UM Program and UM Policies. The outcome of an effective UM Program
demonstrates appropriate utilization of medical resources to maximize the effectiveness of care
and services provided to the members. The UM Program Description is presented by the Medical
Director and Manager of the Care Management Department to the Clinical and Services Quality
Committee, at least annually, for review and approval.
1
UM Responsibilities
The following persons are actively involved in implementing specific aspects of the UM
Program, and delegate daily operational activities as needed: 1) Medical Director, 2) Associate
Medical Director for Mental Health 3) Clinical and Developmental Psychologist 4) Behavioral
Health Services Manager 5) Manager of Pharmacy Services, 6) Chiropractor Chief of Staff, 7)
Manager of Care Management, and 8) Manager of Member Services.
A. Medical Director responsibilities include, but are not limited to:
1. General Care Management (CM) Department oversight.
2. Acts as the liaison between the organization’s primary care practitioners and external
specialists and providers.
3. Assists in the analysis of utilization data for problem identification and prioritization,
development and implementation of action plans along with evaluation of correction
activities.
4. Reviews and makes determinations regarding:
a. All Medical Necessity denial determinations,
b. All potentially cosmetic/experimental procedures,
c. Benefit exceptions,
d. Out-of-network practitioners, and
e. When individual needs and assessment of the local delivery system indicate that the
UM criteria are not appropriate for the member.
5. Assists in the selection of UM criteria, reviews medical policies.
6. Chairs Technology Assessment Committee and participates in reviews.
7. Collaborates with vendors, employer groups, and providers regarding UM issues, and
serves as a clinical resource for the CM Department.
8. Acts as the primary physician reviewer to the Care Management Department.
9. Delegates UM decisions to other physician reviewers as needed. Other physician
reviewers include:
 Chief of Staff
 Primary Care Site Chiefs
 Associate Medical Director for Mental Health
 Chiropractor Chief of Staff
 Quality Management Liaison, MD
B. Associate Medical Director for Mental Health responsibilities include, but are not limited to:
1. Assists with the development, revisions, and/or implementation of Mental Health UM
activities, policies, procedures, and reviewing cases.
2. Same activities as described above under Medical Director, MD
3. Reviews and makes determinations for SUD transitional and inpatient UM.
4. Makes determinations for non-staff model behavioral health services, based on medical
necessity regarding the level of care and the appropriate setting.
5. Decisions are based on criteria included in Milliman Care Guidelines, GHC-SCW
Technology Assessment Policies, American Society of Addiction Medicine (ASAM),
CM.MED.115 Referrals to External Mental Health Practitioners, and CM.MED.121
Autism Spectrum Disorder Services: Diagnosis, Intensive, and Non-Intensive Services,
6. Acts as a liaison between the organization’s staff model behavioral health providers and
external specialists and providers,
7. Delegates reviews and determinations regarding medical necessity denial determinations
for autism spectrum disorders treatment to the Clinical and Development Psychologist,
C. Clinical and Developmental Psychologist responsibilities include, but are not limited to:
1. Assists with the development, revisions, and/or implementation of Mental Health UM
activities, policies, procedures, and reviewing cases.
2. Reviews and makes determinations for non-staff model behavioral health services, based
on medical necessity and the criteria listed in 5.B above regarding the level of care and the
2
appropriate setting, with a particular emphasis on services for autsim spectrum disorders
and outpatient psychotherapy.
3. Acts as a liaison between the organization’s staff model behavioral health providers and
external specialists and providers,
D. Behavioral Health Services Manager responsibilities include, but are not limited to:
1. Manages the overall functioning of the Mental Health department including operational,
program and staff-related aspects.
2. Delegates clinical decision making to State of Wisconsin licensed and credentialed staff
model practitioners (Psychiatrists, Advanced Practice Nurse Prescribers, Psychologists,
Licensed Clinical Social Workers, Licensed Professional Counselors, Licensed Marriage
and Family Therapists, Clinical Substance Abuse Counselors regarding outpatient services
including initial assessments, prioritization of patients for behavioral health treatment,
treatment planning and discharge. These staff participate in initiating referrals for external
specialty and provider services, provide clinical information for review, and do not make
decisions about medical necessity.
3. Supports the use of a licensed doctoral level clinical psychologist to oversee outpatient
prioritization of patients and referral activities, and
4. Supports the use of a licensed board certified psychiatrist for oversight of inpatient
utilization.
5. Assists with the development, revisions, and/or implementation of Mental Health UM
activities, policies, procedures, and reviewing cases,
6. Provides input and clinical opinion to reviewers making determinations regarding
referrals for non-staff model behavioral health services,
7. Acts as a liaison between the organization’s staff model behavioral health providers and
external specialists and providers
E. Chiropractor Chief of Staff
1. Reviews and makes determinations regarding Acute Chiropractic Care
F. The Manager of the Care Management Department responsibilities include, but are not
limited to:
1. Directs and manages the UM/CM Processes and the Care Management Department,
2. Collaborates with the Medical Director, on the annual review of the effectiveness of the
UM Program,
3. Ensures that the department is in compliance with NCQA Standards and regulatory
requirements,
4. Develops, revises, and/or implements CM policies,
5. Coordinates Inter-rater reliability activities and UM Rounds, both medical and mental
health (behavioral health and SUD),
6. Collaborates with internal practitioners, external vendors, employer groups, and providers
regarding UM issues,
7. Supervises staff responsible for making administrative denials,
8. Participates in multi-departmental committees related to appeals, benefits, finance,
operations, and technologies.
9. Assists the Medical Director with technology assessment.
10. Presents UM and CM program descriptions annually to CSQC for approval.
G. Case Managers (RN/SW), Utilization RNs, and Utilization Coordinators (LPNs), major
responsibilities for medical and behavioral health include, but are not limited to:
1. Perform pre-service, concurrent, and post-service reviews,
2. CM’s and Utilization RNs can approve UM benefit and medical coverage if medical and
or benefit criteria is met. If medical criteria is not met all decisions must be taken to
medical rounds for the coverage decision to be made by the Medical Director.
3. Utilization Coordinators may approve and deny benefit coverage only.
4. Assure timely referral authorizations and administrative denials,
5. Coordinate transition of care and continuity of services,
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6. Collaborate with internal practitioners, external vendors, employer groups, and providers
regarding UM issues,
7. Actively participate with inter-disciplinary committees related to Disease Management,
8. Collaborate with patient, providers and employer groups to assess, plan, implement,
coordinate, monitor and evaluate options and services,
9. Assist in the management of patient care to ensure optimum outcomes, and
10. Provide education and assistance with available resources to promote quality, and cost
effective outcomes.
H. Worker’s Compensation Assistant responsibilities include, but are not limited to:
A. Performs Worker’s Compensation coordination,
B. Acts as liaison with patient, providers and employer groups to document Worker’s
Compensation information,
I. Care Management Associate (CMA )responsibilities include, but are not limited to:
1. Perform timely data entry of referrals,
2. Care Management Associates can make benefit approvals which procedures and tests that
are listed in on the CMA approval list. This list is reviewed annually.
3. Provide assistance to the Case Managers to ensure timeliness of referral activities,
4. Direct practitioners to appropriate referral resources,
5. Authorize routine referral services;
6. Non-routine, potentially cosmetic/investigational, out of plan/area, and services for
chronic disease requests are referred to the CM staff,
7. Conduct 2nd claims review, and
8. Ensure timely printing of pre-certification, authorization and denial letters.
J. Manager of Pharmacy Services responsibilities include, but are not limited to:
1. Make pharmaceutical determinations based on medical necessity and the use of a
recommended prerequisite drug of a step-therapy protocol, and
2. Authorizes administrative pharmacists to make UM approvals and denials.
K. Manager of Member Services responsibilities include, but are not limited to:
1. Processing appeals of UM denials.
Scope
The scope of UM activities include Behavioral Health, but are not limited to (Care Management
Review Criteria CM.MED.002):
1. Benefit clarification,
2. Referral Management,
3. Pre-service, concurrent, and post-service review and timely determinations,
4. Review of emergency services and out-of-area/plan services,
5. Complex Care Management, including discharge planning and transition of care,
6. Second review of claims,
7. Technology assessment,
8. Inter-rater reliability,
9. Monitoring adverse effects and sentinel events,
10. Integration with QM Department, Pharmacy, Mental Health Department, Marketing,
Gateway, Finance, and Insurance Operations,
11. Interdisciplinary communications,
12. Over and underutilization,
13. Review, discussion, and adaptation of UM criteria to NCQA language.
14. Develop policies to clarify benefits, and
15. Denial and appeal notifications.
UM Review Criteria (UM 2, Elements A&B)
CM staff makes medical necessity and appropriateness determinations for inpatient and outpatient
care, including behavioral health and SUD, using clearly written, published criteria which are
based on sound medical evidence, to evaluate the necessity of medical services. These criteria
4
sets are intended to be used as guidelines, and are not intended to replace appropriate clinical
judgment. Adaptation of these guidelines may be necessary based on individual needs and
assessment of the local delivery system. The Manager of Care Management annually reviews the
criteria and compares the approved GHC-SCW Clinical Practice Guidelines to the approved UM
Criteria to identify any inconsistencies between the documents. Criteria used is the most current
edition of Milliman Care Guidelines released in February of each calendar year, ASAM, and
Technology Assessment Policies. (Care Management Review Criteria CM.MED.002)
Actively practicing practitioners and specialists are part of the Technology Assessment
committee that meets 5 times a year to review and develop new technology and coverage for
GHC-SCW procedures. They are involved in the development, adoption and review of Milliman
Criteria Revisions and nationally developed standards. Criteria used to make UM determinations
are available to practitioners on the GHC-SCW Intranet and upon request. Practitioners are also
informed of the availability of criteria via the GHC-SCW Provider’s Update newsletter. At least
annually, the Clinical Services Quality Committee (CSQC) reviews and approves the criteria
utilized:
1. Milliman Care Guidelines: for Inpatient and Surgical Care
2. Milliman Care Guidelines: Ambulatory Care
3. Milliman Care Guidelines: General Recover Guidelines
4. Milliman Care Guidelines: Behavior Health Guidelines,
5. Milliman Care Guidelines: Recovery Facility Care Guidelines,
6. Milliman Care Guidelines: Home Care Guidelines,
7. Milliman Care Guidelines: Inter-rater Reliability
8. The American Society for Addiction Medicine (ASAM) Criteria for AODA Treatment.
Interrater Reliability (UM 2, Element C)
GHC-SCW reviews twice a year and assesses the consistency of personnel involved in making
utilization review determinations using UM criteria. This process includes physicians, nonphysicians, and pharmacists making medical and behavioral health/SUD determinations. Cases
are reviewed at identified intervals as part of a group educational process; these include but are
not limited to at least weekly UM Medical and Mental Health Rounds to evaluate determinations
and problem cases. When areas of improvement are identified, processes and /or interventions are
developed or revised, and implemented after staff education is provided. Monitoring of these
improvements occurs during weekly Rounds. (Scheduling Behavioral Health Appointments
CL.REC.SCH.021)
The goals of inter-rater reliability include, but are not limited to:
A Minimizing variation in the application of clinical guidelines,
B Evaluating staff’s ability to identify potentially avoidable utilization,
C Evaluating staff’s ability to identify quality-of-care issues,
D Targeting specific areas most in need of improvement,
E Targeting staff needing additional training, and
F Avoiding litigation due to inconsistently applied guidelines.
In addition, the CM department has adopted the use of Milliman Care Guidelines: Inter-rater
Reliability Tool which provides, quarterly on-line testing, where the CM staff work through case
scenarios and are scored on their use of the criteria against their peers.
The Manager of the Care Management Department conducts randomized audits of denials and
daily work of Care Management Department staff. When there are issues or concerns, a process
improvement plan will be determined based on the findings. Areas of improvement which are
identified as part of the audit are then discussed with individuals and/or at departmental staff
meetings and appropriate changes are made within the department’s processes.
5
Communication Services (UM 3)
Care Management (CM) staff are accessible to members and practitioners/providers to discuss
UM issues. (Communication Services CM.MED.021)
A. CM staff is available electronically or by phone between the hours of 8:00 am and 5:00 pm,
Central Standard Time, Monday through Friday, excluding holidays (working hours). There
are both local and toll-free phone numbers for the CM Dept.
B. After normal business hours the CM Department has confidential electronic and phone voice
mailboxes where message can be reviewed within 24 business hours. During weekends,
holidays, and non-working hours, the CM Department has confidential electronic and phone
voice mailboxes which are responded to within 24 business hours from receipt of the
message.
C. CM staff identifies themselves by name, title, and organization/department name when
initiating or returning phone calls.
D. There are both local and toll-free phone numbers for the CM Department to accept collect
calls regarding UM issues.
E. Staff are accessible to callers who have questions about the UM process. The CM Department
has a dedicated fax machine located within the department which is available 24 hours per
day, 7 days per week.
F. GHC-SCW Member Services screen incoming phone calls regarding specific UM issues and
transfers the callers to the appropriate nurse, administrative staff, or to the Manager of the
Care Management Department.
G. GHC-SCW offers TDD/TTY services for deaf, hard of hearing or speech-impaired members
H. GHC-SCW offers free of charge language assistance for members to discuss UM issues.
Appropriate Professional (UM 4, Elements A&F)
Utilization Management (UM) determinations are made by qualified healthcare professionals;
appropriately licensed professionals supervise all medical necessity decisions. Physicians,
chiropractors, dentists, physical/occupational therapists or pharmacists, as appropriate, review
non-behavioral health denials of care based on medical necessity. Physicians, appropriate
behavioral health practitioners, or pharmacists, as appropriate, review any behavioral health
denials of care based on medical necessary. Board-certified physician specialists are utilized to
assist in making medical necessity determinations, when necessary. (Appropriate Professionals
CM.MED.017)
A. Physician reviewers are available for making medical necessity determinations and denials;
the Medical Director, the Chief of Staff, the four Primary Care Site Chiefs, the Chief of
Quality and Care Innovation, the Associate Medical Director for Mental Health, the Clinical and
Developmental Psychologist, and the Chiropractor Chief of Staff. In addition, physician
reviewers make determinations related to potentially cosmetic/experimental procedures,
benefit exceptions, for out-of-network care and services, and when individual needs and
assessment of the local delivery system indicate that the UM criteria utilized are not
appropriate for the member. UM denials are not made based on pre-existing conditions.
B. The Care Management (CM) Department is supervised by a Registered Nurse Manager with
a master’s degree. The Manager, registered nurses, licensed social workers, licensed practical
nurses and care management associates approve services for medical necessity based on
criteria, and make administrative denials based on the members’ certificate of benefits.
Administrative staff makes approvals of services per the direction of the Manager of Care
Management.
C. The Pharmacy Department is supervised by a Registered Pharmacist. The Manager and the
other administrative registered pharmacists, make appropriate medical necessity approvals
and denials based on the member’s use of a recommended prerequisite drug or a step-therapy
protocol.
D. The Mental Health Department is supervised by a Master’s level Licensed Clinical Social
Worker and the Associate Medical Director for Mental Health (psychiatrist). The Manager,
Associate Medical Director, staff psychologists and other clinicians assist the CM RN/SW’s in
6
making appropriate medical necessity approvals based on criteria, and make
recommendations regarding administrative denials based on the members’ benefits.
E. The Associate Medical Director for Mental Health oversees referrals for all levels of non-staff
model care including inpatient, transitional, and outpatient services. Staff model out-patient service
prioritization is overseen by a team that includes a licensed doctoral level clinical psychologist
licensed clinical social workers, and a registered nurse.
F. A licensed Chiropractor oversees the appropriate use of Chiropractic services for acute
chiropractic interventions.
G The Manager of the GHC-SCW Physical Therapy Department does not make UM decisions
but is consulted for clinical expertise when appropriate.
H The physician reviewers and other department managers utilize appropriate board-certified
physician specialists from the University of Wisconsin (UW) Hospital and Clinics and UW
Medical Foundation as consultants, when necessary, to assist in making determinations of
medical necessity when clinical situations occur where the clinical judgment is sufficiently
specialized such that primary care physicians are unable to adequately address the issues in
question. The GHC-SCW Credentialing Coordinator maintains the list of such specialists and
makes it available to the physician reviewers and above mentioned department managers on
an as needed basis.
I UM decision making is based only on appropriateness of care and service and existence of
coverage. The GHC-SCW does not specifically reward practitioners or other individuals for
issuing denials of coverage. Financial incentive for UM decision makers do not encourage
decisions that result in underutilization.
J New employees are presented the Affirmative Statement Regarding Incentives policy
(Affirmative Statement Regarding Incentives CM.MED.020) during their employee
orientation. The Affirmative Statement is signed annually thereafter. This policy is also
located "Under One Roof" on GHC-SCW Internet, in HC and Practitioner's newsletters.
Timeliness and Notification of UM Decisions (UM 5)
CM staff, other GHC-SCW staff, and physician reviewers make timely and consistent
determinations for all UM activities requiring review to assess the medical necessity and/or
appropriateness of care or services. These determinations apply to both urgent and non-urgent,
requests, and extensions of time may be requested if a determination cannot be made timely due
to the lack of necessary information. In whole or in part, decisions and notifications are
communicated to appropriate members, practitioners, and providers in a timely manner to
accommodate the clinical urgency of the situation to minimize any disruption in the provision of
health care. (Policies CM.MED.003, CM.MED.004, CM.MED.007, CM.MED.008,
CM.MED.009)
1. Timeliness of Decision Making for Non-Behavioral Health and Behavioral Health UM
Decision:
1. For non-urgent pre-service decisions, GHC-SCW makes decisions within 15 calendar
days of receipt of the request. GHC-SCW counts the time of receipt as the next business
day
2. For urgent pre-service decisions, GHC-SCW makes decisions within 72 hours of receipt
of the request.
3. For urgent concurrent review, GHC-SCW makes decisions within 24 hours of receipt of
the request.
4. For post-service decision, GHC-SCW makes decisions within 30 calendar days of receipt
of the request.
B. Notification of Non-Behavioral Health and Behavioral Health Decisions:
For all determinations, GHC-SCW gives oral, electronic or written notification of the
decision to practitioners and members within the above designated time frames as per NCQA
guidelines.
7
C. Notification of urgent care requests decisions, GHC-SCW may notify the practitioner only of
the decision since NCQA considers the treating or attending practitioner is acting as the
member’s representative.
D. If the denial decision is either concurrent or post-service (retrospective) and the member is
not at financial risk, GHC-SCW is not required to notify the member. GHC-SCW must notify
the member in all other cases.
E. For urgent care requests, GHC-SCW may notify practitioners only of the decision. If the
decision is either concurrent or post-service (retrospective) and the member is not at financial
risk, GHC-SCW is not required to notify the member. GHC-SCW must notify the member in
all other cases
F. If requests for health care services comes from a practitioner, GHC-SCW may send the
request for additional information to the practitioner; but must notify the member if it denies
the services.
UM Reviews and Timely Determinations (UM 5)
CM staff, other GHC-SCW staff, and physician reviewers make timely and consistent
determinations for all UM activities requiring review to assess the medical necessity and/or
appropriateness of care or services. These determinations apply to both urgent and non-urgent
requests. In whole or in part decisions and notifications are communicated to appropriate
members, practitioners, and providers in a timely manner to accommodate the clinical urgency of
the situation to minimize any disruption in the provision of health care.
Preservice Decisions
Urgent Preservice Decisions
Urgent Concurrent Decisions
Postservice Decisions
Timeline for Decisions
Within 15 days of receipt of request
Within 72 hour of receipt of request
Within 24 hour of receipt of request
Within 30 days of receipt of request
Care Management accepts non-urgent referral requests via fax. Fax requests are accepted and
processed the next business day. On weekends and holidays, fax requests are entered the next
business day.
Medical Necessity/Medically Necessary means a service or supply which is determined by the
Medical Director to be required for the treatment or evaluation of a medical condition, is
consistent with the diagnosis, and which could not have been omitted under generally accepted
medical standards, or provided in a less intensive setting.
A. Pre-Service Review Determinations
1. Pre-service/urgent determinations are defined as any request for medical care or services
whereby application of non-urgent time periods could seriously jeopardize the life or
health of the member or the member’s ability to regain maximum function, based on a
prudent layperson’s judgment, or in the opinion of a practitioner with knowledge of the
member’s medical condition, would subject the member to severe pain that cannot be
adequately managed without the care or treatment that is the subject of the request.
2. Pre-service/non-urgent determinations are defined as those required for a request
presented prior to the member receiving medical care or services.
B. Concurrent Review Determinations
1. Concurrent review determinations are any review for the extension of a previously
approved ongoing course of treatment over a period of time or number of treatments.
These reviews are typically associated with inpatient admissions or ongoing ambulatory
care.
2. Concurrent urgent determinations are defined as any request for medical care or services
whereby application of non-urgent time periods could seriously jeopardize the life or
health of the member or the member’s ability to regain maximum function, based on a
8
prudent layperson’s judgment, or in the opinion of a practitioner with knowledge of the
member’s medical condition, would subject the member to severe pain that cannot be
adequately managed without the care or treatment that is the subject of the request.
3. Concurrent non-urgent determinations are defined as those requests that do not meet the
above definition for urgent care and may be handled as a new request and decided within
the time frame appropriate to the type of decision (i.e., pre-service or post-service).
C. Post-Service Review Determinations
Care Management (CM) staff, other staff, and physician reviewers make timely and
consistent determinations for all UM activities requiring review to assess the medical
necessity and/or appropriateness of care or services requested that have already been
provided to the member. Extensions of time may be requested if a determination cannot be
made timely due to lack of necessary information. Decisions and notifications are
communicated to appropriate members, practitioners, and providers in a timely manner.
Clinical Information (UM 6)
Relevant clinical information, that is pertinent to an identified episode of care, is collected from
the treating physician and other appropriate practitioners and documented to support accurate and
appropriate UM determinations of coverage based on medical necessity for medical and
behavioral health services (MH and SUD). (Documentation Of Clinical Information
CM.MED.013)
A. Sources of patient specific clinical information include, but are not limited to:
 History of presenting problem & physical exam findings
 Patient characteristics and information
 Consultations and evaluations from healthcare practitioners, providers, and consultants,
 Hospital and office medical records,
 Diagnostic testing results,
 Treatment plans and progress notes,
 Operative and pathological reports,
 Information regarding the local delivery systems
B. Levels of care include, but are not limited to:
 Inpatient, and ambulatory care,
 Medical, and surgical care,
 Home health care, hospice, SNF, and
 Behavioral health/ (MH and SUD), including transitional care.
C. Formats for UM documentation include, but are not limited to:
 Hardcopy and computerized case notes,
 GHC-SCW Request for External Mental Health Services (behavioral health and SUD)
Form,
 Computer generated formatted letters and hard copy letters,
 Emails, MyChart Messages
 Epic data files
 Customer Related Message (CRM) in Tapestry.
D. Transition to Other Care
If the member’s benefit is exhausted, documentation by the CM and/or Mental/SUD
Health staff will document attempts to assist with a member’s transition to other care, if
continuing services are needed. This is done in collaboration with the GHC-SCW
Community Services Coordinator and other Community Services Department Staff.
Behavioral Health
GHC-SCW does not have a centralized triage and referral process.
 GHC-SCW members have direct access to behavioral health care without prior
authorization or referral at four different GHC-SCW clinics and at UW Health Gateway
Recovery.
9

GHC-SCW members can directly call or walk in to a clinic to obtain behavioral
healthcare. After hours, GHC-SCW members calling the 24-hour crisis line with
behavioral healthcare inquiries are routed to an on-call behavioral healthcare practitioner.

GHC-SCW Member Services staff provides members with information about network
behavioral healthcare practitioners and how to access care, but do not make judgments
about the needed level of care or type of practitioner that the member should see.
Denial Notices (UM 7)
CM and other GHC-SCW staff clearly document and communicate the reasons for each denial,
provide members and their treating practitioners with the opportunity to discuss a denial with an
appropriate reviewer. A copy of the benefit language or criteria on which the denial
determination was made is sent to the provider, member and practitioner upon request. This
applies to all UM denials: medical, pharmaceutical, and mental health (behavioral health and
SUD). Members are directed to the GHC-SCW Member Services Department for appeal
submission and resolution.
A. CM and other GHC-SCW staff provide written denial notifications for all medical necessity
and benefit denials that include the following:
1. The specific reasons(s) for the denial, in easily understandable language
2. A reference to a UM criteria or benefit provision on which the denial is based
3. An easy to understand summary of that reference
4. Directions on how to obtain an actual copy of the reference mentioned above.
5. Insufficient information and or lack of clinical information can be an appropriated cause
for a medical necessity denial. In such cases the denial notice must contain all the
required components of a medical necessity denial which include a reference to the
clinical criteria that have not been met because of lack of information.
B. Staff members attach written appeal information in all denial notifications which includes:
1. Description of appeal rights, including the right to submit written comments, documents,
or other information relevant to the appeal, and
2. Explanation of the appeal process, including the right to member representation, and time
frames for deciding appeals, and
3. If a denial is an urgent pre-service or urgent concurrent denial, a description of the
expedited appeal process is included. (Policy SM.MS.001)
4. An expedited external review can occur concurrently with the internal appeal process for
urgent care and ongoing treatment.
C. For medical necessity denials, CM staff notifies practitioners of the availability of an
appropriate reviewer for discussion of the denial and how to contact that reviewer either via
written directions in the denial letter, staff messages in the Epic system, or a phone call to the
practitioner’s office. Staff documents the time and date of both the denial notification, the
offer of reviewer availability, as well as, conversations with the practitioner regarding the
specific case while the denial decision was pending.
1. The Medical Director and CM staff is available for discussion of medical denials.
2. The Chief of Chiropractic Services is available for discussion of chiropractic care denials.
3. The Mental Health Medical Director, Manager of Mental Health Services, CM staff and
appropriately qualified clinical mental health staff are available for discussion of
behavioral/SUD health denials.
4. The Manager of Pharmacy Services and administrative pharmacists are available for
discussion of pharmaceutical denials.
5. GHC-SCW Practitioners are informed of the denial and appeal process during their initial
orientation and throughout the year in the “Provider Update”.
6. For lack of information denials, reference to the clinical criteria that has not been met
must be included. If we are unable to provide a specific policy, we describe the
information needed to render a decision.
7. Appeals/grievances will be accepted by Member Services without time limitation
10
D. The External IRO appeal process is administered by the Federal Government Office of
Personnel Management (OPM) The member or representative has the right to request an
independent review. (An insured may authorize another individual to request an independent
review in any written form that is signed by the insured).
1. A written request must be submitted within 4 months of notice of the adverse benefit
determination or final internal adverse benefit determination.
2. The request for an external review must be submitted in writing or electronically to:
DisputedClaim@opm.gov; by faxing it to 202 606-0036; or by mailing it to P O Box
791, Washington DC 20044
3. If there are any questions during the external review process the member or
representative may call toll-free 877 549-8152
4. If additional written comments are submitted to the external reviewer at the mailing
address above, it will be shared with GHC-SCW in order to give GHC-SCW the
opportunity to reconsider the denial.
The IRO’s decision is legally binding on both the complainant and the insurer.
Appropriate Handling of Appeals (UM 9) GHC-SCW has a full and fair process for resolving
member disputes and responding to member’s requests to reconsider a decision they find
unacceptable regarding care and service. The documentation, investigation and appropriate
response to an appeal are coordinated through the Member Services Appeals Representative.
Appeals are resolved within 30 calendar days of receipt for pre and post-service appeals.
Expedited appeals are resolved as expeditiously as the medical condition requires but no later
than one bed day, not to exceed 24 hour of the receipt of the appeal. GHC-SCW provides
nonsubordiante reviewers who are not associated with the initial determination and the same or
similar specialist. Members are notified in writing with the rational for upholding the denial in an
easy and understandable language. Denial letters are printed in the member’s primary language.
Included in the denial letters are the medical or benefit criteria was used in the decision making
process. Member are entitled to reasonable access to and copies of all documents upon request.
(Policy SM.MS.001)
Technology Assessment (UM 10)
The technology assessment process is utilized to evaluate new technologies and new applications
of existing technologies. Medical technology assessment is the determination of value or
significance of scientific methods and materials to effectively achieve a medical objective. This
process is intended to render scientific analysis and opinions that advance the understanding of
complex technology issues. This information allows GHC-SCW to make decisions about
treatments which best improve members’ health outcomes, help GHC-SCW efficiently manage
utilization of health care resources, and make changes in benefit coverage to keep pace with
technology changes and to ensure that members have equitable access to safe and effective care.
(Technology Assessment Committee CM.MED.010)
The Technology Assessment Committee (TAC) is scheduled to meet at least 5 times annually, to
conduct technology assessments. Members of the TAC include the Medical Director, assigned
GHC-SCW physicians, the Manager of Pharmacy Services, and the Manager of Care
Management. The GHC-SCW Mental Health (MH) Medical Director and MH clinicians,
University of Wisconsin (UW) physician specialists, and Care Management (CM) staff attend
meetings upon request of the committee to provide input as relevant specialists and professionals
who have expertise in the technology currently under review. (Policy CM.MED.010)
The Formulary Committee (FC) is the first level committee to evaluate new pharmaceuticals or
new uses of existing pharmaceuticals. Recommendations from the FC are forwarded to the TAC
for final review and approval.
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1. Technology Categories: technologies encompass medical procedures, behavioral health
procedures, pharmaceuticals, and devices.
2. Review Categories:
a. Proactive reviews are usually initiated when a new technology is identified from
published scientific evidence or an appropriate government regulatory body.
b. Reactive or urgent reviews are triggered by a provider’s request for the use of a new
technology, a new application of an existing technology, or a special review case.
c. Retrospective reviews are conducted when the request was received after the service
was provided.
d. Scheduled review of established GHC-SCW technology assessments.
3. Technology Evaluation Sources may include but are not limited to:
a. Hayes Incorporated is a major vendor of technology assessments.
b. The Food and Drug Administration (FDA) information as contained in the Hayes &
TEC reports
c. Technology Evaluation Center (TEC) sponsored by the Blue Cross/Blue Shield
Association and Kaiser Permanente.
d. Reports from governmental agencies and medical associations, i.e. Center for Disease
Control (CDC), American College of Obstetricians & Gynecologists or recognized
sites like Medline may be utilized.
e. Medical literature published in peer reviewed journals or by other health plans i.e.
Aetna, Cigna, United Healthcare, CMS, Medline, etc.
f. Local medical expert opinion or specialty physician consultants.
4. Review Criteria for Determinations: technology assessment decisions are based upon the
following criteria;
a. The technology must have received final approval from the appropriate government
regulatory bodies, if applicable, e.g. FDA, AMA, CMS (formerly known as HCFA).
b. The scientific evidence must permit conclusion concerning the effect of the
technology on health concerns.
c. The technology must be as beneficial as any established alternative.
d. The technology must improve the net health outcome of the patient.
e. The technology must be attainable outside the investigational setting.
Satisfaction with the UM Process (UM 11)
GHC-SCW annually evaluates both member and practitioner satisfaction with the UM Process.
Identifiable sources of dissatisfaction are addressed through process improvement activities to
meet UM goals and objectives, and to meet member and practitioner expectations.
Procedure for Monitoring Member Satisfaction
A. The GHC-SCW Quality Management Department conducts an annual CAHPS Member
Satisfaction Survey; questions related to satisfaction with UM processes are included in that
survey. Results are shared with the Clinical Quality Service Committee, members and
practitioners, and Care Management (CM) staff. (2012 Member Satisfaction with UM Sept
19 CSQC.pptx)
1. CM staff participates in the analysis of data for the identification of improvement
opportunities.
2. GHC-SCW member complaint and appeal process is monitored
3. Evaluation provides opportunities for member education and/or benefit changes.
B. Procedure for Monitoring Practitioner Satisfaction
1. The CM Department conducts an annual Practitioner Satisfaction Survey of all staff
model and network primary care practitioners, the office managers and referral
coordinators of their respective primary care clinics. (CSQC Practitioner Satisfaction
with UM June 2012.pptx)
12
2. CM staff participates with the Manager of Care Management in the evaluation of the
survey responses. Results are presented to the Medical Director, the Clinical Service
Quality Committee (CSQC), the Board of Directors, and the practitioners.
3. Trends and issues are identified for process improvements; action plans are developed by
the Medical Director, Manager of Care Management, CM staff, and other appropriate
practitioner committees and then presented to the Clinical Service Quality Committee
(CSQC).
4. The results of improvement activities are continuously monitored through practitioner
feedback and evaluation of the GHC-SCW complaint and appeal processes; annual
resurveys also provide feedback.
5. Evaluation provides opportunities for practitioners’ education and/or benefit changes.
Emergency Services (UM12)
A. GHC-SCW covers all emergency services necessary to screen and stabilize a member without
prior authorization in cases where a prudent layperson, acting reasonably, would have believed
that an emergency medical condition existed; OR when members have been advised by a
GHC-SCW representative to receive such care.
B. The Wisconsin State Statutes 2011, Wisconsin Act 632.85 is utilized as a reference in the
decision-making.
C. NCQA defines a prudent layperson as a person who is without medical training and who
draws on his or her practical experience when making a decision regarding the need to seek
emergency medical treatment. A prudent layperson will be considered to have acted
“reasonably” if other similarly situated laypersons would have believed, on the basis of
observation of the medical symptoms at hand, emergency medical care was necessary.
D. A physician reviewer retrospectively reviews emergency records to determine if the presenting
symptoms and discharge diagnosis meet the prudent layperson definition; all denials related to
medical necessity are determined by a physician reviewer. (Policy CM.MED.006)
Pharmaceutical Management (UM13)
The complete description of the Pharmaceutical Management Program (CL.PH.BEN.008) can be
found at:
https://ghcscw.com/media/2011_ph_Pharmaceutical_Management_Program_PH033.PDF
Triage and Referral for Behavioral Health (UM 14)
This standard and all three elements are not applicable to Group Health Cooperative of South
Central Wisconsin (GHC-SCW) because the organization does not have a centralized triage and
referral process.
 GHC-SCW members have direct access to behavioral health care without prior
authorization or referral at four different GHC-SCW clinics and at UW Health Gateway
Recovery.
 GHC-SCW members can directly call or walk in to a clinic to obtain behavioral
healthcare. After hours, GHC-SCW members calling the 24-hour crisis line with
behavioral healthcare inquiries are routed to an on-call behavioral healthcare practitioner.

GHC-SCW Member Services staff provide members with information about network
behavioral healthcare practitioners and how to access care, but do not make judgments
about the needed level of care or type of practitioner that the member should see.
Quality of Care Issues
Care Management (CM) staff monitor, identify, document, and report potential quality of care
issues to the Medical Director and the Quality Management (QM) Department. These issues are
referred to as Adverse Events and include issues related to medical and behavioral health care and
services provided to members.
A. An Adverse Event is an untoward event with a less-than-optimal outcome.
B. CM staff report the following adverse events for potential evaluation by the Medical Director
and/or Medical Peer Review Committee (CM policy and procedure CM.018):
13
(1) Unplanned hospital readmission within 10 days of a hospital medical discharge and
within 30 days of a hospital mental health discharge;
(2) Unplanned return to the operating room within 48 hours during the same hospital
admission;
(3) Unanticipated in-hospital deaths;
(4) Severe post-surgical infections;
(5) Unplanned admission to the hospital after outpatient test or procedure;
(6) Prematurity;
(7) Trauma or injury suffered while in a health care facility/practitioner office/HMO site i.e.
surgery on wrong body part, loss of function not related to illness or condition, rape or
suicide in a 24-hour care facility.
Complex Care Management (QI-7)
Complex Care Management is a collaborative process in which a care manager assesses plans,
facilitates and advocates for options and services to meet an individual member’s health needs.
Communication and allocation of resources is part of day to day care management. Members for
complex case management are identified by claim or encounter data, hospital discharge data,
pharmacy data, and data collected through UM management.
Criteria utilized to identify potential cases are 1) complex medical cases e.g severe multiple
trauma, 2) members with a chronic disease diagnosis and multiple co-morbidities, 3) frequent ER
visits and/or 4) frequent hospitalizations.
Oversight of Complex Care Management is performed by the Medical Director, Mental Health
Medical Director, Manager of Care Management and Manager of Mental Health.
Communication is ongoing with the primary care physician to share information and coordinate
the individual’s health care needs
The complete GHC-SCW Complex Care Management Program is found:
https://ghcscw.com/media/2011_ph_CCM_Prog_Man.pdf
14
APPENDIX A.8
COMPLEX CASE MANAGEMENT
Table of Contents
Complex Case Management Purpose & Objectives
 Complex Case Management Criteria
o Complex Case Manager Description
o Meetings
o Complex Case management Purpose and Definition
Population Assessment
Identifying Members for Complex Case Management
Access to Complex Case Management
EPIC Case Management Information System
Complex Care Management Process
Measuring Satisfaction with Complex Case Management
Measuring Effectiveness with Complex Case Management
Action and Re-measurement
Communication and Confidentiality
Interface with Disease Management
Complex Case Management Description
 Member Identification and Selection Process
 Member Assessment
 Care Plan Development and Update Process
 Care Plan Implementation Process
 Care Plan Monitoring & Evaluation Process
 Cost Savings Calculations and Rates
 Complex Case Management Discharge Process
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
3
4
4
4
4
5
5
7
7
8
10
11
11
11
12
12
12
14
16
16
17
18
19
Appendix
Complex Case Management 8 processes
Initial Calling Script
Complex Case Management Referral Form
Patient Activation Measure
Quality Management – Key Quality of Care Indicators
Complex Case Management Process
Case Management Program Patient Satisfaction Survey
Practitioner Satisfaction survey
Complex Case Management Policy CM.MED.03
CCM Introductory Letter
2012 Complex Case Management Program Description
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14
23
24
25
28
29
30
32
36
41
2
Group Health Cooperative of South Central Wisconsin
Complex Case Management Program Description
PURPOSE/DEFINITION
Complex Case Management is the coordination of care and services provided to
members who have experienced a critical event or diagnosis that requires an
extensive use of resources and who need help navigating the health system to
facilitate appropriate delivery of care and services.
POLICY STATEMENT
The Complex Case Management program at Group Health Cooperative of South
Central WI (GHC-SCW) provides proactive, medically appropriate, cost effective,
coordinated care to members with complex medical conditions, or for whom a critical
event has precipitated a need for rehabilitation or additional health care support.
GHC-SCW members inquiring about or accessing health care services are screened
and evaluated to determine their potential need for Complex Case Management
services. The goal of the program is to assist members with multiple or complex
conditions and comorbidities in obtaining access to quality care and appropriate
services through coordination of their health care needs and to help them navigate
the health care system. The Complex Case Management Program description is
approved annually by the Clinical and Service Quality Committee (CSQC).
OBJECTIVES
 To proactively identify members who have multiple or complex medical and/or
psychosocial needs or who are at risk of developing complex needs during an
acute episode of illness.
 To provide early intervention for members appropriate for complex care
management.
 To support the clinical staff focus on the delivery of medical care that
maximizes quality of life and ensures that the care is provided in the most
appropriate and supportive setting.
 To facilitate communication among the member, their families, health care
providers, the community and the health plan in an effort to enhance
cooperation while planning for and meeting the health care needs of the
member.
 To serve as a liaison to community resources regarding options and services
not covered by the benefit plan.
 To allocate resources and maximize the available benefits.
 To track and report episodes of illness at the member and aggregate level for
the purpose of identifying trends, and measuring medical outcomes and
financial impact.
 To increase member and provider satisfaction through the coordination and
management of health care resources.
 To increase member’s satisfaction of GHC-SCW’s Healthcare team.
 To assist in the development and communication of the member’s selfmanagement plan.
 To function as an educator of members, the healthcare team and the
community regarding the case management process and specific health care
issues.
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3


To serve as an advocate for the member and family.
To partner with the member and family in assisting the member to reach
maximum achievable medical potential and maximum independence.
Complex Case Management Criteria
Complex Case Manager Description
The Complex Case Manager, Registered Nurse/ Social Worker (SW), assesses,
plans, implements, monitors, and evaluates the options and services required to
meet an individual’s health needs, using communication and available resources to
promote quality, and cost-effective outcomes.
The Case Management Team Coordinator is responsible for coordinating, leading
and participating in case management programs and projects for the Care
Management Department. The Team Coordinator provides training to Care
Management department staff and monitors compliance with Group Health
Cooperative of South Central Wisconsin (GHC-SCW) and the National Committee
for Quality Assurance (NCQA) procedures and policies.
Meetings
The Medical Director meets monthly with case managers to discuss and review
cases that have questions or concerns. The complex care management staff meets
monthly for educational updates and case review. File audit results are presented at
this time. Complex case managers meet biweekly to review the cases opened and
to review audit results and identify areas for improvement.
PURPOSE
To identify GHC-SCW members who have complex care needs that would benefit
from additional support and help with coordination of their medical care.
To ensure communication with members and practitioners regarding the referrals
and participation in GHC-SCWs Complex Case Management Process.
DEFINITION
Member identification is the initial process of Complex Case Management. Referral
sources use established selection criteria to recognize a potential complex care
management opportunity. The Complex Case Management Selection Criteria
consist of targeted diagnoses and situational criteria which indicate a potential,
chronic, catastrophic or complex case which may benefit from complex care
management intervention. Potential members may also be identified through
member self-referral or referral from other sources.
A. To be considered for Medical Complex Case Management all members must
meet the following criteria:
1. Valid GHC-SCW Healthcare coverage for their medical services, and
2. Chronic disease diagnosis with 2-3 co-morbidities with multiple hospital
admissions and/or multiple Emergency Room visits in six (6) months
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B. To be considered for Complex Case Management for mental health and or
AODA, all members must meet the following criteria:
1. Valid GHC-SCW Healthcare coverage for their mental health services, and
2. Have an acute diagnosis of substance abuse or dependence, major
depressive disorder, personality disorder, psychosis, schizophrenia or autism,
AND
3. Readmission for inpatient mental health within 30 days, OR
4. All of the following criteria must be met:
i.
Two or more ER visits in six months with mental health related
diagnosis, AND
ii.
Two or more hospitalizations in 12 months with mental health related
diagnosis, AND
iii.
Diagnosis impacts ability to perform Activities of Daily Living (ADL)
C. Members with prolonged hospital stays are high dollar cases or are at risk for
severe complications and repeat hospitalizations may be selected for complex
case management.
Element A: Population Assessment
GHC-SCW annually assesses the characteristics of its member population and
relevant subpopulations to identify members for complex case management. GHCSCW reviews and annually updates it complex case management processes and
resources to address member needs if necessary. The annual Ethnicity/Race/Age
Report for GHC-SCW is reviewed as part of the population assessment process.
The initial step in identifying populations with complex case management needs is to
identify specific populations which are at high risk for complex conditions and
comorbidities. It was identified that a small percentage of the GHC-SCW population,
2.4%, identified themselves with an ethnic background through this Assessment.
The ethnic population identified is not significant enough to warrant a change in staff
resources or processes.
1. Ethnicity/Race/Age Report ENR0003060
Element B: Identifying Members for Complex Case Management (CCM)
Member identification is the initial process of Complex Case Management. The goal
is to assist members with multiple or complex conditions and comorbidities in
obtaining access to quality care and appropriate services through coordination of
their health care needs and to assist them with navigating the health care system. (
Policy CM.MED.03) During this identification process, referral sources use
established selection criteria to recognize a potential Complex Case Management
opportunity. The evaluation of pharmacy, claims, hospital ER and Inpatient data,
health risk assessments and the electronic medical records three additional disease
processes were identified for complex case management in 2012. It was through
the critical assessment of the listed data that three additional complex disease
processes were identified for complex case management. Cancer continues to be
complex case managed. Additional Care Management staff was added in 2012 to
address the increase in complex case management cases and complexity. The care
management selection criteria consist of targeted diagnoses and situational criteria
which indicate a potential chronic, catastrophic or complex member which may
benefit from care management intervention. The review and evaluation of reports
2012 Complex Case Management Program Description
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5
weekly, monthly or annually assisted with the identification of members for complex
care management services. The reports reviewed included but were not limited to:
1. Claims or encounter data identifies chronic conditions with complex
co-morbidities and high cost.
1. Claim encounters for Diabetes: crms select etg claims for care
management 0027.pdf
2. Claim encounters for CHF: crms select etg claims for care
management 0268
3. Claim encounters for COPD: crms select etg claims for care
management 0267.pdf
2. Hospital admit/discharge data identifies chronic conditions with
complex co-morbidities requiring frequent inpatient stays affecting
cost ratio.
1. MUM0002010--Hospital Census -- Current Inpatients.pdf
2. MUM0003020--Hospital Census--9 Days or More
3. Daily UW Health census of GHC patients discharged
3. Pharmacy data identifies complex chronic conditions with costs
associated with the treatment of the condition.
1. Top-50 fills detail.xls
4. Data collected through the utilization management process identifies
chronic conditions with complex co-morbidities requiring frequent
inpatient stays affecting cost ratio.
1. Prior Authorization
2. Concurrent review,
a. MUM0026050--High Frequency Emergency Room Patients All HMO
Hospital Readmission data3. MUM0011050--Facility Readmissions within 30 Days of Mental Health
Discharge
a. MUM0007010--All Pended Referrals
b. MUM0025050-Facility Readmission within 30 days of Medical
Discharge
5. Data collected by purchasers – NA
6. Data supplied by member or caregiver
1. Health Risk Assessment
7. Data supplied by practitioners (EPIC-Electronic Medical Records)
allow CCM to evaluate complex conditions of members
Three primary chronic conditions, CHF, COPD and Diabetes have been identified for
the primary focus for complex case management in 2012. Cancer continues to be a
condition that is complex cased managed. The diagnoses have been identified
through claims encounters, pharmacy data and emergency room (ER) visits as
primary, reoccurring, diagnoses with frequent ER visits. Additional Care
Management staff was added in 2012 to address the increase in complex case
management cases and complexity.
Determining whether a member is appropriate for Complex Case Management
services is achieved by gathering and critically assessing relevant, comprehensive
information and data, so that members are selected according to case management
potential to influence positive outcomes and meet GHC-SCW’s complex care
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6
management criteria as outlined in Steps 1 & 2 – Identification and Access to
Complex Case Management. In addition, this determination involves comprehensive
assessment of the member’s condition; determination of available benefits and
resources; and development and implementation of a case management plan with
performance goals, monitoring and follow-up.
GHC-SCW has the option for the member to opt out of complex case management.
This is presented with the initial phone call (Appendix B) and in the Introductory
Letter. (Appendix J)
Element C: Access to Complex Case Management
Members who experience a critical event or diagnosis should receive timely case
management services. To minimize the time between when a member’s need is
identified and when the member receives services, GHC-SCW has multiple avenues
for members to be considered for case management services including, but not
limited to:
1. GHC-SCWs nurses review information from members who contact GHCSCW via the electronic and phone HealthLine to identify members who might
benefit from CCM. Such members are referred to the CCM Department for
consideration for inclusion in the CCM.
2. Referral from GHC-SCWs Disease Management and Health Registries
program. Monthly communication between Disease Management, Health
Educators and Care Management allows members to be identified for CCM.
a. 2012 Transition of Care Cases
b. Health Registries
i.
Asthma - QMI0017060
ii.
Cardiovascular Disease - QMI0008050
iii.
Diabetes - QMI0001020
iv.
Hypertension - QMI0010050
3. Referral from hospital discharge planners contact CCM’s to identify members
who have complex conditions requiring immediate CCM and needs.
a. CCM Cases Opened & Assessments Completed Weekly 2012.xlsx
4. Data gathered from UM activities assist with the identification of members
who may benefit from CCM. The data includes but not limited to ambulatory
care sensitive conditions, diagnoses and readmission rates.
a. MUM0026050--High Frequency Emergency Room Patients All HMO
Hospital Readmission datab. MUM0011050--Facility Readmissions within 30 Days of Mental Health
Discharge
c. MUM0007010--All Pended Referrals
d. MUM0025050-Facility Readmission within 30 days of Medical
Discharge
5. Referral from members or caregivers (Appendix C)
a. Health Risk Assessment
b. CCM Cases Opened & Assessments Completed Weekly 2012.xlsx
6. Referral from internal practitioners including Mental Health Practitioners.
(Appendix C)
a. CCM Cases Opened & Assessments Completed Weekly 2012.xlsx
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7
Information regarding referral and participation in GHC-SCWs Complex Case
Management Program is communicated to both members and practitioners in a
variety of ways, including but not limited to:
 GHC-SCWs website
 GHC-SCW MyChart
 Member, practitioner, and staff electronic communications and postal mailings
 Informational brochure
 House Calls
Element D: EPIC Case Management Information Systems
GHC-SCW facilitates Complex Case Management by providing the necessary tools
and information to help case managers do their jobs effectively.
1. Using evidence-based clinical guidelines or algorithms to conduct
assessment and management.
 The EPIC electronic case management system uses algorithmic logic
such as scripts and other prompts to guide the case managers through
assessment and ongoing management of enrolled members. The clinical
basis of these prompts and scripts are developed by using evidencebased clinical guidelines or algorithms from Milliman Care Guidelines,
published nursing care plans and other resources, which assist the case
managers in conducting initial assessments and ongoing complex care
management.
2. Automatic documentation of the member identification and the date and time
when the organization acted on the case record or interacted with the
member.
 The EPIC electronic case management information system includes
automated features that provide accurate documentation for each entry;
recording actions or interactions with members, practitioners or providers;
and include automatic date, time and user stamps.
3. Automated prompts for follow-up, as required by the complex case
management plan.
 To facilitate care planning and management, the EPIC electronic case
management information system, includes features to set prompts and
reminders for next steps or follow-up contacts.
Element E: Complex Care Management Process
GHC-SCWs Complex Case Management Process addresses all of the following:
Member’s Rights
Prior to initiating Complex Case Management services, the case manager will
obtain appropriate and informed member consent, including their right to
decline participation or dis-enroll from the complex case management
process at any time following enrollment.
1. Health Status
During initial telephonic (or face to face) assessment, the case manager will
evaluate the member’s health status specific to identified health conditions
and likely co-morbidities.
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2. Clinical History
The Complex Case Management process documents the member’s clinical
history, including disease onset: key events such as acute phases; and
inpatient stays, treatment history (therapies or procedures used to care for a
member’s identified health conditions and comorbidities) and current and past
medications, including schedules and dosages.
3. Activities of Daily Living
As part of the initial assessment, the case manager evaluates the members
functional status related to activities of daily living such as eating, bathing and
mobility.
4. Mental Health Status
During the initial assessment, and ongoing evaluations, the case manager
evaluates the member’s mental health status, including psychosocial factors
and cognitive functions such as the ability to communicate, understand
instructions and process information about their illness.
5. Life Planning
The complex care management initial clinical assessment documentation
addresses life planning issues such as wills, living wills, advanced directives
and health care/financial power of attorney. In situations where a life planning
activity is not appropriate, documentation about the situation should be
recorded.
6. Cultural and Linguistic Needs, Preferences, or Limitations
The case manager’s assessment includes cultural and linguistic needs,
preferences or limitations of the member.
7. Visual and Hearing Needs
The case manager’s assessment includes visual and hearing aid needs to
communicate effectively.
8. Caregiver resources
During the initial assessment, the case manager will evaluate caregiver
resources such as family involvement in and decision making about the care
plan.
9. Available Benefits within the organization and community resources
The complex care management plan includes an assessment of the
member’s eligibility for health benefits and other pertinent financial
information regarding benefits within the organization and from community
resources..
10. Individualized Complex Care Management Plan and Prioritized Goals
The care management plan of care identifies, but is not limited to the
following: short and long term prioritized goals; time frame for reevaluation;
resources to be utilized, including the appropriate level of care; planning for
continuity of care, including transition of care and transfers; collaborative
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approaches to be used, and family/caregiver needs, level of involvement and
preferences.
11. Barriers to Meeting and/or Complying with Plan of Care
The complex care management process identifies and addresses barriers to
meeting goals or the member’s ability to comply with the plan. These could
include the member’s lack of understanding (due to clinical understanding of
a condition, language or literacy level), motivation, cultural or spiritual beliefs;
visual or hearing, psychological impairment, any financial needs, insurance
issues or transportation problems. The health plan documents barriers
assessment even if no barriers were identified.
12. Facilitation of member referrals
Members may benefit from referrals to available resources as part of their
benefit. The organization’s case managers facilitate member referral to other
health organizations, when appropriate and when the purchaser provides
information about external referral organizations. The organization bases
referrals on guidelines developed with the plan sponsor.
13. Follow-up Schedule and Communication to Member
The complex care management plan includes a schedule for follow-up
communication that includes, but is not limited to counseling, referrals to
disease management, education or self-management support.
14. Development and Communication of Self-Management Plan
The self-management plan includes the development and communication of
the member’s self-management plan, and may include but is not limited to,
member’s monitoring of their symptoms, activities, weight, blood pressure and
glucose levels and maintaining a prescribing diet.
15. Assessing Progress against case management plans
The Complex Case Management plan includes an assessment of member’s
progress towards overcoming barriers to care and meeting treatment goals.
The complex care management process includes reassessing and adjusting
the care plan and its goals, as needed.
The case management notes must clearly describe the assessment results for each
factor, even if the factor is not applicable to the member. The documentation must
include why the factor is not applicable.
Element F & G: NCQA reviews a random sample of case management files
selected from cases opened for at least 60 days within 12 months prior to the
survey.
Note: If the CCM is unable to locate or communicate with a member after three or
more attempts within a two week period of time and fails to complete the
assessment within 30 calendar days, GHC-SCW may exclude the member from
complex case management and the file will be excluded from review. The CCM
must document its attempts, which may include any form of individualized,
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documented contact by telephone, letter, email or fax. If a complex case
management stops when a member is admitted to a facility and the stay is longer
than 30 calendar days. A new assessment must be performed after discharge if the
member is elegible for complex case management.
Care Management typically completes monthly audits until there are three
consecutive months of 100% on elements E and F (initial assessment and goal
planning). When this is achieved the audits are completed every other month.
NCQA 8/40 methodology is used for file review.
If the member is unable to communicate because of infirmity, assessment may be
completed by professionals on the care team, with assistance from the member’s
family or caregiver. This information is documented in Epic Tapestry notes.
Element H: Measuring Satisfaction with Complex Case Management Program
GHC-SCW annually evaluates satisfaction with Complex Case Management
program by:
 Obtaining feedback from members and practitioners through the following
surveys:
1. Annual Complex Case Management Member Survey (Appendix G )
2. Annual Practitioner Satisfaction Survey (Appendix H)
3. Patient Activation Measure (Appendix D)
 Analyzing member complaints and inquiries.
1. Member Access Report-2012.pptx
GHC-SCW uses three patient experience measures to evaluate satisfaction with the
Complex Care Management Program. The three measures address satisfaction with
Complex Case Management process operations, i.e. satisfaction with the frequency
of contact or satisfaction with the assigned case manager. Examples of other
measures of patient experience include improved quality of life, pain management
and health status.
GHC-SCW will analyze complaints and inquiries to identify opportunities to improve
satisfaction. Analysis considers quantitative and qualitative data to identify patterns
of member comments.
Element I: Measuring Effectiveness with Complex Case Management
Program
GHC-SCW measures the effectiveness of its Complex Case Management by using
three measures:
 Twice a year Patient Activation Measure Survey(PAM 12) (Appendix D)
 Annual Complex Case Management Member Survey (Appendix G )
 Annual Practitioner Satisfaction Survey (Appendix H)
For each of the above measures, GHC-SCW will:
 Identify a relevant process or outcome,
 Use valid methods that provide quantitative results,
 Set a performance goal,
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



Clearly identify measure specifications,
Analyze results,
Identify opportunities for improvement, when applicable,
Develop a plan for intervention and re-measurement.
Element J: Action and Re-measurement (Measuring Effectiveness)
Based on an analysis of both the satisfaction survey results and effectiveness
measures, GHC-SCW will:
 Implement at least one intervention to improve performance
 Re-measure results to determine performance.
The evaluation of the PAM, Complex Case Management Member and Practitioner
Satisfaction Surveys are presented annually to the CSQC committee.
Recommended interventions for areas of improvements are discussed and
approved.



April 2012: 2011 PAM Presentation v3.pptx
May 2012 Complex Case ManagementMemberSATIS APRIL3012PDS.ppt
June 2012: CSQC Practitioner Satisfaction with UM June 2012.pptx
There was a 13% increase in overall statifaction with care managent from 2011 to
2012. This was accomplished with increased case managers in each staff model
clinic providing direct interaction with physicians, clinical staff and members.
Communication and Confidentiality
Effective communication is critical to the success of the Complex Case
Management. Various individuals who have an interest in the well-being of the
member and the management of the member’s care must be kept informed, and
have an opportunity to participate in decisions affecting the member.
In order to facilitate effective and efficient communication, guidelines have been
established to address the exchange of information during the Complex Case
Management process.
To ensure confidentiality, no voluntary disclosure of member specific clinical or nonclinical information will be made except to persons authorized to receive such
information to conduct case management activities. All information is considered
confidential.
Interface With Disease Management
Key quality indicators and criteria have been established and are incorporated into
the Complex Case Management Process. The case manager is responsible for
identifying and sharing any potential quality issues with the Quality Management
Department who will evaluate and follow up as protocol indicates.
The case manager proactively makes referrals to GHC-SCWs Disease Management
programs for members who would benefit from such services from information
gathered during the following case management processes:
 Precertification data
 Concurrent review data
 Prior authorization data
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 Hospital admission data
 Hospital discharge data
 Complex Care Management Initial Assessment data
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Appendix A
COMPLEX CASE MANAGEMENT
Complex Case Management consists of eight processes:
1.
2.
3.
4.
5.
6.
7.
8.
Member Identification
Care Selection
Care Assessment
Plan Development/Update
Plan Implementation
Plan Monitoring and Evaluation
Cost Savings Calculations and Rates
Care Discharge
Steps 1 thru 8 on the subsequent pages, followed by the process descriptions
provide an overview of the Complex Case Management processes.
Steps 1 & 2- Member Identification and Selection Process
PURPOSE
To identify GHC-SCW members who have complex care needs that would benefit
from additional support and help with coordination of their medical care.
To ensure communication to members and practitioners regarding referral and
participation in GHC-SCWs Complex Case Management Process.
DEFINITION
Member identification is the initial process of Complex Case Management. Referral
sources use established selection criteria to recognize a potential complex care
management opportunity. The Complex Case Management Selection Criteria
consist of targeted diagnoses and situational criteria which indicate a potential,
chronic, catastrophic or complex case which may benefit from complex care
management intervention. Potential members may also be identified through
member self-referral or referral from other sources.
A. To be considered for Complex Case Management (Medical, Mental Health, or
Alcohol and Other Drug Abuse [AODA]) all members must meet the following
criteria:
1. Valid GHC-SCW Healthcare coverage for their medical services, and
A. CHF, COPD & Diabetes
B. Chronic disease diagnosis with 2-3 co-morbidities with multiple hospital
admissions and/or multiple Emergency Room visits in six (6) months
B. To be considered for Complex Case Management for mental health and AODA
all members must meet the following criteria:
1. Valid GHC-SCW Healthcare coverage for their mental health services and
AODA and
2. Have an acute diagnosis of substance abuse or dependence, major
depressive disorder, personality disorder, psychosis, schizophrenia or autism,
AND
3. Readmission for inpatient mental health within 30 days, OR
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4. All of the following criteria must be met:
i.
Two or more ER visits in six months with mental health related
diagnosis, AND
ii.
Two or more hospitalizations in 12 months with mental health related
diagnosis, AND
iii.
Diagnosis impacts ability to perform ADLs
C. Members with prolonged hospital stays are high dollar cases or are at risk for
severe complications and repeat hospitalizations may be selected for complex
case management.
Other criteria which may be met:
1. The member requires many resources, such as home health care services or
durable medical equipment, in order to return home or remain at home.
2. The member is at high risk for readmission to the hospital.
3. The member needs extensive interpretation of his health coverage, or the
rules for obtaining medical services.
4. The member needs information about alternative funding sources or referrals
to community based services.
5. There is a cost effective alternative to the member’s current level of care.
Criteria which will not meet enrollment criteria
1. Member is Fee for Service
2. Member is not competent to consent to care management
3. Member is currently enrolled in Hospice Services
4. Member has PPO coverage
If the above criteria are met, the case manager will review further resources to:
1. Evaluate diagnosis, clinical condition, complications, or cost to identify
potential members suitable for effective complex care management
interventions,
2. Consider disease specific risk stratification reports, (i.e., predictive risk,
diagnostic cost groups, etc.)
3. Conduct a thorough and systematic evaluation of the member’s current
status, including but not limited to, the following components:
a. Physical/functional
b. Psychosocial
c. Behavioral
d. Environmental/residential
e. Family dynamics and support
f. Spiritual
g. Cultural
h. Financial
i. Vocational and/or educational
j. Recreation/leisure pursuits
k. Primary caregiver(s) capability and availability
l. Learning capabilities/self-care
m. Health status expectation and goals
n. Transitional or discharge plan
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5. Assess resource utilization and cost management; the diagnosis, past and
present treatment course and services, prognosis, goals, treatment, and
provider options.
The case manager may determine a need for Complex Case Management for
members who do not meet the criteria. This will be at the professional judgment of
the case manager.
Once the potential member is identified, the case manager will:
1. Initiate a case within the EPIC Case Management information system and
place the member in the appropriate disease category roster.
2. Contact the member for potential enrollment in the program using the Initial
Calling Script (Appendix A)
3. If the member elects to participate in the program:
a. Record member opt in status within EPIC. (Opt In-GHC Prime)
b. Send Welcome Letter and business card.
c. The case manager coordinates with the member/family/significant other to
schedule a telephone or face to face conference to conduct the initial
assessment within 2 weeks.
4. If the member elects not to participate in the program at this time:
a. Record member opt out status within EPIC
b. Close the case.
If the CCM is unable to locate or communicate with a member after three or more
attempts within a two week period of time and fails to complete the assessment
within 30 calendar days, GHC-SCW may exclude the member from complex case
management and the file will be excluded from review. The CCM must document its
attempts, which may include any form of individualized, documented contact by
telephone, letter, email or fax.
Step 3 - MEMBER ASSESSMENT
PURPOSE
To assess the needs of each member, to develop an effective process, to improve
health care delivery and management and promote quality, cost-effective outcomes
that will maintain or improve a member’s quality of life, and/or more efficiently utilize
benefit resources.
DEFINITION
Through a comprehensive and objective analysis of a member’s clinical, financial
and psychosocial status, the case manager assesses the benefits for the member
and the health plan for enrollment in GHC-SCWs complex care management
process. Information is gathered for the assessment through interviews with the
patient, family, significant others, the primary care physician and/or additional
healthcare providers. The assessment is used to identify and detail the member’s
current “needs list” and to develop an individualized care management plan which
will be available to the member and providers involved in their care.
PROCEDURE
 The case manager reviews the member’s chart within EPIC
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The case manager reviews other pertinent medical appointments,
consultation notes, test results, etc. and notes them in the contact tab.
The case manager confirms receipt of baseline questionnaires
The case manager conducts the initial assessment using the “Case
Management Start of Care Assessment” questionnaire within Epic, noting any
pertinent comments.
If the baseline questionnaires were not received, obtain responses
telephonically and send copy to Quality Management.
The case manager contacts additional healthcare providers, as needed.
After completing the assessment, the case manager sends communication
(Appendix G) to Primary Care Practitioner with pertinent information and
queue up any necessary order(s) for signature in Epic Care electronic
medical record.
Development of Prioritized Care Plan Goals
 Identify member and caregiver’s needs and preferences
 The case manager will document the discussion of identified goals and
member’s stated priorities.
 The member identifies the order of priority of goals.
Development of Care Plan Interventions
 Identify healthcare services, treatment options, resources, and funding
options.
 Screen options and select those that best meet the member’s needs and
those that will maximize the potential for achieving the goals.
 Discuss the plan with the member and/or family and the healthcare team to
modify as needed and obtain consensus.
 Serve as an advocate for the member as needed.
 Consider contingency options in the overall plan to anticipate treatment
/service gaps and/or complications.
Documentation of Care Plan
 The (Epic) Case record should contain an easily identifiable Case
Management plan that contains the following key elements and should be
documented within the EPIC Case Management system:
o Member needs/opportunities
o Short and Long term goals
o Time frame for reevaluation
o Resources to be utilized including appropriate level of care
interventions/actions
o Planning for continuity of care, including transition of care and transfers
o Collaborative approaches to be used, including family participation
o Self-Management Plan based on activities undertaken by members to
help them manage their condition
o Barriers to Care
o Assessing compliance to Care Plan
 Correspondence regarding the development of the case management plan
should be included in the (Epic) Case record.
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Step 4 - CARE PLAN DEVELOPMENT UPDATE PROCESS
PURPOSE
To determine and document specific goals and a plan of intervention to meet the
member’s needs and provide a framework for monitoring and re-evaluating the
member’s progress.
DEFINITION
Individualized care plan development is the process of reviewing information
gathered during the assessment and acuity rating phase, developing short and long
term goals, and a plan of intervention to achieve those goals. Opportunities for
intervention may include, but are not limited to:
 Over-utilization of services or use of multiple providers/agencies.
 Under-utilization of services.
 Premature discharge from appropriate level of care.
 Use of inappropriate medical treatment or health care center.
 Use of ineffective treatment.
 Permanent or temporary alterations in functioning.
 Medical/psychological/functional complication(s).
 Lack of education of disease course/process.
 Lack of self-management
 Lack of resolution to medical treatment course.
 Lack of an established treatment plan with specific goals.
 Member or family/caregiver noncompliance with the clinical treatment plan.
CARE PLAN DEVELOPMENT PROCEDURES:
 Identification and determination of member needs and opportunities for
intervention.
 Development of short and long term goals.
 Development of plan of intervention including healthcare services, treatment
options, resources, and funding options.
 Documentation of care plan in the EPIC Case Management System.
Step 5 - CARE PLAN IMPLEMENTATION PROCESS
PURPOSE
To coordinate resources and individuals involved in mobilizing the care plan to
accomplish immediate goals, as well as short and long term goals.
DEFINITION
The care plan implementation process is the case manager’s initial step to assist the
member to attain the short and long term goals outlined in the care plan. It is
essential for the case manager to educate and gain the cooperation and confidence
of all the member’s healthcare team, and support system to successfully implement
a care plan.
CARE PLAN IMPLEMENTATION PROCEDURES
 The case manager contacts the PCP and reviews the care plan.
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The case manager contacts the family/significant others/care givers to
explain, review and answer questions about the proposed case management
plan.
The case manager contacts the appropriate facilities, and/or vendors,
agencies, or community organizations to coordinate the required services for
the patient.
The case manager documents their contacts, care plan, interventions, goals,
barriers, and self-care plan within the enrollee’s case record within EPIC.
The case manager sends a copy of the care plan to the member, primary
care practitioner and primary specialist identified by the member.
Step 6 - CARE PLAN MONITORING AND EVALUATION PROCESS
PURPOSE
The care plan monitoring and evaluation process determines the effectiveness in
meeting the goals and achieving the optimal outcome for the member.
DEFINITION
The care plan monitoring and evaluation process is an on-going process of
reviewing and assessing the member’s progress toward achieving the goals
established after the assessment phase. The outcome of the evaluation process can
result in a modification to the previous short or long term goals; adjustment to the
plan to accommodate the member’s current health situation; a change in the
treatment setting; and/or implementation of further options in an attempt to obtain
optimal level of well-being for the member. The monitoring and evaluation process
focuses on the:
 Quality of care
 Appropriateness of the setting and services for the member’s current health
status, satisfaction of the member, family/significant other and the treatment
team regarding the overall plan and care management.
 Member’s response to the health care services and products.
 Financial impact from implementing the plan
 Member’s quality of life.
CARE PLAN MONITORING AND EVALUATION PROCEDURES
Monitoring the member’s progress
 The case manager maintains rapport and consistent communication with the
member, family, and the healthcare team so that information regarding the
member’s care and progress is exchanged in a timely and effective manner.
 The case manager reviews medical records and other documents as needed
to obtain information on the member’s progress.
Evaluating the member’s response and the outcome of the care plan
 The case manager evaluates the member’s response and the outcome of the
plan by considering the following factors:
o The member’s status and progress toward reaching the goals in the
care plan
o Medical status at the time of the initial assessment as compared to the
current status
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o Member and/or family’s satisfaction with the health care services,
products, and the complex care management process
o Member and/or family’s compliance with the care plan
o Financial impact of the plan as compared to the benefits
o Quality of life of the member
o Quality of care issues as defined in the Quality Management – Key
Quality of Care Indicators (Appendix D)
Based on the evaluation, the case manager will implement necessary
changes to the care plan
and modify the goals as needed.
The case manager will work with the member to evaluate, modify, and
implement self-care plan changes.
The case manager will work with the health care team to identify and arrange
for additional services vital to the enhancement of the care plan. The case
manager will also consider alternative treatments, health care settings and
funding options.
Records and Documentation
 The case manager documents any changes in the care plan.
 The case management record contains the following notes and documents
needed for management of the member’s care and for evaluation purposes.
All notes and received records should be documented in the EPIC Case
Management Information System.
o Progress notes and progress reports
o Correspondence to and from providers
o Notes regarding authorizations for services
o Medical records
o Site visit reports
o Team conferences
o Benefit plan and current coverage information
o Case management plan financial impact assessments
o Provider invoices
o Information regarding extra-contractual arrangements
Complex Case Management Mock Audits
Care Management typically completes monthly audits until there are three
consecutive months of 100% on elements E and F (initial assessment and goal
planning), when this is achieved then the audits are completed every other month.
Step 7 - COST SAVINGS CALCULATIONS AND RATES
PURPOSE
To identify complex care management savings opportunities and to calculate the
savings resulting from actions taken to impact these opportunities.
DEFINITION
A case management record documents cost savings whenever a savings is
achieved due to an action recommended or initiated by a Case Manager, Utilization
Coordinator, Care Management Associate, or Medical Director and results in “hard”
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savings. Savings should be a reflection of the impact on changing an existing plan of
care or negotiating actual discounts for services.
1. Examples of situations where a treatment option or alternatives exist include,
but are not limited to:
 Changing an inpatient level of care to a lesser level, such as acute care to
step-down
 Denying medically unnecessary days
 Negotiating discounts for inpatient or outpatient services
 Steering a member from an out-of-network facility to an in-network facility
 Diverting inpatient admissions to outpatient services
 Steering members to the most cost effective, in-network facilities for
diagnostic services, procedures or therapies
2. Monthly or with scheduled review of the case record, complex care
management costs are evaluated and documented for soft savings – this
includes but is not limited to:
 Time saved by PCP or patient care staff.
 Compliance represented with Decreased Emergency Department visits
 Compliance represented with decreased In-patient stays.
 Decreased use of specialty care referrals/visits
3. On an on-going basis, hard and soft case management savings are
reported.
4. At completion, total case management savings are accumulated and
reported.
Case Management Cost Savings Calculations and Rates pre calendar year:
 Changing an inpatient level of care to a lesser level, such as ICU care to
an acute care bed
Intensive care rate per day – Inpatient acute per day = $ Savings per day
 Denying medically unnecessary days
(Inpatient acute rate per day x anticipated LOS) – (Inpatient acute rate per
day x actual LOS) = $ Savings
 Negotiating discounts for inpatient or outpatient services
Vendor’s price – Negotiated amount = $ Savings
 Steering a patient from an out-of-network facility to an in-network
facility
Out-of-network, acute inpatient bed rate/day – In-network, acute inpatient bed
rate/day = $ Savings
 Diverting inpatient admissions to outpatient services
Inpatient acute rate/day – Home Health care/skilled nursing rate = $ Savings
per day
Step 8 - COMPLEX CASE MANAGEMENT DISCHARGE PROCESS
PURPOSE
To define the point, using established criteria, at which a member is eligible for
discharge from GHC-SCWs Complex Case Management process.
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DEFINITION
The role of the case manager is to coordinate services and to assist a patient and/or
family to achieve the short and long term goals outlined on the case management
plan. When the case manager, with input from appropriate individuals, feels the
patient and/or family has accomplished those goals, has the appropriate
skills/knowledge to continue to pursue and achieve those goals, or the patient and/or
family has reached their potential, the member will be discharged from GHC-SCWs
complex care management program. A member can dis-enroll at any time from the
Complex Care Management Program.
Complex Care Management Discharge
1. Member has exhausted their insurance benefits (when specific limits apply)
2. The member terminates with the employer and does not opt for COBRA
3. The member/family/significant other elects to no longer participate in GHC-SCWs
Case Management Program (opts out).
4. The member reaches maximum medical improvement, or achieves his long and
short term goals, and/or is directed to appropriate community resources.
5. The member expires
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APPENDIX A.9
The Asthma Disease Management Program
Element A:
GHC-SCW is committed to helping members, and their practitioners, manage chronic illness by
providing tools and resources to empower members to take action to improve their health and
chronic conditions.
GHC-SCW is committed to helping members self-manage their asthma and stay healthy through a
variety of educational opportunities. Through this program, routine asthma evaluations are performed
and education is given to help members gain control of their asthma and keep it controlled throughout
their life.
Element B - Program Content
GHC-SCW has designed the Asthma Management Program to educate members about asthma, teach
members how to self-manage their disease, emphasize the importance of regular care, and provide
support tools and screenings for disease management. The content of the Asthma program includes
condition monitoring, patient adherence to treatment plans, consideration of other health conditions,
lifestyle issues and ongoing screening for behavioral health concerns.
Element B Factor 1 - Condition monitoring
GHC monitors the following indicators for all members in the program:
•
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•
Assessment of Lung Function (spirometry, peak flow monitoring)
Symptom Assessment
History of Exacerbations
Medication Review
Quality of Life/Functional Status (Asthma Control Test)
Asthma Action Plan
Annual Flu Vaccination
Tobacco Use/Exposure
Members can access their future appointments, outstanding orders for labs and diagnostics,
medication lists, lab results through MyChartSM - an interactive online patient health portal.
Members who have MyChartSM accounts have access to disease management information
outside of GHC via Healthwise, an interactive shared learning tool.
All encounters with health educators are documented in the EMR.
Element B2 - Adherence to treatment plans
Members work with the Asthma Educator, Registered Nurse Health Educators, Tobacco Cessation
Counselor, nursing staff and their primary care practitioner who monitor patient adherence in the
following areas:
Last updated: November 23, 2012
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Modification of risk factors
Medication compliance and appropriateness
Tobacco cessation
Adherence to an individualized Asthma Action Plan
Self-Administration of Inhalants
Adherence to the clinical practice guidelines for asthma
Adherence to peak flow action plans
Adherence to scheduling regular practitioner appointments
Physical Activity Level
Tobacco Cessation
Element B3 - Medical and behavioral health comorbidities and other health conditions
The Asthma registry is updated weekly and includes current lab, prescription and risk factor data. GHCSCW identifies members with asthma who also have ASTHMA, hypertension, cardiovascular disease,
hyperlipidemia and/or depression. GHC-SCW is committed to a collaborative approach to disease
management, especially for those members with multiple co-morbidities. Practitioners are encouraged
to refer members to health educators, complementary therapists as well as to outside resources. GHCSCW is the only local practice group and HMO to offer complementary medicine to its members.
Referrals are quick and easy using our EMR or internal phone system. Members have several
opportunities for a collaborative management approach to asthma care that are included in their
insurance coverage.
The Asthma Educator and Nurse Health Educators complete initial assessments for all members to
assess for learning style preferences, cognitive abilities, socio-economic factors, and physical limitations
prior to creating the patient driven treatment plan
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Clinic staff (includes pharmacy, lab, radiology, CMA’s, LPN’s, RN’s, RT’s, practitioners) have
access to the electronic medical record and can see the problem list for each member. GHC-SCW
utilizes a care team approach for members which ensure collaboration for those members with
multiple co-morbidities requiring more intensive care.
Practitioners have the opportunity to refer patients to a variety of other practitioners to support
the needs of the patient. Examples of referrals are to Nurse Educators and/or Behavioral Health
Specialists.
Registered Dietitians also have access to the EMR and document their encounters with
members, contributing to the plan of care.
A case manager can also be utilized to ensure appropriate care for those with more complex
needs.
Last updated: November 23, 2012
Element B4 - Health Behaviors
Behavior modification is an essential component of an ASTHMA program. The Asthma Educator works
with GHC-SCW members who have asthma to provide personalized education, support and to promote
healthy lifestyle options. Members may have individual or family counseling sessions as needed. Others
within the GHC-SCW system that can support our members include Nurse Educators, Tobacco Cessation
Counselor, and Registered Dietitians if needed.
Members with asthma who have documented tobacco use also receive outreach mailings providing
them with cessation resources. These resources include tobacco cessation classes, individual counseling
sessions with a tobacco cessation counselor, and information on community resources such as the
Wisconsin Quit Line. In addition, GHC-SCW covers tobacco cessation medications on its formulary at
100% for the majority of its members. For those members who participate in the annual Great American
Smoke out campaign, there is no copay for smoking cessation medications and they get free counseling
for one year from the Tobacco Cessation Counselor.
Members are requested to complete a pre-physical General Medical History Form every time they
schedule a physical. They are mailed this before the appointment and are to bring it with them for
review during the appointment. In the survey are questions about health behaviors such as alcohol
consumption, tobacco use, hobby hazards, wearing seat belts, helmets and preventive self- exams.
Based on responses to these questions, practitioners can counsel on at risk behaviors.
Element B5 - Psychosocial issues
GHC-SCW has incorporated the Anxiety Screening tool GAD-7 into its electronic health record. This is a
seven item anxiety questionnaire that has been developed and validated in a primary care setting. It is a
patient self-assessment tool that can be done in the practitioners’ office jointly with the practitioner or
done independently and reviewed at a follow-up appointment. The assessment can be accessed from
the members EMR under “Screening Tools”. All Behavioral Health staff also has access to this screening
tool in their member assessments.
Element B6 - Depression screening
GHC-SCW has incorporated the Depression Screening tool, PHQ-9 into its electronic health record. The
Patient Health Questionnaire - Nine is the standard among scales for monitoring symptoms of
depression. It has been extensively studied as a screening measure for major depression in primary care
settings. It is a patient self-assessment tool that can be done in the practitioners’ office jointly with the
practitioner or done independently and reviewed at a follow-up appointment. The assessment can be
accessed from the members EMR under “Screening Tools”. All Behavioral Health staff also has access to
this screening tool in their member assessments.
Last updated: November 23, 2012
Element B7 - Information about the patient’s condition provided to caregivers who have the patients
consent
Family members and/or caregivers who want or need access to the patient’s medical record are
required to have a “Release of Information” consent form signed by the patient, indicating they may
have access to their records. Patients may choose to share electronic access to their medical record by
sharing password information to their MyChart account with family members and/or caregivers.
Family members and/or caregivers who are GHC-SCW members have access to Healthwise, a shared
decision making tool and healthcare resource available via MyChart. Each member can also see a
Health Educator who can help them create an Action Plan that can be shared with the member’s family,
and is available to the member’s health care team.
Element B8 - Encouraging patients to communicate with their practitioners about their health
conditions and treatment.
Members have the ability to utilize MyChartSM which is a patient portal within Epic, the electronic
medical record software. They can send messages directly to their practitioner, nursing staff, pharmacy,
or member services as well as make appointments, complete the asthma control test, see lab and other
diagnostic results. All members are encouraged to sign up for MyChartSM. MyChartSM is now available on
both the iPhone and Droid smart phones making it convenient for members who may have these
devices.
Outreach letters are sent to members in the Asthma Registry to encourage them to contact their
practitioner and stress the importance of communication. In addition, if a member completes a Health
Risk Assessment (HRA) and based on their results, they are encouraged to follow up with their
practitioner and can click on a link that takes them directly to scheduling an appointment
Element B9 - Additional resources external to the organization
All GHC-SCW members are encouraged to complete a Health Risk Assessment (HRA) that is available
free of charge through their employer or via MyChartSM. Members also have access to Healthwise, a
shared decision making tool and health resource that is also available via MyChartSM. Practitioners can
print information from Healthwise during the visit and give it to members to take home with them.
Element C: Identifying Members for DM Programs
GHC-SCW uses the following data sources to identify members for the ASTHMA management program:
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Claims or encounter data
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Prescription data
Problem list in the electronic medical record (AE updates PL with communication to PCP)
Health risk assessment results
Data collected through the utilization management or care management process
Member referral
Practitioner referral
Clinical Care Management referral
GHC-SCW does not use continuous enrollment criteria for identifying members. The Asthma registry
updates weekly.
Element D: Frequency of Member Identification
The GHC-SCW Asthma disease registry updates weekly. (See Element C) In addition, the disease registry
is run monthly to look for members who have outstanding asthma identifiers such as increased use of
short acting beta agonist medication, decreased ACT score, or increased emergency department
admissions, oral steroids. The asthma educator uses the registry to stratify outreach to our asthma
members.
Element E: Providing Members with Information
How to use services - GHC-SCW sends a letter and a brochure titled “Asthma Zone” to eligible members
annually. These highlight the importance of managing asthma and the resources available both
internally and externally along with contact information.
How members become eligible to participate - Newly diagnosed members are sent a letter and a
brochure “Asthma Zone”. The letter informs them that they are now part of the Asthma Management
Program and the brochure highlights the importance of managing Asthma and the resources available
both internally and externally along with contact information. How to opt in or out - The letter sent to
members explains how they can opt out of the outreach associated with being on the Asthma registry.
When members contact GHC-SCW QM staff to opt out, they are informed that they will be contacted in
one year to follow up to see if they still wish to be excluded from outreach efforts.
Element F: Interventions based on Assessment
GHC-SCW provides interventions for asthma members based on stratification. Different interventions
are provided for members based on severity of illness, participation in completion of testing and
examinations as well as the results of those tests.
Tier 1: All members with Asthma-targets those with well controlled asthma or intermittent asthma
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Interventions
o Asthma Disease Management Program letter & brochure to be mailed to all asthmatic
members annually
Last updated: November 23, 2012
o
o
Annual flu shot reminder
Access to Asthma Educator to help develop comprehensive plan of care including, but not
limited to:
 Asthma assessment
 Spirometry
 Medication evaluation & education
 Trigger assessment
 Asthma education
 Environmental control plan
 Action plan development
Tier 2: Includes members who have had recent Urgent Care visits, Emergency Room visits, and
Hospitalizations for asthma.
o Care includes all aspects of Tier 1 care, with the addition of aggressive outreach to ensure
clinic follow up with a provider or Asthma Educator is obtained within 14 days of asthma
event. Asthma Educator task done weekly.
o Ongoing appointments, GHCMyChart, or letter follow up after interventions
Type of Report
Urgent Care
Emergency Room
Hospitalizations
HEDIS
Pharmacy
Oral Steroids
Member mail out
Daily Weekly Monthly Quarterly Semi-Annual
x
x
x
x
x
x
Annual
x
Tier 3: Case Management
o Includes members referred to Case Management by providers
o Includes those who meet the following criteria:
 Two or more hospitalizations within a 6 month period
 Two or more specialists involved in the patient’s care
 Three or more emergency room visits within a 6 month period
 Two or more co-morbidities
 Acute medical issues
 Complex coordination of care issues
 One asthma ER visit and one asthma hospitalization within a 6 month period
Element G: Eligible Member Active Participation
GHC-SCW annually reports the member participation rate to the Clinical and Service Quality Committee
(CSQC).
Last updated: November 23, 2012
Element H: Informing and Educating Practitioners
Instructions on how to use the Asthma Management Program
Practitioners are informed of the Asthma Management Program in the following ways:
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The Practitioner Handbook contains a copy of the Asthma Management Program description
Practitioners receive a copy of the Asthma Management Program brochure
Newly hired practitioners receive a brief overview from the HE Manager
They are notified when outreach is done on members
There are updates in organizational newsletters
Health Maintenance Modifiers for labs and screening
Best Practice Alerts (BPA’s)
How the organization works with practitioners’ patients in the program
Practitioners have access to see an encounter in Chart Review for all contacts the member has with
health educators, care management and case management. They can communicate using electronic
messaging and/or in person.
Element I: Integrating Member Information
GHC-SCW utilizes a common electronic medical record (i.e. EpicCare) which allows for integration of
member information for continuity of care. This information is extracted into a variety of reporting tools
and reports utilized by GHC-SCW to focus on this member population to ensure focused and relevant
interventions. This then allows for comprehensive resources for the following departments: health
information line, case management program, utilization management program, quality management
outreach program and health education.
GHC-SCW utilizes two other EMR resources to integrate member information. Care Link allows staff to
see the patients’ medical record if they have been seen at a partnering facility utilizing Epic. In addition,
GHC-SCW participates in Care Everywhere, another tool developed by Epic to ensure access to patient
information while they are traveling and out of the service area.
Element J: Satisfaction with Disease Management
All GHC-SCW members in the Asthma registry are surveyed for feedback on their thoughts and
experiences of the program. Additionally, those members who utilize care management are surveyed
through the PAM and Complex Case Management survey tools. Randomly selected GHC-SCW members
who had a visit with their practitioner, health education, complementary medicine, physical and/or
Last updated: November 23, 2012
occupational therapy are sent a Press Ganey survey. Random samplings of members are also sent a
CAHPS survey as part of GHC-SCW’s accreditation process. All complaints are managed through Member
Services per protocol.
Element K: Measuring Effectiveness
HEDIS results are analyzed monthly to look for trends or changes in compliance. GHC-SCW’s Quality
Management Team along with other stakeholders in the organization, actively look for QI projects
throughout the year. These projects look at a variety of issues and target areas where a measure is
below the 50th percentile as well as ensuring measures stay above the 90th and 95th percentile. The
projects will:
1)
2)
3)
4)
5)
Address a relevant process or outcome;
Produce a quantitative result;
Be population based;
Have valid data and methodology;
Analysis with comparison to benchmarks and goals - use the HEDIS national 90th percentile
levels as goals for the Asthma measures. The Quality Management Department reviews and
reports the results annually and compares them to these goals and to past performance.
Last updated: November 23, 2012
APPENDIX A.10
The Diabetes Management Program
Element A: Program Content
GHC-SCW is committed to helping members, and their practitioners, manage chronic illness by providing
tools and resources to empower members to take action to improve their health and chronic conditions.
Diabetes is a major concern for GHC-SCW due to the increase in number of members being diagnosed
and the health risks and costs associated with poor control. GHC-SCW currently has approximately 1,800
members with a diagnosis of diabetes. Proactive practitioner intervention and support, in collaboration
with health education and clinical outreach, helps members manage their chronic conditions.
GHC-SCW has designed the Diabetes Management Program to educate members about diabetes, teach
members how to self-manage their disease, emphasize the importance of regular care, and provide
support tools and screenings for disease management. GHC-SCW’s patient focused Living Well with
Diabetes was developed to help members self-manage their diabetes to reduce diabetic-related
complications, morbidities and death. The content of the diabetes program includes condition
monitoring, patient adherence to treatment plans, consideration of other health conditions, lifestyle
issues and ongoing screening for behavioral health concerns.
Element A Factor 1-Condition monitoring
GHC monitors the following indicators for all members in the program:
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








Date and result of most recent hemoglobin A1C (hbA1C) -if past due, outreach calls and letters
are sent to the member
Dates and results of most recent fasting lipid panel (including LDL, HDL, total cholesterol, and
triglycerides) -if past due, outreach calls and letters are sent to the member
Date of most recent medical attention for diabetic nephropathy (urine microalbumin, etc.) -if
past due, outreach calls and letters are sent to the member
Date of most recent diabetic retinal eye exam (DRE) -if past due, outreach calls and letters are
sent to the member
Prescriptions for diabetic medications (date prescribed, date filled)
Prescriptions for lipid lowering agents (date prescribed, date filled)
Prescriptions for hypertension (date prescribed, date filled)
Co-morbidities (asthma, hypertension, cardiovascular disease, hyperlipidemia)
Date and result of most recent blood pressure measurement-if past due, outreach calls and
letters are sent to the member
Members can access their future appointments, outstanding orders for labs and diagnostics,
medication lists, lab results and diagnostic results through MyChart-an interactive online patient
health portal.
Members who have MyChart accounts have access to disease management information outside
of GHC via Healthwise, an interactive shared learning tool.
1
Last Edited: Friday, March 29, 2013


Members with diabetes receive blood glucose monitoring devices at no cost to the member. The
results can be downloaded during appointments with health educators.
All encounters with health educators are documented in the EMR.
Element A2-Adherence to treatment plans
Members work with Certified Diabetes Educators, Registered Dieticians, nursing staff and their primary
care practitioner who monitor patient adherence in the following areas:












Modification of risk factors
Weight control
Blood Pressure control
Medication compliance
Adherence to Nutritional Guidelines
Adherence to scheduling regular practitioner appointments
Physical Activity Level
Tobacco Cessation
Self-Monitoring of Blood Glucose
Self-Administration of Insulin
Quarterly testing of HBA1C
Adherence to the “Essential Diabetes Mellitus Care Guidelines-Wisconsin”
(https://ghcscw.com/Pages/Provider-Resources/Clinical-Practice-Guidelines.aspx)
Element A3-Medical and behavioral health comorbidities and other health conditions
The diabetes registry is updated weekly and includes current lab, prescription and risk factor data. GHCSCW identifies members with diabetes who also have asthma, hypertension, cardiovascular disease,
hyperlipidemia and/or depression. GHC-SCW is committed to a collaborative approach to disease
management, especially for those members with multiple co-morbidities. Practitioners are encouraged
to refer members to health educators, complementary therapists as well as to outside resources. GHCSCW is the only local practice group and HMO to offer complementary medicine to its members.
Referrals are quick and easy using our EMR or internal phone system. Members have several
opportunities for a collaborative management approach to diabetes care that are included in their
insurance coverage.
The Certified Diabetes Nurse Educators complete initial assessments for all members to assess for
learning style preferences, cognitive abilities, socio-economic factors, and physical limitations prior to
creating the patient driven treatment plan

Clinic staff (includes pharmacy, lab, radiology, CMA’s, LPN’s, RN’s, practitioners) have access to
the electronic medical record and can see the problem list for each member. GHC-SCW utilizes a
care team approach for members which ensures collaboration for those members with multiple
co-morbidities requiring more intensive care.
2
Last Edited: Friday, March 29, 2013



Practitioners have the opportunity to refer patients to a variety of other practitioners to support
the needs of the patient. Examples of referrals are to Nurse Educators and/or Behavioral Health
Specialists.
Registered Dietitians also have access to the EMR and document their encounters with
members, contributing to the plan of care
A case manager can also be utilized to ensure appropriate care for those with more complex
needs.
Element A4-Health Behaviors
Behavior modification is an essential component of a diabetes program. Health Educators (i.e. Certified
Diabetes Nurse Educators, Tobacco Cessation Counselor, Registered Dietitians) work with GHC-SCW
members who have diabetes to provide personalized education, support and to promote healthy
lifestyle options. Members may have individual counseling sessions as needed along with an extensive
offering of classes.
Members with diabetes who have documented tobacco use also receive outreach mailings providing
them with cessation resources. These resources include tobacco cessation classes, individual counseling
sessions with a tobacco cessation counselor, and information on community resources such as the
Wisconsin Quit Line. In addition, GHC-SCW covers tobacco cessation medications on its formulary at
100% for the majority of its members. For those members who participate in the annual Great American
Smokeout campaign, there is no copay for smoking cessation medications and they get free counseling
for one year from the Tobacco Cessation Counselor.
Members are requested to complete a pre-physical General Medical History Form every time they
schedule a physical. They are mailed this before the appointment and are to bring it with them for
review during the appointment. In the survey are questions about health behaviors such as alcohol
consumption, tobacco use, hobby hazards, wearing seat belts, helmets and preventive self- exams.
Based on responses to these questions, practitioners can counsel on at risk behaviors.
Element A5-Psychosocial issues
GHC-SCW has incorporated the Anxiety Screening tool GAD-7 into its electronic health record. This is a
seven item anxiety questionnaire that has been developed and validated in a primary care setting. It is a
patient self-assessment tool that can be done in the practitioners’ office jointly with the practitioner or
done independently and reviewed at a follow-up appointment. The assessment can be accessed from
the members EMR under “Screening Tools”. All Behavioral Health staff also have access to this screening
tool in their member assessments.
Element A6-Depression screening
GHC-SCW has incorporated the Depression Screening tool PHQ-9 into its electronic health record. The
Patient Health Questionnaire-Nine Item is the standard among scales for monitoring symptoms of
depression. It has been extensively studied as a screening measure for major depression in primary care
3
Last Edited: Friday, March 29, 2013
settings. It is a patient self-assessment tool that can be done in the practitioners’ office jointly with the
practitioner or done independently and reviewed at a follow-up appointment. The assessment can be
accessed from the members EMR under “Screening Tools”. All Behavioral Health staff also have access
to this screening tool in their member assessments.
All members are mailed a screening tool prior to their physicals. Imbedded in this document are two
questions from the PHQ-9 that are used as an initial depression assessment. Based on these results,
members can then be directed to complete the entire PHQ-9 for further evaluation and possible followup to a behavioral health specialist if needed.
Element A7-Information about the patient’s condition provided to caregivers who have the patients
consent
Family members and/or caregivers who want or need access to the patient’s medical record are
required to have a “Release of Information” consent form signed by the patient, indicating they may
have access to their records. Patients may choose to share electronic access to their medical record by
sharing password information to their MyChart account with family members and/or caregivers.
Family members and/or caregivers who are GHC-SCW members have access to Healthwise, a shared
decision making tool and healthcare resource available via MyChart. Members with diabetes are given
a brochure called “How Families Can Help”. Each member can also see a Certified Diabetes Educator
who can help them create a Diabetes Action Plan that can be shared with the member’s family, and is
available to the member’s health care team.
Element A8-Encouraging patients to communicate with their practitioners about their health conditions
and treatment.
Members have the ability to utilize MyChart which is a patient portal within Epic, the electronic medical
record software. They can send messages directly to their practitioner, nursing staff, pharmacy, or
member services as well as make appointments, sign up for classes, see lab and other diagnostic results.
All members are encouraged to sign up for MyChart. MyChart is now available on both the IPhone and
Droid smart phones making it convenient for members who may have these devices. Members of the
Disease Management Program who are signed up for MyChart will automatically get care reminders via
MyChart.
Outreach letters that are sent to members in the Diabetes Registry encourages them to contact their
practitioner and stresses the importance of communication. In addition, if a member completes an HRA
and based on their results, they are encouraged to follow up with their practitioner and can click on a
link that takes them directly to scheduling an appointment.
Element A9-Additional resources external to the organization
All GHC-SCW members are encouraged to complete a Health Risk Assessment (HRA) that is available
free of charge through their employer or via MyChart.
4
Last Edited: Friday, March 29, 2013
Members also have access to Healthwise, a shared decision making tool and health resource that is also
available via MyChart. Practitioners can print information from Healthwise during the visit and give it to
members to take home with them.
Element B: Identifying Members for DM Programs
GHC-SCW uses the following data sources to identify members for the diabetic management program:









Claims or encounter data
Prescription data
Problem list in the electronic medical record
Laboratory results-Diabetic Nurse Educator contacts members with an elevated A1C who do not
have Diabetes on their problem list
Health risk assessment results
Data collected through the utilization management or care management process
Member referral
Practitioner referral
Clinical Care Management referral
GHC-SCW does not use continuous enrollment criteria for identifying members. The diabetes registry
updates weekly.
Element C: Frequency of Member Identification
The GHC-SCW diabetes disease registry updates weekly. (see Element C) In addition, the disease
registry is run quarterly to identify members who are overdue for a variety of interventions and follow
ups. (HgbA1C more than 6 six months ago and/or >9% and/or not done in past 13 months; urine for
micro albumin; LDL greater than 6 months ago or >100; Dilated Retinal Exam due; Blood pressure not
recorded for 6 months and/or >140/90 mmHg or not recorded in past 13 months)
Element D: Providing Members with Information
How to use services-GHC-SCW sends a letter and a brochure “Living Well With Diabetes” to eligible
members annually. These highlight the importance of managing diabetes and the resources available
both internally and externally along with contact information.
How members become eligible to participate-Newly diagnosed members are sent a letter and a
brochure “Living Well With Diabetes”. The letter informs them that they are now part of the Diabetes
Management Program and the brochure highlights the importance of managing diabetes and the
resources available both internally and externally along with contact information.
5
Last Edited: Friday, March 29, 2013
How to opt in or out-The brochure “Living Well With Diabetes” explains to members how they can opt
out of the outreach associated with being on the diabetes registry. When Members contact GHC-SCW
QM staff to opt out, they are informed that they will be contacted in one year to follow up to see if they
still wish to be excluded from outreach efforts.
Element E: Interventions based on Assessment
GHC-SCW provides interventions for diabetic members based on stratification. Different interventions
are provided for members based on severity of illness, participation in completion of testing and
examinations as well as the results of those tests.
Tier 1: All members with diabetes

Interventions
o Initial letter sent to those with new diagnosis of diabetes describing the program and
resources available to them
o Diabetes management program letter and brochure mailed to all registry members
annually
o Access to health educators and/or primary care practitioner
o Access to diabetes-related classes
o Practitioners are notified of monthly outreach activities
Tier 2: Subset of members with diabetes; members are contacted if they meet one or more of the
following criteria





Had HgbA1C done 6 or more months ago and it was >9% OR have not had a HgbA1c in 13
months or more;
Had LDL done 6 or more months ago and result was >100mg/dL OR no LDL done in the last 13
months OR had LDL in last 6-13 months and result was incalculable;
Had blood pressure taken 6 or more months ago and it was >_ 140/90 mmHg OR have not had a
blood pressure in 13 months or more;
Have not had medical assessment for nephropathy in 13 months or more;
Have not had a DRE in 13 months or more
Interventions: (same as Tier one and include)


Contact by mail and phone quarterly for needed tests
Offer appointment with health educators and/or primary care
Tier 3: Subset of members who utilize the Clinical Nurse Educators
6
Last Edited: Friday, March 29, 2013
Element F: Eligible Member Active Participation
GHC-SCW annually reports the member participation rate to the Clinical and Service Quality Committee
(CSQC).
Element G: Informing and Educating Practitioners
Instructions on how to use the Diabetes Management Program
Practitioners are informed of the Diabetes Management Program in the following ways:






The Practitioner Handbook contains a copy of the Diabetes Management Program description
Practitioners receive a copy of the Diabetes Management Program brochure
They are notified when outreach is done on members
There are updates in organizational newsletters
Health Maintenance Modifiers for labs and screening
Best Practice Alerts (BPA’s)
How the organization works with a practitioners patients in the program
Practitioners have access to see an encounter in Chart Review for all contacts the member has with
health educators, care management and case management. They can communicate using electronic
messaging and/or in person.
Element H: Integrating Member Information
GHC-SCW utilizes a common electronic medical record (i.e. EpicCare) which allows for integration of
member information for continuity of care. This information is extracted into a variety of reporting tools
and reports utilized by GHC-SCW to focus on this member population to ensure focused and relevant
interventions. This then allows for comprehensive resources for the following departments: health
information line, case management program, utilization management program, quality management
outreach program and health education.
GHC-SCW utilizes two other EMR resources to integrate member information. CareLink allows staff to
see the patients’ medical record if they have been seen a partnering facility utilizing Epic. In addition,
GHC-SCW participates in Care Everywhere, another tool developed by Epic to ensure access to patient
information while they are traveling and out of the service area.
7
Last Edited: Friday, March 29, 2013
Element I: Satisfaction with Disease Management
All GHC-SCW members in the diabetes registry are surveyed for feedback on their thoughts and
experiences of the program. Additionally, those members who utilize care management are surveyed
through the PAM and Complex Case Management survey tools. Randomly selected GHC-SCW members
who had a visit with their practitioner, health education, complementary medicine, physical and/or
occupational therapy are sent a Press Ganey survey. A random sampling of members are also sent a
CAHPS survey as part of GHC-SCW’s accreditation process. All complaints are managed through Member
Services per protocol.
Element J: Measuring Effectiveness
HEDIS results are analyzed monthly to look for trends or changes in compliance. GHC-SCW’s Quality
Management Team along with other stakeholders in the organization, actively look for QI projects
throughout the year. These projects look at a variety of issues and target areas where a measure is
below the 50th percentile as well as ensuring measures stay above the 90th and 95th percentile. The
projects will:
1)
2)
3)
4)
5)
Address a relevant process or outcome;
Produce a quantitative result;
Be population based;
Have valid data and methodology;
Analysis with comparison to benchmarks and goals-use the HEDIS national 90th percentile levels
as goals for the diabetes measure. The Quality Management Department reviews and reports
the results annually and compares them to these goals and to past performance.
8
Last Edited: Friday, March 29, 2013
APPENDIX A.11
The Heart and Vascular Disease Management Program
Element A: Program Content
GHC-SCW is committed to helping members, and their practitioners, manage chronic illness by providing
tools and resources to empower members to take action to improve their health and chronic conditions.
Heart and vascular diseases (HVD) are a major concern for GHC-SCW due to the increase in number of
members being diagnosed and the health risks and costs associated with poor control. GHC-SCW
currently has approximately 1,500 members with a diagnosis of HVD. Proactive practitioner intervention
and support, in collaboration with health education and clinical outreach, helps members manage their
chronic conditions.
GHC-SCW has designed the HVD Management Program to educate members about HVD, teach
members how to self-manage their disease, emphasize the importance of regular care, and provide
support tools and screenings for disease management. GHC-SCW’s patient focused Healthy Heart was
developed to help members self-manage their HVD to reduce related complications, morbidities and
death. The content of the HVD program includes condition monitoring, patient adherence to treatment
plans, consideration of other health conditions, lifestyle issues and ongoing screening for behavioral
health concerns.
Element A Factor 1 - Condition monitoring
GHC monitors the following indicators for all members in the program:










Dates and results of most recent fasting lipid panel (including LDL, HDL, total cholesterol, and
triglycerides) - if past due, outreach calls and letters are sent to the member quarterly
Date of last creatinine and result
Prescriptions for lipid lowering agents (date prescribed, date filled)
Prescriptions for hypertension (date prescribed, date filled)
New prescription and dosage change follow up calls and blood monitoring
Co-morbidities (asthma, hypertension, cardiovascular disease, hyperlipidemia)
Date and result of most recent blood pressure measurement
Members can access their future appointments, outstanding orders for labs and diagnostics,
medication lists, lab results and diagnostic results through MyChartSM - an interactive online
patient health portal.
Members who have MyChartSM accounts have access to disease management information
outside of GHC via Healthwise, an interactive shared learning tool.
All encounters with health educators are documented in the EMR.
Element A2 - Adherence to treatment plans
Members work with a Cardiovascular Nurse Specialist, Registered Nurse Health Educators, Registered
Dieticians, Tobacco Cessation Counselor, nursing staff and their primary care practitioner who monitor
patient adherence in the following areas:
1
Last Edited: Friday, March 29, 2013








Modification of risk factors
Weight control
Blood Pressure control
Medication compliance
Adherence to Nutritional Guidelines
Adherence to scheduling regular practitioner appointments
Physical Activity Level
Tobacco Cessation
Element A3 - Medical and behavioral health comorbidities and other health conditions
The HVD registry is updated weekly and includes current lab, prescription and risk factor data. GHC-SCW
identifies members with HVD who also have asthma, hypertension, cardiovascular disease,
hyperlipidemia and/or depression. GHC-SCW is committed to a collaborative approach to disease
management, especially for those members with multiple co-morbidities. Practitioners are encouraged
to refer members to health educators, complementary therapists as well as to outside resources. GHCSCW is the only local practice group and HMO to offer complementary medicine to its members.
Referrals are quick and easy using our EMR or internal phone system. Members have several
opportunities for a collaborative management approach to HVD care that are included in their insurance
coverage.
The Nurse Health Educators complete initial assessments for all members to assess for learning style
preferences, cognitive abilities, socio-economic factors, and physical limitations prior to creating the
patient driven treatment plan




Clinic staff (includes pharmacy, lab, radiology, CMA’s, LPN’s, RN’s, practitioners) have access to
the electronic medical record and can see the problem list for each member. GHC-SCW utilizes a
care team approach for members which ensure collaboration for those members with multiple
co-morbidities requiring more intensive care.
Practitioners have the opportunity to refer patients to a variety of other practitioners to support
the needs of the patient. Examples of referrals are to Nurse Educators and/or Behavioral Health
Specialists.
Registered Dietitians also have access to the EMR and document their encounters with
members, contributing to the plan of care.
A case manager can also be utilized to ensure appropriate care for those with more complex
needs.
Element A4 - Health Behaviors
Behavior modification is an essential component of a HVD program. Health Educators (i.e. Nurse
Educators, Tobacco Cessation Counselor, and Registered Dietitians) work with GHC-SCW members who
have HVD to provide personalized education, support and to promote healthy lifestyle options.
Members may have individual counseling sessions as needed along with an extensive offering of classes.
2
Last Edited: Friday, March 29, 2013
Members with HVD who have documented tobacco use also receive outreach mailings providing them
with cessation resources. These resources include tobacco cessation classes, individual counseling
sessions with a tobacco cessation counselor, and information on community resources such as the
Wisconsin Quit Line. In addition, GHC-SCW covers tobacco cessation medications on its formulary at
100% for the majority of its members. For those members who participate in the annual Great American
Smoke out campaign, there is no copay for smoking cessation medications and they get free counseling
for one year from the Tobacco Cessation Counselor.
Members are requested to complete a pre-physical General Medical History Form every time they
schedule a physical. They are mailed this before the appointment and are to bring it with them for
review during the appointment. In the survey are questions about health behaviors such as alcohol
consumption, tobacco use, hobby hazards, wearing seat belts, helmets and preventive self- exams.
Based on responses to these questions, practitioners can counsel on at risk behaviors.
Element A5 - Psychosocial issues
GHC-SCW has incorporated the Anxiety Screening tool GAD-7 into its electronic health record. This is a
seven item anxiety questionnaire that has been developed and validated in a primary care setting. It is a
patient self-assessment tool that can be done in the practitioners’ office jointly with the practitioner or
done independently and reviewed at a follow-up appointment. The assessment can be accessed from
the members EMR under “Screening Tools”. All Behavioral Health staff also has access to this screening
tool in their member assessments.
Element A6 - Depression screening
GHC-SCW has incorporated the Depression Screening tool, PHQ-9 into its electronic health record. The
Patient Health Questionnaire - Nine is the standard among scales for monitoring symptoms of
depression. It has been extensively studied as a screening measure for major depression in primary care
settings. It is a patient self-assessment tool that can be done in the practitioners’ office jointly with the
practitioner or done independently and reviewed at a follow-up appointment. The assessment can be
accessed from the members EMR under “Screening Tools”. All Behavioral Health staff also has access to
this screening tool in their member assessments.
All members are mailed a screening tool prior to their physicals. Imbedded in this document are two
questions from the PHQ-9 that are used as an initial depression assessment. Based on these results,
members can then be directed to complete the entire PHQ-9 for further evaluation and possible followup to a behavioral health specialist if needed.
Element A7 - Information about the patient’s condition provided to caregivers who have the patients
consent
Family members and/or caregivers who want or need access to the patient’s medical record are
required to have a “Release of Information” consent form signed by the patient, indicating they may
3
Last Edited: Friday, March 29, 2013
have access to their records. Patients may choose to share electronic access to their medical record by
sharing password information to their MyChart account with family members and/or caregivers.
Family members and/or caregivers who are GHC-SCW members have access to Healthwise, a shared
decision making tool and healthcare resource available via MyChart. Members with HVD are given a
brochure called “Healthy Heart”. Each member can also see a Health Educator who can help them
create an Action Plan that can be shared with the member’s family, and is available to the member’s
health care team.
Element A8 - Encouraging patients to communicate with their practitioners about their health
conditions and treatment.
Members have the ability to utilize MyChartSM which is a patient portal within Epic, the electronic
medical record software. They can send messages directly to their practitioner, nursing staff, pharmacy,
or member services as well as make appointments, sign up for classes, see lab and other diagnostic
results. All members are encouraged to sign up for MyChartSM. MyChartSM is now available on both the
iPhone and Droid smart phones making it convenient for members who may have these devices.
Outreach letters are sent to members in the HVD Registry to encourage them to contact their
practitioner and stress the importance of communication. In addition, if a member completes a Health
Risk Assessment (HRA) and based on their results, they are encouraged to follow up with their
practitioner and can click on a link that takes them directly to scheduling an appointment
Element A9 - Additional resources external to the organization
All GHC-SCW members are encouraged to complete a Health Risk Assessment (HRA) that is available
free of charge through their employer or via MyChartSM. Members also have access to Healthwise, a
shared decision making tool and health resource that is also available via MyChartSM. Practitioners can
print information from Healthwise during the visit and give it to members to take home with them.
Element B: Identifying Members for DM Programs
GHC-SCW uses the following data sources to identify members for the HVD management program:








Claims or encounter data
Prescription data
Problem list in the electronic medical record
Laboratory results - Cardiovascular Nurse Specialist contacts members with an elevated LDL over
100
Health risk assessment results
Data collected through the utilization management or care management process
Member referral
Practitioner referral
4
Last Edited: Friday, March 29, 2013

Clinical Care Management referral
GHC-SCW does not use continuous enrollment criteria for identifying members. The HVD registry
updates weekly.
Element C: Frequency of Member Identification
The GHC-SCW HVD disease registry updates weekly. (See Element C) In addition, the disease registry is
run quarterly to look for members who have outstanding lab work (no LDL in over 13 months, LDL over
100 in past 6-13 months, and if result cannot be calculated).
Element D: Providing Members with Information
How to use services - GHC-SCW sends a letter and a brochure “Healthy Heart” to eligible members
annually. These highlight the importance of managing HVD and the resources available both internally
and externally along with contact information.
How members become eligible to participate - Newly diagnosed members are sent a letter and a
brochure “Health Heart”. The letter informs them that they are now part of the HVD Management
Program and the brochure highlights the importance of managing HVD and the resources available both
internally and externally along with contact information.
How to opt in or out - The brochure “Health Heart” explains to members how they can opt out of the
outreach associated with being on the HVD registry. When members contact GHC-SCW QM staff to opt
out, they are informed that they will be contacted in one year to follow up to see if they still wish to be
excluded from outreach efforts.
Element E: Interventions based on Assessment
GHC-SCW provides interventions for heart and vascular disease members based on stratification.
Different interventions are provided for members based on severity of illness, participation in
completion of testing and examinations as well as the results of those tests.
Tier 1: All members with HVD

Interventions
o Initial letter sent to those with new diagnosis of HVD describing the program and
resources available to them
o HVD management program letter and brochure mailed to all registry members
annually
o Access to health educators and/or primary care practitioner
o Access to HVD-related classes
o Clinical staff are notified of quarterly CVD mailings
o
5
Last Edited: Friday, March 29, 2013
Tier 2: Subset of members with HVD; members are contacted if they meet one or more of the
following criteria:

Had LDL done 6 or more months ago and result was >100mg/dL OR no LDL done in the last 13
months OR had LDL in last 6-13 months and result was incalculable;
Interventions: Same as Tier 1 and include:


Contact by mail and phone quarterly for needed tests
Offer appointment with health educators and/or primary care
Tier 3: Subset of members who utilize the Clinical Nurse Educators
Element F: Eligible Member Active Participation
GHC-SCW annually reports the member participation rate to the Clinical and Service Quality Committee
(CSQC).
Element G: Informing and Educating Practitioners
Instructions on how to use the HVD Management Program
Practitioners are informed of the HVD Management Program in the following ways:






The Practitioner Handbook contains a copy of the HVD Management Program description
Practitioners receive a copy of the HVD Management Program brochure
They are notified when outreach is done on members
There are updates in organizational newsletters
Health Maintenance Modifiers for labs and screening
Best Practice Alerts (BPA’s)
How the organization works with practitioners’ patients in the program
Practitioners have access to see an encounter in Chart Review for all contacts the member has with
health educators, care management and case management. They can communicate using electronic
messaging and/or in person.
Element H: Integrating Member Information
GHC-SCW utilizes a common electronic medical record (i.e. EpicCare) which allows for integration of
member information for continuity of care. This information is extracted into a variety of reporting tools
and reports utilized by GHC-SCW to focus on this member population to ensure focused and relevant
6
Last Edited: Friday, March 29, 2013
interventions. This then allows for comprehensive resources for the following departments: health
information line, case management program, utilization management program, quality management
outreach program and health education.
GHC-SCW utilizes two other EMR resources to integrate member information. CareLink allows staff to
see the patients’ medical record if they have been seen a partnering facility utilizing Epic. In addition,
GHC-SCW participates in Care Everywhere, another tool developed by Epic to ensure access to patient
information while they are traveling and out of the service area.
Element I: Satisfaction with Disease Management
All GHC-SCW members in the HVD registry are surveyed for feedback on their thoughts and experiences
of the program. Additionally, those members who utilize care management are surveyed through the
PAM and Complex Case Management survey tools. Randomly selected GHC-SCW members who had a
visit with their practitioner, health education, complementary medicine, physical and/or occupational
therapy are sent a Press Ganey survey. Random samplings of members are also sent a CAHPS survey as
part of GHC-SCW’s accreditation process. All complaints are managed through Member Services per
protocol.
Element J: Measuring Effectiveness
HEDIS results are analyzed monthly to look for trends or changes in compliance. GHC-SCW’s Quality
Management Team along with other stakeholders in the organization, actively look for QI projects
throughout the year. These projects look at a variety of issues and target areas where a measure is
below the 50th percentile as well as ensuring measures stay above the 90th and 95th percentile. The
projects will:
1)
2)
3)
4)
5)
Address a relevant process or outcome;
Produce a quantitative result;
Be population based;
Have valid data and methodology;
Analysis with comparison to benchmarks and goals - use the HEDIS national 90th percentile
levels as goals for the HVD measure. The Quality Management Department reviews and reports
the results annually and compares them to these goals and to past performance.
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Last Edited: Friday, March 29, 2013