Medicare - Credentialing & Recredentialing |
Reassessment Program (HDOs only)
All Health Delivery Organizations (HDOs) must be reassessed at least every three (3) years. At that time, ConnectiCare may request updated information from the HDO. Copies of credentials may be required and requests may include, but are not be limited to the following:
• State license
• Medicare certification
• Accreditation certificate
• Annual state survey reports
Additionally, through an ongoing monitoring program, ConnectiCare may use information outlined in, Compliance, Termination & Appeals, to evaluate an HDO. Identified deficiencies in any of these areas may be a basis for a referral to ConnectiCare’s Health Delivery Organization Advisory Committee for a determination regarding potential sanctions, up to and including termination.
HDO Compliance Standards
As part of the reassessment process ConnectiCare also looks at HDO compliance with regard to case management standards. The standards for each type of HDO appear below.
Hospitals
1. Concurrent chart reviews must be completed within twenty-four hours of the request from the case manager.
• Reports and updates must be detailed and comprehensive to the extent necessary to make a continuing stay determination.
2. Access to clinical information must be current and in accordance with applicable laws and regulations.
• Clinical information may be obtained through a variety of sources such as physician, nursing staff, chart, etc.
3. Authorized ConnectiCare personnel shall have access to the hospital chart, hospital staff, and members Monday - Friday during regular business hours of the hospital.
4. Hospital staff responsible for discharges must confirm authorization of services with the case manager prior to discharge.
• Members requiring post-discharge services will be referred, whenever possible, to ConnectiCare contracted vendors/facilities.
5. Request for retrospective reviews must be done within five (5) business days of the request from the case manager.
6. Notification of emergency admissions must be within twenty-four (24) hours of the admission.
7. Notification of elective admissions must be at least five (5) days prior to the admission.
8. Admissions for mental health & substance abuse must be pre-authorized prior to admission.
9. Partial hospitalization programs must be pre-authorized prior to providing services.
10. Intensive outpatient programs must be pre-authorized prior to providing services.
Home Care Providers
Case Management Standards/Home Health Care Providers
1. General standards
• Professional staff will conduct themselves in a professional manner when communicating with the case manager and when communicating authorization decisions to the member.
2. Intake and Admissions
• The home care agency will have the ability to accept referrals on a seven (7) days a week, twenty-four (24) hours a day basis.
• The home care provider will confirm the ability to accept an admission within two (2) hours of the request by a case manager.
• If the agency/vendor is unable to accept an admission, it is their responsibility to notify ConnectiCare’s Home Health Care Program.
• The home care provider will obtain pre-authorization for services prior to the first home care visit.
Note: Cases that are not accepted for service are tracked for patterns regarding availability of home care providers.
3. Services
• Upon acceptance of a referral, the home care provider will assume responsibility for the provision of the requested services, including subcontracting for services when they are not directly supplied. The home care vendor is responsible for monitoring the quality of care provided by home care providers with whom the vendor subcontracts.
• The initial evaluation will be done within twenty-four (24) hours of acceptance of a case or as deemed appropriate by the case manager and physician.
• The agency will have available staff for after hour visits as needed, which may be necessary to avoid emergency room visits.
• Care and services are to be provided in accordance with the patient’s rights and responsibilities.
• Coordination of care is the responsibility of the home care provider.
4. Reporting
• The home care agency is responsible for verifying authorization on the first business day following an after hours acceptance of a referral.
• The home care provider will contact the case manager to verify that authorization has been obtained for any change in services provided to members (including new, or additional services, as well as changes in the level of care on current authorized services).
• If a member requires an urgent visit from licensed personnel, and that visit has not been authorized, the visit should be made and the case manager should be notified on the next business day.
• Subsequent reports from the responsible licensed professional will be provided within the requested timeframe in order for authorization determinations to be made.
• Reports must be detailed and comprehensive regarding all services provided.
• Acute changes in the member’s medical condition must be reported to the case manager and primary care physician at the time of the occurrence, or as soon as is reasonable, but not to exceed twenty-four (24) hours after the occurrence. Notification of emergency room visits and hospital readmissions should be immediate.
• The home care provider will provide written documentation if requested.
• The home care provider will utilize appropriate specialty staff when indicated to provide consultation and or direct care as needed.
• The home care professional is responsible for notifying the case manager of plans for discharge at least twenty-four (24) hours in advance of the last visit, and for submitting requested documentation to support discharge if requested.
5. Discharge Planning
• Home care staff is responsible for facilitating member independence and appropriate discharge planning.
• The home care staff is responsible for evaluating the discharge needs of the member and discussing these with the case manager prior to discussion with the member and or family.
• The home care provider is responsible for assuring that the member is safe at time of discharge and verifying that referrals have been made to appropriate agencies if deemed necessary for follow up.
Skilled Nursing Facility
1. General standards:
• Authorized ConnectiCare personnel shall have access to the facility, member charts, key staff and members at any time during regular business hours.
• The facility staff will conduct themselves in a professional manner when communicating with the case manager and when communicating authorization decisions to the member.
2.Intake and Admissions
• The facility will confirm the ability to accept/or decline a member within two (2) hours of the request for service.
• Transfers will be accepted seven days a week during regular business hours. Any exceptions for after hours and weekend admissions should be accommodated with prior discussion and approval of on a case-by-case basis.
• The facility must accept the member on the agreed upon date, unless alternate arrangements for care have been made with the case manager.
3. Services
• The facility will provide the necessary services requested at the agreed upon level of care.
• Licensed therapists must be utilized for all therapy sessions.
• For acute rehabilitation, a minimum of 3 hours a day, 6-7 days a week must be provided.
• For subacute rehabilitation, the facility must provide 1-3 hours of therapy/day 5-7 days per week as ordered.
• Social work services will be made available as needed to assist with short and long- term planning, and to assist in discharge planning if needed.
• Care and services are provided with respect to patients’ rights and responsibilities.
4. Reporting
• Pre-authorization is required for services and supplies in addition to the agreed upon level of care (this includes transportation requests).
• The initial report must include a complete clinical update, treatment plan, and anticipated length of stay.
• Subsequent reports are expected to be communicated within the requested timeframe.
• Reports must be detailed, accurate, and comprehensive regarding member status and all services provided in order for a continued stay determination to be made.
• Verbal reports must be provided within twenty-four (24) hours of a significant change in status.
• Verbal reports on transfers to acute care hospital must be made at time of the occur- rence or as deemed reasonable by staff.
• Retrospective requests for information by a case manager will be provided within five (5) business days of the request. In the event that a member is presently receiving services, the information will be required within twenty-four (24) hours of admission in order for a coverage determination to be made.
5. Discharge Planning
• The facility staff is responsible for facilitating appropriate discharge.
• Facility staff is responsible for evaluating the discharge needs of members and discussing them with the case manager prior to notifying the member or family.
• The designated person responsible for discharges must confirm the authorization of home care services or DME supplies prior to discharge in order to assure continuity with network providers.
• Services not able to be supplied by a contracted vendor must also be authorized.
• The facility staff will address any safety issues prior to discharge and perform an in home evaluation, if indicated.
• The facility staff is responsible for discussing discharge plans with the primary care physician, member and or family to assure a safe and effective transition.
• The facility staff is responsible for supplying the member and primary care physician with a discharge summary and instructions for follow-up care.
