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Credentialing | ConnectiCare

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Credentialing

Commercial
Medicare

Introduction & overview

Program overview (practitioners & HDOs)

Practitioners

To ensure the integrity of its participating practitioner panel, ConnectiCare has developed policies and procedures for credentialing applicants for participation and recredentialing current practitioners. ConnectiCare participates in the CAQH "Universal Provider Datasource" (UPD) to help streamline the initial application and recredentialing process for providers.

Application submitted through the Council for Affordable Quality Healthcare's (CAQH) Universal Provider Datasource ( www.caqh.org)
Verification of unrestricted license to practice their specialty in the state(s) in which the applicant practices
Verification of current, unrestricted DEA certificate, if applicable
Verification of education and training
Review of work history
Review of malpractice coverage
Review of malpractice claims history
Review of Medicare/Medicaid sanctions
Review of disciplinary or other sanction activity
The Data Bank activity
Unrestricted clinical admitting privileges at a participating hospital, or an admitting arrangement by which members are referred for admission to a participating hospital.
Board Certification by the American Board of Medical Specialties or American Osteopathic Association
Coverage provided by a ConnectiCare participating provider of the same specialty
24-hour coverage (required for PCPs and OB/Gyns, preferred for all other practitioners)

Note: In most circumstances, ConnectiCare requires that all members of a group practice, including mid-level practitioners, participate with ConnectiCare in order for the group to participate. The status of an individual member of a group practice may disqualify the rest of the group. ConnectiCare may, at its discretion, waive application of this requirement in ordder to meet member access standards or to meet other business needs.

A ConnectiCare medical irector, or other designated physician, is responsible for, and participates in the credentialing program. Once the credentialing process is complete, all applications that meet ConnectiCare’s established criteria will be forwarded to the senior medical director for review and approval. All other applications will be presented to ConnectiCare’s Quality Improvement Committee, comprised of participating practitioners, for a recommendation. Applicants have the right, upon request, to be informed of the status of their credentialing/recredentialing application.

You have the right to review the information submitted from other sources in support of your application and to correct erroneous information. ConnectiCare will notify you of any information obtained during the credentialing process that varies substantially from the information you provided. All information gained during the credentialing process will be kept strictly confidential, unless otherwise provided or permitted by law. However, we may disclose tax ID numbers to our customers, their consultants, or our vendors who need such information in order to evaluate network adequacy.

ConnectiCare does not discriminate in the selection or termination of practitioners on the basis of sex, age, national origin, race, religion, color, marital status, or sexual preference or orientation.

Health Delivery Organizations (HDOs)

Assessment
To ensure the integrity of its participating provider panel, ConnectiCare has developed policies and procedures for the assessment of applicants for participation in the ConnectiCare network and for the re-assessment of current health delivery organizations (HDOs).

In certain circumstances, the assessment or re-assessment process may require a site visit, which includes a structured review of the facility, environment and practices, a review of medical record-keeping practices, and may include interviews with key personnel. Site visit standards and medical record standards are available upon request.

A ConnectiCare medical director is responsible for and participates in the assessment process. As a participating HDO, you may be asked to submit specific documentation to the Credentialing Department. ConnectiCare will notify you of any information obtained during the assessment and reassessment process that varies substantially from the information you provided to us. You have a right to review the information submitted from other sources during the assessment and reassessment process in order to correct erroneous information. All the information provided to us will be kept strictly confidential, unless otherwise mandated by applicable law.

Credentialing requirements for HDOs

The following is a brief outline of many of the key credentialing requirements. There may be other requirements in addition to those listed.

Organization	Credentialing requirements
Home health agency	State license, as required JCAHO or CHAP accreditation Medicare certification
Hospital	State license JCAHO accreditation Medicare certification
Surgical center (free-standing)	State license Medicare certification JCAHO, AAAHC, ADD, or AAAASF accreditation
Office-based surgical center	State license, as required Medicare certification or accreditation
Skilled nursing facility	State license JCAHO, CARF or CCAC accreditation Medicare certification

PPM/10.16

Credentialing online - CAQH

CAQH - Universal Provider Datasource (UPD)

ConnectiCare is part of more than 550 credentialing organizations currently participating in the CAQH "Universal Provider Datasource" (UPD) in offering practitioners the opportunity to streamline the credentialing process.

Launched in 2002, the UPD allows registered physicians and other health professionals in all 50 states and the District of Columbia to enter their credentialing information, free of charge, into a single, uniform online application that meets the credentialing needs of most health plans, hospitals, and other healthcare organizations. The provider data-collection service streamlines the initial application and recredentialing process, and reduces provider administrative burdens and costs. If you and/or your practice have a ConnectiCare contract, complete the ConnectiCare Credentialing Form and fax it to the number indicated on the form. If you have not yet requested a ConnectiCare contract, please call 1-800-285-0491.

Practitioners not currently participating with CAQH:
If you are not already participating with CAQH, ConnectiCare will use Credentialing Data Form to register you with CAQH so you can start the application process.

Practitioners currently participating with CAQH:
If you have already completed the CAQH application process online, you have to authorize ConnectiCare as an eligible plan to access your information.

Then an initial application or tri-annual recredentialing can be completed by us without having to send you additional paperwork to fill out. Practitioners can participate at no cost. Data is protected and only released to the plans that you authorize.

Universal Provider Datasource (UPD) is supported by the American Medical Association, the American Academy of Family of Physicians, the American College of Physicians, America's Health Insurance Plans, and other provider organizations. The National Committee on Quality Assurance and The Joint Commission on Accreditation of Healthcare Organizations have indicated that the UPD application meets their respective standards.

Practioners-only information

Recredentialing

Recredentialing (practitioners only)

As a participating practitioner, you will be asked at least every three (3) years to complete a recredentialing application and submit specific documentation to the Credentialing and Recredentialing Department.

Practitioners are regularly and rigorously monitored to ensure they continue to meet ConnectiCare’s high standards. This includes, but is not limited to, complaint investigation, compliance with access to care standards, patient satisfaction, maintenance of medical records, HEDIS rates, utilization patterns, and monitoring of sanctions and regulatory actions taken by state and federal agencies.

All quality of care and quality of service complaints from members concerning practitioners are tracked and monitored for recurring patterns or for overall number of complaints. Practitioners must respond to member complaint investigations.

When opportunities for improvement are identified, practitioners may be requested to develop corrective action plans.

PPM/10.16

Medical record review standards

Standards for performing medical record review (Practitioners only)

General standards
1. Patient records must be easily retrievable and accessible.
2. Patient records must be stored in a confidential area or in a secure electronic medical record system and only those staff members whose job description necessitates access to patient information should have authorization to access patient records.
3. Medical information must be current, detailed and organized.
4. The office staff should receive periodic training in confidentiality of member information.
5. The physician office should have 24-hour call-in capability (answering service or answering machine with directions on how to reach the on-call physician).

Chart review standards
1. Page content:
  Each page requires the patient name or identifier, the date of the entry and the author’s signature (as appropriate).
2. Presenting complaints, diagnoses, labs, x-rays, consults, and other diagnostic tests have a plan for treatment documented in the patient record:
  All complaints, diagnoses, and reports must have documentation of a treatment plan for continued evaluation and/or abnormal results.
3. Problem list:
  A problem list with the patient’s ongoing, chronic medical/psychological conditions and/or significant illnesses must be maintained in the patient record. Notation in the record is acceptable. If there are no identified problems, there must be a notation in the record stating that this is a well adult.
4. Medication list:
  There is a medication list, which includes dosages and dates for initial and refill prescriptions. Notation in the record is acceptable.
5. Allergy documentation:
  Allergies and adverse reactions must be specified and prominently documented in the patient record on all patients. If a patient has no allergies, this must be documented prominently in the patient record as NKA or NKDA (no known allergies or no known drug allergies).
6. Advance directives:
  There should be documentation present in the records of all patients 45 years or older that advance directives have been discussed. If the patient chose to make an advance directive (in the past or present), there should be a copy of the advance directive in a prominent part of the member record. Notation should also be made if the patient does not want to make an advance directive.
7. Past medical history:
  Records should include notation of past medical history including physical exams, necessary treatment, and possible risk factors relevant to a particular treatment.
8. Urinary incontinence:
  Documentation of assessment and treatment (if appropriate) for, or discussion of incontinence issues or concerns.
9. Fall prevention:
  Documentation of discussion (if appropriate) regarding level of exercise and/or physical activity, balance walking or falls.
10. Legibility:
  The record must be readable and the contents comprehendible.

PPM/10.16

Site visits

Site visits (practitioners only)

ConnectiCare may conduct site visits for complaints related to physical accessibility, physical appearance, and adequacy of waiting room and examining room space. The site visit includes, but is not limited to, an assessment of the physical accessibility and appearance, the adequacy of waiting room and examining room space, adequacy of equipment, and patient safety practices.

On initial visit, practitioners must achieve a minimum passing score of 75%. A score of 80% must be achieved on subsequent monitoring visits.

Site visits standards

Physical accessibility and physical appearance
Physical accessibility
1. Parking
  1. Handicapped parking is available.
2. Handicap access
  1. All offices should have handicapped accessibility. If handicapped access is not available, the physician must provide some alternative access for handicapped patients under his/her care.
3. Entrance identified
  1. If physician/office is in a multi-physician office/building, the physician’s name must be listed in the directory.
  2. Entrance clearly identified.
  3. Ease of entry into building and office.
Physical appearance
1. Cleanliness: Areas are free from clutter and areas appear to be cleaned regularly.
2. Adequate lighting indoors and outdoors.
3. Safety: Exits, corridors, rooms and entrances are free from clutter and obstruction. No cords, ripped carpets or broken flooring are observed.
Adequacy of waiting room and examining room space
1. Waiting/reception areas neat and clean. These areas appear to be cleaned regularly and are free of excessive clutter.
2. There should be an adequate number of examination rooms to accommodate patient volume. Standard: Two (2) examination/treatment rooms per MD in office per day.
3. Adequate number of seats to accommodate patient volume. Standard: Three (3) chairs per physician.
Adequacy of medical/treatment record keeping: paper records
1. Active patient records must be easily retrieved.
2. Patient records must be stored in a confidential, secure area that cannot be accessed by persons other than office personnel.
3. Office staff should sign a statement, which attests to their maintaining the confidentiality of patient information.
4. Patient records must be bound and organized in a standard, consistent manner.
5. Record release forms available for patients.
6. A current master problem list should be maintained in each file and updated as indicated by the patient’s health status.
7. A current master medication list should be maintained in each file and updated as indicated by the patient’s health status.
Adequacy of medical/treatment record keeping: electronic records
1. Health information and data: Having immediate access to key information such as patient diagnosis, allergies, lab test results and medications.
2. Result management: The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results.
3. Order management: The ability to enter and store orders for prescriptions, tests and other services.
4. Decision support: Using reminders, prompts and alerts, computerized decision-support systems to help improve compliance with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions and facilitate diagnoses and treatments.
Patient safety including adequacy of equipment
1. Medications
  1. All controlled substances are clearly labeled and stored in a locked area.
  2. Drug samples and pharmaceuticals for dispensing to patients have not expired.
  3. Drug samples and pharmaceuticals are stored in a secure location.
  4. Prescription pads are kept in an area/location away from patient access.
  5. Medication and food are not to be kept in the same refrigerator.
2. Emergencies
  1. One staff person, besides the physician, is CPR trained.
3. Disposal
  1. Receptacles for medical waste are readily available and clearly marked.
  2. Receptacles for sharps are located in or near treatment area. (Pediatric treatment rooms should have additional precautions to prevent child access.)
4. Maintenance of equipment
  1. All medical equipment should be maintained according to the manufacturer’s suggested recommendations.
5. Treatment area safety
  1. Contaminated work surfaces should be cleaned and decontaminated with a tuberculocidal disinfectant, a diluted bleach solution or an Environmental Protection Agency-registered hospital disinfectant after contact with blood or other potentially infectious materials. Meticulous cleaning and thorough rinsing must precede disinfection/sterilization.

PPM/10.16

Leave of absence policy

Leave of absence policy (practitioners only)

Leave of absence due to illness, injury or family medical leave

Leave of absence less than 30 days — no notification or reapplication is required. Arrangements should be made for coverage by a participating ConnectiCare practitioner or locum tenens.
For absence greater than 30 days, less than 6 months — written notification is required as soon as possible, but in no instance later than forty-five (45) days after the leave commences. Arrangements should be made for coverage by a participating ConnectiCare practitioner or locum tenens. Medical certification that the practitioner is able and competent to return to practice may be required upon return. If the recredentialing period has expired, recredentialing will be done at that time, and reapplication will not be required.
For absence greater than 6 months — written notification is required as soon as possible, but no later than forty-five (45) days after the leave commences. The practitioner may be terminated from the network until his/her return. Arrangements should be made for coverage by a participating ConnectiCare practitioner or locum tenens. Medical certification that the practitioner is able and competent to return to practice may be required upon return. Reapplication, using credentials policy in force at that time, will be required upon return to the practice.

Leave of absence for reasons other than illness, injury or family medical leave

Leave of absence less than 30 days — no notification is required. Arrangements should be made for coverage by a participating ConnectiCare practitioner or locum tenens.
Leave of absence greater than 30 Days — written notification is required as soon as possible, but no later than 45 days after leave commences. The practitioner may be terminated from the network until his/her return. Arrangements should be made for coverage by a participating ConnectiCare provider or locum tenens (see locum tenens, also in this section). Reapplication, using the credentials policy in force at that time, will be required upon return to the practice.

Note: Closing the practice for any reason and directing patients to an urgent care center or emergency department does not constitute coverage and is a breach of contract and grounds for termination. Also, failure to notify ConnectiCare as outlined above will be considered breach of contract and grounds for termination. Practitioners whose contracts are terminated under these circumstances will have the right to reapply under the rules and policies applicable at the time of his/her reapplication.

PPM/10.16

Locum tenens policy

Locum tenens

If a locum tenens is replacing a participating ConnectiCare practitioner, notice of leave of absence or reduction in practice by the practitioner on leave must be sent to the Credentialing Department at ConnectiCare, as described under the leave of absence policy, discussed earlier in this section.
The practitioner on leave should provide ConnectiCare a notice of locum tenens, including:
- anticipated beginning and end dates
- written documentation outlining an admitting arrangement by which ConnectiCare members under the care of the physician on leave are referred to participating ConnectiCare practitioners and facilities
Notice of locum tenens practitioners must be received at ConnectiCare no later than thirty (30) days prior to start date. The only exceptions to this requirement are in the case of illness, injury or need for family medical leave by the participating practitioner.
ConnectiCare will accept coverage by a locum tenens provider for a period no longer than twelve (12) months. After this time period, locum tenens must apply to become a participating practitioner. Locum tenens physicians who intend to apply to ConnectiCare’s panel must do so at least 60 days prior to their one (1) year locum tenens anniversary date. Failure to do so may result in denial of claims.

PPM/10.16

Practitioner & HDO information

Physician compliance

Practitioner compliance

ConnectiCare and its contracted provider organizations are required to comply with compliance standards in accordance with ConnectiCare policy. Physicians should be aware that lack of compliance with pre-authorization procedures, unauthorized referrals to out-of-plan providers, or noncompliance with ConnectiCare policies may cause significant problems for health plan members. ConnectiCare looks to its physician network to minimize these problems and promote efficient health plan operations.

ConnectiCare's Health Services Department will work with contracted practitioners and provider organizations to uphold these standards. When a provider is not compliant in one of the categories below, and/or per the applicable provider agreement, disciplinary action, including but not limited to termination of the agreement, may be initiated in accordance with ConnectiCare policy and the provider agreement. Some of the reasons for disciplinary actions may include:

Lack of compliance with pre-authorization policy and procedures
Unauthorized out-of-plan referrals
Inappropriate billing of members
Lack of cooperation with case management or Credentialing & Recredentialing Department processes.

Examples:
- Refusal to share information when asked to clarify/substantiate medical necessity for continued hospitalization.
- Refusal to share information when asked to clarify a medical quality issue.
- Two or more attempts made to contact physician/covering physician within a 24 hour period to clarify/substantiate medical necessity for continued hospitalization; physician did not return phone calls.
- Adversarial interaction between the ConnectiCare representative and the physician.
- Inappropriate conduct by physician in attempting to discuss plan of care (e.g., hanging up phone prior to the end of the conversation, demeaning, rude or offensive behavior).
Inadequate off-hours coverage

Examples:
- Office inappropriately instructs patient to go to emergency room/walk-in because office is closed.
- MD or a covering MD does not return call within a reasonable amount of time, but, not to exceed 24 hours of being contacted.
Abuse of billing practices

Health Delivery Organization (HDO) compliance

ConnectiCare’s Quality Improvement Department has several monitoring activities in place for the ongoing assessment of our contracted HDOs.

Quality improvement activities are essential to evaluate and promote physician and member satisfaction, as well as to evaluate the HDO’s compliance with ConnectiCare’s policies and standards. These activities are monitored on an ongoing basis in order to resolve problems and promote safe and efficient delivery of services.

Monitored activities may include but are not limited to:

member satisfaction with provider services
state survey inspection reports
state regulatory action reports
Medicare and Medicaid sanctions
follow up regarding member and physician complaints about quality of care and quality of service

HDOs are required to comply with contractual obligations including compliance with ConnectiCare’s polices and procedures. Those organizations that are not in compliance are subject to potential sanction activity up to and including termination.

Quality of care issues
ConnectiCare’s Quality Improvement Department investigates quality of care issues received by any means. Those which are substantiated may result in suspension or termination. ConnectiCare may, at its discretion, suspend a provider immediately, prior to completing an investigation, when the quality of care issue indicates an imminent danger to the member. ConnectiCare’s medical director has the authority to suspend a provider.

In the case of suspension, the HDO may submit to ConnectiCare’s Quality Improvement Department evidence that the issue/or issues have been resolved and request a reconsideration of the suspension.

PPM/10.16

Termination and appeals

Practitioner termination and appeals

Refer to state-specific requirements found in this manual.

• Connecticut
• Massachusetts

Health Delivery Organization (HDO) termination & appeals

Refer to state-specific appendices found in this Manual.

• Connecticut
• Massachusetts

PPM/10.16

Reassessment program (HDO Only)

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 the "Compliance, Termination & Appeals" section, to evaluate an HDO. Identified deficiencies in any of these areas may be a basis for a referral to ConnectiCare’s Network Evaluation Team 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

Concurrent chart reviews must be completed within 24 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.
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.
Authorized ConnectiCare personnel shall have access to the hospital chart, hospital staff, and members Monday - Friday during regular business hours of the hospital.
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 contracted vendors/facilities.
Request for retrospect reviews must be done within five (5) business days of the request from the case manager.
Notification of emergency admissions must be within 24 hours of the admission.
Notification of elective admissions must be at least five (5) days prior to the admission.
Admissions for mental health & substance abuse must be pre-authorized prior to admission.
Partial hospitalization programs must be pre-authorized prior to providing services.
Intensive outpatient programs must be pre-authorized prior to providing services.

Home care providers

Case management standards/home health care providers

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.
Intake and admissions
- The home care agency will have the ability to accept referrals on a seven (7) days a week, 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 health providers.
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.<
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 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 24 hours in advance of the last visit, and for submitting requested documentation to support discharge if requested.
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

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.
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.
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.
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 occurrence 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 24 hours of admission in order for a coverage determination to be made.
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

PPM/10.16

Introduction & overview

Credentialing/recredentialing program

Program overview (practitioners and HDOs)

Practitioners

To ensure the integrity of its participating practitioner panel, ConnectiCare has developed policies and procedures for credentialing applicants for participation and recredentialing current practitioners. ConnectiCare participates in the CAQH "Universal Credentialing Datasource" (UCD) to help streamline the initial application and recredentialing process for providers.

All applicants undergo a thorough review of the following:

• Application submitted through the Council for Affordable Quality Healthcare's (CAQH) Universal Credentialing Datasource (www.caqh.org)
• Verification of unrestricted license to practice their specialty in the state(s) in which the applicant practices
• Verification of current, unrestricted DEA certificate, if applicable
• Verification of education and training
• Review of work history
• Review of malpractice coverage
• Review of malpractice claims history
• Review of Medicare/Medicaid sanctions
• Review of disciplinary or other sanction activity
• National Practitioner Data Bank activity
• Unrestricted clinical admitting privileges at a participating hospital, or an admitting arrangement by which members are referred for admission to a participating hospital.
• Board Certification by the American Board of Medical Specialties or American Osteopathic Association
• Coverage provided by a ConnectiCare participating provider of the same specialty
• 24-hour coverage (required for PCPs and OB/Gyns, preferred for all other practi-tioners)

Note: In most circumstances, ConnectiCare requires that all members of a group practice, including mid-level practitioners, participate with ConnectiCare in order for the group to participate. The status of an individual member of a group practice may disqualify the rest of the group. ConnectiCare may, at its discretion, waive application of this requirement in order to meet member access standards or to meet other business needs.

A ConnectiCare medical director, or other designated physician, is responsible for, and participates in, the credentialing program. Once the credentialing process is complete, all applications that meet ConnectiCare’s established criteria will be forwarded to the senior medical director for review and approval. All other applications will be presented to ConnectiCare’s Quality Improvement Committee, comprised of participating practitioners, for a recommendation. Applicants have the right, upon request, to be informed of the status of their credentialing/recredentialing application.

Health Delivery Organizations (HDOs)
Assessment
To ensure the integrity of its participating provider panel, ConnectiCare has developed policies and procedures for the assessment of applicants for participation in the ConnectiCare network and for the re-assessment of current health delivery organizations (HDOs).

Credentialing requirements for HDOs
The following is a brief outline of many of the key credentialing requirements. There may be other requirements in addition to those listed.

Organization	Credentialing requirements
Home health agency	State license, as required JCAHO or CHAP accreditation Medicare certification
Hospital	State license JCAHO accreditation Medicare certification
Surgical center (free-standing)	State license Medicare certification JCAHO, AAAHC, ADD, or AAAASF accreditation
Office-based surgical center	State license, as required Medicare certification or accreditation
Skilled nursing facility	State license JCAHO, CARF or CCAC accreditation Medicare certification

Medicare PPM/2.10

Credentialing online - CAQH

CAQH - Universal Provider Datasource (UPD)

Launched in 2002, the UPD allows registered physicians and other health professionals in all 50 states and the District of Columbia to enter their credentialing information, free of charge, into a single, uniform online application that meets the credentialing needs of most health plans, hospitals, and other healthcare organizations. The provider data-collection service streamlines the initial application and recredentialing process, and reduces provider administrative burdens and costs. If you and/or your practice have a ConnectiCare contract, complete the CconnectiCare Credentialing Data Form and fax it to the number indicated on the form. If you have not yet requested a ConnectiCare contract, please call 1-800-285-0491.

Practitioners only information

Recredentialing

Recredentialing (practitioners only)

All quality of care and quality of service complaints from members concerning practitioners are tracked and monitored for recurring patterns or for overall number of complaints.Practitioners must respond to member complaint investigations.

When opportunities for improvement are identified, practitioners may be requested to develop corrective action plans.

Medicare PPM/2.10

Site visits

Site visits (practitioners only)

On initial visit, practitioners must achieve a minimum passing score of 75%. A score of 80% must be achieved on subsequent monitoring visits.

Site visits standards

Physical accessibility and physical appearance

Physical accessibility
1. Parking
  1. Handicapped parking is available.
2. Handicap access
  1. All offices should have handicapped accessibility. If handicapped access is not available, the physician must provide some alternative access for handicapped patients under his/her care.
3. Entrance Identified
  1. If physician/office is in a multi-physician office/building, the physician’s name must be listed in the directory.
  2. Entrance clearly identified.
  3. Ease of entry into building and office.
Physical appearance
1. Cleanliness: Areas are free from clutter and areas appear to be cleaned regularly.
2. Adequate lighting indoors and outdoors.
3. Safety: Exits, corridors, rooms and entrances are free from clutter and obstruction. No cords, ripped carpets or broken flooring are observed.
Adequacy of waiting room and examining room space
1. Waiting/reception areas neat and clean. These areas appear to be cleaned regularly and are free of excessive clutter.
2. There should be an adequate number of examination rooms to accommodate patient volume. Standard: Two (2) examination/treatment rooms per MD in office per day.
3. Adequate number of seats to accommodate patient volume. Standard: Three (3) chairs per physician.
Adequacy of medical/treatment record keeping: paper records
1. Active patient records must be easily retrieved.
2. Patient records must be stored in a confidential, secure area that cannot be accessed by persons other than office personnel.
3. Office staff should sign a statement, which attests to their maintaining the confidentiality of patient information.
4. Patient records must be bound and organized in a standard, consistent manner.
5. Record release forms available for patients.
6. A current master problem list should be maintained in each file and updated as indicated by the patient’s health status.
7. A current master medication list should be maintained in each file and updated as indicated by the patient’s health status.
Adequacy of medical/treatment record keeping: electronic records
1. Health information and data: Having immediate access to key information such as patient diagnosis, allergies, lab test results and medications.
2. Result management: The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results.
3. Order management: The ability to enter and store orders for prescriptions, tests and other services.
4. Decision support: Using reminders, prompts and alerts, computerized decision-support systems to help improve compliance with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions and facilitate diagnoses and treatments.

Patient safety including adequacy of equipment

Medications
1. All controlled substances are clearly labeled and stored in a locked area.
2. Drug samples and pharmaceuticals for dispensing to patients have not expired.
3. Drug samples and pharmaceuticals are stored in a secure location.
4. Prescription pads are kept in an area/location away from patient access.
5. Medication and food are not to be kept in the same refrigerator.
Emergencies
1. One staff person, besides the physician, is CPR trained.
Disposal
1. Receptacles for medical waste are readily available and clearly marked.
2. Receptacles for sharps are located in or near treatment area. (Pediatric treatment rooms should have additional precautions to prevent child access.)
Maintenance of equipment
1. All medical equipment should be maintained according to the manufacturer’s suggested recommendations.
Treatment area safety
1. Contaminated work surfaces should be cleaned and decontaminated with a tuberculocidal disinfectant, a diluted bleach solution or an Environmental Protection Agency-registered hospital disinfectant after contact with blood or other potentially infectious materials. Meticulous cleaning and thorough rinsing must precede disinfection/sterilization.

Medicare PPM/4.14

Medical record review standards

Standards for performing medical record review (practitioners only)

General standards
1. Patient records must be easily retrievable and accessible.
2. Patient records must be stored in a confidential area or in a secure electronic medical record system and only those staff members whose job description necessitates access to patient information should have authorization to access patient records.
3. Medical information must be current, detailed and organized.
4. The office staff should receive periodic training in confidentiality of member information.
5. The physician office should have 24-hour call-in capability (answering service or answering machine with directions on how to reach the on-call physician).

Chart Review Standards

1.	Page content: Each page requires the patient name or identifier, the date of the entry and the author’s signature (as appropriate).
2.	Presenting complaints, diagnoses, labs, x-rays, consults, and other diagnostic tests have a plan for treatment documented in the patient record:All complaints, diagnoses, and reports must have documentation of a treatment plan for continued evaluation and/or abnormal results.
3.	Problem list: A problem list including the patient’s ongoing, chronic medical/psychological conditions and/or significant illnesses must be maintained in the patient record. Notation in the record is acceptable. If there are no identified problems, there must be a notation in the record stating that this is a well adult.
4.	Medication list: There is a medication list, which includes dosages and dates for initial and refill prescriptions. Notation in the record is acceptable.
5.	Allergy documentation: Allergies and adverse reactions must be specified and prominently documented in the patient record on all patients. If a patient has no allergies, this must be documented prominently in the patient record as NKA or NKDA (no known allergies or no known drug allergies).
6.	Advance directives: There should be documentation present in the records of all patients 45 years or older that advance directives have been discussed. If the patient chose to make an advance directive (in the past or present), there should be a copy of the advance directive in a prominent part of the member record. Notation should also be made if the patient does not want to make an advance directive.
7.	Past medical history: Records should include notation of past medical history including physical exams, necessary treatment, and possible risk factors relevant to a particular treatment.
8.	Urinary incontinence: Documentation of assessment and treatment (if appropriate) for, or discussion of incontinence issues or concerns.
9.	Fall prevention: Documentation of discussion (if appropriate) regarding level of exercise and/or physical activity, balance walking or falls.
10.	Legibility: The record must be readable and the contents comprehendible.

Note: We have provided you with sample Patient Summary and Medication Charts to use for medical record-keeping purposes.

Medicare PPM/10.12

Leave of absence policy

Leave of absence policy (practitioners only)

Leave of absence due to illness, injury or family medical leave

1. Leave of absence less than 30 days — no notification or reapplication is required. Arrangements should be made for coverage by a participating ConnectiCare practitioner or locum tenens.

2. For absence greater than 30 days, less than 6 months — written notification is required as soon as possible, but in no instance later than 45 days after the leave commences. Arrangements should be made for coverage by a participating ConnectiCare practitioner or locum tenens. Medical certification that the practitioner is able and competent to return to practice may be required upon return. If the recredentialing period has expired, recredentialing will be done at that time, and reapplication will not be required.

3. For absence greater than 6 months — written notification is required as soon as possible, but no later than 45 days after the leave commences. The practitioner may be terminated from the network until his/her return. Arrangements should be made for coverage by a participating ConnectiCare practitioner or locum tenens. Medical certification that the practitioner is able and competent to return to practice may be required upon return. Reapplication, using credentials policy in force at that time, will be required upon return to the practice.

Leave of absence for reasons other than illness, injury or family medical leave

1. Leave of absence less than 30 days — no notification is required. Arrangements should be made for coverage by a participating ConnectiCare practitioner or locum tenens.

2. Leave of absence greater than 30 days — written notification is required as soon as possible, but no later than 45 days after leave commences. The practitioner may be terminated from the network until his/her return. Arrangements should be made for coverage by a participating ConnectiCare provider or locum tenens. Reapplication, using the credentials policy in force at that time, will be required upon return to the practice.

Medicare PPM/2.10

Locum tenens policy

Locum tenens policy (practitioners only)

1. If a locum tenens is replacing a participating ConnectiCare practitioner, notice of leave of absence or reduction in practice by the practitioner on leave must be sent to the Credentialing Department at ConnectiCare, as described under the leave of absence policy, discussed earlier in this section.

2. The practitioner on leave should provide ConnectiCare a notice of locum tenens, including:

• anticipated beginning and end dates
• written documentation outlining an admitting arrangement by which ConnectiCare members under the care of the physician on leave are referred to participating ConnectiCare practitioners and facilities

3. Notice of locum tenens practitioners must be received at ConnectiCare no later than thirty (30) days prior to start date. The only exceptions to this require- ment are in the case of illness, injury or need for family medical leave by the participating practitioner.

4. ConnectiCare will accept coverage by a locum tenens provider for a period no longer than 12 months. After this time period, locum tenens must apply to become a participating practitioner. Locum tenens physicians who intend to apply to ConnectiCare’s panel must do so at least 60 days prior to their one (1) year locum tenens anniversary date. Failure to do so may result in denial of claims.

Medicare PPM/2.10

Practitoner & HDO Information

Compliance, termination and appeals

Compliance (practitioners and HDOs)

Practitioner and HDO termination and physician appeals

Pursuant to applicable law and the applicable provisions of its network participation contracts, ConnectiCare has the right to suspend, restrict, or terminate practitioners whose conduct adversely affects or could adversely affect the health or welfare of a member or members, who fail to remain in compliance with ConnectiCare’s credentialing criteria, who lose privileges with an institutional provider, who have sanctions or restrictions imposed upon licensure; or who have been arrested, convicted, indicted, or charged with any felony charge related to moral turpitude or the practice of medicine. Under no circumstances will ConnectiCare initiate termination actions against a practitioner/provider solely because he or she has:

• advocated on behalf of a member
• filed a complaint against ConnectiCare with state/federal regulatory bodies
• appealed a preferred health plan decision
• provided information to an appropriate agency
• requested a hearing or review

Physicians have the right to appeal ConnectiCare’s decision to take an adverse professional review action in accordance with the Health Care Quality Improvement Act of 1986. For purposes of this policy, “adverse professional review action” means an action or recommendation of ConnectiCare’s Credentialing Committee (i) which is based on the competence or professional conduct of an individual physician which conduct affects or could affect adversely the health or welfare of a patient, and (ii) which reduces, restricts, suspends, revokes, denies, or prevents renewal of the physician’s participation. In addition, a physician has a right to appeal any termination from ConnectiCare’s Medicare Advantage network under CMS rules. The appeal procedure that applies to both circumstances is outlined below.

ConnectiCare reserves its right to terminate a (i) non-physician’s participation if permitted by the network participation contract and applicable law and (ii) a physician’s participation if permitted by the physician contract and applicable law, to the extent resulting from any reason other than an adverse professional review action or if a physician is terminated from ConnectiCare’s Medicare Advantage network. Physicians who are not subject to an adverse professional review action and all other practitioners have no right to appeal such termination; however, a description of the reconsideration process, if applicable, will be included in the termination letter.

Procedure

1.Should a physician become subject to an adverse professional review action or termination from ConnectiCare’s Medicare Advantage network, ConnectiCare shall provide written notice to the practitioner stating:

• that disciplinary action or termination has been proposed against the physician;
• the reasons for the proposed action;
• that the physician has the right to request a hearing on the proposed action;
• that the physician has 30 calendar days from the date of the notice within which to request such a hearing; and
• a summary of the physician’s rights in the hearing.

2. If a hearing is requested on a timely basis by a physician who receives a notice, within 10 business days of its receipt of the physician’s request for a hearing, ConnectiCare shall send to the physician a notice providing:

• the place, time and date of the hearing, which shall be no more than 60, but not less than 30, business days after the date of the notice; and
• a list of witnesses (if any) expected to testify at the hearing on behalf of ConnectiCare.

3. Within 10 business days of the date of the notice sent to the physician, the physician shall provide written notice to ConnectiCare stating:

• Whether physician will be represented by legal counsel or other representatives;
• What information, including documents, will be presented; and
• Whether physician will be presenting any witnesses, including the names and qualifications of each witness.

4. The appeals hearing shall be held before a subcommittee of ConnectiCare’s Quality Improvement Committee (QIC). The subcommittee shall consist of three physicians who are not in direct economic competition with the physician involved.

5. The right to an appeals hearing may be forfeited if the physician fails, without good cause, to appear. The physician may designate a representative in writing with full authority of himself/herself or through an authorized representative.

6. At the appeals hearing, the physician has the right:

• to representation by an attorney or other person of the physician’s choice;
• to have a record made of the proceedings, copies of which may be obtained by the physician upon payment of any reasonable charges associated with the preparation thereof;
• to present evidence determined to be relevant by the subcommittee, regardless of its admissibility in a court of law; and
• to submit a written statement at the close of the hearing.

7. Within 10 business days of the completion of the appeals hearing, the subcommittee shall render its decision. The QIC’s decision shall be final. The decision, along with the basis of its decision, shall be communicated in writing to the physician within five (5) business days of its having reached such decision.

8. In accordance with the requirements of applicable federal and state law, ConnectiCare shall notify the appropriate regulatory authority of any final decision of the QIC to reduce, suspend or terminate a practitioner’s participation for quality-related reasons.

Medicare PPM/11.19

Termination and appeals

Termination and appeals (practitioners and HDOs)

Health Delivery Organization (HDO) termination

Pursuant to applicable laws and the provisions of its network participation contracts, ConnectiCare has the right to suspend, restrict, or terminate providers whose conduct adversely affects or could adversely affect the health or welfare of a member. Such conduct may include but not be limited to, violations of ConnectiCare’s policies and procedures, failure to remain in compliance with ConnectiCare’s assessment/reassessment criteria, and/or adverse actions taken by state or federal agencies.

1. ConnectiCare shall provide written notice, per network participation agreement, to any HDO terminated under this policy.

2. A description of the reconsideration process, if applicable, will be included in the termination letter.

Medicare PPM/11.19

Reassessment program (HDOs Only)

Reassessment program (HDOs only)

• State license
• Medicare certification
• Accreditation certificate
• Annual state survey reports

Additionally, through an ongoing monitoring program, ConnectiCare may use information outlined in the "Compliance, Termination and Appeals" section, 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 24 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 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 and 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, 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 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 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 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 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 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.

Medicare PPM/2.10

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.

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