Currentblue cross blue shield - kansasPolicy N/A
Quality of Care and Credentialing Policies
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Governs BCBSKS processes for reviewing reported quality-of-care concerns, member satisfaction surveying, disease management/wellness programs, HIPAA PHI disclosures for quality operations, health information exchange, public quality reporting, and credentialing/recredentialing and appeals for network providers.
Policy Summary
Payerblue cross blue shield - kansas
PolicyQuality of Care and Credentialing Policies
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders must respond to requests for records and information during quality-of-care reviews to avoid potential actions up to termination and loss of QBRP incentives.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
36 monthsprovider recredentialing interval
URACDisease Management Program accreditation
60 daysfirst/second-level appeal convene time
30 daystime to request first-level appeal
Monthlymonitoring frequency
Operational Coverage Criteria and Procedures
Policy criteria and procedures
Operational policies and criteria governing review of reported quality-of-care concerns, member disease management/wellness programs, HIPAA PHI disclosures for operations, health information exchange, public quality reporting, and provider credentialing, monitoring, and appeals.
Review of Reported Quality-of-Care Concerns: Reported concerns will be reviewed to determine if services were professionally indicated and within the applicable standard of care; potential concerns may be reported by members, family/representatives, providers or staff, BCBSKS internal staff, or business partners; cases are referred to the Nurse Coordinator of Quality Improvement (designated peer review officer).
Information collection and review: Records will be requested and reviewed by clinical staff and peer reviewers; providers are encouraged to provide additional information and clarification during the review.
Provider obligations and consequences: Failure of a contracting provider to respond to BCBSKS requests for additional information during a quality-of-care review constitutes grounds for further action up to termination of the provider's participation agreement for cause and may result in removal of Quality-Based Reimbursement Program (QBRP) incentives.
Adverse findings and action plans: Cases determined to be outside the acceptable standard of care are communicated in writing to the provider with a request for response and will trigger an action plan that considers standard of care, likelihood of contribution to harm, and extent of harm; action plans may include tracking/trending, corrective actions with monitoring, disciplinary action, and reporting to external oversight entities.
Disease Management and Wellness programs: BCBSKS operates telephone-based Disease Management and Wellness programs (examples: diabetes, CAD, asthma, COPD, CHF, hypertension, hyperlipidemia; wellness examples: maternity, weight loss, tobacco cessation, stress management) that are URAC accredited and HIPAA compliant; registered nurses provide one-on-one support, coaching, and educational tools.
Member identification and enrollment
- Members are identified for Disease Management programs by diagnosis codes on claims and will be invited by letter or telephone.
- Members may self-enroll and providers may refer members; participation is voluntary and may be discontinued at any time; participation does not affect insurance benefits.
HIPAA-permitted disclosures for operations: Providers may disclose PHI to health plans without patient authorization for specified health plan operations including quality assurance/improvement, accreditation (eg, HEDIS), case management, disease management, protocol development, credentialing/provider performance evaluation, training, certification, and licensing when both parties have or had a relationship with the patient and the information relates to that relationship.
Health Information Exchange (HIE) and data submission: BCBSKS supports HIPAA-compliant electronic sharing of clinical information to improve member experience and quality of care and may require electronic submission when requesting clinical information.
Quality reporting and transparency: BCBSKS may establish initiatives to monitor and report participating providers' performance results to the public, employer groups, and members via web or written formats.
Credentialing overview and monitoring: Providers must apply and be granted credentialing status per the Program; initial credentialing and recredentialing (at least every 36 months) are required; BCBSKS will monitor network providers at least monthly for compliance and report derogatory findings to the Credentialing Committee.
Credentialing Committee consideration and eligibility: An applicant must meet all applicable BCBSKS criteria (available on the BCBSKS website) to be considered; applicants who do not meet all applicable criteria may not be considered and are not eligible for reconsideration/appeal.
Reconsideration and appeal rights: If the Committee denies or restricts participation, providers may submit additional documentation for reconsideration; if upheld, providers may submit a written request for a first-level appeal within 30 days of notice of denial or restriction.
Circumstances not eligible for reconsideration/appeal
- Denial/cancellation due to license not at full clinical scope.
- Adverse action against DEA registration.
- Inability to supply documentation of successful completion of at least three years post-graduate training or equivalent work experience.
- Current sanctions imposed by any CMS program or the Federal Employee Health Benefit Program (eg, excluded, suspended, or otherwise ineligible to participate in state or federal health care programs).
Suspension for member safety: BCBSKS will review actions taken against a contracting provider for conduct or practice raising competency concerns or posing significant risk to member safety; suspended providers will be offered appeal rights.
Appeal panel composition and timelines: First-level appeal panels consist of at least three qualified individuals including at least one participating provider who is a clinical peer; BCBSKS has 60 days from receipt of a first-level appeal request to convene the panel; second-level appeals follow similar composition rules and BCBSKS has 60 days to convene a second-level panel; the second-level decision is binding subject to binding arbitration provisions.
Reporting of upheld denials/cancellations: For every provider whose denial or cancellation of credentialing status is upheld, credentialing staff will report the decision to the provider's regulatory board and the National Practitioner Data Bank.
Coding and Program Identification
Disease Management identificationICD-10
| No codes listed |
Program enrollment identification — Members identified by diagnosis codes on claims or self/referral
Identification methodMembers identified for Disease Management programs by diagnosis codes on claims, by invitation (letter or telephone), by self-enrollment, or by provider referral.
Voluntary participationParticipation in Disease Management and Wellness programs is voluntary and members may discontinue at any time.
No effect on benefitsParticipation in the programs will not affect any health insurance benefits.
Program outreachMembers are invited to participate by letter or telephone after identification via claims codes.
Referral optionProviders may refer members for participation in Disease Management or Wellness programs.
Provider Responsibilities and Appeal Procedures
Documentation Required
Respond to information requests; appeal rights and limits for credentialing denials
Providers must respond to BCBSKS requests for records and additional information during quality-of-care reviews; failure to respond may result in further actions up to termination of the provider's participation agreement and removal of Quality-Based Reimbursement Program (QBRP) incentives. Providers who receive a denial or restriction from the Credentialing Committee may submit additional supporting documentation for reconsideration and, if the denial or restriction is upheld, may submit a written request for a first-level appeal within 30 days of the date BCBSKS sends notice. Certain credentialing denials (for example: license not at full clinical scope, adverse DEA action, inability to document required post-graduate training, or current CMS/Federal program sanctions) are not eligible for reconsideration or appeal.
- Respond promptly to BCBSKS requests for records/information during quality-of-care reviews to avoid actions up to contract termination and loss of QBRP incentives.
- If denied or restricted by the Credentialing Committee, submit additional documentation for reconsideration; if upheld, submit a written first-level appeal within 30 days of notice.
- Reconsideration/appeal is not available when denial is due to license not at full clinical scope, adverse DEA registration action, lack of documentation of ≥3 years post‑graduate training or equivalent, or current CMS/Federal sanctions.
Key Definitions
Quality-of-care concern — definition
DefinitionA reported concern that health services rendered may not have been professionally indicated or may not have met the applicable standard of care.
Initial handlingPotential quality-of-care concerns, including adverse events, are referred to the Nurse Coordinator of Quality Improvement for review and peer review officer processing.
Provider responseRecords will be requested and providers are encouraged to provide additional information; failure to respond may lead to actions up to termination and loss of QBRP incentives.
Disease Management/Wellness — telephone-based, voluntary programs
Program modelTelephone-based Disease Management and Wellness programs with registered nurse coaching and educational tools.
Sample disease programsMay include diabetes, coronary artery disease, asthma, COPD, congestive heart failure, hypertension, and hyperlipidemia.
Sample wellness programsMay include maternity, weight loss, tobacco cessation, and stress management.
Accreditation and complianceDisease Management Program is URAC accredited; both Disease Management and Wellness programs are HIPAA compliant.
Member supportPrograms provide one-on-one support, coaching, and tools to assist members with self-management skills.
HIPAA PHI disclosure for operations — HIPAA-permitted disclosures for health plan operations
Permitted operational usesPHI may be disclosed to health plans for quality assurance/improvement, accreditation (HEDIS), case management, disease management, credentialing, training, licensing, protocol development, certification, and related health plan performance evaluation activities.
Authorization not requiredProviders may disclose PHI to health plans for these operations without patient authorization when both have or had a relationship with the patient and the information relates to that relationship.
Examples listedSpecifically includes retrospective review, office record reviews, HEDIS data collection, and care coordination functions.
ScopeDisclosure allowed under the HIPAA Privacy Rule for health plan operations tied to quality and credentialing activities.
Policy Summary
Payerblue cross blue shield - kansas
PolicyQuality of Care and Credentialing Policies
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders must respond to requests for records and information during quality-of-care reviews to avoid potential actions up to termination and loss of QBRP incentives.
SourceLink
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