Quality of Care, Member Surveys, Disease Management, HIPAA, HIE, Reporting, and Credentialing
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Monitor payer policy activity
Governs BCBSKS policies and procedures for quality improvement activities, member satisfaction surveying, disease management and wellness programs, HIPAA-authorized uses of PHI, health information exchange, quality reporting, and provider credentialing processes for participating providers.
No material clinical or coverage changes in this revision.
Coverage Criteria and Operational Policies
inv-01: Quality Review and Remediation
Quality-of-care review and response actions
inv-02: Disease Management / Wellness
Disease Management and Wellness program participation and operation
inv-03: HIPAA-authorized Disclosures
Permitted uses of protected health information (PHI)
inv-04: Credentialing, Monitoring, Suspension, and Appeals
Credentialing and appeals process
Suspension and limitations
- BCBSKS may suspend a contracting provider if conduct or practice raises competency concerns or poses significant risk to member safety; suspended providers are offered appeal rights.
- Reconsideration/appeal is not available when denial or cancellation is for reasons such as license not at full clinical scope, adverse DEA action, inability to document required training/experience, or sanctions/exclusion from federal/state programs.
Appeal process
- If denied or restricted, a provider may submit additional documentation for reconsideration; if upheld, the provider may submit a written request for a first-level appeal within 30 days of notice.
- First-level appeal: panel of at least three qualified individuals including at least one clinical peer; BCBSKS will have 60 days from receipt of the first-level appeal request to convene the panel.
- Second-level appeal: if first-level upholds denial, provider may request a second-level three-member panel distinct from the first-level; BCBSKS has 60 days to convene the second-level panel; the second-level decision is binding on both parties subject to prior arbitration provisions; upheld denials/cancellations are reported to the provider's regulatory board and the National Practitioner Data Bank.
inv-05: Quality Reporting
Quality reporting and transparency
Coding, Identification, and Program Enrollment
| No codes listed |
Provider Obligations and Submission Requirements
Respond to quality-of-care information requests or face termination and loss of QBRP incentives
BCBSKS may request medical records and additional information during a quality-of-care review; contracting providers must respond. Failure to respond to BCBSKS requests for additional information during a quality-of-care review constitutes grounds for further actions, up to and including termination of the provider's participation agreement and removal of Quality-Based Reimbursement Program incentives.
- Providers are encouraged to provide additional information and clarification when appropriate.
- Nonresponse may lead to termination for cause of the provider participation agreement.
- QBRP incentives may be removed if a provider does not respond to requests for additional information.
Be prepared to submit clinical information electronically for HIE requests
BCBSKS may require electronic submission of clinical information to support Health Information Exchange efforts; providers should be prepared to submit records electronically when requested.
- Electronic submissions must be HIPAA-compliant as part of BCBSKS's HIE support.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.