CurrentBlue Cross Blue Shield - KansasPolicy N/A

Quality of Care — Policies and Procedures

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Governs BCBSKS processes for reviewing reported quality-of-care concerns, member satisfaction surveying, disease management/wellness programs, HIPAA/HIE data handling, quality reporting, and provider credentialing and appeals; affects BCBSKS members, contracting providers, and internal staff.

Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyQuality of Care — Policies and Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must respond to requests for records and additional information during quality-of-care reviews to avoid potential termination or loss of QBRP incentives.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

36maximum recredentialing interval

60appeal panel timing (days)

URACDM Program accreditation

monthlyprovider monitoring

30appeal request window (days)

Coverage and Operational Criteria

Quality-of-Care Review Criteria

Process and potential actions when a quality-of-care concern is reported:

Reported quality-of-care concerns will be reviewed to determine if services were professionally indicated and in compliance with applicable standard of care.

Records will be requested and reviewed by clinical staff and peer reviewers; providers are encouraged to provide additional information and clarification when appropriate.

If contracting provider fails to respond to requests for information, BCBSKS may take actions up to termination of provider participation and removal of Quality-Based Reimbursement Program (QBRP) incentives.

Cases that are questionable or potentially substandard will be referred to a contracted external quality improvement and peer review organization for final determination.

If care is determined not to be within the acceptable standard, BCBSKS will communicate findings in writing to the provider and request a response; such a finding will trigger an action plan.

Action plans will consider the standard of care, likelihood that deviation contributed to harm, and extent of injury; plans may include tracking, corrective action, disciplinary action, and reporting to external oversight entities.

BCBSKS will notify the provider of the determination for all quality-of-care concern reviews.

Disease Management/Wellness Criteria

Enrollment and operation of Disease Management/Wellness programs:

Programs are telephone-based, voluntary, and designed to help members improve quality of life, understand health risks, close gaps in care, and make informed decisions.

Members may be identified for participation by diagnosis codes on claims and will be invited by letter or telephone; members may self-enroll or be referred by providers; participation is voluntary and does not affect insurance benefits.

Registered nurses provide one-on-one support, coaching, and educational tools to assist member self-management and preventive care.

The Disease Management Program is URAC accredited; both Disease Management and Wellness programs are HIPAA compliant.

PHI Handling and HIE

Use and exchange of protected health information:

Under the HIPAA Privacy Rule, providers may disclose PHI to health plans for quality assurance, accreditation, case management, disease management, credentialing, and related health care operations without patient authorization when the provider and plan have a relationship with the patient and the information relates to that relationship.

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.

Credentialing and Appeals Criteria

Credentialing, monitoring, and appeals process for providers:

Applicants must apply and be granted credentialing status through the BCBSKS credentialing process; applicants who do not meet all applicable Program criteria will not be considered and are not eligible for reconsideration/appeal.

Providers currently credentialed must undergo recredentialing at least every 36 months; BCBSKS monitors network providers at least monthly for derogatory information and reports findings to the Committee as needed.

If the Committee denies or restricts participation, the provider may submit additional documentation for reconsideration; if upheld, the provider may request a first-level appeal in writing within 30 days of notice.

First- and second-level appeal panels will be convened within 60 days of receipt of the respective appeal request; panels consist of at least three qualified individuals and must include a contracting provider who is a clinical peer not otherwise involved in network management.

Reconsideration and appeal are not available when denial/cancellation is due to lack of full clinical license scope, adverse DEA action, inability to document required postgraduate training, or sanctions/exclusions from CMS or federal programs.

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.

Code Lists and Identification

Actions Required of Providers

Documentation Required

Respond to Quality-of-Care Review Requests

Providers must respond to BCBSKS requests for clinical records and additional information during quality-of-care reviews; failure to respond may lead to further actions up to termination of the provider's participation agreement for cause and removal of Quality-Based Reimbursement Program (QBRP) incentives.

Records will be requested and reviewed by clinical staff and peer reviewers.
Failure to respond constitutes grounds for further actions, up to termination of participation.
QBRP incentives may be removed if a provider does not respond to requests for information.

Documentation Required

Submit Clinical Data / PHI for Permitted Health Plan Operations

BCBSKS may require electronic submission of clinical information to support care, quality activities, and health information exchange; providers may disclose PHI to the plan for permitted health care operations without patient authorization when the provider and plan have or had a relationship with the patient.

Electronic submission may be required when BCBSKS requests clinical information.
Permitted disclosures under HIPAA include quality assurance, accreditation, case management, disease management, credentialing, and related operations without patient authorization when a provider–plan relationship exists.

Key Definitions

inv-08: Quality-of-Care Concern — definition of a quality-of-care concern

DefinitionAny report alleging health services were not professionally indicated or not in compliance with the applicable standard of care; may be reported by members, family/representatives, providers or their staff, BCBSKS staff, or business partners.

Initial review and referralPotential quality-of-care concerns, including adverse events, are referred to the Nurse Coordinator of Quality Improvement (designated peer review officer) and reviewed by clinical staff and peer reviewers.

Provider cooperation requirementProviders are encouraged to provide records and additional information; failure to respond to BCBSKS requests may result in actions up to termination of the provider's participation agreement and removal of Quality-Based Reimbursement Program (QBRP) incentives.

External reviewCases judged questionable or potentially substandard are referred to a contracted external quality improvement and peer review organization for final determination.

Outcome and action planningIf care is found not within the standard, BCBSKS communicates findings in writing, requests a response, and triggers an action plan considering standard of care, likelihood and extent of harm; plans may include tracking, corrective actions, disciplinary action, or reporting to oversight entities.

inv-09: Disease Management/Wellness Programs — definition and examples of programs

DefinitionTelephone-based, voluntary programs (Disease Management and Wellness) that help members improve quality of life and overall health through understanding risks, lifestyle choices, preventive care, and communication with the health care team.

Program examplesDisease Management programs may include diabetes, coronary artery disease, asthma, COPD, congestive heart failure, hypertension, and hyperlipidemia; Wellness programs may include maternity, weight loss, tobacco cessation, and stress management.

Services providedRegistered nurses provide one-on-one support, coaching, and educational tools to assist members with self-management skills and preventive care.

Identification and enrollmentMembers are identified by diagnosis codes on claims and invited by letter or telephone; members may self-enroll or be referred by providers; participation is voluntary and may be discontinued at any time and does not affect benefits.

Accreditation and privacyThe Disease Management Program is URAC accredited and both Disease Management and Wellness programs are HIPAA compliant.

Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyQuality of Care — Policies and Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must respond to requests for records and additional information during quality-of-care reviews to avoid potential termination or loss of QBRP incentives.

SourceLink

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Quality of Care — Policies and Procedures

Customize your policy alerts

Sign up for all blue cross blue shield - kansas policy alerts

Know when blue cross blue shield - kansas releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage and Operational Criteria

Quality-of-Care Review Criteria

Process and potential actions when a quality-of-care concern is reported:

Reported quality-of-care concerns will be reviewed to determine if services were professionally indicated and in compliance with applicable standard of care.

Records will be requested and reviewed by clinical staff and peer reviewers; providers are encouraged to provide additional information and clarification when appropriate.

Cases that are questionable or potentially substandard will be referred to a contracted external quality improvement and peer review organization for final determination.

If care is determined not to be within the acceptable standard, BCBSKS will communicate findings in writing to the provider and request a response; such a finding will trigger an action plan.

BCBSKS will notify the provider of the determination for all quality-of-care concern reviews.

Disease Management/Wellness Criteria

Enrollment and operation of Disease Management/Wellness programs:

Programs are telephone-based, voluntary, and designed to help members improve quality of life, understand health risks, close gaps in care, and make informed decisions.

Registered nurses provide one-on-one support, coaching, and educational tools to assist member self-management and preventive care.

The Disease Management Program is URAC accredited; both Disease Management and Wellness programs are HIPAA compliant.

PHI Handling and HIE

Use and exchange of protected health information:

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.

Credentialing and Appeals Criteria

Credentialing, monitoring, and appeals process for providers:

Actions Required of Providers

Documentation Required

Respond to Quality-of-Care Review Requests

Records will be requested and reviewed by clinical staff and peer reviewers.
Failure to respond constitutes grounds for further actions, up to termination of participation.
QBRP incentives may be removed if a provider does not respond to requests for information.

Documentation Required

Submit Clinical Data / PHI for Permitted Health Plan Operations

Electronic submission may be required when BCBSKS requests clinical information.
Permitted disclosures under HIPAA include quality assurance, accreditation, case management, disease management, credentialing, and related operations without patient authorization when a provider–plan relationship exists.

Key Definitions

inv-08: Quality-of-Care Concern — definition of a quality-of-care concern

External reviewCases judged questionable or potentially substandard are referred to a contracted external quality improvement and peer review organization for final determination.

inv-09: Disease Management/Wellness Programs — definition and examples of programs

Services providedRegistered nurses provide one-on-one support, coaching, and educational tools to assist members with self-management skills and preventive care.

Accreditation and privacyThe Disease Management Program is URAC accredited and both Disease Management and Wellness programs are HIPAA compliant.