CurrentBlue Cross Blue Shield - North DakotaPolicy N/A

Corrective Action Policy for Health Care Providers

Governs how Blue Cross Blue Shield of North Dakota identifies, investigates, and enforces corrective actions for participating and non-participating health care providers whose practices do not meet BCBSND performance standards; affects providers and provider groups contracting with BCBSND.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyCorrective Action Policy for Health Care Providers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 24, 2005

Next Review DateN/A

Key ActionProviders must obtain prior authorization of services per Utilization Management Program policies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsstandard review period for corrective action plans

12 monthsmaximum duration for a corrective action plan

10 business daysnotification timeframe to provider

60 daysminimum notice before committee meeting

18 monthsmember notification lookback

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Coverage and Participation Criteria

Coverage-related performance criteria

Performance standards and circumstances that may trigger corrective action.

Provide or order medically necessary and appropriate services for members.

Comply with accepted professional standards of care, conduct, competence, practices, and reputation.

Comply with BCBSND Medical Policy and coding and billing standards; where BCBSND has no specific policy, follow nationally accepted billing and coding standards.

Engage in accepted practice patterns that are not aberrant, excessive, or inappropriate.

Participating providers and provider groups must cooperate in good faith with BCBSND Quality Management and Fraud, Waste, and Abuse program activities, including responding to inquiries and providing requested information and documents.

Obtain prior authorization of services in accordance with applicable Utilization Management Program policies and procedures.

Noncompliance may lead to

Investigation and initiation of corrective action plans.
Conversion of status to non-participating or non-payable and notification to appropriate boards or agencies as required.

This policy does not apply to non-acceptance for failure to meet pre-credentialing standards, disputes under the appeals process, or corrective action plans initiated by the North Dakota Department of Health and Human Services for Medicaid expansion.

Participation status and immediate action criteria

Rules and procedures governing status changes and immediate actions for Health Care Providers or Provider Groups under corrective action.

Providers will receive at least 60 calendar days written notice of a designated committee meeting to consider a status change; the notice will describe reasons, reference evidence, state the meeting date or advise it will be sent later, explain rights to be present and represented by counsel, allow submission of additional materials with a deadline and process, note that an advisory clinical peer will attend, prohibit audio/visual recording, and state timing for written notification of the panel's decision.

If a provider's status is changed to non-participating, BCBSND will notify members who have been under the provider's care within the past 18 months, issue an Inter-Plan Network Alert as required by BlueCard, and file a report with the National Practitioner Data Bank (NPDB); the designated committee must notify the provider in writing within 60 calendar days of the meeting.

If a provider's status is changed to non-payable, BCBSND will notify affected members within 45 days, report to the North Dakota Insurance Department, issue an Inter-Plan Network Alert, notify FEP as applicable, and file a report with the NPDB; the Board's written determination is final and not subject to internal appeal.

Immediate action (temporary suspension) may be imposed when any of the following apply:

Billing and Coding Compliance

Billing and coding compliancemixedCovered

Providers must comply with BCBSND Medical Policy and coding and billing standards; nationally accepted billing and coding standards apply when BCBSND has no specific policy.

Required Provider Actions and Administrative Controls

Prior Authorization

Prior Authorization Required

Providers must obtain prior authorization of services in accordance with applicable Utilization Management Program policies and procedures. Prior authorization requirements apply to specified treatments or services as determined by BCBSND and must be secured before providing the service to avoid claim denials or non‑payment.

Obtain prior authorization per BCBSND Utilization Management Program.
Failure to secure prior authorization may result in denied or non‑payable claims.

Billing Rule

Administrative Practice Controls — Mandatory Compliance

BCBSND may impose administrative practice controls as part of immediate actions or Reinstatement Plans. These controls are mandatory and may include claim submission requirements, mandatory prior authorizations for specified treatments or services, restrictions on accepting new patients, continuing education, mandatory audits, and other remedial actions. Providers must comply with any specified timelines, documentation requests, monitoring activities, and reporting requirements outlined by the Quality Management Committee or Fraud, Waste, and Abuse Committee.

Definitions and Key Terms

Corrective Action Plan — definition and summary

DefinitionA formally defined disciplinary process intended to direct a Health Care Provider back into compliance with performance standards; during the CAP, practice restrictions can be imposed and payment for care may be denied, restricted, or reduced for all or certain services.

Typical componentsMay include practice restrictions, denial/restriction/reduction of payment for specified services, monitoring activities, and required remediation steps.

DurationCAPs are implemented for a specified period of time (standard monitoring and review periods described elsewhere in the policy).

Fraud, Abuse, Waste — definitions

FraudAn intentional act of deception, misrepresentation, or concealment of material fact or information in order to gain something of value.

Abuse

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyCorrective Action Policy for Health Care Providers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 24, 2005

Next Review DateN/A

Key ActionProviders must obtain prior authorization of services per Utilization Management Program policies.

SourceLink

On This Page

The state licensing/registration/certification agency suspends or restricts the provider's license, registration, or certification.

There is reason to believe the provider knowingly, intentionally, or with reckless disregard violated BCBSND rules and regulations.

There is reason to believe the provider's actions may result in imminent danger to a member's health or welfare.

There is reason to believe the provider's actions will impair BCBSND's reputation or operations.

Temporary suspensions shall be confirmed or resolved by investigation completed within ten (10) business days; the investigating committee will notify the provider of results and present findings to the designated committee for final determination, which may lift the suspension or designate non-participating/non-payable status.

Possible immediate-action outcomes include

Deny the request for immediate action (no temporary requirements).
Implement a Corrective Action Plan (CAP) for a period not to exceed six (6) months; CAP implementation under Section 7 provides no opportunity for appeal.
Recommend changing the provider's status to non-participating in accordance with the participation status process without opportunity for appeal.
Recommend changing the provider's status to non-payable in accordance with the non-payable process without opportunity for appeal.

Providers moved to non-participating may reapply after at least eighteen (18) months; providers moved to non-payable may seek review after at least thirty-six (36) months. Reapplication requires meeting credentialing requirements and submitting evidence of remediation.

Upon successful credentialing after reapplication, participation may be granted subject to a Reinstatement Plan that describes required activities and timelines (which may include counseling, mandatory prior authorizations, claim submission requirements, continuing education, audits, and other actions), monitoring activities, possible costs to the provider, and a review period of no less than six (6) months.

Records and reports of committee activities and investigations are privileged and confidential to the fullest extent permitted by law; the policy is subject to review by internal and Board committees.

Mandatory prior authorizations for specified treatments or services.
Claim submission requirements.
Continuing education and counseling on corrective actions.
Closure of practice to new members or other practice restrictions.
Regular audits and monitoring activities as specified in a Reinstatement Plan.
Providers will receive written notice of required actions, timelines, and the monitoring process.

Excessive or improper use of health care services or actions inconsistent with acceptable business and/or medical practice resulting in unnecessary costs; incidents not considered fraudulent but may cause financial losses.

WasteMismanagement, overutilization, under- or ineffective use of treatments or medication, inadequate oversight, or other practices that result in unnecessary costs that can be eliminated without reducing quality of care.

Health Care Provider — definition of provider types covered by the policy

Covered provider typesMeans an optometrist; a physician; a chiropractor; or an advanced practitioner duly licensed to practice in this state.

Provider GroupA legal entity that has entered into a participation agreement with BCBSND.

Participation relevanceDefinitions apply to determining participation, non-participating, and non-payable status under the policy.

Temporary suspension — making provider non-participating/non-payable pending investigation

Authority to suspendThe Quality Management Committee and Fraud, Waste, and Abuse Committee reserve the right to place a Health Care Provider or Provider Group under temporary suspension, immediately making them non-participating, non-payable, or ineligible.

Triggering circumstancesIncludes state licensing suspension/restriction, belief of knowing/intentional/reckless violation of BCBSND rules, imminent danger to member health or welfare, or actions that impair BCBSND's reputation or operations.

Notification and processThe Committee shall notify the provider in writing of the temporary suspension; Medical Director may immediately issue the action via ad hoc meeting without quorum if needed; investigations related to suspension must be completed within 10 business days.

Confidential records — records of committees and investigations treated as privileged and confidential

Confidentiality standardRecords or information concerning activities of the Quality Committee, Quality Management Committee, Special Investigations Unit and Provider Audit, and/or the Fraud, Waste, and Abuse Committee shall be treated and maintained as privileged and confidential to the fullest extent permitted by state and federal laws.

Scope of confidentialityIncludes records, reports to committees, reports to the Board of Directors, and reports to regulatory agencies; reporting does not alter privileged/confidential status where permitted by law.

Review requirementThis policy and related committee activities are reviewed and approved annually by the internal and Board Committees referenced in the policy.