CurrentCareSourcePolicy Sentinel Events and Provider Preventable Conditions-AR PASSE-AD PASSE-AD-1154

Sentinel Events and Provider Preventable Conditions-AR PASSE-AD PASSE-AD-1154

Administrative policy governing non‑payment and reporting requirements for sentinel events, serious reportable events, and provider preventable conditions for Arkansas PASSE providers; affects CareSource-contracted providers serving Arkansas members.

Policy Summary

PayerCareSource

PolicySentinel Events and Provider Preventable Conditions (PPCs)

Policy CodePolicy Sentinel Events and Provider Preventable Conditions-AR PASSE-AD PASSE-AD-1154

Change TypeAdded language prohibiting reimbursement to same wholly owned inpatient facility; annual review noted

Effective Date01/01/2026

Next Review Date

Key ActionDo not bill, collect from, or accept payment from CareSource or the member for services associated with sentinel events, SREs, or PPCs; refund any received payments within 10 business days.

SourceLink

POLICY UPDATE CHANGES

Added 'wholly owned IPF' language.

Annual review with no changes noted on 11/29/2023.

29NQF list size

10 business daysrefund timeframe

quarterlyPPC tracking

minimum setexample lists

Nonpayment and Coverage Rules

Nonpayment and Reduction Criteria

CareSource will not reimburse for services associated with sentinel events (SEs), serious reportable events (SREs), or provider preventable conditions (PPCs). When a portion of a claim related to a Healthcare Acquired Condition (HCAC) can be reasonably identified and isolated, reimbursement may be reduced per CMS guidance.

CareSource will not reimburse for services associated with sentinel events (SEs) or serious reportable events (SREs).

Providers must not bill, collect from, or accept payment from CareSource or the member for services associated with SEs or SREs.

If the provider receives payment from CareSource or the member for services associated with an SE or SRE, the provider must refund the payment within 10 business days of becoming aware of receipt.

CareSource will not reimburse the same wholly owned inpatient facility (IPF) within a healthcare system for treatment of an SE or SRE that occurred within that system.

CareSource will not reimburse providers for Provider Preventable Conditions (PPCs), which consist of Category 1 Healthcare Acquired Conditions (HCACs) and Category 2 Other Provider Preventable Conditions (OPPCs), in accordance with CMS guidelines.

CareSource will not reimburse the same wholly owned inpatient facility (IPF) within a healthcare system for treatment of a PPC that occurred within that system.

When CareSource can reasonably identify and isolate the portion of a claim directly related to treatment of an HCAC, CareSource will reduce reimbursement of the claim by the specific amount related to the PPC; the level of reduction will follow CMS's most recently published guidelines.

Examples of reportable events/conditions (not exhaustive)

Surgical or Invasive Procedure Events: wrong body part, wrong patient, wrong procedure, intraoperative or immediately postoperative death in an ASA class I patient, unintended retention of a foreign object.
Product or Device Events: death or serious disability associated with contaminated drugs/devices/biologics provided by the facility; device use or function other than intended causing death/serious disability; intravascular air embolism in a healthcare setting.
Patient Protection Events: patient suicide, or attempted suicide resulting in serious disability while being cared for in a healthcare facility.
HCACs (including but not limited to): catheter-associated urinary tract infections (CAUTI); stage 3 or 4 pressure ulcers; surgical site infections (orthopedic, mediastinitis after CABG, bariatric surgery, CIED); air embolism; vascular catheter-associated infection; blood incompatibility; manifestations of poor glycemic control; falls and trauma (fractures, dislocations, intracranial/crushing injuries, burns); DVT/PE following certain orthopedic procedures; foreign object retained after surgery; iatrogenic pneumothorax with venous catheterization.

Providers shall cooperate, to the extent reasonable, with CareSource initiatives designed to analyze or reduce such events.

Reportable Conditions and Coding Guidance

Example reportable conditions (not exhaustive)mixedCovered

CAUTI	catheter-associated urinary tract infections (CAUTI)
Stage 3/4 pressure ulcers	stage 3 or 4 pressure ulcers
Surgical site infection - orthopedic	surgical site infections, orthopedic procedures including spine, neck, shoulder and elbow
Surgical site infection - mediastinitis	surgical site infections: mediastinitis, following coronary artery bypass graft
Surgical site infection - bariatric	surgical site infections: bariatric surgery, including laparoscopic gastric bypass, gastroenterostomy, and laparoscopic gastric restrictive surgery
Surgical site infection - CIED	surgical site infections: cardiac implantable electronic device (CIED)
Air embolism	air embolism
Vascular catheter-associated infection	vascular catheter-associated infection
Blood incompatibility	blood incompatibility
Poor glycemic control manifestations	manifestations of poor glycemic control, including diabetic ketoacidosis, nonketotic hyperosmolar and hypoglycemic coma, secondary diabetes with ketoacidosis or hyperosmolarity

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Reimbursement reduction rules - inv-03

Reimbursement reduction ruleWhen CareSource can reasonably identify and isolate the portion of the claim directly related to treatment of an HCAC, CareSource will reduce reimbursement by the specific amount related to the PPC; the level of reduction will follow CMS's most recently published guidelines.

ApplicabilityApplies to Provider Preventable Conditions consisting of Category 1 HCACs and Category 2 OPPCs as described in policy.

Isolation requirementReduction is applied only when the HCAC‑related portion of the claim can be reasonably identified and isolated.

Scope noteIncludes instances involving the same wholly owned inpatient facility for treatment of a PPC that occurred within that system.

Billing, Refunds, and Reporting Requirements

Billing Rule

Do not bill or retain payment for SEs/SREs/PPCs; refund within 10 business days

Providers must not bill, collect from, or accept payment from CareSource or the member for services associated with sentinel events, serious reportable events, or provider preventable conditions. If payment is received, it must be refunded within 10 business days of becoming aware of receipt. CareSource will also not reimburse the same wholly owned inpatient facility for treatment of an SE, SRE, or PPC that occurred within that system, and providers must cooperate with CareSource initiatives to analyze or reduce such events when reasonable.

Do not bill members or CareSource for services related to SEs/SREs/PPCs.
If payment is received, refund it within 10 business days of awareness.
CareSource will not reimburse the same wholly owned inpatient facility for treatment of an event that occurred within that system.
Cooperate with CareSource initiatives to analyze or reduce events, to the extent reasonable.

Key Definitions

Sentinel Event - inv-05

DefinitionA Sentinel Event (SE) is a patient safety event, not primarily related to the natural course of a patient's illness or underlying condition, resulting in death or severe or permanent harm, regardless of duration or severity of harm.

Related conceptsMay require review and reporting; severe harm and permanent harm are defined to clarify outcome thresholds.

Outcome examplesSevere harm includes life‑threatening injury requiring continuous physiological monitoring or surgery; Permanent harm permanently alters an individual's baseline.

Provider Preventable Condition (PPC) - inv-06

DefinitionProvider Preventable Condition (PPC) — A condition with a negative consequence for the member occurring in any healthcare setting that is reasonably preventable by the provider through application of procedures supported by evidence‑based medical guidelines.