Following NCQA Guidelines

Dr. Jeff Beardmore, AHP Chief Medical Officer

This issue of News and Notes contains important information detailing specifics of various interactions Arnett Health Plans has with your office and your patients. It is our hope that the articles in this edition of News and Notes help to improve your understanding of how and why Arnett Health Plans reviews offices and medical records, what member rights, responsibilities, and appeals processes are, and also serve to provide insight into several guidelines and standards as set forth by the NCQA (National Committee for Quality Assessment). NCQA provides accreditation for health plans through a series of rigorous and comprehensive evaluation processes assessing the quality of the key systems and processes of a particular health plan in comparison to health plans nationally. A part of their accreditation process is that each health plan communicates annually with its providers regarding the above mentioned topics. We hope that you will take a moment to review this important and educational information.

Arnett HMO Members Can NOW Access Imaging Center

Arnett Imaging Center is a comprehensive radiology testing facility prepared to meet all of your Imaging needs.

Our highly skilled staff of Diagnostic Radiologists, Interventional Radiologists, and Registered Radiology Technologists is dedicated to providing the highest quality imaging procedures. Our Radiologists interpret tests in a timely manner and ensure those results are forwarded appropriately.

Tests are performed in a pleasant, non-hospital outpatient setting. We offer convenient parking, along with an easy check-in/out process.

IMAGING SERVICES

Mammography
When cancer is too small to be discovered by breast exam, a mammogram is the best tool available to find a tumor. Women age 40 and older should have a screening mammogram every year.

The Image Center offers the area’s only full-field digital mammography technology, which assists in the early detection of breast cancer by incorporating modern electronics and computers into x-ray mammography methods. Digital mammography allows the Radiologist to manipulate the images on a computer screen, which improves detection and reduces the need for screening callbacks. 
Conventional Mammography, which uses x-ray film for diagnostic and screening, plays an important role, along with breast ultrasound, in solving problems for patients with abnormal screening mammograms and those who present with symptoms. Breast MRI is also available to evaluate selected breast problems or high-risk individuals.

Vein Clinic
Our Physicians treat varicose veins that cause you pain. Our Interventional Radiologists use minimally-invasive techniques to treat the root cause of varicose veins. These treatments offer significant, long-lasting relief of symptoms with a very low rate of recurrence. These relatively painless procedures allows patients to resume normal activity that same day. 

Additional services include: Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Ultrasound, Interventional Radiology, Nuclear Medicine, and PET Scanning Services. 

Our office staff can help schedule an appointment or answer any questions about insurance. Appointments are available 7:30 am – 6:00 pm, Monday through Friday. Call (765) 446-4350 to schedule an appointment.

Arnett Imaging Center
2403 Loy Drive
Lafayette, IN 47909

Practitioner and Provider Availability Standards

Arnett Health Plans is committed to providing quality care in the communities we serve. In doing so, we have established guidelines for our Practitioner and Provider availability standards:

From a member’s primary place of residence, there should be a choice of the following:

• Five primary care physicians within a five mile radius or
• Five primary care physicians within a 15 mile radius
• Five Behavioral Health Care Specialists within a 45 mile radius
• Five High-Volume Specialists within a 45 mile radius
• Three Inpatient Hospital Facilities within a 45 mile radius
• Five pharmacies within a three mile radius or
• Five pharmacies within a 30 mile radius

If it is found that the standards above have not been met, Arnett Health Plans will determine the number of available Practitioners, Providers, and Vendors in that given geographical area. If possible, recruitment of additional Practitioners, Providers, and Vendors in the network will be made. If there are no additional Practitioners, Providers, and Vendors available, the above standards will continue to be monitored. Solutions will be originated to assure that members receive needed medical care.

Appeal and Grievance Process

1. Upon denial of a claim or authorization, a Member may submit an oral or written request for reconsideration (Appeal).
   • All written complaints or reconsideration requests should be addressed to: Arnett HMO, Member Services Department; P.O. Box 6108; Lafayette, IN 47903. You may also contact Arnett HMO directly at 765.448.7440 or 888.448.7440 Monday-Thursday 8:00-6:00 and Friday 8:00-5:00.
     
     
   • At any point in the process, the Member may designate a representative to file the appeal by submitting written authorization to the Plan indicating the name of the representative. A health care provider may be designated to serve as the representative.
     
     
   • An acknowledgement letter detailing the appeal process will be forwarded to the member within three (3) business days of receipt of their appeal.
     
     
2. Upon receipt of this request, the Health Services Committee will review the appeal. The member will be informed in writing of the Health Services Committee determination.
   
   
3. If the Member disagrees with the decision made by the Health Services Committee, the member may submit an oral or written request for reconsideration (grievance hearing). The Member has the right to attend the Grievance Hearing either in person or through telephone conference. The member will be informed in writing of the date, time and location of the hearing.
   
   
4. If the member is dissatisfied with the decision made by the Grievance Committee, the member may request review by an external independent review organization certified by the State of Indiana by submitting a written request to the Member Services Department. The member will be required to pay a fee of twenty-five dollars ($25) toward the cost of the external review. However, please be advised, external review is only intended to resolve grievances regarding;
   
   
   • an adverse utilization review determination; or
   • an adverse determination of medical necessity; or
   • a determination that a proposed service is experimental or investigational.

When a request is made, the external independent review organization will review your case to decide whether one of the three qualifications might apply.

Credentialing

Credentialing and Re-Credentialing Rights:

• Practitioners have the right to review information submitted to support their credentialing or re-credentialing application.
• Practitioners have the right to correct possible erroneous information.
• Practitioners have the right, upon request, to be informed of the status of their credentialing or re-credentialing application.
• The practitioners will also be notified of these rights in the letters sent out with either the credentialing or re-credentialing application.

In order to keep your credentialing information current, please send the Credential Coordinator:

• Copies of any new certification status
• Copies of all new CME hours
• Change in office location, phone numbers
• Letter stating change in Tax ID number
• Letter stating change of employment if no longer working for a contracted office

Change in Recredentialing Policy

Arnett Health Plans has adopted the NCQA guideline of a three-year recredentialing cycle. We formally recredential all participating practitioners every three years with a performance monitoring in between these cycles. The annual performance includes but is not limited to:

• Selected Clinical Practice Guidelines adherence rates
• Selected HEDIS measures from the Effectiveness of Care domain
• Appointment Accessibility for primary care physicians, high volume specialists (orthopedics, ENT and dermatology), and behavioral health care
• Primary care physician change rates for those physicians acting as a primary care physician – dissatisfaction reasons only
• Quality monitors – track and trend category
• Summary of member complaints
• Any Medicare-Medicaid sanctions
• Any reviews conducted by the Medical Licensing Board of Indiana
• Pending litigation or malpractice actions

This information will be summarized and reported to the Credentialing Committee for approval or further action. Each practitioner will receive a letter and a copy of their annual review form following the Credentialing Committee meeting. 

Please contact the Credentialing Coordinator, at 765/448-7457 with questions regarding the credentialing or annual review process.

Clinical Practice Guidelines

Asthma

• Highlights of the Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma
• National Institutes of Health Publication No. 97-4051A
• Plan Review September 2005.

Provides guidelines and presents basic recommendations for the diagnosis and management of asthma that will help physicians and patients make appropriate decisions about asthma care. Components include measures of assessment and monitoring, control of factors contributing to asthma severity, pharmacological therapy and education for a partnership in asthma care.

Cholesterol

• National Institute of Health; National Heart, Lung, and Blood Institute 3rd Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Plan Review September 2005.

This report presents the National Cholesterol Education Program's updated recommendations for cholesterol management. Topics include the clinical management of high blood cholesterol, dietary therapy and physical activity and drug treatment.

Depression

• Institute for Clinical Systems Improvement Health Care Guideline: Major Depression, Panic Disorder and Generalized Anxiety Disorder in Adults in Primary Care. Plan Review January 2005.

Includes diagnostic criteria, differential diagnosis and treatment of Major Depressive Disorder.

Diabetes

• American Diabetes Association: 2003 Clinical Practice Recommendations. Plan Review September 2005.

Hypertension

• National Institute of Health; National Heart, Lung, and Blood Institute The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Plan Review September 2005.

This is a guideline with Arnett Health Plan's recommendations for hypertension intervention. Topics include a classification of blood pressure for adults over age 18, components of major risk factor in patients with hypertension and an algorithm for the treatment of hypertension.

Morbid Obesity

• National Institute of Health; National Heart, Lung, and Blood Institute: The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.

This guideline provides recommendations for brief clinical interventions, intensive clinical interventions and system changes to promote the treatment morbid obesity." Under Tobacco Cessation, simply change the date to say, "Plan Review July 2005".

Tobacco Use

• A Clinical Practice Guideline for Treating Tobacco Use and Dependence
• The Journal of the American Medical Association 

This guideline provides recommendations for brief clinical interventions, intensive clinical interventions and system changes to promote the treatment of tobacco dependence.
Plan Review September 2005

Attention Deficit Hyperactivity Disorder (ADHD)

• Diagnosis and Treatment of ADHD in children
• The American Academy of Pediatrics

This guidelines provides recommendations for the diagnosis and treatment of ADHD. The Plan recommends the use of Straterra as a first line of treatment with an adequate trial of 4 weeks after a 2-3 week titration.

Complaints Initiated by the Member

Arnett Health Plans is committed to investigating and evaluating all member expressions of dissatisfaction in a timely and consistent manner. A complaint may be received verbally or in writing.

Procedure:

1. All member complaints will initially be logged into the Customer Service Inquiry Module (CSIM) Aggregate complaint-call data is collected and analyzed on a quarterly basis by the Operations Committee.
   
   
2. A Plan representative will respond to the complaint during the initial contact with the member. This information is documented in CSIM or departmental log for tracking and trending purposes.
   
   
3. When a member complaint cannot be resolved during the initial contact because additional information is needed or when the member requests further investigation of the complaint, the complaint will be documented and forwarded to the appropriate department manager for review and action in accordance with departmental policies and procedures. The Member Services Manager investigates all Plan related issues that include, but are not limited to quality of service received from the Plan, Benefits, and Payment Issues. The Quality Improvement Manager investigates all complaints against practitioners and providers that include, but are not limited to service, access, and care issues.
   
   
4. The member will be sent a letter from the applicable Department Manager acknowledging receipt of the complaint within five (5) business days (See Attachment #2)

Confidentiality Statement

Arnett Health Plans is committed to protecting the privacy of our members and the confidentiality of their personal and medical information. The following is important information for you regarding Arnett Health Plans’ confidentiality policies:

• Arnett Health Plans (AHP) collects nonpublic¹ personal information about you from information we receive from you on applications or other forms. AHP also acquires information in connection with your medical matters involving us, our affiliate² or others. Arnett Health Plans does not disclose any nonpublic personal information about you or former members to anyone, except as authorized by law.
  
  
• Arnett Health Plans restricts access to nonpublic personal information about you to those employees who need to know that information in order to provide services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.
  
  
• All of our employees, as well as the health care practitioners who serve on our medical review committees, sign a confidentiality statement annually. This statement ensures that the Representatives of Arnett Health Plans will respect your privacy and protect the confidentiality of our members in all situations.
  
  
• Upon enrollment every subscriber signs an Enrollment Form allowing Arnett Health Plans access to medical information necessary to perform routine administrative functions. Should there be a special circumstance where somebody is requesting your medical information from us beyond the normal needs for treatment, payment of benefits or health plan operations, your agreement would be necessary, thereby requiring your specific written permission.
  
  
• All of our members are entitled access to their medical records. If you wish to obtain or view a copy of your medical record, contact your practitioner’s office. Each office has a policy regarding the release of medical records.
  
  
• Arnett Health Plans conducts Quality Improvement studies throughout the year. Often, the data used for these studies is randomly selected from our computer records. However, if you have a chronic illness, we may select you to receive specific information or participate in a care management program. All of these programs are conducted to ensure that our members are receiving the care necessary to keep them healthy.
  
  
• Arnett Health Plans does not share any of your personal medical information with your employer. If for some unusual reason, it becomes appropriate to share your information with your employer, your agreement would be necessary, thereby requiring your specific written permission.

Emergency Language
An emergency is any situation in which a member, as a prudent layperson, feels sudden or immediate danger to life or limb. Medical emergencies are acute conditions that, in the sole judgment of the Plan, meet all of the following criteria:

(a) The condition must be a medical emergency requiring necessary medical services for accidental injury or emergency illness.

(b) Severe symptoms must occur suddenly and unexpectedly. The symptoms must be sufficiently severe to cause a person to seek immediate medical assistance regardless of the hour of the day or night. A chronic condition in which symptoms have existed over a period of time does not qualify for medical emergency consideration.

(c) Immediate care must be secured. A medical emergency will not be considered to exist if medical care is not secured within twenty-four (24) hours of onset. A telephone call to a doctor does not fulfill this requirement if examination and treatment by the practitioner is deferred until the next day. As a general rule, the date of the onset of symptoms and the date of treatment as reported on documentation received from the provider of medical services should be within twenty-four (24) hours.

(d) The illness or condition as finally diagnosed or as indicated by its symptoms was one that would require immediate medical care.

Member Rights and Responsibilities

Member Rights

• Members have the right to receive high quality health care in a manner that shows respect for their privacy and dignity.
• Members have the right to participate with practitioners in any diagnosis, prognosis, and continued course of treatment, in a manner that can be understood.
• Members have the right to be asked to give their informed consent prior to medical treatment, except in the case of a life-threatening emergency.
• Members have the right to know the name, professional status, and function of all health care professionals who provide health care services to them.
• Members have the right to have all medical records and other information pertaining to their medical care treated confidentially, unless release of such information is required by law.
• Members have the right to be informed of the policies and procedures that apply to their conduct as a member of Arnett Health Plans.
• Members have the right to access literature and materials that provide accurate information about Arnett Health Plans and are written in a manner that can be understood.
• Members have the right to report a concern or complaint about the staff or operations of Arnett Health Plans, or the care provided, and to receive timely responses to those concerns or complaints.
• The right to make recommendations regarding the organizations members’ rights and responsibilities.

Member Responsibilities

• Members are responsible for understanding the benefits and exclusions that are described in their Member Certificate and Agreement.
• Members are responsible for paying any co-payments or deductibles required by this plan at the time service is rendered or goods are received.
• Members are responsible for establishing a relationship with an Arnett Health Plans primary care practitioner and for seeking care only from him or her, except in a life-threatening emergency or upon approved referral to a specialist.
• Members are responsible for seeking information from their primary care practitioner concerning any diagnosis, prognosis, and continued course of treatment.
• Members are responsible to follow the plans and instructions for care that has been agreed upon by the member and their practitioners.
• Members are responsible for assisting their primary care practitioner in assembling their medical records by authorizing him or her to obtain medical information from other practitioners.
• Members are responsible for keeping their practitioners informed concerning the status of their health and any changes that could influence the course of their treatment.
• Members are responsible for considering all potential consequences of refusing to comply with their practitioners’ recommendations.
• Members are responsible for understanding their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
• Members are responsible for constructively expressing any concern, complaint, or suggestion they may have concerning the staff or operations of Arnett Health Plans.
• Members are responsible for treating Arnett Health Plans staff members and providers considerately and for respecting the rights of other members.

Medical Record Reviews

Medical record reviews are conducted as part of the recredentialing process for primary care physicians at a minimum of every three years

(1) Each criterion has an equal weight. Some of the criteria include:

• Significant illnesses and medical conditions are indicated on the problem list.
• All entries in the medical record contain author identification.
• Medication allergies and adverse reactions are prominently noted in the record. 
• The history and physical record for new patients is easily identified and includes serious accidents, operations, and illnesses. For children and adolescents, PMH relates to prenatal care, birth, operations, and childhood illnesses.

(2) Re-review dates will be based on cumulative points:

(3) Should a Primary Care Physician’s points exceed 30 points for two (2) consecutive medical record reviews, the Credentials Committee will determine whether disciplinary actions should be taken.

For more information about the medical record review process, please contact the Credentials Coordinator at 765.448.7457.

Office Site Reviews

As part of our on-going Quality Improvement process, AHP conducts office site reviews. These reviews focus on the provider’s facility and procedures and are conducted on the following providers:

• Primary Care Practitioners
• High-Volume Specialists
• OB/GYN Physicians
• Behavioral Health Specialists

The office site review will be conducted as part of the initial and recredentialing process and if a provider relocates their office to a new site. Office site reviews also may occur:

• Between recredentialing reviews if corrective action has taken place or
• If recommended by the Credentials Committee or
• If a deficiency is noted by an AHP Health Services employee during a non-review related visit to a provider office

Providers are expected to meet all standards for each section. If a provider scores below the standard on any section, a recheck of the office will be completed within 90 days of the original office site review. At this time the office site will need to be in compliance with all standards or a corrective action/improvement plan will be requested.

The results of the office site review are forwarded to the provider within one week of the review, and includes:

• Results of the review and the corresponding standards,
• Areas for improvement will be highlighted; and
• Appropriate, the request of a corrective action/improvement plan.

To view a copy of the office site review standards, please contact the Credentials Coordinator at 765.448.7457.

Practitioner/Provider Appeal Process

Practitioners may appeal any medical necessity determination made by the Plan with which they disagree. A determination will be made within five (5) business days after receipt of all necessary information except in emergent situations (see # 7 below).

• A practitioner must notify the Health Services Department either in writing or by telephone when they wish to appeal a Plan decision. An appeal will only be considered if the practitioner has additional clinical information to support the medical necessity of the requested service. Otherwise the member will have to designate the practitioner to be his or her authorized representative in an appeal process. A written consent must be obtained. 
• Group benefits and member eligibility may not be appealed by the practitioner.

Procedure:

1. Denial determinations made at the Claim level or benefit determinations made at the Health Services department level may be reviewed as outlined in Plan policy.
   
   
2. The Plan Chief Medical Officer will complete a review of all medical appropriateness appeals and make a decision within five (5) business days of receipt in the department. The Assistant Behavioral Healthcare Medical Director will be consulted on all behavioral healthcare related reviews that cannot be approved by the Plan Medical Director.
   
   
3. The Chief Medical Officer will seek an opinion from a Physician Consultant of a like specialty and/or other third party regarding the appeal under reconsideration. The Plan will incur the expense of any additional physician reviews.
   
   
4. The appealing physician and member will be notified in writing and / or telephone if the original decision is reversed.
   
   
5. If the denial under reconsideration is upheld, and the appealing physician continues to disagree, he /she may request the appeal be reviewed by the Utilization Management Committee for a final determination.
   
   
6. Any request determined to be emergent by the appealing physician will be handled as such. This will be done as expeditiously as the medical condition requires, including emergency meetings of relevant individuals/physicians as necessary, not to exceed forty-eight (48) hours.

UM Resources – Concurrent Review Nurses

Arnett Health Plans is available to assist in the stay and recovery of our members admitted into the hospital. We are pleased to offer Concurrent Review (CR) Nurses who are available throughout the member’s hospital stay. These nurses assist in gathering information concerning member benefits as well as contacting DME providers and rehabilitation and extended care facilities. Please utilize the CR nurses as an extension of the services you provide as well as a resource to help determine possible treatment regimens. It is in the best interest of our members to ensure their benefits are being administered properly. 

Example: If it is determined that a patient can be transferred safely to an extended care facility or to home with the assistance of Home Health, opposed to remaining in the hospital, our CR nurse would contact you after exploring the Member’s benefits. Upon your approval/order to transition care to the less intense setting, the CR nurse would be able to assist in the transfer of care. Both you and the member benefit from the services of a CR nurse.

CR nurses are a great resource for setting up alternative treatment options.

Example: A patient presents in your office with dehydration. You would like for this patient to receive IV fluids. In most cases, this patient would be sent to the ER for treatment. AHP would like for you to consider utilizing our CR nurse services prior to sending the patient to the ER. If you determine it to be medically safe, please contact AHP and speak with a CR nurse. The CR nurse will be able to assist you in setting up IV fluid treatments from a Home Health provider. The patient will be able to return home with the assistance of Home Health. A Home Health nurse can start an IV, administer IV fluids as well as monitor the progress of the patient and report back to your office. All this can be done from the comfort of the patient’s home.

If you wish to speak with a CR nurse, or would like more information, please contact 448.7430 and your call will be triaged to a CR nurse.

Arnett Health Plans is committed to providing quality care in the communities we serve. Both you and our members benefit from utilizing a CR nurse.