partnership healthplan of california … 8.17... · 2016-08-12 · phc staff: you will be...

PARTNERSHIP HEALTHPLAN OF CALIFORNIA QUALITY/UTILIZATION ADVISORY COMMITTEE MEETING NOTICE

DATE: Friday August 12, 2016 FROM: Kendra Rogers, QI Administrative Assistant (Temp) SUBJECT: Quality/Utilization Advisory Committee (Q/UAC) Meeting

In preparation for the upcoming Q/UAC meeting, please carefully review the agenda topics and corresponding materials.

In addition, please be informed that due to the size of our meeting packets, PHC’s Green Committee has respectfully asked that we reduce our environmental impact, so we encourage you to use your electronic device (ex. iPad, laptop, etc.) during the meeting. However, a few hard copy packets will be available for the external Committee Members only.

PHC Staff: You will be responsible for printing your own copy, if you feel you need it.

If you are calling-in to the meeting, please dial 1 (888) 240-2560. Meeting ID: 870356221 Passcode: 0671

Date: Wednesday, August 17, 2016 Time: 7:30 - 9:00 a.m. Place: Partnership HealthPlan of California

4665 Business Center Drive, Solano/Napa Conference Room – 1st Floor Fairfield, CA 94534

3688 Avtech Parkway/ Trinity Alps Conference Room Redding, CA 96002

Physicians and Consumer Members: Jennifer Wilson, MD Robert Quon, MD Kali Stanger, MD maternity leave Rodrigo Manalo, MD Madhusudan Borde, MD Sara Choudhry, MD Michael Pirruccello, MD Steven Gwiazdowski, MD, FAAP Michael Strain, PHC Consumer Member Steven Namihas, MD Randolph Thomas, MD Thomas Paukert, MD PHC Staff Members: Debra McAllister, RN, Utilization Management Director Michael Vovakes, MD, Northern Region Medical Director James Cotter, MD, Associate Medical Director Nadine Harris, RN, MBA, Quality Compliance Manager Jessica Thacher, MPH, Quality & Performance Improvement Director

Peggy Hoover, RN, Health Services Senior Director

Mark Glickstein, MD, Associate Medical Director Robert Moore, MD, MPH, CMO - Chairman Mark Netherda, MD, Regional Medical Director Scott Endsley, MD, Associate Medical Director Mary Kerlin, Provider Relations Senior Director Heidi Lee, Credentialing Supervisor, Provider Relations Cc: Betsy Campbell, MPH, Senior Health Educator Lynn Scuri, Associate Regional Director Carly Fronefield, Director of Health Services (R) Margaret Kisliuk, MPP, JD, Executive Director Cristina Lauck, Manager, General Case Management Margarita Garcia-Hernandez, Mgr., Health Analytics Heather Brandeburg, Assoc. Dir., Provider Relations Marshall Kubota, MD, Regional Medical Director Jeff Ribordy, MD, Northern Regional Medical Director Nancy Steffen, Quality, Analysis and Project Management

Associate Director (R) Karen Stephen, PhD, HS Mental Health Director Richard Fleming, MD, Associate Medical Director Katherine Barresi, Care Coordination Manager Rosemenia Santos, Manager of Quality Assurance and Patient

Safety Kelley Sewell, Northern Region Director of MS & PR Sarah Molteni-Casper, HEDIS Analyst, HS Quality Improvement

PHC Offices: Please use the “Q/UAC Meeting” directory entry on your video conference unit. If you need assistance please contact IT a minimum of one (1) day prior to the meeting so that they can provide instructions and testing.

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I:\QUALITY\QI Assistant\QUAC\2016 Meetings\8.17.2016\QUAC Agenda\QUAC Agenda 8.17.2016.doc

PARTNERSHIP HEALTHPLAN OF CALIFORNIA QUALITY/UTILIZATION ADVISORY COMMITTEE

MEETING AGENDA

Date: August 17, 2016 Time: 7:30 – 9:00 a.m. Location: Napa/Solano Room (1st Floor)

I. Approval of Minutes Lead Time Page #

1 Quality/Utilization Advisory Committee (QUAC_6.15.2016) (attachment) Internal Quality Improvement (IQI_6.07.2016) (attachment) Robert Moore, MD 7:30 5-30

II.

1 Status of open action items (none) Robert Moore, MD/ Rachael French 7:33

2 Quality and Performance Improvement Update (attachment) Jessica Thacher 7:35 31-36

3 Health Plan Update (discussion) Robert Moore, MD 7:40

III. None.

IV.

1

Consent Calendar (attachments) All 7:45 37 Delegation Reports – Credentialing/Re-credentialing MPQP1026 OB/GYN Facility Site Review Requirements and Guidelines 38-43 MP PR-GR210 Provider Grievance 44-46 Utilization Management, no substantive changes MCUP3012 Discharge Planning (Non-capitated Members)

47-49

HKCP2015 Continuity of Care (HK Only) 50-53 HKUP3069 (formerly MPUP) Emergency Services (HK Only) 54-57 MCCP2014 Continuity of Care (HK Only) 58-62 MCUG3008 Bathroom Equipment Guidelines 63-64 MCUG3011 Criteria for Home Health Services 65-67 MCUP3003 Rehabilitation Guidelines for Acute Skilled Nursing Inpatient Services (previously - Acute Inpatient or Long Term Care Rehabilitation Institution Services)

68-72

MCUP3133 Wheelchair Mobility, Seating and Positional Components 73-83 MCUP3041-A ATTACHMENT ONLY - TAR Review Process 84-91

New Business (Committee Members as Applicable)

2 MPQG1011 Non-Physician Medical Practitioners & Medical Assistants Practice Guidelines Nadine Harris 7:50 92-106

3 MCUG3019 Hearing Aid Guidelines Debbie McAllister 7:55 107-114

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I:\QUALITY\QI Assistant\QUAC\2016 Meetings\8.17.2016\QUAC Agenda\QUAC Agenda 8.17.2016.doc

4 MCUP3014 Emergency Services Debbie McAllister 8:00 115-128

5 MCUP3122 Palliative Care Dr. Cotter/ Debbie McAllister 8:05 129-134

6 MPUP3026 Inter-Rater Reliability Policy Melissa Rosel 8:10 135-148

7 HEDIS 2016 Summary of Performance (attachment) Presentation- Pages 149-159 Performance Summary Report- Pages 160-170

Rachael French 8:15 149-170

8 Cultural & Linguistic Health Education (discussion) Susanna Sibilsky 8:25

9 Tobacco Cessation Monitoring Report (attachment) Betsy Campbell 8:30 171

10 Grievance Report w/ State Hearing (attachment) Catherine Borsetto 8:35 172-173

11 Site Review Bi-Annual Report (attachment) Nadine Harris 8:40 174-180

V. Additional Business VI. Adjournment

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PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEETING MINUTES

I:\QUALITY\QI Assistant\QUAC\2016 Meetings\8.17.2016\Minutes\QUAC 6 15 2016 Meeting Minutes final_KR.docx Page 1 of 14

Committee: Quality and Utilization Advisory Committee (QUAC) Date/Time: June 15, 2016 7:30 – 9:00am

Members Present: Jennifer Wilson, M.D. Michael Strain, PHC Consumer Member Randolph Thomas, M.D. Robert Quon, M.D. Michael Pirruccello, MD Members Absent: Kali Stanger, M.D. – (absent; on maternity leave) Madhusudan Borde, MD Michael Pirruccello, M.D.

Rodrigo Manalo, M.D. Sara Choudhry, M.D. Steven Gwiazdowski, M.D., FAAP Steven Namihas, M.D. Thomas Paukert, M.D.

PHC Members Present: James Cotter, M.D., Associate Medical Director Nadine Harris, RN, MBA, Manager of Quality Compliance Jessica Thacher, Assoc. Director, Quality and PI Peggy Hoover, RN, Health Services Director Mark Glickstein, M.D., Associate Medical Director Robert Moore, M.D., MPH – Chief Medical Officer, Chairman Michael Vovakes, M.D., Northern Reg. Medical Director Scott Endsley, MD, Associate Medical Director Debra McAllister, RN, Associate Director, UM

Mark Netherda, M.D., Regional Medical Director

PHC Members Absent: Mary Kerlin, Senior Director of Provider Relations Amy Lasher, QI Project Coordinator I Karen Goelz, QI Project Coordinator Guests: Caron Lee, MPH, Improvement Advisor

Cheryl Lockhart, RN, PICS II Katherine Barresi, Associate Director/CC Kendra Rogers, QI Admin. Asst. (temp)

Danielle Niculescu, MPH, QI Project Coordinator II Ledra Guillory, Sr. Provider Relations Rep Manager Jess Liu, Manager of Quality Incentive Programs Rosemary Summers, MPH, Project Manager Tami Blockman, QI Project Coordinator II

Jessica Hackwell, GTPP/CHDP Supervisor Samantha Curtis, QI Clerk (temp)

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AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS/

ACTION TARGET

DATE DATE

RESOLVED Call to Order and Ap-proval of Minutes

The meeting was called to order at 7:35 am. Minutes from the 4/20/16 QUAC meeting were reviewed. Minutes from the 4/12/2016 IQI meeting were reviewed.

Dr Moore entertained the motion to approve. Dr Quon moved to approve. Dr, Wilson seconded approval.

6/15/2016

I. Standing Agenda Items 1. Status of open

action items There were no open action items discussed. 6/15/2016

2. QI Update

Jessica Thacher, MPH, Director of Quality and Performance Improvement, provided an update of the Quality Improvement Department activities as follows: Primary Care Provider Quality Improvement Program (PCP QIP): We are in the middle of transitioning for the 2015-2016 PCP/QIP program to the 2016-2017 PCP/QIP program. There will be a webinar in June for the provider network focused on the wrap-up of the current year. In July there will be a webinar for the kick off of the next year. We are moving forward with a plan to change the program from a fiscal year to a calendar year. It is scheduled to begin in January 2018. We will continue with the plan for the 2016-2017 fiscal year program, and will have a half year program in July 2017 then kick off the program in January 2018. HEDIS HEDIS is done; we’ve successfully submitted our rates to NCQA. We reviewed over 15,000 medical records Preliminary rates look show improvement in three of our four ge-ographic regions. We will provide a full report in August. NCQA Accreditation This month, a proposal will go to the Board of Directors seeking approval to move for-ward with NCQA Health Plan Accreditation. The current timeline we are proposing is to become Interim accredited in September 2019 which means we have to be ready by July 2019. This will give us about three years to become interim accredited. Other Please refer to the entire update report, provided in your meeting packet.

None. 6/15/16

3. Health Plan Update

Dr. Moore, Committee Chairman and Chief Medical Officer presented the following update: There are discussions underway on whether or not the Q/UAC meeting is subject to The Brown Act Guidelines which are: The Ralph M. Brown Act, located at California Government Code 54950 et sec., is an act of the California State Legislature, authored by Assembly member Ralph M. Brown and passed in 1953, that guarantees the public's right to attend and participate

None. 6/15/16

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in meetings of local legislative bodies. We are sorting through the details and if we are to follow The Brown Act we will be making changes to this meeting. More information to come. June 15, 2016 is the official kick off day for the new initiative to scrutinize short acting opioid prescriptions. We’ve done a huge outreach campaign to primary care providers and hospitals to speak with staff about the initiative. The Utilization Management Depart-ment reached out to the hospital case managers on the floor for discussions with the dis-charge planners. We’ve done webinars and the pharmacy department has gone on the road to talk to pharmacies throughout the region. This is our largest outreach and education campaign to date. More to come on this. The Death with Dignity Act officially came into state law on June 9, 2016. Commercial insurance is not required to cover the new law so they can choose to cover it or not. The state is working with Medi-Cal to make the death with dignity benefit on a fee for service benefit. The state is asking Medi-Cal managed care organizations not to initiate conversa-tion on death with dignity with patients”. We asked the state for clarification on who gets billed if you’re a primary care provider, and you talk about normal palliative care, end of life options, and write a prescription. For right now PHC’s key message for members is: “Speak with your PCP, we’re not responsible for it, and we don’t have any more infor-mation for you”. For providers, we’re telling them to speak with their local medical soci-eties. CMA has taken a neutral position on this. The state isn’t going to keep a list of doc-tors who provide this service. Kaiser will participate in the program. They will offer the services but the provider cannot offer it to the patient. The patient has to request the ser-vices. The VA’s opting out of the program and we believe Health Center’s will probably be out to. Hospices will act as a consultant but will not write the prescription. Dignity and St. Joseph’s is out as well. The Health Homes Program is in the process of giving the state advice on how the rate structure and the reporting structure will look like

II. Old Business There was no old business discussed at this meeting.

III. New Business

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1. Consent Calendar Consent Calendar (attachments) Quality and Performance Improvement, no substantive changes MPQP1016 Potential Quality Issues Investigation and Resolution Utilization Management, no substantive changes HKUG3071 Hospice Services Guidelines (HK Only) HKUP3067 Appeals/Expedited Appeals of UM Decisions for Medical Necessity Determination (Non-Administrative) HKUP3073 Mastectomy and Breast Reconstruction HKUP3077 PCP to Specialty Care Referral Process (RAF) MCUP3041-A TAR Review Process MCUP3057 Provider Appeals of Health Services Administrative Denials MCUP3124 Referral to Specialists (RAF)

Dr Moore entertained the motion to approve. Dr Wilson moved to ap-prove. Dr, Quon seconded ap-proval. Approved

6/15/16

2. UM Activities - IRR, Total TARs, Timeliness Data (attachment)

Peggy Hoover, RN, Health Services Director , presented a Semi-annual report On UM ac-tivities as follows: Inter-Rater Reliability Audit Outpatient 2015-2016 Nurses conduct reviews of one another’s work. -Accuracy findings are within PHC standards of greater than 90% Outpatient TAR Volume - Manual vs Electronic (Summary) received between 7/1/15-1/14/16 Northern Region Electronic (M2) 20,904 89.04% Manual (Amisys) 2,573 10.96% Region Total: 23,477 34.47% Southern Region Electronic (M2) 36,654 82.14% Manual (Amisys) 7,968 17.86% Region Total: 44,622 65.53% Grand Total: 68,099 100.00% RAF Volume - Manual vs Electronic (Summary) Entered Between 7/1/15- 12/31/15 Northern Region Electronic (M2) 27,410 98.07% Manual (Amisys) 539 1.93% Region Total: 27,949 29.29% Southern Region Electronic (M2) 66,663 98.78% Manual (Amisys) 823 1.22% Region Total: 67,486 70.71% Grand Total: 95,435 100.00%

None 6/15/2016

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Inpatient TAR Volume - Manual vs Electronic (Summary) Received Between 7/1/15-1/5/2016 Northern Region Electronic (M2) 5,599 77.10% Manual (Amisys) 1,663 22.90% Region Total: 7,262 33.09% Southern Region Electronic (M2) 9,694 66.03% Manual (Amisys) 4,988 33.97% Region Total: 14,682 66.91% Grand Total: 21,944 100.00% Denied TAR Volume - As of: 5/18/16 (Southern Region) Southern Region had 8,194 TAR’S Denied over a 6 month period. 865 or 10 Denied TAR Volume - As of: 5/18/16 (Northern Region) Northern region had 3,326 denied TARS All TARs for Each Line of Business by Month/Fiscal Quarter In total for the last 6 months, we had 89,236 TARS processed in the department between the two offices.

3. Member Satisfac-tion Survey (attachment)

Peggy Hoover, RN, Health Services Senior Director presented a PowerPoint presentation on the Member Satisfaction Survey data that was received. In 2013, the CAHPS 5.0 Adult Medicaid Survey was created to assess satisfaction among Partnership HealthPlan of California members. Partnership HealthPlan of California is in-terested in using the CAHPS survey as a benchmark for their member satisfaction. In or-der to meet the state objectives, mail surveys were sent to a randomized sample of Partner-ship HealthPlan of California members. All adult Commercial Partnership HealthPlan of California members who have been continuously enrolled for at least 12 months were eli-gible to receive a survey. A total of 10,000 surveys were mailed in February and March 2016 (306 were returned undeliverable), resulting in a 9.7% net response rate. Surveys were sent in either English or Spanish variations, depending on household preference. Only one survey was sent per household. A total of 936 surveys were received- 786 in English and 150 in Spanish. We believe what might contribute to the low percent of re-turns is that this is an election year and members receiving other surveys. Findings were: 1) rate of all health care received 85% favorable; rating of health plan – 91% favorable; Customer Service – 85% favorable; and Courtesy and Respect given by Customer Service showing 97% and 94%.

None 6/15/2016

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4. Pharmacy Creden-tialing Summary (attachment)

This item was skipped from the meeting.

5. Growing Together Perinatal Program (GTPP) (attachment)

Jessica Hackwell, GTPP/CHDP Supervisor presented a PowerPoint presentation on the status of the program. GTPP Cases – Southern Region More referrals are coming from Sonoma County than Solano County. More high risk in Solano County which could be the cultural and ethnicity differences. There was a dip in the referrals in Solano county because we lost a fulltime perinatal coordinator in the area. We hopefully will be bringing in another one. GTPP Cases- Northern Region Humboldt and Shasta Counties have the largest number of referrals as well as the individ-uals we have on a high risk pathway. The high risk pathway consist of gestational diabe-tes, preterm labor, hypertension, substance use, smoking, as well as individualize high risk plan from abusive relationships to mental health. HEDIS Measures: Prenatal Care ( prior to 13 weeks) In 2015 the Northeastern region has lower numbers because some of the individuals live further way from the providers HEDIS Measures: Postpartum Care (21-56 days) From 2013-2014 there has been an increase in Marin County In 2015, the Northern region was lower. Last year, Dr. Moore and the Quality department asked if we could look into doing something more specific for Postpartum care in the Northern region. New Postpartum Process Worked with health analytics to run a report twice a month from the TAR date of mem-bers who have delivered. With that data, they call the member and ask if they have sched-uled their appointment. If the member has made the appointment, a tickler is set to call the member 2 days following the visit. The case isn’t closed unless the visit has happened or the time has exceeded the 56 day timeframe. Shout out to the Northern Region Perina-tal Enrollment Specialist Jessica Guzman and Maribel Castaneda. They did a fabulous job working with us to make sure there was a process in place and trained the Southern region on how to make the calls. They really helped to implement the process.

None 6/15/2016

6. Managing Pain Safely (attachment)

Danielle Niculescu, MPH Project Manager, Quality and Performance Improvement De-partment, presented a PowerPoint presentation on Managing Pain Safely: A Plan’s ap-proach to combating the opioid epidemic. The aim statement for this year is: By December 31, 2016, we will improve the health of PHC members by ensuring pre-scribed opioids are for appropriate indications, at safe doses, and in conjunction with other treatment modalities as measured by a: – Decrease in total number of initial prescriptions by 75% – Decrease in total number of inappropriate prescription escalations by 90% – Decrease in total number of patients on inappropriate high dose opioids* by 75%

None

6/15/2016

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• Completion of Safe Use Now Project: The Safe Use Now program was utilized to rate providers’ prescribing practices based on 17 risk factors. Individual ratings were shared via peer-to-peer conversations with PHC’s Medical Directors and more than 350 provid-ers, with the intention of highlighting areas for improvement and influencing prescribing habits • Pharmacy Pain Management Registry Developed: Clinical data is tracked for members who are using high-dose opioids. Examples of the type of data tracked include prescribing physician, medication and dose patterns, behavioral health diagnosis, and behavioral health treatment. Registry source data is comprised of pharmacy treatment authorization request data and claims data. • Educational Opportunities- MPS hosted two webinars during the last two quarters of 2015. These webinars covered topics including the treatment of headaches for chronic pain patients and urine toxicology screening. In total, 64 providers, clinic and Partner-ship staff, and key community stakeholders attended the webinars, which offered 2 free CME credits. • Local Community Coalitions: PHC has been actively working at the ground level to support communities. A key focus has been quality improvement and community engage-ment coaching to form collective impact coalitions throughout the 14 PHC counties. To date, 11 of the 14 counties have formed some type of opioid coalition and 10 of the 14 counties have designated funding specifically to support these opioid coalitions. PHC is fiscally sponsoring 2 community coalitions at this time. • Pain Management Oversight Committees: Pain management oversight committees support clinicians caring for patients with chronic pain by providing evidence-based ad-vice on managing pain safely, including the use and management of controlled substances (including opioids), use of adjunctive therapy (including behavioral health and physical modalities), and appropriate referrals to interventional pain specialists. PHC sponsors an oversight committee for providers in our network who do not have access to a local over-sight committee. • MPS Webpage/ Toolkit: The Managing Pain Safely Toolkit, which can be found on the Managing Pain Safely webpage, was developed for providers and includes successful practices, PHC prescribing guidelines, training videos and tutorials, dose calculators, and tapering guides. Projects January- June 2016 • MPS “White Paper”: The MPS White Paper is a detailed description of the MPS Pro-ject. This document can be found on the MPS Webpage. • Taper Toolkit: This comprehensive tool is comprised of a Taper Journal for members and Taper Toolkit for providers to support providers and patients in the tapering process. Managing Pain Safely Project Update August 2015- March 2016.These materials were de-veloped in response to provider requests for additional material and resources to be used while guiding a patient through the tapering process.

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• Pharmacy Toolkit: The Pharmacy Toolkit is a compilation of information regarding PHC pharmacy guidelines, best practices for safe dispensing, warning signs for pharma-cists, and information on naloxone. This Toolkit can be found on the MPS Webpage. • Pharmacy Academic Detailing: Pharmacy academic detailing utilizes the Pharmacy Toolkit to provide 1:1 academic detailing at pharmacies within our network. • Integrated Care Clinic Planning Project: Through a grant funded by the California Healthcare Foundation, PHC is partnering with two clinics in our region to develop a pay-ment plan for implementing and sustaining integrated behavioral health/substance use clinics at primary care sites. PHC will disseminate best practices and look to scale up once the plan is finalized. • Naloxone Program: PHC is supporting provider sites to develop and implement site- level naloxone programs. PHC is working with providers to prescribe naloxone, in con-junction with opioids, for high-risk patients. PHC has funded the purchase of 2000 nasal atomizers to be distributed for use in this program. The MPS team has developed a nalox-one toolkit to assist with this project. • Data Sharing: In an effort to share provider site-level data, which indicates patient dose and dose pattern, the MPS project has developed two data sharing processes: o Voluntary request of provider-site data from provider site; and o Peer-to-peer data sharing wherein PHC medical directors outreach to provider sites who have 15 or more patients on high-dose opioids. • Educational Events: MPS hosted a set of data sharing webinars during the month of February. These webinars showcased MPS’s data collection methodology and detailed how provider sites can request site-level data. • Hospitalization Due to Overdose/ Intoxication Feedback Loop: MPS is currently eval-uating ways to flag members who have been admitted to the emergency department due to intoxication/ overdose, with the intention of reporting this information back to the PCP. • Sustainability Plan: The MPS team is currently drafting plans to develop systems and processes to ensure that the results seen thus far by the MPS project are sustainable over time. • Implementation of Immediate Release Quantity Limit: As of June 1, 2016, Partnership has placed a 30 pill quantity limit on short-acting opioids for new starts. The goal of this initiative is to decrease the number of patients starting down the path of long-term opioid dependence.

7. Hospital QIP Measures Summary (attachment)

Amy Lasher, QI Project Coordinator I, Quality Incentives Program HS Quality Improve-ment Project Coordinator presented this reported on The Hospital QIP Measures.

Proposed to Roll out July 1st for 2016-2017 measurement year. The information will be presented at the Physician Advisory Committee (PAC) Measure 1. Readmission Rate (20 points) No change for 2016-2017 Measure 2. Advance Care Planning (15 points) No change for 2016-2017

None

6/15/2016

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Clinical Quality: OB/Newborn/Pediatrics (40 points) Measures 3-7: Measure 3. Rate of Elective delivery before 39 weeks (Joint

Commission PC-01) *Only applies to hospitals doing deliveries Exclusion: For hospitals with a denominator of 30 or less, elective deliveries for a medical reason not listed under Joint Commission’s PC-01 exclusions may be submitted for PHC’s review and, if approved, be excluded from the denominator

Measure 4. Exclusive Breast Milk Feeding Rate at time of discharge from Hospital for all newborns (Joint Commission PC-05) *Only applies to hospitals doing deliveries. **Joint Commission is changing the PC-05: Exclusive breast milk feeding measure in October 2015. The specifica-tions of this PHC Hospital QIP measure will adopt the changes Target changed for 2016-2017 ≥ 70% = 10 points; 65% - < 70% = 5 points

Measure 5. VBAC Rate, Uncomplicated (IQI #22) *Only applies to hospitals with >200 deliveries during the measurement year Target changed for 2016-2017 ≥ 5% VBAC Uncomplicated = 10 points

Measure 6. Timely Participation in CPQCC Data Reporting *Only applies to hospitals that have intensive care nurseries. No change for 2016-2017

Measure 7. Timely Participation in CMQCC’s Maternal Data Center *Only applies to hospitals that provide maternity services Target changed for 2016-2017 For hospitals new to the 2016-17 QIP: six or more months of Active Track participation during the measurement year = 5 points For hospitals participating prior to 2016-17: 12 months of Active Track partici-pation during the measurement year = 5 points

Patient Safety (15 points) Measures 8-10 Measure 8. VTE Prophylaxis:

VTE-5 VTE Warfarin Therapy Discharge Instructions VTE-6 Hospital-Acquired Potentially-Preventable VTE STK-4 Thrombolytic Therapy Target changed for 2016-2017 VTE-5 ≥ 90% = 5 points; VTE-6 ≤ 5% = 5 points STK-4 ≥ 80% = 5 points

Operations and Efficiency (10 points) (Measures 9-10) Measure 9. Percentage of Inpatient Treatment Authorization -

Requests (TARs) submitted electronically and by close of the next business day (eTARS) No change for 2016-2017

Measure 10 HIE Participation Measure

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One option to fulfill measure requirement: Admission, Discharge, Transfer (ADT) Interface with HIE or PHC* by June 30, 2017 = eligibility to participate in the hospital QIP *PHC is building infrastructure for interface if local HIE is not able to accept

2016-17 Small Hospital QIP Summary of Measures Rationale: The Small Hospital QIP Measurement set is created to incentivize quality performance by hospitals with less than 50 general acute beds with at least 20 PHC Medi-Cal only admis-sions. As part of PHC’s efforts in expanding the Hospital QIP, the small hospital measurement set aims to reach out to hospitals that may not have enough staffing resources to support improvement efforts or data submission across the regular hospital measurement set. Also, some measures in the comprehensive measurement set requires a large denominator to be meaningful. A small hospital measurement set establishes an incremental approach to pay-ing for performance. Measures:

1. Readmission Rate All-Cause 30-day Adult Readmission Rate for PHC members hospitalized (ex-cludes OB admissions and claims for patient with Medicare coverage)

2. Percentage of Inpatient Treatment Authorization Request (e/TAR) Both measures rely on administrative data only and do not require manual sub-missions by participants.

8. Offering and Honoring Choices (attachment)

Caron Lee, MPH, Improvement Advisor presented the following Updates for offering and Honoring Choices. In 2012, PHC began the Offering and Honoring Choices™ initiative to ensure that its members and their families are knowledgeable about health care treatment options, em-powered to define their treatment goals, and able to make informed choices about the in-terventions they choose during the last years of life. The three main areas under Offering and Honoring Choices™ are: 1) Advance Care Planning, 2) Palliative Care, and 3) Policy and Public Education and Engagement. Advance care planning is defined as doing what we can to ensure the health care treat-ment we may receive is consistent with our wishes and preferences should we be unable to make our own decisions or speak for ourselves. Palliative care is defined as patient and family-centered care which optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the con-tinuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs as well as facilitating patient autonomy, access to information, and choice.

None 6/15/2016

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Activities in fostering policy development and public engagement are geared toward sup-porting legislation related to consumer engagement in advance care planning and pallia-tive care. Below are the current activities in each area. Advance Care Planning Since the fall of 2014, Care Coordination staff have been trained to incorporate advance care planning into conversations with and case management of members. Below are the cumulative data by year on advance care planning (ACP) and advance directive (AD), and advance directives signed with Care Coordination staff. These are followed by the monthly data for January 2015 – May 2016 on these measures.

Care Coordination Results

2014 2015 2016 (1/16-5/16)

# advance care planning conversa-tions with CC staff

189 1409 939

# advance directive conversations with CC staff

319 1935 1194

# advance direc-tives signed (based on when member shares that has signed advance directive)

110 84

36

Palliative Care “Partners in Palliative Care” is a new community-based palliative care service delivery model developed by PHC and its community partners (hospice, palliative care providers). The Partners in Palliative Care pilot ran from September 1, 2015 to February 29, 2016. It has been the priority activity within the Offering and Honoring Choices initiative during the 2015-2016 fiscal year. PHC continues to support Partners in Palliative Care and new enrollments until the DHCS palliative care benefit becomes active. As of May 26, 2016, 100 members had enrolled in the program (57 active enrollment, 43 disenrolled). Additional Palliative Care Activities Sponsor palliative care leadership training, provided by the Palliative Care Leadership Centers (PCLC) at the University of California, San Francisco, to help establish palliative care departments in hospitals. Mercy Hospital in Redding was trained in October 2014, and Sutter Santa Rosa was trained in January 2016. Sutter Santa Rosa continues with monthly coaching calls with PHC and PCLC through 2016. On May 12-13, an End-of-

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Life Nursing Education Consortium (ELNEC) training was held in Susanville. The pur-pose of the training was to develop palliative care capacity in hospitals that are not able to support a palliative care department or team (e.g., critical access hospitals). Sixteen partic-ipants representing seven hospitals in PHC’s network attended the training. The training covered: nursing care at the end of life; pain and symptom management; communication; loss, grief, and bereavement; preparation for and care at the time of death; ethical, legal and cultural considerations at end of life. The participants rated the training well and ex-pressed gratitude for this opportunity. Another ELNEC training will be held August 4-5 in Lakeport for a second cohort of nurses. Starting in July, PHC will host monthly calls for both cohorts to provide coaching and additional education on palliative care. Palliative care clinician peer convenings are held quarterly to support palliative care clinicians within PHC’s network. Convenings were held on January 11 and April 20 2016. Next Steps The outcome evaluation for Partners in Palliative Care will be the priority this summer. In anticipation of palliative care becoming a benefit in 2017, transitioning from pilot phase to healthplan benefit will also be a priority. In the advance care planning arena, PHC will be encouraging team-based advance care (ACP) to primary care practices through the revised PCP QIP advance care planning measure and also by offering ACP skills training along with other educational opportuni-ties during the second half of 2016.

9. MCUP3131 Genetic Testing (attachment)

Dr. Moore, Committee Chairman and Chief Medical Officer presented the following updates for this policy MCUP3131: These Items have been added to the revised policy VI. POLICY PROCEDURE: D. Certain genetic tests are not covered by PHC. However, if ordered by a medical geneti-cist with appropriate supporting documents attached to the TAR, the request will be con-sidered on an individual basis. E. If Quest Diagnostics is to be used for BRCA testing, it is recommended that the Pro-vider first complete the Quest Diagnostics BRCAvantage ® Patient and Family Clinical History Form. F. For genetic tests related to pregnancy and newborns, please refer to Medi-Cal guide-lines in the Genetic Counseling and Screening section gene count 1 – 7. Clarification of close blood relative A close blood relative is a 1st or 2nd degree relative. This sentence will be added to the policy for reference. CPT-4 Code Description 81228, 81229 Molecular Cytogenomic Testing

Dr Moore entertained the motion to approve the two changes. Dr Thomas made the motion Dr Wilson Seconded Approved with Changes

6/15/2016

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On pages 160-162 We are changing Comparative Genomic Hybridization (CGH) and Chromosomal Microarray Analysis. Which are the same thing to: Micro Array Based Comparative Genomic Hybridization Not a Medi-Cal covered benefit. Comparative genomic hybridization (CGH) is medically necessary for the following indications: Evaluating fetuses with structural abnormalities detected on fetal ultrasound or fetal magnetic resonance imaging; or For evaluating histologically equivocal Spitzoid melanocytic neoplasms (Spitz nevus and atypical Spitz tumors); or Analyses of stillbirths with congenital abnormalities or in stillbirths in which karyotype results cannot be obtained. CGH is medically necessary for diagnosing genetic abnormalities in children with developmental delay/intellectual disability (DD/ID) or autism spectrum disorder (ASD) according to accepted Diagnostic and Statistical Manual of Medical Disorders 5 (DSM 5) when all of the following criteria are met: If warranted by the clinical situation, biochemical testing for metabolic diseases has been performed and is negative; and Targeted genetic testing, (for example: FMR1 gene analysis for Fragile X), if or when indicated by the clinical and family history, is negative; and The member's clinical presentation is not specific to a well-delineated genetic syndrome*; and In addition to a diagnosis of DD/ID or ASD, the child has one or more of the following: - Two or more major malformations, or - A single major malformation or multiple minor malformations, in an infant or child who is also small-for-dates, or - A single malformation and multiple minor malformations, and - The results for the testing have the potential to impact the clinical management of the member. CGH is considered not medically necessary when a diagnosis of a disorder or syndrome is readily apparent based on clinical evaluation alone. Chromosomal microarray analysis is considered experimental and investigational in all other cases of suspected genetic abnormality in children with developmental delay/ intellectual disability or autism spectrum disorder. CGH is considered experimental and investigational for any other indications including the following (not an all-inclusive list) because of insufficient evidence of its ef-fectiveness: Detection of balanced rearrangements

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Evaluation of autoimmune lymphoproliferative syndrome Evaluation of unexplained epilepsies Screening for prenatal gene mutations in fetuses without structural abnormalities, such as in advanced maternal age, positive maternal serum screen, previous trisomy, or the presence of "soft markers" on fetal ultrasound Testing products of conception Diagnosis of melanoma Additional Criteria for Microarray: If not meeting above criteria and a medical geneticist believes it is necessary, he or she may submit specific justifica-tion to PHC for review. Notes: The Oligo HD Scan is a type of array CGH. The CombiMatrix DNArray is a CGH test for developmental delay.

V. Additional Business There was no additional business discussed at this meeting.

Signature of Approval: ____________________________________ Date: ______________________________ Robert Moore, MD, MPH – Chairman

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I:\QUALITY\QI Assistant\IQI\2016\08.09.2016\IQI Meeting Minutes\IQI Meeting Minutes 6-7-16 final.docx Page 1 of 12


Committee: INTERNAL QUALITY IMPROVEMENT [IQI] MEETING

Date/Time: June 7, 2016Tuesday_1:30PM – 3:30PM_Board Room, 3rd Floor

Members Present: Lauck, Cristina, RN, Manager, General Case Management Campbell, Betsy, MPH, Senior Health Educator Cotter, James, MD, MPH, Associate Medical Director Endsley, Scott, MD, Associate Medical Director Fronefield, Carly, Director of Health Services (S) Gibboney, Liz, MA, Chief Executive Officer Harris, Nadine, RN, MBA, QI Compliance Manager Hoover, Peggy, RN, Senior Health Services Director Kerlin, Mary, Senior Director, PR Kubota, Marshall, MD, Regional Medical Director

Layne, Robert, Director, Government and Public Affairs Leung, Stan, PharmD, Director of Pharmacy Services McAllister, Debra, RN, Associate Director of UM Moore, Robert, MD, MPH, Chief Medical Officer, Chairman

Smith, Lyle, Director, Operations Excellence & PMO Steffen, Nancy, Assoc Director of QI, Analytics, and Project Mgmt Thacher, Jessica, MPH, Director, Quality and Performance Improvement Vovakes, Michael, MD, Northern Regional

Members Absent:

Barresi, Katherine, RN, Associate Director of Care Coordination Barton, Donna, RN, Regional Team Manager/UM (R) Netherda, Mark, MD, Regional Medical Director

Scuri, Lynn, Regional Medical Director

Guests:

Blockman, Tami, QI Project Coordinator II Lasher, Amy, Project Coordinator I, HS Quality Improvement

Cuellar, Dina, CPhT, Associate Director of Pharmacy Operations Hackwell, Jessica, GTPP/CHDP Supervisor Hoerber, Ely, QI Program Manager Liu, Jess, Manager of Quality Incentives Program HS Quality Improvement Kaufer, Jennifer, MPA Manager of Performance Improvement

Lee, Caron, MPH, Improvement Advisor Rosel, Melissa, RN, Utilization Management Team Manager Turnipseed, Amy, Director of Policy and Program Development Villanueva, Angelica, Nurse Coordinator/ UM II HS Utilization Management Summers, Rosemary, MPH Quality Incentive Program Project Manager HS Quality Improvement Garcia-Hernandez, Margarita, Manager, Health Analytics Finance

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AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS

/ ACTION TARGET

DATE DATE

RESOLVED I. Call to Order

and Approval of Minutes

The meeting was called to order at 1:30 pm. Minutes from the 5/10/2016 IQI meeting were reviewed.

Approved without changes. 6/7/2016

II. Standing Agenda Items (Full Committee)

1. Status of Open Action Items

There was no open action item discussed.

2. QI Update

QI Update, continued

Jessica Thacher, MPH, Director of Quality and Performance Improvement, provided an update on key activities occurring in the Quality and Performance Improvement department. Primary Care Provider Quality Improvement Program (PCP QIP): With the 2015-16 PCP QIP year closing June 30, the QIP team is hosting a Wrap-Up webinar on June 14 to share important information on program timelines to help providers maximize their point earnings in the QIP. At the same webinar, the QIP team will also share highlights from the 2014-15 QIP evaluation with the provider network. All provider-submitted data to the QIP are subject to PHC audit. The 2015-16 QIP audit started in May and will conclude by the close of the QIP measurement year at the end of June. The purpose of this audit is to ensure data submissions in eReports can be substantiated with corresponding medical records located in provider offices. These audit results should be helpful in demonstrating eReports is a viable supplemental data source for select measures in HEDIS 2017. The 2016-17 PCP QIP Measurement set will be posted on our website by July 1, 2016. To jump start the new measurement year, the QIP team is hosting two Kick-Off webinars, on July 26 & 27. This is an opportunity for providers to get to know the new/changed measures for 2016-17. Upon the approval of the measurement set for 2016-17, the QIP and IT teams started scoping the eReports upgrade required to launch the new measurement year. The ‘16-17 BRD has routed to IT for review and approval. Coding and testing/validation remain as critical next steps in June and July. The QIP team will bring a high-level proposal on transitioning the QIP program period from the fiscal year (July 1 – June 30) to the calendar year (January 1 – December 31) to the Project Review Board (PRB) on June 7. A detailed project plan and timeline will be drafted following the PRB meeting. In our Northern Region, PR and QIP teams are initiating discussions with PCP sites on how to improve their QIP performance. Thus far, 9 PCPs in Shasta, Lassen, Trinity, Del Norte, and Humboldt counties have agreed to set improvement goals and to meet on a recurring basis with PHC coaching staff.

None. 6/7/2016

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QI Update, continued

HEDIS The HEDIS team has successfully concluded our medical record collection, abstraction and overread as of May 16th. We collected and reviewed over 15,000 medical records. Preliminary regional performance looks good relative to prior years. Three out of four regions have improved from last year and PHC has passed our Medical Record Review Validation audit with zero errors. We are targeting a release date of July 31st for both our Regional and County level performance and will kick-off plan wide communication via committee structure in August. ADVANCE Cohort 2 of the ADVANCE Improvement Advisor Training program will complete their final learning session on June 17, 2016. The eleven participating practices will gather, along with their executive sponsors, to project outcomes and learnings and to develop a plan for spreading and sustaining their improvements. A program evaluation will be completed in July and presented in the fall of 2016. Cohort 3 will launch sometime in the beginning of 2017. Primary Care Access Improvement Seven clinics have submitted an application to participate in the Advanced Access Collaborative. The application period was extended and we anticipate receiving two additional applications. PHC will announce selected participants in early June and host a Kick Off webinar June 23. The program is scheduled to run June 2016 – April 2017. Outbound Call Reminder Pilot UPDATE-Of the 277 Community Medical Centers, Dixon members, Member Services Department was able to reach 74 (27%) members out 277 members regarding colorectal cancer FIT testing. 29 patients had FIT test ordered and 17 members completed screening. NCQA Accreditation PHC is completing a Board proposal seeking approval to move forward with NCQA Health Plan Accreditation. The proposal will include a summary of findings from the Mock Survey, a recommended timeline, and estimated budgetary implications. The Board will review the proposal this month.

III. Old Business (Committee Members as Applicable)

There was no old business discussed.

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IV. New Business (Committee Members as Applicable) 1. Consent

Calendar

The following were on the consent calendar this month: Delegation Reports – Credentialing/Re-credentialing Lucile Packard Children’s Hospital 2016 1st Qtr SPMF Physician Foundation Medical Associates 2016 1st Qtr U.S. Behavioral Health Plan, CA 2016 1st Qtr Quality and Performance Improvement, no substantive changes MPQP1016 Potential Quality Issues Investigation and Resolution Utilization Management, no substantive changes HKUG3071 Hospice Services Guidelines (HK Only) HKUP3067 Appeals/Expedited Appeals of UM Decisions for Medical Necessity Determination (Non-Administrative) HKUP3073 Mastectomy and Breast Reconstruction HKUP3077 PCP to Specialty Care Referral Process (RAF) MCUP3041-A TAR Review Process (attachment only) MCUP3057 Provider Appeals of Health Services Administrative Denials MCUP3124 Referral to Specialists (RAF)

Approved without changes 6/7/2016

2. Pharmacy Credentialing Summary

Dina Cuellar, Associate Director of Pharmacy Operations provided report on the MedImpact (PBM) Network Credentialing Report: Semi-annual (July-Dec 2015) Results: MedImpact’s entire network has 323 operating pharmacies in PHC’s 14 counties. 100% of the pharmacies were licensed for both DEA and State during July- December 2015. All had a pharmacist in charge (PIC) with current licensure. Going forward MedImpact has proposed a different process in regards to the credentialing of the network pharmacies. Instead of providing all of the information on the report; they will provide those within our network for the 14 county coverage area. The pharmacy team will choose 20 samples and have them provide the documentation to us in regards to the network. If all samples pass, then they would get 100%. If the samples have expiration or licensure that were not instated within the appropriate time period of operation, we will inquire about those and choose another sampling.

None. 6/7/2016

3. Growing Together Perinatal Program (GTPP)

Jessica Hackwell, GTPP/CHDP Supervisor presented a PowerPoint presentation on the status of the program. GTPP Cases – Southern Region More referrals are coming from Sonoma County then Solano County. More high risk in Solano County which could be the cultural and ethnicity differences. There was a dip in the referrals in Solano county because we lost a fulltime perinatal coordinator in that area. We hopefully will be bringing in another one. GTPP Cases- Northern Region Humboldt and Shasta Counties have the largest number of referrals as well as the individuals that we have on a high risk pathway. The high risk pathway consist of gestational diabetes, preterm labor, hypertension, substance use, smoking, as well as individualize high risk plan from abusive relationships to mental health. HEDIS Measures: Prenatal Care ( prior to 13 weeks)

None. 6/7/2016

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In 2015 the Northeastern has lower numbers because some of the individuals live further way from the providers HEDIS Measures: Postpartum Care (21-56 days) From 2013-2014 there has been an increase in Marin County In 2015, the Northern region was lower. Last year, Dr. Moore and the Quality department asked if we could look into doing something more specific for Postpartum care in the Northern region. New Postpartum Process Worked with Health analytics to run a report twice a month from the TAR date of patients that have delivered. With that data, they call the member and ask if they have scheduled their appointment. If the patient has made the appointment, a tickler is set to call the member 2 days following the visit. The case isn’t closed unless the visit has happened or the time has exceeded the 56 day timeframe. Shout out to the Northern Region Perinatal Enrollment Specialist Jessica Guzman and Maribel Castaneda. They did a fabulous job working with us to make sure there was a process in place and trained the Southern region on how to make the calls. They really helped to implement the process.

4. Hospital QIP Measures Summary

Amy Lasher, Quality Incentives Program HS Quality Improvement Project Coordinator presented this reported on The Hospital QIP Measures.

Proposed to Roll out July 1st for 2016-2017 measurement year. The information will be presented at the Physician Advisory Committee (PAC) Measure 1. Readmission Rate (20 points) No change for 2016-2017 Measure 2. Advance Care Planning (15 points) No change for 2016-2017 Clinical Quality: OB/Newborn/Pediatrics (40 points) Measures 3-7:Measure 3. Rate of Elective delivery before 39 weeks (Joint

Commission PC-01) *Only applies to hospitals doing deliveries Exclusion: For hospitals with a denominator of 30 or less, elective deliveries for a medical reason not listed under Joint Commission’s PC-01 exclusions may be submitted for PHC’s review and, if approved, be excluded from the denominator

Measure 4. Exclusive Breast Milk Feeding Rate at time of discharge from Hospital for all newborns (Joint Commission PC-05) *Only applies to hospitals doing deliveries. **Joint Commission is changing the PC-05: Exclusive breast milk feeding measure in October 2015. The specifications of this PHC Hospital QIP measure will adopt the changes Target changed for 2016-2017 ≥ 70% = 10 points; 65% - < 70% = 5 points

Measure 5. VBAC Rate, Uncomplicated (IQI #22) *Only applies to hospitals with >200 deliveries during the measurement year Target changed for 2016-2017 ≥ 5% VBAC Uncomplicated = 10 points

Measure 6. Timely Participation in CPQCC Data Reporting *Only applies to hospitals that have intensive care nurseries. No change for 2016-2017

Measure 7. Timely Participation in CMQCC’s Maternal Data Center *Only applies to hospitals that provide maternity services

None. 6/7/2017

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Target changed for 2016-2017 For hospitals new to the 2016-17 QIP: six or more months of Active Track participation during the measurement year = 5 points For hospitals participating prior to 2016-17: 12 months of Active Track participation during the measurement year = 5 points

Patient Safety (15 points) Measures 8-10 Measure 8. VTE Prophylaxis:

VTE-5 VTE Warfarin Therapy Discharge Instructions VTE-6 Hospital-Acquired Potentially-Preventable VTE STK-4 Thrombolytic Therapy Target changed for 2016-2017 VTE-5 ≥ 90% = 5 points; VTE-6 ≤ 5% = 5 points STK-4 ≥ 80% = 5 points

Operations and Efficiency (10 points) (Measures 9-10) Measure 9. Percentage of Inpatient Treatment Authorization -

Requests (TARs) submitted electronically and by close of the next business day (eTARS) No change for 2016-2017

Measure 10 HIE Participation Measure

One option to fulfill measure requirement: Admission, Discharge, Transfer (ADT) Interface with HIE or PHC* by June 30, 2017 = eligibility to participate in the hospital QIP *PHC is building infrastructure for interface if local HIE is not able to accept

2016-17 Small Hospital QIP Summary of Measures Rationale: The Small Hospital QIP Measurement set is created to incentivize quality performance by hospitals with less than 50 general acute beds with at least 20 PHC Medi-Cal only admissions. As part of PHC’s efforts in expanding the Hospital QIP, the small hospital measurement set aims to reach out to hospitals that may not have enough staffing resources to support improvement efforts or data submission across the regular hospital measurement set. Also, some measures in the comprehensive measurement set requires a large denominator to be meaningful. A small hospital measurement set establishes an incremental approach to paying for performance. Measures:

1. Readmission Rate All-Cause 30-day Adult Readmission Rate for PHC members hospitalized (excludes OB admissions and claims for patient with Medicare coverage)

2. Percentage of Inpatient Treatment Authorization Request (e/TAR) Both measures rely on administrative data only and do not require manual submissions by Participants.

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3. UM Activities - IRR, Total TARs, Timeliness Data

Debra McAllister, Utilization Management Director, presented a Semi-annual report On UM activities as follows: Inter-Rater Reliability Audit Outpatient 2015-2016 Nurses conduct reviews of one another’s work. -Accuracy findings are within PHC standards of greater than 90% Outpatient TAR Volume - Manual vs Electronic (Summary) received between 7/1/15-1/14/16 Northern Region Electronic (M2) 20,904 89.04% Manual (Amisys) 2,573 10.96% Region Total: 23,477 34.47% Southern Region Electronic (M2) 36,654 82.14% Manual (Amisys) 7,968 17.86% Region Total: 44,622 65.53% Grand Total: 68,099 100.00% RAF Volume - Manual vs Electronic (Summary) Entered Between 7/1/15- 12/31/15 Northern Region Electronic (M2) 27,410 98.07% Manual (Amisys) 539 1.93% Region Total: 27,949 29.29% Southern Region Electronic (M2) 66,663 98.78% Manual (Amisys) 823 1.22% Region Total: 67,486 70.71% Grand Total: 95,435 100.00% Inpatient TAR Volume - Manual vs Electronic (Summary) Received Between 7/1/15-1/5/2016 Northern Region Electronic (M2) 5,599 77.10% Manual (Amisys) 1,663 22.90% Region Total: 7,262 33.09% Southern Region Electronic (M2) 9,694 66.03% Manual (Amisys) 4,988 33.97% Region Total: 14,682 66.91% Grand Total: 21,944 100.00% Denied TAR Volume - As of: 5/18/16 (Southern Region) Southern Region had 8,194 TAR’S Denied over a 6 month period. 865 or 10 Denied TAR Volume - As of: 5/18/16 (Northern Region)

None. 6/7/2016

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Northern region had 3,326 denied TARS All TARs for Each Line of Business by Month/Fiscal Quarter In total for the last 6 months, we had 89,236 TARS processed in the department between the two offices.

4. Managing Pain Safely

Danielle Niculescu, MPH Project Manager, Quality Improvement Department presented a PowerPoint presentation on Managing Pain Safely: A Plan’s approach to combating the opioid epidemic. Managing Pain Safely program started in January 2014 The aim statement for this year is: By December 31, 2016, we will improve the health of PHC members by ensuring that prescribed opioids are for appropriate indications, at safe doses, and in conjunction with other treatment modalities as measured by a: – Decrease in total number of initial prescriptions by 75% – Decrease in total number of inappropriate prescription escalations by 90% – Decrease in total number of patients on inappropriate high dose opioids* by 75% MPS has been focusing on interventions such as:

• Education • Health plan pharmacy authorization changes • Additional options for treating pain • Community activation • Aligned Incentives • Additional resources

Pharmacy Prior Authorization Changes that we started back in October of 2014: 1.Scrutinize justification for high doses of expensive opioids 2. Scrutinize escalation of high-dose opioids (no matter what the price) 3. Scrutinize all prescriptions for all stable high doses of opioids – Request explanation for stable high dose – Difficult cases may require supporting documentation of mental health, pain specialist, or pain medication oversight committee – Track responses with PHC-level registry of patients on high dose opioids 4. Maximum 30 tablets of immediate release opioids without prior authorization for new onset acute pain is being implemented June 1, 2016.

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The Pharmacy team has been working on keeping track of patients with high doses to help intervene and help the patient. Other activity during the fall of 2015 included the California Healthcare Association grant and coalition support. The PHC Pain Management Oversight Committee provides a venue for providers to request support in managing the prescribing for difficult cases. A few cases have been reviewed by our oversight committee but most sites have their own committees so they don’t need ours which is great. Also to note is the PHC MPS Webpage and Toolkit Managing Pain Safely Activity for Quarter 1 and 2, 2016 January- June, 2016 MPS “White Paper”- Has been written but there hasn’t been an evaluation yet. It will be added once we’ve concluded the program. However you can find the 40 page document on our PHC website and if anyone has questions, please refer them to our website. – Taper Journal/ Toolkit- MPS is working on creating a toolkit because quite a few of our providers are asking for additional resources on tapering patients. Pharmacy Toolkit- We are utilizing it to go out to pharmacies in our network and do academic detailing. Our pharmacy team has gone out to over 30 pharmacies and will continue to go to other pharmacies over the next few quarters. Integrated Clinics Payment Plan Development- PHC is working to develop a payment plan to support clinics that bring behavioral health to patients. The payment plan is scheduled to roll out in July. MSP will report more on this project in the future. Naloxone Program- PHC has purchased atomizers to create a nasal spray for Naloxone to prevent Opioid overdose. We are asking providers to write a prescription for Naloxone in conjunction with high dose opioids. Provider Site-Level Data Sharing- We have two ways in which providers can obtain patient data. They can voluntarily request it by submitting a form and we will send them the data we have on their site. If their site has more the 15 patients on high dose opioids, our medical directors are going out and speaking with them about their list of patients and the importance of tapering patients down. Educational Events- MSP has hosted educational events, webinars, and hosted a Managing Pain Safely Forum back in January 2016 with 180 providers attending. Coalition Building We have community culture meetings scheduled in 13 of our 14 counties and will be meeting this month. Hospitalization Due to Overdose/ Intoxication Feedback Loop We are currently doing a feasibility study for a pilot program on how to close the loop where patients can receive prescriptions in the emergency department without the provider being aware and then prescribe more medication. Sustainability Plan We’ve started to look at what a pain management sustainability plan will look like and work groups are being formed. Opioid Fills PMPM We have seen a 49% decrease January 2014-March 2016 Unsafe Dose (>120 MED) 48% Decrease January 2014- March 2016 Initial Opioid Prescriptions 32% Decrease February 2014- March 2016 Escalating Dose: Cohort Analysis 58% Decrease January 2014- March 2016 for January 2014 Cohort

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What’s Next: Limitation of New Starts Limitation of New Starts As of June 2016, Partnership plans to limit the number of individual pills of any short-acting opioid for any new starts, with the goal to decrease the number of patients starting down the path of long-term opioid dependence Looking Ahead in 2016: Health Plan Activities • Enhance support of local coalitions • Planning process for creating integrated clinics for high utilizers (CHCF support) • Pharmacy academic detailing • MPS provider site-level data sharing • Promotion of site-level naloxone programs • Reducing Recidivism- closing the feedback loop • Additional Educational Opportunities • New Campaign: Avoid Co-Prescribing: Opioids and Benzodiazepines • Project Extension Planning • MPS Evaluation will be coming up the end of this year the beginning of next year.

5. Member Satisfaction Survey

In 2013, the CAHPS 5.0 Adult Medicaid Survey was created to assess satisfaction among Partnership HealthPlan of California members. Partnership HealthPlan of California is interested in using the CAHPS survey as a benchmark for their member satisfaction. In order to meet the state objectives, mail surveys were sent to a randomized sample of Partnership HealthPlan of California members. All adult Commercial Partnership HealthPlan of California members who have been continuously enrolled for at least 12 months were eligible to receive a survey. A total of 10,000 surveys were mailed in February and March 2016 (306 were returned undeliverable), resulting in a 9.7% net response rate. Surveys were sent in either English or Spanish variations, depending on household preference. Only one survey was sent per household. A total of 936 surveys were received- 786 in English and 150 in Spanish. We believe what might contribute to the low percent of returns is that this is an election year and members receiving other surveys. Findings were: 1) rate of all health care received 85% favorable; rating of health plan – 91% favorable; Customer Service – 85% favorable; and Courtesy and Respect given by Customer Service showing 97% and 94%.

None

6. Offering and Honoring Choices

Background In 2012, PHC began the Offering and Honoring Choices™ initiative to ensure its members and their families are knowledgeable about health care treatment options, empowered to define their treatment goals, and able to make informed choices about the interventions they choose during the last years of life. The three main areas under Offering and Honoring Choices

1. Advance Care Planning 2. Palliative Care pilot 3. Policy and Public Education and Engagement.

Since the fall of 2014, Care Coordination staff have been trained to incorporate advance care planning into conversations with and case management of members. In 2016, there were 939 ACP

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conversations, and 1194 advance directive conversations done by CC staff, along with 36 advance directive signed to date. PHC provides financial incentives via the PCP QIP to encourage providers to discuss advance care planning with their patients. We also provide incentives through the Hospital QIP advance care planning attestations – in which six hospitals have participated during the past four years. - Partners in Palliative Care is a new community based palliative care service delivery model developed by PHC and our community partners. Additional activities include leadership training; an End-of-Life Nursing Education Consortium training was held in May, another planned for August and Palliative care clinician peer convening held quarterly. For next steps, PHC will be revising the PCP QIP advance care planning measure and continue to offer ACP skills training and other educational opportunities.

7. STARS Dashboard

Dr. Moore MD, MPH, Chief Medical Officer presented the presentation on the PHC Internal Stars Dashboard High quality healthcare is one of three strategic goals of PHC. In an effort to measure our performance in this area, a workgroup comprised of senior leadership and management met in 2015 and agreed on measures by which PHC will evaluate the quality of care received by our members. The measurement includes measures across the Triple Aim domains of care – Utilization (proxy for cost), Health Outcomes, and Patient Experience. Baseline rates and thresholds were reported in 2015. Below is our updated performance as of June 1, 2016. Notes: The 2015 readmission rate was revised to use new standard data definitions developed since 2015 by health analytics, so that the 2015- 2016 scores would be comparable. All thresholds were made more precise by going to the tenth of a decimal place; this resulted in the statin control for 2015 being revised downwards. Summary of Performance

Revised Baseline (2015) Re-measurement 1 (2016)

3.67 (3.5 stars)

4.00 (4 stars)

PHC improved its weighted performance score from a revised score of 3.67 to 4.00. • The star rating improved on 5 measures: Avoidable ED visits, HEDIS measures below the MPL, High risk medications, med adherence for members on statins, and member rating of the health plan. • Performance was stable for all other measures and our goal was met.

None 6/7/2016

8. MPRP4059 Formulary Utilization Management for Managing

Debra McAllister Associate Director, Utilization Management discussed the changes to this policy The purpose of this policy is to describe the process that PHC Pharmacy plays in helping to improve the health of PHC members by ensuring that all opioids prescribed for chronic non- cancer pain an acute pain are for appropriate indications at safe doses.


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Pain Safely Program

9. MCUP3131 Genetic Testing

Dr. Moore MD, MPH, Chief Medical Officer presented the revisions to this policy. The purpose of this policy is to provide criteria for medical necessity and benefit coverage of genetic testing. Genetic testing is a rapidly expanding aspect of medical care which can be useful for diagnosing disease, guiding treatment, and/or identifying possible genetic risks for development of disease. Given the rapid evolution of this field, it is impossible to establish guidelines to reliably inform when genetic testing is appropriate which will remain valid for a significant time frame. Therefore, the purpose of this policy is to describe the criteria for evaluating requests for genetic testing, and to cite the external professional resources on which we will rely to make coverage determination


V. Additional Business

There was no additional business discussed.

VI. Adjournment

The meeting was adjourned at 3:31 pm.

Respectfully submitted by Nadine Harris, QI Compliance Manager Signature of Approval: ____________________________________ Date: ______________________________ Robert Moore, MD, MPH, Chairman

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IQI QI Department Update August 2016

Prepared by Jessica Thacher, Director of Quality and Performance Improvement

Incentive Programs (QIPs)

Primary Care Provider Quality Improvement Program (PCP QIP)

• The 2015-16 PCP QIP officially ended on June 30. Providers have the opportunity to submit supplemental data on non-clinical measures until July 31 and on clinical measures (captured in eReports) until August 15.

• The QIP team hosted two Kick-Off webinars on July 26th and 27th to officially launch the 2016-17 PCP QIP measurement year. We shared detailed information on the new or changed measures for the upcoming year. We also introduced the Measurement Year Transition plan to the network.

• The Measurement Year Transition plan has been reviewed by the PHC Project Review Board (PRB). A more in-depth plan will be presented to the PRB in August. Here is a short summary of updates:

o The PCP QIP 2016-17 will not be impacted and will run from 07/01/2016 to 06/30/2017. o We will then run an abbreviated, six-month cycle from 07/01/2017 to 12/31/2017. The

abbreviated cycle will use the same measurement set as the 2016-17 program year with a few minimal changes.

o In January 2018, the PCP QIP will begin running on a calendar year. o Major and minor measurement changes will continue to alternate every other year just as

they’ve done on the fiscal calendar cycles. Major changes to the measurement set will be considered for the 2018 program.

• The ’16-17 eReports BRD was approved by key stakeholders in QI and IT in June. Over the course of July, IT has initiated coding development and testing per the joint project plan for ’16-17 eReports. In concluding the ’15-16 MY, the QIP and IT teams have also partnered in applying and sharing relative improvement calculations and continuous enrollment with the provider sites. This required a blackout period in eReports from the end of the ’15-16 MY, starting midnight 7/1/16, through 7/10/16. As of 7/11/16, we have entered the grace period where provider sites are encouraged to upload additional data for ’15-16 dates of service through 8/15/16.

• The 2015-16 QIP audit has been completed. The purpose of this audit was to ensure manual data submitted by providers via eReports matched corresponding medical records. Audit results are very good and are in the process of being analyzed and summarized for the August PCP QIP Technical Workgroup meeting. All errors identified during the audit will be removed and/or corrected in eReports before the close of the ’15-16 grace period. The audit summary will be helpful in demonstrating eReports is a viable supplemental data source for select measures in HEDIS 2017.

Long-Term Care Quality Improvement Program (LTC QIP)

• A multi-disciplinary team from Finance, Utilization Management, Claims, and QI worked together to identify a more streamlined process to calculate the incentive payment for this program. The change will be implemented in the 2017 program year and is being communicated to facilities.

• PHC is partnering with Health Services Advisory Group (HSAG) to provide two educational trainings to Northern Region Long Term Care (LTC) facilities. The training, which has never before been available in these rural areas, will be free. The training will be offered on October 4th in Shasta County and on October 5th in Humboldt County. By attending one of these trainings, PHC-affiliated

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facilities will have the opportunity to receive 15 points in the LTC QIP. Continuing Education credit is also offered to attendees.

• The Long-Term Care technical workgroup – comprised of UM, Finance, Claims, and QI – had its first meeting in late July to develop measures for the 2017 measurement year. The group will continue to meet to discuss the vision, goals, and milestones of the LTC QIP.

Hospital Quality Improvement Program (HQIP)

• Hospitals have until August 31 to submit data for HQIP 2015-16. We are working with IT and community Health Information Exchanges (HIEs) to verify hospital participation. This was implemented as a gateway measure for the HQIP 2015-16.

• Two hospitals have been added to HQIP: Trinity Hospital with 25 licensed acute beds and Sonoma Valley Hospital with 48 licensed acute beds. Both facilities will qualify for the new Small Hospital Measurement Set. We are working with Finance and PR to onboard 10 more hospitals for 2016-17.

• A 2016-17 Kick-off webinar is set for August 17. The webinar will provide an overview of program structure and the measurement set while introducing the addition of the Small Measurement Set (for hospitals with fewer than 50 general acute beds).

Performance Measurement Activities

HEDIS

• We released our HEDIS 2016 performance (regional and county-level performance) to our provider network on July 31st. Plan-wide performance sharing has officially kicked-off through our committee structure.

• Over the summer, the HEDIS team is improving the program’s infrastructure to enhance operational efficiencies. We are developing comprehensive process flows for training purposes and to ensure clarity during the hectic HEDIS data collection project. We recently met with our medical record retrieval vendor to discuss operational improvements for the upcoming season and issued an RFP on July 1st for a medical record abstraction vendor. In addition, we are putting together a number of project management artifacts such as an integrated project schedule, a risk management plan and a stakeholder register. We believe these infrastructure improvements will lead to a successful year with measureable improvements to our data collection processes.

Partnership Quality Dashboard (PQD)

• IT and Finance are working closely on module 1 of the PQD project. The current focus is on integration of the PCP QIP non-clinical measures into the dashboard, as well as on general design principles for displaying the data effectively. Module 2 will integrate annual HEDIS performance into the tool. We are determining a plan for appropriate provider attribution of our HEDIS results (historically the data is collected and reported at a county and regional level only) and will be working closely with IT to integrate HEDIS results files into the data warehouse.

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Partnership Improvement Academy

ABCs of QI

• The Northern Region QI team along with our partners at NCCN and HANC hosted an in-person offering on July 19th in Redding at the Red Lion. This is the second offering in the Northern Region in 2016 and supports our goal to develop qualified trainers to make these offerings more accessible to our rural providers. We were pleased to have 55 participants in attendance and have already received great feedback from NR providers!

Advanced Access Collaborative

• PHC and Tantau & Associates hosted the Advanced Access Collaborative Kick-Off Webinar on June 23rd and the Pre-work webinar on July 13th. On-Site Clinic Assessments have begun and are scheduled through late August. The initial Learning Session will be held in Fairfield, CA on September 27 & 28. Six primary care practices, with a total of 8 teams (some practices are sending more than one team) are participating in the Collaborative (Alexander Valley HealthCare, Community Medical Centers, Northbay HealthCare, Sutter Lakeside, St. Helena Health Center and United Indian Health).

Internal Performance Improvement Training

• In August, the SR QI department will pilot a new training program aimed at developing Performance Improvement skills within QI department staff. Like our ADVANCE program, the training will consist of didactic instruction on the Model for Improvement, hands on application to an improvement project, and 1:1 guidance from a QI coach. We will leverage our initial cohorts of the training to support HEDIS-related performance improvement projects. Initial projects will focus on the following measures: Monitoring for Patients on Persistent Medications, Cervical Cancer Screening, and Well Child Visits. Our goal is to apply rapid improvement methodology in order to gain quick results within 90 to 120 days, thus impacting our HEDIS 2017 (measurement year 2016) performance scores. We will provide progress updates on the specific projects, as well as an evaluation of the internal training pilot program in the coming months.

Improvement Initiatives

HEDIS Improvement Team

• As part of PHC’s team goal process, an inter-disciplinary HEDIS Measure Improvement workgroup has been established, led by QI. This team will focus on developing a long-range strategic plan to improve HEDIS scores, as well as shorter term strategies to improve performance for measurement years 2016 and 2017. Excellent HEDIS rates are strategically important to PHC because 1) they represent the quality of preventive and chronic disease management received by our members, 2) they determine PHC’s quality ranking on DHCS’s managed care performance dashboard, and 3) they will be used by future external quality rating systems such as NCQA Accreditation and the Medi-Cal external rating system.

Managing Pain Safely (MPS)

• The MPS team has created a naloxone toolkit, which includes program recommendations and workflows for the development of a provider level naloxone program, provider and pharmacy

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naloxone guidelines, and patient education material. In Lake County, MPS is partnering with the community initiative SafeRx Lake County to conduct provider site training for physicians and office staff at health centers throughout the county. Partnership is supplying nasal atomizer devises for interested clinics who participate in the training. The naloxone toolkit and a recording of the provider site training can be found on the MPS webpage.

• The MPS team is partnering with Hill Country Health and Wellness Center to develop patient testimonial videos, detailing patients’ stories and experiences of tapering off of opioids. This project has a tentative completion date of October 2016.

• We will be hosting a webinar (August 17 from noon-1pm) and a question-and-answer session (August 31 from noon-1pm) related to tapering. The webinar will cover: selecting appropriate pain medication users for tapering, a brief overview of how to prepare and start the conversation, quick idea for successful conversations, and case studies around tapering. To register: https://attendee.gotowebinar.com/register/1548562447021647875

• On September 22, 2016 PHC will partner with the California Healthcare Foundation to host a large multisite conference for CHCF’s Regional Opioid Safety Coalition Network. This all day conference will highlight key issues related to opioid safety, including medication assisted treatment, naloxone, and safe prescribing. This conference will be hosted live in Oakland, with PHC offering five remote locations- Fairfield, Santa Rosa, Eureka, Redding, and Dunsmuir. Registration will be available for PHC providers starting August 1. More information can be found here: https://www.eventbrite.com/e/opioid-safety-coalitions-network-northern-california-fall-convening-tickets-25829068439.

Offering and Honoring Choices

• Partners in Palliative Care: PHC continues to support Partners in Palliative Care and new enrollments until the DHCS palliative care benefit becomes active. The outcome evaluation is underway.

• Project ECHO: PHC funded ResolutionCare, a palliative care organization, to provide palliative care training to rural health care providers using the University of New Mexico’s Project ECHO model (training via videoconference). ResolutionCare offered 12 sessions between October 2015 and May 2016. Approximately 35 health care practitioners of all levels (MD, DO, PA, NP, RN, MA) from the following rural community clinics in Mendocino and Humboldt counties successfully completed the program: Redwood Coast Medical Services (Gualala and Pt. Arena), Redwoods Rural Health Center (Redway), Heart of the Redwoods Hospice (Garberville), K’ima:w Medical Center (Hoopa), Six Rivers Medical Center (Willow Creek), Arcata Community Life Medical Center, United Indian Health Services (Arcata).

• Expanding Primary Palliative Care Training and Resources: The Medical Director for Quality has been in conversation with multiple organizations throughout CA involved with palliative care training. He facilitated a day-long brainstorming and design session on July 22 that was initiated by the CSU Institute for Palliative Care. Other organizations represented included: California Academy of Family Physicians, California HealthCare Foundation, California Primary Care Association, the PHC Offering and Honoring Choices Team Lead, ResolutionCare, and UCSF. The purpose of the meeting was to identify needed competencies to provide palliative care services, particularly with the go-live of the Medi-Cal palliative care benefit in 2017, and how to meet this need.

• 5th Annual Palliative Care Conference: We are supporting the annual conference that Collabria Care hosts. This year’s conference will be October 20-21 in American Canyon. We have helped plan the agenda and with speaker invitations. PHC will also support Collabria Care in applying for the CME for the conference.

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https://attendee.gotowebinar.com/register/1548562447021647875

https://www.eventbrite.com/e/opioid-safety-coalitions-network-northern-california-fall-convening-tickets-25829068439

https://www.eventbrite.com/e/opioid-safety-coalitions-network-northern-california-fall-convening-tickets-25829068439

Improving Diabetic Retinopathy Screening Rates

• All six clinics began screening using the EyePACS cameras during May or June. Five of the clinics achieved a monthly screening volume of > 9 retinal exams during the month of June, which is the goal for the clinics to sustain each month throughout the project. 5 of the 6 clinics have opted to have monthly performance improvement check-ins with PHC. A Share and Learn webinar to promote peer learning among the group is scheduled for August 3.

Controlling High Blood Pressure

• Open Door’s Eureka Community Health Center continues to partner with PHC and NCCN in conducting a DHCS-required Performance Improvement Project (PIP) on the Controlling High Blood Pressure measure. In June, the team focused on a PDSA to identify standard entry of BP targets in the medical record for each hypertension patient. By investigating and testing a standard entry method in EPIC, the provider will more effectively communicate to his staff an appropriate BP target for each hypertension patient. An appropriate BP target is defined as a target meeting the recommended clinical guidelines, as detailed in the SMART AIM reflecting the HEDIS specifications. Establishing and documenting clear BP targets for hypertension patients will serve as an aid to the Care Team in further patient education, behavior change discussions, and self-management goal setting. This PDSA serves as a foundation to additional interventions being planned, including: offering hands-on training to patients using home-monitoring BP cuffs and developing protocols for follow-up nurse visits after a new patient starts a new or changed BP medication.

Northern Region Consortia Partnership in HEDIS Performance Improvement

• Since receiving the preliminary HEDIS 2016 rates, the NR QI team has been working to leverage activities already underway via our Northern Region consortia partnership, while brainstorming additional, shorter term interventions. As a result, the ’16-17 PHC/HANC/NCCN Improvement Plan has been updated to reflect re-prioritized activities and new rapid-cycle improvement efforts. This has truly been a collaborative effort and has also included partnering with FF QI and NR providers, PR, Member Services, Care Coordination, and Pharmacy teams. Currently, our intervention efforts are focused on improving rates in the following: childhood and adolescent immunizations, well child visits, diabetic retinopathy eye exams, and cervical cancer screening. We are also actively seeking data and subject matter expertise in addressing performance trends in timely prenatal care, timely postpartum care, and annual monitoring for patients on persistent medications (diuretics, ACE, ARB). To support these efforts further, we completed a technical assistance call with our DHCS Nurse Liaison on 7/12 to seek guidance on specific measures the NR team would like to prioritize in anticipation of state-mandated improvement work.

NCQA Accreditation

• In June, the PHC Board approved a proposal to move forward with NCQA Accreditation. PHC’s goal is to achieve Interim Accreditation by September 2019.

• PHC is setting up an interdisciplinary NCQA Steering Committee. The focus for the 16/17 fiscal year will be on setting up project management infrastructure to manage our Accreditation efforts and monitoring progress on our large NCQA-required initiatives, including: Essette Implementation, Disease Management Programs, Provider Director, Member Portal and Delegation Oversight.

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Compliance

Initial Health Assessment (IHA) Improvement

• Beginning May 2016, Medi-Cal eligibility expanded to include all low-income children in California regardless of immigration status. In response to this change, we launched a pilot project to encourage completion of the Initial Health Assessment (IHA) among newly enrolled children to the health plan. IHAs are required by DHCS within the first 120 days of enrollment with a managed care plan. Three high volume pediatric practices, Marin Community Clinics - San Rafael, Ole Health - Napa and Santa Rosa Community Health Centers - Southwest, were selected for the pilot. 533 new pediatric members have enrolled in these three practices since June 1, 2016. QI staff will meet with managers at the three health centers in early August to share current IHA compliance rates and brainstorm strategies to meet the State’s requirement for timely IHAs.

General

• The Fairfield QI Department recently finalized its 2016-2017 Operational Plan. The plan outlines 32 SMART objectives across our major program and project areas. Our driving priorities for the next fiscal year include improving HEDIS performance among Southern Region providers and strengthening our team and operations. Major new work this year includes: NCQA Accreditation, a strategic focus on HEDIS rate improvement through the HEDIS Rate Improvement Team and associated improvement projects, the Partnership Quality Dashboard, an electronic tool to manage Facility Site Review data, and the launch of an internal Performance Improvement training program.

• The Fairfield QI Department has 2 new staff members starting August 1. o The Patient Safety team and QI Management team is excited to welcome Rosemenia “Rose”

Santos as our Manager of Quality Assurance and Patient Safety. Nadine Harris is retiring at the beginning of 2017 and Rose will be assuming most of Nadine’s current duties, including management of the patient safety team, facility site review/medical record review, and the PQI/Peer Review process. Rose is a registered nurse and has worked at Kaiser for more than 20 years in a variety of departments. Since 2007, Rose has been the Manager of the Survey Readiness Unit within Kaiser’s Health Plan Regulatory Services.

o The HEDIS team is excited to welcome Sarah Molteni-Casper as our new HEDIS Analyst. Sara comes with a Masters degree in Healthcare Administration along with five years of experience in project management and data analysis, and two years of healthcare experience. Sarah will be assuming Sue Lee’s role on the HEDIS project. Sue Lee is transitioning into her new position as Sr. Project Manager for NCQA Accreditation.

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I:\QUALITY\QI Assistant\QUAC\2016\08.17.2016\Items on Consent

PARTNERSHIP HEALTHPLAN OF CALIFORNIA QUALITY/UTILIZATION ADVISORY COMMITTEE

CONSENT CALENDAR

Items on the Consent Calendar have minor or no changes and are recommended by staff for approval.

Delegation Reports – Credentialing/Re-credentialing MPQP1026 OB/GYN Facility Site Review Requirements and Guidelines 38-43 MP PR-GR210 Provider Grievance 44-46 Utilization Management, no substantive changes MCUP3012 Discharge Planning (Non-capitated Members)

47-49

HKCP2015 Continuity of Care (HK Only) 50-53 HKUP3069 (formerly MPUP) Emergency Services (HK Only) 54-57 MCCP2014 Continuity of Care (HK Only) 58-62 MCUG 3008 Bathroom Equipment Guidelines 63-64 MCUG 3011 Criteria for Home Health Services 65-67 MCUP 3003 Rehabilitation Guidelines for Acute Skilled Nursing Inpatient Services (previously - Acute Inpatient or Long Term Care Rehabilitation Institution Services)

68-72

MCUP 3133 Wheelchair Mobility, Seating and Positional Components 73-83 MCUP 3041-A ATTACHMENT ONLY - TAR Review Process 84-91

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PARTNERSHIP HEALTHPLAN OF CALIFORNIA

POLICY / PROCEDURE

Page 1 of 6

Policy/Procedure Number: MPQP1026 Lead Department: Health Services Policy/Procedure Title: OB/GYN Facility Site Review Requirements and Guidelines

External Policy Internal Policy

Original Date: 02/18/2004 – Medi-Cal 08/15/2007 - Healthy Kids

Next Review Date: 08/19/2016 Last Review Date: 08/19/2015

Applies to: Medi-Cal Healthy Kids Employees

Reviewing Entities:

IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT

Approving Entities:

BOARD COMPLIANCE FINANCE PAC

CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER

Approval Signature: Robert Moore, MD, MPH Approval Date: 08/19/2015

I. RELATED POLICIES: A. MCUG3118 - Prenatal & Perinatal Care Guidelines (under Utilization Management)

II. IMPACTED DEPTS.:

A. Compliance B. Provider Relations C. Quality Improvement D. Utilization Management

III. DEFINITIONS:

A. N/A IV. ATTACHMENTS:

A. OB/GYN 2012 Site Review Survey Tool B. OB/GYN 2012 Site Review Guidelines

V. PURPOSE:

To provide obstetric/gynecology practice sites a comprehensive guideline for Facility Site Review (FSR) requirements and processes. A FSR is comprised of an initial Site Review Survey (SRS). The purpose of the FSR is to ensure that practice sites have sufficient capacity to: A. Provide appropriate obstetric/gynecology services B. Carry out processes that support continuity and coordination of care C. Maintain patient safety standards and practices, and D. Operate in compliance with applicable federal, state, local laws and regulations

Findings of the FSR are used to:

A. Provide information for credentialing/re-credentialing decisions B. Identify areas where education and technical assistance is needed C. Identify and share best practices in patient safety, medical error prevention, and provision of quality care

VI. POLICY / PROCEDURE:

A. Requirements 1. Review Personnel

a. PHC’s Chief Medical Officer is ultimately responsible for FSR activities completed by PHC personnel. PHC has designated a Registered Nurse to be certified as a Master Trainer by the Department of Health Care Services (DHCS). The Master Trainer is responsible for training

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http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Quality%20Improvement/MPQP1026%20Attachments/MPQP1026-B.doc&action=default

http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Quality%20Improvement/MPQP1026%20Attachments/MPQP1026-A.doc&action=default


☒External Policy ☐Internal Policy



Applies to: ☒ Medi-Cal ☒ Healthy Kids ☐ Employees

Page 2 of 6

and supervising reviewers, certifying RN and physician reviewers and other review team members, monitoring reviews and evaluating reviewers for inter-rater reliability. At a minimum, PHC review teams will consist of a supervising RN that has been certified by DHCS or by PHC’s Master Trainer as a Trainer or a Reviewer. Recertification will occur every three years. Physicians and RNs designated as trainers and reviewers will be required to meet the DHCS criteria for Recertification. DHCS will re-certify the Master Trainer. Trainers and reviewers will be recertified by the Master Trainer and Trainers respectively. The supervising RN may enlist other RNs, physicians, PA’s or LVN’s as part of the review team and is responsible to oversee data collection and assure that reviewers collect data that is appropriate to their level of education, expertise, training and professional licensing scope of practice as determined by California statute. Only RNs or physicians may review survey elements labeled “The supervising RN must sign thecompleted FSR tools. RN/MD Review only”.

2. Initial Site Review a. An initial FSR consists of appropriate review personnel completing the SRS using the standard

review tools. (See Attachments A & B). PHC will accept FSRs completed by other health plans if the basis for the health plan’s review tool meets PHC’s standards for OB/GYN care. The health plan’s site reviewer should be certified by DHCS or a DHCS certified master trainer. All OB/GYN sites contracted with PHC to serve PHC members must attain a minimum passing score of 80% on the FSR tool to be considered as having passed the Facility Site Review.

b. SRS is an on-site review of the office site and processes and covers the following areas: 1) Access/ Safety Access/ Safety 2) Personnel 3) Office Management 4) Clinical Services 5) Preventive Services 6) Infection Control

c. The SRS contains eight (8) critical survey elements related to the potential for adverse effects on patient health or safety. Critical elements must be corrected within 10 business days of the survey. PHC is required to complete an initial SRS prior to credentialing of the site’s OB/GYN practitioners.

3. Initial OB Site Review a. Prior to initiating plan operations in a service area, an initial site review survey will be

completed on 100% of the OB/GYN (non-PCP) provider network. Corrective action plans (CAPs) will be completed as outlined in section III.A.7. below. PHC’s contract with the Department of Health Care Services (DHCS) requires contracted providers to follow current American College of Obstetrics and Gynecology (ACOG) standards as the minimum standards for services to PHC’s pregnant women. In addition, all obstetrical practitioners are required to provide a comprehensive initial risk assessment that includes medical nutrition, health education and psychosocial risks, on all pregnant women at the initiation of pregnancy related services. Formal re-assessments must be offered in each subsequent trimester and in the postpartum period. During the SRS, the reviewers will request documentation to determine if the provider is a CPSP or non-CPSP provider. A non-CPSP provider will be asked for documentation regarding the provider’s contractual agreement with a Certified CPSP Provider who will provide the comprehensive risk assessment, medical nutrition and psychosocial risk assessments. A non- CPSP provider may choose to use CPSP trained staff to do the comprehensive risk assessment and make referrals to the CPSP program for interventions and completion of care plans. The reviewers will request documentation of training for a provider’s CPSP trained staff. An OB/GYN site review is completed only once. There are no additional reviews beyond the initial review.

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Page 3 of 6

4. Focused Review a. Focused reviews are targeted audits consisting of a review of problem areas identified through

FSR monitoring activities or to follow up on a CAP. All deficiencies found during a focused review will require the completion and verification of corrective actions according to the CAP timelines.

5. Requirements for New Practitioners at a Site a. A FSR will not be repeated if a new provider is added to a provider site that has a current

passing FSR score. If an OB/GYN provider moves to a site that has not undergone a previous FSR, PHC performs a FSR at this site.

6. Compliance Levels a. The SRS has a total of 137 points possible. Possible points are adjusted to subtract “not

applicable” items. The reviewer will advise the practice site of any deficiencies in critical elements during the FSR. Compliance level categories include:

Compliance Category SRS Score

Exempted Pass 90% or above Conditional Pass 80-89%

OR 90% or above with deficiencies in

critical elements Not Pass Below 80%

7. Corrective Action Plan (CAP) Requirements and Timelines a. Critical Elements

1) Eight critical elements for the SRS are related to the potential for adverse effects on patient health or safety and have a scored “weight” of two points. All critical element deficiencies found during a full-scope site survey, focused survey, or monitoring visit must be corrected within 10 business days of the visit date and are to be verified by PHC within 30 calendar days of the visit date. Remaining non- critical elements with deficiencies are to be addressed in accordance with CAP timelines detailed in Conditional Pass.

b. Conditional Pass 1) PHC will provide the practice site with a survey findings report and a formal written request

for corrections of all non-critical, non-immediate deficiencies within 10 business days of the site visit. The practice site must submit a CAP to PHC addressing deficiencies within 45 calendar days of the written initial CAP request date. PHC will then review/revise/approve the CAP. The practice site shall complete corrective action plans, and PHC will verify completion, within 90 calendar days from the date of the written initial CAP request date. Under extenuating circumstances, an additional 30-day extension to complete deficiencies that have not been addressed may be granted. However, the total number of days to complete the CAP process should not exceed 120 days from the initial CAP request.

c. Not Pass 1) Pre contractual Provider – Cannot be credentialed as a network provider. Prior to being

approved as a network provider, a site review re-survey must be completed with a passing score. A CAP will be required as addressed in III.A.7.

2) Contracted Network Provider – Survey deficiencies must be corrected by the provider and verified by PHC within the CAP timelines. PHC reserves the right to remove any provider with a not pass score from the provider network. Members will be given a 30-

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Page 4 of 6

day notice of provider termination. Refer to Notification of Provider Termination or Change in Location – policy # 300 for the specific procedures.

d. CAP Documentation 1) CAPs will be completed using a standard format and form. The minimum elements to be

included on a CAP: a) Specific deficiency (ies) b) Corrective Action(s) needed c) Projected date(s) of correction d) Actual date(s) of correction e) Re-evaluation timelines/dates f) Responsible person(s) for each corrective action g) Problems in completing corrective action, if any h) Education and/or technical assistance provided by PHC i) Evidence of the correction(s) j) Completion and closure date k) Name and title of reviewer

8. Non-Compliance with Corrective Action Process a. Providers who do not correct survey deficiencies, or do not cooperate with the CAP process

within the established CAP timelines will be referred to the PHC Credentialing Committee. Actions taken by the Credentialing Committee may include termination of the site from the provider network.

b. Actions taken will be effective until corrections are verified and the CAP is closed. If PHC chooses to remove the site from the network, members will be given a 30-day notice of termination. Refer to Notification of Provider Termination or Change in Location – policy # 300 for the specific procedures.

9. Provider Appeals a. See the PHC Policy/Procedure Fair Hearing Process for Adverse Decisions for appeal

procedures. b. If verified evidence of correction of deficiencies is submitted and the decision to terminate the

provider from the network is reversed, PHC will repeat the full-scope FSR in 12 months. c. If the decision is not reversed, and the provider is terminated from the network, the practice may

reapply to become a network provider and PHC will complete an initial full-scope FSR. 10. Systematic Monitoring

a. Monitoring following the initial site review will include, but is not limited to, data gathered through the following sources: 1) Member complaints, grievances, and appeals (reviewed daily)

Potential Quality Issue information (reviewed when identified) 2) Focused review or other on-site visit (based on initial site review findings, track and

trend quarterly reports) 3) HEDIS® data collection (annually)

a) Problems identified through these mechanisms will require at a minimum 4) Inform provider of concerns 5) Request CAP when problem verified and follow the above CAP process (III.A.6.)

Critical Elements and Other Targeted Areas of Concerns 6) The Master Trainer/Supervising Reviewer will determine and specify follow up action after

the initial site review. Follow up activities may include an additional site visit to review continued compliance.

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Page 5 of 6

B. Delegation of FSR 1. Delegation Agreement

a. Prior to delegating initial site review to a provider, PHC will establish a formal, mutually agreed upon Delegation Agreement that will: 1) Identify specific delegated functions 2) Specify policies/procedures to be used for delegated functions 3) Specify reporting requirements of the delegate 4) Specify PHC training, communication, and oversight activities

b. The Delegation Agreement is modified as needed. FSR personnel from delegated entities will follow the most current DHCS site review policy requirements. PHC is responsible to notify the delegate of any changes in DHCS/PHC policies. Prior to FSR delegation, PHC will obtain DHCS approval.

2. Review Personnel a. Delegate’s reviewers shall be trained, certified and supervised according to the same standards

established for PHC review personnel. PHC’s oversight responsibilities include ensuring that staff who complete the FSR have appropriate certification and/or training.

3. Oversight Responsibilities a. PHC QI staff will review reports and FSR results submitted by delegates as specified in the

Delegation Agreement. A Delegation Review Summary will be prepared and results and recommendations for delegation status reported to the Internal Quality Improvement Committee (IQIC) and the Quality/Utilization Advisory Committee (Q/UAC).

b. Delegation may be revoked on approval of the Q/UAC if the delegate is not meeting the requirements of the Delegation Agreement or PHC staff determines that delegated functions are not properly carried out. The delegate may choose to discontinue performing a delegated function by giving PHC notification 60 days prior to the discontinuance date.

C. Potential Quality of Care Issues

1. Potential quality of care issues identified during the course of the facility site review will be conducted in accordance with the PHC policy for Peer Review Process. The nurse reviewer will complete a PQI Report Form and submit it to the Quality Department for follow up and review.

D. Local Collaboration

1. In an effort to streamline the regulatory process and reduce redundant FSR reviews at OB/GYN sites, PHC will collaborate with other health plans having contracts with mutual providers. PHC will accept the FSR score assigned by other health plans if the basis for the health plan’s review tool meets PHC’s standards. Collaboration processes are defined in detail in PHC Policy/Procedure.

VII. REFERENCES:

A. N/A VIII. DISTRIBUTION:

A. PHC Provider and Practitioner Manuals B. PHC Department Directors

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: PHC’s DHCS Master Trainer X. REVISION DATES:

Medi-Cal 05/18/05; 04/19/06; 08/15/07; 08/20/08; 09/16/09; 03/16/11; 08/21/13; 08/20/14; 08/19/15

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Page 6 of 6

Healthy Kids 08/15/07; 08/20/08; 09/16/09; 03/16/11; 08/21/13; 08/20/14; 08/19/15 PREVIOUSLY APPLIED TO: PartnershipAdvantage: MPQP1026 – 08/15/2007 to 01/01/2015

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POLICY/ PROCEDURE

I:\PR Policies\2016\IQI 8 2016\MPPRGR210.docx Page 1 of 3

Policy/Procedure Number: MP PR-GR 210 Lead Department: Provider Relations

Policy/Procedure Title: Provider Grievance ☒External Policy ☐ Internal Policy

Original Date: 04/25/1994 Next Review Date: 08/09/2017 Last Review Date: 08/10/2016


Reviewing Entities:

☒ IQI ☐ P & T ☐ QUAC ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving Entities:

☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC

☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER

Approval Signature: Richard Bell, MD Approval Date: 08/10/2016

I. RELATED POLICIES: N/A

II. IMPACTED DEPTS:

Provider Relations

III. DEFINITIONS: N/A

IV. ATTACHMENTS: N/A

V. PURPOSE: To describe the process for resolving provider grievances related to determinations of medical decisions made by Partnership HealthPlan of California or contractual disputes between the Health Plan and providers. A provider may request a grievance after all applicable PHC Appeal processes have been exhausted.


A. The Partnership HealthPlan of California, (PHC) Chief Executive Officer has primary responsibility for

maintenance, review, formulation of policy changes and procedural improvements of the grievance review system. The Chief Executive Officer is assisted by the PHC Chief Medical Officer, Health Services Director and Provider Relations Director.

B. Providers must be given an opportunity to have their grievance heard and evaluated. Two mechanisms, an informal and a formal grievance procedure, have been established for that purpose. 1. Informal grievances may be registered by the provider, by telephone, letter or visit to the PHC

office. The provider should contact the Provider Relations Department to register a grievance. The grievance is immediately recorded. If a satisfactory solution has not been reached through discussion with the parties within ten (10) working days after an informal grievance is registered, the grievance automatically becomes a formal grievance.

2. Formal grievance is filed in writing at the PHC offices or by mail within 45 working days of the

final appeal determination. There is a fifteen (15) working day resolution period during which time the PHC staff proposes a resolution to the provider. If the proposed resolution is not satisfactory, the

44 of 180


Policy/Procedure Title: Provider Grievance ☒ External Policy ☐ Internal Policy




provider may request in writing Provider Grievance Review Committee hearing. Decisions of the Provider Grievance Review Committee are binding unless reversed by the Partnership HealthPlan of California Board of Commissions. The Provider Grievance Committee will meet within forty-five (45) working days of receipt of the written provider request of a Provider Grievance Review Committee meeting.

C. The Provider Grievance Review Committee has been established to provide a formal grievance

mechanism. 1. The Provider Grievance Review Committee consists of five members:

a. The PHC Chief Medical Officer or an alternative physician selected by the Chief Medical Officer.

b. The PHC Chief Executive Officer or an alternative non-physician selected by the Chief

Executive Officer.\

c. Three members selected by the Physician Advisory Committee on an ad hoc basis. They are one physician member, one non-physician provider ie: a mid-level practitioner or ancillary provider, and a third member who represents the provider type or specialty type of the party raising the issue(s).

2. The Provider Grievance Review Committee members selected should have the ability to be fair and

impartial. Physician members may not be members of the active medical staff on a hospital if the hospital is the grieving party and non-physician providers may not be representative of a hospital if the grieving party is a physician on the active medical staff of that hospital.

3. Any person involved in the initial evaluation of the issue may not serve as a member of the

Committee but may provide information on the issue as appropriate.

4. The Physician Advisory Committee appoints the Chairperson of the Provider Grievance Review Committee. The chairperson is responsible for conducting the meeting.

5. PHC staff is responsible for selecting a recording secretary, setting the date, time, and location for

the meeting. PHC will forward all correspondence and documents submitted by the provider and PHC which are relevant to the grievance to the Committee Members five (5) working days prior to the Grievance Committee hearing.

6. The Committee meets as needed. The Committee's meeting is documented in minutes and the

provider and PHC are advised in writing of the Committee's decision within ten (10) working days of the meeting.

D. Providers appealing utilization management decisions on behalf of members must follow the procedure

outlined in health services policies and procedures “Appeals/Expedited Appeals of UM Decisions” prior to filing a request for a Provider Grievance Review hearing.

E. If during the review process, the Provider Grievance Review Committee determines that a provider may be deficient in rendering or managing care, or problem areas are discovered, this information is referred to the Performance Improvement Clinical Specialist as a Potential Quality Issue (PQI).

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Policy/Procedure Title: Provider Grievance ☒ External Policy ☐ Internal Policy




F. The plan or the plan’s capitated provider shall not discriminate or retaliate against a provider (including

but not limited to the cancellation of the provider’s contract) because the provider filed a contracted provider dispute or a non-contracted provider dispute.

VII. REFERENCES:

A. - NCQA B. - PHC Board of Commissioners

VIII. DISTRIBUTION:

- PHC Provider Manual IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Provider Relations Director

X. REVISION DATES:

08/23/1996, 10/10/1997, 03/29/2000, 07/24/2000, 09/13/2000, 07/17/2002, 11/17/2003, 2/11/2004, 02/09/2005, 03/08/2006, 07/11/2007, 03/12/2008, 04/08/2009, 07/08/2009, 08/11/2010, 08/10/2011, 08/08/2012, 08/14/2013, 08/13/2014, 08/12/2015, 08/10/2016 PREVIOUSLY APPLIED TO:

N/A

46 of 180


POLICY / PROCEDURE

Page 1 of 3

Policy/Procedure Number: MCUP3012 (previously UP100312) Lead Department: Health Services

Policy/Procedure Title: Discharge Planning (Non-capitated

Members)

☒External Policy

☐ Internal Policy

Original Date: 05/27/1999 Next Review Date: 08/17/2017

Last Review Date: 08/17/2016

Applies to: ☒ Medi-Cal ☐ Healthy Kids ☐ Employees

Reviewing

Entities:

☒ IQI ☐ P & T ☒ QUAC

☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving

Entities:




I. RELATED POLICIES:

A. MCUP3020 - Hospice Services Guidelines

B. MCUG3038 - Long Term Care Facility Review Guidelines

C. MCUP3117 - Identification and Care Coordination for Seniors and Persons with Disabilities

D. MCUG3024 - Inpatient Utilization Management

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. Discharge Planning is the coordinated process that evaluates a patient's needs and ensures that each

patient has an individualized plan for continuing care, follow-up and/or rehabilitation. It can also be

defined as planning for the appropriate continuing care of the patient upon discharge from an acute care

facility.

IV. ATTACHMENTS:

N/A

V. PURPOSE:

To define the process for Discharge Planning. Discharge Planning is part of admission certification and an

integral part of daily inpatient utilization management.


A. OBJECTIVES OF DISCHARGE PLANNING

1. To identify prior to or on admission, "high risk" patients with medical, surgical, or psychosocial

problems which have potential for increased lengths of stay or possible readmission.

2. To coordinate post discharge needs and alternative care.

3. To ensure continuity of care throughout inpatient confinement and following discharge.

4. To ensure appropriate utilization of inpatient facilities and services.

5. To prevent iatrogenic complications that may require hospital readmission. 6. To reduce length of stay by preventing unnecessary inpatient days.

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Policy/Procedure Number: MCUP3012 (previously

UP100312) Lead Department: Health Services


Members)

☒ External Policy

☐ Internal Policy




Page 2 of 3

B. PROCESS

1. Assessment

a. Discharge planning begins prior to admission by assessing the following areas:

1) The patient's living arrangements prior to hospitalization.

2) The expected living arrangements post-discharge.

3) Any significant others who would be available to provide assistance at home.

4) The assessment of patient/family psychosocial status.

5) Family, support group status.

6) The patient's socio-economic status.

7) Available community resources and the estimated cost and benefits.

8) The patient's ability to perform activities of daily living.

9) Special nursing procedures, medication administration, other special ancillary care services

required.

b. Determination of the need for discharge planning is also determined through use of goal-based

criteria. Discharge planning should be considered for all patients admitted to an acute care

facility.

c. The need of all patients for discharge planning should be identified and should commence at the

time of admission.

2. Ongoing Assessment

a. Throughout the patient's confinement, the Utilization Management (UM) Nurse Coordinator,

facility discharge planner, and/or social worker assess the following:

1) The patient/family psychosocial, and emotional status.

2) Any change in the patient's physical status that may affect post-discharge well-being (i.e.,

physical progress or deterioration, new diagnosis, disease or procedure.)

b. Once the alternate care setting has been selected and transfer has taken place, a request is made

to the agency or provider for a written progress report when necessary.

3. Identification of Alternate Medical Services

a. Home health care, hospice, or skilled nursing facility is for patients who may require

intermittent professional nursing care outside the acute care facility. See Partnership HealthPlan

of California’s (PHC’s) policies MCUP3020 Hospice Services Guidelines and MCUG3038

Long Term Care Facility Review Guidelines for authorization of these services.

4. Attending physician or hospital discharge planner must notify the UM Nurse Coordinator prior to

patient discharge for precertification of that service as part of a patient's discharge plan.

5. An alternate notification process is for the service provider to call and request precertification of

services for the patient being discharged.

C. DISCHARGE PLANNING FOR SENIORS AND PERSONS WITH DISABILITIES (SPD) PHC will ensure that the SPD beneficiary is assessed for the services needed after discharge. In the

process of discharge planning, PHC shall ensure that necessary care, services and support are in place

within the community for the SPD beneficiary once he/she is discharged from a hospital or institution.

This would include scheduling of an outpatient appointment and/or conducting follow-up with the

patient and /or caregiver. Discharge planning will also include but is not limited to: 1. Documentation of the member’s preadmission status, including living arrangements, physical and

mental function, social support, durable medical equipment (DME) and other services received.

2. Documentation of pre-discharge factors including an understanding of the medical condition by the

SPD beneficiary/representative and assessments of physical and mental function, financial resources

and social support.

3. Identification of the type of placement preferred by the SPD beneficiary/representative and the

hospital/institution.

4. Identification of the type of placement agreed to by the SPD beneficiary/representative and the

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Members)

☒ External Policy

☐ Internal Policy




Page 3 of 3

hospital/institution.

5. Identification of the specific agency/home recommended by the hospital/institution.

6. Identification of the specific agency/home agreed to by the SPD beneficiary/institution.

7. Pre-discharge counseling.

8. Summary of the nature and outcome of the SPD beneficiary/representative’s involvement in the

discharge planning process, anticipated problems in implementing post-discharge plans and further

action contemplated by the hospital/institution.

VII. REFERENCES: A. Centers for Medicare & Medicaid Services (CMS) Standards

B. Medi-Cal Guidelines

VIII. DISTRIBUTION:

A. PHC Department Directors

B. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services

X. REVISION DATES: 05/05/00; 05/16/01; 05/15/02; 10/20/04; 10/19/05; 10/17/07; 10/15/08; 11/18/09;

05/18/11; 10/15/14; 01/20/16; 08/17/16

PREVIOUSLY APPLIED TO:

*********************************

In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with

involvement from actively practicing health care providers and meets these provisions:

Consistent with sound clinical principles and processes

Evaluated and updated at least annually

If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be

disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar

illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits

covered under PHC.

49 of 180


POLICY / PROCEDURE

Page 1 of 4

Policy/Procedure Number: HKCP2015 (previously HKUP3082,

MPUP3082 & KK UM119) Lead Department: Health Services

Policy/Procedure Title: Continuity of Care External Policy

Internal Policy




Reviewing

Entities:

IQI P & T QUAC

OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT

Approving

Entities:





II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services


IV. ATTACHMENTS:

N/A

V. PURPOSE:

To define Partnership Health Plan of California’s (PHC) policy and procedure for ensuring continuity of care

for newly enrolled members receiving care from non-participating/contracted providers for specified

conditions and for members receiving care for specified conditions from a provider that terminates their

provider contract with PHC

VI. POLICY / PROCEDURE: A. PHC will, at the request of a member, provide the completion of covered services by a terminated or

nonparticipating/non-contracted provider using the following criteria:

1. The terminated provider will provide completion of covered services to a member, who at the time

of the termination was receiving services from the provider for one of the following conditions

(terminated provider is a provider or hospital who is terminating its contract with PHC.)

a. An acute condition. An acute condition is a medical condition that involves an onset of

symptoms due to an illness, injury, or other medical problem that requires prompt medical

attention and has a limited duration. Completion of covered services will be provided for the

duration of the acute condition.

b. A serious chronic condition. A serious chronic condition is a medical condition due to a

disease, illness or other medical problem or medical disorder that is serious in nature and that

persists without full cure or worsens over an extended period of time or requires ongoing

treatment to maintain remission or prevent deterioration. Completion of covered services will

be provided for a period of time necessary to complete a course of treatment and to arrange for a

50 of 180

Policy/Procedure Number: HKCP2015 (previously

HKUP3082, MPUP30822 & KK UM119) Lead Department: Health Services

Policy/Procedure Title: Continuity of Care ☒External Policy

☐Internal Policy



Applies to: ☐ Medi-Cal ☒ Healthy Kids ☐ Employees

Page 2 of 4

safe transfer to another provider, as determined by PHC in consultation with the members and

the terminated provider and consistent with good professional practice. Completion of covered

services for a serious chronic condition will not exceed 12 months from the date of the contract

termination.

c. A pregnancy. Completion of covered services will be provided for the duration of the

pregnancy and the immediate postpartum period (not to exceed 6 weeks).

d. A terminal illness. A terminal illness is an incurable or irreversible condition that has a high

probability of causing death within one year or less. Completion of covered services will be

provided for the duration of the terminal illness.

e. Care of a newborn child from birth to 36 months. Completion of covered services will not

exceed 12 months from the date of the contract termination.

f. Surgery or other procedure Performance of a surgery or other procedure that is authorized by the

plan as part of a documented course of treatment and has been recommended and documented

by the provider to occur within 180 days of the contract termination.

2. A non-participating/non contracted provider will provide the completion of covered services to a

newly enrolled member, who at the time of enrollment was receiving services from the provider for

one of the following conditions. (A non-participating/non-contracted provider is a provider or a

hospital that does not have a current contract with PHC.)

a. An acute condition. An acute condition is a medical condition that involves an onset of

symptoms due to an illness, injury, or other medical problem that requires prompt medical

attention and has a limited duration. Completion of covered services will be provided for the

duration of the acute condition.

b. A serious chronic condition. A serious chronic condition is a medical condition due to a

disease, illness or other medical problem or medical disorder that is serious in nature and that

persists without full cure or worsens over an extended period of time or requires ongoing

treatment to maintain remission or prevent deterioration. Completion of covered services will

be provided for a period of time necessary to complete a course of treatment and to arrange for a

safe transfer to another provider, as determined by PHC in consultation with the members and

the non-participating provider and consistent with good professional practice. Completion of

covered services for a serious chronic condition will not exceed 12 months from the date of the

member’s enrollment.

c. A pregnancy. Completion of covered services will be provided for the duration of the

pregnancy and the immediate postpartum period (not to exceed 6 weeks).

d. A terminal illness. A terminal illness is an incurable or irreversible condition that has a high

probability of causing death within one year or less. Completion of covered services will be

provided for the duration of the terminal illness.

e. Care of a newborn child from birth to 36 months. Completion of covered services will not

exceed 12 months from the date of the member’s enrollment.

f. Surgery or other procedure. Performance of a surgery or other procedure that is authorized by

the plan as part of a documented course of treatment and has been recommended and

documented by the provider to occur within 180 days of the contract termination.

B. A member may request the completion of covered services by calling PHC’s Member Services

Department at 707-863-4120 or 800-863-4155 in order to complete the request for continuity of care

form.

C. In order for a member to receive care completion of covered services by a terminated or non-

participating/non-contracted provider, the provider or hospital must be willing and must agree to the

terms, conditions and payment rates as set by the plan and followed by other plan network providers and

hospitals. Unless otherwise agreed, the continued services shall be compensated at rates and methods of

payments similar to those used by PHC to compensate currently contracted providers for similar

51 of 180




☐Internal Policy




Page 3 of 4

services.

D. PHC is not required to provide completion of covered services if a provider’s contract has been

terminated or not renewed for reasons relating to a medical disciplinary cause or reason, fraud, other

criminal activity or if there is a quality of care issue.

E. Members receiving completion of covered services with a terminated or non-participating/non-

contracted provider are responsible for required co-payment or cost sharing amounts which are the same

as would be paid by the member receiving the same care from a contracted provider.

F. PHC is not responsible to cover services or provide benefits that are not otherwise covered under the

program as outlined in the Evidence of Coverage (EOC).

G. Process for review of a member’s request for the completion of covered services

1. Members will be notified of their right to obtain completion of covered services under the

circumstance specified above via:

a. EOC and via a letter included in the packet of information sent to new enrollees

b. Notification of a provider termination for other members

2. The continuity of care policy and information regarding the process for a member to request

completion of covered services is also available upon request by a member.

3. Members who request completion of covered services will be referred by the Member Services

Representative to the Health Services Manager.

4. The Chief Medical Officer or Physician Designee will review requests for completion of covered

services.

a. The Chief Medical Officer or Physician Designee’s review of the request will include a review

of all records relevant to the member’s medical condition, including a telephonic discussion

with the member’s physician or other specialists as required. If all pertinent medical records are

available, the Chief Medical Officer or Physician Designee will make a decision within 2--5

working days from date request is received. Dependent upon the member’s medical condition

and/or urgency of request the timeframe may be foreshortened accordingly

b. If the Chief Medical Officer or Physician Designee determines the request meets the above-

specified criteria, the member will be notified in writing that the request has been approved

within 2 working days of the decision Dependent upon the member’s condition and medical

needs, the timeframe may be foreshortened accordingly.

c. If the Chief Medical Officer or Physician Designee determines that the request does not meet the

above-specified criteria, the member will notified in writing that the request has been denied

within 2 working days of the decision. The notice to the member will include notification of

their right to file a complaint at this time.

H. In reviewing requests for completion of covered services, the Chief Medical Officer or Physician

Designee will ensure that consideration is given to the potential clinical effect on the member’s treatment

caused by a change of provider.

VII. REFERENCES: A. California Health and Safety Code, Sections 1373.65, 1373.95-.96

B. California Insurance Code, Section 10133.56

C. California Business and Professional Code, Section 805(a)(6)

VIII. DISTRIBUTION: A. Provider Manual

B. PHC Directors


52 of 180




☐Internal Policy




Page 4 of 4

X. REVISION DATES:

08/19/15; 08/17/16


KK UM119

11/16/05

Healthy Kids

HKUP3082 - 11/21/07; 11/19/08; 06/16/10

MPUP3082 – 10/01/2010 to 03/01/2013

HKUP3082 – 03/01/2013 to 08/19/2015

Healthy Families:

MPUP3082 - 10/01/2010 to 03/01/2013

*********************************

In accordance with the California Health and Safety Code, Section 1363.5(b)(5), policies are developed with

involvement from actively practicing health care providers and meet these provisions:



Are made available to the public by accessing our web based portal at

http://www.partnershiphp.org/Providers/Policies/Pages/HealthyKids/ProviderManual_HealthyKids.aspx

If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to

both the member and provider via mail or electronically and will be accompanied by the following statement:

“The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar

illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered

under PHC.”

53 of 180



POLICY / PROCEDURE

Page 1 of 4

Policy/Procedure Number: HKUP3069 (previously MPUP3069 &

KK UM104) Lead Department: Health Services

Policy/Procedure Title: Emergency Services External Policy

Internal Policy




Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. HKUG3072 - Inpatient Utilization Management (Knox-Keene)

B. MPUP3004 - Advice Nurse Program

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS: A. Emergency Medical Condition is defined as a condition which is manifested by acute symptoms of

sufficient severity, including severe pain, such that a prudent layperson who possesses an average

knowledge of health and medicine could reasonably expect the absence of immediate medical attention

could result in:

1. Placing the health of the member (or, if the member is a pregnant woman, the health of the member

and her unborn child) in serious jeopardy

2. Serious impairment to bodily functions or

3. Serious dysfunction of any bodily organ or part

B. URGENT conditions are defined as a sudden onset of a medical condition or the worsening of an

existing medical condition such that the patient is in mild distress, but without severe pain, significant

loss of function or threatened by loss of life and where urgent therapeutic intervention within 48 hours is

needed to minimize the possibility of patient morbidity

C. Triage evaluation is defined as a screening examination performed on a member where emergency or

urgent services are not required in order to determine the appropriate location and time for the definitive

evaluation of that member’s problem.

IV. ATTACHMENTS:

N/A

V. PURPOSE:

To define the circumstances under which emergency services are covered.

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Policy/Procedure Number: HKUP3069 (previously


Policy/Procedure Title: Emergency Services ☒External Policy

☐Internal Policy




Page 2 of 4


A. Payment for Services and Prior Authorization.

1. Partnership HealthPlan of California (PHC) may review claims submitted by facilities and

practitioners to determine the appropriate payment level. PHC reserves the right to monitor claims

submitted to determine that the billing accurately reflects the level of services provided.

2. PHC covers emergency services without prior authorization for evaluation and treatment of an

emergency medical condition.

B. Referral of Triaged Members and Follow-up

1. Under Federal and State laws, a screening examination (triage services) is required to be performed

on every patient presenting to the emergency department (ED). This will be reimbursed by PHC.

If a plan member is determined to not require emergency or urgent services, the facility will

communicate with the Primary Care Provider (PCP) to determine the need for further medical

attention.

2. PHC members may generally be transferred by the treating ED Physician for care to their PCP’s

office or an urgent care facility under the following circumstances:

a. The member is willing to be seen in the PCPs office or urgent care facility.

b. The member has transportation to the alternative site.

c. The Emergency Department staff arranges an appointment for the member at a time suitable and

medically appropriate for the member.

d. The PCP or urgent care facility agrees to see the member at the appointed time.

3. The emergency department or urgent care facility is expected to notify the PCP if follow-up care is

required. The Emergency Department should send a copy of the ED record to the PCP or responsible

physician within 48 hours of the ED visit. The Emergency Department physician should notify the

PCP or the responsible physician at the time of the ED visit if urgent follow-up care by the PCP or

responsible physician is required. Follow-up care by a specialist after an ED visit must have a RAF

from the PCP to be considered for payment (exception to this is for initial orthopedic consult after

ED referral).

4. Emergency department staff will determine if the patient also must be evaluated by an emergency

department physician prior to referral to the PCP for treatment.

5. PHC maintains 24 – hour emergency telephone availability with physician backup through the PHC

Advice Nurse Line. Emergency Department providers are expected to contact the member’s PCP or

appropriate specialist for authorization of medically necessary care, coordination of transfer of

stabilized members from one facility to another, or to authorize additional services for the member.

If issues arise that cannot be resolved by the ED and the member’s provider, the ED may contact the

PHC Advice Nurse for assistance.

C. Advice Nurse Program

1. If the PHC advice nurse directs a member to the ED, PHC will pay for the visit. The advice nurse

faxes a copy of the Triage Call Documentation Report to the PCP and PHC’s Care Coordination

Department.

D. Coverage for Emergency Services Rendered Outside of the Service Area

1. Medically necessary medical care outside of the member’s service area will be provided, within the

limits of benefits, and covered only when one of the following conditions is met:

a. An emergency arises from accident, injury or illness; or

b. The health of the individual would be endangered if care and services are postponed until it is

feasible that the member return to the service area, or

c. The health of the individual would be endangered if travel were undertaken to return to the

service area; or

d. It is customary practice in border communities for residents to access emergency medical

55 of 180




☐Internal Policy




Page 3 of 4

resources in adjacent areas outside California; or

e. The out-of-state treatment plan has been proposed by the member’s attending physician, and the

plan has been received, reviewed and authorized by PHC before the services are provided AND

the proposed treatment is not available from resources and facilities within the State of

California.

E. Emergency Department Contracts

1. Certain in-plan Emergency Departments have voluntarily entered into contractual relationships with

PHC. Services will be reimbursed based on the specified contractual terms.

F. Decisions Made on Medical Appropriateness

1. On an annual basis, PHC distributes a statement to all its practitioners, providers, members and

employees alerting them to the need for special concern about the risks of under-utilization. It

requires employees who make utilization-related decisions and those who supervise them to be

aware that Utilization Management decision-making is based only on the appropriateness of care

and service. Furthermore, PHC does not specifically reward practitioners or other individual

conducting utilization review for issuing denials of coverage or service. Financial incentives for

UM decision-makers do not encourage decisions that result in under-utilization.

G. Prescribed Drugs Under Emergency Circumstances

1. When the course of treatment provided to a member under emergency circumstances requires the

use of drugs, a sufficient quantity of drugs shall be provided to the member to last until the member

can reasonably be expected to have a prescription filled.

VII. REFERENCES: A. California Code of Regulations Section 51056

B. Title 28-Division 1, Chapter 2, Article 7, Section 1300.67(2)

C. Title 28-Division 1, Chapter 2, Article 8 Section 1300.71.4

D. Health and Safety Code Section 1345(h)

E. Health and Safety Code Section 1371.4

VIII. DISTRIBUTION: A. PHC Department Directors



X. REVISION DATES: Healthy Kids

11/21/07; 11/19/08; 06/16/10; 10/01/10; 01/16/13; 08/19/15; 08/17/16


Healthy Families:

MPUP3069 - 10/01/2010 to 03/01/2013

*********************************

In accordance with the California Health and Safety Code, Section 1363.5(b)(5), policies are developed with

involvement from actively practicing health care providers and meet these provisions:


56 of 180




☐Internal Policy




Page 4 of 4


Are made available to the public by accessing our web based portal at


If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to

both the member and provider via mail or electronically and will be accompanied by the following statement:

“The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar


under PHC.”

57 of 180



POLICY / PROCEDURE

Page 1 of 5

Policy/Procedure Number: MCCP2014 Lead Department: HS Department

Policy/Procedure Title: Continuity of Care External Policy

Internal Policy

Original Date: 08/19/2015

Effective Date: 12/29/2014 per DHCS

Next Review Date: 08/17/2017



Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. MCUP3039 Special Case Managed Members

B. MPUP3126 Autism Spectrum Disorder (ASD) Behavioral Health Treatment (BHT)

II. IMPACTED DEPTS:

A. Health Services

B. Member Services

C. Claims

III. DEFINITIONS: A. Existing Relationship with Provider is defined as the situation where a beneficiary has seen an out of

network Primary Care Provider (PCP) or specialist at least once during the 12 months prior to the date of

his/her initial enrollment into Partnership HealthPlan of California (PHC) for a non-emergency visit.

(For children receiving BHT for ASD, an existing relationship means a beneficiary has seen the out-of-

network BHT provider at least one time during the six months prior to transitioning responsibility of

BHT services from the Regional Center to PHC, or the date of the beneficiary’s initial enrollment in

PHC if enrollment occurred on, or after, September 15, 2014.) This does not apply to services that are

not covered by Medi-Cal, and does not extend to the following providers: Durable Medical Equipment,

Transportation, Ancillary Services and/or Carved-Out Services.

IV. ATTACHMENTS:

A. N/A

V. PURPOSE:

The purpose of this guideline is to define the process by which a member may request to be allowed to

continue to receive services by an out of network provider in the event that the member has an established

relationship with the provider who is providing ongoing care to the member prior to his/her enrollment or re-

enrollment into Partnership HealthPlan of California. This policy applies to the following populations:

A. Medi-Cal beneficiaries assigned a mandatory aid code that transitions them from Medi-Cal

fee-for-service into a Medi-Cal managed care plan (Partnership HealthPlan of California).

B. Members newly enrolled directly into Partnership HealthPlan of California

C. Members newly enrolled in the Seniors and Persons with Disabilities Aid codes eligible

D. Members receiving Behavioral Health Treatment (BHT) services

E. Members receiving mild to moderate mental health services

F. Denied Medical Exemption Requests

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Policy/Procedure Number: MCCP2014 Lead Department: Health Services


☐Internal Policy


Effective Date: 12/29/2014




Page 2 of 5

VI. POLICY/ PROCEDURE:

A. Medi-Cal beneficiaries assigned a mandatory aid code who are transitioning into a medical managed care

plan have the right to request continuity of care in accordance with California law and managed care

plan (MCP) contracts with some exceptions. All PHC beneficiaries with pre-existing provider

relationships who make a continuity of care request to PHC must be given the opportunity to continue

treatment for up to 12 months with an out-of-network Medi-Cal provider.

B. PHC will provide continuity of care with an out-of-network provider when the following criteria are met:

1. PHC is able to determine that the beneficiary has an ongoing relationship with the provider. Self-

attestation is not sufficient to provide proof of an established relationship with a provider

2. The provider is willing to accept the higher of PHC’s contract rates or Medi-Cal Fee For Service

(FFS) rates and

3. The provider meets PHC’s applicable professional standards and has no disqualifying quality of care

issues and,

4. The provider is a California State Plan approved provider, and

5. The provider supplies PHC with all relevant treatment information, for the purposes of determining

medical necessity, as well as a current treatment plan, as long as it is under federal and state privacy

laws and regulations.

C. If a beneficiary changes managed care plans, the 12 month continuity of care period may start over one

time. If the beneficiary changes managed care plans a second time, or more, the continuity of care

period does not start over and the member does not have the right to a new 12 month period of continuity

of care. If the beneficiary returns to Medi-Cal fee-for-service and later re-enrolls in PHC the continuity

of care period does not start over. If the beneficiary changes managed care plans the continuity of care

policy does not extend to providers that the beneficiary accessed through their previous managed care

plan.

D. Behavioral Health Treatment for Children Diagnosed with Autism Spectrum Disorder: 1. PHC shall provide continued access to out-of-network BHT providers for up to 12 months beginning

September 15, 2014 when the following criteria are met:

a. PHC is able to determine that the beneficiary has an ongoing relationship with the BHT

provider. For BHT an existing relationship means a beneficiary has seen the out-of-network

BHT provider at least one time during the six months prior to transitioning responsibility of

BHT services from the Regional Center to PHC, or the date of beneficiary’s initial enrollment in

PHC if enrollment occurred on, or after, September 15, 2014.

b. The provider is willing to accept the higher of PHC’s contracted rates or Medi-Cal FFS rates,

and

c. The provider meets PHC’s applicable professional standards and has no disqualifying quality of

care issues.

d. The provider must be a State Plan approved provider as defined in Health & Safety Code

§1374.73 and documentation (i.e. assessment and treatment plan) are provided to the MCP by

the provider to facilitate continuity of care.

2. Retroactive requests for BHT service continuity of care reimbursement are limited to services that

were provided after September 15, 2014, or the date of the beneficiary’s enrollment into PHC if

enrollment occurred after September 15, 2014.

3. PHC will inform beneficiaries of their continuity of care protections through the member welcome

packet and PHC provider website. This information will include how the beneficiary and/or

provider initiate continuity of care requests with PHC. All information provided will be made

available in threshold languages and alternative formats upon request. PHC will also provide on-

going training regarding continuity of care to both the Care Coordination and Member Services staff

who interact regularly with beneficiaries and/or providers.

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E. Pregnancy and Post-Partum Beneficiaries:

Pregnant and post-partum Medi-Cal beneficiaries who are assigned a mandatory aid code and who are

transitioning from Medi-Cal FFS into a MCP have the right to request out-of-network provider

continuity of care for up to 12 months. Per H&S Code §1373.96, at the request of the member PHC will

provide for the completion of covered services relating to pregnancy, during pregnancy and immediately

after the delivery (the postpartum period) and care of a new born child between birth and 36 months by a

terminated or nonparticipating health plan provider. These requirements will apply for pregnant and

post-partum beneficiaries and newborn children who transition from Covered California to Medi-Cal due

to eligibility requirements.

F. Continuity of Care Process: 1. Beneficiaries, their authorized representative, or their provider may make a direct request to PHC for

continuity of care. PHC will begin to process the request within 5 working days of receipt of the

request. The continuity of care process begins when PHC starts the process to determine if the

beneficiary has a pre-existing relationship with the provider. PHC will complete the request within

30 calendar days from the date PHC receives the request, or 15 calendar days if the beneficiary’s

medical condition requires more immediate action such as upcoming appointments or other pressing

care needs, or 3 calendar days if their risk of harm to the beneficiary (as defined above).

2. PHC will accept requests for continuity of care over the telephone, according to the requester’s

preference and will not require that the requester complete and/or submit paper or computer form if

the requester prefers to make the request by telephone. PHC will collect any necessary information

from the requester over the telephone. PHC will consider any Medical Exception Request (MER)

that has been denied as an automatic continuity of care request.

3. PHC will utilize the following criteria to determine if a relationship exists:

a. Fee-for-service utilization data provided by DHCS, or

b. Documentation from the beneficiary and/or provider which demonstrates a pre-existing

relationship, or

c. PHC claims data

4. If a pre-existing relationship has been established with an out-of-network provider, PHC will contact

the provider and make a good faith effort to enter into a contract, letter of agreement, single-case

agreement, or other form of relationship to establish a continuity of care relationship for the

beneficiary.

5. Denial

Each Continuity of Care request is considered complete and a denial will be issued when one or

more of the following has been met:

a. PHC and the out-of-network FFS or prior MCP provider are unable to agree to a rate

b. PHC has documented quality of care issues

c. PHC makes a good faith effort to contact the provider and the provider is non-responsive for 30

calendar days.

When a continuity of care request is denied and/or a beneficiary disagrees with the result of the

process a letter will be generated to the beneficiary advising him/her of the right to purse grievance

and/or appeal when a continuity of care request is denied the beneficiary will be offered an in-

network alternative. If the beneficiary does not make an alternate choice, the beneficiary will be

referred or assigned to an in-network provider.

6. Approval If a provider meets all the necessary requirements including agreeing to a letter of agreement or

contract with PHC, PHC will grant the continuity of care request to allow access to that provider for

the length of the continuity of care period unless the provider is only willing to work with PHC for a

shorter timeframe. Upon approval, PHC will notify the beneficiary in writing within 7 calendar

days. The approval request shall include:

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a. The duration of the continuity of care agreement

b. The process that will occur to transition the beneficiary’s care at the end of the continuity of care

period and

c. The beneficiary’s right to choose a different provider from PHC’s provider network.

PHC will also notify the member 30 calendar days before the end of the continuity of care period

about the process that will occur to transition the member’s care at the end of the continuity of care

period. This process shall include Care Coordination engaging with the member and/or provider

before the end of the continuity of care period to ensure the continuity of services through the

transition to a new provider.

Although not required by DHCS, PHC may continue to work with the member’s out-of-network

provider past the 12 month continuity of care period.

7. Referrals

An approved out-of-network provider must work with PHC and its contracted network and cannot

refer the member to another out-of-network provider without authorization from PHC. In such

cases, PHC will make the referral, if medically necessary, and if PHC does not have an appropriate

provider within its network.

VII. REFERENCES: A. DHCS, All Plan Letter 14-021

B. DHCS, All Plan Letter 14-011

C. Welfare and Institutions Code Section ( ) 14132.03 and 14189




X. REVISION DATES: 8/19/15 effective 12/29/14 per DHCS; 11/18/15; 08/17/16


*********************************









under PHC.

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62 of 180


GUIDELINE / PROCEDURE

Page 1 of 2

Guideline/Procedure Number: MCUG3008 (previously

UG100308) Lead Department: Health Services

Guideline/Procedure Title: Bathroom Equipment Guidelines External Policy

Internal Policy




Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. MCUP3041 - TAR Review Process

B. MCUP3013 - DME Authorization

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS: A. N/A

IV. ATTACHMENTS:

A. N/A

V. PURPOSE: To define the process used by the Utilization Management (UM) staff when reviewing a Treatment

Authorization Request (TAR) for bathroom equipment.

VI. GUIDELINE / PROCEDURE:

A. Bathroom equipment must be ordered by the member’s primary care provider (PCP) or specialist treating

the member through a referral from the PCP. For special members, the bathroom equipment must be

ordered by the physician currently managing the medical care for the member.

B. The following types of bathroom equipment are covered by PHC provided that medical necessity has

been demonstrated.

1. Toilet rail or armrest

2. Raised toilet seat

3. Tub stool, bench or bath seat

4. Bathtub safety rail or grab bars

5. Transfer tub bench

6. Commode (bedside)

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C. The TAR must include documentation of medical necessity for use of the device that includes the

following information related to the condition:

1. Length of time member has been or will be need the equipment

2. Assessment of mental status

3. Evaluation of functional abilities including assessment of body strength/mobility.

D. Documentation should include information concerning the member's ability to properly use the bathroom

equipment.

E. Durable Medical Equipment (DME) items are covered as medically necessary only to preserve bodily

functions essential to activities of daily living or to prevent significant physical disability but not

necessarily to restore the member to previous function.

VII. REFERENCES: A. Medi-Cal Guidelines

VIII. DISTRIBUTION: A. PHC Departmental Directors



X. REVISION DATES: 04/28/00; 10/17/01; 10/16/02; 02/16/05; 10/17/07; 11/18/09; 05/18/11; 08/20/14;

01/20/16; 08/17/16

*********************************









covered under PHC.

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Page 1 of 3



Guideline/Procedure Title: Criteria for Home Health Services External Policy

Internal Policy

Original Date: 08/1998 Next Review Date: 08/17/2017



Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:





A. MCCP2005 - EPSDT Supplemental Shift Nursing Services

B. MCUP3041 - TAR Review Process

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services


IV. ATTACHMENTS:

N/A

V. PURPOSE:

To provide guidelines for Treatment Authorization Request (TAR) submission for Home Health Services.


A. Member Selection Criteria

1. Members receiving home health services must meet all of the following criteria.

a. Member must be Partnership HealthPlan of California (PHC) eligible at the time services are

rendered.

b. Member must be homebound.

1) A member is a homebound recipient if he or she is essentially confined to his or her home

due to illness or injury, and if ambulatory or otherwise mobile, is unable to be absent from

his or her home except on an infrequent basis or for periods of relatively short duration; for

example, for a short walk prescribed as therapeutic exercise.

c. Member must need skilled nursing services on an intermittent basis.

1) To meet the requirement for "intermittent" skilled nursing care, an individual must have a

medically predictable recurring need for skilled nursing services. This may be met if the

member requires a skilled nursing service at least once every sixty (60) days and when the

skilled service is determined to be medically necessary.

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d. Member must be under the care of a physician or specialist.

1) This physician may be the member's primary care provider (PCP). The attending physician

must order the services, establish the plan of treatment, and certify the necessity for home

health care.

B. Home Health Services.

1. The following services may be rendered in the home care agency if medical necessity criteria are

met.

a. Physical, speech, or occupational therapies are subject to benefit limitations and exclusions.

1) Physical Therapy – Authorized services must relate directly and specifically to an active

written treatment regimen established by the physician after any needed consultation with

the qualified physical therapist and must be reasonable and necessary to the treatment of the

member's illness or injury.

2) Occupational Therapy – Authorized services must be prescribed by a physician and it must

be performed by a qualified occupational therapist. Services must be reasonable and

necessary for the treatment of the individual's illness or injury and the therapy must be

expected to result in a significant practical improvement in the individual's level of

functioning within a reasonable period of time.

3) Speech Therapy – Authorized services include assistance to the physician in evaluating

members to determine the type of speech or language disorder and the appropriate

corrective therapy.

b. Medical Social Services

1) Services dealing with social, economic, and emotional factors related to the illness.

c. The services must be performed by or under the direct supervision of a licensed nurse (RN,

LPN, LVN). In some cases, the services of a home health aide may be a covered benefit. In

determining which services require the skill of a nurse, the following are considered:

1) The inherent complexity of the services

2) The condition is such that a service which would normally be classified as skilled can be

provided safely and effectively only by a nurse

d. Daily skilled services generally should not extend beyond three (3) weeks. The physician

should re-evaluate and provide medical documentation for additional services including an

estimate on the length of time daily services will be required.

e. Home nursing services are provided only through certified home health agencies. PHC may

authorize home nursing services through credentialed RN/ LVNs who are EPSDT

supplemental service providers if, and only if, there is documented non-availability of a

home health agency to provide the needed services. See policy MCCP2005 EPSDT

Supplemental Shift Nursing Services. C. Initial TAR Process

1. The home health agency must submit a TAR along with a documented evaluation and treatment plan

to PHC. Items and services must be furnished under a plan of care established and periodically

reviewed by a physician which relate specifically to the patient’s present condition. The treatment

plan must include the following:

a. Date of onset of the illness

b. Medical diagnosis necessitating the service, with a summary of the clinical history

c. Related medical conditions

d. Functional limitations

e. Prognosis

f. Description of home situation, including assistance available from household members or other

care givers, including language or communication problems

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g. Therapeutic goals to be achieved by each discipline and anticipated time to achieve goals

h. Types of services to be rendered by each discipline related to the problem with CPT codes

i. Description of plan to instruct household members or other caregivers to provide needed care

including plans to overcome barriers

2. If the request meets medical criteria, the TAR will be approved. If not, the case will be reviewed by

the Chief Medical Officer or physician designee.

D. If services beyond the initially approved TAR are exceeded, a new TAR must be submitted with home

health progress notes.

1. If another evaluation is needed within 6 months, it will be granted only if there is a significant

change in the member’s condition or family situation which requires a new individual treatment

plan.

2. A monthly evaluation is covered only if there is a significant change in the member’s medical

condition or if the treatment plan is complex and involves a variety of services during the month.

E. In the event of a hospital admission during the time home health services are authorized and being

rendered, notification to PHC must be made. Upon discharge from the acute setting and a return to home

health services, a new TAR with current clinical notes must be submitted. A new treatment plan/ form

485 is not necessary.

VII. REFERENCES: N/A

VIII. DISTRIBUTION: A. PHC Departmental Directors



X. REVISION DATES: 06/21/00; 04/18/01; 01/16/02; 08/20/03; 02/16/05; 10/17/07; 10/15/08; 07/21/10;

02/15/12; 02/20/13; 08/20/14; 01/20/16; 08/17/16

*********************************









under PHC.

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POLICY / PROCEDURE

Page 1 of 5


Policy/Procedure Title: Rehabilitation Guidelines for Acute and

Skilled Nursing Inpatient Services

☒External Policy

☐ Internal Policy




Reviewing

Entities:



Approving

Entities:





A. MCUP3041 - TAR Review Process

B. MCUP3038 - Long Term Care Facility Review Guidelines

C. MCUG3024 - Inpatient Utilization Management

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. Medical Necessity - Necessary health care services are those needed to protect life and to prevent

significant illness or significant disability, or to alleviate pain.

IV. ATTACHMENTS:

A. N/A

V. PURPOSE:

To provide guidelines for review of rehabilitation facility admissions and define the criteria for authorization

of rehabilitation services at either a long-term care (LTC) facility or an acute care facility to ensure that

services that are delivered are medically appropriate and consistent with diagnosis and level of care required

for each individual.


A. Overview

1. Acute rehabilitation is an interdisciplinary process under the direction of a physician skilled in

rehabilitation medicine. It is intended to help the physically or cognitively impaired member

achieve or regain maximum functional potential for mobility, self-care, and independent living.

Certification for inpatient or LTC acute rehabilitation services is contingent upon the presence of

one or more major physical impairments which significantly interfere with function and which

require complex therapeutic interventions to restore function.

2. Rehabilitative services for the physically and/or cognitively impaired member are covered in the following circumstances:

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a. Immediately post hospitalization for acute trauma or other disease resulting in impairment.

b. Maintenance therapy for chronically impaired members is expected to be provided in Long term

or subacute hospitals and is included in the facility’s per diem rate. Outpatient services at a

rehabilitation clinic.

c. In home care for home bound members.

3. The member must demonstrate a need for an interdisciplinary therapeutic program to reach the goals

established by the initial evaluation. A severe functional deficiency must be present in one or more

of the following areas:

a. Self-care skills - including drinking, feeding, dressing, hygiene, grooming, bathing, perineal

care, and/or use of upper or lower extremity prosthesis or orthosis.

b. Mobility skills - including dependence upon an assistant or supervision in transferring to and

from chair, toilet, tub or shower, upright ambulation and/or use of wheelchair.

c. Bladder control and management - needing assistance in urination and in developing and/or

maintaining a bladder program due to lack of bladder control.

d. Bowel control and management - needing assistance in excretion and in developing and/or

maintaining a bowel program due to lack of bowel control.

e. Pain management - pain so severe as to markedly limit functional performance.

f. Safety - needing instruction because of impaired judgment, impulsive behavior, or physical

deficits in the proper and safe management of self-care and/or avoidance of complications such

as contractures, decubiti or urinary tract infections.

g. Cognitive functioning - needing speech and /or language therapy in association with another

primary problem listed above.

h. Communication - needing speech and/or language therapy in association with another primary

problem listed above.

4. Members are not eligible for rehabilitative services unless the member's medical problems are stable

and will not interfere substantially with the rehabilitation program. The member must also

demonstrate a cognitive ability to understand the program and the motivation to participate in all

aspects of the program. The member must have adequate endurance to actually participate in the

program.

5. The attending physician must refer the member to the rehabilitation program for an initial

evaluation. For case managed members, either the member’s primary care provider (PCP) must

make the referral or concur with the physician who made the referral. After the rehabilitation

program has completed the initial evaluation, a treatment plan must be developed, in consultation

with the referring physician as indicated.

6. A Treatment Authorization Request (TAR) must be submitted by the rehabilitation program

indicating the services requested, a description of medical need, level of rehabilitation services, and

a copy of the treatment plan. The referring physician must sign the treatment plan. In order to

expedite care, PHC will accept the TAR with an unsigned treatment plan, however; the rehabilitation

program must obtain the physical signature as soon as possible.

7. The written treatment plan must include the following:

a. Date of onset of the illness

b. Medical diagnosis necessitating the service, with severity and duration of condition

c. Related medical conditions

d. Impairments necessitating an inpatient or LTC admission for rehabilitation services

e. Functional limitations including cognitive abilities, mobility and self-care limitations, emotional

problems, and communication difficulties

f. History and results of previous rehabilitation services and outcomes of treatment

g. Prognosis

h. Therapeutic goals to be achieved by each discipline and anticipated time to achieve goals

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i. Types of services to be rendered by each discipline related to the problem

j. Description of plan to instruct household members or other caregivers to provide needed care

after discharge from the rehabilitation program.

k. Documentation that the member has sufficient strength to actively participate in the proposed

treatment.

8. The LTC Nurse Coordinator reviews the TAR for medical necessity and consults with the referring

physician or rehabilitation staff as indicated. Definition of "medical necessity" states that necessary

health care services are those needed to protect life and, to prevent significant illness or significant

disability, or to alleviate pain. The Chief Medical Officer or physician designee is the only

individual who can deny TARs for inpatient or LTC rehabilitation services.

9. If additional days are needed beyond the initial TAR, a progress report must be submitted to PHC

documenting that significant improvement has occurred with the initial therapy and that continued

therapy will further improve the member’s function, although not necessarily restoration of full

capacity. The progress report must indicate plans for discharge and measured progress in each

problem area being treated. In addition, the report must detail the member's active participation in

therapy and that the member still requires close supervision in an inpatient or LTC setting.

10. Requests for extension of inpatient rehabilitation services are denied for medical necessity for the

following reasons:

a. Therapeutic goals have been attained or the prospect of further incremental improvement is so

small that an additional expense is not justified

b. Lack of progress toward attaining goals, with further progress unlikely

c. Inability or unwillingness of member or family to cooperate with the member’s program

d. Goals can be achieved at a lower level of care

B. Admission Criteria

All statements in Section VI.B.1. Patient Selection and Section VI.B.2. Admission below must apply to

the patient.

1. Patient Selection

a. The patient must have a physical disability of which the medical condition and functional

performance can be realistically improved through intensive, accepted rehabilitation measures.

b. The patient must have the potential to be medically and emotionally stable for management on a

rehabilitation nursing service and be capable of active participation in a rehabilitation program.

c. The patient must be in need of close daily medical supervision by a physician with specialized

training or experience in rehabilitation and must require 24-hour rehabilitation nursing or other

rehabilitation services.

d. Primary admitting diagnosis must include one of the following:

1) Stroke

2) Spinal cord injury

3) Amputation

4) Major multiple trauma

5) Fracture of femur (hip)

6) Brain injury

7) Polyarthritis - including rheumatoid arthritis

8) Neurological disorder, including multiple sclerosis, motor neuron diseases, polyneuropathy,

muscular dystrophy, and Parkinson's Syndrome

9) Burns

10) Other conditions requiring intensive rehabilitative care

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2. Admission

a. Skilled rehabilitation services, as ordered by a physician, must be required and provided on a

daily basis. Daily may be defined to be at least five (5) days a week. A break of a day or two in

service where rehabilitation services are not furnished and discharge is not indicated is also

permissible.

b. The medical director of the rehabilitation unit or the physician designee must perform patient

evaluation and final determination regarding transfer of the patient to the rehabilitation service.

c. Admission medical record (admission physical examination) must include all of the following:

1) Treatment goals - what functional improvements might be realistically expected from

rehabilitation.

2) Potential - what is the realistic possibility of achieving above stated goals - excellent, good,

fair, guarded.

3) Treatment plan - how will treatment goals be achieved. Specifically what therapies will be

utilized - Physical Therapy, Occupational Therapy, Speech, Psychology, Social Service.

4) Duration of stay - realistic estimate of time required to achieve stated goals.

C. CONTINUED STAY CRITERIA

(These criteria will only be applied up to the limit of rehabilitation coverage.)

1. A treatment plan, as outlined on admission physical examination, must be reviewed and revised as

needed, at least weekly, in consultation with rehabilitation nursing, all involved therapies and social

services.

2. The patient must be receiving basic therapeutic and training services at least twice daily from at least

two therapies in addition to rehabilitation nursing.

3. There must be documented, weekly continued improvement in one or more functional abilities in at

least one therapy.

4. If there is development of a complicating medical or emotional problem which requires temporary

suspension of rehabilitation therapies, but which is of such a nature as to expect a return to an active

rehabilitation program within one week (seven days) then rehabilitation services may be continued.

D. DISCHARGE CRITERIA

Must meet either 1, 2, 3, or 4 below:

1. The patient has met the goals established at and subsequent to the time of admission.

2. The patient no longer requires rehabilitative nursing and is receiving treatment in only one therapy

area, i.e., occupational therapy, physical therapy, speech therapy, psychology, neuropsychology.

3. There is no evidence of progress toward documented goals.

4. There are intercurrent medical condition that requires acute care and suspension of rehabilitative

services.

5. A weekend pass may be given the week prior to planned discharge to determine problems or issues

that might exist that would need to be addressed before patient is sent home.

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E. CASE REVIEW CONFERENCES

PHC members in acute rehabilitation facilities are reviewed in case review conferences.

1. Weekly review conferences are held to discuss select hospitalized members.

2. Participants include, but are not limited to, Utilization Management (UM) Nurse Coordinators, Care

Coordination staff, UM Team Manager, Chief Medical Officer and/or Regional Medical Director

and the Director of UM.

3. The purpose of the meeting is to collaborate and facilitate timely medical services and transition to

the next level of care.

4. UM Nurse Coordinators may also attend conferences at assigned hospitals upon request.

5. LTC Nurse Coordinators are expected to follow the review guidelines outlined in policy

MCUG3024 Inpatient Utilization Management Procedure including, but not limited to, admission

review, and concurrent review.

NOTE: The above criteria are neither mutually inclusive nor exclusive. The final judgment must be

reached using professional nursing judgment of the variety of the care needs and the availability of other

care alternative to determine the need for rehabilitation level of care.

VII. REFERENCES: A. Medi-Cal criteria for Inpatient and Outpatient care

B. California Code of Regulations (CCR) Title 22

C. “Rehabilitation Institution Admission, Continued Stay, and Discharge Criteria", GM: Professional

Review Organization - GLSC, Michigan

VIII. DISTRIBUTION:

A. PHC Departmental Directors



X. REVISION DATES: 03/23/95; 08/98; 06/21/00; 04/18/01; 01/16/02; 08/20/03; 09/15/04; 10/19/05;

08/20/08; 05/19/10; 11/28/12; 01/20/16; 08/17/16

PREVIOUSLY APPLIED TO: N/A

***********************************









covered under PHC.

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POLICY/ PROCEDURE

Page 1 of 11

Policy/Procedure Number: MCUP3133 Lead Department: Health Services

Policy/Procedure Title: Wheelchair Mobility, Seating and Positional

Components

☒External Policy

☐ Internal Policy




Reviewing

Entities:



Approving

Entities:





A. MCUP3041 Tar Review Process

II. IMPACTED DEPTS:

A. Health Services

B. Provider Relations

C. Claims

D. Member Services

III. DEFINITIONS:

A. Activities of Daily Living (ADL): The activity of dressing/bathing, eating, ambulating (walking),

toileting and hygiene.

B. Custom Rehabilitation Equipment: Any item, piece of equipment or product system, whether

modified or customized, that is used to increase, maintain or improve functional capabilities with respect

to mobility and reduce anatomical degradation and complications of individuals with disabilities.

Custom rehabilitation equipment includes, but is not limited to, non-standard manual wheelchairs, power

wheelchairs and seating systems, power scooters that are specially configured, ordered, and measured

based upon patient height, weight and disability, specialized wheelchair electronics and cushions, custom

bath equipment, standards, gait trainers and specialized strollers.

C. Durable Medical Equipment (DME): Devices and equipment, other than prosthetic or orthotic

appliances, which have been ordered by a licensed practitioner in the treatment of a specific medical

condition and which have all of the following characteristics:

1. Can withstand repeated use

2. Is used to serve a medical purpose

3. Is not useful to an individual in the absence of an illness, injury, functional impairment or congenital

anomaly; and

4. Is appropriate for use in or out of a patient’s home.

D. Instrumental Activities of Daily Living (IADL): Activities that allow an individual to live

independently in a community and include shopping, housekeeping, accounting, food preparation, taking

medications as prescribed, use of a telephone or other form of communication, and accessing

transportation within one’s community.

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Policy/Procedure Title: Wheelchair Mobility, Seating and

Positional Components

☒ External Policy

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E. Licensed Practitioners: Clinical professionals furnishing medical care, or any other type or remedial

care recognized under State law within their scope of practice as defined by State Law.

F. Medical Necessity: A wheelchair is considered medically necessary if the beneficiary’s medical

condition and mobility limitation are such that without the use of a wheelchair, the beneficiary’s ability

to perform one or more mobility related Activities of Daily Living or Instrumental Activities of Daily

Living, in or out of the home, including access to the community, is impaired and the beneficiary is not

ambulatory or functionally ambulatory without static supports such as a cane, crutches or walker.

G. Power Mobility Device (PMD): - Base codes include both integral frame and modular construction type

power wheelchairs (PWCs) and power operated vehicles (POVs).

H. Power Operated Vehicle (POV): Chair-like battery power fed mobility device for people with

difficulty walking due to illness or disability, with integrated seating system, tiller steering, and four

wheel non-highway construction.

I. Power Wheelchair (PWC): Chair-like battery powered mobility device for people with difficulty

walking due to illness or disability, with integrated seating system, electronic steering, and four or more

wheel non-highway construction.

J. Qualified Rehabilitation Professional (QRP): - Professionals with competence in analyzing the needs

of consumers with disabilities, assisting in the selection of appropriate assistive technology for the

consumer’s needs, and training in the use of the selected device(s). Specialty certification is required for

professionals working in seating, positioning and mobility.

IV. ATTACHMENTS:

A. N/A

V. PURPOSE: To describe the policy and processes for review of wheelchairs (manual and electric powered) and Power

Operated Vehicles (POV) in accordance with the Department of Health Care Services All Plan Letter,

APL15-018 issued July 9, 2015.


A. A request for manual or powered mobility devices (wheelchairs, POVs) requires a written

request/prescription from a licensed professional. Upon receipt of the request, Partnership HealthPlan of

California (PHC) will arrange for an assessment by a qualified rehabilitation professional (QRP). The

purpose of the assessment is to evaluate the appropriateness of the request and to identify the type of

equipment best suited to meet the member’s specific needs. The QRP will submit a written summary of

findings and recommendations for PHC and the ordering provider.

A prescription for a wheelchair will not be denied on the grounds that it is for use only outside the home.

The following sequential questions offer clinical guidance for the ordering of an appropriate device to

meet the medical need of treating and restoring the beneficiary’s ability to perform one or more mobility

related ADLs or IADLs. These guiding principles will be used by PHC in making a benefit coverage

determination.

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1. Does the beneficiary have a mobility limitation that significantly impairs his/her

ability to participate in one or more ADLs or IADLs? A mobility limitation is one that:

a. Prevents the beneficiary from accomplishing the ADLs or IADLs entirely, or,

b. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality

secondary to the attempts to participate in ADLs or IADLs, or

c. Prevents the beneficiary from completing the ADLs or IADLs within a reasonable time frame

2. Are there other conditions that limit the beneficiary’s ability to participate in ADLs or

IADLs?

a. Some examples are impairment of cognition or judgment and/or vision.

b. For these beneficiaries, the provision of a wheelchair and seating and provisional components

(SPC) might not enable them to participate in ADLs or IADLs if the comorbidity prevents

effective use of the wheelchair or reasonable completion of the tasks even with wheelchair and

SPC.

3. If these other limitations exist, can they be ameliorated or compensated such that the additional

provision of wheelchair and SPC will be reasonably expected to improve the beneficiary’s ability to

perform or obtain assistance to participate in ADLs or IADLs?

a. If the amelioration or compensation requires the beneficiary's compliance with treatment, for

example medications or therapy, substantive non-compliance, whether willing or involuntary,

can be grounds for denial of wheelchair and SPC coverage if it results in the beneficiary

continuing to have a limitation.

b. It may be determined that partial compliance results in adequate amelioration or compensation

for the appropriate use of wheelchair and SPC.

4. Does the beneficiary demonstrate the capability and the willingness to consistently operate the

wheelchair and SPC safely and independently?

a. Safety considerations include personal risk to the beneficiary as well as risk to others. The

determination of safety may need to occur several times during the process as the consideration

focuses on a specific device.

b. A history of unsafe behavior may be considered.

5. Can the functional mobility deficit be sufficiently resolved by the prescription of a cane, crutches

or walker?

a. The cane, crutches or walker should be appropriately fitted to the beneficiary for this evaluation.

b. Assess the beneficiary’s ability to safely use a cane, crutches or walker.

6. Does the beneficiary’s typical environment support the use of wheelchair and SPC?

a. Determine whether the beneficiary’s environment will support the use of medically necessary

types of wheel chair and SPC.

b. Keep in mind such factors as physical layout, surfaces, and obstacles, which may render

wheelchair and SPC unusable.

7. Does the beneficiary have sufficient upper extremity function to propel a manual wheelchair to

participate in ADLs or IADLs during a typical day? The manual wheelchair should be optimally

configured (SPC), wheelbase, device weight, and other appropriate accessories) for this

determination.

a. Limitations of strength, endurance, range of motion, coordination, and absence or deformity

in one or both upper extremities are relevant.

b. A beneficiary with sufficient upper extremity function may qualify for a manual wheelchair.

The appropriate type of manual wheelchair, i.e. light-weight, etc., should be determined based on the beneficiary’s physical characteristics and anticipated intensity of use.

c. The beneficiary’s typical environment (in or out of the home) provides adequate

access, maneuvering space and surfaces for the operation of a manual wheelchair.

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d. Assess the beneficiary’s ability and willingness to safely and effectively use a manual

wheelchair.

8. Does the beneficiary have sufficient strength and postural stability to operate a POV/scooter?

a. A covered POV is a 4-wheeled device with tiller steering and limited seat modification

capabilities. The beneficiary must be able to maintain stability and position for adequate

operation without additional SPC (a 3-wheeled device is not covered).

b. The beneficiary’s typical environment (in or out of the home) provides adequate access,

maneuvering space and surfaces for the operation of a POV.

c. Assess the beneficiary’s ability to safely use a POV/scooter.

9. Are the additional features provided by a power wheelchair or powered SPC needed to allow

the beneficiary to participate in one or more ADLs or IADs?

a. The pertinent features of a power wheelchair compared to a POV are typically control

by a joystick or alternative input device, lower seat height for slide transfers, and the ability to

accommodate a variety of seating needs.

b. The type of wheelchair and options provided should be appropriate for the degree of the

beneficiary’s functional impairments.

c. The beneficiary’s typical environment (in or out of the home) provides adequate

access, maneuvering space and surfaces for the operation of a power wheelchair.

d. Assess the beneficiary’s ability to safely and independently use a power wheelchair and

powered SPC.

B. Medical Necessity

1. Manual wheelchairs are medically necessary when:

a. Criteria 1), 2), 3), 4) and 5) below are met; and

b. Criterion 6) or 7) is met, and

c. Criteria is met for specific devices listed below.

1) The beneficiary has a mobility limitation that significantly impairs his/her ability to

participate in one or more ADLs or IADLS, and

2) The beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an

appropriately fitted cane, crutches or walker, and

3) The manual wheelchair supplied to the beneficiary for use in or out of the home and

community settings provides adequate access to these settings (e.g., between rooms, in and

out of the home, transportation, over surfaces and a secure storage space), and

4) Use of a manual wheelchair will improve the beneficiary’s ability to participate in ADLs

5) The beneficiary has expressed a willingness to use the manual wheelchair that is provided,

and

6) The beneficiary has sufficient upper extremity function and other physical and mental

capabilities needed to safely self-propel the manual wheelchair during a typical day.

Limitations of strength, endurance, range of motion, or coordination, presence of pain, or

deformity or absence of one or both upper extremities are relevant to the assessment of

upper extremity function.

7) A standard wheelchair may be medically necessary

a) When the beneficiary is able to self-propel the wheelchair, or

b) Propel with assistance

8) A standard hemi-wheelchair may be medically necessary

a) For disarticulation of one or both lower extremities, or b) Requires a lower seat height because of short stature, or

c) To enable the beneficiary to place his/her feet on the ground for propulsion

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9) A lightweight wheelchair may be medically necessary

a) When a beneficiary’s medical condition and the weight of the wheelchair affects the

beneficiary’s ability to self-propel, or

b) For a beneficiary with marginal propulsion skills.

10) A high strength lightweight wheelchair may be medically necessary when

a) The beneficiary’s medical condition and the weight of the wheelchair affects the

beneficiary’s ability to self-propel while engaging in frequent ADLs or IADs that

cannot be performed in a standard or lightweight wheelchair, or

b) The beneficiary requires a seat width, depth, or height that cannot be

accommodated in a standard, lightweight or hemi-wheelchair

11) An ultra-lightweight multi-adjustable wheelchair may be medically necessary when

a) The beneficiary’s medical condition and the weight of the wheelchair affects the

beneficiary’s ability to self-propel while engaging in frequent ADLs or IADs that

cannot be performed in a standard, lightweight or high strength lightweight

wheelchairs, and

b) The beneficiary’s medical condition and the position of the push rim in relation to the

beneficiary’s arms and hands is integral to the ability to self-propel the wheelchair

effectively, and

c) The beneficiary has demonstrated the cognitive and physical ability to independently

and functionally self-propel the wheelchair, or

d) The beneficiary’s medical condition requires multi-adjustable features or dimensions

that are not available in a less costly wheelchair (e.g., pediatric size and growth

options)

12) A heavy duty wheelchair is medically necessary when

a) The beneficiary weighs more than 250 pounds, or

b) The beneficiary has severe spasticity, or

c) Body measurements cannot be accommodated by standard sized wheelchairs.

13) An extra heavy duty wheelchair is medically necessary when

a) The beneficiary weighs more than 300 pounds, or

b) Body measurements cannot be accommodated by a heavy duty wheelchair

14) Manual tilt-in-space wheelchairs are medically necessary when

a) The beneficiary is dependent for transfers, and

b) The beneficiary has a plan of care that addresses the medical need for frequent

positioning changes (e.g., for pressure reduction or poor/absent trunk control) that do

not always include a tilt position.

15) Back-up manual wheelchairs are medically necessary when

a) The beneficiary meets the criteria for a powered mobility device, and

b) The beneficiary meets the criteria for the rented or purchased back-up manual

wheelchair, and

c) The beneficiary is unable to complete ADLs or IADs without a back-up manual

wheelchair, and

d) The backup wheelchair accommodates the SPC on the primary wheelchair.

16) Pediatric sized folding adjustable wheelchairs with seating systems are covered as primary

or back-up wheeled mobility when

a) The beneficiary meets the criteria for wheeled mobility, and b) The wheelchair is an appropriate size for the beneficiary, and

c) The beneficiary meets the criteria for recline and positioning options, and

d) The wheelchair provides growth capability in width and length

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2. Powered Mobility Devices are medically necessary when:

a. Criteria 1), 2), and 3) below are met, and

b. Criteria is met for specific devices listed below.

1) The beneficiary has a mobility limitation that impairs his or her ability to participate in one

or more ADL or IADLs, and

2) The beneficiary’s mobility limitation cannot be safely resolved by the use of an

appropriately fitted cane, crutches or walker, and

3) The beneficiary does not have upper extremity function to self-propel an optimally-

configured manual wheelchair to perform ADLs or IADs during a typical day. Limitations

of strength, endurance, range of motion, or coordination, presence of pain, or deformity or

absence of one or both upper extremities are relevant to the assessment of upper extremity

function. An optimally-configured manual wheelchair is one with an appropriate

wheelbase, device weight, seating options, and other appropriate non-powered

accessories.

A four wheeled Power Operated Vehicle (POV) is covered if all of the basic coverage criteria 1) - 3) have been met and if criteria 4) - 9) are also met.

4) The beneficiary is able to:

a) Safely transfer to and from a POV, and

b) Operate the tiller steering system, and

c) Maintain postural stability and position in standard POV seating while operating the

POV without the use of any additional positioning aids

5) The beneficiary’s mental capabilities (e.g., cognition, judgment) and physical capabilities

(e.g., vision) are sufficient for safe mobility using a POV in or out of the home, and

6) The beneficiary’s home provides adequate access between rooms, in and out of the home,

maneuvering space, over surfaces and a secure storage space for the operation of the POV

that is provided, and

7) The beneficiary’s weight is less than or equal to the weight capacity of the POV that is

provided, and

8) Use of a POV will significantly improve the beneficiary’s ability to participate in ADLs or

IADs, and

9) The beneficiary has expressed willingness to use a POV

NOTE: Group 2 POVs have added capabilities that must be medically justified; otherwise

payment will be based on the allowance for the least costly medically appropriate alternative,

the comparable Group 1 POV. If coverage criteria 1) – 9) are met and if a beneficiary’s weight can be accommodated by a POV with a lower weight capacity than the POV that is

provided, payment will be based on the allowance for the least costly medically appropriate alternative.

A Power Wheelchair (PWC) is covered if all of the basic coverage criteria 1) – 3) have been met and

i. The beneficiary does not meet coverage criterion 4), 5), or 6) above for a POV; and

ii. Criteria 10) – 13) below are met; and iii. Any coverage criteria pertaining to the specific wheelchair grouping (see below) are

met.

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10) The beneficiary has the mental and physical capabilities to safely and independently operate

the power wheelchair that is provided, and

11) The beneficiary has the mental and physical capabilities to safely and independently operate

the power wheelchair that is provided, and

12) The beneficiary’s typical environment (in or out of the home) provides adequate access

between rooms, maneuvering space, over surfaces and a secure storage space for the

operation of the power wheelchair that is provided, and

13) The beneficiary has expressed willingness to use a power wheelchair.

Power Wheelchairs are segmented into the following groupings:

14) A Group 1 PWC (K0813-K0816) or a Group 2 (K0820-K0829) is covered if all of the

coverage criteria [1) – 3), 10) - 13)] for a PWC are met and the wheelchair is appropriate for

the beneficiary’s weight.

15) Group 2 Single Power Option PWC (K0835 – K0840) is covered if all of the coverage

criteria [1) – 3), 10) - 13)] for a PWC are met and if Criterion a) or b) below is met;

a) The beneficiary requires a drive control interface other than a hand or chin- operated

standard proportional joystick (examples include but are not limited to head control, sip

and puff, switch control), or

b) The beneficiary meets coverage criteria for a power tilt or a power recline seating

system and the system is being used on the wheelchair

16) A Group 2 Multiple Power Option PWC (K0841-K0843) is covered if all of the

coverage criteria [1) – 3), 10) - 13)] for a PWC are met and if Criterion a) or b) below is

met;

a) The beneficiary meets coverage criteria for a power tilt and recline seating system and

the system is being used on the wheelchair, or

b) The beneficiary uses a ventilator which is mounted on the wheelchair.

17) A Group 3 PWC with no power options (K0848-K0855) is covered if all of the coverage

criteria [1) – 3), 10) - 13)] for a PWC are met and if the beneficiary's mobility limitation is

due to a neurological condition, myopathy, or congenital skeletal deformity.

18) A Group 3 PWC with Single Power Option (K0856-K0860) or with Multiple Power

Options (K0861-K0864) is covered if all of the coverage criteria [1) – 3), 10) - 13)] for a

PWC are met and if:

a) The Group 3 criteria [17)] are met, and

b) The Group 2 Single Power Option criteria [15)] or Multiple Power Options [16)] are

met.

19) A Group 4 PWC with no power options (K0868-K0871) is covered if all of the coverage

criteria [1) – 3), 10) - 13)] for a PWC are met and if:

a) The Group 3 criteria [17)] are met, and

b) The minimum range, top end speed, obstacle climb or dynamic stability incline that is

medically necessary for the beneficiary engaging in frequent ADLs or IADs cannot be

performed in a Group 3 PWC.

20) A Group 4 PWC with Single Power Option (K0877-K0880) or with Multiple Power

Options (K0884-K0886) is covered if all of the coverage criteria [1) – 3), 10) - 13)] for a

PWC are met and if: a) The Group 4 criteria [19)] are met, and


met.

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21) A Group 5 (Pediatric) PWC with Single Power Option (K0890) or with Multiple Power

Options (K0891) is covered if the coverage criteria [1) – 3), 10) - 13)] for a PWC are met;

and

a) The beneficiary is expected to grow in height, and


met.

22) A push-rim activated power assist device (E0986) for a manual wheelchair is covered if the

coverage criteria [1) – 3), 10) - 13)] for a PWC are met, and:

a) The beneficiary has been self-propelling in a manual wheelchair for at least one year,

and

b) The beneficiary has a non-progressive disease, and

c) The beneficiary has successfully completed a two month trial period (reimbursable with

prior approval as a rental).

23) SPC may be included with new wheelchair or billed separately under the following

conditions:

a) Refer to the SPC Coverage Criteria for information concerning coverage of general use,

skin protection, positioning, powered and custom made components.

b) A POV or PWC with Captain's Chair seating is not appropriate for a beneficiary who

needs a separate SPC

c) If a beneficiary needs a seat and/or back cushion but does not meet coverage criteria for

a skin protection and/or positioning cushion, it is appropriate to provide a Captain's

Chair seat (if the code exists) rather than a sling/solid seat/back and a separate general

use seat and/or back cushion.

d) A general use seat and/or back cushion provided with a PWC with a sling/solid

seat/back will be considered equivalent to a power wheelchair with Captain's Chair and

will be coded and priced accordingly, if that code exists.

e) If a beneficiary’s weight combined with the weight of seating and positioning

accessories can be accommodated by wheelchair with a lower weight capacity than the

wheelchair that is requested or provided, approval or payment will be based on the

appropriate HCPCS code that meets the medical need.

24) A power mobility device (PMD) will be denied as not medically necessary if the underlying

condition is reversible and the length of need is less than 3 months (e.g., following lower

extremity surgery which limits ambulation).

C. Wheelchairs are NOT covered when:

1. Not medically necessary

2. Not used by the beneficiary

3. Used as a convenience item

4. Used to replace private or public transportation such as an automobile, bus or taxi

5. Not generally used primarily for health care and are not regularly and primarily used by persons who

do not have a specific medical need for them

6. Used in a facility that is expected to provide such items to the beneficiary

7. Used in a skilled nursing facility, unless the beneficiary demonstrates the need for a custom

wheelchair under Title 22 of the Code of Regulation section 51321(h)

8. Not prescribed by a licensed practitioner, or, in the case of a custom wheelchair, by a licensed

practitioner and a QRP.

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D. Seating and Positioning Component Coverage Criteria

SPC are covered when criteria 1., 2. and 3., at least one of 4. – 9., and 10. – 19. (if applicable) are met:

1. The beneficiary has met the criteria for wheelchair, and

2. The SPC meets the quality standards and coding definitions specified in the APL 15-018. The

Medicaid program reserves the right to review any and all coding assignments by vendors and the

Medicare Pricing, Data Analysis and Coding (MPDAC) web site based on submitted and published

product specifications and other relevant information.

3. The primary and back-up wheelchair bases accommodate the SPC.

4. A general use seat cushion and a general use back cushion are covered when 1., 2. and 3. are met.

5. A skin protection seat cushion is covered when 1., 2. and 3. are met and that beneficiary has one of

the following:

a. A current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating

surface; or

b. Absent or impaired sensation in the area of contact with the seating surface due to but not

limited to one of the following diagnoses: spinal cord injury resulting in quadriplegia or

paraplegia, other spinal cord disease, multiple sclerosis , other demyelinating disease, cerebral

palsy, anterior horn cell diseases including amyotrophic lateral sclerosis, post- polio paralysis

traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration,

Alzheimer’s disease, Parkinson’s disease; or

c. Inability to carry out a functional weight shift due to one of, but not limited to, the following

diagnoses: spinal cord injury resulting in quadriplegia or paraplegia, other spinal cord disease,

multiple sclerosis, other demyelinating disease, cerebral palsy, anterior horn cell diseases

including amyotrophic lateral sclerosis, post-polio paralysis, traumatic brain injury resulting in

quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer’s disease, Parkinson’s

disease; or

d. Confined to their wheelchair for more than four (4) continuous hours on a daily basis

e. A well-documented history (as well as current status) of malnutrition.

6. A positioning seat cushion or positioning back cushion, is covered when 1., 2. and 3. are met and

the beneficiary has one of the following:

a. Significant postural asymmetries that are due to but not limited to one of the diagnoses listed in

criterion “5.” above; or

b. One of the following diagnoses: monoplegia of the lower limb or hemiplegia due to stroke,

traumatic brain injury, or other etiology, muscular dystrophy, torsion dystonias, spinocerebellar

disease.

7. A positioning accessory is covered when criteria 1., 2., 3. and 6. are met and specifically:

a. A headrest or headrest extension (sling support for the head) is covered when the recipient has a

covered manual tilt-in space, manual semi or fully reclining back, or power tilt and/or recline

power seating system or needs additional head support. The code for a headrest includes any

type of cushioned headrest, fixed, removable or non-removable hardware.

b. An upper extremity support system (UESS) is covered when the medical need for positioning in

a wheelchair cannot be met with less costly alternatives such as any combination of a safety

belt, pelvic strap, harness, prompts, armrest modifications, recline, tilt in space or other

existing or potential seating or wheelchair features. UESS dimensions should not exceed the

positioning length of the forearms (e.g., 12-15”). UESS and related accessories are not covered

when used solely for activities of daily living. c. UESS padding and positioning blocks are covered in addition to a UESS when there is a

medical need for stabilization of the UESS due to strong spasticity or exaggerated muscle

activity.

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d. Foot-Ankle Padded Positioning Straps (e.g., “ankle huggers”) are covered when there is a

medical need for stabilization of the foot and ankle due to strong spasticity or exaggerated

muscle activity, and positioning in the wheelchair cannot be met with less costly alternatives,

such as any combination of heel loop/holders and or toe/loop/holders, with or without ankle

straps.

8. A combination skin protection and positioning seat cushion is covered when 1., 2., 3., 5. and 6. are

met, i.e., the criteria for both a skin protection seat cushion and a positioning seat cushion are met.

9. A custom fabricated seat cushion is covered if the criteria for 8. are met and there is a

comprehensive written evaluation by a licensed clinician (who is not an employee of or otherwise

paid by a vendor or manufacturer), which clearly explains why a standard seating system is not

sufficient to meet the beneficiary’s seating and positioning needs. (If a custom fabricated seat and

back are integrated into a one-piece cushion, code using the custom seat plus the custom back

codes.)

10. If foam-in-place or other material is used to fit a substantially prefabricated cushion to an individual

recipient, the cushion must be billed as a customized cushion, not custom fabricated.

11. The code for a seat or back cushion includes any rigid or semi-rigid base or posterior panel,

respectively, which is an integral part of the cushion.

12. Payment for all wheelchair seats, backs and accessory codes includes fixed, removable and/or quick-

release mounting hardware if hardware is applicable to the item.

13. The swing away, multi-positioning or removable mounting hardware upgrade code may only be

billed in addition to the codes for a headrest, lateral trunk, hip supports, medial thigh supports, calf

supports, abductors/pommels, and foot supports when medically justified. It must not be billed in

addition to the codes for shoulder harness/straps or chest straps, wheelchair seat cushions or back

cushions, or with PWCs with swing away, fixed or retractable joysticks.

14. A manual tilt in space option is covered when:

a. Criteria 1. – 3. above are met, and

b. The beneficiary is dependent for transfers, and

c. The beneficiary has a plan of care that addresses the medical need for frequent positioning

changes (e.g., for pressure reduction or poor/absent trunk control) that do not always include a

tilt position.

15. A power tilt in space option for a PWC is covered when:

a. Criteria 1. – 3. and 14. above are met, and

b. The beneficiary has the mental and physical capabilities to safely and independently operate the

power tilt in space that is provided.

16. A manual recline option is covered when:

a. Criteria 1. – 3. above are met, and

b. The beneficiary has a plan of care that requires a recline position to complete ADLs or IADs,

and

c. The beneficiary has positioning needs that cannot be met by upright or fixed angle chair, or

d. The beneficiary’s postural control requires a recline feature.

17. A power recline option for a PWC is covered when:

a. Criteria 1. – 3. and 16. above are met, and

b. The beneficiary has a plan of care that requires a recline position to complete ADLs or IADs, and

c. The beneficiary has the mental and physical capabilities to safely and independently operate the

power recline feature that is provided. 18. A combination manual tilt in space and recline option is covered when criteria 14. and 16. are met

and if provided alone will not meet the seating and positioning needs.

19. A combination power tilt in space and recline option is covered when criteria 15. and 17. are met

and if provided alone will not meet the seating and positioning needs.

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VII. REFERENCES: A. Title 22, CCR Sections 52260, 51321

B. DHCS All-Plan Letter #15-018, dated July 9, 2015

VIII. DISTRIBUTION:




X. REVISION DATES: 08/17/16


MCUP3083 - Wheelchair and Power Operated Vehicle Authorization was archived 11/18/2015


Revision Dates: 07/15/09; 05/18/11

*********************************









covered under PHC.

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Attachment A - MCUP3041


Attachment A - HKUP3080

Attachment B - MCUG3007

(TAR to be submitted by the provider performing the service) Revised 08/17/2016

Page 1 of 8

PHC TAR REQUIREMENTS

A. Hospitalization

1. The hospital must notify PHC of any admission within 24 hours of the admission.

2. Authorization for elective admission must be requested by the admitting physician prior

to the admission.

B. Long Term Care

The LTC facilities must notify PHC of any admissions, transfer, bed hold/ leave of absence, or

change in payor status within one working day. (Examples include Medicare non-coverage or

exhaustion of benefits / hospice election.)

C. Outpatient Surgical Procedures – see CPTs Requiring TAR list

D. Pain Management – see CPTs Requiring TAR list

E. Outpatient Hemo / Peritoneal Dialysis

(Note: initial authorization will be limited to 90 days and a lifetime TAR will be granted only after

submission of Medicare determination.)

F. Drugs and Pharmaceuticals – A TAR is required for all prescription drugs, over-the-counter drugs

and injectable drugs (including drugs compounded for IV infusion therapy) not on the PHC

formulary.

PLEASE REFER TO PHC FORMULARY

G. Diagnostic Studies

♦ CT Scans (Except 76497)

♦ MRI (Except 76494, 76380, 76506)

♦ MRA

♦ PET scan

♦ Transcranial Doppler

♦ Sleep Studies / Polysomnography

H. Ancillary / Support Services

RAF authorizes one visit only. Requests for additional visits require the ancillary service provider to

submit copies of initial evaluation and treatment plan attached to TAR. TAR must include total visits

requested including initial visit.

♦ Acupuncturist

• Speech Therapy

♦ Chiropractor • Occupational Therapy

♦ Faith Healer • Home Infusion Therapy (Nursing Component Only)

♦ Physical Therapy • Home Health Care

I. Hospice Care (Inpatient Only)

J. Pulmonary Rehabilitation

K. Hyperbaric Oxygen Pressurization

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L. Non-Emergency Medical Transportation

M. EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Supplemental Services

N. Phototherapy for dermatological condition

O. Dental Anesthesia

P. CCS/GHPP - Authorization for services related to eligible condition(s) must be requested from

CCS or GHPP office(s).

Q. Supplies / Equipment

♦ Orthotics – Cumulative costs for repair/maintenance or purchase exceeds $250 / item

♦ Prosthetics – Cumulative costs for repair / maintenance or purchase exceeds $500 / item

And any unlisted / miscellaneous code including:

- L0999 Addition to spinal orthosis, not otherwise specified

- L1499 Spinal orthosis, not otherwise specified

- L2999 Lower extremity orthosis, not otherwise specified

- L3649 Orthotic shoe, modification, addition or transfer, not otherwise specified

- L3999 Upper limb orthosis, not otherwise specified

- L5999 Lower extremity prosthesis, not otherwise specified

- L7499 Upper extremity prosthesis, not otherwise specified

- L8039 Breast prosthesis, not otherwise specified

- L8499 Unlisted procedure for miscellaneous prosthetic services

- L8699 Prosthetic implant, not otherwise specified

ANY CUSTOM MADE ITEM THAT DOES NOT HAVE A MEDI-CAL RATE (BY-

REPORT OR BY-INVOICE)

♦ Ostomy Supplies – If monthly cumulative cost for all related supplies exceeds $150

♦ Hearing Aid – All purchases, rentals or repairs exceeding $50 / item

(Batteries are non-covered except some CCS / EPSDT cases, in which case TAR is

required)

♦ Oxygen and related supplies

♦ Diabetic Supplies are to be provided by Pharmacies ONLY

♦ Medical Supplies – (If dispensed by PHARMACY, please refer to formulary)

♦ Any unlisted or miscellaneous code

♦ DME – (If dispensed by PHARMACY, please refer to formulary)

- Repairs or maintenance over $250.00 / item (Out of guarantee repairs are to be

guaranteed for at LEAST three (3) months from the date of repair. Reimbursement will

NOT be allowed for parts or labor during a guarantee period if due to a defect in

material or workmanship)

- Purchase items over $100.00 / item (Vendor to guarantee for a MINIMUM of six (6)

months from the date of purchase)

- Rental items over $50.00 / month / item (Rental rate includes equipment related

supplies.)

- Any unlisted or miscellaneous code

- Purchase of any wheelchairs for Medi-Medi members

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Page 3 of 8


♦ Incontinence Supplies

- Incontinence supplies if monthly cumulative cost for all related supplies exceeds

$125.00

AND any unlisted or miscellaneous code

- Washes and creams for members with incontinence will only be authorized if the

physician justifies medical necessity

♦ Nutritional Supplements (Submit TAR to Pharmacy)

R. Genetic Testing – A TAR is required for certain genetic testing as outlined in Attachment A of the

Genetic Testing policy MCUP3131.

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Page 4 of 8


Outpatient Surgical Procedures - CPTs Requiring TAR

CPT Code Description

10040 Acne Surgery 15788 Thru 15793 Chemical Peel, Facial Et Al

15810-11 Salabrasion 15820 Thru 15823 Revision Of Lower Or Upper Eyelid

15845 Skin And Muscle Repair, Face 17360 Skin Peel Therapy 17999 Skin Tissue Procedure 19140 Mastectomy For Gynecomastia 19300 Mastectomy For Gynecomastia 19316 Mastopexy 19318 Reduction Mammoplasty

19324/25 Breast Augment; W/O Prosthetic Implant

19355 Correction Of Inverted Nipples

19380 Revise Breast Reconstruction

19396

Design Custom Breast Implant 19499 Unlisted Procedure, Breast 20999 Musculoskeletal Surgery 21208 Augmentation Of Facial Bones 22899 Spine Surgery Procedure 22999 Abdomen Surgery Procedure

28290 Thru 28299 Correction Of Bunion

28300 Thru 28345 Osteotomy / Repair / Reconstruction

30400 Thru 30520 Reconstruct Of Nose 30520 Repair Nasal Septum 32999 Chest Surgery Procedure 36299 Vessel Injection Procedure

37700

Ligation And Division Of Long Saphenous Vein At Saphenofemoral Junction, Or Distal Interruptions

37718 Ligation, Division, And Stripping, Short Saphenous Vein

37722 Ligation, Division, And Stripping, Long (Greater) Saphenous Veins From Saphenofemoral Junction To Knee Or Below

37735

Ligation And Division And Complete Stripping Of Long Or Short Saphenous Veins With Radical Excision Of Ulcer And Skin Graft And/or Interruption Of Communicating Veins Of Lower Leg, With Excision Of Deep Fascia

37760

Ligation Of Perforator Veins, Subfascial, Radical (Linton Type) Including Skin Graft, When Performed, Open, 1 Leg

37761

Ligation Of Perforator Vein(S), Subfascial, Open, Including Ultrasound Guidance, When Performed, 1 Leg

37765 Stab Phlebectomy Of Varicose Veins, 1 Extremity; 10-20 Stab Incisions

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Page 5 of 8


Outpatient Surgical Procedures - CPTs Requiring TAR (Continued)


37766 More Than 20 Incisions

37780

Ligation And Division Of Short Saphenous Vein At Saphenopopliteal Junction (Separate Procedure)

37785 Ligation, Division, And/or Excision Of Varicose Vein Cluster(S) 1 Leg 38206, 38231 Stem Cell Harvesting

38230 Bone Marrow Harvesting 36511 Therapeutic Apheresis Of WBC ‘s 36512 Therapeutic Apheresis Of RBCs 38204 Unrelated Harvesting Of Cells 38205 Stem Cell Harvesting From Siblings 38207 Stem Cell Storage 41899 Gum Surgery Procedure 43770 Laparoscopy, Surgical, Gastric Restrictive Procedure

43771 Laparoscopy, Surgical, Revision Of Adjust Gastric Band

43772 Laparoscopy, Surgical, Removal Of Adjustable Gastric Band

43773 Laparoscopy, Surgical, Removal & Placement Of Adj Gastric Band

43774 Laparoscopy, Surgical, Removal Of Adjustable Gastric Band

43775 Lap Sleeve Gastrectomy

43842 Gastroplasty, Vertical Banded, For Morbid Obesity

43843 Gastroplasty, Other Than Vertical-Banded, For Morbid Obesity

43845 Gastroplasty 43846 Gastric Bypass For Obesity

43847 Gastric Restrictive Procedure With Gastric Bypass

43848 Revision Of Gastric Restrictive

43886 Gastric Restrictive Procedure

43887 Gastric Restrictive Procedure, Removal Of Subcutaneous Port Component

43888 Gastric Restrictive Proc, Removal & Replacement Of Subcutaneous Port

49999 Abdomen Surgery Procedure 54161 Circumcision –TAR not required if patient < 4 months of age (See policy MCUP3121 Neonatal Circumcision

54360 Penis Plastic Surgery 54400 Thru 54440 Penile Prosthesis / Plastic Procedure For Penis

55175/80 Revision Of Scrotum 55200 Incision Of Sperm Duct 56800 Repair Of Vagina

58150 Thru 58294, 58570 Hysterectomy 58350 Reopen Fallopian Tube

58550 Thru 58554 Laparoscopy, Surgical; With Vaginal Hysterectomy With Or Without Removal Of Tube(S), With Or Without Removal Of Ovary(S) (Laparoscopic Assisted Vaginal Hysterectomy)

58578/79 Unlisted Procedure, Uterus

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Page 6 of 8


Outpatient Surgical Procedures - CPTs Requiring TAR (Continued)


58750 Thru 58770 Tubal Repair 61850 Thru 61888 Insertion, Revision Or Removal Of Cranial Neurostimulator 62290 thru 62291 Discography, Lumbar (62290) and Cervical/Thoracic (62291) 63650 Thru 63688 Insertion, Revision Or Removal Of Spinal Neurostimulator 67900 Thru 67924 Repair Brow, Ptosis, Blepharoptosis, Lid

67950 Thru-66 Revision Of Eyelid 67971-75 Reconstruction Of Eyelid

67999 Unlisted Eyelid Procedure 69300 Revise External Ear 69399 Outer Ear Surgery Procedure 72285 Cervical and Thoracic Discography

72295 Lumbar discography

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Page 7 of 8


Pain Management CPTs Requiring TAR

CPT CODE DESCRIPTION

27096 Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid

0027T Endoscopic lysis of epidural adhesions with direct visualization using mechanical means (e.g., spinal endoscopic catheter system) or solution injection (e.g., normal saline) including radiologic localization and epidurography

0062T Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; single level

0063T Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; one or more additional levels

22521 thru 22525

Percutaneous vertebroplasty and percutaneous vertebral augmentation

62287 Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumber (e.g. manual or automated percutaneous discectomy, percutaneous laser discectomy)

62263 Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiological localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days

62264 Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiological localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day

62360 thru 62362

Implantable or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir

63650 thru 63688

Insertion, revision or removal of spinal neurostimulator

64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level

64480 Cervical or thoracic, each additional level

64483 Lumbar or sacral, single level

64484 Lumbar or sacral, each additional level

64490 Injection(s), diagnostic or therapeutic agent, Paravertebral facet (zygapophyseal) joint with image guidance (fluoroscopy or CT), cervical or thoracic; single level.

64491 Second level (List separately in addition to code for primary procedure)

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Page 8 of 8


Pain Management CPTs Requiring TAR (Continued)

* TARs generated by the Pharmacy Department

64492 Third level (List separately in addition to code for primary procedure

64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT, lumbar or sacral; single level)

64494 Second level (List separately in addition to code for primary procedure)

64495 Third level (List separately in addition to code for primary procedure)

64633 Destruction by neurolytic agent, paravertebral facet joint nerve. cervical or thoracic, single level

64634 Cervical or thoracic, each additional level

64635 Destruction by neurolytic agent, paravertebral facet joint nerve. single level lumbar or sacral

64636 Lumbar or sacral, each additional level

*J0585 (If billed with 64612 & 64613) Botulinum A Toxin – 1 unit extraocular

*J0587 (If billed with 64612 & 64613) Botulinum B Toxin – 10 units facial

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I:\POLICIES\MASTERS (new format - in process of being uploaded to SharePoint) (Do not REMOVE or edit)\January 2015\MPQG1011 Non Physicians Medical Practitioners 01-21-2015.docx Page 1 of 7

Policy/Procedure Number: MPQG1011 Lead Department: Health Services

Policy/Procedure Title: Non-Physician Medical Practitioners &

Medical Assistants Practice Guidelines

External Policy

Internal Policy

Original Date: 10/31/1994 - Medi-Cal

06/20/2007 - Healthy Kids




Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:



Approval Signature: Robert L. Moore, MD, MPH Approval Date: 01/21/2015


II. IMPACTED DEPTS.:

A. Provider Relations

B. Health Services

III. DEFINITIONS:

A. Non-Physicians Medical Practitioners (NPMP) are defined as nurse practitioners, physician assistants

(PA) and nurse midwives.

B. Nurse Midwife, by definition, is a registered nurse who is a graduate of a Board-approved nurse-

midwifery program and is certified by the California Board of Registered Nurses. Nurse-midwifery

practice is the independent, comprehensive management of women’s health care in a variety of settings

focusing particularly on pregnancy, childbirth, and the postpartum period. It also includes care of the

newborn, and the family planning and gynecological needs of women throughout the life cycle.

C. Nurse Practitioner, by definition, shall be currently licensed as a Registered Nurse in California and be

currently certified by a licensed Nurse Practitioner Program, which has met the requirements set forth

and described in Title 16, Section H84 of the California Administrative Code.

D. Medical Assistants are unlicensed persons who have received certificates indicating satisfactory

completion of training requirements specified in Chapter 13, Title 16 of the California Code of

Regulations.

E. Physicians’ Assistant; shall be currently licensed by the Physician Assistant Examining

Committee/Medical Board of California.

F. "Protocols" means protocols that meet the requirements of the Physician Assistant Practice Act and

Regulations of the Physician Assistant Examining Committee for Physician Assistants and standardized

procedures for Nurse Practitioners and Nurse Midwives.

IV. ATTACHMENTS:

A. Sample Non-Physician Medical Practitioners Agreement

V. PURPOSE:

To outline general guidelines describing the nature and scope of practice for non-physician medical

practitioners (NPMP) and medical assistants at primary care sites.


A. Credentialing: See Provider Relation Policies: Non-Physician Medical Practitioner Credentialing Criteria

& Non-Physician Medical Practitioner Re-Credentialing Criteria

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☐Internal Policy


06/20/2007 -Healthy Kids




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B. Supervision:

1. All NPMP clinicians must practice under the supervision of a licensed physician, either directly, or

using medical policies and procedures (e.g., protocols) established by the physician according to the

category of clinician. Any California-licensed physician except those who are expressly prohibited

by the Medical Board from supervising a NPMP will be able to supervise a NPMP.

2. At the time of the facility site review, documents requested for review by the PHC DHCS-certified

reviewer will include:

a. Standardized procedures provided for Nurse Practitioners (NP) and/or Certified Nurse Midwives

(CNM)

b. A Delegation of Services Agreement which defines the scope of services provided by Physician

Assistants (PA) and

c. Supervisory Guidelines that define the method of supervision by the Supervising Physician.

3. Charts involving care provided by the NPMP will be reviewed and co-signed by the supervising

physician within the time frame dictated by current state regulations.

4. For physician assistants, the supervising physician must co-sign any chart within seven (7) days

when a schedule II medication was ordered, and at least a 5% sample of all charts must be co-signed,

and dated within 30 days. The co signature or the countersignature of the supervising physician for

services provided by a Nurse Practitioner or a Certified Nurse Midwife is no longer required.

5. The supervising physician must be available for consultation with the NPMP clinician at all times

when the NPMP is providing services, either by physical presence or by electronic communication.

At all times, the supervising physician is responsible for the NPMP. The physical presence of the

supervising physician for services provided by a Nurse Practitioner or a Certified Nurse Midwife is

no longer required. PHC will review compliance with this standard during the facility site review.

6. An individual supervising physician may not supervise or oversee greater than the following full

time equivalent NPMP ratios:

a. Four (4) Nurse Practitioners

b. Three (3) Nurse Midwives

c. Four (4) Physician Assistants

d. Four (4) NPMP clinicians in any combination that does not exceed the limit stated

7. NPMP may participate in the after-hours call network but the supervising physician must also be

available for consultation at all times that the NPMP is on call. NPMPs can independently authorize

emergency hospitalizations for life threatening conditions only; all other authorizations, denials, or

transfer arrangements must occur only after direct consultation with the supervising physician.

C. Scope of Practice:

1. Each physician and/or contracting medical group/affiliate will define the scope of practice for each

NPMP working in the practice. The scope of practice may vary depending on the skills of the

individual clinician but in all cases shall comply with applicable state laws. Practitioners may

substitute their protocols for scope of practice as long as the protocols meet PHC standards and are

approved by the PHC Chief Medical Officer or his delegate.

2. Reference books, or parts thereof, may be maintained by the office and adapted for use as protocols

by the physician and NPMP to be followed for each type of medical problem that might be

encountered. The supervising physician will determine and specify in writing, as required by

protocols, which books, or parts thereof, are to be used by the NPMP

3. Physician consultation should be obtained as soon as possible for conditions defined as requiring

immediate physician consultation or defined in the protocol.

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☐Internal Policy







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4. Physician consultation is required for the following:

a. Referral to specialist physician

b. Referral for hospitalization

c. Referral for diagnostic procedures requiring a Treatment Authorization Request (TAR)

5. Whenever necessary, the NPMP shall perform emergency care necessary to sustain life. This

includes, but is not limited to establishing and maintenance of airway, control of hemorrhage, CPR,

establish an IV line, administer oxygen, splint skeletal injuries, irrigate and/or suture wounds, and

administration of emergency drugs such as epinephrine, atropine, naloxone, glucose, or inhalation

bronchodilators. Physician consultation shall be obtained as soon as possible and the NPMP shall

comply with any applicable backup emergency procedures specified by protocols

6. The supervising physician may authorize and approve the NPMP to perform certain outpatient

procedures without physician consultation.

7. The supervising physician may authorize the NPMP to diagnose and treat common medical

problems according to accepted criteria and management as per the references utilized in the

practice.

8. Inpatient Care: NPMPs who have been granted hospital privileges may perform procedures

consistent with their education, training and legal scope of practice for which they have been granted

hospital privileges.

D. Physician/Clinician Agreement:

1. Each physician/NPMP clinician team will sign an agreement stating that the NPMP will follow the

protocols developed for practice by the supervising physician, based on the skills and area of

specialty of each clinician. This agreement will be kept on file and will be available for review by

PHC upon request. A sample agreement is attached.

2. In addition to the signed agreement, physician assistants must have protocols that outline and

document delegation, responsibility for transport, backup procedures and guidelines for supervision.

Practice protocols must be reviewed and approved by the supervising physician.

E. Medication:

1. The NPMP may furnish drugs and devices in accordance with Federal or State law, whichever is

more restrictive.

F. Nurse Midwife Guidelines:

1. The practice of midwifery constitutes the assistance by a nurse midwife, under the supervision of a

physician, of a woman in childbirth so long as the medical situation meets criteria accepted as

normal. When a complication develops, the nurse midwife must consult with the supervising

physician promptly.

2. The nurse midwife is able to assume responsibility for the management of normal pregnant women

whose medical, surgical and post-obstetrical history and present health status reveal no conditions

that would adversely influence the patient's course of pregnancy or be unfavorably affected by it.

Such management includes:

a. Observation, assessment and treatment of patients according to medical protocols, approved by

the supervising physician(s)

b. Implementation of care based upon written policies and procedures (e.g., protocols) to establish

a diagnosis when deviation from normal occurs.

c. Management of selected deviations from normal when the diagnosis is clear with a predictable

outcome

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3. During the course of care, the nurse midwife will consult with the physician when deviations from

normal arise and a course of action is not already specified in the protocol. If a condition requires

frequent and/or continuing management by a physician, but certain aspects of care remain within the

scope of nurse midwifery management, a situation of collaborative management exists. Under

collaborative management, all patients will be followed by both the physician and the nurse

midwife. The nurse midwife may institute those nurse midwifery protocols that do not conflict with

the aspect of care under the physician's management. Thus, collaborative management requires

careful communication between the nurse midwife and the physician, who assumes responsibility

for overall provision of the patient's care.

4. When a patient develops a condition, which requires management by a physician, her care, must be

transferred to a physician for management of antepartum, intrapartum, and/or postpartum care.

When a complication develops during the intrapartum period, a transfer order then should be

communicated directly from the obstetrician to the nurse in charge of the labor and delivery area.

The nurse midwife may continue to provide supportive care

5. The supervising physician will provide supervision as required by the Nurse Practice Act and will

provide consultation when needed or requested by the midwife. The supervising physician will

assume active intrapartum management or co-management of those women whose conditions are

beyond the scope of midwifery practice. The supervising physician will countersign all orders

written by the midwife within twenty-four (24) hours and will provide coverage when the midwife is

unavailable. Consultation by the supervising physician must be available at all times, either by

physical presence or electronic communication (i.e.: phone, fax, Internet). One supervising

physician must be available for every 3-nurse midwives who work in the same area at the same time.

G. Physician Assistant Guidelines:

1. When authorized to do so by the supervising physician, the physician assistant may perform patient-

related activities within the scope of practice defined by Title 16 and in accordance with applicable

Federal and State laws.

2. The physician assistant may provide medical care that is either based upon direct consultation with

the physician or contained within written protocols approved by the supervising physician

3. The physician assistant will seek physician consultation as soon as possible for the following

situations, and any others that he/she deems appropriate:

a. Any conditions which have failed to respond to appropriate management or any unusual

symptom

b. Unexplained physical finding

c. Potentially serious or life threatening condition where prompt initiation of appropriate care has a

substantial impact on outcome

d. All emergencies arising after initial care has been started

e. Any patient who desires physician consultation

f. Before performing any invasive procedures

4. The supervising physician shall be a physician licensed by the State of California.

a. This physician will review the findings of the patient's history and physical examination and

supervise the physician assistant performing approved tasks or procedures.

b. The physician assistant will be responsible to communicate with the supervising physician

regarding patient management and seek assistance or additional instructions in patient

management as deemed necessary by the physician assistant, including unusual or non-routine

cases.

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c. The supervising physician will be available for consultation or assistance at all times, either by

physical presence or by electronic communications (phone, fax, Internet).

d. One supervising physician will be available for every four-physician assistants working in an

area at the same time.

H. Nurse Practitioner Guidelines:

1. When authorized to do so by the supervising physician, the Nurse Practitioner may perform the

patient-related activities within the scope of practice defined by Title 16 and applicable Federal and

State laws.

2. The nurse practitioner may provide medical care which is either based upon direct consultation with

the physician or contained within written medical policies and procedures (e.g., protocols) adapted

by the supervising physician. The policies and procedures must be reviewed and approved by the

supervising physician

3. The Nurse Practitioner will seek physician consultation as soon as possible for the following

situations, and any others he/she deems appropriate:

a. Any conditions which have failed to respond to appropriate management or any unusual

symptom.

b. Unexplained physical finding

c. Potentially serious or life threatening condition where prompt initiation of appropriate care has a

substantial impact on outcome

d. All emergencies after initial care have been started.

e. Any patient who desires physician consultation

f. Before performing any invasive procedures

4. The supervising physician shall be a physician licensed by the State of California.

a. This physician will review the findings of the patient's history and physical examination and

supervise the Nurse Practitioner performing approved tasks or procedures.

b. The Nurse Practitioner will be responsible to communicate with the supervising physician

regarding patient management and seek assistance or additional instructions in patient

management as deemed necessary by the nurse practitioner including in unusual or non-routine

cases.


physical presence or by electronic communications (phone, fax, Internet).

d. One supervising physician will be available for every four nurse practitioners working in an area

at the same time.

I. Medical Assistant:

1. In agreement with Title 16, CCR, Section 1366, a medical assistant may perform technical

supportive services such as those specified in section IX.B. Provided that all of the following

conditions are met:

a. The service is a usual and customary part of the medical practice where the medical assistant is

employed.

b. The supervising physician authorized the medical assistant to perform the service and assumed

responsibility for the patient's treatment and care

c. The medical assistant has completed training in the services described in section B and has

demonstrated competence in the performance of the service, as ascertained by the supervising

physician.

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d. Each technical supportive service performed by the medical assistant is documented in the

patient's medical record, indicating the name, date and time, a description of the service

performed, and the name of the physician who gave the medical assistant patient-specific

authorization to perform the task or who authorized the task under a patient-specific standing

order.

2. A medical assistant, in accord with the provisions in section IX.A, performs technical supportive

services such as the following:

a. Administer medication orally, sublingually, topically, vaginally or rectally, or by providing a

single dose to a patient for immediate self-administration. A medical assistant may administer

medication by inhalation if the medications are patient-specific and have been or will be

routinely and repetitively administered to that patient. In every instance, prior to administration

of medication by the medical assistant, a licensed physician or other person authorized by law to

do so shall verify the correct medication and dosage. No anesthetic agent may be administered

by a medical assistant.

b. Perform electrocardiogram, electroencephalogram, or plethysmography tests, except full-body

plethysmography. The medical assistant may not perform tests involving the penetration of

human tissues, except for skin tests, or to interpret test findings or results.

c. Apply and remove bandages and dressings; apply orthopedic appliances such as knee

immobilizers, orthotics, and similar devices; remove casts, splints and other external devices;

obtain impressions for orthotics and custom molded shoes; select and adjust crutches for the

patient and instruct the patient in proper use of crutches.

d. Perform automated visual field testing, tonometry, or other simple or automated ophthalmic

testing not requiring interpretation in order to obtain test results.

e. Remove sutures or staples from superficial incisions or lacerations.

f. Perform ear lavage to remove impacted cerumen.

g. Collect specimens for lab testing by utilizing non-invasive techniques, including urine, sputum,

semen and stool.

h. Assist patients with ambulation and transfers.

i. Prepare patients for and assist the physician, physician assistant or registered nurse in

examinations or procedures including positioning, draping, shaving and disinfecting treatment

sites.

j. As authorized by the supervising physician, provide patient information and instruction.

k. Collect and record patient data including height, weight, temperature, pulse, respiration rate and

blood pressure, and basic information about the presenting and previous conditions.

l. Perform simple laboratory and screening tests customarily performed in a medical office.

m. Cut the nails of otherwise healthy patients.

n. Administer first aid or cardiopulmonary resuscitation in an emergency.

o. A medical assistant may also fit prescription lenses or use any optical device in connection with

ocular exercises, visual training, vision training, or orthoptics.

J. Patient Choice:

1. The patient must be informed that the provider is a NPMP, and be granted the opportunity to see a

physician if they choose.

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K. Monitoring Compliance:

1. PHC monitors compliance with this policy through the facility site review. Corrective action plans

are required when deficiencies are identified and any uncorrected deficiencies may be reported to the

Chief Medical Officer, Provider Relations Department and Credentialing Committee for further

action.


VIII. DISTRIBUTION:

A. PHC Provider

B. Practitioner Manuals

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:

X. REVISION DATES: Medi-Cal

10/14/95, 5/17/00, 8/15/01, 9/18/02, 10/20/04, 04/20/05, 04/19/06, 06/20/07, 07/16/08, 07/15/09, 09/15/10,

01/16/13, 01/15/14, 01/21/15

Healthy Kids

06/20/07, 07/16/08, 07/15/09, 09/15/10, 01/16/13, 01/15/14, 01/21/15


PartnershipAdvantage:

MPQG1011 - 06/20/2007 to 01/01/2015

Healthy Families:

MPQG1011 - 10/01/2010 to 03/01/2013

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SERVICE\654fed4101184b56b67949ffcdad27a9\output.doc Page | 1

(S A M P L E) ATTACHMENT A

Non-Physician Medical Practitioners Agreement

The following is an agreement between

(Supervisory MD or Medical Director)

(Clinician Name)

.

and

The undersigned Non-Physician Medical Practitioners (NPMP) acknowledges the following:

I agree to follow the protocols established by (Name of Practice or Organization)

for NPMP practice.

I understand that failure to follow these protocols may result in disciplinary action.

I agree to consult with my supervising physician for all cases as outlined in the protocols and for any case if I

am unsure about the diagnosis or management.

I understand that I must maintain my current state license and must participate in Continuing Medical Education

relating to my specialty, in accordance with the license and certification requirements applicable to my

specialty.

I understand that a supervising physician will be available either on-site or by electronic communication at all

times while I am treating patients.

I understand that I am expected to stabilize clients during life-threatening emergencies and to contact a

physician as soon as possible and/or arrange for emergency transport to the nearest hospital.

I understand that my charts will be reviewed by the supervising physician who will discuss cases with me on a

regular basis.

I understand that medications must be ordered pursuant to applicable provisions of applicable California and

Federal laws relating to the practice of NPMPs.

I understand that is the provider for purposes of delivering medical services,

determining fees, billing patients and setting office practices and procedures. I further agree that the salary or

wages I receive from said provider constitutes payment in full to me for the services rendered to said provider's

patients.

This agreement is effective until amended in writing or terminated by the supervising physician, and shall

automatically terminate when the NPMP no longer provides services in the practice.

Non-Physician Medical Practitioner Date

Primary Supervising Physician or Medical Director Date

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Policy/Procedure Number: MPQG1011 Lead Department: Health Services Policy/Procedure Title: Non-Physician Medical Practitioners & Medical Assistants Practice Guidelines

External Policy Internal Policy

Original Date: 10/31/1994 - Medi-Cal 06/20/2007 - Healthy Kids



Reviewing Entities:

IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT

Approving Entities:



Approval Signature: Robert L. Moore, MD, MPH Approval Date: 01/21/20158/17/2016

I. RELATED POLICIES: N/A II. IMPACTED DEPTS.:

A. Provider Relations B. Health Services

III. DEFINITIONS:

A. Non-Physicians Medical Practitioners (NPMP) are defined as nurse practitioners, physician assistants (PA) and nurse midwives.

B. Nurse Midwife, by definition, is a registered nurse who is a graduate of a Board-approved nurse-midwifery program and is certified by the California Board of Registered Nurses. Nurse-midwifery practice is the independent, comprehensive management of women’s health care in a variety of settings focusing particularly on pregnancy, childbirth, and the postpartum period. It also includes care of the newborn, and the family planning and gynecological needs of women throughout the life cycle.

C. Nurse Practitioner, by definition, shall be currently licensed as a Registered Nurse in California and be currently certified by a licensed Nurse Practitioner Program, which has met the requirements set forth and described in Title 16, Section H84 of the California Administrative Code.

D. Medical Assistants are unlicensed persons who have received certificates indicating satisfactory completion of training requirements specified in Chapter 13, Title 16 of the California Code of Regulations.

E. Physicians’ Assistant; shall be currently licensed by the Physician Assistant Examining Committee/Medical Board of California.

F. "Protocols" means protocols that meet the requirements of the Physician Assistant Practice Act and Regulations of the Physician Assistant Examining Committee for Physician Assistants and standardized procedures for Nurse Practitioners and Nurse Midwives.

IV. ATTACHMENTS:

A. Sample Non-Physician Medical Practitioners Agreement V. PURPOSE:

To outline general guidelines describing the nature and scope of practice for non-physician medical practitioners (NPMP) and medical assistants at primary care sites.


A. Credentialing: See Provider Relation Policies: Non-Physician Medical Practitioner Credentialing Criteria & Non-Physician Medical Practitioner Re-Credentialing Criteria

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http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Quality%20Improvement/MPQG1011%20Attachments/MPQG1011-A.doc&action=default



Original Date: 10/31/1994 - Medi-Cal 06/20/2007 -Healthy Kids




B. Supervision: 1. All NPMP clinicians must practice under the supervision of a licensed physician, either directly, or

using medical policies and procedures (e.g., protocols) established by the physician according to the category of clinician. Any California-licensed physician except those who are expressly prohibited by the Medical Board from supervising a NPMP will be able to supervise a NPMP.

2. At the time of the facility site review, documents requested for review by the PHC DHCS-certified reviewer will include: a. Standardized procedures provided for Nurse Practitioners (NP) and/or Certified Nurse Midwives

(CNM) b. A Delegation of Services Agreement which defines the scope of services provided by Physician

Assistants (PA) and c. Supervisory Guidelines that define the method of supervision by the Supervising Physician.

3. Charts involving care provided by the NPMP will be reviewed and co-signed by the supervising physician within the time frame dictated by current state regulations.practice policy.

4. For physician assistants, the supervising physician must co-sign any chart within seven (7) days when a schedule II medication was ordered, and at least a 5% sample of all charts must be co-signed, and dated within 30 days. The co signature or the countersignature of the supervising physician for services provided by a Nurse Practitioner or a Certified Nurse Midwife is no longer required.

5. The supervising physician must be available for consultation with the NPMP clinician at all times when the NPMP is providing services, either by physical presence or by electronic communication. At all times, the supervising physician is responsible for the NPMP. The physical presence of the supervising physician for services provided by a Nurse Practitioner or a Certified Nurse Midwife is no longer required. PHC will review compliance with this standard during the facility site review.

6. An individual supervising physician may not supervise or oversee greater than the following full time equivalent NPMP ratios: a. Four (4) Nurse Practitioners (with if have furnishing license, otherwise no limit) b. Three (3) Four (4) Nurse Midwives c. Four (4) Physician Assistants . Four (4) NPMP clinicians in any combination that does not exceed the limit stated

8.7. NPMP may participate in the after-hours call network but the supervising physician must also be available for consultation at all times that the NPMP is on call. NPMPs can independently authorize emergency hospitalizations for life threatening conditions only; all other authorizations, denials, or transfer arrangements must occur only after direct consultation with the supervising physician.

C. Scope of Practice:

1. Each physician and/or contracting medical group/affiliate will define the scope of practice for each NPMP working in the practice. The scope of practice may vary depending on the skills of the individual clinician but in all cases shall comply with applicable state laws. Practitioners may substitute their protocols for scope of practice as long as the protocols meet PHC standards and are approved by the PHC Chief Medical Officer or his delegate.

2. Reference books, or parts thereof, may be maintained by the office and adapted for use as protocols by the physician and NPMP to be followed for each type of medical problem that might be encountered. The supervising physician will determine and specify in writing, as required by protocols, which books, or parts thereof, are to be used by the NPMP

3. Physician consultation should be obtained as soon as possible for conditions defined as requiring immediate physician consultation or defined in the protocol.

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4. Physician consultation is required for the following: a. Referral to specialist physician b. Referral for hospitalization c. Referral for diagnostic procedures requiring a Treatment Authorization Request (TAR)

5. Whenever necessary, the NPMP shall perform emergency care necessary to sustain life. This includes, but is not limited to establishing and maintenance of airway, control of hemorrhage, CPR, establish an IV line, administer oxygen, splint skeletal injuries, irrigate and/or suture wounds, and administration of emergency drugs such as epinephrine, atropine, naloxone, glucose, or inhalation bronchodilators. Physician consultation shall be obtained as soon as possible and the NPMP shall comply with any applicable backup emergency procedures specified by protocols

6. The supervising physician may authorize and approve the NPMP to perform certain outpatient procedures without physician consultation.

7. The supervising physician may authorize the NPMP to diagnose and treat common medical problems according to accepted criteria and management as per the references utilized in the practice.

8. Inpatient Care: NPMPs who have been granted hospital privileges may perform procedures consistent with their education, training and legal scope of practice for which they have been granted hospital privileges.

D. Physician/Clinician Agreement:

1. Each physician/NPMP clinician team will sign an agreement stating that the NPMP will follow the protocols developed for practice by the supervising physician, based on the skills and area of specialty of each clinician. This agreement will be kept on file and will be available for review by PHC upon request. A sample agreement is attached.

2. In addition to the signed agreement, physician assistants must have protocols that outline and document delegation, responsibility for transport, backup procedures and guidelines for supervision. Practice protocols must be reviewed and approved by the supervising physician.

E. Medication: 1. The NPMP may furnish drugs and devices in accordance with Federal or State law, whichever is

more restrictive.

F. Nurse Midwife Guidelines: 1. The practice of midwifery constitutes the assistance by a nurse midwife, under the supervision of a

physician, of a woman in childbirth so long as the medical situation meets criteria accepted as normal. When a complication develops, the nurse midwife must consult with the supervising physician promptly.

2. The nurse midwife is able to assume responsibility for the management of normal pregnant women whose medical, surgical and post-obstetrical history and present health status reveal no conditions that would adversely influence the patient's course of pregnancy or be unfavorably affected by it. Such management includes: a. Observation, assessment and treatment of patients according to medical protocols, approved by

the supervising physician(s) b. Implementation of care based upon written policies and procedures (e.g., protocols) to establish

a diagnosis when deviation from normal occurs. c. Management of selected deviations from normal when the diagnosis is clear with a predictable

outcome

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3. During the course of care, the nurse midwife will consult with the physician when deviations from normal arise and a course of action is not already specified in the protocol. If a condition requires frequent and/or continuing management by a physician, but certain aspects of care remain within the scope of nurse midwifery management, a situation of collaborative management exists. Under collaborative management, all patients will be followed by both the physician and the nurse midwife. The nurse midwife may institute those nurse midwifery protocols that do not conflict with the aspect of care under the physician's management. Thus, collaborative management requires careful communication between the nurse midwife and the physician, who assumes responsibility for overall provision of the patient's care.

4. When a patient develops a condition, which requires management by a physician, her care, must be transferred to a physician for management of antepartum, intrapartum, and/or postpartum care. When a complication develops during the intrapartum period, a transfer order then should be communicated directly from the obstetrician to the nurse in charge of the labor and delivery area. The nurse midwife may continue to provide supportive care

5. The supervising physician will provide supervision as required by the Nurse Practice Act and will provide consultation when needed or requested by the midwife. The supervising physician will assume active intrapartum management or co-management of those women whose conditions are beyond the scope of midwifery practice. The supervising physician will countersign all orders written by the midwife within twenty-four (24) hours and will provide coverage when the midwife is unavailable. Consultation by the supervising physician must be available at all times, either by physical presence or electronic communication (i.e.: phone, fax, Internet). One supervising physician must be available for every 3-nurse midwives who work in the same area at the same time.

G. Physician Assistant Guidelines:

1. When authorized to do so by the supervising physician, the physician assistant may perform patient-related activities within the scope of practice defined by Title 16 and in accordance with applicable Federal and State laws.

2. The physician assistant may provide medical care that is either based upon direct consultation with the physician or contained within written protocols approved by the supervising physician

3. The physician assistant will seek physician consultation as soon as possible for the following situations, and any others that he/she deems appropriate: a. Any conditions which have failed to respond to appropriate management or any unusual

symptom b. Unexplained physical finding c. Potentially serious or life threatening condition where prompt initiation of appropriate care has a

substantial impact on outcome d. All emergencies arising after initial care has been started e. Any patient who desires physician consultation f. Before performing any invasive procedures

4. The supervising physician shall be a physician licensed by the State of California. a. This physician will review the findings of the patient's history and physical examination and

supervise the physician assistant performing approved tasks or procedures. b. The physician assistant will be responsible to communicate with the supervising physician

regarding patient management and seek assistance or additional instructions in patient management as deemed necessary by the physician assistant, including unusual or non-routine cases.

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physical presence or by electronic communications (phone, fax, Internet). d. One supervising physician will be available for every four-physician assistants working in an

area at the same time.

H. Nurse Practitioner Guidelines: 1. When authorized to do so by the supervising physician, the Nurse Practitioner may perform the

patient-related activities within the scope of practice defined by Title 16 and applicable Federal and State laws.

2. The nurse practitioner may provide medical care which is either based upon direct consultation with the physician or contained within written medical policies and procedures (e.g., protocols) adapted by the supervising physician. The policies and procedures must be reviewed and approved by the supervising physician

3. The Nurse Practitioner will seek physician consultation as soon as possible for the following situations, and any others he/she deems appropriate: a. Any conditions which have failed to respond to appropriate management or any unusual

symptom. b. Unexplained physical finding c. Potentially serious or life threatening condition where prompt initiation of appropriate care has a

substantial impact on outcome d. All emergencies after initial care have been started. e. Any patient who desires physician consultation f. Before performing any invasive procedures

4. The supervising physician shall be a physician licensed by the State of California. a. This physician will review the findings of the patient's history and physical examination and

supervise the Nurse Practitioner performing approved tasks or procedures. b. The Nurse Practitioner will be responsible to communicate with the supervising physician

regarding patient management and seek assistance or additional instructions in patient management as deemed necessary by the nurse practitioner including in unusual or non-routine cases.

c. The supervising physician will be available for consultation or assistance at all times, either by physical presence or by electronic communications (phone, fax, Internet).

d. One supervising physician will be available for every four nurse practitioners working in an area at the same time.

I. Medical Assistant:

1. In agreement with Title 16, CCR, Section 1366, a medical assistant may perform technical supportive services such as those specified in section IX.B. Provided that all of the following conditions are met: a. The service is a usual and customary part of the medical practice where the medical assistant is

employed. b. The supervising physician authorized the medical assistant to perform the service and assumed

responsibility for the patient's treatment and care c. The medical assistant has completed training in the services described in section B and has

demonstrated competence in the performance of the service, as ascertained by the supervising physician.

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d. Each technical supportive service performed by the medical assistant is documented in the

patient's medical record, indicating the name, date and time, a description of the service performed, and the name of the physician who gave the medical assistant patient-specific authorization to perform the task or who authorized the task under a patient-specific standing order.

2. A medical assistant, in accord with the provisions in section IX.A, performs technical supportive

services such as the following: a. Administer medication orally, sublingually, topically, vaginally or rectally, or by providing a

single dose to a patient for immediate self-administration. A medical assistant may administer medication by inhalation if the medications are patient-specific and have been or will be routinely and repetitively administered to that patient. In every instance, prior to administration of medication by the medical assistant, a licensed physician or other person authorized by law to do so shall verify the correct medication and dosage. No anesthetic agent may be administered by a medical assistant.

b. Perform electrocardiogram, electroencephalogram, or plethysmography tests, except full-body plethysmography. The medical assistant may not perform tests involving the penetration of human tissues, except for skin tests, or to interpret test findings or results.

c. Apply and remove bandages and dressings; apply orthopedic appliances such as knee immobilizers, orthotics, and similar devices; remove casts, splints and other external devices; obtain impressions for orthotics and custom molded shoes; select and adjust crutches for the patient and instruct the patient in proper use of crutches.

d. Perform automated visual field testing, tonometry, or other simple or automated ophthalmic testing not requiring interpretation in order to obtain test results.

e. Remove sutures or staples from superficial incisions or lacerations. f. Perform ear lavage to remove impacted cerumen. g. Collect specimens for lab testing by utilizing non-invasive techniques, including urine, sputum,

semen and stool. h. Assist patients with ambulation and transfers. i. Prepare patients for and assist the physician, physician assistant or registered nurse in

examinations or procedures including positioning, draping, shaving and disinfecting treatment sites.

j. As authorized by the supervising physician, provide patient information and instruction. k. Collect and record patient data including height, weight, temperature, pulse, respiration rate and

blood pressure, and basic information about the presenting and previous conditions. l. Perform simple laboratory and screening tests customarily performed in a medical office. m. Cut the nails of otherwise healthy patients. n. Administer first aid or cardiopulmonary resuscitation in an emergency. o. A medical assistant may also fit prescription lenses or use any optical device in connection with

ocular exercises, visual training, vision training, or orthoptics.

J. Patient Choice: 1. The patient must be informed that the provider is a NPMP, and be granted the opportunity to see a

physician if they choose.

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K. Monitoring Compliance:

1. PHC monitors compliance with this policy through the facility site review. Corrective action plans are required when deficiencies are identified and any uncorrected deficiencies may be reported to the Chief Medical Officer, Provider Relations Department and Credentialing Committee for further action.

VII. REFERENCES: N/A VIII. DISTRIBUTION:

A. PHC Provider B. Practitioner Manuals

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: X. REVISION DATES:

Medi-Cal 10/14/95, 5/17/00, 8/15/01, 9/18/02, 10/20/04, 04/20/05, 04/19/06, 06/20/07, 07/16/08, 07/15/09, 09/15/10,

01/16/13, 01/15/14, 01/21/15 Healthy Kids 06/20/07, 07/16/08, 07/15/09, 09/15/10, 01/16/13, 01/15/14, 01/21/15 PREVIOUSLY APPLIED TO: PartnershipAdvantage: MPQG1011 - 06/20/2007 to 01/01/2015 Healthy Families: MPQG1011 - 10/01/2010 to 03/01/2013

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Page 1 of 4



Guideline/Procedure Title: Hearing Aid Guidelines External Policy

Internal Policy




Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:





II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS: A. Medically necessary: Reasonable and necessary services to protect life, to prevent significant illness or

significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or

injury.

B. ASHA: American Speech-Language-Hearing Association

IV. ATTACHMENTS:

N/A

V. PURPOSE: To describe the process by which Partnership HealthPlan of California (PHC) authorizes medically necessary

hearing aids for PHC eligible members.


A. Total hearing aid cost is limited to $1510.00 per year per Member.

B. Hearing aids are a covered benefit of PHC under the following guidelines:

1. When supplied by a hearing aid dispenser on prescription of an otolaryngologist or the member’s

attending or primary care provider (PCP).

2. With an audiologic evaluation including a hearing aid evaluation which must be performed by or

under the supervision of the above provider or by a licensed audiologist. 3. The examination of the otolaryngologist or the attending physician shall include a complete ear,

nose, and throat examination.

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Guideline/Procedure Title: Hearing Aid Guidelines ☒External Policy

☐Internal Policy




Page 2 of 4

4. Definition of degrees of hearing loss:

Mild: 26 to 40 decibels (dB)

Moderate: 41 to 55 dB

Moderate - Severe: 56 to 70 dB

Severe: 71 to 90 dB

Profound: 91+ dB (ASHA)

C. Prior authorization is required for the trial period of hearing aids and hearing aid repairs, which exceed a

cost of $50.00 per item (an item is defined as all related components of a given device) or service repair.

Hearing aid cords, receivers, ear molds, and hearing aid garments do not require prior authorization.

D. Generally, authorization for hearing aids may be granted only when:

1. Tests of the better ear, after treatment of any condition contributing to the hearing loss, reveal an

average hearing loss level of 26dB or greater, American National Standards Institute (ANSI), 1969,

for 500, 1000, 2000, and 4000 Hertz (Hz) by pure tone air conduction, or

2. Speech communication is effectively improved or auditory contact is necessary for sound awareness

(personal safety) in the environment in which the recipient exists.

3. Specialized hearing aids for members with an unusual pattern of hearing loss must be authorized for

medical necessity by CCS for children under age 21 or by the Chief Medical Officer or physician

designee for adults. Digital hearing aids may be authorized if the Treatment Authorization Request

(TAR) is submitted with a standard code (V5050 or V5060). Aids requested with an unlisted code

require approval by the Chief Medical Officer of physician designee or CCS for CCS eligible

members.

E. Binaural hearing aids may be authorized under any of the following conditions:

1. For Medi-Cal recipients 20 years of age or under:

a. Tests of each ear reveal a hearing loss level of 26dB or greater, ANSI, 1969, for 500, 1000,

2000, and 4000 Hz by pure tone air conduction.

b. Shall be referred to California Children Services (CCS) for evaluation, consultation, or case

management for patients eligible under CCS.

c. The hearing loss is associated with legal blindness

2. For Medi-Cal recipients 21 years of age or over:

a. Tests of each ear reveal a hearing loss level of 26 dB or greater, ANSI, 1969, for 500, 1000,

2000, and 4000 Hz by pure tone air conduction and

1) The hearing loss is associated with legal blindness

2) There is documentation that binaural aids are medically necessary for the safety of the

member, or

3) Using standard audiometric procedures and recorded work lists, if word discrimination

scores are significantly improved in the binaural condition over the monaural condition in

either quiet or noise, then a binaural fitting may be authorized, or

4) Where the provision of a binaural hearing aid is the basis for employment, recipients with

the above hearing loss shall be referred to the California Department of Rehabilitation for

evaluation, consultation, and case management (Title 22 Section 51014).

3. Binaural hearing aids must be authorized and billed using the appropriate HCPCS codes (V5120 –

V5150) and a quantity of “1” not “2”. V5298 quantity 1 = 1 set hearing aids

F. All hearing aids shall be guaranteed for at least one year exclusive of ear piece, cord and batteries. The

guarantee is to cover the repair or replacement of any or all defective parts and labor on a new hearing

aid (out-of-guarantee repairs are to have a minimum guarantee of at least six months). A separate charge

is payable for postage and handling during the guarantee period.

G. Hearing aid maximum allowances are for new instruments and include up to six post-sale visits for

training, adjustments and fitting, a cord, receiver, and other components normally required to use the

instrument. An additional allowance is included for one standard package of batteries.

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☐Internal Policy




Page 3 of 4

H. Hearing aid replacement may be authorized only if:

1. The prior hearing aid has been lost, stolen, or irreparably damaged due to circumstances beyond the

recipient’s control.

2. The hearing impairment of the recipient requires amplification or correction not within the

capabilities of the recipient’s present hearing aid. The new aid shall be prescribed and authorized in

accordance with the above guidelines described for the purchase of a new hearing aid.

I. Initial hearing aid batteries supplied with the hearing aid are covered by PHC when supplied with a

hearing aid that has been prior authorized. Replacement batteries are not covered generally under PHC.

1. Under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, per Title 22

CCR Section 51340.1(b)(2), children under the age of 21 years may receive one package of

batteries, size 675, 13, 312, or 10A, on a quarterly basis without prior authorization. Batteries in

sizes other than those listed, and hearing aid batteries provided at more frequent intervals may be

obtained with prior authorization.

J. Documentation shall be presented to PHC in a format acceptable to PHC per Title 22 CCR Section

51319(e). The format recommended by PHC is included in Attachment A. Providers may use these

forms or submit documentation in lieu of these forms, containing the following information.

1. For the purchase of new hearing aids:

a. Signed prescription from an otolaryngologist or from the member’s PCP.

1) Appropriately signed and completed ear, nose, and throat examination.

2) Appropriately signed and completed audiologic evaluation including a hearing aid

evaluation performed by or under the supervision of the above physician or by a licensed

audiologist. This examination report must include the results of the following tests:

a) Pure tone air conduction threshold and bone conduction tests of each ear at 500, 1,000,

2,000, 3,000 and 4,000 Hz with effective masking as indicated.

b) Speech tests, aided and unaided, shall include the following:

i. Speech Reception Threshold (SRT) using Spondee words.

ii. A Word Discrimination Score (WDS) derived from testing at 40 dB above the SRT

or at the Most Comfortable Loudness (MCL) using standard discrimination word

lists (such as PB or W22) utilizing either recorded or live voice.

iii. Sound Field Aided and Unaided Speech Scores (SRT or WDS) shall be established.

iv. For the non-English speaking client, the provider must submit a description of

alternative testing and the results of such testing.

v. The ear to be fitted must be specified. 2. For the replacement of lost, stolen, or irreparably damaged hearing aids: A statement describing the

circumstances of the loss, theft, or destruction of the hearing aid, signed by the recipient and the

otolaryngologist or the PCP is required.

a. An audiologic evaluation if other than a duplicate of the prior hearing aid is required.

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☐Internal Policy




Page 4 of 4

3. For the replacement of a hearing aid that no longer meets the needs of the recipient whose hearing

impairment requires amplification or correction not within the capabilities of the recipient’s present

hearing aid, the provider must submit documentation consistent with that required for the purchase

of new hearing aids as detailed above.

4. For hearing aid repairs that exceed the cost of $50.00 per repair service, the provider shall submit all

of the following:

a. Description of the problem requiring repair.

b. Hearing aid manufacturer’s name, unit, model designation, date of purchase, and serial number.

c. Ear to which the aid is fitted.

K. Authorizations for hearing aids take into account the needs of individual patients and the characteristics

of the local delivery system.

L. PHC may consult an independent otolaryngologist on an as needed basis to assist with the review of a

hearing aid request for a member.

VII. REFERENCES: A. Medi-Cal Provider Manual

B. Title 22 California Code of Regulations (CCR) Section 51014

C. Title 22 California Code of Regulations (CCR) Section 51319(e)

D. Title 22 California Code of Regulations (CCR) Section 51340.1(b)(2)


B. HS Department Utilization Management Staff

C. PHC Provider Manual


X. REVISION DATES: 09/07/95; 03/08/00; 11/28/01 vs. 11/21; 10/16/02; 04/21/04; 02/16/05; 08/16/06;

08/20/08; 01/18/12; 08/20/14; 01/20/16; 04/20/16; 08/17/16

***********************************









covered under PHC.

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Page 1 of 4



Guideline/Procedure Title: Hearing Aid Guidelines External Policy

Internal Policy

Original Date: 01/19/1995 Next Review Date: 04/20/201708/17/2017

Last Review Date: 04/20/201608/17/2016


Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:



Approval Signature: Robert Moore, MD, MPH Approval Date: 04/20/201608/17/2016


II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS: A. Medically necessary: Reasonable and necessary services to protect life, to prevent significant illness or

significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or

injury.

B. ASHA: American Speech-Language-Hearing Association

IV. ATTACHMENTS:

N/A

V. PURPOSE: To describe the process by which Partnership HealthPlan of California (PHC) authorizes medically necessary

hearing aids for PHC eligible members.


A. Total hearing aid cost is limited to $1510.00 per year per Member.

B. Hearing aids are a covered benefit of PHC under the following guidelines:

1. When supplied by a hearing aid dispenser on prescription of an otolaryngologist or the member’s

attending or primary care provider (PCP).

2. With an audiologic evaluation including a hearing aid evaluation which must be performed by or

under the supervision of the above provider or by a licensed audiologist. 3. The examination of the otolaryngologist or the attending physician shall include a complete ear,

nose, and throat examination.

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☐Internal Policy


Last Review Date: 04/20/201608/17/2016


Page 2 of 4

4. Definition of degrees of hearing loss:

Mild: 26 to 40 decibels (dB)

Moderate: 41 to 55 dB

Moderate - Severe: 56 to 70 dB

Severe: 71 to 90 dB

Profound: 91+ dB (ASHA)

C. Prior authorization is required for the trial period of hearing aids and hearing aid repairs, which exceed a

cost of $50.00 per item (an item is defined as all related components of a given device) or service repair.

Hearing aid cords, receivers, ear molds, and hearing aid garments do not require prior authorization.

D. Generally, authorization for hearing aids may be granted only when:

1. Tests of the better ear, after treatment of any condition contributing to the hearing loss, reveal an

average hearing loss level of 25 26dB or greater, American National Standards Institute (ANSI),

1969, for 500, 1000, 2000, and 4000 Hertz (Hz) by pure tone air conduction, or

2. Speech communication is effectively improved or auditory contact is necessary for sound awareness

(personal safety) in the environment in which the recipient exists.

3. Specialized hearing aids for members with an unusual pattern of hearing loss must be authorized for

medical necessity by CCS for children under age 21 or by the Chief Medical Officer or physician

designee for adults. Digital hearing aids may be authorized if the Treatment Authorization Request

(TAR) is submitted with a standard code (V5050 or V5060). Aids requested with an unlisted code

require approval by the Chief Medical Officer of physician designee or CCS for CCS eligible

members.

E. Binaural hearing aids may be authorized under any of the following conditions:

1. For Medi-Cal recipients 20 years of age or under:

a. Tests of each ear reveal a hearing loss level of 25 26dB or greater, ANSI, 1969, for 500, 1000,

2000, and 4000 Hz by pure tone air conduction.

b. Shall be referred to California Children Services (CCS) for evaluation, consultation, or case

management for patients eligible under CCS.

c. The hearing loss is associated with legal blindness

2. For Medi-Cal recipients 21 years of age or over:

a. Tests of each ear reveal a hearing loss level of 35 26 dB or greater, ANSI, 1969, for 500, 1,000,

and 2,000, and 4000 Hz by pure tone air conduction and

1) The hearing loss is associated with legal blindness

2) There is documentation that binaural aids are medically necessary for the safety of the

member, or

3) Using standard audiometric procedures and recorded work lists, if word discrimination

scores are significantly improved in the binaural condition over the monaural condition in

either quiet or noise, then a binaural fitting may be authorized, or

4) Where the provision of a binaural hearing aid is the basis for employment, recipients with

the above hearing loss shall be referred to the California Department of Rehabilitation for

evaluation, consultation, and case management (Title 22 Section 51014).

3. Binaural hearing aids must be authorized and billed using the appropriate HCPCS codes (V5120 –

V5150) and a quantity of “1” not “2”. V5298 quantity 1 = 1 set hearing aids

F. All hearing aids shall be guaranteed for at least one year exclusive of ear piece, cord and batteries. The

guarantee is to cover the repair or replacement of any or all defective parts and labor on a new hearing

aid (out-of-guarantee repairs are to have a minimum guarantee of at least six months). A separate charge

is payable for postage and handling during the guarantee period.

G. Hearing aid maximum allowances are for new instruments and include up to six post-sale visits for

training, adjustments and fitting, a cord, receiver, and other components normally required to use the

instrument. An additional allowance is included for one standard package of batteries.

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☐Internal Policy


Last Review Date: 04/20/201608/17/2016


Page 3 of 4

H. Hearing aid replacement may be authorized only if:

1. The prior hearing aid has been lost, stolen, or irreparably damaged due to circumstances beyond the

recipient’s control.

2. The hearing impairment of the recipient requires amplification or correction not within the

capabilities of the recipient’s present hearing aid. The new aid shall be prescribed and authorized in

accordance with the above guidelines described for the purchase of a new hearing aid.

I. Initial hearing aid batteries supplied with the hearing aid are covered by PHC when supplied with a

hearing aid that has been prior authorized. Replacement batteries are not covered generally under PHC.

1. Under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, per Title 22

CCR Section 51340.1(b)(2), children under the age of 21 years may receive one package of

batteries, size 675, 13, 312, or 10A, on a quarterly basis without prior authorization. Batteries in

sizes other than those listed, and hearing aid batteries provided at more frequent intervals may be

obtained with prior authorization.

J. Documentation shall be presented to PHC in a format acceptable to PHC per Title 22 CCR Section

51319(e). The format recommended by PHC is included in Attachment A. Providers may use these

forms or submit documentation in lieu of these forms, containing the following information.

1. For the purchase of new hearing aids:

a. Signed prescription from an otolaryngologist or from the member’s PCP.

1) Appropriately signed and completed ear, nose, and throat examination.

2) Appropriately signed and completed audiologic evaluation including a hearing aid

evaluation performed by or under the supervision of the above physician or by a licensed

audiologist. This examination report must include the results of the following tests:

a) Pure tone air conduction threshold and bone conduction tests of each ear at 500, 1,000,

2,000, 3,000 and 4,000 Hz with effective masking as indicated.

b) Speech tests, aided and unaided, shall include the following:

i. Speech Reception Threshold (SRT) using Spondee words.

ii. A Word Discrimination Score (WDS) derived from testing at 40 dB above the SRT

or at the Most Comfortable Loudness (MCL) using standard discrimination word

lists (such as PB or W22) utilizing either recorded or live voice.

iii. Sound Field Aided and Unaided Speech Scores (SRT or WDS) shall be established.

iv. For the non-English speaking client, the provider must submit a description of

alternative testing and the results of such testing.

v. The ear to be fitted must be specified. 2. For the replacement of lost, stolen, or irreparably damaged hearing aids: A statement describing the

circumstances of the loss, theft, or destruction of the hearing aid, signed by the recipient and the

otolaryngologist or the PCP is required.

a. An audiologic evaluation if other than a duplicate of the prior hearing aid is required.

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Page 4 of 4

3. For the replacement of a hearing aid that no longer meets the needs of the recipient whose hearing

impairment requires amplification or correction not within the capabilities of the recipient’s present

hearing aid, the provider must submit documentation consistent with that required for the purchase

of new hearing aids as detailed above.

4. For hearing aid repairs that exceed the cost of $50.00 per repair service, the provider shall submit all

of the following:

a. Description of the problem requiring repair.

b. Hearing aid manufacturer’s name, unit, model designation, date of purchase, and serial number.

c. Ear to which the aid is fitted.

K. Authorizations for hearing aids take into account the needs of individual patients and the characteristics

of the local delivery system.

L. PHC may consult an independent otolaryngologist on an as needed basis to assist with the review of a

hearing aid request for a member.

VII. REFERENCES: A. Medi-Cal Provider Manual

B. Title 22 California Code of Regulations (CCR) Section 51014

C. Title 22 California Code of Regulations (CCR) Section 51319(e)

D. Title 22 California Code of Regulations (CCR) Section 51340.1(b)(2)


B. HS Department Utilization Management Staff

C. PHC Provider Manual


X. REVISION DATES: 09/07/95; 03/08/00; 11/28/01 vs. 11/21; 10/16/02; 04/21/04; 02/16/05; 08/16/06;

08/20/08; 01/18/12; 08/20/14; 01/20/16; 04/20/16; 08/17/16

***********************************









covered under PHC.

114 of 180


POLICY / PROCEDURE

Page 1 of 7



☐ Internal Policy




Reviewing

Entities:



Approving

Entities:





A. MCUP3124 - Referral to Specialists (RAF) Policy


II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. Emergency Medical Condition is defined as a condition which is manifested by acute symptoms of



could result in:

1. Placing the health of the member (or, in the case of a pregnant woman, the health of the member and

her unborn child) in serious jeopardy

2. Serious impairment to bodily functions; or


B. Urgent conditions are defined as a sudden onset of a medical condition or the worsening of an existing

medical condition such that the patient is in mild distress, but without severe pain, significant loss of

function or threatened by loss of life and where urgent therapeutic intervention within 48 hours is needed

to minimize the possibility of patient morbidity.




IV. ATTACHMENTS:

ADDENDA

A. Non-Urgent Problems

B. Urgent Problems

C. Emergent Problems

V. PURPOSE:

To define the circumstances under which emergency services are covered. This policy follows the guidelines

as recommended in MMCD Policy Letter 95-01.

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Policy/Procedure Title: Emergency Services ☒ External Policy

☐ Internal Policy




Page 2 of 7


A. Payment for Services and Prior Authorization








on every patient presenting to the emergency department. This will be reimbursed by PHC. If a

plan member is determined to not require emergency or urgent services, the facility will

communicate with the Primary Care Provider (PCP) to determine the need for further medical

attention.

2. PHC members may generally be transferred by the treating Emergency Department (ED) Physician

for care to their PCP’s office or an urgent care facility under the following circumstances:

a. The member is willing to be seen in the PCP’s office or urgent care facility.


3. The Emergency Department staff arranges an appointment for the member at a time suitable and


4. The PCP or urgent care facility agrees to see the member at the appointed time.

5. The emergency department or urgent care facility is expected to notify the PCP if follow-up care is

required. The emergency department should send a copy of the ED record to the PCP or responsible

physician within 48 hours of the ED visit. The emergency department physician should notify the


responsible physician is required. Follow-up care by a specialist after an ED visit must have a

Referral Authorization Form (RAF) from the PCP to be considered for payment (exception to this is

for initial orthopedic consult after ED referral and for certain capitated specialist services).

6. Emergency department staff will determine if the patient also must be evaluated by an emergency


7. PHC maintains 24-hour emergency telephone availability with physician backup through the PHC

Advice Nurse Line. Emergency department providers are expected to contact the member’s PCP or



If issues arise that cannot be resolved by the ED and the member’s physician, the ED may contact

the PHC Advice Nurse for assistance.

C. Omnibus Reconciliation Act (OBRA) REGULATIONS:

1. Every person who presents to an emergency department must receive a medical screening evaluation

by a physician or person under the supervision of a physician without prior authorization.

2. Medical screening must be performed prior to asking about the individual's ability to pay or before

verifying health plan eligibility.

3. Each person who presents to the ED must be stabilized by medical treatment.

4. The ED physician has the obligation to treat a patient in the emergency department, if in the

physician's judgment, adequate care will not be obtained at another facility.

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Page 3 of 7

5. Transfers between emergency departments are appropriate only if the emergency physician at the

second hospital accepts the transfer.

6. OBRA members have coverage for emergency services ONLY. Upon retrospective medical review,

if services rendered are considered to be non-emergent, they will not be covered by the plan.

D. Advice Nurse Program

1. If the PHC Advise Nurse directs a member to the ED, PHC will pay for the visit. The advice nurse

faxes a copy of the Triage Call Documentation Report to the ED. This report is to be attached to the

claim when it is submitted for payment.

E. Coverage for Services Rendered Outside of the State of California, but within the U.S.

1. Medically necessary medical care outside of the State of California, within the limits of benefits as

outlined in Title 22, is covered only when one of the following conditions is met:



feasible that the member return to California; or

c. The health of the individual would be endangered if travel were undertaken to return to

California; or

d. It is customary practice in border communities for residents to use medical resources in adjacent

areas outside California; or




California.

f. Prior authorization is required for ALL out-of-state services, except:

1) Emergency services as defined in Section 51056 – California Code of Regulations

2) Services provided in border areas adjacent to California where it is customary practice for

California residents to avail themselves of such services. Under these circumstances,

program controls and limitations are the same as for services from providers within the

State.

3) No services are covered outside the United States, except for emergency services requiring

hospitalization in Canada or Mexico.

F. Emergency Department Contracts


PHC. Addendums A, B and C are samples of non-urgent, urgent & emergent problems applicable to

these contracted Emergency Departments.

G. Decisions Made on Medical Appropriateness

1. On an annual basis PHC distributes a statement to all its practitioners, providers, members and


requires employees who make utilization-related decisions and those who supervise them to sign a

statement, which affirms that UM decision making is based only on the appropriateness of care and

service. Furthermore, PHC does not specifically reward practitioners or other individual conducting

utilization review for issuing denials of coverage or service. Financial incentives for UM decision-

makers do not encourage decisions that result in under-utilization.

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Page 4 of 7

H. Prescribed Drugs Under Emergency Circumstances




VII. REFERENCES: A. MMCD Policy Letter 95-01

B. Omnibus Reconciliation Act (OBRA) regulations

C. Title 22 California Code of Regulations

D. California Code of Regulations Section 51056

VIII. DISTRIBUTION:




X. REVISION DATES: 05/09/95; 10/10/97 (name change only); 06/21/00; 10/18/00; 08/15/01; 09/18/02;

10/20/04; 02/16/05, 10/18/06; 10/17/07, 08/20/08; 11/18/09; 05/18/11; 05/15/13; 01/20/16; 08/17/16


*********************************









covered under PHC.

118 of 180




☐ Internal Policy




Page 5 of 7

ADDENDUM A

NON-URGENT PROBLEMS

The following are considered non-urgent problems with regards to payment to contracted facilities unless

extenuating circumstances exist as documented in the record that necessitate urgent or emergent treatment as

determined by the ED physician. In these circumstances, PHC reserves the right to review the record.

* Rash - minimally symptomatic

* External parasites

* First degree burns (small)

* Insect bites (no systemic symptoms)

* Minor puncture wounds (no evidence of infection or foreign object)

* Uncomplicated diarrhea (no blood in stool, no vomiting or symptoms of dehydration)

* Non-active but prior history of nausea/vomiting/diarrhea

* Hemorrhoids – minimally symptomatic

* Uncomplicated constipation

* URI symptoms with no shortness of breath

* Simple UTI – minimally symptomatic

* Urethral or vaginal discharge without bleeding

* Routine tetanus immunization

* Suture removal

* Routine dressing changes

* Missed physician appointments

* Prescription refills

* Follow-up visits

* Pre-employment physical examinations

* Exposures to communicable diseases (e.g. hepatitis, TB, STD, except accidental exposure to blood)

Any other condition, which appears uncomplicated and stable per judgment of ED staff.

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Page 6 of 7

ADDENDUM B

URGENT PROBLEMS

The following problems are considered URGENT services with regards to payment to contracted facilities

unless extenuating circumstances exist as documented by the record that necessitates emergent treatment as


* Chickenpox

* Localized cellulitis

* Abscess requiring I & D

* Insect bites with systemic symptoms

* Small second degree burns

* Otitis media/Ear ache

* Otitis externa

* URI, complicated by abnormal vital signs

* Bronchitis

* Conjunctivitis

* Pharyngitis

* Sinusitis

* Back pain not requiring parenteral analgesics

* Stable Angina – not requiring diagnostic evaluation or parenteral therapy

* Asthma without SOB and/not requiring nebulizer treatment and 80% or greater of predicted peak flow

measurement

* UTI-symptomatic

* Vaginitis

* Urethritis

* Menstrual cramps

* Dysfunctional Uterine Bleeding (DUB) without hemorrhage

* Acute gastroenteritis

* Hemorrhoids with bleeding

* Mild abdominal pain

* Minor contusion

* Minor laceration - no suturing

* Mild sprain/strain

* Headache not requiring diagnostic evaluation or parenteral analgesic

* Accidental Exposure to Blood with HIV risk

* Chronic arthritis

* Minor joint pain

* Localized tooth pain (mild)

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☐ Internal Policy




Page 7 of 7

ADDENDUM C

EMERGENT PROBLEMS

The following are problems that are considered emergent services with regard to contracted facilities. This list is

not intended to be all inclusive, and the ED physician may determine that emergent treatment was indicated for

problems other than those listed below. In these cases, PHC reserves the right to review the record.

*Chest pain - R/O cardiac problem *Large first or second degree burn

*Angina - unstable *Third degree burns

*Myocardial Infarction *MVA

*Congestive heart failure *Gunshot/stabbing

*Stroke *Loss of consciousness

*Significant abdominal pain with *Poisoning

Diagnostic work-up *Overdose

*Pyelonephritis

*Acute GI bleed

*Asthma requiring nebulizer treatment or peak flow less than 80% of expected measurement.

*Pneumonia

*Acute back pain requiring parenteral analgesics

*Fractures or joint injury requiring splinting or reduction

*Lacerations requiring suturing

*Traumatic amputation

*Pyrexia - R/O sepsis in children with diagnostic work-up

*Hypovolemia/dehydration with IV treatment

*Acute psychiatric conditions

*Intoxication

*Delirium

*Hemorrhage in early pregnancy

*PID

*Genital tract hemorrhage

*Rape/sexual assault

*Labor/pre-term labor (to L & D)

*Acute allergic reaction with therapeutic injection of medication

*Acute seizure

*Severe headache requiring therapeutic injection for pain or diagnostic evaluation (CT)

*Uncontrolled epistaxis

*Meningitis

*Sepsis

*Significant acute change in vision

*Foreign body in eye

*Corneal abrasion

121 of 180


POLICY / PROCEDURE

Page 1 of 7



☐ Internal Policy


Last Review Date: 01/20/201608/17/2016


Reviewing

Entities:



Approving

Entities:





A. MCUP3124 - Referral to Specialists (RAF) Policy


II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. Emergency Medical Condition is defined as a condition which is manifested by acute symptoms of



could result in:

1. Placing the health of the individual member (or, in the case of a pregnant woman, the health of the

woman member andor her unborn child) in serious jeopardy

2. Serious impairment to bodily functions; or


B. Urgent conditions are defined as a sudden onset of a medical condition or the worsening of an existing

medical condition such that the patient is in mild distress, but without severe pain, significant loss of

function or threatened by loss of life and where urgent therapeutic intervention within 48 hours is needed

to minimize the possibility of patient morbidity.




IV. ATTACHMENTS:

ADDENDA

A. Non-Urgent Problems

B. Urgent Problems

C. Emergent Problems

V. PURPOSE:

To define the circumstances under which emergency services are covered. This policy follows the guidelines

as recommended in MMCD Policy Letter 95-01.

122 of 180




☐ Internal Policy


Last Review Date: 01/20/201608/17/2016


Page 2 of 7


A. Payment for Services and Prior Authorization








on every patient presenting to the emergency department. This will be reimbursed by PHC. If a

plan member is determined to not require emergency or urgent services, the facility will

communicate with the Primary Care Physician Provider (PCP) to determine the need for further

medical attention.

2. PHC members may generally be transferred by the treating Emergency Department (ED) Physician

for care to their PCP’s office or an urgent care facility under the following circumstances:

a. The member is willing to be seen in the PCP’s office or urgent care facility.


3. The Emergency Department staff arranges an appointment for the member at a time suitable and


4. The PCP or urgent care facility agrees to see the member at the appointed time.

5. The emergency department may notify PHC’s Health Educator regarding non-compliant members.

The Health Educator will contact the member to discuss how to more appropriately obtain services.

6.5. The emergency department or urgent care facility is expected to notify the PCP if follow-up care is

required. The emergency department should send a copy of the ED record to the PCP or responsible

physician within 48 hours of the ED visit. The emergency department physician should notify the


responsible physician is required. Follow-up care by a specialist after an ED visit must have a

Referral Authorization Form (RAF) from the PCP to be considered for payment (exception to this is

for initial orthopedic consult after ED referral and for certain capitated specialist services).

7.6. Emergency department staff will determine if the patient also must be evaluated by an emergency


8.7. PHC maintains 24-hour emergency telephone availability with physician backup through the PHC

Advice Nurse Line. Emergency department providers are expected to contact the member’s PCP or



If issues arise that cannot be resolved by the ED and the member’s physician, the ED may contact

the PHC Advice Nurse for assistance.

C. Omnibus Reconciliation Act (OBRA) REGULATIONS:

1. Every person who presents to an emergency department must receive a medical screening evaluation

by a physician or person under the supervision of a physician without prior authorization.

2. Medical screening must be performed prior to asking about the individual's ability to pay or before

verifying health plan eligibility.

3. Each person who presents to the ED must be stabilized by medical treatment.

4. The ED physician has the obligation to treat a patient in the emergency department, if in the

physician's judgment, adequate care will not be obtained at another facility.

123 of 180




☐ Internal Policy


Last Review Date: 01/20/201608/17/2016


Page 3 of 7

5. Transfers between emergency departments are appropriate only if the emergency physician at the

second hospital accepts the transfer. Otherwise, the initiating ED physician must contact the

member's physician, who is responsible for arranging the transfer to second hospital.

6. OBRA members have coverage for emergency services ONLY. Upon retrospective medical review,

if services rendered are considered to be non-emergent, they will not be covered by the plan.

D. Advice Nurse Program

1. If the PHC Advise Nurse directs a member to the ED, PHC will pay for the visit. The advice nurse

faxes a copy of the Triage Call Documentation Report to the ED. This report is to be attached to the

claim when it is submitted for payment.

E. Coverage for Services Rendered Outside of the State of California, but within the U.S.

1. Medically necessary medical care outside of the State of California, within the limits of benefits as

outlined in Title 22, is covered only when one of the following conditions is met:



feasible that the member return to California; or

c. The health of the individual would be endangered if travel were undertaken to return to

California; or

d. It is customary practice in border communities for residents to use medical resources in adjacent

areas outside California; or




California.

f. Prior authorization is required for ALL out-of-state services, except:

1) Emergency services as defined in Section 51056 – California Code of Regulations

2) Services provided in border areas adjacent to California where it is customary practice for

California residents to avail themselves of such services. Under these circumstances,

program controls and limitations are the same as for services from providers within the

State.

3) No services are covered outside the United States, except for emergency services requiring

hospitalization in Canada or Mexico.

F. Emergency Department Contracts


PHC. Addendums A, B and C are samples of non-urgent, urgent & emergent problems applicable to

these contracted Emergency Departments.

G. Decisions Made on Medical Appropriateness

1. On an annual basis PHC distributes a statement to all its practitioners, providers, members and


requires employees who make utilization-related decisions and those who supervise them to sign a

statement, which affirms that UM decision making is based only on the appropriateness of care and

service. Furthermore, PHC does not specifically reward practitioners or other individual conducting

utilization review for issuing denials of coverage or service. Financial incentives for UM decision-

makers do not encourage decisions that result in under-utilization.

124 of 180




☐ Internal Policy


Last Review Date: 01/20/201608/17/2016


Page 4 of 7

H. Prescribed Drugs Under Emergency Circumstances




VII. REFERENCES: A. MMCD Policy Letter 95-01

B. Omnibus Reconciliation Act (OBRA) regulations

C. Title 22 California Code of Regulations

D. California Code of Regulations Section 51056

VIII. DISTRIBUTION:




X. REVISION DATES: 05/09/95; 10/10/97 (name change only); 06/21/00; 10/18/00; 08/15/01; 09/18/02;

10/20/04; 02/16/05, 10/18/06; 10/17/07, 08/20/08; 11/18/09; 05/18/11; 05/15/13; 01/20/16; 08/17/16


*********************************









covered under PHC.

125 of 180




☐ Internal Policy


Last Review Date: 01/20/201608/17/2016


Page 5 of 7

ADDENDUM A

NON-URGENT PROBLEMS

The following are considered non-urgent problems with regards to payment to contracted facilities unless

extenuating circumstances exist as documented in the record that necessitate urgent or emergent treatment as


* Rash - minimally symptomatic

* External parasites

* First degree burns (small)

* Insect bites (no systemic symptoms)

* Minor puncture wounds (no evidence of infection or foreign object)

* Uncomplicated diarrhea (no blood in stool, no vomiting or symptoms of dehydration)

* Non-active but prior history of nausea/vomiting/diarrhea

* Hemorrhoids – minimally symptomatic

* Uncomplicated constipation

* URI symptoms with no shortness of breath

* Simple UTI – minimally symptomatic

* Urethral or vaginal discharge without bleeding

* Routine tetanus immunization

* Suture removal

* Routine dressing changes

* Missed physician appointments

* Prescription refills

* Follow-up visits

* Pre-employment physical examinations

* Exposures to communicable diseases (e.g. hepatitis, TB, STD, except accidental exposure to blood)

Any other condition, which appears uncomplicated and stable per judgment of ED staff.

126 of 180




☐ Internal Policy


Last Review Date: 01/20/201608/17/2016


Page 6 of 7

ADDENDUM B

URGENT PROBLEMS

The following problems are considered URGENT services with regards to payment to contracted facilities

unless extenuating circumstances exist as documented by the record that necessitates emergent treatment as


* Chickenpox

* Localized cellulitis

* Abscess requiring I & D

* Insect bites with systemic symptoms

* Small second degree burns

* Otitis media/Ear ache

* Otitis externa

* URI, complicated by abnormal vital signs

* Bronchitis

* Conjunctivitis

* Pharyngitis

* Sinusitis

* Back pain not requiring parenteral analgesics

* Stable Angina – not requiring diagnostic evaluation or parenteral therapy

* Asthma without SOB and/not requiring nebulizer treatment and 80% or greater of predicted peak flow

measurement

* UTI-symptomatic

* Vaginitis

* Urethritis

* Menstrual cramps

* Dysfunctional Uterine Bleeding (DUB) without hemorrhage

* Acute gastroenteritis

* Hemorrhoids with bleeding

* Mild abdominal pain

* Minor contusion

* Minor laceration - no suturing

* Mild sprain/strain

* Headache not requiring diagnostic evaluation or parenteral analgesic

* Accidental Exposure to Blood with HIV risk

* Chronic arthritis

* Minor joint pain

* Localized tooth pain (mild)

127 of 180




☐ Internal Policy


Last Review Date: 01/20/201608/17/2016


Page 7 of 7

ADDENDUM C

EMERGENT PROBLEMS

The following are problems that are considered emergent services with regard to contracted facilities. This list is

not intended to be all inclusive, and the ED physician may determine that emergent treatment was indicated for

problems other than those listed below. In these cases, PHC reserves the right to review the record.

*Chest pain - R/O cardiac problem *Large first or second degree burn

*Angina - unstable *Third degree burns

*Myocardial Infarction *MVA

*Congestive heart failure *Gunshot/stabbing

*Stroke *Loss of consciousness

*Significant abdominal pain with *Poisoning

Diagnostic work-up *Overdose

*Pyelonephritis

*Acute GI bleed

*Asthma requiring nebulizer treatment or peak flow less than 80% of expected measurement.

*Pneumonia

*Acute back pain requiring parenteral analgesics

*Fractures or joint injury requiring splinting or reduction

*Lacerations requiring suturing

*Traumatic amputation

*Pyrexia - R/O sepsis in children with diagnostic work-up

*Hypovolemia/dehydration with IV treatment

*Acute psychiatric conditions

*Intoxication

*Delirium

*Hemorrhage in early pregnancy

*PID

*Genital tract hemorrhage

*Rape/sexual assault

*Labor/pre-term labor (to L & D)

*Acute allergic reaction with therapeutic injection of medication

*Acute seizure

*Severe headache requiring therapeutic injection for pain or diagnostic evaluation (CT)

*Uncontrolled epistaxis

*Meningitis

*Sepsis

*Significant acute change in vision

*Foreign body in eye

*Corneal abrasion

128 of 180


GUIDELINE/ PROCEDURE

Page 1 of 3

Guideline/Procedure Number: MCUP3122 Lead Department: Health Services

Guideline/Procedure Title: Palliative Care ☒External Policy

☐ Internal Policy


Effective 03/01/2013 Next Review Date: 08/17/2017



Reviewing

Entities:



Approving

Entities:





A. MCUP3020 Hospice Service Guidelines

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. N/A

IV. ATTACHMENTS:

A. N/A

V. PURPOSE:

To describe the services provided under Partnership HealthPlan of California’s (PHC’s) palliative care

program.

NOTE: PHC began a pilot program entitled Partners in Palliative Care on 09/01/2015 based on the

draft policy paper issued by the California Department of Health Care Services (DHCS) for SB 1004 to

establish minimum standard palliative care services and eligible conditions for Medi-Cal beneficiaries.

PHC’s pilot program is taking place at 4 sites which include Collabria Care in Napa, Yolo Hospice in

Davis, Interim Home Healthcare in Redding, and ResolutionCare in Eureka. PHC has extended

funding for the pilot program to continue until the anticipated effective date of the new Medi-Cal

palliative care benefit in January 2017. When further direction has been received from DHCS, PHC

will update this policy based upon new guidelines.


A. Background

Palliative Medicine became recognized as an official subspecialty by the American Board of Medical

Specialties in 2006. It is referred to as Hospice and Palliative Medicine. To be certified in this subspecialty, a physician has to pass the Palliative Medicine board examination. Effective January 1,

2013, physicians will only be certified if they have completed a Palliative Medicine fellowship training

program, as well as passing the board examination. PHC recognized Palliative Medicine as a

subspecialty in 2012.

129 of 180


Guideline/Procedure Title: Palliative Care ☒ External Policy

☐ Internal Policy





Page 2 of 3

B. Who is Eligible for Palliative Medicine Consultations?

Eligible members are those who are either very frail and debilitated, or suffering from significant chronic

illness and whose health is expected to continue to decline.

C. PHC Palliative Care Benefit

PHC began paying for Palliative Medicine consultations effective March 1, 2013. The palliative care

benefit is available and appropriate for patients in both the inpatient and outpatient setting.

D. Services Provided

Among the services provided by Palliative Medicine are:

1. Symptom management

2. Medication management

3. Psychological counseling

4. Support for family members

5. Addressing unmet needs in the realm of appropriate living arrangements

6. Discussion of Advance Directives and POLST form completion, and

7. Other issues relating to the member’s declining health status.

Palliative Medicine services are often delivered by a multi-disciplinary team, under the leadership of a

certified Palliative Medicine physician.

E. How are Palliative Medicine Referrals Made?

In the outpatient setting, Primary Care Providers (PCPs) can refer to a Palliative Medicine specialist

without filling out a Referral Authorization Form (RAF). In the inpatient setting, referrals can be made

without a RAF by either the hospitalist or by any specialist involved with the patient’s care in the

hospital.

F. Palliative Medicine/PCP Communication

In the course of a Palliative Medicine consultation, a number of recommendations will typically be made

by the specialist. It is incumbent on the Palliative Medicine specialist to communicate his or her

assessment and recommendations to the PCP, whether the consultation was initiated in the hospital or in

the outpatient setting. That communication should clearly indicate which recommendations the

specialist will be implementing, which ones the PCP should follow through on, and whether the

Palliative Medicine specialist will continue to follow the patient in an ongoing way, or whether the

patient’s future palliative care treatment is being delegated to the PCP. Where appropriate and needed, it

is the responsibility of the PCP to follow-up with those recommendations. After a patient has been

discharged from Palliative Medicine specialist care, if the PCP needs additional consultative help, the

patient can be referred back to Palliative Medicine.

VII. REFERENCES: A. N/A

VIII. DISTRIBUTION:

A. Provider Manual

B. PHC Directors




130 of 180



☐ Internal Policy





Page 3 of 3

*********************************









covered under PHC.

131 of 180


GUIDELINE/ PROCEDURE

Page 1 of 3


Guideline/Procedure Title: Palliative Care ☒External Policy

☐ Internal Policy


Effective 03/01/2013 Next Review Date: 01/16/201508/17/2017

Last Review Date: 01/16/201308/17/2016


Reviewing

Entities:



Approving

Entities:





A. MCUP3020 Hospice Service Guidelines

II. IMPACTED DEPTS:

A. Health Services

B. Claims

A.C. Member Services

III. DEFINITIONS:

A. N/A

IV. ATTACHMENTS:

A. N/A

V. PURPOSE:

To describe the services provided under Partnership HealthPlan of California’s (PHC’s) palliative care

program.

NOTE: PHC began a pilot program entitled Partners in Palliative Care on 09/01/2015 based on the

draft policy paper issued by the California Department of Health Care Services (DHCS) for SB 1004 to

establish minimum standard palliative care services and eligible conditions for Medi-Cal beneficiaries.

PHC’s pilot program is taking place at 4 sites which include Collabria Care in Napa, Yolo Hospice in

Davis, Interim Home Healthcare in Redding, and ResolutionCare in Eureka. PHC has extended

funding for the pilot program to continue until the anticipated effective date of the new Medi-Cal

palliative care benefit in January 2017. When further direction has been received from DHCS, PHC

will update this policy based upon new guidelines.


A. Background

Palliative Medicine became recognized as an official subspecialty by the American Board of Medical

Specialties in 2006. It is referred to as Hospice and Palliative Medicine. To be certified in this subspecialty, a physician has to pass the Palliative Medicine board examination. Effective January 1,

2013, physicians will only be certified if they have completed a Palliative Medicine fellowship training

program, as well as passing the board examination. PHC recognized Palliative Medicine as a

subspecialty in 2012.

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Last Review Date: 01/16/201308/17/2016


Page 2 of 3

B. Who is Eeligible for Palliative Medicine Cconsultations?

Eligible members are those who are either very frail and debilitated, or suffering from significant chronic

illness and whose health is expected to continue to decline.

C. PHC Ppalliative Ccare Bbenefit

PHC will beginbegan paying for Palliative Medicine consultations effective March 1, 2013. The

palliative care benefit is available and appropriate for patients in both the inpatient and outpatient setting.

D. Services Pprovided

Among the services provided by Palliative Medicine are:

1. Symptom management

2. Medication management

3. Psychological counseling

4. Support for family members

5. Addressing unmet needs in the realm of appropriate living arrangements

6. Discussion of Advance Directives and POLST form completion, and

7. Other issues relating to the member’s declining health status.

Palliative Medicine services are often delivered by a multi-disciplinary team, under the leadership of a

certified Palliative Medicine physician.

E. How are Palliative Medicine Rreferrals Mmade?

In the outpatient setting, Primary Care Providers (PCPs) can refer to a Palliative Medicine specialist

without filling out a Referral Authorization Form (RAF). In the inpatient setting, referrals can be made

without a RAF by either the hospitalist or by any specialist involved with the patient’s care in the

hospital.

F. Palliative Medicine/PCP Ccommunication

In the course of a Palliative Medicine consultation, a number of recommendations will typically be made

by the specialist. It is incumbent on the Palliative Medicine specialist to communicate his or her

assessment and recommendations to the PCP, whether the consultation was initiated in the hospital or in

the outpatient setting. That communication should clearly indicate which recommendations the

specialist will be implementing, which ones the PCP should follow through on, and whether the

Palliative Medicine specialist will continue to follow the patient in an ongoing way, or whether the

patient’s future palliative care treatment is being delegated to the PCP. Where appropriate and needed, it

is the responsibility of the PCP to follow-up with those recommendations. After a patient has been

discharged from Palliative Medicine specialist care, if the PCP needs additional consultative help, the

patient can be referred back to Palliative Medicine.

VII. REFERENCES: A. N/A

VIII. DISTRIBUTION:

A. Provider Manual

B. PHC Directors




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Last Review Date: 01/16/201308/17/2016


Page 3 of 3

*********************************









covered under PHC.

134 of 180


POLICY / PROCEDURE

Page 1 of 4

Policy/Procedure Number: MPUP3026 (previously UP100326) Lead Department: Health Services

Policy/Procedure Title: Inter-Rater Reliability Policy ☒External Policy

☐ Internal Policy

Original Date: 02/16/00 – Medi-Cal





Reviewing

Entities:



Approving

Entities:






II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. IRR: Inter-Rater Reliability

IV. ATTACHMENTS:

A. Inter-Rater Reliability Study TAR Audit Report – UM Nurse Coordinator Review

B. Inter-Rater Reliability Audit Reporting Form – Physician Review

C. Inter-Rater Reliability Form – Pharmacy Department

V. PURPOSE:

To evaluate the consistent application of standardized medical management criteria among personnel within

the Utilization Management (UM) department.


A. Goal

1. To ensure that medical management criteria are being utilized appropriately and consistently in

making decisions to approve Treatment Authorization Requests (TAR) for members.

B. UM Nurse Coordinator Review

1. Method of Data Collection

a. Retrospective review of TARs for services reviewed by Health Services UM Coordinators

2. Staff Responsible

a. Health Services Project Coordinator

135 of 180

http://eshare/sites/PoliciesnProcedures/Utilization%20Management/MPUP3026%20Attachments/MPUP3026-A.pdf

http://eshare/sites/PoliciesnProcedures/Utilization%20Management/MPUP3026%20Attachments/MPUP3026-B.pdf

http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame2.aspx?sourcedoc=/sites/PoliciesnProcedures/Utilization%20Management/MPUP3026%20Attachments/MPUP3026-C.docx&action=default

Policy/Procedure Number: MPUP3026 (previously


Policy/Procedure Title: Inter-Rater Reliability Policy ☒ External Policy

☐ Internal Policy






Page 2 of 4

3. Sample

a. Inpatient Service

1) A random sample of all TARs done for inpatient services will be selected for audit with a

sample size of 5 per UM Nurse Coordinator per month. At least one of the samples

reviewed for each nurse must be a denied TAR.

2) Each selected TAR will be audited by a clinical staff member who was not involved in the

original determination. The audit will include compliance with eligibility and timeliness

issues, as well as evaluation of the application of criteria and accuracy of the determination.

b. Outpatient Services

1) A random sample of all TARs done for outpatient services will be selected with a sample

size of 30 per month. Distribution will be selected to cover the following areas of review:

a) Medical, Ancillary, DME, Long Term Care, Incontinence and Denied TARs.

b) Each selected TAR will be audited by a clinical staff member who was not involved in

the original determination. The audit will include compliance with eligibility and

timeliness issues, as well as evaluation of the application of criteria and accuracy of the

determination.

4. Time Frame

a. The audit compliance summary will be reported at the Internal Quality Improvement (IQI)

meeting each October for the preceding year.

5. Results

a. An accuracy rate of 90% is targeted; if PHC falls below this, a corrective action is initiated by

the Health Services Department under the direction of the UM Director. The corrective action

plan may include but not be limited to educational activities, increased scrutiny of decisions

and/or institution of staff probationary period combined with supervision of decisions. When

compiled, results are presented to, and reviewed by, the Quality/Utilization Advisory Committee

(Q/UAC).

C. Physician Review:


a. Retrospective review of TARs for services denied by a Physician Reviewer



3. Sample:

a. The Health Services Project Coordinator will coordinate and schedule a biannual audit review of

TARs for services denied by a Physician Reviewer. The Health Services Project Coordinator

will randomly select 5 denial files from each physician reviewer who issued a denial

determination for the previous 6 months. Sample TARs selected will be audited by a different

physician than the one who originally reviewed the TAR. The Chief Medical Officer will review

the findings of the audit.

b. If there is no alternate physician available to perform an inter-rater reliability audit, a physician

experienced in UM employed by a Medi-Cal Managed Care Plan performs the review.

4. Results:

a. An accuracy rate of 90% is targeted. If a Physician Reviewer falls below 90%, a corrective

action plan is initiated by the CMO. Corrective action plans could include but not be limited to

educational activities, supervision of decisions, increased scrutiny of decisions, or removal of that physician from making UM decisions.

D. Pharmacy Review:


a. Retrospective review of TARs for services reviewed by Pharmacy Reviewers.

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☐ Internal Policy






Page 3 of 4


a. Pharmacy Director

3. Sample

a. The Pharmacy Administrative Assistant (AA) coordinates and schedules the auditing for each

year. The annual summary is reported in July. The AA randomly selects 10 approved TARs and

10 deferred TARs each month. Over the course of a year period each reviewer will have a

resulting sample size of at least 20 TARs (comprised of 10 approved plus10 deferred) reviewed.

A pharmacist reviewer performs the inter-rater reliability audit reviewing determinations

rendered by another pharmacy reviewer.

4. Results

a. An accuracy rate of 90% is targeted; if PHC falls below this, a corrective action plan is required.

Corrective action plans could include, but are not limited to educational activities, increased

scrutiny of decisions and/or institution of a probationary period combined with supervision of

decisions. When compiled, results are presented to and reviewed by the Quality/Utilization

Advisory Committee (Q/UAC).


VIII. DISTRIBUTION:





11/28/01; 01/15/03; 10/20/04; 10/19/05; 10/18/06, 08/20/08; 08/18/10; 10/01/10; 05/16/12; 01/20/16;

08/17/16

Healthy Kids

10/18/06; 08/20/08; 08/18/10; 10/01/10; 05/16/12; 01/20/16; 08/17/16


*********************************








137 of 180




☐ Internal Policy






Page 4 of 4


covered under PHC.

138 of 180

___

__

__

___ ___

__

__

__ __

___ ___ ___

__ __

___ ___

Inter-Rater Reliability Study TAR Audit Report

TAR#

Eligibility

TAR Type:

Ancillary Denials DME Incontinence LTC Inpatient Medical

Was the member eligible for date of service at time TAR received? If not eligible, was TAR appropriately denied?

Yes No Yes No

Comments:

Timeliness

Was the TAR submitted within 15 days of the date of service or within 60 days of retrospective eligibility?

If not submitted within timeframe was TAR appropriately denied?

Yes No

Yes No

Was the TAR completed within the appropriate timeframe per policy? Eligible: Medi-Cal=5 days HK= 5 days Retro: MediCal-60 days

Yes No

Comments:

Criteria

What criteria were applied to this case? InterQual PHC Other

Do you agree with the determination made? YES NO

(If not, why?)

Misc

Other Comments:

Name of Auditor Date of Audit

Attachment A

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Partnership HealthPlan of California Inter- Rater Reliability Audit Reporting Form

Physician Review Name of Reviewer: _______________

Review of denied TARs

Record Number Agree? Comment Only if you Disagree/Or Criteria Errors Found

Previously Reviewed By YES NO

Signature ___________________

Attachment B

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Inter-Rater Reliability Form Pharmacy Department

Reviewer: __________________________

Date: ________________

The following TARs were completed by: _____________________________________ Date of Final Review

Member ID # TAR # or PA Agree/Disagree Yes/No

Comments

Reviewed: _________________________________

Attachment C

141 of 180


POLICY / PROCEDURE

Page 1 of 4

Policy/Procedure Number: MPUP3026 (previously UP100326) Lead Department: Health Services

Policy/Procedure Title: Inter-Rater Reliability Policy ☒External Policy

☐ Internal Policy



Next Review Date: 01/20/201708/17/2017

Last Review Date: 01/20/201608/17/2016


Reviewing

Entities:



Approving

Entities:






II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. IRR: Inter-Rater Reliability

IV. ATTACHMENTS:

A. Inter-Rater Reliability Study TAR Audit Report – UM Nurse Coordinator Review

B. Inter-Rater Reliability Audit Reporting Form – Physician Review

C. Inter-Rater Reliability Form – Pharmacy Department

V. PURPOSE:

To evaluate the consistent application of standardized medical management criteria among personnel within

the Utilization Management (UM) department.


A. Goal

1. To ensure that medical management criteria are being utilized appropriately and consistently in

making decisions to approve Treatment Authorization Requests (TAR) for members.

B. UM Nurse Coordinator Review


a. Retrospective review of TARs for services reviewed by Health Services UM Coordinators


a. Health Services UM ManageProject Coordinator

Health Services Director

b. Chief Medical Officer.

142 of 180

http://eshare/sites/PoliciesnProcedures/Utilization%20Management/MPUP3026%20Attachments/MPUP3026-A.pdf

http://eshare/sites/PoliciesnProcedures/Utilization%20Management/MPUP3026%20Attachments/MPUP3026-B.pdf

http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame2.aspx?sourcedoc=/sites/PoliciesnProcedures/Utilization%20Management/MPUP3026%20Attachments/MPUP3026-C.docx&action=default




☐ Internal Policy



Next Review Date: 01/20/201708/17/2017

Last Review Date: 01/20/201608/17/2016


Page 2 of 4

3. Sample

a. Inpatient Service

1) A random sample of all TARs done for all inpatient services will be selected for audit with a

sample size of 5 per UM Nurse Coordinator per month. At least one of the samples

reviewed for each nurse must be a denied TAR.

1)2) Each selected TAR will be audited by a clinical staff member who was not involved in the

original determination. The audit will include compliance with eligibility and timeliness

issues, as well as evaluation of the application of criteria and accuracy of the

determination.members are reviewed weekly in Grand Rounds attended by the Chief

Medical Officer or Physician Designee, Health Services Director, UM Manager, UM Nurse

Coordinators, and Care Coordination representatives.

b. Outpatient Services

1) A random sample of all TARs done for outpatient services will be selected with a sample

size of 30 per month. Distribution will be selected to cover the following areas of review:

a) Medical, Ancillary, DME, and Long Term Care (including , Incontinence and Denied

TARs.)

b) Each selected TAR will be audited by a clinical staff member who was not involved in

the original determination. The audit will include compliance with eligibility and

timeliness issues, as well as evaluation of the application of criteria and accuracy of the

determination.

4. Time Frame

a. The audit compliance summary will be reported at the Internal Quality Improvement (IQI)

meeting each February October for the preceding year.

5. Results

a. An accuracy rate of 90% is targeted; if PHC falls below this, a corrective action is initiated by

the Health Services Department under the direction of the UM ManagerDirector. The corrective

action plan may include but not be limited to educational activities, increased scrutiny of

decisions and/or institution of staff probationary period combined with supervision of decisions.

When compiled, results are presented to, and reviewed by, the Quality/Utilization Advisory

Committee (Q/UAC).

C. Physician Review:


a. Retrospective review of TARs for services denied by a Physician Reviewer



a. UM Manager

b. Health Services Director

c. Chief Medical Officer (CMO), Associate and Regional Medical Directors

3. Sample:

a. When there is more than one physician reviewer for the UM decision making processes, Tthe

Health Services Project CoordinatorChief Medical Officer will coordinate and schedule a bithe-

annual audit review of TARs for services denied by a Physician Reviewer.. The Health Services

Project Coordinator Chief Medical Officer will randomly select 10 5 denial files from each

physician reviewer who issued a denial determination for the previous 12 6 months. Sample TARs selected will be audited by a different physician than the one who originally reviewed the

TAR. The Chief Medical Officer will review the findings of the audit.

b. If there is no alternate physician available to perform an inter-rater reliability audit, a physician

experienced in UM employed by a Medi-Cal Managed Care Plan performs the review.

143 of 180




☐ Internal Policy



Next Review Date: 01/20/201708/17/2017

Last Review Date: 01/20/201608/17/2016


Page 3 of 4

4. Results:

a. An accuracy rate of 90% is targeted. If a Physician Reviewer falls below 90%, a corrective

action plan is initiated by the CMO. Corrective action plans could include but not be limited to

educational activities, supervision of decisions, increased scrutiny of decisions, or removal of

that physician from making UM decisions.

D. Pharmacy Review:


a. Retrospective review of TARs for services reviewed by Pharmacy Reviewers.


a. Pharmacy Director

3. Sample

a. The Pharmacy Administrative Assistant (AA) coordinates and schedules the auditing for each

year. The annual summary is reported in July. The AA randomly selects 10 approved TARs and

10 deferred TARs each month. Over the course of a year period each reviewer will have a

resulting sample size of at least 20 TARs (comprised of 10 approved plus10 deferred) reviewed.

A pharmacist reviewer performs the inter-rater reliability audit reviewing determinations

rendered by another pharmacy reviewer.

4. Results

a. An accuracy rate of 90% is targeted; if PHC falls below this, a corrective action plan is required.

Corrective action plans could include, but are not limited to educational activities, increased

scrutiny of decisions and/or institution of a probationary period combined with supervision of

decisions. When compiled, results are presented to and reviewed by the Quality/Utilization

Advisory Committee (Q/UAC).


VIII. DISTRIBUTION:





11/28/01; 01/15/03; 10/20/04; 10/19/05; 10/18/06, 08/20/08; 08/18/10; 10/01/10; 05/16/12; 01/20/16;

08/17/16

Healthy Kids

10/18/06; 08/20/08; 08/18/10; 10/01/10; 05/16/12; 01/20/16; 08/17/16


*********************************


144 of 180




☐ Internal Policy



Next Review Date: 01/20/201708/17/2017

Last Review Date: 01/20/201608/17/2016


Page 4 of 4








covered under PHC.

145 of 180

___

__

__

___ ___

__

__

__ __

___ ___ ___

__ __

___ ___

Inter-Rater Reliability Study TAR Audit Report

TAR#

Eligibility

TAR Type:

Ancillary Denials DME Incontinence LTC Inpatient Medical

Was the member eligible for date of service at time TAR received? If not eligible, was TAR appropriately denied?

Yes No Yes No

Comments:

Timeliness

Was the TAR submitted within 15 days of the date of service or within 60 days of retrospective eligibility?

If not submitted within timeframe was TAR appropriately denied?

Yes No

Yes No

Was the TAR completed within the appropriate timeframe per policy? Eligible: Medi-Cal=5 days HK= 5 days Retro: MediCal-60 days

Yes No

Comments:

Criteria

What criteria were applied to this case? InterQual PHC Other

Do you agree with the determination made? YES NO

(If not, why?)

Misc

Other Comments:

Name of Auditor Date of Audit

Attachment A

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Partnership HealthPlan of California Inter- Rater Reliability Audit Reporting Form

Physician Review Name of Reviewer: _______________

Review of denied TARs

Record Number Agree? Comment Only if you Disagree/Or Criteria Errors Found

Previously Reviewed By YES NO

Signature ___________________

Attachment B

147 of 180

Inter-Rater Reliability Form Pharmacy Department

Reviewer: __________________________

Date: ________________

The following TARs were completed by: _____________________________________ Date of Final Review

Member ID # TAR # or PA Agree/Disagree Yes/No

Comments

Reviewed: _________________________________

Attachment C

148 of 180

Healthcare Effectiveness Data Information Set(HEDIS)

2016Performance

Measuring quality of care and services provided to our members!

Date: August 10, 2016

Presenter:Rachael French

Manager of Quality Improvement Programs

149 of 180

Objectives

• HEDIS Overview

• 2016 Regional and County Level Performance

• Next Steps

• Q & A

150 of 180

HEDIS Overview

PHC Internal Use Only

• What is HEDIS?• Healthcare Effectiveness Data Information Set• Administrative vs. Hybrid Measures

• Why is HEDIS Important?• Evaluates clinical quality in a standardized way• Identifies opportunities for improvement • Regional-level performance is publicly reported• Regional-level reporting is required by the State• HEDIS/CAHPS equates to 50% NCQA

Accreditation

151 of 180

HEDIS Overview


Southeast: Solano, Yolo, Napa

Southwest: Sonoma, Marin, Mendocino, Lake

Northeast: Lassen, Modoc, Siskiyou, Trinity, Shasta

Northwest: Humboldt, Del Norte

152 of 180

HEDIS 2016 Goals


1. No measures below the Minimum Performance Level in the Southeast and Southwest Regions – Partial Met

2. Less than 3 measures (per region) below the Minimum Performance Level in the Northeast and Northwest Regions – Not Met

Region # of measures below MPL

Southeast 0 measures

Southwest 1 measure

Region # of measures below MPL

Northeast 9 measures

Northwest 6 measures

153 of 180

Summarizing HEDIS Performance


DHCS Scoring Methodology:

• 4 points for the 90th percentile

• 3 points for the 75th-89th percentile

• 2 points for the 50th-74th percentile

• 1 point for the 25th-49th percentile

• NO points for below the 25th percentile

154 of 180

Composite HEDIS Performance


59.09%

48.86%

22.50%27.50%

56.82% 55.68%

29.55%35.23%

40.18%44.32%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

SE(N=22)

SW(N=22)

NE(N=20)

NW(N=20)

SE(N=22)

SW(N=22)

NE(N=22)

NW(N=22)

HEDIS 2015 HEDIS 2016

155 of 180

Detailed Regional and County Level Performance

HEDIS 2016 Summary of Regional and County Level Performance

http://www.partnershiphp.org/Providers/Quality/Documents/HEDIS/HEDIS16Performance_07.22.16.pdf

156 of 180

http://www.partnershiphp.org/Providers/Quality/Documents/HEDIS/HEDIS16Performance_07.22.16.pdf

Next Steps

• Rapid cycle improvement projects focused on measures falling below the MPL

• Plan-wide focus on HEDIS measure score improvement

• Continuous work to improve operational efficiencies

157 of 180

Thank You!

Providers and Office Staff:

On Behalf of Partnership HealthPlan of California;

We thank you for you continuous support, effort and patience during our annual HEDIS project

158 of 180

Questions?

Please visit our HEDIS webpage at:http://www.partnershiphp.org/Providers/Quality/Pages/HEDISLandingPage.aspx

Robyn GerdesProgram Manager, [email protected](707) 420-7507

159 of 180

Partnership HealthPlan of CA HEDIS 2016 PerformanceDistribution of Percentile Rankings by Region Across All Measures

Mendocino

Humboldt

Del Norte

Sonoma

Siskiyou

Lassen

Solano

Shasta

Modoc

Trinity

Marin

Lake

Yolo

Percentile Northeast Northwest Southeast Southwest90th (HPL)75th50th25thBelow MPL

5

3

5

9

1

3

6

6

6

4

4

8

6

4

4

8

5

1

Measure Northeast Northwest Southeast Southwest

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)*

Prenatal and Postpartum Care (PPC)- Timeliness of Prenatal Care

Use of Imaging Studies for Low Back Pain (LBP)*

Weight Assessment and Counseling for Nutrition & Physical Activity (WCC) -Physical ActivityWeight Assessment and Counseling for Nutrition & Physical Activity (WCC)- BMIPercentilesWeight Assessment and Counseling for Nutrition & Physical Activity (WCC)-Nutrition

Measures At or Above the High Performance Level (90th Percentile)


Annual Monitoring for Patients on Persistent Medications (MPM) - ACE or ARB*

Annual Monitoring for Patients on Persistent Medications (MPM) - Diuretics*

Cervical Cancer Screening (CCS)

Childhood Immunization Status (CIS-3)- Combo 3 Immunizations

Comprehensive Diabetes Care (CDC)- Eye Exam

Immunizations for Adolescents (IMA-1)- Combo 1 Immunizations

Prenatal and Postpartum Care (PPC)- Postpartum Care


Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34)

Measures Below the Minimum Performance Level (25th Percentile)

*Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eli-gible population for the hybrid measures).Notes: Excludes measures reported to DHCS where DHCS does not hold Manged Care Plans accountable for meeting specific performancetargets; (All-Cause Readmission, Ambulatory Care, Annual Monitoring for Patients on Persistent Medications – Digoxin, Children & Adoles-cents Access to Primary Care Practitioners).

Northeast

Northwest

Southeast

Southwest

160 of 180

Partnership HealthPlan of CA HEDIS 2016 Performance Regional Rates and Benchmarks

Above HPL (high performance level, based on NCQA's national Medicaid 90th percentile)

Below MPL (minimum performance level, based on NCQA's national Medicaid 25th percentile)

Measure NortheastNorthwestSoutheastSouthwest

Annual Monitoring for Patients on PersistentMedications (MPM) - ACE or ARB*

Annual Monitoring for Patients on PersistentMedications (MPM) - Diuretics*

Avoidance of Antibiotic Treatment in Adults withAcute Bronchitis (AAB)*


Childhood Immunization Status (CIS-3)- Combo 3Immunizations

Comprehensive Diabetes Care (CDC)- BloodPressure Control (<140/90)


Comprehensive Diabetes Care (CDC)- HbA1cAdequate Control (<8)

Comprehensive Diabetes Care (CDC)- HbA1c PoorControl (>9)

Comprehensive Diabetes Care (CDC)- HBA1CTesting

Comprehensive Diabetes Care (CDC)- MedicalAttention for Nephropathy

Controlling High Blood Pressure (CBP)

Immunizations for Adolescents (IMA-1)- Combo 1Immunizations

Medication Management for People with Asthma(MMA-50) Total Population 50%*


Prenatal and Postpartum Care (PPC)- PostpartumCare

Prenatal and Postpartum Care (PPC)- Timelinessof Prenatal Care


Weight Assessment and Counseling for Nutrition& Physical Activity (WCC) - Physical Activity

Weight Assessment and Counseling for Nutrition& Physical Activity (WCC)- BMI Percentiles

Weight Assessment and Counseling for Nutrition& Physical Activity (WCC)- Nutrition

Well-Child Visits in the Third, Fourth, Fifth, andSixth Years of Life (W34)

83.40%78.82%81.68% 86.39%

80.46%83.40% 85.03%85.33%

41.15%34.81%34.43%27.22%

44.04%42.09% 57.78%60.10%

56.54%56.61% 66.77%71.67%

71.29%63.66%60.58%64.23%

42.82%43.07% 54.01%60.98%

48.91%54.15%48.42%44.04%

40.15%35.61%39.66%46.96%

87.10%85.12%83.70%86.86%

86.62%87.56%85.16%87.35%

65.53%65.59%60.34%54.74%

46.23% 70.00%80.99%66.25%

55.60%53.88%56.72%65.60%

29.91%28.77%34.87%43.84%

49.27% 68.33%66.38%59.37%

72.44% 91.94%84.46%80.54%

87.86%86.27%85.71%81.63%

76.28% 63.75%56.20%51.58%

86.37%87.06%78.10%83.45%

81.40% 72.99%57.18%58.64%

60.05%63.66% 73.13%77.64%

Regional Rates

25th(MPL) 50th 75th 90th(HPL)

84.88% 87.74% 89.88% 92.01%

84.70% 87.10% 89.53% 91.78%

22.00% 26.30% 32.80% 40.38%

54.33% 60.98% 67.88% 73.08%

66.19% 71.53% 76.50% 81.25%

56.45% 62.20% 69.13% 76.64%

47.06% 54.74% 63.38% 67.86%

40.00% 47.91% 54.01% 58.58%

49.89% 42.27% 34.66% 29.68%

83.19% 86.29% 89.55% 91.94%

77.95% 81.75% 84.88% 87.70%

49.88% 57.47% 65.29% 70.32%

63.79% 73.15% 81.51% 87.71%

47.41% 53.71% 59.57% 67.24%

23.72% 29.61% 35.03% 44.12%

55.47% 62.77% 68.85% 72.43%

77.44% 85.19% 88.66% 91.73%

71.82% 74.97% 78.06% 82.86%

44.16% 53.89% 64.43% 71.53%

51.27% 67.23% 77.98% 85.61%

51.98% 61.44% 72.87% 79.56%

65.54% 72.02% 78.46% 83.75%

Benchmarks

*Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligiblepopulation for the hybrid measures) .

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Partnership HealthPlan of CA HEDIS 2016 Performance HEDIS measures and percentiles change from HEDIS 2015 to HEDIS 2016


Annual Monitoring for Patients on Persistent Medications (MPM) - ACE or ARB*

Annual Monitoring for Patients on Persistent Medications (MPM) - Diuretics*

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)*



Comprehensive Diabetes Care (CDC)- Blood Pressure Control (<140/90)


Comprehensive Diabetes Care (CDC)- HbA1c Adequate Control (<8)

Comprehensive Diabetes Care (CDC)- HbA1c Poor Control (>9)

Comprehensive Diabetes Care (CDC)- HBA1C Testing

Comprehensive Diabetes Care (CDC)- Medical Attention for Nephropathy



Medication Management for People with Asthma (MMA-50) Total Population50%*

Medication Management for People with Asthma (MMA-75) Total Population75%*




Weight Assessment and Counseling for Nutrition & Physical Activity (WCC) -Physical Activity

Weight Assessment and Counseling for Nutrition & Physical Activity (WCC)- BMIPercentiles

Weight Assessment and Counseling for Nutrition & Physical Activity (WCC)-Nutrition

Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34) 1.1%

10.2%

-0.2%

10.0%

-0.1%

5.8%

0.0%

-8.0%

-3.8%

1.1%

11.5%

10.0%

0.0%

-3.2%

2.2%

4.9%

6.8%

-7.0%

1.6%

0.2%

1.7%

0.2%

2.3%

8.3%

10.0%

8.3%

-0.9%

-3.0%

-2.8%

-11.4%

-5.1%

9.9%

7.1%

2.7%

-2.9%

0.2%

0.5%

6.8%

1.7%

3.0%

1.9%

0.0%

-3.6%

-1.9%

-2.5%

10.7%

11.2%

20.0%

1.5%

-2.4%

9.0%

8.3%

12.9%

-0.7%

-8.5%

8.5%

-7.8%

3.7%

2.2%

0.4%

-5.6%

5.1%

-3.2%

-1.6%

1.6%

2.7%

-2.7%

11.2%

1.2%

-6.4%

-3.5%

7.1%

6.3%

11.2%

-0.5%

4.4%

-4.9%

8.3%

7.5%

-2.0%

-3.9%

4.9%

0.2%

-0.4%

Percentage Change between 2015 and 2016 HEDIS

*Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eli-gible population for the hybrid measures).

N/A

N/A

N/A

N/A

Measures that increased more than 5.0% from HEDIS 2015

Measures that decreased more than 5.0% from HEDIS 2015

162 of 180

Partnership HealthPlan of CA HEDIS 2016 Performance HEDIS measures and percentiles change from HEDIS 2015 to HEDIS 2016

Measure

Northeast

2015 2016

Northwest

2015 2016

Southeast

2015 2016

Southwest

2015 2016

Annual Monitoring for Patients on Persistent Medications (MPM) -ACE or ARB*

Annual Monitoring for Patients on Persistent Medications (MPM) -Diuretics*

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis(AAB)*



Comprehensive Diabetes Care (CDC)- Blood Pressure Control(<140/90)


Comprehensive Diabetes Care (CDC)- HbA1c Adequate Control (<8)

Comprehensive Diabetes Care (CDC)- HbA1c Poor Control (>9)


Comprehensive Diabetes Care (CDC)- Medical Attention forNephropathy



Medication Management for People with Asthma (MMA-50) TotalPopulation 50%*

Medication Management for People with Asthma (MMA-75) TotalPopulation 75%*




Weight Assessment and Counseling for Nutrition & PhysicalActivity (WCC) - Physical Activity

Weight Assessment and Counseling for Nutrition & PhysicalActivity (WCC)- BMI Percentiles

Weight Assessment and Counseling for Nutrition & PhysicalActivity (WCC)- Nutrition

Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life(W34)

<25

25th

75th

25th

75th

<25

<25

75th

75th

<25

25th

75th

50th

25th

25th

<25

50th

<25

<25

50th

<25

<25

<25

25th

90th

<25

75th

25th

<25

<25

<25

25th

50th

50th

50th

<25

25th

<25

<25

25th

<25

<25

<25

25th

75th

50th

90th

25th

25th

50th

50th

25th

50th

75th

25th

50th

50th

<25

25th

<25

<25

75th

<25

<25

<25

<25

50th

<25

90th

25th

<25

<25

<25

75th

90th

75th

75th

<25

25th

<25

<25

50th

<25

<25

50th

90th

90th

90th

90th

25th

50th

25th

50th

50th

75th

75th

25th

50th

75th

50th

50th

50th

25th

75th

25th

25th

50th

75th

75th

75th

90th

50th

50th

75th

75th

25th

50th

75th

75th

75th

75th

25th

50th

25th

25th

75th

50th

50th

50th

75th

90th

50th

90th

90th

50th

50th

50th

25th

75th

75th

50th

50th

50th

25th

75th

25th

25th

90th

25th

<25

50th

50th

90th

50th

90th

50th

50th

75th

75th

25th

25th

25th

50th

50th

50th

25th

50th

50th

25th

90th

<25

<25

Measures with Percentiles Changed from HEDIS 2015


Measure ranking improved since HEDIS 2015

Measure ranking decreased since HEDIS 2015

163 of 180

Partnership Healthplan of CA : HEDIS 2016 County Level Performance

Mendocino

Humboldt

Del Norte

Sonoma

Siskiyou

Lassen

Solano

Shasta

Modoc

Trinity

Marin

Napa

Lake

Yolo

Percentile

Southeast

Solano Yolo Napa

Southwest

Sonoma Mendoci.. Marin Lake

Northeast

Shasta Siskiyou Lassen Trinity Modoc

Northwest

HumboldtDel Norte

90th (HPL)75th50th25th

Below MPL

9

7

4

2

5

7

6

4

7

6

6

2

1

5

5

8

3

1

3

7

6

4

2

5

5

3

7

2

8

9

3

2

8

3

6

4

1

8

3

6

4

1

12

5

3

2

12

4

2

2

2

12

3

3

2

2 5

9

6

1

1

9

6

4

2

1

Distribution of Percentile Rankings by County

164 of 180

Partnership HealthPlan of CA HEDIS 2016 Performance

Measure

Solano

Yolo

Napa

Sonoma

Mendocino

Marin

Lake

Shasta

Siskiyou

Trinity

Modoc

Humboldt

Del Norte

















County Level Measures At or Above the High Performance Level (90th Percentile)

*Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population forthe hybrid measures).

165 of 180

Partnership HealthPlan of CA HEDIS 2016 Performance

Measure

Napa

Sonoma

Mendocino

Marin

Lake

Shasta

Siskiyou

Lassen

Trinity

Modoc

Humboldt

Del Norte














Prenatal and Postpartum Care (PPC)- Timeliness ofPrenatal Care


Weight Assessment and Counseling for Nutrition &Physical Activity (WCC) - Physical Activity

Weight Assessment and Counseling for Nutrition &Physical Activity (WCC)- BMI Percentiles

Weight Assessment and Counseling for Nutrition &Physical Activity (WCC)- Nutrition


County Level Measures Below the Minimum Performance Level (Below 25th Percentile)

*Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population forthe hybrid measures).

166 of 180

County Level Performance within Southeast RegionAbove HPL (high performance level, based on NCQA's national Medicaid 90th percentile)


Measure Napa Solano Yolo



Avoidance of Antibiotic Treatment in Adultswith Acute Bronchitis (AAB)*


Childhood Immunization Status (CIS-3)- Combo3 Immunizations




Comprehensive Diabetes Care (CDC)- HbA1cPoor Control (>9)




Immunizations for Adolescents (IMA-1)- Combo1 Immunizations

Medication Management for People withAsthma (MMA-50) Total Population 50%*

Medication Management for People withAsthma (MMA-75) Total Population 75%*

Prenatal and Postpartum Care (PPC)-Postpartum Care







80.39%

73.33%

83.97%

77.11%

73.91%

80.56%

73.33%

86.36%

90.12%

86.05%

98.84%

86.05%

91.28%

58.82%

74.51%

79.41%

79.05%

80.95%

91.57%

27.67%

53.64%

79.25%

86.21%

87.93%

36.21%

54.31%

58.62%

57.76%

68.18%

61.98%

33.33%

85.71%

86.51%

76.67%

85.00%

80.70%

62.28%

29.36%

54.41%

81.22%

62.16%

84.77%

35.80%

53.09%

59.26%

64.20%

71.63%

59.19%

36.09%

85.03%

86.47%

78.46%

86.00%

62.00%

27.96%

51.66%

83.64%

68.00%

78.43%

33.33%

74.51%

77.19%

59.65%

30.00%

86.26%

85.77%

Southeast Region


84.88% 87.74% 89.88% 92.01%

84.70% 87.10% 89.53% 91.78%

22.00% 26.30% 32.80% 40.38%

54.33% 60.98% 67.88% 73.08%

66.19% 71.53% 76.50% 81.25%

56.45% 62.20% 69.13% 76.64%

47.06% 54.74% 63.38% 67.86%

40.00% 47.91% 54.01% 58.58%

49.89% 42.27% 34.66% 29.68%

83.19% 86.29% 89.55% 91.94%

77.95% 81.75% 84.88% 87.70%

49.88% 57.47% 65.29% 70.32%

63.79% 73.15% 81.51% 87.71%

47.41% 53.71% 59.57% 67.24%

23.72% 29.61% 35.03% 44.12%

55.47% 62.77% 68.85% 72.43%

77.44% 85.19% 88.66% 91.73%

71.82% 74.97% 78.06% 82.86%

44.16% 53.89% 64.43% 71.53%

51.27% 67.23% 77.98% 85.61%

51.98% 61.44% 72.87% 79.56%

65.54% 72.02% 78.46% 83.75%

Benchmarks


167 of 180

County Level Performance within Southwest RegionAbove HPL (high performance level, based on NCQA's national Medicaid 90th percentile)


Measure Lake Marin Mendoc..Sonoma























84.38%

60.71%

55.56%

47.22%

82.66%

62.00%

83.58%

46.00%

80.65%

59.68%

37.10%

46.77%

47.27%

40.74%

81.04%

80.95%

94.22%

73.33%

88.02%

90.57%

50.62%

84.80%

94.57%

91.87%

74.55%

49.37%

88.19%

92.86%

78.76%

76.89%

91.46%

71.34%

29.58%

55.37%

75.38%

68.72%

89.15%

31.60%

56.13%

54.72%

72.64%

74.85%

62.38%

85.51%

73.68%

63.77%

81.16%

49.28%

69.57%

33.57%

59.29%

54.79%

79.17%

86.11%

41.67%

41.67%

58.33%

69.44%

30.90%

85.77%

78.46%

78.46%

49.23%

90.00%

68.00%

25.39%

49.74%

77.78%

84.62%

87.69%

47.69%

44.62%

53.85%

73.85%

72.00%

68.12%

86.46%

68.00%

61.54%

69.23%

59.62%

57.14%

30.81%

57.30%

60.00%

83.87%

66.13%

24.56%

Southwest Region


84.88% 87.74% 89.88% 92.01%

84.70% 87.10% 89.53% 91.78%

22.00% 26.30% 32.80% 40.38%

54.33% 60.98% 67.88% 73.08%

66.19% 71.53% 76.50% 81.25%

56.45% 62.20% 69.13% 76.64%

47.06% 54.74% 63.38% 67.86%

40.00% 47.91% 54.01% 58.58%

49.89% 42.27% 34.66% 29.68%

83.19% 86.29% 89.55% 91.94%

77.95% 81.75% 84.88% 87.70%

49.88% 57.47% 65.29% 70.32%

63.79% 73.15% 81.51% 87.71%

47.41% 53.71% 59.57% 67.24%

23.72% 29.61% 35.03% 44.12%

55.47% 62.77% 68.85% 72.43%

77.44% 85.19% 88.66% 91.73%

71.82% 74.97% 78.06% 82.86%

44.16% 53.89% 64.43% 71.53%

51.27% 67.23% 77.98% 85.61%

51.98% 61.44% 72.87% 79.56%

65.54% 72.02% 78.46% 83.75%

Benchmarks

*Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligiblepopulation for the hybrid measures).

168 of 180

County Level Performance within Northeast RegionAbove HPL (high performance level, based on NCQA's national Medicaid 90th percentile)


Measure Modoc TrinitySiskiyouShasta Lassen























60.00%

48.00%

28.00%

46.00%

20.00%

82.00%

32.00%

40.00%

48.00%

18.18%

77.50%

76.64%

64.09%

68.28%

48.51%

46.10%

61.25%

40.61%

82.71%

81.40%

52.46%

50.00%

44.00%

50.77%

40.00%

50.00%

45.95%

83.37%

48.00%

28.00%

30.00%

72.00%

44.00%

41.86%

58.00%

36.00%

34.00%

56.00%

30.00%

84.09%

52.00%

44.00%

70.83%

68.57%

45.71%

63.41%

48.00%

34.00%

52.00%

59.52%

42.00%

84.56%

91.11%

44.68%

67.36%

87.86%

84.56%

92.31%

78.46%

53.85%

80.77%

88.00%

93.24%

70.59%

82.35%

94.00%

56.00%

82.43%

78.00%

40.82%

63.27%

58.00%

84.00%

48.00%

40.00%

58.00%

55.93%

52.96%

81.23%

57.65%

86.79%

45.36%

45.71%

47.14%

62.14%

27.86%

68.57%

71.76%

72.94%

57.65%

86.89%

34.65%

52.48%

86.15%

43.08%

27.54%

85.00%

74.00%

81.40%

52.00%

84.00%

66.00%

35.00%

62.00%

80.00%

86.00%

38.00%

52.00%

33.33%

86.44%

Northeast Region


84.88% 87.74% 89.88% 92.01%

84.70% 87.10% 89.53% 91.78%

22.00% 26.30% 32.80% 40.38%

54.33% 60.98% 67.88% 73.08%

66.19% 71.53% 76.50% 81.25%

56.45% 62.20% 69.13% 76.64%

47.06% 54.74% 63.38% 67.86%

40.00% 47.91% 54.01% 58.58%

49.89% 42.27% 34.66% 29.68%

83.19% 86.29% 89.55% 91.94%

77.95% 81.75% 84.88% 87.70%

49.88% 57.47% 65.29% 70.32%

63.79% 73.15% 81.51% 87.71%

47.41% 53.71% 59.57% 67.24%

23.72% 29.61% 35.03% 44.12%

55.47% 62.77% 68.85% 72.43%

77.44% 85.19% 88.66% 91.73%

71.82% 74.97% 78.06% 82.86%

44.16% 53.89% 64.43% 71.53%

51.27% 67.23% 77.98% 85.61%

51.98% 61.44% 72.87% 79.56%

65.54% 72.02% 78.46% 83.75%

Benchmarks

*Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible pop..

169 of 180

County Level Performance within Northwest RegionAbove HPL (high performance level, based on NCQA's national Medicaid 90th percentile)


Measure Del Norte Humboldt






Comprehensive Diabetes Care (CDC)- Blood PressureControl (<140/90)













Weight Assessment and Counseling for Nutrition &Physical Activity (WCC) - Physical Activity

Weight Assessment and Counseling for Nutrition &Physical Activity (WCC)- BMI Percentiles

Weight Assessment and Counseling for Nutrition &Physical Activity (WCC)- Nutrition

Well-Child Visits in the Third, Fourth, Fifth, and SixthYears of Life (W34)

58.04%

43.34%

57.63%

44.07%

79.70%

78.85%

73.33%

38.67%

48.28%

79.55%

40.91%

52.38%

43.86%

82.76%

78.74%

87.65%

88.64%

56.07%

77.17%

56.07%

82.14%

63.99%

34.16%

55.65%

71.20%

59.74%

84.21%

84.83%

39.94%

48.30%

61.30%

37.00%

69.01%

63.08%

83.08%

56.92%

79.03%

37.17%

60.18%

62.14%

38.64%

48.86%

57.95%

27.40%

Northwest Region


84.88% 87.74% 89.88% 92.01%

84.70% 87.10% 89.53% 91.78%

22.00% 26.30% 32.80% 40.38%

54.33% 60.98% 67.88% 73.08%

66.19% 71.53% 76.50% 81.25%

56.45% 62.20% 69.13% 76.64%

47.06% 54.74% 63.38% 67.86%

40.00% 47.91% 54.01% 58.58%

49.89% 42.27% 34.66% 29.68%

83.19% 86.29% 89.55% 91.94%

77.95% 81.75% 84.88% 87.70%

49.88% 57.47% 65.29% 70.32%

63.79% 73.15% 81.51% 87.71%

47.41% 53.71% 59.57% 67.24%

23.72% 29.61% 35.03% 44.12%

55.47% 62.77% 68.85% 72.43%

77.44% 85.19% 88.66% 91.73%

71.82% 74.97% 78.06% 82.86%

44.16% 53.89% 64.43% 71.53%

51.27% 67.23% 77.98% 85.61%

51.98% 61.44% 72.87% 79.56%

65.54% 72.02% 78.46% 83.75%

Benchmarks


170 of 180

Partnership HealthPlan of CaliforniaCurrent Members With a Primary or Secondary Tobacco/Nicotin DiagnosisClaim or Service Between January-July 31, 2016 As of Report Run Date 8/1/2016

Region County#Members With

Tobacco / Nicotin Dx

%By Region GTPP July 2016 Eligibility

DEL NORTE 579 8% 4 11,368

HUMBOLDT 1,745 24% 21 51,834

LASSEN 1,761 24% 19 7,163

MODOC 104 1% 3 3,000

SHASTA 2,329 32% 34 61,180

SISKIYOU 662 9% 9 17,310

TRINITY 154 2% 0 4,564 Northern Region Total ==>> 7,334 100% 90 156,419

Region County#Members With

Tobacco / Nicotin Dx

%By Region GTPP July 2016 Eligibility

LAKE 1,237 11% 10 29,611

MARIN 580 5% 2 37,274

MENDOCINO 1,287 12% 13 37,785

NAPA 611 6% 3 28,978

SONOMA 1,885 17% 5 113,597

SOLANO 4,218 39% 29 114,881

YOLO 1,006 9% 8 53,774

10,824 100% 70 415,900

18,158 100% 160 572,319 Grand Total == >>

Northern Region

Southern Region

Southern Region Total ==>>

Note: There are so many CMR GTPP records that did not match the claims data due to State Mom or dummy CMR Identifier

Northern Region

90

Southern Region

70

PREGNANT WOMEN TOBACCO USERS

Northern Region

7,334 Southern

Region10,824

TOBACCO USERS BY REGION

171 of 180

GRIEVANCE SUMMARY 2nd QUARTER 2016

Healthy Kids -0 grievance received Partnership Advantage – 0 grievances Medi-Cal - 254 grievances received. (Complaints/Appeals/State Hearings)

BREAKDOWN BY MEDI-CAL GRIEVANCE TYPE

MEDI-CAL COMPLAINTS

(114) complaints were filed during the review period. The top 5 reasons for complaints to be filed: (62) Other – The top 5 reasons:

o (17) Disagreement with treatment plan/PCP not prescribing pain medication o (7) VSP o (9) Unhappy with PCP treatment, chart incorrect, difficult to understand, subpar exam o (4) Disenrollment o (3) Unhappy with discharge from living center

(29) Quality of Care/ Quality of Service

o (21) Poor Provider/Staff Attitude – Miscommunication; Rudeness o (3) Denial of treatment

o Member not receiving treatment and medication for Lupus. Member did not cooperate with grievance process.

o PCP dis-enrolled member without approval from PHC. PCP refused to see member. o PCP refused to see member. PCP told member they were dis-enrolled, however, had not

filed discharge paperwork with PHC. o (1) Inadequate facility, non-access related

o Lakeport Hospital did not have equipment to test internal blood loss. Member transferred to St. Helena Hospital.

o (1) Inappropriate ancillary care o Rite Aid filled member’s prescription with Hydrocodone but bottle was labeled

Oxycodone. Head pharmacist drove correct medication to member’s home 1 hour away. o (1) Inappropriate Provider care

o Member with chronic liver disease upset with lack of treatment and alleged inappropriate touching. Provider notes non-compliance with treatment and denies other.

o (2) Inappropriate Hospital care o Member complained released from hospital without receiving necessary surgery.

Hospital documented members injury to shoulder non operable and member refused P.T. placement in a nursing facility and placement in men’s shelter upon discharge.

o MRI denial overturned despite normal neurological exam, on patient with history of traumatic brain injury and previous abnormal MRI.

(11) Access

o (7) Access to PCP – Long wait time for apt.; Apt. cancellations o (4) Access to Specialist – No in county specialist (Humboldt; Del Norte; Napa)

172 of 180

(5) Billing

MEDI-CAL APPEALS

• (92) appeals were filed during the review period. The top 3 reasons for filing an appeal: o (14) Opioid o (7) POV – Group 2 o (3) RAF - Stanford

• Below are the outcomes: (39) Overturned - The top 4 reasons: o (3) POV – Group 2 (Re-assessment by DME, fall risk, leg lift needed not available on

standard wheelchair) o (7) Opioid – (most often approved with change of quantity; approved for reimbursement for

out of pocket; retro payment approved) o (2)Facial feminization surgery o (6) RAF Stanford – (rare lymphatic disorder unable to advanced apt. with UCSF; No-in-

county/otherwise specialist - Dermatology; Neurology, ENT) (38) Upheld (1) Overturned with modifications (1) Partially Overturned (2) Modified (11) Withdrawn

STATE HEARINGS

• (48) state hearings were filed during the review period. Here are the results: o (30) Withdrawn o (7) Claim Denied – PHC position upheld (no medical necessity/ alt. or less exp. Drug required) o (7) Decision/Hearing Pending o (2) Non-appearance o (1) Stipulated o (1) Lack of Jurisdiction (Provider)

• The top 3 reasons for filing a state hearing: o (9) Denial of Opioid o (3) POV – Group 2 o (3) Denied Claim

• Two Q1 State Hearing decisions were granted. Case #1- Group 2 Power Wheel Chair based on ALJ’s decision member had degenerative disease that would warrant POV in future. Case #2 - Cialis prescription initially approved for trial period only..

173 of 180

Prepared By: Nadine Harris, RN and Lauri Stevenson, RN Reporting Period: 1/1/2016 – 6/30/2016

Site Review Compliance Report August 2016

Overview Facility Site Reviews are conducted for credentialing and re-credentialing purposes. It is a state mandate that PCP sites meet patient safety and access standards in order to see PHC members. There are two components:

1) Facility Site Review (FSR) – domains: a. Access/Safety b. Personnel c. Office Management d. Clinical Services e. Preventive Services f. Infection Control

2) Medical Record Review (MRR) – domains: a. Format b. Documentation c. Continuity/Coordination d. Pediatric Preventive e. Adult Preventive f. OB/CPSP Preventive

Methodology Facility Site Review and Medical Record Review data is gathered by the PHC Nurses who are DHCS Certified to conduct these reviews at the network provider sites.

• The Facility Site Review portion looks at areas ranging from Access and Safety to Infection Control with an overall passing score of 80%.

• For the Medical Record Review, a random sample of members’ records is selected. The sample can range from 10 to 30 records depending on the number of PCPs at the site. An 80% overall score is required to pass. If any of the domains fall below 80%, a Corrective Action Plan is required for the entire review.

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Review Location and Populations Served Review findings cover the following regions: 1. North West ( Del Norte, Humboldt counties) 2. North East (Siskiyou, Modoc, Trinity, Shasta and Lassen counties) 3. South East (Napa, Solano, Yolo) 4. South West (Mendocino Lake, Sonoma and Marin counties) Review Summary

Facility Site Review: 1. SE – Significant improvement seen in Personnel. 2. SW – No significant changes were noted. 3. NE – No significant changes were noted. 4. NW – No significant changes were noted.

Medical Record Review 1. SE – Significant improvement seen in Pediatric and Adult Preventive Domains. 2. SW - Significant increase in the Pediatric Preventive Domain. 3. NE – Significant decrease was noted in Pediatric and Adult Preventive screening scores. 4. NW – Significant improvement noted in Pediatric Preventive, however Adult Preventive noted a significant decrease.

Review Nurses’ Comments: Site Review nurses have noticed that for the most part, the facilities do well with the Site Review portion of the Review or “Part A”. For “Part B”, or the Medical Record Review, the majority of sites struggle with the Preventive Measure criteria, most noticeably the Adult Preventive Measures. Many sites receive a Corrective Action Plan in Preventive Criteria. The areas most noted to fall short are:

1) Initial or subsequent IHEBA/SHA (especially adults) 2) Risk Assessment for TB exposure (both adults and pediatrics)

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3) Documented Pap smears 4) Colorectal cancer screening in adults over 50 years old 5) Immunizations for Adults this includes Tdap, Pneumovax (where indicated) and flu 6) Immunizations for adolescents 7) Well child for children over 5 8) Annual hearing and vision screening and dental assessments/referral for children

In addition to preventive measures, another area of frequent low scoring is documentation of offering or discussion of Advanced Healthcare Directive. Ideas to Explore

• Continue to monitor and report trended data to IQI and QUAC semi-annually. • Work continues with IT on the electronic FSR/MRR template to facilitate increased efficiency of DHCS reporting and track /

trend data on all areas measured in the FSR/MRR Tools. Use of an electronic tool will allow PHC to report data to assist on other initiatives, such as advance care planning, immunizations, and other areas related to patient safety. We are on schedule to be testing this tool beginning in October, and the timeline for “go live” is January 1, 2017..

• We have begun to share best practices on the website and take time at each review to educate providers on the areas in which they are struggling.

• Strengthen the standardization of the review process with regular reviewer meetings and education.

• Strengthen Facility Site IRR in the next quarter.

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Facility Site Review: Table 1 2014 – Facility Site Reviews by Region

Jul-14 – Dec-14: SE SW NE NW

Access & Safety 93% 100% 95% 96% Personnel 94% 96% 100% 98% Office Mgmt. 97% 100% 100% 97% Clinical Services 91% 96% 90% 91% Preventive Services 97% 98% 96% 98% Infection Control 91% 99% 100% 94% Sites: 17 14 2 7 Compliance 94% 98% 97% 96%

Table 2 2015 – Facility Site Reviews by Region Jan-15 - Jun-15: SE SW NE NW

Access & Safety 99% 98% 100% 96% Personnel 95% 100% 100% 95% Office Mgmt. 100% 100% 96% 100% Clinical Services 96% 100% 98% 90% Preventive Services 99% 100% 100% 100% Infection Control 98% 99% 100% 89% Sites: 18 12 2 1 Compliance 98% 100% 99% 95%

84%86%88%90%92%94%96%98%

100%

Facility Site Scores - December 2014

SE SW NE NW

80%85%90%95%

100%

Facility Site Scores - June 2015

SE Jun-15 SW NE NW

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Table 3 2016 – Facility Site Reviews by Region

85%

90%

95%

100%

Access &Safety

Personnel OfficeMgmt.

ClinicalServices

PreventiveServices

InfectionControl

Facility Site Review Scores - June 2016

SE SW NW NE

Jan - Jun-16: SE SW NW NE Access & Safety 99% 98% 96% 97% Personnel 100% 98% 98% 98% Office Mgmt. 100% 99% 99% 99% Clinical Services 98% 99% 97% 98% Preventive Services 100% 99% 97% 99%

Infection Control 99% 97% 90% 98% Sites: 10 15 6 12 Compliance 99% 98% 96% 98%

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Medical Record Review:

Table 4 - 2014 – MR Results by Region

Jul - Dec-14: SE SW NE NW

Format 98% 97% 98% Documentation 88% 95% 91% Coord/Cont 98% 98% 100% Peds 85% 85% Adults 76% 75% 73% OB Sites 17 11 1 Compliance 89% 90% 91%


Jan - Jun-15: SE SW NE NW

Format 100% 98% 96% 99% Documentation 91% 88% 89% 88% Coord/Cont 99% 98% 100% 96% Peds 60% 75% 85% 54% Adult 74% 76% 81% 77% OB 99% 97% 69% Sites 18 11 1 6 Compliance 87% 89% 87% 83%

40%50%60%70%80%90%

100%

Medical Record Review Scores -December 2014

SE SW NE NW

40%50%60%70%80%90%

100%

Medical Record Review Scores -June 2015

SE SW NE NW

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50%60%70%80%90%

100%

Medical Record Review Scores - June 2016

SE SW NW NE

Jan - Jun-16: SE SW NW NE

Format 100% 99% 99% 98%

Documentation 94% 89% 89% 86%

Coord/Cont 100% 99% 100% 99%

Peds 92% 87% 81% 80%

Adult 85% 75% 71% 71%

OB 100% 100% 91%

Sites 8 20 9 14

Compliance 95% 91% 90% 88%

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