Transcription of Health Care Professional and Provider Manual
1 Health care Professional and Provider ManualiTable of ContentsSelect Health of South Carolina Health care Professional and Provider Manual | Updated March 2018 ContentsIntroduction ..1 Our Vision .. 1 Our Mission .. 1 Our Values .. 1 Practice and Facility Changes .. 1 Medicaid Managed care Overview .. 1 Quality Assurance and Performance Improvement Program .. 2 Quality Assessment Performance Improvement Committee .. 2 Quality Clinical care Committee 2 Quality of Service Committee 2 Pharmacy and Therapeutics Committee 3 Compliance Committee
2 3 Credentialing Committee 3 Administrative Appeal and Grievance Committee 3 Appeals Committee 3 Practitioner Involvement 3 QAPI Activities.
3 3 Performance Improvement Projects 3 Ensuring Appropriate Utilization of Resources 3 Chronic care Improvement Programs 3 Measuring Member and Provider Satisfaction 3 Participant and Provider Dissatisfaction 3 Member Safety Programs 4 NCQA HEDIS Reporting Measures.
4 4 Important Phone Numbers .. 4 Select Health Credentialing Requirements .. 4 Required Credentialing Documentation .. 5 Collaborative Agreements ( for PA s) .. 6 Nurse Practitioners (NP s) Protocols .. 7 Licensed Dietitian (LD) Enrollment 7 Ancillary Providers .. 7 Ancillary Providers Organizational 7 Ancillary Providers Non Organizational 8 Non-accredited Organizational Providers 10 Ongoing Monitoring Of Sanctions & Complaints 10 Required Re-credentialing Documentation
5 10 Select Health Credentialing/Re-credentialing Actions 10 Delegated Credentialing Requirements 11 Disclosure of Ownership and Control Interest Statement 11 Health care Professional / Provider Site Visit Requirements 11 Prohibition on Payments to Excluded/Sanctioned Persons 11 Credentialing Health care Professional / Provider Rights 12 Provider Network Credentialing Appeals Process 12 Termination 13 Specialist Termination
6 13 Health care Professional / Provider s Bill of Rights .. 13 Select Health of South Carolina Provider Manual Table of ContentsiiTable of ContentsSelect Health of South Carolina Health care Professional and Provider Manual | Updated March 2018 Fraud and Abuse .. 14 Fraud and Abuse Contact Information 14 False Claims Act 15 Culturally and Linguistically Appropriate Services (CLAS).
7 16 Advances in Medicine .. 16 Bariatric Surgery Centers .. 16 Medical Management Department .. 17 Utilization Management Program ..17 Adverse Benefit Determinations 17 Medical Record Review Standards 17 Medical Record Documentation Standards 18 Medical Record Retention 20 Referral and Authorization for Specialists.
8 Hospitals and Ancillary Health care Professionals/Providers ..21 Participating Specialty care Health care Professionals/Providers 21 Specialty care Access Standards: 21 Non-Participating Health care Professionals/Providers 21 Services That Require Prior Authorization 21 Services That DO NOT Require Authorization 22 Services That Require Notification
9 23 Clinical Guidelines ..23 Ancillary Services .. 23 Authorization for Ancillary Services ..23 Children s Rehabilitative Services and Baby Net ..23 Durable Medical Equipment .. 24 Home Health care /Family Support Services .. 24 Home Infusion/Specialty Pharmacy .. 24 Speech, Physical and Occupational Therapies .. 24 Behavioral Health Under First Choice .. 24 Rehabilitative Behavioral Health Services (RBHS) ..25 Prior authorization requirements 26 Autism Spectrum Disorder (ASD).
10 27 Psychiatric Residential Treatment Facilities (PRTF) .. 28 Psychotherapy Supervision Guidelines .. 28 Licensed Independent Practitioners (LIPs) .. 29 Emergency/Urgent care Services .. 29 Hysterectomy ..29 Inpatient Admissions/Outpatient Admissions or Procedures .. 30 Extension of Authorization Time frames .. 30 Administrative Days ..31 Sterilization .. 31 Telemedicine Services .. 32 Therapeutic and Non-elective Abortion .. 32 Therapeutic Abortions ..32 Non-elective Abortions ..32 Billing Notes ..32 Well-Woman Exam .. 33 Health care Professional / Provider Disputes .. 33 Medical Review Determinations.
