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Section 4: Operational Processes

4.1 Closing Practice to New Members

In order for a Provider to close their practice to any new Member, a Provider must complete the following:

1. Provider must notify AHP Network Services Department in writing within 60 days of closing the practice to new Members.
2. Provider must close the practice to all new patients; not just AHP Members.
3. Provider must notify AHP Network Services Department in writing if or when the practice re-opens to new Members. 

AHP Service Center will notify inquiring Members that the Provider’s practice is closed to new Members. 

 

4.2 Effective Date of Contract

The effective date of the contract is contingent on two activities:

1. Both parties have agreed to the contract terms and signed the agreement, and
2. There is at least one Provider at the clinic that has been successfully credentialed by AHP (please refer to Section 5.3, Credentialing Process, for a definition of effective date of participation). 

The effective date will be the date when both of these activities have been completed.  This date defines when claims are eligible to be paid at the in-network benefit level should should the Provider see one of our Members.  The effective date will be noted in the recitals (first section of the contract) of the executed contract. AHP Network Services Representatives will work closely with Providers to ensure clear communication during this process.

Note:  Based on requests from either party, there may be situations that require more than one Provider be successfully credentialed before AHP Members can receive services.

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4.3 Informed Medical Decision Making

AHP does not prohibit or penalize Provider’s from:

1. Discussing with the Member all treatment options irrespective of the Health Plan’s position on the treatment;
2. Advocating on behalf of covered Members within the utilization review or grievance processes established by the Health Plan; or
3. Reporting to state or federal authorities any act or practice by the Health Plan that jeopardizes patient health or welfare.
   

 

4.4 Medical Record Standards

The Provider is responsible for assuring the medical records of Members are secure, complete, accurately documented, organized, readily accessible and maintained in a format that facilitates retrieval of information in an efficient manner.

The Provider must maintain a record of health services rendered to each Member. 

Content

The record should be legible and include:

• patient demographic information
• patient medical history and physical documentation
• allergies and adverse reactions
• a medical, family and social history
• documentation of clinical findings and evaluation for each visit
• preventive services or risk screening
• diagnostic and therapeutic services
• immunization record
• ambulatory encounters
• consults, x-rays and laboratory reports
• referral services
• current medication list
• problem list
• any other specific medical information or services provided by the Participating Provider.

Availability

Providers will make Member medical records, or a copy thereof, available during reasonable hours to other Participating Providers to which the Member is referred or to the individual Member.

The Provider will ensure that the medical records are stored and organized in a manner that allows for easy retrieval.  In addition, medical records will be stored in a secure manner that only authorized personnel can access.

Confidentiality

The Provider will be responsible for assuring that the security and privacy of the medical record and information contained therein is held in confidence and in conformity with the Health Insurance Portability and Accountability Act of 1996, and the regulations promulgated there under.  It is understood that at the time of enrollment, AHP Members have signed a consent giving access of the medical record to the Member, his/her representatives, regulatory/accreditation bodies, and for all other purposes that relate to the Member’s treatment, payment of claims for services rendered, or other healthcare operations.

The Provider will ensure that staff receives periodic training in confidentiality of Member information. 

Assessment

AHP may periodically conduct a review of medical records to assess, ensure or improve the quality of patient care.  The results of this review will be communicated to the Provider and are used in AHP Quality Improvement activities. 

AHP will provide professional consultations on medical record assembly and maintenance when requested, or as needed.

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4.5 Access Standards

In order to ensure that AHP Members have timely access to services, Providers are required to have set access standards as well as a process to monitor compliance to these standards. 

Primary Care:

A primary care provider (PCP) is a participating provider who is a Medical Doctor (MD), Doctor of Osteopathy (DO), Nurse Practitioner (NP) or a Physician Assistant (PA).  PCPs are available in the fields of Family Practice, Internal Medicine, General Practice, Obstetrics / Gynecology and Pediatrics.  The minimum appointment access standards are:

Type of Care	Access Standard
Preventive Care	4 weeks
Routine Care	14 days
Urgent Care	24 hours (depending on severity)
Emergency Care	Immediate - access to 911 and emergency care facility
Telephone Access	24 hours/7 days a week/365 days per year

 

Specialty Care:

A specialty care provider is a participating provider who is a Medical Doctor (MD), Doctor of Osteopathy (DO), Nurse Practitioner (NP) or a Physician Assistant (PA).  Specialists are available in the following fields:

Allergy / Immunology	Anesthesiology	Audiology
Cardiology	Chiropractor	Dermatology
Durable Medical Equipment	Emergency Medicine	Ear, Nose & Throat
Gastroenterology	Hematology	Infectious Disease
Substance Abuse	Neonatology	Nephrology
Neurology	Occupational Medicine	Oncology
Ophthalmology	Optometry	Orthopedics
Pathology	Physical Medicine	Podiatry
Psychology	Psychiatry	Pulmonary Disease
Radiology	Rheumatology	Surgery
Urology

 

The minimum appointment access standards for specialists are:

Type of Care	Access Standard
Preventive Care	4 weeks
Routine Care	14 days
Urgent Care	24 hours (depending on severity)
Emergency Care	Immediate - access to 911 and emergency care facility
Telephone Access	24 hours/7 days a week/365 days per year

 

Behavioral Health:

A behavioral health provider is a participating provider who is a master’s level behavioral health provider or a licensed psychologist.  The minimum appointment access standards are:

Type of Care	Access Standard
Routine Care	10 days
Non-Life Threatening Emergency	6 hours
Urgent Care	48 hours
Emergency Care	Immediate - access to 911 and emergency care facility
Telephone Access	24 hours/7 days a week/365 days per year

 

 

4.6 Compliance

Referral to Participating Providers

As AHP has done in the past and will continue to do in the future, if pattern of referrals are outside of the network we will work with providers to educate and inform them of available in-network providers.

 

4.7 Patient Waivers

Patients may sign a form to assume financial responsibility for services that are deemed not medically necessary.  Patients who request such services should sign a completed waiver agreement form before these services are performed and after they have been informed these services do not meet medically necessary criteria.  A new form should be completed for each incident and kept on file with your patients records.  Do not file the waiver with the claim.

The waiver should contain:

• Date
• Place of Service
• Description of the service
• A statement that you have informed the patient that the services provided may not be considered medically necessary by the patient’s health insurance policy and that the patient is liable for the charges.
  

 

4.8 Contract Disputes

Contract disputes are a way for providers to contest a claims processing determination regarding contracted fee schedule rates. At this time, there are no State regulations defining this proces; however, AHP will strive to respond to inquiries in a timely manner.

Complaints and grievances against the Health Plan can be filed by a Member or a Provider can file a grievance on behalf of the Member as the Member’s authorized representative. AHP strictly adheres to all State regulations and guidelines pertaining to this matter. All complaints and grievances will be acknowledged and decided on within the specified time frame. 

For your convenience, please utilize our Provider Request for Reconsideration Form (fill-able PDF form) and Provider Reconsideration Guidelines  to help expedite the contract dispute process. This form will ensure all pertinent information is included with the initial request so there is not a delay with the review process. 

If you have any questions pertaining to these processes, please call Network Services Monday - Friday, 8 a.m. – 5 p.m. CT at (605) 322-4545 or toll-free at 1 (888) 322-2115. 

 

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4.9 National Provider Identifier (NPI)

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for healthcare providers. The HIPAA final rule adopted the National Provider Identifier (NPI) as this standard. The NPI is a 10-digit numeric identifier that does not carry information about healthcare providers, such as specialty or location of practice.

All healthcare providers—individual and/or organizational—are eligible for NPIs and must obtain an NPI to identify themselves in HIPAA standard transactions.  By May 23, 2007, HIPAA-covered entities—including healthcare providers (individuals or organizations), healthcare clearinghouses and all but small health plans—must use only the NPI to identify HIPAA-covered healthcare providers in standard transactions.

Note: A sole proprietor/sole proprietorship is an individual and is eligible for a single NPI.  For more information about NPI, view the CMS NPI Fact Sheet.

Do you need to register for the NPI?  Visit the NPPES website to register.

AHP’s claims system will maintain and match HIPAA transactions using providers’ NPIs, so please submit a listing of NPIs for providers in your office, as well as for your organization:

BY FAX: 

Attn: Network Services
605-322-4540

BY EMAIL:
providers@averahealthplans.com

 

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4.10 Continuation of Covered Services

PURPOSE

To provide Transition of Care for Members when their Participating Provider has terminated his or her relationship with Avera Health Plans (AHP) and Continuity of Care for Members who are new to the Plan and have already begun a defined course of treatment with a non-Participating Provider that cannot reasonably be transferred to a Participating Provider without risking an adverse impact on the Member’s health status or likely outcome of care.  View our complete policy for more details.