Health Share Policies
For
Plan Partners

 

 

 

Issued: December 2016


 

Download the Policy Manual

Policy Manual (PDF) »

Or review it below:

Open All

Close All


COMP-02 Delegated Functions and Oversight

TITLE:  DELEGATED FUNCTIONS AND OVERSIGHT

PURPOSE:

To establish the authority of Health Share of Oregon (Health Share) to delegate specific functions to
other entities and the process through which that delegation occurs.

To establish the annual process for monitoring performance of Delegated Entities.

DEFINITION(S):
Delegation: The assignment of responsibility or authority to another entity to carry out specific
activities or perform certain administrative or operational functions on behalf of the delegating
organization.

Delegation Agreement: A mutual agreement between a delegating organization and its Delegated Entity
that specifies the activities and reporting responsibilities delegated. A contract entered into between
Health Share and the Delegated Entity is considered to be the Delegation Agreement.

Delegated Entity: An entity with which Health Share has entered into a written agreement to perform
certain functions required under, or governed by, the Health Plan Services Contract, federal and/or state
regulations that would otherwise be the responsibility of Health Share.

Delegation Audit: An annual evaluation of a Delegated Entity's capacity to perform delegated activities
using established criteria.

Health Plan Services Contract (CCO Contract): Contract entered into between Health Share of Oregon
and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid
program.

POLICY:
I. Health Share may subcontract work to be performed under the ceo Contract, and may delegate
specific responsibilities to qualified entities. Health Share oversees and retains accountability
for any functions and responsibilities that it delegates to any entity. When a business need has
been established for delegation of functions, appropriate Health Share staff shall follow the
guidelines outlined in this policy.

II. Pre-delegation assessments are conducted prior to entering into a Delegation Agreement to
assess the organization's ability to perform the functions identified in the proposed Delegation
Agreement. If deficiencies are identified, the organization must submit a plan of correction that
is acceptable to and approved by Health Share prior to entering into a Delegation Agreement.

Ill. Health Share shall conduct an annual Delegation Audit of Delegated Entities to ensure
compliance with Health Share policies, requirements of the CCO Contract, Oregon
Administrative Rules and all other related state and federal rules and regulations relevant to the
functions delegated. If deficiencies are found, the organization must submit a plan of correction
that is acceptable to and approved by Health Share.

IV. If Health Share amends the Delegation Agreement to include additional activities less than 12
months prior to the annual Delegation Audit date, a pre-delegation evaluation must be
performed for the additional duties.

V. A Delegation Agreement must be in place prior to any delegated activities being performed. The
Delegation Agreement includes a business associate agreement consistent with privacy
requirements for protected health information.

PROCEDURE:
I. Health Share will perform a pre-delegation assessment ofthe organization's ability to perform
the specific functions to be delegated. At a minimum, the pre-delegation assessment shall
include:
• Review of relevant policies and procedures;
• An assessment ofthe organization's administrative, operational and staffing capabilities
and past performance record;
• An evaluation of the organization's processes and systems related to each delegated
function;
• Site visits and/or pre-delegation meetings, as needed; and
• An evaluation of the organization's programs and compatibility with Health Share
policies related to the delegated function(s) under consideration.

II. Results of the pre-delegation assessment will be documented and retained by the Manager for
Compliance and Quality Assurance and a summary presented to the Compliance and Delegation
Oversight Committee. A recommendation will be provided to the Committee to proceed with
delegation, proceed with stipulations, or deny the Delegation Agreement.

Il l. Health Share shall monitor Delegated Entities on an on-going basis and shall perform a formal
Delegation Audit annually to assess performance of the Delegated Entity in accordance with 42
CFR 438.230.
A. The annual review may be composed of elements that are universal to all Delegated
Entities as well as elements that are specific to each Entity.
B. The annual audit process will follow the same general process as the pre-delegation
assessment described in I above.
C. Upon completion of the audit, a draft report with findings will be provided to the
Delegated Entity, which will be given the opportunity to resolve findings before a final
report is provided.
D. The final report is presented to the Compliance and Delegation Oversight Committee.

IV. Upon identification of areas of non-compliance or inadequate performance, Health Share shall
notify the Delegated Entity and require submission of a plan of corrective action. The
Compliance and Delegation Oversight Committee is accountable for on-going monitoring of
plans of corrective action submitted by Delegated Entities.

V. A summary of plans of corrective action and their status shall be submitted to the Quality and
Governance Committee on a quarterly basis or as needed to inform the Committee of areas of
non-compliance or inadequate performance by Delegated Entities. The Quality and Governance
Committee may request additional information be presented by the Delegated Entity to ensure
the prompt and adequate resolution of deficiencies.

VI. Health Share staff shall submit a summary of annual Delegation Audits to the Quality and
Governance Committee to inform them of the status of each Delegated Entity's performance.

VII. Health Share retains ultimate accountability for any functions or responsibilities it delegates.
ATTACHMENT:
Delegation Matrix

Department: Compliance and Quality Assurance Author: Barbara Carey, Sr. Manager,
Compliance and Quality Assurance
Effective Date(s): August 2013 Review Frequency: Every 2 years
Revision Date(s): December 2015; November
2016


COMP-03 EXCLUDED INDIVIDUALS AND ORGANIZATIONS

TITLE: EXCLUDED INDIVIDUALS AND ORGANIZATIONS 

DEFINITIONS:

Delegated Entity: An entity with which Health Share has entered into a written agreement to perform certain functions required under, or governed by, the Health Plan Services Contract, federal and/or state regulations that would otherwise be the responsibility of Health Share.

Health Plan Services Contract (CCO Contract): Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

List of Excluded Individuals and Entities (LEIE): The list of individuals and entities that are excluded by the Office of the Inspector General from participating in federally funded health care programs.

Member:  An Oregon Health Plan client assigned to Health Share of Oregon.

System for Award Management (SAM): An electronic database maintained and posted by the General Services Administration containing the list of all parties suspended, proposed for debarment, debarred, declared ineligible, or excluded or disqualified under the non- procurement common rule by agencies, government corporations, or by the Government Accountability Office.

PURPOSE:

To ensure Health Share of Oregon (Health Share) and Delegated Entities do not employ, contract for services with or compensate individuals and organizations which are excluded from participation in federal or state health care programs, and regularly monitor individuals and organizations to determine whether  they are excluded from participation  in the Medicare or Medicaid  programs.

POLICY:

I. Individuals and organizations covered by this policy include, but are not limited to, employees, temporary employees, volunteers, consultants, providers, sub-contractors, board members and advisory members of Health Share and Delegated Entities.

II. An excluded individual or organization is one that is currently excluded, debarred, suspended or otherwise ineligible to participate in federal or state health care programs or in federal or state procurement or non-procurement programs; or has been convicted of a criminal offense related to the provision of health care items or services but has not yet been excluded, debarred or otherwise declared ineligible.

III.       Health Share and Delegated  Entities will not refer Members to  or contract with  providers or organizations who have been terminated by the Oregon Health Authority or excluded as Medicaid providers or who are subject to exclusion under 42 CFR 1001.101 and 42 CFR 455.3.b.

IV. Health Share and Delegated Entities will not employ or contract with individuals or providers excluded from participation in federal health care programs under either section 1128 or section 1128A of the Social Security Act and in accordance with 42 CFR 438.214(d).

V. Health Share and Delegated Entities will not accept billings nor pay for services, equipment or drugs prescribed by or provided to Members after the date of the provider's exclusion, conviction, or terminatio n.

VI. If Health Share or a Delegated Entity knows or has reason to know that a provider has been convicted of a felony or misdemeanor related to a crime, or violation of federal or state laws  under Medicare, Medicaid, or Title XIX (including a plea of "nolo contendere"), Health Share and Delegated Entity will immediately notify the Oregon Health Authority's Provider Services  Unit .

VII. Health Share and Delegated Entities are responsible for reviewing the List of Excluded Individuals and Entities and the System for Award Management at the time of employment or contracting and on a monthly basis to ensure that the individual or organization is not excluded or have become excluded from participation in federal or state  programs .

VIII. Before imposing exclusions, Health Share or Delegated Entity must afford the individual or organization the opportunity to submit additional documents and a written appeal against the exclusion. This pertains only to their right to disprove the exclusion. Reinstatement after exclusion may only be executed by the state or federal agency that imposed the  exclusion.

REFERENCES

Health Plan Services Contract 42 CFR§455.100-101

42  CFR§438.214(d)42 CFR§§422.503(b)(4)(vi)(F)

42 CFR§§422.504(b)(4)(vi)(F)

42 CFR§§1002

42 CFR§§lOOl.1901 Balanced Budget Act; Subtitle D "Anti-Fraud and Abuse Provisions and Improvements  in Protecting Program Integrity

Exec cr

 

Department:  Compliance

Author: Barbara Carey, Compliance and Quality Assurance  Manager

Effective Date(s): December 2013

Review Frequency: Every 2 years

Revision Date(s): July 2015, April 2016


COMP-04 MANAGEMENT AND RETENTION OF RECORDS

TITLE: MANAGEMENT AND RETENTION OF RECORDS 

DEFINITIONS:

Health Plan Services Contract (CCO Contract): Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

Health Insurance Portability and Accountability Act (HIPAA): The federal law (Public Law 104-191, August 21, 1996) with the legislative objective to assure health insurance portability, reduce health care fraud and abuse, enforce standards for health information, and guarantee security and privacy of health information.

Member:  An Oregon Health Plan client assigned to Health Share of Oregon.

Oregon Health Authority (OHA): The State of Oregon acting by and through its Oregon Health Authority, Health Services Division

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE:

To ensure maintenance of a record keeping system and management of financial, contractual, data, and clinical records by Health Share of Oregon (Health Share) and to ensure maintenance of such record keeping systems by Risk Accepting Entities, consistent with Oregon statute and federal  regulations.

POLICY:

I. Health Share uses best practices in the management of finances, contracts and data processing functions and maintains appropriate record keeping systems. Such record keeping systems include sufficient detail and clarity to permit internal and external reviewers to validate that records conform to accepted professional practice, and are in compliance with requirements of the CCO Contract.

II. Through the delegation oversight process, Health Share ensures that RAEs also maintain adequate and appropriate financial, contractual, data, claims processing and clinical records and shall follow the requirements of the CCO Contract in the maintenance and retention of records.

III. Health Share shall provide, and shall require RAEs to provide, timely access to records and facilities and cooperate with OHA in the collection of information through onsite reviews, financial reporting and financial record reviews, and other information for the purposes of monitoring compliance with the CCO  Contract.

IV. Health Share shall have, and shall require RAEs to have, procedures that ensure maintenance of a record keeping system that includes maintaining the security of Members' clinical records as required by HIPAA, and the federal regulations implementing HIPAA. Such procedures ensure that records are secured, safeguarded and stored in accordance with applicable laws.

V. Health Share, RAEs and contracted provider networks shall cooperate with the OHA, the Department of Justice Medicaid Fraud Unit, the Centers for Medicare and Medicaid Services, or other authorized state or federal reviewers for the purposes of audits, inspection and examination of Members'  clinical records.

VI. Health Share, RAEs and contracted provider networks shall retain Members' clinical records for seven (7) years after the date of services for which claims are made. If an audit, litigation, research and evaluation, or other action involving the records is started before the end of the seven-year period, Health Share, RAEs and contracted providers shall retain the clinical records until all issues arising out of the action are resolved.

VII. Health Share and RAEs shall maintain all financial records relating to the CCO Contract in accordance with generally accepted accounting principles or National Association of Insurance Commissioners accounting standards. Health Share and RAEs shall maintain other records, documents, papers, plans and writings that are pertinent to the CCO Contract and that document Health Share or RAE performance.

VIII. All clinical records, financial records, other records, books, documents, papers, plans, records of payments and other writings, whether in paper, electronic or other format, that are pertinent  to the CCO Contract shall be collectively referred to as "Records". Health Share and RAEs shall retain and keep accessible all Records as described below:

A. For non-clinical Records, six (6) years following final payment and termination of the CCO Contract, whichever is later;
B. For clinical Records, seven (7) years following the date of service;
C. For certain kinds of Records, the retention period specified in the CCO Contract;
D.The period that may be required by applicable law, including the records retention schedules set forth in OAR Chapters 410 and 166; or
E. Until the conclusion of any audit or litigation arising out of or related to the CCO Contract.

IX. Health acknowledges and agrees that OHA, the Secretary of State's Office, Department of Health and Human Services, the Comptroller General of the United States, the Oregon Department of Justice Medicaid Fraud Control Unit and their duly authorized representatives  shall have access to all Records retained by Health Share and RAEs to perform audits and evaluate the quality, appropriateness and timeliness of services to Members. During the course of any such audit or evaluation, no Records related to the audit or evaluation   will be destroyed.

REFERENCES:

Health Plan Services Contract

ORS 192.561, 413.171 and 414.679

OAR 410-120-1360; 943-014-0300 through -0320; 943-120-000 through 0200

Department: Compliance

Author: Deborah Friedman, Chief Operating Officer

Effective Date(s):  March 2016

Review Frequency: Every 2 years

Revision Date(s):


COMP-05 FRAUD AND ABUSE PREVENTION AND DETECTION

TITLE:  FRAUD AND ABUSE PREVENTION AND DETECTION

PURPOSE:

To ensure Health Share of Oregon (Health Share) has a mechanism in place to prevent and detect fraud and abuse relating to Health Share members and  providers.

To identify, evaluate and reduce the potential risk management concerns associated with care and services by anticipating problems and taking preventive measures.

To educate Health Share providers, employees and contractors of their accountability for monitoring and identifying potential fraud and abuse.

DEFINITIONS:

Abuse: Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to Medicare, Medicaid, Health Share or an enrollee, or in reimbursement for services that are not necessary or that fail to meet professionally recognized standards for health care.   Abuse also includes enrollee practices that result in unnecessary costs.

False Claims Act: A federal law that imposes liability and sets criminal and civil penalties on persons or organizations who defraud governmental programs by the submission of a claim for payment to the government that is known to  be false in  whole or in part.

Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person. It includes any act that constitutes fraud under applicable state or federal law.

Health Plan Services Contract: Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

Member: An Oregon Health Plan client assigned to Health Share of Oregon.

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

POLICY:

I. Health Share maintains a compliance program which includes a compliance plan, code of conduct  for employees  and related policies.

II. Health Share's Compliance and Quality Improvement Manager is designated as the compliance officer and reports directly to the Chief Executive Officer and Board of Directors on compliance­ related matters. The compliance officer is responsible for ensuring the proper operation and monitoring of the fraud and abuse program.

III.  Health Share maintains a system for detecting and responding to fraud and abuse allegations that relate to administration of benefits to Members. This includes, but is not limited to, theimplementation of operational policies and controls, reporting, educational efforts, monitoring and auditing .

IV. Health Share prohibits any acts of intentional deceptions or misrepresentations made by a person that has knowingly acted with the knowledge that the deception(s) could result in some unauthorized benefit to him/ her or some other person. The term "knowingly," in the context of the False Claims Act means that a person, with regard to specific information:

  • Has actual knowledge of the  information;
  • Acts in deliberate ignorance of the truth or falsity of the information; or
  • Acts in reckless disregard to the truth or falsity of the information.

V. Health Share does not contract with or reimburse providers which engage in inconsistent and/or unsound fiscal, business or clinical practices that may result in unnecessary costs to Health Share, or in services that are not  clinically necessary or that fail to meet professionally recognized standards for health care reimbursement. If Health Share is contracted, either   directly or through the RAEs, with an individual provider or organization that commits fraud   and/or abuse, Health Share or the RAE will report the fraudulent activities as outlined in this  policy and take other necessary action up to and including terminating the applicable contract   .

VI. If providers, suppliers or other subc ontractors are suspended or terminated by the OHA or CMS this action is report ed to Healt h Share who will notify the respective RAE within 2 business days of the decision.    If the RAE is notified, the RAE in turn will report the suspension to Health  Share within two (2) business days. The RAE will assist members with finding a new provider in the event that their provider  is suspended or terminate d.

VII. Health Share does not allow Health Share employee, RAEs, or other contractors to intimidate, threaten, coerce, discriminate against, or take any other form of retaliation against any individual who submits complaint of alleged fraud or abuse. This includes participating in any process covered including the filing of a complaint with Health Share and/or a RAE or with the Oregon Healt h Authori ty and any subsequent testi mony, investigati on part icipati on and assist an ce, com pliance review, procee ding, or hearing relatin g. This also includes opposing any unlawful act or practice provided the individual (in cluding an employee) believes in good faith that the act or practice being opposed is unlawful; and that the manner of such opposition is reasonable and does not involve a use or disclosure of an individual's protected information in violation of Health Insurance Privacy and Portability Act or Health Share  policy.

VIII. Health Share's compliance hotline (503-416-1459) allows employees, members, vendors and subcontractors to immediately and anonymously report suspected violations without fear of retaliation.

IX. Health Share utilizes various risk evaluation techniques to monitor compliance and assist in the reduction of fraud and abuse activities as referenced in the 2016 OHA CCO Amended and Restated Contract Exhibit B Part 8 Section 14 a (1)-(10).

X. As part of Health Share's efforts to prevent potential fraud and abuse activities, Health Share responds promptly to allegations of improper or illegal activities and enforces appropriate disciplinary actions against employees, RAEs or subcontractors found to be violating applicable fraud and abuse policies and procedures, applicable federal and state statutes, rules, regulations, and other federal or state health care requirements.

  1. If a situation of fraud and/or abuse is suspected, prompt referral to the Medicaid Fraud Control Unit and OHA/DHS Provider Fraud Unit is required.
  2. RAE's are expected to simultaneously report investigations to the appropriate federal and state agencies and to Health Share.
  3. If Health Share becomes aware of credible allegations of fraud for which  an investigation is pending with the Medicaid Fraud Control Unit or the Provider Audit Unit, payment suspension is required as referenced in the Health Plan Services Contract.

XI. Initial written reports of fraud and/or abuse must be sent to:

Department of Justice Medicaid Fraud Control Unit

  • 1515 SW 5th Ave Suite 410
    Portland,  OR  97201
    Phone number:  971-673-1880

 

  • OHA/DHS Provider Audit Unit
    P.O . Box 14152
    3406 Cherry Ave., NE Salem, OR 97309-9965
    Phone number is 888 -372-8301 Fax number is 503-378-2577

 

  • Health Share of Oregon
    2121 SW Broadway Suite 200
    Portland, OR 97201
    503-416-1459

XII. In the event of suspected fraud or abuse, Health Share will cooperate with the Medicaid Fraud Control Unit and the OHA/DHS Provider Audit Unit to the extent referenced in the Health Plan Services Contract.

REFERENCES:

Health Plan Services Contract

OAR 410-120-1510; OAR 410-120-0000; OAR 410-141-0080 (2) (a); OAR 410-120-1395 to 410-120-1510

42 CFR 433.116; 42 CFR 438.214; 42 CFR 438.600-438.610; 42 CFR 438.808; 42 CFR 455.20; 42 CFR

455.104-455.106; 42 CFR 1002.3; 42 USC 1320a-7b; 42 CFR  433.116(c)(f)

False Claims Act Sections 3729-3733 of title 31 USC Employee Code of Conduct

ORS 410.610; ORS 411.670 to 411.690; ORS 4198.010; ORS 430.735; ORS 433.705; ORS 44.630;

ORS chapter 162; ORS 165.690-165.698; ORS 166.715-166.735 ORS 659A.200 659A.224 and ORS 659A.230-659A.233

False Claims Act Sections 3729-3733 of title 31USC: htt p:/ / uscode.house.gov/ downlo ad/ p1s/ 31C37.txt

Department: Compliance

Author:  Barbara Carey RN CPHQ

Effective Date(s): February  2013

Review Frequency: Annual

Revision Date(s): June 2014; August 2014; January 2015; January 2016


COMM-01 MEMBER AND POTENTIAL MEMBER EDUCATION, INFORMATION, AND MARKETING MATERIALS REVIEW PROCESS

TITLE: MEMBER AND POTENTIAL MEMBER EDUCATION, INFORMATION, AND MARKETING MATERIALS REVIEW PROCESS

PURPOSE:

To ensure all member and potential member information and education materials meet the requirements of the CCO Contract and Oregon Administrative Rules, and to define the process by which materials developed by subcontractors of Health Share of Oregon (Health Share) are submitted to Health Share for review.

DEFINITIONS:

Education and Information materials: Any materials that provide information to Health Share of Oregon members or potential members about Oregon Health Plan or Medicaid benefits, or significant changes in benefits; providers and provider sites; or significant changes in programs or services pursuant to Subcontractor's contract with Health Share that affect the member's ability to access care or services.

Health Plan Services Contract (CCO Contract): Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

Member: An Oregon Health Plan member assigned to Health Share of  Oregon.

Marketing materials: Materials that are produced in any medium by a CCO or on behalf of a CCO by its subcontractors and that can reasonably be interpreted as intended to compel or entice a potential member to enroll in that particular  CCO.

Oregon Health Authority (OHA): The State of Oregon acting by and through its Oregon Health Authority, Health Services Division.

Potential member: An individual who meets the eligibility requirements to enroll in the Oregon Health Plan but has not yet enrolled with a CCO.

Risk Accepting Entity (RAE):   An entity that holds a fully capitated contract with Health Share of Oregon   to provide services as defined in the Health Plan Services Contract between the Oregon Health Authority and Health Share of Oregon.

Subcontractor: RAE or other organization contracted with or doing business on behalf of Health Share of Oregon

POLICY:

I. Health Share is accountable to OHA through the CCO Contract to ensure that materials developed for Health Share Members or Potential Members are consistent with federal and state regulations including OAR 410-141-3270, OAR 410-141-3280, and OAR 410-141-3300.

II. Health Share is required to submit certain Member and Potential Member Education and Information and Marketing materials produced by itself or by its Subcontractors to OHA for approval  prior  to distribution.

III.  Subcontractors shall submit all Education and Information  and Marketing materials,   meeting the definitions above, to Health Share for  review, and Health Share shall be responsible for  obtaining OHA approval, if necessary.  Subcontractors shall not submit Education and Information  or Marketing materials  directly  to OHA.

IV. Health Share shall be responsible for producing the Member ID Card and Member Handbook for all Members assigned to Health Share. No Subcontractor shall produce a Member ID Card or Member Handbook for Health Share Members with the exception of Kaiser Permanente. Health Share Members assigned to Kaiser Permanente and Kaiser Permanente Dental will receive a Kaiser Permanente card in addition to their Health Share Member ID Card.

V. In addition to materials which require review and approval by OHA, Health Share reserves the right to submit any materials produced by itself or a Subcontractor to OHA for consultation purposes only, if Health Share believes it needs guidance as to whether the materials require OHA review and approval.

VI. Health Share reserves the right to reasonably require Subcontractor to alter the language or design of material based on OHP rules and regulations or Health Share policy and guidelines, prior to submission to OHA or distribution to Health Share Members.

VII. Health Share shall provide to each Subcontractor, for informational purposes only, copies of or access to all material, in any form, produced and provided to Health Share Members served by Health Share.

VIII. Subcontractors shall provide to Health Share, for informational purposes only, copies of or  access to other materials not meeting the definition of Education and Information or Marketing materials, in any form, provided to Health Share  members.

PROCEDURE:

I. Subcontractors shall submit any Member Education and Informational and Marketing materials  to the Health Share Communications Specialist for review:

  1. The materials must follow and be consistent with all pertinent statutes, rules, policies, and procedures related to Member Education and Information and Marketing materials, including intent, reading level, and font size.
  2. Subcontractors shall submit information regarding audience and distribution methods  with materials.

II. Within ten (10) business days after receipt of materials, the Health Share Communications Specialist will review the materials and notify the submitter of any concerns that will or may prevent approval of the material by Health Share or OHA, if required. If concerns are present, Subcontractor will be provided an opportunity to revise the materials, as suggested or  required, and resubmit to the Health Share Communications Specialist.

III. Within three (3) business days after materials are reviewed by Health Share, the Communications Specialist will submit those materials to OHA for review as required, or for consultation purposes, with an accompanying OHP Materials Submission and Approval Form for each document. In accordance with their procedures, OHA will review submitted materials within ten (10) business days.

  1. If OHA responds to Health Share with suggested edits to submitted materials, the Communications Specialist will review those edits with Subcontractor and jointly determine the next course of action, to include agreeing on which suggested edits will be incorporated  into the material and which  will  not.
  2. If any revisions are required by OHA or Health Share, the Subcontractor shall make those revisions and resubmit the materials to the Communications Specialist. The Communications Specialist shall resubmit the revised materials to OHA for review along with a new OHP Materials Submission and Approval Form for each document. That process will continue, if needed, until final approval is obtained from   OHA.
  3. When final approval of materials is received from OHA, the Communications Specialist shall inform Subcontractor and provide Subcontractor with an approval code supplied by the OHA. That approval code must be printed in 12 pt. type on the approved material.

IV. Health Share will maintain a tracking system to ensure the procedures in this policy are followed and the material review process moves forward in a timely and efficient    manner.

V. Subcontractors shall provide the Health Share Communications Specialist with a single point of contact for receipt and distribution of materials. That single point of contact shall be the only individual authorized to submit and/or communicate with the Communications Specialist regarding communications materials unless other arrangements are made with the Communications Specialist.

OTHER  RELATED INFORMATION:

Health Share of Oregon Co-Branding Policy Health Share of Oregon Co-Branding Guidelines

REFERENCES:

OAR 410-141-3270 Coordinated Care Organization Marketing Requirements

OAR 410-141-3280 Coordinated Care Organization Potential Member Information  Requirements

OAR 410-141-3300 Coordinated Care Organization Member Education and Information Requirements

Department: Communications

Author: Beth Sorensen, Communications Specialist

Effective Date(s): July 2015

Review Frequency: Every 2 years

Revision Date(s):


COMM-02 MATERIALS CO-BRANDING POLICY

TITLE: MATERIALS CO-BRANDING POLICY

PURPOSE:

To ensure appropriate, accurate, and consistent representation of Health Share of Oregon (Health Share) in name or brand by Health Share subcontractors and grant recipients.

POLICY:

  1. Health Share subcontractors (organizations contracted with or doing business on behalf of Health Share) and grant recipients shall include Health Share of Oregon's name and/or logo on all materials, printed or electronic, which are  produced:
    1. specifically for distribution to a Health Share member or members that meet the definition  of Education and Information or Marketing materials as defined in the Member and  Potential Member Education, Information and Marketing Materials Review Process   Policy;
    2. for  or about a program funded through a grant provided by Health Share; or
    3. for  other audiences to  provide information about Health Share
  1. Health Share subcontractors and grantees will follow the attached Health Share Brand Guidelines for accurate and consistent representation of Health Share's name, identity and brand or   logo.

Ill. The materials to which this co-branding policy apply include, but are not limited to, websites, newsletters, special programs or offers, , postcards, fliers, posters, brochures, advertising, Notice of Action (NOA) letter,  Notice of Appeals Resolution (NOAR) letter, any grievance resolution notice and any extension letter to either a NOA/NOAR and grievance review .

    REFERENCE:

    Health Share of Oregon Brand Guidelines
    Risk Accepting Entity Agreement
   Health Plan Services Contract

Department:  Communications

Author: Beth Sorensen, Communications Manager

Effective Date(s): July 1, 2015

Review Frequency: Every 2 years

Revision Date(s):

 


HEALTH SHARE OF OREGON CO-BRANDING GUIDELINES

HEALTH SHARE OF OREGON CO-BRANDING  GUIDELINES

 

  1. Use of the Health Share of Oregon Name

 

A consistent name identity used by Health Share of Oregon and its subcontractors and grantees supports a strong brand for the  organization.

 

  1. Health Share of Oregon, Health Share

 

  1. "Health Share of Oregon" is to be used on first reference in written materials. "Health Share" may  be used as the shortened version in further references.

 

  1. The abbreviation "HSO" is not to be used in any formal communication.

 

  1. "HealthShare" as a single word is not to be used in any written communication.

 

  1. Coordinated Care Organization, CCO

 

  1. "Coordinated Care Organization" is to be used on the first reference. "CCO" may be used as the shortened  version thereafter.

 

  1. Combined Reference to Health Share and Risk Accepting Entity (RAE)

 

  1. The appropriate designation to jointly represent a Risk Accepting Entities' relationship to Health Share for those members assigned to them is "Health Share/RAE Name". For example, "Health Share/Providence", "Health Share/Multnomah County" or "Health Share/Willamette Dental".

 

  1. RAEs are not to use any other configuration or variation, such as "Providence/Health Share" or "Health Share of Multnomah County" or "HSO/Family Dental".

 

  1. Health Share of Oregon Brand/Logo

 

  1. Sub-contractors and grantees are responsible for ensuring they are using the correct version of   the Health Share of Oregon logo. To ensure recognition on any materials being used externally,  the Health Share blocks that make up the logo must always be used with the words "Health Share of Oregon" at the bottom. The correct logo can be requested in any format from the Health Share  of Oregon Communications Manager.

 

  1. The logo is not to be altered in any way, including for color or stretched vertically    or horizontally.

 

  1. If materials are co-branded with the logo or logos of subcontractors or grantees, the Health Share of Oregon logo must be represented in a size equal to all other logos.

CORP-OS DELEGATED ENTITY CORRECTIVE ACTION AND SANCTIONS

TITLE: DELEGATED ENTITY CORRECTIVE ACTION AND SANCTIONS

 

DEFINITIONS:

Delegated Entity: An entity with which Health Share has entered into a written agreement to perform certain functions required under, or governed by, the Health Plan Services Contract, federal and/or state regulations that would otherwise be the responsibility of Health Share.

 

Health Plan Services Contract (CCC Contract): Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

 

Inadequate Performance: Repeated or consistent failures to respond to requests from Health Share related to delegated functions, or repeated lack of timeliness of submission of required reports or documentation that put Health Share at risk of being in violation of contractual obligations.

 

Material Breach of Contract: Acts or failures to act that demonstrate substantial and/or persistent violations of contractual or legal obligations, regulatory requirements and/or Health Share policies and procedures that endanger Health Share's performance under the Health Plan Services Contract and/or put Health Share at risk of noncompliance with federal and state regulations governing the Medicaid program.

 

Member:  An Oregon Health Plan client assigned to Health Share of Oregon.

 

Non-Compliance: Acts or failures to act that demonstrate a pattern of failure to adhere to contractual or legal obligations, regulatory requirements, Health Share policies or performance standards; and/or patterns of issues identified through review of grievances and appeals and provider complaints; and/or severity or number of findings through the Delegated Entity oversight and audit process.

 

Oregon Health Authority (CHA): The State of Oregon acting by and through its Oregon Health Authority, Health Services Division

 

PURPOSE:

To ensure a fair and objective process by which Health Share of Oregon (Health Share) addresses situations where a Delegated Entity is non-compliant with Health Share policies and procedures and/or does not meet its contractual  obligations with Health Share.

 

POLICY:

  1. Health Share complies with, and is responsible for ensuring that Delegated Entities comply with, the terms and conditions of the Health Plan Services Contract and all state and federal laws and regulations governing Coordinated Care Organizations, the Oregon Health Plan and the  Medicaid program.
     
  2. Delegated Entities are responsible for  fulfilling their contractual and legal obligations subsequent to the contract they hold with Health Share, and for following Health Share policies related to those contractual obligations. Failure to adhere to those obligations may require corrective action or result in sanctions up to and including termination of the contract between Health Share and the Delegated Entity.
     
  3. Health Share management shall investigate all performance and compliance concerns related to performance of Delegated Ent i t iesconsistent with Health Share contracts and related policies and procedures.
  1. If management concludes that the Delegated Entity has engaged in Non-Compliance the matter shall be taken to the Compliance and Delegation Oversight Committee for review and determination of appropriate action. The Compliance and Delegation Oversight Committee has  the authority to require submission of plans of correction related to matters of Non-Compliance. The Compliance and Delegation Oversight Committee may also refer matters to the Quality and Governance Committee for review and determination  of  action(s).
     
  2. If management concludes that the actions of the Delegated Entity constitute a Material Breach   of Contract, the matter shall be taken to the Quality and Governance Committee for review and disposition. Unresolved issues of Non-Compliance may be considered to meet the standard of Material Breach of Contract. The Quality and Governance Committee has the authority to issue written reprimands and place holds on assignment of Members to Delegated Entities. The Board of Directors has final authority  for imposition of sanctions,  including:
    • Revocation of delegation of all or parts of delegated or administrative functions, including a withhold of funds suff icient to cover the cost to Health Share to administer and provide the delegated function(s);
    • Financial penalties, including deductions or compensation  or withholds;  and/or
    • Termination of the contract with the Delegated Entity.

 

PROCEDURE:

 

Inadequate  Performance

  1. Instances of potential Inadequate Performance by Delegated Entities will be identified through evidence of lack of timely submission of reports, data, encounters and other required submissions , and/or lack of responsiveness to requests for submission of materials and documents by Health Share staff .
  1. Issues of Inadequate Performance will be brought to the attention of the Senior Manager for Compliance and Quality Assurance who will issue a warning letter to the Delegated  Entity.
     
  2. If the matter  remains unresolved following the issuance of the warning   letter, or if the Delegated Entity repeatedly engages in Inadequate Performance, the matter may be referred to the Compliance and Delegation Oversight Committee for review and consideration of issuance  of  a notice of Non-Compliance.    

 

Non-Compliance

  1. Instances of potential Non-Compliance will be identified through delegation oversight, including results of audit processes and on-going monitoring; provider complaints; Member grievances;  and other sources, including on-going, unresolved issues of Inadequate Performance. Such instances will be reported to the Senior Manager for Compliance and Quality Assurance who will review the matter with the Chief Operating Officer or other executive    staff.
  1. If the review substantiates a finding of Non-Compliance, the matter will be presented to the Compliance and Delegation Oversight Committee.
    1. Upon review of the evidence, if the Committee makes a determination of Non­ compliance, the Chief Operating Officer will issue a written notice to the Delegated  Entity, including a summary description of the Non-Compliance and an identification of  the regulation(s), policy(ies), standard(s) or section(s) of the Delegated Entity agreement violated; the date by which the plan of correction must be received; and, if appropriate,  the date by which the Non-Compliance must be  resolved.
    2. If the decision reached by the Compliance and Delegation Committee is that the matter does not meet the standard of Non-Compliance, the matter will be considered to be closed.
       
  2. The Compliance  and Quality Assurance staff will monitor the plan of correction  and provide status updates to the Compliance and Delegation Oversight Committee. The Quality and Governance Committee will be informed on a regular basis of Delegated Entities which have been found to have engaged in Non-Compliance.
     
  3. If the Delegated Entity does not  submit the required plan of correction, or if   the Non­ Compliance remains unresolved, the Compliance and Delegation Oversight Committee will refer the matter to the Quality and Governance Committee for review and consideration of potential actions.
     
  4. The Quality and Governance Committee may take action to (i) issue a written reprimand or (ii) place a hold on Member assignments. Factors considered in taking action include, but are not limited  to:
    • The nature of the Non-Compliance and the seriousness and circumstances surrounding it;
    • Whether the Delegated Entity has been reprimanded or sanctioned in the past; and/or
    • Whether the Non-Compliance  was intentional or  negligent.
  1. Should the Quality and Governance Committee place a hold on Member assignments to the Delegated Entity and such hold continues for more than sixty (60) days because the Delegated Entity has not remedied or corrected the Non-Compliance as determined by the Quality and Governance Committee, the Committee shall promptly resume review of the matter and make a recommendation to  the Board of Directors for imposition  of  sanctions.
  1. Delegated Entities do not have the right of appeal of a decision by the Quality and Governance Committee to issue a written reprimand or place a hold on Member assignments to the Delegated Entity, provided, however, that such hold shall not exceed sixty (60) days without further review by the Quality and Governance Committee and a recommendation to the Board of Directors.
  1. If the OHA issues a Notice of Formal Work Plan or Compliance Status Agreement to Health Share in which a Delegated Entity is a responsible party, the matter will be considered an instance of Non-Compliance and the Delegated Entity will be required to develop a plan of correction to resolve the notice.
     

    1. Health Share management will submit a plan of correction to the Quality and Governance Committee that addresses the OHA Work Plan or Compliance Status Agreement. Management will report to the Quality and Governance Committee on its progress and ultimate resolution of the Work Plan or Compliance Status  Agreement.
       
    2. Should the Delegated Entity fail to submit the required plan or correction, and/or should the Delegated Entity continue to engage in the Non-Compliance which led to the  issuance of the Notice of Formal Work Plan or Compliance Status Agreement, the   matter may be considered a Material Breach of Contract and be referred for   investigation  and possible recommendation of sanctions as described below.
       
  2. Should Health Share become aware of issues related to a provider within a Delegated Entity's contracted  network, including but not  limited to,  sanctions on the provider's license; evidence   of commission of fraud or abuse; have been excluded as a Medicaid or Medicare provider; evidence of provision of poor quality services endangering the health and safety of Health Share Members; or other acts of commission or omission that put Health Share's performance under  the CCO Contract at risk, Health Share will work with the Delegated Entity to ensure the issue(s) are addressed, up to and including termination of the provider from the Delegated Entity's network.

 

  1. Should Health Share determine that the Delegated Entity is not taking appropriate corrective action with the provider, the matter will be referred to the Quality and Governance Committee for review and potential action as described in IV above.

 

  1. Should the matter continue to be unresolved by the Delegated Entity, Health Share reserves the right to take action against the provider, either through direct oversight and required corrective action by the provider, or through termination of the provider's right to provide services to Health Share Members.

 

Material Breach of Contract

  1. Instances of potential Material Breach of Contract will be identified through delegation   oversight, including results of audit processes and on-going monitoring; provider complaints; Member grievances; and other sources, as well as on-going, unresolved issues of Non­ compliance.  Such instances will be reported to the Senior Manager for Compliance and  Quality Assurance who will review the matter with the Chief Operating Officer or other executive staff and conduct an investigation of the Delegated  Entity.

 

  1. The Delegated Entity that is the subject of an investigation will be notified by the Chief Operating Officer as to the nature of the concern, and may be asked to submit information related to the concern. The Delegated Entity shall submit any and all required information requested in a timely fashion and shall cooperate fully with Health Share staff in the investigation.
     
  2. The Delegated Entity may provide a written response in addition to submitting required information and other supportive documentation. The written statement and documentation will be considered before any findings are made.
     
  3. If the decision reached by the Compliance and Delegation Committee is that the matter does not meet the standard of Material Breach of Contract, the Chief Operating Officer will notify the Delegated Entity in writing that the matter is closed.
     
  4. If the Compliance and Delegation Oversight Committee finds that the matter does meet the standard of Material Breach of Contract , it will recommend to the Quality and Governance Committee that the Delegated Entity be required to submit a plan of correction.  The Chair of    the Quality and Governance Committee will issue a written notice to the Delegated Entity, including a summary description of the Non-Compliance and an identification of the   regulation(s), policy(ies), standard(s) or section(s) of the Delegated Entity agreement violated; violated; the date by which the Material Breach of Contract must be resolved; the date by which the plan of correction must be received; and, if appropriate, the potential sanctions that may be applied if  the Delegated Entity fails to  comply with submitting a plan of  correction.

 

  1. If the Delegated Entity disputes the finding of Material Breach of Contract, the Delegated Entity may submit a written request for an in-person meeting with the Quality and Governance Committee. The Delegated Entity may alternatively submit a written statement for consideration by the Committ ee.

 

  1. After consideration of all of the information obtained by Health Share and the   information presented by the Delegated Entity, the Committee shall determine whether the finding of Material Breach of Contract is supported by the facts, and whether the submission of a plan of correction is  warranted.

 

  1. The Compliance and Delegation Oversight Committee will monitor the plan of correction and provide status updates to the Quality and Governance Committee.

 

  1. When the Compliance and Delegation Oversight Committee determines that the plan of correction has been fully completed and on schedule, it will notify the Quality and Governance Committee and recommend the matter be closed. If the Quality and Governance Committee agrees that the plan of correction has been fully completed, the Chair of the Committee will notify the Delegated Entity in writing of the conclusion of the matter.
  1. lf the Compliance and Delegation Oversight Committee finds that the plan of correction has not been completed and/or is not on schedule, it will review the lack of compliance and if it determines that appropriate improvement has not been made, will refer the matter to the Quality and Governance Committee for review and possible recommendation to the Board of Directors for consideration of imposition of sanctions.

 

  1. The Quality and Governance Committee may take action to recommend a sanction to the Board of  Directors based on, but not limited to, the following   factors:
  • The nature of the Material Breach of Contract and the seriousness and circumstances surrounding it;
  • Whether the Delegated Entity has been reprimanded or sanctioned in the   past;
  • Whether the Material Breach of Contract was intentional or negligent;
  • Mitigating factors such as the Delegated Entity's efforts to rectify the consequences of the Inadequate Performance and cooperation with Health Share in the investigation and in submitting a plan of correction; and/or
  • The financial and operational impacts of the sanction on the Delegated Entity and/or Health Share.

 

  1. The Board of Directors shall review recommendations from the Quality and Governance Committee and shall determine whether and how to sanction the Delegated Entity.

 

  1. The Delegated Entity shall be notified in writing by the Chief Operating Officer of the Board's intent to review the recommendations of the Quality and Governance Committee.
     
  2. The Delegated Entity shall have the right to submit a written statement that describes the basis for its objection to the recommendations and includes any supporting documentation not already submitted. The Delegated Entity may also request an in­ person meeting with the Board of Directors. Written statements and requests for meetings are to be submitted to the Chief Operating Officer within ten (10) days of notification of the intent of the Board of Directors to make a determination regarding sanctions.
     
  3. Following review of the recommendations, the Board of Directors will issue written notice of its decision within 45 days of referral from the Quality and Governance Committee.
     
  4. If the Board of Directors determines that a sanction should be imposed, it will issue written notification signed by the Chair of the Board to the Delegated Entity  to    include:
    • A summary of the Material Breach of Contract, including the policy, contractual requirement or standard violated;
    • A description  of the factors considered  in making the sanction  determination;
    • A description of the sanction;
    • The date the sanction is effective; and
    • The term for which the sanction shall be  imposed.
  1. If the Board of Directors determines that a sanction should not be imposed, it will issue written notification signed by the Chair of  the Board to  the Delegated Entity to  that effect .
     
  2. The decision of the Board of Directors regarding sanctions is final with the exception that if the Bylaws of Health Share of Oregon require that a particular sanction be approved by the Member Directors, then such action shall not be final unless and until the Member Directors approve the  sanction.

 

  1. All deliberations by the Quality and Governance Committee and Board of Directors regarding sanctions will be done in closed session without the presence of representatives, employees or agents of the Delegated Entity. The Chair of the Quality and Governance Committee and members of Health Share management staff may be requested to participate in deliberations, along with any consultants deemed useful to the deliberati ons, including legal counsel.

 

  1. In situations where immediate action is required or deemed prudent, the Chief Executive Officer and Chief Operating Officer have the authority to recommend or initiate appropriate corrective based on the results of the investigation by the Senior Manager for Compliance and Assurance and the recommendation of the Compliance and Delegation Oversight committee .

 

Department: Compliance

Author: Deborah Friedman, Chief Operating Officer

Effective Date(s): July 2014

Review Frequency: Every 2 years

Revision Date(s): November 2016

 


QUAL-01 GRIEVANCE SYSTEM OVERVIEW

TITLE:  GRIEVANCE SYSTEM OVERVIEW

DEFINITIONS:

Action: The denial or limited authorization of a requested, covered service, including the type or level of service; the reduction, suspension or termination of a previously authorized service; the denial in whole or in part, of a payment for a service; the failure to provide services in a timely manner, as defined by the Oregon Health Authority; or the failure to act within the timeframes provided in 42 CFR 438.408(b).

Appeal: A request for a review of an Act ion .

Grievance: A Member's expression of dissatisfaction to Health Share of Oregon, a Risk Accepting Entity, or a provider about any matter other than an Action.

Health Plan Services Contract: Contract entered into between Health Share of Oregon and the Oregon Health Authority  pertaining to  the administration of the Oregon Health Plan Medicaid   program .

Member:   An Oregon Health  Plan client  assigned  to  Health Share of  Oregon .

Oregon Health Authority (OHA): The State of Oregon acting by and through its Oregon Health Authority, Health Services Division

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE:

To ensure that Health Share of Oregon (Health Share) Members have access to a robust process for handling Grievances, Appeals and contested case hearings regarding the services they receive through Health Share and its affiliated Risk Accepting Entities.  Health Share retains the adjudication of final  appeals.

To ensure the appropriate collection of Grievances and Appeals from Members so that Health Share may improve the quality of care or experience of care for   Members.

To ensure that all Grievance, Appeal and contested case hearing requests have an appropriate and timely resolution.

 

POLICY:

  1. Health Share's grievance system includes a grievance process, an appeals process and access to a contested case hearing. It ensures all grievances, and requests for appeals and hearings are reported according to the Health Plan Services Contract and the Oregon Administrative  Rules.
     
  2. A Member or member representative may file a Grievance, an Appeal or request a contested case hearing orally or in writing. The Member or member representative may also withdraw an appeal or contested case hearing request at any time.  The Member, the member's  representative, or the    legal representative of a deceased member ' s estate may be included as parties to the grievance, appeal or contested case hearing.
     
  3. Health Share's grievance system allows members or their representatives the right to  file a Grievance regarding any dissatisfaction about any matter other than an Action. Members are informed of their right to file a Grievance and instructed on how to  submit their concern in writing    via the Health Share Member handbook or verbally when speaking to any Health Share employee or Risk Accepting Entity. Members are provided with assistance in filing a Grievance, including interpreter services, toll-free numbers and Tele-Typewriter (TIY) or other accommodations, as indicated.
  1. An Appeal and subsequent contested case hearing request to the Oregon Health Authority may be filed when the Member or their representative disagrees with a notice of action. Forms for requesting a contested case hearing are included in all notices of action for completion of the appeals and hearing process. All Members are provided the opportunity for assistance in completing the forms.
     
  2. Health Share follows the process for responding to Member Grievances outlined in OAR 410-141- 3260 through 410-141-3266 and holds each RAE to the same process.
     
  3. Each RAE will provide a quarterly Grievance, Appeals and contested hearings log and analysis report to Health Share within 20 days of the end of each calendar  quarter.
     
  4. Health Share is responsible for the final adjudication of Grievances or Appeals. RAEs will abide by the final determination of Health Share regarding Grievances and Appeals.

 

REFERENCES:

Health Plan Services CCO Contract .

OAR 410-141-3260 through 410-141-3266

42 CFR Subpart  F 438.402-438.414

45 CFR   6 .501

Department:  Quality

Author: Barbara Carey RN CPHQ

Effective Date(s): July 2012

Review Frequency: Every 2 years

Revision Date(s): August 2013

December 2015

 


QUAL-02 MEMBER RIGHTS

TITLE:  MEMBER RIGHTS

DEFINITIONS:

Member:  An Oregon Health Plan client assigned to Health Share of Oregon.

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of Oregon .

PURPOSE:

Health Share of Oregon (Health Share) is committed to treating our Members in a manner that respects their rights, and defines our expectations of our Members. It is our goal to  recognize the specific needs  of and maintain  a mutually respectful  relationship  with our Members.

POLICY:

  1. Health Share will provide information to Members regarding their rights, including the right to be treated with respect and dignity, the right not to be discriminated against and the right to privacy and confidentiality. Members will also be informed of their responsibilities and expectations for their behavior while receiving services through the Oregon Health Plan and enrolled with Health Share.
     
  2. Health Share will communicate these rights and responsibilities to Members initially upon their enrollment and on-going throughout their Health Share membership.
     
  3. Members are provided a handbook upon enrollment upon enrollment with Health Share which details the Member's rights and responsibilities. Members may also receive information regarding rights and responsibilities in communications from and interactions with the RAEs to which they are assigned. 
     
  4. RAEs are responsible for providing education regarding Member rights and responsibilities  to all contracted providers who provide services to Health Share  members.

REFERENCES:

42 CFR § 438.100 Enrollee Rights

42 CFR § 438.10 (f) (2) Information Requirements

OAR 410-141-3320 Oregon Health Plan Prepaid Health Plan Member Rights and Responsibilities

 

Department: Compliance and Quality Assurance

Author: Barbara Carey, Manager, Compliance and Quality Assurance

Effective Date(s):  December  2013

Review Frequency: Every 2 years

Revision Date(s):  December 2015

 


QUAL-03 NONDISCRIMINATION

TITLE: NONDISCRIMINATION

DEFINITIONS:

Delegated  Entity:   An entity with which Health Share has entered into a written agreement  to   perform certain functions required under, or governed by, the Health Plan Services Contract, federal and/or state regulations that would otherwise be the responsibility of Health Share.

Health Plan Services Contract (CCO Contract): Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

Member: An Oregon Health Plan client assigned to Health Share of Oregon. 

PURPOSE:

To ensure that Health Share of Oregon (Health Share) Members receive all benefits and services to which they are entitled without discrimination, to advance equity and reduce health disparities, and to ensure that Members' rights are protected as specified under the law.

POLICY:

  1. Health Share of Oregon does not exclude, deny benefits to, or otherwise discriminate against any Member on the grounds of race, color, or national origin, religion, sex, sexual orientation, gender identity/expression, protected veteran's status, genetic information, or on the basis of disability or age, participation in, or receipt of the services and benefits under any of Health Share's programs and activities, whether carried out by Health Share directly or through a Delegated Entity, contractor or any other entity with which Health Share arranges to carry out its programs and activities.
  1. Health Share acts, and requires Delegated Entities to act, in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973; Title II of the Americans with Disabilities Act of 1990; the Age Discrimination Act of 1975; Title IX of the Education Amendments of 1972 (regarding education programs and activities); Section 1557  of the Affordable Care Act; and the Regulations of the U.S. Department of Health and Human Services issued pursuant to these statutes at Title 45 Code of Federal Regulations (CFR) Parts 80, 84, 86 and 91, and 28 CFR Part 35.
     
  2. Health Share's notice of nondiscrimination is communicated to Members and other interested persons through multiple methods, including but not limited to the Member handbook and on Health Share's website or through Delegated Entities.
     
  3. If assistance or communication aids for impaired hearing, vision, speech, or manual skills are needed by Members, Health Share and Delegated Entities will make reasonable accommodations and provide auxiliary aids and services. Such aids and services include, but are not  limited to:
    • Qualified sign language interpreters
    • Large print materials
    • Text telephones (TTYs)
    • Captioning
    • Screen reader software
    • Video remote interpreting services
  1. Health Share requires Delegated Entities to take reasonable steps to assure that Members with limited English proficiency are provided meaningful access to health care services, programs and activities. Reasonable steps may include the provision of language assistance services, such as oral language assistance or written translations. Delegated Entities must offer a qualified interpreter when oral interpretation is a reasonable step to provide an individual with limited English proficiency with meaningful access.
     
  2. Health Share assures that all Members with sensory or speech impairment are able to receive notices, including nondiscrimination and notices concerning benefits or services, or information concerning waivers of rights or consent to treatment, regardless of their disability in the alternative format requested.
     
  3. Health Share has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by the U.S. Department of Health and Human Services regulations (45 C.F. R. Part 84), implementing Section 504 of the Rehabilitation Act of 1973 as amended (29 U.S.C. 794). Section 504 states, in part, that "no otherwise qualified disabled individual…shall solely by reason of his/her disability, be excluded from participation in, be denied benefits of, or be subject to discrimination under any program or activity receiving federal financial assistance…" as referenced in the Oregon Health Authority Health Plan Services Contract.
     
  4. These rules shall be liberally construed to protect the substantial rights of interested persons to meeting appropriate due process standards and assure Health Share's compliance with Section 504 of the Rehabilitation Act of 1973 and associated regulations.
     
  5. Members wishing to file a discrimination complaint with Health Share may submit it to the Civil Rights Coordinator:

Sr . Manager of Compliance and Quality Assurance 2121 SW Broadway Suite 200

Portland, OR 97201

(503) 416-4962

  1. VIX. A Member who files a discrimination complaint may pursue other remedies including filing with:

Office for Civil Rights

U.S. Department of Health and Human Services

2201 Sixth Avenue – M/S: RX-11 Seatt le, WA 98121-1831 Voice Phone: (800) 368-1019

Fax : (206) 615-2297

TDD: (800) 537-7697

 

Department: Quality

Author: Barbara Carey, Manager, Compliance and Quality Assurance

Effective  Date(s): March 2015

Review Frequency: Every 2 years

Revision Date(s): March 2016, September 2016

 


QUAL-04 MEMBER GRIEVANCES

TITLE:    MEMBER GRIEVANCES

DEFINITIONS:

Action: The denial or limited authorization of a requested covered service, including the type or level of service; the reduction, suspension or termination of a previously authorized service; the denial in whole or in part, of a payment for a service; the failure to provide services in a timely manner, as defined by the Oregon Health Authority; or the failure to act within the timeframes provided in 42 CFR 438.408(b).

Grievance: A Member's expression of dissatisfaction to Health Share of Oregon, a Risk Accepting Entity, or a provider about any matter other than an   Action.

Health Plan Services Contract (CCO Contract) – Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

HIPAA Privacy Rules: The federal law (Public Law 104-191, August 21, 1996) with the legislative objective to assure health insurance portability, reduce health care fraud and abuse, enforce standards for health information, and guarantee security and privacy of health information.

Member: An Oregon Health Plan client assigned to Health Share of  Oregon.

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract  with Health Share of Oregon  to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE:

To ensure Health Share of Oregon (Health Share) Members are afforded at all times the right to submit a Grievance and have described to in the Member handbook available to them for appropriate resolution of the Grievance.

To ensure Members receive a timely response to any inquiry via phone, written, or other appropriate means  of communication.

To ensure the Member's right to confidentiality during the Grievance process.

POLICY:

  1. Health Share takes Member Grievances seriously and ensures they are responded to in a timely manner. A Grievance may be an oral or written communication that addresses issues with any aspect of the operations, activities, or conduct of Health Share, its RAEs or their contracted provider networks that pertains to the availability, delivery or quality of care including utilization review decisions that are believed to be adverse to the Member.
  1. Members are informed of their right to file a Grievance, and the process for doing so, through the Member handbook, through interactions with Health Share customer service staff, and through communications from RAEs.
     
  2.  Health Share and RAEs handle all Member Grievances in confidence in accordance with established Health Share policy, the Health Plan Services Contract, ORS 411.320, 42 CFR 431.300 et seq, and HIPAA Privacy Rules.  The Member must authorize disclosure or release of information if there is a need to discuss the Grievance with other providers that are not involved with the Grievances to resolve the issue.
     
  3. A Member's authorization to release information related to the Grievance does not constitute authorization to disclose medical information unrelated to the Grievance. However, if the Grievance is alleged to be a quality of care issue, Health Share and the RAE have the right to use this information for purposes of resolving the Grievance and for health oversight purposes without a signed release from the Member.
     
  4. A Member may file a Grievance with Health Share or a RAE. When the Grievance is filed directly with Health Share, it is forwarded to the RAE to  conduct the review.
  1. Grievances concerning denial of service shall be handled according to the Health Share policy on denials, appeals and contested case hearings.
     
  2. Members who are dissatisfied with the disposition of a Grievance may present their Grievance to the Governor's Advocacy Office or the Oregon Health Authority Ombudsman .
     
  3. Grievances are a source of information that may be used to evaluate the quality of access, provider service, clinical care, or RAE service to members.
     

PROCEDURE:

  1. Receipt and resolution of oral or written Grievances are managed by the RAES in accordance with the OHA HSD Contract.
    1. If the RAE is unable to resolve the Grievance within 5 working days, the RAE will inform the Member in writing that a delay of up to 30 calendar days may be necessary to resolve the Grievance.
    2. All Grievances must be resolved within 30 days.
       
  2. Health Share and RAEs will provide the Member with any reasonable assistance in completing forms and taking other procedural steps related to filing and disposition of a Grievance. When necessary Health Share and RAEs will provide interpreter services and toll free phone numbers that have adequate TTY/TID capabilities.
     
  3. Notification of resolution of a Grievance may be made verbally or in writing to the Member, depending on the method the original Grievance was initiated. lfthe Grievance was received in writing, the resolution must be in writing. The written resolution on the Grievance shall review each element of the Member's Grievance and address each of those concerns specifically, including the reasons for the RAE's decision. Verbal resolutions shall address each aspect of the Member's Grievance and explain the reason for the decision  verbally.
  1. Health Share reviews and approves RAE's policies and procedures with regard to submission and resolution of Grievances as part of the annual delegation oversight  process.
     
  2. Quarterly reports of Grievances will be submitted by each RAE to Health Share within 20 calendar days of the end of the quarter, including an analysis and trending of Grievances.
     
  3. Health Share oversight of the Grievance process includes the receipt of the RAE grievance and appeals log documents quarterly, completed in accordance with the Health Plan Services contract. Documentation shall be retained by both Health Share and RAE for seven years.

REFERENCES:

Health Plan Services Contract

OAR 410-141-0260 through OAR 410-141-0266

42 CFR 431.300, 438.10, 438,400 through 438.424

45 CFR 1 64.501

 

Department:  Quality

Author: Barbara Carey RN CPHQ

Effective Date(s):  April 2013

Review Frequency: Every 2  years

Revision Date(s):  January 2016

 

 

 

 


QUAL-05 APPEALS AND CONTESTED CASE HEARINGS

TITLE: APPEALS AND CONTESTED CASE HEARINGS

DEFINITIONS:

Action: The denial or limited authorization of a requested, covered service, including the type or level of service; the reduction, suspension or termination of a previously authorized service; the denial in whole or in part, of a payment for a service; the failure to provide services in a timely manner, as defined by the Oregon Health Authority; or the failure to act within the timeframes provided in 42 CFR 438.408(b).

Appeal:  A request for a review of an Action.

Health Plan Services Plan Contract: Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

Member: An Oregon Health Plan client assigned to Health Share of Oregon.

Oregon Health Authority: The State of Oregon acting by and through its Oregon Health Authority, Health Services Division

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE:

To define standards, accountabilities, and processes for the review of Health Share of Oregon (Health Share) Member appeals or contested case hearings regarding adverse determinations and actions taken.

POLICY:

  1. Health Share Members have the right to appeal and request a review of an action taken that is adverse to the Member, and to request a contested case hearing on an action. Members are informed of these rights through the Member handbook, through interactions with Health Share customer service, and through communications from RAEs.
     
  2. With the exception of the final adjudication of all appeals, the process for issuing denials, managing appeals and contested case hearings is conducted by the RAEs with appropriate oversight by Health Share.
     
  3. Contested case hearings are conducted pursuant to ORS 183.411 to 183.497 and the Attorney General's Uniform and Model Rules of Procedure for the Office of Administrative Hearings, OAR 137-003-0501 to 137-003-0700.
     
  4. Responses by the RAE to an appeal or request for a contested case hearing will be made consistent with the requirements of the Health Plan Services Contract and Oregon Administrative Rules governing these processes.
  1. Appeal requests may be received orally or in writing. Notices of resolution of an Appeal shall be in writing unless the request is expedited.
     
  2. Health Share, RAE and participating providers will cooperate with the Governor's Advocacy Office, the Oregon Health Authority Ombudsman, and hearing representatives in all activities related to Member appeals and contested case hearing requests, including providing all requested written materials.
     
  3. In a contested case hearing, the final order issued by the administrative law judge is the final decision of the Oregon Health Authority, and Health Share and RAE must abide by that decision.

PROCEDURE:

  1. When the RAE takes an Action that is adverse to a Member, the RAE will mail a written Notice of Action on Health Share letterhead to the Member in accordance with the requirements in the Health Plan Services Contract and Oregon Administrative Rules. The Notice of Action informs the Member of their appeal and contested case hearing rights.
     
  2. Health Share and RAEs will provide the Member with any reasonable assistance in completing forms and taking other procedural steps related to filing and disposition of the appeal or contested case hearing form. When necessary Health Share and RAEs will provide interpreter services and toll free phone numbers that have adequate TIY/TID   capabilities.
     
  3.  RAE will cooperate with Health Share in providing requested documentation and in  acting as witnesses in contested case hearings.
     
  4. Records of all appeals and contested case hearings are maintained in accordance with the Health Plan Services Contract. Documentation shall be retained by both Health Share and RAE for seven years.

REFERENCES:

Health Plan Services Contract

42 CFR 438.420(c)

Janet Meyer, CEO                    Date

Department: Quality

Author: Barbara Carey RN CPHQ

Effective Date(s):  June 2014

Review Frequency: Every 2 years

Revision Date(s): January 2015 January 2016

 


QUAL-06 ADVANCE DIRECTIVES AND DECLARATION FOR MENTAL HEATLH TREATMENT

TITLE:  ADVANCE DIRECTIVES AND DECLARATION FOR MENTAL HEATLH TREATMENT

DEFINITIONS:

Advance Directive: Written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when a Member is incapacitated.

Adult: A Member who is 18 years of age or older, who has been adjudicated an emancipated minor or who is married.

Declaration for Mental Health Treatment: A legal document that allows the Member to make decisions about future mental health care in case they are unable to make their own care decisions.

Health Care: Diagnosis, treatment or care of disease, injury and congenital or degenerative conditions, including the use, maintenance, withdrawal or withholding of life-sustaining procedures and the use, maintenance, withdrawal or withholding of artificially administered nutrition and hydration.

Health Care Decision: Consent, refusal of consent or withholding or withdrawal of consent to health care, including decisions regarding admission to or discharge from a health care  facility.

Health Care Representative: An adult given medical power of attorney to make health care decisions on the Member's behalf.

Incapacitation: Inability of the Member, in the opinion of the court in a proceeding to appoint or confirm authority of a Health Care Representative, or in the opinion of the Member's attending physician, to make and communicate health care decisions to health care  providers.

Member: An Oregon Health Plan client assigned to Health Share of  Oregon.

Risk Accepting Entity (RAE):  An entity that holds a fully capitated contract with Health Share of Oregon  to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE:

Health Share of Oregon (Health Share) recognizes the right of Members to be informed about medical care and to consent to, or refuse, treatment. Health Share also recognizes Members' rights to make health care decisions in advance, thus ensuring their treatment wishes will be carried out whether or not they are capable of speaking for themselves.

POLICY:

I. Members or their assigned Health Care Representative are assisted in completing advance planning documents including an Advanced Directive or Declaration for Mental Health Treatment.

  1. Information is provided by Health Share to  Members regarding advanced planning,  including:
    1. The Member's rights under Oregon Law including their right to accept or refuse mental, dental, medical or surgical treatment  and the right to  formulate, at the Member's   option, an Advance Healthcare  Directive or Declaration for  Mental Health  Treatment.
    2. Notification that whether or not the Member executes  an Advance Healthcare   Directive or a Declaration for Mental Health Treatment will have no effect on provision  of health care services, and they will not be discriminated against in any  way.
    3. The process for a Member to request a copy of the Advance Healthcare Directive or Declaration  for  Mental Health Treatment.
    4. Notification that should the Member be incapacitated at the time of initial Health Share enrollment and not able to receive information (due to the incapacitating condition or mental disorder) or articulate whether or not he or she has executed an Advance Directive or Declaration for Mental Health Treatment, the physical or mental Health RAE may give information to the Member's family in accordance with State law.
    5. Existing Advance Directives or Declarations for Mental Health Treatment may be reviewed and amended at the Member's   request.
       
  2. RAEs are required to inform providers of their responsibilities regarding Advance Directives and Declarations for Mental Health Treatment. This includes the requirement that physician offices should ask adult Members if they have completed an Advance Directive and mental health providers should ask adult Members if they have completed a Declaration for Mental Health Treatment. Documentation of the existence of advanced planning documents should be prominently displayed in the Member's clinical record.
     
  3.  RAEs are required to educate and train staff regarding Members' rights to complete  an Advance Directive  or Declaration  for Mental Health Treatment.

PROCEDURE:

  1. Health Share Members receive information on how to obtain an Advance Directive in the Health Share of Oregon Member handbook. Members receive a handbook upon initial enrollment or at their request. The handbook is also available on the Health Share website. The handbook describes the rights of the member, including information about how to obtain an Advance Directive or Declaration for Mental Health Treatment and how to  file a complaint with the   Oregon Board of Medical Examiners if the advance directive has not been  followed.
     
  2. Information regarding Advance Directives and Declaration for Mental Health Treatment may also be provided to Members through RAE newsletters, provider offices, hospitals, or case managers.
     
  3. If a Member is unable to  receive advance planning information due to Incapacitation  or has executed an Advance Directive or Declaration for Mental Health Treatment, information regarding advanced planning, may be provided to the Health Care Representative in the same manner in which a Member would receive the information. If the Member's incapacitated state resolves, the information  will be provided directly to the Member  at that time.
     
  4.  Members and authorized Health Care Representatives may file a complaint if a health care provider has not followed an Advance Directive or Declaration for Mental Health Treatment. Information on how to file Advance Directive complaints with the State Survey and Certification office can be obtained  from:

Health Care Regulation and Quality Improvement Office of Community Health and Health Planning Oregon  Health Authority

800 NE Oregon Street, Suite 305

Portland, OR 97232

971-673-0546; fax 971-673-0556

REFERENCES:

Health Plan Services Contract

Oregon Revised Statute 127.505 – 127.995

42 CFR 417


QUAL-07 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT PROGRAM

 

TITLE:  QUALITY ASSURANCE AND PERFORMANCE  IMPROVEMENT  PROGRAM

DEFINITIONS

Health Plan Services Contract: Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

Member: An Oregon Health Plan client assigned to Health Share of Oregon.

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE

To describe how Health Share of Oregon {Health Share) identifies the goals, objectives and intended outcomes for the Quality Assurance and Performance Improvement {QAPI) program, setting the structure for and guiding an annual work plan that addresses quality assurance and ongoing improvement  of services provided to Members.

POLICY

  1. The Quality Assurance and Performance Improvement (QAPI) program provides a framework to establish a planned, systematic and comprehensive approach for assessing the quality and appropriateness of services provided to Members, and to identify opportunities for   improvement.
     
  2. Health Share develops and implements the QAPI program in accordance with 42 CFR 438.240 and consistent with the requirements of the Health Plan Services Contract. The QAPI program is implemented largely through the aligned efforts of the RAEs and delivery system
  3. The goals of the QAPI program include:
  1. Continuously improving the quality, appropriateness, availability, accessibility, coordination and continuity of health care services across the continuum of covered benefits
  2. Identifying and measuring quality and performance outcomes
  3. Ensuring continual high level Member satisfaction and access to culturally and linguistically appropriate  care
  4. Ensuring the achievement of the statewide quality measures adopted by the Metrics and Scoring Committee
  5. Monitoring the quality improvement and quality assurance functions delegated to RAEs

 

  1. An annual work plan is developed to implement the QAPI program and identifies each project and the goal of the project with enough detail to demonstrate its connection to the quality and performance improvement strategy.
  1. Components of the QAPI program include but are not limited  to:
    • Health information systems that collect, analyze, integrate and report data to assist in the identification of goals and objectives of the QAPI  program
    • Implementation of performance improvement projects designed to achieve improvements in health outcomes of Members, through ongoing interventions and measurements
    • A process to evaluate and monitor ongoing performance on outcome and quality measures adopted by the Oregon Health Authority
    • A process to evaluate and monitor ongoing performance of RAEs related to quality and performance  improvement

 

  1. RAEs are required to assist in the development and implementation of the QAPI program. RAEs are required to implement quality assurance and improvement measures that are developed by Health Share. In addition, each RAEs shall have its own QAPI program which include an annual review and contains measures for demonstrating the methods and means by which the RAE carries out the performance improvement projects that are developed by Health Share's QAPI program.
     
  2. Health Share conducts an annual review of the impact and effectiveness of its QAPI program, and revises the program as necessary, and monitors the RAEs compliance with the QAPI program and work plan.

REFERENCES:

Health Plan Services Contract 42 CFR 438.240

OAR 410-141-3200

Health Share Delegated Functions and Oversight policy

Department: Quality

Author : Barbara Carey RN CPHQ

Effective Date(s): January 2016

Review Frequency: Every 2 years

Revision Date(s):

 


QUAL-08 SYSTEM OF CARE/WRAPAROUND INITIATIVE

TITLE: SYSTEM OF CARE/WRAPAROUND INITIATIVE

DEFINITIONS:

Health Plan Services Contract (CCO Contract): Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

Member: An Oregon Health Plan client assigned to Health Share of Oregon.

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE:

To ensure that Wraparound is implemented consistently and in a standardized manner by each of Health Share of Oregon's (Health Share} Behavioral Health Risk Accepting Entities (RAE}.

To ensure that Wraparound coordination provided to Members is family driven, youth guided, community-based, culturally and linguistically competent, multi-systemic, comprehensive, well­ coordinated, outcome driven and provided in the least restrictive setting possible.

To ensure active family and youth voice at all levels of Wraparound and provide a forum to resolve conflicts that arise within the Wraparound   team.

POLICY:

  1. System of Care values and principles and Wraparound practices will guide program implementation and service delivery for youth and family participating in the Wraparound Initiative.

 

  1. The core values of Systems of Care are:
    • Family driven and youth guided, with the strengths and needs of the child and family determining the types and mix of services and supports provided.
    • Community based, with the locus of services as well as system management resting within a supportive, adaptive infrastructure of structures, processes, and relationships at the community  level.
    • Culturally and linguistically competent, with agencies, programs, and services that reflect the cultural, racial, ethnic, and linguistic differences of the populations they serve to facilitate access to and utilization of appropriate services and supports, and to eliminate disparities in care.
  1. Wraparound refers to a definable, team-based planning process for youth Members with complex needs and multiple system involvement, who may have complex behavioral health needs. The Wraparound Initiative is "hosted" by the behavioral health system, however Wraparound is not solely for youth with complex or acute behavioral health needs. Wraparound results in a unique set of community services, and services and supports individualized for the youth and family to achieve a set of positive outcomes.

 

  1. Health Share delegates implementation of the Wraparound Initiative to its Behavioral Health RAEs, and will ensure provision of a fidelity Wraparound process to Member youth and families by the RAEs .
PROCEDURE:
  1. Each Behavioral Health RAE employs Wraparound care coordinators who have caseloads of 15 or fewer youth and families, and are trained in the Wraparound model.
     
  2. Workforce development provided to Wraparound care coordinators should include, but not be limited to, the following elements of Wraparound:
    • Wraparound team meeting facilitation skills
    • Family and youth driven care
    • Utilizing family partners
    • Phases of Wraparound teams
    • Conducting Strengths and Needs Assessments
    • Developing and using natural supports
    • Working with cross-system mandates
    • Cultural and linguistic competence
    • Engaging transition-aged youth
       
  3. Upon meeting criteria  for Wraparound,  youth and their families receive  an orientation packet with information about the program, services, philosophy and expectations. The assigned Wraparound care coordinator  reviews these materials with the   family.
     
  4. When a youth is found eligible for Wraparound care coordination by the Wraparound Review Committee, a Wraparound Team is established. The Wraparound Team consists of the youth, family members, natural supports identified by the family, youth and family partners,  community agencies and partners, providers and the assigned care  coordinator.
     
  5. The Wraparound Team is responsible for developing an individualized and strengths-based service coordination plan, also called a Wraparound Plan. Goals and services identified by the team should be family-centered, with the objectives of maintaining or reintegrating the youth into the home and community, improving or reducing system involvement, and/or treatment in lower levels of care. The care coordinator monitors implementation of the Service Coordination Plan and progress toward goals through the Wraparound Team meetings.
     
  6. A transition plan will be developed by the Wraparound Team when there is agreement that the youth and family are ready to  transition from  Wraparound.
  1. When there is disagreement within a Wraparound Team regarding the service coordination plan and/or the services needed by the youth and family that is not able to be resolved at the team level, the case can be brought to an ad hoc supervisory group, a Practice Workgroup, or a similar structure within the Behavioral Health RAE for problem resolution. Health Share members or their representatives may file a grievance or appeal a Notice of Action when there is a disagreement that cannot be resolved.
     
  2. All Wraparound care coordination services are youth and family centered, culturally and linguistically competent and developmentally appropriate based on the youth's age and current level of functioning.

 

Department: CCO Operations

Author: Deborah Friedman, Chief Operating Officer

Effective Date(s): November 2014

Review Frequency: Annually

Revision Date(s):  November 2015

 


QUAL-09 – PROVIDER APPEAL AND ADMINISTRATIVE REVIEW PROCESS

TITLE: PROVIDER APPEAL AND ADMINISTRATIVE REVIEW PROCESS

DEFINITIONS:

Delegated Entity: An entity with which Health Share has entered into a written agreement to perform certain functions required under, or governed by, the Health Plan Services Contract, federal and/or state regulations that would otherwise be the responsibility of Health Share.

Provider: An individual, facility, institution, corporate entity, or other organization that supplies  health services or items, also termed a rendering provider, or bills, obligates and receives reimbursement  on behalf  of  a rendering provider, also termed  a billing provider.

PURPOSE:

To describe the process by which providers may appeal adverse decisions to Health Share of Oregon (Health Share) in relation to health care services provided to Health Share members in accordance with Oregon Administrative Rule 410-120-1560 Provider Appeals.

POLICY:

I.               Providers have the right to appeal a decision made by a Delegated Entity inwhich the Provider is directly adversely affected.

JI.     All Provider appeals are reviewed first by the Delegated Entity that made  the adverse determination. Final  determination  of the appeal is the responsibility of Health   Share.

Ill.     All Provider appeals where the Delegated Entity upholds their denial will be sent for external review.

IV.              All Provider appeals where the denial is upheld by the external review organization   will be considered upheld by Health Share of Oregon .

PROCEDURE:

  1. Providers must submit appeals within 180 calendar days of the initial determination to the Delegated Entity that made the adverse decision consistent with OAR 410-120-1560 to 410- 120-1580 . The review of the appeal by the Delegated Entity shall be completed within 20 calendar days of receipt.

 

  1. The burden of presenting evidence to support an appeal rests on the Provider. The Delegated Entity has no obligation to request or review additional documentation or evidence.
  1. If the original denial is overturned (approved) on review of the appeal, the Delegated Entity shall provide a written notice of appeal resolution to the Provider and make arrangements for  immediate payment of the claim.
     
  2. If upon review by the Delegated Entity's clinical director, the decision is made to uphold the denial, the following steps apply, based on clinical or non-clinical determinations:
    1. If the denial is non-clinical (diagnosis and treatment do not pair, diagnosis is not funded according to the Oregon Health Plan Prioritized List, or no Prior Authorization was obtained when required) the Delegated Entity will send the provider a letter with their determination. The Delegated Entity will send the file including the Provider appeal request and Delegated Entity's appeal resolution letters to Health Share of Oregon for review and determination.
       
    2. If the denial is a clinical determination (diagnosis and treatment pair on a funded line, but clinical criteria for are not met, formulary criteria is not met, or the determination is that the requested services are not medically appropriate or necessary), the Delegated Entity shall send the file to an external review organization for a decision. The Delegated Entity shall request that the determination be based on plan criteria and the national/community standard
      .
    3. If the denial is upheld by the external review organization, the Delegated Entity shall submit the appeal and all documentation  relating to  the appeal, including the determination, to Health Share at : [email protected] on the same day the determination  is received.

 

  1. Health Share shall review the Provider appeal within 14 calendar days of receipt of the file from the Delegated Entity.
    1. If Health Share overturns the Delegated Entity's adverse determination, Health Share will provide written notice to both the Delegated Entity and the Provider. The Delegated Entity shall make arrangements for immediate payment of the claim without resubmission by the Provider.

 

  1. If Health Share agrees with the Delegate Entity's decision to uphold the original denial decision Health Share will provide a final written notice of determination to both the Provider and the Delegated Entity. The notice shall include form OHP 3085 for submission to the Oregon Health Authority, Health Services Division for a Provider Administrative Review.
     
  2. The Provider may file a request for an administrative review with the Oregon Health Authority, Health Services Division within 30 calendar days of receipt of notification from Health Share ofthe decision to uphold the denial decisio n. Requests for administrative review to the Oregon Health Authority shall be limited to issues related to the scope of coverage and authorization of services under the Oregon Health Plan, including whether services are a covered benefit. The administrative review process does not include Health Share or the Delegated Entity's payment or reimbursement amounts.

 

Ill.             This policy does not apply to contract administration issues that may arise between the Delegated Entity and the Provider, or Health Share and the Provider. Those issues shall be governed by the terms of the applicable contract between the parties.

REFERENCES:

Oregon Administrative  Rules 410-120-1560, 1570, 1580

Department: Compliance and Quality Assurance

Author: Barbara Carey RN CPHQ, Senior Manager, Compliance and Quality Assurance

 

Effective Date(s): July 2016

Review Frequency: Every 2 years

Revision Date(s): October 2016

 


QUAL-10 ACCESS TO CARE

TITLE: ACCESS TO CARE DEFINITION:

Health Plan Services Contract: Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

Member: An Oregon Health Plan client assigned to Health Share of Oregon.

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE:

To ensure all Health Share of Oregon (Health Share) Members have an ongoing source of primary physical health care, and access to dental, mental health and substance use disorders care appropriate to the Members' needs.

 

To ensure all services provided to Members are culturally and linguistically appropriate, geographically available as close as possible to where Members reside, and to the extent necessary and available, offered in nontraditional settings that are accessible to families, diverse communities and underserved populations .

POLICY:

  1. Health Share requires that each RAE maintain a provider network that meets standards of timely access to care and services, taking into account the urgency of the need for services in accordance with the requirements of the Health Plan Services Contract and Oregon Administrative Rules. RAEs shall develop a provider network that delivers access to high quality care, that is geographically dispersed, that assures access to integrated and coordinated care provided in linguistically and culturally appropriate settings, and that includes access to a primary care team that is responsible for coordination of Members' care.
     
  2. RAEs are responsible for the development and implementation of an access plan that establishes and monitors access to all covered services, including access to urgent and emergent care including post-stabilization services; determines delivery system capacity for their provider network; manages risk in times of reduced participating provider capacity; identifies populations in need of interpreter services and populations in need of accommodation under the Americans with Disabilities Act.
     
  3.   Behavioral health RAEs are responsible for an emergency response system of services needed to respond to mental health crises, including but not limited to a crisis hotline, mobile crisis team, walk-in/drop-off crisis center and respite or short-term stabilization.
  1. Dental health RAEs are responsible for ensuring Members have access to emergency dental services and urgent care services for emergency dental conditions.
     
  2. RAEs are required to monitor appointment accessibility and after-hours access within their provider networks to ensure Members have access to appropriate clinical care 24 hours a day, 7 days a week.
     
  3. RAEs shall comply with the requirements of Title II of the Americans with Disabilities Act and Title VI of the Civil Rights Act by assuring communication and delivery of covered services to Members who have difficulty communicating due to a disability, or limited English  proficiency, or diverse cultural and ethnic backgrounds. RAE shall maintain written policies and procedures regarding accessibility of services, including provision of certified or   qualified interpreter services, and provision of coordinated services which are culturally appropriate.
     
  4. RAEs shall regularly track Member utilization of urgent and emergent care and take action to reduce and improve the appropriate utilization of these services through actions including but not limited to:
    • Individual counseling with the  member
    • Education of members regarding appropriate access to the following services:
      •  Emergency Rooms
      • Dental care providers.
      • Behavioral health providers
      • Patient Centered Primary Care Home or primary care provider
      • Non-traditional health care workers
      • Walk in clinics
      • Urgent care centers
    • Implementation of innovative strategies to decrease unnecessary utilization.

 

  1. RAEs are responsible for implementing a monitoring and reporting system that   demonstrates Members have equal access to covered services, including routine, urgent and emergent services in accordance with the Health Plan Services Contract.
     
  2. RAEs shall provide Members with access to a second opinion from a qualified provider to determine medically appropriate services. If RAE cannot arrange for a second opinion from  a provider participating in their network, RAE shall arrange for the Member to obtain the second opinion  from a non-participating provider  at no cost to  the Member.
     
  3. If a RAE is unable to provide necessary services to Members within its existing provider network, RAE shall cover those services out of network for the Member for as long as RAE is unable to  provide  them within network.

REFERENCES:

Health Plan Services Contract

OAR 410-141-3120, 3140, 3160, 3220

OAR 410-123  -1000  through 410-123-1640

 

Department: Quality Assurance

Author: Barbara Carey, Compliance and Quality Assurance Manager

Effective Date(s): July 2012

Review Frequency: Every 2 years

Revision Date(s): July 2013, July 2015, January 2016, July 2016

 


UM-01 UTILIZATION MANAGEMENT

TITLE: UTILIZATION MANAGEMENT

DEFINITIONS:

Covered Services: Medically appropriate health services described in ORS Chapter 414 and applicable administrative rules that the Legislature funds, based on the Prioritized List of Health Services.

Health Plan Services Contract: Contract entered into between Health Share of Oregon and the Oregon Health Authority  pertaining to  the  administration of the Oregon Health Plan Medicaid  program.

Member: An Oregon Health plan client assigned to Health Share of Oregon.

Prioritized List of Health Services: The listing of condition and treatment pairs developed by the Health Evidence Review Commission for the purpose of administering the Oregon Health Plan .

Risk Accepting Entities (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE:

To ensure an effective and efficient health care delivery system serving Health Share of Oregon {Health Share) Members, and the appropriate utilization of services and allocation of resources by Risk Accepting Entities (RAE), which includes the evaluation of both potential overutilization and underutilization.

To ensure that utilization review decisions by RAEs regarding Health Share Members are made in a fair, impartial and consistent  manner.

I. Health Share requires that each RAE develop and implement a utilization management program that includes the collection, assessment and monitoring of data that pertains to Covered Services available to Health Share Members. Utilization management program activities should include the evaluation of the appropriateness of clinical services and treatment, and encourage the highest quality care.

11. Utilization management includes retrospective review of Covered Services already rendered or already incurred costs and the use of predictive modeling to identify individuals or populations for disease management or care management programs.

  1. An effective utilization management  program achieves the  following  objectives:
    • Facilitates the delivery of health care services in the setting most appropriate to the Member's needs;
    • Monitors, evaluates and improves continuity and coordination of care across physical, behavioral  and oral health;
    • Identifies specific services that are over- or under-utilized and develops appropriate responses to these findings;
    • Identifies potential quality of care issues which may require further review;
  • Reduces health care costs through maximizing use of prevention, population health and care management strategies;
  • Assists in the promotion and maintenance of optimally achievable quality of care;   and
  • Guards against fraud, waste and abuse, and ensures appropriate use of Medicaid funds

 

  1. A component of a utilization management program is utilization review, the process by which determinations are made as to whether a requested Covered Service is clinically appropriate and necessary.
    1. Utilization review includes prospective review of proposed Covered Services; concurrent review of ongoing services; disease management; and care management.
    2. Utilization determinations are to be based on practice guidelines that incorporate valid and reliable clinical evidence or the consensus of health care professionals in the particular field; are adopted in consultation with contracting health care professionals; and are reviewed and updated periodically as  appropriate.
    3. Authorization decisions are to be made consistent with the timelines and requirements in the Code of Federal Regulations, Health Plan Services Contract and Oregon Administrative Rules.
    4. Utilization review activities should take into consideration that Medicaid recipients  are an at-risk population whose biopsychosocial and economic circumstances increase the risk of harm, and that special interventions relying on non-traditional approaches  may be required to meet the unique needs of the   member.
    5. All services provided to Health Share members must be medically appropriate and medically necessary, and the presenting diagnosis and proposed treatment must qualify as a covered condition-treatment pair on the Oregon Health Plan Prioritized List of Health Services.
    6. Authorized services must be sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished and include the following:
      1. The prevention, diagnosis and treatment of health impairments;
      2. The ability to achieve age-appropriate growth and development;   and
      3. The ability to attain, maintain or regain functional capacity.
         
  2. Health Share does not provide incentives to RAEs, provider networks, employees or other utilization reviewers to inappropriately deny, limit or discontinue medically appropriate  services  to any Member, nor does it allow RAEs to provide such incentives.

REFERENCES:

42 CFR 438.210

Health Plan Services Contract OAR 410-141-0480,  0500, 0520

Department: Compliance and Quality Assurance

Author: Barbara Carey, Manager, Compliance and Quality Assurance

Effective Date(s): August  2013

Review Frequency: Every 2 years

Revision Date(s):  December  2015, July 2016

 


UM-02 INTEGRATED CARE MANAGEMENT

TITLE: INTEGRATED CARE MANAGEMENT

DEFINITIONS:

Member:  An Oregon Health Plan client assigned to Health Share of Oregon.

Risk Accepting Entity (RAE):  An entity that holds a fully capitated contract with Health Share of Oregon  to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE:

To ensure the development and implementation of a continuum of care for Health Share of Oregon (Health Share) Members that integrates mental health, substance use disorder, oral health and physical health services to  achieve the objectives of whole person, integrated care.

POLICY:

  1. Health Share acknowledges that integrated care spans a continuum ranging from communication to coordination to co-management to co-location to fully integrated team-based care in medical or behavioral health homes or patient centered primary care homes.
     
  2. Health Share requires RAEs to participate in and support integration activities such as, but not limited to:
    1. Communication  and coordination between behavioral, dental and physical health RAEs;
    2. Development of infrastructure support for sharing information, coordinating care and monitoring results, including participation in Health Share sponsored care management collaboratives;
    3. Use of screening tools, treatment standards and guidelines that support integration;
    4. Support of a culture of collaboration with Health Share, and with behavioral, dental and physical health RAEs; and
    5. Implementation of a system of care approach that is member-driven, community-based and culturally and linguistically appropriate.

Ill.       In support of an integrated model of care, RAEs shall provide the following elements  of care management:

  1. Support for an appropriate flow of information across behavioral, dental and physical health RAEs and provider networks;
  2. Implementation of person-centered care coordination and treatment planning and a standardized approach to effective transition planning;
  3. Use of culturally and linguistically appropriate tools and evidence-based and innovative strategies to ensure coordinated and integrated person-centered care, including individualized care plans reflecting Member preferences and goals to ensure engagement and satisfaction; and
  4. Support for contracted providers in developing the tools and skills necessary to communicate  in a linguistically and culturally  appropriate  manner with Members.
  1. RAEs shall ensure member access to coordinated care services that provide effective wellness and prevention services, a Member- and family-centered approach to all aspects of care; and an emphasis on whole-person care in order to comprehensively address Members' physical, behavioral and oral health care needs.
     
  2. RAEs shall ensure coordination of the following elements of an integrated system of care:
    1. Outpatient mental health and substance use disorder treatment coordinated with physical health care services;
    2. Coordination with patient-centered primary care and transition to the most appropriate, independent and integrated care setting, including home and community-based or palliative care settings; and
    3. Adequate, timely and appropriate access to specialty and hospital services.
       
  3. RAEs shall ensure Members have access to a consistent and stable relationship with a primary care team, behavioral or medical home, or patient centered primary care home responsible for comprehensive care management and transitions, and provide assistance to Members in  navigating the health care delivery system and in accessing community and social support services and resources

REFERENCES:

Health Plan Services Contract

Oregon Administrative Rule 410-141-3160

Department: Utilization Management

Author: Barbara Carey, Senior Manager, Compliance and Quality Assurance

Effective Date(s):  July 2016

Review  Frequency: Every 2 years

Revision Date(s):

 


UM-03 : INTENSIVE CARE COORDINATION FOR SPECIAL HEALTH MEMBERS

TITLE: INTENSIVE CARE COORDINATION FOR SPECIAL HEALTH MEMBERS

DEFINITIONS:

Care Coordination: A collaborative process to facilitate the appropriate delivery of health care services, often managed by the exchange of information among participants responsible for different aspects of care.

Intensive Case Management (ICM): A specialized case management service provided to Members identified as aged, blind or disabled, or  who have complex medical needs, including early identification   of members eligible for ICM services; assistance to ensure timely access to providers and services; coordination with providers to ensure consideration is given to unique needs in treatment planning; assistance to providers with coordination of services and discharge planning; and coordinating necessary and appropriate linkage of community support and social service systems with medical care  systems.

Member:   An Oregon Health Plan client assigned to  Health Share of   Oregon.

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

Special Health Care Needs: Members who have high health care needs, multiple chronic conditions, mental illness or substance use disorders and either have functional disabilities, or live with health or social conditions that place them at risk of  developing functional  disabilities.

PURPOSE:

To ensure that Health Share of Oregon (Health Share) Members with Special Health Care Needs receive timely and effective care coordination services from the Risk Accepting Entities (RAEs) to which they are assigned, and receive health services necessary to maintain physical, behavioral and oral health and to prevent or mitigate the  effects of  functional  disabilities.

To ensure coordination between behavioral, dental and physical health RAEs for Members with Special Health Care Needs through joint care planning and delivery of intensive care coordination  services.

POLICY:

 
  1. RAEs shall make intensive Care Coordination services available to Members with Special Health Care Needs and Members with severe and persistent behavioral health issues receiving home and community-based services under the Oregon Health Authority's 1915(i) State Plan Amendment and the Health Plan Services Contract.
     
  2. RAEs shall ensure that Members have access to ICM, either directly through the RAE or through arrangements with health care providers, to  improve the quality of care and   outcomes.
     
  3. The Member, Member's representative, provider, other medical personnel serving the Member, or a case manager may request intensive care coordination services. RAEs shall respond to requests for intensive Care Coordination services with an initial response by the next business day following the request.      
  1. RAEs shall actively engage Members in accessing and managing appropriate preventive, remedial and supportive care and services to reduce the use of avoidable emergency room visits and hospital admissions.
     
  2. RAEs shall have a standing referral process for direct access to specialists, and for identifying, assessing and producing a treatment plan, for each Member identified has having a special health care need.
     
  3. RAEs shall have an established process for connecting intensive Care Coordination staff with those of other RAEs, for purposes of joint planning and care coordination to reduce unnecessary duplication of services and to achieve optimal outcomes for  Members.

REFERENCES:

 

Health Plan Services Contract

Oregon Administrative Rules 410-141-0300, 3170

Date

 

Department:   Quality Assurance

Author: Barbara Carey, Senior Manager, Compliance and Quality Assurance

Effective Date(s): June 2016

Review Frequency: Every 2 years

Revision Date(s):

 


UM-04 TITLE: MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES

TITLE: MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES

DEFINITIONS:

Health Plan Services Contract (CCO Contract): Contract entered into between Health Share of Oregon and the Oregon Health Authority pertaining to the administration of the Oregon Health Plan Medicaid program.

Member:  An Oregon Health Plan client assigned to Health Share of Oregon.

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE:

To describe Health Share of Oregon's (Health Share) policies related to provision of mental health and substance use disorder services to Members, and to identify those functions delegated to Behavioral Health Risk Accepting Entities for assessment, care planning, service delivery and system monitoring.

POLICY:

  1. Health Share promotes resilience in and recovery of its Members experiencing mental health conditions. We support a system of care that promotes and sustains a person's recovery by identifying and building upon the strengths and competencies within the individual to assist them in achieving a meaningful  life within their   community.
     
  2. Members are to be served in the most normative, least restrictive, least intrusive and most cost­ effective level of care appropriate to their diagnosis and symptoms, degree of impairment, level of functioning, treatment history, individual voice and choice, and extent of family and community supports.
  3.  Assessment and care planning should incorporate the principles of resilience and recovery; be strengths-based, individualized and person-centered; promote access and engagement; encourage family participation; support continuity of care; respect the rights of the individual and empower the individual to make choices regarding their care; and use natural supports as the norm rather than the exception.
     
  4. Service delivery shall be age and gender appropriate, culturally competent, evidence-based and trauma-informed.
     
  5. Behavioral Health RAEs shall provide for mental health emergency and urgent care services, including post-stabilization care services for Members on a 24-hour, 7-day-per-week basis, and shalt establish policies, procedures and monitoring systems to ensure the emergency response system includes the necessary array of services to respond to mental health crises.
  1. Behavioral Health RAEs shall coordinate with the Community Mental Health Program in their community regarding involuntary psychiatric care for adult Members, including alternatives to such care when appropriate.
     
  2. Behavioral Health RAEs shall develop and implement comprehensive, person-centered, individualized, integrated, community-based and cost-effective mental health and substance use disorder services for child and adult Members.
     
  3. Behavioral Health RAEs shall develop policies and procedures to ensure children, especially those in custody of the State of Oregon, Department of Human Services, who need or are being considered for psychotropic medications receive medications that are for medically accepted indications. Behavioral Health RAEs shall prioritize service coordination and the provision of other services and supports for these children.
     
  4. Behavioral Health RAEs shall comply with all requirements of the Health Plan Services Contract, inclusive of the Oregon Administrative Rules and Oregon Revised Statutes, in providing for and managing the provision of covered mental health and substance use disorders services to Members.

REFERENCES:

Health Plan Services Contract

42 CFR 438.114

Oregon  Administrative Rule 410-141-3140

Oregon Revised Statutes 426.130

Department: Quality Assurance

Author: Barbara Carey, Senior Manager, Compliance and Quality Assurance

Effective Date(s): June 2016

Review Frequency: Every 2 years

Revision Date(s):

 


UM-05 OUT OF AREA COORDINATION

TITLE: OUT OF AREA COORDINATION

DEFINITIONS:

Member:  An Oregon Health Plan client assigned to Health Share of Oregon.

Risk Accepting Entity (RAE): An entity that holds a fully capitated contract with Health Share of Oregon to provide services as defined in the Health Plan Services Contract for Coordinated Care Organizations between the Oregon Health Authority and Health Share of  Oregon.

PURPOSE:

To ensure that Health Share of Oregon (Health Share) Members have access to and receive the necessary primary care, specialty care, mental health, substance use disorder and oral care services whether the member receives those services within or outside of Health Share's service  area.

To ensure coordination between the behavioral, dental and physical RAEs for Members receiving services temporarily outside the Health Share service area.

To ensure that each RAE pays for medically necessary services out of area regardless of any formal arrangement  with providers and consistent  with Oregon Health Authority  policies.

POLICY:

  1. Health Share Members may require services that are not available within Health Share's service area. While a Member is temporarily receiving services outside the Health Share service area, each RAE to which the Member is assigned is responsible for ensuring the Member receives all necessary services and that providers are compensated for those services.
     
  2. Out of area coordination is required for children and youth who are receiving behavioral rehabilitation services; children, youth and adults receiving psychiatric residential treatment services; and youth and adults receiving alcohol and drug residential services.
     
  3. When Health Share becomes aware of a Member receiving services out  of area, it  will notify each RAE to which the member is assigned. If a RAE becomes aware of a Member being out of area, it will notify Health Share by completing the Member Out of Area Notification form (Attachment  1).
     
  4. When a child or youth is receiving Behavioral Rehabilitation Services, the Department of Human Services submits a Form 92 to Health Share which distributes the Form to the appropriate RAEs.
     
  5. Each RAE is responsible for arranging for necessary care and making payment arrangements, either by contract or through a non-participating provider agreement. A RAE may not  decline  to  reimburse a provider simply because that provider is not  in their  network.
  1. At time of discharge from the treatment setting, the RAE that has been primarily coordinating the care ofthe Member will notify Health Share that the Member has discharged and returned to Health Share's service area. Health Share will notify the other RAEs ofthe Member's return to Health Share's service area.
     
  2. Should the Member choose to remain in the community in which they have been receiving treatment services, Health Share will work with the Oregon Health Authority to transfer enrollment to a Coordinated Care Organization serving the area in which they now  reside.
     
  3. If a RAE contracts with a third party for benefit and utilization management, the RAE is responsible  for ensuring that the third party complies fully with this   policy.

REFERENCES

Health Plan Services Contract

Oregon Administrative Rule 410-141-3066(6)

Department: Quality Assurance

Author: Barbara Carey, Senior Manager, Compliance and Quality Assurance

Effective Date(s): July 2016

Review Frequency: Every 2 years

Revision Date(s):