2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
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Quality Improvement Programimplemented (Improve), <strong>and</strong> process improvementshardwired (Control).QI Program Activities1. Availability of <strong>Provider</strong>sAvailability of providers is measured to assesssufficient numbers of primary care <strong>and</strong> specialtycare practitioners by geographic distribution <strong>and</strong> inratios of members per provider.Results are compared to established st<strong>and</strong>ards toidentify opportunities for improvement. Stateregulations determine the geographic st<strong>and</strong>ards forMedicaid.2. Accessibility of Services (AppointmentAvailability)Data CollectionData is collected, including the following:Consumer Assessment of <strong>Healthcare</strong><strong>Provider</strong>s <strong>and</strong> Systems (CAHPS ® ) results forquestions related to accessibility of servicesfor primary care, behavioral health, <strong>and</strong>specialty careMystery shopping surveys as supplementaldata to the CAHPS ® results3. Credentialing <strong>and</strong> Recredentialing<strong>Presbyterian</strong> credentials <strong>and</strong> recredentialsindividual practitioners <strong>and</strong> organizationalproviders. The credentialing program ensurescompliance with credentialing policies <strong>and</strong>procedures, NCQA st<strong>and</strong>ards, <strong>and</strong> state <strong>and</strong>federal requirements for verification of credentialsincluding but not limited to license, boardcertification, <strong>and</strong> education.Delegation<strong>Presbyterian</strong> may delegate to designated entities allor some of the credentialing responsibilities. Theperformance of the entity is monitored on anongoing basis for compliance with <strong>Presbyterian</strong>requirements <strong>and</strong> all applicable regulatory <strong>and</strong>accreditation st<strong>and</strong>ards. <strong>Presbyterian</strong> retains theright based on quality issues to approve, suspend,<strong>and</strong> terminate individual providers in situationswhere it has delegated decision-making.Performance by the delegate is evaluated inaccordance with regulatory requirements <strong>and</strong>results are reported to the Credentialing ReviewCommittee.Site VisitsSite visits are included as part of the initialcredentialing for primary care providers (PCPs),obstetrician/gynecologists, <strong>and</strong> high-volumebehavioral health specialists. Site visits are alsoperformed for organizational providers who havenot been approved by an accrediting body.Initial applicants whose site visit score is below anacceptable threshold are notified that thecredentialing process is discontinued. Applicantsmay contact <strong>Presbyterian</strong> for information about howto improve their sites <strong>and</strong> to restart thecredentialing process once the deficiencies havebeen corrected.If a provider receives two or more complaintsregarding their site within a 12-month period, a sitevisit is scheduled. If during the site visit an issue isidentified, the provider must develop a correctiveaction plan to address the deficiencies. A follow-upreview is conducted within six months to determine12-32014 <strong>Practitioner</strong> <strong>and</strong> <strong>Provider</strong> <strong>Manual</strong> - Ver. 3
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