2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Site Visits ..................................................................................................................................... 12-3Ongoing Monitoring ...................................................................................................................... 12-44. Quality of Clinical Care ................................................................................................................. 12-45. Peer Review ................................................................................................................................. 12-46. Continuity and Care Coordination ................................................................................................. 12-57. Standards of Care ........................................................................................................................ 12-58. Service Quality Concerns ............................................................................................................. 12-59. Clinical Practice Guidelines .......................................................................................................... 12-510. Preventive Health Care Guidelines ............................................................................................... 12-511. Member Medical Records ............................................................................................................. 12-512. Integrated Care Management Program ........................................................................................ 12-613. Continuum of Care ....................................................................................................................... 12-614. Special Populations ...................................................................................................................... 12-615. Early and Periodic Screening, Diagnosis, and Treatment ............................................................. 12-716. Health Risk Assessment and Personal Health Assessments ........................................................ 12-717. Culturally Appropriate Services .................................................................................................... 12-718. Oversight of Delegated, Subcontracted, and High-Volume or Single-Source Functions ............... 12-819. Nurse Advice Line ........................................................................................................................ 12-920. Utilization Management Program ................................................................................................. 12-921. Web Resources .......................................................................................................................... 12-1022. Voice of the Customer ................................................................................................................ 12-10Survey Data ............................................................................................................................... 12-10Complaint and Inquiry Data ........................................................................................................ 12-10Qualitative Research .................................................................................................................. 12-10Service Quality Committee and Delegated Teams ..................................................................... 12-11Member and Provider Satisfaction Prioritization Processes ........................................................ 12-1123. Patient Safety Program .............................................................................................................. 12-11Objectives of the Patient Safety Program ................................................................................... 12-11Focus ......................................................................................................................................... 12-11QI Program: HEDIS ® Medical Record Data Abstraction .............................................................. 12-11Where does HEDIS data come from? ......................................................................................... 12-12How does HEDIS reporting impact the practice setting? ............................................................. 12-13How does Presbyterian use the HEDIS reporting system? ......................................................... 12-1313. Health Insurance Portability and Accountability Act ................................................................................ 13-1What Requires Your Particular Attention? .............................................................................................. 13-1Who is Legally Responsible for HIPAA Compliance?............................................................................. 13-1Which Providers Must Be HIPAA Compliant? ........................................................................................ 13-2xiv2014 Practitioner and Provider Manual - Ver. 3