Care Improvement Plus! This provider manual

The Chief Medical Officer (CMO) and clinical leadership team are responsible for identifying appropriate
nationally recognized clinical guidelines for use in Care Improvement Plus clinical programs. All guidelines
are evidence-based so as to achieve optimum, high-quality health outcomes. The complete set of guidelines
is reviewed annually by Care Improvement Plus Medical Advisory Board comprised of community based
physicians and clinical experts.
Preventive Services Guidelines
When providers consistently offer preventive services, patients are able to maintain or improve their health,
while avoiding more costly and invasive medical procedures. With prevention, everybody wins. These
guidelines are evidence-based, offering only recommendations that are well supported in the medical
literature. Every year the guidelines are reviewed and updated as needed.
Health Plan Employer Data and Information Set (HEDIS)
Care Improvement Plus is required by CMS to submit data annually for HEDIS reporting that measures the
quality of clinical care provided to our members and health plan performance. At various times throughout
the year and especially during annual HEDIS preparation, Care Improvement Plus may request medical
files, including lab results, blood pressures and other clinical data which will be reviewed for adherence
with HEDIS clinical performance indicators. The HEDIS quality indicators may be viewed on the National
Committee for Quality Assurance website at: www.ncqa.org.
Medical Records
Care Improvement Plus requires all affiliated providers to abide by the medical record standards established
by Care Improvement Plus policy as well as state and federal regulations. These standards are based on the
requirements of NCQA, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and other
regulatory bodies. Care Improvement Plus’s Quality Improvement department routinely audits provider
documentation for medical record-keeping practices during the credentialing process and re-credentialing
process, when applicable.
Model of Care Training
As a Special Needs Plan, Care Improvement Plus must implement a model of care consistent with CMS
standards. Requirements include conducting initial and annual Model of Care training for employees,
contracted personnel and the provider network to keep everyone informed about the care management
structure and revisions made based on performance improvement activities. Providers satisfy this
requirement by completing the presentation provided on our learning management system (LMS) website
and passing a short test. Instructions to access the LMS are distributed annually.
SECTION M – MEMBER RIGHTS AND RESPONSIBILITIES
Member Rights
Care Improvement Plus members have the right to understand their health conditions and to
participate in health care decisions. To ensure that members attain the maximum benefits, we
encourage members to exercise their rights, including but not limited to:
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