Policy and Procedures Toolkit

Tapping Your Untapped Engagement Advantage
Members are increasingly demanding that the interactions they have with their health plans be timely, relevant, and convenient. In response, payers should capitalize on this opportunity by ensuring they are optimizing their existing member communication channels to be as effective as possible. This white paper explores engagement best practices from hyper-personalization to omni-channel communications that members respond to.

BEN-002-POL-Benefit Design for HPA 09-2023
Benefit Design Policy - to ensure that we comply with all requirements of health insurance issuers of both individual and group coverage in the design and provision of our benefit packages. Applies to Commercial lines of business

AlliantHealthPlans_PandP_ERM_LegalDocumentRequest
Alliant Health Plans policy for subpoena requests, outlines the process for responding to legal requests for documents containing member PHI.

AlliantHealthPlans_PandP_ERM_CyberSecurity
Alliant Health Plans policy for CyberSecurity, provides a guide of how to handle and when to report a security incident to the Company's cyber liability insurance carrier.

AlliantHealthPlans_PandP_ERM_CyberSecurity
Alliant Health Plans policy for CyberSecurity, provides a guide of how to handle and when to report a security incident to the Company's cyber liability insurance carrier.

AlliantHealthPlans_PandP_ERM_CyberSecurityMalware
Alliant Health Plans policy for CyberSecurity, provides a guide of how to handle and when to report a security incident to the Company's cyber liability insurance carrier.

AlliantHealthPlans_PandP_ERM_IncidentResponsePrivacy
Alliant Health Plans policy for Privacy, provides guidance for the implementation of workforce training on all policies, procedures, and regulations for each department who handles PHI. In accordance with HIPAA.

AlliantHealthPlans_PandP_ERM_RiskManagementPrivacy
Alliant Health Plans policy for Privacy, provides guidance for the implementation of workforce training on all policies, procedures, and regulations for each department who handles PHI. In accordance with HIPAA.

AlliantHealthPlans_PandP_ERM_WorkforceSecurity
Alliant Health Plans policy for Privacy, provides guidance for the implementation of workforce training on all policies, procedures, and regulations for each department who handles PHI. In accordance with HIPAA.

AlliantHealthPlans_PandP_ThirdPartyRelationships_BusinessAssociates
Alliant Health Plans policy for contract review, provides guidance regarding the execution of business associate contracts.

AlliantHealthPlans_PandP_ThirdPartyRelationships_ThirdPartySubrogation
Alliant Health Plans policy for third party subrogation, provides guidelines for requesting accident and injury details sustained by a member.

AlliantHealthPlans_PandP_ThirdPartyRelationships_OperationsCommCharter
Alliant Health Plans document for Operations or Business Owner Policy & Procedures, facilitates operational issues from the organization and allows for long-term strategies and policy recommendations to be formulated among directors and vice presidents.

AlliantHealthPlans_PandP_ThirdPartyRelationships_ProviderDirectory
Alliant Health Plans policy for Provider Directory Accuracy, outlines the elements and process for maintaining an online provider directory to assist members in identifying providers participating in-network.

AlliantHealthPlans_PandP_ThirdPartyRelationships_DelegationPolicies
Alliant Health Plans policy for delegated vendor oversight, with emphasis on scope of work elements audited prior and during the contractual agreement process with a vendor entity.

AlliantHealthPlans_PandP_ThirdPartyRelationships_DelegationPolicies
Alliant Health Plans policy for delegated vendor oversight, with emphasis on scope of work elements audited prior and during the contractual agreement process with a vendor entity.

AlliantHealthPlans_PandP_ThirdPartyRelationships_DelegationPolicies
Alliant Health Plans policy for delegated vendor oversight, with emphasis on scope of work elements audited prior and during the contractual agreement process with a vendor entity.

AlliantHealthPlans_PandP_ThirdPartyRelationships_DelegationPolicies
Alliant Health Plans policy for delegated vendor oversight, with emphasis on scope of work elements audited prior and during the contractual agreement process with a vendor entity.

Medical Associates Fraud Waste Abuse
Medical Associates Fraud, Waste and Abuse Compliance Policy

Medical Associates Population Health Registries Database
Medical Associates Health Plans (MAHP), Live360 Health Plan and Health Choices (HC) Population Health Registries (PHR) database allows for complete and accurate record keeping for members participating in any of our population health programs. This tool is the central database utilized by population health staff to continually monitor, manage and assist members/participants throughout their continuum of care.

Medical Associates Disease Management
Medical Associates Disease Management Program Identification and Interventions

Medical Associates Health Coach and Case Management
Medical Associates Health Coach and Case Management Program.

Medical Associates Utilization Management Review
Medical Associates Utilization Management Review Policy: requests for services requiring authorization are reviewed according to member contract or plan documents and established Health Care Services (HCS) Guidelines

Medical Associates Authorization Timeframe and Determinations
Medical Associates Authorization Timeframe and Determinations: Requests for services requiring authorization are viewed according to member contract or plan document and established Medical Associates Health Plans, Health Care Services Guidelines. These Guidelines are reviewed and approved annually.

Medical Associates Continuity and Coordination of Care
Medical Associates Continuity and Coordination of Care: Medical Associates Health Plans (MAHP) and Health Choices (HC) are committed to meeting the medical, surgical, behavioral health and other health care needs and concerns of its enrollees as well as assuring that continuity and coordination of care exists between primary care, specialty care practitioners, as well as health delivery organizations.

Medical Associates Risk Assessment
Medical Associates Risk Assessment: Risk analysis and risk management are recognized as important components of the Medical Associates Health Plans (MAHP)Compliance Program. It is the policy of MAHP to conduct regular assessment of critical risks to the business

Medical Associates Monitoring of HIPAA Standards
Medical Associates Monitoring and Auditing of employee workstations for compliance with HIPAA Privacy Standards.

Medical Associates Compliance Complaints and Hotline
Medical Associates Compliance Complaints and Compliance Hotline Policy.

Medical Associates Notice of Privacy Practice
Medical Associates Notice of Privacy Practice policy: To establish procedures for compliance with all laws and regulations regarding notification of privacy practices, including the Health Insurance Portability and Accountability Act (HIPAA).

Medical Associates Security Incident Response
Medical Associates Information Security Incident Response policy. (Cybersecurity)

Medical Associates Participating Provider Contract Content
Medical Associates Provider Contracting Policy: To ensure that all participating provider contracts include appropriate terms, including terms required by state and/or federal laws, for NCQA accreditation, and for maintaining MAHP standards for quality of care and service provided to members.

Medical Associates Provider Directories
Medical Associates Provider Directory Policy: Medical Associates Health Plans (MAHP) is committed to providing members an accurate listing of participating providers.

Medical Associates Appeal and Grievance Policy
Medical Associates Internal appeal of an Adverse Benefit Determination for Commercial members: To assure a timely, efficient, and compliant response to internal appeal of an Adverse Benefit Determination for members covered by a Large Group or Small Group Subscriber Agreement

Medical Associates Coordination of Benefits
Medical Associates Coordination of Benefits

NetworkHealth_PandP_ANOC_EOC
Plans must ensure the Centers for Medicare and Medicaid Services (CMS) model Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents are developed for each of its contracted Medicare Advantage plans for distribution to all members within the specific CMS required instructions and timeframes.

NetworkHealth_PandP_AppealsGrievancesComplaints
To describe the policy governing receipt, investigation, tracking, and resolution of all written appeals and grievances as well as verbal complaints received at Network Health from all commercial insured, self-insured, and Marketplace members/participants or their authorized representatives, in accordance with applicable state and federal regulations, and National Committee of Quality Assurance (NCQA) standards.

NetworkHealth_PandP_AuditingMonitoring
Network Health's compliance department will establish and maintain a plan for monitoring, auditing, and regulatory reporting to test and confirm compliance with the Centers for Medicare and Medicaid Service (CMS) and Wisconsin Office of the Commissioner of Insurance (OCI) regulations, sub-regulatory guidance, contractual agreements, and all applicable state and federal laws, as well as internal policies and procedures.

NetworkHealth_PandP_AuditingMonitoringOperations
Network Health will conduct effective auditing and monitoring of operational departments in order to identify risks including non compliance, fraud, waste and abuse to achieve and maintain operational compliance.

NetworkHealth_PandP_AvailabilityofDirectories
Network Health Plan will provide members/participants with provider directories.

NetworkHealth_PandP_BusinessContinuity
Network Health is committed to providing its stakeholders with an operational and administrative business continuity management (BCM) program, including policies, standards, risk mitigation controls, procedures and action plans. The BCM program is designed to ensure that the long-term viability of the enterprise is maintained in the event of an interruption to mission-critical/essential business operations. This document establishes the BCM program policy for Network Health, which is endorsed by Network Health's executive management team.

NetworkHealth_PandP_ClaimsReprocessing
Establish consistent guidelines for reprocessing claims under Network Health.

NetworkHealth_PandP_ClaimsSubmissions
This guideline outlines Network Health's procedure for clean claim submissions, corrected claims, and timely filing.

NetworkHealth_PandP_Coding
This policy provides the resources utilized by Network Health to ensure correct coding is applied to all claims.

NetworkHealth_PandP_CommercialDeductibleMOOP
Network Health ensures consistent application of deductible and/or out of pocket credit to reduce member's cost sharing for the Commercial lines of business (HMO, POS, OPT, IFP and SF) within the same benefit year.

NetworkHealth_PandP_CommercialPreventiveMedicine
This reimbursement policy outlines Network Health's process, for the Commercial (HMO/POS) product, when preventive medicine Evaluation and Management (E&M) services are performed on the same day as problem-oriented E&M services. This policy applies to services provided in a professional setting.

NetworkHealth_PandP_CompliancePolicyandProcedure
The compliance department of Network Health maintains a comprehensive compliance program description. The purpose of the compliance program description is to describe Network Health's commitment to preventing and detecting non-compliance and fraud, waste and abuse (FWA) with federal, state statutory, regulatory, and all other requirements related to the Government and commercial insurance programs. Network Health enhances a culture of compliance through education and open lines of communication in compliance with all Federal and State regulations.

NetworkHealth_PandP_ContinuityContinuedAccess
Network Health uses information at its disposal to facilitate continuity and coordination of member's medical and behavioral health care across its delivery system. Continued access is maintained for members affected by the termination of a practitioner or practice group.

NetworkHealth_PandP_CoordinationofBenefits
This reimbursement policy outlines Network Health's process, for all lines of business, when a member has medical insurance coverage with more than one plan.

NetworkHealth_PandP_CorrectingProviderPayments
This reimbursement policy outlines Network Health's process, for all lines of business, when correcting provider overpayments and/or underpayments related to claims audit findings. This policy is not applicable to the following: -Coordination of benefit (COB) claims -Corrected claims -Provider disputes or appeals -Subrogation claims

NetworkHealth_PandP_DelegationOversight
This policy defines the responsibility of each business owner for oversight of delegated entities as they relate to Network Health 's insurance products in providing or administering health care services for members of, including but not limited to, Medicare Part C, D or Qualified Health Plan benefits.

NetworkHealth_PandP_DisclosingtoLawEnforcement
This policy is established to ensure that Network Health safeguards the privacy of member/participant protected health information (PHI) when reporting or disclosing member/participant PHI to law enforcement officials as required or permitted by law.

NetworkHealth_PandP_DisposalandReuseofMedia
This policy provides guidance for addressing the disposal and potential re-use of data storage devices and media, including fixed and removable disk drives, CD-ROMs, backup tapes, computers, and file storage cabinets.

NetworkHealth_PandP_InpatientHospitalReadmission
This reimbursement policy outlines Network Health's process, for all lines of business, related to inpatient hospital readmissions.

NetworkHealth_PandP_ISSecurityResponse
The purpose of this policy is to establish guidelines for the identification, response, reporting, assessment, analysis, and follow-up to all suspected information security incidents. The information security response plan helps to ensure the security, confidentiality, integrity and availability of electronic information and the automated systems that contain it and the networks over which it travels.

NetworkHealth_PandP_LargeGroupCOBRA
Define Network Health's policy for employers having 20 or more employees where federal law requires continuation of health insurance coverage.

NetworkHealth_PandP_MAAnnualWellness
This reimbursement policy outlines Network Healthâ??s process, when claims are submitted for an annual wellness visit (AWV), a preventive exam, and/or an evaluation and management (E&M) exam.

NetworkHealth_PandP_MAGrievanceandAppeals
To define Network Health Insurance Corporation's (NHIC) Appeals and Grievance Process for Members who have a NHIC Medicare Advantage Policy, in accordance with the Centers for Medicare and Medicaid Services (CMS) and National Committee of Quality Assurance (NCQA) standards.

NetworkHealth_PandP_MAInpatientReadmissions
This guideline is to provide Network Health's reimbursement process related to inpatient hospital readmissions.

NetworkHealth_PandP_MASelfAdminDrugs
This reimbursement policy outlines Network Health's process, for the Medicare Advantage line of business, when self-administered drugs are provided in a facility setting.

NetworkHealth_PandP_MedicaidVerification
This policy describes the process for verifying and maintaining Special Needs Plan eligibility for all Network Health Insurance Corporation Medicare Special Needs Plan (SNP) members. NHIC is contracted as an All- Dual's Special Needs Plan with the Centers for Medicare and Medicaid (CMS).

NetworkHealth_PandP_MedicareDefaultPricing
This reimbursement policy outlines Network Health's process and payment determination, when default procedure codes are submitted for Medicare Advantage members.

NetworkHealth_PandP_MedicareMidYearChanges
Network Health Insurance Corporation (NHIC) is required to notify members at least 30 days prior to the effective date of any mid-year changes impacting their health plan coverage. Examples of mid-year changes include National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), legislative changes in benefits, formulary changes, plan rule changes or significant provider network changes.

NetworkHealth_PandP_MonitoringAuditingFWA
Network Health proactively audits and monitors all allegations and risks for potential Fraud, Waste, and Abuse (FWA) across its Medicare and Commercial products. Network Health reviews information regarding Fraud alerts and other creditable resources to ensure timely and relevant awareness of potential FWA schemes for impact, Network Health's Payment Integrity & Recovery Special Investigations Unit (SIU) monitors and conducts investigational audits associated with daily plan operations to eliminate or reduce the risk of FWA.