Policy and Procedures Toolkit
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FWA360Leads Overview
FWA360Leads is a NEW user experience designed to automate the identification of leads that are of the highest value for review for potential FWAE. FWA360Leads combines the power of Artificial Intelligence (AI) and our extensive library of alerts in summary form using Natural Language Generation along with AI explanations. FWA360Leads will learn from user feedback to automatically recalibrate the feed based on AI models that learn over time both the company and individual user preferences.
FWAShield Overview
Healthcare Fraud Shield offers a fully integrated fraud, waste, and abuse (FWA) software solution platform called FWAShield. It utilizes unique and proprietary data sources to maximize Return on Investment (ROI) and achieve superior results. Our platform is deployed utilizing a Software-as-a-Service model which allows us to quickly adopt new system enhancements and fraud analytics with minimal work for our customers.
RxShield Overview
As pharmacy expenditures rise, pharmacy fraud, waste, and abuse (FWA) continue to be a prevalent issue for both commercial and government payers. RxShield® is fully integrated with PreShield®, PostShield®, QueryShield® and CaseShield®.
Health First Health Plans_PandP_Claims Processing Disputes for Timely Filing Claim Denials
Health First Health Plans Policy for processing claim disputes
Health First Health Plans_PandP_Claims Processing Disputes for Timely Filing Claim Denials
Health First Health Plans Procedure for processing claims disputes.
Related Party Agreements for Medicare Advantage and Part D Bids
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
AHP Annual Compliance Risk Assessment Questionnaire - Template
Aspire Health’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business
Risk Assessment Auditing and Monitoring
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Compliance Plan
Aspire Health Plan's policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Record Retention
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Risk Assessment, Auditing andMonitoring Compliance Policy
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Aspire Risk Assessment_2023 - Template
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Check Run Process
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Special Investigation Unit (SIU)
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Utilization Management Program Description
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business
Continuity of Care - Provider Termination
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Care Management
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Continuity of Care
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
2022-2023 Utilization Management Program Description
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business
Continuity of Care - Provider Termination
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Care Management
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Continuity of Care
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Special Investigation Unit (SIU)
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Compliance Risk Assessment Questionnaire - Template
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Risk Assessment Auditing and Monitoring
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business
Compliance Plan
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Record Retention
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Risk Assessment, Auditing And Monitoring Compliance Policy
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Aspire Risk Assessment_2023 - Templates
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Delegation Oversight
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business
New Vendor Contract Checklist
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Provider Network Credentialing Standards - CR1
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Provider Network Credentialing Committee - CR2
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Provider Network Credentialing - CR3
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Provider Network Recredentialing Cycle Length - CR4
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Provider Network Ongoing Monitoring and Interventions - CR5
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Provider Network Notification to Authorities and Practitioner Appeal Rights â?? CR 6
Aspire Health’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Standard Part C Appeal Processing
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Effectuating Overturned Appeals by the Health Plan, IRE, ALJ, the MAC, or Judicial Review
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Expedited Part C Appeal Processing
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Further Appeal Rights
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Part C Grievance Processing
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
QIO Fast-Track Appeals Of Coverage Terminations SNF, HHA or CORF
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Reopening & Revising Determinations And Decisions
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
A&G Standards for communicating decisions and paymentss
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
Payment Of Non-Contracted Provider Claims
Aspire Health Plan’s policy for delegated vendor oversight, with emphasis on scope of work elements audited prior to finalizing the contractual agreement with a new vendor entity supporting our Medicare Advantage line of business.
BEN-002-STD-Benefit Design for HPA 09-2023
Benefit Design Standard - 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
HealthPlanName_PandP_FWA_RecissionOfCoverage
Alliant Health Plans policy for Fraud, Waste and Abuse, defines the guidelines for recission of coverage as appropriate, when an individual has demonstrated fraud.
A Troubling Cardiac Trend: The Rise of Unnecessary Vascular Procedures
Earlier this month, the New York Times reported on a concerning trend's unnecessary atherectomies are putting patients at an increased risk of amputation. The procedure, used to treat peripheral artery disease, deploys metal blades to remove plaque from artery walls. Its use has nearly doubled in Medicare patients over the last decade, and a significant portion of this volume has shifted to outpatient settings, namely vascular clinics.
HealthPlanName_PandP_ThirdParty_VendorManagement_APAVBP_
As CBH, like the healthcare industry at large, moves away from fee-for-service payments to outcomes-based payment strategies, select programs or service lines may be considered for transition to value-based payment arrangements (VBP). This policy outlines how VBPs may be proposed and how they are vetted, selected, and prioritized by CBH.
HealthPlanName_PandP_RiskManagement_ Subpoenas& Court Orders
All subpoenas and all court orders related to a Member's Protected Health Information (PHI) shall be directed to CBH's main location at 801 Market Street, 7th floor, Philadelphia, PA 19107 and received by Operations Support Services and reviewed by the Legal Department. If an individual attempt to serve a subpoena and/or court order on a CBH employee at another location, that individual should be directed to CBHâ??s main office. The repository for all subpoenas and court orders for protected health information (PHI) will be Operation Support Services.
HealthPlanName_PandP_RiskManagement_ DocRetention& Destruction
The intent of this policy is to establish the rules that must be followed by CBH staff when retaining or destroying records generated at CBH or in relation to CBH. Records include both paper and digital records maintained by CBH. Consistent with OMHSAS policy, CBH recognizes digitally stored record-keeping copies of an original paper record as meeting the record retention requirements
HealthPlanName _PandP_FWA_FraudWasteAbuse
CBH has dedicated resources to the monitoring, deterrence, resolution and mitigation of fraud, waste and/or abuse committed by its providers, employees, subcontractors, and/or members.
HealthPlanName_PandP_Claims_Grievance& Appeals
CBH will follow Appendix H of the Program Standards and Requirements guidelines for the resolution of member or personal representative grievances.
HealthPlanName_PandP_RiskManagementComplianceOversight_ IntCompliance
All CBH employees will receive compliance training that includes training on the CBH Code of Conduct as well as detection and prevention of fraud, waste, and abuse. This will be completed within the first 14 days of employment, and annually thereafter or on an as needed basis.
HealthPlanName_PandP_RiskManagementComplianceOversight_ Privacy&SecurityIncidents
CBH workforce members will be subject to disciplinary action for violation of CBH HIPAA policies and procedures. Violations that jeopardize the privacy or security of PHI are particularly serious and will subject the responsible workforce member(s) to disciplinary action up to and including termination of employment.
HealthPlanName_PandP_RiskManagementComplianceOversight_ Monitoring InternalPPService
The Quality Management (QM) Department works cross-departmentally to monitor and evaluate CBH's internal processes and provider performance to ensure an organization and provider network that serves CBH members in an effective and efficient manner. Internal and provider network monitoring and evaluation activities are guided by the contract standards of HealthChoices Program Standards & Requirements (PS&R), operational efficiencies, and cost- and quality-improvement strategies. The Quality Improvement Committee (QIC) provides oversight of the QM Program, and provides recommendations and approval for all QM policies, procedures, and quality improvement activities. The QIC includes representatives from CBH leadership, Philadelphia Department of Behavioral Health and Intellectual DisAbility Services, network practitioners, and member representatives.
HealthPlanName_PandP_ThirdParty_VendorManagement_ProviderDirectory Maintenance
This policy applies to processes that ensure that accurate in-network provider information is made available to CBH members for all in plan services.
HealthPlanName_PandP_BenefitDev_OutreachtoMembers
CBH is committed to ensuring that members have access to treatment, and to facilitating connection and engagement throughout the treatment process. CBH staff will comply with 96-150 Customer Service Policy in all outreach communication with Members.
HealthPlanName_PandP_Claims_IdentifyOverpaymentRecovery
CBH Compliance Department audits and provider self-audits will often identify fraud, waste, or abuse resulting in financial consequences for providers. CBH will recoup payments, settlements, and extrapolated amounts for unsubstantiated services.
HealthPlanName_PandP_RiskManagementComplianceOversight_ Security
CBH employees will be subject to disciplinary action for violation of CBH HIPAA policies and procedures