Policy and Procedures Toolkit

HealthPlanName_PandP_ThirdParty_VendorManagement_ThirdPartyLiability
This policy is to assure that Community Behavioral Health (CBH) is the payer of last resort for services that are covered by another payer. CBH will take all reasonable measures to identify legally liable third parties and treat TPL as a resource of the Medicaid recipient.

HealthPlanName_PandP_ThirdParty_VendorManagement_VendorContracting
This Contracting Policy (Policy; formerly Vendor Contracting Policy) provides guidance for the development and use of written contracts, describes situations for which they are required, and identifies exceptions to those requirements. It also outlines CBH's responsibilities before executing contracts, and the roles of the CBH Business Owner, Approving Officer, the Contracts & Procurements Team (C&P), and CBH Signatories in the contracting process.

HealthPlanName_PandP_BenefitDev_ThirdPartyLiability
This policy is to assure that Community Behavioral Health (CBH) is the payer of last resort for services that are covered by another payer. CBH will take all reasonable measures to identify legally liable third parties and treat TPL as a resource of the Medicaid recipient.

Western Health Advantage_Org Chart_2023 HPA update
Western Health Advantage uploads its executive organization chart.

SIU: Appeals Process
To create a consistent internal process and timeframe for appeals after the Special Investigations Unit (SIU) identifies overpayment or coding issues which resulted in findings that may require one or more of the following: recoupment, education, or corrective action.

Categorization of Entities as Delegated Vendors
To set forth the process to categorize First-Tier, Downstream, Related Entity (FDR) vendors and determine the vendor risk level based on delegated services being provided for all of our product lines, or its affiliates or subsidiaries, including FirstCarolinaCare (â??FCCâ?).

NetworkHealth_PandP_PrivacyMemberRecords
State and federal law requires Network Health to ensure that anyone who handles Protected Health Information (PHI) maintains its confidentiality. PHI includes medical records, claims, benefits and other administrative data that are personally identifiable. Use of aggregated data in which an individual's personal information is not identifiable to a statistically significant degree is not subject to privacy restrictions.

Unlocking the Potential of Healthcare Automation
How to develop a winning robotic process automation strategy and use case examples.

PCHP.PV.105 Safeguarding and Storing PHI
PCHP uploads guidelines for safeguarding and storing PHI for the Policy & Procedures toolkit.

PCHP.PV.109 Retention and Destruction of PHI
PCHP uploads a guideline surrounding PHI retention/destruction guidelines for the Policy & Procedures toolkit.

PCHP.PV.101 HIPAA Privacy & Security P&Ps
PCHP uploads a guideline surrounding HIPAA Privacy & Security for the Policy & Procedures toolkit.

Health Alliance Medical Plan's External Review/Independent Review Appeals Process Based on Medically Necessary and Rescission of Coverage Denials (SF Plans)
The purpose of the policy is to standardize per governmental regulation both at state and federal level (health care reform) the intake, tracking and resolution of external or independent reviews to ensure compliance.

Medicare Advantage - Internal Expedited Appeals Process
The Health Alliance Member/Provider Resolution Unit will provide the appeal process for all situations that meet the expedited criteria for appeal. This policy will also be followed when an member/authorized representative/provider misses the deadline for filing an immediate Quality Improvement Organization (QIO) appeal for a discontinuation of services for Skilled Nursing Facility (SNF), Home Health Agency (HHA), Comprehensive Outpatient Rehabilitation Facility (CORF) or discontinuation of Therapy services.

Medicare Advantage - Reconsideration Appeals Process
It is the purpose of this policy to offer two types of procedures for resolving enrollee complaints; the Medicare appeals procedures and the internal grievance procedures.

Health Alliance Medical Plan' sEmergency Department Reviews - Self-Funded Plans
The purpose of this policy is to outline the workflow and action steps necessary to comply with self-funded group requirements regarding emergency department (ED) benefits.

Compliance Oversight of Delegated Vendors
To comply with CMS Medicare Managed Care and Part D guidelines set forth in Chapter 21 of the Medicare Managed Care Manual and Chapter 9 of the Part D manual (Chapter 9/21), 42 CFR 422.504, 423.504, 423.505, 422.2268, 423.2268, and 45 CFR 156.340 for Qualified Health Plans regarding oversight of Delegated Vendors. This policy is applicable to all product lines where vendors are performing administrative services on behalf of Health Alliance or its affiliates or subsidiaries, including FirstCarolinaCare Insurance Company (FCC).

Creation, Review and Approval of Policies and Procedures
To document the creation, review, approval and withdraw of policies and procedures to ensure standardization throughout Health Alliance.

Anti Kickback
his policy was established to set forth the duties and responsibilities for complying with the federal Anti Kickback Statute (AKS) and applicable state laws.

Contract Review, Approval and Termination
To establish internal standards and controls that monitor and support compliance with contract terms, applicable federal and state laws and regulations, and Health Alliance policies and procedures for the management of risk in all contractual relationships.

Privacy: Notice of Privacy Practices
To ensure Health Alliance abides by the requirements set forth by the HIPAA Privacy (45 CFR 164.520) URAC and state and federal laws regarding a Notice of Privacy Practices.

Communication of New/Revised MA & PD Statutes, Regulations and CMS Guidelines
To comply with the Centers for Medicare and Medicaid Services (CMS) guidelines for the Medicare Advantage (MA), Part D Sponsor (Part D) and Qualified Health Plan (QHP).

Health Alliance Medical Plan's False Claims Act and Whistleblowing Protections
This policy is intended to describe the Federal False Claims Act, the Fraud Enforcement Recovery Act, the Illinois False Claims Act, the Illinois Insurance Claims Fraud Prevention Act and the Illinois Whistleblowers Act.

SIU: Fraud, Waste, & Abuse Investigations
This policy outlines Health Alliance's process to detect, prevent, investigate, correct, and report potential fraud, waste, and/or abuse (FWA) occurrences affecting Health Alliance's payment integrity efforts. It will also set forth the duties and responsibilities for conducting and documenting investigations of reported potential FWA identified through internal and external sources as well as through proactive leads by SIU and any vendor partners.

Reporting Suspected Misconduct, Compliance Violations, Potential Fraud or Abuse and Privacy or Security Incidents
To establish a mechanism to report suspected misconduct, compliance violations and potential fraud or abuse of another employee, provider, employer group, vendor or other client of Health Alliance.

Compliance Auditing and Monitoring
This policy was established to comply with the Centers for Medicare and Medicaid Services (CMS) regulations and guidelines related to Medicare Advantage (MA, Prescription Drug (PD) and Qualified Health Plans (QHP).

Privacy: Accounting of Disclosures of PHI
Members have the right to receive an accounting of disclosures of their protected health information (PHI) as set forth by the HIPAA Privacy Rule (Title 45, CFR 164.528), Illinois State Law 215 ILCS 5/1009, as well as policies developed by Health Alliance.

Appeals Process Based on Administrative Denials Pre-Service, Post-Service, Urgent/Expedited, Concurrent (Except MA/QHP)
The purpose of the policy is to standardize the intake, tracking and resolution of benefit appeals to ensure compliance with regulatory and/or accreditation requirements.

Privacy: Business Associate Agreements
To ensure Health Alliance disclosure of PHI to business associates is appropriate and contracts with business associates meet the requirements set forth by the HIPAA Privacy Rule (Title 45 CFR 164.500, 164.501, 164.502, 164.504, 164.514, 164.530).

Privacy: Definitions
To provide Health Alliance employees with the HIPAA Privacy definitions for terms that may appear in the HIPAA Privacy policies. To identify such definitions in the Privacy policies, the first letter of each word is capitalized.

Internal Compliance Investigations
This policy was established to outline the duties and responsibilities for conducting and documenting internal investigations of reported suspected misconduct, issues of non-compliance, potential fraud/abuse, privacy and/or security incidents.

Privacy: Permitted and Required Uses and Disclosures of PHI
The purpose of this policy is to ensure Health Alliance employees abide by the requirements set forth by the HIPAA Privacy Rule (Title 45, CFR 164.502, 164.510, 164.512) as well as policies developed by Health Alliance.

Privacy: Minimum Necessary
This policy establishes the general rule regarding the minimum necessary limitation on the Use or Disclosure of Protected Health Information (PHI) as set forth by the HIPAA Privacy Rule (45 CFR 164.502(b), 164.514(d)).

Privacy: Marketing of PHI
From time to time, Health Alliance may want to inform members of services or products that may be beneficial to them. However, it is important to respect the privacy of members, and recognize the responsibility of avoiding unwanted or unnecessary mail and other communications.

Compliance Training and Education
This policy establishes guidelines for the education and training of all Health Alliance employees on the organization's compliance, privacy and security guidelines and specific policies and procedures.

Privacy: Routine and Recurring Disclosures of PHI
To establish Disclosures of Protected Health Information (PHI) that are routine and recurring.

Privacy: Safeguarding PHI
This policy establishes guidelines to help safeguard Protected Health Information (PHI) from being seen, heard or disclosed to those who are not authorized to see or hear it as set forth by the HIPAA Privacy Rule (45 CFR 164.530(c)) as well as other policies developed by Health Alliance.

Privacy: Verification of the Identity of the Member and Verification of the Authority of an Individual Requesting PHI on behalf of the Member
There are a number of situations in which Health Alliance Employees disclose Protected Health Information (PHI). Disclosures of PHI must be made in accordance with the applicable Health Alliance policies. Employees must verify the identity of the member and the authority of any such person to have access to protected health information, if the identity or any such authority of such person is not known to the covered entity as set forth by the HIPAA Privacy Act (45 CFR 164.514(h)).

PCHP.FWA.101 Comprehensive FWA Program
PCHP uploads a guideline surrounding FWA Program for the Policy & Procedures toolkit.

Risk Assessment - Internal Operations
To comply with the Centers for Medicare and Medicaid Services (CMS) related to the Medicare Advantage (MA), Part D and Qualified Health Plan (QHP) regulations and guidelines.

Corrective Action Process
This policy was established to outline the duties and responsibilities for implementing corrective actions needed to resolve confirmed misconduct, issues of non-compliance, fraud or abuse cases and privacy and security incidents.

Privacy: Amend PHI
Members have the right to request that Health Alliance amend certain Protected Health Information (PHI) as set forth by the HIPAA Privacy Rule (45 CFR 164.526), State of Illinois law 215 ILCS 5/1009, as well as policies developed by Health Alliance

Privacy: Authorization to Use and Disclose PHI
This policy was established to ensure that all Health Alliance employees abide by the requirements set forth by the HIPAA Privacy Rule (Title 45 CFR 164.508) as well as policies developed by Health Alliance.

Privacy: Confidential Communication
To ensure that Health Alliance employees abide by the requirements set forth by the HIPAA Privacy Rule (Title 45 CFR 164.502(h) and 164.522(b)) as well as policies developed by Health Alliance.

Privacy: Access to PHI
Members have a right to inspect or to receive a copy of their Protected Health Information (PHI) in Health Alliance's records as set forth by the HIPAA Privacy Rule (Title 45 CFR 164.524). Some exceptions apply, as defined further in this policy.

Privacy: Confidentiality of Health Information Related to Minors
To ensure that Health Alliance employees abide by the rules and regulations set forth by state law related to confidentiality of health information for minors.

Privacy: Designation of Record Sets
To designate what is considered a record set of Health Alliance for purposes of accessing and amending Protected Health Information (PHI).

Privacy: Facsimile Transmission of PHI
To ensure that Health Alliance employees safeguard Protected Health Information (PHI) when transmitting PHI by facsimile.

Privacy: Breach Notification
The purpose of this policy is to establish a process by which Health Alliance Medical Plans, Inc. assures that confirmed breaches are documented in accordance with the breach notification requirements outlined in the American Recovery and Reinvestment Act of 2009 (ARRA), Title XIII, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) and the Health and Human Services (HHS) Breach Notification for Unsecured PHI Rule.

Privacy: Member Complaints
To ensure that Employees abide by the requirements set forth by the HIPAA Privacy Rule as well as policies developed by Health Alliance.

Privacy: Personal Representative
The purpose of this policy is to define a Personal Representative and the authority they have for member matters related to Health Alliance services.

Privacy: Restriction of Use and/or Disclosure of PHI
To ensure that Health Alliance employees abide by the requirements set forth by the HIPAA Privacy Rule (45 CFR 164.502(c) and 164.522(a)) as well as policies developed by Health Alliance.

Privacy: Revocation of an Authorization
This policy was established to ensure Health Alliance abides by the requirements set forth in the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR 164.508) regarding revocation of an authorization as well as policies developed by Health Alliance.

Appeals Process Based on Medically Necessary Denials Pre-Service, Post-Service, Urgent/Expedited, Concurrent (Self-Funded)
To standardize the intake, tracking and resolution of medical necessity appeals to ensure compliance with regulatory and/or accreditation requirements

External Review Process Based on Medically Necessary Denials Pre-Service, Post-Service, Urgent/Expedited, Concurrent and Rescission of Coverage Denials (FI)
To provide uniform standards for the establishment and Maintenance of external review procedures to assure that members have the opportunity for an independent review of an adverse determination or final adverse determination as required by the Illinois Health Care External Review Act, 215 ILCS 180/ Health Care External Review Act.

PCHP.CP.106 Routine Monitoring, Auditing
PCHP uploads established protocols for internal monitoring & auditing to evaluate compliance with Federal, State and internal standards for the Policy & Procedures toolkit.

PCHP.CP.107 Prompt Response to Compliance and FWA Issues
PCHP uploads a guideline for CAPs, detected violations and/or non-compliance with Federal, State or internal standards for the Policy & Procedures toolkit.

PCHP.DE.102 Oversight of Delegated Entities
PCHP uploads a guideline surrounding DE Oversight for the Policy & Procedures toolkit.

Appeals Process Based on Medically Necessary Denials Pre-Service, Post-Service, Urgent/Expedited, Concurrent Reviews (Except MA/SF/Fed)
The purpose of the policy is to standardize the intake, tracking and resolution of benefit appeals to ensure compliance with regulatory and/or accreditation requirements.

Member Prescription Drug Appeal Process
The purpose of the policy is serving as guidelines to support Health Alliance in the delegation of appeals for FirstCarolinaCare Insurance Company (FCCI) to standardize for all Commercial Fully Insured groups the intake, tracking and resolution for prescription drug appeals to ensure compliance with Regulatory and/or Accreditation requirements. To describe a process for prescription drug appeal first level appeal, second level appeal (grievance) and external reviews for standard and expedited prescription drug appeals. This policy is specific for prescription drug appeals. Health Alliance fully adopts and will follow the FCCI Member Appeal and Grievance Process policy for drugs processed under the Medical Benefit (ex. Outpatient and MD Office setting).

PCHP.ADM.104 Maintenance of Records
PCHP uploads record retention for the Policy & Procedures toolkit.

Medicare Advantage - Excluded Drugs, Inquiry vs. Grievance vs. Coverage Determination Process for Medicare Part D (Prescription Benefit)
It is the purpose of this policy to offer guidance on how to determine what classification should be given when a transaction involves an excluded Part D drug, i.e., is excluded under section 1927(d)(2) of the Social Security Act.

SIU: Lead Intake, Electronic Case File and Tracking Processes
This policy establishes guidelines for the Health Alliance Special Investigations Unit (SIU) to process and track reported issues related to potential and/or alleged fraud, waste, and abuse (FWA) for Health Alliance and its affiliates and subsidiaries, such as FirstCarolinaCare Insurance Company (FCC).