Policy and Procedures Toolkit

Responding to Subpoenas, Court Orders and Attorney Correspondence Requesting Informatio
To document Health Alliance's process for receipt of and response to a subpoena, court order or attorney's request for information.

Pre-Existing Condition Review
Health Alliance Medical Plans uploads a guideline to provide a consistent process for reviewing post-service claims to determine if the claim is related to the member's preexisting condition for the Policy and Procedures toolkit.

Health Alliance Medical Plan's External Review Process Based on Medically Necessary Denials Pre-Service, Post-Service, Urgent/Expedited, Concurrent and Rescission of Coverage Denials (Iowa)
The purpose of the policy is to provide uniform standards for the establishment and maintenance of external review procedures to assure that members have the opportunity to have an independent review of an adverse determination or final adverse determination as required by the federal Patient Protection and Affordable Care Act. 2011 Iowa Acts, House File 597 (https://iid.iowa.gov/).

External Review Process Based on Medically Necessary Denials Pre-Service, Post-Service, Urgent/Expedited, Concurrent and Rescission of Coverage Denials (Ind QHP)
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 Office of the Insurance Commissioner's (OIC) RCW 48.43.535, WAC 284-43-550 and WAC 284-43-630.

Department/Division of Insurance (DOI) Complaints
Health Alliance Medical 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.

Medicare Advantage - Organization Appeal and Grievance Data Disclosure Requirements
The Medicare Advantage organization will be expected to comply with disclosing grievance and appeal data to eligible Medicare individuals upon request. This allows the eligible individual who requests this information to use it to evaluate and compare plan performance.

Medicare Advantage - Peer Review Process (Acute Inpatient)
To ensure compliance with the Center for Medicare / Medicaid Services (CMS) guidelines regarding Peer Review processes for inpatient services.

Appeals Process Based on Medically Necessary Denials Pre-Service, Post-Service, Urgent/Expedited, Concurrent (Fed)
This policy was established to standardize the intake, tracking and resolution of benefit appeals to ensure compliance with regulatory and/or accreditation requirements for Federal Plan enrollees.

Security Control & Auditing and Monitoring of Appeals Staff
Health Alliance Medical Plans uploads a guideline surrounding compliance with State, Federal, and URAC regulation/standards.

BEN-005-PRO-Benefit Approval Procedures for HPA 09-2023
Benefit Approval Procedures - These are the procedures that are followed for the benefit approval policy noted above. Indicates which department is responsible for what part of the benefit process (from creation to approval), to ensure that we are in compliance with all state and federal regulations. Applies to Commercial lines of business.

Medicare Advantage - Redetermination Appeals Process for Medicare Part D (Prescription Benefit)
It is the purpose of this policy to offer a procedure for resolving an enrollee's appeal under Medicare Part D (Pharmaceutical coverage) as defined in Title 42, 423.560. The Part D appeals process is modeled after the Medicare Advantage appeals process.

Medicare Advantage - Redetermination Appeals Process for Medicare Part D (Prescription Benefit)
It is the purpose of this policy to offer a procedure for resolving an enrollee's appeal under Medicare Part D (Pharmaceutical coverage) as defined in Title 42, 423.560. The Part D appeals process is modeled after the Medicare Advantage appeals process.

BEN-005-POL-Benefit Approval Policy for HPA 09-2023
Benefit Approval Policy - This is more of an internal workflow policy that indicates which department is responsible for what part of the benefit process (from creation to approval), to ensure that we are in compliance with all state and federal regulations. Applies to Commercial lines of business.

Parties and Persons Who May Request a Reconsideration
Health Alliance Medical Plans ensures the member is allowed an authorized representative to act on their behalf at all levels of appeal.

AlliantHealthPlans_PandP_Claims_MonitoringClaims
Alliant Health Plans procedure for Claim Standard and metrics, identifies areas of opportunities within the system, resources, and manual processes.

AlliantHealthPlans_PandP_Clincal_UMOversight
Alliant Health Plans policy for Utilization Management, focuses on the quality and effectiveness of healthcare services in a manner consistent with the member's illness.

AlliantHealthPlans_PandP_Clincal_CCMDescription
Alliant Health Plans policy for Complex Case Management, coordinates appropriate levels of care by assessing problems, needs, available resources, and benefits to develop a suitable case management care plan.

AlliantHealthPlans_PandP_Clincal_UMProgramDescription
Alliant Health Plans policy for Utilization Management, focuses on the quality and effectiveness of healthcare services in a manner consistent with the member's illness.

AlliantHealthPlans_PandP_BenefitDev_BenefitCoverage
Alliant Health Plans procedure for Benefit Coverage, defines the process used by Client Service Representatives to assist members by providing accurate and timely information related to benefits.

AlliantHealthPlans_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.

BEN-003-POL-Summary of Benefits and Coverage Policy for HPA 09-2023
Summary of Benefits and Coverage Policy - to ensure that we comply with all requirements of health insurance issuers of both individual and group coverage in the provision of the written summary of benefits (SBCs) for each benefit package.

BEN-003-STD-Summary of Benefits and Coverage Standard for HPA 09-2023
Summary of Benefits and Coverage Standard - to ensure that we comply with all requirements of health insurance issuers of both individual and group coverage in the provision of the written summary of benefits (SBCs) for each benefit package.

AlliantHealthPlans_PandP_ERM_ComplianceOperationsMonitoring
Alliant Health Plans policy for Compliance/ Operations Monitoring, guides employees with day-to-day conduct and operations, developed under the direction of department leads and the HOA Compliance Officer.

AlliantHealthPlans_PandP_Clincal_ContinuityOfCare
Alliant Health Plans policy for Continuity of Care, defines the process of notifying members who are patients of a provider terming from network participation.

AlliantHealthPlans_PandP_Clincal_EPSDT
Alliant Health Plans policy for EPSDT (Early and Periodic Screening, Diagnostic, and Treatment), establishes standardized methodology to reduce variation of care and improve preventive health guidelines.

AlliantHealthPlans_PandP_BenefitDev_BenefitConfiguration
Alliant Health Plans policy for Benefit Configuration, details and assists in complying with benefit design, marketing, compensation, and transactions.

AlliantHealthPlans_PandP_BenefitDev_QHPApplication
Alliant Health Plans document for Benefit Coverage/Configuration, defines the annual application process for QHP submission and certification by CMS.

AlliantHealthPlans_PandP_Claims_PharmacyAppeals
Alliant Health Plans policy for Appeals, explains the member appeal process, provides a fair review of all adverse benefit determinations, and ensures administrative process are in place to support consistent decision making.

AlliantHealthPlans_PandP_Claims_UMAppeals
Alliant Health Plans policy for Appeals, explains the member appeal process, provides a fair review of all adverse benefit determinations, and ensures administrative process are in place to support consistent decision making.

AlliantHealthPlans_PandP_Clincal_UMAppealsProcess
Alliant Health Plans policy for Appeals, explains the member appeal process, provides a fair review of all adverse benefit determinations, and ensures administrative process are in place to support consistent decision making.

AlliantHealthPlans_PandP_ERM_InterestPayments
Alliant Health Plans policy for Interest payments, provides timely processing to both paper and electronic claims in accordance with the rules/regulations set forth by the Georgia Department of Insurance.

AlliantHealthPlans_PandP_ERM_ComplianceRiskAssessment
Alliant Health Plans policy for Compliance Risk Assessment and Mitigation, provides guidance for the implementation of reasonable security measures for each department who handles PHI.

AlliantHealthPlans_PandP_ERM_DataRetention
Alliant Health Plans policy for Data retention, ensures that records are retained in accordance with HIPAA privacy and security rules, QHP requirements and ERISA standards.

AlliantHealthPlans_PandP_Clincal_ContinuityCareForm
Alliant Health Plans document for Continuity of Care, allows the member to submit a formal request to continue care at in-network cost with a provider that is terming from network participation.

AlliantHealthPlans_PandP_BenefitDev_CoordinationOfBenefits
Alliant Health Plans document for Benefit Coordination, outlines the order of benefits used following a list of applicable rules, as it relates to a member's plan and group coverage.

AlliantHealthPlans_PandP_Claims_ClaimDisputeForm
Alliant Health Plans document request for Claim Disputes, allows the member to formally request a change in an adverse decision related to his/her coverage.

Phcy_-and_Combo_ID_Card_Imp_Guide_v7-1 (1).pdf
Providence Health Plan uploads a guideline surrounding PHARMACY AND/OR COMBINATION ID CARD for the Policy and Procedures toolkit.