Provider Manual

Providers

This section illustrates Commonwealth Care Alliance's provider credentialing process and the provider's responsibilities once contracted with Commonwealth Care Alliance. This section also describes the provider's responsibility regarding advance directives/guardianships and provider marketing, as well as information on access and availability of the provider network.

Credentialing

Overview

Commonwealth Care Alliance participating providers are required to go through an initial credentialing process prior to joining the network and re-credentialed at least every three years. The credentialing process may be performed by Commonwealth Care Alliance or delegated to another agency. When credentialing responsibilities are delegated to another agency, the process is in accordance with the standards promulgated by the National Committee for Quality Assurance (NCQA), the Medicare Advantage Program, other accrediting agencies, and as required by state and federal law. Commonwealth Care Alliance is required to maintain oversight of the designee's credentialing process.

The credentialing process necessitates the collection of relevant documentation from the provider and direct verification through numerous outside agencies all in accordance with NCQA and other accrediting agencies, and as required by state and federal law. The following information is reviewed prior to the final assessment of each provider:

Board certification status
Internal quality assurance events and member complaint reports (re-credentialing only)
Information obtained from the National Practitioner Data Bank
Medicare/MassHealth sanctions
State disciplinary actions
Office of Inspector General

Commonwealth Care Alliance requires physicians to achieve board certification prior to plan participation. Practitioners who are not board certified are required to submit a letter from the Chief of Service at their primary admitting hospital attesting to their competence. Commonwealth Care Alliance understands that certain specialty boards may require newly trained physicians to have clinical practice experience before granting permission to sit for the certification examination. In these cases, board-eligible physicians are expected to pass the certification exam within five years of becoming a participating practitioner. In rare cases, a provider who may be ineligible for board certification or whose board certification has lapsed may be considered. For these circumstances, an alternative credentialing pathway has been established.

Provider Credentialing Requirements

Providers must comply with Commonwealth Care Alliance or the provider designee's credentialing and re-credentialing requirements by submitting the following information for evaluation:

Completed credentialing/re-credentialing application and attestation signed within 180 days of committee review
Signed release form
Curriculum vitae or work history (for initial credentialing, dating back a minimum of five years)
Current malpractice insurance binder
Signed W-9 form (initial credentialing only)

Physicians are required to designate a primary admitting hospital. As mandated by state regulation, Commonwealth Care Alliance or their designee sends a letter to the primary hospital requesting a physician performance assessment. The hospital is queried again during re-credentialing. An appointment verification letter is sent to the hospital for each physician. Physicians are required to notify Commonwealth Care Alliance in writing of changes in primary hospital affiliation.

Provider Termination, Suspension or Denial

Providers are required to immediately notify Commonwealth Care Alliance, in writing, when any individual rendering services to a Commonwealth Care Alliance member:

Is censured or reprimanded by any health care facility (and such discipline is reportable to the regulatory body for licensure)
Has privileges at any health care facility suspended revoked, restricted, made probationary, or otherwise diminished in any way, including resignations
Has a license, certification, or MassHealth/Medicare participation limited, suspended or revoked

In any of these cases, Commonwealth Care Alliance will objectively assess the situation and determine if the provider's status or contract should be suspended, denied or terminated. When a decision has been made, written notification will be sent via certified or registered mail.

Facility Credentialing Requirements

In accordance with the National Committee for Quality Assurance (NCQA) and based on licensure and accreditation as set forth by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), Commonwealth Care Alliance verifies the credentials of the following organizations:

Acute-care hospitals
Skilled nursing facilities (SNFs)
Rehabilitation facilities
Behavioral health facilities

Primary Care Sites

The primary care site (PCS) is an essential element to the Commonwealth Care Alliance care delivery system. A PCS, in most cases a community-based medical care or physician practice, is an organized medical group that has demonstrated experience with, and a particular commitment to, the populations Commonwealth Care Alliance serves. The primary care physician (PCP) and some members of the primary care team (PCT) are based at the PCS. The PCT provides, arranges for, and coordinates the provision of covered services to members.

For a comprehensive, detailed list of SCO responsibilities, see Primary Care Program Specifications for Non-delegated primary care sites and Delegated primary care sites.

Provider Responsibilities

General Responsibilities

When giving services to a member, Commonwealth Care Alliance providers are required to comply with all state/federal laws and regulations and CMS requirements applicable to Commonwealth Care Alliance's plans. Providers must also comply with obligations listed in the provider/Commonwealth Care Alliance contract.

Overall, Commonwealth Care Alliance contracted providers must:

Coordinate care, clinical referrals, and prior authorizations with the member's PCP/PCT
Transfer indicated information to the primary care site and/or centralized enrollee record (CER) in a timely fashion
Provide care in a culturally and linguistically appropriate manner
Follow Commonwealth Care Alliance clinical guidelines and standards of care
Adhere to Commonwealth Care Alliance member rights statement
Abide by prompt access to care standards as outlined in Access & Availability Standards of Provider Network
Submit written notification to inform Commonwealth Care Alliance of relevant changes (i.e., name, address, TIN, panel status)
Comply with Commonwealth Care Alliance administrative policies and procedures
Confirm member's eligibility on each date of service
Cooperate with Commonwealth Care Alliance's Quality Management Program
Participate in Commonwealth Care Alliance provider surveys/trainings
Report to Commonwealth Care Alliance Category I & II incidents, which include the following:
- Any death required to be reported to the medical examiner or in which the medical examiner takes jurisdiction (M.G.L. c38 section 3)
- A serious injury while in a health care facility that results in hospitalization
- Sexual assault or alleged sexual assault to or by a member while at a health care facility
- Physical assault or alleged physical assault to or by a member while at a health care facility

To report Category I & II incidents call Commonwealth Care Alliance's Quality and Clinical Management Department at 1-866-610-2273 and use the Provider Incident Report form.

Commonwealth Care Alliance/Provider Responsibilities Regarding Advance Directives, Guardianships, HCP

In 1991, United States Congress passed the Federal Patient Self Determination Act (FPSDA) in order to protect the rights of patients. The FPSDA gives people the right to have control over their medical care decisions and requires health care facilities and/or agencies to discuss health care directives upon entering their system.

Health care proxies, advance directives and guardianships should be addressed and discussed with the member or verified member representative at time of initial assessment, at time of re-assessment, and/or when the member identifies that one or more of the three have been initiated. The enrollment coordinator, the GSSC, the clinician, the PCP or the MA, can address all three statuses. Required documentation can be initiated by the clinician, the GSSC or MA
The primary clinician or GSSC, if aware that the member has advance directives, health care proxy, or a guardian, must review with the member/guardian that the PCP office, primary acute-care hospital and Commonwealth Care Alliance should have a copy of these form/s
Commonwealth Care Alliance reserves the right to audit the presence of health care proxies/advance directives in medical records

Centralized Enrollee Record

The centralized enrollee record (CER) is a provider-driven, secure (HIPAA compliant), web based application that may be accessed to its authorized users from any Internet accessible computer. It is available 24 hours a day, 7 days a week. Authorized users may include the member's Commonwealth Care Alliance primary care registered nurse or nurse practitioner, the primary care site's clinician, primary care physician, or other members of the members PCT.

Every Commonwealth Care Alliance member has a CER. The CER is the repository for all pertinent information regarding the member's health, functional, and social status. At a minimum, the CER contains member demographics, the Individualized Plan of Care (IPC), a service plan, assessments, progress notes, and emergency contacts. It also includes problem lists, medications, and allergy information. All actions taken with or on behalf of the member must be documented in the CER by a member of the PCT. For additional information related to a Commonwealth Care Alliance member and that member's treatment, call the PCT during business or after hours.

Commonwealth Care Alliance works with the PCT to ensure:

Information is updated in a timely manner
Information is available and accessible 24 hours per day, 7 days per week either in its entirety or in a current summary of key clinical information to triage and acute care providers for emergency conditions and urgent care
Information is available and accessible to specialty, long term care, and behavioral health and substance abuse providers
Information is maintained and in compliance with Commonwealth Care Alliance's written policies to ensure confidentiality of the CER

The CER contains the following member information:

Member identifying information
For new members: problem list, allergies and sensitivities, vital signs, immunizations, and medication orders
Multidisciplinary assessments, including diagnoses, prognoses, reassessments, plans of care, and treatment and progress notes, signed and dated by the appropriate provider
Lab and radiology reports
Prescribed medications, including dosages and any known drug contraindications
Reports about involvement of community services that are not a part of the provider network, including any services provided
Documentation of contacts with family and persons giving informal support, if any
Physician orders
Disenrollment agreement (if applicable)
Member's individual advance directives and health care proxy, which must be recorded and maintained in a prominent place
Plan for emergency and urgent care, including identifying information about any emergency contact persons
Allergy and special dietary needs

Commonwealth Care Alliance has a 24 hours a day, 7 days a week on-call coverage system for its members. Any other providers involved in providing care to a Commonwealth Care Alliance member may contact Commonwealth Care Alliance to obtain information necessary to inform the provision of care that has been authorized by the PCP and/or PCT. In certain situations including emergency or urgent circumstances, Commonwealth Care Alliance staff may forward a servicing provider a summary of the Commonwealth Care Alliance member's demographic and clinical profile to inform the provision of care.

Provider Marketing

Guidelines associated with provider marketing activities and additional information can be found in the Medicare Marketing Guidelines on the CMS website.

Primary Care Team

The Primary Care Team Components

Primary Care Physician (PCP)

A physician who meets state requirements and is trained to give basic medical care
The PCP is responsible to coordinate care and services, along with reviewing, authorizing, and approving changes to the Individualized Plan of Care
The PCP is responsible for reassessing a member's needs at least every six months, but more frequently, if necessary

Nurse Practitioner (NP)/Registered Nurse (RN)/Physician Assistant (PA)

Must be licensed by the Massachusetts Board of Registration of Nursing, with annual continuing education units in geriatric practice
Must be certified as a geriatric nurse practitioner or demonstrate at least two years' professional experience in the care of persons over the age of 65

Aging Services Access Point (ASAP)

Entities established under state law that contract with the Commonwealth's Executive Office of Elder Affairs to manage the Home Care Program as well as other elder service programs in Massachusetts

Geriatric Support Services Coordinator (GSSC)

Licensed social workers who are employees of ASAPs and have expertise in geriatric practice
Participate in initial and ongoing member health and functional status assessments
Arrange, coordinate, and monitor the provision of appropriate long term care and social support services
Track member transfers from one setting to another
Assist the PCT in promoting independent functioning of the member and provide services in the most appropriate, least restrictive setting
Determine with the PCT appropriate discharge plans after admissions to an institution

PCT Role and Responsibilities

The PCT is responsible for making clinical decisions on behalf of Commonwealth Care Alliance and in conjunction with the member or member's representative.

Responsibilities include, but are not limited to:

Performing initial and ongoing member health and functional status assessments
Performing ongoing member health and functional status reassessments
- At least once every 6 months, or
- When a significant change in the member's health status occurs
Developing and revising, as appropriate, the Individual Plan of Care (IPC) and Service Plan which identifies and addresses the member's status and needs for medical, behavioral health, social, and long term care supports
Coordinating care, clinical referrals, and prior authorizations
Promoting health, prevention wellness informational activities relevant to the specific health status needs and high risk behaviors for members
Recording, collecting, and maintaining current and updated clinical and demographic information on each member in the CER
Attending PCT meetings to ensure effective communication

Access & Availability Standards of Provider Network

Commonwealth Care Alliance ensures that the availability of contracted providers in the network is sufficient in numbers, types, and geographic distribution to provide covered services to our members. Commonwealth Care Alliance's Provider Network Management Department continuously monitors its provider network to ensure this availability remains present at all times.

In order to ensure the availability of providers, Commonwealth Care Alliance performs analysis of:

Member complaint/grievance data
Enrollment data
Disenrollment data
Input from primary care providers
Health services delivery tables

Establishing Adequate PCP and Behavioral Health Network

Under Commonwealth Care Alliance's programs, home visits by the PCTs are a key component of the care model and enable Commonwealth Care Alliance to achieve proximity standards as well as appointment access standards.

SCO Availability of PCPs and PCTs

Provider Type	Proximity Standard
Primary Care Physician	15 mile radius or 30 minutes from member's residence zip code
Primary Care Team	15 mile radius or 30 minutes from member's residence zip code
Behavioral Health	15 mile radius or 30 minutes from member's zip code of residence

SCO Standards for Appointment Accessibility

Appointment Type	Standard
Non-symptomatic Office Visits	Within 30 days
Urgent Care and Symptomatic Office Visits	Within 48 hours
After-Hours Care	24-hours per day, 7 days a week toll free system with access to a skilled health care professional who has immediate access to the CER
Emergency Care	Immediate

24-Hour Coverage

To ensure quality and continuity of care, Commonwealth Care Alliance provides members with 24 hours a day, 7 days a week, access to clinical coverage by a skilled professional. The toll-free telephone number is 1-866-610-2273. The answering clinician is responsible for:

Triaging the call
Responding to immediate clinical concerns
Completing the appropriate documentation in the member's CER
Contacting the covering clinician at the member's primary care site, if appropriate
Follow up/addressing any medical/social needs of the member

Procedures:

Member calls the toll free phone number listed on the member's ID card
The call is answered by a Commonwealth Care Alliance contracted clinician
The answering clinician requests required information
Clinician responds to member within 15 minutes of the initial call
Clinician is able to provide clinical triage as needed
Clinician documents the after-hours call in the member's CER and any actions taken
Commonwealth Care Alliance's Clinical Program Manager will review the performance of the on-call coverage system on a regular basis
The Program Manager will also review the performance of the answering clinicians
Commonwealth Care Alliance member service may also follow up with enrolled members who have utilized the coverage system after hours to assess their satisfaction
Commonwealth Care Alliance reports any discrepancies of compliance to the Provider Network Management staff as well as the Chief Medical Officer

Commonwealth Care Alliance also has an administrator on call 24 hours a day, 7 days a week to serve as a resource to both the answering clinician and primary care sites. The toll-free telephone number is 1-866-610-2273.

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Last Updated 1/19/12

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