Peoples Health must:
- Clearly define its quality improvement (QI) structures and processes and assign responsibility to appropriate individuals
- Assure that the QI Committee and practitioners develop, implement and oversee the QI program
- Assure that provider contracts specify that providers cooperate with its QI program and allow the plan to use practitioner performance data
- Implement mechanisms to assess and improve member satisfaction
- Ensure coordination of services for members with complex conditions and help them access needed resources
- Actively work to improve the health status of members with chronic conditions
- Be accountable for adopting and disseminating clinical practice guidelines relevant to its members for the provision of nonpreventive acute and chronic medical services and for preventive and nonpreventive behavioral health services
- Monitor and take action, as necessary, to improve continuity and coordination of care across the health care network
- Collaborate with behavioral health care practitioners and use information at its disposal to coordinate medical care and behavioral health care
- Distribute a statement to all practitioners, providers and employees who make utilization management decisions, affirming the following:
- Utilization management decision-making is based only on appropriateness of care and service and existence of coverage.
- The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
- Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization.
If Peoples Health delegates NCQA-required QI activities, there must be evidence of oversight of the delegated activities.
Peoples Health contracts with practitioners must include an affirmative statement indicating that practitioners may freely communicate with patients about their treatment, regardless of benefit coverage. Please be aware that we may use practitioner performance data for quality improvement activities.
QI Outline
The Peoples Health QI team works to ensure plan members get the quality health care they deserve. At any time, a member or provider can ask us to send a written outline of our QI program. This document describes the measures we take to ensure that our members get the best health care possible. For a copy of the QI program, contact your Peoples Health representative. It should arrive in your mailbox within three business days.
Provider Manuals and the Provider Reference Guide
Participating providers acknowledge and agree that in addition to the provisions of an agreement, the Provider Reference Guide is an extension of the contract, and providers must abide by the conditions set forth in the contract and in the guide. Peoples Health has established policies and procedures, which are contained in the Medical Policies and Evidence-Based Practice Guidelines and other written manuals distributed to providers in print or electronic format. Providers agree to be bound by and to comply with all such manuals, policies and procedures. Peoples Health agrees to make available to providers any updated policies and procedures in print or electronic format.
Confidentiality and Accuracy of Plan Member Records
A provider shall, with respect to any medical records or other health and enrollment information that a provider maintains with respect to Peoples Health patients:
- Safeguard the privacy of any information that identifies a patient. Information from or copies of records may be released only to authorized persons. Unauthorized persons should not be permitted to gain access to or alter patient records. Original medical records shall be released by a provider only in accordance with federal and state laws, court orders and subpoenas.
- Maintain such records and information in an accurate and timely manner.
- Ensure patients have timely access to the records and information pertaining to them.
- Abide by all federal and state laws regarding confidentiality and disclosure for mental health records, medical records, or other health and patient information.
Open Communication With Patients
Nothing in a contract shall be construed in any way to impede the open clinical dialogue and clinical communication between a provider and a patient. Peoples Health encourages providers to freely communicate with Peoples Health patients about clinical treatment options, including medications available to them, regardless of benefit coverage limitations.
Compliance With Accreditation Agency Standards
In providing services and in the performance of an agreement, a provider, as well as provider personnel, shall comply with all applicable regulatory and accreditation standards applicable to Peoples Health. Peoples Health also agrees to abide by such accreditation standards.
If you have any questions about Peoples Health NCQA accreditation, or to request information about our progress toward QI goals, contact your Peoples Health representative or member services.