PARTNERSHIP HEALTHPLAN OF CALIFORNIA …...clusions on hospitals with

PARTNERSHIP HEALTHPLAN OF CALIFORNIA

QUALITY/UTILIZATION ADVISORY COMMITTEE MEETING NOTICE

DATE: Friday June 10, 2016

FROM: Jennifer Secretaria, QI Administrative Assistant

SUBJECT: Quality/Utilization Advisory Committee (Q/UAC) Meeting

In preparation for the upcoming Q/UAC meeting, please carefully review the agenda topics and corresponding materials.

In addition, please be informed that due to the size of our meeting packets, PHC’s Green Committee has respectfully asked

that we reduce our environmental impact, so we encourage you to use your electronic device (ex. iPad, laptop, etc.) during

the meeting. However, a few hard copy packets will be available for the external Committee Members only.

PHC Staff: You will be responsible for printing your own copy, if you feel you need it.

If you are calling-in to the meeting, please dial 1 (888) 240-2560. Meeting ID: 870356221 Passcode: 0671

Date: Wednesday, June 15, 2016

Time: 7:30 - 9:00 a.m.

Place: Partnership HealthPlan of California

4665 Business Center Drive, Solano/Napa Conference Room – 1st Floor

Fairfield, CA 94534

Physicians and Consumer Members:

Jennifer Wilson, MD Robert Quon, MD

Kali Stanger, MD maternity leave Rodrigo Manalo, MD

Madhusudan Borde, MD Sara Choudhry, MD

Michael Pirruccello, MD Steven Gwiazdowski, MD, FAAP

Michael Strain, PHC Consumer Member Steven Namihas, MD

Randolph Thomas, MD Thomas Paukert, MD

PHC Staff Members:

Debra McAllister, RN, Utilization Management Director Michael Vovakes, MD, Northern Region Medical Director

James Cotter, MD, Associate Medical Director Nadine Harris, RN, MBA, Quality Compliance Manager

Jessica Thacher, MPH, Quality & Performance

Improvement Director

Peggy Hoover, RN, Health Services Senior Director

Mark Glickstein, MD, Associate Medical Director Robert Moore, MD, MPH, CMO - Chairman

Mark Netherda, MD, Regional Medical Director Scott Endsley, MD, Associate Medical Director

Mary Kerlin, Provider Relations Senior Director

Cc:

Betsy Campbell, MPH, Senior Health Educator Kelley Sewell, Northern Region Director of MS & PR

Carly Fronefield, Director of Health Services (R) Lynn Scuri, Associate Regional Director

Cristina Lauck, Manager, General Case Management Margaret Kisliuk, MPP, JD, Executive Director

Heather Brandeburg, Assoc. Dir., Provider Relations Margarita Garcia-Hernandez, Mgr., Health Analytics

Jeff Ribordy, MD, Northern Regional Medical Director Marshall Kubota, MD, Regional Medical Director

Karen Stephen, PhD, HS Mental Health Director Nancy Steffen, Quality, Analysis and Project Management

Associate Director (R)

Katherine Barresi, Care Coordination Manager Richard Fleming, MD, Associate Medical Director

PHC Offices: Please use the “Q/UAC Meeting” directory entry on your video conference unit. If you need assistance please contact IT a

minimum of one (1) day prior to the meeting so that they can provide instructions and testing.

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QUALITY/UTILIZATION ADVISORY COMMITTEE

MEETING AGENDA

Date: June 15, 2016 Time: 7:30 – 9:00 a.m. Location: Napa/Solano Room (1st Floor)

I. Approval of Minutes Lead Time Page #

1 Quality/Utilization Advisory Committee (QUAC_5.18.2016) (attachment)

Internal Quality Improvement (IQI_5.10.2016) (attachment) Robert Moore, MD 7:30

5-10

11-17

II. Standing Agenda Items (Full Committee)

1 Status of open action items (none) Robert Moore, MD/

Nadine Harris 7:33 ---

2 Quality and Performance Improvement Update (attachment) Jessica Thacher 7:35 18-22

3 Health Plan Update (discussion) Robert Moore, MD 7:40 ---

III. Old Business (Committee Members as Applicable)

None. ---

IV. New Business (Committee Members as Applicable)

1 Consent Calendar (attachments) All 7:45 23-101

Quality and Performance Improvement, no substantive changes

MPQP1016 Potential Quality Issues Investigation and Resolution 24-39

Utilization Management, no substantive changes

HKUG3071 Hospice Services Guidelines (HK Only) 40-47

HKUP3067 Appeals/Expedited Appeals of UM Decisions for Medical Necessity Determination

(Non-Administrative)

48-54

HKUP3073 Mastectomy and Breast Reconstruction 55-58

HKUP3077 PCP to Specialty Care Referral Process (RAF) 59-67

MCUP3041-A TAR Review Process 68-91

MCUP3057 Provider Appeals of Health Services Administrative Denials 92-95

MCUP3124 Referral to Specialists (RAF) 96-101

2 UM Activities - IRR, Total TARs, Timeliness Data (attachment) Debra McAllister 7:50 102-110

3 Member Satisfaction Survey (attachment) Debbie Shaffer 7:55 111-120

4 Pharmacy Credentialing Summary (attachment) Dina Cuellar 8:05 121

5 Growing Together Perinatal Program (GTPP) (attachment) Jessica Hackwell 8:15 122-126

6 Managing Pain Safely (attachment) Danielle Niculescu 8:25 127-138

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New Business, continued

7 Hospital QIP Measures Summary (attachment) Jess Liu/Amy Lasher 8:35 139-145

8 Offering and Honoring Choices (attachment) Caron Lee 8:45 146-151

9 MCUP3131 Genetic Testing (attachment) Robert Moore, MD 8:55 152-199

V. Additional Business

VI. Adjournment

Page 4 of 199


MEETING MINUTES

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Committee: Quality and Utilization Advisory Committee (QUAC)

Date/Time: May 18, 2016 7:30 – 9:00am

Members Present: Jennifer Wilson, M.D. Robert Quon, M.D.

Madhusudan Borde, M.D. Rodrigo Manalo, M.D.

Michael Strain, PHC Consumer Member Sara Choudhry, M.D.

Randolph Thomas, M.D. (phone) Steven Gwiazdowski, M.D., FAAP (phone)

Members Absent: Kali Stanger, M.D. – absent; on maternity leave Steven Namihas, M.D.

Michael Pirruccello, M.D. Thomas Paukert, M.D.

PHC Members Present: Debra McAllister, RN, Associate Director, UM Nadine Harris, RN, MBA, Manager of Quality Compliance

James Cotter, M.D., Associate Medical Director Nancy Steffen, Quality, Analysis and PM Associate Director

Jessica Thacher, Assoc. Director, Quality and PI Peggy Hoover, RN, Health Services Director

Mark Glickstein, M.D., Associate Medical Director Robert Moore, M.D., MPH – Chief Medical Officer, Chairman

Michael Vovakes, M.D., Northern Reg. Medical Director

PHC Members Absent: Mark Netherda, M.D., Regional Medical Director Scott Endsley, MD, Associate Medical Director

Mary Kerlin, Senior Director of Provider Relations

Guests: Amy Lasher, QI Project Coordinator I Jessica Delaney, QI Project Coordinator

Betsy Campbell, MPH, Senior Health Educator Karen Goelz, QI Project Coordinator

Carly Fronefield, Associate Director of Health Services (R) Katherine Barresi, Associate Director/CC

Caron Lee, MPH, Improvement Advisor Ledra Guillory, Sr. Provider Relations Rep Manager

Cheryl Lockhart, RN, PICS II Marianne Gerardi, RN, MPH, PICS I

Danielle Domino, Manager of Pharmacy Operations (R) Mary Enos, Associate Director of Enrollment

Danielle Niculescu, MPH, QI Project Coordinator II Matt Hintereder, PMO Project Manager

Dina Cuellar, CPhT, Assoc. Director of Pharmacy Operations Rosemary Summers, MPH, Project Manager

Donna Barton, Regional Team Manager/UM (R) Samantha Curtis, QI Clerk (temp)

Jess Liu, Manager of Quality Incentive Programs

AGENDA

ITEM DISCUSSION / CONCLUSIONS

RECOMMENDATIONS/

ACTION

TARGET

DATE

DATE

RESOLVED

Call to Order and Ap-

proval of Minutes

The meeting was called to order at 7:40 am.

Minutes from the 4/20/16 QUAC meeting were reviewed.

Minutes from the 4/12/2016 IQI meeting were reviewed.

QUAC Minutes:

Approved without changes.

IQI Minutes: Accepted.

5/18/2016

Page 5 of 199


MEETING MINUTES


I. Standing Agenda Items

1. Status of open

action items

There were no open action items discussed.

2. QI Update

Jessica Thacher, MPH, Director of Quality and Performance Improvement, provided an

update of the Quality Improvement Department activities as follows:

Incentive Programs - Internally exploring possible transition of PCP QIP program period

from July 1st -June 30th of next calendar year to aligned pay for performance program

with HEDIS measurement year. The goal is to improve HEDIS rates.

Hospital QIP - Measurement Development Cycle Program ended. Changes highlighted on

page 23. We are wrapping up the measurement development period for HQIP 2016-17.

Some of the proposed changes are: 1) Re-clarification of the Rate of Elective Delivery ex-

clusions on hospitals with <30 denominator; 2) New targets for the Exclusive Breast Milk

Feeding Rate, and Vaginal Birth After Cesarean (VBAC) measures to reflect recom-

mended targets from the Joint Commission and national averages; 3) Reassignment of full

and partial points in the California Maternal Quality Collaborative (CMQCC) measure to

accommodate new vs. existing hospitals’ participation in the data center The final meas-

urement set will go to PAC for approval this month. The HQIP is introducing a small

measurement set for 2016-17 for hospitals with less than 50 general acute beds with at

least 20 PHC MediCal only admissions.

Performances Measurement Activity - HEDIS Medical Record abstraction and over read

ended Monday for QI and the HEDIS nurses reviewed over 11,00 records. We are now

preparing for the HSAG HEDIS auditors to review charts for accuracy and will be fol-

lowed by a final HEDIS rates reporting. Preliminary rates are looking pretty good and

showing improvement on some measures

Partnership Improvement Academy –

1. There were two primary training mechanism to teach improvement skills within the

PHP teams, ABCs of QI (one day- program) and ADVANCE (10 month- program).

ABCs of QI was held in Eureka last April and for Redding in July. The third season of

ADVANCE program will re-launch early 2017. A curriculum inspired by this program

is underway to establish a better mechanism on improving skills within teams.

2. Improvement Initiative - Summary of recent activity was highlighted on page 24. The

Management Pain Safety (MPS) team is working on a formulary change that would

take effect in June in response to CDC recommendation on limits of prescription.

3. Partners in Palliative Care pilot completed and results were shared in April. A signifi-

cant finding showed that Providers (PCPs and specialists) and the general public do not

have a clear understanding of palliative care. Recommendations included: 1) Provide

advance care planning and POLST training to teams (focus on having conversations

with younger patients); 2) Select provider sites with an interdisciplinary palliative care

team, adequate FTEs, and outreach plan; 3) Continue providing infrastructure and pro-

ject support (at the health plan level) to promote project continuity and sustainability.

Summary bullet points can be found on page 25.

None. 5/18/2016

Page 6 of 199


MEETING MINUTES


QI Update, continued

4. Advance Access Collaborative period ended with six applications from primary care

practices who were interested in the program. Applications that were received are cur-

rently on review. Interested practices could still reach out to QI Program as the appli-

cation period has been extended. The Primary Care Access workgroup continues to

monitor PCP access data, including, clinics open/closed to auto assignment, members

within 10 miles of a PCP office, and specific activities targeted at improving access.

In the coming months we’ll be integrating NCQA PCP access measurement require-

ments into our work.

The State Mandated Performances Improvement Project:

1. Open Door’s Eureka Community Health Center continues to partner with PHC and

North Coast Clinical Network (NCCN) in conducting a DHCS-required Performance

Improvement Project (PIP) on the Controlling High Blood Pressure measure. In April,

the team kicked off its first intervention which focused on taking a second BP meas-

urement for all hypertension patients later in the office visit. The team has started plan-

ning two additional interventions, including offering hands-on training to patients us-

ing home-monitoring BP cuffs and developing nurse protocols for follow-up nurse vis-

its after a patient starts a new or changed BP medication.

2. PHC is excited to partner with Baechtel Creek in Mendocino County on our DHCS-

required Performance Improvement Project (PIP), focused on Diabetic Retinopathy

Screening. Baechtel Creek is one of six EyePACs camera recipients. Caron Lee, QI

Improvement Advisor will be working closely with Baechtel Creek in teaching the

Model for Improvement and supporting the 12-18 month PIP.

NCQA Accreditation Mock Survey was conducted April 7and 8, 20016. Interim

Accreditation could move forward in early mid- 2017, however the evidence for the First

full survey will require additional work that includes updating delegation agreements; de-

veloping and implementing two disease management programs, providing a case manage-

ment system that meets NCQA requirements and assignment of NCQA elements to PHC

staff. We are in the process of completing a proposal seeking Board approval for moving

forward in June.

3. Health Plan Update

Dr. Moore, Committee Chairman and Chief Medical Officer presented the following up-

date: Pharmacy Department - Implementing next formulary modification in managing

Pain and Safety program that focuses on Opioids Medications limit to thirty (30) tablets

without prior authorization. Prior authorization will be required for additional fills. A total

of 14,575 patients were on chronic short acting Opioids. Concerns amongst Surgeons in

regards to limiting Opioid use were discussed. Weekend hourly staff are in placed to mini-

mize delays on waiting period for patients on Opioids. Please refer to the FAQ for more

details. In addition, PHC found large numbers of Dentists were prescribing Opioids to

their patients. Reference materials were distributed to Dentists within PHC’s network in

regards to controlled use of Opioids Medications for dental pain. As mentioned, our Phar-

macy Dept. is working on re-evaluating usage carefully to be more cost-effective. Health

Homes for Patients with Complex Needs Program - The State estimate to give out rates in

September are perceived as non-favorable numbers. PHC is developing its own cost esti-

None. 5/18/2016

Page 7 of 199


MEETING MINUTES


Health Plan Update,

continued

mates to the State for considering rates based on experience. In June, Cal State San Mar-

cos is offering online curriculums for Case Managers. Courses will include Introductory,

Advance and Leadership training. These models were considered better than the previous

courses. Regional Medical Director Meetings - Clinical leaders from various regions par-

ticipated in the last of the four meeting held in Ukiah CA. The meeting had a positive out-

come and seems to becoming less controversial.

II. Old Business

There was no old business discussed at this meeting.

III. New Business

1. Consent Calendar Consent Calendar (attachments)


MCQP1025 Behavioral Health/ Substance Abuse Facility Site Review

MPQP1003 Physician Advisory Committee (PAC) Policy

MPQP1023 Access Standards


HKUG3072 Inpatient Utilization Management (Knox-Keene)

HKUP3070 External Independent Medical Review

HKUP3074 Medical Transportation

MCUG3002 Acupuncture Services Guidelines

MCUG3010 Chiropractor Services Guidelines

MCUG3024 Inpatient Utilization Management

MCUP3100 Women, Infants and Children (WIC) Supplemental Food Program

MCUP3128 Cardiac Rehabilitation

MCUP3130 Osteopathic Manipulation Therapy

Approved with changes to

MPQP 1003, which was de-

ferred.

5/18/2016

2. Cultural & Linguis-

tic Health Educa-

tion Update.

Betsy Campbell, MPH, Senior Health Educator, presented findings of a recently con-

ducted PHC provider relations survey which surveyed many areas that addressed culture

and linguistic needs of our membership. This report gave a description of provider sites in

counties, comparing small and large practice sites. Questions asked included 1) Serving

patients who speak limited or no English; 2) Interpretation needs and informing patients

of their options for interpretation services; 3) Documentation in the member’s record

when family members/friends provide the interpretation; 4) Documentation in the record

when patients decline interpretation services; 5) Site assessment of the fluency of inter-

preting skills of employees; 6) Effectiveness of the PHC Language Line; 7) Difficulty for

staff in communicating with patients due to language barrier; 8) Member’s noncompliant

due to cultural difference or language barriers; 9) Use of alternative medicines and treat-

ment; 10) Reading level of health literature and instructions. As a result of the findings,

improvement interventions are in place. Several articles have been published that address

the use of friends and family members to interpret; documentation in the medical record

when members decline services, reminder that patient educational materials should be at

an appropriate reading level – 6th grade; and reimbursement for the medical interpreter

certification assistance program. Also work has begun to make it easily to find and access

patient educational materials on our website.

None. 5/18/2016

Page 8 of 199


MEETING MINUTES


3. Grievances Report

w/ State Hearing

Dr. James Cotter, Associate Medical Director, reported on 4th Quarter 2015 Complaints

and Grievances. . Eighty-four (84) complaints were filed during the review period. The

top 5 reasons for complaints to be filed were: Other (43); Quality of Care (21); Rudeness

(10); Miscommunication (4); Denial of care (4) and Access (2). Ninety-eight percent

(98%) of directed issues for “quality of care concerns” were not quality concerns but due

to requests for change of primary care providers. The Grievance Department will provide

more detail in the next reporting to better understand the quality concern issues. For Ap-

peals: 66 appeals were filed during the review period. The top 3 reasons were Power

Wheelchairs; Direct Member Reimbursement and transforaminal Epidural Injection. Of

the 60 appeals closed during this period; 30 were overturned, 24 upheld, 3 overturned with

modification, 1 partially overturned, 1 modified and 1 dismissed. The Grievance staff

continuously seeks improvement on processing appeals.

None. 5/18/2016

4. PCP QIP Final

Measure Set

Jess Liu, Manager of Quality Incentive Programs, presented information on the final

measurement set. MS. Liu highlighted informational approved changes in fixed pool

measures and unit service measures for 2016-2017(attachment p.54 of the e-packet). The

Fixed Pool Measures consists of Clinical Care; Appropriate Use of Resources; Access,

Operations, and Patient Experience. In the Unit of Service Measures, a noticeable change

mentioned was the expansion of Advance Care planning Attestations for all adult Medi

Cal members. Other Unit of Services measures include access, peer led self-management

support groups, immunization registry, SBIRT to name a few. In closing, HIE 2nd measure

adds $2500 incentive for sites who establish linkage to HIE. For more specification please

see attachments.

None. 5/18/2016

5. 2014-15 QP

Evaluation

Ms. Liu revisited highlights from 2014-2015 PCP QIP Evaluation. Briefly discussed were

the QIP’s financial incentives, data reporting, and technical assistance to all primary care

providers, and the two category measures (fixed pool and unit of service). In 2014-2015

reporting year, we experienced over 200 providers that participated across 14 counties

with 28 million dollar total payout. This period shows membership growth. Ms. Liu ad-

dressed quality of care provided to our members as measured by the PCP QIP; and how

well providers perform across the measures. Nancy Steffen, Associate Director of QI,

Analytics and Project Management, addressed distribution of total points and earnings

across provider sites and provider engagement. Some of the summary findings noted in-

cluded: Quality of care received by our members has improved across the QIP measures.

Providers performed better on clinical measures which were risk-adjusted. Adjusted

points earned remained stable compared to 2013-14 and the distribution of points was

similar in both regions. Provider engagement remains strong. PHC will continue to reach

out to consortia and providers in both regions.

None. 5/18/2016

6. PHC Star Update

Due to the limited time for discussion, members were referred to the PHC Star Update in

the packet.

None. 5/18/2016

7. MCQG1005 Adult

Preventive Health

Guidelines

Dr. Moore gave an overview of changes to the adult preventive health screening guide-

lines attachment to policy MCQG1005 ( Guideline discussion starts p. 218 of the e-

packet )

Updated approved Policy:

Recommendation for HIV screenings

Approved with changes. 5/18/2016

Page 9 of 199


MEETING MINUTES


MCQG1005,

continued Lung Cancer screening

TB screening “typo error” changed

Vaccination made more generic

Diabetes screening for over age 40

Dental annual referral

Depression screening for all ages when risk factor is present

Pregnancy screening

Mammography modified

MCUP3105

8. Coordination of

Services for

Members Requiring

Long Term Care

Debra McAllister, RN, Associate Director, UM presented the policy revisions. The pur-

pose of the policy is to define the process for coordinating services for PHC’s members

requiring long term care. Ms. McAllister noted revision to Section VI.E. UM review and

Determination. This pertains to newly admitted member for custodial care request, along

with other minor revised language.


5/18/2016

MCUP3041

9. TAR Review

Process

This policy describes the procedure used by PHC Utilization Management Department to

process Referral Authorization Forms (RAFs) and Treatment Authorization Requests

(TARs) based upon the medical necessity of the request. Revisions were discussed by

Ms. McAllister.


5/18/2016

HKUP3080

10. TAR Process (HK

only)

Ms. McAllister also discuss the changes to this policy which describes the procedure used

by the UM Department to process Treatment Authorization Requests (TARs) based upon

the medical necessity of the request.


5/18/2016

11. Policy Disclaimer Peggy Hoover, RN, Health Services Senior Director, discussed Policy Disclaimer policy. Approved without changes.

5/18/2016

V. Additional Business

There was no additional business discussed at this meeting.

Signature of Approval: ____________________________________ Date: ______________________________

Robert Moore, MD, MPH – Chairman

Page 10 of 199

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MEETING MINUTES

Committee: INTERNAL QUALITY IMPROVEMENT [IQI] MEETING

Date/Time: May 10, 2016_Tuesday_1:30PM – 3:30PM_Board Room, 3rd Floor

AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS

/ ACTION

TARGET

DATE

DATE

RESOLVED

I. Call to Order

and Approval

of Minutes

The meeting was called to order at 1:30 pm.

Minutes from the 4/12/2016 IQI meeting were reviewed.

Approved without changes. 5/10/2016

II. Standing Agenda Items (Full Committee)

1. Status of Open

Action Items

There was no open action item discussed.

2. QI Update

Jessica Thacher, MPH, Director of Quality and Performance Improvement, provided an update on

key activities occurring in the Quality and Performance Improvement department. Primary Care

Provider Quality Improvement Program (PCP QIP): We internally are exploring the possibility to

transition the PCP QIP program period from the fiscal year (July 1 – June 30) to the calendar year

(January 1 – December 31). This proposal is to align the pay-for-performance program with HEDIS,

with the goal to improve HEDIS performance, which is important in our understanding of the quality

None. 5/10/2016

Members Present:

Barton, Donna, RN, Regional Team Manager/UM (R) Lauck, Cristina, RN, Manager, General Case Management

Campbell, Betsy, MPH, Senior Health Educator Leung, Stan, PharmD, Director of Pharmacy Services

Cotter, James, MD, MPH, Associate Medical Director Moore, Robert, MD, MPH, Chief Medical Officer, Chairman

Gibboney, Liz, MA, Chief Executive Officer Netherda, Mark, MD, Regional Medical Director

Harris, Nadine, RN, MBA, QI Compliance Manager Scuri, Lynn, Regional Medical Director

Kerlin, Mary, Senior Director, PR Smith, Lyle, Director, Operations Excellence & PMO

Kubota, Marshall, MD, Regional Medical Director Thacher, Jessica, MPH, Director, Quality and Performance Improvement

Members Absent:

Endsley, Scott, MD, Associate Medical Director McAllister, Debra, RN, Associate Director of UM

Hoover, Peggy, RN, Senior Health Services Director Shaffer, Debbie, Senior Director, Member Services

Layne, Robert, Director, Government and Public Affairs

Guests: Barresi, Katherine, RN, Associate Director of Care Coordination Guillory, Ledra, Senior Provider Relations Representative Manager

Bjork, Sonja, JD, Chief Operating Officer Jenkins, Shauncey, Member Services MSR Supervisor

Blockman, Tami, QI Project Coordinator II Liu, Jess, MPH, Manager of Quality Incentive Programs

Borsetto, Catherine, Grievance Manager Sewell, Kelley, Northern Region Director of MS & PR

Choudhry, Marya, MPH, QI Senior Project Manager Stephen, Karen, PhD, Health Services Mental Health Director

Dionisio, Joy, MPH, QI Project Coordinator I Turnipseed, Amy, Director of Policy and Program Development

Gerardi, Marianne, RN, MPH, Performance Improvement Clinical Specialist I

Page 11 of 199


QI Update,

continued

of care delivered to our members and in our upcoming NCQA accreditation. The QIP team will

collaborate with other departments to come up with a detailed project timeline and will bring this

recommendation to the Project Review Board. Hospital Quality Improvement Program (HQIP): We

are wrapping up the measurement development period for HQIP 2016-17. The proposed changes

are: 1) Re-clarification of the Rate of Elective Delivery exclusions on hospitals with <30

denominator; 2) New targets for the Exclusive Breast Milk Feeding Rate, and Vaginal Birth After

Cesarian (VBAC) measures to reflect recommended targets from the Joint Commission and national

averages; 3) Reassignment of full and partial points in the California Maternal Quality Collaborative

(CMQCC) measure to accommodate new vs. existing hospitals’ participation in the data center; 4)

Proposal of new Venous thromboembolism (VTE) measures to replace retired Centers for Medicare

and Medicaid Services (CMS) measures; 5) Usage of an ADT interface with Health Information

Exchange (HIE) or PHC interface. The final measurement set will go to PAC for approval this

month. HEDIS: PHC’s Quality Improvement team is in the final stage of Medical Record Retrieval

and Review. As of May 1, 2016, PHC retrieved and reviewed over 11,000 medical records. The

HEDIS team continues to work hard to ensure we capture the quality of care provided to our

members. Performance for HEDIS 2016 will be available by August 1, 2016 to both internal and

external stakeholders. Partnership Quality Dashboard: IT and Finance are working closely on phase

1 of the PQD project. The current focus is on integration of the PCP QIP Non-clinical measures into

the dashboard, as well as on general design principles for displaying the data effectively. The QI

department is evaluating staffing needs to effectively support this project from the business

perspective. ADVANCE: The ADVANCE Cohort 2 is winding down, with only two short months to

go. The eleven participating practices continue to apply the Model for Improvement methodology to

their selected project and many are beginning to see some exciting outcomes. The teams will meet

for a final learning session and program celebration on June 16 – 17, 2016. As a result of one of our

provider practice’s focus on improving colorectal cancer screening rates, PHC is working with Quest

to make important process changes to the FIT test that is offered to many of our members, reducing

the test from a two-sample to a one-sample test. We believe this will improve member compliance

and, thus, improve rates. The Southern Region QI department is creating a new program – inspired

by ADVANCE – to help train internal staff on the Model for Improvement and related improvement

skills. The program will combine didactic instruction with project-based application and coaching.

The pilot training will be offered primarily to QI department staff, with a few spots open to other

interested PHC participants. The goal is to offer the training on a recurring basis. Cohort 1 will run

from Sept – Dec 2016. ABCs of QI: Redding QI department staff attended the training, with the aim

to teach the ABCs of QI in the Northern Region moving forward, beginning with the next ABCs of

QI planned for July 19 in Redding. Managing Pain Safely: In March 2016 the CDC made a new

recommendation for using opioid pain medications for acute pain. According to the CDC, the lowest

effective dose of fast-acting opioid prescriptions should be prescribed for 3 days or less. In June

2016 PHC will adopt these recommendations and implement an additional formulary enhancement.

PHC will place a quantity limit of 30 pills on all new start immediate release prescriptions. If more

medication is needed, a Treatment Authorization Request (TAR) will be required to ensure the

treatment is safe and appropriate. These limits will not affect patients on stable, ongoing short-acting

opioid prescriptions. Offering and Honoring Choices: Partners in Palliative Care: The qualitative

evaluation of the pilot is complete; the consultant who led the evaluation presented the findings and

recommendations to DHCS, CHCF, and the four palliative care teams on 4/26/16. Controlling High

Page 12 of 199


QI Update,

continued

Blood Pressure: Open Door’s Eureka Community Health Center continues to partner with PHC and

NCCN in conducting a DHCS-required Performance Improvement Project (PIP) on the Controlling

High Blood Pressure measure. In April, the team kicked off its first intervention which focused on

taking a second BP measurement for all hypertension patients later in the office visit. The team has

started planning two additional interventions, including: offering hands-on training to patients using

home-monitoring BP cuffs and developing nurse protocols for follow-up nurse visits after a patient

starts a new or changed BP medication. HSAG also requested a small revision to our process map in

the Module 3 submission from the end of February. The PHC team members completed this revision

and returned it to HSAG for final review on 4/18. Compliance: The NCQA Accreditation Mock

Survey was completed April 7 and 8. Primary findings included: Interim survey could be

accomplished as early as mid-2017, however, the evidence for First survey is lagging. Since First

survey occurs within 18 months of Interim survey, the organization needs time to implement all of

the Member Connection (MEM) standards and the Web-based provider directory. These standards

are resource and time intensive. All delegation agreements must be updated. This is one of the most

significant findings in this report for Interim survey. The consultant will provide an example

delegation agreement. Develop and implement two disease management programs; another

significant finding. Case management must be supported with a system that includes NCQA

requirements; an important resource to ensure file review goes well. All NCQA elements must

assign a responsible party. The organization should develop a timeline for completion of outstanding

evidence using the recommendations in this report. PHC is completing a Board proposal seeking

approval to move forward with accreditation. The proposal will include a summary of findings from

the Mock Survey, a recommended timeline, and estimated budgetary implications. We submitted our

2016 QI Program Description, 2016 QI WorkPlan and 2015 QI Program Evaluation to DHCS in

early May. Staffing: The QI departments in Fairfield and Redding continue to welcome and onboard

new team members.

Robyn Gerdes, MPH – HEDIS Program Manager (Southern Region)

Amy Lasher – QIP Project Coordinator (Southern Region)

Jessica Delaney – QI Project Coordinator (Northern Region)

Christina McClenaghan – Analyst (Northern Region)

III. Old Business (Committee Members as Applicable)

There was no old business discussed.

IV. New Business (Committee Members as Applicable)

1. Consent

Calendar

There following were on the consent calendar this month:

Delegation Reports – Credentialing/Re-credentialing

BayChildren’s Physicians 2016 1st Qtr

Vision Service Plan – Health Kids 2016 1st Qtr

Vision Service Plan – Medi-Cal 2016 1st Qtr

Sutter Medical Foundation – Solano Regional Medical Group 2016 1st Qtr

Sutter Medical Foundation – Sutter West Medical Group 2016 1st Qtr

Sutter Pacific Medical Foundation – Redwoods and Marin Headlands 2016 1st Qtr

UC San Francisco Medical Group 2016 1st Qtr

Woodland Clinic 2016 1st Qtr


Page 13 of 199


Consent

Calendar,

continued

Provider Relations, no substantive changes

MPCR4B - Identification of HIV/AIDS Specialists

MPCR17 - Standards for Contracted Primary Care Providers

MPCR#6- Non-Physician Medical Practitioner Credentialing Criteria

MPCR#8 - Non-Physician Medical and Allied Health Practitioner Re-Credentialing Criteria

KKPDR#1 – Provider Dispute Resolution Process

KKPDR#2 – Acknowledgement of Provider Disputes

KKPDR#5 – Dispute Logs and Reports

KKPDR#7 – PHC Staff Provider Dispute Review Committee

KKPDR#8 – Dispute Resolution on Appeals

KKPDRPRO#3 – Provider Disputes

KKPDRPRO#4 – Provider Dispute Case File

KKPDRPRO#6 – Review of Provider Disputes


MCQP1025 Behavioral Health/ Substance Abuse Facility Site Review

MPQP1003 Physician Advisory Committee (PAC)

MPQP1023 Access Standards


HKUG3072 Inpatient Utilization Management (Knox-Keene)

HKUP3070 External Independent Medical Review

HKUP3074 Medical Transportation

MCUG3002 Acupuncture Services Guidelines

MCUG3010 Chiropractor Services Guidelines

MCUG3024 Inpatient Utilization Management

MCUP3100 Women, Infants and Children (WIC) Supplemental Food Program

MCUP3128 Cardiac Rehabilitation

MCUP3130 Osteopathic Manipulation Therapy

2. Cultural &

Linguistic

Health

Education

Update

Betsy Campbell, MPH, Senior Health Educator, reviewed the Cultural and Linguistic survey results.

Responses were addressed in a Corrective Action Plan (CAP) based on results of the C&L survey of

our contracted primary care provider sites, conducted by PHC Provider Relations staff during the

months of August and September, 2015. A total of 276 surveys were sent, 201 returned, for a 72.8%

response rate. Results were reviewed by the C& L workgroup. Suggestions and recommendations

for a corrective action plan were discussed. Best practices on handling conference calls between

patients, providers, and doctors were also discussed.

None. 5/10/2016

3. Grievance

Report w/

State Hearing

Catherine Borsetto, Grievance System Manager, provided a brief report as follows: For the 4th quarter

of 2015, there were 84 complaints, 66 appeals, and 30 state hearings. The top reasons for complaints

to be filed were quality of care, access to care, denial of care, rudeness, and miscommunication. The

top reasons for filing an appeal were power wheelchairs, direct member reimbursement, and

transforaminal epidural injection. The top reasons for filing a state hearing were member request

disenrollment from PHC, power wheelchair, special member status, and denied claims. For the 1st

quarter of 2016, there were 93 complaints, 74 appeals, and 27 state hearings. The top reasons for

complaints to be filed were quality of care, access to care, denial of care, and rudeness. The top

reasons for filing an appeal were billing issues, Lyrica, power wheelchairs, Stanford referrals, and

None. 5/10/2016

Page 14 of 199


Grievance

Report,

continued

transforaminal epidural injection. The top reasons for filing a state hearing were member request

disenrollment from PHC, power wheelchair, and Stanford referrals.

4. PCP QIP Final

Measure Set

There were fewer changes on the measurements as well as new ones. The monitoring process with

HEDIS for quality of healthcare services were again compared. Event Planning were also mentioned

on the agenda. The Advance Care Planning were mentioned as open to all member. In closing, the

Health Information Exchange Measures would be added for established sites in alliance with QIP.

None. 5/10/2016

5. 2014-15 QIP

Evaluation

Marya Choudhry, MPH, Senior Project Manager, and Joy Dionisio, MPH, Project Coordinator I,

discussed the 2014-15 QIP evaluation. The evaluation is pertaining to the payment sent last year

with the reporting period from June 2014 to July 2015. The PCP QIP is PHC’s pay for performance

program for our primary care provider network. The PCP QIP measurement set includes two

categories of measures which are the fixed pool measures and unit of service measures. 218 provider

sites participated in the 2014-15 program. The total pay-out for the 2014-15 PCP QIP was $28

million, $10 million more than the 2013-14 program. Relative to the 2013-14 PCP QIP year,

performance improved among Southern Region providers on pediatric measures including: Child

BMI, Nutrition Counseling, Physical Activity Counseling, DTaP, and Adolescent Immunizations.

Performance declined significantly on the Monitoring for Patients on Persistent Medications and

Cervical Cancer Screening measures. There were some shifts in performance across the suite of

diabetes measures. Relative to national Medicaid HEDIS benchmarks, high performing measures

included Child BMI (>90th), Adolescent Immunizations (75th), Nutrition Counseling (75th), DM BP

Control (75th) and DM Nephropathy (75th). The population-level rate for Cervical Cancer Screening

fell below the national MPL benchmark. There were two second-year measures reported by Northern

Region provider sites – Cervical Cancer Screening and DTaP. Both saw statistically significant

improvement compared to baseline; however, very few providers met the 90th percentile targets.

Among first year measures, more than half of the sites met the 50th percentile target in Adolescent

Immunization, DM Nephropathy, Child BMI, and DM LDL-Testing. Few sites met the 50th

percentile in Well Child Visits and Retinal Eye Exam, and no site met the Controlling High Blood

Pressure target. Hospital utilization – both Admissions and Readmissions – is high in both regions

compared to prior years. Access to primary care, as measured by the number of Office Visits and the

number of Practice Open to PHC Members, continues to be a challenge our members face.

Performance was strong in both the formulary and generic prescription rates. The Northern Region

saw significant improvement in the ED utilization measure. Because targets are risk adjusted for

many non-clinical measures, the drop in performance on some measures did not necessarily correlate

to less providers meeting targets. Despite higher performance targets and more members, program

performance as measured by adjusted points earned remained stable compared to 2013-14.

Distribution of points was similar in both regions. Larger sites earned more points than smaller sites.

Engagement of providers remained strong. Compared to the previous year, more sites participated in

webinars, utilized eReports, and submitted data to maximize point earnings.

None. 5/10/2016

6. PHC Stars

Update

Robert Moore, MD, MPH, Chief Medical Officer, provided an update on the PHC Stars program.

The first of our PHC-wide goals is to ensure our members receive high quality care, as reflected in

our PHC Stars program. PHC stars includes 13 measures. In the last four months, the PHC team has

implemented the plan put together in the latter half of 2015, around HEDIS data collection, re-

pursuit, technology and staff training. The team is in the middle of the re-pursuit efforts, so final

None. 5/10/2016

Page 15 of 199


PHC Stars,

continued

scores are not yet known. The HEDIS team is gathering lessons learned to develop a plan for next

year. A number of supplemental data sets were used to improve data collection.

7. Mental Health

Oversight:

Beacon,

Kaiser, Optum

There were no substantive changes in teams and meetings. Although, organizational change in the

Beacon chart was mentioned. General issues found on pages 258-262 were highlighted to reflect

minor variations from November’s reporting. In summary, several points were discussed.

Mainly, a resolved potential dispute, participations in Small County Meetings, exploring Beacon’s

new Cal Consult Program and most importantly the timeliness of Claims.

None. 5/10/2016

8. MCQG1005

Adult

Preventive

Health

Guidelines

Dr. Moore discussed the changes to this policy, which was deferred at the April meeting. The

purpose of this policy is to specify and define PHC guidelines for adult health screening and

preventive services provided by primary care physicians to adults age 19 and over, as recommended

by the United States Preventive Services Task Force (USPSTF) and other nationally recognized

standards of practice.


9. MPQP1023

Access

Standards

This policy was moved to the consent calendar due to minor changes.

10. MPRP4020

Restricted

Status for

Members

Receiving

Prescription

Medications

Stan Leung, PharmD, Interim Pharmacy Services Director, discussed the changes to this policy. The

purpose of this policy is to describe the process for members to be placed on restricted status for

receiving prescription medications.


11. MCUP3105

Coordination

of Services

for Members

Requiring

Long Term

Care

Debbie McAllister, RN, Director of Utilization Management, discussed the changes to this policy.

The purpose of this policy is to define the process for coordinating services for PHC members

requiring long term care.


12. MCUP3041

TAR Review

Process

Ms. McAllister discussed the changes to this policy. The purpose of this policy is to describe the

procedure used by the Partnership HealthPlan of California (PHC) Utilization Management (UM)

Department to process Referral Authorization Forms (RAFs) and Treatment Authorization Requests

(TARs) based upon the medical necessity of the request.


13. HKUP3080

TAR Process

(HK only)

Peggy Hoover, RN, Senior Director of Health Services, discussed the changes to this policy. The

purpose of this policy is to describe the procedure used by the PHC Utilization Management

(UM) Department to process Treatment Authorization Requests (TARs) based upon the medical

necessity of the request.


14. NEW: Policy

Disclaimer

(HK only)

Ms. Hoover presented the suggested wording for a new policy disclaimer for Healthy Kids only. Approved without changes. 5/10/2016

V. Additional

Business

There was no additional business discussed.

Page 16 of 199


VI. Adjournment

The meeting was adjourned at 3:31 pm.

Respectfully submitted by Nadine Harris, QI Compliance Manager

Signature of Approval: ____________________________________ Date: ______________________________

Robert Moore, MD, MPH, Chairman

Page 17 of 199

IQI QI Department Update June 2016

Prepared by Jessica Thacher, Director of Quality and Performance Improvement

Incentive Programs (QIPs)

Primary Care Provider Quality Improvement Program (PCP QIP):

• With the 2015-16 PCP QIP year closing June 30, the QIP team is hosting a Wrap-Up webinar on June 14 to share important information on program timelines to help providers maximize their point earnings in the QIP. At the same webinar, the QIP team will also share highlights from the 2014-15 QIP evaluation with the provider network.

• All provider-submitted data to the QIP are subject to PHC audit. The 2015-16 QIP audit started in May and will conclude by the close of the QIP measurement year at the end of June. The purpose of this audit is to ensure data submissions in eReports can be substantiated with corresponding medical records located in provider offices. These audit results should be helpful in demonstrating eReports is a viable supplemental data source for select measures in HEDIS 2017.

• The 2016-17 PCP QIP Measurement set will be posted on our website by July 1, 2016. To jump start the new measurement year, the QIP team is hosting two Kick-Off webinars, on July 26 & 27. This is an opportunity for providers to get to know the new/changed measures for 2016-17.

• Upon the approval of the measurement set for 2016-17, the QIP and IT teams started scoping the eReports upgrade required to launch the new measurement year. The ‘16-17 BRD has routed to IT for review and approval. Coding and testing/validation remain as critical next steps in June and July.

• The QIP team will bring a high-level proposal on transitioning the QIP program period from the fiscal year (July 1 – June 30) to the calendar year (January 1 – December 31) to the Project Review Board (PRB) on June 7. A detailed project plan and timeline will be drafted following the PRB meeting.

• In our Northern Region, PR and QIP teams are initiating discussions with PCP sites on how to improve their QIP performance. Thus far, 9 PCPs in Shasta, Lassen, Trinity, Del Norte, and Humboldt counties have agreed to set improvement goals and to meet on a recurring basis with PHC coaching staff.

Long-Term Care Quality Improvement Program (LTC QIP)

• Health Services Advisory Group (HSAG) is hosting the last session of its learning series “Infection Control” in Berkeley, CA, on June 30. By attending this training, facilities will have the opportunity to receive their first 15 points in the LTC QIP. We are collaborating with HSAG to organize the same training in the Redding/Eureka area sometime in October. We will share more information once the details are finalized.

Hospital Quality Improvement Program (HQIP)

• We are in the process of potentially onboarding 12 new hospitals for 2016-17 Hospital QIP. We are working closely with Finance and PR on the onboarding process.

• We have finalized our proposed measurement set for the 2016-17 Hospital QIP and will seek approval from the Physician Advisory Committee in the June meeting. The measure specifications document will be posted on our website by July 1.

Page 18 of 199

Performance Measurement Activities

HEDIS

• The HEDIS team has successfully concluded our medical record collection, abstraction and overread as of May 16th. We collected and reviewed over 15,000 medical records. Preliminary regional performance looks good relative to prior years. Three out of four regions have improved from last year and PHC has passed our Medical Record Review Validation audit with zero errors. We are targeting a release date of July 31st for both our Regional and County level performance and will kick-off plan wide communication via committee structure in August. Congratulations HEDIS team on a successful HEDIS 2016!

Partnership Quality Dashboard

• IT and Finance are working closely on phase 1 of the PQD project. The current focus is on integration of the PCP QIP Non-clinical measures into the dashboard, as well as on general design principles for displaying the data effectively.

Partnership Improvement Academy

ADVANCE

• Cohort 2 of the ADVANCE Improvement Advisor Training program will complete their final learning session on June 17, 2016. The eleven participating practices will gather, along with their executive sponsors, to project outcomes and learnings and to develop a plan for spreading and sustaining their improvements. A program evaluation will be completed in July and presented in the fall of 2016.

ABCs of QI

• PHC, NCCN and HANC will host an in-person offering on July 19th in Redding at the Red Lion. This is the second offering in the Northern Region in 2016 and supports our goal to develop qualified trainers to make these offerings more accessible to our rural providers.

Improvement Initiatives

Managing Pain Safely

• In March 2016 the CDC made a new recommendation for using opioid pain medications for acute pain. According to the CDC, the lowest effective dose of fast-acting opioid prescriptions should be prescribed for 3 days or less. On June 1, 2016, PHC adopted these recommendations and implemented an additional formulary enhancement. PHC has placed a quantity limit of 30 pills on all new start immediate release prescriptions. If more medication is needed, a Treatment Authorization Request (TAR) will be required to ensure the treatment is safe and appropriate. These limits will not affect patients on stable, ongoing short-acting opioid prescriptions.

• The PHC Medical Directors began sharing site-level data for provider sites with 15 or more patients on high dose opioids (>120mg MED). Throughout the month of May, PHC shared data with over 20 provider sites.

Page 19 of 199

• The MPS Pharmacy Workgroup will be utilizing the MPS Pharmacy Toolkit to conduct academic detailing in Sonoma and Napa counties during the month of June. The toolkit has been piloted with 35 pharmacies and is now available on the PHC webpage.

• PHC will be expanding the naloxone program to additional sites. The MPS team has created a naloxone toolkit, which includes site level program recommendations and workflows, provider and pharmacy naloxone guidelines, and patient education material. Thus far, 6 provider sites have partnered with PHC in this program, and 4 additional sites are interested in starting. PHC is currently seeking additional sites to participate.

• On June 21, 2016, Dr. Tom Bertolli will be conducting a webinar on the Who, What, Why, and Where of Medication Assisted Treatment. This webinar will discuss setting up a site level medication assisted treatment program at an FQHC. You may register for the webinar here: https://attendee.gotowebinar.com/register/5640717126055426306 . Following the webinar, on June 28, 2016 from noon-12:30, Dr. Bertolli will be available for a question and answer office hour session (call in- 1-866-951-1151; 9879782).

• Sonoma County has adopted an Opioid Reduction and Safe Use group through their well-established Community Health Initiative. The Provider Action Team has developed prescribing guidelines, which are expected to be adopted soon.

• We continue to target further community engagement and potential coalition building opportunities in our more rural areas. A Lunch-n-Learn is planned for 6/28 in Crescent City with a goal of creating a local community coalition in the upper NW region. So far, 13 of 26 invitations have been accepted. The Siskiyou Healthcare Collaborative is actively leading efforts to establish a county wide coalition with PHC assistance. The Shasta NoRxabuse coalition is working to provide 25 nasal sprays to first responders in law enforcement and developing an MAT education session for the fall.

• The Partnership for Complex Care team has develop an integrated system to improve care for opioid-dependent high utilizers. The team submitted their initial implementation plan to CHCF on 5/31. A final version of the plan is due to CHCF in mid-July. The focus until then will be refining data collection processes and responding to CHCF review comments.

Offering and Honoring Choices

• Partners in Palliative Care: PHC continues to support Partners in Palliative Care and new enrollments until the DHCS palliative care benefit becomes active. As of May 26, 2016, 100 members had enrolled in the program (57 active enrollment, 43 disenrolled).

• CCCC Annual Summit: The Coalition for Compassionate Care of California (CCCC) hosted its annual conference on palliative care on May 12-13 in Newport Beach. In addition to PHC’s Chief Medical Officer sharing about Partners in Palliative Care as part of a panel presentation, PHC presented a poster at the conference.

• Advance Care Planning at PHC: The internal workgroup aiming to promote advance care planning for PHC staff put together a survey to gauge knowledge of and interest in advance care planning. Training and Development released the survey at the end of May. The work group will use the survey results to determine what type of interventions to try and at what scale to promote advance care planning at PHC.

• PHC sponsored a train-the-trainer End of Life Nursing Education Consortium (CORE) program on 5/12-5/13 in Susanville at Banner Lassen. This program provided nursing staff necessary tools and education to improve Palliative Care services within hospitals and prepared staff to teach these principles to other nurses. This initial offering was very successful with 16 people in attendance,

Page 20 of 199

https://attendee.gotowebinar.com/register/5640717126055426306

representing 8 different hospitals and hospices in the region. PHC will be facilitating coaching sessions with this cohort in July to open dialogue on aspects of the training implemented at their institutions. The next training offering will be in Lake County on August 4-5, targeting 10 additional critical access hospitals.

Primary Care Access Improvement

• Seven clinics have submitted an application to participate in the Advanced Access Collaborative. The application period was extended and we anticipate receiving two additional applications. PHC will announce selected participants in early June and host a Kick Off webinar June 23. The program is scheduled to run June 2016 – April 2017.

• The Primary Care Access workgroup continues to monitor both aggregate and individual provider level data and patient level data, including, clinics open/closed to auto assignment, members within 10 miles of a PCP office, and specific activities targeted at improving access. This group will also be responsible for identifying, consolidating, and retiring policies related to access and/or access monitoring.

Social Determinants of Health: No new updates on the grant-funded projects. The SDOH steering committee will consider 16/17 goals and conduct some strategic planning around additional ways PHC can catalyze and support SDOH improvements.

Improving Diabetic Retinopathy Screening Rates:

• All 6 clinics participating in the Expanding DRS program submitted Diabetic Retinopathy (DR) screening baseline data in May. Baseline screening rates for PHC members at participating clinics ranges from 7% to 35%.

• EyePACS Screening was added to the list of allowable PCP to PCP RAFS. Providers are eligible for reimbursement for screening non-assigned members.

• An Important Provider Notice for PCPs using EyePACS Cameras was faxed to participating primary care providers and posted on the PHC Claims webpage (MCPN0217).

Controlling High Blood Pressure: Open Door’s Eureka Community Health Center continues to partner with PHC and NCCN in conducting a DHCS-required Performance Improvement Project (PIP) on the Controlling High Blood Pressure measure. Our focus in June will be in documenting a BP target in the medical record as determined by the provider and discussed with the member.

Outbound Call Reminder Pilot with Member Services – Colorectal Cancer Screening: This spring, Member Services offered to make outbound reminder calls for a clinic in the PHC network. In April, it made reminder calls to members assigned to Community Medical Centers, Dixon, who were due to complete colorectal cancer screening (which is also a new measure as part of the PCP QIP for the current fiscal year). CMC Dixon is one of the teams in the ADVANCE improvement advisor training program, and its QI project is to improve on its colorectal cancer screening rate. Of 277 CMC patients, Member Services reached (spoke with) 74 members (27%) and left voice messages for 96 (35%). It was

Page 21 of 199

unable to contact the remaining 107 members (39%) due to invalid phone numbers, inability to leave a voicemail or no one answered the phone. Focusing on the 74 members with whom Member Services spoke with when making the calls, as of 5/20/16:

• 29 had the FIT ordered (39% of 74 members) • 17 had completed the screening, or 59% of those who had the FIT ordered (23% of the 74 members) • The clinic will follow up with the 12 individuals for whom the FIT was ordered yet have not returned

their sample.

Compared to outreach oriented interventions (making reminder calls, sending reminder letters), these results are comparable. CMC Dixon has expressed profound thanks to Partnership for making these reminder calls and to inform patients of the colon cancer screening fair that it hosted on 4/25.

Northern Region Consortia Partnership: The NR QI, NCCN, and HANC teams continue to work under the action plans defined as part of our joint 2016-17 strategic improvement plan for the region. A summary of updates include:

• A successful focus group was held on May 9 in Redding with a small group of PCP providers and Women’s Health Specialists on the Cervical Cancer Screening HEDIS measure. This has been a particularly challenging measure for the region and thus, we are interested to learn more from providers who have performed well in this measure. Our goal is to develop future improvement ideas based on this sharing of best practices and efforts to overcome known obstacles in member and provider engagement. Our first step in sharing the learnings is to present the outcome of the discussion with the NCCN/HANC QI Peer Network on 6/9. We have also identified two NR providers to partner with us in a related improvement project this summer.

• The NR team met with Public Health in Shasta County in May to review shared goals in improving immunization rates. We are actively working together to support an immunization clinic (Tdap, MCV4) in early August at the Mount Shasta Mall. We expect further efforts to include providing member outreach and collaborating in targeted provider education.

• A subset of the team is working diligently to develop a multi-layered, cross-walk tool for educating providers on UDS, HEDIS, FSR, and QIP measurement sets. In May, the focus has been on building out the most detailed layer of the tool by measure groupings. The consortia has completed this work for UDS and the NR team will have QIP, HEDIS, and Site Review measures detailed by the end of June. We are on track to solicit provider feedback on our initial development by mid-summer and share the overall tool with all consortia members by October 2016.

NCQA Accreditation

• PHC is completing a Board proposal seeking approval to move forward with NCQA Health Plan Accreditation. The proposal will include a summary of findings from the Mock Survey, a recommended timeline, and estimated budgetary implications. The Board will review the proposal this month.

Page 22 of 199

I:\QUALITY\QI Assistant\QUAC\2016 Meetings\6.15.2016\Items on Consent\Consent Calendar 06.15.2016.doc


QUALITY IMPROVEMENT AVISORY COMMITTEE

CONSENT CALENDAR

Items on the Consent Calendar have minor or no changes and are recommended by staff for approval.


MPQP1016 Potential Quality Issues Investigation and Resolution 24-39


HKUG3071 Hospice Services Guidelines (HK Only) 40-47

HKUP3067 Appeals/Expedited Appeals of UM Decisions for Medical Necessity Determination

(Non-Administrative) 48-54

HKUP3073 Mastectomy and Breast Reconstruction 55-58

HKUP3077 PCP to Specialty Care Referral Process (RAF) 59-67

MCUP3041-A TAR Review Process 68-91

MCUP3057 Provider Appeals of Health Services Administrative Denials 92-95

MCUP3124 Referral to Specialists (RAF) 96-101

Page 23 of 199


POLICY/ PROCEDURE

I:\QUALITY\QI Assistant\QUAC\2016 Meetings\6.15.2016\Items on Consent\MPQP1016.docx

Page 1 of 8

Policy/Procedure Number: MPQP1016 (previously QP100116) Lead Department: Health Services

Policy/Procedure Title: Potential Quality Issue Investigation and

Resolution

☒External Policy

☐ Internal Policy

Original Date: 01/20/1996 - Medi-Cal

07/16/2008 - Healthy Kids Next Review Date: 06/15/2017

Last Review Date: 06/15/2016

Applies to: ☒ Medi-Cal ☒ Healthy Kids ☐ Employees

Reviewing

Entities:

☒ IQI ☐ P & T ☒ QUAC

☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving

Entities:

☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC

☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER

Approval Signature: Robert Moore, MD, MPH Approval Date: 06/15/2016

I. RELATED POLICIES:

A. MPCR #9 Fair Hearing Process for Adverse Decisions

B. MPQP1053 - Peer Review Committee Policy

II. IMPACTED DEPTS:

A. All Departments

III. DEFINITIONS:

A. A Potential Quality Issue (PQI) is defined as a possible adverse variation from expected clinician

performance, clinical care, or outcome of care. PQIs requires further investigation to determine whether

an actual quality issue or opportunity for improvement exists. Not all PQIs represent quality of care

issues.

B. A quality issue is defined as a confirmed adverse variation from expected clinician performance, clinical

care, or outcome of care, as determined through the PQI process.

C. A clinician or provider is any individual or entity engaged in the delivery of health care services licensed

or certified by the State to engage in that activity if licensure or certification is required by State law or

regulation.

D. A Corrective Action Plan (CAP) is a plan approved by the Peer Review Committee to help ensure that a

related quality issue does not occur in the future. CAPs contain clearly stated goals and time frames for

completion.

E. Severity Level: Refer to Attachment B: Case Leveling Grid

F. Egregious: Where the quality of care was significantly outside accepted and common standards of

practice and/or where the adverse outcome of the care provided was especially serious.

IV. ATTACHMENTS:

A. PQI Referral Form and Reference Table

B. Case Leveling Grid

V. PURPOSE: To provide a systematic method for the identification, reporting, and processing of a Potential Quality Issue

(PQI), to determine opportunities for improvement in the provision of care and services to Partnership

HealthPlan of California (PHC) members, and to direct appropriate actions for improvement based upon outcome, risk, frequency, and severity.

VI. POLICY / PROCEDURE:

A. IDENTIFICATION OF POTENTIAL QUALITY ISSUES

Page 24 of 199

http://eshare/sites/PoliciesnProcedures/Quality%20Improvement/MPQP1016%20-%20Attachments/MPQP1016-A.pdf

http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Quality%20Improvement/MPQP1016%20-%20Attachments/MPQP1016-B.doc&action=default



Resolution

☒ External Policy

☐ Internal Policy


07/16/2008 - Healthy Kids

Next Review Date: 06/15/2017



Page 2 of 8

1. PQIs are identified through the systematic review of a variety of data sources, including but not

limited to:

a. information gathered through concurrent, prospective, and retrospective utilization review;

b. referrals from health plan staff or clinicians;

c. facility site reviews;

d. claims and encounter data;

e. pharmacy utilization data;

f. HEDIS medical record abstraction process;

g. medical records audits;

h. phone log detail; or

i. grievances

2. TPQI reviews can be conducted on services provided by:

a. contracted clinicians or providers, including subcontractors, who provide inpatient and

outpatient services;

b. non-contracted clinicians and providers: cases involving non-contracted providers will be

discussed with the Chief Medical Officer (CMO) to determine next steps prior to embarking on

a review of the PQI;

c. durable medical equipment and medical supply providers;

d. pharmacy providers; home health; skilled nursing; long term care and rehabilitation facilities;

ancillary service providers including but not limited to lab, pharmacy, radiology, and

Emergency Medical Services; e. Division providers: complaints are tracked to their resolution by the Complaints, Grievances and

Appeals (CGA) Department. CGA refers vision complaints to the Peer Review Lead (PRL) to

monitor and trend.

f. Behavioral health: member complaints regarding behavioral health are referred to the

Behavioral Health staff in the Health Services Department for tracking, intervention, and

resolution.

B. PQI REFERRAL

1. PQIs may be reported by any of the following:

a. any PHC staff member;

b. anonymously using the PHC "confidential line” which is available 24 hours a day, 7 days a week

(1-800-601-2146);

c. any member of the community;

d. any contracted or non-contracted clinician or provider.

2. A PQI is reported to the PRL using the PQI Referral Form (RF). See Attachment A.

a. The following information, at a minimum, should be documented and promptly forwarded to the

PRL with a cc to the QI Administrative Assistant (QI AA).

1) the member's name, date of birth, gender, PHC member number, and Client Identifying

Number (CIN);

2) admission/discharge dates for any relevant hospitalization, and/or office visit dates if

applicable;

3) physician/provider name(s);

4) facility where problem may have occurred;

5) the date of the suspected/reported occurrence;

6) the date the PQI Referral Form was completed;

7) the name and department of the individual identifying the PQI, unless the issue was

submitted anonymously;

8) the box marked on the referral form that most closely describes the issue; and

9) a concise, factual description of the potential problem.

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3. Time frame limitations: In general, PHC will not investigate PQIs which occurred more than 2 years

prior to first notification of the QI department of the issue. If a PQI is identified that occurred more

than 2 years prior to the first notification, no investigation will be routinely started. The PQI form

will be reviewed by the CMO or designee. If the CMO or designee believes a serious quality issue

may have occurred and that the case warrants investigating, the CMO or designee may request the

PRL to start an investigation or refer it to PHC’s Per Review Committee (PRC) or to another peer

review body or regulatory agency, depending on the findings in the case.

C. PQI REVIEW-PRIMARY and/or URGENT REFERRAL FOR SECONDARY REVIEW

1. Upon receipt of the RF, the QI AA or his/her designee will enter it into the PQI database within two

business days. The QI AA will notify the PRL by e-mail that an RF has been entered and is ready

for initial review.

2. The RF is processed within 7 business days unless the issue is urgent. The PRL will triage the RF on

day one for urgent issues. If the issue is urgent, the PRL will contact the CMO or his/her designee

by phone with a follow-up secure-email by close of business that day.

3. Processing of the RF may include a request for pertinent medical records. The PRL must complete

review of the PQI within 20 business days from receipt of all medical records. The QI AA notifies

the PRL by e-mail when all records have arrived and the case is ready for review. During the 20-day

review period, if the PRL discovers that more records are required, an additional medical record

request is completed and given to the QI AA to follow-up. The QI AA notifies the PRL when

additional records have arrived and the 20 business day timeframe resets.

4. If the PQI occurred exclusively at one or more organizations with an accredited Peer Review

Organization (PRO) responsible for oversight of the care provided by the Clinician or Provider(s) of

Concern (POC), the PQI is not found to be urgent, and the potential severity of the PQI has been

determined by the CMO/designee to not reflect an egregious lapse in quality, the PQI will be

referred to the PRO. A response will be required from the PRO acknowledging they have received

the letter of concern. After this response is received, the case will be closed by the CMO/designee.

When a referral is sent to the outside PRO, a copy will be sent to the Chief of Quality and the

Quality Director at the outside organization. Concomitantly, the POC will be notified of the PRO

referral. No medical records will be requested. If the PQI cannot be leveled prior to referral, the case

will be leveled as either: Provider Unable to Determine or Facility Unable to Determine.

5. If the PQI is determined by the CMO/designee to be urgent or the potential severity may represent

an egregious lapse in the quality of care, the case will be referred to the outside PRO, but the

CMO/designee may elect to request medical records and review the case.

6. During case review, professionally recognized standards of care will be used to assess the care

provided. A PQI may be a single event or occurrence. While one report alone may not represent a

quality issue, trending of similar events may reveal a quality issue and may lead to the re-opening of

a case previously reviewed or closed.

7. If the PRL’s initial review determines there are no clinician/provider or system issues, the case is

leveled as a P0 (no provider issues) or an S0 (no system issues) and the PQI is closed in the

database. If the PRL determines that the member needs immediate assistance beyond the scope of

peer review, appropriate information will be forwarded to other involved departments for action and

follow-up. If the PRL determines that the PQI may be beyond a P0/S0, the case is forwarded to the

CMO/designee for secondary review.

D. PQI REVIEW-SECONDARY

1. During secondary review, the CMO/designee may: a. assign a potential severity level of P0/S0 and instruct the PRL to close the case;

b. assign a potential severity level of P1/S1and instruct the PRL to send a letter to the POC without

a response required;

c. assign a potential severity level of P1/S1 or P2/S2 and instruct the PRL to send a letter to the

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POC with a response required within 14 calendar days. During routine secondary review, when

a letter is sent to the POC, a copy will be sent to the Chief of Quality and Quality Director of the

affected organization. The letter will request a coordinated response. A 14 calendar day

extension may be granted by the CMO/designee/PRL for reasonable concerns. If the clinician or

provider’s response satisfies the secondary reviewer’s concerns, the CMO/designee may instruct

the PRL to close the case or prepare the case for presentation to PHC’s PRC, depending on the

significance of the findings;

d. request that the PRL send the case to be reviewed by a physician of the same specialty as the

POC. The specialist has 14 calendar days to return the case to the PRL with a written response.

The PRL will discuss the specialist’s findings with the CMO/designee;

e. determine that the case is potentially greater than a P2/S2 and instruct the PRL to prepare the

case for presentation to the PRC;

f. instruct the PRL to prepare a case for the PRC at any time, for any case, regardless of the

severity level;

g. final severity levels can be determined by the secondary reviewer for cases assigned a severity

level less than P3/S3 after all information requested has been received and reviewed.

2. Emergency action: If the CMO determines that a situation exists where immediate action is required

to protect the life or well-being of a PHC member or any person, or to reduce substantial and

imminent likelihood of significant impairment of the life, health, or safety of any patient or person,

the CMO may summarily suspend or terminate the POC’s credentialed status. See policy MP CR #9

“Fair Hearing Process for Adverse Decisions.”

E. OPPORTUNTITIES FOR DISCUSSION BY THE CLINICIAN OR PROVIDER OF CONCERN

1. When the PQI is assigned a potential severity level of S1-S3 or P1-P3, the POC will be sent a letter

of concern including the following:

a. patient demographics;

b. brief statement explaining the purpose of quality review activities;

c. brief summary of the background of the case;

d. potential severity level;

e. confidentiality statement; and

f. CMO or designee signature

2. The POC will be given an opportunity to discuss the case by one of 4 methods: written, telephonic,

in-person, or by encrypted e-mail. The POC will have 14 calendar days to respond.

3. If the POC fails to provide additional information within the required timeframe, the CMO or

designee may choose to make a decision or the case may be referred to the PRC. If the PRC desires

additional information before making a determination, a follow-up letter will be sent to the clinician

or provider. If an individual clinician is a member of a contracted medical group, the Director of the

QA Department and/or Medical Director of the group will also be sent a copy of the request for

additional information. In addition to the content in the original letter, the following will be

included:

a. A reminder that the organization's PHC contract requires them to adhere to PHC policies and

procedures, which includes timely response to potential quality incidents.

b. An additional 14 calendar day deadline for response.

4. When additional information is received from the POC, the CMO or designee may refer the case to

the PRC, a physician on the Peer Review Committee within the same or a similar specialty, or to an

outside physician within the same specialty. The original reviewer should be among those who review the additional information. In all such cases, the physician will conduct the second review

and make a recommended determination, which is then presented to the PRC for final approval.

5. The POC will receive a final determination letter that will include the following:

a. a summary of the case findings, including a preferred course of action;

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b. final severity level and any actions to be taken;

c. a statement of any opportunity to provide additional information;

d. CMO/designee signature.

6. Phone conversations between a POC and a peer reviewer or the CMO/designee will be documented

with written notes, which will be entered into the peer review file and sent to the clinician in a

subsequent peer review letter, to offer the opportunity to make corrections.

7. If no response is heard from the POC for the second time, the CMO/designee or PRL will contact the

clinician to ensure the peer review letter was received and reviewed.

F. PQI REVIEW-TERTIARY

1. All cases designated a severity level S3 or P3 must be referred by the CMO/designee to the PRC for

review and determination of next steps.

2. PRC recommendations for cases determined to be S3/P3 may be forwarded to the Credentialing

Committee for possible action.

3. For cases where the PRC recommends that the Credentialing Committee requests a Corrective

Action Plan (CAP) for an S3/P3 problem:

a. A notice shall be given to the POC within 7 calendar days of the recommendation of a CAP

being required. Grounds for recommending a CAP include but are not limited to:

1) failure to provide professional services of acceptable quality;

2) failure to follow PHC utilization review policies;

3) failure to follow PHC quality improvement policies;

4) failure to treat patients for whom the provider is responsible;

5) failure to adhere to the provider contract or PHC policies;

6) acts constituting disruptive behavior or an inability to work collaboratively with others;

7) failure to report adverse action by another peer review body or a hospital.

b. If a CAP is recommended, it is included in the PQI case file. A CAP includes the goals,

objectives, desired outcomes, time frames, persons responsible, follow-up, and CAP evaluation.

The time frame for clinicians to respond to a CAP is 30 calendar days. The POC will be sent a

reminder notice on day 15. If the CAP is not received by PHC by day 31, the PRL will contact

the POC. A 15 day extension may be granted for reasonable concerns. If the CAP has not been

received by day 46, the case is forwarded to the CMO for further determination, including

possible review by the Credentialing Committee. Upon completion, the CAP will be reviewed

and the results reported to the PRC.

c. The CAP may include but is not limited to:

1) required attendance at continuing education programs applicable to the issue identified and

approved by PHC;

2) required training/re-training and/or certification/re-certification for performance of those

procedures that require specific training and professional certification;

3) continuing concurrent trend analysis of the adverse quality issues identified in the clinician's

practice patterns;

4) monitoring of POC’s medical record documentation by physicians selected by the PRC for a

prescribed length of time; and

5) in-service training for clinicians and/or their staff.

4. The PRC may also recommend that the Credentialing Committee review the POC’s status,

including but not limited to the following:

a. clinician or provider contract changes, including modification, restriction, or termination of

participation privileges with PHC;

b. summary suspension: immediate suspension from credentialed status based on the need to take

immediate action to protect the life or well-being and or reduce the possibility of substantial or

imminent threat to the life, health, or safety of any PHC member or other person;

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c. recommendation of counseling for behavior modification;

d. focused review of the provider’s cases including but not limited to:

1) second opinion for invasive procedures;

2) retrospective or prospective medical claims reviews;

e. preceptorship with a physician of the same specialty;

f. institute a monitoring process through proctoring by another qualified, specialty-matched

physician; or

g. recommendation to the Credentialing Committee for suspension, restriction, or termination of

the clinician’s PHC credentials.

5. In the following situations, in addition to the other measures applicable to S3/P3 cases, immediate

referral will be made to the CMO for consideration of the need for immediate follow-up and

potential rapid escalation to the Credentials Committee, Board of Commissioners, Medical Board of

California, and other regulatory and/or law enforcement agencies, depending the severity of the

concern:

a. actions or omissions constituting unethical or unprofessional conduct;

b. sexual misconduct with a patient;

c. sexual harassment of a patient;

d. discriminatory actions or behavior towards a patient based on racial, gender, gender identity,

religious beliefs, disability status, or other factors generally viewed as constituting unfair bias.

6. The clinician has the right to request a Fair Hearing for certain adverse actions as outlined in PHC

policy. Please refer to the Fair Hearing Process for Adverse Actions. This Policy also describes

reporting requirements to the PHC Board of Commissioners.

7. All PRC/Credentialing Committee recommendations and necessary attachments are forwarded to the

CMO for coordination of any recommended action.

8. If a quality issue has multiple clinicians or providers involved in care who are separately evaluated

by a clinical reviewer or the PRC, determinations of severity ratings will not be final until all

involved clinicians have been assigned final severity ratings. If any data is pending before making a

final determination for one involved clinician, the other clinicians’ determinations will be pending

and notifications will not be made until all determinations are complete.

9. For contracted providers who are not individuals (for example: hospitals, skilled nursing facilities,

community clinics), where a final determination is an S1, S2, or S3, the case will be referred in

writing to the quality assurance committee of the facility involved. This referral will request

acknowledgement that the issue has been reviewed and assurance that action has or will be taken to

prevent similar system issues in the future. These system issues will be tracked and reviewed at the

time of the facility’s re-contracting. If the CMO or PRC determines that the system issue at a

facility places our members at risk of adverse health outcomes, they may recommend that the

contract with this facility be suspended or terminated.

10. The PHC Board of Commissioners has the ultimate authority for final decisions regarding

credentialing and appeals. Credentialing Committee recommendations for adverse action are

forwarded to the next regularly scheduled Board of Commissioners meeting for a final decision.

G. MEDICAL RECORD REQUESTS

1. Contracted clinicians or providers are to forward a copy of the PHC member's medical records to the

QI AA within 30 calendar days from the date of the request.

2. The QI AA will call the clinician or provider weekly to inquire about the status of the request. If the

QI AA has not received the requested records by day 35, she/he will inform the PRL and request the

assistance of the Provider Relations Department. The QI AA is to inform the PRL at any time if

she/he is having difficulty retrieving medical records.

3. If PHC does not receive a copy of the member's medical records within 45 calendar days of the

request, the PRL will forward the concern to the CMO for further assistance. The CMO or designee

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may contact the clinician personally to ensure he or she is aware of the request for information. In

addition, if the individual POC works at a facility, the Chief of Quality, the Quality Director, the

CMO, and/or the CEO of the facility may be contacted to inform them of the delay in obtaining

medical records.

4. If medical records have not been received after following the procedure above, the CMO will be

notified. The CMO/designee will use all available information to rate the PQI. If the PQI cannot be

rated due to the lack of medical records, the PQI will be referred to the licensing body that oversees

the clinician or facility for investigation and disposition. Concomitantly a letter will be sent to the

CMO of the POC or facility of concern informing them of the lack of response to the request for

medical records.

5. Further action may be necessary including but not limited to termination from the provider network.

H. CASE COMPLETION

1. Each confirmed quality issue is assigned a final severity level with an action code by the CMO,

designee, or PRC to denote the severity of the problem and action taken as a result of review.

2. While under evaluation, all PQI cases are kept in a secure file cabinet in the QI department and only

designated personnel have access to these files. Each file includes the PQI RF, all correspondence,

pertinent copies of medical records, reports, and other documents associated with the review and

disposition of the PQI case.

I. REPORTING REQUIREMENTS

1. If a recommendation is made to revoke, suspend, or restrict the privileges of a clinician, or to

terminate the provider's contract with PHC, the following individuals and committees will be

notified:

a. CEO of PHC.

b. Credentialing Committee recommendations are forwarded to the next regularly scheduled Board

of Commissioners meeting for final action.

c. Chief of Staff and Hospital Administrators of facilities where clinician has hospital privileges.

d. The CEO of the medical group that employs the clinician, if applicable, and/or the Medical

Director of the clinic where the clinician is employed.

e. The Department of Health Care Services (DHCS) requires PHC to notify them when a sub-

contracted provider has been terminated from being a Medi-Cal or Medicare provider and has

been placed on the Suspended and Ineligible Provider list. Providers on the Medi-Cal/Medicaid

suspended and ineligible provider list cannot participate in the PHC provider network.

f. If the provider is a member of a medical group or clinic, a paraphrased summary of the final

determinations of levels S1, S2, S3, P1, P2, and P3 will be reported to the supervising Medical

Director. If the final determination is an S3, the CEO of the institution will also be notified.

J. INTER-RATER RELIABILITY (IRR)

1. Inter-rater reliability studies will be performed quarterly to ensure cases reviewed by the PRL were

appropriately assessed a P0 or S0. Ten cases will be randomly selected for review by the Manager

of Quality and Compliance for the quarterly assessment. The goal is to achieve a 90% inter-rater

reliability score.

K. RECORD RETENTION

1. Medical records received for cases with a P0/P1/S0/S1 severity rating will be scanned into the PHC

system by the QI AA along with all pertinent supporting documentation. After scanning is

complete, the documents will be destroyed. The scanned file will be maintained for a period of 10

years. Cases assigned a P2/P3/S2/S3 will be scanned into the system. All original documentation - such as certified letters, responses to letters, policies and procedures will be kept in-house along with

the scanned file for a minimum of 3 years and offsite for a minimum of 7 additional years. L. CONFIDENTIALITY

1. Peer review records proceedings as well as records obtained for the quality/peer review process are

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protected by California Evidence Code § 1157 and are not subject to discovery when confidentiality

has been maintained. To maintain confidentiality, peer review records are retained by the Quality

Department and are not released to anyone for purposes other than peer review. Records are

maintained in a locked file cabinet with access restricted to the CMO, the Director of Quality

Performance and Improvement, Manager of Quality and Compliance, PRLs, the QI AA, and peer

reviewers. While records are being reviewed, or during transport to peer review meetings, a QI staff

person accompanies them at all times. If a subpoena is served to PHC regarding a peer review case,

the PRL may act as the “certifier of the medical records” being requested.

M. SUBCOMMITTEES

1. The Pain Management Oversight Committee is a subcommittee of the PRC.

VII. REFERENCES: A. Exhibit A, Attachment 9 Quality Improvement System from the DHCS contract

B. Please refer to the Delegation Policy for Delegated Providers

VIII. DISTRIBUTION:

A. PHC Department Directors

B. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Performance Improvement

Clinical Specialist (PICS) II

X. REVISION DATES: Medi-Cal

07/01/96; 06/02/97; 10/10/97 (name change only); 01/13/99; 06/16/99; 06/21/00; 05/16/01; 05/15/02;

08/20/03; 04/20/05; 07/16/08; 10/19/11; 08/20/14; 11/19/14; 05/20/15; 06/17/15; 06/15/16

Healthy Kids

07/16/08; 10/19/11; 08/20/14; 11/19/14; 05/20/15; 06/17/15; 06/15/16

PREVIOUSLY APPLIED TO: Healthy Families

MPQP1016 - 10/19/2011 to 03/01/2013

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POLICY/ PROCEDURE

I:\QUALITY\QI Assistant\QUAC\2016 Meetings\6.15.2016\Items on Consent\MPQP1016.docx Page 1 of 8

Policy/Procedure Number: MPQP1016 (previously QP100116) Lead Department: Health Services Policy/Procedure Title: Potential Quality Issue Investigation and Resolution

☒External Policy ☐ Internal Policy

Original Date: 01/20/1996 - Medi-Cal 07/16/2008 - Healthy Kids

Next Review Date: 06/17/201606/17/2017 Last Review Date: 06/17/201506/17/2016


Reviewing Entities:

☒ IQI ☐ P & T ☒ QUAC ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving Entities:



Approval Signature: Robert Moore, MD, MPH Approval Date: 06/17/201506/17/2016

I. RELATED POLICIES: A. MPCR #9 Fair Hearing Process for Adverse Decisions B. MPQP1053 - Peer Review Committee Policy

II. IMPACTED DEPTS:

A. All Departments

III. DEFINITIONS: A. A Potential Quality Issue (PQI) is defined as a possible adverse variation from expected clinician

performance, clinical care, or outcome of care. PQIs requires further investigation to determine whether an actual quality issue or opportunity for improvement exists. Not all PQIs represent quality of care issues.

B. A quality issue is defined as a confirmed adverse variation from expected clinician performance, clinical care, or outcome of care, as determined through the PQI process.

C. A clinician or provider is any individual or entity engaged in the delivery of health care services licensed or certified by the State to engage in that activity if licensure or certification is required by State law or regulation.

D. A Corrective Action Plan (CAP) is a plan approved by the Peer Review Committee to help ensure that a related quality issue does not occur in the future. CAPs contain clearly stated goals and time frames for completion.

E. Severity Level: Refer to Attachment B: Case Leveling Grid F. Egregious: Where the quality of care was significantly outside accepted and common standards of

practice and/or where the adverse outcome of the care provided was especially serious.

IV. ATTACHMENTS: A. PQI Referral Form and Reference Table B. Case Leveling Grid

V. PURPOSE: To provide a systematic method for the identification, reporting, and processing of a Potential Quality Issue (PQI), to determine opportunities for improvement in the provision of care and services to Partnership HealthPlan of California (PHC) members, and to direct appropriate actions for improvement based upon outcome, risk, frequency, and severity.


A. IDENTIFICATION OF POTENTIAL QUALITY ISSUES

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http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Quality%20Improvement/MPQP1016%20-%20Attachments/MPQP1016-B.doc&action=default


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1. PQIs are identified through the systematic review of a variety of data sources, including but not limited to: a. information gathered through concurrent, prospective, and retrospective utilization review; b. referrals from health plan staff or clinicians; c. facility site reviews; d. claims and encounter data; e. pharmacy utilization data; f. HEDIS medical record abstraction process; g. medical records audits; h. phone log detail; or i. grievances

2. TPQI reviews can be conducted on services provided by: a. contracted clinicians or providers, including subcontractors, who provide inpatient and

outpatient services; b. non-contracted clinicians and providers: cases involving non-contracted providers will be

discussed with the Chief Medical Officer (CMO) to determine next steps prior to embarking on a review of the PQI;

c. durable medical equipment and medical supply providers; d. pharmacy providers; home health; skilled nursing; long term care and rehabilitation facilities;

ancillary service providers including but not limited to lab, pharmacy, radiology, and Emergency Medical Services;

e. Division providers: complaints are tracked to their resolution by the Complaints, Grievances and Appeals (CGA) Department. CGA refers vision complaints to the Peer Review Lead (PRL) to monitor and trend.

f. Behavioral health: member complaints regarding behavioral health are referred to the Behavioral Health staff in the Health Services Department for tracking, intervention, and resolution.

B. PQI REFERRAL 1. PQIs may be reported by any of the following:

a. any PHC staff member; b. anonymously using the PHC "confidential line” which is available 24 hours a day, 7 days a week

(1-800-601-2146); c. any member of the community; d. any contracted or non-contracted clinician or provider.

2. A PQI is reported to the PRL using the PQI Referral Form (RF). See Attachment A. a. The following information, at a minimum, should be documented and promptly forwarded to the

PRL with a cc to the QI Administrative Assistant (QI AA). 1) the member's name, date of birth, gender, PHC member number, and Client Identifying

Number (CIN); 2) admission/discharge dates for any relevant hospitalization, and/or office visit dates if

applicable; 3) physician/provider name(s); 4) facility where problem may have occurred; 5) the date of the suspected/reported occurrence; 6) the date the PQI Referral Form was completed; 7) the name and department of the individual identifying the PQI, unless the issue was

submitted anonymously; 8) the box marked on the referral form that most closely describes the issue; and 9) a concise, factual description of the potential problem.

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3. Time frame limitations: In general, PHC will not investigate PQIs which occurred more than 2 years prior to first notification of the QI department of the issue. If a PQI is identified that occurred more than 2 years prior to the first notification, no investigation will be routinely started. The PQI form will be reviewed by the CMO or designee. If the CMO or designee believes a serious quality issue may have occurred and that the case warrants investigating, the CMO or designee may request the PRL to start an investigation or refer it to PHC’s Per Review Committee (PRC) or to another peer review body or regulatory agency, depending on the findings in the case.

C. PQI REVIEW-PRIMARY and/or URGENT REFERRAL FOR SECONDARY REVIEW 1. Upon receipt of the RF, the QI AA or his/her designee will enter it into the PQI database within two

business days. The QI AA will notify the PRL by e-mail that an RF has been entered and is ready for initial review.

2. The RF is processed within 7 business days unless the issue is urgent. The PRL will triage the RF on day one for urgent issues. If the issue is urgent, the PRL will contact the CMO or his/her designee by phone with a follow-up secure-email by close of business that day.

3. Processing of the RF may include a request for pertinent medical records. The PRL must complete review of the PQI within 20 business days from receipt of all medical records. The QI AA notifies the PRL by e-mail when all records have arrived and the case is ready for review. During the 20-day review period, if the PRL discovers that more records are required, an additional medical record request is completed and given to the QI AA to follow-up. The QI AA notifies the PRL when additional records have arrived and the 20 business day timeframe resets.

4. If the PQI occurred exclusively at one or more organizations with an accredited Peer Review Organization (PRO) responsible for oversight of the care provided by the Clinician or Provider(s) of Concern (POC), the PQI is not found to be urgent, and the potential severity of the PQI has been determined by the CMO/designee to not reflect an egregious lapse in quality, the PQI will be referred to the PRO. A response will be required from the PRO acknowledging they have received the letter of concern. After this response is received, the case will be closed by the CMO/designee. When a referral is sent to the outside PRO, a copy will be sent to the Chief of Quality and the Quality Director at the outside organization. Concomitantly, the POC will be notified of the PRO referral. No medical records will be requested. If the PQI cannot be leveled prior to referral, the case will be leveled as either: Provider Unable to Determine or Facility Unable to Determine.

5. If the PQI is determined by the CMO/designee to be urgent or the potential severity may represent an egregious lapse in the quality of care, the case will be referred to the outside PRO, but the CMO/designee may elect to request medical records and review the case.

6. During case review, professionally recognized standards of care will be used to assess the care provided. A PQI may be a single event or occurrence. While one report alone may not represent a quality issue, trending of similar events may reveal a quality issue and may lead to the re-opening of a case previously reviewed or closed.

7. If the PRL’s initial review determines there are no clinician/provider or system issues, the case is leveled as a P0 (no provider issues) or an S0 (no system issues) and the PQI is closed in the database. If the PRL determines that the member needs immediate assistance beyond the scope of peer review, appropriate information will be forwarded to other involved departments for action and follow-up. If the PRL determines that the PQI may be beyond a P0/S0, the case is forwarded to the CMO/designee for secondary review.

D. PQI REVIEW-SECONDARY 1. During secondary review, the CMO/designee may:

a. assign a potential severity level of P0/S0 and instruct the PRL to close the case; b. assign a potential severity level of P1/S1and instruct the PRL to send a letter to the POC without

a response required; c. assign a potential severity level of P1/S1 or P2/S2 and instruct the PRL to send a letter to the

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POC with a response required within 14 calendar days. During routine secondary review, when a letter is sent to the POC, a copy will be sent to the Chief of Quality and Quality Director of the affected organization. The letter will request a coordinated response. A 14 calendar day extension may be granted by the CMO/designee/PRL for reasonable concerns. If the clinician or provider’s response satisfies the secondary reviewer’s concerns, the CMO/designee may instruct the PRL to close the case or prepare the case for presentation to PHC’s PRC, depending on the significance of the findings;

d. request that the PRL send the case to be reviewed by a physician of the same specialty as the POC. The specialist has 14 calendar days to return the case to the PRL with a written response. The PRL will discuss the specialist’s findings with the CMO/designee;

e. determine that the case is potentially greater than a P2/S2 and instruct the PRL to prepare the case for presentation to the PRC;

f. instruct the PRL to prepare a case for the PRC at any time, for any case, regardless of the severity level;

g. final severity levels can be determined by the secondary reviewer for cases assigned a severity level less than P3/S3 after all information requested has been received and reviewed.

2. Emergency action: If the CMO determines that a situation exists where immediate action is required to protect the life or well-being of a PHC member or any person, or to reduce substantial and imminent likelihood of significant impairment of the life, health, or safety of any patient or person, the CMO may summarily suspend or terminate the POC’s credentialed status. See policy MP CR #9 “Fair Hearing Process for Adverse Decisions.”

E. OPPORTUNTITIES FOR DISCUSSION BY THE CLINICIAN OR PROVIDER OF CONCERN 1. When the PQI is assigned a potential severity level of S1-S3 or P1-P3, the POC will be sent a letter

of concern including the following: a. patient demographics; b. brief statement explaining the purpose of quality review activities; c. brief summary of the background of the case; d. potential severity level; e. confidentiality statement; and f. CMO or designee signature

2. The POC will be given an opportunity to discuss the case by one of 4 methods: written, telephonic, in-person, or by encrypted e-mail. The POC will have 14 calendar days to respond.

3. If the POC fails to provide additional information within the required timeframe, the CMO or designee may choose to make a decision or the case may be referred to the PRC. If the PRC desires additional information before making a determination, a follow-up letter will be sent to the clinician or provider. If an individual clinician is a member of a contracted medical group, the Director of the QA Department and/or Medical Director of the group will also be sent a copy of the request for additional information. In addition to the content in the original letter, the following will be included: a. A reminder that the organization's PHC contract requires them to adhere to PHC policies and

procedures, which includes timely response to potential quality incidents. b. An additional 14 calendar day deadline for response.

4. When additional information is received from the POC, the CMO or designee may refer the case to the PRC, a physician on the Peer Review Committee within the same or a similar specialty, or to an outside physician within the same specialty. The original reviewer should be among those who review the additional information. In all such cases, the physician will conduct the second review and make a recommended determination, which is then presented to the PRC for final approval.

5. The POC will receive a final determination letter that will include the following: a. a summary of the case findings, including a preferred course of action;

Page 35 of 199






Page 5 of 8

b. final severity level and any actions to be taken; c. a statement of any opportunity to provide additional information; d. CMO/designee signature.

6. Phone conversations between a POC and a peer reviewer or the CMO/designee will be documented with written notes, which will be entered into the peer review file and sent to the clinician in a subsequent peer review letter, to offer the opportunity to make corrections.

7. If no response is heard from the POC for the second time, the CMO/designee or PRL will contact the clinician to ensure the peer review letter was received and reviewed.

F. PQI REVIEW-TERTIARY 1. All cases designated a severity level S3 or P3 must be referred by the CMO/designee to the PRC for

review and determination of next steps. 2. PRC recommendations for cases determined to be S3/P3 may be forwarded to the Credentialing

Committee for possible action. 3. For cases where the PRC recommends that the Credentialing Committee requests a Corrective

Action Plan (CAP) for an S3/P3 problem: a. A notice shall be given to the POC within 7 calendar days of the recommendation of a CAP

being required. Grounds for recommending a CAP include but are not limited to: 1) failure to provide professional services of acceptable quality; 2) failure to follow PHC utilization review policies; 3) failure to follow PHC quality improvement policies; 4) failure to treat patients for whom the provider is responsible; 5) failure to adhere to the provider contract or PHC policies; 6) acts constituting disruptive behavior or an inability to work collaboratively with others; 7) failure to report adverse action by another peer review body or a hospital.

b. If a CAP is recommended, it is included in the PQI case file. A CAP includes the goals, objectives, desired outcomes, time frames, persons responsible, follow-up, and CAP evaluation. The time frame for clinicians to respond to a CAP is 30 calendar days. The POC will be sent a reminder notice on day 15. If the CAP is not received by PHC by day 31, the PRL will contact the POC. A 15 day extension may be granted for reasonable concerns. If the CAP has not been received by day 46, the case is forwarded to the CMO for further determination, including possible review by the Credentialing Committee. Upon completion, the CAP will be reviewed and the results reported to the PRC.

c. The CAP may include but is not limited to: 1) required attendance at continuing education programs applicable to the issue identified and

approved by PHC; 2) required training/re-training and/or certification/re-certification for performance of those

procedures that require specific training and professional certification; 3) continuing concurrent trend analysis of the adverse quality issues identified in the clinician's

practice patterns; 4) monitoring of POC’s medical record documentation by physicians selected by the PRC for a

prescribed length of time; and 5) in-service training for clinicians and/or their staff.

4. The PRC may also recommend that the Credentialing Committee review the POC’s status, including but not limited to the following: a. clinician or provider contract changes, including modification, restriction, or termination of

participation privileges with PHC; b. summary suspension: immediate suspension from credentialed status based on the need to take

immediate action to protect the life or well-being and or reduce the possibility of substantial or imminent threat to the life, health, or safety of any PHC member or other person;

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Page 6 of 8

c. recommendation of counseling for behavior modification; d. focused review of the provider’s cases including but not limited to:

1) second opinion for invasive procedures; 2) retrospective or prospective medical claims reviews;

e. preceptorship with a physician of the same specialty; f. institute a monitoring process through proctoring by another qualified, specialty-matched

physician; or g. recommendation to the Credentialing Committee for suspension, restriction, or termination of

the clinician’s PHC credentials. 5. In the following situations, in addition to the other measures applicable to S3/P3 cases, immediate

referral will be made to the CMO for consideration of the need for immediate follow-up and potential rapid escalation to the Credentials Committee, Board of Commissioners, Medical Board of California, and other regulatory and/or law enforcement agencies, depending the severity of the concern: a. actions or omissions constituting unethical or unprofessional conduct; b. sexual misconduct with a patient; c. sexual harassment of a patient; d. discriminatory actions or behavior towards a patient based on racial, gender, gender identity,

religious beliefs, disability status, or other factors generally viewed as constituting unfair bias. 6. The clinician has the right to request a Fair Hearing for certain adverse actions as outlined in PHC

policy. Please refer to the Fair Hearing Process for Adverse Actions. This Policy also describes reporting requirements to the PHC Board of Commissioners.

7. All PRC/Credentialing Committee recommendations and necessary attachments are forwarded to the CMO for coordination of any recommended action.

8. If a quality issue has multiple clinicians or providers involved in care who are separately evaluated by a clinical reviewer or the PRC, determinations of severity ratings will not be final until all involved clinicians have been assigned final severity ratings. If any data is pending before making a final determination for one involved clinician, the other clinicians’ determinations will be pending and notifications will not be made until all determinations are complete.

9. For contracted providers who are not individuals (for example: hospitals, skilled nursing facilities, community clinics), where a final determination is an S1, S2, or S3, the case will be referred in writing to the quality assurance committee of the facility involved. This referral will request acknowledgement that the issue has been reviewed and assurance that action has or will be taken to prevent similar system issues in the future. These system issues will be tracked and reviewed at the time of the facility’s re-contracting. If the CMO or PRC determines that the system issue at a facility places our members at risk of adverse health outcomes, they may recommend that the contract with this facility be suspended or terminated.

10. The PHC Board of Commissioners has the ultimate authority for final decisions regarding credentialing and appeals. Credentialing Committee recommendations for adverse action are forwarded to the next regularly scheduled Board of Commissioners meeting for a final decision.

G. MEDICAL RECORD REQUESTS 1. Contracted clinicians or providers are to forward a copy of the PHC member's medical records to the

QI AA within 30 calendar days from the date of the request. 2. The QI AA will call the clinician or provider weekly to inquire about the status of the request. If the

QI AA has not received the requested records by day 35, she/he will inform the PRL and request the assistance of the Provider Relations Department. The QI AA is to inform the PRL at any time if she/he is having difficulty retrieving medical records.

3. If PHC does not receive a copy of the member's medical records within 45 calendar days of the request, the PRL will forward the concern to the CMO for further assistance. The CMO or designee

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Page 7 of 8

may contact the clinician personally to ensure he or she is aware of the request for information. In addition, if the individual POC works at a facility, the Chief of Quality, the Quality Director, the CMO, and/or the CEO of the facility may be contacted to inform them of the delay in obtaining medical records.

4. If medical records have not been received after following the procedure above, the CMO will be notified. The CMO/designee will use all available information to rate the PQI. If the PQI cannot be rated due to the lack of medical records, the PQI will be referred to the licensing body that oversees the clinician or facility for investigation and disposition. Concomitantly a letter will be sent to the CMO of the POC or facility of concern informing them of the lack of response to the request for medical records.

5. Further action may be necessary including but not limited to termination from the provider network. H. CASE COMPLETION

1. Each confirmed quality issue is assigned a final severity level with an action code by the CMO, designee, or PRC to denote the severity of the problem and action taken as a result of review.

2. While under evaluation, all PQI cases are kept in a secure file cabinet in the QI department and only designated personnel have access to these files. Each file includes the PQI RF, all correspondence, pertinent copies of medical records, reports, and other documents associated with the review and disposition of the PQI case.

I. REPORTING REQUIREMENTS 1. If a recommendation is made to revoke, suspend, or restrict the privileges of a clinician, or to

terminate the provider's contract with PHC, the following individuals and committees will be notified: a. CEO of PHC. b. Credentialing Committee recommendations are forwarded to the next regularly scheduled Board

of Commissioners meeting for final action. c. Chief of Staff and Hospital Administrators of facilities where clinician has hospital privileges. d. The CEO of the medical group that employs the clinician, if applicable, and/or the Medical

Director of the clinic where the clinician is employed. e. The Department of Health Care Services (DHCS) requires PHC to notify them when a sub-

contracted provider has been terminated from being a Medi-Cal or Medicare provider and has been placed on the Suspended and Ineligible Provider list. Providers on the Medi-Cal/Medicaid suspended and ineligible provider list cannot participate in the PHC provider network.

f. If the provider is a member of a medical group or clinic, a paraphrased summary of the final determinations of levels S1, S2, S3, P1, P2, and P3 will be reported to the supervising Medical Director. If the final determination is an S3, the CEO of the institution will also be notified.

J. INTER-RATER RELIABILITY (IRR) 1. Inter-rater reliability studies will be performed quarterly to ensure cases reviewed by the PRL were

appropriately assessed a P0 or S0. Ten cases will be randomly selected for review by the Manager of Quality and Compliance for the quarterly assessment. The goal is to achieve a 90% inter-rater reliability score.

K. RECORD RETENTION 1. Medical records received for cases with a P0/P1/S0/S1 severity rating will be scanned into the PHC

system by the QI AA along with all pertinent supporting documentation. After scanning is complete, the documents will be destroyed. The scanned file will be maintained for a period of 10 years. Cases assigned a P2/P3/S2/S3 will be scanned into the system. All original documentation - such as certified letters, responses to letters, policies and procedures will be kept in-house along with the scanned file for a minimum of 3 years and offsite for a minimum of 7 additional years.

L. CONFIDENTIALITY 1. Peer review records proceedings as well as records obtained for the quality/peer review process are

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Page 8 of 8

protected by California Evidence Code § 1157 and are not subject to discovery when confidentiality has been maintained. To maintain confidentiality, peer review records are retained by the Quality Department and are not released to anyone for purposes other than peer review. Records are maintained in a locked file cabinet with access restricted to the CMO, the Director of Quality Performance and Improvement, Manager of Quality and Compliance, PRLs, the QI AA, and peer reviewers. While records are being reviewed, or during transport to peer review meetings, a QI staff person accompanies them at all times. If a subpoena is served to PHC regarding a peer review case, the PRL may act as the “certifier of the medical records” being requested.

M. SUBCOMMITTEES 1. The Pain Management Oversight Committee is a subcommittee of the PRC.

VII. REFERENCES:

A. Exhibit A, Attachment 9 Quality Improvement System from the DHCS contract B. Please refer to the Delegation Policy for Delegated Providers

VIII. DISTRIBUTION:

A. PHC Department Directors B. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Performance Improvement

Clinical Specialist (PICS) II

X. REVISION DATES: Medi-Cal 07/01/96; 06/02/97; 10/10/97 (name change only); 01/13/99; 06/16/99; 06/21/00; 05/16/01; 05/15/02; 08/20/03; 04/20/05; 07/16/08; 10/19/11; 08/20/14; 11/19/14; 05/20/15; 06/17/15 Healthy Kids 07/16/08; 10/19/11; 08/20/14; 11/19/14; 05/20/15; 06/17/15 PREVIOUSLY APPLIED TO:

Healthy Families MPQP1016 - 10/19/2011 to 03/01/2013

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GUIDELINE / PROCEDURE

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Guideline/Procedure Number: HKUG3071 (previously

MPUG3071 & KK UM106) Lead Department: Health Services

Guideline/Procedure Title: Hospice Services External Policy

Internal Policy

Original Date: 11/16/2005 Next Review Date: 06/15/2017


Applies to: Medi-Cal Healthy Kids Employees

Reviewing

Entities:

IQI P & T QUAC

OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT

Approving

Entities:

BOARD COMPLIANCE FINANCE PAC

CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER


I. RELATED POLICIES: A. HKUP3080 - TAR Process

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS: A. N/A

IV. ATTACHMENTS:

A. N/A

V. PURPOSE:

The purpose of the guideline is to delineate the Hospice Benefit available when an enrollee has been

determined to have a terminal illness. Hospice Services are a specialized form of interdisciplinary health

care designed to provide palliative care, alleviate the physical, emotional and social and spiritual discomfort

experienced in the last phases of life due to the existence of a terminal disease.

VI. GUIDELINE / PROCEDURE: A. HOSPICE BENEFIT

1. Election of hospice care occurs when the member (or guardian) voluntarily completes and signs the

Hospice Election Form and selects a hospice provider. Only those entities licensed pursuant to the

California Hospice Licensure Act of 1990 (Health and Safety Code Section 1745.et seq) or a

licensed home health agency with federal Medicare certification (Health and Safety Code Section

1726 and 1747.1) may provide hospice services to Partnership HealthPlan of California (PHC)

members.

2. Signing this form indicates the member’s understanding that hospice care is intended to alleviate

pain and suffering, rather than to cure the disease. The hospice provider must submit the hospice

election form to PHC with the initial claim.

3. All services related to the terminal illness must then be authorized by hospice provider. Members

who select hospice care can receive services related to the terminal illness only from the attending

physician or the hospice physician. All other medical services related to care of the terminal illness

must be arranged by the Hospice Provider. The member can continue to obtain services that are

Page 40 of 199



Guideline/Procedure Title: Hospice Services ☒External Policy

☐Internal Policy



Applies to: ☐ Medi-Cal ☒ Healthy Kids ☐ Employees


unrelated to the terminal illness through the regular PHC authorization process.

4. The following services are part of the hospice benefit:

a. The enrollee and the enrollee’s family are the unit of care.

b. An interdisciplinary team will assess the physical, medical, psychological, social and spiritual

needs of the enrollee and the enrollee’s family.

c. The team will develop an overall plan of care and provide coordinated care which emphasizes

supportive service, including, but not limited to, home care, pain control, and short-term

inpatient services which are intended to ensure continuity of care and appropriateness of service

when enrollees cannot be managed at home due to acute complications or the temporary absence

of a capable primary care giver.

d. The hospice provider will provide palliative medical treatment of pain and other symptoms

associated with the terminal illness but not efforts to cure.

e. Bereavement services following the enrollees death will be provided that will assist the family

to cope with their social and emotional needs.

f. To the extent appropriate based on medical needs, service will be provided in the home or

primary place of residence.

g. 24 hour availability to the extent necessary to meet the needs of the individual

5. The interdisciplinary care team shall include the following:

a. Medical social services

b. Hospice physician services

c. Counseling/bereavement services

d. Skilled nursing services

e. Home health aide and attendant cares services

f. Medical supplies and durable medical equipment

g. Physical, occupational, and speech therapy

h. Medications and infusion therapy (based on the Hospice Formulary)

i. Nutritionist services

j. Respite care (limited to an occasional bases no more than 5 (five) consecutive days at a time)

k. Short-term in-patient care at hospital or subacute facility

l. Volunteer Services

m. Medical transportation

6. Services not related to the terminal illness requiring prior authorization will be authorized by PHC in

accordance with the applicable requirements.

7. Treatment Authorization Request (TAR)

a. A PHC Treatment Authorization Request is not required for the following services;

1) Routine home care

2) Continuous home care

3) Respite Care

4) Hospice Care room and board provided in a SNF or Intermediate Care Facility (ICF)

b. If a member currently resides in an Independent Care Facility-Developmentally Disabled (ICF-

DD) facility or is admitted to an ICF-DD facility, PHC continues to be financially responsible

for the ICF-DD per diem payment.

c. Non-emergency inpatient care related to the terminal illness requires preauthorization by PHC.

The Hospice provider must submit a TAR using inpatient code Z7106 for general inpatient care

and attach a copy of the Hospice Election Form.

d. Emergency admission related to the terminal illness is reviewed for medical necessity by the

Utilization Management (UM) nurse coordinator and if appropriate, a length of stay assigned.

PHC must be notified within 24 hours of any emergency admission related to the terminal

illness. The hospice provider must submit a TAR using inpatient code (Z7106) and attach a

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☐Internal Policy





copy of the Hospice Election Form.

e. The hospice provider is financially responsible for emergency room services related to

complications of the terminal illness if the Hospice provider authorized the service.

f. PHC continues to authorize and be financially responsible for outpatient, inpatient and

emergency services not related to the terminal illness.

g. For members with Medicare/Medi-Cal coverage, Medicare is the first payor for the hospice

daily care. Medi-Cal (PHC) is financially responsible for medications not related to the hospice

diagnosis and the room and board per diem if the member resides in a LTC facility. The claim

must include a copy of the Medicare Explanation of Medical Benefits (EOMB) that shows that

Medicare payment was made for hospice services during the period covered.

h. For members with other coverage, Medi-Cal is the secondary payor and the hospice must submit

a copy of the EOB (Explanation of Benefits) from the other insurer when billing Medi-Cal.

B. CRITERIA FOR ADMISSION TO A HOSPICE PROGRAM

1. A patient and family will be admitted to the hospice program when

a. The patient has a limited life expectancy less than 12 months.

b. Cure of the disease process is no longer the treatment or goal.

c. The primary goal is palliative care for the patient with focus on comfort, pain control, and

emotional, spiritual, and psychological support.

d. It is appropriate to direct treatment to improve the quality of the remaining days for the patient

and family.

e. It is agreed by doctor and patient and/or family that advanced technology is used solely for the

purpose of sparing the patient discomfort or limitations he or she would otherwise suffer.

f. The patient, family, and physician are all willing to participate in the program with the

understanding that withdrawal is possible at any time.

VII. REFERENCES: A. Title 28 Article 8 Section 1300.68.2

B. California Health and Safety Code Section 1745, 1726 and 1747.1

VIII. DISTRIBUTION: A. PHC Departmental Directors


IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services

X. REVISION DATES: 11/21/07; 11/19/08; 07/21/10; 10/01/10; 06/17/15; 10/21/15; 06/15/16

PREVIOUSLY APPLIED TO: Healthy Families:

MPUG3071 - 10/01/2010 to 03/01/2013

***********************************

In accordance with the California Health and Safety Code, Section 1363.5(b)(5), policies are developed with

involvement from actively practicing health care providers and meet these provisions:

Consistent with sound clinical principles and processes

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☐Internal Policy





Evaluated and updated at least annually

Are made available to the public by accessing our web based portal at

http://www.partnershiphp.org/Providers/Policies/Pages/HealthyKids/ProviderManual_HealthyKids.aspx

If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to

both the member and provider via mail or electronically and will be accompanied by the following statement:

“The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar

illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered

under PHC.”

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GUIDELINE / PROCEDURE

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Guideline/Procedure Title: Hospice Services External Policy

Internal Policy

Original Date: 11/16/2005 Next Review Date: 10/21/201606/15/2017

Last Review Date: 10/21/201506/15/2016


Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. HKUP3080 - TAR Process

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services


IV. ATTACHMENTS:

A. N/A

V. PURPOSE:

The purpose of the guideline is to delineate the Hospice Benefit available when an enrollee has been

determined to have a terminal illness. Hospice Services are a specialized form of interdisciplinary health

care designed to provide palliative care, alleviate the physical, emotional and social and spiritual discomfort

experienced in the last phases of life due to the existence of a terminal disease.

VI. GUIDELINE / PROCEDURE: A. HOSPICE BENEFIT

1. Election of hospice care occurs when the member (or guardian) voluntarily completes and signs the

Hospice Election Form and selects a hospice provider. Only those entities licensed pursuant to the

California Hospice Licensure Act of 1990 (Health and Safety Code Section 1745.et seq) or a

licensed home health agency with federal Medicare certification (Health and Safety Code Section

1726 and 1747.1) may provide hospice services to Partnership HealthPlan of California ( PHC)

members.

2. Signing this form indicates the member’s understanding that hospice care is intended to alleviate

pain and suffering, rather than to cure the disease. The hospice provider must submit the hospice

election form to PHC with the initial claim.

3. All services related to the terminal illness must then be authorized by hospice provider. Members

who select hospice care can receive services related to the terminal illness only from the attending

physician or the hospice physician. All other medical services related to care of the terminal illness

must be arranged by the Hospice Provider. The member can continue to obtain services that are

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☐Internal Policy


Last Review Date: 10/21/201506/15/2016



unrelated to the terminal illness through the regular PHC authorization process.

4. The following services are part of the hospice benefit:

a. The enrollee and the enrollee’s family are the unit of care.

b. An interdisciplinary team will assess the physical, medical, psychological, social and spiritual

needs of the enrollee and the enrollee’s family.

c. The team will develop an overall plan of care and provide coordinated care which emphasizes

supportive service, including, but not limited to, home care, pain control, and short-term

inpatient services which are intended to ensure continuity of care and appropriateness of service

when enrollees cannot be managed at home due to acute complications or the temporary absence

of a capable primary care giver.

d. The hospice provider will provide palliative medical treatment of pain and other symptoms

associated with the terminal illness but not efforts to cure.

e. Bereavement services following the enrollees death will be provided that will assist the family

to cope with their social and emotional needs.

f. To the extent appropriate based on medical needs, service will be provided in the home or

primary place of residence.

g. 24 hour availability to the extent necessary to meet the needs of the individual

5. The interdisciplinary care team shall include the following:

a. Medical social services

b. Hospice physician services

c. Counseling/bereavement services

d. Skilled nursing services

e. Home health aide and attendant cares services

f. Medical supplies and durable medical equipment

g. Physical, occupational, and speech therapy

h. Medications and infusion therapy (based on the Hospice Formulary)

i. Nutritionist services

j. Respite care (limited to an occasional bases no more than 5 (five) consecutive days at a time)

k. Short-term in-patient care at hospital or subacute facility

l. Volunteer Services

m. Medical transportation

6. Services not related to the terminal illness requiring prior authorization will be authorized by PHC in

accordance with the applicable requirements.

7. Treatment Authorization Request (TAR)

a. A PHC Treatment Authorization Request is not required for the following services;

1) Routine home care

2) Continuous home care

3) Respite Care

4) Hospice Care room and board provided in a SNF or Intermediate Care Facility (ICF)

b. If a member currently resides in an Independent Care Facility-Developmentally Disabled (ICF-

DD) facility or is admitted to an ICF-DD facility, PHC continues to be financially responsible

for the ICF-DD per diem payment.

c. Non-emergency inpatient care related to the terminal illness requires preauthorization by PHC.

The Hospice provider must submit a TAR using inpatient code (Z7106 for general inpatient

care) and attach a copy of the Hospice Inpatient InformationElection Form.

d. Emergency admission related to the terminal illness is reviewed for medical necessity by the

Utilization Management (UM) nurse coordinator and if appropriate, a length of stay assigned.

PHC must be notified within 24 hours of any emergency admission related to the terminal

illness. The hospice provider must submit a TAR using inpatient code (Z7106) and attach a

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☐Internal Policy


Last Review Date: 10/21/201506/15/2016



copy of the Hospice Inpatient InformationElection Form.

e. The hospice provider is financially responsible for emergency room services related to

complications of the terminal illness if the Hospice provider authorized the service.

f. PHC continues to authorize and be financially responsible for outpatient, inpatient and

emergency services not related to the terminal illness.

g. For members with Medicare/Medi-Cal coverage, Medicare is the first payor for the hospice

daily care. Medi-Cal (PHC) is financially responsible for medications not related to the hospice

diagnosis and the room and board per diem if the member resides in a LTC facility (658 for SNF

or ICF). The claim must include a copy of the Medicare Explanation of Medical Benefits

(EOMB) that shows that Medicare payment was made for hospice services during the period

covered.

h. For members with other coverage, Medi-Cal is the secondary payor and the hospice must submit

a copy of the EOB (Explanation of Benefits) from the other insurer when billing Medi-Cal.

B. CRITERIA FOR ADMISSION TO A HOSPICE PROGRAM

1. A patient and family will be admitted to the hospice program when:66

a. The patient has a limited life expectancy less than 12 months.

b. Cure of the disease process is no longer the treatment or goal.

c. The primary goal is palliative care for the patient with focus on comfort, pain control, and

emotional, spiritual, and psychological support.

d. It is appropriate to direct treatment to improve the quality of the remaining days for the patient

and family.

e. It is agreed by doctor and patient and/or family that advanced technology is used solely for the

purpose of sparing the patient discomfort or limitations they he or she would otherwise suffer.

f. The patient, family, and physician are all willing to participate in the program with the

understanding that withdrawal is possible at any time.

VII. REFERENCES: A. Title 28 Article 8 Section 1300.68.2

B. California Health and Safety Code Section 1745, 1726 and 1747.1

VIII. DISTRIBUTION: A. PHC Departmental Directors



X. REVISION DATES: 11/21/07; 11/19/08; 07/21/10; 10/01/10; 06/17/15; 10/21/15; 06/15/16

PREVIOUSLY APPLIED TO:

Healthy Families:

MPUG3071 - 10/01/2010 to 03/01/2013

***********************************



Page 46 of 199




☐Internal Policy


Last Review Date: 10/21/201506/15/2016











under PHC.”

In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with

involvement from actively practicing health care providers and meets these provisions:



If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be

disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar

illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits

covered under PHC.

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POLICY / PROCEDURE

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Policy/Procedure Number: HKUP3067 (previously MPUP3067 &

KK UM101) Lead Department: Health Services

Policy/Procedure Title: Appeals/ Expedited Appeals of UM

Decisions for Medical Necessity Determination (Non-Administrative) External Policy

Internal Policy




Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. HKUP3080 TAR Process

B. HKUG3072 Inpatient Utilization Management (Knox-Keene)

C. MP PR-GR 210 Provider Grievance

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services


IV. ATTACHMENTS:

A. Provider Request for Appeal of UM Decision for Medical Necessity Determination

V. PURPOSE:

This policy describes the process for providers to appeal Utilization Management (UM) decisions for medical

necessity determination by Partnership HealthPlan of California (PHC) on behalf of members. Appeals will

not be considered for any request in excess of 180 days of the decision.


Beneficiaries and providers are provided fair and solution-oriented means to address perceived problems in

accordance with the Evidence of Coverage.

A. Provider Appeal

1. A provider may request an appeal of a non-administrative UM decision on behalf of a member by

calling or writing the Health Services Department. The provider may use the “Appeal of UM

Decision” form if desired. After receipt of the request for appeal, the Chief Medical Officer or

Physician Designee reviews the request. The Chief Medical Officer or Physician Designee may

request further information from the provider such as diagnostic information, previous treatment,

clinical justification, opinions from specialists or other providers, or evidence from the scientific

literature prior to processing the request. The provider is expected to respond to a request for further

information within 30 working days. If the provider does not respond to the request for further

information, the appeal is denied for lack of timely response.

2. After receipt of the request for appeal or receipt of the requested additional information, the Chief

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Policy/Procedure Number: HKUP3067 (previously

MPUP3067 & KK UM101) Lead Department: Health Services


Decisions for Medical Necessity Determination (Non-

Administrative)

☒External Policy

☐Internal Policy





Medical Officer or Physician Designee refers the appeal to a member of the Quality / Utilization

Advisory Committee (Q/UAC) or to a board certified specialist consultant selected by the Chief

Medical Officer or Physician Designee for consideration. The Q/UAC member or consultant may

request further information from the provider or expert consultants. The Q/UAC or consultant has

30 working days, from receipt of all pertinent information, to make a determination. The decision is

communicated to the provider within one (1) working day and member in writing within two (2)

working days.

B. Providers who disagree with the decision of the Q/UAC member or specialist consultant may then file a

grievance with PHC by the process described in the MP PR-GR 210 Provider Grievance policy.

C. Expedited Appeals of Non-Administrative Determinations

1. Expedited appeals may be initiated by the member or by a practitioner acting on behalf of the

member. The practitioner requests an expedited appeal by calling or writing the PHC Health

Services Department. A member requests an expedited appeal by calling or writing the PHC

Member Services Department. Expedited appeals are performed by PHC only when, in the

judgment of PHC, a delay in decision making imposes an imminent and serious threat to the health

of the enrollee including, but not limited to, severe pain, potential loss of life, limb or major bodily

function.

2. PHC refers the appeal request to either an appropriate board certified contracted specialist consultant

or an appropriate member of the Q/UAC for decision on the appeal. The consultant or Q/UAC

member is expected to make a decision as expeditiously as the medical condition requires, but no

later than seventy-two (72) hours after the receipt of the appeal request. Expedited reviews are also

granted to all requests concerning admissions, continued stay or other health care services for a

member who has received emergency services but has not been discharged from a facility. PHC

provides notification to the practitioner within one (1) working day of the determination and written

confirmation of the decision to the enrollee within two working days of the decision. The letter will

contain reference to the specific criteria or guideline used in making the determination.

VII. REFERENCES: A. Title 28, Managed Health Care, Division I, Chapter 2, Article 8 Section 1300.68-68.1

B. California Health and Safety Code Sections 1368.-1368.1

VIII. DISTRIBUTION: A. PHC Department Directors



X. REVISION DATES: 11/21/07; 11/19/08; 06/16/10; 10/01/10; 11/18/15; 06/15/16


Healthy Families:

MPUP3067 - 10/01/10 to 03/01/2013

*********************************



Page 49 of 199





Administrative)

☒External Policy

☐Internal Policy













under PHC.”

Page 50 of 199


I:\POLICIES\Draft policies for review\Healthy Kids\UM\UM Policies for 06-07-16 IQI\HKUP3067-A.doc Page 1 of 1

Partnership HealthPlan of California Provider Request for

Appeal / Expedited Appeal of UM Decision for Medical

Necessity Determination

Requesting Provider ________________________________ Please Print

Member Name ______________________________________ Please Print

ID Number ________________________________________

Service Denied ____________________________________

Date of Denial ____________________________________

TAR Number ______________________________________

Do you wish this request to be expedited? Yes No Expedited appeals are performed only when a delay in decision making might

seriously jeopardize the life or health of the member.

Please state the reason: ________________________________________________

I am supplying additional clinical information and wish to appeal the

original decision Please sign and date and attach documentation to this form

____________________________________________________

-----OR----- I do not have additional clinical information. I am appealing the original

decision Please sign and date

___________________________________________________________________

Please submit completed form to the PHC UM Department FAX # (707) 863-4118

Page 51 of 199


POLICY / PROCEDURE





Decisions for Medical Necessity Determination (Non-Administrative) External Policy

Internal Policy


Last Review Date: 11/18/201506/15/2016


Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. HKUP3080 TAR Process

B. HKUG3072 Inpatient Utilization Management (Knox-Keene)

B.C. MP PR-GR 210 Provider Grievance

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services


IV. ATTACHMENTS:

A. Provider Request for Appeal of UM Decision for Medical Necessity Determination

V. PURPOSE:

This policy describes the process for providers to appeal Uutilization Mmanagement (UM) decisions for

medical necessity determination by Partnership HealthPlan of CaliforniaA (PHC) on behalf of members.

Appeals will not be considered for any request in excess of 180 days of the decision.


Beneficiaries and providers are provided fair and solution-oriented means to address perceived problems in

accordance with the Evidence of Coverage.

A. Provider Appeal

1. A provider may request an appeal of a non-administrative UM decision on behalf of a member by

calling or writing the Health Services Department. The provider may use the “Appeal of UM

Decision” form if desired. After receipt of the request for appeal, the Chief Medical Officer or

Physician Designee reviews the request. The Chief Medical Officer or Physician Designee may

request further information from the provider such as diagnostic information, previous treatment,

clinical justification, opinions from specialists or other providers, or evidence from the scientific

literature prior to processing the request. The provider is expected to respond to a request for further

information within 30 working days. If the provider does not respond to the request for further

information, the appeal is denied for lack of timely response.

2. After receipt of the request for appeal or receipt of the requested additional information, the Chief

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Administrative)

☒External Policy

☐Internal Policy


Last Review Date: 11/18/201506/15/2016



Medical Officer or Physician Designee refers the appeal to a member of the Quality / Utilization

Advisory Committee (Q/UAC) or to a board certified specialist consultant selected by the Chief

Medical Officer or Physician Designee for consideration. The Q/UAC member or consultant may

request further information from the provider or expert consultants. The Q/UAC or consultant has

30 working days, from receipt of all pertinent information, to make a determination. The decision is

communicated to the provider within one (1) working day and member in writing within two (2)

working days.

B. Providers who disagree with the decision of the Q/UAC member or specialist consultant may then file a

grievance with PHC by the process described in the MP PR-GR 210 Provider Grievance policy.

C. Expedited Appeals of Non-Administrative Determinations

1. Expedited appeals may be initiated by the member or by a practitioner acting on behalf of the

member. The practitioner requests an expedited appeal by calling or writing the PHC Health

Services Department. A member requests an expedited appeal by calling or writing the PHC

Member Services Department. Expedited appeals are performed by PHC only when, in the

judgment of PHC, a delay in decision making imposes an imminent and serious threat to the health

of the enrollee, including, but not limited to, severe pain, potential loss of life, limb or major bodily

function.

2. PHC refers the appeal request to either an appropriate board certified contracted specialist consultant

or an appropriate member of the Q/UAC for decision on the appeal. The consultant or Q/UAC

member is expected to make a decision as expeditiously as the medical condition requires, but no

later than seventy-two (72) hours after the receipt of the appeal request. Expedited reviews are also

granted to all requests concerning admissions, continued stay or other health care services for a

member who has received emergency services but has not been discharged from a facility. PHC

provides notification to the practitioner within one (1) working day of the determination and written

confirmation of the decision to the enrollee within two working days of the decision. The letter will

contain reference to the specific criteria or guideline used in making the determination.

VII. REFERENCES: A. Title 28, Managed Health Care, Division I, Chapter 2, Article 8 Section 1300.68-68.1

B. California Health and Safety Code Sections 1368.-1368.1

VIII. DISTRIBUTION: A. PHC Department Directors,



X. REVISION DATES: 11/21/07; 11/19/08; 06/16/10; 10/01/10; 11/18/15; 06/15/16


Healthy Families:

MPUP3067 - 10/01/10 to 03/01/2013

*********************************



Page 53 of 199





Administrative)

☒External Policy

☐Internal Policy


Last Review Date: 11/18/201506/15/2016











under PHC.”









covered under PHC.

Page 54 of 199



POLICY / PROCEDURE




Policy/Procedure Title: Mastectomy and Breast Reconstruction External Policy

Internal Policy




Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. N/A

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services


IV. ATTACHMENTS:

A. N/A

V. PURPOSE:

To define coverage for procedures related to mastectomy/breast reconstruction surgery and complications

related to those procedures

VI. POLICY / PROCEDURE: A. The benefit provides for medically necessary mastectomy and lymph node dissection, including

prosthetic devices or reconstructive surgery, to restore and achieve symmetry incident to the

mastectomy.

B. The length of the hospitalization for such procedures shall be determined by the attending physician and

surgeon in consultation with the member, and shall be consistent with national and local community

medical standards.

C. If needed services are due to a California Children’s Services (CCS) condition, those shall be

EXCLUDED from coverage under this program.

VII. REFERENCES: A. California Health and Safety Code Section 1367.6 (d-f)

VIII. DISTRIBUTION: A. Provider Manual

B. PHC Directors

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Policy/Procedure Title: Mastectomy and Breast Reconstruction ☒External Policy

☐Internal Policy






X. REVISION DATES: Healthy Kids

11/21/07; 11/19/08; 07/21/10; 10/01/10; 01/16/13; 08/19/15; 06/15/16


Healthy Families:

MPUP3073 - 10/01/2010 to 03/01/2013

***********************************











under PHC.”

Page 56 of 199



POLICY / PROCEDURE




Policy/Procedure Title: Mastectomy and Breast Reconstruction External Policy

Internal Policy


Last Review Date: 08/19/201506/15/2016


Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. N/A

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services


IV. ATTACHMENTS:

A. N/A

V. PURPOSE:

To define coverage for procedures related to mastectomy/breast reconstruction surgery and complications

related to those procedures

VI. POLICY / PROCEDURE: A. The benefit provides for medically necessary mastectomy and lymph node dissection, including

prosthetic devices or reconstructive surgery, to restore and achieve symmetry incident to the

mastectomy.

B. The length of the hospitalization for such procedures shall be determined by the attending physician and

surgeon in consultation with the member, and shall be consistent with national and local community

medical standards.

C. If needed services are due to a California Children’s Services (CCS) condition, those shall be

EXCLUDED from coverage under this program.

VII. REFERENCES: A. California Health and Safety Code Section 1367.6 (d-f)

VIII. DISTRIBUTION: A. Provider Manual

B. PHC Directors

Page 57 of 199



Policy/Procedure Title: Mastectomy and Breast Reconstruction ☒External Policy

☐Internal Policy


Last Review Date: 08/19/201506/15/2016




X. REVISION DATES: Healthy Kids

11/21/07; 11/19/08; 07/21/10; 10/01/10; 01/16/13; 08/19/15; 06/15/16


Healthy Families:

MPUP3073 - 10/01/2010 to 03/01/2013

***********************************











under PHC.”

*********************************









covered under PHC.

Page 58 of 199



POLICY / PROCEDURE

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KK UM 114) Lead Department: Health Services

Policy/Procedure Title: PCP to Specialty Care Referral Process

(RAF) External Policy

Internal Policy




Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. MPUP3004 Advice Nurse Program

B. HKUP3069 Emergency Services

C. MPCP2002 California Children’s Services (CCS)

D. HKUP3075 Mental Health Services

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services


IV. ATTACHMENTS:

A. Referral Authorization Form (RAF) (Healthy Kids)

V. PURPOSE: To define the procedure used for Partnership HealthPlan of California (PHC) members to obtain specialty

referral.

ALL members who have a Primary Care Provider (PCP) assignment must obtain a Referral Authorization

Form (RAF) for specialty referrals EXCEPT for the indications outlined in Section VI. B of this policy.


A. The Referral Process-PCP to-Specialist

1. The primary care provider shall initiate the referral process for specialty care.

2. The authorizing PCP completes the RAF after making a determination of either the number of visits

or timeframe of services to be rendered. The preferred method is for the E-RAF (Electronic RAF)

via On Line Services to be completed. This will expedite processing time and will automatically

send a copy of the request to the specialty provider. The PCP should be sure to provide the clinical

information that the specialty provider will need to make an accurate assessment of the situation and

make recommendations for on-going care and treatment if needed.

3. The PCP is expected to keep a copy of the RAF, along with the specialist’s written follow-up

report(s) and or recommendation(s) in the patient’s medical record.

4. A copy of the RAF is also sent to the Specialist by the PCP office if a paper form is used or will

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MPUP3077 & KK UM 114) Lead Department: Health Services


(RAF)

☒External Policy

☐Internal Policy





automatically be system generated if the E-RAF system is used.

5. A copy of the RAF should be given to the member so that he/she will have the information about the

specialist to whom he/she is being referred. This should be provided by the Primary Care Provider.

6. Upon completion of the initial evaluation and subsequent treatment (if indicated), the specialist

provider shall:

a. Notify the PCP of the member’s condition, proposed treatments and prognosis though the

timeframe of treatment

b. Provide the PCP with a written, or other oral reports as appropriate in regard to the diagnosis

and prognosis of the member’s treatment

7. If the request is for a non-contracted provider, a determination of the request will be rendered within

the timeframes outlined under section VI. E.

8. Non-contracted referrals will be approved when there is a compelling medical reason for why the

service cannot be performed by a contracted provider. Also, if there is non-availability of the

service within the network, the referral will be approved.

B. Services EXCLUDED from the Referral Process

1. Emergency Service Referrals:

a. Emergency services are defined as those services necessary to evaluate or stabilize an

Emergency Medical Condition that is found to exist using a prudent layperson definition

b. Emergency Medical Condition is defined as a medical condition which is manifested by acute

symptoms of sufficient severity (including severe pain) such that a prudent layperson, who

possesses an average knowledge of health and medicine, could reasonably expect the absence of

immediate medical attention to result in:

1) Placing the health of the individual (or, in the case of a pregnant woman, the health of the

woman and her unborn child) in serious jeopardy OR

2) Serious impairment to bodily functions OR

3) Serious dysfunction of any bodily organ or part

4) PCPs are required to maintain 24 hour/ 7 days a week access for members, which includes

availability for response to Emergency Services and urgent requests of members. When

possible, the PCP is to triage members and direct to the most appropriate level of service

based on the needs of the member.

5) When the above is NOT possible, members may self-refer to the Emergency Department

(ED) based on the member’s belief that there is an emergency situation occurring.

6) Members may be referred to the ED by the PHC Advice Nurse.

7) Members who have requested specialty referral from their PCP, but the request has been

declined by the PCP, may appeal directly to the health plan.

2. Family Planning Services

a. Health education and counseling necessary to understand contraceptive methods and make

informed choices

b. History and physical examination as indicated

c. Laboratory tests, if medically indicated, as part of decision making process for choice of

contraceptive methods. (e.g., Pap smear at appropriate intervals)

d. Diagnosis and treatment of sexually transmitted diseases (STDs), if medically indicated.

e. Screening, testing and counseling of individuals at risk for human immunodeficiency virus (HIV) and referral for treatment

f. Provision of contraceptive pills/devices/supplies

g. Tubal ligation

h. Vasectomy

Page 60 of 199




(RAF)

☒External Policy

☐Internal Policy





i. Pregnancy testing and counseling

3. Routine Obstetrical and Gynecological Services

a. Female members have the right to self-refer to any contracted OB/GYN, family practitioner

and/or certified nurse midwife who provides OB/GYN services without a referral from the

member’s PCP.

b. The selected provider shall communicate with the member’s PCP regarding services provided

and the need for additional or follow-up care.

4. Termination of Pregnancy

a. PHC permits members to obtain termination of pregnancy services, without prior authorization,

from any in-network/contracted provider of their choice.

5. Mental Health Services

a. Members may self-refer to our contracted provider, Beacon Health Strategies, or to the County

Mental Health Department.

6. Routine vision care services

a. Members may self-refer to contracted in-plan providers of Vision Care Services

7. Dental Services

a. Members may self-refer to contracted in-plan providers of Dental Care. Certain specialty care

may require a referral from your dentist.

8. Native American Indians seeking care at an Indian Health Center

9. Urgent Care Services when traveling outside of the service area

C. Extended Referral Authorizations

1. Members with chronic conditions may require repeated specialty visits over an extended period of

time, in order to sustain the appropriate level of medical supervision. In instances where there is a

recurring need that is predictable, the PCP may initiate the referral for a period of up to a one-year

time frame. If after that time, the need still exists for continued care, a new referral can be

generated.

2. Members who have requested a long term referral from their PCP, but the request has been declined

by the PCP, may appeal directly to the health plan.

D. CCS Conditions

1. For member with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome

(AIDS), or any other condition as defined in California Code of Regulations, Title 22, Division 2,

Part 2, Subdivision 7, CCS Chapter 4 Medical Eligibility, Sections 41800-41872, these are eligible

for coverage under the CCS program for the specialty services related to those conditions. CCS

shall approve for and pay for all services in these instances.

2. The PCP, or other treating provider, is responsible to refer the individual to the local CCS office in

the county in which the member resides. This shall include providing CCS with the needed

documentation to make an eligibility determination.

3. PHC’s benefits are exclusive of services for CCS conditions and will not pay providers who render

those services.

E. Turn Around Times

1. For in-plan contracted specialist, there is not an approval process from the health plan. The function performed is to enter the RAF into the PHC system so that the claim is paid when it is received in

the claims department. These are put into the system within five (5) business days of receipt.

2. For non-contracted specialty referrals, the plan will determine the medical necessity using InterQual

established criteria and render a determination to as to whether or not the referral is approved and if

Page 61 of 199




(RAF)

☒External Policy

☐Internal Policy





so, make arrangements for payment within 1 business day on Emergent or Urgent requests and five

(5) business days for routine requests.

3. If care can be rendered by a contracted specialist, the member will be redirected to a contracted

provider.

VII. REFERENCES: A. California Health and Safety Code Section 1367.695 AND 1374.16

B. Title 28, Division 1, Chapter 2, Article 7 Section 1300.67

C. InterQual Criteria

VIII. DISTRIBUTION: A. PHC Directors

B. Provider Manual


X. REVISION DATES: 11/21/07; 11/19/08; 07/21/10; 10/01/10; 01/16/13; 09/16/15; 06/15/16


Healthy Families:

MPUP3077 – 10/01/2010 to 03/01/2013

Page 62 of 199

Referred to:

Address:

Telephone:

Services requested:[ ] Consult and / or Continuing Care [ ] Please call me when you have seen patient.

[ ] 2 months [ ] 4 months [ ] up to 12 mos. [ ] I would like to receive periodic status report.[ ] Call me if procedures or admission planned.

Is requested provider contracted with PHC. This referral is:[ ] Urgent: potentially life-threatening condition.[ ] Indicated: important to health; not life-threatening.

Reason for referral:

Work-up and treatment to date: (Include copies of lab reports, imaging studies, etc.):

Questions I need answered:

Provisional Diagnosis:

Date of Issue: Clinician Signature:

Print Name

Send consult report to:

Final Report (please check all that apply) [ ] Typed consultation note will be sent to you.[ ] My medical record note will be sent to you. [ ] I will call you to discuss case.

[ ] Patient was not seen as schedulted on

Preliminary Report:

Plan:

Distribution Copies: Consultant, PCP, PHCFax No.Signature / Print Name Date Seen Phone No.

Date of Birth:

TO BE COMPLETED BY THE REFERRING CLINICIAN

ID#:

Referral Authorization Form (RAF)

Member Name:

City, Zip:

(from date of issue)

TO BE COMPLETED BY CONSULTANT

Primary ICD-CM/Dx:

The consultant name must be the same as that used to bill for these services.

Consultants should verify PCPPayment subject to member eligibility.Approval of consultation limited to covered benefits.

If Non-Contracted provider, RAF must be approved by PHC before given to member.

Consults must be initiated < 30 days of date below.

Phone FaxCityAddress

4665 Business Center Drive

Farifield, CA 94534(707) 863-4133 or (800) 863-4144(707) 863-4118 FAX

PARTNERSHIP HEALTHPLAN OF CALIFORNIA RAF NUMBER

Member Phone:

PHC Determination:

Approved Redirected to Contracted Provider Denied Signature____________________Date_______

Page 63 of 199


POLICY / PROCEDURE


Policy/Procedure Number: HKUP3077 (previously MPUP3077 & KK UM 114) Lead Department: Health Services

Policy/Procedure Title: PCP to Specialty Care Referral Process (RAF)

External Policy Internal Policy

Original Date: 11/16/2005 Next Review Date: 06/15/2017 Last Review Date: 06/15/2016


Reviewing Entities:

IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT

Approving Entities:




I. RELATED POLICIES: A. MPUP3004 Advice Nurse Program B. HKUP3069 Emergency Services C. MPCP2002 California Children’s Services (CCS) C.D. HKUP3075 Mental Health Services

II. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services


IV. ATTACHMENTS: A. Referral Authorization Form (RAF) (Healthy Kids)

V. PURPOSE: To define the procedure used for Partnership HealthPlan of California (PHC) members to obtain specialty referral. ALL members who have a Primary Care Physician Provider (PCP) assignment must obtain a Referral Authorization Form (RAF) for specialty referrals EXCEPT for the indications outlined in Section VI. B of this policy.

VI. POLICY / PROCEDURE: A. The Referral Process-PCP to-Specialist

1. The primary care physician provider shall initiate the referral process for specialty care. 2. The authorizing PCP completes the RAF after making a determination of either the number of visits

or timeframe of services to be rendered. The preferred method is for the E-RAF (Electronic RAF) via On Line Services to be completed. This will expedite processing time and will automatically send a copy of the request to the specialty provider. The PCP should be sure to provide the clinical information that the specialty provider will need to make an accurate assessment of the situation and make recommendations for on-going care and treatment if needed.

3. The PCP is expected to keep a copy of the RAF, along with the specialist’s’ written follow-up report(s) and or recommendation(s) in the patient’s medical record.

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☒External Policy ☐Internal Policy




4. A copy of the RAF is also sent to the Specialist by the PCP office if a paper form is used or will automatically be system generated if the E-RAF system is used.

5. A copy of the RAF should be given to the member so that he/she will have the information about the specialist to whom he/she is being referred. This should be provided by the Primary Care Provider.

6. Upon completion of the initial evaluation and subsequent treatment (if indicated), the referral specialist provider shall: a. Notify the PCP of the member’s condition, proposed treatments and prognosis though the

timeframe of treatment b. Provide the PCP with a written, or other oral reports as appropriate in regard to the diagnosis

and prognosis of the member’s treatment 7. If the request is for a non-contracted/out ofnon-network provider, a determination of the request will

be rendered within the timeframes outlined under section VI. E. 8. Out of NetworkNon-contracted referrals will be approved when there is a compelling medical reason

for why the service cannot be performed by an in-plana contracted provider. Also, if there is non-availability of the service within the network, the referral will be approved.

B. Services EXCLUDED from the Referral Process

1. Emergency Service Referrals: a. Emergency services are defined as those services necessary to evaluate or stabilize an

Emergency Medical Condition that is found to exist using a prudent layperson definition b. Emergency Medical Condition is defined as a medical condition, which is manifested by acute

symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: 1) Placing the health of the individual (or, in the case of a pregnant woman, the health of the

woman and her unborn child) in serious jeopardy OR 2) Serious impairment to bodily functions OR 3) Serious dysfunction of any bodily organ or part 4) PCPs are required to maintain 24 hour/ 7 days a week access for members, which includes

availability for response to Emergency Services and urgent requests of members. When possible, the PCP is to triage members and direct to the most appropriate level of service based on the needs of the member.

5) When the above is NOT possible, members may self-refer to the Emergency Department (ED) based on the member’s’ belief that there is an emergency situation occurring.

6) Members may be referred to the ED by the PHC Advice Nurse. 7) Members who have requested specialty referral from their PCP, but the request has been

declined by the PCP, may appeal directly to the health plan. 2. Family Planning Services

a. Health education and counseling necessary to understand contraceptive methods and make informed choices

b. History and physical examination as indicated c. Laboratory tests, if medically indicated, as part of decision making process for choice of

contraceptive methods. (e.g., Pap smear at appropriate intervals) d. Diagnosis and treatment of sexually transmitted diseases (STDs), if medically indicated. e. Screening, testing and counseling of individuals at risk for human immunodeficiency virus

(HIV) and referral for treatment f. Provision of contraceptive pills/devices/supplies g. Tubal ligation

Page 65 of 199







h. Vasectomy i. Pregnancy testing and counseling

3. Routine Obstetrical and Gynecological Services a. Female members have the right to self-refer to any contracted/in-network OB/GYN, family

practitioner and/or certified nurse midwife who provides OB/GYN services without a referral from the member’s PCP.

b. The selected provider shall communicate with the member’s PCP regarding services provided and the need for additional or follow-up care.

4. Termination of Pregnancy a. PHC permits members to obtain termination of pregnancy services, without prior authorization,

from any in-network/contracted provider of their choice. 5. Mental Health Services

a. Members may self-refer to our contracted in-planp provider, Beacon Health Strategies,s or to the County Mental Health Department.

6. Routine vision care services a. Members may self-refer to contracted in-plan providers of Vision Care Services

7. Dental Services a. Members may self-refer to contracted in-plan providers of Dental Care. Certain specialty care

may require a referral from your dentist. 8. Native American Indians seeking care at an Indian Health Center 9. Urgent Care Services when traveling outside of the service area

C. Extended Referral Authorizations

1. Members with chronic conditions may require repeated specialty visits over an extended period of time, in order to sustain the appropriate level of medical supervision. In instances where there is a recurring need that is predictable, the PCP may initiate the referral for a period of up to a one-year time frame. If after that time, the need still exists for continued care, a new referral can be generated.

2. Members who have requested a long term referral from their PCP, but the request has been declined by the PCP, may appeal directly to the health plan.

D. CCS Conditions

1. For member with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), or any other condition as defined in California Code of Regulations, Title 22, Division 2, Part 2, Subdivision 7, CCS < Chapter 4 Medical Eligibility, Sections 41800-41872, these are eligible for coverage under the CCS program for the specialty services related to those conditions. CCS shall approve for and pay for all services in these instances.

2. The PCP, or other treating provider, is responsible to refer the individual to the local CCS office in the county in which the member resides. This shall include providing CCS with the needed documentation to make an eligibility determination.

3. PHC’s benefits are exclusive of services for CCS conditions and will not pay providers who render those services.

E. Turn Around Times

1. For in-plan contracted specialist, there is not an approval process from the health plan. The function performed is to enter the RAF into the PHC system so that the claim is paid when it is received in the claims department. These are put into the system within five (5) business days of receipt.

Page 66 of 199







2. For non-contracted specialty referrals, the plan will determine the medical necessity using InterQual established criteria and render a determination to as to whether or not the referral is approved and if so, make arrangements for payment within 1 business day on Emergent or Urgent requests and five (5) business days for routine requests.

3. If care can be rendered by a contracted specialist, the member will be redirected to a contracted provider.

VII. REFERENCES:

A. California Health and Safety Code Section 1367.695 AND 1374.16 B. Title 28, Division 1, Chapter 2, Article 7 Section 1300.67 C. InterQual Criteria

VIII. DISTRIBUTION:

A. PHC Directors B. Provider Manual


X. REVISION DATES: 11/21/07; 11/19/08; 07/21/10; 10/01/10; 01/16/13; 09/16/15; 06/15/16

PREVIOUSLY APPLIED TO: Healthy Families: MPUP3077 – 10/01/2010 to 03/01/2013

Page 67 of 199

Attachment A - MCUP3041


Attachment A - HKUP3080

Attachment B - MCUG3007

(TAR to be submitted by the provider performing the service) Revised 06/15/2016

Page 1 of 8

PHC TAR REQUIREMENTS

A. Hospitalization

1. The hospital must notify PHC of any admission within 24 hours of the admission.

2. Authorization for elective admission must be requested by the admitting physician prior

to the admission.

B. Long Term Care

The LTC facilities must notify PHC of any admissions, transfer, bed hold/ leave of absence, or

change in payor status within one working day. (Examples include Medicare non-coverage or

exhaustion of benefits / hospice election.)

C. Outpatient Surgical Procedures – see CPTs Requiring TAR list

D. Pain Management – see CPTs Requiring TAR list

E. Outpatient Hemo / Peritoneal Dialysis

(Note: initial authorization will be limited to 90 days and a lifetime TAR will be granted only after

submission of Medicare determination.)

F. Drugs and Pharmaceuticals – A TAR is required for all prescription drugs, over-the-counter drugs

and injectable drugs (including drugs compounded for IV infusion therapy) not on the PHC

formulary.

PLEASE REFER TO PHC FORMULARY

G. Diagnostic Studies

♦ CT Scans

♦ MRI

♦ MRA

♦ PET scan

♦ Transcranial Doppler

♦ Sleep Studies / Polysomnography

H. Ancillary / Support Services

RAF authorizes one visit only. Requests for additional visits require the ancillary service provider to

submit copies of initial evaluation and treatment plan attached to TAR. TAR must include total visits

requested including initial visit.

♦ Acupuncturist

• Speech Therapy

♦ Chiropractor • Occupational Therapy

♦ Faith Healer • Home Infusion Therapy (Nursing Component Only)

♦ Physical Therapy • Home Health Care

I. Hospice Care (Inpatient Only)

J. Pulmonary Rehabilitation

K. Hyperbaric Oxygen Pressurization

Page 68 of 199






Page 2 of 8


L. Non-Emergency Medical Transportation

M. EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Supplemental Services

N. Phototherapy for dermatological condition

O. Dental Anesthesia

P. CCS/GHPP - Authorization for services related to eligible condition(s) must be requested from

CCS or GHPP office(s).

Q. Supplies / Equipment

♦ Orthotics – Cumulative costs for repair/maintenance or purchase exceeds $250 / item

♦ Prosthetics – Cumulative costs for repair / maintenance or purchase exceeds $500 / item

And any unlisted / miscellaneous code including:

- L0999 Addition to spinal orthosis, not otherwise specified

- L1499 Spinal orthosis, not otherwise specified

- L2999 Lower extremity orthosis, not otherwise specified

- L3649 Orthotic shoe, modification, addition or transfer, not otherwise specified

- L3999 Upper limb orthosis, not otherwise specified

- L5999 Lower extremity prosthesis, not otherwise specified

- L7499 Upper extremity prosthesis, not otherwise specified

- L8039 Breast prosthesis, not otherwise specified

- L8499 Unlisted procedure for miscellaneous prosthetic services

- L8699 Prosthetic implant, not otherwise specified

ANY CUSTOM MADE ITEM THAT DOES NOT HAVE A MEDI-CAL RATE (BY-

REPORT OR BY-INVOICE)

♦ Ostomy Supplies – If monthly cumulative cost for all related supplies exceeds $150

♦ Hearing Aid – All purchases, rentals or repairs exceeding $50 / item

(Batteries are non-covered except some CCS / EPSDT cases, in which case TAR is

required)

♦ Oxygen and related supplies

♦ Diabetic Supplies are to be provided by Pharmacies ONLY

♦ Medical Supplies – (If dispensed by PHARMACY, please refer to formulary)

♦ Any unlisted or miscellaneous code

♦ DME – (If dispensed by PHARMACY, please refer to formulary)

- Repairs or maintenance over $250.00 / item (Out of guarantee repairs are to be

guaranteed for at LEAST three (3) months from the date of repair. Reimbursement will

NOT be allowed for parts or labor during a guarantee period if due to a defect in

material or workmanship)

- Purchase items over $100.00 / item (Vendor to guarantee for a MINIMUM of six (6)

months from the date of purchase)

- Rental items over $50.00 / month / item (Rental rate includes equipment related

supplies.)

- Any unlisted or miscellaneous code

- Purchase of any wheelchairs for Medi-Medi members

Page 69 of 199






Page 3 of 8


♦ Incontinence Supplies

- Incontinence supplies if monthly cumulative cost for all related supplies exceeds

$125.00

AND any unlisted or miscellaneous code

- Washes and creams for members with incontinence will only be authorized if the

physician justifies medical necessity

♦ Nutritional Supplements (Submit TAR to Pharmacy)

R. Genetic Testing – A TAR is required for certain genetic testing as outlined in Attachment A of the

Genetic Testing policy MCUP3131.

Page 70 of 199






Page 4 of 8


Outpatient Surgical Procedures - CPTs Requiring TAR CPT Code Description

10040 Acne Surgery

15788 Thru 15793 Chemical Peel, Facial Et Al

15810-11 Salabrasion

15820 Thru 15823 Revision Of Lower Or Upper Eyelid

15845 Skin And Muscle Repair, Face

17360 Skin Peel Therapy

17999 Skin Tissue Procedure

19140 Mastectomy For Gynecomastia


19316 Mastopexy

19318 Reduction Mammoplasty

19324/25 Breast Augment; W/O Prosthetic Implant

19355 Correction Of Inverted Nipples

19380 Revise Breast Reconstruction

19396

Design Custom Breast Implant

19499 Unlisted Procedure, Breast

20999 Musculoskeletal Surgery

21208 Augmentation Of Facial Bones

22899 Spine Surgery Procedure

22999 Abdomen Surgery Procedure

28290 Thru 28299 Correction Of Bunion

28300 Thru 28345

Osteotomy / Repair /

Reconstruction

30400 Thru 30520 Reconstruct Of Nose

30520 Repair Nasal Septum

32999 Chest Surgery Procedure

36299 Vessel Injection Procedure

37700

Ligation And Division Of Long Saphenous Vein At Saphenofemoral Junction, Or Distal Interruptions

37718 Ligation, Division, And Stripping, Short Saphenous Vein

37722

Ligation, Division, And Stripping, Long (Greater) Saphenous Veins From Saphenofemoral Junction To Knee Or Below

37735

Ligation And Division And Complete Stripping Of Long Or Short Saphenous Veins With Radical Excision Of Ulcer And Skin Graft And/or Interruption Of Communicating Veins Of Lower Leg, With Excision Of Deep Fascia

37760

Ligation Of Perforator Veins, Subfascial, Radical (Linton Type) Including Skin Graft, When Performed, Open, 1 Leg

37761

Ligation Of Perforator Vein(S), Subfascial, Open, Including Ultrasound Guidance, When Performed, 1 Leg

37765 Stab Phlebectomy Of Varicose Veins, 1 Extremity; 10-20 Stab Incisions

Page 71 of 199






Page 5 of 8


Outpatient Surgical Procedures - CPTs Requiring TAR (Continued) CPT Code Description

37766 More Than 20 Incisions

37780

Ligation And Division Of Short Saphenous Vein At Saphenopopliteal Junction (Separate Procedure)

37785 Ligation, Division, And/or Excision Of Varicose Vein Cluster(S) 1 Leg

38206, 38231 Stem Cell Harvesting

38230 Bone Marrow Harvesting

36511 Therapeutic Apheresis Of WBC ‘s

36512 Therapeutic Apheresis Of RBCs

38204 Unrelated Harvesting Of Cells

38205 Stem Cell Harvesting From Siblings

38207 Stem Cell Storage

41899 Gum Surgery Procedure

43770 Laparoscopy, Surgical, Gastric Restrictive Procedure

43771 Laparoscopy, Surgical, Revision Of Adjust Gastric Band

43772 Laparoscopy, Surgical, Removal Of Adjustable Gastric Band

43773 Laparoscopy, Surgical, Removal & Placement Of Adj Gastric Band


43842 Gastroplasty, Vertical Banded, For Morbid Obesity

43843 Gastroplasty, Other Than Vertical-Banded, For Morbid Obesity

43845 Gastroplasty

43846 Gastric Bypass For Obesity

43847 Gastric Restrictive Procedure With Gastric Bypass

43848 Revision Of Gastric Restrictive

43886 Gastric Restrictive Procedure

43887 Gastric Restrictive Procedure, Removal Of Subcutaneous Port Component

43888 Gastric Restrictive Proc, Removal & Replacement Of Subcutaneous Port


54161 Circumcision –TAR not required if patient < 4 months of age (See policy MCUP3121 Neonatal Circumcision

54360 Penis Plastic Surgery

54400 Thru 54440 Penile Prosthesis / Plastic Procedure For Penis

55175/80 Revision Of Scrotum

55200 Incision Of Sperm Duct

56800 Repair Of Vagina

58150 Thru 58294, 58570 Hysterectomy

58350 Reopen Fallopian Tube

58550 Thru 58554 Laparoscopy, Surgical; With Vaginal Hysterectomy With Or Without Removal Of Tube(S), With Or Without Removal Of Ovary(S) (Laparoscopic Assisted Vaginal Hysterectomy)

58578/79 Unlisted Procedure, Uterus

Page 72 of 199






Page 6 of 8


Outpatient Surgical Procedures - CPTs Requiring TAR (Continued)

CPT Code Description

58750 Thru 58770 Tubal Repair

61850 Thru 61888 Insertion, Revision Or Removal Of Cranial Neurostimulator

62290 thru 62291 Discography, Lumbar (62290) and Cervical/Thoracic (62291)

63650 Thru 63688 Insertion, Revision Or Removal Of Spinal Neurostimulator

67900 Thru 67924 Repair Brow, Ptosis, Blepharoptosis, Lid

67950 Thru-66 Revision Of Eyelid

67971-75 Reconstruction Of Eyelid

67999 Unlisted Eyelid Procedure

69300 Revise External Ear

69399 Outer Ear Surgery Procedure

72285 Cervical and Thoracic Discography

72295 Lumbar discography

Page 73 of 199






Page 7 of 8


Pain Management CPTs Requiring TAR

CPT CODE DESCRIPTION 27096 Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid

0027T Endoscopic lysis of epidural adhesions with direct visualization using mechanical means

(e.g., spinal endoscopic catheter system) or solution injection (e.g., normal saline)

including radiologic localization and epidurography

0062T Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including

fluoroscopic guidance; single level


fluoroscopic guidance; one or more additional levels

22521 thru

22525

Percutaneous vertebroplasty and percutaneous vertebral augmentation

62287 Aspiration or decompression procedure, percutaneous, of nucleus pulposus of

intervertebral disk, any method, single or multiple levels, lumber (e.g. manual or

automated percutaneous discectomy, percutaneous laser discectomy)

62263 Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline,

enzyme) or mechanical means (e.g., catheter) including radiological localization (includes

contrast when administered), multiple adhesiolysis sessions; 2 or more days



contrast when administered), multiple adhesiolysis sessions; 1 day

62360 thru

62362

Implantable or replacement of device for intrathecal or epidural drug infusion;

subcutaneous reservoir

63650 thru

63688

Insertion, revision or removal of spinal neurostimulator

64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging

guidance (fluoroscopy or CT); cervical or thoracic, single level

64480 Cervical or thoracic, each additional level

64483 Lumbar or sacral, single level

64484 Lumbar or sacral, each additional level

64490 Injection(s), diagnostic or therapeutic agent, Paravertebral facet (zygapophyseal) joint

with image guidance (fluoroscopy or CT), cervical or thoracic; single level.

64491 Second level (List separately in addition to code for primary procedure)

Page 74 of 199






Page 8 of 8


Pain Management CPTs Requiring TAR (Continued)

* TARs generated by the Pharmacy Department

64492 Third level (List separately in addition to code for primary procedure

64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or

nerves innervating that joint) with image guidance (fluoroscopy or CT, lumbar or sacral;

single level)


64495 Third level (List separately in addition to code for primary procedure)

64633 Destruction by neurolytic agent, paravertebral facet joint nerve. cervical or thoracic,

single level


64635 Destruction by neurolytic agent, paravertebral facet joint nerve. single level lumbar or

sacral


*J0585 (If billed with 64612 & 64613) Botulinum A Toxin – 1 unit extraocular

*J0587 (If billed with 64612 & 64613) Botulinum B Toxin – 10 units facial

Page 75 of 199





(TAR to be submitted by the provider performing the service) Revised

01/20/201606/15/2016

Page 1 of 8


A. Hospitalization

1. The hospital must notify PHC of any admission within 24 hours of the admission.

2. Authorization for elective admission must be requested by the admitting physician prior

to the admission.

B. Long Term Care

The LTC facilities must notify PHC of any admissions, transfer, bed hold/ leave of absence, or

change in payor status within one working day. (Examples include Medicare non-coverage or

exhaustion of benefits / hospice election.)

C. Outpatient Surgical Procedures – see CPTs Requiring TAR list

D. Pain Management – see CPTs Requiring TAR list

E. Outpatient Hemo / Peritoneal Dialysis

(Note: initial authorization will be limited to 90 days and a lifetime TAR will be granted only after

submission of Medicare determination.)

F. Drugs and Pharmaceuticals – A TAR is required for all prescription drugs, over-the-counter drugs

and injectable drugs (including drugs compounded for IV infusion therapy) not on the PHC

formulary.

PLEASE REFER TO PHC FORMULARY

G. Diagnostic Studies

♦ CT Scans

♦ MRI

♦ MRA

♦ PET scan

♦ Transcranial Doppler

♦ Sleep Studies / Polysomnography

H. Ancillary / Support Services

RAF authorizes one visit only. Requests for additional visits require the ancillary service provider to

submit copies of initial evaluation and treatment plan attached to TAR. TAR must include total visits

requested including initial visit.

♦ Acupuncturist

• Speech Therapy

♦ Chiropractor • Occupational Therapy

♦ Faith Healer • Home Infusion Therapy (Nursing Component Only)

♦ Physical Therapy • Home Health Care

I. Hospice Care (Inpatient Only)

J. Pulmonary Rehabilitation

K. Hyperbaric Oxygen Pressurization

Page 76 of 199






01/20/201606/15/2016

Page 2 of 8


L. Non-Emergency Medical Transportation

M. EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Supplemental Services

N. Phototherapy for dermatological condition

O. Dental Anesthesia

P. CCS/GHPP - Authorization for services related to eligible condition(s) must be requested from

CCS or GHPP office(s).

Q. Supplies / Equipment

♦ Orthotics – Cumulative costs for repair/maintenance or purchase exceeds $250 / item

♦ Prosthetics – Cumulative costs for repair / maintenance or purchase exceeds $500 / item

And any unlisted / miscellaneous code including:

- L0999 Addition to spinal orthosis, not otherwise specified

- L1499 Spinal orthosis, not otherwise specified

- L2999 Lower extremity orthosis, not otherwise specified

- L3649 Orthotic shoe, modification, addition or transfer, not otherwise specified

- L3999 Upper limb orthosis, not otherwise specified

- L5999 Lower extremity prosthesis, not otherwise specified

- L7499 Upper extremity prosthesis, not otherwise specified

- L8039 Breast prosthesis, not otherwise specified

- L8499 Unlisted procedure for miscellaneous prosthetic services

- L8699 Prosthetic implant, not otherwise specified

ANY CUSTOM MADE ITEM THAT DOES NOT HAVE A MEDI-CAL RATE (BY-

REPORT OR BY-INVOICE)

♦ Ostomy Supplies – If monthly cumulative cost for all related supplies exceeds $150

♦ Hearing Aid – All purchases, rentals or repairs exceeding $50 / item

(Batteries are non-covered except some CCS / EPSDT cases, in which case TAR is

required)

♦ Oxygen and related supplies

♦ Diabetic Supplies are to be provided by Pharmacies ONLY

♦ Medical Supplies – (If dispensed by PHARMACY, please refer to formulary)

♦ Any unlisted or miscellaneous code

♦ DME – (If dispensed by PHARMACY, please refer to formulary)

- Repairs or maintenance over $250.00 / item (Out of guarantee repairs are to be

guaranteed for at LEAST three (3) months from the date of repair. Reimbursement will

NOT be allowed for parts or labor during a guarantee period if due to a defect in

material or workmanship)

- Purchase items over $100.00 / item (Vendor to guarantee for a MINIMUM of six (6)

months from the date of purchase)

- Rental items over $50.00 / month / item (Rental rate includes equipment related

supplies.)

- Any unlisted or miscellaneous code

- Purchase of any wheelchairs for Medi-Medi members

Page 77 of 199






01/20/201606/15/2016

Page 3 of 8


♦ Incontinence Supplies

- Incontinence supplies if monthly cumulative cost for all related supplies exceeds

$125.00

AND any unlisted or miscellaneous code

- Washes and creams for members with incontinence will only be authorized if the

physician justifies medical necessity

♦ Nutritional Supplements (Submit TAR to Pharmacy)

R. Genetic Testing – A TAR is required for certain genetic testing as outlined in Attachment A of the

Genetic Testing policy MCUP3131.

Page 78 of 199






01/20/201606/15/2016

Page 4 of 8


Outpatient Surgical Procedures - CPTs Requiring TAR CPT Code Description

10040 Acne Surgery

15788 Thru 15793 Chemical Peel, Facial Et Al

15810-11 Salabrasion

15820 Thru 15823 Revision Of Lower Or Upper Eyelid

15845 Skin And Muscle Repair, Face

17360 Skin Peel Therapy

17999 Skin Tissue Procedure



19316 Mastopexy

19318 Reduction Mammoplasty

19324/25 Breast Augment; W/O Prosthetic Implant

19355 Correction Of Inverted Nipples

19380 Revise Breast Reconstruction

19396

Design Custom Breast Implant

19499 Unlisted Procedure, Breast

20999 Musculoskeletal Surgery

21208 Augmentation Of Facial Bones

22899 Spine Surgery Procedure


28290 Thru 28299 Correction Of Bunion

28300 Thru 28345

Osteotomy / Repair /

Reconstruction

30400 Thru 30520 Reconstruct Of Nose

30520 Repair Nasal Septum

32999 Chest Surgery Procedure

36299 Vessel Injection Procedure

37700

Ligation And Division Of Long Saphenous Vein At Saphenofemoral Junction, Or Distal Interruptions

37718 Ligation, Division, And Stripping, Short Saphenous Vein

37722

Ligation, Division, And Stripping, Long (Greater) Saphenous Veins From Saphenofemoral Junction To Knee Or Below

37735

Ligation And Division And Complete Stripping Of Long Or Short Saphenous Veins With Radical Excision Of Ulcer And Skin Graft And/or Interruption Of Communicating Veins Of Lower Leg, With Excision Of Deep Fascia

37760

Ligation Of Perforator Veins, Subfascial, Radical (Linton Type) Including Skin Graft, When Performed, Open, 1 Leg

37761

Ligation Of Perforator Vein(S), Subfascial, Open, Including Ultrasound Guidance, When Performed, 1 Leg

37765 Stab Phlebectomy Of Varicose Veins, 1 Extremity; 10-20 Stab Incisions

Page 79 of 199






01/20/201606/15/2016

Page 5 of 8




37766 More Than 20 Incisions

37780

Ligation And Division Of Short Saphenous Vein At Saphenopopliteal Junction (Separate Procedure)

37785 Ligation, Division, And/or Excision Of Varicose Vein Cluster(S) 1 Leg

38206, 38231 Stem Cell Harvesting

38230 Bone Marrow Harvesting

36511 Therapeutic Apheresis Of WBC ‘s

36512 Therapeutic Apheresis Of RBCs

38204 Unrelated Harvesting Of Cells

38205 Stem Cell Harvesting From Siblings

38207 Stem Cell Storage

41899 Gum Surgery Procedure

43770 Laparoscopy, Surgical, Gastric Restrictive Procedure

43771 Laparoscopy, Surgical, Revision Of Adjust Gastric Band


43773 Laparoscopy, Surgical, Removal & Placement Of Adj Gastric Band


43842 Gastroplasty, Vertical Banded, For Morbid Obesity

43843 Gastroplasty, Other Than Vertical-Banded, For Morbid Obesity

43845 Gastroplasty

43846 Gastric Bypass For Obesity

43847 Gastric Restrictive Procedure With Gastric Bypass

43848 Revision Of Gastric Restrictive

43886 Gastric Restrictive Procedure

43887 Gastric Restrictive Procedure, Removal Of Subcutaneous Port Component

43888 Gastric Restrictive Proc, Removal & Replacement Of Subcutaneous Port


54161 Circumcision –TAR not required if patient < 4 months of age (See policy MCUP3121 Neonatal Circumcision

54360 Penis Plastic Surgery

54400 Thru 54440 Penile Prosthesis / Plastic Procedure For Penis

55175/80 Revision Of Scrotum

55200 Incision Of Sperm Duct

56800 Repair Of Vagina

58150 Thru 58294, 58570 Hysterectomy

58350 Reopen Fallopian Tube

58550 Thru 58554 Laparoscopy, Surgical; With Vaginal Hysterectomy With Or Without Removal Of Tube(S), With Or Without Removal Of Ovary(S) (Laparoscopic Assisted Vaginal Hysterectomy)

Page 80 of 199






01/20/201606/15/2016

Page 6 of 8


58578/79 Unlisted Procedure, Uterus



58750 Thru 58770 Tubal Repair

61850 Thru 61888 Insertion, Revision Or Removal Of Cranial Neurostimulator

62290 thru 62291 Discography, Lumbar (62290) and Cervical/Thoracic (62291)

63650 Thru 63688 Insertion, Revision Or Removal Of Spinal Neurostimulator

67900 Thru 67924 Repair Brow, Ptosis, Blepharoptosis, Lid

67950 Thru-66 Revision Of Eyelid

67971-75 Reconstruction Of Eyelid

67999 Unlisted Eyelid Procedure

69300 Revise External Ear

69399 Outer Ear Surgery Procedure

72285 Cervical and Thoracic Discography

72295 Lumbar discography

Page 81 of 199






01/20/201606/15/2016

Page 7 of 8


Pain Management CPTs Requiring TAR

CPT CODE DESCRIPTION 27096 Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid

0027T Endoscopic lysis of epidural adhesions with direct visualization using mechanical means

(e.g., spinal endoscopic catheter system) or solution injection (e.g., normal saline)

including radiologic localization and epidurography


fluoroscopic guidance; single level


fluoroscopic guidance; one or more additional levels

22521 thru

22525

Percutaneous vertebroplasty and percutaneous vertebral augmentation

62287 Aspiration or decompression procedure, percutaneous, of nucleus pulposus of

intervertebral disk, any method, single or multiple levels, lumber (e.g. manual or

automated percutaneous discectomy, percutaneous laser discectomy)



contrast when administered), multiple adhesiolysis sessions; 2 or more days



contrast when administered), multiple adhesiolysis sessions; 1 day

62360 thru

62362

Implantable or replacement of device for intrathecal or epidural drug infusion;

subcutaneous reservoir

63650 thru

63688

Insertion, revision or removal of spinal neurostimulator

64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging

guidance (fluoroscopy or CT); cervical or thoracic, single level


64483 Lumbar or sacral, single level


64490 Injection(s), diagnostic or therapeutic agent, Paravertebral facet (zygapophyseal) joint

with image guidance (fluoroscopy or CT), cervical or thoracic; single level.


Page 82 of 199






01/20/201606/15/2016

Page 8 of 8


Pain Management CPTs Requiring TAR (Continued)

* TARs generated by the Pharmacy Department

64492 Third level (List separately in addition to code for primary procedure

64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or

nerves innervating that joint) with image guidance (fluoroscopy or CT, lumbar or sacral;

single level)


64495 Third level (List separately in addition to code for primary procedure)

64633 Destruction by neurolytic agent, paravertebral facet joint nerve. cervical or thoracic,

single level


64635 Destruction by neurolytic agent, paravertebral facet joint nerve. single level lumbar or

sacral


*J0585 (If billed with 64612 & 64613) Botulinum A Toxin – 1 unit extraocular

*J0587 (If billed with 64612 & 64613) Botulinum B Toxin – 10 units facial

Page 83 of 199


POLICY / PROCEDURE

Page 1 of 8

Policy/Procedure Number: MCUP3041 (previously UP100341) Lead Department: Health Services

Policy/Procedure Title: TAR Review Process ☒External Policy

☐ Internal Policy

Original Date: (UM-2) 04/25/1994

(Effective 06/19/2013 - TAR/RAF Review

Policy split)



Applies to: ☒ Medi-Cal ☐ Healthy Kids ☐ Employees

Reviewing

Entities:



Approving

Entities:





A. MCUP3124 – Referral to Specialists (RAF) Policy

B. MCUP3033 – Out of Area Emergency Admissions

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. Medical Necessity – Medical Necessity means reasonable and necessary services to protect life, to

prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or

treatment of disease, illness or injury.

IV. ATTACHMENTS:

A. PHC TAR Requirements list (including Outpatient Surgical Procedures CPTs Requiring TAR list and

Pain Management CPTs Requiring TAR list

V. PURPOSE:

To describe the procedure used by the PHC Utilization Management (UM) Department to process Referral

Authorization Forms (RAFs) and Treatment Authorization Requests (TARs) based upon the medical

necessity of the request.


A. TAR REVIEW PROCESS

1. General Procedures

a. Partnership HealthPlan of California (PHC) pays for authorized services according to the

specific terms of each physician, hospital, or other provider contract. PHC will reimburse only

if individuals are eligible at the time the service is rendered.

b. Resources necessary to help in determining review decisions, include, but are not limited to the

published, current, InterQual criteria; Medi-Cal (State of California) criteria, Medicare criteria,

and PHC internally developed and approved guidelines. Determinations also take into account

individual member needs and characteristics of the local delivery system.

1) The Provider of service must verify eligibility of the member via PHC systems at the time

of service. This verification is necessary for all service authorizations.

Page 84 of 199

Policy/Procedure Number: MCUP3041 (previously

UP100341) Lead Department: Health Services

Policy/Procedure Title: TAR Review Process ☒ External Policy

☐ Internal Policy


(Effective 06/19/2013 - TAR/RAF

Review Policy split)




Page 2 of 8

2) PHC’s eEligibility and Interactive Voice Response (IVR) Systems are available to verify

eligibility and determine the member’s assigned PCP. Information required to verify the

eligibility of an individual is as follows:

a) Name

b) Date of Birth

c) Sex

d) Social Security Number

e) Medi-Cal number/CIN

f) PHC member number

g) Address and name of parent may be necessary in some cases.

2. Services Requiring Treatment Authorization

a. Certain procedures, services, and medications require prior authorization from PHC before

reimbursement is made. Those services requiring a Treatment Authorization Request (TAR) are

listed as attachments to this policy. The attachment consists of:

1) PHC TAR Requirements List

2) Outpatient Surgical Procedures Requiring TAR

3) Pain Management CPTs Requiring TAR

b. All elective inpatient hospital admissions require prior authorization except anticipated two (2)

day post vaginal delivery stays and four (4) day post C-Section stay (Please see section for the

inpatient TAR process). A service being provided that is not pregnancy related requires the

admitting physician to submit the TAR for the elective procedure prior to the actual hospital

admission. Although an approved TAR will assign a specified number of initial days approved,

the hospital is required to notify PHC within one working day of the actual date of admission.

c. All Skilled Nursing or Long Term Care facility admissions require approval prior to the

admission, and throughout the length of stay.

d. For those providers contracting with PHC, if a member has primary coverage through Medicare

Part A, a TAR is not required until the member exhausts the benefits available under Medicare.

Once benefits have been exhausted, the TAR must be submitted along with written verification

from Medicare that the benefits have been exhausted. The TAR must be submitted within 15

days of the date the benefits exhausted or within 60 days of retrospective eligibility.

e. Exception: If the provider receives a denial from Medicare or any other primary payor source,

they must submit a TAR to PHC’s Health Services Department, along with a copy of the

Medicare denial and the medical record documentation. The TAR must be received by PHC

within 60 days of the issue date of the denial from Medicare or the other payor source.

f. TARs are not required for services related to emergency services, minor consent, family

planning and preventive services, basic prenatal care, sexually transmitted disease services and

HIV testing.

3. Outpatient Service TAR Submission Process

a. TARs should be submitted electronically via PHC’s Online Services portal. Electronic

submission will allow for more expedient processing. If online submission is not possible, the

TAR may be submitted via fax or mail.

b. Expedited Process

1) Expedited processing is available for requests in which the provider indicates or PHC

determines that the standard timeframe could seriously jeopardize the Member’s life or

health or ability to attain, maintain, or regain maximum function. Under these circumstances

PHC will expedite the review determination and provide notice as expeditiously as the

Page 85 of 199




☐ Internal Policy







Page 3 of 8

member’s health condition requires, but no later than three (3) business days after receipt of

the request for services.

2) Requests for an expedited determination should be submitted via e-TAR or fax, and be

clearly marked “Urgent” or “Expedited” and should indicate the reason there is an urgent

need for authorization. A TAR for elective (non-emergent) surgery submitted urgently due

only to an imminent date of service is NOT considered to be urgent. TARs submitted under

these circumstances will be processed as a routine TAR.

3) The Nurse Coordinator will process the expedited request and will notify the provider

within one calendar day of the determination.

4) Members will be notified of all adverse determinations in writing.

c. Routine Outpatient TARs

1) TARs for members who require services should be submitted electronically via PHC’s

Online Services. If electronic submission is not available, the TAR may be faxed or mailed

to PHC’s Health Services Department for review.

2) If the TAR is received without sufficient information to render a determination, the Provider

and Member will be notified in writing requesting the information required. In addition to

sending a letter, the UM Staff will contact the Provider and/or designated office staff

member to remind him/her of the specific information requested and the regulatory

timeframe for submission.

3) Routine TARs will be processed within 5 business days of receipt of all required

documentation, but no longer than within 14 calendar days from receipt of the request.

4) A decision may be deferred and the time limit extended an additional 14 calendar days only

where the Member or the Member’s provider requests an extension, or PHC can provide

justification upon request by the State for the need for additional information and how it is

in the Member’s interest. Any decision delayed beyond the time limits is considered a

denial and will be immediately processed as such.

5) The provider will be notified of the decision to approve, modify, defer, or deny the TAR in

writing within one (1) working day.

6) Members or their authorized representative will be notified of denials, deferrals, and

modifications in writing within two (2) working days of the determination.

4. Inpatient Prior Authorization TARs

a. The TAR procedure for elective services is as follows:

1) Authorization for elective hospital admissions must be submitted by the admitting physician

and include the following:

a. Procedure code or service being performed

b. Facility where procedure will be performed

c. Anticipated date of procedure

d. Number of days being requested if inpatient admission

e. Diagnosis

2) Please note that PHC will assign a number of initially approved days however, it is the

hospital’s responsibility to notify PHC within one working day of the date of the actual

admission.

3) If the patient’s condition necessitates hospitalization beyond the pre-approved time frame,

PHC will perform concurrent review on the remainder of the stay.

4) The Nurse Coordinator reviews the information received from the provider utilizing PHC

approved review guidelines. The Nurse Coordinator approves the request if it meets

medically necessary criteria. Requests that do not meet review guidelines are referred to the

Chief Medical Officer (CMO) or Physician Designee for further evaluation.

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☐ Internal Policy







Page 4 of 8

5) PHC’s Chief Medical Officer or Physician Designee reviews all TARs referred to him/her,

taking the action deemed appropriate. He/She may contact the requesting provider for

further information. Once the Chief Medical Officer or Physician Designee approves or

modifies the request, the TAR will be returned to the Nurse Coordinator for completion.

Denials for medical necessity are made only by the Chief Medical Officer or Physician

Designee.

b. Emergency admissions

1) For all emergency and obstetrical admissions, the hospital or LTC facility must notify PHC

and the member’s PCP of the admission as soon as possible, but not later than the first

working day following the date of admission.

2) The preferred method of notification is electronically using PHC’s Online Services Portal. If

a facility is not contracting with PHC, or if online submission is not possible, the TAR may

be submitted via fax or mail. It is recommended that the provider maintain documentation

of successful transmission and receipt.

3) The case is reviewed by the Nurse Coordinator and a decision on length of stay is

authorized based on PHC established criteria within one calendar day.

4) The provider is notified of decision within one calendar day.

c. Obstetrical delivery services

1) Obstetrical admissions do not require a TAR prior to admission, for obstetrical delivery.

2) PHC will approve two (2) consecutive days for both mother and baby for post vaginal

deliveries and four (4) days for a Caesarean Section delivery.

3) The hospital must notify PHC if the mother and/or baby require additional days of acute

care. The Nurse Coordinator reviews the case for medical necessity during the next UM

review.

5. Nurse Coordinator/UM Review Process

a. A Nurse Coordinator can approve, modify, defer (pend) the TAR, or deny the TAR for

administrative reasons.

b. TARs that require clinician review due to questions of medical necessity are pended to the Chief

Medical Officer / Physician Designee. The Nurse Coordinator attaches all relevant

documentation and the Medical Director Worksheet.

c. TARs can be denied, for reasons of medical necessity, ONLY by the Chief Medical Officer or

Physician Designee.

6. TARs with Special Processing Requirements

a. Dialysis TAR Process

Initial TAR requests for Dialysis services for members who have no other insurance will be

authorized for a 90 day period only.

1) Per CCR Title 22 section 50763 “Medi-Cal beneficiaries must apply for any available health

care coverage when no cost is involved.” All members receiving dialysis must submit an

application to Social Security for Medicare benefits. The provider must submit a denial

from Medicare for PHC to approve services beyond the initial 90 days.

2) Once a Medicare determination of denial of coverage is received, PHC will issue a TAR

that will remain valid for the member’s lifetime or until the member receives a kidney

transplant.

b. Hospice Services

1) Hospice services require a TAR ONLY for inpatient services (i.e. acute or SNF/LTC

facility). However, a Hospice election form signed by the member or his/her legal

representative must accompany any initial claim for hospice services (all outpatient and

inpatient services).

Page 87 of 199




☐ Internal Policy







Page 5 of 8

7. Chief Medical Officer / Physician Designee Review

a. The Chief Medical Officer or Physician Designee must be available physically or by telephone

during business hours to assist with evaluating TAR requests.

b. The Chief Medical Officer or Physician Designee review is done in all cases of potential denial

due to medical necessity, interpretation issues, or other issues as requested by the UM staff.

c. The Chief Medical Officer or Physician Designee may contact involved providers or consultants

for additional information as required to assist him/her in rendering a decision about the case.

The Chief Medical Officer or Physician Designee documents the rationale for any decision on

the Medical Director Worksheet.

d. The Chief Medical Officer or Physician Designee is the only person authorized to sign denials

for medical necessity or to make any exceptions or modifications to the established PHC

medical criteria.

e. PHC makes available to physicians a physician reviewer (Chief Medical Officer or Physician

Designee) to discuss by telephone determinations based on medical necessity.

8. Finalization of TARs

a. TARs are not processed by PHC until the TAR is completely filled out with all the information

on the member and all attachments noted on the TAR are received. For the provider of service

and service(s) being requested - this includes the requirement that correct and valid codes be

utilized.

b. Authorizations are only valid for the timeframe approved by PHC. If the timeframe is exceeded

due to an unforeseen delay, the Provider may submit a request for an extension of the time

period, noting the reason for the delay

c. All TARs s including worksheets, letters, and other documentation are kept on site for 12

months and archived off site for 10 years or until member reaches age 21.

9. Administrative Denials

a. Health Services staff designee may process denials based on administrative criteria.

Administrative denial criteria shall include: TAR not required, member not eligible with PHC

on date of service, member has other insurance, duplicate request, TAR or service line not

accepted due to coding issue, TAR not submitted on a timely basis and additional information

not received by PHC within 14 days of request. Each month a report of all administrative

denials is reviewed and signed by the Chief Medical Officer or Physician Designee.

Administrative denials are not subject to the Provider Appeals process.

10. Delegated Entities

a. Kaiser and Woodland Healthcare are delegated to perform some aspects of utilization

management for members assigned to them and will make determinations on service requests

for their assigned members. PHC’s Senior Health Services Director is responsible for

monitoring the Utilization Management activities and receives biannual reports from the

delegated entities.

b. Multi-specialty medical groups do not require pre-authorization from PHC for services for

which they are delegated. All elective hospital admissions must be pre-authorized by the

medical group and reported to PHC at the time of admission.

11. Non-Contracting Hospital Review

a. Elective admissions to non-contracted hospitals require approval of a TAR, which is subject to

PHC’s timeline policies. Since most admissions to non-contracted hospitals are for emergency

conditions, the procedure for non-contracting hospital review is as follows:

1) PHC electronically notifies the member's assigned PCP or medical group of the admission

to the non-contracted hospital, and assigns an initial length of stay (LOS) if the admission is

an emergency as set forth in Title 22, California Code of Regulations.

Page 88 of 199




☐ Internal Policy







Page 6 of 8

2) If the admission does not meet admission criteria, it is referred to the Chief Medical Officer

or Physician Designee for review. The Nurse Coordinator notifies the non-contracting

hospital of the Chief Medical Officer or Physician Designee's decision and provides the

process for appeal or the opportunity to discuss the determination with the CMO/Physician

Designee.

3) If the member is not medically stable for discharge or transfer to a lower level of care by the

last certified day, the admitting hospital must obtain telephone authorization for extensions

of stay from PHC's Nurse Coordinator.

4) For a member capitated to an in-plan hospital who is admitted to a non-capitated hospital,

please refer to the MCUP3033 Out of Area Emergency Admissions policy.

b. When the admission is elective and has been given prior authorization, no further

communication is required until the approved number of days is nearing expiration and the

member is expected to remain hospitalized beyond the days previously approved. The facility is

required to provide to the Nurse Coordinator appropriate clinical information supporting the

medical necessity of continued stay.

12. Retrospective Review for TAR Required Services

a. Retrospective (Retro) TARs must be received by PHC within fifteen (15) business days of the

date of service or within 60 days of a denial from the primary insurance carrier. Retro TARs

received after that timeframe are considered for review only under the following conditions:

1) When a member does not identify himself/herself to the provider as a PHC member by

deliberate concealment or because of physical or mental incapacity to so identify

himself/herself.

2) If a member has obtained retroactive eligibility. The TAR must be received by PHC within

60 days of the members obtaining Medi-Cal eligibility.

b. For retrospective medical review, the decision for authorization is made within 30 days of

obtaining all the necessary information.

c. Members and providers are notified in writing within 5 working days of the determination.

13. Correction TARS

a. The provider has up to 6 months from the approved date of the ORIGINAL authorized TAR to

submit modifications of approved services. A new TAR must be submitted with the requested

modifications and MUST reference the ORIGINAL TAR number and code(s) or date(s) to be

modified. Modifications will be accepted or made only on approved TARS for the following:

1) Types of service. For example, only similar items or procedures may be modified (e.g.

micropore tape versus paper tape, right wheels versus left wheels, etc.).

2) Minor extension or change of dates may be requested (e.g. start of service May 15 versus

May 20).

3) Units of service (e.g. 9 visits versus 6 visits). This usually coincides with a change of, or

extension of, dates of service requested.

14. UM Decision Timelines

a. For precertification of nonurgent care, PHC makes decisions within five working days of

obtaining all the necessary information.

b. For precertification of nonurgent care, PHC notifies practitioners of the decisions within one

working day of making the decision.

c. For precertification of nonurgent care that result in a denial, PHC gives members and

practitioners written or electronic confirmation of the decisions within two working days of

making the decision.

Page 89 of 199




☐ Internal Policy







Page 7 of 8

d. Post Stabilization Services

1) Upon receipt of an authorization request from an emergency services provider, UM shall

render a decision within 30 minutes or the request is deemed approved, pursuant to Title 28

CCR Section 1300.71.4.

e. For precertification of urgent care, PHC makes decisions and notify practitioners of the

decisions within one calendar day.

f. For precertification of urgent care that results in a denial, PHC notifies both members and

practitioners of how to initiate an expedited appeal at the time they are notified of the denial.

g. For precertification of urgent care that results in a denial, PHC gives members and practitioners

written or electronic confirmation of the decisions within two working days of making the

decision.

h. For concurrent review, PHC makes decisions within one working day of obtaining all the

necessary information.

i. For concurrent review, PHC notifies practitioners of decisions within one working day of

making the decision.

j. For concurrent review decisions that result in a denial, PHC gives members and practitioners

written or electronic confirmation within one working day of the original notification.

k. For concurrent review decisions that result in a denial, PHC notifies both members and

practitioners of how to initiate an expedited appeal at the time they are notified of the denial.

l. For retrospective review, PHC makes the decision within 30 working days of obtaining all the

necessary information.

m. For retrospective review, PHC notifies practitioners and members of denials in writing within

five working days of making the decision.

15. Monitoring of the TAR Process

a. Aggregate TAR data is subject to retrospective analysis by PHC’s UM Department. This review

is designed to:

1) Identify individual provider practice patterns relative to standards of medical practice.

2) Evaluate over and under-utilization of services.

b. PHC monitors turnaround times of internal processing for compliance with standards.

c. Denials or modifications for medical necessity are monitored weekly to ensure accuracy in

regulatory requirements, review processes, and correspondence.

d. PHC performs inter-rater reliability audits as outlined in the policy at least annually on both

physician and nurse reviewers.

e. Member & provider grievances, as well as PHC’s member and provider satisfaction survey

responses, serve as an evaluation tool.

f. Administrative denials are monitored quarterly to identify trends and/or the need for additional

provider education, outreach, or other intervention. A summary is presented to the Internal

Quality Improvement Committee every six months.

VII. REFERENCES:

A. Medicare Home Health Agency Manual

B. U.S. Department of Health and Human Services

C. HCFA - Pub 11 (2/84) thru Rev. 149 ICN 403750

VIII. DISTRIBUTION:

A. PHC Departmental Directors


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☐ Internal Policy







Page 8 of 8


X. REVISION DATES: TAR Procedure [UM-2]: 11/19/96; 12/15/99; 01/12/00 – RAF Procedure [UM-1]:

12/27/95; 05/27/99); (TAR/RAF [UP100341] - 06/21/00; 04/18/01; 03/20/02, 05/21/03 attachments revised

10/01/03; 04/21/04; 01/19/05; 04/20/05; 09/21/05, 10/18/06, 08/20/08, 07/15/09; 05/19/10; 07/20/11);

06/19/13; 06/17/15; 09/16/2015


Page 91 of 199


POLICY / PROCEDURE

I:\POLICIES\Draft policies for review\Medi-Cal\U MGMT\UM Policies for 06-07-16 IQI\MCUP3057\MCUP3057 06-15-16.docx Page 1 of 2


Policy/Procedure Title: Provider Appeals of Health Services

Administrative Denials

☒External Policy

☐ Internal Policy




Reviewing

Entities:



Approving

Entities:





A. MCUP3041 TAR Review Process

B. MCUP3124 Referral to Specialists (RAF)

C. MCUG3024 Inpatient Utilization Management

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. N/A

IV. ATTACHMENTS:

A. N/A

V. PURPOSE:

To define Partnership HealthPlan of California (PHC) Health Services departmental policy regarding

administrative denials and other avenues available to providers for resolution of issues.


A. Administrative denials are NOT subject to the provider appeals process.

B. If a provider has received an administrative denial and they believe the information is incorrect, they

should submit a NEW Treatment Authorization Request (TAR) to the Health Services department with

the required documentation, within the timeframes defined for submission, so that the TAR may be

processed.

1. The following are reasons that an administrative denial is issued by the Health Services Department:

a. Member is not currently eligible/or was not eligible with PHC at the time of service.

b. Member has other health insurance and the primary carrier is responsible for the service

requested.

c. TAR NOT received timely. Please refer to the PHC policies MCUP3041 TAR Review Process and MCUP3124 Referral to Specialists (RAF). NO exceptions are made to the policies.

d. Share of Cost (SOC) - It is the provider’s responsibility to clear the share of cost. Members

have no eligibility with PHC UNTIL their SOC has been satisfied.

Page 92 of 199





☒ External Policy

☐ Internal Policy





e. Other provider must authorize service requested. PHC has delegated other entities to authorize

services for members assigned to them. The appeal is to be directed to the other provider if the

service is delegated to another entity.

f. Requested documentation/information and or Medical Records were not received timely. Per

PHC policy, providers have 14 days to submit requested additional documentation.

C. If a provider incorrectly submits a TAR on a PHC member to the Medi-Cal field office, PHC applies

timeliness requirements to that request. If the member was eligible with PHC at the time of the request,

TARs submitted beyond the 15 working day requirement are denied for lack of timely submission. If the

member was retroactively granted eligibility with PHC, then the provider must submit the authorization

to PHC within the 60 days of PHC eligibility.

D. If a member has other health coverage and that coverage denies the service and PHC requires a TAR for

the services, the provider must submit evidence of the denial along with a new TAR to the PHC

Utilization Management department within 60 days of the date of the denial by the other carrier for

review and approval.

VII. REFERENCES: A. N/A

VIII. DISTRIBUTION:

A. PHC Provider Manual

B. PHC Department Directors


X. REVISION DATES: 08/20/03; 09/15/04; 09/21/05; 10/18/06; 10/17/07; 10/15/08; 11/18/09; 05/18/11;

02/20/13; 11/18/15; 06/15/16


*********************************









covered under PHC.

Page 93 of 199


POLICY / PROCEDURE





☒External Policy

☐ Internal Policy


Last Review Date: 11/18/201506/15/2016


Reviewing

Entities:



Approving

Entities:





A. MCUP3041 TAR Review Process

B. MCUP3124 Referral to Specialists (RAF)

C. MCUG3024 Inpatient Utilization Management

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. N/A

IV. ATTACHMENTS:

A. N/A

V. PURPOSE:

To define Partnership HealthPlan of California (PHC) Health Services departmental policy regarding

administrative denials and other avenues available to providers for resolution of issues.


A. Administrative denials are NOT subject to the provider appeals process.

B. If a provider has received an administrative denial and they believe the information is incorrect, they

should submit a NEW Treatment Authorization Request (TAR) to the Health Services department with

the required documentation, within the timeframes defined for submission, so that the TAR may be

processed.

1. The following are reasons that an administrative denial is issued by the Health Services Department:

a. Member is not currently eligible/or was not eligible with PHC at the time of service.

b. Member has other health insurance and the primary carrier is responsible for the service

requested.

c. TAR NOT received timely. Please refer to the PHC policies MCUP3041 TAR Review Process and MCUP3124 Referral to Specialists (RAF). NO exceptions are made to the policies.

d. Share of Cost (SOC) - It is the provider’s responsibility to clear the share of cost. Members

have no eligibility with PHC UNTIL their SOC has been satisfied.

Page 94 of 199





☒ External Policy

☐ Internal Policy


Last Review Date: 11/18/201506/15/2016



e. Other provider must authorize service requested. PHC has delegated other entities to authorize

services for members assigned to them. The appeal is to be directed to the other provider if the

service is delegated to another entity.

f. Requested documentation/information and or Medical Records were not received timely. Per

PHC policy, providers have 14 days to submit requested additional documentation.

C. If a provider incorrectly submits a TAR on a PHC member to the Medi-Cal field office, PHC applies

timeliness requirements to that request. If the member was eligible with PHC at the time of the request,

TARs submitted beyond the 15 working day requirement are denied for lack of timely submission. If the

member was retroactively granted eligibility with PHC, then the provider must submit the authorization

to PHC within the 60 days of PHC eligibility.

D. If a member has other health coverage and that coverage denies the service and PHC requires a TAR for

the services, the provider must submit evidence of the denial along with a new TAR to the PHC

Utilization Management department within 60 days of the date of the denial by the other carrier for

review and approval.

VII. REFERENCES: A. N/A

VIII. DISTRIBUTION:

A. PHC Provider Manual

B. PHC Department Directors


X. REVISION DATES: 08/20/03; 09/15/04; 09/21/05; 10/18/06; 10/17/07; 10/15/08; 11/18/09; 05/18/11;

02/20/13; 11/18/15; 06/15/16


*********************************









covered under PHC.

Page 95 of 199


POLICY / PROCEDURE


Policy/Procedure Number: MCUP3124 Lead Department: Health Services

Policy/Procedure Title: Referral to Specialists (RAF) Policy External Policy

Internal Policy


(Effective 08/21/2013 - RAF Review Policy

split from TAR/RAF Review)




Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:




I. RELATED POLICIES: A. MCUP3041 - TAR Review Process

B. MCUP3039 – Special Case Managed Members

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS: A. Referral Authorization Form (RAF) process is defined as the process by which the primary care provider

(PCP) submits a request to Partnership HealthPlan of California (PHC) to refer a PHC enrollee to a

specialist for evaluation and/or treatment.

B. Tertiary Medical Care is specialized consultative care, usually on referral from primary or secondary

medical care personnel, by specialists working in a center that has personnel and facilities for special

investigation and treatment.

IV. ATTACHMENTS: A. N/A

V. PURPOSE: To describe the procedure used by the PHC Utilization Management (UM) Department to process Referral

Authorization Forms (RAFs) based upon the medical necessity of the request.


A. Members assigned to a primary care provider must have an approved RAF on file for the PHC Claims

Department to reimburse the specialist for elective/scheduled services rendered. RAFs are not required

for members who have another insurance plan as the primary carrier or are assigned a PHC special

member status.

B. Specialist to Specialist Referral

1. A specialist may request a referral to another specialist from the primary care provider ONLY under

the following circumstances:

a. Referral must be within the same specialty field as the specialist

b. Referrals must be for emergent or urgent conditions only

c. Referral must be sent to the member’s PCP to submit to PHC

Page 96 of 199


Policy/Procedure Title: Referral to Specialists (RAF) Policy ☒External Policy

☐Internal Policy

Original Date:

(UM-1) 12/27/1995

(Effective 08/21/2013 - RAF Review

Policy split from TAR/RAF Review)





C. Obstetric/Gynecological Services (OB/GYN)

1. OB/GYN services do not require a RAF. During obstetrical care the member may be referred to

another provider for medically necessary obstetrical subspecialty services (e.g. amniocentesis,

perinatology services, etc.)

D. Referral to Tertiary Care Center

1. PHC has a number of tertiary care centers (TCC) within our provider network. If a referral to a non-

contracting tertiary care center is received, PHC clinical staff will review the request to determine if

the services are available from one of the contracting facilities. If the services are available within

the contracting network, PHC’s Chief Medical Officer (CMO) or Physician Designee will review the

request to determine if there are medical reasons the member should be referred to the non-

contracting facility. If the CMO or Physician Designee determines the member may receive services

within the contracting network, a letter of denial of the referral to the non-contracting TCC will be

issued to the PCP, Member, and facility. The Notice of Action letter will include the member’s right

to appeal and all grievance and appeal rights will apply.

E. Standing Referrals

1. A member with a condition or disease that requires an extended access referral for specialized

medical care may receive an extended referral to a specialist or specialty care center that has

expertise in treating the condition or disease.

2. The PCP should refer the member to a specialist within the PHC provider network. Referrals to out

of network providers may occur only when the specialty care required is not available within the

PHC network of providers.

F. Referral Authorization Process

1. A PCP should submit the RAF electronically using PHC’s On Line Services system. Paper RAFs

will be accepted if electronic submission is not possible, however, for appropriate tracking and to

expedite the request, electronic submission is preferred.

2. RAFs submitted electronically allow completion of most RAFs within one to two business days,

however those submitted on paper may take up to 5 business days for processing.

3. An electronic copy of the RAF determination is sent via electronic fax to both the referring PCP and

the receiving specialist.

4. In general, there are no limits to the number of visits, but in certain circumstances such as

transitioning care back to local specialist or if a pattern of over utilization is noted on retrospective

review, then PHC may impose limits on the number of visits or time period covered by the RAF.

At the end of one year period a new RAF from the PCP will be required.

G. Treatment Authorization Requirements

1. If the services to be rendered require a Treatment Authorization Request (TAR) from PHC, it is the

responsibility of the rendering provider (specialist and/or facility) to submit a TAR to PHC for

review.

Page 97 of 199



☐Internal Policy

Original Date:

(UM-1) 12/27/1995







H. Monitoring Referrals

1. PHC monitors referrals to specialists, including open or unused referrals, using data from PHC’s

electronic Referral System (eRAF) and claims. This information is submitted to the Internal Quality

Improvement (IQI) Committee every six months.

2. PHC requires its high volume providers to submit an annual report of their referral completion rate

for review by the specialty access workgroup and by the IQI Committee.

VII. REFERENCES:

A. InterQual Criteria

B. Medi-Cal Guidelines

VIII. DISTRIBUTION: A. Department Directors

B. Provider Manual


X. REVISION DATES: : RAF Procedure [UM-1]: 12/27/95; 05/27/99; (TAR/RAF [UP100341] - 06/21/00;

04/18/01; 03/20/02, 05/21/03 attachments revised 10/01/03; 04/21/04; 01/19/05; 04/20/05; 09/21/05,

10/18/06, 08/20/08, 07/15/09; 5/19/10; 07/20/11, 08/21/13; 03/19/14; 04/15/15; 09/16/15; 06/15/16


Page 98 of 199


POLICY / PROCEDURE



Policy/Procedure Title: Referral to Specialists (RAF) Policy External Policy

Internal Policy


(Effective 08/21/2013 - RAF Review Policy

split from TAR/RAF Review)

Next Review Date: 09/16/201606/15/2017

Last Review Date: 09/16/201506/15/2016


Reviewing

Entities:

IQI P & T QUAC


Approving

Entities:





A.B. MCUP3039 – Special Case Managed Members

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS: A. Referral Authorization Form (aka: RAF) ) process is defined as the process by which the primary care

physician provider (PCP) submits a request to Partnership HealthPlan of California (PHC) to refer a

PHC enrollee to a specialist for evaluation and/or treatment.

B. Tertiary Medical Care is specialized consultative care, usually on referral from primary or secondary

medical care personnel, by specialists working in a center that has personnel and facilities for special

investigation and treatment.

IV. ATTACHMENTS: A. N/A

V. PURPOSE: To describe the procedure used by the PHC Utilization Management (UM) Department to process Referral

Authorization Forms (RAFs) based upon the medical necessity of the request.


A. Members assigned to a primary care physician provider must have an approved RAF on file for the PHC

Claims Department to reimburse the specialist for elective/scheduled services rendered. RAFs are not

required for members who have another insurance plan as the primary carrier or are assigned a PHC

special member status.

B. Specialist to Specialist Referral

1. A specialist may request a referral to another specialist from the primary care physician provider

ONLY under the following circumstances:

a. Referral must be within the same specialty field as the specialist.

b. Referrals must be for emergent or urgent conditions only.

c. Referral must be sent to the member’s PCP to submit to PHC.

Page 99 of 199



☐Internal Policy

Original Date:

(UM-1) 12/27/1995



Next Review Date: 09/16/201606/15/2017

Last Review Date: 09/16/201506/15/2016



C. Obstetric/Gynecological Services (OB/GYN)

1. OB/GYN services do not require a RAF. During obstetrical care the member may be referred to

another provider for medically necessary obstetrical subspecialty services (e.g. amniocentesis,

perinatology services, etc.)

D. Referral to Tertiary Care Center

1. PHC has a number of tertiary care centers (TCC) within our provider network. If a referral to a non-

contracting tertiary care center is received, PHC clinical staff will review the request to determine if

the services are available from one of the contracting facilities. If the services are available within

the contracting network, PHC’s Chief Medical Officer (CMO) or Physician Designee will review the

request to determine if there are medical reasons the member should be referred to the non-

contracting facility. If the CMO or Physician Designee determines the member may receive services

within the contracting network, a letter of denial of the referral to the non-contracting TCC will be

issued to the PCP, Member, and facility. The Notice of Action letter will include the member’s right

to appeal and all grievance and appeal rights will apply.

E. Standing Referrals

1. A member with a condition or disease that requires an extended access referral for specialized

medical care may receive an extended referral to a specialist or specialty care center that has

expertise in treating the condition or disease.

2. The PCP should refer the member to a specialist within the PHC provider network. Referrals to out

of network providers may occur only when the specialty care required is not available within the

PHC network of providers.

F. Referral Authorization Process

1. A PCP should submit the Referral Authorization RequestRAF electronically using PHC’s On Line

Services system. Paper RAFs will be accepted if electronic submission is not possible, however, for

appropriate tracking and to expedite the request, electronic submission is preferred.

2. RAFs submitted electronically allow completion of most RAFs within one to two business days,

however those submitted on paper may take up to 5 business days for processing.

3. An electronic copy of the RAF determination is sent via electronic fax to both the referring PCP and

the receiving specialist.

4. In general, there are no limits to the number of visits, but in certain circumstances such as

transitioning care back to local specialist or if a pattern of over utilization is noted on retrospective

review, then PHC may impose limits on the number of visits or time period covered by the RAF.

At the end of one year period a new RAF from the PCP will be required.

G. Treatment Authorization Requirements

1. If the services to be rendered require a Treatment Authorization Request (TAR) from PHC, it is the

responsibility of the rendering provider (specialist and/or facility) to submit a TAR to PHC for

review.

Page 100 of 199



☐Internal Policy

Original Date:

(UM-1) 12/27/1995



Next Review Date: 09/16/201606/15/2017

Last Review Date: 09/16/201506/15/2016



H. Monitoring Referrals

1. PHC monitors referrals to specialists, including open or unused referrals, using data from PHC’s

electronic Referral System (eRAF) and claims. This information is submitted to the Internal Quality

Improvement (IQI) Committee every six months.

2. PHC requires its high volume providers to submit an annual report of their referral completion rate

for review by the specialty access workgroup and by the Internal Quality Improvement IQI

Committee.

VII. REFERENCES:

A. InterQual Criteria

B. Medi-Cal Guidelines

VIII. DISTRIBUTION:

A. Department Directors

B. Provider Manual


X. REVISION DATES: : RAF Procedure [UM-1]: 12/27/95; 05/27/99; (TAR/RAF [UP100341] - 06/21/00;

04/18/01; 03/20/02, 05/21/03 attachments revised 10/01/03; 04/21/04; 01/19/05; 04/20/05; 09/21/05,

10/18/06, 08/20/08, 07/15/09; 5/19/10; 07/20/11, 08/21/13; 03/19/14; 04/15/15; 09/16/15; 06/15/16


Page 101 of 199

Received and Last Status Dates Between: 07/01/2015 - 12/31/2015

1st Quarter 2nd Quarter

Line of Business Type Jul Aug Sep Subtotal: Oct Nov Dec Subtotal: Total:

Healthy Kids: Hospital 1 1 1

Medical 1 2 1 4 2 1 1 4 8

Subtotal: 1 2 1 4 2 2 1 5 9

MediCal: Hospital 2,590 2,938 3,047 8,575 3,028 2,836 3,184 9,048 17,623

LTC 559 541 686 1,786 684 555 528 1,767 3,553

Medical 10,370 11,439 11,313 33,122 12,072 11,031 11,688 34,791 67,913

Subtotal: 13,519 14,918 15,046 43,483 15,784 14,422 15,400 45,606 89,089

Partnership Advantage: Hospital 4 4 1 1 2 6

Medical 19 1 9 29 3 3 5 11 40

Subtotal: 23 1 9 33 3 4 6 13 46

Unknown: Hospital 14 11 12 37 9 6 9 24 61

LTC 1 1 1 1 2

Medical 4 7 4 15 10 4 14 29

Subtotal: 18 18 17 53 9 17 13 39 92

Total: 13,561 14,939 15,073 43,573 15,798 14,445 15,420 45,663 89,236

Report Title: All TARs for Each Line of Business by Month/Fiscal QuarterReport Name/Date: All TARs - 5/18/16

Page 102 of 199

Report Title: Denied TAR Volume - As of: 5/18/16 (Southern Region)

Status DescriptionStatusCode Ancillary

BehavioralHealth

Therapy CBAS

DurableMedical

EquipmentHospital

Acute

HospitalSkilledNursingFacility

IncontinenceSupplies

Medical(Physician) Total: % Total:

'Blank' Status Code 10 1 3 14 0.17%

Duplicate TAR WD 213 1 3 401 218 127 70 640 1,673 20.42%

Medical necessity not justified W2 18 190 25 1 262 496 6.05%

Member not eligible WE 14 19 46 15 94 1.15%

Needs CCS authorization WC 32 66 326 167 591 7.21%

Needs RAF WF 1 6 7 0.09%

Not a benefit W1 131 49 27 68 275 3.36%

Not accepted WA 41 1 78 16 50 203 389 4.75%

No TAR required WR 128 1 113 188 1 1,103 1,534 18.72%

Not timely WT 197 56 53 5 1 72 384 4.69%

Other Insurance Coverage WI 149 2 251 959 11 488 1,860 22.70%

Requested information not received W4 150 1 294 16 26 137 241 865 10.56%

VOIDED V1 2 5 1 4 12 0.15%

Total TARS: 1,075 5 4 1,522 1,886 209 221 3,272 8,194 100.00%

% Total: 13.12% 0.06% 0.05% 18.57% 23.02% 2.55% 2.70% 39.93% 100.00%

Received Between: 07/01/2015 - 12/31/2015

Report Name/Date: Denied TARs - 5/18/16

Page 103 of 199

Report Title: Denied TAR Volume - As of: 5/18/16 (Northern Region)

Status DescriptionStatusCode Ancillary

BehavioralHealth

Therapy CBAS

DurableMedical

EquipmentHospital

Acute

HospitalSkilledNursingFacility

IncontinenceSupplies

Medical(Physician) Total: % Total:

'Blank' Status Code 3 3 0.09%

DENIED - PER MEDICAL REVIEW 42 4 4 0.12%

Duplicate TAR WD 137 9 4 187 101 74 25 347 884 26.58%

Medical necessity not justified W2 20 155 3 276 454 13.65%

Member not eligible WE 4 2 3 2 11 0.33%

Needs CCS authorization WC 24 31 254 76 385 11.58%

Needs RAF WF 6 6 0.18%

Not a benefit W1 12 15 1 17 45 1.35%

Not accepted WA 19 29 3 38 46 135 4.06%

No TAR required WR 39 19 63 307 428 12.87%

Not timely WT 75 31 18 4 1 48 177 5.32%

Other Insurance Coverage WI 26 1 89 247 1 131 495 14.88%

Requested information not received W4 96 2 1 99 1 21 65 285 8.57%

Unknown ¿ 1 1 0.03%

VOIDED V1 6 2 3 2 13 0.39%

Total TARS: 452 12 5 663 703 119 49 1,323 3,326 100.00%

% Total: 13.59% 0.36% 0.15% 19.93% 21.14% 3.58% 1.47% 39.78% 100.00%


Report Name/Date: Denied TARs - 5/18/16

Page 104 of 199

Utilization ManagementInter-Rater Reliability Audit Inpatient 2015 -2015 Month Total TARs

Process Errors

No Process Errors

Could not determine % Total TARs

Criteria Did not Agree

Criteria Agreed %

Could not determine

Jul-15 60 1 59 0 98.3% 60 2 58 96.7% 0Aug-15 55 0 55 0 100.0% 55 1 53 96.4% 1Sep-15 55 1 54 0 98.2% 55 2 52 94.5% 1Oct-15 55 3 51 1 92.7% 55 1 52 94.5% 2Nov-15 55 0 55 0 100.0% 55 2 53 96.4% 0Dec-15 50 2 48 0 96.0% 50 0 49 98.0% 1

#DIV/0! #DIV/0!#DIV/0! #DIV/0!#DIV/0! #DIV/0!#DIV/0! #DIV/0!#DIV/0! #DIV/0!#DIV/0! #DIV/0!

Month Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15Process Compliance

98.3% 100.0% 98.2% 92.7% 100.0% 96.0%

Criteria Compliance

96.7% 96.4% 94.5% 94.5% 94.5% 98.0%

Target Compliance Rate 90% 90% 90% 90% 90% 90%

Page 105 of 199

Report Title: Inpatient TAR Volume - Manual vs Electronic (Summary)

Region Input Source Count Auths Percentage

Northern Region Electronic (M2) 5,599 77.10%

Manual (Amisys) 1,663 22.90%

Northern Region Region Total: 7,262 33.09%


Southern Region Electronic (M2) 9,694 66.03%


Southern Region Region Total: 14,682 66.91%

Grand Total: 21,944 100.00%


Report Name/Date: Manual vs Electronic - Inpatient and LTC TAR Volume - 5/18/16

Inpatient TAR Statistics:

Total InpatientTAR Volume: 21,944

Total Manual (Amisys) TARs: 6,651

Total Electronic (M2) TARs: 15,293

Percent of Manual (Amisys) TARs: 30.31%

Percent of Electronic (M2) TARs: 69.69%

Page 106 of 199

Region AS Code Groupings Electronic (M2) Manual (Amisys) Total: %

Northern Region Hospital Acute 4,652 1,498 6,150 84.69%

Hospital Skilled Nursing Facility 947 165 1,112 15.31%

Northern Region Region Totals: 5,599 1,663 7,262 33.09%

Southern Region Hospital Acute 7,538 4,633 12,171 82.90%

Hospital Skilled Nursing Facility 2,156 355 2,511 17.10%

Southern Region Region Totals: 9,694 4,988 14,682 66.91%

Total Outpatient TARs: 15,293 6,651 21,944 100.00%

Report Title: Inpatient TAR Volume - Manual vs Electronic (By AS Code)


Report Name/Date: Manual vs Electronic - Inpatient and LTC TAR Volume - 5/18/16

Page 107 of 199

Report Title: Outpatient TAR Volume - Manual vs Electronic (Summary)









Grand Total: 68,099 100.00%


Report Name/Date: Manual vs Electronic - Outpatient TAR Volume - 5/18/16

Outpatient TAR Statistics:

Total Outpatient TAR Volume: 68,099

Total Manual (Amisys) TARs: 10,541

Total Electronic (M2) TARs: 57,558

Percent of Manual (Amisys) TARs: 15.48%

Percent of Electronic (M2) TARs: 84.52%

Page 108 of 199

Report Title: RAF Volume - Manual vs Electronic (Summary)



Manual (Amisys) 539 1.93%




Manual (Amisys) 823 1.22%


Grand Total: 95,435 100.00%

Entered Between: 7/1/15 - 12/31/15

Report Name/Date: Manual vs Electronic - RAF Volume - 5/18/16

Outpatient RAF Statistics:

Total Outpatient RAF Volume: 95,435

Total Manual (Amisys) RAFs: 1,362

Total Electronic (M2) RAFs: 94,073

Percent of Manual (Amisys) RAFs: 1.43%

Percent of Electronic (M2) RAFs: 98.57%

Page 109 of 199

Utilization ManagementInter-Rater

Reliability

Audit

Outpatient

2015 -2015 Month Total TARs

Process

Errors

No Process

Errors

Could not

determine % Total TARs

Criteria

Did not

Agree

Criteria

Agreed %

Could not

determine

Jul 30 2 28 0 93.3% 30 0 30 100.0% 0

Aug 28 2 26 0 92.9% 28 0 26 92.9% 2

Sep 30 0 30 0 100.0% 30 1 29 96.7% 0

Oct 30 2 27 1 90.0% 30 0 28 93.3% 2

Nov 30 0 30 0 100.0% 30 0 30 100.0% 0

Dec 30 1 29 0 96.7% 30 0 30 100.0% 0

#DIV/0! #DIV/0!

#DIV/0! #DIV/0!

#DIV/0! #DIV/0!

#DIV/0! #DIV/0!

#DIV/0! #DIV/0!

#DIV/0! #DIV/0!

Month Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

Process

Compliance93.3% 92.9% 100.0% 90.0% 100.0% 96.7%

Criteria

Compliance100.0% 92.9% 96.7% 93.3% 100.0% 100.0%

Target

Compliance

Rate 90% 90% 90% 90% 90% 90%

Page 110 of 199

Partnership HealthPlan

of California

April 2016

2016 Member Satisfaction Survey

Page 111 of 199

IntroductionIntroduction and Objectives

In 2013, the CAHPS 5.0 Adult Medicaid Survey was created to assess satisfaction among Partnership

HealthPlan of California members. Partnership HealthPlan of California is interested in using the CAHPS

survey as a benchmark for their member satisfaction.

In 2014, the Partnership HealthPlan of California Membership Satisfaction Survey was created to assess

and track member satisfaction; it was compared to the CAHPS survey and results were fairly comparable.

This is the third year this member satisfaction survey has been conducted.

Comparing satisfaction across regions to display differences between members in the Northern and

Southern regions over time is also of interest.

Methodology

In order to meet the stated objectives, mail surveys were sent to a randomized sample of Partnership

HealthPlan of California members.

– All Adult Commercial Partnership HealthPlan of California members who have been continuously

enrolled for at least 12 months were eligible to receive a survey.

– A total of 10,000 surveys were mailed in February and March 2016 (306 were returned undeliverable),

resulting in a 9.7% net response rate.

– Surveys were sent in either English or Spanish variations, depending on household preference.

– Only one survey was sent per household.

– A total of 936 surveys were received – 786 in English and 150 in Spanish.

Q & A Research 2Page 112 of 199

Rating of All Health Care

1% 1% 1%3% 2%

6%4%

7%

25%

18%

32%

1% 1% 1%2% 2%

5%4%

7%

25%

21%

31%

1% 1% 1%2%

1%

5%3%

9%

26%

19%

32%

0%

10%

20%

30%

40%

50%

0 1 2 3 4 5 6 7 8 9 10

2014 2015 2016

Q & A Research 3

Comparison between years for total respondents.

Base: Total respondents answering

2. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to

rate all your health care in the last 6 months? Scale: 0 = Worst health care possible, 10 = Best health care possible.

(n=939)

82% (7 to 10 Rating)

2014


2015

(n=1,029)

Ratings for all health care received in the last 6 months remain strong across years, with 85% of respondents giving a 7 to 10 rating in 2016.


2016

(n=907)

Page 113 of 199

Rating of All Health Care by Region

Q & A Research 4

Comparison between years among Southern Regions and Northern Regions (Member SAT Survey only).

Overall, Northern Region respondents continue to provide significantly lower scores (7 to 10

rating) for all health care they received in the last 6 months than Southern Region respondents, even though their scores have improved significantly since 2014.

(Letter denotes a significant difference)


2. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to

rate all your health care in the last 6 months? Scale: 0 = Worst health care possible, 10 = Best health care possible.

Rating

Southern Region 2014 (a)

Northern Region 2014 (b)

Southern Region 2015 (c)

Northern Region 2015 (d)

Southern Region 2016 (e)

Northern Region 2016

(f)

n=681 n=258 n=694 n=335 n=610 n=297

0 1% 2% ace 1% 2% ae 1% 3% ace

1 1% 1% 0% 1% 1% c 1%

2 1% 2% 1% 3% acef 1% 1%

3 1% 6% acde 2% 1% 1% 3% e

4 1% 5% acef 1% 3% ac 1% 1%

5 4% 11% acde 4% 6% 4% 8% ace

6 4% 5% 3% 6% ce 3% 4%

7 6% 9% 7% 8% 8% 9%

8 25% 26% 24% 27% 25% 28%

9 19% 15% 23% bf 18% 21% bf 14%

10 37% bdf 19% 35% bdf 24% 34% bdf 28% b

7 to 10 Rating 87% bdf 69% 88% bdf 77% b 88% bdf 79% b

Page 114 of 199

Rating of Health Plan

Q & A Research 5



3. Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to

rate your health plan in the last 6 months? Scale: 0 = Worst health plan possible, 10 = Best health plan possible.

1% 1%

bc

2% 2% 2%

c

5%4%

6%

27%

17%

34%

1% 1% 1%2%

1%

4%2%

6%

25% a

22%

36%

1%0%

1% 1% 1%3% 3%

6%

25%

20%

a

40%

0%

10%

20%

30%

40%

50%

0 1 2 3 4 5 6 7 8 9 10

2014 2015 2016

(a) n=933


2014

89% a (7 to 10 Rating)

2015

(b) n=970


Health plan scores also remain high in 2016, with 91% of respondents giving a 7 to 10 rating (significantly higher compared to 2014).

(c) n=858

91% a(7 to 10 Rating)

2016

Page 115 of 199

Rating of Health Plan by Region

Q & A Research 6



3. Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to

rate your health plan in the last 6 months? Scale: 0 = Worst health plan possible, 10 = Best health plan possible.

Southern Region respondents rate (7 to 10 rating) their health plan positively, significantly more often than Northern Region respondents.

Health plan ratings among both Southern Region respondents and Northern Region respondents remain significantly higher in 2016 than in 2014.


Rating

Southern Region 2014 (a)

Northern Region 2014 (b)

Southern Region 2015 (c)

Northern Region 2015 (d)

Southern Region 2016 (e)

Northern Region 2016

(f)

n=681 n=252 n=661 n=309 n=583 n=275

0 1% 3% ace 0% 1% 1% 1%

1 1% 0% 1% 1% 0% 1%

2 1% c 3% cef 0% 2% c 1% 1%

3 2% 2% 1% 3% 1% 1%

4 1% 4% ace 1% 3% ace 1% 2%

5 4% e 10% acdef 3% e 4% e 1% 5% e

6 3% 6% ace 2% 3% 2% 4%

7 5% 8% 6% 8% 5% 7%

8 26% 28% 24% 28% 25% 27%

9 19% b 13% 22% b 22% b 21% b 17%

10 38% bd 23% 41% bd 26% 42% bd 36%bd

7 to 10 Rating 88% b 72% 92% abdf 84% b 93% abdf 86% b

Page 116 of 199

Frequency of Customer Service

Information or Help Given

Q & A Research 7



4. In the last 6 months, how often did your health plan’s customer service give you the information or help you needed?

Scale: 1 = Never, 2 = Sometimes, 3 = Usually, 4 = Always.

b

7% 8%

24%

61%

4%

9%

26%

61%

6% 9%

27%

59%

0%

20%

40%

60%

80%

100%

Never Sometimes Usually Always

2014 2015 2016

(a) n=718

85% (Top Two Rating)

2014


2015

(b) n=752


With little difference year to year, respondents (59% in 2016) typically “always” receive the information or help they need from their health plan’s customer service.

(c) n=666


2016

Page 117 of 199

Frequency of Customer Service

Information or Help Given by Region

5%7%

22%

bf

65%

ace

12%9%

a

29%

50%

3%

8%

27%

b

62%

c

6%9%

24%

b

60%

5%9%

26%

b

59%

c

8% 8%

27%

57%

0%

20%

40%

60%

80%

100%


Southern Region 2014 Northern Region 2014 Southern Region 2015 Northern Region 2015 Southern Region 2016 Northern Region 2016

Q & A Research 8



4. In the last 6 months, how often did your health plan’s customer service give you the information or help you needed?


(a) n=538 (b) n=180 (c) n=529 (d) n=223

Frequency of receiving information or help by a health plan’s customer service is consistent between regions in 2016.


89% b(Top Two Rating)

2015


2014

87% b (Top Two Rating)

2014


2015

86% b (Top Two Rating)

2016


2016

(e) n=472 (f) n=194

Page 118 of 199

Frequency of Courtesy and Respect

Given by Customer Service

Q & A Research 9



5. In the last 6 months, how often did your health plan’s customer service staff treat you with courtesy and respect?


c

3% 3%

18%

76%

2% 3%

16%

79%

1%3%

17%

79%

0%

20%

40%

60%

80%

100%


2014 2015 2016

(a) n=719


2014


2015

(b) n=756


Year to year, respondents (79% in 2016) typically report that they are “always” treated with courtesy and respect by their health plan’s customer service staff.

(c) n=649


2016

Page 119 of 199

Frequency of Courtesy and Respect

Given by Customer Service

by Region

e

3% 2%

17%

78%

e

4% 3%

d

22%

71%

2% 2%

17%

b

79%

e

4%

ac

5%

14%

78%

1% 2%

17%

b

80%

2% 3%

19%

76%

0%

20%

40%

60%

80%

100%


Southern Region 2014 Northern Region 2014 Southern Region 2015 Northern Region 2015 Southern Region 2016 Northern Region 2016

Q & A Research 10



5. In the last 6 months, how often did your health plan’s customer service staff treat you with courtesy and respect?


(a) n=542 (b) n=177 (c) n=533 (d) n=223

With an increase in “usually” and “always” receiving courtesy and respect from health plan’s customer service ratings, 2016 Northern Region scores are now at statistical parity with Southern Region ratings.


96% bd(Top Two Rating)

2015


2014


2014


2015

97% bd(Top Two Rating)

2016


2016

(e) n=468 (f) n=181

Page 120 of 199

Pharmacy Credentialing Summary Presented by: Dina Cuellar, Associate Director of Pharmacy Operations Summary of MedImpact (PBM) Network Credentialing Report: Semi-annual (July - Dec 2015)

June 7, 2016: IQI

Date report was run by MI Date of review Region (County)

# of Pharmacies

State License (Y/N)

DEA License (Y/N)

PIC License (Y/N)

2/22/2016 4/29/2016 Sonoma 66 100% 100% 100% 2/22/2016 4/29/2016 Lassen 5 100% 100% 100% 2/22/2016 4/29/2016 Del Norte 4 100% 100% 100% 2/22/2016 4/29/2016 Mendocino 16 100% 100% 100% 2/22/2016 4/29/2016 Siskiyou 8 100% 100% 100% 2/22/2016 4/29/2016 Modoc 1 100% 100% 100% 2/22/2016 4/29/2016 Lake 13 100% 100% 100% 2/22/2016 4/29/2016 Solano 55 100% 100% 100% 2/22/2016 4/29/2016 Trinity 3 100% 100% 100% 2/22/2016 4/29/2016 Shasta 35 100% 100% 100% 2/22/2016 4/29/2016 Marin 41 100% 100% 100% 2/22/2016 4/29/2016 Yolo 27 100% 100% 100% 2/22/2016 4/29/2016 Napa 21 100% 100% 100% 2/22/2016 4/29/2016 Humboldt 28 100% 100% 100%

Results: MedImpact’s entire network has 323 operating pharmacies in PHC’s 14 counties. 100% of the pharmacies were licensed for both DEA and State during July- December 2015. All had a pharmacist in charge (PIC) with current licensure.

Notes: Full detailed report is available upon request.

Page 121 of 199

Jessica S. Hackwell, CPHQ

GTPP/CHDP Supervisor

Growing Together Perinatal ProgramGTPP

GTPP Cases – Southern Region

Lake Marin Mendocino Napa Solano Sonoma Yolo

2013 Total Cases 122 413 217 491 1274 1322 863

2013 High Risk 11 42 18 97 234 172 137

2014 Total Cases 235 251 185 415 1338 1351 707

2014 High Risk 25 43 34 81 318 189 167

2015 Total Cases 246 236 173 329 1129 1376 667

2015 High Risk 36 50 41 84 268 210 146

2016* Total Cases 142 178 205 184 632 663 341

2016* High Risk 14 17 21 25 129 71 57

122

413

217

491

12741322

863

1142 18

97

234

172137

235 251

185

415

1338 1351

707

25 43 3481

318

189 167

246 236

173

329

1129

1376

667

36 50 4184

268210

146142178

205 184

632663

341

14 17 21 25

12971 57

0

200

400

600

800

1000

1200

1400

1600

* 2016 Jan - May data only

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GTPP Cases – Northern Region

Del Norte Humboldt Lassen Modoc Shasta Siskiyou Trinity

2013 Total Cases 33 74 27 9 316 32 12

2013 High Risk 5 11 7 1 33 2 1

2014 Total Cases 75 271 88 24 769 128 29

2014 High Risk 7 36 19 5 149 28 5

2015 Total Cases 106 476 119 34 915 134 61

2015 High Risk 18 49 29 8 154 15 15

2016* Total Cases 36 192 49 17 345 48 17

2016* High Risk 9 32 14 2 80 7 4

33

74

279

316

32125 11 7 1

332 1

75

271

88

24

769

128

297

3619 5

149

285

106

476

119

34

915

134

61

1849

298

154

15 1536

192

4917

345

48179

3214 2

80

7 4

0

100

200

300

400

500

600

700

800

900

1000

2013 Data from Sept - Dec 2013 * 2016 Data from Jan- May 2016

HEDIS Measures: Prenatal Care (prior to 13 weeks)

2013 2014

Eastern 81.4% 80.0%

Sonoma 86.0% 89.1%

Marin 78.2% 84.9%

Mendocino 88.0% 83.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Page 123 of 199

HEDIS Measures: Prenatal Care (prior to 13 weeks)

2015

Northeast 78.8%

Northwest 83.0%

Southeast 87.5%

Southwest 86.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

HEDIS Measures: Postpartum Care (21-56 days)

2013 2014

Eastern 75.9% 68.9%

Sonoma 73.7% 74.1%

Marin 57.8% 67.6%

Mendocino 69.7% 64.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Page 124 of 199

HEDIS Measures: Postpartum Care (21-56 days)

2015

Northeast 52.8%

Northwest 50.4%

Southeast 69.2%

Southwest 68.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

• Delivery Report (2 times per month)

• Procedure• Postpartum Update Call - call from

• PP appt confirmation for (date) f/up

• Postpartum Appointment Confirmed – scheduled 2 days after appointment date• PP appt on (date) confirmed, PNC, Dr. name

• Date Started• Pilot Northern Region – November 2015

• Southern Region – May 2016

New Postpartum Process

Page 125 of 199

Questions

Page 126 of 199

Managing Pain Safely:

A Plan’s approach to combating the

opioid epidemic

Danielle Niculescu, MPHProject Manager, Quality Improvement Department

June 7, 2016

Health Plan Internal Workgroups

Pharmacy

Provider Network

Care Coordination/Utilization Management/ Member Services

Legislative Policy/Regulation/Communication

Community SupportMP

S Te

chn

ical

Su

pp

ort

Data Management

MP

S St

ee

rin

g C

om

mit

tee

Page 127 of 199

• By December 31, 2016, we will improve the health of

PHC members by ensuring that prescribed opioids are for

appropriate indications, at safe doses, and in conjunction

with other treatment modalities as measured by a:

– Decrease in total number of initial prescriptions by 75%

– Decrease in total number of prescription escalations by 90%

– Decrease in total number of patients on high-dose opioids* by

75%

Managing Pain Safely – Aim Statement

*Defined as greater than 120 mg. MED

• Education

• Health plan pharmacy prior authorization

changes

• Additional options for treating pain

• Community activation

• Aligned incentives

• Additional resources

Interventions

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1. Scrutinize justification for high doses of expensive opioids

2. Scrutinize escalation of high-dose opioids (no matter what the price)

3. Scrutinize all prescriptions for all stable high doses of opioids

– Request explanation for stable high dose

– Difficult cases may require supporting documentation of mental health, pain specialist, or pain medication oversight committee

– Track responses with PHC-level registry of patients on high dose opioids

4.Maximum 30 tablets of immediate release opioids without prior authorization for new onset acute pain.

Pharmacy Prior Authorization Changes

• September- December 2015– Completion of Safe Use Now Project

– Pharmacy Registry Developed and Maintained

– Educational Opportunities

– CHCF Grant and Coalition Support

– Pain Management Oversight Committees

– MPS Webpage/ Toolkit

Managing Pain Safely Quarter 3 and 4, 2015

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• January- June, 2016– MPS “White Paper”

– Taper Journal/ Toolkit

– Pharmacy Toolkit

– Pharmacy Academic Detailing

– Integrated Clinics Payment Plan Development

– Naloxone Program

– Provider Site-Level Data Sharing

– Educational Events

– Coalition Building

– Hospitalization Due to Overdose/ Intoxication Feedback Loop

– Sustainability Plan

– Implementation of Immediate Release Quantity Limit

Managing Pain Safely Quarter 1 and 2, 2016

• County Coalitions

– 11 of 14 PHC counties with active county coalitions

– Goals• Agree upon and disseminate standards for use of opioids and other

controlled substances

• Nurture sense of urgency at local level

• Develop shared commitment to making improvement, with mutual accountability

• Ensure all parts of community work together towards a common purpose, instead of working at odds with each other

– Essential elements• Convening organizations

• Local leaders

– CHCF grant support

Community Activation

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PHC Counties Participating in CHCF Regional Opioid Safety Coalition

Grant Program

10 PHC Counties are

participating in CHCF’s

Regional Opioid Safety

Coalition Grant Program

Community Coalition Status

10

1

5

3

2

5

2 2

4 4

1

3

4

1

2

PHC COUNTY COALITION STATUS

Key

1 Little or No Effort (Yet)

2 Initial Meetings, Beginning of Framework Formation

3 Framework Formation, Action Teams Initiating

4 Strong Effort- Framework Implemented, Regular Meetings, Active Action Teams, Working

towards Milestones

5 Robust Effort- Active Action Teams, Accomplishing Milestones, Measurable Results

Page 131 of 199

Additional Resources – MPS Toolkit

MPS Toolkit provides key resources in one location

MPS Data

Page 132 of 199

Opioid Fills PMPM

49% DecreaseJanuary 2014-March 2016

Unsafe Dose (>120 MED)

48% Decrease January 2014-March 2016

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Initial Opioid Prescriptions

32% Decrease February 2014-March 2016

Escalating Dose: Cohort Analysis

58% Decrease January 2014-March 2016 for January 2014 Cohort

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What’s Next: Limitation of New Starts

Limitation of new starts. As of June 1, 2016, Partnership has placed a 30 pill quantity

limit on short-acting opioids for new starts. The goal of this initiative is to decrease the

number of patients starting down the path of long-term opioid dependence.

• Enhance support of local coalitions

• Planning process for creating integrated clinics for high utilizers (CHCF support)

• Pharmacy academic detailing

• MPS provider site-level data sharing

• Promotion of site-level naloxone programs

• Reducing Recidivism- closing the feedback loop

• Additional Educational Opportunities

• New Campaign: Avoid Co-Prescribing: Opioids and Benzodiazepines

• Project Extension Planning

• MPS Evaluation

Looking Ahead in 2016: Health Plan Activities

Page 135 of 199

Contact Information

Danielle Niculescu, MPH, Project Manager

Quality Improvement Department

[email protected]

Page 136 of 199

Managing Pain Safely Project Update August 2015- March 2016

1

Projects August-December 2015

• Completion of Safe Use Now Project: The Safe Use Now program was utilized to rate providers’ prescribing practices based on 17 risk factors. Individual ratings were shared via peer-to-peer conversations with PHC’s medical directors and more than 350 providers, with the intention of highlighting areas for improvement and influencing prescribing habits

• Pharmacy Pain Management Registry Developed: Clinical data is tracked for members who are using high-dose opioids. Examples of the type of data tracked include prescribing physician, medication and dose patterns, behavioral health diagnosis, and behavioral health treatment. Registry source data is comprised of pharmacy treatment authorization request data and claims data.

• Educational Opportunities- MPS hosted two webinars during the last two quarters of 2015. These webinars covered topics including the treatment of headaches for chronic pain patients and urine toxicology screening. In total, 64 providers, clinic and Partnership staff, and key community stakeholders attended the webinars, which offered 2 free CME credits.

• Local Community Coalitions: PHC has been actively working at the ground level to support communities. A key focus has been quality improvement and community engagement coaching to form collective impact coalitions throughout the 14 PHC counties. To date, 11 of the 14 counties have formed some type of opioid coalition and 10 of the 14 counties have designated funding specifically to support these opioid coalitions. PHC is fiscally sponsoring 2 community coalitions at this time.

• Pain Management Oversight Committees: Pain management oversight committees support clinicians caring for patients with chronic pain by providing evidence-based advice on managing pain safely, including the use and management of controlled substances (including opioids), use of adjunctive therapy (including behavioral health and physical modalities), and appropriate referrals to interventional pain specialists. PHC sponsors an oversight committee for providers in our network who do not have access to a local oversight committee.

• MPS Webpage/ Toolkit: The Managing Pain Safely Toolkit, which can be found on the Managing Pain Safely webpage, was developed for providers and includes successful practices, PHC prescribing guidelines, training videos and tutorials, dose calculators, and tapering guides.

Projects January- June 2016

• MPS “White Paper”: The MPS White Paper is a detailed description of the MPS Project. This document can be found on the MPS Webpage.

• Taper Toolkit: This comprehensive tool is comprised of a Taper Journal for members and Taper Toolkit for providers to support providers and patients in the tapering process.

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http://www.partnershiphp.org/Providers/HealthServices/Pages/Managing-Pain-Safely.aspx

Managing Pain Safely Project Update August 2015- March 2016

2

These materials were developed in response to provider requests for additional material and resources to be used while guiding a patient through the tapering process.

• Pharmacy Toolkit: The Pharmacy Toolkit is a compilation of information regarding PHC pharmacy guidelines, best practices for safe dispensing, warning signs for pharmacists, and information on naloxone. This Toolkit can be found on the MPS Webpage.

• Pharmacy Academic Detailing: Pharmacy academic detailing utilizes the Pharmacy Toolkit to provide 1:1 academic detailing at pharmacies within our network.

• Integrated Care Clinic Planning Project: Through a grant funded by the California Healthcare Foundation, PHC is partnering with two clinics in our region to develop a payment plan for implementing and sustaining integrated behavioral health/substance use clinics at primary care sites. PHC will disseminate best practices and look to scale up once the plan is finalized.

• Naloxone Program: PHC is supporting provider sites to develop and implement site-level naloxone programs. PHC is working with providers to prescribe naloxone, in conjunction with opioids, for high-risk patients. PHC has funded the purchase of 2000 nasal atomizers to be distributed for use in this program. The MPS team has developed a naloxone toolkit to assist with this project.

• Data Sharing: In an effort to share provider site-level data, which indicates patient dose and dose pattern, the MPS project has developed two data sharing processes:

o Voluntary request of provider-site data from provider site; and o Peer-to-peer data sharing wherein PHC medical directors outreach to provider

sites who have 15 or more patients on high-dose opioids. • Educational Events: MPS hosted a set of data sharing webinars during the month of

February. These webinars showcased MPS’s data collection methodology and detailed how provider sites can request site-level data.

• Hospitalization Due to Overdose/ Intoxication Feedback Loop: MPS is currently evaluating ways to flag members who have been admitted to the emergency department due to intoxication/ overdose, with the intention of reporting this information back to the PCP.

• Sustainability Plan: The MPS team is currently drafting plans to develop systems and processes to ensure that the results seen thus far by the MPS project are sustainable over time.

• Implementation of Immediate Release Quantity Limit: As of June 1, 2016, Partnership has placed a 30 pill quantity limit on short-acting opioids for new starts. The goal of this initiative is to decrease the number of patients starting down the path of long-term opioid dependence.

Page 138 of 199

Page 1 of 5

Attachment 1.1) 2016-17 Hospital QIP Summary of Measures Providers have the potential to earn a total of 100 points in five domains: a) Readmission; b) Advance Care Planning; c) Clinical Quality; d) Patient Safety; and e) Operations and Efficiency

1. Readmission Rate (20pts) 2. Advance Care Planning (15pts) Clinical Quality: OB/ Newborn/ Pediatrics 3. Rate of Elective Delivery before 39 weeks (10pts) – new exclusion criteria 4. Exclusive Breast Milk Feeding Rate (10pts) – new targets 5. Vaginal Birth After Cesarean (VBAC) (10pts) – new targets 6. Timely Participation in California Perinatal Quality Care Collaborative (CPQCC) (5pts) 7. Timely Participation in California Maternal Quality Care Collaborative (CMQCC) (5pts) – new participation

criteria Patient Safety 8. Venous Thromboembolism (VTE) (15pts) – new measures and targets Operations and Efficiency 9. Percentage of Inpatient Treatment Authorization Requests (e/TARS) (10pts) 10. Health Information Exchange (gateway measure) – new criteria

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Page 2 of 5

Measure Target Rationale

Readmission Rate (20 points) 1. All-Cause 30-day Adult Readmission Rate for PHC patients hospitalized at hospital (excludes OB admissions and claims for patients with Medicare coverage) Back-up measure If readmission target is not met: Percentage of Discharges with Follow-Up Post Discharge Visit within 4 calendar days of discharge based on claims and encounter submissions to PHC

≤12.0% Readmission Rate = 20 points 12.1%-15.0% Readmission Rate = 10 points OR Follow Up Post-Discharge Target: ≥ 30.0% of members who have a physician office visit within 4 calendar days of discharge = 20 points

• This measure is used in most local and national value-based payment programs

• This is a priority for PHC, given poor quality outcomes and high costs related to readmissions

• Readmissions are continuing to increase in the PHC network

Advance Care Planning (15 points) 2. Percentage of Patients 65 years of age and older admitted with Advance Directive status recorded as structured data

Option 1: Documentation of Inquiry: ≥90.0% = 15 points 80.0% to <90.0% = 7.5 points

• ACP continues to be a priority area for PHC • Past performance presents an opportunity

for improvement as not all hospitals are reaching the targets

Option 2: Obtained Documentation: ≥ 50.0% = 15 points 40.0% to ˂50.0% = 7.5 points

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Page 3 of 5

Clinical Quality: OB/Newborn/Pediatrics (40 points) 3. Rate of Elective delivery before 39 weeks (Joint Commission PC-01) *Only applies to hospitals doing deliveries Exclusion: For hospitals with a denominator of 30 or less, elective deliveries for a medical reason not listed under Joint Commission’s PC-01 exclusions may be submitted for PHC’s review and, if approved, be excluded from the denominator

≤ 3.0% = 10 points 3.1% to 5.0% = 5 points

• This is a Joint Commission Quality Core Measure, due to the serious neonatal and maternal health risks associated with early elective deliveries that are not medically indicated

• Some rare medical conditions may be valid reasons for an early elective delivery, but the Joint Commission has not tried to define each and every one

4. Exclusive Breast Milk Feeding Rate at time of discharge from Hospital for all newborns (Joint Commission PC-05) *Only applies to hospitals doing deliveries **Joint Commission is changing the PC-05: Exclusive breast milk feeding measure in October 2015. The specifications of this PHC Hospital QIP measure will adopt the changes

≥ 70% = 10 points 65% - < 70% = 5 points

• Establishing performance targets is to align with our guiding principle to pay for outcomes

• This is a Joint Commission Perinatal Care Core Measure. PHC is following the recommended targets from Joint Commission

• This measure is endorsed by NQF

5. VBAC Rate, Uncomplicated (IQI #22) *Only applies to hospitals with >200 deliveries during the measurement year

≥ 5% VBAC Uncomplicated = 10 points No partial points are available for this measure

• Establishing performance targets is to align with our guiding principle to pay for outcomes

• According to OSHPD, the average VBAC rate in Northern CA in 2013 is 10%. The new target is based on this data

• This measure is an AHRQ Inpatient Quality Indicator

• Small facilities are excluded because they do not have adequate resources for the safe implementation of VBACs

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Page 4 of 5

6. Timely Participation in CPQCC Data Reporting *Only applies to hospitals that have intensive care nurseries

Six or more months participating (submitting data) in CPQCC data reporting = 5 points Join CPQCC and submit data by June 30, 2017 (End of Measurement Year) = 2.5 points

• Hospitals participating in CPQCC have improved quality outcomes such as decreased maternal mortality and length of stay in intensive nurseries

• QI Collaborative provides infrastructure to improve the quality of maternal and neonatal care

7. Timely Participation in CMQCC’s Maternal Data Center *Only applies to hospitals that provide maternity services

For hospitals new to the 2016-17 QIP: six or more months of Active Track participation during the measurement year = 5 points For hospitals participating prior to 2016-17: 12 months of Active Track participation during the measurement year = 5 points

• Hospitals participating in CMQCC have improved quality outcomes such as decreased maternal mortality and shorter length of stay in intensive nurseries

• QI Collaborative provides infrastructure to improve the quality of maternal and neonatal care

• Hospital QIP is incentivizing increased provider engagement and active participation in the Maternal Data Center tool

For all hospitals: Establish Active Track participation in CMQCC OR active participation in the CMQCC QI Collaborative to Support Vaginal Births and Reduce Unnecessary Cesareans during the measurement year = 2.5 points

*Active track participation is defined by hospital submission of data to the Maternal Data Center by the end of the measurement year.

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Page 5 of 5

Patient Safety (15 points) 8. VTE Prophylaxis VTE-5 VTE Warfarin Therapy Discharge Instructions VTE-6 Hospital-Acquired Potentially-Preventable VTE STK-4 Thrombolytic Therapy

VTE-5 ≥ 90% = 5 points VTE-6 ≤ 5% = 5 points STK-4 ≥ 80% = 5 points

No partial points are available for these measures

• These are CMS measures and are National Hospital Inpatient Quality Measures

• CMS retired VTE-1, VTE-2, STK-1 in January, 2016 due to topped-out performance

• The targets are based on the Joint Commission’s Annual Report 2015: VTE-5 92.3% VTE-6 4.6% STK-4 84.6%

Operations and Efficiency (10 points) 9. Percentage of Inpatient Treatment Authorization Requests (TARs) submitted electronically and by close of the next business day (eTARS)

≥ 85.0% = 10 points 80.0% to ˂85.0% = 5 points

• This is a priority for PHC as it increases operational efficiency

• Timely eTAR submissions allows timely data feeds to PCPs, providing notifications of admissions and enhancing coordinated care

• There remain several hospitals that are not submitting authorization requests electronically; the QIP has proven an excellent motivator

10. HIE Participation Measure One option to fulfill measure requirement: Admission, Discharge, Transfer (ADT) Interface with HIE or PHC* by June 30, 2017 = eligibility to participate in the hospital QIP *PHC is building infrastructure for interface if local HIE is not able to accept

• Hospitals are critical for making HIEs successful and are often the most difficult to get on board. Inland Empire Health Plan incorporated this measure in their hospital pay-for-performance program and was successful in increasing HIE participation

• Hospitals are encouraged to use and continue implementing HIE

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Page 1 of 2

Attachment 2.1) 2016-17 Small Hospital QIP Summary of Measures

Rationale:

The Small Hospital QIP Measurement set is created to incentivize quality performance by hospitals with less than 50 general acute beds with at least 20 PHC Medi-Cal only admissions. As part of PHC’s efforts in expanding the Hospital QIP, the small measurement set aims to reach out to hospitals that may not have enough staffing resources to support improvement efforts or data submission across the regular hospital measurement set. Also, some measures in the comprehensive measurement set requires a large denominator to be meaningful. A small hospital measurement set establishes an incremental approach to paying for performance.

Measures:

1. Readmission Rate 2. Percentage of Inpatient Treatment Authorization Requests (e/TARs)

Both measures rely on administrative data only and do not require manual submissions by participants.

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Page 2 of 2

Measure Target Rationale

Readmission Rate (50 points) 1. All-Cause 30-day Adult Readmission Rate for PHC patients hospitalized at hospital (excludes OB admissions and claims for patients with Medicare coverage)

Back-up measure If readmission target is not met: Percentage of Discharges with Follow-Up Post Discharge Visit within 4 calendar days of discharge based on claims and encounter submissions to PHC

≤12.0% Readmission Rate = 50 points 12.1%-15.0% Readmission Rate = 25 points OR Follow Up Post-Discharge Target: ≥ 30.0% of members who have a physician office visit within 4 calendar days of discharge = 50 points

• This measure is used in most local and national Value Based Payment Programs

• This is a priority for PHC, given poor quality outcomes and high costs related to readmissions

• Readmissions are continuing to increase in the PHC network

Operations and Efficiency (50 points) 2. Percentage of Inpatient Treatment Authorization Requests (TARs) submitted electronically and by close of the next business day (eTARS)

≥ 85.0% = 50 points 80.0% to ˂85.0% = 25 points

• This is a priority for PHC as it increases operational efficiency

• Timely eTAR submissions allows timely data feeds to PCPs, providing notifications of admissions and enhancing coordinated care

• There remain several hospitals that are not submitting authorization requests electronically; the QIP has proven an excellent motivator

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1

June 2016 To: Internal Quality Improvement Committee From: Caron Lee, MPH, Improvement Advisor Topic: Offering and Honoring Choices™ Initiative Background In 2012, PHC began the Offering and Honoring Choices™ initiative to ensure that its members and their families are knowledgeable about health care treatment options, empowered to define their treatment goals, and able to make informed choices about the interventions they choose during the last years of life. The three main areas under Offering and Honoring Choices™ are: 1) Advance Care Planning, 2) Palliative Care, and 3) Policy and Public Education and Engagement. Advance care planning is defined as doing what we can to ensure that the health care treatment we may receive is consistent with our wishes and preferences should we be unable to make our own decisions or speak for ourselves. Palliative care is defined as patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitating patient autonomy, access to information, and choice. Activities in fostering policy development and public engagement are geared toward supporting legislation related to and consumer engagement in advance care planning and palliative care. Below are the current activities in each area. Advance Care Planning

• Since the fall of 2014, Care Coordination staff have been trained to incorporate advance

care planning into conversations with and case management of members. Below are the cumulative data by year on advance care planning (ACP) and advance directive (AD), and advance directives signed with Care Coordination staff. These are followed by the monthly data for January 2015 – May 2016 on these measures.

Care Coordination Results 2014 2015 2016 (1/16-5/16)

# advance care planning conversations with CC staff

189 1409 939

# advance directive conversations with CC staff

319 1935 1194

# advance directives signed (based on when member shares that has signed advance directive)

110 84

36

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2

78 88

132 121104 117

86

152

104128 127

172201 192

154

199 193

0

50

100

150

200

250

ACP Conversations with CC staff,Jan 2015 - May 2016

6165

139

187 180200

148

251

138

188 188 190213

233 229258 261

0

50

100

150

200

250

300

AD Conversations with CC staff,Jan 2015 - May 2016

76

9

1211

10

3

8

5 5 5

3

87

11

9

10

2

4

6

8

10

12

14

# AD signed with CC staff,Jan 2015 - May 2016

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3

• PHC provides financial incentive via the PCP QIP to encourage providers to discuss advance care planning with their patients. PHC provides $100 for documented advance care planning conversations. Below are the results from the past three QIP measurement periods indicating that the number of attestations has increased, particularly between the 2012-2013 and 2013-2014 QIP measurement years.

For the 2016-2017 QIP measurement year, the criteria for the attestation have been revised to allow providers to attest to doing advance care planning with a wider population of PHC members. There will also be tiered payment levels with $100 payments for completion of an advance directive or Physician Orders for Life-Sustaining Treatment (POLST) form, and $50 payments for having an advance care planning conversation.

• PHC also provides financial incentives through the Hospital QIP advance care planning attestation, in which six hospitals have participated during the past four years. For the 2014-2015 Hospital QIP measurement year, among these six hospitals, 92%-100% of unique patients > 65 years of age were asked during admission about their advance directive status. The measure aligns with the Stage 2 Meaningful Use Measure on advance directives for hospitals.

• On January 20, 2016, we hosted a webinar, “POLST in Primary Care.” Dr. Mark Apfel, from Anderson Valley Health Center, presented on the history of POLST, why it is so important, how to introduce and complete the POLST form with patients, a recent state policy change allowing NPs and PAs to complete the form, and responded to Q&A. At least 51 individuals viewed the webinar. 30 of 31 survey respondents rated the webinar as “Good” or “Excellent.”

Palliative Care “Partners in Palliative Care” is a new community-based palliative care service delivery model developed by PHC and its community partners (hospice, palliative care providers). The Partners in Palliative Care pilot ran from September 1, 2015 to February 29, 2016. It has been the priority

123

12951401

0

500

1000

1500

2012-2013 2013-2014 2014-2015

# Advance Care Planning Attestations perQIP measurement year

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4

activity within the Offering and Honoring Choices initiative during the 2015-2016 fiscal year, largely because the pilot and the evaluation are to inform the palliative care benefit (SB 1004) that is anticipated to become an active in 2017. PHC continues to support Partners in Palliative Care and new enrollments until the DHCS palliative care benefit becomes active. As of May 26, 2016, 100 members had enrolled in the program (57 active enrollment, 43 disenrolled). As part of the service delivery model, the four teams provide:

• Initial assessment • 24/7 telephonic support • Pain/symptom management • Advance care planning • POLST completion • Acute symptom management • Assess caregiver support needs • Warm hand-offs from hospital and to hospice • Spiritual care • Case management

Teams receive monthly payment per enrolled member in the program, and incentive payments for advance care planning and POLST completion, and when members do not use the ED or hospital. A third party consultant completed the evaluation of the implementation of the pilot in April 2016. The evaluation report was shared with PHC internal stakeholders, the pilot teams, DHCS, and the California Health Care Foundation (which funded the pilot) and also presented via webinar on April 26, 2016 to the same audience. The evaluation results are grouped into three themes: Service Delivery Model

• The service delivery model focus on home and community-based support was responsive to the needs of patients.

• Advance care planning and completion of the POLST took more time than expected and/or were challenging to complete with members in the pilot.

Identifying and Enrolling Patients

• Building a referral network takes time and resources; many providers and the general public do not understand the nature of palliative care.

• The level and intensity of psychosocial need among pilot members was greater than expected.

• Late stage cancer (48%) and cirrhosis (15%) have been the most common diagnoses. Global Payment Model

• All four sites were satisfied with the monthly payment per enrolled member model.

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5

• Several sites recommended a tiered payment system based on psychosocial and clinical acuity.

The key recommendations by the evaluator were: Service Delivery Model

• Continue to offer a community-based palliative care service based on the State’s benefit and learning from this pilot.

• Provide advance care skills training to palliative care teams who would like additional training and practice.

• At the health plan level, continue to provide infrastructure and project support to palliative care providers.

Identifying and Enrolling Patients

• Better inform PHC members and network providers about palliative care and this program.

• Contract with palliative care providers with robust interdisciplinary teams that are able to provide the service model.

• Provide palliative care teams with clinical practice guidelines for psychosocial interventions.

Global Payment Model

• Consider a tiered payment model (i.e., higher payments for higher levels of clinical and psychosocial care) following completion of the outcome evaluation (analysis of the cost, utilization, and health care outcomes) in September 2016.

For the outcome evaluation, we are contracting with Dr. Brian Cassel from Virginia Commonwealth University. He is recognized as a national expert in evaluation of palliative care. The outcome evaluation will be completed in September 2016. Results will also be shared with DHCS and CHCF to inform the SB 1004 palliative care benefit. PHC has been sharing about the pilot and our learning from it at various meetings and conferences related to palliative care. Additional Palliative Care Activities

• Sponsor palliative care leadership training, provided by the Palliative Care Leadership

Centers (PCLC) at the University of California, San Francisco, to help establish palliative care departments in hospitals. Mercy Hospital in Redding was trained in October 2014, and Sutter Santa Rosa was trained in January 2016. Sutter Santa Rosa continues with monthly coaching calls with PHC and PCLC through 2016.

• On May 12-13, an End-of-Life Nursing Education Consortium (ELNEC) training was held in Susanville. The purpose of the training was to develop palliative care capacity in hospitals that are not able to support a palliative care department or team (e.g., critical

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6

access hospitals). Sixteen participants representing seven hospitals in PHC’s network attended the training. The training covered: nursing care at the end of life; pain and symptom management; communication; loss, grief, and bereavement; preparation for and care at the time of death; and ethical, legal and cultural considerations at end of life. The participants rated the training well and expressed gratitude for this opportunity. Another ELNEC training will be held August 4-5 in Lakeport for a second cohort of nurses. Starting in July, PHC will host monthly calls for both cohorts to provide coaching and additional education on palliative care.

• Palliative care clinician peer convening held quarterly to support palliative care clinicians within PHC’s network. Convening were held on January 11 and April 20 2016.

Public Education and Engagement

• A work group aimed at supporting advance care planning for PHC staff has been meeting

regularly since February 2016. The work group posted an article on the PHC web site for staff to commemorate National Healthcare Decisions Day in April. It also submitted an article encouraging advance care planning to local newspapers. Training and Development is in the process of surveying staff on their knowledge of and interest in advance care planning. The work group will use the survey results to determine what type of interventions to try and at what scale to promote advance care planning at PHC.

• Support community coalition work dedicated to consumer engagement in advance care planning. Currently, PHC supports two coalitions:

o Honoring Choices Napa Valley (HCNV): the PHC Chief Medical Officer regularly attends the monthly HCNV steering committee meetings. HCNV is in the process of developing a new strategic plan.

o My Care, My Plan Speak Up Sonoma County: the coalition hosted advance care planning sessions on April 14 for National Healthcare Decision Day. It screened the film, “Being Mortal,” on April 21 for Sonoma county residents to attend.

Next Steps The outcome evaluation for Partners in Palliative Care will be the priority this summer. In anticipation of palliative care becoming a benefit in 2017, transitioning from pilot phase to health plan benefit will also be a priority. In the advance care planning arena, PHC will be encouraging team-based advance care (ACP) to primary care practices through the revised PCP QIP advance care planning measure and also by offering ACP skills training and other educational opportunities during the second half of 2016.

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POLICY / PROCEDURE

I:\POLICIES\Draft policies for review\Medi-Cal\U MGMT\UM Policies for 06-07-16 IQI\MCUP3131\Changes after IQI\MCUP3131 06-15-16 changed after IQI.docx Page 1 of 3


Policy/Procedure Title: Genetic Testing ☒External Policy

☐ Internal Policy




Reviewing

Entities:



Approving

Entities:





A. MCUP3041 - TAR Review Process

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. N/A

IV. ATTACHMENTS:

A. Genetic Testing Requirements

B. Quest Diagnostics BRCAvantage ® Patient and Family Clinical History Form

V. PURPOSE: To provide criteria for medical necessity and benefit coverage of genetic testing. Genetic testing is a rapidly

expanding aspect of medical care which can be useful for diagnosing disease, guiding treatment, and/or

identifying possible genetic risks for development of disease. Given the rapid evolution of this field, it is

impossible to establish guidelines to reliably inform when genetic testing is appropriate which will remain

valid for a significant time frame. Therefore, the purpose of this policy is to describe the criteria for

evaluating requests for genetic testing, and to cite the external professional resources on which we will rely

to make coverage determination.


A. Genetic testing generally aims to achieve one of the following goals:

1. Confirm the diagnosis of a genetic disease

2. Identify genetic factors which significantly increase an individual’s risk for developing a disease

3. Determine whether a high-risk couple’s genetic makeup increases the risk of their children having a

genetic disease

4. Help determine prognosis, effectiveness of various treatment options, and guide management of

appropriate diseases 5. Prenatal or newborn genetic testing to identify diseases in high-risk situations

B. Partnership HealthPlan of California’s (PHC’s) intent is to follow National Comprehensive Cancer

Network (NCCN) guidelines. Decisions about which genetic tests to approve will rely on the most up-

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Policy/Procedure Title: Genetic Testing ☒ External Policy

☐ Internal Policy





to-date recommendations provided by the Centers for Disease Control and Prevention, the National

Comprehensive Cancer Network, and the American College of Medical Genetics and Genomics. See

Section VII. for URLs for these guidelines.

C. A Treatment Authorization Request (TAR) is required for certain genetic testing as outlined in

Attachment A. Please note PHC requirements may differ from California Department of Health Care

Services (DHCS) Requirements. Please use PHC’s grid entitled Genetic Testing Requirements

(Attachment A) for PHC members. When a TAR is required, medical necessity will be determined upon

TAR submission and the following factors will be considered for genetic testing requests:

1. A definitive diagnosis cannot be made without performing the genetic test being requested AND the

results of the genetic testing will influence the treatment or medical management of the patient.

2. There are identifiable reasons to perform the genetic tests being requested, including a relevant

family history or the presence of a clinical condition which suggests a genetic component is relevant

to diagnosis or management.

3. Genetic testing is needed to help guide family planning decisions.

4. The accuracy of the test has been established, with low proportions of false positive and false

negative results.

5. If a common single gene test is likely to be the cause of the genetic issue in question, a multi-gene

test will not be approved until after the single gene test result is negative.

6. In performing genetic testing of parents to determine risk of an autosomal recessive disease in their

offspring, one parent will be tested initially. The other parent will only be tested if the first parent’s

test indicates the genetic abnormality is present.

7. The test will be ordered by a clinician who has familiarity with the genetic testing being requested

and who has the appropriate expertise to understand the implications of the test and how to follow-

up the results.

8. Testing for any specific gene mutation will only be approved once for the lifetime of any individual

person.

9. Non-disease specific gene panel testing will not be approved (e.g. ancestral testing).

10. Testing solely for the purposes of determining paternity or familial relationships will not be

approved.

11. Genetic testing needed for forensic purposes is not covered.

12. Genetic testing will not be approved if the results or outcome may pose a harm to the individual.

13. Genetic testing will not be approved if the only purpose for ordering the testing is one of the

following:

a. As part of a research project

b. For general screening purposes where there are no high-risk factors indicating that genetic

testing may be useful

c. Where the results of the genetic testing have no therapeutic or medical management

implications.

14. If expert guidance is not available to validate the appropriateness of a particular genetic test, we

reserve the right to request the patient see a geneticist prior to approving the test.

D. Certain genetic tests are not covered by PHC. However, if ordered by a medical geneticist with

appropriate supporting documents attached to the TAR, the request will be considered on an individual

basis.

E. If Quest Diagnostics is to be used for BRCA testing, it is recommended that the Provider first complete

the Quest Diagnostics BRCAvantage ® Patient and Family Clinical History Form (see Attachment B).

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Policy/Procedure Title: Genetic Testing ☒ External Policy

☐ Internal Policy





F. For genetic tests related to pregnancy and newborns, please refer to Medi-Cal guidelines in the Genetic

Counseling and Screening section gene coun 1 – 7.

VII. REFERENCES: A. The Centers for Disease Control and Prevention: http://www.cdc.gov/genomics/gtesting/tier.htm.

B. The National Comprehensive Cancer Network:

http://www.nccn.org/professionals/physician_gls/f_guidelines.asp

C. The American College of Medical Genetics and Genomics:

https://www.acmg.net/ACMG/Publications/Practice_Guidelines/ACMG/Publications/Practice_Guideline

s.aspx

D. Medi-Cal Guidelines (path molec, gene coun)

E. Lynch Syndrome PREMM1,2,6 Model: Prediction Model for MLH1, MSH2, and MSH6 Gene

Mutations: http://premm.dfci.harvard.edu/ Kastrinos F, Steyerberg EW, Mercado R, Balmaña J, Holter

S, Gallinger S, Siegmund KD, Church JM, Jenkins MA, Lindor NM, Thibodeau SN, Burbidge LA,

Wenstrup RJ, Syngal S. The PREMM(1,2,6) model predicts risk of MLH1, MSH2, and MSH6 germline

mutations based on cancer history. Gastroenterology. 2011;140:73–81. doi: 10.1053/j.gastro.2010.08.021

VIII. DISTRIBUTION:

A. PHC Departmental Directors



X. REVISION DATES: 8/19/15; 11/18/15; 06/15/16


MCUP3108 BRCA - Gene Sequence Analysis was archived 08/19/2015

*********************************









covered under PHC.

Page 154 of 199

http://www.cdc.gov/genomics/gtesting/tier.htm


https://www.acmg.net/ACMG/Publications/Practice_Guidelines/ACMG/Publications/Practice_Guidelines.aspx


http://premm.dfci.harvard.edu/

MCUP3131- A Genetic Testing Requirements: Providers should refer to the CPT-4 or HCPCS Level II code book, as appropriate, for full descriptions of codes.

CPT-4 Code Description

PHC TAR Required TAR and/or Billing Requirements Frequency

Limit BENEFIT COMMENTS

MCUP 3131 Attachment A Page 1 of 40

81201 APC gene analysis; full gene sequence

No One of the following ICD-10-CM codes is required on the claim:

C18.0 – C18.9, D12.0 – D12.6, K63.5, Z86.010

Once-in-a-lifetime

81202 APC gene analysis; known familial variants

Yes Requires documentation on the Treatment Authorization Request (TAR) of a family history of familial adenomatous polyposis that includes a relative with a known deleterious APC mutation

Once-in-a-lifetime

81203 APC gene analysis; duplication/deletion variants


C18.0 – C18.9, D12.0 – D12.6, K63.5, Z86.010

Once-in-a-lifetime

81206 BCR/ABL1 translocation analysis; major breakpoint


C91.00 – C91.02 or C92.10 – C92.12

1 per month

81207 BCR/ABL1 translocation analysis; minor breakpoint


C91.00 – C91.02 or C92.10 – C92.12

1 per month

81208 BCR/ABL1 translocation analysis; other breakpoint


C91.00 – C91.02 or C92.10 – C92.12

1 per month

81210 BRAF (v-raf murine sarcoma viral oncogene homolog B1) gene analysis, V600E variant


C18.0 – C18.9, C19, C20, C43.0 – C43.9, C79.2 or D03.0 – D03.9

Once-in-a-lifetime

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81211 BRCA1, BRCA2 gene analysis; full sequence analysis Continued below

Yes A TAR for code 81211 requires documentation of one or more of the following numbered criteria:

1. An individual from a family member with a known deleterious BRCA mutation; OR

2. Personal history of breast cancer plus one or more of the following:

Diagnosed at ≤ 45 years of age; OR

Diagnosed at ≤ 50 years of age with:

– An additional breast cancer primary – One or more close blood relatives with breast cancer at any age – One or more close blood relatives with pancreatic cancer – One or more close blood relatives with prostate cancer (Gleason score ≥ 7)

– An unknown or limited family history

Diagnosed at ≤ 60 years of age with a triple negative breast cancer

Diagnosed at any age with:

– One or more close blood relatives with breast cancer diagnosed at ≤ 50 years of age – Two or more close blood relatives with breast cancer at any age – One or more close blood relatives with invasive ovarian cancer – Two or more close blood relatives with pancreatic cancer and/or prostate cancer (Gleason score ≥ 7) at any age – A close male blood relative with breast cancer – For an individual of ethnicity associated with higher mutation frequency (for example, Ashkenazi Jewish), no additional family history may be required

Continued

Once-in-a-lifetime

See Attachment B - Quest Diagnostics BRCAvantage ® Patient and Family Clinical History Form which is suggested for use prior to ordering BRCA testing

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Continued from above 81211 BRCA1, BRCA2 gene analysis

Yes 3. Personal history of invasive ovarian cancer

4. Personal history of male breast cancer

5. Personal history of prostate cancer (Gleason score ≥ 7) at any age with one or more close blood relatives with breast cancer (≤ 50 years of age) and/or invasive ovarian and/or pancreatic or prostate cancer (Gleason score ≥ 7) at any age

6. Personal history of pancreatic cancer at any age with one or more close blood relative with breast cancer (≤ 50 years of age) and/or invasive ovarian and/or pancreatic cancer at any age

7. Personal history of pancreatic cancer and Ashkenazi Jewish ancestry.

8. For an individual without history of breast or ovarian cancer:

First or second degree blood relative meeting any of the above criteria

Third degree blood relative who has breast cancer and/or invasive ovarian cancer and who has two or more close blood relatives with breast cancer (at least one with breast cancer ≤ 50 years of age) and/or invasive ovarian cancer

Once-in-a-lifetime


81211 (Reflex BRCA1, BRCA2 gene analysis billed with modifier QP)

Yes A TAR for code 81211 billed with modifier QP requires documentation of the following:

A negative result in the single mutation (codes 81215 or 81217) or three-mutation (code 81212) analysis, and

One or more criteria listed under code 81211

Once-in-a-lifetime


81212 BRCA1, BRCA2 gene analysis; variants

Yes Requires documentation on the TAR of the following:

An individual is of an ethnicity associated with the Ashkenazi Jewish population

No additional family history may be required

Once-in-a-lifetime


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81213 BRCA1, BRCA2 gene analysis; uncommon duplication/deletion variants

Yes Requires documentation on the TAR of one or more criteria listed under CPT-4 code 81211

Once-in-a-lifetime


81215 BRCA1 (breast cancer 1) gene analysis; known familial variant

Yes Requires documentation on the TAR of family history of breast or ovarian cancer that includes a relative with a known deleterious BRCA mutation

Once-in-a-lifetime


81217 BRCA2 (breast cancer 2) gene analysis; known familial variant

Yes Requires documentation on the TAR of family history of breast or ovarian cancer that includes a relative with a known deleterious BRCA mutation

Once-in-a-lifetime


81220 CFTR (cystic fibrosis transmembrane conductance regulator) gene analysis; common variants

No When used to bill for cystic-fibrosis screening requires ICD-10-CM code Z31.430 or Z31.440

Not reimbursable with code 81224 for same date of service, recipient and provider

May be billed separately with an appropriate National Correct Coding Initiative (NCCI) associated modifier

Refer to the Genetic Counseling and Screening section in the Medi-Cal Manual for additional information

Once-in-a-lifetime

81221 Cystic Fibrosis known family variants

Yes Not a Medi-Cal covered benefit

Testing family members of those previously diagnosed with Cystic Fibrosis (CF)

Once-in-a-lifetime

TAR must be ordered by a medical geneticist with appropriate supporting documentation attached to be considered for authorization.

81222 Cystic Fibrosis Deletion/Duplication


Used to identify causal mutations when only a single common mutation or rare variant of CF are detected. (Previous tests with a screening assay for common mutations and variants followed by CFTR full gene sequence analysis revealed only heterozygosity –a single mutation)

Once-in-a-lifetime


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81223 Cystic Fibrosis Full Gene Sequencing


Used to identify rare mutations in individuals suspected of having CF but where only a single common mutation or variant has been identified

Once-in-a-lifetime


81225 CYP2C19 Gene common variants


The cytochrome P450 (CYP450) enzymes catalyze the oxidation of many drugs and chemicals. Individual differences of cytochrome P450 activity can result in total absence of metabolism of certain drugs to ultrafast metabolism of drugs. This can lead to adverse drug reactions or a lack of therapeutic effect under standard therapy conditions. CYP2C19 is a gene within the family of the CYP450 superfamily. It metabolizes 15% of all prescribed drugs, such as clopidogrel (Plavix).

Once-in-a-lifetime


81226 CYP2D6 Gene common variants


The cytochrome P450 (CYP450) enzymes catalyze the oxidation of many drugs and chemicals. Individual differences of cytochrome P450 activity can result in total absence of metabolism of certain drugs to ultrafast metabolism of drugs. This can lead to adverse drug reactions or a lack of therapeutic effect under standard therapy conditions. CYP2D6 is a gene within the family of the CYP450 superfamily. It metabolizes 25% of all prescribed drugs, such as codeine, tricyclic antidepressants, classical antipsychotics, and β-blockers. Specific variants in this gene also influence the metabolism of the breast cancer drug, tamoxifen, in postmenopausal women. Genetic variants of CYP2D6 can be used to predict the altered enzyme activity and address the potential effects of metabolized drugs.

Once-in-a-lifetime


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81227 CYP2C9 Gene common variants


The presence of certain variants in the CYP2C9 gene can result in poor metabolizer phenotypes that are associated with lack of enzyme activity and drugs may be metabolized slowly or not at all. This results in increased concentrations of the drug with a reduced or absent therapeutic response and the potential for serious side effects. Warfarin metabolism is reduced by 30% to 50% by the *2 variant and 90% by the *3 variant. Individuals with at least one copy of *2 or *3 have an increased risk of bleeding compared to individuals without *2 or *3. A lower maintenance dose may be required.

Once-in-a-lifetime


81228, 81229 Molecular Cytogenomic Testing

Continued below

Yes Not a Medi-Cal covered benefit.

Comparative genomic hybridization (CGH) is medically necessary for the following indications:

Evaluating fetuses with structural abnormalities detected on fetal ultrasound or fetal magnetic resonance imaging; or

For evaluating histologically equivocal Spitzoid melanocytic neoplasms (Spitz nevus and atypical Spitz tumors); or

Analyses of stillbirths with congenital anomalies or in stillbirths in which karyotype results cannot be obtained.

Continued

If for fetal evaluation, Once per pregnancy

If for child or adult

evaluation,

Once-in-a-lifetime

Although not a Medi-Cal covered benefit, PHC will consider TARs for these codes with appropriate supporting documentation attached. Claims without documentation showing the specified criteria have been met will be denied.

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Continued from above 81228, 81229 Molecular Cytogenomic Testing

Continued below

Yes CGH is medically necessary for diagnosing genetic abnormalities in children with developmental delay/intellectual disability (DD/ID) or autism spectrum disorder (ASD) according to accepted Diagnostic and Statistical Manual of Medical Disorders 5 (DSM 5) when all of the following criteria are met:

If warranted by the clinical situation, biochemical testing for metabolic diseases has been performed and is negative; and

Targeted genetic testing, (for example: FMR1 gene analysis for Fragile X), if or when indicated by the clinical and family history, is negative; and

The member's clinical presentation is not specific to a well-delineated genetic syndrome*; and

In addition to a diagnosis of DD/ID or ASD, the child has one or more of the following:

- Two or more major malformations, or

- A single major malformation or multiple minor malformations, in an infant or child who is also small-for-dates, or

- A single malformation and multiple minor malformations, and

- The results for the testing have the potential to impact the clinical management of the member.

* CGH is considered not medically necessary when a diagnosis of a disorder or syndrome is readily apparent based on clinical evaluation alone.

Continued



evaluation,

Once-in-a-lifetime


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Continued from above 81228, 81229

Yes Chromosomal microarray analysis is considered experimental and investigational in all other cases of suspected genetic abnormality in children with developmental delay/intellectual disability or autism spectrum disorder.

CGH is considered experimental and investigational for any other indications including the following (not an all-inclusive list) because of insufficient evidence of its effectiveness:

Detection of balanced rearrangements

Evaluation of autoimmune lymphoproliferative syndrome

Evaluation of unexplained epilepsies

Screening for prenatal gene mutations in fetuses without structural abnormalities, such as in advanced maternal age, positive maternal serum screen, previous trisomy, or the presence of "soft markers" on fetal ultrasound

Testing products of conception

Diagnosis of melanoma

Additional Criteria for Microarray: If not meeting above criteria and a medical geneticist believes it is necessary, he or she may submit specific justification to PHC for review.

Notes: The Oligo HD Scan is a type of array CGH. The CombiMatrix DNArray is a CGH test for developmental delay.



evaluation,

Once-in-a-lifetime


81235 EGFR (epidermal growth factor receptor) gene analysis, common variants


C33, C34.00 – C34.92

Once-in-a-lifetime

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81243 FMR1 (fragile X mental retardation 1) gene analysis; evaluation to detect abnormal alleles


F70, F71 – F73, F78, F80.0 – F89, H93.25, R48.0

Once-in-a-lifetime

81244 FMR1 (fragile X mental retardation 1) gene analysis; characterization of alleles


F70, F71 – F73, F78, F80.0 – F89, H93.25, R48.0

Once-in-a-lifetime

81250 G6PC (glucose-6-phosphatase, catalytic subunit) gene analysis, common variants

Yes The patient has clinical features suspicious for, or requires the laboratory service as a diagnostic test for glycogen storage disease,

type 1a

Once-in-a-lifetime

81256 HFE (hemochromatosis) gene analysis, common variants


E83.10, E83.110 or E83.118 – E83.119

Once-in-a-lifetime

81260 IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B-cells, kinas complex-associated protein) gene analysis, common variants

No Indicated for:

Hypotonia in infancy

Decreased or absent deep tendon reflexes

Decreased taste and absence of fungiform papillae of the tongue

Absence of overflow tears with emotional crying (alacrima)

Absence of axon flare response after intradermal histamine injection

Pupillary hypersensitivity to parasympathomimetic agents

Once-in-a-lifetime

While DHCS requires a TAR for this test, PHC has chosen to have no TAR requirement.

81265 Comparative analysis using Short Tandem Repeat markers


C81.00 – C96.9, D45, T86.00 – T86.09 or T86.5

Once-in-a-lifetime

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81266 Comparative analysis using Short Tandem Repeat markers; each additional specimen


C81.00 – C96.9, D45, T86.00 – T86.09 or T86.5

Once-in-a-lifetime

81267 Chimerism (engraftment) analysis, post transplantation specimen; without cell selection


T86.01, T86.02, T86.09 or T86.5

1 per month

81268 Chimerism (engraftment) analysis, post transplantation specimen; with cell selection


T86.01, T86.02, T86.09 or T86.5

1 per month

81270 JAK2 (Janus kinase 2) gene analysis, p. Val617Phe (V617F) variant


D45, D47.1 or D47.3

Once-in-a-lifetime

81275 KRAS (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) gene analysis, variants in codons 12 and 13


C18.0, C18.2 – C20, D01.1, D01.2, D01.40, D01.49, D37.4 or D37.5

Once-in-a-lifetime

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81280 Long QT syndrome gene analyses; full sequence analysis

Yes Not split-billable and must not be billed with modifier 26, 99 or TC

Document on the TAR a copy of the report of the physician-interpreted 12-lead electrocardiogram (ECG) with pattern consistent with or suspicious for prolonged QT interval, and clinical documentation of one or more of the following:

Torsade de pointes in the absence of drugs known to prolong QT interval

T-wave alternans

Notched T-wave in three leads

Syncope

Family members with LQTS

Sudden death in family members less than 30 years of age without defined cause

Once-in-a-lifetime

81281 Long QT syndrome gene analyses; known familial sequence variant

Yes Not split-billable and must not be billed with modifier 26, 99 or TC

Document on the TAR:

The family member being tested is a Medi-Cal recipient, and

There is clinical documentation of at least one first-degree relative (parent, sibling or offspring) with a laboratory-confirmed LQTS genetic mutation

Once-in-a-lifetime

81287

MGMT (0-6 methylguanin-DNA methyltransferase) methylation analysis

No Indicated for:

The patient has the diagnosis of glioblastoma multiforme, and

Treatment strategy will be contingent on the test results

Reimburseable when billed with ICD-10 : C71.9.

Once-in-a-lifetime,

any provider

While DHCS requires a TAR for this test, PHC has chosen to have no TAR requirement when billed with ICD-10 code C71.9

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81288 MLH1 gene analysis; promoter methylation analysis

Yes Document the following criteria on the TAR:

Patient with colon cancer, and

The tumor demonstrates microsatellite instability or immunohistochemistry results indicating loss of MLH1 protein expression

Once-in-a-lifetime

81291 MTHFR Methylenetetrahydrofolate Reductase, DNA Mutation Analysis

Yes Not a Medi-Cal covered benefit Once-in-a-lifetime


81292 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) gene analysis; full sequence analysis


C18.0, C18.2 – C18.9

Once-in-a-lifetime

PHC will also reimburse for these ICD-10 codes :

C54.1, C56.1 – C56.9, Z80.0

81293 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) gene analysis; known familial variants

Yes Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious MLH1 mutation

Once-in-a-lifetime

Prediction model calculator suggested for use prior to ordering Lynch syndrome testing:


81294 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) gene analysis; duplication/deletion variants

Yes Document on the TAR patient history of colon cancer and a negative result for MLH1 full sequence analysis

Once-in-a-lifetime

81295 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) gene analysis; full sequence analysis


C18.0 or C18.2 – C18.9

Once-in-a-lifetime


C54.1, C56.1 – C56.9, Z80.0

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81296 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) gene analysis; known familial variants

Yes Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious MSH2 mutation

Once-in-a-lifetime



81297 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) gene analysis; duplication/deletion variants

Yes Document on the TAR patient history of colon cancer and a negative result for MSH2 full sequence analysis

Once-in-a-lifetime

81298 MSH6 (mutS homolog 6 [E. coli]) gene analysis; full sequence analysis


C18.0 or C18.2 – C18.9

Once-in-a-lifetime


C54.1, C56.1 – C56.9, Z80.0

81299 MSH6 (mutS homolog 6 [E. coli]) gene analysis; known familial variants

Yes Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious MSH6 mutation

Once-in-a-lifetime



81300 MSH6 (mutS homolog 6 [E. coli]) gene analysis; duplication/deletion variants

Yes Document on the TAR patient history of colon cancer and a negative result for MSH6 full sequence analysis

Once-in-a-lifetime

81301 Microsatellite instability analysis of markers for mismatch repair deficiency


C18.0 or C18.2 – C18.9

Once-in-a-lifetime

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81315 PML/RAR-alpha (promyelocytic leukemia/retinoic acid receptor alpha) translocation analysis; common breakpoints


C92.40 – C92.42

1 per month

81316 PML/RAR-alpha (promyelocytic leukemia/retinoic acid receptor alpha) translocation analysis; single breakpoint


C92.40 – C92.42

1 per month

81317 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) gene analysis; full sequence analysis


C18.0 or C18.2 – C18.9

Once-in-a-lifetime

81318 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) gene analysis; known familial variants

Yes Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious PMS2 mutation

Once-in-a-lifetime



81319 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) gene analysis; duplication/deletion variants

Yes Document on the TAR patient history of colon cancer and a negative result for PMS2 full sequence analysis

Once-in-a-lifetime

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81321 PTEN (phosphatase and tensin homolog) gene analysis; full sequence analysis Continued below

Yes A TAR for CPT-4 code 81321 requires documentation of one or more of the following numbered criteria:

1. Individual with a personal history of:

Bannayan-Riley-Ruvalcaba syndrome, or

Adult Lhermitte-Duclos disease, or

Autism spectrum disorder AND macrocephaly, or

Two or more biopsy-proven trichilemmomas, or

Two or more major criteria (one macrocephaly), or

Three major criteria without macrocephaly, or

One major and three or more minor criteria, or

Four or more minor criteria (please see list below)

2. At-risk individual:

With a relative who has a clinical diagnosis of Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome for whom testing has not been performed AND who has any one major criterion or two minor criteria

(continued on next page)

Once-in-a-lifetime

Page 169 of 199






Continued from above

81321 PTEN gene analysis; full sequence analysis

Yes Major Criteria

Breast cancer

Mucocutaneous lesions

One biopsy-proven trichilemmoma

Multiple palmoplantar keratosis

Multifocal or extensive oral mucosal papillomatosis

Multiple cutaneous facial papules (often verrucous)

Macular pigmentation of glans penis

Macroencephaly (megalocephaly, ie, ≥97th percentile)

Endometrial cancer

Non-medullary thyroid cancer

Multiple GI tract hamartomas or ganglioneuromas

Minor Criteria

Other thyroid lesions (adenoma, nodule, goiter)

Mental retardation (IQ ≤75)

Autism spectrum disorder

Single GI tract hamartoma or ganglioneuroma

Fibrocystic disease of the breast

Lipomas

Fibromas

Renal cell carcinoma

Uterine fibroids

Once-in-a-lifetime

81322 PTEN gene analysis; known familial variant

Yes Requires documentation on the TAR that patient

is from a family with a known PTEN mutation

Once-in-a-lifetime

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81323 PTEN gene analysis; duplication/deletion variant

Yes Requires documentation on the TAR of a negative result in the full sequence analysis in PTEN (CPT-4 code 81321), and that patient meets one or more criteria listed under code 81321

Once-in-a-lifetime

81331 SNRPN/UBE3A methylation analysis

Yes Document the following age-specific criteria on the TAR

Birth to 2 years: Hypotonia with poor suck

2 – 6 years: Hypotonia with history of poor suck and global development delay

6 – 13 years: History of hypotonia with poor suck (hypotonia often persists); global development delay; and excessive eating (hyperphagia; obsession with food) with central obesity if uncontrolled

13 years – adult: Cognitive impairment – usually mild mental retardation; excessive eating (hyperphagia; obsession with food) with central obesity if uncontrolled; and hypothalamic hypogonadism and/or typical behavior problems (including temper tantrums and obsessive-compulsive features)

Once-in-a-lifetime

Human Leukocyte Antigen Typing 81370 - 81383

No TAR required

when CPT

codes listed are

billed

CPT-4 codes 81370 – 81380, 81382 and 81383 (human leukocyte antigen typing) are reimbursable only with an ICD-10-CM diagnosis in the range of Z01.812, Z01.89, Z48.21 – Z48.298, Z94.0 – Z94.9.

CPT-4 code 81381 (HLA Class I typing, high resolution, one allele or allele group) is only reimbursable with an ICD-10-CM diagnosis of B20, F31.0 – F31.9, G40.001 – G40.919, G50.0, R75, Z21, Z48.21 – Z48.298, Z94.0 – Z94.9

Once-in-a-lifetime

No payment will be made without diagnosis codes listed.

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81400 (Molecular Pathology Procedure, Level 1) Continued below

Yes Providers are required to document one of the following on the TAR:

Human Platelet Antigen genotyping:

- The patient has clinical features suspicious for, or requires the service as a confirmatory test for neonatal alloimmune thrombocytopenia, or,

- The patient has clinical features suspicious for, or requires services as a confirmatory test for post transfusion purpura

CCR5 (chemokine C-C motif receptor 5):

- Initial test:

The use of a CCR5 inhibitor is being considered, or

The patient exhibits virologic failure on a CCR5 inhibitor

- Subsequent tests:

A previous Trofile test was performed including the test date and the results showing that the recipient has a CCR5 virus, and,

The recipient’s previous Trofile test was not less than 90 days from subsequent request, and,

The recipient has clinical scenario such as, but not limited to the following:

The treatment with CCR5 antagonist drug therapy was interrupted and the clinician wishes to reinstitute CCR5 antagonist drug therapy, or,

Continued

Once-in-a-lifetime

Page 172 of 199






Continued from above 81400 (Molecular Pathology Procedure, Level 1)

Yes The recipient had a Trofile test performed previously that showed that the recipient had the CCR5 virus, but the CCR5 antagonist drug therapy was never initiated.

SMN1 (spinal muscular atrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinal muscular atrophy

IL28B

- The patient has genotype 1 hepatitis C virus infection, and,

- Treatment will be contingent on the test results.

Claims without documentation showing the preceding criteria have been met will be denied.

Once-in-a-lifetime


Yes Coverage for CPT-4 code 81401 (molecular pathology procedure, Level 2) is limited to the listed services. Reimbursement for code 81401 requires an approved TAR and requires providers to document one of the following on the TAR:

ABCC8 (familial hyperinsulinism):

- The patient has persistent hyperinsulinemic hypoglycemia of infancy (PHHI), failed medical therapy, and

- The patient is under evaluation for surgical intervention

Continued

Once-in-a-lifetime

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Continued from above 81401 (Molecular Pathology Procedure, Level 2) Continued below

Yes ABL (c-abl oncogene 1, receptor tyrosine kinase) – The patient has chronic myeloid leukemia (CML) and failed tyrosine kinase inhibitor (TKI) therapy

AR (spinal & bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinal and bulbar muscular atrophy or Kennedy disease

ATN1 (dentatorubral-pallidoluysian atrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for dentatorubral pallidoluysian atrophy

ATXN1 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia


ATXN3 (spinocerebellar ataxia, Machado-Joseph disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia


Continued

Once-in-a-lifetime

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Yes ATXN10 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

ATXN80S (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

CACNA1A (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

CNBP (myotonic dystrophy, type 2) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for myotonic dystrophy, type 2

CSTB (Unverricht-Lundborg disease):

The patient has clinical features suspicious for, or requires the service as a confirmatory test for myoclonic epilepsy type 1, and

Treatment will be contingent on test results

DMPK (dystrophia myotonica-protein kinase) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for myotonic dystrophy type 1

Continued

Once-in-a-lifetime

Page 175 of 199






Continued from above 81401 (molecular pathology procedure, Level 2) Continued below

Yes E2A/PBX1 (acute lymphocytic leukemia):

- The patient has the diagnosis of acute lymphocytic/lymphoblastic leukemia, and

- Treatment or monitoring strategy will be contingent on the test results

ETV6/RUNX1 (acute lymphocytic leukemia) –The patient has the diagnosis of acute lymphocytic or lymphoblastic leukemia, and requires the test for assessment of cancer prognosis

FXN (Friedreich ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Friedreich ataxia

H19 (Beckwith-Wiedemann syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Beckwith-Wiedemann syndrome

KCNQ1OT1 (Beckwith-Wiedemann syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Beckwith-Wiedemann syndrome

MLL/AFF1 (acute lymphoblastic leukemia):

- The patient has the diagnosis of acute lymphoblastic leukemia, and

Treatment or monitoring strategy will be contingent on the test results

Continued

Once-in-a-lifetime

Page 176 of 199







Yes MLL/MLLT3 (acute myeloid leukemia):

- The patient has the diagnosis of acute myeloid leukemia, and

- Treatment or monitoring strategy will be contingent on the test results

MUTYH (MYH-associated polyposis) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for MUTYH- associated polyposis

MT-ATP6 (neuropathy with ataxia and retinitis pigmentosa [NARP], Leigh syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for NARP or Leigh syndrome

PPP2R2B (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

PRSS1 (hereditary pancreatitis):

An unexplained documented episode of acute pancreatitis in childhood, or

Recurrent acute attacks of pancreatitis of unknown cause, or

Chronic pancreatitis of unknown cause, particularly with onset younger than 25 years of age, or

A family history of recurrent acute pancreatitis, chronic pancreatitis of unknown cause, and/or childhood pancreatitis of unknown cause consistent with autosomal dominant inheritance

Continued

Once-in-a-lifetime

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Yes PYGM (glycogen storage disease type V, McArdle disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease type V

RUNX1/RUNX1T1 (t[8;21]) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for acute myeloid leukemia

TBP (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia


Once-in-a-lifetime

81402 (Molecular Pathology Procedure, Level 3)


KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) – The patient has clinical features suspicious for, or requires the service as a diagnostic test for mastocytosis

Chromosome 1p-/19q- (e.g. glial tumors), deletion analysis – Patient with diagnosis of grade II, III or IV glioma


Once-in-a-lifetime

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DNMT3A (acute myeloid leukemia):

The patient has diagnosis of acute myeloid leukemia, and

The treatment strategy will be contingent on test results

EPCAM (Lynch syndrome) – The patient has colorectal cancer and/or Lynch syndrome

IDH1 – Patient with diagnosis of grade II, III or IV glioma

IDH2 – Patient with diagnosis of grade II, III or IV glioma

JAK 2 (Janus kinase 2) – The patient has clinical features suspicious for, or requires the service as a diagnostic test for myeloproliferative disorder

KCNC3 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

KCNJ11 (familial hyperinsulinism):

- The patient has persistent hyperinsulinemic hypoglycemia of infancy (PHHI) and failed medical therapy, and


Continued

Typically once-in-a-

lifetime unless there is a special

circumstance



Page 179 of 199








Yes KIR (killer cell immunoglobulin-like receptor for hematopoietic stem cell transplantation):

The patient has diagnosis of acute myeloid leukemia, and

The test is used for donor search process for patients considering hematopoietic stem cell transplantation

KRAS (Carcinoma), exon 3, codon 61:

The patient has colorectal cancer, and

The intention to treat or not to treat with anti-EGFR antibodies (cetuximab or panitumumab) will be contingent on the test results

MICA (solid organ transplantation):

The patient is undergoing evaluation for kidney transplantation, or

The patient is post kidney transplantation

MPL (myeloproliferative leukemia virus oncogene, thrombopoietin receptor, TPOR) – The patient has clinical features suspicious for, or requires the service as a diagnostic test for myeloproliferative disorder

NDP (Norrie disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Norrie disease

Continued



circumstance

Page 180 of 199







Yes SH2D1A (X-linked lymphoproliferative syndrome) – The patient is a male with the diagnosis of:

Common variable immune deficiency, or

Hypogammaglobulinemia, or

Hemophagocytic lymphohistiocytosis, or

Severe infectious mononucleosis, or

Lymphoma, or

Family history of X-linked lymphoproliferative syndrome

VHL (von Hippel-Lindau tumor suppressor), deletion/duplication analysis – The patient has clinical features suspicious for, or requires the service as a diagnostic test for von Hippel-Lindau syndrome




circumstance

Page 181 of 199







Yes Coverage for CPT-4 code 81404 (molecular pathology procedure Level 5) is limited to the listed services. Reimbursement for code 81404 requires an approved Treatment Authorization Request (TAR) and requires providers to document one of the following on the TAR:

ACADS (acyl-CoA dehydrogenase, C-2 to C-3 short chain), targeted sequence analysis:

The patient has elevated C4-C on newborn screening test, and

Confirmation (urine acylglycines or urine organic acids) that C4 (butyrylcarnitine) and/or ethylmalonic acid (EMA) are elevated

CD40LG (X-linked hyper IgM syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for hyperimmunoglobulin M syndromes

CSTB (Unverricht-Lundborg disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Unverricht-Lundborg disease

DMPK (dystrophia myotonica-protein kinase) – The patient has clinical features suspicious for, or requires the service as a diagnostic test for myotonic dystrophy

EMD (Emery-Dreifuss muscular dystrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Emery-Dreifuss muscular dystrophy

Continued



circumstance

Page 182 of 199







Yes EPM2A (progressive myoclonus epilepsy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for progressive myoclonus epilepsy

FHL1 (Emery-Dreifuss muscular dystrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Emery-Dreifuss muscular dystrophy

FXN (Friedreich ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Friedreich ataxia

NDP (Norrie disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Norrie disease

PRNP (genetic prion disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for genetic prion disease

PRSS1 (hereditary pancreatitis):

An unexplained documented episode of acute pancreatitis in childhood, or

Recurrent acute attacks of pancreatitis of unknown cause, or

Chronic pancreatitis of unknown cause, particularly with onset younger than 25 years of age, or

A family history of recurrent acute pancreatitis, chronic pancreatitis of unknown cause, and/or childhood pancreatitis of unknown cause consistent with autosomal dominant inheritance

Continued



circumstance

Page 183 of 199







Yes RET (ret proto-oncogen), common variants

The patient has a personal history of primary C cell hyperplasia, Medullary Thyroid Carcinoma (MTC), or Multiple Endocrine Neoplasia (MEN), type 2B, or

The patient has a family history consistent with MEN, type 2B or MTC, and at risk for autosomal dominant inheritance of the syndrome

SH2D1A (X-linked lymphoproliferative syndrome) – The patient is a male with the diagnosis of:

Common variable immune deficiency, or

Hypogammaglobulinemia, or

Hemophagocytic lymphohistiocytosis, or

Severe infectious mononucleosis, or

Lymphoma, or

Family history of X-linked lymphoproliferative syndrome

SPINK1 (hereditary pancreatitis):

- An unexplained documented episode of acute pancreatitis in childhood, or

- Recurrent acute attacks of pancreatitis of unknown cause, or

- Chronic pancreatitis of unknown cause, particularly with onset younger than 25 years of age, or

- A family history of recurrent acute pancreatitis, chronic pancreatitis of unknown cause, and/or childhood pancreatitis of unknown cause consistent with autosomal dominant inheritance




circumstance

Page 184 of 199







Yes Coverage for CPT-4 code 81405 (molecular pathology procedure, level 6) is limited to the listed services. Reimbursement for code 81405 requires an approved TAR and requires providers to document one of the following on the TAR:

ABCD1 (adrenoleukodystrophy):

The patient has clinical features suspicious for adrenoleukodystrophy, and

Measurement of plasma concentration of very long chain fatty acids (VLCFA) is inconclusive, and

The service is required as a confirmatory test for the diagnosis of adrenoleukodystrophy

ACADS (acyl-CoA dehydrogenase, C-2 to C-3 short chain), full gene sequence:

The patient has elevated C4-C on newborn screening test, and

Confirmation (urine acylglycines or urine organic acids) that C4 (butyrylcarnitine) and/or ethylmalonic acid (EMA) are elevated

EMD (Emery-Dreifuss muscular dystrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Emery-Dreifuss muscular dystrophy

GLA (galactosidase alpha [for example, Fabry disease]), full gene sequence:

The patient has a family member with documented disease-causing mutation, and

Continued

Once-in-a-lifetime

Page 185 of 199








Yes

The decision whether to initiate enzyme replacement therapy will be contingent on the results

LAMP2 (Danon disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease IIb (Danon disease)

NF2 (neurofibromatosis, type 2):

The patient has clinical features suspicious for, or requires the service as a confirmatory test for type 2 neurofibromatosis, OR

The patient is at high risk for neurofibromatosis with one or more of the following:

A first-degree relative with type 2 neurofibromatosis

Multiple spinal tumors (schwannomas, meningiomas)

Cutaneous schwannomas

Sporadic vestibular schwannoma younger than 30 years of age, or spinal tumor or meningioma younger than 20 years of age

NPHS2 (steroid resistant nephrotic syndrome [SRNS])

- The patient has clinical diagnosis of SRNS, and

- Treatment will be contingent on the test results

Continued

Once-in-a-lifetime

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Yes OTC (ornithine transcarbamylase deficiency) – The patient has clinical signs and symptoms of urea cycle disorders with positive biochemical laboratory results and requires the service as a confirmatory test for ornithine transcarbamylase deficiency

RET (multiple endocrine neoplasia [MEN], type 2A and familial medullary thyroid carcinoma [MTC]) – exons 10, 11, 13 – 16:

The patient has a personal history of MTC, or MEN, type 2A, or

The patient has pheochromocytoma and a family history of MTC or pheochromocytoma, or

The patient has sporadic MEN2-related tumors and is younger than 35 years of age, multicentric tumors in one organ, and/or two different organs affected, or

The patient has a family history consistent with MEN, type 2A

RET (ret proto-oncogen), targeted sequence analysis:

The patient has a personal history of primary C cell hyperplasie, MTC, or MEN, type 2A, or

The patient has a family history consistent with MEN, type 2A or MTC, and at risk for autosomal dominant inheritance of the syndrome

SLC2A1 (glucose transporter type 1 [GLUT 1] deficiency syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for GLUT 1 deficiency syndrome

Continued

Once-in-a-lifetime

Page 187 of 199







Yes SMN1 (spinal muscular atrophy) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinal muscular atrophy

SPRED1 (Legius syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Legius syndrome

TCF4 (Pitt-Hopkins syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Pitt-Hopkins syndrome


Once-in-a-lifetime



ACADVL (very long chain acyl-coenzyme A dehydrogenase deficiency) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for ACADVL

AFG3L2 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

ATP7B (Wilson disease):

- The patient has clinical features suspicious for Wilson disease, and

Continued

Once-in-a-lifetime

Page 188 of 199








Yes - Diagnosis cannot be made based on the results of biochemical testing and liver biopsy, and

- The patient requires the service as a confirmatory test for Wilson disease

BTK (X-linked agammaglobulinemia):

- The male patient has clinical features suspicious for X-linked agammaglobulinemia, and

The male patient has less than two percent CD19+ B cells

CDH1 (hereditary diffuse gastric cancer):

Two gastric cancer cases in family, one confirmed diffuse gastric cancer younger than 50 years of age, or

Three confirmed diffuse gastric cancer cases in first or second degree relatives, regardless of age, or

Diffuse gastric cancer diagnosed younger than 40 years of age, or

Personal or family history of diffuse gastric cancer and lobular breast cancer, one diagnosed younger than 50 years of age

CNTNAP2 (Pitt-Hopkins-like syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Pitt-Hopkins syndrome

GLUD1 (familial hyperinsulinism):

The patient has persistent hyperinsulinemic hypoglycemia of infancy (PHHI) and failed medical therapy, and

The patient is under evaluation for surgical intervention

Continued

Once-in-a-lifetime

Page 189 of 199








Yes JAG1 (Alagille syndrome) – duplication/deletion – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Alagille syndrome

MUTYH (MYH-associated polyposis) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for MUTYH-associated polyposis

NF2 (neurofibromatosis, type 2):

The patient has clinical features suspicious for, or requires the service as a confirmatory test for type 2 neurofibromatosis, or

The patient is at high risk for neurofibromatosis with one or more of the following

A first-degree relative with type 2 neurofibromatosis

Multiple spinal tumors (schwannomas, meningiomas)

Cutaneous schwannomas

Sporadic vestibular schwannoma younger than 30 years of age, or spinal tumor or meningioma younger than 20 years of age

PRKCG (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

PYGM (glycogen storage disease type V, McArdle disease) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease type V (McArdle disease)

Continued

Once-in-a-lifetime

Page 190 of 199








Yes SCNN1A (pseudohypoaldosteronism) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for pseudohypoaldosteronism

SCNN1B (Liddle syndrome, pseudohypoaldosteronism) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Liddle syndrome, pseudohypoaldosteronism

SCNN1G (Liddle syndrome, pseudohypoaldosteronism) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Liddle syndrome, pseudohypoaldosteronism

SLC37A4 (glycogen storage disease, type Ib) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease, type Ib

TCF4 (Pitt-Hopkins syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Pitt-Hopkins syndrome

UMOD (glomerulocystic kidney disease with hyperuricemia and isosthenuria) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glomerulocystic kidney disease with hyperuricemia and isosthenuria

WAS (Wiskott-Aldrich syndrome) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Wiskott-Aldrich syndrome


Once-in-a-lifetime

Page 191 of 199








ABCC8 (familial hyperinsulinism):

- The patient has persistent hyperinsulinemic hypoglycemia of infancy (PHHI) who failed medical therapy, and


AGL (glycogen storage disease type III) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease type III

JAG1 (Alagille syndrome) – full gene sequence – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Alagille syndrome

NPHS1 (congenital Finnish nephrosis)

- The patient has clinical diagnosis of steroid-resistant nephritic syndrome (SRNS)/congenital Finnish nephrosis, and

- Treatment will be contingent on the test results

SPTBN2 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocrebellar ataxia


Once-in-a-lifetime

Page 192 of 199







Yes Coverage for CPT-4 code 81408 (molecular pathology procedure, Level 9) is limited to the listed services. Reimbursement for code 81408 requires an approved Treatment Authorization Request (TAR) and requires providers to document one of the following on the TAR:

ITPR1 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia

Once-in-a-lifetime

81409 - 81471

Yes Not a Medi-Cal covered benefit Once-in-a-lifetime


Genomic Sequencing Procedures and Other Molecular Multianalyte Assays 81435, 81436

No TAR required

when CPT

codes listed are

billed

Reimbursement for CPT-4 codes 81435 (hereditary colon cancer syndromes; genomic sequence analysis panel, must include analysis of at least seven genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and PMS2) and 81436 (…duplication/deletion gene analysis panel, must include analysis of at least eight genes, including APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, and MUTYH) is limited to once-in-a-lifetime with Treatment Authorization Request (TAR). Codes 81435 and 81436 are reimbursable only when billed in conjunction with one of the following ICD-10-CM diagnosis codes:

C18.0 C18.6 Z80.0

C18.2 C18.7 Z85.030 – Z85.038

C18.3 C18.8 Z85.040 – Z85.048

C18.4 C18.9 Z86.010

C18.5 C19

Once-in-a-lifetime

While DHCS requires a TAR for this test, PHC has chosen to have no TAR requirement.

Page 193 of 199






Testing for Telomerase Reverse Transcriptase (TERT) 81479

Yes Testing for Telomerase Reverse Transcriptase (TERT) gene in patients with glioma may be billed using CPT-4 code 81479 (unlisted molecular pathology procedure). A TAR is required. A TAR for the test requires documentation that the patient has the diagnosis of grade II, III or IV glioma.

Once-in-a-lifetime

Multianalyte Assays With Algorithmic Analyses 81500, 81503, 81506 – 81512 (Note: These are biochemical tests, not genetic tests)

No

CPT-4 codes 81500, 81503, 81506 – 81512 encompass all analytical services required in addition to the algorithmic analysis itself.

Codes 81500, 81503 and 81507 – 81512 are reimbursable for females only.

Reimbursement for code 81507 is limited to once a year, any provider.


lifetime unless

otherwise noted

Multianalyte Assays With Algorithmic Analyses 81519 Genetic Test

No

Providers must document that all of the following criteria of early stage breast cancer have been met for reimbursement of CPT-4 code 81519 (oncology, mRNA, gene expression profiling by real time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score).

This once-in-a-lifetime benefit may be billed more than once for the same recipient if the provider can prove via documentation that the recipient has a new second primary breast cancer that meets the necessary criteria listed above.

As noted No TAR required for CPT-4 code 81519 billed with ICD-10 code C50

Karyotype (aka Cytogenetic Studies) 88261 – 88269 88280

No Karyotype testing for codes 88261-3 may be ordered once in a lifetime in children with phenotype of syndrome most commonly associated with a chromosomal abnormality.

For perinatal indication, see Medi-Cal guidelines in the Genetic Counseling and Screening section gene coun 2.

Once-in-a-lifetime

Page 194 of 199

MCUP3131 Attachment B

Page 195 of 199


POLICY / PROCEDURE

I:\QUALITY\QI Assistant\QUAC\2016 Meetings\6.15.2016\Presentations_Reports\MCUP3131 06-15-16 changed after IQI.docx Page 1 of 4


Policy/Procedure Title: Genetic Testing ☒External Policy ☐ Internal Policy

Original Date: 08/19/2015 Next Review Date: 11/18/201606/15/2017 Last Review Date: 11/18/201506/15/2016


Reviewing Entities:

☒ IQI ☐ P & T ☒ QUAC ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving Entities:





II. IMPACTED DEPTS:

A. Health Services B. Claims C. Member Services

III. DEFINITIONS:

A. N/A

IV. ATTACHMENTS: A. N/AGenetic Testing Requirements A.B. Quest Diagnostics BRCAvantage ® Patient and Family Clinical History Form

V. PURPOSE: To provide criteria for medical necessity and benefit coverage of genetic testing. Genetic testing is a rapidly expanding aspect of medical care which can be useful for diagnosing disease, guiding treatment, and/or identifying possible genetic risks for development of disease. Given the rapid evolution of this field, it is impossible to establish guidelines to reliably inform when genetic testing is appropriate which will remain valid for a significant time frame. Therefore, the purpose of this policy is to describe the criteria for evaluating requests for genetic testing, and to cite the external professional resources on which we will rely to make coverage determination.


A. Genetic testing generally aims to achieve one of the following goals: 1. Confirm the diagnosis of a genetic disease 2. Identify genetic factors which significantly increase an individual’s risk for developing a disease 3. Determine whether a high-risk couple’s genetic makeup increases the risk of their children having a

genetic disease 4. Help determine prognosis, effectiveness of various treatment options, and guide management of

appropriate diseases 5. Prenatal or newborn genetic testing to identify diseases in high-risk situations

B. Partnership HealthPlan of California’s (PHC’s) intent is to follow National Comprehensive Cancer

Network (NCCN) guidelines. Ddecisions about which genetic tests to approve will rely on the most up-

Page 196 of 199


Policy/Procedure Title: Genetic Testing ☒ External Policy ☐ Internal Policy




to-date recommendations provided by the Centers for Disease Control and Prevention, the National Comprehensive Cancer Network, and the American College of Medical Genetics and Genomics. See Section VII. for URLs for these guidelines.

C. A Treatment Authorization Request (TAR) is required for certain genetic testing as outlined in Attachment A. Please note PHC requirements may differ from California Department of Health Care Services (DHCS) Requirements. Please use PHC’s grid entitled Genetic Testing Requirements (Attachment A) for PHC members. When a TAR is required, mMedical necessity will be determined upon TAR submission and the following factors will be considered for genetic testing requests: 1. A definitive diagnosis cannot be made without performing the genetic test being requested AND the

results of the genetic testing will influence the treatment or medical management of the patient. 2. There are identifiable reasons to perform the genetic tests being requested, including a relevant

family history or the presence of a clinical condition which suggests a genetic component is relevant to diagnosis or management.

3. Genetic testing is needed to help guide family planning decisions. 4. The accuracy of the test has been established, with low proportions of false positive and false

negative results. 5. If a common single gene test is likely to be the cause of the genetic issue in question, a multi-gene

test will not be approved until after the single gene test result is negative. 6. In performing genetic testing of parents to determine risk of an autosomal recessive disease in their

offspring, one parent will be tested initially. The other parent will only be tested if the first parent’s test indicates the genetic abnormality is present.

7. The test will be ordered by a clinician who has familiarity with the genetic testing being requested and who has the appropriate expertise to understand the implications of the test and how to follow-up the results.

8. Testing for any specific gene mutation will only be approved once for the lifetime of any individual person.

9. Non-disease specific gene panel testing will not be approved (e.g. ancestral testing). 10. Testing solely for the purposes of determining paternity or familial relationships will not be

approved. 11. Genetic testing needed for forensic purposes is not covered. 12. Genetic testing will not be approved if the results or outcome may pose a harm to the individual. 13. Genetic testing will not be approved if the only purpose for ordering the testing is one of the

following: a. As part of a research project b. For general screening purposes where there are no high-risk factors indicating that genetic

testing may be useful c. Where the results of the genetic testing have no therapeutic or medical management

implications. 14. If expert guidance is not available to validate the appropriateness of a particular genetic test, we

reserve the right to request the patient see a geneticist prior to approving the test.

D. Certain genetic tests are not covered by PHC. However, if ordered by a medical geneticist with appropriate supporting documents attached to the TAR, the request will be considered on an individual basis.

E. If Quest Diagnostics is to be used for BRCA testing, it is recommended that the Provider first complete the Quest Diagnostics BRCAvantage ® Patient and Family Clinical History Form (see Attachment B).

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F. For genetic tests related to pregnancy and newborns, please refer to Medi-Cal guidelines in the Genetic Counseling and Screening section gene coun 1 – 7.

VII. REFERENCES: A. The Centers for Disease Control and Prevention: http://www.cdc.gov/genomics/gtesting/tier.htm. B. The National Comprehensive Cancer Network:

http://www.nccn.org/professionals/physician_gls/f_guidelines.asp C. The American College of Medical Genetics and Genomics:


D. Medi-Cal Guidelines (path molec, gene coun) Lynch Syndrome PREMM1,2,6 Model: Prediction Model for MLH1, MSH2, and MSH6 Gene

Mutations: C.E. http://premm.dfci.harvard.edu/ Kastrinos F, Steyerberg EW, Mercado R, Balmaña J, Holter S,

Gallinger S, Siegmund KD, Church JM, Jenkins MA, Lindor NM, Thibodeau SN, Burbidge LA, Wenstrup RJ, Syngal S. The PREMM(1,2,6) model predicts risk of MLH1, MSH2, and MSH6 germline mutations based on cancer history. Gastroenterology. 2011;140:73–81. doi: 10.1053/j.gastro.2010.08.021.

VIII. DISTRIBUTION: A. PHC Departmental Directors B. PHC Provider Manual


X. REVISION DATES:

8/19/15; 11/18/15; 06/15/16 PREVIOUSLY APPLIED TO: MCUP3108 BRCA - Gene Sequence Analysis was archived 08/19/2015

********************************* In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:

• Consistent with sound clinical principles and processes • Evaluated and updated at least annually • If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be


The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits

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http://www.cdc.gov/genomics/gtesting/tier.htm










covered under PHC.

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