AGENDA - SFHP

Quality Improvement Committee Meeting

Thursday, August 10, 2017 7:30 – 9:00 AM

50 Beale Street, 13th Floor

https://global.gotomeeting.com/join/200002965 You can also dial in using your phone.

United States: +1 (646) 749-3112 Access Code: 200-002-965

AGENDA

Quality Improvement Committee: Open Session Time Topic Objective Assigned

7:30 Follow Up Items (5 min) Update Dr. Glauber

QIC: quorum: 5 QIC members, 3 physicians, including committee chair • Public Comments/Questions • Follow Up Items (p. 2)

o No Follow Up Items in June 2017

•

7:35 Consent Calendar (5 min) Update / Vote Dr. Glauber

• Review of Minutes – June 8, 2017 (p. 3) • Membership Report – July 2017 (p. 13) • Q1 2017 Emergency Room Visit/Prescription

Access Report (p. 19) • Utilization Management Committee Minutes

o May 2017 (p. 22) • Pharmacy & Therapeutics Committee Minutes

o April 2017 (p. 28) • Policies and Procedures

o QI-13: Disease Management (p. 42) o QI-09: Clinical Practice Guidelines

(p. 48) o Pharmacy P&Ps Updates and

Monitoring (p. 52) o Pharm-01: Pharmacy and

Therapeutics Committee (p. 54) o Pharm-02: Pharmacy Prior

Authorization (p. 58)

Vote

7:40 Quality Improvement (80 minutes)

• Pharm-14: Pharmacy Drug Utilization Review (DUR) Program – 10 min. (p. 65)

• QI-06: Member Grievances and Appeals – 10 min. (p. 72)

• HEDIS Results - 20 min. (p. 133) • CAHPS Results - 20 min. (p. 143) • Disease Management Program Update –

15 min. (p. 156) o Disease Management Clinical Practice

Guidelines – 5 min. (p. 161)

Update Update Update Update Update Vote

L. Ghotbi J. Soos E. Sekera S. Weis E. Ratliff/ F. Donald

9:00 PAC

NEXT MEETING THURSDAY, OCTOBER 12, 2017 1

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QIC Meeting Date Follow Up Item Owner Complete By Comments

February 2017Update the Pharmacy Authorizations graph to reflect the correct number of authorizations in Q3 K. McDonald 4/6/17 Completed

The number of authorizations in Q3 are correct. Kirk will reformat the graph so that it is clearer.

February 2017Present an annual review for medical and pharmacy appeals in the next QIC meeting K. McDonald 4/6/17 Completed

Kirk will present the Medical and Pharmacy Appeals Annual Review in the next QIC meeting on April 6, 2017.

February 2017 Provide the committee with the number of completed FSRs in 2016 J. Hagg 4/6/17 CompletedThere was a total of 23 Facility Site Reviews and 23 Medical Record Reviews in 2016.

February 2017 Provide an update on the status of open CAPS in the next QIC meeting O. Leon 4/6/17 CompletedOdalis will provide an update on the status of open Corrective Action Plans in the next QIC meeting on April 6, 2017.

February 2017Include grievance rate across California Medi-Cal health plans in future Grievance Reports. A. Sharma 6/8/17 Completed

The grievance rate across California Medi-Cal health plans are included in the Grievance Report.

April 2017 Include an agenda item on non-specialty mental health in the June QIC meeting. G. Dadios 6/8/17 CompletedGrace included an agenda item on non-specialty mental health and incorporated the documents in the QIC packet.

April 2017 Present year to date Facility Site Review data in the June QIC meeting. J. Hagg 6/8/17 Completed Jackie to present year to date Facility Site Review data in the next QIC meeting on June 8, 2017.

Quality Improvement Committee Follow Up List

2

Quality Improvement Committee Minutes

1 | P a g e

Date: June 8, 2017 Meeting Place: San Francisco Health Plan, 50 Beale Street 13th floor, San Francisco, CA 94105 Meeting Time: 7:30AM - 9:00AM Members Present: Ellen Chen, MD; Irene Conway; Lukejohn Day, MD; Edward Evans; Shawna Lamb; Dennis McIntyre, MD;

Jaime Ruiz, MD; Kenneth Tai, MD; Joseph Woo, MD; James Glauber, MD, MPH Staff Present: Grace Dadios, MPH; Lisa Ghotbi, PharmD; Courtney Gray, MSW; Vanessa Pratt; Jose Mendez; Eloyscia

Ratliff, MPH; Keira Truong, Pharm. D; Jim Soos Members Absent: Edwin Batongbacal; Jeanette Cavano, PharmD; Jeffrey Critchfield, MD; Todd May, MD; Ana Valdes, MD

Topic Discussion [including Identification of Quality Issue]

Follow-up [if Quality Issue identified, Include Corrective Action]

Resolution, or Closed Date [for Quality Issue, add plan

for Tracking after Resolution]

Call to Order • Meeting was called to order at 7:30AM with a quorum. • No public comments or questions.

• No follow up needed. • n/a

Follow Up Items

Follow-Up Items from April 2017 • Include an agenda item on non-specialty mental health in

the June QIC meeting. • Present year to date Facility Site Review data in the June

QIC meeting. Jim Glauber, Chief Medical Officer, provided a few updates: • San Francisco Health Plan (SFHP) is accepting

applications for the Strategic Use of Reserves (SUR) program until mid-June and is scheduled to distribute the funds at the end of the month.

• SFHP recently completed and successfully passed the

• No follow up needed. • n/a

3

National Commission for Quality Assurance (NCQA) mock survey. This is one indicator of the likelihood that SFHP will receive NCQA initial accreditation in October during the actual survey. SFHP currently has interim accreditation.

• Keira Truong, SFHP’s current Pharmacy resident, will be completing her residency on June 30th. Two new pharmacy residents will begin on July 3rd.

• The Teladoc program and benefit went live on June 1st with the first Teladoc visit occurring on June 7th. Member education materials will be sent in weekly waves, with 20,000 members per wave.

Consent Calendar

• Review of Minutes – April 6, 2017 • Membership Report – May 2017 • Health Services Update

o SFHP added local specialty pharmacies, HealthRight 360, Mission Wellness Pharmacy, and North East Medical Services, to the network. USBioservices is supporting these local specialty pharmacies with transition and back-up as needed.

o The HEDIS rates will be presented to QIC in August and to the Governing Board in September.

• P&T Minutes o January 2017

• UM Committee Minutes o February 2017 o March 2017 o April 2017

• Q4 Emergency Room Prescription Access Report o San Francisco now only has one 24-hour

pharmacy (Walgreens – 498 Castro) as opposed to three. SFHP will closely monitor the data in the

Approved: • Review of minutes –

April 6, 2017 • Membership Report –

May 2017 • P&T Minutes – January

2017 • UM Committee Minute

– February, March, April 2017

• Q4 Emergency Room Prescription Access Report

• Q1 2017 PQI Report • Q1 2017 Grievance and

Appeals Report • Facility Site Review

Results – Year to Date

4

report to see if there are any significant changes due to this network change.

o The closures were due to the high operational costs of a 24-hour pharmacy.

• Q1 2017 PQI Report • Q1 2017 Grievance and Appeals Report

o SFHP’s 2015 grievance rate is similar to the Department of Healthcare Services’ (DHCS) 2015 grievance rate, with 2.23 and 2.40 respectively. In 2016, SFHP’s rate was 2.17 while DHCS’ rate was 2.40.

o DHCS does not report the number of grievances that were resolved in 30 days.

• Facility Site Review Results – Year to Date

The consent calendar was unanimously approved.

Quality Improvement

CARE-04 Complex Care Management Courtney Gray, Director of Care Management, presented the revisions of P & P CARE-04 Complex Care Management (CCM). CARE-04 was revised to reflect the Care Management Department reorganization. • Updates to the policy include:

• Streamlining the Care Management process; • Clarifying CCM staffing and defining staff

responsibilities; Core staffing of the program include a

Care Management Community Coordinator, a licensed social worker, and a registered nurse. In addition, the program works closely with SFHP’s Pharmacy team as well as with Beacon for

Approved: CARE-04 Complex Care Management

5

behavioral health. A clinician is also highly involved in cases and helps connect members to resources.

• Defining program oversight and documentation. • The Care Management programs have seen a 60%

success rate in targeted member engagement. Engagement is defined as members’ consenting to be in the program and starting the initial assessment.

• Per NCQA, SFHP has 30 days to outreach to members about the program compared to previously having three months for outreach.

• In July 2017, Care Management will be reengaging members who they have not been able to contact for several weeks due to members being non-responsive. There are protocols in place about the

duration of outreach and what activities should be conducted during that time.

Care Management will start tracking the reengagement rate.

• Across all programs, the percentage of members that are homeless and are experiencing substance abuse is approximately 50-60%.

• The department overall has a caseload of 450. • The structure of the program is in line with the Health

Homes program. SFHP will work with interested community based partners to provide Health Homes services. For members that are not in a Health Homes-participating medical group, our internal CCM program will serve as the member’s Health Homes provider.

• In order to reduce program overlap, SFHP uses Care and Case Management Services (CCMS), a city-run platform that contains information on different case management

6

programs. In addition, SFHP connects with the members to learn what programs they are engaged in.

• Before outreaching to a member, SFHP conducts research on the member to discover what needs are being met and to understand what support is needed.

• The hospitals implemented PreManage ED, a platform that notifies ED providers in real-time when their patients are admitted to and discharged from inpatient care or have emergency visits.

• In regards to sharing CCM eligibility criteria with the Delegated Medical Groups, SFHP will be releasing a memo that outlines program criteria and how to refer patients into the program.

• Annual satisfaction surveys are conducted across all programs. The data is analyzed to measure success and assess what program areas can be improved.

Q1 QI Scorecard Vanessa Pratt, Manager, Population Health presented the Quarter 1 Quality Improvement Scorecard. A few measures from the Scorecard were highlighted including: • SFHP is performing lower in the influenza vaccine

measure this year compared to last year (13.41 and 16.4% respectively). This may be due to a harsher flu season in 2015. SFHP is conducting more outreach on the benefits of flu vaccines via member and provider newsletters.

• Pharmacists receive administrative funding from MediCal to administer flu vaccines. SFHP is currently collecting data on which pharmacies have adopted this and which identify which are performing well.

• Pharmacies are to enter vaccination administrations into the California Immunization Registry (CAIR), but there

Approved: Q1 QI Scorecard

7

have been issues with registering new pharmacies which negatively impacts the quality of this data.

• The committee discussed that because the majority of people qualify for a flu vaccine, the cost of an incentive program would be significant and administratively burdensome.

• Ninety-one percent of grievances and appeals were resolved in a timely manner.

• The turnaround time (TAT) for grievances that do not present a safety issue is 30 days. For expedited grievances, the TAT is 72 hours.

• Pharmacy Point of Sales (POS) Claim Rejection Rate is a new measure in the 2017 QI Workplan. SFHP had a 19.5% claim rejection rate which represents a 7% relative decrease from the 2016 baseline of 21% after just one quarter of improvement activities. The goal is a 10% decrease to 18.9%.

• Potential Quality Issues (PQI) is also a new measure to QI Workplan. 100% of PQIs were resolved in a timely manner in the first quarter of measurement.

• The TAT standard for PQIs is 45 days. • SFHP created this standard which is not mandated

by DHCS or DHMC.

Pain Program Update Eloyscia Ratliff, Project Manager, Disease Management, presented the Pain Management Program Update. • Staff Provider Training: “Pain Day 5.0”

• The training is scheduled for Wednesday, September 20, 2017.

• The morning session will include a member and provider panel.

8

• The afternoon session will be for providers only. • SFHP relaunched the ongoing online provider training in

March 2017. • Developed by the San Francisco Safety Net Pain

Management Workgroup, San Francisco Health Plan, and Quality Healthcare Concepts, the training is an online learning experience on acute pain management.

• SFHP is continuing to outreach to providers and to those interested. Free CME credits are given to providers for completing the course.

• The new Pain Management website will be launched at the end of June.

• The results of the National Safety Net Health Plan Benchmarking study for opiate use (ACAP) will be released in the fall.

• These results will provide SFHP with information on high dose opiate use in health plan populations comparable to SFHP.

• There is a proposed HEDIS measure for opiate use looking at both chronic high dose use and members receiving opiates from multiple pharmacies and prescribers.

• The committee discussed the importance of activities such as exercise, massage, yoga, and other non-medication modalities for treating pain. The Centers for Disease Control and Prevention (CDC) guidelines emphasize that the focus should be on people’s function and not on treating pain.

• The committee discussed the member-reported anecdotal long wait time for an appointment with a physical therapist. A referral to a physical therapist is also dependent on the primary care

9

provider. • Regarding the percentage of members that get an opiate

prescription, SFHP has seen a 45% reduction per member per month over the past three years.

• The committee discussed that discontinuing members’ opiate prescriptions may lead to members buying opiates through illegal sources. SFHP has processed a few grievances in which illicit supply was asserted by the member.

• The focus has shifted on acute pain management and trying to further reduce the number of people that get an opiate prescription and reducing the amount of medication in the first prescription.

• SFHP’s formulary removed a few pain medications including methadone and phenergan with codeine cough syrup.

• Pharmacy will be conducting an analysis on the dose and day-supply of the first opiate prescription and seeing how many of these members received subsequent refills.

• The committee discussed that activities that are beneficial to health are not always medically necessary and thus are not a covered benefit.

• Opiate use and data will be discussed in future QIC meetings.

Behavioral Health Update: Jim Glauber presented the Behavioral Health Update. • SFHP contracts with Beacon to provide non-specialty

mental health (NSMH) services to our members while the County provides specialty mental health.

• Highlights from the presentation include:

10

• In 2013, the percentage of the San Francisco population that has a specialty mental illness (SMI) is 6.95% while statewide the percentage is 7.69%.

• Currently the County is serving a high percentage of members that fall into the NSMH category.

• SFHP’s 12 month penetration rate for children is very low and not increasing.

• The County is serving approximately 10% of children and a majority of these children likely do not have a serious mental illness.

• Although children are getting services, the services may best be provided by the entity being funded to provide the benefit.

• There has been a significant improvement in the adult penetration rate but is starting to level off.

• As of December 2016, SFHP’s penetration rate is 2.39%.

• In January 2015, SFHP’s penetration rate was 0.58%.

• According to Dr. Kenneth Tai, Northeast Medical Services (NEMS) have begun to analyze their penetration rate and results show an 8% penetration rate. They are working closely with the County to transition members who are in the NSMH category back to NEMS.

• SFHP will discuss NSMH and SMI trend data with the County as well as discuss issues of transitioning pediatric cases from the County benefit to Beacon at the SFHP, SFHN, and Beacon Quarterly Join Operating Committee meeting on Friday, June 9.

• The committee discussed a few barriers to providing behavioral health services including the lack of bilingual

11

QI Committee Chair's Signature & Date: ____________________6/28/17__ Minutes are considered final only with approval by the QIC at its next meeting.

providers, operational challenges such as billing, and members with SMI not being able to obtain services at the County due to the increasing caseload.

• Many members being served by the County can be transitioned back to Beacon as most do not have a SMI.

• The penetration rate by medical groups is very different with the San Francisco Consortium Clinics collectively serving over 7% while the lowest in the network is 0.39%.

• SFHP will work with the medical groups with the lowest penetration rates to improve rates.

• The committee discussed that at times the patient or the therapist is reluctant to transition as there is a bond that forms between them.

12

Report Date: 7/12/2017Date of Service: 6/1/2016-7/1/2017Report Criteria: Limited to Active Members; Plan Side Only

SummaryBusiness Intelligence

Print Date: 7/20/2017Page 1 of 6

January 2016Membership by Network - All Lines of Business

JUN 2016 JUL 2016 AUG 2016 SEP 2016 OCT 2016 NOV 2016 DEC 2016 JAN 2017 FEB 2017 MAR 2017 APR 2017 MAY 2017 JUN 2017 JUL 2017CCC 13,719 13,571 13,569 13,718 13,933 13,864 13,939 14,024 14,121 14,229 14,295 14,365 14,398 14,356 CHN Other 1,140 1,106 1,158 1,209 1,228 1,258 1,286 1,337 1,389 1,416 1,491 1,551 1,627 1,608 SFHN Primary Care Clinics 54,115 54,383 54,359 54,828 55,442 55,374 55,750 55,366 55,317 55,174 55,031 54,908 54,604 54,287 UCSF 11,803 11,704 11,840 11,939 12,082 12,147 12,169 12,165 12,276 12,370 12,419 12,482 12,398 12,391 NMS 2,942 3,017 3,124 3,248 3,328 3,387 3,422 3,550 3,633 3,713 3,838 3,900 4,008 4,153 Kaiser 8,486 8,503 8,518 8,591 8,643 8,625 8,650 8,593 8,645 8,651 8,676 8,684 8,696 8,689 NEM 33,279 33,239 33,352 33,528 33,630 33,559 33,595 33,424 33,413 33,347 33,406 33,465 33,500 33,417 HIL 4,735 4,689 4,673 4,605 4,627 4,601 4,590 4,593 4,576 4,542 4,571 4,594 4,592 4,573 BTP 4,692 4,680 4,679 4,722 4,820 4,794 4,781 4,771 4,756 4,680 4,645 4,617 4,558 4,505 CCHCA 11,141 11,073 10,999 11,022 11,021 10,954 10,914 10,873 10,854 10,803 10,795 10,748 10,705 10,669 Total 146,052 145,965 146,271 147,410 148,754 148,563 149,096 148,696 148,980 148,925 149,167 149,314 149,086 148,648

Membership Total 148,648 CHN Total 70,251 Aid Categories^ BTP CHI CCC CHN Other

SFHN Primary

Care Clinics HIL Kaiser NEM NMS UCSFAdult>19 572 1,148 1,304 239 3,381 605 1,114 4,673 611 1,757

# % of Total Duals 211 973 633 93 2,692 200 795 2,163 129 642

Medi-Cal 136,099 91.6% Medi-Cal Expansion

1,177 3,951 6,059 765 22,330 806 3,166 13,994 2,244 3,896

Healthy Workers 11,212 7.5% SPD* 459 888 1,998 282 5,304 404 448 2,393 227 1,499 Healthy Kids 1,337 0.9% Child 1,968 3,461 4,273 223 9,232 2,427 3,165 9,833 902 4,372

Notes: ^BCCTP and Unknown are excluded as aid categories;*SPD aid category excludes Dual Disabled and Dual Aged populations

San Francisco Health Plan Membership Summary

% SFHP Active Member by LOB as of Jul 2017

44.9% 33.2% 30.0%

13.9% 21.5%

54.6%

36.4% 29.7%

21.9% 35.9%

10.5%

8.5% 14.0%

17.6% 12.4%

9.1%

5.2% 7.2%

5.5%

12.3%

26.8%

37.9% 42.5%

47.8% 52.0%

18.1%

36.4% 42.3% 54.6%

32.0%

4.8% 9.3% 4.4%

5.8% 6.3%

4.5% 9.2% 6.5% 3.1% 5.3%

13.0% 11.0% 9.1% 14.9% 7.9% 13.6% 12.8% 14.1% 14.9% 14.4%

BTP CHI CCC CHN OTHER SFHN PCCLINICS

HIL KSR NEM NMS UCS

% Active Members by Network and Aid Category^ Medi-Cal ONLY As of July 2017

Adult>19

Dual

MC-EXPANSION

SPD

Child

SFHN Primary Care Clinics,

36.5%

NEM, 22.5%

CCC, 9.7%

UCSF, 8.3%

CCHCA, 7.2%

Kaiser, 5.8%

BTP, 3.0%

HIL, 3.1%

NMS, 2.8%

CHN Other, 1.1%

0.0% 10.0% 20.0% 30.0% 40.0%

% Active Members by Network All Lines of Business

As of July 2017

13

Report Date: 7/12/2017Date of Service: 8/1/2015 - 7/1/2017 Report Criteria: Limited to Active Medi-Cal Members; Plan Side Only

Holds and DisenrollsBusiness Intelligence


* Note: Members who disenrolled in one month may re-enroll the following month.

San Francisco Health PlanMembership Summary by Network

AUG2015

SEP2015

OCT2015

NOV2015

DEC2015

JAN2016

FEB2016

MAR2016

APR2016

MAY2016

JUN2016

JUL2016

AUG2016

SEP2016

OCT2016

NOV2016

DEC2016

JAN2017

FEB2017

MAR2017

APR2017

MAY2017

JUN2017

JUL2017

CHI 147 143 110 110 105 33 136 134 210 187 154 229 155 180 192 168 142 129 155 137 192 162 184 193BTP 115 93 69 56 68 15 92 78 128 131 114 170 178 122 122 83 95 71 141 99 136 97 123 106UCS 203 233 159 141 164 70 154 191 269 280 220 316 284 262 306 194 224 190 233 194 295 230 253 232NMS 29 23 43 38 45 10 48 53 93 86 65 124 68 62 96 70 51 76 84 63 122 96 82 88NEM 453 472 299 355 292 84 407 391 758 657 451 776 482 488 622 426 373 379 477 438 699 527 583 528KSR 143 125 86 108 110 25 111 110 188 180 131 217 189 175 182 146 147 140 158 150 209 166 191 188HIL 128 107 74 69 47 17 85 64 66 123 121 143 176 129 115 65 89 82 82 59 86 91 98 95CHN 1,802 1,915 1,284 1,104 1,129 556 1,286 1,366 2,529 2,325 1,591 3,165 2,420 1,749 1,827 1,400 1,333 1,352 1,781 1,294 2,066 1,602 1,666 1,679

0

1,000

2,000

3,000

4,000

5,000

6,000

Mem

ber C

ount

SFHP Disenrolled Members by Network by Year and Month* Eligibility Period: Aug 2015 - Jul 2017

AUG2015

SEP2015

OCT2015

NOV2015

DEC2015

JAN2016

FEB2016

MAR2016

APR2016

MAY2016

JUN2016

JUL2016

AUG2016

SEP2016

OCT2016

NOV2016

DEC2016

JAN2017

FEB2017

MAR2017

APR2017

MAY2017

JUN2017

JUL2017

CHI 246 238 199 250 264 486 539 583 599 543 537 503 498 449 382 370 382 472 484 555 534 543 532 495BTP 150 120 103 131 139 270 315 352 422 376 375 330 272 266 192 257 262 346 310 335 304 285 255 252UCS 311 273 233 278 309 566 705 716 802 772 779 802 697 636 508 562 537 678 654 708 658 624 694 708NMS 55 73 73 83 89 178 227 223 263 244 226 187 185 190 188 197 214 246 262 266 255 254 252 243NEM 807 730 609 732 846 1,698 1,975 1,932 1,950 1,668 1,622 1,478 1,413 1,351 1,110 1,183 1,175 1,597 1,664 1,790 1,632 1,591 1,566 1,625KSR 206 204 216 224 224 420 519 525 561 542 568 530 485 464 422 442 426 517 518 583 563 574 553 563HIL 145 118 90 119 133 183 217 253 351 321 323 303 246 234 168 192 178 202 214 264 279 270 265 271CHN 2,330 1,724 1,471 1,728 2,076 4,315 5,380 5,459 6,203 5,522 5,492 4,251 3,865 3,734 3,219 3,623 3,612 4,424 4,216 4,549 4,338 4,372 4,538 4,663

0

2000

4000

6000

8000

10000

12000

Mem

ber C

ount

SFHP Members on Hold by Network by Year and Month Eligibility Period: Aug 2015 - Jul 2017

14

Report Date: 7/12/2017Date of Service: 8/1/2016 - 7/1/2017Report Criteria: Limited to Active Members; Plan Side Only

Medi-CalBusiness Intelligence


AUG 2016 SEP 2016 OCT 2016 NOV 2016 DEC 2016 JAN 2017 FEB 2017 MAR 2017 APR 2017 MAY 2017 JUN 2017 JUL 2017Medi-Cal 133,877 135,258 136,634 136,436 136,993 136,370 136,601 136,534 136,714 136,818 136,548 136,099 136,099

Net New 1,201 1,381 1,376 (198) 557 (623) 231 (67) 180 104 (270) (449) 132,676% New 0.91% 1.03% 1.02% -0.14% 0.41% -0.45% 0.17% -0.05% 0.13% 0.08% -0.20% -0.33% 3,423 2.58%

Part A % Part B% Full A/B Duals % MCE% Non-MCE% SPD% Non-SPD%JUL 2017 0.05% 1.41% 6.62% 42.90% 57.10% 16.49% 83.51%JUL 2016 0.09% 1.41% 6.05% 42.79% 57.21% 16.50% 83.50%

Difference -0.04% 0.01% 0.58% 0.11% -0.11% -0.01% 0.01%

BTP 4,388CCHCA 10,421

# % CHN 58,8144,388 3.2% HIL 4,442

10,421 7.7% KAISER 8,68958,814 43.2% NEM 33,059

4,442 3.3% NMS 4,113KAISER 8,689 6.4% UCSF 12,173NEMS 33,059 24.3%NMS 4,113 3.0%UCSF 12,173 8.9%Total 136,099 100.0%

Language # % Chinese 41,969Chinese 41,969 30.8% English 65,839English 65,839 48.4% Others 4,372Others 4,372 3.2% Russian 604Russian 604 0.4% Spanish 19,853Spanish 19,853 14.6% Vietnamese 3,462

Vietnamese 3,462 2.5%Total 136,099 100.0%

Note: ^BCCTP is included in the total member count

% of Total87%13%

Source: http://www.dhcs.ca.gov/dataandstats/reports/Documents/MMCD_Enrollment_Reports/MMCEnrollRptJun2017.pdf

No. of Members136,42720,307

San Francisco Health Plan Anthem Blue Cross

Market Share

San Francisco Health Plan

HILL

Annual GrowthJUL 2017JUL 2016

Difference/% Change

Medical Group

BTP

CCHCA (aka CHI)

SFCCC + DPH (aka CHN)

Other Membership Indicators

Medi-Cal Membership Summary^

133,877 135,258 136,634 136,436 136,993 136,370 136,601 136,534 136,714 136,818 136,548

136,099 136,998 137,568

138,139 138,709 139,280 139,891 140,502 141,113 141,724 142,335 142,945

136,851

50,000

60,000

70,000

80,000

90,000

100,000

110,000

120,000

130,000

140,000

150,000

Mem

ber C

ount

Medi-Cal Projected vs. Actual Membership as of Jul 2017

Actual Projected

3% 8%

43%

3%

7%

24%

3% 9%

Medi-Cal Membership by Network as of Jul 2017

31%

48%

3% 0%

15%

3%

Medi-Cal Membership by Language as of Jul 2017

15

Report Date: 7/12/2017Date of Service: 6/1/2016 - 7/1/2017Report Criteria: Limited to Active Members; Plan Side Only

Medi-Cal - Aid Category LanguageBusiness Intelligence


January 2016Medi-Cal Membership by Aid Category

Aid Categories^ JUN 2016 JUL 2016 AUG 2016 SEP 2016 OCT 2016 NOV 2016 DEC 2016 JAN 2017 FEB 2017 MAR 2017 APR 2017 MAY 2017 JUN 2017 JUL 2017Adult>19 16,565 16,068 16,081 16,143 16,246 16,080 15,915 15,860 15,726 15,664 15,686 15,607 15,600 15,404 Duals 7,394 7,573 7,677 7,751 7,862 7,986 8,060 8,125 8,174 8,278 8,367 8,459 8,483 8,531 Medi-Cal Expansion 56,367 56,784 57,342 57,831 58,429 58,205 58,661 58,130 58,306 58,315 58,441 58,524 58,368 58,388 SPD* 14,414 14,315 14,232 14,197 14,128 14,104 14,073 14,019 14,011 13,981 13,945 13,967 13,981 13,902 Child 37,851 37,885 38,486 39,275 39,926 40,017 40,233 40,187 40,325 40,249 40,242 40,217 40,078 39,856 Total 132,591 132,625 133,818 135,197 136,591 136,392 136,942 136,321 136,542 136,487 136,681 136,774 136,510 136,081

Notes: ^BCCTP is excluded as an aid category;*SPD aid category excludes Dual Disabled and Dual Aged populations

Medi-Cal Membership by LanguageAll Languages BTP CHI CHN HIL KSR NEM NMS UCS

Chinese 3.2% 75.5% 8.4% 2.5% 13.7% 73.8% 61.7% 6.6%English 58.8% 19.1% 60.6% 51.5% 70.9% 19.3% 31.4% 78.2%Spanish 29.6% 0.2% 24.6% 38.9% 9.9% 1.6% 3.0% 6.9%Others 6.1% 1.7% 4.0% 5.5% 3.3% 1.2% 0.9% 4.8%Russian 2.0% 0.1% 0.4% 1.2% 0.5% 0.2% 0.0% 0.8%

Vietnamese 0.5% 3.5% 2.0% 0.2% 1.8% 3.9% 3.0% 2.7%

San Francisco Health PlanMedi-Cal Membership - Aid Category & Language^

58.8%

19.1%

60.6% 51.5%

70.9%

19.3%

31.4%

78.2%

3.2% 75.5%

8.4%

2.5%

13.7%

73.8%

61.7%

6.6% 29.6%

0.2%

24.6%

38.9%

9.9%

1.6% 3.0% 6.9%

8.5%

5.2% 6.4% 7.0% 5.6%

5.3% 4.0%

8.3%

BTP CHI CHN HIL KSR NEM NMS UCS

Medi-Cal Members by Language and Network

As of Jul 2017

All Other

Spanish

Chinese

English

42.9%

29.3%

11.3%

10.2%

6.3%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0%

Medi-Cal Expansion

Child

Adult>19

SPD*

Duals

Medi-Cal Membership by Aid Category

As of Jul 2017

16


Healthy KidsBusiness Intelligence


AUG 2016 SEP 2016 OCT 2016 NOV 2016 DEC 2016 JAN 2017 FEB 2017 MAR 2017 APR 2017 MAY 2017 JUN 2017 JUL 2017Healthy Kids 1,129 897 881 863 886 1,078 1,120 1,144 1,204 1,275 1,329 1,337 1,337

Net New (844) (232) (16) (18) 23 192 42 24 60 71 54 8 1,973

% New -0.64% -20.55% -1.78% -2.04% 2.67% 21.67% 3.90% 2.14% 5.24% 5.90% 4.24% 0.60% (636) -32.24%

Medical Group # %117 8.8%248 18.5%225 16.8%131 9.8% BTP 117

0 0.0% CCHCA 248358 26.8% CHN 225

40 3.0% HIL 131218 16.3% KAISER 0

1,337 100.0% NEM 358NMS 40UCSF 218

Chinese 344English 802Others 16

Language # % Russian 1Chinese 344 25.7% Spanish 161English 802 60.0% Vietnamese 13Others 16 1.2%Russian 1 0.1%Spanish 161 12.0%

Vietnamese 13 1.0%Total 1,337 100.0%

Difference/% Change

UCSF

Total

BTP

HILLSFCCC + DPH (aka CHN)

CCHCA (aka CHI)

NMS

KAISER

NEMS

Healthy Kids Membership SummarySan Francisco Health Plan

Annual GrowthJUL 2017

JUL 2016

1,129

897 881 863 886

1,078 1,120 1,144

1,204

1,275 1,329 1,337

769

680

591 602 613 624 635 646 657 668 679

1,134

0

500

1,000

1,500

Mem

ber C

ount

Healthy Kids Projected vs. Actual Membership as of Jul 2017

Actual Projected

9%

18%

17%

10% 0%

27%

3%

16%

Healthy Kids Membership by Network as of Jul 2017

26%

60%

1% 0% 12%

1%

Healthy Kids Membership by Language as of Jul 2017

17


Healthy WorkersBusiness Intelligence


AUG 2016 SEP 2016 OCT 2016 NOV 2016 DEC 2016 JAN 2017 FEB 2017 MAR 2017 APR 2017 MAY 2017 JUN 2017 JUL 2017Healthy Workers 11,265 11,255 11,239 11,264 11,217 11,248 11,259 11,247 11,249 11,221 11,209 11,212 11,212

Net New (51) (10) (16) 25 (47) 31 11 (12) 2 (28) (12) 3 11,316

% New -0.04% -0.09% -0.14% 0.22% -0.42% 0.28% 0.10% -0.11% 0.02% -0.25% -0.11% 0.03% (104) -0.92%

Medical Group # %0 0.0%0 0.0%

11,212 100.0%0 0.0% BTP 00 0.0% CCHCA 00 0.0% CHN 11,2120 0.0% HIL 00 0.0% KAISER 0

11,212 100.0% NEM 0NMS 0UCSF 0

Chinese 5,035English 2,380Others 1,343

Language # % Russian 1,717Chinese 5,035 44.9% Spanish 586English 2,380 21.2% Vietnamese 151Others 1,343 12.0%Russian 1,717 15.3%Spanish 586 5.2%

Vietnamese 151 1.3%Total 11,212 100.0%

NEMS

NMS

UCSF

Total

BTPCCHCA (aka CHI)

SFCCC + DPH (aka CHN)HILL

KAISER

Difference/% Change

San Francisco Health PlanHealthy Workers Membership Summary

Annual GrowthJUL 2017

JUL 2016

11,265 11,255 11,239 11,264 11,217

11,248 11,259 11,247 11,249 11,221 11,209 11,212

11,513 11,495 11,477 11,460 11,442 11,425 11,407 11,390 11,373 11,356 11,339 11,249

10,000

10,200

10,400

10,600

10,800

11,000

11,200

11,400

11,600

Mem

ber C

ount

Healthy Workers Projected vs. Actual Membership as of Jul 2017

Actual Projected

100%

Healthy Workers Membership by Network as of Jul 2017

45%

21%

12%

15%

5%

2%

Healthy Workers Membership by Language as of Jul 2017

18

Prepared: 07/24/17 SFHP Pharmacy Services

Emergency Room Visit / Prescription Access Report 1st Quarter 2017

San Francisco Health Plan Medi-Cal LOB Goal: Evaluate access to medications prescribed pursuant to an emergency room visit and determine whether any barriers to care exist. Methodology: All claim and encounter records for an emergency room visit (without an admission) during a calendar quarter are evaluated and consolidated into a unique record of each emergency room (ER) visit date by member. These unique ER visits are analyzed by SFHP, ER facility site, and member count (see Tables 1A & 1B). Top diagnoses were evaluated for reason of ER visit (see Table 2). Selected key diagnoses with a high likelihood for ER discharge prescription are analyzed (see Table 3). A review of the pharmacy locations where members filled their prescriptions within 72 hours of discharge was assessed to reflect any medication barriers (see Table 4). Findings:

Section 1 - ER Visits

In 1Q2017, 9,700 members had 15,148 ER visits, averaging 1.6 ER visits per member. This reflects an ER visit by 7.6% of our Medi-Cal membership within the quarter. The distribution of ER visits by ER facility is reported in Table 1A. The number of ER visits by member is reported in Table 1B.

Table 1A: Visits by ER Facility Table 1B: Member ER Visits ER Facility ER Visits # ER Visits Members San Francisco General Hospital 5,457 1 7,050 UC San Francisco Medical Center 2,544 2 1,667 St Francis Memorial Hospital 1,999 3 476 CPMC St Luke’s 1,913 4 192 CPMC Pacific Campus 1,079 5 88 St Mary’s Medical Center 741 6 69 CPMC Davies Campus 522 7 42 Chinese Hospital 244 8 27 Kaiser Foundation Hospital 231 9 17 Chinese Community Health Care 110 10 13 Other 308 11 – 37 59 TOTAL 15,148 TOTAL 9,700

19


Section 2 - Top Diagnoses

Of the 15,148 ER visits in 1Q2017, 9,680 visits (64%) resulted in a medication (from ER or pharmacy) within 72 hours of the ER Visit and 5,468 (36%) did not. Not all ER visits warranted medication treatment (ie. chest pain, abdominal pain or altered mental status). For the top diagnoses of ER visit, upper respiratory infection and pneumonia showed an increase of 33% (308 to 409) and 36% (115 to 156) respectively compared to last quarter possibly due to the winter season. The top diagnoses for ER Visits are reported in Table 2.

Table 2: Percent ER Visits by Diagnoses Top Diagnoses Categories ICD10 ER Visits % of Visits Chest pain R07.xx 599 4.0% Upper Respiratory Infection J06.9 409 2.7% Fever R50.xx, R68.xx 384 2.5% Abdominal Pain R10.xx 364 2.4% Cough R05 308 2.0% Asthma J45.xx 229 1.5% Altered Mental Status R41.82 215 1.4% Shortness of Breath R06.2 199 1.3% Headache R51 170 1.1% Pneumonia J18.9 156 1.0% Low Back Pain M54.5 153 1.0% Nausea w/wo Vomiting R11.xx 151 1.0% Urinary Tract Infection N39.0 113 0.7% Bronchitis J20.8, J20.9 79 0.5% All Other Diagnoses 11,619 76.7% TOTAL 15,148 100%

Section 3 - Key Diagnoses Category

Selected key diagnoses category with a high likelihood for ER discharge prescription is reported in Table 3. For 1Q2017, at least 95% of ER visits for Asthma, UTI, Pneumonia, and Bronchitis received medication treatment within 72 hours of the visit. The number of medications filled for bronchitis increased from 85% to 96% since 4Q2016. For the selected key diagnoses with no prescriptions, members may already have asthma medications or antibiotics from previous pharmacy fills. In some cases, antibiotic treatment or dexamethasone one-time dose for asthma in the emergency room is sufficient to treat the presenting symptoms and no discharge prescription is required.

Table 3: ER Visit – Key Diagnoses Category Diagnoses Category

ICD10 RX filled ER treated

No RX Total %RX

Asthma J45.901,J45.909 103 52 8 163 95% UTI N39.0 83 11 5 99 95% Pneumonia J18.9 80 30 5 115 96% Bronchitis J20.8, J20.9 52 14 3 70 96%

20


Section 4 - Pharmacy Location

For the members that did fill a prescription from a Pharmacy within 72 hours of their ER visit date, a further analysis evaluated the location of the pharmacy in relation to where the member received emergency care and the hours of operation for these pharmacies. SFHP has one 24 hour pharmacy in our San Francisco network and 50% of our pharmacies are open until 9pm. Access to a pharmacy after an ER visit can occur throughout the day and would not be limited to only after-hours. In this analysis, member visits are defined as unique days that prescriptions are filled for a member per unique pharmacy. Of the 7,517 member visits to a pharmacy after an ER discharge, the most utilized pharmacies are reported in Table 4.

Table 4. Pharmacies where Members obtained Rx within 72 hours of ER Visit Pharmacy Hours of Operation Mbr Visits % of Visits

Walgreens 3711(1189 Potrero Ave) 8AM – 10PM 696 9% SF General (1001 Potrero Ave) 9AM – 8PM M-F, 9AM-1PM Sat 532 7% Walgreens 1327 (498 Castro St) 24 Hours 341 5% Walgreens 5487 (5300 3rd St) 9AM – 9PM 334 4% Walgreens 4609 (1301 Market St) 8AM – 8PM 235 3% Walgreens 2153 (790 Van Ness) 8AM – 8PM 196 3% Walgreens 7150 (965 Geneva Ave) 9AM – 9PM 196 3% All Others 4,987 66% TOTAL 7,517 100 % Summary: The number of ER visits and utilizing members has slightly increased compared to last quarter. In 1Q2017, the number of medications filled for bronchitis changed from 85% to 96%. No selected key diagnoses had less than 90% for 2 consecutive quarters that warranted an ad hoc analysis. No barrier to pharmacy access during after-hours was identified in this quarter. Monitoring of ER visits, key diagnoses and access to emergency room prescription will continue.

21

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Pharmacy Services San Francisco Health Plan Pharmacy & Therapeutics Committee Wednesday, April 19, 2017 7:30AM – 9:30AM 50 Beale St., 13th Floor, San Francisco, CA 94119

Meeting called by: James Glauber, MD Minutes: Sheila Zeno, CPhT (SFHP Pharmacy Analyst) Andrew Costiniano, CPhT (SFHP Pharmacy Specialist)

Meeting Objective: Vote on proposed formulary and PA criteria changes Type of meeting: Quarterly

Attendees: Voting Members: James Glauber, MD (SFHP Chief Medical Officer) Lisa Ghotbi, Pharm. D (SFHP Director of Pharmacy) Nicolas Jew, MD Jamie Ruiz, MD Ronald Ruggiero, Pharm. D Robert (Brad) Williams, MD Shawn Houghtaling, Pharm. D. Linda Truong, Pharm. D. Ted Li, MD Joseph Pace, MD

Others in Attendance: Olga Mostovetsky, Pharm. D (SFHP Pharmacist) Ralph Crowder, R.Ph. (SFHP Pharmacist) Keira Truong, Pharm. D (SFHP Pharmacist) Jenna Heath, Pharm. D (PerformRx Pharmacist) Patrick DeHoratius, Pharm. D (Perform Rx Pharmacist)) Jessica Huang, Pharm. D (Perform Rx Pharmacist) Jennifer Denning (BMS) Michael Pazirandeh (BMS) James Shean (Gilead) Dawn Dynak (Gilead) Coleen Fong (Gilead)

Members Absent: Roger Tiao, Pharm. D Steven Wozniak, MD

Meeting Materials:

Summary of all approved changes are posted under “Materials” section at http://www.sfhp.org/providers/formulary/pharmacy-therapeutics-committee/ SFHP formulary is located at http://www.sfhp.org/providers/formulary/sfhp-formulary/ SFHP prior authorization criteria are located at http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf

Topic Brought By Time/

Duration Discussion Action

1. Call to Order and Instructions James Glauber The meeting was called to order at 7:29am. 2. Agenda overview and other

topics

James Glauber 2 min Introduction agenda topics. Conflicts of Interest checked and instructions given.

28

http://www.sfhp.org/providers/formulary/pharmacy-therapeutics-committee/

http://www.sfhp.org/providers/formulary/sfhp-formulary/

http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf

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Topic Brought By Time/ Duration

Discussion Action

3. Informational Updates James Glauber Lisa Ghotbi

5 min • In effort, to complete our yearly formulary drug class review, we have a substantial agenda to get through today to ensure its completion.

• We would like thank Olga Mostovetsky for her support of our P&T committee meetings for the last 3+ years. We wish her well in her new role at Hills Physicians.

• Our specialty network is being expanded with Mission Wellness pharmacy for some HR360 members effective 3/1/17 and North East Medical Services (NEMS) pharmacy in the near future. USBioservices will remain our specialty pharmacy for all other members and as a back-up for NEMS and Mission Wellness.

• We also want to thank Keira Truong (our current resident pharmacist) for her work with our team this past year. Her year residency ends this June. We wish her luck on her future endeavors. SFHP will welcome two new pharmacy residents starting in July 2017. We plan to have them do some community as well as health plan rotations.

4. Review and Approval of January 18, 2017 P&T Minutes

James Glauber 2 min The committee recommended no corrections to the minutes.

VOTE: Review and Approval of Jan 18, 2017 P&T Minutes Motion: Nicolas Jew Vote: Unanimous approval (7/7) (7 expected members are present during discussion & the vote)

5. Annual Formulary Review Olga Mostovetsky 7 min • SFHP Medi-Cal Formulary and Formulary changes for calendar year 2016 were approved by Department of Healthcare Services (DHCS) effective 1/25/17 with one change required: o Nuplazid® status changed from non-

formulary to excluded (carve-out) Committee asked to approve this new process as our annual formulary review.

• Formulary Tier Structure Changes. Effective

3/1/17, San Francisco Health Plan updated its formulary tier structure pursuant to California Assembly Bill No. 399, Chapter 619 on Health care coverage: outpatient prescription drugs.

VOTE: Review and Approval of Annual Formulary Review Motion: Ron Ruggiero Vote: Unanimous approval (9/9) (9 expected members are present during discussion & the vote)

29

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Discussion Action

****Adjourn to Closed Session**** Closed Session pursuant to Welfare and Institutions Code Section 14087.36 (w)

a. Discussion and Recommendation for Change to SFHP Formulary and Prior Authorization Criteria for Select Drug Classes

Allergy/Cold/Cough (abbreviated) (40-54 April of 2017 P&T Packet)

Olga Mostovetsky Keira Truong

20 min The plan presented therapeutic review and recommendations for Allergy/Cold/Cough medications. Major recommendations included the following: Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco) • Add age limit (≥2) to promethazine-

containing products currently without age limits

• Add age limit (≥12) to codeine-containing products currently without age limits

• Remove promethazine and codeine products from formulary due to safety concerns

• Remove hydroxyzine products from formulary with grandfathering due to safety concerns

• Add the following utilized, cost-effective products to formulary with quantity limits for intranasal formulations: o Rhinocort Allergy (budesonide) 32

mcg/actuation OTC nasal spray o Desloratadine 5 mg tablet

• Remove the following due to availability of lower cost formulary alternatives:

o cetirizine chew tab o diphenhydramine oral elixir o clemastine tablet

• Remove non-utilized products from formulary • Refer to Product Table detailed list of

recommended changes PA Criteria Recommendations: • Update criteria for Second Generation

Antihistamines and Intranasal Steroids to reflect formulary changes

• No changes for Therapeutic Allergenic Extracts criteria

Committee Discussion: The committee inquired about hydroxyzine remaining available on formulary as it is used for intractable itch. Many MDs use it for poison oak and often have tried OTC options before coming to see the doctor. A step edit was considered but determined to be challenging for HW because

VOTE: Allergy/Cold/Cough (abbreviated) Approve recommendations with noted change of hydroxyzine remaining on formulary. Motion: Ron Ruggiero Vote: Unanimous approval (10/10) (All 10 expected members are present during discussion & the vote)

30

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Discussion Action

they cannot identify OTC claims if we require T/F before approval. A quantity edit was considered to possibly limit to 30 day supply. The Committee recommended leaving hydroxyzine on formulary as is and monitor use.

Infectious Disease o Hepatitis B – Vemlidy®

(P55-68 of April 2017 P&T Packet)

Olga Mostovetsky

5 min The plan presented therapeutic review and recommendations for Infectious Disease medications with a focus on Vemlidy®. Major recommendations included the following: Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco) • Remove adefovir (Hespera®) from formulary

due to limited place in therapy, high cost and low utilization

• Keep Vemlidy® non-formulary for Healthy Workers and Healthy Kids and a carve-out for Medi-Cal

PA Criteria Recommendations: (Healthy Kids and Healthy Workers)

• Implement prior authorization criteria for Vemlidy® and adeforvir requiring trial with entacavir and Viread®

Committee Discussion: The committee had no comments or questions.

VOTE: Infectious Disease Hepatitis B – Vemlidy® Approve recommendations as presented. Motion: Nicholas Jew Vote: Unanimous approval (10/10)

Emergency Epinephrine o Epinephrine auto-injectors (P69-72 of April 2017 P&T Packet)

Olga Mostovetsky 5 min The plan presented therapeutic review and recommendations for Emergency Epinephrine auto-injectors. Major recommendations included the following: Formulary Recommendations: (Medi-Cal, Healthy Workers, Healthy Kids, Healthy San Francisco) • Remove brand EpiPen® and EpiPen Jr®

from formulary. Implement point of sale (POS) message on branded products to use generic formulation. Generic substitution by the pharmacist is allowed.

• Implement a quantity limit for formulary auto-injectors of six pens (three two-pen packs) per year.

Committee Discussion: What is the vehicle of informing providers to prescribe epinephrine? Answer – List POS message to use epinephrine at the POS then the pharmacy can inform the provider.

VOTE: Emergency Epinephrine Epinephrine auto-injectors Approve recommendations as presented. Motion: Brad Williams Vote: Unanimous approval (11/11)

Endocrine Jenna Heath 25 min The plan presented therapeutic review and VOTE:

31

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Discussion Action

o Gaucher Disease o Somatostatin Analogs, Dopamine Receptor Agonists, GH Receptor Antagonists o Thyroid disorders o Osteoporosis/Bone Disease o Anti-Obesity o Oral Glucocorticoids (abbreviated) o Emflaza o Desmopressin o Lupron o HP Acthar o Increlex o Kuvan o Myalept o Natpara o Engrifta (P73-195 of April 2017 P&T Packet)

Keira Truong (Thyroid) recommendations for Endocrine medications. Major recommendations are listed below. Gaucher Disease: Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers) • Add Cerdelga® to formulary with prior

authorization requirement for CYP2D6 genotype.

PA Criteria Recommendations: • Implement PA criteria to reflect labeled

indications for Zavesca® and Cerdelga®. Committee Discussion: The committee had no comments or questions Somatostatin Analogs, Dopamine Receptor Agonists, GH Receptor Antagonists: Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers, Healthy San Francisco) • Remove quantity limits from cabergoline to

align with bromocriptine. • Add octreotide vials and syringes to

formulary with prior authorization requirement to ensure appropriate diagnosis and dosing, given high cost. Keep octreotide ampules non-formulary due to lower cost-effectiveness compared to vials and syringes.

PA Criteria Recommendations: • New criteria proposed for octreotide requiring

confirmation of diagnosis and dose. Committee Discussion: The committee had no comments or questions. Thyroid Disorders: Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco) • Add Nature-Throid pork thyroid tablets and

Tirosint® to formulary without restrictions. PA Criteria Recommendations: • Remove criteria for Tirosint®

• Implement new criteria for Thyrolar®

Committee Discussion: The committee had comments or questions about levothyroxine caps v. tabs. Committee recommendation is to keep caps (Tirosint®

Endocrine: Approve recommendations with noted change of keeping Tirosint® capsules non formulary. Motion: Shawn Houghtaling Vote: Unanimous approval (10/10)

32

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Discussion Action

capsules) as non-formulary. Osteoporosis, Paget’s and CKD-MBD: Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers, and Healthy San Francisco) • Add prior authorization requirement to

Sensipar® • Add ibandronate to formulary without

restrictions due to cost-effectiveness • Remove quantity limits from all formulary

medications • Remove age limit from raloxifene • Remove etidronate, alendronate 40 mg

tablet and Fosamax plus D® from formulary due to lack of utilization

• Added Prolia® and Xvega® to formulary with prior authorization

PA Criteria Recommendations: • Implement new criteria to Sensipar® to

confirm diagnosis and baseline calcium levels

• Implement new criteria for Prolia® and Xgeva® requiring diagnosis and use of oral agents prior to Prolia®

• Update criteria for Forteo® to remove requirement for one year of bisphosphonate therapy, update requirement for initiation of therapy to include “high fracture risk" in addition to “history of fracture”

• Update bisphosphonates criteria to reflect changes in formulary status, add criteria for zoledronic acid (Reclast®), separate criteria for non-formulary medications by individual drug.

Committee Discussion: The committee had no comments or questions Anti-Obesity: Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers) Add the following to formulary with prior authorization: • Phentermine 15, 30 mg capsule; 37.5 mg

tablet and capsule • Alli® (orlistat) 60 mg capsule (Medi-Cal Only) • Belviq® (lorcaserin)

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Discussion Action

• Contrave® (naltrexone/bupropion) PA Criteria Recommendations: • Remove requirement for Alli® and

phentermine as preferred medications. • Allow pharmacotherapy to be used as an

adjunct to lifestyle modifications. • Include Contrave® and Saxenda® in criteria.

Require use of separate ingredient products for Contrave®.

• Add requirement for baseline weight and BMI.

• Update continuation of therapy section to define response to therapy.

Committee Discussion: The committee had no comments or questions. Systemic Corticosteroids: Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers, and Healthy San Francisco) • Remove prednisolone 5 mg tablet from

formulary due to high cost and availability of formulary alternatives

• Remove cortisone 25 mg tablet due to high cost and lack of utilization

• Add Dexamethasone Intensol 1 mg/ml oral solution to formulary without restrictions

PA Criteria Recommendations: • No drug specific criteria. Apply the following

blanket criteria where appropriate: • Criteria for non-specialty non-formulary or

PA required medications without drug specific criteria

• Criteria for non-tablet/capsule formulations Committee Discussion: The committee had no comments or questions Emflaza® (deflazacort): Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers) • Add Emflaza® to formulary with prior

authorization. PA Criteria Recommendations: • New criteria is proposed in the meeting

packet. Committee Discussion: The committee had no comments or questions

34

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Discussion Action

Desmopressin: Formulary Recommendations: (Medi-Cal, Healthy Workers, Healthy Kids, Healthy San Francisco) • Add desmopressin 10 mcg/spray nasal spray

to formulary without restrictions • Remove desmopressin 0.1 mg/ml nasal

solution (rhinal tube) and 4 mcg/ml ampule from formulary due to lack of utilization.

PA Criteria Recommendations: • Implement new criteria for desmopressin

nasal solution and Stimate® nasal spray based on indication and dosing.

Committee Discussion: The committee had no comments or questions Lupron Depot-Ped® (leuprolide): Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers) • Add Lupron Depot-Ped® to formulary with

prior authorization PA Criteria Recommendations: • Implement prior authorization criteria

requiring confirmation of diagnosis, age cut-offs and monitoring

Committee Discussion: The committee had no comments or questions. HP Acthar Formulary Recommendations: • No changes PA Criteria Recommendations: • Add criteria for acute exacerbation of

multiple sclerosis and blanket criteria for other labeled indications.

• Remove requirement for use of oral corticosteroids prior to HP Acthar from infantile spasms criteria.

Committee Discussion: The committee had no comments or questions Increlex® (mecasermin) Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers, and Healthy San Francisco) • Keep non-formulary due to lack of utilization

and coverage by CCS for Medi-Cal members.

PA Criteria Recommendations:

35

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Discussion Action

• No drug specific criteria in place today. Committee Discussion: The committee had no comments or questions. Kuvan® (sapropterin dihydrochloride) Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers, and Healthy San Francisco) • Keep non-formulary due to lack of utilization

and coverage by CCS for Medi-Cal members.

PA Criteria Recommendations: • No drug specific criteria in place today. Committee Discussion: The committee had no comments or questions Myalept® (metreleptin) Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers, and Healthy San Francisco) • Keep non-formulary due to lack of utilization

and secondary place in therapy. PA Criteria Recommendations: • No drug specific criteria in place today. Committee Discussion: The committee had no comments or questions Natpara® (parathyroid hormone) Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers, and Healthy San Francisco) • Keep non-formulary due to lack of utilization

and secondary place in therapy. PA Criteria Recommendations: • No drug specific criteria in place today. Committee Discussion: The committee had no comments or questions EgriftaTM (tesamorelin for injection) Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco) • Keep non-formulary due to low utilization

and lack of guideline defined place in therapy.

PA Criteria Recommendations: • Implement new criteria requiring diagnosis,

known contraindications, baseline CT or waist circumference and improvement in either parameter for continuation of therapy.

36

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Discussion Action

Committee Discussion: The committee had no comments or questions

Cardiology o Heart Failure/Angina o Ergoloid o Isoxsuprine o Samsca (P196-223 of April 2017 P&T Packet)

Olga Mostovetsky 15 min The plan presented therapeutic review and recommendations for Cardiology medications. Major recommendations are listed below: Angina Pectoris and Heart Failure: Formulary Recommendations: (Medi-Cal, Healthy Kids, and Healthy Workers) • Add Ranexa® to formulary with prior

authorization requirement for at least one antianginal agent.

• Keep BiDil® non-formulary due to lack of utilization and availability of separate ingredient products

• Keep Corlanor® non-formulary due lack of utilization and place in therapy as a second line therapy

• Change Entresto® to formulary, step therapy with ACE-Is or ARBs in the last 90 days

PA Criteria Recommendations: • No changes to Ranexa® criteria • Update Entresto® criteria to reflect change in

formulary status Committee Discussion: Suggested Renexa Step therapy (ST) instead F-PA. Committee decision to add Ranexa® to formulary with Step therapy requirement of at least one antianginal agent. Ergoloid Mesylates (Hydergine®): Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco) • Keep non-formulary given lack of definitive

place in therapy and low utilization. PA Criteria Recommendations: • Implement PA criteria requiring use of first-

line therapies. Committee Discussion: The committee had no comments or questions Isoxsuprine: Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers, and Healthy San Francisco) • Add to formulary with step therapy

requirement for first line therapies (i.e. cilostazol and pentoxifylline)

VOTE: Cardiology: Approve recommendations with noted change of Renexa Step therapy (ST) instead F-PA Motion: Ron Ruggiero Vote: Unanimous approval (10/10)

37

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Discussion Action

PA Criteria Recommendations: • Implement step therapy criteria Committee Discussion: The committee had no comments or questions Samsca® (tolvaptan): Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco) • Keep non-formulary given lack of

recommendation as first-line therapy for hyponatremia, safety concerns, administration challenges and lack of utilization.

PA Criteria Recommendations: • Implement step therapy criteria Committee Discussion: The committee had no comments or questions

b. Additional Proposed Changes to SFHP Formulary (P223-223 of April 2017 P&T Packet)

Olga Mostovetsky 3 min The plan discussed miscellaneous proposed formulary changes which included: o Removing quantity limits from Pentoxifylline

400 mg ER tab o Removing PA from Dutasteride 0.5 mg cap o Adding PA to formulary Endometrin 100 mg

vaginal inserts o Making Opana ER 5, 7.5, 10, 15, 20, 30, 40

mg crush resistant tablet non-formulary. Committee Discussion: The committee had no comments or questions

VOTE: Additional Proposed Changes to SFHP Formulary Approve recommendations as presented. Motion: Lisa Ghotbi Vote: Unanimous approval (10/10)

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Discussion Action

c. Provider Request for Formulary Modification (P224-224 of April 2017 P&T Packet)

Olga Mostovetsky 3 Mins The plan discussed request for formulary modification by providers which included: Bowel preparation products: Recommendation: Added the following products to formulary without restrictions effective 2/15/17:

o Suprep Bowel Prep Kit 17.5 gram-3.13 gram-1.6 gram oral solution

o Prepopik 10 mg-3.5 gram-12 gram oral powder packet

o MoviPrep 100 g-7.5 g-2.691 g-4.7 g oral powder packet

Melatonin: Recommendation: Add the following commonly utilized melatonin formulations to formulary without restrictions:

o Melatonin 1, 3, 5 mg tablet o Melatonin 1, 3 mg ODT o Melatonin 5 mg/15 ml oral liquid


VOTE: Provider Request for Formulary Modification Approve recommendations as presented. Motion: Nicholas Jew Vote: Unanimous approval (10/10)

6. ****RECONVENE IN OPEN SESSION**** 7. Summary of Closed Session

James Glauber 2 min Reconvened Open session around 9:15am Non-voting

8. Additional Proposed Changes to SFHP Prior Authorization Criteria (P225-239 of April 2017 P&T Packet)

Olga Mostovetsky 5 min The plan presented new criteria for the following: • Non-formulary Blood Glucose Monitors • Endometrin® (progesterone) vaginal

insert • Metronidazole 1% topical gel (Metrogel) • Durezol (difluprednate) 0.05% eye drops

SFHP presented changes to existing criteria for the following:

• Genitourinary-Antispasmodics/Anticholinergics

• Hepatitis C • Topical Vitamin D Analogs • Makena® (hydroxyprogesterone

caproate 250 mg/mL IM oil) • Long-Acting Opioids • Modafinil and Armodafinil • Dutasteride (Avodart®)


VOTE: Additional Proposed Changes to SFHP Prior Authorization Criteria Approve recommendations as presented. Motion: Brad Williams Vote: Unanimous approval (10/10)

9. Pharmacy Policy & Procedure Updates and

Ralph Crowder 3 min The plan presented changes to the Pharmacy Policy and Procedures (P&P) Pharm-02:

VOTE: Pharmacy Policy and Procedure

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Discussion Action

Monitoring (P240-247 April 2017 P&T Packet)

Pharmacy Prior Authorization as follows: o Changed: Definitions and time frames

regarding “Appeals/Grievances”, “reconsiderations” and resubmissions. Brings P&P in alignment with new procedures from Appeal and Grievance.

o Added: Under “Monitoring” procedure put into effect that changed inter-rater reliability monitoring to a mock case review by all pharmacists, done monthly.

o Deleted: Blind reference to “After Hours Emergency Access” in another section.


Updates Approve recommendations as presented. Motion: Jaime Ruiz Vote: Unanimous approval (10/10)

10. Review and Approval of Interim Formulary Changes and Formulary Placement for New Drugs to Market (P248-253 of April 2017 P&T Packet)

Olga Mostovetsky 5 min The plan presented interim formulary changes and formulary status for new drugs to market. Committee Discussion: The committee had no comments or questions

VOTE: Review and Approval of Interim Formulary Changes and Formulary Placement for New Drugs to Market Approve recommendations as presented. Motion: Joseph Pace Vote: Unanimous approval (10/10)

11. Follow up discussion from January 2017 P&T Committee Meeting (P254-254 of April 2017 P&T Packet)

Olga Mostovetsky 5 min The plan provided follow up items from January P&T Committee meeting. SFHP proposed changing quantity limit for Albenza® 200 mg tablet from 2 fills per year to 4 tablets per year in order to restrict dispensed quantity to the one that reflects most common dosing. Committee requested indications for which more than 4 tablets of Albenza® would be required given claims for 6 tablets in utilization. The recommendation was given low likelihood of use of Albenza® for above indications in SFHP population; recommend keeping quantity limit for Albenza® at 4 tablets per year. Advair Diskus® Generic Status: On March 29, 2017 Mylan reported that FDA declined to approve its generic for Advair but did not disclose any details regarding the FDA’s complete response letter (CRL).

Non-voting item

12. Adjournment

James Glauber 2 min The meeting adjourned at 9:30 am. 2017 P&T Committee Meeting dates are:

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Discussion Action

• Wednesday, July 19, 2017 • Wednesday, October 18, 2017

The meeting was adjourned at 9:30 AM

Respectfully submitted by: ------------------------------------------------------- ---------------------------------

James Glauber, MD, MPH Date Chief Medical Officer

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Summary of Policy and Procedure Changes QI-13: Disease Management • Deletes the reference to electronic health records as a data source to identify potentially eligible

members. • Updates the Monitoring section to reference “Disease Management” rather than “Health

Improvement” as the responsible department for oversight. • Updates the Monitoring section to clarify that the SFHP population analysis is conducted

annually.

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1

SFHP POLICY AND PROCEDURE

Disease Management Policy and Procedure number:

QI-13

Department Owner: Health Improvement Lines of Business Affected: Medi-Cal, Healthy Workers, Healthy Kids

POLICY STATEMENT San Francisco Health Plan (SFHP) identifies two (2) highly prevalent chronic conditions among its membership and establishes culturally and linguistically appropriate Disease Management (DM) programs that are fully compliant with current The National Committee for Quality Assurance (NCQA) standards and clinical guidelines (QI-09).

PROCEDURE 1. SFHP’s Disease Management (DM) programs address condition monitoring, patient adherence to

treatment plans, medical and behavioral health co-morbidities and other health conditions, health behaviors, psychosocial issues, and depression screening. Information is also provided to caregivers about their role in supporting loved ones with chronic illnesses. Members are encouraged to communicate with their practitioners about their health conditions and treatment. SFHP provides additional external resources that include programs and services available in the community to help members with their primary condition and comorbidities.

2. The DM programs identify members who qualify for disease management services using the following

data sources: claims or encounter data, pharmacy data (if applicable), health risk appraisal results (if available), laboratory results (if applicable), data collected through the case management/utilization management process, and member and practitioner referral. SFHP uses the following sources to identify members:

a. Claim or encounter data: SFHP utilizes claims and encounter data to identify members with the diagnoses of the identified chronic conditions.

b. Pharmacy data: Pharmacy data are collected from the pharmacy benefit manager (PBM) monthly.

c. Health appraisal results: SFHP’s Health Risk Assessment (HRA) is mailed to new SFHP members on a monthly basis and contains questions regarding member diagnoses. The data are collected in SFHP’s care management system, Essette.

d. Laboratory results: Laboratory results are collected for condition monitoring only, using SFHP’s care management system, Essette.

e. Data collected through the UM process, case management process, or care management process: SFHP utilizes referrals from UM and the care management programs to identify members who qualify for the program. Referrals are tracked in Essette.

f. Data from health management, wellness or health coaching programs (e.g. Members who identify themselves as having diabetes or asthma who are enrolled in SFHP’s Chronic Disease Self-Management program, Healthier Living, are enrolled in the program).

g. Information from EHRs: San Francisco Health Plan collects EHR data from multiple medical groups on a monthly basis. Relevant EHR data are included in the monthly data loads from SFHP’s electronic data warehouse and utilized to identify members for the DM program in Essette.

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2

h.g. Member and practitioner referrals: Members and practitioner referrals to the DM program are documented and tracked in Essette.

2. The DM programs systematically identify members who qualify for each program on a monthly basis. 3. SFHP informs eligible members about the DM programs through member newsletters and letters,

and through the member page of the SFHP website. This information includes how to use the services, how members become eligible to participate, and how to opt out. Members may opt out by calling SFHP’s Customer Service Department.

4. The DM programs provide interventions to members based on risk stratification and assessment.

Members may move between risk stratification levels depending on algorithm criteria, feedback from their Primary Care Provider (PCP), clinical assessment of the available member information, and member outreach responsiveness. After reclassification, members receive the interventions appropriate to their new stratum. Risk stratification criteria are contained in the DM Program Description, and criteria to re-stratify members include but are not limited to:

a. Validation from the member’s PCP of member’s true risk level or diagnoses. b. Clinical events based on medication or treatment plan noncompliance, inpatient admissions

for diabetes/asthma, and pharmacy profiles.

5. The DM programs annually measure member active participation rates by utilizing the following methodology:

a. Denominator: Number of identified eligible members. b. Numerator: Number of identified eligible members with at least one interactive program

contact.

6. The DM programs provide practitioners with written program information, including instructions on how to use disease management services and how the DM programs work with a practitioner’s patients.

a. SFHP provides practitioners with information about the DM program through the SFHP website as well as regular communications via the monthly SFHP Provider Update email newsletter.

b. SFHP maintains a current list of emails for all practitioners. Any without email are provided the newsletter by fax or hardcopy mail.

7. The DM programs are aligned with nationally recognized evidence-based clinical practice guidelines. The QICThe QIC reviews and approves the Clinical Practice Guidelines every two (2) years,years or more frequently if national guidelines change within the two (2) year period. Clinical Practice Guidelines are available on our provider resources portion of the website. Please refer to QI-9 Policy and Procedure Practice Guidelines for details.

8. SFHP ensures that all member communication related to DM is culturally and linguistically

appropriate, reading-level approved, and approved by all regulating bodies (DHCS and/or DMHC as needed) prior to dissemination. Please refer to CLS-05 (Health Education Standards) for details.

9. SFHP ensures that a member’s Protected Health Information (PHI) is protected according to

regulations. Refer to CRA-06 (PHI Breach Investigation and Reporting), CRA-07 (PHI Breach Notification), and CRA-13 (Restricting the Use and Disclosure of PHI) for policies and procedures on protection of PHI.

10. Using integrated information allows SFHP to offer interventions that match the severity of the

condition. Through use of the Essette database, SFHP integrates information from the following programs to facilitate access to member health information for coordination of care:

a. A health information line (Nurse Advice Line).

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3

b. SFHP’s population management programs (including member incentives, health education mailers, and preventive service reminders).

c. The CareSupport Care Management program, as applicable. d. The Complex Medical Case Management program. e. UM data (precertification, concurrent review, prior authorizations, and hospital admission and

discharge data).

As staff works with members in the DM programs, information is documented in Essette and shared with the various areas listed above.

11. Should SFHP contract with a vendor for any component of the DM Program, SFHP ensures that the vendor meets contractual requirements, is a licensed and accredited body, and has adequate policies and procedures in place to protect member PHI. SFHP conducts appropriate vendor oversight as needed.

MONITORING Health ImprovementDisease Management staff is responsible for:

1. Conducting SFHP member population analysis annually to ensure that DM programs remain relevant to the needs of SFHP’s member population.

2. Ensuring that members are appropriately and systematically identified on a monthly basis for DM program participation.

3. Recommending adoption of new, retirement of old, or changes to existing DM programs to the CMO based upon the annual review of SFHP population analysis.

DEFINITIONS Clinical Practice Guidelines – Evidence–based, systematically developed tools that help practitioners make decisions about appropriate health care for specific clinical circumstances.

Disease Management – A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant (Disease Management Association of America). Interactive Contact – This DM program includes the following interactive contact with the member: Interactive Voice Response (IVR) robocalls, live Customer Service Representative (CSR) calls, live DM RN calls, live Pharmacist phone support National Committee for Quality Assurance (NCQA) – A non-profit organization committed to evaluating and publicly reporting on the quality of managed care plans. Protected Health Information (PHI) – Individually identifiable health information (essentially member information) that is transmitted and maintained in any form or medium. PHI excludes individually identifiable health information in education records covered by the Family Educational Rights and Privacy Act (FERPA), employment records held by SFHP in its role as employer, and such information regarding a person who has been deceased for more than fifty (50) years. Risk Stratification – To put a member into a risk category, such as high, medium, or low, that indicates a potential need for intervention.

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4

AFFECTED DEPARTMENTS/PARTIES Health Improvement Business Intelligence Care Coordination Claims Information Technology Services Marketing and Communications Clinical Operations Complex Medical Case Management Pharmacy

RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS CRA-06: PHI Breach Investigation and Reporting CRA-07: PHI Breach Notification CRA-13: Restricting the Use and Disclosure of Protected Health Information (PHI) QI-09: Practice Guidelines CLS-05: Health Education Standards SFHP Annual Disease Management Program Description

REVISION HISTORY Effective Date: September 14, 2015 Approval Date: September 14, 2015, April 21, 2016, July 20, 2017 Revision Date(s): March 7, 2016, June 19, 2017

REFERENCES DHCS/SFHP Contract Exhibit A, Attachment 11, Provision 4 NCQA Standards: QI 8QI 6: Disease Management

46

5

47


Clinical Practice Guidelines Policy and Procedure number:

QI-09


POLICY STATEMENT San Francisco Health Plan (SFHP) approves and adopts clinical practice guidelines and promotes them to providers and members in an effort to improve health care quality and reduce unnecessary variation in care. SFHP approves, adopts, and distributes evidenced-based guidelines from recognized sources for perinatal care, preventive care for children up to 24 months old, preventive care for children 2-19 years old, preventive care for adults 20-64 years old, and preventive care for adults 65 years and older. SFHP also approves, adopts, and promotes evidenced-based clinical practice guidelines from recognized sources for at least two (2) behavioral conditions, one (1) of which addresses children and adolescents, and at least two (2) chronic diseases. Please refer to QI-13 Disease Management Policy & Procedure for additional details regarding clinical practice guidelines for SFHP’s Disease Management Program.

PROCEDURE 1. San Francisco Health Plan (SFHP) determines which practice guideline topics to adopt through the use of a population analysis and Health Improvement program goals. Consideration and review is given to any guidelines that the Centers for Medicare and Medicaid Services (CMS) have adopted as a standard benchmark. Additionally, the SFHP Quality Improvement Committee (QIC) considers guidelines for those diseases where standardized care would benefit SFHP’s members. Guidelines may also be developed or adopted to address the needs of special populations. SFHP preventive health care guidelines are clinical practice recommendations published by a recognized association or government agency and informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. SFHP adopts the American Academy of Pediatrics (AAP) periodicity schedule, Child Health and Disability Prevention (CHDP) guidelines, Advisory Committee on Immunization Practices (ACIP) guidelines for childhood immunizations, and Early & Periodic Screening, Diagnosis & Treatment (EPSDT) guidelines for children. SFHP adopts the U.S. Preventive Services Task Force (USPSTF) Guidelines to Clinical Preventive Services for adults (recommendations grade A & B). 2. The Chief Medical Officer (CMO) or relevant specialists in the Health Improvement department develop or review a practice guideline.

a. A literature search is conducted by relevant specialists in the Health Improvement department, including a search for established practice guidelines from national organizations, professional associations, or other health plans.

b. A previously-adopted guideline or a new guideline draft may be modified based on the material

retrieved from the literature search. The CMO or relevant specialist in the Health Improvement

48

department initiates the modification. The practice guideline draft is presented to the QIC for review and approval.

c. Member benefits are reviewed to ensure that approved guidelines are services that are covered

in the member benefit package. 3. After discussion at the QIC, any changes are incorporated into the guideline. 4. The CMO or physician designee (MD) may send a revised version of the guideline to all contracted providers who treat the condition or perform the procedure, requesting review and comment. The CMO may elect to utilize a sample of the provider population for this purpose. In all cases where SFHP is considering modifying a nationally recognized guideline, or in situations where SFHP is developing its own guideline based on published clinical evidence, a board certified practitioner who would normally treat the condition addressed by the guideline is involved in review and adoption. 5. The QIC reviews and discusses the comments received and the CMO, or relevant specialists in the Health Improvement department, incorporate any changes into the final version. 6. Once approved by the QIC, the guideline is posted on the SFHP Provider page of the SFHP website and a link is included in the provider online newsletter and email newsletter. The provider newsletter is used to communicate guidelines that have been reviewed, updated and/or posted on the Providers page of the SFHP website. The staff member who presents the guideline to the QIC is responsible for ensuring that the updated guideline is posted to the Providers page of the SFHP website and that the Provider Relations staff is notified so they can include the information in the next provider newsletter. Hardcopy and faxed provider newsletters are available upon request and sent to all providers without an updated email. SFHP PNO staff performs annual email reconciliation per Health and Safety Code Section 1367.27; please see PR-21 Policy Procedure for more information. 7. Practice Guidelines information is included in new provider training packets. Delegated medical groups are notified by email; and a link to the provider site is provided. The Network Operations Manual (NOM) directs providers to the Providers page of the SFHP website for all approved Practice Guidelines. Providers are also notified via the website and the NOM that hard copies of any or all approved SFHP Practice Guidelines are available upon request from the Health Improvement department. 8. Once approved, information on new practice guidelines are included in the member newsletter and posted on the Members page of the SFHP website. All guidelines are published/updated in the member’s handbooks as well. 9. The QIC reviews adopted guidelines biennially to ensure they are consistent with current research and national standards. Guidelines are reviewed more frequently if they are revised or updated by the issuing entity. Revisions are made as needed. Providers and Members pages of the SFHP website are updated accordingly. All updates and/or revisions are communicated via the provider website and the next provider newsletter following adoption of guideline revisions. 10. The QIC work plan includes a calendar that indicates when approved guidelines are due for their two-year review. When revised guidelines are presented to the QIC for review and approval, a summary of the changes to the guidelines is distributed to the QIC members.

MONITORING Health Improvement staff is responsible for:

1. Review of adopted guidelines for revisions or updates by the issuing entity to ensure they are up-to-date with current practice.

49

2. Ensuring adopted guidelines are reviewed by the QIC biennially or more frequently if revised or updated by the issuing entity.

3. Review of population analysis data annually to ensure that adopted guidelines are relevant to SFHP members.

4. Recommending adoption of new or retirement of old guidelines to the CMO based upon review of SFHP population analysis.

5. Ensuring updated guidelines are posted to the Providers page of the SFHP website and Provider Relations staff is notified to include the update and link to the guidelines in the next Provider Newsletter.

DEFINITIONS

Advisory Committee on Immunization Practices – The Advisory Committee on Immunization Practices (ACIP) provides advice and guidance on effective control of vaccine-preventable diseases in the U.S. civilian population. The ACIP develops written recommendations for routine administration of vaccines to the pediatric and adult populations, along with vaccination schedules regarding appropriate periodicity, dosage, and contraindications. ACIP statements are official federal recommendations for the use of vaccines and immune globulins in the U.S., and are published by the Centers for Disease Control and Prevention. American Academy of Pediatrics – A professional association of 64,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists founded to address pediatric healthcare standards and dedicated to the health, safety and well-being of infants, children, adolescents, and young adults. Centers for Medicare and Medicaid Services (CMS) – The federal agency within the Department of Health and Human Services that is responsible for administration of the Medicare and Medicaid programs as well as overseeing other federal health care programs such as the Children’s Health Insurance Program (CHIP).

Clinical Practice Guidelines – Evidence-based, systematically developed tools that help practitioners make decisions about appropriate health care for specific clinical circumstances. Preventive Care – Health care services designed for prevention and early detection of illness in asymptomatic people, generally including routine physical examinations, tests and immunizations.

Recognized Sources – Are organizations that develop or promulgate evidence-based clinical practice guidelines and include professional medical associations, voluntary health organizations and National Institutes of Health (NIH) Centers and Institutes. USPSTF Recommendations – The US Preventive Services Task Force (USPSTF) is an independent panel of national experts in prevention and evidence-based medicine. Their recommendations are intended to help primary care clinicians and patients make care decisions together. Recommendations with a grade of “A” are recommended by the USPSTF because there is a high certainty that the net benefit is substantial. Those with a grade of “B” are also recommended because there is a high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial. Services with a grade of C, D, or I are not recommended, and therefore not covered by SFHP.

AFFECTED DEPARTMENTS/PARTIES Health Improvement Marketing and Communications Provider Network Operations

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RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS HE-03: Preventive Health Care Guidelines QI-13: Disease Management PR-03: Provider Training CLS-05: Health Education Standards PR-21: Provider Data Maintenance

REVISION HISTORY Effective Date: April 10, 2014 Approval Date: April 10, 2014, October 9, 2014, April 21, 2016 Revision Date(s): August 14, 2014, March 7, 2016

REFERENCES Health and Safety Code §1367.27 NCQA Standard: QI 8: Disease Management NCQA Standard: QI 9: Practice Guidelines

51

Pharmacy and Therapeutics Committee Pharmacy Policies and Procedures

July 2017

Pharmacy Policies and Procedures (P&Ps) Updates and Monitoring

P&P Updates: Policy Summary of Updates Pharm-01: Pharmacy and Therapeutics Committee

In response to the APL 17-008 “Requirement To Participate In The Medi-Cal Drug Utilization Review Program”. The DUR program requirements noted are integrated into the responsibly of the Pharmacy & Therapeutic committee as follows: • Added:

o Clarifying that the committee evaluates, recommends or approves changes in pharmaceutical management procedures as well as already required noted tasks.

o Clarify the types of members (Voting & Non-voting) that are on the committee.

o The committee meets quarterly and not just at least 4 times a year. o Under Committee Operations- “SFHP Pharmacy staff pharmacists

coordinate the preparation and distribution of materials reviewed by the committee.”

o Changes under: Committee Responsibilities o Changes under: Committee Review Requirements

Pharm-02: Pharmacy Prior Authorization

• Changed: PA TAT Requirements for Medi- Cal members regarding response and decision time frames from (1) business day to (24) hours of receiving the request or necessary medical information.

• Added: Under “PA TAT Requirements for Medi- Cal members”: “A request for information (RFI) extends the turn-around-time requirement to provide time for the prescriber to submit the information needed to make a decision. Non-urgent requests are held open for no more than 30 days from the date of the initial PA request. Urgent requests are held open no more than 72 hours from the time of the original request.”

• Deleted: TAT references to a decision for Urgent & Non-urgent PA requests. Pharm-14: Pharmacy Prior Authorization

In response to the APL 17-008 “Requirement To Participate In The Medi-Cal Drug Utilization Review Program”. The DUR program requirements noted are integrated into the responsibly of the Pharmacy & Therapeutic committee as follows:

• Changed: o Title of P&P from “Formulary Exclusions, Limits, and Quotas” to

“Pharmacy Drug Utilization Review (DUR) Program” and the policy statement to include all lists requirements of APL 17-008.

• Added: o The details of the procedure of the SFHP Pharmacy DUR program’s

“three sub-programs: Prospective DUR, Retrospective DUR, and an Education Program for provider, pharmacist and member education.”

o Additions under: Prospective DUR Program Clinical Drug Utilization Review (DUR) Edits Days’ Supply Policy- “Contraceptive therapy for Medi-Cal is

available for a 365 day supply.” Retrospective DUR Program Formulary Class Utilization Review Clinical Monitoring Reports Targeted Retrospective Over/Under Utilization DUR Fraud, Waste and Abuse Program Education Program DHCS Med-Cal DUR Board

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Pharmacy and Therapeutics Committee Pharmacy Policies and Procedures

July 2017

o Statement: The Prospective DUR program is grounded in current, scientifically sound medical evidence and is approved by the SFHP Pharmacy and Therapeutics annually and when changes are recommended.

o Monitoring: “Annual report to DHCS describing the DUR program activities

in the prior calendar year by April 1 of each year.” “Prospective DUR screens, audits, edits, messaging are

presented and reviewed by SFHP P&T Committee for all formulary modifications on a quarterly basis and annually.”

• Deleted: o Information regarding specific products and quantity limits for

Diabetics & Respiratory supplies, and Blood pressure monitors

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Page 1 of 4


Pharmacy and Therapeutics Committee Policy and Procedure number: Pharm-01 Department Owner: Pharmacy Services Lines of Business Affected: Medi-Cal, Healthy Kids and Healthy Workers

POLICY STATEMENT

The San Francisco Health Plan (SFHP) Pharmacy and Therapeutics Committee assures that the pharmacy benefit is consistent with sound clinical principles and processes, and that it complies with current standards of practice. The Committee evaluates, recommends or approves changes in the SFHP drug formulary as well as pharmaceutical management procedures and therapeutic treatment guidelines.

PROCEDURE

I. COMMITTEE COMPOSITION

Chair 1. the SFHP Chief Medical Officer (CMO) or designee

Voting Members 2. the SFHP Associate Medical Director(s) and/or Chief Medical Officer (CMO) 3. the SFHP Director of Pharmacy 4. at least three (3) network physician representatives 5. at least two (2) network pharmacists representatives

Non-Voting Members

1. Aa pharmacist rrepresentative of the pharmacy benefit manager (PBM) 1.2. SFHP staff pharmacist(s), resident(s) and intern(s)

II. COMMITTEE OPERATIONS

1. The SFHP CMO or Associate Medical Director nominates members to the Pharmacy and Therapeutics Committee. The Quality Improvement Committee approves the appointment of these members. Members are appointed for two-year terms and may be reappointed.

2. If a committee member misses two consecutive meetings without notifying SFHP, the committee member may be dismissed from appointment.

3. The Pharmacy and Therapeutics Committee meets quarterly, at least 4 times a year. 4. A quorum is at least 51% of voting members, three (3) of which are physician

representatives. A simple majority vote of those present is required.

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5. The Chair of the committee/CMO is responsible for making specialty physician consultation available to assist the committee, if needed.

6. A Confidentiality and Conflict of Interest Policy governs the committee’s proceedings and statements are signed by committee members annually. Members of the committee shall abstain from voting on any issue in which the member has a conflict of interest with respect to the issuer or the pharmaceutical manufacturer.

6.7. SFHP Pharmacy staff pharmacists coordinate the preparation and distribution of materials reviewed by the committee.

III. COMMITTEE RESPONSIBILITIES

Committee responsibilities include, but are not limited to: 1. Consider safety, access, comparative efficacy, and cost in all matters before the

committee. 2. Review, evaluate, recommend, and/or approve all formulary revisions based on

safety, comparative efficacy and costincluding:. 1. Assessment of safety, efficacy and cost are used to adopt pharmaceutical

management procedures including: a. Pharmaceutical or therapeutic classes covered at any level b. Classes preferred or covered at any level c.b. Preferred medications or preferred therapeutic classes d.c. Limitation of access to medications within therapeutic classes e.d. Prior authorization criteria of each class of pharmaceuticals, where

applicable f.e. Generic substitution, therapeutic interchange, quantity limits, step therapy or

other pharmaceutical management methodsprocedures, g. Quantity limits h.f. Within each class of pharmaceuticals, assess

Preferred agents medicationswithin each class Exceptions process for members Generic substitutions made automatically RequirementsPrior authorization requirements, restrictions, or

limitations applying to the use of certain pharmaceuticals medications 2.3. Review, evaluate and approve the prior authorization process for members and

prescribers. 3.4. Review, evaluate, and/or approve Evaluate and approve interim formulary

changes made by the Pharmacy DepartmentServices. 5. Review, evaluate, and/or approve requests for additions and/or deletions to the

formulary from members, pharmacists or practitioners. 4. Review, evaluate, recommend and/or approve pharmacy and therapeutic treatment

guidelines. 5.6. Review, evaluate, recommend and/or approve prospective drug utilization review

(DUR) programs, prior authorization criteria, and step therapy criteria. 6. Review and evaluate requests for additions and/or deletions to the formulary from

members, pharmacists or practitioners. 7. Review, evaluate, recommend and/or approve retrospective drug utilization review

(DUR) programs including drug class utilization data, over-utilization or under-utilization analysis, and other periodic assessment of claims data and evaluate, recommend and/or approve and recommend formulary modifications or other educational programs when substantive concerns of over- or under-utilization are identifiedas appropriate.

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8. Review, evaluate, recommend and/or approve therapeutic treatment guidelines and pharmaceutical use educational programs.

9. Review and approve annually and upon update, the SFHP periodic updates to the formulary and the pharmaceutical management policies and procedures.

8. made by the Pharmacy Department. 10. Develop and submit the approved Pharmacy and Therapeutics Committee meeting

minutes to the QI Committee. 11. Direct the SFHP Director of Pharmacy to ensure committee actions are effective by

the 20th of the month following each quarterly Pharmacy and Therapeutics Committee meeting after members and providers have been provided notification.

9.12. Direct the SFHP Director of Pharmacy to ensure members and providers have communication annually and after updates to the formulary drug list and pharmaceutical management procedures. Communication should include how to access and use pharmaceutical management procedures and how to request a prior authorization or exception.

IV. COMMITTEE REVIEW REQUIREMENTS

The clinical and biopharmaceutical sources CLINICAL AND BIOPHARMACEUTICAL SOURCES used referenced by the committee to determine formulary and prior authorization criteria and treatment algorithms include, but are not limited to: 1. Peer-reviewed medical journals. 2. Drug information references including Facts and Comparisons (Facts), Up to Date,

Lexi-Comp drug reference database, 3. National evidence-based practice guidelines available through the Agency for

Healthcare Research and Quality - National Guideline Clearinghouse (AHRQ-NGC), the National Comprehensive Cancer Network (NCCN) or other nationally recognized medical organization.

4. Non-promotional materials from drug manufacturers, including FDA-approved drug package inserts and indications for use or AMCP (Academy of Managed Care Pharmacy) formatted formulary dossier documents.

5. Government resources such as US Food and Drug Administration (FDA), US National Library of Medicine (NLM), the Agency for Healthcare Research and Quality (AHRQ), clinicaltrials.gov, and the cdc.gov.

6. Therapeutic class reviews, and new drug monographs, and abbreviated drug reviewsreviews presented at P&T Ccommittee meetings.

7. Recommendations from expert clinicians including members of the P&TPharmacy and Therapeutics Committee.

8. Other materials and/or recommendations of advisory professionals as deemed appropriate by SFHP Medical Directors or Plan Pharmacists.

MONITORING

SFHP’s quarterly Pharmacy and Therapeutics &T Committee meeting agendas and minutes are maintained and subject to retrospective review by SFHP’s Health Services Department.

DEFINITIONS

None

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AFFECTED DEPARTMENTS/PARTIES

Pharmacy Services Health Improvement Pharmacy Benefit Manager

RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS Pharm-02 Pharmacy Prior Authorization Pharm-14 Formulary Exclusions, Limits, and QuotasPharmacy DUR Program PerformRx Policy PTFD-2-01

REVISION HISTORY Effective Date: July 11, 2006 Approval Date: July 11, 2006, March 18, 2009, October 27, 2010, August 22, 2014,

February 16, 2017 Revision Date(s): Revision Date(s): July 11, 2006, February 6, 2009, October 15, 2010,

March 1, 2012, November 7, 2013, August 6, 2014, June 1, 2015, September 9, 2015, September 6, 2016, January 10, 2017, July 19, 2017.

REFERENCES

NCQA Standard UM Procedures for Pharmaceutical Management Health and Safety Code §1367.41 (P&T committee; duties of committee)

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SFHP POLICY AND PROCEDURE Pharmacy Prior Authorization Policy and Procedure number:

Pharm-02

Department Owner: Pharmacy Services Lines of Business Affected: Medi-Cal, Healthy Kids, Healthy Workers

POLICY STATEMENT San Francisco Health Plan (SFHP) requires prior authorization for all non-formulary medications and for select formulary medications. SFHP Pharmacy Services ensure the timely and consistent processing of authorization requests for medications when prescribed for Medi-Cal members who are covered under the terms of the plan’s contract with the Department of Health Care Services (DHCS) and for Healthy Kids and Healthy Workers members who are covered under the terms required by the Department of Managed Health Care (DMHC). Prior authorization decisions are grounded in current, scientifically sound, medical evidence following criteria approved by the SFHP Pharmacy and Therapeutics Committee.1

PROCEDURE SFHP contracts with a pharmacy benefits manager (PBM) to initiate the process for prior authorization (PA) requests. The PBM Authorization Department receives and processes PA requests for SFHP members using SFHP-approved criteria. PA requests that do not meet the SFHP-approved criteria are forwarded to SFHP Pharmacy Services for further review. PA requests are processed according to defined turnaround requirements. Additional processes are established for members to access a short supply of medications after business hours, weekends and holidays. 1. PA Response Turn-Around-Time (TAT) Requirements

SFHP Pharmacy Services department ensures the timely and consistent processing of PA requests for medications when prescribed for all plan members, in accordance

1Per 22 CCR §51003(f), authorization may be granted only for the lowest cost item or service covered by the Medi-Cal program that meets the beneficiary’s medical needs.

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with the terms of the plan’s contract with the DHCS and/or the terms required by the DMHC, by providing the following: A. PA TAT Requirements for Medi-Cal Members:

i. A response (a response is defined as an approval decision, a denial decision or a request for additional information) within one (1) business day24 hours of receiving the request for covered medication requiring prior authorization.

i.ii. A request for information (RFI) extends the turn-around-time requirement to provide time for the prescriber to submit the information needed to make a decision. Non-urgent requests are held open for no more than 30 days from the date of the initial PA request. Urgent requests are held open no more than 72 hours from the time of the original request.

ii.iii. A decision (a decision is defined as an approval or denial) within one (1) business day 24 hours of receiving the necessary medical information.

iii. A decision within 72 hours of receiving the request for an urgent request and for pain management medications for terminally ill members.

iv. A decision for all non-urgent requests within 30 calendar days of receiving the request. Any response or decision delayed beyond this 30-day limit is considered a denial and is processed as such.

B. PA TAT Requirements for Healthy Kids and Healthy Workers Members: i. A decision within 24 hours of receiving the request for a prior authorization

marked “urgent”. ii. A decision within 72 hours of receiving the request for a non-urgent prior

authorization. iii. A decision that requires additional clinical information that cannot be obtained

within 72 hours of the receipt of the request is denied. iv. Any decision delayed beyond 72 hours of the receipt of the request when all

clinical information has been provided is considered an approval and is processed as such.

2. Prior Authorization Process

The PA process consists of several steps beginning with a practitioner request for PA. SFHP contracts with a pharmacy benefits manager (PBM) to initiate the process for prior authorization (PA) requests. PA requests that do not meet the SFHP-approved criteria are forwarded to SFHP Pharmacy Services for further review. PA notification and tracking requirements are managed by the PBM. PA appeal, PA resubmission and PA renewal are further actions in the PA process. A. Requesting a PA

When a practitioner prescribes a medication requiring prior authorization, the practitioner, designee, or contracted pharmacy completes a Prescription Drug Authorization Request Form2 and submits it to SFHP’s PBM for review. PA

2SFHP uses the Prescription Drug Authorization Request Form required for non-Medicare plans per DMHC regulations (Section 1300.67.241)

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requests are received via telephone, fax, or web portal and are date/time stamped by PBM for tracking purposes.

i. The PBM Authorization Department processes all PA requests in accordance with SFHP-approved criteria. SFHP reviews and approves the PBM’s prior authorization policy and procedures annually.

ii. PA requests that do not meet the SFHP-approved criteria are forwarded to SFHP Pharmacy Services department for review. The SFHP Pharmacy Services department may request medically necessary additional information to establish medical necessity from prescribing practitioners by phone and/or fax in order to complete the review of the PA request.

iii. Urgent requests must be clearly marked “urgent” by the provider. Pain management medications for terminally ill members must clearly be marked as such by the provider. (see: H&S Section 1367.215)

iv. Only an SFHP or PBM physician or clinical pharmacist may downgrade a request from “urgent” to “non-urgent.” SFHP notifies the requesting provider of a downgrade within 24 hours of receiving the request.

B. PA Request - Approval Decision All PA requests undergo an initial review by the PBM. If approvable under the SFHP-approved criteria, the PBM issues an approval decision. When a PA request is approved, the PBM automatically faxes an approval notice to the requesting provider. The PA approval notice contains detailed information for the provider on the approved medication, dosage strength, quantity and the duration the authorization. If the dispensing pharmacy is identified, an approval notice is also sent to the dispensing pharmacy.

C. PA Request – Denial Decision PA requests that are not approvable by the PBM are forwarded to SFHP Pharmacy Services for review.

i. PA requests are reviewed by a SFHP Clinical Pharmacist through the PBM case processing system using appropriate P&T approved criteria and/or compendia

ii. PA requests for medications without SFHP-approved PA criteria are reviewed by the SFHP Medical Director.

a. SFHP will not deny coverage for a drug on the basis that the drug is prescribed for a use that is different from the use for which that drug has been approved for marketing by the federal Food and Drug Administration (FDA). (see: H&S Section 1367.21)

iii. Requests for off-label indications, that are not supported by compendia or published clinical trials, can be sent for review by an independent review organization (i.e., Medical Review Institute of America – MRIoA) if deemed necessary by the SFHP Medical Director and/or reviewing pharmacist. MRIoA reviews are done by a board-certified physician in the specialty appropriate to the diagnosis being treated.

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When a PA request is denied, member and requesting physician Notification of Action letters are generated on the same day of the decision. The NOA letter explains the denial decision and includes the name of the SFHP clinician (pharmacist or medical director) who made the decision. Additionally the prescriber NOA letter provides the reviewing clinician’s direct phone number in the event the prescriber wishes to discuss the denial. The NOA letter informs the member and the practitioner of their right to request copies of the criteria used to reach the decision, appeal rights, and instructions on how to appeal the decision.

D. PA Request – Request for Information (RFI) Response For authorization requests where additional clinical information is required, the SFHP pharmacist or Medical Director may contact the prescriber’s office by phone to obtain the information needed to determine medical necessity. Alternatively, a formal RFI can be faxed to the prescriber which will extend the timer in the PBM case processing system. (Section A. ii.)

E. Appeals If a PA request is submitted for a medication that was previously denied and is marked “Appeal” or has some statement regarding an appeal, grievance, or second level review, the request must be forwarded to SFHP Grievance Coordinator for processing. . Appeals are not reviewed by the PBM, but are sent directly to SFHP and are reviewed by the SFHP Grievance Coordinator and Medical Director. (See QI-06: Member Grievances and Appeals)

F. Requests received subsequent to a Denial If a PA request for a medication is resubmitted within 30 days of a previous denial and the request contains additional clinical information that was not available when the original determination was made, then the case can be processed as a reconsideration under the previous case, with notes clearly indicating that the original denial is being reconsidered. If the new request is received via FAX and entered as a new case by the PBM, it is also processed as a new case instead of a “reconsideration” noting the previous case. If the subsequent request is received without new information, it is closed using language to the provider outlining the previous denial and reiterating the appeal process. If the subsequent request is received beyond 30 days, regardless of additional information status, it is processed as a new request and reviewed as such.

G. Prior Authorization Renewal When an approved PA expires, the provider or designee must complete a new authorization request.

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3. Staff Qualification and Responsibilities SFHP uses licensed health care professionals (pharmacists and physicians) to make pharmacy UM decisions that require clinical judgment. Pharmacists may approve, defer, or deny services, while non-professional pharmacy UM staff, under the supervision of appropriately licensed health professionals may approve services when there are explicit Pharmacy Prior Authorization criteria and clinical judgment is not required,. The Pharmacy supervisor, a licensed pharmacist, supervises the above stated pharmacy UM activities. The Pharmacy supervisor provides day-to-day supervision of assigned pharmacy UM staff, participates in staff training, monitors for consistent application of Pharmacy Prior Authorization criteria by pharmacy UM staff for each level and type of UM decision, monitors documentation for adequacy, and is available to UM staff onsite or by telephone.

4. Emergency Supply of Medications outside the PA Process SFHP has established a process for allowing the pharmacy to dispense up to a five (5) day supply of a covered outpatient medication in an emergency situation. When a member presents a prescription that requires an urgent PA outside of normal PBM or SFHP business hours, the pharmacy may fill the prescription with an emergency supply of medication. Pharmacy providers may employ their professional judgment to determine that patient is in need of an emergency supply of medication and may dispense up to a five (5) day supply for select medications without obtaining a PA. The PBM contracts with multiple 24-hour pharmacies to provide services after hours. (See Pharm-07: Emergency Medication Supply)

5. Continuity of Care Prior Authorization Process Medi-Cal members are permitted to continue the use of a Single-Source Medication that is part of a prescribed therapy in effect for the beneficiary immediately prior to the date of enrollment, whether or not the medication is covered by the plan, until the prescribed therapy is no longer prescribed by the physician. Continuity of care approval requires PA request stating that continuity of care is the reason for the request. Continuity of care authorization requests should include evidence of medication claim history in the prior 30 days and the medication must be requested within three (3) months of the member’s initial enrollment.

6. DHCS, Medi-Cal Managed Care Division Non-capitated Drugs: AIDS drugs,

most psychiatric drugs, and drugs to treat alcohol, heroin dependence as defined by DHCS, Medi-Cal Managed Care Division, must be billed as carve outs to Medi-Cal Fee-for-Service (FFS). These medications are not the responsibility of SFHP, but may be obtained through Medi-Cal FFS. Requests received for these medications are logged and the prescribing provider is sent an NOA letter redirecting the provider to Medi-Cal FFS. These requests are not classified as PA requests by SFHP.

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MONITORING

1. SFHP receives and reviews quarterly performance reports from the PBM that include turnaround times for urgent and non-urgent authorization requests.

2. SFHP tracks and reports authorization request turnaround times on a monthly basis to ensure timely processing of authorization requests.

3. SFHP performs monthly inter-rater reliability mock case reviews for all pharmacists making case determinations (SFHP & PBM pharmacists). Individual and aggregate scores are used to determine the need for additional training and/or clarifications to medication utilization review criteria. The results of the inter-rater reliability review and any associated criteria changes are reported to the Utilization Management (UM) Committee.

DEFINITIONS

Response – An approval, denial, or request for information (RFI) if additional clinical information is needed to make a determination of medical necessity. Decision – An approval or denial decision.

AFFECTED DEPARTMENTS/PARTIES Pharmacy Services Health Improvement Provider Relations PerformRx - PBM

RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS 1. Pharm-01 Pharmacy and Therapeutics Committee 2. Pharm-03 Credentialing and Re-credentialing of Pharmacy Providers 3. Pharm-07 Emergency Medication Supply 4. Pharm-08 Pharmacy Annual Review 5. Pharm-14 Formulary Exclusions, Limits, and Quotas 6. Formulary Exception Process Document and flowchart 7. Continuity of Care Single Source Brand Process Document 8. QI-06 Member Grievances and Appeals

REVISION HISTORY

Effective Date: July 11, 2006 Approval Date: July 11, 2006, March 18, 2009, February 13, 2014, December 11,

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2014, October 15, 2015, December 17, 2015, November 16, 2016, February 16, 2017, April 20, 2017

Revision Date(s): July 11, 2006, February 6. 2009, March 1, 2012, June 2012, February 2, 2014, December 2, 2014, September 30, 2015, December 2, 2015, September 8, 2016, January 10, 2017, April 1, 2017

REFERENCES DHCS/SFHP Contract – Exhibit A, Attachment 10, Provision 8G DHCS/SFHP Contract – Exhibit A, Attachment 5, Provision 3F H&S Code §1367.215 H&S Code §1367.21 W&I Code §14185 28 CCR §1300.67.241 NCQA Standard, Procedures for Pharmaceutical Management

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SFHP POLICY AND PROCEDURE Pharmacy Drug Utilization Review (DUR) Program Formulary Exclusions, Limits, and Quotas Policy and Procedure number:

Pharm-14

Department Owner: Pharmacy Services Lines of Business Affected: Medi-Cal, Healthy Kids and Healthy Workers

POLICY STATEMENT San Francisco Health Plan (SFHP) Drug Utilization Review (DUR) Program consists of a Prospective DUR Program, a Retrospective DUR Program and an Educational Program promoting optimal medication use to prescribers, pharmacists, and members. The SFHP DUR Program coordinates with the Medi-Cal DUR Board on retrospective DUR and educational activities for the Med-Cal line of business. The Pharmacy DUR Program activities may focus on identifying medication use patterns to reduce fraud, abuse, waste, inappropriate, unsafe or unnecessary care and develop education programs to optimize medication useuses exclusions, limits, and quotas in order to assure appropriate use of medications, determine formulary and prior authorization criteria, and treatment algorithms. The SFHP DUR Program is Formulary exclusions, limits and quotas are grounded in current, scientifically sound medical evidence and are is approved by the SFHP Pharmacy and Therapeutics Committee.

PROCEDURE The SDFHP Pharmacy DUR Program is managed as three sub-programs: Prospective DUR, Retrospective DUR, and an Education Program for provider, pharmacist and member education. The components of each iscomponents of each are described below: A. PROSPECTIVE DUR PROGRAM The prospective drug utilization review (DUR) program consists of claim system screens, audits, edits, and messaging conducting before each prescription is filled or delivered to the member at the point-of-sale (POS) or point of distribution. Prospective DUR includes screening and audits for drug-disease contraindications, drug-drug

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interactions, appropriate dosing and duration of treatment, therapeutic duplication and other safety and formulary management requirements uEXCLUSIONS, LIMITS, AND QUOTAS used to determine formulary and prior authorization criteria and treatment algorithms. Prescriber, pharmacist and/or member education may be included in the prospective DUR program. Prospective DUR includes, but are is not limited to the following:

1. Brand Medication Policy SFHP has a mandatory generic policy and requires generic substitution when an equivalent AB-rated generic product is available. Dispensing of brand name medications when generic equivalent is available is allowed only in the following cases:

a. Pharmacy bills brand medication as DAW 5 (i.e. billed as a generic product).

b. Pharmacy bills brand medication as DAW 8 (i.e. generic formulation is not currently available).

c. Pharmacy is dispensing one (1) of the following narrow therapeutic index drugs: Armour Thyroid, Coumadin, Dilantin, Synthroid.

d. For all other brand name medication requests, prior authorization with documentation that two (2) generic medications from different manufacturers were tried and did not meet the medical needs of the member. All brand name medication prior authorization requests are reviewed by an SFHP pharmacist or Medical Director.

2. Clinical Drug Utilization Review (DUR) Edits

Clinical DUR edits applicable to SFHP formularies include: safety edits, step therapy, medication quantity limits and age limitations. All DUR edits are based on FDA approved indications, standards of practice, safety and abuse potential considerations.

a. Safety Edits: The First Data Bank (FDB) Duplicate Therapy, Drug-Drug Interaction, Minimum-Maximum dosing, form the basis for the safety screening and auditing that is performed on every prescripitionprescription with warning messages presented to the pharmacist prior to dispensing.

a.b. Step Therapy (ST): ST medications process automatically at the pharmacy point-of-sale if the required prior medications have been tried as evidence by paid claims found in the PBM claim database. If prior paid claims do not exist in the PBM claim database, a prior authorization request must be submitted for consideration of coverage. (See Pharm-02 Pharmacy Prior Authorization). Detailed information on all active step therapy rules is available on SFHP public website at http://www.sfhp.org/providers/formulary/sfhp-formulary/.

b.c. Quantity Limits (QL): limits on medication quantity are applied for safety reasons and to ensure appropriate use of medications.

c.d. Age Limitations (AL): medications with age limitations are available without restriction for all members within the specified age

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group. Members outside the age group must meet specific criteria before the medication is approved.

3. Formulary Preferred Medications Preferred medications listed in the SFHP formulary must be adequately considered or tried and found not to meet the medical needs of a member before SFHP will approve a non-preferred medication. A medication is considered not to meet the medical needs of a member when:

a. The preferred medication is listed on the authorization request as having been tried; OR

b. The preferred medication is in the pharmacy claims history with quantity and duration required by prior authorization criteria or step therapy rules; OR

c. The preferred medication resulted in an adverse reaction for the member.

4. Therapeutic Interchange

Per American College of Clinical Pharmacy (ACCP), therapeutic interchange is defined as the dispensing of a medication that is therapeutically equivalent to but chemically different from the medication originally prescribed by a physician or other authorized prescriber. SFHP follows ACCP’s definition of therapeutic interchange and only employs therapeutic interchange with the prescriber’s approval. Upon receipt of request for a non-formulary medication, SFHP or its Pharmacy Benefits Manager (PBM) makes recommendations for therapeutic interchange alternatives. Recommendations are forwarded to prescriber for review of appropriateness and approval. Criteria for consideration in therapeutic interchange include but are not limited to, availability of agents within a therapeutic class, therapeutic equivalence, safety data, and cost.

5. Formulary Exclusions

The following drugs classes are excluded from the SFHP Medi-Cal formulary and are covered by fee-for-service Medi-Cal. TAR may need to be submitted to fee-for-service Medi-Cal for certain medications.

a. Anti-psychotics b. AIDS/HIV drugs (except didanosine, zidovudine; covered on SFHP

Medi-Cal formulary) c. Alcohol, heroin detoxification and dependency treatment drugs d. Coagulation factors

Medications in the following categories are excluded from the SFHP Medi-Cal, Healthy Kids and Healthy workers formulary:

a. Fertility agents b. Drugs for cosmetic indication (e.g. hydroquinone for hyperpigmentation

of the skin)

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c. Erectile dysfunction (ED) drugs when used for the treatment of ED

Over-the-counter (OTC) medications, supplies and device (such as medications not requiring a prescription) are excluded from the SFHP Healthy Kids and Healthy workers with some exceptions:

a. Insulin and diabetic supplies b. Smoking cessation products b. Prenatal vitamins and folic acid c. Fluoride preparations d. For products for the treatment Phenylketonuria (PKU)

6. Day Supply Policy

SFHP’s standard day supply policy is 30-day supply for brand and 90-day supply for generic medications. Exceptions to the 90-day supply policy for generic medications are as follows:

a. 30-day supply only is allowed for all opiate medications except tramadol.

b. 90-day supply is allowed for select brand medications used to treat chronic conditions. Examples of drug classes include but are not limited to: antidiabetic agents, anticonvulsants, anticoagulants, antidepressants, antihyperlipidemics, antihypertensives, inhaled glucocorticoids, contraceptives.

c. 90-day supply is allowed for all insulin products. d. Up to 100-day supply is allowed for test strips and lancets. e. Up to 90-day supply for brand contraceptives AFTER a 30-day trial on

the brand medication. f. For brand medication not on the select brand medication list, a prior

authorization request must be submitted explaining the need for 90-day supply of brand medication and documenting that one-month trial has been completed and no side effects were experienced.

f.g. Contraceptive therapy for Medi-Cal is available for a 365 day supply.

The Prospective DUR program is is grounded in current, scientifically sound medical evidence and is approved by the SFHP Pharmacy and Therapeutics annually and when changes are recommended.

7. Diabetic Supplies

a. The following diabetic supplies are covered: Glucometers: ACCU-CHEK Nano SmartView and ACCU-CHEK

Aviva Plus, Accu-Chek Designer Care Kit, 1 glucometer per 365 days.

Test strips: ACCU-CHEK SmartView (for Nano) and ACCU-CHEK Aviva Plus test strips with the following quantity limits: 400 per 100 days for all members 800 per 100 days for members with gestational diabetes

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Lancets: ACCU-CHEK FastClix, Multiclix, SoftClix lancets, 100-day supply

8. Respiratory Supplies

a. The following respiratory supplies are covered for members with quantity limit of #2 per 365 days: Inhalers and inhaler assist devices Nebulizers Peak flow meters

9. Blood Pressure Monitors (applicable for Medi-Cal and Medicare/Medi-Cal

formularies) a. Blood pressure monitors with a value up to $100 are covered through

pharmacy benefits with quantity limit of (one) 1 monitor per member every 5 (five) years.

B. RETROSPECTIVE DUR PROGRAM The retrospective drug utilization review (DUR) program consists of reporting and analysis for prescription claims data and other records to identify patterns of fraud, abuse, gross overuse, inappropriate or medically unnecessary care and other formulary management requirements. Prescriber, pharmacist and/or member education may be included in the retrospective DUR program. Retrospective DUR includes, but is not limited to the following:

1. Formulary Class Utilization Review SFHP Pharmacy & Therapeutics Committee requires a utilization analysis of prescription claims for the prior one year when reviewing a drug class. This retrospective utilization analysis evaluates at minimum, the following parameters at the individual drug level for each class review:

a. Unique members b. Total prescriptions c. Cost per prescription d. Total Annual Cost e. Authorization requests (if applicable) f. Authorization approvals (if applicable) g. Prospective edits (if applicable) h. Formulary status

2. Clinical Monitoring Reports

On a monthly or quarterly basis, standard reports are generated and reviewed by clinical pharmacists including but not limited to:

a. Proportion of Days Covered (PDC) and Medication Possession Ratio (MPR) reports for hypertensive, diabetes, cholesterol and asthma medications to assess compliance

b. Acetaminophen accumulator monitoring report

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c. Morphine Equivalents accumulator monitoring report d. Concurrent use of opiates and benzodiazepines report

3. Targeted Retrospective Over/Under Utilization DUR

On a monthly or quarterly basis, standard reports are generated and reviewed by clinical pharmacists including but not limited to:

a. Percent of total zero fill claims for ACE Inhibitors, Angiotensin Receptor Blockers, Beta Blockers, metformin and cholesterol statins

b. Outlier utilization reports by pharmacy, prescriber, and member. c. Members utilizing multiple pharmacies and prescribers d. Members utlilizingutilizing high number of controlled substances

4. Fraud, Waste and Abuse Program

On a quarterly basis, standard reports are generated and reviewed by clinical pharmacist. If appropriate, findings are escalated to the SFHP Compliance department for further review.

C. EDUCATION PROGRAM The Education program consists of verbal and written communication outreach activities developed by the Medi-Cal DUR team and by SFHP to educate prescribers, pharmacists and members on common drug therapy problems with the aim of improving prescribing and dispensing practices. Educational programs are reviewed and approved by the Pharmacy & Therapeutics Committee and may also coincide with activities of the SFHP annual quality Improvement plan. SFHP distributes the DHCS-developed educational program materials, as well as SFHP-developed materials, which are based on SFHP-specific demographics and trends, to providers, pharmacists, and members through newsletter articles, content on provider and member website pages, and as targeted educational campaigns as determined appropriate by the P&T Committee. D. DHCS Med-Cal DUR Board SFHP participates in the State DUR Board by means of a California Association of Health Plans (CAHP) representative. State DUR Board recommendations and advisory positions will be considered for their applicability to the SFHP Medi-Cal members and provider community and may be adopted by SFHP as determined by the SFHP Pharmacy & Therapeutics Committee. SFHP P&T Committee minutes will record the rationale for adopting or declining a recommendation or advisory position. All formulary exclusions, limits, and quotas are approved by the SFHP Pharmacy and Therapeutics Committee and reviewed annually.

MONITORING

A. Annual report to DHCS describing the DUR program activititesactivities in the prior calendar year by April 1 of each year.

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B. Prospective DUR screens, audits, edits, messaging are presented and reviewed by SFHP P&T Committee for all formulary modifications on a quarterly basis and annually.

A.C. Aggregate utilization data is subject to retrospective analysis at least annually, to evaluate over- and under-utilization of services.

B.D. SFHP, on a monthly basis, evaluates member and provider grievances, appeals, and SFHP’s member and provider satisfaction survey responses to identify patters and determine need for modifications.

C. SFHP reviews Managed Care Medi-Cal Noncapitated and Carve-out Drug List from DHCS, when it is available, and make updates accordingly.

D. Exclusions, limits and quotas are presented and reviewed by SFHP P&T Committee for all formulary modifications on a quarterly basis.

DEFINITIONS None

AFFECTED DEPARTMENTS/PARTIES Health Improvement Pharmacy Benefit Manager

RELATED POLICIES AND PROCEDURES, DESKTOP PROCESS and PROCESS MAPS

Pharm-01 Pharmacy and Therapeutics Committee Pharm-02 Pharmacy Prior Authorization

REVISION HISTORY Effective Date: October 15, 2015 Approval Date: October 15, 2015, November 19, 2015, April 21, 2016, November

16, 2016, February 16, 2017 Revision Date(s): November 11, 2015, April 15, 2016, September 8, 2016, January

11, 2017, May 12June 26, 2017

REFERENCES NCQA Standard UM Procedures for Pharmaceutical Management DHCS APL 17-008

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Summary of Policy and Procedure Changes QI-06: Member Grievances and Appeals SFHP made a number of changes to QI-06 to meet the requirements of APL 17-006 and implementation of the federal Mega Reg requirements, including: • Logging of exempt grievances (grievances received over the phone that do not involve coverage

disputes or disputed health care services and resolved by the close of the next business day). • 72-hour turnaround time for expedited grievances (formerly 3 calendar days). • Process of escalation to the Medical Director for potential quality issues. • Person making a grievance/appeal decision did not participate in the prior decision and is not

subordinate to the person who made the prior decision. • Member has 60 calendar days from the NOA to file an appeal (formerly 90 calendar days). • One SFHP level of appeal. • Member must exhaust SFHP appeal process prior to requesting State Fair Hearing. • Member or member’s representative may file a written or oral appeal, but member must sign

written appeal. • SFHP sends acknowledgement letter within 5 days of receipt of appeal. • Same or similar specialty reviewer for clinical appeals. • Services need to be authorized or provided within 72 hours of an overturned appeal or State Fair

Hearing. • Establishes a timeframe (14 calendar days) for resolution extension. • Failure to meet turnaround times allows member to request State Fair Hearing. • State Fair Hearing request must be made within 120 calendar days of Notice of Appeal

Resolution (formerly 90 calendar days). • The Chief Medical Officer is responsible for oversight of the Grievance and Appeal process • Defines “Appeal” (A request by a member for review of an Adverse Benefit Determination,

including, delay, modification or denial of services based on medical necessity, or a determination that the requested service was not a covered benefit).

• Defines “Adverse Benefit Determination” (Any of the following actions taken by SFHP: Denial or limited authorization of a requested service, including determinations based on the type or level of service, including determinations based on the type or level of service, medical necessity, appropriateness, setting, or effectiveness of a covered benefit; Reduction, suspension, or termination of a previously authorized service; Denial, in whole or in part, of payment for a service; Failure to provide services in a timely manner; Failure to act within required timeframes for resolution of Grievances and Appeals; Denial of a beneficiary’s request to dispute financial liability).

• Clarified: Your Rights will only be sent out with the Notice of Appeal Resolution Letters • Updated: When a provider or representative requests an appeal on the member’s behalf, the

member will be sent a grievance/appeal form for their written consent.

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1


Member Grievances and Appeals Policy and Procedure number:

QI-06


POLICY STATEMENT San Francisco Health Plan (SFHP) encourages its members or member’s representative(s) to voice their dissatisfaction with SFHP and/or providers services through the Grievances and Appeals process. The SFHP grievance process is designed to address and resolve members’ concerns in a manner that is timely, fair, and thorough.

PROCEDURE SCOPE The basic grievance process described in this policy and procedure is available to all SFHP members. This policy also includes specific processes that are available only to Medi-Cal beneficiaries. Additional policies govern SFHP’s utilization management process, including the process for initially denying, delaying, or modifying health care services. The grievance process is used when a member or the member’s representative elects to dispute a utilization management decision, or to express any other form of dissatisfaction with the services provided by SFHP or its providers.

I. General

A. Member Rights 1. A member has the right to file a grievance for any reason. Members can file a

grievance that is not about a Notice of Action (NOA) or Notice of Adverse Benefit Determination (NABD) at any time. within one hundred and eighty (180) calendar days from the date the incident or action occurred which caused the member to be dissatisfied. If a member is dissatisfied with a NOA, the member has ninety sixty (6090) calendar days from the date of the NOA to file an appeal. However, Healthy

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Workers (HW) and Healthy Kids (HK) members have (180) calendar days from the date of the NOA to file an appeal.

2. SFHP does not discriminate against a member, or dis-enroll a member because he/she filed a grievance.

3. A member has a right to continuous medical care. A SFHP provider cannot withhold or terminate care because a member has filed a grievance.

4. A member has the right to have a representative; advocate and/or lawyer assist in the grievance process.

5. A member has the right to language translation during any part of the grievance process. Standard documents and correspondence are available in SFHP’s threshold languages. SFHP’s policy, “Use of Interpreter Service and Bilingual Staff and Translation of Member Materials,” details SFHP’s system for addressing cultural and linguistic requirements.

6. A member has the right to propose a solution to a grievance. 7. A member has the right to be informed, by SFHP, of the limited time available to

present evidence in support of an appeal; in addition, if requested by the member, SFHP must provide documentation records in connection with a grievance.

8. The member and/or his/her representative may request copies of the information SFHP used to make the initial adverse determination or the denial decision of an appeal, including any criteria or guidelines used, free of charge.

B. Cultural and Linguistic Requirements The Customer Service Grievance Coordinator and the Clinical Quality Coordinator are trained by the Program Manager, Population Health on cultural and linguistic requirements. This procedure ensures that all grievances are reviewed by the Customer Service (CS) or Clinical Quality Grievance Coordinators for any cultural and linguistic issues. Grievances that are identified as having cultural and linguistic issues are submitted to DHCS for review. Identifying these issues ensure that the grievance process is accessible and fair to all members. In addition, the Program Manager, Population Health will perform annual oversight audits of grievances to ensure that cultural and linguistic issues are being identified, logged and appropriately addressed (CLS-02).

C. Identification, Documentation and Tracking/Trending Disability Components of Member Grievances

SFHP is committed to identifying and reporting on member grievances that have a disability component to them. All grievances are reviewed by the Customer Service and Clinical Quality Coordinators for Disability Components, for example, wheelchair access. The coordinators are responsible for identifying grievances with a disability component and logging the disability component of the grievance in SFHP’s Care Management System.

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D. Member Information SFHP assists its members in understanding and using all internal and external grievance and appeal processes available to them. It provides all members access to comprehensive, accurate and easily understood information about the grievance and appeals procedure. The procedure is published in the Member Handbook or in the Evidence of Coverage (EOC). At minimum, the following information is included: 1. How to file a grievance, by phone or in person, verbally or in writing, by contacting

the primary care practitioner’s office, the medical group or SFHP. 2. How to appeal a grievance determination. 3. How to contact the SFHP Customer Service Department for assistance in the

grievance process, to find an independent advocate, to access translation services or for any other reason.

4. How to request an expedited medical review. 5. How to contact the DMHC, using the toll-free telephone number, the telephone

number for relay services provided for the hearing and speech-impaired, and the website (A separate SFHP policy governs independent medical review).

6. For Medi-Cal beneficiaries: how to request a State Fair Hearing and how to reach the Ombudsman, using toll-free and TDD phone numbers.

E. Provider Information SFHP informs its providers about grievance and appeal procedures through the Network Operations Manual and through regular trainings and audits. SFHP distributes Grievance Intake Forms (attached) in the required threshold languages to all primary care and medical group offices.

F. SFHP Customer Service Department The SFHP Health Improvement Department is responsible for coordinating and processing all clinical grievances. The SFHP Customer Service Department is responsible for coordinating and processing all non-clinical member grievances. Whenever any issue arises that is, in any part, an expression of dissatisfaction, SFHP staff will complete a Grievance Intake form (attached) and forward it to the Customer Service Grievance Coordinator. The intake form documents that a grievance has been expressed by a member and requires resolution through the grievance process. An issue that is an “imminent and serious threat to health” is brought to the immediate attention of the SFHP Medical Director. The intake form includes a description of the problem, a summary of what the member would like done to resolve the grievance, what the member has been told by the SFHP staff and information about how to reach the member. The Customer Service

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Department refers members with grievances involving carved out services to the appropriate agency.

II. How a Member Files a Grievance The SFHP ensures that members have the opportunity to fully express a grievance.

1. Members or their representatives may file a grievance with SFHP by phone, mail, fax, email, in person, or through SFHP’s website.

2. The medical group staff and providers may refer the member to the SFHP Customer Service Department and/or directly assist the member to file a grievance by phone.

3. The member and/or the member’s representative may complete a SFHP Grievance Form and submit it to the SFHP Customer Service Department. Grievance Forms are available in threshold languages through the SFHP Customer Service Department (by mail, fax, in person, or on SFHP’s website) and in all primary care and medical group offices. A member’s signature is not required. Grievances may also be received and identified as the result of receiving a State Fair Hearing from the Department of Health Care Services (DHCS) or Independent Medical Review request or Consumer Complaint from the Department of Managed Health Care (DMHC).

4. Grievances may also be received and identified as the result of an inquiry or other communication with the Department of Health Care Services or DMHC.

5. Upon intake, per the Code of Federal Regulations, members, or their representative, are informed that they may review all documents associated with the grievance case, at any time during the appeal process, including medical records. Members are also informed that they have the right to submit additional evidence in support of their grievance. For an appeal, the member and/or the member representative can request copies of the information SFHP used to make the denial decision, free of charge.

6. If a member or a member’s representative calls the SFHP Customer Service Department with a complaint or an expression of dissatisfaction regarding the plan and/or provider, and the member declines to file a formal grievance, the call will be classified as a grievance.

III. Decline to File a Grievance If a member or his/her representative calls the SFHP Customer Service Department with a complaint or an expression of dissatisfaction regarding the plan and/or provider, and the member declines to file a grievance, SFHP will perform the following procedure: 1. Customer Service Representative will notify the Quality Review Nurse, Customer

Service Manager and Grievance Coordinator. 2. The Quality Review Nurse reviews member’s statement for any clinical and/or

Potential Quality Issues (PQI). 3. If the complaint or expression of dissatisfaction is determined to be non-clinical by

the Quality Review Nurse, Customer Service records this information into

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department’s non-clinical grievance log and sends an acknowledgement letter to the member.

4. If the complaint or expression of dissatisfaction is determined to be clinical by the Quality Review Nurse, the Grievance Coordinator records this information into the Potential Quality Issue Log (see UM-56 Potential Quality Issues) and sends an acknowledgement letter to the member.

IV. Exempt Grievances

Grievances received over the telephone that are not coverage disputes, disputed health care services involving medical necessity or experimental or investigational treatment, and that are resolved by the close of the next business day, are exempt from the requirement to send a written acknowledgement and response. These grievances are entered in QNXT. A grievance that is resolved during the duration of a phone call will be categorized as an “exempt” grievance in the grievance log in QNXT. If the grievance is not resolved during the duration of a call, the grievance will be entered in SFHP’s Care Management System. If the grievance is resolved by the close of the next business day, the grievance will be categorized as “exempt” in SFHP’s Care Management System. If the exempt grievance is not resolved by the close of the next business day, it will be processed as a regular grievance with standard timelines. SFHP will maintains a log of all exempt grievances that will contains the date of the call, the name of the complainant, beneficiarymember identification number, nature of the Grievance, nature of the resolution, and the name of the representative's name who took the call and resolved the Grievance.

V. Expedited Review When grievances of disputed health care services involve a serious and imminent threat to the health of the member, including but not limited to, severe pain, potential loss of life, limb or major bodily function, the grievance process is expedited, and the clinical status of the patient is monitored throughout the process and acts as expeditiously as the member’s health requires. The total time permitted for an expedited review is three-calendar days72 hours (including the specific time the grievance was received). A Medi-Cal member may bypass SFHP’s grievance process and apply for an expedited State Fair Hearing. The member may also file for an expedited State Fair Hearing concurrently with using the SFHP grievance process. If SFHP fails to resolve an expedited issue in 72 hours or its resolution is wholly or partially adverse, the member may also file a grievance. SFHP and/or the member’s provider will provide documentation supporting the need for an expedited hearing. SFHP responds within

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two business days to requests for documents pertinent to the expedited hearing and assigns a representative to participate. 1. The Clinical Quality Coordinator or Quality Review RN informs the member of

his/her right to concurrently notify the DMHC about the grievance, and provides the member with all information contained in the notice for “Filing a Grievance with the DMHC.” SFHP notifies the member of receipt of the grievance through a telephone call, which is documented in SFHP’s case management system. The Clinical Quality Coordinator updates the case in the Care Management System to indicate an expedited review, and documents the date and time of each action taken.

2. The expedited review is initiated immediately upon receipt, and is resolved as soon as possible, but no later than three (3) calendar days72 hours from receipt. SFHP will makes reasonable efforts to provide the member and/or provider with an oral notice of The member and provider are informed of the resolution immediately, by phone or fax by the Clinical Quality Coordinator or Quality Review RN. A written resolution letter follows mailed by the Clinical Quality Coordinator.

3. The Clinical Quality Coordinator sends a resolution letter regarding the disposition or status of the grievance no later than three-calendar days after the grievance is filed. The letter is sent to the member and the practitioner. The letter, at minimum, contains all the components and information contained in the disputed health care services resolution letter template attached to this policy.

If the SFHP’s Quality Review Nurse or designee determines that the request by the member does not qualify as an expedited grievance because the grievance does not involve an imminent and serious threat to the member's health, including but not limited to severe pain, potential loss of life, limb or major bodily function, the Grievance Coordinator Quality Review RN will notify the member by telephone that the member’s grievance will be processed within the standard timeframe of 30 calendar days from receipt and informs the member of his/her right to concurrently notify the DMHC about the grievance, and provides the member with all information contained in the notice for “Filing a Grievance with the DMHC.” In addition, a letter will be sent to the member acknowledging SFHP’s receipt of the member’s grievance and notifying the member that the grievance will be processed as a standard grievance. VI. Clinical and Non-Clinical Grievances All grievances are reviewed by the Quality Review Nurse within one business day to determine whether the grievance or appeal is clinical or non-clinical. If the grievance or appeal is clinical in nature, the Quality Review Nurse works with the assigned Clinical Quality Coordinator to investigate and process the grievance. If the grievance or appeal is determined to be both clinical and non-clinical, it will be processed as a clinical grievance. Also, the Quality Review Nurse will reviews the grievance for any possible PQI. If there is a possible PQI, the Quality Review Nurse will consults with the Medical

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Director (MD) to confirm a PQI investigation should be pursued. Also tThe Quality Review Nurse also reviews the grievance or appeal for any medical quality of care issues or PQI. Any grievances or appeals related to medical quality of care issues or PQI are immediately submitted to the Medical Director. The Quality Review Nurse consults with the Medical Director to confirm a medical quality of care issue or PQI should be pursued. If the grievance is non-clinical, the Quality Review Nurse forwards the grievance to the Customer Service Grievance Coordinator for processing and resolution. VII. Dual Eligible Members The Clinical Quality Coordinator will send a written letter with instructions regarding how to contact and file a grievance with Medicare to members who are dual-eligible (Medi-Medi) and express dissatisfaction with a service related to a Medicare benefit. The Clinical Quality coordinator will not investigate grievances related to Medicare benefits.

VIII. Grievances Alleging Provider Directory Inaccuracies Member expressions of dissatisfaction regarding potential inaccuracies in SFHP’s printed or online directory are processed as grievances. Upon receipt of a grievance alleging inaccuracies in SFHP’s provider directories, the Customer Service Grievance Coordinator will immediately notify and coordinate with the Provider Relations Department. The Provider Relations Department will notify the affected provider within five (5) business days and investigate the allegation pursuant to the processes described in PR-21. The Customer Service Grievance Coordinator will provide a written resolution to the member within thirty (30) calendar days of receipt of the grievance. The Provider Relations Department will correct provider data, if necessary, within thirty (30) business days of receipt of the grievance. When SFHP contracts with Knox-Keene licensed plans, e.g., Kaiser, Delta Dental, VSP, etc., these plans are delegated for grievance resolution and maintenance of their affiliated/contracted providers’ directory information. Grievances regarding directory inaccuracies about providers affiliated with these contracted Knox-Keene licensed health plans are investigated by the respective Knox-Keene licensed plan. These grievances are forwarded by SFHP to the affected Knox-Keene licensed health plan for resolution and are not investigated by SFHP’s Provider Relations Department.

IX. Grievance Process 1. The SFHP Customer Service and Clinical Quality Coordinators are available to

assist the member throughout the grievance process. 2. The Clinical Quality Coordinator will initiate and track all grievances in SFHP’s Care

Management System. 3. A written acknowledgement letter is provided within five (5) calendar days of receipt.

This acknowledgement advises the member that the grievance has been received,

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the date of the receipt, and provides the name, telephone number and address of the SFHP Customer Service Grievance Coordinator for non-clinical grievances and the SFHP Clinical Quality Coordinator for clinical grievances. The letter, at minimum, contains all the components and information included in the acknowledgement letter template attached to this policy.

4. The SFHP Customer Service Grievance Coordinator will route grievances to the member clinical determination queue for the Quality Review Nurse for review. The Quality Review Nurse makes the determination of whether a grievance is clinical or non-clinical or if the grievance should be expedited or not expedited.

5. For non-clinical grievances, this can include administrative appeals, the Customer Service Grievance Coordinator processes and resolves the complaint, under the supervision of the Customer Service Manager. The Customer Service Grievance Coordinator investigates and records all findings in SFHP’s care management system. The findings are presented to the Customer Service Grievance Team to ensure the grievance is fully investigated. The Chief Operations Officer is consulted on an as-needed basis.

6. If the grievance is clinical, this can include administrative appeals; the Clinical Quality Coordinator investigates and processes the grievance. The investigation questions will be developed by the Quality Review Nurse. The investigation responses will be presented to the Grievance Review Committee to ensure that the grievance is fully investigated and will include the all components of the grievance that should be included in the resolution letter. The Grievance Review Committee will also determine if the PQI determination is appropriate. The participants of the Grievance Review Committee will be recorded in SFHP’s Care Management System with at least one SFHP Medical Director present.

7. As needed, the Clinical Quality Coordinators will consult with other staff responsible for the areas of service related to the grievance.

8. All grievances and appeals will obtain documentation of the substance of the issue and investigation of the substance of the grievance/administrative appeal, including any aspect of clinical care involved.

9. The person who filed the grievance is contacted and given the opportunity to present more information regarding the grievance.

10. The Manager, Clinical Quality will review the proposed determine language of each clinical grievance. The proposed determine language will include the nature of the member’s grievance and all investigation results. The Grievance Review Committee comments are included in the final determination letter.

11. The Quality Management Nurse and Clinical Quality Coordinator document all aspects of the grievance and appeal review process in Care Management System, including the Grievance Review Committee comments and attendance, follow up investigation and the Manager of Clinical Quality’s review of the proposed determination language. The name of the physician who provides the initial denial for an appeal is noted to ensure a fair and thorough reassessment by the appropriate reviewers.

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12. The Customer Service Grievance Coordinator drafts the non-clinical grievance resolution letter summarizing the grievance, findings, and resolution. The Customer Service Manager reviews all non-clinical grievance resolution letters prior to mailing.

13. For clinical and non-clinical (including administrative appeals) grievances, the Clinical Quality Coordinator mails the clinical grievance resolution letter to the member within 30 calendar days of receipt. For non-clinical grievances, the Customer Service Grievance Coordinator mails the grievance resolution letter to the member within 30 calendar days of receipt.

14. For any expedited grievance (clinical or non-clinical), the resolution letter is mailed to the member within 72 hours.

15. The written response of clinical and non-clinical grievances includes an explanation of SFHP’s investigation and the specific criteria, as applicable, used to determine the resolution. The letter also includes information regarding the member’s rights to appeal. The resolution template letter is attached to this policy. The resolution letter is timed to allow sufficient time for an appeal (administrative appeal), if the member requests it, within the 30 day time period.

16. The letter includes a member’s right to appeal the decision by a State Fair Hearing, an Independent Medical Review form and the State Ombudsman’s office.

17. SFHP ensures that the person making the final decision for the proposed resolution of a grievance or appeal has not participated in any prior decisions related to the grievance or appeal. Additionally, the decision-maker shall beis a health care professional with clinical expertise in treating a beneficiary’s condition or disease if any of the following apply:

a. an appeal of an Adverse Benefit Determination that is based on lack of medical necessity;

b. , a grievance regarding denial of an expedited resolution of an appeal; or c. any grievance or appeal involving clinical issues.

16. 17.18. For grievances involving a denial of medical services based in whole or in part

that the service is not medically necessary, the Clinical Quality Coordinator includes in the resolution letter:

a. A clear statement of the criteria, clinical guidelines or medical policies used in reaching the determination;

b. An IMR form, IMR instructions, and a return envelope addressed to the DMHC with the resolution letter.

18.19. For grievances involving a denial of medical services based on a determination that the requested service is not a covered benefit, the Clinical Quality Coordinator will include in the resolution letter:

a. A description and page number of the provision of the contract, Evidence of Coverage or Member Handbook that excludes the service; and

b. The following statement: “If you believe the service you requested was denied on the grounds that it was not medically necessary, you can contact the Department of Managed Health Care to see if you are eligible for Independent Medical Review.”

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20. SFHP utilizes the required DHCS letter templates when informing members of a denial or appeal resolution. Copies attached to this Policy.

19. Medi-Cal members have ninety sixty (9060) calendar days from the date on the Notice of Action to file an appeal of the Notice of Action with San Francisco Health Plan. HW and HK members have (180) calendar days from the date on the Notice of Action to file an appeal of the Notice of Action with San Francisco Health Plan. A member may request a State Hearing regarding the Notice of Action from the Department of Social Services (DSS) within ninety (90) calendar days from the date on the Notice of Action at the same time the appeal is filed with the San Francisco Health Plan. However, an IMR may not be requested if a State Hearing has already been held for that Notice of Action.

21. All resolution letters will contain provision information of language assistance services and a nondiscrimination notice for a grievance (administrative appeal) process.

20. 21.22. The Grievance Coordinator is responsible for compiling grievance trending data

for the Quality Improvement Committee’s review and monthly review by the Grievance Oversight Committee, as applicable.

22.23. SFHP adheres to the requirements and timeframes in processing member grievances.

23.24. SFHP, medical group staff and committee members who assist in the grievance process agree to strict standards of confidentiality.

24.25. SFHP stores all grievances electronically in SFHP’s Care Management System. Hard copy files may be printed from SFHP’s Care Management System. Hard copy grievance files that pre-date the implementation of SFHP’s Care Management System are stored in a secure location for at least seven years from the date of the file’s creation or the date when the service occurred, whichever is later (Privacy Rule). Books and records related to Medi-Cal shall be maintained for a minimum of seven years from the termination of the Contract with the Department of Health Care Services (DHCS).

X. Grievances of Disputed Health Care services (Denial Member Appeals) 1. Medi-Cal members have ninety sixty (6090) calendar days and HW and HK

members have (180) calendar days from the date of the NOA to file an appeal. 2. The member must first exhaust SFHP’s internal appeal process before filing a State

Fair Hearing. SFHP has only one level of appeal for members. 1.3. If the member is not satisfied with the appeal decision, the member is given

instructions for initiating an appeal through the State Fair Hearing Process or an application for IMR.

2. Members may file an appeal with SFHP regarding the NOA and request a State Fair Hearing regarding the NOA at the same time. However, an IMR may not be requested if a State Fair Hearing has been held for the NOA.

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4. Appeals may be filed by a beneficiary, a provider acting on behalf of the beneficiary, or an authorized representative either orally or in writing.

5. An oral appeal (excluding expedited Appeals) shall be followed by a written, signed appeal. The date of the oral appeal establishes the filing date for the appeal. The SFHP Grievance Analyst sends the member SFHP’s Member Grievance/Appeal Form and contacts the member by phone to assist the member with completion.

6. If an appeal is filed on behalf of a member, SFHP requires a written, signed consent from the member. If the consent form is not received from the member, SFHP will still process the appeal. The consent form will be sent to the member and documented in the Care Management System.

3.7. Both pre-service and post-service appeals adhere to the above timelines. 4.8. The Clinical Quality Coordinator sends the member an acknowledgement letter

within five (5) calendar days upon receipt of the appeal. The letter, at minimum, contains all the components (i.e., receipt date, name, telephone number, and address of representative who may be contacted) and information included in the acknowledgement letter template attached to this policy. A copy of the acknowledgement letter will be sent to the provider, if the provider appeals on the member’s behalf.

5.9. For appeals that are denied, the Clinical Quality Coordinator ensures that the appeal fully documents the substance of the appeal and any actions taken. This will include but not limited to the member’s reason for appealing the previous decision, additional clinical or other information provided with the appeal request, any clinical care involved, previous denial or appeal history, and any follow-up activities associated with the denial and conducted before the current appeal.

6.10. SFHP fully investigates the content of the appeal and documents findings. SFHP does not give deference to the denial decision.

7.11. The member has the opportunity to submit written comments, documents or other information relating to the appeal within five (5) calendar days.

8.12. For clinical appeals, the reviewer must be a new physician who was not involved in the initial determination and who is not the subordinate of any physician involved in the initial determination.

13. At least one of the physician reviewers should be a practitioner in the same or similar specialty in the event that the initial decision is upheldif any of the following apply:

a. an appeal of an Adverse Benefit Determination that is based on the lack of medical necessity;

b. , a grievance regarding denial of an expedited resolution of an appeal;, or a.c. any grievance or appeal involving clinical issues.

9.14. If the initial decision is not overturned, the SFHP Medical Director may send the appeal to an independent external medical review organization appropriately qualified to review the medical issue for a final decision. The outside final reviewer may recommend overturning or upholding the initial decision.

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10.15. The decision of a pre-service appeal and notification to the member is within 30 calendar days of the receipt of the request. A copy of the resolution letter will be sent to the provider, if the provider appeals on the member’s behalf.

11.16. The decision for a post-service appeal and notification to the member is within 30 calendar days of the receipt of the request. A copy of the resolution letter will be sent to the provider, if the provider appeals on the member’s behalf.

17. The decision of an expedited appeal and notification to the member is within 72 hours of the receipt of the request. A copy of the resolution letter will be sent to the provider, if the provider appeals on the member’s behalf.

12.18. The decision of anFor overturned appeals, must beservices are authorized or provided services no later thanwithin 72 hours from the date SFHPof reverses the determinationdecision to overturn.

13.19. SFHP’s Medical Director reviews and signs all appeal resolution letters which reference the benefit provision, guidelines, protocols or other similar criterion on which the appeal decision is based.

14.20. The appeal resolution letters includes a list of titles and qualifications, including specialties of the individuals participating in the appeal review.

15.21. The appeal resolution letters is written in easy-to-understand language. The resolution letter includes a complete explanation of the grounds for the denial written in plain language that a layperson can understand and does not include abbreviations or acronyms that are not defined or health care procedure codes that are not explained.

16.22. Additional information for further appeal rights will be given to the member with the resolution letter.

17.23. Members will have reasonable access to and copies of all documents relevant to the appeal, free of charge, upon request.

18.24. The notice of the appeals process to members will be in a culturally and linguistically appropriate manner.

19. An authorized representative may act on behalf of the member. 25. The member will have continued coverage pending the outcome of an appeal. 20.26. SFHP utilizes the required DHCS letter templates when informing members of a

denial or appeal resolution. Copies attached to this Policy. Appeals that are addressed by the member grievance process include disputes that are regarding denials of pharmaceuticals or clinical services that were requested, but have not been provided. Appeals that are addressed by the Provider Dispute Resolution Process (see CL-07) are regarding the denial of a claim or the denial of a service that has been rendered. SFHP may utilize the right to verify if an appeal has been made on behalf of the member.

XI. Administrative Appeals

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Administrative appeals are appeals of denial decisions that are based on reasons other than lack of medical necessity are processed as non-clinical grievances, as well as appeals of a grievance resolution. The investigation will include: 1. Documentation of the substance of appeals and actions taken. 2. Investigation of the substance of appeals, including any aspect of clinical care

involved.

XII. Reporting The Clinical Quality Coordinator initiates member grievances in Care Management System, which is used for generation, aggregation and tabulation of grievances. The Care Management System records the following information: 1. The date and time the grievance or appeal is filed 2. The name of the member filing the grievance or appeal and if applicable, the person

representing the member 3. The name of the staff person receiving recording the grievance or appeal 4. A description of the grievance 5. A code for tracking the grievance by category (attached) 6. Information regarding physical or language requirements that are relevant to

ongoing communication with the member or the member’s representative 7. Designation that the grievance has a cultural and/or linguistic component 8. Designation that the grievance has a disability component 9. Designation that the grievance included a report of potential inaccuracy in the

provider directory 10. A description of all actions taken to investigate and resolve the grievance or appeal

and the dates the actions were taken 11. The proposed resolution 12. The date that the member is notified of the proposed resolution 13. A dated record of all member contacts 14. The name of the person responsible for resolving the grievance or appeal 15. The date that the issue is resolved XIII. Pending and Unresolved Grievances

SFHP makes every effort to resolve grievances within the required timeframe, but for grievances that are pending or unresolved for 30 calendar days or more, SFHP continues to work towards a grievance resolution and highlights that SFHP exceeds the 30-day timeframe in the Grievance Log. SFHP reports any pending grievances that are unresolved for 30 calendar days or morethese greivancesgrievances to DMHC and DHCS on a quarterly basis through the quarterly grievance reports. If a grievance or appeal is not resolved within 30 calendar days, SFHP may extend the resolution timeframes by up to 14 calendar days when a member requests an extension

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or SFHP notifies DHCS that there is a need for additional information to delay which is in the best interest of the member. When a member does request an extension, SFHP must adhere to the following:

• Make reasonable efforts to provide the member with an oral notice of the extension

• Provide written notification within two (2) calendar days (oral notice) and notify the member of the right to file a grievance if the member does not agree.

• The extension will not go beyond the 14 calendar days. • If SFHP fails to adhere to the extension timelines, the member can file a State

Fair Hearing.

XIV. Filing a Grievance with the DMHC A SFHP member may file a grievance with the DMHC after completing SFHP’s grievance process or after 30 calendar days since the grievance was filed. An earlier review with DMHC may be allowed in expedited situations. For grievances pertaining to dissatisfaction with a Notice of Action, an IMR may not be requested if there was a State Hearing regarding the Notice of Action. 1. SFHP includes the following language in all correspondence related to the grievance

and appeal process and in SFHP’s Member Handbook: "The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1 (800) 288-5555 or (415) 547-7800 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online."

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2. When SFHP receives notification that a member has filed a grievance with the DMHC, the Compliance & Regulatory Affairs Department submits a response and copies of relevant documents from the SFHP grievance file, including all related medical records and the applicable evidence of coverage within five-business days of the request or 24 hours for expedited requests.

3. Upon receipt of a DMHC grievance determination, SFHP acts to implement the decision within the deadlines set by the DMHC.

XV. State Ombudsman Office SFHP informs Medi-Cal beneficiaries in their Handbook, and in all correspondence regarding the grievance and appeal process that they may call the State Ombudsman for help with a grievance. The Ombudsman Office is reached toll-free at 1-888-452-8609. The TDD number is 1-800-952-8349. Its office hours are Monday-Friday, 8am to 5 pm, closed on State holidays. XVI. State Fair Hearing SFHP informs Medi-Cal beneficiaries in their Member Handbook and in all correspondence regarding the grievance and appeal process that, in addition to the SFHP grievance process, they members may request a State Fair Hearing. For grievances pertaining to dissatisfaction with a Notice of Action (appeals), members must exhaust SFHP’s appeal process first before requesting members may request a State Fair Hearing. Requests for State Fair Hearing must be filed within regarding the Notice of Appeal Resolution (NAR) notice of Action from the Department of Social Services (DSS) within ninety sixty (6012090) calendar days from the date on the Notice of Action Notice of Appeal Resolution (NAR). If SFHP fails to issue a NAR within the required timeframe, the member is considered to have exhausted SFHP’s appeal process and may request a State Fair Hearing. Members may file an appeal with San Francisco Health Plan regarding a Notice of Action and request a State Hearing regarding that Notice of Action at the same time. 1. The member or the member’s representative is informed that:

• Information regarding the State Fair Hearing process is available by writing the California Department of Social Services (CDSS), State Hearing Division, PO Box 944243, MS 19-37, Sacramento, CA, 94244-2430, or by calling 1-800-952-5253. The TDD number is 1-800-952-8349.

• Requests for a State Fair Hearing can be made one of the following ways: o To the county welfare department at the address shown on the Notice of

Action. o To the California Department of Social Services, State Hearings Division,

P.O. Box 944243, Mail Station 19-37, Sacramento, California 94244-2430. o To the State Hearings Division

California Department of Social Services Public Inquiry and Response

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Phone 1-800-952-5253 (Voice) 1-800-952-8349 (TDD) Fax (916) 651-5210 or (916) 651-2789

• The member or the member’s representative may choose to be represented by a

friend, an attorney, or another person at the State Fair Hearing. To find out about free legal assistance, the member may call the toll-free number of Public Inquiry and Response Unit at 1-800-952-5253.

• The member or the member’s representative may call the State Ombudsman for

help. The Ombudsman Office is reached toll-free at 1-888-452-8609. The TDD number is 1-800-952-8349, Monday-Friday. Its hours are 8 a.m. to 5 p.m., closed on State holidays.

• The member or the member’s representative must request the hearing within

12090 calendar days of an action to delay, defer or modify health care servicesfrom the date of the Notice of Appeal Resolution (NAR). When a member files for a hearing within 10 days of a notice to delay, modify or deny medical services, current services will be authorized until a State Fair Hearing decision is made.

• • The member or the member’s representative may examine the materials that

make up the record for the State Fair Hearing decision, and may locate the record by contacting the Public Inquiry and Response Unit at 1-800-952-5253.

• Any information that the member provides for a hearing may be shared with the county Department of Social Services or with the United States Department of Health and Human Services.

2. When SFHP receives notification that a member has requested a State Fair Hearing, the Compliance and Regulatory Affairs Department coordinates an investigation, compiles evidence for the case, and prepares a written statement of position responsive to the member’s request. As part of its investigation, SFHP’s Customer Service may be asked to contact the member directly in order to obtain clarification of the member’s issue, or to resolve the member’s issue prior to the State Fair Hearing. If SFHP and the member are able to resolve the member’s issue prior to a State Fair Hearing, and the member agrees to withdraw his/her request for a State Fair Hearing, SFHP’s Customer Service assists the member in accordance with the procedure detailed below: • State Fair Hearing requests can only be withdrawn by the member, not by SFHP. • Customer Service conducts a conference call with the member and the

Department of California Social Services Office by calling (800) 743-8525.

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3. 4.3. A copy of the position statement is sent by certified mail via the United States

Postal Service to the member, to the Department of Health Care Services MMCD – Ombudsman Unit PO Box 997413, MS 4412, Sacramento, CA 95899-7413; and to CDSS, State Hearing Division, PO Box 944243, MS19-37, Sacramento, CA 94244-2430. SFHP submits its position statement at least five-business days prior to the date of the hearing.

5.4. When a finding on the final disposition of the case is received from the State Fair Hearing Officer, SFHP acts to implement the order within the deadlines set by the order. If the issue is a medical service, it is authorized within five business daysno later than 72 hours from the date SFHP receives notice reversing the determination or sooner if medically indicated. If the service has already been rendered, any outstanding claims are reimbursed within five (5) business days.

XVII. The Medical Group’s Role

1. SFHP relies on its medical groups to encourage SFHP members to express any

service dissatisfaction directly to SFHP and to work with SFHP to resolve grievances as quickly and as fairly as possible. The member has the right to file a grievance directly to their Medical Group.

2. Medical groups and primary care providers are required to inform members of their right to submit their concern to the Health Plan and must know how to assist members in the SFHP grievance process and have SFHP Grievance Forms available.

3. When a member expresses any form of dissatisfaction, the medical group staff and providers must give the member a SFHP Grievance Form, and offer assistance to submit it. Medical group staff may also advise the member to contact SFHP's Customer Service Department by phone, fax or email and may directly assist the member with filing a grievance with the SFHP Customer Service Department by phone.

4. Medical group staff and providers are required to assist in the review and resolution of member grievances. This process includes retrieving medical records and providing any other information necessary to resolve the grievance.

5. The medical group assures that the member receives continuous medical care during the grievance process.

6. Medical groups and providers must take corrective action as determined by a member grievance resolution, and also address systemic issues identified in the grievance process.

XVIII. Delegation

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1. SFHP delegates the grievance process to one (1) medical group, Kaiser Health Plan Foundation, and one vendor for non-specialty mental health, Beacon Health Strategies.

2. SFHP requires corrective action whenever it identifies a problem in Kaiser Health Plan’s grievance process, and assigns a deadline for receiving evidence that the problem has been resolved. For serious or persistent problems, SFHP may require that Kaiser Health Plan refer all member grievances directly to SFHP for resolution.

XIX. Quality Improvement Committee Oversight 1. The SFHP Quality Improvement Committee oversees the grievance process. The

SFHP Director of Health Improvement is responsible for maintaining grievance procedures, reviewing the operation of the process, and leading SFHP’s quality committees in identifying emergent patterns of grievances in order to initiate systemic improvements in SFHP operations.

2. The SFHP quarterly grievance report identifies grievances by category. The report includes grievances that have a cultural and linguistic, disability, or provider directory component.

c. 3. At least quarterly, the Governing Board reviews the activities of all quality committees. SFHP also conducts a review and analysis on at least a quarterly basis, of all recorded grievances related to access to care, quality of care and denial of services, and takes appropriate action to remedy any system problems identified in such reviews. Annually, the Governing Board reviews the Quality Improvement Evaluation, which includes tabulated grievance data, an evaluation of grievance and complaint trends, member satisfaction survey results and related data. The Quality Improvement Evaluation also proposes priority areas for improvement, and related activities and goals. The Governing Board may direct SFHP to improve the quality and efficiency of the grievance process, or to initiate improvement activities that directly address the individual or systemic issues raised.

XX. Grievance Oversight Committee (Internal) 1. The San Francisco Health Plan’s Member Grievance Oversight Committee is a

multidisciplinary committee composed of representatives from the Chief Medical Officer, Chief Operations Officer, Customer Service, Provider Relations, Health Improvement, Care Support, Pharmacy, Clinical Operations and State and Regulatory Affairs.

2. The Chief Medical Officer (CMO) is responsible for overseeing the Grievance and Appeal System.

1.3. The CMO along with Tthe committee members reviews individual member grievances and works as a team to resolve the issues. In addition, the committee

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also identifies systematic internal and external issues to prevent further occurrences and reviews grievance data for trends.

2.4. The committee meets monthly. Ad hoc meetings can be called by any member of the committee to discuss issues.

3.5. A committee member will notify the grievance department when an urgent issue cannot wait for the next scheduled meeting.

4.6. Each issue brought to the committee will include a summary of the issue, appropriate facts and action(s) taken to date to resolve the issue.

5.7. Committee members will discuss the issue(s), recommend action(s) to resolve, and assign responsibility for actions to committee member(s).

6.8. Committee member(s) with assigned task(s) will update the grievance staff member of outcomes prior to the following meeting or sooner depending on the urgency of the issue(s).

7.9. The committee will review aggregate data for trends and make recommendations for interventions when opportunities for improvement are identified. This also includes review of delegate grievance reports.

8.10. The committee will review any system level trends or trends identified at the monthly meetings and initiate a corrective plan (CAP) if necessary.

9.11. The committee will discuss internal and external updates that could potentially affect the volume or type of grievances received.

XXI. Grievance Review Committee (Internal) 1. San Francisco Health Plan’s Grievance Review Committee is a multidisciplinary

committee composed of representatives from the Chief Medical Officer, Associate Medical Director, Customer Service, Provider Relations, Health Improvement, and Compliance and Regulatory Affairs. The committee reviews individual member grievances and works as a team to ensure that all the components of the grievances have been resolved.

2. Each grievance brought to the committee will include a summary of the grievance, appropriate facts and action(s) taken to date to resolve the issue with the provider’s response.

3. Committee members will discuss the issue(s) and recommend any additional action(s) to resolve the grievance.

4. Committee members will ensure that all components of the grievance have been resolved and recommend these components to be included in the resolution letter.

5. Committee members will determine if the grievance involves a PQI. 6. Committee member(s) with assigned task(s) will update the grievance staff member

of outcomes prior to the following meeting or sooner depending on the urgency of the issue(s).

7. The committee will review any trends identified at the weekly meetings and initiate a corrective plan (CAP) if necessary.

8. The committee will discuss internal and external updates that could potentially affect the volume or type of grievances received.

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XXII. Reporting Grievances to the State 1. SFHP submits a quarterly grievance report to DHCS and DMHC using their

respective report templates. 2. SFHP submits an annual grievance report to DHCS and DMHC using their

respective report templates.

XXIII. Trending Grievances 1. All grievances will be analyzed on a monthly basis. For a threshold of three or more

grievances identified in the prior three months (filed by unique members) a summary will be sent to the clinic or medical group.

2. The trended grievance report will be presented with recommendations at the Grievance Oversight and Access Committees. The committees will provide additional recommendations.

3. For any identified trending level grievances not listed above, the Grievance Analyst will submit a summary to the clinic or medical group.

4. If one grievance is identified as egregious, the Grievance Review Committee, Grievance Oversight Committee or Access to Care Committee may recommend a CAP or notification as appropriate.

MONITORING

Reporting: 1. SFHP submits quarterly grievance reports to DMHC and DHCS which include:

a. DMHC – i. Grievance Report,

b. DHCS- i. Grievance Report ii. Community Based Adult Services (CBAS) Report Medi-Cal Only

Report iii. Mental Health Report iv. Optional Targeted Low Income Children (OTLIC) Report,

c. v. Seniors and Disabilities (SPD) Report, Universal Report 2. SFHP submits a quarterly grievance report to the Delegated Medical Groups. 3. SFHP submits a quarterly grievance report to QIC. 4. SFHP submits a quarterly grievance report for access grievance to the Access to

Care Committee.

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5. SFHP oversees the delegation of the grievance process that is conducted by Kaiser Health Plan through quarterly reviews of Kaiser’s grievance log and annual audits.

6. SFHP submits a quarterly report of Decline to File Grievances and Exempt Grievances to the Grievance Oversight Committee (GOC).

Internal Monitoring: 1. 1. SFHP reviews and analyzes all grievances on a monthly basis. For a

threshold of three or more grievances identified in the prior three months (filed by unique members), or for any exceptions that meet the documented thresholds, a summary will be sent to the clinic or medical group.

2. To ensure the appropriate initial classification of grievances between clinical and non-clinical grievances and expedited and non-expedited, internal monitoring by inter-rater reliability will be conducted on a quarterly basis. Each quarter, a random selection of 10 cases will be selected for review. The 10 cases will be blinded and the SFHP Medical Director will review the cases and assign “clinical or non-clinical” classifications to each case. A 90% inter-rater reliability threshold has been established. If the results are less than 90%, additional training and supervision will be provided to the Quality Review RN.

3. The Grievance Coordinator is responsible for compiling grievance trending data for the Quality Improvement Committee’s review and monthly review by the Grievance Oversight Committee, as applicable.

DEFINITIONS

1. Administrative Appeals: an appeal of a denial based on reasons other than the lack of medical necessity.

2. Adverse Benefit Determination: any of the following actions taken by SFHP: • Denial or limited authorization of a requested service, including determinations

based on the type or level of service, including determinations based on the type or level of service, medical necessity, appropriateness, setting, or effectiveness of a covered benefit.

• Reduction, suspension, or termination of a previously authorized service. • Denial, in whole or in part, of payment for a service. • Failure to provide services in a timely manner. • Failure to act within required timeframes for resolution of Grievances and

Appeals. • Denial of a beneficiary’s request to dispute financial liability.

3. Appeal: a request by a member for review of an Adverse Benefit Determination, including, delay, modification or denial of services based on medical necessity, or a determination that the requested service was not a covered benefit.

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4. Clinical Grievance: a clinical grievance is defined as any issue concerning the services provided by a clinic, hospital, provider or pharmacy. The types of grievances considered to be clinical in nature include: • Quality of Service (by clinic/hospital/provider) • Access • Pharmacy issues • Quality of Medical Care • Denials, Refusals (formulary, denial of service/treatment) • Cultural, Linguistic, and Health Education (by clinic/hospital/provider)

5. Complainant: is the same as “grievant,” and means the person who filed the grievance including the enrollee, a representative designated by the enrollee, or other individual with authority to act on behalf of the enrollee.

6. Complaint: is the same as “grievance.” 7. Disputed health care service: Any health care service that is eligible for coverage

and payment by SFHP or medical group that has been delayed, denied, or modified by a decision of SFHP or one of its medical groups. The decision to delay, deny or modify must be made, in whole or in part, due to a finding that the service is not medically necessary.

8. Expedited review: an accelerated review and reporting process for grievances involving an imminent and serious threat to the member’s health. An “imminent and serious threat to health” includes, but is not limited to, serious pain, the potential loss of life, limb, or major bodily function, or the immediate and serious deterioration of the health of the member.

1.9. Grievance: a written or oral expression of dissatisfaction regarding the plan and/or provider about any matter other than an Adverse Benefit Determination, including quality of care concerns, and may include a complaint, or dispute, request for reconsideration or appeal made by an enrollee or the enrollee’s representative to SFHP or to any entity with delegated authority to resolve grievances on behalf of SFHP. Where the plan is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance.

2.1. Complaint: is the same as “grievance.” 3. Member Appeal: a request to change a previous decision made by SFHP. A

member or the authorized representative of a member may appeal any adverse decision, benefit coverage decision, delay, modification or denial of services based on medical necessity, or a determination that the requested service was not a covered benefit as well as an appeal of a grievance resolution.

4. Pre-service Appeal: a request to change an adverse determination for care or service that the organization must approve, in whole or part, in advance of the member obtaining care or services. A member’s request for an appeal of a denial for service excluded from SFHP’s benefits package is a pre-service appeal if the member has not received the requested services. In this case, the member may not receive coverage for the requested.

5. Post-service Appeal: a request by a provider to change an adverse determination for care or services that have already been received by the member.

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6.1. Complainant: is the same as “grievant,” and means the person who filed the grievance including the enrollee, a representative designated by the enrollee, or other individual with authority to act on behalf of the enrollee.

7.1. Resolved: the grievance has reached a final conclusion with respect to the member’s submitted grievance, and there are no pending member appeals within the plan’s grievance system, including entities with delegated authority.

8.1. Expedited review: an accelerated review and reporting process for grievances involving an imminent and serious threat to the member’s health. An “imminent and serious threat to health” includes, but is not limited to, serious pain, the potential loss of life, limb, or major bodily function, or the immediate and serious deterioration of the health of the member.

9.10. Independent medical review (IMR): The expert review of disputed health care services by an outside organization that contracts with the Department of Managed Health Care (DMHC).

11. Non-Clinical Grievance: a non-clinical grievance is defined as any issue concerning the services provided by SFHP and its non-clinical components. The types of complaints considered to be non-clinical in nature include: • Billing • Benefits/Coverage (benefits, does not like HMO business rules) • Cultural, Linguistic, and Health Education (by SFHP staff, SFHP materials) • Quality of Service (by SFHP staff) • Enrollment (cancellation of coverage, premium increase) • Report of potential inaccuracy in the printed or online provider directory(ies)

12. Notice of Action (NOA): a formal letter telling members that a medical service has been denied, deferred, or modified.

13. Notice of Adverse Benefit Determination (NABD): same definition of NOA. 14. Notice of Appeal Resolution (NAR): appeal resolution letter determining if the appeal

will be overturned or upheld. 15. Potential Quality Issue (PQI): these are potential issues with the quality of care or

service delivered by a practitioner. SFHP provides a mechanism for peer review for PQIs in the form of a committee that meets to evaluate the need to alter the practitioner’s participation in its health care delivery system based on evidence of serious quality deficiencies. The Plan also provides reports to the Medical Board of CA and other reporting agencies as required. PQIs include provider preventable conditions (PPC). As defined by federal regulations, PPCs are healthcare acquired conditions (HCAC) in inpatient hospital settings, as well as other provider-preventable conditions (OPPC) in all healthcare settings.

16. Resolved: the grievance has reached a final conclusion with respect to the member’s submitted grievance, and there are no pending member appeals within the plan’s grievance system, including entities with delegated authority.

10.1. Disputed health care service: Any health care service that is eligible for coverage and payment by SFHP or medical group that has been delayed, denied, or modified by a decision of SFHP or one of its medical groups. The decision to delay, deny or

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modify must be made, in whole or in part, due to a finding that the service is not medically necessary.

1. Notice of Action (NOA): a formal letter telling members that a medical service has been denied, deferred, or modified.

1. Notice of Adverse Benefit Determination (NABD):same definition of NOA. 11.1. Notice of Appeal Resolution (NAR):appeal resolution letter determining if the

appeal will be overturned or upheld. 12.1. Clinical Grievance: a clinical grievance is defined as any issue concerning the

services provided by a clinic, hospital, provider or pharmacy. The types of grievances considered to be clinical in nature include: • Quality of Service (by clinic/hospital/provider) • Access • Pharmacy issues • Quality of Medical Care • Denials, Refusals (formulary, denial of service/treatment) • Cultural, Linguistic, and Health Education (by clinic/hospital/provider)

13.1. Non-Clinical Grievance: a non-clinical grievance is defined as any issue concerning the services provided by SFHP and its non-clinical components. The types of complaints considered to be non-clinical in nature include: • Billing • Benefits/Coverage (benefits, does not like HMO business rules) • Cultural, Linguistic, and Health Education (by SFHP staff, SFHP materials) • Quality of Service (by SFHP staff) • Enrollment (cancellation of coverage, premium increase) • Report of potential inaccuracy in the printed or online provider directory(ies) • Potential Quality Issue (PQI): these are potential issues with the quality of care or

service delivered by a practitioner. SFHP provides a mechanism for peer review for PQIs in the form of a committee that meets to evaluate the need to alter the practitioner’s participation in its health care delivery system based on evidence of serious quality deficiencies. The Plan also provides reports to the Medical Board of CA and other reporting agencies as required. PQIs include provider preventable conditions (PPC). As defined by federal regulations, PPCs are healthcare acquired conditions (HCAC) in inpatient hospital settings, as well as other provider-preventable conditions (OPPC) in all healthcare settings.

15. Provider Appeal: request to reconsider an initial denial decision of clinical services or pharmaceuticals that were requested that have occurred where it is not done on the behalf of the member.

16. Administrative Appeals: an appeal of a denial based on reasons other than the lack of medical necessity.

AFFECTED DEPARTMENTS/PARTIES Claims Clinical Operations (UM)

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Customer Service Pharmacy Provider Relations Health Improvement Performance & Process Improvement Compliance & Regulatory Affairs

RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS 1. Provider Complaint and Problem Resolution (PR-05) 2. Provider Dispute Resolution Workflow (CL-07) 3. Independent Medical Review (QI-07) 4. Oversight of Delegated Functions (DO-02) 5. Oversight of Delegated Grievances (DO-08) 6. Use of Interpreter Service and Bilingual Staff (CLS-02) 7. Translation of Member Material (MC-03) 8. Provider Dispute Resolution Workflow 9. Potential Quality Issues (UM-56) 10. DTP Grievance Oversight Committee 11. DTP Grievance Review Committee 12. Provider Data Maintenance (PR-21) 13. Print Provider Directory (MC-04)

REVISION HISTORY Effective Date: November 18, 2005 Approval Date: May 12, 2011, February 13, 2014, October 9, 2014, January 22,

2015, April 9, 2015, June 11, 2015, August 13, 2015, October 8, 2015, November 19, 2015, April 21, 2016, July 21, 2016, September 22, 2016, November 16, 2016, April 20, 2017, June 15, 2017

Revision Date(s): Revised November 18, December 18, 2005; November 6, 2006 Revised July 22, 2008 for DHCS contract deliverable requirement Revised June 15, 2009 to include MMCD Policy Letter 09-006, 2009 DMHC/DHCS Joint Audit CAP Req. 4.1.1 & 6.1.1, and internal processes to include trending grievances for members with disabilities. Revised December 24, 2009 for internal process changes related to the DMHC/DHCS Joint Audit CAP Req. 4.1.1 & 6.1.1 Revised March 23, 2010 for internal review Revised April 15, 2011 to include services to SPD members Revised February 22, 2012,to include schedule for reporting to DHCS and DMHC April 2012

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July 29, 2013 January 22, 2014: revised to include NCQA standards April 1, 2014 Revised September 8, 2014 to include DHCS Audit 2014 Recommendations Revised November 21, 2014 to include process for non-expedited grievances. Revised March 20, 2015 to update appeal process for NCQA 2015 standards. Revised April 29, 2015 update that the committee will review the most severe PQI cases following UM-56. Revised July 8, 2015 update grievance and appeal process for NCQA 2015 Revised September 8, 2015 update internal committee responsibilities Revised November 4, 2015 update grievance process, include separate section for exempt grievances Revised January 12, 2016 Revised April 13, 2016 NCQA Revised May 6, 2016 Reports of provider directory inaccuracies Revised June 27, 2016 Clarified Expedited process; Administrative appeals for NCQA Revised September 16, 2016 DHCS 2015 CAP Responses Revised November 11, 2016 NCQA 2017 Standard UM Revised December 20, 2016 NCQA 2017 Standard UM Revised April 1, 2017 NCQA 2017 Standards UM and RR Revised May 19, 2017 APL 17-006 Revised June 713, 2017 DHCS AIR APL 17-006

REFERENCES 1. MMCD All Plan 03009: Expedited State Hearings 2. MMCD All Plan 03008: Submission of Quarterly Logs 3. Title 28, California Code of Regulations, Section 1300.68 4. Title 22, California Code of Regulations, Section 53858, 53893, 51014 5. Health and Safety Code, Sections 1367.01, 1367.27, 1368, 1368.01, 1368.02,

1368.03, 1368.04, 1370.4, 1374.30, 1374.31, 1374.32, 1374.33, 1374.35, and 1374.36

6. Welfare and Institutions Code 10961 7. Code of Federal Regulations, Title 42, Section 438.406 (b)3 8. MMCD Policy Letter 09-006: Timeframes for Member Grievances 8.9. APL 17-006 Grievance and Appeal Requirements

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San Francisco Health Plan1. San Francisco Health Plan Grievance Categories

1. ACCESS • Geographic/Distance Access Hospital • Geographic/Distance Access Other • Geographic/Distance Access PCP • Geographic/Distance Access Specialist • Language Assistance Plan • Language Assistance Provider • Office Wait Time • Provider Directory Error • Provider Not Taking New Patients • Telephone Access Plan

• Telephone Access Provider • Timely Access Other • Timely Access PCP • Timely Access Specialist • Timely Authorization Other • Timely Authorization Specialist • ADA Access

2. QUALITY OF MEDICAL CARE

• Delay of Care • Disagreement with Diagnosis

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• Disagreement with Treatment • Inappropriate Care • Inadequate Facilities • Lack of Care • Modification of Care • Denial of Care • Other • Coordination of Care

3. QUALITY OF SERVICE

• Poor Attitude • Poor Communication • Slow Reply • Administrative Services • Pharmacy/UM Authorization • Incentive gift card delayed by SFHP • Incentive gift card not received by member • Incentive form not received by SFHP • Incentive other • Other

4. BENEFITS/COVERAGE

• Dispute over Benefits • Does not like Benefit • Does not like HMO business rules • Exclusions and Limitations • Formulary • Other

5. DENIALS/REFUSALS • Denial of Service or Treatment • Denial of Experiment/Investigational Procedure • Denial of Emergency/Urgent Service • Refusal to Pay for Treatment • Refusal to Refer • Pharmacy denial and/or modification • Refusal to Pay for Equipment • Other

6. BILLING • Inappropriate Billing • Insufficient Payment • Slow Payment • Co-payment • Other

7. ENROLLMENT

• Cancellation of Coverage • Non-Acceptance of Coverage • Premium Refund Request • Kaiser • Premium Increase • Dis-enrollment

• Clinic closed • Other

8. CULTURAL, LINGUISTIC & HEALTH EDUCATION

• Discrimination • Lack of Health Education Program • Lack of Cultural Sensitivity • Lack of Translated Materials • Inappropriate Literacy Level • Other

9. OTHER 10. CBAS

• Appeal inability to receive services or receiving

more limited services than requested • Appeals related to requesting a CBAS Provider and

inability to access provider • Excess travel times to access CBAS • Grievances regarding CBAS Providers • Grievances regarding CBAS assessment and/or

reassessment

11. Mental Health • Access • Authorization • Medication/Pharmacy • Psychotherapy – evaluation & treatment • Outpatient Services (including lab & supplies) • Other

For each grievance a third level of categorization will identify the source of the grievance (i.e. the location or entity that has caused the grievance to occur)

1. SFHP 2. SFHP – UM Outpatient 3. SFHP – UM Inpatient 4. SFHP – Care Management 5. SFHP - Pharmacy 6. Medical Group 7. Hospital 8. Clinic 9. PCP 10. Specialist 11. Ancillary Services 12. Pharmacy 13. Other 14. Transportation 15. CBAS

These categories have been developed taking into consideration the reporting requirement for the DMHC, DHCS and MRMIB.

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If you need free assistance to translate this letter in another language, please contact

San Francisco Health Plan at (800) 288-5555. 若您需要將此函翻譯成其他語言，請聯絡

San Francisco Health Plan，電話 (800) 288-5555。 Si necesita ayuda para traducir esta carta a otro idioma,

comuníquese con San Francisco Health Plan al (800) 288-5555.

Nếu quý vị cần hỗ trợ dịch thư này sang một ngôn ngữ khác, vui lòng liên lạc

San Francisco Health Plan theo số (800) 288-5555. ACKNOWLEDGEMENT

Date «FName» «LName» «Address» «City», «State» «Zip» SFHP ID Number: «SFHP_ID» «LOB» Dear Member / Parent / Guardian: San Francisco Health Plan has received an expression of dissatisfaction from you with one of our areas

of service:

• By: «VIA» • On: «GDATE»

We call an issue like this a grievance. We will work with you or your representative to find a solution to your grievance in the next 30 days. If you believe your grievance involves an imminent and serious threat to your health, including but not limited to severe pain, potential loss of life, limb or major bodily function, please contact me immediately.

Grievance Coordinator San Francisco Health Plan

P.O. Box 194247 San Francisco, CA 94119-4247

(415) 547-7800 or (800) 288-5555

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (415) 547-7800 or (800) 288-5555 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance

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that has not been resolved satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (888) HMO-2219 and a TDD line (877) 688-9891 for the hearing and speech impaired. The department’s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. Attention Medi-Cal members: If you receive Medi-Cal, you or your representative can request a State Fair Hearing. If you believe there is a serious threat to your health you may also file for an expedited State Fair Hearing. Your representative is a friend, relative or lawyer that you ask to represent you. If you decide to request a hearing, you must do so within 120 90 days of the mailing of this noticenotice of appeal resolution letter. If you ask for a State Fair Hearing within 10 days of the notice to delay, modify or deny health care services, current services will be authorized until a State Fair Hearing decision is made. Information about the State Fair Hearing process is available by writing the California Department of Social Services (CDSS), State Hearing Division, PO Box 944243, MS 9-17-37, Sacramento, CA, 94244-2430, or by calling (800) 952-5253. The TDD number is (800) 952-8349. The forms you need are also available from the San Francisco Department of Human Services by calling (415) 558-4742. The TDD is (415) 558-2222. You have a right to examine the materials that make up the record for the State Fair Hearing decision. Any information you provide may be shared with the Department of Social Services or with the United States Department of Health and Human Services. You can locate your record by contacting the Public Inquiry and Response Unit at (800) 952-5253. The Public Inquiry and Response Unit also can help you find someone to represent you at the hearing, or you can ask someone to represent you, or represent yourself. The State of California Office of the Ombudsman will also help you with your grievance and State Fair Hearing. You can call them, toll-free, at (888) 452-8609. The TDD number is (800) 952-8349. Its office hours are Monday-Friday, 8 a.m. to 5 p.m., closed on State holidays. Please contact me by phone or mail any time you have a question or need assistance. You can reach me through the Customer Services Department at (415) 547-7800 or (800) 288-5555. I will do my best to further assist you. Our office hours are from 8:30 a.m. to 5:30 p.m. Monday through Friday.

Sincerely, Grievance Coordinator San Francisco Health Plan NOTE: Add CC: to member if grievance comes from member representative (i.e. provider)

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If you need free assistance to translate this letter in another language, please contact San Francisco Health Plan at (800) 288-5555. 若您需要將此函翻譯成其他語言，請聯絡 San Francisco Health Plan，電話 (800) 288-5555。 Si necesita ayuda para traducir esta carta a otro idioma, comuníquese con San Francisco Health Plan al (800) 288-5555. Nếu quý vị cần hỗ trợ dịch thư này sang một ngôn ngữ khác, vui lòng liên lạc San Francisco Health Plan theo số (800) 288-5555.

CLINICAL GRIEVANCE RESOLUTION Date «FName» «LName» «Address» «City», «State» «Zip» SFHP ID Number: «SFHP_ID» «LOB» Dear Member / Parent / Guardian: San Francisco Health Plan (SFHP) received your expression of dissatisfaction by «VIA» on «GDATE».

An issue like this is a grievance and we understood it as follows:

«DESCRIPTION»

We have reviewed your grievance carefully and

«RESOLUTION[For appeals include pertinent citations from EOC, guideline, criteria, etc.]»

We believe this resolves your grievance. If not, you or your representative may contact us by phone or mail if you have any additional questions or need assistance. Our office hours are from 8:30 a.m. to 5:30 p.m. Monday through Friday.

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Nicole A. Ylagan Clinical Quality Coordinator San Francisco Health Plan


Phone: (415) 547-7800

If you believe your grievance involves an imminent and serious threat to your health, including but not limited to severe pain, potential loss of life, limb or major bodily function, please contact me immediately. You, your representative or your doctor or nurse can get copies of the information we used to make this decision free of charge. Please call San Francisco Health Plan to obtain a copy of the criteria. Also, read below about your rights to contact the State immediately for a resolution of your urgent grievance.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (415) 547-7800 or (800) 288-5555 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been resolved satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR).

If you are eligible for an IMR with the Department of Managed Health Care, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number: (888) HMO-2219 and a TDD line: (877) 688-9891 for the hearing and speech impaired. The department’s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR Application forms and instructions online. Attention Medi-Cal members: If you receive Medi-Cal, you or your representative can request a State Fair Hearing. If you believe there is a serious threat to your health you may also file for an expedited State Fair Hearing. Your representative is a friend, relative or lawyer that you ask to represent you. If you decide to request a hearing, you must do so within 90 120 days of the mailing of this notice notice of appeal resolution letter. If you ask for a State Fair Hearing within 10 days of the notice to delay, modify or deny health care services, current services will be authorized until a State Fair Hearing decision is made. Information about the State Fair Hearing process is available by writing the California Department of Social Services (CDSS), State Hearing Division, PO Box 944243, MS 9-17-37, Sacramento, CA, 94244-2430, or by calling (800) 952-5253. The TDD number is (800) 952-8349. The forms you need are also available from the San Francisco Department of Human Services by calling (415) 558-4742. The TDD is (415) 558-2222. You have a right to examine the materials that make up the record for the State Fair Hearing decision. Any information you provide may be shared with the Department of Social Services or with the United States Department of Health and Human Services. You can locate your record by contacting the Public Inquiry and Response Unit at 1-800-952-5253. The Public Inquiry and Response Unit also can help you

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find someone to represent you at the hearing, or you can ask someone to represent you, or represent yourself. The State of California Office of the Ombudsman will also help you with your grievance and State Fair Hearing. You can call them, toll-free, at (888) 452-8609. The TDD number is (800) 952-8349. Its office hours are Monday-Friday, 8 a.m. to 5 p.m., closed on State holidays. Please contact the Plan by phone, mail or e-mail via our website any time you have a question or need assistance. You or your representative can reach me by calling SFHP (415) 547-7800 or (800) 288-5555. Our office hours are from 8:30 a.m. to 5:30 p.m. Monday through Friday. Sincerely, James Glauber, MD, MPH Chief Medical Officer San Francisco Health Plan

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If you need assistance to translate this letter in another language, please contact San Francisco Health Plan at (800) 288-5555. 若您需要將此函翻譯成其他語言，請聯絡 San Francisco Health Plan，電話 (800) 288-5555。 Si necesita ayuda para traducir esta carta a otro idioma, comuníquese con San Francisco Health Plan al (800) 288-5555. Nếu quý vị cần hỗ trợ dịch thư này sang một ngôn ngữ khác, vui lòng liên lạc San Francisco Health Plan theo số (800) 288-5555.

GRIEVANCE WITHDRAWL Date «FName» «LName» «Address» «City», «State» «Zip» SFHP ID Number: «SFHP_ID» «LOB» Dear Member / Parent / Guardian: San Francisco Health Plan (SFHP) received your expression of dissatisfaction by «VIA» on «GDATE».

An issue like this is a grievance and we understood it as follows:

«DESCRIPTION»

We have reviewed your grievance carefully and

«RESOLUTION»

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San Francisco Health Plan has received your request to withdraw your grievance. Your concerns have been noted in our grievance tracking system. We regret any difficulty you may have encountered with this grievance. If it was not your intent to withdraw your grievance, then please contact me at your earliest convenience. You have grievance rights and additional options you may take with regards to this matter. The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (415) 547-7800 or (800) 288-5555 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been resolved satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). For any questions please contact me by phone (415) 547-7800 or mail. Sincerely, Nicole A. Ylagan Quality Management Specialist San Francisco Health Plan 201 Third Street, 7th Floor San Francisco, CA 94103

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If you need assistance to translate this letter in another language, please contact San Francisco Health Plan at (800) 288-5555. 若您需要將此函翻譯成其他語言，請聯絡 San Francisco Health Plan，電話 (800) 288-5555。 Si necesita ayuda para traducir esta carta a otro idioma, comuníquese con San Francisco Health Plan al (800) 288-5555. Nếu quý vị cần hỗ trợ dịch thư này sang một ngôn ngữ khác, vui lòng liên lạc San Francisco Health Plan theo số (800) 288-5555.

DECLINE TO FILE GRIEVANCE Date «FName» «LName» «Address» «City», «State» «Zip» SFHP ID Number: «SFHP_ID» «LOB» Dear Member / Parent / Guardian: San Francisco Health Plan received your expression of dissatisfaction by «VIA» on «GDATE».

We understood your issue as follows:

«DESCRIPTION»

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You stated that you did not want to file a grievance with us, so we have not done so. We would like to give you this opportunity to contact us to discuss this issue further if you need any additional help. Please contact Terence Ung, San Francisco Health Plan’s Customer Service Supervisor/Grievance Coordinator if you would like to discuss your concerns further.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (415) 547-7800 or (800) 288-5555 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been resolved satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (888) HMO-2219 and a TDD line (877) 688-9891 for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. Attention Medi-Cal members: If you receive Medi-Cal, you or your representative can request a State Fair Hearing. If you believe there is a serious threat to your health you may also file for an expedited State Fair Hearing. Your representative is a friend, relative or lawyer that you ask to represent you. If you decide to request a hearing, you must do so within 90 days of the mailing of this noticenotice of appeal resolution letter. If you ask for a State Fair Hearing within 10 days of the notice to delay, modify or deny health care services, current services will be authorized until a State Fair Hearing decision is made. Information about the State Fair Hearing process is available by writing the California Department of Social Services (CDSS), State Hearing Division, PO Box 944243, MS 9-17-37, Sacramento, CA, 94244-2430, or by calling (800) 952-5253. The TDD number is (800) 952-8349. The forms you need are also available from the San Francisco Department of Human Services by calling (415) 558-4742. The TDD is (415) 558-2222. You have a right to examine the materials that make up the record for the State Fair Hearing decision. Any information you provide may be shared with the Department of Social Services or with the United States Department of Health and Human Services. You can locate your record by contacting the Public Inquiry and Response Unit at

Terence Ung San Francisco Health Plan


(415) 547-7800 or (800) 288-5555

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(800) 952-5253. The Public Inquiry and Response Unit also can help you find someone to represent you at the hearing, or you can ask someone to represent you, or represent yourself. The State of California Office of the Ombudsman will also help you with your grievance and State Fair Hearing. You can call them, toll-free, at (888) 452-8609. The TDD number is (800) 952-8349. Its office hours are Monday-Friday, 8 a.m. to 5 p.m., closed on State holidays. Please contact the Plan by phone, mail or e-mail via our website if you have additional questions or need assistance. You or your representative can reach the Customer Service Department at by calling (415) 547-7800 or (800) 288-5555. Our office hours are from 8:30 a.m. to 5:30 p.m. Monday through Friday. Sincerely, Terence Ung Grievance Coordinator San Francisco Health Plan

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If you need free assistance to translate this letter in another language, please contact San Francisco Health Plan at (800) 288-5555. 若您需要將此函翻譯成其他語言，請聯絡 San Francisco Health Plan，電話 (800) 288-5555。 Si necesita ayuda para traducir esta carta a otro idioma, comuníquese con San Francisco Health Plan al (800) 288-5555. Nếu quý vị cần hỗ trợ dịch thư này sang một ngôn ngữ khác, vui lòng liên lạc San Francisco Health Plan theo số (800) 288-5555.

ACKNOWLEGEMENT AND DENIAL OF REQUEST FOR EXPEDITED REVIEW [Date] SFHP ID Number:

Dear [Member Name]:

San Francisco Health Plan has received an expression of dissatisfaction from you with one of our areas of service: • By: • On: We call an issue like this a grievance. You told us that your issue was urgent and you asked SFHP to review your issue as an expedited grievance. SFHP wil l give an expedited review (resolved in 72 hours) if a grievance involves an imminent and serious threat to your health inc luding, but not l imited to, loss of l ife or limb, major bodily function or severe pain. W e reviewed your request carefully and we determined that your issue does not qualify for expedited review. Therefore, we wil l work with you or your representative to f ind a solution to your grievance within 30 days of the date we received your grievance. If you are not satisf ied with our decis ion to review your issue as a standard grievance, you or your representative has a right to f i le an appeal with San Francisco Health Plan. Please contact SFHP by phone, mail or e-mail via our website any t ime you have a question or need assistance.

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Nicole Ylagan San Francisco Health Plan


(415) 547-7800 or (800) 288-5555 Also, read below about your r ights to contact the State immediately if you believe your grievance is urgent.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (415) 547-7800 or (800) 288-5555 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been resolved satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (888) HMO-2219 and a TDD line (877) 688-9891 for the hearing and speech impaired. The department’s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. Attention Medi-Cal members: If you receive Medi-Cal, you or your representative can request a State Fair Hearing. If you believe there is a serious threat to your health you may also file for an expedited State Fair Hearing. Your representative is a friend, relative or lawyer that you ask to represent you. If you decide to request a hearing, you must do so within 12090 days of the mailing of this noticenotice of appeal resolution letter. If you ask for a State Fair Hearing within 10 days of the notice to delay, modify or deny health care services, current services will be authorized until a State Fair Hearing decision is made. Information about the State Fair Hearing process is available by writing the California Department of Social Services (CDSS), State Hearing Division, PO Box 944243, MS 9-17-37, Sacramento, CA, 94244-2430, or by calling (800) 952-5253. The TDD number is (800) 952-8349. The forms you need are also available from the San Francisco Department of Human Services by calling (415) 558-4742. The TDD is (415) 558-2222. You have a right to examine the materials that make up the record for the State Fair Hearing decision. Any information you provide may be shared with the Department of Social Services or with the United States Department of Health and Human Services. You can locate your record by contacting the Public Inquiry and Response Unit at (800) 952-5253. The Public Inquiry and Response Unit also can help you find someone to represent you at the hearing, or you can ask someone to represent you, or represent yourself. The State of California Office of the Ombudsman will also help you with your grievance and State Fair Hearing. You can call them, toll-free, at (888) 452-8609. The TDD number is (800) 952-8349. Its office hours are Monday-Friday, 8 a.m. to 5 p.m., closed on State holidays.

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Please contact me by phone or mail any time you have a question or need assistance. You can reach me through the Customer Services Department at (415) 547-7800 or (800) 288-5555. I will do my best to further assist you. Our office hours are from 8:30 a.m. to 5:30 p.m. Monday through Friday. Sincerely,

Nicole Ylagan San Francisco Health Plan

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FORM TO FILE FOR A STATE HEARING You can file this form by phone call, fax, or by mail: Phone: 1(800) 952-5253 TDD: 1(800) 952-8349 Fax: 1(916) 651-5210 or 1(916) 651-2789 Attn: State Hearing Support Mail: California Department of Social Services State Hearings Division P.0. Box 944243, MS 19-37 Sacramento, CA 94244-2430 For free help in filling out this form, call the legal help phone number listed on "Your Rights". My Health Plan: _____________________________________________________________ My Name: _________________________________________________________________ Address: ___________________________________________________________________ My Medi-Cal Card ID Number: ___________________________________ (Your hearing will be delayed if this number is not provided.) I do not agree with my health plan’s decision about my health care. Please explain below: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ (If you need more space, please use another piece of paper. Make a copy for your records.) Check any box(es) that apply to you:

☐ (1) I want the person named below to represent me. He/she can see my medical records related to this hearing, come to the hearing and speak for me. Name: __________________________________ Phone: _______________________ Address:______________________________________________________________

☐ (2) I need a free interpreter. My language or dialect is: ______________________________

☐ (3) I also want to file a grievance against the health plan. I understand the State will send my health plan a copy of this form.

☐ (4) Please keep me enrolled with my health plan until my hearing.

☐ (5) Urgent. I need a quick decision and cannot wait 90 days. (You also need a letter from your doctor or health plan to expedite your hearing. See "Your Rights"). Please explain below: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ My Signature: ____________________________________________ Date: ______________ After you complete this form, make a copy for your records.

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State of California Health and Human Services Agency Department of Managed Health Care INDEPENDENT MEDICAL REVIEW APPLICATION-English DMHC 20-086 New: 01/02 Rev: 09/12

INDEPENDENT MEDICAL REVIEW APPLICATION

If you want to give another person the authority to assist you with your IMR, you must also complete the Authorized Assistant Form.

PATIENT INFORMATION

First Name Middle Initial Last Name

Name of Parent or Guardian if Filing for Minor Child

Street Address

City State Zip

Day Phone # Evening Phone #

Health Plan Name

Patient’s Membership Number

Patient’s Date of Birth (mm/dd/yy) Gender □ Male □ Female

Do you have Medi-Cal? □ Yes □ No

Do you have Medicare or Medicare Advantage? □ Yes □ No

Have you filed a complaint or grievance with your health plan? □ Yes □ No

Are you seeking payment for a service that you have already received? □ Yes □ No

YOUR HEALTH PROBLEM (Use a separate sheet and attach other documents if needed.)

1 What is your health condition or doctor’s diagnosis?

2 What medical treatment or service are you requesting?

3 How would you like this case to be decided?

4 Do you have a condition that is a serious threat to your health? □ Yes □ No

If “yes,” please explain.

5 Did your health plan say that the treatment you want is (check one):

□ Not medically necessary □ Experimental or investigational □ Other (please explain)

6 List the name and phone number of your primary care doctor and other doctors who have seen, treated or advised you for your condition. Are they in your health plan’s network? (Use a separate sheet if needed.)

7 I am asking for an Independent Medical Review (IMR) to make a decision about my problem with my health plan. If my issue does not qualify for an IMR, please review as a standard complaint. I allow my providers, past and present, and my health plan to release my medical records and information to review this issue. These records may include medical, mental health, substance abuse, HIV, diagnostic imaging reports, and other records related to my case. These records may also include non-medical records and any other information related to my case. I allow the Department of Managed Health Care (DMHC) to review these records and information and send them to my health plan. My permission will end one year from the date below, except as allowed

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by law. For example, the law allows the DMHC to continue to use my information internally. I can end my permission sooner if I wish. All the information that I have provided on this sheet is true.

Patient or Parent Signature Date

Mail or fax your form and any attachments to: Help Center, Department of Managed Health Care, IMR Unit, 980 9th Street Suite 500, Sacramento CA 95814-2725; FAX: 916-255-5241

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IMR Application Instructions

If your health plan denies your request for medical services or treatment, you can file a complaint (grievance) with your plan. If you disagree with your plan's decision, you can ask the Help Center at the Department of Managed Health Care (DMHC) for an Independent Medical Review (IMR). An IMR is a review of your case by doctors who are not part of your health plan. If the IMR is decided in your favor, your plan must give you the service or treatment you requested. You pay no costs for an IMR.

You Can Apply for an IMR if Your Health Plan: • Denies, changes, or delays a service or treatment because the plan determines it is not medically necessary. • Will not cover an experimental or investigational treatment for a serious medical condition. • Will not pay for emergency or urgent medical services that you have already received.

Before You Apply In most cases, you must complete your health plan's complaint process before you apply for an IMR. Your plan must give you a decision within 30 days or within 3 days if your problem is an immediate and serious threat to your health.

If your plan denied your treatment because it was experimental / investigational, you do not have to take part in your plan's complaint process before you apply for an IMR.

You must apply for an IMR within six months after your health plan sends you a written response to your grievance. We may accept your application after six months, if we determine that circumstances prevented timely submission.

Please be aware that if you decide not to participate in the IMR process, you may be giving up your statutory rights to pursue legal action against your plan regarding the service or treatment you are requesting.

How to Apply Fill out the IMR Application Form. Fill out the Authorized Assistant form if someone is helping you with your IMR. If you have medical records from non-contracting providers regarding your health care issue, please include them with your application. Your health plan will be required to obtain medical records from contracting providers.

Attach copies of letters or other documents about the treatment or service that your health plan denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return documents.

If you have questions about filling out your application form, call the Help Center at 1-888-466-2219 or TDD at 1-877-688-9891. There is no charge for this call.

Mail or fax your form and any attachments to: Help Center FAX: 916-255-5241 Department of Managed Health Care 980 9th Street Suite 500 Sacramento CA 95814-2725

What Happens if You Qualify for an IMR? The Help Center will review your application and send you a letter within 7 days telling you if you qualify for an IMR. When all your information, including relevant medical records, is received, the IMR will be sent to the Review Organization who will make a decision within 30 days or within 3 to 7 days if your case is urgent. You will be notified of the decision made by the doctors who have reviewed your case. If the IMR is decided in your favor, your plan must give you the service or treatment you requested.

What Happens if You Do Not Qualify for an IMR? Your issue will be reviewed through the Department’s standard complaint process. You will receive a written notice of our decision within 30 days.

This Notice is Required by Law

• California’s Knox-Keene Act gives the Department of Managed Health Care (DMHC) the authority to regulate health plans and investigate the complaints of health plan members.

• The DMHC’s Help Center uses your personal information to investigate your problem with your health plan and to provide an Independent Medical Review if you qualify for one.

• You give us this information voluntarily. You do not have to give us this information. • However, if you do not give us the information, we may not be able to investigate your complaint or provide an

Independent Medical Review. • We may share your personal information, as needed, with the health plan and the doctors who are doing the

Independent Medical Review. • We may also share your information with other government agencies as required or allowed by law. • You have a right to see your personal information. To do this, contact the DMHC Records Request Coordinator, DMHC, Office

of Legal Services, 980 9th Street Suite 500, Sacramento CA 95814-2725, 916-322-6727.

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• The law that requires this notice is the Information Practices Act of 1977 (California Civil Code Section 1798.17)

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State of California Health and Human Services Agency Department of Managed Health Care AUTHORIZED ASSISTANT FORM-English DMHC 20-160 New: 04/06 Rev: 09/12

AUTHORIZED ASSISTANT FORM

If you want to give another person the authority to assist you with your Independent Medical Review (IMR) or complaint, complete Parts A and B below.

If you are a parent or legal guardian filing this IMR or complaint for a child under the age of 18, you do not need to complete this form.

If you are filing this IMR or complaint for a patient who cannot complete this form because the patient is either incompetent or incapacitated, and you have legal authority to act for this patient, please complete Part B only. Also attach a copy of the power of attorney for health care decisions or other documents that say you can make decisions for the patient.

PART A: PATIENT

I allow the person named below in Part B to assist me in my IMR or complaint filed with the Department of Managed Health Care (DMHC). I allow the DMHC and IMR staff to share information about my medical condition(s) and care with the person named below. This information may include mental health treatment, HIV treatment or testing, alcohol or drug treatment, or other health care information.

I understand that only information related to my IMR or complaint will be shared.

My approval of this assistance is voluntary and I have the right to end it. If I want to end it, I must do so in writing.

Patient Signature Date

PART B: PERSON ASSISTING PATIENT

Name of Person Assisting (print)

Signature of Person Assisting

Address

City State Zip

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Relationship to Patient

Daytime Phone #

Evening Phone #

□ My power of attorney for health care decisions or other legal document is attached.

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[Health Plan or PPG Letterhead]

[Health Plan or PPG Tracking Number – optional]

NOTICE OF APPEAL RESOLUTION [Date]

[Member’s Name] [Treating Provider’s Name] [Address] [Address] [City, State Zip] [City, State Zip]

Identification Number

RE: [Service requested]

You or [Name of requesting provider or authorized representative], on your behalf, appealed the [denial, delay, modification, or termination] of [Service requested]. [Health Plan or PPG] has reviewed the appeal and has decided to overturn the original decision. This request is now approved. This is because [Insert: 1. A clear and concise explanation of the reasons for the decision; 2. A description of the criteria or guidelines used, including a reference to the specific regulations or plan authorization procedures that support the action; and 3. The clinical reasons for the decision regarding medical necessity].

[Health Plan or PPG] has 72 hours to give you the service.

The State Medi-Cal Managed Care “Ombudsman Office” can help you with any questions. You may call them at 1-888-452-8609. You may also get help from your doctor, or call us at [Health Plan’s Member Services telephone number].

This notice does not affect any of your other Medi-Cal services.

[Medical Director’s Name]

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[Health Plan or PPG Letterhead] [Health Plan or PPG Tracking Number – optional]

NOTICE OF APPEAL RESOLUTION [Date]

[Member’s Name] [Treating Provider’s Name] [Address] [Address] [City, State Zip] [City, State Zip]

Identification Number

RE: [Service requested]

You or [Name of requesting provider or authorized representative], on your behalf, appealed the [denial, delay, modification, or termination] of [Service requested]. [Health Plan or PPG] has reviewed the appeal and has decided to uphold the decision. This request is still denied. This is because [Insert: 1. A clear and concise explanation of the reasons for the decision; 2. A description of the criteria or guidelines used, including a reference to the specific regulations or plan authorization procedures that support the action; and 3. The clinical reasons for the decision regarding medical necessity].

You may ask for free copies of all information used to make this decision. This includes a copy of the actual benefit provision, guideline, protocol, or criteria that we based our decision on. To ask for this, please call [Health Plan name] at [telephone number].

You may appeal this decision. The enclosed “Your Rights” information notice tells you how. It also tells you where you can get free help. This also means free legal help. You are encouraged to send in any information that could help your case. The “Your Rights” notice tells you the cut off dates to ask for an appeal.

The State Medi-Cal Managed Care “Ombudsman Office” can help you with any questions. You may call them at 1-888-452-8609. You may also get help from your doctor, or call us at [Health Plan’s Member Services telephone number].

This notice does not affect any of your other Medi-Cal services.

[Medical Director’s Name]

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For Knox-Keene Plans (NOA)

1

Enclosed: “Your Rights under Medi-Cal Managed Care”

(Enclose notice with each letter)

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YOUR RIGHTS UNDER MEDI-CAL MANAGED CARE

IF YOU DO NOT AGREE WITH THE DECISION MADE FOR YOUR MEDICAL TREATMENT, YOU CAN FILE AN APPEAL. THIS APPEAL IS FILED WITH YOUR HEALTH PLAN.

HOW TO FILE AN APPEAL

You have 60 days from the date of this “Notice of Action” letter to file an appeal. But, if you are currently getting treatment and you want to continue getting treatment, you must ask for an appeal within 10 days from the date this letter was postmarked or delivered to you, OR before the date your health plan says services will stop. You must say that you want to keep getting treatment when you file the appeal.

You can file an appeal by phone, in writing, or electronically:

• By phone: Contact [Health Plan] between [hours of operation] by calling

[telephone number]. Or, if you cannot hear or speak well, please call [TYY/TDD number].

• In writing: Fill out an appeal form or write a letter and send it to:

[Health Plan] [address]

Your doctor’s office will have appeal forms available. Your health plan can also send a form to you.

• Electronically: Visit your health plan’s website. Go to [Health Plan’s weblink].

You may file an appeal yourself. Or, you can have a relative, friend, advocate, doctor, or attorney file the appeal for you. You can send in any type of information you want your health plan to review. A doctor who is different from the doctor who made the first decision will look at your appeal.

Your health plan has 30 days to give you an answer. At that time, you will get a “Notice of Appeal Resolution” letter. This letter will tell you what the health plan has decided. If you do not get a letter within 30 days, you can:

• Ask for an “Independent Medical Review” (IMR) and an outside reviewer that

is not related to the health plan will review your case.

• Ask for a “State Hearing” and a judge will review your case

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Please read the section below for instructions on how to ask for an IMR or State Hearing.

EXPEDITED APPEALS

If you think waiting 30 days will hurt your health, you might be able to get an answer within 72 hours. When filing your appeal, say why waiting will hurt your health. Make sure you ask for an “expedited appeal.”

IF YOU DO NOT AGREE WITH THE APPEAL DECISION

If you filed an appeal and received a “Notice of Appeal Resolution” letter telling you that your health plan will still not provide the services, or you never received a letter telling you of the decision and it has been past 30 days, you can:


is not related to the health plan will review your case

• Ask for a “State Hearing” and a judge will review your case You can ask for both an IMR and State Hearing at the same time. You can also ask for one before the other to see if it will resolve your problem first. For example, if you ask for an IMR first, but do not agree with the decision, you can still ask for a State Hearing later. However, if you ask for a State Hearing first, but the hearing has already taken place, you cannot ask for an IMR. In this case, the State Hearing has the final say.

You will not have to pay for an IMR or State Hearing.

INDEPENDENT MEDICAL REVIEW (IMR)

If you want an IMR, you must first file an appeal with your health plan. If you do not hear from your health plan within 30 days, or if you are unhappy with your health plan’s decision, then you may then request an IMR. You must ask for an IMR within 180 days from the date of the “Notice of Appeal Resolution” letter.

You may be able to get an IMR right away without filing an appeal first. This is in cases where your health is in immediate danger or the request was denied because treatment is considered experimental or investigational.

The paragraph below will provide you with information on how to request an IMR. Note that the term “grievance” is talking about both “complaints” and “appeals.”

127


4

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at [health plan telephone number] and use your health plan’s grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department’s Internet Website (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms, and instructions online.

STATE HEARING

If you want a State Hearing, you must ask for one within 120 days from the date of the “Notice of Appeal Resolution” letter. You can ask for a State Hearing by phone or in writing:

• By phone: Call 1-800-952-5253. This number can be very busy. You may get a

message to call back later. If you cannot speak or hear well, please call TTY/TDD 1-800-952-8349.

• In writing: Fill out a State Hearing form or send a letter to:

California Department of Social Services State Hearings Division P.O. Box 944243, Mail Station 9-17-37 Sacramento, CA 94244-2430

Be sure to include your name, address, telephone number, Social Security Number, and the reason you want a State Hearing. If someone is helping you ask for a State Hearing, add their name, address, and telephone number to the form or letter. If you need an interpreter, tell us what language you speak. You will not have to pay for an interpreter. We will get you one.

After you ask for a State Hearing, it could take up to 90 days to decide your case and send you an answer. If you think waiting that long will hurt your health, you might be able to get an answer within 3 working days. Ask your doctor or health plan to write a

128


For Knox-Keene Plans (NAR)

1

letter for you. The letter must explain in detail how waiting for up to 90 days for your case to be decided will seriously harm your life, your health, or your ability to attain, maintain, or regain maximum function. Then, make sure you ask for an “expedited hearing” and provide the letter with your request for a hearing.

You may speak at the State Hearing yourself. Or, you can have a relative, friend, advocate, doctor, or attorney speak for you. If you want another person to speak for you, then you must tell the State Hearing office that the person is allowed to speak on your behalf. This person is called an “authorized representative.”

LEGAL HELP

You may be able to get free legal help. Call the [name and telephone number of the county’s consumer rights hotline]. You may also call the local Legal Aid Society in your county at 1-888-804-3536.

129


2

YOUR RIGHTS UNDER MEDI-CAL MANAGED CARE

If you still do not agree with this decision, you can:


is not related to the health plan will review your case

• Ask for a “State Hearing” and a judge will review your case You can ask for both an IMR and State Hearing at the same time. You can also ask for one before the other to see if it will resolve your problem first. For example, if you ask for an IMR first, but do not agree with the decision, you can still ask for a State Hearing later. However, if you ask for a State Hearing first, but the hearing has already taken place, you cannot ask for an IMR. In this case, the State Hearing has the final say.

You will not have to pay for an IMR or State Hearing.

INDEPENDENT MEDICAL REVIEW (IMR)

If you want an IMR, you must ask for one within 180 days from the date of this “Notice of Appeal Resolution” letter. The paragraph below will provide you with information on how to request an IMR. Note that the term “grievance” is talking about both “complaints” and “appeals.”

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at [health plan telephone number] and use your health plan’s grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department’s Internet Website (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms, and instructions online.

130



3

STATE HEARING

If you want a State Hearing, you must ask for one within 120 days from the date of this “Notice of Appeal Resolution” letter. But, if you are currently getting treatment and you want to continue getting treatment, you must ask for a State Hearing within 10 days from the date this letter was postmarked or delivered to you, OR before the date your health plan says services will stop. You must say that you want to keep getting treatment when you ask for the State Hearing.

You can ask for a State Hearing by phone or in writing:

• By phone: Call 1-800-952-5253. This number can be very busy. You may get a

message to call back later. If you cannot speak or hear well, please call TTY/TDD 1-800-952-8349.

• In writing: Fill out a State Hearing form or send a letter to:

California Department of Social Services State Hearings Division P.O. Box 944243, Mail Station 9-17-37 Sacramento, CA 94244-2430

A State Hearing form is included with this letter. Be sure to include your name, address, telephone number, Social Security Number, and the reason you want a State Hearing. If someone is helping you ask for a State Hearing, add their name, address, and telephone number to the form or letter. If you need an interpreter, tell us what language you speak. You will not have to pay for an interpreter. We will get you one.

After you ask for a State Hearing, it could take up to 90 days to decide your case and send you an answer. If you think waiting that long will hurt your health, you might be able to get an answer within 3 working days. Ask your doctor or health plan to write a letter for you. The letter must explain in detail how waiting for up to 90 days for your case to be decided will seriously harm your life, your health, or your ability to attain, maintain, or regain maximum function. Then, make sure you ask for an “expedited hearing” and provide the letter with your request for a hearing.

You may speak at the State Hearing yourself. Or, you can have a relative, friend, advocate, doctor, or attorney speak for you. If you want another person to speak for you, then you must tell the State Hearing office that the person is allowed to speak on your behalf. This person is called an “authorized representative.”

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Page 4 of 60

LEGAL HELP

You may be able to get free legal help. Call the [name and telephone number of the county’s consumer rights hotline]. You may also call the local Legal Aid Society in your county at 1-888-804-3536.

132

QIC 8/10/17

133

Measures with Auto

Assignment in the 90th

Childhood Immunization

Status (Combo-3)

83.18%

Controlling High Blood Pressure

71.02%

Meaningful Higher Performing Measures

Comprehensive Diabetes Care – Eye Exam

70.53%

Counseling for Nutrition 87.59%

Counseling for Physical Activity

84.07%

Asthma Medication

Ratio 80.02%

Reported Measure Highlights

134

Most Improved Rates

01020304050607080

Cervical CancerScreening

ComprehensiveDiabetes

Control - BloodPressureControl

Avoidance ofAntibiotic

Treatment inAdults With

Acute Bronchitis

2016 Rate2017 Rate

3.41%

7.76%

5.29%

135

NEW MEASURES IN 2017 External

Accountability Set

Immunization For Adolescents

Combo-2

(39.25% / No Benchmark)

Breast Cancer Screening

(62.66% / 50th)

Asthma Medication Ratio

(80.02% / 90th)

SFHP Chart Pursuit

Adult BMI

(90.93% / 75th)

Childhood Immunization Status

Combo-10

(62.38% / 90th)

136

OPPORTUNITIES FOR IMPROVEMENT

Diabetes Care • HbA1C Control decreased by 5.18%

• (2017 Rate 63.11% / 75th Percentile)

Pregnancy Care • Prenatal Care decreased by 4.88%

• (2017 Rate 90.07% / 50th Percentile) • Postpartum Care decreased by 3.40%

• (2017 Rate 70.83% / 75th Percentile)

Immunizations in Adolescents Combo 2 • Low Rate for recommended HPV immunization

• (2017 Rate 39.25% / No Benchmark)

137

What's Next? Clinical Oversight

Committee

A central place where data and ideas for HEDIS measure

improvement can be taken into consideration

by clinicians, and prioritized for the

organization.

Interventions Committee

A multidisciplinary team that generates and

operationalizes improvement projects

for the prioritized HEDIS measures.

138

What's Next?

COC

Determine SFHP Priority

Measures

IC

Propose interventions

for SFHP Priority

Measures COC

Review and approve

proposed interventions

IC

Operationalize approved

interventions

139

F

FY 2017-2018 SFHP Priority

Measures

2017-2018 SFHP Priority Measures for the Interventions Committee

Data Quality Interventions

Breast Cancer Screening (BCS)

Chlamydia Screening in Women (CHL) Pharmacotherapy Management of COPD Exacerbation (PCE)

Provider or Member Facing Interventions

Cervical Cancer Screening (CCS)

These Four Priority Measures Were Chosen Out of 51 Total Measures 140

Prioritization Criteria

Clinical relevance Current HEDIS performance

Measure denominator size and population

relevance / disparities

Group Needs Assessment NCQA strategy

Other relevant initiatives and regulatory

requirements (DHCS PIPs, APL’s, Auto

assignment designation)

141

Questions?

142

HP-CAHPS 2017

Quality Improvement Committee

Sari Weis, MPA Manager of Access and Care Experience

143

HP-CAHPS 2017

2

Results

Best Practices

Next Steps 144

Survey information

3

2016 Rate (Adults) • 366/1350 responses • SFHP Response

Rate=28% • Medicaid Average=23%

2017 Rate (Adults) • 586/2160 responses • SFHP Response

Rate=27% • Medicaid Average=22%

Follows NCQA Methodology except for: • Surveys administered in

Chinese 145

Organizational goal

• 2015=66.0% • 2016=65.3% • 2017=68.1% • Meets

organizational goal (> 2% improvement)

Getting Care

Quickly

• 2015=62.0% • 2016=66.1% • 2017=68.5% • Meets

organizational goal (> 2% improvement)

Getting Needed

Care

146

Comparison to prior two years

Composite 2015 2016 2017

Rating of Health Plan

64.2% 67.8% 72.8%

Rating of Personal Doctor

75.5% 75.7% 80.7%

Rating of Specialist Seen Most Often

73.4% 76.5% 83.9%

Rating of All Health Care

64.8% 68.3% 73.9%

Getting Needed Care

62% 66.1% 68.5%

Getting Care Quickly

66% 65.3% 68.1%

Coordination of Care

77.5% 83.3% 77.8%

Customer Service 74.4% 80.7% 81.2% 147

Comparison to NCQA benchmarks

Composite SFHP 2017 Score

NCQA SFHP Percentile

Rating of Health Plan 72.8% 25th Rating of Personal Doctor 80.7% 25th

Rating of Specialist Seen Most Often 83.9% 25th

Rating of All Health Care 73.9% 50th

Getting Needed Care 68.5% Below 25th

Getting Care Quickly 68.1% Below 25th

Customer Service 77.8% Below 25th

Coordination of Care 81.2% Below 25th 148

Key drivers for improvement

149

Self-reported routine care

8

32%

8%

23%

20%

0%

5%

10%

15%

20%

25%

30%

35%

None 5 or more visits

In the last 6 months, not counting the times you went to an emergency room, how many times did you go to a doctor's office or clinic to get healthcare for yourself?

SFHPNational

150

9 151

10 152

Response rate by language

11 153

12

Best practices for improvement

• Open access or patient-driven scheduling

• Process improvements to streamline patient flow

• Patient-Centered Medical Homes

Getting Needed

Care

• Develop customer service standards

• Service recovery trainings

Customer Service

154

Next steps

• Teladoc • Strategic Use of Reserves • Access monitoring • Increase percentage of members with a

primary care visit in the past 12 months • Other suggestions? • Questions?

13 155

P.O. Box 194247 San Francisco, CA 94119 1(415) 547-7800 1(415) 547-7821 FAX www.sfhp.org

Date: July 25, 2017

To SFHP Quality Improvement Committee

From Fiona Donald, Medical Director, and Eloycsia Ratliff, Disease Management Project Manager

Regarding 2017 Disease Management Program Update

Background:

In 2016, SFHP implemented its Disease Management program as part of its organizational goal of achieving First Year Medicaid NCQA Accreditation by November 2017. Requirements of a Health Plan disease management (DM) program, as outlined by NCQA standards are as follows: “the organization, which possesses data about the health status of its members and which has a responsibility for meeting their health needs, actively intervenes to help members and practitioners manage chronic conditions.”

Based on an analysis of disease prevalence in its MediCal population, SFHP selected the chronic conditions of Asthma and Diabetes for its disease management program. Due to the number of eligible members with these chronic conditions, SFHP implemented a tiered outreach approach based on acuity. Eligible members were assigned an acuity level of 1, 2 or 3 (please see brief description at end of memo). All eligible members received written materials. Those members with acuity levels of 2 or 3 received a telephonic disease management intervention. Both written and telephonic interventions are available in member SFHP MediCal threshold languages. In consultation with network providers and QI staff, SFHP developed call scripts and condition specific information. SHFP has contracted with a vendor, Carenet to call members and provide them with the disease management information that SFHP has developed. In 2017, the total number of SFHP members eligible for the Disease Management program is almost 11,397: 8,966 with Diabetes and 2,431 with Asthma.

156

Disease Management Program 2016 Highlights- Population: 10,205

Disease Management Program 2017

• Population= 11,397 (Asthma = 2,431 & Diabetes = 8,966) Asthma Level 1= 553 Level 2= 1,212 Level 3=666 Diabetes Level 1= 1,252 Level 2= 7312 Level 3= 402

• Interventions -Health Education Mailer (All acuity levels) – Mailing dropped in early July -Telephone Intervention (Levels 2-3) - Started in mid-July

• Members with Both Asthma and Diabetes will be given an intervention with the condition of the higher acuity level

Based on analysis of the 2016 program, SFHP will implement the following for its 2017 DM intervention:

• SFHP will continue to provide both written material and target the Level 2 and 3 acuity members with a telephonic intervention

• Based on feedback of call length in 2016, SFHP has modified the call scripts to allow members to receive and focus on information that is relevant to them (i.e. they can choose intervention)

0.00%20.00%40.00%60.00%80.00%

100.00%

% of DiseaseManagement Members

by Condition

73.30%

22.10%

4.60%

Both

Asthma

Diabetes

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Asthma by AcuityLevel

20.30%

53.50%

26.20%

L3

L2

L1

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Diabetes by AcuityLevel

11.80%

83.90%

4.40%

L3

L2

L1

157


• Members will be asked if they would like additional information from the primary care

provider or clinic site and targeted follow up with be done with the primary care sites.

2017 Disease Management Stratification Criteria

Asthma and Diabetes were selected as the two chronic conditions based on high prevalence, identified gaps in performance measures (low HEDIS rates), availability of nationally recognized, evidence based clinical guidelines governing treatment, and potential for high impact (improvement) on member’s clinical outcomes.

Asthma Intervention Criteria Level 3 - Assessment call from

Customer Service Representative

- Health Education Passport Mailer with incentive opportunities

All SFHP members (4+years) with at least 1 of the following: > 2 ER, Acute admission or Non-Acute admissions in the last 4 months. The 2 visits can include any combination of ER / inpatient admission. The 2 visits must have a primary diagnosis code of asthma. OR > 3 rescue inhalers (albuterol) in the past 4 months

OR > 2 systemic steroids in the past 4 months with a primary asthma diagnosis in the past 12 months.

Level 2 - Assessment call from


- Health Education Passport Mailer with incentive opportunities

All SFHP members (4+years) with at least 1 of the following within the past 12 months:

> 4 rescue medications prescriptions OR > 2 systemic steroid prescriptions with at least 1 rescue medication OR > 4 unique claims/encounter dates of service with asthma as the primary diagnosis OR > 1 hospital visit (acute/non-acute) with asthma as the primary diagnosis OR > 2 ER visits with asthma as the primary diagnosis

Level 1 - Health Education Passport

Mailer

All SFHP members (4+ years) with at least 1 of the following within the past 12 months:

> 2 outpatient visits with asthma as the primary diagnosis OR

158

> 1 systemic steroid with asthma as the primary diagnosis and: > 1 bronchodilator and/or > 1 controller prescription OR 2 or 3 only rescue medications or short acting bronchodilator prescriptions and > 1 systemic steroid prescriptions with asthma as the primary diagnosis

Diabetes Intervention Criteria Level 3 - Assessment call from


- Health Education Mailer with incentive opportunities


> 2 ER visits (as defined in NCQA specifications) with a diagnosis of diabetes (1st, 2nd & 3rd only) within the past 6 months;

OR > 2 acute or non-acute hospital admissions with a diagnosis of diabetes (1st, 2nd & 3rd only) within the past 6 months

Level 2 - Assessment call from Customer Service Representative

- Health Education Mailer with incentive opportunities


> 2 outpatient visits, ED visits or non-acute inpatient encounters, on different dates of service, with a diagnosis (1st, 2nd & 3rd only) of diabetes. Visit type need not be the same for the two visits. OR > 1 acute inpatient encounter with a diagnosis of diabetes (1st, 2nd & 3rd only) OR Members with > 1 Anti-diabetic prescription with at least 1 claim/encounter with a diagnosis of diabetes (1st, 2nd & 3rd only)

Level 1 - Health Education Mailer with incentive opportunities


> 2 outpatient visits, ED visits or non-acute inpatient encounters, on different dates of service, with a diagnosis (1st, 2nd & 3rd only) of diabetes. Visit type need not be the same for the two visits.

159


OR > 1 acute inpatient encounter with a diagnosis of diabetes (1st, 2nd & 3rd only) OR Members with > 1 Anti-diabetic prescription with at least 1 claim/encounter with a diagnosis of diabetes (1st, 2nd & 3rd only)

For additional information about SFHP Disease Management Program, please contact: Eloycsia Ratliff, Disease Management Project Manager

[email protected] 415-615-5198

160

mailto:[email protected]

P.O. Box 194247 San Francisco, CA 94119 1(415) 547-7800

1(415) 547-7821

Date: July 25, 2017

To SFHP Quality Improvement Committee

From Fiona Donald, Medical Director, and Eloycsia Ratliff, Disease Management Project Manager

Regarding Disease Management Clinical Practice Guidelines

Preventive Health Guidelines

• Review and Approval of Guidelines

Background Clinical Practices Guidelines are evidence-based clinical management strategies adopted by San Francisco Health Plan (SFHP) in order to:

• Provide a resource for providers on current evidence-based clinical management guidelines • To minimize inter-practitioner variation by supporting the use of the most recent clinical

practice guidelines for certain conditions. • To define best practices and resources for use in SFHP Disease Management, Care

Management and Health Education programs • Clinical practice guidelines are provided for both preventive health as well as disease specific

conditions. San Francisco Health Plan (SFHP) determines which practice guideline topics to adopt through the use of a population analysis and Health Improvement program goals. Per SFHP policies, (QI 9 and QI 13), clinical practice guidelines are reviewed and presented to the Quality Improvement Committee for discussion and adoption. The purpose of this memo is to review updated Preventive Health and Disease Management guidelines for adoption by SFHP

Clinical Practice Guidelines Asthma National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, Full Report 2007 http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf

161

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf

P.O. Box 194247 San Francisco, CA 94119 1(415) 547-7800

1(415) 547-7821 Diabetes Standards of Medical Care in Diabetes-2017 American Diabetes Association Position Statement http://clinical.diabetesjournals.org/content/early/2016/12/15/cd16-0067?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Clin_Diabetes_TrendMD_0 http://care.diabetesjournals.org/content/40/Supplement_1

Preventive Health Guidelines Adult Preventive Health Guidelines SFHP Adult Preventive Health Care Guidelines http://www.sfhp.org/files/providers/guidelines/HealthGuidelines_Adults.pdf USPSTF Preventive Guidelines Primary Care Internet Citation: Recommendations for Primary Care Practice. U.S. Preventive Services Task Force. May 2017. https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations Pediatric Preventive Health Guidelines SFHP Pediatric Preventive Health Care Guidelines http://www.sfhp.org/files/providers/guidelines/HealthGuidelines_Pediatric.pdf US Preventive Services Task Force Pediatric Adolescent Guidelines Internet Citation: Published Recommendations. U.S. Preventive Services Task Force. Jul 2017. https://www.uspreventiveservicestaskforce.org/BrowseRec/Index?age=Pediatric,Adolescent Adopted Guidelines: Providers may find adopted guidelines at sfhp.org Relevant Policies and Procedures Currently, SHFP has two policy and procedures in place to explain how we use these adopted guidelines to address our population. QI9 Practice Guidelines QI13 Disease Management

162

http://care.diabetesjournals.org/content/40/Supplement_1

http://www.sfhp.org/files/providers/guidelines/HealthGuidelines_Adults.pdf

https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations

http://www.sfhp.org/files/providers/guidelines/HealthGuidelines_Pediatric.pdf

http://www.sfhp.org/providers/provider-resources/clinical-guidelines/

http://teams.sfhp.org/square1/Shared%20Documents/PP_CQ_(QI-09)%20Clinical%20Practice%20Guidelines.pdf

http://teams.sfhp.org/square1/Shared%20Documents/PP_CQ_(QI-13)_Disease%20Management.pdf