Download Reporting of PHC Specialist Physician Network Availability and

PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Policy/Procedure Number: MP PR #202A
Policy/Procedure Title: Reporting of PHC Specialist Physician
Network Availability
Lead Department: Provider Relations
☒External Policy
☐ Internal Policy
Next Review Date: 11/08/2017
Last Review Date: 11/16/2016
Original Date: 08/12/1998
Applies to:
☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☒ PAC
☐ CREDENTIALING
☐ DEPT. DIRECTOR/OFFICER
Approving
Entities:
☐ CEO
☐ COO
Approval Signature: Robert Moore, MD, MPH
Approval Date: 11/16/2016
I.
RELATED POLICIES:
A. N/A
II.
IMPACTED DEPTS:
A. Provider Relations
III.
DEFINITIONS:
A. N/A
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
To document the procedure used to evaluate and report availability of Contracted Specialist Physicians for
Partnership HealthPlan of California (PHC).
VI.
POLICY / PROCEDURE:
The HealthPlan is responsible for annually evaluating and reporting the availability of Specialist Physicians
network.
A. The Standard as defined by PHC:
1. High Volume Key Specialist Physician is available within 30 miles of member's residence. A
specialist to member ratio is established and monitored by PHC.
2. High volume specialty services are identified through PHC claims data. A claim data report is
generated by the PHC Claims Department on an annual basis and evaluated to identify non-hospital
based, high volume specialties. The top ten specialties are identified by the highest number of
unique member claims.
3. PHC takes into consideration the special cultural and linguistic needs of its members when
reviewing plan administrative data.
4. The HealthPlan will conduct a GeoAccess® analysis of non-hospital based high volume specialties
to ensure one specialist within 30 miles of member's residence.
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Policy/Procedure Number: MP PR #202A
Lead Department: Provider Relations
Policy/Procedure Title: Reporting of PHC Specialist Physician ☒ External Policy
Network Availability
☐ Internal Policy
Next Review Date: 11/08/2017
Original Date: 08/12/1998
Last Review Date: 11/16/2016
☐ Employees
Applies to: ☒ Medi-Cal
☐ Healthy Kids
5. The Provider Relations Department issues a report documenting the findings. The report is reviewed
by the Internal Quality Improvement Committee (IQI).
6. The final report is forwarded to the QUAC for review, recommendations, and approval.
7. The PHC Provider Relations Department is responsible for implementation, monitoring and
subsequent reporting of the Corrective Action Plan to the QUAC.
8. When a practitioner terminates a contract with PHC, the member is allowed to receive ongoing care
with the practitioner for up to 60 days to treat an illness and through the postpartum period for
deliveries.
VII.
REFERENCES:
A. - NCQA, QUAC
VIII.
DISTRIBUTION:
A. - PHC Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:
Senior Director, Provider Relations
X.
REVISION DATES:
02/15/2000, 03/01/2000, 04/19/2000, 03/18/2001, 07/15/2001, 04/17/2002, 05/21/2003, 06/16/2004,
05/18/2005, 06/15/2005, 06/21/2006, 05/16/2007, 07/16/2008, 07/15/2009, 07/21/2010, 07/20/2011,
08/15/2012, 08/14/2013, 09/10/2014, 11/18/2015, 11/16/2016
PREVIOUSLY APPLIED TO:
N/A
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