The Plan evaluates several factors in Credentialing and

[Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Credentialing and Recredentialing The Plan evaluates several factors in Credentialing and Recredentialing for practitioners in the organization’s network, such as:  how fully the organization investigates each practitioner’s qualifications and practice history before letting the practitioner into the network  how the organization assesses practitioners in its network on an ongoing basis Guidelines for Use:  When conducting file review for multiple Provider Organizations who are serviced by the same MSO, the Auditing Plan must determine whether all Provider Organizations use the same Credentials Committee:  If so, then the plan may pull one file sample across all contracted organizations and apply the same score for CR 3-8 for each organization.  If not, the plan should pull one file sample for each organization.     Surveyors are to provide support for any deficiency, even if the score is 100%. Clarify any issues related to each element. For questions regarding evaluation of compliance with NCQA standards, go to www.ncqa.org For questions regarding posted results send e-mail to Health Plan auditor. This tool was developed by the Industry Collaboration Effort in cooperation with the National Committee on Quality Assurance (NCQA). It is based on the NCQA 2008 MCO Credentialing Standards, Medicare Managed Care Manual (CMS), Medicare Advantage Deeming Standards, Department of Healthcare Services (DHCS) and the Department of Managed Health Care (DMHC). Approved by ICE Shared Credentialing Policy Team 6/08 2008 POC Shared Audit Tool 010109 1 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Table of Contents Audit Summary Report ................................................................................................................................................ 3 Audit Results ............................................................................................................................................................... 4 File Results ................................................................................................................................................................... 5 CR 1 - Credentialing Policies ........................................................................................................................................ 6 CR 2 - Credentialing Committee ................................................................................................................................... 9 CR 3 - Initial Credentialing Verification .................................................................................................................... 10 CR 4 - Application and Attestation ........................................................................................................................... 13 CR 5 - Initial Sanction Information ............................................................................................................................ 14 CR 6 - Practitioner Office Site Quality........................................................................................................................ 15 CR 7 - Recredentialing Verification ............................................................................................................................ 16 CR 8 - Recredentialing Cycle Length ........................................................................................................................... 20 CR 9 - Ongoing Monitoring ........................................................................................................................................ 21 CR 10 - Notification to Authorities and Practitioner Appeal Rights ........................................................................... 22 CR 11 - Assesment of Organizational Providers ......................................................................................................... 24 CR 12 - Delegation of Credentialing ........................................................................................................................... 28 CR 13 - Identification of HIV/AIDS Specialists ...................................................................................................... 34 2008 POC Shared Audit Tool 010109 2 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Audit Summary Report Name of Plan Auditor: Auditor Phone #: NCQA Accreditation Status Health Plan Audit Demographics Name of Plan Performing Audit: Auditor E-mail: Excellent (3-year) Commendable (3-year) Accredited (1-year) Expiration Date: PO Name: PO’s MSO: PO’s Contact: Contact Phone: PO’s Medical Director: Audit Date: Physician Organization Certification: File Selection Methodology: Provider Organization (PO) Audit Demographics Audit Address: City/State/Zip: Contact E-mail: Medical Director E-mail: Provider Organization Certified MSO Certified 8/30 8/30 plus 10 (add comment) Other (add comment) POC Expiration Date: Comments: Time frame of file selection (mm/yy – mm/yy) Secondary or additional organization names: 2008 POC Shared Audit Tool 010109 3 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Audit Results Credentialing Assessment: Standard Element Compliance A B C D E F G H 1 2 3 4 5 6 7 8 9 10 11 12 13 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Note: For all NCQA certification elements auto credit is given. 2008 POC Shared Audit Tool 010109 4 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy File Results Initial Credentialing File Review CR 3.A: License to Practice CR 3.B.1: DEA/CDS Certificate CR 3.B.2: Education, Training, Board Certification CR 3.B.3: Work History CR 3.B.4: Malpractice History CR 3.C: Hospital Admitting Privileges CR 3.D: Medicare Opt-Out Verification (CMS) CR 4.A.1: Reasons for Inability to Perform CR 4.A.2: Lack of Present Illegal Drug Use CR 4.A.3: Hx of Loss of License/Felony Conviction CR 4.A.4: Hx of Loss/Limitations of Privileges/Discipl. Action CR 4.A.5: Current Malpractice Insurance Coverage CR 4.A.6: Attestation Correct and Complete CR 5.A.1: State Sanctions or Restrictions on Licensure CR 5.A.2: Medicare/Medicaid Sanctions Recredentialing File Review CR 7.A: License to Practice CR 7.B.1: DEA/CDS Certificate CR 7.B.2: Board Certification CR 7.B.3: Malpractice History CR 7.C.1: Reasons for Inability to Perform CR 7.C.2: Lack of Present Illegal Drug Use CR 7.C.3: Hx of Loss of License/Felony Convictions CR 7.C.4: Hx of Loss/Limitations of Privileges/Discipl. Action CR 7.C.5: Current Malpractice Insurance Coverage CR 7.C.6: Attestation Correct and Complete CR 7.D.1: State Sanctions or Restrictions on Licensure CR 7.D.2: Medicare/Medicaid Sanctions CR 7.E: Hospital Admitting Privileges CR 7.F: Performance Monitoring (CMS/DHCS) CR 7.G: Medicare Opt-Out Verification (CMS) CR 8: Recredentialing Cycle # Compliant # Non Compliant Denominator % Compliance H/M/L* 8 8 8 8 8 0 0 0 0 0 8 8 8 8 8 100 100 100 100 100 H H H H H 8 8 8 8 8 8 8 8 # Compliant 0 0 0 0 0 0 0 0 # Non Compliant 8 8 8 8 8 8 8 8 Denominator 100 100 100 100 100 100 100 100 % Compliance H H H H H H H H H/M/L* 8 8 8 8 8 8 8 8 8 8 8 8 0 0 0 0 0 0 0 0 0 0 0 0 8 8 8 8 8 8 8 8 8 8 8 8 100 100 100 100 100 100 100 100 100 100 100 100 H H H H H H H H H H H H 8 M = 60-89% L = 0-59% 0 8 100 H *Key: H = 90-100% 2008 POC Shared Audit Tool 010109 5 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy CR 1: Credentialing Policies The organization has a well-defined credentialing and recredentialing process for evaluating and selecting licensed independent practitioners to provide care to its members. Intent The organization has a rigorous process to select and evaluate practitioners. Element A: Practitioner Credentialing Guidelines The organization’s credentialing policies and procedures specify: 1. 2. 3. 4. 5. 6. 7. 8. The types of practitioners to credential and recredential The verification sources used The criteria for credentialing and recredentialing The process for making credentialing and recredentialing decisions The process for managing credentialing files that meet the organization's established criteria The process for delegating credentialing or recredentialing The process for ensuring that credentialing and recredentialing are conducted in a nondiscriminatory manner The process for notifying practitioners if information obtained during the organization's credentialing process varies substantially from the information they provided to the organization The process for ensuring that practitioners are notified of the credentialing and recredentialing decision within 60 calendar days of the committee's decision Yes No 9. 10. The medical director or other designated physician's direct responsibility and participation in the credentialing program 11. The process for ensuring the confidentiality of all information obtained in the credentialing process, except as otherwise provided by law 12. This number is reserved to maintain consistency with NCQA standards. Do not measure. 100% The organization meets all 11 factors 80% The organization meets 8-10 factors 50% The organization meets 5-7 factors 20% The organization meets 3-4 factors 0% The organization meets 0-2 factors Scoring 100 Comments: PO is NCQA Certified 2008 POC Shared Audit Tool 010109 6 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element B: Practitioner Rights The organization’s policies and procedures include the right to: 1. Review information submitted to support their credentialing application 2. Correct erroneous information 3. Receive the status of their credentialing or recredentialing application, upon request 4. Receive notification of these rights. 100% The organization meets all 4 factors 80% The organization meets 3 factors 50% No scoring option Yes No Scoring 100 20% The organization meets 1-2 factors 0% The organization meets no factors Comments: PO is NCQA Certified Element C: Performance Monitoring for Recredentialing – CMS/DHCS The organization’s recredentialing policies and procedures requires information from quality improvement activities and enrollee complaints in the recredentialing decision-making process. (Source: Medicare Advantage Deeming Module: Standard 16, Element A, MMCD 02-03 and Exhibit A, Attachment 4 of plan contract) Note: For ICE Purposes, performance monitoring is required for all practitioners for Health Plans not deemed. Yes No Scoring 100% Met 80% No scoring option 50% No scoring option 20% No scoring option 0% Not Met Not applicable if the PO does not hold Medicare and/or MediCal Contracts Comments: 2008 POC Shared Audit Tool 010109 7 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element D: Contracts – Opt-Out Provisions - CMS The Medicare Advantage organization has policies and procedures to ensure that it only contracts with physicians who have not opted out. (Source: Medicare Advantage Deeming Module: Standard 10, Element A) Yes No Scoring 100% Met 80% No scoring option 50% No scoring option 20% No scoring option 0% Not Met Not applicable if the PO does not hold Medicare Contracts Comments: Element E: Medicare-Exclusions/Sanctions - CMS The Medicare Advantage organization must have policies and procedures that prohibits employment or contracting with practitioners (or entities that employ or contract with such practitioners) that are excluded/sanctioned from participation. (Source: Medicare Managed Care Manual, Chapter 6, 60.2) Yes No Scoring 100% Met 80% No scoring option 50% No scoring option 20% No scoring option 0% Not Met Not applicable if the PO does not hold Medicare Contracts Note: Standard Eff. 1/1/09 Comments: 2008 POC Shared Audit Tool 010109 8 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy CR 2: Credentialing Committee The organization designates a credentialing committee that uses a peer-review process to make recommendations regarding credentialing decisions. Intent The organization obtains meaningful advice and expertise from participating practitioners when it makes credentialing decisions. Element A: Credentialing Committee The Credentialing Committee includes representation from a range of participating practitioners. 100% 80% No scoring option 50% The committee does not include a range of participating practitioners 20% No scoring option 0% The committee does not include participating practitioners Scoring 100 For HMO & PPO The committee includes a range of participating practitioners Comments: PO is NCQA Certified Element B: Credentialing Committee Decisions The organization provides evidence of the following: 1. Credentialing Committee review of credentials for practitioners who do not meet established thresholds 2. Medical director or equally qualified individual review and approval of clean files Exception: Not applicable if organization presents all files (including clean files) to the CR committee. If factor 2 is NA = factor met. Yes No NA 100% 80% No scoring option 50% The organization meets 1 factor 20% No scoring option 0% The organization does not meet either factor Scoring 100 Factor 2 – Clean file process is acceptable effective 7/1/08 for DHCS The organization meets both factors Comments: PO is NCQA Certified 2008 POC Shared Audit Tool 010109 9 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy CR 3: Initial Credentialing Verification The organization verifies credentialing information through primary sources, unless otherwise indicated. Intent The organization conducts timely verification of information to ensure that practitioners have the legal authority and relevant training and experience to provide quality care. File Review Results CR 3: File Review Results Total Practitioners: PCPs and Ratio Assessment of the Following File Review Elements (8) A. Licensure: 8/8 B.1 DEA or CDS: B.2 Education, training, and board certification: B.3 Work history: B.4 Malpractice history: C. Hospital Admitting Privileges (PSV not required): *If the denominator for any element is less than 30, explain why: 8/8 8/8 8/8 8/8 SCPs Ratio (30)* Percentage 100 100 100 100 100 H/M/L H H H H H Assessment of the Following File Review Element (CMS ) D. Medicare Opt-out Verification *If the denominator for any element is less than 30, explain why: Ratio (8) Ratio (30)* Percentage H/M/L Element A: Licensure Verification The organization verifies that a current, valid license to practice is present and within the prescribed time limits. 100% 80% No scoring option 50% Medium (6089%) on file review 20% No scoring option 0% Low (0-59%) on file review Scoring 100 Not applicable if no initial credentialing was performed during the audit period. High (90-100%) on file review Comments: PO is NCQA Certified 2008 POC Shared Audit Tool 010109 10 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element B: Initial Primary Source Verification The organization verifies that the following are within the prescribed time limits: 1. A valid DEA or CDS certificate, if applicable 2. Education and training, including board certification, as specified in the Explanation 3. Work history 4. A history of professional liability claims that resulted in settlements or judgments paid on behalf of the practitioner 100% 80% High (90-100%) on file review for at least 3 factors, medium (60-89%) on file review for no more than 1 factor 50% High (90-100%) on file review for 1-2 factors, medium (6089%) on 1-2 factors and low on no more than 1 factor (059%) 20% Medium (6089%) on file review for at least 3 factors; low (0-59%) on file review for no more than 1 factor 0% Low (0-59%) on file review for 2 or more factors Scoring 100 Not applicable if no initial credentialing was performed during the audit period. High (90-100%) on file review for all 4 factors Comments: PO is NCQA Certified Element C: Hospital Admitting Privileges – CMS/DMHC/DHCS Practitioners must have clinical privileges in good standing. Physicians must indicate their current hospital affiliation or admitting privileges at participating hospitals. (Source: Medicare Managed Care Manuel, Chapter 6, section 60.3., MMCD Policy Letter 02-03 and DMHC 6/05) 100% 80% No scoring option 50% Medium (6089%) on file review 20% No scoring option 0% Low (0-59%) on file review Scoring High (90-100%) on file review Applicable for all products. Not applicable if no initial credentialing was performed during the audit period. Comments: 2008 POC Shared Audit Tool 010109 11 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element D: Monitoring Physicians Who Have Opted Out - CMS The Medicare Advantage organization monitors its credentialing files to ensure that it only contracts with physicians who have not opted out. (Source: Medicare Advantage Deeming Module: Standard 10, Element B and Medicare Managed Care Manual, Chapter 6, 60.2) 100% 80% No scoring option 50% Medium (6089%) on file review 20% No scoring option 0% Low (0-59%) on file review Scoring High (90-100%) on file review Not applicable if no initial credentialing was performed during the audit period. Not applicable if the PO does not hold Medicare Contracts Not applicable if PO employs their practitioners and contracts have been reviewed to validate appropriate language regarding opt-out provisions. Comments: 2008 POC Shared Audit Tool 010109 12 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy CR 4: Application and Attestation Practitioners complete an application for network participation that includes a current and signed attestation regarding their health status and any history of loss or limitation of licensure or privileges. Intent The organization requires practitioners to disclose information that may adversely impact their ability to provide care. File Review Results CR 4: File Review Results Total Practitioners: PCPs and SCPs Ratio Ratio Assessment of the Following File Review Elements (8) (30)* Percentage H/M/L Reasons for inability to perform the essential functions of the position 8/8 100 H with or without accommodation Lack of present illegal drug use 8/8 100 H History of loss of license and felony conviction 8/8 100 H History of loss or limitation of privileges or disciplinary actions 8/8 100 H Current malpractice insurance coverage 8/8 100 H A signed attestation to the correctness and completeness of the 8/8 100 H application** *If the denominator for any element is less than 30, explain why: **If the attestation is not signed, all application elements are noncompliant (Except current malpractice coverage if copy of face sheet obtained). Element A: Contents of the Application The application includes a current and signed attestation and addresses the following: 1. Reasons for inability to perform the essential functions of the position, with or without accommodation 2. Lack of present illegal drug use 3. History of loss of license and felony conviction 4. History of loss or limitation of privileges or disciplinary actions 5. Current malpractice insurance coverage 6. The correctness and completeness of the application 100% 80% High (90-100%) on file review for 4 or 5 factors and medium (60-89%) on file review for remaining 1-2 factors 50% High (90-100%) or medium (6089%) on file review for 5 factors and low (0-59% )on no more than 1 factor 20% High (90-100%) or medium (6089%) on file review for 4 factors and low (0-59% )on no more than 2 factors 0% Low (0-59%) on file review for 3 or more factors Scoring 100 Not applicable if no initial credentialing was performed during the audit period High (90-100%) on file review for all 6 factors Comments: PO is NCQA Certified 2008 POC Shared Audit Tool 010109 13 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy CR 5: Initial Sanction Information The organization receives information on practitioner sanctions before making a credentialing decision. Intent The organization verifies whether there has been any sanction activity that might impact a practitioner’s ability to provide safe, appropriate care to members. File Review Results CR 5: File Review Results Total Practitioners: PCPs and State Board Queries and Medicare and Medicaid Sanctions Information about sanctions or limitations on licensure from State Board of Medical Examiners, Federation of State Medical Boards, or the Department of Professional Regulations; State Board of Chiropractic Examiners or the Federation of Chiropractic Licensing Boards; State Board of Dental Examiners; State Board of Podiatric Examiners (as applicable): Information on previous sanction activity by Medicare and Medicaid: *If the denominator for any element is less than 30, explain why: SCPs Ratio (30)* Percentage H/M/L Ratio (8) 8/8 100 H 8/8 100 H Element A: Sanctions Information The organization verifies the following sanction information for initial credentialing. 1. State sanctions, restrictions on licensure or limitations on scope of practice 2. Medicare and Medicaid sanctions Scoring 100 Not applicable if no initial credentialing was performed during the audit period. 100% High (90-100%) on file review for both factors 80% High (90-100%) on file review for 1 factor and medium (6089%) on file review for 1 factor 50% Medium (6089%) on file review for both factors 20% High (90-100%) or medium (60-89%) on file review for 1 factor and low (0-59%) on file review for 1 factor 0% Low (0-59%) on file review for both factors Comments: PO is NCQA Certified 2008 POC Shared Audit Tool 010109 14 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy CR 6: Practitioner Office Site Quality The organization has a process to ensure that the offices of all practitioners meet its office-site standards. Intent The organization assesses the quality, safety and accessibility of the office sites where care is delivered. Element A: Performance Standards and Thresholds The organization: 1. Sets standards and performance thresholds for office-site criteria 2. Sets standards and performance thresholds for medical/treatment record-keeping criteria 100% The organization meets both factors 80% No scoring option 50% The organization meets 1 factor 20% No scoring option 0% There are no standards or thresholds Yes No Scoring 100 Comments: PO is NCQA Certified Element B: Site Visits and Ongoing Monitoring The organization implements appropriate interventions by: 1. Conducting site visits of offices about which it has received member complaints 2. Instituting actions to improve offices that do not meet thresholds 3. Evaluating the effectiveness of the actions at least every six months, until deficient sites meet the thresholds 4. Monitoring member complaints for all practitioner sites at least every six months 5. Documenting follow-up visits for offices that had subsequent deficiencies. 100% 80% The organization meets 3-4 factors Yes No NA 50% The organization meets 2 factors 20% The organization meets 1 factor 0% The organization meets no factors Scoring 100 Factor 1=Not applicable for physicians who provide care in patient’s homes. Factor 5=Not applicable if all sites meet the organization’s performance thresholds and no new deficiencies are identified The organization meets all 5 factors Comments: PO is NCQA Certified 2008 POC Shared Audit Tool 010109 15 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy CR 7: Recredentialing Verification The organization formally recredentials its practitioners through information verified from primary sources, unless otherwise indicated. Intent The organization identifies changes that have occurred since the last credentialing and which may affect the care provided to members. File Review Results CR 7: File Review Results Total Practitioners: PCPs and Assessment of the Following File Review Elements A. Licensure B.1 DEA/CDS certificates B.2 Board certification (if appropriate) B.3 Malpractice history Application** C.1Reasons for any inability to perform the essential functions of the position, with or without accommodation C.2 Lack of present illegal drug use C.3 History of loss of license and felony convictions C.4 History of loss or limitations of privileges or disciplinary action C.5 Current malpractice insurance coverage C.6 Attestation to the correctness and completeness of information provided by the practitioner D.1 Information about sanctions or limitations on licensure from State Board of Medical Examiners, Federation of State Medical Boards, or the Department of Professional Regulations; State Board of Chiropractic Examiners or the Federation of Chiropractic Licensing Boards; State Board of Dental Examiners; State Board of Podiatric Examiners; Osteopathic Medical Board (as applicable): D.2 Information on previous sanction activity by Medicare and Medicaid: E. Hospital Admitting Privileges (PSV not required): *If the denominator for any element is less than 30, explain why: **If the attestation is not signed, all application elements are noncompliant (Except current malpractice coverage, if copy of face sheet obtained). 8/8 8/8 8/8 8/8 8/8 8/8 100 100 100 100 100 100 H H H H H H SCPs Ratio (30)* Percentage 100 100 100 100 Ratio (8) 8/8 8/8 8/8 8/8 H/M/L H H H H 8/8 100 H 8/8 100 H Assessment of the Following File Review Elements (CMS or DHCS) F. Review of Performance Information (CMS & DHCS) G. Medicare Opt-out Verification (CMS Only) *If the denominator for any element is less than 30, explain why: 2008 POC Shared Audit Tool 010109 Ratio (8) Ratio (30)* Percentage H/M/L 16 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element A: Licensure Verification The organization verifies that a current, valid license or certification from the state to practice is present and within the prescribed time limits. 100% 80% No scoring option 50% Medium (60-89%) on file review 20% No scoring option 0% Low (0-59%) on file review Scoring 100 Not applicable if no recredentialing was performed during the audit period High (90-100%) on file review Comments: PO is NCQA Certified Element B: Recredentialing Verification The organization verifies the following factors within prescribed time limits. 1. A valid DEA or CDS certificate, as applicable 2. Board certification, as applicable 3. History of professional liability claims that resulted in settlements or judgments paid by or on behalf of the practitioner. 100% 80% High (90-100%) on file review for at least 2 factors and medium (60-89%) on file review for 1 factor 50% High (90-100%) on file review for 1 factor; medium (60-89%) for 2 factors or high (90-100%) file review for 2 factors, low (059%) on file review for 1 factor or medium (6089%) on file review for 3 for all factors 20% High (90-100%) or medium (60-89%) on file review for 1 factor, low (0-59%) on file review for 2 factors 0% Low (0-59%) on file review for all 3 factors Scoring 100 Not applicable if no recredentialing was performed during the audit period High (90-100%) on file review for all 3 factors Comments: PO is NCQA Certified 2008 POC Shared Audit Tool 010109 17 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element C: Contents of the Application The application includes a current and signed attestation and addresses the following: 1. Reasons for inability to perform the essential functions of the position, with or without accommodation 2. Lack of present illegal drug use 3. History of loss of license and felony convictions 4. History of loss or limitation of privileges or disciplinary action 5. Current malpractice insurance coverage 6. Correctness and completeness of the application Scoring 100 Not applicable if no recredentialing was performed during the audit period 100% High (90-100%) on file review for all 6 factors 80% High (90-100%) on file review for 4 or 5 factors and medium (60-89%) on file review for remaining 1-2 factors 50% High (90-100%) on file review or medium (6089%) on file review for 5 factors and low (0-59) on no more than 1 factor 20% High (90-100%) or medium (6089%) on file review for 4 factors and low (0-59%) on no more than 2 factors 0% Low (0-59% on file review for 3 or more factors Comments: PO is NCQA Certified Element D: Sanction Information The organization verifies the following sanction information for recredentialing. 1. State sanctions, restrictions on licensure or limitations on scope of practice 2. Medicare and Medicaid sanctions 100% 80% High (90-100%) on file review for 1 factor and medium (6089%) on file review for 1 factor 50% Medium (60-89%) on file review for both factors 20% High (90-100%) or medium (60-89%) on file review for 1 factor and low (0-59%) on file review for 1 factor 0% Low (0-59%) on file review for both factors Scoring 100 Not applicable if no recredentialing was performed during the audit period High (90-100%) on file review for both factors Comments: PO is NCQA Certified 2008 POC Shared Audit Tool 010109 18 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element E: Hospital Admitting Privileges – CMS/DMHC/DHCS Practitioners must have clinical privileges in good standing. Physicians must indicate their current hospital affiliation or admitting privileges at participating hospitals. (Source: Medicare Managed Care Manual, Chapter 6, section 60.3., MMCD Policy Letter 02-03 and DMHC 6/05)) 100% High (90-100%) on file review 80% No scoring option 50% Medium (6089%) on file review 20% No scoring option 0% Low (0-59%) on file review Scoring Applicable for all products Not applicable if no recredentialing was performed during the audit period Comments: Element F: Review of Performance Information – CMS/DHCS The organization includes information from quality improvement activity and enrollee complaints in the recredentialing decision-making process. Performance indicators include: (Source: Medicare Advantage Deeming Module: Standard 16, Element B, Medicare Managed Care Manual, Chapter 6, section 60.3., MMCD Policy Letter 02-03 and Exhibit A, Attachment 4 of plan contract)) Note: For ICE Purposes, all practitioners will be audited for Health Plans not deemed. 1. quality activities (e.g., utilization management system, enrollee satisfaction surveys, other activities of the organization) 2. grievance/complaints 100% 80% No scoring option Yes No 50% Medium (60-89%) on file review 20% No scoring option 0% Low (0-59%) on file review Scoring High (90-100%) on file review Not applicable if no Medicare and/or MediCal contracts. Comment on missing elements Comments: 2008 POC Shared Audit Tool 010109 19 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element G: Monitoring Physicians Who Have Opted Out: CMS The Medicare Advantage organization monitors its recredentialing files to ensure that it only contracts with physicians who have not opted out. (Source: Medicare Advantage Deeming Module: Standard 10, Element B and Medicare Managed Care Manual, Chapter 6, 60.2) 100% 80% No scoring option 50% Medium (6089%) on file review 20% No scoring option 0% Low (0-59%) on file review Scoring High (90-100%) on file review Not applicable if no recredentialing was performed during the audit period. Not applicable if the PO does not hold Medicare Contracts Not applicable if PO employs their practitioners and contracts have been reviewed to validate appropriate language regarding opt-out provisions. Comments: CR 8: Recredentialing Cycle Length The organization formally recredentials its practitioners at least every 36 months. Intent The organization conducts timely recredentialing. Element A: Recredentialing Cycle Length The length of the recredentialing cycle is within the required 36-month time frame. Of the 8 files sampled, 100% were compliant. 100% High (90-100%) on file review 80% No scoring option 50% Medium (60-89%) on file review 20% No scoring option 0% Low (0-59%) on file review Scoring 100 Not applicable if no recredentialing was performed during the audit period Comments: PO is NCQA Certified 2008 POC Shared Audit Tool 010109 20 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy CR 9: Ongoing Monitoring The organization develops and implements policies and procedures for ongoing monitoring of practitioner sanctions, complaints and quality issues between recredentialing cycles and takes appropriate action against practitioners when it identifies occurrences of poor quality. Intent The organization identifies and, when appropriate, acts on important quality and safety issues in a timely manner during the interval between formal credentialing. Element A: Ongoing Monitoring and Interventions The organization implements ongoing monitoring and takes appropriate interventions by: Yes 1. Collecting and reviewing Medicare and Medicaid sanctions 2. Collecting and reviewing sanctions or limitations on licensure 3. Collecting and reviewing complaints 4. Collecting and reviewing information from identified adverse events 5. Implementing appropriate interventions when it identifies instances of poor quality, when appropriate 100% 80% The organization meets 4 factors No NA 50% The organization meets 3 factors 20% The organization meets 2 factors 0% The organization meets 0-1 factors Scoring 100 Factor 5 = NA if there is no sanction/complaints or adverse events between recred. cycle The organization meets all 5 factors Comments: PO is NCQA Certified Element B: Monitoring Medicare Opt-Out Report - CMS The organization maintains a documented process for monitoring whether network physicians have opted out of participating in the Medicare program. (Source: Medicare Managed Care Manual, Chapter 6, 60.3) Scoring 100% Met 80% No scoring option 50% No scoring option 20% No scoring option 0% Not met Not applicable if organization does not have a Medicare contract Comments: 2008 POC Shared Audit Tool 010109 21 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element C: Monitoring Medi-Cal Suspended and Ineligible Provider Report - DHCS The contractor will verify that their subcontracted providers have not been terminated as Medi-Cal providers or have not been placed on the Suspended and Ineligible Provider List. (Source: Exhibit A Attachment 4 - MCL Contract) 100% 80% 50% 20% 0% Scoring Met Not applicable if organization does not have a Medi-Cal contract No scoring option No scoring option No scoring option Not met Comments: CR 10: Notification to Authorities and Practitioner Appeal Rights An organization that has taken action against a practitioner for quality reasons reports the action to the appropriate authorities and offers the practitioner a formal appeal process. Intent The organization uses objective evidence and patient care considerations to decide on the means of altering its relationship with a practitioner who does not meet its quality standards. Element A: Actions Against Practitioners The organization has policies and procedures for: 1. The range of actions available to the organization 2. Reporting to authorities 3. A well-defined appeal process 4. Making the appeal process known to practitioners 100% The organization meets all 4 factors 80% No scoring option 50% The organization meets 3 factors 20% No scoring option 0% The organization meets 0-2 factors Yes No Scoring 100 Comments: PO is NCQA Certified 2008 POC Shared Audit Tool 010109 22 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element B: Reporting to Appropriate Authorities There is documentation that the organization reports practitioner suspension or termination to the appropriate authorities. Scoring 100 Not applicable if there were no suspensions or terminations to report 100% The organization reports actions to authorities, when appropriate 80% No scoring option 50% No scoring option 20% No scoring option 0% The organization does not report actions to authorities, when appropriate Comments: PO is NCQA Certified Element C: Practitioner Appeal Process The organization has an appeal process for instances in which it chooses to alter the conditions of practitioner participation based on issues of quality of care or service, and informs practitioners of the appeal process. 100% 80% No scoring option 50% No scoring option 20% No scoring option 0% The organization does not implement a practitioner appeal process, when appropriate Scoring 100 Not applicable if organization did not alter conditions of a practitioner’s participation based on quality of care and/or service issues There is documentation that the organization offers an appeal process to practitioners, when appropriate Comments: PO is NCQA Certified Element D: Medicare Advantage Policies and Procedures - CMS The Medicare Advantage organization’s policies and procedures regarding suspension or termination of a participating physician require the organization to: Provide that the majority of the hearing panel members are peers of the affected physician. (Source: Medicare Advantage Deeming Module: Standard 8, Element A.3 and Medicare Managed Care Manual, Chapter 6, 60.4) Yes No Scoring 100% Met 80% No scoring option 50% No scoring option 20% No scoring option 0% Not Met Not applicable if organization does not have a contract for Medicare Comments: 2008 POC Shared Audit Tool 010109 23 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy CR 11: Assessment of Organizational Providers Applicable  Not Applicable (if not applicable, do not complete this section) Check the above boxes for contracting with organizational providers, as applicable. The organization has written policies and procedures for the initial and ongoing assessment of providers with which it contracts. Intent The organization evaluates the quality of providers with which it contracts. Element A: Assessment of Organizational Providers The organization’s policy for assessing of health care delivery providers specifies that it: 1. Confirms that the provider is in good standing with state and federal regulatory bodies 2. Confirms that the provider has been reviewed and approved by an accrediting body 3. Conducts an on-site quality assessment, if the provider is not accredited 4. Confirms, at least every 3 years, that the provider continues to be in good standing with state and federal regulatory bodies and, if applicable, is reviewed and approved by an accrediting body. 100% 80% The organization meets all factors except 3-year cycles Yes No NA 50% The organization meets 2 factors 20% The organization meets 1 factor, or is unclear 0% No written policy exists Scoring Not applicable if PO does not hold any organizational provider contracts and has no intent to do so. The organization meets all 4 factors Comments: Element B: Medical Providers The organization includes at least the following medical providers in its assessment: 1. Hospitals 2. Home health agencies 3. Skilled nursing facilities 4. Free-standing surgical centers Yes No NA Scoring Not applicable if PO does not hold any organizational provider contracts and has no intent to do so. 100% The organization meets all 4 factors 80% The organization meets 3 factors, including hospitals 50% The organization meets 2 factors, including hospitals 20% The organization meets 1 factor 0% No written policy exists Comments: 2008 POC Shared Audit Tool 010109 24 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element C: Behavioral Health Providers The organization includes behavioral health facilities providing mental health or substance abuse services in the following settings: 1. Inpatient 2. Residential 3. Ambulatory Yes No NA Scoring 100% The organization meets all 3 factors 80% No scoring option 50% The organization meets 1-2 factors 20% No scoring option 0% The organization meets no factors Not applicable if PO does not hold any organizational provider contracts and does not intend to do so. Score 100% if contracts with Behavioral Health OPs. Comments: File Review Results for Medical Organizational Providers If the organization uses a comprehensive spreadsheet or log showing credentialing of organizational providers, use spreadsheet results to calculate compliance, and completion of the File Review Results Grid is not required. If individual records are used, then implement the NCQA 8/30 rule for file selection and review of the four types of organizational providers under Element B, using the File Review Results grid to document findings. Total Medical Organizational Providers: Hospitals Home Health Agencies CR 11: File Review Results SNF Free-standing Surgery Centers Ratio Ratio (8) (30)* Percentage Verification Elements and Sources Good standing with State and Federal regulatory bodies: Reviewed and approved by accrediting body OR Onsite quality assessment if not accredited**: Reconfirms every three years: *If the denominator for any element is less than 30, explain why: H/M/L **See element F regarding California State requirements for non-accredited freestanding surgical centers. 2008 POC Shared Audit Tool 010109 25 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element D: Assessing Medical Providers The organization has documentation that it assessed contracted medical health care delivery providers. 100% Documentation is present that the organization completed an assessment of contracted medical providers. No deficiencies. 80% No scoring option 50% Documentation is present that the organization completed an assessment of contracted medical providers. 80% of the files had no deficiencies. 20% No scoring option 0% Documentation is present that the organization completed an assessment of contracted medical providers. 0-79% of the files had deficiencies and/or no documentation is present of a completed assessment. Scoring Not applicable if group has no contracted organizational providers in this category. Comments: File Review Results for Behavioral Health Organizational Providers If the organization uses a comprehensive spreadsheet or log showing credentialing of organizational providers, use spreadsheet results to calculate compliance, and completion of the File Review Results Grid is not required. If individual records are used, then implement the NCQA 8/30 rule for file selection and of the behavioral health organizational providers under Element C, using the File Review Results grid to document findings. CR 11: File Review Results Total Behavioral Health Organizational Providers: Inpatient Residential Ambulatory Ratio Verification Elements and Sources (8) Good standing with State and Federal regulatory bodies: Reviewed and approved by accrediting body OR Onsite quality assessment if not accredited**: Reconfirms every three years: *If the denominator for any element is less than 30, explain why: Ratio (30)* Percentage H/M/L 2008 POC Shared Audit Tool 010109 26 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element E: Assessing Behavioral Health Providers The organization has documentation that it assessed contracted behavioral health care delivery providers. 100% 80% No scoring option 50% Documentation is present that the organization completed an assessment of contracted medical providers. 80% of the files had no deficiencies. 20% No scoring option 0% Documentation is present that the organization completed an assessment of contracted medical providers. 0-79% of the files had deficiencies and/or no documentation is present of a completed assessment. Scoring Not applicable if group has no contracted organizational providers in this category. Score 100% if contracts with Behavioral Health OPs. Documentation is present that the organization completed an assessment of contracted medical providers. No deficiencies. Comments: Element F: Accreditation/Certification of Free-Standing Surgical Centers in California – CH&SC The organization has documentation of assessment of free-standing surgical centers to ensure that if the provider is not accredited by an agency accepted by the State of California, the provider is certified to participate in the Medicare Program, in compliance with California Health and Safety Code 1248.1., 42 CFR 498.2 100% High (90-100%) on file review 80% No scoring option 50% Medium (60-89%) on file review 20% No scoring option 0% Low (0-59%) on file review Scoring Not applicable if group has no contracted organizational providers in this category Comments: 2008 POC Shared Audit Tool 010109 27 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy CR 12: Delegation of CR Applicable  Not Applicable (if not applicable, do not complete this section) Check the above boxes for delegation, as applicable. If the organization delegates any NCQA – required credentialing activities, there is evidence of oversight of the delegated activities. Intent The organization remains accountable for credentialing and recredentialing its practitioners, even if it delegates all or part of these activities. Organizations to which the Provider Organizations delegates any credentialing functions: Type Name/Description of Entity Type NCQA Cert Expiration Date Contract Effective Date Provider Organization BH Facility CVO MSO Other Always complete the above box when a PO delegates any part of the credentialing process 2008 POC Shared Audit Tool 010109 28 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element A: Written Delegation Agreement The written delegation document: 1. Is mutually agreed upon 2. Describes the responsibilities of the organization and the delegated entity 3. Describes the delegated activities 4. Requires at least semiannual reporting to the organization 5. Describes the process by which the organization evaluates the delegated entity's performance 6. Describes the remedies available to the organization if the delegated entity does not fulfill its obligations, including revocation of the delegation agreement Element/ Factor A.1 A.2 A.3 A.4 A.5 A.6 Totals PO Yes No CVO Yes No MSO Yes No BH Yes No Other Yes No Sum Factors Met For each contract, obtain a total number of factors met and document that number in the [Totals] row under each delegate/contract column. Then add the total factors met for all contracts across the [Totals] row and document the sum in the [Sum] column. For the final number of factors met, take the sum and divide it by the number of contracts reviewed. Round down to nearest whole number. Document that number in this row under the [Factors Met] Column. Use this number to calculate Scoring for Element A below: 100% 80% The organization meets 4 - 5 factors 50% The organization meets 3 factors Scoring The organization meets all 6 factors Not applicable if organization does not delegate credentialing or recredentialing activities. For DHCS: Quarterly reporting is required. Note in comments 20% The organization meets 1-2 factors 0% The organization meets no factors Comments: 2008 POC Shared Audit Tool 010109 29 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element B: Provision for PHI The delegation document includes the use of protected health information (PHI), if any, by the delegate, including: 1. A list of the allowed uses of protected health information 2. A description of delegate safeguards to protect the information from inappropriate use or further disclosure 3. A stipulation that the delegate will ensure that subdelegates have similar safeguards 4. A stipulation that the delegate will provide individuals with access to their PHI 5. A stipulation that the delegate will inform the organization if inappropriate uses of the information occur 6. A stipulation that the delegate will ensure that PHI is returned, destroyed or protected if the delegation agreement ends. This number is reserved to maintain consistency with NCQA standards. Do not measure. Element C: Right to Approve and to Terminate The organization retains the right to approve, suspend and terminate individual practitioners, providers and sites in situations where it has delegated decision making. This right is reflected in the delegation document. Element/ Factor C Totals PO Yes No NA CVO Yes No NA MSO Yes No NA BH Yes No NA Other Yes No NA 100% 80% No scoring option 50% The right is assumed or implemented, but not written in the delegation document 20% No scoring option 0% The organization has no right to approve or to terminate Scoring Not applicable if organization does not delegate credentialing or recredentialing activities Not applicable if delegate does not have decision-making authority, e.g. CVO for PSV. The right is written in the delegation document Comments: 2008 POC Shared Audit Tool 010109 30 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element D Pre-Delegation Evaluation For delegation agreements that have been in effect for less than 12 months, the organization evaluated delegate capacity before the delegation document was signed. Element/ Factor D Totals PO Yes No NA CVO Yes No NA MSO Yes No NA BH Yes No NA Other Yes No NA Scoring Not applicable if organization does not delegate credentialing or recredentialing activities Not applicable if delegation has been in effect more that 12 months 100% The organization evaluated delegate capacity before the delegation document was signed 80% No scoring option 50% The organization evaluated delegate capacity after the delegation document was signed 20% No scoring option 0% The organization did not evaluate delegate capacity Comments: Element E: Annual File Audit For delegation arrangements in effect for 12 months or longer, the organization has audited credentialing files against NCQA standards for each year that the delegation has been in effect. Element/ Factor E Totals PO Yes No NA CVO Yes No NA MSO Yes No NA BH Yes No NA Other Yes No NA Scoring 100% The organization annually audited the appropriate number of files 80% The organization audited the appropriate number of files less than annually 50% The organization audited fewer than the appropriate number of files 20% The organization provided general evaluation without an adequate audit 0% The organization provided no evaluation Not applicable if organization does not delegate credentialing or recredentialing activities Not applicable if delegation has been in effect less than 12 months, Comments: 2008 POC Shared Audit Tool 010109 31 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element F: Annual Evaluation For delegation arrangements that have been in effect for more than 12 months, the organization has performed an annual substantive evaluation of delegated activities against delegated NCQA standards and organization expectations. Element/ Factor F Totals PO Yes No NA CVO Yes No NA MSO Yes No NA BH Yes No NA Other Yes No NA 100% 80% No scoring option 50% The organization conducted an incomplete evaluation without specific standards or conducted an evaluation less than annually 20% No scoring option 0% The organization did not conduct an evaluation within the past 2 years Scoring Not applicable if organization does not delegate credentialing or recredentialing activities and is NCQA accredited or certified. Not applicable if delegation has been in effect less than 12 months. The organization conducted complete evaluations annually Comments: Element G: Reporting For delegation arrangements in effect for 12 months or longer, the organization evaluated regular reports. Element/ Factor G Totals PO Yes No NA CVO Yes No NA MSO Yes No NA BH Yes No NA Other Yes No NA Scoring 100% The organization evaluated regular reports 80% No scoring option 50% No scoring option 20% No scoring option 0% The organization did not evaluate regular reports Not applicable if organization does not delegate credentialing or recredentialing activities. Not applicable if delegation has been in effect less than 6 months. For DHCS: Quarterly reporting is required. Note in comments 2008 POC Shared Audit Tool 010109 32 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Comments: Element H: Opportunities for Improvement For delegation arrangements that have been in effect for more than 12 months, at least once in each of the past 2 years, the organization has identified and followed up on opportunities for improvement, if applicable. Element/ Factor H Totals PO Yes No NA CVO Yes No NA MSO Yes No NA BH Yes No NA Other Yes No NA 100% 80% No scoring option 50% The organization has taken inappropriate or weak action, or has taken action only in the past year 20% No scoring option 0% The organization has taken no action on identified problems Scoring Not applicable if organization does not delegate credentialing or recredentialing activities and is NCQA accredited or certified. Not applicable if delegation has been in effect less than 12 months Not applicable if no Opportunities for Improvement. At least once in each of the past 2 years that the delegation arrangement has been in effect, the organization has acted on identified problems, if any Comments: 2008 POC Shared Audit Tool 010109 33 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy CR 13: Identification of HIV/AIDS Specialists The organization documents and implements a method for identifying HIV/AIDS specialists. Intent The organization is accountable for identifying practitioners who qualify as HIV/AIDS specialists to whom appropriate members may be given a standing or extended referral when the member’s condition requires the specialist medical care over a prolonged period of time or is life-threatening, degenerative or disabling, to a specialist or specialty care center that has expertise in treating HIV/AIDS, in accordance with California Health and Safety Codes. Element A: Written Process There is a written policy and procedure describing the process that the organization identifies or reconfirms the appropriately qualified physicians who meet the definition of an HIV/AIDS specialist according to California State regulations on an annual basis. 100% 80% No scoring option 50% No scoring option 20% No scoring option 0% No written process Scoring NA if group is not contracted for HMO commercial product . There is a written process delineating how screening and identification is achieved Explanation Ca H&SC 1374.16 requires the establishment of a process for standing referrals to a specialist, to include a process to refer a member with a condition or disease that requires specialist medical care over a prolonged period of time or is life-threatening, degenerative or disabling to a specialist or specialty care center that has expertise in treating the condition or disease. 28CCR1300.67.60 (California AB 2168, effective 1/15/03) establishes the required qualifications of an HIV/AIDS specialist to whom a member is being referred on an extended or standing basis, under the conditions of Ca H&SC 1374.16 Comments: 2008 POC Shared Audit Tool 010109 34 Confidential [Name of Provider Organization] Assessment Report [City], CA Date of Survey: mm/dd/yyyy Element B: Evidence of Implementation On an annual basis, the organization identifies or reconfirms the appropriately qualified physicians who meet the definition of an HIV/AIDS specialist according to California State regulations. 100% 80% No scoring option 50% No scoring option 20% No scoring option 0% No screening has occurred. Scoring NA if group is not contracted for HMO commercial product There is evidence that annual screening has occurred Explanation This does not require screening of all of the group’s physicians – only of those that potentially may qualify and wish to be listed as HIV/AIDS specialists; e.g., PCPs, Internist Specialists, Pulmonologists and/or Infectious Disease physicians. It may be that the department responsible for standing referrals performs the annual survey instead of the credentialing department. This would meet the intent of the requirement. Comments: Element C: Distribution of Findings The list of identified qualifying physicians is provided to the department responsible for authorizing standing referrals. 100% 80% No scoring option 50% List is available, but has not been given to appropriate department. 20% No scoring option 0% No list. Scoring NA if group is not contracted for HMO commercial product . List is available to surveyor and has been given to the appropriate department Explanation Once the PO has determined which, if any, of its physicians qualify as HIV/AIDS specialists under the above regulations, this list of qualifying practitioners is sent or made available to the department responsible for authorizing standing referrals. If the survey revealed that none of the physicians within the group qualify as HIV/AIDS specialists, this information should be communicated to the appropriate department. Comments: 2008 POC Shared Audit Tool 010109 35 Confidential