Exhibit
10.152


 


AMENDMENT


 


CALIFORNIACARE
MEDICAL SERVICES AGREEMENT


 


This Amendment to CaliforniaCare Medical Services
Agreement (“Amendment”), is entered into at Woodland Hills, Los Angeles County,
California as of January 1, 1999, by and between Blue Cross of California and
its Affiliates (“BLUE CROSS”) and Northwest Orange County Medical Group
(“PARTICIPATING MEDICAL GROUP”).


 


RECITALS


 


A.                                   BLUE
CROSS and PARTICIPATING MEDICAL GROUP have previously entered into a
CaliforniaCare Medical Services Agreement, whereby PARTICIPATING MEDICAL GROUP
is designated as a Participating Medical Group.  The foregoing agreement and any amendments thereto shall be
referred to herein as the “Agreement.” All capitalized terms not otherwise
defined herein shall have the meanings ascribed to them in the Agreement.


 


B.                                     BLUE
CROSS is responsible for the performance of certain activities (“Compliance
Activities”) related to Medical Services in order to comply with applicable
state and federal laws and accreditation and certification requirements of
managed care organization oversight agencies, including, but not limited to,
the California Department of Corporations (“DOC”) and the National Committee
for Quality Assurance (“NCQA”).


 


C.                                     BLUE
CROSS may delegate responsibility for some or all Compliance Activities
(“Delegated Compliance Activities”) to qualified PARTICIPATING MEDICAL GROUPs.


 


D.                                    The
parties desire to amend the Agreement to memorialize the delegation of certain
Compliance Activities by BLUE CROSS to PARTICIPATING MEDICAL GROUP and to set
forth the terms thereof.


 


NOW, THEREFORE, IT IS AGREED:


 


I.                                         BLUE
CROSS and PARTICIPATING MEDICAL GROUP hereby agree to add the following
additional provisions to the Agreement:


 


A.            Delegation of Compliance Activities


 


1.                                       BLUE
CROSS hereby authorizes PARTICIPATING MEDICAL GROUP to perform, and
PARTICIPATING MEDICAL GROUP agrees to perform on BLUE CROSS’ behalf, the
Delegated Compliance Activities delineated in the Division of Responsibilities
For Compliance Activities.  Attachment 1
(incorporated by reference herein).


 


2.                                       BLUE
CROSS retains primary responsibility for Compliance Activities that are not
specifically delegated to PARTICIPATING MEDICAL GROUP.  PARTICIPATING MEDICAL GROUP shall cooperate
and comply with BLUE CROSS’ performance of such activities, as necessary.


 

















 


3.                                       [ILLEGIBLE]
PARTICIPATING MEDICAL GROUP attains and maintains NCQA Physician Organization
Certification (“POC”), or other certification deemed acceptable by BLUE CROSS
during the term of the Agreement.  BLUE
CROSS agrees to exempt PARTICIPATING MEDICAL GROUP from predelegation, annual,
and follow-up onsite audits of Delegated Compliance Activities, except to the
extent those Delegated Compliance Activities must be monitored by BLUE CROSS as
required by  any regulatory agency
having jurisdiction over BLUE CROSS, PARTICIPATING MEDICAL GROUP shall supply
written evidence of such POC certification to BLUE CROSS no less than once
every twelve (12) months and upon renewal. 
PARTICIPATING MEDICAL GROUP shall immediately notify BLUE CROSS in the
event such certification is revoked or is not renewed.


 


4.                                       Notwithstanding
any delegation of credentialing or recredentialing activities to PARTICIPATING
MEDICAL GROUP, BLUE CROSS retains the right to approve, suspend or deny any
Health Professional from providing services to Members under the Agreement.


 


B.            Compliance Activities Performance
Measurement


 


1.                                       PARTICIPATING
MEDICAL GROUP agrees to comply with the Compliance Activity Performance
Measurements indicated in Attachment 1 for each listed Compliance Activity
Standard for which it is delegated responsibility.


 


2.                                       PARTICIPATING
MEDICAL GROUP shall submit all required written documentation demonstrating
compliance with the Compliance Activity Performance Measurement, as delineated
in Attachment 2 (incorporated by reference herein).  Such materials must be submitted to the appropriate BLUE CROSS
contact person as indicated in Attachment 2 by the deadlines set forth therein.  PARTICIPATING MEDICAL GROUP will be  monitored for compliance with meeting
submission time frames.


 


3.                                       UPON
REASONABLE NOTICE, PARTICIPATING MEDICAL GROUP agrees to give BLUE CROSS a
continuing right of access to PARTICIPATING MEDICAL GROUP’s records and
information pertaining to Delegated Compliance Activities as necessary to
evaluate ongoing qualification for delegation, and to copy those records and
information as needed at a cost of ten cents ($0.10) per page.


 


C.            Corrective Actions
and Revocation of Delegation


 


1.                                       In
the event that BLUE CROSS determines that PARTICIPATING MEDICAL GROUP is in
breach of the terms of this Amendment and/or that PARTICIPATING MEDICAL GROUP
fails to satisfactorily fulfill its responsibilities for performing any
Delegated Compliance Activity, BLUE CROSS may, in addition to any other available
remedy:


 


(a)                                  Require
that PARTICIPATING MEDICAL GROUP submit, within 30 calendar days of request, a
corrective plan of action acceptable to BLUE CROSS and adhere to such plan; or 


 


2

















If PMG fails to adhere to Corrective Action Plan in
I.C.1(a) then Blue Cross may, 


 


(b)                                 Revoke
PARTICIPATING MEDICAL GROUP’s delegation status, in whole or in part, by giving
thirty (30) calendar days prior written notice to PARTICIPATING MEDICAL GROUP.


 


2.                                       In
the event BLUE CROSS determines that continued performance by PARTICIPATING
MEDICAL GROUP of any Delegated Compliance Activity poses a risk of physical,
mental, emotional, or financial harm to a Member, BLUE CROSS may revoke the
delegation of such Compliance Activity, immediately upon written notice to
PARTICIPATING MEDICAL GROUP.


 


3.                                       BLUE
CROSS retains the right to modify Attachments 1 and 2 on an annual basis or as
may be reasonably necessary or required to comply with applicable laws or
regulations or the accreditation requirements of regulatory agencies and
managed care organization oversight bodies. 
In any such event, BLUE CROSS shall provide PARTICIPATING MEDICAL GROUP
with written notice.


 


Upon acceptance by the parties, this Amendment, as of the date
specified above, shall become a part of the Agreement, and all provisions of
the Agreement not specifically inconsistent herewith shall remain in full force
and effect.


 


 


	
  BLUE CROSS OF CALIFORNIA

  	
  Northwest Orange County Medical Group

  
	
   

  	
   

  
	
  Signature:

  	
  /s/ Barry Ford

  	
   

  	
  Signature:

  	
  /s/ Pratihba
  Patel

  	
   

  
	
   

  	
   

  
	
  Name:

  	
  Barry Ford

  	
   

  	
  Name:

  	
  PRATIHBA PATEL,
  MD

  	
   

  
	
   

  	
   

  
	
  Title:

  	
  VP, Network Development/Management

  	
   

  	
  Title:

  	
  PRESIDENT

  	
   

  
	
   

  	
   

  
	
  Date:

  	
  3-25-99

  	
   

  	
  Date:

  	
  3/22/99

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  HARRIMAN JONES MSO

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  /S/ James P. Agronick

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  JAMES P. AGRONICK

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  CEO

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  3/22/99

  	
   

  
												



 


3

















 


Attachment
1


 


	
  CaliforniaCare

  Division of Responsibilities for Compliance Activities



  
	
  

  PARTICIPATING MEDICAL GROUP: Northwest Orange County Medical Group

  

  PMG/IPA Code: 0DN

  	
   

  	
  

  Effective Date: 1/1/99

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Quality
  Management Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
  QI 1 *Program Structure

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.1

  	
   

  	
  QM program description in writing

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Program is accountable to governing body

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Program updated/evaluated/approved annually

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.4

  	
   

  	
  Designated physician has substantial involvement

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.5

  	
   

  	
  Committee involvement

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.6

  	
   

  	
  Program specifies committee role, structure/function

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.7

  	
   

  	
  Annual QM work plan

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.8

  	
   

  	
  Program resources adequate to meet needs

  	
   

  	
  ý

  	
   

  	
   

  
	
  QI 2 *Program Operations

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  2.1

  	
   

  	
  Committee recommends policy decisions, evaluates
  results of QM activities

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  2.2

  	
   

  	
  Contemporaneous/dated/signed minutes of QM committee
  decisions and actions

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  2.3

  	
   

  	
  Practitioners actively participate in QM program

  	
   

  	
  ý

  	
   

  	
   

  
	
  QI 3 Health Services Contracting

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  ý

  	
   

  	
   

  
	
  QI 4 Availability of Practitioners

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *4.4

  	
   

  	
  When practitioner’s contract is discontinued, a
  member undergoing active course of treatment is allowed continued access to
  that practitioner

  	
   

  	
  ý

  	
   

  	
   

  
											



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Quality
  Management Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
  QI 5 *Accessibility of Services

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.1

  	
   

  	
  Establishes standards for:

  •
  timeliness of preventive care appointments

  •
  timeliness of routine primary care appointments

  •
  timeliness of urgent care appointments

  •
  timeliness of emergency care

  •
  access to after-hours care

  •
  key elements of telephone service

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  5.2

  	
   

  	
  Collects/analyzes data to measure performance
  against standards

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  5.3

  	
   

  	
  Identifies opportunities for improvement

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  5.4

  	
   

  	
  Implements interventions to improve performance

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  5.5

  	
   

  	
  Measures effectiveness of interventions

  	
   

  	
  ý

  	
   

  	
   

  
	
  QI 6 *Member Satisfaction

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  6.1

  	
   

  	
  Assesses member satisfaction by:

  •
  evaluating member complaints/appeals

  •
  evaluating requests to change practitioners and/or sites

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  6.2

  	
   

  	
  Utilizes appropriate methods to collect data

  •
  appropriate population is identified

  •
  appropriate samples drawn from population

  •
  valid and reliable data collected

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  6.3

  	
   

  	
  Analyzes data for activities in QI 6.1 and HEDIS
  consumer survey

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  6.4

  	
   

  	
  Identifies opportunities for improvement

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  6.5

  	
   

  	
  Implements interventions to improve performance

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  6.6

  	
   

  	
  Measures effectiveness of interventions

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  6.7

  	
   

  	
  Informs practitioners/providers of results of member
  satisfaction activities

  	
   

  	
  ý

  	
   

  	
   

  
	
  QI 7 *Health Management Systems

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  7.1

  	
   

  	
  Identifies members with chronic conditions and
  offers services to manage their conditions

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  7.2

  	
   

  	
  Informs/educates practitioners regarding health
  management programs for members assigned to them

  	
   

  	
  ý

  	
   

  	
   

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Quality
  Management Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
  QI 8 *Clinical Practice Guidelines

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.1

  	
   

  	
  Guidelines are based on reasonable medical evidence

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  8.2

  	
   

  	
  Practitioner involvement in adoption of guidelines

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  8.3

  	
   

  	
  Reviews/updates guidelines every 2 years

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  8.4

  	
   

  	
  Distributes guidelines to practitioners

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  8.5

  	
   

  	
  Annually, measures performance against 2 guidelines

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  8.6

  	
   

  	
  Decision making in those areas where clinical guidelines
  are applicable is consistent with guidelines

  	
   

  	
  ý

  	
   

  	
   

  
	
  QI 9 Continuity and Coordination of Care

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *9.1

  	
   

  	
  Continuity and coordination of care that members
  receive across practices and provider sites is monitored including at a
  minimum primary care sites with 50 or more members

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  9.2

  	
   

  	
  Ensures continuity and coordination with behavioral
  healthcare.  There is collaboration
  with behavioral health specialists to:

  •
  *exchange information in an effective, timely and confidential manner,
  including patient-approved communications between medical practitioners and
  behavioral health practitioners and providers

  •
  *promote appropriate diagnosis, treatment & referral of behavioral health
  disorders commonly seen in primary care

  •
  psychopharmacological medication

  •
  *timely access for treatment and followup for individuals with coexisting
  medical and behavioral disorders

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  9.3

  	
   

  	
  Collect/analyze data to evaluate continuity and
  coordination of care

  •
  analyzes data to identify any opportunities for improvement

  •
  collaborates with its behavioral health specialists to identify an
  opportunity to improve coordination of behavioral health with general medical
  care

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  9.4

  	
   

  	
  Implementation to improve continuity and
  coordination of care

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  interventions identify opportunity for improvement

  •
  *collaborates with behavioral health specialists to take action to improve
  coordination of behavioral health with general medical care

  	
   

  	
  ý

  	
   

  	
   

  
	
  QI 10 Clinical Measurement Activities

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  ý

  	
   

  	
   

  
	
  QI 11 Intervention and Follow-Up for Clinical Issues

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  ý

  	
   

  	
   

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Quality
  Management Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
  QI 12 Effectiveness of the QI Program

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *12.1

  	
   

  	
  Annual written evaluation of QM program includes:

  •
  description of completed/ongoing activities

  •
  trending of measures to assess performance

  •
  analysis of demonstrated improvements in clinical care/quality of service to
  members

  •
  evaluation of effectiveness of QM program

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  12.2

  	
   

  	
  QM activities provide meaningful improvement in
  quality of clinical care and of service to members

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  12.3

  	
   

  	
  Information regarding QM program, including
  description/report on progress, is available to members and practitioners

  	
   

  	
  ý

  	
   

  	
   

  
	
  QI 13 *Delegation of QI Activity

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  13.1

  	
   

  	
  A mutually agreed upon documents describes:

  •
  responsibilities of delegated agency and entity

  •
  the delegated activities

  •
  frequency of reporting

  •
  process utilized to evaluate the delegated agency’s performance

  	
   

  	
  Not Applicable

  	
   

  	
   

  
	
   

  	
   

  	
  13.2

  	
   

  	
  There is evidence that:

  •
  delegated agency’s capacity to perform activities prior to delegation is
  evaluated

  •
  the delegated agency’s QM workplan/QM program description is approved
  annually

  •
  regular reports as specified in 13.1 are evaluated

  •
  there is an annual evaluation on whether delegated agency activities are
  conducted in accordance with the entities expectations/NCQA standards

  	
   

  	
  Not Applicable

  	
   

  	
   

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Utilization
  Management Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
  UM 1 *Utilization Management Structure

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.1

  	
   

  	
  UM program description in writing

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Designated senior physician has substantial
  involvement in program implementation

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Description includes scope, processes and
  information sources used to make determinations of benefit coverage and
  medical appropriateness

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.4

  	
   

  	
  Program updated/evaluated/approved annually

  	
   

  	
   

  	
   

  	
  ý

  
	
  UM 2 *Clinical UM Criteria

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  2.1

  	
   

  	
  Criteria for determination of medical
  appropriateness are clearly documented and include procedures for applying
  criteria based on the needs of individual patients and characteristics of the
  local delivery system

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  2.2

  	
   

  	
  Actively practicing practitioners are involved in
  development or adoption of criteria and in the development and review of
  procedures for applying the criteria

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  2.3

  	
   

  	
  Reviews and updates criteria as necessary

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  2.4

  	
   

  	
  How practitioners can obtain criteria is stated in
  writing and criteria is provided to practitioners upon request

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  2.5

  	
   

  	
  Annually, evaluates how practitioners involved
  consistently apply criteria in decision making

  	
   

  	
   

  	
   

  	
  ý

  
	
  UM 3 *Appropriate Professionals

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  3.1

  	
   

  	
  Licensed health professionals supervise review
  decisions

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  3.2

  	
   

  	
  Licensed physician reviews denials based on medical
  appropriateness

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  3.3

  	
   

  	
  Board certified physicians from appropriate
  specialty areas are used to assist in making determination of medical
  appropriateness

  	
   

  	
   

  	
   

  	
  ý

  
	
  UM 4 *Timeliness of UM Decision

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  4.1

  	
   

  	
  NCQA standards for timeliness of UM decision making
  are followed

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  4.2

  	
   

  	
  Procedures for registering/responding to expedited
  appeals are established

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
   

  	
   

  	
  •
  initiated by member/practitioner on behalf of member

  •
  decision is made no later than 72 hours after review and member and
  practitioner are notified

  	
   

  	
   

  	
   

  	
   

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Utilization
  Management Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
   

  	
   

  	
   

  	
   

  	
  •
  there is written confirmation within 2 working days of providing notification
  of decision, if initial decision not in writing

  	
   

  	
   

  	
   

  	
   

  
	
  UM 5 *Medical Information

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  When making a determination of coverage based on
  medical appropriateness, relevant clinical information is obtained and the
  treating physician is consulted

  	
   

  	
   

  	
   

  	
  ý

  
	
  UM 6 *Denial Notices

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  The reasons for each denial are clearly documented
  and communicated

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  6.1

  	
   

  	
  Physician reviewer available to physician to discuss
  determinations based on medical appropriateness

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  6.2

  	
   

  	
  Written notification to members/practitioners of
  reason for denial, including specific utilization review criteria or benefits
  provisions used in the determination

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  6.3

  	
   

  	
  Information regarding appeal process included in
  denial notifications

  	
   

  	
   

  	
   

  	
  ý

  
	
  UM 7 Evaluation of New Technology

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  ý

  	
   

  	
   

  
	
  UM 8 *Satisfaction with the UM Process

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.1

  	
   

  	
  Every 2 years, information is gathered from members
  and practitioners regarding satisfaction with UM process

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  8.2

  	
   

  	
  Addresses identified sources of dissatisfaction

  	
   

  	
   

  	
   

  	
  ý

  
	
  UM 9 Emergency Services

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  *There is provision, arrangement for or otherwise
  facilitation of all needed emergency services, including appropriate coverage
  of costs

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  *9.1

  	
   

  	
  Any emergency services necessary to screen/stabilize
  members without precertification of ER services where prudent layperson
  believed emergency medical condition existed is covered

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  *9.2

  	
   

  	
  ER services if practitioner has authorized is
  covered

  	
   

  	
   

  	
   

  	
  ý

  
	
  UM 10 Drug Formulary Use

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  The MCO has processes to ensure that its drug
  formulary, if any, is based on sound clinical evidence and is reviewed and
  updated at specified intervals.  The
  MCO develops its formulary with input from actively practicing practitioners
  and makes the formulary available to its practitioners.  The MCO with a closed formulary has an
  exceptions policy in place.

  	
   

  	
  ý

  	
   

  	
   

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Utilization
  Management Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
  UM 11 Ensuring Appropriate Service and Coverage

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *11.1

  	
   

  	
  Data to detect potential underutilization and
  overutilization is monitored

   

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
   

  	
   

  	
  •
  monitors utilization data for organization as a whole/for individual product
  lines

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  *monitors utilization data across practices and provider sites for PCP and
  high volume specialists to detect potential under/overutilization

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *11.2

  	
   

  	
  All data collected to detect underutilization and
  overutilization is routinely analyzed

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  *11.3

  	
   

  	
  Implements appropriate interventions whenever it
  identifies under utilization or over utilization

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  *11.4

  	
   

  	
  There are measurements to ascertain whether the
  interventions have been effective and implements strategies to achieve
  appropriate utilization

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  *11.5

  	
   

  	
  Policies for informing practitioners, providers and
  staff who make utilization-related decisions of the need for special concern
  about the risks of under utilization are implemented.  A statement to all practitioners,
  providers, members and employees is distributed which affirms that:

  •
  decision making based on appropriateness of care and service

  •
  there is no compensation of practitioners or other individuals conducting
  utilization review for denials of service or coverage

  •
  financial incentives for UM decision makers do not encourage denials of
  coverage or service

  	
   

  	
   

  	
   

  	
  ý

  
	
  UM 12 * Delegation of UM

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  12.1

  	
   

  	
  A mutually agreed upon document describes:

  • responsibilities of delegated agency
  and entity

  •
  the delegated activities

  •
  frequency of reporting

  •
  process utilized to evaluate delegated agency’s performance

  •
  remedies available if obligations are not fulfilled

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  12.2

  	
   

  	
  There is evidence that:

  	
   

  	
   

  	
   

  	
  ý

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Utilization
  Management Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
   

  	
   

  	
   

  	
   

  	
  •
  delegated agency’s capacity to perform activities prior to delegation is
  evaluated

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  the delegated agency’s UM program is approved annually

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  reports as specified in 12.1 are evaluated

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  there is annual evaluation on whether delegated agency’s activities are
  conducted in accordance with the entity’s expectations/NCQA standards

  	
   

  	
   

  	
   

  	
   

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Credentialing
  and Recredentialing Compliance

  Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
  CR 1 *Credentialing Policies

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.1

  	
   

  	
  Scope of practitioners covered

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Criteria and primary source verification information
  used to meet criteria

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Process used to make decisions

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.4

  	
   

  	
  Extent of delegated credentialing/recredentialing
  arrangements

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.5

  	
   

  	
  Practitioner’s right to review information submitted
  in support of applications

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.6

  	
   

  	
  Notification of information obtained that varies
  from information provided by practitioner

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.7

  	
   

  	
  Practitioner’s right to correct erroneous
  information

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.8

  	
   

  	
  Medical director or designated physician’s
  responsibility/participation in credentialing program

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.9

  	
   

  	
  Confidentiality of all information obtained in
  process

  	
   

  	
   

  	
   

  	
  ý

  
	
  CR 2 *Credentialing Committee

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  A Credentialing committee that makes recommendations
  regarding credentialing decisions is designated

  	
   

  	
   

  	
   

  	
  ý

  
	
  CR 3 *Initial Primary Source Verification

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  3.1

  	
   

  	
  License

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  3.2

  	
   

  	
  Clinical privileges

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  3.3

  	
   

  	
  DEA

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  3.4

  	
   

  	
  Education/training

  •
  MDs/DOs: medical school/residency

  •
  DCs: chiropractic college

  •
  DDSs: dental school/specialty training

  •
  DPMs: podiatry school/residency

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  3.5

  	
   

  	
  Board certification

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  3.6

  	
   

  	
  Work history

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  3.7

  	
   

  	
  Malpractice insurance

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  3.8

  	
   

  	
  Professional liability claims

  	
   

  	
   

  	
   

  	
  ý

  
	
  CR 4 *Application and Attestation

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  4.1

  	
   

  	
  Inability to perform essential functions

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  4.2

  	
   

  	
  Lack of present illegal drug use

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  4.3

  	
   

  	
  History of loss of license/felony convictions

  	
   

  	
   

  	
   

  	
  ý

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Credentialing
  and Recredentialing Compliance

  Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
   

  	
   

  	
  4.4

  	
   

  	
  History of loss/limitation of
  privileges/disciplinary activity

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  4.5

  	
   

  	
  Attestation by applicant of the correctness/completeness
  of application

  	
   

  	
   

  	
   

  	
  ý

  
	
  CR 5 *Initial Sanction Information

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.1

  	
   

  	
  NPDB

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  5.2

  	
   

  	
  Sanctions/limitations on license from following
  agencies:

  •
  State Board Medical Examiners, FSMB or Department of Professional Regulations

  •
  State Board of Chiropractor/CIN-BAD

  •
  State Board of Dental Examiners

  •
  State Board of Podiatric Examiners

   

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  5.3

  	
   

  	
  Medicare and Medicaid

  	
   

  	
   

  	
   

  	
  ý

  
	
  CR 6 *Initial Credentialing Site Visits (All
  potential Primary Care Practitioners and Obstetricians/Gynecologists)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  6.1

  	
   

  	
  Review that evaluates site

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  6.2

  	
   

  	
  Evaluation of medical record keeping practices

  	
   

  	
   

  	
   

  	
  ý

  
	
  CR 7 *Recredentialing Primary Source Verification:

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Practitioners are formally recredentialed at least
  every two years.  During the
  recredentialing process, verification of at least the following information
  from primary sources is obtained:

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  7.1

  	
   

  	
  License

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  7.2

  	
   

  	
  Clinical privileges

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  7.3

  	
   

  	
  DEA

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  7.4

  	
   

  	
  Board certification

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  7.5

  	
   

  	
  Malpractice insurance

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  7.6

  	
   

  	
  Professional liability claims

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  7.7

  	
   

  	
  Attestation by applicant regarding:

  •
  inability to perform essential functions

  •
  lack of present illegal drug use

  	
   

  	
   

  	
   

  	
  ý

  
	
  CR 8 *Recredentialing Sanction Information

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.1

  	
   

  	
  NPDB

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  8.2

  	
   

  	
  Sanctions/limitations on license from following
  agencies:

  	
   

  	
   

  	
   

  	
  ý

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Credentialing
  and Recredentialing Compliance

  Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
   

  	
   

  	
   

  	
   

  	
  •
  State Board Medical Examiners, FSMB or Department of Professional Regulations

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • State Board
  of Chiropractor/CIN-BAD

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • State Board
  of Dental Examiners

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  State Board of Podiatric Examiners

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.3

  	
   

  	
  Medicare and Medicard

  	
   

  	
   

  	
   

  	
  ý

  
	
  CR 9 *Performance Monitoring

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  The following data is incorporated into the
  recredentialing decision-making process for primary care practitioners

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  9.1

  	
   

  	
  Member complaints

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  9.2

  	
   

  	
  Information from quality improvement activities

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  9.3

  	
   

  	
  Member satisfaction (optional)

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CR 10 *Recredentialing Site Visits (All primary Care
  Practitioners who have more than 50 Members)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  10.1

  	
   

  	
  Review that evaluates site

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  10.2

  	
   

  	
  Evaluation of medical record keeping practices

  	
   

  	
   

  	
   

  	
  ý

  
	
  CR 11 *Practitioner Appeal Rights

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  There are policies and procedures for altering the
  conditions of the practitioner’s participation with the entity based on
  issues of quality of care and service

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  11.1

  	
   

  	
  Procedures for reporting quality deficiencies that
  could result in a practitioner’s suspension or termination

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  11.2

  	
   

  	
  Description of appeal process/practitioners are
  informed of the appeal process

  	
   

  	
   

  	
   

  	
  ý

  
	
  CR 12 *Assessment of Organizational Providers
  (hospitals, home health agencies, skilled nursing facilities and nursing
  homes and free standing surgical centers)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  There are written policies and procedures for the
  initial and ongoing assessment of organizational providers with which it
  intends to contract

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  12.1

  	
   

  	
  Confirms good standing with state/federal regulatory
  bodies

  	
   

  	
   

  	
   

  	
  ý

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Credentialing
  and Recredentialing Compliance

  Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
   

  	
   

  	
  12.2

  	
   

  	
  Confirms accreditation  

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  12.3

  	
   

  	
  If not approved, develop/implement standards of
  participation and review for compliance

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  12.4

  	
   

  	
  At least every 3 years, confirms continued good
  standing with state/federal regulatory bodies and, if applicable, accrediting
  body

  	
   

  	
   

  	
   

  	
  ý

  
	
  CR 13 *Delegation of Credentialing

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  13.1

  	
   

  	
  A mutually agreed upon document describes:

  •
  responsibilities of delegated agency and entity

  •
  the delegated activities

  •
  process utilized to evaluate delegated agency’s performance

  •
  remedies available if obligations are not fulfilled

  	
   

  	
  ý

  	
   

  	
  ý

  
	
   

  	
   

  	
  13.2

  	
   

  	
  The right to approve/retain/terminate/suspend
  practitioners, providers and sites is retained

  	
   

  	
  ý

  	
   

  	
  ý

  
	
   

  	
   

  	
  13.3

  	
   

  	
  There is evidence that:

  •
  delegated agency’s capacity to perform activities prior to delegation is
  evaluated

  •
  there is annual evaluation on whether delegated agency’s activities are
  conducted in accordance with the entity’s expectations/NCQA standards

  	
   

  	
  ý

  	
   

  	
  ý

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Members’
  Rights and Responsibilities

  Compliance Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
  RR 1 *Statement of Members’ Rights and
  Responsibilities

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  A written policy addresses the following members’
  rights/responsibilities:

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.1

  	
   

  	
  Right to receive information about the entity, its
  services, its practitioners/providers

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Right to be treated with respect, recognition of
  their dignity and right to privacy

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Right to participate with practitioners in decision
  making

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.4

  	
   

  	
  Right to a candid discussion of treatment options

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.5

  	
   

  	
  Right to voice complaints/appeals about the entity
  or care provided

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.6

  	
   

  	
  Responsibility to provide information regarding care

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.7

  	
   

  	
  Responsibility to follow instructions for care

  	
   

  	
  ý

  	
   

  	
   

  
	
  RR 2 *Distribution of Rights Statements to Members
  and Practitioners

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  The policy on members’ rights and responsibilities
  is distributed to members and participating practitioners

  	
   

  	
  ý

  	
   

  	
   

  
	
  RR 3 Policies for Complaints and Appeals

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  *3.1

  	
   

  	
  Procedures for registering and responding to
  oral/written complaints include:

  •
  documentation of complaint/action taken

  •
  investigation of complaint

  •
  notification to member of disposition of complaint/right to appeal

  •
  timeliness in responding to complaints that accommodate clinical urgency of
  the situation

  	
   

  	
  ý

  	
   

  	
  ý

  
	
   

  	
   

  	
  *3.2

  	
   

  	
  Procedures for registering/responding to oral and
  written 1st level appeals include:

  •
  appeal process notification to member within 5 working days of receiving
  request for 1st level appeal

  •
  documentation of appeal and action taken

  •
  investigation of appeal

  •
  resolution of the appeal, including:

  	
   

  	
   

  	
   

  	
  ý

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Members’
  Rights and Responsibilities

  Compliance Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
   

  	
   

  	
   

  	
   

  	
  •
  panel appointed to review 1st level appeal not involved in initial
  determination

  •
  of appointed panel, at least 1 practitioner in similar or same specialty

  •
  if no decision within 30 days, written decision within 15 additional working
  days is issued and notice to member with reasons for delay before 30th
  working day is provided

  •
  for acute/urgent appeal, the expedited appeals procedure is followed:

  •
  written notification to member of disposition of appeal/right to appeal
  further

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  3.3

  	
   

  	
  Procedure for registering/responding to 2nd level
  appeals

  	
   

  	
  ý

  	
   

  	
  ý

  
	
   

  	
   

  	
  *3.4

  	
   

  	
  Procedure for allowing practitioner/member
  representative to act on behalf of the member

  	
   

  	
  ý

  	
   

  	
  ý

  
	
  RR 4 *Appropriate Handling of Complaints and Appeals

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Members’ complaints and 1st level appeals are
  adjudicated in a thorough, appropriate, and timely manner.  All the requirements of standard RR3 for
  1st level appeals and its own standards for handling the following are met:

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  4.1

  	
   

  	
  Complaints about clinical care

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  4.2

  	
   

  	
  Complaints about service

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  4.3

  	
   

  	
  Appeals

  	
   

  	
   

  	
   

  	
  ý

  
	
  RR 5 Subscriber Information

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Each subscriber is provided with the information
  needed to understand benefit coverage and obtain care

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  5.1

  	
   

  	
  Written information about benefits/charges
  applicable to subscriber addresses:

  •
  benefits/services included in, and excluded from, coverage

  •
  drug formulary information

  •
  copayments/other charges for which the member is responsible

  •
  restrictions on benefits

  •
  instructions on submitting claims

  	
   

  	
  ý

  	
   

  	
   

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Members’ Rights and Responsibilities

  Compliance Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
   

  	
   

  	
  5.2

  	
   

  	
  Written instructions
  provided to members addresses how to obtain primary/specialty care:

  •
  *information regarding participating practitioners

  •
  *primary care services, including points of access

  •
  *specialty, behavioral and hospital care/services

  •
  *care after normal office hours

  •
  *emergency care

  •
  care/coverage when out of area

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  5.3

  	
   

  	
  Written information
  provided to members addresses how to:

  •
  *voice a complaint

  •
  *appeal decision that affects member’s coverage/benefits/relationship to
  organization

  •
  how new technology for inclusion as a covered benefit is evaluated

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  5.4

  	
   

  	
  Notification to members
  of practitioner or practice site termination and helps with selection of new
  practitioner or practice site

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RR 6 Member
  Confidentiality

  	
   

  	
   

  	
   

  	
   

  The confidentiality of
  member information and records is protected

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *6.1

  	
   

  	
  Written confidentiality
  policies and procedures to ensure confidentiality of member information is
  adopted/implemented

  	
   

  	
  ý

  	
   

  	
  ý

  
	
   

  	
   

  	
  *6.2

  	
   

  	
  Contract explicitly
  slates expectations regarding confidentiality of member information/records

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  6.3

  	
   

  	
  Data shared with
  employers, whether fully insured or self-insured, are not implicitly or
  explicitly member identifiable, unless specific consent is provided by
  members

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  6.4

  	
   

  	
  Patients have
  opportunity to consent/deny release of information, except when required by
  law

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  6.5

  	
   

  	
  Communicates to
  prospective members its policies/practices regarding
  collection/use/disclosure of medical information

  	
   

  	
  ý

  	
   

  	
  ý

  
	
   

  	
   

  	
  6.6

  	
   

  	
  Informs members,
  practitioners and providers of policies/procedures on obtaining consents for
  use of member medical information, allowing members access to their medical
  records and protecting access to member medical information

  	
   

  	
  ý

  	
   

  	
  ý

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Members’ Rights and Responsibilities

  Compliance Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
   

  	
   

  	
  6.7

  	
   

  	
  Designates internal
  review board to create/review confidentiality policies and procedures

  	
   

  	
  ý

  	
   

  	
  ý

  
	
  RR 7 Marketing
  Information

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  BCC ensures that
  communications with prospective members correctly and thoroughly represent
  the benefits and operating procedures of the organization

  	
   

  	
  ý

  	
   

  	
   

  
	
  RR 8 * Delegation of
  Members’ Rights and Responsibilities

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.1

  	
   

  	
  A Mutually agreed upon
  document describes:

  •
  responsibilities of delegated agency and entity

  •
  the delegated activities

  •
  frequency of reporting

  •
  process utilized to evaluate the delegated agency’s performance

  •
  remedies available if obligations are not fulfilled

  	
   

  	
  ý

  	
   

  	
  ý

  
	
   

  	
   

  	
  8.2

  	
   

  	
  There is evidence that:

  •
  delegated agency’s capacity to perform activities prior to delegation is
  evaluated

  •
  regular reports as specified in 8.1 are evaluated

  •
  there is an annual evaluation on whether delegated agency activities are
  conducted in accordance with the entity’s expectations/NCQA standards

  	
   

  	
  ý

  	
   

  	
  ý

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Preventive Health Services Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
  PH 1 *Adoption of
  Preventive Health (PH) Guidelines

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.1

  	
   

  	
  There are guidelines
  for following categories:

  •
  preventive care for infants up to 24 months

  •
  preventive care for children/adolescents 2-19 years

  •
  prenatal and perinatal care

  •
  preventive care for adults 20-64 years

  •
  preventive care for elderly 65 and older

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Guidelines describe
  recommended prevention and/or early detection interventions and
  frequency/conditions under which interventions are required.  Documents scientific basis/authority upon
  which guidelines are based

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Practitioners are
  involved in adoption of guidelines

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.4

  	
   

  	
  Guidelines have been
  available for at least 2 years

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  1.5

  	
   

  	
  Guidelines in place at
  least 2 years are reviewed/updated at least every 2 years

  	
   

  	
  ý

  	
   

  	
   

  
	
  PH 2 *Distribution of
  Guidelines to Practitioners

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Distribution of
  preventive health guidelines and any updates to practitioners occurs

  	
   

  	
  ý

  	
   

  	
   

  
	
  PH 3 Health Promotion
  with Members

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  3.1

  	
   

  	
  Guidelines distributed
  to members annually

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  *3.2

  	
   

  	
  Members are encouraged
  to use health promotion, education and services available

  	
   

  	
  ý

  	
   

  	
   

  
	
   

  	
   

  	
  *3.3

  	
   

  	
  Members, identified as
  high risk, are urged to use health promotion/prevention services

  	
   

  	
  ý

  	
   

  	
   

  
	
  PH 4 *Delegation of PH

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  4.1

  	
   

  	
  A mutually agreed upon
  document describes:

  •
  responsibilities of delegated agency and entity

  •
  the delegated activities

  •
  frequency of reporting

  •
  process utilized to evaluate the delegated agency’s performance

  •
  remedies available if obligations are not fulfilled

  	
   

  	
  Not Applicable

  	
   

  	
   

  
	
   

  	
   

  	
  4.2

  	
   

  	
  There is evidence that:

  	
   

  	
  Not Applicable

  	
   

  	
   

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Preventive Health Services Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
   

  	
   

  	
   

  	
   

  	
  •
  delegated agency’s capacity to perform activities prior to delegation is
  evaluated

  •
  the delegated agency’s PH workplan is approved annually

  •
  regular reports as specified in 4.1 are evaluated

  •
  there is an annual evaluation on whether delegated agency activities are
  conducted in accordance with the entity’s expectations/NCQA standards

  	
   

  	
   

  	
   

  	
   

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Medical Record Compliance Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
  MR 1 *Medical Record
  Documentation Standards

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Medical records will be
  maintained in a manner that is current, detailed, and organized and permits
  effective and confidential patient care and quality review

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.1

  	
   

  	
  Medical record
  confidentiality policies and procedures are maintained

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Medical record
  documentation standards are maintained and distributed to practice sites

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Organized medical
  record keeping system and standards for the availability of medical records
  appropriate to the practice site

  	
   

  	
   

  	
   

  	
  ý

  
	
  MR 2 *MCO Review of
  Medical Records

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  2.1

  	
   

  	
  At least every 2 years,
  review of medical records from primary care practice sites is conducted

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  2.2

  	
   

  	
  There is a mechanism to
  assess the effectiveness of corrective action plans to ascertain improved
  compliance

  	
   

  	
   

  	
   

  	
  ý

  
	
  MR 3 *Compliance with
  NCQA Medical Records Standards

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Documentation of items
  on the NCQA medical record review summary sheet demonstrates that medical
  records are in conformity with good professional medical practice and
  appropriate health management

  	
   

  	
   

  	
   

  	
  ý

  
	
  MR 4 *Delegation of
  Medical Records

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  4.1

  	
   

  	
  A mutually agreed upon
  document describes:

  •
  responsibilities of delegated agency and entity

  •
  the delegated activities

  •
  frequency of reporting

  •
  process utilized to evaluate the delegated agency’s performance

  •
  remedies available if obligations are not fulfilled

  	
   

  	
   

  	
   

  	
  ý

  
	
   

  	
   

  	
  4.2

  	
   

  	
  There is evidence that:

  •
  delegated agency’s capacity to perform activities prior to delegation is
  evaluated

  •
  the delegated agency’s MR workplan/MR program description if approved
  annually

  •
  regular reports as specified in 4.1 are evaluated

  	
   

  	
   

  	
   

  	
  ý

  



 












*BCC
Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party Responsible For

  Compliance Activity

  
	
  Medical Record Compliance Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  
	
   

  	
   

  	
   

  	
   

  	
  •
  there is an annual evaluation on whether delegated agency activities are
  conducted in accordance with the entity’s expectations/NCQA

  	
   

  	
   

  	
   

  	
   

  



 












*BCC
Oversight Monitoring Required


 

















 


CaliforniaCare


Annual
Documentation Submission Requirements


 


	
  Delegated Compliance Activity

  Standard Group

  	
   

  	
  Required Documentation Materials

  	
   

  	
  Documentation

  Submission

  [Illegible]

  	
   

  	
  Blue Cross

  Contact

  [Illegible]

  
	
  Utilization Management

  	
   

  	
  Written and approved
  Utilization Management Plan (including signature page) consistent with BLUE
  CROSS HMO criteria.

  	
   

  	
  15 days following
  PARTICIPATING MEDICAL GROUP UM Committee approval

  	
   

  	
  Quality Management
  Analyst

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  UM Workplan

  	
   

  	
  1/31

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Quarterly Utilization
  Management Reports (California HMO Quality Management Coalition format
  preferred)

  	
   

  	
  4/30, 7/31, 10/31

  1/31

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Annual UM Program
  Evaluation

  	
   

  	
  1/31

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Quality Management

  	
   

  	
  Written and approved
  Quality Management Plan (including signature page) consistent with BLUE CROSS
  HMO criteria.

  	
   

  	
  15 days following
  PARTICIPATING MEDICAL GROUP QM Committee approval1

  	
   

  	
  Quality Management
  Analyst

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  QM Workplan

  	
   

  	
  1/31

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Quarterly Quality
  Management Reports (California HMO Quality Management Coalition format
  preferred).

  	
   

  	
  4/30, 7/31, 10/31, 1/31

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Annual QM Program Evaluation

  	
   

  	
  1/31

  	
   

  	
   

  



 

















 


	
  Delegated Compliance Activity

  Standards Group

  	
   

  	
  Required Documentation Materials

  	
   

  	
  Documentation

  Submission

  [Illegible]

  	
   

  	
  Blue Cross

  Contact

  [Illegible]

  
	
  Credentialing/Recredentialing/Peer
  Review

  	
   

  	
  Written and approved
  Credentialing/Recredentialing/Peer Review Policies and Procedures consistent
  with BLUE CROSS HMO criteria.

  	
   

  	
  15 days following
  PARTICIPATING MEDICAL GROUP Credentialing Committee approval

  	
   

  	
  Quality Management
  Analyst

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Practitioner/Provider
  Roster.

  	
   

  	
  Prior to on-site audits

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Grievances and Appeals

  	
   

  	
  Grievances and Appeals
  data consistent with BLUE CROSS HMO’s sample format.

  	
   

  	
  Quarterly

  	
   

  	
  Care Management
  Department

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Health Management

  	
   

  	
  Roster of Health
  Education/Promotion programs offered to members.

  	
   

  	
  3/31

  	
   

  	
  Health Promotion
  Department

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Health Management
  program effectiveness evaluation (may be included in Annual QM Program
  Evaluation

  	
   

  	
  1/31

  	
   

  	
  Quality Management
  Analyst

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Corrective Action Plan

  (if applicable)

  	
   

  	
  Corrective action plan
  addressing any identified audit deficiencies in BLUE CROSS Audit Summation
  letter.

  	
   

  	
  30 days from letter
  notification

  	
   

  	
  Quality Management
  Analyst

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Encounter Data

  	
   

  	
  Electronic submission
  of ambulatory encounter data.

  	
   

  	
  Monthly

  	
   

  	
  Integrated Medical
  Systems