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Policies and Procedures

Gateway has developed policies and procedures to provide guidelines for identifying and resolving issues with practitioners who fail to comply with the terms and conditions of the applicable Practitioner Agreement, Gateway policies and procedures, or accepted Utilization Management Standards and Quality Improvement Guidelines.

Department of Public Welfare Policy Changes

In order for Gateway to meet the standards set forth by the Commonwealth of Pennsylvania Department of Public Welfare (DPW) standard contract, Gateway must promptly implement new policies or changes in policy at the request of the Department of Public Welfare.

Upon notice from DPW of program or policy changes, Gateway will assess those policies or practices that require practitioner notice. Depending upon the DPW effective date of the change, practitioners cannot always be notified prior to such alterations. Gateway is committed to notifying all appropriate practitioners, via the most appropriate medium, within 60 days of receipt of the notice of a new policy or policy change when sufficient notice is provided by DPW.

Additionally, practitioners need to be aware that no regulatory order or requirement of the Departments of Insurance, Health or Public Welfare shall be subject to arbitration with Gateway.

Practitioner Education and Sanctioning

Gateway practitioners will be monitored for compliance with administrative procedures, trends of inappropriate resource utilization, potential quality of care concerns and compliance with medical record review standards. Practitioner education is provided through Quality Improvement Nurses, Provider Relations Representatives and Gateway Medical Directors. Network practitioners who do not improve through the provider education process will be referred to the Gateway Quality Improvement/Utilization Management Committee for evaluation and recommendations. To request additional information or to obtain a copy of this policy, please contact Gateway’s Provider Services Department at 1-800-392-1145.

Practitioner Due Process

Gateway has established a policy and procedure to define the situations when due process procedures are afforded to practitioners, and to specify the due process procedures available in accordance with federal and state regulations, in particular the Healthcare Quality Improvement Act of 1986.

The Practitioner Due Process Policy will be updated in accordance with federal and state regulations. To request additional information or to obtain a copy of this policy, please contact Gateway’s Provider Servicing Department at 1-800-392-1145.

TITLE VI of the Civil Rights Act of 1964

Practitioners are expected to comply with Title VI of the Civil Rights Act of 1964 that prohibits race, color or national origin discrimination in programs receiving Federal funds. Practitioners are obligated to take reasonable steps to provide meaningful access to services for members with limited English proficiency, including provision of translator services as necessary for these members. For interpreter services, please contact a qualified medical interpretation service such as Language Line Services. Language Line Services can be reached at 1-800-752-6096.

Access and Interpreters for Disabled Members

Practitioner offices are expected to address the need for interpreter services in accordance with the Americans with Disabilities Act (ADA). Each practitioner is expected to arrange and coordinate interpreter services to assist members who are hearing impaired. Gateway will assist practitioners in locating resources upon request. Gateway offers the Member Handbook and other Gateway information in large print, Braille, on cassette tape, or computer diskette at no cost to the member. Please instruct members to call Member Services at 1-800-392-1147 to ask for these other formats.

Practitioner offices are required to adhere to the Americans with Disabilities Act guidelines, Section 504, the Rehabilitation Act of 1973 and related federal and state requirements that are enacted from time-to-time.

Practitioners may obtain copies of documents that explain legal requirements for translation services by contacting Gateway’s Provider Services Department at 1-800-392-1145.

Confidentiality

All practitioners and providers participating with Gateway have agreed to abide by all Gateway policies and procedures regarding member confidentiality. The performance goal for confidentiality is maintaining patient records secure from public access.

Under these policies, the practitioner or provider must meet the following:

  1. Provide the highest level of protection and confidentiality of members’ medical and personal information used for any purposes in accordance with federal and state laws or regulations including the following:
    • The Mental Health Procedures Act, 50 P.S. §§7101 et seq.
    • Patient Medical Records, 28 Pa. Code §115.27
    • Pennsylvania Drug and Alcohol Abuse Control Act
    • Pennsylvania Confidentiality of HIV-Related Information Act 35 P.S. §§ 7601 et seq.
    • Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160, 162 and 164
  2. Assure that member records, including information obtained for any purpose, are considered privileged information and, therefore, are protected by obligations of confidentiality.
  3. Assure that a member’s individually identifiable health information as defined by HIPAA, also known as Protected Health Information (PHI), necessary for treatment, payment or healthcare operations (TPO) is released to Gateway without seeking the consent of a member. This information includes PHI used for claims payment, continuity and coordination of care, accreditation surveys, medical record audits, treatment, quality assessment and measurement, quality of care issues, medical management, appeals, case management and disease management. Further, providers will assure that PHI for TPO will be made available to the Department of Public Welfare, Department of Health, Department of Insurance or Business Associates of Gateway for use without member consent. All other requests for release of or access to PHI will be handled in accordance with federal and state regulations. Gateway follows the requirements of HIPAA and limits its requests to the amount of PHI that is minimally necessary to meet the payment, treatments or operational function.
  4. The member, or a member’s representative including head of household, legal guardian, or durable power of attorney, shall have access to view and/or receive copies of the medical record upon request. There is no charge for the copied medical record if the record is sent to another practitioner, however, if the copy is provided directly to the member, the office may charge for this service. The request must allow reasonable notice and follow the specific procedures of the practitioner or provider.
  5. All providers are required to conduct environmental security of confidential information and monitor practice and provider sites. Provider and practitioner sites must comply with the Environmental Assessment standards that require that patient records be protected from public access.
  6. Medical records must be available for all member visits for established patients.
Fraud and Abuse

Gateway has a comprehensive policy for handling the prevention, detection and reporting of fraud and abuse. It is Gateway’s policy to investigate any action by members, employees or practitioners that affects the integrity of Gateway and/or the Medical Assistance Program.

As a participating practitioner with Gateway, the contract that is signed requires compliance with Gateway’s policies and procedures for the detection and prevention of fraud and abuse. Such compliance may include referral of information regarding suspected or confirmed fraud or abuse to Gateway and submission of statistical and narrative reports regarding fraud and abuse detection activities.

If fraud or abuse is suspected, whether it is by a member, employee or practitioner, it is your responsibility to immediately notify Gateway at (412) 255-4340. In cooperation with the Department of Public Welfare, Gateway maintains a Recipient Restriction Program, which restricts members who mis-utilize medical services or pharmacy benefits. Gateway enforces and monitors these restrictions.

It is Gateway’s policy to discharge any employee, terminate any practitioner or recommend any member be withdrawn from the Medical Assistance Program who, upon investigation and referral to the Department of Public Welfare, has been identified as being involved in fraudulent or abusive activities.

The Department of Public Welfare has established a Medical Assistance Provider Compliance Hotline, 1-866-DPW-TIPS (1-866-379-8477), to report suspected fraud and abuse committed by any entity providing services to Medical Assistance recipients. The hotline operates between the hours of 8:30 am and 3:30 pm, Monday through Friday. Voicemail is available at all other times. Callers may remain anonymous and may call after hours and leave a voicemail if they prefer.

Some common examples of fraud and abuse are:

  • Billing or charging Medical Assistance recipients for covered services
  • Billing more than once for the same service
  • Dispensing generic drugs and billing for brand name drugs
  • Falsifying records
  • Performing inappropriate or unnecessary services

Suspected fraud and abuse may also be reported via the Department of Public Welfare website at: http://www.dpw.state/oa/us/omap or emailed to omaptips@state.pa.us. Information reported via the website or email can also be done anonymously. The website contains additional information on reporting fraud and abuse.

The Department of Public Welfare has a protocol available to practitioners/providers to voluntarily come forward and disclose overpayments and improper payments of Medical Assistance funds. Gateway and the Department of Public Welfare encourage practitioners and providers to utilize the Pennsylvania Medical Assistance Provider Self-Audit Protocol when concerns over payment compliance arise. The protocol, which includes options for conducting self-audit and examples of inappropriate payments that may constitute a self-audit, can be found at www.dpw.state.pa.us/omap/omapprotocol.asp or by contacting Gateway’s Finance Department at 412-255-4340.

Practitioners or their representatives that have questions regarding this protocol may also contact the Department of Public Welfare’s Bureau of Program Integrity at (717) 772-4606 for additional information.

Environmental Assessment Standards

Gateway has established specific guidelines for conducting Environmental Assessment Site Visits, including medical record-keeping standards, at primary care practitioner practices. An initial Environmental Assessment will be conducted at all primary care practitioner and dental practitioner office sites as part of the credentialing process. Gateway’s subcontracted vendor conducts all site visits for contracted dental providers. The purpose of the site visit is to assure that practitioners are in compliance with Gateway’s Environmental Assessment Standards.

A Provider Relations Representative will schedule an on-site visit at each office site to conduct an Environmental Assessment. The Environmental Assessment must be conducted with the Office Manager or with a practitioner of the practice. The Provider Relations Representative will complete the Initial Environmental Assessment Form and tour the office as well as interview staff and examine the appointment schedule. The Gateway Provider Relations Representative will assess the office for evidence of compliance with the Environmental Assessment Standards.

Upon completion of the review, the Provider Relations Representative will conduct an exit interview with the Office Manager and/or practitioner. The results of the Environmental Assessment will be reviewed. Non-compliance issues must be addressed with a corrective action plan within 30-days of receipt for non-compliant standards.

The Provider Relations Representative will conduct a follow-up visit within 90 days or until the office site is compliant. The Medical Director will review the Environmental Assessment as part of the initial credentialing process. If any of the standards are not met, the Medical Director will assess the potential impact of the discrepancy to patient care and evaluate the corrective action plan. If the plan is reasonable, the practitioner will continue with the credentialing process. If the plan is not acceptable, the Medical Director may suggest a different corrective action plan or delay the credentialing process until the issue is resolved. If the office is not agreeable to correcting the identified problem, the information will be presented to the Quality Improvement/Utilization Management Committee for review. Special circumstances may be granted based upon size, geographic location of the practice, and potential harm to members. The Provider Relations Representative will communicate the final results to the practitioners.

An Environmental Assessment will not be conducted if a new practitioner joins an office site or if the practitioner relocates to an office that has already been reviewed and meets Gateway standards. When credentialing a new practitioner who joins an existing office site, the documentation from that site visit for that office will be included in the new practitioner’s initial credentialing file prior to the Quality Improvement/Utilization Management Committee review. Site visits for relocated offices must be conducted prior to the practitioner’s recredentialing date. The documentation of that site visit will be included in the recredentialing file.

Gateway Health Plan® Provider Relations Representatives conduct site visits to assess practice compliance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973 for those practices as determined by the Department of Public Welfare.

Environmental Assessment Standards PRIMARY CARE PRACTITIONER ENVIRONMENTAL ASSESSMENT STANDARDS
PHYSICAL ACCESSIBILITY AND APPEARANCE
Parking
  1. Parking Lot should have 96" wide parking spaces available for vans and cars that also have an adjacent 96" wide striped access isle.
  2. Parking Lot spaces that are handicap accessible have a sign or signs that will not be blocked by parked vehicles, and that display the International Symbol of Accessibility and provide "van-accessible" designation.
  3. The designated parking space for handicap accessibility is the 96" accessible space closest on the path of travel to the entrance.
Exterior Pat of Travel
  1. The path of travel is at least 36" wide, except at doorways and gates.
  2. The Surface in the exterior path of travel is stable, firm and slip resistant.
Curb Ramp
  1. There are curb ramps where the path of travel crosses a curb.
  2. There are curb ramps at least 36" wide.
  3. The slope of the curb ramps is less than or equal to 1:12.
Ramps
  1. If a route has changes in level greater than 1/2", a ramp is provided.
  2. The slope of the ramp is no greater than 1:12 for each run of the ramp.
  3. There is a level landing at the top and bottom of each run, at least as wide as the ramp and 60" in length.
  4. If the ramp changes direction, there is a landing at least 60" x 60".
  5. Ramps are non-slip.
  6. If the ramp rises more than 6", or has a horizontal run longer than 72", there are handrails on each side.
  7. The width of the ramp is at least 36" wide or if handrails are present, the clear width between railings is at least 36" wide.
Building Entrance
  1. There is directional signage indicating the locations of an entrance for use by people with disabilities.
  2. If there is signage, the entrance shows the International Symbol for Accessibility.
  3. There are no steps or changes in level at the entrance or in route to the entrance greater than 1/2" high.
  4. The entrance door has at least a 32" clear opening width.
  5. The door handle is operable without tight grasping or twisting of the wrist.
  6. There is a threshold that is at least 1/2" or less in height.
Airlock Doors
  1. If there are two doors in a series, the space between them is at least 48" plus the width of any door swinging into the space.
  2. The airlock door has at least a 32" clear opening width.
  3. The airlock door handle is operable without tight grasping or twisting of the wrist.
  4. There is a threshold that is 1/2" or less in height.
Stairs
  1. The use of stairs is not necessary to access the provider's office.
Elevator
  1. The Elevator door provides a clear opening width of at least 36".
  2. The Elevator operating controls are no higher than 54".
Interior Space
  1. The route to all provider spaces is at least 36" wide
Hallway Doors
  1. Doors on interior paths of travel have at least 32" of clear opening width.
  2. Door handles are operable without tight grasping or twisting of the wrist.
Provider Entrance
  1. The door into the provider space is at least a 32" clear opening width.
  2. Door handles are operable without tight grasping or twisting of the wrist.
  3. Thresholds are at least 1/2" or less in height.
Provider Interior Path
  1. Pathways to waiting rooms and receptionist desk are unobstructed and at least 36" wide
Provider Interior Doors
  1. Doors on the Provider interior path of travel have at least 32" of clear opening width.
Exam Rooms
  1. Doorways to exam rooms provide a minimum clear opening width of 32".
  2. Exam and treatment rooms must provide for patient confidentiality.
WAITING AREA
  1. Waiting area must adequately accommodate size of practice, and there must be a minimum of 4 chairs, or 2 per physician, whichever is greater.
  2. The waiting area and treatment areas must be clean and neat.
  3. There must be at least one exam room per physician.
  4. There must be at least one treatment room in a specialty office if office procedures are done. (No requirement for PCPs).
DRUG STORAGE
  1. Pharmaceuticals must be stored in an area that is not accessible to patients.
  2. Narcotics must be stored in a locked area and a log must be kept.
  3. There should be a separate refrigerator for storage of immunizations, medical supplies.
MEDICAL RECORD KEEPING
  1. All providers must maintain current and comprehensive medical records which conform to standard medical practices.
  2. Patient records must be secure from public access at all times.
  3. The office must have a written confidentiality policy that applies to all staff.
  4. Records are documented legibly.
  5. Office must have an organized filing system to insure prompt retrieval of patient records. (alphabetically, social security numbers)
  6. There must be a single chart for each patient. If family records are kept, individual records must be clearly delineated.
  7. Records must identify the member on each page.
  8. All medically related patient phone calls documented in the medical record.
  9. Office recalls missed appointments and makes documentation in the medical record.
  10. Chart Documentation:
    • Allergy or NKA visible in the same place on every record.
    • Patient medical history in each record. Is there a medical history in each patient record.
    • Treatment/progress notes in each patient record.
    • Problem List in the medical record. (PCPs and PCP Specialists Only)
    • Standard place in the medical record for preventive care/immunizations (PCPs and Specialists only).
**IF PROVIDER RELATIONS HAS QUESTIONS OR CHART DOES NOT MEET THE STANDARD THEN A COPY OF ONE RECORD NEEDS TO BE GIVEN TO QI FOR REVIEW.
SCHEDULING/AVAILABILITY/ OFFICE PROTOCOLS
SCHEDULING
PCPs and PCP/Specialists Only
  1. Waiting time to schedule a routine appointment must be no more than 10 business days. (Within 30 Days for Medicare Assured®)
  2. Waiting time to schedule a health assessment/preventive physical examination and first examination must be scheduled within three weeks. (Within 30 Days for preventive care appointment for Medicare Assured®)
  3. Waiting time to schedule an urgent care appointment must be no more than 24 hours.
  4. Waiting time to schedule non-urgent care, but in need of attention appointment must be no more than 1 week for Medicare Assured®.
  5. Waiting time to schedule an EPSDT screen for a new member assigned to the practice must be within 45 days of the effective date of enrollment. (N/A for Medicare Assured®)
  6. Wait time in the waiting room should be no more than 30 minutes or at any time no more than up to 1 hour when the physician encounters an unanticipated urgent medical visit or is treating a patient with a difficult need.
  7. Practice must have at least 20 hours of patient scheduling time per week per office.
  8. There must be open appointments on the schedule for emergencies.
  9. Emergency care must be seen immediately or referred to an emergency facility.
  10. Practice must have physician coverage arrangements for vacations, etc.
  11. Waiting time to schedule an appointment for any new patient diagnosed with HIV must be within seven days of enrollment.
  12. Waiting time to schedule an appointment for an SSI patient must be within forty-five days of enrollment.
OFFICE PROTOCOLS
  1. The office must have a recall system for patients who miss appointments and document in Medical Record, whether a postcard, or a telephone call was made/sent. At least one attempt to contact the member must be made by telephone. At least three attempts must be made.
  2. PCP and PCP/Specialist Only – The Office is able to perform EPSDT screens. (Offices whose panel limit is 21 and under) Should the PCP be unable to conduct the necessary EPSDT Screens, the PCP is responsible and willing to arrange to have the necessary EPSDT Screens conducted by another network practitioner and ensure that all relevant medical information, including the results of the EPSDT Screens, are incorporated into the Member’s PCP medical record.
EMERGENCY CARE
  1. PCP and PCP/ Specialist--A Physician must be available 24 hours a day, 7 days per week directly or through on-call arrangements for urgent or emergency care and provide triage and appropriate treatment or referrals for treatment. This can be accomplished by answering machine, or answering service.
EXIT INTERVIEW WITH OFFICE
  • Review the Environmental Assessment Standards and your findings at this time. Provide the standards for the medical record review process and give approximate date for completion of the credentialing process.
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Last Updated: 4/19/2010