Policies and Procedures

• Department of Public Welfare Policy Changes
• Practitioner Education and Sanctioning
• Practitioner Due Process
• TITLE VI of the Civil Rights Act of 1964
• Translators During Clinical Visits
• Confidentiality
• Environmental Assessment Standards
  • Environmental Assessment Standards

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 standard contract, Gateway must promptly implement new policies or changes in policy at the request of the Department of Public Welfare.  Upon notice of program or policy changes, an assessment of those that require practitioner notice is made.  Depending upon the Department of Public Welfare 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 the Department of Public Welfare. Additionally, practitioners need to be aware that no regulatory order or requirement of the Department of 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 Servicing 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 Health Care 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.

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.

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. 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 Servicing Department at 18003921145.

Through contractual agreements, all practitioners and providers participating with Gateway agree to abide by all policies and procedures regarding member confidentiality.  The performance goal for confidentiality is for practitioners to secure patient records from public access. Under these policies, the practitioner or provider must meet the following:

• 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. §7111
  • The Patient Bill of Rights, 28 Pa. Code §115.27 and 71 P.S. §103.21
  • Pennsylvania Drug and Alcohol and Abuse Act of 1972, 71 P.S. §1690.108 and 42 CFR, Part 2
  • 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 and 164
• Assure that member records, including information obtained for any purpose, are considered privileged information and, therefore, are protected by obligations of confidentiality.
• 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.
• 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.
• 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.
• Medical records must be available for all member visits for established patients.

Gateway has established specific guidelines for conducting Environmental Assessment Site Visits, including medical record-keeping standards, at primary care practitioner and OB/GYN practices.  An initial Environmental Assessment will be conducted at all primary care practitioner, specialist/PCP, certified nurse midwife and OB/GYN practitioner office sites as part of the credentialing process.   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 StandardsMedical records must be available for all member visits for established patients. Medical records must be available for all member visits for established patients.

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 All Critical Factors (CF) must be met in order to proceed with credentialing/recredentialing.

EXTERIOR OFFICE

Office should have a wheelchair ramp, door can be easily opened, or a push button is available for summoning assistance.  The door should be wide enough (32 inches) to allow wheelchair access.

CF For those offices not handicapped accessible, office staff should be willing to make special provisions to accommodate handicapped persons.

Office must be clearly marked and visible.

Office hours must be visible, either on the door, window, or in the waiting room.

INTERIOR OFFICE

WAITING AREA

CF Waiting area must adequately accommodate size of practice, and there must be a      minimum of 4 chairs, or 2 per physician, whichever is greater.

CF Office should be handicapped accessible, i.e. bathrooms equipped with side rails and call lights.  For offices that are not, staff should be willing to make special provisions to accommodate handicapped persons.

CF Emergency Exits are also handicapped accessible.

CF The waiting area and treatment areas must be clean and neat.

PATIENT TREATMENT AREA

CF Exam and treatment rooms must provide for patient confidentiality.

There must be at least one exam room per physician.

There must be at least one treatment room in a specialty office if office procedures are done. (no requirement for PCPs).

DRUG STORAGE

CF Pharmaceuticals must be stored in an area that is not accessible to patients.

CF Narcotics must be stored in a locked area and a log must be kept.

There should be a separate refrigerator for storage of immunizations, and medical supplies.

MEDICAL RECORDS

CF Patient records must be secure from public access at all times.

CF The office must have a written confidentiality policy that applies to all staff.

CF The office must have an organized filing system to insure prompt retrieval of patient records. (alphabetically, social security numbers)

CF There must be a single chart for each patient.  If family records are kept, individual records must be clearly delineated.

CF All medically related patient phone calls are documented in the medical record.

CF Office recalls missed appointments and makes documentation in the medical record.

Chart Documentation: Non-Critical Factors o       Allergy or NKA visible in the same place on every record. o       Patient medical history in each record. Is there a medical history in each patient record. o       Treatment/progress notes in each patient record. o       Problem List in the medical record.  (PCPs and PCP Specialists Only) o       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 QUALITY IMPROVEMENT FOR REVIEW.

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.