Policies and Procedures

• Policy Changes
• Practitioner Education and Sanctioning
• Practitioner Due Process
• TITLE VI of the Civil Rights Act of 1964
• Translators During Clinical Visits
• Confidentiality
• Provider Changes

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.

Policy Changes

In order for Gateway to be in compliance with Federal and State Laws, Regulations and Regulatory Bulletins governing the Medicare and Medicaid Program in the course of providing services, Provider and its staff, will be bound by all applicable federal and state Medicare and Medicaid laws and regulations.  Providers will comply with all applicable instructions, bulletins and fee schedules promulgated under such laws and all applicable program requirements of regulatory agencies regarding the Medicare and Medicaid programs.

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.

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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 1-800-685-5205.

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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 Services Department at 1800-685-5205.

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TITLE VI of the Civil Rights Act of 1964

Practitioners are expected to comply with the Civil Rights Act of 1964. Title V of the Act pertains to discrimination on the basis of national origin or limited English proficiency. 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.

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Translators During Clinical Visits

Practitioner offices are expected to address the need for interpreter services in accordance with the Americans with Disabilities Act (ADA).  Each practitioner is obligated to identify those Members who may require such assistance and arrange and coordinate oral translation, oral interpretation and sign language services and pay for such services.  Members may not be held liable for the cost of such services.  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. 

Practitioner offices can contact the AT&T Language Line at 1-800-874-9426 for assistance with Limited English Proficient (LEP) patients and the TTY line at 1-800-654-5988 for patients with hearing impairments. 

Practitioners may obtain copies of documents that explain legal requirements for translation services or request further assistance by contacting Gateway's Provider Services Department.  (Refer to the Quick Reference section in this manual for phone number.)  

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Confidentiality

Through contractual agreements, all practitioners and providers participating with Gateway have agreed 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:

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:
   • 42 USC 1296a(a)(7)
   • 42 CFR § 431,300
   • The Mental Health Procedures Act, 50 P.S. §§7111
   • Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 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, and disease management.  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.  All other requests for release of or access to PHI will be handled in accordance with federal and state regulations. 
4. Environmental security of confidential information is conducted by all providers and practitioners treating Gateway members.  This includes both internal and external monitoring of 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. 

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Provider Changes

Gateway Health Plan's physician agreement indicates participating providers must submit written notice ninety (90) calendar days prior to the date the provider intends to terminate.  There is also sixty (60) days notice required if you plan to close your practice to new patients and thirty (30) days notice required for a practice location change.  Please refer to the Practice/Provider Change Request Form in the Forms and Reference Materials Section of this Manual.