DCS Comprehensive Health Plan

Policy Development and Review

Statement/Purpose

The DCS Comprehensive Health Plan (CHP) ensures that all health plan policies and procedures are developed and maintained to promote an integrated, coordinated approach for the delivery of services to members.

Definitions

Policy: A statement of the Department’s stance, determination, or course of action on a topic. Department policies are based upon an authority.

Procedures: The specific actions that must be taken to implement the policy. Procedures must comply with the intent and definitions of the governing policy

Policy

DCS CHP and its contracted MCO develop and maintain written, health plan specific policies and procedures that comply with Federal and State statutes, program requirements and best practices. The DCS CHP Senior Leadership Team oversees the development, maintenance and approval of all health plan policies and procedures.

All health plan policies and procedures are reviewed at least annually and when necessary to incorporate changes in applicable Federal and State statutes, as well as AHCCCS requirements. An internal cross-agency review of new and existing policies is conducted when necessary.

If DCS CHP deems a policy or procedure submitted by its contracted MCO to be inefficient and/or place an unnecessary burden on members or providers, DCS CHP works with its MCO to change the policy or procedure within a time period specified by DCS CHP.

Health plan policies that set forth clinical requirements, quality improvement, oversight standards, and any changes to policy, are subject to review and approval of DCS CHP’s Chief Medical Officer (CMO). All other policies are dated and signed by the responsible function area manager and DCS CHP’s Chief Executive Officer (CEO). The review process is documented in writing and held on file reflecting the review and approval of the policies by an appropriate committee, chaired by DCS CHP’s CEO/Administrator or Chief Financial Officer.

DCS CHP policies and procedures are published in a standard format to the DCS Policy Library to ensure consistent communication.

DCS CHP and its contracted MCO provide initial and ongoing staff training that includes an overview of health plan policies, including AHCCCS Policy and Procedure Manuals, contract requirements, and State and Federal requirements specific to individual job functions.

Procedure

General Formatting Requirements

Approved policy and desktop templates are published in the DCS CHP Shared Drive and can be accessed by all DCS CHP staff. General policy formatting requirements include:

• Policy title;

• Policy number (assigned by CHP Policy Coordinator);

• Responsible function area;

• Approval and effective dates;

• Legal/contract references;

• Signature block; and

• Revision history with review dates.

Responsibilities

DCS CHP staff, through their Function Area Managers, may request development of a new policy or the revision of an existing policy. DCS CHP Function Area Managers serve as SMEs responsible for initiating policy review at least annually or when needed to ensure that written policies and procedures reflect current practices.

The DCS CHP Policy Coordinator works with DCS CHP Function Area managers to coordinate review, revision, approval, and maintenance activities for all health plan policies. This includes scheduling meetings, sending necessary agendas and attachments, documenting meeting minutes, and maintaining policy documents in electronic files.

Collaboration

DCS CHP Function Area Managers obtain input and provide oversight on policy creation and revision from internal and external SMEs and/or other identified stakeholders, including the contracted MCO. Input may be solicited through workgroups, review of draft policies and procedures, and/or discussions at Medical Management and/or Quality Management meetings.

Review and Approval

DCS CHP Function Area Managers are responsible for conducting an annual review of the policies for their function areas 30 days prior to the annual review date, unless immediate attention to the policy is required. Revised/edited policies are sent to the Policy Coordinator, to coordinate additional review and collaboration. Policies developed by the contracted MCO are also reviewed annually.

All policies are presented and discussed during dedicated monthly meetings attended by DCS CHP Function Area Managers and SMEs. Function Area Managers make policy determinations as follows:

• Approve with no recommended changes;

• Approve subject to minor changes;

• Recommend implementation of the policy as a desktop procedure instead of a policy;

• Approve an extension if additional pending information is required for adequate annual review;

• Deny with comment;

• Retire, if the policy is no longer applicable or redundant to another existing policy.

Policy determinations are recorded in meeting minutes. Policy determinations that affect the contracted MCO are promptly communicated to the appropriate MCO department through the DCS CHP Compliance Team.

Once a policy is approved, the DCS CHP Policy Coordinator collects applicable signatures and informs all affected function areas that the policy is signed and final. Function Area Managers advise DCS CHP staff of the new or revised policy and procedure and facilitates training, as needed.

Retirement of Policies

A policy may be retired if its content has been merged into an existing or new policy or if the DCS CHP policy review team determines that the policy is no longer applicable to health plan operations and practices. An annotation is placed in the DCS CHP Policy Tracking Matrix indicating the reason for retirement.

Publishing

The DCS CHP Policy Coordinator maintains official signed policies and procedures in the DCS CHP Shared Drive and forwards an electronic copy to the DCS Field Resources and Policy Unit for review and publishing to the DCS intranet.

Reporting

The DCS CHP Policy Coordinator tracks and records the review and approval activities in the DCS CHP Policy Matrix located on the CHP Shared Drive. The policy matrix provides the following information:

• Policy name and assigned number;

• Responsible function area;

• Review and approval dates;

• Approval/signature dates;

• Policy publication dates;

• Associated documents and forms, and

• Associated process flows/desktop references.