DCS Comprehensive Health Plan

Provider Network Oversight

Statement/Purpose

This policy outlines the authority and principles guiding DCS CHP Provider Network Oversight and Performance Management.

Definitions

Contractor: An organization or entity that has a prepaid capitated Contract with AHCCCS pursuant to A.R.S. § 36-2904, A.R.S. § 36- 2940, A.R.S. § 36-2944, or Chapter 34 of A.R.S. Title 36, to provide goods and services to members either directly or through subcontracts with providers, in conformance with contractual requirements and State and Federal law, rule, regulations, and policies.

Network: Physicians, health care providers, suppliers and hospitals that contract with a health plan to give care to members.

Network Administrator: An employee who is located in Arizona and who manages and oversees network development, network sufficiency and network reporting functions.

Network Performance Liaison: A DCS CHP employee who assists the DCS CHP Network Administrator in monitoring of the Contractor’s performance, conducts provider site visits and other duties related to network adequacy and access to care.

Provider: A person, institution, or group engaged in the delivery of services, or ordering and referring those services, who has an agreement with AHCCCS to provide services to AHCCCS members.

Policy

The Department of Child Safety Comprehensive Health Plan (DCS CHP) contracts with a Managed Care Organization (MCO) to develop, maintain and oversee a provider network in accordance with the network standards outlined in the AHCCCS Contractor Operations Manual (ACOM) 436. DCS CHP has established appropriate structures and mechanisms to oversee delegated network management activities performed by the contracted MCO.

Responsibilities of the MCO Contractor:

• Network Management: Maintain an adequate network of primary care, behavioral healthcare and specialty care providers and monitoring how effectively this network meets the needs and preferences of DCS CHP membership. This includes developing and maintaining a Provider Network Development and Management Plan (NDMP) that ensures the provision of covered services adheres to the contract. The NDMP outlines the Contractor’s process for developing, maintaining, and monitoring an adequate provider network, supported by written agreements, sufficient to provide access to all services covered under the contract;

• Staffing: Retain sufficient staffing, including a Network Administrator, to ensure providers receive assistance and prompt resolution of their issues and inquiries;

• Network Adequacy: Ensure network adequacy and appointment access, develop network resources in response to identified unmet needs, and ensuring that the contractor determines, monitors, and adjusts the number of members assigned to each PCP;

• Cultural Competency: Assess and adjust the availability of providers within the network to provide the types and number of providers necessary to meet the cultural, ethnic, racial and linguistic needs of members within defined geographical areas. This may include requiring existing providers to complete cultural competency training, providing culturally and linguistically appropriate health education materials, or recruiting practitioners with backgrounds similar to the underrepresented member population. DCS CHP determines appropriate adjustments based on identified needs;

• Service Delivery: Ensure contracted network providers deliver services in conformance with Arizona Vision-Twelve Principles for Children Behavioral Health Service Delivery as outlined in AHCCCS Medical Policy Manual (AMPM), Policy 430, and abide by the AHCCCS Appointment Standards as per AHCCCS Contractor Operations Manual (ACOM), Policy 417;

• Provider Directory: Maintain a provider directory that offers useful information to members for selecting a physician and hospital;

• Performance Measures: Assist DCS CHP in ensuring provider compliance with performance measures by overseeing contracted network provider performance of each related measure; and

• Contract Adherence: Adhere to other provisions in accordance with the DCS CHP and MCO contract, ACOM Policies 415, 417, 430, 436 and other applicable policies.

Responsibilities of DCS CHP:

• Network Oversight: Retain a Network Administrator who ensures the Contractor’s network adequacy and appointment access, develops network resources in response to identified unmet needs, and ensures members have a choice of providers.

• Compliance Monitoring: Monitor Contractor compliance with network quality and service appropriateness expectations through independent audits and the review of required MCO Contractor deliverables as set forth in the contract, program-specific performance measures and Performance Improvement Plans (PIPs);

• NDMP Review: Review, independently validate, and, if necessary, require the Contractor to update the Provider Network Development and Management Plan (NDMP) the network offers additional services that meet the needs of children in care, as appropriate;

• Administrative Action: Take administrative action, if needed, for Contractor provider network performance, including performance measures in reserved status or those below minimum performance standards.

Procedure

Processes/Guidelines

The DCS CHP Network Performance Team is responsible for overseeing delegated Network Management activities, including but not limited to:

• Conducting statewide site visits of healthcare facilities and physician offices to ensure compliance with applicable federal and state laws;

• Providing education to healthcare entities related to the special needs of DCS CHP enrolled children and youth and serving as an escalation for addressing provider concerns;

• Assisting DCS internal stakeholders in resolving member access to care issues, investigating and reporting on member and DCS field experience feedback and complaints;

• Assisting the DCS CHP Network Administrator with network development in various geographic regions;

• Monitoring and tracking DCS CHP Contractor performance in accordance with Active Contract Management (ACM) guidelines and metrics;

• Reporting results, findings and impressions back to the Network Administrator, bolstering oversight and Network Management efficacy;

• Documenting in-field encounters to identify trends, provide a historical record, and inform process improvement activities;

• Cultivating relationships with provider partners in the field to facilitate meaningful two-way communication and education;

DCS CHP activities and protocols are implemented and monitored through:

• Policies and procedures;

• Reports;

• Audits independent of Contractor data or audit work;

• Direct observation; and

• Other information and data deemed appropriate to support changes made to the scope of Network Team;

Data Utilization Process:

The DCS CHP Network Performance Team maintains a documentation system for collecting, analyzing, and disseminating data related to network management and performance, member experience, and access to care. This data is used in conjunction with other data for enhancing quality, network and clinical operations for children enrolled in DCS CHP.

The DCS CHP Network Performance Team uses data to:

• Review and evaluate the results of Network Performance Liaison activities;

• Identify opportunities for improving member, DCS field experience and access to care;

• Monitor and evaluate provider and facility compliance;

• Monitor performance measures;

• Prepare statistical reports for AHCCCS and other constituents.

Participation and Reporting:

The DCS CHP Network Team is comprised of experienced, trained staff who work closely together to complete Network Management activities under the direction of the Network Administrator, in collaboration with the Chief Medical Officer (CMO) and Chief Quality Officer (CQO).

Network data is reported to the Network Administrator and other functional areas of DCS CHP to monitor process improvement activities.

Training:

Provider Network Representatives within DCS CHP and the contracted MCO are adequately trained. DCS CHP reviews the training syllabus for network staff, ensuring it includes all the required elements outlined in AHCCCS ACOM 416, along with evidence of staff completing the training.

Provider Network Representatives receive training that includes, at a minimum, the following elements:

• Provider inquiry handling and tracking (includes resolution timeframes);

• Internal procedures for initiating contracting or AHCCCS registration;

• Evidence that training occurred for Provider Services Representatives