FOUNDATION FOR MEDICAL CARE of TULARE & KINGS COUNTIES, INC.

FOUNDATION FOR MEDICAL CARE of
TULARE & KINGS COUNTIES, INC.
CREDENTIALING & RE-CREDENTIALING
POLICIES & PROCEDURES
FOR 2013
1
Last Update: September 2012
CREDENTIALING TABLE OF CONTENTS
POLICY
PAGE
Introduction and plan updates
3
Credentialing Committee
4
Scope of practitioners
5
Non physician practitioner credentialing policy
6
AIDS provider Credentialing
7
Primary source verification
9
Monitoring of provider sanctions
15
Attestation for Credentialing
15
Non-discrimination policy
16
Credentialing timelines
16
Credentialing workflow
17
Confidentiality
17
Practitioner rights during credentialing
18
PCP Participation Criteria schedule
19
Notification of Adverse Actions or Limitations
24
PCP responsibilities
25
PCP Service Guidelines
25
Re-credentialing Policy and Procedure
30
Site visits
35
Medical Record documentation
38
Practitioner office site quality
45
Complaint Investigation
46
Non-compliance and Corrective Action plan
55
Termination of a provider for cause
58
Organizational and Facility Credentialing
59
Ongoing Monitoring
59
Member notification of physician termination
61
OB-GYN’S as PCP’s
61
Schedule B
66 Fair Hearing process
67
2
POLICY: INTRODUCTION/PLAN UPDATES Date: 11/18/09, 07/15/10, 09/08/11, 09/11/12 INTRODUCTION: Foundation for Medical Care of Tulare and Kings Counties, Inc. (FMC) evaluates and determines the appropriate licensing of physicians to ensure that licensed health care providers meet the minimum credentialing and performance standards for participation in FMC. All contracted physicians participating on the provider panel and published as a FMC physician must be credentialed. To accomplish these goals, FMC has developed a comprehensive credentialing program plan. The credentialing program plan applies to all FMC HMO products. MECHANISM FOR UPDATING PLAN: The credentialing program plan is reviewed annually. The initial plan was produced in 1997 with input from the Quality Management Committee. The plan is reviewed for compliance with NCQA requirements and reflects the process in place for credentialing of physicians withinFMC. At the time of the annual review, revisions are suggested by FMC quality and credentialing staff, the Quality Management Committee and the Credentialing Chairperson. The Credentialing Committee reviews the document and recommended changes and the document is submitted to the Quality Management Committee for review and adoption. 3
POLICY: CREDENTIALING COMMITTEE DATE: 11/18/09 12/08/08, 07/13/11, 09/08/11, 09/11/12 The Credentialing Committee consists of the Credentialing chairperson and a multidisciplinary committee with representation from various specialties and Primary Care practitioners who are active members of Foundation for Medical Care of Tulare and Kings Counties, Inc. The Committee consists of 10 members, who also make up the Board of Directors for the Foundation. A quorum for meetings will be at least 3 voting members or a simple majority (50% +1). Only licensed physicians are eligible to vote at Committee meetings. Minutes of the meeting must be reviewed and signed within 30 days of the meeting date. The Committee reviews the completed initial credentialing packets, determines approval/denial of applications and reviews re‐credentialing files, including performance review data. If a provider has deficiencies on re‐credentialing, the committee may take appropriate action. The Credentialing Committee meetings may be held as real‐time virtual meetings (video conferencing, web conferencing with audio) or live meetings only. Meetings may not be held through e‐mail. The Credentialing Chairperson is a physician who oversees the credentialing process, including reviewing completed new credentialing files and re‐credentialing files prior to Committee review with his/her determination of whether criteria/standards are met. The Credentialing Committee has the final decision on the acceptance or denial of the files. The Chairperson may approve clean files for credentialing with a slate of new providers to be submitted to the Committee for final authorization. Credentialing Chairperson also reviews the Credentialing Program Plan and any proposed changes to the plan. (A clean file is one that has no new liabilities or any type of actions against them since the last credentialing cycle.) The Credentialing Committee must receive and review the credentials of practitioners who do not meet the organization’s established criteria. The Credentialing Committee must give thoughtful consideration of the credentialing information before making recommendations about a practitioner’s ability to deliver care. The committee’s discussion must be documented within its meeting minutes. 4
POLICY: SCOPE OF PRACTITIONERS DATE: 11/18/09, 07/13/11, 09/08/11, 09/11/12 SCOPE OF PRACTITIONERS Foundation for Medical Care of Tulare and Kings Counties, Inc. requires that practitioners be credentialed according to NCQA standards prior to becoming a member of the medical group. All providers must be board certified or meet the following criteria: PCP’s‐ Completed residency in family practice, Internal medicine, Pediatrics or OB/GYN services and out of training less than 5 years or in practice more than 5 years and completed CME of at last 25 hours of AMA category one for each of the last 3 years or as the state requires. Specialists‐ In solo practice and completed residency less than 5 years ago in ABMS or AOA specialty and completed at least 25 hours of AMA category one CME for the last 3 years, or if in group practice, completed residency in ABMS or AOA specialty and where at least 50% of physicians within the group are board certified in the same specialty. These practitioners include: Physicians—All physicians who see members outside of an inpatient hospital setting or freestanding surgical centers. This includes MD’s, DO’s, DPM’s and DC’s. Some physicians (i.e. hospital based university faculty or out of area specialty medical groups) are delegated for their own credentialing mechanism. Physicians who are wholly hospital based, such as pathologists, radiologists and emergency room physicians do not require credentialing by Foundation for Medical Care of Tulare and Kings Counties, Inc. Mental Health providers—Psychiatrists and physicians who are certified in addiction medicine, doctoral and or master’s level psychologists who are state certified or state licensed and any other behavioral health care specialists who are licensed, certified or registered by the state to practice independently. Dentists—This includes DDS and DMD oral surgeons who provide care to members of FMC. Foundation for Medical Care does not contract with any health care facilities or mental health facilities as per the contract with health plans, these facilities are contracted through the health plan exclusively. Locum Tenens Physicians‐ Any locum tenens physicians covering for a contracted practitioner for more than 90 days must be credentialed by Foundation for Medical Care of Tulare and Kings Counties, Inc.. Foundation for Medical Care of Tulare and Kings Counties, Inc. does not delegate credentialing activities at this time. Foundation for Medical Care of Tulare and Kings Counties, Inc. does not make credentialing and re‐credentialing decisions based solely on an applicant’s race, ethnic/national identity, gender, age, sexual orientation or the types of procedures or patients the practitioner specializes in thereby maintaining a heterogeneous credentialing committee membership and requiring those responsible for credentialing decisions to sign an affirmative statement to make decisions in a nondiscriminatory manner. 5
NON PHYSICIAN PRACTITIONERS CREDENTIALING POLICY Date: 11/18/09, 07/15/10, 09/08/11, 09/11/12 It is the policy of Foundation for Medical Care of Tulare and Kings Counties, Inc. that appropriate physician supervision is conducted for nurse practitioners and physician assistants. The following is the expectation of Foundation for Medical Care of Tulare and Kings Counties, Inc. for physicians supervising nurse practitioners/Physician assistants: 1) The physician must submit allied professional licensure to Foundation for Medical Care of Tulare and Kings Counties, Inc. prior to allowing these professionals to treat Foundation for Medical Care of Tulare and Kings Counties, Inc. members. All appropriate licensures and certifications of the supervising physician must be current. 2) The supervising Physician has continuing responsibility for all medical services provided by NP/PC’s under their supervision. 3) PA/NP’s may perform medical services set forth by regulations of the MBC when the services are rendered under the appropriate supervision of a licensed MD. At all times the supervising physician must be physically or electronically available to the PA for consultation, except in emergency situations. 4) The supervising physician must not supervise more than 2 PA’s at one time. 5) NP’s who prescribe drugs and/or devices must be in accordance with standardized procedures or protocols developed by the NP and supervising MD. The supervising MD is not required to be present physically. Telephone contact is sufficient. 6) The supervising physician must not supervise more than 4 NP’s at one time. 6
POLICY: AIDS PROVIDER CREDENTIALING DATE: 11/18/09, 07/15/10, 09/08/11, 09/11/12 Provider’s with expertise in the area of AIDS/HIV treatment will be identified at the time of initial credentialing with Foundation for Medical Care of Tulare and Kings Counties, Inc. Expertise will be defined as a background in an appropriate specialty, advanced education in the field of AIDS/HIV and a willingness to provide services to the members of Foundation for Medical Care of Tulare and Kings Counties, Inc. Physician who holds a valid, unrevoked and unsuspended certificate to practice medicine in the state of California
and meets any one of the following four criteria:
- Is credentialed as an "HIV Specialist" by the American Academy of HIV Medicine
- Is board certified, or has earned a Certificate of Added Qualification, in the field of HIV medicine
- Is board certified in the field of infectious diseases by a member board of the American Board of
Medical Specialties and meets the following qualifications: (A) In the immediately preceding 12
months has clinically managed medical care to a minimum of 25 patients who are infected with HIV;
and (B) In the immediately preceding 12 months has successfully completed a minimum of 15 hours
of category 1 continuing medical education in the prevention of HIV infection, combined with
diagnosis, treatment, or both, of HIV-infected patients, including a minimum of 5 hours related to
antiretroviral therapy per year
- Meets the following qualifications: (A) In the immediately preceding 24 months has clinically managed
medical care to a minimum of 20 patients who are infected with HIV; and (B) Has completed any of
the following:
- In the immediately preceding 12 months has obtained board certification or
recertification in the
field of infectious diseases or 30 hours of category 1 continuing medical education in the prevention
of HIV infection, combined with diagnosis, treatment, or both, of HIV-infected patients.
- In the immediately preceding 12 months has successfully completed a minimum of 15 hours of
category 1 continuing medical education in the prevention of HIV infection, combined with diagnosis,
treatment, or both, of HIV-infected patients and has successfully completed the HIV Medicine
Competency Maintenance Examination administered by the American Academy of HIV Medicine.
Annually a questionnaire will be sent to these identified physicians to confirm their willingness to continue to provide services to AIDS/HIV members and to update information regarding their ongoing education in the field. 7
DATE MD NAME ADDRESS CITY, STATE, ZIP Dear Dr. NAME: You were identified at the time of credentialing as a specialist in the field of infectious disease. As a part of this process, you were also identified as willing to act as a specialist in the field of HIV. Yearly, we are required to update our records on HIV specialists. Per guidelines, a specialist in the field of HIV. In order to be considered an HIV specialist for Foundation for Medical Care of Tulare and Kings Counties, Inc. the following requirements must be met: Physician who holds a valid, unrevoked and unsuspended certificate to practice medicine in the state of
California and meets any one of the following four criteria:
- Is credentialed as an "HIV Specialist" by the American Academy of HIV Medicine
- Is board certified, or has earned a Certificate of Added Qualification, in the field of HIV medicine
- Is board certified in the field of infectious diseases by a member board of the American Board of
Medical Specialties and meets the following qualifications: (A) In the immediately preceding 12
months has clinically managed medical care to a minimum of 25 patients who are infected with HIV;
and (B) In the immediately preceding 12 months has successfully completed a minimum of 15 hours
of category 1 continuing medical education in the prevention of HIV infection, combined with
diagnosis, treatment, or both, of HIV-infected patients, including a minimum of 5 hours related to
antiretroviral therapy per year
- Meets the following qualifications: (A) In the immediately preceding 24 months has clinically managed
medical care to a minimum of 20 patients who are infected with HIV; and (B) Has completed any of
the following:
- In the immediately preceding 12 months has obtained board certification or
recertification in
the field of infectious diseases or 30 hours of category 1 continuing medical education in the
prevention of HIV infection, combined with diagnosis, treatment, or both, of HIV-infected patients.
- In the immediately preceding 12 months has successfully completed a minimum of 15 hours of
category 1 continuing medical education in the prevention of HIV infection, combined with
diagnosis, treatment, or both, of HIV-infected patients and has successfully completed the HIV
Medicine Competency Maintenance Examination administered by the American Academy of HIV
Medicine.
We need you to update your attestation for Foundation for Medical Care of Tulare and Kings Counties, Inc. Please sign and fax the following statement to Foundation for Medical Care of Tulare and Kings Counties, Inc. at (559) 734‐3828. Thank you! I hereby attest that I am willing to serve as an HIV specialist for Foundation for Medical Care of Tulare and Kings Counties, Inc. and have met one of the requirements listed above and are willing to provide this information as requested to Foundation for Medical Care of Tulare and Kings Counties, Inc. __________________________________ ______________________________ 8
Policy: Primary source verification
Date: 11/18/09, 07/15/10, 09/08/11, 2/2/12, 9/11/12 As a pre-requisite for participation in the Foundation for Medical Care of Tulare and Kings Counties, Inc. provider
network, all new applicants must provide an application and information for verification prior to consideration
by the Credentialing committee. The information required consists of:
1. A current, unencumbered license to practice medicine in the state of California.
2. Valid, current, unencumbered DEA drug registration, or CDS certificate for oral surgeons, or evidence
that the applicant does not require registration in order to deliver appropriate care. Licensure must be
valid at the time of the credentialing decision.
 The Provider Group verifies that a current, valid DEA certificate is present and within the
prescribed time limits for practitioners who prescribe medications. One of the following is
required:
 Copy of the DEA certificate
 Pending DEA certificate - FMC may credential a practitioner whose DEA certification is
pending if it has a documented process for allowing a practitioner with a valid DEA
certificate to write all prescriptions requiring a DEA number for the prescribing practitioner
until the practitioner has a valid DEA certificate.
 Documented visual inspection of the original certificate
 Entry in the NTIS database
 Entry in the AMA Physician Master File
 Confirmation with the state pharmaceutical licensing agency, where applicable
 Confirmation with the DEA
- If unable to obtain a copy of the DEA certificate, the Provider Group may confirm with
the DEA Registration Validation Web site:
‐ https://www.deadiversion.usdoj.gov/webforms/validateLogin.jsp
If the provider does not have a DEA or CDS certificate, Foundation for Medical Care of Tulare and Kings Counties, Inc. will require a written statement from the physician regarding the reasons why
he/she does not have certification or does not prescribe medications. It is required that the
physician must also provide, in writing, the arrangements made for by the physician for the
provision of medications requiring DEA certification to patients. This will be reviewed by the
credentialing chairman/committee at the time of credentialing/re-credentialing.
Board certification by a board recognized by the American Board of Medical Specialties
(ABMS) or the American Osteopathic Association (AOA) if the practitioner states he/she is
board certified on the application.
3. Completion of a residency-training program.
4. Graduation from medical school.
5. History of any disciplinary or adverse actions related to providers:
-licensure
-DEA or state narcotics registration
-hospital or clinical privileges
-managed care participation
-other professional associations
9
6. Office Site visit and Medical Records reviews must be completed prior to file
reviews.
8. Evidence that there have been no unexplained breaks in at least the last five years of work history. For
providers who have gaps in work history of 6 months or more should be clarified orally with provider
and documented and dated as verbal verification. Any gaps that exceed one year must be clarified in
writing. This must be completed prior to Committee approval date.
9. The Credentialing Staff will verify that the applicant has provided FMC with:
10. Copies of current state controlled drug certificate, where required.
11. Copies of current professional liability coverage in amounts satisfactory to FMC.
12. Liability Claims history
13. Medicare Opt-Out status will be reviewed and documented as part of both the initial credentialing and
re-credentialing process. Opt-Out status will be documented in the provider credentialing file.
14. Providers are required to have a valid National Provider Identifier (NPI).
15. Providers may not be listed on the Medi-Cal Suspended or Ineligible list database.
10
The following sources will be used for primary verification for:
Item
Source
Current,
unrestricted state
license
State Medical Licensing
Board
DEA Registration
National Technical
Information Service or a copy
of the provider’s DEA
certificate
State Controlled
Drug Certificate
Copy from provider
Board Certification
American Boards of Medical
Specialties (ABMS), CertiFacts online, American
Osteopathic Association
(AOA) or AMA Masterfile;
Specialty Board; Medical
Board Hotsheets
Completion of
Residency Training
ABMS; AOA; Association of
American Medical Colleges;
(AAMC); residency program;
Specialty Board; State
Licensing Board, if State
primarily verifies.
Graduation from
medical school
AMA Masterfile; AOA;
AAMC, medical school;
Educational Commission for
Foreign Medical Graduates
(for international medical
graduates licensed after
1986); Specialty Board; State
Licensing Board, if State
primarily verifies.
Disciplinary
Actions
Federation of State Medical
Boards (FSMB); NPDB; State
Licensing Agency; 805
Report
Professional
Disciplinary
National Practitioner Data
11
History
Bank (NPDB)
Medicare/Medicaid/ FSMB/NPDB, Cin-Bad for
CHAMPUS
chiropractic
Sanctions; Military
Disciplinary Action
Hospital Privileges
Hospital roster or privilege
letter from primary
participating hospital
Current
Professional
Liability Insurance
Copy of Insurance Policy
Face Sheet from provider
Liability Claims
History
National Practitioner Data
Bank, malpractice verification
and claims history
Work History
From application or CV
‐
‐
Foundation for Medical Care of Tulare and Kings Counties, Inc. must verify only the highest
level of credentials obtained. The Provider Group must verify the highest of the 3 levels
(Graduation from medical or professional school, Training/Residency, or Board Certification)
obtained by the practitioner (making N/A all levels under the highest level achieved), except for
dentists. For dentists, board certification is not an acceptable source of PSV for dental school
graduation because not all dental boards verify graduation from dental school and training.
Confirmation from the applicable state board, state licensing agency or registry is acceptable if
those entities perform PSV. If this type of confirmation is utilized, FMC must obtain written
confirmation from the applicable entity on an annual basis.
For Anthem only: Effective 8/1/09 OIG and EPLS must also be run if using the NPDB.
Cumulative Sanction Report - The report is made available through the OEC of the HHS
OIG. The Web site http://oig.hhs.gov/fraud/exclusions/exclusions_list.asp also includes
monthly updates in the form of lists from the Federal Register, noting exclusion actions taken
since the last Cumulative Sanction Report was produced.
For Anthem only: Effective 8/1/09 NPDB and EPLS must also be run if using the OIG.
EPLS - contains current information about practitioners who are excluded throughout the
U.S. Government (unless otherwise noted) from receiving Federal contracts or certain
subcontracts and from certain types of Federal financial and nonfinancial assistance and
benefits. (If using this source, it must be run at least monthly on each practitioner.
12
Graduation from medical or professional school
Confirmation of graduation from the medical school
 Confirmation from the appropriate state licensing agency
 Entry in the AMA Physician Master File
 Confirmation from the ECFMG for international medical graduates after 1986. This will
be verified by confirmation letter from ECFMG confirmation verification service.
 Completion of AMA’s Fifth Pathway Program - If a physician states that education and
training were completed through the AMA’s Fifth Pathway program, the Provider Group
must confirm it through PSV from the AMA. To verify a physician’s Fifth Pathway
credentials, contact the AMA Department of Education at 800-665-2882.
The Fifth Pathway is an avenue by which students who have attended four years at a
foreign medical school may complete their supervised clinical work at a U.S. medical
school, become eligible for entry to U.S. residency training, and ultimately obtain a
license to practice in the U.S. This program will terminate effective 7/1/09; the final
class will complete the program 12/09.
DO only - one of the following is required:
 Entry in the AOA Official Osteopathic Physician Profile Report
 Entry in the AOA Physician Master File
 National Student Clearinghouse at 703-742-4200,
[email protected] or www.degreechk.com
DPM - one of the following is required:
 Confirmation of graduation from the podiatric school
 Confirmation from the appropriate state licensing agency
 National Student Clearinghouse at 703-742-4200,
[email protected] or www.degreechk.com
 Entry in the American Podiatric Medical Association Master file at www.apma.org



‐
Training (Residency) requirements for credentialing:

DDS/DMD - one of the following is required:
 Confirmation from the state licensing agency
 Confirmation from the residency training program
DO - one of the following is required:
 Confirmation from the residency training program
 Confirmation from the state licensing agency
 Entry in the AOA Official Osteopathic Physician Profile Report
 Entry in the AOA Physician Master File
DPM - one of the following is required:
 Confirmation from the residency training program
 Confirmation from the state licensing agency
 Entry in the American Podiatric Medical Association Master file - www.apma.org
MD (includes Psychiatrists) - one of the following is required:
 Confirmation from the residency training program
 Confirmation from the state licensing agency
 Entry in the AMA Physician Master File



13
NOTE:
A status of “being verified” or “being re-verified” is not acceptable.
State sanctions will be reviewed also as part of the credentialing process. This can come from the appropriate
State Board, NPDB, Continuous Query (CONTINUOUS QUERY (PDS)), HIPDB or FSMB.
The provider also must agree to abide by Foundation for Medical Care of Tulare and Kings Counties, Inc.
participation criteria. (Attachment A).
A physician profile report is kept with the credentialing file as a tracking device to ensure that all required
information is obtained and in a timely manner.
Copies of the Medical Board of California hot sheets or NPDB, CONTINUOUS QUERY (PDS), HIPDB,
FSMB, are reviewed within 30 days of release to identify deficiencies for the credentialing/re-credentialing
process and to identify ongoing problems. All Foundation for Medical Care of Tulare and Kings Counties, Inc. are enrolled in CONTINUOUS QUERY (PDS).
For behavioral health providers confirmation of board certification can be obtained from the specialty board or
state licensing agency (only if agency conducts primary source verification of board certification and is updated
yearly). Education and training must be verified by Foundation for Medical Care of Tulare and Kings Counties,
Inc.
For Podiatrists confirmation of board certification can be obtained from the appropriate specialty board or state
licensing agency (if primary verification of podiatry school graduation and completion of residency is
performed. For actions, the Board of Podiatry Action Report is queried.
Foundation for Medical Care of Tulare and Kings Counties, Inc. does not make credentialing and recredentialing decisions based solely on applicant’s race, ethnic/national identity, gender, age, sexual orientation
or type of procedure performed or type of patient Physician specializes in.
The provider must indicate on the application the dates and amount of malpractice insurance coverage. In
addition, one of the following is required: written confirmation of the past 5 years of history of malpractice
settlement from the malpractice carrier, NPDB query, Proactive Disclosure service of the National Practitioner
data Bank or written confirmation of the past 5 years of history of malpractice settlements from the malpractice
carrier.
At the time of initial credentialing any specialist who has education/training in the field of HIV/AIDS and will
be performing in the capacity of HIV/AIDS specialist will be identified and will be listed as such on the IPA
provider list.
14
POLICY: Monitoring of provider sanctions DATE: 5/11/10, 09/08/11, 09/11/12 POLICY: Foundation for Medical Care of Tulare and Kings Counties, Inc. will utilize the NPDB and CONTINUOUS QUERY (PDS) to monitor provider sanctions, restriction or limitations on scope of practice. PROCEDURE: All Foundation for Medical Care of Tulare and Kings Counties, Inc. providers will be enrolled in CONTINUOUS QUERY (PDS) within 180 calendar days of credentialing and documentation that a CONTINUOUS QUERY (PDS) report has been obtained within the 180 days will be placed in the provider file. CONTINUOUS QUERY (PDS) alerts will be monitored monthly and the report printed and filed. If no actions were taken on FMC Providers the report will be initialed by credentialing staff to document review. Any reports/actions taken regarding a Foundation for Medical Care of Tulare and Kings Counties, Inc. provider will be noted and placed in the provider’s credentialing file. These reports will be reviewed as part of the re‐credentialing process. Any reports/actions taken regarding a Foundation for Medical Care of Tulare and Kings Counties, Inc. provider will be noted in their credentialing file, submitted and reviewed by the credentialing committee. If any action needs to be taken committee will advise staff of the action to be taken and this will be documented and follow up by the credentialing staff as appropriate. POLICY: ATTESTATION FOR CREDENTIALING DATE: 11/18/09, 07/15/10, 09/08/11, 09/11/12 As a part of the credentialing and re‐credentialing process the practitioner must complete an attestation form regarding: 1. Any reasons for inability to perform essential functions of the position, with or without reasonable accommodation. 2. Lack of present illegal drug use 3. Any history of loss of license or felony conviction, or loss or limitation of clinical privileges or disciplinary activity. 4. Current malpractice coverage 5. Correctness and completeness of application. If a provider indicates on the attestation that there is any reason for inability to perform essential functions (marks no) the provider will be contacted to determine if this was an error or if the practitioner needs to submit a written explanation. This attestation also includes notification of the provider rights to review information provided for credentialing and to correct erroneous information. The attestation must have the providers’ signature. A fax or scanned copy of the signature meets the intent. A stamp of the signature is not acceptable. 15
POLICY: NON‐DESCRIMINATION POLICY DATE: 11/18/09, 07/13/11, 09/08/11, 09/11/12 Foundation for Medical Care of Tulare and Kings Counties, Inc. does not make credentialing and re‐credentialing decisions based solely on an applicant’s race, ethnic/national identity, gender, age, sexual orientation or the types of procedures (e.g., abortions) or patients in which the practitioner specializes. To monitor and prevent discrimination Foundation for Medical Care of Tulare and Kings Counties, Inc. does the following: ‐
‐
‐
Periodic audits of practitioner grievances/complaints to determine if there are grievances/complaints alleging discrimination. Maintaining a heterogeneous credentialing committee membership. Requiring those responsible for credentialing decisions to sign a statement affirming that they do not discriminate when they make decisions. 
Foundation for Medical Care of Tulare and Kings Counties, Inc. will actively monitor on an ongoing basis the credentialing policy to ensure that the process is done in a non‐discriminatory manner. To do so, any member or provider complaints regarding possible discrimination will be brought to the attention of credentialing staff. The credentialing staff will notify the CEO of Foundation for Medical Care of Tulare and Kings Counties, Inc. and as appropriate, the credentialing committee chairman. A response will be requested of the party and the issue will be thoroughly researched by staff. If an issue is found to be of merit, as determined by the CEO/Credentialing Chairman, the issue will be brought to the Credentialing Committee for appropriate action. POLICY: CREDENTIALING TIMELINES DATE: 11/18/09, 07/15/10, 09/08/11, 09/11/12 There are specific timelines as set forth by NCQA for managed care organizations to verify credentials. These timelines are counted back from the day of provider acceptance by the credentialing committee into Foundation for Medical Care of Tulare and Kings Counties, Inc. For licensure: 180 days, must be in effect at time of credentialing decision. For DEA: Must be in effect at time of credentialing decision. (Unless DEA certificate is pending and practitioner has an MD with a valid DEA certificate who will be writing all prescriptions requiring DEA number until DEA certificate is obtained). For Education and Training: None For Board Certification: Any NCQA recognized source is valid up to 1 year, however if source is periodically updated, verification must be from the most current edition. ABMS alone is not sufficient as primary source verification for board certification. Work History: 180 days NPDB: 180 days Limitations and sanctions queries: 180 days Current Insurance Coverage: 180 days Hospital Privileges: 180 days 16
All credentialing decisions should be made within 180 days of application and notification made to the practitioner within 60 days of the committee decision. If there are delays in the process, the applicant is required to re‐sign an attestation that the information on the original application is still correct. Credentials must be valid at the time of the committee review and the provider must not provide care to enrollees until the final decision on credentialing is made. The provider group has the right to make the final determination about which practitioner may be a part of Foundation for Medical Care of Tulare and Kings Counties, Inc. Providers may only be provisionally credentialed by FMC once. If a physician is a member of FMC due to a delegation agreement and the delegation agreement is terminated, the provider cannot be provisionally credentialed directly through FMC but must be credentialed as a full provider. Providers may also be provisionally credentialed if they are applying for member status for the first time. The provisional status will end when the provider is accepted as a member of Foundation for Medical Care of Tulare and Kings Counties, Inc. POLICY: Credentialing Workflow DATE: 11/18/09, 07/15/10, 09/08/11, 09/11/12 The Credentialing workflow involves the credentialing staff, credentialing chairperson and the credentialing committee. 1.
2.
3.
4.
Provider submits application and supporting documents as requested. Credentialing staff verifies professional criteria, professional competence and conduct criteria. Credentialing staff does office site visit using Primary Care Physician Office assessment. Credentialing Chairperson reviews all data and decides whether provider meets criteria for credentialing and is timely. Makes recommendations on acceptance. If an applicant does not meet standards, this information is also sent to the committee. 5. The Credentialing Committee makes peer review decisions about acceptance/denial. All determinations are made based solely on applicant meeting standards. POLICY: Confidentiality DATE: 11/18/09, 07/15/10, 09/08/11, 09/11/12 Credentialing of providers is a highly confidential process. Credentialing staff must fully understand the confidential nature of the information obtained in the credentialing process. All staff and physicians involved in the credentialing process shall sign a confidentiality form. No information obtained in connection with the performance of duties in Credentialing may be revealed or disclosed in any manner or under any circumstance except to: A member’s attending physician or other care providers involved in the credentialing process. The representatives of insurance carriers (pursuant to appropriate authorization for release of information.) Government or state agencies, as required under the provisions of federal and state law. Others, as may be appropriate and permissible under applicable law. All information received by Foundation for Medical Care of Tulare and Kings Counties, Inc. regarding physician credentialing shall be considered confidential. All records will be kept in a locked filing cabinet in an area with limited access. 17
POLICY: PRATITIONER RIGHTS DURING THE CREDENTIALING PROCESS DATE: 11/18/09, 07/15/10, 09/08/11, 09/11/12 Practitioners who are applying for membership in the Foundation for Medical Care of Tulare and Kings Counties, Inc. have specific rights during the credentialing process. These include: A practitioner may contact credentialing staff to find out the status of their application at any point in the credentialing process. This contact may be by phone, fax or mail. Information may be supplied to the practitioner regarding all aspects of their application, except for confidential information such as responses from references. Applicants will be notified of this right at the time of application. Practitioner has the right to be notified of the credentialing process in writing during initial credentialing and this information will be provided to the member as part of the credentialing application. Practitioner applicants have the right to review information obtained by Foundation for Medical Care of Tulare and Kings Counties, Inc. to evaluate the credentialing application. Practitioners will be notified in writing, via certified letter or fax, when information obtained by primary sources varies substantially from information provided on the practitioner’s application. Practitioners will be notified of the variance at the time of primary source verification. Sources will not be revealed if information obtained is not intended for verification of credentialing elements or is protected from disclosure by law. If a practitioner believes that erroneous information has been supplied to Foundation for Medical Care of Tulare and Kings Counties, Inc. by primary sources, the practitioner may correct such information by submitting written notification to the credentialing department. Practitioners must submit a written notice, via letter or fax along with a detailed explanation to the credentialing department of Foundation for Medical Care of Tulare and Kings Counties, Inc. Notification to the practitioner by the credentialing staff must occur within 30 days of the discrepancy being noted and the practitioner has 30 days to respond. The credentialing staff will document in the practitioner file when the correction was received. A practitioner has the right to review information obtained by Foundation for Medical Care of Tulare and Kings Counties, Inc. for the purpose of credentialing or re‐credentialing. This includes non‐privileged information obtained from outside sources but does not extend to review of information, references or recommendations protected by law from disclosure. 18
Primary Care Physician Participation Criteria Schedule I. BUSINESS CRITERIA A. Applicability 1. These criteria shall apply to each applicant for participation and each Primary Care Physician participating in FMC and shall be enforced at the sole discretion of FMC. 2. Each applicant for participation as a Primary Care Physician must satisfactorily document evidence meeting the criteria stated in item 4 for at least six (6) months prior to application, unless applicant has entered clinical practice or completed a residency or a fellowship program within the past six (6) months. 3. Each participating Primary Care Physician must continue to meet the following criteria for the duration of participation in the FMC Plans. 4. A Primary Care Physician must be an internist, pediatrician, family and/or a general practitioner who for the two (2) years prior to applying for participation, unless Primary Care Physician has been in practice less than two (2) years or has had a hiatus in practice, and during his or her participation with FMC performs the functions of a Primary Care Physician at least fifty percent (50%) of the time in which he/she engages in the practice of medicine. These functions shall include the supervision, coordination and provision of initial and basic care to patients, as well as referring patients for specialist care and maintaining the continuity of their care. 5. Each Primary Care Physician must execute a Provider Agreement under which the Primary Care Provider agrees to provider services to Members of health products, plans or programs issued, administered, or serviced by FMC. 6. Each applicant must fully complete the participation application form, and each applicant and participating Primary Care Physician shall periodically supply to FMC all requested information, including the confidential information forms. B. Office Standards Each Primary Care Physician's medical office must: 1. Have a sign containing the names of all physicians practicing at the office. The office sign must be visible when the office is open. 2. Have a mechanism for notifying members if an Allied Health Professional (i.e., physician assistant, advanced practice nurse, nurse practitioner, nurse midwife) may provide care. 3. Be readily accessible to all patients, including but not limited to its entrance, parking and bathroom facilities. 4. Be clean, presentable, and have a professional appearance. 5. Provide clean, properly equipped patient toilet and hand washing facilities. 6. Have a waiting room able to accommodate at least five (5) patients. 7. Have at least two (2) examining rooms which are clean, properly equipped, and provide privacy for the patient. 8. Have a gynecology table and equipment for pelvic exams for acute conditions (except for pediatric age limit ‐ newborn through 17) 9. Have a no‐smoking policy. 19
10. Have an assistant in office during scheduled hours. 11. Require a medical assistant to attend specialized (e.g., gynecological) examinations, unless the patient declines to allow such assistant to be present 12. Provide evidence that physician has a copy of current licenses for all Allied Health Professionals practicing in the office, including: state professional license, Federal Drug Enforcement Agency and State Controlled Drug Substance (where applicable). 13. Keep on file and make available to FMC any state required practice protocols or supervising agreements for Allied Health Professionals practicing in office. 14. Complete a Location Form, attached hereto, identifying the address (es) and physical location(s) of office(s) C. Coverage 1. Twenty‐four (24) hours‐a‐day coverage for Members must be arranged with another FMC Participating Primary Care Physician except as provided in Section C.4 below. 2. Covering physician office must be located within 25 minutes of the Primary Care Physician office. 3 Inpatient coverage must be arranged with a Participating Physician who has privileges at the same hospital as the covered physician 4. A Primary Care Physician must submit for prior approval by FMC any coverage arrangements made with a nonparticipating Primary Care Physician. Approval of coverage by a nonparticipating Primary Care Physician is subject to FMC’s sole discretion, and such approval must be in writing. If Primary Care Physician receives approval from FMC for coverage by a nonparticipating Primary Care Physician, Primary Care Physician shall require such nonparticipating Primary Care Physician to comply with applicable terms of this Agreement. Primary Care Physician shall make suitable arrangements regarding the amount and manner in which such covering nonparticipating Primary Care Physician shall be compensated, provided, however, that Primary Care Physician shall ensure that the covering physician will not under any circumstances bill Members (except for applicable Copayments, Coinsurance and Deductibles) for any Covered Services. D. Access 1. Each Primary Care Physician’s medical office must throughout the term of participation with FMC, have at least one (1) Primary Care Physician for every three thousand (3,000) active patients, defined as those patients seen within the past two (2) years. 2. Each Primary Care Physician’s medical office must have, at a minimum, twenty (20) hours of regularly scheduled office hours for the treatment of patients (whether Members or other patients) over at least four (4) days per week. 3. If a Primary Care Physician has more than one office location participating with FMC, then the Primary Care Physician must have, at a minimum, twenty (20) hours over at least four (4) days per week of regularly scheduled office hours for the treatment of patients in each location. 4. Each Primary Care Physician or his or her covering Primary Care Physician must respond to a Member within thirty (30) minutes after notification of an urgent call. 5. Each Primary Care Physician must schedule appointments with Members within the following time frames: 
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Emergency care: must be seen immediately (or referred to ER, as appropriate) Urgent complaint: same day or within twenty‐four (24) hours Symptomatic/non‐urgent: acute complaint within three days Routine care: within seven days Preventive routine care: within four weeks Follow‐up visit: within two weeks 20
6. Each Primary Care Physician office must have adequate plans for managing an increase in patient load. 7. Each Primary Care Physician must have a reliable twenty‐four (24) hours‐a‐day, seven (7) days‐a‐
week answering service or machine with a beeper or paging system. A recorded message or answering service which refers Members to emergency rooms is not acceptable. E. Hospital Care 1. At the time of application, a Primary Care Physician must show that during the six (6) months immediately prior to application, he/she had hospital privileges to admit his/her patients on his/her own service, unless such applicant has more recently entered clinical practice or completed his/her residency or fellowship training program. This showing may be in the form of: (a) A letter from the Chief of Staff of the admitting hospital; or (b) A letter from the Chief of Service of the admitting hospital. (c) A letter from the admitting hospital verifying privileges. 2. Throughout the term of the Agreement and participation with FMC, a Primary Care Physician must have admitting privileges in good standing at a Participating Hospital. 3. A Primary Care Physician must admit Members whose conditions require hospitalization to said physician's own service or to the service of a plan participating physician if Member’s condition is within said physician's range of expertise and scope of privileges. 4. Any exceptions to the above must be approved in advance by the applicable network Credentialing Chairperson in accordance with relevant FMC policies and procedures. F. Office Procedures FMC representative must confirm during office site visits that: 1. Primary Care Physician does EKGs (except for pediatric age limit ‐ newborn through age 17) 2. Primary Care Physician does pelvic exams for acute conditions in all offices caring for female Members over the age of seventeen (17). 3. Age appropriate immunizations are provided. 4. Primary Care Physician or staff draws blood in his/her office, uses “finger sticks” for hematocrits and hemaglobin (peds only), or uses a FMC designated laboratory drawing station. 5. Primary Care Physician performs blood glucose monitoring on site. G. Patient Load 1. Each Primary Care Physician practice must agree to and be able to demonstrate the capability to accept a minimum of two hundred and fifty (250) Members. 2. Each Primary Care Physician must designate by age, according to FMC guidelines, those Members for whom the physician will provide care. 3. Any use of an allied health professional (Advanced Practice Nurse or Physicians Assistant) by a Primary Care Physician must comply with FMC’s then current policies and all applicable legal requirements regarding practice of allied health professionals. H. Office Records 1. A Primary Care Physician must demonstrate, at the time of application and thereafter, that his/her medical records are legible, reproducible and otherwise meet FMC’s standards for confidentiality and medical record keeping practices, and that clinical documentation demonstrates comprehensive 21
care. Members’ medical records shall include reports from referred and/or referring providers, discharge summaries, records of emergency care received and such other information as FMC may require from time to time. All records containing patient information must be stored in an anonymous manner. 2. Each Member encounter must be documented in writing and signed or initialed by the Primary Care Physician or as required by state law. I. Professional Liability Insurance 1. During the entire term of this Agreement, Primary Care Physician shall maintain insurance at minimum levels required from time to time by FMC, Primary Care Physician shall maintain the maximum level of professional liability insurance required by law; and (b) comprehensive general liability insurance at a minimum level of $1 million dollars ($1,000,000) per claim and $3 million dollars ($3,000,000) in the annual aggregate. Primary Care Physician’s insurance shall cover the acts and omissions of Primary Care Physicians, as well as Primary Care Physician’s agents and employees. Memorandum copies of such policies shall be delivered to FMC upon request. Primary Care Physician must notify FMC at least thirty (30) days in advance of the cancellation, limitation or material change of said policies.\ J. Philosophy 1. A Primary Care Physician must be supportive of the philosophy and concept of managed care and FMC. A Primary Care Physician shall not differentiate or discriminate in the treatment of or in the access to treatment of, patients on the basis of their status as Members, or other grounds identified in the Agreement. 2. Each Primary Care Physician shall have the right and is encouraged to discuss with his or her patients pertinent details regarding the diagnosis of the patient's condition, the nature and purpose of any recommended procedure, the potential risks and benefits of any recommended treatment, and any reasonable alternatives to such recommended treatment. 3. Primary Care Physician's obligations under the Agreement not to disclose Proprietary Information do not apply to any disclosures to a patient determined by Primary Care Physician to be necessary or appropriate for the diagnosis and care of a patient, except to the extent such disclosure would otherwise violate Primary Care Physician's legal or ethical obligations. 4. Primary Care Physician is encouraged to discuss FMC’s provider reimbursement methodology with Primary Care Physician's patients who are Members, subject only to Primary Care Physician's general contractual and ethical obligations not to make false or misleading statements. II. PROFESSIONAL CRITERIA A. Licensure 1. A Primary Care Physician must have a valid, unencumbered license to practice medicine or osteopathy in his/her state of practice, or in the case of a Primary Care Physician with an encumbered license, the applicant demonstrates to the applicable peer review committee’s satisfaction that encumbered license does not raise concern about possible future substandard professional performance, competence, or conduct. 2. A Primary Care Physician must have an unrestricted DEA certification, and, where applicable, a state‐
mandated controlled drug certification. B. Education 2. A Primary Care Physician must be a graduate of a school of medicine or osteopathy which is accredited by the Liaison Committee on Medical Education and is listed by the Association of American Medical Colleges or the American Osteopathic Association, or in the World Health Organization’s directory World Wide Medical Schools. 22
B. Continuing Education 1. A Primary Care Physician shall meet the continuing medical education requirements of the American Medical Association (AMA), American Osteopathic Association (AOA), American Academy of Pediatrics (AAP), or American Academy of Family Physicians (AAFP), or as required by state law, if greater. Applicants for participation in FMC must demonstrate that they have met such continuing education requirements for the three (3) years immediately prior to submitting his/her application for participation. If an applicant has been in practice less than three (3) years, or has had a hiatus in practice, the applicant need only demonstrate that he/she has met such continuing education requirements during the period of his/her practice. III. PROFESSIONAL COMPETENCE AND CONDUCT CRITERIA A. General 1. Primary Care Physician must be of sound moral character and must not have been indicted, arrested for or charged with, or convicted (i.e., finding of guilt by a judge or jury, a plea of guilty or nolo contendere, participation in a first offender program or any other such program which may be available as an alternative to proceeding with prosecution, whether or not the record has been closed or expunged) of any felony or criminal charge related to moral turpitude or the practice of medicine. 2. Primary Care Physician must not have engaged in any unprofessional conduct, unacceptable business practices or any other act or omission which in the view of the applicable peer review committee may raise concerns about possible future substandard professional performance, competence or conduct. B. Professional Liability Claims History 1. Primary Care Physician must not have a history of professional liability claims, including, but not limited to, lawsuits, arbitration, mediation, settlements or judgments, which in the view of the applicable peer review committee may raise concerns about possible future substandard professional performance, competence or conduct. C. History of Involuntary Termination or Restriction 1. Primary Care Physician must not have a history of involuntary termination (or voluntary termination during or in anticipation of an investigation or dismissal) of employment or any other sort of engagement as a health care professional, or reduction or restriction of duties or privileges, or of a contract to provide health care services, which in the view of the applicable peer review committee may raise concerns about possible future substandard professional performance, competence or conduct. 23
Notification of Adverse Actions or Limitations Date: 07/13/11, 09/08/11, 09/11/12 1. Primary Care Physician shall provide immediate notice to FMC of any adverse action relating to said physician’s (i) hospital staff privileges; (ii) DEA or state narcotics numbers; (iii) participation in the Medicare, Medicaid, or other governmental programs, or (iv) state licensure including censure. Each applicant and Primary Care Physician shall inform the FMC in writing of any previous adverse actions with respect to any of the above. For the purpose of this section, “adverse action” includes, but is not limited to, any of the following or their substantial equivalents (regardless of any subsequent action or expungement of the record): denial; exclusions; fine; monitoring; probation; suspension; letter of concern, guidance, censure, or reprimand; debarment; expiration without renewal; subjection to disciplinary action or other similar action or limitation; restriction; counseling; medical or psychological evaluation; loss, in whole or in part; staff privileges reduced, withheld, suspended, voluntarily surrendered, resigned, revoked or subject to any special provision; termination or refused participation; revocation; administrative letter; non‐renewal; incompetence gross or repeated deviation from the standard of care involving death or serious bodily injury that is dangerous or injurious to any person The use of, prescribing for or self administration of any controlled substance, dangerous drug (as specified), or alcoholic beverages, that is dangerous or injurious to the licentiate, any other person, public, or that the licentiate’s ability to practice safely is impaired by that use; Repeated acts of clearly excessive prescribing, furnishing, administering of controlled substances, repeated acts of prescribing, dispensing, or furnishing of controlled substances without a good faith effort prior examination of the patient and the medical reason for prescribing (note that in no event shall a physician or surgeon who is lawfully treating intractable pain be reported for excessive prescribing). Sexual misconduct with one or more patients during a course of treatment or an examination, voluntary or involuntary surrender of licensure or status to avoid, or in anticipation of, any of the adverse actions listed regardless of whether said action is or may be reportable to the National Practitioner Data Bank or any other officially sanctioned or required registry; and initiation of investigations, inquiries or other proceedings that could lead to any of the actions listed, regardless of whether said action is or may be reportable to the National Practitioner Data Bank or any other officially sanctioned or required registry. Any such adverse actions may be grounds for action, including without limitation denial, termination or other sanctions imposed pursuant to FMC’s credentialing/quality improvement programs. Foundation for Medical Care of Tulare and Kings Counties, Inc. will notify Specific health plan of California of any adverse actions regarding a contracted physician. 2. Primary Care Physician shall provide immediate notice to FMC of any condition or circumstance that impairs or limits his/her ability to perform the essential functions of a Participating Primary Care Physician. 3. Primary Care Physician shall provide immediate notice to FMC of any condition or circumstance of which he/she is aware that may pose a direct threat to the safety of himself/herself, coworkers or patients. 4. Primary Care Physician shall provide immediate notice to FMC and to Members of any condition or circumstance of which he/she is aware which law or regulation requires Primary Care Physician to report. E. References 1. Each applicant for participation must supply references as requested by the applicable FMC peer review committee. 2. The applicable FMC peer review committee shall have the right to act on any reference or information received from a Primary Care Physician's colleagues. Primary Care Physician waives any and all rights to bring any legal action relating to such information or the collection or use thereof against FMC, any Affiliates or related companies or any director, officer, employee or agent thereof, or any person or entity providing a reference or information at the request of the applicable FMC peer review committee. DATE: 11/18/09 12/08/08, 07/15/10, 09/08/11, 09/11/12 24
PCP RESPONSIBILITIES
Primary care services are provided by internal medicine providers, family providers, pediatricians, general providers and obstetricians/gynecologists. Nurse practitioners, physician assistants and certified nurse midwives, under the supervision and direct monitoring of the PCP, may also be included. The scope of service for the Primary Care Physician (PCP) for FMC is defined as noted in the [Health and Safety Code of California (section 1367.69) and existing Knox‐Keene] regulations as physicians who have the responsibility for providing initial and primary care for patients, for maintaining the continuity of patient care, and for initiating referral for specialty care. This includes, but is not limited to, preventive services (as outlined in the current HEDIS clinical indicators), acute and chronic care and to address psychosocial issues. The PCP is responsible for the direction and coordination of the patient’s complete medical care for covered services. The PCP will arrange for laboratory diagnostics, imaging diagnostics, referrals to specialist, hospitalization or any other covered benefit that is medically necessary. A referral is required for cases beyond the scope of expertise and practice of the PCP. RESPONSIBILITIES: 1. The PCP is responsible for providing the majority of and coordinating all the services required for the member, except when emergent circumstances preclude the role of the PCP. 2. The PCP is to provide periodic evaluation of all body systems, including annual health exams, preventive services, acute and chronic care and to address psychosocial issues. (For Medi‐Cal members, the PCP is required to conduct an Initial Health Assessment within 120 days of member’s enrollment with the PCP). 3. For Senior HCFA members, the PCP is required to conduct an Initial Health Assessment within 90 days of members’ enrollment with the PCP. 4. The PCP is required to perform all duties expected of a PCP such as on‐call rotation and/or coverage for emergencies. 5. When care by a Specialist is necessary, the PCP coordinates all services required by the Specialist. 6. The PCP provides those services within the skills of that specialty and obtains authorization for consultations when additional expertise or skills are required. 7. The PCP is expected to relay FMC or health plan decisions in a positive manner. When the purpose of the visit is for a non‐covered service/benefit, the PCP must inform the member that the service is non‐
covered. This needs to be documented in the medical record, and the member must sign a waiver. These responsibilities will be reviewed and revised as necessary, on an annual basis and approved by the Quality Management Committee and Board of Directors. Primary Care Physician Service Guidelines
Listed below, but not limited to, are services considered PCP functions. This is dependent on the level of training the physician has received, the limitations of scope of practice and consistent with State and Federal rules and regulations. These guidelines are based on routine uncomplicated cases that are ordinarily seen by a PCP. 25
Allergy:  Treat seasonal allergies  Treat hives  Treat chronic rhinitis  Allergy history  Environmental counseling  Minor insect bites/stings  Asthma, (chronic/acute) active with or without co‐existing infection Cardiology:  Perform electrocardiograms  Interpret electrocardiograms  Evaluate chest pain, murmurs, palpitations  Evaluate and treat coronary risk factors, including smoking, hyperlipidemia, diabetes, HTN, lifestyle  Evaluate and treat CHF, stable angina, non life‐threatening arrhythmias  Evaluate syncope (cardiac and non‐cardiac) Dermatology: 
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Treat acne (acute and recurrent) Treat painful or disabling warts with topical suspensions, electrocautery, liquid nitrogen Diagnose and treat common rashes including: Contact dermatitis, dermatophytosis, herpes genitalis, herpes zoster, impetigo, pediculosis, pityriasis rosea, psoriasis, seborrheic dermatitis and tinea versicolor  Identify suspicious moles  Screen for basal or squamous cell carcinomas  Biopsy suspicious lesions  Punch Bx  Excisional Bx  Treat Actinic Keratosis  Diagnose and treat common hair and nail problems and dermal injuries. Common hair problems include: fungal infections, ingrown hairs, virilizing causes of hirsutism, or alopecia as a result of scarring or endocrine effects. Common nail problems include: trauma, disturbances associated with other dermatoses or systemic illness, bacterial or fungal infections, and ingrown nails. Dermal injuries include: minor burns, lacerations, and treatment of bites and stings  Counsel patients regarding removal of cosmetic(non‐covered) lesions Endocrinology:  Diabetic management, including Type I and Type II patient  Patient education  Supervision of home testing  Medication management  Diagnose and treat thyroid disorders  Identify and treat hyperlipidemia  Diet instruction  Exercise instruction  Provide patient education for osteoporosis risk factors Gastroenterology: 
Diagnose and treat lower abdominal pain 26
 Diagnose and treat acute diarrhea  Treat protracted vomiting  Occult blood testing  Diagnose and treat heartburn, upper abdominal pain, hiatal hernia, acid peptic disease  Diagnose and treat irritable bowel syndrome  Diagnose and treat chronic jaundice under SPC recommendations  Diagnose and treat chronic ascites under SPC recommendations  Diagnose and treat symptomatic, bleeding or prolapsed hemorrhoids  Manage inflammatory bowel disease under SPC recommendations General Surgery:  Evaluate and follow small breast lumps  Order mammograms  Aspirate cysts  Foreign body removal  Laceration repairs (minor)  Local minor surgery for hemorrhoids  Minor surgical procedures Gynecology: 
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Perform routine pelvic exams and PAP smears Perform lab testing for sexually transmitted diseases Wet mounts Diagnose and treat vaginitis and sexually transmitted diseases Evaluate lower abdominal pain to distinguish gynecological from gastrointestinal causes Diagnose vaginal bleeding Diagnose and treat endometriosis with hormone therapy Manage premenstrual syndrome with non‐steroidal anti‐inflammatory agents, hormones and other symptomatic treatment Hematology:  Initial differential diagnosis of anemias  Hemoglobinopathies Infectious Disease:  Common infectious diseases  Initial evaluation for HIV positive  Viral disorders  Tuberculosis prophylaxis Neurology: 
Diagnose and treat all psychophysiological diseases; headaches, low back pain, myofascial pain syndromes, neuropathies  Diagnose and treat tension and migraine headaches  Treat syncope (cardiac and non‐cardiac)  Treat uncomplicated seizure disorders after SPC neurological evaluation  Manage degenerative neurological disorders with respect to general medical care (i.e., Parkinson's)  Treat stroke and TIA patients  Manage dementia, Alzheimer’s Ophthalmology: 27
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Perform thorough ophthalmologic history including symptoms and subjective visual acuity Perform common eye related services including: Distant/near testing, color vision testing, gross visual field testing by confrontation, alternate cover testing, direct fundoscopy without dilation, extraocular muscle function evaluation, red reflex testing in pediatric patients  Diagnose and treat common eye conditions including: viral, bacterial and allergic conjunctivitis, blepharitis, hordeolum, chalazion, small subconjunctival hemorrhage, dacryocystitis and sty Orthopedics:  Treat low back pain  Treat sprains, strains, pulled muscles, overuse syndromes  Treat inflammatory conditions  Conservative treatment of chronic knee problems  Manage chronic pain problems  Diagnose and treat common foot problems: Ingrown nails, corns/callouses, bunions  Arthrocentesis Otolaryngology:  Treat tonsillitis and streptococcal infections  Perform throat cultures  Evaluate and treat oropharyngeal infections: Stomatitis, Herpes simplex  Treat acute otitis media  Treat serous effusion  Evaluate tympanograms/audiograms  Treat acute and chronic sinusitis  Treat allergic or vasomotor rhinitis  Remove ear wax  Diagnose and treat acute parotitis and acute salivary gland infections  Evaluate neck masses Pulmonology:  Diagnose and treat asthma, acute bronchitis, pneumonia  Diagnose and treat chronic bronchitis  Diagnose and treat chronic obstructive pulmonary disease  Manage home aerosol medications and oxygen  Work up possible tuberculosis or fungal infections  Treat opportunistic infection Rheumatology: 
Diagnose and treat non‐articular muscloskeletal problems: Overuse syndromes, injuries and trauma, soft tissue syndromes, bursitis or tendonitis  Provide steroid injections  Manage osteoarthritis  Diagnose gout, pseudogout  Diagnose and treat rheumatoid arthritis  Diagnose and treat inflammatory arthritic diseases  Diagnose and treat uncomplicated collagen diseases Urology/Nephrology: 
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Diagnose and treat initial and recurrent urinary tract infections Provide long term chemoprophylaxis for recurrent UTI 28
 Diagnose and treat urethritis  Explain hematospermia  Evaluate hematuria  Evaluate incontinence  Diagnose and treat epididymitis and prostatitis  Differentiate scrotal or peritesticular masses from testicular masses  Evaluate prostatism and prostatic nodules  Manage urinary stones  Monitor PSA levels  Post Circumcision Care Vascular Surgery:  Diagnose abdominal aortic aneurysm  Diagnose and treat venous diseases, i.e., DVT, varicose veins, stasis dermatitis  Treat non‐surgical stasis ulcers  Manage intermittent claudication  Manage transient ischemic attacks  Manage asymptomatic bruits Other: 
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Basic life support Heimlich maneuver 29
POLICY: RECREDENTIALING POLICY AND PROCEDURE DATE: 11/18/09, 07/15/10, 09/08/11, 09/11/12 A practitioner is considered to be credentialed as of the date of the initial credentialing decision. A practitioner must be re‐credentialed within 3 years (3 years as of November 2001, prior to November 2001, the cycle was 2 years) to the month of the date of the initial credentialing. A practitioner cannot be initially credentialed or early re‐credentialed if their previous re‐credentialing is past due. If a practitioner is re‐credentialed at a time that is not consistent with the standard cycle due to a system wide problem, the reason for the variance must be documented in the credentialing minutes at the time of the onsite audit. Prior to the provider being presented for re‐credentialing committee review and every three years thereafter, an FMC Credentials Verification Unit or Delegated Entity will verify with Primary the following data obtained from the Provider Application and supporting documentation Sources (sources and methods of verification are as described in section I ‐ Credentialing I. ‐ Criteria and Primary Source Verification section): 
Valid, current, unencumbered license for the state(s) in which the applicant will provide care for FMC members  Valid, current, unencumbered Drug Enforcement Agency (DEA) drug registration, or evidence that the applicant does not require registration in order to deliver appropriate care.  Board Certification by a board recognized by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) if the practitioner states he/she is board certified on application. FMC verifies board certification through Certi‐Facts. 
History of any disciplinary or adverse action/s related to provider's:  Licensure;  DEA or state narcotics registration;  hospital or other clinical privileges;  managed care participation;  other professional association; or  Hospital privileges at the primary participating admitting facility.  The Credentialing Staff will verify that the applicant has provided FMC with:  copies of current state controlled drug certificate, where required.  copies of current professional liability coverage in amounts satisfactory to FMC.  evidence that there have been no unexplained breaks in at least the last five years of work history. For providers who have gaps in work history of 6 months or more should be clarified orally with provider and documented and dated as verbal verification. Any gaps that exceed one year must be clarified in writing.  Liability Claims History  A current attestation form as to the correctness of above information.  Provider performance monitoring from QM data  Member Complaints  Ongoing monitoring from other areas This information will be audited on all re‐credentialed providers. 30
The Credentialing staff will gather further documentation for providers who:  have a history of Adverse Actions, professional liability claims history, and  items to which a “Yes” response is indicated on the Confidential Information page of the Provider Application. If during the re‐credentialing process information is found to vary substantially from that provided by the practitioner the Credentialing staff will notify the provider of their right to review the erroneous data. If the practitioner provides data that does conflict with the data FMC received, FMC will notify the agency that provided the data of the erroneous information. Reporting Requirements Foundation for Medical Care of Tulare and Kings Counties, Inc. shall comply with reporting requirements of the Medical Board of California and the National Practitioner Data Bank as required by law. Foundation for Medical Care of Tulare and Kings Counties, Inc. shall comply with the reporting requirements of the California Business and Professions Code and the Federal Healthcare Quality Improvement Act regarding adverse credentialing and peer review actions. The provider will be notified of the report and its contents. Documentation of malpractice history, explanations of adverse actions, work history and any other credentialing information will be gathered to the providers last credentialing date. Behavioral health providers are re‐credentialed following the same criteria as medical providers, with emphasis on member complaints and QI monitoring activities. Information on physicians will be gathered from the National Practitioner Data Bank, state medical board and Medicare and Medi‐cal regarding sanctions on licensure or actions taken. All verifications are subject to the standard 180 day time limit. Primary verification documentation and checklist will be assembled by the Credentialing staff. Credentialing staff will prepare re-credentialing files, assemble provider performance data as available
and applicable for Credentialing Chairperson review. Once the Chairperson reviews the data the files are
ready for Committee review. This includes:
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results of any office site visits, utilization management data, member satisfaction and complaint data, and quality management data ongoing monitoring from other areas In addition, credentialing staff will conduct ongoing monitoring of any sanctions (Medicare/Medi‐Cal) or member via monthly review of “Hot Sheets”. Any adverse information received via this method will result in a letter to the provider requesting further information, and upon receipt of that information, appropriate action will be taken by the chairman of the committee. Sanctions will be reviewed within 30 days of receipt. Practitioner specific complaints will be investigated on receipt and will be tracked/trended for review as part of the re‐credentialing process. Every 6 months the practitioner file will be reviewed for number of complaints, type of complaints and findings. The review will be based on the date of initial credentialing or re‐credentialing, which ever is more current. 31
The files of providers who do not meet Foundation for Medical Care of Tulare and Kings Counties, Inc. Participation Criteria and DEA/CDS are to be reviewed by the credentialing chairperson. They do not need to be presented for peer review. Providers who do not have current licensure to practice as a physician are automatically disqualified from participation and do not go before the credentialing chairperson or credentialing/peer review committee. All applicants who meet Foundation for Medical Care of Tulare and Kings Counties, Inc. Participation Criteria and hav
a current license must be presented to the credentialing committee for peer review of Professional Competence and
Conduct. All data must be current at the time of credentialing committee review, i.e., not older than 180 days from the date of the provider’s signature on the application to the date the file is completed and approved by the credentialing/peer review committee. The office site visit must be completed within twenty four months prior to the credentialing decision regarding OB/Gyn applicants to the network and within twenty four months prior to each re‐credentialing decision of the credentialing committee for OB/Gyn specialists and High Volume Specialists. License renewal is verified at the time of license expiration for all providers between credentialing cycles. RE‐CREDENTIALING OF PROVIDERS ON SABBATICAL: Verification of an active license to practice medicine must be obtained for providers who have not been actively practicing as part of the medical group due to military assignment, maternity leave or a sabbatical prior to the physician resuming care of members. Re‐credentialing must take place within 60 days of when the practitioner resumes practice. If the termination is 30 days or less, the practitioner can be credentialed prior to rejoining the IPA. ADMINISTRATIVE TERMINATION: Date: 05/03/11, 09/8/11 If a practitioner is given administrative termination for reasons beyond the organization’s control (e.g., the practitioner failed to provide complete credentialing information), and is then reinstated within 30 calendar days, the organization may recredential the practitioner as long as it provides documentation that the practitioner was terminated for reasons beyond its control and was recredentialed and reinstated within two calendar days of termination. Practitioners that are reinstated more than 30 calendar days after termination must complete the initial credentialing process. 32
A. Review by Credentialing Chairperson Once the Credentialing Staff has: (a) reviewed the provider's application for continued participation for completeness; and (b) determined that the provider appears to meet the FMC Professional Criteria, the provider's application will be forwarded to the Credentialing Chairperson. The Credentialing Chairperson will review the application for compliance with Foundation for Medical Care of Tulare and Kings Counties, Inc. criteria. 1) If, after the Credentialing Staff and/or the Credentialing Chairperson have performed any further investigation that, in their discretion, may be appropriate under the circumstances, the Credentialing Chairperson determines that the provider appears to meet the Participation Criteria, the Credentialing Chairperson will forward the provider’s re‐
credentialing file to the Credentialing Committee, along with his/her determination that the provider appears to have met the Participation Criteria. After review the files are ready for the Committee review. 2) If, after the Credentialing Staff and/or the Credentialing Chairperson have performed any further investigation that, in their discretion, may be appropriate under the circumstances, the Credentialing Chairperson determines that the Participation Criteria have NOT been met by the applicant and, provided that NONE of the reason(s) the Participation Criteria have not been met are related to Professional Competence and Conduct, the Credentialing Chairperson will notify the provider, in writing, that his/her application has been denied and that his/her participation agreement will be terminated, in accordance with its terms. The provider will be informed of the specific Criteria not met. The Credentialing Chairperson shall have discretion to overturn this determination if the provider responds within thirty (30) calendar days correcting any factual discrepancies or correctable deficiencies. However, the provider will not be afforded a review by the Credentialing Committee or any other appeal. 3) If, after the Credentialing Staff and/or the Credentialing Chairperson have performed any further investigation that, in their discretion, may be appropriate under the circumstances, the Credentialing Chairperson determines that the Participation Criteria have NOT been met, and provided that ANY of the reason(s) the Participation Criteria have not been met is/are related to Professional Competence and Conduct, the Credentialing Chairperson will forward the provider's file to the Credentialing Committee for review/determination. 4) If, after the Credentialing Staff and/or the Credentialing Chairperson have performed any further investigation that, in their discretion, may be appropriate under the circumstances and have taken appropriate steps under any applicable risk management practices, the Credentialing Chairperson determines, in his/her sole discretion, that the provider's continued participation in the network could pose a threat of imminent harm to the health or safety of patients, the Credentialing Chairperson shall have the ability to immediately suspend the provider's network participation for thirty (30) days, or for such longer period of time as may become necessary under the circumstances. In such event, the Credentialing Chairperson will notify the provider of the suspension and the specific Participation Criteria which served as the basis for the suspension, by certified mail or overnight carrier, return receipt requested. The notice will inform the provider that he/she has the right to request a review of the suspension decision, by the Credentialing Committee, by submitting a response, in writing, within thirty (30) calendar days of the date of the Credentialing Chairperson's notice. The provider will also be informed that he/she may submit any additional information that he/she would like to have considered by the Credentialing Committee. The provider will be informed that failure to respond within the thirty (30)‐day time frame will result in the immediate termination of his/her network participation without further review or appeal . While such suspension is in effect, the provider will not be authorized to provide services, as a participating provider, to any Members. (Exceptions, if any, to the prohibition on providing services during such a suspension may be made in certain circumstances (in accordance with FMC’s policies and/or practices), but only after any Member who is to receive such services has been informed that the provider is no longer participating in the network and has given his/her consent to continued treatment by the provider.) (a) If the provider fails to respond within the thirty (30)‐day time frame, the provider's network participation will be terminated. The Credentialing Chairperson will send a notice of termination to the provider; such notice will inform the provider that his/her participation is terminated immediately and that he/she is not entitled to further review or appeal. (b) If the provider responds within the thirty (30)‐day time frame, the provider's file, including the provider's response and any additional information he/she has submitted, will be forwarded by the Credentialing Chairperson to the Credentialing Committee. 33
B. Review by Credentialing Committee Upon receipt from the Credentialing Chairperson, the Credentialing Committee will review the provider for compliance with the Professional Competence and Conduct Criteria for the applicable type of provider. The Credentialing Committee should not make any determinations regarding Participation Criteria that are not Professional Competence and Conduct Criteria. 1) If the Credentialing Committee determines that the provider appears to meet the HMO's Professional Competence and Conduct Criteria for the applicable type of provider, the Credentialing Committee will communicate its decision to local network management staff who will, provided that all other Participation Criteria appear to have been met, notify the provider, in writing, that his/her application for continued network participation has been accepted within 15 days of the determination. However, if the other Participation Criteria are not met, the Credentialing Chairperson will inform the provider of the specific criteria not met, and will notify the provider that his/her participation agreement will be terminated in accordance with its terms. The Credentialing Chairperson shall have discretion to overturn this determination if the provider responds within thirty (30) days correcting any factual discrepancies or correctable deficiencies. However, the provider will not be afforded any further review or appeal. 2) If the Credentialing Committee determines that the provider does NOT meet the HMO's criteria for the applicable type of provider, the Credentialing Committee may make one of the following decisions regarding the provider's continued network participation: (a) The provider's application for continued network participation may be denied. The provider will be permitted to continue providing services under his/her participation agreement, pending exhaustion of the appeals process. (b) In the event that the Credentialing Committee determines, in its sole discretion, that the provider's continued participation in the network could pose a threat of imminent harm to the health or safety of patients, the Credentialing Committee shall have the ability to immediately suspend the provider's network participation for thirty (30) days, or for such longer period of time as may become necessary under the circumstances. The provider may appeal such determination as described in the appeals section of this policy; however, while such suspension is in effect, the provider will not be authorized to provide services, as a participating provider, to any Members. (Exceptions, if any, to the prohibition on providing services during such a suspension may be made in certain circumstances (in accordance with the FMC's policies and/or practices), but only after any Member who is to receive such services has been informed that the provider is no longer participating in the network and has given his/her consent to continued treatment by the provider.) (c) The Credentialing Committee may institute a corrective action plan for the provider. A corrective action plan may not reduce, restrict, suspend, revoke, deny or fail to renew the provider's network participation. A corrective action plan may include, but not be limited to, the following: (i) training and/or education; (ii) chart reviews and/or audits; or (iii) Credentialing Chairperson and/or Credentialing Staff site visits. A corrective action plan may not include intensive review of individual patients' care or specific procedures. A corrective action plan must include a time frame for the Committee’s review of the provider’s compliance with such plan. (d) In conjunction with instituting a corrective action plan, the Credentialing Committee may impose an Administrative Freeze of the provider’s participation with the HMO. An “Administrative Freeze” means that the provider may not accept new members who are not already in the provider’s panel or being treated by the provider. However, Administrative Freezes must be time‐limited, and unless extenuating circumstances are present, an Administrative Freeze shall not be longer than three (3) to six (6) months. At the end of the time period of the Administrative Freeze, the Credentialing Committee must review the provider’s compliance with the corrective action plan, and determine whether the provider may continue participation or whether further sanctions are appropriate. Except under certain extenuating circumstances, the Credentialing Committee may impose only one Administrative Freeze on a provider for the conduct in question. 3) The HMO may appoint to the Credentialing Committee, as ad hoc voting member(s), participating providers practicing in the provider's general area of specialty, for the purpose of reviewing the provider's application for continued participation. Any voting member of the Credentialing Committee who is in direct economic competition with the provider, who is in a position to benefit financially from the outcome of the hearing, or 34
who is otherwise involved in circumstances that could be construed as a conflict of interest (financial or otherwise), shall recuse himself/herself from all deliberations and voting affecting such provider. POLICY: MD OFFICE SITE VISITS DATE: 05/11/2010, 07/15/10, 09/08/11, 09/11/12 Foundation for Medical Care of Tulare and Kings Counties, Inc. has a process for ensuring that offices of all contracted physicians follow standard practices for maintaining their offices. All site visits are performed by licensed healthcare professionals. Site visits will be performed if there are 1 or more complaints regarding the physical site. Complaints will be logged onto a spreadsheet that will be kept by the credentialing coordinator. Issues that will require a site visit can include: Handicap accessibility issues‐ access into the building and within the building itself. Adequacy of space including waiting room seating and number of examining rooms per practitioner Cleanliness and orderliness‐including cleanliness, lighting and safety Posted office hours Record keeping‐ record orderliness, security, confidentiality and documentation practices. Other issues as brought to the attention of Foundation for Medical Care of Tulare and Kings Counties, Inc. that are of concern (To be determined in an individual basis at the discretion of FMC staff). At the time of the site visit additional evaluations will be made. These include: Availability of appointments‐ To be within ICE guidelines for physician accessibility. Adequacy of equipment (Fire protection equipment is up‐to‐date, accessible and in working order, Refrigerator thermometer temperature is maintained and documented daily at 35° ‐ 46° Fahrenheit, Medications are stored in a separate refrigerator from food, drinks, and personal items, Radiology technologist(s) license(s) is/are current, Radiology equipment maintenance documentation is current, Routine maintenance of autoclave is documented, Cold chemical sterilization containers are dated) Medical record keeping (Patient medical records have a secure/confidential filing system, Patient medical records have legible file markers, Forms and methodology for filing within a chart is consistent, Patient medical records can be easily located, Refusal of interpretation services is documented in the chart, if applicable) An office will be considered deficient if any of these areas are not adequate at the time of the visit. The Physician’s office and Foundation for Medical Care of Tulare and Kings Counties, Inc. identify any deficiencies and a plan is formulated to correct them. Any complaints that require action on the part of the health plan will be forwarded to them immediately after the office site visit or confirmation of a potential issue. Evaluation of the effectiveness of the plan is done at least every 6 months until the deficiencies are corrected. If deficiencies are not corrected in a timely manner, the credentialing committee will be notified and will review the deficiencies for action. NON‐MEDICARE ACCREDITED ORGANIZATION SITE VISITS If Foundation for Medical Care of Tulare and Kings Counties, Inc. contracts with non‐medicare organizations to provider ancillary care, such as therapy services site visits will be preformed every 36 months (3 years). SITE EVALUATIONS/MEDICAL RECORDS AUDIT
Date: 11/18/09, 07/15/10, 09/08/11, 09/11/12 PURPOSE: To assess the quality, safety and accessibility of office sites and medical record-keeping practices where
healthcare is delivered
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This policy applies to all practitioners within the scope of credentialing and establishes the standards and
thresholds for office site criteria and medical record-keeping practices.
All site reviews will be performed by a healthcare professional holding at least current LVN California licensure.
The site visit review and medical record‐keeping practices will include the standards and thresholds for each of the following elements: Physical Accessibility ‐ Accommodations for persons with disabilities  Adequacy of waiting and examining room space ‐ Adequate waiting room seating ‐ Adequate number of examining rooms per practitioner  Physical appearance ‐ Cleanliness and orderliness ‐ Well‐lit waiting areas ‐ Posted office hours  Availability of appointments Appointments for Internists, General and Family Practitioners, Pediatricians and Gynecologists/ Obstetricians: o Routine office visits are available within seven (7) days o Urgent care visits are available with twenty‐four (24) hours o Physical examinations available within thirty (30) days  Adequacy of equipment ‐ Current fire extinguisher ‐ Current and complete Emergency resuscitation unit (crash cart) ‐ Refrigerator housing specimens and medications is at the correct temperature and is separate from food and personal items ‐ Sterilization equipment ‐ Current certifications for imaging equipment ‐ Separate container(s) for needle disposal  Adequacy of medical/treatment record keeping ‐ Secure/confidential filing system ‐ Forms and methods for consistency (orderliness) o Patients identified on each sheet in record o Biographical data present o Allergies and adverse medical reactions, appropriate record of past medical history, completed immunization record, laboratory and other studies and consultative records (if appropriate) are present /displayed o Evidence that advance directive information has been made available to the patient o Provider signature on each visit/report in the record and all entries dated and legible ‐ Records easily located Performance Thresholds: 
The performance threshold for the Office Site Visit is a score of 87%. The performance threshold for the Medical Record‐Keeping review is 87%. Member complaints of practitioner offices: Member complaints related to the quality of all practitioner office sites will be monitored and investigated when received. Foundation for Medical Care of Tulare and Kings Counties, Inc. has established a threshold of conducting an office site visit upon the receipt of 1 complaints. When 1 complaints are received related to physical accessibility, physical appearance and adequacy of waiting or examining room space, a site visit will be performed within sixty (60) days of the complaint to assess the elements listed. 
When a site does not meet Foundation for Medical Care of Tulare and Kings Counties, Inc. performance thresholds, the site must develop an action plan for improvement. 36
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Foundation for Medical Care of Tulare and Kings Counties, Inc. will revisit the site at least every six (6) months until the performance standards are met. Documentation of these revisits will be included in the practitioner/practitioners file/files. 
Foundation for Medical Care of Tulare and Kings Counties, Inc. will record all information gathered from the above mentioned site visits in the provider credentialing file which will be accessible to all applicable staff, additionally these results will be reported at the Credentials Committee Meeting at that time. 
Foundation for Medical Care of Tulare and Kings Counties, Inc. will monitor member grievances/complaints related to the quality of practitioner office sites on all applicable practitioners within the Foundation for Medical Care of Tulare and Kings Counties, Inc. network, every 6 months. 
Foundation for Medical Care of Tulare and Kings Counties, Inc. will conduct and document a follow up office site audit of a previously deficient office if the practice site is identified as meeting the reasonable grievance/complaint threshold subsequent to correcting the previously identified deficiencies. Requirements for the qualifications of staff who conduct audits: 
Must have previous clinical or provider relations experience in medical/surgical, ambulatory care, Health Plan, IPA or medical group environment and must have knowledge of regulatory and accreditation standards and guidelines such as DHS, NCQA and CMS. Auditor must hold at minimum a current LVN license in the state of California. 
Must be willing to travel and must maintain adequate auto insurance. 
Must possess strong communication skills, both verbal and written. 
Must have strong organizational skills, be able to complete the ICE California Shared Commercial & Medicare Provider Office Survey and Corrective Action Plan audit tool and follow‐up on the CAP. 
Must understand how to document accurately and appropriately on the ICE California Shared Commercial and Medicare Provider Office Survey and Corrective Action Plan. 
Staff will meet, at least quarterly, to address any areas of concern. Training of staff which will be conducted on the office site audits: 
Staff will be trained on what to look for when conducting a facility audit and how to properly document its findings. 
Staff will be trained on how to properly complete the ICE California Shared Commercial and Medicare Provider Office Survey and Corrective Action Plan tool and follow‐up on offices requiring CAPs. 
Any new staff to conduct audits will be personally trained by the current auditor and will accompany the existing auditor on a few audits prior to doing audits on their own. 37
POLICY: Medical Record Documentation Date: 11/18/09, 07/15/10, 09/08/11, 09/11/12 Purpose: To ensure that the contracted provider medical offices have established medical record documentation procedures consistent with state and federal regulatory and accrediting agency standards. Policy: It is the policy of Foundation for Medical Care of Tulare and Kings Counties, Inc. to ensure that medical record documentation standards facilitate timely communication of clinical information, coordination and continuity of care, and promotes efficient and effective treatment, consistent with state and federal regulatory and accrediting agency standards. Foundation for Medical Care of Tulare and Kings Counties, Inc. will establish medical record thresholds which will be reviewed at least every two years. Regular policy compliance oversight will be conducted by Foundation for Medical Care of Tulare and Kings Counties, Inc., and corrective action instituted as needed. Responsibility: Quality Management and contracted Practitioners/Practitioner Office Staff Procedure: 
Foundation for Medical Care of Tulare and Kings Counties, Inc. will develop standards and performance thresholds for medical record documentation as follows:  Problem list  Allergies and adverse reactions or a notation of no known allergies or history  Medications including dosages and dates of initial or refill prescriptions  History and physical  Documentation of clinical findings and evaluation for each visit  Preventive services/risk screening  Member identification  Identification for all practitioners participating in member’s care  Information on advance directives  All services provided directly by a PCP  All ancillary services and diagnostic tests ordered by a practitioner  All diagnostic and therapeutic services for which a member was referred by a practitioner. Examples include: ‐ Home Health Nursing reports ‐ Specialty Physician reports ‐ Hospital Discharge reports ‐ Physical Therapy reports 
Foundation for Medical Care of Tulare and Kings Counties, Inc. documentation will include:
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Personal information must include name, address, DOB, home, work or contact phone number. Each page of the medical record will include a unique identifier, which may include patient ID number, medical record number, first and last name. Emergency contact for children can be the parent’s home/work number, or any number where the parents can be reached. For adults, the number of a friend or relative, beeper number or any number where a contact may be reached and/or a message left is sufficient. 38
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All services provided by the PCP, as well as diagnostic and therapeutic services for which a member was referred by a practitioner will be documented Each medical record will contain the ID of all practitioners/providers participating in the patient’s care, and information on services they render. All entries in the medical record will contain the author’s identification (may be a handwritten signature, an “initials” stamped signature or a unique electronic identifier. All entries in the medical record will be dated. All entries in the medical record will be legible to someone other than the writer. A problem list of all the member’s chronic/significant illnesses (inclusive of behavioral health), will be maintained and dated. A chronic problem is defined as one which is of long duration, shows little change or is of slow progression. Absence of chronic problems will be noted on the problem list. Medication allergies and adverse reactions will be prominently noted in the medical record. If the member has no known allergies or history of adverse reactions, this is appropriately noted in the medical record. Medications must be listed and updated as necessary with dosage changes and the date the change was made. All medications, prescribed and over‐the‐counter, taken on an ongoing basis, will be noted in the medical record. The drug, dose, route, duration, dates of initial ore refill prescriptions, and quantity of all prescribed medications will be noted. Ongoing medications that have been discontinued sine the last visit will be noted. Past medical history (for members seen >/=3 times) is easily identified and includes serious accidents, operations, and illnesses. For children and adolescents (</=18 years), past medical history relates to prenatal care, birth, operations, and childhood illnesses. For members >/= 14 years, there is appropriate notation concerning the use of cigarettes, ETOH, and substances (for members seen >/= 3 times, substance abuse history is queried). History and physical exam identifies appropriate subjective and objective information pertinent to the member’s presenting complaints. Documentation of clinical findings and evaluation for each visit. Laboratory and other studies are ordered, as appropriate. Working diagnoses are consistent with findings. Treatment plans are consistent with diagnoses and care is medically appropriate Treatment consents are appropriately documented. Risk factors for the member relevant to the particular treatment are noted. Encounter forms or notes have a notation, when indicated, regarding follow‐up care, calls, or visits. The specific time of return is noted in weeks, months, or as needed. Missed/Failed appointments are tracked to ensure appropriate medical care and monitor member non‐
compliance. “No Show”, “Rescheduled” or “Canceled” is noted in the medical records, as applicable. Practitioner documents intervention in the medical record. Member calls after hours are documented in the medical record. Unresolved problems from previous office visits are addressed in subsequent visits. There is documentation of appropriate use of consultants, and if a consultation is requested, there is a consultant note in the medical record. All ancillary services and diagnostic tests ordered by the practitioner – e.g. consultation, lab, and imaging reports, are documented, filed in the medical record, and initialed by the ordering physician to signify review. Consultation, abnormal lab, and imaging study results have an explicit notation in the medical record of follow‐
up plans. Children and adult immunization records are complete and current. There is evidence that risk/preventive screening and services are offered in accordance with Anthem Specific health plan’ preventive care and practice guidelines. Health maintenance flow sheets may be utilized. Practitioners making referrals will transmit necessary information to practitioners receiving referrals (i.e., specialist consultant reports). Practitioners furnishing a referral service will report appropriate information to the referring practitioner. The record contains referral notes from medical practitioners to behavioral health practitioners (as applicable) and documented evidence of clinical feedback (i.e., consultation report inclusive of diagnosis, treatment plan, 39
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and psychopharmacological medication, as applicable) from the behavioral health practitioners to the medical practitioners.  Each medical record contains documented evidence of PCP use of behavioral health practice guidelines (if applicable).  Each adult (defined as >/= 18) medical record contains Advance Directive information, and evidence that this was discussed with member.  Pertinent inpatient records must be maintained in the office medical record. These records may include but are not limited to the following: history and physical, surgical procedure reports, ER reports and/or discharge summaries.  For Senior Service Members: There are no charges for medical record and information transfers. Foundation for Medical Care of Tulare and Kings Counties, Inc. will allow any adult member who inspects their medical record to have the right to provide to the healthcare practitioner a written addendum with respect to any item or statement in his or her record that the member believes to be incomplete or incorrect. Members must have timely access to all of their medical records and health information in accordance with federal and state law. There must be timely Confidential exchange of information between professionals Examples: ‐ Medical charts from old PCP to new PCP ‐ Reports sent between PCP and SCP Foundation for Medical Care of Tulare and Kings Counties, Inc. will establish criteria for medical record documentation compliance thresholds for all applicable practitioners within its network. Foundation for Medical Care of Tulare and Kings Counties, Inc. will conduct medical record documentation compliance audits every 2 years on all primary care practitioners within its network who are identified as performing poorly in this area. ‐ Identification of primary care practitioners to conduct focused audits on may include: ‐ Assessment of practitioner records that did not pass HEDIS or other audits. ‐ Assessment of practitioner records identified as having previous documentation deficiencies. Foundation for Medical Care of Tulare and Kings Counties, Inc. will provide evidence that assessments of primary care practitioners are conducted at least every two years for compliance with established medical record documentation standards and performance thresholds. For practitioners that do not meet established performance thresholds, Foundation for Medical Care of Tulare and Kings Counties, Inc. institutes corrective actions which may include: ‐ 
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Distribute examples of best practices or blinded records that meet the Provider Group’s standards to practitioners. ‐ Publish best practices for medical record documentation in the practitioner newsletter. ‐ Assess the sample of records selected for a review of HEDIS measures against Provider Group standards and identify deficiencies. ‐ Assess a sample of practitioner records that did not pass HEDIS or other audits. ‐ Review a sample of medical records based on a practitioner’s volume of members, past documentation deficiencies or other criteria. Foundation for Medical Care of Tulare and Kings Counties, Inc. will conduct focused follow‐up audits on those practitioners that did not meet established compliance thresholds. Foundation for Medical Care of Tulare and Kings Counties, Inc. will distribute its medical record documentation policies and procedures to all applicable practitioners and appropriate staff members within its network ‐ Distribution may be via practitioner manual, practitioner newsletter, Intranet or Internet. Reference Sources: NCQA CR 6.A.2, QI 12.A.1‐4, 12.B; 42 CFR § 422.112(b)(4)(ii) 40
SAMPLE MEDICAL DOCUMENTATION AUDIT TOOL
Physician Name:
Physician Site Address:
Auditor Name:
Auditor Address:
PG Name:
PG Address:
Physician Phone:
Physician License #:
Home Office? [ ] Yes [ ] No
Multiple MD site? [ ] Yes [ ] No
Auditor Phone:
Auditor Signature:
Audit Date/Time:
Initial Audit [ ]
1st F/U Audit [ ]
2nd F/U Audit [ ]
Medical Record Documentation
Medical Record #
Y
N
N/A
A. Medical Record Documentation Standards Policy and Procedure
B. Documentation
1. Includes appropriate personal information
2. Each page includes an appropriate unique identifier
3. Includes emergency contact information
4. All practitioner/providers treating patient are identified
5. All entries include the author’s identification
6. All entries are dated
7. All entries are legible to auditor
8. Problem List
9. Drug allergies/adverse reactions
10. Prescribed medications
11. Past medical/Behavioral Health history
12. Cigarettes, ETOH, Substances Use
13. History and exam identifies appropriate information
14. Appropriate Lab/Studies ordered
15. Working diagnosis consistent with findings
16. Treatment plan documented and consistent with diagnosis
17. Treatment consents are appropriately documented
18. F/U care indicated, as needed
19. Missed/Failed appoints are tracked
20. Member calls after hours are documented
21. Unresolved issues are addressed in subsequent visits
22. Appropriate use of consultants
23. MD initials reports
24. Children and adult immunization records are complete and current
25. Evidence of use of Medical and Behavioral Health practitioner guidelines
26. Evidence of appropriate, timely communication between treating
practitioners
27. Each adult (defined as >/=18) MR contains an Advance Directive
28. Pertinent inpatient records are maintained
29. Senior Service members are not charged for MR transfers
COMMENTS:_______________________________________________
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SAMPLE MEDICAL DOCUMENTATION AUDIT TOOL REVIEWER GUIDELINES
I.
ADMINISTRATIVE POLICIES AND PROCEDURES
A. Copies of these written policies and procedures should be on‐site and staff should verbalize familiarity and compliance with administrative procedures. See Sample associated policies and procedures. The medical office should have written policies and procedures with similar criteria. II.
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There is evidence that staff receive orientation/training about P&Ps relevant to their job description. 2.
There is evidence of compliance with HIPAA privacy regulations, including evidence that the disclosure of privacy practices is signed by patient and posted. MEDICAL RECORD DOCUMENTATION
A. Auditor to verify that office has medical record documentation standards policy and procedure with acceptable criteria. B. Documentation ‐ Auditor to verify through review of 3 medical records. If no medical records, auditor to review based on sample audit record and P&P) 1.
Personal information must include name, address, DOB, home, work or contact phone number. 2.
Each page of the medical record will include a unique identifier, which may include patient ID number, medical record number, first and last name. 3.
Emergency contact for children can be the parent’s home/work number, or any number where the parents can be reached. For adults, the number of a friend or relative, beeper number or any number where a contact may be reached and/or a message left is sufficient. 4.
Each medical record will contain the ID of all practitioners/providers participating in the patient’s care, and information on services they render. 5.
All entries in the medical record will contain the author’s identification (may be a handwritten signature, an initials stamped signature or a unique electronic identifier. 6.
All entries in the medical record will be dated. 7.
All entries in the medical record will be legible to someone other than the writer. 8.
A problem list of all the member’s chronic/significant illnesses (inclusive of behavioral health), will be maintained and dated. A chronic problem is defined as one which is of long duration, shows little change or is of slow progression. Absence of chronic problems will be noted on the problem list. 9.
Medication allergies and adverse reactions will be prominently noted in the medical record. If the member has no known allergies or history of adverse reactions, this is appropriately noted in the medical record. 10. Medications must be listed and updated as necessary with dosage changes and the date the change was made. All medications, prescribed and over‐the‐counter, taken on an ongoing basis, will be noted in the medical record. The drug, dose, route, duration and quantity of all prescribed medications will be noted. Ongoing medications that have been discontinued sine the last visit will be noted. Dates of initial and refill prescriptions will be noted. 11. Past medical/Behavioral Health history (for members seen >/=3 times) is easily identified and includes serious accidents, operations, and illnesses. For children and adolescents (</=18 years), past medical history relates to prenatal care, birth, operations, and childhood illnesses. 42
12. For members >/= 14 years, there is appropriate notation concerning the use of cigarettes, ETOH, and substances (for members seen >/= 3 times, substance abuse history is queried). 13. History and physical exam identifies appropriate subjective and objective information pertinent to the member’s presenting complaints. 14. Laboratory and other studies are ordered, as appropriate. 15. Working diagnoses are consistent with findings. 16. Treatment plans are consistent with diagnoses and care is medically appropriate 17. Treatment consents are appropriately documented. Risk factors for the member relevant to the particular treatment are noted. 18. Encounter forms or notes have a notation, when indicated, regarding follow‐up care, calls, or visits. The specific time of return is noted in weeks, months, or as needed. 19. Missed/Failed appointments are tracked to ensure appropriate medical care and monitor member non‐
compliance. “No Show”, “Rescheduled” or “Canceled” is noted in the medical records, as applicable. Practitioner documents intervention in the medical record. 20. Member calls after hours are documented in the medical record. 21. Unresolved problems from previous office visits are addressed in subsequent visits. 22. There is documentation of appropriate use of consultants, and if a consultation is requested, there is a consultant note in the medical record. 23. Consultation, lab, and imaging reports, filed in the medical record, are initialed by the ordering physician to signify review. Consultation, abnormal lab, and imaging study results have an explicit notation in the medical record of follow‐up plans. 24. Children and adult immunization records are complete and current. 25. There is evidence of use of Anthem Specific health plan’ behavioral health practice guidelines. Health maintenance flow sheets may be utilized. 26. Practitioners making referrals will transmit necessary information to practitioners receiving referrals (i.e., specialist consultant reports). Practitioners furnishing a referral service will report appropriate information to the referring practitioner. The record contains referral notes from medical practitioners to behavioral health practitioners (as applicable) and documented evidence of clinical feedback (i.e., consultation report inclusive of diagnosis, treatment plan, and psychopharmacological medication, as applicable) from the behavioral health practitioners to the medical practitioners. 27. Each adult (defined as >/= 18) medical record contains Advance Directive information, and evidence that this was discussed with member. 28. Pertinent inpatient records must be maintained in the office medical record. These records may include but are not limited to the following: history and physical, surgical procedure reports, ER reports and/or discharge summaries. 29. Senior Service Members are not charged for medical record and information transfers. 43
DOCUMENTATION AUDIT CORRECTIVE ACTION PLAN Practitioner Name: _______________________________________________
Affiliated PG: ____________________________________________________ Audit Date: 11/18/09 ______________________________________________________ Auditor Name: ___________________________________________________ Date CAP Sent to Practitioner: _____________________________________ AUDIT CATEGORY AND INDICATOR AREA REQUIRING IMPROVEMENT RE‐EVALUATION DATE CAP/RESPONSIBLE PERSON 44
POLICY: Office Site Evaluations Date: 11/18/09, 07/15/10, 09/08/11, 09/11/12 Purpose: Foundation for Medical Care of Tulare and Kings Counties, Inc. has a process to ensure that the offices of all practitioners’ meet its office‐site standards Policy & Procedures: 
Foundation for Medical Care of Tulare and Kings Counties, Inc. will assess for sites who meet “1” threshold for complaints of Physical Accessibility (handicapped accessible), Adequacy of waiting and examining room space (adequate waiting room seating, adequate number of examining rooms per practitioner), Adequacy of waiting and examining room space (adequate waiting room seating, adequate number of examining rooms per practitioner), Physical Appearance (cleanliness and orderliness, well‐lit waiting room, posted office hours)  For Medicare contracted practitioners, sites will be assessed for adequacy of equipment which may consist of current fire extinguisher, current and complete emergency resuscitation unit (crash cart), refrigerator housing specimens and medications is correct temperature and separate from food and personal items, sterilization equipment, current certifications for imaging equipment. 
Performance threshold compliance standards will be established and delineated to ascertain need for corrective action plan and follow‐up audits to correct identified deficiencies. 
Staff training will be documented on those who conduct office site audits. 
Office site audit will be conducted and documented within 60 calendar days of initial identification of grievance/complaint threshold having been met. 
Correction Action Plan (CAP) will be implemented by the practitioner office site to improve the deficiencies that did not meet the established office‐site audit tool compliance thresholds. 
The CAP will be evaluated and documented by conducting follow‐up audits on deficient sites at least every six months, until performance compliance standards are met. 
Member grievances/complaints related to the quality of practitioner office‐sites on all applicable practitioners within the Provider Group’s network will be monitored every 6 months. 
Follow‐up office‐site audit will be conducted within 60 calendar days of grievance/complaint threshold being met for offices that had subsequent deficiencies. 
Standards and performance thresholds for medical record keeping criteria for all applicable practitioners within its network will be met. Secure/confidential filing system, legible file markers, records easily located and forms and methods for consistency will be evaluated. 
All site assessments will be documented in a spreadsheet or log. Responsibility: References: NCQA CR 6.A.1‐2; 42 CFR § 422.204(b)(2)(i); NCQA CR 6.B.1‐5; 42 CFR § 422.204(b)(2)(i) 45
Office site complaint tool 2009
Completed w/in
60 calendar days
(Y/N)
Office
Site
Practitioner
Contracted
Health Plan
Date of
Complaint
Type of
Complaint
Met
Threshold
Name
Address
Date of
Site
Visit
Yes/No
(Y/N)
46
Date
Completed
Corrective Action
Plan
Site
Findings
Date CAP
Sent
Date CAP
completed
Follow-Up
F/U
Required
(None/3m
os/6mos
F/U
Date
F/U Site
Findings
California Shared Commercial & Medicare Provider
Office Survey & Corrective Action Plan
Initial Survey Date
Before undertaking any review, please go the Office Reviews Document posting area of www.iceforhealth.org and do a search to avoid duplicative surveys. You will find
an instruction guide on how to access posted results and how to post completed survey forms after each review or CAP follow-up via the following link:
http://www.iceforhealth.org/library.asp?sf=&scid=1164#scid1164. This tool resulted from a statewide, multi-stakeholder effort to standardize and simplify the credentialing
office survey process. When conducting a survey, written verification of criteria is not required unless specifically stated. Reviewers deviating from criteria should indicate
rationale in comments section. All deficiencies should be noted and those pages left with provider (forms completed electronically may be sent to the provider upon the reviewer’s
return to office). Reviewer is responsible for conducting CAP follow-up and for determining format of follow-up. This form may be used for all CAP follow-up, please note
deficiency-specific comments on CAP Section page 6 and follow-up dates on this page.
Total number of on-site staff =
Physician Info: ___PCP (or)
Specialty:_________
Name
Reviewer Information:
Name
Address
Physician
NP
Organization
RN
PA
Contact For Questions About this Survey:
LVN
MA
Name/Title
License Number
Clerical
CNM
Phone
Medical Group/IPA
Other
Phone
Fax
Group Practice (if applicable)
Names of additional doctors and licenses in practice:
Name of Office Manager:
Doctor has signed an Authorization form? ____Y ____N
Posting the review will enable doctors to comply with
credentialing requirements without incurring an
additional Provider Office Survey. Doctors must sign an
Authorization form for posting.
Site Point Summary; Initial Visit
Enter total earned (yes) points and total
available (yes + no) points for each section. Earned
Available
Email
Visit Purpose
Office Survey Exemption
____ Initial Credentialing – Primary Location
____ Initial Credentialing – Other Location
____ CAP Follow-up 1 (date of this followup) _________
____ CAP Follow-up 2 (date of this follow-up
_________________
____ CAP Follow-up 3 (date of this follow-up
___________
Other_________________________
____ MediCal Visit (indicate date and status)
_________________________________________
____ PMG Accreditation (indicate date, accreditor, and
status)
_________________________________________
____ “Shared” Site Visit (indicate date and
reviewer
contact info.)
________________________________________
Site Score Summary;
Initial Visit
Corrective Action Plan
Calculate the percentage score for
each section (earned/available).
Calculate Site score (total
earned/total available). Section Score
Site Score
A.
Access/Safety
_____
_____
______ %
Total Earned
B.
Personnel
_____
_____
______ %
__________
C.
Office
Management
_____
_____
______ %
D.
Medical Record
Keeping
_____
_____
______ %
Total
Available
E.
Clinical Services
_____
_____
______ %
__________
F.
Preventive
Services
_____
_____
______ %
G.
Infection Control
_____
_____
______ %
_________%
47
Scores below100% require a CAP
CAP INFORMATION Next Follow-up Date: 11/18/09 _____________
Next Follow-up Date: 11/18/09 ____________
Next Follow-up Date: 11/18/09 ____________
Type of Follow-up Required
In-person
Documentation Req’d
visit
Telephone
follow-up
Leave a copy of all CAP form pages that include
deficiencies with provider. A. Access/Safety Survey Criteria
yes
no
n/a
Comments
Outside Building
1.
Access to building is adequate, evidenced by reasonable parking and/or feasible public transportation
within walking distance. Reviewer to consider regional site characteristics.
2.
Accommodations for persons with disabilities are available, evidenced by designated parking, loading
zone, and/or public transportation within close proximity to the building. Reviewer to consider
regional site characteristics.
Inside Building
3.
Accommodations for persons with disabilities include all of the following:
a.
external ramp (if applicable)
b.
automatic entry option or alternative access method.
c.
elevator for public use (if applicable).
d.
restroom equipped with large stall and safety bars or other reasonable
accommodation.
4.
Exit signs are clearly visible.
5.
An Evacuation plan is posted in a visible location.
6.
Fire protection equipment (fire extinguisher, smoke detector, fire alarm, or sprinkler system) is
accessible and in working order:
Inside Office
7.
Emergency medications (injectable epinephrine, benadryl) are available on-site.
8.
There is a procedure for the management of non-medical emergencies (i.e., earthquakes).
9.
There is a procedure for handling medical emergencies appropriate to the patient population.
B. Personnel Survey Criteria
yes no
1.
There is evidence that staff receive orientation/training about policies and procedures relevant to their
job description.
2.
Appropriate licensure or certification is current and available (as applicable for RN, NP, LVN, PA,
MA).
3.
Standardized protocols are in place for all physician extenders (as applicable).
4.
Staff signs Confidentiality Agreements at time of hire.
48
n/a Comments
C. Office Management Survey Criteria
yes no
1.
Office hours are posted or are available on request.
2.
There is provision for 24 hour, 7 day per week coverage.
3.
The average number of patients scheduled per day does not exceed 5 per hour (6 pediatric patients
per hour).
4.
There is access to interpreter services for patients with limited English proficiency and those with
hearing impairments.
5.
The average wait time is less than 30 minutes from the scheduled appointment time.
6.
Urgent visits are scheduled within 24 hours.
7.
Non-urgent appointments are scheduled within 7 calendar days
8.
Preventive exam appointments are scheduled within 30 days, Well baby visits with 14 days and 1st
trimester prenatal visits within 7 days
9.
There is a policy to follow-up on missed appointments.
n/a Comments
10. There is a policy for compliance with HIPAA privacy regulations including evidence that the
disclosure of privacy practices is signed by patient and posted.
D. Medical Record Keeping Survey Criteria
yes no
(Note to reviewer: This is not a chart audit. There is no minimum requirement for
number of charts. A model chart or blinded chart may be used.)
1.
Medical records are secured from patient and public access and are restricted to
identified staff.
2.
Medical record release procedures are compliant with State and federal
regulations.
3.
Patient records are available for each encounter.
4.
There is an individual record for each patient.
5.
Forms and methodology for filing within a chart is consistent 6.
Allergies and reaction or NKA are clearly indicated on each chart.
7.
Discussion about advanced directive is documented for patients older than 18.
8.
The patient name appears on each sheet in the chart.
9.
There is a date and signature or initial on each entry/report in the chart.
10. There is a procedure for documenting MD review and patient notification prior
to filing lab, x-ray and other reports in the chart.
11.
There is a procedure for documenting patient phone communications.
49
n/a Comments
E. Clinical Service Survey Criteria
Comments
Pharmaceutical Services
1.
yes no
n/a
yes no
n/a
The following are inaccessible to patients.
a. Prescription pads
b. Needles
c. Syringes
d. Medications (including sample drugs)
2.
Narcotics are stored in a secured locked cabinet accessible to only authorized licensed
personnel.
3.
A current inventory is maintained for each controlled substance.
4.
Medications (including samples) are checked monthly for expiration dates.
5.
There is a policy for disposal of expired medications.
6.
Refrigerator thermometer temperature is maintained and documented daily at 35-46
Fahrenheit. .
7.
Freezer thermometer temperature is maintained and documented daily at 5Fahrenheit
if varicella vaccine is present.
8.
Drugs are stored in a separate refrigerator from food and drinks.
Laboratory Services
9.
CLIA certificate number or CLIA Waiver is current (if applicable).
a. Indicate certificate number here: _______________________
Area blanked out to match the numbering on the
excel fil
b. Indicate issue date here:______________________
c. Indicate expiration dates here: _____________________
Radiology Services
yes no
n/a
10. X-ray technician license(s) is current.
Area blanked out to match the numbering on the
excel fil
a. Indicate license number(s) here:_______________________
b. Indicate expiration date(s) here: _____________________
11.
X-ray equipment maintenance documentation is current.
50
F. Preventive Services Survey Criteria
1.
There are at least 2 exam rooms per doctor on duty, or alternative procedure to
minimize waiting time between patients.
2.
Exam rooms are neat and clean and have exam tables with protective barriers.
3.
The office has age-appropriate equipment, including but not limited to:
4.
a.
weight scale
b.
length/height measuring devices
c.
sphygmomanometer
d.
thermometer
e.
exam gowns
f.
eye chart
yes no
n/a Comments
yes no
n/a
At least one exam room can accommodate physically challenged patients.
Health Education
5.
Educational materials are:
a.
available for patients
b.
age appropriate for the patient population.
c.
language appropriate for the patient population
G. Infection Control Survey Criteria
1.
yes
no
n/a Comments
yes
no
n/a
The following autoclave processes are documented (as applicable):
2.
a.
Routine maintenance (inspection dates, service results, calibration, repairs, etc)
b.
Monthly spore checks
The following cold chemical sterilization processes are documented (as applicable)
3.
a)
Containers dated
b)
Solutions used must kill HIV, HBV, TB (should be indicated on label)
c)
Solutions used according to product label
Specimens requiring refrigeration are stored in sealed containers and separated
from drugs.
Hazardous Waste/Sharps
4.
There is a needle disposable system available.
5.
There is a policy for the handling of biohazardous waste
6.
There is a contract or written agreement for the secured disposal of biohazardous
waste.
7.
Biohazardous waste is stored in rigid leak resistant containers.
51
Corrective Action Plan (CAP) Follow-up
Deficiency # and
Description
Date of
Comment
Comment
(Note here how deficiency was adequately addressed, why it is excused, or what additional follow-up is required)
52
AUTHORIZATION TO SHARE SITE REVIEW
RESULTS
Provider Name
Reviewed Address
City, State, Zip
Provider Phone Number
Date of Initial Review
Name of Reviewer/Organization
Reviewer Phone Number
Reviewer E-Mail Address
The California Shared Commercial and Medicare Site Survey was developed by a statewide, multistakeholder team in an effort to standardize and simplify the credentialing office-review process.
Accreditors and regulators agree that if an office review is completed using this tool, results of the
review may be shared, thereby eliminating the need to duplicate an additional site visit.
AUTHORIZATION
_________________________________________________________________
(Insert name of reviewed physician above)
The physician whose name appears above grants permission for the data from his/her office review to be made available
to other commercial and Medicare reviewers in an effort to reduce the number of duplicative reviews borne by
practitioners, provider groups and health plans throughout the credentialing/recredentialing process. A completed
California Shared Commercial & Medicare Site Review Survey and Corrective Action Plan will be available on a
restricted portion of www.iceforhealth.org. Access to the shared review information is limited to authorized users as
verified by logging into the ICE web site Office Review Documents posting area from an appropriate organization type
and entering a password.
Authorization of the appropriate sharing of this information may result in the physician's / practitioner's participation in
fewer office reviews.
________________________________________________ ___________________________
(Signature of Reviewed Physician or Authorized Personnel)
Please Print Name
Notes to reviewers:
1.
2.
3.
This completed form and completed survey tool must be posted (as a single document) to the
www.iceforhealth.org web site. Instructions for posting can be found via the following link:
http://www.iceforhealth.org/library.asp?sf=&scid=1164#scid1164 Authorization must be received prior to posting review results, and this signed form must be posted along
with the survey tool; otherwise, the results will be removed from the web site. The original must be maintained with the original review documentation by the reviewing organization. 53
PATIENT COMPLAINT POLICY/INVESTIGATION PROCEDURE
Date: 11/18/09 12/08/08, 07/15/10, 09/08/11, 09/11/12 Policy: Foundation for Medical Care of Tulare and Kings Counties, Inc. will research all
complaints/grievances by members regarding quality of care or access issues with any Foundation for Medical Care of Tulare and Kings Counties, Inc. provider to ensure quality of care.
Procedure:
Complaints regarding quality of care issues may be brought to the attention of Foundation for Medical Care of Tulare and Kings Counties, Inc. in the following manner:
Member calling FMC with a grievance
Notification from the health plan of a grievance filed by the member with the health plan.
At the time the grievance/complaint is filed the following information will be obtained from the
member or health plan.
Name of member, date of birth, health plan ID number
Specifics of grievance/complaint including MD name, date of service in issue.
A request will be sent to the provider office requesting a response from the provider and a copy
of all pertinent medical records including a date by which a response is expected.
If the complaint is filed directly with Foundation for Medical Care of Tulare and Kings Counties,
Inc., all pertinent information will be reviewed by the Medical Director or his/her designee and
an action plan developed. The physician will be notified within 24 hours of the determination of
any corrective plan and recommended methods of implementation. Foundation for Medical Care
of Tulare and Kings Counties, Inc. is not delegated for member grievances/complaints and all
issues will be forwarded immediately to the health plan. Grievance data will be reviewed every
6 months through the UM/QM Committee as part of the Quality Management reporting review.
If the complaint is filed with the health plan, all pertinent information will be forwarded to the
plan within the time frame requested by the health plan. This information can include the
Physician response and medical records and a response by the IPA.
If the complaint is found to be correct, and the issue is egregious, the physician and case will be
referred to the credentialing committee for possible corrective action or sanction. The health
plan will also be notified immediately.
Copies of all grievances/complaints will be filed in the physician credentialing file and be
reviewed as part of the re-credentialing process.
54
POLICY: NON‐COMPLIANCE AND CORRECTIVE ACTION PLAN DATE: 11/18/09, 12/08/08, 07/13/11, 09/08/11, 09/11/12 A. Review by Credentialing Chairperson If the HMO becomes aware of a participating provider's potential failure to comply with any of the Participation Criteria, the provider's file will be called to the attention of the Credentialing Chairperson. Network management staff and/or the Credentialing Chairperson will take such steps, if any, as are appropriate to determine whether a compliance issue may exist. If quality deficiencies are determined to be severe enough to warrant reporting to NPDB, the reporting will be done at the time the deficiency is confirmed. 1) If, after HMO Staff and/or the Credentialing Chairperson have performed any further investigation that, in their discretion, may be appropriate under the circumstances, the Credentialing Chairperson determines that the provider appears to meet the HMO's Participation Criteria, no further action will be taken with respect to the provider. 2) If, after HMO Staff and/or the Credentialing Chairperson have performed any further investigation that, in their discretion, may be appropriate under the circumstances, the Credentialing Chairperson determines that the Participation Criteria have NOT been met by the applicant and, provided that NONE of the reason(s) the Participation Criteria have not been met are related to Professional Competence and Conduct, the Credentialing Chairperson will notify the provider, in writing, that his/her participation agreement will be terminated in accordance with its terms. The provider will be informed of the specific criteria not met. The Credentialing Chairperson shall have discretion to overturn this determination if the provider responds within thirty (30) calendar days correcting any factual discrepancies or correctable deficiencies. However, the provider will not be afforded a review by the Credentialing Committee or any other appeal. 3) If, after HMO Staff and/or the Credentialing Chairperson have performed any further investigation that, in their discretion, may be appropriate under the circumstances, the Credentialing Chairperson determines that the Participation Criteria have NOT been met, and provided that ANY of the reason(s) the Participation Criteria have not been met is/are related to Professional Competence and Conduct, the Credentialing Chairperson will forward the provider's file to the Credentialing Committee. 4) If, after HMO Staff and/or the Credentialing Chairperson have performed any further investigation that, in their discretion, may be appropriate under the circumstances and have taken appropriate steps under any applicable risk management practices, the Credentialing Chairperson determines, in his/her sole discretion, that the provider's continued participation in the network could pose a threat of imminent harm to the health or safety of patients, the Credentialing Chairperson shall have the ability to immediately suspend the provider's network participation, for thirty (30) days, or for such longer period of time as may become necessary under the circumstances. In such event, the Credentialing Chairperson will notify the provider of the suspension and the specific Participation Criteria which served as the basis for the suspension, by certified mail or overnight carrier, return receipt requested. The notice will inform the provider that he/she has the right to request a review of the suspension decision, by the Credentialing Committee, by submitting a response, in writing, with any documentation the provider feels is appropriate and has bearing on the issue, within thirty (30) calendar days of the date of the Credentialing Chairperson's notice. The provider will also be informed that he/she may submit any additional information that he/she would like to have considered by the Credentialing Committee. The provider will be informed that failure to respond within the thirty (30)‐day time frame will result in the immediate termination of his/her network participation without further review or appeal. 55
While such suspension is in effect, the provider will not be authorized to provide services, as a participating provider, to any Members. (Exceptions, if any, to the prohibition on providing services during such a suspension may be made in certain circumstances (in accordance with the HMO's policies and/or practices), but only after any Member who is to receive such services has been informed that the provider is no longer participating in the network and has given his/her consent to continued treatment by the provider.) (a) If the provider fails to respond within the thirty (30)‐day time frame, the provider's network participation will be terminated. The Credentialing Chairperson will send a notice of termination to the provider; such notice will inform the provider that his/her participation is terminated immediately and that he/she is not entitled to further review or appeal. (b) If the provider responds within the thirty (30)‐day time frame, the provider's file, including the provider's response and any additional information he/she has submitted, will be forwarded by the Credentialing Chairperson to the Credentialing Committee. Providers who are terminated, suspended or have had their privileges reduced for a medical disciplinary cause or reason will be afforded the opportunity for a hearing in accordance with Section 809 of the California Business Code. A medical disciplinary cause or reason relates to the conduct, performance or competence of providers. It addresses conduct which requires the filing of a report under Section 805 (b) of the California Business and Professional Code with the Medical Board of California, any successor agency, or other appropriate state licensing
board. Health plan of California will also be notified of any providers who meet this
criteria and who have actions pending.
Section 805 reporting: Foundation for Medical Care of Tulare and Kings Counties, Inc. will report to the Medical Board of California as needed any physician that is found to be non‐complaint with California Business and professions Code section 805.01. Reporting will be as per the following guidelines. All reporting will be provided within and according to the guidelines of the Medical Board of California (15 days). Reporting will be done for when a final determination is made by a peer review board for: Incompetence, or gross or repeated deviation from the standard of care involving death or serious bodily injury to one or more patients, to the extent or in such a manner as to be dangerous or injurious to any person or to the public; 2. The use of, or prescribing for or administering to himself or herself of any controlled substance, any dangerous drug (as specified), or alcoholic beverages, to the extent or in such a manner as to be dangerous or injurious to the licentiate, any other person, or the public, or to the extent that the licentiate’s ability to practice safely is impaired by that use; 3. Repeated acts of clearly excessive prescribing, furnishing, or administering of controlled substances or repeated acts of prescribing, dispensing, or furnishing of controlled substances without a good faith effort prior examination of the patient and the medical reason therefore (note that in no event shall a physician or surgeon who is lawfully treating intractable pain be reported for excessive prescribing, and if a report is made, the licensing board must promptly review any such report to ensure these standards are properly applied); and 4. Sexual misconduct with one or more patients during a course of treatment or an examination. These 4 reasons do not have to go to hearing before the 805.01 form is filled out. The proposed action must be given to the practitioner within 15 days after the peer review body makes the recommendation or final decision. 56
B. Review by Credentialing Committee Upon receipt of the provider's file, the Credentialing Committee will review the file for compliance with the HMO's Professional Competence and Conduct Criteria for the applicable type of provider. The Credentialing Committee should not make any determinations regarding Participation Criteria that are not Professional Competence and Conduct Criteria. 1) If the Credentialing Committee determines that the provider appears to meet the HMO's Professional Competence and Conduct Criteria for the applicable type of provider, the Credentialing Committee will communicate its decision to local network management staff who will, provided that all other Participation Criteria appear to have been met, notify the provider, in writing, that his/her network participation will be continued. However, if the other Participation Criteria are not met, the Credentialing Chairperson will inform the provider of the specific Professional Criteria and/or Business Criteria not met, and will notify the provider that his/her participation agreement will be terminated in accordance with its terms. The Credentialing Chairperson shall have discretion to overturn this determination if the provider responds within thirty (30) days correcting any factual discrepancies or correctable deficiencies. However, the provider will not be afforded any further review or appeal. 2) If the Credentialing Committee determines that the provider does NOT meet the HMO's Professional Competence and Conduct Criteria for the applicable type of provider, the Credentialing Committee may make one of the following decisions regarding the provider's continued network participation: (a) The provider's network participation may be terminated. The provider will be permitted to continue providing services under his/her participation agreement, pending exhaustion of the appeals process described in Section IV of this policy. (b) In the event that the Credentialing Committee determines, in its sole discretion, that the provider's continued participation in the network could pose a threat of imminent harm to the health or safety of patients, the Credentialing Committee shall have the ability to immediately suspend the provider's network participation for thirty (30) days, or for such longer period of time as may become necessary under the circumstances. The provider may appeal such determination as described under Section IV of this policy; however, while such suspension is in effect, the provider will not be authorized to provide services, as a participating provider, to any Members. (Exceptions, if any, to the prohibition on providing services during such a suspension may be made in certain circumstances (in accordance with the HMO's policies and/or practices), but only after any Member who is to receive such services has been informed that the provider is no longer participating in the network and has given his/her consent to continued treatment by the provider.) (c) The Credentialing Committee may institute a corrective action plan for the provider. A corrective action plan may not reduce, restrict, suspend, revoke, deny or fail to renew the provider's network participation. A corrective action plan may include, but not be limited to, the following: (i) training and/or education; (ii) chart reviews and/or audits; or (iii) Credentialing Chairperson and/or HMO Staff site visits. A corrective action plan may not include intensive review of individual patients' care or specific procedures. A corrective action plan must include a time frame for the Committee’s review of the provider’s compliance with such plan. (d) In conjunction with instituting a corrective action plan, the Credentialing Committee may impose an Administrative Freeze of the provider’s participation with the HMO. An “Administrative Freeze” means that the provider may not accept new members who are not already in the provider’s panel or being treated by the provider. However, Administrative Freezes must be time‐limited, and unless extenuating circumstances are present, an Administrative Freeze shall not be longer than three (3) to six (6) months. At the end of the time 57
period of the Administrative Freeze, the Credentialing Committee must review the provider’s compliance with the corrective action plan, and determine whether the provider may continue participation or whether further sanctions are appropriate. Except under certain extenuating circumstances, the Credentialing Committee may impose only one Administrative Freeze on a provider for the conduct in question. 3) The HMO may appoint to the Credentialing Committee, as ad hoc voting member(s), participating providers practicing in the provider's general area of specialty, for the purpose of reviewing the provider's continued participation. Any voting member of the Credentialing Committee who is in direct economic competition with the provider, who is in a position to benefit financially from the outcome of the hearing, or who is otherwise involved in circumstances that could be construed as a conflict of interest (financial or otherwise), shall recuse himself/herself from all deliberations and voting affecting such provider. If a provider is terminated by Foundation for Medical Care of Tulare and Kings Counties, Inc. and later is to be reinstated, the physician must be credentialed as an initial credentialing if the break in service is more than 30 days. All credentials must be updated and be effective at the time of Committee review. POLICY: Termination of a provider for cause DATE: 11/18/09, 12/07/09, 07/15/10, 09/08/11, 09/11/12 Foundation for Medical Care of Tulare and Kings Counties, Inc. reserves the right to terminate a physician provider for cause. Cause may include: ‐‐Inability to perform essential functions, including drug use or loss of license. ‐‐Felony conviction ‐‐Lack of malpractice insurance ‐‐Falsification of application for membership in Foundation for Medical Care of Tulare and Kings Counties, Inc. ‐‐State or Medicare sanctions or restriction on licensure ‐‐Loss of hospital privileges due to misconduct In addition, Foundation for Medical Care of Tulare and Kings Counties, Inc. may terminate a provider who does not meet Foundation for Medical Care of Tulare and Kings Counties, Inc. standards. This can include multiple complaints regarding the physician or office site that are found to have merit, repeated failure of office site review including medical record review and non‐compliance with an agreed upon corrective action plan. If Foundation for Medical Care of Tulare and Kings Counties, Inc. credentialing staff becomes aware of any of these issues, staff will make the credentialing chairman aware of the problem. If the credentialing chairman determines that the issue has merit, the credentialing staff will notify NPDB within 14 days of the determination that the issue has merit. All possible cases of physician termination will be reviewed by the credentialing committee and the determination will be made by the committee. The physician will have the right to appeal the determination following the Credentialing Appeals policy of Foundation for Medical Care of Tulare and Kings Counties, Inc.. 58
POLICY: ORGANIZATIONAL/FACILITY CREDENTIALING DATE: 11/18/09, 12/08/08, 07/15/10, 09/08/11, 09/11/12 Foundation for Medical Care of Tulare and Kings Counties, Inc. does not credential facilities at this time. Per contractual arrangements with the Health Plans, these are directly credentialed and contracted with the health plans not the medical group. Policy Number:
Policy Name: Ongoing Monitoring
Policy Approval Date: 11/18/09 06/08/09,
07/15/10, 09/08/11, 09/11/12 Policy Revision Date: 11/18/09 11/20/09,
09/08/11, 09/11/12 Purpose:
Foundation for Medical Care of Tulare and Kings Counties, Inc. implements the process for ongoing
monitoring of practitioner sanctions, complaints and quality issues between recredentialing cycles and
takes appropriate action against practitioners when it identifies occurrences of poor quality.
Policy: Foundation for Medical Care of Tulare and Kings Counties, Inc. identifies and, when
appropriate, acts on important quality and safety issues in a timely manner during the interval between
formal credentialing
Responsibility:
Procedure:
Medicaid and Medicare Status

Foundation for Medical Care of Tulare and Kings Counties, Inc. will verify the practitioner’s Medicaid
and Medicare status.

Verification sources used may include the following:
 NPDB - if using this source, it will be run at least monthly on each practitioner.
Note: NPDB only is not acceptable for verifying Medicare/Medicaid sanctions.
If NPDB is used the Office of Inspector General must be queried also.
 Proactive Disclosure Service of the National Practitioner Data Bank
(CONTINUOUS QUERY (PDS))
 HIPDB - if using this source, it will be run at least monthly on each practitioner.
 FSMB - if using this source, it will be run at least monthly on each practitioner.

Cumulative Sanction Report at www.oig.hhs.gov/fraud/exclusions/database.html

EPLS at www.epls.gov.

IntelliCred at www.intellisoftgroup.com
59


Medicare and Medicaid Sanctions and Reinstatement Report distributed to federally contracted
organizations

The FEHB Program department record published by the OPM, OIG

Entry in the AMA Physician Master File (if using this source, it must be run at least monthly on
each practitioner).

State Medicaid agency or intermediary and Medicare Intermediary
The information will be reviewed within 30 calendar days of its release.
Sanctions and/or Limitations on Licensure

Foundation for Medical Care of Tulare and Kings Counties, Inc. will review sanction or limitations
on licensure.

Verification sources used may include the following:
 NPDB - if using this source, it will be run at least monthly on each practitioner.
 Proactive Disclosure Service of the National Practitioner Data Bank
(CONTINUOUS QUERY (PDS))
 HIPDB - if using this source, it will be run at least monthly on each practitioner.
 FSMB - if using this source, it will be run at least monthly on each practitioner.

Cumulative Sanction Report at www.oig.hhs.gov/fraud/exclusions/database.html

EPLS at www.epls.gov. (run monthly)

IntelliCred at www.intellisoftgroup.com

Medicare and Medicaid Sanctions and Reinstatement Report distributed to federally contracted
organizations

Medi-Cal Provider Suspended and Ineligible List www.medi-cal.ca.gov (if using this source, it
must be run monthly on each practitioner).

The FEHB Program department record published by the OPM, OIG (monthly)
 Entry in the AMA Physician Master File (if using this source, it must be run at
least monthly on each practitioner).

State Medicaid agency or intermediary and Medicare intermediary

The information will be queried monthly where reporting entities do not publish sanction information
on a set schedule.

Any affected practitioner will be individually queried 12-18 months after the last credentialing cycle if
the reporting entity does not release sanction information reports.

Foundation for Medical Care of Tulare and Kings Counties, Inc., as often as reports of sanctions or
limitations on licensure are available, will obtain and review documentation, and identify whether any
sanctions or other actions have been taken against any Provider Group practitioner. Staff will report
this information to the committee within 30 days of becoming aware of any sanctions. The
credentialing committee will be responsible for reviewing this information and taking action.

The information will be reviewed within 30 calendar days of its release.
Grievances/Complaints

Foundation for Medical Care of Tulare and Kings Counties, Inc. will investigate and document practitioner‐specific grievances/complaints from members upon their receipt. THIS IS DONE THROUGH THE UM/QM COMMITTEE AS PART OF THE SEMI ANNUAL REVIEW OF GRIEVANCES AND COMPLAINTS. 
 Both the specific grievance/complaint and the practitioner history of issues will be evaluated. 60
Adverse Events

Foundation for Medical Care of Tulare and Kings Counties, Inc. will monitor practitioner adverse
events monthly. This information will be reported to the credentialing chairman for review and to the
committee for action as needed.
Instances of Poor Quality

Foundation for Medical Care of Tulare and Kings Counties, Inc. will implement appropriate
interventions when instances of poor quality are identified, when appropriate. Appropriate
intervention will be determined by the Credentialing Chairman and the Committee as indicated.

Policy: Member notification of physician termination DATE: 07/15/10, 09/08/11, 09/11/12 Procedure: For PCP termination: The PCP must notify Foundation for Medical Care of Tulare and Kings Counties, Inc. 90 days in advance of the termination date. It is the responsibility of the PCP to notify Foundation for Medical Care of Tulare and Kings Counties, Inc. subscribers assigned to them of their termination with the group. A copy of the letter sent to assigned members will be provided to FMC for the physician credentialing file. For Specialist termination: The physician must notify Foundation for Medical Care of Tulare and Kings Counties, Inc. 90 days in advance of the termination date. It is the responsibility of Foundation for Medical Care of Tulare and Kings Counties, Inc. to notify subscribers of the change in the provider panel. Letter will be sent to members who have seen the specialist within the last 6 months notifying them of the unavailability of this provider. FMC staff will assist members as needed in transferring care to another contacted specialist within the provider panel. POLICY: OB/GYN PHYSICIANS AS PRIMARY CARE PHYSICIANS
DATE: 02/11/11, 09/08/11, 09/11/12 PURPOSE: On or after January 1, 1995, every health care service plan that provides hospital, medical, or surgical coverage, that is issued, amended, delivered, or renewed in this state, shall include obstetrician/gynecologists as eligible primary care physicians, provided they meet the plan’s eligibility criteria for all specialists seeking primary care physician status. As the entity contracted with the health care service plan to provide or arrange for the provision of primary care physician service, Provider Groups are responsible for ensuring compliance with the requirement. OBJECTIVES: Foundation for Medical Care of Tulare and Kings Counties, Inc. Provider Group will include obstetrician/gynecologists as eligible primary care physicians. Foundation for Medical Care of Tulare and Kings Counties, Inc. Provider Group will establish reasonable requirements for the participating obstetrician/gynecologist seeking primary care physician status. PROCEDURE: 1. Foundation for Medical Care of Tulare and Kings Counties, Inc. Provider Group shall allow an enrollee the option to seek primary care physician services directly from a participating obstetrician/gynecologist. 61
2. Foundation for Medical Care of Tulare and Kings Counties, Inc. Provider Group has established reasonable requirements for the participating obstetrician/gynecologist to practice as a primary care physician. Foundation for Medical Care of Tulare and Kings Counties, Inc. Provider Group requires that the obstetrician/gynecologist seeking primary care physician status meet the definition/expectations as defined in § 14254 of the Welfare and Institutions Code as follows. The term “primary care physician” means a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues. 3. Foundation for Medical Care of Tulare and Kings Counties, Inc. Provider Group requires that an OB/GYN meet all requirements of a PCP and is able to provide routine PCP care. This includes the following, as per FMC Credentialing PCP requirements: Primary Care Physician Service Guidelines Listed below, but not limited to, are services considered PCP functions. This is dependent on the level of training the physician has received, the limitations of scope of practice and consistent with State and Federal rules and regulations. These guidelines are based on routine uncomplicated cases that are ordinarily seen by a PCP. Allergy:  Treat seasonal allergies  Treat hives  Treat chronic rhinitis  Allergy history  Environmental counseling  Minor insect bites/stings  Asthma, (chronic/acute) active with or without co‐existing infection Cardiology:  Perform electrocardiograms  Interpret electrocardiograms  Evaluate chest pain, murmurs, palpitations  Evaluate and treat coronary risk factors, including smoking, hyperlipidemia, diabetes, HTN, lifestyle  Evaluate and treat CHF, stable angina, non life‐threatening arrhythmias  Evaluate syncope (cardiac and non‐cardiac) Dermatology:  Treat acne (acute and recurrent)  Treat painful or disabling warts with topical suspensions, electrocautery, liquid nitrogen  Diagnose and treat common rashes including: Contact dermatitis, dermatophytosis, herpes genitalis, herpes zoster, impetigo, pediculosis, pityriasis rosea, psoriasis, seborrheic dermatitis and tinea versicolor  Identify suspicious moles  Screen for basal or squamous cell carcinomas  Biopsy suspicious lesions  Punch Bx  Excisional Bx 62


Treat Actinic Keratosis Diagnose and treat common hair and nail problems and dermal injuries. Common hair problems include: fungal infections, ingrown hairs, virilizing causes of hirsutism, or alopecia as a result of scarring or endocrine effects. Common nail problems include: trauma, disturbances associated with other dermatoses or systemic illness, bacterial or fungal infections, and ingrown nails. Dermal injuries include: minor burns, lacerations, and treatment of bites and stings  Counsel patients regarding removal of cosmetic(non‐covered) lesions Endocrinology:  Diabetic management, including Type I and Type II patient  Patient education  Supervision of home testing  Medication management  Diagnose and treat thyroid disorders  Identify and treat hyperlipidemia  Diet instruction  Exercise instruction  Provide patient education for osteoporosis risk factors Gastroenterology:  Diagnose and treat lower abdominal pain  Diagnose and treat acute diarrhea  Treat protracted vomiting  Occult blood testing  Diagnose and treat heartburn, upper abdominal pain, hiatal hernia, acid peptic disease  Diagnose and treat irritable bowel syndrome  Diagnose and treat chronic jaundice under SPC recommendations  Diagnose and treat chronic ascites under SPC recommendations  Diagnose and treat symptomatic, bleeding or prolapsed hemorrhoids  Manage inflammatory bowel disease under SPC recommendations General Surgery:  Evaluate and follow small breast lumps  Order mammograms  Aspirate cysts  Foreign body removal  Laceration repairs (minor)  Local minor surgery for hemorrhoids  Minor surgical procedures Gynecology:  Perform routine pelvic exams and PAP smears  Perform lab testing for sexually transmitted diseases  Wet mounts  Diagnose and treat vaginitis and sexually transmitted diseases  Evaluate lower abdominal pain to distinguish gynecological from gastrointestinal causes  Diagnose vaginal bleeding  Diagnose and treat endometriosis with hormone therapy 63

Manage premenstrual syndrome with non‐steroidal anti‐inflammatory agents, hormones and other symptomatic treatment Hematology:  Initial differential diagnosis of anemias  Hemoglobinopathies Infectious Disease:  Common infectious diseases  Initial evaluation for HIV positive  Viral disorders  Tuberculosis prophylaxis Neurology:  Diagnose and treat all psychophysiological diseases; headaches, low back pain, myofascial pain syndromes, neuropathies  Diagnose and treat tension and migraine headaches  Treat syncope (cardiac and non‐cardiac)  Treat uncomplicated seizure disorders after SPC neurological evaluation  Manage degenerative neurological disorders with respect to general medical care (i.e., Parkinson's)  Treat stroke and TIA patients  Manage dementia, Alzheimer’s Ophthalmology:  Perform thorough ophthalmologic history including symptoms and subjective visual acuity  Perform common eye related services including: Distant/near testing, color vision testing, gross visual field testing by confrontation, alternate cover testing, direct fundoscopy without dilation, extraocular muscle function evaluation, red reflex testing in pediatric patients  Diagnose and treat common eye conditions including: viral, bacterial and allergic conjunctivitis, blepharitis, hordeolum, chalazion, small subconjunctival hemorrhage, dacryocystitis and sty Orthopedics:  Treat low back pain  Treat sprains, strains, pulled muscles, overuse syndromes  Treat inflammatory conditions  Conservative treatment of chronic knee problems  Manage chronic pain problems  Diagnose and treat common foot problems: Ingrown nails, corns/callouses, bunions  Arthrocentesis Otolaryngology:  Treat tonsillitis and streptococcal infections  Perform throat cultures  Evaluate and treat oropharyngeal infections: Stomatitis, Herpes simplex  Treat acute otitis media  Treat serous effusion  Evaluate tympanograms/audiograms  Treat acute and chronic sinusitis 64
 Treat allergic or vasomotor rhinitis  Remove ear wax  Diagnose and treat acute parotitis and acute salivary gland infections  Evaluate neck masses Pulmonology:  Diagnose and treat asthma, acute bronchitis, pneumonia  Diagnose and treat chronic bronchitis  Diagnose and treat chronic obstructive pulmonary disease  Manage home aerosol medications and oxygen  Work up possible tuberculosis or fungal infections  Treat opportunistic infection Rheumatology:  Diagnose and treat non‐articular muscloskeletal problems: Overuse syndromes, injuries and trauma, soft tissue syndromes, bursitis or tendonitis  Provide steroid injections  Manage osteoarthritis  Diagnose gout, pseudogout  Diagnose and treat rheumatoid arthritis  Diagnose and treat inflammatory arthritic diseases  Diagnose and treat uncomplicated collagen diseases Urology/Nephrology:  Diagnose and treat initial and recurrent urinary tract infections  Provide long term chemoprophylaxis for recurrent UTI  Diagnose and treat urethritis  Explain hematospermia  Evaluate hematuria  Evaluate incontinence  Diagnose and treat epididymitis and prostatitis  Differentiate scrotal or peritesticular masses from testicular masses  Evaluate prostatism and prostatic nodules  Manage urinary stones  Monitor PSA levels  Post Circumcision Care Vascular Surgery:  Diagnose abdominal aortic aneurysm  Diagnose and treat venous diseases, i.e., DVT, varicose veins, stasis dermatitis  Treat non‐surgical stasis ulcers  Manage intermittent claudication  Manage transient ischemic attacks  Manage asymptomatic bruits Other:  Basic life support  Heimlich maneuver 65
Credentialing Schedule B Date: 7/15/10, 5/3/11, 09/08/11, 09/11/12 Division of credentialing oversight between the Foundation For Medical Care of Tulare and King’s Counties Inc., and Foundation for Medical Care of Tulare and Kings Counties, Inc. The Foundation is responsible for the following credentialing activities: Ensure compliance with all NCQA,CMS/DHCS, DMHC and health plan regulations Maintain all files, rosters, policies and procedures for credentialing/re‐credentialing in a confidential, complete and updated manner. Perform the process of credentialing/re‐credentialing physicians including all applications/reapplications, verifications (from NCQA approved sources), attestations, notification of practitioner rights and responsibilities and site visits within the required time frame. Perform ongoing monitoring and review of Medicare sanctions, sanctions or limitations on licensures, complaints, adverse events and Medicare opt out report (if applicable). Review and submit all required reporting to health plans and FMC semi annually. Notify FMC and the health plans of any serious quality issues. Identifying HIV/AIDS specialists within the group. Foundation for Medical Care of Tulare and Kings Counties, Inc. is responsible for the following credentialing activities: FMC will maintain a credentialing committee with the appropriate number of practitioners as required by NCQA and health plans. The committee will meet at least on a quarterly basis. This committee will review all minimum participation thresholds and all requests for participation in FMC. FMC retains the right to approve, suspend or terminate any practitioner. The Committee will delegate the Medical Director to approve “clean” files as per FMC policies and procedures. The committee will determine action for physicians who are not compliant with standards or who have had complaints with FMC, up to and including termination from the group. If a physician is non‐compliant, and actions are taken, FMC will evaluate at least every 6 months until the issue is resolved or the provider terminated. FMC will perform an annual audit of credentialing files against NCQA standards and other regulatory bodies, if applicable. In lieu of FMC performing the annual audit, FMC may use the annual credentialing audit performed by a NCQA accredited Health Plan. The findings of this audit will be reported into the credentialing committee. FMC will perform an annual substantive evaluation of delegated activities, if any delegated activities, against NCQA standards and other regulatory bodies, if applicable. In lieu of FMC performing this audit, FMC my use the annual credentialing audit performed by a NCQA accredited Health Plan. The findings of the audit will be reported into the credentialing committee. 66
POLICY: Fair Hearing Process Date: 07/12/12, update for 2013 Note: At a minimum, this policy shall be annually reviewed and revised as necessary 1. SCOPE Foundation for Medical Care of Tulare and Kings Counties, Inc. hereinafter referred to as FMC, has established policies for monitoring and recredentailing participating providers who seek continued participation with the IPA. The FMC QI Committee also reviews grievances or allegations regarding professional conduct and competence of participating providers. Information reviewed during these reflective activities may indicate that the professional conduct and competence standards are no longer being met, and FMC may wish to terminate providers. FMC also seeks to treat participating providers fairly, and thus provides participating providers with a process to appeal determinations limiting or terminating their participation with FMC. 2. PURPOSE The purpose of this policy is to set forth an appeal process for participating providers who wish to appeal a suspension of greater than fifteen (15) days duration or a termination from FMC. Only adverse determinations relative to professional conduct and competence are subject to this policy. 3. POLICY STATEMENT It is the intent of FMC to give each participating provider the opportunity to appeal any decision of the Executive Board to terminate the provider’s participation in FMC, and to provide fair hearing process. 4. DEFINITIONS Participating Provider: Any person or professional corporation who provides health care services that has entered into an agreement with FMC to provide health care services to FMC members. 5. PROCEDURES Notice and Request for First Level Review. A. Notice. Upon decision by the Executive Board to suspend or terminate a provider’s participation, the FMC Medical Director will notify the provider via certified letter of the decision at least thirty (30) days prior to the effective date of the suspension or termination. The letter will contain the reason for the decision, a statement that the provider has the opportunity for an appeal of the decision and a summary description of the process described below. The letter also will state that if the provider desires to appeal, the provider must submit, within the thirty (30) calendar day period immediately following the date of receipt of the letter (unless otherwise required by state regulation), a written request to the Executive Board for a review of the decision, along with any additional information the provider wishes to be considered. In the event the provider elects to appeal the decision, the effective date of the termination or suspension will be stayed until completion of the appeal process. First Level Appeal Process A. First Level Review. As reconsideration, any additional information submitted subsequent to the initial decision of the Executive Board will be presented to the Board for its consideration. The Executive Board will review the basis for its initial decision, along with any additional information submitted by the provider. This review may take place at a regularly scheduled Executive Board meeting or at a special review meeting. The provider shall not be present during the review. FMC may have QI Committee members and legal representatives present for the first level review as non‐voting members. 67
B. Review Results. FMC’s Executive Board shall report the decision on the first level review to the Medical Director within five (5) business days of the decision. The FMC Medical Director shall notify the provider via certified mail within fourteen (14) calendar days after receiving notification from the Executive Board of its decision. Any suspension or termination will be effective thirty (30) days from the date of notification of the provider of the results of the first level review. If the provider requests a second level review, the effective date of any suspension or termination will again be stayed until completion of the second level appeal process. Second Level Appeal Process A. Formal Hearing, Upon Request. As a second level of review, the provider may request a formal hearing if the decision of the first level review is adverse to the provider. This request must be in writing and received by the Executive Board via certified mail within the thirty (30) day period immediately following the date of the provider’s receipt of the letter from FMC’s Executive Board with its determination based on the first level review results. If a provider timely requests a hearing, the following procedures will be followed. B. The Executive Board will notify FMC’s Medical Director and FMC’s legal counsel, of the provider’s request for a hearing. C. Hearing Panel. FMC’s Medical Director will select the members of the hearing panel. The hearing panel will be comprised of at least three (3) and no more than five (5) practitioners, none of whom shall have been involved in the first level appeal or the decision to suspend or terminate the provider. One of the members of the hearing panel will be the Chairman of the QI Committee. The hearing panel will be chaired by FMC’s Medical Director, who is not entitled to vote and who is not counted as a member of the hearing panel D. Hearing Notice. The Executive Board will send a certified letter notifying the provider of the date, time, and place of the formal hearing. This letter also will summarize the hearing procedures and notify the provider that he/she has the right to: 
present evidence determined to be relevant by the FMC Medical Director regardless of its admissibility in a court of law; 
ask questions and cross‐examine witnesses 
submit a written statement at the close of the hearing, and 
receive, upon completion of the hearing, the written decision of the panel, including a statement of the basis for the decision. The hearing notice will also state that the provider will forfeit his/her right to a hearing if the provider fails to attend the hearing in person without good cause. E. In advance of the hearing, the Executive Board will give each hearing panel member a copy of the suspension, and/or termination letter originally sent to the applicable provider. The panel members may also be provided with any other material deemed relevant by FMC at or in advance of the hearing. F. Hearing Date. The hearing date will be not less than fourteen (14) nor more than thirty (30) calendar days after the date of the notice given to the provider of the date, time, and place of the formal hearing or as otherwise agreed to by FMC and the affected provider. G. The right to a hearing will be forfeited if the provider fails, without good cause; to attend the hearing in person after notice of the hearing is given. Hearing Procedures. A. The chairperson of the hearing panel will open and run the hearing by stating the purpose of the hearing and the procedure that will be followed. 68
B. During the hearing, the provider will have the right: 
to present evidence determined to be relevant by the FMC Medical Director regardless of its admissibility in a court of law; 
to ask questions and cross‐examine witnesses 
to submit a written statement at the close of the hearing; 
to receive, upon completion of the hearing, the written decision of the panel, including a statement of the basis for the decision. C. During the hearing, the provider will not have the right to: 
to have legal counsel present; 
to call witnesses to testify. D. FMC cannot have legal counsel present if the provider does not have legal representation. E. A representative of FMC will present the reasons for the Executive Board’s decision to suspend, or terminate the applicable provider. F. The provider will present reasons why his/her participation should not be suspended, or terminated. G. The hearing panel will meet privately after the hearing to reach a decision. The hearing panel will have the authority to uphold, reject, or modify the original decision based on the preponderance of evidence presented at the hearing. The decision must be reached by a majority vote. H. The hearing panel will prepare a written account of its decision, stating the reasons for its decision. A copy of the written decision will be provided to the Executive Board. I.
Review Results. The FMC Medical Director shall notify the provider via certified mail, return receipt requested, within ten (10) calendar days of the hearing panel’s decision, including a statement of the basis for such decision. J.
This determination will be viewed as the final determination in the appeals process, though the Executive Board will retain final authority to exercise its right to review and modify any determinations made by the hearing panel, if it so chooses. Reporting Final Adverse Actions. FMC will report any final adverse actions in accordance with Credentialing Policy and Procedures and/or other organizations as required by law. 6. RESPONSIBILITIES FMC Medical Director, Credentials Staff 7. CONFIDENTIALITY All credentialing and peer review records and proceedings shall be confidential as contemplated by section 1157 of the California Evidence Code. 69
Date:
?-hI /r?,
Name: Jason T. Britt
Title: Director of Human Service, Tulare County Health and Human Services Agency
~~~~-Tt:)~+=~----------------
Approved: ______
Date:
~ b1/13
Name: Steve Beargeon
Title: Chief Executive Officer, Foundation for Medical Care of Tulare & Kings Counties, Inc.
70
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