10 minute read
Ch 2: Resources for Providers
This Chapter Includes:
1. Getting Assistance from VHP 2. Provider Relations Department 3. Notification of Practice or Demographic Changes
Requirements
4. Provider Directory Audit 5. Termination of Patient/Practitioner Relationship 6. Reasonable Notice
Alert
Alert draws attention to critical information that has changed this year.
Contact
Contact information on who to contact for assistance.
Book Table of Contents
Click the purple VHP circle logo, located at the bottom left corner, to return to the main TOC.
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When you have questions or need assistance, we encourage you to first use the many resources that are available for providers on VHP’s website: www.valleyhealthplan.org/ providers.
Accessing VHP’s website can significantly reduce the number of telephone calls you make to VHP. The website allows immediate access to current provider and member information 24 hours a day, seven days a week. On the provider website, you can find information about: • Provider Billing/Claims Submission • Forms and Resources - Provider Manual - Authorizations and Referrals - Case Management - Evidence of Coverage - Clinical Guidelines
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- Training - Dispute and Grievance Form - Provider Directory Online Verification and Change Form - And many more resources • How to Join VHP networks • Pharmacy Information If you are not able to locate answers to your questions using VHP’s online provider resources and this Provider Manual, you can also contact VHP’s Provider Relations staff at 1.408.885.2221 (For TTY, contact California Relay by dialing 711), available Monday – Friday from 8:00 am to 5:00 pm (Pacific) to answer questions or provide other assistance. When calling VHP, please have the following information available: • National Provider Identifier (NPI) • Tax Identification Number (TIN) • VHP Member Identification Number
Provider Relations Department
VHP’s Provider Relations Department is dedicated to making each provider’s experience with VHP a positive one. Provider Relations is responsible for oversight, coordination or initiation of the services listed below: • Conducting physician and office staff initial and ongoing education (Initial training occurs within ten business days of a provider’s active status in VHP’s core operating system, QNXT); • Conducting hospital, facility and ancillary provider initial and ongoing education and training; • Distributing Provider Manuals and similar provider reference materials. As noted above, the Provider Manual is available on VHPs website (https://www.valleyhealthplan.org/sites/p/ Pages/Providers.aspx) and is generally distributed no later than seven calendar days after the provider requests a hard copy from the Provider Relations Department; • Providing assistance with claims inquiries, electronic submission of claims and other administrative services; • Providing assistance with installation, functional training and securing access to web-based tools, including completing access request forms for VHP’s referral authorization system; • Distributing notices, bulletins, newsletters, and other information related to VHP’s programs, processes or policy updates or changes; • Facilitating completion of forms, including electronic funds transfer or Automated Clearing House (ACH) and W-9 or other required tax forms; • Conducting “secret shopper” evaluations to assess compliance with VHP’s timely access, availability, or other regulatory requirements;
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Conducting on-site facility reviews, which are generally conducted during the initial credentialing process, and periodically as needed or required; Scheduling periodic meetings to resolve issues and identify opportunities to improve VHP’s service to its providers, or Providing information on provider performance with respect to quality indicators measured by VHP and engagement of provider office staff in quality improvement activities.
As a participating provider in VHP’s network, you and your office staff have a dedicated Provider Relations Specialist (PRS) who is your resource to provide education and training regarding VHP’s administrative and regulatory requirements. The PRS is expected to communicate with you or your designated office manager on a routine basis. The PRS conducts regularly scheduled outreach activities as a proactive way to: • Build a positive relationship with you and your staff. • Identify issues, trends, or concerns quickly. • Answer questions. • Share new information regarding VHP. • Discuss changes within your practice such as changes in office staff, new location, or scope of service.
You may contact your PRS to: • Report any change to your practice (i.e., practice or pay-to TIN, NPI, name, phone numbers, fax numbers, practice location, address, language capabilities, addition or termination of providers, or patient acceptance status (i.e., open/closed panel).
Please note: Updates of changes in your language capabilities or that of your office staff must be communicated to VHP on an annual basis.
Initiate credentialing of providers who are new to the practice. Schedule an in-service training for new staff. Conduct on-going education for existing staff. Obtain clarification of state and health plan policies, procedures and/or contract language. Learn about special programs available for members and/or providers. Request fee schedule information. Ask questions regarding your membership assignment list (patient panel) or capitation payments, as applicable. Receive assistance related to claims or encounter submissions.
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Back to Chapter 2 Table of Contents
Learn how to use electronic solutions for web authorizations, claims submissions or checking member eligibility. Provide recommendations for enhancements to VHP’s participating provider network to maintain consistency with specialist, ancillary and post stabilization referral and utilization preferences and practices.
Another key responsibility of the Provider Relations Department is to continuously monitor network adequacy to ensure that VHP members have access to care that mirrors community access standards and to maintain compliance with VHP and DMHC access standards. Your PRS will keep you and your staff apprised of network changes, provider additions or terminations, or to discuss your needs for specific types of providers within the geographic area you serve.
To help VHP maintain an accurate Provider Directory and claim payments, it is important that you or your designated office staff proactively notify your PRS at least 30 days prior to any changes to your practice. You can access the Provider Directory Online Verification and Change Form on VHP’s website using the following link:
www.valleyhealthplan.org/sites/p/Pages/Provider-directory-change-form.aspx
For more routine demographic changes, you or your office staff can access the Provider Directory Online Verification and Change Form on VHP’s website using the following link:
www.valleyhealthplan.org/sites/p/Pages/Provider-directory-change-form.aspx
Examples of the types of information providers must submit to VHP to allow for the verification and maintenance of VHP’s Provider Directory include: 1. The provider's name 2. The provider’s practice location or locations 3. The provider’s contact information 4. The provider’s office hours by day of the week 5. Type of practitioner (PCP, Specialist, etc.) 6. NPI 7. California license number and type of license 8. For physicians, the American Board of Medical Specialty designation and subspecialty, including board certification, as applicable 9. For advanced practice providers, specialty designation, including any board certification
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Back to Chapter 2 Table of Contents
10. The provider's office email addressThe provider’s office fax number 11. The name of each VHP contracted affiliated provider group in which the provider sees members 12. A listing for each of the following provider types that are under contract with VHP, such as: – For physicians and surgeons: The name of the provider group and the name(s) of the hospital(s) or ambulatory surgery center(s) at which the physician has admitting privileges. Admitting privileges at a VHP contracted hospital or ambulatory surgery center is a prerequisite for participation in VHP’s network. – Nurse practitioners, physician assistants, psychologists, acupuncturists, optometrists, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, nurse midwives, and dentists. – For Federally Qualified Health Centers (FQHC), rural health center (RHC) or primary care clinics: the name of the FQHC, RHC or clinic. a. For any provider described in subparagraph (a) or (b) above who is employed by an FQHC, RHC or primary care clinic, and to the extent their services may be accessed and are covered through the contract with VHP, the name of the provider and the name of the FQHC, RHC or clinic is required. b. Facilities, including but not limited to general acute care hospitals, skilled nursing facilities, urgent care clinics, ambulatory surgery centers, inpatient hospice, residential care facilities, and inpatient rehabilitation facilities. c. Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services.
If any of the above information changes, notify VHP by contacting Provider Data Management at 1.408.885.2566 or email ProviderDataMgt@vhp.sccgov.org or use the Provider Directory Online Verification and Change Form located on VHP’s website:
www.valleyhealthplan.org/sites/p/Pages/Provider-directory-change-form.aspx
All other changes require 30 day advance written notice. When provider demographic updates are submitted, please list only the address(es) where a member was able to make an appointment to see the departing or terminating provider.
On-call, locum tenens and substitute providers who are not regularly available to provide covered services at an office or practice location, should not be listed at that address.
Provider Directory Audit
All provider and medical groups are obligated to participate in VHP’s annual provider directory audit to verify the accuracy of the provider contact and profile information in VHP’s Provider Directory.
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Non-responsive providers may be removed from VHP’s Provider Directory until their information is submitted and verified as accurate.
Providers should direct members to VHP’s Member Services Call Center at 1.888.421.8444 for any assistance or questions related to the Provider Directory.
Termination of Provider-Patient Relationship (or Termination of Patient Care)
Once the provider-patient relationship is established, the provider must continue to provide care to the patient to avoid allegations of abandonment until one of the following occurs: • The patient terminates the provider-patient relationship. • The provider-patient relationship is terminated by mutual consent. • The patient’s condition no longer requires the care of this particular provider. • The provider agrees to treat only a specific condition or agrees to treat only at a specific time or place. • The provider terminates the provider-patient relationship by notifying the patient in writing of withdrawal from care after a specific time which is stated in the letter. The patient is also given information necessary to obtain their medical records or transfer to another provider. According to the American Medical Associations Council on Ethical & Judicial Affairs, a physician may not terminate a patient relationship as long as further treatment is indicated without sufficient time to make other arrangements for necessary care. Additionally, in the rare situation of an acute episode of illness, the transfer of care may be physician to physician to avoid any lapse in continuity of care.
When a provider withdraws from a member who needs continuity of care at that time, the provider must complete all of the following steps:
1. Give the member reasonable notice (30 days, in most cases) of their intent to withdraw from providing services or care.
2. Provide the member with a reasonable amount of time (30 days, in most cases) to find alternative services.
3. Continue to be available during the transition period to treat the member up and until the date indicated in the notice of termination to the member.
Note: The same rules apply to termination of health care services for nonpayment of fees.
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Reasonable Notice
In most cases, a 30-day advance notice would be considered reasonable for member termination. If the basis for termination of a VHP member is for disruptive behavior, and/or behavior that is dangerous to other members or staff, the period may be shortened to as little as one day. This change to VHP’s normal notification process is dependent upon the seriousness of the threat and VHP’s ability to either terminate the member from VHP or to locate another provider to accept the member. This process will also take into consideration both the severity of the member’s condition and the availability of other providers within the time-period selected. It is not necessary to indicate to the member why the relationship is being terminated.
Note: Notify VHP’s Member Services Call Center of the termination at the same time you notify the member at 1.888.421.8444 or by sending a fax to 1.408.885.4634.
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