QUEST Integration - Provider Participation Requirements

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

• Providers must meet state and federal regulations relating to their practice and comply with the terms and conditions of HMSA's Medical Service Agreement for QUEST Integration (please refer to your agreement for the full requirements).
• Providers must provide needed medical and mental health services regardless of race, color, sex, national origin, religion, creed, age, marital status, sexual preference, or mental or physical challenges.
• Primary Care Providers (PCP) may limit the number of QUEST Integration patients they manage by declaring a capacity limit at the time of application. Updates to capacity may be done as follows:
• Increases may be made at any time by mutual agreement between the PCP and HMSA.
• Decreases may be made 45 days after the date of written notification to HMSA so that affected patients have time to select a new PCP. The PCP should continue to provide care until the end of the 45-day period, or the patient has been re-assigned, whichever occurs first. For patients who are in their 2nd or 3rd trimester of pregnancy, physicians are obligated to provide or arrange for continued care through the post partum period. The physician is also required to offer continued care for up to 90 days to patients receiving an active course of treatment or until the active course of treatment is completed. An active course of treatment is one in which discontinuity of care would cause a recurrence or worsening of the condition and interfere with anticipated outcomes.
• Providers must notify HMSA of any status changes such as address, specialty, etc., so that provider records may be updated (see HMSA Quick Reference Guide).
• Providers must certify the accuracy, completeness, and truthfulness of any data, including but not limited to, encounter data, data upon which payment is based, and other required information that may be submitted to determine the basis for payment. Claims and encounter form data must be submitted timely, be accurate, and complete. Data and reports shall be mathematically correct and present accurate information. An accurate encounter is one that reports a complete and accurate description of the service provided as documented in a patient's medical records.
• Providers must develop and fully and clearly discuss treatment or service plans with members, including non-treatment options and alternative treatments, regardless of benefit status or limitations. Discussions should include information on the risks, benefits, and consequences of treatment or non-treatment. Members must be involved in their treatment planning and decisions, including the right to refuse treatment and to express their preferences about future treatment decisions.

Accessibility Standards

The following accessibility standards have been adopted by HMSA's Plan for QUEST Integration Members for both PCPs and specialists:

• Immediate care and without prior authorization for emergency medical services
• Appointments within 24 hours for urgent care and for PCP pediatric sick visits
• Appointments within 72 hours for PCP adult sick visits
• Appointments within 21 days for PCP routine visits for adults and children
• Appointments within 21 days for behavioral health (routine visits for adults and children)
• Appointments within four weeks or within sufficient timeliness to meet medical necessity for visits with a specialist or for non-emergency hospital admissions.

Emergency care must be available 24 hours a day, seven days a week through the use of recorded messages, the Physician Exchange service or backup coverage. Backup coverage also should be arranged when a provider is not available during regular practice hours (i.e., out of town, vacation, etc.). A hospital emergency room is not acceptable backup coverage and patients should not routinely be directed to a hospital emergency room for care that is not considered urgent/emergent.

Note: The backup provider need not be part of HMSA's provider network and may submit claims directly to HMSA's Plan for QUEST Integration Members. However, the backup provider must understand and agree that any services provided to QUEST Integration patients will be paid in accordance with the HMSA Medical Service Agreement with the provider for whom backup coverage is provided. The physician involved also must understand that prescriptions written by a nonparticipating provider may not be covered. Please inform HMSA's QUEST Integration Provider Service of backup coverage and the period of time for which backup is being arranged.

Compliance with ADA Requirements

Providers must provide needed medical and behavioral health services regardless of race, color, sex, national origin, religion, creed, age, marital status, sexual preference, or mental or physical challenges. Compliance with the provisions of the Americans with Disabilities Act (ADA), including providing sign language interpretation services, is required. Provider offices with special language and communication skills should let us know of these abilities to facilitate member assignment to providers able to communicate with them.

To help providers in this respect, we also offer member information and assistance in a variety of formats, including oral foreign language and sign language interpretation, TDD for the hearing impaired, audio and large print materials. Arrangements for language translators for individuals with limited English proficiency, or sign language interpreter services must be planned in advance. Please call QUEST Integration Provider Service when scheduling an appointment for a patient who requires interpreter services so that arrangements to have an interpreter available for the visit can be made.

Confidentiality of Records

All records must be kept confidential and maintained according to standard medical practice (see QUEST Integration - Medical Records Standards. They must permit effective professional medical review and audit processes and allow for the tracking of follow-up treatments. Records must be maintained for a minimum of seven years from the last entry in the records. For minors, records must be maintained while they are minors plus a minimum of seven years after the age of majority. During the period of record retention, the state and federal governments must be allowed full access to the records to the extent allowed by law.

If a patient changes PCP or health plan, the medical records are to be transferred to the new PCP within seven (7) business days from receipt of the records request.

Persons covered under HMSA's Plan for QUEST Integration Members are subject to federal and state law and administrative rules that apply to Medicaid programs, including those governing consent for release of records that are needed for claims adjudication and reporting purposes. Such records must be made accessible to DHS, its representatives, HMSA and others as specified by DHS. Under no circumstances, however, will HIV or AIDS and mental health information be released by HMSA or an HMSA participating QUEST Integration provider to any requester, including DHS, without the patient's expressed written consent.

Members also have the right to request and receive a copy of their medical records, and to request they be amended, as specified by federal regulation ((45 CFR Part 164).

Provider release of information to attorneys, no-fault insurance companies or other parties must be in accordance with state and federal laws governing such access. Providers should notify QUEST Integration Provider Service of any release of information for potential third party liability.

Revision History