Provider Network

• Monitoring Provider to Member Ratio
• PCP/Provider Network Changes
• Provider Directory
• Provider Termination Process - Under Construction
• Provider Resources
• Leave of Absence/PCP Covering
• Unsatisfactory Relations Between Member and Provider

Credentialing and Recredentialing

• QA23 - Credentialing
• QA24 - Recredentialing
• QA25 - Delegated Credentialing and Recredentialing

Access Standards

• QA04 - Primary Care Availability Standards
• QA04a - Missed Appointments and Patient Recall
• UM55 - Transportation Services
• QA14 - Facility Access for Physically Disabled Members
• CL03 - Access to Interpretive Services
• UM12 - Sensitve Healthcare Services
• UM42 - Prenatal Care

Enrollment and Assignment

• Enrollment and Eligibility - Under Construction
• Eligibile Members - Under Construction
• HPSJ Service Area
• PRO11 - PCP Assignment
• CS04 - Maintaining Patient/Provider Relationship When Assigning Members to Primary Care Providers
• Member Welcome Packet - Under Construction
• Member Identification Cards - Under Construction

Grievance Resolution

• CS13 - Member Grievance Procedures
• CS16 - Distribution of Member Rights and Responsibilities
• Provider Grievance and Appeal/Dispute Resolution Process - Under Construction
• UM13 - Provider Appeals/Expedited Appeal of UM Decisions to Deny, Defer or Modify for Medical Necessity Determinations

Utilization Management

• UM01 - Authorization/Referral Policy
• UM16 - Second Medical Opinions
• UM04 - Emergency Department Services

Claims Processing Under Construction

Encounter Data Reporting

• Encounter Data Submission - Under Construction
• Capitation - Under Construction

Quality Management

• QA08 - Quality Improvement Plan (QI Plan)
• QA05 - Facility Site Review
• QA28 - Mid-Level Practioners

Pharmacy Benefits

• UM25 - Formulary and Pre-authorization Process
• UM27 - Formulary Additions and Deletions

Medical Care Standards

• QI22 - Initial Health Assessments
• UM47 - Immunization Schedule
• UM42 - Prenatal Care
• QA22 - Adult Preventive Health
• UM36 - CHDP/Child Health and Disability Prevention Program
• QA03 - Reporting Infectious Disease to Public Health
• UM12 - Sensitve Healthcare Services
• UM52 - Women, Infants, and Children (WIC) Supplemental Food Program
• MM01 - Advice Nurse Program
• UM37 - Med-ical Waiver Program Criteria

Compliance

• HIPAA
• CMP05 - Fraud and Abuse Reporting

Eligibility and Verification

• Eligibility Verification - Under Construction
• Interactive Voice Response (IVR) - Under Construction
• Online Eligibility Verification System (DRE) - Under Construction
• Other (Advice Nurse/HPSJ Customer Service, ID Cards) - Under Construction

Infection Control

• QA03 - Reporting of Infectious Disease to Public Health

Coordination of Care

• PCP Role in Case Management - Under Construction
• Identifying and Reporting Potential Abue of HPSJ members - Under Construction
• UM35 - Major Organ Transplant Cases - Identification and Referral Process
• UM41 - California Children's Services (CCS)
• UM49 - Mental Health Services
• UM46 - Alcohol and Substance Abuse Treatment Services
• UM51 - (CSHCN) Children with Special Health Care Needs – Identification of and Coordination of Care with VMRC/Early Start Program
• UM40 - Dental Care and Dental Anesthesia
• UM56 - Vision Services - Under Construction
• UM53 - Developmental Disabilities Services Program

Member Transfers and Disenrollment

• Cust05 - Primary Care Provider Assignment - Member Requested
• Cust17 - Transition of Members from Terminated Providers
• Cust11 - Voluntary Member Disenrollment from Health Plan
• Cust12 - Involuntary Member Disenrollment from Health Plan
• Cust20 - Plan Initiated Member Disenrollment
• Provider Charging Members

Rights and Responsibilities

• Cust16 - Members' Rights and Responsibilities
• Practitioners' Rights and Responsibilities - Under Construction

Cultural and Linguistics Services

• C&L01 - Cultural and Linguistic Procedures
• C&L03 - Access to Interpreter Services
• C&L04 - Profiency of Interpreters
• C&L05 - Translated Written Member Materials
• C&L06 - Translation Process of Written Member Materials
• C&L07 - Cultural Awareness and Sensitivity Training
• C&L08 - Enrollee Assessment
• C&L09 - Notification of Language Assistance Program
• C&L10 - Provider Language Assessment
• C&L11 - Readibility of Member Materials