Provider Corrective Action Plan Process - Santa Clara Family Health ...

Title: Delegated Entity(ies)Provider
Corrective Action Plan Process
Previous Title (if applicable): Provider
Corrective Action Plan Process
Policy No.: PS077 _01
Supersedes Previous Policy No. : HA-06-04,
CO-06-04, PS-06-19, CP018_04
Department Applicability: All
Policy Review Frequency: Annual/Semi-
Departments
Annually
Lines of Business: All Lines of Business Date Originated: April 2006
Originating Dept.: Provider Services
Originating Dept. Approval:
Date:
Dept. Approval:
Date:
Chief Medical Officer/Medical Director
Approval:
Date:
Date Approved by P&P Committee:
Revision Date(s): 11/07, 5/08, 7/09, 4/11, 06/12
CEO Approval:
Date:
1. Policy Statement
Santa Clara Family Health Plan (SCFHP) issues corrective action plans to
Delegated Entities who do not comply with SCFHP policies and procedures and
state and federal laws.
2. Purpose
The purpose of this policy is to require that SCFHP’s contracted providers who
do not comply with SCFHP policies and state and federal laws, receives and
complies with appropriate corrective action plans.
3. Definitions
A. Delegated Entity(ies) means any party to an agreement with a
subcontractor descending from and subordinate to a subcontract, which is
entered into for the purpose of providing any goods or services connected
with the obligations under SCFHP’s contract.
Authority: DHCS Contract Exhibit A, Attachment 4, Provisions 1, 6(B)(3), 8(B), & 10(D) & Exhibit A, Attachment 6, Provision 14(B), &
Exhibit A, Attachment 7, Provision 7(D), & Exhibit A, Attachment 14, Provision 2(E); 28 CCR § 1300.70(a) & (b)(2)(E; 42 CFR § 438.230
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B. Corrective Action Plan (CAP) means a written notification outlining the
mandatory steps a non-compliant Delegated Entity must implement in
order to become compliant with SCFHP policies and/or state and federal
laws.
C. DOC means SCFHP’s Delegation Oversight Committee.
4. Procedures
A. SCFHP does not delegate the verification and effectiveness of the
corrective action plan process to any of its delegated entities.
B. Using a variety of means, one or more of SCFHP’s departments may
identify a Delegated Entity’s non-compliance and report it to the delegation
oversight committee (DOC). Identification methods may include but are
not limited to:
1. Audit
2. Breach of Contract
3. Failure to follow SCFHP Policy and Procedures, and/or state and
federal laws.
C. Written notification of non-compliance along with all appropriate
supporting documentation is created and mailed to the appropriate
provider, Medical Group or IPA by the DOC in cooperation with the
department that discovered the non-compliance.
The written notification:
1. Contains the signature of the DOC representative verifying noncompliance.
2. Stipulates that the provider has 30 business days to submit a written
response identifying the steps taken to meet SCFHP’s compliance
requirements.
D. Once the initial CAP timeframe is reached:
1. The DOC determines if the written response from the provider meets
the CAP requirements
a. If yes, the DOC will send a written notification to the provider
that the CAP response was accepted. A representative from
the originating department will review the response to
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determine that the correct actions were taken or will be taken
to meet SCFHP’s compliance requirements.
b. If no, the DOC submits to the provider another written
notification identifying the areas in need of correction within
30 the next days.
2. The DOC submits a written revised CAP addressing the compliant and
non-compliant areas based on the provider’s CAP response. The
written notification:
a. Contains the signature of the DOC representative in
cooperation with the department who verified that the CAP
was deficient.
b. Provides a deadline in which the provider is required to
submit a written response identifying the steps taken to meet
SCFHP’s compliance requirements.
c. Identifies potential disciplinary action if provider fails to
comply, if applicable.
E. The DOC determines if the second written response from the provider
meets the CAP requirements
1. If yes, the DOC representative sends written notification to the
provider that the CAP response was accepted.
2. If the provider remains non-compliant after the second CAP deadline,
the DOC advises the CEO for determination.
a. The Chief Executive Officer will determine if additional action
is needed by the Peer Review Committee, which may include
termination.
5. Confidentiality of Information
In accordance with SCFHP’s Confidentiality Policy, and all applicable state and
federal laws, any and all information that is required to be kept confidential, is
kept confidential.
6. Recordkeeping
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Each department is responsible for retaining and maintaining documents/
records/paperwork for a minimum of ten (10) years for their own department
(refer to policy CP-005 Record Retention).
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