Skip Maine state header navigation

Agencies | Online Services | Help

Skip First Level Navigation | Skip All Navigation

Anthem Blue Cross and Blue Shield
2 Gannett Drive
South Portland, Maine 04106

Interagency Committee for the Quality Oversight of Commercial HMO's
Exposure Draft Quality Examination Report

Examination Conducted
November 6-7 2002

Survey Team

Ellen Austin Reitchel, R.N. Comprehensive Health Planner II, Quality Improvement, Bureau of Medical Services
Margaret Ross, R. N. Nurse Consultant
Joanne Rawlings-Sekunda, Health Policy Specialist
Ruth Martin, M.B.A., M.P.H. Consultant


Respectfully Submitted January 30, 2003

Glenn Griswold, Chair
Interagency Committee for the Quality Oversight of Commercial HMO's

Findings and Recommendations

The Bureau of Insurance and the Bureau of Medical Services completed a joint triennial examination of Anthem Blue Cross and Blue Shield of Maine, hereafter "Anthem BCBS", for compliance with 24-A M.R.S.A., Chapters 56 and 56A, Bureau of Insurance Rule Chapter 850, and Department of Human Services Rule Chapter 109. This report represents the finding of State surveyors as of November 7, 2002. Anthem BCBS scored a "Pass" for this triennial examination. Refer to Appendix 1 to review the scoring procedure. Acknowledgement of cooperation and assistance extended to the examiners by all Anthem representatives is hereby expressed.

Findings:

This section highlights the findings associated with the examination of Anthem. A detailed report, which outlines each element and standard, is enclosed within this packet.

I. Quality Management Program, Structure and Process were found to be in full compliance with Rule 109.

II. Quality Management Program, Operations were found to be in full compliance with Rule 109.

III. Quality Management Program, Clinical Guideline development, implementation and evaluation of preventative and non-preventative conditions were found to be in full compliance with Rule 109.

IV. Quality Management Program, Studies and Analysis were found to be in full compliance with Rule 109.

V. Quality Management Program, Interventions and Assessments were found to be in significant compliance with Rule 109.

VI. Quality Management Program, Continuity and Utilization of Care/Services were found to be in full compliance with Rule 850.

VII. Quality Management Program, Evaluation was determined to be in full compliance with Rule 109.

VIII. Credentialing Program was determined to be in full compliance with Rule 850.

IX. Utilization Review Program and Structure were determined to be in full compliance with Rule 850.

X. Utilization Review File Review was determined to be in full compliance with Rule 850.

XI. Grievance and Appeals procedures were determined to be in full compliance with Rule 850.

XII. Access, Availability, and Continuity of Care in areas of member-to-provider ratios were determined to be in full compliance with Rule 850.

XIII. Access, Availability and Continuity of Care in areas of rural access and barriers to access were found to be in full compliance with Rule 850.

XIV. Access, Availability and Continuity of Care in areas of appointment and waiting times were determined to be in full compliance with Rule 850.

XV. Access, Availability and Continuity of Care in areas of coordination and continuity of care policies and procedures were determined to be in full compliance with Rule 850 and 24-A M.R.S.A. s 4303.


Recommendations:

Based on the findings of the joint Bureau of Insurance and Bureau of Medical Services examination and pursuant to 21-A S 4221 (2), the following recommendations have been made:

  1. Anthem BCBS’ policies and procedures for reviewing adverse utilization review determinations; expedited review and adverse determination notification meet the requirements under Rule 850. Anthem BCBS was given credit in 2 areas: "The covered person may appeal directly to the HMO rather than the HMO delegate", and inclusion on adverse determination notifications of "Instructions for requesting copies of any reference evidence, documentation or review criteria". These were not covered in policies and procedures but were found to be done as a standard of practice. Anthem BCBS is encouraged to include these within their policies and procedures.
  2. On its quality of care study, Follow-Up after Hospitalization for Mental Illness, Anthem BCBS argued that assigning an individual to follow-up with members after discharge from a mental health admission is potentially a strong intervention, but did not provide documentation that it has consistently implemented this intervention throughout the study period nor described the process by which the assigned individual(s) encouraged members to keep follow-up appointments. Anthem BCBS did not provide any process measures, such as the number of members that the designated individual(s) contacted after discharge and the outcomes of the calls, to demonstrate that they had an ongoing, functioning system. Anthem BCBS is encouraged to develop these measures, as well as procedures for encouraging members to keep follow-up appointments.


Table of Standards and Elements
Explanation of Terms

The table of individual standards and elements reflects the following information:

  • Column 1 labeled “Standard and Element as identified in the Data Collection Tool Version 1/2/01,” identifies the standard or element as it appears in the State's Data Collection Tool. Please note these standards and elements do not directly correspond to the standards or elements and lettering and numbering system used by NCQA.
  • Columns 2, labeled "Authorizing Rule or Statute," identify the law or rule governing this element. (An example includes 109.3-1, which indicates Rule 109, section 3-1).
  • Column 3, labeled “NCQA,” identifies the NCQA standard or element comparable to Maine law. In situations where NCQA does not have an element or standard equivalent then “No Equivalent” is written in the column.
  • Column 4, labeled “Score,” identifies the individual score awarded to the plan for compliance with the element or standard. The following scores may be awarded:
    • Deemed (Full or Significant). Indicates that the plan was given credit for complying with an equivalent NCQA standard. (Credit given only for a designation of “full” or “significant” compliance with equivalent NCQA standard. The State reserves the right to review all information needed to determine compliance with promulgated rules. This includes the right to review standards, elements or components that may have an equivalent NCQA standard and which NCQA found to be in full or significant compliance with NCQA standards.)
    • Full. Indicates that the State has reviewed the standard or element and has determined that the plan is in full compliance with this element or standard.
    • Significant. Indicates that the State has reviewed the standard or element and has determined that the plan is in significant compliance.
    • Partial. Indicates that the State has reviewed the standard or element and has determined that the plan is in partial compliance.
    • No Credit. Indicates that the State has reviewed the standard or element and has determined that the plan is not in compliance.
  • Column 5, labeled “Findings” provides an overview of the findings within each element or standard. This narrative section documents findings that are either compliant or non-compliant with the elements or standards.


Appendix 1

SCORING

Based on the HMO’s Total Rating for all components, the HMO will have the following status and the Interagency Committee (IAC) will take the following actions:

81 – 100

Pass. If the HMO rates a Pass, the IAC shall identify those areas in which the HMO was not in full or significant compliance. This report will also identify follow-up steps to be taken and a date by which the HMO shall report back to the IAC. By this date the HMO shall demonstrate to the satisfaction of the IAC how the HMO has improved its performance and come into full or significant compliance with all requirements, or, if appropriate, submit a work plan for coming into full compliance within a time frame acceptable to the IAC. At its discretion, the IAC may schedule a follow-up review focused on previously identified problem areas.

 

51 - 80

Provisional Pass. For a Provisional Pass, the IAC identifies for the HMO those areas in which the HMO is not in full or significant compliance. This report will also identify follow-up steps to be taken and a date by which the HMO shall come into full or significant compliance or, if appropriate, submit a work plan for coming into full compliance within a time frame acceptable to the IAC. The IAC shall schedule a follow-up review focused on previously identified problem areas. If, upon completion of these follow-up steps and review, the IAC is not satisfied that the HMO has come into full or significant compliance on all of the items specified, or, if applicable, the HMO has no work plan for coming into full compliance, the IAC shall recommend to the Commissioner and Superintendent that proceedings to suspend or revoke the HMO’s Certificate or Authority be initiated.

 

0 - 50 Fail. If the HMO fails the Desk Audit and Onsite Examination, the IAC shall recommend to the Commissioner and the Superintendent that proceedings to suspend or revoke the HMO’s Certificate of Authority be initiated.

 

 

Plan Name: Anthem Blue Cross and Blue Shield of Maine
NCQA/State Survey Date: 4/22-24/02
State Survey Date: 11/06-07/02

Survey Team Members: Mary Ellen Austin Reitchel RN, HSS, Department of Human Services
Joanne Rawlings-Sekunda MPP, Policy Development Specialist, Bureau of Insurance
Margaret Ross RN, Nurse Consultant
Ruth Martin M.B.A., M.P.H. Consultant

Quality Improvement Program

Standard and Element as Identified in the Data Collection Tool Version 1/2/01 Authorizing Rule or Statute NCQA Equivalent
(2000 Standards)
Score Findings
Quality Management Structure and Process
QM.SP 1 109-03-1 QI 1 Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
Quality Management Operations
QM.OP 1 (Committee Functions) 109-03-2(A) QI 2.1A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.OP 2 (Minutes) 109-03-2 (B) QI 2.2B Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.OP 3 (Coordinated Activities) 109-03-2(c) No Equivalent Full Anthem BCBS demonstrated evidence of routine discussion by the Quality Management Oversight Committee of other performance monitoring and at least 3 types of monitoring data was used in coordination of QM activities.
QM.OP (Physician Participation) 109-03-2 (D) QI 2.3C Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.OP 5 (Practitioner Contracts) 109-03-2 (E)(1)&(3) QI 3.1A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.OP 6 (Facility Contracts/QM & Records) 109-03-2(E)(2)&(3) QI 3.2B Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.OP 7 (Contracts/ Confidentiality) 109-03-2(E)(4) RR 6.3B Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
Quality Management Guidelines
QM.GU 1 (All Non- Preventative) 109-03-3(A) QI 8.0A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.GU 2 (All Preventative) 109-03-3(A) PH 1.1A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.GU 3 (Non-Preventative/ Development) 109-03-3 (A) QI 8.0A
QI 8.1B
QI 8.2C
Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.GU 4 (Non-Preventative/ Updated) 109-03(A)(6) QI 8.3D Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.GU 5 (Non-Preventative/ Distributed) 109-03(A)(3) QI 8.4E Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.GU 6 (Preventative/ Development) 109-03(A) PH 1.1A
PH1.2C
PH 1.3D
PH 1.4E
Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.GU 7 (Preventative/ Updated) 109-03(A)(6) PH 1.5F Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.GU 8 (Preventative/ Distributed) 109-03(A)(3) PH 2.0 A,B,C Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.GU 9 (Non-Preventative/ Measured) 109-03(B)(1) QI 8.5F Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.GU 10 (Non-Preventative/ Consistency) 109-03(B)(2) QI 8.6G Full Anthem BCBS was able to demonstrate compliance with the requirements for reviewing consistency with 2 comprehensive clinical guidelines addressing chronic or acute conditions in the areas of UR criteria and practitioner instructions.
Quality Management Studies and Analysis
QM.SA 1 109-04C QI 10.0A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.SA 2 109-04D QI 10.1.1 -
QI 10.1.2B
Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.SA 3 109-04E QI 10.1.3 Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.SA 4 109-04F QI 10.2D Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.SA 5 109-04G&H QI 10.3E Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.SA 6 109-04C QI 12.2B Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.SA 7 109-04D QI 12.2B Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.SA 8 109-04E QI 12.2B Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.SA 9 109-04F QI 12.2B Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.SA 10 109-04G&H QI 12.2B Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
Quality Management Interventions and Assessments
QM.IA 1 109-05 QI 11.1A Partial Anthem BCBS selected interventions for at least 3 quality of care studies addressing chronic or acute conditions during the past 3 years. Anthem BCBS initiated strong interventions and conducted remeasurement during the past 3 years on 2 quality of care studies; it did not document strong intervention on the third study.
QM.IA 2 109-05 QI 4.2.4E
QI 4.2.5F
QI 4.2.6G
QI 4.3.3K
QI 4.3.4L
QI 5.3C
QI5.4 D
QI 5.5E
QI 6.3
QI 6.4E
QI 6.5F
QI 6.6G
Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
Quality Management Continuity and Utilization
QM.CU 1 (Continuity and Monitoring) 109-06 (A)(1)&(2) QI 9.1A
QI 9.3.1C
Full Anthem BCBS has demonstrated compliance with the following requirements:
  • Monitoring the overall continuity of care provided to its members
  • Using appropriate mechanisms to monitor the overall continuity of care
  • Appropriately identifying opportunities for improvement or appropriately concluding that no action is necessary.
  • Monitoring overall continuity of care for at least 12 months.
QM.CU 2 (Utilization/ Monitoring) 109-06B1&2 UM 13A,B,C Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.CU 3 (Continuity/ Interventions) 109-06A3 QI 9.4.1E Full Anthem BCBS was able to demonstrate compliance with the requirements to implement actions when they have identified problems in continuity or coordination of care.
QM.CU 4 (Utilization/ Interventions) 109-06B3 UM 11.G Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
Quality Management Program Evaluation
QM.EV 1 (Evaluation) 109-07A QI 12.1A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
QM.EV 2 (Notification) 109-07B No Equivalent Full Anthem BCBS was able to demonstrate compliance with requirements to periodically report QM activities to its members, the governing body, practitioners and appropriate organization staff.

 

Credentialing Program

Standard and Element as Identified in the Data Collection Tool Version 1/2/01 Associated Rule NCQA Equivalent Score Findings
CR1 (Policies and Procedures) 850 (7G) CR 1.1A
CR 1.2B
CR 1.3C
CR 1.5 - 1.9
Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
CR 2 (Credentialing Committee) 850 (7G4) CR 2.0 A,B,C Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
CR 3 (Physician File Review/ Primary Verification) 850 (7G8) CR 3.1 - 3.7A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
CR 4 (Physician File Review/ Secondary Verification) 850 (7G9) CR 3.1 - 3.7A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
CR 5 (Physician File Review / Recredentialing) 850 (7G10) CR 7.1 - 7.7A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
CR 6 (Non-Physician File Review/ Primary Verification) 850 (7G8) No Equivalent Full 8 of 8 non-physician credentialing files included: timely primary verification of license, privileges, Drug Enforcement Agency registration and specialty board certification when applicable.
CR 7 (Non-Physician File Review/ Secondary Verification) 850 (7G9) No Equivalent Full 8 of 8 non-physician credentialing files included: timely primary verification of licensing history, malpractice history, work history and liability coverage.
CR 8 (Non-Physician File Review/ Recredentialing) 850 (7G10) No Equivalent Full 8 of 8 non-physician re-credentialing files included timely primary verification of licensing, Drug Enforcement Agency registration and specialty board certification when applicable.
CR 9 (Procedures for Termination and Appeals) 850 (7G12) CR 10.1
CR 10.2A,B
Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.

 

Utilization Review Program

 

Standard and Element as Identified in the Data Collection Tool Version 1/2/01 Associated Rule NCQA Equivalent Score Findings
UR 1 (Annual Evaluation) 850 (8A) UM 1.4 E Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 2 (Program Description) 850 (8C) UM 1.1
UM 1.3A
Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 3 (Program Description) 850 (8D) No Equivalent Full Anthem BCBS demonstrated that the UR program description and UR criteria were available to the Superintendent of the Bureau of Insurance upon request. In addition, a policy to collect only that personal medical information necessary to certify treatment requested was available.
UR 4 (Clinical Review Criteria) 850 (8D1) UM 2.1 A
UM 2.2 E
Full Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 5 (Clinical Review Criteria) 850 (8D2) UM 3.1A
UM 3.2 B
UM 3.3 C
Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 6 (Consistency of Decisions) 850 (8D3) UM 5A
UM 2.5G
Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 7 (Assessment of Effectiveness) 850 (8D4) UM 1.4 Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 8 (Toll Free Access) 850 (8D7) No Equivalent Full Anthem BCBS met the following elements:
  • Providing members with access to review staff through a toll free or collect telephone line
  • Providing providers with access to review staff through a toll free or collect telephone line
  • Access to telephone is adequately publicized
  • Response time is adequate.
UR 9 (Compensation Incentives/UR Staff) 850 (8D9) UM 13.5I Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 10 (Compensation Incentives/ Providers) 24-4/ 4303-3B UM 13.5I Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 11 (Decision Notification) 850 (8E) No Equivalent Full Anthem BCBS met the following elements:
  • A policy for making initial determinations requiring written notice within 2 working days of request and receipt of necessary information
  • A policy for conducting concurrent reviews requiring written notice within 1 working day of the request and receipt of necessary information
  • A policy for making retrospective review determinations within 30 working days of the request and receipt of necessary information
  • A policy for written notice of adverse determinations in retrospective review determinations within 5 days.
UR 12 (Notice Requirements) 850 (8E) No Equivalent Full Anthem BCBS met the following elements:
  • A policy for notifying members and providers of adverse determinations included principal reasons for determination. However, the plan did not have evidence to reflect that attempts were made to provide this information in manner that would be understandable to the member. The plan also included instructions for requesting initiating an appeal or reconsideration, instructions for requesting a written statement of clinical rationale and review criteria and phone numbers for obtaining assistance or information.
  • A policy for written notification of concurrent review determination that included the number of extended days or next review dates, total number of days approved, services approved and the date of admission or initiation of services.
UR 13 (File Review) 850 (8D&E) No Equivalent Full 8 of 8 UR denial files (including the behavioral health delegate) contained determinations within the specified timeframes, had peer reviews, had all pertinent and appropriate clinical information, contained the reason for denial and information on the re-appeal process.
UR 14 (Liability Pending Concurrent Review) 850 (8F) No Equivalent Full Anthem BCBS had policies to provide for continued liability for services pending notification of a concurrent review determination.
UR 15 (Reconsideration) 850 (8F) No Equivalent Full Anthem BCBS had policies which addressed providers’ ability to request a reconsideration by phone, fax or in writing. In addition, the plan had policies requiring a response within 1 working day of the receipt of the request.
UR 16 (Emergency Room Services) 850 (8H) UM 11 Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 17 (Disclosure) 850 (8I) No Equivalent Full Anthem BCBS’ marketing materials contained a summary of its UR procedures and a toll free number for initiating UR decisions. In addition the member handbook contained the required information.
UR 18 (Behavioral/ Protocols) 850 (8) UM 14 A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 19 (Behavioral/ Updating Protocols) 850 (8) UM 14 B Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 20 (Behavioral/ Decision Making) 850 (8) UM 14 C Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 21 (Behavioral/ Decision Making) 850 (8) UM 14 C Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 22 (Behavioral/ Oversight) 850 (8) UM 14 Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
UR 23 (ER File Review/ Presenting Symptoms) 850 (8) UM 11 B Deemed Anthem BCBS did not deny any ER services.
UR 24 (ER File Review/Prior Approval) 850 (8) UM 11C Deemed Anthem BCBS did not deny any ER services.

 

 

Grievance and Appeals

Standard and Element as Identified in the Data Collection Tool Version 1/2/01 Associated Rule NCQA Equivalent Score Findings
GA 1 (UR Appeals Procedure) 850 (8G&H) No Equivalent Full Anthem BCBS policies and procedures for reviewing adverse utilization review determinations, expedited review and adverse determination notification meet the requirements. Anthem BCBS was given credit in 2 areas: "The covered person may appeal directly to the HMO rather than the HMO delegate", and inclusion on adverse determination notifications of "Instructions for requesting copies of any reference evidence, documentation or review criteria". These were not covered in policies and procedures but were found to be done as a standard of practice. Anthem is encouraged to include these within their policies and procedures.
GA 2 (Disclosure of Procedure) 850 (9B2) No Equivalent Full Anthem BCBS has developed a 2-page explanation of all procedures: first level, second level and external reviews. The membership booklet also briefly describes using these procedures.
GA 3 (1st Level Non-UR Procedures) 850 (9C)
24-A/4303 (4C)
24-A/4312
No Equivalent Full Anthem BCBS policies and procedures for conducting first level grievance review and for notifying covered persons of first level grievance decisions satisfy all requirements.
GA 4(2nd Level Procedures) 850 (9D)
24-A/4303 (4C)
24-A/4312
No Equivalent Full Anthem BCBS policies and procedures for conducting second level grievance reviews and for notifying covered persons of second level grievance decisions satisfy all requirements.
GA 5 (File Review/ 1st Level UR) 850 (8G) No Equivalent Full 21 of 21 files reviewed (all files available) demonstrated that reviewers had no previous involvement, and included notices that identified reviewers, stated the HMO's understanding of the basis for the appeal, adequately explained the decision and rationale, referred to evidence relied upon, and described process for requesting a second review. In addition 20 of 21 files reviewed met the time limit and 19 of 21 files used an appropriate clinical peer.
GA 6 (File Review 2nd Level UR) 850 (9D) No Equivalent Full 24 of 24 files reviewed (all files available) demonstrated a majority of the panel was appropriately comprised of clinical peers who had not previously been involved in decision-making, met time limits and provided an appropriate notice of the review to the member when indicated. In addition, the files demonstrated the HMO's understanding of the grievance, adequately explained the decision and rationale, referred to the evidence relied upon, and contained the Superintendent’s toll-free number.
GA 7 (File Review/ 1st Level Non-UR) 850 (9C) No Equivalent Full 8 of 8 files reviewed met all of the required elements.
GA 8 (File Review/ 2nd Level Non-UR) 850 (9D) No Equivalent Full 8 of 8 files reviewed me all the required elements. Although Statute does not require the HMO to provide notice of external review rights other than in cases of adverse health care treatment decisions, Anthem BCBS is encouraged to provide this notice in all cases except those related to membership decisions.

 

Access and Availability

 

Standard and Element as Identified in the Data Collection Tool Version 1/2/01 Associated Rule NCQA Equivalent Score Findings
AC 1 (Member/ Provider Ratios) 850 (7B2, 4&5) No Equivalent Full Anthem BCBS was able to demonstrate compliance with the following requirements:
  • A minimum ratio of 1 full-time equivalent PCP to 2000 members
  • Steps to assure that it had adequate numbers of providers with hospital privileges
  • Steps to ensure that its members had timely access to necessary admission that was consistent with generally accepted practices
  • A system that readily identified availability of practitioners and determined areas of low access or availability of specialists.
AC 2 (24-Hour ER Access) 850 (7B3) QI 5.1A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
AC 3 (Out of Network Coverage) 850 (7B6) No Equivalent Full Anthem BCBS had a written policy allowing a member to obtain a covered benefit from non-participating providers, at no additional cost, when the plan does not have an appropriate participating provider.
AC 4 (Geographic Accessibility) 850 (7C) No Equivalent Full Anthem BCBS demonstrated compliance with the following requirements:
  • Steps to ensure that its members had access to primary care services within the required distance or had met the requirements for an exception
  • Steps to ensure that its members had access to specialty care services within the required distance or had met the requirements of an exception
  • Steps to ensure that its members had access to hospital services within the required distance or had met the requirements for an exception.
AC 5 (Rural Access) 850 (7A4) No Equivalent Full Anthem BCBS demonstrated compliance with the following requirements:
  • A plan for providing services for rural and underserved populations
  • Implementation of the plan
  • Evaluation of the effectiveness of its plan or identification of opportunities for improvement.
AC 6 (Barrier to Access) 850 (7A5) QI 4.1 A Deemed Anthem BCBS received a designation of full on the equivalent standard in its final report from NCQA.
AC 7 (Appointment/ Waiting Times) 850 (7D) No Equivalent Full Anthem BCBS demonstrated compliance with the following requirements:
  • A plan for identifying and addressing language and literacy barriers to accessing medical services
  • Implementation of a plan to address the barriers
  • Evaluation of the effectiveness of its plan or identification of opportunities for improvement.
AC 8 (Coordination/ Continuity of Care) 850 (7F)
24- 1/4303 (6, 7)
No Equivalent Full Anthem BCBS demonstrated compliance with the following requirements:
  • Steps to ensure that members could obtain symptomatic primary care services within 7 days
  • Steps to ensure that its members could obtain preventative primary care services within 90 days
  • Steps to ensure that its members could obtain urgent primary care services within 24 hours
  • Steps to ensure its members were not kept waiting longer than 45 minutes for a scheduled appointment.
  • Written standards to ensure its members could obtain non-urgent symptomatic or chronic care specialty services within 30 days
  • Written standards to ensure that its members could obtain urgent specialty care services within 24 hours.

 

Last Updated: August 22, 2012