Provider Participation Requirements

Network providers should educate enrollees whose care is managed by CBHA about the treatment process and encourage enrollees to be familiar with procedures required by their plan. The following contains information that should be discussed with enrollees at the beginning of their treatment program:

• Patients' Rights and Responsibilities;
• Fees and co-payments;
• Benefit plan coverage;
• After-hour procedure for contact and/or procedures to follow if a clinical emergency occurs;
• Confidentiality issues;
• Treatment options available;
• Medication risks and potential side effects, if applicable;
• Communication with the primary care physician and other relevant health care providers.

Administrative Sanction

• Definition: CBHA defines an administrative sanction as a denial of payment as a result of a network provider's failure to obtain one or more of the following:
• Pre-certification of an inpatient admission, except in the case of an emergency admission. In those cases the facility must notify CBHA within 48 hours or by close of the first business day after care is rendered. Clinical case managers are responsible to ascertain whether the admission is a true emergency as defined in the Certificate of Coverage.
• Emergency Definition: An emergency mental health or substance abuse condition means the sudden or unexpected onset of a mental or substance abuse condition requiring immediate mental health or substance abuse treatment which an enrollee secures after the onset of such condition, and in the absence of immediate medical attention it could reasonably be expected by a prudent layperson, possessing an average knowledge of health and medicine, to result in any of the following: 1) serious physical impairment or death; 2) serious permanent dysfunction of the enrollee's mental health; or 3) enrollee's or a third party's health placed in serious jeopardy.
• Pre-certification of partial hospitalization or intensive outpatient treatment prior to the end of the first day of service;
• Concurrent review to obtain certification for an ongoing inpatient, partial hospitalization or intensive outpatient treatment;
• An administrative sanction is enforced when there is failure to adhere to the terms of the provider contract with CBHA; an administrative sanction is not related to medical necessity criteria.
• Network providers and providers who have signed a single case contract, and have an administrative sanction imposed upon them, may not balance bill or impose any surcharge upon an enrollee or individuals responsible for the enrollee's care.
• Clinical Case Managers are responsible to identify situations requiring an administrative sanction, to inform the provider and to enter a note into the electronic record documenting the date(s) and reason(s) for the sanction. Clinical Case Managers are also responsible to notify the QI Manager of the sanction prior to the end of the current workday.
• The QI Manager is responsible to send an Administrative Sanction Letter to the provider within 72 hours of the decision to impose the sanction. The letter identifies the enrollee, level of care, dates of service that have been sanctioned and the reason for the sanction.

Obligation to Report Abuse

Network providers must comply with all applicable state and federal child abuse, elder abuse and other emergency reporting laws. It is the provider's responsibility to understand and comply with the professional and legal requirements of the state where s/he practices.

Duty to Warn

The duty to warn may override an enrollee's usual right to confidentiality when confiding in a clinician. A CBHA network provider may release relevant clinical data or history information if a life-threatening situation exists. In instances where the provider feels that an enrollee represents a threat to others; s/he must attempt to warn the potential victim(s) in a timely manner, preferably by contacting local law enforcement.

American With Disabilities Act (ADA)

Network providers are required to comply with all provisions of The American With Disabilities Act that are applicable to the provision of care to CBHA enrollees.

Provider Sanctions

In the event CBHA becomes aware of a breach of contract by a specific provider, efforts will be made to assist the provider to correct the situation. The provider is notified, in writing, of the specific breach of contract related to a sanction. Written notification includes the following:

1. The reason for the notice;
2. The specific breach of contract;
3. The steps necessary to correct the breach;
4. Review date.

A review is scheduled to determine if corrective action has been taken; this review may include an on-site visit by CBHA staff. In the event correction has not been made at the time the review takes place, CBHA will:

1. Suspend new patient referrals to the provider for a period of six months;
2. Present the issue(s) to the Behavioral Health Quality Improvement Committee (BQIC) for a review of the provider's status;
3. Notify the provider of any recommendations made by the BQIC prior to the end of the suspension.

If the BQIC recommends approval for the provider to remain on panel pending correction of the breach, the provider will be notified of the next review date. If the BQIC recommends termination from the panel, the provider will be notified that the contract is terminated.

Termination of Providers

Providers may be terminated from the CBHA provider network in accordance with the terms outlined in the provider contract. Providers are given notification of termination in writing. Criteria for termination of a provider contract with CBHA include, but are not limited to:

1. Suspension, revocation or limitation of license, DEA certificate or practice privileges; probation, reprimand or otherwise disciplined or restricted by any state agency;
2. Suspension, censure, exclusion or disqualification by Medicare or Medicaid;
3. Submission of false or incomplete information on the application form or in the re-credentialing process;
4. Failure to return the re-credentialing application;
5. Failure to comply with any aspect of the provider contract, including failure to comply with Utilization Review procedures or BQIC recommendations;
6. Submission of erroneous, false or incomplete claims information or claims that are in violation of the provider agreement, including rendering services outside the scope of the provider's professional license;
7. Indictment or conviction of a felony or any criminal charge related to the practice of psychiatry or related health services;
8. Termination or material suspension of privileges at a network facility or another hospital where the provider has privileges, where the provider for business or other purposes did not initiate such termination not related to avoiding disciplinary action.
9. Failure of the provider to meet the credentialing standards of CBHA.

Appeal of Termination

Providers who have been terminated from the provider network for reasons related to the provider's competency and/or professional conduct would be afforded an opportunity to appeal the decision. The provider shall have the following rights in an appeal:

1. The right to represent him/herself in an appeals hearing;
2. The right to have a record made of the proceedings; copies of which may be obtained upon payment of any reasonable charges associated with preparation thereof;
3. The right to present evidence determined to be relevant to the panel, regardless of its admissibility in a court of law;
4. The right to submit a written statement at the close of the hearing.

Appeal Procedures: Network providers are given thirty (30) days from the date of the Notice of Termination to request a hearing; the request must be made in writing. A hearing date shall be scheduled not less than thirty (30) days or more than sixty (60) days after the provider's request for a hearing is received.

The hearing shall be held before a panel of individuals appointed by CBHA; panel members shall gain no direct financial benefit from the outcome and shall not have acted as accusers, investigators, fact finders, and initial decision makers or otherwise have actively participated in consideration of the matter leading up to the recommendation or action. The provider shall be entitled to a reasonable opportunity to question and challenge the impartiality of hearing panel members. Once approved, the panel members shall select a chairperson among themselves.

The provider has a right 1) to counsel; 2) to have a record made; 3) to call, examine and cross-examine witnesses, 4) to a copy of the written recommendation from the panel that includes its basis for the recommendation and, 5) to a copy of the written decision of the BQIC, including a statement of the basis for the decision if the BQIC does not adopt the hearing panel's recommendations.

The BQIC/Credentialing Committee is responsible to make a written disposition with respect to the termination within thirty (30) days after the hearing. The provider is to be notified in writing of the panel's decision within fifteen (15) days of the decision.

If, based upon facts presented at the hearing, a decision is made to reverse the termination, the termination shall be cancelled and the provider reinstated to the network.

If the BQIC/Credentialing Committee decides, based upon facts presented at the hearing, that the termination is justified and the termination is relative to the provider's professional competency and/or professional conduct, the termination is upheld and the findings are submitted to the appropriate licensing/certifying board and/or the National Practitioner's Data Bank (NPDB).