Quality Improvement

CBHA Quality Improvement Program

Carolina Behavioral Health Alliance, LLC, is committed to ensuring that network providers and enrollees receive the highest quality services possible. The CBHA Quality Improvement Program is designed to provide a framework for continuous assessment and ongoing performance improvement of all organizational functions to assure that treatment is efficient and effective and services are provided in a dignified and confidential manner. CBHA integrates generally accepted recommendations from the behavioral health community into its Quality Improvement Program to help identify areas of behavioral health practice where there are opportunities to promote an improved standard of care.

The CBHA Medical Director has the overall responsibility to ensure quality of care. The CBHA QI Manager is responsible for coordination of the operational components of the QI Program under the direction of the Medical Director. This program ensures the review and ongoing evaluation of all aspects of patient care. The CBHA QI process includes, but is not limited to:

1. Development, implementation and annual review of organization policies and procedures;
2. Development and implementation of a consistent performance improvement process;
3. Identification of key monitors and indicators;
4. Risk Management;
5. Utilization Management;
6. Credentialing and re-credentialing;
7. Preventive Behavioral Health;
8. Members/Enrollees rights and responsibilities;
9. Enrollee satisfaction;
10. Provider satisfaction;
11. Program Evaluation;
12. Treatment records, and
13. Regulatory compliance.

Behavioral Health Quality Improvement Committee (BQIC)

The CBHA Medical Director and Behavioral Health Quality Improvement Committee (BQIC) are responsible for the functions of the Quality Improvement Program. The BQIC is an action body and conducts comprehensive review and approval of the Quality Improvement Program and the annual Quality Improvement Work Plan. This committee also approves organizational policies and procedures and provides guidance for all QI activities. The Quality Improvement Program and QI Work Plan are also presented to the Board of Directors upon request.

CBHA contracts with facilities and individuals for the provision of services to its enrollees. CBHA has the following expectations of its providers and facilities relative to quality improvement:

• To maintain the confidentiality of enrollee information;
• To provide CBHA with copies of enrollees' medical records upon request;
• To accept phone calls from CBHA and to return calls concerning QI issues;
• To cooperate with clinical practice guidelines distributed by CBHA and other clinical outcome monitoring activities as requested by CBHA.

Complaint & Grievance Procedures

CBHA responds to all complaints and grievances in a timely and efficient manner that meets all regulatory and accrediting body requirements. The intent is to resolve most concerns or complaints in an informal manner to the mutual satisfaction of all involved within a very short time frame.

Complaint: A complaint is a verbal/telephone report of concern expressed by an enrollee, representative or provider relative to services received, billing/claims issues or overall satisfaction with CBHA. The majority of complaints can be resolved informally within one business day. Complainants will be advised of the formal grievance process in cases where the issue cannot be resolved on an informal basis.

Grievance: A grievance is a written report of a concern by an enrollee, representative or provider regarding any of the following:

• CBHA decisions, policies or actions related to availability, delivery or quality of behavioral health services;
• Claims payment or handling; or reimbursement for services;
• The contractual relationship between the enrollee and the insurer;
• The outcome of an appeal of a non-certification.

First Level Grievance Review: An enrollee, representative or a provider acting on an enrollee's behalf may submit a grievance to:

Grievance/Appeals Manager
Carolina Behavioral Health Alliance, LLC
P.O. Box 571137
Winston-Salem, NC 27157-1137

CBHA has thirty days to investigate a grievance and prepare a written response to the complainant. Grievances concerning quality of care provided by a provider are referred to the CBHA Medical Director, the CBHA Professional Relations Department, and the Behavioral Health Quality Improvement Committee for review and consideration of any appropriate action against a provider.

Appeals Procedure

Appeal: An appeal is a challenge by an enrollee, representative or provider acting on behalf of an enrollee, of a non-certification determination made by CBHA relative to an admission, availability of care, continued stay or other behavioral health service that had been reviewed and denied, reduced or terminated based upon CBHA's requirements for medical necessity, appropriateness, health care setting, or level of care or effectiveness.

First Level Appeal: An enrollee, representative or a provider acting on an enrollee's behalf may submit a formal written appeal within one hundred eighty (180) days of a non-certification; additional clinical information may be submitted, if available. Appeals should be addressed to:

Grievance/Appeals Manager
Carolina Behavioral Health Alliance, LLC
P.O. Box 571137
Winston-Salem, NC 27157-1137

CBHA has thirty (30) days to review the appeal and develop a written response. If the decision is not in favor of the enrollee, the decision shall include the professional qualifications and licensure of the individual conducting the review; a statement of the reviewer's understanding of what is being appealed; the reviewer's decision including criteria used, instructions for requesting a written copy of the criteria and a description of the procedure for submitting a second level review.

Expedited Appeal: An expedited appeal may be requested by an enrollee, representative or provider acting on an enrollee's behalf when a non-expedited appeal would reasonably appear to seriously jeopardize an enrollee's life, health or ability to maintain maximum function. Medical documentation may be required to justify the appeal. A written decision will be delivered to the enrollee no later than 72 hours after receiving information to justify an expedited appeal.