Affinity Health Plan

  • Quality Management
    • 1) What is QARR?

      QARR stands for Quality Assurance Reporting Requirements, which is the New York State Department of Health's version of the national Health Plan Employer Data and Information Set (HEDIS) developed and overseen by the National Committee on Quality Assurance (NCQA).
       
      The QARR consists of a set of clinical and administrative performance measures reported annually by health plans for their commercial, Medicaid, Child Health Plus and, eventually, Family Health Plus programs. The State publishes QARR results for public consumption, and uses the results in decisions affecting health plan operations. The QARR is posted on the Department of Health's Web site (http://www.health.state.ny.us/nysdoh/mancare/mcmain.htm).
       
      Examples of QARR measures include rates of childhood immunization, prenatal and postpartum visits, HbA1c testing and control for diabetics, cervical cancer screening, access to PCPs, inpatient utilization, provider turnover, and HIV testing in pregnant women. The QARR also includes a DOH administered Member Satisfaction Survey.

    • 2) Why does Affinity Health Plan Quality Management (QM) staff perform site visits to provider practices?

      There are several reasons why the QM Department might request an appointment to come to your practice site:
       
      Conduct chart review:  
      » to retrieve information on services delivered to our Members for which we have no encounter or claim in our database;
      » to review indicators of care for a clinical study or monitoring process;
      » to validate diagnoses and/or services recorded in our administrative database;
      » to review quality of documentation and/or care for the recredentialing process; or
      » to investigate a member complaint.
      » When the QM team reviews charts, it is the provider's responsibility to pull the requested charts.
       
      Copy charts: 
      » For SDOH studies conducted by IPRO, such as the Prenatal Care Review of PCAP Standards;
      » for our SDOH annual licensure review; or
      » for complaint investigations.
      » When the QM Team copies charts, it is the provider's responsibility to pull the charts and make a copy machine available.
      » Conduct Performance Improvement Meetings:
      » For collaborative brainstorming, identification of opportunities for improvement, and evaluation of barriers and development of plans to improve performance rates; or
      » For quality management activities including QARR, studies, recredentialing and/or SDOH reviews of care
      » When the QM team requests these meetings, it is the provider's responsibility to make appropriate staff available to meet at an agreed upon time.

    • 3) What is a report card or performance profile?

      A report card or performance profile is a summary of a network or practice site’s and/or performance rates on various types of care provided to our Members. Following the annual QARR review, for example, a provider's performance rates for the QARR measures are compared to the aggregate performance of county and all Affinity Health Plan providers.

      Best practices and opportunities for improvement are identified evident and form a basis for the QM Department to work with the provider on sharing successful methodologies and/or overcoming barriers to improving performance.

  • Medical Management
    • 1) What is the difference between a referral and a prior authorization?

      A Referral Form is required whenever a PCP refers a patient to another provider for consultation or treatment. Referrals for most services do not require prior approval by our Medical Management (MM) Department; the provider receiving the referral can provide the requested service based on the PCP referral alone. Those services that do require MM Department authorization are listed at the bottom of the Referral Form. For these services, the provider (PCP or specialist receiving the referral) must contact our MM Department and submit clinical information to support the request before delivering the service.

    • 2) What specifically is Medical Management looking for when they ask me to submit clinical information?

      Our MM Department is reviewing the information to determine medical necessity using nationally accepted clinical review criteria. In most cases, the elements needed to make a decision are contained in the physician's progress notes including past history, signs and symptoms, current treatment regime and reason for requesting the service. Providers can fax a copy of the patient's progress notes to us to facilitate the authorization process (1-718-794-7822 or 1-718-536-3329).

    • 3) Does a specialist need to refer the patient back to the PCP to order an MRI?

      No, the specialist may order the MRI, but must adhere Affinity Health Plan rules regarding prior authorization. The specialist is expected to relay his/her findings and recommendations back to the PCP. The specialist cannot refer the patient to another specialist.

    • 4) How long does the authorization process take?

      For non-urgent requests, we comply with the State mandate that determinations be made and communicated back to the provider and Member within three (3) business days of receipt of necessary clinical information.

    • 5) What if the provider considers a situation to be life threatening and cannot take the time to call Affinity for authorization?

      In urgent cases, the provider can provide the service, and then request retrospective authorization by submitting supportive clinical information to us with notification that the service has already been performed.

    • 6) What can be done if Affinity denies the requested service?

      The provider may wish to pursue a more conservative treatment approach first. If the provider does not agree with our decision, he/she may file an appeal with us. Information on how to file an appeal is included with our adverse determination, i.e., denial letter.

  • Transportation
  • Personal Care Services
    • 1) How is Affinity Health Plan (Affinity) handling new cases that have an existing authorization from HRA? Do we honor the HRA full authorization period or authorize for a limited time?

      Affinity was provided a list of approved HRA cases from New York City, Long Island, Westchester, Rockland and Orange counties. Affinity will honor the authorizations and their assigned expiration dates for up to six months from the date of transition to Affinity. Personal care service providers with HRA issued authorizations beyond 2/28/2012 will need to request authorization for an updated nursing assessment and personal care services. Affinity requires that providers request the nursing assessment and personal care services at least 30 days prior to the expiration date of the existing authorization.

      Affinity received a list of HRA cases with expired authorization dates. Affinity will extend those authorizations up to 60 days but no longer than 10/1/11. Affinity requires that providers request an authorization for the nursing assessment and personal care services at least 30 days prior to the expiration date of the existing authorization.

      Personal care service providers will need to submit a new MD order 30 days prior to the end of the authorization for evaluation of continued services.

    • 2) When are we required to perform the first nursing assessment for Affinity?

      Upon receipt of the completed MD order, Affinity will authorize a Nursing Assessment (RN evaluation) for personal care services. This assessment in the approved Affinity Health Plan format should be completed within 2 business days of the RN Assessment authorization.

      For re-authorization, Affinity requires that personal care service providers request authorization for continued services at least 30 days prior to the end of the authorization period. At that time, providers must submit a new MD order. Affinity will issue an authorization for the RN Assessment for re-evaluation, and continuation of personal care services.

    • 3) Who is responsible for obtaining the MD order, when the nursing assessment form is required?

      Affinity providers that are contracted for conducting Nursing Assessments are required to obtain the MD order for the RN evaluation and personal care services.

    • 4) How frequently should Nursing Supervisory visits be performed?

      Supervisory nursing visits should be performed by the contracted personal care agency at least every 6 months when:

      • the patient is self-directing; and the patient's medical condition is not expected to require any change in the level, amount or frequency of personal care services authorized during this time period.

      Nursing supervisory visits must be made at least every 90 days when:

      • the patient's medical condition requires more frequent visits; or
      • the patient is not self-directing; or
      • the person providing personal care services needs additional or more frequent on-the-job training to perform assigned functions and tasks competently and safely.

      The nurse supervisor must prepare a written report of each orientation visit and each nursing supervisory visit.

      A copy of the report must be submitted to Affinity via the Home Care Fax line (718-536-3328) and maintained in the Member’s record.

      One vendor stated that historically, they were not required to obtain nursing assessment for housekeeping clients. A vendor stated that for housekeeping clients, the nurses only completed a supervisory form.

    • 5) Do Level 1 or housekeeping services require prior authorization?

      All Nursing Assessments, Level 1 (includes housekeeping services) and Level 2 personal care services require an MD order and prior authorization. A nursing assessment should be completed to confirm that the level of care required has not changed. Supervisory visits of assigned staff do not provide the same depth of information.

    • 6) Is Case Management the responsibility of the Plan?

      The Plan of Care is the plan's responsibility and is based in part upon the completed nursing assessment.

    • 7) Do you require any documentation (i.e.certificates or profiles) to be sent to your agency for all permanent or replacement aides?

      Please refer to credentialing requirements in your Affinity Provider Agreement.

      Medical Management requires standard documentation of the care provided during the personal care visit.

    • 8) How should the agency handle the following related to personal care services?

      A. aide changes

      Notification within 1 business day of occurrence via the Home Care Fax Line (718-536-3328)

      B. replacement aides

      Notification within 1 business day of occurrence via the Home Care Fax Line (718-536-3328)
      C. schedule changes (hours)

      Notification within 1 business day of occurrence via the Home Care Fax Line (718-536-3328)

      D. client hospitalizations

      Notification same business day with name of facility, date of admission via the Home Care Fax Line (718-536-3328)

      E. client vacations

      Notification same business day via the Home Care Fax Line (718-536-3328)

      F. refusal of service

      Notification same business day with reason for refusal; whether refusal one-time only or for remainder of authorized care via the Home Care Fax Line (718-536-3328)

      G. medication issues

      Notification same business day with concurrent notification to prescribing physician as indicated, via the Home Care Fax Line (718-536-3328)

    • 9) What is your procedure if a client needs or requests an emergency increase?

      • Notify Affinity Health Plan immediately of precipitating event.
      • Notify primary care or prescribing physician immediately for request of emergency increase or recommendation for alternate level of care.
      • Contact Affinity Health Plan with physician orders for emergency increase.
      • If unable to contact physician, notify Affinity Health Plan for coordination of alternate level of care.

    • 10) Should we be notifying your agency at the moment at which this occurs or within 24 hours?

      Yes, notification same day via the Home Care Fax Line (718-536-3328).

    • 11) How do we submit for payment as the emergency is not authorized?

      Please follow above-referenced process. Authorization will be issued after receipt of physician orders for emergency care.

    • 12) When and how do you want to be notified of falls and incidences? What is your time frame for notification? Do you have specific protocols that we need to follow? Is our documentation sufficient or do you have your own reports that you require us to complete?

      Please submit an Affinity Sentinel Event Form on same business day of occurrence. Please complete form in its entirety and fax to the Home Care Fax line at 718-536-3328.

    • 13) To whom do you want non-business hour and weekend communication directed to which may include incidents, inability to locate a client and or hospitalizations?

      Please provide the appropriate and specific persons, contact information to report/address any client concerns. Please contact supervisor on call for emergent issues at 917-807-5845, non emergent issues to the Home Care Fax line at 718-536-3328.

    • 14) What is PERS?

      At this time, NY Medicaid Personal Emergency Response Services (PERS) are provided through contracts negotiated between local departments of social service and the PERS provider.

      The local department of social service authorization for PERS services is based on a physician's order and a comprehensive assessment which must include an evaluation of the client's physical disability status, the degree that they would be at risk of an emergency due to medical or functional impairments or disability and the degree of their social isolation.

      Affinity Health Plan personal care services providers are asked to complete the PERS Assessment and PERS Evaluation forms as part of the Nursing Assessment for personal care services.

    • 15) How can member eligibility be checked to ensure Members belong to Affinity?

      For Medicaid members, eligibility may be checked by calling 866-247-5678 (follow the prompt for provider relations), or to check online visit www.emedny.org/epaces.

    • 16) How long does it take to pay a claim?What is the timeframe for submitting an appeal?

      Claims are paid within 30 days; the timeframe is calculated from the claim’s receipt date to pay date. A provider’s verbal or written requests for appeal must be communicated to Affinity within 45 days following receipt of the Explanation of Benefits.