overall quality management

7O v e r a l l Q u a l i t yM a n a g e m e n t

Over view ........................................125

Credentialing and Recredentialing ....129

Medical Record Review ....................133

Continuity of Care ..........................136

Provider Disciplinar y Policies and Procedures ...............................139

Disciplinar y Action Appeals .............145

124 www.oxfordhealth.com

Section 7 — Overall Quality Management

Overview

Oxford’s Quality Management (QM) program focuses on the delivery of healthcare and services for all Oxford Members through the implementation of a comprehensive, integrated, systematic process that is based on quality improvement principles. QM program activities include:

• Identification of the scope of care and servicesrendered by providers

• Development of clinical guidelines and servicestandards by which performance will be measured

• Objective evaluation and systematic monitoring of the quality and appropriateness of services andmedical care received from Oxford providers

• Assessment of the medical qualifications ofparticipating providers

• Continuing improvement of Member healthcare and services

• Efforts to assure patient safety and confidentiality of Member medical information

• Resolution of identified quality issues

The ultimate authority and oversight responsibility of our QM program lies with the Oxford Board ofDirectors. Day-to-day QM operations are delegated to the Director of Quality and Disease ManagementOperations and the Medical Director of Quality and Disease Management.

To request information regarding our QualityManagement program, please write to:

Oxford Health PlansQuality Management DepartmentDirector of Quality Management Programs44 South BroadwayWhite Plains, NY 10601

Quality Management

Committee Structure

Regional Quality Management Committees (RQMCs)oversee QM activities and address specific issues that arise in their respective geographic regions. These issues include review and recommendationsregarding clinical practice guidelines, medical policies,credentialing and recredentialing, service standards,and Member complaints and grievances aboutproviders that relate to quality of care and service.These committees also provide input on decisionsrelated to physician disciplinary activities, makerecommendations regarding the selection of QMstudies (based on identified high-volume, high-risk and problem-prone areas in their regions) and develop and implement regional components of the QM work plan. Please refer to the QM CommitteeFlow Chart on the following page.

OOXF O R D | I M PO RTA NT A D D R ES S

www.oxfordhealth.com 125

Overall Quality Management — Section 7



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Quality Management

Program Activities

• Identifying high-volume, high-risk and problem-prone areas of care and service affecting Oxford’s population

• Developing Clinical Practice Guidelines forpreventive screening, acute and chronic care, andappropriate drug usage, based on the availability of accepted national guidelines; the ability to monitor compliance; and the ability to make asignificant impact upon important aspects of care

• Undertaking quality improvement studies in clinical areas identified through careful claims data analyses; these include frequency and costbreakdowns by Member’s age, sex and line ofbusiness, episode treatment groups, major medical, procedure categories, diagnosis, and DRGs; additional clinical areas are identified andstudied per government contract requirements and healthcare industry standards

See HEDIS Measures in this section.

• Utilizing population-based preventive healthcareaudits to assess the level of preventive care renderedacross Oxford’s membership; separate studies arecompleted for special risk groups

• Conducting regular surveys to assess Membersatisfaction, provider satisfaction, employer (client) satisfaction, and reasons for voluntaryprovider disenrollment

• Tabulating adherence to physician service standardsin areas such as wait times for appointments, in-office care and practice size and availability; somemeasurement methods we use are examination ofproviders’ appointment books, interviews with officemanagers during site-visits, direct surveys measuringprovider compliance with the above standards, andreview of PCP and OB/GYN panel size

See section 3 on Participating ProviderResponsibilities and Information.

• Monitoring performance of QM-related functions for compliance with contract, including activities such as oversight of policies and procedures,reporting activities, encounter reporting, andregulatory compliance

• Conducting routine medical record audits to assessphysician compliance with Oxford’s medical recordreview standards and preventive care guidelines, aswell as monitoring coordination and continuity ofcare between PCPs and specialists

• Completing a comprehensive medical record review by a Clinical Reviewer from Oxford’s QMDepartment for a statistically significant sample of PCP offices with panels of 50 or more Membersand high volume OB/GYNs; for PCPs with fewer than 50 Members and for all new PCP applicantsundergoing the initial site survey, a representative of Oxford’s Provider Relations Department reviews a sample of a blank medical record to assess medicalrecord keeping practices as part of the site-visitevaluation; findings of the audit are reported to the provider; Oxford expects providers whose auditsfall below standards to take corrective action

• Reviewing and resolving Member complaintsregarding the provision of medical care and services;investigation may include verbal and written contactwith the Member and provider as well as a review of relevant medical records; once the complaintreview is completed, Oxford sends the Member and the provider(s) a resolution letter describing the outcome of the review; Oxford maintains adatabase of complaint resolution dates

HEDIS Measures The annual Health Plan Employer Data InformationSet (HEDIS) was developed by the National Committee for Quality Assurance (NCQA). NCQA is an independent group established to provideobjective measurements of the performance ofmanaged healthcare plans, including access to care, use of medical services, effectiveness of care, preventiveservices, and immunization rates, as well as each plan’sfinancial status. HEDIS measures have become keycriteria that employers, consultants, the Centers for Medicare & Medicaid (CMS) (Medicare), state regulators (commercial), and prospectiveMembers use to evaluate the demonstrated value and quality of different health plans. Oxford alsodiscloses disenrollment rates, information on enrolleesatisfaction and health outcomes data for OxfordMedicare AdvantageSM Members to CMS.



HEDIS Measures on which Oxford is Focused

Category Measure

Pediatric Childhood immunization rates preventive care for age 2

Lead and growth screening up to age 2

Well-child visits by age 15 months

Well-child visits at ages 3, 4, 5, and 6

Adolescent Adolescent immunization rates preventive care

Adolescent well-care

Prenatal Prenatal and postpartum care

Adult Advising smokers to quitpreventive care

Influenza and pneumoniavaccinations for older adults

Breast cancer screening rates

Cervical cancer screening rates

Chlamydia screening rates for women

Chronic/ Diabetic retinal examsacute care

Comprehensive diabetes care

Beta blocker treatment after heart attack

Controlling high blood pressure

Use of appropriate medicines for the treatment of asthma

Management of menopause

Cholesterol management after acute cardiovascular events

Glycohemoglobin testing for diabetics

Follow-up after hospitalization for mental illness

Antidepressant medicationmanagement

Seniors’ health

Patient Safety Program

Oxford has established a series of initiatives designed to improve the safety and security of its Members. The Patient Safety Program involves the measurement,monitoring, trending, and reporting of key indicatorsacross all departments within Oxford.

The initiatives include:

• Improving continuity and coordination of careamong providers to assure optimum outcomes for Members

• Improving continuity and coordination between sites of care such as hospitals and nursing homes to assure timely and accurate communication

• Using visit credentialing reports andrecommendations to improve safe practices among providers and medical facilities

• Evaluating current clinical practices against aspects of national practice guidelines and recommendingchanges where appropriate

• Tracking adverse event reporting to identify systemsissues that contribute to poor safety

• Analyzing and taking actions on complaint andsatisfaction data that relate to clinical safety

• Educating members to make informed decisionsthrough the use of Subimo™ Healthcare Advisor; this application on Oxford’s web site providesMembers with customized information on hospitals,treatment options, complication rates, and questionsto ask their doctors

In addition, Oxford is a member and supports theinitiatives of the Leapfrog Group. Composed of over145 employers, Leapfrog works with medical expertsthroughout the U.S. to identify problems and proposesolutions that will improve hospital systems. Oxfordencourages our provider network to complete theLeapfrog web survey and share information with theircommunities about their efforts to reduce preventablemedical mistakes.

The Best Practices ProgramSM

Oxford’s Best Practices Program (BPP) aims to workcollaboratively with physicians and providers to refinepractice patterns according to nationally acceptedstandards. To achieve these goals, we evaluate physiciantreatment patterns based on quality measures and on



utilization of tests and procedures in the context ofeach specialty and patients seen. We provide the resultsto providers so that you can compare your practicepatterns to those of your peers and, where applicable,make refinements to those practices and costs that vary markedly from the industry’s highest standards.

As part of our BPP and NCQA process, Oxford will continue to assess clinical quality and measureutilization at least annually through Episode TreatmentGroup™ (ETG) analysis. ETG is a patented illnessclassification system that draws on national health data to match patient-specific diagnoses to patient-specificcosts, including pharmaceuticals and length of treatmentepisode, in over 500 different diseases or conditions. The scope of the ETG database, which is drawn from100 million disease-specific episodes, allows for weightedcomparisons across a range of patient demographics,including age, gender and co-morbidity, therebysupporting sophisticated quality assessment.

Oxford’s BPP is specifically designed to encourage the use of appropriate care and services to preventand/or treat illnesses. It does not offer any incentives to reduce or deny service as a means of controllingcosts. Members should be assured that all utilizationmanagement decisions made by you or an Oxford staffmember are based on the appropriateness of the careand services requested and the existence of coverage.

Credentialing andRecredentialing

Oxford is dedicated to providing its Members with access to effective (medically necessary) healthcare and,as such, requires participating physicians to be board-certified or eligible to become board-certified within five years of satisfactory completion of an accreditedresidency/fellowship program. However, exceptions will be evaluated on a case-by-case basis. Considerationsinclude, but are not limited to, physicians servingcommunities in which a special requirement is identifiedand where the population is otherwise under served byOxford’s physicians. Typically, this includes familiaritywith a foreign language or culture dominant amongMembers in that community.

Oxford periodically reviews the credentials of everynetwork provider in order to maintain and improve thequality of care and services delivered to our Members.Oxford’s credentialing standards are more extensivethan (though fully compliant with) NCQA requirements.

A credentials file is maintained on all Oxford providers.Credentialing decisions are made by Oxford’s RQMC or the Vice President of Quality Management.Recommendations for action are passed to thiscommittee on a timely basis and all applicants arenotified by a letter of any decision made by the RQMC. RQMC regional offices are located in Trumbull,Connecticut; New York, New York; and Iselin, New Jersey.

Provider Types that Can Be Credentialed

• Physicians (MDs)

• Osteopaths (DOs)

• Dentists (DDS or DMDs)

• Podiatrists (DPMs)

• Select health delivery facilities:

• Hospitals

• Home healthcare agencies

• Skilled nursing facilities

• Ambulatory surgery centers

• Mental health facilities

• Birthing centers

• Alcohol/drug rehabilitation facilities

• Sub-acute centers



Provider Types that Can Be Credentialed (continued)

• Providers affiliated with freestanding ancillaryfacilities that do not already have accreditationsatisfactory to Oxford

• Non-physician providers:

• Social workers (CSWs and MSWs)

• Marriage and family therapists

• Psychologists

• Nurse midwives

• Physical therapists

• Occupational therapists

• Speech therapy/pathology providers

• Audiologists

• Optometrists

• Nurse practitioners

• Registered dietitians

• Psychiatric clinical nurse specialists

• Naturopathic doctors

• Acupuncturists

• Chiropractors

• Massage therapists

• Nutritionists

• Yoga instructors

• Physician assistants

• Licensed professional counselors

Double-Boarded Providers

Physicians who are boarded as PCPs (does not apply to pediatricians) and who practice in the subspecialtieslisted below must elect to participate as either a PCP or a specialist. Participation in both is prohibited.Physicians of these subspecialty groups who are alreadycredentialed as both PCPs and specialists will remainparticipating as both:

• Cardiology

• Gastroenterology

• Pulmonary medicine

• Hematology/oncology

• Allergy/immunology

Individual Providers

Credentialing Requirements

Oxford requires the listed credentials and documentsfor the following provider types:

• Physicians and osteopaths (MDs, DOs, DDS, DMDs, DPMs):

• Current, valid state license

• Current, valid Drug Enforcement Agency (DEA)registration certificate

• Current, valid Controlled Dangerous Substances(CDS) certificate (NJ only)

• Board certification or satisfactory completion of an approved residency program within the last five years

• Malpractice insurance in the amounts of $1,000,000per occurrence, $3,000,000 in the aggregate($500,000 per occurrence and $1,000,000 inaggregate for PA)

• Admitting privileges at an Oxford participatinghospital for all PCPs and most specialists (when applicable)

• History of professional liability claims

• Medicaid and Medicare sanctions

• A work history with explanations of any gaps from completion of the residency/fellowshipprogram to date of current practice

• Non-physician providers:

• Current, valid state license

• Certification/registration

• Advanced degree

• Graduation from appropriate school

• Malpractice insurance in the amounts of $1,000,000per occurrence, $3,000,000 in the aggregate($500,000 per occurrence, $1,000,000 in theaggregate for PA)

• History of professional liability claims



• Medicaid and Medicare sanctions

• Collaborative practice agreement, as applicable by specialty

• Post-graduate training, as applicable by specialty

• Documentation of a formal arrangement forpsychiatric medication consultation, as applicable by specialty

• A work history with explanations of any gaps from completion of school/training program to date of current practice

• Ancillary providers:

• Providers affiliated with an accredited facilityaccepted by Oxford do not need to be credentialed by Oxford

See Facilities Credentialing in this section for a list of approved accreditation agencies.

• Providers affiliated with non-accredited facilities maybe credentialed by Oxford following the criteriapreviously outlined

Credentialing ApplicationOxford is a member of the Council for AffordableQuality Healthcare (CAQH) and as such utilizes the CAQH Universal Credentialing DataSource forgathering credentialing data for physicians, dentists and chiropractors.* Oxford made provider dataavailable to CAQH during the initial rollout of thedatabase to help CAQH prepopulate the database.CAQH agrees to maintain the confidentiality of theinformation and to use it solely for the purpose ofperforming services for Oxford in connection with the credentialing process.

* All other practitioners complete the appropriate Oxford Provider Application.

For more information on CAQH, please visitwww.caqh.org.

Completed applications include:

• General demographic and practice information(PCPs are required to keep a minimum of 20 hoursper week available for office appointments)

• Educational history, both undergraduate andmedical/dental school

• Postgraduate training

• Continuing medical education (CME) (physicians who are not board-certified must submit documentation of CME credits obtainedwithin the last three (3) years; Oxford requires either 150 CME credits every three years or submission of the American Medical Association [AMA]Physicians Recognition Award)

• Malpractice insurance policy information

• Details of continuous work history (i.e., no breaks since completion of training)

• Attestation by the provider alerting Oxford of anymalpractice issues or sanctions against the provider byfederal or state agencies, hospitals or other healthcareinstitutions to which the provider has been appointed

• Unaltered and signed Oxford Provider Agreement

Credentialing Review Process for Physicians

• Oxford verifies state license, postgraduate training,DEA certification, CDS certification (NJ only), andboard certification

• We contact the National Practitioner Data Bank(NPDB) and the Healthcare Integrity and ProtectionDatabank (HIPDB) concerning malpracticesettlements or any reported actions; NPDB reportswhether any hospital or managed care organizationhas sought to limit, suspend or abolish your privileges;NPDB also verifies current state and federal listings of physicians barred from providing Medicare orMedicaid services; HIPDB maintains any federal orstate civil or criminal judgments against providers

• An Oxford Provider Relations Field Representativemakes a site visit to all PCPs, OB/GYNs andbehavioral health providers to evaluate officeprocedures, safety precautions, emergency protocols,and medical-record keeping

• Oxford may enter into contracts with third parties to perform services for Oxford in connection with the credentialing review process; Oxford may disclose information to the third party; however, the information is kept confidential



RecredentialingTo maintain the integrity of our provider network, allparticipating providers must adhere to credentialing and recredentialing standards. An important standardthat NCQA measures for recredentialing is the timelinessof recredentialing. The standard states that managedcare organizations should formally recredential theirproviders at least every three (3) years.

To remain in good standing as a network provider it is imperative that you complete your recredentialing as instructed by Oxford and CAQH.

Recredentialing Review Process for Physicians

• Oxford verifies state license, DEA certification and board certification through primary source verification

• Oxford confirms malpractice claims liability historythrough NPDB and HIPDB; Oxford queries HIPDBfor information on all providers undergoing therecredentialing process; this data bank providesOxford with data on civil judgments related tohealthcare delivery, federal or state criminalconvictions against healthcare providers, actions byfederal or state licensing agencies against healthcareproviders, and exclusions of healthcare providers fromparticipation in federal or state healthcare programs

• Oxford may enter into contracts with third parties to perform services for Oxford in connection with the recredentialing review process; Oxford maydisclose information to the third party; however, the information is kept confidential

• Various Oxford departments contribute quality-related data on each provider undergoing therecredentialing process; the information gatheredand the responsible departments are as follows:

Information Department

Complaint profile Quality Management

Medical record review data Quality Management

Results of site evaluations Provider Relations/Quality Management

Any adverse action Various departments

Notification

All information compiled during the recredentialingreview process will be evaluated by the Regional QualityManagement Committee or the Vice President ofQuality Management, whose decision will becommunicated to the provider by letter. Oxforddepartments maintain documentation of allcorrespondence in the provider’s credentials file.

Facilities

Credentialing RequirementsOxford requires that an initial quality assessment becompleted for all newly participating facilities prior tothe finalization of a contract relationship. All hospitals,home health agencies, skilled nursing facilities,ambulatory surgery centers, mental health facilities,birthing centers, alcohol/drug rehabilitation, and sub-acute centers must demonstrate good standing with state and federal regulatory agencies. In addition,Oxford requires all facilities to be accredited by arecognized and relevant accrediting agency. (Please see chart below.) Facilities that do not meet thisaccreditation standard may be included in Oxford’sprovider network only if they are able to demonstratecompliance with our Standards for Participation.

Facility Accreditation Required

Hospitals JCAHO1

Home health agency JCAHO or CHAP2

Skilled nursing facility JCAHO or CARF3

Ambulatory surgical JCAHO or AAAHC4

center or AAAASF5

Mental health facility JCAHO or CARF

Birthing centers JCAHO, CABC6 or AAAHC

Alcohol/drug JCAHO or CARFRehabilitation facility

Sub-acute center JCAHO or CARF or AAAHC

1 Joint Commission on Accreditation of Healthcare Organizations 2 Community Health Accreditation Program 3 Commission on Accreditation of Rehabilitation Facilities4 Accreditation Association for Ambulatory Health Care5 American Association for Accreditation of Ambulatory Surgery Facilities6 Commission for the Accreditation of Birth Centers



Credentialing Review Process for Facilities

Prior to contracting with a facility, an Oxford ContractCoordinator must obtain the following documentsnecessary for credentialing either from the facility orfrom primary verification sources:

• Completed facility questionnaire

• Current, valid state license and/or written or verbal verification of such licensure from theappropriate state licensing agency

• Verification that the facility is in good standing with state and federal regulatory agencies (notnecessary if facility is accredited); CMS delegates the assessment of compliance with federal regulations to the state regulatory agencies for all of the previously listed facilities

• Verification of good standing with independentaccrediting agencies

• Special certificate (only required for mammography centers)

• Clinical Laboratory Improvement Amendment(CLIA) Certificate

• Malpractice insurance

• Medicaid and Medicare certification and/or provider number

• Medicaid and Medicare sanctions and/or verification of none

• Facility site visit from an Oxford Medical DeliverySystem’s representative and/or facility site visit doneby one of QM’s registered nurses (if not accredited)

• Individual providers credentialed, if not accredited(MDs and DOs only)

• W-9 substitution form

Recredentialing • All facilities must be recredentialed every three (3) years

• The facility must confirm the information submittedfor the original credentialing process and provideupdated copies of all credentialed materials

• Those facilities not accredited will have an on-sitereview from an Oxford representative

• All documents submitted as well as documentsOxford may have obtained while verifying thefacilities credentials are added to the file

• All facilities receive written notification of the statusof their recredentialing

Medical Record Review

Monitoring the Quality of

Medical Care Through

Review of Medical Records

A well-documented medical record reflects the qualityand completeness of care delivered to patients. Regularreview of medical records can provide data that helpsproviders improve preventive, acute and chronic carerendered to patients. Accreditation and regulatoryorganizations, such as your state Department of Health(DOH) and CMS, include review of medical records aspart of their oversight activities. Oxford requires medicalrecords to be maintained in a manner that is current,detailed and organized, and which permits effective and confidential patient care and quality review.

One of the purposes for which Oxford regularlyconducts medical record audits is to assess appropriate,accurate and complete documentation of Members’care. Oxford’s QM clinical review staff audits themedical records of a random sample of PCPs with 50 or more Members in their practice. Medical records are also monitored for appointment access and coordination and continuity of care. We derive our standards for medical record review from the CMS Documentation Guidelines for Evaluation and Management Services, The American MedicalAssociation, and the NCQA Guidelines for ManagedCare Organizations. These standards address four (4) major categories:

• General Member information

• Medical history

• Physical assessment and treatment plan

• Continuum of care, which addresses specialty care,emergent care, home healthcare, and inpatient stays in acute and non-acute settings

In addition to these standards, medical records are alsoreviewed for documentation of nationally recommendedpreventive and chronic care measures, as well as selectedHEDIS measures. Reviews are performed on-site at theprovider’s office. A representative sample of charts isselected to obtain an accurate cross-section of thepractice. The following are examples of a review sample.



Internal medicine practitioner charts reviewed includeat least:

• One (1) female age 20-50

• Two (2) females and two (2) males greater than age 50

Pediatrician charts reviewed include at least:

• Two (2) children age two (2)

• Two (2) children whose 3rd, 4th, 5th, or 6th birthdayoccurred the previous year

• Two (2) adolescents

Please note: Oxford also performs chart audits for othervalid business purposes as permitted by your contract with Oxford.

Communicating Audit ResultsResults of such medical record reviews arecommunicated in a number of ways. Aggregatescores are reported by region to the Regional andExecutive Quality Management Committees. Inaddition, interventions to promote improvement in documentation are developed and implementedbased on these results.

Individual results of all reviews are tabulated in a reportmailed to each reviewed provider. Each report containsinformation of passing thresholds and the reviewedprovider’s scores, both aggregate and for each measure,indicating levels of passage, areas of strength andopportunities for improvement. Providers who fallbelow established thresholds are encouraged todevelop a plan of corrective action that addressesdeficient areas. Implementation and effectiveness ofthe plans are re-evaluated within the following year.

Independent Medical Record Audit ResultsOxford recently retained an independent agency toperform an audit of records from random groups ofproviders. The results of that audit illustrate how wellprovider’s medical records conform to standards. Amongcritical chart elements, treatment plans and appropriatetreatment were consistently evident in charts. Amongnon-critical elements, appropriate use of consultants, lab and other studies ordered as appropriate, as well ascomplete immunization records were also consistentlypresent in charts. However, one element found to begenerally deficient in our providers’ records wasprominent display of patient allergy history on the

medical record. The recent audit also recommendedthat improvements were warranted in the area ofmedical record documentation as it applies toemergent care follow up through interim visits.

Standards for Medical

Records

Oxford has established the following standards formedical recordkeeping for PCPs in recognition of theimportance of maintaining organized, up-to-date anddetailed medical records as an aid in the delivery ofquality care:

• Charts must be kept for individual patients in asecured area, away from patient access but readilyavailable to practitioners

• Charts must be legible and organized in a mannerthat reflects continuity and allows for easyidentification of major medical problems

• The office must have policies in place for maintainingpatient confidentiality in accordance with state andfederal laws

• Providers must follow applicable professional andclinical guidelines for documenting care provided to Members

Confidentiality of Medical RecordsOxford requires providers to maintain Memberconfidentiality related to medical records in accordancewith current applicable state and federal laws.

Medical Records DocumentationMedical records should include the followingdocumentation, as well as any other information deemed appropriate or required by applicable standards:

General Information

• Patient name on each page

• Address, phone number, Social Security number, or other identifiers

• Name of next of kin

• Date of visit

• Signature of person making the entry




Immunization Record

• For all children of school age

• Record of Tetanus-diphtheria (Td) booster, flu vaccine and pneumococcal vaccine for applicable adults

Treatment Plan

• Documentation to support that the treatment plan is appropriately carried out through the following:

• Diagnostic testing

• Use of medication

• Referrals to specialists

• Surgical interventions

Medical History

• Documentation of past medical, surgical, family, and social history

• Birth history should be noted for children under age 10

• Notation of the chief complaint or reason for eachvisit with history of the present illness

Preventive Screening

• Evidence of appropriate preventive screening, based on clinical guidelines, by sex and age

See Preventive Care Guidelines in Section 3.

Continuity of Care

• Evidence of continuity of care in the following areas:

• Problems of previous visits are addressed

• The physician reports (dated and initialized)showing review results of diagnostic testing and abnormal results are noted and followed up appropriately

• Consultation reports or notes are made by the physician reflecting the results of specialistreferrals with evidence that recommendations are followed through

• Recent hospitalizations, ER visits, ambulatorysurgeries, etc., are recorded and follow-up iscompleted as needed

• A complete problem list and medication list aremaintained for patients with multiple and/orchronic problems

• Documentation of communication between PCP and behavioral health provider for thoseMembers in ongoing treatment

Allergies

• Notation of allergies or lack of allergies on a face sheet or initial visit sheet

• Allergies to medications or any other severe,potentially life-threatening allergic reactions that should be flagged (e.g., severe food allergies, bee stings, contrast dye)

Physical Exam Information

• Documentation of a pertinent physical exam that includes:

• Height and weight by the third visit, followed up as applicable for pediatrics, obesity, etc.

• Record of vital signs, including baseline heart rate,respirations and temperature, as applicable, for any complaint indicating possible infection

• Blood pressure, recorded as appropriate for age and history

• Complete review of systems for a complete physicalexam and/or review of pertinent systems for anyacute care or follow-up visits

• Notation and revision of a working diagnosis

• Written plan consistent with the diagnosis

Family Communications

• Evidence of communication with the patient/familyabout the following:

• Patient/family notification of abnormal test results

• Need for return visit

• Need for special diet, therapeutic exercise,restriction of activity, or any other special instruction

• Signed consent form for all invasive procedures

• Signed release of confidential information as necessary



Continuity of Care

Continuity and

Coordination of Care

Continuity and coordination of care ensures ongoingcommunication, monitoring, and overview by the PCPacross each patient’s entire healthcare continuum.Documentation of services provided by specialists suchas podiatrists, ophthalmologists and behavioral healthpractitioners, as well as ancillary care providersincluding home care and rehabilitation facilities, helpthe PCP maintain a medical record that comprises acomplete picture of the healthcare delivered to eachindividual. To further address the continuum of care,the PCP should note in the medical record anyemergent or inpatient care received from facilities orancillary services, as well as any specialist care receivedby their patient. The PCP should specifically requestthis history from their Members.

Please note: Elements of the chart indicating continuityand coordination of care among practitioners are required byNCQA and state Departments of Health in the tri-state area.

Oxford monitors the continuity and coordination of care that Members receive through the following mechanisms:

• Medical record reviews are conducted on a sample of primary care physicians with 50 or more Oxfordpatients in their practices. To monitor for continuityand coordination of care effectively, an annotated panellist is created for each provider to identify Member visitsto specialty and ancillary providers. The MedicalRecord Review examines the following indicators:

• Communication from the medical specialist

• Communication from the behavioral health specialist

• Communication from the surgical specialist

• Documentation of hospital stay or same-day surgery

• Documentation of emergency room visit

• Documentation of home care

• Documentation of skilled nursing facility stay

• Adverse outcomes which may develop as the result of disruptions in continuity or coordination of careand service are tracked annually. These include:

• Admission to hospital for adverse results ofoutpatient management

• Injury or extended time of recovery due to failureto provide, or a delay in, home care services

• Failure to provide and follow through with a safe,timely discharge plan

• Practitioner satisfaction surveys are conductedquarterly with PCPs and specialists to elicit feedback on coordination of care efforts with other practitionersand providers. The following areas are addressed inthe survey:

• Clinical follow-up reports (PCP only)

• Behavioral health provider feedback (PCP only)

• Hospital provider feedback (PCP only)

• Home care provider feedback (PCP only)

• Information provided to understand cases referred(specialist only)

In addition, Oxford stresses the continuity andcoordination of care for Members receiving medicaland behavioral healthcare. There are five areas thatOxford specifically monitors:

• The exchange of information between a behavioralhealth provider and the primary care physician

• Appropriate diagnosis, treatment and referral ofbehavioral health disorders

• The use and continuing evaluation ofpsychopharmacological medications

• Coordination of appropriate treatment and follow-upfor Members with co-existing medical and behavioralhealth disorders

• Adherence to preventive behavioral healthguidelines/program




Reassignment of Members in Cases of Provider Termination

Provider Type Reason for Termination Member Notification Process and Time Frames

PCP or OB/GYN Provider-initiated Oxford sends written notice to the Member 30 business daysprior to the date of the provider’s termination. The noticeinforms the Member of the effective date of the termination, and advises them of the procedure for selecting a new PCP or OB/GYN within Oxford’s network. Connecticut law requiresthat Oxford provide notification to Members within 30 days ofreceiving the termination request from the provider.

Members who are in an ongoing course of treatment with theprovider may be allowed to continue to see the provider for anadditional 120-day transition period from receipt of notification,if the provider agrees to follow Oxford policies, procedures andreimbursement rates. New Jersey law requires physicians to followOxford policies, procedures and reimbursement rates during this period of post-termination coverage.

Women who have entered into their second trimester ofpregnancy (New York and Connecticut) or women who arepregnant and have been seen by an Oxford obstetrician for that pregnancy (New Jersey) may be allowed to continue withone provider up to six (6) weeks post delivery. In New York and Connecticut, the provider must agree to follow Oxfordpolicies, procedures and reimbursement rates during thecontinuation period. New Jersey law requires physicians tofollow Oxford policies, procedures and reimbursement ratesduring this period of post-termination coverage.

Specialist Provider-initiated Oxford sends written notice to any Member who can beidentified as undergoing a course of treatment with the specialtyprovider. The notice is sent 30 business days prior to thetermination of the provider.

Members who are in an ongoing course of treatment with theprovider may be allowed to continue to see the provider for an additional 120-day transition period, if the provider agrees to follow Oxford policies and procedures. New Jersey law requires physicians to follow Oxford policies, procedures andreimbursement rates during this period of post-terminationcoverage. In New Jersey, professionals may be required tocontinue to provide services in accordance with the Oxfordprovider contract to:

• Members receiving post-operative care — for up to six (6) months

• Members receiving oncological treatment — for up to one (1) year

• Members receiving psychiatric treatment (excluding substance abuse treatment) — for up to one (1) year



Reassignment of Members in Cases of Provider Termination (continued)


PCP or OB/GYN Oxford-initiated: If the provider does not appeal the termination, Oxford sends no provider appeals written notice to that provider’s Members within 30 business

days before effective date of the physician’s termination. Thenotification process and required transition time frames areidentical to those outlined in provider initiated terminations,except when the following has occurred:

• Terminations for imminent harm to patient care

• Determination of fraud

• Final disciplinary action by a state licensing board or other agency that impairs the provider’s ability to practice

In these situations, Oxford is not required to, and may not arrange for, post-termination continuation of care from the physician.

PCP or OB/GYN Oxford-initiated: provider If the provider appeals the termination, Oxford sends appeals the termination written notice to any Members within 15 days of the final

determination of the appeal hearing. The notification process and required transition time frames are identical to those outlined for provider-initiated terminations, exceptwhen the following has occurred:



• Final disciplinary action by a state licensing board or otheragency that impairs the provider’s ability to practice


Specialist Oxford-initiated: Oxford sends written notice to any Member who can be no provider appeal identified as undergoing a course of treatment with the

specialty provider. The notice is sent 30 business days before the effective date of the physician’s termination, and no laterthan 30 days after the provider is notified of the termination. The notification process and required transition time frames are identical to those outlined for provider initiatedterminations, except when the following has occurred:







Reassignment of Members in Cases of Provider Termination (continued)


Specialist Oxford-initiated: provider Oxford sends written notice to any Member who can be appeals the termination identified as undergoing a course of treatment with the specialty

provider within 15 days prior of the final determination. Thenotification process and required transition time frames areidentical to those outlined for provider-initiated terminations,except when the following has occurred:




In these situations, Oxford is not required to, and may not arrangefor, post-termination continuation of care from the physician.

Reassignment of Members Who Are in an Ongoing Course of Care or Who Are Being Treated for Pregnancy Oxford adheres to the following guidelines whennotifying Members affected by the termination of a provider:

• All Members who are patients of any terminated PCP’spanel — internal medicine, family practice, pediatrics,nurse practitioner, obstetrician-gynecologist, and nursemidwife — are notified of our policy and what steps tofollow should the Member require continuity of care;the same notification procedures hold true for patientsbeing seen regularly by a specialist who is terminated

• Patients of such a PCP’s panel are instructed to call theCustomer Service Department if they choose to select anew PCP, or to request continuity of care from theircurrent practitioner; they are also encouraged to requesta provider roster, if needed to make their new selection

• Patients of a terminated specialist are instructed to call the Customer Service Department if they need torequest continuity of care from their current specialist;they are also directed to call their current PCP for analternate specialist referral

Termination of the Physician-

Patient Relationship at

the Request of the

Participating Physician

An Oxford participating physician may request that an Oxford Member be removed from his or her

patient group. Should you wish to do so, please send a certified letter, return receipt requested, to theMember stating that he or she:

• Will be removed from your practice

• Has 90 days from date of receipt to find a new PCP

• May continue in your care during this 90-daycontinuation period

To maintain continuity of care, providers should provideinformation to assist Members in transferring their care to another provider and make timely transfer of patients’records upon request.

Providers should send a copy of the termination letter totheir respective Oxford Provider Relations regional officeand include the Member’s name and Oxford ID number,the provider’s name and Oxford provider ID number, anda description of the Member’s non-compliant behavior.

Provider DisciplinaryPolicies and Procedures

Disciplinary Actions

Oxford may take disciplinary action against aparticipating provider as a result of any adverse quality-of-care, utilization, licensing, credentialing, and/or administrative issues. Potential issues can be identified through a number of sources including but not limited to: medical record reviews, complaintinvestigation, adverse-event monitoring, credentialingissues, quality improvement studies, and review and discussion of over- and underutilization thatcontinues after an opportunity to correct.



The following entities have the authority to recommendand implement disciplinary action:

• The Regional Quality Management Committees(RQMCs) for New York, New Jersey and Connecticut

• The Corporate Utilization Peer Review Committee(CUPRC)

• The Administrative Management Committee (AMC)

• Oxford’s Vice President of Quality Management (inrare situations) may institute immediate disciplinaryaction in response to state or federal notification oflicense suspension or imminent threat of patientharm; such action will later be reported and reviewedby the appropriate committee.

Both the CUPRC and RQMC are composed of at leastsix (6) Oxford participating providers who represent all primary care and major specialty providers for theirregion. A quorum must be present to vote on actions.

The AMC is composed of a director or higher rankingrepresentative from each of the following Oxforddepartments: Legal, Finance and Healthcare Services.A quorum must be present to vote on actions.

Disciplinary action is considered in the following circumstances:

• Confirmed quality-of-care and/or administrativeissues that have not been corrected through theroutine ongoing monitoring process

• Determination of an egregious act that has resulted or may result in imminent patient harm

• Confirmation of fraud and/or abuse

• Credentialing/recredentialing issues

• Licensing issues

Issues that may warrant disciplinary actions:

• Quality-of-care Issues

• Access issue of any kind

• Inadequate patient screening/monitoring

• Inadequate workup/evaluation

• Delay in diagnosis

• Delay in treatment or inadequate treatment

• Inadequate management

• Inappropriate discharge

• Inadequate follow-up

• Failure to follow-up or to address patient non-compliance

• Communications issues

• Underutilization of appropriate services

• Overutilization of services that may put patients at risk for adverse outcomes

• Failure to cooperate with credentialing orrecredentialing efforts or to meet applicable criteria

• Failure to cooperate with any QA activities,including complaint resolution, medical recordreviews or any other QA or utilization concerns or issues

• Referral from the AMC of any provider who may have committed both administrative violations and QM violations

• Other quality related issues

• Administrative Issues

• Overutilization of services (non-QA)

• Up-coding, unbundling and similar billing techniques

• Failure to follow precertification/notificationpolicies and procedures

• Unapproved out-of-network referrals/services

• Documentation deficiencies

• Billing or copay issues

• Repeated use of referral to non-participatingfacilities, providers or laboratories, except in casesof clinical need or out-of-area situations

• Failure to cooperate with QA activities includingaudits, complaint resolution, medical record reviews, etc.

• Submission of fraudulent, false or misleadinginformation for the purpose of influencingpayment or credentialing decisions

• Other miscellaneous administrative issues

Severity and Sanction LevelsConfirmed quality, utilization and/or administrativeissues are assigned a specific severity level. Disciplinaryactions are instituted based on the severity of the issue.Oxford has defined three (3) levels of severity and three(3) levels of disciplinary action for quality-of-care andutilization issues, and two (2) severity levels and two (2)levels of disciplinary action for administrative issues.



Association of Severity Levels with Sanction Levels for Quality-of-care/Utilization Issues

Resolution of Severity Level I Issues and End of Level I Sanctions:

If the Committee determines that the action taken by the provider has resulted in the correction of the problem,the provider is notified that the issue is resolved and the sanction is lifted.

Severity Level II Sanction Level II

Resolution of Severity Level II Issues and End of Level II Sanctions:

If the Committee determines that the action taken by the provider has resulted in the correction of the problem, the provider is notified that the issue is resolved and the sanction is lifted. The provider may continue to be monitored.

Severity Level I

Issues are rated at Severity Level I whenthere are quality-of-care issues that have no obvious adverse effect or a minoradverse effect on the Member.

Examples include:

• Failed routine medical record review or office site visit

• Non-compliance with appointment or after-hours access standards

• Minor utilization concerns

Sanction Level I

Actions taken for issues ranked at Severity Level I may include, but are not limited to, any of the following:

• Reminder or warning letter that advises the provider of the findingsand that may request a response with a plan of corrective action

• Educational site visit meeting by a Provider Relations Representative,Quality Management Representative or an Oxford Medical Directorto discuss the issue and the provider plan for corrective action

Depending on the provider response, the committee may take one of the following actions:

• Approve the response and/or plan of correction and/or results of site visit, no further action is taken

• Conditionally accept the response and/or plan of corrective actionand/or results of site visit and establish a follow-up plan

• Initiate Sanction Level II if the response and/or plan of correctiveaction is unacceptable, or if the provider remains non-compliantwith the request

Issues are rated at Severity Level II when:

• There is a failure to correct Severity Level Iissues after Sanction Level I notification

• There is a failure to respond to aCommittee request for reply

• There are quality-of-care or utilizationissues that have, or may result in, severe*adverse effects on the Member(s)

Examples of severe adverse effects include:

• Need for minor additional or prolonged treatment

• Avoidable readmission to the hospital

• Temporary functional impairment

• Severe overutilization or up-coding, orminor up-coding and overutilization

* Severe is defined in this context as overutilization or up-coding in two (2) or more CPT code ranges or upcoding greater than two (2) levels of intensity (persistent Level five [5] level office coding where Level three [3] is deemed appropriate).

Actions taken for issues ranked at Severity Level II may include,but are not limited to any of the following:

• Placement on probation with close observation

• Closure of the provider patient panel to new Members, orremoval of name from the provider roster (inside reports)

• An imposed withhold penalty or other financial sanctions penalties

• Require precertification review by an Oxford Medical Director, forprocedures or services, including those that do not otherwiserequire such precertification already

The provider is notified of the Sanction Level II in writing within 30 days of the determination and is requested to submit a plan of corrective action. The provider may file an appeal for certainSanction Level II matters.

Depending on the provider’s response to the Sanction Level II, the Committee may take one of the following actions:

• Accept the plan of corrective action and lift the sanction after asuitable period, and continue the provider on monitoring status

• Conditionally accept the response and/or plan of correctiveaction and establish a follow-up time period for re-evaluation

• Initiate a Sanction Level III if the plan of corrective action is unacceptable or the provider remains non-compliant with the request



Severity Level III

Issues are rated at Severity Level III when:

• There is repeated failure or refusal tocorrect Severity Level I or II violationsafter multiple warnings (Sanction Level Iand II)

• The case involves severe quality-of-careissues that have resulted or may bedeemed to potentially result in imminentharm to the Member(s) (e.g., avoidabledeath, permanent functional impairment)

• There has been final disciplinary action by a state licensing board or other governmental agency that impairsthe provider’s ability to practice

• A determination of fraudulent behaviorhas been made

Sanction Level III

Actions taken for issues ranked at Sanction Level III may include,but are not limited to, any of the following:

• Any of the actions under Sanction Level II, with a notation thatthe action constitutes final notice

• Limitations placed on the provider’s practice (e.g., restriction ofcertain procedures, or only allowed to treat certain types of patients)

• Termination of participation with Oxford

In all of the above situations, the provider is notified in writingwithin 30 days of the determination. For non-termination actions,the provider is requested to submit a plan of corrective action.The provider may file an appeal for all certain Sanction Level IIImatters. For sanctions not involving terminations, depending onthe provider’s response to the Sanction Level III, the Committeemay take one of the following actions, except in the case of risk or imminent harm to Members or fraud:

• Conditionally accept the response and/or plan of correctiveaction and establish a follow-up time period for re-evaluation

• Terminate the provider if the response and/or plan of correctionis unacceptable or the provider remains non-compliant with the request

• Deny renewal of the provider’s contract with Oxford

In New York and Connecticut, if the provider does not elect toappeal the determination, the termination takes effect 60 days afterfinal written notice to the provider. In New Jersey, terminationstake effect 90 days after final written notice to the provider.

Resolution of Severity Level III Issues and End of Level III Sanctions other than terminations:


Association of Severity Levels with Sanction Levels for Quality-of-care/Utilization Issues (continued)



Association of Severity Levels with Sanction Levels for Administrative Issues

Resolution of Level Severity I Issues and End of Level I Sanctions:

If the Committee determines that the action taken by the provider has resulted in the correction of the problem,the provider is notified that the issue is resolved and the sanction is lifted.

Severity Level I

A Severity Level I Administrative disciplinaryaction is appropriate for administrativeviolations where it is reasonable to concludethat the practitioner is intentionally orrecklessly committing an administrativeviolation. Examples include, but are notlimited to:

• Failure to respond to the AMC request for reply

• Failure to correct an administrativeviolation after notification by arepresentative of Oxford within areasonable period

• Minor billing concerns involving forexample, a confirmed pattern ofupcoding one level in one CPT coderange or unbundling of services involved in one type of procedure

• Failure to cooperate with audits of any type

• Failure to follow precertification, referralor similar requirements

Sanction Level I

Administrative disciplinary actions taken for issues ranked at Severity Level I may include, but are not limited to, any of the following:

• A letter that advises provider of the findings and requests an explanation and/or a plan of corrective action

• An educational discussion relating to the issue and the provider’s plan for corrective action

• Closure of the provider’s panel to new Members or removal of name from the provider roster (inside reports)

• Required precertification review by Oxford’s MedicalManagement, for procedures or services including those that do not otherwise require such pre-certification

• Imposed with-hold, penalty, fee reduction or other financial penalty

• A requirement that the provider submit notes or other medical records in order for Oxford to process their claim submissions

• Placement on probation with close observation

Reporting of Disciplinary

Actions to Regulatory

Agencies

Oxford utilizes the web-based reporting system that was implemented by the National Practitioner DataBank (NPDB) to report disciplinary actions.

In accordance with the Federal Health Care QualityImprovement Act of 1986 and accompanyingregulations, Oxford must report applicable disciplinaryactions to the NPDB and the appropriate state licensingboard(s). Oxford reports the following actions:

• Termination due to alleged mental or physicalimpairment, misconduct or impairment of patient safety or welfare



Resolution of Level Severity II Issues and End of Level II Sanctions:


Severity Level II

Administrative violations may be rated atSeverity Level II when:

• There is repeated failure or refusal to correctSeverity Level I administrative violations afterwarning by the AMC

• There are severe billing concerns confirmedthrough chart review

• There is a determination of fraud orintentional or reckless billing abuse

Sanction Level II

Administrative disciplinary actions taken for issues ranked at Severity Level II may include, but are not limited to, any of the following:

• Any of the actions under Sanction Level I, with a notationthat the action constitutes final notice

• Limitations on reimbursement for certain procedures thatare part of the provider’s practice (i.e., refusal to pay forcertain procedures or only reimbursed for treatment tocertain types of patients; in each case, the provider isprohibited from balance billing members), except for when quality issues exist, which shall only be addressed by CUPRC or an RQMC

• Deny renewal of provider’s contract with Oxford

• Termination of participation with Oxford

In the case of termination, the provider is notified in writingwithin 30 days of the determination. For non-terminationactions, the provider is requested to submit a plan ofcorrective action in addition to having the sanction imposed.

For sanctions not involving terminations or non-renewal ofcontract, when informing the provider of the sanction, theCommittee will provide guidance as to the time period forremeasurement. After the remeasurement, depending on the provider’s response to the Sanction Level II, the Committee may take one of the following actions:

• Conditionally accept the response and/or plan of correctiveaction, and establish a follow-up time period for re-evaluation,allowing the sanction to continue in effect during the follow-up period and for a suitable period thereafter

• Terminate the provider if the plan of corrective action is unacceptable or the provider remains non-compliant with the request

Association of Severity Levels with Sanction Levels for Administrative Issues (continued)



• Voluntary or involuntary termination of a contract oraffiliation to avoid the imposition of disciplinary action

• Termination for determination of fraud

• Knowledge of any information that reasonablyappears to show that a health professional is guilty of professional misconduct

• Any disciplinary action that adversely affects theclinical privileges of a provider for a period longerthat 30 days

Oxford reports disciplinary action to the following statelicensing boards:

New York

Office of Professional Medical ConductOffice of ProfessionsNew York State Education DepartmentOne Park AvenueNew York, NY 10016-5802

1-212-951-6400

New Jersey

New Jersey State Board of Medical Examiners28 W. State Street, Room 602Trenton, NJ 08608

1-609-292-4843

Connecticut

Connecticut Division of Medical Quality Assurance150 Washington StreetHartford, CT 06106

1-203-566-7398

The Oxford Quality Management Department is responsible for notifying the CredentialingDepartment when a reportable disciplinary action is taken. The Credentialing Department is responsiblefor completing the reporting procedure.

Disciplinary Action Appeals

Quality-of-care and

Util ization Issues

All providers have the right to appeal certain SanctionLevel II and Level III disciplinary actions imposed by Oxford. The appeals process is structured so thatappeals for terminations, except for non-renewal of the provider’s contract with Oxford, or limitations onthe provider’s practice for quality reasons can be heardprior to disciplinary action being implemented, exceptin the following situations:

• Severe quality-of-care issues that may result inimminent harm to a Member or Members


• Denial of participation with Oxford for failure tomeet credentialing or recredentialing criteria

• Final disciplinary action by a state licensing board or other governmental agency that impairs theprovider’s ability to practice

All other sanctions under this policy shall be effectiveimmediately, whether or not the provider has a right to appeal.

Except for the above situations, terminations from the plan are effective as follows:



• New York and Connecticut — 60 days after finalwritten notice to the provider

• New Jersey — 90 days after final written notice to the provider

Filing an Appeal for Quality-of-care and Utilization IssuesThe practitioner must request an appeal in writing within30 days of delivery of notice of the QM DisciplinaryAction. Failure to submit an appeal within the 30 dayswill be deemed a waiver of any appeal rights. Theprovider should indicate whether or not he/she wishesan administrative appeal or a hearing. The provider isencouraged to submit any additional information abouthis/her case together with the appeal.

Appeal Hearings for Quality-of-care and Utilization IssuesProviders are entitled to a hearing before a panel ofpeers in response to the following actions:

• Any Sanction Level II or Level III disciplinary actionthat limits or restricts the provider’s ability to practice(i.e., restrictions on types of procedures that can beperformed, etc.)

• Termination from the health plan as result of any disciplinary process except:

• Severe quality-of-care issues that may result inimminent harm to the Member(s)

• Denial of participation with Oxford for failure to meet credentialing or recredentialing criteria

• Final disciplinary action by a state licensing board or other governmental agency that impairs theprovider’s ability to practice

• Denied renewal of the provider’s contract

Upon receipt of an appeal entitled to and requesting ahearing, the committee chair or designee assembles aQM Disciplinary Actions Appeals Committee to hear theprovider’s appeal. The Committee is made up of oneOxford Medical Director not previously involved in thereview of the case, at least one participating provider ofthe same specialty as the provider, also not previously

involved in the case, and one additional Oxfordrepresentative. The provider is notified of the scheduledhearing date within 15 days of receipt of the appeal. At this time, the provider is notified of his/her right to representation by a third party at the hearing.

The QM Disciplinary Actions Appeals Committee meetsto hear the case within 30 days of receipt of the appeal.Oxford will consider any reasonable request to hear the case beyond 30 days of receipt of notice; however,repeated requests to postpone and/or reschedulehearing dates will lead to waiver of appeal rights.

A decision may be made on the day of the hearing orwithin a short time thereafter. The Committee mayuphold or reverse the underlying determination or may impose a provisional reinstatement subject to certain conditions to be determined by the Committee.The provider is notified in writing of the decision within15 days of the decision. The decision made by the QMDisciplinary Actions Appeals Committee is final.

Records of the hearing are maintained in the form of alog that includes at a minimum, the date of the hearing,attendees and resolution. All records are maintained bythe Quality Management Department for a period ofnot less than seven (7) years.

Administrative Issues

Provider’s have the right to appeal Sanction Level Iadministrative disciplinary actions that impose withholds,fee reductions or other direct financial penalties, and all Sanction Level II administrative disciplinary actionsimposed by Oxford, except for non-renewal of contractand determination of fraud. All other Sanction Level Iadministrative disciplinary actions do not give providersthe right to appeal. All Sanction Level I and certainSanction Level II administrative disciplinary actions shallbe effective immediately upon decision by the AMC. Theappeals process for Sanction Level II actions involving a hearing right (terminations for repeated billing abuseor repeated failure to correct administrative violationsafter imposition of Sanction Level I) is structured so that appeals can be heard prior to disciplinary actionbeing implemented.



A provider may file an administrative appeal in responseto the following actions:

• A Sanction Level I action that imposes a withhold, fee reduction or other financial penalty; and

• Terminations from Oxford for any reason permittedhereunder except for repeated billing abuse andrepeated failure or refusal to correct Severity Level Iadministrative violations after warning by the AMC

Terminations from Oxford for repeated billing abuseand repeated failure or refusal to correct severity Level Iadministrative violations after warning by the AMC areeffective as follows:

• New York and Connecticut — 60 days after finalwritten notice to the provider

• New Jersey — 90 days after final written notice to the provider

Filing an Appeal for Administrative ViolationsThe provider must request an appeal by hearing inwriting within 30 days of the mailing of notice of thedecision to impose the administrative disciplinary action. Failure to submit an appeal within the 30 dayswill be deemed a waiver of any appeal rights. Theprovider should indicate whether or not he/she isrequesting a hearing. The provider is encouraged to submit any additional information about his/her case along with the appeal.

Appeal Hearings for Administrative ViolationsProviders are entitled to a hearing before a panel ofpeers in response to being terminated from Oxford as a result of repeated billing abuse and repeated failure or refusal to correct Severity Level I administrativeviolations after warning by the AMC. Appeals are notavailable for non-renewal of contract or termination forfraud. A provider may waive his/her right to an appealby hearing and opt for an administrative appeal instead.

If the provider requests a hearing, the AMC willassemble an Administrative Disciplinary Actions AppealsCommittee (ADAAC) to hear the appeal. The ADAACwill be composed of one Oxford Medical Director notpreviously involved in the review of the case, at least one participating provider of the same specialty as theprovider, also not previously involved in the case, andone additional Oxford representative.

The ADAAC sets a date to hear the case within 30 daysafter receipt of the appeal. The provider is given advancenotice of the hearing, if a hearing is requested. Oxfordwill consider any reasonable request to hear the case on a date other than that originally scheduled; however,repeated requests to postpone and/or reschedule hearing dates will lead to waiver of appeal rights.

A decision may be made on the day of the hearing or within a short time thereafter. The ADAAC mayuphold or reverse the underlying determination or may impose a provisional reinstatement subject tocertain conditions to be determined by the ADAAC. The provider is notified in writing of the decision within 15 days of the decision. The decision made by the ADAAC is final.

Oxford Health PlansVice President of Medical Programs(or Regional Medical Director)

48 Monroe TurnpikeTrumbull, CT 06611

OOXF O R D | I M PO RTA NT A D D R ES S

overall quality management

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