Quality of Care/Critical Incident Form

https://mediproviders.anthem.com/va HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Commonwealth Coordinated Care Plus (CCC Plus) benefits to enrollees. AVAPEC-1884-18 December 2018

Per state guidelines, providers are required to report critical incidents within 24 hours for members enrolled in the Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus plan (Anthem CCC Plus) programs. Providers may notify HealthKeepers, Inc. by filling out this form and emailing it to the appropriate mailbox for each plan. The form can also be faxed to 1-855-273-6831. The provider may also report critical incidents verbally by calling Anthem CCC Plus Provider Services at 1-855-323-4687 and Anthem HealthKeepers Plus Provider Services at 1-800-901-0020. If the provider makes a verbal initial notification of a critical incident, they will be notified

of the requirement to submit a written follow-up report within 48 hours. For Medallion members, use QOC-HKP@anthem.com For Anthem CCC Plus members, use cccpluscis@anthem.com Clarification: A quality of care incident is defined as any incident that calls into question the competence or professional conduct of a health care provider while providing medical services and has adversely affected, or could adversely affect the health or welfare of a member. These are incidents of a less critical nature than those defined as sentinel events. A sentinel event is a patient safety event (not primarily related to the natural course of a patient's illness of underlying condition) that reaches a patient and results in any of the following: (1) death, (2) permanent harm, (3) severe temporary harm and intervention required to sustain life.

Member plan

☐ Anthem CCC Plus ☐ Medallion

Reason for report

☐ Sentinel event ☐ Quality of care ☐ Other critical incident

Member information

Last name First name Date of birth Gender

☐ Male ☐ Female

Member dually eligible?

☐ Yes ☐ No

State Medicaid ID # Medicare # Health plan ID #

Primary care physician Contact phone # Consumer directed?

☐ Yes ☐ No

Person submitting report to HealthKeepers, Inc.

Last name First name

How reporter notified (family member, NF, etc.) Reporter title/role/department

Date and time report notified of incident Date: Time:

Email address Contact phone number

Was this incident called in? ☐ Yes ☐ No

Date: Time:

Date/time report submitted Date: Time:

Provider(s) involved in incident information (if more, please add additional sheets)

Provider name (1) Provider ID Provider NPI number

Provider address (1) Provider type (for example, hospital, PCP)

Provider name (2) Provider ID Provider NPI number

Provider address (2) Provider type (for example, hospital, PCP)

Incident information

Date and time incident occurred Date: Time:

Location and setting (address and indoor/outdoor)

Address of incident

Anthem HealthKeepers Plus Quality of Care/Critical Incident Form

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Type of incident — high-level description

☐Sexual abuse (known or suspected)* ☐Financial exploitation* ☐Medication error

☐Physical abuse (known or suspected)* ☐Theft ☐Severe injury or fall

☐Mental abuse (known or suspected)* ☐Neglect (known or suspected)*

☐Death (not primarily related to the natural course of the patient’s illness or underlying condition)

☐Other__________________________________________________________________________

* Known or suspected exploitation, abuse or neglect must be reported immediately to APS or CPS

Cause of death or event type

Incident detailed description

Please describe in detail the events that took place leading up to, during and after the incident. Please provide as much information as possible (use additional pages if necessary).

Other individuals/witnesses involved

Name Contact number Email address

Other departments contacted (grievance, appeals, case management, care coordination)

Was formal grievance filed? ☐ Yes ☐ No

External agency information (APS, CPS, police, etc.)

Agency type Contact name/number Address Date and time reported

Anthem HealthKeepers Plus Quality of Care/Critical Incident Form

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Information reported to external agency

Additional needs

Is the member subject to further harm, or does he or she have further emergency needs at this time?

☐ Yes ☐ No

If yes, please explain:

Follow-up/resolution that has taken place