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PBH Network Provider Responsibilities Published: October, 2001 Sentinel Event Reporting Confidentiality and Release of Information Alternative Provider Coverage Compliance with State and Federal Laws Obligation to Report/Duty to Warn Accessibility Communication of Treatment Options Member Communications Information Updates Points to Remember Sentinel Event Reporting PacifiCare Behavioral Health (PBH) maintains programs that reduce and prevent risk and assure the safety of the member through ongoing processes of risk identification, risk analysis, action implementation and action evaluation. Sentinel events are defined as an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof. Serious injury includes loss of limb or function. "Risk thereof" includes process variation for which a recurrence would carry a significant chance of a serious adverse outcome. The sentinel event review process provides a mechanism to: identify unusual or untoward occurrences that could result in risk/liability; and, investigate whether standards of care were met. Sentinel events are reviewed by Regional PBH Clinical Staff and are investigated by Regional Quality Improvement (QI) staff. Appropriate action/interventions are taken in consultation with the Regional Medical Director or his/her physician designee. These events need to be reported to PBH. Death/Completed Suicide: Any death that occurs during treatment provided under authorization from PBH, or within twelve (12) months of the individual receiving care authorized by PBH. For cases that appear to be medical in nature, review with a Regional Medical Director to ascertain potential relevancy of coexisting behavioral health issues (such as type of authorized care or lack of authorization/care). Homicide: Any act of a member currently in treatment authorized by PBH or of a member for whom treatment was authorized by PBH within the twelve (12) months prior to the incident, who kills another individual. Suicide Attempt Requiring Medical Intervention: An act of self-harm, which may result in a life-threatening situation. Consideration is given to lethality of suicide attempt, intent of member, and potential pattern of behavior. Suicide attempts should only be reported, however, if the member is currently in treatment authorized by PBH or within twelve (12) months of the individual receiving care authorized by PBH. It is not necessary to complete a report if the member has neither been previously assessed by PBH nor authorized for treatment by PBH. Other: An occurrence other than those defined by death, completed suicide, homicide or suicide attempt requiring medical attention, that is a process variation for which its occurrence or recurrence would carry a significant chance of a serious adverse outcome for the member. Back to Top Confidentiality and Release of Information PacifiCare Behavioral Health has written policies and procedures that protect the confidentiality of member health information and that conform to federal and state confidentiality regulations and applicable standards of the National Committee for Quality Assurance (NCQA). PBH's contracting practitioners are required by their provider contracts with PBH to maintain the confidentiality of all patient health information and other personal information about members. Contracting practitioners must implement procedures and safeguards to ensure that the confidentiality of all member records and information is maintained. Only the practitioners involved in the member's care and treatment, claims processing staff, UM and care management staff, QI staff and other authorized persons who must have access to confidential patient information in order to perform their functions for the contracting practitioner shall have access to such information. Contracting practitioners should not disclose confidential patient information to any person or entity except upon the written authorization of the member to whom the information relates or as otherwise permitted or required by applicable state law. Legal exceptions to this are when a patient's mental condition becomes an issue in a lawsuit, when a patient presents as a physical danger to self or others or when child or elder abuse/neglect is suspected. Also see Obligation to Report/Duty to Warn below. PBH providers should not release patient information pertaining to a member who is a minor or an incompetent adult to any person or entity without a valid authorization for the disclosure, unless disclosure without authorization is specifically permitted by law. PBH will apply state law to determine what constitutes a valid authorization to disclose patient medical information pertaining to minors and incompetent adults. Whenever a PBH provider begins treating a PBH member, the provider must have the member or, if appropriate, the next-of-kin or legal guardian sign a consent form authorizing the release of treatment record information to PBH. Providers are responsible for ensuring they have all necessary member consents. If the member refuses to sign the consent form, this should be documented in the member's clinical record. Providers are required to comply with patient requests for their own medical record. Back to Top Alternative Provider Coverage A PBH provider must contact PBH to discuss alternative provider coverage arrangements in any situation when s/he is unable to maintain a PBH member in active treatment. Prior notification to PBH is required regardless of the reasons for utilizing an alternative provider (e.g. coverage while on vacation). The alternative provider must be a PBH network provider and must receive prior authorization for all services rendered. Back to Top Compliance with State and Federal Laws PBH expects its providers to comply with all provisions of the Americans With Disabilities Act (ADA), the Age Discrimination Act of 1975, Title VI of the Civil Rights Act of 1964 and all other laws applicable to recipients of Federal Funds as they are applicable to the provision of care for PBH members. Back to Top Obligation to Report/Duty to Warn PBH providers must comply with all applicable state and federal child abuse and other reporting laws. It is the provider's responsibility to understand and comply with the professional and legal requirements in his/her state. The duty to warn may override the usual right to confidentiality of which an individual is assured when speaking to a clinician. This applies to any PBH provider who receives information during assessment or treatment. In any life-threatening situation, relevant clinical data or history may be released. If a PBH provider believes that a patient represents a threat to others, the provider must attempt to warn the potential victim(s) in a timely manner. It is preferable to contact the police, but the provider should warn the intended victim by telephone if that is the best way to ensure the potential victim's safety. PBH should also be made aware of any such situation. Back to Top Accessibility PacifiCare Behavioral Health is concerned that members receive timely access to treatment. To this end, we have established performance standards regarding appointment times for routine, urgent and emergent referrals. For routine referrals, it is our expectation that practitioners will offer an appointment within 5 business days of referral and ensure that the member will be seen within 10 business days of referral. For urgent referrals, it is our expectation that practitioners will see a member within 48 hours of their referral. For emergent referrals, be it life threatening or non-life threatening, it is our expectation that practitioners will see the member immediately. PBH has implemented a process whereby we ask members for their permission to provide practitioners with a phone number to contact them for scheduling an appointment. While we still encourage members to contact the practitioner, we expect that if the practitioners have not heard from a member, they will use this number to call the member to schedule an appointment. Back to Top Communication of Treatment Options Providers can freely communicate with patients regarding the treatment options available to them, including alternative medications, regardless of the benefit coverage limitations. Back to Top Member Communications Providers must send any proposed member correspondence other than individual patient communication regarding test results, preventive health screens, or appointment reminders to PBH prior to distribution. Providers should be aware that in certain circumstances PBH will also need to obtain approval from the members' health plan(s) and/or HCFA prior to approving communications to be sent to members. Back to Top Information Updates To ensure accurate and timely changes to our provider records, PBH must receive prompt written notification within thirty (30) days of any additions, deletions or changes (including the effective dates) related to any of the following: Changes in practice locations or mailing address, phone numbers or tax ID numbers Changes in services or levels of care offered Changes in appointment availability or ability to accept new referrals State licensure or certification renewal Facility accreditation status with JCAHO, CARF, COA, AOA or other national accrediting organizations PBH should be notified immediately of any accusation or allegation against you filed with a state licensing board or other regulatory agency and any actions taken including probation, reprimand, suspension, or revocation of your license Federal DEA certification for Physicians or DOs, RNs (if applicable) Registered nurse certification for prescriptive authority, if applicable ANA "clinical specialist" certification (advanced registered nurse practitioners) DEA license for Clinical Nurse Specialist (CNS) with prescriptive authority Individual malpractice liability insurance, with limits, dates of coverage and provider's name Back to Top Remember Notify PBH of changes in phone numbers, office location, licensure status and insurance Notify PBH of vacation schedules or inability to accept new patients Back to Top