제공자 매뉴얼

PROVIDER SANCTIONS

Though Carelon is able to resolve most provider credentialing and quality issues through consultation and education, occasionally further action is necessary to ensure quality service delivery and protection of members. The National Credentialing Committee (NCC) may impose provider sanctions for issues related to member complaints/grievances, quality of care or provider contract compliance. Carelon will comply with all applicable local, state and federal reporting requirements regarding professional competence and conduct to ensure the highest quality of care for our members. A provider has the right to appeal any sanction through the Carelon Provider Appeals Committee (PAC)/Fair Hearing Appeals process. The following is a list of sanctions available to the NCC and the PAC:

Individual Practitioner Sanctions

Type Definition
Consultation A call is placed to notify the practitioner of the alleged action or incident. The practitioner will be provided with an explanation of possible sanctions if corrective actions are not taken. The call will be documented to include the date and subject for consultation. A copy of the consultation will be placed in the practitioner’s file. Appropriate educational materials will be sent via certified mail.
Written Warning A written notice is sent to the practitioner notifying him/her of the alleged action or incident. Possible sanctions, if corrective actions are not taken, will be explained. A copy of the letter is retained in the practitioner’s file; educational material is sent via certified mail. Corrective action will be monitored as necessary.
Second Warning/Monitoring At the discretion of the Medical Director, a second written notice may be sent to the practitioner and a copy of such letter shall remain in Carelon’s file. The practitioner can be placed on monitoring when data indicate non-conformance with standards and if Carelon determines it is in the member’s interest Carelon may elect to suspend new member referrals, new patient authorizations and/or redirect all current patients to other providers. The practitioner will be given written notice via facsimile and certified mail of the issues for which he/she is being suspended. A copy of the letter is placed in the practitioner’s file. The suspension may last for a period of 30 days during which time an investigation may take place. The NCC may extend this time period as necessary to gather additional information. Suspension is only used for serious infractions that are probable cause for termination.
Termination The practitioner may be terminated from the network. Termination requires NCC action. The practitioner will be given written notice via facsimile and certified mail that he/she is being terminated from the network and the reason for the termination. A copy of the letter is put in the practitioner’s file. Members in care will be notified and given assistance for referral to a new practitioner for continuing care, as necessary.