Manual do Provedor

VISITAS AO LOCAL

Carelon will conduct site visits to the facility or practitioner’s office(s). The criteria for selection of providers to whom site visits are made includes:

• Volume. If Carelon identifies the provider as a potential high-volume provider, a site visit will be conducted upon:
  • Credenciamento inicial
  • Recredentialing (at Carelon’s discretion)
  • Adicionando um novo local de prática ou alterando as afiliações do grupo desde a decisão de credenciamento anterior.
• Qualidade. Uma visita ao local pode ser realizada como parte do monitoramento de uma investigação decorrente de uma reclamação de membro ou outro problema de qualidade.

The provider will be contacted by Carelon to arrange a mutually convenient time for the site visit unless the site visit is conducted as part of a complaint or other quality issue. Site visits for quality issues may occur with little or no notice. It is the provider’s responsibility to be able to produce and/or provide access to all member records, policies and procedures, and other relevant documentation requested at the time of the visit.

It is important to note that the site visit process is intended as a consultative and educational process. It allows Carelon the opportunity to acknowledge areas of strength and identify opportunities for improvement in our provider network. For site visits occurring based on volume, providers are sent a copy of the site visit tool prior to the actual site visit so they are aware of the areas in which they will be measured. The site visit tools are also available upon request by calling the toll-free provider line at 877-615-8503.

Following the site visit, the provider will receive a written report that details the site visit findings. Included in the report will be an Action Plan that will provide guidance in areas that the provider needs to strengthen in order to be in compliance with Carelon’s standards.