J-8 Operations Manual TOC.pdf

I. Introduction

A. Purpose of the Operations Manual B. Overview of the WTC NRHP C. Objectives of the NRHP D. Quick Reference Phone Numbers

II. Member Eligibility, Enrollment and Transfer A. Eligibility Criteria B. Eligibility Determination Process C. Enrollment Process D. Member Transfer Procedure E. Dual Membership

III. Covered Services/Conditions A. Covered Conditions B. Approved Procedures C. Approved HCPCS D. Approved Durable Medical Equipment E. Monitoring Examination F. Treatment Examination G. Referral Definition with Classes H. Utilization of Prior Test Results

IV. Other Conditions A. Trackable Conditions B. Procedure for Considering New Covered Conditions

V. Financial Accounting A. Claim Forms B. Claims Processing and Payment

VI. Healthcare Provider Network Staffing Process A. Recruitment Initiatives B. Initial Enrollment Application C. Credentialing & Re-Credentialing Process D. Participating Physician Program Management E. Local Coverage Determinations F. Provider Training

VII. Member Services A. Call Center Operations B. Explanation of Services C. No Show Policy D. Member Inquiries and Complaints E. Member Satisfaction F. Bi-Annual Benefits Summary

VIII. Case Management Services A. Case Management Overview B. Watch List Responders C. Coordinate Continuity of Care D. Comprehensive Assessment of Need

E. Arrangement of Services to Reach Outcomes F. Evaluation of the Plan of Care G. Crisis Counseling H. Emergent Referrals

IX. Social Services Referral Program A. Overview B. Resource Guide

X. Medical Review Request A. Member B. Provider

XI. Member Rights and Responsibilities A. Member Rights B. Member Responsibilities

XII. Healthcare Network Provider Responsibilities A. Best Practices B. HIPAA and Privacy Rule Guidelines C. Patient Documentation Process D. Appropriate Coding E. Cultural Competency

XIII. HIPAA Compliance Standards A. Compliancy and Privacy B. Contractor Staff Training C. Transfer of Protected Health Information D. HIPAA Complaint Procedure

XIV. Quality Assurance for Provider Activities A. Periodic Chart Audits B. Performance Measures C. Penalties for Noncompliance of Program Requirements D. Corrective Action Plan

XV. Program Awareness A. Website B. Member Outreach and Retention Activities

XVI. Public Affairs A. Press Inquiries B. Public Inquiries

XVII. Advisory Groups A. Clinical Director Consortium B. Steering Committee

XVIII. Healthcare Information A. Elements B. System C. Maintenance D. Tracking E. Analysis F. Transfer and Security G. Error Resolution

XIX. Reporting Requirements A. Financial Information B. Programmatic Information

XX. Program Evaluation A. Goals and Objectives B. Process Metrics C. Performance Indicators

XXI. Acronyms and Glossary A. Acronym List B. Glossary