Attachment 5 - Transfer Policy.pdf

Member Transfer Policy

WTC Health Program Administration & Management

Most Recent Revision Date: July 19, 2021

Member Transfer Policy

WTC Health Program Administration & Management Most Recent Revision Date: July 19, 2021

I. Title: Member Transfer

II. Description: Policy and Procedure for Member Transfer for Clinical Centers of Excellence (CCE) and

Nationwide Provider Network (NPN) Members

III. Policy and Procedure Overview

Members of the World Trade Center (WTC) Health Program may transfer to a new clinic between the CCEs and/or the NPN. The term “clinic” refers to either a CCE in the New York City Metropolitan Area (NYCMA), or the NPN that serves members outside of the NYCMA. Member transfers may occur between Responder CCEs, Survivor CCEs, or between any of the clinics and the NPN. Members may not request a transfer between the NYCMA Responder and Survivor programs.1

When members request to transfer from their current clinic (the originating clinic), their care must be coordinated with the clinic to which they are transferring (the destination clinic). The Health Program Support (HPS) contractor is also involved in the member transfer process, as the entity responsible for the collection, storage, and archiving of member data for the WTC Health Program.

The originating clinic, the destination clinic, and the HPS contractor must use the WTC Health Program Member Transfer Module (MTM) to process a member transfer. The MTM is an online application that allows for the secure transfer of member care, medical records, and clinic assignment status between the CCEs, NPN, HPS contractor, and WTC Health Program. The originating clinic, destination clinic, and HPS contractor must follow the process outlined in this document to ensure that members’ medical records and clinic assignment are properly coordinated to avoid any interruption in care. A glossary of terms is included in Appendix A.

IV. Conditions for Member Transfer

Members of the WTC Health Program may transfer to a new clinic between the CCEs and/or the NPN without prior approval from the WTC Health Program under any one of the following circumstances:

A. Time-Determined Transfer

Members have the right to transfer for any reason if it has been a year since their last transfer. Generally, this means that members need to stay with a clinic for at least one year (the “year rule”). However, members who request a transfer within their first year

1 Reclassification of members between NYCMA Responder and Survivor Programs may be considered under certain circumstances. Refer to <<Reclassification Process>> for procedures related to member reclassification between NYCMA Responder and Survivor Programs.

of enrollment are also able to transfer without prior approval. In such instances, the “year rule” takes effect after a member is assigned to the destination CCE/NPN.

B. Urgent Transfers For urgent transfers, the originating CCE/NPN submits the transfer request in the MTM and marks it as urgent. The destination clinic must respond to the request within 48 hours or 2 days. The NIOSH Transfer Team will receive an email notification of the request and follow up with the destination clinic if a decision is not made within 48 hours or 2 days of the submission of the request in the MTM.

C. Clinic Reassignment

Members may request to change clinics prior to intake, before any records have been generated. In such instances, the “year rule” takes effect after a member is assigned to the destination CCE/NPN. because no records are being transferred, clinic reassignments do not require a signed Release of Information (ROI) and should be completed within five business days. To submit a clinic reassignment request, the originating clinic must check the “Clinic V1 Reassignment” box in the MTM. There is one exception to this, and it involves members who are auto-assigned to the NPN post-enrollment, who have a completed exposure questionnaire with the NPN, and want to be re-assigned to a CCE.

While these members have a record, (i.e., the exposure questionnaire), the originating clinic, the NPN, can submit re-assignment requests of this type in the in the MTM by checking the “Clinic V1 Reassignment” checkbox in the MTM as described above. In addition, the NPN must include in the notes of the reassignment that the member was auto-assigned to the NPN post-enrollment and also include the date of completion of the exposure questionnaire. No records (i.e., a copy of the exposure questionnaire) need to be attached to the reassignment because just like all other clinic reassignments, no signed ROI is required. All other requests require prior approval from the WTC Health Program through a transfer exception. The three main types of transfer exceptions include:

D. Geographically-Determined Transfer

Members may request to change clinics in the event of a geographic relocation that results in difficulty traveling to their current clinic. For example, if a NYC-based member moves to Florida, they would likely want to transfer to the NPN. This type of transfer does not require approval from the WTC Health Program.

E. Exception to Care Generally, members who live in and around the NYCMA or NJ catchment area attend a Responder or Survivor CCE and members, who do not live in and around the NYCMA or NJ catchment area, attend the NPN. However, members in the NYCMA or NJ catchment area may choose to request an “exception to care” if they would like to transfer to the NPN and members, who do not live in and around the NYCMA or NJ catchment area may choose to request an “exception to care” if they would like to transfer to a CCE.

Exceptions to care need to be approved by both the originating clinic and the WTC Health Program. Typically, members only receive approval in such situations if they have a demonstrated need to attend the NPN (e.g., mobility limitations) or have a demonstrated need to attend a Responder or Survivor CCE (e.g., an inability to locate a provider in their area).

F. Transfer Exceptions Transfer exceptions require prior approval from NIOSH. When a member requests to transfer prior to the passing of one year since the last time they transferred, this is known as a transfer exception. Other instances of transfer exceptions include transfers mid-monitoring and transfers that occur when members receive monitoring via telehealth.

1. Transfer Mid-Monitoring Unlike members at the CCEs, NPN members complete their monitoring exam in three parts: exposure questionnaire, work-up (labs), and a provider visit. Due to the administrative and financial burden of duplicate testing, a request for transfer exception needs to be submitted for NPN members wishing to transfer to a CCE between completing work-up and the provider visit.

2. Monitoring Exams via Telehealth When members receive monitoring exams via telehealth and they want to transfer, the originating clinic must submit the transfer as an exception in the MTM.

3. Urgent Transfers

For urgent transfer requests that involve an exception, the NIOSH Transfer Team will respond to the urgent request within 1 day or 24 hours of the originating CCE/NPN’s submission. For urgent transfer exceptions that are approved by the NIOSH Transfer Team, the destination clinic must respond to the urgent transfer exception within 48 hours or 2 days of NIOSH’s approval.

V. Member Transfer Process

In order to initiate the member transfer process, members must request a transfer from the clinic to which they are currently assigned. If the member tries to request a transfer from the WTC Health Program, the HPS contractor, or a clinic other than the one to which they are currently assigned, then they should be directed back to their originating clinic to initiate the transfer. Members initiate transfers by completing and signing a medical authorization release form or a Release of Information (ROI) form and providing it to their originating clinic. The member should be offered assistance from the appropriate contact at their originating clinic. If a destination clinic learns that a member is having difficulty with their originating clinic, the destination clinic should contact the originating clinic to notify them that the member expressed the desire to transfer. The originating clinic should then follow up with the member and address their concerns. The WTC Health Program may be contacted for policy-related issues. These policy-related issues include, but are not limited to, instances where members express their desire to transfer and are provided a medical authorization release form or a Release of Information (ROI) form, but do not return the form to their originating clinic. If a member does not return their ROI within 14-business days from the date they were provided the form, whether that be via electronic format and within 21-days via mail, the originating clinic must contact the member to obtain justification for the delay in returning the ROI.

If a member requests a transfer but notifies the originating clinic that they have changed their mind before medical records have been sent to the destination clinic, this is considered a cancellation and is permitted under this policy. A cancellation does not require approval from the WTC Health Program. If the request occurs after medical records have been sent, then the transfer must be completed in the MTM/Transfer Web Portal, though the destination clinic retains the right to accept or deny the transfer.

In instances where the request occurs after medical records have been sent, if the destination clinic has accepted the transfer, they retain the right to initiate a transfer back to the member’s originating clinic and do so outside of the transfer exception process (in other words, the destination clinic can transfer the member back without having to submit the request as a transfer exception in the MTM).

The following steps describe the member transfer process in terms of the roles and responsibilities of the involved parties including the originating clinic, the destination clinic, and the HPS contractor. A transfer checklist (Appendix B) is provided to facilitate the process, with an accompanying flowchart (Appendix C) available as a visual reference guide.

A. Initiating Member Transfer at the Originating Clinic

1. When a member informs their current clinic that they want to transfer, the clinical staff must inform the transfer POC at their clinic (Appendix D). Each clinic may have additional internal policies regarding the protocol to follow when members transfer out of their clinic.

a. If a clinic is transferring a member who they identify as having a history of behavioral issues or needs that should be handled in a more sensitive manner during the transfer of care between two clinics, then the originating clinic must notify the WTC Health Program to discuss these issues. This may include members who have active substance abuse, persistent or severe mental health conditions, behavioral or disciplinary issues, drug-seeking or “doctor shopping” behaviors, and more.

The WTC Health Program will serve as a liaison with the member, the originating clinic, and the destination clinic during the transfer process. In some cases, the WTC Health Program may coordinate a call with both clinic administrators to discuss the member. The outlined process will still occur, but only after agreement between both the originating and destination clinics is reached to start the process.

b. For urgent transfer requests, the originating clinic must select the “Urgent” checkbox in the MTM to generate a notification email to all parties and must also make a phone call to the destination clinic’s transfer POC. Urgent requests include situations in which members are moving to a new area and need immediate medical attention, and more.

2. The originating clinic will determine if the member is registered with the WTC Health

Program by verifying that the member is present in the system at their Data Center.

3. The CCE/NPN transfer POC should review with the member the changes that would take place with respect to the member’s healthcare via an exit interview2 (Appendix E).

They should also ensure that the member is provided with a copy of the member transfer information sheet (Appendix F). The member should be informed about the

2 Reporting requirement on semi & annual report and technical guidance document created.

following aspects of the transfer process:

a. Members should be informed that once a transfer is complete, their WTC-related health care will be handled by the destination clinic, including all WTC-related treatment services, medical care, and mental health care.

b. Members must be informed that they can only transfer once a year unless special circumstances justify a transfer exception.

c. Members must be informed that WTC monitoring and treatment services (if applicable) will be shifted to the requested destination clinic, and though they will go through another intake process, they will remain on the same monitoring schedule.

This means that responders and certified-eligible survivors will get their first monitoring exam at their new clinic approximately one year after their last exam at their last clinic. Screening-eligible survivors will not get another initial health evaluation; however, they retain the right to pay out-of-pocket for an additional health evaluation.

d. Members should be informed that any care (e.g., surgeries, lab test, and/or procedures such as CT scan) which are currently pending at the originating clinic will be evaluated through administrative consultation with the destination clinic. The member should be informed that some pending care may need to be cancelled and re-initiated by the requested destination clinic.

e. Members should be informed that any medications which they are currently receiving will no longer be provided through the originating clinic. However, members should have a discussion with their originating clinic about adequate medication coverage during and after the transfer process. Members will need to be evaluated by the destination clinic to obtain further medication after the transfer is completed. If members are referred by the destination clinic to services in the community, the destination clinic will be responsible for the case management of the member once the transfer is finalized. The originating and destination clinic should coordinate to ensure that members do not have a lapse in medication.

f. Exit interviews should be completed prior to sending the member a medical records release form/release of information (ROI) form, if applicable. During the exit interview, the originating clinic should ascertain the member’s reason for transfer, discuss differences between their current clinic and the clinic they are transferring to, which includes, but is not limited to, education on out-of-pocket transportation costs, in-house providers versus preferred provider networks, and ensuring that transferring members are provided with information on providers (within a 250-mile radius) of the area of which they are transferring to. In addition, members must be notified that all their care will be transferred to and provided by the destination clinic.

4. The transferring member must complete a medical records release form before any records or demographic information can be released by the originating clinic or the HPS contractor to the destination clinic.

a. Transfers resulting after a reclassification also follow the aforementioned guidelines including completing a medical records release form. Originating clinics transferring reclassified members have up to 7 business days from the date of reclassification completion (i.e., reclassification effective date) to contact the member to obtain their medical records release form to initiate the transfer request to the destination clinic.

Destination clinics receiving transferred members post-reclassification have up to 7 business days post transfer acceptance to ensure that HPS-Enrollment (Karna) has updated all systems with the correct information including CCE designation Karna’s Plexis database and NIOSH’s Case Management Reporting System (CMRS) database which populate the MTM.

This will ensure that transferred members can receive services and care in a timely manner post-transfer.

5. To initiate the member transfer after a records release form is received, the originating clinic should add the request in the MTM. Only the originating clinic can initiate a transfer in the

MTM.

6. The originating clinic should choose the member’s selected destination clinic in the MTM, while providing a reason for the transfer request. The originating clinic may proceed with the transfer request if the reason for the transfer is because (1) it has been more than twelve months since the member last transferred, or (2) the member will move/has moved out of the area. All other requests will require approval by the WTC Health Program via a transfer exception.3

7. After the originating clinic initiates the transfer in the MTM, a system-generated email notification is sent to the HPS contractor, the Data Centers, and the destination clinic, making them aware of the transfer request. The system email will include the following member information:

a. Transfer initiation notice

b. Member 911 number

c. Originating clinic

d. Destination clinic

B. HPS Contractor Confirmation of Enrollment and Eligibility

1. Upon receiving a notification that a transfer request has been initiated, the HPS contractor will attach a member Transfer Report to the request within the MTM and/or within the SAMS portal (for the transfers that occur manually, outside of the MTM, which includes WSC/HHC transfers and transfers that occur as a result of a reclassification). The Transfer Report will include:

a. 911 number

3 If the member transfer request requires a transfer exception, the request will be sent to the WTC Health Program via the MTM. If the WTC Health Program approves the member transfer, the originating clinic will be notified and the request will be forwarded to the destination clinic. If the WTC Health Program denies the member transfer, the originating clinic will be notified of the reason for the denial.

b. First and last name

c. Address

d. Date of birth

e. Gender

f. Phone number(s)

g. Email address

h. Certification record, including all WTC-related health conditions and health conditions medically associated with a WTC-related health condition.

C. Coordination of Care between Originating Clinic and Destination Clinic

1. When the originating clinic has (1) confirmed that the transfer may be initiated, (2) has informed the member of the transfer conditions as stated above, and (3) has received a completed and signed medical records release form from the member, then the member’s records can be sent to the requested destination clinic via the MTM. The transfer process must be completed within 30 days4 of the member signing the medical records release, in accordance with the HIPAA Privacy Rule regulation on timely access to protected health information (45 CFR 164.524(b)(2)).5

2. The originating clinic must complete the Abbreviated Medical Records Form (Appendix G) to facilitate transfer of medical records. The following records should also be delivered to the destination clinic, as applicable: all treatment records, medication records, mental health records (with the exception of psychotherapy notes), external medical records, and the first and last monitoring exam.

For transfers between clinics that use Trial DB6, any records that are not available in Trial DB must be sent to the destination clinic via mail or a secure portal that is accessible to both the originating and destination clinics. Alternatively, where feasible, the originating clinic may scan and send the medical records (physical and/or mental health) to the destination clinic via SAMS.

2. If the member is receiving treatment for a certified mental health condition at the originating clinic and is seeking ongoing care, the destination clinic must consult with the originating clinic to determine appropriate transfer of care. The originating clinic must also make the following available to the destination clinic, as applicable, facilitated by the required Mental Health Addendum (Appendix H):

a. Mental health clinical summary;

b. List of conditions certified for treatment and conditions that are being treated under the rubric of medically necessary care;

c. Date and outcome of most recent mental health monitoring exam;

4 Completed transfer in excess of 30 days requires written explanation.

5 If there are no medical records to be sent, the current CCE can request a reassignment by the HPS Contractor as opposed to a transfer (as per Section IV.C. of the policy).

6 Trial DB is the records management system used by the Mount Sinai Data Center and shared by NYMCA Responder clinics. Trial DB is not used by HHC, LHI, or the FDNY clinics.

d. Mental health intake assessment;

e. Psychological testing results;

f. Medication management treatment notes;

g. List of current medications as well as date/supply of most recent prescription, along with name and contact number of prescribing clinician;

h. Date of last psychotherapy session, if applicable;

i. Discharge summary related to any psychiatric hospitalization;

j. Reason the member is seeking transfer; and

k. Name and contact information of a clinician on the member’s treatment team who can provide detailed information about the member’s disposition/course of treatment should questions arise. Clinics should ensure that contact information for Points of Contact are up-to-date and reviewed at least once quarterly.

As a reminder, mental health records should be sent separately from physical health records. Psychotherapy (individual or group) notes should not be included in the medical records sent to the destination clinic. Clinical contacts at the originating and destination clinics should schedule a call to discuss relevant psychotherapy-related information.

4. The transfer POC at the originating clinic should coordinate with the appropriate transfer POC (i.e., primary or mental or physical health POC) at the destination clinic for appropriate transition of the member’s case management. The originating clinic’s transfer POC should not terminate case management services, or any other services covered by the Program, until the transfer is approved by the destination clinic, and the originating clinic has received notification of the acceptance.

D. Approval of Transfer by the Destination Clinic

1. The destination clinic has the right to review member’s records prior to acceptance of transfer. The destination clinic should contact the originating clinic to perform an administrative consultation to discuss the case in detail, including the member’s clinical status. As a reminder, the entire transfer process should not exceed 30 days.

2. The destination clinic may require certain stipulations to be met in order to approve a member’s transfer request. This includes requirements regarding member behavior, additional evaluation measures, and adherence to treatment recommendations. To ensure that the member understands the destination clinic’s expectations, the destination clinic may contact the member directly to reach an agreement prior to accepting transfer. Please note that NIOSH is available to participate, if necessary.

3. During review of the case, the following issues may arise regarding certifications:

a. If it is determined that the originating clinic was preparing to submit a certification request, then the destination clinic may, if appropriate, complete the certification request using the WTC-3 process.

b. If a certification was not pursued by the originating clinic because they determined that there was a lack of WTC-relatedness to the condition, the destination clinic may not provide treatment unless and until it is determined that there is sufficient information to pursue a certification.

c. If the originating clinic determines that a certification was insufficient or lacked WTC-relatedness during the initial certification review and during secondary review, the destination clinic may opt not to pursue certification for that same condition again.

3. If the destination clinic decides not to accept the member, then they must first consult with the WTC Health Program and provide justification for the denial before entering it into the MTM. Valid reasons for denying acceptance of a member are primarily due to documented behavioral issues such as:

a. Acts of violence or threats against staff or other patients, including verbal or physical abuse;

b. Rude or vulgar language, including cursing or shouting; and

c. Engaging in criminal behavior.

If member has a history of non-compliance (i.e., missing appointments) the Program recommends that the destination clinic speak first speak to member and notify NIOSH of the member’s history of non-compliance while including written documentation of the non-compliance (i.e., missed appointments with dates included and/or a history of repeated appointment cancellations with dates included). Prior to transfer acceptance and finalization, NIOSH will send the member a letter of non-compliance equipped with the member’s roles and responsibilities as a Program member, including being compliant and attending scheduled appointments and the consequences of non-compliance.

The WTC Health Program will review all denials submitted into the MTM before they are finalized.

E. Transition of Member after Transfer Approval

1. The destination clinic will notify members that the transfer has been completed within 2-3 days of approving the member.

2. The originating clinic must coordinate with the destination clinic to evaluate all active pre-authorizations with external providers prior to final transfer. The abbreviated medical record form and the transfer checklist enables both the originating clinic and the destination clinic to see that all services related to the member have been properly coordinated to maintain continuity of care where possible, including mental health care.

3. The transfer POCs at the originating and the destination clinic should communicate concerning any durable medical equipment (DME)—such as a CPAP or BIPAP—that the member is currently using. The current DME provider would need to be identified to determine if they are in-network for the destination clinic. If the current DME provider is in-network, then the destination clinic can work with the member to update the DME provider of the change. If the DME provider is not in-network, then the destination clinic could attempt to bring them into their network, or work with the member to switch to a provider in-network in order to prevent a lapse in treatment.

4. The transfer POCs at the originating and the destination clinics must communicate concerning the management of the member’s health care in the interim period until such time that the member can be seen at the destination clinic.

5. The transfer POCs at the originating and destination clinics should coordinate any cancer treatment that the patient is receiving, by identifying the current cancer treatment provider, and determining if this provider is in-network, out-of-network, or in-network via a single-case agreement (SCA) contract with originating clinic only. If in-network via SCA, the destination clinic will have to bring that provider in network via HPS contracting team, or work with the member to switch to an in-network provider.

6. Once the medical records have been reviewed by the destination clinic, and the member transfer request has been approved in the MTM, the transfer is considered complete. The destination clinic will call the member within 2-3 days of transfer completion to establish the relationship with the member and to initiate services.

F. Administrative Responsibilities after Transfer Completion

1. The HPS contractor will send a letter (Appendix I) notifying member that their transfer is complete. The letter will include the destination clinic POC information. The HPS contractor will then update their internal system to reflect the member's new clinic affiliation.

2. The appointment will be documented in EHR/EMR and the destination clinic will notify the member of the appointment information. The member will also be provided with a reminder by the destination clinic prior to their appointment.

3. Any outstanding appointments made by the originating clinic should be cancelled unless a decision has been made between the originating and destination clinic to maintain appointments for continuity of care. If an appointment is not cancelled, it should be billed by the provider at the originating clinic. Note that continued care by the originating clinic is generally not allowed after a transfer has been approved unless authorized by the destination clinic.

4. The effective date of the transfer is determined by the destination clinic’s acceptance date in the MTM. For example, if a transfer is accepted on 5/19 in the MTM, then the last day that the member is with the originating clinic is 5/18 and the first day with the destination clinic is 5/19. For destination clinics that use Trial DB, the transferred member’s effective date in Trial DB would be 5/19.

APPENDIX A. Glossary of Terms

Approval of Transfer: Occurs when a destination clinic decides to accept a member transfer. The date the transfer is approved is the effective date of the transfer. As an example, if a transfer is accepted on 5/19 in the MTM, then the HPS contractor’s records and Trial DB should show the member’s last day with the originating clinic to be 5/18 and the first day with the destination clinic as 5/19.

Cancellation of Transfer: Occurs when a member changes their mind about transferring before medical records have been sent to the destination clinic. Cancellations do not require approval from the WTC Health Program. If the member changes their mind after medical records are sent, the transfer must be completed. The member will have to get a transfer exception to transfer back to their original clinic.

Clinic Reassignment: Allows members to change clinics prior to intake before the member has any medical records. This is not considered a transfer, and so the Year Rule takes effect after the member is assigned to the new clinic. Reassignments do not require prior approval from the WTC Health Program.

Denial of Transfer: Occurs when a destination clinic decides not to accept a member transfer. The destination clinic must provide a justification for the decision (i.e., capacity) to the WTC Health Program, and the Program will have to approve the denial before it is entered into the MTM.

Destination Clinic: A clinic that a member is requesting a transfer to.

Exception to Care: Occurs when a member lives within the NYCMA/NJ Catchment area and they want to transfer to the NPN or when a member lives outside the NYCMA/NJ Catchment area and they want to transfer to a CCE.

Exit Interview: Should occurs when a member initiates transfer. The originating clinic should ascertain the member’s reason for transfer, discuss differences between their current clinic and the clinic they are transferring to, which includes, but is not limited to, education on out-of-pocket transportation costs, in-house providers versus preferred provider networks, and ensuring that transferring members are provided with information.

Geographically Determined Transfer: An exception to the Year Rule. Allows members to request a transfer in the event of a geographic relocation and/or address change. This type of transfer does not require prior approval from the WTC Health Program.

Initiation of Transfer: Occurs when a member requests a transfer from their originating clinic by submitting a medical records release form. The originating and destination clinics have 30 days to complete the transfer. The transfer request should be documented in the MTM.

Member Transfer Module (MTM): An online application located in the SAMS portal that allows for the secure transfer of member care and medical records between the CCEs, the NPN, the HPS Contractor, and the WTC Health Program.

Mid-Monitoring: Occurs when an NPN member has an incomplete monitoring exam and wants to transfer to a CCE or member had their monitoring exam via telehealth.

Originating Clinic: A member’s current clinic that they are requesting a transfer from.

Time-Determined Transfer: See the Year Rule.

Transfer Exception: Occurs when member wants to transfer to a new clinic, but 1) it has been less than twelve months since the member last transferred, and 2) the member is not requesting a geographically determined transfer. These requests do require prior approval by the WTC Health Program.

Transfer Post-Reclassification: Occurs after a member’s enrollment reclassification from a Survivor to Responder and is completed manually out of the MTM Portal. Updates are sent via SAMS Web Portal.

Trial DB: Records management system used by the Mount Sinai Data Center and shared by NYC Metropolitan Area Responder clinics. Trial DB is not used by HHC, LHI, or the FDNY clinics.

Year Rule: Restriction stating that members may only request to change their clinic once a year, barring special circumstances (ex: geographically determined transfer, clinic reassignment). Also known as a Time- Determined Transfer.