Providing Quality Care
As our valued provider, your ability to serve our participants is important. PA Health & Wellness is here with information to help you provide the very best care. This information is part of our Quality Improvement (QI) program designed to address both the quality and safety of services provided to your patients and our participants.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is a chance for your patients to report their satisfaction with their healthcare, including their experience with their providers and health plan. The CAHPS survey scores are made available to the public and can determine whether patients and participants stay with their provider or health plan or look elsewhere for their care. Surveys are sent to our participants from February through June.
You are essential to providing the highest-quality healthcare possible for our participants, and your satisfaction is important to us, too. We assess your experience with the health plan through an annual Provider Satisfaction Survey. These survey results will be reviewed by PA Health & Wellness and will be key to helping us improve the provider experience, so please be sure to complete the survey if you receive one in the 3rd or 4th quarter.
During the credentialing process, PA Health & Wellness obtains information from various sources to evaluate your application. Ensuring the accuracy of this information is key, so please review and provide any corrected information as soon as possible. You also have the right to review the status of your credentialing or recredentialing application at any time by calling your health plan Provider Engagement Representative.
If your address or telephone number changes, or if you can no longer accept new patients or are leaving the network, please notify PA Health & Wellness as soon as possible so we can update our Provider Directory. Having access to accurate provider information is vitally important to our participants, and we want to work together to ensure continuity of care can be maintained for PA Health & Wellness participants.
Utilization Management (UM) decisions are based only on the appropriateness of care and service and the existence of coverage.
PA Health & Wellness does not reward providers, practitioners or other individuals for issuing denials of coverage or care and does not have financial incentives in place that encourage decisions resulting in underutilization. Denials are based on lack of medical necessity or lack of covered benefit. Nationally recognized criteria (such as InterQual or MCG) are used if available for the specific service request, with additional criteria (e.g., clinical/medical policies) developed internally through a process that includes a review of scientific evidence and input from relevant specialists.
Submitting complete clinical information with the initial request for a service or treatment will help us make appropriate and timely UM decisions. You may discuss any UM denial decisions with a physician or another appropriate reviewer at the time of notification of an adverse determination. You may also request UM criteria pertinent to a specific authorization request or for any other UM-related request or issue by contacting the UM department at the health plan.
Providing quality care to our participants includes helping adolescents transition to an adult care provider. If you or one of your patients need assistance in finding an adult primary care provider or specialist, contact PA Health & Wellness or reference the information in the Provider Manual. We can assist in locating an in-network adult care provider or arranging care if needed.
The health plan formulary/Preferred Drug List (PDL) is based on the plan benefits and is updated on a regular basis. The current PDL, which includes information regarding covered drugs, restrictions, prior authorization requirements, limitations, etc., is located on the health plan website.
Our Care Management team is available for participants who may benefit from increased coordination of services. The team is available to assist and support providers with participant issues including non-adherence to medications/medical advice, multiple complex co-morbidities, or to offer guidance with a new diagnosis.
The care management team helps participants:
- Achieve optimum health, functional capability and quality of life through improved management of their disease or condition.
- Determine and access available benefits and resources.
- Develop goals and coordinate with family, providers and community organizations to achieve these goals.
- Facilitate timely receipt of appropriate services in the right setting.
Early intervention is essential to maximizing treatment options and minimizing potential complications associated with illnesses, injury or chronic conditions. Participants can receive services through face-to-face visits, over the phone or in a provider's office. You can directly refer participants to the Care Management program at any time by calling the health plan or initiating a referral on the Provider Portal.
Every year PA Health & Wellness assesses appointment availability for PCPs, specialists and behavioral health practitioners. There are established standards for each type of appointment (routine care, urgent/sick visits, etc.) and type of practitioner. Please review the Provider Manual for the expectations of how quickly our participants should be able to get an appointment.
Providers are expected to follow participant rights. Participants are informed of their rights and responsibilities in their participant handbook.
Participant rights include, but are not limited to:
- Receiving all services the health plan provides.
- Being treated with dignity and respect.
- Knowing their medical records will be kept private, consistent with state and federal laws and health plan policies.
- Being able to see their medical records.
- Being able to receive information in a different format in compliance with the Americans with Disabilities Act.
Participant responsibilities include:
- Understanding their health problems and telling their healthcare providers if they do not understand their treatment plan or what is expected of them.
- Keeping scheduled appointments and calling the physician's office whenever possible if there is a delay or cancellation.
- Showing their participant ID card at appointments.
- Following the treatment plans and instructions for care that they have agreed on with their healthcare.
We encourage you to refer to the Provider Manual to review the full list of rights and responsibilities.