Appointment Access Standards

1. Physical / Wellness Examinations (Appointment availability guideline: adults within 90 days of request) Physical / Wellness examinations include adult physical exams, well woman exams, and WIC screenings. Adult preventive / wellness visits are expected to be provided in accordance with the U.S. Preventative Task Force requirements.
2. Routine Care (Appointment availability guideline: within 14 days of the request)
3. Urgent Care (Appointment availability guideline: within 24 hours of the request) Urgent care means those services necessary for treatment of a health condition, which are required in order to prevent rapid and/or serious deterioration in the member’s health as a result of injury or illness.
4. Prenatal Care (Appointment availability guideline: Pre-natal care must be provided within 14 days of request, except for high-risk pregnancies or new Members in the third trimester, for whom an appointment must be offered within five days, or immediately, if an emergency exists)
5. Well Child Care (Appointment availability guideline: STAR Children in accordance with American Academy of Pediatrics (AAP) periodicity schedule with the THSteps Program modifications. For newly enrolled STAR members under 21, overdue or upcoming well-child checkups, including THSteps medical checkups, should be offered as soon as practicable, but in no case later than 14 days of enrollment for newborns, and no later than 60 days of enrollment for all other eligible child members. CHIP and CHIP perinate newborns - AAP recommended well-child exams and preventive health services (including, but not limited to, vision and hearing screening and immunizations) Well child care includes well baby and well child care, THSteps services, WIC screenings, school physicals, and Headstart physicals.
6. Emergent Care (Appointment availability guideline: upon member presentation at the service delivery site, including at non-network and out-of-area facilities) Emergent care means a mental or physical condition manifesting itself by acute symptoms of sufficient severity (including but no limited to severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
   • Placing the patient’s life or health in serious jeopardy (or with respect to pregnant women, the life or health of an unborn child)
   • Serious impairment of bodily function; or
   • Serious dysfunction of any bodily organ or part; or
   • Serious disfigurement
7. Routine Specialty Care Referrals: Within 30 days of request (when approved by the PCP), or within 24 hours of an urgent request
8. Wait times in the office: No exam room wait time greater than 15 minutes
9. Exclusive Provider Organization (EPO) Requirements:
   • Routine Care: Within 2 weeks of appointment request
   • Urgent Care: Within 24 hours of contact by the CHIP Member or a person acting on behalf of the CHIP Member
   • Preventive Health services: Within two months

Credentialing Program Summary

The Regency Building
2100 South IH 35, Suite 202
Austin, Texas 78704

The Superior HealthPlan Credentialing Program collects, assesses, and validates qualifications and other relevant information pertaining to physicians and licensed providers to determine their eligibility to deliver health care services to Superior HealthPlan members.

Who is credentialed?

Licensed independent practitioners to include:

• Physicians, MDs and DOs
• Oral Surgeons (DDS)
• Podiatrists (DPM)
• Chiropractors (DCs)
• Optometrist (OD)

Licensed Mid-Level Practitioners to include:

• Nurse Practitioners, Nurse Mid-wives
• Physician Assistants
• Physical Therapists
• Speech Therapists
• Occupational Therapists
• Behavioral Health Practitioners (psychologists, social workers)

Health Delivery Organizations to include:

• Hospitals
• Home Health Agencies
• Skilled Nursing Facilities
• Mental Health Services
• Substance Abuse Services
• Laboratories
• Medical Equipment Suppliers
• Rehabilitation Centers

How are Providers Credentialed?

• Providers complete the Texas Standard Credentialing application.
• Providers submit copies of key documents such as their license to practice and evidence of malpractice insurance.
• Primary source verification is completed.
• The Plan’s Quality Improvement Committee reviews applicants’ credentials.

What do we monitor?

• Is the Plan processing applications within 180 days?
• Are providers re-credentialed every three years?
• Continuous monitoring for sanctions or adverse actions applied to professional licenses of Plan providers.

Providers are re-credentialed every three years. During the re-credentialing process, Primary Care Provider performance related to pre-established quality indicators is evaluated. A more detailed description of the program may be requested in writing. Please direct all inquires to the Quality Improvement Department or Superior HealthPlan’s Medical Director.

Medical Record Documentation Standards

These standards will be utilized during medical record documentation reviews by SHP to ensure that medical records are maintained in a manner that is current, detailed and organized, and which permits evaluation of effective patient care and quality reviews and to ensure that all aspects of patient care are appropriate and comprehensive.

Superior HealthPlan Medical Management and Quality Improvement Departments may also conduct medical record reviews including but not limited to the purposes of utilization review, quality management, medical claim or member complaint or appeal process or targeted review activity. In addition, these standards may be used during medical record reviews for Behavioral Health Providers when applicable.

The records reflect all aspects of patient care, including ancillary services. The records shall, at a minimum, include:

• Each and every page in the record contains the patient's name or ID number.
• Personal/biographical data includes address, employer, home and work telephone numbers, and martial status as well as assessment of cultural and/or linguistic needs such as deaf/blind, etc.
• All entries in the medical record contain author identification.
• All entries are dated.
• The record is legible to someone other than the writer and in ink.
• Significant illnesses and medical conditions are indicated on a problem list.
• Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record.
• Medication information list includes instructions to member regarding dosage, initial date of prescription, and number of refills.
• Past medical history (for patients seen three or more times) are easily identified and include serious accidents, operations, and illnesses. For children and adolescents (18 yrs. or younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses.
• For patients 11 years and over, there are appropriate notations concerning use of cigarettes, alcohol, and substance abuse (for patients seen three or more times). THSteps Medical Checkup Periodicity Schedule includes screening for behavior risks starting at age 10 and includes the following footnote: Screening for adolescent lifestyle risk factors is to include eating disorders, sexual activity, alcohol (and other drug use), tobacco use, school performance, depression, and risk of suicide.
• The history and physical exam records appropriate subjective and objective information for presenting complaints.
• Laboratory and other studies are ordered, as appropriate.
• Working diagnoses are consistent with findings.
• Treatment plans are consistent with diagnoses.
• Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls, or visits. The specific time of return is noted in weeks, months, or PRN.
• Unresolved problems from previous office visits are addressed in subsequent visits.
• If a consultation is requested, there is a note from the consultant in the record.
• Consultation/lab/imaging reports in the chart are initialed (or other documentation of review) by the practitioner who ordered them signifying review. Abnormal lab and imaging study results have an explicit notation in the record of follow-up plans.
• No evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure (does the care appear to be medically appropriate?).
• An immunization record has been initiated for children, or an appropriate history has been made in the medical record for adults. THSteps Medical Checkup Periodicity Schedule footnotes related to immunizations includes: If a child comes under care for the first time at any point on the schedule or if procedures are not accomplished at the appropriate age, the client must be brought up to date with the required procedures as soon as possible.
• Evidence that preventive screening and services are offered in accordance with the Plan's practice guidelines.
• Evidence of an Advance Directive for patients over 18 years of age. (Medicaid or Medicare only) For members 18 years of age and older, federal law and the HHSCS contract standards mandate that the medical record document whether or not the individual has executed an Advance Directive. Federal and State law also requires providers to maintain written policies and procedures for informing and providing written information to all adult members 18 years of age and older about their rights under state and federal law, in advance of their receiving care. Advance Directives documentation is included in the Provider Manual as attachment 11-B.
• Records are stored securely with access limited to authorized personnel.
• Record format is organized and consistent.

Additional Behavioral Health Documentation Standards:

• For members receiving behavioral health treatment, documentation is to include "at risk" factors (danger to self/others, ability to care for self, affect, perceptual disorders, cognitive functioning, and significant social history).
• For members receiving behavioral health treatment, an assessment is done with each visit relating to client status/symptoms to treatment process. Documentation may indicate initial symptoms of behavioral health condition as decreased, increased, or unchanged during treatment period.
• For members who receive behavioral health treatment, documentation shall include evidence of family involvement, as applicable, and include evidence that family was included in therapy sessions, when appropriate.

Quality Improvement Program Summary

Quality Improvement Program

The Regency Building
2100 South IH 35, Suite 202
Austin, Texas 78704

Quality Improvement Program Summary

The over arching goal of the Superior HealthPlan Quality Improvement Program is to promote the best possible level of health outcomes for our members. To reach this goal, the plan identifies opportunities for improvement in the quality of care and service provided by the plan and it’s providers. Working in an environment of quality and performance improvement, the plan strives to comply with all applicable regulatory and accreditation agency’s rules, regulations and standards, and state and federal law.

Annual Objectives

To operationalize the program goal, the plan establishes annual program objectives and a calendar of specific activities designed to:

• Collect pertinent data,
• Analyze results,
• Compare results with internally developed performance targets or industry benchmarks and published best practices,
• Establish and implement interventions to performance improvement and
• Evaluate the success of interventions by measuring improvement in performance

Program Activities

Samples of key measurement activities included in the Superior HealthPlan Quality Improvement Program are:

• Member Satisfaction
• Provider Satisfaction
• Provider Credentialing
• Satisfaction with Health Plan services
• Access to appointments with providers
• Availability of providers in the network

Clinical initiatives are planned in the areas of:

• Adult Preventive Health
• Child Preventive Health
• Asthma Disease Management
• Pre-natal Care Services
• Use of Behavioral Health Care services
• Appropriate use of the Emergency Room

Providers and members are invited and encouraged to participate in Superior HealthPlan’s quality improvement program. A more detailed evaluation of the program and results of measurement activities may be requested in writing. Please direct all inquires to the Quality Improvement Department or Superior HealthPlan’s Medical Director.