HealthChoices Provider FAQs
Quality Management
What is a Significant Member Incident?
A Significant Member Incident (SMI) or sentinel event is an unexpected and ndesirable outcome that has an adverse impact on the outcome of care.
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What are the reporting timelines?
Serious incidents that put our members at significant immediate risk are to be reported by close of business day. All other incidents are to be reported to Community Care within 2 business days.
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What form do I use to report?
A provider may use its own reporting form, and if the provider does not have one, Community Care can provide one.
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Does this replace having to report incidents to my county?
No, Community Care’s Significant Member Incident (SMI) reporting process does not take the place of the reporting process a provider has established with its county.
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Where can I find more information on this topic of Significant Member Incident’s (SMI)?
The SMI reporting process can be found in the Provider Manual which is available on Community Care’s website: www.ccbh.com
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Will you come to my office and perform chart audits/record reviews?
Community Care performs chart audits/record reviews annually on various levels of care. If your level of care is selected, you will be notified by Community Care and a mutually agreed upon time will be arranged for this process. You will be given feedback on the review and at times, be asked for a “corrective action plan” if your rate is below an acceptable threshold.
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How quickly do I have to give an appointment for consumers requesting services?
Community Care follows the access standards promulgated by the Department of Public Welfare (DPW). For life threatening needs, care must be delivered immediately; for non-life threatening within 1 hour; for urgent needs within 24 hours; and for routine care within 7 calendar days. Community Care measures provider adherence to these standards.
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Do I have to cooperate with Consumer/Family Satisfaction Teams (C/FST)?
Yes, you have to cooperate with providing space and making consumers available to the teams when they ask. C/FST results are an important way to get feedback from consumers on their care. When you become a provider in the Community Care network, your contract obligations include this.
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How do I know how I am doing as a Community Care provider?
You are given feedback on your care delivery in a variety of ways. For example, you will be given feedback (including benchmarking) through the following processes: member complaints, significant member incidents, denials, record reviews, and utilization factors such as average length of stay, authorization and discharge functions. We believe that excelling in HealthChoices requires a collaboration between you and Community Care and we look forward to working with you in such a team approach.
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What activities are being measured in the Quality Department?
There are a variety of activities being monitored and measured within the department. We follow the continuous quality improvement (CQI) process and always look for areas to improve and then follow through with measurement and review until the process has been completed. You will get detailed information about our various activities via the provider manual and newsletters, as well as by visiting our website at www.ccbh.com. We also invite providers to be participants on our Quality and Care Management Committee to directly work on processes in tandem with consumers, the counties, Office of Mental Health and Substance Abuse Services (OMHSAS), and Community Care. If you would like to participate in these meetings and are committed to attending routinely please contact Community Care and ask for a Quality Representative.
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