Provider Performance Issues

The collaboration between Community Care and its provider network is a way for Community Care to ensure a successful partnership with providers. The purpose of this partnership is to improve the clinical and quality of care that is delivered to HealthChoices members. Comprehensive Provider Evaluations are a means by which Community Care monitors the quality of service provided to members. Some goals of Comprehensive Provider Evaluation Include:

  • Ensuring that each provider is providing best practice clinical and quality standards to members
  • Striving to continually improve the practice standards of the provider network
  • Utilizing both qualitative and quantitative measures to provide feedback to providers
  • Identifying areas for improvement
  • Ensuring a safe and healthy environment for members
  • Ensuring that providers practice within an environment conducive to recovery

The Comprehensive Provider Evaluation includes identifying trends by tracking Provider Performance Issues (PPIs). If a trend is identified, Community Care may request that the provider submit a plan in order to improve member quality of care. In collaboration with network providers, Community Care has identified the following service and access indicators when tracking Provider Performance Issues. Provider Performance Issues and Community Care’s expectations are described below:

Completed precert in a timely fashion

  • Expectation: Providers are required to obtain authorization PRIOR to admission for those services that indicate precertification (see Provider Manual, page iii). Inpatient Mental Health (IMH) has been permitted a precert within 48 hours of admission.

A coordination of care plan was developed while Member is still in hospital

  • Expectation: Provider is actively coordinating resources for discharge through admission as evidence by the discharge plan reflects the goals of the treatment plan, the Member is linked with a service Provider within 7 days of discharge, and the Provider notifies Community Care of discharge (within 48 hours).

Provider kept patient in facility without authorization

  • Expectation: Providers are expected to discharge on scheduled date and notify Community Care if discharge date is in need of change.

Discharge review is completed in a timely fashion

  • Expectation: For Behavioral Health Rehabilitative Services (BHRS) and Residential Treatment Facilities (RTF), provider discharge reviews should be received within 14 days of discharge. For Acute levels of care, provider discharge reviews should be within 1 business day. For Inpatient Mental Health (IMH), provider discharge reviews are due within 24 hours of discharge. ***The Community Care Discharge Form, for all levels of care, is to be received by the Care Manger within 24 hours of discharge.

Provider is prepared for Clinical review and has all necessary information

  • Expectation: Provider provides necessary information to establish medical necessity criteria (including 5-axis diagnosis), demonstrates evidence of active and appropriate treatment, case management, and discharge planning (i.e., if neuropsychological testing, then a list of tests to be performed is necessary).

Provider reviewed continued stay (CSR) in designated time frame

  • Expectation: CSR must be conducted on the Last Covered Day of authorization.

Provider followed Care Plan developed by facility and care manager

  • Expectation: This is a broad category which is defined by the specific individualized member care plan. The Care Plan outlines specific treatment indicators agreed upon between the Provider and the Care Manager (CM) from the treatment team. The Plan can define specific administrative processes pertinent to coordination of care efforts. Providers are expected to adhere to plans as well as other administrative processes, such as holding timely Interagency Service Planning Team (ISPT) meeting after an evaluation. Examples of information that must be provided in the Care Plan include aftercare planning, family sessions as part of treatment requirements, school input if services provided therein, and specific BHRS services to be implemented.

Cultural Competency: Provider meets member’s cultural preferences

  • Expectation: Providers should make every attempt in meeting Member’s identified cultural preferences, especially in relation to language barriers. Community Care should be notified if they cannot be met.

Discharging provider scheduled aftercare appointment within 7 days of discharge

  • Expectation: Discharging Providers for IMH, both Mental Health and Drug & Alcohol, should schedule the aftercare appointment within 7 days of discharge. If the appointment cannot be scheduled related to network capacity Community Care should be notified. Discharging Providers are expected to engage in active discharge planning as part of transitioning, and appointments should be scheduled prior to discharge. Providers are expected to notify Community Care of transition plan and any barriers to discharge. If Co-occurring, both appointments should be scheduled in a timely manner.

Aftercare providers schedule an appointment within 7 days of discharge

  • Expectation: Receiving Providers should provide routine aftercare appointment within 7 days of discharge.

Timely reporting of incidents by provider

  • Expectation: When a Significant Member Incident (SMI) occurs, the Provider is expected to report/submit an Unusual Incident Report (UIR) to Community Care. Reports for all incidents are due within 24 hours of the incident occurring, or within 24 hours of the provider learning of the incident. The reports can be via phone or fax, in order to meet the requirement.

Timely submission of BHRS/RTF packets

  • Expectation: Packet submission timeframes include: Initial Packets – Community Care must receive packet within 7 calendar days from the ISPT meeting date. Continued Stay Packets: Community Care must receive BHRS packets 14 days prior to the last covered day, RTF packets 21 days prior to the last covered day.

Appropriate BHRS/RTF treatment plan submitted

  • Expectation: Treatment plans should be unique and individualized (“not cut and paste”). The plan should reflect current information, specific, measurable goals and objectives with target dates, specific, measurable interventions, and a concrete discharge plan. The team’s input regarding goals, a connection to concerns outlined in the evaluation/prescription, along with the response to treatment should be in included. Providers are also encouraged to provide timely responses to requests for additional information to prevent unnecessary denials related to lack of information.

BHRS/RTF: Psychological Evaluation (PE) meets standards

  • Expectation: PE should be current, unique, reflect attention to life domain format, and follow the Best Practice Standards. If PE is a CSR, it should reflect progress updates, and outline changes in treatment.

Provider at capacity

  • Expectation: Provider must notify Community Care when they can no longer take referrals (at capacity).


  • Expectation: Providers are expected to adhere to Provider Manual specifics and performance standards, follow administrative processes, communicate and coordinate with treatment team, and ensure quality of care to Members. This category is used sparingly since and would be used to trend any other outlying issues.

Care Manager (CM) is invited to ISPT meeting

  • Expectation: Providers are expected to invite the CM to every ISPT meeting at least 7 days prior to meeting date/time.

Complete Packet

  • Expectation: All packets must be received and contain the required and up-to-date documentation prior to the packet due date. If only partial documentation is received prior to, or on, the packet due date the packet is considered incomplete.

Complete Discharge Summary submitted

  • Expectation: The Discharge Summary, containing all required information, must be received on or before the due date to be considered complete.

Community Care monitors these various provider benchmarking areas and works with providers when opportunities for improvement are identified. Community Care recognizes that there is a wide variance in the volume of Members that Providers may serve. Therefore, this is taken into consideration when establishing trends related to Provider Performance Issues.