Trustmark Insurance Company

Trustmark Insurance Company

Trustmark Insurance Companies

Managed Care Department Policies and Procedures

Policy Name: Network Filings Policy
Policy Number: MGDCARE 29 / Effective Date: 12/1/2006 /

Last Revision Date: 11/1/07

Subject Matter: State filing requirements for PPO network approval.
Accountability: Senior Manager Managed Care Compliance.
Approved by: 2nd VP Managed Care

Policy:The purpose of this policy is to document the filing requirements for states requiring PPO network filing and/or approval prior to carrier implementation.

Parameters:

  1. Senior Manager, Managed Care Compliance will coordinate all state filings based on state requirements as noted
  1. Senior Manager, Managed Care Compliance will obtain network specific information through the Network Manager as applicable for the filings
  1. Senior Manager, Managed Care Compliance will obtain copies and maintain a file of state certifications, accreditations and licenses from our contracted PPO network partners as these items are routinely needed for many different types of filings.

States Requiring Filing and Approval prior to implementation of a new network:

  • Massachusetts, New Jersey, North Carolina, New York, Virginia, Georgia and South Dakota. Department Compliance Analyst will furnish the correct filing format for each state.

-VA and GA require a network to be filed 30 days prior to implementation. After the 30-day period these states have allowed implementation while reviewing the filing for approval. If approval is not granted, discontinuation of the network may be required.

Note: Trustmark is an approved MCHIP in VA and, at renewal (bi-annual) of this certification, all network information must be provided. Any violation of the regulations with regard to the VA networks offered must be cured before the Trustmark MCHIP renewal can be approved by the state.

States Requiring Filing of networks for informational purposes:

  • IL, PA, WA, and NH. The compliance analyst will furnish the correct filing format for each state.

- In NH (file within 30 days of commencing a new preferred provider arrangement)

- In WA (file 15 days prior to commencing a new preferred provider arrangement)

Note: If the DOI subsequently objects to the informational filing, any objections must be cured or discontinuation of the network may be required.

State Specific Requirements:

States Requiring Filing and Approval prior to implementation of a new network:

Massachusetts

If the network has a current MA PPA License, Senior Manager Managed Care Compliance will obtain the following documentation to submit to the state for the network filing

  1. Copy of the Service Agreement
  2. Copy of the network PPA License

If the network does not have PPA License, Senior Manager Managed Care Compliance will obtain the following documentation to submit to the state for the network filing

  1. Copy of the Service Agreement
  2. Copy of the Certificates of Coverage to be used with the Provider Plan
  3. Copies of the network Provider Contract Templates
  4. Copies of the network Provider Directory/Directories
  5. Copies of the following network Policies and Procedures (P&P)
  6. Provider Credentialing P&P
  7. Confidentiality of Medical Records P&P
  8. Quality Assurance (QA) P&P
  9. Network Adequacy P&P
  10. Network Grievance and Appeals P&P

New Jersey

NJ requires submission of an SCA Application for each new network filing. TMK Law Department Compliance Analyst will secure the current NJ SCA Application and complete the document with assistance from Senior Manager Managed Care Compliance

Senior Manager Managed Care Compliance will obtain or draft (as applicable) the following documentation required for submission with the completed NJ SCA Application

  1. Copy of the Service Agreement
  2. Copy of the network Provider Contract Templates
  3. Copies of the following network Policies and Procedures (P&P)
  4. Provider Credentialing P&P
  5. Network Grievance and Appeals P&P
  6. Quality Assurance/Quality Improvement (QA/QI) P&P
  7. Provider Access and Accessibility P&P
  8. Copy of the network Provider Directory/Directories (must list provider name, address, phone number and county), and description of the geographical service areas in which the plan will be offered.

States Requiring Filing and Approval prior to usage of a new network (continued):

North Carolina

NC requires submission using their unique state-filing document. TMK Law Department Compliance Analyst will secure the current NC filing documents, and will complete the document with assistance from Senior Manager, Managed Care Compliance.

Senior Manager Managed Care Compliance will obtain or draft (as applicable) the following documentation required for submission with the completed NC network-filing document:

  1. Network Attestation (completed by Senior Manager Managed Care Compliance)
  2. Compliance Certifications (completed by Senior Manager Managed Care Compliance)
  3. Copies of the following network Policies and Procedures (P&P)
  4. Network Utilization Review P&P (PHCS ONLY)
  5. Provider Credentialing criteria P&P
  6. Network Grievance and Appeals P&P
  7. Quality Improvement (QI) P&P
  8. Availability Standards/Accessibility Standards P&P
  9. Copy of the Network Service Agreement
  10. Copies of the Network Provider Contract Templates
  • If the network is already state approved, Senior Manager Managed Care Compliance will obtain a copy of the approval letter from the network
  • If the network is not state approved, Senior Manager Managed Care Compliance will obtain a certification from the network that the agreements are NC compliant and have the network complete the NC contract checklist for submission.
  1. Statement from 2nd VP Managed Care that Trustmark has reviewed and approved the network Provide Credentialing P&P
  2. Statement from 2nd VP Managed Care that Trustmark has reviewed and approved the network Availability Standards/Accessibility Standards P&P and attest to the fact that they comply with NC statutes.
  3. Copy of the Trustmark Utilization Review Program P&P
  4. Copy of the Trustmark Grievance and Appeals P&P
  5. Copy of the network Provider Directory

New York

Senior Manager Managed Care Compliance will obtain or draft (as applicable) the following documentation to submit to NY for the network filing:

  1. Copies of the Certificates of Insurance to be used with the network
  2. Copy of the Service Agreement
  3. Copy of all network Provider Contract Templates
  4. Copy of network Provider Directory/Directories (this must list providers by county)
  5. Copy of the following network Policies and Procedures (P&P)
  6. Provider Credentialing Criteria P&P
  7. Network Adequacy P&P
  8. Grievance and Appeals P&P
  9. Quality Assurance (QA) P&P
  10. Notification of entity that is performing Utilization Review (Senior Manager Managed Care
  11. Compliance will refer to the PHCS approved filing if available and applicable)

(Out of state associations are exempt from the filing but the network used must be filed).

States Requiring Filing and Approval prior to usage of a new network (continued):

Virginia

VA requires submission of an MCHIP Form for Network Approval thirty (30) days prior to implementation. TMK Law Department Compliance Analyst will secure the current MCHIP form and complete the document with assistance from Senior Manager Managed Care Compliance

Senior Manager, Managed Care Compliance will obtain or draft (as applicable) the following documentation required for submission with the completed MCHIP Form for Network Approval:

  1. Copy of the Service Agreement
  2. Confirmation of network ownership
  3. Confirmation of network medical director
  4. Copies of the network Provider Contract Templates (if this is a national network partner, Senior Manager Managed Care Compliance will confirm whether or not the network has specific provisions for VA providers)
  5. Copies of the following network Policies and Procedures (P&P)
  6. Quality Assurance/Quality Improvement P&P (must include an organization chart for committee members)
  7. Provider Recruitment P&P
  8. Credentialing and Re-credentialing P&P
  9. Complaint Handling P&P
  10. HIPAA Privacy P&P
  11. Network Adequacy P&P (must detail travel and appointment wait time standards)
  12. Emergency and Urgent Care P&P
  13. Certifications and/or attestations as follows:
  14. For national networks, Senior Manager, Managed Care Compliance will obtain certification and/or attestation for credentialing and/or any other service that the national network partner furnishes to Trustmark
  15. For regional networks, Senior Manager, Managed Care Compliance will obtain certification from the network that the provider contracts are in compliance with VA regulations
  16. Copy of the network Provider Directory/Directories (must include a map and list providers by county)

Georgia

GA requires submission of an Application for Certification. TMK Law Department Compliance Analyst will secure the current GA Application for Certification and complete the document with assistance from Senior Manager, Managed Care Compliance

Senior Manager, Managed Care Compliance will obtain or draft (as applicable) the following documentation required for submission with the completed GA network-filing document:

  1. Copy of the Service Agreement
  2. Copy of the network Provider Contract Templates
  3. Copy of network Provider Directory/Directories (Directory must be sorted by county and specialty)
  4. Copies of the following network Policies and Procedures (P&P):
  5. Provider Credentialing P&P (this must identify the members and qualifications of the network Credentialing Committee)
  6. Grievance/Appeals P&P
  7. Quality Assurance/Quality Improvement (QA/QI) P&P
  8. Provider Access and Accessibility Standards P&P (this must include targets and strategies for appointment wait times and scheduling benchmarks)
  9. Geo Access Report based on valid zip codes within the state, Provider Map and Provider count by County.

6. An outline, detailing methods of informing enrollees of the process for choosing and changing provider.

States Requiring Filing and Approval prior to usage of a new network (continued):

South Dakota

Senior Manager, Managed Care Compliance will obtain or draft (as applicable) the following documentation to submit to SD for the network filing:

  1. Copy of the Service Agreement
  2. Copy of the Network Provider Contract Templates
  3. Copy of the Network Provider Directory/Directories (must be sorted by county and specialty)
  4. Copies of the following network Policies and Procedures (P&P)
  5. Access and Accessibility P&P
  6. Provider Credentialing P&P (must include documents identifying the members and qualifications of the network Credentialing Committee)

______

States Requiring Filing of networks for informational purposes:

Illinois

If the network has a current IL PPA License, Senior Manager Managed Care Compliance will obtain the following documentation to submit to the state for the network filing

  1. Copy of the Service Agreement
  2. Copy of the network PPA License if they have one.

If the network does not have a current IL PPA License, Senior Manager Managed Care Compliance will obtain the following documentation to submit to the state for the network filing

  1. Copy of the Service Agreement
  2. Copy of the Certificates of Coverage to be used with the Provider Plan
  3. Copies of the network Provider Contract Templates
  4. Copies of the network Provider Directory/Directories

Pennsylvania

If the network has a current PA PPA License, Senior Manager Managed Care Compliance will obtain the following documentation to submit to the state for the network filing

  1. Copy of the Service Agreement
  2. Copy of the network PPA License

If the network does not have a current PA PPA License, Senior Manager Managed Care Compliance will obtain the following documentation to submit to the state for the network filing:

  1. Copy of the Service Agreement
  2. Copy of the Certificates of Coverage to be used with the Provider Plan
  3. Copies of the network Provider Contract Templates
  4. Copies of the network Provider Directory/Directories

Washington

Senior Manager, Managed Care Compliance will obtain or draft (as applicable) the following documentation to submit to WA 15 days within commencing a new provider network.

  1. Copy of the Service Agreement
  2. Copies of the network Provider Contract Templates

If additional information is required WA will request it.

New Hampshire

Senior Manager, Managed Care Compliance will obtain or draft (as applicable) the following documentation to submit to NH 30 days within commencing a new provider network.

1 Copy of the Service Agreement

2. Copies of the network Provider Contract Templates

If additional information is required WA will request it.

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