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Click on a question below to view the answer.
| 1. |
What is QARR? |
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QARR stands for Quality Assurance Reporting Requirements, which is the New York State Department of Health's version of the national Health Plan Employer Data and Information Set (HEDIS) developed and overseen by the National Committee on Quality Assurance (NCQA).
The QARR consists of a set of clinical and administrative performance
measures reported annually by health plans for their commercial, Medicaid, Child
Health Plus and, eventually, Family Health Plus programs. The State publishes
QARR results for public consumption, and uses the results in decisions affecting
health plan operations. The QARR is posted on the Department of Health's Web
site (http://www.health.state.ny.us/nysdoh/mancare/mcmain.htm).
Examples of QARR measures include rates of childhood immunization,
prenatal and postpartum visits, HbA1c testing and control for diabetics, cervical
cancer screening, access to PCPs, inpatient utilization, provider turnover, and HIV
testing in pregnant women. The QARR also includes a DOH administered Member
Satisfaction Survey.
Affinity QARR 2000 Performance Rates. |
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| 2. |
Why does Affinity Health Plan Quality Management (QM) staff perform site visits to provider practices? |
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There are several reasons why the QM Department might request an appointment to come to your practice site.
- Conduct chart reviews:
- to retrieve information on services delivered to our Members for which we have no encounter or claim in our database;
- to review indicators of care for a clinical study or monitoring process;
- to validate diagnoses and/or services recorded in our administrative database
- to review quality of documentation and/or care for the recredentialing process; or
- to investigate a member complaint.
When the QM team reviews charts, it is the provider's
responsibility to pull the requested charts.
- Copy Charts:
- For SDOH studies conducted by IPRO, such as the Prenatal Care Review of PCAP Standards;
- for our SDOH annual licensure review; or
- for complaint investigations.
When the QM Team copies charts, it is the provider's responsibility to
pull the charts and make a copy machine available.
- Conduct Performance Improvement Meetings:
- For collaborative brainstorming, identification of opportunities for improvement, and evaluation of
barriers and development of plans to improve performance rates; or
- For quality management activities including QARR, studies, recredentialing and/or SDOH reviews of care
When the QM team requests these meetings, it is the provider's
responsibility to make appropriate staff available to meet at an agreed upon time.
- Conduct an Environmental Site Review (ESR):
- For credentialing of a new PCP or OB/GYN practice site; or
- For recredentialing of an existing PCP, OB/GYN or Specialist site.
When the QM Department schedules an ESR, it is the
provider's responsibility to provide access to the facility, answer questions about
the practice environment and make a few charts available for review of record keeping practices.
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| 3. |
What is a report card or performance profile? |
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A report card or performance profile is a summary of a practice site and/or individual practitioner's performance rates on various types of care provided to our Members. Following the annual QARR review, for example, a provider's performance rates for the QARR measures are trended for two years and compared to the aggregate performance of all Affinity Health Plan providers.
Best practices and opportunities for improvement become evident and form a basis
for the QM Department to work with the provider on sharing successful methodologies and/or
overcoming barriers to improving performance.
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| 4. |
What is the difference between a referral and a prior authorization? |
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A Referral Form is required whenever a PCP refers a patient to another provider
for consultation or treatment. Referrals for most services do not require prior approval by our
Utilization Management (UM) Department; the provider receiving the referral can provide the
requested service based on the PCP referral alone. Those services that do require UM Department
authorization are listed at the bottom of the Referral Form. For these services, the provider
(PCP or specialist receiving the referral) must contact our UM Department and submit clinical
information to support the request before delivering the service.
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| 5. |
What specifically is UM looking for when they ask me to submit clinical information? |
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Our UM Department is reviewing the information to determine medical necessity using
nationally accepted clinical review criteria. In most cases, the elements needed to make a decision
are contained in the physician's progress notes including past history, signs and symptoms,
current treatment regime and reason for requesting the service. Providers can fax a copy of the
patient's progress notes to us to facilitate the authorization process.
- Bronx and Manhattan providers fax to 718-817-6864
- Providers in all other counties fax to 718-817-6894
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| 6. |
Does a specialist need to refer the patient back to the PCP to order an MRI? |
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No, the specialist may order the MRI, but must adhere Affinity Health Plan rules
regarding prior authorization. The specialist is expected to relay his/her findings and recommendations
back to the PCP. The specialist cannot refer the patient to another specialist.
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| 7. |
How long does the authorization process take? |
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For non-urgent requests, we comply with the State mandate that determinations
be made and communicated back to the provider and Member within three (3) business days of
receipt of necessary clinical information.
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| 8. |
What if the provider considers a situation to be life threatening and cannot take the time to call Affinity for authorization? |
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In urgent cases, the provider can provide the service, and then request retrospective
authorization by submitting supportive clinical information to us with notification that the service
has already been performed.
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| 9. |
What can be done if Affinity denies the requested service? |
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The provider may wish to pursue a more conservative treatment approach first. If
the provider does not agree with our decision, he/she may file an appeal with us. Information on
how to file an appeal is included with our adverse determination, i.e., denial letter.
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