Policies and Procedures

Claims

• Definition of a Clean Claim 
• Paper Claim Submissions
• Claim Adjudication
• Overpaid Claims
• Plan Coverage and Eligibility Determination
• Provider Appeal Process
• Gap in Authorization Form

Compliance

• Auditing and Monitoring
• Criminal History Screening and Excludable Convictions
• Fraud Waste and Abuse
• Business Associates and PHI
• Appealing a Compliance Decision
• Clinical Documentation
  
  

Credentialing

• Clean Credentialing – Recredentialing Files
• Credentialing – Recredentialing
  • Credentialing Standards – Individual Practitioners
  • Credentialing Standards – Organizational Provisioners

• Credentialing Committee

• Credentialing Committee Confidentiality Statement Form

• Credentialing Records and Confidentiality

Home and Community-Based Services  (HCBS)

• Home and Community-Based Provisional Approval
  • HCBS Residential Provisional Provider Application
  • HCBS Non-Residential Provisional Provider Application

Incident Reporting

• Incident Review and Reporting
• Incident Reporting Form

Appeals, Grievances, and Second Opinions

• Grievances for Medicaid Beneficiaries

• Second Opinions

• Autism Second Opinions

• Appeals

Provider Network

• Communication
• Grievances and Appeals
• Notification of Summit Pointe Provider Network Changes
• Ongoing Compliance Monitoring
• Written Notice of Termination Contractual Provider
• Procurement
• Use of Out-of-Network Providers
  

SWMBH Policy and Procedures