Module 1 lesson 5 hbm pre auth (mco)
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To be able to address all customers, within your own environment, on the roles and functions of each service provider within the GEMS network
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บทบาทความสำคัญเภสัชในบริการปฐมภูมิ
This document summarizes the roles and services provided by pharmacists in the UK healthcare system. It outlines essential services like dispensing medications and providing advice for self-care that all pharmacies must offer. It also describes advanced and locally commissioned services pharmacists can provide, such as managing prescriptions, reviewing medications, and screening for conditions. The document discusses how pharmacists aim to optimize medication use, support independent living, and promote public health. It notes payment incentives for pharmacists, like the Quality and Outcomes Framework, to improve care for conditions like diabetes, hypertension, and mental health issues.
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This document provides an overview of the Joint Commission International (JCI) including its mission, organizational structure, history, standards development process, accreditation programs, and the impact of accreditation. The key points are:
1) JCI's mission is to improve safety and quality of care internationally through education, publications, consultation and evaluation services.
2) It is a division of Joint Commission Resources which is a non-profit affiliate of The Joint Commission.
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บทบาทความสำคัญเภสัชในบริการปฐมภูมิ
This document summarizes the roles and services provided by pharmacists in the UK healthcare system. It outlines essential services like dispensing medications and providing advice for self-care that all pharmacies must offer. It also describes advanced and locally commissioned services pharmacists can provide, such as managing prescriptions, reviewing medications, and screening for conditions. The document discusses how pharmacists aim to optimize medication use, support independent living, and promote public health. It notes payment incentives for pharmacists, like the Quality and Outcomes Framework, to improve care for conditions like diabetes, hypertension, and mental health issues.
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1) JCI's mission is to improve safety and quality of care internationally through education, publications, consultation and evaluation services.
2) It is a division of Joint Commission Resources which is a non-profit affiliate of The Joint Commission.
3) JCI has accredited over 40 hospitals internationally and developed standards for laboratories, medical transport and other areas.
4) Accreditation aims to stimulate continuous quality improvement and reduces risks through the use of consensus-based, measurable standards.
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The Credentials and Privileges Committee reviews the credentials of providers applying for initial appointment or reappointment to the medical staff at SHC. It makes recommendations for membership and delineation of privileges in compliance with bylaws and policies. It also reviews credentialing forms and processes. Additionally, it reviews reports from the Interdisciplinary Practice Committee regarding the appointment and evaluations of Advanced Practice Providers.
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Dr hatem el bitar1د حاتم البيطار د حاتم البيطار
د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار
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Dr hatem el bitar1د حاتم البيطار د حاتم البيطار
د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار د حاتم البيطار
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- JCI is a US-based nonprofit that sets international standards for healthcare providers. Over 820 hospitals in 47 countries are JCI-accredited.
- The JCI accreditation process involves surveys to evaluate
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Similar to Module 1 lesson 5 hbm pre auth (mco)
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Chapter 11 Risk Management inSelected High-Risk Hospital Dep
Chapter 11: Risk Management in
Selected High-Risk Hospital Depts
High Risk Depts. in Hospitals
All clinical depts. in hospitals have potential for risk, but some are greater than others:
Emergency Room
Obstetrics and Neonatology
Surgery and Anesthesia
Diagnostic Imaging
Treat highly vulnerable patients in often chaotic settings where the results of errors can be catastrophic and costly
Emergency Medicine
Which Definition?
AMA – any condition clinically determined to require immediate medical care
Federal Legislation – condition manifested by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to an individual’s health, serious impairment to bodily functions or serious dysfunction of any body organ or part
Clinicians –view emergencies as life-threatening situations
The mere existence of an ER implies a duty to treat any patient who arrives
Emergency Medicine Issues
Emergency Medical Treatment and Active Labor Act (EMTALA)
Pre-hospital services
Dept Capabilities and Staffing
Triage Process
Emergency Medicine Issues
Medical Records Documentation and Consent
Support Services
Departures, Discharges and Transfers
Risk Management
Obstetrics and Neonatology
Lawsuits in this category are usually the most expensive
Advanced technology has improved survival rates for infants but led to increased risks for facilities
Ethical Dilemmas
Standards and Guidelines
Levels of Care
Level 1 – least intensive and designed to treat low-risk mothers and babies
Level 2 – must be able to manage high-risk mothers, high-risk fetuses and small, sick neonates
Level 3 – must be able to monitor and maintain critical functions of mothers and neonates the nurse to patient ratio is more intensive as well
Obstetrics and Neonatology
Obstetrics and Neonatology
Prenatal and Perinatal Care
Intrapartum Period
Delivery
Neonatal Resuscitation and Management
Maternal Exam Post Delivery
Family Attendance Issues
Obstetrics and Neonatology
Medical Record Documentation
Neonatal Services
Infant Transport
Infant Abduction
Surgery and Anesthesia
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Increased number of surgeries performed in outpatient or ambulatory settings with decrease in number of claims
Paid malpractice claims are higher in the outpatient setting
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Surgery and Anesthesia
Negligence and Malpractice
Surgical Services Staff
Preoperative Assessment and Treatment
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Documentation
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Surgery and Anesthesia
Intraoperative Risks
Sedation and Anesthesia
Wrong Site, Wrong Procedure, Wrong Person
Implants
Retained Foreign Bodies
Patient Burns and Pressure Injuries
Surgical Fires
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Diagnostic Imaging
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X-rays
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This document provides information about the setup and procedures of a basic hospital. It describes the various departments found in a hospital such as outpatient, inpatient, laboratory, pharmacy, radiology, etc. It explains the functions of each department and gives examples of services provided. The document also discusses classifications of hospitals, functions of a hospital, and elements of total patient care like demonstrating knowledge of a health facility setup and applying basic patient care procedures.
Hospital and its organization
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2) Hospitals are organized into primary, secondary and tertiary levels of care. Primary hospitals provide basic care, secondary hospitals provide specialist care, and tertiary hospitals provide specialized consultative care usually through referrals.
3) Hospitals have complex organizational structures with various clinical and non-clinical departments, services, and staff to provide patient care and run daily operations. Primary services include emergency care, inpatient, outpatient and operating rooms. Secondary services support primary care
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1© P.R. KongstvedtChapter 3 The Provider Network.docx
1
© P.R. Kongstvedt
Chapter 3: The Provider Network
Learning Objectives
Understand the basic elements of payer-provider contracts
Understand service areas and access standards
Understand basic credentialing
Understand the basic types of contracted healthcare professionals
Understand the basic types of contracted healthcare facilities
Understand the basic types of contracted integrated provider health care delivery systems
Understand basic contracting for ancillary services
Understand basic network maintenance
2
2
Payer and Provider Reasons for Contracting
[Put Table 3 – 1 here]
3
Non-Negotiable Contracting Terms Required by Laws and Regulations
No Balance Billing and/or Hold Harmless
Compliance with Quality and Utilization Management programs
Maintenance of clinical standards, licensure, malpractice insurance, etc.
Maintenance and retention of records
Non-discrimination requirements
Compliance with privacy and security requirements
Acceptance of minimum number of patients from plan
Compliance with certain administrative requirements such as timely billing, access to records, addressing patient/member complaints, etc.
Compliance with Other Party Liability processes
4
Contract Structure:
Main Body vs. Appendices or Attachments
Elements that rarely change are in the main body; e.g. descriptions of provider services and the health plan’s obligations
Elements that often change are only referred to in the main body of the contract; actual terms are found in Appendices or Attachments
Allow certain terms to be modified without having to open the entire contract up for renegotiation
Actual payment terms and methods are almost always in an Appendix or an Attachment
Payment methods often separated from the specific dollar amounts
Payer may use one main contract body but use different payment Appendices for different products
Risk-sharing may also be separate even from payment terms for same reason
Any other non-payment terms that change from time to time
5
Service Areas and Provider Access Standards
A service area is the specific geographic area in which a payer may sell certain products and services
Indemnity health insurers, administrators of self-funded plans, and TPAs are able to sell their products and services anywhere in the entire state in which they are licensed
HMOs are different
The service area for an HMO depends on the geographic area of its network
If the HMO cannot provide sufficient access to providers in an area, it cannot sell in that area either
Access standards usually determined by drive times or zip codes
Access standards differ by rural vs. urban, and by type of provider
States vary on PPO access standards, but usually do not have them
6
The Professional Network
7Examples of Non-Physician Professionals who may Contract with PayersClinical Nurse Practitioners (CNPs)CNP MidwivesRespiratory therapistsPsychologist PodiatristsOptometristsClinical Social Worker Physical therapistsNutritionistsLicensed Profess.
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Gems cholesterol reference
This document provides references for information related to heart health. It lists organizations like the Heart and Stroke Foundation South Africa and resources from Mayo Clinic on maintaining a healthy heart. The document expresses gratitude to readers at its conclusion.
Gems cholesterol module 9
Cholesterol screenings are available once per year at no additional cost for all beneficiaries aged 20 years and older as part of preventative benefits. Screenings can be accessed through onsite events scheduled by managers or via tariff codes at clinics and pharmacies.
Gems cholesterol module 8
Statins are the primary medication used to lower cholesterol and work by blocking cholesterol production in the liver. Other medications include bile acid sequestrants which bind bile acids in the digestive system, forcing the liver to use cholesterol to make more bile acids, and cholesterol absorption inhibitors which limit the absorption of dietary cholesterol. For people who cannot tolerate statins or who have very high cholesterol levels, newer injectable PCSK9 inhibitors can help lower LDL cholesterol. Additional medications may be prescribed for high triglycerides including fibrates to reduce triglyceride production and niacin, though it has risks. Omega-3 fatty acid supplements can also help lower triglycerides when prescribed by a doctor.
Gems cholesterol module 7
Normal cholesterol levels are: total cholesterol less than 5 mmol/L, LDL cholesterol less than 3 mmol/L, HDL cholesterol more than 1.2 mmol/L for women or 1.0 mmol/L for men, and fasting triglyceride levels less than 1.7 mmol/L. The document provides guidelines for normal cholesterol levels, including total cholesterol, LDL, HDL, and triglycerides.
Gems cholesterol module 5
People can reduce their cholesterol and maintain a healthy level through lifestyle changes like eating a heart-healthy diet, exercising regularly for 30 minutes most days, avoiding smoking and limiting alcohol, losing weight and managing stress. Making these lifestyle changes will decrease the risk of heart disease and heart attack.
Gems cholesterol module 6
A blood test called a lipid panel checks four measures of cholesterol and fats: total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. For the most accurate results, patients should fast for 8 to 12 hours before the blood sample is taken, drinking only water during that time. The lipid panel screening provides key health information about cholesterol and fat levels in the blood.
Gems cholesterol module 4
High cholesterol can lead to a build-up of plaque in the arteries called atherosclerosis, which narrows and hardens arteries. This plaque can reduce blood flow and lead to complications like chest pain if the coronary arteries are affected, a heart attack if blood flow to the heart is completely blocked, or a stroke if a blood clot blocks blood flow to the brain.
Gems cholesterol module 2
Inactivity, obesity, and an unhealthy diet can cause high cholesterol and low HDL cholesterol as these are factors within an individual's control. Genetic makeup may contribute to high cholesterol beyond one's control by making cells less efficient at removing LDL cholesterol or causing the liver to overproduce cholesterol.
Gems cholesterol module 3
Eating saturated and trans fats found in animal products and processed foods, as well as foods high in cholesterol like red meat and full-fat dairy, can raise cholesterol levels. Lack of exercise and obesity increase risk of high cholesterol, while exercise boosts good cholesterol and improves cholesterol particles. Smoking damages blood vessels and may lower good cholesterol, putting one at risk. Age, diabetes, and high blood sugar also increase cholesterol risks as the body changes over time.
Gems cholesterol module 2
Inactivity, obesity, and an unhealthy diet can cause high cholesterol and low HDL cholesterol as these are factors within an individual's control. Genetic makeup may contribute to high cholesterol beyond one's control by making cells less efficient at removing LDL cholesterol or causing the liver to overproduce cholesterol.
Gems cholesterol introduction
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Gems TB module 7
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Gems TB module 6
34% of people living with HIV in the African Region were infected with TB in 2016. HIV greatly increases the risk of developing active TB disease, and the two diseases form a lethal combination that accelerates the other's progression. In 2016, 320,000 people in Africa died from HIV-associated TB. WHO recommends a 12 part approach including prevention and treatment actions to reduce deaths from the deadly combination of HIV and TB.
Gems TB module 5
The document discusses two types of tests that can detect tuberculosis (TB) infection: the Mantoux tuberculin skin test and the TB blood test. The Mantoux test involves injecting tuberculin fluid into the arm and checking for a reaction 2-3 days later. The TB blood test measures the immune system's response to the TB germs.
Gems TB module 4
1. The document discusses treating exposure and infection from tuberculosis (TB). If exposed to someone with latent TB infection, testing is not needed as the person cannot spread the infection. However, testing is recommended if exposed to someone with active TB disease or symptoms of TB.
2. A positive TB infection test only indicates exposure to the bacteria, not active TB disease, which requires further tests like a chest x-ray and sputum sample. Treatment for latent TB infection may be recommended for those at higher risk of developing active TB disease, such as people with HIV or recent exposure.
3. Active TB disease is treated with multiple drugs over 6-12 months, and it is important to take the full course as prescribed
Gems TB module 3
Tuberculosis is spread through the air from one person to another. When someone with active TB disease of the lungs or throat coughs, sneezes, speaks, or sings, they expel infectious respiratory fluids into the air. If another person inhales these fluids, they may become infected with the TB bacteria.
Gems TB module 2
TB germs are spread through the air when a person with active TB disease of the lungs or throat coughs, sneezes, speaks, or sings. These germs can remain in the air for several hours and be breathed in, causing a latent TB infection. People with latent TB have TB germs in their body but are not sick, while those with active TB disease are sick from multiplying germs destroying tissue and usually have symptoms. Treatment is prescribed to those with latent TB to prevent future disease and those with active TB disease to cure the illness and stop spread.
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- 1. Working towards a healthier you MODULE 1 LESSON 5
- 2. Working towards a healthier you HOSPITAL BENEFIT MANAGEMENT-PRE AUTHORISATION MHRS MANAGED CARE SERVICES (MCO)
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- 5. What We Do 5
- 6. Why We Do What We Do Pre-authorisation is required for as per Scheme Rules Annexure C for the following: Hospital admissions Certain out-of-hospital procedures In-hospital physiotherapy Advanced radiology investigations (e.g. CT, MRI, Angiogram, Radio-isotope scans) All requests for pre-authorisation are evaluated against: Membership validity (Active, Suspended, Terminated) Patient Authentication (Name, Surname, DOB) Underwriting limitation or restrictions Scheme rules and available benefit limits Medical necessary and clinical appropriateness Clinical Protocols & Funding Guidelines & PMB Legislation 6
- 7. What We Don’t Do Confirm member benefits Investigate non-disclosure Advise members on best treatment or which provider to consult Health Education of members Pathology Allied Healthcare pre-authorisations 7
- 8. Which SPN We Collaborate With Metropolitan Medikredit DENIS- Dental Managed care services Opticlear- optometry services MH 8
- 9. Contact Details For Referrals Pre-authorisation requests: 0860 00 4367 IVR options 4-1-1 0860436777 9
- 10. Escalation Information Pre authorization (waiting for authorisations that is pended , declined, under writing) Step 1 : hospitalauths@gems.gov.za then after 8 hours Step 2: Team Leaders: HBMJHBTeamLeaders@medscheme.co.za then after 8 hours Step 3: Manager Call Center: Itumelengmat@medscheme.co.za then after 8 hours Step 4: Manager (Back Office): DebrahM@medscheme.co.za for Under Writing then after 8 hours Step 5: Senior Manager: Raphaelm@medscheme.co.za 10
- 11. 11
Editor's Notes
- Insert company brand / CI to reinforce “Name”.. Use .png image if possible. Delete the GEMS logo example in this slide and replace
- Insert company brand / CI to reinforce “Name”.. Use .png image if possible. Delete the GEMS logo example in this slide and replace
- Give a brief overview of your company
- Describe and list the scope of services applicable to your company
- Explain the rationale behind the services your company is required to provide
- List the out-of-scope services for your company. This could potentially link to common FAQs and incorrect transfers. Provide name of the SPN responsible for the identified out-of-scope service – this is a solution to the incorrect transfer.
- Illustrate, with the use of an example, which other SPN your company collaborates with. This will illustrate the interface matrix.
- List a set of contact details for referrals within your company
- Explain the escalation process and provide a list of contact persons