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PROVIDING QUALITY CARE

As our valued provider, your ability to serve our members is important. Magnolia
Health is here with information to help you provide the very best care. This
information is part of our Quality Improvement (QI) program designed to address
both the quality and safety of services provided to your patients and our
members.


ANNUAL CAHPS SURVEY

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is a
chance for your patients to report their satisfaction with their healthcare,
including their experience with their providers and health plan. The CAHPS
survey scores are made available to the public and can determine whether
patients and members stay with their provider or health plan or look elsewhere
for their care. Surveys are sent to our members from February through June.


ANNUAL PROVIDER SATISFACTION SURVEY

You are essential to providing the highest-quality healthcare possible for our
members, and your satisfaction is important to us, too. We assess your
experience with the health plan through an annual Provider Satisfaction Survey.
These survey results will be reviewed by Magnolia Health and will be key to
helping us improve the provider experience, so please be sure to complete the
survey if you receive one in the 4th quarter.


PROVIDER CREDENTIALING RIGHTS

During the credentialing process, Magnolia Health obtains information from
various sources to evaluate your application. Ensuring the accuracy of this
information is key, so please review and provide any corrected information as
soon as possible. You also have the right to review the status of your
credentialing or recredentialing application at any time by calling your health
plan Provider Engagement Representative.


PROVIDER DIRECTORY & CONTINUED ACCESS TO CARE

If your address or telephone number changes, or if you can no longer accept new
patients or are leaving the network, please notify Magnolia Health as soon as
possible so we can update our Provider Directory. Having access to accurate
provider information is vitally important to our members, and we want to work
together to ensure continuity of care can be maintained for Magnolia Health
members.


UTILIZATION MANAGEMENT

Utilization Management (UM) decisions are based only on the appropriateness of
care and service and the existence of coverage.

Magnolia Health does not reward providers, practitioners or other individuals
for issuing denials of coverage or care and does not have financial incentives
in place that encourage decisions resulting in underutilization. Denials are
based on lack of medical necessity or lack of covered benefit. Nationally
recognized criteria (such as InterQual or MCG) are used if available for the
specific service request, with additional criteria (e.g., clinical/medical
policies) developed internally through a process that includes a review of
scientific evidence and input from relevant specialists.

Submitting complete clinical information with the initial request for a service
or treatment will help us make appropriate and timely UM decisions. You may
discuss any UM denial decisions with a physician or another appropriate reviewer
at the time of notification of an adverse determination. You may also request UM
criteria pertinent to a specific authorization request or for any other
UM-related request or issue by contacting the UM department at the health plan.


TRANSITION TO OTHER CARE

Providing quality care to our members includes helping adolescents transition to
an adult care provider. If you or one of your patients need assistance in
finding an adult primary care provider or specialist, contact Magnolia Health or
reference the information in the Provider Manual. We can assist in locating an
in-network adult care provider or arranging care if needed.


PHARMACY

The health plan Preferred Drug List (PDL) is based on the plan benefits and is
updated on a regular basis. The current PDL, which includes information
regarding covered drugs, restrictions, prior authorization requirements,
limitations, etc., is located on the health plan website.


ACCESS TO CASE MANAGEMENT

Our Care Management team is available for members who may benefit from increased
coordination of services. The team is available to assist and support providers
with member issues including non-adherence to medications/medical advice,
multiple complex co-morbidities, or to offer guidance with a new diagnosis.

The care management team helps members:

 * Achieve optimum health, functional capability and quality of life through
   improved management of their disease or condition.
 * Determine and access available benefits and resources.
 * Develop goals and coordinate with family, providers and community
   organizations to achieve these goals.
 * Facilitate timely receipt of appropriate services in the right setting.

Early intervention is essential to maximizing treatment options and minimizing
potential complications associated with illnesses, injury or chronic conditions.
Members can receive services through face-to-face visits, over the phone or in a
provider's office. You can directly refer members to the Care Management program
at any time by calling the health plan or initiating a referral on the Provider
Portal.


APPOINTMENT ACCESS STANDARDS

Every year Magnolia Health assesses appointment availability for PCPs,
specialists and behavioral health practitioners. There are established standards
for each type of appointment (routine care, urgent/sick visits, etc.) and type
of practitioner. Please review the Provider Manual for the expectations of how
quickly our members should be able to get an appointment.


MEMBER RIGHTS AND RESPONSIBILITIES

Providers are expected to follow member rights. Members are informed of their
rights and responsibilities in their member handbook.

Member rights include, but are not limited to:

 * Receiving all services the health plan provides.
 * Being treated with dignity and respect.
 * Knowing their medical records will be kept private, consistent with state and
   federal laws and health plan policies.
 * Being able to see their medical records.
 * Being able to receive information in a different format in compliance with
   the Americans with Disabilities Act.

Member responsibilities include:

 * Understanding their health problems and telling their healthcare providers if
   they do not understand their treatment plan or what is expected of them.
 * Keeping scheduled appointments and calling the physician's office whenever
   possible if there is a delay or cancellation.
 * Showing their member ID card at appointments.
 * Following the treatment plans and instructions for care that they have agreed
   on with their healthcare.

We encourage you to refer to the Provider Manual to review the full list of
rights and responsibilities.


CHOOSING WISELY

Magnolia Health is pleased to introduce the Choosing Wisely initiative. The
American Board of Internal Medicine (ABIM) Foundation encourages practitioners
and patients to "Choose Wisely." This initiative seeks to advance a national
dialogue on avoiding unnecessary medical tests, treatments and procedures.

Please visit choosingwisely.org to download informational resources for your
patients and clinicians to promote shared-decision making.

 





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