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Table of Contents
 
INTRODUCTION
    
Vision / Mission Statement 2003
Prism Health Networks: Structure 2003
Prism Health Networks: Committees 2003
Table of Contents: ADM 08/21/06
Table of Contents: QI 08/21/06
Table of Contents: UM 08/21/06
Table of Contents: CRED 08/21/06
Table of Contents: RR 08/21/06
Crosswalk: 2002 Policies - Retired Policies Printed03/15/02
Crosswalk: Retired Policies - 2002 Policies Printed03/15/02
 
ADMINISTRATIVE POLICIES
  Current Revision Date
ADM 1 Policy Development & Review Process 02/25/08
ADM 2 Privacy & Confidentiality 02/25/08
ADM 3 Corporate Committees 02/25/08
ADM 4 Professional Discipline - reporting and investigating 02/25/08
ADM 5A
ADM 5B
ADM 5C
 Complaint Policy 02/25/08
ADM 6 Record Retention Requirements 02/25/08
ADM 7 Requesting Medical Records 02/25/08
ADM 8 Reimbursement for Medical Records 02/25/08
ADM 11 Provider Relations Program 02/25/08
ADM 13 IS - User Account Maintenance 02/25/08
ADM 14 IS - User Authentication 02/25/08
ADM 15 Regulatory Compliance 02/25/08
ADM 20 Processing of Claims for Payment and Segregation of Duties 02/25/08
ADM 21 Interest Calculation and Payment on Late Claims for Payment 02/25/08
 
QUALITY MANAGEMENT & IMPROVEMENT
    
QI 1 Quality Management & Improvement Program Description 12/22/08
QI 2 Surveying Member & Practitioner/Provider Satisfaction 03/20/07
QI 3 Process Improvement Activities 02/25/08
QI 4 Quality Referral Process 02/25/08
QI 5 Medical Record Documentation Standards 02/25/08
QI 6 Safety - Network Practitioner Office Standards Referral Process 12/22/08
QI 8 Clinical Practice Guidelines 02/25/08
QI 10 Accessibility of Practitioners: Standards 02/25/08
QI 11 Accessibility of Services: Standards 02/25/08
 
UTILIZATION MANAGEMENT
   
UM 1 Utilization Management Plan 02/25/08
UM 2 Clinical Criteria for UM Decisions 02/25/08
UM 2A Evaluating Inter-Reviewer Consistency 02/25/08
UM 3A Clinical UM Personnel 02/25/08
UM 3B Non-Clinical Administrative UM Personnel 02/25/08
UM 3C Utilization Management Communication Services 02/25/08
UM 4 Timeliness of UM Decisions 02/25/08
Appendix A New York State Article 49 02/25/08
Appendix B New Jersey 02/25/08
Appendix C Connecticut 02/25/08
Appendix D Federal Medicare Advantage 02/25/08
Appendix F New York State Government Programs: Family Health Plus (FHP), Medicaid (MA) 02/25/08
UM 5 Transition to Other Care 02/25/08
UM 6 Denials Notices 02/25/08
UM 7 Policies for Appeals 02/25/08
Appendix A New York State Article 49 02/25/08
Appendix B New Jersey 02/25/08
Appendix C Connecticut 02/25/08
Appendix D Federal Medicare Advantage 02/25/08
Appendix F New York State Government Programs: Family Health Plus (FHP), Medicaid (MA) 02/25/08
NYS Insurance Department Standard Description
 NEW YORK STATE
STANDARD DESCRIPTION, INSTRUCTIONS & APPLICATION
FOR HEALTH CARE CONSUMERS
TO REQUEST AN EXTERNAL APPEAL
 03/02/06
NYS External Appeal Application
 New York State External Appeal Application 03/02/06
UM 8 Appropriate Heandling of Appeals Retired
UM 9 Evaluation of New Technology 02/25/08
UM 10 Employee Assistance Program 02/25/08
UM 11 Emergency Care 02/25/08
UM 12 External Appeals 02/25/08
UM 13 Ensuring Appropriate Service & Coverage 02/25/08
UM 14 Triage and referral for Behavioral Health Care Retired
UM 15 Authorized Representative Action on Behalf of Members 02/25/08
UM 16A Member Grievance/ Appeal Process 02/25/08
Grid for UM 16 Guidelines for Review of Adverse Benefit Determinations 02/25/08
UM 16B Administrative Denial / Practitioner Complaint Process 02/25/08
UM 17 Timely Filing of Service Requests 02/25/08
 
CREDENTIALING
    
CRED 1 Backup Practitioners/Substitute Practitioners 02/19/08
Cred 2 Change of Location/Additional Location/No Location Retired
CRED 3 Adding New Practitioners, Providers, or Locations 02/19/08
CRED 4
Credentialing and Recredentialing Practitioners and Providers 02/19/08
Grid for CRED 4 Difference in Criteria - All Disciplines 02/19/08
CRED 5 Hospital Policy 02/19/08
CRED 6 Alleged Fraud or Misconduct 02/19/08
CRED 7 Leave of Absence 02/19/08
CRED 8 Malpractice History 02/19/08
CRED 9 24 Hour Access to Care 02/19/08
CRED 10 Terminations 02/19/08
CRED 11 Conducting Site Visits 02/19/08
 
MEMBERS' RIGHTS & RESPONSIBLITIES
    
RR 1 Sentinel Event Policy 02/25/08
RR 2 Members Rights & Responsibilities 02/25/08
 
MEDICAL RECORDS
   
MR 1 Medical Record Documentation Standards 03/20/07
MR 2 Reserved for "Monitoring Compliance to Medical Record Documentation Standards"  
     
Glossary
    
  02/25/08
     
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