Providing Quality Care
As our valued provider, your ability to serve our members is important. Sunshine 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.
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.
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 Sunshine 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.
During the credentialing process, Sunshine 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.
If your address or telephone number changes, or if you can no longer accept new patients or are leaving the network, please notify Sunshine 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 Sunshine Health members.
Utilization Management (UM) decisions are based only on the appropriateness of care and service and the existence of coverage.
Sunshine 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 (suc as InterQual or MCG) are used if available for the specific service request, without 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.
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 Sunshine 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.
The health plan formulary/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.
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.
Every year Sunshine 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.
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.
Sunshine 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.
HEDIS (Healthcare Effectiveness Data and Information Set)
HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. Through HEDIS, NCQA holds Sunshine Health accountable for the timeliness and quality of healthcare services (acute, preventive, mental health, etc) delivered to its diverse membership.
Use of HEDIS Scores
As both State and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company’s preventive health outreach efforts. Physician specific scores are being used as evidence of preventive care from primary care office practices. These rates then serve as a basis for physician profiling and incentive programs.
Calculating HEDIS Rates
HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Measures typically calculated using administrative data include: annual mammogram, annual Chlamydia screening, annual Pap test, treatment of pharyngitis, treatment of URI, appropriate treatment of asthma, cholesterol management, antidepressant medication management, access to PCP services, and utilization of acute and mental health services. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data reduces the necessity of medical record review. Measures typically requiring medical record review include: comprehensive diabetes care, control of high-blood pressure, immunizations, prenatal care, and well-child care.
HEDIS and HIPAA
As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or health care operations is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member/patient. The medical record review staff and/or vendor will have a signed HIPAA compliant Business Associate.
HEDIS Quick Reference Guide
Sunshine Health strives to provide quality healthcare to our members as measured through HEDIS quality metrics. We created this HEDIS Quick Reference Guide (PDF) to help you increase your practice’s HEDIS rates.