PARTNERSHIP HEALTHPLAN OF CALIFORNIA PHYSICIAN ADVISORY COMMITTEE ~ MEETING NOTICE Members: Angela Brennan, D.O. Willard Hunter, M.D. Thomas Paukert, M.D. Jeffrey Gaborko, M.D. (Chair) Mills Matheson, M.D. Teresa Shinder, D.O. David Gorchoff, M.D. Douglas McMullin, M.D. Karen Sprague, MSN, CFNP Steve Gwiazdowski, M.D. Danielle Oryn, D.O. Matthew Symkowick, M.D. Michele Herman, M.D. Bessant Parker, M.D. Suzanne Eidson-Ton, M.D. Lisa Ward, M.D.

PHC Staff: Liz Gibboney, Chief Executive Officer Robert Moore, MD, MPH, Chief Medical Officer Wendi West, Northern Executive Director Peggy Hoover, RN, Senior Director, Health Services Patti McFarland, Chief Financial Officer Mary Kerlin, Senior Dir., Provider Relations (PR) Dept. Marshall Kubota, MD, Regional Medical Director Mark Netherda, MD, Assoc. Medical Director of Quality Jeffrey Ribordy, MD, Regional Medical Director Colleen Townsend, MD, Regional Medical Director Stan Leung, Pharm.D., Director, Pharmacy Services Erika Robinson, Director, Quality & Performance Improvement (S) Debra McAllister, RN, Assoc. Dir. of UM Strategies Nancy Steffen, Director, Quality & Performance Improvement (N) David Glossbrenner, MD, N. Regional Medical Director

Ad Hoc PHC Sonja Bjork, Chief Operating Officer Kevin Spencer, Director of Member Services Members: Kirt Kemp, Chief Information Officer James Cotter, MD, Associate Medical Director Lynn Scuri, Regional Director Bettina Spiller, MD, Associate Medical Director Chloe Secor-Schafer, Northern Regional Manager Mark Glickstein, MD, Associate Medical Director Tahereh Daliri Sherafat, N. Region Mbr Services & PR Dir. Margaret Kisliuk, Behavioral Health Administrator Sharon Hoffman-Spector, RN, N. UM Manager Rebecca Boyd Anderson, RN, Director, Population Health Ledra Guillory, Senior Prov. Relations Rep. Manager Katherine Barresi, RN, Director, Care Coordination Margarita Garcia-Hernandez, Assoc. Dir., Health Analytics Diane Wong, Pharm.D., Senior Clinical Pharmacist Vic Patel, Pharm.D., Clinical Pharmacy Manager Rachael French, Assoc. Dir., Quality & Performance Improvement Jeffrey DeVido, MD, Behavioral Health Clinical Director Amy McCune, Manager, Quality Incentive Programs Doreen Crume, RN, Northern Manager, Care Coordination Karl Santos, Director, Network Operations Kim Sivers, RN, Assoc. Director Utilization Management Lisa O’Connell, Sr. Mgr., Network Education & Credentialing

cc: PHC Commission Chair Gabriel Samuel Chua, MD Kali Stanger, MD Voltaire Velarde, MD Richard Fogg Jerry Douglas, MD Amy Brom, Psy.D Karen Relucio, MD David Danzeisen, MD Jeremy Austin, MD Bela T. Matyas, MD Susan Foster, MSN, FNP-BC Francisco Trilla, MD

FROM: Linda Largent DATE: April 7, 2021 SUBJECT: PHYSICIAN ADVISORY COMMITTEE MEETING

The Physician Advisory Committee will meet as follows and will continue to meet the second Wednesday of every month (July and December are tentative.) Please review the Meeting Agenda and attached packet, as discussion time is limited.

DATE: Wednesday, April 14, 2021 TIME: 7:30 a.m. – 9:00 a.m.

LOCATIONS – DUE TO COVID-19 AND SOCIAL DISTANCING, ACCESS IS LIMITED See Agenda for Call-In Information: ______Via Video Conference______

Partnership HealthPlan of CA PHC – Sonoma Office PHC – Redding Office 4665 Business Center Drive 495 Tesconi Circle 2525 Airpark Drive (Please Park in Front of Bldg.) Santa Rosa Redding Fairfield, CA

Please contact me at (707) 863-4228, or e-mail [email protected] if you are unable to attend. Blank Page

2 of 229 REGULAR MEETING OF PARTNERSHIP HEALTHPLAN OF CALIFORNIA’S PHYSICIAN ADVISORY COMMITTEE (PAC) - AGENDA

Date: April 14, 2021 Time: 7:30 – 9:00 a.m. Location: PHC Per Governor Newsom’s Executive Order, N-25-20 that relates to social distancing measures being taken for COVID-19: The Executive Order authorizes public meetings with Brown Act requirements to be held via teleconference or telephone. It waives the Brown Act requirement for physical presence at the meeting for members, the clerk, and/or other personnel of the body as a condition of participation for a quorum. However, the Executive Order requires at least one public location consistent with ADA requirements to be made available for members of the public to attend the meeting, so all PHC offices will be available for members of the public to attend the meeting in-person.

To Join by Telephone: 1-844-621-3956 Access code: 807 289 275 REMINDER – TO MUTE / UNMUTE YOUR TELEPHONE, PLEASE USE *6

w Speaker 2 minutes Speaker 2 minutes This Brown Act meeting may be recorded. Any audio or video tape record of this meeting, made by or at the direction of PHC, is subject to inspection under the Public Records Act and will be provided without charge, if requested. Welcome / Introductions I. Approval of Minutes – Chair 5 – 13 7:30 II. Standing Agenda Items Lead Pg # Time A. Status Update  Administration Ms. Gibboney 7:40  Medical / Health Services Report Dr. Moore 7:50  Regional Medical Director Reports - Napa & Southeast Counties Dr. Townsend 7:55 - Southwest Counties Dr. Kubota 7:58 - Northwest Counties Dr. Ribordy 8:01 - Northeast Counties Dr. Glossbrenner 8:04 A.1. Committee Member Highlight Dr. Parker -- 8:07

B. Quality / Utilization Advisory Committee (Q/UAC) Activities Report with Dr. Moore 14 - 89 8:17 attachments – Consent Review Acceptance of Meeting Minutes: Activities & Minutes of the March 17, 2021 meeting - Minutes – Internal Quality Improvement meetings 02/09/21 - Quality Improvement Update – March 2021 Approval of Committee’s Action Items & Material Reviewed: Note – only pages with significant changes are included for policies Policies & Procedures: Policy Summary - See Pages 37 - 39 - Substance Use Disorder (SUD) Site & Medical Record Review (MCQP1025) - Treatment Auth. Request (TAR) Review Process (MCUP3041) Redline/Excerpt - Quarterly Grievance & Appeals – Inaugural Edition of the PULSE Report - Annual Evaluation of the 2020 UM Program (UM / Pharmacy) - Pharmacy Operations Update - Medical Equipment Dist. Services Program (presented to Committee in March) B.1. 2020-2021 QI Work Plan Update – Mid-Year Report Ms. Robinson 90 - 93 8:17 No Action Required – For Information Purposes Only B.2. Clinical Practice Guidelines for the Diagnosis & Management of Asthma Dr. Moore 94 – 8:17 (MPXG5001) Redline only Approval Required under Consent 104 B.3. Major Depression in Adults Clinical Practice Guidelines (MPXG5003) Dr. Moore 105 - 8:17 Redline only Approval Required under Consent 111 B.4. Clinical Practice Guidelines: Pain Management, Chronic Pain Dr. Moore 112 - 8:17 Management, and Safe Opioid Prescribing (MPXG5008) Redline only 116 Approval Required under Consent B.5. Utilization Management Program Description (MPUP3001) Ms. McAllister 117 - 8:17 Approval Required under Consent 182

Page 1 of 2 Continued REMINDER – TO MUTE / UNMUTE YOUR TELEPHONE, PLEASE USE *6

C. Pharmacy &Therapeutics (P&T) Committee / Consent Review Dr. Leung / -- -- Acceptance of Meeting Minutes: Dr. Moore Approval of Committee’s Action Items & Material Reviewed: No Meeting in March D. Provider Advisory Group (PAG) Report – Consent Review Ms. Sherafat / -- -- Ms. Kerlin “Due to the ongoing COVID-19 pandemic, Partnership HealthPlan of California (PHC) will not be conducting the Provider Advisory Group (PAG) meeting.” E. Credentialing Committee Meeting Summary (Committee Approved) Dr. Kubota 183 - 8:17 Acceptance of Meeting Minutes: 190 Approval of Committee’s Action Items & Material Reviewed Summary and Credentialed List for the February 10, 2021 meeting (attached) F. Pediatric Quality Subcommittee Dr. Ribordy -- -- Acceptance of Meeting Minutes: Approval of Committee’s Action Items & Material Reviewed Minutes & Recommendations from the February 3, 2021 meeting (deferred) G. Recommended Committee Appointments / Resignations for Approval: Dr. Moore -- --

III. Old Business Lead Pg # Time IV. New Business A. Pediatric TeleHealth Pilot (see attached – presentation) Ms. Bains 191 - 8:18 No Action Required 199 B. CalAIM: Enhanced Care Management (ECM) and In Lieu-of Services Ms. Barresi 200 – 8:30 (ILOS) (see attached – presentation) No Action Required 213

C. Video Interpretation Pilot (see attached – presentation) Mr. Spencer 214 - 8:45 No Action Required 229 V. Adjournment 8:55

This agenda contains a brief description of each item to be considered. Except as provided by law, no action shall be taken on any item not appearing on the agenda.

Government Code §54957.5 requires that public records related to items on the open session agenda for a regular committee meeting be made available for public inspection. Records distributed less than 72 hours prior to the meeting are available for public inspection at the same time they are distributed to all members, or a majority of the members of the committee. The committee has designated the Administrative Assistant to the Chief Medical Officer as the contact for Partnership HealthPlan of California located at 4665 Business Center Drive, Fairfield, CA 94534, for the purpose of making those public records available for inspection. The Physician Advisory Committee Agenda and supporting documentation is available for review from 8:00 AM to 5:00 PM, Monday through Friday at all PHC regional offices (see locations under the Meeting Notice). It can also be found online at www.partnershiphp.org.

In compliance with the Americans with Disabilities Act, PHC meeting rooms are accessible to people with disabilities. Individuals who need special assistance or a disability-related modification or accommodation (including auxiliary aids or services) to participate in this meeting, or who have a disability and wish to request an alternative format for the agenda, meeting notice, agenda packet or other writings that may be distributed at the meeting, should contact the Administrative Assistant to the Chief Medical Officer at least two (2) working days before the meeting at (707) 863-4228 or by email at [email protected]. Notification in advance of the meeting will enable PHC to make reasonable arrangements to ensure accessibility to this meeting and to materials related to it.

Meeting Notes – Physician Advisory Committee – 04/14/2021

Action Items Assigned To:

1.

2.

Page 2 of 2 PARTNERSHIP HEALTHPLAN OF CALIFORNIA (PHC) MEETING MINUTES PAGE 1 OF 9 Committee: Physician Advisory Committee Date / Time: March 10, 2021 - 7:30 to 8:31 am

Per Governor Newsom’s Executive Order, N-25-20 that relates to social distancing measures being taken for COVID-19: The Executive Order authorizes public meetings with Brown Act requirements to be held via teleconference or telephone. It waives the Brown Act requirement for physical presence at the meeting for members, the clerk, and/ or other personnel of the body as a condition of participation for a quorum. However, the Executive Order requires at least one public location consistent with ADA requirements to be made available for members of the public to attend the meeting, so all PHC offices will be available for members of the public to attend the meeting in-person. Members Angela Brennan, DO Steve Gwiazdowski, MD Danielle Oryn, DO Matthew Symkowick, MD – Present: Jeffrey Gaborko, MD (Chair) Michele Herman, MD Teresa Shinder, DO – start 7:44 start 7:42 David Gorchoff, MD Mills Matheson, MD Karen Sprague, MSN, CFNP Suzanne Eidson-Ton, MD Douglas McMullin, MD Lisa Ward, MD Members Willard Hunter, MD Excused: Bessant Parker, MD Members Thomas Paukert, MD Note: Most attendees attended via Video Conf. (VC) via WebEx (W) Absent: via remote connection. via Teleconference (TC) PHC Staff Liz Gibboney, Chief Executive Officer Robert Moore, MD, Chief Medical Officer David Glossbrenner, MD, Northern Regional Medical Dir. Present: Sonja Bjork, Chief Operating Officer Peggy Hoover, RN, Senior Dir., Health Services Marshall Kubota, MD, Regional Medical Director Patti McFarland, Chief Financial Officer Colleen Townsend, MD, Regional Med. Director Jeffrey Ribordy, MD, Regional Medical Director Wendi West, Northern Executive Director Mark Netherda, MD, Assoc. Med. Director, Quality Jeffrey DeVido, MD, Behavioral Health Clinical Director Kirt Kemp, Chief Information Officer Stan Leung, Pharm.D., Director, Pharmacy Services Erika Robinson, Dir., S. Quality & Perf. Improvement Mary Kerlin, Sr. Dir., Prov. Relations (PR) Bettina Spiller, MD, Associate Medical Director Nancy Steffen, Dir., N. Quality & Perf. Improvement Tahereh Daliri Sherafat – Dir. Member Svcs/ Katherine Barresi, RN, Director, Care Coordination Debra McAllister, RN, Assoc. Director, UM Strategies Prov. Relations (N) Lisa O’Connell, Sr. Manager Network Education & Kim Sivers, RN, Assoc. Director, Utilization Management Margaret Kisliuk, Behavioral Health Admin. Credentialing Sharon Hoffman-Spector, RN, Northern UM Manager Lynn Scuri, Regional Director Amy McCune, Mgr. Quality Incentive Programs Doreen Crume, RN, Northern Mgr., Care Coordination Chloe Secor-Schafer, N. Regional Manager Somer Harris, Program Manager, Administration Stephanie Chandler, Project Mgr., Quality Improvement Ledra Guillory, Sr. PR Representative Mgr. Jasleen Bains, Program Coordinator, Administration Melissa Stewart, Project Manager, Quality Improvement Note – All Telephone Participants may not be listed – Unidentifiable on Report AGENDA DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE ITEM DATE RESOLVED Public Comments The Committee’s Chairperson, asked for public comments. None were N/A N/A presented.

Quorum Committee quorum requirements met.

I. Approval of The Committee’s Chair presented the meeting minutes for approval. MOTION: Dr. Gwiazdowski moved to approve 03/10/21 Minutes Agenda Item [I.] as presented, seconded by Dr. Eidson-Ton. ACTION SUMMARY: [11] yes, [0] no, [0] abstentions. Motion carried.

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Physician Advisory Committee Minutes – 03/10/21 - Page 2 of 9 AGENDA DISCUSSION / CONCLUSIONS RECOMMENDATIONS DATE ITEM / ACTION RESOLVED II.A. Status The HealthPlan’s Chief Executive Officer (CEO), provided the following report on PHC activities. Update  COVID Vaccination Distribution – PHC staff continues to volunteer at different events in their communities. For information only, no 03/10/21 Administration The distribution and administration of the vaccine continues to be challenging for Partnership. Medi-Cal formal action required. claims for the vaccine are going through the fee-for-service system at the State, and PHC has to rely on the Department of Health Care Services (DHCS) to share the claims data, which has not been coming through. Real time data is also not being received, so information on how members are doing (in terms of vaccines) is unknown. The increase in vaccine supplies is encouraging.

The Committee’s Chair offered that his wife received her COVID vaccination at the vaccine clinic held in Solano County, and was amazed at how well it was run, which mirrored input from other Kaiser Permanente members.

 Federal Administration – The hearings and appointment process for key positions are being watched closely, For information only, no 03/10/21 specifically for the Health and Human Services Secretary (Xavier Becerra, currently California’s Attorney formal action required. General.) He has undergone his two hearings, with the process now going to the Floor, due to the previous tie vote. It is expected that the nominee for the Centers for Medicare & Medicaid Services (CMS) Administrator position, Chiquita Brooks-LaSure, will begin the hearing process soon afterward.  State – There is a lot of legislation coming. Given the current virtual nature of business, it was expected that For information only, no 03/10/21 this Legislative Session would be lighter, but that is not the case. Topics include health information exchange formal action required. (HIE), health equity, same-day billing for Federally Qualified Health Centers (FQHCs), which seems to be a yearly topic, full-scope Medi-Cal for undocumented adults, along with many other focuses. As the new Bills start through the hearing process, PHC staff will monitor.  Medi-Cal Rx – The pharmacy carve-out has been delayed indefinitely at this point. The State has placed the For information only, no 03/10/21 transition on hold, while they work out conflict of interest issues between Magellan Health and the Centene formal action required. Corporation, which are two large state contractors and planning to merge. PHC continues to advocate for a delay, and to add more transparency around the conflict of interest issues. Partnership has also shared that the starting and stopping of the transition process is very disruptive for members and providers.  California Advancing and Innovating Medi-Cal (CalAIM) Waiver (Waiver) – Partnership’s planning on the For information only, no 03/10/21 CalAIM Waiver continues, which is set to start phasing in next January 2022. The first round of discussions formal action required. will be held with the five Whole Person Care counties, since they are currently seeing members who will be first in line for those services (either through Enhanced Care Management [ECM] or In-Lieu of Services.) PHC staff will be spending more time in the community, talking about the ECM and how it will relate to members, as more clarity is received from the State. A number of deliverables will be due to the State from Partnership by June.

II.A. Status The HealthPlan’s Chief Medical Officer (CMO) presented an overview of some Health Services activities. Both For information only, no 03/10/21 Update the Medical Equipment Distribution Program and Home Blood Pressure Monitoring Initiative will be discussed in formal action required. Medical more detail later in the meeting. - Healthcare Effectiveness Data and Information Set (HEDIS®) – PHC is in the midst of its HEDIS data collection season, which is obviously challenged, due to the impact of the pandemic on providers last year.

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Physician Advisory Committee Minutes – 03/10/21 - Page 3 of 9

AGENDA DISCUSSION / CONCLUSIONS RECOMMENDATIONS DATE ITEM / ACTION RESOLVED II.A. Status It is expected that numbers across the country will decline. And, it is unclear what benchmarks will be used to Update determine relative performance. Results should be available in June or July. Medical - Medical Nutrition Therapy (MNT) and Diabetes Education – Partnership has covered MNT for many years, which can be provided by a Registered Dietician (RD) or a Certified Diabetes Educator. PHC has some contracted providers in its network, but it is not a Prospective Payment System (PPS) reimbursable service for patients other than non-pregnant women, so many FQHCs do not offer it. Other options available include TeleMed2U, which is integrating their endocrinology visits with the RD visits virtually. Recently, due to the pandemic, the Center for Wellbeing in Santa Rosa moved their program on-line and have agreed to take patients from out-of-county to participate in the program. The upcoming clinical newsletter will have additional information regarding this opportunity. Providers are encouraged to refer appropriate patients to this service. - Grant Opportunity by the Centers for Disease Control and Prevention (CDC) – The CDC is offering grant funds ($250,000 to $500,000) for improving childhood lead screening. It is targeted toward government entities. In light of PHC’s low measurement rates, particularly in the Northeast, some of the government agencies may want to apply for the funds, though the turnaround time is quick. - Specialty Telemedicine Program – With the impact of COVID, the requirement that specialty telemedicine be performed from a primary care provider (PCP) host site was suspended. Direct specialty care can be provided to patients in their home. Providers who did not participate in this telemedicine program previously can now offer specialty consultations as an option.

PHC’s Regional Medical Director for Napa and the Southeast (SE) counties presented a brief update. For information only, no 03/10/21 - Access – There is a new cardiologist in Napa, along with a new orthopedist. In the Yolo and Solano County formal action required. region, there are no known specific provider changes. However, in Solano County, Sutter Solano Medical Center is closing their labor and delivery unit in mid-May. PHC is working with its community partners (La Clinica, Great Beginnings), and obstetrics and gynecology (OB/GYN) providers to ensure PHC members have seamless access to delivery care. - Quality Improvement (QI) - Also in Solano County, Partnership staff are working with the four community health centers to focus on quality improvement. A collaborative workgroup has been formed and meets monthly to report back on successes and best practices. Each health center is assigned an improvement advisor to help facilitate their improvement. This month, the quality meeting will include all the teams from the three counties to share best practices and review data as the group works toward improving quality measures.

PHC’s Regional Medical Director for the Southwestern (SW) counties presented a brief overview. For information only, no 03/10/21 - COVID – Much of the activities in the region relate to COVID. The four counties are looking forward to formal action required. improving their numbers. Lake County has a relatively high case rate. Sonoma and Mendocino counties are slated to get out of the purple tier, and into red. Marin County has almost improved to the level of the orange tier. The vaccine rate is actually good in the region, with those

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Physician Advisory Committee Minutes – 03/10/21 - Page 4 of 9 Minutes reflect the Meeting Agenda sequence, not the order in which Agenda Items were presented. AGENDA DISCUSSION / CONCLUSIONS RECOMMENDATIONS TARGET DATE ITEM / ACTION DATE RESOLVED II.A. Status over 60 years of age having received their first or second dose. Rates are as high as 48% in Update, Marin, Sonoma and Mendocino counties. Lake County is at 30%, which is still higher than the Medical, State’s rate at around 24%. Continued - Health Officer – Lake County has lost its Health Officer, Dr. Gary Pace, who has been in that position the past couple of years. Dr. Pace has been a physician in the community for over thirty years. It is hoped that he will remain in the area, since he is a valuable physician asset.

PHC’s Regional Medical Director for the Northwestern (NW) counties presented a brief overview. For information only, no 03/10/21 - Access – The provider network in the area has been stable. Providence St. Joseph’s Health formal action required. announced that they will be closing the labor and delivery unit at Redwood Memorial Hospital, which is a small critical access hospital in Fortuna. St. Joseph’s tried to do this back in 2013, and the community’s outcry stopped them from closing the services. When Providence and St. Joseph’s merged in 2015, there was an agreement made with the State Attorney General that no changes would be made for five years. There are a number of reasons to close the unit, one of which is the difficulty in physician coverage, including pediatrics. Also, deliveries are down approximately 20% in the county, and almost 50% at Redwood Memorial. The already small program is now even smaller. Recruitment of physicians has been difficult, with few OB/GYN providers left in the community. A lot of obstetrics care is being done by family practice providers who specialize in obstetrics or have a strong interest in that field. There does not appear to be as much resistance in the community to the closure as there was in 2013. Beginning July 1, it is expected that the county will be down to two obstetric programs. - COVID – Cases in the region are fairly steady, with the area still in the red tier. It is hoped that with more vaccinations being done the number will improve, allowing the region to get back to the orange tier.

PHC’s Northern Regional Medical Director presented a brief overview of the Northeast region. For information only, no 03/10/21 - Network / Access – formal action required.  Churn Creek has a new provider - pediatrician and child psychologist, Dr. Amna Aziz  Mount Shasta has a new cardiologist  Shasta Cascades is purchasing a new building to expand their services  Dr. Alan Cohn accepted the CMO position at Mountain Valley. Dr. Cohn’s practice was previously merged into Mountain Valley.  Anav Tribal has a new medical director, Dr. Kyle Knuppel  Banner Lassen Hospital has a new medical director

II.A1. Dr. Parker was unavailable for the meeting, and asked to be deferred to April. Committee Member 04/14/21 Committee Highlight will resume in Member April. Highlight

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Physician Advisory Committee Minutes – 03/10/21 - Page 5 of 9 Minutes reflect the Meeting Agenda sequence, not the order in which Agenda Items were presented.

AGENDA DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION DATE ITEM RESOLVED II.B. Quality/ Utiliz. There were no items pulled from the Consent Calendar for further discussion. MOTION: Dr. Symkowick moved to 03/10/21 Advisory Committee approve Agenda Items (II.B., II.B.1., and (Cmt), II.B.1. Care II.E.) as presented, seconded by Coordination Program Dr. Eidson-Ton. ACTION SUMMARY: Description, and II.E. [13] yes, [0] no, [0] abstentions. Motion Credentialing Cmt carried.

IV.A. Medical Equipment Partnership’s Program Coordinator for PHC’s Medical Equipment Distribution Distribution Services Services program (also known as PMEDS), advised that the presentation highlights the (Post-Meeting update: Revised presentation 03/10/21 purpose of the program, current devices available, program utilization, the expansion slides will be distributed to the Committee, occurring this month, and how providers can submit requests for the devices. The and the packet updated under PHC’s presentation included some updates to the information in the Committee’s packet. website.)

PMEDS was developed in response to COVID-19, becoming effective on July 1, 2020. Currently, the program includes the distribution of blood pressure monitors, oximeters, and thermometers, which are sent to PHC members at no cost when requested by their provider. All PHC contracted providers can participate in the program, but are required to submit an electronic request form directly to PHC when a member’s diagnosis meets specific guidelines. Devices are shipped directly to the member’s home or specified location by PHC. Some exceptions are made for urgent delivery when medically necessary (i.e. member diagnosed with COVID-19.) For homeless members, or those without a permanent place of residence, providers are encouraged to have devices delivered to their clinic or office for distribution to the member. Participating providers must also ensure that their members are educated on the proper use and setup of the device and instructed on how to self-report the data when needed.

The devices currently being offered under the program are:  VIVE Precision Blood Pressure Monitor, which is a portable device that allows the user to track their blood pressure from their location  Contec Pulse Oximeter, which conducts a test to measure the oxygen level of the user’s blood  Care Line Instant Digital Thermometer, which gives a quick and true reading of the user’s body temperature

The current utilization of the program has been very favorable, with over 2,000 devices provided to members (1,606 BP monitors, 443 oximeters, and 166 thermometers.) Of the diagnoses given by providers, hypertension has been the leading cause for requests.

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Physician Advisory Committee Minutes – 03/10/21 - Page 6 of 9 Minutes reflect the Meeting Agenda sequence, not the order in which Agenda Items were presented.

AGENDA DISCUSSION / CONCLUSIONS RECOMMENDATIONS DATE ITEM / ACTION RESOLVED IV.A. Medical An expansion to the program is occurring this month, which includes additional devices that will be carved Equipment out from the Medi-Cal Rx benefit. These devices are, but not limited to: Distribution  Humidifiers Services, Continued  Scales  Vaporizers  Nebulizers

Access to additional BP cuff sizes, nebulizer replacement parts, user instructions in the member’s preferred language, and more will be offered, along with some exceptions for bulk equipment requests. As of this past Monday, the additional devices have been added to the equipment request form, which is available through PHC’s website. An official announcement will be sent to all providers next Monday. Electronic mail (e-mail) notifications and fax-blasts have been sent out by Partnership’s Provider Relations team.

Devices that the PMEDS program will be offering are:  Vicks Mini Filter Free Cool Mist Humidifier  Cardinal Health Essentials Compressor Nebulizers & Replacement Parts

 Vive Precision Digital Scales

 SVYHUOK Talking Scales (for low vision members)

 GreaterGoods Smart Baby Scale (infants & toddlers under 2 years of age)  Vicks Warm Steam Vaporizer  RENPHO Talking BP Monitor (for low vision members)

Providers can submit request forms via secure e-mail to [email protected] or by sending a secure fax to (707) 420-7855. The request form and guidelines can be accessed through PHC’s website under the Provider Resources section. Any questions can be submitted through the preceding e-mail address.

The Committee’s Chair asked about the indications for the humidifier and vaporizer, which he uses in his practice. Getting updated weights on babies since the pandemic has been challenging. The addition of scales for infants will be very helpful. PHC’s Program Coordinator shared the criteria for those devices, and pulled up the location under the website for viewing of the guidelines, request form and instructions with the Committee (link included here for reference http://www.partnershiphp.org/Providers/Medi- Cal/Documents/OnDemandTrainingWebinars/Flyers%20and%20Bulletins/Medical%20Equipment%20Dist ribution%20Services%20Guidelines.pdf.) The request form is fillable and downloadable, and can be completed by office staff at the request of the physician. The guidelines include a high level overview of the program, the notification, and the criteria. If the member has an address, PHC is happy to ship the device to their location. If being sent to the provider’s location for distribution to the patient, it is recommended to add an “Attention To” in the request.

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Physician Advisory Committee Minutes – 03/10/21 - Page 7 of 9 Minutes reflect the Meeting Agenda sequence, not the order in which Agenda Items were presented.

AGENDA DISCUSSION / CONCLUSIONS RECOMMENDATIONS DATE ITEM / ACTION RESOLVED IV.A. Medical PHC’s CMO noted that shipping to post office boxes generally results in the item being returned, so it is Equipment not recommended. Also, until the Medi-Cal Rx carve-out takes effect, devices can still be ordered through Distribution Services, the pharmacy by providers. Along with the carve-out, the State will not be covering these items. The Continued program is an alternative mechanism to ensure members receive these needed items, and is being built as a more comprehensive program to include items not typically carried by pharmacies. There are some devices the State will be providing (i.e. peak flow meters, which will be covered by PHC and the State), For information only, no 03/10/21 though the preferred models may differ. Ultimately, it is believed that the PMEDS program will provide formal action required. better service to PHC’s members and be more comprehensive.

IV. B. Home Blood One of PHC’s QI Project Managers for the Home Blood Pressure Monitoring Initiative (Initiative) shared Pressure Monitoring that the goal of the program is to increase the monitoring of members who are hypertensive and have other Initiative diagnoses that place them at a higher risk of health conditions that could be exacerbated by hypertension. The target is for 80% of PHC members with this condition to maintain a blood pressure reading less than 140/90. The focus of the Initiative is on increasing the distribution of blood pressure monitoring devices, and providing education on the best use of the devices to PHC’s providers and members.

A member story was highlighted, noting that the 64 year old woman with hypertension (HTN) was having a difficult time getting to in-person medical appointments, due to transportation issues. Since visits were sporadic, a step-wise approach to improve her poorly controlled blood pressure (BP) was difficult. With her home pressure monitoring unit and telehealth visits, the PCP team has been able to provide consistent education on BP management, and introduce self-management through routine home monitoring. Between these short appointments and medication adjustments, the member’s BP gradually decreased into her target range. As the patient saw the gradual improvement, her interest in managing her BP increased, along with recognizing her role in her own health outcome.

Another of Partnership’s QI Project Managers for the Initiative offered some clinically known facts related to reducing HTN. These included:  Nearly 1 out of 2 adults in the country has hypertension  BP control has shown to reduce heart attacks and strokes, reducing morbidity and mortality  Cardiovascular diseases can be reduced by BP control  Most adults with HTN in the United States (U.S.) do not have their hypertension under control

Comparing hypertension control for 2020 in PHC counties to the 2019 data for several Kaiser Permanente facilities, a number of counties are falling behind. The most current data available for national benchmarks was from 2018. When looking at HTN control for different PHC member ethnicities, the African / American / Black and Other populations also fall short.

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Physician Advisory Committee Minutes – 03/10/21 - Page 8 of 9 Minutes reflect the Meeting Agenda sequence, not the order in which Agenda Items were presented.

AGENDA DISCUSSION / CONCLUSIONS ITEM IV. B. Home Studies have shown the cost effectiveness of home BP monitors, especially when medical team-based care is included. The U.S. Preventive Services Task Blood Pressure Force (USPSTF) also recognizes a role for home BP monitoring. And, data has shown the cost of these monitors is outweighed by the cost-savings in treating Monitoring more acute conditions related to hypertension. Initiative, Continued Partnership’s Associate Medical Director of Quality (Quality Medical Director) shared that staff is looking more closely at the data related to BP control in different populations. As noted earlier, BP control for PHC’s African/American/Black members (particularly in the Southwest region and especially in Marin County) is lower than other demographic groups. Staff is reviewing ways to target those populations so that results are more equitable.

Providers were consulted to determine what their preferred workflow was, in terms of home blood pressure monitoring devices. There are BP devices that can link to the member’s medical record automatically, and download the information. It was learned that this can involve a significant amount of data being put onto the provider’s system, while patients can be left wondering why their PCP office has not contacted them. The intent of the program was not to leave providers feeling overwhelmed. With this in mind, devices have been chosen that do not automatically link to the member’s medical record, while still meeting the requirements that Partnership has for HEDIS and DHCS. As many Committee members are aware, BP control is also included in PHC’s Quality Improvement Program (QIP), but there are some stipulations.

The method in which patients report their BP levels to their provider’s office so that the data can count toward the QIP and HEDIS measurement was reviewed. The preferred workflow includes:

 Unconnected device versus connected device  Patient uses home blood pressure monitor  Patient records results in log (given to the member along with the device)  Patient shows device reading at appointment  Member materials in development include: - VIVE Instructions (for specific type of monitor PHC is providing) - Visual on how to take BP correctly (by the CDC) – Also, PHC has developed a reference showing how the BP tubing should align - Chart on how to respond to results - Log sheet

Based on much discussion, consultations with providers, and significant research, PHC developed a chart as a guide for patients to refer to. The information recommends the type of action to be taken, depending on their blood pressure reading. The last column of the chart allows the member’s health care provider to individualize the recommendations, based on their treatment plan. Providers are encouraged to add their specific instructions to the chart, should they not agree with the information included. A list of symptoms that members should be aware of as a precursor to contacting their health care provider or advice nurse is also included, along with PHC’s Advice Nurse telephone number, which is manned 24 hours a day, 7 days per week.

Dr. Herman questioned the allowance that patients could call in their BP readings, which would be accepted for the QIP, versus having to show a digital readout of their blood pressure reading. There are many homeless patients at La Clinica, along with those who do not have the technology to report their BP readings other than by telephone. The clinic has been making great strides in controlling the blood pressure for some patients using this method, which has

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Physician Advisory Committee Minutes – 03/10/21 - Page 9 of 9 Minutes reflect the Meeting Agenda sequence, not the order in which Agenda Items were presented.

AGENDA DISCUSSION / CONCLUSIONS RECOMMENDATIONS DATE ITEM / ACTION RESOLVED IV. B. Home empowered physicians to make a difference. The blood pressure units PHC has distributed has reached Blood Pressure homeless communities, and these individuals are talking to clinic staff about their blood pressure for the first Monitoring time in years. Dr. Eidson-Ton agreed with Dr. Herman, noting that physicians had been assured last year that Initiative, telephonic reporting of blood pressure readings by patients was acceptable. Continued PHC’s Quality Medical Director apologized to the group for any misinformation presented, asking for clarity from other staff, and thanking Drs. Herman and Eidson-Ton for addressing. There was discussion among Committee members regarding previous specifications and what was allowed, recognizing the significance of Dr. Herman’s comment about feeling empowered. It was also noted that the pilot program for the distribution of blood pressure monitoring units overlooked the requirement. Partnership’s Director of Quality and For information only, no 03/10/21 Performance Improvement in the North advised that she pulled up the detailed specifications made available to formal action required. participants of the QIP, which confirms the allowance of verbal BP reporting by members. The clarification was appreciated by the Committee. p Adjournment The Committee adjourned at 8:31 AM Respectfully submitted: Linda Largent

The foregoing minutes were APPROVED AS PRESENTED on: ______Date Jeffrey Gaborko, M.D., Committee Chairman

The foregoing minutes were APPROVED WITH MODIFICATION on: ______Date Jeffrey Gaborko, M.D., Committee Chairman

13 of 229 PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEETING MINUTES Quality and Utilization Advisory Committee (Q/UAC) Meeting Wednesday, March 17, 2021 / 7:30 AM – 9:00 AM Napa/Solano Room, 1st Floor

Governor Newsom’s Executive Order N-25-20 that relates to social distancing measures being taken for COVID-19 authorizes public meetings with Brown Act requirements to be held via teleconference or telephone. It waives the Brown Act requirement for physical presence at the meeting for members, the clerk, and/ or other personnel of the body as a condition of participation for a quorum. However, the Executive Order requires at least one public location consistent with ADA requirements to be made available for members of the public to attend, so PHC Fairfield, Redding and Santa Rosa conference rooms were made available.

Members Virtually Present: Brom, Amy, MSW, PsyD Lane, Brandy, PHC Consumer Member Stockton-Joreteg, Candy, MD Choudhry, Sara, MD Montenegro, Brian MD Swales, Chris MD Gwiazdowski, Steven, MD, FAAP Murphy, John, MD Thomas, Randolph, MD Hackett, Emma, MD Quon, Robert, MD Wilson, Jennifer, MD Members Absent: Borde, Madhusudan, MD; Strain, Michael, PHC Consumer Member PHC Ex-Officio Members Present: Banks, La Rae, MBA-HM, Director of Grievance and Appeals Barresi, Leung, Stan, Pharm.D, Director of Pharmacy Services Katherine, RN, Director of Care Coordination (SR) McAllister, Debra, RN, Associate Director, Utilization Management Strategies Devido, Jeff, MD, Behavioral Health Clinical Director Moore, Robert, MD, MPH, MBA, Chief Medical Officer – Chairman Glickstein, Mark, MD, Associate Medical Director Netherda, Mark, MD, Associate Medical Director of Quality Glossbrenner, David, MD, Regional Medical Director (Northeast) Ribordy, Jeff, MD, Regional Medical Director (Northwest) Hoover, Peggy, RN, Senior Director of Health Services Robinson, Erika, Director of Quality & Performance Improvement (SR) Katz, Dave, MD, Associate Medical Director Santos, Rose, RN, Manager, Quality Assurance & Patient Safety Kisliuk, Margaret, Behavioral Health Administrator Spiller, Bettina, MD, Northern Region Associate Medical Director Kubota, Marshall, MD, Regional Medical Director (Southwest) Townsend, Colleen, MD, Regional Medical Director (Southeast) PHC Ex-Officio Members Absent: Boyd Anderson, Rebecca, RN, Director of Population Health McCartney, Melissa, RN, Director of Care Coordination Operations (NR) Cotter, James, MD, Associate Medical Director Scuri, Lynn, Regional Director Guillory, Ledra, Senior Manager of Provider Relations Representatives Steffen, Nancy, Director of Quality & Performance Improvement (NR) Kerlin, May, Senior Director of Provider Relations Guests: Bains, Jasleen, Program Coordinator II, Administration (PMO) Porter, Shawn, RN, Perf. Improvement Clinical Specialist, QI Chandler, Stephanie, Project Manager I, Quality Improvement Schiewe, Janet, Project Coordinator II, Administration (Behavioral Health) Gazzigli, Michelle, LCSW, W&R Site Review & Improvement Sivers, Kim, RN, Associate Director, Utilization Management Programs Hoffman-Spector, Sharon, RN, Manager of Utilization Management Stewart, Melissa, Project Manager I, Quality Improvement McCune, Amy, Manager of Quality Incentive Programs Veneracion, Bianca, Provider Education Specialist Nakatani-Phipps, Stephanie, Lead Senior Provider Relations Rep Vij, Namita, Education Specialist, Provider Relations O’Connell, Lisa, Senior Mgr of Network Education & Credentialing Willett, Lori-Michelle, RN, Perf. Improvement Clinical Specialist, QI Peterson, Rachel, RN, Manager of Clinical Quality and Patient Safety

14 of 229 Minutes of the March 17, 2021 PHC Quality/Utilization Advisory Committee Page 1 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION Call to Order Chairman Robert Moore, MD, MPH, MBA, called the meeting to order at 7:32 a.m. Motion on IQI Minutes: Steven Gwiazdowski, MD Public Comment No public comments were made. Second: Amy Brom, MSW, PsyD Approval of Minutes The Internal Quality Improvement (IQI) Minutes of Feb. 9, 2021, 2020 were acknowledged. All members present voted yes with no exceptions. The Quality/Utilization Advisory Committee (Q/UAC) Minutes of Feb. 17, 2021 were reviewed and approved. Motion on Q/UAC Minutes: Robert Quon, MD Second: Sara Choudhry, MD All members present voted yes with no exceptions.

II. Standing Agenda Items – Updates 1. Open Action Items None.

2. 2020-2021 QI The QI Work Plan is designed to track progress on key QI activities and initiatives throughout the year. For information only; no Work Plan Approved by PHC quality committees and Board of Commissioners, it includes progress updates on planned formal action required. activities and objectives for improving quality of clinical care, safety of clinical care, quality of service and Erika Robinson, . Director of Quality and members’ experience. The work plan is set on a fiscal year schedule. This update includes progress on activities Performance from 7/1/2020 – 12/31/2020. The year-end report capturing progress through 6/30/21 will be presented as part of Improvement(SR) the “QI Trilogy” documents, first to QI committees in August, the Physicians Advisory Committee (PAC) in September and the Board of Commissioners in October. Erika briefly added that the deliverables provide our progress on goals. This report covers some discontinued deliverables and also which deliverables have had their time frames pushed out. Items cover NCQA (National Committee for Quality Assurance) clinical care, which are influenced by our overall QI Evaluation. If the quantitative assessment shows certain things aren’t met, we will do a qualitative assessment to inform the next year’s Work Plan. The Grand Analysis will review the standards for accreditation. Dr. Moore thanked Erika for her summary. There were no questions. 3. Quality Erika reported: For information only; no Improvement (QI)  We are making good progress toward completing MY2020 PCP QIPs (Measurement Year 2020 Primary formal action required. Department Update Care Provider Quality Improvement Programs). It is anticipated that the latest PQD (Partnership Quality Dashboard) on MY2021 will be available to providers in mid-May. Erika Robinson, Director of Quality and  Joint Leadership Initiative (JLI) in the Southern Region met March 16 with Solano County Family Health Performance Services to discuss continuing education programs. Another “ABCs of QI” opportunity is expected in June. Improvement(SR) and  We are now in the midst of the HEDIS® (Health Effectiveness Data Information Set) season. Our audit was Nancy Steffen, Director of successful. We are working on completing the medical record review. Quality and Performance Nancy reported: Improvement(NR)  The recently postponed kick-off webinar for eReports now rescheduled to March 23 will help with the PCP QIP transition from MY2020 to MY2021.  PHC is offering two new webinars: “Understanding the Benefits Delivery System,” on March 18 and “Engaging Patients in Quality Improvements” on March 30. (Thank you, Colleen Townsend, MD, for

15 of 229 Minutes of the March 17, 2021 PHC Quality/Utilization Advisory Committee Page 2 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION helping to develop content for the March 18 offering.)  Thank you to the Pharmacy team for contributing to academic detailing sessions on asthma care interventions with our two largest Northern Region providers, Open Door Community Health Centers and Shasta Community Health Centers, on March 5 and March 9, respectively. Dr. Moore thanked Erika and Nancy for their updates. There were no questions.

 It’s been a busy year for the California Legislature: 4. HealthPlan Update – Dr. Moore’s March 2021 Medical Dentist and Assemblyman Jim Wood (D-Santa Rosa) on Feb. 19 introduced a bill that would address o Directors newsletter was Chief Medical Officer “white zones” (areas where there are no regional health information exchanges, which includes most of forwarded to Q/UAC members on Robert Moore, MD the Bay Area and all of PHC’s counties but for Napa, Sonoma and Solano). PHC opposes mandating a state-wide solution rather than letting the counties themselves come together to decide a solution. March 12, 2021. It contains  A link to Provider Relations’ o PHC would support AB 1234 authored by former emergency room physician and Assemblyman Joaquin Arambula (D-Fresno) that would allow electronic signatures on POLST (Physician Orders for Life- session on blood toxicity and Sustaining Treatment) forms. The bill also proposes a statewide electronic registry that would interact lead level requirements; with the existing four regional electronic registries.  Details on the May 21 o PHC is opposed to provisions in Marin-based Assemblyman Marc Levine’s AB 1355 introduced Feb. 19 meeting of the Regional that would add appeal options for members involved in grievances or disputes. We think the current Medical Directors; system is sufficient and that these provisions in this bill would add confusion and inefficiencies.  Links to Kaiser physician-  CalAIM (California Advancing and Innovating Medi-Cal): recorded, member-focused o The most pressing provisions are those within the enhanced case care management program, which videos targeted to specific would start Jan 1 in the counties that have whole-person care, which in Partnership is Marin, Sonoma, ethnic groups re COVID Napa, Mendocino and Shasta. The State has yet to adopt exact criteria of who would qualify and has done vaccinations. no financial modeling as yet. We have significant precedent to fear that it will be an under-funded mandate. o “In lieu-of-services” – those services not paid for now that will be paid for by the State after this takes effect – will only be paid if they would forestall other health care expense that are more expensive than the in-lieu service itself, things like respite housing, silver centers, medically tailored meals, etc. PHC is working on infrastructure for this. o PHC is actively preparing for other CalAIM components (e.g., population health and preparation for Medi-Care) but these are further down the road. o One of the requirements is that PHC be NCQA-accredited, and we’ve achieved that.  The Pharmacy Rx carveout has been delayed indefinitely, ostensibly while conflict of interest language is being worked out between Magellan as the would-be program administrator and Centene, the managed-care organization that has acquired Magellan. The State of Ohio has now sued to stop what they see as cost shifting at the expense of the taxpayer. Twice now, PHC has been given six weeks’ notice to not discontinue the benefit and this has left us with Pharmacy staff shortages. PHC is hopeful that the State will decide to not execute its plans.  NCQA next steps are to maintain the gains in our accreditation standards and to focus on improving the quality of member experience outcomes.  In response to the ongoing pandemic: o We now have a direct telemedicine specialty option for members: they no longer need come into the primary care office to access a specialist. PHC encourages sites having challenges with any specialist, particularly cognitive specialists, to consider implementing this program.

16 of 229 Minutes of the March 17, 2021 PHC Quality/Utilization Advisory Committee Page 3 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION o Santa Rosa has agreed to expand its direct telemedicine options for certified diabetes education and registered dietician services to all 14 PHC counties. Refer to Dr. Moore’s newsletter for details. III. Old Business (Committee Members as Applicable) Melissa Stewart, Stephanie Chandler and Mark Netherda, MD, went through a brief presentation before For information only; no discussing the still evolving BP education form. The goal of this initiative is to increase the monitoring of formal action required. those who are hypertensive and have other diagnoses that place them at great risk of health conditions that Jen Wilson, MD, will share could be exacerbated by hypertension. The focus is to increase the distribution of BP monitoring devices with Dr. Netherda her and to provide education on the optimal use of same to providers and members alike. Melissa shared a organization’s discovery patient success story. Stephanie went through medical reasons for monitoring BPs, referencing the U.S. through a BP management Surgeon General’s Million Hearts campaign, and showed how PHC’s four regions fared against that goal in grant that at least 50% of 2020. participating patients be 1. Review of Dr. Netherda presented the preferred workflow using unconnected devices. (Providers have feared that offered and continue to use updated connected devices would both flood data into electronic medical records (EMRs) and raise patient connected devices. Member-facing expectations of immediate provider response.) The member-facing “what to do with your blood pressure Blood Pressure result” chart has space for providers to provide specific direction to individual members. Education Form (follow- Dave Katz, MD, wondered if it is realistic to expect patients to repeat self-checks three times one-to-three up to Feb 17 minutes apart every time. He also asked if a simple filter could be developed whereby only abnormal BPs discussion on could upload into EMRs. Dr. Netherda responded that the three-time guideline is just that; Chris Swales, QI Initiative: MD, noted that most of his patients check at least twice each time. Candy Stockton-Joreteg, MD, said it BP Device isn’t a simple process to get all the various EMRs to recognize which data is critical and which is not: “it’s Support) a heavy logistical lift to get the data uploaded and then to filter the data to just what you want to show the providers.” Jen Wilson, MD, said her site has applied for a BP management grant that requires that 50% of participating members are offered and are using connected monitors. Eventually, workflows will need to develop to manage this influx of data. This was of interest to doctors Moore and Netherda. Dr. Wilson will forward this information to Dr. Netherda. Robert Quon, MD, added that patients also need to be educated about lead time between reporting data and getting an appropriate response from their provider. 2. Consent: Action required to restore now that State Medi-Cal Rx Carveout is indefinitely postponed: Motion to Approve: Restoring Candy Stockton-Joreteg, MD Quality Improvement pharmacy Second: Robert Quon, MD MPQP1006 – Clinical Practice Guidelines language only All members present voted yes MPXG5001 – Clinical Practice Guidelines for the Diagnosis & Management of Asthma to policies that with no exceptions. MPXG5003 – Major Depression in Adults Clinical Practice Guidelines had been MPXG5008 – Clinical Practice Guidelines: Pain Management, Chronic Pain Management, and Safe Opioid Next Step: approved Prescribing without such at April 14 Physicians Advisory Feb. 17 Care Coordination Committee (PAC) Q/UAC MCCP2024 – Whole Child Model for California Children’s Services (CCS)

IV. New Business – Consent (Committee Members as Applicable)

17 of 229 Minutes of the March 17, 2021 PHC Quality/Utilization Advisory Committee Page 4 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION 1. Grievance & The PULSE Report is the new format for Grievance and Appeals’ quarterly report. Dr. Moore invited committee Motion to Accept PULSE Report Appeals Quarterly members to send comments on opportunities for improvement to him and to La Rae Banks. The intent of this and to Approve MCCP2028 and Report publication is to meet regulatory and informational needs. MCUG3024: Steven Gwiazdowski, MD 2. Consent Calendar Care Coordination Second: Candy Stockton-Joreteg, Policies MCCP2028 – Residential Substance Use Disorder Treatment Authorization MD Utilization Management MCUG3024 – Inpatient Utilization Management Motion to approve MPUG3025 as MPUG3025 – Insulin Infusion Pump and Continuous Glucose Monitor Guidelines amended: Steven Gwiazdowski, MD MPUG3025 was pulled from consent to verbalize another necessary change: “Certified Diabetes Care and Second: Robert Quon, MD Education Specialists (CDCES)” replaces “certified diabetes educator” in Section VI.F.1. The Committee approved. V. Discussion Policies – Quality Improvement – Michelle Gazzigli, LCSW

1. MCQP1025 – “Facility” is added to the policy title. Motion to approve as amended: Substance Use Section VI.A.1 – “or virtual” is added to how Site Reviews may be conducted. Robert Quon, MD Disorder (SUD) Section VI.C is rewritten to make clear that “Site Review” consists of two components: Facility Site Review Second: Randy Thomas, MD Facility Site Review (FSR) and Medical Record Review (MRR). Next Steps: and Medical Record Section VI.G – Compliance Level language now mirrors that contained in related policy MPQP1022 – Site April 14 PAC Review (previously Review Requirements and Guidelines. References to specific “points” are now deleted. Behavioral Section VI.H.1.a: Timeline changed from 45 days to 30 days to mirror the PCP Site Review Corrective Action Health/Substance Plan (CAP) timeline. Abuse Facility Site Attachment A: Additional updates made to Facility Site Review (FSR) tool to include elements from the Drug Review) Medi-Cal Organized Delivery System (DMC ODS) monitoring instrument: Page 11 – Add: All providers and staff conducting (American Society of Addiction Medicine) ASAM assessments have completed two ASAM e-Trainings Page 11 – Clarify: Cultural and Linguistic training is an annual requirement. Page 13 – Add: “Obtain copies of licenses” under Personnel Reviewer Guidelines Criteria B. Page 17 – Under Office Management Reviewer Guidelines Criteria C: Add “including client assignment to counselor and contact information” to #3 and “including recovery services” to #4 Add (California Code of Regulations) “CCR Title 9, Division 4: NTP/OTP Policies: All NTP/OTP medical policies shall conform with CCR, Title 9, Division 4 with regard to medication practices.” Page 24 – Add “Section G – Evidence Based Practices are used” to Office Management Survey Criteria.

Rose Santos, RN, pointed out that as MPCR9 – “Fair Hearings Process for Adverse Credentialing Decisions” – is mentioned in section VI.J, it should be added to Section I, Related Policies. Amy Brom, MSW, PsyD, noted that the new “evidence based practices are used” language in Office Management Survey Guidelines Section G does not match that in the form’s Section P. The latter’s language will be used and the sections will now match.

18 of 229 Minutes of the March 17, 2021 PHC Quality/Utilization Advisory Committee Page 5 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION Utilization Management – Debra McAllister, RN / Bettina Spiller, MD

1. MCUP3041 – Section I.G. – Added CGA-024 Medi Cal Member Grievance System as a Related Policy per recommendation Motion to approve: Revised Name: at prior IQI meeting. Sara Choudhry, MD Treatment Section VI.A.2.b. – Added phone number for Interactive Voice Response (IVR) System and updated the Second: Jennifer Wilson, MD Authorization information that is required to verify eligibility for a member. Request (TAR) Section VI. C. – Added statement to clarify that all TARs will be reviewed for medical necessity as per Next Steps: Review Process regulatory requirements, even if submitted late. April 14 PAC Attachment A: Section G – Updated description for Genetic Testing to also include “Screening” as per our policy. Attachment A: HCPCS Codes – Added code C9757 for Spine/Lumbar surgery Attachment A: Outpatient Surgical Procedure Codes and Pain Management CPTs – Updated codes for neurostimulators. Deleted 61885, 61886, 63661, 63663 and 63688, which will no longer require a TAR. Deleted 63658 because it is no longer a valid code. Attachment A: Outpatient Surgical Procedure Codes – Added CPT code 30468 for nasal repair. There were no questions for presenter Debra McAllister, RN. 2. MPUP3059 – Section I.C. – Updated new title of policy MCUP3041 Motion to approve: Negative Pressure Section VI.A. – Specified that NPWT TARs are reviewed in one month increments. Robert Quon, MD Wound Therapy Section VI.A.1.b.1)d) – Specified that the evaluation of nutritional status must include recent serum albumin. Second: Steven Gwiazdowski, (NPWT) Section VI.D.1.e. – Suggested labs (CBC, CMP, albumin, wound cultures, HgA1C) to include in evaluation for MD Device/Pump impeded wound healing beyond 4 months. Next Steps: Section VII.A. – Clarified Medi-Cal Provider Manual section as “dura other.” April 14 PAC There were no questions for presenter Bettina Spiller, MD. 3. MPUD3001 – UM Overall minor grammar and clarifying language updates throughout. Also removed footer from each page that Motion to approve: Program Description previously explained the anticipated changes for Wellness & Recovery program because the benefit is now Steven Gwiazdowski, MD effective (since July 1, 2020) as stated on page 15. Second: Jennifer Wilson, MD Page 4 – Added statement to say the Behavioral Health Clinical Director attends the Substance Use Internal Next Steps: Quality Improvement Subcommittee. Page 5 – Added description for the Pharmacy Services Director under Program Staff as Pharmacy authorizations April 14 PAC fall under UM according to NCQA and there is no separate Pharmacy Program Description. Page 5 – Deleted two Program Staff positions which no longer apply to the UM Program - Director of Health Services – Northern Region and Director of Utilization Management – Southern Region. Pages 6, 7 – Modified the previous Associate Director of UM position. Due to department reorganization, there are now three UM Associate Director positions as follows: A.D. of UM Programs, A.D. of UM Strategies, and A.D. of UM Regulations. The different responsibilities of each position were detailed. Page 8 – Added Inpatient Nurse Supervisor to the Program Staff list and deleted Nurse Coordinator/UM Lead position. Page 11 – Added Continuing Education Program Coordinator to the Program Staff list. Page 11 – Updated Health Services Administrative Assistant – CMO to a level II and specified additional responsibilities. Page 13 – Changed description of Pharmacy & Therapeutics Committee to say that it is chaired by the CMO

19 of 229 Minutes of the March 17, 2021 PHC Quality/Utilization Advisory Committee Page 6 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION instead of the Pharmacy Director. Added statement that P&T also serves as PHC’s Drug Utilization Review (DUR) Board, and added a disclaimer statement that Pharmacy benefit may change when Medi-Cal Rx goes live. Page 13 – Specified that Provider Advisory Group (PAG) meets quarterly. Page 15 – Disclaimer added after “Pharmacy drug formulary” in the list of UM program services to say that the Pharmacy benefit may change when Medi-Cal Rx goes live. Pages 15, 16 – Clarified language in Mental Health section and specified that Kaiser treats their members for moderate to severe mental health conditions in Solano County. Also added statement to say that Dispute Resolution Between PHC and Mental Health Plans (MHPs) in Delivery of Behavioral Health Services is defined not only in policy MCUP3127 but also in State regulations and in individual County/PHC Memorandum of Understanding (MOU). Pages 16, 17 – Removed itemized list of counties participating in the Wellness & Recovery program and stated instead that SUD treatment services are administered either by PHC or through individual counties. Page 18 – Added further language to match same on page 1 to say that “PHC does not use incentives to encourage barriers to care and service. This does not preclude the use of appropriate incentives for fostering efficient, appropriate care.” Page 18 – Added availability of residential treatment (SUD) facilities to the list of facility types considered in our delivery system. Page 19 – Clarified that when TARs are submitted with incomplete information to make an assessment of medical necessity, PHC will notify the provider and give them an opportunity to provide additional information. Page 21 – Added statement to say that TARs submitted beyond our specified timeframes are considered late but will still be reviewed for medical necessity. Page 22 – In the Review Criteria section, stated the description of the InterQual® criteria sets we use more generally as “the current criteria sets,” and added reference to our new policy MCUP3139 Criteria and Guidelines for Utilization Management. Page 23 – Specified another category we evaluate for Inter-Rater Reliability (IRR) as Nurse Coordinator Review of Long Term Care Services. Page 28 – Specified that delegate reports are evaluated at Delegation Oversight Review Sub-Committee (DORS). Page 30 – Deleted “Director of UM” and specified plural “Associate Directors of UM” in the list of participants who prepare the UM Program Evaluation annually.

There were no questions for presenter Debra McAllister, RN. VI. Presentations 1. UM/Pharmacy The document was pulled from discussion to correct/update TAR numbers. The updated TAR numbers will Evaluation/Grand be briefly presented at April 13 Analysis IQI; the Grand Analysis itself will be presented in total at April 21

Q/UAC. 2. Pharmacy Dr. Leung began with Key Indicators and Trends: less than 1% of prescriptions paid for by Partnership is After the meeting, it was Operations Update considered a specialty medication yet they accounted for 45.42% of our 2020 medication spend, up from 43.41% discovered that the Site of Care in 2019. He believes that plan-paid specialty medications will exceed 50% of the total drug spend within the next page contained discrete patient

20 of 229 Minutes of the March 17, 2021 PHC Quality/Utilization Advisory Committee Page 7 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION three to five years. medical record numbers. These Stan Leung, have since been deleted from this Pharm.D., Director The top three therapeutic classes of spend are diabetic, asthma/COPD and inflammatory disease. This is quite a report. The original Q/UAC of Pharmacy departure from when Dr. Leung started with PHC about five years ago: then infectious disease was always near packet has been deleted from Services or at the top because of Hepatitis C treatment. Lower pricing, decreased regimens and decreasing time to treat PHC’s external website and Hep C has brought down infectious disease treatment costs quite a bit. From 2019 to 2020, we see a 33% drop in replaced with an amended packet infectious disease spend, mostly driven by Hep C and a 2020 change in PHC’s preferred formulary to Epclusa®. containing no personal health Today, inflammatory disease accounts for 13% of the total drug spend; much is due to TNF (tumor necrosis information (PHI). factor) alfa inhibitors such as Humira® and Enbrel®, which alone make up about 30% of that category spend. PMPM (per member per month) trends are summarized month-to-month and year-to-date. PMPM data shows that the number of unique members who had a prescription filled fell 5.7% and the number of actual prescriptions filled fell 4.1% in 2020 compared to 2019. The declines are likely due to COVID, new generics, and how the PHC formulary has been managed. The total number of TARs received and processed in 2020 remained constant, causing some organizational stress as we were dismantling part of our program preparing for the State Rx carveout, losing some staff as a result. Every year, we process about 80,000 TARs, 10% of which are the more complicated physician administered drugs (PADs). Our Site of Care program – where we see if it is appropriate to transition some patients receiving injections or infusions from hospital outpatient settings to either home or a local pharmacy infusion suite – has identified 115 likely candidates, eight to 10 of whom have successfully on boarded. Another four or five will soon participate pending medication orders. Pharmacists who made these outbound calls report that members greatly appreciate this option, especially those who would otherwise need to drive three or four hours one-way to receive treatment. Pharmacy activities and initiatives for 2021 include migrating systems to a platform Utilization Management also uses. Our PAD formulary search tool is under development and will be brought online, making it easier for providers to lookup coverage and benefits. This could also reduce TAR loads too if, by looking up drug codes, providers can see right away which require no TAR. Pharmacy also continues to prepare for the Medi-Cal Rx carveout and anticipates additional information will be forthcoming from the State sometime in May. Also in 2021, Pharmacy is preparing medication-related HEDIS® performance. Of 19 HEDIS measures, there are 24 reportable rates. Summary tables include those for which PHC is also accountable to the State, including controlling blood pressure and depression medication.

Pharmacy is also looking at post ED/hospitalization event interventions using EDIE (Emergency Department Information Exchange) notification. We are planning to develop interventions, including PCP notification, for when a member has an opioid related event. We will also focus on asthma/COPD events, assessing asthma against the asthma medication ratio (AMR) HEDIS measure and COPD against the PCE (Pharmacotherapy Management of COPD Exacerbation) HEDIS measure, making sure patients have systemic steroids and the appropriate rescue inhalers with a specific time frame from discharge. Pharmacy is looking at potential preventable admissions (PPA), specifically on asthma, to see if there are ways we might help members improve self-care and stay connected to their assigned PCP in established care. In 2019, asthma accounted for nearly 3,500 ED admissions among PHC patients.

21 of 229 Minutes of the March 17, 2021 PHC Quality/Utilization Advisory Committee Page 8 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION Dr. Moore thanked Dr. Leung for his summary and reminded everyone that this will be an annual report. John Murphy, MD, asked Dr. Leung if he thinks we’ll continue to see a 5% increase in drug costs year-over-year for the foreseeable future. He replied yes, based on two drivers: specialty medications and increases in the Average Wholesale Price (AWP). There were no other questions. 3. Medical Equipment Jasleen presented the purpose of the program, the current devices available, the program’s utilization, the An announcement was made to all Distribution expansion that is occurring this month, and how providers can request the devices we have available. PHC providers March 15 about Services Program the expanded program. The program was developed in response to COVID-19 and became effective July 1, 2020. The program Jasleen Bains, Program currently includes distribution of blood pressure monitors, oximeters, and digital thermometers, which are given Questions should be directed to Coordinator II, to PHC members at zero cost when requested by their provider. Participating providers are required to submit an [email protected]. Administration (PMO) electronic request form directly to PHC when a member’s diagnosis meets specific guidelines. PHC then ships

the requested device directly to the member’s home or specified location via routine delivery service. Participating providers must also ensure that members are educated on proper use and setup of the device and instructed on how to self-report the data when needed. We’ve provided more than 2,200 devices to members thus far and continue to receive requests. Hypertension remains the leading cause for these requests. As of this month, we are now offering additional equipment (that will be carved out in the Medi-Cal Rx program): humidifiers, scales, vaporizers and nebulizers. Additional BP cuff sizes, nebulizer parts and user instructions in the member’s preferred language are also available. Jasleen thanked Provider Relations staff for their work enabling this expansion. Providers can submit durable medical equipment (DME) requests through the PHC website provider pages. The fillable form captures specific conditions why the device is being requested. Randy Thomas, MD, asked how devices might be added to the program. Dr. Moore invited him to email a summary of his specific issues. If it’s expanding the criteria, that’s one thing but if it’s actually getting PHC to provide this additional equipment, that is something we could consider. Dr. Swales has been using the form and has been successful in getting devices for his practice’s patients. Dr. Moore added that OLE Health has been a “superstar” in using this program to distribute blood pressure monitors. Dr. Thomas asked whether providers are notified when devices are shipped. Jasleen said only if the devices are returned but that providers can check status with PHC. Dr. Moore added that currently much of this program is manual but we are looking to automate more in future. VII. Additional Business – None Adjournment – The meeting adjourned at 9:07 a.m. Next Meeting: April 21, 2021 Respectfully submitted by: Leslie Erickson, Administrative Assistant II Signature of Approval: Date: ______Robert Moore, MD, MPH, MBA

Committee Chair

22 of 229 Minutes of the March 17, 2021 PHC Quality/Utilization Advisory Committee Page 9 PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEETING MINUTES

Committee: Internal Quality Improvement (IQI) Meeting Date/Time: Tuesday, Feb. 9, 2021 / 1:30 PM – 3:30 PM Napa/Solano Conference Room

Members Present: Banks, La Rae, MBA-HM, Director of Grievance and Appeals Moore, Robert, MD, MPH, MBA, Chief Medical Officer, Committee Chair Barresi, Katherine, RN, Director of Care Coordination Netherda, Mark, MD, Associate Medical Director of Quality Bjork, Sonja, JD, Chief Operating Officer Robinson, Erika, Director of Quality and Performance Improvement Boyd Anderson, Rebecca, RN, Director of Population Health Santos, Rose, RN, Manager of Quality Assurance/Patient Safety Gibboney, Liz, MA, Chief Executive Officer Shafer, Chloe, Regional Manager Hoffman-Spector, Sharon, RN, Manager of Utilization Management Steffen, Nancy, RN, Director of Quality and Performance Improvement Hoover, Peggy, RN, Senior Director, Health Services Turnipseed, Amy, Senior Director of External and Regulatory Affairs Kubota, Marshall, MD, Regional Medical Director Villasenor, Edna, Associate Director of Call Center Leung, Stan, Pharm.D, Director of Pharmacy Services Watkins, Kory, Compliance Manager, Grievance & Appeals McAllister, Debra, RN, Associate Director, Utilization Management Strategies Members Absent: Cotter, James, MD, Regional Medical Director McCartney, Melissa, RN, Director of Care Coordination Operations Daliri Sherafat, Tahereh, NR Director of MS and PR Scuri, Lynn, MPH, Regional Director Glossbrenner, David, MD, Regional Medical Director – on PTO Spiller, Bettina, MD, Associate Medical Director Ingram, Jeff, Director of Financial Planning & Analysis Thomas, Catherine, MPH, Senior Health Educator – on maternity leave Katz, Dave, MD, Associate Medical Director Townsend, Colleen, MD, Regional Medical Director Kerlin, Mary, Senior Director of Provider Relations Guests: Bides, Robert, RN, Supervisor of Patient Safety Poncy, Kenzie, Compliance Program Analyst Cabrera, Maria, Member Services Lead Rep Supervisor Rodekohr, Dianna, Project Manager I, Configuration Campbell, Anna, Administrative Assistant II, UM Sackett, Anthony, Project Manager I, Quality Improvement Chandler, Stephanie, Project Manager I, Quality Improvement Santos, Karl, Director of Network Ops, Information Technology Devan, James, Manager of Performance Improvement, QI Schiewe, Janet, Project Coordinator II, Behavioral Health Devido, Jeffrey, MD, Behavioral Health Clinical Director Sinner, Kyli, PR Representative, Provider Relations Fogliasso, Tara, Project Manager II, Quality Improvement Sivers, Kim, RN, Associate Director, Utilization Management Programs Hightower, Tony, CPhT, Associate Director of Pharmacy Operations Spencer, Tegan, Project Manager I, QI Lee, Donna, Manager of Claims Stewart, Melissa, Project Manager I, Quality Improvement O’Connell, Lisa, Manager of Provider Education Trotsky, Renee, Program Manager, Provider Relations O’Donovan, Olevia, Executive Assistant, Finance Veneracion, Bianca, Provider Education Specialist Peterson, Rachel, RN, Manager of Clinical Quality and Patient Safety Vij, Namita, Provider Education Specialist Plascencia, Dolores, Project Manager I, Configuration

Minutes of the Feb. 9, 2021 PHC Internal Quality Improvement (IQI) Committee 23 of 229 Page 1

RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION I. Call to Order Committee Chair Robert Moore, MD, called the meeting to order at 1:30 p.m. Motion to approve: Approval of Debra McAllister, RN The Jan. 12, 2021 minutes were approved without changes or comments. Minutes Second: Marshall Kubota, MD II. Standing Agenda Items (Full Committee) – None III. Old Business (Committee Members as applicable)

Consent: Re-archiving Pharmacy Policies as of April, 1, 2021 State Medi-Cal Rx Carveout MCRO4018 – Pharmacy TAR Procedure (with Attachment A) Motion to approve: MPRG4025 – Palivizumab (Synagis) Guidelines (with Attachments A1-A3) Marshall Kubota, MD MPRP4020 – Restricted Status for Members Receiving Prescription Medication (with Att. A-F) Second: Debra McAllister, RN MPRP4033 – Brand Name Drug Requests (with Attachment A) MPRP4049 – Chronic Opioid Therapy in Chronic Non-Cancer Pain (with Attachments A-E) MPRP4056 – Pediatric Enteral Nutrition (with Attachments A-E) MPRP4059 – Formulary Utilization Management for Managing Pain Safely Programs (with Att. A-B) MPRP4061 – Enteral Nutrition Products (with Attachments A-F) MPRP4063 – Designated Specialty Drugs (with Attachment A)

Soon after this meeting, it became known that the State Medi-Cal Rx carveout go-live date of April 1 may be postponed. The affected Health Services consent and discussion policies (except for Pharmacy’s) will still go to Q/UAC Feb. 17 for further discussion. See more specific postscripts discussion policies below. IV. New Business (Committee Members as applicable) Consent Calendar Quality Improvement Motion to approve slate except for MPQP1052 – Physical Accessibility Review Survey – SR Part C MPQP1052: Marshall Kubota, MD Care Coordination Second: Debra McAllister, RN MCCP2021 – Women, Infants and Children (WIC) Supplemental Food Program MCCP2024 – Whole Child Model for California Children’s Services (CSS) effective 4/1/21 Motion to approve MPQP1052 as amended: Pharmacy Rose Santos, RN MCRP4064 – Continuation of Prescription Drugs Second: Marshall Kubota, MD MCRP4068 – Medical Benefit Medication TAR Policy (with Attachment A)

MPRP4001 – Pharmacy & Therapeutics (P&T) Committee archive Attachment A as of 4/1/21 Next Steps: MPRP4020 – Restricted Status for Members Receiving Prescription Medication (with Att. A-F)  Health Services policies go to MPRP4034 – Pharmaceutical Patient Safety (with Attachments A-C) Quality/Utilization Advisory MPRP4056 – Pediatric Enteral Nutrition (with Attachments A-E) Committee (Q/UAC) Feb. 17 MPRP4062 – Drug Wastage Payments (with Attachment A)  Provider Relations policies go Population Health Management to the Credentialing Committee MCNP9003 – Cultural & Linguistics Services effective 4/1/21  The Director of Member Utilization Management Services approves MC334 MCUG3011 – Criteria for Home Health Services MCUG3038 – Review Guidelines for Member placement in Long Term Care (LTC) Facilities MCUP3017 – Health Services Review of Non-admission In-hospital Obstetrical Evaluations (Solano County only) . MCUP3051 – Long Term Care SSI Regulation (Previously Long Term Care Admissions)

Minutes of the Feb. 9, 2021 PHC Internal Quality Improvement (IQI) Committee 24 of 229 Page 2 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION MCUP3052 – Medical Nutrition Services effective 4/1/21 MCUP3121 – Neonatal Circumcision MCUP3125 – Gender Dysphoria/Surgical Treatment effective 4/1/21 MPUP3018 – Health Services Review of Observation Code Billing MPUP3048 – Dental (including Dental Anesthesia) effective 4/1/21 Provider Relations MP CR 300 – Physician Credentialing and Re-credentialing Requirements MP CR 301 – Non-Physician Credentialing and Re-credentialing Requirements MP CR 302 – Behavioral and Mental Health Practitioner Credentialing and Re-credentialing Requirements MP CR 303 – Applied Behavioral Health and Substance Use Disorder Practitioner Credentialing and Re-credentialing Requirements MP CR 304 – Allied Health Practitioners Credentialing and Re-credentialing Requirements Member Services MC334 – American Indian

Rose Santos, RN, pulled MCQP1052 to change wording in its Attachment C from “primary care physician” to “primary care provider.” Anna Campbell noted that the same change needed to occur in Attachment D. V. Discussion Policies Quality Improvement MPQP1006 – Section VI.A.4.c: Draft CPG inclusion language is amended in anticipation of the Medi-Cal Pharmacy Rx carveout to read: Motion to approve: Clinical Practice Identification of PHC formulary medications effective in treatment of that particular condition until such time that the Mark Netherda, MD Guidelines formulary is rendered obsolete under the State Medi-Cal Rx carveout program anticipated to go-live in Spring 2021. Second: Marshall Kubota, MD Section VI.A.5: Who reviews new draft CPGs is clarified to include the Associate Director of Utilization Management and Robert Moore, MD the Senior Health Educator. Next Steps: Chief Medical Section VI.C is deleted and partially subsumed into VI.B., Monitoring Use of CPGs, which is thus amended with this Feb. 17 Q/UAC Officer addition: Once a CPG is approved by the PAC, a copy of the CPG is forwarded to a designated physician at the provider site. The site may adopt the PHC CPG, or submit its CPG to PHC for approval.

There were no questions. Postscript: elements of VI.A.4.c may change at Q/UAC Feb. 17. All the changes approved at January IQI were accepted at Q/UAC Jan. 20 but have yet to be considered at PAC. MPXG5001 – Motion to approve: Section VI.B is deleted effective April 1, 2021. Clinical Practice Mark Netherda, MD Section VI.C is renamed Asthma Medication List, effective April 1, 2021. Guidelines for the Second: Debbie McAllister, RN Attachment A is deleted per State Medi-Cal Rx carveout anticipated to take effect April 1, 2021. This footer was added for Diagnosis & historical perspective: The pharmacy (prescription) benefit is carved-out to State Medi-Cal as of April 1, 2021. Please refer Management of Next Steps: to the State Medi-Cal Contract Drugs List (CDL), which is found in both the Medical and Pharmacy provider manual Asthma Feb. 17 Q/UAC sections of the website. The provider manuals are available at https://files.medi-cal.ca.gov/pubsdoco/manuals_menu.aspx. Robert Moore, MD There were no questions. Postscript: the effective date of the deletions may change at Q/UAC Feb. 17. Attachment A is amended to reflect new State Medi-Cal Rx carveout effective date of April 1, 2021. Motion to approve: MPXG5003 – Major Attachment B is deleted per State Medi-Cal Rx carveout anticipated to take effect April 1, 2021. Same footer as above Jeff Devido, MD Depression in added. Second: Mark Netherda, MD

Minutes of the Feb. 9, 2021 PHC Internal Quality Improvement (IQI) Committee 25 of 229 Page 3 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION Adults Clinical Practice There were no questions. Next Steps: Postscript: the effective dates may change at Q/UAC Feb. 17. Feb. 17 Q/UAC Robert Moore, MD MPXG5008 – Section II: Provider Relations is added as an Impacted Department. Motion to approve: Clinical Practice Section VI.B.1.a is amended to read: Complex pain management where the diagnosis is unclear or the condition is Mark Netherda, MD Guidelines: Pain unresponsive to standard medication and non-pharmacologic therapy for a period of 3 to 6 months. Second: Marshall Kubota, MD Managements Section VI.E: Language is added to Emergency Room Guidelines: The emergency department can be a critical access Chronic Pain point for members with substance use disorder (SUD). ED personnel should consider screening for SUD and initiating Next Steps: Management, and medication-assisted treatment (MAT). A hyperlink follows. This language and the hyperlink are also added into Feb. 17 Q/UAC Safe Opioid Attachment C. Prescribing References: An article on MAT is added as Reference H. Attachment A: In anticipation of the Medi-Cal Pharmacy Rx carveout, Paragraph E.10 is deleted from the discussion of Robert Moore, MD routine monitoring of patients on chronic opioid therapy. Attachment C: Language in recommendations B and C is amended to terminology used in the policy itself. Attachment D: Language in recommendation 1 reflects terminology used in the policy itself.

Dr. Kubota’s and Stan Leung’s contributions to these policy changes are appreciated. There were no questions. Postscript: Attachment A edits noted above may change at Q/UAC Feb. 17. Utilization Management MCUP3041 – Section I.E: Medi-Cal Rx change: Deleted Pharmacy policy MCRO4018 and replaced with MCRP4068 Medical Benefit Motion to approve: Revised Name: Medication TAR Policy. Marshall Kubota, MD Treatment Section I.G: Added CGA-024 Medi Cal Member Grievance System as a Related Policy per recommendation at prior IQI Second: Mark Netherda, MD Authorization meeting. Request (TAR) Section VI.C: Added statement to clarify that all TARs will be reviewed for medical necessity as per regulatory Next Steps: effective 4/1/21 requirements, even if submitted late. Feb. 17 Q/UAC Section VII.D: Medi-Cal Rx change: Added All Plan Letter (APL) 20-020 as Reference – the Medi-Cal Rx APL. Debra McAllister, Attachment A: Sections D and O - Medi-Cal Rx change: Deleted “Drugs and Pharmaceuticals” Section D. Added new RN, Associate Section O to describe “Medications” under new Medi-Cal Rx program. Director, UM Attachment A: Section G – Updated description for Genetic Testing to also include “Screening” as per our policy. Strategies Attachment A: Section Y7, 9. and 11. - Medi-Cal Rx change: Updated Pharmacy and Formulary language. Added * to refer to note at bottom of page regarding pharmacy carve-out. Attachment A - HCPCS Codes: Added code C9757 for Spine/Lumbar surgery Attachment A - Outpatient Surgical Procedure Codes and Pain Management CPTs: Updated codes for neurostimulators. Deleted 61885, 61886, and 63663 which will no longer require a TAR. Deleted 63658 because it is no longer a valid code. There were no questions. Postscript: both policy and Attachment A effective date and language may change at Q/UAC Feb. 17. Care Coordination

Minutes of the Feb. 9, 2021 PHC Internal Quality Improvement (IQI) Committee 26 of 229 Page 4 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION MCCP2018 – Attachment A: Section G – Updated description for Genetic Testing to also include “Screening” as per our policy. Motion to approve: Advice Nurse Attachment A: Section Y7, 9. and 11. - Medi-Cal Rx change: Updated Pharmacy and Formulary language. Added * to Debra McAllister, RN Program refer to note at bottom of page regarding pharmacy carve-out. Second: Marshall Kubota, MD Attachment A - HCPCS Codes: Added code C9757 for Spine/Lumbar surgery Katherine Barresi, Attachment A - Outpatient Surgical Procedure Codes and Pain Management CPTs: Updated codes for Next Steps: RN, Director of neurostimulators. Deleted 61885, 61886, and 63663 which will no longer require a TAR. Deleted 63658 because it is no Feb. 17 Q/UAC Care Coordination longer a valid code. March 10 PAC

There were no questions. MCCP2020 – Updated policy for Medi-Cal Rx. Motion to approve: Lactation Policy and Section 1.C: Deleted Related Policy MPRP4056 Pediatric Enteral Nutrition as it will be archived when Pharmacy benefit Marshall Kubota, MD Guidelines is carved out. Second: Mark Netherda, MD (formerly Section VI.C.7.b: Section on special infant formulas updated to explain that under pharmacy carve-out, these prescribed Breastfeeding formulas will be provided by the State Medi-Cal pharmacy through their TAR process. Also clarified that WIC “may” Next Steps: Guidelines) instead of “will” provided specialty formulas when an authorization is pending. Feb. 17 Q/UAC Section VII.G: Added APL 20-020 as Reference – the Medi-Cal Rx APL. Katherine Barresi,

RN There were no questions. Postscript: effective date may change at Q/UAC Feb. 17. Pharmacy MCRP4064 – Drug Updated definitions in accordance with Medi-Cal Rx Pharmacy Carve-out. Motion to approve: Utilization Review Section V: Updated requirements to reflect compliance with APL 17-008 and APL 20-020 Marshall Kubota, MD (DUR) Program Section VI.A.1.a-d: Further outlined activities related to participation in Global Medi-Cal DUR program. Second: Mark Netherda, MD Section VI.A.2.a-h: Outlined Retrospective DUR activities, pursuant to APL 20-020 Tony Hightower, Section VI.A.3: Outlined Educational Outreach responsibilities retained by PHC, pursuant to APL 20-020. Next Steps: CPhT, Associate Section VI.A.4: Further clarified requirements for Annual DUR Report, pursuant to APL 20-020. Coming back to IQI March 9 Director of Section VII: Included APL 20-020 and APL 19-012 to References Pharmacy

Operations There were no questions. Stan Leung, Pharm.D, added that we will continue to look for opportunities to clinically improve pharmacy aspects for which PHC will remain responsible after the carveout occurs. Provider Relations MP CR 500 – Section VI: Updated procedure definition Motion to approve as amended: Ongoing Monitoring Section VI.A: Ongoing Monitoring of Sanctions – deleted “Monthly” and added Medicare sanctions. Debra McAllister, RN and Interventions Section VI.A.1. Deleted “reports are pulled the last Thursday of each month”. Second: Marshall Kubota, MD Section VI.A.4: Added language that the Peer Review Committee may recommend the Credentialing Committee review Lisa O’Connell the status of a Practitioner of Concern at any time during the credentialing cycle per MPQP1016. Next Steps: Manager of Section VI.A.5: Added results of monthly sanctions monitoring are reported to the Credentialing Committee at the Credentialing Committee Provider Education following month’s meeting. Section VI.B: Added that the Practitioner-Specific Complaints and Adverse Events will be collated into a rolling Track and Trend Report – collected from Grievance & Appeals and Quality Improvement departments every six months. Section VI.B.1: Explanation of process for Credentialing Committee Chair to review and present to Credentialing Meeting. Section VII: Updated to 2021 National Committee for Quality Assurance (NCQA) standards and correct APLs.

Minutes of the Feb. 9, 2021 PHC Internal Quality Improvement (IQI) Committee 27 of 229 Page 5 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION Section IX: Updated position responsible.

The Committee agreed with Dr. Kubota that “Regional Medical Director” should be removed from Section VI.B.1 language.. VI. Presentations Quality and Erika began by thanking Amy McCune and her team for their work preparing the Quality Measure Highlights now posted to the Primary Care Provider Quality Performance Improvement Program (PCP QIP) web page under Resources. Erika also thanked Deanna Watson and Melissa Stewart for their continuing work transitioning the Improvement Palliative Care Quality Network (PCQN) to the Palliative Care Quality Collaborative (PCQC) and Jessica Delaney, who is helping to support finalization and Update review of the Perinatal Quality Measure Highlight. Great cross regional collaboration continues with best practices discussion, Peer Review and PQI Rounds. Erika Robinson, The annual Healthcare Effectiveness Data and Information Set (HEDIS®) season has begun. The annual HEDIS Audit will virtually occur with auditor Elisabeth Director of Hunt on Feb. 11. Week-long clinical training for the HEDIS nurses begins Feb. 16. Quality and Nancy discussed eReports: the validation period during which providers were able to review their final rates on their clinical measures for Measurement Year 2020 Performance closed Feb. 7. The release of eReports 2021 remains on track for the first week of March. Improvement (SR) and Nancy Steffen, Ninety persons attended the Feb. 3 session of PHC’s Performance Improvement Academy’s two-part webinar series, “Project Management 101.” That session and Director of the second on Feb. 10 covered project management principles and the tools used in each phase to successfully manage projects. The recordings will soon be Quality and available at http://www.partnershiphp.org/Providers/Quality/Pages/PIATopicWebinarsToolkits.aspx. Performance We are looking to visualize HEDIS administrative data by midsummer. Both Northern and Southern QI teams are invested in ongoing dialog with the Department Improvement (SR) of Health Care Services (DHCS). There were no questions for Erika and Nancy. Care Coordination Pages 2-6: This program description takes into account NCQA outcomes and timelines: see language for NCQA Program guidelines. Description – Pages 8-9: Current staffing, including the additional titles of Director of Care Coordination Operations and Manager, MPCD2013 Transportation Programs, is reflected.. The Senior Director of Health Services now includes oversight of Population Health Management. Katherine Barresi, Page 11: Additional evidence-based citations for programmatic organization and interventions is added to reflect Motion to approve: RN inclusion of pediatric to adult setting interventions, CMSA (Case Management Society of America) Integrated framework, Marshall Kubota, MD and outcomes for Case Management in Medicaid populations. Second: Debra McAllister, RN Page 12: Removed requirement for individuals rated at Acuity 3 and above to receive a satisfaction survey at the end of program participation as NCQA Standard PHM 5 Element F has been retired. Modified to include flexibility to conduct Next Steps: member satisfaction surveys at plan determined intervals. Feb. 17 Q/UAC March 10 PAC Katherine noted that perhaps the biggest change is that the program evaluation language is now refined to reflect Care

Coordination and Population Health Management department split. Care Coordination will conduct its own annual program evaluation and share results with both PHM and QI respectively for their documentation purposes. This revision does not impact the annual required activities for CC to present in Q/UAC and PAC committees. Katherine believes that substantial changes to this program description will occur in the months to come. There were no questions.

Minutes of the Feb. 9, 2021 PHC Internal Quality Improvement (IQI) Committee 28 of 229 Page 6 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION Seventy four potential quality issues (PQI) came largely from Grievance & Appeals (39), Utilization Management (12) and Medical Directors (12) in the last half PQI/PPC Report of 2020. During the past three years, referrals have tracked down from 279 in 2018 to 209 in 2019 to 128 in 2020. A centralized referral process, a transition of all Q3/Q4 2020 PQI cases to the Patient Safety unit in the Southern Region, and the COVID-19 pandemic have contributed to this downward trend. Rosa Santos, RN Sixty seven PQI cases closed in Q3/Q4 2020. These 67 cases involved 93 providers, including 17 in Shasta; 14 each in Solano and Sonoma, and 13 in Humboldt. Manager of Quality Less than one third of the closed cases (20) involved severity ratings higher than P1/S1 (i.e., minor opportunity for improvement in a practitioner’s performance Assurance/Patient and/or systems). Safety PHC’s Peer Review Committee look at all cases designated a severity level higher than P1/S1. In 2020, this committee reviewed just 31 cases, 14 of which were in Q3/Q4. In addition, PHC Associate Medical Director Mark Netherda, MD, conducted a focused review related to one case in Q1/Q2; Regional Medical Director Jeff Ribordy, MD, in Q3/Q4 did the same for two cases, one of which involved an individual practitioner in multiple PQIs at one site. That site and the providers involved in the three 2020 reviews were referred to Credentialing. PQI individual provider track and trend data is bi-annually submitted to Provider Relations. There has been no significant trends to report regarding repeating practitioners during this period. Cases deemed as “provider preventable conditions” (PPCs) are reported DHCS. PPCs are medical conditions or complications that a patient develops during a hospital stay or ambulatory surgical encounter that was not present at admission. In 2020, nine PPC cases were reported to DHCS and processed as PQIs. Dr. Moore, speculated that although the number of cases rating higher than P1/S1 went up while the overall case load went down, we are now catching more, which is great. Dr. Moore wondered if this was the same as in 2018, and Rose recalled that it is about the same. Our review today is more sophisticated because our medical directors are now involved. Sometimes more than one provider is involved in a case and we score each provider separately. Dr. Netherda had no additional comments but further clarified that sometimes a single case will have four or five providers attached. Sometimes the member doesn’t know who to blame and will call out their PCP but when we look into it, the problem is often somewhere else with someone else. Dr. Moore said that he is very proud of Rose’s team: “there’s a real dedication in striving to improve quality.” Rose’s next report on Q1/Q2 2021 will be on September’s consent calendar. QI Initiative: Blood This initiative focuses on increasing the distribution of blood pressure monitoring devices, and providing education on their optimal benefits and use to providers Pressure Device and members alike. It will also involve the creation of a comprehensive communications protocol and educational resources to assist members with appropriate use Support of blood pressure monitoring devices and support cross collaboration with workforce partners (e.g., medical assistants, health educators, nurses, physicians) in alerting identified members to the benefit and importance of BP control. This initiative will increase the monitoring of those who are hypertensive and have other Stephanie Chandler diagnoses that place them at greater risk of health conditions that could be exacerbated by hypertension. and Melissa Stewart, Project Twenty-five percent of PHC’s adult member have hypertension: our aim is for 80% of this population to maintain a reading that is < 140/90. Melissa shared one Managers, QI success story of a 64-year-old female patient who was having trouble getting to appointments, but by monitoring at home, her team was able to change her medications and her situation improved. Stephanie noted that studies have shown home BP monitors coupled with team-based care for communicating with patents about modifications driven by results is cost effective. Different devices were looked at before it was decided, with provider input, to utilize an “unconnected” home monitor. Stephanie also explained the roles, deliverables and timeframes for each of the three internal PHC workgroups on this initiative: Provider Education and Engagement; Member Education, and Evaluation. Chief Operating Officer Sonja Bjork, said she was pleased that Northbay Healthcare, with whom PHC is about to enter contract negotiations, is one of PHC’s larger partners that is already achieving the Million Hearts Campaign goals. Sonja questioned whether this BP initiative would take into account race or specific community. Dr. Moore replied that we could look into it but that this hybrid measure may have too small a denominator, based on the small random sample drawn by Healthcare Effectiveness Data and Information Set (HEDIS ). He added that, although HEDIS data doesn’t look at disparities, it is possible that the QIP data might be aggregated and looked at by ethnic group. Erika Robinson said that one of our QIPs is to drill down on this: PHC’s Health Analytics team is helping us do a deeper dive beyond HEDIS metrics. Sonja would like this tracked so we might focus future energies elsewhere if indicated.

Minutes of the Feb. 9, 2021 PHC Internal Quality Improvement (IQI) Committee 29 of 229 Page 7 RECOMMENDATIONS / AGENDA ITEM DISCUSSION ACTION There were no other questions. Dr. Moore said a provider who has been giving out many BP monitors through this initiative has emailed that he is looking forward to getting the educational materials to share with patients. Current project timelines has both member education materials and provider outreach plan development rolling out in the second quarter. Project maintenance and data analysis will continue thereafter; an evaluation is expected at the end of this calendar year.

QI Initiative: Nancy said that the pilot was introduced a year ago at which time we had to reconcile both how to launch and how it fell under our QI and in Member Engagement ePrompts – goals within our 5-Star Strategic Plan. PHC’s Northern Region’s Member Services and Care Coordination teams May 27-Aug. 31, 2020 began engaging members Northern Region eligible for one or more of four measures: Women’s Health (i.e., breast cancer and cervical cancer screenings) and Diabetic Measures (i.e., A1Clab testing and Pilot Evaluation retinal eye exams). The pilot was extended through Nov. 30, 2020 to get more data. (Low volumes were attributed to the COVID-19 pandemic.) Nancy Steffen and Tara went over the initiative’s pilot scope and timelines: ePrompts strategically looks at expanding member engagement tailored to individual needs in chronic Tara Fogliasso, disease management and preventive screening. ePrompts utilizes eReports, which does all our online clinical tracking and allows our provider network to see as Project Manager II, close as possible in real time what measures might benefit a member. eReports refreshes every two weeks; its five major data sources are Claims, Lab, the QI California Immunization Registry (CAIR), Pharmacy and the eReports user. eReports’ new year will begin in March. Tara shared a Call Center view. The ePrompts screenshot shows what measure(s) a member is eligible for or needs to complete, how many times and when the member has been previously advised of this information. The system tracks on 30-day and 60-day periods, giving both the member time (30 days) to complete a service without being bothered again by PHC, and the provider time (60 days) as well. Each measure has its own hyperlink “script” that can pop up to give the Call Center person some questions to ask of and general information to share with the member. The member can see and respond to similar information on the PHC website’s Member Portal. Tara went through the pilot workflow process. During any call, Member Services can click on the ePrompt tab, look for measures with a “due now” status, and proceed with the appropriate call script. If the member needs further assistance, Member Service can connect the member with their primary care provider or send a referral via email to Care Coordination. Nancy, as analyst on the project, shared the pilot results. On average, ePrompts opportunity rates represent 18% of the NR call volume; on average 556 calls/month involved NR members eligible for at least one ePrompt. Nancy also shared some challenges staff faced in the early days.

Nancy looked at data of members eligible for a least one of the four measures and who was captured and how many members weren’t. Sometimes we are unable to clearly distinguish if service completions occurred before or after ePrompt engagement. Claims lag and lack of member awareness of recently competed services were key barriers in assessing influence. Overall, however, it has been shown that members with ePrompt contact had a higher completion rate than those who didn’t. Tara said feedback from more than 20 CC or Member Services PHC staff has been positive. Staff is finding it easier to remember to utilize ePrompts as time goes on and are cheered to realize that they are also educating members as to some plan benefits. Nancy recommends expanding pilot to the Southern Region MS and CC departments; adding in Child and Adolescent well care visit measures. Dr. Netherda and Dr. Kubota agreed that if we chose to go forward with ePrompts, the wording of information visible to the member should be in “lay” language. Cross regional QI, CC and operations staff will meet Feb. 24 to look at the feasibility of expanding and continuing the program.

Adjournment The meeting adjourned at 3:25 p.m. IQI next meets Tuesday, March 9, 2021

Respectfully submitted by: Leslie Erickson, Administrative Assistant II

Signature of Approval: ______Ro Date: ______bert Moore, MD, MPH, MBA

Committee Chair

Minutes of the Feb. 9, 2021 PHC Internal Quality Improvement (IQI) Committee 30 of 229 Page 8 QI DEPARTMENT UPDATE MARCH 2021 PREPARED BY ERIKA R OBINSON & NANCY STEFFEN IRECTORS UALITY AND ERFORMANCE MPROVEMENT D , Q P I

QUALITY IMPROVEMENT PROGRAMS (QIPS) NEWS- UPDATE – HIGH LEVEL

QIP PROGRAM UPDATE PRIMARY CARE PROVIDER . The 2021 Q1 Measure Focus includes: QUALITY IMPROVEMENT - Asthma Medication Ratio PROGRAM (PCP QIP) - Childhood Immunization Status - Combination 10 - Comprehensive Diabetic Care - HbA1c Control - Controlling High Blood Pressure - Well Child Visits in the First 15 Months of Life - Child and Adolescent Well Care Visit . After careful, thoughtful and thorough claims analysis, the threshold for the 2020 PCP office visit measure has been lowered from 2.1 to 1.65 visits per year (including virtual visits) due to the impact of the COVID pandemic. Providers who are below the amended 1.65 target are encouraged to submit all dates-of-service claims between 01/01/2020 – 12/31/2020 to the PHC Claims Department no later than 03/15/2021. Providers can view their estimated PCP Office Visit scores in the Partnership Quality Dashboard (PQD), via eReports, 03/01/2021. . The PCP QIP team is hosting its annual kick-off webinar for 2021 eReports on 03/09/2021 from 12p.m.-1p.m. A recording will be posted on the PHC website for anyone interested but unable to attend. LONG TERM CARE QUALITY . The LTC QIP remains suspended for the 2021 measurement year until IMPROVEMENT PROGRAM further notice. We are hopeful the program will resume in 2022. (LTC QIP) PALLIATIVE CARE QUALITY . Transition of the Palliative Care Quality Network (PCQN) to Palliative Care IMPROVEMENT PROGRAM Quality Collaborative (PCQC) is gradually rolling out as providers’ PCQC (PALLIATIVE CARE QIP) membership requirements are completed and approved. PERINATAL QUALITY . 2021-2022 Measure Development is underway. IMPROVEMENT PROGRAM . Quarterly reports representative of 4Q 2020 performance were prepared (PERINATAL QIP) and sent to participating providers on 02/11-12/2021. INTENSIVE OUTPATIENT CASE . No update. MANAGEMENT QUALITY IMPROVEMENT PROGRAM (IOPCM QIP) HOSPITAL QUALITY . Partnership HealthPlan of California (PHC) will host the 2021 Hospital IMPROVEMENT PROGRAM Quality Symposium (HQS) on 06/22/2021. Due to continued COVID-19 (HQIP) related restrictions, this year’s HQS will be hosted virtually and presented on the above date only. . The QIP team posted updates to the 2020-2021 Hospital QIP specifications on 01/28/2021 to clarify earlier changes made to Readmissions, California Immunization Registry (CAIR), and Substance Use measures. . The QIP team is working with participating hospitals to better understand challenges they face relative to completing advanced directives/POLSTs 31 of1 229

QIP PROGRAM UPDATE (Physician Orders for Life-Sustaining Treatment). Given continued COVID related precautions in the hospital setting, it has proven difficult to ratify these documents with appropriate witness signatures. SPECIALTY QUALITY . No update. IMPROVEMENT PROGRAM (SPECIALTY QIP) DATA TOOL UPDATES PARTNERSHIP QUALITY . A new stoplight report is being piloted that visualizes the number of care DASHBOARD (PQD) gaps to close within multi-site locations to reach QIP targets. The internal facing report can be downloaded and shared at Joint Leadership Initiative (JLI) meetings, Joint Operating Meetings, or other provider facing meetings where the QIP is discussed. Based on the feedback from teams who use the report, a decision will be made in succeeding months about whether to make this utility provider facing in PQD. . A survey will be sent to departments as a precursor to further discussion about PQD needs. The deeper dive discussions and survey will support future development, training and enhancements for PQD. . The final business requirements for the Healthcare Effectiveness Data and Information Set (HEDIS®) Monthly dashboard development were shared with the HEDIS and Enterprise Data Warehouse (EDW) teams on 02/09/2021. . Business requirement review for the QIP dashboard development began on 02/24/2021. PQD views specific to PCP QIP will be available 03/01/2021 with refreshed data relative to the nearly-finalized-MY2020 performance. These views will be available to providers via the PQD link in eReports. This access will be key for providers still working to submit claims from 2020 to affect their final PCP Office Visit score. QIP views relative to YTD performance on MY2021 are in development and remain on track for release in early May. . QI leadership, the PQD team and Health Analytics are reviewing current health equity data visualizations as PHC considers embedding health equity based measures in the QIP. EREPORTS . The PCP QIP MY2020 grace period began on 01/11/2021 and concluded 01/31/2021. Providers were then encouraged to review their final numerator and denominator values and overall rates during the validation period of 02/01-07/2021. Some disputes were identified by providers and investigated by the PHC team in February. Resulting adjustments will be made before finalizing clinical measure performance data and payments on MY2020. . eReports was down for planned maintenance and measurement year change over from 03/08-28/2021. The release of eReports 2021 remains on track for 03/01/2021.

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PERFORMANCE IMPROVEMENT (PI)

ACTIVITY UPDATE STATE MANDATED WORK: . We are partnering with CommuniCare on the Health Equity PIP to improve on PERFORMANCE HEALTH breast cancer screening in a small county per the Department of Healthcare EQUITY IMPROVEMENT Services (DHCS) definition of county size and population and will submit PROJECT (PIP) & PLAN-TO- Module 1 toward the end of March. DO-STUDY-ACT (PDSA) . The Well-Child Visit (W15) PIP intervention plans, in partnership with Shasta CYCLE Community Health Centers (SCHC), is in final review with the Health Services Advisory Group (HSAG). In early February, HSAG provided feedback on PHC’s intervention submissions. The feedback was relatively minor and did not inhibit continuation of the local improvement activities. The goal of this longer term improvement project, recently restarted in fall 2020, is to improve well child visits rates for 0-2 year olds through innovative workflow changes to improve access. . PHC is in the process of providing a written status update to its COVID-19 quality plan, which was formally submitted to DHCS in late July 2020. Progress under several objectives in PHC’s 5-Star Quality Tactical Plan and the 2020-21 QI Work Plan will be leveraged to summarize PHC’s ongoing efforts to improve the quality of care our members receive, as measured and reported per HEDIS. This submission is on-track to be delivered to DHCS by 03/01/2021. JOINT LEADERSHIP INITIATIVE . The spring JLI meeting with Adventist Health (Clearlake) occurred on (JLI) 02/17/2021. The next JLI meetings are: - Solano County FHS (03/16/2021) - Mendocino Community Health Clinic (MCHC) (03/30/2021) - Santa Rosa Community Health (SRCH) (03/31/2021) - La Clínica de La Raza (04/01/2021) - Adventist Health Ukiah (04/08/2021) - Ole Health (04/22/2021) . In the Northern Region, the Fairchild Medical Center JLI has been rescheduled after being postponed in December due to a COVID case surge in Siskiyou County. It will now occur 02/25/2021; it has been over a year since our last meeting in December 2019. Fall 2020 JLI meetings were completed as planned with Shasta Community Health Centers (SCHC) and Open Door Community Health Centers (ODCHC), with brief status updates incorporated in recent QI updates. PHC is pleased to have finalized its spring JLI meetings with each of these organizations, SCHC on 04/13/2021 and ODCHC on 05/06/2021.

. ODCHC

. ODCHC on May 6

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ACTIVITY UPDATE IMPROVEMENT ACADEMY . A two-part webinar series, “Project Management 101,” was offered on 02/03/2021 and 02/10/2021. - For session 1, there was a total of 79 participants, representing 27 unique organizations. - For session 2, there was a total of 42 participants, representing 14 unique organizations. . PHC is providing practice facilitation support to an effort led by the Community Clinic Consortium and four Federally Qualified Health Centers (FQHCs) in Solano County (Community Medical Centers, La Clínica de La Raza, Ole Health, and Solano County Family Health Services) to collectively focus and improve on a specific PCP QIP measure - well-child visits in the first 15 months of life. . A new webinar is being offered by PHC on 03/18/2021 from Noon - 1 p.m., titled: “Understanding the Benefits Delivery System.” Ordering screenings in the primary care setting can trigger a common question from members, “Do my benefits cover that?” This webinar will explore opportunities to close gaps in care through an increased understanding of member benefit coverage. It also aims to aid providers in increasing their patients’ knowledge of coverage and accessing their benefits. The target audience is clinicians, practice managers, quality improvement staff and those who are responsible for billing, documentation, referrals and other aspects of screening completions. See PHC’s Performance Improvement Academy webpage for registration details. . Another new webinar is being offered by PHC on 03/30/2021 from Noon- 1 p.m., titled: “Engaging Patients in Quality Improvement.” This session will introduce the concept of patient engagement in quality improvement with the goal to improve patient experience and health outcomes. Participants will learn why engaging patients in quality improvement is important and several successful strategies to apply in their practice settings. See PHC’s Performance Improvement Academy webpage for registration details. REGIONAL IMPROVEMENT . The Southeast Region Quality meeting for primary care provider organizations MEETINGS is scheduled for 03/24/2021. . The QIP Improvement meeting for primary care provider organizations in Lake and Mendocino counties is scheduled for 03/26/2021. . On the heels of a successful asthma care intervention with Hill Country Health and Wellness Center in 4Q 2020, the NR QI and Rx teams are working to provide tailored academic detailing sessions with both Open Door Community Health Centers and Shasta Community Health Centers on 03/05/2021 and 03/09/2021, respectively. PHC is also sharing this regional success and offering detailing sessions to other NR providers, through both the QIP team and northern consortia QI Peer Network. QI TRILOGY DOCUMENTS . No update.

TEAM #11/WORKFORCE . No update. DEVELOPMENT

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ACTIVITY UPDATE PROMOTING HOME BLOOD . For the “Promoting Home Blood Pressure Monitoring” initiative, the member PRESSURE MONITORING education materials are drafted and under review for approval.

OTHER (e.g., OFFERING AND . The Annual Intensive Outpatient Palliative Care meeting for contracted HONORING CHOICES), palliative care providers occurred on 02/12/2021. HEALTH ANALYTICS . In conjunction with the Population Health team, the QI department worked STRATEGY PLAN) with West County Health Center, Sonoma Valley Community Health Center, and Alinea Medical Imaging to offer mobile mammography clinics on 03/05/2021 and 03/06/2021. . Two offerings of a new internal training, “A Closer Look at HEDIS Specifications,” are scheduled for 03/10/2021 and 03/30/2021. The objectives are for participants to learn: - Basics of HEDIS® -the what and how. - Data sources used to measure HEDIS. - How HEDIS® is reported and how does PHC rank. - How to use and interpret the HEDIS® technical specifications

Note: Detailed information and recordings of webinars are posted to the PHC Website: http://www.partnershiphp.org/Providers/Quality/Pages/PIATopicWebinarsToolkits.aspx

QUALITY ASSURANCE AND PATIENT SAFETY TEAM (CROSS REGIONAL UPDATE)

ACTIVITY UPDATE POTENTIAL QUALITY ISSUES . 26 PQI referrals were received from the following sources: Utilization (PQI) FOR THE PERIOD: Management - 8, Regional Compliance - 7, Grievance & Appeals - 5, JANUARY 21, 2021 - Associate Medical Director - 4 and Pharmacy - 2. FEBRUARY 18, 2021 . 10 PQI cases were processed and closed to completion. . 3 PQI cases were reviewed/scored and will be referred to Peer Review Committee for further review. . 2 cases were presented to the Peer Review Committee in February 2021. . 2 cases are being prepared for the next Peer Review Committee in March 2021. FACILITY SITE REVIEWS . FSR (FSRS)FOR THE PERIOD: Region # of FSR # of MRR # of FSR # of MRR CAP JANUARY 22, 2021 - conducted conducted CAP issued issued FEBRUARY 19, 2021 NR 1 1 1 1

SR 3 2 3 1

New sites opened this period: - PCP – Marin Community Clinics, Greenbrae - NORTHERN REGION QUALITY . In addition to conducting virtual site reviews and corresponding provider ASSURANCE AND PATIENT educations, the NR Patient Safety team is working closely with Provider SAFETY Relations (PR) in a new project per DHCS’ All Plan Letter (APL) 20-016: Blood Lead Screening for Young Children. With the assistance of Health Analytics, QI and PR will start distributing quarterly reports to providers indicating progress of their assigned members, ages 6 months to 6 years old, in completing timely blood lead screenings. PR and QI are leveraging their

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ACTIVITY UPDATE varied contacts at provider sites to assure the reports are received and action steps are taken, as needed. The first set of quarterly reports are targeted for distribution by late March or early April.

HEALTHCARE EFFECTIVENESS DATA & INFORMATION SET (HEDIS®)

ACTIVITY UPDATE HEDIS® . Our Annual HEDIS on-site audit was conducted via Virtual Audit this year on 02/11/2021. We are happy to share that we had an outstanding outcome with zero findings and with no opportunities for improvement noted. As communicated earlier this year, we have a new HSAG Auditor, Elisabeth Hunt. She was very complimentary on PHC’s robust and comprehensive processes across all sessions, and she indicated how impressed she was with how prepared, structured and detailed the PHC staff were in each session. . We would like to extend our sincere appreciation to all those who participated and acknowledge the preparation that went into supporting the details necessary, which required some live system or process demonstrations. The Auditor applauded PHC for the implementation of a Data Stewardship program as she has worked with other plans who have this program in place and spoke highly of them. . We have launched our annual medical records project for the HEDIS MY 2020 season. Activities are underway and on track to complete and meet audit deliverables. . We have launched our on-boarding process and refresher clinical training for the HEDIS nurses. We are excited to have our returning nurses who began on 02/08/2021.

QUALITY COMPLIANCE AND ACCREDITATION

ACTIVITY UPDATE NATIONAL COMMITTEE FOR . PHC obtained NCQA Accreditation on 01/25/2021. The NCQA Program QUALITY ASSURANCE Management team is gathering lessons learned from First Survey and (NCQA) distributed debrief surveys to the executive team, department leadership, and other key stakeholders to obtain feedback pertaining to critical areas of the NCQA program at PHC. The feedback will be used to strengthen the program and ensure sustainability of NCQA requirements through Renewal Survey. . FY 20-21 NCQA-related Department Goal activities are in progress. The activities associated with this goal are designed to support sustainability of NCQA requirements.

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April 2021 PHCSystem Updates

New Old Provider Policy/Procedures/Guidelines Assigned Comments Number Manual Number

The following documents were reviewed by the Quality / Utilization Advisory Committee (Q/UAC) in March 2021

***Due to the postponement of the Medi-Cal Rx carve out, the following language (or similar) has been added to policies and/or their attachments as applicable:

“PHC’s formulary and medication coverage benefits shall continue as described in this policy until such time as the pharmacy benefit carve-out to Medi-Cal Fee-for-Service described in APL 20-020 and the Governor’s Executive Order N-01-19 may take effect.”

Health Services – Quality Clinical Practice Guidelines MPQP1006 Regular review; edits made for clarity and X verbiage added as described above***

Substance Use Disorder (SUD) Facility MCQP1025 Regular review; revised for clarity, ability X Site Review and Medical Record Review for PHC to conduct annual review virtually (the word “Facility” re-added to title) added; section highlighting two basic components of the Site Review (Facility Attachments: updated Site Review [FSR] and Medical Record A. Substance Use Disorder (SUD) Review {MRR] updated along with section Facility Site Review Tool & Guidelines on Compliance Levels; timelines updated B. Substance Use Disorder (SUD) under Conditional Pass – PHC will provide Medical Record Review Tool & review findings report and formal request Guidelines for corrections within 10 calendar (not business) days and the practice site must submit a Correction Action Plan (CAP) addressing deficiencies within 30 calendar days (not 45) Health Services – Clinical Practice Guidelines Clinical Practice Guidelines for the MPXG5001 Regular review; language clarity added; X Diagnosis & Management of Asthma ***reference added as above Attachment: updated, reference added*** A. PHC Asthma/COPD Pharmacotherapy Major Depression in Adults Clinical MPXG5003 Regular review; ***reference added as X Practice Guidelines above Attachments: updated with reference*** A. Clinical Decision Flow Chart B. Common Antidepressant Agents – PHC Formulary Status, Dosing Regimens and Monthly Costs

37 of 229 Page 1 of 3 New Old Provider Policy/Procedures/Guidelines Assigned Comments Number Manual Number

Clinical Practice Guidelines: Pain MPXG5008 Regular review; clarifications added; X Management, Chronic Pain Management, language added that the emergency and Safe Opioid Prescribing department (ED) can be a critical access point for members with substance use Attachments: updated disorder (SUD), and that ED personnel A. PHC Recommendations for Safe Use should consider screening for SUB and of Opioid Medications: Primary Care initiating medication-assisted treatment & Specialist Prescribing Guidelines (MAT); References updated B. PHC Recommendations for Safe Use of Opioid Medications: Community Pharmacy Guidelines C. PHC Recommendations for Safe Use of Opioid Medications: Emergency Department Guidelines D. PHC Recommendations for Safe Use of Opioid Medications: Dental Prescribing Guidelines

Health Services – Care Coordination Whole Child Model for California MCCP2024 Regular review; the use of video was X Children’s Services (CCS) added as method that PHC Care Coordination staff can use when Attachment: unchanged assessing high or low risk members for A. Pediatric Risk Stratification Process intervention purposes Residential Substance Use Disorder MCCP2028 Regular review; no changes to policy X Treatment Authorization content; References updated

Health Services – Utilization Management Inpatient Utilization Management MCUG3024 Regular review; language clarifications X added; References updated

Insulin Infusion Pump and Continuous MPUG3025 Regular review; no changes to guideline X Glucose Monitor Guidelines content; References updated Attachments: A updated, B unchanged A. CCS NL 06-1120 Authorization of Insulin Infusion Pumps Rev. 11/17/2020 B. CCS NL 14-0818 Continuous Glucose Monitoring (CGM) as a CCS/GHPP Program Benefit – Rev. 08/29/2018 Treatment Authorization Request (TAR) MCUP3041 Regular review; telephone number for X Review Process PHC’s Eligibility and Interactive Voice (term “TAR” extended in title) Response (IVR) System added; information required to verify PHC Attachment: updated * member eligibility updated; statement A. PHC TAR Requirements list added that TARs submitted beyond noted (including Outpatient Surgical timeframes are considered late but will still Procedures CPTs Requiring TAR list be reviewed for medical necessity and Pain Management CPTs Requiring TAR list PHC TAR Requirements list (as above) * Attachments only updated – policy and X guideline not reviewed Pain Management Specialty Services MCUP3049-A Authorization of Ambulatory Procedures MCUG3007-B and Services

38 of 229 Page 2 of 3 New Old Provider Policy/Procedures/Guidelines Assigned Comments Number Manual Number

Negative Pressure Wound Therapy MPUP3059 Regular review; clarification that NPWT X (NPWT) Device/Pump TARs are reviewed in one month increments; language added that recent serum albumin must be included as a component of a wound therapy program (addressed, applied, considered and ruled out) prior to application of NPWT; relevant labs listed (CBC, CMP, albumin, wound cultures, HgA1C) under requirements for consideration of coverage beyond four months Utilization Management Program MPUD3001 Regular review; processes, staffing and X Description committee participation, timing and purpose updated; revisions include Requires Board Approval after contractual obligations Physician Advisory Committee

39 of 229 Page 3 of 3 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE

Policy/Procedure Number: MCQP1025 (previously MPQP1025, Lead Department: Health Services QP100125) Policy/Procedure Title: Substance Use Disorder (SUD) Facility Site External Policy Review and Medical Record Review (previously Behavioral Health/ Internal Policy Substance Abuse Facility Site Review) Next Review Date: 04/08/202104/13/2022 Original Date: 02/18/2004 Last Review Date: 04/08/202004/14/2021 Applies to: Medi-Cal Employees Reviewing IQI P & T QUAC Entities: OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT Approving BOARD COMPLIANCE FINANCE PAC Entities: CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 04/08/202004/14/2021

I. RELATED POLICIES: A. MPQP1022 – Site Review Requirements and Guidelines B. MPQP1016 – Potential Quality Issue Investigation & Resolution C. MPQP1053 – Peer Review Committee D. CMP36 – Delegation Oversight and Monitoring

II. IMPACTED DEPTS: A. Health Services B. Provider Relations C. External and Regulatory Affairs

III. DEFINITIONS: Substance Use Disorder Treatment Provider: Person or entity that provides direct alcohol and other drug treatment services and has been certified by the State as meeting the certification requirements for participation in the Drug Medi-Cal (DMC) program set forth in the DMC certification Standards for Substance Abuse Clinics and Standards for Drug Treatment Programs in California.

IV. ATTACHMENTS: A. Substance Use Disorder (SUD) Facility Site Review Tool & Guidelines B. Substance Use Disorder (SUD) Medical Record Review Tool & Guidelines

V. PURPOSE: A. To provide SUD practice sites a comprehensive guideline for Facility Site Review (FSR) and Medical Record Review (MRR) requirements and processes. This policy will apply to DMC-certified providers contracted with Partnership HealthPlan of California (PHC). The purpose of the Site Review is to ensure that practice sites have sufficient capacity to: 1. Provide appropriate SUD services 2. Carry out processes that support continuity and coordination of care 3. Maintain patient safety standards and practices, and B. Operate in compliance with applicable federal, state, and local laws and regulations Findings of the Site Review are used to: 1. Provide information for credentialing/re-credentialing decisions 2. Identify areas where education and technical assistance is needed 3. Identify and share best practices in patient safety, medical error prevention, and provision of quality care

40 of 229 Page 1 of 6 Policy/Procedure Number: MCQP1025 (previously Lead Department: Health Services MPQP1025, QP100125) Policy/Procedure Title: Substance Use Disorder (SUD) Facility ☒External Policy Site Review and Medical Record Review (previously Behavioral ☐ Health/ Substance Abuse Facility Site Review) Internal Policy Next Review Date: 04/08/202104/13/2022 Original Date: 02/18/2004 Last Review Date: 04/08/202004/14/2021 Applies to: ☒ Medi-Cal ☐ Employees

VI. POLICY / PROCEDURE: A. Requirements 1. PHC will conduct annual onsite or virtual monitoring reviews of services and subcontracted services for programmatic and fiscal requirements, and submit a copy of their monitoring and audit reports to the Department of Health Care Services (DHCS) within two weeks of issuance. B. Review Personnel 1. The Partnership HealthPlan of California (PHC) Chief Medical Officer (CMO) is ultimately responsible for Site Review activities completed by PHC personnel. At a minimum, PHC review teams will consist of a Registered Nurse (RN), Licensed Practitioner of the Healing Arts (LPHA), Physician Assistant (PA), certified counselor or Physician. 2. Partnership HealthPlan of California will assure that reviewers collect data that is appropriate to their level of education, expertise, training and professional licensing scope of practice as determined by California statute. Only RNs, PAs, LPHAs or physicians may review survey elements labeled “  RN/MD/LPHA Review only or RN/MD Review only”. The Reviewer must sign the completed Site Review tool. C. Site Review – A Site Review consists of two basic components: the Facility Site Review (FSR) and the Medical Records Review (MRR). (See Attachments A and B, respectively.) PHC’s Credentialing Department assesses the accreditation status of Substance Use Disorder Treatment Providers as part of the credentialing process. If any SUD providers are not accredited and have not had State or Centers for Medicare and Medicaid Services (CMS) reviews conducted within the last 36 months, PHC will conduct annual Site Reviews using the review tools in attachments A and B. Subsequently, PHC conducts Site Reviews regardless of accreditation status.

3.1. A Facility Site Review (FSR) is an on-site review of the office site and its, processes., and covers the following areas: A FSR covering the following areas is required to be completed prior to final credentialing of the site’s SUD practitioners: a. Access/Safety b. Personnel c. Office Management d. Pharmaceutical 4. A Facility Site Review is required to be completed prior to final credentialing of the site’s SUD practitioners. a. PHC’s Credentialing Department assesses the accreditation status of Substance Use Disorder Treatment Providers as part of the credentialing process. If any SUD providers are not accredited and have not had State or Centers for Medicare and Medicaid Services (CMS) reviews conducted within the last 36 months, PHC will conduct annual Site Reviews using the review tools in attachments B and C. Subsequently, PHC conducts (Facility?)Site Reviews regardless of accreditation status. 5.e. In the review tool (See Attachment A), there is a specific section that aids the reviewer in assessing the extent to which the site is accessible and useable by individuals with physical disabilities. The site provides access to, or has written policy to provide alternative access for members. C.2. A Medical Records Review (MRR) – assesses Tthe following elements will be reviewed in the MRR (See Attachment B): 1. In addition to the standard review tool, the following elements will be reviewed in the Medical Record Review a. Format Criteria b. Intake Services

41 of 229 Page 2 of 6 Policy/Procedure Number: MCQP1025 (previously Lead Department: Health Services MPQP1025, QP100125) Policy/Procedure Title: Substance Use Disorder (SUD) Facility ☒External Policy Site Review and Medical Record Review (previously Behavioral ☐ Health/ Substance Abuse Facility Site Review) Internal Policy Next Review Date: 04/08/202104/13/2022 Original Date: 02/18/2004 Last Review Date: 04/08/202004/14/2021 Applies to: ☒ Medi-Cal ☐ Employees

c. Treatment Services d. Discharge Services e. Recovery Services f. Residential (if applicable) D. Out of Network Providers 1. For providers outside of PHC’s network, PHC will determine whether to conduct a Site Review or accept review findings from an outside entity that performed the most recent review. A copy of the annual reviews will be provided by the entity or PHC will conduct the review. E. Focused Review 1. Focused reviews are targeted audits consisting of review of problem areas identified through Site Review monitoring activities, to follow up on Corrective Action Plans (CAPs), from patient grievances, from potential quality issue reports or from observations of PHC staff. All deficiencies found during a focused review will require the completion and verification of corrective actions according to the CAP timelines. F. Requirements for New Practitioners at a Site 1. A Site Review will not be repeated if a new provider is added to a provider site that has a current passing Site Review score. If a Substance Use Services Disorder Treatment provider moves to a site that has not undergone a previous Site Review, PHC performs a Site Review at this site. G. Compliance Levels 1. The FSR and the MRR are scored separately by the Site Reviewer. a. The total points will differ from site to site because the “not applicable” items do not factor into the scoring where noted. All standards where review determinations result in a “N/A” (non- applicable) or “No” shall include an explanation regarding this finding. 2. The Facility Site Review has a total of 62 points possible The Medical Record Review has a total of XX points possible. Possible points are adjusted to subtract “not applicable” items. The reviewer will advise the practice site of any deficiencies in critical elements during the Site Review. 1.a. Compliance level categories include:

Compliance Category FSR Site Review MRR Score Score Exempted Pass 90% or above 90% or above Conditional Pass 80-89% 80-89% Not Pass Below 80% Below 80%

H. Corrective Action Plan (CAP) Requirements and Timelines 1. Conditional Pass a. PHC will provide the practice site with a review findings report and a formal written request for corrections of all deficiencies within 10 business calendar days after the site visit. The practice site must submit a CAP to PHC addressing deficiencies within 45 30 calendar days of the written initial CAP request date. PHC will then review/revise/approve the CAP. Under extenuating circumstances, an additional 30 day extension to complete deficiencies that have not been addressed may be granted. However, the total number of days to complete the CAP process may not exceed 120 days from the initial CAP request. PHC will follow the process and timeline outlined in Section VI. A8. CAP Timeline Table Attachment G of policy MPQP1022. 2. Not Pass a. Pre-contractual Provider – Cannot be credentialed as a network provider. Prior to being approved as a network provider, a Site Review re-survey must be completed with a passing score. A CAP will be required as addressed in F1.

42 of 229 Page 3 of 6 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE

Policy/Procedure Number: MCQP1025 (previously MPQP1025, Lead Department: Health Services QP100125) Policy/Procedure Title: Substance Use Disorder (SUD) Facility Site External Policy Review and Medical Record Review (previously Behavioral Health/ Internal Policy Substance Abuse Facility Site Review) Next Review Date: 04/13/2022 Original Date: 02/18/2004 Last Review Date: 04/14/2021 Applies to: Medi-Cal Employees Reviewing IQI P & T QUAC Entities: OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT Approving BOARD COMPLIANCE FINANCE PAC Entities: CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 04/14/2021

I. RELATED POLICIES: A. MPQP1022 – Site Review Requirements and Guidelines B. MPQP1016 – Potential Quality Issue Investigation & Resolution C. MPQP1053 – Peer Review Committee D. CMP36 – Delegation Oversight and Monitoring

II. IMPACTED DEPTS: A. Health Services B. Provider Relations C. External and Regulatory Affairs

III. DEFINITIONS: Substance Use Disorder Treatment Provider: Person or entity that provides direct alcohol and other drug treatment services and has been certified by the State as meeting the certification requirements for participation in the Drug Medi-Cal (DMC) program set forth in the DMC certification Standards for Substance Abuse Clinics and Standards for Drug Treatment Programs in California.

IV. ATTACHMENTS: A. Substance Use Disorder (SUD) Facility Site Review Tool & Guidelines B. Substance Use Disorder (SUD) Medical Record Review Tool & Guidelines

V. PURPOSE: A. To provide SUD practice sites a comprehensive guideline for Facility Site Review (FSR) and Medical Record Review (MRR) requirements and processes. This policy will apply to DMC-certified providers contracted with Partnership HealthPlan of California (PHC). The purpose of the Site Review is to ensure that practice sites have sufficient capacity to: 1. Provide appropriate SUD services 2. Carry out processes that support continuity and coordination of care 3. Maintain patient safety standards and practices, and B. Operate in compliance with applicable federal, state, and local laws and regulations Findings of the Site Review are used to: 1. Provide information for credentialing/re-credentialing decisions 2. Identify areas where education and technical assistance is needed 3. Identify and share best practices in patient safety, medical error prevention, and provision of quality care

43 of 229 Page 1 of 5 Policy/Procedure Number: MCQP1025 (previously Lead Department: Health Services MPQP1025, QP100125) Policy/Procedure Title: Substance Use Disorder (SUD) Facility ☒External Policy Site Review and Medical Record Review (previously Behavioral ☐ Health/ Substance Abuse Facility Site Review) Internal Policy Next Review Date: 04/13/2022 Original Date: 02/18/2004 Last Review Date: 04/14/2021 Applies to: ☒ Medi-Cal ☐ Employees

VI. POLICY / PROCEDURE: A. Requirements 1. PHC will conduct annual onsite or virtual monitoring reviews of services and subcontracted services for programmatic and fiscal requirements, and submit a copy of their monitoring and audit reports to the Department of Health Care Services (DHCS) within two weeks of issuance. B. Review Personnel 1. The Partnership HealthPlan of California (PHC) Chief Medical Officer (CMO) is ultimately responsible for Site Review activities completed by PHC personnel. At a minimum, PHC review teams will consist of a Registered Nurse (RN), Licensed Practitioner of the Healing Arts (LPHA), Physician Assistant (PA), certified counselor or Physician. 2. Partnership HealthPlan of California will assure that reviewers collect data that is appropriate to their level of education, expertise, training and professional licensing scope of practice as determined by California statute. Only RNs, PAs, LPHAs or physicians may review survey elements labeled “  RN/MD/LPHA Review only or RN/MD Review only”. The Reviewer must sign the completed Site Review tool. C. Site Review – A Site Review consists of two basic components: the Facility Site Review (FSR) and the Medical Record Review (MRR). (See Attachments A and B, respectively.) PHC’s Credentialing Department assesses the accreditation status of Substance Use Disorder Treatment Providers as part of the credentialing process. If any SUD providers are not accredited and have not had State or Centers for Medicare and Medicaid Services (CMS) reviews conducted within the last 36 months, PHC will conduct annual Site Reviews using the review tools in attachments A and B. Subsequently, PHC conducts Site Reviews regardless of accreditation status.

1. A Facility Site Review (FSR) is an on-site review of the office site and its processes. A FSR covering the following areas is required to be completed prior to final credentialing of the site’s SUD practitioners: a. Access/Safety b. Personnel c. Office Management d. Pharmaceutical e. In the review tool (See Attachment A), there is a specific section that aids the reviewer in assessing the extent to which the site is accessible and useable by individuals with physical disabilities. The site provides access to, or has written policy to provide alternative access for members. 2. A Medical Record Review (MRR) – assesses the following elements (See Attachment B): a. Format Criteria b. Intake Services c. Treatment Services d. Discharge Services e. Recovery Services f. Residential (if applicable) D. Out of Network Providers 1. For providers outside of PHC’s network, PHC will determine whether to conduct a Site Review or accept review findings from an outside entity that performed the most recent review. A copy of the annual reviews will be provided by the entity or PHC will conduct the review. E. Focused Review 1. Focused reviews are targeted audits consisting of review of problem areas identified through Site Review monitoring activities, to follow up on Corrective Action Plans (CAPs), from patient

44 of 229 Page 2 of 5 Policy/Procedure Number: MCQP1025 (previously Lead Department: Health Services MPQP1025, QP100125) Policy/Procedure Title: Substance Use Disorder (SUD) Facility ☒External Policy Site Review and Medical Record Review (previously Behavioral ☐ Health/ Substance Abuse Facility Site Review) Internal Policy Next Review Date: 04/13/2022 Original Date: 02/18/2004 Last Review Date: 04/14/2021 Applies to: ☒ Medi-Cal ☐ Employees

grievances, from potential quality issue reports or from observations of PHC staff. All deficiencies found during a focused review will require the completion and verification of corrective actions according to the CAP timelines. F. Requirements for New Practitioners at a Site 1. A Site Review will not be repeated if a new provider is added to a provider site that has a current passing Site Review score. If a Substance Use Disorder Treatment provider moves to a site that has not undergone a previous Site Review, PHC performs a Site Review at this site. G. Compliance Levels 1. The FSR and the MRR are scored separately by the Site Reviewer. a. The total points will differ from site to site because the “not applicable” items do not factor into the scoring where noted. All standards where review determinations result in a “N/A” (non- applicable) or “No” shall include an explanation regarding this finding. 2. The reviewer will advise the practice site of any deficiencies during the Site Review. a. Compliance level categories include:

Compliance Category FSR Score MRR Score Exempted Pass 90% or above 90% or above Conditional Pass 80-89% 80-89% Not Pass Below 80% Below 80%

H. Corrective Action Plan (CAP) Requirements and Timelines 1. Conditional Pass a. PHC will provide the practice site with a review findings report and a formal written request for corrections of all deficiencies within 10 calendar days after the site visit. The practice site must submit a CAP to PHC addressing deficiencies within 30 calendar days of the written initial CAP request date. PHC will then review/revise/approve the CAP. Under extenuating circumstances, an additional 30 day extension to complete deficiencies that have not been addressed may be granted. However, the total number of days to complete the CAP process may not exceed 120 days from the initial CAP request. PHC will follow the process and timeline outlined in Section VI. A8. CAP Timeline Table of policy MPQP1022. 2. Not Pass a. Pre-contractual Provider – Cannot be credentialed as a network provider. Prior to being approved as a network provider, a Site Review re-survey must be completed with a passing score. A CAP will be required as addressed in F1. b. Contracted Network Provider – Survey deficiencies must be corrected by the provider and verified by PHC within the CAP timelines. PHC reserves the right to remove any provider with a not pass score from the provider network. Members will be given a 30-day notice of provider termination. Refer to Member Notification of Primary Care or Specialist Termination – policy # 300 for the specific procedures. 3. CAP Documentation a. CAPs will be completed using a standard format and form. The minimum elements to be included on a CAP: a. Specific deficiency(ies) b. Corrective Action(s) needed c. Projected date(s) of correction d. Actual date(s) of correction e. Re-evaluation timelines/dates f. Responsible person(s) for each corrective action

45 of 229 Page 3 of 5 Policy/Procedure Number: MCQP1025 (previously Lead Department: Health Services MPQP1025, QP100125) Policy/Procedure Title: Substance Use Disorder (SUD) Facility ☒External Policy Site Review and Medical Record Review (previously Behavioral ☐ Health/ Substance Abuse Facility Site Review) Internal Policy Next Review Date: 04/13/2022 Original Date: 02/18/2004 Last Review Date: 04/14/2021 Applies to: ☒ Medi-Cal ☐ Employees

g. Problems in completing corrective action, if any h. Education and/or technical assistance provided by PHC i. Evidence of the correction(s) j. Completion and closure date k. Name and title of reviewer I. Non-Compliance with Corrective Action Process 1. Providers who do not correct survey deficiencies, or do not cooperate with the CAP process within the established CAP timelines will be referred to the PHC Chief Medical Officer; Provider Relations Staff and/or Credentialing Committee. Actions taken by the Credentialing Committee may include termination of the site from the provider network. 2. Actions taken will be effective until corrections are verified and the CAP is closed. If PHC chooses to remove the site from the network, members will be given a 30-day notice of termination. Refer to Member Notification of Primary Care or Specialist Termination – policy # 300 for the specific procedures. J. Organizational Provider Appeals 1. See PHC Policy MPCR 9 “Fair Hearings Process for Adverse Credentialing Decisions” for appeal procedures 2. If verified evidence of correction of deficiencies is submitted and the decision to terminate the provider from the network is reversed, PHC will repeat the Site Review in 12 months. 3. If the decision is not reversed, and the provider is terminated from the network, the practice may reapply to become a network provider and PHC will complete a new site review. K. Systematic Monitoring 1. Monitoring following the Site Review will include, but is not limited to, data gathered through the following sources: a. Member grievances and appeals (reviewed daily) b. Potential Quality Issue information (reviewed when identified) c. Focused review or other on-site visit (based on Site Review findings, track and trend quarterly reports)- d. Request CAP when problem verified and follow the above CAP process in Section F1. 2. The CMO or Site Reviewer will determine and specify follow up action after the Site Review. Follow up activities may include an additional site visit to review continued compliance. L. Delegation of Site Reviews 1. Delegation Agreement a. Prior to delegating Site Review to a provider, PHC will establish a formal, mutually agreed upon Delegation Agreement that will: a. Identify specific delegated functions b. Specify policies/procedures to be used for delegated functions c. Specify reporting requirements of the delegate d. Specify PHC training, communication, and oversight activities 2. Potential Quality of Care Issues a. Potential quality of care issues identified during the course of the Site Review will be conducted in accordance with the PHC policy for Peer Review Process. The clinical reviewer will complete a PQI Report Form, submit it to the Quality Department for follow up, and review. 3. Local Collaboration a. In an effort to streamline the regulatory process and reduce redundant Site Reviews at SUD sites, PHC will collaborate with other health plans having contracts with mutual providers. PHC will accept the Site Review score assigned by other health plans if the collaboration processes are defined in detail and meet and/or exceed the standards addressed in MPQP1025. PHC may

46 of 229 Page 4 of 5 Policy/Procedure Number: MCQP1025 (previously Lead Department: Health Services MPQP1025, QP100125) Policy/Procedure Title: Substance Use Disorder (SUD) Facility ☒External Policy Site Review and Medical Record Review (previously Behavioral ☐ Health/ Substance Abuse Facility Site Review) Internal Policy Next Review Date: 04/13/2022 Original Date: 02/18/2004 Last Review Date: 04/14/2021 Applies to: ☒ Medi-Cal ☐ Employees

choose to repeat the Site Review of a site that had passed a Site Review by another health plan’s reviewers.

VII. REFERENCES: A. MMCD Policy Letter (PL) 12-006 Revised Facility Site Review Tool B. DHCS All Plan Letter (APL) 20-006 Site Reviews: Facility Site Review and Medical Record Review C. DHCS All Plan Letter (APL) 15-023 Facility Site Review Tools for Ancillary Services and Community- Based Adult Services Providers D. 3 CCR §504; 24 CCR (CA Building Standards Code); 28 CFR §35 (American Disabilities Act of 1990, Title II, Title III) E. Department of Health Care Services (DHCS) Intergovernmental Agreement for Drug Medi-Cal Organized Delivery System (DMC-ODS) Services

VIII. DISTRIBUTION: A. PHC Provider Manual B. PHC Department Directors

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Chief Medical Officer

X. REVISION DATES: Medi-Cal 05/18/05; 04/19/06; 06/20/07; 06/18/08; 07/15/09; 09/15/10; 02/20/13; 05/15/13; 05/21/14; 09/20/17; *10/10/18; 11/13/19; 04/08/20; 4/14/21

*Through 2017, Approval Date reflective of the Quality Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO: PartnershipAdvantage: MPQP1025 - 06/20/2007 to 02/20/2013 Healthy Families: MPQP1025 - 10/01/2010 to 02/20/2013 Healthy Kids MPQP1025 - 06/20/2007 to 02/20/2013

47 of 229 Page 5 of 5 Policy/Procedure Number: MCUP3041 (previously Lead Department: Health Services UP100341) Policy/Procedure Title: Treatment Authorization Request (TAR) ☒ External Policy Review Process ☐ Internal Policy Original Date: (UM-2) 04/25/1994 Next Review Date: 09/09/202104/14/2022 (Effective 06/19/2013 - TAR/RAF Last Review Date: 09/09/202004/14/2021 Review Policy split) Applies to: ☒ Medi-Cal ☐ Employees

2. In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request. E. Non-urgent Request: A request for medical care or services for which application of the time periods for making a decision does not jeopardize the life or health of the member or the member’s ability to regain maximum function and would not subject the member to severe pain. F. Concurrent Request: A request for coverage of medical care or services made while a member is in the process of receiving the requested medical care or services, even if PHC did not previously approve the earlier care. G. Pre-service Request: A request for coverage of medical care or services that the organization must approve in advance, in whole or in part. H. Post-service Request: A request for coverage of medical care or services that have been received (e.g., retrospective review).

IV. ATTACHMENTS: A. PHC TAR Requirements list (including Outpatient Surgical Procedures CPTs Requiring TAR list and Pain Management CPTs Requiring TAR list

V. PURPOSE: To describe the procedure used by the Partnership HealthPlan of California (PHC) Utilization Management (UM) Department to process Referral Authorization Forms (RAFs) and Treatment Authorization Requests (TARs) based upon the medical necessity of the request.

VI. POLICY / PROCEDURE: A. GENERAL PROCEDURES 1. Partnership HealthPlan of California pays for authorized services according to the specific terms of each physician, hospital, or other provider contract. PHC will reimburse only if individuals are eligible at the time the service is rendered. 2. Resources necessary to help in determining review decisions, include, but are not limited to the published, current, InterQual® criteria; Medi-Cal (State of California) criteria, Medicare criteria, and PHC internally developed and approved guidelines. Determinations also take into account individual member needs and characteristics of the local delivery system. a. The Provider of service must verify eligibility of the member via PHC systems at the time of service. This verification is necessary for all service authorizations. b. PHC’s Eligibility and Interactive Voice Response (IVR) Systems are is available at this direct phone number (800) 557-5471 to verify eligibility and determine the member’s assigned primary care provider (PCP). Information required to verify the eligibility of an individual is as follows: 1) NameProvider NPI (National Provider Identifier) 2) Date of BirthMember Social Security number or PHC Member ID number 3) SexDate of Service 4) Social Security Number 5) Medi-Cal number/Client Index Number (CIN) 6) PHC member number 7) Address and name of parent may be necessary in some cases. 3. TARs are not processed by PHC until the TAR form is complete and includes all member information and all attachments noted on the TAR are received. When completing information fields for the provider of service and service(s) being requested, the correct and valid codes must be

48 of 229 Page 2 of 10

GRIEVANCE & APPEALS THE PULSE REPORT

Our Mission

To help our members, and the communities INSIDE we serve, be healthy THIS ISSUE

PG. 6

A judge approves a member’s G&A PULSE REPORT denied Appeal, member receives special rotation bed. VOLUME 1 | MARCH 2021 Welcome to our very first G&A PULSE Report! The purpose of this report is to provide objective PG. 7 updates to all stakeholders regarding trending disruptions that members experience as expressed through Appeals, Grievances, Exempt Grievances, and State Hearings. Reports will be published PHC stands strong against quarterly. discrimination and revises its policies. Partnership HealthPlan of California (PHC) is committed to member satisfaction. When members understand their PHC Medi‐Cal benefits, understand how to access them, and service meets PG. 9‐11 expectations, we believe members are likely to seek care and maintain their health. We invite all members to tell us about their concerns or challenges they encounter so that we can help remove NCQA Spotlights! Highlights any barriers. We take great pride in the trust that members have in us to resolve their concerns. member dissatisfaction trends for 2020.

49 of 229 1

4Q20 TRENDS

THE NUMBERS

There were 1,065 cases investigated of which 99.8% were investigated timely. All members were notified that their case was received within five (5) days of receipt, resulting in 100% timely notice. An Administrative Law Judge approved a member’s request for a continuous rotation bed in a State Hearing (see CCS Related page for more information).

TOP TRENDS DURING 4Q20

The #1 member‐reported issue based on volume is the provider’s service. Members disagreed with their provider’s plan of care, experienced communication issues, or had problems scheduling appointments. Communication‐related problems involve barriers, breakdowns, or disagreements with providers. They often result in members requesting a change in their primary care provider. Also notable, members contested denied lodging under the non‐medical transportation benefit or requesting longer lodging requests than initially approved.

OTHER NOTEWORTHY MENTIONS

Diagnostic Testing ‐ The number of Appeals regarding diagnostic testing doubled from 3Q20 to 4Q20, 9 cases to 17 respectively. The most commonly disputed benefit was a denied MRI. Medical records demonstrating medical necessity by meeting PHC Policies and/or InterQual® criteria was submitted through the Appeal process, resulting in approval on most Appeal cases.

Diabetic Supplies ‐ Members continued to report service issues with Solara Medical Supplies. There were notable delays, incorrect supplies, and/or damaged glucometer supplies shipped to members. Customer Service wait times were reportedly one‐hour long, Treatment Authorization Requests (TAR) were delayed, and Solara failed to ship products that were ready for shipment. The Provider Relations team is working with Solara to improve service.

In 4Q20, only Amrit did a great job 0.70 cases filed listening to me. Five per every 1,000 stars for her help! PHC members ‐Yelp Reviewer

50 of 229 2

KEY STATISTICS

CHARTS OF KEY REPORTING TRENDS

The following charts represent key data metrics used to track and trend Appeals, Grievances, Second Level Grievances, and State Hearings over time.

PHC provided coverage to 583,949 members in December 2020, the highest membership in PHC’s history

# Closed Cases by Quarter 1Q20 2Q20 3Q20 4Q20 1,203 885 1,021 1,065

51 of 229 3 DEMOGRAPHICS

CHARACTERISTICS OF FILING MEMBERS

The following charts represent key demographic data of members who filed an Appeal, Grievance, Second Level Grievance, or State Hearing during 4Q20.

4Q20 % CASES BY AGE The most common filing member was a white female between MBR Age % Cases 45‐65 years old who lives in Shasta County and speaks English Age 0‐17 11.42% Age 18‐45 29.96% Age 46‐65 47.89%

Age 66‐100 10.72% Grand Total 100.00% 4Q20 % CASES BY ETHNICITY

MBR Ethnicity % Cases White 65.47% Hispanic 13.62%

Other 11.25% African American 5.89% Alaskan Native or American Ind 2.28% Other Asian 0.44% Vietnamese 0.26% Asian Indian 0.18% Cambodian 0.18% Filipino 0.18% 4Q20 % CASES BY MBR COUNTY

Guamanian 0.09% MBR County % Cases Hawaiian 0.09% Shasta 17.66% Korean 0.09% Solano 17.40%

Grand Total 100.00% Sonoma 13.88% Humboldt 10.19% Marin 9.40%

Yolo 7.03%

4Q20 % CASES BY LANGUAGE Siskiyou 6.06% MBR Language % Cases Lake 4.66% English 92.71% Napa 4.39% Mendocino 3.87% Spanish 6.59% Del Norte 2.72% American Sign Language 0.18% Unknown 0.18% Lassen 1.41% Tagalog 0.18% Modoc 0.88% Vietnamese 0.18% Trinity 0.44%

Grand Total 100.00% Grand Total 100.00%

Shasta county members represented 10.8% of all PHC’s total membership, yet they filed the most cases

52 of 229 4 W&R RELATED

THE BENEFIT REVIEWED

Effective July 1, 2020, PHC offers a new Wellness & Recovery (W&R) benefit. It provides coverage for those who strive to be free of drug and/or alcohol addictions. Services include outpatient treatment, intensive outpatient treatment, residential treatment, withdrawal management, opioid treatment, medication assisted treatment, recovery services, and case management. Available on www.partnershiphp.org, the Drug Medi‐Cal Organized Delivery System Wellness and Recovery Handbook provides a detailed description of each benefit. The W&R benefit is available to PHC members and non‐PHC members who live in Humboldt, Lassen, Mendocino, Modoc, Shasta, Siskiyou, and Solano counties.

TRENDING STATISTICS & ISSUES

There were four (4) new W&R cases reported in 4Q20. This represents 0.4% of all 1,065 4Q20 W&R Case Inventory reported concerns. With only four cases filed, there were no trends identified. However, one # Total New Cases 4 case revealed a general opportunity to improve education regarding the availability of the # of Recei ved Gri eva nces 4 residential treatment benefit to those under 18 years old. The W&R Member Handbook states # of Received Appeals 0 30‐days of residential treatment is available to youths when medically necessary and prior # Total Closed Cases 5 authorization has been approved by PHC. Furthermore, members who are eligible for Early # of Grievance Resolutions 5 Periodic Screening, Diagnosis, and Treatment (EPSDT) screening may be eligible to waive the # of Appeal Resolutions 0 30‐day limit if medical necessity establishes a need for ongoing residential treatment. Investigations also identified a need to make it easier for members to locate 4Q20 DHCS Appeal Outcomes residential treatment facilities who can serve the youth population on PHC’s website. Appeal Resolution Outcomes Until such enhancements are implemented, PHC’s Care Coordination team can help # of Appeals Resolved in Favor of PHC 0 any member find a qualifying treatment facility and coordinate the necessary # of Appeals Resolved in Favor of Member 0 approvals. 4Q20 DHCS Grievance Categories DHCS REPORTING Access to Care 1 The Department of Health Care Services (DHCS) has unique requirements for Quality of Care 0 reporting W&R Cases. The three tables within this section reflect the counts Program Requirements 0 provided by PHC on behalf of participating W&R‐counties to DHCS, as mandated Failure to Respect Enrollee's Rights 0 quarterly. For 4Q20, there were four (4) cases received related to members’ Interpersonal Relationship Issues 3 experience with the W&R program, while five (5) cases were closed from the Other 0 previous quarter. Note that there were no Appeal cases or State Hearings filed.

53 of 229 5

CCS RELATED

THE BENEFIT REVIEWED

Since January 1, 2019, PHC has offered California Children Services (CSS) through PHC’s Whole Child Model (WCM). It provides coverage for children under 21 years old with certain diseases, physical limitations, or chronic health problems. This benefit offers improved coordination of care for CCS and non‐CCS services. Like all Medi‐Cal‐coverage, PHC does not determine a member’s eligibility for CCS services. Members must consult with their local county, who will notify PHC.

TRENDING STATISTICS & ISSUES

There were 27 total CCS‐related cases reported by members in 4Q20. This represents 2.5% of all 1,065 reported concerns. The most contested benefit was durable medical equipment (DME). There were no notable trends within the DME category. Members filed a variety of cases regarding wheelchairs, specialty beds, diabetic supplies, and other supply needs. The second most contested benefit was gas mileage reimbursement claims denied under the Non‐ Medical Transportation benefit. Members filed cases seeking reimbursement for claims filed beyond the 90‐day time filing limit or when they encountered problems with their driver’s credentials. 4Q20 % CCS Case Types LOST STATE HEARING Appeals Grievances State Hearings There was one State Hearing overturned by an Administrative Law State Hearings Judge (ALJ) from the Department of Social Services. The member was 7% diagnosed with cerebral palsy, was immobile, needed continuous head Appeals Grievances 37% elevation, and required a higher level of care to prevent stage 3‐4 56% pressure ulcers. Cared for by home health nurses, the parents requested a continuous lateral rotation hospital bed for the member. The ALJ approved coverage for a specialized rotation bed by Freedom Bed™, absent of PHC not offering an identifiable solution that meets the member’s holistic medical needs at a lower cost.

DISCRIMINATION & QUALITY HEALTHCARE

PHC monitors all reported cases to ensure all members have quality, equal and just access to healthcare services. We are pleased to report there were no discrimination cases filed by any CCS members during 4Q20. One member reported their provider was negligent in managing their health by refusing to perform testing, ultimately missing the diagnosis of nasopharyngeal cancer later identified during a hospitalization.

The case was referred to PHC’s Quality Improvement department for a comprehensive clinical review of the provider’s care.

54 of 229 6 DISCRIMINATION

IN RESPONSE TO A SOCIAL MOVEMENT

PHC stands strong against discrimination. It clouds our vision – to be the most highly regarded managed care plan in California. It interrupts our mission – to help our members, and the communities we serve, be healthy. It interferes with our responsibility. We are proudly responsible for the healthcare of every single member in our diverse population. We want to know that all members are treated equally and have the same opportunities to seek care. This is why we revisited our policies and procedures on how we handle discrimination.

On October 13, 2020, our Physician Advisory Committee (PAC) approved the newly revised PHC Policy CGA022, formally called the Member Discrimination Grievance Procedure. The policy ensures that all Members are aware of their discrimination rights, know how to report a violation to PHC, can identify discrimination categories protected by civil rights law, and understands the investigation process. We also made internal changes to improve the process and guard against discrimination.

DISCRIMINATION CATEGORIES

PHC recognizes federal and state civil rights laws. If federal civil rights laws do not provide protection against a reported incident, we will explore protection under California civil rights laws. The goal is to ensure all personal rights are invoked. Because we honor both federal and state laws, we recognize an expanded number of categories protected by all civil rights laws.

Age Gender Identity Nationality Limited English Proficiency Disability Gender Expression Race or Ethnicity Group or Character Associations Basis of Sex Sex Sterotypes Religion Auxiliary Aids Services Gender Sexual Orientation Language Assistance Services Genetic Information

Refer to PHC Policy CGA022 for a working definition of each category. The policy also explains how we guard against discrimination in the context of healthcare. For example, members cannot be denied any covered services or availability of a service due to any of the categories above.

4Q20 DISCRIMINATION TRENDS

There were 31 cases of alleged discrimination during 4Q20. Of the 31 cases, 23 of the reported incidents fell under one of the federal or state civil rights laws. The most common category of discrimination was race, followed by disability. Investigations found that that discrimination likely occurred in one (1) case. All cases were referred to the Office of Civil Rights for review and further investigation.

55 of 229 7 QUALITY ASSURANCE

3Q20 INTER‐RATER RELIABILITY RESULTS

The quarterly Inter‐Rater Reliability (IRR) audit provides physician oversight over clinical decisions made by PHC’s Grievance Registered Nurse team. A list of cases are forwarded to PHC’s Chief Medical Officer (CMO) that were not previously reviewed by a PHC Medical Director, of which a sample size is selected and evaluated.

The 4Q20 IRR results are still under evaluation; however, 3Q20 results are complete. A sample size of 30 cases was evaluated and all clinical assessments were deemed accurate. However, there were other areas for improvement. First, if the nature of the case includes attributes of discrimination protected by civil right laws even though a member may not use the term, it should be investigated as a discrimination case. Secondly, member allegations of discrimination that do not fall under any civil rights law should result in a non‐discriminatory DHCS case classification (e.g., Quality of Service). Thirdly, members should be informed on their rights to contact the DHCS Ombudsman Office when reporting health care concerns regarding Skilled Nursing Facilities. Lastly, deploy deeper investigations when the offending party is not providing an appropriate response or solution to the member‐reported issue(s). The cases were further reviewed for operational improvements: achieve greater efficiencies in processing cases, record correct provider information associated with cases, capturing all DHCS/NCQA reporting identifiers, and improve investigations of Second Level Grievances.

CASES PROCESSED TIMELY

DHCS requires PHC to investigate cases within specific investigation Turnaround Times (TAT), ranging from 72 hours to 44 days. If a member’s health, life, or limb is in immediate danger, the case must close within 72‐hours. If not, the case must be investigated within 30‐calendar days. A 14‐day extension is allowed if the additional time is believed to benefit the member. DHCS also requires PHC to acknowledge receipt of a member’s case by mail by the fifth day.

4Q20 Timeliness Performance For 4Q20, There were only two (2) late cases out of 839 cases Performance Performance Performance subject to DHCS‐TAT, resulting in stellar performance. Workflow Category Goal # Late Result Status improvements were implemented throughout 2020 to improve Investigations 98.00% 2 99.8% timeliness of acknowledgement letters (a.k.a., ack‐letters), Ack‐Letters 98.00% 0 100.0% resulting in zero (0) late letters by 4Q20.

56 of 229 8

MEMBER EXPERIENCE

NCQA SPOTLIGHT ‐ A SPECIAL EDITION

This NCQA Spotlight edition highlights member dissatisfaction reported over an annual period. More specifically, an analysis was conducted to reveal increases in dissatisfaction in 2020, compared to 2019. This edition of the PULSE Report includes Supplemental Reports that should be referenced when reading the NCQA Spotlight pages.

MEMBER SATISFACTION, NOT DISSATISFACTION

PHC monitors member dissatisfaction year‐round through Appeals, Grievances and Second Level Grievances. Statistical trends are analyzed and proactively managed in anticipation of member satisfaction survey results.

Every year, PHC surveys our members to assess their overall satisfaction with their PHC Medi‐Cal plan. General surveyed areas are:

 Getting care quickly  Getting needed care  Quality of provider’s communication  Customer service  Claim processing

NO THRESHOLD FINDINGS

Good news! An analysis of all cases found there was no significant increase in member dissatisfaction from 2019 to 2020 across the broad NCQA categories of access, attitude/service, billing/financial, quality of care, or quality of practitioner office. In fact, there was a reduction in the number of reported concerns in all categories. This is mostly attributed to the COVID‐19 pandemic, as fewer members sought healthcare services. Consequently, there was a 24% decrease in the total number of reported cases in 2020 compared to 2019. Refer to the Supplemental PULSE Reports titled NCQA ME.7 Member Experience Threshold Report for more information.

DRIVERS AND OPPORTUNITIES

Although there were no improvement opportunities identified in analyzing the broad NCQA‐categories, a deep dive of cases provided insightful improvement opportunities. This is important work as we can forecast member dissatisfaction that may be revealed in the upcoming Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

Members reported 370 concerns regarding the quality of communication with their providers. This represents 15.3% of the 2,414 Grievances in 2020. There was a wide variety of issues. Some members found their provider office unresponsive to their inquiries, condescending in their communication, not forthcoming about their treatment, or failed to listen to their concerns. Some members experienced problems with interrupters. Other members experienced a breakdown in communication between them and their provider, some requesting a change in their primary care provider.

The Provider‐Focus section highlights reported delays in receiving needed care and receiving it quickly, along with language barriers problems. Members filed cases requesting reimbursement after choosing to pay out‐of‐pocket for medications while the TAR process was underway. Members are typically discouraged from paying out‐of‐pocket, as such expense is not reimbursable if the TAR is denied.

57 of 229 9

THE UM EXPERIENCE

REPORTING PERIOD

This NCQA Spotlight highlights trends discovered from January 1, 2020 to December 31, 2020.

OVERVIEW

Members have the right to contest denied benefits when they are not happy with the decision. This is reason for an Appeal. An Appeal requires PHC to reconsider the original decision to approve a benefit in full or part.

However, sometimes members express dissatisfaction regarding the approval process itself. PHC’s authorization process is intended to work smoothly between the providers and PHC, keeping members out of the middle. It requires clinical information or discussions about a member’s health in order to assess medical necessity, secure necessary approvals, and coordinate care. This section reports our findings about members who encountered problems during the authorization or referral process.

DELAYED ACCESS TO SPECIALISTS

In 2020, there was an increase in member dissatisfaction regarding access to specialists through the Referral Authorization Form (RAF) process. There were 45 Grievances in 2020, resulting in 0.09 cases per 1,000 members. This is statistically significant compared to a lower trend in 2019 with only 14 Grievances reported, resulting in 0.03 cases per 1,000 members. Of the 45 cases, members alleged in 51% that their providers delayed the RAF process and in 16% the provider refused to submit a RAF request. Other reported reasons were that PHC either delayed or denied their RAF (4%) or expressed concerns over lack of specialty providers (8%). The increased trends can mostly be contributed to the COVID‐19 pandemic when access to elective services, frequently completed by specialist providers, was limited nationwide across our healthcare system.

DISSATISFACTION WITH TAR PROCESS # Reported Concerns With TAR Process There was a significant increase in member dissatisfaction in the TAR process from 2019 to 2020. In 2020, Medication 51 104 cases were reported compared to three (3) cases reported in 2019. This increased the number of filed DME 37 cases per 1,000 members from 0.01 to 0.21. Of the 104 cases, 49% were related to medications. Reasons of Ancillary 6 dissatisfaction varied widely. In many cases, members chose to pay out‐of‐pocket for these expenses. Diagnostic 4 Members reported problems with pharmacies being out of stock of their medications, lower quantities Surgery 3 disbursed, and lack of coordination with other medical coverage. Some members were upset that their medical records did not met medically necessary criteria in the Appeal process. Other members were upset Other 3 that their Medi‐Cal coverage did not cover non‐formulary medications or over‐the‐counter products such flax Total 104 seeds. Eligible expenses were reimbursed. When denied, members were educated on their State Hearing rights, as applicable. PHC will create new Reporting Interests (RI) categories to track and trend key concerns in the future.

Members also reported problems with a variety of durable medical equipment, representing 36% of their dissatisfaction. Of these 37 cases, 18 were related to CPAP supplies and wheelchairs. CPAP concerns generally reflect concerns over delayed supplies or receiving the CPAP machine. Members also reported problems 104 cases regarding wheelchairs. Members were unhappy that requests for power wheelchairs were denied, wanted represent .03% special wheelchair accessories, and reported broken wheelchairs. Members continued to report delays by of all cases filed Solara Medical Supplies for diabetic supplies. in 2020

The remaining 15% of Grievances regarding benefits, billing, or financial issues, were related to diagnostic testing, surgery, or ancillary services such as physical therapy, speech therapy, chiropractic, and/or acupuncture services. Members typically requested a quicker review process, wanted services longer than PHC would approve, or were dissatisfied with denied Appeals. Refer to the Supplemental PULSE Reports titled NCQA UM.18 Member Experie58 ofnce/UM Threshold Report for more information. 229 10

PROVIDER FOCUSED

REPORTING PERIOD

This NCQA Spotlight highlights trends discovered from January 1, 2020 through December 31, 2020.

APPOINTMENTS

PHC monitors member‐reported dissatisfaction regarding issues that prevent members from scheduling timely appointments with their providers. The PHC Medi‐Cal Handbook defines timely access to care as the following:

Urgent Care 48 hours Non‐urgent: w/PCP 10 Business Days Non‐urgent: w/Specialist 15 Business Days Non‐urgent: w/Mental Health 10 Business Days Non‐urgent: w/Ancillary Service 15 Business Days Telephone Wait Times 10 minutes

Investigations show that members are not typically aware of these standards. Members are educated about the appropriate timeframes during the Grievance process, as applicable. However, the health system faced unprecedented challenges during 2020 as the COVID‐19 pandemic took shape. Providers had to minimize elective treatment, postpone preventive services, function with smaller staff, and discover new capacities in managing COVID‐19 patients.

APPOINTMENT DELAYS WITH PROVIDERS # Reported Concerns Primary Care Providers – As the bandwidth of providers’ capacity was restricted during the pandemic, Appointment Barriers by County members reported 39 concerns against their primary care providers for untimely appointments in 2020. NR Shasta 10 Reported problems were long wait times, office hours, unable to connect with the provider via the NR Humboldt 6 telephone, and/or the provider refused to see the member. Of those cases, 26 originated from NR Del Norte 1 southern counties, with Marin County leading as the most impacted area. Members reported the SR Marin 12 majority of cases against Marin Community Clinics. SR Solano 9 SR Sonoma 4 Specialists – Access to specialists are approved by PHC through the RAF process. PHC monitors timely SR Napa 4 appointments with high‐volume or high‐impact specialty providers, which are defined as cardiologist, dermatologists, ophthalmologist, orthopedist, general surgeon, or OB/GYN. There were nine (9) cases SR Lake 1 filed against specialty providers, of which one (1) was a high‐volume specialist. Reported problems SR San Francisco 1 were appointment unavailability and unable to connect with the provider via the telephone. Total 48 # Reported Concerns MEETING CULTURAL & LINGUISTIC NEEDS CE&L Concerns by County NR Shasta 2 PHC monitors our provider network to ensure it meets the cultural, ethnic, racial, gender and linguistic SR Solano 6 needs of our diverse membership. Members reported 15 cases against medical groups, individual SR Sonoma 4 doctors, office staff, nurse practitioners, and/or physician assistants who did not meet these needs. Southern counties incurred the largest number of cases with 13 filed. The most commonly reported SR Marin 2 problem was alleged discrimination due to race and language barriers. Typically, language barriers SR Yolo 1 involve challenges with access to, quality with, or disagreement with the interpreter services. There Total 15 were three (3) cases by one member against Santa Rosa Health by who claimed discrimination because she was white. An inactive participant in the Grievance process, the member was unable to provide substantive details during the investigation to make positive improvements in the healthcare system. 59 of 229 11 1Q21 Grievance and Appeals PULSE Report: Supplemental Data NCQA ME.7: Member Experience Threshold Report Annual Report

Grievances Only Reporting Period: 2019 vs. 2020

Previous Period: 2019 Current Period: 2020 Avg PHC Grievances Avg PHC Grievances Threshold NCQA Category Grievances Mship p/1,000 Grievances Mship p/1,000 Threshold Met? Access 742 481,518 1.5 528 488,359 1.1 1.70 Yes Attitude/Service 1,461 481,518 3.0 1,400 488,359 2.9 3.34 Yes Billing/Financial 669 481,518 1.4 399 488,359 0.8 1.53 Yes Quality of Care 98 481,518 0.2 80 488,359 0.2 0.22 Yes Quality of Provider Office 13 481,518 0.0 7 488,359 0.0 0.03 Yes TOTAL 2,983 481,518 6.2 2,414 488,359 4.9 6.8 Yes

Appeals & Second Level Grievances Reporting Period: 2019 vs. 2020

Previous Period: 2019 Current Period: 2020 Appeals Appeals Appeals Avg PHC & SLGs Appeals Avg PHC & SLGs Threshold NCQA Category & SLG Mship p/1,000 & SLG Mship p/1,000 Threshold Met? Access 81 481,518 0.2 66 488,359 0.1 0.19 Yes Attitude/Service 30 481,518 0.1 20 488,359 0.0 0.07 Yes Billing/Financial 956 481,518 2.0 633 488,359 1.3 2.18 Yes Quality of Care 0 481,518 0.0 0 488,359 0.0 0.00 Yes Quality of Provider Office 0 481,518 0.0 0 488,359 0.0 0.00 Yes TOTAL 1,067 481,518 2.2 719 488,359 1.5 2.44 Yes

Purpose of report: Grievance & Appeals evaluates Member Experience year‐over‐year to assess member dissatisfaction. If the number of cases per 1,000 members in the current period increases by more than 10% from the previous period, then the Threshold is triggered. An unmet NCQA Threshold(s) identifies growing areas of member dissatisfaction and intervention(s) maybe required. This report is published bi‐ annually. The March report provides an annual depiction of the two years under evaluation. The September report provides a mid‐year update. All data is reported with a 95% confidence level.

Published March 202160 of 229 12 1Q21 Grievance and Appeals PULSE Report: Supplemental Data NCQA UM 1B: Member Experience‐UM Threshold Report Annual Report

Grievances Only Reporting Period: 2019 vs. 2020

Previous Period: 2019 Current Period: 2020 Avg PHC Grievances Avg PHC Grievances Threshold NCQA Category Grievances Mship p/1,000 Grievances Mship p/1,000 Threshold Met? Access 14 481,518 0.03 45 488,359 0.09 0.03 No Attitude/Service 539 481,518 1.12 107 488,359 0.22 1.23 Yes Billing/Financial 3 481,518 0.01 104 488,359 0.21 0.01 No Quality of Care 0 481,518 0 0 488,359 0 0 Yes QOPS 0 481,518 0 0 488,359 0 0 Yes TOTAL 556 481,518 1.16 256 488,359 0.52 1.27 Yes

Purpose of report: It reflects a subset of data from the ME.7 Member Experience Report. Data reflects member‐reported dissatisfaction related to experiences with the TAR and RAF process. If the number of cases per 1,000 members in the current period increases by more than 10% from the previous period, then the Threshold is triggered. An unmet NCQA Threshold(s) identifies growing areas of member dissatisfaction and an intervention(s) maybe required. This report is published bi‐annually. The March report provides an annual depiction of the two years under evaluation. The September report provides an mid‐year update. All data is reported with a 95% confidence level.

Published March 202161 of 229 13 PARTNERSHIP HEALTHPLAN OF CALIFORNIA

We are a non‐profit community based health care organization that contracts with the State to administer Medi‐Cal benefits through local care providers to ensure Medi‐Cal recipients have access to high‐quality comprehensive cost‐effective CONTACT US health care. PHC is available to Medi‐Cal‐ Partnership HealthPlan of California qualifying residences in Del Norte, Humboldt, Lake, Lassen, Marin, 4665 Business Center Drive Fairfield, CA 94534 Mendocino, Modoc, Napa, Shasta, Siskiyou, Solano, Sonoma, Trinity, and Yolo. 2525 Airpark Drive Redding, CA 96001

www.partnershiphp.org 62 of 229 14 4665 Business Center Drive Fairfield, California 94534

Annual Evaluation of the 2020 UM Program – NCQA UM Standard 1 Element B

Production Date: March 11, 2021

Related Reports:

1. Consistency in Applying Criteria – NCQA Utilization Management Standard 2 Element C 2. UM Timeliness Report – NCQA Utilization Management Standard 5 Element D

Executive Summary:

The Annual Utilization Management (UM) Program Evaluation analyzes all aspects of data related to the UM program, identifies gaps and opportunities for improvement, and updates the program as necessary to ensure the program remains current and appropriate. Key elements in this annual evaluation include program structure, program scope, processes, and information sources, as well as level of involvement of senior-level physicians and designated behavioral healthcare practitioners in the UM program. In addition, data for member and practitioner experience with the UM process is evaluated to identify improvement and actionable opportunities. This report does not contain Kaiser Permanente or Beacon Health Options data for evaluation of the UM program. Kaiser Permanente and Beacon Health Options are NCQA accredited, and as such, reports from Kaiser Permanente and Beacon Health Options will be reviewed through delegation oversight.

One opportunity identified for improvement was Pharmacy PAD Urgent Concurrent timeliness. Interventions for this opportunity were developed with set goals to evaluate the intervention’s effectiveness. Activities will be monitored and measured by a designated workgroup with a full analysis for effectiveness and sustainability to be included in the next annual UM Program Evaluation.

Methodology / Data:

As outlined below, Partnership HealthPlan of California (PHC) collects all aspects of data related to the UM program and evaluates key elements and performance indicators of the UM program against its established goals and thresholds. From this evaluation, PHC determines if any gaps exist in particular program activities or structure, identifies opportunities for improvement, prioritizes those opportunities, and takes actions that will improve the UM program in order to better serve our members. The evaluation was conducted as a collaboration between UM, Pharmacy, Provider Relations, Member Services, and Grievances and Appeals.

Program Structure  Physician to Nurse ratio  Physician to Pharmacist ratio  Physician to Licensed Practitioner of the Healing Arts (LPHA) ratio  Staff to Treatment Authorization Request (TAR) ratio

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Program scope, processes, and information sources used to determine benefit coverage and medical necessity  Monitoring and evaluation of services and updates to policies and procedures (P&P), as appropriate, but at least annually  Utilization Management activities to ensure appropriate care  TAR timeliness  Inter-Rater Reliability (IRR)  Electronic vs manual Referral Authorization Form (RAF)  Level of care

Level of involvement of senior level physician in the UM determination  Advisory committee structure and participation

Member and Practitioner experience with the UM program  Member Grievances and Appeals  Provider Satisfaction Survey

I. Program Evaluation

A. Program Structure

1. Staffing

Physician to Nurse, Physician to Pharmacist and Physician to LPHA ratios are measured annually to evaluate the level of involvement of senior level physicians in the UM program. PHC establishes a minimum threshold of Medical Directors to Nurses at 1:5, Medical Directors to Pharmacists at 1:5, and Medical Directors to LPHAs at 1:5. A ratio falling below PHC’s established threshold will require an evaluation of the current staffing structure and UM processes to determine if changes will be implemented.

Medical Director Staff Staff count Threshold Threshold Met to Staff Ratio Nurse 40 0.27 0.20 Yes Pharmacist 13 0.92 0.20 Yes LPHA 2 0.50 0.20 Yes Medical Director 12 - - -

Staff to TAR ratios are measured and monitored monthly to evaluate the level of staffing to ensure PHC has adequate and appropriate staffing to meet the daily workload demands and comply with standards and requirements set forth by PHC P&P. A ratio falling below PHC established threshold will require an evaluation of the current staffing structure and UM processes to determine if changes will be implemented.

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For calendar year (CY) 2020, the UM Department processed a total of 187,901 Treatment Authorization Requests (TARs) that included requests for outpatient settings, inpatient acute hospital settings, durable medical equipment, skilled nursing/long term care facilities, and residential treatment for substance use disorders (SUD). On a business daily average, PHC’s UM Department processed 745 TARs. Nurse full-time employees (FTEs) are defined by the total number of respective FTEs at the end of the month. TARs per staff ratios are expressed as the daily average of TARs per nurse FTE.

For CY 2020, PHC’s Pharmacy Department processed a combined total of 70,760 Treatment Authorization Requests (TARs) which included requests for Physician Administered Drugs and pharmacy-dispensed drug (Rx). On a business daily average, PHC’s Pharmacy Department processed 252 TARs. Technician and pharmacist full-time employees (FTEs) are defined by the total number of respective FTEs at the end of the month. TARs per staff ratios are expressed as the daily average of TARs per technician and pharmacist FTE.

The UM and Pharmacy departments monitor and evaluate TAR to FTE ratio to assess staffing adequacy. A 20% change in the month-over-month ratio is established as the UM and Pharmacy Departments’ threshold for further assessment of staffing model and to determine if an intervention is necessary. Calculation used is the month to month difference between TARs/staff/day divided by TARs/staff/day from the preceding month. Example below is Outpatient number for TARs/Nurse/day in June = 24 and July = 31. The month to month change is 7/24 = 0.29 or 29%.

Utilization Management: For 2020, the UM department noted a ratio variance of slightly greater than 20% for inpatient nurse TARs each month between August to November: 22% increase between August and September; 21% decrease between September and October; 21% increase between October and November. Some variance is expected and this was most likely due to a temporary seasonal variance and pandemic related admissions.

The UM department also noted a ratio variance of greater than 20% for outpatient nurse TARs between March to April (31% decrease) and June to July (26% increase). The March to April decrease was clearly attributed to a decrease in outpatient services secondary to the pandemic. Increased TAR volume from June to July is also attributed to COVID-19 due to a backlog of elective medical services that members were able to access by that time. When TAR volumes have increased, the UM intervention is to have nurses prioritize their TAR review workload and put special projects on hold. PHC also offers overtime to staff in order to maintain TAR timeliness when necessary. We will continue to monitor the TAR/staff ratio to determine if additional actions are needed as we return to pre-COVID conditions.

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Pharmacy: For 2020, change in month-over-month TAR to FTE ratio did not reach 20% for the pharmacy department. No further action or change to this aspect of the pharmacy program was deemed necessary.

Utilization Management: Inpatient TARs – All Regions

2020 JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NO V DEC Nurse FTE 18 18 18 21 21 21 21 21 21 15 15 15 (Inpatient) Total TARs 4,219 3,755 3,872 3,631 3,418 3,766 4,171 4,051 4,934 2,929 3,055 2,963

Working days 21 19 22 22 20 22 22 21 21 22 19 21

TARs per 11.16 10.98 9.78 7.86 8.14 8.15 9.03 9.19 11.19 8.88 10.72 9.41 nurse per day

Outpatient TARs – All Regions

2020 JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NO V DEC

Nurse FTE 20 20 20 19 19 19 19 19 19 19 19 19 (Outpatient) Total TARs 12,747 11,651 11,367 7,486 8,000 10,157 12,776 14,555 13,380 12,848 11,664 12,287

Working 21 19 22 22 20 22 22 21 21 22 19 21 days TARs per nurse per 30.35 30.66 25.83 17.91 21.05 24.30 30.56 36.48 33.53 30.74 32.31 30.79 day SNF/LTC TARs – All Regions

2020 JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NO V DEC

Nurse FTE 6 6 6 (SNF/LTC)

Total TARs 1187 1026 1311

Working SNF/LTC data included in Inpatient TARs January-September 22 19 21 days TARs per nurse per 8.99 9.00 10.40 day

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Wellness & Recovery TARs – All Regions

2020 JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NO V DEC

LPHA FTE 2 2 2 2 2 2 (SUD)

Total TARs 141 110 109 110 113 112

Working Program started July 1, 2020 22 21 21 22 18 19 days TARs per LPHA per 3.20 2.62 2.60 2.50 3.14 2.95 day

Pharmacy: Pharmacy Staffing – All Regions 2020 JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC Tech FTE 28 28 27 27 27 28 27 25 24 25 25 25

Total TARs 6659 6112 6662 6222 5923 6061 6066 5840 5681 5684 4850 5000

Working 21 19 22 22 20 22 22 21 21 22 19 21 days TARs per tech per 11 11 11 10 11 10 10 11 11 10 10 10 day

RPh FTE 11 11 12 12 12 12 12 12 12 12 12 12 TARs per RPh per 29 29 25 23 24 23 23 23 22 21 21 20 day

2. PHC Advisory Committee Structure and Program

Physician Advisory Committee (PAC) The Physician Advisory Committee (PAC) is responsible for oversight and monitoring of the quality and cost-effectiveness of medical care provided to PHC members. The PAC reviews the activities of the Quality/Utilization Advisory Committee (Q/UAC), Provider Advisory Group (PAG), Pharmacy and Therapeutics (P&T) Committee, the Quality Improvement Program (QIP) Advisory Group, the Pediatric Quality Committee (PQC), and the Credentials Committee. The PAC then makes recommendations and assists PHC in other ways as defined in PHC’s P&P. The PAC meets at least ten (10) times a year, and may not convene in the months of July or December, with the option to add additional meetings if needed. Only committee members who are not PHC staff may vote. The Chief Medical Officer (CMO) serves in a tie breaking capacity as necessary. A quorum is the number of members present as described in the PHC by-laws that represents 50 percent plus one (1) of the voting members. Committee attendees include practicing physicians from Kaiser Health Systems, NorthBay Healthcare, and other medical centers. PHC monitors and evaluates meeting the quorum to ensure the UM program and policies are reviewed and approved by this PHC advisory committee in compliance with PHC policies and procedures.

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2020 January February March April May June August September October November Total voting members in 8 9 11 10 13 12 13 13 13 11 attendance Total voting 15 15 15 14 15 15 15 16 16 15 members Q uorum No Yes Yes Yes Yes Yes Yes Yes Yes Yes

Notable findings: A total of 10 PAC meetings were held in 2020. Review of the committee’s activities confirms it executed the responsibilities of its functions. No further action or change to this aspect of the program was deemed necessary.

Quality/Utilization Advisory Committee (Q/UAC)

The Q/UAC is responsible for monitoring the quality of medical care and services provided to PHC members. The Q/UAC annually reviews, recommends, and approves the UM Program Description submitted by the UM section of the Health Services (HS) Department and provides recommendations to the PAC. The Q/UAC meets at least 10 times a year and may convene in the months of July or December if needed. The Q/UAC is chaired by the PHC Chief Medical Officer (CMO) and is comprised of formal voting representatives from community primary and specialty care practices, as well as consumer representative(s). The physician members represent licensed providers from hospitals, medical groups, and practice sites in geographic sections of PHC’s service area. The consumer representative(s) must be a consumer from one of the counties served by PHC. A quorum is greater than 50 percent of the voting members. Voting members with annual attendance of less than 50 percent are evaluated for termination from the Q/UAC. PHC monitors and evaluates meeting quorum to ensure the UM program and policies are reviewed and approved by this PHC advisory committee in compliance with PHC policies and procedures.

2020 January February March April May June July August September October November Total voting members in 8 10 9 10 10 11 8 10 8 12 11 attendance Total voting 13 14 13 13 13 13 16 18 19 19 20 members

Quorum Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Notable findings: A total of 11 Q/UAC meetings were held in 2020. Review of the committee’s activities confirms it executed the responsibilities of its functions. No further action or change to this aspect of the program was deemed necessary.

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Pharmacy & Therapeutics Committee (P&T)

The P&T Committee, as created under the authority of PHC’s Chief Executive Officer (CEO), makes recommendations to the PAC regarding the content of the PHC Medi-Cal Formulary which includes new drug evaluation, new technology related to pharmaceuticals therapeutic class reviews, development of Prior Authorization (PA) Criteria, Formulary Step requirements, Code 1 restrictions, and other matters regarding the PHC drug benefit. The P&T Committee meets four (4) times a year. A quorum, defined by one-third of the practicing members, must be present in order to conduct the P&T Committee meeting. A consensus recommendation is made on formulary additions, changes and deletions and drug/benefit policies. If no consensus is established, the issue is voted on with the decision determined by majority vote of the quorum.

2020 January April July O ctober

Total # of Practicing 2 4 5 3 Members in Attendance Total # of Practicing 12 10 11 11 Members Q uorum No Yes Yes Yes

Notable findings: A total of 4 P&T meetings were held in 2020. For the January 2020 P&T meeting, quorum was not met. The P&T final meeting packet was mailed to practicing members for approval of formulary changes and policy updates and final votes were ratified at April P&T for which quorum was met. No further action or change to this aspect of the program was deemed necessary.

B. Program Scope

1. Policy Review

The UM and Pharmacy Departments review each policy at least annually and are therefore compliant with PHC policy and regulatory requirements. No additional actions needed at this time.

For 2020, the UM Department had 78 policies. Of those 78 policies, 41 policies did not have substantive revisions and were approved as consent. 37 polices had substantive revisions that were reviewed and approved by the respective external advisory committee.

For 2020, the Pharmacy Department had 18 policies. Of those 18 policies, 9 policies did not have substantive revisions and were approved as consent. The remaining 9 polices had substantive revisions that were reviewed and approved by the respective external advisory committee.

2020 Policies Policies reviewed for consent Policy revisions approved

UM 78 41 37 Rx 18 9 9

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C. Program Process

1. UM and Pharmacy Timeliness

UM and Pharmacy monitored timeliness compliance on a quarterly basis to evaluate performance and identify opportunities for operation and reporting improvements. Opportunities identified include improvement in timeliness for the category of Routine Pre-service, Urgent Pre-service, and Urgent Concurrent reviews. Below are the 2020 results, interventions and ongoing activities by UM and Pharmacy to address identified gaps and opportunities.

 UM achieved 97.46% annual compliance toward NCQA determination timeliness standards and also 97.46% annual compliance toward notification timeliness standards.  Pharmacy achieved 99.71% annual compliance toward NCQA determination timeliness standards and also 99.71% annual compliance toward notification timeliness standards.

UM Intervention and Action Plan:  UM did not meet the 95% timeliness goal for Routine Pre-service requests in Q1 (92.87%) or for Urgent Pre-Service Requests in Quarter 1 (90.90%) as reported in the UM 5D report. This was due to a lack of staff awareness of specific NCQA timeliness standards which differed from their original training.  Action plan taken to improve UM timeliness for Routine Pre-service and Urgent Pre-Service requests included staff education on NCQA timeliness standards and weekly monitoring by UM Management who reviewed timeliness reports to evaluate performance.

Pharmacy Intervention and Action Plan:  Pharmacy did not meet the 95% timeliness goal for Urgent Concurrent requests in Q1 as reported in the UM5D report. This is largely due to timeliness for Physician Administered Drug (PAD) requests not meeting goal for this category (90.93% timeliness). PAD requests comprise 49% of all Urgent Concurrent requests.  Action plan taken to improve pharmacy timeliness for Urgent Concurrent PAD requests includes additional oversight and monitoring for timeliness of PAD TARs and monthly monitoring of PAD timeliness reports to identify trends and opportunities for improvement.

2020 Summary of Results: UM and Pharmacy did meet overall timeliness goals in 2020 and will continue to monitor performance and assess interventions to continually improve timeliness.

2. Consistency of Applying UM Criteria

The organization uses a methodology of 5% or 50 TARS, whichever is less, for each staff member to test inter-rater reliability (IRR). For 2020, 50 TARs per reviewer pursuant to PHC Policy MPUP3026 (including appeal cases where indicated on PHC’s P&P) were reviewed by each nurse

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coordinator, pharmacy technician lead, pharmacist, LPHA, and physician for IRR. An IRR concurrence rate of 93.97% was achieved for inpatient nurse coordinators, 95.99% for outpatient nurse coordinators, 97.49% for LTC nurse coordinator, 100% for LPHAs for Wellness and Recovery TARs, 99.82% for pharmacy technicians, 97.28% for pharmacists, and 98.20% for physicians. The organization has met the established goal of 90% concurrence rate for IRR.

2020 Results: PHC met the 90% concurrence score goal for all reviewer types.

3. Manual versus Electronic RAF (eRAF)

Electronic RAF (eRAF) submission is measured to evaluate efficiency of RAF submission. A higher percentage of electronic versus manual submissions indicates improved efficiency and provider adherence to electronic submission.

Manual vs Percent of total electronically Manual RAF Electronic RAF Goal Met Electronic RAF submitted RAF (Threshold = 90%)

2020 1002 161459 99.38 Yes

Notable findings: eRAF met the goal percentage for electronically submitted RAF. No change to this aspect of the program was necessary.

4. Appropriate Care: Monitoring for Over/Underutilization

2020 Summary of Over/Underutilization Workgroup Activities prepared February, 2021 Summarized by Robert Moore, MD, MPH, MBA, Chief Medical Officer

Overview:

PHC has systematic processes for monitoring for over-utilization and under-utilization of services (see policy MPUP 3006 and UM program description MPUD 3001 for details). Evaluation and analysis of the availability of primary care and specialty care providers and accessibility of primary care and specialty care services are evaluated as part of the network adequacy and availability section of the QI evaluation, following DHCS and NCQA standards. Over and under- utilization of specialty visits is addressed by the Specialty Workgroup and is summarized in the QI evaluation. The Over/Under Utilization Workgroup evaluates available data on PCP utilization to determine if any apparent under-utilization is associated with capitation of providers (versus due to data incompleteness).

The under-utilization of preventive care is initially identified in two ways: results of annual quality data reporting (HEDIS® measures and some others); and medical record reviews conducted

71 of 229 Page 9 of 19 4665 Business Center Drive Fairfield, California 94534 periodically at each PCP and prenatal care site. HEDIS® results are reviewed by the quality committees (Internal Quality Improvement Committee (IQI) and QUAC) and governance committees (PAC and the Board of Commissioners). The HEDIS® Measure Improvement Workgroup prioritizes interventions to improve HEDIS measures and monitors these interventions and the NCQA Steering Committee oversees these efforts. Preventive healthcare deficiencies identified through the site review process are addressed with corrective action plans, or other actions as detailed in the site review policy MPQP 1022. Additional analysis of selected preventive care measures that are under-utilized is also presented at each Over/Under Utilization Workgroup meeting.

Over-utilization of clinical activities/procedures may be prevented through the overall prior authorization process for pharmacy, inpatient hospital, long-term care, skilled nursing, durable medical equipment etc. The potential and propensity of health care providers to over-utilize a service is a factor for deciding which services/medications etc. are subject to prior authorization; cost is the other major factor that is considered. The policies and standards which define prior authorization criteria are designed to assure medically necessary use without overuse. Surveillance for over-utilization of medications/services/equipment that do not require prior authorization is conducted by the medical directors, nurses and pharmacists when reviewing clinical records for other purposes (in the UM/pharmacy prior review, peer review, HEDIS data abstraction, medical record review, fraud/waste/abuse reporting and grievance processes). Individual instances of over- utilization are noted and potentially addressed with the individual clinician (depending on the certainty of over-utilization by the reviewer and the implications of the over-utilization). If a systematic or more global over-utilization is suspected, the CMO or designee is consulted. Based on the review of the CMO or designee, data analysis related to the potential over-utilization will be conducted and the results presented at the Over/Under Utilization Workgroup. Actions based on the over-utilization depend on the circumstances but may include referral to PHC’s Fraud, Waste & Abuse (FWA) Subcommittee, Peer Review Subcommittee, Credentials Committee, and/or other quality committees.

Summary of Over/Under Utilization Workgroup Analyses for January 2020 through December 2020.

Analysis of PCP visits for under-utilization is conducted at each meeting. The average number of billed visits per capitated member per year is calculated for each PCP site.

Several sites in Solano County have low numbers of visits, due to a shortage of provider capacity. This area is addressed in the QI Program Evaluation, under the access and availability section. A brief summary: PCP access has been an issue in Solano County due to resignations of several PCP clinicians at Solano County Family Health Services and La Clinica. Most PCP services are provided by one County-run FQHC (Solano County Family Health Services with sites in Fairfield, Vallejo and Vacaville) and three community FQHCs: La Clinica with three sites in Vallejo, Ole Health with two sites in Fairfield, and Community Medical Centers with sites in Vacaville and Dixon. Ole Health’s assigned population has grown, but not enough to resolve the overall PCP shortage in the county. Kaiser’s enrollment in Solano County has grown, which is

72 of 229 Page 10 of 19 4665 Business Center Drive Fairfield, California 94534 also helpful. PHC has Joint Leadership engagement with Solano County, Ole Health and La Clinica to influence their leadership on access and quality issues.

Effects of COVID-19.

The COVID-19 Pandemic has had a significant effect on the supply and demand for PCP visits, with an enormous increase in virtual visits (largely telephonic), which varies by provider. This has led to a notable decrease in well child visits, vaccination visits, lead screening rates and most quality parameters. This global under-utilization due to COVID is mediated in a variety of ways: decreased staff, offices closed or with decreased availability of in-person visits. One notable exception: use of mental health services increased for PHC during the pandemic, reflective of national trends.

Preventive care metrics reviewed for under-utilization in this time period are:

 Tdap and Influenza Vaccination in pregnancy: Rates are far below ideal, although rising slowly. This measure was made part of the perinatal pay for performance pilot in 2018. Sites that participated in the perinatal QIP showed improvement, in an evaluation of the first 6 months of the pilot. As the perinatal QIP expands, this will continue to be a measure. This is also part of a new HEDIS® measure, expected to begin in 2022.  Childhood immunization as measured by the HEDIS® CIS-10 measure: Prior to reporting year 2020, we were accountable for the CIS-3 measure, which was also the focus of the PCP QIP for 2019, and many Plan-Do-Study-Act (PDSA) cycles, as well as a state-wide corrective action plan, which has since been resolved. With the change to CIS-10, overall rates dropped, as expected for this more difficult measure. The northern region scored below the 25th percentile and the southern region (significantly supported by Kaiser’s vaccination rates) scored between the 75th and 90th percentiles. The CIS-10 is now part of the PCP QIP, so additional attention to the 3 new vaccines may help this rate for measure year (MY) 2020. A new organization-wide focus on well-child visits may also help with this, complementing continuing activities focusing on childhood immunization.  Well child visits (ages 3-6): There was improvement between 2018 and 2019 in this measure of under-utilization, with only the Northwest region falling below the 50th percentile. Overall, well child visits dropped dramatically in the first wave of COVID in the southern region, with some partial recovery seen since then. Interventions: PHC has partnered both internally with interdepartmental team goals, as well as externally with our provider network, to increase well child visit rates. The Birthday Club pilot program was implemented to engage members and drive timely visits to their primary care provider (PCP). Through this pilot, PHC targets members eligible for the measure based on their birthday month. PHC sends a birthday card with a $25 gift card reward offered for completion of the exam within 60 days of the child’s birthday month. The pilot has been expanded in the past year.  Specialty Visits/Telemedicine/E-Consult. The annual Access and Availability Grand Analysis includes a more detailed analysis of specialty care trends. Through the end of 2019, there has

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been an average of 8% increase per year in specialist visits, for the past 5 years. A big contributor to this steady increase has been an increase in the use of telemedicine and E-consult services. Regional and county trends were reviewed, with the low rates in Yolo county attributable to data issues related to capitated medical groups. Interestingly, counties with more constrained primary care access but with larger hospitals/specialist populations have higher overall rates of specialty use, suggesting a relationship. A special focus on rheumatology and endocrinology has resulted in improvements compared to the “well- managed benchmark” in 2018, with a small decline in 2019. Main specialties with access/under-utilization, by this parameter are: rheumatology, dermatology, endocrinology, otolaryngology, and allergy/immunology.

Other evaluations for potential under-utilization included:

 Breast Cancer Screening. Based on MY 2019 HEDIS® results, there is under-utilization of Breast Cancer Screening, particularly in the northern regions, which are below the 50th percentile of health plans nationally. Performance improved across all regions each year from 2017 to 2018 to 2019. Unfortunately, due to COVID-19, we expect under-utilization to increase dramatically in 2020. Interventions: Working with providers on focused screening outreach and events, educational sessions for providers, focused grants, a well-woman birthday club pilot, an outbound call campaign, on hold messaging, appointment streamlining, and staff incentives.  Asthma prevalence and utilization: PCP visits for children with asthma were significantly lower for Black children compared to other ethnicities. Emergency Department (ED) use was highest in this group, suggesting a relationship between over-utilization of ED services with under-utilization of PCP visits.  Lead Testing was evaluated by county: Screening rates have increased each year through 2019, but considerable under-utilization in the northeastern counties is noted. Rates of screening dropped in 2020, due to COVID-19. Interventions: An increased focus on lead screening by DHCS has led to additional educational activities offered by PHC and increased monitoring/compliance activities through the site review process.  Perinatal data: C-section rates appear low, compared to state data; likely a data issue. Deliveries are steady at just over 5000 per year. Comprehensive Perinatal Services Program (CPSP) enrollment is lowest in Siskiyou, Del Norte and Modoc counties, at less than 5%. Siskiyou and Modoc have the lowest rate of post-partum visits recorded. The use of the Growing Together Program (GTP) program was above 50% in all counties.  OB and Newborn outcomes for PHC Hospitals: Data from CDPH, through Cal Hospital Compare. Over-utilization of C-section found in Fairchild Medical Center, Redwood Memorial Hospital, Queen of the Valley Hospital and NorthBay Medical Center. Episiotomy rates were high in the Northern Region, except at Mercy Redding and Mad River Hospital. Breastfeeding rates are low (under-utilization) in Mercy Redding, St. Joseph Eureka, Sutter Santa Rosa, and Sutter Lakeside. Interventions: These measures are part of the Hospital QIP, which aligns incentives. Unblinded comparative data was shared in several public forums.

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 Prop 56 Analysis: The Value-Based Purchasing Program portion of Proposition 56 pays supplemental payments for a variety of clinical measures. Some of these measures are closely linked to services provided, when linked to services routinely billed in claims; others require special codes to be billed. There are low rates in the latter category, likely due to the burden of setting up use of these codes.

Additional analysis of use of Adverse Childhood Experiences (ACEs) screening codes showed low utilization, likely due to the same administrative barrier to reporting screening.

Analyses for potential over-utilization that were presented at the Over/Under Utilization Workgroup include the following:

Areas of over-utilization with ongoing activities; no new activities planned:

 Readmission data is reviewed annually to look for trends. All-cause readmission is a PCP QIP measure and a hospital QIP measure, which has prompted our network to work together in a variety of ways to reduce readmissions. Rates vary from year to year at different hospitals. No new initiatives for addressing readmissions in the past year. Of note, a new risk adjusted readmission began in 2019. PHC’s region was below average, although a few hospitals had higher risk adjusted readmission rates, which impacted their hospital QIP payments.  Opioid use: This is the annual review of data on opioid use, which began with the initiation of the Managing Pain Safely initiative in January 2014. The major decreases in high dose prescription opioid use since the program inception are now apparently plateauing. There is no evidence of continued over-utilization in our network.  Plantar Fasciotomy: Two providers in Shasta County are performing many more of these procedures than anyone else. These procedures do not require a prior authorization. A number of different podiatrists are performing these, suggesting that there has become a local standard of care that is different in Redding than any other PHC area. A sample of charts were pulled and reviewed. No evidence of over-utilization was found.  Skin Grafting: We did find that the cost of different skin substitute products ranges from $2 to $175 per square cm; this information was passed onto the claims/finance team to see if action is needed on the higher cost products.

D. Information source used to determine benefit coverage and medical necessity

PHC uses the most currently available InterQual® Criteria sets as the primary review guidelines for UM medical necessity decisions. For calendar year 2020, UM used the 2019 InterQual decision criteria until the 2020 version became electronically available.

InterQual criteria and other approved UM criteria outside of InterQual, are reviewed, discussed, and evaluated at PHC’s QUAC and PAC as described in policy MCUP3139 Criteria and Guidelines for Utilization Management. Criteria utilized include, but are not limited to, Medi-Cal (State of California) guidelines, Medicare criteria, State policy letters, national treatment guidelines, and clinical practice

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recommendations from UpToDate®. UM criteria are also reviewed at the monthly internal CMO/MD meeting attended by the CMO and Medical Directors, leadership from UM, Care Coordination, Quality, Pharmacy, and Grievances & Appeals, as well as ad hoc specialists in the appropriate field of the policies being developed.

In addition, PHC’s medication decision criteria and pharmacological drug classes are reviewed in collaboration with external and internal providers on an on-going and annual basis. Criteria are selected, reviewed, updated or modified using feedback from the PHC staff, the P&T Committee, the PAC, the Consumer Advisory Committee (CAC), external providers, State policy letters, or medical literature among other sources.

Notable findings: UM and Pharmacy criteria are timely and comprehensively reviewed. No change to this aspect of the program was deemed necessary.

E. Involvement of Senior Level Physicians in the UM Process

PHC’s CMO and Medical Directors actively participate in the monthly review, discussion, and approval of policies and procedures in PHC’s IQI, P&T, and QUAC Committees. Policies approved in IQI, P&T, and QUAC are presented at PAC where attending network practitioners and PHC’s CMO and Medical Directors discuss and approve the presented policies. The CMO and Medical Directors also actively participate in clinical rounds and perform UM review and decisions to fulfill their assigned responsibilities for their scope of work. PHC delegates the behavioral health UM process to NCQA Accredited organizations. However, PHC has a designated Behavioral Health Clinical Director who actively participates in PHC’s UM Program. PHC’s committees also include network behavioral health practitioners who actively participate and contribute to PHC’s UM Program. Throughout the year, PHC’s UM Program demonstrated practitioners were actively involved in key aspects of the UM program, and therefore no further action is needed.

F. Assessing Experience with the UM Process

1. Improving Practitioner Experience with the UM process

PHC contracts with an external NCQA certified entity, Morpace, to administer the Provider Satisfaction Survey annually. All contracted Primary Care Provider (PCP) sites and Specialists were surveyed across PHC’s Northern and Southern Region network. Data was collected in April of 2020, based on a 12 month look-back period from the survey date. A total of 626 surveys were mailed out. Total response rate was 65%.

Please refer to Appendix I for Provider Satisfaction Survey Data.

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Summary of PCP Outcomes: a. Organization-wide, all questions met their respective 2020 goal for strongly agree or agree. No further interventions needed. b. One question did not meet its respective projected goal in 2019 for strongly agree or agree, however has met its respective goal in 2020, which was “I think the process for obtaining non- formulary prescriptions for my patients is reasonable.” 1) The question increased in performance by 5% year over year (YOY) 2019-2020 from 76% to 81%.

Summary of Specialist Outcomes: Organization-wide, all questions met their respective 2020 goal for strongly agree or agree. No further interventions needed.

Interventions:

In 2019, the pharmacy department created a one-page user guide for the PHC Pharmacy Formulary Navigator Search Tool as a provider education piece. This intervention was created to address the question that did not meet goal among PCPs, which was “I think the process for obtaining non- formulary prescriptions for my patients is reasonable.” The search tool web traffic was monitored as a way to measure effectiveness / determine if there was an impact. Analytics showed an overall increase in web traffic from 40,696 for the month of October 2019 (prior to the intervention) to 41,139 for the month of February 2020 (after intervention). Other factors may have also contributed to the increase in web traffic (business may be busier in February, increase in TAR workload, etc.). The intervention may have proved to be effective based on the results from the 2020 Provider Satisfaction Survey, as the question “I think the process for obtaining non- formulary prescriptions for my patients is reasonable” overall increased in score from 76% in 2019 to 81% in 2020, meeting its projected goal of 80%.

Conclusion:

The results from the 2020 Morpace Provider Satisfaction Survey showed overall improvements in provider satisfaction with PHC’s UM process. All questions related to UM and Pharmacy met their respective 2020 goals for strongly agree or agree among PCPs and specialists. No further interventions needed. UM and Pharmacy departments will continue to monitor survey results annually and provide interventions as needed.

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2. Improving Member Experience with the UM process

This report contains an analysis of member-reported Grievance concerns about any dissatisfactory experience related to Utilization Management (UM). The need for intervention is determined by a 10% increase in Grievance per 1000 rate for each NCQA category relating to UM from the Previous Period (CY 2019) to Current Period (CY 2020). A 10% increase for each NCQA category becomes the threshold point for intervention.

2020 Results:

Notable Findings: NCQA categories Access and Billing/Financial did not meet the Threshold requirement.

Discussion: Grievances per 1000 members in the Access category (Access to Specialists) increased from 0.03 to 0.09. Of the 45 cases reported for dissatisfaction regarding access to specialists in 2020, 51% alleged their Providers delayed the RAF process as their complaint and 16% indicated provider refusal to submit a RAF request as the reason for their dissatisfaction. Among other reported reasons, 4% felt that PHC delayed or denied their RAF, and 8% cited concern over lack of specialty providers. From our analysis, the increased rate of grievances for Access is likely attributed to the COVID-19 pandemic and its impact on limiting access to elective services and specialist providers. To address the Access category, UM will continue to monitor referral volume, determination rates and processing timeframes and will also evaluate ongoing grievance trends to determine if the anticipated decline in COVID-19 cases will reduce Access related grievances, or if further intervention will be required.

Grievances per 1000 members in the Billing/Financial category (Dissatisfaction with TAR Process) increased from 0.01 to 0.21. As noted in the table above, there were 104 Billing/Financial grievances in 2020 versus 3 reported in 2019. For the 104 grievances in 2020, 49% pertained to medications and pharmacy issues with a wide variety of complaints including pharmacies being out of stock of medications, lack of coordination with other medical coverage, and denial of TARs and Appeals for not meeting medical justification. Another 36% of the Billing/Financial grievances related to the TAR process for Durable Medical Equipment (DME),

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with almost half of those DME complaints relating to CPAP supplies and wheelchairs. CPAP concerns were mainly over delayed supplies or receiving the CPAP machine. For wheelchairs, members were unhappy that requests for power wheelchairs or special wheelchair accessories were denied, or they reported broken wheelchairs. Also in the DME category, members reported delays in receiving diabetic supplies. The remaining 15% of Billing/Financial grievances were related to diagnostic testing, surgery, or ancillary services such as physical therapy, speech therapy, chiropractic, and acupuncture services. Members typically wanted a quicker authorization review process, a duration of services longer than PHC would approve, or they were dissatisfied with denied appeals.

While no singular reason has been identified for the increase in member dissatisfaction in the TAR process from 2019 to 2020, the UM and Pharmacy departments will monitor and address this concern in a variety of ways. To address grievances related to medication and pharmacy issues, the PHC Pharmacy department will monitor and review their denial notification process for coordination of benefits to determine if change is needed to improve network pharmacy awareness and knowledge for processing these claims. In addition, the PHC Pharmacy department will monitor and review IRR results to evaluate if TAR reviews and application of coverage criteria and policies are consistent.

To address grievances related to DME, surgical, diagnostic, and ancillary services, the UM department will monitor and review IRR to ensure consistency in the application of established criteria as well as accurate execution of all review processes. For delays in members receiving diabetic supplies, PHC has identified an issue with one vendor that has been brought to their attention, and the vendor is now being consistently monitored for improvement. For all UM issues, the UM department will continue to monitor quarterly Grievance & Appeals reports to evaluate grievance trends and identify any potential gaps in data methodology or integrity.

Conclusion:

The UM Program Evaluation report assesses the program’s effectiveness, capacity, and integrity in managing the utilization of healthcare resources delivered to our members and ensures our members receive the appropriate quality and quantity of care at the appropriate time and setting. In addition, the evaluation report identifies gaps and improvement opportunities for which interventions are developed and measured for effectiveness and sustainability.

In this evaluation, the results demonstrated strengths in the areas of TAR timeliness, consistency in applying criteria, efficient submission process of eRAFs, comprehensive review of information sources, and others. The analysis also identified an improvement opportunity in the area of Pharmacy PAD review for Urgent Concurrent requests. Based on the results from the 2020 UM program evaluation, PHC concludes there are no significant changes required for the 2021 UM program. PHC’s UM program functions effectively and efficiently through a solid program structure, comprehensive set of policies, and robust support, guidance, and engagement from senior level physicians and advisory committee members. Activities addressing the improvement opportunities will continue to be monitored, measured, and reported in future evaluations.

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APPENDIX I: Improving Provider Experience with the UM process

Trended PCP Regional and Plan-wide Performance on the Provider Satisfaction Survey

Key:  ≥5% Improvement relative to prior year  ≥5% Decline relative to prior year

2019 Total 2020 Total % Difference PCP Utilization Management North South North South 2020 (% Strongly Agree or 2020 (# of (# of Total (# of (# of Total North South Total Performance Goal Agree) respondents) respondents) respondents) respondents) Goal Met

I am satisfied with my interactions with Utilization Management Staff (RAFs, 100% (32) 96% (141) 98% 96% (48) 100% (130) 99% -4% 4% 1% 90% Yes TARs, Case Management Programs) (Medical Review Process)

I am satisfied with the PHC e-RAF system. (Medical 86% (35) 97% (145) 95% 96% (51) 98% (132) 97% 10% 1% 2% 90% Yes Review Process)

I think the process for obtaining non-formulary prescriptions for my 79% (33) 75% (127) 76% 85% (46) 79% (122) 81% 6% 4% 5% 80% Yes patients is reasonable. (Pharmacy Review Process) The PHC Pharmacy’s Formulary Search Tool is 96% (27) 93% (101) 94% 98% (40) 93% (103) 94% 2% - 0% 90% Yes easy to use and navigate I am satisfied with my interaction with PHC 84% (32) 97% (113) 94% 100% (42) 100% (105) 100% 16% 3% 6% 90% Yes Pharmacy Staff. (Pharmacy Review Process) When a Pharmacy TAR is denied by the Plan, the basis for denial is clearly 59% (34) 94% (125) 87% 85% (47) 85% (117) 85% 26% -9% -2% 85% Yes specified. (Pharmacy Review Process) PHC’s Formulary allows me to prescribe medications needed to effectively 76% (33) 81% (126) 80% 89% (45) 88% (122) 88% 13% 7% 8% 80% Yes manage my patients’ health and well-being

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Trended Specialist Regional and Plan-wide Performance on the Provider Satisfaction Survey Key: ≥5% Improvement relative to prior year ≥5% Decline relative to prior year

2019 Total 2020 Total % Difference Specialist Utilization Management North South North South 2020 (% Strongly Agree or Total Total 2020 (# of (# of (# of (# of North South Total Performance Agree) Rate Rate Goal respondents) respondents) respondents) respondents) Goal Met I know how to determine whether or not a service requires that TAR 91% (35) 99% (138) 97% 96% (50) 96% (157) 96% 5% -3% -1% 90% Yes (Authorization) be submitted to PHC. My TARs are approved in a 100% (28) 92% (138) 93% 94% (48) 95% (146) 95% -6% 3% 2% 90% Yes timely manner. When a TAR for medical service is denied by the 100% (29) 92% (133) 93% 96% (49) 95% (147) 95% -4% 3% 2% 90% Yes plan, the basis for denial is clearly specified. When one of my TARs is returned/deferred for more information, I know what 100% (29) 89% (130) 91% 94% (49) 96% (148) 96% -4% 7% 5% 90% Yes additional documentation I need to submit. I am satisfied with my interactions with Utilization Management Staff (RAFs, 100% (25) 100% (128) 100% 96% (48) 99% (153) 98% -4% -1% -2% 90% Yes TARs, Case Management Programs) I am satisfied with the PHC 100% (31) 96% (111) 97% 95% (42) 96% (146) 96% -5% 0% -1% 90% Yes e-RAF system I am satisfied with the PHC 100% (29) 97% (126) 98% 93% (43) 97% (145) 96% -7% 0% -2% 90% Yes e-TAR system (UM) I think the process for obtaining non-formulary 84% (19) 93% (98) 92% 81% (32) 88% (120) 87% -3% -5% -5% 80% Yes prescriptions for my patients is reasonable. The PHC Pharmacy’s Formulary Search Tool is 95% (20) 97% (91) 97% 90% (30) 95% (107) 94% -5% -2% -3% 90% Yes easy to use and navigate. When a Pharmacy TAR is denied by the Plan, the 100% (26) 95% (100) 96% 97% (34) 93% (115) 94% -3% -2% -2% 85% Yes basis for denial is clearly specified. I am satisfied with my interaction with Pharmacy 100% (23) 98% (91) 98% 89% (28) 98% (109) 96% -11% 0% -2% 90% Yes Staff. PHC’s Formulary allows me to prescribe medications needed to effectively 76% (17) 90% (96) 88% 90% (30) 91% (116) 91% 14% 1% 3% 85% Yes manage my patients’ health and well-being.

81 of 229 Page 19 of 19 March 2021 Q/UAC Pharmacy Operations Update

• Key indicators and PMPM trends

• 2020 TAR Summary

• Site of Care

• 2021 Pharmacy activities

82 of 229 Report Period: 01/01/2020 to 12/31/2020 Key Indicators and Trends Comparison Period: 01/01/2019 to 12/31/2019

Paid PMPM Trend 5.54% p Utilization Trend 0.49% p Unit Price Trend 9.89% p Total Cost vs AWP Trend -0.45%q Plan Paid PMPM $46.92 (Days Supply PMPM) Plan Paid per Rx $84.31 detail detail Generic % Rx, 88.89% Generic % Plan Paid, 28.08% % Utilizers, 19.93% Top Therapeutic Classes by Plan Paid PMPM Specialty % Rx, 0.81% Specialty % Plan Paid, 45.42% 14%

50% 50% 40% 60% 40% 60%

30% 70% 30% 70% 40% 13%

20% 80% 20% 80%

10% 90% 10% 90% 11% 0% 100% 0% 100%

3% 9% Comparison Reporting 4% 5%

% Generic % Generic % Plan Specialty % Specialty % Plan DIABETES INFLAMMATORY DISEASE ASTHMA AND COPD Period Utilizers Rx Paid Rx Paid NEOPLASTIC DISEASE CARDIOVASCULAR DISEASE - H... INFECTIOUS DISEASE - VIRAL Comparison 21.14% 88.67% 27.75% 0.73% 43.41% HEMATOLOGICAL DISORDERS ALL OTHERS Reporting 19.93% 88.89% 28.08% 0.81% 45.42% 30% 25.8% detail Member Plan 20%

12.2% 11.4% 10.9% 10% Non-Drug 7.1% 3.7% 3.7%

0% MS Brand

-10%

Generic -20%

-30% SS Brand -33.6% -40% 0% 20% 40% 60% 80% 100%

Paid per Rx % Change PMPM

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Copyright © 2015-2021 MedImpact Healthcare Systems, Inc. All rights reserved. Report Period: 01/01/2020 to 12/31/2020 Back to dashboard Comparison Period: 01/01/2019 to 12/31/2019

Key Indicators Comparison Period Reporting Period % Change Summary Paid PMPM $44.46 $46.92 5.5% $45.70 Eligible Member Months 6,649,295 6,758,265 1.6% 13,407,560 Paid Amount $295,603,567 $317,080,037 7.3% $612,683,604 Total Cost $295,600,258 $317,137,757 7.3% $612,738,015 AWP Cost $685,600,329 $738,842,031 7.8% $1,424,442,360 Ingredient Cost per Unit $0.65 $0.71 9.9% $0.68 Utilization (DS PMPM) 19.46 19.55 0.5% 19.50 % Utilizers 21.1% 19.9% -5.7% 20.5% # of Rx's 3,922,795 3,760,851 -4.1% 7,683,646 Generic % Rx 88.7% 88.9% 0.2% 88.8% Generic % Plan Paid 27.7% 28.1% 1.2% 27.9% Generic PMPM $12.34 $13.17 6.8% $12.76 Specialty % Rx 0.7% 0.8% 0.0% 0.8% Specialty % Plan Paid 43.4% 45.4% 4.6% 44.5% Specialty PMPM $19.30 $21.31 10.4% $20.31

Cost Share Drug Product Type Plan Paid per Rx Total Cost per Rx Member Paid per Rx SS Brand $831.93 $832.16 $0.24 MS Brand $193.65 $193.69 $0.04 Non-Drug $74.97 $74.94 $0.00 Generic $26.63 $26.63 $0.00 Summary $84.31 $84.33 $0.02

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Copyright © 2015-2021 MedImpact Healthcare Systems, Inc. All rights reserved. PMPM Trend Analysis by Adjudicated Date

2020 2019 Difference

Month Monthly PMPM YTD PMPM Monthly PMPM YTD PMPM YTD PMPM YTD PMPM %

January $47.74 $47.74 $47.66 $47.66 $0.08 0.2%

February $44.02 $45.88 $44.05 $45.86 $0.02 0.1%

March $49.98 $47.25 $45.48 $45.73 $1.51 3.3%

April $48.98 $47.68 $46.24 $45.86 $1.82 4.0%

May $44.62 $47.06 $46.28 $45.94 $1.12 2.4%

June $47.18 $47.08 $41.44 $45.20 $1.88 4.2%

July $47.51 $47.14 $44.29 $45.07 $2.07 4.6%

August $45.36 $46.91 $45.22 $45.09 $1.82 4.0%

September $45.79 $46.78 $41.47 $44.69 $2.09 4.7%

October $47.68 $46.88 $44.84 $44.70 $2.17 4.9%

November $45.42 $46.74 $41.78 $44.44 $2.29 5.2%

December $48.81 $46.92 $44.62 $44.46 $2.46 5.5%

PMPM Trend Analysis $80.00

$40.00

$0.00

July January March April May June August February SeptemberOctoberNovember December Reporting Year Comparison Year

Copyright © 2012-2021 MedImpact Healthcare Systems, Inc. All rights reserved. This document is confidential and proprietary to MedImpact and contains material MedImpact may consider Trade Secrets. This document is intended for specified use by Business Partners of MedImpact under permission by MedImpact and may not otherwise be used, reproduced, transmitted, published, or disclosed to others without prior written authorization. MedImpact maintains the sole and exclusive ownership, right, title, and interest in and to this document.

Mar 3, 2021 1 of 1 85 of 229 Partnership HealthPlan of California PHARMACY TARs - Approved / Denied - Count By Month

Last Processed Date Between: 01/01/2020 thru 12/31/2020 As of Report Run Date: 3/3/21

Approved D2 Denied

TAR Approved Tar Log Last Denial Stands Denial stands Overturned TAR Approved w/ TAR Denied Date on 2nd Appeal on 1st appeal Modifications

Jan 2 418 1 1 230

Feb 419 1 2 235

Mar 1 432 1 206

Apr 1 474 1 1 219

May 435 231

Jun 442 199 2020 Jul 1 482 217

Aug 474 1 246

Sep 1 509 1 223

Oct 454 2 216

Nov 3 381 1 189

Dec 2 452 1 226

Total == >> 11 5,372 4 1 9 2,637

Total 11 5,372 4 1 9 2,637

032 - Pharmacy TARs - Amisys Data - Approved and Denied Created by ECarri Page: 1/2

86 of 229 Site of Care

32 members consented to transition from HOPD to home infusion

Members transitioned to home infusion.

Medical Annual Medical claim Drug MedImpact Annual Cost Claim $$ Remicade $4,633.00 $41,697.00 $1,259.00 $11,331.00 Gamunex $7,271.00 $87,252.00 $3,258.00 $29,322.00 Inflectra $4,693.00 $32,851.00 $1,594.00 $14,346.00 Gamuenx $3,872.00 $46,464.00 $1,467.00 $13,203.00 Entyvio $6,940.00 $48,580.00 $3,896.00 $35,064.00 Entyvio $6,940.00 $48,580.00 $3,774.00 $33,966.00 Remicade $4,633.00 $60,229.00 $2,052.00 $18,468.00 Total $38,982.00 $365,653.00 $17,300.00 $155,700.00

Referral pending MD order

7 Ocrevus Avg $$/Rx=$23,070

3 Entyvio Avg $$/Rx=$6,940

3 Remicade Avg $$/Rx = $4,633

87 of 229 2021 Pharmacy activities and initiatives

1. Programs and Systems a. M2 to Essette b. PAD formulary search tool c. Medi-Cal Rx

2. Medication-related HEDIS® performance

Respiratory conditions Cardiovascular conditions Diabetes Behavioral Health Opioid overuse/appropriteness AMR Asthma Medication Ratio CBP Controlling High Blood Pressure CDC Comprehensive Diabetes ADD Follow-Up Care for Children Prescribed Care—HbA1c Control (<8%) ADHD Medication—Continuation & Use of Opioids at High HDO Maintenance Phase Dosage

PCE Pharmacotherapy Management of COPD PBH Persistence of Beta-Blocker Treatment After a Heart Comprehensive Diabetes APM Metabolic Monitoring for Children and Use of Opioids from Exacerbation—Systemic Corticosteroid Attack Care—Blood Pressure Control Adolescents on Antipsychotics—Total Multiple (<140/90) UOP Providers—Multiple Prescribers and Multiple Pharmacies Pharmacotherapy Management of COPD SPC Statin Therapy for Patients With Cardiovascular Comprehensive Diabetes AMM Antidepressant Medication Exacerbation—Bronchodilator Disease—Received Statin Therapy--Total Care—Eye Exams Management—Continuation Phase Risk of Continued Opioid COU Statin Therapy for Patients With Cardiovascular KED Kidney Health Evaluation for POD Pharmacotherapy for Opioid Use Use Disease—Statin Adherence 80%--Total Patients With Diabetes Disorder SPD Statin Therapy for Patients With SSD Diabetes Screening for People With Diabetes—Received Statin Schizophrenia or Bipolar Disorder Who Therapy Are Using Antipsychotic Medications

Statin Therapy for Patients With SMD Diabetes Monitoring for People With Diabetes—Statin Adherence 80% Diabetes and Schizophrenia

SMC Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia SAA Adherence to Antipsychotic Medications for Individuals With Schizophrenia

NCQA: 19 HEDIS measures; 24 rates

DHCS/MCAS: CBP, AMM (acute/cont.), AMR, COB, SSD, ADD (init, C&M), APM, OHD* (not NCQA)

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3. Post-ED/Hospitalization event intervention using EDIE notification

a. Opioid overdose events 1. Review CURES 2. PCP Notification

b. Asthma, COPD 1. AMR, PCE HEDIS performance 2. Potential Preventable Admissions-AHRQ Prevention Quality Indicators (Admissions with a principal diagnosis of COPD or asthma per 100,000 population, ages 40 years and older. Excludes obstetric admissions and transfer from other institutions.

89 of 229 Partnership HealthPlan of California Executive Summary – QI Work plan Mid-Year Report Reporting Period – 7/1/2020 – 12/31/2020

Background: The QI Work Plan is designed to track progress on key QI activities and initiatives throughout the year. Approved by the Partnership HealthPlan of California quality committees and Board of Commissioners, it includes progress updates on planned activities and objectives for improving quality of clinical care, safety of clinical care, quality of service and members’ experience. The work plan is set on a fiscal year schedule. This update includes progress on activities from 7/1/2020 – 12/31/2020.

Results: Of the 118 deliverables outlined in the work plan, 36 are “Complete”, 78 are “On Track”, 3 are “Delayed”, and 1 has been “Terminated”.

Table 1 Goal Status 7/1/2020 – 12/31/2020 Status n % Complete 36 31% On Track 78 66% Delayed 3 3% Terminated 1 1%

2020-21 QI WORK PLAN STATUS UPDATE 7/1/2020 - 12/31/2020

Complete On Track Delayed Terminated

3%1%

31%

66%

90 of 229 Partnership HealthPlan of California Executive Summary – QI Work plan Mid-Year Report Reporting Period – 7/1/2020 – 12/31/2020

QI Major Milestones and Activities:

 The Quality Measure Score Improvement team goal group continued to make inroads during the first half of the 2020-2021 fiscal year. This includes the ongoing work to improve multi-year measure performance, sustain and expand initiatives related to asthma medication practices and work to encourage more members to have their infants and toddlers complete well-baby visits inclusive of immunizations.  The 2020/ 2021 fiscal year QI Work Plan, QI Program Description and QI Evaluation were approved by the PHC Board of Commissioners in October 2020.  The Patient Safety Facility Site Review team created virtual site review processes and protocols that were recognized by DHCS as a best practices.  PHC completed the submission of documents for the NCQA First Survey Accreditation in November 2020.  The Patient Safety Potential Quality Issues (PQI) team enhanced processes for PQI Rounds and Peer Review and partnered with the Wellness and Recovery team to develop PQI processes related to behavioral health care and services.  Member Services, Grievance and Appeals, Pharmacy, QI and Provider Relations and Care Coordination teams completed work and reports related to NCQA Grand Analysis reporting.  In the absence of DHCS calculated plan wide performance formal reporting, the HEDIS® team leadership and QI analysts generated these reports and ranking table for HEDIS MY 2019.  The cross regional Performance Improvement and Quality Incentive Program teams spearheaded best practice meetings to create opportunities for providers to learn from one another in support of improved QIP performance.  The Performance Improvement team successfully moved the ABCs of QI into virtual format. Initial sessions were offered in the fall 2020 and will be offered again in June 2021.  HEDIS 2020 results were shared with quality committees and the Board of Commissioners.  The Partnership Quality Dashboard baseline program evaluation was completed.  The Perinatal QIP program moved from being a pilot program to a permanent, institutionalized QIP offering.  Well-Child Birthday Club programs for children ages 3-6 years of age were piloted in the Southern Region. The Northern Region Birthday club program was expanded to more sites.  QI continued to partner with IT in the development of the Clinical Data Repository.

91 of 229 Partnership HealthPlan of California Executive Summary – QI Work plan Mid-Year Report Reporting Period – 7/1/2020 – 12/31/2020

Current Deliverable Status

Goal Status - Delayed

Current items with a goal progress status of delayed include work to assess provider satisfaction and process improvements to protocols for the QIP program and internal, LMS based training for HEDIS®.

Project or Program Deliverable Status Details Next Steps

2d - PCP QIP Complete MY2020 Three-part Provider Survey Requests for feedback to Provider Experience provider level survey request to begin end of the provider network in Data to assess satisfaction January 2021, following a February and March 2021. with the QIP 2021 PCP QIP Kick-off webinar, email request to provider network in February 2021 and final request in March 2021 following the eReports kick- off webinar. 3a - Primary Care MY 2020: Program Shifting and competing The formalized program Provider Quality protocol review, priorities have pushed the protocol review will begin Improvement update and add new start of this goal into in the 2nd quarter of Program (PCP QIP) process beginning of 2nd quarter of calendar year 2021. improvements and 2021. lessons learned. 8c - Cross Finalize content for This deliverable is delayed Content development will Departmental HEDIS 101 LMS due to competing priorities continue during 2021 HEDIS Education training: and staffing  Collaborate with changes/challenges on the other QI teams to HEDIS team. finalize content Content development is in for the LMS progress. training  Provide T&D with training material and resources/tools  Record LMS training

92 of 229 Partnership HealthPlan of California Executive Summary – QI Work plan Mid-Year Report Reporting Period – 7/1/2020 – 12/31/2020

Goal Status - Terminated

There is one deliverable that was terminated related to the development of internal performance metrics for the QIP team. The team determined such a metric was not necessary as there are other means of ensuring the team is effective in the administration of the PCP QIP program.

Project or Program Deliverable Status Details Next Steps

3a - Primary Care Develop department Goal developed during a N/A - Deliverable Provider Quality PCP Program time of managerial terminated Improvement Performance Metrics transition. Goal does not Program (PCP QIP) and how to measure meet the needs of the team program/team and is not something we are performance looking to implement.

93 of 229

PARTNERSHIP HEALTHPLAN OF CALIFORNIA GUIDELINE/ PROCEDURE

Guideline/Procedure Number: MPXG5001 (previously XG100501) Lead Department: Health Services Guideline/Procedure Title: Clinical Practice Guidelines for the ☒External Policy Diagnosis & Management of Asthma ☐ Internal Policy Next Review Date: 02/09/202204/13/2022 Original Date: 04/19/2000 Last Review Date: 02/10/202104/14/2021 Applies to: ☒ Medi-Cal ☐ Employees Reviewing ☒ IQI ☐ P & T ☒ QUAC Entities: ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving ☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC Entities: ☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 02/10/202104/14/2021

I. RELATED POLICIES: MPUG3031 - Nebulizer Guidelines

II. IMPACTED DEPTS: Health Services

III. DEFINITIONS: N/A

IV. ATTACHMENTS: A. PHC Asthma/COPD Pharmacotherapy 1

V. PURPOSE: Asthma is a chronic condition of airway inflammation which manifests in wheezing, coughing, and dyspnea. The prevalence of asthma has been increasing in the U.S. for many years, and it currently affects 8.4% of the population, age under 18 years and 7.7% of the population, ages 18 years and older (2017 National Health Interview Survey (NHIS) Data.

VI. GUIDELINE / PROCEDURE: A. Key Points in Diagnosis and Management 1. Diagnosis – The symptoms of asthma can be caused by other conditions, including, allergies, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), gastroesophageal reflux disease (GERD), bronchiectasis, sarcoidosis, pulmonary embolism, panic disorder, and vocal cord dysfunction, among others. An accurate diagnosis rests on an accurate history, physical findings, pulmonary function tests (PFTs), and chest x-ray (CXR). 2. Treatment – The long term goals of asthma management are symptom control and risk reduction. Main principles of management consist of medications and non-pharmacologic therapies and strategies as well as training and educating patients on essential asthma self-management skills. Pharmacotherapy should be individualized to the particular patient. This guideline cannot cover every situation, but therapy for asthma generally includes anti-inflammatory inhalers (controller therapy) used regularly, and bronchodilator inhalers (rescue therapy) used as needed. B. PHC Formulary allows up to a 3-month supply of all asthma controller medications. C. PHC Formulary and other Asthma Medications List (Listing not inclusive)

1PHC’s formulary and medication coverage benefits shall continue as described in this policy until such time as the pharmacy benefit carve-out to Medi-Cal Fee-for-Service described in APL 20-020 and the Governor’s Executive Order N-01-19 may take effect.

94 of 229 Page 1 of 3 Guideline/Procedure Number: MPXG5001 (previously Lead Department: Health Services XG100501) Guideline/Procedure Title: Clinical Practice Guidelines for ☒ External Policy the Diagnosis & Management of Asthma ☐ Internal Policy Next Review Date: 02/09/202204/13/2022 Original Date: 04/19/2000 Last Review Date: 02/10/202104/14/2022 Applies to: ☒ Medi-Cal ☐ Employees

1. Controller therapy (inhaled corticosteroids): Beclomethasone (QVAR RediHaler), budesonide (Pulmicort Flexhaler), fluticasone (Flovent Diskus, mometasone (Asmanex), flunisolide (Aerospan), ciclesonide (Alvesco), and fluticasone (Arnuity Ellipta) 2. Rescue therapy (short-acting beta agonist inhalers): Inhaled albuterol (Ventolin HFA, ProAir HFA, Proventil HFA, ProAir RespiClick); ICS-Formoterol (Symbicort, Dulera) for mild asthma ages ≥ 12 (off label, see below). a. Global Initiative for Asthma (GINA) 2019 recommendations, adults & adolescents: Should no longer use SABA-only treatment for any degree of asthma severity. Recommended treatment options (off-label): 1. Mild asthma can be treated with either PRN low-dose Budesonide-Formoterol (Symbicort), or PRN low dose ICS taken at the same time as SABA., or 2. Regular ICS or ICS-LABA daily, plus PRN SABA, or 3. Controller and rescue therapy with budesonide-formoterol (Symbicort) 3. Other agents: a. Inhaled long-acting beta agonists: salmeterol (Serevent). Salmeterol is not recommended as monotherapy for asthma and is non-formulary for those diagnosed with asthma. b. Mast cell stabilizer: Cromolyn nebulizer solution c. Leukotriene Receptor Antagonists: Montelukast (Singulair). d. Combination inhaled therapy options: Fluticasone/salmeterol (AirDuo RespiClick, Advair Diskus), budesonide/formoterol (Symbicort), and mometasone/formoterol (Dulera) e. Inhaled long-acting anticholinergic agent: Tiotropium (Spiriva Respimat), f. Non-formulary Biologics: reslizumab (Cinqair), benralizumab (Fasenra) (benralizumab), mepolizumab (Nucala), omalizumab (Xolair), and dupilumab (Dupixent). D. Indicator Monitored by Partnership HealthPlan of California (PHC): The following indicator will be monitored for measurement of adherence to this guideline (as reference from Healthcare Effectiveness Data and Information Set [HEDIS®] measure: Asthma Medication Ratio) 1. The percentage of members 5–64 years of age during the measurement year who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year. 2. Consider targeted intervention on those patients with suboptimal AMR score (<0.5) Interventions may include evaluating patient’s asthma pharmacotherapy for underuse of ICS and overuse of rescue inhalers, confirming pharmacy records for prescriptions filled in the pharmacy, and engaging patients on the importance of medication adherence.

VII. REFERENCES: PHC has adopted the asthma guidelines entitled Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention 2019. Available from www.ginasthma.org. A 2020 update, which suggests interim guidance on asthma and COVID-19, can be found at https://ginasthma.org/wp- content/uploads/2020/04/GINA-2020-full-report_-final-_wms.pdf

VIII. DISTRIBUTION: A. PHC Pharmacy Department B. PHC Utilization Management Staff C. PHC Provider Manual D. PHC Department Directors

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Chief Medical Officer

X. REVISION DATES:

95 of 229 Page 2 of 3 MPXG5001 – Attachment A Partnership HealthPlan of California – Asthma and COPD Pharmacotherapy PHC’s formulary and medication coverage benefits shall continue as described in this policy until such time as the pharmacy benefit carve-out to Medi-Cal Fee-for- Service described in APL 20-020 and the Governor’s Executive Order N-01-19 may take effect.

Cost per Unit AWP FDA per Approved Age PHC Restriction/Criteria (see RedBook FDA Limits (yrs) or Dosage Formulary formulary search tool for full Drug *10/2019* Source Indication PHC limit Form Status criteria details) Ventolin HFA® (Albuterol $62 Asthma/ Limited to18 gm (1 inhaler) per Generic ≥ 4 MDI F HFA, 18 gm) 90 mcg COPD 15 days ProAir HFA® (Albuterol $74 Asthma/ Limited to 8.5 gm (1 inhaler) per Generic ≥ 4 MDI F HFA, 8.5 gm) 90 mcg COPD 15 days Proventil HFA® (Albuterol $74 Asthma/ Limited to 6.7 gm (1 inhaler) per Generic ≥ 4 MDI F HFA, 6.7 gm) 90 mcg COPD 15 days ProAir RespiClick® $73 Asthma/ Limited to 1 unit (1 inhaler) per Brand ≥ 4 DPI F (Albuterol) 90 mcg COPD 15 days Albuterol Sulfate $47/30 0.63 mg/3 ml & 1.25 mg/3 ml has a Asthma/ F Limit of 270 ml (90 vials) per 25 days. 0.63 mg/3 ml, 1.25 mg/3 ml, vials Generic NS 2.5 mg/3 ml, COPD ≥ 2 2.5 mg/3 ml has a limit of 225 ml (75 vials) per 25 days Albuterol Sulfate, concentrate $58/20 ml Asthma/ Generic ≥ 2 NS F Limited to 40 ml per month 2.5 mg/0.5 ml, 5 mg/1 ml COPD Xopenex HFA® 45 mcg $74 Asthma/ Documentation of failure or Generic ≥ 4 MDI NF (Levalbuterol HFA) COPD intolerance to albuterol HFA products. Xopenex® (Levalbuterol) $161/24 Asthma/ 0.31 mg/3 ml, 0.63 mg/3 ml, vials Generic ≥ 6 NS NF Documentation of failure or intolerance COPD solution to albuterol HFA w/spacer, 1.25 mg/3 ml albuterol nebulizer solution and Xopenex® (Levalbuterol), $200/30 Asthma/ ≥ 6 Generic NS NF levalbuterol HFA with spacer. Concentrate 1.25 mg/0.5 ml vials COPD

STEP: These formulary agents require prior treatment with prerequisite 1st line drug therapy. Member must have had a previous trial or one or more designated 1st line agent(s) as evidenced by a paid claim within the designated time frame in order for the STEP medication claim to adjudicate without a TAR. Code I Restriction: Code 1 medications are formulary, but the use is limited to a specific medical condition. Although Code 1 restricted drugs do not require a TAR when the Code 1 restriction is met, pharmacy providers must maintain documentation that the specific Code 1 condition is met. Key to Restriction Abbreviations: DPI = Dry Powder Inhaler MDI = Meter Dosed Inhaler NS= Nebulizing Solution STE = Step Therapy Requirement F= Formulary NF = Non-Formulary, TR required C1 = Code 1 Restriction AL = Age Limit QL = Quantity Limit SQ = Subcutaneous Injection IV = Intravenous Injection pg. 1 of 9 96 of 229 MPXG5001 – Attachment A Partnership HealthPlan of California – Asthma and COPD Pharmacotherapy

Cost per Unit AWP FDA per Approved Age PHC Restriction/Criteria (see RedBook FDA Limits (yrs) or Dosage Formulary formulary search tool for full Drug *10/2019* Source Indication PHC limit Form Status criteria details) LONG ACTING BETA AGONIST (LABA) Serevent Diskus® 50 mcg $465 Brand COPD ≥ 4 DPI C1 Treatment of COPD, not on LABA (Salmeterol) product. For asthma, use combination ICS/LABA after ICS failure. Brovana® (Arformoterol) $1236/60 Brand COPD ≥ 18 NS NF Treatment of COPD with reason(s) 15 mcg/2 ml vials why hand held inhalers cannot be Perforomist® (Formoterol $1225/60 Brand COPD ≥ 18 NS NF used & failure to Serevent & Striverdi Fumarate) 20 mcg/2 ml vials or Arcapta (TAR required). ULTRA LONG ACTING BETA AGONIST (ULTRA-LABA) Arcapta Neohaler® $309 Brand COPD ≥ 18 DPI NF Treatment of COPD with documen- (Indacaterol) 75 mcg tation of trial and failure to Striverdi. Striverdi Respimat® $254 Brand COPD ≥ 18 MDI C1 Treatment of COPD with 1 inhaler (Olodaterol) 2.5 mcg per fill. INHALED CORTICOSTEROIDS (ICS) Aerospan HFA® (Flunisolide) $245 Brand Asthma ≥ 6 MDI F 80 mcg

Alvesco® (Ciclesonide) 80 mcg $329 Brand Asthma ≥ 12 MDI F Allows up to 3 inhalers per 90-day 160 mcg supply Arnuity Ellipta® (Fluticasone) $208 - $280 Brand Asthma ≥ 4 DPI F 200 mcg

STEP: These formulary agents require prior treatment with prerequisite 1st line drug therapy. Member must have had a previous trial or one or more designated 1st line agent(s) as evidenced by a paid claim within the designated time frame in order for the STEP medication claim to adjudicate without a TAR. Code I Restriction: Code 1 medications are formulary, but the use is limited to a specific medical condition. Although Code 1 restricted drugs do not require a TAR when the Code 1 restriction is met, pharmacy providers must maintain documentation that the specific Code 1 condition is met. Key to Restriction Abbreviations: DPI = Dry Powder Inhaler MDI = Meter Dosed Inhaler NS= Nebulizing Solution STE = Step Therapy Requirement F= Formulary NF = Non-Formulary, TR required C1 = Code 1 Restriction AL = Age Limit QL = Quantity Limit SQ = Subcutaneous Injection IV = Intravenous Injection pg. 2 of 9 97 of 229 MPXG5001 – Attachment A Partnership HealthPlan of California – Asthma and COPD Pharmacotherapy

Cost per Unit AWP FDA per Approved Age PHC Restriction/Criteria (see RedBook FDA Limits (yrs) or Dosage Formulary formulary search tool for full Drug *10/2019* Source Indication PHC limit Form Status criteria details) Asmanex HFA® (Mometasone) $230 - $270 Brand Asthma ≥ 12 MDI F 100 mcg, 200 mcg

INHALED CORTICOSTEROIDS (ICS) continued Asmanex Twisthaler® (Mometasone) 110 mcg, 220 $192 - $322 Brand Asthma ≥ 4 DPI F mcg Flovent Diskus® (Fluticasone) ≥ 4 $213 - $301 Brand Asthma DPI F 50 mcg, 100 mcg, 250 mcg Allows up to 3 inhalers per 90-day Pulmicort Flexhaler® ≥ 6 supply $212 - $284 Brand Asthma DPI F (Budesonide) 90 mcg, 180 mcg Qvar RediHaler® ≥ 4 (Beclomethasone) 40 mcg, 80 $215 - $288 Brand Asthma DPI F mcg Flovent HFA® (Fluticasone) AL: ≤ 11 yrs $224 - $301 Brand Asthma ≥ 4 MDI F Allows up to 3 inhalers per 90 44 mcg, 110 mcg, 220 mcg day supply. Prior use of Flovent 44 mcg or Flovent HFA® (Fluticasone) 110 mcg in the past 6 months before $467 Brand Asthma ≥4 MDI STE 220mcg stepping up to 220 mcg. AL: ≤ 11 yrs Pulmicort® (Budesonide) 0.25 For the treatment of asthma with limit $282 - $692/ Of twice a day dosing for 0.25 mg/ 2ml mg/2 ml, 0.5 mg/2 ml, Generic Asthma 1 - 8 NS C1 30 vials & 0.5 mg/ 2 ml & one per day for 1.0 mg/2 ml 1.0 mg/2 ml STEP: These formulary agents require prior treatment with prerequisite 1st line drug therapy. Member must have had a previous trial or one or more designated 1st line agent(s) as evidenced by a paid claim within the designated time frame in order for the STEP medication claim to adjudicate without a TAR. Code I Restriction: Code 1 medications are formulary, but the use is limited to a specific medical condition. Although Code 1 restricted drugs do not require a TAR when the Code 1 restriction is met, pharmacy providers must maintain documentation that the specific Code 1 condition is met. Key to Restriction Abbreviations: DPI = Dry Powder Inhaler MDI = Meter Dosed Inhaler NS= Nebulizing Solution STE = Step Therapy Requirement F= Formulary NF = Non-Formulary, TR required C1 = Code 1 Restriction AL = Age Limit QL = Quantity Limit SQ = Subcutaneous Injection IV = Intravenous Injection pg. 3 of 9 98 of 229 MPXG5001 – Attachment A Partnership HealthPlan of California – Asthma and COPD Pharmacotherapy

Cost per Unit AWP FDA per Approved Age PHC Restriction/Criteria (see RedBook FDA Limits (yrs) or Dosage Formulary formulary search tool for full Drug *10/2019* Source Indication PHC limit Form Status criteria details) ICS/LABA COMBINATION INHALERS Advair HFA® (fluticasone/

salmeterol) 45 mcg/21 mcg, Documentation of failure to fluticasone/ $380–$622 Brand Asthma ≥ 12 MDI NF salmeterol (generic AirDuo or generic 115 mcg/21 mcg, 230 mcg/ Advair Diskus), Symbicort & Dulera. 21 mcg Advair DIskus® (Fluticasone/ Salmeterol and Wixela Inhub) Asthma/ $358 -$584 Generic ≥ 4 DPI F 100 mcg/50 mcg, 200 mcg/ COPD 50 mcg, 500 mcg/50 mcg AirDuo RespiClick® (Fluticasone/salmeterol) $119 Generic Asthma ≥ 12 DPI F 55 mcg/14 mcg, 113 mcg/ Allows up to 3 inhalers per 90-day 14 mcg, 232 mcg/14 mcg supply Dulera® (Mometasone/ Asthma/ Fomoterol) 100 mcg/5 mcg, $374 Brand ≥ 12 MDI F COPD 200 mcg/5 mcg Symbicort® (Budesonide/ Asthma/ Formoterol) 80 mcg/4.5 mcg, $352 -$403 Generic ≥ 6 MDI F COPD 160 mcg/4.5 mcg Breo Ellipta® (Fluticasone Asthma/ Documentation of failure to fluticasone/ Furoate/Vilanterol) 100 mcg/ $422 Brand ≥ 18 DPI NF salmeterol (generic AirDuo or generic COPD 25 mcg, 200 mcg/25 mcg Advair Diskus), Symbicort & Dulera.

STEP: These formulary agents require prior treatment with prerequisite 1st line drug therapy. Member must have had a previous trial or one or more designated 1st line agent(s) as evidenced by a paid claim within the designated time frame in order for the STEP medication claim to adjudicate without a TAR. Code I Restriction: Code 1 medications are formulary, but the use is limited to a specific medical condition. Although Code 1 restricted drugs do not require a TAR when the Code 1 restriction is met, pharmacy providers must maintain documentation that the specific Code 1 condition is met. Key to Restriction Abbreviations: DPI = Dry Powder Inhaler MDI = Meter Dosed Inhaler NS= Nebulizing Solution STE = Step Therapy Requirement F= Formulary NF = Non-Formulary, TR required C1 = Code 1 Restriction AL = Age Limit QL = Quantity Limit SQ = Subcutaneous Injection IV = Intravenous Injection pg. 4 of 9 99 of 229 MPXG5001 – Attachment A Partnership HealthPlan of California – Asthma and COPD Pharmacotherapy

Cost per Unit AWP FDA per Approved Age PHC Restriction/Criteria (see RedBook FDA Limits (yrs) or Dosage Formulary formulary search tool for full Drug *10/2019* Source Indication PHC limit Form Status criteria details) SHORT ACTINGMUSCARINIC ANTAGONIST (SAMA)

Atrovent HFA® $466 Brand COPD ≥ 18 MDI F Limited to 1 inhaler per 30 days. (Ipratropium ), 17 mcg

Atrovent Solution® $116/60 Limited to up to 20 ml per day or 600 (Ipratropium) 0.5 mg/ Generic COPD ≥ 18 NS F vials ml per month. 2.5 ml (0.02%) LONG ACTING MUSCARINIC ANTAGONIST (LAMA) Incruse Ellipta® For the treatment of COPD. (Umeclidinium Bromide) $401 Brand COPD ≥ 18 DPI C1

62.5 mcg Prior fills of Spiriva HandiHaler (STE Seebri Neohaler® therapy required) or Spiriva $473 Brand COPD ≥ 18 STE (Glycopyrrolate) 15.6 mcg DPI Respimat, Incruse Ellipta or Tudorza Pressair in the past 120 days. Spiriva HandiHaler® DPI Previous claim for Spiriva Respimat (Tiotropium) 18mcg $515 Brand COPD STE ≥ 18 in the last 180 days.

Spiriva Respimat ® Asthma/ Allows up to 3 inhalers per 90-day $515 Brand ≥ 6 MDI F (Tiotropium) 1.25 mcg, 2.5 mcg COPD supply Tudorza Pressair® Previous claim of Spiriva Respimat (Aclidinium bromide) 400 $624 Brand COPD ≥ 18 DPI STE or Spiriva HandiHaler in the past 90 mcg days.

STEP: These formulary agents require prior treatment with prerequisite 1st line drug therapy. Member must have had a previous trial or one or more designated 1st line agent(s) as evidenced by a paid claim within the designated time frame in order for the STEP medication claim to adjudicate without a TAR. Code I Restriction: Code 1 medications are formulary, but the use is limited to a specific medical condition. Although Code 1 restricted drugs do not require a TAR when the Code 1 restriction is met, pharmacy providers must maintain documentation that the specific Code 1 condition is met. Key to Restriction Abbreviations: DPI = Dry Powder Inhaler MDI = Meter Dosed Inhaler NS= Nebulizing Solution STE = Step Therapy Requirement F= Formulary NF = Non-Formulary, TR required C1 = Code 1 Restriction AL = Age Limit QL = Quantity Limit SQ = Subcutaneous Injection IV = Intravenous Injection pg. 5 of 9 100 of 229 MPXG5001 – Attachment A Partnership HealthPlan of California – Asthma and COPD Pharmacotherapy

Cost per Unit AWP FDA per Approved Age PHC Restriction/Criteria (see RedBook FDA Limits (yrs) or Dosage Formulary formulary search tool for full Drug *10/2019* Source Indication PHC limit Form Status criteria details) LONG ACTING MUSCARINIC ANTAGONISY (LAMA) continued Lonhala Magnair® $1,359/60 (Glycopyrrolate) 25 mcg/ Brand COPD ≥ 18 NS NF For treatment of COPD with reasons vials why hand-held inhalers cannot be ml used & failure to Seebri Neohaler Yupelri® (Revefenacin) $1,236/30 Brand COPD ≥ 18 NS NF (STE required). 175 mcg/3 ml vials SAMA/SABA COMBINATION Combivent Respimat® $483 Limit of up to 4 gm (1 inhaler) per (Ipratropium/albuterol) Brand COPD ≥ 18 MDI F 20 days 20 mcg/100 mcg

$126/60 Limited to up to 270 ml (90 vials) per Duoneb® (ipratropium/ Generic COPD ≥ 18 NS F vials 25-day supply albuterol) 0.5 mg/2.5 mg/3 ml LAMA/LABA COMBINATION Anoro Ellipta® For the treatment of COPD. (Umeclidinium/Vilanterol) $492 Brand COPD ≥ 18 DPI C1 Limited up to 1 unit per 30 days. 62.5 mcg/25 mcg

Bevespi Aerosphere HFA

(Formoterol Fumarate/ $438 Prior claim for Stiolto Respimat AND Brand COPD ≥ 18 MDI STE Anoro Ellipta in the past 120 Glycopyrrolate) 9 mcg/ days. Limited up to 1 unit per 30 days. 4.8 mcg

STEP: These formulary agents require prior treatment with prerequisite 1st line drug therapy. Member must have had a previous trial or one or more designated 1st line agent(s) as evidenced by a paid claim within the designated time frame in order for the STEP medication claim to adjudicate without a TAR. Code I Restriction: Code 1 medications are formulary, but the use is limited to a specific medical condition. Although Code 1 restricted drugs do not require a TAR when the Code 1 restriction is met, pharmacy providers must maintain documentation that the specific Code 1 condition is met. Key to Restriction Abbreviations: DPI = Dry Powder Inhaler MDI = Meter Dosed Inhaler NS= Nebulizing Solution STE = Step Therapy Requirement F= Formulary NF = Non-Formulary, TR required C1 = Code 1 Restriction AL = Age Limit QL = Quantity Limit SQ = Subcutaneous Injection IV = Intravenous Injection pg. 6 of 9 101 of 229 MPXG5001 – Attachment A Partnership HealthPlan of California – Asthma and COPD Pharmacotherapy

Cost per Unit AWP FDA per Approved Age PHC Restriction/Criteria (see RedBook FDA Limits (yrs) or Dosage Formulary formulary search tool for full Drug *10/2019* Source Indication PHC limit Form Status criteria details) LAMA/LABA COMBINATION continued Stiolto Respimat® (Tiotropium Bromide/ $477 For the treatment of COPD. Brand COPD ≥ 18 MDI C1 Limited up to 4 gm (1 inhaler) Olodaterol) 2.5 mcg/2.5 per 30 days. mcg Utibron Neohaler® For the treatment of COPD. (Indacaterol/Glycopyrrolate) $441 Brand COPD ≥ 18 DPI C1 Limited up to 1 unit per 30 days. 27.5 mcg/15.6 mcg LAMA/LADA/ICS COMBINATION Trelegy Ellipta® (Umeclidinium, Vilanterol, Prior claims for LABA/ICS OR $655 Brand COPD ≥ 18 DPI STE LAMA/LABA in the past 90 days. Fluticasone Furoate) Limited to 1 unit per month. 100 mcg/62.5 mcg/25 mcg MAST CELL STABILIZER Intal® (Cromolyn) $,1301.40/60 Generic Asthma ≥ 2 NS F 20 mg/2 ml vials LEUKOTRIENE RECEPTOR ANTAGONIST (LRT) $14/month Singulair® (Montelukast) (maximum Generic Asthma ≥ 15 Oral F 10 mg tablets allowable cos

STEP: These formulary agents require prior treatment with prerequisite 1st line drug therapy. Member must have had a previous trial or one or more designated 1st line agent(s) as evidenced by a paid claim within the designated time frame in order for the STEP medication claim to adjudicate without a TAR. Code I Restriction: Code 1 medications are formulary, but the use is limited to a specific medical condition. Although Code 1 restricted drugs do not require a TAR when the Code 1 restriction is met, pharmacy providers must maintain documentation that the specific Code 1 condition is met. Key to Restriction Abbreviations: DPI = Dry Powder Inhaler MDI = Meter Dosed Inhaler NS= Nebulizing Solution STE = Step Therapy Requirement F= Formulary NF = Non-Formulary, TR required C1 = Code 1 Restriction AL = Age Limit QL = Quantity Limit SQ = Subcutaneous Injection IV = Intravenous Injection pg. 7 of 9 102 of 229 MPXG5001 – Attachment A Partnership HealthPlan of California – Asthma and COPD Pharmacotherapy

Cost per Unit AWP FDA per Approved Age PHC Restriction/Criteria (see RedBook FDA Limits (yrs) or Dosage Formulary formulary search tool for full Drug *10/2019* Source Indication PHC limit Form Status criteria details) LEUKOTRIENE RECEPTOR ANTAGONIST (LRT) continued Singulair® (Montelukast) $6/month 4 mg chewable tablets (maximum Generic Asthma ≥ 2 Oral F allowable cost) Singulair® (Montelukast) $4/month (maximum Generic Asthma ≥ 6 Oral F 5 mg chewable tablets allowable cost) Singulair® (Montelukast) $117/month Submit diagnosis and reason(s) (maximum Generic Asthma ≥ 1 Oral NF why formulary and non-formulary 4 mg oral granules allowable cost) preferred products cannot be used. $30 - $60/ Accolate® (Zafirlukast) 10 mg, month Generic Asthma ≥ 5 Oral NF 20 mg tablets (maximum allowable cost) MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E (IgE)

Xolair® (Omalizumab) See formulary search tool for full $1,328/ml Brand Asthma ≥ 6 SQ NF 75 mg/0.5 ml, 150 mg/ml criteria

MONOCLONAL ANTIBODY-INTERLEUKIN-5 (IL-5) ANTAGONIST

Cinqair® (Reslizumab) $1,118/10 ml Brand Asthma ≥ 18 IV NF 10 mg/ml See formulary search tool for full criteria Nucala® (Mepolizumab) ≥ 12 $3,546/ml Brand Asthma SQ NF 100 mg/ml STEP: These formulary agents require prior treatment with prerequisite 1st line drug therapy. Member must have had a previous trial or one or more designated 1st line agent(s) as evidenced by a paid claim within the designated time frame in order for the STEP medication claim to adjudicate without a TAR. Code I Restriction: Code 1 medications are formulary, but the use is limited to a specific medical condition. Although Code 1 restricted drugs do not require a TAR when the Code 1 restriction is met, pharmacy providers must maintain documentation that the specific Code 1 condition is met. Key to Restriction Abbreviations: DPI = Dry Powder Inhaler MDI = Meter Dosed Inhaler NS= Nebulizing Solution STE = Step Therapy Requirement F= Formulary NF = Non-Formulary, TR required C1 = Code 1 Restriction AL = Age Limit QL = Quantity Limit SQ = Subcutaneous Injection IV = Intravenous Injection pg. 8 of 9 103 of 229 MPXG5001 – Attachment A Partnership HealthPlan of California – Asthma and COPD Pharmacotherapy

Cost per Unit AWP FDA per Approved Age PHC Restriction/Criteria (see RedBook FDA Limits (yrs) or Dosage Formulary formulary search tool for full Drug *10/2019* Source Indication PHC limit Form Status criteria details) MONOCLONAL ANTIBODY-INTERLEUKIN-5 (IL-5) RECEPTOR ALPHA ANTAGONIST

Fasenra® (Benralizumab) See formulary search tool for full $5,875/ml Brand Asthma ≥ 12 SQ NF 30 mg/ml criteria

MONOCLONAL ANTIBODY – INTERLEUKIN-4 (IL-4) RECEPTOR ALPHA ANTAGONIST

Dupixent® (Dupilumab) See formulary search tool for full $3,623/ml Brand Asthma ≥ 12 SQ NF 200 mg/1.14 ml, 300 mg/2 ml criteria

STEP: These formulary agents require prior treatment with prerequisite 1st line drug therapy. Member must have had a previous trial or one or more designated 1st line agent(s) as evidenced by a paid claim within the designated time frame in order for the STEP medication claim to adjudicate without a TAR. Code I Restriction: Code 1 medications are formulary, but the use is limited to a specific medical condition. Although Code 1 restricted drugs do not require a TAR when the Code 1 restriction is met, pharmacy providers must maintain documentation that the specific Code 1 condition is met. Key to Restriction Abbreviations: DPI = Dry Powder Inhaler MDI = Meter Dosed Inhaler NS= Nebulizing Solution STE = Step Therapy Requirement F= Formulary NF = Non-Formulary, TR required C1 = Code 1 Restriction AL = Age Limit QL = Quantity Limit SQ = Subcutaneous Injection IV = Intravenous Injection pg. 9 of 9 104 of 229

PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY/ PROCEDURE

Policy/Procedure Number: MPXG5003 Lead Department: Health Services Policy/Procedure Title: Major Depression in Adults Clinical Practice ☒External Policy Guidelines ☐ Internal Policy Next Review Date: 11/10/202104/13/2022 Original Date: 04/19/2000 Last Review Date: 11/11/202004/14/2021 Applies to: ☒ Medi-Cal ☐ Employees Reviewing ☒ IQI ☐ P & T ☒ QUAC Entities: ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving ☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC Entities: ☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 11/11/202004/14/2021

I. RELATED POLICIES: MPCP2017 – Scope of Primary Care – Behavioral Health and Indication for Referral Guidelines

II. IMPACTED DEPTS: A. Health Services B. Provider Relations

III. DEFINITIONS: N/A

IV. ATTACHMENTS: A. Clinical Decision Flow Chart 1 B. Common Antidepressant Agents – PHC Formulary Status, Dosing Regimens and Monthly Costs 1

V. PURPOSE: To define the appropriate diagnostic criteria and therapy for patients with major depression.

This guideline is meant to be a basic guideline, not an enforceable standard, and is intended to assist the primary care professional in caring for PHC adult members with major depression. Recommendations are not intended to replace sound clinical judgment in caring for individual patients.

VI. POLICY / PROCEDURE: A. Overview Nationally accepted clinical practice guidelines for depression are created and updated regularly. Pharmacologic choices for depression also continually change as new products enter the market. For these reasons, and upon the recommendation of the Partnership Health Plan of California (PHC) Physician Advisory Committee, this CPG will be annually updated with the appropriate internet references which will provide timely guidelines for the management of major depression in adults.

VII. REFERENCES: A. From the American Psychiatric Association: https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf

1 PHC’s formulary and medication coverage benefits shall continue as described in this policy’s attachments until such time as the pharmacy benefit carve-out to Medi-Cal Fee-for-Service described in APL20-020 and the Governor’s Executive Order N-01-19 may take effect.

105 of 229 Page 1 of 2 Policy/Procedure Number: MPXG5003 Lead Department: Health Services Policy/Procedure Title: Major Depression in Adults Clinical ☒ External Policy Practice Guidelines ☐ Internal Policy Next Review Date: 11/10/2104/13/22 Original Date: 04/19/2000 Last Review Date: 11/11/2004/14/21 Applies to: ☒ Medi-Cal ☐ Employees

B. From the MacArthur Initiative on Depression and Primary Care https://www.depression-primarycare.org/clinicians/toolkits C. From the US Preventive Services Task Force: Screening for Depression in Adults https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in- adults-screening D. National Institute of Mental Health: Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study https://www.nimh.nih.gov/funding/clinical-research/practical/stard/index.shtml E. VA/DoD Clinical Practice Guidelines: Assessment and Management of Patients at Risk for Suicide (2019) https://www.healthquality.va.gov/guidelines/mh/srb/index.asp

VIII. DISTRIBUTION: A. PHC Provider Manual B. PHC Department Directors

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Chief Medical Officer

X. REVISION DATES: Medi-Cal 09/18/02; 10/20/04; 11/15/06; 05/18/11; 06/19/13; 7/27/15; 08/19/15; 08/19/16; 11/15/17; *10/10/18; 11/13/19; 11/11/20; 04/14/21

*Through 2017, Approval Date reflective of the Quality Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO: Healthy Families 05/18/11 PartnershipAdvantage 11/15/06; 05/18/11 Healthy Kids 11/15/06; 05/18/11; 08/19/15, 08/19/16 (Healthy Kids Program ended 12/01/2016)

106 of 229 Page 2 of 2 Depression Treatment Flow Diagram PROVIDERS PLEASE NOTE: (MPXG5003 Policy Attachment A) PHC’s formulary and medication coverage benefits shall continue as described in this policy until such time By: Diane Wong, Pharm. D. 10-2-2020 as the pharmacy benefit carve-out to Medi-Cal Fee-for-Service described in APL 20-020 and the Governor’s ADULT WITH Executive Order N-01-19 may take effect. Check the State Medi‐Cal Provider Manuals for information on Mild to Moderate DEPRESSION Severe covered drugs and how to submit TARS. Web links are provided for your convenience (see references). (no psychosis) PHC Note on Antidepressants: Antidepressant medications may not be as effective in treating depressed mood ABSENCE of risks for: tied to external factors (i.e. adjustment Cardiovascular issues, Seizures, No Prescriber selects agent which has disorder with depressed mood) or M CYP40 interactions? acceptable risk:benefit ratio. ul depressed mood resulting from medical ti illness (i.e., anemia) or substance use. It ‐ Yes d is important to carefully assess r u depressive symptoms via thorough g ON/AFTER Carveouttx : history, physical examination and Min 6-12 wk (6 if no response, 12 if State Medi-Cal CDL Submit TAR to STATE‐ laboratory work up as indicated.If PHQ9 State CDL agents r partial response) trial, max. dosing of a (Covered Drug List) MEDI-CAL with patient-e <15 and no hx of benefit from an AD, agent is appropriate are not appropriate si covered first-line agent specific contraindicationsst or refer to a BH specialist for help with interactionsa diagnostic clarification, as medication Progress through treatment n c may not be appropriate. Important to levels per STAR-D study w/ e:

evaluate for current or past history of 6-12wk min. trials, maximized N manic episodes, as monotherapy dosing, adjunctive tx & CBT o s antidepressant medication treatment can (cognitive behavioral therapy) p No as appropriate & available. e rarely precipitate mania in those with Remission? ci latent bipolar disorder. If pharmacotherapy STATE TAR may be requiredfi for c is appropriate treatment of Treatment ResistantS T Depression, including useA of adjunctive agents or progressingR to nd rd th * other 2 /3 /4 line pharmacotherapiesD Consider referral to a T/F 3 first-line agents such as: SSRI, r e psychotherapist for help and SNRI, TCA, Mirtazapine, Bupropion c o possible further assessment for SR or ER, alone &/or in combination m appropriateness of medication Pharmacotherapy Remission? No with adjunctive therapies; CBT, Li, m is not appropriate Yes e T3, aripiprazole or other n d pharmacologic agent indicated for at adjunctive management. io Continue psychotherapy or n s other non-pharmacologic af Continue treatment te therapy. r 4 tr e Individuals who answer "yes" to PHQ-9 question pertaining to thoughts NOTE: This document is not intended to provide or infer DHCS TAR requirements for a drugat that is not on the State CDL. State TAR criteria are not available publically at this time. m about self harm require further evaluation and suicide risk stratification. e However, it is reasonable to consider that documentation of adequate trials of State-coveredn See VA/DoD Clinical Practice Guidelines (refer to PHC Policy MPXG5003 t antidepressants would be the MINIMUM that should be included on a TAR, together with anyfa Reference section or this attachment's References & Resources page for il 107 of 229 additional patient-specific justification. u r the web address). e s … Treatment Algorithm based on STAR*D prospective trial, through 4 treatment changes

Pt w/ non‐psychotic depression, no bipolar d/o, no OCD, no STAR*D Study Inclusion Criteria: eating d/o, no seizure d/o, no CYP interaction considerations, no  Age 18‐75 cardiovascular dx.  Non‐psychotic major depression  Score >/= 14 on Hamilton Rating Scale for Depression  STAR‐D Treatment Level 1: Citalopram was used as representative of SSRI class. Those who could not tolerate None of the following: bipolar d/o, OCD, it or did not remit progressed to Level 2. STAR‐D discussions have said that any first‐line antidepressant (SSRI, eating d/o, seizure d/o SNRI or other) could be used in lieu of citalopram and the theory of this algorithm would still pertain, as main objective is to give adequate trial of single agent during pharmacologic initiation.

Following min. 8 wk trial @ max tolerated dosing Note regarding adequate trial durations: STAR‐D recommends a minimum 8 wk trial once pt is at max tolerated dose. PHC Subcommittee STAR‐D Treatment Level 2: Trial participants were given the option of either changing recommends that 6 wk is adequate to determine Remission medications or adding on to existing citalopram. The “switch group” were randomly failure if no response present; if partial response, No assigned to sertraline, bupropion‐SR, or venlafaxine‐ER. The “add on group” were given Achieved? should continue tx x 12 wks before considering either bupropion SR or buspirone. Cognitive psychotherapy was also offered as either add‐ changing. on or switch.

Yes Following min. 8 wk trial, @ max tolerated dosing Continue STAR‐D Treatment Level 3: “Switch Group” assigned to either Remission treatment No mirtazapine or nortriptyline. “Add on group” assigned to either achieved? lithium or triiodothyronine (T3).

Following min. 8 wk trial, Yes Multidrug Resistance: If depression @ max tolerated dosing does not remit satisfactorily, it may be STAR‐D Treatment Level 4: Taken off all other necessary to refer to psychiatric Continue medications and randomly switched to either specialist &/or consider other Remission No treatment tranylcypromine (MAOI) or combination of treatments not included in the achieved? mirtazapine with venlafaxine‐ER. STAR*D study may need to be considered, such as esketamine nasal Yes Following min. 8 wk trial, spray (Spravato™), which is a Note on discontinuation of drug therapy: @ max tolerated dosing consideration for severe depression. Pharmacotherapy discontinuation can be considered when symptoms Continue Spravato™, like other drug therapies, have resolved and patient is fully re-evaluated. Abrupt discontinuations treatment No would be the responsibility of State of medications are to be avoided, with several-week tapers usually Remission Medi‐Cal regardless of whether billed preferable. Monitor closely for symptom recurrence during taper and for achieved? as a pharmacy or medical clinic as a several months after discontinuation. medical claim, because treatment of Yes severe depression is carved out to State (PHC is responsible only for mild 108 of 229 Continue to moderate behavioral health treatment treatment). References & Resources: 1. Thase, Michael, MD, Connolly, K Ryan, M, MS; Unipolar depression in adults: Choosing treatment for resistant depression UpToDate May 10, 2019 2. Gaynes, Bradley N., et al. The STAR*D Study: Treating Depression in the Real World. Cleveland Clinic Journal of Medicine, 2008, vol 75, no 1, pp 57-66. 3. Kirsch, I, et al. Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration, PLoS Medicaine, 2008; vol 5, no 2, pp 260-268. 4. PL Detail-Document, Treatment Resistant Depression: An Update. Pharmacist’s Letter/Prescriber’s Letter 2009; 25(5):250510. 5. Weber, J, et al. Aripiprazole: In Major Depressive Disorder. CNS Drugs, 2008, 22(10):807-13; http://www.ncbi.nlm.nih.gov/pubmed/18788833 6. Trintellix® (Vortioxetine) [prescribing information]. Takeda Pharmaceuticals America, Inc., Deerfield, IL. October 2018. 7. Fetzima® (Levomilnacipran) [prescribing information]. Allergan USA, Inc., Irvine, CA. January 2017. 8. Viibryd® (Vilazodone) [prescribing information]. Allergan USA, Inc., Madison, NJ. May 2018. 9. Spravato® (Esketamine) [prescribing information]. Janssen Pharmaceuticals, Inc. Titusville, NJ. March 2019. 10. ClinicalTrials.gov [Internet]. Bethesda, MD: National Library of Medicine (US). 2000 Feb 29 – Identifier: NCT02418585, A study to evaluate the efficacy, safety, and tolerability of flexible doses of intranasal esketamine plus an oral antidepressant in adult participants with treatment-resistant depression (TRANSFORM-2); 2018 May 31. Available from: https://clinicaltrials.gov/ct2/show/NCT02418585 11. ClinicalTrials.gov [Internet]. Bethesda, MD: National Library of Medicine (US). 2000 Feb 29 – Identifier: NCT02493868, A study of intranasal esketamine plus an oral antidepressant for relapse prevention in adult with treatment-resistant depression (SUSTAIN-1); 2019 February 15. Available from: https://clinicaltrials.gov/ct2/show/NCT02493868 12. ClinicalTrials.gov [Internet]. Bethesda, MD: National Library of Medicine (US). 2000 Feb 29 – Identifier: NCT02497287, A long-term, safety and efficacy study of intranasal esketamine in treatment-resistant depression (SUSTAIN-2); 2018 October 26. Available from: https://clinicaltrials.gov/ct2/show/NCT02493868 13. Saef MA, Saadabadi A. Protriptyline. [Updated 2019 Jan 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499828/ 14. Rush AJ et al. "Acute and longer-term outcomes in depressed outpatient requiring one or several treatment steps: A STAR*D report". The American Journal of Psychiatry. 2006. 163(11):1905-1917. 15. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder. Arlington, VA: American Psychiatric Association, 2010. Available online at https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf 17. NIH: Questions & Answers about the NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study – all medication levels. November 2006. www.nimh.nih.gov/funding/clinical-research/practical/stard/allmedicationlevels.shtml 18. VA/DoD Clinical Practice Guidelines: Assessment and Mangement of Patients at Risk for Suicide (2019). Available online at: https://www.healthquality.va.gov/guidelines/mh/ srb/index.asp

State Medi-Cal Pharmacy Benefit Resources: Pharmacy Communications (News, Bulletins, Manuals): https://files.medi-cal.ca.gov/pubsdoco/community/Pharmacy.aspx Pharmacy Manual: https://files.medi-cal.ca.gov/pubsdoco/manual/man_query.aspx?wSearch=*_*p00*+OR+*_*z00*+OR+*_*z02*&wFLogo=Part2+%23+Pharmacy&wPath=N State Medi-Cal Covered Drug Lists (aka pharmacy formulary) – note that drugs are listed in State CDL by generic name only By Therapeutic Class: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/drugscdlp4.pdf Covered Drug List Online Search Tool: https://www.dhcs.ca.gov/services/Pages/FormularyFile.aspx Covered Drug List, A-D: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/drugscdlp1a.pdf Covered Drug List, E-M: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/drugscdlp1b.pdf Covered Drug List, N-R: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/drugscdlp1c.pdf Covered Drug List, S-Z: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/drugscdlp1c.pdf

Covered Drug List, OTC: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/109 of 229part2/drugscdlp2.pdf

MPXG5003 - Attachment B Revised 11/11/2020 Common Antidepressant Agents – PHC Formulary Status, Dosing Regimens and Monthly Costs

+COST/ USUAL USUAL MAXIMUM MAXIMUM +COST/ FORMULARY MONTH TRADE STARTING DAILY DAILY DOSE DAILY DOSE MONTH GENERIC NAME STATUS starting NAME DOSE DOSE (PCP) (Specialist) Max Dose dose

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) AND TRICYCLICS (TCAs)

Citalopram tabs Celexa® F 20mg QD $5 10-40mg 40mg 60mg $10 Escitalopram tabs Lexapro F 5mg QD $5 5-10mg 20mg 20mg $10 Fluoxetine caps Prozac® F 10mg QAM $5 10-40mg 30mg 80mg $27 Fluoxetine tabs Sarafem® NF 20mg QAM $50 20mg 20mg 60mg $72 Fluvoxamine tabs Luvox® F 50mg QD $10 50-300mg 200mg 300mg $60 Fluvoxamine ER caps Luvox CR® NF 100mg QHS $250 100-300mg 200mg 300mg $420 Paroxetine tabs Paxil® F 10mg QD $5 10-40mg 40mg 60mg $15 Paroxetine ER tabs Paxil CR NF 25 mg QAM $150 25 -62.5mg 50mg 62.5mg $310 Sertraline tabs Zoloft® F 25mg QD $5 50-100mg 200mg 200mg $25 Amitriptyline tabs Elavil® F 25-50mg QHS $25 150-200mg 300mg 300mg $100 Desipramine tabs Norpramin® F 25-50mg QHS $60 150-200mg 300mg 300mg $400 Doxepin caps Sinequan® F 25-50mg QHS $45 150-200mg 300mg 300mg $40 Imipramine HCl++ tabs Tofranil® F 25-50mg QHS $10 150-200mg 300mg 300mg $55 Imipramine Pamoate caps Tofranil PM® NF 75mg $280 150mg 200mg 300mg $750 Nortriptyline++ caps Pamelor® F 10-25mg QHS $5 75-100mg 150mg 150mg $20 Clomipramine tabs Anafranil® NF 25mg QD $175 25-250mg 25mg 250mg $470 Protriptyline tabs Vivactil® F 10mg QHS $90 15-40mg 60mg 60mg $600 SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs) Venlafaxine tabs Effexor® F 37.5mg BID $15 75mg BID 375mg 375mg $40 Venlafaxine ER caps Effexor-XR® F 37.5-75mg QD $10 150mg QD 300mg 300 mg. $12 (no trade Venlafaxine ER tabs NF 37.5-75mg QD $200 150mg QD 300mg 300mg $470 name) Duloxetine caps Cymbalta® F,QL 20 mg BID $25 40-60 mg QD 60mg 120 mg $12 Desvenlafaxine Succinate Pristiq F, QL 50mg QD $50 50mg QD 50mg QD 400mg $120 ER tabs Desvenlafaxine ER tabs Khedezla® NF 50mg QD $280 50mg QD 50mg QD 400mg $1,700

(table continued next page)

PHC’s formulary and medication coverage benefits shall continue as described in this policy until such time as the pharmacy benefit carve-out to Medi-Cal Fee-for-Service described in APL 20- 020 and the Governor’s Executive Order N-01-19 may take effect. Please refer to the State Medi-Cal Contract Drugs List (CDL), which is found in both the Medical and Pharmacy provider manual sections of the website. The provider manuals are available at https://files.medi-cal.ca.gov/pubsdoco/manuals_menu.aspx. 110 of 229

MPXG5003 - Attachment B, continued Revised 11/11/2020 Common Antidepressant Agents – Formulary Status, Dosing Regimens and Monthly Costs

+COST/ +COST/ USUAL USUAL MAXIMUM MAXIMUM FORMULARY MONTH MONTH TRADE STARTING DAILY DAILY DOSE DAILY DOSE GENERIC NAME STATUS starting max dose NAME DOSE DOSE (PCP) (Specialist) dose

OTHER

Bupropion tabs Wellbutrin® F 100mg BID or $35 100mg TID 400mg 400mg $50 75mg TID Bupropion SR tabs Wellbutrin- F 100mg BID $15 150mg BID 400mg 400mg $25 SR® Bupropion XL tabs Wellbutrin® F,QL 150mg QD $15 300mg 450mg 450mg $45 XL Mirtazapine tabs Remeron® F,QL 15mg QHS $10 15-45mg 45mg 45mg $ 15 Nefazodone Serzone® F, AL 50-100mg BID $50 200mg BID 600mg 600mg $160 Trazodone 50, 100, Desyrel® F 100mg QHS $5 300-600 mg 200mg 600mg $45 150mg tabs Trazodone 300mg tabs Desyrel® NF -- -- 300-600mg -- 600mg $225 Vilazodone Viibryd ® F, STE, QL, AL 10mg QD x 7d t $270 40mg 40mg 40mg $270 20mg QD x 7d t 40mg QD Vortioxetine tabs Trintellix® F, STE, QL, AL 10 mg QD $415 20mg 20mg 20mg $382

F=Formulary; NF=Non-Formulary; QL=Quantity Limit; STE=Step Therapy Edit; AL=Age Limit +Cost based on AWP for single source brands, MAC for generic as of October 2017; rounded to the nearest $5 ++Consider blood level monitoring. Patients over age 60 have an 8 fold increase in hip fracture due to postural hypotension even on low doses and may experience significant memory impairment from anticholinergic effects.

F= FORMULARY NF= NON-FORMULARY

PHC’s formulary and medication coverage benefits shall continue as described in this policy until such time as the pharmacy benefit carve-out to Medi-Cal Fee-for-Service described in APL 20-020 and the Governor’s Executive Order N-01-19 may take effect. Please refer to the State Medi-Cal Contract Drugs List (CDL), which is found in both the Medical and Pharmacy provider manual sections of the website. The provider manuals are available at https://files.medi-cal.ca.gov/pubsdoco/manuals_menu.aspx.

111 of 229 PARTNERSHIP HEALTHPLAN OF CALIFORNIA GUIDELINE / PROCEDURE

Guideline/Procedure Number: MPXG5008 (previously QG100129 & MPQG1029) Lead Department:` Health Services Guideline/Procedure Title: Clinical Practice Guidelines: Pain ☒External Policy Management, Chronic Pain Management, and Safe Opioid Prescribing ☐ Internal Policy Next Review Date: 03/11/202104/13/2022 Original Date: 6/16/2004 Last Review Date: 03/11/202004/14/2021 Applies to: ☒ Medi-Cal ☐ Employees Reviewing ☒ IQI ☐ P & T ☒ QUAC Entities: ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving ☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC Entities: ☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, M.D., MPH, MBA Approval Date: 03/11/202004/14/2021

I. RELATED POLICIES: MCUP3049 – Pain Management Specialty Services MPRP4049 – Chronic Opioid Therapy in Chronic Non-Cancer Pain

II. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services C.D. Provider Relations

III. DEFINITIONS: N/A

IV. ATTACHMENTS: A. PHC Recommendations for Safe Use of Opioid Medications: Primary Care & Specialist Prescribing Guidelines B. PHC Recommendations for Safe Use of Opioid Medications: Community Pharmacy Guidelines C. PHC Recommendations for Safe Use of Opioid Medications: Emergency Department Guidelines D. PHC Recommendations for Safe Use of Opioid Medications: Dental Prescribing Guidelines

V. PURPOSE: The purpose of this guideline is to improve care for Partnership HealthPlan of California (PHC) members with chronic pain by: A. Clarifying the roles of primary care practitioners and specialists who care for members with chronic pain. The guideline is designed to help primary care practitioners make appropriate use of pain management specialists. B. Summarizing best practices in opioid prescribing to create a series of recommendations for safe prescribing of opioid medications.

VI. GUIDELINE / PROCEDURE: Partnership HealthPlan is the County Organized Health System covering Medical and Mental Health Benefits for Medi-Cal beneficiaries in 14 counties in Northern California. Our mission is to help our members, and the communities we serve, be healthy. In this spirit, we have launched a community-wide initiative to promote safer use of opioid medications. In addition, PHC’s 14 counties have long supported Substance Use Disorder (SUD) treatment services through the Drug Medi-Cal program.

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Guideline/Procedure Number: MPXG5008 (previously MPQG1029 & QG100129) Lead Department: Health Services Guideline/Procedure Title: Clinical Practice Guidelines: Pain ☒ External Policy Management, Chronic Pain Management, and Safe Opioid Prescribing ☐ Internal Policy Next Review Date: 03/11/202104/13/2022 Original Date: 6/16/2004 Last Review Date: 03/11/202004/14/2021 Applies to: ☒ Medi-Cal ☐ Employees

This guideline recognizes the services and responsibilities of primary care providers (PCPs), pain management and other specialists in caring for members with chronic pain. This guideline is highly dependent upon the individual clinical circumstances and the delivery system. Because of these circumstances, expectations may appropriately deviate from the guideline. The PCP is responsible for coordinating all services required by the patient except when precipitous circumstances preclude the PCP’s role. The scope of the responsibility is comprehensive, (i.e. all required services including preventive services). The PCP should provide those services which can be provided within his/her competence and should obtain consultation when additional knowledge or skills are required. PHC recognizes that differences in skill levels exist among PCPs and that this document serves as a general guideline to define the scope of services and the indications for specialty referral to a pain management specialist. PCPs should continue to use their sound clinical judgment when considering the need for specialty evaluation. Consultation includes advice received from a telephone discussion with a specialist, e-consults, telehealth consultations and the referral of a patient to a specialist for services. When care by a specialist is required, it is the responsibility of the PCP and the specialist to coordinate all services. A. The primary care physician PCP should be responsible for providing the following basic pain management services: 1. The PCP should assess the nature of the chronic pain syndrome, including onset, duration, characteristics and intensity of the pain. FUNCTIONAL CAPACITY SHOULD BE EVALUATED AND IS THE KEY TARGET OF ANY TREATMENTS. In addition, the PCP should assess for depression, anxiety, and secondary gain along with possible alcohol or substance use disorder and should include a thorough medication history. The many possible causes of chronic pain, including osteoarthritis, rheumatoid arthritis, and other inflammatory conditions, degenerative disease and neuropathic pain should be considered. When indicated, the PCP should assess for pain related to work injuries and ask about the relation to accidents or legal issues. 2. A thorough physical exam should be performed as clinically indicated. 3. The PCP should distinguish between physiologic dependence, or tolerance, and or addiction. 4. A pain management contract is an important part of the scope of pain management. PCPs should consider a pain management contract for all chronic pain patients whom who they are following. 5. A referral to a pain management center should be considered when clinically appropriate. Members should not be referred to a pain management specialist until treatable underlying causes have been evaluated thoroughly by the PCP and specialists other than pain management specialists as indicated. All psychiatric illnesses should be under treatment. Any illegal drug usage should be identified, documented and addressed. When specialty consultation is requested, the PCP is responsible for sending all relevant clinical information to the specialist. Referrals solely for purposes of reducing a PCP caseload of opioid-using patients should not be made. 6. Consider referring a member with complex pain management as indicated under Pain Management Specialist referral or whenever the PCP feels the member would benefit from pain management evaluation based on his/her sound clinical judgment. 7. For members who have been referred and evaluated by a pain management or other specialist, the PCP should participate in the ongoing follow-up as jointly determined by the PCP and the specialist for members with these conditions who have reached a high degree of stability. B. Specialist Referral Referral to an appropriate specialist should be considered appropriate in the following situations: 1. Pain Management Specialist a. Complex pain management where the diagnosis is unclear or the condition is unresponsive to usual conservative therapy standard medication and non-pharmacologic therapy for a period of 3 to 6 months.

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Guideline/Procedure Number: MPXG5008 (previously MPQG1029 & QG100129) Lead Department: Health Services Guideline/Procedure Title: Clinical Practice Guidelines: Pain ☒ External Policy Management, Chronic Pain Management, and Safe Opioid Prescribing ☐ Internal Policy Next Review Date: 03/11/202104/13/2022 Original Date: 6/16/2004 Last Review Date: 03/11/202004/14/2021 Applies to: ☒ Medi-Cal ☐ Employees

b. Complex pain management compromised by severe functional impairment. c. Complex pain management complicated by mental health condition or substance use disorder unresponsive to usual therapy and treatment by referral to an appropriate behavioral health specialist. d. For performance and/or supervision of procedures done by pain management specialists. (See MCUP3049 Attachment A – Pain Management Specialty Services Procedure Codes.) 2. Refer to other specialists such as neurology, orthopedics, rheumatology, physical medicine and rehabilitation or behavioral health. Specific indications for referral to specialties other than pain management are beyond the scope of this guideline. The PCP should perform a careful evaluation of conditions with a known cause and initiate conservative therapy consistent with the PCP’s skill and best judgment. Expert consultation should be considered in situations where the diagnosis is uncertain, the member has not responded to usual conservative therapy or specialty care is required based on the diagnosis. 3. After initial specialist consultation or a significant change in the patient status or when the specialist terminates care of patient, the specialist is responsible to send all relevant information back to the PCP. 4. Patients with substance use disorder (SUD) should be referred for treatment, including possible medication-assisted therapy (MAT). C. Opioid Prescribing Guidelines For Physicians 1. Initial treatment considerations should include non-pharmacological therapies, including physical therapy, acupuncture, chiropractic treatment, activity modifications (rest, splinting), and mobility assistance (canes). 2. Based on provider skill level, the PCP should prescribe appropriate analgesics when indicated for the initial management of chronic pain: a. Initial pharmacologic treatment should rely on non-opioid analgesics, including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS). b. The use of opioids (tramadol, and opioids such as codeine, hydrocodone, methadone, oxycodone, morphine, and fentanyl) should be reserved for: 1) Temporary use following trauma or surgery if non-opioid treatment is inadequate, with plan for discontinuation. 2) For chronic use intermittently at the lowest doses in combination with other non- pharmacologic and non-opioid therapies. 3) Severe functional disability, at the lowest doses in combination with other non- pharmacologic and non-opioid therapies (may involve ongoing regular doses). c. Before committing patients to long term regular opioid treatment that may become lifelong, the patient’s age should be taken into consideration. . d. Opioids in the frail elderly may be contraindicated due to safety concerns. e. Consider prescribing naloxone for any patient prescribed high dose opioids (90 daily MED). 3. Pain modulating agents should be considered when appropriate, such as tricyclic antidepressants (amitriptyline and nortriptyline), and anticonvulsants, (gabapentin, pregabalin and carbamazepine). 4. As a minimum standard, PHC policy requires for the prescribing of long-acting opioids for patients with pain not due to active cancer and non-cancer pain who are taking more than 90 mg oral morphine equivalents daily: a. Request a random toxicology screen performed at least once a year to detect prescribed and non- prescribed opioids and other controlled or illicit drugs. Certain in-office toxicology screens are covered by PHC (see Important Provider Notice on PHC website for details). Consider a confirmatory serum test if the results of an in-office screen are unexpected, because false

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Guideline/Procedure Number: MPXG5008 (previously MPQG1029 & QG100129) Lead Department: Health Services Guideline/Procedure Title: Clinical Practice Guidelines: Pain ☒ External Policy Management, Chronic Pain Management, and Safe Opioid Prescribing ☐ Internal Policy Next Review Date: 03/11/202104/13/2022 Original Date: 6/16/2004 Last Review Date: 03/11/202004/14/2021 Applies to: ☒ Medi-Cal ☐ Employees

positive and negative screening results are common. If a patient is at higher risk for substance use disorder (SUD), strongly consider more frequent toxicology screens. b. Require a signed medication use agreement with the prescriber or prescribing office, renewed yearly. c. Provider to check California Department of Justice Controlled Substance Utilization Review and Evaluation System (CURES) report at least yearly, or more frequently, as required by state law. d. Schedule at a minimum, three office visits yearly for chronic pain and monitoring opioid use. 5. Further Recommendations for PCPs and Specialists are found in Attachment AB, PHC Recommendations for Safe Use of Opioid Medications: Primary Care & Specialist Prescribing Guidelines D. Community Pharmacy Guidelines Community Pharmacies play a key role in helping prevent Opioid overdoses, Opioid induced hyperalgesia, Opioid diversion, and Opioid addiction, and have a legal responsibility to do so. PHC recommends that all community pharmacies develop policies and standards to fulfill this responsibility. For detailed recommendations, see Aattachment BC, PHC Recommendations for Safe Use of Opioid Medications: Community Pharmacy Guidelines. E. Emergency Room Guidelines The emergency department has two key roles in helping with community-wide efforts to control Opioid overuse: assuring acute pain is treated in a way that decreases the probability of future over-use of Opioids; working closely with primary care providers to ensure a coherent, safe approach to treating chronic pain. PHC recommendations are found in Attachment CD, PHC Recommendations for Safe Use of Opioid Medications: Emergency Department Guidelines. 1. The emergency department can be a critical access point for members with SUD. ED personnel should consider screening for SUD and initiating medication-assisted treatment (MAT). See https:/www.chch.org/wp-content/uploads/2017/12/PDF-EDMATOpioidProtocols.pdf. F. Dentist Guidelines Dentists play a key role in community-wide efforts to ensure safe prescribing of opioid medications. PHC recommendations are found in Attachment DE, PHC Recommendations for Safe Use of Opioid Medications: Dentist Prescribing Guidelines. G. Indicators Monitored by PHC: These indicators will be monitored for measurement of adherence to this guideline. 1. Treatment authorization request (TAR) will be the initial screening requirement for opioid therapy when the dose of 90mg/day of oral morphine equivalent is exceeded: a. Opioid use for pain due to active cancer or for patients in hospice or palliative care, Sutter’s Advanced Illness Management Program, Napa Valley Hospice’s Transition Program or another concurrent care program (not on hospice but with life expectancy less than 12 months) will be approved as prescribed. When in remission, the opioid treatment should be tapered and discontinued. b. Opioid use in patients with pain not due to active cancer and non-cancer pain: 1) May require initial submission of a copy of a Controlled Substance Utilization Review and Evaluation System (CURES) report and Urine Toxicology (UTOX) screen report. Review of these reports is recommended before starting any patient on opioids. 2) Dose escalation beyond 90mg/day of oral morphine equivalent Opioid for patients with chronic non-cancer and non-terminal pain is not recommended by the medical literature, and therefore generally do not meet criteria for medical necessity. Requests for dose escalation will be reviewed on a case by case basis for extenuating circumstances by a Medical Director.

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Guideline/Procedure Number: MPXG5008 (previously MPQG1029 & QG100129) Lead Department: Health Services Guideline/Procedure Title: Clinical Practice Guidelines: Pain ☒ External Policy Management, Chronic Pain Management, and Safe Opioid Prescribing ☐ Internal Policy Next Review Date: 03/11/202104/13/2022 Original Date: 6/16/2004 Last Review Date: 03/11/202004/14/2021 Applies to: ☒ Medi-Cal ☐ Employees

3) Continuing care requests may require updated documentation of yearly CURES and UTOX reports, attestation that patient is being seen at least three times annually, and presence of a medication use agreement.

VII. REFERENCES: A. American Pain Society. Guideline for the Use of Chronic Opioid Therapy in Chronic Non-cancer Pain Evidence Review. Available at: http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf Accessibility verified on Dec.ember 10, 20199, 2020 B. Becker BE. Pain Management: Part 1: Managing Acute and Postoperative Dental Pain. Anesthesia Progress: A Journal for Pain and Anxiety Control in Dentistry. 2010; 57 (2): 67-69. DOI: 10.2344/0003- 3006-57.2.67, Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886920/ Accessibility verified on Dec.ember 109, 201920 C. Kahan M, Mailis-Gagnon A, Wilson L, and Srivastava A. Canadian Guideline for Safe and Effective Use of Opioids for Chronic Noncancer Pain: Clinical Summary for Family Physicians. The Official Journal of the College of Family Physicians of Canada. Vol 57, November 2011. Available at: http://www.cfp.ca/content/57/11/1257.full.pdf Accessibility verified on Dec.ember 109, 20192020 D. Prescribe to Prevent: Prescribe Naloxone, Save a Life. Instructions for Healthcare Professionals: Prescribing Naloxone. Available at: http://www.prescribetoprevent.org/wp- content/uploads/2012/11/one-pager_12.pdf Accessibility verified on Dec.ember 109, 20192020 E. Washington State Agency Medical Directors’ Group (AMDG). Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain, 2015 Update. Available at: http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf Accessibility verified on Dec.ember 109, 20192020 F. Washington State Agency Medical Directors’ Group (AMDG). Cautious Evidence-Based Opioid Prescribing. Available at: http://www.agencymeddirectors.wa.gov/Files/PrescGuide.pdf Accessibility Verified on December 109, 20192020 G. CDC Guidelines for Prescribing Opioids for Chronic Pain—United States, 2016 https://www.cdc.gov/drugoverdose/prescribing/guideline.html JAMA. 2016;315(15):1624-1645. doi:10.1001/jama.2016.1464 Accessibility verified on Dec. 9, 2020 H. Herring, Andrew A., MD, Emergency Department Medication-Assisted Treatment of Opioid Addiction, August 2016, Available at https:/www.chch.org/wp-content/uploads/2017/12/PDF- EDMATOpioidProtocols.pdf. Accessibility verified on Jan. 22, 2021

VIII. DISTRIBUTION: A. PHC Provider Manual B. PHC Department Directors

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Chief Medical Officer

X. REVISION DATES: Medi-Cal 10/20/04; 03/15/06; 03/21/07; 06/18/08; 07/15/09; 01/16/13; 01/15/14; 01/20/15; 02/17/16; 04/19/17; *03/14/18; 04/10/19; 03/11/20; 3/10/21

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Partnership HealthPlan of California

UTILIZATION MANAGEMENT PROGRAM DESCRIPTION MPUD3001

April 20202021

Amendment 1. 06/10/2020

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PROGRAM PURPOSE ...... 21 PROGRAM OBJECTIVES ...... 21 PROGRAM STRUCTURE ...... 2 PROGRAM STAFF ...... 2 COMMITTEES ...... 111212 UTILIZATION MANAGEMENT PROGRAM SCOPE ...... 131415 MENTAL HEALTH ...... 141516 SUBSTANCE USE DISORDER TREATMENT SERVICES/ WELLNESS & RECOVERY PROGRAM ...... 151617 BEHAVIORAL HEALTH TREATMENT (BHT) FOR MEMBERS UNDER 21 YEARS OF AGE ...... 161718 QUALITY IMPROVEMENT COLLABORATION ...... 161718 UTILIZATION MANAGEMENT PROCESS ...... 171819 Elective Admission Precertification ...... 181920 Referral Management ...... 181920 Continued Stay/Concurrent Review ...... 181920 Skilled Nursing/Sub acute/ Long- Term Acute/Rehabilitation Facility Review ...... 192021 Discharge Planning ...... 192021 Post-Service Retrospective Review ...... 202121 TIMELINESS OF UM DECISIONS ...... 202122 REVIEW CRITERIA ...... 212223 INTER-RATER RELIABILITY (IRR) ...... 222324 COMMUNICATION SERVICES ...... 222324 DENIAL DETERMINATIONS ...... 232425 PROCESS FOR A PROVIDER TO APPEAL AN ADVERSE BENEFIT DETERMINATION ON BEHALF OF A MEMBER ...... 242526 DATA SOURCES ...... 262728 EVAL U ATI O N OF NEW MEDICAL TECHNOLOGY ...... 272829 DELEGATION ...... 272829 PROTECTED HEALTH INFORMATION (PHI) ...... 282929 STATEMENT OF CONFIDENTIALITY ...... 282930 NON-DISCRIMINATION STATEMENT ...... 282930 STATEMENT OF CONFLICT OF INTEREST ...... 293031 PROVIDER AND MEMBER SATISFACTION ...... 293031 ANNUAL PROGRAM EVALU ATI ON ...... 293031 REFERENCES: ...... 303132 UM PROGRAM DESCRIPTION APPROVAL ...... 323333

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PROGRAM PURPOSE

Partnership HealthPlan of California (PHC) is a County Organized Health System (COHS) contracted by the State of California to provide Medi-Cal Beneficiaries with a health care delivery system to meet their medical needs.

The mission of Partnership HealthPlan of California is “To help our Members, and the Communities we serve, be healthy.” Our vision is to be “the most highly regarded health plan in California.”

PHC has program descriptions and policies to describe the structures needed to provide high quality health care while being stewards of taxpayer resources. In the Utilization Management Program Description, PHC outlines the structure of our measurement and management of utilization of health care services within our system.

The PHC Utilization Management (UM) program serves to implement a comprehensive integrated process that actively evaluates and manages utilization of health care resources delivered to all members, and to actively pursue identified opportunities for improvement.

The utilization program is housed within the Health Services Department which consists of five teams including: . Utilization Management . Care Coordination . Population Health . Pharmacy . Quality Improvement

The PHC UM program serves to accomplish the following:

. Ensure that members receive the appropriate quality and quantity of healthcare service . Ensure that healthcare service is delivered at the appropriate time . Ensure that the setting in which the service is delivered is consistent with the medical care needs of the individual

The UM program provides a reliable mechanism to review, monitor, evaluate, recommend and implement actions on identification and correction of potential and actual utilization and resource allocation issues.

PHC recognizes the potential for under-utilization and takes appropriate steps and actions to monitor for this. The processes for UM decision making are based solely on the appropriateness of care and services and existence of coverage. PHC does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in under- utilization and PHC does not use incentives to encourage barriers to care and service. This does not preclude the use of appropriate incentives for fostering efficient, appropriate care.

PROGRAM OBJECTIVES

UM Program Objectives The PHC UM program serves to ensure that appropriate, high quality cost-effective utilization of health care resources is available to all members. This is accomplished through the systematic and consistent application of utilization management processes based on current, relevant medical review criteria and expert clinical opinion when needed. The utilization management process provides a system that ensures equitable access to high quality health care across the network of providers for all eligible members as follows:

. Ensures authorized services are covered under contract with the State of California Department of Health Services (DHCS) California Code of Regulations (CCR) Title 22 - For Medi-Cal Members (Title 22).

119 of 229 . Coordinates thorough and timely investigations and responses to member and provider reconsideration and appeals associated with utilization issues

. Initiates needed operational revisions to prevent problematic issues from reoccurring

. Ensures that services which are delivered are medically needed and consistent with diagnosis and level of care required for each individual, taking into account any co-morbid condition that exists and the ability of the local delivery system to meet the need

. Educates members, practitioners, providers and internal staff about PHC’s goals for providing quality, cost-effective, managed health care

. Defines the methods by which utilization criteria and clinical practice guidelines are selected, developed, reviewed, and modified based upon appropriate and current standards of practice and professional review

. Promotes and ensures the integration of utilization management with quality monitoring and improvement, risk management, and case management activities

. Ensures a process for critical review and assessment of the UM program and plan on, at minimum, an annual basis, with updates occurring more frequently if needed. The process incorporates provider, practitioner and member input along with any regulatory changes, changes to current standards of care, and technological advances

. Evaluates the ability of delegates to perform UM activities and to monitor performance

Program Structure

This section outlines the individual program staff and the assigned activities, including approval authority and the involvement of the designated physician.

Assigned Responsibilities

Program Staff

Chief Medical Officer (CMO) – MD/DO The Chief Medical Officer is responsible for the implementation, supervision, oversight and evaluation of the UM Program.

This position provides guidance and overall direction of UM activities and has the authority to make decisions based on medical necessity which result in the approval or denial of coverage. The assigned activities for this position include but are not limited to: . Assuring that the UM program fulfills its purpose, works towards measurable goals, and remains in regulatory compliance . In collaboration with the Senior Director of Health Services and the Associate Directors of Utilization Management; oversees UM program operations and assists in the development and coordination of UM policies and procedures. . Reviews for the consistent application of UM decision criteria at least annually and implements corrective actions when needed . Serves as the Committee Chair for the Quality/Utilization Advisory Committee (Q/UAC), and regularly attends the Pharmacy and Therapeutics (P&T) Committee and regularly attends the Physician Advisory Committee (PAC)

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit on July 1, 2020. 2

120 of 229 . Ensures timely medical necessity review and decisions are made by daily staffing physicians for medical review consultation . Guides and assists in the development and revision of PHC medical policy, criteria, clinical practice guidelines, new technology assessments, and performance standards for Q/UAC review, adaptation and PAC approval . Is As the chairman of the Q/UAC,; and presents UM activities on a regular basis to the Q/UAC and provides periodic updates on utilization management activities to the PAC and the Board of Commissioners . Evaluates the overall effectiveness of the UM program . Evaluates and uses provider and member experience data when evaluating the UM program in Formatted: Tab collaboration with the Senior Director of Health Services and appropriate committees stops: Not at 0.25"

Regional Medical Director - MD/DO The Regional Medical Director is a physician with the authority to make decisions based on medical necessity which result in the approval or denial of coverage.

The assigned activities for this position include but are not limited to: . Evaluates the appropriateness and quality of medical care delivered through PHC in the designated regional area . Participates in enterprise-wide projects that require Physician involvement . Other duties as assigned by the Chief Medical Officer.

Associate Medical Director - MD/DO This Physician has the authority to make decisions based on medical necessity that result in the approval or denial of coverage. The assigned activities for this position include: . Coverage in the UM Department for medical necessity reviews applying evidence-based UM decision criteria to the review process in determining medical appropriateness and necessity of services for PHC members . Provides review of quality of care issues and serves on Q/UAC . Other duties as assigned by the Chief Medical Officer

Behavioral Health Clinical Director - MD/DO/PhD/ PsyD The PHC Behavioral Health Clinical Director is an MD, DO, clinical PhD, or PsyD who is actively involved in the behavioral health aspects of the UM program. This Director provides clinical oversight of PHC’s behavioral health activities including substance use services and the activities of PHC’s delegated managed behavioral health organization(s). The Behavioral Health Clinical Director has the authority to make decisions based on medical necessity which result in the approval or denial of coverage for behavioral health or substance use services*. The assigned activities for this position include: . Establishes UM policies and procedures in collaboration with PHCs delegated managed behavioral health organization(s) . Oversees and monitors quality improvement activities . Facilitates network adequacy . Participates in the peer review process . Evaluates behavioral health care and substance use disorder (SUD) treatment services* requests in collaboration with PHC’s delegated managed behavioral health organization(s) . Oversees and monitors functions of PHC’s delegated managed behavioral health organizations . Serves on Quality/Utilization Advisory Committee; Pharmacy and Therapeutics . Committee; Credentials Committee and Internal Quality Improvement Committee including the Substance Use Internal Quality Improvement Subcommittee.

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit on July 1, 2020. 3

121 of 229 Pharmacy Services Director – Pharm.D. This position is responsible for overseeing all HealthPlan activities related to pharmacy services and supervising the PHC Pharmacy management team, PHC Clinical Pharmacists, and support staff. The assigned activities for this position include but are not limited to: . Formulary management . Development of applicable policies and guidelines . Serves on the Pharmacy and Therapeutics (P&T) Committee, the Drug Utilization Review (DUR) Board and the Pediatric Quality Committee (PQC) . Drug utilization review . Drug prior authorization . Implementation of cost effective pharmacy measures . Serving as primary contact with the contracted Pharmacy Benefit Manager (PBM), pharmacy providers, and pharmacists . Participation in provider education initiatives such as academic detailing with plan physicians . Medical education meetings . Assisting with development of Clinical Practice Guidelines . . Other duties as assigned by the Chief Medical Officer

Senior Director of Health Services - RN Responsible for the day-to-day implementation of the PHC Utilization Management Program. This position has the authority to make decisions on coverage not relating to medical necessity. The assigned activities include: . Provides oversight and guidance for the UM program across all regions . Reports to the Q/UAC on UM activity . Coordinates departmental UM and Quality Improvement efforts . Collaborates with providers and facilities . Monitors and analyses UM data to inform decision making . Develops recommendations based on data analysis and strategic planning. . Collaborates with the Chief Medical Officer and the Q/UAC on UM activities . Evaluates and uses provider and member experience data when evaluating the UM program in collaboration with the Chief Medical Officer . Prepares and presents the annual evaluation, program description to Q/UAC and PAC Director of Health Services - Northern Region - RN Responsible for the day-to-day operations of the UM and Care Coordination (CC) Programs. This position has the authority to make decisions on coverage not relating to medical necessity. The assigned activities include: . Implements the UM program within assigned regions . Reports to the Senior Director of Health Services on the regional activities and actions taken to remain in regulatory compliance . Reports to the Q/UAC on UM activity . Coordinates departmental UM and QI efforts . Collaborates with providers and facilities . Conducts monitoring activities . Analyzes data . Develops recommendations . Collaborates with the Chief Medical Officer and the Q/UAC on UM issues Director of Utilization Management - Southern Region - RN Manages and provides day to day direction to the Utilization Management department for all product lines ensuring consistent development, implementation and maintenance of health services programs. This position has the authority to make decisions on coverage not relating to medical necessity. The assigned activities include: . Implements the UM program within assigned region

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit on July 1, 2020. 4

122 of 229 . Provides day to day supervision to UM leadership team, oversees daily operations of the department and is available to staff on site or by telepho . Conducts annual performance evaluations for assigned UM staff . Participates in staff trainings and on-site continuing education . Audits medical records as appropriate and monitors for consistent application of UM criteria by UM staff, for each level and type of UM decision . Reports to the Q/UAC on UM act . Responsible for establishing and maintaining reports which relay the efficacy of UM activities and summarizes, at least annually, the UM activity, quality improvement activities and utilization outcomes, with supporting statistical data . Coordinates departmental UM and Quality ef . Collaborates with providers and faci . Conducts monitoring activities . Develops recommendations

Associate Director of Utilization Management Programs- RN Under the direction of the Director of Utilization Management orSenior Director of Health Services, manages and provides direction to the Utilization Management dDepartment mManagers, supervisors and staff for all product lines ensuring consistent development, implementation, and maintenance of health services programs. This position has the authority to make decisions on coverage not relating to medical necessity. Assigned activities include: . Implements the UM program within assigned region . Provides day to day direction to UM Managers and Supervisors within assigned region to meet department goals and objectives and is available to staff on-site or by telephone . Conducts annual performance evaluations for assigned UM staff . Conducts monitoring activities . Participates in staff trainings and on-site continuing education . Audits medical records as appropriate and monitors for consistent application of UM criteria by UM staff, for each level and type of UM decision . Collaborates with providers and facilities . Develops recommendations for program improvements . Coordinates activities with Quality Improvement, Member Services, Claims, and Provider Relations departments to identify, track, and monitor quality of care outcomes and trends . Participates in establishing and maintaining reports which relay the efficacy of UM activities and summarizes, at least annually, the UM activity, quality improvement activities and utilization outcomes, with supporting statistical data at IQI and Q/UAC

Associate Director of Utilization Management Strategies- RN Under the direction of the Senior Director of Health Services, plans, monitors and evaluates utilization management activities to identify strategic initiatives to enhance the efficacy of the UM program, while improving health outcomes, in a cost effective manner. This position has the authority to make decisions on coverage not relating to medical necessity. Assigned activities include: . Collaborates with the provider relations contracting team to identify strategic opportunities and develops recommendations . Participates in contract review and negotiations . Attends regular meetings with hospitals, long-term care facilities and community agencies to facilitate cost effective and appropriate alternative placements . In collaboration with the Senior Director of Health Services and Senior Director of Provider Relations, reviews and processes provider grievances in accordance with appropriate regulatory requirements and participates in provider grievance meetings . Works collaboratively with claims and configuration department leaders and team members to identify systematic issues or opportunities for staff and/or provider education

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit on July 1, 2020. 5

123 of 229 . Attends claims configuration meetings and Benefit Review Evaluation Workgroup (BREW) as well as IQI, Q/UAC and PAC . Works with providers and/or vendors to facilitate issue resolution and ensure a consistent UM process . Develops, reviews, and/or revises PHC UM policies and procedures in collaboration with the Senior Director of health services as appropriate.

Associate Director of Utilization Management Regulations Under the direction of the Senior Director of Health Services, provides oversight of the UM Program to ensure compliance with regulatory requirements including, but not limited to, requirements of DHCS and the National Committee for Quality Assurance (NCQA). Assigned activities include: . Coordinates activities with External and Regulatory Affairs Compliance, Member Services, Claims, and Provider Relations departments to identify, track, and monitor quality of care issues and trends related to UM Department processes . Prepares reports on departmental activities according to established schedules and format. Identifies patterns and trends, conducts retrospective review as needed and works with UM Leadership to develop corrective action plans. . Participates in the grievance process . Acts as primary contact and support to each UM Delegate, providing training and support as necessary . Conducts delegation oversight through regular auditing of each UM Delegate, prepares audit reports for review by the Senior Director of Health Services and the Chief Medical Officer or physician designee, and prepares information for the Delegation Oversight Review Sub-Committee (DORS) . Collaborates with the Associate Director of UM Programs to ensure that all policies and procedures related to regulatory requirements are updated at least annually, or as needed, and presented to appropriate committees for review. Assists PHC staff and providers with the interpretation of PHC policies, procedures, and regulatory requirements. . Works with UM Leadership and Trainer to develop standardized training content and materials for new staff and ongoing education for existing staff . Participates in the planning and development of new/ enhanced Health Services plan benefits or product lines as needed. Attends Benefits Review and Evaluation Workgroup meetings . Participates in audits by various regulatory agencies as necessary

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit on July 1, 2020. 6

124 of 229 Utilization Management Team Manager - RN Responsible for the implementation, management and evaluation of an effective and systematic UM Program. Provides day-to-day guidance to UM staff and manages all aspects of utilization review activities and is available to staff on-site or by telephone. Working with the Chief Medical Officer, Senior Director of Health Services, Associate Directors of UM, utilization committees, and Health Plan Directors, promotes efficient resource utilization throughout the organization, providing leadership, teambuilding and direction needed to ensure attainment of UM Targetsgoals. This position has the authority to make decisions on coverage not relating to medical necessity. The assigned activities include: . Coordinates completion of activities . Presents work plan status reports and updates to the Q/UAC. . Monitors for consistent application of UM criteria by UM staff for each level and type of UM decision . Participates in staff trainings and on-site continuing education . Provides recommendations for interventions designed to improve utilization management issues . Coordinates implementation of interventions . Develops UM policy and procedures for Q/UAC approval . Develops, or coordinates development of, documentation of UM activities . Conducts annual performance evaluations for assigned UM staff

Inpatient/Outpatient Nurse Supervisor UM - RN This position is responsible for the daily mentorship and oversight of the staff assigned to inpatient or outpatient services. This position has the authority to make decisions on coverage not relating to medical necessity. The assigned activities include: . Works collaboratively with all levels of leadership within the department to efficiently coordinate workflow and individual staff assignments . Provides day to day supervision to the assigned team, overseeing daily operation of the inpatient or outpatient review process . Participates in staff trainings and on-site continuing education. With UM ManagerLeadership, conducts annual performance evaluations for assigned UM staff . Audits medical records as appropriate and monitors for consistent application of UM Criteria by UM staff, for each level and type of UM decision. . This position, in addition to his/her own case load, may be assigned cases in the area of oversight as deemed necessary to provide coverage Nurse Coordinator/ UM Lead – RN/LVN Under the direction of the UM Team Supervisor, provides assistance with oversight during the daily operations of the outpatient/inpatient review process. This position has the authority to make decisions on coverage not relating to medical necessity. The assigned activities include: . Provides day to day direction and support to staff concerning daily assignments and is available to staff on-site or by telephone . Assists in the refinement/improvement of the Health Services programs. Participates in continuous process improvement endeavors and monitors for consistent application of UM Criteria by UM staff for each level and type of UM decision . Works with other PHC departments to resolve issues relating to authorization of medical services

Nurse Coordinator/ UM II - RN/ LVN Work collaboratively with all levels of UM leadership and other PHC staff to develop, implement, and evaluate health outcomes, provider performance and other performance indicators pertinent to quality of care. This position has the authority to make decisions on coverage not relating to medical necessity. Assigned activities include: . Assist in training and orientation of new staff to the department upon request . Review and authorization of DME, Ancillary and Medical TARs based on established guidelines . Review and authorization of Long Term Care TARs based on established guidelines . Review and authorization of inpatient Hospital TARs based on established guidelines . Retrospective review of services to determine medical necessity

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125 of 229 . Refer cases to the Chief Medical Officer for requests that may not appear to meet evidence- based medical necessity criteria . Determines if requested services are part of the member’s benefit package . Work collaboratively with the Care Coordination, Population Health, Pharmacy and Quality Improvement staff on UM issues

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126 of 229 Nurse Coordinator/ UM I - RN/ LVN Work collaboratively with all levels of UM leadership and other PHC staff to develop, implement, and evaluate health outcomes, provider performance and other performance indicators pertinent to quality of care. This position has the authority to make decisions on coverage not relating to medical necessity. Activities assigned include: . Review and authorization of DME, Ancillary and Medical TARs based on established guidelines. . Review and authorization of Long Term Care TARs based on established guidelines. . Review and authorization of inpatient Hospital TARs based on established guidelines. . Retrospective review of services to determine medical necessity . Refer cases to the Chief Medical Officer for requests that may not meet medical necessity criteria . Determine if requested services are part of the member’s benefit plan . Work collaboratively with the Care Coordination, Population Health, Pharmacy, and Quality Improvement staff on UM issues

Behavioral Health Clinical Specialist – LCSW or LMFT or other licensed behavioral health specialties Licensed Practitioner of the Healing Arts (LPHA)1 who develops, implements, and coordinates medically necessary treatment services within PHC’s Health Services for adults and children with behavioral health and/or substance use services needs. Reviews residential placement authorization requests for residential treatment services according to the specific terms of the contract with the provider and in accordance with the medical necessity requirements for Medi-Cal eligible beneficiaries.*

Data Coordinator/ Supervisor UM – Administrative Works closely with UM Team Manager Leadership to establish consistent evaluation of Data Coordinators’ work performance. Responsible for oversight of Data Coordinators. . Monitors day to day functions including coordination of assignments, monitoring of call volume and adherence to PHC workplace policy and is available to staff on-site or by telephone . Assists in the refinement/improvement of the HS programs . Provides performance feedback to the Data Coordinator staff and conducts staff trainings as needed. . Monitors UM Data Coordinator activity for consistent application of desktop processes and procedures by UM Data Coordinator staff . Provides leadership, direction, training, and support to the assigned staff . Participates in staff trainings and on-site continuing education . Conducts annual performance evaluations for assigned UM staff

Data Coordinator/ UM Lead - Administrative Under the direction of the Data Coordinator Supervisor and UM Team ManagerLeadership: . Monitors Data Coordinator documentation for accuracy . Ensures Data Coordinator staff have the resources required for completing TAR entry and using good judgment and is available to staff on-site or by telephone . Enters both manual and electronic submitted data into PHC systems for RAF and TAR authorizations . Monitors UM Data Coordinator staff for consistent application of desktop processes and procedures . Responsible for assisting with ongoing staff education in proper use of systems and PHC UM Departmental policies and procedures . Participates in staff trainings and on-site continuing education

1 Licensed Practitioner of the Healing Arts (LPHA): Physicians, Nurse Practitioners, Physician Assistants, Registered Nurses, Registered Pharmacists, Licensed Clinical Psychologist, Licensed Clinical Social Worker (LCSW), Licensed Professional Clinical Counselor, Licensed Marriage and Family Therapist (LMFT), and licensed-eligible practitioners working under the supervision of licensed clinicians.

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127 of 229 Executive Assistant to CMO - Administrative Provides administrative support to the Chief Medical Officer. Responsible for maintaining and updating online policy and procedure manuals and managing appointment calendars. Coordinates setup and executes minutes for designated meetings.

Continuing Education Program Coordinator - Administrative Provides administrative support to the Chief Medical Officer. Responsible for coordinating the Continuing Education program, including planning meetings and trainings. Audits each CME/CE activity to ensure all elements required by organizations overseeing PHC’s educational programs are documented. Maintains organized electronic versions of all continuing education records.

Health Services Administrative Assistant II - Administrative Provides administrative support to the Senior Director and/or Health Services Director.other UM Leadership. Responsible for maintaining and updating online policy and procedure manuals and managing appointment calendars. Coordinates setup and executes minutes for designated meetings.

Health Services Administrative Assistant I – UM - Administrative Provides administrative support to the Director of UM, UM LeadershipAssociate Director of UM, and UM Team Manager. Responsible for maintaining and updating policy and procedure manuals, managing appointment calendars, and working closely with the Information Technology Department to ensure appropriate electronic functioning for the Health Services Department.

Health Services Administrative Assistant II – CMO - Administrative Responsible for administrative support to the Associate and Regional Medical Directors. Responsible for managing appointment calendars, scheduling daily UM and pharmacy workload coverage for the MDs, developing weekly and monthly schedules for distribution to other departments, and coordinating Peer-to-Peer requests from providers. Coordinates setup and executes minutes for designated meetings.

Authorization Specialist/ UM Trainer – Administrative MA Responsible for providing training on all appropriate software platforms for new hires. Creates and maintains current training materials for Data Coordinators, Coordinator Supervisor, Nurse Coordinators, and Team Managers of the UM departmentincluding eligibility, TAR processes, and UM policy and procedures. In conjunction with UM leadership team, prepares and delivers retraining of identified topics as deemed necessary. . Facilitates independent DME consultant evaluation visits to members for specialty equipment needs as needed or directed by Team Manager or Associate Director of UMUM Leadership. . Acts as a resource regarding UM department software programs and special projects upon request and is available to staff on-site or by telephone . Coordinates with Member Services Call Center system to place members into appropriate health plansDirect Member status related to their care.: HP 06, HP 11, and HP 38

Coordinator II - Administrative Under the direction of the UM Team Manager and/or the Data Coordinator Supervisor: . Serves as a resource to other departments who have inquiries into the UM process . Responsible for the input of data and information concerning UM Referrals and Authorizations . Receives and responds to telephonic inquiries from providers regarding status of authorization requests and other questions or concerns . Performs triage and transfers calls to appropriate professional staff when indicated

Coordinator I - Administrative Under the direction of the UM Team Manager and/or the Data Coordinator Supervisor - responsible for the input of data and information concerning UM Referrals and Authorizations. . Maintains departmental documents

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128 of 229 . Receives and responds to telephonic inquiries from providers regarding status of authorization requests and other questions or concerns . Performs triage and transfers calls to appropriate professional staff when indicated

Coordinator I - Appeals - Administrative Under the direction of the UM Team Manager and the Associate Director of UM Programs: . Responsible for clerical processing of provider appeals in accordance with policy, procedures, timeframes and requirements of various regulatory bodies for all lines of business . Acts as liaison to Claims Department in coordinating timely response to all claims inquiries . Participates in special projects, tasks and assignments as directed

Delegation Program Coordinator I -– Administrative Under the direction of the UM Associate Director of UM Regulations . Responsible for collecting and tracking required document submissions from delegated entities . Coordinates and participates in both desktop and onsite audits of delegated entities . Ensures efficient and appropriate collaboration between the Utilization Management staff and UM delegated entities

Project Coordinator II - Administrative Under the direction of the UM DirectorSenior Director of Health Services or other designated leadership. . Tracks project deliverables and resources using appropriate internal tools to ensure deadlines are met . Works collaboratively with the HS analyst, IT and Finance to design and implement reports to accurately reflect the work completed and outcomes achieved within the Department and its programs . Coordinates with the Regulatory Affairs Department to conduct research on regulations, statutes, laws, administrative policies and procedures

Committees

Board of Commissioners The Board of Commissioners on Medical Care (the Commission) promotes, supports, and has ultimate accountability, authority and responsibility for a comprehensive and integrated UM program. The Commission is ultimately accountable for the efficient management of healthcare resources and services provided to members. The Commission has delegated direct supervision coordination, and oversight of the UM program to the Q/UAC which reports to the PAC, the committee with overall responsibility for the program. Members of the Commission are appointed by the county Boards of Supervisors for each geographic service area and include representation from the community, consumers, business, physicians, providers, hospitals, community clinics, HMOs, local government, and County Health Departments. The Commission meets six times a year.

Physician Advisory Committee (PAC) The PAC monitors and evaluates all Health Services activities and is directly accountable to the Board of Commissioners for the oversight of the UM program. The PAC meets at least ten (10) times a year and may not convene monthly; excluding in the months of July and December, with the option to add additional meetings if need. and vVoting membership includes external Primary Care Providers (PCPs), board certified high-volume specialists, and behavioral health practitioners. A voting provider member of the committee chairs the PAC. The PHC Chief Executive Officer, Chief Operating Officer, Chief Financial Officer, Chief Medical Officer, Associate Medical Director of Quality, Regional Medical Director(s), Clinical Director of Behavioral Health, Senior Director of Health Services and leadership from the Quality and Performance Improvement, Provider Relations, Health Services, Utilization Management, and Pharmacy departments attend the PAC meetings regularly. Other PHC staff attend on an ad hoc basis to provide expertise on specific agenda

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129 of 229 items. The PAC oversees the activities of the Q/UAC and other quality-related committees and reports activities to the Board of Commissioners.

Quality/Utilization Advisory Committee (Q/UAC) The Q/UAC is responsible to assure that quality, comprehensive health care, and services are provided to PHC members through an ongoing, systematic evaluation and monitoring process that facilitates continuous quality improvement. Q/UAC voting membership includes consumer representative(s) and external providers who are contracted primary care providers (PCPs) and board certified specialists in the areas of internal medicine, family medicine, pediatrics, OB/GYN, nephrology, neonatology, behavioral health, and representatives from other high volume specialties. The PHC Chief Medical Officer (CMO) (chair of the committee), Clinical Director of Behavioral Health, Associate Medical Director of Quality, Associate and Regional Medical Directors and leadership from the Quality and Performance Improvement, Provider Relations, Utilization Management, Care Coordination, Population Health, Pharmacy, and Grievance Departments attend the Q/UAC meetings regularly. Other PHC staff attend on an ad hoc basis to provide expertise on specific agenda items. The committee meets on a monthly at least ten (10) times per year, with the option to add additional meetings if needed. Q/UAC activities and recommendations are reported to the PAC and to the Commission at least quarterly. The Q/UAC provides guidance and direction to the UM program by coordinating activities and by functioning as the expert panel when needed. Coordination includes but is not limited to:

. Reviewing, making recommendations to, and approving the UM Program Description annually . Assuring individual member needs are taken into consideration when determinations for care are rendered and in the development of medical policy and procedures. . Analyzing summary data and making recommendations for action . Reviewing action plans for quality improvements of UM activities and providing ongoing monitoring and evaluation . Reviewing medical policy, protocol, criteria and clinical practice guidelines . Providing oOversight of delegated activities

Pharmacy and Therapeutics Committee (P&T) The P&T Committee is chaired by the PHC’s Chief Medical Officer (CMO) Pharmacy Director and is comprised of PHC’s Chief Medical OfficerPharmacy Director, Associate and Regional Medical Directors, PHC staff and network practitioners including pharmacists, primary care physicians, behavioral health and other specialists. P&T makes decisions and recommendations on development and review of the prescription drug formulary*, pharmacy policy and procedures, and drug approval criteria. P&T Committee also serves as PHC’s Drug Utilization Review (DUR) Board to review PHC’s DUR program and activities and make recommendations where necessary to improve PHC’s drug utilization. The P&T meets quarterly, providing regular activity reports and recommendations to the PAC, the approval authority for P&T related activities. (*Note: PHC’s formulary and medication coverage benefits shall continue as described in this policy until such time as the pharmacy benefit carve-out to Medi-Cal Fee-for-Service described in APL 20-020 and the Governor’s Executive Order N-01-19 may take effect.)

Provider Advisory Group (PAG) The PAG is one of the Commission’s advisory committees and acts as a liaison between practitioner offices and PHC. The committee meets quarterly and has representatives from physician groups and individual offices, community clinics, ancillary providers, long term care facilities, employees of cCounty hHealth & Social Services departments, and community advisory groups. The PAG reports directly to the Board of Commissioners, providing feedback and making recommendations related to health care service issues, community health activities, and issues for special needs populations.

Substance Use Services* Internal Quality Improvement Subcommittee (SUIQI) A committee comprised of appropriate PHC and County staff tracks progress towards successful completion of quality initiatives, surveys, audits, and accreditation for the PHC’s Substance Use Services* oversight. The

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130 of 229 SUIQI meets at least quarterly.ing frequency will be determined at a later date, closer to the implementation of the benefit. Activities and progress are reported to the IQI. This also includes • Review of Utilization Management retroactive and appeals review • Review of inter-rater reliability for peer review and utilization management • Review of quality of service, quality of facility, and access complaints and grievances • Investigation of potential over-use, under-use, and misuse of services. • Review of policies related to provision of SU services

Members of the committee include the Clinical Director, Behavioral Health Clinical Director, the CMO, and representatives from the Provider Relations, Member Services, Claims, Compliance, Behavioral Health and Quality Improvement Departments. Consumer Advisory Committee (CAC) The CAC is composed of PHC health care consumers who represent the diversity and geographic areas of PHC’s membership. There are two CAC committees – one in PHC’s Northern seven counties and a second in PHC’s Southern seven counties. Both groups meet quarterly. The CAC is a liaison group between members and PHC, advocating for members by ensuring that the health plan is responsive to the health care and information needs of all members. The CAC reviews and makes recommendations regarding Member Services’ Quality Improvement Activities, provides feedback on Quality Initiatives and serves in the capacity of a focus group. A consumer from each region serves on the Board to provide consumer input and report back to their respective CAC.

UTILIZATION MANAGEMENT PROGRAM SCOPE

UM activities are developed, implemented and conducted by the PHC Health Services Department under the direction of the Chief Medical Officer and the Senior Director of Health Services. The UM staff performs specific activities.

Specific functions include: . Prospective, concurrent and retrospective utilization review for medical necessity, appropriateness of hospital admission, level of care and continued inpatient confinement on a frequency consistent with evidence-based criteria and PHC guidelines, PHC criteria/ medical policy and the member's condition. This review is performed cooperatively with the facility care team which may consist of the attending physician(s) and any associated health care personnel who can provide information that will substantiate medical necessity and level of care. . Discharge planning in collaboration with the facility care team . Review inpatient and outpatient UM data to determine appropriateness of member and provider utilization patterns . Use of most current edition of InterQual® Criteria for medical authorization, and other PHC UM guidelines and medical policy as developed and approved by the Quality / Utilization Advisory Committee (Q/UAC) . Use of California Department of Health and Welfare Code of Regulations Title 22, Center for Medicare & Medicaid Services (CMS) Code of Federal Regulations (CFR) Title 42 and National and Local Coverage Determinations . Review certification requests for skilled nursing care, home health care, durable medical equipment, ambulatory surgery, ambulatory diagnostic and treatment procedures such as physical, occupational and speech therapies.

The UM program incorporates the monitoring and evaluation for the subsequent services and reviews and updates policies and procedures as appropriate but at least annually. . Acute hospital services . Subacute care . Ambulatory care

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131 of 229 . Emergency and urgent care services . Durable Medical Equipment and supplies . Ancillary care services, including but not limited to home health care, skilled nursing care, subacute care, pharmacy, laboratory and radiology services . Long-term care including Skilled Nursing Facility (SNF) Care and Rehabilitation Facility Care . Pharmacy drug formulary (Note: PHC’s formulary and medication coverage benefits shall continue as described in this policy until such time as the pharmacy benefit carve-out to Medi-Cal Fee-for-Service described in APL 20-020 and the Governor’s Executive Order N-01-19 may take effect.)

Mental Health

Members may self-refer for mental health services to the appropriate mental health providers using the delegated Behavioral Health Organization’sProvider’s toll-free referral numbers or by contacting the preferred behavioral health provider directly. Members do not need a referral or prior authorization from their Primary Care Provider (PCP) to receive mental health services.

In an effort to coordinate the member’s overall health care, medical and mental health care, mental health providers are instructed to ask members to sign a release of information so that the mental health provider can contact the member's PCP or other providers. However, Mental health treatment however, is considered a confidential service and the release of information is not a condition for the approval or provision of services.

Mental health services for Members with Medi-Cal as their primary insurance are provided as follows: . Members determined to have mental health needs that require mild to moderate mental health treatment are served by PHC’s delegated contractor, Beacon Health Options at (855) 765-9703. . Members assigned to Kaiser are assessed by Kaiser and served or appropriately referred. . Members determined to have moderate to severe mental health conditions are referred to the County Mental Health Plan in the Member’s county of eligibilityresidence (Except for Solano County Kaiser . members who will have their moderate to severe mental health conditions managed by Kaiser). The administration of such referrals is addressed in the respective Memorandum of Understanding (MOU) with each respective County Mental Health Plan, consistent with California statutes and regulations. . An initial assessment may be performed by any of these entities described above to determine the most appropriate level of service for the Member, including appropriate referral.

* Note that Effective July 1, 2020, PHC will also provides substance use disorder treatment services as outlined in the Regional Drug Medi-Cal Model when the benefit becomes effective (estimated late Spring 2020). PHC will performs utilization management for residential treatment of substance use disorders. For more information, please see the Substance Use Disorder Treatment Services/ Wellness & Recovery Program section below.

County Mental Health Plans provide crisis assessments and authorizations for acute in-patient care. Immediate access to the crisis service remains an option throughout all phases of treatment by any provider. Each The County operates crisis services which tabilization service to address clients in crisis; crisis services also acts as a backup after hours and on weekends as well as at other times of provider unavailability. Members may call the County crisis line directly, without a referral. Members eligible for mental health services from PHC delegated contractors will be re-directed to appropriate County crisis services as needed.

A certain level of mental health services is appropriately dealt with in a primary care practice, including screening and referrals to services. Primary Care Providers may contact each county’s Mental Health Plan or PHC’s delegated contractor, Beacon Health Options, for telephone consultation. For detailed referral and

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132 of 229 consultation procedures, PCPs can refer to PHC Policy MPCP2017 Scope of Primary Care—Behavioral Health and Indications for Referral Guidelines.

PHC is responsible for the delivery of non-specialty mental health services for children under age 21 and outpatient mental health services for adult beneficiaries with mild to moderate impairment of mental, emotional, or behavioral functioning resulting from a mental health disorder, as defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM). Outpatient mental health services are delivered as specified in policy MCUP3028 Mental Health Services whether they are provided by PCPs within their scope of practice or through PHC’s provider network. PHC continues to be responsible for the arrangement and payment of all medically necessary, Medi-Cal-covered physical health care services, not otherwise excluded by contract, for PHC beneficiaries who require specialty mental health services.

In compliance with Mental Health Parity requirements on October 1, 2017, as required by Title 42, CFR Section 438.930, PHC ensures direct access to an initial mental health assessment by a licensed mental health provider within the PHC provider network. No referral from a PCP or prior authorization is required for an initial mental health assessment to be performed by a network mental health provider.

PHC meets the general parity requirement (Title 42, CFR, §438.910(b)) which stipulates that treatment limitations for mental health benefits may not be more restrictive than the predominant treatment limitations applied to medical or surgical benefits. Neither a referral from the PCP nor prior authorization is required for a beneficiary to seek any mental health service, including the initial mental health assessment from a network mental health provider.

If a dispute occurs between the local County Mental Health plan and Partnership HealthPlan of California (PHC) or its delegated contractors, Kaiser or Beacon Health Options, both parties will participate in a dispute resolution process as defined in PHC Policy MCUP3127 Dispute Resolution Between PHC and MHPs in Delivery of Behavioral Health Services. This is consistent with the dispute resolution process outlined by State regulations and the individual County/PHC Memoranda of Understanding.

Triage and Referral for Mental Health

PHC monitors the triage and referral protocols for the delegated behavioral health services provider(s) to assure they are appropriately implemented, monitored and professionally managed. Protocols employed by delegates must be clinical evidence- based and an accepted industry practice. Protocols shall outline the level of urgency and appropriateness of the care setting.

Triage and referral decisions are performed by the Care Coordination and UM teams of the delegated Behavioral Health Services Provider which are co-located in the PHC offices with oversight by PHC’s Behavioral Health Clinical Director. Both work collaboratively with the designated County Mental Health PlansDepartments to ensure members receive care at the appropriate level in a timely manner.

Substance Use Disorder Treatment Services/ Wellness & Recovery Program*

PHC works to ensure that members receive effective and appropriate behavioral health care services for both mental health and substance use disorders. Substance Use Disorder (SUD) treatment services are administered either by PHC or through individual counties. offered through the state Drug Medi-Cal program are being greatly expanded in seven of our counties (Humboldt, Lassen, Mendocino, Modoc, Shasta, Siskiyou, and Solano) through our new Wellness & Recovery Program, a benefit to become which became effective July 1, 2020. (Expanded SUD services are available in Napa, Marin, and Yolo counties, and are administered by the

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133 of 229 counties. A more limited benefit is administered by the remaining four counties — Del Norte, Lake, Sonoma and Trinity)

The range of services in the Wellness & Recovery Program include:

. Outpatient treatment (licensed professional or certified counselor, up to nine hours per week for adults) . Intensive outpatient treatment for individuals with greater treatment needs (licensed professional or certified counselor, structured programming, 9-19 hours per week for adults) . Detoxification services (withdrawal management) . Residential treatment (Prior authorization is required as per policy MCCP2028 Residential Substance Use Disorder Treatment Authorization) . Medicationlly assisted treatment (methadone, buprenorphine, disulfiram, naloxone) . Case management . Recovery services (aftercare)

Behavioral Health Treatment (BHT) for Members Under 21 Years of Age

PHC has provided benefits for Behavioral Health Therapy for children diagnosed with Autism Spectrum Disorder (ASD) since September 2014.

Effective July 1, 2018, PHC expanded its benefit coverage to include Behavioral Health Treatment (BHT) for eligible Medi-Cal members under the age of 21 as required by the Early and Periodic Screening and Diagnostic Treatment (EPSDT) mandate.

Treatment services may include Applied Behavioral Analysis (ABA) and other services known as Behavioral Health Treatment (BHT).

BHT is the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the direct observation, measurement and functional analysis of the relations between environment and behavior.

BHT services teach skills through the use of behavioral observation and reinforcement, or through prompting to teach each step of targeted behavior. BHT services include a variety of behavioral interventions that have been identified as evidence-based by nationally recognized research reviews and/or other nationally recognized scientific and clinical evidence that are designed to be delivered primarily in the home and in other community settings.

PHC will provide BHT services for all members who meet the eligibility criteria for services as stated in 1905® of the Social Security Administration (SSA) and outlined in DHCS All Plan Letter (APL) 19-014. . Additional detailed information regarding the BHT benefit can be found in the following PHC Policies and Procedures: o MPUP3126 Behavioral Health Treatment (BHT) for Members Under the Age of 21 o MCCP2014 Continuity of Care

Quality Improvement Collaboration

The UM team works collaboratively with the Quality Improvement Department to enhance the care provided to our members through venues such as the Internal Quality Improvement Committee (IQI) , the Quality/ Utilization Advisory Committee (Q/UAC) and daily UM activities.

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134 of 229 In the committee environment, the UM team takes an analytical, evaluative and strategic look at predetermined metrics to evaluate and offer recommendations which further enhance the UM program. Data is reviewed and discussed at least bi-annually during the IQI and Q/UAC meetings. The Q/UAC provides guidance and direction to the UM program by coordinating activities and by functioning as the expert panel when needed. Collaboration includes but is not limited to:

. Reviewing, making recommendations to, and approving the UM Program Description annually . Assuring individual member needs are taken into consideration when determinations for care are rendered . Analyzing summary data and making recommendations for action . Reviewing the recommendations of Process Implementation Teams to develop UM improvement action plans, ongoing monitoring, and evaluation . Recommending medical policy, protocol, and clinical practice guidelines based on provider and member experience information.

During daily activities, the UM team supports QI efforts in the identification of potential quality of care issues, reporting adverse occurrences identified while conducting um UM case review, improvement of Healthcare Effectiveness Data and Information Set (HEDIS®) scoring by referrals to care coordination, and care coordination efforts to ensure members are seen by the appropriate provider for their condition. UTILIZATION MANAGEMENT PROCESS

PHC applies written, objective, evidence-based criteria (InterQual®) and considers the individual member’s circumstance, and community resources when making medical appropriateness determinations for behavioral health and physical health care services.

On an annual basis, PHC distributes a statement to all its practitioners, providers, members and employees alerting them to the need for special concern about the risks of under-utilization. It requires employees who make utilization-related decisions and those who supervise them to sign a statement, which affirms that UM decision making is based only on appropriateness of care and service.

Furthermore, PHC does not reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service. Financial incentives for UM decision makers do not encourage decisions that result in under-utilization and PHC does not use incentives to encourage barriers to care and service. This does not preclude the use of appropriate incentives for fostering efficient, appropriate care.

Working with practitioners and providers of care, the following factors are taken into consideration when applying guidelines to a particular case in review:

. Input from the treating practitioner . Age of member . Comorbidities in existence . Complications . Progress of treatment . Psychosocial situation . Home environment . Consideration of the delivery system and availability of services to include but not be limited to: o Availability of inpatient, outpatient and, transitional and residential treatment (SUD) facilities o Availability of outpatient services o Availability of highly specialized services, such as transplant facilities or cancer centers o Availability of skilled nursing facilities, subacute care facilities or home care in the organization’s service area to support the patient after hospital discharge o Local hospitals’ ability to provide all recommended services . Benefit coverage

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135 of 229

Referrals and requests for prior authorization of services are to be submitted by the provider of service to the PHC UM department by mail, fax or through PHC’s Provider Portal which is a Secure Electronic Internet system. The following information must be provided on all requests.

. Member demographic information . Provider demographic information . Requested service/procedure to include specific CPT/HCPCS code(s) . Member diagnosis (Using current ICD Code sets) . Clinical indications necessitating service or referral . Pertinent medical history, treatment or clinical data . Location of service to be provided . Requested length of stay for all inpatient requests . Proposed date of procedure for all outpatient surgical requests

Pertinent data and information is required to enable a thorough assessment of medical necessity. If information is missing or incomplete, the requestor will be notified and given an opportunity to submit returned to the requester.additional information.

Elective Admission Precertification The UM department evaluates every proposed treatment plan, and determines benefit eligibility, suitability of location and level of care prior to the approval of service delivery for select diagnoses and procedures.

Utilizing written criteria such as InterQual®, Medi-Cal Criteria and PHC medical policy approved by the Q/UAC, licensed and professional UM staff review and approve completed Treatment Authorization Requests (TARs).

Only the Chief Medical Officer or physician designee may make a medical necessity determination and have the authority to deny a service request based on lack of medical necessity. PHC offers the practitioner the opportunity to discuss any medical necessity denial determination with the physician reviewer rendering the decision.

Referral Management Referrals are generated by the primary care provider and submitted to PHC either by mail, fax or secure Provider Portal. PCH PHC monitors and analyzes requests to identify trends and assist in follow-up care. Requests for out-of-network referrals are reviewed to determine if the service is available and can be provided within the service area. Out-of-Network requests are also used to evaluate provider access and to determine if the local network requires enhancements to meet member needs.

Continued Stay/Concurrent Review Acute care hospitalization reviews are performed by licensed professionals to ensure medical necessity of continued stay, the appropriateness of level of care, and care duration. This review is conducted either on site, by accessing the facility electronic medical record through a secure portal, or telephonically using written PHC medical policy, InterQual®, and/or Medi-Cal guidelines. PHC UM staff in conjunction with the use of written criteria consider the following:

. Patient age . Patient comorbidities . Complications . Progress of treatment . Psychosocial circumstance . and Home environment where applicable

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136 of 229 Requests for authorization are reviewed within 24 hours of notification of admission and concurrently throughout the stay. The UM team facilitates discharge planning in collaboration with the facility care team and makes referrals to PHC case management and social services as appropriate.

Consideration of available services in the local service area or delivery system and the ability to meet the member’s specific health care needs are evaluated as part of application of criteria and the development of an ongoing plan of care and discharge plan.

Only the Chief Medical Officer or physician designee has the authority to deny a request for service based on lack of medical necessity. PHC offers the practitioner with clinical expertise in the area being reviewed the opportunity to discuss the application of criteria in determining medical necessity or any determination based on lack of clinical justification with the physician reviewer.

In addition to individual conversations with practitioners on specific case reviews, PHC conducts several committees for the purpose of hearing and incorporating practitioner input in the development of medical policy. PHC, through the Physician Advisory Ccommittee (PAC), the Pharmacy and Therapeutics Committee (P&T) and the Physician Advisory Group (PAG), provides practitioners with clinical expertise in several areas the opportunity to advise or comment on the development and/ or adaptation of UM criteria and provide feedback or instruction on the application of that criteria. Within the previously stated committees, PHC evaluates UM criteria and procedures against current clinical and medical evidence and updates them accordingly.

Skilled Nursing/Sub acute/ Long- Term Acute/Rehabilitation Facility Review Review of all Skilled Nursing and Rehabilitation Facility confinements are performed by licensed professionals to ensure medical necessity of continued stay and the appropriateness of level and duration of care. This review is conducted telephonically using written PHC medical policy, Title 22 criteria, and/or InterQual® criteria. PHC UM staff in conjunction with the use of written criteria consider the following:

. Age . Comorbidities . Complications . Progress of treatment . Psychosocial circumstance . and Home environment where applicable

Requests for authorization are reviewed within 24 hours of notification of admission. The UM team facilitates discharge planning in collaboration with the facility care team and makes referrals to PHC case management and social services as appropriate.

Consideration of available services in the local service area or delivery system, and the ability to meet the member’s specific health care needs are evaluated as part of applying criteria and the development of an ongoing plan of care and discharge plan.

Discharge Planning Discharge planning is a critical component of the utilization management process and begins with upon admission with an assessment of the patient's potential discharge needs. It includes preparation of the family and the patient for continuing care needs and initiation of arrangements for services or placement needed after acute care discharge.

PHC Nurse Coordinators work with hospital discharge planners, case managers, admitting/attending physicians and ancillary service providers to assist in making necessary arrangements for post-discharge needs.

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Post-Service Retrospective Review Post-service retrospective reviews may occur when a member is retroactively granted Medi-Cal benefits by the State of California, when a provider does not realize an authorization is required prior to rendering a service, when the rendered service code billed does not match the code authorized, or the service may have been rendered after the expiration of the authorization. TARs must be received by PHC within fifteen (15) business days of the date of service or within 60 calendar days of either a denial from the primary insurance carrier or retrospective eligibility. (TARs submitted beyond these timeframes are considered late but will still be reviewed for medical necessity.)

All retrospective reviews are completed within 30 calendar days of receipt of request. Electronic or written notification of the decision and how to initiate a routine or expedited appeal will be provided to the provider within 24 hours of decision, but no longer than 30 calendar days from the date of the receipt of the request. PHC is not required to notify members of post-service review decisions as the member is not at financial risk for the services being requested.

Services requiring an authorization can be retrospectively reviewed for medical necessity, appropriateness of setting, and length of stay up to one year after services are rendered and may result in an adverse determination. Emergency Room Visits Emergency room visits where a prudent layperson, acting reasonably, would believe an emergency condition exists, DO NOT require prior authorization.

Timeliness of UM Decisions PHC makes UM decisions in a timely manner to accommodate the clinical urgency of the situation and to minimize any disruption in the provision of care. PHC measures the timeliness of decisions from the date when the organization receives the request from the member or PCP, even if the PHC does not have all the information necessary to make a decision. PHC documents the date when the request is received and the date a decision is rendered in the UM documentation system.

PHC has communicated to both providers and members the practice of processing non-urgent requests during the next business day if the request is received after business hours.

PHC Utilization Management abides by the following timeliness guidelines when processing health services requests.

Urgent Requests A request for medical care or services where application of the time frame for making routine or non-life threatening care determinations could jeopardize the live, health or safety of the member or others due to the member’s psychological state or, in the opinion of the practitioner with knowledge of the members medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment requested.

Concurrent Review Request: A request for coverage of medical care or services made while a member is in the process of receiving the requested medical care or services, even if the organization did not previously approve the earlier care.

Pre-Service Request A request for medical care or services that PHC must approve in advance, in whole or in part.

Non-Urgent Request

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138 of 229 A request for medical care or services for which application of the time periods for making a decision does not jeopardize the life or health of the member or the member’s ability to regain maximum function and would not subject the member to severe pain.

Post-Service Request / Retrospective Review A request for medical care or services that have been received.

Non-Behavioral Healthcare Decisions and Behavioral Healthcare Decisions

Type of Request Decision Time Frame Notification1 Time Frame Extended Time Frame Urgent concurrent 72 hours (3 calendar days ) of 72 hours (3 calendar days) May be extended one time review receipt of request of receipt of request up to 14 calendar days Urgent pre-service 72 hours (3 calendar days ) of 72 hours (3 calendar days ) May be extended one time receipt of request of receipt of request up to 14 calendar days Non-urgent pre- 5 business days of receipt of 24 hours of determination May be extended two times service request date up to 14 calendar days2 Post-service 30 calendar days of receipt of 30 calendar days of receipt N/A request of request

1 Notification: Give electronic or written notification of decision to practitioner (and member when required) 2 Per DHCS regulations

Review Criteria The cCurrent InterQual® Level of Care Adult and Pediatric cCriteria sets are used as the main review guidelines. Additional criteria are selected or developed using other resources as necessary to help in determining review decisions which include, but are not limited to, Medi-Cal (State of California) guidelines and State policy letters (see policy MCUP3139 Criteria and Guidelines for Utilization Management). InterQual® criteria are produced using a rigorous development process based on evidence-based medicine and reviewed at least annually, but as frequently as quarterly, by a panel of board-certified specialists. All UM policies are based on InterQual® criteria and are reviewed annually by the Quality/Utilization Committee (Q/UAC) and the Physician Advisory Committee (PAC) which also include board-certified specialists.

In the absence of applicable criteria, the PHC UM medical staff refers the case for review to a licensed, board- certified practitioner in the same or similar specialty as the requested service. The reviewing practitioners base their determinations on their training, experience, the current standards of practice in the community, published peer-reviewed literature, the needs of the individual patients (age, comorbidities, complications, progress of treatment, psychosocial situation, and home environment when applicable), and characteristics of the local delivery system. Board-certified consultants are available through our providers on our Quality/Utilization Advisory Committee (Q/UAC). PHC also contracts with a third-party independent medical review organization which provides objective, unbiased medical determinations to support effective decision making based only on medical evidence. (See policy MCUP3138 External Independent Medical Review.)

Criteria are selected, reviewed, updated or modified using feedback from the Q/UAC and PAC as well as member feedback identified in member survey results and the Consumer Advisory Committee (CAC), State policy letters, State Memorandums of Understanding and/or medical literature, among other sources. In collaboration with actively practicing practitioners, criteria are evaluated on at least an annual basis. Relevant clinical information is obtained when making a determination based on medical appropriateness and the treating practitioner is consulted as appropriate. All information obtained to support decision-making is documented in the utilization management documentation system.

Decisions are based on information derived from the following sources:

. Clinical records . Medical care personnel

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139 of 229 . Facility utilization management staff . Attending physician (attending physician can be the primary care physician, hospitalist or the specialist physician (or all three as necessary) . Board-certified specialists are consulted when medically necessary

The needs of individual patients and the characteristics of the local delivery system are taken into account when determining the medical necessity of an inpatient hospitalization.

Inter-Rater Reliability (IRR) PHC assesses the consistency with which physician and non-physician reviewers apply UM criteria in decision making and evaluates Inter-Rater Reliability. The Inter-Rater Reliability mechanism uses live cases to ensure medical management criteria are appropriately and consistently applied in making UM determinations. The methodology employed is designed to annually assess 50 cases or 5% of reviewer case load, whichever is less, over the course of a year period.

The following types of reviews/reviewers are audited: . Nurse Coordinator Review of Inpatient Services . Nurse Coordinator Review of Outpatient Services . Nurse Coordinator Review of Long Term Care Services . Physician Review of Medical Necessity Authorizations . Pharmacist and Pharmacy Technician Review of Pharmacy TARs . LCSW/LMFT Review of Residential Substance Use Disorder Treatment Authorizations*

A performance target of 90% accuracy is set for inter-rater reliability. An audit summary is reported at least annually or more often as needed to the Internal Quality Improvement (IQI) Committee. If a reviewer falls below the targeted threshold, a corrective action plan is initiated and monitored and results are presented to the Quality/Utilization Advisory Committee (Q/UAC) for review and discussion. Please refer to policy MPUP3026 Inter-Rater Reliability Policy for a full description of the IRR process.

Availability of Criteria

All criteria used to review authorization request are available upon request. In the case of an adverse determination, the criteria used are made part of the determination file. Access to and copies of specific criteria utilized in the determination are also available to any requesting practitioner by mail, fax, email, or on our website: http://www.partnershiphp.org. To obtain a copy of the UM criteria, practitioners may call the PHC UM Department at (800) 863-4155.

Members may request criteria used in making an authorization determination by calling the member services department to request a copy of the criteria. The UM team will work with member services to provide the criteria used in the review decision.

PHC’s Provider Relations Department notifies providers in writing through the New Provider Credentialing Packet and the provider’s contract that UM criteria is available online at http://www.partnershiphp.org in the Provider Manual section. Providers are also notified quarterly in writing via the Quarterly Provider Newsletter about the on-line availability of UM criteria and policies at http://www.partnershiphp.org in the Medi-Cal Provider Manual section.

COMMUNICATION SERVICES PHC provides access to staff for members and practitioners seeking information about the UM process and the authorization of care in the following ways:

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140 of 229 . Calls from members are triaged through member services staff who are accessible to practitioners and members to discuss UM issues during normal working hours when the health plan is in operation (Monday - Friday 8 a.m. - 5 p.m.). . Members and Providers may contact the PHC voice mail service to leave a message which is communicated to the appropriate person on the next business day. Calls received after normal business hours are returned on the next business day and calls received after midnight on Monday - Friday are returned on the same business day. . After normal business hours, members may contact the advice nurse line for clinical concernsassistance . Practitioners may contact UM staff directly either through secure email or voicemail. Each voice mailbox is confidential and will accept messages after normal business hours. Calls received after normal business hours are returned on the next business day and calls received after midnight on Monday - Friday are returned on the same business day. . PHC has a toll free number (800) 863-4155 that is available to either member or practitioners. . UM staff identify themselves by name, title and organization name when initiating or returning calls regarding UM issues. . Members can view information about PHC’s language assistance services and disability services in the Member Handbook which is mailed to members upon enrollment and is always available online at http://www.partnershiphp.org/Members/Medi-Cal/Documents/MCMemberHandbook.pdf Additionally, PHC provides annual written notice to Members about our language assistance services and disability services in our Member Newsletter. Linguistic services are provided by PHC to monolingual, non-English speaking or limited English proficiency (LEP) Medi-Cal beneficiaries for population groups as determined by contract. These services include the following: No cost linguistic services: . Oral interpreters, sign language interpreters or bilingual providers and provider staff at key points of contact available in all languages spoken by Medi-Cal beneficiaries . Written informing materials (to include notice of action, grievance acknowledgement and resolution letters) fully translated into threshold languages, upon request . Use of California Relay Services for hearing impaired [TTY/TDD: (800) 735- 2929 or 711]

PHC regularly assesses and documents member cultural and linguistic needs to determine and evaluate the cultural and linguistic appropriateness of its services. Assessments cover language preferences, reported ethnicity, use of interpreters, traditional health beliefs and beliefs about health and health care utilization.

Denial Determinations

Denial determinations may occur at any time in the course of the review process. Only the Chief Medical Officer, or a physician designee acting through the designated authority of the Chief Medical Officer, has the authority to render a denial determination based on medical necessity (see Pprogram Sstructure section for details).

A denial determination may occur during continued stay/concurrent review in which case notification and/or discussion with the treating practitioner and the Health Plan physician adviser/Chief Medical Officer or physician designee is offered.

Denial determinations may occur at different times and for various reasons including but not limited to: . At the time of prior authorization; when the requested services is not medically indicated or not a covered benefit.

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141 of 229 . When timely notification was not received from a facility for an inpatient stay to foster transfer of a medically stable patient . When an inpatient facility fails to notify the Health Plan of admission within one business day of the admission or appropriate clinical information is not received . Or after services are rendered at claims review when the services were not authorized, or are medically unnecessary A denial may also occur for inappropriate levels of care or inappropriate care. Notwithstanding previous authorization, payment for services may be denied if it is found that information previously given in support of the authorization was inaccurate.

PHC offers the practitioner the opportunity to discuss any denial or potential denial determination based on lack of medical necessity with the Health Plan Chief Medical Officer, or a physician designee.

The denial notification states the reason for the denial in terms specific to the member’s condition or service request and in language that is easy to understand and references the criterion used in making the determination so the member and provider have a clear understanding of the Health Plan’s rationale and enough information to file an appeal.

Partnership HealthPlan of California is aware of the need to be concerned about under-utilization of care and services for our members. PHC monitors over and under-utilization through the Over/Under Utilization Workgroup which reviews annual utilization patterns. Decisions made by PHC’s Utilization Reviewers are solely based on the appropriateness of the care or service.

The Health Plan does not compensate any individual involved in the utilization process to deny care or services for our members nor do we encourage or offer incentives for denials.

Process for a Provider to Appeal an Adverse Benefit Determination on Behalf of a Member

Members and providers are provided fair and solution-oriented means to address perceived problems in exercising rights as a Medi-Cal beneficiary or provider, in accordance with requirements of PHC’s contract with the Department of Health Care Services (DHCS). This process is entirely separate from that of State Fair Hearings, to which members retain their access. Please refer to PHC policy MCUP3037 Appeals of Utilization Management/ Pharmacy Decisions for a full description of the process.

Appeals of Adverse Benefit Determinations (ABDs)

A member, a member’s authorized representative, or a provider acting on behalf of a member, has 60 calendar days from the date of determination to submit an appeal request in response to a Notice of Action (NOA) letter. A member or a member’s authorized representative may initiate an appeal by contacting PHC’s Member Services department. An appeal initiated in this way is considered a Member Appeal and will be referred to the PHC Grievance and Appeals department for processing. A provider may also request an appeal on behalf of a member, with written consent from that member, by faxing or writing PHC’s UM or Pharmacy Department.

After receipt of the request for appeal, PHC will provide written acknowledgement to the member and provider that is dated and postmarked within five (5) business days of receipt of the appeal. PHC has 30 calendar days from the receipt of the appeal request to render a determination.

The Chief Medical Officer or physician designee reviews the request for appeal if the determination was based on medical necessity. The Chief Medical Officer or physician designee may request further information from the provider such as:

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142 of 229 . Diagnostic information . Previous treatment . Clinical justification . Opinions from specialists or other providers . Evidence from the scientific literature prior to processing the request.

The provider is expected to respond to a request for further information within the 30 calendar day determination time frame. If the provider does not respond to the request for further information within that time frame, the appeal can be extended no more than 14 calendar days.

When a decision has been made, the provider and/or member, if applicable, are notified in writing within five (5) business days with a Notice of Appeal Resolution (NAR) letter. PHC is not required to notify the member of a decision when the member is not at financial risk for the services being requested (e.g. concurrent or retroactive reviews).

Providers who disagree with the appeal decision may then file a grievance with PHC by the process described in the Provider Grievance policy MP PR-GR 210.

If PHC’s determination specifies the requested service is not a covered benefit, PHC shall include in its written response the provision in the Contract, Evidence of Coverage, or Member Handbook that excludes the service.

The response shall either identify the document and page where the provision is found, direct the provider and member to the applicable section of the contract containing the provision, or provide a copy of the provision and explain in clear concise language how the exclusion applies to the specific health care service or benefit request.

Expedited Appeals of Adverse Benefit Determinations

Expedited appeals may be initiated by the member or the provider. A member may initiate an expedited appeal by calling the Member Services Department. A provider may initiate an expedited appeal on behalf of a member with written consent by faxing or writing the PHC UM or Pharmacy Department. If the request for expedited appeal is not accompanied by written consent from the member, the Plan will proceed with the request.

Expedited appeals are performed by PHC only when, in the judgment of the Chief Medical Director or Physician Designee, a delay in decision-making may seriously jeopardize the life or health of the member.

PHC refers the expedited appeal request to the Chief Medical Officer or Physician Designee for decision on the appeal. The Chief Medical Officer or Physician Designee is expected to make a decision as expeditiously as the medical condition requires, but no later than seventy-two (72) hours after the receipt of the request for an expedited appeal.

Expedited reviews are also granted to all requests concerning admissions, continued stay or other health care services for a member who has received emergency services but has not been discharged from a facility.

PHC provides verbal confirmation of its decisions concurrent with mailing of written notification no later than seventy-two (72) hours after receipt of an expedited appeal. If the expedited appeal involves a concurrent review determination, the member continues to receive services until a decision is made and written notification is sent to the provider. PHC is not required to notify the member of a concurrent decision as the member is not at financial risk for the services being requested.

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143 of 229 Appeal Rights

A member may ask assistance from a patient advocate, provider, ombudsperson or any other person to represent them in their request.

A member may also request a State Hearing if a member has filed an appeal and received a “Notice of Appeal Resolution” letter upholding the initial denial of service. Information on how to obtain an expedited State Hearing is included as a part of the “Notice of Appeal Resolution” letter to the member.

Member grievance and appeal information is included in the member handbook, distributed annually in the member newsletter, and is posted on the PHC website.

It is the responsibility of the Member Services Director and the Member Services Department to ensure:

. Member Rights and Responsibilities are included in the member handbook which is mailed to all new members and posted on the PHC website . Members are advised of their right to receive a copy of the Member Rights and Responsibility statement annually in the PHC’s member newsletter. . Members are notified of all revisions to the Member Rights and Responsibilities statement in the member newsletter following revisions.

It is the responsibility of the Provider Relations Director and the Provider Relations Department to ensure

. The Member’s Rights and Responsibilities statement is included in the PHC provider manual issued to all contracted providers. The manual is issued to providers after their contract has been fully executed. . Any revisions to the Member’s Rights and Responsibilities statement are issued to all contracted providers within 90 days from the date these revisions are finalized.

Data Sources

Utilization Management supports the effective, efficient, and appropriate utilization of member benefits through ongoing review, evaluation and monitoring of the member’s personal health information in making medical necessity determinations.

Data sources may include, but are not limited to: . Medical records, from outpatient provider offices and hospital records (including accessing hospital Electronic Medical Records (EMR); for current and historical data . Member handbook or Evidence of Coverage . Consultations with treating physicians . network adequacy information . Local delivery system capacity information . Specialist referrals . Recent Physical exam results . Diagnostic testing results . Treatment plans and progress notes . Operative and pathological reports . Rehabilitation evaluations . Patient characteristics and information . Patient psychosocial history . Information from family / social support network . Prospective/concurrent/retrospective utilization management activities . Claim/encounter (administrative) data

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Data Collection, Analysis, and Reporting Data collection activities for analysis and reporting are coordinated by the UM department. At the data gathering/performance measurement phase, participants in the process include programmers and analysts in the Finance and Health Services departments, staff nurses, and any other personnel required for the collection and validation of data. All data collection activities are documented and reported to the Q/UAC twice a year and more often if requested. Data collection activities may include, but are not limited to:

. Member satisfaction surveys . Provider satisfaction surveys . Readmission statistics . Potential quality incident data . Member appeal data . Provider appeal data . Internally developed databases . Pharmacy utilization data . Other administrative or clinical data

EVA L UATI O N O F NEW MEDICAL TECHNOLOGY

PHC evaluates the inclusion of new medical technologies and the new application of existing technologies in its benefit packages. While the basic benefits are set by the State of California Department of Health Care Services (DHCS) and outlined in Title 22 of the Health and Welfare Code, PHC has the option of adding to this basic package of benefits for its members.

PHC’s Policy MCUP3042 Technology Assessment outlines the steps taken during the determination process. The PHC Physician Advisory Committee will review all cases and make a final recommendation to the Board of Commissioners as to new benefits. The Commission is the only entity that can add benefits. Once a new benefit is added, the information is disseminated to all Primary Care Providers and appropriate specialists in the form of a mail notification of benefit addition, and to all members in the next member newsletter.

New technologies are handled on a case-by-case basis which includes obtaining information regarding the safety, efficacy and indications that support the use of the intervention. There must be evidence that the proposed intervention will add to improved outcomes as compared to what is currently available. The service provider must have a record of safety and success with the intervention and cannot be part of a funded research protocol. The Chief Medical Officer works closely with the requesting physician and specialists as needed in researching these cases.

DELEGATION

UM activities that are delegated to contract providers are reviewed and approved on an annual basis by the Q/UAC. A delegation agreement, including a detailed list of activities delegated and reporting requirements is signed by both the delegate and PHC.

. Providers to whom UM activities have been delegated are responsible for reporting results and analyses to PHC on a quarterly or annual basis. Reports are summarized for review and evaluation by PHC’s Ddelegation workgroup Oversight Review Sub-Committee (DORS) and Q/UAC. . Audits are conducted no less than annually and eEvaluation includes a review of both the processes applied in carrying out delegated UM activities, and the outcome achieved in accordance with the respective policy(s) and agreement governing the delegated responsibility.

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145 of 229 . The Q/UAC reviews evaluations and make recommendations regarding opportunities for improvement and continuation of delegated functions.

A pre-delegation evaluation is conducted when delegation of functions to providers is being considered.

Protected Health Information (PHI) The Privacy Rule, described in 45 CFR Parts 160 and 165, applies to covered entities. The Privacy Rule allows covered providers, entities, and health plans to disclose PHI in order to carry out their health care functions.

Partnership HealthPlan of California is fully compliant with the general rules, regulations and implementation specified in The Privacy Rule. PHC also provides reasonable administrative, technical, and physical safeguards to ensure PHI confidentiality, integrity and availability and to prevent unauthorized or inappropriate access, use or disclosure of PHI.

The PHC Director of Regulatory Affairs and Program Development also serves as the PHC Privacy Officer. PHC has implemented a comprehensive program that includes “Notice of Privacy Practices” (NPP) sent to all members, as well as implementation of a confidential toll-free complaint line available to members, providers and PHC staff. For non-covered entities, PHC requires Business Associate Agreements (BAA). Additionally, there is training on an annual basis for the PHC workforce and PHC providers/networks, and PHC maintains policies and procedures around documentation of complaints of violations or suspected privacy incidents.

STATEMENT OF CONFIDENTIALITY

Confidentiality of provider and member information is ensured at all times in the performance of UM activities through enforcement of the following:

. Members of the Q/UAC and PAC are required to sign a confidentiality statement that will be maintained in the QI files. . UM documents are restricted solely to authorized Health Services Department staff, members of the PAC, Q/UAC, and Credentialing Committee, and reporting bodies as specifically authorized by the Q/UAC. . Confidential documents may include, but are not limited to Q/UAC and Credentialing meeting minutes and agendas, QI and Peer Review reports and findings, UM reports, or any correspondence or memos relating to confidential issues where the name of a provider or member are included. . Confidential documents are stored in locked file cabinets with access limited to authorized persons only, or they are electronically archived and stored on protected drives. . Confidential paper documents are destroyed by shredding.

NON-DISCRIMINATION STATEMENT

PHC complies with applicable Federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.

PHC will not deny or limit coverage, deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions on coverage, for any health services that are ordinarily or exclusively available to individuals of one sex, to a transgender individual based on the fact that an individual’s sex assigned at birth, gender identity, or gender otherwise recorded is different from the one to which such health services are ordinarily are exclusively available. Also, PHC will not otherwise deny or limit coverage, deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions on coverage, for specific health services related to gender transition if such denial, limitation, or restriction results in discrimination against a transgender individual.

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146 of 229 PHC provides free aids and services to people with disabilities to communicate with us, such as: . Qualified sign language interpreters . Written information in other formats (large print, audio, accessible electronic formats, other formats)

PHC provides free language services to people whose primary language is not English or those with limited English proficiency (LEP), such as. These services include the following: . Qualified sign language interpreters . Information written in other languages . Use of California Relay Services for hearing impaired

STATEMENT OF CONFLICT OF INTEREST

Any individual who has been personally involved in the care and/or service provided to a patient, an event or finding undergoing quality evaluation may not vote or render a decision regarding the appropriateness of such care. All members of the Q/UAC are required to review and sign a conflict of interest statement, agreeing to abide by its terms.

PROVIDER AND MEMBER SATISFACTION

PHC conducts satisfaction surveys on both members and providers. Included in the evaluation are questions that deal with both member and provider satisfaction with the UM program. The responses to the survey are reviewed by staff from Health Services, Member Services, and Provider Services. Thresholds are set and responses that fall below are considered for corrective action by the HealthPlan. The results, as well as plans for corrective action, are developed in conjunction with the Q/UAC. Corrective actions that were in place are evaluated at the time the follow-up annual survey is done unless the committee feels an expedited time frame needs to be implemented.

ANNUAL PROGRAM EVALUATI ON

The Utilization Management program undergoes a written evaluation of its overall effectiveness annually by the Q/UAC, which is reviewed and approved by the PAC.

At a minimum the evaluation considers UM department activities and outcomes, the review of Key Performance Indicator metrics such as Productivity, Timeliness, Bed-days, readmission rates and denial rates along with resource effectiveness and barriers to performance.

Preparation for the Annual Program Evaluation involves participation by all Utilization Management and Pharmacy leadership including but not limited to: . Senior Health Services Director . Director of UM . Director, Pharmacy Services . Associate Directors of UM . UM Team Manager

Elements of the program evaluation include an objective assessment of meeting targeted goals to ensure appropriate, efficient utilization of resources/services for PHC members across the continuum of care in compliance with requirements of state/federal and regulatory entities.

. Annual UM Program Description update . Annual review and evaluation of UM processes (meeting goals and identifying opportunities for process improvements) *Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit on July 1, 2020. 29

147 of 229 . Timely review and update of UM policies and procedures . Obtain approval of UM policies and procedures at Q/UAC

Inter-Rater Reliability scoring, TAR timeliness, percentage of eRAFs vs. Manual RAFs, and Call Performance is compared with regulatory compliance standards and internal benchmarks.

To determine if the UM program remains current and appropriate, the organization annually evaluates:

. The program structure . The program scope, processes, information sources used in the determination of benefit coverage and medical necessity . The level of involvement of the senior-level physician and designated behavioral healthcare practitioner in the UM program . And cConsiderations of member’s and practitioner’s experience data when evaluating the UM program

The organization updates the UM program and its description annually based on the evaluation.

To ensure the provision of healthcare services at the appropriate level of care the evaluation considers: . Inpatient bed day rate . Inpatient average length of stay . SNF admit rate . SNF average length of stay . Readmission rate . Denial rate . Timely completion of notifications of denial of care . Timely completion of notifications of authorization of care . Rate of referrals to Care Coordination . Effectively integrating feedback - the program reflects on Member/Provider satisfaction results concerning the UM program looking at: o Daily Work Flow Monitoring o Call Abandonment rates o Call Volume o Average caller wait time

An assessment of Department resources are is determined by looking at the impact of staffing changes, learning curves and system limitations which impede work effectiveness. There is a review of Inter-Rater Reliability scoring in relation to staff training/re-education, acclimation to new technology such as documentation software/ hardware based on evaluating user acceptance, and the assessment of appropriate staffing ratio to ensure adherence to regulatory and internal performance standards.

A summary of the program evaluation, including a description of the program, is provided to members or practitioners upon request. When the evaluation is complete, an announcement indicating the availability of UM information is published in the member and provider newsletter.

REFERENCES: Department of Health Care Services (DHCS) standards National Committee for Quality Assurance (NCQA) Guidelines (Effective July 1, 2020) UM Standards 1-5, 7

Original Date: QI/UM Program 04/22/1994 effective 05/01/1994 Revision Date(s): 08/16/95

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148 of 229 Revision Date(s): UM Program Description - 04/17/97; Board Approval January 28, 1998; 06/10/98; 01/20/99; 05/2000; 05/01/01; (UD100301) 03/20/02; 08/20/03; 10/20/04; 10/13/05; 06/21/06; (MPUD3001) 04/16/08; 08/03/10; 11/19/14; 02/17/16; 04/19/17; *06/13/18; 04/10/19, 06/12/19 (Amended), 10/09/19 (Amended); 04/08/20; 06/10/20 (Amended); 04/14/21

*Through 2017, Approval Date reflective of the Quality/Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

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UM PROGRAM DESCRIPTION APPROVAL

Robert Moore, MD, MPH, MBA 03/18/202003/17/2021

Quality/Utilization Advisory Committee Chairperson Date Approved

Jeffrey Gaborko, MD 04/08/202004/14/2021

Physician Advisory Committee Chairperson Date Approved

Nancy Starck 04/22/202004/28/2021

Board of Commissioners Chairperson Date Approved

UM PROGRAM DESCRIPTION APPROVAL (Amended Version)

Robert Moore, MD, MPH, MBA 05/20/2020

Quality/Utilization Advisory Committee Chairperson Date Approved

Robert Moore, MD, MPH, MBA 06/10/2020

Physician Advisory Committee Acting Chairperson Date Approved

Nancy Starck 06/24/2020

Board of Commissioners Chairperson Date Approved

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit on July 1, 2020. 32

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Partnership HealthPlan of California

UTILIZATION MANAGEMENT PROGRAM DESCRIPTION MPUD3001

April 2021

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Table of Contents

PROGRAM PURPOSE ...... 27 PROGRAM OBJECTIVES ...... 27 PROGRAM STRUCTURE ...... 28 PROGRAM STAFF ...... 28 COMMITTEES ...... 36 UTILIZATION MANAGEMENT PROGRAM SCOPE ...... 38 MENTAL HEALTH ...... 39 SUBSTANCE USE DISORDER TREATMENT SERVICES/ WELLNESS & RECOVERY PROGRAM ...... 40 BEHAVIORAL HEALTH TREATMENT (BHT) FOR MEMBERS UNDER 21 YEARS OF AGE ...... 41 QUALITY IMPROVEMENT COLLABORATION ...... 41 UTILIZATION MANAGEMENT PROCESS ...... 42 Elective Admission Precertification ...... 43 Referral Management ...... 43 Continued Stay/Concurrent Review ...... 43 Skilled Nursing/Sub acute/ Long- Term Acute/Rehabilitation Facility Review ...... 44 Discharge Planning ...... 44 Post-Service Retrospective Review ...... 44 TIMELINESS OF UM DECISIONS ...... 45 REVIEW CRITERIA ...... 46 INTER-RATER RELIABILITY (IRR) ...... 46 COMMUNICATION SERVICES ...... 47 DENIAL DETERMINATIONS ...... 48 PROCESS FOR A PROVIDER TO APPEAL AN ADVERSE BENEFIT DETERMINATION ON BEHALF OF A MEMBER ...... 49 DATA SOURCES ...... 51 EVAL UATI O N OF NEW MEDICAL TECHNOLOGY ...... 52 DELEGATION ...... 52 PROTECTED HEALTH INFORMATION (PHI) ...... 52 STATEMENT OF CONFIDENTIALITY ...... 53 NON-DISCRIMINATION STATEMENT ...... 53 STATEMENT OF CONFLICT OF INTEREST ...... 53 PROVIDER AND MEMBER SATISFACTION ...... 54 ANNUAL PROGRAM EVALUATION ...... 54 REFERENCES: ...... 55 UM PROGRAM DESCRIPTION APPROVAL ...... 56

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PROGRAM PURPOSE

Partnership HealthPlan of California (PHC) is a County Organized Health System (COHS) contracted by the State of California to provide Medi-Cal Beneficiaries with a health care delivery system to meet their medical needs.

The mission of Partnership HealthPlan of California is “To help our Members, and the Communities we serve, be healthy.” Our vision is to be “the most highly regarded health plan in California.”

PHC has program descriptions and policies to describe the structures needed to provide high quality health care while being stewards of taxpayer resources. In the Utilization Management Program Description, PHC outlines the structure of our measurement and management of utilization of health care services within our system.

The PHC Utilization Management (UM) program serves to implement a comprehensive integrated process that actively evaluates and manages utilization of health care resources delivered to all members, and to actively pursue identified opportunities for improvement.

The utilization program is housed within the Health Services Department which consists of five teams including: . Utilization Management . Care Coordination . Population Health . Pharmacy . Quality Improvement

The PHC UM program serves to accomplish the following:

. Ensure that members receive the appropriate quality and quantity of healthcare service . Ensure that healthcare service is delivered at the appropriate time . Ensure that the setting in which the service is delivered is consistent with the medical care needs of the individual

The UM program provides a reliable mechanism to review, monitor, evaluate, recommend and implement actions on identification and correction of potential and actual utilization and resource allocation issues.

PHC recognizes the potential for under-utilization and takes appropriate steps and actions to monitor for this. The processes for UM decision making are based solely on the appropriateness of care and services and existence of coverage. PHC does not reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in under-utilization and PHC does not use incentives to encourage barriers to care and service. This does not preclude the use of appropriate incentives for fostering efficient, appropriate care.

PROGRAM OBJECTIVES

UM Program Objectives The PHC UM program serves to ensure that appropriate, high quality cost-effective utilization of health care resources is available to all members. This is accomplished through the systematic and consistent application of utilization management processes based on current, relevant medical review criteria and expert clinical opinion when needed. The utilization management process provides a system that ensures equitable access to high quality health care across the network of providers for all eligible members as follows:

. Ensures authorized services are covered under contract with the State of California Department of Health Services (DHCS) California Code of Regulations (CCR) Title 22 - For Medi-Cal Members (Title 22). *Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 153 of 229 27

. Coordinates thorough and timely investigations and responses to member and provider reconsideration and appeals associated with utilization issues

. Initiates needed operational revisions to prevent problematic issues from reoccurring

. Ensures that services which are delivered are medically needed and consistent with diagnosis and level of care required for each individual, taking into account any co-morbid condition that exists and the ability of the local delivery system to meet the need

. Educates members, practitioners, providers and internal staff about PHC’s goals for providing quality, cost-effective, managed health care

. Defines the methods by which utilization criteria and clinical practice guidelines are selected, developed, reviewed, and modified based upon appropriate and current standards of practice and professional review

. Promotes and ensures the integration of utilization management with quality monitoring and improvement, risk management, and case management activities

. Ensures a process for critical review and assessment of the UM program and plan on, at minimum, an annual basis, with updates occurring more frequently if needed. The process incorporates provider, practitioner and member input along with any regulatory changes, changes to current standards of care, and technological advances

. Evaluates the ability of delegates to perform UM activities and to monitor performance

Program Structure

This section outlines the individual program staff and the assigned activities, including approval authority and the involvement of the designated physician.

Assigned Responsibilities

Program Staff

Chief Medical Officer (CMO) – MD/DO The Chief Medical Officer is responsible for the implementation, supervision, oversight and evaluation of the UM Program.

This position provides guidance and overall direction of UM activities and has the authority to make decisions based on medical necessity which result in the approval or denial of coverage. The assigned activities for this position include but are not limited to: . Assuring that the UM program fulfills its purpose, works towards measurable goals, and remains in regulatory compliance . In collaboration with the Senior Director of Health Services and the Associate Directors of Utilization Management; oversees UM program operations and assists in the development and coordination of UM policies and procedures. . Reviews for the consistent application of UM decision criteria at least annually and implements corrective actions when needed

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 154 of 229 28 . Serves as the Committee Chair for the Quality/Utilization Advisory Committee (Q/UAC) and the Pharmacy and Therapeutics (P&T) Committee and regularly attends the Physician Advisory Committee (PAC) . Ensures timely medical necessity review and decisions are made by daily staffing physicians for medical review consultation . Guides and assists in the development and revision of PHC medical policy, criteria, clinical practice guidelines, new technology assessments, and performance standards for Q/UAC review, adaptation and PAC approval . As the chairman of the Q/UAC, presents UM activities on a regular basis to the Q/UAC and provides periodic updates on utilization management activities to the PAC and the Board of Commissioners . Evaluates the overall effectiveness of the UM program . Evaluates and uses provider and member experience data when evaluating the UM program in collaboration with the Senior Director of Health Services and appropriate committees

Regional Medical Director - MD/DO The Regional Medical Director is a physician with the authority to make decisions based on medical necessity which result in the approval or denial of coverage.

The assigned activities for this position include but are not limited to: . Evaluates the appropriateness and quality of medical care delivered through PHC in the designated regional area . Participates in enterprise-wide projects that require Physician involvement . Other duties as assigned by the Chief Medical Officer.

Associate Medical Director - MD/DO This Physician has the authority to make decisions based on medical necessity that result in the approval or denial of coverage. The assigned activities for this position include: . Coverage in the UM Department for medical necessity reviews applying evidence-based UM decision criteria to the review process in determining medical appropriateness and necessity of services for PHC members . Provides review of quality of care issues and serves on Q/UAC . Other duties as assigned by the Chief Medical Officer

Behavioral Health Clinical Director - MD/DO/PhD/ PsyD The PHC Behavioral Health Clinical Director is an MD, DO, clinical PhD, or PsyD who is actively involved in the behavioral health aspects of the UM program. This Director provides clinical oversight of PHC’s behavioral health activities including substance use services and the activities of PHC’s delegated managed behavioral health organization(s). The Behavioral Health Clinical Director has the authority to make decisions based on medical necessity which result in the approval or denial of coverage for behavioral health or substance use services. The assigned activities for this position include: . Establishes UM policies and procedures in collaboration with PHCs delegated managed behavioral health organization(s) . Oversees and monitors quality improvement activities . Facilitates network adequacy . Participates in the peer review process . Evaluates behavioral health care and substance use disorder (SUD) treatment services requests in collaboration with PHC’s delegated managed behavioral health organization(s) . Oversees and monitors functions of PHC’s delegated managed behavioral health organizations . Serves on Quality/Utilization Advisory Committee; Pharmacy and Therapeutics . Committee; Credentials Committee and Internal Quality Improvement Committee including the Substance Use Internal Quality Improvement Subcommittee.

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 155 of 229 29

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 156 of 229 30 Pharmacy Services Director – Pharm.D. This position is responsible for overseeing all HealthPlan activities related to pharmacy services and supervising the PHC Pharmacy management team, PHC Clinical Pharmacists, and support staff. The assigned activities for this position include but are not limited to: . Formulary management . Development of applicable policies and guidelines . Serves on the Pharmacy and Therapeutics (P&T) Committee, the Drug Utilization Review (DUR) Board and the Pediatric Quality Committee (PQC) . Drug utilization review . Drug prior authorization . Implementation of cost effective pharmacy measures . Serving as primary contact with the contracted Pharmacy Benefit Manager (PBM), pharmacy providers, and pharmacists . Participation in provider education initiatives such as academic detailing with plan physicians . Medical education meetings . Assisting with development of Clinical Practice Guidelines . Other duties as assigned by the Chief Medical Officer

Senior Director of Health Services - RN Responsible for the day-to-day implementation of the PHC Utilization Management Program. This position has the authority to make decisions on coverage not relating to medical necessity. The assigned activities include: . Provides oversight and guidance for the UM program across all regions . Reports to the Q/UAC on UM activity . Coordinates departmental UM and Quality Improvement efforts . Collaborates with providers and facilities . Monitors and analyses UM data to inform decision making . Develops recommendations based on data analysis and strategic planning. . Collaborates with the Chief Medical Officer and the Q/UAC on UM activities . Evaluates and uses provider and member experience data when evaluating the UM program in collaboration with the Chief Medical Officer . Prepares and presents the annual evaluation, program description to Q/UAC and PAC

Associate Director of Utilization Management Programs- RN Under the direction of the Senior Director of Health Services, manages and provides direction to the Utilization Management department managers, supervisors and staff for all product lines ensuring consistent development, implementation, and maintenance of health services programs. This position has the authority to make decisions on coverage not relating to medical necessity. Assigned activities include: . Implements the UM program within assigned region . Provides day to day direction to UM Managers and Supervisors within assigned region to meet department goals and objectives and is available to staff on-site or by telephone . Conducts annual performance evaluations for assigned UM staff . Conducts monitoring activities . Participates in staff trainings and on-site continuing education . Audits medical records as appropriate and monitors for consistent application of UM criteria by UM staff, for each level and type of UM decision . Collaborates with providers and facilities . Develops recommendations for program improvements . Coordinates activities with Quality Improvement, Member Services, Claims, and Provider Relations departments to identify, track, and monitor quality of care outcomes and trends . Participates in establishing and maintaining reports which relay the efficacy of UM activities and summarizes, at least annually, the UM activity, quality improvement activities and utilization outcomes, with supporting statistical data at IQI and Q/UAC *Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 157 of 229 31

Associate Director of Utilization Management Strategies- RN Under the direction of the Senior Director of Health Services, plans, monitors and evaluates utilization management activities to identify strategic initiatives to enhance the efficacy of the UM program, while improving health outcomes, in a cost effective manner. This position has the authority to make decisions on coverage not relating to medical necessity. Assigned activities include: . Collaborates with the provider relations contracting team to identify strategic opportunities and develops recommendations . Participates in contract review and negotiations . Attends regular meetings with hospitals, long-term care facilities and community agencies to facilitate cost effective and appropriate alternative placements . In collaboration with the Senior Director of Health Services and Senior Director of Provider Relations, reviews and processes provider grievances in accordance with appropriate regulatory requirements and participates in provider grievance meetings . Works collaboratively with claims and configuration department leaders and team members to identify systematic issues or opportunities for staff and/or provider education . Attends claims configuration meetings and Benefit Review Evaluation Workgroup (BREW) as well as IQI, Q/UAC and PAC . Works with providers and/or vendors to facilitate issue resolution and ensure a consistent UM process . Develops, reviews, and/or revises PHC UM policies and procedures in collaboration with the Senior Director of health services as appropriate.

Associate Director of Utilization Management Regulations Under the direction of the Senior Director of Health Services, provides oversight of the UM Program to ensure compliance with regulatory requirements including, but not limited to, requirements of DHCS and the National Committee for Quality Assurance (NCQA). Assigned activities include: . Coordinates activities with External and Regulatory Affairs Compliance, Member Services, Claims, and Provider Relations departments to identify, track, and monitor quality of care issues and trends related to UM Department processes . Prepares reports on departmental activities according to established schedules and format. Identifies patterns and trends, conducts retrospective review as needed and works with UM Leadership to develop corrective action plans. . Participates in the grievance process . Acts as primary contact and support to each UM Delegate, providing training and support as necessary . Conducts delegation oversight through regular auditing of each UM Delegate, prepares audit reports for review by the Senior Director of Health Services and the Chief Medical Officer or physician designee, and prepares information for the Delegation Oversight Review Sub-Committee (DORS) . Collaborates with the Associate Director of UM Programs to ensure that all policies and procedures related to regulatory requirements are updated at least annually, or as needed, and presented to appropriate committees for review. Assists PHC staff and providers with the interpretation of PHC policies, procedures, and regulatory requirements. . Works with UM Leadership and Trainer to develop standardized training content and materials for new staff and ongoing education for existing staff . Participates in the planning and development of new/ enhanced Health Services plan benefits or product lines as needed. Attends Benefits Review and Evaluation Workgroup meetings . Participates in audits by various regulatory agencies as necessary

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 158 of 229 32 Utilization Management Team Manager - RN Responsible for the implementation, management and evaluation of an effective and systematic UM Program. Provides day-to-day guidance to UM staff and manages all aspects of utilization review activities and is available to staff on-site or by telephone. Working with the Chief Medical Officer, Senior Director of Health Services, Associate Directors of UM, utilization committees, and Health Plan Directors, promotes efficient resource utilization throughout the organization, providing leadership, teambuilding and direction needed to ensure attainment of UM goals. This position has the authority to make decisions on coverage not relating to medical necessity. The assigned activities include: . Coordinates completion of activities . Presents work plan status reports and updates to the Q/UAC . Monitors for consistent application of UM criteria by UM staff for each level and type of UM decision . Participates in staff trainings and on-site continuing education . Provides recommendations for interventions designed to improve utilization management issues . Coordinates implementation of interventions . Develops UM policy and procedures for Q/UAC approval . Develops, or coordinates development of, documentation of UM activities . Conducts annual performance evaluations for assigned UM staff

Inpatient/Outpatient Nurse Supervisor UM - RN This position is responsible for the daily mentorship and oversight of the staff assigned to inpatient or outpatient services. This position has the authority to make decisions on coverage not relating to medical necessity. The assigned activities include: . Works collaboratively with all levels of leadership within the department to efficiently coordinate workflow and individual staff assignments . Provides day to day supervision to the assigned team, overseeing daily operation of the inpatient or outpatient review process . Participates in staff trainings and on-site continuing education. With UM Leadership, conducts annual performance evaluations for assigned UM staff . Audits medical records as appropriate and monitors for consistent application of UM Criteria by UM staff, for each level and type of UM decision. . This position, in addition to his/her own case load, may be assigned cases in the area of oversight as deemed necessary to provide coverage

Nurse Coordinator/ UM II - RN/ LVN Work collaboratively with all levels of UM leadership and other PHC staff to develop, implement, and evaluate health outcomes, provider performance and other performance indicators pertinent to quality of care. This position has the authority to make decisions on coverage not relating to medical necessity. Assigned activities include: . Assist in training and orientation of new staff to the department upon request . Review and authorization of DME, Ancillary and Medical TARs based on established guidelines . Review and authorization of Long Term Care TARs based on established guidelines . Review and authorization of inpatient Hospital TARs based on established guidelines . Retrospective review of services to determine medical necessity . Refer cases to the Chief Medical Officer for requests that may not appear to meet evidence- based medical necessity criteria . Determines if requested services are part of the member’s benefit package . Work collaboratively with the Care Coordination, Population Health, Pharmacy and Quality Improvement staff on UM issues

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 159 of 229 33 Nurse Coordinator/ UM I - RN/ LVN Work collaboratively with all levels of UM leadership and other PHC staff to develop, implement, and evaluate health outcomes, provider performance and other performance indicators pertinent to quality of care. This position has the authority to make decisions on coverage not relating to medical necessity. Activities assigned include: . Review and authorization of DME, Ancillary and Medical TARs based on established guidelines. . Review and authorization of Long Term Care TARs based on established guidelines. . Review and authorization of inpatient Hospital TARs based on established guidelines. . Retrospective review of services to determine medical necessity . Refer cases to the Chief Medical Officer for requests that may not meet medical necessity criteria . Determine if requested services are part of the member’s benefit plan . Work collaboratively with the Care Coordination, Population Health, Pharmacy, and Quality Improvement staff on UM issues

Behavioral Health Clinical Specialist – LCSW or LMFT or other licensed behavioral health specialties Licensed Practitioner of the Healing Arts (LPHA)1 who develops, implements, and coordinates medically necessary treatment services within PHC’s Health Services for adults and children with behavioral health and/or substance use service needs. Reviews residential placement authorization requests for residential treatment services according to the specific terms of the contract with the provider and in accordance with the medical necessity requirements for Medi-Cal eligible beneficiaries.

Data Coordinator/ Supervisor UM – Administrative Works closely with UM Leadership to establish consistent evaluation of Data Coordinators’ work performance. Responsible for oversight of Data Coordinators. . Monitors day to day functions including coordination of assignments, monitoring of call volume and adherence to PHC workplace policy and is available to staff on-site or by telephone . Assists in the refinement/improvement of the HS programs . Provides performance feedback to the Data Coordinator staff and conducts staff trainings as needed. . Monitors UM Data Coordinator activity for consistent application of desktop processes and procedures by UM Data Coordinator staff . Provides leadership, direction, training, and support to the assigned staff . Participates in staff trainings and on-site continuing education . Conducts annual performance evaluations for assigned UM staff

Data Coordinator/ UM Lead - Administrative Under the direction of the Data Coordinator Supervisor and UM Leadership: . Monitors Data Coordinator documentation for accuracy . Ensures Data Coordinator staff have the resources required for completing TAR entry and using good judgment and is available to staff on-site or by telephone . Enters both manual and electronic submitted data into PHC systems for RAF and TAR authorizations . Monitors UM Data Coordinator staff for consistent application of desktop processes and procedures . Responsible for assisting with ongoing staff education in proper use of systems and PHC UM Departmental policies and procedures . Participates in staff trainings and on-site continuing education

1 Licensed Practitioner of the Healing Arts (LPHA): Physicians, Nurse Practitioners, Physician Assistants, Registered Nurses, Registered Pharmacists, Licensed Clinical Psychologist, Licensed Clinical Social Worker (LCSW), Licensed Professional Clinical Counselor, Licensed Marriage and Family Therapist (LMFT), and licensed-eligible practitioners working under the supervision of licensed clinicians.

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 160 of 229 34 Executive Assistant to CMO - Administrative Provides administrative support to the Chief Medical Officer. Responsible for maintaining and updating online policy and procedure manuals and managing appointment calendars. Coordinates setup and executes minutes for designated meetings.

Continuing Education Program Coordinator - Administrative Provides administrative support to the Chief Medical Officer. Responsible for coordinating the Continuing Education program, including planning meetings and trainings. Audits each CME/CE activity to ensure all elements required by organizations overseeing PHC’s educational programs are documented. Maintains organized electronic versions of all continuing education records.

Health Services Administrative Assistant II - Administrative Provides administrative support to the Senior Director and/or other UM Leadership. Responsible for maintaining and updating online policy and procedure manuals and managing appointment calendars. Coordinates setup and executes minutes for designated meetings.

Health Services Administrative Assistant I – UM - Administrative Provides administrative support to UM Leadership. Responsible for maintaining and updating policy and procedure manuals, managing appointment calendars, and working closely with the Information Technology Department to ensure appropriate electronic functioning for the Health Services Department.

Health Services Administrative Assistant II – CMO - Administrative Responsible for administrative support to the Associate and Regional Medical Directors. Responsible for managing appointment calendars, scheduling daily UM and pharmacy workload coverage for the MDs, developing weekly and monthly schedules for distribution to other departments, and coordinating Peer-to-Peer requests from providers. Coordinates setup and executes minutes for designated meetings.

Authorization Specialist/ UM Trainer – Administrative Responsible for providing training on all appropriate software platforms for new hires. Creates and maintains current training materials for the UM department. In conjunction with UM leadership team, prepares and delivers retraining of identified topics as deemed necessary. . Facilitates independent DME consultant evaluation visits to members for specialty equipment needs as needed or directed by UM Leadership. . Acts as a resource regarding UM department software programs and special projects upon request and is available to staff on-site or by telephone . Coordinates with Member Services Call Center system to place members into appropriate Direct Member status related to their care.

Coordinator II - Administrative Under the direction of the UM Team Manager and/or the Data Coordinator Supervisor: . Serves as a resource to other departments who have inquiries into the UM process . Responsible for the input of data and information concerning UM Referrals and Authorizations . Receives and responds to telephonic inquiries from providers regarding status of authorization requests and other questions or concerns . Performs triage and transfers calls to appropriate professional staff when indicated

Coordinator I - Administrative Under the direction of the UM Team Manager and/or the Data Coordinator Supervisor - responsible for the input of data and information concerning UM Referrals and Authorizations. . Maintains departmental documents . Receives and responds to telephonic inquiries from providers regarding status of authorization requests and other questions or concerns . Performs triage and transfers calls to appropriate professional staff when indicated

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Coordinator I - Appeals - Administrative Under the direction of the Associate Director of UM Programs: . Responsible for clerical processing of appeals in accordance with policy, procedures, timeframes and requirements of various regulatory bodies for all lines of business . Acts as liaison to Claims Department in coordinating timely response to all claims inquiries . Participates in special projects, tasks and assignments as directed

Delegation Program Coordinator I – Administrative Under the direction of the Associate Director of UM Regulations . Responsible for collecting and tracking required document submissions from delegated entities . Coordinates and participates in both desktop and onsite audits of delegated entities . Ensures efficient and appropriate collaboration between the Utilization Management staff and UM delegated entities

Project Coordinator II - Administrative Under the direction of the Senior Director of Health Services or other designated leadership. . Tracks project deliverables and resources using appropriate internal tools to ensure deadlines are met . Works collaboratively with the HS analyst, IT and Finance to design and implement reports to accurately reflect the work completed and outcomes achieved within the Department and its programs . Coordinates with the Regulatory Affairs Department to conduct research on regulations, statutes, laws, administrative policies and procedures

Committees

Board of Commissioners The Board of Commissioners on Medical Care (the Commission) promotes, supports, and has ultimate accountability, authority and responsibility for a comprehensive and integrated UM program. The Commission is ultimately accountable for the efficient management of healthcare resources and services provided to members. The Commission has delegated direct supervision coordination, and oversight of the UM program to the Q/UAC which reports to the PAC, the committee with overall responsibility for the program. Members of the Commission are appointed by the county Boards of Supervisors for each geographic service area and include representation from the community, consumers, business, physicians, providers, hospitals, community clinics, HMOs, local government, and County Health Departments. The Commission meets six times a year.

Physician Advisory Committee (PAC) The PAC monitors and evaluates all Health Services activities and is directly accountable to the Board of Commissioners for the oversight of the UM program. The PAC meets at least ten (10) times a year and may not convene in the months of July and December, with the option to add additional meetings if need. Voting membership includes external Primary Care Providers (PCPs), board certified high-volume specialists, and behavioral health practitioners. A voting provider member of the committee chairs the PAC. The PHC Chief Executive Officer, Chief Operating Officer, Chief Financial Officer, Chief Medical Officer, Associate Medical Director of Quality, Regional Medical Director(s), Clinical Director of Behavioral Health, Senior Director of Health Services and leadership from the Quality and Performance Improvement, Provider Relations, Utilization Management, and Pharmacy departments attend the PAC meetings regularly. Other PHC staff attend on an ad hoc basis to provide expertise on specific agenda items. The PAC oversees the activities of the Q/UAC and other quality-related committees and reports activities to the Board of Commissioners.

Quality/Utilization Advisory Committee (Q/UAC)

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 162 of 229 36 The Q/UAC is responsible to assure that quality, comprehensive health care, and services are provided to PHC members through an ongoing, systematic evaluation and monitoring process that facilitates continuous quality improvement. Q/UAC voting membership includes consumer representative(s) and external providers who are contracted primary care providers (PCPs) and board certified specialists in the areas of internal medicine, family medicine, pediatrics, OB/GYN, nephrology, neonatology, behavioral health, and representatives from other high volume specialties. The PHC Chief Medical Officer (CMO) (chair of the committee), Clinical Director of Behavioral Health, Associate Medical Director of Quality, Associate and Regional Medical Directors and leadership from the Quality and Performance Improvement, Provider Relations, Utilization Management, Care Coordination, Population Health, Pharmacy, and Grievance Departments attend the Q/UAC meetings regularly. Other PHC staff attend on an ad hoc basis to provide expertise on specific agenda items. The committee meets on a monthly at least ten (10) times per year, with the option to add additional meetings if needed. Q/UAC activities and recommendations are reported to the PAC and to the Commission at least quarterly. The Q/UAC provides guidance and direction to the UM program by coordinating activities and by functioning as the expert panel when needed. Coordination includes but is not limited to:

. Reviewing, making recommendations to, and approving the UM Program Description annually . Assuring individual member needs are taken into consideration when determinations for care are rendered and in the development of medical policy and procedures. . Analyzing summary data and making recommendations for action . Reviewing action plans for quality improvements of UM activities and providing ongoing monitoring and evaluation . Reviewing medical policy, protocol, criteria and clinical practice guidelines . Providing oversight of delegated activities

Pharmacy and Therapeutics Committee (P&T) The P&T Committee is chaired by PHC’s Chief Medical Officer (CMO) and is comprised of PHC’s Pharmacy Director, Associate and Regional Medical Directors, PHC staff and network practitioners including pharmacists, primary care physicians, behavioral health and other specialists. P&T makes decisions and recommendations on development and review of the prescription drug formulary*, pharmacy policy and procedures, and drug approval criteria. P&T Committee also serves as PHC’s Drug Utilization Review (DUR) Board to review PHC’s DUR program and activities and make recommendations where necessary to improve PHC’s drug utilization. The P&T meets quarterly, providing regular activity reports and recommendations to the PAC, the approval authority for P&T related activities. (*Note: PHC’s formulary and medication coverage benefits shall continue as described in this policy until such time as the pharmacy benefit carve-out to Medi-Cal Fee-for-Service described in APL 20-020 and the Governor’s Executive Order N-01-19 may take effect.)

Provider Advisory Group (PAG) The PAG is one of the Commission’s advisory committees and acts as a liaison between practitioner offices and PHC. The committee meets quarterly and has representatives from physician groups and individual offices, community clinics, ancillary providers, long term care facilities, employees of county health departments, and community advisory groups. The PAG reports directly to the Board of Commissioners, providing feedback and making recommendations related to health care service issues, community health activities, and issues for special needs populations.

Substance Use Services Internal Quality Improvement Subcommittee (SUIQI) A committee comprised of appropriate PHC and County staff tracks progress towards successful completion of quality initiatives, surveys, audits, and accreditation for the PHC’s Substance Use Services oversight. The SUIQI meets at least quarterly. Activities and progress are reported to the IQI. This also includes • Review of Utilization Management retroactive and appeals review • Review of inter-rater reliability for peer review and utilization management • Review of quality of service, quality of facility, and access complaints and grievances

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 163 of 229 37 • Investigation of potential over-use, under-use, and misuse of services. • Review of policies related to provision of SU services

Members of the committee include the Behavioral Health Clinical Director, the CMO, and representatives from the Provider Relations, Member Services, Claims, Compliance, Behavioral Health and Quality Improvement Departments. Consumer Advisory Committee (CAC) The CAC is composed of PHC health care consumers who represent the diversity and geographic areas of PHC’s membership. There are two CAC committees – one in PHC’s Northern seven counties and a second in PHC’s Southern seven counties. Both groups meet quarterly. The CAC is a liaison group between members and PHC, advocating for members by ensuring that the health plan is responsive to the health care and information needs of all members. The CAC reviews and makes recommendations regarding Member Services’ Quality Improvement Activities, provides feedback on Quality Initiatives and serves in the capacity of a focus group. A consumer from each region serves on the Board to provide consumer input and report back to their respective CAC.

UTILIZATION MANAGEMENT PROGRAM SCOPE

UM activities are developed, implemented and conducted by the PHC Health Services Department under the direction of the Chief Medical Officer and the Senior Director of Health Services. The UM staff performs specific activities.

Specific functions include: . Prospective, concurrent and retrospective utilization review for medical necessity, appropriateness of hospital admission, level of care and continued inpatient confinement on a frequency consistent with evidence-based criteria and PHC guidelines, PHC criteria/ medical policy and the member's condition. This review is performed cooperatively with the facility care team which may consist of the attending physician(s) and any associated health care personnel who can provide information that will substantiate medical necessity and level of care. . Discharge planning in collaboration with the facility care team . Review inpatient and outpatient UM data to determine appropriateness of member and provider utilization patterns . Use of most current edition of InterQual® Criteria for medical authorization, and other PHC UM guidelines and medical policy as developed and approved by the Quality / Utilization Advisory Committee (Q/UAC) . Use of California Department of Health and Welfare Code of Regulations Title 22, Center for Medicare & Medicaid Services (CMS) Code of Federal Regulations (CFR) Title 42 and National and Local Coverage Determinations . Review certification requests for skilled nursing care, home health care, durable medical equipment, ambulatory surgery, ambulatory diagnostic and treatment procedures such as physical, occupational and speech therapies.

The UM program incorporates the monitoring and evaluation for the subsequent services and reviews and updates policies and procedures as appropriate but at least annually. . Acute hospital services . Subacute care . Ambulatory care . Emergency and urgent care services . Durable Medical Equipment and supplies . Ancillary care services, including but not limited to home health care, skilled nursing care, subacute care, pharmacy, laboratory and radiology services . Long-term care including Skilled Nursing Facility (SNF) Care and Rehabilitation Facility Care

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 164 of 229 38 . Pharmacy drug formulary (Note: PHC’s formulary and medication coverage benefits shall continue as described in this policy until such time as the pharmacy benefit carve-out to Medi-Cal Fee-for- Service described in APL 20-020 and the Governor’s Executive Order N-01-19 may take effect.)

Mental Health

Members may self-refer for mental health services to mental health providers using the delegated Behavioral Health Organization’s toll-free referral numbers or by contacting the preferred behavioral health provider directly. Members do not need a referral or prior authorization to receive mental health services.

In an effort to coordinate the member’s overall health care, , mental health providers are instructed to ask members to sign a release of information so that the mental health provider can contact the member's PCP or other providers. However, the release of information is not a condition for the approval or provision of services.

Mental health services for Members with Medi-Cal as their primary insurance are provided as follows: . Members determined to have mental health needs that require mild to moderate mental health treatment are served by PHC’s delegated contractor, Beacon Health Options at (855) 765-9703. . Members assigned to Kaiser are assessed by Kaiser and served or appropriately referred. . Members determined to have moderate to severe mental health conditions are referred to the County Mental Health Plan in the Member’s county of eligibility (Except for Solano County Kaiser . members who will have their moderate to severe mental health conditions managed by Kaiser). The administration of such referrals is addressed in the respective Memorandum of Understanding (MOU) with each respective County Mental Health Plan, consistent with California statutes and regulations. . An initial assessment may be performed by any of these entities described above to determine the most appropriate level of service for the Member, including appropriate referral.

Effective July 1, 2020, PHC provides substance use disorder treatment services as outlined in the Regional Drug Medi-Cal Model. PHC performs utilization management for residential treatment of substance use disorders. For more information, please see the Substance Use Disorder Treatment Services/ Wellness & Recovery Program section below.

County Mental Health Plans provide crisis assessments and authorizations for care. Immediate access to the crisis service remains an option throughout all phases of treatment by any provider. Each County operates crisis services which to address clients in crisis; crisis services also act as a backup after hours and on weekends as well as at other times of provider unavailability. Members may call the County crisis line directly, without a referral. Members eligible for mental health services from PHC delegated contractors will be re-directed to appropriate County crisis services as needed.

A certain level of mental health services is appropriately dealt with in a primary care practice, including screening and referrals to services. Primary Care Providers may contact each county’s Mental Health Plan or PHC’s delegated contractor, Beacon Health Options, for telephone consultation. For detailed referral and consultation procedures, PCPs can refer to PHC Policy MPCP2017 Scope of Primary Care—Behavioral Health and Indications for Referral Guidelines.

PHC is responsible for the delivery of non-specialty mental health services for children under age 21 and outpatient mental health services for adult beneficiaries with mild to moderate impairment of mental, emotional, or behavioral functioning resulting from a mental health disorder, as defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM). Outpatient mental health services are

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 165 of 229 39 delivered as specified in policy MCUP3028 Mental Health Services whether they are provided by PCPs within their scope of practice or through PHC’s provider network. PHC continues to be responsible for the arrangement and payment of all medically necessary, Medi-Cal-covered physical health care services, not otherwise excluded by contract, for PHC beneficiaries who require specialty mental health services.

In compliance with Mental Health Parity requirements on October 1, 2017, as required by Title 42, CFR Section 438.930, PHC ensures direct access to an initial mental health assessment by a licensed mental health provider within the PHC provider network. No referral from a PCP or prior authorization is required for an initial mental health assessment to be performed by a network mental health provider.

PHC meets the general parity requirement (Title 42, CFR, §438.910(b)) which stipulates that treatment limitations for mental health benefits may not be more restrictive than the predominant treatment limitations applied to medical or surgical benefits. Neither a referral from the PCP nor prior authorization is required for a beneficiary to seek any mental health service, including the initial mental health assessment from a network mental health provider.

If a dispute occurs between the local County Mental Health plan and Partnership HealthPlan of California (PHC) or its delegated contractors, Kaiser or Beacon Health Options, both parties will participate in a dispute resolution process as defined in PHC Policy MCUP3127 Dispute Resolution Between PHC and MHPs in Delivery of Behavioral Health Services. This is consistent with the dispute resolution process outlined by State regulations and the individual County/PHC Memoranda of Understanding.

Triage and Referral for Mental Health

PHC monitors the triage and referral protocols for the delegated behavioral health services provider(s) to assure they are appropriately implemented, monitored and professionally managed. Protocols employed by delegates must be clinical evidence-based and an accepted industry practice. Protocols shall outline the level of urgency and appropriateness of the care setting.

Triage and referral decisions are performed by the Care Coordination and UM teams of the delegated Behavioral Health Services Provider which are co-located in the PHC offices with oversight by PHC’s Behavioral Health Clinical Director. Both work collaboratively with the designated County Mental Health Plans to ensure members receive care at the appropriate level in a timely manner.

Substance Use Disorder Treatment Services/ Wellness & Recovery Program

PHC works to ensure that members receive effective and appropriate behavioral health care services for both mental health and substance use disorders. Substance Use Disorder (SUD) treatment services are administered either by PHC or through individual counties.

The range of services in the Wellness & Recovery Program include:

. Outpatient treatment (licensed professional or certified counselor, up to nine hours per week for adults) . Intensive outpatient treatment for individuals with greater treatment needs (licensed professional or certified counselor, structured programming, 9-19 hours per week for adults) . Detoxification services (withdrawal management) . Residential treatment (Prior authorization is required as per policy MCCP2028 Residential Substance Use Disorder Treatment Authorization) . Medication assisted treatment (methadone, buprenorphine, disulfiram, naloxone)

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 166 of 229 40 . Case management . Recovery services (aftercare)

Behavioral Health Treatment (BHT) for Members Under 21 Years of Age

PHC has provided benefits for Behavioral Health Therapy for children diagnosed with Autism Spectrum Disorder (ASD) since September 2014.

Effective July 1, 2018, PHC expanded its benefit coverage to include Behavioral Health Treatment (BHT) for eligible Medi-Cal members under the age of 21 as required by the Early and Periodic Screening and Diagnostic Treatment (EPSDT) mandate.

Treatment services may include Applied Behavioral Analysis (ABA) and other services known as Behavioral Health Treatment (BHT).

BHT is the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the direct observation, measurement and functional analysis of the relations between environment and behavior.

BHT services teach skills through the use of behavioral observation and reinforcement, or through prompting to teach each step of targeted behavior. BHT services include a variety of behavioral interventions that have been identified as evidence-based by nationally recognized research reviews and/or other nationally recognized scientific and clinical evidence that are designed to be delivered primarily in the home and in other community settings.

PHC will provide BHT services for all members who meet the eligibility criteria for services as stated in 1905® of the Social Security Administration (SSA) and outlined in DHCS All Plan Letter (APL) 19-014. . Additional detailed information regarding the BHT benefit can be found in the following PHC Policies and Procedures: o MPUP3126 Behavioral Health Treatment (BHT) for Members Under the Age of 21 o MCCP2014 Continuity of Care

Quality Improvement Collaboration

The UM team works collaboratively with the Quality Improvement Department to enhance the care provided to our members through venues such as the Internal Quality Improvement Committee (IQI) , the Quality/ Utilization Advisory Committee (Q/UAC) and daily UM activities.

In the committee environment, the UM team takes an analytical, evaluative and strategic look at predetermined metrics to evaluate and offer recommendations which further enhance the UM program. Data is reviewed and discussed at least bi-annually during the IQI and Q/UAC meetings. The Q/UAC provides guidance and direction to the UM program by coordinating activities and by functioning as the expert panel when needed. Collaboration includes but is not limited to:

. Reviewing, making recommendations to, and approving the UM Program Description annually . Assuring individual member needs are taken into consideration when determinations for care are rendered . Analyzing summary data and making recommendations for action . Reviewing the recommendations of Process Implementation Teams to develop UM improvement action plans, ongoing monitoring, and evaluation . Recommending medical policy, protocol, and clinical practice guidelines based on provider and member experience information. *Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 167 of 229 41

During daily activities, the UM team supports QI efforts in the identification of potential quality of care issues, reporting adverse occurrences identified while conducting UM case review, improvement of Healthcare Effectiveness Data and Information Set (HEDIS®) scoring by referrals to care coordination, and care coordination efforts to ensure members are seen by the appropriate provider for their condition. UTILIZATION MANAGEMENT PROCESS

PHC applies written, objective, evidence-based criteria (InterQual®) and considers the individual member’s circumstance and community resources when making medical appropriateness determinations for behavioral health and physical health care services.

On an annual basis, PHC distributes a statement to all its practitioners, providers, members and employees alerting them to the need for special concern about the risks of under-utilization. It requires employees who make utilization-related decisions and those who supervise them to sign a statement which affirms that UM decision making is based only on appropriateness of care and service.

Furthermore, PHC does not reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service. Financial incentives for UM decision makers do not encourage decisions that result in under-utilization and PHC does not use incentives to encourage barriers to care and service. This does not preclude the use of appropriate incentives for fostering efficient, appropriate care.

Working with practitioners and providers of care, the following factors are taken into consideration when applying guidelines to a particular case in review:

. Input from the treating practitioner . Age of member . Comorbidities in existence . Complications . Progress of treatment . Psychosocial situation . Home environment . Consideration of the delivery system and availability of services to include but not be limited to: o Availability of inpatient, outpatient, transitional and residential treatment (SUD) facilities o Availability of outpatient services o Availability of highly specialized services, such as transplant facilities or cancer centers o Availability of skilled nursing facilities, subacute care facilities or home care in the organization’s service area to support the patient after hospital discharge o Local hospitals’ ability to provide all recommended services . Benefit coverage

Referrals and requests for prior authorization of services are to be submitted by the provider of service to the PHC UM department by mail, fax or through PHC’s Provider Portal which is a Secure Electronic Internet system. The following information must be provided on all requests.

. Member demographic information . Provider demographic information . Requested service/procedure to include specific CPT/HCPCS code(s) . Member diagnosis (Using current ICD Code sets) . Clinical indications necessitating service or referral . Pertinent medical history, treatment or clinical data . Location of service to be provided . Requested length of stay for all inpatient requests . Proposed date of procedure for all outpatient surgical requests

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 168 of 229 42

Pertinent data and information is required to enable a thorough assessment of medical necessity. If information is missing or incomplete, the requestor will be notified and given an opportunity to submit additional information.

Elective Admission Precertification The UM department evaluates every proposed treatment plan, and determines benefit eligibility, suitability of location and level of care prior to the approval of service delivery for select diagnoses and procedures.

Utilizing written criteria such as InterQual®, Medi-Cal Criteria and PHC medical policy approved by the Q/UAC, licensed and professional UM staff review and approve completed Treatment Authorization Requests (TARs).

Only the Chief Medical Officer or physician designee may make a medical necessity determination and have the authority to deny a service request based on lack of medical necessity. PHC offers the practitioner the opportunity to discuss any medical necessity denial determination with the physician reviewer rendering the decision.

Referral Management Referrals are generated by the primary care provider and submitted to PHC either by mail, fax or secure Provider Portal. PHC monitors and analyzes requests to identify trends and assist in follow-up care. Requests for out-of-network referrals are reviewed to determine if the service is available and can be provided within the service area. Out-of-Network requests are also used to evaluate provider access and to determine if the local network requires enhancements to meet member needs.

Continued Stay/Concurrent Review Acute care hospitalization reviews are performed by licensed professionals to ensure medical necessity of continued stay, the appropriateness of level of care, and care duration. This review is conducted either on site, by accessing the facility electronic medical record through a secure portal, or telephonically using written PHC medical policy, InterQual®, and/or Medi-Cal guidelines. PHC UM staff in conjunction with the use of written criteria consider the following:

. Patient age . Patient comorbidities . Complications . Progress of treatment . Psychosocial circumstance . and Home environment where applicable

Requests for authorization are reviewed within 24 hours of notification of admission and concurrently throughout the stay. The UM team facilitates discharge planning in collaboration with the facility care team and makes referrals to PHC case management and social services as appropriate.

Consideration of available services in the local service area or delivery system and the ability to meet the member’s specific health care needs are evaluated as part of application of criteria and the development of an ongoing plan of care and discharge plan.

Only the Chief Medical Officer or physician designee has the authority to deny a request for service based on lack of medical necessity. PHC offers the practitioner with clinical expertise in the area being reviewed the opportunity to discuss the application of criteria in determining medical necessity or any determination based on lack of clinical justification with the physician reviewer.

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 169 of 229 43 In addition to individual conversations with practitioners on specific case reviews, PHC conducts several committees for the purpose of hearing and incorporating practitioner input in the development of medical policy. PHC, through the Physician Advisory Committee (PAC), the Pharmacy and Therapeutics Committee (P&T) and the Physician Advisory Group (PAG), provides practitioners with clinical expertise in several areas the opportunity to advise or comment on the development and/or adaptation of UM criteria and provide feedback or instruction on the application of that criteria. Within the previously stated committees, PHC evaluates UM criteria and procedures against current clinical and medical evidence and updates them accordingly.

Skilled Nursing/Sub acute/ Long- Term Acute/Rehabilitation Facility Review Review of all Skilled Nursing and Rehabilitation Facility confinements are performed by licensed professionals to ensure medical necessity of continued stay and the appropriateness of level and duration of care. This review is conducted telephonically using written PHC medical policy, Title 22 criteria, and/or InterQual® criteria. PHC UM staff in conjunction with the use of written criteria consider the following:

. Age . Comorbidities . Complications . Progress of treatment . Psychosocial circumstance . and Home environment where applicable

Requests for authorization are reviewed within 24 hours of notification of admission. The UM team facilitates discharge planning in collaboration with the facility care team and makes referrals to PHC case management and social services as appropriate.

Consideration of available services in the local service area or delivery system, and the ability to meet the member’s specific health care needs are evaluated as part of applying criteria and the development of an ongoing plan of care and discharge plan.

Discharge Planning Discharge planning is a critical component of the utilization management process and begins upon admission with an assessment of the patient's potential discharge needs. It includes preparation of the family and the patient for continuing care needs and initiation of arrangements for services or placement needed after acute care discharge.

PHC Nurse Coordinators work with hospital discharge planners, case managers, admitting/attending physicians and ancillary service providers to assist in making necessary arrangements for post-discharge needs.

Post-Service Retrospective Review Post-service retrospective reviews may occur when a member is retroactively granted Medi-Cal benefits by the State of California, when a provider does not realize an authorization is required prior to rendering a service, when the rendered service code billed does not match the code authorized, or the service may have been rendered after the expiration of the authorization. TARs must be received by PHC within fifteen (15) business days of the date of service or within 60 calendar days of either a denial from the primary insurance carrier or retrospective eligibility. (TARs submitted beyond these timeframes are considered late but will still be reviewed for medical necessity.)

All retrospective reviews are completed within 30 calendar days of receipt of request. Electronic or written notification of the decision and how to initiate a routine or expedited appeal will be provided to the provider within 24 hours of decision, but no longer than 30 calendar days from the date of the receipt of the request.

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 170 of 229 44 PHC is not required to notify members of post-service review decisions as the member is not at financial risk for the services being requested.

Services requiring an authorization can be retrospectively reviewed for medical necessity, appropriateness of setting, and length of stay up to one year after services are rendered and may result in an adverse determination. Emergency Room Visits Emergency room visits where a prudent layperson, acting reasonably, would believe an emergency condition exists, DO NOT require prior authorization.

Timeliness of UM Decisions PHC makes UM decisions in a timely manner to accommodate the clinical urgency of the situation and to minimize any disruption in the provision of care. PHC measures the timeliness of decisions from the date when the organization receives the request from the member or PCP, even if the PHC does not have all the information necessary to make a decision. PHC documents the date when the request is received and the date a decision is rendered in the UM documentation system.

PHC has communicated to both providers and members the practice of processing non-urgent requests during the next business day if the request is received after business hours.

PHC Utilization Management abides by the following timeliness guidelines when processing health services requests.

Urgent Requests A request for medical care or services where application of the time frame for making routine or non-life threatening care determinations could jeopardize the live, health or safety of the member or others due to the member’s psychological state or, in the opinion of the practitioner with knowledge of the members medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment requested.

Concurrent Review Request: A request for coverage of medical care or services made while a member is in the process of receiving the requested medical care or services, even if the organization did not previously approve the earlier care.

Pre-Service Request A request for medical care or services that PHC must approve in advance, in whole or in part.

Non-Urgent Request A request for medical care or services for which application of the time periods for making a decision does not jeopardize the life or health of the member or the member’s ability to regain maximum function and would not subject the member to severe pain.

Post-Service Request / Retrospective Review A request for medical care or services that have been received.

Non-Behavioral Healthcare Decisions and Behavioral Healthcare Decisions

Type of Request Decision Time Frame Notification1 Time Frame Extended Time Frame Urgent concurrent 72 hours (3 calendar days ) of 72 hours (3 calendar days) May be extended one time review receipt of request of receipt of request up to 14 calendar days Urgent pre-service 72 hours (3 calendar days ) of 72 hours (3 calendar days ) May be extended one time receipt of request of receipt of request up to 14 calendar days Non-urgent pre- 5 business days of receipt of 24 hours of determination May be extended two times service request date up to 14 calendar days2

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 171 of 229 45 Post-service 30 calendar days of receipt of 30 calendar days of receipt N/A request of request

1 Notification: Give electronic or written notification of decision to practitioner (and member when required) 2 Per DHCS regulations

Review Criteria Current InterQual® criteria sets are used as the main review guidelines. Additional criteria are selected or developed using other resources as necessary to help in determining review decisions which include, but are not limited to, Medi-Cal (State of California) guidelines and State policy letters (see policy MCUP3139 Criteria and Guidelines for Utilization Management). InterQual® criteria are produced using a rigorous development process based on evidence-based medicine and reviewed at least annually, but as frequently as quarterly, by a panel of board-certified specialists. All UM policies are based on InterQual® criteria and are reviewed annually by the Quality/Utilization Committee (Q/UAC) and the Physician Advisory Committee (PAC) which also include board-certified specialists.

In the absence of applicable criteria, the PHC UM medical staff refers the case for review to a licensed, board- certified practitioner in the same or similar specialty as the requested service. The reviewing practitioners base their determinations on their training, experience, the current standards of practice in the community, published peer-reviewed literature, the needs of the individual patients (age, comorbidities, complications, progress of treatment, psychosocial situation, and home environment when applicable), and characteristics of the local delivery system. Board-certified consultants are available through our providers on our Quality/Utilization Advisory Committee (Q/UAC). PHC also contracts with a third-party independent medical review organization which provides objective, unbiased medical determinations to support effective decision making based only on medical evidence. (See policy MCUP3138 External Independent Medical Review.)

Criteria are selected, reviewed, updated or modified using feedback from the Q/UAC and PAC as well as member feedback identified in member survey results and the Consumer Advisory Committee (CAC), State policy letters, State Memorandums of Understanding and/or medical literature, among other sources. In collaboration with actively practicing practitioners, criteria are evaluated on at least an annual basis. Relevant clinical information is obtained when making a determination based on medical appropriateness and the treating practitioner is consulted as appropriate. All information obtained to support decision-making is documented in the utilization management documentation system.

Decisions are based on information derived from the following sources:

. Clinical records . Medical care personnel . Facility utilization management staff . Attending physician (attending physician can be the primary care physician, hospitalist or the specialist physician (or all three as necessary) . Board-certified specialists are consulted when medically necessary

The needs of individual patients and the characteristics of the local delivery system are taken into account when determining the medical necessity of an inpatient hospitalization.

Inter-Rater Reliability (IRR) PHC assesses the consistency with which physician and non-physician reviewers apply UM criteria in decision making and evaluates Inter-Rater Reliability. The Inter-Rater Reliability mechanism uses live cases to ensure medical management criteria are appropriately and consistently applied in making UM determinations. The methodology employed is designed to annually assess 50 cases or 5% of reviewer case load, whichever is less, over the course of a year period.

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 172 of 229 46 The following types of reviews/reviewers are audited: . Nurse Coordinator Review of Inpatient Services . Nurse Coordinator Review of Outpatient Services . Nurse Coordinator Review of Long Term Care Services . Physician Review of Medical Necessity Authorizations . Pharmacist and Pharmacy Technician Review of Pharmacy TARs . LCSW/LMFT Review of Residential Substance Use Disorder Treatment Authorizations

A performance target of 90% accuracy is set for inter-rater reliability. An audit summary is reported at least annually or more often as needed to the Internal Quality Improvement (IQI) Committee. If a reviewer falls below the targeted threshold, a corrective action plan is initiated and monitored and results are presented to the Quality/Utilization Advisory Committee (Q/UAC) for review and discussion. Please refer to policy MPUP3026 Inter-Rater Reliability Policy for a full description of the IRR process.

Availability of Criteria

All criteria used to review authorization request are available upon request. In the case of an adverse determination, the criteria used are made part of the determination file. Access to and copies of specific criteria utilized in the determination are also available to any requesting practitioner by mail, fax, email, or on our website: http://www.partnershiphp.org. To obtain a copy of the UM criteria, practitioners may call the PHC UM Department at (800) 863-4155.

Members may request criteria used in making an authorization determination by calling the member services department to request a copy of the criteria. The UM team will work with member services to provide the criteria used in the review decision.

PHC’s Provider Relations Department notifies providers in writing through the New Provider Credentialing Packet and the provider’s contract that UM criteria is available online at http://www.partnershiphp.org in the Provider Manual section. Providers are also notified quarterly in writing via the Quarterly Provider Newsletter about the on-line availability of UM criteria and policies at http://www.partnershiphp.org in the Medi-Cal Provider Manual section.

COMMUNICATION SERVICES PHC provides access to staff for members and practitioners seeking information about the UM process and the authorization of care in the following ways: . Calls from members are triaged through member services staff who are accessible to practitioners and members to discuss UM issues during normal working hours when the health plan is in operation (Monday - Friday 8 a.m. - 5 p.m.). . Members and Providers may contact the PHC voice mail service to leave a message which is communicated to the appropriate person on the next business day. Calls received after normal business hours are returned on the next business day and calls received after midnight on Monday - Friday are returned on the same business day. . After normal business hours, members may contact the advice nurse line for assistance . Practitioners may contact UM staff directly either through secure email or voicemail. Each voice mailbox is confidential and will accept messages after normal business hours. Calls received after normal business hours are returned on the next business day and calls received after midnight on Monday - Friday are returned on the same business day. . PHC has a toll free number (800) 863-4155 that is available to either member or practitioners. . UM staff identify themselves by name, title and organization name when initiating or returning calls regarding UM issues.

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 173 of 229 47 . Members can view information about PHC’s language assistance services and disability services in the Member Handbook which is mailed to members upon enrollment and is always available online at http://www.partnershiphp.org/Members/Medi-Cal/Documents/MCMemberHandbook.pdf Additionally, PHC provides annual written notice to Members about our language assistance services and disability services in our Member Newsletter. Linguistic services are provided by PHC to monolingual, non-English speaking or limited English proficiency (LEP) Medi-Cal beneficiaries for population groups as determined by contract. These services include the following: No cost linguistic services: . Oral interpreters, sign language interpreters or bilingual providers and provider staff at key points of contact available in all languages spoken by Medi-Cal beneficiaries . Written informing materials (to include notice of action, grievance acknowledgement and resolution letters) fully translated into threshold languages, upon request . Use of California Relay Services for hearing impaired [TTY/TDD: (800) 735- 2929 or 711]

PHC regularly assesses and documents member cultural and linguistic needs to determine and evaluate the cultural and linguistic appropriateness of its services. Assessments cover language preferences, reported ethnicity, use of interpreters, traditional health beliefs and beliefs about health and health care utilization.

Denial Determinations

Denial determinations may occur at any time in the course of the review process. Only the Chief Medical Officer, or a physician designee acting through the designated authority of the Chief Medical Officer, has the authority to render a denial determination based on medical necessity (see Program Structure section for details).

A denial determination may occur during continued stay/concurrent review in which case notification and/or discussion with the treating practitioner and the Health Plan physician adviser/Chief Medical Officer or physician designee is offered.

Denial determinations may occur at different times and for various reasons including but not limited to: . At the time of prior authorization; when the requested service is not medically indicated or not a covered benefit. . When timely notification was not received from a facility for an inpatient stay to foster transfer of a medically stable patient . When an inpatient facility fails to notify the Health Plan of admission within one business day of the admission or appropriate clinical information is not received . Or after services are rendered at claims review when the services were not authorized, or are medically unnecessary A denial may also occur for inappropriate levels of care or inappropriate care. Notwithstanding previous authorization, payment for services may be denied if it is found that information previously given in support of the authorization was inaccurate.

PHC offers the practitioner the opportunity to discuss any denial or potential denial determination based on lack of medical necessity with the Health Plan Chief Medical Officer, or a physician designee.

The denial notification states the reason for the denial in terms specific to the member’s condition or service request and in language that is easy to understand and references the criterion used in making the determination so the member and provider have a clear understanding of the Health Plan’s rationale and enough information to file an appeal. *Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 174 of 229 48

Partnership HealthPlan of California is aware of the need to be concerned about under-utilization of care and services for our members. PHC monitors over and under-utilization through the Over/Under Utilization Workgroup which reviews annual utilization patterns. Decisions made by PHC’s Utilization Reviewers are solely based on the appropriateness of the care or service.

The Health Plan does not compensate any individual involved in the utilization process to deny care or services for our members nor do we encourage or offer incentives for denials.

Process for a Provider to Appeal an Adverse Benefit Determination on Behalf of a Member

Members and providers are provided fair and solution-oriented means to address perceived problems in exercising rights as a Medi-Cal beneficiary or provider, in accordance with requirements of PHC’s contract with the Department of Health Care Services (DHCS). This process is entirely separate from that of State Fair Hearings, to which members retain their access. Please refer to PHC policy MCUP3037 Appeals of Utilization Management/ Pharmacy Decisions for a full description of the process.

Appeals of Adverse Benefit Determinations (ABDs)

A member, a member’s authorized representative, or a provider acting on behalf of a member, has 60 calendar days from the date of determination to submit an appeal request in response to a Notice of Action (NOA) letter. A member or a member’s authorized representative may initiate an appeal by contacting PHC’s Member Services department. An appeal initiated in this way is considered a Member Appeal and will be referred to the PHC Grievance and Appeals department for processing. A provider may also request an appeal on behalf of a member, with written consent from that member, by faxing or writing PHC’s UM or Pharmacy Department.

After receipt of the request for appeal, PHC will provide written acknowledgement to the member and provider that is dated and postmarked within five (5) business days of receipt of the appeal. PHC has 30 calendar days from the receipt of the appeal request to render a determination.

The Chief Medical Officer or physician designee reviews the request for appeal if the determination was based on medical necessity. The Chief Medical Officer or physician designee may request further information from the provider such as:

. Diagnostic information . Previous treatment . Clinical justification . Opinions from specialists or other providers . Evidence from the scientific literature prior to processing the request.

The provider is expected to respond to a request for further information within the 30 calendar day determination time frame. If the provider does not respond to the request for further information within that time frame, the appeal can be extended no more than 14 calendar days.

When a decision has been made, the provider and/or member, if applicable, are notified in writing within five (5) business days with a Notice of Appeal Resolution (NAR) letter. PHC is not required to notify the member of a decision when the member is not at financial risk for the services being requested (e.g. concurrent or retroactive reviews).

Providers who disagree with the appeal decision may then file a grievance with PHC by the process described in the Provider Grievance policy MP PR-GR 210. *Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 175 of 229 49 If PHC’s determination specifies the requested service is not a covered benefit, PHC shall include in its written response the provision in the Contract, Evidence of Coverage, or Member Handbook that excludes the service.

The response shall either identify the document and page where the provision is found, direct the provider and member to the applicable section of the contract containing the provision, or provide a copy of the provision and explain in clear concise language how the exclusion applies to the specific health care service or benefit request.

Expedited Appeals of Adverse Benefit Determinations

Expedited appeals may be initiated by the member or the provider. A member may initiate an expedited appeal by calling the Member Services Department. A provider may initiate an expedited appeal on behalf of a member with written consent by faxing or writing the PHC UM or Pharmacy Department. If the request for expedited appeal is not accompanied by written consent from the member, the Plan will proceed with the request.

Expedited appeals are performed by PHC only when, in the judgment of the Chief Medical Director or Physician Designee, a delay in decision-making may seriously jeopardize the life or health of the member.

PHC refers the expedited appeal request to the Chief Medical Officer or Physician Designee for decision on the appeal. The Chief Medical Officer or Physician Designee is expected to make a decision as expeditiously as the medical condition requires, but no later than seventy-two (72) hours after the receipt of the request for an expedited appeal.

Expedited reviews are also granted to all requests concerning admissions, continued stay or other health care services for a member who has received emergency services but has not been discharged from a facility.

PHC provides verbal confirmation of its decisions concurrent with mailing of written notification no later than seventy-two (72) hours after receipt of an expedited appeal. If the expedited appeal involves a concurrent review determination, the member continues to receive services until a decision is made and written notification is sent to the provider. PHC is not required to notify the member of a concurrent decision as the member is not at financial risk for the services being requested.

Appeal Rights

A member may ask assistance from a patient advocate, provider, ombudsperson or any other person to represent them in their request.

A member may also request a State Hearing if a member has filed an appeal and received a “Notice of Appeal Resolution” letter upholding the initial denial of service. Information on how to obtain an expedited State Hearing is included as a part of the “Notice of Appeal Resolution” letter to the member.

Member grievance and appeal information is included in the member handbook, distributed annually in the member newsletter, and is posted on the PHC website.

It is the responsibility of the Member Services Director and the Member Services Department to ensure:

. Member Rights and Responsibilities are included in the member handbook which is mailed to all new members and posted on the PHC website

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 176 of 229 50 . Members are advised of their right to receive a copy of the Member Rights and Responsibility statement annually in the PHC’s member newsletter. . Members are notified of all revisions to the Member Rights and Responsibilities statement in the member newsletter following revisions.

It is the responsibility of the Provider Relations Director and the Provider Relations Department to ensure

. The Member’s Rights and Responsibilities statement is included in the PHC provider manual issued to all contracted providers. The manual is issued to providers after their contract has been fully executed. . Any revisions to the Member’s Rights and Responsibilities statement are issued to all contracted providers within 90 days from the date these revisions are finalized.

Data Sources

Utilization Management supports the effective, efficient, and appropriate utilization of member benefits through ongoing review, evaluation and monitoring of the member’s personal health information in making medical necessity determinations.

Data sources may include, but are not limited to: . Medical records, from outpatient provider offices and hospital records (including accessing hospital Electronic Medical Records (EMR); for current and historical data . Member handbook or Evidence of Coverage . Consultations with treating physicians . network adequacy information . Local delivery system capacity information . Specialist referrals . Recent Physical exam results . Diagnostic testing results . Treatment plans and progress notes . Operative and pathological reports . Rehabilitation evaluations . Patient characteristics and information . Patient psychosocial history . Information from family / social support network . Prospective/concurrent/retrospective utilization management activities . Claim/encounter (administrative) data

Data Collection, Analysis, and Reporting Data collection activities for analysis and reporting are coordinated by the UM department. At the data gathering/performance measurement phase, participants in the process include programmers and analysts in the Finance and Health Services departments, staff nurses, and any other personnel required for the collection and validation of data. All data collection activities are documented and reported to the Q/UAC twice a year and more often if requested. Data collection activities may include, but are not limited to:

. Member satisfaction surveys . Provider satisfaction surveys . Readmission statistics . Potential quality incident data . Member appeal data . Provider appeal data . Internally developed databases . Pharmacy utilization data

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 177 of 229 51 . Other administrative or clinical data

EVAL UATI O N OF NEW MEDICAL TECHNOLOGY

PHC evaluates the inclusion of new medical technologies and the new application of existing technologies in its benefit packages. While the basic benefits are set by the State of California Department of Health Care Services (DHCS) and outlined in Title 22 of the Health and Welfare Code, PHC has the option of adding to this basic package of benefits for its members.

PHC’s Policy MCUP3042 Technology Assessment outlines the steps taken during the determination process. The PHC Physician Advisory Committee will review all cases and make a final recommendation to the Board of Commissioners as to new benefits. The Commission is the only entity that can add benefits. Once a new benefit is added, the information is disseminated to all Primary Care Providers and appropriate specialists in the form of a mail notification of benefit addition, and to all members in the next member newsletter.

New technologies are handled on a case-by-case basis which includes obtaining information regarding the safety, efficacy and indications that support the use of the intervention. There must be evidence that the proposed intervention will add to improved outcomes as compared to what is currently available. The service provider must have a record of safety and success with the intervention and cannot be part of a funded research protocol. The Chief Medical Officer works closely with the requesting physician and specialists as needed in researching these cases.

DELEGATION

UM activities that are delegated to contract providers are reviewed and approved on an annual basis by the Q/UAC. A delegation agreement, including a detailed list of activities delegated and reporting requirements is signed by both the delegate and PHC.

. Providers to whom UM activities have been delegated are responsible for reporting results and analyses to PHC on a quarterly or annual basis. Reports are summarized for review and evaluation by PHC’s Delegation Oversight Review Sub-Committee (DORS) and Q/UAC. . Audits are conducted no less than annually and evaluation includes a review of both the processes applied in carrying out delegated UM activities, and the outcome achieved in accordance with the respective policy(s) and agreement governing the delegated responsibility. . The Q/UAC reviews evaluations and make recommendations regarding opportunities for improvement and continuation of delegated functions.

A pre-delegation evaluation is conducted when delegation of functions to providers is being considered.

Protected Health Information (PHI) The Privacy Rule, described in 45 CFR Parts 160 and 165, applies to covered entities. The Privacy Rule allows covered providers, entities, and health plans to disclose PHI in order to carry out their health care functions.

Partnership HealthPlan of California is fully compliant with the general rules, regulations and implementation specified in The Privacy Rule. PHC also provides reasonable administrative, technical, and physical safeguards to ensure PHI confidentiality, integrity and availability and to prevent unauthorized or inappropriate access, use or disclosure of PHI.

The PHC Director of Regulatory Affairs and Program Development also serves as the PHC Privacy Officer. PHC has implemented a comprehensive program that includes “Notice of Privacy Practices” (NPP) sent to all

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 178 of 229 52 members, as well as implementation of a confidential toll-free complaint line available to members, providers and PHC staff. For non-covered entities, PHC requires Business Associate Agreements (BAA). Additionally, there is training on an annual basis for the PHC workforce and PHC providers/networks, and PHC maintains policies and procedures around documentation of complaints of violations or suspected privacy incidents.

STATEMENT OF CONFIDENTIALITY

Confidentiality of provider and member information is ensured at all times in the performance of UM activities through enforcement of the following:

. Members of the Q/UAC and PAC are required to sign a confidentiality statement that will be maintained in the QI files. . UM documents are restricted solely to authorized Health Services Department staff, members of the PAC, Q/UAC, and Credentialing Committee, and reporting bodies as specifically authorized by the Q/UAC. . Confidential documents may include, but are not limited to Q/UAC and Credentialing meeting minutes and agendas, QI and Peer Review reports and findings, UM reports, or any correspondence or memos relating to confidential issues where the name of a provider or member are included. . Confidential documents are stored in locked file cabinets with access limited to authorized persons only, or they are electronically archived and stored on protected drives. . Confidential paper documents are destroyed by shredding.

NON-DISCRIMINATION STATEMENT

PHC complies with applicable Federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.

PHC will not deny or limit coverage, deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions on coverage, for any health services that are ordinarily or exclusively available to individuals of one sex, to a transgender individual based on the fact that an individual’s sex assigned at birth, gender identity, or gender otherwise recorded is different from the one to which such health services are ordinarily are exclusively available. Also, PHC will not otherwise deny or limit coverage, deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions on coverage, for specific health services related to gender transition if such denial, limitation, or restriction results in discrimination against a transgender individual.

PHC provides free aids and services to people with disabilities to communicate with us, such as: . Qualified sign language interpreters . Written information in other formats (large print, audio, accessible electronic formats, other formats)

PHC provides free language services to people whose primary language is not English or those with limited English proficiency (LEP). These services include the following: . Qualified sign language interpreters . Information written in other languages . Use of California Relay Services for hearing impaired

STATEMENT OF CONFLICT OF INTEREST

Any individual who has been personally involved in the care and/or service provided to a patient, an event or finding undergoing quality evaluation may not vote or render a decision regarding the appropriateness of such care. All members of the Q/UAC are required to review and sign a conflict of interest statement, agreeing to abide by its terms. *Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 179 of 229 53

PROVIDER AND MEMBER SATISFACTION

PHC conducts satisfaction surveys on both members and providers. Included in the evaluation are questions that deal with both member and provider satisfaction with the UM program. The responses to the survey are reviewed by staff from Health Services, Member Services, and Provider Services. Thresholds are set and responses that fall below are considered for corrective action by the HealthPlan. The results, as well as plans for corrective action, are developed in conjunction with the Q/UAC. Corrective actions that were in place are evaluated at the time the follow-up annual survey is done unless the committee feels an expedited time frame needs to be implemented.

ANNUAL PROGRAM EVALUATION

The Utilization Management program undergoes a written evaluation of its overall effectiveness annually by the Q/UAC, which is reviewed and approved by the PAC.

At a minimum the evaluation considers UM department activities and outcomes, the review of Key Performance Indicator metrics such as Productivity, Timeliness, Bed-days, readmission rates and denial rates along with resource effectiveness and barriers to performance.

Preparation for the Annual Program Evaluation involves participation by all Utilization Management and Pharmacy leadership including but not limited to: . Senior Health Services Director . Director, Pharmacy Services . Associate Directors of UM . UM Team Manager

Elements of the program evaluation include an objective assessment of meeting targeted goals to ensure appropriate, efficient utilization of resources/services for PHC members across the continuum of care in compliance with requirements of state/federal and regulatory entities.

. Annual UM Program Description update . Annual review and evaluation of UM processes (meeting goals and identifying opportunities for process improvements) . Timely review and update of UM policies and procedures . Obtain approval of UM policies and procedures at Q/UAC

Inter-Rater Reliability scoring, TAR timeliness, percentage of eRAFs vs. Manual RAFs, and Call Performance is compared with regulatory compliance standards and internal benchmarks.

To determine if the UM program remains current and appropriate, the organization annually evaluates:

. The program structure . The program scope, processes, information sources used in the determination of benefit coverage and medical necessity . The level of involvement of the senior-level physician and designated behavioral healthcare practitioner in the UM program . Consideration of member and practitioner experience data when evaluating the UM program

The organization updates the UM program and its description annually based on the evaluation.

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 180 of 229 54

To ensure the provision of healthcare services at the appropriate level of care the evaluation considers: . Inpatient bed day rate . Inpatient average length of stay . SNF admit rate . SNF average length of stay . Readmission rate . Denial rate . Timely completion of notifications of denial of care . Timely completion of notifications of authorization of care . Rate of referrals to Care Coordination . Effectively integrating feedback - the program reflects on Member/Provider satisfaction results concerning the UM program looking at: o Daily Work Flow Monitoring o Call Abandonment rates o Call Volume o Average caller wait time

An assessment of Department resources is determined by looking at the impact of staffing changes, learning curves and system limitations which impede work effectiveness. There is a review of Inter-Rater Reliability scoring in relation to staff training/re-education, acclimation to new technology such as documentation software/ hardware based on evaluating user acceptance, and the assessment of appropriate staffing ratio to ensure adherence to regulatory and internal performance standards.

A summary of the program evaluation, including a description of the program, is provided to members or practitioners upon request. When the evaluation is complete, an announcement indicating the availability of UM information is published in the member and provider newsletter.

REFERENCES: Department of Health Care Services (DHCS) standards National Committee for Quality Assurance (NCQA) Guidelines (Effective July 1, 2020) UM Standards 1-5, 7

Original Date: QI/UM Program 04/22/1994 effective 05/01/1994 Revision Date(s): 08/16/95 Revision Date(s): UM Program Description - 04/17/97; Board Approval January 28, 1998; 06/10/98; 01/20/99; 05/2000; 05/01/01; (UD100301) 03/20/02; 08/20/03; 10/20/04; 10/13/05; 06/21/06; (MPUD3001) 04/16/08; 08/03/10; 11/19/14; 02/17/16; 04/19/17; *06/13/18; 04/10/19, 06/12/19 (Amended), 10/09/19 (Amended); 04/08/20; 06/10/20 (Amended); 04/14/21

*Through 2017, Approval Date reflective of the Quality/Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 181 of 229 55 UM PROGRAM DESCRIPTION APPROVAL

Robert Moore, MD, MPH, MBA 03/17/2021

Quality/Utilization Advisory Committee Chairperson Date Approved

04/14/2021

Physician Advisory Committee Chairperson Date Approved

04/28/2021

Board of Commissioners Chairperson Date Approved

*Services related to substance use services as outlined in the Regional Drug Medi-Cal Model are placeholders for when DHCS releases the benefit. Activity is not anticipated to be effective until late Spring 2020. 182 of 229 56 CREDENTIALING COMMITTEE SUMMARY FOR PARTNERSHIP HEALTHPLAN OF CALIFORNIA PHYSICIAN ADVISORY COMMITTEE

Pg. 1 of 3* = by phone conference

Committee: Credentialing Committee Date/Time: February 10, 2021, 7:00 A.M. – 7:30 A.M. Members Present: Jeffrey Gaborko MD*; Bradley Sandler, MD*; David Gorchoff, MD; Michele Herman, MD*. Marshall Kubota, MD*, PHC Regional Medical Director; Robert Moore, MD, MPH, MBA, PHC PHC Staff: Chief Medical Officer*; Bettina Spiller, MD* PHC Northern Region Medical Director; Mark Netherda, MD*, Associate Medical Director, Quality; Jeff Ribordy, MD* Regional Medical Director; Jeffery Devido, MD* Behavioral Health Clinical Director*; Mary Kerlin, Senior Director*; Lisa O’Connell*, Senior Manager of Provider Network Education and Credentialing, Erika Roach*, Credentialing Specialist I; J’aime Seale*, Credentialing Specialist I; Brooke Vance*, Senior Lead Auditor.

AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE DATE RESOLVED I. Meeting called to I. PHC Regional Medical Director Marshall Kubota, MD 2/10/2021 order. called the meeting to order at 7:00 AM. Dr. Kubota reminded everyone that all items discussed are confidential. a. Voting member a. Marshall Kubota, MD, PHC Regional Medical 2/10/2021 reminder. Director, reminded The Committee of who the voting members are, and voting is restricted to non-PHC staff. Dr. Kubota reminded the committee that all information discussed is confidential in nature.

II. Review and approval II. The Credentialing Committee meeting minutes for II. Minutes were reviewed with no revisions. A motion for 2/10/2021 of January 13, 2021 January 13, 2021 were reviewed by the Committee. No approval of the minutes was made by: Bradley Sandler, Credentialing Meeting changes were made. MD and seconded by: David Gorchoff, MD. Meeting Minutes. minutes were unanimously approved without changes.

III. Old Business. III. Old Business III. Old Business 2/10/2021 No old business to report.

IV. New Business IV. New Business IV. New Business 2/10/2021 a. Review and Approval a. Dr. Kubota referred the Committee to pages 7-11, a. The Committee reviewed the list of practitioners. A 2/10/2021 of Routine Practitioner he asked the Committee to review the routine list of motion to approve the list of practitioners was made by: List. practitioners. Jeffrey Gaborko, MD; seconded by: Bradley Sandler, MD. The Committee unanimously approved the routine list. b. Review and Approval b. Dr. Kubota directed the committee’s attention to Lisa b. A motion for the approval of MPCR revised policies 2/10/2021 of Revised Policies. O’Connell for a review of the revised policies. Lisa drew 183 wasof 229 made by: Bradley Sandler, MD and seconded by: PHC Credentialing Meeting Minutes 2/10/2021 Page 2 of 3

AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE DATE RESOLVED the committee’s attention to MPCR 500 and stated these Michelle Herman MD. The Committee unanimously are changes are updates made to policies because of the approved. change in process on how we monitor practitioner specific complaints and adverse events. PHC is collating them into a track and trend report that is collected by the Grievance/Appeals Department and QI for Adverse Events. It will be collated into a rolling Track and Trend Report that Dr. Kubota reviews. These reports will be brought to the Credentialing meeting every six months for report and review. Dr. Kubota explained that all other policy changes are administrative updates to meet NCQA requirements. c. Exceptions: Provider c. Dr. Kubota directed the committee’s attention to c. A motion to approve this provider to administer wound 2/10/2021 Provider whose specialty is pathology but would like to care was made by: Jeffery Gaborko, MD and was be credentialed as wound care provider. Dr. Kubota said seconded by: Bradley Sandler, MD. The Committee there is no board for wound care or certifying body such unanimously approved. as ABMS and this is a relatively new company providing these services. Dr. Kubota mentioned he wanted to know more about the abilities of these providers and so he . spoke to the CMO. The CMO confirmed there are trainings, concurrent reviews, case discussions, and chart reviews. The CMO also sent over their training program on pages 47-49. Dr. Kubota felt after reviewing everything that it was good to approve the credentialing of this provider and asked for a motion to approve.

V. Ongoing Monitoring V. Ongoing Monitoring of Sanctions Report and V. Ongoing Monitoring of Sanctions Report and 2/10/2021 of Sanctions Report and Practitioner Monitoring List. Practitioner Monitoring List. Practitioner Monitoring List. a. Review and Approval a. Review and Approval of Ongoing Monitoring of a. The Committee members reviewed the reports. A 2/10/2021 of Ongoing Monitoring Sanctions Report. The Committee was asked to review motion for approval of the Ongoing Monitoring of of Sanctions Report. and approve the Ongoing Monitoring of Sanctions Sanctions Report was made by: Jeffery Gaborko, MD and Report, page 50. was seconded by: Bradley Sandler, MD. The Committee unanimously approved. b. Practitioner b. The Committee was asked to review the Practitioner b. Informational only 2/10/2021 Monitoring List. Monitoring List on pages 51-55. Dr. Kubota reminded the committee that the credentialing department monitors

184 of 229 2

PHC Credentialing Meeting Minutes 2/10/2021 Page 3 of 3

AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE DATE RESOLVED these boards for any actions regarding our providers.

VI. Review and VI. Review and Approval of Consent Calendar Items. VI. Review and Approval of Consent Calendar Items. 2/10/2021 Approval of Consent Calendar Items. a. Report of Long Term a. Dr. Kubota asked the Credentialing Committee a, The Committee members reviewed the list of Consent 2/10/2021 Care Facility, Hospital, members to review the report of Long Term Care Facility, Calendar Items. A motion for approval was made by: and Ancillary provider Hospital, and Ancillary provider list on page 56. Jeffery Gaborko, MD and was seconded by: Bradley list. Sandler, MD. and was unanimously approved by the Credentialing Committee. VII. Meeting VII. Meeting adjourned at 7:15 AM. 2/10/2021 Adjourned.

185 of 229 3

February 2021 Routine Clean File List

Provider Board App. Type County Certifie Type Full Name Code Name/Street Name Specialty Description Board Name d Hospital Name Acosta, Rosalba American Academy of Nurse Practitioners I M.,FNP PCP Marin Community Clinic: Campus Clinic Marin Family Nurse Practitioner Certification Board Yes Mercy Medical Center of R Alvarez, Marta E.,MD SPEC Marta E. Alvarez MD, PC Shasta Wound Care None No Redding Admitting I Antelo, Fernando MD SPEC Wound MD PC Solano Wound Care None No Agreement R Arons, Scott S.,DC SPEC Arons Chiropractic Inc. Shasta Chiropractic None No Sutter Medical Center R Atray, Naveen K.,MD SPEC Capital Nephrology Medical Group Yolo Nephrology ABMS of Internal Medicine Yes Sacramento Admitting I Aziz, Amna S.,MD PCP Redding Rancheria: Churn Creek Healthcare Shasta Pediatrics ABMS of Pediatrics Yes Agreement Badgett, John Jr., California Consortium of Addiction Programs I CADC II W&R Archway Recovery Services IOP W & R Solano Wellness and Recovery Professionals Yes

I Bailey, Karla R.,FNP BOTH La Clinica Solano Family Nurse Practitioner American Nurses Credentialing Center Yes American Academy of Nurse Practitioners R Barylski, Chad R.,FNP BOTH Annadel Medical Group (Family Practice) Sonoma Family Nurse Practitioner Certification Board Yes American Academy of Nurse Practitioners I Bennett, Erin M.,FNP SPEC Planned Parenthood Northern CA: Lake Lake Family Nurse Practitioner Certification Board Yes Berkowitz, Liana Humboldt Medical Specialists: Orthopedic and Physician Assistant National Commission on Certification of I M.,PA-C SPEC Pain Mngt. Humboldt Certified Physician Assistants Yes Brantingham, Steven Curry General I T.,DPM SPEC Curry Medical Center Podiatry Confirmed per AMA, AOA or Residency Letter No Hospital Brown, Laurence R J.,FNP PCP Santa Rosa Community Health - Vista Campus Sonoma Family Nurse Practitioner American Nurses Credentialing Center Yes John Buechner DC Strength and Spine I Buechner, John DC SPEC Chiropractic Humboldt Chiropractic None No Byrnes, Rebecca R R.,BCBA BHP Gateway Learning Group Marin Behavioral Health Behavior Analyst Certification Board Yes Carlevato, Catherine I RD RD As You Are Nutrition Napa Registered Dietitian Commission of Dietetic Registration Yes Caravelli, Michael Adventist Health - I L.,MD SPEC Napa Valley Orthopaedic Medical Group Inc. Napa Orthopaedic Surgery ABMS of Orthopaedic Surgery Yes St. Helena Cavanaugh, Amy California Consortium of Addiction Programs I L.,RADT W&R Aegis Treatment Centers, LLC - Redding Shasta Wellness and Recovery Professionals Yes American Academy of Nurse Practitioners R Chase, Karen G.,FNP BOTH Sutter Coast Community Walk-In Clinic Del Norte Family Nurse Practitioner Certification Board Yes

West Coast Retina Medical Group-San California Pacific R Chen, Judy J.,MD SPEC Francisco Marin Ophthalmology ABMS of Ophthalmology Yes Medical Center Sutter Medical Sacramento Heart & Vascular Medical Center R Clark, Richard A.,MD SPEC Associates Yolo Cardiovascular Disease ABMS of Internal Medicine Yes Sacramento Cromar, Jennifer R H.,CNM SPEC Marin Community Clinic: Campus Clinic Marin Certified Nurse Midwife American Midwifery Certification Board Yes

February 2021 186 of 229 February 2021 Routine Clean File List

Santa Rosa David, Frederick Memorial R C.,MD SPEC Annadel Medical Group Sonoma Radiation Oncology ABMS of Radiology No Hospital Davidson, Danielle I M.,RD Allied Enjoy Life Nutrition LLC Marin Registered Dietitian Commission of Dietetic Registration Yes Deck, Tatyana L.,PA- Physician Assistant National Commission on Certification of R C PCP Elica Health Centers Yolo Certified Physician Assistants Yes Admitting R DeRose, David J.,MD PCP Adventist Health Clearlake Lake Internal Medicine ABMS of Internal Medicine Yes Agreement QVMA: Queen of the Valley Medical Associates Admitting I Eapen, Manoj K.,MD SPEC Cardiology Napa Internal Medicine ABMS of Internal Medicine Yes Agreement Physician Assistant National Commission on Certification of I Frazer, Stacy L.,PA-C SPEC Innovative Sleep Centers Inc Shasta Certified Physician Assistants Yes Gatchel, Angel California Consortium of Addiction Programs I A.,RAC W&R MedMark Treatment Centers- Fairfield, Inc. Solano Wellness and Recovery Professionals Yes Gatmen, Jean American Academy of Nurse Practitioners R Paulette A.,FNP PCP West Sacramento Pediatric Medical Group Yolo Family Nurse Practitioner Certification Board Yes Golafshani, Sayeh PA- Physician Assistant National Commission on Certification of I C PCP Elica Health Centers-Halyard Medical Center Yolo Certified Physician Assistants Yes Novato Gordon, Anthony Community I K.,MD SPEC Marin Advanced Wound Center, PC Diagnostic Radiology ABMS of Radiology Yes Hospital Mendocin Adventist - Ukiah I Gould, Brian S.,DO SPEC Adventist Health Ukiah Valley o Sports Medicine None Valley Graham, Nicole Visions of the Cross/ Women's Residential California Consortium of Addiction Programs I W.,RADT W&R Treatment Shasta Wellness and Recovery Professionals Yes John Muir Guevara, Salvador John Muir Specialty Medical Group - Colon and Rectal Medical Center - I G.,MD SPEC Gastroenterology Solano Surgery ABMS of Colon and Rectal Surgery Yes Concord Admitting I Ha, David K.,DO SPEC Summit Pain Alliance, Inc. Sonoma Pain Management None No Agreement Hanks, Madeleine Meets MPCR #17, Verified Residency on Marin General I B.,MD PCP Tamalpais Pediatrics Marin Pediatrics AMA/AOIA No Hospital Harmon, Michael St Joseph I W.,MD SPEC Michael W. Harmon MD, Inc. Humboldt Radiation Oncology ABMS of Radiology Yes Hospital Obstetrics and Sutter Coast I Hobeika, Elie M.,MD SPEC Sutter Coast Community Clinic (OB-GYN) Del Norte Gynecology ABMS of Obstetrics and Gynecology Yes Hospital Humboldt Medical Specialists - Physical Physical Medicine & St. Joseph R Holder, Pinella A.,DO SPEC Medicine & Rehabilitation Humboldt Rehabilitation ABMS of Physical Medicine & Rehabilitation Yes Hospital-Eureka

R Hughes, Marie B.,DO PCP Napa Valley Family Medical Group Napa Family Medicine ABMS of Family Medicine Yes I Huynh, Vivian BCBA BHP Behavior Treatment & Analysis, Inc. Solano Behavioral Health Behavior Analyst Certification Board Yes

R Iverson, Jena BCBA BHP Multiplicity Therapeutic Services, Inc. Humboldt Behavioral Health Behavior Analyst Certification Board Yes Jamison, Emma Obstetrics and Marin General I L.,MD SPEC Marin Community Clinic: Campus Clinic Marin Gynecology Confirmed per AMA, AOA or Residency Letter No Hospital Johnk, Dorien A.,PA- National Commission on Certification of I C SPEC California Orthopedics & Spine, Inc Marin Physician Assistant Physician Assistants Yes Admitting I Johnson, David L.,MD W&R Siskiyou County Behavioral Health Siskiyou Wellness and Recovery None No Agreement

February 2021 187 of 229 February 2021 Routine Clean File List

Johnson, Julissa I BCBA BHP Burnett Therapeutic Services, Inc. Napa Behavioral Health Behavior Analyst Certification Board Yes Mendocin Ukiah Valley R Joseph, Jay S.,MD SPEC Annadel Medical Group o Radiation Oncology ABMS of Radiology Yes Medical Center Asante Rogue Asante Physician Partners: Maternal Fetal Maternal and Fetal Regional Medical R Kahn, Daniel A.,MD SPEC Medicine Siskiyou Medicine ABMS of Obstetrics and Gynecology Yes Center Sutter General R Kashyap, Rohit MD SPEC Capital Nephrology Medical Group Yolo Nephrology ABMS of Internal Medicine Yes Hospitals Mercy Medical Center Mt. R Katana, John M.,MD PCP Dignity Health - Mercy Mt. Shasta Comm Clinic Siskiyou Family Medicine ABMS of Family Medicine Yes Shasta Mercy San Juan R Kazak, Marat DPM SPEC Sacramento Foot and Ankle Center, Inc. Yolo Podiatry None No Hospital Keenan, Amber American Academy of Nurse Practitioners I R.,FNP SPEC North Bay Allergy & Asthma Associates, Inc. Napa Family Nurse Practitioner Certification Board Yes I Knouse, Jordan PT Allied Selah Women's Health Shasta Pelvic Floor Therapy None Admitting I Knuppel, Kyle A.,MD PCP Anav Tribal Health Clinic Siskiyou Family Medicine ABMS of Family Medicine Yes Agreement Marin Community Clinic: Novato Clinic (FP/IM Admitting I Korr, Kenneth S.,MD SPEC and Spec) Marin Cardiovascular Disease ABMS of Internal Medicine Yes Agreement Kruusmagi, Ellen Admitting R B.,MD PCP Sonoma County Indian Health Project, Inc. Sonoma Family Medicine ABMS of Family Medicine Yes Agreement Solano County Health & Social Services: Adult Admitting R Leary, Michele F.,DO PCP Clinic Solano Family Medicine AOB-Family Medicine No Agreement

I Lee, Lindsay C.,BCBA BHP Burnett Therapeutic Services, Inc. Napa Behavioral Health Behavior Analyst Certification Board Yes CommuniCare Health Centers-Hansen Family Physician Assistant National Commission on Certification of R Lee, Marge PA-C PCP Medical Center Yolo Certified Physician Assistants Yes American Academy of Nurse Practitioners R Loe, Louise R.,FNP PCP Lake County Tribal Health Center Lake Family Nurse Practitioner Certification Board Yes Longchamp, Carla Santa Rosa Community Health - Dutton Admitting R P.,MD PCP Campus Sonoma Family Medicine ABMS of Family Medicine Yes Agreement Admitting R Lynn, Collin W.,MD PCP SCHC: Shasta Community Health Center Shasta Family Medicine ABMS of Family Medicine Yes Agreement MacLaughlin, Kathryn I S.,FNP PCP Marin Community Clinic: San Rafael Clinic Marin Family Nurse Practitioner American Nurses Credentialing Center Yes Madrilejo, Nelson Meets MPCR#17, Previously Board Certified in Admitting I G.,MD PCP Redding Rancheria: Trinity Health Center Trinity Internal Medicine FM, IM, or PEDs No Agreement Manubens, Sergio QVMA: Queen of the Valley Medical Associates Queen of the R M.,MD SPEC Cardiology Napa Cardiovascular Disease ABMS of Internal Medicine Yes Valley Novato Marino, Vincent Community I C.,DPM SPEC San Francisco Foot and Ankle Center Marin Podiatry AB Podiatric Medicine Yes Hospital Martin-Ko, Anne Mendocino Community Health Clinic: Hillside Mendocin Ukiah Valley R C.,MD PCP Health Center o Pediatrics ABMS of Pediatrics Yes Medical Center Matsuda, James Admitting I J.,MD PCP UIHS - Potawot Health Village Humboldt Pediatrics ABMS of Pediatrics Yes Agreement

February 2021 188 of 229 February 2021 Routine Clean File List

San Ramon East Bay Cardiovascular and Thoracic Regional Medical I Mikkineni, Karthik MD SPEC Associates Solano Vascular Surgery ABMS Vascular Surgery Yes Center Montano, Danette R R.,BCBA BHP Starfish Hero Inc Humboldt Behavioral Health Behavior Analyst Certification Board Yes O'Keefe, Galina R BCBA BHP Center for Autism and Related Disorders, LLC Behavioral Health Behavior Analyst Certification Board Yes Orquiz, Chelsea R D.,BCBA BHP Center for Autism and Related Disorders, LLC Solano Behavioral Health Behavior Analyst Certification Board Yes American Academy of Nurse Practitioners I Owens, Jillian P.,FNP PCP Northeastern Rural Health Clinics, Inc. Lassen Family Nurse Practitioner Certification Board Yes Pabolo, Kristina California Consortium of Addiction Programs I M.,CADC I W&R Archway Recovery Services Inc W & R Solano Wellness and Recovery Professionals Yes NBHG: Orthopaedics and Podiatry, A NorthBay American Academy of Nurse Practitioners I Parikh, Jolly D.,FNP SPEC Affiliate Solano Nurse Practitioner Certification Board Yes San Ramon Peterson, Michael East Bay Cardiovascular and Thoracic Regional Medical I B.,MD SPEC Associates Solano Surgery ABMS of Surgery Yes Center Provencher, Kallie I A.,BCBA BHP Center for Autism and Related Disorders, LLC Yolo Behavioral Health Behavior Analyst Certification Board Yes Ragsdale, Richard Admitting R A.,MD SPEC Greenville Rancheria Shasta Pulmonary Diseases ABMS of Internal Medicine Yes Agreement Admitting I Reed, Gudrun H.,MD PCP Sutter Coast Community Clinic (PCP/SPEC) Del Norte Family Medicine ABMS of Family Medicine Yes Agreement Rezai, Mohammed Admitting R T.,DO BOTH Redding Rancheria: Churn Creek Healthcare Shasta Urgent Care None No Agreement Robinson, Ann Mendocin Acute Care Nurse I F.,ACNP SPEC Adventist Health Howard Memorial o Practitioner American Nurses Credentialing Center Yes Rodriguez-Mao, Gina Admitting I L.,MD PCP Lassen Medical Clinic- Red Bluff Shasta Pediatrics ABMS of Pediatrics Yes Agreement Romo, Vanessa Community Medical Centers, Inc Vacaville I A.,RD Allied (Telehealth) Solano Registered Dietitian Commission of Dietetic Registration Yes Hospice and Palliative Admitting R Safra, Jessica A.,MD SPEC Hospice by the Bay Marin Medicine ABMS of Internal Medicine Yes Agreement Sanchez, Erica I N.,BCBA BHP Autism Spectrum Therapies-Fairfield Solano Behavioral Health Behavior Analyst Certification Board Yes Schuster, Nikki Santa Rosa Midwifery Center DBA Santa Rosa I A.,CNM SPEC Birth Center Sonoma Certified Nurse Midwife American Midwifery Certification Board Yes Shackelford, Chanda California Association of DUI Treatment I F.,SUDRC W&R Empire Recovery Center Shasta Wellness and Recovery Programs Yes Admitting I Shah, Sanjay N.,MD SPEC Banner Health Clinic Lassen General Surgery ABMS of Surgery Yes Agreement Admitting I Shenvi, Edna MD SPEC Banner Health Clinic Lassen General Surgery Confirmed per AMA, AOA or Residency Letter No Agreement Sherdiwala, Bhumika Admitting I B.,MD SPEC Humboldt Medical Specialists - Pain Medicine Humboldt Anesthesiology Agreement Singh, Amandeep I BCBA BHP Behavior Matters California, LLC Solano Behavioral Health Behavior Analyst Certification Board Yes Stroup, Allegra American Academy of Nurse Practitioners I B.,FNP SPEC UIHS - Potawot Health Village Humboldt Nurse Practitioner Certification Board Yes

February 2021 189 of 229 February 2021 Routine Clean File List

Teasdale, Robert Marin General R D.,Jr., MD SPEC Robert Teasdale, Jr. MD Marin Orthopaedic Surgery ABMS of Orthopaedic Surgery Yes Hospital Tovmassian, Gregory Mercy San Juan R DPM SPEC Sacramento Foot and Ankle Center, Inc. Yolo Podiatry None No Hospital Meets MPCR #17, Verified Residency on Fairchild Medical I Tran, Kien DO PCP Fairchild Medical Clinic (PCP Clinic) Siskiyou Internal Medicine AMA/AOIA Yes Center Venglarcik, Carey Admitting R A.,MD PCP SCHC: Shasta Community Health Center Shasta Pediatrics ABMS of Pediatrics Yes Agreement National Commission on Certification of I Vincent, Margarita PA PCP Elica Health Centers-Halyard Medical Center Yolo Physician Assistant Physician Assistants Yes

R Wada, Hitomi BCBA BHP Center for Autism and Related Disorders, LLC Solano Behavioral Health Behavior Analyst Certification Board Yes Visions of the Cross/ Women's Residential California Consortium of Addiction Programs I Wahl, Cherie RADT W&R Treatment Shasta Wellness and Recovery Professionals Yes Mendocin Certification Board of Diabetes Care and I Wallace, Laurie RD Allied Consolidated Tribal Health Project o Registered Dietitian Education Yes Wheeler, Jonathan R W.,MD PCP Napa Valley Medical Group Inc. Napa Family Medicine ABMS of Family Medicine Yes Wyborny, Tessa Queen of the R M.,MD PCP Ole Health Napa Pediatrics ABMS of Pediatrics Yes Valley Yamashiro, Marcia I M.,RD Allied Marcia Yamashiro, RD Solano Registered Dietitian Commission of Dietetic Registration Yes Yuen-Green, Monita Mendocin Adventist - Ukiah I S.,MD PCP Adventist Health Ukiah Valley o Internal Medicine ABMS of Internal Medicine Yes Valley I Zogg, Katia RD Allied Lake County Tribal Health Center Lake Registered Dietitian Commission of Dietetic Registration Yes

February 2021 190 of 229 Pediatric Telehealth Program

191 of 229 About Our Program

Partnership HealthPlan of California (PHC) and UC Davis Health (UCD) launched a pediatric telehealth pilot program that began on July 1, 2020. The pediatric telehealth services will become available to all contracted providers on July 1, 2021. Our program provides: • Access to more than 15 pediatric specialties • Care to members 20 years and younger • An easy referral pathway • Decreases travel time and costs for members • Timely access to appointments with decreased wait times • Assist providers in meeting timely access standards

Eureka | Fairfield | Redding | Santa Rosa 192 of 229 Services Available

Televideo Econsult

• Allergy and Immunology • Allergy & Immunology • Cardiology • Endocrinology • Dermatology (store and forward) • Gastroenterology • Endocrinology • Nephrology • ENT/Otolaryngology (cleft and craniofacial) • Pulmonology • Gastroenterology • Urology • Infectious Disease • Neurology to be added soon • Neonatology • Nephrology • Neurology • Neuromuscular Disease Medicine • Orthopedics • Palliative Care • Pulmonary • Rheumatology • Urology

Eureka | Fairfield | Redding | Santa Rosa 193 of 229 FY20-21 Peds Utilization

4 Video Visits Econsult • FY20‐21 Total Visits: 181 • FY20‐21 Total Econsults: 44 • 78% visit rate • 49% patients needs addressed • 17% no‐show rate • 47% refer for face‐to‐face visit • Avg. Days to Apt: 16

Video Visits Month‐Over‐Month Econsults Month‐Over‐Month

35 32 14 12 12 30 26 24 12 25 23 23 19 18 10 8 20 16 8 7 15 6 4 10 4 1 5 2 00 0 0 Jul‐20 Aug‐20 Sep‐20 Oct‐20 Nov‐20 Dec‐20 Jan‐21 Feb‐21 Jul‐20 Aug‐20 Sep‐20 Oct‐20 Nov‐20 Dec‐20 Jan‐21 Feb‐21

Eureka | Fairfield | Redding | Santa Rosa 194 of 229 Current Participation

• 6 healthcare organizations across 5 counties and multiple specialties

1. Fairchild Medical Center (Siskiyou) • Nephrology, Neurology, and Endocrinology 2. Karuk Tribal Health Services (Humboldt) • Dermatology, Urology, Gastroenterology, Allergy & Immunology, and Endocrinology 3. Northeastern Rural Health Center (Lassen) • Endocrinology, Gastroenterology, and Neurology 4. Open Door Community Health (Humboldt & Del Norte) • Urology, Gastroenterology, Neurology, Endocrinology, and Pulmonology 5. Shasta Community Health Center (Shasta) • Endocrinology and Neurology 6. Mayers Memorial Hospital (Shasta) • Gastroenterology

Eureka | Fairfield | Redding | Santa Rosa 195 of 229 Testimonials

From Providers

• The site's coordinator communicated that their clinics have been going very well, and they are seeing an uptake in telehealth interest. There have been many new patients participating in their telehealth clinics. - Cathy Hill, Telehealth Supervisor, Fairchild Medical Center

• Karuk had their meet and greet with the allergy and immunology specialist and thought she was amazing. The specialist even offered to work with the site on provider specialty education, and the site appreciated that. - Jamie Wasson, Telemedicine Coordinator, Karuk Tribal Health Clinics

• The UCD pediatric clinics have been going very smoothly. We had to request an additional endocrinology clinic since we had many patients interested in telehealth. UCD was able to offer us another clinic block in a timely manner. - Camay Tirri, Telemedicine Coordinator, Shasta Community Health

From our Members

• “We are finding telehealth to be extremely beneficial. Traveling from Redding to UC Davis would be an extreme hardship. We are very happy with the quality of service.”

• “Very pleased with my visit!”

• “Everything was great!”

Eureka | Fairfield | Redding | Santa Rosa 196 of 229 How To Get Started

Identify top 3 specialty Review, Complete, Complete the Confirm your telehealth Schedule and care services needed & Submit Pediatric implementation clinic date/s host your telehealth for your Pediatric PHC Tele-video or Econsult process and meet the clinic/s Members application to PHC specialists

If you are interested in participating in our pediatric telehealth program and would like to learn more:

• Visit our Pediatric Telehealth program page or view the following resources • Pediatric Tele-video Program Application • Pediatric Telehealth FAQ • Pediatric Tele-video Flyer

Eureka | Fairfield | Redding | Santa Rosa 197 of 229 Interested Providers

Health care organizations interested in Pediatric Telehealth Specialty Services Contact: [email protected]

Eureka | Fairfield | Redding | Santa Rosa 198 of 229 Thank You!

199 of 229 CalAIM: Enhanced Care Management & In Lieu of Services

Katherine Barresi, RN, BSN, PHN, CCM Director Care Coordination

200 of 229 What Is CalAIM?

• CalAIM stands for “California CalAIM Proposal Timeline** Advancing and Innovating

Medi-Cal.” It is a multi-year Enhanced Care Management (ECM) 1/1/2022, initiative by DHCS to improve 7/1/2022 the quality of life and health In‐Lieu of Services (ILOS) 1/1/2022, outcomes of individuals on 7/1/2022 Medi-Cal by implementing Population Health Management 1/1/2023 broad delivery system, program and payment reform Incarcerated population eligible for 1/1/2023 across the Medi-Cal program. ECM services Dual Eligible Special Needs Program 1/1/2025 (D‐SNP) Required • CalAIM contains various NCQA Accreditation Required 1/1/2026 proposals within it that focus on this stated goal. ** DHCS proposed dates may subject to CMS approval/change

Eureka | Fairfield | Redding | Santa Rosa 201 of 229 Goals of CalAIM

• Identify and manage member risk and need through whole person care approaches and addressing Social Determinants of Health

• Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility; and

• Improve quality outcomes, reduce health disparities, and drive delivery system transformation and innovation through value based initiatives, modernization of systems and payment reform

Eureka | Fairfield | Redding | Santa Rosa 202 of 229 What is Enhanced Care Management? (ECM)

• A Medi-Cal benefit that would replace the current Whole Person Care (WPC) Pilot activities with a standardized set of case management services and interventions, building on positive outcomes from those programs. Behavioral Health • Face-to-Face with members, in the Clinician Charmaine community Rable, of the Sonoma County Department of • PHC required to contract with WPC Health Services gives an counties invitation letter for the Whole Person Care program to Jeremiah • Members can opt-out at anytime White, who has been homeless off and on for • 7 Target populations eligible for the four years, as he rests in benefit an alcove at St. Paul's Episcopal Church in Healdsburg, California, on Thursday, March 21, 2019. (Alvin Jornada / The Press Democrat).

Eureka | Fairfield | Redding | Santa Rosa 203 of 229 Enhanced Care Management (ECM)

**Target Populations: 7 identified groups of individuals that PHC must identify and authorize ECM services for.

Target Populations: 1. Children or youth with complex physical, behavioral or developmental health needs (ex: CCS, foster care, youth with Clinical Risk syndrome, or first episode of psychosis.) 2. Individuals experiencing homelessness, or who are at risk of homelessness, with complex health and/or behavioral health conditions 3. High utilizers with frequent hospital admissions, short ‐term skilled nursing facility stays, or emergency room visits 4. Individuals at risk for institutionalization who are eligible for long‐term care services 5. Nursing facility residents who want to transition to the community 6. Individuals at risk for institutionalization who have co‐occurring chronic health conditions (ex: SMI – adults, SED – children/youth, or SUD) 7. Individuals transitioning from incarceration who have significant complex physical and behavioral health needs requiring immediate transition of services to the community.

**DHCS is currently revising and refining criteria for each of the populations.

Eureka | Fairfield | Redding | Santa Rosa 204 of 229 ECM Model - Key Points

• Different than WPC activities today • Standardize set of case management services • Medical • Dental • Behavioral Health • Long‐term Support Services • Transitions across settings • Referrals to community resources, social services, ILOS services, etc. • Face-to-face engagement with members • 7 mandated target populations

Eureka | Fairfield | Redding | Santa Rosa 205 of 229 What is In-Lieu of Services? (ILOS)

• Non-Medi-Cal benefits (services) that PHC may chose to offer in a particular county “in lieu” of a traditional Medi- Cal covered service. • Allows plans to address Social Determinants of Health in a way that is cost-effective • DHCS has provided a list of 14 possible services; PHC is currently reviewing • PHC can add ILOS over time • Individuals DO NOT need to be receiving ECM in order to receive an ILOS service.

Eureka | Fairfield | Redding | Santa Rosa 206 of 229 In-Lieu of Services (ILOS)

1. Housing Transition 8. Nursing Facility Transition / Navigation Services Diversion 2. Housing Deposits 9. Nursing Facility transition to 3. Housing Tenancy Home 10. Personal Care / Homemaker 4. Short-Term Post Services Hospitalization Housing 11. Home Modifications 5. Recuperative Care (Medical Respite) 12. Medically Tailored Meals 6. Respite Services 13. Sobering Centers 7. Day Habilitation Programs 14. Asthma Remediation

Eureka | Fairfield | Redding | Santa Rosa 207 of 229 In-Lieu of Services (ILOS) – Key Points

• Optional services • May vary by county • In-Lieu of a Medi- Cal benefit; • Must be cost effective • Focusing on Social Determinants of Health • PHC can add more later

Eureka | Fairfield | Redding | Santa Rosa 208 of 229 ECM & ILOS Implementation Timeline

The ECM & ILOS services will go‐live in PHC Network, in 2 phases:

• Phase I – existing Whole Person Care Programs that will transition the new ECM benefit • Phase II –counties without existing Whole Person Care Programs

Phase I – January 1, 2022 Phase II – July 1, 2022 Marin Solano Trinity Napa Lake Siskiyou Mendocino Yolo Modoc Shasta Humboldt Lassen Sonoma Del Norte

Eureka | Fairfield | Redding | Santa Rosa 209 of 229 ECM & ILOS – What We Don’t Know Yet…

• ECM Target Population estimates • DHCS anticipates 1‐3% of PHC’s population • Rates • Reporting requirements • Data exchange requirements • Appeal rights

Eureka | Fairfield | Redding | Santa Rosa 210 of 229 PHC’s Next Steps - DHCS

• PHC is meeting with Phase I Whole Person Care (WPC) county partners. • Deliverables due to DHCS 7/1/21 and 9/1/21 • ECM & ILOS policies and procedures • Transition planning for clients currently enrolled in WPC

• PHC is awaiting further guidance and documents from DHCS (ex: APLs, FAQs, rates, target population criteria, etc.)

• Working with LHPC and CAHP for feedback on contract language, materials, etc.

• Conversations with other plans when possible

MORE INFORMATION: https://www.dhcs.ca.gov/provgovpart/Pages/CalAIM.aspx

Eureka | Fairfield | Redding | Santa Rosa 211 of 229 PHC’s Next Steps – Local Planning

• PHC will be hosting regional convening for Phase I and Phase II county/provider partners in May of 2021. • Phase I: Counties with existing Whole Person Care Programs • Phase II: Counties without existing Whole Person Care Programs

• PHC will be scheduling meeting to discuss next steps with existing Intensive Outpatient Care Management (IOPCM) sites. • IOPCM services to transition to ECM benefit

• PHC is working with Collective Medical Technologies (EDIE) to support data exchange requirements. Internal planning and planning with community partners is active and on‐going

Eureka | Fairfield | Redding | Santa Rosa 212 of 229 Questions

Eureka | Fairfield | Redding | Santa Rosa 213 of 229 Updated Presentation

INTERPRETING SERVICES: PHASE 3 Video Remote Interpreting (VRI) Pilot with AMN Language Services (fka Stratus Video)

Project Sponsor: Sonja Bjork, COO Project Owner: Kevin Spencer, Director, Member Services Project Managers: My Tirado and Kelly Eckman, OpEx/PMO AGENDA

• Project Goals • Pilot Overview & Outcomes o Utilization Report & Summary o Provider Survey Feedback o Lessons Learned • Implementation Plan Overview • Benefits Summary PROJECT GOALS

• Conduct VRI pilot with AMN Language Services

• Select 4 high‐utilizer provider sites to participate (NR & SR)

• Assess and present data outcome, Key Performance Indicators and survey feedback

• Seek Sr. Leadership’s approval for Phase 3 (full implementation) if data and outcome determines beneficial gain for PHC PILOT OVERVIEW

VRI Pilot Period: 12/2/2020 – 1/22/2021 (~7 weeks)

# of Devices Deployed: 10 (iPads & Stands)

Participating Provider Sites: • Associated Kidney Specialists of the North Bay (SR) • Microtone Audiology (SR) • Northeastern Rural Health Center (NR) • Shasta Community Health Center (NR)

• Alternate: Redding Rancheria Trinity Health Center (NR) (Rural test calls re: connectivity & app performance using own iPad) PILOT OUTCOME REPORT PILOT OUTCOME REPORT PILOT OUTCOME REPORT

Rating scale 1‐5 17 calls were rated in December (5 being the highest) 5 calls were rated in January

Average Interpreter Rating: 4.6 Average Video Quality Rating: 4.4 PILOT OUTCOME SUMMARY

• 1,141 Total Minutes Utilized • 92 Total VRI Calls Made

• 11 Seconds Average Answer Speed (Benchmark: under 30 seconds) • Top 3 Languages Utilized: Spanish, Tagalog, ASL • Spanish was the most utilized language o Contributed to 84% of Total Minutes with 67 Total Calls o Average Call Duration 14.27 Minutes (Benchmark: 15 minutes)

• 22 Calls were rated after VRI sessions from Members (Rating scale 1‐5, 5 being the highest) o 4.6 Average Interpreter Rating o 4.4 Average Video Quality Rating PROVIDER SURVEY FEEDBACK

• Navigation / Ease of Use: 100% Very Satisfied o “The providers were very happy with the translation service.” o “All of the providers found it easy to navigate.”

• Speed of Connection: 100% Very Satisfied o “We know with our rural setting, things can back up a bit. But the connection was great 99.9%.” o “All providers found it easy to get connected.”

• Audio Quality: 100% Very Satisfied o “Easy for both the provider and patients to hear and communicate.”

• Video Quality: 100% Very Satisfied

• VRI helped streamline or improve current interpreter request process? 100% Yes o “Ease of use and quick for our busy office.” o “This app is better than the other app we currently use.”

• Any languages needed that were not available? 100% No o (AMN offers 40 VRI and 146 OPI Languages) PROVIDER SURVEY FEEDBACK

• Continue to use VRI in the future if available? 100% Yes

• Likely to recommend VRI app to patients and providers? 100% Very Likely

• Overall Satisfaction with VRI service: 100% Very Satisfied o “Great addition to the practice.”

• Experienced Technical Issues: 2of 4 providers o Northeastern Rural Health Clinic –minor credential login issue resolved o Shasta Community Health Center –minor audio and video connection issue possibly due to weak wifi signal or firewall issues. Tech specs sent to providers to check requirements are met. (Overall, the team said the process was easy and quicker than their existing interpreting service (Language Line).

• Overall Comments & Feedback: Very Positive o “Found it was easy to use and a valuable tool in our office.” o “We have enjoyed using the service. I hope we are able to continue with the service.” o “Great with face‐to‐face follow‐up appointment. Unable to use this service with Testing of patient while in the audio booth.” LESSONS LEARNED

• Provider Communication/Education/Training is key to ensure: o Providers know how to properly use the device (VRI, Audio, Languages available) o Login credentials and troubleshooting solutions are easily accessible o Technical requirements are met to avoid connection issues

• Face‐to‐Face interpreting is still needed with limited utilization o For specific needs or treatments that cannot be met with VRI or OPI (e.g. Audio testing in audio booth or special ASL needs)

• Providers using own device/tablet will need to have own tabletop stand or holder o Difficult for patient to do ASL while holding the iPad at the same time IMPLEMENTATION PLAN OVERVIEW

PHASE 3: Provider Rollout Plan (High‐level): FULL IMPLEMENTATION Rollout VRI and Phone service to all providers (Equipment limited based on PHC threshold) 1. Analyze previous year utilization • Data will be used to help determine high Update Policies & Procedures utilizers for AMN devices Contracting  Execute Current Phone Vendor Phase‐out Plan  Execute AMN Master Service Agreement 2. Rollout new interpreting phone number to all providers first Communication Plan • Easiest modality for mass transition  External –All Providers & Members • No equipment to sort out  Internal –Impacted Depts to engage o MS o PR 3. Rollout VRI second o G&A • Done in phases, possibly by counties in each o CC o Pharmacy region, targeting: o RAC a) High Utilizers, FQHCs, large PCPs o Communications b) Smaller clinics o IT‐Web Team

Implementation Plan  Develop plan and execute full implementation BENEFITS SUMMARY

Benefits: . On‐demand service scalable as interpreting demand increases . Almost eliminates Face‐to‐Face interpreting request churn . Improves & increases access to service for members (esp. in rural areas) . VRI eliminates no‐shows/cancellation fees/travel fees/2‐hour minimum charges . Advanced data tracking and reporting capabilities . User friendly app –easy adoption for providers . No equipment purchase necessary (Option to use own devices/tablets, same rates apply) . Safer, more efficient and convenient for members and providers due to COVID . Potential cost savings Telehealth Integration INTERPRETING SERVICES: PHASE 2

Questions? Benefits

 Most competitive VRI and Phone rates  Cloud‐based platform, no system integration required

 Asset Device Management  VRI service only requires 512 kbps bandwidth

 AMN Right to Use Program –inclusive monthly  Telehealth interoperability with video and audio minimum requirement support (100 minutes monthly per device. Applicable minutes include Phone, VRI, Non‐member usage and non‐AMN devices)  Option to use own devices, same rates apply, no  145+ Languages available by Phone 24/7/365 requirements  40 Languages available by VRI* (including ASL) (*Includes PHC threshold languages)

 Solely focused on healthcare industry  Advanced data tracking and reporting capabilities

 Interpreters are HIPAA trained ‐ medically certified  AMN manages onboarding, training and and qualified implementation

 Data integrity and Secure Network  Tech support/customer service available 24/7/365 All VRI and OPI calls are fully encrypted from end‐to‐end to ensure HIPAA compliance AMN App Overview

Easy to use for providers and members