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Appeals of HNS Participation Status
Health care professionals have the right to appeal the HNS Participation Status.
To appeal participation status, the provider must notify HNS, in writing, within 30 days of the date shown on the CPR report in which participation status was assigned. If the physician does not appeal his HNS Participation Status within the time frame allowed, HNS concludes the physician does not dispute the data included on the CPR, the assigned participation status, and, as applicable, understands that termination of network participation may occur if performance does not improve within the specified period of time.
The written notice of appeal must include the specific reasons why the provider believes reconsideration of his participation status should occur. Disagreeing with the CPR program parameters and/or the methodology for establishing averages utilized in the CPRs is not an acceptable basis for reconsideration of participation status.
Upon the timely receipt of the written notice of appeal, HNS will change the provider's status to "pending review" until the QUM Committee completes a review and a final determination has been made.
Upon receipt of the written notice of appeal, HNS may request additional information, including but not limited to, copies of specific health care records for patients whose health care plans contract with HNS. If additional information is required, the physician will be notified, in writing, of the specific information that must be submitted and the date by which HNS must receive the information. Requested information must be submitted by the due date or the appeals process will terminate and the original participation status will stand.
In most cases, a determination regarding the appeal will be made within 60 days from the date the written notice of appeal was received, or if additional information was requested, within 60 days of HNS' review of the information received.
HNS may, but is not required to, hold a hearing as a result of an appeal of participation status. If a hearing is scheduled, it will be subject to the policies and procedures outlined below (under Hearings).
Appeals of Termination Decisions In most cases, health care professionals have the right to appeal CPR decisions resulting in termination of participation in the HNS network.
If a physician wishes to appeal the termination decision, the physician must notify HNS, in writing, within 30 days of the date shown on the notice of termination. The written notice of appeal must include the specific reasons why the provider believes reconsideration of his participation status should occur. Disagreeing with the CPR program parameters and/or the methodology for establishing averages utilized in the CPRs is not an acceptable basis for reconsideration of CPR termination decisions.
Upon the timely receipt of the written notice of appeal, HNS will change the physician's status to "pending review" until the Hearing Panel completes a final review and a final determination has been made.
Upon receipt of the written notice of appeal, HNS may request additional information, including but not limited to, copies of specific health care records for patients whose health care plans contract with HNS. If additional information is required, the physician will be notified, in writing, of the specific information which must be submitted and the date by which HNS must receive the information. Requested information must be submitted by the due date or the appeals process will terminate and the original termination decision will stand.
Hearings The Hearing Panel is intended to be a medical peer review committee as that term is defined by the provisions of NCGS 90-21.22A and SCGS 40-71 and shall operate consistent with the requirements of those statutes to ensure that its protections apply to the Committee's proceedings, records, and materials.
If additional information is not requested by HNS, best efforts will be made to schedule a hearing within 60 days of receipt of the written appeal.
If additional information is requested, best efforts will be made to schedule a hearing within 60 days of HNS' review of the requested information.
HNS shall establish a Hearing Panel to review the appeal. The panel shall include, at a minimum, three physicians. At least two of the physicians must be licensed chiropractors. Members of the hearing panel who are charged with decision-making associated with the appeal will not be physicians in direct economic competition with the provider who is appealing, or who were involved in the initial decision-making.
At the hearing, the provider will be provided an opportunity to present his/her reasons for requesting reconsideration of the decision. The members of the Hearing Panel shall consider, and make a final determination, based on the information and evidence produced at the hearing. The provider's history of compliance to HNS policies will also be considered.
All hearings will be held at the HNS offices in Cornelius, NC. The physician will be notified, in writing, of the date and time of the hearing.
The physician has the right to be represented at the hearing by an attorney or any other person of the physician's choice but may not be accompanied by more than one individual. No less than five (5) days in advance of the hearing, the provider must provide HNS with the name of the person who will be attending the hearing on their behalf. Notification to HNS may be via facsimile, email, or U.S. mail.
Should the physician fail to appear at the hearing on the date and at the time specified, the physician forfeits all rights to the appeals process.
Within 15 days of the date of the hearing, HNS will notify the physician, in writing, of the decision of the Hearing Panel. The written notice will include the basis for the decision.
Decisions of the Hearing Panel are final.
No Second Appeals If the provider has received a written notice of termination, appealed the decision, and was allowed to remain in the network, and subsequently fails to comply with CPR program parameters, resulting in a second notice of termination, the provider may not be allowed to appeal the termination decision.
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