We’ve developed a payment policy illustrating reimbursement, reporting, and billing policies and requirements for services related to serious reportable events (SREs) and provider preventable conditions (PPC) for our Harvard Pilgrim Health Care StrideSM (HMO)/(HMO-POS) Medicare Advantage products.
As a reminder, Point32Health does not reimburse for services associated with SREs and PPCs for members of any of our products, and providers are not permitted to bill members for these services.
SREs and PPCs defined
The new Stride policy provides more detail on what constitutes an SRE or a PPC, which are defined as follows:
- An SRE is an event that is clearly identifiable and measurable, usually preventable, and which is serious in its consequences (e.g., resulting in death or loss of a body part, an injury more than transient loss of a body function). SREs are also categorized as adverse in nature, represent a clear indication of a health care provider’s lack of safety systems, and/or are events that are important measures for public credibility or public accountability.
- A PPC is a condition that meets the definition of a “Health Care Acquired Condition (HCAC)” or an “Other Provider Preventable Condition (OPPC)” as defined by the Centers for Medicare and Medicaid Services (CMS).
You’ll also find clarity around other services and scenarios connected to SREs and PPCs that are not considered reimbursable. As a caveat, we will reimburse providers who provide follow-up care necessitated by the occurrence of an SRE or PPC when they were not responsible for it.
Provider billing and reporting requirements
Providers are required to notify us of SREs and PPCs that occur when they are providing services to our members, within 30 calendar days of the date the event occurred.
The policy illustrates how these events should be reported, as well as specific billing instructions for different related services and procedures.
Compensation will be adjusted according to present on admission (POA) indicator guidelines and CMS requirements. When provider payments are denied or retracted in accordance with SREs and PPCs, an explanatory notification will be included on the claim explanation of payment.
For complete information, please refer to the Stride Serious Reportable Events and Provider Preventable Conditions Payment Policy.
Audrey Kleinberg,
Director, Provider Relations & Communications
Annmarie Dadoly,
Senior Manager, Provider Communications
Joseph O’Riordan, Susan Panos, Stephen Wong,
Writers
Kristin Edmonston,
Production Coordinator
Kristina Cicelova,
Graphic Designer