Point32Health has reviewed and updated our Payment Policy for Serious Reportable Events and Provider Preventable Conditions for enhanced clarity and to provide various additional state and federal resources for reference.
As outlined in the updated policy, consistent with applicable regulatory guidelines, Point32Health does not reimburse services associated with Serious Reportable Events (SREs) and Provider Preventable Conditions (PPCs). Providers are not permitted to bill members related to these events and/or conditions.
An SRE, which may also be referred to as an adverse event or sentinel event, is an event that is designated as such by state and federal agencies such as the Department of Public Health and Executive Office of Health and Human Services. SREs are events that are clearly identifiable and measurable, usually preventable, and are serious in their consequences (e.g., resulting in death or loss of a body part, injury more than transient loss of a body function). They are also characterized 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.
The policy provides in-depth detail regarding obligations and requirements from governing bodies, and from Point32Health, related to the reporting and notification of SREs and PPCs that occur when providing services to Point32Health members (including members of affiliates or subsidiaries that utilize Point32Health provider networks).
You’ll also find information on billing and reimbursement for providers who treat a Point32Health member following an SRE, PPC, Health Care Acquired Condition (HCAC), or Other Provider-Preventable Condition (OPPC) caused by another provider, as well as Point32Health’s rights to request additional clinical documentation after reviewing a reported SRE, HCAC, or PPC and retract payments upon review as necessary – and the provider’s obligation to comply with such requests within the specified timeframe.
We encourage you and your practice to review the updated policy, which you can find in the Payment Policies section of our provider website, for complete information.