A. Routine Status:
Routine Providers or Practitioners are reviewed on-site annually by the PBH Quality Management Department. The review consists of compliance based Routine Review and a Billing Audit. The Provider or Practitioner must maintain an overall combined score between 75%-100%. Providers or Practitioners scoring below a 100% are required to submit a plan of correction (POC). Providers or Practitioners scoring below a 75% are evaluated by the PBH Network Operations Committee to determine their profile status and follow up required from Quality Management. Providers or Practitioners scoring below a 75% are evaluated six (6) months following the review to ensure implementation of the POC.
B. Advanced Placement (Preferred, Exceptional, Gold Star):
Continuation of achieved profile status is contingent upon meeting the “must pass” domain elements identified by PBH. Failure to meet the required “must pass” items could result in a decrease in level placement or freeze status with level placement.