To maintain licensure by the Michigan Department of Community Health (MDCH) and accreditation from the National Committee for Quality Assurance (NCQA), Priority Health evaluates facilities and medical records according to NCQA and MDCH requirements. Priority Health gives each provider score for the facility review and another for the medical record review.

Passing score parameters and calculations

Facility scoring

• 85% and higher: Passing score. No follow-up needed.
• 80-84%: No re-visit is required. However, the office is given three months to provide a written statement that details how the identified problem will be corrected.
• 79% and below: Priority Health will re-visit the office in approximately 6 months for a follow up review.

Medical records scoring

Priority Health will review medical record documentation ad medical record keeping on a biannual basis. The threshold for this will be 90% accuracy.

Review procedure

Priority Health follows the procedure outlined below to conduct facility and medical record reviews.

1. New applicants:

   a. Priority Health conducts new applicant site visits for all Primary Care Providers, all OB/GYNs, potential high volume Behavioral Health practitioners, and Ambulatory Surgical Facilities.

   b. New applicants must pass their facility site visit with an 85% or higher to be considered by the Credentialing Committee for approval.Priority Heath also reviews documentation guidelines during the initial facility site visit. If a new applicant scores below 79% for the facility review, the Credentialing Committee will not consider the applicant for approval until a passing score is achieved.

   c. The Quality Management Coordinator will contact the facility within two weeks for a revisit. Following the initial site visit, Priority Health will implement an action plan for improvement to address the identified deficiencies.

2. Ongoing monitoring of provider office compliance to facility guidelines:

   Priority Health will monitor member complaints as a means for monitoring potential subsequent deficiencies to Provider office compliance. All complaints will be investigated by the Quality Concern Committee (QCC) and the QCC will determine the validity of the complaint and determine the appropriate action.

3. Deficiencies not addressed:

   a. If the additional information is still not acceptable and deficiencies remain, the Chief Medical Officer or Credentialing Committee may recommend any or all of the following steps until the practitioner achieves full compliance:

   Schedule another visit in approximately six (6) months

   Close the PCP to new members

   Require related CME

   Withhold and /or bonus withheld

   Suspension of the practitioner

   Cancel PCP eligibility for the Physician Incentive Program.

   b. If the additional information is still not acceptable and deficiencies remain, the Chief Medical Officer or Credentialing Committee may recommend any or all of the following steps until the practitioner achieves full compliance:

4. Specialist - new applicant and recredentialing:

   Priority Health does not make routine specialist practitioner facility site visits and medical record reviews.