Blue Distinction Centers for Fertility Care 2018 Provider Survey

Transcription

1 Blue Distinction Centers for Fertility Care 2018 Provider Survey Printed version of this document is for reference purposes only. A completed Provider Survey must be submitted via the online web application BD Portal SM. Paper copies of the Provider Survey will not be accepted. Review instructions below to complete both the Provider Survey and Team Table via online web application BD Portal. NOTE: Part 1: Provider Survey and Part 2: Team Table must be submitted via BD Portal to complete the application. Please complete Part 2: Team Table via the Survey Actions tab in BD Portal. In addition to information provided in Parts 1 and 2 of this Survey, each Provider will be evaluated using publicly available outcome data that Blue Cross and Blue Shield Association will obtain directly from the Society for Assisted Reproductive Technology (SART). Part 1: Provider Survey Question Numbers Provider Information 1-6 Fertility Care Program Information 7-9 Part 2: Team Table Physician Information See Part 2 Attestation See Part 2 PART 1: PROVIDER SURVEY This Provider Survey supports the quality based evaluation process for the Blue Distinction Centers for Fertility Care designation. All information in this application pertains to your current and active assisted reproductive technology (ART) program. Please be sure that your application is complete before submitting. All Questions are directed to the Provider entity for this ART program, as identified in the Center for Disease Control s (CDC) 2015 Fertility Clinic Success Rates Report. Additional program materials for the Blue Distinction Centers for Fertility Care program are available at: BDCFC038_FINAL_

2 PROVIDER INFORMATION VI PROVIDER ADDRESS AND IDENTIFIERS WILL BE PRE-POPULATED IN THE ONLINE VERSION OF THIS SURVEY. PROVIDER NAME: ADDRESS: CITY: STATE: ZIP: If any of the Provider Information shown above is incorrect, please Raise a Case in BD Portal or contact your local Blue Plan directly to have the information corrected. Instructions on how to Raise a Case are posted in the Document Library in BD Portal. 1. Are both the pre-populated Provider entity name and address (shown above) the same as what is publicly posted on the SART website? YES NO (Complete Question 1a) NOT APPLICABLE This Provider entity is not a SART Member (Complete Question 1b) 1a.Please list your Provider entity s name and address exactly as it is publicly posted on the SART website: Provider name as posted publicly on the SART website: Address: City: State: Zip: 1b.You indicated that this Provider entity s ART program is NOT a SART Member. Do you still wish to complete the remainder of this Survey? YES NO: Please click Save and Release in this Survey. 2. What is this Provider entity s National Provider Identifier (NPI) and Tax ID? NPI: Tax ID: Questions 3 4 are directed to this Provider entity s ART program, as reflected in its current SART Clinic Summary Report. Due to the structure of SART Registry Data, it is possible that a Provider entity s IVF Success Rates may be rolled up into one SART Clinic Summary Report that includes multiple locations for that Provider entity (e.g., offices, satellite clinics, etc.) and/or multiple Physicians who are included in that Provider s ART program. 3. Does the SART Clinic Summary Report for your Provider entity s ART program include additional locations (e.g., offices, satellite clinics, etc.) where your ART program provides in vitro fertilization procedures, other than the pre-populated address shown above in Part 1? YES (Complete Question 3a) NO BDCFC038_FINAL_

3 3a. Complete the table with ALL additional Provider entity locations (e.g., offices, satellite clinics, etc.) where your ART program provides in vitro fertilization procedures that are included in your ART program s SART Clinic Summary Report, other than the prepopulated address shown above in Part 1. Provider Entity Name: List the Provider entity name for each location; Address: List the address, city, state and zip code for each location; NPI Number: List the NPI# for each location; and Tax ID: List the Tax ID for each location. Provider Entity Name Address City State Zip NPI# Tax ID # 3b. Additional rows are needed. Provider Entity Name Address City State Zip NPI# Tax ID # Physician Information 4. Complete the following table and additional Questions pertaining to ALL Physician(s) who are included in your Provider entity s ART program and who provide in vitro fertilization procedures. Include the first name, last name, and NPI# for each Physician. Additional Questions will pop-up for each Physician as you enter name(s) in the table. BDCFC038_FINAL_

4 System Generated ID R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 Physician First Name Physician Last Name Physician NPI# (10 digit number) R1a. Is (PHYSICIAN FIRST AND LAST NAME PREPOPULATED FROM TABLE ABOVE) the Medical Director of your ART program? YES NO R1b. Is (PHYSICIAN FIRST AND LAST NAME PREPOPULATED FROM TABLE ABOVE) board certified (or in the process of becoming board certified) in Reproductive Endocrinology and Infertility (REI)? YES NO R1c. For (PHYSICIAN FIRST AND LAST NAME PREPOPULATED FROM TABLE ABOVE), enter the oocyte aspiration volumes for the specified timeframes. Note: Only enter zero (0) if the reported volume is zero (0). If the program is unable to report or does not have the volume information requested for a specific timeframe, choose the radio button indicating that the program is unable to report volumes. Physician Oocyte Aspiration Timeframe Volume 1/1/ /31/2016 Unable to report volumes for this timeframe. 1/1/ /31/2017 Unable to report volumes for this timeframe. Additional Physicians need to be added. System Generated ID R16 Physician First Name Physician Last Name Physician NPI# (10 digit number) BDCFC038_FINAL_

5 5. Please provide the following information to identify the person responsible for completing and submitting this Provider Survey: Primary Contact Name: Title: Phone: 6. Please provide your Provider entity s legal contact, if applicable. This individual may be contacted in the event there are Questions related to potential brand conflicts that need to be addressed. Provider Legal Counsel/Representative Contact: Name: Title: Phone: The Provider entity for this ART program does not have a Legal Counsel/Representative Contact FERTILITY CARE PROGRAM INFORMATION Questions in this section that refer to my, your, my program s or your program all refer to your Provider entity s own assisted reproductive technology (ART) program (not the Blue Distinction Centers for Fertility Care program). Program Structure/Process Information 7. Please indicate the diagnostic and treatment services your ART program offers. Check ALL that apply. Infertility diagnosis services Surgical treatment of correctable causes of infertility Local embryology services (on-site or off-site) ART (assisted reproductive technology), including IVF (in vitro fertilization) and frozen embryo transfer eset (elective single-embryo transfer) Donor egg capability Day five embryo transfer Access to preimplantation genetic diagnosis (PGD) My ART program does not offer any of the above diagnostic or treatment services. BDCFC038_FINAL_

6 8. Has your ART program adopted the evidence-based treatment guidelines set forth by the American Society of Reproductive Medicine (ASRM), which includes embryo transfer protocol adherence? YES NO Program Volume Information 9. Complete the table for your ART program s cumulative in vitro fertilization (IVF) cycle volumes. Please include this Provider entity s volumes from ALL Physicians who are currently practicing in your ART program, as well as all Physicians who are not currently practicing in your ART program but did practice there during any part of the corresponding time periods below. Note: Only enter zero (0) if the reported volume is zero (0). If this Provider entity is unable to report or does not have the volume information requested for a specific timeframe, choose the radio button indicating that you are unable to report volumes for your ART program. 1/1/ /31/2016 Number of Cycle Starts 1/1/ /31/2017 Number of Cycle Starts Unable to report volumes for my ART program for this timeframe. Unable to report volumes for my ART program for this timeframe. BDCFC038_FINAL_

7 PART 2: TEAM TABLE In addition to Part 1: Provider Survey, each Provider entity must also complete Part 2: Team Table via the Survey Actions tab in BD Portal to complete the application. Physician Team Table Please complete the Team Table for ALL Physicians who are actively performing in vitro fertilization (IVF) procedures in your ART program. Exclude all Physicians who are not currently practicing in your ART program at the time of this application s submission. There are two options to complete the requested information: Option 1 Download an Excel template to enter Physician names and upload the template to automatically populate the Team Table OR Option 2 Manually enter each Physician s name (one at a time) using the form below. Option 1 Download and Upload Template Step 1 - Click Download Template and open the file in Excel. Complete a row for each Physician; make sure the 'Type' column contains only the word Physician. Save the completed Excel spreadsheet as a CSV file to your computer, as you will need to upload it into BD Portal in Step 2. Step 2 - Browse your computer to locate the saved Excel CSV file. Step 3 - Once you have located the saved Excel file on your computer, click the Upload Template button. Note: Uploading a template will over-write existing information in the table below. Option 2 Manually Enter Using Form Step 1 - Manually enter Physician information into the form below. Step 2 - Click the Save button to update the Physician Team Table. Repeat as necessary until all Physicians are added to the Team Table below. Physician Team Table FIRST NAME LAST NAME TYPE 1 NATIONAL PROVIDER IDENTIFIER (NPI) PHYSICIAN xxx xxx xxx xxx BDCFC038_FINAL_

8 Terms & Conditions Attestation for Provider Survey Participation Blue Distinction Centers for Specialty Care Program(s) By submitting its response to this Provider Survey for consideration as a participant in this Blue Distinction Centers for Specialty Care Program(s) (the Program(s) ), and, if accepted by BCBSA, as a condition to any designation and participation in the Program(s), this provider ( Provider ) represents and agrees as follows: 1. All information that Provider provides in its response to BCBSA's Provider Survey for consideration as a participant in this Program(s) (including information provided in Provider's initial response, as well as any additional materials submitted throughout the evaluation and appeal process for this Provider Survey cycle) is and will be true and complete, as of the date Provider provides such information to BCBSA. Provider will advise BCBSA immediately of any material change in such information during this Provider Survey process, and if Provider is designated as a Blue Distinction Center under this Program(s), for the duration of such designation. 2. BCBSA may share Provider's individual Provider Survey responses ( Raw Data ) and results ( Scores ) with BCBSA's member Plans and, pursuant to a confidentiality agreement, member Plans' current and prospective accounts, for purposes of evaluation, care management, quality improvement, and member Plans' design of customized products and networks. BCBSA may combine Provider's Raw Data and Scores together with other Providers data to create aggregate information for public dissemination, provided that such aggregate information will not identify Provider by name, and will not contain any Protected Health Information ( PHI ), as defined under the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (45 C. F. R. Parts ). Provider s Raw Data and Scores will not be publicly disseminated beyond the extent permitted above without Provider's prior written consent, unless required by law (e.g., subpoena). 3. Neither Provider nor any entity in which Provider holds a controlling interest uses or intends to use in a logo any cross or shield design (or design that gives the commercial impression of a cross or shield) that contains the color blue (or that gives the commercial impression of the color blue), or any other name, mark, or design logo that is confusingly similar to or dilutes the BLUE CROSS or BLUE SHIELD word or design trademarks, or any other trademarks owned by BCBSA. BDCFC038_FINAL_