Critical incident reporting

A critical incident is any alleged or actual event or incident that generates a substantial risk or severe harm to the physical, mental, or emotional well-being of an Anthem Blue Cross and Blue Shield (Anthem) member.

Reportable critical incidents

All mandated reporters are to inform Anthem of the following alleged or suspected incidents:

Abuse: The injury, confinement, control, intimidation, or punishment of an individual that has resulted in physical harm, pain, fear, or mental anguish. Abuse includes but is not limited to physical, emotional, verbal, or sexual abuse, or the use of restraint, seclusion, or the use of restrictive intervention implemented without authorization from the waiver case management agency, or the OhioRISE plan or its designee.

Neglect: When there is a duty to do so, failing to provide an individual with any treatment, care, goods, or services necessary to maintain the health or welfare of the individual.

Exploitation: The unlawful or improper act of using an individual or an individual's resources through means of manipulation, intimidation, threats, deceptions, or coercion for monetary or personal benefit, profit, or gain.

Misappropriation: The act of depriving, defrauding, or otherwise obtaining the money, real or personal property (including prescribed medication) of an individual by any means prohibited by law that could potentially impact the health and welfare of the individual.

Unnatural or accidental death: Death that could not have reasonably been expected, or the cause of death is not related to any known medical condition of the individual, including inadequate oversight of prescribed medication or misuse of prescribed medication.

Anthem, in collaboration with the Ohio Department of Medicaid, may request further review of any incident, conduct a separate independent review or investigation of any incident, determine necessary additional action, and assume responsibility for conducting an investigation or review.

Report a critical incident

If you feel a member is at significant risk or has shown signs of mistreatment, please fill out our Critical Incident Report form.

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