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Only be responsible for cost-sharing in accordance with 42 CFR The Contractor shall develop, maintain, and mail or make electronically available, subject to the requirements of Sections 6. The Contractor shall distribute the Provider Directory, within five 5 Calendar Days of sending the notice of Enrollment referenced in Section 5.
The Contractor is not required to mail a Provider Directory to an Enrollee who may have been disenrolled and subsequently reenrolled if Enrollee was provided a Provider Directory within the past year. However, this exception does not apply to pregnant Enrollees under the age of twentyone The Contractor shall update the paper Provider Directory once a month and distribute it to Enrollees upon Enrollee request. The Contractor shall make the Provider Directory available on its website in a machine readable file and format as specified by CMS.
The Provider Directory shall include the names, provider group affiliations, locations, office hours, telephone numbers, websites, cultural and linguistic capabilities, completion of Cultural Competency training, and accommodations for people with physical disabilities of current Network Providers. The Provider Directory shall also identify all Network Providers that are not accepting new patients. However, the Contractor must provide the Enrollee Handbook and Provider Directory in paper form upon request by the Enrollee at no charge and within five 5 Business Days.
In accordance with 42 CFR The Contractor shall provide oral interpreter services to any Enrollee or Potential Enrollee who speaks any language other than English or Spanish as his or her primary language, regardless of whether the Enrollee or Potential Enrollee speaks a language that meets the threshold of a Prevalent Non-English Language.
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The Contractor is required to notify its Enrollees of the availability of oral interpretation services and to inform them of how to access oral interpretation services. There shall be no charge to an Enrollee or Potential Enrollee for interpreter services or other auxiliary aids. Prohibited Activities. The Contractor is prohibited from engaging in the following activities:.
Section 7. The Enrollee paid the Provider for the service. In such a case, the expenses will be reimbursed under the GHP; or. Organ and tissue transplants, except skin, bone and corneal transplants. The Contractor shall be responsible for timely payment for emergency transportation services in the other USA jurisdictions for Enrollees who are Medicaid or CHIP Eligibles, if the emergency transportation is associated with an Emergency Service in the other USA jurisdictions covered under Section 7.
If, in an extenuating circumstance, a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses for emergency transportation services provided in the other USA jurisdictions, the Contractor shall reimburse the Enrollee for such expenses in a timely manner, and the reimbursement shall be considered a Covered Service. Other FDA approved contraceptive medications or methods not covered by sections 7. Immediately following Section 7. Maternity services, including family planning and postpartum services, must be covered for a sixty 60 day period, beginning on the day the pregnancy ends.
These services will also be covered for any remaining days in the month in which the sixtieth 60 th day falls. The Contractor shall ensure that Medical and Psychiatric Emergency Services are available twenty-four 24 hours a day, seven 7 days per Week. The Contractor shall ensure that emergency rooms and other Providers qualified to furnish Emergency Services have appropriate personnel to provide physical and Behavioral Health Services. All Emergency Services must be billed appropriately to the Contractor based on the applicable treatment and site of care.
No Prior Authorization will be required for Emergency Services, and the Contractor shall not deny payment for treatment if a representative of the Contractor instructed the Enrollee to seek Emergency Services. Emergency Services shall include, but are not limited to, the following:. The Contractor shall make Emergency Services available:. The Contractor shall be responsible for fulfilling payment for Emergency Services rendered in the other USA jurisdictions in a timely manner. If, in an extenuating circumstance, a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses for Emergency Services provided in the other USA jurisdictions, the Contractor shall reimburse the Enrollee for such expenses in a timely manner, and the reimbursement shall be considered a Covered Service.
An Enrollee who has been treated for an Emergency Medical Condition or Psychiatric Emergency shall not be held liable for any subsequent screening or treatment necessary to stabilize or diagnose the specific condition in order to stabilize the Enrollee. The Contractor shall provide notice on a Prior Authorization request by telephone or other telecommunication device in the required timeframes.
The Contractor shall cover a drug that is not included on either the FMC or the LME, only as part of an exceptions process, provided that the drug is being prescribed for a use approved by the FDA or for a medically accepted indication, as defined in Section k 6 of the Social Security Act for the treatment of the condition. In addition to demonstrating that the drug is being prescribed for a medically accepted indication, as defined in Section k 6 of the Social Security Act and as referenced in Section 7.
Formulary Management Program.
Utilization Management and Reports. The Contractor shall:.
The Contractor shall adhere to these updates. Information on Pharmacy Benefits Coverage. The Contractor shall provide Information on the FMC and LME in electronic or paper form, including which generic or brand medications are covered, and what formulary tier each medication is on. The Contractor shall require, in its Provider Contracts with PCPs, that Special Coverage registration treatment plans be submitted to the Contractor for review and approval in a timely manner.
The system will advocate for, and link Enrollees to, services as necessary across Providers, including community and social support Providers, and settings. Care Management functions include:. The Contractor shall also make its best efforts to perform this needs assessment for all new Enrollees within ninety 90 Calendar Days of the Effective Date of Enrollment, and to comply with all other requirements for such assessments set forth in 42 CFR In compliance with 42 CFR The Contractor shall provide these policies and procedures written at a fourth 4 th grade reading level in English and Spanish to all Enrollees eighteen 18 years of age and older and shall advise Enrollees of:.
The Contractor must enter into a Coordination of Benefits Agreement with Medicare within sixty 60 days from the Effective Date of the Contract and participate in the automated claims crossover process in order to appropriately allocate reimbursement for Dual Eligible Beneficiaries.
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Any crossover claims not appropriately reimbursed by the applicable Medicaid program will be considered an Overpayment and shall be reported and returned in accordance with Section ASES may extend the sixty 60 day time frame set forth in Section 7. The Contractor acknowledges that such objections will be factored into the calculation of rates paid to the Contractor and, when made during the course of the Contract period, may serve as grounds for recalculation of the rates paid.
Section Specify that ASES, CMS, the Office of Inspector General, the Comptroller General, the Medicaid Fraud Control Unit, and their designees, shall have the right at any time to inspect, evaluate, and audit any pertinent records or documents, and may inspect the premises, physical facilities, and equipment where activities or work related to the GHP program is conducted. The right to audit exists for ten 10 years from the final date of the contract period or from the date of completion of any audit, whichever is later;.
The Contractor shall, within fifteen 15 Calendar Days of issuance of a notice of termination to a Provider, provide written notice of the termination to Enrollees who received his or her Primary Care from, or was seen on a regular basis by, the terminated Provider, and shall assist the Enrollee as needed in finding a new Provider. With the exceptions noted below, the Contractor shall negotiate rates with Providers, and such rates shall be specified in the Provider Contract. Payment arrangements may take any form allowed under Federal law and the laws of Puerto Rico, including Capitation payments, Fee-for-Service payment, and salary, if any, subject to Section Any use of the Medicare fee schedule to set maximum provider reimbursement rates shall not obligate the Contractor to increase current provider reimbursement rates that have been previously negotiated.
Any Capitation payment made by the Contractor to Providers shall be based on sound actuarial methods in accordance with 42 C. The Contractor shall submit data on the basis of which ASES will certify the actuarial soundness of Capitation payments, including the base data generated by the Contractor. All Provider payments by the Contractor shall be reasonable, and the amount paid shall not jeopardize or infringe upon the quality of the services provided.
If the Contractor delegates any of its utilization management responsibilities under this Section Neither the Contractor nor any Provider or Subcontractor may impose a requirement that Referrals be submitted for the approval of committees, boards, Medical Directors, etc.
The Contractor shall strictly enforce this directive and shall issue Administrative Referrals see Section With the exception of Prior Authorization of covered prescription drugs as described in Section 7. A method of monitoring, analyzing, evaluating, and improving the delivery, quality and appropriateness of health care furnished to all Enrollees including over, under, and inappropriate Utilization of services and including those with special health care needs, as defined by ASES in the quality strategy;. Immediately following Section As per 42 CFR At a minimum, the Contractor shall have a PIPs work plan and activities that are consistent with Federal and Puerto Rico statutes, regulations, and Quality Assessment and Performance Improvement Program requirements for pursuant to 42 C.
In compliance with Federal requirements at 42 CFR Upon the request of ASES, the Contractor shall provide its protocols for providing Information, participating in review activities, and using the results of the reviews to improve the quality of the services and programs provided to Enrollees. The Contractor shall exercise diligent efforts to ensure that no payments are made to any person or entity that has been excluded from participation in Federal health care programs. The Contractor shall Immediately report to ASES the identity of any Provider or other person who is debarred, suspended, or otherwise prohibited from participating in procurement activities.
In accordance with 42 CFR Part , Subpart F, the Contractor shall establish an internal Grievance System under which Enrollees, or Providers acting on their behalf, may express dissatisfaction with the Contractor or challenge the denial of coverage of, or payment for, Covered Services. The Contractor shall ensure that the individuals who make decisions on Grievances and Appeals are individuals:. Who take into account all comments, documents, records and other information submitted by Enrollee without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination.
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The Contractor and Subcontractors, as applicable, shall have a system in place to collect, analyze, and integrate Data regarding Complaints, Grievances, and Appeals. The Contractor shall resolve each Complaint within seventy-two 72 hours of the time the Contractor received the initial Complaint, whether orally or in writing.
If the Complaint is not resolved within this timeframe, the Complaint shall be treated as a Grievance. The Contractor cannot require the Enrollee to file a separate Grievance before proceeding to Appeal. An Enrollee may file a Grievance at any time. If the Grievance originated from a Complaint that was not resolved within the seventy-two 72 hour timeframe set forth in Section If the Contractor extends the timeframe, it shall, for any extension not requested by the Enrollee:.
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Pursuant to 42 CFR The right of Enrollee to be provided, upon request and at no expense to Enrollee, reasonable access to and copies of all documents, records and other information relevant to the Adverse Benefit Determination. If the Contractor extends the timeframe for the authorization decision and issuance of Notice of Adverse Benefit Determination according to Section The requirements of the Appeal process shall be binding for all types of Appeals, including expedited Appeals, unless otherwise established for expedited Appeals.
Only one 1 level of Appeal is permitted before proceeding to an Administrative Law Hearing. If the Enrollee disagrees with the decision to extend the prescribed timeframe, he or she shall be informed of the right to file a Grievance and the Grievance shall be resolved within twenty-four 24 hours. The Contractor shall also make reasonable efforts to provide oral notice for resolution of an expedited review of an Appeal.
The written notice of Disposition shall be in a format and language that, at a minimum, meets applicable notification standards and shall include:. However, if the Contractor fails to adhere to all notice and timing requirements set forth in 42 CFR The Contractor shall not pay any Claim submitted by a Provider during the period of time when such Provider is excluded or suspended from the Medicare, Medicaid, CHIP or Title V Maternal and Child Health Services Block Grant programs for Fraud, Waste, or Abuse or otherwise included on the Department of Health and Human Services Office of the Inspector General exclusions list, or employs someone on this list, and when the Contractor knew, or had reason to know, of that exclusion, after a reasonable time period after reasonable notice has been furnished to the Contractor.
The Provider will have a period of sixty 60 Calendar Days to make the requested payment, to agree to Contractor retention of said payment, or to dispute the recovery action following the process described in Section The duration of the retention period may be extended at the discretion of and as indicated to the Contractor by ASES as needed for ongoing audits or other purposes.
The files will contain settled Claims and Claim adjustments and Encounter Data from Providers for the most recent month for which all such transactions were completed. The Contractor shall make changes or corrections to any systems, processes or Data transmission formats as needed to comply with Encounter Data quality standards as originally defined or subsequently amended. If ASES requests any revisions to the reports already submitted, the Contractor shall make the changes and re-submit the reports, according to the time period and format specified by ASES.
The Contractor shall submit a quarterly Provider Preventable Conditions Report describing any identified Provider preventable conditions as defined in Sections 7.
The report shall include but not be limited to, a description of each identified instance of a provider preventable condition, the name of the applicable Provider, and a summary of corrective actions taken by the Contractor or Provider to address any underlying causes of the provider preventable condition. In addition to the actions described under Section Judicial Review - To the extent administrative review is sought by the Contractor pursuant to Section ASES will have the discretion to recoup payments made to the Contractor for ineligible Enrollees, including, but not limited to, the following:.
The PMPM Payment for Enrollees not enrolled for the full month shall be determined on a pro rata basis by dividing the monthly Capitation amount by the number of days in the month and multiplying the result by the number of days including and following the Effective Date of Enrollment or the number of days prior to and including the Effective Date of Disenrollment, as applicable.