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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.
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;.
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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. 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:. 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.
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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. The profit of the Contractor and Subcontractors for each fiscal year of the Contract Term shall not exceed two point five percent 2. The Contractor shall initially determine its Excess Profit for each fiscal year and shall submit a sworn certification annually to attest to the truth and accuracy of its Excess Profit and the assumptions on which it is calculated to ASES.
The Excess Profit calculation will include the entire fiscal year total aggregated earned premium for all Service Regions. The same regulations shall apply to any and all Subcontractors. The Contractor shall include in its calculation of Excess Profit, as reported under this Section Original Section To comply with 42 CFR The Contractor must also require and have a mechanism for a Provider to report to the Contractor when it has received an Overpayment, to return that Overpayment to the Contractor with a written reason for the Overpayment within sixty 60 Calendar Days after the date on which the Overpayment was identified.
Medical Loss Ratio. Effective July 1, , the Contractor is expected to achieve a target medical loss ratio standard, as calculated under 42 CFR Time Period Incurred service. Preventive Clinical. The Contractor shall submit a quarterly report no later than ninety 90 Calendar Days after the end of each quarter regarding each of the performance indicators to be evaluated, as determined by ASES from those listed in Section Immediately following Original Section The Contractor shall provide assurances to ASES that its provision against the risk of insolvency is adequate, in compliance with the Federal standards set forth in 42 CFR In particular, the Contractor shall, according to the timeframe specified in Attachment 12 to this Contract, furnish documentation, certified by a Certified Public Accountant, of:.
The Contractor shall establish a stop-loss limit amount that is in compliance with the limits specified in 42 CFR The limit shall be activated when the expense of providing Covered Services to an Enrollee, including all outpatient and inpatient expenses, reaches this sum. The Contractor shall have mechanisms in place to identify the stop loss once it is reached for an Enrollee, and shall establish monthly reports to inform PMGs of Enrollees who have reached the stop-loss limit.
The Contractor shall assume all losses exceeding the limit. Disclosures of Information on Annual Business Transactions or other reports of transactions between the Contractor and parties in interest provided to ASES or other agencies must be made available to Enrollees upon reasonable request. ASES is prohibited by law from entering into contracts with any person or entity that has been, or whose affiliated subsidiary companies, or any of its shareholders, partners, officers, principals, managing employees, subsidiaries, parent companies, officers, directors, board members, or ruling bodies have been, under investigation for, accused of, convicted of, or sentenced to imprisonment, in Puerto Rico, the other USA jurisdictions, or any other jurisdiction, for any crime involving corruption, fraud, embezzlement, or unlawful appropriation of public funds, pursuant to Act , as amended, and Act 84 of All contracts between the Contractor and Subcontractors must be in writing, must comply with all applicable Medicaid laws and regulations, including subregulatory guidance and provisions set forth in this Agreement, as applicable, and must specify the activities and responsibilities delegated to the Subcontractor containing terms and conditions consistent with this Contract.
The Contractor and the Subcontractors must also make reference to a business associates agreement between the Parties. ASES shall have the right to review all financial or business transactions between the Contractor and a Subcontractor at any time upon request.
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ASES shall also retain the right to review all criminal background checks for all employees of the Subcontractor, as referenced in Article 29, as well as any past exclusions from Federal programs. Pursuant to the requirements of 42 CFR All Subcontractors must fulfill the requirements of 42 CFR Subcontractors shall also retain, as applicable, enrollee grievance and appeal records as per 42 CFR The Contractor shall insert the substance of this Section in each Subcontract hereunder. The Contractor and its Subcontractors, if any, shall preserve and make available all of its records pertaining to the performance under this Contract for inspection or audit, as provided below, throughout the Contract Term, for a period of ten 10 years from the date of final payment under this Contract, and for such period, if any, as is required by applicable statute or by any other section of this Contract.
The Contractor is responsible to preserve all records pertaining to its performance under this Contract, and to have them available and accessible in a timely manner, and in a reasonable format that assures their integrity. 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. Any records requested hereunder shall be produced Immediately for on-site review or sent to the requesting authority by mail within fourteen 14 Calendar Days following a request.
All records shall be provided at the sole cost and expense of the Contractor. ASES shall have unlimited rights to use, disclose, and duplicate all Information and Data in any way relating to this Contract in accordance with applicable Puerto Rico and Federal laws and regulations. Any revisions to the PMPM Payments under this Section would be applicable only from January 1, until June 30, , or from the effective date of any new law or regulation, whichever is later. This Contract shall be governed in all respects by the laws of Puerto Rico.
Any lawsuit or other action brought against ASES or the Commonwealth based upon or arising from this Contract shall be brought in a court of competent jurisdiction in Puerto Rico. For the purposes of this Section, a person or corporation with an ownership or control interest shall mean a person or corporation:. The Contractor shall consent to any such amendment. The following amended attachments, copies of which are included, are substituted in this Agreement as follows:.
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All other terms and provisions of the original Contract, as amended by Contracts Number A, B, C, D, E, F, G, and of any and all documents incorporated by reference therein, not specifically deleted or modified herein shall remain in full force and effect. The parties hereby affirm their respective undertakings and representations as set forth therein, as of the date thereof.
Capitalized terms used in this Amendment, if any, shall have the same meaning assigned to such terms in the Contract. Pending CMS approval, this Amendment shall serve as a binding letter of agreement between the Parties. Unless a provision contained in this Amendment specifically indicates a different effective date, for purposes of the provisions contained herein, this Amendment shall become effective retroactively July 1, and end on June 30 th , This Amendment constitutes the entire understanding and agreement of the parties with regards to the subject matter hereof, and the parties by their execution and delivery of this Seventh Amendment to the Contract hereby ratify all of the terms and conditions of the Contract, as amended by Contracts Number A, B, C, D, E, F, G, and as supplemented by this Agreement.
The Parties agree that ASES will be responsible for the submission and registration of this Amendments in the Office of the Comptroller General of the Commonwealth, as required under law and applicable regulations. Avila Marrero. Angela M. Avila Marrero, Executive Director.