SCOPE OF WORK – HOOSIER HEALTHWISE. ▪ Premium Receivable Analysis by line of business ▪ Affiliate and Inter-company Receivables ▪ Current Liability Payables by line of business ▪ Medical Liabilities by line of business ▪ Copies of any correspondence to and from the IDOI
SCOPE OF WORK – HOOSIER HEALTHWISE. Specialties Ancillary Providers ⮚ Optometrists* ⮚ Orthodontists* ⮚ Orthopedic surgeons* ⮚ Orthopedists ⮚ Otolaryngologists ⮚ Pathologists** ⮚ Physical therapists* ⮚ Psychiatrists* ⮚ Pulmonologists* ⮚ Radiation oncologists** ⮚ Rheumatologists** ⮚ Speech therapists* ⮚ Urologists* OMPP requires that the Contractor maintain network access standards for the listed ancillary providers as follows: ▪ Two (2) durable medical equipment providers shall be available to provide services to the Contractor’s members in each county or contiguous county; and ▪ Two (2) home health providers shall be available to provide services to the Contractor’s members in each county or contiguous county. In addition, the Contractor shall demonstrate the availability of providers with training, expertise and experience in providing tobacco dependence treatment services, especially to pregnant women. Evidence that providers are trained to provide tobacco dependence treatment services must be available during OMPP’s monthly onsite visits. The Contractor shall contract with the Indiana Hemophilia and Thrombosis Center or a similar OMPP-approved, federally recognized hemophilia treatment center. This requirement is based on the findings of the Centers for Disease Control and Prevention (CDC) which illustrate that persons affected by a bleeding disorder receiving treatment from a federally recognized treatment center require fewer hospitalizations, experience less bleeding episodes and experience a forty percent (40%) reduction in morbidity and mortality. The Contractor shall arrange for laboratory services only through those IHCP enrolled laboratories with Clinical Laboratory Improvement Amendments (CLIA) certificates.
SCOPE OF WORK – HOOSIER HEALTHWISE. The Contractor shall work with each FQHC and RHC in assisting OMPP and/or its designee in the resolution of disputes concerning year-end reconciliations between the federally required interim payments (made by OMPP to each FQHC and RHC on the basis of provider reported encounter activity) and the final accounting that is based on the actual encounter data provided by the Contractor.
SCOPE OF WORK – HOOSIER HEALTHWISE. The Contractor’s policies on non-payment of certain hospital-acquired conditions must comply with 405 IAC 1-10.5-5 and the IHCP Provider Bulletin regarding Present on Admission Indicator for Hospital Acquired Conditions dated August 25, 2009 (BT200928), as well as any updates or amendments thereto. In accordance with 42 CFR 447.26(d), the Contractor shall require that as a condition of payment, all providers agree to comply with the reporting requirements in 42 CFR 447.26(d). The Contractor’s policy on non-payment of certain never events shall be developed in accordance with current Medicare National Coverage Determinations (NCDs), as well as any Indiana Medicaid FFS rules or other guidance adopted or issued by OMPP at a future date.
SCOPE OF WORK – HOOSIER HEALTHWISE. Unless a member specifically states their alternate-format request is a one-time request, the Contractor shall consider the request an ongoing request and supply all future mailed materials in the preferred format to the member. For first-time or one-time requests from a member, the Contractor shall mail the alternate version of the document in no more than seven (7) business days from the date of the request. If, for example, the member received a wellness visit reminder flyer and called the Contractor to ask for the flyer to be sent in braille, the Contractor shall take no more than seven (7) business days to mail the braille version from the date of the member request call. For first-time or one-time requests from a member, when the mailing is governed by NCQA or statutory requirements, the Contract shall have two (2) additional days from the NCQA or statutory timeframe to mail the document if no mailing has yet been sent to the member. For first-time or one-time requests from a member, when the mailing is governed by NCQA or statutory requirements and the statutory notice has already been fulfilled with a regular printed letter, the Contractor shall mail the alternate version of the document in no more than seven (7) business days from the date of the request. For existing on-going alternate format requests, the Contractor shall have two (2) additional business days from when the document would normally be required to be mailed, to mail the document in the alternate format. If, for example, a member had previously requested materials in braille, and an ID card would be sent to the member in five (5) business days, the timeline would be seven (7) business days for the braille version. The additional two (2) days applies for Contract requirements (such as ID cards) and additional mailings at the will of the Contractor, such as a wellness visit reminder postcard. For existing on-going alternate format requests which must comply with NCQA or State law requirement, such as utilization management letters, the Contractor shall mail the documents in the alternate format within the statutory or NCQA required timeline. The Contractor shall provide notification to OMPP, to the Enrollment Broker and to its members of any covered services that the Contractor or any of its sub-contractors or networks do not cover on the basis of moral or religious grounds and guidelines for how and where to obtain those services, in accordance with 42 CFR 438.102, which relates to p...
SCOPE OF WORK – HOOSIER HEALTHWISE. ▪ A determination and analysis of the number and the type of drugs subject to a restriction. ▪ A review of the rationale for the prior authorization of a drug and a restriction on a drug. ▪ A review of the number of requests a Contractor received for prior authorization, including the number of times prior authorization was approved and disapproved. ▪ A review of patient and provider satisfaction survey reports and pharmacy-related grievance data for a twelve (12) month period. The Contractor shall provide OMPP with the information necessary for the DUR Board to conduct this review in the timeframe and format specified by OMPP. In addition to the DUR Board approval, the Contractor shall also seek the advice of the Mental Health Medicaid Quality Advisory Committee, as required in IC 12-15-35.5, prior to implementing a restriction on a mental health drug described in IC 12-15-35.5-3(b). The Contractor shall supply, on a quarterly basis, a report to the Office and the DUR Board of the number of member days of missed therapy due to prior authorization. The format of this report will be agreed upon by the Contractor, the Office and the DUR Board. In addition, the Contractor shall comply with any additional reporting requests required for submission to the DUR Board. Please refer to the Hoosier Healthwise MCE Reporting Manual for more information on pharmacy reporting requirements. The Contractor shall provide the DUR Board statistics at the DUR Board’s monthly meetings. These statistics may include information on drug utilization or prior authorization reports as requested by the State.
SCOPE OF WORK – HOOSIER HEALTHWISE. The Contractor cannot entice a potential member to join its health plan by offering any other type of insurance as a bonus for enrollment, and the Contractor shall ensure that a potential member can make his/her own decision as to whether or not to enroll. Marketing materials and plans shall be designed to reach a distribution of potential members across age and gender categories. The Contractor must conduct marketing and advertising in a geographically balanced manner, paying special attention to rural areas of the State. The Contractor must provide information to potentially eligible individuals who live in medically underserved rural areas of the State. Potential members may not be discriminated against on the basis of health status or need for health care services, or on any other basis inconsistent with state or federal law, including Section 1557 of the Affordable Care Act / 45 CFR 92.1. The Contractor may distribute or mail an informational brochure or flyer to potential members and/or provide (at its own cost, including any costs related to mailing) such brochures or flyers to the State for distribution to individuals at the time of application. The Contractor shall submit product naming and associated domains to FSSA for review and approval to minimize confusion for members and providers.
SCOPE OF WORK – HOOSIER HEALTHWISE. ▪ The Contractor shall have a written agreement in place that specifies the subcontractor’s responsibilities and provides an option for revoking delegation or imposing other sanctions if performance is inadequate per 42 CFR 438.230(c)(1)(iii). The written agreement shall be in compliance with all the State of Indiana statutes, and will be subject to the provisions thereof. The subcontract cannot extend beyond the term of the State’s Contract with the Contractor. ▪ The Contractor shall collect performance and financial data from its subcontractors and monitor delegated performance on an ongoing basis and conduct formal, periodic and random reviews, as directed by FSSA. The Contractor shall incorporate all subcontractors’ data into the Contractor’s performance and financial data for a comprehensive evaluation of the Contractor’s performance compliance and identify areas for its subcontractors’ improvement when appropriate. The Contractor shall take corrective action if deficiencies are identified during the review. ▪ All subcontractors shall fulfill all state and federal requirements including Medicaid laws, regulations, applicable sub-regulatory guidance, and contract provisions appropriate to the services or activities delegated under the subcontract. In addition, all subcontractors shall fulfill the requirements of the Contract (and any relevant amendments) that are appropriate to any service or activity delegated under the subcontract. ▪ The Contractor shall submit a plan to the State on how the subcontractor will be monitored for debarred employees. ▪ For the purposes of an audit, evaluation, or inspection by the State, CMS, the Department of Health and Human Services (DHHS) Inspector General, the Comptroller General or their designees, the subcontractor shall make available for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later, its premises, physical facilities, equipment, books, records contracts, computer, or other electronic systems relating to its Medicaid enrollees per 42 CFR 438.230(c)(3)(iii) and 42 CFR 438.3(k). This contract term shall specify that if the State, CMS, or the DHHS Inspector General determine that there is a reasonable possibility of fraud or similar risk, the above State and federal agencies may inspect, evaluate, and audit the subcontractor at any time. ▪ The Contractor shall comply with all subcontract requirements specified in 42 CFR 438.230, which contai...
SCOPE OF WORK – HOOSIER HEALTHWISE. Members may not self-refer to a provider who is not enrolled in IHCP. The following services are considered self-referral services. The Indiana Administrative Code 405 IAC 5 (Hoosier Healthwise) and provides further detail regarding these benefits. ▪ Chiropractic services may be provided by a licensed chiropractor, enrolled as an Indiana Medicaid provider, when rendered within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-1 who has entered into a provider agreement under IC 12-15-11. ▪ Eye care services, except surgical services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-24 (optometrist) who has entered into a provider agreement under IC 12-15-11. ▪ Routine Dental services may be provided by any in-network licensed dental provider who has entered into a provider agreement under IC 12-15-11. ▪ Podiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-29 (doctor of podiatric medicine) who has entered into a provider agreement under IC 12-15-11. ▪ Psychiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) who has entered into a provider agreement under IC 12-15-11. ▪ Family planning services under federal regulation 42 CFR 431.51(b)(2) and section 1902(a)(23) of the Social Security Act requires a freedom of choice of providers and access to family planning services and supplies. Family planning services are those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. Contractors may place appropriate limits on the service for utilization control, provided family planning services are provided in a manner that protects and enables the member’s freedom to choose the method of family planning to be used per 42 CFR 438.210(a)(4)(ii)(C). Family planning services also include sexually transmitted disease testing. Members may self-refer to any IHCP provider qualified to provide the family planning service(s), including providers that are not in the Contractor’s network. Members may not be restricted in choice of a family planning service provider, so long as the provider is an IHCP provider. The IHCP Provider Manual provides a complete and current list of family planning services. Abortions and abortifacients are not covered family planning services except as allowable un...
SCOPE OF WORK – HOOSIER HEALTHWISE. The Contractor will ensure that children with elevated blood lead levels are identified, their provider is notified and they receive the recommended follow-up treatment.
