Administrative and Organizational Structure. The Contractor shall maintain an administrative and organizational structure that supports effective and efficient delivery of integrated services to all members in a family. The organizational structure shall demonstrate a coordinated approach to managing the delivery of health care services to its Hoosier Healthwise members. The Contractor’s organizational structure shall support collection and integration of data from every aspect of its delivery system and its internal functional units to accurately report the Contractor’s performance. The Contractor shall also have policies and procedures in place that support the integration of financial and performance data and comply with all applicable federal and state requirements. Prior to the Contract effective date, FSSA will provide a series of orientation sessions to assist the Contractor in developing its internal operations to support the requirements of the Contract (i.e., data submission, data transmissions, reporting formats, etc.). The Contractor shall have in place sufficient administrative and clinical staff and organizational components to comply with all Hoosier Healthwise program requirements and standards. The Contractor shall manage the functional linkage of the following major operational areas: Administrative and fiscal management Member services Provider services Marketing Provider enrollment Network development and management Quality management and improvement Utilization and care management Special investigations and waste, fraud and abuse detection Behavioral and physical health Information systems Performance data reporting and encounter claims submission Claims payments Grievances and appeals
Administrative and Organizational Structure. The Contractor shall maintain an administrative and organizational structure that supports effective and efficient delivery of integrated services to all members in a family. The organizational structure shall demonstrate a coordinated approach to managing the delivery of health care services to its Hoosier Healthwise members. The Contractor’s organizational structure shall support collection and integration of data from every aspect of its delivery system and its internal functional units to accurately report the Contractor’s performance. The Contractor shall also have policies and procedures in place that support the integration of financial and performance data and comply with all applicable federal and state requirements. Prior to the Contract effective date, FSSA will provide a series of orientation sessions to assist the Contractor in developing its internal operations to support the requirements of the Contract (i.e., data submission, data transmissions, reporting formats, etc.). The Contractor shall have in place sufficient administrative and clinical staff and organizational components to comply with all Hoosier Healthwise program requirements and standards. The Contractor shall not be located outside of the United States per 42 CFR 438.602(i). The Contractor shall manage the functional linkage of the following major operational areas: ▪ Administrative and fiscal management ▪ Member services ▪ Provider services ▪ Marketing ▪ Provider enrollment ▪ Network development and management ▪ Quality management and improvement ▪ Utilization management ▪ Clinical assessment, disease management, care management and complex case management ▪ Special investigations and waste, fraud and abuse detection ▪ Behavioral and physical health ▪ Information systems ▪ Performance data reporting and encounter claims submission ▪ Claims payments ▪ Grievances and appeals
Administrative and Organizational Structure. The Contractor shall have in place an organizational and operational structure capable of fulfilling all Contract requirements. This structure must support collection and integration of data across the Contractor’s delivery system and internal functional units to accurately report the Contractor’s performance. The Contractor must have in place sufficient administrative and clinical staff and organizational components to achieve compliance with Contract requirements and performance standards. The Contractor must manage the functional linkage of the following major operational areas: Administrative and fiscal management; Member services; Provider services; Marketing; Provider enrollment; Network development and management; Quality management and improvement; Utilization management; Clinical assessment, disease management, care management and complex case management; Behavioral and physical health; Information systems; Performance data reporting and encounter claims submission; Claims payments; and Grievances and appeals.
Administrative and Organizational Structure. The Contractor shall maintain an administrative and organizational structure that supports effective and efficient delivery of integrated services to all members in a family. The organizational structure shall demonstrate a coordinated approach to managing the delivery of health care services to its HIP populations. The Contractor’s organizational structure shall support collection and integration of data from every aspect of its delivery system and its internal functional units to accurately report the Contractor’s performance. The Contractor shall also have policies and procedures in place that support the integration of financial and performance data and comply with all applicable federal and state requirements. Prior to the Contract effective date, FSSA will provide a series of orientation sessions to assist the Contractor in developing its internal operations to support the requirements of the Contract (i.e., data submission, data transmissions, reporting formats, etc.). The Contractor shall have in place sufficient administrative and clinical staff and organizational components to comply with all HIP program requirements and standards. The Contractor shall manage the functional linkage of the following major operational areas: ▪ Administrative and fiscal management ▪ Member services ▪ Provider services ▪ Marketing ▪ Provider enrollment ▪ Network development and management ▪ Quality management and improvement ▪ Utilization and care management ▪ Special investigations and waste, fraud and abuse detection ▪ Behavioral and physical health ▪ POWER Account administration ▪ POWER Account contribution collections ▪ Information systems ▪ Performance data reporting and encounter claims submission ▪ Claims payments ▪ Grievances and appeals ▪ Pharmacy Benefits Management
Administrative and Organizational Structure. The Contractor shall maintain an administrative and organizational structure that supports effective and efficient delivery of integrated services to all members in a family. The organizational structure shall demonstrate a coordinated approach to managing the delivery of health care services to its Hoosier Healthwise members. The Contractor’s organizational structure shall support collection and integration of data from every aspect of its delivery system and its internal functional units to accurately report the Contractor’s performance. The Contractor shall also have policies and procedures in place that support the integration of financial and performance data and comply with all applicable federal and state requirements. EXHIBIT 1.E
Administrative and Organizational Structure. The Contractor shall maintain an administrative and organizational structure that supports effective and efficient delivery of integrated services to members. The organizational structure shall demonstrate a coordinated approach to managing the delivery of health care services to its PathWays members. The Contractor’s organizational structure shall support the collection and integration of data from every aspect of its delivery system and its internal functional units to accurately report the Contractor’s performance. The Contractor shall also have policies and procedures in place that support the integration of financial and performance data and comply with all applicable federal and state requirements. Prior to the Contract effective date, FSSA will provide a series of orientation sessions to assist the Contractor in developing its internal operations to support the requirements of the Contract (i.e., data submission, data transmissions, reporting formats, etc.). The Contractor shall have in place sufficient administrative and clinical staff and organizational components to comply with all PathWays program requirements and standards. The Contractor shall manage the functional linkage of the following major operational areas: ▪ Administrative and fiscal management ▪ Member services ▪ Provider enrollment and services ▪ Case Management ▪ Marketing ▪ Network development and management ▪ Quality management and improvement ▪ Utilization management ▪ Clinical assessment, prevention and wellness program(s), care coordination, complex case management, and service coordination, ▪ Special investigations and waste, fraud, and abuse detection ▪ Behavioral and physical health ▪ Information systems ▪ Performance data reporting and encounter claims submission EXHIBIT 1 SCOPE OF WORK – INDIANA PATHWAYS FOR AGING ▪ Claims payments ▪ Grievances and appeals ▪ Medicare and Medicaid coordination
Administrative and Organizational Structure. The Contractor shall have in place an organizational and operational structure capable of fulfilling all Contract requirements and shall not be located outside of the United States per 42 CFR 438.602(i). This structure must support collection and integration of data across the Contractor’s delivery system and internal functional units to accurately report the Contractor’s performance. The Contractor must have in place sufficient administrative and clinical staff and organizational components to achieve compliance with Contract requirements and performance standards. The Contractor must manage the functional linkage of the following major operational areas: ▪ Administrative and fiscal management; ▪ Member services; ▪ Provider services; ▪ Marketing; ▪ Provider enrollment; ▪ Network development and management; ▪ Quality management and improvement; ▪ Utilization management; ▪ Clinical assessment, disease management, care management and complex case management; ▪ Behavioral and physical health; ▪ Information Technology systems; ▪ Performance data reporting and encounter claims submission; ▪ Claims payments; and ▪ Grievances and appeals.
Administrative and Organizational Structure. The Contractor shall have in place an organizational and operational structure capable of fulfilling all Contract requirements. This structure must support collection and integration of data across the Contractor’s delivery system and internal functional units to accurately report the Contractor’s performance. The Contractor must have in place sufficient administrative and clinical staff and organizational components to achieve compliance with Contract requirements and performance standards. The Contractor must manage the functional linkage of the following major operational areas: • Administrative and fiscal management; • Member services; • Provider services; • Marketing; • Provider enrollment; • Network development and management; • Quality management and improvement;
Administrative and Organizational Structure. The Contractor shall maintain an administrative and organizational structure that supports effective and efficient delivery of integrated services to all members in a family. The organizational structure shall demonstrate a coordinated approach to managing the delivery of health care services to its Hoosier Healthwise members. The Contractor’s organizational structure shall support collection and integration of data from every aspect of its delivery system and its internal functional units to accurately report the Contractor’s performance. The Contractor shall also have policies and procedures in place that support the integration of financial and performance data and comply with all applicable federal and state requirements. Prior to the Contract effective date, FSSA will provide a series of orientation sessions to assist the Contractor in developing its internal operations to support the requirements of the Contract (i.e., data submission, data transmissions, reporting formats, etc.).
Administrative and Organizational Structure. The Contractor shall maintain an administrative and organizational structure that supports effective and efficient delivery of integrated services to all members in a family. The organizational structure shall demonstrate a coordinated approach to managing the delivery structure shall support collection and integration of data from every aspect of its delivery system and The Contractor shall also have policies and procedures in place that support the integration of financial and performance data and comply with all applicable federal and state requirements. Prior to the Contract effective date, FSSA will provide a series of orientation sessions to assist the Contractor in developing its internal operations to support the requirements of the Contract (i.e., data submission, data transmissions, reporting formats, etc.). The Contractor shall have in place sufficient administrative and clinical staff and organizational components to comply with all Hoosier Healthwise program requirements and standards. The Contractor shall manage the functional linkage of the following major operational areas: Administrative and fiscal management Member services Provider services Marketing Provider enrollment Network development and management Quality management and improvement Utilization and care management Special investigations and waste, fraud and abuse detection Behavioral and physical health Information systems Performance data reporting and encounter claims submission Claims payments Grievances and appeals
