Common use of Agent and Learning Collaborative Clause in Contracts

Agent and Learning Collaborative. a. OHA will assign an Innovator Agent to Contractor. The Innovator Agent is responsible for: (i) serving as a single point of contact between Contractor and OHA on matters regarding innovation, (ii) facilitating the exchange of information, (iii) working with Contractor and its CAC, (iv) working with Contractor and its governing body, and (v) working with Contractor to identify and develop strategies to support Quality Improvement and the adoption of innovations in care. b. Contractor shall participate in face-to-face meetings of any CCO Learning Collaborative at least once per month. 1. Covered Services a. Subject to the provisions of this Contract, Contractor shall provide to Members, at a minimum, those Covered Services that are Medically Appropriate and as described as funded Condition/Treatment Pairs on the Prioritized List of Health Services, including Ancillary Services, as provided for in OAR 410-141-3830 and as identified, defined, and specified in the OHP Administrative Rules. b. Contractor shall provide the Covered Services, including Diagnostic Services, that are necessary and reasonable to diagnose the presenting condition, regardless of whether or not the final diagnosis is covered. c. Contractor shall make available to any Member, Potential Member, or Participating Member, as may be requested from time to time, the criteria for Medically Appropriate determinations with respect to the Benefit Package for physical health, Behavioral Health (which includes mental health and Substance Use Disorders), and Oral Health. d. Contractor shall provide treatment, including Ancillary Services, which is included in or supports the Condition/Treatment Pairs that are above the funding line on the Prioritized List as provided in OAR 410-141-3830. e. Except as otherwise provided in OAR 410-141-3820, Contractor is not responsible for excluded or limited services as set forth in OAR 410-141-3825. f. Before denying any Member treatment for a condition that is below the funding line on the Prioritized List, including without limitation, disabilities or co-morbid conditions, Contractor shall determine whether the Member has a funded condition/treatment pair that would entitle the Member to treatment under OAR 410-141-3820. g. Contractor shall use the same limits and criteria for transplants as those established in the Transplant Services Rules in OAR Chapter 410, Division 124. h. Except as permitted under Section 1903(i) of the Social Security Act, Contractor is prohibited from paying for organ transplants. i. Contractor is responsible for Covered Services for Full Benefit Dual Eligibles for Medicare and Medicaid. Contractor shall pay for Covered Services for Members who are Full Benefit Dual Eligibles in accordance with applicable contractual requirements that include CMS and OHA.

Agent and Learning Collaborative. a. OHA will assign an Innovator Agent to the Contractor. The Innovator Agent is responsible for: (i) serving Agent’s roles are to act as a single point of contact between the Contractor and OHA on matters regarding innovation, (ii) facilitating to facilitate the exchange of information, (iii) working to work with the Contractor and its CAC, (iv) working with Contractor and its governing bodyCommunity Advisory Council, and (v) working to work with the Contractor to identify and develop strategies to support Quality Improvement and the adoption of innovations in care. b. Contractor shall participate in face-to-face meetings of any CCO Learning Collaborative at least once per month.monthly, if available. Exhibit B –Statement of Work - Part 2 – Covered and Non-Covered Services 1. Covered Services a. Subject to the provisions of this Contract, Contractor shall provide to Members, at a minimum, those Covered Services that are Medically Appropriate and as described as funded Condition/Treatment Pairs on the Prioritized List of Health Services, including Ancillary Services, as provided for contained in OAR 410-141-3830 0520 and as identified, defined, defined and specified in the OHP Administrative Rules. b. Contractor shall provide the Covered Services, including Diagnostic Services, Services that are necessary and reasonable to diagnose the presenting condition, regardless of whether or not the final diagnosis is covered. c. Contractor shall make available to any Member, Potential Member, or Participating Member, as may be requested from time to time, the criteria for Medically Appropriate determinations with respect to the Benefit Package for physical health, Behavioral behavioral healthBehavioral Health (which includes mental health and Substance Use Disorders), and Oral Healthoral health to any Member, Potential Member or Participating Provider, upon request. d. Contractor shall provide treatment, including Ancillary Services, which is included in or supports the Condition/Treatment Pairs that are above the funding line on the Prioritized List as provided in of Health Services, OAR 410-141-38300520. e. Except as otherwise provided in OAR 410-141-38200480, Contractor is not responsible for excluded or limited services as set forth described in OAR 410-141-38250500. f. Before denying any Member treatment for a condition that is below the funding line on the Prioritized ListList of Health Services for any Member, including without limitation, disabilities especially a Member with a disability or coCo-morbid conditionsCondition, Contractor shall determine whether the Member has a funded conditionCondition/treatment pair Treatment Pair that would entitle the Member to treatment under OAR 410-141-38200480. g. Contractor shall notify OHA’s Transplant Coordinator of all transplant Prior Authorizations. Contractor must use the same limits and criteria for transplants as those established in the Transplant Services Rules in Rules, OAR Chapter 410, 410 Division 124. h. Except as permitted under Section 1903(i) of the Social Security Act, Contractor is prohibited from paying for organ transplantstransplants unless the State Plan, Section 1903(i), provides and the Contractor follows written standards that provide for similarly situated individuals to be treated alike and for any restriction on facilities or practitionersPractitioners to be consistent with the accessibility of high quality care to Members. i. Contractor is responsible for Covered Services for Full Benefit Fully Dual Eligibles for Medicare and Medicaid. Contractor shall pay for Covered Services for Members who are Full Benefit Fully Dual Eligibles Eligible in accordance with applicable contractual requirements that include CMS and OHA.