Common use of Contractor must Clause in Contracts

Contractor must. 1.1 Meet timeliness standards, complete regular reviews, and communicate the decision as specified by HHSC within 10 calendar days from the date of the assignment. Expedited reviews, as determined by HHSC, must be completed no later than the next Business Day from the date of the assignment. 1.2 Review assignments and identify Conflicts of Interest not identified by HHSC and return to HHSC for reassignment to another IRO/contractor. 1.3 Accurately complete clinical reviews and determine if the services are medically necessary in accordance with Texas Medicaid guidelines, this OE, managed care contracts, and the Texas Medicaid Provider Procedures Manual (TMPPM), as directed by HHSC. HHSC reserves the right to audit Contractor files and evaluate the accuracy of Contractor determinations. 1.4 Submit a monthly report detailing all contract-related activities in a format specified by HHSC no later than the 10th calendar day of the month. 1.5 Upon written request of the provider associated with the denied services of the Member requesting the EMR, provide written notice of the EMR decision to the requesting provider, following HIPAA standards outlined in Exhibit C of this Open Enrollment. 1.6 Have Reviewers available for cases that represent the full range of expertise needed to accept and process appeals for (1) service reductions or denials that may be covered or sought to be covered by Texas Medicaid, and (2) eligibility benefits for medical and functional necessity determinations. Reviewers may be a Contractor employee or subcontractor. 1.7 Have licensed, certified, or credentialed Reviewers, as applicable, by the State of Texas licensing, certifying, or credentialing body for their respective specialty or area of practice that would generally provide the type of treatment that is the subject of the assigned review. 1.8 Ensure each Reviewer is in good standing with their respective State of Texas licensing, certifying, or credentialing body and must contractually require that all Reviewers immediately disclose to Contractor any action taken by a licensing, certification or credentialing body, health care facility or health plan to condition, suspend or revoke the Reviewer’s license, certification, or credentials. When such notification is received, Contractor must immediately exclude that Reviewer from all Texas EMRs. 1.9 Meet or exceed the objectives set forth in this Contract. All areas of responsibility and all requirements listed in this Contract will be subject to a performance evaluation at any time at the discretion of HHSC. If the Contractor falls below the performance standard for meeting timeliness or other standards, HHSC may exclude the Contractor from alternating assignments until such time as the Contractor has successfully completed a corrective action plan, as determined by HHSC, which may require, among other things, Contractor increasing its staffing to handle caseloads. If an assignment must be reassigned due to non-compliance by the Contractor, the EMR will be reassigned. Contractor will not be paid for EMRs reassigned to another IRO/contractor. 1.10 Ensure Reviewers and supervisors successfully complete HHSC training modules and attest to training completion prior to contract implementation. Contractor Reviewers and supervisors must complete required training within 30 days of hire or subcontract execution. External Medical Reviews must not be conducted by Contractor or its Reviewers unless Contractor and its Reviewers and supervisors have completed the HHSC training. 1.11 Submit to HHSC a complete list of Reviewers that will be assigned EMRs within 30 days of the contract execution date. Contractor must provide an updated list of Reviewers on a quarterly basis on the 15th of the month following the end of the preceding state fiscal quarter in a format specified by HHSC. 1.12 If the Contractor determines the MCO or DMO submitted incomplete documentation, or instructed as such by HHSC, the Contractor may overturn the MCO or DMO service denial, or service reduction, that is adverse to the Member. The Contractor should not delay a decision based on lack of complete documentation from the MCO or DMO. 1.13 Ensure that a physician Reviewer makes the final Contractor decision to overturn a MCO adverse benefit determination if the Contractor internal decision recommendation was made by a Contractor non-physician Reviewer. 1.14 Notify HHSC in writing within five Business Days of any change in key personnel, such as, including but not limited to, designated points of contact, the Contractor’s chief executive officer or equivalent, medical director, or director of operations or equivalent.