Covered MCO Services Clause Samples

Covered MCO Services. The MCO must provide to enrollees under this Contract, directly or through arrangements with others, all of the covered services described in Contract Appendix A (Description of Covered and Excluded Services). Contract Appendix A presents an explanation of the medical services which the MCO is required to provide, as well as those which are excluded; however, the Medicaid and WVCHIP policy is the final source for defining these services. Medicaid and WVCHIP policy collectively refers to documents and other written materials including the State Medicaid plan, WVCHIP State Plan, program instructions, attendant provider manuals, program bulletins, and all published policy decisions issued by BMS. These materials are available through BMS. The MCO must promptly provide or arrange to make available for enrollees all Medically Necessary services listed in Contract Appendix A and assume financial responsibility for the provision of these services. The MCO is responsible for determining whether services are Medically Necessary and whether the MCO will require prior approval for services. Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, and RNs. The MCO is also responsible for providing emergency transportation as outlined in Article III, Section 1.2.2 and in Appendix A. Additionally, the MCO’s providers must meet the provider requirements as specified by the West Virginia Medicaid program.

Covered MCO Services. The MCO must provide to enrollees under this Contract, directly or through arrangements with others, all of the covered services described in Contract Appendix A (Description of Covered and Excluded Services). Contract Appendix A presents an explanation of the medical, dental, behavioral health, and residential services, which the MCO is required to provide, as well as those which are excluded. It also includes the types of SNS services provided through the ASO. However, the Medicaid policy is the final source for defining Medicaid covered services. Medicaid policy collectively refers to documents and other written materials including the State Medicaid plan, applicable Medicaid waivers, program instructions, attendant provider manuals, program bulletins, and all published policy decisions issued by BMS. These Medicaid materials are available through BMS. The Title IV State Plan is the final source for defining services covered under the child welfare umbrella. The MCO must promptly provide or arrange to make available for enrollees all Medically Necessary and SNS listed in Contract Appendix A. The MCO shall be financially responsible for the coverage of all Medicaid services as defined by Appendix A. The MCO is responsible for determining whether services are Medically or Socially Necessary and whether the MCO will require prior approval for services. Qualified medical personnel must be accessible twenty-four

Covered MCO Services. The MCO must provide to enrollees enrolled under this Contract, directly or through arrangements with others, all of the covered services described in Contract Appendix A (Description of Covered and Excluded Services). Contract Appendix A presents an explanation of the medical services which the MCO is required to provide, as well as those which are excluded; however, the Medicaid policy is the final source for defining these services. Medicaid policy collectively refers to documents and other written materials including the State Medicaid plan, program instructions, attendant provider manuals, program bulletins, and all published policy decisions issued by BMS. These materials are available through BMS. The MCO must promptly provide or arrange to make available for enrollees all Medically Necessary services listed in Contract Appendix A and assume financial responsibility for the provision of these services. The MCO is responsible for determining whether services are Medically Necessary and whether the MCO will require prior approval for services. Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, and registered nurses. The MCO is also responsible for providing emergency transportation as outlined in Article III, Section 1.2.2 and in Appendix A. Additionally, the MCO’s providers must meet the provider requirements as specified by the West Virginia Medicaid program.