Common use of Directed Payments Clause in Contracts

Directed Payments. The CONTRACTOR shall comply with Directed Payments established by HCA and approved by CMS. All assurances specified in 42 C.F.R. § 438.6(c)(2)(ii)-(iii) applicable to the type of Directed Payment, as defined in 42 C.F.R. § 438.6(c)(1)(i)-(iii), and made by HCA part of the approval process for Directed Payments are restated and reaffirmed. HCA shall communicate the requirements of the Directed Payment to the CONTRACTOR through a Letter of Direction. The Directed Payments listed in Attachment 10: Directed Payments are required of the CONTRACTOR, subject to annual approval by CMS unless otherwise specified. Non-Risk Arrangements The CONTRACTOR shall comply with non-risk arrangements established by HCA and approved by CMS. HCA shall communicate the requirements of the non-risk arrangement to the CONTRACTOR through a Letter of Direction. The non-risk arrangements comply with the upper payment limits specified in 42 C.F.R. § 447.362. The non-risk arrangements listed in Attachment 11: Non-Risk Arrangements are required of the CONTRACTOR. Provider Services Provider Handbook The CONTRACTOR shall issue a provider handbook to all Contract Providers. The CONTRACTOR may distribute the Provider handbook electronically (e.g., via its website) as long as Providers are notified about how to obtain the electronic copy and how to request a hard copy at no charge to the Provider. At a minimum, the Provider handbook shall include the following information: A table of contents; Description of Turquoise Care, including eligibility, enrollment, and Member assessment information; Information about CISC Members and the CISC CONTRACTOR; Covered Services; Description of the role of care coordinators; Cultural competency and cultural humility; How the Provider can access language interpretation and specialized communication services; Description of the SDCB and the Agency-Based Community Benefit; Emergency Services responsibilities; Information on Member Grievance and Appeal rights and processes, including Fair Hearings; Policies and procedures of the provider complaint system; Medically Necessary Service standards and clinical practice guidelines; PCP responsibilities; Member lock in standards and requirements; The CONTRACTOR’s Fraud and Abuse policies and procedures, including how to report suspected Fraud and/or Abuse; Coordination with other Providers, Major Subcontractors, or HCA contractors; Requirements regarding background checks; Information on identifying and reporting suspected Abuse, neglect, and exploitation of Members; Prior authorization, referral, and other Utilization Management requirements and procedures; Protocol for Encounter Data reporting and records; Claims submission protocols and standards, including instructions and all information necessary for Clean Claims; Payment policies; Credentialing and recredentialing requirements; Confidentiality and HIPAA requirements with which the Provider must comply; Member rights and responsibilities; The telephone number for the Provider services line; and A separate section and/or addendum that specifically address the ABP services and ABP Exempt Members. The CONTRACTOR shall disseminate bulletins as needed to incorporate any necessary changes to the provider handbook.

Directed Payments. The CONTRACTOR shall comply with Directed Payments established by HCA HSD and approved by CMS. All assurances specified in 42 C.F.R. § 438.6(c)(2)(ii)-(iii) applicable to the type of Directed Payment, as defined in 42 C.F.R. § 438.6(c)(1)(i)-(iii), and made by HCA HSD as part of the approval process for Directed Payments are restated and reaffirmed. HCA HSD shall communicate the requirements of the Directed Payment to the CONTRACTOR through a Letter of Direction. The Directed Payments listed in Attachment 10: Directed Payments are required of the CONTRACTOR, subject to annual approval by CMS unless otherwise specified. Non-Risk Arrangements The CONTRACTOR shall comply with non-risk arrangements established by HCA HSD and approved by CMS. HCA HSD shall communicate the requirements of the non-risk arrangement to the CONTRACTOR through a Letter of Direction. The non-risk arrangements comply with the upper payment limits specified in 42 C.F.R. § 447.362. The non-risk arrangements listed in Attachment 11: Non-Risk Arrangements are required of the CONTRACTOR. Provider Services Provider Handbook The CONTRACTOR shall issue a provider handbook to all Contract Providers. The CONTRACTOR may distribute the Provider handbook electronically (e.g., via its website) as long as Providers are notified about how to obtain the electronic copy and how to request a hard copy at no charge to the Provider. At a minimum, the Provider handbook shall include the following information: A table of contents; Description of Turquoise Care, including eligibility, enrollment, and Member assessment information; Information about CISC Members and the CISC CONTRACTOR; Covered Services; Description of the role of care coordinators; Cultural competency and cultural humility; How the Provider can access language interpretation and specialized communication services; Description of the SDCB and the Agency-Based Community Benefit; Emergency Services responsibilities; Information on Member Grievance and Appeal rights and processes, including Fair Hearings; Policies and procedures of the provider complaint system; Medically Necessary Service standards and clinical practice guidelines; PCP responsibilities; Member lock in standards and requirements; The CONTRACTOR’s Fraud and Abuse policies and procedures, including how to report suspected Fraud and/or Abuse; Coordination with other Providers, Major Subcontractors, or HCA HSD contractors; Requirements regarding background checks; Information on identifying and reporting suspected Abuse, neglect, and exploitation of Members; Prior authorization, referral, and other Utilization Management requirements and procedures; Protocol for Encounter Data reporting and records; Claims submission protocols and standards, including instructions and all information necessary for Clean Claims; Payment policies; Credentialing and recredentialing requirements; Confidentiality and HIPAA requirements with which the Provider must comply; Member rights and responsibilities; The telephone number for the Provider services line; and A separate section and/or addendum that specifically address the ABP services and ABP Exempt Members. The CONTRACTOR shall disseminate bulletins as needed to incorporate any necessary changes to the provider handbook.