HOOSIER HEALTHWISE SCOPE OF WORK. Requirements for Reinsurance Companies The Contractor shall submit documentation that the reinsurer follows the National Association of Insurance Commissioners' (NAIC) Reinsurance Accounting Standards. The Contractor shall be required to obtain reinsurance from insurance organizations that have Standard and Poor's claims- paying ability ratings of "AA" or higher and a Xxxxx’x bond rating of “A1” or higher, unless otherwise approved by OMPP. Subcontractors Subcontractors’ reinsurance coverage requirements must be clearly defined in the reinsurance agreement. Subcontractors should be encouraged to obtain their own stop-loss coverage with the above-mentioned terms. If subcontractors do not obtain reinsurance on their own, the Contractor is required to forward appropriate recoveries from stop- loss coverage to applicable subcontractors.
HOOSIER HEALTHWISE SCOPE OF WORK. The MLR calculation shall be performed separately for each program. The MLR for the Hoosier Healthwise program shall be calculated separately from other managed care programs. For each MLR reporting year, a preliminary calculation will be performed with six months of incurred claims run-out, and a final calculation will be performed with 18 months of incurred claims run-out. Incurred claims reported in the MLR should relate only to members who were enrolled with the MCE on the date of service, based on data and information available on the reporting date. (Claims for members who were retroactively disenrolled should be recouped from providers and excluded from MLR reporting). Under Sub-Capitated or Sub-Contracted arrangements, the MCE may only include amounts actually paid to providers for covered services and supplies as incurred claims. The non-benefit portion of sub-capitated and sub-contracted payments should be excluded from incurred claims. The MCE should ensure all subcontracts provide for sufficient transparency to allow for this required reporting. The Contractor shall maintain, at minimum, a MLR of eighty-five percent (85%) for its Hoosier Healthwise line of business. The Contractor is required to submit MLR reporting as described in the MCE Reporting Manual for Hoosier Healthwise. FSSA shall recoup excess capitation paid to the Contractor in the event that the Contractor’s MLR is less than eighty-five percent (85%) for the Hoosier Healthwise line of business.
HOOSIER HEALTHWISE SCOPE OF WORK provide shall monitor the financial stability of subcontractor(s) whose payments are equal to or greater than five percent (5%) of premium/revenue. The Contractor shall obtain the following information from the subcontractor at least quarterly and use it to monitor the subcontractor’s performance: A statement of revenues and expenses A balance sheet Cash flows and changes in equity/fund balance IBNR estimates At least annually, the Contractor must obtain the following additional information from the subcontractor and use this information to monitor the subcontractor’s performance: audited financial statements including statement of revenues and expenses, balance sheet, cash flows and changes in equity/fund balance and an actuarial opinion of the IBNR estimates. The Contractor shall make these documents available to OMPP upon request and OMPP reserves the right to review these documents during Contractor site visits. The Contractor shall comply with 42 CFR 438.230 and the following subcontracting requirements: The Contractor shall obtain the approval of FSSA before subcontracting any portion of the project’s requirements. Subcontractors may include, but are not limited to a transportation broker, behavioral health organizations (BHOs) and Physician Hospital Organizations (PHOs). The Contractor shall give FSSA a written request and submit a draft contract or model provider agreement at least sixty (60) calendar days prior to the use of a subcontractor. If the Contractor makes subsequent changes to the duties included in the subcontractor contract, it shall notify FSSA sixty (60) calendar days prior to the revised contract effective date and submit the amendment for review and approval. FSSA must approve changes in vendors for any previously approved subcontracts. The Contractor shall evaluate prospective subcontractors’ abilities to perform delegated activities prior to contracting with the subcontractor to perform services associated with the Hoosier Healthwise program. The Contractor shall have a written agreement in place that specifies the subcontractor’s responsibilities and provides an option for revoking delegation or imposing other sanctions if performance is inadequate. The written agreement shall be in compliance with all the State of Indiana statutes, and will be subject to the provisions thereof. The subcontract cannot extend beyond the term of the State’s Contract with the Contractor. The Contractor shall collect performance and ...
HOOSIER HEALTHWISE SCOPE OF WORK. Effective April 1, 2020, if the Contractor chooses to use a list of diagnosis codes to initially determine whether a service may be an emergency, the MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. By April 1, 2020 the Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers: Where to submit medical records for prudent layperson review. That the provider has 120 days to submit medical records for prudent layperson review. The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization: A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour. A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services. A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly. A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line and pay claims resulting from such referral as emergent. A mechanism, policies and procedures for conducting prudent layperson reviews within 30 days of receiving medical records. A mechanism and process to accept medical records for a prudent layperson review with an initia...
HOOSIER HEALTHWISE SCOPE OF WORK. Provide a written plan and evidence of ongoing, increased communication between the PMP, the Contractor and the behavioral health care provider; and Coordinate management of utilization of behavioral health care services with MRO and 1915(i) services and services for physical health.
HOOSIER HEALTHWISE SCOPE OF WORK. The toll-free numbers that the member can use to file a grievance or appeal by phone; The fact that, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; Information about the availability of the prior claims payment program for certain members and how to access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information on the structure and operation of the health plan; and In accordance with 42 CFR 438.10(f)(3), that upon request of the member, information on the Contractor’s provider incentive plans will be provided.
HOOSIER HEALTHWISE SCOPE OF WORK. Section 5.11. The Contractor must update the on-line provider network information every two (2) weeks, at a minimum; The Contractor’s contact information for member inquiries, member grievances and appeals; The Contractor’s member services phone number, TDD number, hours of operation and after-hours access numbers, including the 24-hour Nurse Call Line; A member portal with access to electronic Explanation of Benefit (EOB) statements. Preventive care and wellness information. For Hoosier Healthwise, this information shall include information about well child visits and the Contractor’s prenatal services; Information about the cost and quality of health care services, as further described in Section 4.4.5; A description of the Contractor’s disease management programs and care coordination services
HOOSIER HEALTHWISE SCOPE OF WORK. In accordance with the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), OMPP shall make supplemental payments to FQHCs and RHCs that subcontract (directly or indirectly) with the Contractor. These supplemental payments represent the difference, if any, between the payment to which the FQHC or RHC would be entitled for covered services under the Medicaid provisions of BIPA and the payments made by the Contractor. OMPP requires the Contractor to identify any performance incentives it offers to the FQHC or RHC. OMPP shall review and must approve any performance incentives. The Contractor shall report all such FQHC and RHC incentives which accrue during the Contract period related to the cost of providing FQHC-covered or RHC-covered services to its members along with any fee-for-service and/or capitation payments in the determination of the amount of direct reimbursement paid by the Contractor to the FQHC or RHC. If the incentives vary between the Contractor’s Hoosier Healthwise lines of business, the Contractor shall so specify in its reporting to OMPP. The Contractor shall perform quarterly claim reconciliation with each contracted FQHC or RHC to identify and resolve any billing issues that may impact the clinic’s annual reconciliation conducted by OMPP. Annually, OMPP requires the Contractor to provide the Contractor’s utilization and reimbursement data for each FQHC and RHC in each month of the reporting period. The report shall be completed in the form and manner set forth in the Hoosier Healthwise MCE Reporting Manuals, are updated annually. The data shall be submitted on an incurred claims basis, including separate reporting of Package A FFS claims, Package A capitation claims, Package C FFS claims and Package C capitation claims. The data shall be submitted on a paid claims basis. The submitted FQHC and RHC data must be accurate and complete. The Contractor shall pull the data by NPI or LPI, rather than other means, such as a Federal Tax ID number. The Contractor shall establish a process for validating the completeness and accuracy of the data, and a description of this process shall be available to OMPP upon request. The claims files should not omit claims for practitioners rendering services at the clinic nor should the files contain claims for practitioners who did not practice at the clinic. In addition, OMPP requires the FQHC or RHC and the Contractor to maintain and submit records documenting the number and t...
HOOSIER HEALTHWISE SCOPE OF WORK. (i.e., those with a controlling interest) excluded from the Federal Government or by the State's Medicaid program for fraud or abuse. The Contractor, as well as its subcontractors and providers, whether contract or non-contract, shall comply with all federal requirements (42 CFR 1002) on exclusion and debarment screening. All tax- reporting provider entities that xxxx and/or receive Indiana Medicaid funds as the result of this Contract shall screen their owners and employees against the federal exclusion databases (such as LEIE and EPLS). Any services provided by excluded individuals shall be refunded to and/or obtained by the State and/or the Contractor as prescribed in section 7.4
HOOSIER HEALTHWISE SCOPE OF WORK. Include a termination clause stipulating that the Contractor shall terminate its contractual relationship with the provider as soon as the Contractor has knowledge that the provider’s license or IHCP provider agreement has terminated. Terminate the provider’s agreement to serve the Contractor’s Hoosier Healthwise members at the end of the Contract with the State. Monitor providers and apply corrective actions for those who are out of compliance with FSSA’s or the Contractor’s standards. Obligate the terminating provider to submit all encounter claims for services rendered to the Contractor’s members while serving as the Contractor’s network provider and provide or reference the Contractor’s technical specifications for the submission of such encounter data. Not obligate the provider to participate under exclusivity agreements that prohibit the provider from contracting with other state contractors. Provide the PMP with the option to terminate the agreement without cause with advance notice to the Contractor. Said advance notice shall not have to be more that ninety (90) calendar days. Provide a copy of a member’s medical record at no charge upon reasonable request by the member, and facilitate the transfer of the member’s medical record to another provider at the member’s request. Require each provider to agree that it shall not seek payment from the State for any service rendered to a Hoosier Healthwise member under the agreement. For behavioral health providers, require that members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge. This treatment must be provided within seven (7) calendar days from the date of the member’s discharge. Require each provider to agree to use best commercial efforts to collect required copayments for services rendered Package C members. The Contractor shall have written policies and procedures for registering and responding to claims disputes for out-of-network providers, in accordance with the claims dispute resolution process for non-contracted providers outlined in 405 IAC 1-1.6-1.
