Nursing Facility. If Provider is a nursing facility, in addition to the other requirements set forth in the Agreement or this Appendix, Provider shall: i) Promptly notify United, and/or the State as directed by the Division of TennCare, of a Covered Person’s admission or request for admission to the nursing facility regardless of payor source for the nursing facility stay, or when there is a change in a Covered Person’s known circumstances. Provider shall also notify United, and/or the State as directed by ▇▇▇▇▇▇▇▇, prior to a Covered Person’s discharge from the nursing facility; ii) Provide written notice to the Division of TennCare and United in accordance with State and federal requirements before voluntarily terminating the Agreement. Provider shall comply with all applicable State and federal requirements regarding voluntary termination; iii) Notify United immediately if Provider is considering discharging a Covered Person. Provider shall consult with the Covered Person’s Care Coordinator to intervene in resolving issues if possible. If Provider is not able to resolve such issues, Provider shall prepare and implement a discharge and/or transition plan as appropriate; iv) Notify a Covered Person and/or a Covered Person’s representative (if applicable) in writing prior to discharge in accordance with State and federal requirements; v) Provider shall accept payment or appropriate denial made by United (or, if applicable, payment by United that is supplementary to the Covered Person’s third party payer) plus the amount of any applicable Patient Liability, as payment in full for services provided and shall not solicit or accept any surety or guarantee of payment from a Covered Person in excess of the amount of applicable Patient Liability. For purposes of this Section 4.7(v), Covered Person shall include the patient, parent(s), guardian, spouse or any other legally responsible person of the Covered Person being served; vi) Provider’s responsibilities regarding a Covered Person’s Patient Liability as specified in sections A.2.6.7 and A.2.21.5 of the CRA, which shall include but not be limited to collecting the applicable Covered Person Patient Liability amounts from CHOICES Group 1 members, notifying the Covered Person’s Care Coordinator if there is an issue with collecting a Covered Person’s Patient Liability, and making good faith efforts to collect payment; vii) Provider shall timely seek certification and recertification (as applicable) of a Covered Person’s level of care eligibility for Level I and/or Level II nursing facility care and shall cooperate fully with United in the completion and submission of the level of care assessment; viii) Provider shall notify United of any change in a Covered Person’s medical or functional condition that could impact the Covered Person’s level of care eligibility for the currently authorized level of nursing facility services; ix) Provider shall submit complete and accurate Pre-Admission Evaluations (PAEs) to United that satisfy all technical requirements specified by TennCare, and accurately reflect the Member’s current medical and functional status, including Safety Determination Requests. The nursing facility shall also submit all supporting documentation required in the PAE and Safety Determination Request Form, as applicable and required pursuant to TennCare Rules. x) Provider shall comply with State and federal laws and regulations applicable to nursing facilities as well as any applicable court orders, including, but not limited to, those that govern admission, transfer, and discharge policies; xi) Provider shall comply with federal Preadmission Screening and Resident Review (PASRR) requirements applicable to all CHOICES nursing facility residents, regardless of payor source, including that a level I screening be completed prior to admission, a level II evaluation be completed prior to admission when indicated by the level I screening, and a review be completed based upon a significant physical or mental change in the resident’s condition that might impact a Covered Person’s need for or benefit from specialized services; xii) Provider shall collaborate with United and other providers as needed to help ensure that current information regarding the Covered Person’s mental health or intellectual disabilities needs (as available) is reflected in the PASRR screening in order to support an appropriate PASRR determination; xiii) Provider shall cooperate with United in developing and implementing protocols as part of United’s CHOICES nursing facility diversion and transition plans, which shall include, at a minimum, Provider’s obligation to promptly notify United upon a admission or request for admission of an eligible Covered Person regardless of payor source for the CHOICES nursing facility stay, how Provider will assist United in identifying residents who may want to transition from CHOICES nursing facility services to CHOICES HCBS; Provider’s obligation to promptly notify United regarding all such identified members, and how Provider will work with United in assessing a Covered Person’s transition potential and needs and in developing and implementing a transition plan (as applicable); xiv) Provider shall coordinate with United in complying with the requirements in 42 C.F.R.
Appears in 2 contracts
Sources: Tenncare Program Regulatory Requirements Appendix, Provider Agreement
Nursing Facility. If Provider is a nursing facility, in addition to the other requirements set forth in the Agreement or this Appendix, Provider shall:
i(a) Promptly notify United, Subcontractor and Health Plan and/or the State as directed by the Division of TennCare, of a Covered Person’s admission or request for admission to the nursing facility regardless of payor source for the nursing facility stay, or when there is a change in a Covered Person’s known circumstances. Provider shall also notify United, Subcontractor and Health Plan and/or the State as directed by ▇▇▇▇▇▇▇▇, prior to a Covered Person’s discharge from the nursing facility;
ii(b) Provide written notice to the Division of TennCare TennCare, Subcontractor and United Health Plan in accordance with State and federal requirements before voluntarily terminating the Agreement. Provider shall comply with all applicable State and federal requirements regarding voluntary termination;
iii(c) Notify United Subcontractor and Health Plan immediately if Provider is considering discharging a Covered Person. Provider shall consult with the Covered Person’s Care Coordinator to intervene in resolving issues if possible. If Provider is not able to resolve such issues, Provider shall prepare and implement a discharge and/or transition plan as appropriate;
iv(d) Notify a Covered Person and/or a Covered Person’s representative (if applicable) in writing prior to discharge in accordance with State and federal requirements;
v(e) Provider shall accept payment or appropriate denial made by United Subcontractor or Health Plan, as applicable, (or, if applicable, payment by United Subcontractor or Health Plan that is supplementary to the Covered Person’s third party payer) plus the amount of any applicable Patient Liability, as payment in full for services provided and shall not solicit or accept any surety or guarantee of payment from a Covered Person in excess of the amount of applicable Patient Liability. For purposes of this Section 4.7(v4.6(e), Covered Person shall include the patient, parent(s), guardian, spouse or any other legally responsible person of the Covered Person being served;
vi(f) Provider’s responsibilities regarding a Covered Person’s Patient Liability as specified in sections A.2.6.7 and A.2.21.5 of the CRA, which shall include but not be limited to collecting the applicable Covered Person Patient Liability amounts from CHOICES Group 1 members, notifying the Covered Person’s Care Coordinator if there is an issue with collecting a Covered Person’s Patient Liability, and making good faith efforts to collect payment;
vii(g) Provider shall timely seek certification and recertification (as applicable) of a Covered Person’s level of care eligibility for Level I and/or Level II nursing facility care and shall cooperate fully with United Subcontractor and Health Plan in the completion and submission of the level of care assessment;
viii(h) Provider shall notify United Subcontractor and Health Plan of any change in a Covered Person’s medical or functional condition that could impact the Covered Person’s level of care eligibility for the currently authorized level of nursing facility services;
ix(i) Provider shall submit to Subcontractor and/or Health Plan complete and accurate Pre-Pre- Admission Evaluations (PAEs) to United that satisfy all technical requirements specified by TennCare, and accurately reflect the Member’s current medical and functional status, including Safety Determination Requests. The nursing facility shall also submit all supporting documentation required in the PAE and Safety Determination Request Form, as applicable and required pursuant to TennCare Rules.
x(j) Provider shall comply with State and federal laws and regulations applicable to nursing facilities as well as any applicable court orders, including, but not limited to, those that govern admission, transfer, and discharge policies;
xi(k) Provider shall comply with federal Preadmission Screening and Resident Review (PASRR) requirements applicable to all CHOICES nursing facility residents, regardless of payor source, including that a level I screening be completed prior to admission, a level II evaluation be completed prior to admission when indicated by the level I screening, and a review be completed based upon a significant physical or mental change in the resident’s condition that might impact a Covered Person’s need for or benefit from specialized services;
xii(l) Provider shall collaborate with United Subcontractor, Health Plan and other providers as needed to help ensure that current information regarding the Covered Person’s mental health or intellectual disabilities needs (as available) is reflected in the PASRR screening in order to support an appropriate PASRR determination;.
xiii(m) Provider shall cooperate with United Subcontractor and Health Plan in developing and implementing protocols as part of UnitedHealth Plan’s CHOICES nursing facility diversion and transition plans, which shall include, at a minimum, Provider’s obligation to promptly notify United Subcontractor and Health Plan upon a admission or request for admission of an eligible Covered Person regardless of payor source for the CHOICES nursing facility stay, how Provider will assist United Subcontractor and Health Plan in identifying residents who may want to transition from CHOICES nursing facility services to CHOICES HCBS; Provider’s obligation to promptly notify United Subcontractor and Health Plan regarding all such identified members, and how Provider will work with United Subcontractor and Health Plan in assessing a Covered Person’s transition potential and needs and in developing and implementing a transition plan (as applicable);
xiv(n) Provider shall coordinate with United Subcontractor and Health Plan in complying with the requirements in 42 C.F.R.
Appears in 2 contracts
Sources: Provider Agreement, Provider Agreement
Nursing Facility. If Provider is a nursing facility, in addition to the other requirements set forth in the Agreement or this Appendix, Provider shall:
i) Promptly notify United, and/or the State as directed by the Division of TennCare, of a Covered Person’s admission or request for admission to the nursing facility regardless of payor source for the nursing facility stay, or when there is a change in a Covered Person’s known circumstances. Provider shall also notify United, and/or the State as directed by ▇▇▇▇▇▇▇▇, prior to a Covered Person’s discharge from the nursing facility;
ii) Provide written notice to the Division of TennCare and United in accordance with State and federal requirements before voluntarily terminating the Agreement. Provider shall comply with all applicable State and federal requirements regarding voluntary termination;
iii) Notify United immediately if Provider is considering discharging a Covered Person. Provider shall consult with the Covered Person’s Care Coordinator to intervene in resolving issues if possible. If Provider is not able to resolve such issues, Provider shall prepare and implement a discharge and/or transition plan as appropriate;
iv) Notify a Covered Person and/or a Covered Person’s representative (if applicable) in writing prior to discharge in accordance with State and federal requirements;
v) Provider shall accept payment or appropriate denial made by United (or, if applicable, payment by United that is supplementary to the Covered Person’s third party payer) plus the amount of any applicable Patient Liability, as payment in full for services provided and shall not solicit or accept any surety or guarantee of payment from a Covered Person in excess of the amount of applicable Patient Liability. For purposes of this Section 4.7(v), Covered Person shall include the patient, parent(s), guardian, spouse or any other legally responsible person of the Covered Person being served;
vi) Provider’s responsibilities regarding a Covered Person’s Patient Liability as specified in sections A.2.6.7 and A.2.21.5 of the CRA, which shall include but not be limited to collecting the applicable Covered Person Patient Liability amounts from CHOICES Group 1 members, notifying the Covered Person’s Care Coordinator if there is an issue with collecting a Covered Person’s Patient Liability, and making good faith efforts to collect payment;
vii) Provider shall timely seek certification and recertification (as applicable) of a Covered Person’s level of care eligibility for Level I and/or Level II nursing facility care and shall cooperate fully with United in the completion and submission of the level of care assessment;
viii) Provider shall notify United of any change in a Covered Person’s medical or functional condition that could impact the Covered Person’s level of care eligibility for the currently authorized level of nursing facility services;
ix) Provider shall submit complete and accurate Pre-Admission Evaluations (PAEs) to United that satisfy all technical requirements specified by TennCare, and accurately reflect the Member’s current medical and functional status, including Safety Determination Requests. The nursing facility shall also submit all supporting documentation required in the PAE and Safety Determination Request Form, as applicable and required pursuant to TennCare Rules.
x) Provider shall comply with State and federal laws and regulations applicable to nursing facilities as well as any applicable court orders, including, but not limited to, those that govern admission, transfer, and discharge policies;
xi) Provider shall comply with federal Preadmission Screening and Resident Review (PASRR) requirements applicable to all CHOICES nursing facility residents, regardless of payor source, including that a level I screening be completed prior to admission, a level II evaluation be completed prior to admission when indicated by the level I screening, and a review be completed based upon a significant physical or mental change in the resident’s condition that might impact a Covered Person’s need for or benefit from specialized services;
xii) Provider shall collaborate with United and other providers as needed to help ensure that current information regarding the Covered Person’s mental health or intellectual disabilities needs (as available) is reflected in the PASRR screening in order to support an appropriate PASRR determination;
xiii) Provider shall cooperate with United in developing and implementing protocols as part of United’s CHOICES nursing facility diversion and transition plans, which shall include, at a minimum, Provider’s obligation to promptly notify United upon a admission or request for admission of an eligible Covered Person regardless of payor source for the CHOICES nursing facility stay, how Provider will assist United in identifying residents who may want to transition from CHOICES nursing facility services to CHOICES HCBS; Provider’s obligation to promptly notify United regarding all such identified members, and how Provider will work with United in assessing a Covered Person’s transition potential and needs and in developing and implementing a transition plan (as applicable);
xiv) Provider shall coordinate with United in complying with the requirements in 42 C.F.R.42
Appears in 1 contract
Sources: Provider Agreement
Nursing Facility. If Provider is a nursing facility, in addition to the other requirements set forth in the Agreement or this Appendix, Provider shall:
i(a) Promptly notify United, Subcontractor and Health Plan and/or the State as directed by the Division of TennCare, of a Covered Person’s admission or request for admission to the nursing facility regardless of payor source for the nursing facility stay, or when there is a change in a Covered Person’s known circumstances. Provider shall also notify United, Subcontractor and Health Plan and/or the State as directed by ▇▇▇▇▇▇▇▇, prior to a Covered Person’s discharge from the nursing facility;
ii(b) Provide written notice to the Division of TennCare TennCare, Subcontractor and United Health Plan in accordance with State and federal requirements before voluntarily terminating the Agreement. Provider shall comply with all applicable State and federal requirements regarding voluntary termination;
iii(c) Notify United Subcontractor and Health Plan immediately if Provider is considering discharging a Covered Person. Provider shall consult with the Covered Person’s Care Coordinator to intervene in resolving issues if possible. If Provider is not able to resolve such issues, Provider shall prepare and implement a discharge and/or transition plan as appropriate;
iv(d) Notify a Covered Person and/or a Covered Person’s representative (if applicable) in writing prior to discharge in accordance with State and federal requirements;
v(e) Provider shall accept payment or appropriate denial made by United Subcontractor or Health Plan, as applicable, (or, if applicable, payment by United Subcontractor or Health Plan that is supplementary to the Covered Person’s third party payer) plus the amount of any applicable Patient Liability, as payment in full for services provided and shall not solicit or accept any surety or guarantee of payment from a Covered Person in excess of the amount of applicable Patient Liability. For purposes of this Section 4.7(v4.7(e), Covered Person shall include the patient, parent(s), guardian, spouse or any other legally responsible person of the Covered Person being served;
vi(f) Provider’s responsibilities regarding a Covered Person’s Patient Liability as specified in sections A.2.6.7 and A.2.21.5 of the CRA, which shall include but not be limited to collecting the applicable Covered Person Patient Liability amounts from CHOICES Group 1 members, notifying the Covered Person’s Care Coordinator if there is an issue with collecting a Covered Person’s Patient Liability, and making good faith efforts to collect payment;
vii(g) Provider shall timely seek certification and recertification (as applicable) of a Covered Person’s level of care eligibility for Level I and/or Level II nursing facility care and shall cooperate fully with United Subcontractor and Health Plan in the completion and submission of the level of care assessment;
viii(h) Provider shall notify United Subcontractor and Health Plan of any change in a Covered Person’s medical or functional condition that could impact the Covered Person’s level of care eligibility for the currently authorized level of nursing facility services;
ix(i) Provider shall submit to Subcontractor and/or Health Plan complete and accurate Pre-Pre- Admission Evaluations (PAEs) to United that satisfy all technical requirements specified by TennCare, and accurately reflect the Member’s current medical and functional status, including Safety Determination Requests. The nursing facility shall also submit all supporting documentation required in the PAE and Safety Determination Request Form, as applicable and required pursuant to TennCare Rules.
x(j) Provider shall comply with State and federal laws and regulations applicable to nursing facilities as well as any applicable court orders, including, but not limited to, those that govern admission, transfer, and discharge policies;
xi(k) Provider shall comply with federal Preadmission Screening and Resident Review (PASRR) requirements applicable to all CHOICES nursing facility residents, regardless of payor source, including that a level I screening be completed prior to admission, a level II evaluation be completed prior to admission when indicated by the level I screening, and a review be completed based upon a significant physical or mental change in the resident’s condition that might impact a Covered Person’s need for or benefit from specialized services;
xii(l) Provider shall collaborate with United Subcontractor, Health Plan and other providers as needed to help ensure that current information regarding the Covered Person’s mental health or intellectual disabilities needs (as available) is reflected in the PASRR screening in order to support an appropriate PASRR determination;.
xiii(m) Provider shall cooperate with United Subcontractor and Health Plan in developing and implementing protocols as part of UnitedHealth Plan’s CHOICES nursing facility diversion and transition plans, which shall include, at a minimum, Provider’s obligation to promptly notify United Subcontractor and Health Plan upon a admission or request for admission of an eligible Covered Person regardless of payor source for the CHOICES nursing facility stay, how Provider will assist United Subcontractor and Health Plan in identifying residents who may want to transition from CHOICES nursing facility services to CHOICES HCBS; Provider’s obligation to promptly notify United Subcontractor and Health Plan regarding all such identified members, and how Provider will work with United Subcontractor and Health Plan in assessing a Covered Person’s transition potential and needs and in developing and implementing a transition plan (as applicable);
xiv(n) Provider shall coordinate with United Subcontractor and Health Plan in complying with the requirements in 42 C.F.R.
Appears in 1 contract
Sources: Provider Agreement
Nursing Facility. If Provider is a nursing facility, in addition to the other requirements set forth in the Agreement or this Appendix, Provider shall:
i) Promptly notify United, and/or the State as directed by the Division of TennCare, of a Covered Person’s admission or request for admission to the nursing facility regardless of payor source for the nursing facility stay, or when there is a change in a Covered Person’s known circumstances. Provider shall also notify United, and/or the State as directed by ▇▇▇▇▇▇▇▇, prior to a Covered Person’s discharge from the nursing facility;
ii) Provide written notice to the Division of TennCare and United in accordance with State and federal requirements before voluntarily terminating the Agreement. Provider shall comply with all applicable State and federal requirements regarding voluntary termination;
iii) Notify United immediately if Provider is considering discharging a Covered Person. Provider shall consult with the Covered Person’s Care Coordinator to intervene in resolving issues if possible. If Provider is not able to resolve such issues, Provider shall prepare and implement a discharge and/or transition plan as appropriate;
iv) Notify a Covered Person and/or a Covered Person’s representative (if applicable) in writing prior to discharge in accordance with State and federal requirements;
v) Provider shall accept payment or appropriate denial made by United (or, if applicable, payment by United that is supplementary to the Covered Person’s third party payer) plus the amount of any applicable Patient Liability, as payment in full for services provided and shall not solicit or accept any surety or guarantee of payment from a Covered Person in excess of the amount of applicable Patient Liability. For purposes of this Section 4.7(v), Covered Person shall include the patient, parent(s), guardian, spouse or any other legally responsible person of the Covered Person being served;
vi) Provider’s responsibilities regarding a Covered Person’s Patient Liability as specified in sections A.2.6.7 and A.2.21.5 of the CRA, which shall include but not be limited to collecting the applicable Covered Person Patient Liability amounts from CHOICES Group 1 members, notifying the Covered Person’s Care Coordinator if there is an issue with collecting a Covered Person’s Patient Liability, and making good faith efforts to collect payment;
vii) Provider shall timely seek certification and recertification (as applicable) of a Covered Person’s level of care eligibility for Level I and/or Level II nursing facility care and shall cooperate fully with United in the completion and submission of the level of care assessment;
viii) Provider shall notify United of any change in a Covered Person’s medical or functional condition that could impact the Covered Person’s level of care eligibility for the currently authorized level of nursing facility services;
ix) Provider shall submit make available to United complete and accurate documentation related to Pre-Admission Evaluations (PAEs) such that United is able to United submit such PAEs to TennCare that satisfy all technical requirements specified by TennCare, and accurately reflect the Member’s current medical and functional status, including Safety Determination Requests. The nursing facility shall also submit all supporting documentation required in the PAE and Safety Determination Request Form, as applicable and required pursuant to TennCare Rules.
x) Provider shall comply with State and federal laws and regulations applicable to nursing facilities as well as any applicable court orders, including, but not limited to, those that govern admission, transfer, and discharge policies;
xi) Provider shall comply with federal Preadmission Screening and Resident Review (PASRR) requirements applicable to all CHOICES nursing facility residents, regardless of payor source, including that a level I screening be completed prior to admission, a level II evaluation be completed prior to admission when indicated by the level I screening, and a review be completed based upon a significant physical or mental change in the resident’s condition that might impact a Covered Person’s need for or benefit from specialized services;
xii) Provider shall collaborate with United and other providers as needed to help ensure that current information regarding the Covered Person’s mental health or intellectual disabilities needs (as available) is reflected in the PASRR screening in order to support an appropriate PASRR determination;
xiii) Provider shall cooperate with United in developing and implementing protocols as part of United’s CHOICES nursing facility diversion and transition plans, which shall include, at a minimum, Provider’s obligation to promptly notify United upon a admission or request for admission of an eligible Covered Person regardless of payor source for the CHOICES nursing facility stay, how Provider will assist United in identifying residents who may want to transition from CHOICES nursing facility services to CHOICES HCBS; Provider’s obligation to promptly notify United regarding all such identified members, and how Provider will work with United in assessing a Covered Person’s transition potential and needs and in developing and implementing a transition plan (as applicable);
xiv) Provider shall coordinate with United in complying with the requirements in 42 C.F.R.42
Appears in 1 contract
Sources: Provider Agreement
Nursing Facility. If Provider is a nursing facility, in addition to the other requirements set forth in the Agreement or this Appendix, Provider shall:
i(a) Promptly notify United, Subcontractor and Health Plan and/or the State as directed by the Division of TennCare, of a Covered Person’s admission or request for admission to the nursing facility regardless of payor source for the nursing facility stay, or when there is a change in a Covered Person’s known circumstances. Provider shall also notify United, Subcontractor and Health Plan and/or the State as directed by ▇▇▇▇▇▇▇▇, prior to a Covered Person’s discharge from the nursing facility;
ii(b) Provide written notice to the Division of TennCare TennCare, Subcontractor and United Health Plan in accordance with State and federal requirements before voluntarily terminating the Agreement. Provider shall comply with all applicable State and federal requirements regarding voluntary termination;
iii(c) Notify United Subcontractor and Health Plan immediately if Provider is considering discharging a Covered Person. Provider shall consult with the Covered Person’s Care Coordinator to intervene in resolving issues if possible. If Provider is not able to resolve such issues, Provider shall prepare and implement a discharge and/or transition plan as appropriate;
iv(d) Notify a Covered Person and/or a Covered Person’s representative (if applicable) in writing prior to discharge in accordance with State and federal requirements;
v(e) Provider shall accept payment or appropriate denial made by United Subcontractor or Health Plan, as applicable, (or, if applicable, payment by United Subcontractor or Health Plan that is supplementary to the Covered Person’s third party payer) plus the amount of any applicable Patient Liability, as payment in full for services provided and shall not solicit or accept any surety or guarantee of payment from a Covered Person in excess of the amount of applicable Patient Liability. For purposes of this Section 4.7(v4.6(e), Covered Person shall include the patient, parent(s), guardian, spouse or any other legally responsible person of the Covered Person being served;
vi(f) Provider’s responsibilities regarding a Covered Person’s Patient Liability as specified in sections A.2.6.7 and A.2.21.5 of the CRA, which shall include but not be limited to collecting the applicable Covered Person Patient Liability amounts from CHOICES Group 1 members, notifying the Covered Person’s Care Coordinator if there is an issue with collecting a Covered Person’s Patient Liability, and making good faith efforts to collect payment;
vii(g) Provider shall timely seek certification and recertification (as applicable) of a Covered Person’s level of care eligibility for Level I and/or Level II nursing facility care and shall cooperate fully with United Subcontractor and Health Plan in the completion and submission of the level of care assessment;
viii(h) Provider shall notify United Subcontractor and Health Plan of any change in a Covered Person’s medical or functional condition that could impact the Covered Person’s level of care eligibility for the currently authorized level of nursing facility services;
ix(i) Provider shall submit to Subcontractor and/or Health Plan complete and accurate Pre-Pre- Admission Evaluations (PAEs) to United that satisfy all technical requirements specified by TennCare, and accurately reflect the Member’s current medical and functional status, including Safety Determination Requests. The nursing facility shall also submit all supporting documentation required in the PAE and Safety Determination Request Form, as applicable and required pursuant to TennCare Rules.
x(j) Provider shall comply with State and federal laws and regulations applicable to nursing facilities as well as any applicable court orders, including, but not limited to, those that govern admission, transfer, and discharge policies;
xi(k) Provider shall comply with federal Preadmission Screening and Resident Review (PASRR) requirements applicable to all CHOICES nursing facility residents, regardless of payor source, including that a level I screening be completed prior to admission, a level II evaluation be completed prior to admission when indicated by the level I screening, and a review be completed based upon a significant physical or mental change in the resident’s condition that might impact a Covered Person’s need for or benefit from specialized services;
xii(l) Provider shall collaborate with United Subcontractor, Health Plan and other providers as needed to help ensure that current information regarding the Covered Person’s mental health or intellectual disabilities needs (as available) is reflected in the PASRR screening in order to support an appropriate PASRR determination;.
xiii(m) Provider shall cooperate with United Subcontractor and Health Plan in developing and implementing protocols as part of UnitedHealth Plan’s CHOICES nursing facility diversion and transition plans, which shall include, at a minimum, Provider’s obligation to promptly notify United Subcontractor and Health Plan upon a an admission or request for admission of an eligible Covered Person regardless of payor source for the CHOICES nursing facility stay, how Provider will assist United Subcontractor and Health Plan in identifying residents who may want to transition from CHOICES nursing facility services to CHOICES HCBS; Provider’s obligation to promptly notify United Subcontractor and Health Plan regarding all such identified members, and how Provider will work with United Subcontractor and Health Plan in assessing a Covered Person’s transition potential and needs and in developing and implementing a transition plan (as applicable);
xiv(n) Provider shall coordinate with United Subcontractor and Health Plan in complying with the requirements in 42 C.F.R.
Appears in 1 contract
Sources: Provider Agreement
Nursing Facility. If Provider is a nursing facility, in addition to the other requirements set forth in the Agreement or this Appendix, Provider shall:
i(a) Promptly notify United, Subcontractor and Health Plan and/or the State as directed by the Division Bureau of TennCare, of a Covered Person’s admission or request for admission to the nursing facility regardless of payor source for the nursing facility stay, or when there is a change in a Covered Person’s known circumstances. Provider shall also notify United, Subcontractor and Health Plan and/or the State as directed by ▇▇▇▇▇▇▇▇, prior to a Covered Person’s discharge from the nursing facility;
ii(b) Provide written notice to the Division Bureau of TennCare TennCare, Subcontractor and United Health Plan in accordance with State and federal requirements before voluntarily terminating the Agreement. Provider shall comply with all applicable State and federal requirements regarding voluntary termination;
iii(c) Notify United Subcontractor and Health Plan immediately if Provider is considering discharging a Covered Person. Provider shall consult with the Covered Person’s Care Coordinator to intervene in resolving issues if possible. If Provider is not able to resolve such issues, Provider shall prepare and implement a discharge and/or transition plan as appropriate;
iv(d) Notify a Covered Person and/or a Covered Person’s representative (if applicable) in writing prior to discharge in accordance with State and federal requirements;
v(e) Provider shall accept payment or appropriate denial made by United Subcontractor or Health Plan, as applicable, (or, if applicable, payment by United Subcontractor or Health Plan that is supplementary to the Covered Person’s third party payer) plus the amount of any applicable Patient Liability, as payment in full for services provided and shall not solicit or accept any surety or guarantee of payment from a Covered Person in excess of the amount of applicable Patient Liability. For purposes of this Section 4.7(v4.6(e), Covered Person shall include the patient, parent(s), guardian, spouse or any other legally responsible person of the Covered Person being served;
vi(f) Provider’s responsibilities regarding a Covered Person’s Patient Liability as specified in sections A.2.6.7 and A.2.21.5 of the CRA, which shall include but not be limited to collecting the applicable Covered Person Patient Liability amounts from CHOICES Group 1 members, notifying the Covered Person’s Care Coordinator if there is an issue with collecting a Covered Person’s Patient Liability, and making good faith efforts to collect payment;
vii(g) Provider shall timely seek certification and recertification (as applicable) of a Covered Person’s level of care eligibility for Level I and/or Level II nursing facility care and shall cooperate fully with United Subcontractor and Health Plan in the completion and submission of the level of care assessment;
viii(h) Provider shall notify United Subcontractor and Health Plan of any change in a Covered Person’s medical or functional condition that could impact the Covered Person’s level of care eligibility for the currently authorized level of nursing facility services;
ix(i) Provider shall submit to Subcontractor and/or Health Plan complete and accurate Pre-Pre- Admission Evaluations (PAEs) to United that satisfy all technical requirements specified by TennCare, and accurately reflect the Member’s current medical and functional status, including Safety Determination Requests. The nursing facility shall also submit all supporting documentation required in the PAE and Safety Determination Request Form, as applicable and required pursuant to TennCare Rules.
x(j) Provider shall comply with State and federal laws and regulations applicable to nursing facilities as well as any applicable court orders, including, but not limited to, those that govern admission, transfer, and discharge policies;
xi(k) Provider shall comply with federal Preadmission Screening and Resident Review (PASRR) requirements applicable to all CHOICES nursing facility residents, regardless of payor source, including that a level I screening be completed prior to admission, a level II evaluation be completed prior to admission when indicated by the level I screening, and a review be completed based upon a significant physical or mental change in the resident’s condition that might impact a Covered Person’s need for or benefit from specialized services;
xii(l) Provider shall collaborate with United Subcontractor, Health Plan and other providers as needed to help ensure that current information regarding the Covered Person’s mental health or intellectual disabilities needs (as available) is reflected in the PASRR screening in order to support an appropriate PASRR determination;.
xiii(m) Provider shall cooperate with United Subcontractor and Health Plan in developing and implementing protocols as part of UnitedHealth Plan’s CHOICES nursing facility diversion and transition plans, which shall include, at a minimum, Provider’s obligation to promptly notify United Subcontractor and Health Plan upon a admission or request for admission of an eligible Covered Person regardless of payor source for the CHOICES nursing facility stay, how Provider will assist United Subcontractor and Health Plan in identifying residents who may want to transition from CHOICES nursing facility services to CHOICES HCBS; Provider’s obligation to promptly notify United Subcontractor and Health Plan regarding all such identified members, and how Provider will work with United Subcontractor and Health Plan in assessing a Covered Person’s transition potential and needs and in developing and implementing a transition plan (as applicable);
xiv(n) Provider shall coordinate with United Subcontractor and Health Plan in complying with the requirements in 42 C.F.R.
Appears in 1 contract
Sources: Provider Agreement