{"component": "clause", "props": {"groups": [{"snippet_links": [{"key": "provider-agrees", "type": "clause", "offset": [0, 15]}, {"key": "new-enrollees", "type": "clause", "offset": [36, 49]}, {"key": "new-patients", "type": "clause", "offset": [81, 93]}, {"key": "government-sponsored-programs", "type": "definition", "offset": [106, 135]}, {"key": "scope-of", "type": "clause", "offset": [151, 159]}, {"key": "regulatory-requirements", "type": "definition", "offset": [230, 253]}, {"key": "not-limited", "type": "clause", "offset": [268, 279]}, {"key": "to-provider", "type": "definition", "offset": [280, 291]}, {"key": "provider-shall", "type": "clause", "offset": [311, 325]}, {"key": "notice-to", "type": "definition", "offset": [373, 382]}, {"key": "available-to", "type": "definition", "offset": [449, 461]}, {"key": "prospective-enrollees", "type": "clause", "offset": [462, 483]}], "size": 8, "snippet": "Provider agrees that it will accept new Enrollees for as long as it is accepting new patients enrolled in government sponsored programs subject to the scope of Provider's licensure or certification and any applicable Mandates and regulatory requirements including but not limited to provider-to-patient ratios. Provider shall provide at least sixty (60) days prior written notice to ILS Community Network if it or any of its locations are no longer available to prospective Enrollees.", "samples": [{"hash": "fxHD7IjPAms", "uri": "/contracts/fxHD7IjPAms#provider-availability", "label": "Standard Provider Agreement", "score": 20.5441474915, "published": true}, {"hash": "ifXmpROHTJx", "uri": "/contracts/ifXmpROHTJx#provider-availability", "label": "Standard Provider Agreement", "score": 20.5414104462, "published": true}, {"hash": "gRzCtw1GKaE", "uri": "/contracts/gRzCtw1GKaE#provider-availability", "label": "Provider Agreement", "score": 20.5414104462, "published": true}], "hash": "1aa18d9a2c3baaf54227e553981c96c9", "id": 1}, {"snippet_links": [{"key": "provider-shall", "type": "clause", "offset": [0, 14]}, {"key": "covered-services", "type": "definition", "offset": [27, 43]}, {"key": "a-day", "type": "definition", "offset": [145, 150]}, {"key": "a-week", "type": "definition", "offset": [167, 173]}], "size": 3, "snippet": "Provider shall ensure that Covered Services, when necessary, or when Practice Provider is otherwise absent, are available twenty-four (24) hours a day, seven (7) days a week.", "samples": [{"hash": "8g6Eklbjywn", "uri": "/contracts/8g6Eklbjywn#provider-availability", "label": "Direct Contracting Entity Participant Provider Agreement", "score": 32.4175605774, "published": true}, {"hash": "5SxRm14JFhV", "uri": "/contracts/5SxRm14JFhV#provider-availability", "label": "Direct Contracting Entity Participant Provider Agreement", "score": 26.7015743256, "published": true}, {"hash": "bTyL5GHYFDQ", "uri": "/contracts/bTyL5GHYFDQ#provider-availability", "label": "Direct Contracting Entity Participant Provider Agreement", "score": 26.6249141693, "published": true}], "hash": "4a143344cc34420c1664ab10a12149d7", "id": 2}, {"snippet_links": [{"key": "all-providers", "type": "definition", "offset": [0, 13]}, {"key": "by-the-contractor", "type": "clause", "offset": [56, 73]}, {"key": "of-the-contractor", "type": "clause", "offset": [82, 99]}, {"key": "affiliated-entities", "type": "clause", "offset": [113, 132]}, {"key": "network-provider", "type": "definition", "offset": [247, 263]}, {"key": "managed-care-organization", "type": "definition", "offset": [272, 297]}, {"key": "contracts-with", "type": "clause", "offset": [303, 317]}, {"key": "managed-care-services", "type": "clause", "offset": [335, 356]}, {"key": "reimbursement-rate", "type": "definition", "offset": [431, 449]}, {"key": "provider-type", "type": "clause", "offset": [459, 472]}, {"key": "the-applicable", "type": "clause", "offset": [474, 488]}, {"key": "disproportionate-share", "type": "clause", "offset": [539, 561]}, {"key": "education-payments", "type": "clause", "offset": [574, 592]}], "size": 2, "snippet": "All providers owned (wholly or partially) or controlled by the CONTRACTOR, or any of the CONTRACTOR\u2019S related or affiliated entities, and any and all providers that own (wholly or partially) or control the CONTRACTOR, shall be willing to become a network provider for any managed care organization that contracts with HSD for Medicaid managed care services, to be reimbursed by such MCO at the then-current and applicable Medicaid reimbursement rate for that provider type. The Applicable Medicaid reimbursement rate is defined to exclude disproportionate share and medical education payments.", "samples": [{"hash": "bEY8ianIVfR", "uri": "/contracts/bEY8ianIVfR#provider-availability", "label": "Medicaid Managed Care Services Agreement (Molina Healthcare Inc)", "score": 21.0, "published": true}], "hash": "5861f9460eeafe2977cb25e380113292", "id": 3}, {"snippet_links": [{"key": "the-contractor-must-provide", "type": "clause", "offset": [3, 30]}, {"key": "a-registered-nurse", "type": "clause", "offset": [100, 118]}, {"key": "access-to-the", "type": "clause", "offset": [141, 154]}, {"key": "centralized-enrollee-record", "type": "clause", "offset": [155, 182]}, {"key": "respond-to", "type": "clause", "offset": [218, 228]}, {"key": "medical-concerns", "type": "definition", "offset": [264, 280]}, {"key": "experience-and-knowledge", "type": "clause", "offset": [293, 317]}, {"key": "to-provide", "type": "clause", "offset": [318, 328]}, {"key": "business-hours", 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"living-facility", "type": "definition", "offset": [5395, 5410]}, {"key": "day-care-programs", "type": "definition", "offset": [5416, 5433]}, {"key": "the-contractor-shall", "type": "clause", "offset": [5438, 5458]}, {"key": "network-providers", "type": "definition", "offset": [5471, 5488]}, {"key": "hours-of-operation", "type": "definition", "offset": [5495, 5513]}, {"key": "persons-eligible", "type": "clause", "offset": [5668, 5684]}, {"key": "an-exception", "type": "clause", "offset": [5731, 5743]}, {"key": "access-standards", "type": "clause", "offset": [5751, 5767]}, {"key": "written-request", "type": "definition", "offset": [5814, 5829]}, {"key": "equal-to", "type": "definition", "offset": [5898, 5906]}, {"key": "usual-and-customary", "type": "definition", "offset": [5937, 5956]}, {"key": "community-standards", "type": "definition", "offset": [5957, 5976]}, {"key": "accessing-care", "type": "clause", "offset": [5981, 5995]}, {"key": "approval-by", "type": "clause", "offset": [6002, 6013]}, {"key": "in-consultation-with", "type": "definition", "offset": [6021, 6041]}, {"key": "in-writing", "type": "definition", "offset": [6085, 6095]}, {"key": "system-in-place", "type": "definition", "offset": [6166, 6181]}, {"key": "document-access", "type": "clause", "offset": [6197, 6212]}, {"key": "appointment-scheduling", "type": "clause", "offset": [6217, 6239]}, {"key": "sampling-methods", "type": "clause", "offset": [6296, 6312]}, {"key": "the-appointment", "type": "clause", "offset": [6344, 6359]}, {"key": "appendix-n", "type": "clause", "offset": [6489, 6499]}, {"key": "report-to", "type": "clause", "offset": [6535, 6544]}], "size": 1, "snippet": "1. The Contractor must provide a 24-hours-per-day, 7-days-per-week toll- free system with access to a registered nurse who:\na. Has immediate access to the Centralized Enrollee Record (see Section 2.6.F);\nb. Is able to respond to Enrollee questions about health or medical concerns;\nc. Has the experience and knowledge to provide clinical triage;\nd. Is able to provide options other than waiting until business hours or going to the emergency room; and\ne. Is able to provide access to oral interpretation services available as needed, free-of-charge.\n2. The Contractor must follow Federal and State regulations about 24-hour service availability (for example, hospital, home health, and hospice require 24-hour availability; adult day health, homemaker, and chore services do not).\n3. The Contractor\u2019s provider network must ensure access to 24-hour Emergency Services for all Enrollees, whether they reside in institutions or in the community. The Contractor must:\na. Have a process established to notify the PCP or ICT (or the designated covering physician) of an Emergency Condition within one business day after the Contractor is notified by the provider. If the Contractor is not notified by the provider within 10 calendar days of the Enrollee\u2019s presentation for Emergency Services, the Contractor may not refuse to cover Emergency Services.\nb. Have a process to notify the PCP or ICT of required Urgent Care within 24 hours of the Contractor being notified.\nc. Record summary information about Emergency Conditions and Urgent Care services in the Centralized Enrollee Record no more than 18 hours after the PCP or ICT is notified, and a full report of the services provided within two business days.\nd. Pay the provider or reimburse the Enrollee, in the fee-for-service amount that would have been paid by Medicare or MassHealth, if services are obtained out of network for Emergency Conditions. This must be done within 60 calendar days after the claim has been submitted. The Contractor must ensure that cost to the Enrollee is no greater than it would be if the services were furnished within the network.\ne. Cover and pay for any services obtained for Emergency Conditions in accordance with 42 C.F.R. 438.114(c). The Contractor may not deny payment for treatment obtained when an enrollee had an Emergency Condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in 42 C.F.R 438.114(a) of the definition of emergency medical condition.\nf. Ensure that an Enrollee who has an Emergency Condition may not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the patient.\n4. The Contractor\u2019s provider network must comply with the Emergency Medical Treatment and Labor Act (EMTALA), which requires;\na. Qualified hospital medical personnel provide appropriate medical screening examinations to any individual who \u201ccomes to the emergency department,\u201d as defined in 42 C.F.R. 489.24(b).\nb. As applicable, provide individuals stabilizing treatment or, if the hospital lacks the capability or capacity to provide stabilizing treatment, conduct appropriate transfers.\nc. The Contractor\u2019s contracts with its providers must clearly state the provider\u2019s EMTALA obligations and must not create any conflicts with hospital actions required to comply with EMTALA.\n5. The Contractor Provider Network must ensure availability of office visits as follows;\na. All Urgent Care and symptomatic office visits must be available to Enrollees within 48 hours. A symptomatic office visit is an encounter associated with the presentation of medical symptoms or signs, but not requiring immediate attention. Examples include recurrent headaches or fatigue.\nb. Except as described in Section 2.9.B.5.c below, all nonsymptomatic office visits must be available to Enrollees within 30 calendar days. Examples of nonsymptomatic office visits include, but are not limited to well and preventive-care visits for Covered Services, such as annual physical examinations or immunizations. (See Appendix A and B for a list of Covered Services.)\nc. Office visits must be available within the following timeframes to Enrollees for Behavioral Health Services Other Than Emergency Services, ESP, or Urgent Care\n(1) All Other Behavioral Health Services: within 14 calendar days.\n(2) For services described in the Inpatient or 24-Hour Diversionary Services Discharge Plan:\n(A) Non-24-Hour Diversionary Services \u2013 within two calendar days of discharge;\n(B) An appointment to review and refill medications \u2013 within 14 calendar days of discharge; and\n(C) Other outpatient services \u2013 within seven calendar days of discharge;\n6. The Contractor\u2019s provider network must ensure availability of Long Term Services and Supports as follows;\na. Provider Network must offer a selection of nursing facility and community long term services and supports providers that meets Enrollee needs and preferences and satisfies the proximity requirements of this Contract.\n7. The Contractor must demonstrate the capacity to deliver or arrange for the delivery of scheduled and unscheduled services in the Enrollee's place of residence when office visits are unsafe or inappropriate for the Enrollee's clinical status. Service sites must include, but not be limited to the Enrollee's private residence, a nursing or assisted-living facility, and day care programs.\n8. The Contractor shall ensure that Network Providers offer hours of operation that are no less than the hours of operation offered to commercial enrollees or MassHealth Fee-For-Service if the Provider serves only Enrollees or other persons eligible for MassHealth.\n9. The Contractor may request an exception to the access standards set forth in this Section 2.9 by submitting a written request to EOHHS. Such request shall include alternative standards that are equal to, or more permissive than, the usual and customary community standards for accessing care. Upon approval by EOHHS, in consultation with CMS, the Contractor shall notify Enrollees in writing of such alternative access standards.\n10. The Contractor shall have a system in place to monitor and document access and appointment scheduling standards. The Contractor shall use statistically valid sampling methods for monitoring compliance with the appointment/access standards specified above in Section 2.9 and shall promptly address any access deficiencies. Annually, in accordance with Appendix N, the Contractor shall evaluate and report to EOHHS Network-wide compliance with the access standards specified in Section 2.9.", "samples": [{"hash": "39DeWueCPt9", "uri": "/contracts/39DeWueCPt9#provider-availability", "label": "Three Way Contract for Capitated Model", "score": 20.5394153595, "published": true}], "hash": "fd28e5eea5f53ecb80a418b4adf661fc", "id": 4}, {"snippet_links": [{"key": "all-providers", "type": "definition", "offset": [9, 22]}, {"key": "by-the-contractor", "type": "clause", "offset": [65, 82]}, {"key": "of-the-contractor", "type": "clause", "offset": [91, 108]}, {"key": "affiliated-entities", "type": "clause", "offset": [122, 141]}, {"key": "to-the-extent", "type": "clause", "offset": [227, 240]}, {"key": "legal-authority", "type": "definition", "offset": [248, 263]}, {"key": "network-provider", "type": "definition", "offset": [294, 310]}, {"key": "contracts-with", "type": "clause", "offset": [335, 349]}, {"key": "the-state", "type": "clause", "offset": [350, 359]}, {"key": "covered-services", "type": "definition", "offset": [364, 380]}, {"key": "reimbursement-rate", "type": "definition", "offset": [462, 480]}, {"key": "provider-type", "type": "clause", "offset": [490, 503]}, {"key": "the-applicable", "type": "clause", "offset": [505, 519]}, {"key": "disproportionate-share", "type": "clause", "offset": [570, 592]}, {"key": "education-payments", "type": "clause", "offset": [605, 623]}], "size": 1, "snippet": "126\n35.1 All providers owned (wholly or partially) or controlled by the CONTRACTOR, or any of the CONTRACTOR\u2019S related or affiliated entities, and any and all providers that own (wholly or partially) or control the CONTRACTOR, to the extent of its legal authority, shall be willing to become a network provider for any Contractor that contracts with the State for Covered Services, to be reimbursed by such Contractor at the then-current and applicable Medicaid reimbursement rate for that provider type. The applicable Medicaid reimbursement rate is defined to exclude disproportionate share and medical education payments.", "samples": [{"hash": "foCHdnqeP9Q", "uri": "/contracts/foCHdnqeP9Q#provider-availability", "label": "Medicaid Long Term Services Agreement (Amerigroup Corp)", "score": 21.0, "published": true}], "hash": "5e32e9e9439642f33b8949ab4c71a8d7", "id": 5}, {"snippet_links": [{"key": "not-available", "type": "definition", "offset": [47, 60]}, {"key": "the-hospital", "type": "definition", "offset": [66, 78]}], "size": 1, "snippet": "Definition: OB Providers that are available or not available from the hospital; For no OB hospitals, a directory list will be coded under this.", "samples": [{"hash": "f5HWff8KpZ2", "uri": "/contracts/f5HWff8KpZ2#provider-availability", "label": "Distribution Agreement", "score": 29.0120868683, "published": true}], "hash": "8a225558f1901b3419ac1f93415a183a", "id": 6}, {"snippet_links": [{"key": "provider-shall", "type": "clause", "offset": [0, 14]}, {"key": "the-services", "type": "definition", "offset": [23, 35]}, {"key": "during-the-term-of-this-agreement", "type": "clause", "offset": [62, 95]}], "size": 1, "snippet": "PROVIDER shall provide the SERVICES on a daily 24- hour basis during the term of this Agreement.", "samples": [{"hash": "4j222bntVip", "uri": "/contracts/4j222bntVip#provider-availability", "label": "Service Level Agreement", "score": 33.4204521179, "published": true}], "hash": "bae5e7ddda9d8bb15fc9cb313e9fd338", "id": 7}, {"snippet_links": [{"key": "day-care-provider", "type": "definition", "offset": [9, 26]}, {"key": "late-hours", "type": "definition", "offset": [99, 109]}, {"key": "work-shifts", "type": "clause", "offset": [145, 156]}, {"key": "be-flexible", "type": "clause", "offset": [177, 188]}, {"key": "extended-hours", "type": "definition", "offset": [190, 204]}, {"key": "the-providers", "type": "definition", "offset": [225, 238]}, {"key": "hours-of-care", "type": "definition", "offset": [248, 261]}], "size": 1, "snippet": "The home day care provider must be available between the hours 7:00 am to 6:00pm Some parents work late hours, overnights, or weekends, and some work shifts. Home day care must be flexible. Extended hours fee will be paid to the providers after 12 hours of care. 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