Care Management The Contractor’s protocol for referring members to care management shall be reviewed by OMPP and shall be based on identification through the health needs screening or when the claims history suggests need for intervention. In addition to population-based disease management educational materials and reminders, these members should receive more intensive services. Members with newly diagnosed conditions, increasing health services or emergency services utilization, evidence of pharmacy non-compliance for chronic conditions and identification of special health care needs should be strongly considered for case management. Care management services include direct consumer contacts in order to assist members with scheduling, location of specialists and specialty services, transportation needs, 24-Hour Nurse Line, general preventive (e.g. mammography) and disease specific reminders (e.g. ▇▇▇ ▇▇▇), pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency services. The Contractor shall make every effort to contact members in care management telephonically. Materials should also be delivered through postal and electronic direct-to-consumer contacts, as well as web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth grade reading level. All members with the conditions of interest shall receive materials no less than quarterly. The Contractor shall document the number of persons with conditions of interest, outbound telephone calls, telephone contacts, category of intervention, intervention delivered, mailings and website hits. Care management shall be coordinated with the Right Choices Program for members qualifying for the Right Choices Program. However, the Right Choices Program is not a replacement for care management.
SITE MANAGEMENT We reserve the right, but not the obligation, to: (1) monitor the Site for violations of these Terms of Use; (2) take appropriate legal action against anyone who, in our sole discretion, violates the law or these Terms of Use, including without limitation, reporting such user to law enforcement authorities; (3) in our sole discretion and without limitation, refuse, restrict access to, limit the availability of, or disable (to the extent technologically feasible) any of your Contributions or any portion thereof; (4) in our sole discretion and without limitation, notice, or liability, to remove from the Site or otherwise disable all files and content that are excessive in size or are in any way burdensome to our systems; and (5) otherwise manage the Site in a manner designed to protect our rights and property and to facilitate the proper functioning of the Site.
Case Management Prompt resolution of any dispute is important to both parties; and the parties agree that the arbitration of any dispute shall be conducted expeditiously. The arbitrators are instructed and directed to assume case management initiative and control over the arbitration process (including scheduling of events, pre-hearing discovery and activities, and the conduct of the hearing), in order to complete the arbitration as expeditiously as is reasonably practical for obtaining a just resolution of the dispute.
Executive Management The Contractor agrees to have an executive management function with clear authority over all the administrative functions noted herein.
General Management In the discharge of its general duty to manage the successful performance of the Services, Vendor shall:
3.2.1.1. within thirty (30) calendar days of the Effective Date, identify to Citizens the primary and secondary management contacts responsible for the oversight and management of Services for Citizens;
3.2.1.2. ensure Vendor Staff tasked with management and oversight of the Services are available promptly to perform Services during Business Hours;
3.2.1.3. ensure each assigned Adjuster submits a time record directly to Vendor’s manager or point of contact. At any time during this Agreement, Citizens may require copies of time records from Vendor;
3.2.1.4. ensure that no Vendor Staff carries a weapon on their person while performing Services;
3.2.1.5. ensure that no Vendor Staff uses impairing drugs, chemicals, or alcohol while performing Services;
3.2.1.6. ensure that Vendor Staff avoid using their duties and obligations under this Agreement to engage in any conduct that could create either an actual or perceived conflict of interest, such as due to an ongoing business relationship with an entity other than Citizens that would enable Vendor Staff to receive an improper benefit or unfair competitive advantage;
3.2.1.7. ensure that the Services comply with the Best Claims Practices & Estimating Guidelines as applicable to each Service Category and any other policies or processes set forth by Citizens, including but not limited to:
a. monitoring applicable file production on a weekly basis to determine compliance with Citizens’ production requirements; and,
b. providing detailed reports to Citizens related to Vendor performance upon request.
