Operations Reports. ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System OP-01 [RETIRED] POSC OP-02 OP-02 Inbound Managed Care Provider Directory Interface (ACPD) Inbound Managed Care Provider Directory Interface (ACPD) Monthly POSC OP-03 OP-03 Long-term Care Report Log Long-term Care Report Log Weekly OnBase OP-04 OP-04 Member Discrepancy Report Member Discrepancy Report Monthly OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System OP-05 [RETIRED] OP-06 OP-06 Address Change File Address Change File Bi-Weekly OnBase OP-07 OP-07 Multiple ID File Multiple ID File Bi-Weekly OnBase OP-08 OP-08 Date of Death Report Date of Death Report Bi-Weekly OnBase OP-09 OP-09 Cost Sharing Copay Overage Report Cost Sharing Copay Overage Report Monthly OnBase H. Pharmacy Reports ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-01 PH-01 Pharmacy Claims Level Interface Plans use the Pharmacy Claims Level Interface to submit rebate data for Pharmacy claims. The original claims file submission is due within 5 calendar days following the close of the prior month. Monthly POPS Portal PH-02 [RETIRED] PH-03 PH-03 Pharmacy Provider Network Identification Layout Pharmacy Provider Network Identification Layout Ad-Hoc POPS Portal PH-04-A PH-04-A Drug Utilization Review Report Drug Utilization Review Report (Note: Due by May 1st of each year) Annually Secure Email PH-04-B PH-04-B Clinical Information request for the DUR Board meeting Clinical Information request for the DUR board meeting Ad-Hoc Email PH-04-C PH-04-C Clinical Criteria for Prior Authorization and Utilization Management Clinical Criteria for Prior Authorization and Utilization Management Ad-Hoc Email PH-05-A PH-05-A Pharmacy MassHealth Drug Rebate File Submission Report Pharmacy MassHealth Drug Rebate File Submission Report for the plans to self- report monthly on the upload of the report PH-01 to the POPS Portal. The File Submission Report is due within 3 business days following the upload of PH-01. Monthly Email ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-05-B [RETIRED] PH-06 [RETIRED] PH-07 PH-07 Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Ad-Hoc OnBase PH-08 PH-08 Clinical Policy Initiative Report Clinical Policy Initiative Report Ad-Hoc OnBase PH-09 PH-09 MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report Ad-Hoc OnBase PH-10 PH-10 Hepatitis C Utilization Report Hepatitis C Utilization Report Ad-Hoc OnBase PH-11 PH-11 Pediatric BH Medication Initiative Report Pediatric BH Medication Initiative Report Ad-Hoc OnBase PH-12-A PH-12-A PBM Pricing Report - Quarterly PBM Pricing Report- Quarterly Quarterly POPS Portal, or as directed by EOHHS PH-12-B PH-12-B PBM Pricing Report - Ad-Hoc PBM Pricing Report- Ad-Hoc Ad-Hoc POPS Portal, or as directed by EOHHS PH-13 PH-13 Mail Order Pharmacy Program Report Mail Order Pharmacy Program Report- Ad-Hoc Ad-Hoc OnBase PH-14 PH-14 Change in BIN/PCN/Group Number Report Change in BIN/PCN/Group Number Report- Ad-Hoc (Note: Due at least 30-days before new BIN/PCN/Group Number is effective) Ad-Hoc OnBase PH-15 PH-15 Vitrakvi Monitoring Report Vitrakvi Monitoring Report- Quarterly Quarterly OnBase PH-16-A PH-16-A Zolgensma Monitoring Program- Quarterly Zolgensma Monitoring Program- Quarterly Quarterly OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-16-B PH-16-B Zolgensma Monitoring Program- Annual Zolgensma Monitoring Program- Annual Annually OnBase PH-17 PH-17 CAR-T Monitoring Program CAR-T Monitoring Program-Quarterly Quarterly OnBase PH-18 PH-18 Controlled Substance Management Program Enrollees Leaving Health Plan Controlled Substance Management Program Enrollees Leaving Health Plan- Monthly Monthly OnBase PH-19 PH-19 Givlaari Monitoring Program Givlaari Monitoring Program – Annual (Note: Due by the last business day of April each year) Annually OnBase PH-20 [RETIRED] PH-21 PH-21 reSET and reSET-O Utilization reSET and reSET-O Utilization (Note: Due by the last business day of the second month following the end of each quarter) Quarterly OnBase PH-22-A PH-22-A 340B Contract Pharmacies -Annual 340B Contract Pharmacies- Annual Annually OnBase PH-22-B PH-22-B 340B Contract Pharmacies – Ad-Hoc 340B Contract Pharmacies – Ad-Hoc Ad-Hoc OnBase PH-23- A PH-23-A 340B Margin Usage -Annual 340B Margin Usage Annually OnBase PH-23-B PH-23-B 340B Margin Usage- Ad-Hoc 340B Margin Usage- Ad-Hoc Ad-Hoc OnBase PH-24 PH-24 Oxlumo Monitoring Program Oxlumo Monitoring Program Quarterly OnBase PH-25 PH-25 Amyloidosis Therapies Monitoring Program Amyloidosis Therapies Monitoring Program -Quarterly Quarterly OnBase I. Program Integrity ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PI-01 PI-01 Fraud and Abuse Notification (within 10 days) and Activities Fraud and Abuse Notification (within 10 days) and Activities Ad-Hoc OnBase and e- mail PI-02 PI-02 Notification of For-Cause Provider Suspensions and Terminations Notification of Provider Suspensions and Terminations Notification: Within 3 Business Days OnBase PI-03 PI-03 Summary Report of For-Cause Provider Suspensions and Terminations Summary Report of Provider Suspensions and Terminations Annual OnBase PI-04 PI-04 Notification of Provider Overpayments Notification of Provider Overpayments Ad-hoc OnBase PI-05 PI-05 Summary of Provider Overpayments Summary of Provider Overpayments Semi- annually OnBase PI-06 PI-06 Response to Overpayments Identified by EOHHS Report Response to Overpayments Identified by EOHHS Report Ad-hoc OnBase PI-07 PI-07 Agreed Upon Overpayments Collection Report Agreed Upon Overpayments Collection Report Ad-hoc OnBase PI-08 PI-08 - Self-Reported Disclosures Self-Reported Disclosures Ad-Hoc OnBase PI-09 PI-09 Program Integrity Compliance Plan and Anti-Fraud, Waste and Abuse Plan Program Integrity Compliance Plan and Anti-Fraud, Waste and Abuse Plan Annual OnBase PI-10 PI-10 Payment Suspension Quarterly Payment Suspension Report Quarterly OnBase
Appears in 23 contracts
Samples: www.mass.gov, www.mass.gov, www.mass.gov
Operations Reports. ACO MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System OP-01 [RETIRED] POSC OP-02 OP-02 Inbound Managed Care Provider Directory Interface (ACPD) Inbound Managed Care Provider Directory Interface (ACPD) Monthly POSC OP-03 OP-03 Long-term Care Report Log Long-term Care Report Log Weekly OnBase OP-04 OP-04 Member Discrepancy Report Member Discrepancy Report Monthly OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System OP-05 [RETIRED] OP-06 OP-06 Address Change File Address Change File Bi-Weekly OnBase OP-07 OP-07 Multiple ID File Multiple ID File Bi-Weekly OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System Multiple ID File OP-08 OP-08 Date of Death Report Date of Death Report Bi-Weekly OnBase OP-09 OP-09 Cost Sharing Copay Overage Report Cost Sharing Copay Overage Report Monthly OnBase H. Pharmacy Reports ACO MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-01 PH-01 Pharmacy Claims Level Interface Plans use the Pharmacy Claims Level Interface to submit rebate data for Pharmacy claims. The original claims file submission is due within 5 calendar days following the close of the prior month. Monthly POPS Portal PH-02 [RETIRED] PH-03 PH-03 Pharmacy Provider Network Identification Layout Pharmacy Provider Network Identification Layout Ad-Hoc POPS Portal PH-04-A PH-04-A Drug Utilization Review Report Drug Utilization Review Report (Note: Due by May 1st of each year) Annually Secure Email PH-04-B PH-04-B Clinical Information request for the DUR Board meeting Clinical Information request for the DUR board meeting Ad-Hoc Email [RETIRED] PH-04-C PH-04-C Clinical Criteria for Prior Authorization and Utilization Management Clinical Criteria for Prior Authorization and Utilization Management Ad-Hoc Email [RETIRED] PH-05-A PH-05-A Pharmacy MassHealth Drug Rebate File Submission Report Pharmacy MassHealth Drug Rebate File Submission Report for the plans to self- report monthly on the upload of the report PH-01 PH- 01 to the POPS Portal. The File Submission Report is due within 3 business days following the upload of PH-01. Monthly Email ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-05-B [RETIRED] PH-06 [RETIRED] PH-07 PH-07 Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Ad-Hoc OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-08 PH-08 Clinical Policy Initiative Report Clinical Policy Initiative Report Ad-Hoc OnBase PH-09 PH-09 MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report Ad-Hoc OnBase [RETIRED] PH-10 PH-10 Hepatitis C Utilization Report Hepatitis C Utilization Report Ad-Hoc OnBase PH-11 PH-11 Pediatric BH Medication Initiative Report Pediatric BH Medication Initiative Report Ad-Hoc OnBase PH-12-A PH-12-A PBM Pricing Report - Quarterly PBM Pricing Report- Quarterly Quarterly POPS Portal, or as directed by EOHHS PH-12-B PH-12-B PBM Pricing Report - Ad-Hoc PBM Pricing Report- Ad-Hoc Ad-Hoc POPS Portal, or as directed by EOHHS PH-13 PH-13 Mail Order Pharmacy Program Report Mail Order Pharmacy Program Report- Ad-Hoc Ad-Hoc OnBase PH-14 PH-14 Change in BIN/PCN/Group Number Report Change in BIN/PCN/Group Number Report- Ad-Hoc (Note: Due at least 30-days before new BIN/PCN/Group Number is effective) Ad-Hoc OnBase PH-15 PH-15 Vitrakvi Monitoring Report Vitrakvi Monitoring Report- Quarterly Quarterly OnBase PH-16-A PH-16-A Zolgensma Monitoring Program- Quarterly Zolgensma Monitoring Program- Quarterly Quarterly OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-16-B PH-16-B Zolgensma Monitoring Program- Annual Zolgensma Monitoring Program- Annual Annually OnBase PH-17 PH-17 CAR-T Monitoring Program CAR-T Monitoring Program-Quarterly Quarterly OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-18 PH-18 Controlled Substance Management Program Enrollees Leaving Health Plan Controlled Substance Management Program Enrollees Leaving Health Plan- Monthly Monthly OnBase PH-19 PH-19 Givlaari Monitoring Program Givlaari Monitoring Program – Annual (Note: Due by the last business day of April each year) Annually OnBase PH-20 [RETIRED] PH-21 PH-21 reSET and reSET-O Utilization reSET and reSET-O Utilization (Note: Due by the last business day of the second month following the end of each quarter) Quarterly OnBase [RETIRED] PH-22-A PH-22-A 340B Contract Pharmacies -Annual 340B Contract Pharmacies- Annual Annually OnBase PH-22-B PH-22-B 340B Contract Pharmacies – Ad-Hoc 340B Contract Pharmacies – Ad-Hoc Ad-Hoc OnBase PH-23- A PH-23-A 340B Margin Usage -Annual 340B Margin Usage Annually OnBase PH-23-B PH-23-B 340B Margin Usage- Ad-Hoc 340B Margin Usage- Ad-Hoc Ad-Hoc OnBase PH-24 PH-24 Oxlumo Monitoring Program Oxlumo Monitoring Program Quarterly OnBase PH-25 PH-25 Amyloidosis Therapies Monitoring Program Amyloidosis Therapies Monitoring Program -Quarterly Quarterly OnBase I. PH-26 PH-26 Zynteglo Monitoring Program Integrity ACO Contract Exhibit Number Name Zynteglo Monitoring Program – Annual (Note: Due by the last business day of Report Deliverable Frequency Target System PI-01 PI-01 Fraud and Abuse Notification (within 10 daysApril each year) and Activities Fraud and Abuse Notification (within 10 days) and Activities Annually OnBase PH-27 PH-27 Clinical Monitoring Program Clinical Monitoring Program – Ad-Hoc OnBase and e- mail PI-02 PI-02 Notification of For-Cause Provider Suspensions and Terminations Notification of Provider Suspensions and Terminations Notification: Within 3 Business Days OnBase PI-03 PI-03 Summary Report of For-Cause Provider Suspensions and Terminations Summary Report of Provider Suspensions and Terminations Annual OnBase PI-04 PI-04 Notification of Provider Overpayments Notification of Provider Overpayments Ad-hoc OnBase PI-05 PI-05 Summary of Provider Overpayments Summary of Provider Overpayments Semi- annually OnBase PI-06 PI-06 Response to Overpayments Identified by EOHHS Report Response to Overpayments Identified by EOHHS Report Ad-hoc OnBase PI-07 PI-07 Agreed Upon Overpayments Collection Report Agreed Upon Overpayments Collection Report Ad-hoc OnBase PI-08 PI-08 - Self-Reported Disclosures Self-Reported Disclosures Ad-Hoc OnBase PI-09 PI-09 Program Integrity Compliance Plan and Anti-Fraud, Waste and Abuse Plan Program Integrity Compliance Plan and Anti-Fraud, Waste and Abuse Plan Annual OnBase PI-10 PI-10 Payment Suspension Quarterly Payment Suspension Report Quarterly OnBase
Appears in 1 contract
Samples: www.mass.gov
Operations Reports. ACO MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System OP-01 [RETIRED] POSC OP-02 OP-02 Inbound Managed Care Provider Directory Interface (ACPD) Inbound Managed Care Provider Directory Interface (ACPD) Monthly POSC OP-03 OP-03 Long-term Care Report Log Long-term Care Report Log Weekly OnBase OP-04 OP-04 Member Discrepancy Report Member Discrepancy Report Monthly OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System OP-05 [RETIRED] OP-06 OP-06 Address Change File Address Change File Bi-Weekly OnBase OP-07 OP-07 Multiple ID File Multiple ID File Bi-Weekly OnBase OP-08 OP-08 Date of Death Report Date of Death Report Bi-Weekly OnBase OP-09 OP-09 Cost Sharing Copay Overage Report Cost Sharing Copay Overage Report Monthly OnBase H. Pharmacy Reports ACO MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-01 PH-01 Pharmacy Claims Level Interface Plans use the Pharmacy Claims Level Interface to submit rebate data for Pharmacy claims. The original claims file submission is due within 5 calendar days following the close of the prior month. Monthly POPS Portal PH-02 [RETIRED] PH-03 PH-03 Pharmacy Provider Network Identification Layout Pharmacy Provider Network Identification Layout Ad-Hoc POPS Portal MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-04-A PH-04-A Drug Utilization Review Report Drug Utilization Review Report (Note: Due by May 1st of each year) Annually Secure Email PH-04-B PH-04-B Clinical Information request for the DUR Board meeting Clinical Information request for the DUR board meeting Ad-Hoc Email PH-04-C PH-04-C Clinical Criteria for Prior Authorization and Utilization Management Clinical Criteria for Prior Authorization and Utilization Management Ad-Hoc Email PH-05-A PH-05-A Pharmacy MassHealth Drug Rebate File Submission Report Pharmacy MassHealth Drug Rebate File Submission Report for the plans to self- report monthly on the upload of the report PH-01 to the POPS Portal. The File Submission Report is due within 3 business days following the upload of PH-01. Monthly Email ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-05-B [RETIRED] PH-06 [RETIRED] PH-07 PH-07 Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Ad-Hoc OnBase PH-08 PH-08 Clinical Policy Initiative Report Clinical Policy Initiative Report Ad-Hoc OnBase PH-09 PH-09 MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report Ad-Hoc OnBase PH-10 PH-10 Hepatitis C Utilization Report Hepatitis C Utilization Report Ad-Hoc OnBase PH-11 PH-11 Pediatric BH Medication Initiative Report Pediatric BH Medication Initiative Report Ad-Hoc OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-12-A PH-12-A PBM Pricing Report - Quarterly PBM Pricing Report- Quarterly Quarterly POPS Portal, or as directed by EOHHS PH-12-B PH-12-B PBM Pricing Report - Ad-Hoc PBM Pricing Report- Ad-Hoc Ad-Hoc POPS Portal, or as directed by EOHHS PH-13 PH-13 Mail Order Pharmacy Program Report Mail Order Pharmacy Program Report- Ad-Hoc Ad-Hoc OnBase PH-14 PH-14 Change in BIN/PCN/Group Number Report Change in BIN/PCN/Group Number Report- Ad-Hoc (Note: Due at least 30-days before new BIN/PCN/Group Number is effective) Ad-Hoc OnBase PH-15 PH-15 Vitrakvi Monitoring Report Vitrakvi Monitoring Report- Quarterly Quarterly OnBase PH-16-A PH-16-A Zolgensma Monitoring Program- Quarterly Zolgensma Monitoring Program- Quarterly Quarterly OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-16-B PH-16-B Zolgensma Monitoring Program- Annual Zolgensma Monitoring Program- Annual Annually OnBase PH-17 PH-17 CAR-T Monitoring Program CAR-T Monitoring Program-Quarterly Quarterly OnBase PH-18 PH-18 Controlled Substance Management Program Enrollees Leaving Health Plan Controlled Substance Management Program Enrollees Leaving Health Plan- Monthly Monthly OnBase PH-19 PH-19 Givlaari Monitoring Program Givlaari Monitoring Program – Annual (Note: Due by the last business day of April each year) Annually OnBase PH-20 [RETIRED] PH-21 PH-21 reSET and reSET-O Utilization reSET and reSET-O Utilization (Note: Due by the last business day of the second month following the end of each quarter) Quarterly OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-22-A PH-22-A 340B Contract Pharmacies -Annual 340B Contract Pharmacies- Annual Annually OnBase PH-22-B PH-22-B 340B Contract Pharmacies – Ad-Hoc 340B Contract Pharmacies – Ad-Hoc Ad-Hoc Annually OnBase PH-23- A PH-23-A 340B Margin Usage -Annual 340B Margin Usage Annually OnBase PH-23-B PH-23-B 340B Margin Usage- Ad-Hoc 340B Margin Usage- Ad-Hoc Ad-Hoc OnBase PH-24 PH-24 Oxlumo Monitoring Program Oxlumo Monitoring Program Quarterly OnBase PH-25 PH-25 Amyloidosis Therapies Monitoring Program Amyloidosis Therapies Monitoring Program -Quarterly Quarterly OnBase I. Program Integrity ACO MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PI-01 PI-01 Fraud and Abuse Notification (within 10 days) and Activities Fraud and Abuse Notification (within 10 days) and Activities Ad-Hoc OnBase and e- mail PI-02 PI-02 Notification of For-Cause Provider Suspensions and Terminations Notification of Provider Suspensions and Terminations Notification: Within 3 Business Days OnBase PI-03 PI-03 Summary Report of For-Cause Provider Suspensions and Terminations Summary Report of Provider Suspensions and Terminations Annual OnBase PI-04 PI-04 Notification of Provider Overpayments Notification of Provider Overpayments Ad-hoc OnBase PI-05 PI-05 Summary of Provider Overpayments Summary of Provider Overpayments Semi- annually OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PI-06 PI-06 Response to Overpayments Identified by EOHHS Report Response to Overpayments Identified by EOHHS Report Ad-hoc OnBase PI-07 PI-07 Agreed Upon Overpayments Collection Report Agreed Upon Overpayments Collection Report Ad-hoc OnBase PI-08 PI-08 - Self-Reported Disclosures Self-Reported Disclosures Ad-Hoc OnBase PI-09 PI-09 Program Integrity Compliance Plan and Anti-Fraud, Waste and Abuse Plan Program Integrity Compliance Plan and Anti-Fraud, Waste and Abuse Plan Annual OnBase PI-10 PI-10 Payment Suspension Quarterly Payment Suspension Report Quarterly OnBaseOnBase J. Quality Reports MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System QR-01 QR-01 QM/QI Program Description/Workplan Report needs to be submitted as per Appendix B, Quality Improvement Goals. Annually OnBase QR-02 QR-02 CAHPS Reports (Submission of full CAHPS Report) CAHPS Reports (Submission of full CAHPS Report as well Member-level and aggregate data made available via NCQA submission process) Annually OnBase QR-03 QR-03 External Research Project Notification External Research Project Notification Ad-Hoc OnBase QR-04 QR-04 External Audit/Accreditation External Accreditation (Submission of NCQA accreditation report and associated results) Ad-Hoc OnBase QR-05 QR-05 HEDIS IDSS Report HEDIS IDSS Report (Submission in Excel and CSV formats). Annually OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System QR-06 QR-06 HEDIS Member Level Data Annually Email QR-09 QR-09 Validation of Performance Measures Performance Measure Data (Format for submission determined and communicated by External Quality Review Organization). Annually EQRO QR-10 QR-10 Performance Improvement Projects Performance Improvement Project Reports (Format for submission determined by and communicated by External Quality Review Organization). Bi-Annually EQRO QR-11 QR-11 Serious Reportable Events (SREs) and Provider Preventable Conditions (PPCs) Serious Reportable Events (SREs) and Provider Preventable Conditions (PPCs) (including Health care Acquired Conditions (HCACs) and Other Provider Preventable Conditions (OPPCs) Submission using EOHHS developed template). Notification: Within 30 calendar days of occurrence OnBase QR-12 QR-12 Summary of Serious Reportable Events (SREs) and Provider Preventable Conditions (PPCs) Summary of Serious Reportable Events (SREs) and Provider Preventable Conditions (PPCs) (Submission using EOHHS- developed template). Annually OnBase APPENDIX C Exhibit 1: MCO Covered Services ✓ Denotes a covered service The Contractor shall provide to each Enrollee each of the MCO Covered Services listed below in an amount, duration, and scope that is Medically Necessary (as defined in Section 1 of this Contract), provided that the Contractor is not obligated to provide any MCO Covered Service in excess of any service limitation expressly set forth below. Except to the extent that such service limitations are set forth below, the general descriptions below of MCO Covered Services do not limit the Contractor’s obligation to provide all Medically Necessary services. Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Special Kids Special Care Acupuncture Treatment - the insertion of metal needles through the skin at certain points on the body, with or without the use of herbs, an electric current, heat to the needles or skin, or both, for pain relief or anesthesia. ✓ ✓ ✓ ✓ Acute Inpatient Hospital –all inpatient services such as daily physician intervention, surgery, obstetrics, radiology, laboratory, and other diagnostic and treatment procedures. Coverage of acute inpatient hospital services shall include Administratively Necessary Days. Administratively Necessary Day shall be defined as a day of Acute Inpatient Hospitalization on which an Enrollee’s care needs can be provided in a setting other than an Acute Inpatient Hospital and on which an Enrollee is clinically ready for discharge. ✓ ✓ ✓ ✓ Ambulatory Surgery/Outpatient Hospital Care - outpatient surgical, related diagnostic, medical and dental services. ✓ ✓ ✓ ✓ Audiologist – audiologist exams and evaluations. See related hearing aid services. ✓ ✓ ✓ ✓ Behavioral Health Services – see Appendix C, Exhibit 3. ✓ ✓ ✓ ✓ Breast Pumps – to expectant and new birthing parents as specifically prescribed by their attending physician, consistent with the provisions of the Affordable Care Act of 2010 and Section 274 of Chapter 165 of the Acts of 2014, including but not limited to double electric breast pumps one per birth or as medically necessary. ✓ ✓ ✓ ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Special Kids Special Care Certain COVID-19 Specimen Collection and Testing – until May 11, 2023, Specimen collection codes G2023 and G2024 billed with modifier CG, used when provider 1) has a qualified ordering clinician present at the specimen collection site available to order medically necessary COVID-19 diagnostic tests; and 2) ensures the test results are provided to the patient (along with any initial follow-up counseling, as appropriate), either directly or through the patient’s ordering clinician. ✓ ✓ ✓ ✓ Chiropractic Services – The Contractor is responsible for providing chiropractic manipulative treatment, office visits, and radiology services for all Enrollees. The Contractor may establish a per Enrollee per Contract Year service limit of 20 office visits or chiropractic manipulative treatments, or any combination of office visits and chiropractic manipulative treatments. ✓ ✓ ✓ ✓ Chronic, Rehabilitation Hospital or Nursing Facility Services – services, for all levels of care, including for eligible Enrollees under the age of 22 in accordance with applicable state requirements, provided at either a nursing facility, chronic or rehabilitation hospital, or any combination thereof, 100 days per Contract Year per Enrollee The 100- day limitation shall not apply to Enrollees receiving Hospice services and the Contractor may not request disenrollment of Enrollees receiving Hospice services based on the length of time in a nursing facility. The Contractor shall use the following MassHealth admission/coverage criteria for admission into a chronic hospital, rehabilitation hospital and nursing facility, and may not request disenrollment of any Enrollee who meets such coverage criteria until the Enrollee exhausts such 100-day limitation described above. For the applicable criteria, see 130 CMR 456.408, 456.409, 456.410 and 435.408, 435.409 and 435.410 (rehabilitation hospitals). In addition, for Enrollees under the age of 22, the Contractor shall ensure that its contracted nursing facilities comply with the relevant provisions of 105 CMR 150.000, et seq. The Contractor must ensure that its contracted nursing facilities establish and follow a written policy regarding its bed-hold period, consistent with the MassHealth bed-hold policy. For applicable criteria, see 130 CMR 456.425. For clarification purposes, an Enrollee’s stay while recovering from COVID-19 in a nursing facility or chronic or rehabilitation hospital, or any combination ✓ ✓ ✓ ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Special Kids Special Care thereof, shall count towards the 100-day per Contract Year per Enrollee coverage described in this section; provided, however for an Enrollee’s stays in a Commonwealth- designated COVID-19 nursing facility, see non-MCO Covered Services in Exhibit 2 below. Dental - Emergency related dental services as described under Emergency Services in Appendix C, Exhibit 1 and oral surgery which is Medically Necessary to treat a medical condition performed in any place of service, including but not limited to an outpatient setting, as described in Ambulatory Surgery/Outpatient Hospital Care in Appendix C, Exhibit 1 as well as a clinic or office settings. ✓ ✓ ✓ ✓ Diabetes Self-Management Training – diabetes self-management training and education services furnished to an individual with pre-diabetes or diabetes by a physician or certain accredited mid-level providers (e.g., registered nurses, physician assistants, nurse practitioners, and licensed dieticians). ✓ ✓ ✓ ✓ Dialysis – laboratory; prescribed drugs; tubing change; adapter change; and training related to hemodialysis; intermittent peritoneal dialysis; continuous cycling peritoneal dialysis; continuous ambulatory peritoneal dialysis. ✓ ✓ ✓ ✓
Appears in 1 contract
Samples: www.mass.gov
