STANDARD FOR COMPLIANCE. The MCO will establish and maintain a procedure to protect the rights and interests of both enrollees and managed care plans by receiving, processing, and resolving grievances and complaints in an expeditious manner, with the goal of ensuring resolution of complaints and APPENDIX J October 1, 2004 J-8 access to appropriate services as rapidly as possible. All enrollees must be informed about the complaint process within their plan and the procedure for filing complaints. This information will be made available through the member handbook, the SDOH toll-free complaint line [1-(800) 206-8125] and the plan's complaint process annually, as well as when the MCO denies a benefit or referral. The MCO will inform enrollees of: the MCO's complaint procedure; enrollees' right to contact the local district or SDOH with a complaint, and to file an appeal or request a fair hearing; the right to appoint a designee to handle a complaint or appeal; the toll free complaint line. The MCO will maintain designated staff to take and process complaints, and be responsible for assisting enrollees in complaint resolution. The MCO will make all information regarding the complaint process available to and usable by people with disabilities, and will assure that people with disabilities have access to sites where enrollees typically file complaints and requests for appeals. SUGGESTED METHODS FOR COMPLIANCE
STANDARD FOR COMPLIANCE. The Company shall be deemed in compliance with the Handbook’s maximum tolerance standard for claim procedures (presently 7%) unless the collective number of claim files with errors for the Company and its affiliated companies executing substantially similar agreements as of this date (the “Group”) results in an error rate that exceeds such maximum tolerance standard. Such error rate(s) shall be determined by the Lead Regulators’ review of separate statistically credible random samples of the total files for the Group’s long term group and individual disability income insurance claims denied or benefits terminated on or after the Implementation Date, in accordance with paragraph B.3.i above. Separate Group error rates shall be determined for the Group’s long term: (i) group disability income claims; and, (ii) individual disability income claims.
STANDARD FOR COMPLIANCE. The Contractor must have in place satisfactory methods/guidelines for identifying persons at risk of, or having, chronic diseases and disabilities and determining their specific needs in terms of specialist physician referrals, durable medical equipment, medical supplies, home health services etc. The Contractor may not discriminate against a Prospective Enrollee based on his/her current health status or anticipated need for future health care. The Contractor may not discriminate on the basis of disability, or perceived disability of an Enrollee or their family member. Health assessment forms may not be used by the Contractor prior to Enrollment. Once a MCO has been chosen, a health assessment form may be used to assess the person's health care needs. APPENDIX J October 1, 2005 J-6 SUGGESTED METHODS FOR COMPLIANCE
STANDARD FOR COMPLIANCE. I Member Services sites and functions will be made accessible to, and usable by, people with disabilities. SUGGESTED METHODS FOR COMPLIANCE (include, but are not limited to those identified below)
STANDARD FOR COMPLIANCE. MCOs must have in place satisfactory methods/guidelines for identifying persons at risk of, or having, chronic diseases and disabilities and determining their specific needs in terms of specialist physician referrals, durable medical equipment, medical supplies, home health services etc. MCOs may not discriminate against a potential enrollee based on his/her current health status or anticipated need for future health care. MCOs may not discriminate on the basis of disability, or perceived disability of an enrollee or their family member. Health assessment forms may not be used by plans prior to enrollment. ( Once a plan has been chosen, a health assessment form may be used to assess the person's health care needs.) Medicaid Advantage Contract State ,2006
STANDARD FOR COMPLIANCE. Enrollees will be given information sufficient to ensure that they understand how to access medical care through the plan. This information will be made accessible to, and usable by, people with disabilities.
STANDARD FOR COMPLIANCE. MCOs must have m place adequate case management systems to identify the service needs of all enrollees, including enrollees with chronic illness and enrollees with disabilities, and ensure that medically necessary covered benefits are delivered on a timely basis. These systems may include procedures for standing referrals, specialists as PCPs, and referrals to specialty centers for enrollees who require specialized medical care over a prolonged period of time (as determined by a treatment plan approved by the MCO in consultation with the primary care provider, the designated specialist and the enrollee or his/her designee), out of plan referrals and continuation of existing treatment relationships with out-of-plan providers (during transitional period)
STANDARD FOR COMPLIANCE. MCO networks will include all the provider types necessary to finish the-benefit package, to assure appropriate and timely health care to all enrollees, including those with chronic illness and/or disabilities. Physical accessibility is not limited to entry to a provider site, but also includes access to services within the site, e.g. exam tables and medical equipment Suggested Methods for Compliance
STANDARD FOR COMPLIANCE. The Contractor's network will include all the provider types necessary to furnish the Benefit Package, to assure appropriate and timely health care to all Enrollees, including those with chronic illness and/or disabilities. Physical accessibility is not limited to entry to a provider site, but also includes access to services within the site, e.g. exam tables and medical equipment. APPENDIX J October 1, 2005
