Transitions of Care Sample Clauses

Transitions of Care. The CONTRACTOR shall identify and facilitate coordination of care for all Members during various transitions consistent with the requirements in the Managed Care Policy Manual. Examples of Member transitions of care include but are not limited to the following transitions: Justice-Involved Individuals from prisons, jails, and detention facilities into the community, including tribal communities and reservations for Native American Members; Between health care settings and levels of care; Between MCOs; Between FFS and the CONTRACTOR; Between the CONTRACTOR and the Health Insurance Exchange; Child Members transitioning in and out of state custody; Age-related transitions; and Members transitioning to the CONTRACTOR who are pregnant. The CONTRACTOR’s Care Coordination program description shall describe each type of transition and the CONTRACTOR’s protocols that ensure continuity of care and timely access to Covered services for its Members during the transition. The CONTRACTOR’s program description shall include the circumstances and time period in which the CONTRACTOR will allow Members to continue receiving services from Non-Contract Providers and honor existing service authorizations, unless otherwise set forth in this Section 4.4.11. For planned transitions, the CONTRACTOR shall conduct a transition of care assessment using the HCA-approved, standardized transition of care assessment tool and develop a transition plan, facilitated by the care coordinator with the Member and/or Member’s Representative, which shall remain in place until the transition has occurred and a new CCP is in place. For all transitions of care of CYFD-involved children and youth, the CONTRACTOR shall involve the assigned CYFD PPW for CPS involved children and youth in the development of the transition of care plan, and notify the assigned CYFD PPW for CPS within three (3) Business Days prior to transition in care. The CONTRACTOR shall ensure the continuity of care for CISC Members by allowing CISC Members to continue receiving services from Non-Contract Providers, honor existing service authorizations, and reimbursing Non-Contract Providers at the greater of CONTRACTOR’s Contract provider rate or Medicaid FFS rate.
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Transitions of Care. 4.4.15.1 The CONTRACTOR must identify and facilitate coordination of care for all Members during various transition scenarios (outlined in Section 4.4.15.4). The methods for identification of members in need of care coordination during a transit ion of care shall include, at a minimum:
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Transitions of Care. The Process of assisting a Member to transition between PHPs; between payment delivery systems; including transitions that result in the disenrollment from managed care. Transitions of care also includes the process of assisting a Member to transition between providers upon a provider’s termination from the PHP network.
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Transitions of Care. 1. t is essential for patient safety and resident education that effective transitions in care occur. Residents may be allowed to remain on- site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours.
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Transitions of Care. The process of assisting a Member to transition; from PIHP to Standard Plans or PIHP to BH I/DD Tailored Plans; between delivery systems; including transitions that result in the disenrollment from managed care. Transitions of care also includes the process of assisting a Member to transition between Providers upon a Participating Provider’s termination from the PIHP Network. Transferring Entity: The entity (e.g., BH I/DD Tailored Plan, Standard Plan, PIHP) that is disenrolling the transitioning Member and transferring the Member’s information. Unmet Health-Related Resource Needs: Non-medical needs of individuals that foundationally influence health, including but not limited to needs related to housing, food, transportation and addressing interpersonal violence/toxic stress.
Sample 1
Transitions of Care. The MCOP must effectively and comprehensively manage transitions of care between settings in order to prevent unplanned or unnecessary readmissions, emergency department visits, and/or adverse outcomes. The MCOP must at a minimum:
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Transitions of Care i. The BH I/DD Tailored Plan shall handle Pilot-related transitions of care as described in this Section and further detailed in the Healthy Opportunities Pilot Transitions of Care Protocol:
Sample 1
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Related to Transitions of Care

  • Continuity of Care OMPP is committed to providing continuity of care for members as they transition between various IHCP programs and the Contractor’s enrollment. The Contractor shall have mechanisms in place to ensure the continuity of care and coordination of medically necessary health care services for its Hoosier Healthwise members. The State emphasizes several critically important areas where the Contractor shall address continuity of care. Critical continuity of care areas include, but are not limited to:  Transitions for members receiving HIV, Hepatitis C and/or behavioral health services, especially for those members who have received prior authorization from their previous MCE or through fee-for-service;  Transitions for members who are pregnant;  A member’s transition into the Hoosier Healthwise program from traditional fee- for-service or HIP;  A member’s transition between MCEs, particularly during an inpatient stay;  A member’s transition between IHCP programs, Members exiting the Hoosier Healthwise program to receive excluded services;  A member’s exiting the Hoosier Healthwise program to receive excluded services;  A member’s transition to a new PMP;  A member’s transition to private insurance or Marketplace coverage; and  A member’s transition to no coverage. In situations such as a member or PMP disenrollment, the Contractor shall facilitate care coordination with other MCEs or other PMPs. When receiving members from another MCE or fee-for-service, the Contractor shall honor the previous care authorizations for a minimum of thirty (30) calendar days from the member’s date of enrollment with the Contractor. Contractor shall establish policies and procedures for identifying outstanding prior authorization decisions at the time of the member’s enrollment in their plan. For purposes of clarification, the date of member enrollment for purposes of the prior authorization time frames set forth in this section begin on the date the Contractor receives the member’s fully eligible file from the State. Additionally, when a member transitions to another source of coverage, the Contractor shall be responsible for providing the receiving entity with information on any current service authorizations, utilization data and other applicable clinical information such as disease management, case management or care management notes. This process shall be overseen by the Transition Coordination Manager. The Contractor will be responsible for care coordination after the member has disenrolled from the Contractor whenever the member disenrollment occurs during an inpatient stay. In these cases, the Contractor will remain financially responsible for the hospital DRG payment and any outlier payments (without a capitation payment) until the member is discharged from the hospital or the member’s eligibility in Medicaid terminates. The Contractor shall coordinate discharge plans with the member’s new MCE. See Section 3.7.5 for additional requirements regarding continuity of care for behavioral health services. The Hoosier Healthwise MCE Policies and Procedures Manual describes the Contractor’s continuity and coordination of care responsibilities in more detail.

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