Access to Services. 1. Subject to DHCS provider enrollment certification requirements, the Contractor shall maintain continuous availability and accessibility of covered services and facilities, service sites, and personnel to provide the covered services through use of DMC certified providers. Such services shall not be limited due to budgetary constraints. 2. When a beneficiary makes a request for covered services, the Contractor shall require services to be initiated with reasonable promptness. Contractor shall have a documented system for monitoring and evaluating the quality, appropriateness, and accessibility of care, including a system for addressing problems that develop regarding waiting times and appointments. 3. In addition to the coverage and authorization of service requirements set forth in Article II.E.4 of this Agreement, the Contractor shall: i. Authorize DMC-ODS services in accordance with the medical necessity requirements specified in Title 22, Section 51303 and the coverage provisions of the approved State Medi-Cal Plan. ii. Inform the beneficiary in accordance with Article II.G.2 of this Agreement if services are denied. iii. Provide prior authorization for residential services within 24 hours of the prior authorization request being submitted by the provider. a. Prior authorization is prohibited for non-residential DMC-ODS services. b. The Contractor’s prior authorization process shall comply with the parity requirements set forth in 42 CFR §438.910(d). iv. Review the DSM and ASAM Criteria documentation to ensure that the beneficiary meets the requirements for the service. v. Have written policies and procedures for processing requests for initial and continuing authorization of services. vi. Have a mechanism in place to ensure that there is consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate. vii. Track the number, percentage of denied, and timeliness of requests for authorization for all DMC-ODS services that are submitted, processed, approved, and denied. viii. Pursuant to 42 CFR 438.3(l), allow each beneficiary to choose his or her health professional to the extent possible and appropriate. ix. Require that treatment programs are accessible to people with disabilities in accordance with CFR Title 45, Part 84 and the Americans with Disabilities Act. x. Have a 24/7 toll free number for prospective beneficiaries to call to access DMC-ODS services and make oral interpretation services available for beneficiaries, as needed. xi. Must guarantee that it will not avoid costs for services covered in this Agreement by referring enrollees to publicly supported health care resources. 4. Covered services, whether provided directly by the Contractor, through the subcontractor, or network providers , shall be provided to beneficiaries in the following manner: i. DMC-ODS services approved through the Special Terms and Conditions shall be available to all beneficiaries that reside in the ODS County and enrolled in the ODS Plan. ii. Access to State Plan services shall remain at the current, pre-implementation level or expand upon implementation.
Appears in 9 contracts
Samples: Behavioral Health Services Agreement, Behavioral Health Services Agreement, Behavioral Health Services Agreement
Access to Services. 1. A. Subject to DHCS provider enrollment certification requirements, the Contractor shall maintain continuous availability and accessibility of covered services and facilities, service sites, and personnel to provide the covered services through use of DMC certified providers. Such services shall not be limited due to budgetary constraints.
2. 1) When a beneficiary makes a request for covered servicesservices is made by a beneficiary, the Contractor shall require services to be initiated with reasonable promptness. Contractor shall have a documented system for monitoring and evaluating the quality, appropriateness, appropriateness and accessibility of care, including a system for addressing problems that develop regarding waiting times and appointments.
3. In addition to the coverage and authorization of service requirements set forth in Article II.E.4 of this Agreement, the Contractor shall:
i. Authorize 2) The contractor shall authorize DMC-ODS services in accordance with the medical necessity requirements criteria specified in Title 22, Section 51303 and the coverage provisions of the approved State state Medi-Cal Plan.
ii. Inform For residential services, room and board are not reimbursable DMC services. If services are denied, the provider shall inform the beneficiary in accordance with Article II.G.2 of this Agreement if services are deniedTitle 22, Section 51341.1 (p) and 42 CFR 438.404.
iii. Provide a) The Contractor must provide prior authorization for residential services within 24 hours of the prior authorization request being submitted by the provider.,
a. i. Prior authorization is prohibited not required for non-residential DMC-ODS services.
b. b) The Contractor’s prior authorization process Contractor shall comply with the parity requirements set forth in 42 CFR §438.910(d).
iv. Review review the DSM and ASAM Criteria documentation to ensure that the beneficiary meets the requirements for the service.
v. Have c) The Contractor shall have written policies and procedures for processing requests for initial and continuing authorization of services.
vi. Have d) The Contractor shall have a mechanism in place to ensure that there is consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate.
vii. Track e) The Contractor shall meet the number, percentage of denied, and timeliness of requests following timelines for authorization decisions for all DMC-ODS services that are submitted, processed, approved, and deniedservice authorization.
viii. Pursuant i. Contractor must provide for the following decisions and notices:
a. For standard authorization decisions, Contractor shall provide notice as expeditiously as the beneficiary's health condition requires, not to 42 CFR 438.3(l)exceed 14 calendar days following receipt of the request for service, allow each beneficiary with a possible extension of up to choose his 14 additional calendar days, if:
(i) The beneficiary, or her health professional the provider, requests extension; or
(ii) The Contractor justifies (to the extent possible State agency upon request) a need for additional information and appropriate.
ix. Require that treatment programs are accessible to people with disabilities in accordance with CFR Title 45, Part 84 and how the Americans with Disabilities Act.
x. Have a 24/7 toll free number for prospective beneficiaries to call to access DMC-ODS services and make oral interpretation services available for beneficiaries, as needed.
xi. Must guarantee that it will not avoid costs for services covered in this Agreement by referring enrollees to publicly supported health care resources.
4. Covered services, whether provided directly by the Contractor, through the subcontractor, or network providers , shall be provided to beneficiaries extension is in the following manner:
i. DMC-ODS services approved through the Special Terms and Conditions shall be available to all beneficiaries that reside in the ODS County and enrolled in the ODS Planbeneficiary's best interest.
ii. Access to State Plan services shall remain at the current, pre-implementation level or expand upon implementation.
Appears in 8 contracts
Samples: Standard Agreement, Standard Agreement, Intergovernmental Agreement
Access to Services. 1. Subject to DHCS provider enrollment certification requirements, the Contractor shall maintain continuous availability and accessibility of covered services and facilities, service sites, and personnel to provide the covered services through use of DMC certified providers. Such services shall not be limited due to budgetary constraints.
2. When a beneficiary makes a request for covered services, the Contractor shall require services to be initiated with reasonable promptness. Contractor shall have a documented system for monitoring and evaluating the quality, appropriateness, and accessibility of care, including a system for addressing problems that develop regarding waiting times and appointments.for
3. In addition to the coverage and authorization of service requirements set forth in Article II.E.4 of this Agreement, the Contractor shall:
i. Authorize DMC-ODS services in accordance with the medical necessity requirements specified in Title 22, Section 51303 and the coverage provisions of the approved State Medi-Cal Plan.
ii. Inform If services are denied, inform the beneficiary in accordance with Article II.G.2 of this Agreement if services are deniedAgreement.
iii. Provide prior authorization for residential services within 24 hours of the prior authorization request being submitted by the provider.
a. Prior authorization is prohibited for non-residential DMC-ODS services.
b. The Contractor’s prior authorization process shall comply with the parity requirements set forth in 42 CFR §438.910(d).
iv. Review the DSM and ASAM Criteria documentation to ensure that the beneficiary meets the requirements for the service.
v. Have written policies and procedures for processing requests for initial and continuing authorization of services.
vi. Have a mechanism in place to ensure that there is consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate.
vii. Track the number, percentage of denied, and timeliness of requests for authorization for all DMC-ODS services that are submitted, processed, approved, and denied.
viii. Pursuant to 42 CFR 438.3(l), allow each beneficiary to choose his or her health professional to the extent possible and appropriate.
ix. Require that treatment programs are accessible to people with disabilities in accordance with CFR Title 45, Part 84 and the Americans with Disabilities Act.Code of Federal
x. Have a 24/7 toll free number for prospective beneficiaries to call to access DMC-ODS services and make oral interpretation services available for beneficiaries, as needed.
xi. Must guarantee that it will not avoid costs for services covered in this Agreement by referring enrollees to publicly supported health care resources.
4. Covered services, whether provided directly by the Contractor, Contractor or through the subcontractor, or network providers subcontractor with DMC certified and enrolled programs, shall be provided to beneficiaries in the following manner:
i. DMC-ODS services approved through the Special Terms and Conditions shall be available to all beneficiaries that reside in the ODS County and enrolled in the ODS Plan.
ii. Access to State Plan services shall remain at the current, pre-implementation level or expand upon implementation.
Appears in 2 contracts
Samples: Intergovernmental Agreement, Intergovernmental Agreement
Access to Services. 1. Subject to DHCS provider enrollment certification requirements, the Contractor shall maintain continuous availability and accessibility of covered services and facilities, service sites, and personnel to provide the covered services through use of DMC certified providers. Such services shall not be limited due to budgetary constraints.
2. When a beneficiary makes a request for covered services, the Contractor shall require services to be initiated with reasonable promptness. Contractor shall have a documented system for monitoring and evaluating the quality, appropriateness, appropriateness and accessibility of care, including a system for addressing problems that develop regarding waiting times and appointments.
3. In addition to the coverage and authorization of service services requirements set forth in Article II.E.4 of this Agreement, the Contractor shall:
i. Authorize DMC-ODS services in accordance with the medical necessity requirements criteria specified in Title 22, Section 51303 and the coverage provisions of the approved State state Medi-Cal Plan.
ii. Inform If services are denied, inform the beneficiary in accordance with Article II.G.2 of this Agreement if services are deniedAgreement.
iii. Provide prior authorization for residential services within 24 hours of the prior authorization request being submitted by the provider.
a. Prior authorization is prohibited for non-residential DMC-ODS services.
b. The Contractor’s prior authorization process shall comply with the parity requirements set forth in 42 CFR §438.910(d).
iv. Review the DSM and ASAM Criteria documentation to ensure that the beneficiary meets the requirements for the service.
v. Have written policies and procedures for processing requests for initial and continuing authorization of services.
vi. Have a mechanism in place to ensure that there is consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate.
vii. Track the number, percentage of denied, denied and timeliness of requests for authorization for all DMC-ODS services that are submitted, processed, approved, approved and denied.
viii. Pursuant to 42 CFR 438.3(l), allow each beneficiary to choose his or her health professional to the extent possible and appropriate.
ix. Require that treatment programs are accessible to people with disabilities in accordance with CFR Title 45, Code of Federal Regulations (hereinafter referred to as CFR), Part 84 and the Americans with Disabilities Act.
x. Have a 24/7 toll free number for prospective beneficiaries to call to access DMC-ODS services and make oral interpretation services available for beneficiaries, as needed.
xi. Must guarantee that it will not avoid costs for services covered in this Agreement by referring enrollees to publicly supported health care resources.
4. Covered services, whether provided directly by the Contractor, Contractor or through the subcontractor, or network providers subcontractor with DMC certified and enrolled programs, shall be provided to beneficiaries in the following manner:
i. DMC-ODS services approved through the Special Terms and Conditions shall be available to all beneficiaries that reside in the ODS County and enrolled in the ODS Plan.
ii. Access to State Plan services shall remain at the current, pre-implementation level or expand upon implementation.
Appears in 2 contracts
Access to Services. 1. Subject to DHCS provider enrollment certification requirements, the Contractor shall maintain continuous availability and accessibility of covered services and facilities, service sites, and personnel to provide the covered services through use of DMC certified providers. Such services shall not be limited due to budgetary constraints.
2. When a beneficiary makes a request for covered services, the Contractor shall require services to be initiated with reasonable promptness. Contractor shall have a documented system for monitoring and evaluating the quality, appropriateness, and accessibility of care, including a system for addressing problems that develop regarding waiting times and appointments.
3. In addition to the coverage and authorization of service requirements set forth in Article II.E.4 of this Agreement, the Contractor shall:
i. Authorize DMC-ODS services in accordance with the medical necessity requirements specified in Title 22, Section 51303 and the coverage provisions of the approved State Medi-Cal Plan.
ii. Inform the beneficiary in accordance with Article II.G.2 of this Agreement if services are denied.
iii. Provide prior authorization for residential services within 24 hours of the prior authorization request being submitted by the provider.
a. Prior authorization is prohibited for non-residential DMC-ODS services.
b. The Contractor’s prior authorization process shall comply with the parity requirements set forth in 42 CFR §438.910(d).
iv. Review the DSM and ASAM Criteria documentation to ensure that the beneficiary meets the requirements for the service.
v. Have written policies and procedures for processing requests for initial and continuing authorization of services.
vi. Have a mechanism in place to ensure that there is consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate.
vii. Track the number, percentage of denied, and timeliness of requests for authorization for all DMC-ODS services that are submitted, processed, approved, and denied.
viii. Pursuant to 42 CFR 438.3(l), allow each beneficiary to choose his or her health professional to the extent possible and appropriate.
ix. Require that treatment programs are accessible to people with disabilities in accordance with CFR Title 45, Part 84 and the Americans with Disabilities Act.
x. Have a 24/7 toll free number for prospective beneficiaries to call to access DMC-ODS services and make oral interpretation services available for beneficiaries, as needed.
xi. Must guarantee that it will not avoid costs for services covered in this Agreement by referring enrollees to publicly supported health care resources.
4. Covered services, whether provided directly by the Contractor, Contractor or through the subcontractor, or network providers subcontractor with DMC certified and enrolled programs, shall be provided to beneficiaries in the following manner:
i. DMC-ODS services approved through the Special Terms and Conditions shall be available to all beneficiaries that reside in the ODS County and enrolled in the ODS Plan.
ii. Access to State Plan services shall remain at the current, pre-implementation level or expand upon implementation.
1. In addition to meeting the coordination and continuity of care requirements set forth in Article II.E.3, the Contractor shall develop a care coordination plan that provides for seamless transitions of care for beneficiaries with the DMC-ODS system of care. Contractor is responsible for developing a structured approach to care coordination to ensure that beneficiaries successfully transition between levels of SUD care (i.e. withdrawal management, residential, outpatient) without disruptions to services.
2. In addition to specifying how beneficiaries will transition across levels of acute and short-term SUD care without gaps in treatment, the Contractor shall ensure that beneficiaries have access to recovery supports and services immediately after discharge or upon completion of an acute care stay, with the goal of sustained engagement and long-term retention in SUD and behavioral health treatment.
3. Contractor shall enter into a Memorandum Of Understanding (MOU) with any Medi-Cal managed care plan that enrolls beneficiaries served by the DMC-ODS. This requirement may be met through an amendment to the Specialty Mental Health Managed Care Plan MOU.
i. The following elements in the MOU should be implemented at the point of care to ensure clinical integration between DMC-ODS and managed care providers:
a. Comprehensive substance use, physical, and mental health screening.
b. Beneficiary engagement and participation in an integrated care program as needed.
c. Shared development of care plans by the beneficiary, caregivers, and all providers.
d. Collaborative treatment planning with managed care.
e. Delineation of case management responsibilities.
f. A process for resolving disputes between the Contractor and the Medi-Cal managed care plan that includes a means for beneficiaries to receive medically necessary services while the dispute is being resolved.
g. Availability of clinical consultation, including consultation on medications.
h. Care coordination and effective communication among providers including procedures for exchanges of medical information.
i. Navigation support for patients and caregivers.
j. Facilitation and tracking of referrals between systems including bidirectional referral protocol.
Appears in 2 contracts
Samples: Intergovernmental Agreement, Intergovernmental Agreement
Access to Services. 1. Subject to DHCS provider enrollment certification requirements, the Contractor shall maintain continuous availability and accessibility of covered services and facilities, service sites, and personnel to provide the covered services through use of DMC certified providers. Such services shall not be limited due to budgetary constraints.
2. When a beneficiary makes a request for covered services, the Contractor shall require services to be initiated with reasonable promptness. Contractor shall have a documented system for monitoring and evaluating the quality, appropriateness, appropriateness and accessibility of care, including a system for addressing problems that develop regarding waiting times and appointments.
3. In addition to the coverage and authorization of service services requirements set forth in Article II.E.4 of this Agreement, the Contractor shall:
i. Authorize DMC-ODS services in accordance with the medical necessity requirements criteria specified in Title 22, Section 51303 and the coverage provisions of the approved State state Medi-Cal Plan.
ii. Inform If services are denied, inform the beneficiary in accordance with Article II.G.2 of this Agreement if services are deniedAgreement.
iii. Provide prior authorization for residential services within 24 hours of the prior authorization request being submitted by the provider.
a. Prior authorization is prohibited for non-residential DMC-DMC- ODS services.
b. The Contractor’s prior authorization process shall comply with the parity requirements set forth in 42 CFR §438.910(d).
iv. Review the DSM and ASAM Criteria documentation to ensure that the beneficiary meets the requirements for the service.
v. Have written policies and procedures for processing requests for initial and continuing authorization of services.
vi. Have a mechanism in place to ensure that there is consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate.
vii. Track the number, percentage of denied, denied and timeliness of requests for authorization for all DMC-ODS services that are submitted, processed, approved, approved and denied.
viii. Pursuant to 42 CFR 438.3(l), allow each beneficiary to choose his or her health professional to the extent possible and appropriate.
ix. Require that treatment programs are accessible to people with disabilities in accordance with CFR Title 45, Code of Federal Regulations (hereinafter referred to as CFR), Part 84 and the Americans with Disabilities Act.
x. Have a 24/7 toll free number for prospective beneficiaries to call to access DMC-ODS services and make oral interpretation services available for beneficiaries, as needed.
xi. Must guarantee that it will not avoid costs for services covered in this Agreement by referring enrollees to publicly supported health care resources.
4. Covered services, whether provided directly by the Contractor, Contractor or through the subcontractor, or network providers subcontractor with DMC certified and enrolled programs, shall be provided to beneficiaries in the following manner:
i. DMC-ODS services approved through the Special Terms and Conditions shall be available to all beneficiaries that reside in the ODS County and enrolled in the ODS Plan.
ii. Access to State Plan services shall remain at the current, pre-pre- implementation level or expand upon implementation.
Appears in 1 contract
Samples: Intergovernmental Agreement
Access to Services. 1. Subject to DHCS provider enrollment certification requirements, the Contractor shall maintain continuous availability and accessibility of covered services and facilities, service sites, and personnel to provide the covered services through use of DMC certified enrolled providers. Such services shall not be limited due to budgetary constraints.
2. When a beneficiary makes a request for covered services, the Contractor shall require services to be initiated with reasonable promptness. Contractor shall have a documented system for monitoring and evaluating the quality, appropriateness, and accessibility of care, including a system for addressing problems that develop regarding waiting times and appointments.
3. In addition to the coverage and authorization of service requirements set forth in Article II.E.4 of this Agreement, the Contractor shall:
i. Authorize DMC-ODS services in accordance with the medical necessity requirements specified in Title 22, Section 51303 and the coverage provisions of the approved State Medi-Cal Plan.
ii. Inform the beneficiary in accordance with Article II.G.2 of this Agreement if services are denied.
iii. Provide prior authorization for residential services within 24 hours of the prior authorization request being submitted by the provider.
a. Prior authorization is prohibited for non-residential DMC-ODS services.
b. The Contractor’s prior authorization process shall comply with the parity requirements set forth in 42 CFR §438.910(d).
iv. Review the DSM and ASAM Criteria documentation to ensure that the beneficiary meets the requirements for the service.
v. Have written policies and procedures for processing requests for initial and continuing authorization of services.
vi. Have a mechanism in place to ensure that there is consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate.
vii. Track the number, percentage of denied, and timeliness of requests for authorization for all DMC-ODS services that are submitted, processed, approved, and denied.
viii. Pursuant to 42 CFR 438.3(l), allow each beneficiary to choose his or her health professional to the extent possible and appropriate.
ix. Require that treatment programs are accessible to people with disabilities in accordance with CFR Title 45, Part 84 and the Americans with Disabilities Act.
x. Have a 24/7 toll free number for prospective beneficiaries to call to access DMC-ODS services and make oral interpretation services available for beneficiaries, as needed.
xi. Must guarantee that it will not avoid costs for services covered in this Agreement by referring enrollees to publicly supported health care resources.
4. Covered services, whether provided directly by the Contractor, Contractor or through the subcontractor, or network providers subcontractor with DMC certified and enrolled programs, shall be provided to beneficiaries in the following manner:
i. DMC-ODS services approved through the Special Terms and Conditions shall be available to all beneficiaries that reside in the ODS County and enrolled in the ODS Plan.
ii5. Access to State Plan services shall remain at the current, pre-pre- implementation level or expand upon implementation.
6. According to STC 147(c), the Contractor shall ensure that a beneficiary that resides in a county that does not participate in DMC-ODS does not experience a disruption of OTP/NTP services. The Contractor shall require all OTP/NTP subcontractors to provide any medically necessary NTP services covered by the California Medi-Cal State Plan to beneficiaries that reside in a county that does not participate in DMC-ODS. The Contractor shall require all OTP/NTP subcontractors that provide services to an out-of-county beneficiary to submit the claims for those services to the county in which the beneficiary resides (according to MEDS).
Appears in 1 contract
Samples: Intergovernmental Agreement
Access to Services. 1. A. Subject to DHCS provider enrollment certification requirements, the Contractor shall maintain continuous availability and accessibility of covered services and facilities, service sites, and personnel to provide the covered services through use of DMC certified providers. Such services shall not be limited due to budgetary constraints.
2. 1) When a beneficiary makes a request for covered servicesservices is made by a beneficiary, the Contractor shall require services to be initiated with reasonable promptness. Contractor shall have a documented system for monitoring and evaluating the quality, appropriateness, appropriateness and accessibility of care, including a system for addressing problems that develop regarding waiting times and appointments.
3. In addition to the coverage and authorization of service requirements set forth in Article II.E.4 of this Agreement, the Contractor shall:
i. Authorize 2) The contractor shall authorize DMC-ODS services in accordance with the medical necessity requirements criteria specified in Title 22, Section 51303 and the coverage provisions of the approved State state Medi-Cal Plan.
ii. Inform For residential services, room and board are not reimbursable DMC services. If services are denied, the provider shall inform the beneficiary in accordance with Article II.G.2 of this Agreement if services are deniedTitle 22, Section 51341.1 (p) and 42 CFR 438.404.
iii. Provide a) The Contractor must provide prior authorization for residential services within 24 hours of the prior authorization request being submitted by the provider.,
a. i. Prior authorization is prohibited not required for non-residential DMC-ODS services.
b. b) The Contractor’s prior authorization process Contractor shall comply with the parity requirements set forth in 42 CFR §438.910(d).
iv. Review review the DSM and ASAM Criteria documentation to ensure that the beneficiary meets the requirements for the service.
v. Have c) The Contractor shall have written policies and procedures for processing requests for initial and continuing authorization of services.
vi. Have d) The Contractor shall have a mechanism in place to ensure that there is consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate.
vii. Track e) The Contractor shall meet the number, percentage of denied, and timeliness of requests following timelines for authorization decisions for all DMC-ODS services that are submitted, processed, approved, and deniedservice
f) authorization.
viii. Pursuant i. Contractor must provide for the following decisions and notices:
a. For standard authorization decisions, Contractor shall provide notice as expeditiously as the beneficiary's health condition requires, not to 42 CFR 438.3(l)exceed 14 calendar days following receipt of the request for service, allow each beneficiary with a possible extension of up to choose his 14 additional calendar days, if:
(i) The beneficiary, or her health professional the provider, requests extension; or
(ii) The Contractor justifies (to the extent possible State agency upon request) a need for additional information and appropriate.
ix. Require that treatment programs are accessible to people with disabilities in accordance with CFR Title 45, Part 84 and how the Americans with Disabilities Act.
x. Have a 24/7 toll free number for prospective beneficiaries to call to access DMC-ODS services and make oral interpretation services available for beneficiaries, as needed.
xi. Must guarantee that it will not avoid costs for services covered in this Agreement by referring enrollees to publicly supported health care resources.
4. Covered services, whether provided directly by the Contractor, through the subcontractor, or network providers , shall be provided to beneficiaries extension is in the following manner:
i. DMC-ODS services approved through the Special Terms and Conditions shall be available to all beneficiaries that reside in the ODS County and enrolled in the ODS Planbeneficiary's best interest.
ii. Access to State Plan services shall remain at the current, pre-implementation level or expand upon implementation.
Appears in 1 contract
Samples: Standard Agreement
Access to Services. 1. Subject to DHCS provider enrollment certification requirements, the Contractor shall maintain continuous availability and accessibility of covered services and facilities, service sites, and personnel to provide the covered services through use of DMC certified providers. Such services shall not be limited due to budgetary constraints.
2. When a beneficiary makes a request for covered services, the Contractor shall require services to be initiated with reasonable promptness. Contractor shall have a documented system for monitoring and evaluating the quality, appropriateness, and accessibility of care, including a system for addressing problems that develop regarding waiting times and appointments.
3. In addition to the coverage and authorization of service requirements set forth in Article II.E.4 of this Agreement, the Contractor shall:
i. Authorize DMC-ODS services in accordance with the medical necessity requirements specified in Title 22, Section 51303 and the coverage provisions of the approved State Medi-Cal Plan.
ii. Inform If services are denied, informInform the beneficiary in accordance with Article II.G.2 of this Agreement if services are denied.
iii. Provide prior authorization for residential services within 24 hours of the prior authorization request being submitted by the provider.
a. Prior authorization is prohibited for non-residential DMC-ODS services.
b. The Contractor’s prior authorization process shall comply with the parity requirements set forth in 42 CFR §438.910(d).
iv. Review the DSM and ASAM Criteria documentation to ensure that the beneficiary meets the requirements for the service.
v. Have written policies and procedures for processing requests for initial and continuing authorization of services.
vi. Have a mechanism in place to ensure that there is consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate.
vii. Track the number, percentage of denied, and timeliness of requests for authorization for all DMC-ODS services that are submitted, processed, approved, and denied.
viii. Pursuant to 42 CFR 438.3(l), allow each beneficiary to choose his or her health professional to the extent possible and appropriate.
ix. Require that treatment programs are accessible to people with disabilities in accordance with CFR Title 45, Code of Federal Regulations (hereinafter referred to as CFR),CFR Title 45, Part 84 and the Americans with Disabilities Act.
x. Have a 24/7 toll free number for prospective beneficiaries to call to access DMC-ODS services and make oral interpretation services available for beneficiaries, as needed.
xi. Must guarantee that it will not avoid costs for services covered in this Agreement by referring enrollees to publicly supported health care resources.
4. Covered services, whether provided directly by the Contractor, through the subcontractor, or network providers , shall be provided to beneficiaries in the following manner:
i. DMC-ODS services approved through the Special Terms and Conditions shall be available to all beneficiaries that reside in the ODS County and enrolled in the ODS Plan.
ii. Access to State Plan services shall remain at the current, pre-implementation level or expand upon implementation.
Appears in 1 contract
Samples: Standard Agreement Amendment