Common use of Access to Services Clause in Contracts

Access to Services. of transportation ordinarily used by Medi-Cal beneficiaries, and physical access for disabled beneficiaries. 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 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 criteria specified in Title 22, Section 51303 and the coverage provisions of the approved state Medi-Cal Plan. ii. If services are denied, inform the beneficiary in accordance with Article II.G.2 of this Agreement. 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. 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 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. 4. Covered services, whether provided directly by the Contractor or through 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.