Adjustments in Service Area or Enrollment. a. If Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which have significant impact on access in that Service Area and which may result in transferring a substantial number of Members to other Providers employed or subcontracted with Contractor, Contractor shall provide OHA with a (1) If a Provider or group terminates its subcontract or employment with Contractor or if Contractor is affected by circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day notice, less than the required notice to OHA may be provided with the approval of OHA. (2) If Contractor cannot demonstrate sufficient Provider capacity, OHA may seek other avenues to provide services to Members. If OHA determines that some or all of the affected Members must be disenrolled from Contractor, the applicable provisions of this Section shall apply. b. If Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which has significant impact on access in that Service Area and which may result in reducing or terminating Contractor’s Service Area or disenrolling a substantial number of Members from Contractor, Contractor shall provide OHA with a written notice and a plan for implementation (which may include an intent to transfer its Members in the Service Area to a Contractor designated by OHA) at least 90 days prior to the date of such action. Contractor shall remain responsible for providing all Covered Services through the end of the 90 day period, without limitation, for all Members for which the Contractor received a CCO Payment. (1) If Contractor must terminate a Provider or group due to circumstances that could compromise Member care, less than the required notice to OHA may be provided with the approval of OHA. (2) If a Provider or group terminates its Subcontract or employment with Contractor or Contractor is affected by other circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day notice, less than the required notice to OHA may be provided with the approval of OHA. (3) If Contractor provides OHA with the required 90 day notice but provides no Letter of Intent to transfer its Members to a designated Contractor within 30 days of the 90 day notice, Members in the affected Service Area will be disenrolled from Contractor and will be assigned to existing Contractors providing services in the affected Service Area(s) who can demonstrate Provider capacity. (4) If Contractor provides OHA with the required 90 day notice and also provides a Letter of Intent to transfer its Members to a designated Contractor, and OHA determines that the designated Contractor(s) will have sufficient Provider capacity as of the date of the proposed transfer, OHA may approve the Disenrollment and transfer of Members and develop such Contract amendment(s) as may be necessary to effect the transfer. (5) OHA may seek other avenues to provide services to the Members in the affected area(s). c. If Members are required to disenroll from Contractor pursuant to this Section 11, Contractor remains responsible for all Covered Services, without limitation, for each Member until the effective date of Disenrollment. Unless specified otherwise by OHA, Disenrollments shall be effective the end of the month in which the Disenrollment occurs. Contractor shall cooperate in notifying the affected Members and coordinating care and transferring records during the transition to the designated contractor or to the contractor that has been assigned to the Member or to such other PCP as may be designated. If OHA must notify affected Members of the change, Contractor shall provide OHA with the name, prime number, and at least one address label for each of the affected Members not less than 45 days prior to the effective Disenrollment date. d. Contractor shall complete submission and corrections to encounter data for services received by Members; shall assure payment of Valid Claims by employees and Subcontractors, and for Non- Participating Providers providing Covered Services to Members; and shall comply with the other terms of this Contract applicable to the dates of service before Disenrollment of Members pursuant to this section. OHA may, in its discretion, withhold up to 20% of Contractor’s monthly CCO Payment (subject to actuarial considerations) until all contractual obligations have been met to OHA’s satisfaction. Contractor’s failure to complete or ensure completion of said contractual obligations within a reasonable period of time will result in a forfeiture of the amount withheld. e. If Contractor is assigned or transferred Clients pursuant to Subsections b. or c. of this section, Contractor accepts all assigned or transferred Clients without regard to the Enrollment exemptions in OAR 410-141-3060. f. If this Contract is amended to reduce the Service Area or the Enrollment limit, or both, OHA may recalculate the CCO Payment rates using the following methodology, as further described in Exhibit C: g. If this Contract is amended to expand the Service Area or the Enrollment limit, or both, OHA may recalculate the CCO Payment rates using the following methodology, as further described in Exhibit C: (1) If the calculation based on the expanded Service Area or Enrollment limit would result in a rate increase, OHA may provide Contractor with an amendment to this Contract to increase the amount of the CCO Payment rates in Exhibit C, Attachment 1, which (subject to CMS approval) will be effective the date of the expansion of the Service Area or Enrollment limit. (2) If the calculation based on the expanded Service Area or Enrollment limit would result in a rate decrease, OHA will provide Contractor with an amendment to this Contract to adjust Contractor’s rates when the next OHP-wide rate adjustment occurs.
Appears in 1 contract
Samples: Health Plan Services Contract
Adjustments in Service Area or Enrollment. a. If Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which have significant impact on access in that Service Area and which may result in transferring a substantial number of Members to other Providers employed by or subcontracted with Contractor, Contractor shall provide provide, via Administrative Notice, to OHA’s Provider Services Unit a written plan for transferring the Members and an updated DSN Provider Report, as required under Exhibit G of this Contract, at least 90 days prior to the date of the implementation of such plan .
b. If Contractor experiences a change which may result in the reduction or termination of any portion of Contractor’s Service Area or may result in the Disenrollment of a substantial number of Members from Contractor, Contractor shall provide, via Administrative Notice to OHA’s Contract Administrator, written notice of such change and a plan for implementation at least 90 days prior to the date of the implementation of such plan .
c. OHA will not approve a transfer of Members if the Provider’s contract with athe transferring Contractor is terminated for reasons related to quality of care, competency, Fraud or other reasons described in OAR 410-141-3080.
d. OHA reserves the right, in certain circumstances, to waive the required time period in which Administrative Notice is required , including but not limited to:
(1) If Contractor must terminate a Provider or group due to circumstances that could compromise Member care;
(2) If a Provider or group terminates its subcontract Subcontract or employment with Contractor or if Contractor is affected by circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day notice, less than the required notice to OHA may be provided with the approval of ; or,
(3) At OHA’s discretion.
(2) If Contractor cannot demonstrate e. OHA will reassign any transferring Members to another Managed Care Plan in the Service Area with sufficient Provider capacity, OHA capacity or may seek other avenues to provide services to Members. If OHA determines that some or all of the affected Members must be disenrolled from Contractor, the applicable provisions of this Section shall apply.
b. If f. Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which has significant impact on access in that Service Area retains responsibility for ensuring sufficient capacity and which may result in reducing or terminating Contractor’s Service Area or disenrolling a substantial number of Members from Contractor, Contractor shall provide OHA with a written notice solvency and a plan for implementation (which may include an intent to transfer its Members in the Service Area to a Contractor designated by OHA) at least 90 days prior to the date of such action. Contractor shall remain responsible for providing all Covered Services through the end of the 90 day period, period without limitation, for all Members for which the Contractor received a CCO Payment.
(1) If Contractor must terminate a Provider or group due to circumstances that could compromise Member care, less than the required notice to OHA may be provided with the approval of OHA.
(2) If a Provider or group terminates its Subcontract or employment with Contractor or Contractor is affected by other circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day notice, less than the required notice to OHA may be provided with the approval of OHA.
(3) If Contractor provides OHA with the required 90 day notice but provides no Letter of Intent to transfer its Members to a designated Contractor within 30 days of the 90 day notice, Members in the affected Service Area will be disenrolled from Contractor and will be assigned to existing Contractors providing services in the affected Service Area(s) who can demonstrate Provider capacity.
(4) If Contractor provides OHA with the required 90 day notice and also provides a Letter of Intent to transfer its Members to a designated Contractor, and OHA determines that the designated Contractor(s) will have sufficient Provider capacity as of the date of the proposed transfer, OHA may approve the Disenrollment and transfer of Members and develop such Contract amendment(s) as may be necessary to effect the transfer.
(5) OHA may seek other avenues to provide services to the Members in the affected area(s).
c. g. If Members are required to disenroll Disenroll from Contractor pursuant to this Section 11section, Contractor remains responsible retains responsibility for providing access to all Covered Services, without limitation, for each Member until the effective date of Disenrollment. Unless specified otherwise by OHA, Disenrollments shall be effective the end of the month in which the Disenrollment occurs. Contractor shall cooperate in notifying the affected Members and coordinating care and transferring records during the transition to the designated contractor or accepting plan, to the contractor that has been assigned to the Member or to such other PCP as may be designated. If OHA must notify affected Members of the change, Contractor shall provide OHA with the name, prime numberMember’s new Providers, and at least one address label for each of the affected Members not less than 45 days prior to the effective Disenrollment dateany designated PCP.
d. h. Contractor shall complete submission and corrections to encounter data Encounter Data for services received by Members; shall assure payment of Valid Claims by employees and Subcontractors, and for Non- Participating Providers providing Covered Services to Members; and shall comply with the other terms of this Contract applicable to the dates of service before Disenrollment of Members pursuant to this section. OHA mayshall have the right , in its discretion, to withhold up to 20% of Contractor’s monthly CCO Payment (subject to actuarial considerations) until all contractual obligations under this Contract have been met to OHA’s satisfaction. Contractor’s failure to complete or ensure completion of said contractual obligations within a reasonable period of time timeframe defined by OHA will result in a forfeiture of the amount withheld.
e. i. If Contractor is assigned or transferred Clients pursuant to Subsections b. or c. of this section, Contractor accepts all assigned or transferred Clients without regard to the Enrollment exemptions in OAR 410-141-141- 3060.
f. j. If this Contract is amended to reduce the Service Area or the Enrollment limit, or both, OHA may recalculate the CCO Payment rates using the following methodology, as further described in Exhibit C:
g. k. If this Contract is amended to expand the Service Area or the Enrollment limit, or both, OHA may recalculate the CCO Payment rates using the following methodology, as further described in Exhibit C:
(1) If the calculation based on the expanded Service Area or Enrollment limit would result in a rate increase, OHA may provide Contractor with an amendment to this Contract to increase the amount of the CCO Payment rates in Exhibit C, Attachment 1, which (which, subject to CMS approval) , will be effective the date of the expansion of the Service Area or Enrollment limit.
(2) If the calculation based on the expanded Service Area or Enrollment limit would result in a rate decrease, OHA will provide Contractor with an amendment to this Contract to adjust Contractor’s rates when the next OHP-wide rate adjustment occurs. Exhibit B –Statement of Work - Part 8 – Operations
1. Accountability and Transparency of Operations
a. Contractor shall adhere to any industry standards, and state and federal law in the management of finances, contracts, claims processing, payment functions and Provider Networks consistent with ORS 414.625.
b. Contractor shall provide, and require its Subcontractors to provide, timely access to records and facilities and cooperate with OHA in collection of information through consumer surveys, on- site reviews, medical chart reviews, financial reporting and financial record reviews, interviews with staff, and other information for the purposes of monitoring compliance with this Contract, including but not limited to verification of services actually provided, and for developing and monitoring performance and outcomes.
c. Contractor shall assist OHA with development and distribution of survey instruments and participate in other evaluation procedures defined by OHA for evaluating CCO progress on payment reform and delivery system change including the achievement of benchmarks, progress toward eliminating health disparities, results of evaluations, customer satisfaction, use of patient centered primary care homes, the involvement of local governments in governance and service delivery, or other developments as determined necessary by OHA, CMS or external review organizations.
d. Contractor shall ensure record keeping policies and procedures are in accordance with 42 CFR
e. Contractor shall develop and maintain a record keeping system that:
(1) Includes sufficient detail and clarity to permit internal and external review to validate encounter submissions and to assure Medically Appropriate services are provided consistent with the documented needs of the Member; and
(2) Conforms to accepted professional practice; and
(3) Is supported by written policies and procedures; and
(4) Allows the Contractor to ensure that data received from Providers is accurate and complete by:
(a) Verifying the accuracy and timeliness of reported data;
(b) Screening the data for completeness, logic, and consistency; and
(c) Collecting service information in standardized formats
f. Contractor shall ensure that the record keeping systems of its Participating Providers conform to the standards of this section.
g. Contractor shall review all internal policies and procedures on a biennial basis or as required by other sections in this Contract. Contractor shall submit timely, accurate and complete reports to OHA. OHA will post on its web site information about required reports, including the type of report, its location in Contract, the reporting due date, and where the report is to be Submitted or otherwise provided to OHA in accordance with this Contract .
h. Contractor’s failure to Submit or otherwise provide data, access to records or facilities, participate in consumer surveys or other accountability requirements in accordance with this Contract is noncompliance with and breach of the terms of this Contract and is grounds for
i. Contractor shall inform OHA if it has been accredited by a private independent accrediting entity. If the Contractor has been so accredited, Contractor shall authorize the private independent accrediting entity to provide OHA a copy of its most recent accreditation review, including:
(1) Accreditation status, survey type, and level (as applicable);
(2) Accreditation results, including recommended actions or improvements, Corrective Action Plans, and summaries of findings; and
(3) Expiration date of the accreditation.
Appears in 1 contract
Samples: Health Plan Services Contract
Adjustments in Service Area or Enrollment. a. If Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which have significant impact on access in that Service Area and which may result in transferring a substantial number of Members to other Providers employed or subcontracted with Contractor, Contractor shall provide OHA with aa written plan for transferring the Members and an updated Provider Report, Exhibit G, at least 90 days prior to the date of such action. Contractor shall remain responsible for maintaining sufficient capacity and solvency and providing all Covered Services through the end of the 90 day period. OHA will not approve a transfer of Members if the Provider’s contract with the transferring Contractor is terminated for reasons related to quality of care, competency, Fraud or other reasons described in OAR 410-141-3080. If Contractor must terminate a Provider or group due to circumstances that could compromise Member care, less than the required notice to OHA may be provided with the approval of OHA.
(1) If a Provider or group terminates its subcontract or employment with Contractor or if Contractor is affected by circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day notice, less than the required notice to OHA may be provided with the approval of OHA.
(2) If Contractor cannot demonstrate sufficient Provider capacity, OHA may seek other avenues to provide services to Members. If OHA determines that some or all of the affected Members must be disenrolled from Contractor, the applicable provisions of this Section shall apply.
b. If Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which has significant impact on access in that Service Area and which may result in reducing or terminating Contractor’s Service Area or disenrolling a substantial number of Members from Contractor, Contractor shall provide OHA with a written notice and a plan for implementation (which may include an intent to transfer its Members in the Service Area to a Contractor designated by OHA) at least 90 days prior to the date of such action. Contractor shall remain responsible for providing all Covered Services through the end of the 90 day period, without limitation, for all Members for which the Contractor received a CCO Payment.
(1) If Contractor must terminate a Provider or group due to circumstances that could compromise Member care, less than the required notice to OHA may be provided with the approval of OHA.
(2) If a Provider or group terminates its Subcontract or employment with Contractor or Contractor is affected by other circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day notice, less than the required notice to OHA may be provided with the approval of OHA.
(3) If Contractor provides OHA with the required 90 day notice but provides no Letter of Intent to transfer its Members to a designated Contractor within 30 days of the 90 day notice, Members in the affected Service Area will be disenrolled from Contractor and will be assigned to existing Contractors providing services in the affected Service Area(s) who can demonstrate Provider capacity.
(4) If Contractor provides OHA with the required 90 day notice and also provides a Letter of Intent to transfer its Members to a designated Contractor, and OHA determines that the designated Contractor(s) will have sufficient Provider capacity as of the date of the proposed transfer, OHA may approve the Disenrollment and transfer of Members and develop such Contract amendment(s) as may be necessary to effect the transfer.
(5) OHA may seek other avenues to provide services to the Members in the affected area(s).
c. If Members are required to disenroll from Contractor pursuant to this Section 11, Contractor remains responsible for all Covered Services, without limitation, for each Member until the effective date of Disenrollment. Unless specified otherwise by OHA, Disenrollments shall be effective the end of the month in which the Disenrollment occurs. Contractor shall cooperate in notifying the affected Members and coordinating care and transferring records during the transition to the designated contractor or to the contractor that has been assigned to the Member or to such other PCP as may be designated. If OHA must notify affected Members of the change, Contractor shall provide OHA with the name, prime number, and at least one address label for each of the affected Members not less than 45 days prior to the effective Disenrollment date.
d. Contractor shall complete submission and corrections to encounter data for services received by Members; shall assure payment of Valid Claims by employees and Subcontractors, and for Non- Participating Providers providing Covered Services to Members; and shall comply with the other terms of this Contract applicable to the dates of service before Disenrollment of Members pursuant to this section. OHA may, in its discretion, withhold up to 20% of Contractor’s monthly CCO Payment (subject to actuarial considerations) until all contractual obligations have been met to OHA’s satisfaction. Contractor’s failure to complete or ensure completion of said contractual obligations within a reasonable period of time will result in a forfeiture of the amount withheld.
e. If Contractor is assigned or transferred Clients pursuant to Subsections b. or c. of this section, Contractor accepts all assigned or transferred Clients without regard to the Enrollment exemptions in OAR 410-141-3060.
f. If this Contract is amended to reduce the Service Area or the Enrollment limit, or both, OHA may recalculate the CCO Payment rates using the following methodology, as further described in Exhibit C:
g. If this Contract is amended to expand the Service Area or the Enrollment limit, or both, OHA may recalculate the CCO Payment rates using the following methodology, as further described in Exhibit C:
(1) If the calculation based on the expanded Service Area or Enrollment limit would result in a rate increase, OHA may provide Contractor with an amendment to this Contract to increase the amount of the CCO Payment rates in Exhibit C, Attachment 1, which (subject to CMS approval) will be effective the date of the expansion of the Service Area or Enrollment limit.
(2) If the calculation based on the expanded Service Area or Enrollment limit would result in a rate decrease, OHA will provide Contractor with an amendment to this Contract to adjust Contractor’s rates when the next OHP-wide rate adjustment occurs. Exhibit B –Statement of Work - Part 5 – Health Equity and Elimination Health Disparities
1. Ensuring that VBPs are structured to improve quality, manage cost growth, and reduce incentives for network providers to focus on volume of services
2. Ensuring that Contractor pays Hospitals other than Rural Type A Hospitals and Rural Type B Hospitals using Medicare-like payment methodologies that pay for bundles of care rather than paying a percentage of charges.
3. Ensuring that Contractor does not pay any Provider for services rendered in a facility if the condition being treated is a health care acquired condition for which Medicare would not pay the facility.
4. In addition to the base CCO Payment rate paid to Contractor, OHA pays a Hospital reimbursement adjustment to the CCO Payment rate to Contractor in accordance with the CCO Payments calculation reflected in the rate schedule in Exhibit C. Contractor shall distribute such Hospital reimbursement adjustment amounts to eligible Hospitals located in Oregon that receive Medicare reimbursement based upon diagnostic related groups (DRGs), in accordance with requirements established by OHA. In the event that OHA removes the Hospital reimbursement adjustment from the CCO Payment rate, Contractor shall no longer be required to distribute such Hospital reimbursement adjustment amount to eligible Hospitals.
5. Ensuring that Contractor or its Subcontractors is responsible for appropriate management of all federal and state tax obligations applicable to compensation or payments paid to Subcontractors under this Contract.
6. Contractor shall engage in collaborative efforts with OHA to develop a Value-based Purchasing Roadmap that will detail goals and targets for CCOs and network providers to increase adoption of Value-based payment methodologies.
1. Contractor shall maintain a health information system that meets the requirements of this Contract, as specified in 42 CFR 438.242 and section 1903(r)(1)(F) of PPACA and that will collect, analyze, integrate and report data that can provide information on areas including but not limited to:
a. Names and phone numbers of the Member’s Primary Care Physician or clinic;
b. Client Process Monitoring System Forms data. Over the next two years, OHA will be closing the CPMS system and replacing it with the Measures and Outcome Tracking System (MOTS).
c. Copies of completed Request for LTPC Determination Forms;
d. Evidence that the Member has been informed of rights and responsibilities;
e. Grievance, Appeal and hearing records;
f. Utilization of services;
g. Disenrollment for other than loss of Medicaid eligibility;
h. Covered Services provided to Members, through encounter data system or other documentation system; and
i. Member characteristics, including but not limited to race, ethnicity and preferred language in accordance with OHA and DHS standards.
2. Contractor shall collect data at a minimum on:
a. Member characteristics and Provider characteristics as required in Exhibit G;
b. Member Enrollment; and
c. Services provided to Members for pharmacy, and encounter data reporting.
3. Contractor shall ensure claims data received from Providers, either directly or through a third party submitter, is accurate, truthful and complete in accordance with OAR 410-120-1280 and OAR 410-141- 3420 by:
a. Verifying accuracy and timeliness of reported data;
b. Screening data for completeness, logic and consistency;
c. Submitting the certification contained in Exhibit B, Part 8, Section 7;
d. Collecting service information in standardized formats in accordance with OHA Electronic Data Transmission (EDT) procedures in OAR Chapter 943 Division 120; and
e. Confirming Member’s responsibility for its portion of payment as stated in 42 CFR 438.10
f. Contractor shall provide to OHA, upon request, verification that Members were contacted to confirm that billed services were provided in accordance with 42 CFR §455.20 and 433.116 (e) and (f) by:
(1) Providing a notice, within 45 days of the payment of a claim, to all or a sample group of the Members who received services;
(2) The notice must, based on information from the Contractor’s claims payment system, specify:
(i) The services furnished;
(ii) The name of the Provider furnishing the services;
(iii) The date on which the services were furnished; and
(iv) The amount of the payment made by the Member, if any, for the services; and
(3) The sample shall not include specially protected information such as genetic, mental health, alcohol and drug or HIV/AIDS.
g. Contractor shall make all collected and reported data available upon request to OHA and CMS (as specified in 42 CFR §438.242).
Appears in 1 contract
Samples: Health Plan Services Contract
Adjustments in Service Area or Enrollment. a. If Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which have significant impact on access in that Service Area and which may result in transferring a substantial number of Members to other Providers employed or subcontracted with Contractor, Contractor shall provide OHA with a
(1) If a Provider or group terminates its subcontract or employment with Contractor or if Contractor is affected by circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day notice, less than the required notice to OHA may be provided with the approval of OHA.
(2) If Contractor cannot demonstrate sufficient Provider capacity, OHA may seek other avenues to provide services to Members. If OHA determines that some or all of the affected Members must be disenrolled from Contractor, the applicable provisions of this Section shall apply.
b. If Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which has significant impact on access in that Service Area and which may result in reducing or terminating Contractor’s Service Area or disenrolling a substantial number of Members from Contractor, Contractor shall provide OHA with a written notice and a plan for implementation (which may include an intent to transfer its Members in the Service Area to a Contractor designated by OHA) at least 90 days prior to the date of such action. Contractor shall remain responsible for providing all Covered Services through the end of the 90 day period, without limitation, for all Members for which the Contractor received a CCO Payment.
(1) If Contractor must terminate a Provider or group due to circumstances that could compromise Member care, less than the required notice to OHA may be provided with the approval of OHA.
(2) If a Provider or group terminates its Subcontract or employment with Contractor or Contractor is affected by other circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day notice, less than the required notice to OHA may be provided with the approval of OHA.
(3) If Contractor provides OHA with the required 90 day notice but provides no Letter of Intent to transfer its Members to a designated Contractor within 30 days of the 90 day notice, Members in the affected Service Area will be disenrolled from Contractor and will be assigned to existing Contractors providing services in the affected Service Area(s) who can demonstrate Provider capacity.
(4) If Contractor provides OHA with the required 90 day notice and also provides a Letter of Intent to transfer its Members to a designated Contractor, and OHA determines that the designated Contractor(s) will have sufficient Provider capacity as of the date of the proposed transfer, OHA may approve the Disenrollment and transfer of Members and develop such Contract amendment(s) as may be necessary to effect the transfer.
(5) OHA may seek other avenues to provide services to the Members in the affected area(s).
c. If Members are required to disenroll from Contractor pursuant to this Section 11, Contractor remains responsible for all Covered Services, without limitation, for each Member until the effective date of Disenrollment. Unless specified otherwise by OHA, Disenrollments shall be effective the end of the month in which the Disenrollment occurs. Contractor shall cooperate in notifying the affected Members and coordinating care and transferring records during the transition to the designated contractor or to the contractor that has been assigned to the Member or to such other PCP as may be designated. If OHA must notify affected Members of the change, Contractor shall provide OHA with the name, prime number, and at least one address label for each of the affected Members not less than 45 days prior to the effective Disenrollment date.
d. Contractor shall complete submission and corrections to encounter data for services received by Members; shall assure payment of Valid Claims by employees and Subcontractors, and for Non- Participating Providers providing Covered Services to Members; and shall comply with the other terms of this Contract applicable to the dates of service before Disenrollment of Members pursuant to this section. OHA may, in its discretion, withhold up to 20% of Contractor’s monthly CCO Payment (subject to actuarial considerations) until all contractual obligations have been met to OHA’s satisfaction. Contractor’s failure to complete or ensure completion of said contractual obligations within a reasonable period of time will result in a forfeiture of the amount withheld.
e. If Contractor is assigned or transferred Clients pursuant to Subsections b. or c. of this section, Contractor accepts all assigned or transferred Clients without regard to the Enrollment exemptions in OAR 410-141-3060.
f. If this Contract is amended to reduce the Service Area or the Enrollment limit, or both, OHA may recalculate the CCO Payment rates using the following methodology, as further described in Exhibit C:
g. If this Contract is amended to expand the Service Area or the Enrollment limit, or both, OHA may recalculate the CCO Payment rates using the following methodology, as further described in Exhibit C:
(1) If the calculation based on the expanded Service Area or Enrollment limit would result in a rate increase, OHA may provide Contractor with an amendment to this Contract to increase the amount of the CCO Payment rates in Exhibit C, Attachment 1, which (subject to CMS approval) will be effective the date of the expansion of the Service Area or Enrollment limit.
(2) If the calculation based on the expanded Service Area or Enrollment limit would result in a rate decrease, OHA will provide Contractor with an amendment to this Contract to adjust Contractor’s rates when the next OHP-wide rate adjustment occurs. Exhibit B –Statement of Work - Part 5 – Health Equity and Elimination Health Disparities
1. Ensuring that Contractor pays Hospitals other than Rural Type A Hospitals and Rural Type B Hospitals using Medicare-like payment methodologies that pay for bundles of care rather than paying a percentage of charges.
2. Ensuring that Contractor does not pay any Provider for services rendered in a facility if the condition being treated is a health care acquired condition for which Medicare would not pay the facility.
3. In addition to the base CCO Payment rate paid to Contractor, OHA pays a Hospital reimbursement adjustment to the CCO Payment rate to Contractor in accordance with the CCO Payments calculation reflected in the rate schedule in Exhibit C. Contractor shall distribute such Hospital reimbursement adjustment amounts to eligible Hospitals located in Oregon that receive Medicare reimbursement based upon diagnostic related groups (DRGs), in accordance with requirements established by OHA. In the event that OHA removes the Hospital reimbursement adjustment from the CCO Payment rate, Contractor shall no longer be required to distribute such Hospital reimbursement adjustment amount to eligible Hospitals.
4. Ensuring that Contractor or its Subcontractors is responsible for appropriate management of all federal and state tax obligations applicable to compensation or payments paid to Subcontractors under this Contract.
1. Contractor shall maintain a health information system that meets the requirements of this Contract, as specified in 42 CFR 438.242 and that will collect, analyze, integrate and report data that can provide information on areas including but not limited to:
a. Names and phone numbers of the Member’s Primary Care Physician or clinic;
b. Client Process Monitoring System Forms data. Over the next two years, AMH will be closing the CPMS system and replacing it with the Measures and Outcome Tracking System (MOTS).
c. Copies of completed Request for LTPC Determination Forms;
d. Evidence that the Member has been informed of rights and responsibilities;
e. Grievance, Appeal and hearing records;
f. Utilization of services;
g. Disenrollment for other than loss of Medicaid eligibility;
h. Covered Services provided to Members, through encounter data system or other documentation system; and
i. Member characteristics, including but not limited to race, ethnicity and preferred language in accordance with OHA and DHS standards.
2. Contractor shall collect data at a minimum on:
a. Member characteristics and Provider characteristics as required in Exhibit G;
b. Member Enrollment; and
c. Services provided to Members for pharmacy, and encounter data reporting.
3. Contractor shall ensure claims data received from Providers, either directly or through a third party submitter, is accurate, truthful and complete in accordance with OAR 410-120-1280 and OAR 410-141- 3420 by:
a. Verifying accuracy and timeliness of reported data;
b. Screening data for completeness, logic and consistency;
c. Submitting the certification contained in Exhibit B, Part 8, Section 7;
d. Collecting service information in standardized formats in accordance with OHA Electronic Data Transmission (EDT) procedures in OAR Chapter 943 Division 120; and
e. Confirming Member’s responsibility for its portion of payment as stated in 42 CFR 438.10
f. Contractor shall provide to OHA, upon request, verification that Members were contacted to confirm that billed services were provided in accordance with 42 CFR 455.20 and 433.116 (e) and (f) by:
(1) Providing a notice, within 45 days of the payment of a claim, to all or a sample group of the Members who received services;
(2) The notice must, based on information from the Contractor’s claims payment system, specify:
(i) The services furnished;
(ii) The name of the Provider furnishing the services;
(iii) The date on which the services were furnished; and
(iv) The amount of the payment made by the Member, if any, for the services; and
(3) The sample shall not include specially protected information such as genetic, mental health, alcohol and drug or HIV/AIDS.
4. Contractor shall make all collected and reported data available upon request to OHA and CMS (as specified in 42 CFR 438.242).
Appears in 1 contract
Samples: Health Plan Services Contract
Adjustments in Service Area or Enrollment. a. If Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which have significant impact on access in that Service Area and which may result in transferring a substantial number of Members to other Providers employed or subcontracted with Contractor, Contractor shall provide OHA with aa written plan for transferring the Members and an updated Provider Report, Exhibit G, at least 90 days prior to the date of such action, notwithstanding the Contract renewal date. Contractor shall remain responsible for maintaining sufficient capacity and solvency, and providing all Coordinated Care Services through the end of the 90-day period.
(1) If Contractor must terminate a Provider or group due to circumstances that could compromise Member care, less than the required notice to OHA may be provided with the approval of OHA.
(2) If a Provider or group terminates its subcontract or employment with Contractor or if Contractor is affected by circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day days notice, less than the required notice to OHA may be provided with the approval of OHA.
(23) If Contractor cannot demonstrate sufficient Provider capacity, OHA may seek other avenues to provide services to Members. If OHA determines that some or all of the affected Members must be disenrolled from Contractor, the applicable provisions of this Section shall apply.
b. If Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which has significant impact on access in that Service Area and which may result in reducing or terminating Contractor’s Service Area or disenrolling a substantial number of Members from Contractor, Contractor shall provide OHA with a written notice and a plan for implementation (which may include an intent to transfer its Members in the Service Area to a Contractor designated by OHA) at least 90 days prior to the date of such action. Contractor shall remain responsible for providing all Covered Services through the end of the 90 day period, without limitation, for all Members for which the Contractor received a CCO Payment.
(1) If Contractor must terminate a Provider or group due to circumstances that could compromise Member care, less than the required notice to OHA may be provided with the approval of OHA.
(2) If a Provider or group terminates its their Subcontract or employment with Contractor or Contractor is affected by other circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day days notice, less than the required notice to OHA may be provided with the approval of OHA.
(3) If Contractor provides OHA with the required 90 90-day notice but provides no Letter of Intent to transfer its Members to a designated Contractor within 30 days of the 90 90-day notice, Members in the affected Service Area will be disenrolled from Contractor and will be assigned to existing Contractors providing services in the affected Service Area(s) who can demonstrate Provider capacity.
(4) If Contractor provides OHA with the required 90 90-day notice and also provides a Letter of Intent to transfer its Members to a designated Contractor, and OHA determines that the designated Contractor(s) will have sufficient Provider capacity as of the date of the proposed transfer, OHA may approve the Disenrollment and transfer of Members and develop such Contract amendment(s) as may be necessary to effect the transfer.
(5) OHA may seek other avenues to provide services to the Members in the affected area(s).
c. If Members are required to disenroll from Contractor pursuant to this Section 112, Contractor remains responsible for all Covered Coordinated Care Services, without limitation, for each Member until the effective date of Disenrollment. Unless specified otherwise by OHA, Disenrollments shall be effective the end of the month in which the Disenrollment occurs. Contractor shall cooperate in notifying the affected Members and coordinating care and transferring records during the transition to the designated contractor or to the contractor that has been assigned to the Member or to such other PCP as may be designated. If OHA must notify affected Members of the change, Contractor shall provide OHA with the name, prime number, and at least one address label for each of the affected Members not less than 45 days prior to the effective Disenrollment date.
d. Contractor shall complete submission and corrections to encounter data for services received by Members; shall assure payment of Valid Claims valid claims by employees and Subcontractors, and for Non- Participating Providers providing Covered Services to Members; and shall comply with the other terms of this Contract applicable to the dates of service before Disenrollment of Members pursuant to this section. OHA may, in its discretion, withhold up to 20% of Contractor’s monthly CCO Payment (subject to actuarial considerations) until all contractual obligations have been met to OHA’s satisfaction. Contractor’s failure to complete or ensure completion of said contractual obligations within a reasonable period of time will result in a forfeiture of the amount withheld.
e. If Contractor is assigned or transferred Clients pursuant to Subsections b. or c. of this section, Contractor accepts all assigned or transferred Clients without regard to the Enrollment exemptions in OAR 410-141-3060.
f. If this Contract is amended to reduce the Service Area or and/or to reduce the Enrollment limit, or both, OHA may recalculate the CCO Payment rates may be recalculated using the following methodology, as further methodology described in Exhibit C, Attachment 1, as follows:
g. If this Contract is amended to expand the Service Area or and/or the Enrollment limit, or both, OHA may recalculate the CCO Payment rates may be recalculated using the following methodology, as further methodology described in Exhibit C, Attachment 1, as follows:
(1) If the calculation based on the expanded Service Area or and/or Enrollment limit would result in a rate increase, OHA may provide Contractor with an amendment to this Contract will be amended to increase the amount of the CCO Payment rates in Exhibit C, Attachment 12, which (subject to CMS approval) will be effective the date of the expansion of the Service Area or and/or Enrollment limit.
(2) If the calculation based on the expanded Service Area or and/or Enrollment limit would result in a rate decrease, OHA Contractor’s rates will provide Contractor with an amendment to this Contract be amended to adjust Contractor’s the rates when the next OHP-wide rate adjustment occurs. Exhibit B –Statement of Work - Part 5 – Health Equity and Elimination Health Disparities Exhibit B –Statement of Work - Part 6 – Payment Methodologies That Support the Triple Aim
1. Ensuring that Contractor pays hospitals other than Type A and B Rural hospitals using Medicare-like payment methodologies that pay for bundles of care rather than paying a percentage of charges.
2. Ensuring that Contractor does not pay any provider for services rendered in a facility if the condition being treated is a health care acquired condition for which Medicare would not pay the facility.
3. In addition to the base CCO Payment rate paid to Contractor, OHA pays a hospital reimbursement adjustment to the CCO Payment rate to Contractor in accordance with the CCO Payments calculation reflected in the rate schedule in the Core Contract. Contractor shall distribute such hospital reimbursement adjustment amounts to eligible hospitals located in Oregon that receive Medicare reimbursement based upon diagnostic related groups (DRGs), in accordance with requirements established by OHA.
4. Ensuring that Contractor or its Subcontractors is responsible for appropriate management of all federal and state tax obligations applicable to compensation or payments paid to Subcontractors under this Contract.
1. Contractor shall maintain a health information system that meets the requirements of this Contract, as specified in 42 CFR 438.242 and that will collect, analyze, integrate and report data that can provide information on areas including but not limited to:
a. Names and phone numbers of the Member’s Primary Care Physician or clinic, primary Dentist and mental health Practitioner;
b. Copies of Client Process Monitoring System (CPMS) Enrollment forms;
c. Copies of long term psychiatric care determination request forms;
d. Evidence that the Member has been informed of rights and responsibilities;
e. Grievance, Appeal and hearing records;
f. Utilization of services;
g. Disenrollment for other than loss of Medicaid eligibility;
h. Coordinated Care Services provided to Members, through encounter data system or other documentation system; and
i. Member characteristics, including but not limited to race, ethnicity and preferred language in accordance with OHA and DHS standards.
2. Contractor shall collect data at a minimum on:
a. Member characteristics and provider characteristics as required in Exhibit G;
b. Member Enrollment; and
c. Services provided to Members for pharmacy, and encounter data reporting.
3. Contractor shall ensure Claims data received from Providers, either directly or through a third party submitter, is accurate, truthful and complete in accordance with OAR 000-000-0000 and OAR 410-120- 1280 by:
a. Verifying accuracy and timeliness of reported data;
b. Screening data for completeness, logic and consistency;
c. Submitting the certification contained in Exhibit B, Part 8, Section 7;
d. Collecting service information in standardized formats to the extent feasible and appropriate, if HIPAA standard Contractor must utilize the HIPAA standard including OHA Electronic Data Transmission (EDT) procedures; and
e. Confirming Member’s responsibility for its portion of payment as stated in 42 CFR 438.10
4. Contractor shall make all collected and reported data available upon request to OHA and CMS (as specified in 42 CFR 438.242).
Appears in 1 contract
Samples: Health Plan Services Contract
