Common use of Administrative and Organizational Structure Clause in Contracts

Administrative and Organizational Structure. The Contractor shall maintain an administrative and organizational structure that supports effective and efficient delivery of integrated services to members. The organizational structure shall demonstrate a coordinated approach to managing the delivery of health care services to its PathWays members. The Contractor’s organizational structure shall support the collection and integration of data from every aspect of its delivery system and its internal functional units to accurately report the Contractor’s performance. The Contractor shall also have policies and procedures in place that support the integration of financial and performance data and comply with all applicable federal and state requirements. Prior to the Contract effective date, FSSA will provide a series of orientation sessions to assist the Contractor in developing its internal operations to support the requirements of the Contract (i.e., data submission, data transmissions, reporting formats, etc.). The Contractor shall have in place sufficient administrative and clinical staff and organizational components to comply with all PathWays program requirements and standards. The Contractor shall manage the functional linkage of the following major operational areas: ▪ Administrative and fiscal management ▪ Member services ▪ Provider enrollment and services ▪ Case Management ▪ Marketing ▪ Network development and management ▪ Quality management and improvement ▪ Utilization management ▪ Clinical assessment, prevention and wellness program(s), care coordination, complex case management, and service coordination, ▪ Special investigations and waste, fraud, and abuse detection ▪ Behavioral and physical health ▪ Information systems ▪ Performance data reporting and encounter claims submission ▪ Claims payments ▪ Grievances and appeals ▪ Medicare and Medicaid coordination