Common use of Behavioral Health Clinical Assessment Clause in Contracts

Behavioral Health Clinical Assessment. The comprehensive clinical assessment of an Enrollee that includes a full bio‑psycho social and diagnostic evaluation that informs behavioral health treatment planning. A Behavioral Health Clinical Assessment is performed when an Enrollee begins behavioral health treatment and is reviewed and updated during the course of treatment. Behavioral Health Providers— Providers of mental health and substance use disorder services that are Covered Services. Behavioral Health Services — Mental health and substance use disorder services that are Covered Services. Benefit Coordination — The function of coordinating benefit payments from other payers, for services delivered to an Enrollee, when such Enrollee is covered by another coverage source. Capitated Financial Alignment Model (“the Demonstration”) — A model where a State, CMS, and a health plan enter into a three‑way contract, and the plan receives a prospective blended payment to provide comprehensive, coordinated care. Capitation Rate — The sum of the monthly capitation payments for Demonstration Year 1 (reflecting coverage of Medicare Parts A & B services, Medicare Part D services, and Medicaid services, pursuant to Appendix A and B of this Contract) including: 1) the application of risk adjustment methodologies, as described in Section 4.3.5; 2) any payment adjustments as a result of the reconciliation described in Section 4.6; and 3) any payments as a result of the High‑Cost Risk Pool, as described in Section 4.3.6. Total Capitation Rate Revenue will be calculated as if all Contractors had received the full quality withhold payment. Care Coordinator — A clinician or other trained individual employed or contracted by the PCP or the Contractor who is accountable for providing care coordination services, which include assuring appropriate referrals and timely two‑way transmission of useful patient information; obtaining reliable and timely information about services other than those provided by the PCP; participating in the Comprehensive Assessment; and supporting safe transitions in care for Enrollees moving between settings. See Section 2.5.4.4 for more information about the requirements, qualifications, and responsibilities of a Care Coordinator. Centers for Medicare & Medicaid Services (CMS) — The federal agency under the Department of Health and Human Services responsible for administering, in relevant part, the Medicare and Medicaid programs. Centralized Enrollee Record — Centralized and comprehensive documentation, containing information relevant to maintaining and promoting each Enrollee's general health and well‑being, as well as clinical information concerning illnesses and chronic medical conditions. See Section 2.6.6 for more information about the contents of the Centralized Enrollee Record. Chronically Homeless ‑‑ Enrollees who meet the definition of “Chronically Homeless” as set forth by the U.S. Department of Housing and Urban Development, described as an unaccompanied homeless individual with a disabling condition who either has been continuously homeless for a year or more, or has had at least four (4) episodes of homelessness in the past three (3) years, as determined by EOHHS. Clinical Care Management — A set of services provided by a Clinical Care Manager that comprise intensive monitoring, follow‑up, care coordination, and clinical management of individuals with Complex Care Needs. Clinical Care Manager — A licensed registered nurse or other individual licensed and/or certified to provide Clinical Care Management, and will serve as the Care Coordinator for individuals with Complex Care Needs. Clinical Criteria — Criteria used to determine the most clinically appropriate and necessary level of care and intensity of services to ensure the provision of Medically Necessary Services. Community Health Workers — See Appendix B, Exhibit 4. Complaint — Any dispute, other than one that constitutes an organization determination under 42 C.F.R. § 422.566, expressing dissatisfaction with any aspect of the Contractor’s or provider’s operations, activities, or behavior, regardless of whether remedial action is requested. 42 C.F.R. § 422.561. Possible subjects for Complaints (as provided for in 42 C.F.R. § 438.400) include, but are not limited to, quality of care or services provided, aspects of interpersonal relationships such as rudeness of a PCP or employee of Contractor, or failure to respect the Enrollee’s rights. See also Grievance. Complex Care Need — Enrollees who are determined to have significant health care needs and require intensive care coordination services/activities geared towards addressing their physical, behavioral health and/or social care needs. These Enrollees typically have co‑morbidities and psychosocial needs that if not addressed can significantly diminish their quality of life as well as their ability to adhere to treatment plans. Care Coordination services for these Enrollees are typically provided by a licensed registered nurse or other individuals licensed to provide Clinical Care Management, as these Enrollees typically require very individualized services tailored to their needs and stage of readiness with a goal of averting the need for more intensive medical services.

Behavioral Health Clinical Assessment. The comprehensive clinical assessment of an Enrollee that includes a full bio‑psycho bio-psycho social and diagnostic evaluation that informs behavioral health treatment planning. A Behavioral Health Clinical Assessment is performed when an Enrollee begins behavioral health treatment and is reviewed and updated during the course of treatment. Behavioral Health Providers— Providers of mental health and substance use disorder services that are Covered Services. Behavioral Health Services — Mental health and substance use disorder services that are Covered Services. Benefit Coordination — The function of coordinating benefit payments from other payers, for services delivered to an Enrollee, when such Enrollee is covered by another coverage source. Capitated Financial Alignment Model (“the Demonstration”) — A model where a State, CMS, and a health plan enter into a three‑way three-way contract, and the plan receives a prospective blended payment to provide comprehensive, coordinated care. Capitation Rate — The sum of the monthly capitation payments for Demonstration Year 1 (reflecting coverage of Medicare Parts A & B services, Medicare Part D services, and Medicaid services, pursuant to Appendix A and B of this Contract) including: 1) the application of risk adjustment methodologies, as described in Section 4.3.54.2.D; 2) any payment adjustments as a result of the reconciliation described in Section 4.64.5; and 3) any payments as a result of the High‑Cost High-Cost Risk Pool, as described in Section 4.3.6. 4.2.E. Total Capitation Rate Revenue will be calculated as if all Contractors had received the full quality withhold payment. Care Coordinator — A clinician or other trained individual employed or contracted by the PCP Primary Care Provider or the Contractor who is accountable for providing care coordination services, which include assuring appropriate referrals and timely two‑way two-way transmission of useful patient information; obtaining reliable and timely information about services other than those provided by the PCPPrimary Care Provider; participating in the Comprehensive Assessment; and supporting safe transitions in care for Enrollees moving between settings. See Section 2.5.4.4 2.5.C.2 for more information about the requirements, qualifications, and responsibilities of a Care Coordinator. Centers for Medicare & Medicaid Services (CMS) — The federal agency under the Department of Health and Human Services responsible for administering, in relevant part, the Medicare and Medicaid programs. Centralized Enrollee Record — Centralized and comprehensive documentation, containing information relevant to maintaining and promoting each Enrollee's general health and well‑being, as well as clinical information concerning illnesses and chronic medical conditions. See Section 2.6.6 for more information about the contents of the Centralized Enrollee Record. Chronically Homeless ‑‑ Enrollees who meet the definition of “Chronically Homeless” as set forth by the U.S. Department of Housing and Urban Development, described as an unaccompanied homeless individual with a disabling condition who either has been continuously homeless for a year or more, or has had at least four (4) episodes of homelessness in the past three (3) years, as determined by EOHHS. Clinical Care Management — A set of services provided by a Clinical Care Manager that comprise intensive monitoring, follow‑up, care coordination, and clinical management of individuals with Complex Care Needs. Clinical Care Manager — A licensed registered nurse or other individual licensed and/or certified to provide Clinical Care Management, and will serve as the Care Coordinator for individuals with Complex Care Needs. Clinical Criteria — Criteria used to determine the most clinically appropriate and necessary level of care and intensity of services to ensure the provision of Medically Necessary Services. Community Health Workers — See Appendix B, Exhibit 4. Complaint — Any dispute, other than one that constitutes an organization determination under 42 C.F.R. § 422.566, expressing dissatisfaction with any aspect of the Contractor’s or provider’s operations, activities, or behavior, regardless of whether remedial action is requested. 42 C.F.R. § 422.561. Possible subjects for Complaints (as provided for in 42 C.F.R. § 438.400) include, but are not limited to, quality of care or services provided, aspects of interpersonal relationships such as rudeness of a PCP or employee of Contractor, or failure to respect the Enrollee’s rights. See also Grievance. Complex Care Need — Enrollees who are determined to have significant health care needs and require intensive care coordination services/activities geared towards addressing their physical, behavioral health and/or social care needs. These Enrollees typically have co‑morbidities and psychosocial needs that if not addressed can significantly diminish their quality of life as well as their ability to adhere to treatment plans. Care Coordination services for these Enrollees are typically provided by a licensed registered nurse or other individuals licensed to provide Clinical Care Management, as these Enrollees typically require very individualized services tailored to their needs and stage of readiness with a goal of averting the need for more intensive medical services.

Behavioral Health Clinical Assessment. The comprehensive clinical assessment of an Enrollee that includes a full bio‑psycho bio-psycho social and diagnostic evaluation that informs behavioral health treatment planning. A Behavioral Health Clinical Assessment is performed when an Enrollee begins behavioral health treatment and is reviewed and updated during the course of treatment. Behavioral Health Providers— Providers of mental health and substance use disorder services that are Covered Services. Behavioral Health Services — Mental health and substance use disorder services that are Covered Services. Benefit Coordination — The function of coordinating benefit payments from other payers, for services delivered to an Enrollee, when such Enrollee is covered by another coverage source. Capitated Financial Alignment Model (“the Demonstration”") — A model where a State, CMS, and a health plan enter into a three‑way three-way contract, and the plan receives a prospective blended payment to provide comprehensive, coordinated care. Capitation Rate — The sum of the monthly capitation payments for Demonstration Year 1 (reflecting coverage of Medicare Parts A & B services, Medicare Part D services, and Medicaid services, pursuant to Appendix A and B of this Contract) including: 1) the application of risk adjustment methodologies, as described in Section 4.3.5; 2) any payment adjustments as a result of the reconciliation described in Section 4.6; and 3) any payments as a result of the High‑Cost High-Cost Risk Pool, as described in Section 4.3.6. Total Capitation Rate Revenue will be calculated as if all Contractors had received the full quality withhold payment. Care Coordinator — A clinician or other trained individual employed or contracted by the PCP or the Contractor who is accountable for providing care coordination services, which include assuring appropriate referrals and timely two‑way two-way transmission of useful patient information; obtaining reliable and timely information about services other than those provided by the PCP; participating in the Comprehensive Assessment; and supporting safe transitions in care for Enrollees moving between settings. See Section 2.5.4.4 for more information about the requirements, qualifications, and responsibilities of a Care Coordinator. Centers for Medicare & Medicaid Services (CMS) — The federal agency under the Department of Health and Human Services responsible for administering, in relevant part, the Medicare and Medicaid programs. Centralized Enrollee Record — Centralized and comprehensive documentation, containing information relevant to maintaining and promoting each Enrollee's general health and well‑beingwell-being, as well as clinical information concerning illnesses and chronic medical conditions. See Section 2.6.6 for more information about the contents of the Centralized Enrollee Record. Chronically Homeless ‑‑ -- Enrollees who meet the definition of “Chronically Homeless” " as set forth by the U.S. Department of Housing and Urban Development, described as an unaccompanied homeless individual with a disabling condition who either has been continuously homeless for a year or more, or has had at least four (4) episodes of homelessness in the past three (3) years, as determined by EOHHS. Clinical Care Management — A set of services provided by a Clinical Care Manager that comprise intensive monitoring, follow‑upfollow-up, care coordination, and clinical management of individuals with Complex Care Needs. Clinical Care Manager — A licensed registered nurse or other individual licensed and/or certified to provide Clinical Care Management, and will serve as the Care Coordinator for individuals with Complex Care Needs. Clinical Criteria — Criteria used to determine the most clinically appropriate and necessary level of care and intensity of services to ensure the provision of Medically Necessary Services. Community Health Workers — See Appendix B, Exhibit 4. Complaint — Any dispute, other than one that constitutes an organization determination under 42 C.F.R. § 422.566, expressing dissatisfaction with any aspect of the Contractor’s Contractor‘s or provider’s provider‘s operations, activities, or behavior, regardless of whether remedial action is requested. 42 C.F.R. § 422.561. Possible subjects for Complaints (as provided for in 42 C.F.R. § 438.400) include, but are not limited to, quality of care or services provided, aspects of interpersonal relationships such as rudeness of a PCP or employee of Contractor, or failure to respect the Enrollee’s Enrollee‘s rights. See also Grievance. Complex Care Need — Enrollees who are determined to have significant health care needs and require intensive care coordination services/activities geared towards addressing their physical, behavioral health and/or social care needs. These Enrollees typically have co‑morbidities co-morbidities and psychosocial needs that if not addressed can significantly diminish their quality of life as well as their ability to adhere to treatment plans. Care Coordination services for these Enrollees are typically provided by a licensed registered nurse or other individuals licensed to provide Clinical Care Management, as these Enrollees typically require very individualized services tailored to their needs and stage of readiness with a goal of averting the need for more intensive medical services.

Behavioral Health Clinical Assessment. The comprehensive clinical assessment of an Enrollee that includes a full bio‑psycho bio-psycho social and diagnostic evaluation that informs behavioral health treatment planning. A Behavioral Health Clinical Assessment is performed when an Enrollee begins behavioral health treatment and is reviewed and updated during the course of treatment. Behavioral Health Providers— Providers of mental health and substance use disorder services that are Covered Services. Behavioral Health Services — Mental health and substance use disorder services that are Covered Services. Benefit Coordination — The function of coordinating benefit payments from other payers, for services delivered to an Enrollee, when such Enrollee is covered by another coverage source. Capitated Financial Alignment Model (“the Demonstration”) — A model where a State, CMS, and a health plan enter into a three‑way three-way contract, and the plan receives a prospective blended payment to provide comprehensive, coordinated care. Capitation Rate — The sum of the monthly capitation payments for Demonstration Year 1 (reflecting coverage of Medicare Parts A & B services, Medicare Part D services, and Medicaid services, pursuant to Appendix A and B of this Contract) including: 1) the application of risk adjustment methodologies, as described in Section 4.3.5; 2) any payment adjustments as a result of the reconciliation described in Section 4.6; and 3) any payments as a result of the High‑Cost High-Cost Risk Pool, as described in Section 4.3.6. Total Capitation Rate Revenue will be calculated as if all Contractors had received the full quality withhold payment. Care Coordinator — A clinician or other trained individual employed or contracted by the PCP or the Contractor who is accountable for providing care coordination services, which include assuring appropriate referrals and timely two‑way two-way transmission of useful patient information; obtaining reliable and timely information about services other than those provided by the PCP; participating in the Comprehensive Assessment; and supporting safe transitions in care for Enrollees moving between settings. See Section 2.5.4.4 2.5.3.4 for more information about the requirements, qualifications, and responsibilities of a Care Coordinator. Centers for Medicare & Medicaid Services (CMS) — The federal agency under the Department of Health and Human Services responsible for administering, in relevant part, the Medicare and Medicaid programs. Centralized Enrollee Record — Centralized and comprehensive documentation, containing information relevant to maintaining and promoting each Enrollee's general health and well‑beingwell-being, as well as clinical information concerning illnesses and chronic medical conditions. See Section 2.6.6 for more information about the contents of the Centralized Enrollee Record. Chronically Homeless ‑‑ -- Enrollees who meet the definition of “Chronically Homeless” as set forth by the U.S. Department of Housing and Urban Development, described as an unaccompanied homeless individual with a disabling condition who either has been continuously homeless for a year or more, or has had at least four (4) episodes of homelessness in the past three (3) years, as determined by EOHHS. Clinical Care Management — A set of services provided by a Clinical Care Manager that comprise intensive monitoring, follow‑upfollow-up, care coordination, and clinical management of individuals with Complex Care Needs. Clinical Care Manager — A licensed registered nurse or other individual licensed and/or certified to provide Clinical Care Management, and will serve as the Care Coordinator for individuals with Complex Care Needs. Clinical Criteria — Criteria used to determine the most clinically appropriate and necessary level of care and intensity of services to ensure the provision of Medically Necessary Services. Community Health Workers — See Appendix B, Exhibit 4. Complaint — —Any dispute, other than one that constitutes an organization determination under 42 C.F.R. § 422.566, expressing dissatisfaction with any aspect of the Contractor’s or provider’s operations, activities, or behavior, regardless of whether remedial action is requested. 42 C.F.R. § 422.561. Possible subjects for Complaints (as provided for in 42 C.F.R. § 438.400) include, but are not limited to, quality of care or services provided, aspects of interpersonal relationships such as rudeness of a PCP or employee of Contractor, or failure to respect the Enrollee’s rights. See also Grievance. Complex Care Need — Enrollees who are determined to have significant health care needs and require intensive care coordination services/activities geared towards addressing their physical, behavioral health and/or social care needs. These Enrollees typically have co‑morbidities co-morbidities and psychosocial needs that if not addressed can significantly diminish their quality of life as well as their ability to adhere to treatment plans. Care Coordination services for these Enrollees are typically provided by a licensed registered nurse or other individuals licensed to provide Clinical Care Management, as these Enrollees typically require very individualized services tailored to their needs and stage of readiness with a goal of averting the need for more intensive medical services.