Enrollment of Newborns Clause Samples

Enrollment of Newborns. 2.4.9.1 TennCare-eligible newborns and their mothers, to the extent that the mother is eligible for TennCare, should be enrolled in the same MCO with the exception of newborns that are SSI eligible at birth. Newborns that are SSI eligible at birth shall be assigned to TennCare Select but may opt out and enroll in another MCO. 2.4.9.2 A newborn may be inadvertently enrolled in an MCO different than its mother. When such cases are identified by the CONTRACTOR, the CONTRACTOR shall immediately report to TENNCARE, in accordance with written procedures provided by TENNCARE, that a newborn has been incorrectly enrolled in an MCO different than its mother. 2.4.9.3 Upon receipt of notice from the CONTRACTOR or discovery by TENNCARE that a newborn has been incorrectly enrolled in an MCO different than its mother, TENNCARE shall immediately: 2.4.9.3.1 Disenroll the newborn from the incorrect MCO; 2.4.9.3.2 Enroll the newborn in the same MCO as its mother with the same effective date as when the newborn was enrolled in the incorrect MCO; 2.4.9.3.3 Recoup any payments made to the incorrect MCO for the newborn; and 2.4.9.3.4 Make payments only to the correct MCO for the period of coverage. 2.4.9.4 The MCO in which the newborn is correctly enrolled shall be responsible for the coverage and payment of covered services provided to the newborn for the full period of eligibility. Except as provided below, the MCO in which the newborn was incorrectly enrolled shall have no liability for the coverage or payment of any services during the period of incorrect MCO assignment. TENNCARE shall only be liable for the capitation payment to the correct MCO. 2.4.9.5 There are circumstances in which a ▇▇▇▇▇▇▇’s mother may not be eligible for participation in the TennCare program. The CONTRACTOR shall be required to process claims received for services provided to newborns within the time frames specified in Section A.2.22.4 of this Contract. A CONTRACTOR shall not utilize any blanket policy which results in the automatic denial of claims for services provided to a TennCare-eligible newborn, during any period of enrollment in the CONTRACTOR’s MCO, because the newborn’s mother is not a member of the CONTRACTOR’s MCO. However, it is recognized that in complying with the claims processing time frames specified in Section A.2.22.4 of this Contract, a CONTRACTOR may make payment for services provided to a TennCare-eligible newborn enrolled in the CONTRACTOR’s MCO at the time of payment but th...

Enrollment of Newborns. ‌ The PH-MCO must have written administrative policies and procedures to enroll and provide all Medically Necessary services to newborn infants of Members, effective from the time of birth, without delay, in accordance with Section V.F.12, Services for New Members, and Exhibit BB, PH-MCO Recipient Coverage Document. The PH-MCO must receive advance written approval from the Department regarding these policies and procedures. The PH-MCO must notify the Department if there are errors or inconsistencies in the newborn’s MA or PH-MCO eligibility dates per the established procedures found on the HealthChoices Intranet. For pregnant members, the PH-MCO must make every effort to identify what PCP/pediatrician the mother chooses to use for the newborn prior to the birth, so that this chosen Provider can be assigned to the newborn on the date of birth. The PH-MCO is not responsible for the payment of newborn metabolic screenings.

Enrollment of Newborns. The PH-MCO must have written administrative policies and procedures to enroll and provide all Medically Necessary services to newborn infants of Members, effective from the time of birth, without delay, in accordance with Section V.F.12 of this Agreement, Services for New Members, and Exhibit BB of this Agreement, MCO Recipient Coverage Document. The PH-MCO must receive advance written approval from the Department regarding these policies and procedures. For pregnant members, the PH-MCO must make every effort to identify what PCP/pediatrician the mother chooses to use for the newborn prior to the birth, so that this chosen Provider can be assigned to the newborn on the date of birth. The PH-MCO is not responsible for the payment of newborn metabolic screenings.

Enrollment of Newborns. Newborns will not be enrolled in CHC. Newborns will be auto-assigned to the HealthChoices PH-MCO aligned with the mother’s CHC-MCO if available in the Zone where they reside.

Enrollment of Newborns. Newborns and infants who are added to the Case of an adult Enrollee who is the Head of Case and enrolled with Contractor are enrolled as follows: 4.6.1 When an Enrollee gives birth and the newborn is added to the Case before the newborn is forty‐five (45) days old, the newborn is automatically enrolled with Contractor. Contractor shall provide coverage of the newborn Enrollee retroactively to the date of birth. 4.6.2 When an Enrollee gives birth and the infant Potential Enrollee is added to the Case when the infant Potential Enrollee is over forty‐five (45) days old but less than one (1) year old, the infant Potential Enrollee is automatically enrolled with Contractor. Enrollment shall be prospective as provided in section 4.7.

Enrollment of Newborns. All newborns of Medicaid MCO program members, where the newborn resides in the same household as the mother, are the responsibility of the Contractor, unless the mother has specified otherwise prior to delivery. A newborn is defined as a Medicaid eligible beneficiary who is under 365 days of age. To assure continuity of care in the crucial first months of the newborn's life, every effort shall be made by the ContractorSCDHHS to expedite enrollment of newborns into the Contractor's Plan. For Medicaid MCO Program members, the SCDHHS will enroll newborns into the same managed care plan as the mother, for the first ninety (90) calendar days from birth unless otherwise specified by the mother. The newborn will be enrolled in the same managed care plan as the mother through the end of the month in which the ninetieth (90th) day falls. The newborn's effective date will be the first day of the month of birth. The enrollment form will contain a statement that the member understands that a child born into the family unit will be enrolled in the same MCO as the mother unless otherwise specified by the mother. The newborn shall continue to be enrolled with the mother's MCO unless the mother/guardian changes the enrollment. For retro newborns, a break in a newborn’s enrollment could occur between the end of the required 90 days and the next period of enrollment in the Managed Care Plan. This break in enrollment is determined by the date of notification of the newborn to SCDHHS or the date of the creation of the newborn’s eligibility record in MEDS. Newborn enrollment for Medicaid MCO program members will occur through the following procedures: 6.4.1 All hospital subcontracts entered into by the Contractor shall meet the requirements as outlined in § 5 of this Contract. In addition, such subcontracts shall require that the hospitals notify the Contractor and SCDHHS of the births when the mother is a member of the Contractor's plan. The subcontract shall also specify that the hospital is responsible for completing SCDHHS Request for Medicaid ID Number (Form 1716 ME) and submitting them to the local SCDHHS/state SCDHHS office. 6.4.2 The Contractor's hospital subcontractor must notify SCDHHS of the newborn's birth through completion of the Request for Medicaid ID Number Form 1716 ME. A sample form is in MCO Policy and Procedure Guide of this contract. This must be completed according to the instructions indicated on the form. 6.4.3 SCDHHS will add the newborn to the Medica...

Enrollment of Newborns. 49 7. Transitioning Members Between PH-MCOs ............................49 8.

Enrollment of Newborns. The Contractor must have written administrative policies and procedures to enroll and provide all necessary services to newborn infants of Members, effective from the time of birth, without delay, in accordance with Section V.F.11 of this Agreement, Services for New Members, and Exhibit BB of this Agreement, PH-MCO Recipient Coverage Document. The Contractor must receive advance written approval from the Department regarding these policies and procedures. The Contractor is not responsible for the payment of newborn metabolic screenings.

Enrollment of Newborns. Newborns of Medicaid eligible mothers who were enrolled at the time of the newborn's birth will be automatically enrolled with the mother’s CCN, retroactive to the month of the birth.