FUNCTIONS AND DUTIES OF THE DEPARTMENT. In consideration of the functions and duties of the HMO contained in this Contract, the Department must:
FUNCTIONS AND DUTIES OF THE DEPARTMENT. In consideration of the functions and duties of the County contained in this Contract, the Department shall:
A. ELIGIBILITY DETERMINATION Verify, at the time of enrollment, that members identified on the enrollment requests from the County are:
1. BadgerCare Plus eligible, if all other enrollment eligibility requirements are met.
2. Under 19 years of age or if the member had aged out of the xxxxxx care system, under 21 years old
3. Not currently residing in a psychiatric hospital.
FUNCTIONS AND DUTIES OF THE DEPARTMENT. In consideration of the functions and duties of the County contained in this Contract, the Department shall:
A. ELIGIBILITY DETERMINATION Verify, at the time of enrollment, that members identified on the enrollment requests from the County are:
1. BadgerCare Plus eligible, if all other enrollment eligibility requirements are met.
2. Under 19 years of age.
3. Not currently residing in a psychiatric hospital.
4. Residents of Dane County.
5. Verified, during on-site medical record reviews conducted by the Department, that the individuals enrolled in the County meet the definition of severely emotionally disturbed.
6. At imminent risk of placement in a psychiatric hospital, a residential care center, or a juvenile correction facility.
7. Are residents of Dane County.
8. Have been screened as eligible for services by Community Partnerships.
B. ENROLLMENT Promptly notify the County of all BadgerCare Plus members enrolled under this Contract. Notification shall be effected through the County Enrollment Reports. All members listed as an ADD or CONTINUE on either the Initial or Final County Enrollment Report are members of the County Managed Care Program during the enrollment month. The reports shall be generated in the sequence specified under the County Enrollment Reports. These reports shall be in hard copy formats or available through electronic file transfer capability and shall include medical status codes.
C. DISENROLLMENT Promptly notify the County of all BadgerCare Plus members no longer eligible to receive services through the County under this Contract. Notification shall be effected through the County Enrollment Reports, which the Department will transmit to the County for each month of coverage throughout the term of the Contract. The reports shall be generated in the sequence under COUNTY ENROLLMENT REPORTS. Any member who was enrolled in the County’s Managed Care Program in the previous enrollment month, but does not appear as an ADD or CONTINUE on either the Initial or Final County Enrollment report for the current enrollment month, is disenrolled from the County’s Managed Care Program effective the last day of the previous enrollment month. Members will be disenrolled if either:
1. Member loses BadgerCare Plus eligibility.
2. Member loses Dane County eligibility.
3. Member is disenrolled upon their request.
4. Member completes the program.
5. Court ordered correctional placements.
6. Member is 19 years of age or older.
7. The Department approv...
FUNCTIONS AND DUTIES OF THE DEPARTMENT.
A. Department of Health Services The Division of Medicaid Services (DMS) is the primary point of contact among the Department, the Contractor, and the Department’s contracted agencies responsible for the administration and operation of the IRIS program. DMS staff may assist the Contractor in identifying system barriers to implementation of the programs and may facilitate intra- and interagency communications and work groups necessary to accomplish full implementation.
FUNCTIONS AND DUTIES OF THE DEPARTMENT. In consideration of the functions and duties of the County contained in this Contract, the Department shall:
A. ELIGIBILITY DETERMINATION Verify, at the time of enrollment, that members identified on the enrollment requests from the County are:
1. BadgerCare Plus eligible, if all other enrollment eligibility requirements are met.
2. Under 19 years of age.
3. Not currently residing in a psychiatric hospital.
4. Residents of Dane County.
5. Verified, during on-site medical record reviews conducted by the Department, that the individuals enrolled in the County meet the definition of severely emotionally disturbed.
6. At imminent risk of placement in a psychiatric hospital, a residential care center, or a juvenile correction facility.
7. Are residents of Dane County.
8. Have been screened as eligible for services by Community Partnerships.
B. ENROLLMENT Promptly notify the County of all BadgerCare Plus members enrolled under this Contract. Notification shall be effected through the County Enrollment Reports. All members listed as an ADD or CONTINUE on either the Initial or Final County Enrollment Report are members of the County Managed Care Program during the enrollment month. The reports shall be generated in the sequence specified under the County Enrollment Reports. These reports shall be in hard copy formats or available through electronic file transfer capability and shall include medical status codes.
FUNCTIONS AND DUTIES OF THE DEPARTMENT. Department of Health Services Notification of Changes in Functional Eligibility Criteria Reports from the Contractors
FUNCTIONS AND DUTIES OF THE DEPARTMENT. A. Utilization Review and Control The Department will waive, to the extent allowed by law, any present Department requirements for prior authorization, second opinions, , or other BadgerCare Plus and/or Medicaid SSI restrictions for the provision of contract services provided by the HMO to members, except as may be required by the terms of this contract.
B. Department Audit Schedule The HMO will be notified approximately 30 days prior to regularly scheduled, routine audits being conducted via a letter from the Department.
C. HMO Review of Study or Audit Results The Department will submit to the HMO for a 30 business day review/comment period, any BadgerCare Plus and/or Medicaid SSI and HMO audits, HMO report card, HMO Consumer Satisfaction Reports, or any other BadgerCare Plus and/or Medicaid SSI HMO studies the Department releases to the public that identifies the HMO by name. The HMO may request an extension and the Department will exercise reasonable discretion in making the determination to waive the 30 business day review/comment requirement.
D. Vaccines for Children (BadgerCare Plus Only) The Department will assure that HMO providers participate in the Vaccines for Children (VFC) program for administration of immunizations to BadgerCare Plus HMO members according to the policies and procedures in the Wisconsin Health Care Programs Online Handbook. The Department will reimburse the HMO for the cost of new vaccines that are newly approved during the contract year and not yet part of the Vaccine for Children program. The reimbursement of the vaccine shall be the same as the Department reimburses FFS providers during the period of VFC availability. The HMO retains liability for the cost of administering the vaccines.
E. Fraud and Abuse Training The Department will provide fraud and abuse detection training to the HMO annually. The Department will provide training for HMOs on implementation of suspension of payments to providers with a credible allegation of fraud.
F. Provision of Data to the HMO The Department will provide to the HMO immunization information from the Wisconsin Immunization Registry, to the extent available.
G. Conflict of Interest The Department will maintain state employee conflict of interest safeguards at least equal to federal safeguards (41 USC 423). ARTICLE XIV
FUNCTIONS AND DUTIES OF THE DEPARTMENT. 6.1 Eligibility Determinations
6.2 Ineligibility Determinations
6.3 Enrollment / Disenrollment
6.4 Lock-In / Open Enrollment
6.5 Capitation Payments to the MCO 6.6 Newborn Retroactive Adjustments 6.7 Information
FUNCTIONS AND DUTIES OF THE DEPARTMENT. 6.01 ELIGIBILITY DETERMINATIONS The DEPARTMENT or its agent will determine the initial and ongoing eligibility for the HUSKY B program of each Member enrolled under this contract in accordance with the DEPARTMENT'S eligibility policies.
FUNCTIONS AND DUTIES OF THE DEPARTMENT
