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 approves a Just Cause Disenrollment. D. ENROLLMENT ERRORS The Department must investigate enrollment errors brought to its attention by the County. The Department must correct systems errors and human errors and ensure that the County is not financially responsible for members that the Department determines have been enrolled in error. Capitation payments made in error will be recouped. E. COUNTY ENROLLMENT REPORTS For each month of coverage throughout the term of the Contract, the Department will transmit “County Enrollment Reports” to the County. These reports will provide the County with ongoing information about its BadgerCare Plus members and disenrollees and will be used as the basis for the monthly capitation claims. County Enrollment Reports will be generated in the following sequence: 1. The Initial County Enrollment Report will list all of the County’s members and disenrollees for the enrollment month that are known on the date of report generation. The Initial County Enrollment Report will be available to the County on or about the twenty-first day of each month. A capitation claim shall be generated for each member listed as an ADD or CONTINUE on this report. Members who appear as PENDING on the Initial Report and are reinstated into the County prior to the end of the month will appear CONTINUE on the Final Report, and a capitation claim shall be generated according to the conditions of this Contract. 2. The final County Enrollment Report will list all of the County’s members for the enrollment month that were not included in the Initial County Enrollment Report. The Final County Enrollment Report will be available to the County by the first day of the capitation month. A capitation claim shall be generated for each member listed as an ADD or CONTINUE on this report according to the conditions of this Contract. Members in PENDING status will not be included on the final report. 3. Members will be enrolled effective the date the enrollment request is received by the Department. The County will not receive a regular capitation payment for the month of enrollment. The DHS will reimburse the County for partial months of enrollment through payment of a daily rate. The daily rate will be equal to the monthly capitation multiplied by 12 and divided by 365. F. COUNTY REVIEW Submit to the County for prior approval materials that describe the County and that will be distributed by the Department or the County to members. G. COUNTY REVIEW OF STUDY OR AUDIT RESULTS Submit to the County for a 30 business day review/comment period, any Medicaid audits, comparison reports, consumer satisfaction reports, or any other studies the Department releases to the public. The review/comment period will commence on the fifth business day after the audit report was mailed. The County may request an extension and the Department will exercise reasonable discretion in making the determination to waive the 30 business day review/comment requirement. H. FRAUD AND ABUSE TRAINING The Department will provide fraud and abuse detection training to the County annually. ARTICLE VI
Appears in 1 contract
Samples: Contract for Services
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, Verified 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 Partnershipsthe County.
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 approves a Just Cause Disenrollment.
D. ENROLLMENT ERRORS The Department must investigate enrollment errors brought to its attention by the County. The Department must correct systems errors and human errors and ensure that the County is not financially responsible for members that the Department determines have been enrolled in error. Capitation payments made in error will be recouped.
E. COUNTY ENROLLMENT REPORTS For each month of coverage throughout the term of the Contract, the Department will transmit “County Enrollment Reports” to the County. These reports will provide the County with ongoing information about its BadgerCare Plus members and disenrollees and will be used as the basis for the monthly capitation claims. County Enrollment Reports will be generated in the following sequence:
1. The Initial County Enrollment Report will list all of the County’s members and disenrollees for the enrollment month that are known on the date of report generation. The Initial County Enrollment Report will be available to the County on or about the twenty-first day of each month. A capitation claim shall be generated for each member listed as an ADD or CONTINUE on this report. Members who appear as PENDING on the Initial Report and are reinstated into the County prior to the end of the month will appear CONTINUE on the Final Report, and a capitation claim shall be generated according to the conditions of this Contract.
2. The final County Enrollment Report will list all of the County’s members for the enrollment month that were not included in the Initial County Enrollment Report. The Final County Enrollment Report will be available to the County by the first day of the capitation month. A capitation claim shall be generated for each member listed as an ADD or CONTINUE on this report according to the conditions of this Contract. Members in PENDING status will not be included on the final report.
3. Members will be enrolled effective the date the enrollment request is received by the Department. The County will not receive a regular capitation payment for the month of enrollment. The DHS will reimburse the County for partial months of enrollment through payment of a daily rate. The daily rate will be equal to the monthly capitation multiplied by 12 and divided by 365.
F. COUNTY REVIEW Submit to the County for prior approval materials that describe the County and that will be distributed by the Department or the County to members.
G. COUNTY REVIEW OF STUDY OR AUDIT RESULTS Submit to the County for a 30 business day review/comment period, any Medicaid audits, comparison reports, consumer satisfaction reports, or any other studies the Department releases to the public. The review/comment period will commence on the fifth business day after the audit report was mailed. The County may request an extension and the Department will exercise reasonable discretion in making the determination to waive the 30 business day review/comment requirement.
H. FRAUD FRAUD, WASTE AND ABUSE TRAINING The Department will provide fraud fraud, waste and abuse detection training to the County annually. ARTICLE VI.
Appears in 1 contract
Samples: Contract for Services
FUNCTIONS AND DUTIES OF THE DEPARTMENT. In consideration of the functions and duties of the County contained in this Contract, the Department shall:
A. will: ELIGIBILITY DETERMINATION VerifyDETERMINATION----Verify, at the time of enrollment, enrollment that members identified on the enrollment requests from the County are:
1. : BadgerCare Plus – Standard Plan 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, 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 the Administrative Review Board (ARB). 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 . 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 – Standard Plan 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 approves a Just Cause Disenrollment.
D. disenrollment. ENROLLMENT ERRORS ERRORS --- The Department must investigate enrollment errors brought to its attention by the County. The Department must correct systems errors and human errors and ensure that the County is not financially responsible for members that the Department determines have been enrolled in error. Capitation payments made in error will be recouped.
E. . COUNTY ENROLLMENT REPORTS For REPORTS----For each month of coverage throughout the term of the Contract, the Department will transmit “County Enrollment Reports” to the County. These reports will provide the County with ongoing information about its BadgerCare Plus members and disenrollees and will be used as the basis for the monthly capitation claims. County Enrollment Reports will be generated in the following sequence:
1. : The Initial County Enrollment Report will list all of the County’s members and disenrollees for the enrollment month that are known on the date of report generation. The Initial County Enrollment Report will be available to the County on or about the twenty-first day of each month. A capitation claim shall be generated for each member listed as an ADD or CONTINUE on this report. Members who appear as PENDING on the Initial Report and are reinstated into the County prior to the end of the month will appear CONTINUE on the Final Report, and a capitation claim shall be generated according to the conditions of this Contract.
2. The final County Enrollment Report will list all of the County’s members for the enrollment month that were not included in the Initial County Enrollment Report. The Final County Enrollment Report will be available to the County by the first day of the capitation month. A capitation claim shall be generated for each member listed as an ADD or CONTINUE on this report according to the conditions of this Contract. Members in PENDING status will not be included on the final report.
3. Members will be enrolled effective the date the enrollment request is received by the Department. The County will not receive a regular capitation payment for the month of enrollment. The DHS will reimburse the County for partial months of enrollment through payment of a daily rate. The daily rate will be equal to the monthly capitation multiplied by 12 and divided by 365.
F. . COUNTY REVIEW Submit REVIEW----Submit to the County for prior approval materials that describe the County and that will be distributed by the Department or the County to members.
G. . COUNTY REVIEW OF STUDY OR AUDIT RESULTS Submit RESULTS----Submit to the County for a 30 business day review/comment period, any Medicaid audits, comparison reports, consumer satisfaction reports, or any other studies the Department releases to the public. The review/comment period will commence on the fifth business day after the audit report was mailed. The County may request an extension and the Department will exercise reasonable discretion in making the determination to waive the 30 business day review/comment requirement.
H. . FRAUD AND ABUSE TRAINING The TRAINING----The Department will provide fraud and abuse detection training to the County annually. ARTICLE VIVI
Appears in 1 contract
Samples: Contract for Services
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 DETERMINATION Verify, at the time of enrollment, enrollment that members recipients identified on the enrollment requests from the County are:
1. Medicaid eligible, including Medicaid/BadgerCare Plus eligible, if all other enrollment eligibility requirements are met.
2. Under 19 18 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, 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 CountyCounty and, if necessary, to access services, a client of the County Human Services Department.
8. Have been screened as eligible for services by Community Partnershipsthe Administrative Review Board (ARB).
B. ENROLLMENT ENROLLMENT Promptly notify the County of all Medicaid/BadgerCare Plus members recipients enrolled under this Contract. Notification shall be effected through the County Enrollment Reports. All members recipients 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 both tape and hard copy formats or available through electronic file transfer capability and shall include medical status codes.
C. DISENROLLMENT DISENROLLMENT Promptly notify the County of all Medicaid/BadgerCare Plus members recipients 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 recipient 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 Enrollees will be disenrolled if either:
1. Member Enrollee loses Medicaid/BadgerCare Plus eligibility.
2. Member Enrollee loses Dane County eligibility.
3. Member Enrollee is disenrolled upon their request.
4. Member Enrollee completes the program.
5. Court ordered correctional placements.
6. Member Enrollee is 19 years of age or older.
7. The Department approves a Just Cause Disenrollmentdisenrollment.
D. ENROLLMENT ERRORS ERRORS --- The Department must investigate enrollment errors brought to its attention by the County. The Department must correct systems errors and human errors and ensure that the County is not financially responsible for members recipients that the Department determines have been enrolled in error. Capitation payments made in error will be recouped.
E. COUNTY ENROLLMENT REPORTS REPORTS For each month of coverage throughout the term of the Contract, the Department will shall transmit “County Enrollment Reports” to the County. These reports will provide the County with ongoing information about its Medicaid/BadgerCare Plus members enrollees and disenrollees and will be used as the basis for the monthly capitation claims. County Enrollment Reports will be generated in the following sequence:
1. The Initial County Enrollment Report will list all of the County’s members enrollees and disenrollees for the enrollment month that are known on the date of report generation. The Initial County Enrollment Report will be available to the County on or about the twenty-first day of each month. A capitation claim shall be generated for each member enrollee listed as an ADD or CONTINUE on this report. Members Enrollees who appear as PENDING on the Initial Report and are reinstated into the County prior to the end of the month will appear CONTINUE on the Final Report, and a capitation claim shall be generated according to the conditions of this Contract.
2. The final County Enrollment Report will list all of the County’s members enrollees for the enrollment month that were not included in the Initial County Enrollment Report. The Final County Enrollment Report will be available to the County by the first day of the capitation month. A capitation claim shall be generated for each member recipient listed as an ADD or CONTINUE on this report according to the conditions of this Contract. Members Enrollees in PENDING status will not be included on the final report.
3. Members Recipients will be enrolled effective the date the enrollment request is received by the Department. The County will not receive a regular capitation payment for the month of enrollment. The DHS DHFS will reimburse the County for partial months of enrollment through payment of a daily rate. The daily rate will be equal to the monthly capitation multiplied by 12 and divided by 365.
F. COUNTY REVIEW REVIEW Submit to the County for prior approval materials that describe the County and that will be distributed by the Department or the County to membersrecipients.
G. COUNTY REVIEW OF STUDY OR AUDIT RESULTS RESULTS Submit to the County for a 30 business day review/comment period, any Medicaid audits, comparison reports, consumer satisfaction reports, or any other studies the Department releases to the public. The review/comment period will commence on the fifth business day after the audit report was mailed. The County may request an extension and the Department will exercise reasonable discretion in making the determination to waive the 30 business day review/comment requirement.
H. FRAUD AND ABUSE TRAINING TRAINING The Department will provide fraud and abuse detection training to the County annually. ARTICLE VI.
Appears in 1 contract
Samples: Contract for Services
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 DETERMINATION Verify, at the time of enrollment, enrollment that members identified on the enrollment requests from the County are:
1. Medicaid eligible, including BadgerCare Plus eligible, if all other enrollment eligibility requirements are met.
2. Under 19 18 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, 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 Partnershipsthe Administrative Review Board (ARB).
B. ENROLLMENT 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 both tape and hard copy formats or available through electronic file transfer capability and shall include medical status codes.
C. DISENROLLMENT 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 recipient 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 Member loses BadgerCare Plus eligibility. 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 approves a Just Cause Disenrollment.
D. ENROLLMENT ERRORS The Department must investigate enrollment errors brought to its attention by the County. The Department must correct systems errors and human errors and ensure that the County is not financially responsible for members that the Department determines have been enrolled in error. Capitation payments made in error will be recouped.
E. COUNTY ENROLLMENT REPORTS For each month of coverage throughout the term of the Contract, the Department will transmit “County Enrollment Reports” to the County. These reports will provide the County with ongoing information about its BadgerCare Plus members and disenrollees and will be used as the basis for the monthly capitation claims. County Enrollment Reports will be generated in the following sequence:
1. The Initial County Enrollment Report will list all of the County’s members and disenrollees for the enrollment month that are known on the date of report generation. The Initial County Enrollment Report will be available to the County on or about the twenty-first day of each month. A capitation claim shall be generated for each member listed as an ADD or CONTINUE on this report. Members who appear as PENDING on the Initial Report and are reinstated into the County prior to the end of the month will appear CONTINUE on the Final Report, and a capitation claim shall be generated according to the conditions of this Contract.
2. The final County Enrollment Report will list all of the County’s members for the enrollment month that were not included in the Initial County Enrollment Report. The Final County Enrollment Report will be available to the County by the first day of the capitation month. A capitation claim shall be generated for each member listed as an ADD or CONTINUE on this report according to the conditions of this Contract. Members in PENDING status will not be included on the final report.
3. Members will be enrolled effective the date the enrollment request is received by the Department. The County will not receive a regular capitation payment for the month of enrollment. The DHS will reimburse the County for partial months of enrollment through payment of a daily rate. The daily rate will be equal to the monthly capitation multiplied by 12 and divided by 365.
F. COUNTY REVIEW Submit to the County for prior approval materials that describe the County and that will be distributed by the Department or the County to members.
G. COUNTY REVIEW OF STUDY OR AUDIT RESULTS Submit to the County for a 30 business day review/comment period, any Medicaid audits, comparison reports, consumer satisfaction reports, or any other studies the Department releases to the public. The review/comment period will commence on the fifth business day after the audit report was mailed. The County may request an extension and the Department will exercise reasonable discretion in making the determination to waive the 30 business day review/comment requirement.
H. FRAUD AND ABUSE TRAINING The Department will provide fraud and abuse detection training to the County annually. ARTICLE VI
Appears in 1 contract
Samples: Contract for Services
