Common use of Grievance System Summaries Clause in Contracts

Grievance System Summaries. Information regarding Grievances, Appeals and Denial, Termination, or Reduction (DTR) Notices as required under Article 8. Administration and Subcontracting Information. Information relating to MCO administration and subcontracting arrangements, as specified by the STATE and CMS. Reporting Requirement if using an alternative arrangement for Health Care Home. The MCO shall annually provide a description of each comprehensive payment arrangement and its proposed outcome or performance measures, that the MCO uses as an alternative to Health Care Homes payment in a reporting template provided by the STATE. The template shall include the following: Identify each Certified Health Care Home for whom the MCO is paying a comprehensive payment arrangement instead of the standard Health Care Home care coordination fee. Number of Enrollees served under each arrangement; Description of payment arrangements;‌ Scope of the services included in the arrangement (for example, if a total cost of care, whether long term care, Medicare and Medicaid costs and chemical, mental and/or behavioral health services are included, and whether any services are carved out of the arrangement); Describe the MCO’s process for overseeing the entities and evaluating their performance; Describe quality indicators used to measure performance; Describe the benchmarks used to determine whether the Provider entity is within the cost of care expectations. The completed template is due September 1 of the Contract Year. Reporting Requirement for ICSP. The MCO shall annually provide information on ICSPs described in section 7.9 below and ICSP outcome or performance, using formats provided by the STATE. The MCO shall report aggregate ICSP payments and recipients, separated by payment type and project type by September 1 of the Contract Year, as requested by the STATE and using the template provided. The MCO shall cooperate with the STATE to document ICSP case study briefs by September 1 of the Contract Year, as requested by the STATE and using the template provided. The MCO must provide briefs for at least the minimum required number and type of ICSP arrangements, and is encouraged to provide briefs describing all ICSP arrangements. The briefs shall be used for the purpose of identifying innovations due to the program. Third Party Resources. Pursuant to section 10.2, the MCO shall report to the STATE any additional Third Party Resources, including Long Term Care Insurance, except for Medicare. Third Party Payments. Pursuant to section 10.4 the MCO shall report all recovery and Cost Avoidance amounts on the encounter claim as Third Party Liability payments. For MSC+, Medicare cost avoidance and recovery amounts must include fee-for-service Medicare. For MSHO, the MCO shall provide a separate report that is an estimate of Medicare payment, and may base the estimate on the methodology used for submitting bids to CMS to derive the amount. Quality Assurance Work Plan. The MCO shall submit its Quality Assurance Workplan, pursuant to Article 7. If the MCO has submitted this report under its PMAP Families and Children contract, and that report addresses MSHO and MSC+ Enrollees, this report is waived. Disclosure of Ownership and Management Information (MCO). By September 1st of the Contract Year, the MCO shall report to the STATE full disclosure information in order to assure compliance with 42 CFR § 455.104. The MCO shall also report full disclosure information upon request from the STATE or within thirty-five (35) days of a change in MCO ownership. The required information includes: The name, address, date of birth, social security number (in the case of an individual) and tax identification number (in the case of a corporation) of each Person, with an Ownership or Control Interest in the MCO or in any subcontractor in which the MCO has direct or indirect ownership of five percent (5%) or more. The address for corporate entities must include primary business address, every business location and P.O. box address; A statement as to whether any Person with an Ownership or Control Interest in the MCO or in any subcontractor as identified in section 3.7.2(Q)(1) is related (if an individual) to any other Person with an Ownership or Control interest as a spouse, parent, child, or sibling; The name of any other disclosing entity in which a Person with an Ownership or Control Interest in the MCO also has an ownership or control interest in the other disclosing entity; and The name, address, date of birth, and social security number of any Managing Employee of the MCO. This information must be accompanied by a data certification pursuant to section 9.10

Grievance System Summaries. Information regarding Grievances, Appeals and Denial, Termination, or Reduction (DTR) Notices as required under Article 8. Administration and Subcontracting Information. Information relating to MCO administration and subcontracting arrangements, as specified by the STATE and CMS. Reporting Requirement if using an alternative arrangement for Health Care Home. The MCO shall annually provide a description of each comprehensive payment arrangement and its proposed outcome or performance measures, that the MCO uses as an alternative to Health Care Homes payment in a reporting template provided by the STATE. The template shall include the following: Identify each Certified Health Care Home for whom the MCO is paying a comprehensive payment arrangement instead of the standard Health Care Home care coordination fee. Number of Enrollees served under each arrangement; Description of payment arrangements;‌ Scope of the services included in the arrangement (for example, if a total cost of care, whether long term care, Medicare and Medicaid costs and chemical, mental and/or behavioral health services are included, and whether any services are carved out of the arrangement); Describe the MCO’s process for overseeing the entities and evaluating their performance; Describe quality indicators used to measure performance; Describe the benchmarks used to determine whether the Provider entity is within the cost of care expectations. The completed template is due September 1 of the Contract Year. Reporting Requirement for ICSP. The MCO shall annually provide information on ICSPs described in section 7.9 below and ICSP outcome or performance, using formats provided by the STATE. The MCO shall report aggregate ICSP payments and recipients, separated by payment type and project type by September 1 of the Contract Year, as requested by the STATE and using the template provided. The MCO shall cooperate with the STATE to document ICSP case study briefs by September 1 of the Contract Year, as requested by the STATE and using the template provided. The MCO must provide briefs for at least the minimum required number and type of ICSP arrangements, and is encouraged to provide briefs describing all ICSP arrangements. The briefs shall be used for the purpose of identifying innovations due to the program. Third Party Resources. Pursuant to section 10.2, the MCO shall report to the STATE any additional Third Party Resources, including Long Term Care Insurance, except for Medicare. Third Party Payments. Pursuant to section 10.4 the MCO shall report all recovery and Cost Avoidance amounts on the encounter claim as Third Party Liability payments. For MSC+, Medicare cost avoidance and recovery amounts must include fee-for-service Medicare. For MSHO, the MCO shall provide a separate report that is an estimate of Medicare payment, and may base the estimate on the methodology used for submitting bids to CMS to derive the amount. Quality Assurance Work Plan. The MCO shall submit its Quality Assurance Workplan, pursuant to Article 7. If the MCO has submitted this report under its PMAP Families and Children contract, and that report addresses MSHO and MSC+ Enrollees, this report is waived. Disclosure of Ownership and Management Information (MCO). By September 1st of the Contract Year, the MCO shall report to the STATE full disclosure information in order to assure compliance with 42 CFR § 455.104. The MCO shall also report full disclosure information upon request from the STATE or within thirty-five (35) days of a change in MCO ownership. The required information includes: The name, address, date of birth, social security number (in the case of an individual) and tax identification number (in the case of a corporation) of each Person, with an Ownership or Control Interest in the MCO or in any subcontractor in which the MCO has direct or indirect ownership of five percent (5%) or more. The address for corporate entities must include primary business address, every business location and P.O. box address; address;‌ A statement as to whether any Person with an Ownership or Control Interest in the MCO or in any subcontractor as identified in section 3.7.2(Q)(1) is related (if an individual) to any other Person with an Ownership or Control interest as a spouse, parent, child, or sibling; The name of any other disclosing entity in which a Person with an Ownership or Control Interest in the MCO also has an ownership or control interest in the other disclosing entity; and The name, address, date of birth, and social security number of any Managing Employee of the MCO. This information must be accompanied by a data certification pursuant to section 9.10