Healthy Opportunities Pilot Service Authorization Sample Clauses

Healthy Opportunities Pilot Service Authorization i. Within NCCARE360, the PIHP shall review the Designated Pilot Care Management Entity’s recommended Healthy Opportunities Pilot services for a Member and verify whether the Member is eligible for the recommended Healthy Opportunities Pilot service(s). (a) The PIHP shall verify that the Member meets the Healthy Opportunities Pilot service-specific eligibility criteria as articulated in the Healthy Opportunities Pilot Fee Schedule (xxxxx://xxx.xxxxxx.xxx/healthy-opportunities-pilot-fee-schedule-and-service- definitions/open). (b) The PIHP shall review any required documentation or narrative for Healthy Opportunities Pilot services in NCCARE360 if required by the Healthy Opportunities Pilot Fee Schedule (e.g., Member attestation of enrollment in SNAP or recent determination of SNAP ineligibility for a healthy food box). ii. The PIHP shall make best efforts to validate that no other federal, State or local service, resource or program is available (including Medicaid State Plan services, 1915(i) services, Medicaid waiver services, State-funded Services provided by the PIHP, or other resources or programs available to the Member, including those provided by the PIHP) and would better meet the Member’s needs at the time of Healthy Opportunities Pilot service authorization. (a) For this Section 2.j.ii., the Department defines “best efforts” as using: 1. The PIHP’s understanding of its own covered services, such as Medicaid State Plan services, Medicaid waiver services, and State-funded Services provided by the PIHP; 2. The PIHP’s understanding of other federal, State, and locally funded services and programs, such as SNAP and WIC; and 3. Department resources available to assist with this effort. (b) If a Member’s need(s) may be met by either an In Lieu-Of Service (ILOS) offered by the PIHP or a Healthy Opportunities Pilot service (i.e., the Healthy Opportunities Pilot service is a component of the ILOS or the Healthy Opportunities Pilot service and the ILOS essentially offer the same or substantially similar services) and the Member is eligible for both the ILOS and the Pilot service, the PIHP shall provide the ILOS. 1. The PIHP shall identify whether an ILOS is duplicative of a Healthy Opportunities Pilot service when submitting new ILOS and Value-Added Services to the Department for approval. 2. The PIHP shall make available, upon request, an analysis of ILOS that were approved by the Department thirty (30) Calendar Days prior to PIHP launch of Healthy Opportu...
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