Common use of HOOSIER HEALTHWISE SCOPE OF WORK Clause in Contracts

HOOSIER HEALTHWISE SCOPE OF WORK. Effective April 1, 2020, if the Contractor chooses to use a list of diagnosis codes to initially determine whether a service may be an emergency, the MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. By April 1, 2020 the Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers:  Where to submit medical records for prudent layperson review.  That the provider has 120 days to submit medical records for prudent layperson review.  The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.  A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line and pay claims resulting from such referral as emergent.  A mechanism, policies and procedures for conducting prudent layperson reviews within 30 days of receiving medical records.  A mechanism and process to accept medical records for a prudent layperson review with an initial claim and after a claim has processed. For dates of service after April 1, 2020 the MCE must at a minimum allow a provider to submit medical records for a prudent layperson review within 120 days of a claim’s adjudication. EXHIBIT 1.E

HOOSIER HEALTHWISE SCOPE OF WORK. Effective April 1, 2020, if the Contractor chooses to use a list of diagnosis codes to initially determine whether a service may be an emergency, the MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. By April 1, 2020 the Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers:  ▪ Where to submit medical records for prudent layperson review.  ▪ That the provider has 120 days to submit medical records for prudent layperson review.  ▪ The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  ▪ A mechanism in place for a plan provider or Contractor representative to respond within one (1) hour to all emergency room providers twenty four (24) hours-a-day, seven (7) days-a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  ▪ A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  ▪ A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.  ▪ A mechanism in place to document a member’s referral to the emergency room by the Contractor’s 24-Hour Nurse Call Line and pay claims resulting from such referral as emergent.  ▪ A mechanism, policies and procedures for conducting prudent layperson reviews within 30 days of receiving medical records.  ▪ A mechanism and process to accept medical records for a prudent layperson review with an initial claim and after a claim has processed. For dates of service after April 1, 2020 the MCE must at a minimum allow a provider to submit medical records for a prudent layperson review within 120 days of a claim’s adjudication. EXHIBIT 1.E