Identification and Services for At-Risk Enrollees. Contractor agrees to identify and proactively manage Enrollees with existing and newly diagnosed need for dental treatment beyond diagnostic and preventive dental services and Enrollees with chronic conditions and who are most likely to benefit from well-coordinated care (“At-Risk Enrollees”). As described in Section 2.04, Contactor shall determine the health status of its new Enrollees including identification of those with chronic conditions or other significant dental needs within the first one hundred twenty (120) days of enrollment, provided the Exchange has provided timely notification of enrollment. The Exchange will work with Contractor to develop a documented process, care management plan, and strategy for targeting At-Risk Enrollees. Such documentation may include the following:
(a) Methods to identify and target At-Risk Enrollees;
(b) Description of Contractor’s predictive analytic capabilities to assist in identifying At-Risk Enrollees who would benefit from early, proactive intervention;
(c) Communication plan for known At-Risk Enrollees to receive information prior to provider visit;
(d) Process to update At-Risk Enrollee dental history in the Contractor maintained Plan Enrollee health profile;
(e) Mechanisms to evaluate access within provider network, on an ongoing basis, to ensure that an adequate network is in place to support a proactive intervention and care management program for At-Risk Enrollees;
(f) Care and network strategies that focus on supporting a proactive approach to At-Risk Plan Enrollee intervention and care management. Contractor agrees to provide the Exchange with a documented plan and include “tools” and strategies to supplement or expand care management and Provider network capabilities, including an expansion or reconfiguration of specialties or health care professionals to meet clinical needs of At-Risk Enrollees.
Identification and Services for At-Risk Enrollees. Contractor agrees to identify and proactively manage the Plan Enrollees with existing and newly diagnosed chronic conditions and who are most likely to benefit from well-coordinated care (“At-Risk Enrollees”). Contractor will target the at risk enrollees, typically with one or more conditions, including, but not limited to, diabetes, asthma, heart disease or hypertension. As described in sections 3.06, Contactor shall determine the health status of its new enrollees that includes identification of chronic conditions and other significant health needs within the first one hundred twenty (120) days of enrollment, provided the Exchange has provided timely notification of enrollment. Contractor will provide the Exchange with a documented process, care management plan and strategy for targeting these specific Enrollees, which will include the following:
(a) Methods to identify and target At-Risk Enrollees;
(b) Description of Contractor’s predictive analytic capabilities to assist in identifying At Risk Plan Enrollees who would benefit from early, proactive intervention;
(c) Communication plan for known At-Risk Enrollees to receive information prior to provider visit;
Identification and Services for At-Risk Enrollees. Contractor agrees to identify and proactively manage Enrollees with existing and newly diagnosed need for dental treatment beyond diagnostic and preventive dental services and Enrollees with chronic conditions and who are most likely to benefit from well-coordinated care (“At-Risk Enrollees”). Contractor agrees to support disease management activities at the plan or dental provider level that meet standards of accrediting programs such as the Utilization Review Accreditation Commission (URAC). As described in Section 2.04, Contactor shall determine the health status of its new Enrollees including identification of those with chronic conditions or other significant dental needs within the first one hundred twenty (120) days of enrollment, provided Covered California has provided timely notification of enrollment. Covered California will work with Contractor to develop a documented process, care management plan, and strategy for targeting At-Risk Enrollees. Such documentation may include the following:
(a) Methods to identify and target At-Risk Enrollees;
(b) Description of Contractor’s predictive analytic capabilities to assist in identifying At-Risk Enrollees who would benefit from early, proactive intervention;
(c) Communication plan for known At-Risk Enrollees to receive information prior to provider visit;
(d) Process to update At-Risk Enrollee dental history in the Contractor maintained Plan Enrollee health profile;
(e) Mechanisms to evaluate access within provider network, on an ongoing basis, to ensure that an adequate network is in place to support a proactive intervention and care management program for At-Risk Enrollees;
(f) Care and network strategies that focus on supporting a proactive approach to At-Risk Plan Enrollee intervention and care management. Contractor agrees to provide Covered California with a documented plan and include “tools” and strategies to supplement or expand care management and Provider network capabilities, including an expansion or reconfiguration of specialties or health care professionals to meet clinical needs of At-Risk Enrollees.
(g) Data on number of Enrollees identified and types of services provided.
Identification and Services for At-Risk Enrollees. Contractor agrees to identify and proactively manage the Plan Enrollees with existing and newly diagnosed chronic conditions and who are most likely to benefit from well-coordinated care (“At-Risk Enrollees”). Contractor will target at-risk enrollees, typically with one or more conditions, including, but not limited to, diabetes, asthma, heart disease or hypertension. As described in Section 3.06, Contactor shall determine the health status of its
Identification and Services for At-Risk Enrollees. Contractor agrees to identify and proactively manage the Plan Enrollees with existing and newly diagnosed chronic conditions and who are most likely to benefit from well-coordinated care (“At-Risk Enrollees”). Contractor will target the at risk enrollees, typically with one or more conditions, including, but not limited to, diabetes, asthma, heart disease or hypertension. As described in sections 3.06, Contactor shall determine the health status of its
(a) Methods to identify and target At-Risk Enrollees;
(b) Description of Contractor’s predictive analytic capabilities to assist in identifying At Risk Plan Enrollees who would benefit from early, proactive intervention;
(c) Communication plan for known At-Risk Enrollees to receive information prior to provider visit;
Identification and Services for At-Risk Enrollees. Contractor agrees to identify and proactively manage the Plan Enrollees with existing and newly diagnosed chronic conditions and who are most likely to benefit from well-coordinated care (“at- risk plan enrollees”). Contractor will target the highest risk individuals, typically with one or more conditions, including, but not limited to, diabetes, asthma, heart disease or hypertension.
(a) Methods to identify and target At Risk Enrollees; (b) Description of Contractor’s predictive analytic capabilities to assist in identifying At Risk Plan Enrollees who would benefit from early, proactive intervention; (c) Communication plan for known At Risk Enrollees to receive information prior to provider visit; (d) Process to update At Risk Enrollee medical history in the Contractor maintained Plan Enrollee health profile; (e) Mechanisms to evaluate access within provider network, on an ongoing basis, to ensure that an adequate network is in place to support a proactive intervention and care management program for At Risk Enrollees; (f) Care and network strategies that focuses on supporting a proactive approach to at-risk Plan Enrollee intervention and care management. Contractor agrees to provide the Exchange with a documented plan and include “tools” and strategies to supplement and/or expand care management and provider network capabilities, including an expansion and/or reconfiguration of specialties or health care professionals to meet clinical needs of At Risk Enrollees.
Identification and Services for At-Risk Enrollees. Contractor agrees to identify and proactively manage the Plan Enrollees with existing and newly diagnosed chronic conditions and who are most likely to benefit from well-coordinated care (“at-risk plan enrollees”). Contractor will target the highest risk individuals, typically with one or more conditions, including, but not limited to, diabetes, asthma, heart disease or hypertension. Contactor shall be required to identify Plan Enrollees with chronic conditions and other significant health needs within the first ninety (90) days of enrollment. Contractor will provide the Exchange with a documented process, care management plan and strategy for targeting these specific Enrollees, which will include the following:
(a) Methods to identify and target At Risk Enrollees
(b) Description of Contractor’s predictive analytic capabilities to assist in identifying At Risk Plan Enrollees who would benefit from early, proactive intervention
(c) Communication plan for At Risk Enrollees to receive information prior to provider visit
(d) Process to update At Risk Enrollee medical history in the Contractor maintained Plan Enrollee health profile
(e) Mechanisms to evaluate access within provider network, on an ongoing basis, to ensure that an adequate network is in place to support a proactive intervention and care management program for At Risk Enrollees
(f) Care and network strategies that focuses on supporting a proactive approach to at-risk Plan Enrollee intervention and care management. Contractor agrees to provide the Exchange with a documented plan and include “tools” and strategies to supplement and/or expand care management and provider network capabilities, including an expansion and/or reconfiguration of specialties or health care professionals to meet clinical needs of At Risk Plan Enrollees.
(g) Strategies or “tools” not otherwise described in Section 7.03 may include but are not limited to the following:
(i) Enrollment of At Risk Enrollees in care, case and disease management program(s)
(ii) At Risk Plan Enrollee’s access to Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMH), Ambulatory ICUs or other new delivery models designed to focus on individual chronic condition management and focused intervention. If new models exist, Contractor shall provide the Exchange with Contractor’s available capacity to accept new Plan Enrollees
Identification and Services for At-Risk Enrollees. Contractor agrees to identify and proactively manage the Plan Enrollees with existing and newly diagnosed need for dental treatment beyond diagnostic and preventive dental services and Plan Enrollees with chronic conditions and who are most likely to benefit from well-coordinated care (“At-Risk Enrollees”). As described in Section 2.04, Contactor shall determine the health status of its new enrollees including identification of those with chronic conditions or other significant dental needs within the first one hundred twenty (120) days of enrollment, provided the Exchange has provided timely notification of enrollment. The Exchange will work with Contractor to develop a documented process, care management plan and strategy for targeting these specific Enrollees. Such documentation may include the following:
Identification and Services for At-Risk Enrollees. Contractor agrees to identify and proactively manage the Plan Enrollees with existing and newly diagnosed need for dental treatment beyond diagnostic and preventive dental services and Plan Enrollees with chronic conditions and who are most likely to benefit from well-coordinated care (“At-Risk Enrollees”). As described in sections 3.04, Contactor shall determine the health status of its new enrollees that includes identification of chronic conditions and other significant health dental needs within the first one hundred twenty (120) days of enrollment, provided the Exchange has provided timely notification of enrollment. The Exchange will work with Contractor to develop will provide the Exchange with a documented process, care management plan and strategy for targeting these specific Enrollees, which will include the following:
(a) Methods to identify and target At-Risk Enrollees;
(b) Description of Contractor’s predictive analytic capabilities to assist in identifying At Risk Plan Enrollees who would benefit from early, proactive intervention;
(c) Communication plan for known At-Risk Enrollees to receive information prior to provider visit;
