Intelligent Assignment. Enrollment activities specific to Two-Plan Counties and GMC Counties (Los Angeles, San Diego, San Bernardino, Santa Xxxxx, Riverside): 2.3.1.5.1. At least ninety (90) days prior to the start of the Cal MediConnect program, Contractor shall provide DHCS with a complete list of Network Providers and National Provider Identifier (NPI) numbers to assist in the assignment of eligible beneficiaries as part of the Passive Enrollment process. The Network Provider list will include all network providers for the Provider Network, where applicable. 2.3.1.5.2. Updates to the Network Provider list shall be sent to DHCS on a quarterly basis for the purposes of intelligent assignment, or as changes to the Provider Network are applied. 2.3.1.5.3. As part of the enrollment process, DHCS will initially assign an Enrollee to a Cal MediConnect Plan based on a hierarchical logic in accordance with Section 2.3.1.5.1. Enrollees shall have the ability to change Cal MediConnect Plans at any time. 2.3.1.5.3.1. DHCS shall utilize the following hierarchical logic to determine Primary Contractor Plan assignment: 2.3.1.5.3.1.1. If a beneficiary is in a Medi-Cal Managed Care Plan that is participating in the Cal MediConnect Program and is not enrolled in a Medicare Advantage product, DHCS will assign the beneficiary to the matching Cal MediConnect plan. 2.3.1.5.3.1.2. If the beneficiary is in a Medicare Advantage Dual Special Needs Plan owned by the parent organization of an MMP, DHCS will assign the beneficiary to the matching MMP. 2.3.1.5.3.1.3. If a beneficiary is in fee-for-service Medi-Cal and Medicare, DHCS will match the beneficiary’s highest utilized and paid prescribing and/or rendering provider data [based on the most recent and available twelve
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Intelligent Assignment. Enrollment activities specific to Two-Plan Counties and GMC Counties (Los Angeles, San Diego, San Bernardino, Santa Xxxxx, Riverside):
2.3.1.5.1. At least ninety (90) days prior to the start of the Cal MediConnect programOn a quarterly basis, Contractor shall provide DHCS with a complete list of Network Providers and National Provider Identifier (NPI) numbers to assist in the assignment of eligible beneficiaries as part of the Passive Enrollment process. The Network Provider list will include all network providers Network Providers for the Provider Network, where applicable.
2.3.1.5.2. Updates to the Network Provider list shall be sent to DHCS on a quarterly basis for the purposes of intelligent assignment, or as changes to the Provider Network are applied.
2.3.1.5.3. As part of the enrollment Enrollment process, DHCS will exclude individuals identified as at-risk or potentially at-risk for abuse or overuse of specified prescription drugs per 42 C.F.R. §§ 423.100 and 423.153(f).
2.3.1.5.4. As part of the Passive Enrollment process, DHCS will initially assign an Enrollee to a Cal MediConnect Plan based on a hierarchical logic in accordance with Section
Section 2.3.1.5.1. Subject to 42 C.F.R. §§ 423.100 and 423.153(f), Enrollees shall have the ability to change Cal MediConnect Plans at any time.
2.3.1.5.3.12.3.1.5.4.1. DHCS shall utilize the following hierarchical logic to determine Primary Contractor Plan assignment:
2.3.1.5.3.1.12.3.1.5.4.1.1. If a beneficiary is in a Medi-Cal Managed Care Plan that is participating in the Cal MediConnect Program and is not enrolled in a Medicare Advantage product, DHCS will assign the beneficiary to the matching Cal MediConnect plan.
2.3.1.5.3.1.22.3.1.5.4.1.2. If the beneficiary is in a Medicare Advantage Dual Special Needs Plan owned by the parent organization of an MMP, DHCS will assign the beneficiary to the matching MMP.
2.3.1.5.3.1.32.3.1.5.4.1.3. If a beneficiary is in fee-for-service Medi-Cal and Medicare, DHCS will match the beneficiary’s highest utilized and paid prescribing and/or rendering provider data [based on the most recent and available twelvetwelve (12) months of Medicare and Medi-Cal claim data] to the list of Network Providers supplied by the Contractor, in accordance with Section 2.3.1.5.1.
2.3.1.5.4.1.4. If only one (1) Cal MediConnect Plan is identified with the beneficiary’s provider(s) in its network, DHCS will assign the beneficiary to that Cal MediConnect Plan.
2.3.1.5.4.1.5. If two (2) or more Cal MediConnect Plans are identified or if there is insufficient claim data to match to a Cal MediConnect Plan, the system will select a Cal MediConnect Plan based on an equal distribution ratio. For example, if there are two (2) Cal MediConnect Plans in the county, DHCS will assign based on a 50/50 split. In San Diego, the system will divide beneficiary assignments equally across the four (4) Cal MediConnect Plans.
2.3.1.5.4.1.6. This distribution is dependent on Contractor capacity and subject to be altered per the direction of the Contract Management Team (CMT).
2.3.1.5.5. DHCS will notify CMS and the Contractor of the beneficiary assignments via the enrollment transactions sent to CMS and the 834 Enrollment file.
2.3.1.5.6. DHCS will inform the Contractor of the provider NPIs used in the plan selection process.
2.3.1.5.7. CMS will notify the Contractor of the beneficiary assignments via the Daily Transaction Response Reply (DTRR) file distributed through the CMS Enrollment Broker.
2.3.1.5.8. Contractor is responsible for outreach to the Network Provider for enrollment related activities and for providing data to DHCS.
2.3.1.5.9. Contractor shall maintain systems to accept enrollment transactions from CMS’ and the State’s systems. Contractor shall process enrollment and disenrollment transactions according to the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance, posted at xxxx://xxx.xxx.xxx/Medicare-Medicaid- Coordination/Medicare-and-Medicaid-Coordination/Medicare- Medicaid-Coordination- Office/Downloads/MMPFinalEnrollGuidance.pdf
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Intelligent Assignment. Enrollment activities specific to Two-Plan Counties and GMC Counties (Alameda, Los Angeles, San Diego, San Bernardino, Santa Xxxxx, Riverside):
2.3.1.5.1. At least ninety (90) days prior to the start of the Cal MediConnect program, Contractor shall provide DHCS with a complete list of Network Providers and National Provider Identifier (NPI) numbers to assist in the assignment of eligible beneficiaries as part of the Passive Enrollment process. The Network Provider list will include all network providers for the Provider Network, where applicable.
2.3.1.5.2. Updates to the Network Provider list shall be sent to DHCS on a quarterly basis for the purposes of intelligent assignment, or as changes to the Provider Network are applied.
2.3.1.5.3. As part of the enrollment process, DHCS will initially assign an Enrollee to a Cal MediConnect Plan based on a hierarchical logic in accordance with Section
2.3.1.5.1. Enrollees shall have the ability to change Cal MediConnect Plans at any time.
2.3.1.5.3.1. DHCS shall utilize the following hierarchical logic to determine Primary Contractor Plan assignment:
2.3.1.5.3.1.1. If a beneficiary is in a Medi-Cal Managed Care Plan that is participating in the Cal MediConnect Program and is not enrolled in a Medicare Advantage product, DHCS will assign the beneficiary to the matching Cal MediConnect Prime Contractor plan.
2.3.1.5.3.1.2. If the beneficiary is in a Medicare Advantage Dual Special Needs Plan owned by the parent organization of an MMP, DHCS will assign the beneficiary to the matching MMP.
2.3.1.5.3.1.3. If a beneficiary is in fee-for-service Medi-Cal and Medicare, DHCS will match the beneficiary’s highest utilized and paid prescribing and/or rendering provider data [based on the most recent and available twelve
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Samples: Contract
