MCO Responsibilities Sample Clauses
MCO Responsibilities. When the MCO becomes aware that a member intends to change the member’s residence, the MCO shall, in addition to updating its records when the change of address occurs, do the following: For Moves Within the Geographic Service Region: Inform the member of any changes in IDT staff, service providers or other aspects of the member's care plan that may result from the move. Complete Section D of the Family Care /Partnership /PACE Change Routing Form per instructions. The form is available at Family Care/Partnership/PACE/IRIS - Change Routing Form (F- 02404). Do not disenroll the member; only a transfer of Medicaid eligibility between income maintenance consortia is necessary if applicable. For Moves to Another Geographic Service Region Served by the MCO: Inform the member of any changes in IDT staff, service providers or other aspects of the member's care plan that will result from the move. Complete Section D of the Family Care /Partnership /PACE Change Routing Form per instructions. The form is available at Family Care/Partnership/PACE/IRIS - Change Routing Form (F- 02404). Do not disenroll the member; only a transfer of Medicaid eligibility between income maintenance consortia is necessary if applicable. Inform the member that options counseling is available from the ADRC or Tribal ADRS (if applicable) in the county to which the member is moving should the member wish to consider a change in MCO (if another MCO operates in the geographic service region) or in long-term care program. For Moves to Another Geographic Service Region Not Served by the MCO: Unless the move is due to an MCO-initiated placement in a nursing home or community residential facility, inform the member that she or he will be disenrolled, will need to select a different MCO, and that the IDT staff will help with this transition. Explain to the member that to assure uninterrupted services, and in the case of a member in the special home and community-based waiver eligibility group (Group B or B+) uninterrupted Medicaid eligibility, it is necessary to contact the ADRC or Tribal ADRS (if applicable) in the new county of residence to enroll in another MCO or another long-term care program, preferably with the same effective date as the disenrollment from the current MCO. The MCO should facilitate this contact and coordinate disenrollment/enrollment dates with the receiving ADRC or Tribal ADRS (if applicable). Complete Section D of the Family Care /Partnership /PACE Change Routing Form per i...
MCO Responsibilities. In those instances where the Contractor directly receives disenrollment forms, the Contractor will forward these disenrollments to the LDSS for processing within five (5) business days (or according to Section F of this Appendix). During pulldown week, these forms may be faxed to the LDSS with the hard copy to follow.
MCO Responsibilities. The Contractor must notify the LDSS in writing of any Enrollee that is pregnant within thirty (30) days of knowledge of the pregnancy. Notifications should be transmitted to the LDSS at least monthly. The notifications should contain the pregnant woman's name, Client ID Number (CIN), and the expected date of confinement (EDC).
MCO Responsibilities. In those instances in which the Contractor is marketing to persons already in receipt of Medicaid, the Contractor will submit plan enrollments to the LDSS, within a maximum of five (5) business days from the day the enrollment is received by the Contractor (unless otherwise agreed to by SDOH and LDSS).
MCO Responsibilities. The Contractor is also responsible for providing notification to individuals regarding their enrollment status as specified in Section A of this Appendix.
MCO Responsibilities. When the MCO becomes aware that a member intends to change her or his residence, the MCO shall, in addition to updating its records when the change of address occurs, do the following:
a. For Moves Within the Geographic Service Region:
i. Inform the member of any changes in IDT staff, service providers or other aspects of the member's care plan that may result from the move.
ii. Complete Section D of the Family Care /Partnership /PACE Change Routing Form per instructions. The form is available at Family Care/Partnership/PACE/IRIS - Change Routing Form (F- 02404). Do not disenroll the member; only a transfer of Medicaid eligibility between income maintenance consortia is necessary if applicable.
b. For Moves to Another Geographic Service Region Served by the MCO:
i. Inform the member of any changes in IDT staff, service providers or other aspects of the member's care plan that will result from the move.
ii. Complete Section D of the Family Care /Partnership /PACE Change Routing Form per instructions. The form is available at Family Care/Partnership/PACE/IRIS - Change Routing Form (F- 02404). Do not disenroll the member; only a transfer of Medicaid eligibility between income maintenance consortia is necessary if applicable.
iii. Inform the member that options counseling is available from the ADRC in the county to which the member is moving should the member wish to consider a change in MCO (if another MCO operates in the geographic service region) or in long term care program.
c. For Moves to Another Geographic Service Region Not Served by the MCO:
i. Unless the move is due to an MCO-initiated placement in a nursing home or community residential facility, inform the member that ii.
MCO Responsibilities. The MCO shall be responsible for duplication, mailing and postage expenses related to said notification;
MCO Responsibilities. Each of the MCOs shall transfer to a zero balance bank account to be set up by the Contractor, sufficient funds to cover the total payment of Claims to Pharmacies that are required to be made by the Contractor under this Contract. The Contractor must inform the MCOs in writing the amount of Claims to be paid, at least two (2) Business Days prior to the date when the actual payment will be made. The MCOs will automatically cause the transfer of the funds for the payment of the Claims to the Contractor’s zero balance account upon presentation of payment instructions. The MCOs must provide adequate notice to Contractor and ASES as to the transfer of funds. The zero balance bank account shall be utilized by the Contractor exclusively for the purpose of paying Claims to Pharmacies. As required in 42 CFR 447.511(c), MCOs are to provide Physician Administered Drug (“PAD”) Encounter Data based on date of service to Contractor for DUR reporting and Rebate processing and reporting within forty-five (45) Calendar Days after each quarterly Rebate period. The MCOs will electronically submit on a daily basis a list of all MCO’s Network Providers and a list of Enrollees to the PBM.
5.4.1 The notification will include all new Enrollees as of the Business Day before the notification is issued, and will be sent no later than the following Business Day after the Enrollment process has been completed (as signified by issuance of the Enrollee ID Card, either in person or by surface mail) or the Disenrollment process has been completed (as signified by the issuance of a Disenrollment notice). MCO shall also provide notice whenever an Enrollee previously enrolled with a different MCO selects another MCO as a new plan. Consistent with the requirements of Section 1927(d)(5) of the Social Security Act, some or all prescription drugs may be subject to Prior Authorization. All clinical Prior Authorizations shall be managed by the MCO according to policies and procedures established by the ASES Pharmacy and Therapeutics (“P&T”) Committee. Data regarding the approval or denial of clinical Prior Authorizations will be shared with the Contractor according to the timeframes established in the MCO contract with ASES. The MCOs are responsible for Enrollee Appeals of Adverse Benefit Determinations related to prescription drugs as established in the MCO contract with ASES.
5.7.1 Provide written notification to ASES and to the Contractor regarding the procedure for prescribing drugs not includ...
MCO Responsibilities. The MCO shall undertake the following:
a. Provide information to any enrollee determined to be in need of home care that CDPAS is available and the conditions under which a consumer is eligible.
b. Conduct initial and semi-annual nursing and social assessments of consumers.
c. Determine that the consumer is eligible for long term care services provided by a certified home health agency, the AIDS home care program or personal care services, and is in need of home care services or private duty nursing.
d. Determine that the consumer is eligible to participate in the CDPAP program. A consumer is eligible if the consumer: (1) has a stable medical condition; (2) is self- directing or if, non-self-directing, has a designated representative; (3) needs some or total assistance with one or more personal care services, home health aide services or skilled nursing tasks; (4) is able and willing or has a designated representative able and willing to fulfill the responsibilities of a consumer, including but not limited to, making informed choices as to the type and quality of services, including but not limited to nursing care, personal care, transportation and respite services; (5) participates, as needed, or has a designated representative participate in the required assessment and bi-annual reassessment process, or if the MCO determines an unexpected change in the consumer's social circumstances, mental status or medical condition has occured during the authorization or reauthorization period that would affect the type, amount or frequency of consumer directed personal assistance provided during such period and does not have (a) voluntary assistance available from informal caregivers, including, but not limited to, the consumer’s family, friends or other responsible adult, provided that thsis shall include an evaluation of the potential contribution of informal supports, such as family members or friends, to the individual's care, which must consider the number and kind of informal supports available to the individual; the ability and motivation of informal supports to assist in care; the extent of informal supports' potential involvement; the availability of informal supports for future assistance; and the acceptability to the individual of the informal supports' involvement in his or her care; or formal services provided by an entity or agency or (b) adaptive or specialized equipment or supplies including, but not limited to, bedside commodes, urinals, walkers and...
MCO Responsibilities. 3.1 MCO shall be obligated to perform all of the responsibilities contained in this Agreement.