Member Handbook Requirements. 4.3.3.1 The Contractor shall mail to all newly enrolled Members a Member Handbook within ten (10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The Contractor shall mail to all enrolled Members a Member Handbook at least annually thereafter. 4.3.3.2 Pursuant to the requirements set forth in 42 CFR 438.10, the Member Handbook shall include, but not be limited to: 4.3.3.2.1 A table of contents; 4.3.3.2.2 Information about the roles and responsibilities of the Member (this information to be supplied by DCH); 4.3.3.2.3 Information about the role of the PCP; 4.3.3.2.4 Information about choosing a PCP; 4.3.3.2.5 Information about what to do when family size changes; 4.3.3.2.6 Appointment procedures; 4.3.3.2.7 Information on Benefits and services, including a description of all available GHF Benefits and services; 4.3.3.2.8 Information on how to access services, including Health Check services, non-emergency transportation (NET) services, and maternity and family planning services; 4.3.3.2.9 An explanation of any service limitations or exclusions from coverage; 4.3.3.2.10 A notice stating that the Contractor shall be liable only for those services authorized by the Contractor; 4.3.3.2.11 Information on where and how Members may access Benefits not available from or not covered by the Contractor; 4.3.3.2.12 The Medical Necessity definition used in determining whether services will be covered; 4.3.3.2.13 A description of all pre-certification, prior authorization or other requirements for treatments and services; 4.3.3.2.14 The policy on Referrals for specialty care and for other Covered Services not furnished by the Member’s PCP; 4.3.3.2.15 Information on how to obtain services when the Member is out of the Service Region and for after-hours coverage; 4.3.3.2.16 Cost-sharing; 4.3.3.2.17 The geographic boundaries of the Service Regions; 4.3.3.2.18 Notice of all appropriate mailing addresses and telephone numbers to be utilized by Members seeking information or authorization, including an inclusion of the Contractor’s toll-free telephone line and Web site; 4.3.3.2.19 A description of Utilization Review policies and procedures used by the Contractor; 4.3.3.2.20 A description of Member rights and responsibilities as described in Section 4.3.4; 4.3.3.2.21 The policies and procedures for Disenrollment; 4.3.3.2.22 Information on Advance Directives; 4.3.3.2.23 A statement that additional information, including information on the structure and operation of the CMO plan and physician incentive plans, shall be made available upon request; 4.3.3.2.24 Information on the extent to which, and how, after-hours and emergency coverage are provided, including the following: i. What constitutes an Urgent and Emergency Medical Condition, Emergency Services, and Post-Stabilization Services; ii. The fact that Prior Authorization is not required for Emergency Services; iii. The process and procedures for obtaining Emergency Services, including the use of the 911 telephone systems or its local equivalent; iv. The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered herein; and v. The fact that a Member has a right to use any hospital or other setting for Emergency Services; 4.3.3.2.25 Information on the Grievance Systems policies and procedures, as described in Section 4.14 of this Contract. This description must include the following: i. The right to file a Grievance and Appeal with the Contractor; ii. The requirements and timeframes for filing a Grievance or Appeal with the Contractor; iii. The availability of assistance in filing a Grievance or Appeal with the Contractor; iv. The toll-free numbers that the Member can use to file a Grievance or an Appeal with the Contractor by phone; v. The right to a State Administrative Law Hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing; vi. Notice that if the Member files an Appeal or a request for a State Administrative Law Hearing within the timeframes specified for filing, the Member may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Member; and vii. Any Appeal rights that the State chooses to make available to Providers to challenge the failure of the Contractor to cover a service. 4.3.3.3 The Member Handbook shall be submitted to DCH for review and approval within sixty (60) Calendar Days of Contract Award.
Appears in 2 contracts
Samples: Contract (Wellcare Health Plans, Inc.), Contract for Provision of Services (Centene Corp)
Member Handbook Requirements. 4.3.3.1 The Contractor shall mail to all newly enrolled Members a Member Handbook within ten (10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The Contractor shall mail to all enrolled Members a Member Handbook at least annually thereafter.
4.3.3.2 Pursuant to the requirements set forth in 42 CFR 438.10, the Member Handbook shall include, but not be limited to:
4.3.3.2.1 A table of contents;
4.3.3.2.2 Information about the roles and responsibilities of the Member (this information to be supplied by DCH);
4.3.3.2.3 Information about the role of the PCP;
4.3.3.2.4 Information about choosing a PCP;
4.3.3.2.5 Information about what to do when family size changes;
4.3.3.2.6 Appointment procedures;
4.3.3.2.7 Information on Benefits and services, including a description of all available GHF GF Benefits and services;
4.3.3.2.8 Information on how to access services, including Health Check services, non-emergency transportation (NET) services, and maternity and family planning services;
4.3.3.2.9 An explanation of any service limitations or exclusions from coverage;
4.3.3.2.10 A notice stating that the Contractor shall be liable only for those services authorized by the Contractor;
4.3.3.2.11 Information on where and how Members may access Benefits not available from or not covered by the Contractor;
4.3.3.2.12 The Medical Necessity definition used in determining whether services will be covered;
4.3.3.2.13 A description of all pre-certification, prior authorization or other requirements for treatments and services;
4.3.3.2.14 The policy on Referrals for specialty care and for other Covered Services not furnished by the Member’s PCP;
4.3.3.2.15 Information on how to obtain services when the Member is out of the Service Region and for after-hours coverage;
4.3.3.2.16 Cost-sharing;
4.3.3.2.17 The geographic boundaries of the Service Regions;
4.3.3.2.18 Notice of all appropriate mailing addresses and telephone numbers to be utilized by Members seeking information or authorization, including an inclusion of the Contractor’s toll-free telephone line and Web site;
4.3.3.2.19 A description of Utilization Review policies and procedures used by the Contractor;
4.3.3.2.20 A description of Member rights and responsibilities as described in Section 4.3.4;
4.3.3.2.21 The policies and procedures for Disenrollment;
4.3.3.2.22 Information on Advance Directives;
4.3.3.2.23 A statement that additional information, including information on the structure and operation of the CMO plan and physician incentive plans, shall be made available upon request;
4.3.3.2.24 Information on the extent to which, and how, after-hours and emergency coverage are provided, including the following:
i. What constitutes an Urgent and Emergency Medical Condition, Emergency Services, and Post-Stabilization Services;
ii. The fact that Prior Authorization is not required for Emergency Services;
iii. The process and procedures for obtaining Emergency Services, including the use of the 911 telephone systems or its local equivalent;
iv. The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered herein; and
v. The fact that a Member has a right to use any hospital or other setting for Emergency Services;
4.3.3.2.25 Information on the Grievance Systems policies and procedures, as described in Section 4.14 of this Contract. This description must include the following:
i. The right to file a Grievance and Appeal with the Contractor;
ii. The requirements and timeframes for filing a Grievance or Appeal with the Contractor;
iii. The availability of assistance in filing a Grievance or Appeal with the Contractor;
iv. The toll-free numbers that the Member can use to file a Grievance or an Appeal with the Contractor by phone;
v. The right to a State Administrative Law Hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing;
vi. Notice that if the Member files an Appeal or a request for a State Administrative Law Hearing within the timeframes specified for filing, the Member may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Member; and
vii. Any Appeal rights that the State chooses to make available to Providers to challenge the failure of the Contractor to cover a service.
4.3.3.3 The Member Handbook Contractor shall be submitted submit to DCH for review and approval within sixty any changes and edits to the Member Handbook at least thirty (6030) Calendar Days before the effective date of Contract Awardchange.
Appears in 1 contract
Samples: Contract for Provision of Services (Amerigroup Corp)
Member Handbook Requirements. 4.3.3.1 The Contractor shall mail to all newly enrolled Members a Member Handbook within ten (10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The Contractor shall mail to all enrolled Members a Member Handbook at least annually thereafter.
4.3.3.2 Pursuant to the requirements set forth in 42 CFR 438.10, the Member Handbook shall include, but not be limited to:
4.3.3.2.1 A table of contents;
4.3.3.2.2 Information about the roles and responsibilities of the Member (this information to be supplied by DCH);
4.3.3.2.3 Information about the role of the PCP;
4.3.3.2.4 Information about choosing a PCP;
4.3.3.2.5 Information about what to do when family size changes;
4.3.3.2.6 Appointment procedures;
4.3.3.2.7 Information on Benefits and services, including a description of all available GHF GF Benefits and services;
4.3.3.2.8 Information on how to access services, including Health Check services, non-emergency transportation (NET) services, and maternity and family planning services;
4.3.3.2.9 An explanation of any service limitations or exclusions from coverage;
4.3.3.2.10 A notice stating that the Contractor shall be liable only for those services authorized by the Contractor;
4.3.3.2.11 Information on where and how Members may access Benefits not available from or not covered by the Contractor;
4.3.3.2.12 The Medical Necessity definition used in determining whether services will be covered;
4.3.3.2.13 A description of all pre-certification, prior authorization or other requirements for treatments and services;
4.3.3.2.14 The policy on Referrals for specialty care and for other Covered Services not furnished by the Member’s PCP;
4.3.3.2.15 Information on how to obtain services when the Member is out of the Service Region and for after-hours coverage;
; 4.3.3.2.16 Cost-sharing;
4.3.3.2.17 The geographic boundaries of the Service Regions;
4.3.3.2.18 Notice of all appropriate mailing addresses and telephone numbers to be utilized by Members seeking information or authorization, including an inclusion of the Contractor’s toll-free telephone line and Web site;
4.3.3.2.19 A description of Utilization Review policies and procedures used by the Contractor;
4.3.3.2.20 A description of Member rights and responsibilities as described in Section 4.3.4;
4.3.3.2.21 The policies and procedures for Disenrollment;
4.3.3.2.22 Information on Advance Directives;
4.3.3.2.23 A statement that additional information, including information on the structure and operation of the CMO plan and physician incentive plans, shall be made available upon request;
4.3.3.2.24 Information on the extent to which, and how, after-hours and emergency coverage are provided, including the following:
i. What constitutes an Urgent and Emergency Medical Condition, Emergency Services, and Post-Stabilization Services;
ii. The fact that Prior Authorization is not required for Emergency Services;
iii. The process and procedures for obtaining Emergency Services, including the use of the 911 telephone systems or its local equivalent;
iv. The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered herein; and
v. The fact that a Member has a right to use any hospital or other setting for Emergency Services;
4.3.3.2.25 Information on the Grievance Systems policies and procedures, as described in Section 4.14 of this Contract. This description must include the following:
i. The right to file a Grievance and Appeal with the Contractor;
ii. The requirements and timeframes for filing a Grievance or Appeal with the Contractor;
iii. The availability of assistance in filing a Grievance or Appeal with the Contractor;
iv. The toll-free numbers that the Member can use to file a Grievance or an Appeal with the Contractor by phone;
v. The right to a State Administrative Law Hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing;
vi. Notice that if the Member files an Appeal or a request for a State Administrative Law Hearing within the timeframes specified for filing, the Member may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Member; and
vii. Any Appeal rights that the State chooses to make available to Providers to challenge the failure of the Contractor to cover a service.
4.3.3.3 The Member Handbook shall be submitted to DCH for review and approval within sixty (60) Calendar Days of Contract Award.
Appears in 1 contract
Samples: Contract (Centene Corp)
Member Handbook Requirements. 4.3.3.1 The Contractor shall mail to all newly enrolled Members a Member Handbook within ten (10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The Contractor shall mail to all enrolled Members a Member Handbook at least annually thereafter.
4.3.3.2 Pursuant to the requirements set forth in 42 CFR 438.10, the Member Handbook shall include, but not be limited to:
4.3.3.2.1 A table of contents;
4.3.3.2.2 Information about the roles and responsibilities of the Member (this information to be supplied by DCH);
4.3.3.2.3 Information about the role of the PCP;
4.3.3.2.4 Information about choosing a PCP;
4.3.3.2.5 Information about what to do when family size changes;; Revised 5/19/2008
4.3.3.2.6 Appointment procedures;
4.3.3.2.7 Information on Benefits and services, including a description of all available GHF GF Benefits and services;
4.3.3.2.8 Information on how to access services, including Health Check services, non-emergency transportation (NET) services, and maternity and family planning services;
4.3.3.2.9 An explanation of any service limitations or exclusions from coverage;
4.3.3.2.10 A notice stating that the Contractor shall be liable only for those services authorized by the Contractor;
4.3.3.2.11 Information on where and how Members may access Benefits not available from or not covered by the Contractor;
4.3.3.2.12 The Medical Necessity definition used in determining whether services will be covered;
4.3.3.2.13 A description of all pre-certification, prior authorization or other requirements for treatments and services;
4.3.3.2.14 The policy on Referrals for specialty care and for other Covered Services not furnished by the Member’s 's PCP;
4.3.3.2.15 Information on how to obtain services when the Member is out of the Service Region and for after-hours coverage;
4.3.3.2.16 Cost-sharing;
4.3.3.2.17 The geographic boundaries of the Service Regions;
4.3.3.2.18 Notice of all appropriate mailing addresses and telephone numbers to be utilized by Members seeking information or authorization, including an inclusion of the Contractor’s 's toll-free telephone line and Web site;
4.3.3.2.19 A description of Utilization Review policies and procedures used by the Contractor;
4.3.3.2.20 A description of Member rights and responsibilities as described in Section 4.3.4;
4.3.3.2.21 The policies and procedures for Disenrollment;; Revised 5/19/2008
4.3.3.2.22 Information on Advance Directives;
4.3.3.2.23 A statement that additional information, including information on the structure and operation of the CMO plan and physician incentive plans, shall be made available upon request;
4.3.3.2.24 Information on the extent to which, and how, after-hours and emergency coverage are provided, including the following:
i. What constitutes an Urgent and Emergency Medical Condition, Emergency Services, and Post-Stabilization Services;
ii. The fact that Prior Authorization is not required for Emergency Services;
iii. The process and procedures for obtaining Emergency Services, including the use of the 911 telephone systems or its local equivalent;
iv. The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered herein; and
v. The fact that a Member has a right to use any hospital or other setting for Emergency Services;
4.3.3.2.25 Information on the Grievance Systems policies and procedures, as described in Section 4.14 of this Contract. This description must include the following:
i. The right to file a Grievance and Appeal with the Contractor;
ii. The requirements and timeframes for filing a Grievance or Appeal with the Contractor;
iii. The availability of assistance in filing a Grievance or Appeal with the Contractor;
iv. The toll-free numbers that the Member can use to file a Grievance or an Appeal with the Contractor by phone;
v. The right to a State Administrative Law Hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing;; Revised 5/19/2008
vi. Notice that if the Member files an Appeal or a request for a State Administrative Law Hearing within the timeframes specified for filing, the Member may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Member; and
vii. Any Appeal rights that the State chooses to make available to Providers to challenge the failure of the Contractor to cover a service.
4.3.3.3 The Member Handbook Contractor shall be submitted submit to DCH for review and approval within sixty any changes and edits to the Member Handbook at least thirty (6030) Calendar Days before the effective date of Contract Awardchange.
Appears in 1 contract
