Common use of Member Information Requirements Clause in Contracts

Member Information Requirements. The CONTRACTOR’s Member information requirements shall include, but not be limited to accepting, maintaining, and transmitting all required Member information. The CONTRACTOR shall receive, process, and update enrollment files sent daily by HCA. The CONTRACTOR shall update its eligibility/enrollment databases within twenty-four (24) hours of receipt of said files. The CONTRACTOR shall be capable of uniquely identifying a distinct Member across multiple populations and systems within its span of control. The CONTRACTOR shall be able to identify potential duplicate records for a single Member and, upon confirmation of said duplicate record by HCA, resolve the duplication such that the enrollment, service utilization and customer interaction histories of the duplicate records are linked or merged. The CONTRACTOR shall: Provide a means for Providers and Major Subcontractors to verify Member eligibility and enrollment status twenty-four (24) hours a day, seven (7) days a week, three hundred sixty-five (365) Calendar Days a year; Ensure that current and updated eligibility information received from HCA is available to all Providers via the CONTRACTOR’s eligibility verification system and all Subcontractors’ eligibility verification systems within twenty-four (24) hours of receipt of any and all enrollment files from HCA; Assign as the key Medicaid Member ID number, the RECIP-MCD- CARD-ID-NO that is sent on the enrollment roster file and capture and store the Medicare ID, SSN and pseudo-SSN if they are included on the enrollment roster file for use in identification, eligibility verification, and Claims adjudication by the CONTRACTOR or any Subcontractor, Major Subcontractor, or Contract Provider that pay Claims. These numbers will be cross-referenced to the Member’s Social Security number and any internal number used in the CONTRACTOR’s system to identify Members; Meet federal CMS and HIPAA standards for release of Member information (applies to Subcontractors, Major Subcontractors, and Providers as well). Standards are specified in the MCO Systems Manual and at 42 C.F.R. § 431.306(b); Maintain accurate Member eligibility and demographic data to include but not be limited to, XXX, CCL, population identification and risk stratification, NF LOC and SOC, Community Benefit status, copayment maximum, copayment spent amount, Medicare status, Health Home status, Behavioral Health needs, age, sex, race, residence county, parent/non parent status, Native American status, institutional status and disability status on its system’s database consistent with HCA requirements. This requirement also applies to any Subcontractor who maintains a copy of the Member enrollment files for the purpose of distributing eligibility or enrollment information to Providers for verifying Member eligibility; Upon learning of third party coverage that was previously unknown, notify HCA within fifteen (15) Calendar Days, according to the reporting process outlined in the MCO Systems Manual; Exclude the Member’s Social Security number from the Member’s ID card; Have system functionality to manage different financial fields identified as annual maximum out-of-pocket amounts, benefit maximums, and copayment amounts for different services and for Members with different copayment requirements, including effective dates of the financial fields, as they could change over time; and Transmit to HCA a daily update file that contains Member information specific to NF LOC, Community Benefit status, Care Coordination Level, Health Home status, PCP assignment, disability status, and identifying information as specified in the MCO Systems Manual.

Member Information Requirements. The CONTRACTOR’s Member information requirements shall include, but not be limited to accepting, maintaining, and transmitting all required Member information. The CONTRACTOR shall receive, process, and update enrollment files sent daily by HCAHSD. The CONTRACTOR shall update its eligibility/enrollment databases within twenty-four (24) hours of receipt of said files. The CONTRACTOR shall be capable of uniquely identifying a distinct Member across multiple populations and systems within its span of control. The CONTRACTOR shall be able to identify potential duplicate records for a single Member and, upon confirmation of said duplicate record by HCAHSD, resolve the duplication such that the enrollment, service utilization and customer interaction histories of the duplicate records are linked or merged. The CONTRACTOR shall: Provide a means for Providers and Major Subcontractors to verify Member eligibility and enrollment status twenty-four (24) hours a day, seven (7) days a week, three hundred sixty-five (365) Calendar Days a year; Ensure that current and updated eligibility information received from HCA HSD is available to all Providers via the CONTRACTOR’s eligibility verification system and all Subcontractors’ eligibility verification systems within twenty-four (24) hours of receipt of any and all enrollment files from HCAHSD; Assign as the key Medicaid Member ID number, the RECIP-MCD- CARD-ID-NO that is sent on the enrollment roster file and capture and store the Medicare ID, SSN and pseudo-SSN if they are included on the enrollment roster file for use in identification, eligibility verification, and Claims adjudication by the CONTRACTOR or any Subcontractor, Major Subcontractor, or Contract Provider that pay Claims. These numbers will be cross-referenced to the Member’s Social Security number and any internal number used in the CONTRACTOR’s system to identify Members; Meet federal CMS and HIPAA standards for release of Member information (applies to Subcontractors, Major Subcontractors, and Providers as well). Standards are specified in the MCO Systems Manual and at 42 C.F.R. § 431.306(b); Maintain accurate Member eligibility and demographic data to include but not be limited to, XXX, CCL, population identification and risk stratification, NF LOC and SOC, Community Benefit status, copayment maximum, copayment spent amount, Medicare status, Health Home status, Behavioral Health needs, age, sex, race, residence county, parent/non parent status, Native American status, institutional status and disability status on its system’s database consistent with HCA HSD requirements. This requirement also applies to any Subcontractor who maintains a copy of the Member enrollment files for the purpose of distributing eligibility or enrollment information to Providers for verifying Member eligibility; Upon learning of third party coverage that was previously unknown, notify HCA HSD within fifteen (15) Calendar Days, according to the reporting process outlined in the MCO Systems Manual; Exclude the Member’s Social Security number from the Member’s ID card; Have system functionality to manage different financial fields identified as annual maximum out-of-pocket amounts, benefit maximums, and copayment amounts for different services and for Members with different copayment requirements, including effective dates of the financial fields, as they could change over time; and Transmit to HCA HSD a daily update file that contains Member information specific to NF LOC, Community Benefit status, Care Coordination Level, Health Home status, PCP assignment, disability status, and identifying information as specified in the MCO Systems Manual. Electronic Visit Verification System (EVV) The CONTRACTOR shall contract with HSD’s EVV vendor to monitor Member receipt and utilization of applicable services under EPSDT, Community Benefit, and Home Health benefit to include but not be limited to PCS, respite, skilled nursing, home health aide and therapy service. The CONTRACTOR must provide the following EVV options: (i) use of the Member’s landline when the Member consents to such use; or (ii) use of the Caregiver’s personal cellular phone utilizing the EVV vendor’s phone application with the CONTRACTOR providing a monthly stipend for such use; or (iii) use of a tablet allowing the EVV vendor’s application by the Caregiver, provided by the CONTRACTOR to the PCS and Home Health agency. The CONTRACTOR shall maintain an EVV system capable of leveraging up-to-date technology as it emerges to improve functionality in all areas of the State, including rural areas. The CONTRACTOR is responsible for issuing devices to its Providers, as needed, and shall ensure that all contracted personal care service, respite and home health Providers are participating in the EVV system unless granted a HSD approved written exception. The CONTRACTOR shall oversee its contracted EVV vendor to ensure the EVV system operates in compliance with this Agreement, policies and protocols established by HSD, and State and federal statute and regulations. The CONTRACTOR shall notify HSD within five (5) Business Days of the identification of any issue affecting EVV system operation that impacts the CONTRACTOR’s performance of this Agreement, including actions that will be taken by the CONTRACTOR to resolve the issue and the specific time frames within which such actions shall be completed. For a period of at least twelve (12) months following Go-Live, the CONTRACTOR shall conduct monthly education and training for affected Providers regarding the use of the EVV system. Such period may be extended as determined necessary by HSD. The CONTRACTOR shall ensure the following system functionality, including the ability to: Log the arrival and departure of the Provider delivering the service; Verify, in accordance with business rules, that services are being delivered in the correct location (e.g., the Member’s home); Verify the identity of the individual Provider providing the service to the Member; Match services provided to a Member with services authorized for the Member; Ensure that the Provider delivering the service is authorized to deliver such services; Ensure that the Provider establishes a plan for EPSDT and Agency-Based Community Benefit services for each Member. Establish a schedule of Agency Based Community Benefit PCS for each Member identifying the time at which each service is needed, as well as the amount, frequency, duration, and scope of each service and to ensure adherence to the established schedule; Provide reasonable notification to care coordinators if a Provider does not arrive as scheduled or otherwise deviates from the authorized schedule so that service gaps and the reason the service was not provided as scheduled, are immediately identified and addressed, including through the implementation of back-up plans, as appropriate; Permit the Provider to submit Claims to the CONTRACTOR (Claims from self-directed Providers shall be submitted initially to the FMA and the FMA shall provide Claims information to the CONTRACTOR as specified in the subcontract with the FMA); and Reconcile paid Claims with service authorizations. The CONTRACTOR shall monitor and use information from the EVV system to verify that authorized services are provided in accordance with the established schedule, including the amount, frequency, duration, and scope of each service, and that services are provided by the authorized Provider; and to identify and immediately address service gaps, including late and missed visits. The CONTRACTOR shall monitor services anytime a Member is receiving services, including after the CONTRACTOR’s regular business hours. The CONTRACTOR shall submit reports on its EVV system as directed by HSD. The CONTRACTOR shall employ a dedicated full-time staff person who is responsible for managing and overseeing all EVV system functions and requirements.