MEMBERS WITH SPECIAL NEEDS. 62 4.5.1 GENERAL REQUIREMENTS 62-68 4.5.2 CHILDREN WITH SPECIAL HEALTH CARE NEEDS 68-69 4.5.3 CLIENTS OF THE DIVISION OF DEVELOPMENTAL DISABILITIES 69-70 4.5.4 PERSONS WITH HIV/AIDS 70-71 4.6 QUALITY MANAGEMENT SYSTEM 71-72 4.6.1 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PLAN 72-77 4.6.2 QAPI ACTIVITIES 77-88 4.6.3 REFERRAL SYSTEMS 88-89 4.6.4 UTILIZATION MANAGEMENT 89-99 4.6.5 CARE MANAGEMENT 99-103
MEMBERS WITH SPECIAL NEEDS. 52 4.5.1 GENERAL REQUIREMENTS ........................................................................................ 52-56 4.5.2 CHILDREN WITH SPECIAL HEALTH CARE NEEDS ............................................... 56-58 4.5.3 CLIENTS OF THE DIVISION OF DEVELOPMENTAL DISABILITIES .................... 58-59 4.5.4 PERSONS WITH HIV/AIDS ........................................................................................... 59-60 4.6 QUALITY MANAGEMENT SYSTEM ....................................................................................... 60-61 4.6.1 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PLAN............. 61-65 4.6.2 QAPI ACTIVITIES........................................................................................................... 65-77 4.6.3 REFERRAL SYSTEMS ................................................................................................... 77-78 4.6.4 UTILIZATION MANAGEMENT.................................................................................... 78-87 4.6.5 CARE MANAGEMENT .................................................................................................. 87-92 4.7 MONITORING AND EVALUATION ......................................................................................... 92 4.7.1 GENERAL PROVISIONS................................................................................................ 92-93 4.7.2 EVALUATION AND REPORTING – CONTRACTOR RESPONSIBILITIES............. 93-96 4.7.3 MONITORING AND EVALUATION – DEPARTMENT ACTIVITIES....................... 96-97 4.7.4 INDEPENDENT EXTERNAL QUALITY REVIEW ORGANIZATION REVIEWS ... 97-98 4.8 PROVIDER NETWORK ............................................................................................................... 98 4.8.1 GENERAL PROVISIONS................................................................................................ 98-102 4.8.2 PRIMARY CARE PROVIDER REQUIREMENTS ........................................................ 103-104 4.8.3 PROVIDER NETWORK FILE REQUIREMENTS......................................................... 104-105 4.8.4 PROVIDER DIRECTORY REQUIREMENTS ............................................................... 105-106 4.8.5 CREDENTIALING/RECREDENTIALING REQUIREMENTS/ISSUES ...................... 106 4.8.6 LABORATORY SERVICE PROVIDERS....................................................................... 106-107 4.8.7 SPECIALTY PROVIDERS AND CENTERS..............................................
MEMBERS WITH SPECIAL NEEDS. A more specific model for all SSI members can be found in Article. III. C. However, for other individuals deemed to be a member with special needs, the following is required:
MEMBERS WITH SPECIAL NEEDS. 44 3.6.8 Provider Services............................................................................... 45 3.6.9 Provider Credentialing.......................................................................... 45 3.6.9.1 Provider Enrollment and Education........................................................... 50 3.6.9.2 Maintenance of Medical Records.............................................................. 50 3.6.9.3 MCO Communications with Providers........................................................... 50 3.6.10 Program Integrity Plan and Reporting Standard................................................... 51 3.6.10.1 MCO Communications With Indiana Medicaid Fraud Control Unit (IMFCU)..................... 52 3.6.11 Regional Network Development Requirement and Reporting Standard................................. 53 3.6.12 Quality Improvement and Utilization Review Program.............................................. 53 3.6.12.1 Quality Assessment and Performance Improvement Program and Reporting Standard........... 53 3.6.12.2 Utilization Review (UR) Requirement and UR Reporting Standard.......................... 56 3.6.13 Management Information Systems.................................................................. 60 3.6.13.1 Member Enrollment Data Exchange......................................................... 61 3.6.13.2 Claims Processing....................................................................... 62 3.6.13.3
MEMBERS WITH SPECIAL NEEDS. The MCO must also assist OMPP with identifying, assessing and tracking its members with special needs, as required by OMPP and pursuant to 42 CFR 438.208(c). The MCO must have procedures in place to conduct assessments of each member identified as having potential special health care needs in order to identify any ongoing special conditions of the member that may require a course of treatment or regular care monitoring. The assessment procedures must use appropriate health care professionals. Grievances and appeals filed by members with special needs must be reported separately in the grievance reports.
MEMBERS WITH SPECIAL NEEDS. In accordance with 42 CFR 438.208(c)(2), the CCN shall submit policy and procedures for approval by DHH during Step 2 of the CCN Enrollment Process, after any material revision and annually thereafter, the mechanisms to assess each Medicaid/CHIP enrollee identified as having special health care needs in order to identify any ongoing special conditions of the enrollee that require a course of treatment or regular care monitoring. The assessment mechanisms must use appropriate health care professionals. Per 42 CFR 438.240(b)(3) and (4), the CCN shall also have mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs and to detect both underutilization and overutilization of services.
