Common use of New Enrollee Procedures Clause in Contracts

New Enrollee Procedures. a. The Health Plan shall not delay Service Authorization if written documentation is not available in a timely manner. b. The Health Plan shall contact each new Enrollee at least two (2) times, if necessary, within ninety (90) Calendar Days of the Enrollee's Enrollment to schedule the Enrollee's initial appointment with his/her PCP for the purpose of obtaining a health risk assessment and/or CHCUP Screening. For this subsection, "contact" is defined as mailing a notice to, or telephoning, an Enrollee at the most recent address or telephone number available. c. The Health Plan shall urge Enrollees to see their PCPs within 180 Calendar Days of Enrollment. d. The Health Plan shall contact each new Enrollee within thirty (30) Calendar Days of Enrollment to request that the Enrollee authorize the release of his or her Medical Records (including those related to Behavioral Health Services) to the Health Plan, or the Health Plan's health services Subcontractor, from those providers who treated the Enrollee prior to the Enrollee's Enrollment with the Health Plan. Also, the Health Plan shall request or assist the Enrollee's new PCP by requesting the Enrollee's Medical Records from the Enrollee’s previous providers. e. The Health Plan shall use the Enrollee's health risk assessments and/or released Medical Records to identify Enrollees who have not received CHCUP Screenings in accordance with the Agency approved periodicity schedule. f. The Health Plan shall contact, up to two (2) times if necessary, any Enrollee more than two (2) months behind in the Agency approved periodicity Screening schedule to urge those Enrollees, or their legal representatives, to make an appointment with the Enrollees' PCPs for a Screening visit. g. Within thirty (30) Calendar Days of Enrollment, the Health Plan shall notify Enrollees of, and ensure the availability of, a Screening for all Enrollees known to be pregnant or who advise the Health Plan that they may be pregnant. The Health Plan shall refer Enrollees who are, or may be, pregnant to the appropriate Provider stating that the Enrollee can obtain appropriate prenatal care. h. The Health Plan shall honor any written documentation of Prior Authorization of ongoing Covered Services for a period of thirty (30) Business Days after the effective date of Enrollment, or until the Enrollee's PCP reviews the Enrollee's treatment plan for the following types of Enrollees: (1) Enrollees who voluntarily enrolled; and (2) Those Enrollees who were automatically reenrolled after regaining Medicaid eligibility. i. For Mandatory Assignment Enrollees, the Health Plan shall honor any written documentation of Prior Authorization of ongoing services for a period of one (1) month after the effective date of Enrollment or until the Mandatory Assignment Enrollee's PCP reviews the Enrollee's treatment plan, whichever comes first. j. For all Enrollees, written documentation of Prior Authorization of ongoing services includes the following, provided that the services were prearranged prior to Enrollment with the Health Plan: (1) Prior existing orders; (2) Provider appointments, e.g. dental appointments, surgeries, etc.; and (3) Prescriptions (including prescriptions at non-participating pharmacies). k. The Health Plan shall not delay Service Authorization if written documentation is not available in a timely manner. The Health Plan is not required to approve claims for which it has received no written documentation. l. The Health Plan shall not deny claims submitted by an out-of-network provider solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds 365 days. m. The Enrollee's guardian, next of kin or legally authorized responsible person is permitted to act on the Enrollee's behalf in matters relating to the Enrollee's Enrollment, plan of care, and/or provision of services, if the Enrollee: (1) Was adjudicated incompetent in accordance with the law; (2) Is found by his or her Provider to be medically incapable of understanding his or her rights; or (3) Exhibits a significant communication barrier. n. The Health Plan shall take immediate action to address any identified urgent medical needs. "Urgent medical needs" means any sudden or unforeseen situation which requires immediate action to prevent hospitalization or nursing home placement. Examples include hospitalization of spouse or caregiver or increased impairment of an Enrollee living alone who suddenly cannot manage basic needs without immediate help, hospitalization or nursing home placement.

New Enrollee Procedures. a. The Health Plan shall not delay Service Authorization if written documentation is not available in a timely manner. b. The Health Plan shall contact each new Enrollee at least two (2) times, if necessary, within ninety (90) Calendar Days of the Enrollee's Enrollment to schedule the Enrollee's initial appointment with his/her the PCP for the purpose of obtaining a health risk assessment and/or CHCUP Screening. For this subsection, "contact" is defined as mailing a notice to, or telephoning, an Enrollee at the most recent address or telephone number available. c. The Health Plan shall urge Enrollees to see their PCPs within 180 Calendar Days of Enrollment. d. The Health Plan shall contact each new Enrollee within thirty (30) Calendar Days of Enrollment to request that the Enrollee authorize the release of his or her Medical Records (including those related to Behavioral Health Services) to the Health Plan, or the Health Plan's health services Subcontractorsubcontractor, from those providers who treated the Enrollee prior to the Enrollee's Enrollment with the Health Plan. Also, the Health Plan shall request or assist the Enrollee's new PCP by requesting the Enrollee's Medical Records from the Enrollee’s previous providers. e. The Health Plan shall use the Enrollee's health risk assessments and/or released Medical Records to identify Enrollees Enrollee's who have not received CHCUP Screenings in accordance with the Agency approved periodicity schedule. f. The Health Plan shall contact, up to two (2) times if necessary, any Enrollee more than two (2) months behind in the Agency approved periodicity Screening schedule to urge those Enrollees, or their legal representatives, to make an appointment with the Enrollees' PCPs for a Screening visit. g. Within thirty (30) Calendar Days of Enrollment, the Health Plan shall notify Enrollees of, and ensure ensures the availability of, a Screening for all Enrollees known to be pregnant or who advise the Health Plan that they may be pregnant. The Health Plan shall refer Enrollees who are, or may be, pregnant to the appropriate Provider stating that the Enrollee can obtain appropriate prenatal care. h. The Health Plan shall honor any written documentation of Prior Authorization of ongoing Covered Services for a period of thirty (30) Business Days after the effective date of Enrollment, or until the Enrollee's PCP reviews the Enrollee's treatment plan for the following types of Enrollees: (1) Enrollees who voluntarily enrolled; and (2) Those Enrollees who were automatically reenrolled after regaining Medicaid eligibility. i. For Mandatory Assignment Enrollees, the Health Plan shall honor any written documentation of Prior Authorization of ongoing services for a period of one (1) month after the effective date of Enrollment or until the Mandatory Assignment Enrollee's PCP reviews the Enrollee's treatment plan, whichever comes first. j. For all Enrollees, written documentation of Prior Authorization of ongoing services includes the following, provided that the services were prearranged prior to Enrollment with the Health Plan: (1) Prior existing orders; (2) Provider appointments, e.g. dental appointments, surgeries, etc.; and (3) Prescriptions (including prescriptions at non-participating pharmacies). k. The Health Plan shall not delay Service Authorization if written documentation is not available in a timely manner. The Health Plan is not required to approve claims for which it has received no written documentation. l. The Health Plan shall not deny claims submitted by an out-of-network provider solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds 365 days. m. The Enrollee's guardian, next of kin or legally authorized responsible person is permitted to act on the Enrollee's behalf in matters relating to the Enrollee's Enrollment, plan of care, and/or provision of services, if the Enrollee: (1) Was adjudicated incompetent in accordance with the law; (2) Is found by his or her Provider to be medically incapable of understanding his or her rights; or (3) Exhibits a significant communication barrier. n. The Health Plan shall take immediate action to address any identified urgent medical needs. "Urgent medical needs" means any sudden or unforeseen situation which requires immediate action to prevent hospitalization or nursing home placement. Examples include hospitalization of spouse or caregiver or increased impairment of an in Enrollee living alone who suddenly cannot manage basic needs without immediate help, hospitalization or nursing home placement.