Non-PCP Minimum Provider Network. In addition to the PCP capacity requirements, each MCP is also required to maintain adequate capacity in the remainder of its provider network within the following categories: hospitals, dentists, pharmacies, vision care providers, obstetricians/gynecologists (OB/GYNs), allergists, general surgeons, otolaryngologists, orthopedists, certified nurse midwives (CNMs), certified nurse practitioners (CNPs), federally qualified health centers (FQHCs)/rural health centers (RHCs) and qualified family planning providers (QFPPs). CNMs, CNPs, FQHCs/RHCs and QFPPs are federally-required provider types. All Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered services to their members and therefore their complete provider network will include many other additional specialists and provider types. MCPs must ensure that all non-PCP network providers follow community standards in the scheduling of routine appointments (i.e., the amount of time members must wait from the time of their request to the first available time when the visit can occur). Although there are currently no FTE capacity requirements for any of the non-PCP required provider types, MCPs are required to ensure that adequate access is available to members for all required provider types. ODJFS will monitor access to services through a variety of data sources, including: consumer satisfactionsurveys; member appeals/grievances/complaints and state hearing notifications/requests; clinical quality studies; encounter data volume; provider complaints, and clinical performance measures. Hospitals - MCPs must contract with at least one hospital in the service area or an alternate provider area, and this hospital, alone or in combination with other contracted hospitals within the service area or the alternate provider area, must be capable and agree to provide all of the following services during the contract period: general medical/surgical services for both the adult and pediatric population; obstetrical services; nursery services; adult, pediatric and neonatal (Levels I and II) intensive care; cardiac care; outpatient surgery; and emergency room services. ODJFS utilizes each hospital’s most current Annual Hospital Registration and Planning Report, as filed with the Ohio Department of Health, in determining what types of services that hospital provides. It will be possible to meet the hospital requirement for some service areas by contracting only with one full- service general hospital outside the service area, however, MCPs are required to contract with at least one hospital in the service area if at least two general hospitals (which are not both members of the same hospital system) are located in that service area. Failing to contract with a local hospital may make such a provider network less attractive to potential members. OB/GYNs - MCPs must contract with the specified number of OB/GYNs, all of whom must maintain a full-time obstetrical practice at a site(s) located in the service area or alternate provider area, as well as having current hospital delivery privileges at a hospital under contract to the MCP in the service area or an alternate provider area. Certified Nurse Midwives (CNMs) and Certified Nurse Practitioners (CNPs) - MCPs must ensure access to at least one CNM and one CNP in the service area or alternate provider area, if such provider types are present. Access to additional CNMs and CNPs must be added on an as needed basis to ensure that no member is denied access to such services. For this provider panel requirement, the MCP may contract directly with the CNM or CNP, or with a physician or other provider entity who is able to obligate the participation of the CNM or CNP. If an MCP does not contract with a CNM or CNP and such providers are present within a service area or alternate provider area, the MCP will be required to allow members to receive CNM or CNP services outside of the MCP’s provider network. Contracting CNMs must have hospital delivery privileges at a hospital under contract to the MCP in the service area or an alternate provider area. The MCP must always ensure a member’s access to CNM and CNP services if such providers are present within the service area. Vision Care Providers - MCPs must contract with the specified number of ophthalmologists/optometrists for each service area, all of whom must regularly perform routine eye examinations and who maintain a full- time practice at a site(s) within the service area. If optical dispensing is not available in a particular service area through the MCP’s contracting ophthalmologists/optometrists, the MCP must separately contract with an optical dispenser. Dental Care Providers- MCPs must assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting dentists accepting new patients. The charts in Section H of this appendix reflect the number of dental providers which ODJFS will use as a guideline in assessing the MCP’s capacity to assure access to dental services. ODJFS will aggressively monitor access to dental services through a variety of data sources, including: consumer satisfaction surveys; member appeals/grievances/complaints and state hearing notifications/requests; member just-cause for disenrollment requests; dental quality studies; dental encounter data volume; provider complaints, and dental performance measures. Federally Qualified Health Centers/Rural Health Clinics (FQHCs/RHCs) - MCPs are required to ensure member access to any federally qualified health center or rural health clinic (FQHCs/RHCs), regardless of contracting status. Even if no FQHC/RHC is available within the service area, MCPs must have mechanisms in place to ensure coverage for FQHC/RHC services in the event that a member accesses these services outside of the service area. In order to assure FQHC/RHC access to members, MCPs must make provisions for the following: • Non-contracting FQHC/RHC providers serving as a PCP for an MCP’s member must be allowed to refer that member to another provider in the MCP’s provider panel. • MCPs may require that their members request a referral from their PCP in order to access FQHC/RHC providers; however, such referral requests must be approved. In order to ensure that any FQHCs/RHCs has the ability to submit a claim to ODJFS for the state’s supplemental payment, MCPs must offer FQHCs/RHCs reimbursement pursuant to the following: • MCPs must provide expedited reimbursement on a service-specific basis in an amount no less than the payment made to other providers for the same or similar service. • If the MCP has no comparable service-specific rate structure, the MCP must use the regular Medicaid fee-for-service payment schedule for non-FQHC/RHC providers. • MCPs must make all efforts to pay FQHCs/RHCs as quickly as possible and not just attempt to pay these claims within the prompt pay time frames. MCPs are required to educate their staff and providers on the need to assure member access to FQHC/RHC services. Qualified Family Planning Providers (QFPPs) - All MCP members must be permitted to self-refer to family planning services provided by a QFPP. A QFPP is defined as any public or not-for-profit health care provider that complies with Title X guidelines/standards, and receives either Title X funding or family planning funding from the Ohio Department of Health. MCPs must reimburse all medically-necessary Medicaid-covered family planning services provided to eligible members by a QFPP provider on a patient self-referral basis, irrespective of the provider’s status as a panel or non-panel provider. MCPs will be required to work with QFPPs in their service area to develop mutually-agreeable policies and procedures to preserve patient/provider confidentiality, and convey pertinent information to the member’s PCP and/or MCP. Other Specialty Types (pediatricians, general surgeons, otolaryngologists, allergists, and orthopedists) - MCPs must contract with the specified number of all other specialty provider types. In order to be counted toward meeting the minimum provider panel requirements, these specialty providers must maintain a full-time practice at a site(s) located within the service area or alternate provider area. Contracting general surgeons, orthopedists and otolaryngologists must have admitting privileges at a hospital under contract with the MCP in the service area or an alternate provider area.
Appears in 1 contract
Samples: Ohio Medical Assistance Provider Agreement for Managed Care Plan
Non-PCP Minimum Provider Network. In addition to the PCP capacity requirements, each MCP is also required to maintain adequate capacity in the remainder of its provider network within the following categories: hospitals, dentists, pharmacies, vision care providers, obstetricians/gynecologists (OB/GYNs), allergists, . general surgeons, otolaryngologists, . orthopedists, certified nurse midwives (CNMs), . certified nurse practitioners (CNPs), federally qualified health centers (FQHCs)/rural health centers (RHCs) and qualified family planning providers (QFPPs). , CNMs, CNPs, FQHCs/RHCs and QFPPs are federally-required provider types. All Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered services to their members and therefore their complete provider network will include many other additional specialists and provider types. MCPs must ensure that all non-PCP network providers follow community standards in the scheduling of routine appointments (i.e., i.e.. the amount of time members must wait from the time of their request to the first available time when the visit can occur). Although there are currently no FTE capacity requirements for any of the non-PCP required provider types, MCPs are required to ensure that adequate access is available to members for all required provider types. Additionally, for certain non-PCP required provider types, MCPs must ensure that these providers maintain a full-time practice at a site(s) located in the specified county/region (i.e., the ODJFS-specified county within the region or anywhere within the region if no particular county is specified). A full-time practice is defined as one where the provider is available to patients at their practice site(s) in the specified county/region for at least 25 hours a week. ODJFS will monitor access to services through a variety of data sources, including: consumer satisfactionsurveyssatisfaction surveys; member appeals/grievances/complaints and state hearing notifications/requests; clinical quality studies; encounter data volume; provider complaints, and clinical performance measures. Appendix H Hospitals - MCPs must contract with at least one the number and type of hospitals specified by ODJFS for each county/region. In developing these minimum hospital in requirements, ODJFS considered, on a county-by-county basis, the service area or an alternate provider area, population size and this hospital, alone or in combination with other contracted hospitals within the service area or the alternate provider area, must be capable and agree to provide all utilization patterns of the following services during Covered Families and Children (CFC) consumers and integrated the existing utilization patterns into the minimum hospital network requirements to avoid disruption of care. For this reason, ODJFS may require that MCPs contract period: general medical/surgical services for both the adult and pediatric population; obstetrical services; nursery services; adultw ith out-of-state hospitals (i.e. Kentucky, pediatric and neonatal (Levels I and II) intensive care; cardiac care; outpatient surgery; and emergency room servicesWest Virginia, etc.). For each Ohio hospital. ODJFS utilizes each the hospital’s 's most current Annual Hospital Registration and Planning Report, as filed with the Ohio Department of Health, in determining what verifying types of services that hospital provides. It will be possible Although ODJFS has the authority, under certain situations, to meet the obligate a non-contracting hospital requirement for some service areas by contracting only with one full- service general to provide non-emergency hospital outside the service area, howeverservices to an MCP's members, MCPs are required to must still contract with at least one the specified number and type of hospitals unless ODJFS approves a provider panel exception (see Section 4 of this appendix - Provider Panel Exceptions). If an MCP-contracted hospital elects not to provide specific Medicaid-covered hospital services because of an objection on moral or religious grounds, then the MCP must ensure that these hospital services are available to its members through another MCP-contracted hospital in the service area if at least two general hospitals (which are not both members of the same hospital system) are located in that service area. Failing to contract with a local hospital may make such a provider network less attractive to potential membersspecified county/region. OB/GYNs - MCPs must contract with the specified number of OB/GYNsGYNs for each county/region, all of whom must maintain a full-time obstetrical practice at a site(s) located in the service area or alternate provider area, as well as having specified county/region. All MCP-contracting OB/GYNs must have current hospital delivery privileges at a hospital under contract to with the MCP in the service area or an alternate provider arearegion. Certified Nurse Midwives (CNMs) and Certified Nurse Practitioners (CNPs) - MCPs must ensure access to at least one CNM and one CNP services in the service area or alternate provider area, region if such provider types are present. Access to additional CNMs and CNPs must be added on an as needed basis to ensure that no member is denied access to such servicespresent within the region. For this provider panel requirement, the MCP may contract directly with the CNM or CNPCNP providers, or with a physician or other provider entity who is able to obligate the participation of the a CNM or CNP. If an MCP does not contract with a for CNM or CNP services and such providers are present within a service area or alternate provider areathe region, the MCP will be required to allow members to receive CNM or CNP services outside of the MCP’s 's provider network. Contracting CNMs must have hospital delivery privileges at a hospital under contract to the MCP in the service area or an alternate provider arearegion. The MCP must always ensure a member’s 's access to CNM and CNP services if such providers are present practicing within the service arearegion. Vision Care Providers - MCPs must contract with the specified number of ophthalmologists/optometrists for each service areaspecified county/region , all of whom must regularly perform routine eye examinations and who maintain a full- full-time practice at a site(s) within located in the service areaspecified county/region. All ODJFS-approved vision providers must regularly perform routine eye exams. (MCPs w'ill be expected to contract with an adequate number of opthalmologists as part of their overall provider panel, but only opthalmologists who regularly perform routine eye exams can be used to meet the minimum vision care provider panel requirement.) If optical dispensing is not sufficiently available in a particular service area region through the MCP’s 's contracting ophthalmologists/optometrists, the MCP must separately Appendix H contract with an adequate number of optical dispenserdispensers located in the region. Dental Denial Care Providers- Providers - MCPs must contract with the specified number of dentists. In order to assure sufficient access to dental services. MCPs will be required to provide access to all Medicaidadult MCP members, no more than two-covered dental services regardless thirds of the number of dentists under contract and/or used to meet the number of contracting dentists accepting new patients. The charts in Section H of this appendix reflect the number of dental providers which ODJFS will use as a guideline in assessing the MCP’s capacity to assure access to dental services. ODJFS will aggressively monitor access to dental services through a variety of data sources, including: consumer satisfaction surveys; member appeals/grievances/complaints and state hearing notifications/requests; member just-cause for disenrollment requests; dental quality studies; dental encounter data volume; minimum provider complaints, and dental performance measurespanel requirement may be pediatric dentists. Federally Qualified Health Centers/Rural Health Clinics (FQHCs/RHCs) - MCPs are required to ensure member access to any federally qualified health center or rural health clinic (FQHCs/RHCs), . regardless of contracting status. Contracting FQHC/RHC providers must be submitted for ODJFS approval via the PVS process. (ODJFS maintains a list of FQHCs/RHCs on our website). Even if no FQHC/RHC is available within the service arearegion, MCPs must have mechanisms in place to ensure coverage for FQHC/RHC services in the event that a member accesses these services outside of the service arearegion. In order to assure FQHC/RHC access to members, MCPs must make provisions for the following: • Non-contracting FQHC/RHC providers serving as a PCP for an MCP’s member must be allowed to refer that member to another provider in the MCP’s provider panel. • MCPs may require that their members request a referral from their PCP in order to access FQHC/RHC providers; however, such referral requests must be approved. In order to ensure that any FQHCsFQHC/RHCs RHC has the ability to submit a claim to ODJFS for the state’s 's supplemental payment, MCPs must offer FQHCs/RHCs reimbursement pursuant to the following: • MCPs must provide expedited reimbursement on a service-specific basis in an amount no less than the payment made to other providers for the same or similar service. • If the MCP has no comparable service-specific rate structure, the MCP must use the regular Medicaid fee-for-service payment schedule for non-FQHC/RHC providers. • MCPs must make all efforts to pay FQHCs/RHCs as quickly as possible and not just attempt to pay these claims within the prompt pay time frames. MCPs are required to educate their staff and providers on the need to assure member access to FQHC/RHC services. Qualified Family Planning Providers (QFPPs) - All MCP members must be permitted to self-refer to family planning services provided by a QFPP. A QFPP is defined as any public or not-for-profit health care provider that complies with Title X guidelines/standards, and receives either Title X funding or family planning funding from the Ohio Department of Health. MCPs must reimburse all medically-necessary Medicaid-covered family planning services provided to eligible members by a QFPP provider (including on-site pharmacy and diagnostic services) on a patient self-referral basis, irrespective of the provider’s 's status as a panel or non-panel provider. MCPs will be required to work with QFPPs in their service area the region to develop mutually-agreeable policies Appendix H and procedures to preserve patient/provider confidentiality, and convey pertinent information to the member’s 's PCP and/or MCP. Behavioral Health Providers - MCPs must assure member access to all Medicaid-covered behavioral health services for members as specified in Appendix G.b.ii. Although ODJFS is aware that certain outpatient substance abuse services may only be available through Medicaid providers certified by the Ohio Department of Drug and Alcohol Addiction Services (ODADAS) in some areas, MCPs must maintain an adequate number of contracted mental health providers in the region to assure access for members who are unable to timely access services or unwilling to access services through community mental health centers. MCPs are advised not to contract with community mental health centers as all services they provide to MCP members are to be billed to ODJFS. Other Specialty Types (pediatricians, general surgeons, otolaryngologists, allergists, and orthopedists) - MCPs must contract with the specified number of all other ODJFS designated specialty provider types. In order to be counted toward meeting the minimum provider panel requirements, these specialty providers must maintain a full-time practice at a site(s) located within the service area or alternate provider areaspecified county/region. Contracting general surgeons, orthopedists and otolaryngologists must have admitting privileges at a hospital under contract with the MCP in the service area or an alternate provider arearegion.
Appears in 1 contract
Samples: Ohio Medical Assistance Provider Agreement for Managed Care Plan (Wellcare Health Plans, Inc.)
Non-PCP Minimum Provider Network. In addition to the PCP capacity requirements, each MCP is also required to maintain adequate capacity in the remainder of its provider network within the following categories: hospitals, dentists, pharmacies, vision care providers, obstetricians/gynecologists (OB/GYNs), allergists, general surgeons, otolaryngologists, orthopedists, certified nurse midwives (CNMs), certified nurse practitioners (CNPs), federally qualified health centers (FQHCs)/rural health centers (RHCs) and qualified family planning providers (QFPPs). , CNMs, CNPs, FQHCs/RHCs and QFPPs are federally-required provider types. All Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered services to their members and therefore their complete provider network will include many other additional specialists and provider types. MCPs must ensure that all non-PCP network providers follow community standards in the scheduling of routine appointments (i.e., the amount of time members must wait from the time of their request to the first available time when the visit can occur). Although there are currently no FTE capacity requirements for any of the non-PCP required provider types, MCPs are required to ensure that adequate access is available to members for all required provider types. Additionally, for certain non-PCP required provider types, MCPs must ensure that these providers maintain a full-time practice at a site(s) located in the contract service area. A full-time practice is defined as one where the provider is available to patients at their practice site(s) in the contract service area for at least 25 hours a week. ODJFS will monitor access to services through a variety of data sources, including: consumer satisfactionsurveyssatisfaction surveys; member appeals/grievances/complaints and state hearing notifications/requests; clinical quality studies; encounter data volume; provider complaints, and clinical performance measures. Hospitals - MCPs must contract with at least one hospital in the service area or an alternate provider area, and this hospital, alone or in combination with other contracted hospitals within the service area or the alternate provider area, must be capable and agree to provide all of the following services during the contract period: general medical/surgical services for both the adult and pediatric population; obstetrical services; nursery services; adult, pediatric and neonatal (Levels I and II) intensive care; cardiac care; outpatient surgery; and emergency room services. ODJFS utilizes each hospital’s most current Annual Hospital Registration and Planning Report, as filed with the Ohio Department of Health, in determining what types of services that hospital provides. If an MCP-contracted hospital elects not to provide specific Medicaid-covered hospital services because of an objection on moral or religious grounds, then the MCP must ensure that these hospital services are available to its members through another MCP-contracted hospital in the contract service area. It will be possible to meet the hospital requirement for some service areas by contracting only with one full- full-service general hospital outside the service area, however, MCPs are required to contract with at least one hospital in the service area if at least two general hospitals (which are not both members of the same hospital system) are located in that service area. Failing to contract with a local hospital may make such a provider network less attractive to potential members. OB/GYNs - MCPs must contract with the specified number of OB/GYNsGYNs for each service area, all of whom must maintain a full-time obstetrical practice at a site(s) located in the service area or alternate provider area, as well as having . All MCP-contracting OB/GYNs must have current hospital delivery privileges at a hospital under contract to with the MCP in the service area or an alternate provider area. Certified Nurse Midwives (CNMs) and Certified Nurse Practitioners (CNPs) - MCPs must ensure access to at least one CNM and one CNP in the service area or alternate provider area, if such provider types are present. Access to additional CNMs and CNPs must be added on an as needed basis to ensure that no member is denied access to such services. For this provider panel requirement, the MCP may contract directly with the CNM or CNP, or with a physician or other provider entity who is able to obligate the participation of the CNM or CNP. If an MCP does not contract with a CNM or CNP and such providers are present within a service area or alternate provider area, the MCP will be required to allow members to receive CNM or CNP services outside of the MCP’s provider network. Contracting CNMs must have hospital delivery privileges at a hospital under contract to the MCP in the service area or an alternate provider area. The MCP must always ensure a member’s access to CNM and CNP services if such providers are present within the service area. Vision Care Providers - MCPs must contract with the specified number of ophthalmologists/optometrists for each service area, all of whom must regularly perform routine eye examinations and who maintain a full- full-time practice at a site(s) within located in the service area or alternate provider area. All ODJFS-approved vision providers must regularly perform routine eye exams. If optical dispensing is not available in a particular service area or alternate provider area through the MCP’s contracting ophthalmologists/optometrists, the MCP must separately contract with an optical dispenserdispenser located in the service area or alternate provider area. Dental Care Providers- Providers - MCPs must assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting dentists accepting new patients. The charts in Section H of this appendix reflect the number of dental providers which ODJFS will use as a guideline in assessing the MCP’s capacity to assure access to dental services. ODJFS will aggressively monitor access to dental services through a variety of data sources, including: consumer satisfaction surveys; member appeals/grievances/complaints and state hearing notifications/requests; member just-cause for disenrollment requests; dental quality studies; dental encounter data volume; provider complaints, and dental performance measures. Federally Qualified Health Centers/Rural Health Clinics (FQHCs/RHCs) - MCPs are required to ensure member access to any federally qualified health center or rural health clinic (FQHCs/RHCs), regardless of contracting status. Even if no FQHC/RHC is available within the service area, MCPs must have mechanisms in place to ensure coverage for FQHC/RHC services in the event that a member accesses these services outside of the service area. In order to assure FQHC/RHC access to members, MCPs must make provisions for the following: • Non-contracting FQHC/RHC providers serving as a PCP for an MCP’s member must be allowed to refer that member to another provider in the MCP’s provider panel. • MCPs may require that their members request a referral from their PCP in order to access FQHC/RHC providers; however, such referral requests must be approved. In order to ensure that any FQHCs/RHCs has the ability to submit a claim to ODJFS for the state’s supplemental payment, MCPs must offer FQHCs/RHCs reimbursement pursuant to the following: • MCPs must provide expedited reimbursement on a service-specific basis in an amount no less than the payment made to other providers for the same or similar service. • If the MCP has no comparable service-specific rate structure, the MCP must use the regular Medicaid fee-for-service payment schedule for non-FQHC/RHC providers. • MCPs must make all efforts to pay FQHCs/RHCs as quickly as possible and not just attempt to pay these claims within the prompt pay time frames. MCPs are required to educate their staff and providers on the need to assure member access to FQHC/RHC services. Appendix H Qualified Family Planning Providers (QFPPs) - All MCP members must be permitted to self-refer to family planning services provided by a QFPP. A QFPP is defined as any public or not-for-profit health care provider that complies with Title X guidelines/standards, and receives either Title X funding or family planning funding from the Ohio Department of Health. MCPs must reimburse all medically-necessary Medicaid-covered family planning services provided to eligible members by a QFPP provider on a patient self-referral basis, irrespective of the provider’s status as a panel or non-panel provider. MCPs will be required to work with QFPPs in their service area to develop mutually-agreeable policies and procedures to preserve patient/provider confidentiality, and convey pertinent information to the member’s PCP and/or MCP. Behavioral Health Providers - MCPs must assure member access to all Medicaid-covered behavioral health services for members as specified in Appendix G.b.ii. Although ODJFS is aware that certain outpatient substance abuse services may only be available through ODADAS-certified Medicaid providers in some areas, MCPs must maintain an adequate number of contracted mental health providers in the contract service area to assure access for members who are unable to timely access services or unwilling to access services through community mental health centers. Other Specialty Types (pediatricians, general surgeons, otolaryngologists, allergists, and orthopedists) - MCPs must contract with the specified number of all other specialty provider types. In order to be counted toward meeting the minimum provider panel requirements, these specialty providers must maintain a full-time practice at a site(s) located within the service area or alternate provider area. Contracting general surgeons, orthopedists and otolaryngologists must have admitting privileges at a hospital under contract with the MCP in the service area or an alternate provider area.
Appears in 1 contract
Samples: Ohio Medical Assistance Provider Agreement (Centene Corp)
Non-PCP Minimum Provider Network. In addition to the PCP capacity requirements, each MCP is also required to maintain adequate capacity in the remainder of its provider network within the following categories: hospitals, dentists, pharmacies, vision care providers, obstetricians/gynecologists (OB/GYNs), allergists, general surgeons, otolaryngologists, orthopedists, certified nurse midwives (CNMs), certified nurse practitioners (CNPs), federally qualified health centers (FQHCs)/rural health centers (RHCs) and qualified family planning providers (QFPPs). CNMs, CNPs, FQHCs/RHCs and QFPPs are federally-required provider types. All Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered services to their members and therefore their complete provider network will include many other additional specialists and provider types. MCPs must ensure that all non-PCP network providers follow community standards in the scheduling of routine appointments (i.e., the amount of time members must wait from the time of their request to the first available time when the visit can occur). Although there are currently no FTE capacity requirements for any of the non-PCP required provider types, MCPs are required to ensure that adequate access is available to members for all required provider types. ODJFS will monitor access to services through a variety of data sources, including: consumer satisfactionsurveyssatisfaction surveys; member appeals/grievances/complaints and state hearing notifications/requests; clinical quality studies; encounter data volume; provider complaints, and clinical performance measures. Hospitals - MCPs must contract with at least one hospital in the service area or an alternate provider area, and this hospital, alone or in combination with other contracted hospitals within the service area or the alternate provider area, must be capable and agree to provide all of the following services during the contract period: general medical/surgical services for both the adult and pediatric population; obstetrical services; nursery services; adult, pediatric and neonatal (Levels I and II) intensive care; cardiac care; outpatient surgery; and emergency room services. ODJFS utilizes each hospital’s 's most current Annual Hospital Registration and Planning Report, as filed with the Ohio Department of Health, in determining what types of services that hospital provides. It will be possible to meet the hospital requirement for some service areas by contracting only with one full- full-service general hospital outside the service area, however, MCPs are required to contract with at least one hospital in the service area if at least two general hospitals (which are not both members of the same hospital system) are located in that service area. Failing to contract with a local hospital may make such a provider network less attractive to potential members. OB/GYNs - MCPs must contract with the specified number of OB/GYNs, all of whom must maintain a full-time obstetrical practice at a site(s) located in the service area or alternate provider area, as well as having current hospital delivery privileges at a hospital under contract to the MCP in the service area or an alternate provider area. Certified Nurse Midwives (CNMs) and Certified Nurse Practitioners (CNPs) - MCPs must ensure access to at least one CNM and one CNP in the service area or alternate provider area, if such provider types are present. Access to additional CNMs and CNPs must be added on an as needed basis to ensure that no member is denied access to such services. For this provider panel requirement, the MCP may contract directly with the CNM or CNP, or with a physician or other provider entity who is able to obligate the participation of the CNM or CNP. If an MCP does not contract with a CNM or CNP and such providers are present within a service area or alternate provider area, the MCP will be required to allow members to receive CNM or CNP services outside of the MCP’s 's provider network. Contracting CNMs must have hospital delivery privileges at a hospital under contract to the MCP in the service area or an alternate provider area. The MCP must always ensure a member’s 's access to CNM and CNP services if such providers are present within the service area. Vision Care Providers - MCPs must contract with the specified number of ophthalmologists/optometrists for each service area, all of whom must regularly perform routine eye examinations and who maintain a full- full-time practice at a site(s) within the service area. If optical dispensing is not available in a particular service area through the MCP’s 's contracting ophthalmologists/optometrists, the MCP must separately contract with an optical dispenser. Dental Care Providers- MCPs must assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting dentists accepting new patients. The charts in Section H of this appendix reflect the number of dental providers which ODJFS will use as a guideline in assessing the MCP’s 's capacity to assure access to dental services. ODJFS will aggressively monitor access to dental services through a variety of data sources, including: consumer satisfaction surveys; member appeals/grievances/complaints and state hearing notifications/requests; member just-cause for disenrollment requests; dental quality studies; dental encounter data volume; provider complaints, and dental performance measures. Federally Qualified Health Centers/Rural Health Clinics (FQHCs/RHCs) - MCPs are required to ensure member access to any federally qualified health center or rural health clinic (FQHCs/RHCs), regardless of contracting status. Even if no FQHC/RHC is available within the service area, MCPs must have mechanisms in place to ensure coverage for FQHC/RHC services in the event that a member accesses these services outside of the service area. In order to assure FQHC/RHC access to members, MCPs must make provisions for the following: • Non-contracting FQHC/RHC providers serving as a PCP for an MCP’s member must be allowed to refer that member to another provider in the MCP’s provider panel. • - MCPs may require that their members request a referral from their PCP in order to access FQHC/RHC providers; however, such referral requests must be approved. In order to ensure that any FQHCs/RHCs has the ability to submit a claim to ODJFS for the state’s 's supplemental payment, MCPs must offer FQHCs/RHCs reimbursement pursuant to the following: • - MCPs must provide expedited reimbursement on a service-specific basis in an amount no less than the payment made to other providers for the same or similar service. • - If the MCP has no comparable service-specific rate structure, the MCP must use the regular Medicaid fee-for-service payment schedule for non-FQHC/RHC providers. • - MCPs must make all efforts to pay FQHCs/RHCs as quickly as possible and not just attempt to pay these claims within the prompt pay time frames. MCPs are required to educate their staff and providers on the need to assure member access to FQHC/RHC services. Qualified Family Planning Providers (QFPPs) - All MCP members must be permitted to self-refer to family planning services provided by a QFPP. A QFPP is defined as any public or not-for-profit health care provider that complies with Title X guidelines/standards, and receives either Title X funding or family planning funding from the Ohio Department of Health. MCPs must reimburse all medically-necessary Medicaid-covered family planning services provided to eligible members by a QFPP provider on a patient self-referral basis, irrespective of the provider’s 's status as a panel or non-panel provider. MCPs will be required to work with QFPPs in their service area to develop mutually-agreeable policies and procedures to preserve patient/provider confidentiality, and convey pertinent information to the member’s 's PCP and/or MCP. Other Specialty Types (pediatricians, general surgeons, otolaryngologists, allergists, and orthopedists) - MCPs must contract with the specified number of all other specialty provider types. In order to be counted toward meeting the minimum provider panel requirements, these specialty providers must maintain a full-time practice at a site(s) located within the service area or alternate provider area. Contracting general surgeons, orthopedists and otolaryngologists must have admitting privileges at a hospital under contract with the MCP in the service area or an alternate provider area.
Appears in 1 contract
Samples: Provider Agreement (Centene Corp)
