Other Requirements Pertaining to Covered Services. MCOs must assume responsibility for all covered medical conditions, inclusive of pre-existing conditions of each enrollee as of the effective date of enrollment in the plan. MCOs may not prohibit or otherwise restrict a covered health professional from advising his/her patient about the health status of the individual or medical care or treatment for the individual’s condition or disease, regardless of whether benefits for that care or treatment are provided under the Contract, if the professional is acting within the lawful scope of practice.6 MCOs and their participating providers may not bill or collect any payment from Medicaid enrollees for care that was determined not to be Medically Necessary. Anyone who knowingly and willfully charges for any service provided to a patient under a State Plan approved under Title XIX or under a MCO Contract under 1903(m) of the Social Security Act, money or other consideration at a rate in excess of the rates established by BMS or Contract will be guilty of a felony and upon conviction will be fined no more than $25,000 or imprisoned for no more than five years, or both.
Other Requirements Pertaining to Covered Services. 66 1.6 Requirements Pertaining to Medicaid Managed Care Programs 66 2. PROVIDER NETWORK 66
Other Requirements Pertaining to Covered Services. MCOs must assume responsibility for all covered medical conditions, inclusive of pre-existing conditions of each enrollee as of the effective date of enrollment in the plan. MCOs may not prohibit or otherwise restrict a covered health professional from advising his/her patient about the health status of the individual or medical care or treatment for the individual’s condition or disease, regardless of whether benefits for that care or treatment are provided under the Contract, if the professional is acting within the lawful scope of practice.5 MCOs and their participating providers may not bill or collect any payment from enrollees for a Medicaid service that was determined not to be Medically Necessary or an SNS that was determined not to be Socially Necessary. Anyone who knowingly and willfully charges for any service provided to a patient under a State Plan approved under Title XIX or under a MCO Contract under 1903(m) of the Social Security Act, money or other consideration at a rate in
Other Requirements Pertaining to Covered Services. MCOs must assume responsibility for all covered medical conditions, inclusive of pre-existing conditions of each enrollee as of the effective date of enrollment in the plan. MCOs may not prohibit or otherwise restrict a covered health professional from advising his/her patient about the health status of the individual or medical care or treatment for the individual’s condition or disease, regardless of whether benefits for that care or treatment are provided under the Contract, if the professional is acting within the lawful scope of practice.5 MCOs and their participating providers may not bill or collect any payment from Medicaid enrollees for care that was determined not to be Medically Necessary. Anyone who knowingly and willfully charges for any service provided to a patient under a State Plan approved under Title XIX or under a MCO Contract under 1903(m) of the Social Security Act, money or other consideration at a rate in excess of the rates established by BMS or Contract will be guilty of a felony and upon conviction will be fined no more than $25,000 or imprisoned for no more than five years, or both. 4 Infertility services are excluded per West Virginia State law, section 33-25A-4(2)(b).
Other Requirements Pertaining to Covered Services. 62 2.6 Requirements Pertaining to Medicaid Managed Care Programs 62 3. PROVIDER NETWORK 63 3.1 General Requirements 63 3.5 Mainstreaming 77 3.6 Provider Services 77 3.7 Provider Reimbursement 82 3.8 Prohibitions on Inappropriate Physician Incentives 87 4. ENROLLMENT & MEMBER SERVICES 87 4.1 Marketing 88 4.2 Enrollment 89 4.3 Member Services Department 92 4.4 Materials 92 4.6 Enrollee Rights 99 4.7 Enabling Services 101 4.8 Grievances and Appeals 102 4.9 Cost-Sharing Obligations 109 4.10 Value-Added Services 110 5. MEDICAID ADMINISTRATOR/CONTRACT LIAISON FUNCTIONS 110 6. HEALTH CARE MANAGEMENT 111 6.1 Second Opinions 111 6.2 Out-of-Network Services 112 6.3 Continuity and Coordination of Care 112 6.4 Service Authorization (Prior Authorization) 112 6.5 Rural Option 114
Other Requirements Pertaining to Covered Services. MCOs must assume responsibility for all covered medical conditions, inclusive of pre-existing conditions of each enrollee as of the effective date of enrollment in the plan. MCOs may not prohibit or otherwise restrict a covered health professional from advising his/her patient about the health status of the individual or medical care or treatment for the individual’s condition or disease, regardless of whether benefits for that care or treatment are provided under the Contract, if the professional is acting within the lawful scope of practice.5 MCOs and their participating providers may not bill or collect any payment from enrollees for a Medicaid service that was determined not to be Medically Necessary or an SNS that was determined not to be Socially Necessary. Anyone who knowingly and willfully charges for any 4 Infertility services are excluded per West Virginia State law, section 33-25A-4(2)(b).
Other Requirements Pertaining to Covered Services. 48 1.6 Requirements Pertaining to Medicaid Redesign 48 2. PROVIDER NETWORK 49
Other Requirements Pertaining to Covered Services. MCOs must assume responsibility for all covered medical conditions, inclusive of pre-existing conditions of each enrollee as of the effective date of enrollment in the plan. MCOs may not prohibit or otherwise restrict a covered health professional from advising his/her patient about 5 Infertility services are excluded per West Virginia State law, section 33-25A-4(2)(b). the health status of the individual or medical care or treatment for the individual’s condition or disease, regardless of whether benefits for that care or treatment are provided under the Contract, if the professional is acting within the lawful scope of practice.6 MCOs and their participating providers may not bill or collect any payment from Medicaid enrollees for care that was determined not to be Medically Necessary. Anyone who knowingly and willfully charges for any service provided to a patient under a State Plan approved under Title XIX or under a MCO Contract under 1903(m) of the Social Security Act, money or other consideration at a rate in excess of the rates established by BMS or Contract will be guilty of a felony and upon conviction will be fined no more than $25,000 or imprisoned for no more than five years, or both.
Other Requirements Pertaining to Covered Services. MCOs must assume responsibility for all covered medical conditions, inclusive of pre-existing conditions of each enrollee as of the effective date of enrollment in the plan. MCOs may not prohibit or otherwise restrict a covered health professional from advising his/her patient about 6 Infertility services are excluded per West Virginia State law, section 33-25A-4(2)(b). the health status of the individual or medical care or treatment for the individual’s condition or disease, regardless of whether benefits for that care or treatment are provided under the contract, if the professional is acting within the lawful scope of practice.7 MCOs cannot impose any enrollee copayments or fees for contracted services. MCOs and their participating providers may not xxxx or collect any payment from Medicaid enrollees for care that was determined not to be medically necessary. Anyone who knowingly and willfully charges for any service provided to a patient under a State Plan approved under Title XIX or under a MCO contract under 1903(m) of the Social Security Act, money or other consideration at a rate in excess of the rates established by BMS or contract shall be guilty of a felony and upon conviction shall be fined no more than $25,000 or imprisoned for no more than five years, or both.
Other Requirements Pertaining to Covered Services. The MCO must assume responsibility for all covered medical conditions, inclusive of pre- existing conditions of each enrollee as of the effective date of enrollment in the plan. The MCO may not prohibit or otherwise restrict a covered health professional from advising his/her patient about the health status of the individual or medical care or treatment for the individual’s condition or disease, regardless of whether benefits for that care or treatment are provided under the Contract, if the professional is acting within the lawful scope of practice.6 The MCO and its participating providers may not bill or collect any payment from Medicaid or WVCHIP enrollees for care that was determined not to be Medically Necessary. Anyone who knowingly and willfully charges for any service provided to a patient under a State Plan approved under Title XIX, Title XXI or under a MCO Contract under 1903(m) of the Social Security Act, money or other consideration at a rate in excess of the rates established by BMS or Contract will be guilty of a felony and upon conviction will be fined no more than $25,000 or imprisoned for no more than five (5) years, or both.
