Prerequisite to Enrolling Members. The Department reserves the right to conduct an on-or-off-site readiness review prior to the enrollment of Medicaid Members with the Contractor. The purpose of the review is to provide the Department with assurances the Contractor is able and prepared to perform all administrative functions and to provide high-quality services to enrolled Members. Specifically, the review will assess the Contractor’s ability to meet the requirements set forth in the Contract and federal requirements outlined in 42 CFR 438 and shall include at a minimum: A. A review of the Contractor’s ability to provide services to Medicaid Members; B. A review of an adequate statewide network of providers; C. A review of the Contractor’s QI/UM function capability; D. A review of the Contractor’s ability to provide adequate, accessible PCP and Specialty Providers; E. A review of the Contractor’s technical capacity to process claims and pay providers and respond to Member’s needs and send/receive files as required by the Department; and F. A review of the Contractor’s ability to process complaints, grievances and appeals. The readiness review activities will be conducted by a team appointed by the Department and may include contract staff.
Appears in 4 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract, Medicaid Managed Care Contract
