Common use of Provider Services Department Clause in Contracts

Provider Services Department. The MCO must maintain a Provider Services Department and operate a toll-free provider phone line for at least eight (8) hours a day during regular business hours. The MCO Provider Services Department is responsible for the following, but not limited to: 1. Assisting providers with questions concerning enrollee eligibility status; 2. Assisting providers with plan prior authorization and referral procedures; 3. Assisting providers with claims payment procedures; 4. Handling provider complaints; 5. Providing and encouraging training to providers to promote sensitivity to the special needs of this population; 6. Educating providers in regards to Mountain Health Trust and West Virginia Health Bridge; and 7. Educating providers in regards to the MCO’s written policies on the False Claims Act, including policies and procedures for detecting and preventing waste, fraud, and abuse. This requirement is pursuant to the Deficit Reduction Act of 2005, Section 6032. The MCO must ensure that after regular business hours the line is answered by an automated system with the capability to provide callers with operating hours, information and instructions on how to verify enrollment for a member with an Urgent Condition or an Emergency Medical Condition. The MCO must ensure that the toll-free provider phone line meets the following minimum performance requirements: 1. Eighty three (83) percent of calls are answered live within thirty (30) seconds during operating hours. Time measured begins when the provider is placed in the call queue to wait to speak to a Provider Services representative; and 2. The call abandonment rate does not exceed five (5) percent of total calls for the reporting period. If the MCO’s Subcontractor operates a separate call center, the Subcontractor’s call center must at a minimum meet the provider phone line performance standards set forth in this Section.

Provider Services Department. The MCO must maintain a Provider Services Department and operate a toll-free provider phone line for at least eight (8) 8 hours a day during regular business hours. The MCO Provider Services Department is responsible for the following, but not limited to: 1. Assisting providers with questions concerning enrollee eligibility status; 2. Assisting providers with plan prior authorization and referral procedures; 3. Assisting providers with claims payment procedures; 4. Handling provider complaints; 5. Providing and encouraging training to providers to promote sensitivity to the special needs of this population; 6. Educating providers in regards to Mountain Health Trust and West Virginia Health Bridge; and 7. Educating providers in regards to the MCO’s written policies on the False Claims Act, including policies and procedures for detecting and preventing waste, fraud, and abuse. This requirement is pursuant to the Deficit Reduction Act of 2005, Section 6032. The MCO must ensure that after regular business hours the line is answered by an automated system with the capability to provide callers with operating hours, information and instructions on how to verify enrollment for a member with an Urgent Condition or an Emergency Medical Condition. The MCO must ensure that the toll-free provider phone line meets the following minimum performance requirements: 1. Eighty three percent (83%) percent of calls are answered live within thirty (30) seconds during operating hours. Time measured begins when the provider is placed in the call queue to wait to speak to a Provider Services representative; and; 2. The call abandonment rate does not exceed five (5) percent of total calls for the reporting period. If the MCO’s Subcontractor subcontractor operates a separate call center, the Subcontractorsubcontractor’s call center must at a minimum meet the provider phone line performance standards set forth in this Section.