Common use of Public Health Providers Clause in Contracts

Public Health Providers. a. The Health Plan shall make a good faith effort to execute memoranda of agreement with the local CHDs to provide services which may include, but are not limited to, family planning services, services for the treatment of sexually transmitted diseases, other public health related diseases, tuberculosis, immunizations, xxxxxx care emergency shelter medical screenings, and services related to Healthy Start prenatal and post-natal screenings. The Health Plan shall provide documentation of its good faith effort upon the Agency’s request. b. A capitated Health Plan shall pay, without prior authorization, at the contracted rate or the Medicaid fee-for-service rate, all valid claims initiated by any CHD for office visits, prescribed drugs, laboratory services directly related to DCF emergency shelter medical screening, and tuberculosis. A capitated Health Plan shall reimburse the CHD when the CHD notifies the Health Plan and provides the Health Plan with copies of the appropriate medical records and provides the enrollee's PCP with the results of any tests and associated office visits. c. The Health Plan shall authorize all claims from a CHD, a migrant health center funded under Section 329 of the Public Health Services Act or a community health center funded under Section 330 of the Public Health Services Act, without prior authorization for the services listed below. Such providers shall attempt to contact the Health Plan before providing health care services to enrollees and shall provide the Health Plan with the results of the office visit, including test results. The Health Plan shall not deny claims for services delivered by these providers solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three-hundred and sixty-five (365) calendar days, and shall be reimbursed by the Health Plan at the rate negotiated between the Health Plan and the public provider or the applicable Medicaid fee-for-service rate. (1) The diagnosis and treatment of sexually transmitted diseases and other reportable infectious diseases, such as tuberculosis and HIV; (2) The provision of immunizations; (3) Family planning services and related pharmaceuticals; (4) School health services listed in a, b and c above, and for services rendered on an urgent basis by such providers; and, HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract (5) In the event that a vaccine-preventable disease emergency is declared, the Health Plan shall authorize claims from the CHD for the cost of the administration of vaccines. d. Other clinic-based services provided by a CHD, migrant health center or community health center, including well-child care, dental care, and sick care services not associated with reportable infectious diseases, require prior authorization from the Health Plan in order to receive reimbursement. If prior authorization is provided, the Health Plan shall reimburse at the entity’s cost-based reimbursement rate. If prior authorization for prescription drugs is given and the drugs are provided, the Health Plan shall reimburse the entity at Medicaid’s standard pharmacy rate. e. The Health Plan shall make a good faith effort to execute a contract with a Federally Qualified Health Center (FQHC) and, if applicable, a Rural Health Clinic (RHC). (1) The capitated Health Plan shall reimburse FQHCs and RHCs at rates comparable to those rates paid for similar services in the FQHC’s or RHC’s community. (2) The capitated Health Plan shall report quarterly to BMHC, the payment rates and the payment amounts made to FQHCs and RHCs for contractual services provided by these entities. f. The Health Plan shall make a good faith effort to execute memoranda of agreement with school districts participating in the certified match program regarding the coordinated provision of school-based services pursuant to ss. 1011.70 and 409.908(21), F.S.

Public Health Providers. a. The Health Plan shall make a good faith effort to execute memoranda of agreement with the local CHDs to provide services which may include, but are not limited to, family planning services, services for the treatment of sexually transmitted diseases, other public health related diseases, tuberculosis, immunizations, xxxxxx care emergency shelter medical screenings, and services related to Healthy Start prenatal and post-natal screenings. The Health Plan shall provide documentation of its good faith effort upon the Agency’s request. b. A capitated Health Plan shall pay, without prior authorization, at the contracted rate or the Medicaid fee-for-service rate, all valid claims initiated by any CHD for office visits, prescribed drugs, laboratory services directly related to DCF emergency shelter medical screening, and tuberculosis. A capitated Health Plan shall reimburse the CHD when the CHD notifies the Health Plan and provides the Health Plan with copies of the appropriate medical records and provides the enrollee's PCP with the results of any tests and associated office visits. c. The Health Plan shall authorize all claims from a CHD, a migrant health center funded under Section 329 of the Public Health Services Act or a community health center funded under Section 330 of the Public Health Services Act, without prior authorization for the services listed below. Such providers shall attempt to contact the Health Plan before providing health care services to enrollees and shall provide the Health Plan with the results of the office visit, including test results. The Health Plan shall not deny claims for services delivered by these providers solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three-hundred and sixty-five (365) calendar days, and shall be reimbursed by the Health Plan at the rate negotiated between the Health Plan and the public provider or the applicable Medicaid fee-for-service rate. The Medicaid FFS rate is the standard Medicaid fee schedule rate or the CHD cost-based rate as WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract specified by the County Health Department Clinic Services Coverage and Limitations Handbook for applicable rates. (1) The diagnosis and treatment of sexually transmitted diseases and other reportable infectious diseases, such as tuberculosis and HIV; (2) The provision of immunizations; (3) Family planning services and related pharmaceuticals; (4) School health services listed in a, b and c above, and for services rendered on an urgent basis by such providers; and, HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract, (5) In the event that a vaccine-preventable disease emergency is declared, the Health Plan shall authorize claims from the CHD for the cost of the administration of vaccines. d. Other clinic-based services provided by a CHD, migrant health center or community health center, including well-child care, dental care, and sick care services not associated with reportable infectious diseases, require prior authorization from the Health Plan in order to receive reimbursement. If prior authorization is provided, the Health Plan shall reimburse at the entity’s cost-based reimbursement rate. If prior authorization for prescription drugs is given and the drugs are provided, the Health Plan shall reimburse the entity at Medicaid’s standard pharmacy rate. e. The Health Plan shall make a good faith effort to execute a contract with a Federally Qualified Health Center (FQHC) and, if applicable, a Rural Health Clinic (RHC). (1) f. The capitated Health Plan shall reimburse FQHCs and RHCs at rates comparable to those rates paid for similar services in the FQHC’s or RHC’s community. (2) g. The capitated Health Plan shall report quarterly to BMHCBMHC as part of its quarterly financial reports, the payment rates and the payment amounts made to FQHCs and RHCs for contractual services provided by these entities. f. h. The Health Plan shall make a good faith effort to execute memoranda of agreement with school districts participating in the certified match program regarding the coordinated provision of school-based services pursuant to ss. 1011.70 and 409.908(21), F.S.

Public Health Providers. a. The Health Plan shall make a good faith effort to execute memoranda of agreement with the local CHDs to provide services which may include, but are not limited to, family planning services, services for the treatment of sexually transmitted diseases, other public health related diseases, tuberculosis, immunizations, xxxxxx care emergency shelter medical screenings, and services related to Healthy Start prenatal and post-natal screenings. The Health Plan shall provide documentation of its good faith effort upon the Agency’s request. b. A capitated Health Plan shall pay, without prior authorization, at the contracted rate or the Medicaid fee-for-service rate, all valid claims initiated by any CHD for office visits, prescribed drugs, laboratory services directly related to DCF emergency shelter medical screening, and tuberculosis. A capitated Health Plan shall reimburse the CHD when the CHD notifies the Health Plan and provides the Health Plan with copies of the appropriate medical records and provides the enrollee's ’s PCP with the results of any tests and associated office visits. c. The Health Plan shall authorize all claims from a CHD, a migrant health center funded under Section 329 of the Public Health Services Act or a community health center funded under Section 330 of the Public Health Services Act, without prior authorization for the services listed below. Such providers shall attempt to contact the Health Plan before providing health care services to enrollees and shall provide the Health Plan with the results of the office visit, including test results. The Health Plan shall not deny claims for services delivered by these providers solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three-hundred and sixty-five (365) calendar days, and shall be reimbursed by the Health Plan at the rate negotiated between the Health Plan and the public provider or the applicable Medicaid fee-for-service rate. (1) The diagnosis and treatment of sexually transmitted diseases and other reportable infectious diseases, such as tuberculosis and HIV; (2) The provision of immunizations; (3) Family planning services and related pharmaceuticals; (4) School health services listed in a, b and c above, and for services rendered on an urgent basis by such providers; and, HealthEase of AMERIGROUP Florida, Inc. d/b/a Medicaid HMO Non-Reform and Reform AMERIGROUP Community Care HMO Contract (5) In the event that a vaccine-preventable disease emergency is declared, the Health Plan shall authorize claims from the CHD for the cost of the administration of vaccines. d. Other clinic-based services provided by a CHD, migrant health center or community health center, including well-child care, dental care, and sick care services not associated with reportable infectious diseases, require prior authorization from the Health Plan in order to receive reimbursement. If prior authorization is provided, the Health Plan shall reimburse at the entity’s cost-based reimbursement rate. If prior authorization for prescription drugs is given and the drugs are provided, the Health Plan shall reimburse the entity at Medicaid’s standard pharmacy rate. e. The Health Plan shall make a good faith effort to execute a contract with a Federally Qualified Health Center (FQHC) and, if applicable, a Rural Health Clinic (RHC). (1) The capitated Health Plan shall reimburse FQHCs and RHCs at rates comparable to those rates paid for similar services in the FQHC’s or RHC’s community. (2) The capitated Health Plan shall report quarterly to BMHC, the payment rates and the payment amounts made to FQHCs and RHCs for contractual services provided by these entities. f. The Health Plan shall make a good faith effort to execute memoranda of agreement with school districts participating in the certified match program regarding the coordinated provision of school-based services pursuant to ss. 1011.70 and 409.908(21), F.S.

Public Health Providers. a. The Health Plan shall make a good faith effort to execute memoranda of agreement with the local CHDs to provide services which may include, but are not limited to, family planning services, services for the treatment of sexually transmitted diseases, other public health related diseases, tuberculosis, immunizations, xxxxxx care emergency shelter medical screenings, and services related to Healthy Start prenatal and post-natal screenings. The Health Plan shall provide documentation of its good faith effort upon the Agency’s request. b. A capitated Health Plan shall pay, without prior authorization, at the contracted rate or the Medicaid fee-for-service rate, all valid claims initiated by any CHD for office visits, prescribed drugs, laboratory services directly related to DCF emergency shelter medical screening, and tuberculosis. A capitated Health Plan shall reimburse the CHD when the CHD notifies the Health Plan and provides the Health Plan with copies of the appropriate medical records and provides the enrollee's PCP with the results of any tests and associated office visits. c. The Health Plan shall authorize all claims from a CHD, a migrant health center funded under Section 329 of the Public Health Services Act or a community health center funded under Section 330 of the Public Health Services Act, without prior authorization for the services listed below. Such providers shall attempt to contact the Health Plan before providing health care services to enrollees and shall provide the Health Plan with the results of the office visit, including test results. The Health Plan shall not deny claims for services delivered by these providers solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three-hundred and sixty-five (365) calendar days, and shall be reimbursed by the Health Plan at the rate negotiated between the Health Plan and the public provider or the applicable Medicaid fee-for-service rate. (1) The diagnosis and treatment of sexually transmitted diseases and other reportable infectious diseases, such as tuberculosis and HIV; (2) The provision of immunizations; (3) Family planning services and related pharmaceuticals; (4) School health services listed in a, b and c above, and for services rendered on an urgent basis by such providers; and, HealthEase WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO Non-Reform Contract (5) In the event that a vaccine-preventable disease emergency is declared, the Health Plan shall authorize claims from the CHD for the cost of the administration of vaccines. d. Other clinic-based services provided by a CHD, migrant health center or community health center, including well-child care, dental care, and sick care services not associated with reportable infectious diseases, require prior authorization from the Health Plan in order to receive reimbursement. If prior authorization is provided, the Health Plan shall reimburse at the entity’s cost-based reimbursement rate. If prior authorization for prescription drugs is given and the drugs are provided, the Health Plan shall reimburse the entity at Medicaid’s standard pharmacy rate. e. The Health Plan shall make a good faith effort to execute a contract with a Federally Qualified Health Center (FQHC) and, if applicable, a Rural Health Clinic (RHC). (1) The capitated Health Plan shall reimburse FQHCs and RHCs at rates comparable to those rates paid for similar services in the FQHC’s or RHC’s community. (2) The capitated Health Plan shall report quarterly to BMHC, the payment rates and the payment amounts made to FQHCs and RHCs for contractual services provided by these entities. f. The Health Plan shall make a good faith effort to execute memoranda of agreement with school districts participating in the certified match program regarding the coordinated provision of school-based services pursuant to ss. 1011.70 and 409.908(21), F.S.

Public Health Providers. a. The Health Plan shall make a good faith effort to execute memoranda of agreement with the local CHDs to provide services which may include, but are not limited to, family planning services, services for the treatment of sexually transmitted diseases, other public health related diseases, tuberculosis, immunizations, xxxxxx fxxxxx care emergency shelter medical screenings, and services related to Healthy Start prenatal and post-natal screenings. The Health Plan shall provide documentation of its good faith effort upon the Agency’s request. b. A capitated Health Plan shall pay, without prior authorization, at the contracted rate or the Medicaid fee-for-service rate, all valid claims initiated by any CHD for office visits, prescribed drugs, laboratory services directly related to DCF emergency shelter medical screening, and tuberculosis. A capitated Health Plan shall reimburse the CHD when the CHD notifies the Health Plan and provides the Health Plan with copies of the appropriate medical records and provides the enrollee's PCP with the results of any tests and associated office visits. c. The Health Plan shall authorize all claims from a CHD, a migrant health center funded under Section 329 of the Public Health Services Act or a community health center funded under Section 330 of the Public Health Services Act, without prior authorization for the services listed below. Such providers shall attempt to contact the Health Plan before providing health care services to enrollees and shall provide the Health Plan with the results of the office visit, including test results. The Health Plan shall not deny claims for services delivered by these providers solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three-hundred and sixty-five (365) calendar days, and shall be reimbursed by the Health Plan at the rate negotiated between the Health Plan and the public provider or the applicable Medicaid fee-for-service rate. The Medicaid FFS rate is the standard Medicaid fee schedule rate or the CHD cost-based rate as WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract specified by the County Health Department Clinic Services Coverage and Limitations Handbook for applicable rates. (1) The diagnosis and treatment of sexually transmitted diseases and other reportable infectious diseases, such as tuberculosis and HIV; (2) The provision of immunizations; (3) Family planning services and related pharmaceuticals; (4) School health services listed in a, b and c above, and for services rendered on an urgent basis by such providers; and, HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract, (5) In the event that a vaccine-preventable disease emergency is declared, the Health Plan shall authorize claims from the CHD for the cost of the administration of vaccines. d. Other clinic-based services provided by a CHD, migrant health center or community health center, including well-child care, dental care, and sick care services not associated with reportable infectious diseases, require prior authorization from the Health Plan in order to receive reimbursement. If prior authorization is provided, the Health Plan shall reimburse at the entity’s cost-based reimbursement rate. If prior authorization for prescription drugs is given and the drugs are provided, the Health Plan shall reimburse the entity at Medicaid’s standard pharmacy rate. e. The Health Plan shall make a good faith effort to execute a contract with a Federally Qualified Health Center (FQHC) and, if applicable, a Rural Health Clinic (RHC). (1) f. The capitated Health Plan shall reimburse FQHCs and RHCs at rates comparable to those rates paid for similar services in the FQHC’s or RHC’s community. (2) g. The capitated Health Plan shall report quarterly to BMHCBMHC as part of its quarterly financial reports, the payment rates and the payment amounts made to FQHCs and RHCs for contractual services provided by these entities. f. h. The Health Plan shall make a good faith effort to execute memoranda of agreement with school districts participating in the certified match program regarding the coordinated provision of school-based services pursuant to ss. 1011.70 and 409.908(21), F.S.