Reporting Requirements and Reporting Deliverables. A Provider who has exhausted the Contractor’s internal appeal process shall have a right to appeal a final denial, in whole or in part, by the Contractor to an external independent third party in accordance with applicable state laws and regulations including denials, in whole or in part, involving emergency care services. The Contractor shall provide written notification to the Provider of its right to file an appeal. A provider shall have a right to appeal a final decision by an external independent third party to the Cabinet for Health and Family Services Division of Administrative Hearings for a hearing in accordance with applicable state laws and regulation.
Reporting Requirements and Reporting Deliverables. The Contractor shall indicate in its notice to the Department the reason or reasons for which the PCP ceases participation. The Contractor shall notify any Member of the Provider’s termination provided such Member has received a service from the terminating Provider within the previous six months. Such notice shall be mailed the later of the following: (i) thirty (30) days prior to the effective date of the termination or (ii) within fifteen (15) days of receiving notice.
Reporting Requirements and Reporting Deliverables. The contractor agrees to provide any information requested by the Department regarding expenditures related to this Contract. Including but not limited to any findings of the Medicaid Managed Care Operations Examination. APPENDICES Table of Contents APPENDIX A. CAPITATION PAYMENT RATES 2 APPENDIX B. MEDICAL LOSS RATIO CALCULATION 5 APPENDIX C. THIRD PARTY PAYMENTS/COORDINATION OF BENEFITS 7 APPENDIX D. MANAGEMENT INFORMATION SYSTEM REQUIREMENTS 9 APPENDIX E. BUSINESS ASSOCIATES AGREEMENT APPENDIX F. ENCOUNTER DATA SUBMISSION REQUIREMENTS AND QUALITY STANDARDS 00 XXXXXXXX X. XXXXX XXXXXXXX XXXXXXXXX PROGRAM 29 APPENDIX H. COVERED SERVICES APPENDIX I. TRANSITION/COORDINATION OF CARE PLANS 35 APPENDIX J. CREDENTIALING PROCESS 35 APPENDIX L. MCO PROVIDER NETWORK FILE LAYOUT (EFFECTIVE 11-07-12) 39 APPENDIX M. EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM (EPSDT) 00 XXXXXXXX X. PROGRAM INTEGRITY REQUIREMENTS 57 APPENDIX O. PAID CLAIMS LISTING REQUIREMENTS 61 APPENDIX P. MCO CAPITATION RECONCILIATION INBOUND/OUTBOUND FILE LAYOUTS 62 APPENDIX A. CAPITATION PAYMENT RATES Capitation Rates Effective July 1, 2017 - December 31, 2017 Base Captiation Rates Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Families & Children Infant - Age Under 1 $571.58 $694.79 $801.42 $615.51 $779.93 $1,020.94 $734.68 $900.88 Child - Age 1 to 5 $126.16 $133.21 $148.33 $141.82 $140.45 $151.52 $152.24 $164.58 Child - Age 6 to 12 $145.08 $146.63 $181.87 $174.78 $150.19 $175.99 $193.87 $188.40 Child - Age 13 to 18 Female $238.23 $258.77 $265.58 $261.63 $256.43 $274.87 $269.29 $271.35 Child - Age 13 to 18 Male $219.92 $194.41 $243.73 $194.92 $191.57 $198.11 $196.67 $196.61 Adult - Age 19 to 24 Female $536.69 $502.27 $512.24 $472.49 $521.27 $494.55 $491.18 $506.29 Adult - Age 19 to 24 Male $173.50 $168.78 $170.33 $130.92 $194.19 $128.08 $169.05 $160.21 Adult - Age 25 to 39 Female $548.22 $498.00 $551.56 $489.68 $579.07 $528.93 $545.39 $558.28 Adult - Age 25 to 39 Male $314.91 $281.46 $325.73 $275.40 $367.55 $335.60 $323.13 $370.64 Adult - Age 40 or Older Female $571.94 $588.10 $648.86 $618.29 $695.08 $628.44 $656.59 $695.44 Adult - Age 40 or Older Male $601.76 $615.85 $563.07 $535.01 $614.69 $536.48 $527.93 $581.79 SSI Adults w ithout Medicare Age 19 to 24 Female $921.83 $853.17 $880.48 $1,336.15 $879.86 $816.02 $682.85 $741.11 Age 19 to 24 Male $902.16 $303.79 $513.11 $404.80 $700.59 $878.80 $714.28 $444.71 Age 25 to 44 Female $1,027.81 $1,116.13 $1,33...
Reporting Requirements and Reporting Deliverables. The following regarding reporting requirements and deliverables as found in Appendix K. “Reporting Requirements and Reporting Deliverables” shall be considered Contract violations for which fines shall be imposed:
