Required Functions. The Contractor shall have an Enrollee Services function that includes a call center which is staffed and available by telephone Monday through Friday 7:00 am to 7:00 pm Eastern Time (ET). The call center shall meet the current American Accreditation Health Care Commission/URAC- designed Health Call Center Standard (HCC) for call center abandonment rate, blockage rate and average speed of answer for all Contractor programs with the exception of behavioral health which is addressed in Section 33.6 “Behavioral Health Services Hotline.” If a Contractor has separate telephone lines for different Medicaid populations, the Contractor shall report performance for each individual line separately. The Contractor shall also provide access to medical advice and direction through a centralized toll- free call-in system, available twenty-four (24) hours a day, seven (7) days a week nationwide. The twenty-four/seven (24/7) call-in system shall be staffed by appropriately trained medical personnel. For the purposes of meeting this requirement, trained medical professionals are defined as physicians, physician assistants, licensed practical nurses, and registered nurses. The Contractor shall self-report their prior month performance in the three (3) areas listed above, call center abandonment rate, blockage rate and average speed of answer, for their Enrollee services and twenty-four/seven (24/7) hour toll-free medical call-in system to the Department. Appropriate foreign language and/or oral interpreters shall be provided by the Contractor and available free of charge and as necessary to ensure availability of effective communication regarding treatment, medical history, or health education and otherwise comply with 42 C.F.R. 438.10(d). Enrollee written materials shall be provided and printed in English, Spanish, and each Prevalent Non-English Language. Oral interpretation shall be provided for all non-English languages. The Contractor staff shall be able to respond to the special communication needs of the disabled, blind, deaf, and aged, and effectively interpersonally relate with economically and ethnically diverse populations. The Contractor shall provide ongoing training to its staff and Providers on matters related to meeting the needs of economically disadvantaged and culturally diverse individuals. The Contractor shall require that all Service Locations meet the requirements of the Americans with Disabilities Act, Commonwealth and local requirements pertaining to adequate space, supplies, sanitation, and fire and safety procedures applicable to health care facilities. The Contractor shall cooperate with the Cabinet for Health and Family Services’ independent ombudsman program, including providing immediate access to an Enrollee’s records when written Enrollee consent is provided. The Contractor’s Enrollee Services function shall also be responsible for: A. Ensuring that Enrollees are informed of their rights and responsibilities; B. Ensuring each Enrollee is free to exercise his or her rights without the Contractor or its Providers treating the Enrollee adversely; C. Guaranteeing each Enrollee’s right to receive information on available treatment options and alternatives, presented in a manner appropriate to the Enrollee’s condition and ability to understand; X. Xxxxxxxxxx updated demographic information for Enrollees, including address, phone numbers, etc.; E. Monitoring the selection and assignment process of PCPs;

Appears in 2 contracts

Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract

Required Functions. The Contractor shall have ~~an Enrollee~~ a Member Services function that includes a call center which is staffed and available by telephone Monday through Friday ~~7:00~~ 7 am to ~~7:00~~ 7 pm Eastern Time (ET). The call center shall meet the current American Accreditation Health Care Commission/~~URAC-~~ URAC-designed Health Call Center Standard (HCC) for call center abandonment rate, blockage rate and average speed of answer for all Contractor programs with the exception of behavioral ~~health which is addressed in Section 33.6 “Behavioral Health Services Hotline.”~~ health. If a Contractor has separate telephone lines for different Medicaid populations, the Contractor shall report performance for each individual line separately. The Department will inform the Contractor of any changes/updates to these URAC call center standards. The Contractor shall also provide access to medical advice and direction through a centralized ~~toll-~~ toll-free call-in system, available twenty-four (24) hours a day, seven (7) days a week nationwide. The twenty-four/seven (24/7) call-in system shall be staffed by appropriately trained medical personnel. For the purposes of meeting this requirement, trained medical professionals are defined as physicians, physician assistants, licensed practical nurses, and registered nurses. The Contractor shall self-report their prior month performance in the three ~~(3)~~ areas listed above, call center abandonment rate, blockage rate and average speed of answer, for their ~~Enrollee~~ member services and twenty-four/seven (24/7) hour toll-free medical call-in system to the Department. Appropriate foreign language and/or oral interpreters shall be provided by the Contractor and available free of charge and as necessary to ensure availability of effective communication regarding treatment, medical history, or health education and otherwise comply with 42 ~~C.F.R.~~ CFR 438.10(d). ~~Enrollee~~ Member written materials shall be provided and printed in ~~English, Spanish, and~~ each ~~Prevalent Non-English Language~~language spoken by five (5) percent or more of the Members in each county. Oral interpretation shall be provided for all non-English languages. The Contractor staff shall be able to respond to the special communication needs of the disabled, blind, ~~deaf,~~ deaf and ~~aged,~~ aged and effectively interpersonally relate with economically and ethnically diverse populations. The Contractor shall provide ongoing training to its staff and Providers on matters related to meeting the needs of economically disadvantaged and culturally diverse individuals. The Contractor shall require that all Service Locations meet the requirements of the Americans with Disabilities Act, Commonwealth and local requirements pertaining to adequate space, supplies, sanitation, and fire and safety procedures applicable to health care facilities. The Contractor shall cooperate with the Cabinet for Health and Family Services’ independent ombudsman program, including providing immediate access to ~~an Enrollee~~a Member’s records when written ~~Enrollee~~ Member consent is provided. The Contractor’s ~~Enrollee~~ Member Services function shall also be responsible for: A. Ensuring that ~~Enrollees~~ Members are informed of their rights and responsibilities; B. Ensuring each ~~Enrollee~~ Member is free to exercise his or her rights without the Contractor or its Providers treating the ~~Enrollee~~ Member adversely;. C. Guaranteeing each ~~Enrollee~~Member’s right to receive information on available treatment options and alternatives, presented in a manner appropriate to the ~~Enrollee~~Member’s condition and ability to understand;. ~~X. Xxxxxxxxxx updated demographic information for Enrollees, including address, phone numbers, etc.; E.~~ D. Monitoring the selection and assignment process of PCPs; E. Identifying, investigating, and resolving Member Grievances about health care services; F. Assisting Members with filing formal Appeals regarding plan determinations; G. Providing each Member with an identification card that identifies the Member as a participant with the Contractor, unless otherwise approved by the Department; H. Explaining rights and responsibilities to members or to those who are unclear about their rights or responsibilities including reporting of suspected fraud and abuse; I. Explaining Contractor’s rights and responsibilities, including the responsibility to assure minimal waiting periods for scheduled member office visits and telephone requests, and avoiding undue pressure to select specific Providers or services; J. Providing within five (5) business days of the Contractor being notified of the enrollment of a new Member, by a method that will not take more than three (3) days to reach the Member, and whenever requested by member, guardian or authorized representative, a Member Handbook and information on how to access services; (alternate notification methods shall be available for persons who have reading difficulties or visual impairments); K. Explaining or answering any questions regarding the Member Handbook; L. Facilitating the selection of or explaining the process to select or change Primary Care Providers through telephone or face-to-face contact where appropriate. The Contractor shall assist members to make the most appropriate Primary Care Provider selection based on previous or current Primary Care Provider relationship, providers of other family members, medical history, language needs, provider location and other factors that are important to the Member. The Contractor shall notify members within thirty (30) days prior to the effective date of voluntary termination (or if Provider notifies Contractor less than thirty (30) days prior to the effective date, as soon as Contractor receives notice), and within fifteen (15) days prior to the effective date of involuntary termination if their Primary Care Provider leaves the Program and assist members in selecting a new Primary Care Provider; M. Facilitating direct access to specialized providers in the circumstances of: (1) Members with long-term, complex health conditions; (2) Aged, blind, deaf, or disabled persons; and (3) Members who have been identified as having special healthcare needs and who require a course of treatment or regular healthcare monitoring. This access can be achieved through referrals from the Primary Care Provider or by the specialty physician being permitted to serve as the Primary Care Provider. N. Arranging for and assisting with scheduling EPSDT Services in conformance with federal law governing EPSDT for persons under the age of twenty-one (21) years; O. Providing Members with information or referring to support services offered outside the Contractor’s Network such as WIC, child nutrition, elderly and child abuse, parenting skills, stress control, exercise, smoking cessation, weight loss, behavioral health and substance abuse; P. Facilitating direct access to primary care vision services; primary dental and oral surgery services, and evaluations by orthodontists and prosthodontists; women’s health specialists; voluntary family planning; maternity care for Members under age 18; childhood immunizations; sexually transmitted disease screening, evaluation and treatment; tuberculosis screening, evaluation and treatment; and testing for HIV, HIV-related conditions and other communicable diseases; all as further described in Appendix H. “Covered Services” of this Contract; Q. Facilitating access to behavioral health services and pharmaceutical services; R. Facilitating access to the services of public health departments, Community Mental Health Centers, rural health clinics, Federally Qualified Health Centers, the Commission for Children with Special Health Care Needs and charitable care providers, such as Xxxxxxx’x Hospital for Children; S. Assisting members in making appointments with Providers and obtaining services. When the Contractor is unable to meet the accessibility standards for access to Primary Care Providers or referrals to specialty providers, the Member Services staff function shall document and refer such problems to the designated Member Services Director for resolution;

Appears in 2 contracts

Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract

Appears in 2 contracts

Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract

Appears in 1 contract

Samples: Medicaid Managed Care Contract

Required Functions. The Contractor shall have ~~an Enrollee~~ a Member Services function that includes a call center which is staffed and available by telephone Monday through Friday ~~7:00~~ 7 am to ~~7:00~~ 7 pm Eastern Standard Time (ETEST). The call center shall meet the current American Accreditation Health Care Commission/~~URAC-~~ URAC-designed Health Call Center Standard (HCC) for call center abandonment rate, blockage rate and average speed of ~~answer for all Contractor programs with the exception of behavioral health which is addressed in Section 33.6 “Behavioral Health Services Hotline.”~~ answer. If a Contractor has separate telephone lines for different Medicaid populations, the Contractor shall report performance for each individual line separately. The Department will inform the Contractor of any changes/updates to these URAC call center standards. The Contractor shall also provide access to medical advice and direction through a centralized ~~toll-~~ toll-free call-in system, available twenty-four (24) hours a day, seven (7) days a week nationwide. The twenty-four/seven (24/7) call-in system shall be staffed by appropriately trained medical personnel. For the purposes of meeting this requirement, trained medical professionals are defined as physicians, physician assistants, licensed practical ~~nurses~~nurses (LPN), and registered ~~nurses~~nurses (RNs). The Contractor shall self-report their prior month performance in the three ~~(3)~~ areas listed above, call center abandonment rate, blockage rate and average speed of answer, for their ~~Enrollee~~ member services and twenty-four/seven (24/7) hour toll-free medical call-in system to the Department. Appropriate foreign language ~~and/or oral~~ interpreters shall be provided by the Contractor and available free of charge and as necessary to ensure availability of effective communication regarding treatment, medical history, or health ~~education and otherwise comply with 42 C.F.R. 438.10(d)~~education. ~~Enrollee written~~ Member materials shall be provided and printed in ~~English, Spanish, and~~ each ~~Prevalent Non-English Language. Oral interpretation shall be provided for all non-English languages~~language spoken by five (5) percent or more of the Members in each county. The Contractor staff shall be able to respond to the special communication ~~needs~~ need of the disabled, blind, ~~deaf,~~ deaf and ~~aged,~~ aged and effectively interpersonally relate with economically and ethnically diverse populations. The Contractor shall provide ongoing training to its staff and Providers on matters related to meeting the needs of economically disadvantaged and culturally diverse individuals. The Contractor shall require that all Service Locations meet the requirements of the Americans with Disabilities Act, Commonwealth and local requirements pertaining to adequate space, supplies, sanitation, and fire and safety procedures applicable to health care facilities. The Contractor shall cooperate with the Cabinet for Health and Family Services’ independent ombudsman program, including providing immediate access to ~~an Enrollee~~a Member’s records when written ~~Enrollee~~ Member consent is provided. The Contractor’s ~~Enrollee~~ Member Services function shall also be responsible for: A. Ensuring that ~~Enrollees~~ Members are informed of their rights and responsibilities; B. Ensuring each Enrollee is free to exercise his or her rights without the Contractor or its Providers treating the Enrollee adversely; C. Guaranteeing each Enrollee’s right to receive information on available treatment options and alternatives, presented in a manner appropriate to the Enrollee’s condition and ability to understand; X. Xxxxxxxxxx updated demographic information for Enrollees, including address, phone numbers, etc.; E. Monitoring the selection and assignment process of PCPs; C. Identifying, investigating, and resolving Member Grievances about health care services; D. Assisting Members with filing formal Appeals regarding plan determinations; E. Providing each Member with an identification card that identifies the Member as a participant with the Contractor, unless otherwise approved by the Department; F. Explaining rights and responsibilities to members or to those who are unclear about their rights or responsibilities including reporting of suspected fraud and abuse; G. Explaining Contractor’s rights and responsibilities, including the responsibility to assure minimal waiting periods for scheduled member office visits and telephone requests, and avoiding undue pressure to select specific Providers or services; H. Providing within five (5) business days of the Contractor being notified of the enrollment of a new Member, by a method that will not take more than three (3) days to reach the Member, and whenever requested by member, guardian or authorized representative, a Member Handbook and information on how to access services; (alternate notification methods shall be available for persons who have reading difficulties or visual impairments); I. Explaining or answering any questions regarding the Member Handbook; J. Facilitating the selection of or explaining the process to select or change Primary Care Providers through telephone or face-to-face contact where appropriate. The Contractor shall assist members to make the most appropriate Primary Care Provider selection based on previous or current Primary Care Provider relationship, providers of other family members, medical history, language needs, provider location and other factors that are important to the Member. The Contractor shall notify members within thirty (30) days prior to the effective date of voluntary termination (or if Provider notifies Contractor less than thirty (30) days prior to the effective date, as soon as Contractor receives notice), and within fifteen (15) days prior to the effective date of involuntary termination if their Primary Care Provider leaves the Program and assist members in selecting a new Primary Care Provider; K. Facilitating direct access to specialty physicians in the circumstances of: (1) Members with long-term, complex health conditions; (2) Aged, blind, deaf, or disabled persons; and (3) Members who have been identified as having special healthcare needs and who require a course of treatment or regular healthcare monitoring. This access can be achieved through referrals from the Primary Care Provider or by the specialty physician being permitted to serve as the Primary Care Provider. L. Arranging for and assisting with scheduling EPSDT Services in conformance with federal law governing EPSDT for persons under the age of twenty-one (21) years; M. Providing Members with information or referring to support services offered outside the Contractor’s Network such as WIC, child nutrition, elderly and child abuse, parenting skills, stress control, exercise, smoking cessation, weight loss, behavioral health and substance abuse; N. Facilitating direct access to primary care vision services; primary dental and oral surgery services, and evaluations by orthodontists and prosthodontists; women’s health specialists; voluntary family planning; maternity care for Members under age 18; childhood immunizations; sexually transmitted disease screening, evaluation and treatment; tuberculosis screening, evaluation and treatment; and testing for HIV, HIV-related conditions and other communicable diseases; all as further described in Appendix I of this Contract; O. Facilitating access to behavioral health services and pharmaceutical services; P. Facilitating access to the services of public health departments, Community Mental Health Centers, rural health clinics, Federally Qualified Health Centers, the Commission for Children with Special Health Care Needs and charitable care providers, such as Xxxxxxx’x Hospital for Children; Q. Assisting members in making appointments with Providers and obtaining services. When the Contractor is unable to meet the accessibility standards for access to Primary Care Providers or referrals to specialty providers, the Member Services staff function shall document and refer such problems to the designated Member Services Director for resolution; R. Assisting members in obtaining transportation for both emergency and appropriate non-emergency situations; S. Handling, recording and tracking Member Grievances properly and timely and acting as an advocate to assure Members receive adequate representation when seeking an expedited Appeal; T. Facilitating access to Member Health Education Programs; U. Assisting members in completing the Health Risk Assessment (HRA) as outlined in Covered Services upon any telephone contact; and referring Members to the appropriate areas to learn how to access the health education and prevention opportunities available to them including referral to case management or disease management; and V. The Member Services staff shall be responsible for making an annual report to management about any changes needed in member services functions to improve either the quality of care provided or the method of delivery. A copy of the report shall be provided to the Department.

Appears in 1 contract

Samples: Managed Care Contract (Wellcare Health Plans, Inc.)

Common use of Required Functions Clause in Contracts