Required Functions. The Contractor shall maintain a Provider Services function that is responsible for the following services and tasks: A. Enrolling, credentialing and recredentialing and performance review of providers; B. Assisting Providers with Member Enrollment status questions; C. Assisting Providers with Prior Authorization and referral procedures; D. Assisting Providers with Claims submissions and payments; E. Explaining to Providers their rights and responsibilities as a member of Contractor’s Network; F. Handling, recording and tracking Provider Grievances and Appeals properly and timely; G. Developing, distributing and maintaining a Provider manual; H. Developing, conducting, and assuring Provider orientation/training; I. Explaining to Providers the extent of Medicaid benefit coverage including EPSDT preventive health screening services and EPSDT Special Services; J. Communicating Medicaid policies and procedures, including state and federal mandates and any new policies and procedures; K. Assisting Providers in coordination of care for child and adult members with complex and/or chronic conditions; L. Encouraging and coordinating the enrollment of Primary Care Providers in the Department for Public Health and the Department for Medicaid Services Vaccines for Children Program. This program offers certain vaccines free of charge to Medicaid members under the age of 21 years. The Contractor is responsible for reimbursement of the administration fee associated with vaccines provided through the program; M. Coordinating workshops relating to the Contractor’s policies and procedures; N. Providing necessary technical support to Providers who experience unique problems with certain Members in their provision of services; O. Annually addressing fraud, waste and abuse with providers; P. Consult with a requesting Provider on authorization decisions, when appropriate; and
Appears in 2 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract
Required Functions. The Contractor shall maintain a Provider Services function that is responsible for the following services and tasks:
A. Enrolling, credentialing and recredentialing and performance review of providers;
B. Assisting Providers with Member Enrollment status questions;
C. Assisting Providers with Prior Authorization and referral procedures;
D. Assisting Providers with Claims submissions and payments;
E. Explaining to Providers their rights and responsibilities as a member of Contractor’s Network;
F. Handling, recording and tracking Provider Grievances and Appeals properly and timely;
G. Developing, distributing and maintaining a Provider manual;
H. Developing, conducting, and assuring Provider orientation/training;
I. Explaining to Providers the extent of Medicaid benefit coverage including EPSDT preventive health screening services and EPSDT Special Services;
J. Communicating Medicaid policies and procedures, including state and federal mandates and any new policies and procedures;
K. Assisting Providers in coordination of care for child and adult members with complex and/or chronic conditions;
L. Encouraging and coordinating the enrollment of Primary Care Providers in the Department for Public Health and the Department for Medicaid Services Vaccines for Children Program. This program offers certain vaccines free of charge to Medicaid members under the age of 21 years. The Contractor is responsible for reimbursement of the administration fee associated with vaccines provided through the program;
M. Coordinating workshops relating to the Contractor’s policies and procedures;
N. Providing necessary technical support to Providers who experience unique problems with certain Members in their provision of services; ;
O. Annually addressing fraud, waste and abuse with providers; and
P. Consult with a requesting Provider on authorization decisions, when appropriate; and.
Q. Ensures no punitive action is taken against a Provider who either requests an expedited resolution or supports a Member’s appeal. Provider Services shall be staffed, at a minimum, Monday through Friday 8:00 am – 6:00 pm Eastern Time. Staff members shall be available to speak with providers any time during open hours. The Contractor shall operate a provider call center that meets standards as determined by the Department. Provider Services staff shall be instructed to follow all contractually-required provider relation functions including, policies, procedures and scope of services.
Appears in 2 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract
Required Functions. The Contractor shall maintain a Provider Services function that is responsible for the following services and tasks:
A. Enrolling, credentialing and recredentialing and performance review of providers;
B. Assisting Providers with Member Enrollment status questions;
C. Assisting Providers with Prior Authorization and referral procedures;
D. Assisting Providers with Claims submissions and payments;
E. Explaining to Providers their rights and responsibilities as a member of Contractor’s Network;
F. Handling, recording and tracking Provider Grievances and Appeals properly and timely;
G. Developing, distributing and maintaining a Provider manual;
H. Developing, conducting, and assuring Provider orientation/training;
I. Explaining to Providers the extent of Medicaid benefit coverage including EPSDT preventive health screening services and EPSDT Special Services;
J. Communicating Medicaid policies and procedures, including state and federal mandates and any new policies and procedures;
K. Assisting Providers in coordination of care for child and adult members with complex and/or chronic conditions;
L. Encouraging and coordinating the enrollment of Primary Care Providers in the Department for Public Health and the Department for Medicaid Services Vaccines for Children Program. This program offers certain vaccines free of charge to Medicaid members under the age of 21 years. The Contractor is responsible for reimbursement of the administration fee associated with vaccines provided through the program;
M. Coordinating workshops relating to the Contractor’s policies and procedures;
N. Providing necessary technical support to Providers who experience unique problems with certain Members in their provision of services; and
O. Annually addressing fraud, waste and abuse with providers; P. Consult providers Provider Services shall be staffed, at a minimum, Monday through Friday 8am – 6pm Eastern Standard Time. Staff members shall be available to speak with providers any time during open hours. The Contractor shall operate a requesting provider call center that meets standards as determined by the Department. Provider on authorization decisionsServices staff shall be instructed to follow all contractually-required provider relation functions including, when appropriate; andpolicies, procedures and scope of services.
Appears in 1 contract
Samples: Managed Care Contract (Wellcare Health Plans, Inc.)
