Scope of Exhibit. Business Associate acknowledges and agrees that all PHI that is created or received by Covered Entity and disclosed or made available in any form, including paper record, oral communication, audio recording and electronic display, by Covered Entity or its operating units to Business Associate, or is created or received by Business Associate on Covered Entity’s behalf, shall be subject to this Exhibit.
Scope of Exhibit. 1.01 This Exhibit specifies the terms and conditions, including compensation, under which BellSouth and Carrier will compensate each other for Intercompany Settlements (ICS) messages.
Scope of Exhibit. 1.01 This exhibit specifies the terms and conditions, including compensation, under which BellSouth shall provide message distribution service to BTI. As described herein, message distribution service includes the following:
1) Message Forwarding to Intraregion LEC/ALEC - function of receiving an ALEC message and forwarding the message to another LEC/ALEC in the BellSouth region.
2) Message Forwarding to CMDS - function of receiving an ALEC message and forwarding that message on to CMDS.
3) Message Forwarding from CMDS - function of receiving a message from CMDS and forwarding that message to BTI.
Scope of Exhibit. The provisions of this Exhibit apply to Covered Services rendered to BJC Medicaid Members, regardless of whether such BJC Medicaid Members receive Covered Services from BJC Providers, Participating Providers or non-Participating Providers within or outside of BJC's Service Sites or within or outside of Plan's Service Area.
Scope of Exhibit. ▪ Technical support services staff to ensure the timely and efficient maintenance of information technology support services, production of reports and processing of data requests and submission of encounter data. ▪ Quality management improvement staff dedicated to perform quality management and improvement activities, and participate in the Contractor’s internal Quality Management and Improvement Committee. ▪ Utilization and medical management staff dedicated to perform utilization management and review activities. ▪ Member services representatives to coordinate communications between the Contractor and its members, respond to member inquiries, and assist all members regarding issues such as the Contractor’s policies, procedures, general operations, benefit coverage and eligibility. Member services staff should have access to real time data on members, including, but not limited to, eligibility status and all service and utilization data. Member services staff must have the appropriate training and demonstrate full competency before interacting with members. ▪ Member marketing and outreach staff to manage marketing and outreach efforts for the HIP program. ▪ Compliance staff to support the Compliance Officer and help ensure all Contractor functions are in compliance with state and federal laws and regulations, the State’s policies and procedures and the terms of the Contract. ▪ Provider representatives to develop the Contractor’s network and coordinate communications between the Contractor and contracted and non-contracted providers. ▪ Claims processors to process electronic and paper claims in a timely and accurate manner, process claims correction letters, process claims resubmissions and address overall disposition of all claims for the Cont ractor, per state and federal guidelines. ▪ A sufficient number of staff to ensure the submission of timely, complete and accurate encounter claims data. ▪ Member and provider education/outreach staff to promote health-related and preventive care education and programs, maintain member and provider awareness of the Contractor’s policies and procedures, and identify and address barriers to an effective health care delivery system for the Contractor’s members and providers. ▪ Website staff to maintain and update the Contractor’s member and provider websites.
Scope of Exhibit. The Contractor shall implement a transition of care policy that is consistent with federal requirements and at least meets the State defined transition of care policies in the HIP MCE Policies and Procedures Manual per 42 CFR 438.62(b)(1)-(2). In accordance with 42 CFR 438.208(b)(2)(i)-(iv) and 42 CFR 438.208(b)(4), the Contractor shall implement procedures to coordinate: ▪ Services the Contractor furnishes to the member between settings of care, including appropriate discharge planning for short-term and long-term hospital and institutional stays; ▪ Services the Contractor furnishes to the member with the services the member receives from any other MCE or health plan; ▪ Services the Contractor furnishes to the member with the services the member receives in FFS Medicaid; ▪ Services the Contractor furnishes to the member with the services the member receives from community and social support providers; and ▪ Sharing results of any identification of member needs from assessments with the State or other health plans.
Scope of Exhibit. The Contractor cannot entice a potential member to join its health plan by offering any other type of insurance as a bonus for enrollment, and the Contractor shall ensure that a potential member can make his/her own decision as to whether or not to enroll. Marketing materials and plans shall be designed to reach a distribution of potential members across age and gender categories. The Contractor must conduct marketing and advertising in a geographically balanced manner, paying special attention to rural areas of the State. The Contractor must provide information to potentially eligible individuals who live in medically underserved rural areas of the State. Potential members may not be discriminated against on the basis of health status or need for health care services, or on any other basis inconsistent with state or federal law, including Section 1557 of the Affordable Care Act / 45 CFR 92.1. The Contractor may distribute or mail an informational brochure or flyer to potential members and/or provide (at its own cost, including any costs related to mailing) such brochures or flyers to the State for distribution to individuals at the time of application. The Contractor shall submit product naming and associated domains to FSSA for review and approval to minimize confusion for members and providers.
Scope of Exhibit. Medicaid product lines. The Utilization Management Manager shall, at a minimum, be responsible for directing the activities of the utilization management staff. With direct supervision by the Medical Director, the Utilization Management Manager shall direct staff performance regarding prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care, care coordination and other clinical and medical management programs. The Utilization Management Manager shall work with the Special Investigation Unit (SIU) Manager to assure that service billing and utilization issues are documented and reported to the SIU, and matters requiring SIU review or investigation shall be timely submitted within five (5) business days to enable recovery of overpayments or other appropriate action. For more information regarding the utilization management requirements, see Section 6.3.
Scope of Exhibit. ▪ For any calendar month, at least ninety-five percent (95%) of all phone calls to an approved automated helpline must be answered by a helpline representative within sixty (60) seconds after the call has been routed through the call center menu. Answered means that the call is picked up by a qualified helpline staff person. ▪ If the Contractor does not maintain an approved automated call distribution system, for any calendar month, at least ninety-five percent (95%) of all phone calls to the helpline must be answered within thirty (30) seconds. ▪ Hold time does not exceed one (1) minute in any instance, or thirty (30) seconds, on average. ▪ For any calendar month, the lost call (abandonment rate) associated with the helpline does not exceed five percent (5%). The Contractor shall provide a backup solution for phone service in the event of a power failure or outage or other interruption in service. Such plan shall include, at minimum, the following: ▪ A notification plan that ensures FSSA is notified when the Contractor's phone system is inoperative or a back-up system is being utilized; and ▪ Manual back-up procedure to allow requests to continue being processed if the system is down. In addition to the member services helpline which is staffed during regular business hours, the Contractor shall operate a toll-free twenty-four (24) hour nurse call line. The Contractor shall provide nurse triage telephone services for members to receive medical advice twenty-four (24) hours-a-day/seven (7)-days-a-week from trained medical professionals. The twenty-four (24) hour nurse call line should be well publicized and designed as a resource to members to help discourage inappropriate Emergency room use. The twenty-four (24) hour nurse call line must have a system in place to communicate all issues with the member’s providers. In addition, as set forth in Section 4.3.1, the 24-Hour Nurse Call Line must be equipped to provide advice and copayment waivers for Healthy Indiana Plan members seeking services from hospital Emergency departments.
Scope of Exhibit. The provisions of this Exhibit apply during the term and any Renewal Term(s) of this Agreement, Covered Services rendered to Members (i) who have not chosen a BJC Provider as his or her PCP (and therefore are are not BJC Members, BJC Medicaid Members or BJC Medicare Members), and (ii) who are covered by all Plan Benefit Plans including without limitation insured and self-funded (ASO) products (Benefit Plans) sponsored or issued by all Payors (excluding those Benefit Plans covered by Exhibits A-1, X-0 xxx A-3), (iii) when such Members receive Covered Services from BJC Providers or at a BJC Service Site. The terms of this Exhibit A-4 and the attached schedules also shall determine the amounts to be paid to BJC Providers out of the Claims Payment Account(s) referenced in Exhibits A-1, X-0 xxx A-3 of this Agreement. The terms of this Exhibit A-4 and the attached schedules also shall determine the rates to be paid to BJC Providers during the continuation period reference in Section 9.4 and Section 10.1 of the Agreement.
