Soft Limits/Service Thresholds for Certain Physical Health Services Sample Clauses

Soft Limits/Service Thresholds for Certain Physical Health Services. 2.6.1.4.1 TENNCARE has established thresholds that apply to certain covered physical health services for non-institutionalized Medicaid adults. The CONTRACTOR shall track, in a manner prescribed by TENNCARE, and report on accumulated benefit information for each service that has a threshold. Depending on the service, once a member reaches a threshold, the CONTRACTOR shall evaluate and enroll the member in MCO case management or a disease management program as appropriate. 2.6.1.4.2 The service thresholds and the CONTRACTOR’s responsibility once a non- institutionalized adult has met the threshold are as follows: Service Threshold for Non- Institutionalized Medicaid Eligibles, Age 21 and Older CONTRACTOR Responsibility Once Member Has Reached Threshold Inpatient Hospital 20 days per state fiscal year Enroll member in MCO case Services (SFY) management or disease management program, whichever is more appropriate

Soft Limits/Service Thresholds for Certain Physical Health Services. 2.6.1.3.1 TENNCARE has established thresholds that apply to certain covered physical health services for non-institutionalized Medicaid adults. The CONTRACTOR shall track, in a manner prescribed by TENNCARE, and report on accumulated benefit information for each service that has a threshold. Depending on the service, once a member reaches a threshold, the CONTRACTOR shall enroll the member in MCO case management or a disease management program or shall determine whether the person should be enrolled in MCO case management or a disease management program. 2.6.1.3.2 The service thresholds and the CONTRACTOR’s responsibility once a non-institutionalized adult has met the threshold are as follows: Inpatient Hospital Services 20 days per SFY Enroll member in MCO case management or disease management program, whichever is more appropriate Outpatient Hospital Services 8 visits per SFY Determine whether member should be enrolled in MCO case management or a disease management program and enroll member if appropriate Physician Outpatient Services/Community Health Clinic Services/Other Clinic Services 12 visits per SFY Determine whether member should be enrolled in MCO case management or a disease management program and enroll member if appropriate Lab and X-ray Services 10 visits per SFY Determine whether member should be enrolled in MCO case management or a disease management program and enroll member if appropriate 2.6.1.3.3 As provided in Section 2.30.3, the CONTRACTOR shall report on the number of members who reach each threshold, were assessed, and/or were enrolled in MCO case management or a disease management program, and the reasons for failure to enroll in MCO case management or disease management.