Subcontracting for Services. a. Licensed health care facilities, group practices and licensed health care professionals operating within the scope of their practice may contract with the MCO directly or indirectly through a subcontractor who directly contracts with the MCO. The MCO shall be held directly accountable and liable for all of the contractual provisions under this contract regardless of whether the MCO chooses to subcontract their responsibilities to a third party. No subcontract shall operate to terminate the legal responsibility of the MCO to assure that all activities carried out by the subcontractor conform to the provisions of the contract. Subcontracts shall not terminate the legal liability of the MCO under this contract. b. The MCO may subcontract for any function, excluding Member Services, covered by this contract, subject to the requirements of this contract. All subcontracts shall be in writing, shall include any general requirements of this contract that are appropriate to the services being provided, and shall assure that all delegated duties of the MCO under this contract are performed. All subcontracts shall also provide for the right of the DEPARTMENT or other governmental entity to enter the subcontractor's premises to inspect, monitor or otherwise evaluate the work being performed as a delegated duty of this contract, as specified in Section 3.33, Inspection of Facilities. All subcontracts shall comply with 42 CFR Section 434.6 (b) and (c). c. With the exception of subcontracts specifically excluded by the DEPARTMENT, all subcontracts shall include verbatim the HUSKY A definitions of Medical Appropriateness / Medically Appropriate and Medically Necessary/Medical Necessity as set forth in Part II, General Contract Terms for the MCOs. All subcontracts shall require the use of these definitions by subcontractors in all requests for approval of coverage of goods or services made on behalf of HUSKY
Appears in 1 contract
Samples: Purchase of Service Contract (Wellcare Health Plans, Inc.)
Subcontracting for Services. a. Licensed health care facilities, group practices and licensed health care professionals operating within the scope of their practice may contract with the MCO directly or indirectly through a subcontractor who directly contracts with the MCO. The MCO shall be held directly accountable and liable for all of the contractual provisions under this contract regardless of whether the MCO chooses to subcontract their its responsibilities to a third party. No subcontract shall operate to terminate the legal responsibility of the MCO to assure that all activities carried out by the subcontractor conform to the provisions of the this contract. Subcontracts shall not terminate the legal liability of the MCO under this contract.
b. The MCO may subcontract for any function, excluding Member Services, covered by this contract, subject to the requirements of this contract. All subcontracts shall be in writing, shall include any general requirements of this contract that are appropriate to the services being provided, and shall assure that all delegated duties of the MCO under this contract are performed. All subcontracts shall also provide for the right of the DEPARTMENT or other another governmental entity to enter the subcontractor's premises to inspect, monitor or otherwise evaluate the work being performed as a delegated duty of this contract, as specified in Section 3.33, Inspection of Facilities. All subcontracts shall comply with 42 CFR Section 434.6 (b) and (c).
c. With the exception of subcontracts specifically excluded by the DEPARTMENT, all subcontracts shall include verbatim the HUSKY A B definitions of Medical Appropriateness / Appropriateness/Medically Appropriate and Medically Necessary/Medical Necessity as set forth in the Definitions, Part II, General Contract Terms for the MCOsSection 1 of this contract. All subcontracts shall require the use of these definitions by subcontractors in all requests for approval of coverage of goods or services made on behalf of HUSKYHUSKY B Members. All subcontracts shall also provide that decisions concerning both acute and chronic care must be made according to these definitions. 0501 07 HUSKY B Final
d. Within fifteen (15) days of the effective date of this contract the MCO shall provide the DEPARTMENT with a report of those functions under this contract that the MCO will be providing through subcontracts and copies of the contracts between the MCO and the subcontractor. Such report shall identify the names of the subcontractors, their addresses and a summary of the services they will be providing. If the MCO enters into any additional subcontracts after the MCO's initial compliance with this section, the MCO shall obtain the advance written approval of the DEPARTMENT. The MCO shall provide the DEPARTMENT with a draft of the proposed subcontract thirty (30) days in advance of the completion of the MCO's negotiation of such subcontract. In addition, amendments to any such subcontract, excluding those of a technical nature, shall require the pre-review and approval of the DEPARTMENT.
e. All dental subcontracts, which include the payment of claims on behalf of HUSKY B Members for the provision of goods or services to HUSKY B Members shall require a performance bond, letter of credit, statement of financial reserves or payment withhold requirements. The performance bond, letter of credit, statement of financial reserves or payment withhold requirements shall be in a form to be mutually agreed upon by the MCO and the subcontractor. The amount of the performance bond shall be sufficient to ensure the completion of the subcontractor's claims processing and provider payment obligations under the subcontract in the event the contract between the MCO and the subcontractor is terminated. The MCO shall submit reports to the DEPARTMENT upon the DEPARTMENT'S request related to any payments made from the performance bonds or any payment withholds.
f. All subcontracts shall include provisions for a well-organized transition in the event of termination of the subcontract for any reason. Such provisions shall ensure that an adequate provider network will be maintained at all times during any such transition period and that continuity of care is maintained for all Members.
g. Prior to the approval by the DEPARTMENT of any subcontract with a dental subcontractor, the MCO shall submit a plan to the DEPARTMENT for the resolution of any outstanding claims submitted by providers to the MCO's previous dental subcontractor. Such plan shall meet the requirements described in subsection (h) below.
h. In the event that a subcontract is terminated, the MCO shall submit a written transition plan to the DEPARTMENT sixty (60) days in advance of the scheduled termination. The transition plan shall include provisions concerning financial responsibility for the final settlement of provider claims and data reporting, which at a minimum must include a claims aging report prepared in accordance with Section 3.40 (c)(5) of this contract, with steps to ensure the resolution of the outstanding amounts. This plan shall be submitted prior to the DEPARTMENT'S approval.
Appears in 1 contract
Subcontracting for Services. a. Licensed health care facilities, group practices and licensed health care professionals operating within the scope of their practice may contract with the MCO directly or indirectly through a subcontractor who directly contracts with the MCO. The MCO shall be held directly accountable and liable for all of the contractual provisions under this contract regardless of whether the MCO chooses to subcontract their its responsibilities to a third party. No subcontract shall operate to terminate the legal responsibility of the MCO to assure that all activities carried out by the subcontractor conform to the provisions of the this contract. Subcontracts shall not terminate the legal liability of the MCO under this contract.
b. The MCO may subcontract for any function, excluding Member Services, covered by this contract, subject to the requirements of this contract. All subcontracts shall be in writing, shall include any general requirements of this contract that are appropriate to the services being provided, and shall assure that all delegated duties of the MCO under this contract are performed. All subcontracts shall also provide for the right of the DEPARTMENT or other another governmental entity to enter the subcontractor's premises to inspect, monitor or otherwise evaluate the work being performed as a delegated duty of this contract, as specified in Section 3.33, Inspection of Facilities. All subcontracts shall comply with 42 CFR Section 434.6 (b) and (c).
c. With the exception of subcontracts specifically excluded by the DEPARTMENT, all subcontracts shall include verbatim the HUSKY A B definitions of Medical Appropriateness / Appropriateness/Medically Appropriate and Medically Necessary/Medical Necessity as set forth in the Definitions, Part II, General Contract Terms for the MCOsSection 1 of this contract. All subcontracts shall require the use of these definitions by subcontractors in all requests for approval of coverage of goods or services made on behalf of HUSKYHUSKY B Members. All subcontracts shall also provide that decisions concerning both acute and chronic care must be made according to these definitions.
d. Within fifteen (15) days of the effective date of this contract the MCO shall provide the DEPARTMENT with a report of those functions under this contract that the MCO will be providing through subcontracts and copies of the contracts between the MCO and the subcontractor. Such report shall identify the names of the subcontractors, their addresses and a summary of the services they will be providing. If the MCO enters into any additional subcontracts after the MCO's initial compliance with this section, the MCO shall obtain the advance written approval of the DEPARTMENT. The MCO shall provide the DEPARTMENT with a draft of the proposed subcontract thirty (30) days in advance of the completion of the MCO's negotiation of such subcontract. In addition, amendments to any such subcontract excluding those of a technical nature, shall require the pre-review and approval of the DEPARTMENT.
e. In accordance with JUNE SPECIAL SESSION, PUBLIC ACT NO.01-2, all behavioral health and dental subcontracts, which include the payment of claims on behalf of HUSKY B Members for the provision of goods or services to HUSKY B Members shall require a performance bond, letter of credit, statement of financial reserves or payment withhold requirements. The performance bond, letter of credit, statement of financial reserves or payment withhold requirements shall be in a form to be mutually agreed upon by the MCO and the subcontractor. The amount of the performance bond shall be sufficient to ensure the completion of the subcontractor's claims processing and provider payment obligations under the subcontract in the event the contract between the MCO and the subcontractor is terminated. The MCO shall submit reports to the DEPARTMENT upon the DEPARTMENT's request related to any payments made from the performance bonds or any payment withholds.
f. All subcontracts shall include provisions for a well-organized transition in the event of termination of the subcontract for any reason. Such provisions shall ensure that an adequate provider network will be maintained at all times during any such transition period and that continuity of care is maintained for all Members.
g. In the event that a subcontract is terminated, the MCO shall submit a written transition plan to the DEPARTMENT sixty (60) days in advance of the scheduled termination. The transition plan shall include provisions concerning financial responsibility for the final settlement of provider claims and data reporting, which at a minimum must include a claims aging report prepared in accordance with Section 3.39 (c)(5) of this contract, with steps to ensure the resolution of the outstanding amounts. This plan shall be submitted prior to the DEPARTMENT's approval.
h. All subcontracts shall also include a provision that the MCO will withhold a portion of the final payment to the subcontractor, as a surety bond to ensure compliance under the terminated subcontract.
i. The MCO shall have no right to and shall not assign, transfer or delegate this contract in its entirety, or any right or duty arising under this contract without the prior written approval of the DEPARTMENT. The DEPARTMENT in its discretion may grant such written approval of an assignment, transfer or delegation provided, however, that this paragraph shall not be construed to grant the MCO any right to such approval.
Appears in 1 contract
Samples: Purchase of Service Contract (Wellcare Health Plans, Inc.)
Subcontracting for Services. a. Licensed health care facilities, group practices and licensed health care professionals operating within the scope of their practice may contract with the MCO directly or indirectly through a subcontractor who directly contracts with the MCO. The MCO shall be held directly accountable and liable for all of the contractual provisions under this contract regardless of whether the MCO chooses to subcontract their responsibilities to a third party. No subcontract shall operate to terminate the legal responsibility of the MCO to assure that all activities carried out by the subcontractor conform to the provisions of the contract. Subcontracts shall not terminate the legal liability of the MCO under this contract.
b. The MCO may subcontract for any function, excluding Member Services, covered by this contract, subject to the requirements of this contract. Before delegating any of the requirements of this contract, the MCO shall evaluate the prospective subcontractor's ability to perform the activities to be delegated. All subcontracts shall be in writing, shall include any general requirements of this contract that are appropriate to the services being provided, and shall assure that all delegated duties of the MCO under this contract are performed, including any reporting requirements. The subcontract shall also provide for revocation or other sanctions if the subcontractor's performance is inadequate. All subcontracts shall also provide for the right of the DEPARTMENT or other governmental entity to enter the subcontractor's premises to inspect, monitor or otherwise evaluate the work being performed as a delegated duty of this contract, as specified in Section 3.333.34, Inspection of Facilities. All subcontracts shall comply with the requirements of 42 CFR Section 434.6 (b) and (c)438.6 that are appropriate to the service or activity delegated under the subcontract.
c. With the exception of subcontracts specifically excluded by the DEPARTMENT, all subcontracts shall include verbatim the HUSKY A definitions of Medical Appropriateness / Medically Appropriate and Medically Necessary/Medical Necessity as set forth in Part II, General Contract Terms for the MCOs. All subcontracts shall require the use of these definitions by subcontractors in all requests for approval of coverage of goods or services made on behalf of HUSKYHUSKY A Members. All subcontracts shall also provide that decisions concerning both acute and chronic care must be made according to these definitions.
d. Within fifteen (15) days of the effective date of this contract, the MCO shall provide the DEPARTMENT with a report of those functions under this contract that the MCO shall be providing through a subcontract and copies of the contracts between the MCO and the subcontractor. The report shall identify the names of the subcontractors, their addresses and a summary of the services they will be providing. If the MCO enters into any additional subcontracts after the MCO's initial compliance with this section, the MCO shall obtain the advance written approval of the DEPARTMENT. The MCO shall provide the DEPARTMENT with a draft of the proposed subcontract thirty (30) days in advance of the completion of the MCO's negotiation of such subcontract. In addition, amendments to any subcontract, excluding those of a technical nature, shall require the pre-review and approval of the DEPARTMENT.
e. All dental subcontracts which include the payment of claims on behalf of HUSKY A Members for the provision of goods and services to HUSKY A Members shall require a performance bond, letter of credit, statement of financial reserves or payment withhold requirements. The performance bond, letter of credit, statement of financial reserves or payment withhold requirements shall be in a form mutually agreed upon by the MCO and the subcontractor. The amount of the performance bond shall be sufficient to ensure the completion of the subcontractor's claims processing and provider payment obligations under the subcontract in the event the contract between the MCO and the subcontractor is terminated. The MCO shall submit reports to the DEPARTMENT upon the DEPARTMENT'S request related to any payments made from the performance bonds or any payment withholds.
f. All dental subcontracts which include the payment of claims on behalf of HUSKY A Members for the provision of goods and services to HUSKY A members shall require the submission of a capitation income and disbursement report in a format specified by the DEPARTMENT. The report shall be submitted quarterly and shall include the amount of payment received for Medicaid members; amount paid directly to providers of health services on behalf of Medicaid members; administrative costs and profits.
g. All subcontracts shall include provisions for a well-organized transition in the event of termination of the subcontract for any reason. Such provisions shall ensure that an adequate provider network will be maintained at all times during any such transition period and that continuity of care is maintained for all Members.
h. Prior to the approval by the DEPARTMENT of any subcontract with a dental subcontractor, the MCO shall submit a plan to the DEPARTMENT for the resolution of any outstanding claims submitted by providers to the MCO's previous dental subcontractor. Such plan shall meet the requirements described in subsection (j) below.
i. The MCO shall monitor all subcontractors' performance on an ongoing basis and subject the subcontractor to formal review once a year. AH subcontracts shall provide that if the MCO identifies deficiencies or areas for improvement, the MCO and the subcontractor shall take corrective action.
j. In the event that a subcontract is terminated, the MCO shall submit a written transition plan to the DEPARTMENT sixty (60) days in advance of the scheduled termination. The transition plan shall include provisions concerning financial responsibility for the final settlement of provider claims and data reporting, which at a minimum must include a claims aging report prepared in accordance with Section 3.40 (c)(4) of this contract, with steps to ensure the resolution of the outstanding amounts. This plan shall be submitted prior to the DEPARTMENT'S approval of the replacement subcontractor.
k. All subcontracts shall also include a provision that the MCO will withhold a portion of the final payment to the subcontractor, as a surety bond to ensure compliance under the terminated subcontract.
l. The MCO shall have no right to and shall not assign, transfer or delegate this contract in its entirety, or any right or duty arising under this contract without the prior written approval of the DEPARTMENT. The DEPARTMENT in its discretion may grant such written approval of an assignment, transfer or delegation provided, however, that this paragraph shall not be construed to grant the MCO any right to such approval.
m. This section shall not be construed as restricting the MCO from entering into contracts with participating providers to provide health care services to Members.
Appears in 1 contract
