Subcontractual Relationships and Delegation. If the MCP delegates to any first tier, downstream and related entity (FDR), they shall ensure it has an arrangement with the FDR to perform administrative services as defined below on the MCP’s behalf. a. Unless otherwise specified by ODM, administrative services include: care management, marketing, utilization management, quality improvement, enrollment, disenrollment, membership functions, claims administration, licensing and credentialing, provider network management, and coordination of benefits. b. Parties to administrative services arrangements are defined as: i. First tier entity: any party that enters into a written arrangement, acceptable to ODM, with the MCP to provide administrative services for Ohio Medicaid eligible individuals. ii. Downstream entity: any party that enters into a written arrangement, acceptable to ODM, with a first tier or related entity or below the level of a first tier or related entity to provide administrative services for Ohio Medicaid eligible individuals. These arrangements continue down to the level of the ultimate provider of the administrative services. iii. Related entity: any party related to the MCP by common ownership or control, and under an oral or written arrangement performs some of the administrative services under the MCP’s contract with ODM. c. Before the MCP enters into an arrangement with an FDR to perform an administrative function not listed above that could impact a member’s health, safety, welfare or access to Medicaid covered services, the MCP shall contact ODM to request a determination of whether or not the function should be included as an administrative service that complies with the provisions listed herein.
Appears in 2 contracts
Samples: Provider Agreement, Provider Agreement
Subcontractual Relationships and Delegation. If the An MCP that delegates to any first tier, downstream and related entity (FDR), they shall must ensure that it has an arrangement with the FDR to perform administrative services as defined below on the MCP’s behalf.
a. Unless otherwise specified by ODM, administrative services include: care management, marketing, utilization management, quality improvement, enrollment, disenrollment, membership functions, claims administration, licensing and credentialing, provider network management, and coordination of benefits.
b. Parties to administrative services arrangements are defined as:
i. First tier entity: any party that enters into a written arrangement, acceptable to ODM, with the a MCP to provide administrative services for Ohio Medicaid eligible individuals.
ii. Downstream entity: any party that enters into a written arrangement, acceptable to ODM, with a first tier or related entity or below the level of a first tier or related entity to provide administrative services for Ohio Medicaid eligible individuals. These arrangements continue down to the level of the ultimate provider of the administrative services.
iii. Related entity: any party that is related to the MCP by common ownership or control, and under an oral or written arrangement performs some of the administrative services under the MCP’s contract with ODM.
c. Before the an MCP enters into an arrangement with an FDR to perform an administrative function not listed above that could impact a member’s health, safety, welfare or access to Medicaid covered services, the MCP shall must contact ODM to request a determination of whether or not the function should be included as an administrative service that complies with the provisions listed herein.
d. An MCP that enters into a written arrangement with an FDR shall include the following enforceable provisions:
i. A description of the administrative services to be provided by the FDR and any requirements for the FDR to report information to the MCP.
ii. The beginning date and expiration date or automatic renewal clause for the arrangement, as well as applicable methods of extension, renegotiation and termination.
iii. Identification of the service area and Medicaid population, either “non-dual” or “non-dual and dual” the FDR will serve.
iv. A provision stating that the FDR shall release to the MCP and ODM any information necessary for the MCP to perform any of its obligations under the MCP’s provider agreement with ODM, including but not limited to compliance with reporting and quality assurance requirements.
v. A provision that the FDR’s applicable facilities and records will be open to inspection by the MCP, ODM, its designee or other entities as specified in OAC rule.
vi. A provision that the arrangement is governed by, and construed in accordance with all applicable state or federal laws, regulations and contractual obligations of the MCP. The arrangement shall be automatically amended to conform to any changes in laws, regulations and contractual obligations without the necessity for written amendment.
vii. A provision that Medicaid eligible individuals and ODM are not liable for any cost, payment, copayment, cost-sharing, down payment, or similar charge, refundable or otherwise for services performed, including in the event the FDR
viii. The procedures to be employed upon the ending, nonrenewal or termination of the arrangement including at a minimum to promptly supply any documentation necessary for the settlement of any outstanding claims or services.
ix. A provision that the FDR will abide by the MCP’s written policies regarding the False Claims Act and the detection and prevention of fraud, waste and abuse.
x. A provision that the FDR, and all employees of the FDR, are subject to the applicable provider qualifications in OAC rule 5160-26-05.
xi. For an FDR providing administrative services that result in direct contact with a Medicaid eligible individual, a provision that the FDR will identify, and where indicated, arrange pursuant to the mutually agreed upon policies and procedures between the MCP and FDR for the following at no cost to the individual or ODM:
1. Sign language services; and
2. Oral interpretation and oral translation services.
xii. For an FDR providing licensing and credentialing services of medical providers, a provision that:
1. The credentials of medical professionals affiliated with the party or parties will be reviewed by the MCP; or
2. The credentialing process will be reviewed and approved by the MCP and the MCP will audit the credentialing process on an ongoing basis.
xiii. For an FDR providing administrative services that result in the selection of providers, a provision that the MCP retains the right to approve, suspend, or terminate any such selection.
xiv. A provision that permits ODM or the MCP to seek revocation or other remedies, as applicable, if ODM or the MCP determines that the FDR has not performed satisfactorily or the arrangement is not in the best interest of the MCP’s members.
e. The MCP is ultimately responsible for meeting all contractual obligations under the MCP’s provider agreement with ODM. The MCP must:
i. Ensure that the performance of the FDR is monitored on an ongoing basis to identify any deficiencies or areas for improvement;
ii. Impose corrective action on the FDR as necessary; and
iii. Maintain policies and procedures that ensure there is no disruption in meeting its contractual obligations to ODM, if the FDR or MCP terminates the arrangement between the FDR and the MCP.
f. Unless otherwise specified by ODM, all information required to be submitted to ODM must be submitted directly by the MCP.
g. Information regarding new, changes to, or termination of FDR arrangements must be reported to ODM no less than 15 days prior to it taking effect.
h. Delegation requirements do not apply to care management arrangements between an MCP and a Comprehensive Primary Care Practice or Patient Centered Medical Home as cited in Appendix K. The following are the Ohio Department of Medicaid (ODM) responsibilities or clarifications that are not otherwise specifically stated in OAC Chapter 5160-26 or elsewhere in the Provider Agreement.
1. ODM will provide MCPs with an opportunity to review and comment on the rate-setting time line and proposed rates, and proposed changes to the OAC program rules and the provider agreement.
2. ODM will notify MCPs of managed care program policy and procedural changes and, whenever possible, offer sufficient time for comment and implementation.
3. ODM will provide regular opportunities for MCPs to receive program updates and discuss program issues with ODM staff.
4. ODM will provide technical assistance sessions where MCP attendance and participation is required. ODM will also provide optional technical assistance sessions to MCPs, individually or as a group.
5. ODM will provide MCP’s linkages to organization that can provide guidance on the development of effective strategies to eliminate health disparities.
6. ODM will conduct an annual analysis of Medicaid eligible individuals to identify whether there are any prevalent common primary languages, other than English, in the MCP service areas. ODM will notify the MCP of any languages that are identified as prevalent for the purpose of translating marketing and member materials (See Appendix C.).
7. ODM will provide MCPs with an annual MCP Calendar of Submissions outlining major submissions and due dates.
8. ODM will identify contact staff, including the Contract Administrator (CA), selected for each MCP.
9. ODM will provide MCPs with an electronic Provider Master File containing all the Ohio Medicaid fee-for-service (FFS) providers, which includes their Medicaid Provider Number, as well as all providers who have been assigned a provider reporting number for current encounter data purposes. This file also includes NPI information when available.
Appears in 1 contract
Samples: Provider Agreement
Subcontractual Relationships and Delegation. If the MCP delegates to any first tier, downstream and related entity (FDR), they shall ensure it has an arrangement with the FDR to perform administrative services as defined below on the MCP’s behalf.
a. Unless otherwise specified by ODM, administrative services include: care management, marketing, utilization management, quality improvement, enrollment, disenrollment, membership functions, claims administration, licensing and credentialing, provider network management, and coordination of benefits.
b. Parties to administrative services arrangements are defined as:
i. First tier entity: any party that enters into a written arrangement, acceptable to ODM, with the MCP to provide administrative services for Ohio Medicaid eligible individuals.
ii. Downstream entity: any party that enters into a written arrangement, acceptable to ODM, with a first tier or related entity or below the level of a first tier or related entity to provide administrative services for Ohio Medicaid eligible individuals. These arrangements continue down to the level of the ultimate provider of the administrative services.
iii. Related entity: any party related to the MCP by common ownership or control, and under an oral or written arrangement performs some of the administrative services under the MCP’s contract with ODM.
c. Before the MCP enters into an arrangement with an FDR to perform an administrative function not listed above that could impact a member’s health, safety, welfare or access to Medicaid covered services, the MCP shall contact ODM to request a determination of whether or not the function should be included as an administrative service that complies with the provisions listed herein.
d. Upon request, the MCP shall disclose to ODM all financial terms and arrangements for payment of any kind that apply between the MCP, or the MCP’s FDR, and any provider of a Medicaid service. ODM acknowledges that such information may be considered confidential and proprietary and thus shall be held strictly confidential by ODM as specified in Article VII of this Agreement.
e. The MCP that enters into a written arrangement with an FDR shall include the following enforceable provisions:
i. A description of the administrative services to be provided by the FDR and any requirements for the FDR to report information to the MCP.
ii. The beginning date and expiration date or automatic renewal clause for the arrangement, as well as applicable methods of extension, renegotiation and termination.
iii. Identification of the service area and Medicaid population, either “non-dual” or “non- dual and dual” the FDR will serve.
iv. A provision stating that the FDR shall release to the MCP and ODM any information necessary for the MCP to perform any of its obligations under the MCP’s provider agreement with ODM, including but not limited to compliance with reporting and quality assurance requirements.
v. A provision that the FDR’s applicable facilities and records will be open to inspection by the MCP, ODM, its designee or other entities as specified in OAC rule.
vi. A provision that the arrangement is governed by, and construed in accordance with all applicable state or federal laws, regulations and contractual obligations of the MCP. The arrangement shall be automatically amended to conform to any changes in laws, regulations and contractual obligations without the necessity for written amendment.
vii. A provision that Medicaid eligible individuals and ODM are not liable for any cost, payment, copayment, cost-sharing, down payment, or similar charge, refundable or otherwise for services performed, including in the event the FDR or the MCP cannot or will not pay for the administrative services. This provision does not prohibit waiver entities from collecting patient liability payments from MCP members as specified in OAC rule 5160:1-6-05.
viii. The procedures to be employed upon the ending, nonrenewal or termination of the arrangement including at a minimum to promptly supply any documentation necessary for the settlement of any outstanding claims or services.
ix. A provision that the FDR will abide by the MCP’s written policies regarding the False Claims Act and the detection and prevention of fraud, waste and abuse.
x. A provision that the FDR, and all employees of the FDR, are subject to the applicable provider qualifications in OAC rule 5160-26-05.
xi. For an FDR providing administrative services that result in direct contact with a Medicaid eligible individual, a provision that the FDR will identify, and where indicated, arrange pursuant to the mutually agreed upon policies and procedures between the MCP and FDR for the following at no cost to the individual or ODM:
1. Sign language services; and
2. Oral interpretation and oral translation services.
xii. For an FDR providing licensing and credentialing services of medical providers, a provision that:
Appears in 1 contract
Samples: Provider Agreement
Subcontractual Relationships and Delegation. If the An MCP that delegates to any first tier, downstream and related entity (FDR), they shall must ensure that it has an arrangement with the FDR to perform administrative services as defined below on the MCP’s behalf.
a. Unless otherwise specified by ODM, administrative services include: care management, marketing, utilization management, quality improvement, enrollment, disenrollment, membership functions, claims administration, licensing and credentialing, provider network management, and coordination of benefits.
b. Parties to administrative services arrangements are defined as:
i. First tier entity: any party that enters into a written arrangement, acceptable to ODM, with the a MCP to provide administrative services for Ohio Medicaid eligible individuals.
ii. Downstream entity: any party that enters into a written arrangement, acceptable to ODM, with a first tier or related entity or below the level of a first tier or related entity to provide administrative services for Ohio Medicaid eligible individuals. These arrangements continue down to the level of the ultimate provider of the administrative services.
iii. Related entity: any party that is related to the MCP by common ownership or control, and under an oral or written arrangement performs some of the administrative services under the MCP’s contract with ODM.
c. Before the an MCP enters into an arrangement with an FDR to perform an administrative function not listed above that could impact a member’s health, safety, welfare or access to Medicaid covered services, the MCP shall must contact ODM to request a determination of whether or not the function should be included as an administrative service that complies with the provisions listed herein.
d. An MCP that enters into a written arrangement with an FDR shall include the following enforceable provisions:
i. A description of the administrative services to be provided by the FDR and any requirements for the FDR to report information to the MCP.
ii. The beginning date and expiration date or automatic renewal clause for the arrangement, as well as applicable methods of extension, renegotiation and termination.
iii. Identification of the service area and Medicaid population, either “non-dual” or “non-dual and dual” the FDR will serve.
iv. A provision stating that the FDR shall release to the MCP and ODM any information necessary for the MCP to perform any of its obligations under the MCP’s provider agreement with ODM, including but not limited to compliance with reporting and quality assurance requirements.
v. A provision that the FDR’s applicable facilities and records will be open to inspection by the MCP, ODM, its designee or other entities as specified in OAC rule.
vi. A provision that the arrangement is governed by, and construed in accordance with all applicable state or federal laws, regulations and contractual obligations of the MCP. The arrangement shall be automatically amended to conform to any changes in laws, regulations and contractual obligations without the necessity for written amendment.
vii. A provision that Medicaid eligible individuals and ODM are not liable for any cost, payment, copayment, cost-sharing, down payment, or similar charge, refundable or otherwise for services performed, including in the event the FDR or MCP cannot or will not pay for the administrative services. This provision does not prohibit waiver entities from collecting patient liability payments from MCP members as specified in OAC rule 5160:1-3-04.3.
viii. The procedures to be employed upon the ending, nonrenewal or termination of the arrangement including at a minimum to promptly supply any documentation necessary for the settlement of any outstanding claims or services.
ix. A provision that the FDR will abide by the MCP’s written policies regarding the False Claims Act and the detection and prevention of fraud, waste and abuse.
x. A provision that the FDR, and all employees of the FDR, are subject to the applicable provider qualifications in OAC rule 5160-26-05.
xi. For an FDR providing administrative services that result in direct contact with a Medicaid eligible individual, a provision that the FDR will identify, and where indicated, arrange pursuant to the mutually agreed upon policies and procedures between the MCP and FDR for the following at no cost to the individual or ODM:
a. Sign language services; and
b. Oral interpretation and oral translation services.
xii. For an FDR providing licensing and credentialing services of medical providers, a provision that:
a. The credentials of medical professionals affiliated with the party or parties will be reviewed by the MCP; or
b. The credentialing process will be reviewed and approved by the MCP and the MCP will audit the credentialing process on an ongoing basis.
xiii. For an FDR providing administrative services that result in the selection of providers, a provision that the MCP retains the right to approve, suspend, or terminate any such selection.
xiv. A provision that permits ODM or the MCP to seek revocation or other remedies, as applicable, if ODM or the MCP determines that the FDR has not performed satisfactorily or the arrangement is not in the best interest of the MCP’s members.
e. The MCP is ultimately responsible for meeting all contractual obligations under the MCP’s provider agreement with ODM. The MCP must:
i. Ensure that the performance of the FDR is monitored on an ongoing basis to identify any deficiencies or areas for improvement;
ii. Impose corrective action on the FDR as necessary; and
iii. Maintain policies and procedures that ensure there is no disruption in meeting its contractual obligations to ODM, if the FDR or MCP terminates the arrangement between the FDR and the MCP.
f. Unless otherwise specified by ODM, all information required to be submitted to ODM must be submitted directly by the MCP.
g. Information regarding new, changes to, or termination of FDR arrangements must be reported to ODM no less than 15 days prior to it taking effect.
h. Delegation requirements do not apply to care management arrangements between an MCP and a Comprehensive Primary Care Practice or Patient Centered Medical Home as cited in Appendix K. The following are the Ohio Department of Medicaid (ODM) responsibilities or clarifications that are not otherwise specifically stated in OAC Chapter 5160-26 or elsewhere in the ODM-MCP Provider Agreement.
1. ODM will provide MCPs with an opportunity to review and comment on the rate-setting time line and proposed rates, and proposed changes to the OAC program rules and the provider agreement.
2. ODM will notify MCPs of managed care program policy and procedural changes and, whenever possible, offer sufficient time for comment and implementation.
3. ODM will provide regular opportunities for MCPs to receive program updates and discuss program issues with ODM staff.
4. ODM will provide technical assistance sessions where MCP attendance and participation is required. ODM will also provide optional technical assistance sessions to MCPs, individually or as a group.
5. ODM will provide MCP’s linkages to organization that can provide guidance on the development of effective strategies to eliminate health disparities.
6. ODM will conduct an annual analysis of Medicaid eligible individuals to identify whether there are any prevalent common primary languages, other than English, in the MCP service areas. ODM will notify the MCP of any languages that are identified as prevalent for the purpose of translating marketing and member materials (See Appendix C.22).
7. ODM will provide MCPs with an annual MCP Calendar of Submissions outlining major submissions and due dates.
8. ODM will identify contact staff, including the Contract Administrator (CA), selected for each MCP.
9. ODM will provide MCPs with an electronic Provider Master File containing all the Ohio Medicaid fee-for-service (FFS) providers, which includes their Medicaid Provider Number, as well as all providers who have been assigned a provider reporting number for current encounter data purposes. This file also includes NPI information when available.
Appears in 1 contract
Samples: Provider Agreement
