The Contractor’s Request for Enrollee Disenrollment. a. The Contractor shall not request the disenrollment of any Enrollee because of 1) an adverse change in the Enrollee’s health status; 2) the Enrollee’s utilization of medical services, including but not limited to the Enrollee making treatment decisions with which a provider or the Contractor disagrees (such as declining treatment or diagnostic testing); 3) missed appointments by the Enrollee; 4) the Enrollee's diminished mental capacity, 5) or the Enrollee’s uncooperative or disruptive behavior resulting from his or her special needs (except when the Enrollee’s enrollment seriously impairs the Contractor’s ability to furnish services to either the particular Enrollee or other Enrollees. b. As further specified by EOHHS, and in accordance with 130 CMR 508.003(D), the Contractor may submit a written request to EOHHS to disenroll an Enrollee as follows: 1) The Contractor shall submit the written request in a form and format specified by EOHHS and accompanied by supporting documentation specified by EOHHS; 2) The Contractor shall follow all policies and procedures specified by EOHHS relating to such request, including but not limited to the following: a) The Contractor shall take all serious and reasonable efforts specified by EOHHS prior to making the request. Such efforts include, but are not limited to: (i) Assisting the particular Enrollee to receive Medically Necessary TCOC Included Services through at least three PCPs or other relevant Providers that: (ii) Attempting to provide all resources routinely used by the Contractor to meet Enrollees’ needs, including but not limited to, Behavioral Health Services and Care Management; b) The Contractor shall include with any request the information and supporting documentation specified by EOHHS, including demonstrating that the Contractor took the serious and reasonable efforts specified by EOHHS and, despite such efforts, the Enrollee’s continued enrollment with the Contractor seriously impairs the Contractor’s ability to furnish services to either the particular Enrollee or other Enrollees; and c) The Contractor shall provide any EOHHS-specified notices to the Enrollee relating to the request. c. EOHHS reserves the right, at its sole discretion, to determine when and if a Contractor’s request to terminate the enrollment of an Enrollee will be granted in accordance with this section and related EOHHS policies. In addition, if EOHHS determines that the Contractor too frequently requests termination of enrollment for Enrollees, EOHHS reserves the right to deny such requests and require the Contractor to initiate corrective action to improve the Contractor’s ability to serve such Enrollees.
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Samples: Primary Care Accountable Care Organization Contract, Primary Care Accountable Care Organization Contract, Primary Care Accountable Care Organization Contract
The Contractor’s Request for Enrollee Disenrollment. a. The Contractor shall not request the disenrollment of any Enrollee because of:
1) an adverse change in the Enrollee’s health status;
2) the Enrollee’s utilization of medical services, including but not limited to the Enrollee making treatment decisions with which a provider or the Contractor disagrees (such as declining treatment or diagnostic testing);
3) missed appointments by the Enrollee;
4) the Enrollee's diminished mental capacity,
5) or the Enrollee’s uncooperative or disruptive behavior resulting from his or her their special needs (except when the Enrollee’s enrollment seriously impairs the Contractor’s ability to furnish services to either the particular Enrollee or other Enrollees.
b. As further specified by EOHHS, and in accordance with 130 CMR 508.003(D), the Contractor may submit a written request to EOHHS to disenroll an Enrollee as follows:
1) The Contractor shall submit the written request in a form and format specified by EOHHS and accompanied by supporting documentation specified by EOHHS;
2) The Contractor shall follow all policies and procedures specified by EOHHS relating to such request, including but not limited to the following:
a) The Contractor shall take all serious and reasonable efforts specified by EOHHS prior to making the request. Such efforts include, but are not limited to:
(i) Assisting the particular Enrollee to receive Medically Necessary TCOC Included Services through at least three PCPs or other relevant Providers that:Providers;
(ii) Attempting to provide all resources routinely used by the Contractor to meet Enrollees’ needs, including but not limited to, Behavioral Health Services and Care Management;
b) The Contractor shall include with any request the information and supporting documentation specified by EOHHS, including demonstrating that the Contractor took the serious and reasonable efforts specified by EOHHS and, despite such efforts, the Enrollee’s continued enrollment with the Contractor seriously impairs the Contractor’s ability to furnish services to either the particular Enrollee or other Enrollees; and
c) The Contractor shall provide any EOHHS-specified notices to the Enrollee relating to the request.
c. EOHHS reserves the right, at its sole discretion, to determine when and if a Contractor’s request to terminate the enrollment of an Enrollee will be granted in accordance with this section Section and related EOHHS policies. In addition, if EOHHS determines that the Contractor too frequently requests termination of enrollment for Enrollees, EOHHS reserves the right to deny such requests and require the Contractor to initiate corrective action to improve the Contractor’s ability to serve such Enrollees.
Appears in 2 contracts
Samples: Standard Contract, Standard Contract
The Contractor’s Request for Enrollee Disenrollment. a. The Contractor shall not request the disenrollment of any Enrollee because of
1) an adverse change in the Enrollee’s health status;
2) the Enrollee’s utilization of medical services, including but not limited to the Enrollee making treatment decisions with which a provider or the Contractor disagrees (such as declining treatment or diagnostic testing);
3) missed appointments by the Enrollee;
4) the Enrollee's diminished mental capacity,
5) or the Enrollee’s uncooperative or disruptive behavior resulting from his or her their special needs (except when the Enrollee’s enrollment seriously impairs the Contractor’s ability to furnish services to either the particular Enrollee or other Enrollees.
b. As further specified by EOHHS, and in accordance with 130 CMR 508.003(D), the Contractor may submit a written request to EOHHS to disenroll an Enrollee as follows:
1) The Contractor shall submit the written request in a form and format specified by EOHHS and accompanied by supporting documentation specified by EOHHS;
2) The Contractor shall follow all policies and procedures specified by EOHHS relating to such request, including but not limited to the following:
a) The Contractor shall take all serious and reasonable efforts specified by EOHHS prior to making the request. Such efforts include, but are not limited to:
(i) Assisting the particular Enrollee to receive Medically Necessary TCOC Included Services through at least three PCPs or other relevant Providers that:
(ii) Attempting to provide all resources routinely used by the Contractor to meet Enrollees’ needs, including but not limited to, Behavioral Health Services and Care Management;
b) The Contractor shall include with any request the information and supporting documentation specified by EOHHS, including demonstrating that the Contractor took the serious and reasonable efforts specified by EOHHS and, despite such efforts, the Enrollee’s continued enrollment with the Contractor seriously impairs the Contractor’s ability to furnish services to either the particular Enrollee or other Enrollees; and
c) The Contractor shall provide any EOHHS-specified notices to the Enrollee relating to the request.
c. EOHHS reserves the right, at its sole discretion, to determine when and if a Contractor’s request to terminate the enrollment of an Enrollee will be granted in accordance with this section Section and related EOHHS policies. In addition, if EOHHS determines that the Contractor too frequently requests termination of enrollment for Enrollees, EOHHS reserves the right to deny such requests and require the Contractor to initiate corrective action to improve the Contractor’s ability to serve such Enrollees.
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