Tobacco Cessation Program. The CONTRACTOR shall operate a tobacco cessation program to assist Members with tobacco cessation. The tobacco cessation program shall include, at a minimum, the following: Cessation Quitline; Group counseling; Individual counseling; and U.S. Food and Drug Administration (FDA) approved pharmacotherapies and/or nicotine replacement therapies such as Bupropion, Varenicline, nicotine patch, chewing gum, nasal spray, inhaler, and lozenges. The CONTRACTOR shall not require prior authorization for tobacco cessation services, including counseling, or nicotine replacement products or therapies. The CONTRACTOR shall have no limits on length of treatment or quit attempts per year and no step therapy requirements, and shall encourage but not require enrollment in counseling as part of the tobacco cessation program. The CONTRACTOR shall establish and implement a UM program that follows NCQA UM standards and promotes quality of care, adherence to standards of care, the efficient use of resources, Member choice, and the identification of service gaps within the service system. The CONTRACTOR’s UM program shall: Ensure that Members receive services based on their current condition and effectiveness of previous treatment; Ensure that services are based on the history of the problem/illness, its context, and desired outcomes; Assist Members and/or their Representatives in choosing among Providers and available treatments and services; Ensure the use of the least restrictive setting for crisis response and stabilization, emphasizing relapse and crisis prevention, not just crisis intervention; Detect over- and under-utilization of services to assess the quality and appropriateness of services furnished to Members with special health care needs, and to identify health care disparities for remediation; Inform Population Health Management strategies and activities; Accept the New Mexico Uniform Prior Authorization Form for non-emergency medical and pharmaceutical benefits, as required per the 2019 New Mexico Health Insurance Prior Authorization Act; Respond to prescription drug prior authorization requests in accordance with NMAC 8.308.9.26.E(7)(a)(b); Ensure that prior authorization requirements comply with the requirements for parity in mental health and SUD benefits as specified in 42 C.F.R. § 438.910(d); and Ensure that prior authorization is not required for service codes specified by HCA. The CONTRACTOR shall comply with State and federal requirements for Utilization Management, including but not limited to, 42 C.F.R. § 438.910(d) and 42 C.F.R. part 456. The CONTRACTOR shall maximize the effectiveness of care by evaluating clinical appropriateness and authorizing the type and volume of services through fair, consistent, and Culturally Competent decision-making processes while ensuring equitable access to care and a successful link between care and outcomes. The CONTRACTOR shall submit to HCA on an annual basis the UM edits in the CONTRACTOR’s Claims processing system that control utilization and prevent payment for Claims that are duplicates, unbundled when they should be bundled, or already covered under another charge. The CONTRACTOR shall define and submit annually to HCA a written copy of the CONTRACTOR’s UM program description, UM work plan, and UM evaluation, which shall include, but not be limited to: A description of the CONTRACTOR’s UM program structure and accountability mechanisms; A description of how the UM work plan supports the goals described in the UM program description and specific indicators that will be used for periodic performance tracking and trending as well as processes or mechanisms used for assessment and intervention. The UM work plan must be data driven with key indicators that are used to ensure that under-and-over utilization are detected by the CONTRACTOR and addressed appropriately; and A comprehensive UM program evaluation that includes an evaluation of the overall effectiveness of the UM program, an overview of UM activities and an assessment of the impact of the UM program on management and administrative activities. The review and analysis of any impact from the previous year shall be incorporated in the development of the following year’s UM work plan.
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Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement
Tobacco Cessation Program. The CONTRACTOR shall operate a tobacco cessation program to assist Members with tobacco cessation. The tobacco cessation program shall include, at a minimum, the following: Cessation Quitline; Group counseling; Individual counseling; and U.S. Food and Drug Administration (FDA) approved pharmacotherapies and/or nicotine replacement therapies such as Bupropion, Varenicline, nicotine patch, chewing gum, nasal spray, inhaler, and lozenges. The CONTRACTOR shall not require prior authorization for tobacco cessation services, including counseling, or nicotine replacement products or therapies. The CONTRACTOR shall have no limits on length of treatment or quit attempts per year and no step therapy requirements, and shall encourage but not require enrollment in counseling as part of the tobacco cessation program. The CONTRACTOR shall establish and implement a UM program that follows NCQA UM standards and promotes quality of care, adherence to standards of care, the efficient use of resources, Member choice, and the identification of service gaps within the service system. The CONTRACTOR’s UM program shall: Ensure that Members receive services based on their current condition and effectiveness of previous treatment; Ensure that services are based on the history of the problem/illness, its context, and desired outcomes; Assist Members and/or their Representatives in choosing among Providers and available treatments and services; Ensure the use of the least restrictive setting for crisis response and stabilization, emphasizing relapse and crisis prevention, not just crisis intervention; Detect over- and under-utilization of services to assess the quality and appropriateness of services furnished to Members with special health care needs, and to identify health care disparities for remediation; Inform Population Health Management strategies and activities; Accept the New Mexico Uniform Prior Authorization Form for non-emergency medical and pharmaceutical benefits, as required per the 2019 New Mexico Health Insurance Prior Authorization Act; Respond to prescription drug prior authorization requests in accordance with NMAC 8.308.9.26.E(7)(a)(b); Ensure that prior authorization requirements comply with the requirements for parity in mental health and SUD benefits as specified in 42 C.F.R. § 438.910(d); and Ensure that prior authorization is not required for service codes specified by HCAHSD. The CONTRACTOR shall comply with State and federal requirements for Utilization Management, including but not limited to, 42 C.F.R. § 438.910(d) and 42 C.F.R. part 456. The CONTRACTOR shall maximize the effectiveness of care by evaluating clinical appropriateness and authorizing the type and volume of services through fair, consistent, and Culturally Competent decision-making processes while ensuring equitable access to care and a successful link between care and outcomes. The CONTRACTOR shall submit to HCA HSD on an annual basis the UM edits in the CONTRACTOR’s Claims processing system that control utilization and prevent payment for Claims that are duplicates, unbundled when they should be bundled, or already covered under another charge. The CONTRACTOR shall define and submit annually to HCA HSD a written copy of the CONTRACTOR’s UM program description, UM work plan, and UM evaluation, which shall include, but not be limited to: A description of the CONTRACTOR’s UM program structure and accountability mechanisms; A description of how the UM work plan supports the goals described in the UM program description and specific indicators that will be used for periodic performance tracking and trending as well as processes or mechanisms used for assessment and intervention. The UM work plan must be data driven with key indicators that are used to ensure that under-and-over utilization are detected by the CONTRACTOR and addressed appropriately; and A comprehensive UM program evaluation that includes an evaluation of the overall effectiveness of the UM program, an overview of UM activities and an assessment of the impact of the UM program on management and administrative activities. The review and analysis of any impact from the previous year shall be incorporated in the development of the following year’s UM work plan.
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