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Back to Form 8-K [form_8-k.htm]
 
Exhibit 10.1
 
 

PROVIDER AGREEMENT

BETWEEN STATE OF OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES AND
WELLCARE OF OHIO, INC.
Amendment No. 2
 
Pursuant to Article IX.A. the Provider Agreement between the State of Ohio,
Department of Job and Family Services, (hereinafter referred to as "ODJFS") and
WELLCARE OF OHIO, INC. (hereinafter referred to as "MCP") for the Aged, Blind or
Disabled (hereinafter referred to as "ABD") population dated December 1, 2006,
is hereby amended as follows:

1. Appendix C is modified as attached.

2. All other terms of the provider agreement are hereby affirmed.

The amendment contained herein shall be effective March 1, 2007.

 
WELLCARE OF OHIO, INC.:
     
BY:
/s/ Todd S. Farha
 
DATE:
2/19/2007
 
TODD S. FARHA, PRESIDENT & CEO
 
     
OHIO DEPARTMENT OF JOB AND FAMILY SERVICES:
     
BY:
/s/ Helen E. Jones-Kelly
 
DATE:
  2/27/2007  
HELEN E. JONES-KELLY, DIRECTOR
     

 

APPENDIX C
 
MCP RESPONSIBILITIES ABD ELIGIBLE POPULATION
 
The MCP must meet on an ongoing basis, all program requirements specified in
Chapter 5101:3-26 of the Ohio Administrative Code (OAC) and the Ohio Department
of Job and Family Services (ODJFS) - MCP Provider Agreement. The following are
MCP responsibilities that are not otherwise specifically stated in OAC rule
provisions or elsewhere in the MCP provider agreement, but are required by
ODJFS.
 
General Provisions
 
1. The MCP agrees to implement program modifications as soon as reasonably
possible or no later than the required effective date, in response to changes in
applicable state and federal laws and regulations.
 
2. The MCP must submit a current copy of their Certificate of Authority (COA) to
ODJFS within 30 days of issuance by the Ohio Department of Insurance.
 
3. The MCP must designate the following:
 
a. A primary contact person (the Medicaid Coordinator) who will dedicate a
majority of their time to the Medicaid product line and coordinate overall
communication between ODJFS and the MCP. ODJFS may also require the MCP to
designate contact staff for specific program areas. The Medicaid Coordinator
will be responsible for ensuring the timeliness, accuracy, completeness and
responsiveness of all MCP submissions to ODJFS.
 
b. A provider relations representative for each service area included in their
ODJFS provider agreement. This provider relations representative can serve in
this capacity for only one service area (as specified in Appendix H).
 
If an MCP serves both the CFC and ABD populations, they are not required to
designate a separate provider relations representative or Medicaid Coordinator
for each population group.
 
4. All MCP employees are to direct all day-to-day submissions and communications
to their ODJFS-designated Contract Administrator unless otherwise notified by
ODJFS.
 
5. The MCP must be represented at all meetings and events designated by ODJFS as
requiring mandatory attendance.
 
6. The MCP must have an administrative office located in Ohio.
 

Appendix C
Page 2

7. Upon request by ODJFS, the MCP must submit information on the current status
of their company's operations not specifically covered under this Agreement (for
example, other product lines, Medicaid contracts in other states, NCQA
accreditation, etc.) unless otherwise excluded by law.
 
8. The MCP must have all new employees trained on applicable program
requirements, and represent, warrant and certify to ODJFS that such training
occurs, or has occurred.
 
9. If an MCP determines that it does not wish to provide, reimburse, or cover a
counseling service or referral service due to an objection to the service on
moral or religious grounds, it must immediately notify ODJFS to coordinate the
implementation of this change. MCPs will be required to notify their members of
this change at least thirty (30) days prior to the effective date. The MCP's
member handbook and provider directory, as well as all marketing materials, will
need to include information specifying any such services that the MCP will not
provide.
 
10. For any data and/or documentation that MCPs are required to maintain, ODJFS
may request that MCPs provide analysis of this data and/or documentation to
ODJFS in an aggregate format, such format to be solely determined by ODJFS.
 
11. The MCP is responsible for determining medical necessity for services and
supplies requested for their members as specified in OAC rule 5101:3-26-03.
Notwithstanding such responsibility, ODJFS retains the right to make the final
determination on medical necessity in specific member situations.
 
12. In addition to the timely submission of medical records at no cost for the
annual external quality review as specified in OAC rule 5101:3-26-07, the MCP
may be required for other purposes to submit medical records at no cost to ODJFS
and/or designee upon request.
 
13. The MCP must notify their Contract Administrator of the termination of an
MCP panel provider that is designated as the primary care physician for ≥100 of
the MCP's ABD members. The MCP must provide notification within one working day
of the MCP becoming aware of the termination.
 
14. Upon request by ODJFS, MCPs may be required to provide written notice to
members of any significant change(s) affecting contractual requirements, member
services or access to providers.
 
15. MCPs may elect to provide services that are in addition to those covered
under the Ohio Medicaid fee-for-service program. Before MCPs notify potential or
current members of the availability of these services, they must first notify
ODJFS and advise ODJFS of such planned services availability. If an MCP elects
to provide additional services, the MCP
 
Appendix C
Page 3

must ensure to the satisfaction of ODJFS that the services are readily available
and accessible to members who are eligible to receive them.
 
a. MCPs are required to make transportation available to any member
that must travel thirty (30) miles or more from their home to receive a
medically-necessary Medicaid-covered service. If the MCP offers transportation
to their members as an additional benefit and this transportation benefit only
covers a limited number of trips, the required transportation listed above may
not be counted toward this trip limit.
 
b. Additional benefits may not vary by county within a region except out of
necessity for transportation arrangements (e.g., bus versus cab). MCPs approved
to serve consumers in more than one region may vary additional benefits between
regions.
 
c. MCPs must give ODJFS and members ninety (90) days prior notice when
decreasing or ceasing any additional benefit(s). When it is beyond the control
of the MCP, as demonstrated to ODJFS' satisfaction, ODJFS must be notified
within one (1) working day.
 
16. MCPs must comply with any applicable Federal and State laws that pertain to
member rights and ensure that its staff adhere to such laws when furnishing
services to its membrs. MCPs shall include a requirement in its contracts with
affiliated providers that such providers also adhere to applicable Federal and
State laws when providing services to members.
 
17. MCPs must comply with any other applicable Federal and State laws (such as
Title VI of the Civil rights Act of 1964, etc.) and other laws regarding privacy
and confidentiality, as such may be applicable to this Agreement.
 
18. Upon request, the MCP will provide members and potential members with a copy
of their practice guidelines.
 
19. The MCP is responsible for promoting the delivery of services in a
culturally competent manner, as solely determined by ODJFS, to all members,
including those with limited English proficiency (LEP) and diverse cultural and
ethnic backgrounds.
 
All MCPs must comply with the requirements specified in OAC rules
5101:3-26-03.1, 5101:3-26-05(D), 5101:3-26-05.1(A), 5101:3-26-08 and
5101:3-26-08.2 for providing assistance to LEP members and eligible individuals.
In addition, MCPs must provide written translations of certain MCP materials in
the prevalent non-English languages of members and eligible individuals in
accordance with the following:
 
Appendix C
Page 4

a. When 10% or more of the ABD eligible individuals in the MCP's service
areahave a common primary language other than English, the MCP must translate
all ODJFS-approved marketing materials into the primary language of that group.
The MCP must monitor changes in the eligible population on an ongoing basis and
conduct an assessment no less often than annually to determine which, if any,
primary language groups meet the 10% threshold for the eligible individuals in
each service area. When the 10% threshold is met, the MCP must report this
information to ODJFS, in a format as requested by ODJFS, translate their
marketing materials, and make these marketing materials available to eligible
individuals. MCPs must submit to ODJFS, upon request, their prevalent non
English language analysis of eligible individuals and the results of this
analysis.
 
b. When 10% or more of an MCP's ABD members in the MCP's service area have a
common primary language other than English, the MCP must translate all
ODJFS-approved member materials into the primary language of that group. The MCP
must monitor their membership and conduct a quarterly assessment to determine
which, if any, primary language groups meet the 10% threshold. When the 10%
threshold is met, the MCP must report this information to ODJFS, in a format as
requested by ODJFS, translate their member materials, and make these materials
available to their members. MCPs must submit to ODJFS, upon request, their
prevalent non-English language member analysis and the results of this analysis.
 
20. The MCP must utilize a centralized database which records the special
communication needs of all MCP members (i.e., those with limited English
proficiency, limited reading proficiency, visual impairment, and hearing
impairment) and the provision of related services (i.e., MCP materials in
alternate format, oral interpretation, oral translation services, written
translations of MCP materials, and sign language services). This database must
include all MCP member primary language information (PLI) as well as all other
special communication needs information for MCP members, as indicated above,
when identified by any source including but not limited to ODJFS, ODJFS
selection services entity, MCP staff, providers, and members. This centralized
database must be readily available to MCP staff and be used in coordinating
communication and services to members, including the selection of a PCP who
speaks the primary language of an LEP member, when such a provider is available.
MCPs must share member specific communication needs information with their
providers [e.g., PCPs, Pharmacy Benefit Managers (PBMs), and Third Party
Administrators (TPAs)], as applicable. MCPs must submit to ODJFS, upon request,
detailed information regarding the MCP's members with special communication
needs, which could include individual member names, their specific communication
need, and any provision of special services to members (i.e., those special
services arranged by the MCP as well as those services reported to the MCP which
were arranged by the provider).

 

Appendix C
Page 5
 
Additional requirements specific to providing assistance to hearing-impaired,
vision-impaired, limited reading proficient (LRP), and LEP members and eligible
individuals are found in OAC rules 5101:3-26-03.1, 5101:3-26-05(D),
5101:3-26-05.1(A), 5101:3-26-08, and 5101-3-26-08.2.
 
21. The MCP is responsible for ensuring that all member materials use easily
understood language and format. The determination of what materials comply with
this requirement is in the sole discretion of ODJFS.
 
22. Pursuant to OAC rules 5101:3-26-08 and 5101:3-26-08.2, the MCP is
responsible for ensuring that all MCP marketing and member materials are prior
approved by ODJFS before being used or shared with members. Marketing and member
materials are defined as follows:
 
a. Marketing materials are those items produced in any medium, by or on behalf
of an MCP, including gifts of nominal value (i.e., items worth no more than
$15.00), which can reasonably be interpreted as intended to market to eligible
individuals.
 
b. Member materials are those items developed, by or on behalf of an MCP, to
fulfill MCP program requirements or to communicate to all members or a group
ofmembers. Member health education materials that are produced by a source other
than the MCP and which do not include any reference to the MCP are not
considered to be member materials.
 
c. All MCP marketing and member materials must represent the MCP in an honest
and forthright manner and must not make statements which are inaccurate,
misleading, confusing, or otherwise misrepresentative, or which defraud eligible
individuals or ODJFS.
 
d. All MCP marketing cannot contain any assertion or statement (whether written
or oral) that the MCP is endorsed by CMS, the Federal or State government or
similar entity.
 
e. MCPs must establish positive working relationships with the CDJFS offices and
must not aggressively solicit from local Directors, MCP County Coordinators, or
or other staff. Furthermore, MCPs are prohibited from offering gifts of nominal
value (i.e. clipboards, pens, coffee mugs, etc.) to CDJFS offices or SSE staff,
as these may influence an individual's decision to select a particular MCP.
 
23. Advance Directives - All MCPs must comply with the requirements specified in
42 CFR 422.128. At a minimum, the MCP must:
 
a. Maintain written policies and procedures that meet the requirements for
advance

Appendix C
Page 6

directives, as set forth in 42 CFR Subpart I of part 489.
 
b. Maintain written policies and procedures concerning advance directives with
respect to all adult individuals receiving medical care by or through the MCP to
ensure that the MCP:
 
i. Provides written information to all adult members concerning:
 
a. the member's rights under state law to make decisions concerning their
medical care, including the right to accept or refuse medical or surgical
treatment and the right to formulate advance directives. (In meeting this
requirement, MCPs must utilize form JFS 08095 entitled You Have the Right, or
include the text from JFS 08095 in their ODJFS-approved member handbook).
 
b. the MCP's policies concerning the implementation of those rights including a
clear and precise statement of any limitation regarding the implementation of
advance directives as a matter of conscience;
 
c.  any changes in state law regarding advance directives as soon as possible
but no later than ninety (90) days after the proposed effective date of the
change; and
 
d. the right to file complaints concerning noncompliance with the advance
directive requirements with the Ohio Department of Health.
 
ii. Provides for education of staff concerning the MCP's policies and procedures
on advance directives;
 
iii. Provides for community education regarding advance directives directly or
in concert with other providers or entities;
 
iv. Requires that the member's medical record document whether or not the member
has executed an advance directive; and
 
v. Does not condition the provision of care, or otherwise discriminate against a
member, based on whether the member has executed an advance directive.
 
Appendix C
Page 7
 
24. New Member Materials
Pursuant to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member an
MCP identification (ID) card, a new member letter, a member handbook, a provider
directory, and information on advance directives.
 
a. MCPs must use the model language specified by ODJFS for the new member
letter.
 
b. The ID card and new member letter must be mailed together to the member via a
method that will ensure its receipt prior to the member's effective date of
coverage. No other materials may be included with this mailing.
 
c. The member handbook, provider directory and advance directives information
must be mailed separately from the ID card and new member letter. MCPs will meet
the timely receipt requirement for these materials if they are mailed to the
member within twenty-four (24) hours of the MCP receiving the ODJFS-produced
monthly membership roster (MMR). This is provided the materials are mailed via a
method with an expected delivery date of five (5) days. If the MCP is unable to
mail the materials within twenty-four (24) hours, the materials must be mailed
via a method that will ensure receipt by no later than the effective date of
coverage.
 
d. MCPs must designate two (2) MCP staff members to receive a copy of the new
member materials on a monthly basis in order to monitor the timely receipt of
these materials. At least one of the staff members must receive the materials at
their home address.
 
25. Call Center Standards
The MCP must provide assistance to members through a member services toll-free
call-in system pursuant to OAC rule 5101:3-26-08.2(A)(1). MCP member services
staff must be available nationwide to provide assistance to members through the
toll-free call-in system every Monday through Friday, at all times during the
hours of 7:00 am to 7:00 pm Eastern Time, except for the following major
holidays:
 
• New Year's Day
• Martin Luther King's Birthday
• Memorial Day
• Independence Day
• Labor Day
• Thanksgiving Day
• Christmas Day
• 2 optional closure days: These days can be used independently or in
combination with any of the major holiday closures but cannot both be
 
Appendix C
Page 8

used within the same closure period. Before announcing any optional closure
dates to members and/or staff, MCPs must receive ODJFS prior-approval which
verifies that the optional closure days meet the specified criteria.
 
If a major holiday falls on a Saturday, the MCP member services line may be
closed on the preceding Friday. If a major holiday falls on a Sunday, the member
services line may be closed on the following Monday. MCP member services closure
days must be specified in the MCP's member handbook, member newsletter, or other
some general issuance to the MCP's members at least thirty (30) days in advance
of the closure.
 
The MCP must also provide access to medical advice and direction through a
centralized twenty-four-hour, seven day, toll-free call-in system, available
nationwide, pursuant to OAC rule 5101:3-26-03.1(A)(6). The twenty-four (24)/7
hour call-in system must be staffed by appropriately trained medical personnel.
For the purposes of meeting this requirement, trained medical professionals are
defined as physicians, physician assistants, licensed practical nurses, and
registered nurses.
 
MCPs must meet the current American Accreditation HealthCare
Commission/URAC-designed Health Call Center Standards (HCC) for call center
abandonment rate, blockage rate and average speed of answer. By the 10th of each
month, MCPs must self-report their prior month performance in these three areas
for their member services and twenty-four (24) hour toll-free call-in systems to
ODJFS. ODJFS will inform the MCPs of any changes/updates to these URAC call
center standards.
 
MCPs are not permitted to delegate grievance/appeal functions [Ohio
Administrative Code (OAC) rule 5101:3-26-08.4(A)(9)]. Therefore, the member
services call center requirement may not be met through the execution of a
Medicaid Delegation Subcontract Addendum or Medicaid Combined Services
Subcontract Addendum.
 
26. Notification of Optional MCP Membership
 
In order to comply with the terms of the ODJFS State Plan Amendment for the
managed care program (i.e., 42 CFR 438.50), MCPs in mandatory membership service
areas must inform new members, as applicable, that MCP membership is optional
for certain populations. Specifically, MCPs must inform any applicable pending
member or member that the following ABD population is not required to select an
MCP in order to receive their Medicaid healthcare benefit and what steps they
need to take if they do not wish to be a member of an MCP:
-  Indians who are members of federally-recognized tribes, except as permitted
under 42 C.F.R 438.50(d)(21).

Appendix C
Page 9

27. HIPAA Privacy Compliance Requirements
 
The Health Insurance Portability and Accountability Act (HIPAA) Privacy
Regulations at 45 CFR. § 164.502(e) and § 164.504(e) require ODJFS to have
agreements with MCPs as a means of obtaining satisfactory assurance that the
MCPs will appropriately safeguard all personal identified health information.
Protected Health Information (PHI) is information received from or on behalf of
ODJFS that meets the definition of PHI as defined by HIPAA and the regulations
promulgated by the United States Department of Health and Human Services,
specifically 45 CFR 164.501, and any amendments thereto. MCPs must agree to the
following:
 
a. MCPs shall not use or disclose PHI other than is permitted by this Agreement
or required by law.
 
b. MCPs shall use appropriate safeguards to prevent unauthorized use or
disclosure of PHI.
 
c. MCPs shall report to ODJFS any unauthorized use or disclosure of PHI of which
it becomes aware. Any breach by the MCP or its representatives of protected
health information (PHI) standards shall be immediately reported to the State
HIPAA Compliance Officer through the Bureau of Managed Health Care. MCPs must
provide documentation of the breach and complete all actions ordered by the
HIPAA Compliance Officer.
 
d. MCPs shall ensure that all its agents and subcontractors agree to these same
PHI conditions and restrictions.
 
e. MCPs shall make PHI available for access as required by law.
 
f. MCP shall make PHI available for amendment, and incorporate amendments as
appropriate as required by law.
 
g. MCPs shall make PHI disclosure information available for accounting as
required by law.
 
h. MCPs shall make its internal PHI practices, books and records available to
the Secretary of Health and Human Services (HHS) to determine compliance.
 
i. Upon termination of their agreement with ODJFS, the MCPs, at ODJFS' option,
shall return to ODJFS, or destroy, all PHI in its possession, and keep no copies
of the information, except as requested by ODJFS or required by law.
 
j. ODJFS will propose termination of the MCP's provider agreement if ODJFS
determines that the MCP has violated a material breach under this section of the
agreement, unless inconsistent with statutory obligations of ODJFS or the MCP.
 
Appendix C
Page 10

 
28. Electronic Communications - MCPs are required to purchase/utilize Transport
Layer Security (TLS) for all e-mail communication between ODJFS and the MCP. The
MCP's e-mail gateway must be able to support the sending and receiving of e-mail
using Transport Layer Security (TLS) and the MCP's gateway must be able to
enforce the sending and receiving of email via TLS.
 
29. MCP Membership acceptance, documentation and reconciliation
 
a. Selection Services Contractor: The MCP shall provide to the selection
services contractor (SSC) ODJFS prior-approved MCP materials and directories for
distribution to eligible individuals who request additional information about
the MCP.
 
b. Monthly Reconciliation of Membership and Premiums:  The MCP shall reconcile
member data as reported on the SSC-produced consumer contact record (CCR) with
the ODJFS-produced monthly member roster (MMR) and report to the ODJFS any
difficulties in interpreting or reconciling information received. Membership
reconciliation questions must be identified and reported to the ODJFS prior to
the first of the month to assure that no member is left without coverage. The
MCP shall reconcile membership with premium payments reported on the monthly
remittance advice (RA).
 
The MCP shall work directly with the ODJFS, or other ODJFS-identified entity, to
resolve any difficulties in interpreting or reconciling premium information.
Premium reconciliation questions must be identified within thirty (30)days of
receipt of the RA.
 
c. Monthly Premiums: The MCP must be able to receive monthly premiums in a
method specified by ODJFS. (ODJFS monthly prospective premium issue dates are
provided in advance to the MCPs.) Various retroactive premium payments and
recovery of premiums paid (e.g., retroactive terminations of membership,
deferments, etc.,) may occur via any ODJFS weekly remittance.
 
d. Hospital Deferment Requests: When the MCP learns of a new member's
hospitalization that is eligible for deferment prior to that member's discharge,
the MCP shall notify the hospital and treating providers of the potential that
the MCP may not be the payer. The MCP shall work with hospitals, providers and
ODJFS to assure that discharge planning assures continuity of care and accurate
payment. Notwithstanding the MCP's right to request a hospital deferment up to
six (6) months following the member's effective date, when the MCP learns of a
 

Appendix C
Page 11

deferment-eligible hospitalization, the MCP shall make every effort to notify
ODJFS and request the deferment as soon as possible. When the MCP is notified by
ODJFS of a potential hospital deferment, the MCP must make every effort to
respond to ODJFS within ten (10) business days of the receipt of the deferment
information.
 
e. Just Cause Requests: The MCP shall follow procedures as specified by ODJFS in
assisting the ODJFS in resolving member requests for member-initiated requests
affecting membership.
 
f. Eligible Individuals: If an eligible individual contacts the MCP, the MCP
must provide any MCP-specific managed care program information requested. The
MCP must not attempt to assess the eligible individual's health care needs.
However, if the eligible individual inquires about continuing/transitioning
health care services, MCPs shall provide an assurance that all MCPs must cover
all medically necessary Medicaid-covered health care services and assist members
with transitioning their health care services.
 
g. Pending Member If a pending member (i.e., an eligible individual subsequent
to plan selection but prior to their membership effective date) contacts the
selected MCP, the MCP must provide any membership information requested,
including but not limited to, assistance in determining whether the current
medications require prior authorization. The MCP must also ensure that any care
coordination (e.g., PCP selection, transition of services) information provided
by the pending member is logged in the MCP's system and forwarded to the
appropriate MCP staff for processing as required. MCPs may confirm any
information provided on the CCR at this time. Such communication does not
constitute confirmation of membership. MCPs are prohibited from initiating
contact with a pending member.
 
h. Transition of Fee-For-Service Members Providing care coordination, access to
preventive and specialized care, case management, member services, and education
with minimal disruption to members' established relationships with providers and
existing care treatment plans is critical for members transitioning from
Medicaid fee-for-service to managed care. MCPs must:
 
i. Develop a transition plan that outlines how the MCP will effectively address
the unique care coordination issues for members in their first three months of
MCP membership that includes at a minimum:

Appendix C
Page 12
 
ii. An effective outreach process to identify each new member's existing and/or
potential health care needs that results in a new member profile that includes,
but is not limited to identification of:
 
a. Health care needs, including those services received through state
sub-recipient agencies [e.g., the Ohio Department of Mental Health (ODMH), the
Ohio Department of Mental Retardation and Developmental Disabilities (ODMR/DD),
and the Ohio Department of Alcohol and Drug Addiction Services (ODADAS);
 
b. Existing sources of care (i.e., primary physicians, specialists, case
manager(s), ancillary and other care givers); and
 
c. Current care therapies for all aspects of health care services, including
scheduled health care appointments, planned and/or approved surgeries (inpatient
or outpatient), ancillary or medical therapies, prescribed drugs, approved home
health care, scheduled lab/radiology tests, necessary/approved durable medical
equipment, supplies and needed/approved transportation arrangements.
 
iii. Strategies for how each new member will obtain care therapies from
appropriate sources of care as an MCP member including reported scheduled health
services as described in Section 28.i.(ii-iv) of this Appendix.
 
iv. Allow their new members that are transitioning from Medicaid fee-for-service
to receive services from out-of-panel providers if the members contact the MCP
to discuss the scheduled health services in advance of the service date and one
of the following applies:
 
a. The member has appointments within the initial three months of the MCP
membership with a primary physician or specialty physicians that were scheduled
prior to the effective date of the MCP membership;
 
b. The member has been approved to receive an organ, bone marrow, or
hematapoietic stem cell transplant pursuant to OAC rule 5101:3-2-07.1;
 
Appendix C
Page 13

c. The member is in her third trimester of pregnancy and has an established
relationship with an obstetrician and/or delivery hospital;
 
d. The member has been scheduled for an inpatient/outpatient surgery and has
been prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40
(surgical procedures would also include follow-up care as appropriate);
 
e. The member is receiving ongoing chemotherapy or radiation treatment;
 
f. The member has been released from the hospital within the last thirty (30)
days and is following a treatment plan;
 
g. The member has been pre-certified to receive durable medical equipment (DME)
which has not yet been received.
 
v. Reimburse out-of-panel providers that agree to provide the transition
services identified in section 28.i.section ii at 100% of the current Medicaid
fee-for-service provider rate for the service(s).
 
vi. Document the provision of transition services as follows:
 
a. As expeditiously as the situation warrants, contact the provider's offices
via telephone to confirm that the service(s) meets the above criteria.
 
b. For services that meet the above criteria, inform the provider that the MCP
is sending a form for signature to document that they accept/do not accept the
terms for the provision of the services and copy the member on the form.
 
c. If the provider agrees to the terms, notify the member and provider of the
MCP's authorization and ensure that the MCP's claims processing system will not
deny the claim payment because the provider is out-of-panel. MCPs must include
their non-contracting provider materials as outlined in Appendix G.4.e with the
provider notice.
 
d. If the provider does not agree to the terms, notify the member and assist the
member with locating a provider as expeditiously as the member's condition
warrants.

Appendix C
Page 14
 
e. Use the ODJFS-specified model language for the provider and member notices.
 
f. Maintain documentation of all member and/or provider contacts relating to
such out-of-panel services, including but not limited to telephone calls and
letters.
 
vii. Not require prior-authorization of any prescription drug that does not
require prior authorization by Medicaid fee-for-service for the initial three
months of a member's MCP membership. Additionally, all atypical anti-psychotic
drugs, that do not require prior authorization by Medicaid fee-for-service, must
be exempted from prior authorization requirements for all MCP ABD members
through December 2007, after which time ODJFS will re-evaluate the continuation
of this pharmacy utilization strategy.
 
30. Health Information System Requirements
The ability to develop and maintain information management systems capacity is
crucial to successful plan performance. ODJFS therefore requires MCPs to
demonstrate their ongoing capacity in this area by meeting several related
specifications.
 
a. Health Information System
 
i. As required by 42 CFR 438.242(a), each MCP must maintain a health information
system that collects, analyzes, integrates, and reports data. The system must
provide information on areas including, but not limited to, utilization,
grievances and appeals, and MCP membership terminations for other than loss of
Medicaid eligibility.
 
ii. As required by 42 CFR 438.242(b)(l), each MCP must collect data on member
and provider characteristics and on services furnished to its members.
 
iii. As required by 42 CFR 438.242(b)(2), each MCP must ensure that data
received from providers is accurate and complete by verifying the accuracy and
timeliness of reported data; screening the data for completeness, logic, and
consistency; and collecting service information in standardized formats to the
extent feasible and appropriate.
 
Appendix C
Page 15
 
iv. As required by 42 CFR 438.242(b)(3), each MCP must make all collected data
available upon request by ODJFS or the Center for Medicare and Medicaid Services
(CMS).
 
v. Acceptance testing of any data that is electronically submitted to ODJFS is
required:
 
a. Before an MCP may submit production files
b. Whenever an MCP changes the method or preparer of the electronic media;
and/or

c. When the ODJFS determines an MCP's data submissions have an unacceptably high
error rate.
 
MCPs that change or modify information systems that are involved in producing
any type of electronically submitted files, either internally or by changing
vendors, are required to submit to ODJFS for review and approval a transition
plan including the submission of test files in the ODJFS-specified formats. Once
an acceptable test file is submitted to ODJFS, as determined solely by ODJFS,
the MCP can return to submitting production files. ODJFS will inform MCPs in
writing when a test file is acceptable. Once an MCP's new or modified
information system is operational, that MCP will have up to ninety (90) days to
submit an acceptable test file and an acceptable production file.
 
Submission of test files can start before the new or modified information system
is in production. ODJFS reserves the right to verify any MCP's capability to
report elements in the minimum data set prior to executing the provider
agreement for the next contract period. Penalties for noncompliance with this
requirement are specified in Appendix N, Compliance Assessment System of the
Provider Agreement.

b. Electronic Data Interchange and Claims Adjudication Requirements
 
Claims Adjudication
 
The MCP must have the capacity to electronically accept and adjudicate all
claims to final status (payment or denial). Information on claims submission
procedures must be provided to non-contracting providers within thirty (30) days
of a request. MCPs must inform providers of its ability to electronically
process and adjudicate claims and the process for submission. Such information
must be initiated by the MCP and not only in response to provider requests.
 
The MCP must notify providers who have submitted claims of claims status [paid,
denied, pended (suspended)] within one month of receipt. Such notification may
be in the form of a claim payment/remittance advice produced on a routine
monthly, or more frequent, basis.
 
Appendix C
Page 16

Electronic Data Interchange
The MCP shall comply with all applicable provisions of HIPAA including
electronic data interchange (EDI) standards for code sets and the following
electronic transactions:
Health care claims;
Health care claim status request and response;
Health care payment and remittance status; and Standard code sets.
 
Each EDI transaction processed by the MCP shall be implemented in conformance
with the appropriate version of the transaction implementation guide, as
specified by applicable federal rule or regulation.
 
The MCP must have the capacity to accept the following transactions from the
Ohio Department of Job and Family services consistent with EDI processing
specifications in the transaction implementation guides and in conformance with
the 820 and 834 Transaction Companion Guides issued by ODJFS:
 
ASC XI 2 820 - Payroll Deducted and Other Group Premium Payment for Insurance
Products; and
 
ASC X12 834 - Benefit Enrollment and Maintenance.
 
The MCP shall comply with the HIPAA mandated EDI transaction standards and code
sets no later than the required compliance dates as set forth in the federal
regulations.
 
Documentation of Compliance with Mandated EDI Standards The capacity of the MCP
and/or applicable trading partners and business associates to electronically
conduct claims processing and related transactions in compliance with standards
and effective dates mandated by HIPAA must be demonstrated, to the satisfaction
of ODJFS, as outlined below.
 
Verification of Compliance with HIPAA (Health Insurance Portability and
Accountability Act of 1995)
 
MCPs shall submit written verification to ODJES for transaction standards and
 
Appendix C
Page 17

code sets specified in 45 CFR Part 162 - Health Insurance Reform: Standards for
Electronic Transactions (HIPAA regulations), that the MCP has established the
capability of sending and receiving applicable transactions in compliance with
the HIPAA regulations. The written verification shall specify the date that the
MCP has: 1) achieved capability for sending and/or receiving the following
transactions, 2) entered into the appropriate trading partner agreements, and 3)
implemented standard code sets. If the MCP has obtained third-party
certification of HIPAA compliance for any of the items listed below, that
certification may be submitted in lieu of the MCP's written verification for the
applicable item(s).
 
i. Trading Partner Agreements
ii. Code Sets
iii. Transactions

a. Health Care Claims or Equivalent Encounter Information (ASC X12N 837 &NCPDP
5.1) b. Eligibility for a Health Plan (ASC X12N 270/271)
c. Referral Certification and Authorization (ASC X12N 278)
d. Health Care Claim Status (ASC X 12N 276/277)
e. Enrollment and Disenrollment in a Health Plan (ASC X12N 834) f. Health Care
Payment and Remittance Advice (ASC X12N 835)
g. Health Plan Premium Payments (ASC X12N 820)
h. Coordination of Benefits
 
Trading Partner Agreement with ODJFS
MCPs must complete and submit an EDI trading partner agreement in a format
specified by the ODJFS. Submission of the copy of the trading partner agreement
prior to entering into this Agreement may be waived at the discretion of ODJFS;
if submission prior to entering into the Agreement is waived, the trading
partner agreement must be submitted at a subsequent date determined by ODJFS.
 
Noncompliance with the EDI and claims adjudication requirements will result in
the imposition of penalties, as outlined in Appendix N, Compliance Assessment
System, of the Provider Agreement.
 
c. Encounter Data Submission Requirements
 
General Requirements
Each MCP must collect data on services furnished to members through an encounter
data system and must report encounter data to the ODJFS. MCPs are required to
submit this data electronically to ODJFS on a monthly basis in the following
standard formats:

Appendix C
Page 18
 
• Institutional Claims - UB92 flat file
• Noninstitutional Claims - National standard format
• Prescription Drug Claims - NCPDP
 
ODJFS relies heavily on encounter data for monitoring MCP performance. The ODJFS
uses encounter data to measure clinical performance, conduct access and
utilization reviews, reimburse MCPs for newborn deliveries and aid in setting
MCP capitation rates. For these reasons, it is important that encounter data is
timely, accurate, and complete. Data quality, performance measures and standards
are described in the Agreement.
 
An encounter represents all of the services, including medical supplies and
medications, provided to a member of the MCP by a particular provider,
regardless of the payment arrangement between the MCP and the provider. (For
example, if a member had an emergency department visit and was examined by a
physician, this would constitute two encounters, one related to the hospital
provider and one related to the physician provider. However, for the purposes of
calculating a utilization measure, this would be counted as a single emergency
department visit. If a member visits their PCP and the PCP examines the member
and has laboratory procedures done within the office, then this is one encounter
between the member and their PCP.)
 
If the PCP sends the member to a lab to have procedures performed, then this is
two encounters; one with the PCP and another with the lab. For pharmacy
encounters, each prescription filled is a separate encounter.
 
Encounters include services paid for retrospectively, through fee-for-service
payment arrangements, and prospectively. through capitated arrangements. Only
encounters with services (line items) that are paid by the MCP, fully or in
part, and for which no further payment is anticipated, are acceptable encounter
data submissions.
 
All other services that are unpaid or paid in part and for which the MCP
anticipates further payment (e.g., unpaid services rendered during a delivery of
a new-born) may not be submitted to ODJFS until they are paid. Penalties for
noncompliance with this requirement are specified in Appendix N, Compliance
Assessment System of the Agreement.
 
Acceptance Testing
The MCP must have the capability to report all elements in the Minimum Data Set
as set forth in the ODJFS Encounter Data Specifications and must submit a

Appendix C
Page 19

test file in the ODJFS-specified medium in the required formats prior to
contracting or prior to an information systems replacement or update.
 
Acceptance testing of encounter data is required as specified in Section
29(a)(v) of this Appendix.
 
Encounter Data File Submission Procedures
A certification letter must accompany the submission of an encounter data file
in the ODJFS-specified medium. The certification letter must be signed by the
MCP's Chief Executive Officer (CEO), Chief Financial Officer (CFO), or an
individual who has delegated authority to sign for, and who reports directly to,
the MCP's CEO or CFO.
 
No more than two production files in the ODJFS-specified medium per format
(e.g., NSF) should be submitted each month. If it is necessary for an MCP to
submit more than two production files in the ODJFS-specified medium for a
particular format in a month, they must request and receive permission to do so
from their designated Contract Administrator.
 
Timing of Encounter Data Submissions
ODJFS recommends that MCPs submit encounters no more than thirty-five (35) days
after the end of the month in which they were paid. (For example, claims paid in
January are due March 5.) ODJFS recommends that MCPs submit files in the
ODJFS-specified medium by the 5th of each month. This will help to ensure that
the encounters are included in the ODJFS master file in the same month in which
they were submitted.
 
d. Information Systems Review
 
Every two (2) years, and before ODJFS enters into a provider agreement with a
new MCP, ODJFS or designee may review the information system capabilities of
each MCP. Each MCP must participate in the review, except as specified below.
The review will assess the extent to which MCPs are capable of maintaining a
health information system including producing valid encounter data, performance
measures, and other data necessary to support quality assessment and
improvement, as well as managing the care delivered to its members.
 
The following activities, at a minimum, will be carried out during the review.
ODJFS or its designee will:
 
i. Review the Information Systems Capabilities Assessment (ISCA) forms, as
developed by CMS; which the MCP will be required to complete.

Appendix C
Page 20

ii. Review the completed ISCA and accompanying documents;
 
iii. Conduct interviews with MCP staff responsible for completing the ISCA, as
well as staff responsible for aspects of the MCP's information systems function;
 
iv. Analyze the information obtained through the ISCA, conduct follow-up
interviews with MCP staff, and write a statement of findings about the MCP's
information system.
 
v. Assess the ability of the MCP to link data from multiple sources;
 
vi. Examine MCP processes for data transfers;
 
vii. If an MCP has a data warehouse, evaluate its structure and reporting
capabilities;
 
viii. Review MCP processes, documentation, and data files to ensure that they
comply with state specifications for encounter data submissions; and
 
ix. Assess the claims adjudication process and capabilities of the MCP.
 
As noted above, the information system review may be performed every two years.
However, if ODJFS or its designee identifies significant information system
problems, then ODJFS or its designee may conduct, and the MCP must participate
in, a review the following year, or in such a timeframe as ODJFS, in their sole
discretion, deems appropriate to ensure accuracy and efficiency of the MCP
health information system.
 
If an MCP had an assessment performed of its information system through a
private sector accreditation body or other independent entity within the two
years preceding the time when ODJFS or its designee will be conducting its
review, and has not made significant changes to its information system since
that time, and the information gathered is the same as or consistent with the
ODJFS or its designee's proposed review, as determined by the ODJFS, then the
MCP will not required to undergo the IS review. The MCP must provide ODJFS or
its designee with a copy of the review that was performed so that ODJFS can
determine whether or not the MCP will be required to participate in the IS
review. MCPs who are determined to be exempt from the IS review must participate
in subsequent information system reviews, as determined by ODJFS.
 
Appendix C
Page 21
 
31. If the MCP will be using the Internet functions that will allow approved
users to access member information (e.g., eligibility verification), the MCP
must receive prior written approval from ODJFS that verifies that the proper
safeguards, firewalls, etc., are in place to protect member data.
 
32. MCPs must receive prior written approval from ODJFS before adding any
information to their website that would require ODJFS prior approval in hard
copy form (e.g., provider listings, member handbook information).
 
33. Pursuant to 42 CFR 438.106(b), the MCP acknowledges that it is prohibited
from holding a member liable for services provided to the member in the event
that the ODJFS fails to make payment to the MCP.
 
34. In the event of an insolvency of an MCP, the MCP, as directed by ODJFS, must
cover the continued provision of services to members until the end of the month
in which insolvency has occurred, as well as the continued provision of
inpatient services until the date of discharge for a member who is
institutionalized when insolvency occurs.
 
35. Franchise Fee Assessment Requirements
 
a. Each MCP is required to pay a franchise permit fee to ODJFS for each calendar
quarter as required by ORC Section 5111.176. The current fee to be paid is an
amount equal to 4'/2 percent of the managed care premiums, minus Medicare
premiums that the MCP received from any payer in the quarter to which the fee
applies. Any premiums the MCP returned or refunded to members or premium payers
during that quarter are excluded from the fee.
 
b. The franchise fee is due to ODJFS in the ODJFS-specified format on or before
the 30th day following the end of the calendar quarter to which the fee applies.
 
c. At the time the fee is submitted, the MCP must also submit to ODJFS a
completed form and any supporting documentation pursuant to ODJFS
specifications.
 
d. Penalties for noncompliance with this requirement are specified in Appendix
N, Compliance Assessment System of the Provider Agreement and in ORC Section
5111.176.
 
36. Information Required for MCP Websites
 
a. On-line Provider Directory - MCPs must have an internet-based provider
directory available in the same format as their ODJFS-approved provider

Appendix C
Page 22

directory, that allows members to electronically search for the MCP panel
providers based on name, provider type, geographic proximity, and population (as
specified in Appendix H). MCP provider directories must include all
MCP-contracted providers [except as specified by ODJFS] as well as certain ODJFS
non-contracted providers.
 
b. On-line Member Website - MCPs must have a secure internet-based website
which is regularly updated to include the most current ODJFS approved materials.
The website at a minimum must include: (1) a list of the counties that are
covered in their service area; (2) the ODJFS-approved MCP member handbook,
recent newsletters/announcements, MCP contact information including member
services hours and closures; (3) the MCP provider directory as referenced in
section 36(a) of this appendix; (4) the MCP's current preferred drug list (PDL),
including an explanation of the list, which drugs require prior authorization
(PA), and the PA process; (5) the MCP's current list of drugs covered only with
PA, the PA process, and the MCP's policy for covering generic for brand-name
drugs; and (6) the ability for members to submit
questions/comments/grievances/appeals/etc, and receive a response (members must
be given the option of a return e-mail or phone call). Responses regarding
questions or comments are expected within one working day of receipt, whereas
responses regarding grievances and appeals must be within the timeframes
specified in OAC rule 5101:3-26-08.4. MCPs must ensure that all member materials
designated specifically for CFC and/or ABD consumers (i.e. the MCP member
handbook) are clearly labeled as such. The MCP's member website cannot be used
as the only means to notify members of new and/or revised MCP information (e.g.,
change in holiday closures, change in additional benefits, revisions to approved
member materials etc.). ODJFS may require MCPs to include additional information
on the member website, as needed.
 
c. On-line Provider Website - MCPs must have a secure internet-based website for
providers where they will be able to confirm a consumer's MCP enrollment and
through this website (or through e-mail process) allow providers to
electronically submit and receive responses to prior authorization requests.
This website must also include: (1) a list of the counties that are covered in
their service area; (2) the MCP's provider iTianual.;(3) MCP contact
information; (4) a link to the MCP's on-line provider directory as referenced in
section 36(a) of this appendix; (5) the MCP's current PDL list, including an
explanation of the list, which drugs require PA, and the PA process; and (6) the
MCP's current list of drugs covered only with PA, the PA process, and the MCP's
policy for covering generic for brand-name drugs. MCPs must ensure that all
provider materials designated specifically for CFC and/or ABD consumers (i.e.
The MCP's provider manual) are clearly labeled as such. ODJFS may require MCPs
to include additional information on the provider website, as needed.

Appendix C
Page 23
 
37. MCPs must provide members with a printed version of their PDL and PA lists,
upon request.
 
38. MCPs must not use, or propose to use , any offshore programming or call
center services in fulfilling the program requirements.
 
39. PCP Feedback - The MCP must have the administrative capacity to offer
feedback to individual providers on their: 1) adherence to evidence-based
practice guidelines; and 2) positive and negative care variances from standard
clinical pathways that may impact outcomes or costs. In addition, the feedback
information may be used by the MCP for activities such as physician performance
improvement projects that include incentive programs or the development of
quality improvement programs.