Content of Provider Contracts, including any Provider Performance Incentives, in accordance with Sections 2.7.B., 2.13.D. and 6.1.H; Contractual Agreements with Community Partners, in accordance with Sections 2.5.F and 2.5.G. Enrollee Services capability (materials, processes and infrastructure, e.g., call center capabilities), in accordance with Section 2.10; Comprehensiveness of quality management/quality improvement strategies, in accordance with Section 2.13; Comprehensiveness of Utilization Management strategies, in accordance with Section 2.6.D; Internal Grievance and Appeal policies and procedures, in accordance with Section 2.12; Fraud and Abuse and program integrity, in accordance with Section 2.3.C.3.; Financial solvency, in accordance with Section 2.15; At the request of EOHHS, a walk-through of any information systems, including but not limited to enrollment, claims payment system performance, interfacing and reporting capabilities and validity testing of Encounter Data, in accordance with Section 2.14, including IT testing and security assurances. The scope of the Readiness Review will also include an assessment of the Contractor’s ability and capability to perform satisfactorily in the areas set forth in 42 CFR 438.66(d)(4). MassHealth Members shall not be enrolled into the Contractor’s Plan unless and until EOHHS determines that the Contractor is ready and able to perform its obligations under the Contract as demonstrated during the Readiness Review, except as provided below. EOHHS will identify to the Contractor all areas where the Contractor is not ready and able to meet its obligations under the Contract and may, in its discretion, allow the Contractor to propose a plan to remedy all deficiencies prior to the Contract Operational Start Date. EOHHS may, in its discretion, postpone the Contract Operational Start Date for any Contractor that fails to satisfy all Readiness Review requirements. If, for any
Education of Providers, including, but not limited to, clinically appropriate guidelines and Enrollee-specific information with respect to an Enrollee’s disease or condition, including relevant indicators; and The Care Management activities described in Section 2.5.E. Establish such affiliations with providers (including Community Service Agencies (CSAs) in the Contractor’s geographic area, as determined by EOHHS) and organizations as necessary to fulfil the requirements of this Section, including affiliations with Community Partners and other community-based organizations and social services organizations; Ensure appropriate care for Enrollees with Special Health Care Needs; Make best efforts to minimize boarding of Enrollees in emergency departments as follows: The Contractor shall ensure timely access to medically necessary, clinically appropriate behavioral health services for Enrollees determined by EOHHS to be disproportionately boarded in emergency departments, including, but not limited to, Enrollees with: Autism Spectrum Disorder (ASD); Intellectual or Developmental Disabilities (IDD); Dual diagnosis of mental health and substance use disorder; Co-morbid medical conditions; and Assaultive or combative presentation resulting in the need for special accommodation in an inpatient psychiatric hospital setting; and In accordance with Appendix A, the Contractor shall report to EOHHS on any Enrollee awaiting placement in a 24-hour level of behavioral health care who remains in an emergency department for 24 hours or longer, as further specified by EOHHS; Care Needs Screening and Appropriate Follow-Up The Contractor shall ensure that Enrollees receive screenings to identify their health and functional needs as follows: The Contractor shall develop, implement, and maintain procedures for completing an initial Care Needs Screening for each Enrollee, and shall make best efforts to complete such screening within 90 days of the Enrollee’s Effective Date of Enrollment;
Operate a toll-free telephone line for Provider inquiries during normal business hours for a minimum of eight hours per day, Monday through Friday, and have a process in place to handle after-hours inquiries from Providers seeking to verify enrollment for an Enrollee in need of Urgent or Emergency Services provided, however, that the Contractor and its Providers shall not require such verification prior to providing Emergency Services; Maintain and distribute a Provider Manual(s), which includes specific information about ACO Covered Services, Non-ACO Covered Services, and other requirements of the Contract relevant to Provider responsibilities. The Contractor shall submit an updated Provider Manual(s) to EOHHS annually and such updated Provider Manual(s) shall be distributed to Providers annually and made available to Providers on the Contractor’s website. The Provider Manual(s) shall include, but not be limited to, the following information: Enrollee rights, including those in Section 6.1.L, and the requirement that Enrollees must be allowed to exercise such rights without having their treatment adversely affected; Provider responsibilities, especially those that apply to Enrollee rights; That Enrollees may file a Grievance with the Contractor if the Provider violates any Enrollee rights and the steps the Contractor may take to address any such Grievances; Enrollee privacy matters; Provider responsibility for assisting Enrollees with interpreter services; Provider obligation to accept and treat all Enrollees regardless of race/ethnicity, age, English proficiency, sexual orientation, health status, or disability; General rules of Provider-Enrollee communications; ACO Covered Services lists; Provider obligation to make Enrollees aware of available clinical care management options and all available care options; An explanation to all Providers that in certain situations minors under the law may consent to medical procedures without parental consent; Permissible Provider Marketing activities in accordance with Section 2.11.B.;
Enrollee Services Department Maintain an Enrollee services department to assist Enrollees, Enrollees’ family members or guardians, and other interested parties in learning about and obtaining services under this Contract; Enrollee Services Department Standards Maintain employment standards and requirements (e.g. education, training, and experience) for Enrollee services department staff and provide a sufficient number of staff for the Enrollee services department; Enrollee Services Department Staff Ensure that Enrollee services department staff have access to: The Contractor’s Enrollee database; The Eligibility Verification System (EVS); and An electronic Provider directory that includes, but is not limited to, the information specified in Section 2.7.E. of this Contract; Enrollee Services Telephone Line Operate a toll-free Enrollee services telephone line a minimum of nine hours per day during normal business hours, Monday through Friday, which shall: Have at least 90% of calls answered by a trained customer service department representative (non-recorded voice), within 30 seconds or less as reported in accordance with Appendix A; Have less than a 5% abandoned call rate; Make oral interpretation services available free-of-charge to Members and Enrollees in all non-English languages spoken by Members and Enrollees; and; Maintain the availability of services, such as TTY services or comparable services for the deaf and hard of hearing; Information for Enrollees and Potential Enrollees Ensure that customer service department representatives shall, upon request, make available to Enrollees and Potential Enrollees in the Contractor’s Plan information concerning the following: The identity, locations, qualifications, and availability of Providers;
Submits contract management reports, Care Management reports, or Quality Improvement Goal reports that are either late or missing a significant amount of information or data; Fails to meet any of the standards for data submission described in this Contract, including accuracy, completeness, timeliness, and other standards for Encounter Data described in Section 2.14 and Appendix E. Sanctions for such failure are further described in Section 6.3.K.5 below; or Fails to comply with any other requirements of this Contract. Such sanctions may include, but are not limited to: Civil money penalties in accordance with 42 CFR 438.704 and Section 6.3.K.4. below; Financial measures EOHHS determines are appropriate to address the violation; The appointment of temporary management to oversee the operation of the Contractor in those circumstances set forth in 42 U.S.C. §1396u-2(e)(2)(B) and 42 CFR 438.706; Notifying the affected Enrollees of their right to disenroll; Suspension of enrollment (including assignment of Enrollees); Suspension of payment to the Contractor for Enrollees enrolled after the effective date of the sanction and until CMS or EOHHS is satisfied that the reason for imposition of the sanction no longer exists and is not likely to recur; Disenrollment of Enrollees; Limitation of the Contractor’s coverage area; Additional sanctions allowed under federal law or state statute or regulation that address areas of noncompliance; and Such other measures as EOHHS determines appropriate to address the violation. For any Contractor responsibilities for which the Contractor utilizes a Material Subcontractor, if EOHHS identifies any deficiency in the Contractor’s performance under the Contract for which the Contractor has not successfully implemented an approved corrective action plan in accordance with Section 6.3.L, EOHHS may: