Contractor Request. The Contractor must comply with Section 1.5.1: “Non-Discrimination” of this Contract and seek to disenroll a Dental Health Plan Enrollee only for good cause. The following actions, if found by OHCA, comprise good cause: • Dental Health Plan Enrollee has been enrolled in error, as determined by OHCA; • Dental Health Plan Enrollee has exhibited disruptive behaviors to the extent that the Contractor cannot effectively manage their care, and the Contractor has made all reasonable efforts to accommodate the Dental Health Plan Enrollee; or • Dental Health Plan Enrollee has committed Fraud, including but not limited to, loaning an ID card for use by another person. The Contractor must make a written request to OHCA for Dental Health Plan Enrollee Disenrollment, in a format to be specified by OHCA. The Contractor’s request for disenrollment must document that reasonable steps were taken to educate the Dental Health Plan Enrollee regarding proper behavior and that the Dental Health Plan Enrollee refused to comply, if applicable. The Contractor also must communicate its request to the Dental Health Plan Enrollee in writing, in a format to be specified by OHCA. OHCA shall have sole authority to grant or deny the Disenrollment request. Dental Health Plan Enrollees shall be permitted to disenroll from the Contractor without cause, in accordance with the provisions of Section 1.5.4: “Enrollment Lock-In Period” of this Contract. During the lock-in period, Dental Health Plan Enrollees may be disenrolled for cause, at any time, in accordance with 42 C.F.R. § 438.56(d) and under the following conditions: • The Dental Health Plan Enrollee moves out of the Contractor’s service area; • Dental Health Plan Enrollee seeks covered benefits that the Contractor does not cover for moral or religious reasons; • Dental Health Plan Enrollee needs related services to be performed at the same time; not all related services are available within the Contractor’s network; and the Dental Health Plan Enrollee’s PCD Provider or another Provider determines that receiving the services separately would subject the Dental Health Plan Enrollee to unnecessary risk; • Dental Health Plan Enrollee has filed and prevailed in a Grievance regarding poor quality of care, lack of access to services covered under the Contract or lack of access to Providers experienced in dealing with the Dental Health Plan Enrollee's oral health care needs or other matters deemed sufficient to warrant Disenrollment; or • Dental Health Plan Enrollee has been enrolled in error, as determined by OHCA. Dental Health Plan Enrollees shall seek redress through the Contractor’s Grievance process before OHCA will make a determination on a Dental Health Plan Enrollee’s request for Disenrollment. The Contractor shall accept Dental Health Plan Enrollee requests for Disenrollment orally or in writing. The Contractor shall complete a review of the request within ten days of the Dental Health Plan Enrollee filing the Grievance. If the Dental Health Plan Enrollee remains dissatisfied with the result of the Grievance process, the Contractor shall refer the Disenrollment request to OHCA. The Contractor shall send records gathered during the Grievance process to OHCA to facilitate OHCA’s decision-making process. Disenrollment requests will be adjudicated by OHCA and, if approved, will become effective on a date established by OHCA consistent with Section ▇.▇.▇.▇: “Disenrollment Effective Date" of this Contract. OHCA will initiate Disenrollment of Dental Health Plan Enrollees under the following circumstances: • Loss of eligibility for Medicaid; • Transition to a SoonerCare eligibility group excluded from the SoonerSelect Dental program; • Dental Health Plan Enrollee becomes enrolled in Medicare; • Death; • Dental Health Plan Enrollee becomes an inmate of a public institution; • Dental Health Plan Enrollee commits Fraud or provides fraudulent information; or • Disenrollment is ordered by a hearing officer or court of law. Consistent with 42 C.F.R. § 438.56(e), except as provided for below, and unless OHCA determines that a delay would have an adverse effect on a Dental Health Plan Enrollee’s health, it is OHCA’s intent that a Disenrollment shall be effective on the first day of the second following month. Grievance resolution for poor quality of care, lack of access to services covered under the Contract or lack of access to Providers experienced in dealing with the Dental Health Plan Enrollee's oral health care needs or other matters deemed sufficient to warrant Disenrollment under Section ▇.▇.▇.▇: “Dental Health Plan Enrollee Request” of this Contract must be completed within this timeframe. If the Contractor fails to complete the Grievance process in time to permit Disenrollment by OHCA, the Disenrollment shall be considered approved for the effective date that would have been established had the Contractor complied with this timeframe. Disenrollments for any of the following reasons shall be effective as of the date that the Dental Health Plan Enrollee’s SoonerSelect Dental Program eligibility status changes: • Loss of eligibility for Medicaid; • Transition to a SoonerCare eligibility group excluded from the SoonerSelect Dental Program; • Dental Health Plan Enrollee becomes eligible for Medicare; • Death; • Dental Health Plan Enrollee becomes an inmate of a public institution; • Dental Health Plan Enrollee commits Fraud or provides fraudulent information; or • Disenrollment is ordered by a hearing officer or court of law. Dental Health Plan Enrollees requiring long-term care in a nursing facility or ICF-IID shall be disenrolled from the Contractor when the level of care determination being done by the medical MCO is complete. Notwithstanding the foregoing, the effective date of Disenrollment from the Contractor shall be the date recorded on the outbound ANSI ASC X 12 834 electronic transaction sent by OHCA.
Appears in 1 contract
Sources: Healthcare Agreement
Contractor Request. The Contractor must comply with Section 1.5.1: “Non-Discrimination” of this Contract and seek to disenroll a Dental Health Plan Enrollee only for good cause. The following actions, if found by OHCA, comprise good cause: • Dental Health Plan Enrollee has been enrolled in error, as determined by OHCA; • Dental Health Plan Enrollee has exhibited disruptive behaviors to the extent that the Contractor cannot effectively manage their care, and the Contractor has made all reasonable efforts to accommodate the Dental Health Plan Enrollee; or • Dental Health Plan Enrollee has committed Fraud, including but not limited to, loaning an ID card for use by another person. The Contractor must make a written request to OHCA for Dental Health Plan Enrollee Disenrollment, in a format to be specified by OHCA. The Contractor’s request for disenrollment must document that reasonable steps were taken to educate the Dental Health Plan Enrollee regarding proper behavior and that the Dental Health Plan Enrollee refused to comply, if applicable. The Contractor also must communicate its request to the Dental Health Plan Enrollee in writing, in a format to be specified by OHCA. OHCA shall have sole authority to grant or deny the Disenrollment request. Dental Health Plan Enrollees shall be permitted to disenroll from the Contractor without cause, in accordance with the provisions of Section 1.5.4: “Enrollment Lock-In Period” of this Contract. During the lock-in period, Dental Health Plan Enrollees may be disenrolled for cause, at any time, in accordance with 42 C.F.R. § 438.56(d) and under the following conditions: • The Dental Health Plan Enrollee moves out of the Contractor’s service area; • Dental Health Plan Enrollee seeks covered benefits that the Contractor does not cover for moral or religious reasons; • Dental Health Plan Enrollee needs related services to be performed at the same time; not all related services are available within the Contractor’s network; and the Dental Health Plan Enrollee’s PCD Provider or another Provider determines that receiving the services separately would subject the Dental Health Plan Enrollee to unnecessary risk; • Dental Health Plan Enrollee has filed and prevailed in a Grievance regarding poor quality of care, lack of access to services covered under the Contract or lack of access to Providers experienced in dealing with the Dental Health Plan Enrollee's oral health care needs or other matters deemed sufficient to warrant Disenrollment; or • Dental Health Plan Enrollee has been enrolled in error, as determined by OHCA. Dental Health Plan Enrollees shall seek redress through the Contractor’s Grievance process before OHCA will make a determination on a Dental Health Plan Enrollee’s request for Disenrollment. The Contractor shall accept Dental Health Plan Enrollee requests for Disenrollment orally or in writing. The Contractor shall complete a review of the request within ten days of the Dental Health Plan Enrollee filing the Grievance. If the Dental Health Plan Enrollee remains dissatisfied with the result of the Grievance process, the Contractor shall refer the Disenrollment request to OHCA. The Contractor shall send records gathered during the Grievance process to OHCA to facilitate OHCA’s decision-making process. Disenrollment requests will be adjudicated by OHCA and, if approved, will become effective on a date established by OHCA consistent with Section ▇.▇.▇.▇: “Disenrollment Effective Date" of this Contract. A t OHCA’s Initiation OHCA will initiate Disenrollment of Dental Health Plan Enrollees under the following circumstances: • Loss of eligibility for Medicaid; • Transition to a SoonerCare eligibility group excluded from the SoonerSelect Dental program; • Dental Health Plan Enrollee becomes enrolled in Medicare; • Death; • Dental Health Plan Enrollee becomes an inmate of a public institution; • Dental Health Plan Enrollee commits Fraud or provides fraudulent information; or • Disenrollment is ordered by a hearing officer or court of law. Consistent with 42 C.F.R. § 438.56(e), except as provided for below, and unless OHCA determines that a delay would have an adverse effect on a Dental Health Plan Enrollee’s health, it is OHCA’s intent that a Disenrollment shall be effective on the first day of the second following month. Grievance resolution for poor quality of care, lack of access to services covered under the Contract or lack of access to Providers experienced in dealing with the Dental Health Plan Enrollee's oral health care needs or other matters deemed sufficient to warrant Disenrollment under Section ▇.▇.▇.▇: “Dental Health Plan Enrollee Request” of this Contract must be completed within this timeframe. If the Contractor fails to complete the Grievance process in time to permit Disenrollment by OHCA, the Disenrollment shall be considered approved for the effective date that would have been established had the Contractor complied with this timeframe. Disenrollments for any of the following reasons shall be effective as of the date that the Dental Health Plan Enrollee’s SoonerSelect Dental Program eligibility status changes: • Loss of eligibility for Medicaid; • Transition to a SoonerCare eligibility group excluded from the SoonerSelect Dental Program; • Dental Health Plan Enrollee becomes eligible for Medicare; • Death; • Dental Health Plan Enrollee becomes an inmate of a public institution; • Dental Health Plan Enrollee commits Fraud or provides fraudulent information; or • Disenrollment is ordered by a hearing officer or court of law. Dental Health Plan Enrollees requiring long-term care in a nursing facility or ICF-IID shall be disenrolled from the Contractor when the level of care determination being done by the medical MCO is complete. Notwithstanding the foregoing, the effective date of Disenrollment from the Contractor shall be the date recorded on the outbound ANSI ASC X 12 834 electronic transaction sent by OHCA.
Appears in 1 contract
Sources: Contract