Provider Network Requirements. 1. Network Development, monitoring and maintenance a. Contractor shall establish and maintain a community-based governing or advisory board for local decision-making and input into service delivery and network development. b. The Contractor shall establish, maintain and monitor a provider network that is capable of delivering a full continuum of treatment, rehabilitative and supportive services for children and adults. The continuum of care may be provided directly or through contractual arrangements with qualified providers (Subcontracted Providers). The Contractor shall provide technical assistance to its providers regarding Covered Services, encounter submission and documentation requirements on an as needed basis. c. The Contractor’s network must meet the Minimum Network Standards and Staff Inventory requirements established by CPSA. Contractor must submit quarterly reports documenting these minimum standards in the format prescribed by CPSA and on the time schedule enunciated in Schedule III, Subcontract Deliverables. d. The Contractor’s network must be sufficient to ensure that: i. Capacity to serve eligible and enrolled persons of non-dominant culture and ethnicity is demonstrated; ii. Unnecessary use of emergency departments and urgent care centers is reduced; iii. Use of jail and detention centers is reduced; iv. Covered Services, including emergency care, are provided promptly and are reasonably accessible in terms of location and hours of operation and are delivered in compliance with ADHS/DBHS/CPSA Provider Manual, Section 3.2, Appointment Standards and Timeliness of Service. v. Children with special health care needs have adequate access to behavioral health practitioners with experience in treating the child’s diagnosed condition. e. The Contractor’s network must include intake sites and capacity adequate to ensure the following: i. Scheduled hours for intake appointments must ensure accessibility and ease of entry into the behavioral health system. ii. All service sites must be staffed adequately to complete SMI determinations within time frames established by ADHS/DBHS/CPSA Provider Manual Section 3.10, SMI Eligibility Determination. iii. Financial assessments must be conducted at each intake site by a staff person trained in financial screening and dedicated to the completion of applications for public benefits according to ADHS/DBHS/CPSA Provider Manual, Section 3.1, Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program. Staff must be capable of informing potential members and family members about required documents needed to prove citizenship for Title XIX/XXI eligibility and assist them in obtaining such documents. iv. At intake, written materials will be provided to the Member to include at a minimum: Member Handbook, Rights and Responsibilities of Members, name and phone number of their assigned Clinical Liaison and the procedure for reaching the Clinical Liaison in the event of an urgent or emergent need. v. Intake services are available during non-business hours (evenings and weekends) to accommodate Member’s access into the system. Intake services are also available outside the Contractor’s office, i.e. schools, homes, wellness centers. f. The Contractor’s network must be sufficient to ensure that a Clinical Liaison is assigned to each member. The Clinical Liaison is responsible for providing clinical oversight, working in collaboration with the enrolled person and his/her family or significant others to implement an effective treatment plan, and serves as the point of contact, coordination and communication with other systems where clinical knowledge of the case is important. Contractor must comply with the ADHS/DBHS/CPSA Provider Manual, Section 3.7, Clinical Liaisons. The Contractor shall maintain a roster in the CPSA Information System that identifies the Clinical Liaison and Clinical Liaison contact information for each behavioral health recipient. The Contractor shall update the roster as the Clinical Liaison changes. g. The Contractor shall recruit, evaluate and monitor providers with an appropriate combination of skills, training and experience to provide Covered Services under this Subcontract. h. The Contractor shall, and require its subcontractors to, credential and privilege providers as required in the ADHS/DBHS Provider Manual Section 3.20, Credentialing and Privileging, including processes to expedite temporary credentialing and privileging when needed to ensure the sufficiency of the network and add to specialized providers i. The Contractor shall retain providers based upon performance and quality improvement data acquired while delivering services under this subcontract. j. Contractor shall not restrict or inhibit providers in any way from communicating freely with or advocating for persons regarding: i. Behavioral health care, medical needs and treatment options, even if needed services are not covered by the Contractor or if an alternate treatment is self-administered; ii. Any information the behavioral health recipient needs in order to decide among all relevant treatment options; iii. The risks, benefits, and consequences of treatment or non-treatment; and, iv. The behavioral health recipient’s right to participate in decisions regarding his or her behavioral health care, including the right to refuse treatment, and to express preferences about future treatment decisions. k. Contractor shall provide enrolled persons choice within the provider network, subject to reasonable frequency limitations and contingent on the availability within the Contractor’s service network of an alternative that is suitable to meet the enrolled member’s needs. l. The Contractor shall not discriminate, with respect to participation in its network, against any provider based solely on the provider’s type of licensure or certification. In addition, the Contractor shall not discriminate against providers that service high-risk populations or specialize in conditions that require costly treatment. This provision, however, does not prohibit the Contractor from limiting provider participation to the extent that the Contractor is meeting the needs of those persons covered under this contract. This provision also does not interfere with measures established by the Contractor to control costs consistent with its responsibilities under this subcontract nor does it preclude the Contractor from using different reimbursement amounts for different specialists or for different practitioners in the same specialty. m. If the Contractor or its Subcontracted Provider network is unable to provide a covered service required under this Subcontract, the Contractor shall ensure timely and adequate coverage of these services through an out-of-network provider until a network provider is contracted. The Contractor shall coordinate with respect to authorization and payment under these circumstances. The Contractor shall ensure that any costs incurred by a member for services provided by an out of network provider are no greater than the costs that would be charged if services were furnished with the Network. Any agreement between the Contractor and an out of network provider must limit the charges to a member to an amount no greater than that allowed when services are furnished within the network. n. If the Contractor declines to include individuals or groups of providers in its network, it shall give the affected providers written notice of the reason for its decision. The Contractor may not include providers excluded from participation in Federal health care programs, pursuant to Section 1128 or Section 1128 A of the Social Security Act.
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Provider Network Requirements. 1. Network Development, monitoring and maintenance
a. Contractor shall establish and maintain a community-based governing or advisory board for local decision-making and input into service delivery and network development.
b. The Contractor shall establish, maintain and monitor a provider network that is capable of delivering a full continuum of treatment, rehabilitative and supportive services for children and adults. The continuum of care may be provided directly or through contractual arrangements with qualified providers (Subcontracted Providers). The Contractor shall provide technical assistance to its providers regarding Covered Services, encounter submission and documentation requirements on an as needed basis.
c. The Contractor’s network must meet the Minimum Network Standards and Staff Inventory requirements established by CPSA. Contractor must submit quarterly reports documenting these minimum standards in the format prescribed by CPSA and on the time schedule enunciated in Schedule III, Subcontract Deliverables.
d. The Contractor’s network must be sufficient to ensure that:
i. Capacity to serve eligible and enrolled persons of non-dominant culture and ethnicity is demonstrated;
ii. Unnecessary use of emergency departments and urgent care centers is reduced;
iii. Use of jail and detention centers is reduced;
iv. Covered Services, including emergency care, are provided promptly and are reasonably accessible in terms of location and hours of operation and are delivered in compliance with ADHS/DBHS/CPSA Provider Manual, Section 3.2, Appointment Standards and Timeliness of Service.
v. Children with special health care needs have adequate access to behavioral health practitioners with experience in treating the child’s diagnosed condition.
e. The Contractor’s network must include intake sites and capacity adequate to ensure the following:
i. Scheduled hours for intake appointments must ensure accessibility and ease of entry into the behavioral health system.
ii. All service sites must be staffed adequately to complete SMI determinations within time frames established by ADHS/DBHS/CPSA Provider Manual Section 3.10, SMI Eligibility Determination.
iii. Financial assessments must be conducted at each intake site by a staff person trained in financial screening and dedicated to the completion of applications for public benefits according to ADHS/DBHS/CPSA Provider Manual, Section 3.1, Accessing and Interpreting Eligibility and Enrollment Information and Screening and applying for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program. Staff must be capable of informing potential members and family members about required documents needed to prove citizenship for Title XIX/XXI eligibility and assist them in obtaining such documents.
iv. At intake, written materials will be provided to the Member to include at a minimum: Member Handbook, Rights and Responsibilities of Members, name and phone number of their assigned Clinical Liaison and the procedure for reaching the Clinical Liaison in the event of an urgent or emergent need.
v. Intake services are available during non-business hours (evenings and weekends) to accommodate Member’s access into the system. Intake services are also available outside the Contractor’s office, i.e. schools, homes, wellness centers.
f. The Contractor’s network must be sufficient to ensure that a Clinical Liaison is assigned to each member. The Clinical Liaison is responsible for providing clinical oversight, working in collaboration with the enrolled person and his/her family or significant others to implement an effective treatment plan, and serves as the point of contact, coordination and communication with other systems where clinical knowledge of the case is important. Contractor must comply with the ADHS/DBHS/CPSA Provider Manual, Section 3.7, Clinical Liaisons. The Contractor shall maintain a roster in the CPSA Information System that identifies the Clinical Liaison and Clinical Liaison contact information for each behavioral health recipient. The Contractor shall update the roster as the Clinical Liaison changes.
g. The Contractor shall recruit, evaluate and monitor providers with an appropriate combination of skills, training and experience to provide Covered Services under this Subcontract.
h. The Contractor shall, and require its subcontractors to, credential and privilege providers as required in the ADHS/DBHS Provider Manual Section 3.20, Credentialing and Privileging, including processes to expedite temporary credentialing and privileging when needed to ensure the sufficiency of the network and add to specialized providers
i. The Contractor shall retain providers based upon performance and quality improvement data acquired while delivering services under this subcontract.
j. Contractor shall not restrict or inhibit providers in any way from communicating freely with or advocating for persons regarding:
i. Behavioral health care, medical needs and treatment options, even if needed services are not covered by the Contractor or if an alternate treatment is self-administered;
ii. Any information the behavioral health recipient needs in order to decide among all relevant treatment options;
iii. The risks, benefits, and consequences of treatment or non-treatment; and,
iv. The behavioral health recipient’s right to participate in decisions regarding his or her behavioral health care, including the right to refuse treatment, and to express preferences about future treatment decisions.
k. Contractor shall provide enrolled persons choice within the provider network, subject to reasonable frequency limitations and contingent on the availability within the Contractor’s service network of an alternative that is suitable to meet the enrolled member’s needs.
l. The Contractor shall not discriminate, with respect to participation in its network, against any provider based solely on the provider’s type of licensure or certification. In addition, the Contractor shall not discriminate against providers that service high-risk populations or specialize in conditions that require costly treatment. This provision, however, does not prohibit the Contractor from limiting provider participation to the extent that the Contractor is meeting the needs of those persons covered under this contract. This provision also does not interfere with measures established by the Contractor to control costs consistent with its responsibilities under this subcontract nor does it preclude the Contractor from using different reimbursement amounts for different specialists or for different practitioners in the same specialty.
m. If the Contractor or its Subcontracted Provider network is unable to provide a covered service required under this Subcontract, the Contractor shall ensure timely and adequate coverage of these services through an out-of-network provider until a network provider is contracted. The Contractor shall coordinate with respect to authorization and payment under these circumstances. The Contractor shall ensure that any costs incurred by a member for services provided by an out of network provider are no greater than the costs that would be charged if services were furnished with the Network. Any agreement between the Contractor and an out of network provider must limit the charges to a member to an amount no greater than that allowed when services are furnished within the network.
n. If the Contractor declines to include individuals or groups of providers in its network, it shall give the affected providers written notice of the reason for its decision. The Contractor may not include providers excluded from participation in Federal health care programs, pursuant to Section 1128 or Section 1128 A of the Social Security Act.
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