Required Functions Sample Clauses

Required Functions. The Contractor shall maintain a Provider Services function that is responsible for the following services and tasks: A. Enrolling, credentialing and recredentialing and performance review of providers; B. Assisting Providers with Member Enrollment status questions; C. Assisting Providers with Prior Authorization and referral procedures; D. Assisting Providers with Claims submissions and payments; E. Explaining to Providers their rights and responsibilities as a member of Contractor’s Network; F. Handling, recording and tracking Provider Grievances and Appeals properly and timely; G. Developing, distributing and maintaining a Provider manual; H. Developing, conducting, and assuring Provider orientation/training; I. Explaining to Providers the extent of Medicaid benefit coverage including EPSDT preventive health screening services and EPSDT Special Services; J. Communicating Medicaid policies and procedures, including state and federal mandates and any new policies and procedures; K. Assisting Providers in coordination of care for child and adult members with complex and/or chronic conditions; L. Encouraging and coordinating the enrollment of Primary Care Providers in the Department for Public Health and the Department for Medicaid Services Vaccines for Children Program. This program offers certain vaccines free of charge to Medicaid members under the age of 21 years. The Contractor is responsible for reimbursement of the administration fee associated with vaccines provided through the program; M. Coordinating workshops relating to the Contractor’s policies and procedures; N. Providing necessary technical support to Providers who experience unique problems with certain Members in their provision of services; O. Annually addressing fraud, waste and abuse with providers; and P. Consult with a requesting Provider on authorization decisions, when appropriate. Q. Ensures no punitive action is taken against a Provider who either requests an expedited resolution or supports a Member’s appeal. Provider Services shall be staffed, at a minimum, Monday through Friday 8:00 am – 6:00 pm Eastern Time. Staff members shall be available to speak with providers any time during open hours. The Contractor shall operate a provider call center that meets standards as determined by the Department. Provider Services staff shall be instructed to follow all contractually-required provider relation functions including, policies, procedures and scope of services.

Required Functions. The Contractor agrees to perform the following functions: 4.2.1 Recruit, screen and approve practices for participation. Screening will include, but not be limited to, verifying that potential participating provider practices have not been excluded from participating in Medicaid, Medicare, and/or SCHIP. Federal Financial Participation (FFP) is not available for reimbursement to providers excluded by Medicare, Medicaid or SCHIP except for emergency services. 4.2.2 Assure that participating practices meet the participation criteria as outlined below and in the MHN Policy and Procedure Guide: 4.2.2.1 The practices must provide primary care and patient care coordination services to each member. 4.2.2.2 The practices must provide or arrange for Primary Care coverage for services, consultation or referral, and treatment for emergency medical conditions, twenty-four

Required Functions. The Contractor agrees to perform the following functions: 4.2.1 Recruit, screen and approve individual and group physician practices for participation. Screening will include, but not be limited to, verifying, prior to approval, that practices have not been excluded from participating in Medicaid, Medicare, and/or SCHIP. Federal Financial Participation (FFP) is not available for reimbursement to providers excluded by Medicare, Medicaid or SCHIP except for emergency services. 4.2.2 Assure that participating practices meet the participation criteria and perform the duties specified below and in the MHN Policy and Procedure Guide: 4.2.2.1 Provide primary care and patient care coordination services to each member. 4.2.2.2 Provide or arrange for Primary Care coverage for services, consultation or referral, and treatment for emergency medical conditions, twenty-four (24) hours per day, seven (7) days per week. 4.2.2.3 Provide prompt (within one hour) access to a qualified medical practitioner who is able to provide medical advice, consultation, and authorization for service when appropriate. Primary Care Providers (PCPs) must have at least one telephone line that is answered by office staff during regular office hours. (Use of an automated system to answer the phone is acceptable as long as patients are able to access a live person through one of the automated options.) 4.2.2.4 Provide members with an after-hours telephone number. The after-hours number may be the PCP’s home telephone number, an answering service, etc. The after- hours telephone number must be listed in the member’s handbook. 4.2.2.5 Provide preventive services as defined by the Contractor. 4.2.2.6 Offer general patient education services to all members and potential members as well as disease management services to members for whom the services are appropriate. 4.2.2.7 Establish and maintain hospital admitting privileges or enter into an arrangement with another physician or group practice for the management of inpatient hospital admissions of MHN members. 4.2.2.8 Assist the member by providing systematic, coordinated care and be responsible for all referrals to other health care providers for additional medically necessary care to ensure that services under the contract can be furnished to enrollees promptly and without compromise to the quality of care. 4.2.2.9 Follow the recommended Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screening and immunization schedules, as requir...

Required Functions. The Contractor shall have an Enrollee Services function that includes a call center which is staffed and available by telephone Monday through Friday 7:00 am to 7:00 pm Eastern Time (ET). The call center shall meet the current American Accreditation Health Care Commission/URAC- designed Health Call Center Standard (HCC) for call center abandonment rate, blockage rate and average speed of answer for all Contractor programs with the exception of behavioral health which is addressed in Section 33.6 “