Common use of Required Policies and Procedures Clause in Contracts

Required Policies and Procedures. The CONTRACTOR shall: Maintain written policies and procedures on provider recruitment, retention, and termination of Contract Provider participation with the CONTRACTOR. HCA must prior approve these policies and procedures in writing and may review them upon demand. The recruitment policies and procedures shall describe how a CONTRACTOR responds to a change in the network that affects access and its ability to deliver services in a timely manner; Require that each Provider either billing for or rendering services to Members has a unique identifier in accordance with the provisions of Section 1173(b) of the Social Security Act; Require that any Provider, including Providers ordering or referring a Covered Service, have a National Provider Identifier (NPI) to the extent such Provider is not an atypical provider as defined by CMS; Consider, in establishing and maintaining the network of appropriate Providers, its: Anticipated enrollment; Expected utilization of services, taking into consideration the characteristics and health care needs of specific populations represented in the CONTRACTOR’s population; Numbers and types (in terms of training, experience, and specialization) of Providers required to furnish Covered Services; Numbers of Contract Providers who are not accepting new patients; and Geographic location of Contract Providers and Members, considering distance, travel time, the means of transportation ordinarily used by Members, and whether the location provides physical access for Members with disabilities; Ensure that Contract Providers offer hours of operation that are no less than the hours of operation offered to commercial enrollees; Establish mechanisms such as notices or training materials to ensure that Contract Providers comply with the timely access requirements, monitor such compliance regularly, and take corrective action if there is a failure to comply; Conduct screening of all Major Subcontractors and Contract Providers, in accordance with the Employee Abuse Registry Act, NMSA 1978 § 27-7A-3, the New Mexico Caregivers Criminal History Screening Act, NMSA 1978, 29-17-2 et seq. and NMAC 7.1.9, the New Mexico Children’s and Juvenile Facility and Program Criminal Records Screening Act, NMSA 1978, § 32A-15-1 to 32A-15-4, PPACA (see Section 4.9.2.47 of this Agreement) and ensure that all Major Subcontractor and Contract Providers are screened against the New Mexico “List of Excluded Individuals/Entities” and the Medicare exclusion databases and not employ or contract with entities or Providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act, unless otherwise granted by federal authority; Provide Members and Contract Providers with clear instructions on how to access Covered Services, including those that require prior approval and referral; Meet all availability, time, and distance standards set by HCA and have a system to track and report compliance with these standards; and Provide Member access to Non-Contract Providers if the CONTRACTOR is unable to provide Medically Necessary services covered under this Agreement in a manner that meets the availability, time, and distance standards under this Agreement. The CONTRACTOR shall continue to authorize the use of Non-Contract Providers for as long as the CONTRACTOR is unable to provide these services through Contract Providers. The CONTRACTOR must ensure that the cost to the Member is no greater than it would be if the services were provided within the CONTRACTOR’s network.

Required Policies and Procedures. The CONTRACTOR shall: Maintain : (1) maintain written policies and procedures on provider recruitment, retention, recruitment and termination of Contract Provider provider participation with the CONTRACTOR. HCA must prior approve HSD shall have the right to review these policies and procedures in writing and may review them upon demand. The recruitment policies and procedures shall describe how a CONTRACTOR responds to a change in the network that affects access and its ability to deliver services in a timely manner; Require ; (2) require that each Provider provider either billing for or rendering services to Members has a unique identifier in accordance with the provisions of Section 1173(b) of the Social Security Act; (3) require that subcontracted direct care agencies initiate and maintain records of criminal history/background investigations for employees providing services as specified in 7.1.9 NMAC, Caregivers Criminal History Screening Requirements; (4) annually develop and implement a training plan to educate providers and their respective staffs on CoLTS requirements and the CONTRACTOR’s processes and procedures. The plan shall be submitted to HSD for review and approval on or before August 1st of each year. This training plan shall include, but not be limited to: (a) Prior Authorization Process; (b) Claims/Encounter Data Submission; (c) How to access ancillary providers; (d) Member’s rights and responsibilities; (e) Quality Improvement Program/Quality Improvement Initiatives; (f) Provider and Member appeals and grievances; (g) Recoupment of funds processes and procedures; Require that any Providerand (h) Early and Periodic Screening Diagnostic and Treatment (EPSDT) benefit requirements, including Providers ordering or referring a Covered Service, have a National Provider Identifier Preventative Healthcare Guidelines; (NPI5) to the extent such Provider is not an atypical provider as defined by CMS; Considerconsider, in establishing and maintaining the a network of appropriate Providersproviders, its: Anticipated : (a) anticipated enrollment; Expected ; (b) expected utilization of services, taking into consideration the characteristics and health care needs of specific populations represented in the CONTRACTOR’s population; Numbers CoLTS populations; (c) numbers and types (in terms of training, experience, and specialization) of Providers providers required to furnish Covered Services; Numbers ; (d) numbers of Contract Network Providers who are not accepting new patientsMembers; and Geographic and (e) geographic location of Contract Providers and Members, considering distance, travel time, the means of transportation ordinarily used by Members, Members and whether the location provides physical access for Members with disabilities; Ensure ; (6) ensure that Contract Providers offer Network Providers’ office hours of operation that are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid Fee-For-Service, if the provider serves only Medicaid enrollees; Establish . The CONTRACTOR shall: (a) establish mechanisms such as notices or training materials to ensure that Contract Network Providers comply with the timely access requirements, ; (b) monitor such compliance regularly, and regularly to determine compliance; and (c) take corrective action if there is a failure to comply; Conduct screening of all Major Subcontractors and Contract Providers, and (7) require that Network Providers are conducting abuse registry screenings in accordance with the Employee Abuse Registry Act, NMSA 1978 § 27-7A-3, the New Mexico Caregivers Criminal History Screening Act, NMSA 1978, 29-17-2 et seq. and NMAC 7.1.9, the New Mexico Children’s and Juvenile Facility and Program Criminal Records Screening Act, NMSA 1978, § 32A-15-1 to 32A-15-4, PPACA (see Section 4.9.2.47 of this Agreement) and ensure that all Major Subcontractor and Contract Providers are screened against the New Mexico “List of Excluded Individuals/Entities” and the Medicare exclusion databases and not employ or contract with entities or Providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act, unless otherwise granted by federal authority; Provide Members and Contract Providers with clear instructions on how to access Covered Services, including those that require prior approval and referral; Meet all availability, time, and distance standards set by HCA and have a system to track and report compliance with these standards; and Provide Member access to Non-Contract Providers if the CONTRACTOR is unable to provide Medically Necessary services covered under this Agreement in a manner that meets the availability, time, and distance standards under this Agreement. The CONTRACTOR shall continue to authorize the use of Non-Contract Providers for as long as the CONTRACTOR is unable to provide these services through Contract Providers. The CONTRACTOR must ensure that the cost to the Member is no greater than it would be if the services were provided within the CONTRACTOR’s network§§7.1.12 and 8.11.6.1 NMAC.

Required Policies and Procedures. The CONTRACTOR shall: Maintain written policies and procedures on provider recruitment, retention, and termination of Contract Provider participation with the CONTRACTOR. HCA HSD must prior approve these policies and procedures in writing and may review them upon demand. The recruitment policies and procedures shall describe how a CONTRACTOR responds to a change in the network that affects access and its ability to deliver services in a timely manner; Require that each Provider either billing for or rendering services to Members has a unique identifier in accordance with the provisions of Section 1173(b) of the Social Security Act; Require that any Provider, including Providers ordering or referring a Covered Service, have a National Provider Identifier (NPI) to the extent such Provider is not an atypical provider as defined by CMS; Consider, in establishing and maintaining the network of appropriate Providers, its: Anticipated enrollment; Expected utilization of services, taking into consideration the characteristics and health care needs of specific populations represented in the CONTRACTOR’s population; Numbers and types (in terms of training, experience, and specialization) of Providers required to furnish Covered Services; Numbers of Contract Providers who are not accepting new patients; and Geographic location of Contract Providers and Members, considering distance, travel time, the means of transportation ordinarily used by Members, and whether the location provides physical access for Members with disabilities; Ensure that Contract Providers offer hours of operation that are no less than the hours of operation offered to commercial enrollees; Establish mechanisms such as notices or training materials to ensure that Contract Providers comply with the timely access requirements, monitor such compliance regularly, and take corrective action if there is a failure to comply; Conduct screening of all Major Subcontractors and Contract Providers, in accordance with the Employee Abuse Registry Act, NMSA 1978 § 27-7A-3, the New Mexico Caregivers Criminal History Screening Act, NMSA 1978, 29-17-2 et seq. and NMAC 7.1.9, the New Mexico Children’s and Juvenile Facility and Program Criminal Records Screening Act, NMSA 1978, § 32A-15-1 to 32A-15-4, PPACA (see Section 4.9.2.47 of this Agreement) and ensure that all Major Subcontractor and Contract Providers are screened against the New Mexico “List of Excluded Individuals/Entities” and the Medicare exclusion databases and not employ or contract with entities or Providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act, unless otherwise granted by federal authority; Provide Members and Contract Providers with clear instructions on how to access Covered Services, including those that require prior approval and referral; Meet all availability, time, and distance standards set by HCA HSD and have a system to track and report compliance with these standards; and Provide Member access to Non-Contract Providers if the CONTRACTOR is unable to provide Medically Necessary services covered under this Agreement in a manner that meets the availability, time, and distance standards under this Agreement. The CONTRACTOR shall continue to authorize the use of Non-Contract Providers for as long as the CONTRACTOR is unable to provide these services through Contract Providers. The CONTRACTOR must ensure that the cost to the Member is no greater than it would be if the services were provided within the CONTRACTOR’s network.

Required Policies and Procedures. The CONTRACTOR shall: Maintain : (1) maintain written policies and procedures on provider recruitment, retention, recruitment and termination of Contract Provider provider participation with the CONTRACTOR. HCA must prior approve The State shall have the right to review these policies and procedures in writing and may review them upon demand. The recruitment policies and procedures shall describe how a CONTRACTOR responds to a change in the network that affects access and its ability to deliver services in a timely manner; Require . (2) require that each Provider provider either billing for or rendering services to Members has a unique identifier in accordance with the provisions of Section 1173(b) of the Social Security Act; Require ; (3) require that any Providersubcontracted direct care agencies initiate and maintain records of criminal history/background investigations for employees providing services as specified in 7.1.9 NMAC, including Providers ordering Caregivers Criminal History Screening Requirements; (4) annually develop and implement a training plan to educate providers and their staff on CLTS, provide technical assistance as needed on CLTS, the State policies and procedures, or referring a Covered Service, have a National Provider Identifier (NPI) the CONTRACTOR’s processes and procedures and provide technical assistance as needed on CLTS. The plan shall be submitted to the extent such Provider is not an atypical provider as defined by CMS; ConsiderState for review and approval on or before July 1st of each year; (5) consider, in establishing and maintaining the a network of appropriate Providersproviders, its: Anticipated : (a) anticipated enrollment; Expected ; (b) expected utilization of services, taking into consideration the characteristics and health care needs of specific populations represented in the CONTRACTOR’s population; Numbers CLTS populations; (c) numbers and types (in terms of training, experience, and specialization) of Providers providers required to furnish Covered Services; Numbers ; (d) numbers of Contract Network Providers who are not accepting new patientsMembers; and Geographic and (e) geographic location of Contract Providers and Members, considering distance, travel time, the means of transportation ordinarily used by Members, Members and whether the location provides physical access for Members with disabilities; Ensure ; (6) ensure that Contract Providers offer Network Providers’ office hours of operation that are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid fee-for-service, if the provider serves only Medicaid enrollees; Establish . The CONTRACTOR shall: (a) establish mechanisms such as notices or training materials to ensure that Contract Network Providers comply with the timely access requirements, ; (b) monitor such compliance regularly, and regularly to determine compliance; and (c) take corrective action if there is a failure to comply; Conduct screening of all Major Subcontractors and Contract Providers, . (7) require that Network Providers are conducting abuse registry screenings in accordance with the Employee Abuse Registry Act, NMSA 1978 § 27-7A-3, the New Mexico Caregivers Criminal History Screening Act, NMSA 1978, 29-17-2 et seq. and NMAC 7.1.9, the New Mexico Children’s §§7.1.12 and Juvenile Facility and Program Criminal Records Screening Act, NMSA 1978, § 32A-15-1 to 32A-15-4, PPACA (see Section 4.9.2.47 of this Agreement) and ensure that all Major Subcontractor and Contract Providers are screened against the New Mexico “List of Excluded Individuals/Entities” and the Medicare exclusion databases and not employ or contract with entities or Providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act, unless otherwise granted by federal authority; Provide Members and Contract Providers with clear instructions on how to access Covered Services, including those that require prior approval and referral; Meet all availability, time, and distance standards set by HCA and have a system to track and report compliance with these standards; and Provide Member access to Non-Contract Providers if the CONTRACTOR is unable to provide Medically Necessary services covered under this Agreement in a manner that meets the availability, time, and distance standards under this Agreement. The CONTRACTOR shall continue to authorize the use of Non-Contract Providers for as long as the CONTRACTOR is unable to provide these services through Contract Providers. The CONTRACTOR must ensure that the cost to the Member is no greater than it would be if the services were provided within the CONTRACTOR’s network8.11.6.1 NMAC.