June 11, NCMGMA hopes that the specific comments provided below assist DHHS during the transition in North Carolina to Medicaid Managed Care.
|
|
- Theresa Washington
- 5 years ago
- Views:
Transcription
1 June 11, 2018 VIA NC Department of Health and Human Services Division of Health Benefits 1950 Mail Service Center Raleigh, NC RE: Comments Regarding Medicaid Managed Care To Whom It May Concern: The North Carolina Medical Group Management Association (NCMGMA) appreciates the opportunity to comment on the North Carolina Department of Health and Human Services (DHHS) Medicaid Managed Care Proposed Policy Papers regarding Prepaid Health Plans in North Carolina (issued May 16, 2018) and Supporting Provider Transition to Medicaid Managed Care (issued May 18, 2018). Since 1971, NCMGMA has grown to more than 700 members representing medical practices across North Carolina. Our membership includes executives and managers of private group practices, academic medical centers, integrated delivery systems, and companies that support medical provider organizations. NCMGMA strives to maximize the value and effectiveness of medical group leaders through educational programs, information exchange, networking, advocacy, and professional development opportunities. With the transition of Medicaid in North Carolina to a managed care structure, NCMGMA shares the goal of DHHS of creating a sustainable system that improves health, supports providers, and provides predictable costs. A particular priority of NCMGMA during this transition is DHHS efforts to ease the administrative burdens on providers. Specifically, NCMGMA supports DHHS efforts to, among others, (1) standardize and simplify administrative processes and standards across PHPs, (2) ensure transparent and fair payments for PHPs and providers, and (3) offer contract guidance to providers. NCMGMA hopes that the specific comments provided below assist DHHS during the transition in North Carolina to Medicaid Managed Care. PHP Procurement Currently, as described in Section IV of the Proposed Policy Paper regarding Prepaid Health Plans, DHHS expects to maintain three prepaid health plan (PHP) contracts to provide coverage to
2 North Carolina Medicaid beneficiaries statewide. In addition, DHHS expects up to twelve PHP contracts to provide coverage through provider-led entities (PLEs) for pre-defined regions throughout the state. Furthermore, DHHS leaves open the possibility for PHP contracts with an additional twelve unique PLEs within each county. NCMGMA is concerned that, based on these figures and the regions developed by DHHS, a provider could be faced with upwards of separate contracting entities in each region. NCMGMA believes that the number of possible contracting entities in the current proposed structure would greatly increase the administrative burden on providers throughout North Carolina. While recognizing the need for sufficient choice for Medicaid beneficiaries, NCMGMA recommends imposing a cap on the number of regional PLEs that are awarded contracts by DHHS within a given region. An informed cap on PLE contracts in each region would support DHHS goals of providing sufficient access to care for beneficiaries while at the same time reasonably controlling the administrative burden borne by providers under this new structure. Specifically, NCMGMA recommends that DHHS award no more than three (3) contracts, whether CE or PLE, in each region. Such a cap offers adequate choice to beneficiaries and provides adequate enrollment for PHPs to maintain financial viability. PHP Financial Management If DHHS intends to set a per member per month capitation rate, NCMGMA recommends delaying the withhold program during the first two years of operation. The spread between a target 88% medical loss ratio (MLR) and the capitation rate, if reduced by a 5% withhold, as suggested in the policy paper, could damage the entity s cash flow needs during the critical start-up years. If the withhold causes a PHP to withdraw from the market, then any previous efforts to establish the market allocation of beneficiaries would have been for naught. Furthermore, if the MLR truly is intended for payment to the provider panel, any savings (i.e. amount less than the MLR), should be allocated as gain sharing to the providers who actually enabled the savings. Such a structure would incentive providers to reduce costs through aggressive care management. PHP/Provider Mandatory Contract Language In order to ease the administrative burden on providers following the transition to Medicaid Managed Care, NCMGMA supports the use of a DHHS-approved template for contracts between PHPs and providers. Even with a cap on the number of regional PLEs as described above, providers still will be faced with the prospect of entering into and managing a number of different contractual relationships with PHPs. Therefore, NCMGMA recommends the use of a single DHHS-approved template for PHP/Provider contracting. Use of standard contract terms, provisions, and
3 language in a standardized template will assist providers in managing relationships with PHPs and being able to devote necessary time and resources to Medicaid beneficiaries. With respect to specific standard contract provisions, NCMGMA supports a requirement that PHPs include the applicable standard contract provisions as required in commercial insurance provider contracts and set forth in Title 11 North Carolina Administrative Code In addition, Section VI of the Policy Paper regarding Prepaid Health Plans describes the proposal that any entity that holds a capitated contract with NC DHHS must also hold a PHP license issued by NC DOI. The proposal, thus, would create a state-licensed PHP that assumes financial risk and functions as a health maintenance organization ( HMO ). Therefore, DHHS should ensure that all contracting rules and regulations applicable to any state-licensed HMO, such as prompt pay laws and other applicable provisions within North Carolina General Statutes Chapter 58, also apply to PHPs. Provisions of the contract template where the text is prescribed should include claims submission, prompt pay, renewal and termination of the contract, claims adjudication, utilization review, and provider appeals. NCMGMA supports the claims submission and prompt pay guidance included in Section IV of the Policy Paper regarding Prepaid Health Plans and recommends that the following language be included in a DHHS-approved contract template: The Provider shall submit all claims to the PHP for processing and payment within ninety (90) days from the date of covered service. However, the Provider s failure to submit a claim within the aforementioned time will not invalidate or reduce any claim if it was not reasonably possible for the Provider to submit the claim within that time. In such case, the claim should be submitted as soon as reasonably possible and, in no event, later than one (1) year from the time submittal of the claim is otherwise required. The PHP must send acknowledgement of receipt of electronic claims within forty-eight (48) hours of receipt. Within eighteen (18) processing days of receiving the claim, the PHP must notify the Provider whether the claim is clean or if more information is needed. If the claim is clean, the PHP must pay or deny the claim within thirty (30) days of receipt. If more information is needed from the Provider, the PHP must provide notification to the Provider requesting the additional information within eighteen (18) processing days of receiving the claim. If the PHP fails to pay a clean claim in full within thirty (30) days of receipt, the PHP will be required to pay the Provider interest and penalty. Payments will bear interest at the annual rate of eighteen (18) percent beginning on the date following the day on which the claim should have been paid or was underpaid. Failure to pay a clean claim within thirty (30) days of receipt will result in the PHP paying the Provider a penalty equal to
4 one (1) percent per day of the total amount of the claim beginning on the date following the day on which the claim should have been paid or was underpaid. In addition, NCMGMA recommends inclusion of the following language regarding the renewal and termination of the PHP/Provider contract: Renewal: Upon the anniversary of each Term as defined herein, the Agreement shall automatically renew for additional one-year terms unless either party provides written notice to the other party at least forty-five (45) days prior to the end of the Term; provided, however, that the PHP shall provide written notice to the Provider of a proposed payment rate schedule at least ninety (90) days prior to the end of the Term. Termination without Cause: Either party may terminate this Agreement at any time without cause by providing written notice to the other party at least ninety (90) days in advance of such termination. Termination for Cause: Either party may terminate this Agreement immediately upon the other party s Default, as defined below, by providing written notice to the other party. The term Default includes any of the following: (1) Failure to comply with or to perform any provision or condition of this Agreement for ten (10) business days following receipt of the other party s written notice of such failure. (2) Failure to obtain or maintain any licenses, insurance, or certifications required by applicable law or regulation. The termination of this Agreement will not relieve the parties of any right or obligation accruing hereunder prior to such termination, or of any right or obligation to continue beyond the termination date as prescribed by state or federal law. With respect to the credentialing process, NCMGMA recommends that credentialing remain consistent with N.C. Gen. Stat Providers should not be required to navigate two or three different credentialing process as suggested in the concept and policy papers by DHHS. The process requiring providers to conduct multiple credentialing through NCTracks and submit applications with expanded questions to PHPs lacks justification or rationale, particularly when all other carriers regulated by the Department of Insurance operate well with the North Carolina Uniform Application. Not only would the multiple credentialing process place a heavy administrative burden and cost on providers, but it would also result in added cost and time to DHHS and the PHPs through the necessary development of new and different forms and paperwork. Provider Participation in PLEs
5 NCMGMA supports efforts by DHHS to address potential anti-competitive or self-dealing behavior. PHPs should be prohibited from paying more for services rendered by a provider or subcontractor that is related to the PHP, than for similar services rendered by a provider or subcontractor that is not related to the PHP. Furthermore regarding network adequacy, as capitation rates will be set by DHHS rather than by PHPs, DHHS must ensure the adequacy of such rates so as not to alienate experienced PHPs who may choose not to accept an otherwise inadequate rate. NCMGMA agrees with DHHS that exclusivity provisions in contracts between PHPs and Providers should be prohibited and that entities should negotiate in good faith. However, NCMGMA further agrees with other commenters that DHHS should recognize that all parties, including PHPs, must negotiate in good faith. In addition, NCMGMA recommends addressing PLE referral practices that are inconsistent with Network Adequacy guidelines. PLEs should monitor their assigned beneficiaries in order to identify those with more serious chronic diseases, or those requiring significant resources, that may negatively affect the financial viability of the PLE. PHP contract provisions and oversight tasks should require that PLEs retain these chronically ill patients rather than referring the patients to another PLE or CE for the primary purpose of reducing the financial impact on the referring PLE or CE. Finally, per Federal Trade Commission (FTC) guidelines, providers are prohibited from sharing with competing entities information related to fee setting or design of compensation methodology. Therefore, if a provider is an owner/member of multiple PLEs, then that provider should not be permitted to participate in any aspect of the PLEs financial oversight or decision processes. NCMGMA recommends that in order to appropriately evaluate PLEs, RFP responses should describe a PLE s evaluation of its FTC anti-trust risks and identify the PLE s policies and plans to operate within the FTC guidelines. Network Adequacy With respect to Appendix A, Table 5 of the concept paper regarding Network Adequacy and Accessibility Standards, many of the potential PHP bidders maintain a separate panel for behavioral health. However, the PHPs also use a fee schedule that discounts the same behavioral health service depending on the provider. Under this structure, for example, an internist treating depression may be paid more than a mental health provider treating the same diagnosis. Similarly, the different contracted panels affect the coordination of care between the different contracted providers. NCMGMA recommends that any fee schedule be uniform based on the service and not the diagnosis.
6 With respect to the Specialty Care Access Standards set forth in Appendix B, many of the listed specialties not only are hospital-based, but also have either exclusive service contracts or direct employment contracts with hospitals. As participating physicians may not be included in the typical template for hospital service contracts, PHPs should predicate the acceptance of a hospital contract on the hospital s ability to commit its specialty care providers to participation in the PHP panel. Such a requirement will avoid the conundrum of an enrollee s hospital being in network, but the provider services being out of network. Thank you again for the opportunity to comment on this matter. We look forward to receiving additional information regarding the issues described above and continuing to work with DHHS during and after the transition to Medicaid Managed Care in North Carolina. Sincerely, Sandra Jarrett 2018 NCMGMA President Melissa White Advocacy Committee Co-chair Cameron Cox Advocacy Committee Co-chair
GENERAL ASSEMBLY OF NORTH CAROLINA SESSION 2017 HOUSE BILL 403 RATIFIED BILL AN ACT TO MODIFY THE MEDICAID TRANSFORMATION LEGISLATION.
GENERAL ASSEMBLY OF NORTH CAROLINA SESSION 2017 HOUSE BILL 403 RATIFIED BILL AN ACT TO MODIFY THE MEDICAID TRANSFORMATION LEGISLATION. The General Assembly of North Carolina enacts: SECTION 1. Section
More informationIssue brief: Medicaid managed care final rule
Issue brief: Medicaid managed care final rule Overview In the past decade, the Medicaid managed care landscape has changed considerably in terms of the number of beneficiaries enrolled in managed care
More informationMcKinney s Public Health Law 2999-n n. Accountable care organizations; findings; purpose. Effective: October 3, 2012
2999-n. Accountable care organizations; findings; purpose, NY PUB HEALTH 2999-n McKinney s Consolidated Laws of New York Annotated Public Health Law (Refs & Annos) Chapter 45. Of the Consolidated Laws
More informationPARTICIPATING PROVIDER AGREEMENT RECITALS
PARTICIPATING PROVIDER AGREEMENT This Agreement is made by and between the provider named on the signature page of this Agreement ( Provider ) and Managed Health Network, Inc. ( MHN, Inc. ), and its Affiliates
More informationNorth Carolina Medical Society 2015 Medicaid Reform Analysis Updated 07/15/15
Section 2: (5) Provider-led entity. Any of the following: a. A provider. b. An entity with the primary purpose of owning or operating one or more providers. c. A business entity in which providers hold
More informationMay 10, General Comments
May 10, 2010 BY ELECTRONIC MAIL Lou Felice Chair, Health Care Reform Solvency Impact (E) Subgroup Re: Request for Information: Medical Loss Ratios; Request for Comments Regarding Section 2718 of the Public
More informationCommon Managed Care Terms & Definitions
Contact Us: Email: info@emedbiz.com Phone: 561-430-2090 Fax: 561-430-2091 Website: www.emedbiz.com Common Managed Care Terms & Definitions Balance billing: The practice of billing a patient for the amount
More informationDRAFT NCOIL OUT-OF-NETWORK BALANCE BILLING TRANSPARENCY MODEL ACT
DRAFT NCOIL OUT-OF-NETWORK BALANCE BILLING TRANSPARENCY MODEL ACT Section 1. Title This Act shall be known as the Out-of-Network Balance Billing Transparency Act. Section 2. Purpose The purpose of this
More informationCHAPTER 20 - MANAGED CARE HEALTH BENEFIT PLANS SECTION MANAGED CARE DEFINITIONS
CHAPTER 20 - MANAGED CARE HEALTH BENEFIT PLANS SECTION.0100 - MANAGED CARE DEFINITIONS 11 NCAC 20.0101 SCOPE AND DEFINITIONS (a) Scope. (1) Sections.0200,.0300, and.0400 of this Chapter apply to HMOs,
More information20. CLAIMS PROCESSING. A. Claims Processing APPLIES TO: A. This policy applies to all IEHP Medi-Cal Providers. POLICY:
A. Claims Processing APPLIES TO: A. This policy applies to all IEHP Medi-Cal Providers. POLICY: A. All Capitated Providers are delegated the responsibility of claims processing for noncapitated services
More informationNational Council of Insurance Legislators (NCOIL) OUT-OF-NETWORK BALANCE BILLING TRANSPARENCY MODEL ACT
National Council of Insurance Legislators (NCOIL) OUT-OF-NETWORK BALANCE BILLING TRANSPARENCY MODEL ACT Adopted by the Health, Long Term Care, and Health Retirement Issues Committee on November 18, 2017
More informationInsurance Department PROPOSED RULE MAKING NO HEARING(S) SCHEDULED. Guidelines for the Processing of Coordination of Benefit (COB) Claims
COSTS: Costs for the Implementation of, and Continuing Compliance with this Regulation to Regulated Entity: We estimate this change will increase Medicaid costs by about 7.4 million dollars gross, annually.
More informationS 0831 S T A T E O F R H O D E I S L A N D
======== LC00 ======== 01 -- S 01 S T A T E O F R H O D E I S L A N D IN GENERAL ASSEMBLY JANUARY SESSION, A.D. 01 A N A C T RELATING TO INSURANCE -- HEALTH INSURANCE COVERAGE -- THE MARKET STABILITY AND
More informationH 5988 S T A T E O F R H O D E I S L A N D
======== LC001 ======== 01 -- H S T A T E O F R H O D E I S L A N D IN GENERAL ASSEMBLY JANUARY SESSION, A.D. 01 A N A C T RELATING TO INSURANCE -- HEALTH INSURANCE COVERAGE Introduced By: Representatives
More informationCHAPTER Committee Substitute for Senate Bill No. 2086
CHAPTER 2000-296 Committee Substitute for Senate Bill No. 2086 An act relating to small employer health alliances; amending s. 408.7056, F.S.; providing additional definitions for the Statewide Provider
More informationHouse Health Committee June 1, Department of Health and Human Services Medicaid Reform 1115 Waiver Submission
House Health Committee June 1, 2016 Department of Health and Human Services Medicaid Reform 1115 Waiver Submission Agenda Overview, milestones and vision Alignment with session law Public comments Waiver
More informationStark Law Exceptions and Anti-Kickback Safe Harbors
Law Exceptions and Safe Harbors Price Reductions Offered to Health Plans [No comparable exception] Safe harbor for a reduction in price a contract health care provider offers to a health plan for the sole
More informationUNIFORM INSURANCE BENEFITS ACT
Office of Employee Benefits Administrative Manual UNIFORM INSURANCE BENEFITS ACT INITIAL EFFECTIVE DATE: JUNE 1, 2003 111 LATEST REVISION DATE: AUGUST 1, 2013 PURPOSE: Recodification of Texas Insurance
More informationRecommendations From Staff Relating to Network Adequacy and Accessibility
Recommendations From Staff Relating to Network Adequacy and Accessibility Background In 2013, the National Association of Insurance Commissioner s (NAIC s) Regulatory Framework (B) Task Force was charged
More informationOverview of 1115 Waivers
JOINT LEGISLATIVE OVERSIGHT COMMITTEE ON MEDICAID AND NC HEALTH CHOICE Overview of 1115 Waivers Christen Linke Young Department of Health and Human Services February 28, 2018 State Tools for Modifying
More informationSTATE OF CALIFORNIA DEPARTMENT OF MANAGED HEALTH CARE
STATE OF CALIFORNIA DEPARTMENT OF MANAGED HEALTH CARE TITLE 28, CALIFORNIA CODE OF REGULATIONS DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE CHAPTER 2. HEALTH CARE SERVICE PLANS ARTICLE 2.5 DISCOUNT
More informationMedicaid and CHIP Managed Care Final Rule (CMS-2390-F) Overview of the Final Rule. Center for Medicaid and CHIP Services
Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) Overview of the Final Rule Center for Medicaid and CHIP Services Background This final rule is the first update to Medicaid and CHIP managed care
More informationSouth Carolina Statutes and Regulations
Prompt Payment of Claims Deadline S.C. Code Ann. 38-59- 230(A)-(B) Penalty S.C. Code Ann. 38-59-240 An insurer must pay a clean claim received via paper within 40 business days and clean electronic claims
More informationNorth Carolina Medicaid Reform Status Briefing
North Carolina Medicaid Reform Status Briefing Overview Medicaid reform was signed into law by Gov. McCrory in September 2015, after extensive engagement with the General Assembly, providers, beneficiaries
More informationCh. 358, Art. 4 LAWS of MINNESOTA for
Ch. 358, Art. 4 LAWS of MINNESOTA for 2008 14 paragraphs (c) and (d), whichever is later. The commissioner of human services shall notify the revisor of statutes when federal approval is obtained. ARTICLE
More informationNotice of Proposed Rulemaking Action Title 28, California Code of Regulations
Arnold Schwarzenegger, Governor State of California Business, Transportation and Housing Agency Department of Managed Health Care Office of Legal Services 980 Ninth Street, Suite 500 Sacramento, CA 95814-2725
More informationProposed Amendments: N.J.A.C. 11:4-37.2, 37.3, 37.4, and 37.6 and 11:22-5
INSURANCE DEPARTMENT OF BANKING AND INSURANCE DIVISION OF INSURANCE Selective Contracting Arrangements of Insurers, Minimum Standards for Network-Based Health Benefit Plans Proposed Amendments: N.J.A.C.
More information2016 Medicaid Managed Care Final Rule 1 Summary
2016 Medicaid Managed Care Final Rule 1 Summary The final Medicaid Managed Care rule retains nearly all of the requirements of the proposed rule and does not make substantial changes to it. In particular,
More informationThis regulation is promulgated under the authority of and , C.R.S.
DEPARTMENT OF REGULATORY AGENCIES LIFE, ACCIDENT AND HEALTH, Series 4-6 3 CCR 702-4 Series 4-6 [Editor s Notes follow the text of the rules at the end of this CCR Document.] Regulation 4-6-2 GROUP COORDINATION
More informationNotification of rights under the Affordable Care Act. Non-Grandfathered Group Health Plan Notice
Notification of rights under the Affordable Care Act Non-Grandfathered Group Health Plan Notice Your employer believes the Group Health Plan (GHP) provided to employees is a non-grandfathered health Plan
More informationPlans; Exchange Standards for Employers, 77 Fed. Reg (March 27, 2012) (to be codified at 45 C.F.R. pts. 155, 156, and 157).
May l8, 2012 Establishment of Exchanges and Qualified Health Plans and Exchange Standards for Employers The New England Council James T. Brett President & CEO Healthcare Committee Chairs Frank McDougall
More informationCLINICAL RESOURCE GROUP, INC. CHIROPRACTIC ADMINISTRATIVE MANUAL
CLINICAL RESOURCE GROUP, INC. CHIROPRACTIC ADMINISTRATIVE MANUAL UPDATED: 1-1-2012 TABLE OF CONTENTS Chapter One - Provider Services Contact Information Benefit and Summary Verification Communication Resources
More informationTITLE 73. PROFESSIONS AND VOCATIONS CHAPTER 21. PHARMACISTS PHARMACY BENEFIT PROMPT PAY ACT. Miss. Code Ann (2013)
73-21-151. Short title TITLE 73. PROFESSIONS AND VOCATIONS CHAPTER 21. PHARMACISTS PHARMACY BENEFIT PROMPT PAY ACT Miss. Code Ann. 73-21-151 (2013) Sections 73-21-151 through 73-21-159 shall be known as
More informationUNIFORM INSURANCE BENEFITS ACT
Office of Employee Benefits Administrative Manual UNIFORM INSURANCE BENEFITS ACT INITIAL EFFECTIVE DATE: JUNE 1, 2003 111 LATEST REVISION DATE: SEPTEMBER 1, 2017 PURPOSE: Recodification of Texas Insurance
More informationPHYSICIAN PARTICIPATION AGREEMENT BETWEEN LOS ALAMOS PHYSICIAN AND HOSPITAL ORGANIZATION AND PHYSICIAN
PHYSICIAN PARTICIPATION AGREEMENT BETWEEN LOS ALAMOS PHYSICIAN AND HOSPITAL ORGANIZATION AND PHYSICIAN This PHYSICIAN PARTICIPATION AGREEMENT (the "Agreement') is made and entered into effective, 20 (the
More informationProvider Training Tool & Quick Reference Guide
Provider Training Tool & Quick Reference Guide Table of Contents I. Coastal Introduction II. Services III. Obtaining Authorization a. Coastal Intake Flow Chart b. Referral/Authorization Form (Sample) IV.
More informationKEYSTONE 65 HMO POINT OF SERVICE ( POS ) GROUP MEDICARE ADVANTAGE CONTRACT. effective as of EFF. DATE. by and between. GROUP NAME (Called the Group)
KEYSTONE 65 HMO POINT OF SERVICE ( POS ) GROUP MEDICARE ADVANTAGE CONTRACT effective as of EFF. DATE by and between GROUP NAME (Called the Group) Group Number: GROUP# and KEYSTONE HEALTH PLAN EAST (Called
More informationGEHA Policies & Procedures Connection Dental Network State Specific Policies & Procedures - State of Louisiana
GEHA Policies & Procedures Connection Dental Network State Specific Policies & Procedures - State of Louisiana The below policies and procedures are in addition to the contractual requirements and the
More informationIowa Medicaid Synopsis of Managed Medicaid Request for Proposal
Iowa Medicaid Synopsis of Managed Medicaid Request for Proposal The following information provides summary information of key aspects of the Iowa Medicaid Request For Proposal SOW for Capitated Managed
More informationANCILLARY PROVIDER AFFILIATION AGREEMENT
ANCILLARY PROVIDER AFFILIATION AGREEMENT Preamble This Agreement is made between Blue Care Network of Michigan, Blue Care of Michigan, Inc. and BCN Service Company (hereinafter collectively referred to
More informationMedicaid Transformation
JOINT LEGISLATIVE OVERSIGHT COMMITTEE ON MEDICAID AND NC HEALTH CHOICE Medicaid Transformation Dave Richard and Jay Ludlam Department of Health and Human Services April 10, 2018 Recent Transformation Milestones
More informationMANAGED CARE READINESS TOOLKIT
MANAGED CARE READINESS TOOLKIT Please note: The following managed care definitions reflect a general understanding of the terms. It will be important to read managed care contracts very carefully as they
More informationMedicare Advantage Private Fee-for-service Plan Model Terms and Conditions of Payment
Medicare Advantage Private Fee-for-service Plan Model Terms and Conditions of Payment Table of Contents 1. Introduction 2. When a provider is deemed to accept Humana Gold Choice PFFS terms and conditions
More informationCONTRACT YEAR 2018 MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE PLAN MODEL TERMS AND CONDITIONS OF PAYMENT
CONTRACT YEAR 2018 MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE PLAN MODEL TERMS AND CONDITIONS OF PAYMENT Table of Contents 1. Introduction 2. When a Provider is Deemed to Accept Today s Options PFFS Terms
More informationSENATE, No. 551 STATE OF NEW JERSEY. 215th LEGISLATURE PRE-FILED FOR INTRODUCTION IN THE 2012 SESSION
SENATE, No. STATE OF NEW JERSEY th LEGISLATURE PRE-FILED FOR INTRODUCTION IN THE 0 SESSION Sponsored by: Senator NIA H. GILL District (Essex and Passaic) Senator JOSEPH F. VITALE District (Middlesex) SYNOPSIS
More informationVia Electronic Submission (www.regulations.gov) January 16, 2018
Via Electronic Submission (www.regulations.gov) January 16, 2018 Ms. Seema Verma Administrator Centers for Medicare & Medicaid Services U.S. Department of Health and Human Services ATTN: CMS-4182-P 7500
More informationTIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS
TIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS UnitedHealthcare Oxford Administrative Policy Policy Number: ADMINISTRATIVE 088.17 T0 Effective Date: May 1, 2017 Table of Contents
More informationRE: Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans: Proposed Rule CMS-9989-P
October 25, 2011 Dr. Donald Berwick Centers for Medicare & Medicaid Services Department of Health and Human Services P.O. Box 8010 Baltimore, MD 21244-8010 RE: Patient Protection and Affordable Care Act;
More informationP.L. 2005, CHAPTER 172, approved August 5, 2005 Assembly, No (First Reprint)
P.L. 00, CHAPTER, approved August, 00 Assembly, No. (First Reprint) - C.:S-. - Note to - 0 0 0 AN ACT concerning managed behavioral health care services and amending and supplementing P.L., c.. BE IT ENACTED
More information20. CLAIMS PROCESSING. A. Claims Processing APPLIES TO: A. This policy applies to all IEHP Medi-Cal Providers. POLICY:
A. Claims Processing APPLIES TO: A. This policy applies to all IEHP Providers. POLICY: A. All Capitated Providers are delegated the responsibility of claims processing for non- Capitated services and are
More informationSELF-FUNDED EMPLOYEE BENEFIT PLAN SHORT TERM DISABILITY PLAN DOCUMENT YOSEMITE COMMUNITY COLLEGE DISTRICT. Restated January 1, 2007
SELF-FUNDED EMPLOYEE BENEFIT PLAN SHORT TERM DISABILITY PLAN DOCUMENT YOSEMITE COMMUNITY COLLEGE DISTRICT Restated January 1, 2007 License #0451271 Table of Contents I. DEFINITIONS II. III. IV. ELIGIBILITY
More informationCLAIMS SETTLEMENT PRACTICES & DISPUTE RESOLUTION MECHANISM
CLAIMS SETTLEMENT PRACTICES & DISPUTE RESOLUTION MECHANISM The California Department of Managed Health Care has set forth regulations establishing certain claim settlement practices and a process for resolving
More informationHealth Care Quality Act Application to Insurance Companies, Health Service. Corporations, Hospital Service Corporations and Medical Service
INSURANCE 43 NJR 9(2) September 19, 2011 Filed August 25, 2011 DEPARTMENT OF BANKING AND INSURANCE DIVISION OF INSURANCE Health Maintenance Organizations Health Care Quality Act Application to Insurance
More informationSubpart D MCO, PIHP and PAHP Standards Availability of services.
Center for Medicare & Medicaid Services (CMS) Medicaid and CHIP Managed Care Final Rule (CMS 2390-F) Fact Sheet: Subpart D and E of 438 Quality of Care Each state must ensure that all services covered
More informationDOMINION DENTAL SERVICES, INC.
DOMINION DENTAL SERVICES, INC. 251 18th Street South, Suite 900, Arlington, VA 22202 (703) 518-5000 GROUP DENTAL SERVICE CONTRACT This Agreement is made by and between Dominion Dental Services, Inc. (hereinafter
More informationSTATE OF NEW JERSEY. SENATE, No th LEGISLATURE. Sponsored by: Senator NIA H. GILL District 34 (Essex and Passaic)
SENATE, No. STATE OF NEW JERSEY th LEGISLATURE INTRODUCED FEBRUARY, 00 Sponsored by: Senator NIA H. GILL District (Essex and Passaic) SYNOPSIS Regulates pharmacy benefits management companies. CURRENT
More informationRULES OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF WORKERS COMPENSATION
RULES OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF WORKERS COMPENSATION CHAPTER 0800-02-06 GENERAL RULES OF THE WORKERS COMPENSATION PROGRAM TABLE OF CONTENTS 0800-02-06-.01 Definitions
More informationIC ARTICLE 13. HEALTH MAINTENANCE ORGANIZATIONS
IC 27-13 ARTICLE 13. HEALTH MAINTENANCE ORGANIZATIONS IC 27-13-1 Chapter 1. Definitions IC 27-13-1-1 Applicability of definitions Sec. 1. The definitions in this chapter apply throughout this article.
More informationAFFORDABLE CARE ACT. Group Health Plan- The definition appears in Section 2791(a) of the PHSA, which states as follows: PPACA defines a selfinsured
PPACA defines a selfinsured plan as a Group Health Plan- The definition appears in Section 2791(a) of the PHSA, which states as follows: AFFORDABLE CARE ACT The term group health plan means an employee
More informationChapter 1. Background and Overview
Chapter 1 Background and Overview This handbook provides the basic information needed to effectively administer the Health Care Responsibility Act (HCRA). The appendices provide additional information
More informationTITLE 8. Industrial Relations. Division 1. Department of Industrial Relations. Chapter 4.5. Division of Workers Compensation
TITLE 8. Industrial Relations Division 1. Department of Industrial Relations Chapter 4.5. Division of Workers Compensation Subchapter 1. Administrative Director--Administrative Rules ARTICLE 3.5 Medical
More informationHealth Care Plans and COBRA
Health Care Plans and COBRA COBRA provides workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited
More informationFERRIS STATE UNIVERSITY HEALTH PLAN SUPPLEMENTAL INFORMATION. Bargaining Unit Employees
FERRIS STATE UNIVERSITY HEALTH PLAN SUPPLEMENTAL INFORMATION Bargaining Unit Employees AFSCME Public Safety Officers Public Safety Supervisors Nurses Effective July 1, 2005 1247959-2 TABLE OF CONTENTS
More informationPROVIDER SERVICES Section IV Provider Services
Section IV Provider Services Provider Services 98 NaviNet www.navinet.net Using NaviNet reduces the time spent on paperwork and allows you to focus on more important tasks patient care. NaviNet is a one-stop
More informationMedi-Pak Advantage: Terms and Conditions of Provider Participation
Medi-Pak Advantage: Terms and Conditions of Provider Participation Medi-Pak Advantage is a Medicare Advantage Private Fee-For-Service plan offered by Arkansas Blue Cross and Blue Shield. Medi-Pak Advantage
More informationAdult Preventive Medicine Clinical Coverage Policy No.: 1A-2 Annual Health Assessment Amended Date: October 1, 2015.
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1 General... 1 2.1.2 Specific... 1 2.2 Special
More informationIC Chapter Healthy Indiana Plan 2.0
IC 12-15-44.5 Chapter 44.5. Healthy Indiana Plan 2.0 IC 12-15-44.5-1 "Phase out period" Sec. 1. As used in this chapter, "phase out period" refers to the following periods: (1) The time during which a:
More informationPRIMARY CARE PHYSICIAN AGREEMENT
PRIMARY CARE PHYSICIAN AGREEMENT THIS AGREEMENT is made and entered into by and among HealthKeepers, Inc., Peninsula Health Care, Inc., and Priority Health Care, Inc., corporations organized and operated
More informationGENERAL ASSEMBLY OF NORTH CAROLINA SESSION 2017 H 2 HOUSE BILL 156 Senate Health Care Committee Substitute Adopted 6/22/17
GENERAL ASSEMBLY OF NORTH CAROLINA SESSION H HOUSE BILL Senate Health Care Committee Substitute Adopted // Short Title: Medicaid PHP Licensure/Food Svcs State Bldgs. (Public) Sponsors: Referred to: February,
More informationRe: Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans. File Code CMS 9989 P
October 24, 2011 Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-9989-P P.O. Box 8010 Baltimore, MD 21244-8010 Re: Patient Protection and Affordable Care
More informationVIRGINIA MEDICARE MEDICAID PLAN DUALS DEMONSTRATION PARTICIPATION ATTACHMENT TO THE ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
VIRGINIA MEDICARE MEDICAID PLAN DUALS DEMONSTRATION PARTICIPATION ATTACHMENT TO THE ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT This is a Participation Attachment to the Anthem Blue Cross and
More informationApril 8, Dear Mr. Levinson,
April 8, 2019 Daniel Levinson Office of Inspector General Department for Health and Human Services Cohen Building, Room 5527 330 Independence Ave, SW Washington, DC 20201 Re: Fraud and Abuse; Removal of
More informationSURA/JEFFERSON SCIENCE ASSOCIATES, LLC
SURA/JEFFERSON SCIENCE ASSOCIATES, LLC COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN Summary Plan Description Amended and Restated Effective April 1, 2011 YOUR SUMMARY PLAN DESCRIPTION This document is
More informationGROUP LIFE INSURANCE PROGRAM. Veolia North America, LLC
GROUP LIFE INSURANCE PROGRAM Veolia North America, LLC RELIANCE STANDARD LIFE INSURANCE COMPANY Home Office: Chicago, Illinois Administrative Office: Philadelphia, Pennsylvania CERTIFICATE OF INSURANCE
More informationManaged Care Contracting
NATIONAL COUNCIL FOR BEHAVIORAL HEALTH Managed Care Contracting presented by: Adam J. Falcone, Esq. Partner of FIDELL LLP Disclaimer This presentation has been prepared by the attorneys of Feldesman Tucker
More informationPATIENT AGREEMENT BOISE THYROID-ENDOCRINOLOGY, PC
PATIENT AGREEMENT BOISE THYROID-ENDOCRINOLOGY, PC This is an Agreement entered into on, 20, by and between Boise Thyroid-Endocrinology, PC, an Idaho Professional Corporation, located at 1759 S Millennium
More informationMedicaid Managed Care Final Rule: Analysis & Implications
Medicaid Managed Care Final Rule: Analysis & Implications Joe Greenman, Shareholder, LanePowell Mark Reagan, Managing Partner, Hooper, Lundy & Bookman P.C. Narda Ipakchi, Director of Managed Markets, AHCA
More informationWellCare of Iowa, Inc.
Prior authorization Notice of Admission or Admission Request Prior authorization is required for all Nursing Facility, Skilled Nursing Facility and Long Term Support Services (LTSS) services. Prior Authorization
More informationPatient Protection and Affordable Care Act (PPACA): A Summary of Key Provisions and Implementation Planning in SC March 23, 2011
Patient Protection and Affordable Care Act (PPACA): A Summary of Key Provisions and Implementation Planning in SC March 23, 2011 South Carolina Public Health Institute Mission To promote evidence-based
More informationShared Savings Program ACOs and Payors: Opportunities and Challenges in a New Era of Accountable Care
APRIL 2012 EXECUTIVE SUMMARY PAYORS, PLANS, AND MANAGED CARE PRACTICE GROUP Shared Savings Program ACOs and Payors: Opportunities and Challenges in a New Era of Accountable Care Amy J. Davis, Esquire Lumeris
More informationSUB. H.B. 49 AS PASSED BY THE HOUSE SELECTED HOSPITAL-RELATED PROVISIONS
SUB. H.B. 49 AS PASSED BY THE HOUSE SELECTED HOSPITAL-RELATED PROVISIONS HOSPITAL ISSUES: CONTENTS Medicaid payment rates for hospital services... 2 Medicaid eligibility requirements for expansion group...
More informationGROUP LIFE INSURANCE PROGRAM. Alden Management Services, Inc.
GROUP LIFE INSURANCE PROGRAM Alden Management Services, Inc. RELIANCE STANDARD LIFE INSURANCE COMPANY Home Office: Chicago, Illinois Administrative Office: Philadelphia, Pennsylvania CERTIFICATE OF INSURANCE
More informationTABLE OF CONTENTS. Eligibility for Insurance 1 Effective Date of Insurance 1. Schedule of Benefits 2 Definitions 2 Insuring Provisions 6
TABLE OF CONTENTS ELIGIBILITY FOR INSURANCE PAGE Eligibility for Insurance 1 Effective Date of Insurance 1 LONG TERM DISABILITY INSURANCE Schedule of Benefits 2 Definitions 2 Insuring Provisions 6 PREMIUMS
More informationCMS s 2018 Proposed Medicaid Managed Care Rule: A Summary of Major Provisions
January 2019 Issue Brief CMS s 2018 Proposed Medicaid Managed Care Rule: A Summary of Major Provisions Elizabeth Hinton and MaryBeth Musumeci Executive Summary Managed care is the predominant Medicaid
More informationMedicare Advantage (Part C) Review
Medicare Advantage (Part C) Review 1 Medicare For people 65+ and under 65 with a disability 4 parts of Medicare Part A: Hospital Insurance Part B: Medical Insurance Part C: Medicare Advantage Plans Part
More informationBILLING GLOSSARY OF TERMS
BILLING GLOSSARY OF TERMS Account Number: A unique number that is assigned in your medical record each time you visit the hospital. Adjustment: A portion of your hospital bill that is adjusted in accordance
More informationChecklist: How Consumer Focused Are Your State s Medicaid Managed Long Term Services and Supports?
Checklist: How Consumer Focused Are Your State s Medicaid Managed Long Term Services and Supports? Many states are overhauling the delivery of long-term supports and services (LTSS) for consumers in Medicaid
More informationAppeals Provider Manual - New Jersey 15
Table of Contents Medical Necessity appeals... 15.1 Member or provider on behalf of Member appeals process... 15.1 Internal utilization management appeals... 15.1 Stage I appeals (internal)... 15.3 Nonexpedited
More informationIC Chapter 34. Limited Service Health Maintenance Organizations
IC 27-13-34 Chapter 34. Limited Service Health Maintenance Organizations IC 27-13-34-0.1 Application of certain amendments to chapter Sec. 0.1. The amendments made to section 12 of this chapter by P.L.69-1998
More informationPPO PLANS DISCLOSURE FORM Blue Cross and Blue Shield of Arizona Effective on and after January 1, 2012
PPO PLANS DISCLOSURE FORM Blue Cross and Blue Shield of Arizona Effective on and after January 1, 2012 This form applies to the following plans: BluePreferred 100/50, BluePreferred 90/70, BluePreferred
More informationREVISOR SGS/SA
1.1 A bill for an act 1.2 relating to health; modifying requirements for health maintenance organizations; 1.3 modifying provisions governing health insurance; appropriating money; amending 1.4 Minnesota
More informationTitle I - Health Care Coverage
September 21, 2009 The Honorable Max Baucus Chairman, Senate Finance Committee 511 Hart Senate Office Building Washington, DC 20510 Dear Senator Baucus: On behalf of the American College of Physicians,
More informationSexually Transmitted Disease Treatment Clinical Coverage Policy No: 1D-2 Provided in Health Departments Amended Date: October 1, 2015
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1 General... 1 2.1.2 Specific... 1 2.2 Special
More informationHEALTHCARE REVIEW PROGRAM
HEALTHCARE REVIEW PROGRAM ANNUAL REPORT 2008 North Carolina Department of Insurance Wayne Goodwin, Commissioner A REPORT ON EXTERNAL REVIEW REQUESTS IN NORTH CAROLINA Healthcare Review Program North Carolina
More informationNUTS AND BOLTS TRAINING FOR LEGISLATORS:
NUTS AND BOLTS TRAINING FOR LEGISLATORS: FUNDING FOR COMMUNITY MENTAL HEALTH, SUBSTANCE USE DISORDER AND INTELLECTUAL OR OTHER DEVELOPMENTAL DISABILITIES LEZA WAINWRIGHT, CEO Transforming Lives TRILLIUM
More informationCHAPTER 32. AN ACT concerning health insurance and health care providers and supplementing various parts of the statutory law.
CHAPTER 32 AN ACT concerning health insurance and health care providers and supplementing various parts of the statutory law. BE IT ENACTED by the Senate and General Assembly of the State of New Jersey:
More informationHome Office: Schaumburg, Illinois Administrative Office: Philadelphia, Pennsylvania
Home Office: Schaumburg, Illinois Administrative Office: Philadelphia, Pennsylvania POLICYHOLDER: Sedgwick County Area Educational Services POLICY NUMBER: GL 154255 EFFECTIVE DATE: September 1, 2015, as
More informationI. Claim submission instructions
Humboldt Del Norte Independent Practice Association And Humboldt Del Norte Foundation for Medical Care Claims Settlement Practices and Dispute Resolutions Mechanism As required by Assembly Bill 1455, the
More informationFrom: Center for Consumer Information and Insurance Oversight (CCIIO) Title: DRAFT 2016 Letter to Issuers in the Federally-facilitated Marketplaces
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Consumer Information & Insurance Oversight 200 Independence Avenue SW Washington, DC 20201 Date: December 19, 2014
More informationThe Patient Protection and Affordable Care Act. An In-Depth Analysis of Provisions Directly or Indirectly Affecting Group Health Plans
The Patient Protection and Affordable Care Act An In-Depth Analysis of Provisions Directly or Indirectly Affecting Group Health Plans Table of Contents Section 1 Insurance Plan Provisions Prohibition on
More information