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AGREEMENT # NHPRI RHO 14/16-001CONTRACT BETWEENSTATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONSEXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICESANDNEIGHBORHOOD HEALTH PLAN OF RHODE ISLANDFOR MEDICAID MANAGED INTEGRATED ADULT CARE SERVICESIN THE RHODY HEALTH OPTIONS PROGRAMNovember 1, 2013I
AGREEMENT # NHPRI RHO 14/16-001TABLE OF CONTENTSPageARTICLE 1.381.391.40DEFINITIONS .1CAPITATION PAYMENT .1CARE COORDINATION .1CARE MANAGEMENT .1CASE MANAGEMENT .2CMS .2CROSSOVER CLAIMS .2COLD CALL MARKETING .2COMPREHENSIVE FUNCTIONAL NEEDS ASSESSMENT .2COMPREHENSIVE RISK CONTRACT .2CONFLICT FREE CARE MANAGEMENT .3CONTRACTOR .3CONTRACT SERVICES .3COVERED SERVICES .3DAYS .3DURABLE MEDICAL EQUIPMENT .3DEPARTMENT .3EMERGENCY DENTAL CONDITION .3EMERGENCY SERVICES .4ENROLLEE .4FAMILY .4GRIEVANCE .4HEALTH CARE PROFESSIONAL .4HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACTOF 1996 (HIPAA).4HEALTH PLAN, PLAN, OR HMO .5HOMEMAKER .5HOME MODIFICATIONS .5HOME CARE SERVICES .5HOME HEALTH SERVICES .5IBNR (Incurred But Not Reported) .6INTEGRATED CARE INITIATIVE .6INITIAL HEALTH SCREEN .6MARKETING.6MARKETING MATERIALS .6MEDICAID/MEDICARE ELIGIBLE.6MEDICAL NECESSITY, MEDICALLY NECESSARY, OR MEDICALLYNECESSARY SERVICE.7MEMBER .7MID-LEVEL PRACTITIONERS .7MINOR ASSISTIVE DEVICES .7NON-PARTICIPATING PHYSICIAN .7OPTIONS COUNSELING .7II
AGREEMENT # NHPRI RHO 31.641.651.661.67PARTY .7PATIENT CENTERED MEDICAL HOMES .8PERSONAL CARE SERVICES .8PHASE I.8PHASE II .8PLAN OF CARE .8PLAN PHYSICIAN OR PARTICIPATING PHYSICIAN.9POST-STABILIZATION CARE SERVICES .9POTENTIAL ENROLLEE .9PREPAID BENEFIT PACKAGE.9PRIMARY CARE .9PRIMARY CARE PROVIDER (PCP) .9PRIVATE DUTY NURSING .10PROVIDER PREVENTABLE CONDITION .10RHODY HEALTH OPTIONS .10RHODY HEALTH OPTIONS ELIGIBLES .10RISK CONTRACT .10RITE @ HOME .11SELF-DIRECTED SERVICES .11SHORT-TERM CARE MANAGEMENT .11SIBLING .11SSI .11SPMI AND DEVELOPMENTALLY DISABLED POPULATION .11STABILIZED .12STATE .12UNINSURED .12URGENT MEDICAL CONDITION .12ARTICLE II: HEALTH PLAN PROGRAM STANDARDS .132.01 GENERAL .132.02 LICENSURE, ACCREDITATION, CERTIFICATION .132.02.01Phase I .132.02.02Phase II.152.03 HEALTH PLAN ADMINISTRATION .152.03.01Executive Management .152.03.02Other Administrative Components .152.03.03RI Works Participants .162.04 ELIGIBILITY AND PROGRAM ENROLLMENT .162.04.01Rhody Health Options Eligible Groups .162.04.02Rhody Health Options Exempt Populations .172.04.03Rhody Health Options New Eligibility Groups .172.04.04Rhody Health Options Eligibility Determination .172.04.05Rhody Health Options Eligibility for Long-Term Care Services .172.04.06Rhody Health Options Guaranteed Eligibility .172.04.07Rhody Health Options Non-Biased Enrollment Counseling .182.04.08Voluntary Selection of Health Plan by Rhody Health OptionsMembers .18III
AGREEMENT # NHPRI RHO 14/16-0012.04.092.04.10Rhody Health Options Automatic Assignment to Health Plans .18Rhody Health Options Automatic Re-Assignment FollowingResumption of Eligibility.182.05MEMBER ENROLLMENT AND DISENROLLMENT .192.05.01Health Plan Marketing .192.05.02Health Plan Enrollment Procedures for Rhody Health OptionsEligibles .192.05.03Change in Status .202.05.04Enrollment and Disenrollment Updates .202.05.05Services for New Members .202.05.06New Member Orientation .212.05.07Assignment of Primary Care Providers (PCPs) .212.05.08Changing PCPs .222.05.09Identification Cards .222.05.10Member Handbook .232.05.10.01Required Information .232.05.10.02State Approval .272.05.10.03Languages Other Than English .272.05.11Transitioning Members between Plans .272.05.12Member Disenrollment .272.05.12.01General Authority .282.05.12.02Reasons for Disenrollment .282.05.12.03Disenrollment Effective Dates .292.06IN-PLAN SERVICES .292.06.01Description of Comprehensive Benefit Package for RhodyHealth Partners and Rhody Health Options Members .292.06.01.01General.292.06.01.02Long-Term Services & Supports .312.06.01.03Preventive Services .312.06.01.04Interpreter/Translation Services .312.06.02Enrollee Provider Communication .312.06.03Second Opinion .322.06.04New In-Plan Services .322.07CARE MANAGEMENT AND CARE COORDINATION .322.07.01Coordination of Care.322.07.02Care Management Program .332.08COORDINATION WITH OUT-OF-PLAN SERVICES ANDOTHER HEALTH/ SOCIAL SERVICES AVAILABLE TO MEMBERS .342.08.01General .342.08.02Mental Health Services for the Seriously and PersistentlyMentally Ill.342.08.03Dental Services .342.08.04Services of the Rhode Island Division of Elderly Affairs .35IV
AGREEMENT # NHPRI RHO 10Services of the Rhode Island Department of Human Services .35Services of the Rhode Island Department of Health .35Housing .35CurrentCare .35Non-Emergency Transportation.35PROVIDER NETWORKS .362.09.01Network Composition .362.09.02Primary Care Providers (PCPs) .382.09.02.01PCP Responsibilities .382.09.02.02Eligible Specialties.382.09.02.03PCP Teams .392.09.02.04PCP Sites.392.09.02.05Certified Nurse Practitioners as PCP’s .392.09.02.06Member-to-PCP Ratios .392.09.02.07In-Network Self-Referrals .392.09.02.08Transitioning between Non-Network and NetworkProviders for Medical and Behavioral Health .402.09.03Mental Health Providers .402.09.03.01Provider Mix .402.09.03.02In-Network Self Referrals .412.09.03.03Transitioning between Non-Network and Network Providers .412.09.04Substance Abuse Providers .412.09.04.01Provider Composition .412.09.04.02In-Network Self Referrals .412.09.04.03Transitioning Between Non-Network And Network Providers.422.09.05Physician Specialists .422.09.06Long-Term Care Providers .422.09.06.01Provider Composition .422.09.06.02Service Philosophy.432.09.06.03Provider Monitoring.432.09.07FQHCs/RHCs .432.09.08Department of Health Laboratory .432.09.09Title X Providers .442.09.10Mainstreaming .442.09.11Selective Contracting .442.09.12Provider Network Lists .442.09.13Network Changes .442.09.14Provider Discrimination .452.09.15New Members’ Providers .45SERVICE ACCESSIBILITY STANDARDS .452.10.01Twenty-Four Hour Coverage .452.10.02Travel Time .452.10.03Emergency Medical Services .452.10.04Days to Appointment for Non-Emergency Services .462.10.05Post-Stabilization Care Services .462.10.06Access For Women .47V
AGREEMENT # NHPRI RHO 14/16-0012.112.122.132.142.152.10.07Assessments Standards .472.10.08Compliance with Accessibility Standards .482.10.09Access for Rhody Health Options Members with Special Needs.482.10.10Access Standards for Long-Term Care .482.10.11State Affordability Standards .48MEMBER SERVICES .492.11.01General .492.11.02Toll-Free Telephone Number .492.11.03Annual Notification .492.11.04Cultural Competency .512.11.05Best Practices .51PROVIDER SERVICES .51MEDICAL MANAGEMENT AND QUALITY ASSURANCE .522.13.01General .522.13.02Medical Director's Office.522.13.03Utilization Review and Quality Assurance n Review .542.13.03.03Quality Assurance .552.13.03.04Confidentiality .562.13.03.05State and Federal Reviews .562.13.03.06Practice Guidelines .562.13.03.07Service Provision .572.13.04Provider Credentialing .57OPERATIONAL DATA REPORTING .582.14.01General .592.14.02Utilization Data .592.14.02.01Person-Level Record .592.14.02.02Aggregate Data .592.14.02.03Data Format .592.14.02.04Timing of Data Submittal .592.14.02.05Data Validation .592.14.03Grievance and Appeals Data .602.14.04Quality Assurance Data .602.14.05Member Satisfaction Report .602.14.06Fraud and Abuse Reports .602.14.07RIte Share Reporting.612.14.08Presentation of Findings .612.14.09Health Insurance Portability and Accountability ActRequirements (HIPAA) .612.14.10Certification of Data .612.14.11Patient Protection and Affordability Care Act .61GRIEVANCE AND APPEALS .612.15.01General .622.15.02Complaint Resolution .652.15.03Grievance Process .652.15.04Expedited Resolution of Appeals.65VI
AGREEMENT # NHPRI RHO 14/16-0012.16PAYMENTS TO AND FROM PLANS .662.16.01Acceptance of State Capitation Payments .662.16.01.01Transitional Rate .662.16.02Payments to ive Eligibility Period .672.16.02.03In-Network (Contracted) Services .672.16.02.04Out-of-Network and Out-of-State Providers .682.16.02.05FQHCs/RHCs .692.16.02.06Hospital Services .692.16.02.07Nursing Homes .692.16.02.08Liability During an Active Grievance or Appeal . . 692.16.02.09Limit on Payment to Other Providers .692.16.02.10Physician Incentive Plans .702.16.02.11Actuarial Basis .702.16.02.12Prohibition on Restocking and Doubling of Prescription Drugs .702.16.02.13Payment Adjustment for Provider Preventable Conditions .702.16.03Cost Sharing .702.16.04Third-Party Liability .702.16.05Reinsurance .712.16.06Reserving .712.16.07Claims Processing and MIS .712.16.08Audits .712.16.09Disproportionate Share Payments to Hospitals.722.16.10Incentive Payments for Attainment of Performance Goals .722.17HEALTH PLAN FISCAL STANDARDS .722.17.01General .722.17.02Financial Benchmarks .722.17.03Financial Data Reporting .732.17.04Audit .73RECORDS RETENTION.732.18.01General .732.18.02Operational Data Reports .732.18.03Medical Records .74COMPLIANCE.742.19.01General Requirements .742.19.02Prohibited Affiliations with Individuals Debarred by FederaAgencies .742.19.03Disclosure of the Contractor’s Ownership and Control Interest .752.19.04Disclosure by Providers: Information on Ownershipand Control.762.19.05Disclosure by Providers: Information Related to BusinessTransactions .772.19.06Disclosure by Providers: Information on Persons Convictedof Crimes .772.19.07Disclosures Made by Providers to the Contractor .782.182.19VII
AGREEMENT # NHPRI RHO 14/16-001ARTICLE III: CONTRACT TERMS AND CONDITIONS .813.01 GENERAL PROVISIONS .813.01.01Contract Composition and Order of Precedence .813.01.02Integration Clause .813.01.03Subsequent Conditions.813.01.04Effective Date and Term .823.01.05Contract Administration.823.01.06Contract Officers .823.01.07Liaisons .823.01.08Notification of Administrative Changes .833.01.09Notices .833.01.10Authority .833.01.11Federal Approval of Contract .833.02 INTERPRETATIONS AND DISPUTES .833.02.01Conformance with State and Federal Regulations .833.02.02Waivers .843.02.03Severability .843.02.04Jurisdiction .843.02.05Disputes.843.03 CONTRACT AMENDMENTS .853.04 PAYMENT .863.04.01Capitation Payments .863.04.02Payments to Subcontractors and Providers .863.04.03Liability for Payment .863.05 GUARANTEES, WARRANTIES, AND CERTIFICATIONS .873.05.01Contractor Certification of Truthfulness .873.05.02Contractor Certification of Legality.873.05.03Contractor Certification of HMO Licensure .873.05.04Performance Bond or Substitutes.873.05.05Subcontracts and Delegation of Duty .883.05.06Assignment of the Contract .893.05.07Hold Harmless .
state of rhode island and providence plantations executive office of health and human services and neighborhood health plan of rhode island for medicaid managed integrated adult care services in the rhody health options program november 1, 2013 . . 2.04 eligibility and program enrollment .16 2.04.01 rhody health options eligible groups .
