Regional Generic Provider Agreement - Ohio Department of Job and ...

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Appendix L Covered Families and Children (CFC) population Page 14 The designated PCP is the provider who will manage and coordinate the overall care for CFC members, including those who have case management needs. The MCP must submit a Members’ Designated PCP file every month. Specialists may and should be identified as the PCP as appropriate for the member’s condition per the specialty types specified for the CFC population in ODJFS Member’s PCP Data File and Submission Specifications; however, no CFC member may have more than one PCP identified for a given month. 4.a. Timely submission of Member’s PCP Data Data Quality Submission Requirement: The MCP must submit a Members’ Designated PCP Data file on a monthly basis according to the specifications established in ODJFS Member’s PCP Data File and Submission Specifications. Penalty for noncompliance: See Appendix N, Compliance Assessment System, for the penalty for noncompliance with this requirement. 4.b. Designated PCP for newly enrolled members (only applicable for report periods prior to January 2008) Measure: The percentage of MCP’s newly enrolled members who were designated a PCP by their effective date of enrollment. Report Periods: For the third and fourth quarters of SFY 2007, performance will be evaluated using the January – March 2007 and April – June 2007 report periods. For the SFY 2008 contract period, performance will be evaluated using the July-September 2007, and October – December 2007 report periods. Data Quality Standard: SFY 2007 will be informational only. A minimum rate of 75% of new members with PCP designation by their effective date of enrollment for quarter one and quarter two of SFY 2008. Statewide Approach: MCPs will be evaluated using a statewide result, including all active regions and counties (Mahoning and Trumbull) in which an MCP has CFC membership. Penalty for noncompliance: If an MCP is noncompliant with the standard, ODJFS will impose a monetary sanction of one-half of one percent the current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. As stipulated in OAC rule 5101:3-26-08.2, each new member must have a designated primary care provider (PCP) prior to their effective date of coverage. Therefore, MCPs are subject to additional corrective action measures under Appendix N, Compliance Assessment System, for failure to meet this requirement. 4.b.i. Designated PCP for newly enrolled members (only applicable for report periods after December 2007)
Appendix L Covered Families and Children (CFC) population Page 15 Measure: The percentage of MCP’s newly enrolled members who were designated a PCP by their effective date of enrollment. Statewide Approach: MCPs will be evaluated using their statewide result, including all active regions and counties (Mahoning and Trumbull) in which an MCP has CFC membership. Report Periods: For the SFY 2009 contract period, performance will be evaluated annually using CY 2008. Data Quality Standards: For SFY 2009, a minimum rate of 85% of new members with PCP designation by their effective date of enrollment. Penalty for noncompliance: If an MCP is noncompliant with the standard, ODJFS will impose a monetary sanction of one-half of one percent the current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. As stipulated in OAC rule 5101:3-26-08.2, each new member must have a designated primary care provider (PCP) prior to their effective date of coverage. Therefore, MCPs are subject to additional corrective action measures under Appendix N, Compliance Assessment System, for failure to meet this requirement. 5. APPEALS AND GRIEVANCES DATA Pursuant to OAC rule 5101:3-26-08.4, MCPs are required to submit information at least monthly to ODJFS regarding appeal and grievance activity. ODJFS requires these submissions to be in an electronic data file format pursuant to the Appeal File and Submission Specifications and Grievance File and Submission Specifications. The appeal data file and the grievance data file must include all appeal and grievance activity, respectively, for the previous month, and must be submitted by the ODJFS-specified due date. These data files must be submitted in the ODJFS-specified format and with the ODJFS-specified filename in order to be successfully processed. Penalty for noncompliance: MCPs who fail to submit their monthly electronic data files to the ODJFS by the specified due date or who fail to resubmit, by no later than the end of that month, a file which meets the data quality requirements will be subject to penalty as stipulated under the Compliance Assessment System (Appendix N). 6. NOTES 6.a. Penalties, Including Monetary Sanctions, for Noncompliance
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Baseline Covered Families and Child
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APPENDIX A OAC RULES 5101:3-26 The
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Appendix C Covered Families and Chi
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Appendix D Covered Families and Chi
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Appendix D Covered Families and Chi
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APPENDIX E RATE METHODOLOGY CFC ELI
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APPENDIX F REGIONAL RATES 2. AT-RIS
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Appendix G Covered Families and Chi
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Appendix H Covered Families and Chi
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Appendix H Page 10 ensure that the
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Page 111 and 112: PCPs Capacity 1 North East Central
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Page 117 and 118: County Capacity 1 North West Region
Page 119 and 120: Provider Types Pediatricians 4 Nort
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Page 127 and 128: Appendix I Covered Families and Chi
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Page 131 and 132: Appendix J Page 2 h. Prompt Pay Rep
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Page 193 and 194: Appendix P Covered Families and Chi
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