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

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Appendix N Covered Families and Children (CFC) population Page 3 In situations where a penalty is assessed for a violation an MCP has previously been assessed a CAP (or any penalty or any other related written correspondence), the MCP may be assessed escalating penalties. B. Quality Improvement Directives (QIDs) – A QID is a general instruction that directs the MCP to implement a quality improvement initiative to improve identified administrative or clinical deficiencies. All QIDs remain in effect for twelve months from the date of implementation. MCPs may be required to develop QIDs for any instance of noncompliance. In situations where ODJFS has already determined the specific action which must be implemented by the MCP or if the MCP has failed to submit a QID, ODJFS may require the MCP to comply with an ODJFS-developed or “directed” QID. In situations where a penalty is assessed for a violation an MCP has previously been assessed a QID (or any penalty or any other related written correspondence), the MCP may be assessed escalating penalties. C. Points - Points will accumulate over a rolling 12-month schedule. Each month, points that are more than 12-months old will expire. Points will be tracked and monitored separately for each Agreement the MCP concomitantly holds with the BMHC, beginning with the commencement of this Agreement (i.e., the MCP will have zero points at the onset of this Agreement). No points will be assigned for any violation where an MCP is able to document that the precipitating circumstances were completely beyond their control and could not have been foreseen (e.g., a construction crew severs a phone line, a lightning strike blows a computer system, etc.). C.1. 5 Points -- Failures to meet program requirements, including but not limited to, actions which could impair the member’s ability to obtain correct information regarding services or which could impair a consumer’s or member’s rights, as determined by ODJFS, will result in the assessment of 5 points. Examples include, but are not limited to, the following: • Violations which result in a member’s MCP selection or termination based on inaccurate provider panel information from the MCP. • Failure to provide member materials to new members in a timely manner. • Failure to comply with appeal, grievance, or state hearing requirements, including the failure to notify a member of their right to a state hearing when the MCP proposes to deny, reduce, suspend or
Appendix N Covered Families and Children (CFC) population Page 4 terminate a Medicaid-covered service. • Failure to staff 24-hour call-in system with appropriate trained medical personnel. • Failure to meet the monthly call-center requirements for either the member services or the 24-hour call-in system lines. • Provision of false, inaccurate or materially misleading information to health care providers, the MCP’s members, or any eligible individuals. • Use of unapproved marketing or member materials. • Failure to appropriately notify ODJFS or members of provider panel terminations. • Failure to update website provider directories as required. C.2. 10 Points -- Failures to meet program requirements, including but not limited to, actions which could affect the ability of the MCP to deliver or the consumer to access covered services, as determined by ODJFS. Examples include, but are not limited to, the following: • Discrimination among members on the basis of their health status or need for health care services (this includes any practice that would reasonably be expected to encourage termination or discourage selection by individuals whose medical condition indicates probable need for substantial future medical services). • Failure to assist a member in accessing needed services in a timely manner after request from the member. • Failure to provide medically-necessary Medicaid covered services to members. • Failure to process prior authorization requests within the prescribed time frames. D. Fines – Refundable or nonrefundable fines may be assessed as a penalty separate to or in combination with other sanctions/remedial actions. D.1. Unless otherwise stated, all fines are nonrefundable. D.2. Pursuant to procedures as established by ODJFS, refundable and nonrefundable monetary sanctions/assurances must be remitted to ODJFS within thirty (30) days of receipt of the invoice by the MCP. In addition, per Ohio Revised Code Section 131.02, payments not received within forty-five (45) days will be certified to the Attorney General’s (AG’s) office. MCP payments certified to the AG’s office will be assessed the appropriate collection fee by the AG’s office. D.3. Monetary sanctions/assurances imposed by ODJFS will be based on the most recent premium payments.
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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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General Hospital 1 Hospital System
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Minimum Provider Panel Requirements
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Minimum Provider Panel Requirements
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General Hospital 1 Total Required H
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PCPs Capacity 1 North East Central
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County Capacity 1 Central Region -
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PCPs Capacity 1 Total Required Adam
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County Capacity 1 North West Region
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Provider Types Pediatricians 4 Nort
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Provider Types Pediatricians 4 Tota
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Provider Types Pediatricians 4 Sout
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Provider Types Pediatricians 4 Nort
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