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

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Appendix N Covered Families and Children (CFC) population Page 7 nonrefundable fine for the failure to meet CFC panel requirements; and, (2) a $1,000 nonrefundable fine for the failure to meet ABD panel requirements). • practitioner requirements in Franklin county for the CFC population • practitioner requirements in Franklin county for the ABD population • hospital requirements in Franklin county for the CFC population • PCP capacity requirements in Fairfield county for the CFC population In addition to the pre-determined penalties, ODJFS may assess additional penalties pursuant to this Appendix (e.g. CAPs, points, fines) if member specific access issues are identified resulting from provider panel noncompliance. J.2. Geographic Information System - Compliance with the Geographic Information System (GIS) requirements will be assessed semi-annually. Any failure to meet GIS requirements as specified in Appendix H of the Agreement will result a $1,000 nonrefundable fine for each county and for each population (e.g., ABD, CFC, etc.). For example if the MCP did not meet GIS requirements in the following counties, the MCP would be assessed (1) a nonrefundable $2,000 fine for the failure to meet GIS requirements for the CFC population and (2) a $1,000 nonrefundable fine for the failure to meet GIS requirements for the ABD population. • GIS requirements in Franklin county for the CFC population • GIS requirements in Fairfield county for the CFC population • GIS requirements in Franklin county for the ABD population J.3. Late Submissions - All required submissions/data and documentation requests must be received by their specified deadline and must represent the MCP in an honest and forthright manner. Failure to provide ODJFS with a required submission or any data/documentation requested by ODJFS will result in the assessment of a nonrefundable fine of $100 per day, unless the MCP requests and is granted an extension by ODJFS. Assessments for late submissions will be done monthly. Examples of such program violations include, but are not limited to: • Late required submissions o Annual delegation assessments o Call center report o Franchise fee documentation o Reinsurance information (e.g., prior approval of changes) o State hearing notifications • Late required data submissions o Appeals and grievances, case management, or PCP data • Late required information requests o Automatic call distribution reports o Information/resolution regarding consumer or provider
Appendix N Covered Families and Children (CFC) population Page 8 complaint o Just cause or other coordination care request from ODJFS o Provider panel documentation o Failure to provide ODJFS with a required submission after ODJFS has notified the MCP that the prescribed deadline for that submission has passed If an MCP determines that they will be unable to meet a program deadline or data/documentation submission deadline, the MCP must submit a written request to its Contract Administrator for an extension of the deadline, as soon as possible, but no later than 3 PM EST on the date of the deadline in question. Extension requests should only be submitted in situations where unforeseeable circumstances have occurred which make it impossible for the MCP to meet an ODJFS-stipulated deadline and all such requests will be evaluated upon this standard. Only written approval as may be granted by ODJFS of a deadline extension will preclude the assessment of compliance action for untimely submissions. J.4. Noncompliance with Claims Adjudication Requirements - If ODJFS finds that an MCP is unable to (1) electronically accept and adjudicate claims to final status and/or (2) notify providers of the status of their submitted claims, as stipulated in Appendix C of the Agreement, ODJFS will assess the MCP with a monetary sanction of $20,000 per day for the period of noncompliance. If ODJFS has identified specific instances where an MCP has failed to take the necessary steps to comply with the requirements specified in Appendix C of the Agreement for (1) failing to notify non-contracting providers of procedures for claims submissions when requested and/or (2) failing to notify contracting and non-contracting providers of the status of their submitted claims, the MCP will be assessed 5 points per incident of noncompliance. J.5. Noncompliance with Prompt Payment: - Noncompliance with the prompt pay requirements as specified in Appendix J of the Agreement will result in progressive penalties. The first violation during a rolling 12-month period will result in the submission of quarterly prompt pay and monthly status reports to ODJFS until the next quarterly report is due. The second violation during a rolling 12-month period will result in the submission of monthly status reports and a refundable fine equal to 5% of the MCP’s monthly premium payment or $300,000, whichever is less. The refundable fine will be applied in lieu of a nonrefundable fine and the money will be refunded by ODJFS only after the MCP complies with the required standards for two (2) consecutive quarters. Subsequent violations will result in an enrollment freeze.
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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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Appendix I Covered Families and Chi
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Appendix I Covered Families and Chi
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