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

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Appendix C Covered Families and Children (CFC) population Page 22 includes the delivery of stillborns where the MCP incurred costs related to the delivery. Rejections If a delivery encounter is not submitted according to ODJFS specifications, it will be rejected and MCPs will receive this information on the exception report (or error report) that accompanies every file in the ODJFS-specified format. Tracking, correcting and resubmitting all rejected encounters is the responsibility of the MCP and is required by ODJFS. Timing of Delivery Payments MCPs will be paid monthly for deliveries. For example, payment for a delivery encounter submitted with the required encounter data submission in March, will be reimbursed in March. The delivery payment will cover any encounters submitted with the monthly encounter data submission regardless of the date of the encounter, but will not cover encounters that occurred over one year ago. This payment will be a part of the weekly update (adjustment payment) that is in place currently. The third weekly update of the month will include the delivery payment. The remittance advice is in the same format as the capitation remittance advice. Updating and Deleting Delivery Encounters The process for updating and deleting delivery encounters is handled differently from all other encounters. See the ODJFS Encounter Data Specifications for detailed instructions on updating and deleting delivery encounters. The process for deleting delivery encounters can be found on page 35 of the UB-92 technical specifications (record/field 20-7) and page III-47 of the NSF technical specifications (record/field CA0-31.0a). Auditing of Delivery Payments A delivery payment audit will be conducted periodically. If medical records do not substantiate that a delivery occurred related to the payment that was made, then ODJFS will recoup the delivery payment from the MCP. Also, if it is determined that the encounter which triggered the delivery payment was not a paid encounter, then ODJFS will recoup the delivery payment. 32. If the MCP will be using the Internet functions that will allow approved users to access member information (e.g., eligibility verification), the MCP must receive prior approval from ODJFS that verifies that the proper safeguards, firewalls, etc., are in place to protect member data. 33. MCPs must receive prior written approval from ODJFS before adding any information to their website that would require ODJFS prior approval in hard copy form (e.g., provider
Appendix C Covered Families and Children (CFC) population Page 23 listings, member handbook information). 34. Pursuant to 42 CFR 438.106(b), the MCP acknowledges that it is prohibited from holding a member liable for services provided to the member in the event that the ODJFS fails to make payment to the MCP. 35. In the event of an insolvency of an MCP, the MCP, as directed by ODJFS, must cover the continued provision of services to members until the end of the month in which insolvency has occurred, as well as the continued provision of inpatient services until the date of discharge for a member who is institutionalized when insolvency occurs. 36. Franchise Fee Assessment Requirements a. Each MCP is required to pay a franchise permit fee to ODJFS for each calendar quarter as required by ORC Section 5111.176. The current fee to be paid is an amount equal to 4½ percent of the managed care premiums, minus Medicare premiums that the MCP received from any payer in the quarter to which the fee applies. Any premiums the MCP returned or refunded to members or premium payers during that quarter are excluded from the fee. b. The franchise fee is due to ODJFS in the ODJFS-specified format on or before the 30th day following the end of the calendar quarter to which the fee applies. c. At the time the fee is submitted, the MCP must also submit to ODJFS a completed form and any supporting documentation pursuant to ODJFS specifications. d. Penalties for noncompliance with this requirement are specified in Appendix N, Compliance Assessment System of the Provider Agreement and in ORC Section 5111.176. 37. Information Required for MCP Websites a. On-line Provider Directory – MCPs must have an internet-based provider directory available in the same format as their ODJFS-approved provider directory, that allows members to electronically search for the MCP panel providers based on name, provider type, geographic proximity, and population (as specified in Appendix H). MCP provider directories must include all MCP-contracted providers [except as specified by ODJFS] as well as certain ODJFS non-contracted providers. b. On-line Member Website – MCPs must have a secure internet-based website which is regularly updated to include the most current ODJFS approved materials. The website at a minimum must include: (1) a list of the counties that are covered
Page 1 and 2: Baseline Covered Families and Child
Page 13 and 14: APPENDIX A OAC RULES 5101:3-26 The
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Page 45: APPENDIX E RATE METHODOLOGY CFC ELI
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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 J Page 2 h. Prompt Pay Rep
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Appendix J Page 4 If the financial
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Appendix J Page 6 Penalty for nonco
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Appendix J Page 8 6. NOTIFICATION O
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Appendix K Covered Families and Chi
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Appendix L Covered Families and Chi
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Appendix M Covered Families and Chi
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Appendix N Covered Families and Chi
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Appendix O Covered Families and Chi
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Appendix P Covered Families and Chi
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Appendix P Covered Families and Chi
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Regional Generic Provider Agreement - Ohio Department of Job and ...

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