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

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Appendix D Covered Families and Children (CFC) population Page 3 ODJFS will provide information on what services the MCP will not cover and how and where the MCP’s members may obtain these services in the applicable Consumer Guides. 15. Membership Selection and Premium Payment a. The managed care enrollment center (MCEC): The ODJFS-contracted MCEC will provide unbiased education, selection services, and community outreach for the Medicaid managed care program. The MCEC shall operate a statewide toll-free telephone center to assist eligible individuals in selecting an MCP or choosing a health care delivery option. The MCEC shall distribute the most current Consumer Guide that includes the managed care program information as specified in 42 CFR 438.10, as well as ODJFS prior-approved MCP materials, such as solicitation brochures and provider directories, to consumers who request additional materials. b. Auto-Assignment Limitations – In order to ensure market and program stability, ODJFS may limit an MCP’s auto-assignments if they meet any of the following enrollment thresholds: • 40% of statewide Covered Families and Children (CFC) eligible population; and/or • 60% of the CFC eligibles in any region with two MCPs; and/or • 40% of the CFC eligibles in any region with three MCPs. Once an MCP meets one of these enrollment thresholds, the MCP will only be permitted to receive the additional new membership (in the region or statewide, as applicable) through: (1) consumer-initiated enrollment; and (2) auto-assignments which are based on previous enrollment in that MCP or an historical provider relationship with a provider who is not on the panel of any other MCP in that region. In the event that an MCP in a region meets one or more of these enrollment thresholds, ODJFS, in their sole discretion, may not impose the auto-assignment limitation and auto-assign members to the MCPs in that region as ODJFS deems appropriate. c. Consumer Contact Record (CCR): ODJFS or their designated entity shall forward CCRs to MCPs on no less than a weekly basis. The CCRs are a record of each consumer-initiated MCP enrollment, change, or termination, and each MCEC initiated MCP assignment processed through the MCEC. The CCR contains information that is not included on the monthly member roster.
Appendix D Covered Families and Children (CFC) population Page 4 d. Monthly member roster (MR): ODJFS verifies managed care plan enrollment on a monthly basis via the monthly membership roster. ODJFS or its designated entity provides a full member roster (F) and a change roster (C) via HIPAA 834 compliant transactions. e. Monthly Premiums and Delivery Payments: ODJFS will remit payment to the MCPs via an electronic funds transfer (EFT), or at the discretion of ODJFS, by paper warrant. f. Remittance Advice: ODJFS will confirm all premium payments and delivery payments paid to the MCP during the month via a monthly remittance advice (RA), which is sent to the MCP the week following state cut-off. ODJFS or its designated entity provides a record of each payment via HIPAA 820 compliant transactions. g. MCP Reconciliation Assistance: ODJFS will work with an MCP-designated contact(s) to resolve the MCP’s member and newborn eligibility inquiries, premium and delivery payment inquiries/discrepancies and to review/approve hospital deferment requests. 16. ODJFS will make available a website which includes current program information. 17. ODJFS will regularly provide information to MCPs regarding different aspects of MCP performance including, but not limited to, information on MCP-specific and statewide external quality review organization surveys, focused clinical quality of care studies, consumer satisfaction surveys and provider profiles. 18. ODJFS will periodically review a random sample of online and printed directories to assess whether MCP information is both accessible and updated. 19. Communications a. ODJFS/BMHC: The Bureau of Managed Health Care (BMHC) is responsible for the oversight of the MCPs’ provider agreements with ODJFS. Within the BMHC, a specific Contract Administrator (CA) has been assigned to each MCP. Unless expressly directed otherwise, MCPs shall first contact their designated CA for questions/assistance related to Medicaid and/or the MCP’s program requirements /responsibilities. If their CA is not available and the MCP needs immediate assistance, MCP staff should request to speak to a supervisor within the Contract Administration Section. MCPs should take all necessary and appropriate steps to
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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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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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