provider checklist · 2 revisions should be numbered in accordance according to the version of the...

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HHSC UNIFORM MANAGED CARE MANUAL 8.1 1 of 31

EFFECTIVE DATE

January 10, 2010

Provider Checklist

Version 1.5

DOCUMENT HISTORY LOG

STATUS1 DOCUMENT REVISION2

EFFECTIVE DATE

DESCRIPTION3

Baseline n/a November 15, 2005 Initial version of the Provider Checklist.

Revision 1.1 September 26, 2006

1. Provider Checklist revised to include provisions applicable to STAR+PLUS, CHIP Perinatal, and Foster Care Managed Care Organizations.

2. The “MCO Program Type and Contract Reference” columns are revised for all items.

3. Items 1, 11, 21, 23, 33, 34, 41, 42, 50, and 54 modified.

Revision 1.2 March 1, 2007 1. Provider Checklist revised to add provisions applicable to the ICM Program.

2. Contract reference in Item 33 modified.

Revision 1.3 December 31, 2007 Item 59 is revised to require a THSteps referral from PCPs not enrolled as THSteps providers.

Revision 1.4 September 15, 2008

Item 7, relating to the STAR Health Program is revised to remove sub-item 2, regarding use of the standardized outcome measurement instrument.

Item 8, relating to the STAR Health Program, is revised to require providers to submit Health Passport information in a monthly summary form provided by the MCO, and to add a requirement regarding submission of routine progress evaluations.

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Provider Checklist

Version 1.5

DOCUMENT HISTORY LOG

STATUS1 DOCUMENT REVISION2

EFFECTIVE DATE

DESCRIPTION3

Revision 1.5 January 10, 2010 Provider Checklist revised to include provisions applicable to CHIP Dental Program, and delete provisions applicable to the ICM Program.

1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions 2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the

second revision. 3 Brief description of the changes to the document made in the revision.

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Provider Checklist

Version 1.5

HHSC designed this checklist to help MCOs develop their contracts with Network Providers. Although HHSC has attempted to include all Standard Contract Provisions for Network Providers in this document, MCOs are ultimately responsible for ensuring that their Network Provider contracts comply with all applicable requirements of state and federal laws and the HHSC Managed Care Contract. The HHSC Managed Care Contract includes all documents that are attached to the contract, and all documents incorporated by reference into the contract (such as the HHSC Uniform Managed Care Manual). All Network Provider contracts must be in writing and include the following Standard Contract Provisions. If the Standard Contract Provision is italicized, then the MCO may not alter the language. If the Standard Contract Provision is not italicized, then the MCO may use either the Standard Contract Provision’s language or a substantive equivalent. Unless otherwise noted, the MCO may include the Standard Contract Provisions in either the Network Provider contract or the MCO’s Provider Manual. If the MCO includes Standard Contract Provisions in its Provider Manual, then the Network Provider contract must clearly state that the Provider Manual, and all amendments to the Provider Manual, are incorporated by reference into the contract. If a check mark appears in the column below the MCO Program Type, then the Standard Contract Provision applies to the program and must be included in the Network Provider contract and/or Provider Manual. No. Category Standard Contract Provision MCO Program Type and Contract Reference

CHIP CHIP CHIP STAR STAR+ STAR CHIP HMO EPO Perinatal

HMO HMO PLUS

HMO Health Dental MCO Program

1 Access to Records

The Network Provider agrees to provide the Texas Health and Human Services Commission (HHSC):

√ √ √ √ √ √ √

1. all information required under the MCO’s managed care contract with HHSC, including but not limited to the reporting requirements and other information related to the Network

Att. B-1, §8.1.20

Att. B-1, Att. B-1, §8.1.20

Att. B-1, §8.1.20

Att. B-1, §8.1.20

Att. B-1, §4.1.4.4

Att. B-1, §2.1.3.12 §§6.5 &

8.2.3.7.1

Item 1 modified by Version 1.1

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Provider Checklist

Version 1.5

No. Category Standard Contract Provision MCO Program Type and Contract Reference

CHIP HMO

CHIP EPO

CHIP Perinatal

HMO

STAR HMO

STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program Provider’s performance of its obligations under the contract; and

2. any information in its possession sufficient to permit HHSC to comply with the federal Balanced Budget Act of 1997 or other federal or state laws, rules, and regulations.

All information must be provided in accordance with the timelines, definitions, formats, and instructions specified by HHSC.

2 Advance Directives

Provider must comply with the requirements of state and federal laws, rules and regulations relating to advance directives.

√ Att. B-1, §8.2.12

√ Att. B-1, §8.2.12

√ Att. B-1, §4.1.33

3 Audit or Investigation

The Network Provider agrees to provide the following entities or their designees with prompt, reasonable, and adequate access to the Network Provider contract and any records, books, documents, and papers that are related to the Network Provider contract and/or the Network Provider’s performance of its responsibilities under this contract: 1. HHSC and MCO Program personnel from

HHSC; 2. U.S. Department of Health and Human

√

Att. A, §9.02

√

Att. A, §9.02

√

Att. A, §9.02

√

Att. A, §9.02

√

Att. A, §9.02

√

Att. A, §9.02

√

Att. A, §9.02

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CHIP HMO

CHIP EPO

CHIP Perinatal

HMO

STAR HMO

STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program Services;

3. Office of Inspector General and/or the Texas Medicaid Fraud Control Unit;

4. an independent verification and validation contractor or quality assurance contractor acting on behalf of HHSC;

5. state or federal law enforcement agency; 6. special or general investigation committee of

the Texas Legislature; 7. the U.S. Comptroller General; 8. the Office of the State Auditor of Texas; and 9. any other state or federal entity identified by

HHSC, or any other entity engaged by HHSC.

The Network Provider must provide access wherever it maintains such records, books, documents, and papers. The Network Provider must provide such access in reasonable comfort and provide any furnishings, equipment, and other conveniences deemed reasonably necessary to fulfill the purposes described herein. Requests for access may be for, but are not limited to, the following purposes:

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CHIP HMO

CHIP EPO

CHIP Perinatal

HMO

STAR HMO

STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program 1. examination; 2. audit; 3. investigation; 4. contract administration; 5. the making of copies, excerpts, or transcripts;

or 6. any other purpose HHSC deems necessary

for contract enforcement or to perform its regulatory functions.

4 Audit or Investigation

[Network Provider] understands and agrees that the acceptance of funds under this contract acts as acceptance of the authority of the State Auditor’s Office (“SAO”), or any successor agency, to conduct an investigation in connection with those funds. [Network Provider] further agrees to cooperate fully with the SAO or its successor in the conduct of the audit or investigation, including providing all records requested.

√

Att. A, §9.04

√

Att. A, §9.04

√

Att. A, §9.04

√

Att. A, §9.04

√

Att. A, §9.04

√

Att. A, §9.05

√

Att. A, §9.04

5 Behavioral Network Providers who are Primary Care √ √ √ √ √ √

1 In the EPO’s CHIP Perinatal Program, this requirement applies to a PCP who provides services to CHIP Perinate Newborns. The PCP requirements do not apply to CHIP Perinates.

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CHIP HMO

CHIP EPO

CHIP Perinatal

HMO

STAR HMO

STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program Health

Physicians (PCPs) must have screening and evaluation procedures for detection and treatment of, or referral for, any known or suspected behavioral health problems and disorders.

Att. B-1, §8.1.15.4

Att. B-1, 8.2.1.5.51

Att. B-1, §8.1.15.42

Att. B-1, §8.1.15.4

Att. B-1, §8.1.15.4

Att. B-1, §4.1.18.2

6 Behavioral Health

Network Providers who provide inpatient psychiatric services to a Member must schedule the Member for outpatient follow-up and/or continuing treatment prior to discharge. The outpatient treatment must occur within seven days from the date of discharge. Behavioral health providers must contact Members who have missed appointments within 24 hours to reschedule appointments.

√ Att. B-1, §8.1.15.5

√

Att. B-1, 8.2.1.5.53

√ Att. B-1,

§8.1.15.54

√ Att. B-1,

§8.1.15.55

√ Att. B-1, §8.1.15.5

√ Att. B-1, §4.1.18.6

7 Behavioral Health

Network Providers who are behavioral health providers must:

1. Submit to the MCO for inclusion into the Health Passport treatment plans and referrals to other providers.

√ Att. B-1, §4.1.18

2 This requirement applies to a PCP who provides services to CHIP Perinate Newborns. The PCP requirements do not apply to CHIP Perinates. 3 In the EPO’s CHIP Perinatal Program, this requirement applies to a PCP who provides services to CHIP Perinate Newborns. The PCP requirements do not apply to CHIP Perinates. 4 This requirement applies to a PCP who provides services to CHIP Perinate Newborns. The PCP requirements do not apply to CHIP Perinates. 5 This requirement does not apply to STAR HMOs in the Dallas CSA, whose Members receive Behavioral Health Services through the NorthSTAR Program.

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HMO HMO PLUS


2. Document the outcome measurement scores in the Health Passport.

3. Function as a member of the PCP Team by coordinating with the PCP and Service Manager as appropriate.

4. Testify in court as needed for child protection litigation.


Network Providers who are behavioral health providers must provide a monthly summary form, to be provided by the MCO. The following information must be included in the monthly summary form for the Health Passport:

8 Behavioral Health

√

Att. B-1, §4.1.18

1. Primary and secondary (if present) diagnosis.

2. Assessment information, including results of a mental status exam.

3. Brief narrative summary of the Member’s clinical visits/progress.

4. Scores on each outcome rating form(s). 5. Referrals to other providers or community

resources. 6. Health Care Service Plans and referrals to

providers.


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7. Evaluations of each Member’s progress at intake, monthly, and at termination of the Health Care Service Plan, or as significant changes are made in the treatment plan.

8. Any other relevant care information. Network Providers who are PCPs must use the Texas Health Steps behavioral health forms, at a minimum, for the detection and treatment of, or referral for, any known or suspected behavioral health problems and disorders. Members must be screened for behavioral health problems, including possible substance abuse or chemical dependency. The PCP must submit completed Texas Health Steps screening and evaluation results to the MCO to include in the Health Passport.

9 Behavioral Health

√ Att. B-1, §4.1.18

Network Provider must comply with the Psychotropic Medication Utilization Parameters for Foster Children found at

10 Coordination between Behavioral Health Services Provider and PCP

√ Att. B-1, §4.1.18.2 http://www.dshs.state.tx.us/mhprograms/psychotro

picMedicationFosterChildren.shtm, as amended or modified from time to time.

11 Claims Payment The method of payment applicable to this Network Provider contract are:

√ √ √ √ √ √ √ Att. B-1, Att. B-1, Att. B-1, Att. B-1, Att. B-1, Att. B-1, Att. B-1,


http://www.dshs.state.tx.us/mhprograms/psychotropicMedicationFosterChildren.shtm

http://www.dshs.state.tx.us/mhprograms/psychotropicMedicationFosterChildren.shtm

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CHIP HMO

CHIP EPO

CHIP Perinatal

HMO

STAR HMO

STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program [Note: Here, the MCO must provide a complete description of the payment method or payment amounts.]

§8.1.18.5 §8.2.1.6.1 §8.1.18.5 §8.1.18.5 §8.1.18.5 §4.1.22.56 §2.1.3.4

12 Claims Payment In order to submit a clean claim, Network Provider must provide the following information with the claim: [NOTE: Here, the MCO must include a complete listing of all required information. Include claims coding and processing guidelines for the applicable provider type.]

√ Att. B-1, §8.1.18.5

√ Att. B-1, §8.2.1.6.1

√ Att. B-1, §8.1.18.5

√ Att. B-1, §8.1.18.5

√ Att. B-1, §8.1.18.5

√ Att. B-1,

§4.1.22.57

√ Att. B-1, §2.1.3.4

13 Claims Payment MCO will provide the Network Provider at least 90 days notice prior to implementing a change in the above-referenced claims guidelines, unless the change is required by statute or regulation in a shorter timeframe.

√ Att. B-1, §8.1.18.5

√ Att. B-1, §8.2.1.6.1

√ Att. B-1, §8.1.18.5

√ Att. B-1, §8.1.18.5

√ Att. B-1, §8.1.18.5

√ Att. B-1,

§4.1.22.58

√ Att. B-1, §2.1.3.4

14 Claims Payment Network Providers must submit claims for processing and/or adjudication to the following entity/entities: [NOTE: Here, the MCO must provide a

√ See Att.

B-1, §8.1.18.5

√ Att. B-1, §8.2.1.6.1

√ See Att.

B-1, §8.1.18.5

√ See Att.

B-1, §8.1.18.5

√ See Att.

B-1, §8.1.18.5

√ See Att.

B-1, §4.1.22.59

√ Att. B-1, §2.1.3.4

6 This requirement does not apply to a Foster Care MCO that is a PIHP Contractor. 7 This requirement does not apply to a Foster Care MCO that is a PIHP Contractor. 8 This requirement does not apply to a Foster Care MCO that is a PIHP Contractor.

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CHIP HMO

CHIP EPO

CHIP Perinatal

HMO

STAR HMO

STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program complete list of all entities to whom the Network Providers must submit claims. The list must include the name of the entity, the address to which claims must be sent, an explanation for determination of the correct claims payer based on services rendered, and a phone number the provider may call to make claims inquiries.]

15 Claims Payment The MCO must notify Network Providers in writing of any changes in the list of claims processing or adjudication entities at least 30 days prior to the effective date of change. If the MCO is unable to provide 30 days notice, the MCO must give Network Providers a 30-day extension on their claims filing deadline to ensure claims are routed to the correct processing center.

√ See Att.

B-1, §8.1.18.5

√ Att. B-1, §8.2.1.6.1

√ See Att.

B-1, §8.1.18.5

√ See Att.

B-1, §8.1.18.5

√ See Att.

B-1, §8.1.18.5

√ See Att.

B-1, §4.1.22.5

10

√ Att. B-1, §2.1.3.4

16 Claims Payment The MCO shall adjudicate (finalize as paid or denied adjudicated) clean claims within 30 days from the date the claim is received by the MCO. The MCO will pay Network Providers interest at a

√ See Att.

B-1,

√ See Att.

B-1,

√ See Att.

B-1,

√ See Att.

B-1,

√ See Att.

B-1,

√ See Att.

B-1,

√ Att. B-1, §2.1.3.4

9 This requirement does not apply to a Foster Care MCO that is a PIHP Contractor. 10 This requirement does not apply to a Foster Care MCO that is a PIHP Contractor.

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CHIP HMO

CHIP EPO

CHIP Perinatal

HMO

STAR HMO

STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program rate of 1.5% per month (18% per annum) on all clean claims that are not adjudicated within 30 days.

§8.1.18.5 §8.2.1.6.1

§8.1.18.5 §8.1.18.5 §8.1.18.5 §4.1.22.511

17 Complaints and Appeals

The following complaint and appeal processes apply to the Network Provider contracts: [Note: Here, the MCO should include its Provider complaint and appeal processes. The processes must comply with the requirements of the HHSC Managed Care Contract, and must be the same for all Providers in a particular HMO Program. In addition, for Medicaid Program providers, the processes must comply with the requirements of 42 C.F.R. §438.414. For CHIP and CHIP Perinatal Program providers, the processes must comply with the requirements of Chapter 843, Subchapter G of the Texas Insurance Code.]

√ Att. B-1,

§8.4.2

√ Att. B-1, §8.2.1.5.3

√ Att. B-1,

§8.5.2

√ Att. B-1,

§8.2.5

√ Att. B-1,

§8.2.5

√ Att. B-1, §4.1.29

√ Att. B-1, §2.1.3.3

18 Complaints and Appeals

The Network Provider understands and agrees that HHSC reserves the right and retains the authority to make reasonable inquiry and to conduct investigations into Provider and Member complaints.

√ Att. B-1, §§8.4.2-

8.4.3

√ Att. B-1. §8.2.1.5.3§8.2.1.7

√ Att. B-1, §§8.5.2-

8.5.3

√ Att. B-1, §§8.2.5-

8.2.7

√ Att. B-1, §§8.2.5-

8.2.7

√ Att. B-1, §§4.1.29-

4.1.31

√ Att. B-1, §2.1.3.3 §2.1.3.5

11 This requirement does not apply to a Foster Care MCO that is a PIHP Contractor.

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19 Confidentiality Network Provider must treat all information that is obtained through the performance of the services included in this Network Provider contract as confidential information to the extent that confidential treatment is provided under state and federal laws, rules, and regulations. This includes, but is not limited to, information relating to applicants or recipients of HHSC Programs.

√ √ √ √ √ √ √ Att. A,

§11.01(a) Att. A,

§11.01(a) Att. A,

§11.01(a) Att. A,

§11.01(a) Att. A,

§11.01(a) Att. A,

§11.01(a) Att. A,

§11.01(a)

20 Confidentiality Network Provider shall not use information obtained through the performance of this Network Provider contract in any manner except as is necessary for the proper discharge of obligations and securing of rights under this contract.

√ √ √ √ √ √ √ Att. A,

§11.01(c) Att. A,

§11.01(c) Att. A,

§11.01(c) Att. A,

§11.01(c) Att. A,

§11.01(c) Att. A,

§11.01(c) Att. A,

§11.01(c)

21 Confidentiality – HIPAA

Network Provider shall protect the confidentiality of Member Protected Health Information (PHI), including patient records. Network Providers must comply with all applicable Federal and State laws, including the HIPAA Privacy and Security Rule governing the use and disclosure of protected health information.

√ √ √ √ √ √ √ Att. A, §§7.02, 7.07, 11.01, & 11.03(a)

Att. A, §§7.02,

7.07, 11.01, & 11.03(a)

Att. A, §§7.02,

7.07, 11.01, & 11.03(a)

Att. A, §§7.02,

7.07, 11.01, & 11.03(a)

Att. A, §§7.02,

7.07, 11.01, & 11.03(a)

Att. A, §§7.02,

7.07, 11.01, & 11.03(a)

Att. A, §§7.02,

7.07, 11.01, & 11.03(a)


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22 Co-payments and Deductibles

The Network Provider is responsible for collecting at the time of service any applicable CHIP co-payments or deductibles in accordance with CHIP cost-sharing limitations.

√ √ Att. A,

§10.12(b) Att. A,

§10.0812

√ √ 23 Co-payments and Deductibles

Network Providers shall not charge: Att. A,

§10.12(b) Att. A,

§10.081. cost-sharing or deductibles to CHIP

Members of Native American Tribes or Alaskan Natives;

13

2. co-payments or deductibles to a CHIP Member with an ID card that indicates the Member has met his or her cost-sharing obligation for the balance of their term of coverage; and

3. co-payments for well-child or well-baby visits or immunizations.


24 Co-payments Co-payments are the only amounts that Network Providers may collect from CHIP Members, except for costs associated with unauthorized non-emergency services provided to a Member by out-of-network providers for non-covered services.

√ √ Att. A,

§10.12(b) Att. A,

§10.0814

12 Co-payments and deductibles do not apply to the EPO’s CHIP Perinatal Program. 13 Co-payments and deductibles do not apply to the EPO’s CHIP Perinatal Program.

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CHIP HMO

CHIP EPO

CHIP Perinatal

HMO

STAR HMO

STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program

25 Costs of Non-covered Services

The Network Providers must inform Members of the costs for non-covered services prior to rendering such services and must obtain a signed Private Pay form from such a Member.

√ Att. A,

§10.12(a)

√ Att. A,

§10.12(a)

√ Att. A,

§10.12(a)

√ Att. A,

§10.12(a)

√ Att. A,

§10.12(a)

√ Att. A, §10.10

√ Att. A, §10.07

26 Early Childhood Intervention (ECI)

Network Providers must cooperate and coordinate with local ECI programs to comply with federal and state requirements relating to the development, review and evaluation of Individual Family Service Plans (IFSP). Network Provider understands and agrees that any Medically Necessary Health and Behavioral Health Services contained in an IFSP must be provided to the Member in the amount, duration, scope and setting established in the IFSP.

√ Att. B-1,

§8.1.9

√ Att. B-1, 8.2.1.5.1

√ Att. B-1,

§8.1.9

√ Att. B-1,

§8.1.9

√ Att. B-1,

§8.1.9

√ Att. B-1,

§4.1.9

27 Family Planning If a Member requests contraceptive services or family planning services, the Network Providers must also provide the Member counseling and education about family planning and available family planning services.

√ Att. B-1, §8.2.2.2

√ Att. B-1, §8.2.2.2

√ Att. B-1, §4.1.26.2

28 Family Planning Network Providers cannot require parental consent for Members who are minors to receive family planning services.

√ Att. B-1,

√ Att. B-1,

√ Att. B-1,

14 Co-payments and deductibles do not apply to the EPO’s CHIP Perinatal Program.

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CHIP HMO

CHIP EPO

CHIP Perinatal

HMO

STAR HMO

STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program §8.2.2.2 §8.2.2.2 §4.1.26.2

29 Family Planning Network Provides must comply with state and federal laws and regulations governing Member confidentiality (including minors) when providing information on family planning services to Members.

√ Att. B-1, §8.2.2.2

√ Att. B-1, §8.2.2.2

√ Att. B-1, §4.1.26.2

30 Fraud and Abuse The Network Provider understands and agrees to the following: 1. HHSC Office of Inspector General (“OIG”)

and/or the Texas Medicaid Fraud Control Unit must be allowed to conduct private interviews of Network Providers and their employees, agents, contractors, and patients;

2. requests for information from such entities must be complied with, in the form and language requested;

3. Network Providers and their employees, agents, and contractors must cooperate fully with such entities in making themselves available in person for interviews, consultation, grand jury proceedings, pre-trial conference, hearings, trials and in any other process, including investigations at the Network Provider’s own expense; and

√ See Att.

A, Art. 9; Att. B-1, §8.1.19

√ See Att.

A, Art. 9; Att. B-1, §8.2.3.5

√ See Att.

A, Art. 9; Att. B-1, §8.1.19

√ See Att.

A, Art. 9; Att. B-1, §8.1.19

√ See Att.

A, Art. 9; Att. B-1, §8.1.19

√ See Att.

A, Art. 9; Att. B-1, §4.1.23

√ See Att. A, §4.06; Att.

B-1, §2.1.3.4 §2.1.3.9

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CHIP EPO

CHIP Perinatal

HMO

STAR HMO

STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program 4. compliance with these requirements will be

at the [Network Provider’s] own expense.

31 Fraud and Abuse The Network Provider understands and agrees to the following: 1. Network Providers are subject to all state and

federal laws and regulations relating to fraud, abuse or waste in health care and the Medicaid and/or CHIP Programs, as applicable;

2. Network Providers must cooperate and assist HHSC and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud, abuse or waste;

3. Network Providers must provide originals and/or copies of any and all information, allow access to premises, and provide records to the Office of Inspector General, HHSC, the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services, FBI, TDI, the Texas Attorney General’s Medicaid Fraud Control Unit or other unit of state or federal government, upon request,

√ See Att.

A, Art. 9; Att. B-1, §8.1.19

√ See Att.

A, Art. 9; Att. B-1

§8.2.3.5√

√ See Att.

A, Art. 9; Att. B-1, §8.1.19

√ See Att.

A, Art. 9; Att. B-1, §8.1.19

√ See Att.

A, Art. 9; Att. B-1, §8.1.19

√ See Att.

A, Art. 9; Att. B-1, §4.1.23

√ See Att. A, §4.06; Att.

B-1, §2.1.3.4 §2.1.3.9

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HMO HMO PLUS


and free-of-charge; 4. If the Network Provider places required

records in another legal entity's records, such as a hospital, the Network Provider is responsible for obtaining a copy of these records for use by the above-named entities or their representatives; and

5. Network Providers must report any suspected fraud or abuse including any suspected fraud and abuse committed by the MCO or a Member to the HHSC Office of Inspector General.

32 Health Passport Require Providers to submit information for the Health Passport

√ Att. B-1, §4.1.12

33 Insurance Network Provider shall maintain, during the term of the Network Provider contract, Professional Liability Insurance of $100,000 per occurrence and $300,000 in the aggregate, or the limits required by the hospital at which Network Provider has admitting privileges.

√ √ √ √ √ √ √ Att. A,

§17.01(b) Att. A,

§17.01(b) Att. A,

§17.01(b) Att. A,

§17.01(b) Att. A,

§17.01(b) Att. A,

§17.01(b)Att. A,

§17.01(a)

[NOTE: This provision will not apply if the Network Provider is a state or federal unit of government, or a municipality, that is required

15Item 33 modified by Version 1.2

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to comply with, and is subject to, the provisions of the Texas and/or Federal Tort Claims Act.]

√ √ √ √ √ √ √ 34 Laws, Rules, and Regulations

The Network Provider understands and agrees that it is subject to all state and federal laws, rules, regulations, waivers, policies and guidelines, and court-ordered consent decrees, settlement agreements, or other court orders that apply to the Network Provider Contract and the MCO’s managed care contract with HHSC, the HMO Program, and all persons or entities receiving state and federal funds. The Network Provider understands and agrees that any violation by a provider of a state or federal law relating to the delivery of services pursuant to this Network Provider contract, or any violation of the MCO’s contract with HHSC could result in liability for money damages, and/or civil or criminal penalties and sanctions under state and/or federal law.

Att. A, §7.02

Att. A, §7.02

Att. A, §7.02

Att. A, §7.02

Att. A, §7.02

Att. A, §7.02

Att. A, §7.02


√ √ √ √ √ √ √ 35 Laws, Rules, and Regulations

The Network Provider understands and agrees that the following laws, rules, and regulations, and all amendments or modifications thereto, apply to the Network Provider contract:

Att. A, §§7.04-

7.07

Att. A, §§7.04-

7.07

Att. A, §§7.04-

7.07

Att. A, §§7.04-

7.07

Att. A, §§7.04-

7.07

Att. A, §§7.04-

7.07

Att. A, §§7.04-

7.07


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CHIP HMO

CHIP EPO

CHIP Perinatal

HMO

STAR HMO

STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program 1. environmental protection laws:

a. Pro-Children Act of 1994 (20 U.S.C. §6081 et seq.) regarding the provision of a smoke-free workplace and promoting the non-use of all tobacco products;

b. National Environmental Policy Act of 1969 (42 U.S.C. §4321 et seq.) and Executive Order 11514 (“Protection and Enhancement of Environmental Quality”) relating to the institution of environmental quality control measures;

c. Clean Air Act and Water Pollution Control Act regulations (Executive Order 11738, “Providing for Administration of the Clean Air Act and Federal Water Pollution Control Act with Respect to Federal Contracts, Grants, and Loans”);

d. State Clean Air Implementation Plan (42 U.S.C. §740 et seq.) regarding conformity of federal actions to State Implementation Plans under §176(c) of the Clean

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CHIP Dental

Program Air Act; and

e. Safe Drinking Water Act of 1974 (21 U.S.C. §349; 42 U.S.C. §300f to 300j-9) relating to the protection of underground sources of drinking water;

2. state and federal anti-discrimination laws: a. Title VI of the Civil Rights Act of

1964, Executive Order 11246 (Public Law 88-352);

b. Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112);

c. Americans with Disabilities Act of 1990 (Public Law 101-336); and

d. Title 40, Texas Administrative Code, Chapter 73;

3. the Immigration Reform and Control Act of 1986 (8 U.S.C. §1101 et seq.) and the Immigration Act of 1990 (8 U.S.C. §1101, et seq.) regarding employment verification and retention of verification forms; and

4. the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191).

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Program

36 Liability

In the event the MCO becomes insolvent or ceases operations, the Network Provider understands and agrees that its sole recourse against the MCO will be through the MCO’s bankruptcy, conservatorship, or receivership estate.

√ √ √ √ √ √ √

37 Liability

The Network Provider understands and agrees that the MCO’s Members may not be held liable for the MCO’s debts in the event of the entity’s insolvency.

√ √ √ √ √ √ √

38 Liability The Network Provider understands and agrees that the Texas Health and Human Services Commission (HHSC) does not assume liability for the actions of, or judgments rendered against, the MCO, its employees, agents or subcontractors. Further, the Network Provider understands and agrees that there is no right of subrogation, contribution, or indemnification against HHSC for any duty owed to the Network Provider by the MCO or any judgment rendered against the MCO. HHSC’s liability to the Network Provider, if any, will be governed by the Texas Tort Claims Act, as amended or modified (Tex. Civ. Pract. & Rem. Code §101.001 et seq.).

√

Att. A, §4.05

√

Att. A, §4.05

√

Att. A, §4.05

√

Att. A, §4.05

√

Att. A, §4.05

√

Att. A, §4.06

√

Att. A, §4.05

39 Marketing Network Provider agrees to comply with HHSC’s √ √ √ √ √ √

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marketing policies and procedures, as set forth in the HHSC/MCO Managed Care Contract (which includes HHSC’s Uniform Managed Care Manual).

Att. B-1, §8.1.6; UMCM Ch. 4

Att. B-1, §8.2.2; UMCM Ch. 4

Att. B-1, §8.1.6; UMCM Ch. 4

Att. B-1, §8.1.6; UMCM Ch. 4

Att. B-1, §8.1.6; UMCM Ch. 4

Att. B-1, §2.1.3.7; UMCM Ch. 4

√ √ √ √ √ 40 Marketing The Network Provider is prohibited from engaging in direct marketing to Members that is designed to increase enrollment in a particular health plan. The prohibition should not constrain Network Providers from engaging in permissible marketing activities consistent with broad outreach objectives and application assistance.

√ Att. B-1,

§2.1.3.7; UMCM Ch. 4

Att. B-1, §8.1.6; UMCM Ch. 4

Att. B-1, §8.1.6; UMCM Ch. 4

Att. B-1, §8.1.6; UMCM Ch. 4

Att. B-1, §8.1.6; UMCM Ch. 4

Att. B-1, §8.2.2; UMCM Ch. 4

√ √ √ √ √ √ √ 41 MCO’s Responsibility

The MCO will initiate and maintain any action necessary to stop a Network Provider or employee, agent, assign, trustee, or successor-in-interest from maintaining an action against HHSC, an HHS Agency, or any Member to collect payment from HHSC, an HHS Agency, or any Member, excluding payment for non-covered services. This provision does not restrict a CHIP Network Provider from collecting allowable copayment and deductible amounts from CHIP Members.

Att. A, §§4.05 &

10.12

Att. A, §4.05 &

10.12

Att. A, §§4.05 &

10.12

Att. A, §§4.05 &

10.12

Att. A, §§4.05 &

10.12

Att. A, §§4.06 &

10.10

Att. A, §§4.06 &

10.10

Additionally, this provision does not restrict a CHIP Dental Network Provider from collecting payment for services that exceed a CHIP

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member’s benefit cap.

√ √ √ √ √ √ 42 Provider Network Requirements, Medicaid Agreements, TPI and NPI

Network Acute Care Providers serving Medicaid Members must enter into and maintain a Medicaid provider agreement with HHSC or its agent to participate in the Medicaid Program, and must have a Texas Provider Identification Number (TPIN). All Network Providers, both CHIP and Medicaid, must have a National Provider Identifier (NPI) in accordance with the timelines established in 45 C.F.R. Part 162, Subpart D (for most Providers, the NPI must be in place by May 23, 2007.)

Att. B-1,

§8.1.4 See Att. B-1,

§8.1.4 Att. B-1,

§8.1.4 Att. B-1,

§8.1.4 Att. B-1,

§4.1.4 Att. B-1, §8.3.1.3.2

43 Medical Consent Requirements

Network Providers must comply with medical consent requirements in Texas Family Code §266.004, which require the Member’s Medical Consenter to consent to the provision of medical care.

√ Att. B-1,

§4.1.3

44 Medical Consent Requirements

Network Providers must notify the Medical Consenter about the provision of Emergency Services no later than the second Business Day after providing Emergency Services, as required by Texas Family Code §266.009.

√ Att. B-1,

§4.1.3

45 Member Communications

The MCO is prohibited from imposing restrictions upon the Network Provider’s free communication with a Member about the Member’s medical

√ Att. A,

√ Att. A,

√ Att. A,

√ Att. A,

√ Att. A,

√ Att. A,

√ Att. A,


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STAR+ PLUS HMO

STAR Health MCO

CHIP Dental

Program conditions, treatment options, MCO referral policies, and other MCO policies, including financial incentives or arrangements and all managed care plans with whom the Network Provider contracts.

§7.02 (and BBA §438.102)

§7.02 (and BBA

§438.102)

§7.02 (and BBA

§438.102)

§7.02 (and BBA

§438.102)

§7.02 (and BBA

§438.102)

§7.02 (and BBA

§438.102)

§7.02 (and BBA

§438.102)

46 Payment for Services

The Network Provider is prohibited from billing or collecting any amount from a Medicaid Member for Health Care Services provided pursuant to this Network Provider contract. Federal and state laws provide severe penalties for any provider who attempts to bill or collect any payment from a Medicaid recipient for a Covered Service.

√ Att. A,

§10.12(a)

√ Att. A,

§10.12(a)

√ Att. A, §10.10

47 Payment for Services

The Network Provider understands and agrees that HHSC is not liable or responsible for payment for Covered Services rendered pursuant to the Network Provider contract.

√ See Att.

A, §§4.05 & 10.12

√ See Att.

A, §§4.05 & 10.12

√ See Att.

A, §§4.05 & 10.12

√ See Att.

A, §§4.05 & 10.12

√ See Att.

A, §§4.05 & 10.12

√ See Att.

A, §§4.06 & 10.10

√ See Att. A, §§4.05 &

10.11

48 Primary Care Physicians (PCPs)

PCPs must be accessible to Members 24 hours per day, 7 days per week.

√ Att. B-1,

§8.1.4

√ Att. B-1,

§8.2.1.5.416

√ Att. B-1, §8.1.417

√ Att. B-1,

§8.1.4

√ Att. B-1,

§8.1.4

√ Att. B-1, §4.1.4.5

16 In the EPO’s CHIP Perinatal Program, this requirement applies to a PCP who provides services to CHIP Perinate Newborns. The PCP requirements do not apply to CHIP Perinates. 17 This requirement applies to a PCP who provides services to CHIP Perinate Newborns. The PCP requirements do not apply to CHIP Perinates.

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PCPs must provide preventative care: √ √ √ √ √ √ 1. to children under age 21 in accordance

with AAP recommendations for CHIP Members and CHIP Perinatal Newborns, and the THSteps periodicity schedule published in the THSteps Manual for Medicaid Members; and

Att. B-1, §8.1.4.2

Att. B-1, Att. B-1, §8.1.4.2

Att. B-1, §8.1.4.2

Att. B-1, §4.1.4.5

Att. B-1, §8.1.4.219§8.2.1.5.4

18

2. to adults in accordance with the U.S. Preventative Task Force requirements.


PCPs must assess the medical needs and behavioral health needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members’ care with specialty care providers after referral.

√ √ √ √ √ √ Att. B-1, §8.1.4.2

See Att. B-1,

Att. B-1, §8.1.4.2

Att. B-1, §8.1.4.2

Att. B-1, §8.1.4.2

Att. B-1, §4.1.4.5 21

§§8.2.1.5.4 –

8.2.1.5.520


51 Provider Responsibilities

At the request of HHSC for DFPS, Providers must testify in court as needed for child protection litigation.

√ Att. B-1,

4.1.11


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52 Professional Conduct

While performing the services described in the Network Provider contract, the Network Provider agrees to:

√ √ √ √ √ √ √ Att. A, §4.07

Att. A, §4.07

Att. A, §4.07

Att. A, §4.07

Att. A, §4.07

Att. A, §4.08

Att. A, §4.07

1. comply with applicable state laws, rules, and regulations and HHSC’s requests regarding personal and professional conduct generally applicable to the service locations; and

2. otherwise conduct themselves in a businesslike and professional manner.

53 Quality Assessment and Performance and Improvement (QAPI)

Network Provider agrees to comply with the MCO’s QAPI Program requirements.

√ √ √ √ √ √ √ See Att.

B-1, §8.1.7

See Att. B-1,

See Att. B-1,

§8.1.7

See Att. B-1,

§8.1.7

See Att. B-1,

§8.1.7

See Att. B-1,

§4.1.7

See Att. B-1,

§2.1.3.10.1 §8.2.3.2

54 Termination The Network Provider contracts must contain the MCO’s process for terminating Provider contracts. For CHIP HMOs and managed care organizations participating in the CHIP Perinatal Program, the process must comply with the Texas Insurance Code and TDI regulations.

√ √ √ √ √ √ √ See Att.

B-1, §8.1.4.9

See Att. B-1,

See Att. B-1,

§8.1.4.9

See Att. B-1,

§8.1.4.9

See Att. B-1,

§8.1.4.9

See Att. B-1,

§4.1.4.13

See Att. B-1, §2.1.3.2

§8.2.1.7



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Program

55 Termination The MCO must follow the procedures outlined in §843.306 of the Texas Insurance Code if terminating a contract with a provider, including an STP. At least 30 days before the effective date of the proposed termination of the provider’s contract, the MCO must provide a written explanation to the provider of the reasons for termination. The MCO may immediately terminate a provider contract if the provider presents imminent harm to patient health, actions against a license or practice, fraud or malfeasance. Within 60 days of the termination notice date, a provider may request a review of the MCO’s proposed termination by an advisory review panel, except in a case in which there is imminent harm to patient health, an action against a private license, fraud or malfeasance. The advisory review panel must be composed of physicians and providers, as those terms are defined in §843.306 of the Texas Insurance Code, including at least one representative in the provider’s specialty or a similar specialty, if available, appointed to serve on the standing quality assurance committee or utilization review committee of the MCO. The decision of the advisory review panel must be

√ See Att.

B-1, §8.1.4.9

√ See Att.

B-1, §8.2.1.7

√ See Att.

B-1, §8.1.4.9

√ See Att.

B-1, §8.1.4.9

√ See Att.

B-1, §8.1.4.9

√ See Att.

B-1, §4.1.4.13

√ See Att. B-1, §2.1.3.2

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STAR Health MCO

CHIP Dental

Program considered by the MCO but is not binding on the MCO. The MCO must provide to the affected provider, on request, a copy of the recommendation of the advisory review panel and the MCO’s determination.

56 Termination for Gifts or Gratuities

Network Provider may not offer or give any thing of value to an officer or employee of HHSC or the State of Texas in violation of state law. A “thing of value” means any item of tangible or intangible property that has a monetary value of more than $50.00 and includes, but is not limited to, cash, food, lodging, entertainment and charitable contributions. The term does not include contributions to public office holders or candidates for public office that are paid and reported in accordance with state and/or federal law. The MCO may terminate this Network Provider contract at any time for violation of this requirement.

√ Att. A,

§12.03(b)(5)

√ Att. A,

§12.03(b)(5)

√ Att. A,

§12.03(b)(5)

√ Att. A,

§12.03(b)(5)

√ Att. A,

§12.03(b)(5)

√ Att. A,

§12.03(b)(5)

√ Att. A,

§12.03(b)(5)

57 Third Party Recovery

Network Provider understands and agrees that it may not interfere with or place any liens upon the state’s right or the MCO’s right, acting as the state’s agent, to recovery from third party

√ See Att B-1; §8.2.9

√ See Att B-

1;

√ See Att B-1; §8.2.9

√ See Att B-1; §8.2.9

√ See Att B-1; §8.2.9

√ See Att B-

1;

√ See Att. B-

1,


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22resources. §4.1.32 §2.1.3.12.2 §8.3.1.3.4

58 THSteps Network Providers must send all THSteps newborn screens to the Texas Department of State Health Services (DSHS), formerly the Texas Department of Health, Bureau of Laboratories or a DSHS-certified laboratory. Providers must include detailed identifying information for all screened newborn Members and each Member’s mother to allow HHSC to link the screens performed at the hospital with screens performed at the two-week follow-up.

√ √ √ Att.B-1; §8.2.2.3

Att.B-1; §8.2.2.3

Att.B-1; §4.1.26.3

59 THSteps PCPs must: √ 1. either be enrolled as THSteps providers or

refer Members due for a THSteps check-up to a THSteps provider;

Att. B-1, §4.1.4.5

2. refer Members for follow-up assessments or interventions clinically indicated as a result of the THSteps check-up, including the developmental and behavioral components of the screening;

3. submit information from the THSteps forms and documents to the Medical Passport.

60 Tuberculosis Network Providers must coordinate with the local √ √ √ √ √ √

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CHIP Dental

Program (TB) TB control program to ensure that all Members

with confirmed or suspected TB have a contact investigation and receive Directly Observed Therapy (DOT). The Network Providers must report to the Texas Department of State Health Services (DSHS) or the local TB control program any Member who is non-compliant, drug resistant, or who is or may be posing a public health threat.

See Att.B-1; §8.1.12.2

See Att. B-1; §8.2.1.5.1

See Att.B-1; §8.1.12.2

Att.B-1; §8.2.2.6

Att.B-1; §8.2.2.6

Att.B-1; §4.1.26.6

61 Women, Infants and Children (WIC)

Network Providers must coordinate with the WIC Special Supplemental Nutrition Program to provide medical information necessary for WIC eligibility determinations, such as height, weight, hematocrit or hemoglobin.

√ Att.B-1; §8.1.10

√ Att.B-1;

§8.2.1.5.1

√ Att.B-1; §8.1.10

√ Att.B-1; §8.1.10

√ Att.B-1; §8.1.10

√ Att.B-1; §4.1.10

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