AttachmentA:ModelContract

LOUISIANAMEDICAID
MANAGEDCAREORGANIZATION
MODELCONTRACT
LOUISIANADEPARTMENTOFHEALTH
BUREAUOFHEALTHSERVICESFINANCING
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TABLEOFCONTENTS
PART1:GLOSSARYANDACRONYMS5
PART2: CONTRACTORRESPONSIBILITIES 45
PART3: STATERESPONSIBILITIES 302
PART4: PAYMENTANDFINANCIALPROVISIONS 325
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PART5: TURNOVERREQUIREMENTS 348
PART6: TERMSANDCONDITIONS 351
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LISTOFCONTRACTATTACHMENTS
AttachmentA:ModelContract
AttachmentB:(Reserved)
AttachmentC:MCOCoveredServices
AttachmentD:ActuarialRateCertificationLetter*(tobeaddedafterprocurement)
AttachmentE:APMStrategicPlanRequirementsandReportingTemplate
AttachmentF:ProviderNetworkStandards
AttachmentG:TableofMonetaryPenalties
AttachmentH:QualityPerformanceMeasures
*TheContractorshallreceivethisattachmentimmediatelyuponitscompletionbyLDH’scontracted
actuary.
LISTOFMANUALSANDGUIDES
BatchPharmacyEncounterSystemCompanionGuide
ChisholmComplianceGuide
DOJAgreementComplianceGuide
FinancialReportingGuide
Justice‐InvolvedPre‐ReleaseEnrollmentProgramManual
MarketingandMemberEducationCompanionGuide
MCOManual
MCOQualityCompanionGuide
MCOSystemCompanionGuide
Medicaid834BenefitandEnrollmentTransactionSetCompanionGuide
StateFairHearingCompanionGuide
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PART1:GLOSSARYANDACRONYMS
Glossary
*DenotestermsforwhichtheContractormustusetheState‐developeddefinition.
1915(b)Waivers–Section1915oftheSocialSecurityAct,42U.S.C.§1396n,authorizestheSecretaryof
the UnitedStatesDepartmentofHealthandHumanServicestowaivecertainrequirementsincluding
thosenecessarytoallowtheuseofManagedCareintheMedicaidProgram.Under42U.S.C.§1396n(b),
stateshavethefollowingoptions:
1) 1915(b)(1)‐Implementamanagedcaredeliverysystemthatrestrictsthetypesofprovidersthat
peoplecanusetogetMedicaidbenefits.
2) 1915(b)(2)‐Allowacounty(parish)orlocalgovernmenttoactasachoicecounselororenrollment
brokerinordertohelppeoplepickanMCO.
3) 1915(b)(3)‐UsethesavingsthattheStategetsfromamanagedcaredeliverysystemtoprovide
additionalservices.
4) 1915(b)(4)‐RestrictthenumberortypeofproviderswhocanprovidespecificMedicaidservices
(suchasCareManagementortransportation).
AbandonedCall–Acallinwhichthecallerselectsavalidoptionandeitherisnotpermittedaccesstothat
optionordisconnectsfromthesystem.
Abuse–Practicesthatareinconsistent withsoundfiscal,business, ormedicalpractices, and resultin
unnecessarycosttotheLouisianaMedicaidProgram,orinpaymentforservicesthatarenotmedically
necessaryorthatfailtomeetprofessionallyrecognizedstandardsforhealthcare.
AcuteCare –Preventivecare,primary care,andothermedicalcareprovidedunderthedirectionofa
physicianforaconditionhavingarelativelyshortduration.
Acute Care Hospital – A hospital that provides inpatient medical care and other related services for
surgery,acutemedicalconditionsorinjuries(usuallyforashort‐termillnessorcondition).Forpurposes
ofdeterminingnetworkadequacy,AcuteCarehospitalsmustincludeanemergencydepartment,which
maybeoff‐site.
Adjudicate–Todenyorpayacleanclaim.
AdvanceDirective–Awritteninstruction,suchasalivingwillordurablepowerofattorneyforhealth
care,recognizedunderStatelaw(whetherstatutoryorasrecognizedbythecourtsoftheState),relating
totheprovisionofhealthcarewhentheindividualisincapacitated.
AdverseBenefitDetermination–Anyofthefollowing:
The denial or limited authorization of a requested service, including,butnotlimitedto,
determinations based on the type or level of service, requirements for medical necessity,
appropriateness,setting,oreffectivenessofacoveredbenefit.
Thereduction,suspension,orterminationofapreviouslyauthorizedservice.
Thedenial,inwholeorinpart,ofpaymentforaservice.
ThefailuretoprovideservicesinaTimelymanner,asdefinedbytheState.
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ThefailureofanMCOtoactwithinthetimeframesprovidedin42C.F.R.§438.408(b)(1)and(2)
regardingthestandardresolutionofGrievancesandAppeals.
The denial of an Enrollee’s request to dispute a financial liability, including Cost Sharing,
copayments,premiums,deductibles,coinsurance,andotherEnrolleefinancialliabilities.
AdverseChildhoodExperiences(ACEs)–Stressfulortraumaticevents,includingabuseandneglect.They
mayalsoincludehouseholddysfunctionsuchaswitnessingdomesticviolenceorgrowingupwithfamily
members who have substance use disorders. ACEs are strongly related to the development and
prevalenceofawiderangeofhealthproblemsthroughoutaperson’slifespan,includingthoseassociated
withsubstancemisuse.
Affiliate–Anyindividualorentitythatmeetsanyofthefollowingcriteria:
1) Ownsorholdsmorethanafivepercent(5%)interestintheMCO(eitherdirectly,orthroughone
(1)ormoreintermediaries);
2) IsanentityinwhichtheMCOownsorholdsmorethanafivepercent(5%)interest,eitherdirectly
orthroughone(1)ormoreintermediaries;
3) IsaparententityorsubsidiaryentityoftheMCOregardlessoftheorganizationalstructureofthe
entity;
4) HasacommonparentwiththeMCO,eitherdirectlyorthroughone(1)ormoreintermediaries;
5) Directly,orindirectlythroughone(1)ormoreintermediaries,controls,oriscontrolledby,oris
undercommoncontrolwith,theMCO;or
6) WouldbeconsideredanaffiliatebyanySecuritiesandExchangeCommission(SEC)orInternal
RevenueService(IRS)regulation,FederalAcquisitionRegulations(FAR),orbyanotherapplicable
regulatorybody.
AmbulatoryCare–Preventive,diagnosticandtreatmentservicesprovidedonanoutpatientbasis.
Americans with Disabilities Act of 1990 (ADA) – 42 U.S.C. §12101‐12213, as amended by the ADA
Amendments of 2008, P.L. 110‐325, prohibits discrimination against people with disabilities in
employment,transportation,publicaccommodation,communicationsandgovernmentalactivities.The
ADAalsoestablishesrequirementsfortelecommunicationsrelayservices.
AncillaryServices–Thosesupportsotherthanroom,board,andmedicalandnursingservices,thatare
providedtohospitalpatientsinthecourseofcare.Theyincludeservicessuchaslaboratory,radiology,
pharmacy,andphysicaltherapyservices.
Appeal*–ArequestforareviewofanAdverseBenefitDetermination.
Appeal Procedure – A formal process whereby an Enrollee can contest an adverse determination
renderedbytheContractor,whichresultsinthedenial,reduction,suspension,terminationordelayof
health care benefits/services. The Appeal Procedure shall be governed by Federal and State laws,
regulations,rules,policies,procedures,andmanuals,andallapplicablecourtordersandconsentdecrees.
Attribution–ThemethodusedinaValue‐BasedPaymentmodeltodeterminewhichprovidergroupis
responsibleforanEnrollee’scareandcosts.Attributionisamechanismforcreatingaccountabilityand
aligningincentiveswithinaprovidergrouptocoordinateanEnrollee’soverallcareneeds.
Authorized Representative – An individual or organization designated by a Beneficiary, or authorized
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underStatelaw,including,butnotlimitedto,acourtorderestablishinglegalguardianshiporapowerof
attorney,toactresponsiblyontheirbehalf,inaccordancewith42C.F.R.§435.923.
Automatic Assignment – The process utilized by LDH to enroll Beneficiaries into an MCO, using
predeterminedalgorithms,who (1)arenotexcluded fromtheManagedCare Programand (2)do not
proactivelyselectanMCOwithintheLDH‐specifiedtimeframe.
Basic Behavioral Health Services – Mental health and substance use services which are provided to
Enrolleeswithemotional,psychological,substanceuse,psychiatricsymptomsand/ordisordersthatare
providedintheEnrollee’sPrimaryCareProvider(PCP)officebytheEnrollee’sPCPaspartofprimarycare
service activities. Basic Behavioral Health Services include, butarenotlimitedto,screening,brief
intervention and assessment, prevention, early intervention, medication management, treatment and
referralservicesprovidedinthe primarycaresetting.BasicBehavioralHealthServicesmayfurtherbe
defined as those provided in the Enrollee’s PCP or medical office by the Enrollee’s (non‐Specialist)
physician(e.g.,DO,MD,APRN,PA)aspartofroutinephysicianevaluationandmanagementactivities.
TheseservicesshallbecoveredbytheContractorforEnrolleeswithbothphysicalhealthandbehavioral
healthcoverage.
Beneficiary – An individual who has been determined eligible, pursuant to Federal and Statelaw, to
receivemedicalcare,goods,orservicesundertheLouisianaMedicaidProgram.
BureauofHealthServicesFinancing(BHSF)–TheagencywithintheLouisianaDepartmentofHealththat
isresponsibleforadministrationandoversightoftheLouisianaMedicaidProgram.
BusinessContinuityPlan(BCP)–AplanthatprovidesforaquickandsmoothrestorationofallContractor
functions after a disruptive event. BCP includes business impact analysis, development, testing,
awareness,training,andmaintenance.Thisisaday‐to‐dayplan.
BusinessDay–Monday,Tuesday,Wednesday,Thursday,andFriday,excludingState‐designatedholidays.

BusinessHours–8:00a.m.–5:00p.m.CentralTimeonBusinessDays.
BusinessOwner–Individualwhoisaccountableforandistheprimarypointofcontactforaspecified
businessarea.
CalendarDays–Allseven(7)daysoftheweek.Unlessotherwisespecified,theterm“day”intheContract
referstoCalendarDays.
Can–Atermthatdenotesanallowableactivity,butnotamandatoryrequirement.
CapitationPayment–Apayment,fixedinadvance,thatLDHmakestotheContractorforeachEnrollee
coveredundertheContractforprovisionofMCOCoveredServices.Thispaymentismaderegardlessof
whethertheEnrolleereceivesanyMCOCoveredServicesduringtheperiodcoveredbythepayment.Also
referredtoasaPMPMpayment.
CapitationRate–Ratesthatareprojectedtoprovideforallreasonable,appropriate,andattainablecosts
thatarerequiredunderthetermsoftheContractandfortheoperationoftheContractorforthetime
periodandthepopulationcoveredunderthetermsoftheContractandaredevelopedinaccordancewith
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therequirementsof42C.F.R.§438.4(b).
CareCoordination–Deliberateorganizationofpatientcareactivitiesbyapersonorentity,includingthe
Contractor that is formally designated as primarily responsible for coordinating services furnished by
providersinvolvedintheEnrollee’scare,tofacilitatetheappropriatedeliveryofhealthcareservices.Care
coordinationactivitiesmayincludebutaren’tlimitedtothecoordinationofspecialtyreferrals,assistance
with Ancillary Services, and referrals to and coordination with community services. Organizing care
involvesthemarshallingofpersonnelandotherresourcesneededtocarryoutallrequiredpatientcare
activities and is often managed by the exchange of information among participants responsible for
differentaspectsoftheEnrollee’scare.
CareManagement–AnoverallapproachtomanagingEnrollees’careneedsandencompassesasetof
activities intended to improve patient care and reduce the needformedicalservicesbyenhancing
coordination of care, eliminating duplication, and helping patients and caregivers more effectively
managehealthconditions.
Case Management–Acollaborativeprocessofassessment,planning,facilitation and advocacy for
optionsandservicestomeetanindividualEnrollee’shealth‐relatedneedsthroughcommunicationand
available resources to promote quality and cost‐effective outcomes. Case management implicitly
enhancescarecoordinationthroughthedesignationofacasemanagerwhosespecificresponsibilityisto
overseeandcoordinateaccessandcaredeliverytargetedtohigh‐riskpatientswithdiversecombinations
ofhealth,functional,andsocialneeds.
Case Manager – A licensed registered nurse, licensed mental health practitioner, or other trained
individualwhoisemployedorcontractedbytheContractororanEnrollee’sPCP.Thecasemanageris
accountableforprovidingintensivemonitoring,follow‐up,clinicalmanagementofhighriskEnrollees,and
carecoordinationactivities,whichincludedevelopmentofthePlanofCare,ensuringappropriatereferrals
and Timely two‐way transmission of useful Enrollee information; obtaining reliable and Timely
informationaboutservicesotherthanthoseprovidedbythePCP;supportingtheEnrolleeinaddressing
social determinants of health; and supporting safe transitions in care for Enrollees moving between
institutionalandcommunitycaresettings.Thecasemanagermayserveononeormoremulti‐disciplinary
careteamsandisresponsibleforcoordinatingandfacilitatingmeetingsandotheractivitiesofthosecare
teams.
CentersforMedicareandMedicaidServices(CMS)–TheagencywithintheUnitedStatesDepartmentof
Health & Human Services that provides administration and funding for Medicare under Title XVIII,
Medicaid under Title XIX, and the Children’s Health Insurance Program under Title XXI of the Social
SecurityAct.
Children’s Health Insurance Program (CHIP) – created in 1997 by TitleXXI of the Social Security Act.
KnowninLouisianaasLaCHIP.
ChisholmClassMembers–AllcurrentandfutureBeneficiariesintheStateofLouisianaunderagetwenty‐
onewhoarenowonorwillinthefuturebeplacedontheDevelopmentalDisabilitiesRequestforServices
Registry.
ChoiceCounseling–EnrollmentBrokeractivitiessuchasansweringquestionsandprovidinginformation
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inanunbiasedmanneronavailableMCOsandadvisingPotentialEnrolleesandEnrolleesonwhatfactors
toconsiderwhenchoosingamongthem.
Claim–(1)Abillforservices,(2)alineitemofservice,or(3)allservicesforoneEnrolleewithinabill.
CleanClaim–Aclaimthatcanbeprocessedwithoutobtainingadditionalinformationfromtheprovider
oftheserviceorfromathirdparty.Itincludesaclaimwitherrorsoriginatinginastate’sclaimssystem.It
doesnotincludeaclaimfromaproviderwhoisunderinvestigationforFraudorAbuse,oraclaimunder
reviewformedicalnecessity.
Co‐branding–Arelationshipbetweentwoormoreseparatelegalentities,oneofwhichistheContractor,
wherethereisjointmarketingtopromoteEnrollmentwiththeContractor.
ColdCallMarketing–AnyunsolicitedpersonalcontactwithaMedicaideligibleindividualbytheMCO,its
staff, its volunteers or its vendors/contractors with the purpose of influencing the Medicaid eligible
individualtoenrollintheMCOoreithertonotenrollinordisenrollfromanotherMCO.
CommunityHealthWorker(CHW)–AsdefinedbytheAmericanPublicHealthAssociation,frontlinestaff
whoaretrustedmembersofand/orhaveanunusuallycloseunderstandingofthecommunityserved.This
trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social
servicesandthecommunitytofacilitateaccesstoservicesand improve the quality and cultural
competenceofservicedeliveryforEnrollees.
Consumer Assessment of Healthcare Providers and Systems (CAHPS)–astandardizedsurveyof
Enrollees’experienceswithambulatoryandfacility‐levelcareestablishedbytheAgencyforHealthcare
ResearchandQuality(AHRQ).
ContinuousQualityImprovement–Theprocessofidentifyingproblems,implementingandmonitoring
correctiveactionandstudyingitseffectivenesstoimprovehealthcare.
Contract–ThewrittenagreementbetweenLDHandtheContractor,whichiscomprisedofthetermsand
conditionssetforthhereinandanyamendmentsthereof,theRFP,andanyaddendaissuedthereto,the
Contractor’sproposal,andanyappendices,attachments,andexhibitstheretoorincorporatedthereinby
reference.
ContractExecutionDate–ThedateuponwhichtheOfficeofStateProcurementapprovestheContract.
Contractor–TheentitythatentersintothisContractwithLDHfortheprovisionofservicesdescribed
herein.
Convicted–Aformaldeclarationthatsomeonewasguiltyofacriminaloffense,madebytheverdictofa
juryorthedecisionofajudgeinacourtoflaw.
CoordinatedSystemofCare(CSoC)–Acomponentofthesystemofcareforyouthwhohavesignificant
behavioralhealthchallenges andwho arein orat imminentrisk ofout‐of‐home placement,and their
families,whichisacollaborativeeffortamongfamilies,youth,theDepartmentofChildrenandFamily
Services,theDepartmentofEducation,theDepartmentofHealth,andtheOfficeofJuvenileJustice.
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Coordination of Benefits (COB) – Refers to the activities involved in determining Louisiana Medicaid
ProgrambenefitswhenanEnrolleehascoveragethroughanindividual,entity,insurance,orprogramthat
isliabletopayforhealthcareservices.
Co‐payment*–AfixedamountpermedicalserviceforwhichtheEnrolleeisresponsible.Thisisatypeof
costsharingarrangementandmustbeinaccordancewith42C.F.R.§438.108andSection5006ofthe
AmericanRecoveryandReinvestmentActof2009(ARRA)forNativeAmericanEnrollees.
CorrectiveActionPeriod–TheperiodoftimebetweentheacceptancebyLDHoftheCorrectiveAction
PlanandthedateofcomplianceasdeterminedbyLDH.
CorrectiveAction Plan (CAP) – Aplan developedbythe Contractorthat is designed to ameliorate an
identifieddeficiencyandpreventre‐occurrenceofthatdeficiency.TheCAPoutlinesallsteps/actionsand
timeframenecessarytoaddressandresolvethedeficiency.
CostAvoidance–Amethodofpayingclaimsinwhichtheproviderisnotreimburseduntiltheprovider
hasdemonstratedthatallavailablehealthinsurancehasbeenexhausted.
CostSharing–Anyco‐payment,coinsurance,deductible,orothersimilarchargeasper42C.F.R.§447.51.
Covered Drug List – A list maintained by the Contractor giving details of generic and name brand
medicationspayablebytheContractor.TheCoveredDrugListshallincludealloutpatientdrugsforwhich
themanufacturerhasenteredintotheFederalrebateagreementwithCMSthatmeetsthestandardsin
Section1927oftheSocialSecurityAct.
CoveredEntity‐ Healthcare clearinghousesandthose healthcare providerswho transmitanyhealth
informationinelectronicforminconnectionwithastandardtransaction.
CrisisMitigationServices–Aprovider’sassistancetoEnrolleesduringacrisisthatprovidestwenty‐four
(24)‐houroncalltelephoneassistancetopreventrelapseorharmtoselforothers,toprovidereferralto
otherservices,andtoprovidesupportduringrelatedcrises.Referralto911orahospital’semergency
departmentalonedoesnotconstituteCrisisMitigationServices.
CulturalCompetency–Asetofinterpersonalskillsthatallowindividualstoincreasetheirunderstanding,
appreciation,acceptance,andrespectforculturaldifferencesandsimilaritieswithin,amongandbetween
groups and the sensitivity to know how these differences influence relationships with Enrollees. This
requiresawillingnessandabilitytodrawoncommunity‐basedvalues,traditionsandcustoms,todevise
strategiestobettermeetculturallydiverseEnrolleeneeds,andtoworkwithknowledgeablepersonsof
andfromthecommunityindevelopingfocusedinteractions,communications,andothersupports.
CurrentProceduralTerminology(CPT®)–Currentversion,isalistingofdescriptivetermsandidentifying
codesforreportingmedicalservicesandproceduresperformedbyphysicians.LDHhasdesignatedthe
CPTcodesetasthenationalcodingstandardforphysicianandotherhealthcareprofessionalservicesand
proceduresunderHIPAA.
Deliverable–Anydocument,manual,file,plan,orreportsubmittedtoLDHbytheContractortofulfill
requirementsofthisContract.
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DeniedClaim–AclaimforwhichnopaymentismadetoaproviderbytheContractorforanyofseveral
reasons,includingbutnotlimitedto,theclaimisfornon‐MCOCoveredServices,anineligibleprovideror
Enrollee,isaduplicateofanothertransaction,orhasfailedtopassasignificantrequirementintheclaims
processingsystem.
Department)–TheLouisianaDepartmentofHealth,hereinafterreferredtoasLDH.
DevelopmentalDisability–AsdefinedinLa.R.S.28:451.2,meanseither:
(1)Asevere,chronicdisabilityofapersonthat:
Isattributabletoanintellectualorphysicalimpairmentorcombinationofintellectualandphysical
impairments;
Ismanifestedbeforethepersonreachesagetwenty‐two(22);
Islikelytocontinueindefinitely;
Resultsinsubstantialfunctionallimitationsinthree(3)ormoreofthefollowingareasofmajor
lifeactivity:
o Self‐care;
o Receptiveandexpressivelanguage;
o Learning;
o Mobility;
o Self‐direction;
o Capacityforindependentliving;and
o Economicself‐sufficiency;
Isnotattributablesolelytomentalillness;and
Reflectstheneedforacombinationandsequenceofspecial,interdisciplinary,orgenericcare,
treatment,orotherserviceswhichareoflifelongorextendedduration and are individually
plannedandcoordinated.
(2)Asubstantialdevelopmentaldelayorspecificcongenitaloracquiredconditioninapersonfrom
birththroughagenine(9)which,withoutservicesandsupport,hasahighprobabilityofresultingin
thosecriteriainParagraph(1)laterinlifethatmaybeconsideredtobeadevelopmentaldisability.
Direct Marketing/Cold Call–AnyunsolicitedpersonalcontactwithorsolicitationofaBeneficiary in
person,throughdirectmailadvertisingortelemarketingbyanemployeeoragentoftheContractorfor
thepurposeofinfluencingtheBeneficiarytoenrollwiththeContractor.
Disenrollment–TheremovalofanEnrolleefromparticipationintheContractor’splan,butnotnecessarily
fromtheLouisianaMedicaidProgram.
DispensingFee–Theprofessionalfeewhich:(1)isincurredatthepointofsaleorserviceandpaysforthe
costsinexcessoftheingredientcostofacoveredoutpatientdrugeachtimeacoveredoutpatientdrugis
dispensed;(2)includesonlypharmacycostsassociatedwithensuringthatpossessionoftheappropriate
coveredoutpatientdrugis transferred toan Enrollee.Pharmacycosts include,but are notlimited to,
reasonablecostsassociatedwithapharmacist’stimeincheckingthecomputerforinformationaboutan
Enrollee’s coverage, performing drug utilization review and preferred drug list review activities,
measurement or mixing of the covered outpatient drug, filing the container, Enrollee counseling,
physicallyprovidingthecompletedprescriptiontotheEnrollee,delivery,specialpackaging,andoverhead
associatedwithmaintainingthefacilityandequipmentnecessarytooperatethepharmacy;and(3)does
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notincludeadministrativecostsincurredbytheStateintheoperationofthecoveredoutpatientdrug
benefitincludingsystemcostsforinterfacingwithpharmacies.
DisproportionateShareHospitals‐Hospitalsthatserveadisproportionateshareoflow‐incomepatients.
DocumentedAttempt–Abonafide,orgoodfaith,attempt,inwriting,bytheContractortoenterintoa
contractwithaprovider,madeonorafterthedatetheContractorsignstheContractwithLDH,andno
soonerthansixty(60)CalendarDaysfollowinganyprecedingattempt.Suchattemptsshallincludewritten
correspondenceviacertifiedmailthatoutlinescontractnegotiationsbetweentheparties,includingrate
andcontracttermsdisclosure.If,withinthirty(30)CalendarDaysfollowingthereceiptdate,thepotential
providerrejectstherequestorfailstorespondeitherverballyorinwriting,theContractormayconsider
therequestforinclusionintheprovidernetworkasdeniedbytheprovider.Providerresponsesarenot
limitedtoapprovalorrejectionoftheoffer.Thisshallconstituteone(1)attempt.
DOJAgreement Target Population (Case 3:18‐cv‐00608, MiddleDistrict of Louisiana) – (a)Medicaid‐
eligibleindividualsoverageeighteen(18)withseriousmentalillness(SMI)currentlyresidinginnursing
facilities;(b)individualsoverageeighteen(18)withSMIwhoarereferredforaPre‐AdmissionScreening
andResidentReview(PASRR)LevelIIevaluationofnursingfacilityplacementduringthecourseofthis
Agreement,orhavebeenreferredwithintwoyearspriortotheeffectivedateofthisAgreement;and(c)
excludesthoseindividualswithco‐occurringSMIanddementia,wheredementiaistheprimarydiagnosis.
DualDiagnosis–Thesituationinwhichthesamepersonisdiagnosedwithmorethanonecondition,such
aspsychiatricdisorders,neurodevelopmentaldisorders,substance‐relatedandaddictivedisorders.
DuplicateClaim–Aclaimthatiseitheratotalorpartialduplicateofservicespreviouslypaid.
DurableMedicalEquipment*,Prosthetics,OrthoticsandcertainSupplies(DMEPOS)–DMEisinclusive
ofequipmentwhich1)canwithstandrepeateduse,2)isprimarilyandcustomarilyusedtoserveamedical
purpose,3)generallyisnotusefultoapersonintheabsenceofillnessorinjury,and4)isappropriatefor
useinthehome.POSisinclusiveofprosthetics,orthoticsandcertainsupplies.Certainsuppliesarethose
medicalsuppliesthatareofanexpendablenature,suchascathetersanddiapers.
EarlyandPeriodicScreening,DiagnosisandTreatment(EPSDT)–AllmedicallynecessarySection1905(a)
servicesthatcorrectoramelioratephysicalandmentalillnessesandconditionsarecoveredforEPSDT‐
eligibleBeneficiariesagesbirthtotwenty‐one(21),inaccordancewith42U.S.C.§1396d(r).Thisincludes
but is not limited to, conditions which are discovered through EPSDTWellChildscreeningservices,
whetherornotsuchservicesarecoveredundertheStatePlan.[42U.S.C.§1396d(r)(5)andtheCMSState
MedicaidManual.]
EarlySteps–Programthatprovidesservicestofamilieswithinfantsandtoddlersagedbirthtothree
years(36months)whohaveamedicalconditionlikelytoresultinadevelopmentaldelay,orwhohave
developmentaldelays.Childrenwithdelaysincognitive,motor,vision,hearing,communication,social‐
emotionaloradaptivedevelopmentmaybeeligibleforservices.Theseservicesareprovidedinthe
child'snaturalenvironment,suchasthechild'shome,childcareoranyothercommunitysettingtypical
forchildrenagedbirthto3years(36months).
Electronic Health Records (EHR) – A computer‐based record containing health care information. This
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technology, when fully developed, meets provider needs for real‐time data access and evaluation in
medicalcare.ImplementationofanEHRincreasesthepotentialfor more efficient care and speedier
communicationamongprovidersandtheContractor.
EmergencyDentalServices–Emergencydentalcoverageislimitedtotheemergencytreatmentofinjury
to natural teeth. Treatment includes, but is not limited to, x‐rays and emergency oral surgery to
temporarily stabilize the Enrollee. Dental services provided for the routine care, treatment, or
replacementofteethorstructuresarenotcoveredunderthisContract.
EmergencyMedicalCondition*–Amedicalconditionmanifestingitselfbyacutesymptomsofsufficient
severity(includingseverepain)thataprudentlayperson,whopossessesanaverageknowledgeofhealth
and medicine, could reasonably expect the absence of immediate medical attention to result in: (1)
placingthehealthoftheindividual(or,withrespecttoapregnantwoman,thehealthofthewomanor
herunbornchild)inseriousjeopardy,(2)seriousimpairmenttobodilyfunctions,or(3)seriousdysfunction
ofanybodilyorganorpart.
EmergencyMedicalTransportation*–TransportationprovidedforanEmergencyMedicalCondition.
EmergencyRoomCare*–EmergencyServicesprovidedinanemergencydepartment.
EmergencyServices*–Coveredinpatientandoutpatientservicesthatareasfollows:(a)furnishedbya
providerthatisqualifiedtofurnishtheseservicesunderTitle42oftheCodeofFederalRegulationsand
Title XIX of the Social Security Act; and (b) needed to evaluate or stabilize an Emergency Medical
Condition.
Encounter–AdistinctsetofhealthcareservicesprovidedtoanEnrolleeonthedatesthattheservices
weredelivered.
EncounterData–Healthcareencounterdatainclude:(i)Alldatacapturedduringthecourseofasingle
healthcareencounterthatspecifythediagnoses,procedures(therapeutic,rehabilitative,maintenance,
or palliative), pharmaceuticals, medical devices and equipment associated with the Enrollee receiving
servicesduringtheencounter;(ii)theidentificationoftheEnrolleereceivingandtheprovider(s)delivering
thehealthcareservicesduringthesingleencounter;and(iii)aunique,unduplicated,identifierforthe
singleencounter.
EncounterData Adjustment – Adjustments to encounterdata that are allowable under the Medicaid
ManagementInformationSystem(MMIS)asspecifiedintheMCOManual.
Enrollee–BeneficiarywhoiscurrentlyenrolledinanMCO,eitherbychoiceorAutomaticAssignmentby
theEnrollmentBroker.
Enrollees with Special Health Care Needs (SHCN) – Individuals of any age with a behavioral health
disability,physicaldisability,developmentaldisability,orothercircumstancesthatplacetheirhealthand
abilitytofullyfunctioninsocietyatrisk,requiringindividualizedcareapproaches.EnrolleeswithSpecial
HealthCareNeedsshallincludeanyEnrolleeswho:
have complex needs such as multiple chronic conditions, co‐morbidities, and co‐existing
functionalimpairments;
areathighriskforadmission/readmissiontoahospitalwithinthenextsix(6)months;
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areathighriskofinstitutionalization;
have been diagnosed with a Serious Emotional Disturbance, a Severe and Persistent Mental
Illness, or a Substance Use Disorder, or otherwise have significant behavioral health needs,
including those Enrollees presenting to the hospital or emergency department with a suicide
attemptornon‐fatalopioid,stimulants,andsedative/hypnoticdrugoverdosereason;
arehomelessasdefinedinSection330(h)(5)(A)ofthePublicHealthServicesActandcodifiedby
theUSDepartmentofHealthandHumanServicesin42U.S.C.254(b);
arewomenwithhigh‐riskpregnancies(i.e.,pregnanciesthathaveoneormoreriskfactors)or
whohavehadanadversepregnancyoutcomeduringthepregnancy,includingpretermbirthof
lessthan37weeks;
havebeenrecentlyincarceratedandaretransitioningoutofcustody;
areathighriskofinpatientadmissionoremergencydepartmentvisits,includingcertainEnrollees
transitioning care across acutehospital, chronicdisease and rehabilitation hospital or nursing
facilitysetting;
aremembersoftheDOJAgreementTargetPopulation;
areenrolledundertheAct421Children’sMedicaidOption;or
receivecarefromotherStateagencyprograms,including,butnotlimitedto,programsthrough
OJJ,DCFS,orOPH.
Enrollment–TheprocessconductedbytheEnrollmentBrokerbywhichaneligibleBeneficiarybecomes
enrolledwithanMCO.
Enrollment Broker – The State’s designated contractor that performs functions related to choice
counseling,Enrollment,andDisenrollmentofPotentialEnrolleesandEnrolleesintoanMCO.
EnrollmentPeriod–TheperiodoftimewhenanEnrolleemaychangeMCOswithoutcause(onceperyear
afterinitialEnrollment).
Evidence‐Based Practice –Clinical interventionsthathavedemonstratedpositiveoutcomesinseveral
researchstudiestoassistconsumersinachievingtheirdesiredgoalsofhealthandwellness.
ExcludedPopulations–BeneficiarieswhoareexcludedfromtheManagedCareProgram.
ExcludedServices*–ThoseservicesthatEnrolleesmayobtainundertheStatePlanandforwhichthe
Contractorisnotfinanciallyresponsible.
ExecutiveCapacity–ServingasaChiefExecutiveOfficer,ChiefOperatingOfficer,ChiefFinancialOfficer,
MedicalDirector,oraBehavioralHealthMedicalDirector.
ExternalQualityReview(EQR)–Theanalysisandevaluationbyanexternalqualityrevieworganization
ofaggregatedinformationonquality,timeliness,andaccesstothehealthcareservicesthatthe
ContractororitssubcontractorsfurnishtoEnrollees.
External Quality Review Organization (EQRO) – An organization that meets the competence and
independencerequirementssetforth in42C.F.R.§438.354,andperformsEQR andotherEQR‐related
activitiesassetforthin42C.F.R.§438.358,orboth.
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FamilyPlanningServices – Services for men, women and adolescents that include examinations and
assessments,diagnosticprocedures,healtheducation,andcounselingservicesrelatedtoalternativebirth
controlandpreventionasprescribedandrenderedbyphysicians,hospitals,clinicsandpharmacies.
FederalFinancialParticipation(FFP)–Alsoknownasfederalmatch;thepercentageoffederalmatching
dollars available to a state to provide Medicaid and CHIP services. The federal Medical Assistance
Percentage (FMAP) is calculated annually based on a formula designed to provide a higher federal
matchingratetostateswithlowerpercapitaincome.
FederallyQualifiedHealthCenter(FQHC)–AnentitythatreceivesagrantunderSection330ofthePublic
HealthServiceAct(alsosee42U.S.C.§1396d(l)(2)(B)oftheSocialSecurityAct)toprovideprimaryhealth
care and related diagnostic services and may provide dental, optometric, podiatry, chiropractic, and
behavioralhealthservices.
Fee‐for‐Service (FFS) –Amethodofproviderreimbursementbasedonpaymentsforspecific services
rendered.
Fee‐for‐Service(FFS)Rate–Thereimbursementratepublishedonwww.lamedicaid.comorontheweekly
procedurefilesenttotheContractorbytheFI,oritsequivalent,whicheverismostcurrentonthedateof
service.Alsoreferredtoasthe“Medicaidrate”.
Fidelity–Theaccuracyandconsistencyofaninterventiontoensureitisimplementedasplannedand
thateachcomponentisdeliveredinacomparablemannertoallEnrolleesovertime.
Fiscal Intermediary (FI) – LDH’s contractor responsible in the current delivery model for an array of
support services including MMIS development and support, claims processing, pharmacy support
services,providersupportservices,financialandaccountingsystems,priorauthorizationandutilization
management,FraudandAbusesystems,anddecisionsupport.
ForCause–Foralegitimate,specificreason;withjustification.
Formulary–AlistmaintainedbytheContractorgivingdetailsofmedicationspayablebytheContractor.
Fraud–AsrelatestoMedicaidProgramIntegrity,anintentionaldeceptionormisrepresentationmadeby
apersonwiththeknowledgethatthedeceptioncouldresultinsomeunauthorizedbenefittohimorsome
otherperson.ItincludesanyactthatconstitutesFraudunderapplicableFederalorStatelaw.Fraudmay
include, but is not limited to, deliberate misrepresentation of need or eligibility; providing false
informationconcerningcostsorconditionstoobtainreimbursementorcertification;orclaimingpayment
forserviceswhichwereneverdeliveredorreceived.
FullMedicaidPricing(FMP)‐AprogramtoensureconsistentpricingintheManagedCareProgramfor
hospital services, including inpatient hospital, outpatient, hospital‐based physician, and ambulance
services,andtomaintainandincreaseaccesstothoseservicesforenrolledMedicaidpopulations.
Full‐TimeEquivalentPosition(FTE)–Referstotheequivalentofone(1)individualfull‐timeemployee
whoworksforty(40)hoursperweekorafull‐timeprimarycareproviderdeliveringoutpatientpreventive
and primary (routine, urgent and acute) clinical care for twenty‐four(24)hoursormoreperweek
(exclusiveoftraveltime).
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Grievance*–AnexpressionofEnrolleedissatisfactionaboutanymatterotherthananAdverseBenefit
DeterminationasdefinedinthisContract.Examplesofgrievances include, but are not limited to,
dissatisfactionwithqualityofcare,qualityofservice,rudenessofaprovideroranetworkemployeeand
networkadministrationpractices.Administrativegrievancesaregenerallythoserelatingtodissatisfaction
withthedeliveryofadministrativeservices,coverageissues,andaccesstocareissues.
GrievanceSystem– The mannerinwhich Enrollee Grievances, Appeals,and access tothe State’sfair
hearingsystemaremanaged.
HabilitationServicesandDevices*–HealthcareservicesthathelpEnrolleeskeep,learn,orimproveskills
andfunctioningfordailyliving.
HealthCareProfessional–Aphysicianorotherhealthcarepractitionerlicensed,accreditedorcertified
toperformspecifiedhealthservicesconsistentwithStatelaw.
HealthCareProvider–Ahealthcareprofessionalorentitythatprovideshealthcareservicesorgoods.
Health Disparity–Thepreventabledifferencesinhealthoutcomesintheburden of disease, injury,
violence,oropportunitiestoachieveoptimalhealththatareexperiencedbydisadvantagedpopulations.
HealthEquity–Achievedwheneverypersoninacommunityhastheopportunitytoreachtheirfullhealth
potentialandnooneis"disadvantagedfromachievingthispotentialbecauseofsocialpositionorother
sociallydeterminedcircumstances."
HealthEquityPlan‐TheContractor’sstrategicinitiativesandapproachestoactivatepractices,protocols,
and resources that equitably and effectively support the wellness and well‐being of all the people,
populations, and communities LDH serves, consistent with the LDH Health Equity Plan (see
https://ldh.la.gov/assets/cphe/Equity_Framework.pdf).
HealthInsurance*–Atypeofinsurancecoveragethatpaysformedicalandsurgicalexpensesincurredby
theinsured.Healthinsurancecanreimbursetheinsuredforexpensesincurredfromillnessorinjury,or
paythecareproviderdirectly.
HealthNeedsAssessment–Aperson‐centeredassessmentofanEnrollee’scareneeds,functionalneeds,
accessibilityneeds,goals,andothercharacteristics.
HealthcareEffectivenessDataandInformationSet(HEDIS)–Asetofperformancemeasuresdeveloped
bytheNationalCommitteeforQualityAssurance(NCQA).Themeasuresaredesignedtohelphealthcare
purchasersunderstandthevalueofhealthcarepurchasesandmeasureplan(e.g.MCO)performance.
HIPAAPrivacyRule(45C.F.R.Parts160andSubpartsAandEof164) –Standardsfor theprivacy of
individuallyidentifiablehealthinformation.
HIPAASecurityRule(45C.F.R.Parts160andSubpartsAandEof164)–Partoftherulespromulgated
pursuanttotheHealthInsurancePortabilityandAccountabilityActof1996(HIPAA)whichrequirecovered
entities to maintain reasonable and appropriate administrative, physical, and technical safeguards to
protect the confidentiality, integrity, and availability of their Electronic Protected Health Information
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againstanyreasonablyanticipatedrisks.
HomeandCommunityBasedServices(HCBS)Waiver–Under42U.S.C.§1396n(c)oftheSocialSecurity
Act,statesmayrequestwaiveroftherequirementsrelatingtostatewidecomparabilityofservices,and
communityincomeandresourcerules forthe medicallyneedyinorder todevelop Medicaid‐financed
community‐basedtreatmentalternatives.Non‐MedicaidCoveredServicesthatmaybeofferedinclude
case management, homemaker/home health aide services, personal careservices,adultdayhealth,
habilitation,andrespitecare.
HomeHealthCareorServices*–Patientcareservicesprovidedinthepatient’sresidentialsettingorany
settinginwhichnormallifeactivitiestakeplaceundertheorderofaphysicianthatarenecessaryforthe
diagnosisandtreatmentofthepatient’sillnessorinjury,includingoneormoreofthefollowingservices:
(1)skillednursing;(2)physicaltherapy;(3)speech‐languagetherapy;(4)occupationaltherapy;(5)home
healthaideservices;or(6)medicalsupplies,equipmentandappliancessuitableforuseinanysettingin
whichnormallifeactivitiestakeplace.
Homeless–Asdefinedin42U.S.C.§254b,means,anindividualwho lackshousing(withoutregardto
whethertheindividualisamemberofafamily),includinganindividualwhoseprimaryresidenceduring
the night is a supervised public or private facility (e.g., shelters) that provides temporary living
accommodations,andanindividualwhoisaresidentintransitionalhousing.Ahomelesspersonisan
individualwithoutpermanenthousingwhomayliveonthestreets;stayinashelter,mission,singleroom
occupancyfacilities,abandonedbuildingorvehicle;oranyotherunstableornon‐permanentsituation.A
personmaybeconsideredtobehomelessifthatpersonis“doubledup,”atermthatreferstoasituation
whereindividualsareunabletomaintaintheirhousingsituationandareforcedtostaywithaseriesof
friends and/or extended family members. In addition, previously homeless individuals who are to be
releasedfromaprisonorahospitalmaybeconsideredhomelessiftheydonothaveastablehousing
situationtowhichtheycanreturn.Arecognitionoftheinstabilityofanindividual’slivingarrangementsis
criticaltothedefinitionofhomelessness(HRSA/BureauofPrimaryHealthCare,ProgramAssistanceLetter
99‐12).
Hospice Care or Services* – Analternativetreatmentapproachthatisbasedonarecognition that
impendingdeathrequiresachangefromcurativetreatmenttopalliativecarefortheterminallyillpatient
andsupportingfamily.Palliativecarefocusesoncomfortcareandthealleviationofphysical,emotional
andspiritualsuffering.Insteadofhospitalization,itsfocusisonmaintainingtheterminallyillpatientat
homewithminimaldisruptionsinnormalactivitiesandwithasmuchphysicalandemotionalcomfortas
possible.
HospitalOutpatientCare*–Careinahospitalthatusuallydoesn’trequireanovernightstay.
Hospitalization*–Admissiontoahospitalfortreatment.
ICD‐10‐CM codes – International Classification of Diseases, 10
th
Revision, Clinical Modification codes
representauniform,internationalclassificationsystemofcodingdiseaseandinjurydiagnoses.Thiscoding
systemarrangesdiseasesandinjuriesintocodecategoriesaccordingtoestablishedcriteria.MCOsshall
transitiontonewerversionsastheybecomeeffective.

Immediate–Inanimmediatemanner;instant;instantlyorwithoutdelay,butnotmorethantwenty‐four
(24)hours.
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InLieuofService(ILOS)–Amedically‐appropriateserviceoutsideofMCOCoveredServicesorsettings
(orbeyondservicelimitsestablishedbyLDHforMCOCoveredServices)thatareprovidedtoEnrollees,at
theiroption,bytheContractorasacost‐effectivealternativetoanMCOCoveredServiceorsetting.
IncentiveArrangement–Anypayment mechanismunderwhichtheContractororSubcontractormay
receiveadditionalfundsoverandabovetherateitwaspaidformeetingtargetsspecifiedinthecontract.
IncurredButNotReported(IBNR)–Servicesrenderedbyaproviderforwhichaclaim/encounterhasnot
beenreceivedbytheContractor.
Indian–IncludesanIndian,asdefinedin25U.S.C.§1603(13),anUrbanIndian,asdefinedin25U.S.C.
§1603(28),aCaliforniaIndian,asdefinedin25U.S.C.§1679(a)oranindividualwhohasbeendetermined
eligibleasanIndian,under42C.F.R.§136.12.
IndianHealthCareProvider(IHCP)–AhealthcareprogramoperatedbytheIndianHealthService(IHS)
orbyanIndianTribe,TribalOrganization,orUrbanIndianOrganization(otherwiseknownasanI/T/U)as
thosetermsaredefinedin§4oftheIndianHealthCareImprovementAct(25U.S.C.1603).
InformationSystems(IS)–Acombinationofcomputinghardwareandsoftwarethatisusedin:(a)the
capture, storage, manipulation, movement, control, display, interchange and/or transmission of
information,i.e.structureddata(whichmayincludedigitizedaudioandvideo)anddocuments;and/or(b)
theprocessingofsuchinformationforthepurposesofenablingand/orfacilitatingabusinessprocessor
relatedtransaction.
Insolvency–Afinancialconditionthatexistswhenanentityisunabletopayitsdebtsastheybecomedue
intheusualcourseofbusiness,orwhentheliabilitiesoftheentityexceeditsassets,orasdeterminedby
theLouisianaDepartmentofInsurancepursuanttoTitle22oftheLouisianaRevisedStatutesof1950.
Intellectual Disability–Atypeofdevelopmentaldisability,formerlyknownasmentalretardation,
characterizedbysignificantlyimpairedintellectualandadaptivefunctioning.ItisdefinedbyanIQscore
underseventy(70)inadditiontodeficitsintwo(2)ormoreadaptivebehaviorsthataffecteveryday,
generalliving.AdiagnosisofintellectualdisabilityalonedoesnotconstituteeligibilityforDevelopmental
Disabilitiesservices.
InterdisciplinaryorMultidisciplinaryCareTeam–Agroupthatreviewsinformation,data,andinputfrom
theEnrolleetomakerecommendationsrelevanttotheneedsoftheEnrollee.Theteamconsistsofthe
Enrollee,hislegalrepresentative,ifapplicable,professionalsofvarieddisciplineswhohaveknowledge
relevanttotheEnrollee’sneeds,andmayincludetheEnrollee’sfamilyalongwithotherstheEnrolleehas
designated.
IntermediateCareFacilityforIndividualswithIntellectualDisabilities(ICF/IID)–Afacilitylicensedby
theLouisianaDepartmentofHealth(LDH)HealthStandardsSection(HSS)toprovideresidentialcarefor
four(4)ormoreindividualsthatmeetthecriteriafortwenty‐four(24)hoursperdayofactivetreatment.
ICF/IIDfacilitiesareconsidered“institutions”andnotHomeandCommunityBasedServicesbyCMS.
IntermediateSanctions–Thoseactionsauthorizedby42C.F.R.Part438,SubpartIforcertainactionsor
omissionsbytheContractor.
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
InvestigationalProcedure/Service–SeeExperimentalProcedure/Service.
KickPayment–ThemethodofreimbursingtheContractorintheformofaseparateone(1)timefixed
paymentforspecificservicesinadditiontotheCapitationPayment.
LaboratoryandX‐rayServices–Professionalandtechnicallaboratoryandradiologicalservicesthatare
orderedandprovidedbyorunderthedirectionofaphysicianorotherlicensedpractitionerofthehealing
artswithinthescopeofhispracticeasdefinedbyStatelawororderedbyaphysicianbutprovidedby
referrallaboratory;providedinanofficeorsimilarfacilityotherthanahospitaloutpatientorclinic;and
furnishedbyalaboratorythatmeetstherequirementsof42C.F.R.Part493.
LegendDrugs–DrugswhichbeartheFederallegend:“Caution:Federallawprohibitsdispensingwithout
aprescription.”
LicensedMentalHealthProfessional(LMHP)–AnindividualwhoislicensedintheStateofLouisianato
diagnoseandtreatmentalillnessorsubstanceusedisorderactingwithinthescopeofallapplicableState
lawsandtheirprofessionallicense.ALMHPincludesindividualslicensedtopracticeindependentlyas:
MedicalPsychologists
LicensedPsychologists
LicensedClinicalSocialWorkers(LCSWs)
LicensedProfessionalCounselors(LPCs)
LicensedMarriageandFamilyTherapists(LMFTs)
LicensedAddictionCounselors(LACs)
Advanced Practice Registered Nurses (APRN) (must be a nurse practitioner specialist in Adult
Psychiatric & Mental Health, and Family Psychiatric & Mental Health or a Certified Nurse
SpecialistsinPsychosocial,GerontologicalPsychiatricMentalHealth,AdultPsychiatricandMental
Health, and Child‐Adolescent Mental Health and may practice to the extent that services are
withintheAPRN’sscopeofpractice)
LocalGoverningEntity(LGE)–Oneofseveralindependentregionalhealthcaredistrictsandauthorities
located throughout the State. Within the jurisdiction of LGEs, services are provided through various
arrangements including state operated, state contracted services, private comprehensive providers,
rehabilitationagencies,communityaddictionandmentalhealthclinics,LMHPs,andcertifiedpeersupport
specialists.
LouisianaChildren’sHealthInsuranceProgram(LaCHIP)–Louisiana’sprogramauthorizedbyTitleXXIof
theSocialSecurityActin1997.Provideshealthcarecoverageforuninsuredchildrenuptoagenineteen
(19)throughaMedicaidexpansionprogramforchildrenatorbelowtwohundredpercent(200%)FPLand
aseparatestateCHIPprogramfortheunbornchildoptionandforchildrenwithincomefromtwohundred
percent(200%)uptoandincludingtwohundredfiftypercent(250%)FPL.
LouisianaChildren’sHealthInsuranceProgram(LaCHIP)StatePlan–AnagreementbetweentheState
andCMSthatdescribeshowLaCHIPisadministeredandsetsoutgroupsof individualstobecovered,
servicestobeprovided,methodologiesforproviderstobereimbursed,andtheadministrativeactivities
thatareunderwayintheState.
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Louisiana’sHealthInsurancePremiumPaymentProgram(LaHIPP)–StateMedicaidprogramthatpays
forsomeorallofthehealthinsurancepremiumsforanemployeeandtheirfamilyiftheyhaveinsurance
availablethroughtheirjoboraplanpurchasedontheprivatemarket.
Louisiana Medicaid Program–AsusedinthisContract,includestheState’sMedicaidprogram and
LaCHIP.
LouisianaMedicaidStatePlan–
AnagreementbetweentheStateandCMSthatdescribeshowtheState’s
Medicaid program is administered and sets out groups of individuals to be covered, services to be
provided, methodologies for providers to be reimbursed, and the administrative activities that are
underwayintheState.
Managed Care Organization (MCO) – A private entity that contracts with LDH to provide covered
healthcareservicestoEnrolleesinexchangeforamonthlycapitatedamountperEnrollee.Theentityis
regulated by the Louisiana Department of Insurance with respect to licensure and financial solvency,
pursuanttoLa.R.S.22:1016,butshall,solelywithrespecttoitsproductsandservicesofferedpursuantto
theManagedCareProgram,beregulatedbytheLDH.
Managed Care Program – A managed care delivery system wherein covered health care services are
providedthroughMCOs.
MandatoryMCOPopulation–ThegroupsofBeneficiarieswhoarerequiredtoenrollintheManaged
CareProgramforphysicalhealth,behavioralhealth,and/ortransportationservices.
Marketing – Any communication from the Contractor to and Enrollee or Potential Enrollee that can
reasonablybeinterpretedasintendedtoinfluencetheEnrollee’schoiceofMCO.
MarketingMaterials–Informationproducedinanymedium,byoronbehalfoftheContractorthatcan
reasonablybeinterpretedasintendedtomarkettoPotentialEnrolleesorEnrollees.
MassMedia–AmethodofpublicadvertisingthatcancreateContractornamerecognitionamongalarge
numberofEnrolleesandcanassistineducatingthemaboutpotentialhealthcarechoices.Examplesof
mass media are radio spots, television advertisements, newspaper advertisements, newsletters, and
videoindoctor'sofficewaitingrooms.
Material Changes–Changesaffectingthedeliveryofcareorservicesprovidedunder this Contract.
Material changes include, but are not limited to, changes in composition of the provider network,
Subcontractor,orSubcontractor’snetwork;theContractor‘scomplaintandgrievanceprocedures;health
caredeliverysystems;services;changestoproposedvalue‐addedbenefitsorservices;Enrollmentofa
new population; procedures for obtaining access to or approval for health care services; any and all
policiesandproceduresthatrequireLDHapprovalpriortoimplementation;andtheContractor’scapacity
tomeetminimumEnrollmentlevels.LDHshallmakethefinaldeterminationastowhetherachangeis
material.
Material Subcontract–AnycontractoragreementbywhichtheContractorprocures,re‐procures, or
proposestosubcontractwith,fortheprovisionofall,orpart,ofanyprogramareaorfunctionthatdirectly
relatestothedeliveryorpaymentofMCOCoveredServicesincluding, but not limited to, behavioral
health, claims processing, care management, utilization management, transportation, or pharmacy
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benefits, including specialty pharmacy providers. This shall include master service agreements or
memorandumsofunderstandingbetweentheContractoranditsparentcompany,andanyamendments
thereto.
MaterialSubcontractor–AnyentitywithaMaterialSubcontractwiththeContractor.Forthepurposes
ofthisContract,MaterialSubcontractorsdonotincludeprovidersintheContractor’sprovidernetwork.
Material Subcontractors may include, without limitation, Affiliates, subsidiaries, and affiliated and
unaffiliatedthirdparties.
May–ADenotesanallowableactivity,butnotamandatoryrequirement.
MCO Covered Services – Those Medicaid Covered Services that are required to be provided by the
ContractortoEnrolleesasspecifiedinAttachmentC,MCOCoveredServices,oftheContract.
MCO Manual– A compilation of policies, instructions, and guidelines established by LDH for the
administrationoftheManagedCareProgram.
Measurable–AppliestotheContractorobjectiveandmeanstheabilitytodeterminedefinitivelywhether
ornottheobjectivehasbeenmet,orwhetherprogresshasbeenmadetowardapositiveoutcome.
MeasurementYear–Withregardtohealthcarequalitymeasurereporting,measurementyearrefersto
thetimeframeduringwhichhealthcareservicesareprovided.Forexample,formostHEDIS
®
measures,
thepreviouscalendaryearisthestandardmeasurementyear.Thehealthcarequalitymeasuresteward
definesthemeasurementyear(orperiod)inthetechnicalspecificationsforeachmeasure.
Medicaid–Ameanstestedfederal‐stateentitlementprogramauthorizedin1965byTitleXIXoftheSocial
SecurityAct.MedicaidoffersFederalmatchingfundstostatesforcostsincurredinpayinghealthcare
providersforservingcoveredindividuals.
MedicaidCoveredServices–ThosehealthcarebenefitsandservicestowhichaneligibleBeneficiaryis
entitledundertheStatePlan.
MedicaidIDNumber–The13‐digitidentifyingnumberassignedtoaBeneficiarybytheState.
MedicaidManagementInformationSystem (MMIS)– Mechanizedclaimsprocessing andinformation
retrievalsystemusedtoprocessclaimsforFFSandencountersfortheManagedCareProgram.
Medicaid Provider*–AnyserviceprovidercontractedwithanMCOand/orenrolledin the Louisiana
MedicaidProgram.
MedicalInformation–InformationaboutanEnrollee'smedicalhistoryorconditionobtaineddirectlyor
indirectlyfromalicensedphysician,medicalpractitioner,hospital,clinic,orothermedicalormedically
relatedfacility.
MedicalLossRatio(MLR)–MeasureofthepercentageofadjustedpremiumrevenuesthattheContractor
spendsonincurredclaims,health carequality improvementactivities,and Fraudpreventionactivities,
versusadministrativecostsandprofit,ascalculatedinaccordancewith42C.F.R.§438.8.
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Medical Record – A single complete record kept at the site of the Enrollee's treatment(s), which
documentsmedicaloralliedgoodsandservices,including,butnotlimitedto,outpatientandEmergency
ServiceswhetherprovidedbytheContractor,itssubcontractor, orany out‐of‐NetworkProviders.The
recordsmaybeelectronic,paper,magneticmaterial,filmorothermedia.Inordertoqualifyasabasisfor
reimbursement,therecordsmustbedated,legibleandsignedorotherwiseattestedto,asappropriateto
themedia,andmeettherequirementsof42C.F.R§456.111and§456.211.
Medically Necessary Services*–Thosehealthcareservicesthatareinaccordancewithgenerally
accepted, evidence‐based medical standards or that are considered by most physicians (or other
independentlicensedpractitioners)withinthecommunityoftheirrespectiveprofessionalorganizations
tobethestandardofcare.Inordertobeconsideredmedicallynecessary,servicesmustbe:(1)deemed
reasonablynecessarytodiagnose,correct,cure,alleviateorprevent the worsening of a condition or
conditionsthatendangerlife,causesufferingorpainorhaveresultedorwillresultinahandicap,physical
deformityormalfunction;and(2)thoseforwhichnoequallyeffective,moreconservativeandlesscostly
courseoftreatmentisavailableorsuitablefortheBeneficiary.Anysuchservicesmustbeindividualized,
specificandconsistentwithsymptomsorconfirmeddiagnosisoftheillnessorinjuryundertreatment,
andneithermorenorlessthanwhattheBeneficiaryrequiresatthatspecificpointintime.Althougha
service may be deemed medically necessary, it doesn’t mean the service will be covered under the
Louisiana Medicaid Program. Services that are experimental, non‐FDA approved, investigational, or
cosmeticarespecificallyexcludedfromMedicaidcoverageandwillbedeemed“notmedicallynecessary.”
Medicare–Thefederalmedicalassistanceprogramauthorizedin1965byTitleXVIIIoftheSocialSecurity
Act,toaddressmedicalneeds.MedicareisavailabletoU.S.citizenssixty‐five(65)yearsofageandolder
andsomepeoplewithdisabilistiesundertheageofsixty‐five(65).
MemberMaterials–AllwrittenmaterialsproducedorauthorizedbytheContractoranddistributedto
Enrollees or Potential Enrollees containing information concerning the Contractor. Member materials
include,butarenotlimitedto,MCOMemberIDCards,memberhandbooks,providerdirectories,and
marketingmaterials.
MemberMonth–AmonthofcoverageforanEnrollee.
Mental Health/Substance Use (MH/SU) Providers – Behavioral health professionals engaged in the
treatmentofsubstanceuse,dependency,addiction,ormentalillness.
Monetary Penalty – Financial assessment that may be enforced whenever the Contractor and/or its
SubcontractorsfailtomeettherequirementsofthisContract.
Must–Denotesamandatoryrequirement.
NationalCommitteeforQualityAssurance(NCQA)–Anot‐for‐profitorganizationthatperformsquality‐
orientedaccreditationreviewsonhealthmaintenanceorganizationsandsimilartypesofmanagedcare
plans.HEDISandtheQualityCompassareregisteredtrademarksofNCQA.

Network* – The collective group of providers who have entered into provider agreements with the
ContractorforthedeliveryofMCOCoveredServices.Thisincludes, but is not limited to physical,
behavioral,pharmacy,andAncillaryServiceproviders.AlsoreferredtoasProviderNetwork.
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NetworkAdequacy–ReferstothenetworkofhealthcareprovidersfortheContractorthatissufficient
innumbersandtypesof providers and facilities to ensure that allservicesareaccessibletoEnrollees
withoutunreasonabledelay.Adequacyisdeterminedbyanumberoffactors,includingbutnotlimitedto,
provider‐to‐patient ratios; geographic accessibility and travel distance; appointment access and
timeliness; and hoursof provider operations. Network Adequacy will be assessed onthe Contractor’s
NetworkProvidersexcludingsinglecaseagreementsunlessotherwiseapprovedbyLDH.
NetworkProviderorProvider*–Anappropriatelycredentialedandlicensedindividual,facility,agency,
institution,organizationorotherentity,anditsemployeesandsubcontractorsthathasasignedprovider
agreementwiththeContractorforthedeliveryofMCOCoveredServicestotheContractor’sEnrollees.
Network Provider Agreement – A contract between the Contractor and a Network Provider forthe
deliveryofMCOCoveredServicestoEnrollees,includinganyinlieuofservicesofferedbytheContractor.
Newborn–AliveinfantborntoanEnrollee.
Non‐Emergency Ambulance Transportation (NEAT)–arideprovidedtoanEnrolleewithnoother
transportationresourcesthatisnotambulatoryandmusttravelviaambulance.NEATdoesnotinclude
transportationprovidedonanemergencybasis.
Non‐EmergencyMedicalTransportation(NEMT)–Aride,orreimbursementforaride,providedsothat
anEnrolleewithnoothertransportationresourcescanreceiveservicesfromanentityprovidingMedicaid
CoveredServices.NEMTdoesnotincludetransportationprovidedonanemergencybasis.
Non‐EmergencyServices–ServicesprovidedtoanEnrolleewhohassigns,symptoms,orboth,ofanon‐
EmergencyMedicalCondition
Non‐UrgentSickCare–Medicalcaregivenforanacuteonsetofsymptomsthatisnotemergentorurgent
innature.Examplesofnon‐urgentconditionsincludecoldsymptoms,sorethroat,andnasalcongestion.
NursePractitioner(NP)–Anadvancedpracticeregisterednurseeducatedinaspecifiedareaofcareand
certifiedaccordingtotherequirementsofanationallyrecognizedaccreditingagencysuchastheAmerican
Nurses Association’s AmericanNurses Credentialing Center, National Certification Corporation for the
Obstetric,GynecologicandNeonatalNursingSpecialties,ortheNationalCertificationBoardofPediatric
Nurse Practitioners and Nurses, or as approved by the LouisianaStateBoardofNursingandwhois
authorizedtoprovideprimary,acute,orchroniccare,asanadvancednursepractitioneractingwithin
his/herscopeofpracticetoindividuals,families,andothergroupsinavarietyofsettingsincluding,but
notlimitedto,homes,institutions,offices,industry,schools,andothercommunityagencies.
OCDDStatement ofApproval– A documentreceivedby individuals whohavecompletedthe System
Entryprocessatoneoftheten(10)HumanServiceDistricts/Authorities(alsocalledtheLocalGoverning
Entity or LGE). This document indicates that the individual meets the legal definition of
Intellectual/DevelopmentalDisabilityasdefinedbyLa.R.S.28:451.2.Thisdocumentfurtherindicatesthe
individualmeetsthecriteriatoreceiveservicesfromtheDevelopmentalDisabilityservicesystem.
OpenPanel–PCPswhoareacceptingnewpatientsfortheContractor.
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OperationalStartDate–ThefirstdateonwhichtheContractorisresponsibleforprovidingMCOCovered
ServicestotheirEnrolleesandisresponsibleforcompliancewithallaspectsoftheContract.Thisdateis
atthediscretionofLDH,butisanticipatedtobeJuly1,2022.TheOperationalStartDatemaybedelayed
byLDHforoneormoreMCOsdependingontheresultsoftheReadinessReview.
Out‐of‐Network (OON) Provider – An appropriately licensed individual, facility, agency, institution,
organizationorotherentitythathasnotenteredintoacontractwiththeContractorforthedeliveryof
MCOCoveredServicestotheContractor’sEnrollees.
Outlier–Additionalpaymentthatismadeforcatastrophiccostsassociatedwithservicesprovidedto1)
childrenunder the ageofsix (6)who received inpatient servicesin aDisproportionate ShareHospital
setting,and2)infantswhohavenotattainedtheageofoneyearwhoreceivedinpatientservicesinany
AcuteCaresetting.
OwnershipInterest–Thepossessionofstock,equity,oranyinterestintheprofitsoftheContractor;for
furtherdefinitionsee42C.F.R.§455.101.
Part2Program‐asdefinedin42C.F.R.§2.11.
Patient‐CenteredMedicalHome(PCMH)–Asystemofcareledbyateamofprimarycareproviderswho
partnerwiththepatient,thepatient’sfamilyandthecommunitytocoordinatecareinallsettings,from
specialistsandhospitalstopharmacies,mentalhealthprograms,andhomehealthagencies.
PeerSpecialist–Aparaprofessionalwithspecializedtrainingwhohasapersonalexperienceinspecial
health care needs and chronic or complex illness and who engages with Enrollees, providing person‐
centered,culturallysensitivesupportbuildingonthevalues,strengthsandpreferencesoftheEnrollee.
PendedClaim–Aclaimforwhichadditionalinformationisbeingrequestedinorderfortheclaimtobe
Adjudicated.
PerformanceImprovementProjects(PIP)–Projectsdesignedtoachieve,throughongoingmeasurements
andinterventions,significantimprovement,sustainedovertime,inclinicalcareandnonclinicalcareareas
thathaveafavorableeffectonhealthoutcomesandEnrolleesatisfaction.
PerformanceMeasures–Toolsthatquantifyhealthcareprocesses,outcomes,patientperceptions,and
organizationalstructureand/orsystemsthatareassociatedwiththeabilitytoprovidehigh‐qualityhealth
careand/orthatrelatetooneormorequalitygoalsforhealthcare.
Permanent Supportive Housing (PSH) – Consists of deeply affordable, community‐integrated rental
housing combined with supportive services that are designed to assist households in gaining and
maintainingaccesstosafe,goodqualityhousing.InPSH,theservicebeneficiaryisthetenantandlessee.
Tenancyisnotcontingentuponcontinuedreceiptofservices.
PermanentSupportiveHousing(PSH)Program–Across‐disabilityprogramthatprovidesrentalsubsidies
foraffordablehousingunitsstatewidetolowincomeEnrolleeswithsubstantial,long‐termdisabilities.
PSH services are reimbursed under several HCBS programs, and under Specialized Behavioral Health
ServiceswhereitisbilledasacomponentofCPSTandPSR.TobeeligibleforPSH,Enrolleesmustmeet
PSHProgrameligibilitycriteriaandmedicalnecessitycriteriaforservices.OverallmanagementofthePSH
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ProgramiscentralizedwithinLDHandfinalapprovalforEnrolleestoparticipateinthePSHismadebythe
LDHPSHProgramstaff.
Person‐centered–AcareplanningprocessdrivenbytheEnrolleethatidentifiessupportsandservices
thatarenecessarytomeettheEnrollee’sneedsinthemostintegratedsetting.TheEnrolleedirectsthe
process to the maximum extent possible and is provided sufficient information and support to make
informedchoicesanddecisions.TheprocessisTimelyandoccursattimesandlocationsconvenienttothe
Enrollee,reflectstheculturalandlinguisticconsiderationsoftheEnrollee,providesinformationinplain
languageandinamannerthatisaccessibletoEnrollees,andincludesstrategiesforresolvingconflictor
disagreementthatarisesintheplanningprocess.
PersonalCareServices(PCS)–Providedbyattendantswhenphysicallimitationsduetoillnessorinjury
requireassistancewitheating,bathing,dressing,andpersonalhygiene.Doesnotincludemedicaltasks
suchasmedicationadministration,tracheostomycare,feedingtubesorcatheters.
PharmacyBenefitsManager(PBM)–Athirdpartyadministratorofprescriptiondrugprograms.
PhysicianServices*–TheservicesprovidedbyanindividuallicensedunderStatelawtopracticemedicine
orosteopathy.Itdoesnotincludeservicesthatareofferedbyphysicianswhileadmittedinthehospital,
andchargesthatareincludedinthehospitalclaim.
Plan*–Anindividualorgroupthatprovides,orpaysthecostof,medicalcare.
PlanofCare(POC)–TheplandevelopedbytheContractorinconjunctionwiththeEnrolleeandother
individualsinvolvedintheEnrollee’scasemanagementtosupportthecoordinationofanEnrollee’scare
andprovidesupporttotheEnrolleeinachievingcaregoals.
Population Health – The health outcomes of the Contractor’s Enrollee population, including the
distributionofsuchoutcomeswithinthegroup.Itisanapproachaimedatimprovingthehealthofthe
Enrolleepopulationasawhole.
Post‐StabilizationCareServices–MedicaidCoveredServices,relatedtoanEmergencyMedicalCondition,
thatareprovidedafteranEnrolleeisstabilizedinordertomaintainthestabilizedconditionor,underthe
circumstancesdescribedin42C.F.R.§438.114,toimproveorresolvetheEnrollee’scondition.
PotentialEnrollee–ABeneficiarywhoissubjecttomandatoryEnrollmentormayvoluntarilyelectto
enrollintheManagedCareProgram,butisnotyetenrolledinanMCO.
Pre‐Admission Screening and Resident Review (PASRR) –A federal requirement to help ensure that
individualsarenotinappropriatelyplacedinnursinghomesforlong‐termcare.PASRRrequiresthatall
applicantstoaMedicaid‐certifiednursingfacility(1)beevaluatedformentalillnessand/orintellectual
disability;(2)beofferedthemostappropriatesettingfortheirneeds(inthecommunity,anursingfacility,
orAcuteCaresettings);and(3)receivetheservicestheyneedinthosesettings.
PreferredDrugList(PDL)–AlistmaintainedbyLDHindicatingwhichdrugsarecoveredwithouttheneed
for prior authorization, with the exception that some preferreddrugsrequirepriorauthorizationto
validateclinicalcriteria.
Premium*–Anamounttobepaidforaninsurancepolicy.
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Prescription Drug*–Adrugthatcanbeobtainedonlybymeansofaprescriptionfrom a qualified
provider.
PrescriptionDrugCoverage*–HealthinsuranceorplanthathelpsEnrolleespayforprescriptiondrugs
andmedications.
PreventiveCare–Preventivehealthcareservicesincludeimmunizations,screeningsforcommonchronic
andinfectiousdiseasesandcancers,clinicalandbehavioralinterventionstomanagechronicdiseaseand
reduceassociatedrisks,andcounselingtosupporthealthylivingandself‐managementofchronicdisease.
PrimaryCareProvider (PCP)*–Anindividualphysician,nursepractitioner,orphysicianassistantwho
acceptsprimaryresponsibilityforthemanagementofanEnrollee'shealthcare.Theprimarycareprovider
isthepatient’spointofaccessforpreventivecareoranillnessandmaytreatthepatientdirectly,refer
thepatienttoaspecialist(secondary/tertiarycare),oradmitthepatienttoahospital.
PrimaryCareProvider(PCP)AutomaticAssignment–TheprocessutilizedbytheContractortoassign
EnrolleestoaPCPusingpredeterminedalgorithms.
PrimaryCareServices–Healthcareservicesandlaboratoryservicescustomarilyfurnishedbyorthrough
aPCPfordiagnosisandtreatmentofacuteandchronicillnesses,diseasepreventionandscreening,health
maintenance, and health promotion either through direct service to the Enrollee when possible or
throughappropriatereferraltospecialistsand/orancillaryproviders.
PriorAuthorization–Theprocessofdeterminingmedicalnecessityforspecificservicesbeforetheyare
rendered.
ProspectiveReview–Utilizationreviewconductedpriortoanadmissionoracourseoftreatment.
ProtectedHealthInformation(PHI)–Individuallyidentifiablehealthinformationthatismaintainedor
transmitted in any form or medium and for which conditions for disclosure are defined in the rules
promulgated pursuant to the Health Insurance Portability andAccountability Act of 1996 (HIPAA), 45
C.F.R.Parts160and164.
ProviderAgreement–SeeNetworkProviderAgreement.
ProviderAppeal–TheformalmechanismwhichallowsaprovidertorequestreviewoftheContractor’s
finaldecision.
Provider‐BeneficiaryRelationship–Arelationshipthatisdefinedasoneinwhichtheproviderhasbeen
themain sourceof MedicaidCovered Servicesfor theBeneficiaryduring thepast twelve(12) months
basedonclaimsdatasortedbythemostfrequentlyvisitedPCP.
Provider Complaint–Averbalorwrittenexpressionbyaproviderwhichindicates dissatisfaction or
disputewiththeContractor’spolicy,procedure,claimsprocessingand/orpayment,oranyaspectofthe
Contractor’sfunctions.
ProviderDirectory–AlistingofhealthcareserviceproviderswithintheContractor’sprovidernetwork
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thatispreparedbytheContractorasareferencetooltoassistEnrolleesinlocatingprovidersthatare
availabletoprovideservices.
Provider Preventable Condition – Preventable healthcare‐acquired or other provider‐preventable
conditionsandevents,alsoknownasneverevents,identifiedbyLDHfornonpayment,including,butnot
limitedto,conditionssuchasbedpressureulcersordecubitusulcers;eventssuchassurgicalorinvasive
procedures performed on the wrong body part or wrong patient; or the wrong surgical procedure
performedonapatient.
PrudentLayperson–Apersonwhopossessesanaverageknowledgeofhealthandmedicine.
Quality–Asitpertainstoexternalqualityreview,meansthedegreetowhichtheContractorincreases
the likelihood of desired health outcomes of its Enrollees through its structural and operational
characteristicsandthroughtheprovisionofhealthservicesthatareconsistentwithcurrentprofessional
knowledge.

Quality Assessment and Performance Improvement (QAPI) Plan – A written plan detailing the
Contractor’s quality management and committee structure, performance measures, monitoring and
evaluationprocess,andimprovementactivitiesmeasuresthatrelyuponqualitymonitoringimplemented
toimprovehealthcareoutcomesforEnrollees.
QualityAssessmentandPerformanceImprovement(QAPI)Program)–Programthatobjectivelyand
systematicallydefines,monitorsandevaluatesthequalityandappropriatenessofcareandservices,and
promotes improved patient outcomes through performance improvement projects, medical record
audits,performancemeasures,surveys,andrelatedactivities.
QualityManagement(QM)–TheongoingprocessofensuringthatthedeliveryofMCOCoveredServices
is appropriate, Timely, accessible, available, medically necessary, in accordance with established
guidelinesandstandards,andreflectiveofthecurrentstateofmedicalandbehavioralhealthknowledge.
ReadinessReview–ReferstoLDH’s,oritsdesignee’s,assessmentoftheContractor’sabilitytofulfillthe
Contractrequirements.Suchreview may include, butis notbe limited to,review ofproperlicensure,
operationalprotocols,reviewoftheContractor’sstandards,andreviewofsystems.Thereviewmaybe
doneasadeskreview,on‐sitereview,orcombinationandmayinclude interviews with pertinent
personnel sothat LDH can makeaninformedassessmentof the Contractor’sabilityandreadiness to
renderservices.
Re‐admission – Subsequent admissions of a patient to a hospital or other health care institution for
treatment.
Recovery – In referenceto behavioral health services, a process of change through which individuals
improvetheirhealthandwellness,liveself‐directedlives,andstrivetoreachtheirfullpotential.
ReferralServices–HealthcareservicesprovidedtoEnrolleestobothin‐andout‐of‐NetworkProviders
whenorderedandapprovedbytheContractor,including,butnotlimitedtoin‐networkspecialtycareand
out‐of‐networkservicesthatarecoveredundertheStatePlan.
RegisteredNurse(RN)–PersonlicensedasaRegisteredNursebytheLouisianaStateBoardofNursing.
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RehabilitationServicesandDevices*–ServicesorderedbytheEnrollee’sPCPtohelptheEnrolleerecover
fromanillnessorinjury.Theseservicesareprovidedbynursesandphysical,occupational,andspeech
therapists.
Reinsurance–Anagreementbetweeninsurancecompanies,wherebythecedinginsurertransferssome
partofitsinsuranceliabilitiestotheassuminginsurer,inaccordancewithLa.R.S.22:651,etseq.
Rejected Claim– A claim that does not pass standard, front‐end HIPAA edits, indicating that there is
missingorinvaliddatasuchthatthereisinsufficientinformationtoprocesstheclaim.
RemittanceAdvice–Anelectroniclistingoftransactionsforwhichpaymentiscalculated.Hardcopiesare
availableuponrequestonly.
Reprocessing(Claims)–Upondeterminationoftheneedtocorrecttheoutcomeofoneormoreclaims
processingtransactions,thesubsequentattempttoprocessasingleclaimorbatchofclaims.
RequestforProposals(RFP)–ThedocumentandanysubsequentaddendaissuedbyLDHandresultsin
thisContract.
Risk–Thechanceorpossibilityoflossassociatedwithprovisionofcareforagivenpopulation.
Risk Adjustment – A method for determining adjustments to the Capitation Rate thataccountsfor
variationinhealthrisksamongparticipatingMCOswhendeterminingpayments.
Routine Care –Treatmentofaconditionwhichwouldhavenoadverseeffectsifnottreatedwithin
twenty‐four(24)hoursorthatcouldbetreatedinalessacutesetting(e.g.,physician'soffice)orbythe
patient.
RoutinePrimaryCare–Routineprimarycareservicesincludethediagnosisandtreatmentofconditions
topreventdeteriorationtoamoreseverelevel,orminimize/reduceriskofdevelopmentofchronicillness
ortheneedformorecomplextreatment.Examplesincludepsoriasis,chroniclowbackpain;requiresa
face‐to‐facevisitwithinfour(4)weeksofEnrolleerequest.
RuralHealth Clinic(RHC) –Aclinic locatedinan areathat hasahealthcareprovidershortage andis
certifiedtoreceivespecialMedicareandMedicaidreimbursement.RHCsprovideprimaryhealthcareand
related diagnostic services and may provide optometric, podiatry, chiropractic, and behavioral health
services. RHCs must be reimbursed by the Contractor using prospective payment system (PPS)
methodology.
RuralHospital–HospitallicensedbyLDHthatmeetsthedefinitioninLa.R.S.40:1189.3.
SchoolBasedHealthCenterClinic(SBHC)–AhealthcareprovidercertifiedbytheOfficeofPublicHealth
thatisphysicallylocatedinaschooloronornearschoolgrounds thatprovides convenientaccess to
comprehensive,primaryandpreventivephysicalandmentalhealthservicesforpublicandcharterschool
students.
SecondOpinion–Subsequenttoaninitialmedicalopinion,anopportunityorrequirementtoobtaina
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clinicalevaluationbyaproviderotherthantheprovideroriginally making a recommendation for a
proposedhealthservice,toassesstheclinicalnecessityandappropriatenessoftheinitialproposedhealth
service.
SecureFileTransferProtocol(SFTP)–Softwareprotocolfortransferringdatafilesfromonecomputerto
anotherwithaddedencryption.
ServiceArea–ThedesignatedareainwhichtheContractorisauthorizedtofurnishMCOCoveredServices
toEnrollees.TheserviceareaistheentirestateofLouisiana.
ServiceAuthorization–Autilizationmanagementactivitythatincludespre‐,concurrent,orpostreview
ofaservicebyaqualifiedhealthprofessionaltoauthorize,partiallydeny,ordenythepaymentofa
service,includingaservicerequestedbytheEnrollee.Serviceauthorizationactivitiesmustconsistently
applyreviewcriteria.
Shall–Denotesamandatoryrequirement.
Should–Denotesadesirableaction,butnotamandatoryrequirement.
Significant–AsutilizedinthisContract,exceptwherespecificallydefined,shallmeanimportantineffect
ormeaning.
Skilled Nursing Care*–Alevelofcarethatincludesservicesthatcanonlybeperformed safely and
correctlybyalicensednurse(eitheraregisterednurseoralicensedpracticalnurse).
SocialDeterminantsofHealth(SDOH)–Thecomplex,integrated,andoverlappingsocialstructuresand
economicsystemsthatareresponsibleformosthealthinequities.Thesesocialstructuresandeconomic
systemsincludethesocialenvironment,physicalenvironment,healthservices,andstructuralandsocietal
factors.Social determinants of healthareshaped by thedistributionof money, power,and resources
throughoutlocalcommunities,nations,andtheworld.
SocialSecurityAct–TheSocialSecurityActof1935,asamended,42U.S.C.§301‐1397mmprovidesfor
theMedicaidProgram(TitleXIX)andCHIPProgram(TitleXXI).
Solvency–TheminimumstandardoffinancialhealthfortheContractorwhereassetsexceedliabilities
andTimelypaymentrequirementscanbemet.
SpanofControl–InformationsystemsandtelecommunicationscapabilitiesthattheContractoroperates
orforwhichitisotherwiselegallyresponsibleaccordingtothetermsandconditionswithLDH.Thespan
ofcontrolalsoincludessystemsandtelecommunicationscapabilitiesoutsourcedbytheContractor.
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) – Federal program
administeredbytheOfficeofPublicHealththatprovidesnutritionalcounseling;nutritionaleducation;
breast‐feedingpromotion;andnutritiousfoodstopregnant,postpartumandbreast‐feedingwomenand
infantsandchildrenuptotheageoffive(5)whoaredeterminedtobeatnutritionalriskandwhohavea
lowtomoderateincome.AnindividualwhoiseligibleforLouisianaMedicaidProgramisautomatically
incomeeligibleforWICbenefits.
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Specialist*–AphysicianwhoisnotaPCP.Maybeusedinterchangeablywithsubspecialist.
SpecializedBehavioralHealthServices(SBHS)–Mentalhealthservicesandsubstanceuseservicesthat
areprovidedoutsideofprimarycare,unlessfurnishedinanintegratedcaresetting,andinclude,butare
notlimitedto,servicesprovidedbyapsychiatrist,LMHP,and/ormentalhealthrehabilitationprovider.
Stabilized – WithrespecttoanEmergencyMedicalCondition,thatnomaterial deterioration of the
conditionislikely,withinreasonablemedicalprobability,toresultfromoroccurduringthetransferofthe
individualfromafacility,orwithrespecttoawomaninlabor,thewomanhasdelivered(includingthe
placenta).
State–TheStateofLouisiana.
StateFairHearing–Theprocesssetforthin42C.F.R.SubpartE.
StatePlan–ReferstotheLouisianaMedicaidStatePlanandtheLaCHIPStatePlan.
Stop‐LossCoverage‐Insurancecoveringthelossofaninsuredaboveaspecificamount.Alsoreferredto
as“excesslosscoverage”.
Sterilization–Anymedicaltreatmentorprocedurethatrendersanindividualpermanentlyincapableof
reproducing.
Stratification–Theprocessofpartitioningdataintodistinctornon‐overlappinggroups.
Subcontractor – A person, agency or organization with which the Contractor has subcontracted or
delegated some of its management functions or other contractual responsibilities to provide MCO
CoveredServicesto itsEnrollees.A NetworkProvider isnota subcontractorbyvirtueofthe Network
ProvideragreementwiththeContractor.
Subsidiary–AnAffiliatethatisownedorcontrolledbytheContractor,eitherdirectlyorindirectlythrough
one(1)ormoreintermediaries.
Subspecialist–AphysicianwhoisnotaPCP.Maybeusedinterchangeablywithspecialist.
SubstantialContractualRelationship–Anydirectorindirectbusinesstransactionsthatamountwithina
twelve(12)monthperiodtomorethantwenty‐fivethousanddollars($25,000)orfivepercent(5%)ofthe
Contractor’stotaloperatingexpenses,whicheverisless.
SupplementalSecurityIncome(SSI)–Afederalprogramthatprovidesacashbenefittopeoplewhoare
aged,blindordisabledandwhohavelittleornoincomeorassets.Louisianaisa“Section1634”stateand
anyone determined eligible for SSI is automatically eligible for the Louisiana Medicaid Program, in
accordancewith42U.S.C.§1383c.
SystemFunctionResponseTime–Basedonthespecificsubfunctionbeingperformed:
Record Search Time ‐ the time elapsed after the search command is entered until the list of
matchingrecordsbeginstoappearonthemonitor.
RecordRetrievalTime‐thetimeelapsedaftertheretrievecommandisentereduntiltherecord
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databegintoappearonthemonitor.
PrintInitiationTime ‐ the elapsedtime fromthecommand to print ascreen or reportuntil it
appearsintheappropriatequeue.
On‐lineClaimsAdjudicationResponseTime‐theelapsedtimefromthereceiptofthetransaction
bytheMCOfromtheproviderand/orswitchvendoruntiltheMCOhands‐offaresponsetothe
providerand/orswitchvendor.
SystemUnavailability–MeasuredwithintheContractor’sinformationsystemspanofcontrol.Asystem
isconsiderednotavailablewhenasystemuserdoesnotgetthecomplete,correctfull‐screenresponseto
aninputcommandwithinthree(3)minutesafterdepressingthe“enter”orotherfunctionkey.
TTY/TDD – Telephone Typewriter and Telecommunication Device for the Deaf,whichallowsfor
interpretercapabilityfordeafcallers.
TargetedCaseManagement–CaseManagementservicesfortargetedpopulationgroupsand
certainWaivergroups,inaccordancewithapplicableFederalandStatelaws,regulations,rules,policies,
procedures,andmanuals,theStatePlan,andWaivers.
Telemedicine – ProvisionofMCOCoveredServicesthroughtwo‐way,realtimeinteractive electronic
communicationbetweenthepatientandthephysicianorpractitioneratthedistantsite.Thiselectronic
communicationmeanstheuseofinteractivetelecommunicationsequipmentthatincludes,ataminimum,
audioandvideoequipment.
Tenancy Supports – Supports provided under CPST and PSR to that subset of Enrollees accepted for
participation in Louisiana’s PSH Program.Tenancy and pre‐tenancy supports are designed to help
Enrollees access and maintain successful tenancy in the community‐integrated, affordable housing
providedthroughLouisiana’sPSHProgram.Tenancyandpre‐tenancysupportsconsistofactivitiessuch
ashelpingEnrolleescompleteapartmentapplications,seekreasonableaccommodations,negotiateand
enterintoleases,understandtheroleoftenant,understandtenantrights,developbudgets,makeTimely
rentpayments,complywithtermsoflease,adjusttonewhomeandneighborhood(includinghowtoget
toandaccessessentialservices),applyforincomebenefitssuchasSSI,complywithmedicationandother
treatmentregimes,anddevelop/implementcrisisplanstoavoideviction.
TertiaryCare– Highlyspecializedmedicalcare, usuallyoveranextended periodof timethatinvolves
advancedandcomplexproceduresandtreatmentsperformedbymedicalspecialistsinstate‐of‐the‐art
facilities.
ThirdPartyLiability(TPL)–Referstothelegalobligationofthirdparties,i.e.,certainindividuals,entities,
orprograms,topayallorpartoftheexpendituresformedicalassistancefurnishedundertheStatePlan.
Bylaw,allotheravailablethirdpartyresourcesmustmeettheirlegalobligationtopayclaimsbeforethe
LouisiaaMedicaidProgrampaysforthecareofaBeneficiary.
Timely–Existingortakingplacewithinthedesignatedperiodorwithinthetimerequiredbyapplicable
FederalandStatelaws,regulations,rules,policies,procedures,andmanuals,theStatePlan,Waivers,and
thisContract.
TitleIV‐E–MeansTitleIV,PartE,oftheSocialSecurityAct,42U.S.C.§§670‐679c,whichprovidesforthe
federal‐statefostercare,prevention,andpermanencyprogram.
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TitleV–MeansTitleVoftheSocialSecurityAct,42U.S.C.§§701‐713,whichprovidesformaternaland
child health services. Federal laws and regulations mandate cooperationbetweenStateagencies
responsiblefortheadministrationandsupervisionofbothTitleVandTitleXIXoftheSocialSecurityAct.
TitleX–Means TitleXof thePublic HealthServices Act,42U.S.C.§§§300‐300a‐6, whichprovidesfor
familyplanningservices.
TitleXIX–MeansTitleXIXoftheSocialSecurityAct,42U.S.C.§§1396‐1396w‐5,whichauthorizesand
governstheState’sMedicaidprogram.
TitleXXI–MeansTitleXXIoftheSocialSecurityAct,42U.S.C.§§1397aa‐1397mm,whichauthorizesand
governstheChildren’sHealthInsuranceProgram(CHIP).
TotalCostofCare(TCOC)–Abroadindicatorofspendingforagivenpopulation(i.e.,paymentsfrom
payer to provider organizations). In the context of population‐based payment models, TCOC includes
spendingassociatedwithcaringforadefinedpopulation,typicallyincludingallproviderandfacilityfees,
inpatient and Ambulatory Care, pharmacy, behavioral health,laboratory, imaging, and other Ancillary
Services.
Transition Phase – IncludesallactivitiestheContractorisrequiredtoperformbetweenthe date the
ContractissignedbyallpartiesandtheOperationalStartDateasdefinedinthisContractandtheMCO
Manual.
TransitionalCaseManagement–TheevaluationofanEnrollee’smedicalcareneedsandcoordinationof
anyothersupportservicesinordertoarrangeforsafeandappropriatecareafterdischargefromonelevel
ofcaretoanotherlevelofcare,includingreferraltoappropriateservices.
TransportationBroker–EntitythatmanagesthecoordinationandprovisionofNon‐EmergencyMedical
Transportationservicesinaccordancewith42C.F.R.§440.170(a)(4).
Treatment Planning – An administrative treatment planning activity provided under Medicaid
requirementsat42C.F.R.§438.208(c)fordevelopingandfacilitatingimplementationofPOCsforEnrollees
withSHCNandotherEnrolleesasrequiredunderapplicableFederalandStatelaws,regulations,rules,
policies, procedures, and manuals, the State Plan, Waivers, and this Contract.Treatment Planning is
providedtoaddresstheuniqueneedsofclientslivinginthecommunityanddoesnotduplicateanyother
MedicaidCoveredServiceorservicesotherwiseavailabletotheBeneficiaryatnocost.
TurnoverPhase–IncludesallactivitiestheContractorisrequiredtoperforminconjunctionwiththeend
oftheContract.
TurnoverPlan–ThewrittenplandevelopedbytheContractor,approvedbyLDH,tobeemployedduring
theturnoverphase.
UrgentCare*–MedicalcareprovidedforaconditionthatwithoutTimelytreatment,couldbeexpected
todeteriorateintoanemergency, or cause prolonged, temporaryimpairmentinoneormorebodily
functions,orcausethedevelopmentofachronicillnessorneedforamorecomplextreatment.Examples
of conditions that require urgent care include abdominal pain of unknown origin, unremitting new
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symptomsofdizzinessofunknowncause,andsuspectedfracture.UrgentcarerequiresTimelyface‐to‐
facemedicalattentionwithintwenty‐four(24)hoursofEnrolleenotificationoftheexistenceofanurgent
condition.
Utilization–Theratepatternsofserviceusageortypesofserviceoccurringwithinaspecifiedtime.
UtilizationManagement(UM)–Referstotheprocesstoevaluatethemedicalnecessity,appropriateness,
andefficiency oftheuse ofhealth careservices,procedures, and facilities.UtilizationManagementis
inclusiveofUtilizationReviewandserviceauthorization.
UtilizationReview(UR)–Evaluationoftheclinicalnecessity,appropriateness,efficacy,orefficiencyof
corehealthcarebenefitsandservices,proceduresorsettings,andambulatoryreview,prospectivereview,
concurrentreview,secondopinions,caremanagement,dischargeplanning,orretrospectivereview.
Validation–Thereviewofinformation,data,andprocedurestodeterminetheextenttowhichdatais
accurate,reliable,freefrombiasandinaccordancewithstandardsfordatacollectionandanalysis.
Value‐Added Benefit (VAB) – The additional benefits outside of the MCO Covered Services that are
deliveredattheContractor’sdiscretionandarenotincludedintheCapitationRatecalculations.Value‐
addedbenefitsdonotincludeinlieuofservices.
Value‐Based Payment (VBP) – Broad set of performance‐based payment strategies that link financial
incentivestoproviders’performanceonasetofdefinedmeasuresofqualityand/orcostorresourceuse.
VoluntaryMCOPopulation–ThegroupsofBeneficiarieswhoarenotrequiredtoenrollintheManaged
CareProgram.
Waiver–AbindingwrittenagreementbetweenLDHandCMSthatdescribesapprovedexceptionstothe
StatePlanandadditionalStateassurancesregardinghowtheLouisianaMedicaidProgramisadministered
byLDH(includingMCOswhereapplicable).Waiversmayinclude,butarenotlimitedto,Section1915(c)
HCBSWaivers,Section1915(b)ManagedCareWaivers,andSection1115DemonstrationWaivers.
Week–Theentireseven(7)dayweek,MondaythroughSunday.
Will–Atermthatdenotesamandatoryrequirement.
WraparoundAgency(WAA)–WAAsarethelocusofaccountabilityfordevelopingasingleplanofcare
andprovidingintensivecarecoordinationforchildrenwithintheCSoCneedingsuchsupports,withthe
goalof“onefamily,oneplanofcare,andonewraparoundfacilitator.”
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Acronyms
ACD–AutomatedCallDistribution
ACE–AdverseChildhoodExperience
ACH–AutomatedClearinghouse
ACT–AssertiveCommunityTreatment
ADA–AmericanswithDisabilitiesAct
ADHC–AdultDayHealthCare
ADT—AdmitDischargeTransfer
APM–AlternativePaymentModel
APRN‐AdvancedPracticeRegisteredNurse
ARRA—AmericanRecoveryandReinvestmentAct
ASAM–AmericanSocietyofAddictionMedicine
ASC–AccreditedStandardsCommittee
ASL—AmericanSignLanguage
BCC–BreastandCervicalCancer
BCP–BusinessContinuityPlan
BHSF–BureauofHealthServicesFinancing
CAHPS–TheConsumerAssessmentofHealthProvidersandSystems
CANS–ChildandAdolescentNeedsandStrengths
CAP–CorrectiveActionPlan
CAQH‐‐CouncilforAffordableQualityHealthcare
CARF‐‐CommissiononAccreditationofRehabilitationFacilities
CBO–Community‐basedOrganizations
CC–Children’sChoice
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CCW–CommunityChoicesWaiver
CDC–CentersforDiseaseControlandPrevention
CEHRT—CertifiedElectronicHealthRecordTechnology
CEO—ChiefExecutiveOfficer
C.F.R.–CodeofFederalRegulations
CHAMP–ChildHealthandMaternalProgram
CHIP–Children’sHealthInsuranceProgram
CHW–CommunityHealthWorker
CI–CrisisIntervention
CLAS–CulturallyandLinguisticallyAppropriateServices
CLIA–ClinicalLaboratoryImprovementAmendments
CMO–ChiefMedicalOfficer
CMS–CentersforMedicareandMedicaidServices
COA–CouncilonAccreditation
COB–CoordinationofBenefits
COLA–CostofLivingAdjustment
CON–CertificationofNeed
COO–ChiefOperatingOfficer
CPST–CommunityPsychiatricSupportandTreatment
CPT–CurrentProceduralTerminology
CQI–ContinuousQualityImprovement
CSoC–CoordinatedSystemofCare
CVO–CredentialsVerificationOrganization
CY–CalendarYear
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DCFS–DepartmentofChildrenandFamilyServices
DD–DevelopmentallyDisabled
DME–DurableMedicalEquipment
DOI–LouisianaDepartmentofInsurance
DOS–Date(s)ofService
DRA–DeficitReductionAct
DRP–DisasterRecoveryPlan
DSA–DataSharingAgreement
DSH–DisproportionateShareHospital
DUR–DrugUtilizationReview
EB–EnrollmentBroker
EBP–EvidencedBasedPractices
ED–EmergencyDepartment
EDI–ElectronicDataInterchange
EFT–ElectronicFundsTransfer
EHR–ElectronicHealthRecords
EOB–ExplanationofBenefits
EPO–ExclusiveProviderOrganizations
EPSDT–EarlyandPeriodicScreening,DiagnosisandTreatment
EQR–ExternalQualityReview
EQRO–ExternalQualityReviewOrganization
EVV–ElectronicVisitVerification
FDA–FoodandDrugAdministration
FFP–FederalFinancialParticipation
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FFS–Fee‐for‐Service
FFT–FunctionalFamilyTherapy
FI–FiscalIntermediary
FITAP–FamilyIndependenceTemporaryAssistanceProgram
FMP–FullMedicaidPricing
FNS–FacilityNotificationSystem
FOC–FreedomofChoice
FQHC–FederallyQualifiedHealthCenter
FSO–FamilySupportOrganization

GAO–GovernmentAccountabilityOffice
GME–GraduateMedicalEducation
GPRA–GovernmentPerformanceReportingandResultsAct
HCBS–HomeandCommunityBasedServicesWaiver
HCP‐LAN–HealthCarePaymentLearningandActionNetwork
HEDIS–HealthcareEffectivenessDataandInformationSet
HHS–UnitedStatesDepartmentofHealthandHumanServices
HIE–HealthInformationExchange
HIPAA–HealthInsurancePortabilityandAccountabilityAct
HIPF–HealthInsuranceProviderFee
HITECH–HealthInformationTechnologyforEconomicandClinicalHealthAct
HNA–HealthNeedsAssessment
HPE–HospitalPresumptiveEligibility
HPSA–HealthProfessionalShortageArea
HRSA–HealthResourcesandServicesAdministration
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HSIC–HumanServicesInteragencyCouncil
HSS–HealthStandardsSection
IB–Incentive‐based
ICF/IID–IntermediateCareFacilityforIndividualswithIntellectualDisabilities
ICN–InternalControlNumber
I/DD–Intellectual/DevelopmentalDisability
ID–Identification
IEP–IndividualizedEducationPlan
IHCP–IndianHealthCareProvider
IHS–IndianHealthService
IMD–InstitutionforMentalDiseases
IRS–InternalRevenueService
IS–InformationSystems
ISA–InteroperabilityStandardsAdvisory
ISCA–InformationSystemsCapabilitiesAssessment
IVR–InteractiveVoiceResponse
IV&V–IndependentVerificationandValidation
JLCB–JointLegislativeCommitteeontheBudget
LAALS–LouisianaAdverseActionsListSearch
LAC–LicensedAddictionCounselor
LaCHIP–LouisianaChildren’sHealthInsuranceProgram
LaHIPP–LouisianaHealthInsurancePremiumPaymentProgram
LCSW–LicensedClinicalSocialWorker
LDH–LouisianaDepartmentofHealth
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LDOE–LouisianaDepartmentofEducation
LEERS–LouisianaElectronicEventRegistrationSystem
LEIE–ListofExcludedIndividuals/Entities
LGE–LocalGoverningEntity
LHA–LouisianaHousingAuthority
LLA–LouisianaLegislativeAuditor
LMFT–LicensedMarriageandFamilyTherapists
LMHP–LicensedMentalHealthProfessional
LPC–LicensedProfessionalCounselors
LOCUS–LevelofCareUtilizationSystem
LTC–LongTermCare
LTSS–Long‐TermSupportsandServices
MAC–MaximumAllowableCost
MAT–MedicationAssistedTreatment
MCIP–ManagedCareIncentiveProgram
MCO–ManagedCareOrganization
MEF–MedicaidExclusionFile
MFCU–MedicaidFraudControlUnit
MHR–MentalHealthRehabilitation
MIS–ManagementInformationSystem
MLR–MedicalLossRatio
MMIS–MedicaidManagementInformationSystem
MOU–MemorandumofUnderstanding
MST–Multi‐SystemicTherapy
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MVA–MedicalVendorAdministration
NCCI–NationalCorrectCodingInitiative
NCQA–NationalCommitteeforQualityAssurance
NDC–NationalDrugCode
NEAT–Non‐EmergencyAmbulanceTransportation
NEMT–Non‐EmergencyMedicalTransportation
NF–NursingFacility
NICU–NeonatalIntensiveCareUnit
NIST–NationalInstituteofStandardsandTechnology
NMP–NoticeofMonetaryPenalty
NOA–NoticeofAction
NOMS–NationalOutcomeMeasures
NOW–NewOpportunitiesWaiver
NP–NursePractitioner
NPI–NationalProviderIdentifier
NQTL–NonquantitativeTreatmentLimitations
OCDD–OfficeforCitizenswithDevelopmentalDisabilities
OCR–OpticalCharacterRecognition
ODBC–OpenDatabaseConnectivity
OEM–OriginalEquipmentManufacturer
OIG–OfficeofInspectorGeneral
OJJ–OfficeofJuvenileJustice
OLE–ObjectLinkingandEmbedding
OMH–OfficeofMinorityHealth
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ONC–OfficeoftheNationalCoordinator
OON–Out‐of‐Network
OPH–OfficeofPublicHealth
P&T–PharmaceuticalandTherapeuticCommittee
PA–PriorAuthorization
PACE–ProgramofAll‐InclusiveCarefortheElderly
PASRR–Pre‐AdmissionScreeningandResidentReview
PBM–PharmacyBenefitsManager
PCMH–Patient‐CenteredMedicalHome
PCN–ProcessorControlNumber
PCP–PrimaryCareProvider
PCS–PersonalCareServices
PDL–PreferredDrugList
PHI–ProtectedHealthInformation
PIP–PerformanceImprovementProjects
PMPM–PerMember,PerMonth
POC–PlanofCare
POS–PointofSale
PPACA–PatientProtectionandAffordableCareAct
PPS–ProspectivePaymentSystem
PRTF–PsychiatricResidentialTreatmentFacilities
PSH–PermanentSupportiveHousing
PSR–PsychosocialRehabilitation
PT–PhysicalTherapy
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QA–QualityAssurance
QAPI–QualityAssessmentandPerformanceImprovementPlan
QDWI–QualifiedDisabledWorkingIndividual
QI–QualityImprovement
QI‐1–QualifyingIndividual
QM–QualityManagement
QMB–QualifiedMedicareBeneficiary
QM/QI–QualityManagement/QualityImprovement
RA–RemittanceAdvice
RAC–RecoveryAuditCoordinator
RDBMS–RelationalDatabaseManagementSystem
RFP–RequestforProposals
RHC–RuralHealthClinic
RN–RegisteredNurse
ROW–ResidentialOptionsWaiver
RSDI–Retirement,Survivors,andDisabilityInsurance
SAM–SystemofAwardManagement
SBHC–SchoolBasedHealthCenter
SBHS–SpecializedBehavioralHealthServices
SDF–SoftwareDevelopmentFirm
SDOH–SocialDeterminantsofHealth
SFTP–SecureFileTransferProtocol
SFY–StateFiscalYear
SHCN–SpecialHealthCareNeeds
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SHP–STD/HIVProgram
SIU–SpecialInvestigationUnit
SLMB–SpecifiedLow‐IncomeMedicareBeneficiary
SMART‐‐Specific,Measurable,Action‐Oriented,Realistic,andTime‐Limited
SMI–SeriousMentalIllness
SNAP–SupplementalNutritionAssistanceProgram
SPA–StatePlanAmendment
SSA–SocialSecurityAct
SSI–SupplementalSecurityIncome
SUD–SubstanceUseDisorder
SURS–SurveillanceandUtilizationReviewSubsystems
TCOC–TotalCostofCare
TDD–TelecommunicationsDevicefortheDeaf
TEDS–TreatmentEpisodeDataSets
TGH–TherapeuticGroupHome
TJC–TheJointCommission
TPL–ThirdPartyLiability
TTY/TDD–TelephoneTypewriteandTelecommunicationsDevicefortheDeaf
UM–UtilizationManagement
UPS–UninterruptiblePowerSystem
UR–UtilizationReview
U.S.C.–UnitedStatesCode
VAB–ValueAddedBenefit
VBP–Value‐BasedPayment
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VPN–VirtualPrivateNetwork
WAA–WraparoundAgency
WIC–Women,InfantsandChildrenProgram
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PART2: CONTRACTORRESPONSIBILITIES
ContractTransition&Readiness
2.1.1 TransitionPhase
2.1.1.1 TheContractorshallsubmittoLDHoritsdesigneeaspartofReadinessReview,
foritsreviewandapproval,aTransitionWorkPlanthatdemonstrateshowit
willaccomplishrequiredtaskssetforthinthisContractbeforetheOperational
StartDateandprovidedocumentationofthefollowing:
2.1.1.1.1 Projectmanagementstructure;
2.1.1.1.2 CommunicationprotocolsbetweenLDHandtheContractor;
2.1.1.1.3 Contactsforreadinessactivities;
2.1.1.1.4 Scheduleforkeyactivitiesandmilestones;and
2.1.1.1.5 ProcessforensuringcontinuityofcareforEnrolleesduringthe
transitionwithafocusonhealthandsafety.
2.1.1.2 TheContractorshallprovidemonthlystatusreportsthattrackimplementation
progressagainstthescheduleintheTransitionWorkPlan,asapprovedbyLDH
inwriting,forsix(6)monthsfollowingtheOperationalStartDate.
2.1.2 ReadinessReview
2.1.2.1 LDHor its designee will conducta comprehensive Readiness Review of the
ContractorpriortotheOperationalStartDateinaccordancewith 42C.F.R.
§438.66(d). LDH will provide the Contractor with the Readiness Review
schedule.TheContractoragreestoprovideallmaterialsrequiredtocomplete
theReadinessReviewbythedatesestablishedbyLDH.Thereviewmayinclude
anevaluationofalldeliverablesasdefinedintheContract.Aportionofthe
ReadinessReviewwillbeperformedonsiteattheContractor’sadministrative
office.TheContractorshallberesponsibleforalltravelcostsincurredbyLDH,
oritsdesignee’s,staffparticipatinginonsiteReadinessReviews.Theresultsof
theReadiness Reviewwill besubmittedto CMSby LDHforCMStomakea
determination that the contract or associated contract amendment is
approvedunder42C.F.R.§438.3(a).
2.1.2.2 The Contractor must disclose any changes to proposed key staff,
subcontractors, or value added benefits identified in the proposal for LDH
approval.
2.1.2.3 TheContractormusthavesuccessfullymetallReadinessReviewrequirements
established by LDH no later than sixty (60) Calendar Days priortothe
OperationalStartDateorbythedatesestablishedbyLDHinwriting when
applicable.
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2.1.2.4 IftheContractordoesnotfullymeettheReadinessReviewprior to the
OperationalStartDate,LDHmayimposeaMonetaryPenaltyforeachCalendar
DaybeyondtheOperationalStartDatethattheContractorisnotoperational.
2.1.2.5 TheContractorisrequiredtoprovideaCorrectiveActionPlaninresponseto
anyReadiness Reviewdeficiencyno laterthan ten(10)CalendarDays after
writtennotificationofanysuchdeficiencybyLDHoritsdesignee. If the
Contractor documents to LDH’s satisfaction that the deficiency has been
correctedwithinten(10)CalendarDaysofsuchdeficiencynotificationbyLDH
oritsdesignee,noCorrectiveActionPlanisrequired.
2.1.2.6 SystemReadiness
2.1.2.6.1 The Contractor will define and test modifications to the
Contractor’s system(s) required to support the business
functions of the Contract. The Contractor will produce data
extracts and receive data transfers and transmissions. The
Contractormustbeabletodemonstratetheabilitytoproduce
encounterfiles.
2.1.2.6.2 If any errors or deficiencies are evident, the Contractor will
developresolutionprocedurestoaddresstheproblemidentified.
The Contractor will provide LDH or its designeewith test data
filesforsystemsandinterfacetestingforallexternalinterfaces.
2.1.2.7 The Contractor shall participate in additional Readiness Reviews when
providing or arranging for the provision of MCO Covered Services to new
eligibilitygroupsinaccordancewith42C.F.R.§438.66(d)(1)asdirectedbyLDH.
Administration&ContractManagement
2.2.1 GeneralRequirements
2.2.1.1 TheContractorshallestablishandmaintaininterdepartmentalstructuresand
processes to support the operation and management of this Contract in a
mannerthatfostersintegrationofphysicalandbehavioralhealth service
provisions.The provision of all services shall bebased onprevailing clinical
knowledgeandthestudyofdataontheefficacyoftreatment,whensuchdata
isavailable.
2.2.1.2 TheContractorshallnotifyLDHinwritingwhentherehasbeena Material
Changeinitsoperations.Thewrittennotificationshallincludethedetailsof
thechangeandanassurancethatitwillnotimpacttheabilityoftheContractor
tocomplywiththerequirementsofthisContract.
2.2.1.3 TheContractorshallrequireitssubcontractorstocomplywithallapplicable
Contractrequirements,applicableFederalandStatelaws,regulations,rules,
policies, procedures, and manuals, the State Plan, Waivers, and applicable
subregulatoryguidance.
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2.2.1.4 TheContractorshallcooperatewithLDH,CMS,theExternalQualityReview
Organization(EQRO),andanyotherLDHcontractorsrelatedtotheoperation,
evaluation,andmonitoringofthisContract,theContractor,ortheManaged
CareProgram.
2.2.1.5 TheContractorandallsubcontractorsshallcomply,withinareasonabletime,
withanyinformation,recordsordatarequestfromanyhealthcareoversight
agency,includingtheLouisianaOfficeoftheAttorneyGeneral,MedicaidFraud
ControlUnit(MFCU),relatedtoanyservicesprovidedunderthisContract.This
requirement shall be inclusive of Material Subcontracts with entities who
manageorcoordinatecertainbenefitsforEnrolleesonbehalfoftheMCOsbut
donotdirectlyprovidetheservicetoEnrollees.WhenrequestedbytheMFCU,
theproductionof theinformation,recordsor datarequestedbytheMFCU
shallbedoneatnocost totheMFCU,and theContractororsubcontractor
shall not require the MFCU to enter into any contract, agreement or
memorandumofunderstandingtoobtaintherequestedinformation,records,
or data. The Contractor and/or subcontractor shall agree that the Contract
and/orsubcontractcreateforthehealthcareoversightagencyanenforceable
rightforwhichthehealthcareoversightagencycanpetitionthecourtinthe
eventofnon‐compliancewithaninformation,recordsordatarequest.
2.2.2 StaffingRequirements
2.2.2.1 GeneralStaffingRequirements
2.2.2.1.1 The Contractor shall have in place an organizational and
governance structure capable of fulfilling all Contract
requirements.TheContractorshallrecruit,develop,andretaina
diverse and qualified staff in numbers appropriate to the
Contractor’sEnrollment,asdescribedfurtherbelow.
2.2.2.1.2 The Contractor’s staffing and resource allocation shall be
adequate to achieve positive outcomes and comply with the
requirementsoftheContractandtheMCOManual,includingthe
requirement for providingculturally competent services. If the
Contractordoesnotachievethedesiredoutcomesormaintain
compliance with contractual obligations, non‐compliance
action(s)maybeemployedbyLDH,includingbutnotlimitedto,
requiring the Contractor to hire additional staff and the
applicationofMonetaryPenaltiesasspecifiedinAttachmentG,
TableofMonetaryPenalties.
2.2.2.1.3 TheContractorshallprovideandhaveastaffingplanapproved
byLDHinwritingthatdescribeshowtheContractorshall
maintainthestaffingleveltoensurethesuccessful
accomplishmentofallcontractualduties.
2.2.2.1.4 The Contractor shall not employ or subcontract with any
individual who has been debarred, suspended, or otherwise
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lawfullyprohibitedfromparticipatinginanyfederalhealthcare
program.TheContractorshallscreenallpotentialemployeesand
subcontractors to determine whether any of them have been
excluded from participation in federal healthcare programs
utilizing,ataminimum,thefollowingwebsites:
2.2.2.1.4.1 Office of Inspector General (OIG) List of
ExcludedIndividuals/Entities(LEIE);
2.2.2.1.4.2 LouisianaAdverseActionsListSearch;
2.2.2.1.4.3 TheSystemofAwardManagement(SAM);and
2.2.2.1.4.4 Other applicablesites as may be determined
byLDH.
2.2.2.1.5 The Contractor shall comply with LDH Policy 47.1, “Criminal
History Records Check of Applicants and Employees,” which
requiresLDHcontractorstoconductcriminalbackgroundchecks
onpotentialandcurrentemployeesorsubcontractorswhohave
access to Enrollee Protected Health Information (PHI). The
Contractorshall,uponrequest,provideLDHwithasatisfactory
criminalbackgroundcheckoranattestation thatasatisfactory
criminalbackgroundcheckhasbeencompletedforanyofitsstaff
orsubcontractor’sstaffassignedtoorproposedtobeassigned
toanyaspectoftheperformanceofthisContract.
2.2.2.1.6 TheContractorshallsubmittoLDHoritsdesigneealistingofits
Board of Directors during Readiness Review and an updated
listingofitsBoardofDirectorswheneveranychangesaremade.
2.2.2.1.7 OnanadhocbasiswhenchangesoccurorasdirectedbyLDHin
writing, the Contractor shall submit to LDH an overall
organizationalchartthatincludesseniorandmid‐levelmanagers
for the organization. The organizational chart shall include the
organizationalstaffingforbehavioralhealthservicesand
activities. If such behavioral health services and activities are
provided by a Material Subcontractor, the Contractor shall
submittheorganizationalchartofthebehavioralhealthMaterial
Subcontractorwhichclearlydemonstratestherelationshipwith
theMaterialSubcontractorandtheContractor’soversightofthe
MaterialSubcontractortosupportthefunctionalintegrationof
physicalandbehavioralhealth.Forallorganizationalcharts,the
Contractor shall indicate any staff vacancies and provide a
timelineforwhensuchvacancieswillbefilled.
2.2.2.1.8 TheContractorshall removeor reassign,uponwritten request
from LDH, any employee or subcontractor employee that LDH
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deems to be unacceptable. The Contractor shall hold LDH
harmlessforactionstakenasaresulthereto.
2.2.2.1.9 TheContractormayterminateanyofitsemployeesdesignated
toperformworkorservicesunderthisContract,aspermittedby
applicablelaw.
2.2.2.2 SubstitutionofPersonnel
2.2.2.2.1 TheContractor'spersonnelassignedtotheContractshallnotbe
replacedwithoutthepriorwrittenconsentoftheState.Such
consentshallnotbeunreasonablywithheldordelayedprovided
anequallyqualifiedreplacementisoffered.Intheeventthatany
Contractor personnel become unavailable due to resignation,
illness, or other factors, excluding assignment to a project
outside the Contract, outside of the Contractor's reasonable
control,asthecasemaybe,theContractorshallberesponsible
forprovidinganequallyqualifiedreplacementintimetoavoid
delays in completing tasks. The Contractor will make every
reasonableattempttoassignthepersonnellistedinitsproposal.
2.2.2.3 ExceptionstoStaffingRequirements
2.2.2.3.1 Requests for exceptions to mandatory staffing requirements
shallbesubmittedinwritingtoLDHforpriorapproval.
2.2.2.3.2 The Contractor shall address the reason for the request, the
organization’sabilitytofurnishservicesascontractuallyrequired
with the exception in place, and duration of exception period
requested.
2.2.2.3.3 TheContractormayproposetoLDHastaffingplanthatcombines
positions and functions outlined in the Contract with other
positions, provided the Contractor describes how the staffing
rolesdelineatedintheContractwillbeaddressed.
2.2.2.4 KeyPersonnelRequirements
2.2.2.4.1 The Contractor shall identify the individuals serving as key
personnel.UnlesstheContractorrequestsandreceivesawritten
exception from LDH, all key personnel shall be full‐time
employees (minimum forty (40) hours per week), based in
Louisiana, dedicated one hundred percent (100%) to this
Contract,andserveinonlyonekeypersonnelposition.
2.2.2.4.1.1 Ifanindividualisnotrequiredto,anddoesnot,
serve exclusively in their key personnel
position,theContractorshallprovidetoLDH,
in writing, a description of the individual’s
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other responsibilities. Such description shall
alsobeprovidedwiththeContractor’srequest
foranexceptionfromLDH,ifapplicable.
2.2.2.4.2 TheContractorshallinformLDHinwritingwithinfive(5)Business
Dayswhenanemployeeinakeypersonnelpositionprovides
noticeof resignationregardlessofthereason fordeparture or
when the Contractor has terminated an employee in a key
personnelposition.TheContractorshallinformLDHinwritingas
earlyaspracticablewhenanemployeeinakeypersonnel
positionresignswithoutnotice.Thenameoftheindividual
servinginthatroleonaninterimbasisshallbeprovidedpriorto
thedeparturedatewhenpossible.
2.2.2.4.3 TheContractorshallseekpriorwrittenapprovalfromLDHforall
keypersonnelpositionsbeforeacandidateishired.
2.2.2.4.4 Thefollowingpositionsaredesignedaskeypersonnel:
2.2.2.4.4.1 TheChiefExecutiveOfficer(CEO)shallprovide
overall direction for this Contract, develop
strategies, formulate policies, and oversee
operationstoensuregoalsaremet.TheCEO
shallserveexclusivelyinthispositionandmay
not function in an Executive Capacity for
another insurance product. The CEO shall be
the primary contact for LDH regarding all
issues and shall coordinate with other key
personnel to fulfill the requirements of the
Contract. The CEO shall attend all CEO
designatedmeetingsinperson.
2.2.2.4.4.2 The Chief Operating Officer (COO) shall
manage day‐to‐day operations of multiple
levels of staff and multiple
functions/departments across the
Contractor’s organization to meet the
performance requirements of the Contract.
TheCOOshallbeaccountabletotheCEOfor
operationalresultsandmaybedesignatedto
serve as the primary point‐of‐contact for all
MCOoperationalissues. TheCOO shallserve
exclusively in this position and may not
functioninanExecutiveCapacityforanother
insurance product. The COO shall attend
meetingsinperson,whenrequested.
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2.2.2.4.4.3 The Medical Director/Chief Medical Officer
(CMO) shall be a physician with a current,
unencumbered license through the Louisiana
State Board of Medical Examiners. The CMO
shallhaveatleastthree(3)yearsoftrainingin
amedicalspecialtyandfive(5)yearsofpost‐
trainingexperienceprovidingclinicalservices.
The CMO shall have achieved board
certification in his or her specialty. The CMO
shall be involved in all major clinical and
quality management components of the
Contractor’s activities. The CMO shall be
responsible for ensuring Timely medical
decisions, including after‐hours consultation,
asneeded.DuringperiodswhentheCMOis
not available, the Contractor shall have
physicianstaffavailabletoprovidecompetent
medical direction. The CMO shall serve
exclusively in this position and may not
functioninanExecutiveCapacityforanother
insurance product. The CMO shall attend
meetingsinperson,whenrequested.TheCMO
shallberesponsiblefor:
Development, implementation, and
medicalinterpretationofclinicalpolicies
and procedures, including, but not
limitedto,ServiceAuthorization,claims
review,dischargeplanning,credentialing
and referral management, utilization
management and medical review
includedintheMCOGrievanceSystem;
Administration of all medical
managementactivitiesoftheContractor;
Coordinating withthe Behavioral Health
Medical Director to integrate the
administration and management of
behavioralandphysicalhealthservices;
Servingasmemberofandparticipatingin
personineverymeetingoftheMedicaid
QualityCommittee.TheCMOmay
designate a representative with a
workingunderstandingoftheclinicaland
quality issues impacting the Louisiana
MedicaidProgram;and
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ServingasthechairmanoftheUtilization
Management committee and chairman
orco‐chairmanoftheQualityAssessment
and Performance Improvement
committee.
2.2.2.4.4.4 TheBehavioralHealthMedicalDirectorshall
beaphysicianwithacurrent,unencumbered
license through the Louisiana State Board of
Medical Examiners. The Behavioral Health
Medical Director shall be board‐certified in
psychiatry with at least three (3) years of
traininginamedicalspecialty.TheBehavioral
Health Medical Director shall ensure Timely
medical decisions, including after‐hours
consultation,asneeded.Duringperiodswhen
theBehavioralHealthMedicalDirectorisnot
available,theContractor shallhavephysician
staff available to provide competent medical
direction. The Behavioral Health Medical
Directorshallserveexclusivelyinthisposition
andmaynotfunctioninanExecutiveCapacity
foranotherinsuranceproduct.TheBehavioral
HealthMedicalDirectorshallattendmeetings
inperson,whenrequested.
The Behavioral Health Medical Director shall share
responsibilityforthemanagementofthebehavioral
healthservicesdeliverysystemwiththeContractor’s
BehavioralHealthCoordinator,andshallbeactively
involvedinallmajorclinicalandqualitymanagement
componentsofthebehavioralhealthservicesofthe
Contractor.TheBehavioralHealthMedicalDirector
shall meet regularly with the CMO. The Behavioral
Health Medical Director’s responsibilities shall
include,butnotbelimitedto,thefollowing:
Oversee, monitor, and assist with the
management of psychopharmacology
pharmacy benefits manager (PBM)
activities,including theestablishmentof
Prior Authorization, clinical
appropriatenessofuse,andsteptherapy
requirements for the use of stimulants
andantipsychoticsforallEnrolleesunder
theageofeighteen(18);
Provide clinical case management
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consultations and clinical guidance for
contractedPrimaryCareProviders(PCPs)
treating behavioral health‐related
concerns not requiring referral to
behavioralhealthspecialists;
Develop comprehensive care programs
forthe management ofyouthandadult
behavioral health concerns typically
treated by PCPs, such as ADHD and
depression;
Developtargetededucationandtraining
forcontractedPCPstoscreenformental
healthandsubstanceusedisordersusing
evidence‐based tools (e.g., AUDIT‐C,
PHQ‐9 and GAD‐7), perform diagnostic
assessments, provide counseling and
prescribe pharmacotherapy when
indicated, and build collaborative care
modelsintheirpractices;
CoordinatewiththeMedicalDirector to
integrate the administration and
management of behavioral and physical
healthservices;
Oversee,monitorandassistwith
effective implementation of the Quality
Management(QM)program;and
Work closely with the Utilization
Management (UM) of services and
associated Appeals related to children
andyouthandadultswithmentalillness
and/orsubstanceusedisorders(SUD).
2.2.2.4.4.5 TheChiefFinancialOfficer(CFO)shalloversee
the budget, accounting systems, financial
reporting,andallauditactivitiesimplemented
bytheContractor.TheCFOshallserve
exclusively in this position and may not
functioninanExecutiveCapacityforanother
insurance product. The CFO shall attend
meetingsinperson,whenrequested.
2.2.2.4.4.6 The Pharmacy Director shall be licensed in
Louisiana, with at least five (5) years’
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experience as a pharmacist practicing in a
retailsettingwithmanagerialexperience.The
Pharmacy Director shall serve exclusively in
thispositionandmaynotfunctioninasimilar
capacity for another insurance product. The
Pharmacy Director shall attend meetings in
person,whenrequested.
2.2.2.4.4.7 TheContractComplianceOfficershallserveas
the primary point of contact for all
communications and requests related to this
Contract, including, but not limited to, all
compliance issues. The Contract Compliance
Officer shall manage the connection of
ContractorpersonneltoLDHBusinessOwners,
and shall develop and implement written
policies,procedures,andstandardstoensure
compliance with the requirements of this
Contract. These primary functions may
include, but are not limited to, coordinating
the tracking and submission of all Contract
deliverables, fielding and coordinating
responses to LDH inquiries, coordinating the
preparation and execution of Contract
documents, audits and ad hoc visits. This
position shall report directly to the CEO and
boardofdirectorsinaccordancewith42C.F.R.
§438.608(a)(1)(ii). The Contract Compliance
Officershallattendmeetingsinperson,when
requested.
2.2.2.4.4.8 The Health Equity (HE) Administrator shall
serveasthesinglepointofcontactresponsible
and accountable for all matters related to
health equity within the Contractor’s
organizationandprovidernetworktosupport
the effectiveness and efforts of the
Contractor’s Health Equity Plan. The
Contractor may hire or designate an existing
employee to serve as the HE Administrator.
The HE Administrator must be a high‐level
employee (i.e., director level or above) but
mayhavemorethanoneareaofresponsibility
andjobtitle.Therolesandresponsibilitiesof
theHEAdministratorareto:
Oversee the Contractor's strategic
design, implementation, and evaluation
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ofhealthequityeffortsinthecontextof
the Contractor's population health
initiatives;
Inform decision‐making around best
payer practices related to disparity
reductions, including the provision of
health equity and social determinant of
health resources and research to
leadershipandprogrammaticareas;
Inform decision‐making regarding best
payer practices related to disparity
reductions, including providing
Contractorteamswithrelevantand
applicableresourcesandresearchand
ensuring that the perspectives of
Enrollees with disparate outcomes are
incorporated into the tailoring of
interventionstrategies;
Collaborate with the Contractor’s Chief
Information Officer to ensure the
Contractorcollectsandmeaningfullyuses
race, ethnicity, language, disability and
geographicdatatoidentifydisparities;
Coordinate and collaborate with
Enrollees, providers, local and state
government, community‐based
organizations, LDH, and other LDH
contracted managed care entities to
impacthealthdisparitiesatapopulation
level;and
Ensure that efforts addressed at
improving health equity, reducing
disparities, and improving cultural
competencearedesignedcollaboratively
andthatlessonslearnedareincorporated
intofuturedecision‐making.
2.2.2.5 AdditionalRequiredStaff
2.2.2.5.1 The Contractor shall have sufficient number of qualified staff
withsufficient experience and expertise to meetboth physical
health services and behavioral health services responsibilities,
andshallprovidededicatedstaffwherenecessarytomeetthis
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obligation including all required timeframes and geographic
coverageoutlinedinthisContract.
2.2.2.5.2 TheContractorshallmaintainatleastfiftypercent(50%)ofits
staffwithinthestateofLouisiana.
2.2.2.5.3 The Contractor shall comply with additional staffing
requirementsincludedintheMCOManual.
2.2.2.6 WrittenPolicies,Procedures,andJobDescriptions
2.2.2.6.1 The Contractor shall develop and maintain written policies,
procedures,andjobdescriptionsforeachfunctionalareathatare
consistent in format and style. The Contractor shall maintain
written guidelines for developing, reviewing, and approving all
policies,procedures,andjobdescriptions.
2.2.2.6.2 Allpoliciesandproceduresshallbereviewedatleastannuallyto
ensure that the Contractor's written policies reflect current
practices. Reviewed policies shall be dated and signed by the
Contractor'sappropriatemanager,coordinator,director,orCEO.
Minutesreflectingthereviewandapprovalofthepoliciesbyan
appropriatecommittee are alsoacceptabledocumentation.All
medicalandqualitymanagementpoliciesshallbeapprovedand
signedbytheContractor'sMedicalDirector.Allbehavioralhealth
policies shall be approved and signed by the Contractor’s
Behavioral Health Medical Director. Job descriptions shall be
reviewed at least annually to ensure that current duties
performed by the employee reflect written requirements. The
Contractorshallprovideanypolicies,procedures,andevidence
ofreviewsasdirectedbyLDHinwriting.
2.2.2.6.3 IfLDHdeemsaContractorpolicyorprocesstobeinsufficient
and/or places an unnecessary burden on the Enrollees or
providers,theContractorshallberequiredtoworkwithLDHto
changethepolicyorprocedurewithinatimeperiodspecifiedby
LDH.
2.2.2.7 StaffTraining,Licensure,andMeetingAttendance
2.2.2.7.1 The Contractor shall ensure that all staff members, including
subcontractors, have met any applicable state or federal
licensure and/or certification requirements and have received
appropriate training, education, experience and orientation to
fulfill their requirements of the position. The Contractor shall
prohibitanystaffpersonand/orsubcontractorwhohasfailedto
comply with any requirement in the preceding sentence from
performinganyworkundertheContractunlessanduntilthestaff
person and/or subcontractor has achieved compliance with all
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requirements. LDH may require additional staffing for the
Contractorthathassubstantiallyfailedtomaintaincompliance
withanyprovisionoftheContract.
2.2.2.7.2 TheContractorshallprovideinitialandongoingstafftrainingthat
includes an overview of contractual, state and federal
requirementsspecifictoindividualjobfunctions.TheContractor
shallensurethatallstaffmembershavingcontactwithEnrollees
orprovidersreceiveinitialandongoingtrainingonhealthequity
and social determinants of health, beyond Culturally and
LinguisticallyAppropriateServices(CLAS)requirementsandwith
regardtotheappropriateidentificationandhandlingofquality
ofcareconcerns.
2.2.2.7.3 TheContractorshalleducateallstaffmembersaboutitspolicies
andproceduresonAdvanceDirectives.
2.2.2.7.4 New and existing transportation, Prior Authorization, provider
servicesandEnrolleeservicerepresentativesshallbetrainedin
thegeographyofLouisiana,aswellasitscultureandthecorrect
pronunciation of cities, towns, and surnames. They shall have
access to GPS or mapping search engines for the purposes of
authorizing services in, and recommending providers and
transporting Enrollees to, the most geographically appropriate
location.
2.2.2.7.5 The Contractor shall comply with the following cybersecurity
trainingrequirements:
2.2.2.7.5.1 InaccordancewithLa.R.S.42:1267(B)(3)and
the State of Louisiana’s Information Security
Policy,iftheContractor,anyofitsemployees,
agents, or subcontractors will have access to
State government information technology
assets,theContractor’semployees,agents,or
subcontractors with such access must
completecybersecuritytrainingannually,and
theContractormustpresentevidenceofsuch
compliancetoLDHannuallyanduponrequest.
TheContractormayusethecybersecurity
training course offered by the Louisiana
Department of State Civil Service without
additionalcostormayuseanyalternate
course approved in writing by the Office of
TechnologyServices.
2.2.2.7.5.2 ForpurposesofthisSection,“accesstoState
government information technology assets”
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means the possession of credentials,
equipment, or authorization to access the
internal workings of State information
technology systems or networks. Examples
would include but not be limited to State‐
issuedlaptops,VPNcredentials toaccessthe
State network, badging to access the State’s
telecommunications closets or systems, or
permissionstomaintainormodifyITsystems
usedbytheState.Finaldeterminationofscope
inclusions or exclusions relative to access to
State government information technology
assets will be made by the Office of
TechnologyServices.
2.2.2.7.6 Additionalstaff trainingrequirements shallinclude,but not be
limitedto:
2.2.2.7.6.1 For case managers and case management
supervisors:
Specialized behavioral health policy and
proceduremanualsissuedbyLDH;
Coordinated System of Care (CSoC)
system of care values, the wraparound
process,andprocessesandprotocolsfor
screeningandreferral;
OJJsystem,population,andprocesses;
DCFSsystem,population,andprocesses;
Contractrequirements;
ApprovedWaiversandStatePlan
amendments (SPAs) for specialized
behavioralhealth;
Specialized Behavioral Health Services
(SBHS)forEnrolleesresidinginanursing
facility and/or included in the DOJ
AgreementTargetPopulation;
Pre‐admission screening and resident
review(PASRR);
Services provided by the Office for
CitizenswithDevelopmentDisabilities;
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Current and applicable evidence‐based
practices;
Behavioral health services available
throughotherfundingsources,including
Medicare;and
PermanentSupportiveHousingprovided
bytheOfficeofAgingandAdultServices.
2.2.2.7.6.2 For staff members having contact with
Enrollees or providers – initial and ongoing
training with regard to the appropriate
identification and handling of quality of care
concerns.
2.2.2.7.6.3 For staff members working directly with
Enrollees–crisisinterventiontraining.
2.2.2.7.7 LDHreservestherighttoassignmandatorytrainingforkeystaff,
otherstaff,andsubcontractors.TheContractormayberequired
to submit documentation that all staff have completed LDH
assigned mandatory training, education, professional
experience, orientation, and credentialing, as applicable, to
performassignedjobduties.
2.2.2.7.8 LDHreservestherighttoattendalltrainingprogramsand
seminars conducted by the Contractor. The Contractor shall
provideLDHalistofanymarketingtraining(seeEnrolleeServices
section)dates,times,andlocations,atleastfourteen(14)
CalendarDayspriortotheactualdateoftraining.TheContractor
shallprovidedocumentationofmeetingsandtrainings,including
staff and provider trainings, upon written request. Meeting
minutes,agendas,invitedattendeelists,andsign‐insheets,along
withactionitems,shallbeprovideduponwrittenrequest.
2.2.2.7.9 TheContractorshallprovidesubjectappropriatestafftoattend
and participate in meetings or events, which may be on‐site,
scheduledbyLDH.Allmeetingsshallbeconsideredmandatory
unlessotherwiseindicated.
2.2.3 MaterialSubcontracts/Subcontractors
2.2.3.1 Prior to contracting with a Material Subcontractor, the Contractor shall
evaluate the prospective Material Subcontractor’s ability to perform the
activitiestobesubcontracted.
2.2.3.2 The Contractor shall request prior approval of all Material Subcontracts,
amendments,andsubstitutionstheretofromLDH.Toobtainsuchapproval,
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the Contractor shall submit a written request and a completed Material
SubcontractorchecklistusingthetemplateprovidedbyLDHincludedinthe
MCOManual.TherequestshallalsodescribehowtheContractorwilloversee
theMaterialSubcontractor.
2.2.3.3 TheContractorshallprovideLDHwithanyinformationrequestedbyLDHin
writing in addition to the information required in the checklist, including
identifying whether the proposed Material Subcontractor is partofan
organizationrelatedtotheContractor.
2.2.3.4 AllSubcontractsshall:
2.2.3.4.1 Bewritten;
2.2.3.4.2 Specify,andrequirecompliancewith,allapplicablerequirements
ofthisContractandtheactivitiesandreportingresponsibilities
theSubcontractorisobligatedtoprovide;
2.2.3.4.3 Provide for imposing penalties, up to and including Contract
termination,iftheStateortheContractordeterminesthatthe
Subcontractor’sperformanceisinadequateornon‐compliant;
2.2.3.4.4 RequiretheSubcontractortocomplywithallapplicableContract
requirements, applicable Federal and State laws, regulations,
rules,policies,procedures,andmanuals,theStatePlan,Waivers,
andapplicablesubregulatoryguidance;
2.2.3.4.5 StipulatethatLouisianalaw,withoutregardtoitsconflictoflaws
provisions,willprevailifthereisaconflictbetweenthestatelaw
wheretheSubcontractorisbasedandLouisianalaw.
2.2.3.4.6 Comply with the requirements set forth in 42 C.F.R.
§438.230(c)(3)and42C.F.R.§438.3(k).
2.2.3.5 TheState,includingLDH,MFCU,andtheLouisianaLegislativeAuditor(LLA),
and the Federal government, including, CMS, OIG, and the Comptroller
General,ortheirdesignees,shallhavetherighttoaudit,evaluate,andinspect
anyrecordsorsystemsthatpertaintoanyactivitiesperformedoramounts
payableunderthisContractatanytime.
2.2.3.5.1 Thisrightexistsforten(10)yearsfromtheterminationofthis
ContractfortheContractorandanySubcontractorsorfromthe
date of completion of any audit, whichever is later; provided,
howeverthatifanyoftheentitiesabovedeterminethatthereis
areasonablepossibilityofFraudorsimilarrisk,theymayaudit,
evaluate,andinspectatanytime;
2.2.3.5.2 TheContractorandanySubcontractorsshallmaketheir
premises, facilities, equipment, records, and systems available
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forthepurposesofanyaudit,evaluation,orinspectiondescribed
immediatelyabove;
2.2.3.5.3 The Contractor and any Subcontractors shall retain, as
applicable, Enrollee Grievance and Appeal records in 42 C.F.R.
§438.416, base data in 42 C.F.R. §438.5(c), MLR reports in 42
C.F.R.§438.8(k),andthedata,information,anddocumentation
specifiedin42C.F.R.§438.604,438.606,438.608,and438.610
foraperiodofnolessthanten(10)yearsfollowingtermination
oftheContract;and
2.2.3.6 TheContractorshallmonitoranyMaterialSubcontractor’sperformanceonan
ongoingbasisandperformaformalreviewannually.Ataminimum,theannual
review shall include any performance concerns identified by LDH. If any
deficiencies or areas for improvement are identified, the Contractor shall
requiretheMaterialSubcontractortotakecorrectiveaction.TheContractor
shallprovideLDHwithacopyoftheannualreviewandanycorrectiveaction
plansdevelopedasaresult.Iftherearecorrectiveactiveplansputinplace,
the Contractor shall provide ongoing updates to LDH on the Material
Subcontractor’s activities to improve the performance pursuant to the
correctiveactionplan.
2.2.3.7 Upon notifying any Material Subcontractor, or upon being notified by such
MaterialSubcontractor,oftheintentiontoterminatesuchsubcontract,the
Contractor shall notify LDH in writing no later than the same day as such
notification,andshallotherwisesupportanynecessaryEnrolleetransitionor
relatedactivitiesasdescribedintheContinuityofCaresectionandelsewhere
inthisContract.
2.2.3.8 Notwithstanding any relationship the Contractor may have with a
subcontractor, including Material Subcontractors, the Contractor shall
maintainultimateresponsibilityforadheringtoandotherwisefullycomplying
withalltermsandconditionsofthisContract.Nosubcontractorwilloperate
torelievetheContractorofitslegalresponsibilitiesundertheContract.
2.2.3.9 Asrequiredby42C.F.R. §438.3(k),§438.230(a)and§438.230(b)(1),(2), the
Contractor shall be responsible to oversee all subcontractors’ performance
and shall be held accountable for any function and responsibility that it
delegatestoanysubcontractor.
2.2.3.10 In theeventofatransitionbetweensubcontractorsduringthetermofthis
Contract,theContractormustensurethattheoriginalsubcontractorfulfillsall
subcontractual obligations, including those that survive the subcontract
terminationorexpiration.IntheeventthattheContractterminatesorexpires,
the Contractor must ensure that any existing subcontractor fulfills its
subcontractualobligationsincludingthosethatsurviveContracttermination.
2.2.3.11 UseofaTransportationBroker
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2.2.3.11.1 IftheContractorelectstocontractwithatransportationbroker
to coordinate Non‐Emergency Medical Transportation (NEMT)
services, the Contractor shall contract with and provide
remuneration to thesingle broker designated byLDH.LDH has
thesolediscretiontoestablishthecontractterms.
2.2.3.11.2 The Contractor shall not make amendments to the single
transportationbrokercontractwithoutLDHapproval.
2.2.3.12 UseofaPharmacyBenefitsManager(PBM)
2.2.3.12.1 TheContractorshallcontractwithandprovideremunerationto
thesinglePBMdesignatedbyLDHforpharmacyclaimspayment
and administrative services.LDHhasthesolediscretionto
establishthecontractterms.
2.2.3.12.2 TheContractorshallnot makeamendmentsto thesinglePBM
contractwithoutLDHapproval.
2.2.4 PerformanceReviews
2.2.4.1 TheContractorshallattendregularperformancereviewmeetingsheldbyLDH
atLDH’soffices,oratanotherlocationdeterminedbyLDHinwriting, each
quarterormorefrequentlyatLDH’sdiscretion.
2.2.4.2 The Contractor shall ensure that key personnel and other staff with
appropriateexpertisearepresentinpersonatsuchmeetings,asrequestedby
LDH,including,butnotlimitedto,theContractor’sCEO.
2.2.4.3 TheContractorshallpreparematerialsandinformationforsuchmeetingsas
further directed by LDH, including, but not limited to, materials and
informationsuchas:
2.2.4.3.1 Reports,inaformandformatapprovedbyLDHinwriting,on
Contractor’sperformanceunderthisContract,including,butnot
limitedto,measuressuchas:
2.2.4.3.1.1 Costs of care for Enrollees by program and
categoryofservice;
2.2.4.3.1.2 Performancereportinginformation;
2.2.4.3.1.3 Qualitymeasureperformance;
2.2.4.3.1.4 Measures of Enrollee utilization across
categories of service and other indicators of
changesinpatternsofcare;
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2.2.4.3.1.5 Variationandtrendsinanysuchperformance
measuresatthelevelofindividualPCPs;
2.2.4.3.1.6 Completeness and validity of any data
submissionsmadetoLDH;
2.2.4.3.1.7 Opportunities the Contractor identifies to
improve performance and plans to improve
suchperformance,includingplansproposedto
beimplementedbytheContractorforPCPsor
otherNetworkProviders;
2.2.4.3.1.8 Changes in Contractor’s staffing and
organizationaldevelopment;
2.2.4.3.1.9 Performance of Material Subcontractors,
including,butnotlimitedto,anychangesinor
additions to Material Subcontractor
relationships;and
2.2.4.3.1.10 Any other measures deemed relevant by
ContractororrequestedbyLDH;
2.2.4.3.2 Updates and analytic findings from any reviews requested by
LDH,suchasreviewsofdatairregularities;and
2.2.4.3.3 Updatesonanyactionitemsandrequestedfollow‐upsfromprior
meetingsorcommunicationswithLDH.
2.2.4.4 TheContractorshall,withintwo(2)BusinessDaysfollowingeachperformance
reviewmeeting,prepareandsubmittoLDHforreviewandapprovalalistof
anyactionitems,requestedfollow‐upsforthenextmeeting,andestimated
timelinesfordelivery,inaformandformatspecifiedbyLDH.
2.2.5 ContinuityofOperationsPlan
2.2.5.1 TheContractorshallmaintainaContinuityofOperationsPlanthataddresses
how the Contractor’s, Material Subcontractors’, and other subcontractors’
operations and the ongoing provision of healthcare services shall be
maintainedintheeventofapandemic,naturaldisasterorman‐made
emergencyincluding,butnotlimitedto,localizedactsofnature,accidents,
and technological and/or attack‐related emergencies, or other eventwhich
leadstoasignificantdisruptioninoperationsduetostaffabsenceand/orloss
of utilities that impacts fulfilling the requirements of this Contract. The
Continuity of Operations Plan shall be invoked no later than when the
fulfillmentoftheserequirementsisimpactedbysuchanevent.
2.2.5.2 AspartoftheContinuityofOperationsPlan,theContractorshallprovideits
actionplanfordevelopmentofanemergencypreparednessplanspecificto
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eachofitsEnrolleeswithSpecialHealthCareNeeds(SHCN)duringorfollowing
an event as described above. The emergency preparedness plan must be
provided to the Enrollee in a manner and format that may be easily
understood and is readily accessible. Information in the plan must be
communicated in a way that can be understood by Enrollees of varying
functionalabilityandlanguageproficiency.Theplanmustidentifyanysteps
the Enrollee and/or Enrollee’s caregiver should take in the event of an
emergencyincluding,butnotlimitedto,specialconsiderationsregarding
medications,suppliesanddietaryneeds,orpoweroutages,asapplicable,and
correspondingcontactinformation.
2.2.5.3 The Contractor shall follow all LDH directives regarding accesstocareand
relaxationofauthorizationrequirementsduringanemergency.Corresponding
systemeditsforallservicesshallbeimplementableattheparishlevelduring
anemergency.
2.2.5.3.1 The Contractor must have a method for ensuring that Prior
Authorizations are extended and transferred to new providers
during a pandemic, natural disaster, man‐made emergency, or
othereventifdirectedbyLDH.
2.2.5.4 AspartoftheContinuityofOperationsPlan, theContractorshallprovidea
systemscontingencyplan,regardlessofitssystemarchitecture,toprotectthe
availability,integrity,andsecurityofdataandtocontinueessentialapplication
orsystemfunctionsduringandimmediatelyfollowingtheseevents.
2.2.5.4.1 Thesystemscontingencyplanshallinclude,ataminimum:
2.2.5.4.1.1 A disaster recovery plan designed to recover
systems,networks,workstations,applications,
etc.intheeventofadisaster;and
2.2.5.4.1.2 ABusinessContinuityPlan(BCP)forrestoring
theoperationalfunctionoftheorganizationin
the event of a disaster and includes items
relatedtoIT,aswellasoperationalitemssuch
as employee notification processes and the
procurement ofofficesupplies needed to do
business in the emergency mode operation
environment.
2.2.5.4.2 The systems contingency plan shall address the following
scenarios,ataminimum:
2.2.5.4.2.1 Thecentralcomputerinstallationandresident
softwarearedestroyedordamaged;
2.2.5.4.2.2 The system interruption or failure resulting
fromnetwork,operatinghardware,software,
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or operations errors that compromise the
integrityoftransactionsthatareactiveinalive
systematthetimeoftheoutage;
2.2.5.4.2.3 Systeminterruptionorfailureresultingfrom
network, operating hardware, software or
operations errors that compromise the
integrityofdatamaintainedinaliveorarchival
system;and
2.2.5.4.2.4 Systeminterruptionorfailureresultingfrom
network, operating hardware, software or
operationalerrorsthatdoesnotcompromise
the integrity of transactions or data
maintainedinaliveorarchivalsystem,but
doespreventaccesstotheSystem,suchasit
causesunscheduledSystemunavailability.
2.2.5.4.3 The systems contingency plan shall specify projected recovery
timesanddatalossformission‐criticalSystemsintheeventofa
declareddisaster.
2.2.5.4.4 The Contractor shall annually test its plan through simulated
disastersandlowerlevelfailuresinordertodemonstratetoLDH
thatitcanrestoresystemfunctions.TheContractorshallreport
documentationofthistestinginamannerdeterminedbyLDH.
2.2.5.4.5 IntheeventtheContractorfailstodemonstratethroughthese
teststhatitcanrestoresystemsfunctions,theContractorshall
berequiredtosubmitaCorrectiveActionPlantoLDHdescribing
howthefailureshallberesolvedwithinten(10)BusinessDaysof
theconclusionofthetest.
2.2.5.5 TheContractorshallsubmittheContinuityof OperationsPlantoLDHorits
designeeforapprovalaspartofReadinessReviewandnolaterthanthirty(30)
CalendarDayspriortoimplementationofchanges.
2.2.5.6 The Contractor shall immediately inform LDH, in writing, when invoking its
Continuity of Operations Plan. Ifthenature ofthe triggering event renders
written notification impossible, the Contractor shall notify LDH of the
invocation of the Continuity of Operations Plan through the best available
means. If the nature of triggering event renders immediate notification
impossible,theContractorshallinformLDHoftheinvocationoftheContinuity
ofOperationsPlanassoonaspossible.
2.2.6 ReportsandRequestsforInformation
2.2.6.1 The Contractor shall provide and require its subcontractors to provide, as
applicable, in accordance with the timelines, definitions, formats and
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instructionscontainedherein,intheMCOManual,orasfurtherspecifiedby
LDH:
2.2.6.1.1 All information required under this Contract, or other
information related to the performance of contract
responsibilitiesasrequestedbyLDH;
2.2.6.1.2 All reports and associated requirements as specified in this
ContractandtheMCOManual;
2.2.6.1.3 Any data from their clinical systems, authorization systems,
claims systems, medical record reviews, quality and network
monitoring reviews, network management visits, Enrollee
interaction,andaudits;
2.2.6.1.4 Deliveryof time sensitive data to LDHinaccordance with LDH
timelines;and
2.2.6.1.5 Highquality,accuratedataintheformatandinthemannerof
deliveryspecifiedbyLDH.
2.2.6.2 TheContractorshallrespondtorequestsforinformationfromLDHwithinthe
followingtimelines:
2.2.6.2.1 RequestsfromLDHshallbeacknowledgedinwritingwithinone
(1)BusinessDayandaddressedwithinfive(5)BusinessDays,or
withinthetime‐periodspecifiedbyLDHintherequest;
2.2.6.2.2 RequeststhatoriginatefromtheOfficeoftheGovernor,theLDH
Office of the Secretary, or a Louisiana legislator shall be
addressedwithinseventy‐two(72)hours;
2.2.6.2.3 Requests from the LDH Provider Relations Unit shall be
addressedwithinfive(5)BusinessDays;and
2.2.6.2.4 RequestsfromtheLDHEnrolleeComplaintsUnitandrequestsfor
assistance with locating specialists shall be addressed within
seventy‐two(72)hoursunlessthereisaclinicalindicationthatit
isneededsooner.
2.2.6.3 If the Contractor does not provide the requested information within the
timeframesoutlinedinthisContractorintheLDHrequest,LDHmayassess
Monetary Penalties as outlined in this section and Attachment G, Table of
MonetaryPenalties.
2.2.6.4 TheContractorshallcomplywiththefollowingrequirementsspecifictopublic
records’requestsinadditiontotherequirementsintheMCOManual:
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2.2.6.4.1 DuringReadinessReview,theContractorshallprovideLDH,orits
designee,withthenameoftheindividualwhowillserveasthe
Contractor’s point of contact for handling public records’
requests.Ifthispointofcontactchangesatanytimeduringthe
Contract term, the Contractor shall provide LDH with the
updatedpointofcontactimmediately.
2.2.6.4.2 IfLDHreceivesarequestpursuanttotheLouisianaPublic
RecordsActforrecordsthatareinthecustodyoftheContractor,
the Contractor shall provide all records to LDH that the
Department,initssolediscretion,deemstoberesponsivetothe
request,pursuanttothetimelineandintherequestedformat
establishedbyLDH.
2.2.6.4.3 IftheContractorreceivesthepublicrecords’requestdirectly,the
ContractorshallforwardtherequestviaemailtotheLDHSection
Chief of Program Operations and Compliance within one (1)
BusinessDayofreceipt.Thereafter,theContractorshallprovide
allrecordstoLDHthattheDepartment,initssolediscretion,
deemstoberesponsivetotherequest,pursuanttothetimeline
andintherequestedformatestablishedbyLDH.
2.2.6.5 Apattern of inadequate or untimely responses to requests for information
shallbesubjecttoMonetaryPenaltiesinaccordancewithAttachmentG,Table
ofMonetaryPenalties.
2.2.6.6 The obligations outlined in this section shall survive the termination of the
Contract.
2.2.7 MentalHealthParity
2.2.7.1 The Contractor shall comply with the Paul Wellstone and Pete Domenici
MentalHealthParityandAddictionEquityActof2008,whichrequiresparity
between mental health or substance use disorder benefits and
medical/surgical benefits with respect to financial requirements and
treatmentlimitations.TheContractorshallcomplywithallrequirementsset
forthin42C.F.R.Part438SubpartK,forallEnrollees.
2.2.7.1.1 The Contractor must comply with parity requirements for
aggregate lifetime or annual dollar limits on mental health or
substanceusedisorderbenefits,includingprescriptiondrugsas
specifiedin42C.F.R.§438.905.
2.2.7.1.2 All financial requirements or treatment limitations, including
nonquantitativetreatmentlimitations(NQTL),tomentalhealth
orsubstanceusedisorderbenefitsshallnotbemorerestrictive
thanthepredominantfinancialrequirementortreatment
limitationappliedtosubstantiallyallmedical/surgicalbenefits,in
accordance with 42 C.F.R. §438.910. Financial requirements
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cannotaccumulateseparatelyformedical/surgicalbenefitsand
mentalhealth/SUDbenefits.
2.2.7.2 TheContractorshalldevelopandmaintaininternalcontrolstoensuremental
healthparity.TheContractor’sutilizationpracticessuchasPriorAuthorization,
standards for medical necessity determination, and network policy,
procedures,andpracticesshallcomplywiththefederalregulationsreferenced
above.
2.2.7.2.1 TheContractorshallconductaninitialparityanalysisaspartof
itsReadinessReviewprocessandatothertimesasdirectedby
LDH,basedonbenefitclassificationsforparityasdefinedbyLDH.
IfanEnrolleeisprovidedmentalhealthorsubstanceusedisorder
benefits in any classification of benefits, mental health and
substanceusedisorderbenefitsmustbeprovidedtotheEnrollee
in every classification in which medical/surgical benefits are
provided.
2.2.7.2.2 TheContractorshallcover,inadditiontoMCOCoveredServices,
anyservicenecessaryforcompliancewiththerequirementsfor
parity in mental health and substance use disorder benefits
basedonparityanalysis.AsdirectedbyLDHaspartofongoing
parityreview,theContractormayberequiredtocoverorchange
servicesnecessaryfor compliance, including type and amount,
durationandscopeofservicesandchangepolicyoroperational
procedures in order to achieve and maintain compliance with
parityrequirements.
2.2.7.2.3 TheContractorshallensureEnrolleesreceiveanoticeofAdverse
Benefit Determination per 42 C.F.R. §438.915(b) and other
sections of this Contract which extend notice requirements
beyonddenials.TheContractorshallmakeavailableinhardcopy
uponrequest at nocost tothe requestor andavailable onthe
Contractor’s website, the criteria for medical necessity
determinations for mental health and substance use disorder
benefitstoanyEnrollee, Potential Enrollee,or providerper42
C.F.R.§438.236(c)and438.915(a).
2.2.7.3 TheContractorshallrequirethatallprovidersandallsubcontractorstakesuch
actions as are necessary to ensure compliance with mental health parity
requirements. To the extent that the Contractor delegates oversight
responsibilitiesforbehavioralhealthservicestoaMaterialSubcontractor,the
Contractor shall require that the Material Subcontractor complies with
provisionsofthisContract relatingto mental healthparity. Thecompliance
andreviewshallbeinconjunctionwithparityanalysisonthemedical/surgical
benefit administration. The Contractor shall require mental health parity
disclosureonproviderEnrollmentformsasmandatedbyLDH.
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2.2.7.3.1 Ifatanytime,theStatemovestoasingledeliverysystemand
anyremainingbenefitsfromFee‐for‐Service(FFS)arecompletely
providedthroughmanagedcare,itshallbetheresponsibilityof
the Contractor to review mental health and substance user
disorderandmedical/surgicalbenefitsandconductthecomplete
parityanalysistoensurethefullscopeofservicesavailabletoall
EnrolleesoftheContractorcomplieswiththerequirementsset
forthin42C.F.R.Part438,SubpartK.TheContractorshallbe
requiredtoprovidedocumentationtotheStateandpublic.
2.2.7.4 The Contractor shall provide LDH and its designees, which may include
auditorsandinspectors,withaccesstoContractorservicelocations,facilities,
orinstallations,includinganyandallelectronicandhardcopyrecordsandfiles.
Accessdescribedinthissectionshallbeforthepurposeofexamining,auditing,
orinvestigatingmentalhealthparity.
2.2.7.5 TheContractorshallcomplywithallotherapplicableFederalandStatelaws,
regulations,rules,policies,procedures,andmanualsrelatingtomentalhealth
parity.
EligibilityandEnrollment
2.3.1 MandatoryMCOPopulationsforAllMCOCoveredServices
Unless otherwise excluded in this section, the following Louisiana Medicaid Program
populationsareautomaticallyenrolledintheManagedCareProgramforallMCOCovered
Services:
2.3.1.1 Childrenundertheageofnineteen(19),includingthosewhoareeligibleunder
Section 1931 of the Social Security Act, poverty‐level related groups, and
optionalgroupsofolderchildreninthefollowingcategories:
2.3.1.1.1 CHAMP‐ChildProgram–Povertylevelchildrenundertheageof
nineteen (19) who meet financial and non‐financial eligibility
criteria. Deprivation or uninsured status is not an eligibility
requirement;
2.3.1.1.2 Deemed Eligible Child Program – Infants born to a woman
determined eligible forthe Louisiana MedicaidProgramin any
categoryonthedatetheinfantisborn,regardlessofwhetheror
nottheinfantremainswiththebirthmother,throughtheinfant’s
firstyearoflife.Thisincludesaninfantwhoisborntoamother
whoisdeterminedeligiblefortheLouisianaMedicaidProgram
retroactivetothedatetheinfantwasborn;
2.3.1.1.3 YouthAgingOutofFosterCare(ChafeeOption)–Childrenunder
theageoftwenty‐one(21)whowereinfostercareinthecustody
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ofanystateontheireighteenth(18th)birthday,buthaveaged
outoffostercare;
2.3.1.1.4 Former Foster Care Children – Individuals age eighteen (18)
through twenty‐six (26) who were enrolled in the Louisiana
MedicaidProgramandinfostercareundertheresponsibilityof
theStateontheireighteenth(18th)birthday;
2.3.1.1.5 FosterCareChildren–Childrenundertheageofeighteen(18)
whoarereceivingfostercare,kinshipguardianship,oradoption
assistanceunderTitleIV‐E.
2.3.1.1.6 RegularMedicallyNeedyProgram–Individualsandfamilieswho
meet the non‐financial eligibility criteria for Parents and
Caretaker Relative, Pregnant Women, or Children Under Age
Nineteen (19) and whose income is at orbelow the Medically
NeedyIncomeEligibilityStandard;
2.3.1.1.7 FamilyOpportunitiesActforDisabledChildren‐Medicaidbuy‐in
program for children under the age of nineteen (19) with
disabilitieswhoarenoteligibleforSSIduetoincome;
2.3.1.1.8 LaCHIPProgram–Uninsuredlow‐incomechildrenundertheage
ofnineteen(19)whodonototherwisequalifyfortheLouisiana
MedicaidProgram;and
2.3.1.1.9 Blind/Disabled Children and Related Populations – Individuals,
generallyundertheageofnineteen(19),whoareeligibleforthe
LouisianaMedicaidProgramduetoblindnessordisability.
2.3.1.2 Parents and Caretaker Relatives eligible under Section 1931 of the Social
SecurityActincluding:
2.3.1.2.1 ParentsandCaretakerRelativesProgram‐Individualswhoarea
relativeofadependentchildbyblood,adoption,ormarriageand
withwhomthechildisliving,whoassumesprimaryresponsibility
for the child’s care, and meet financial and non‐financial
eligibilitycriteria;and
2.3.1.2.2 RegularMedicallyNeedyProgram.
2.3.1.3 PregnantWomen–Individualswhosebasisofeligibilityispregnancy,whoare
eligiblealsoforpregnancyrelatedservices[42C.F.R.§440.210(a)(2)]including:
2.3.1.3.1 LaMOMS (CHAMP‐Pregnant Women) Program– Pregnant
womenwho receive full LouisianaMedicaidProgram coverage
andcoverage forprenatalcare, delivery,and carethroughthe
calendarmonthinwhichthesixty(60)CalendarDaypostpartum
periodends;and
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2.3.1.3.2 LaCHIPPhaseIVProgram–Providesonlyprenatalcareservices
fromconceptionthrudeliveryforlow‐incomeuninsuredcitizen
andnon‐citizenpregnantwomenandtheirunbornchildrenwho
arenototherwiseeligiblefortheLouisianaMedicaidProgram.
2.3.1.4 BreastandCervicalCancer(BCC)Program–Uninsuredwomenundertheage
ofsixty‐five(65)whoarenototherwiseeligiblefortheLouisiana Medicaid
Program and are identified through the Centers for Disease Control and
Prevention’s (CDC) National Breast and Cervical Cancer Early Detection
Program and are in need of treatment for breast and/or cervicalcancer,
includingpre‐cancerousconditionsandearlystagecancer.
2.3.1.5 Aged,Blind,andDisabledAdults–Individualswhoareagesixty‐five(65)or
older,blind,orhaveadisability;meetfinancialeligibilitycriteria;anddonot
meet the conditions for inclusion in the Voluntary MCO Populations,
mandatory SBHS and Non‐Emergency Ambulance Transportation (NEAT)
populations,andmandatorySBHSandNEMTpopulations.Theseinclude:
2.3.1.5.1 Supplemental Security Income (SSI) Program – Individuals
nineteen(19)yearsofageandolderwhoreceivecashpayments
underTitleXVIoftheSocialSecurityAct(SupplementalSecurity
Income);and
2.3.1.5.2 ExtendedMedicaidPrograms–CertainindividualswholoseSSI
eligibilitybecauseofaRetirement,Survivors,DisabilityInsurance
(RSDI) cost of living adjustment (COLA) or in some cases
entitlement to or an increase in RSDI benefits. SSI income
standards are used in combination with budgeting rules that
allowtheexclusionofCOLAsand/orcertainbenefits.Extended
MedicaidProgramsconsistsofthefollowing:
2.3.1.5.2.1 DisabledAdultChildren–Individualsoverthe
age of eighteen (18) who became blind or
disabled before the age of twenty‐two (22)
andlostSSIeligibilityonorafterJuly1,1987,
asaresultofentitlementtoorincreasein
SocialSecurityChildInsuranceBenefits;
2.3.1.5.2.2 Widows/Widowers–IndividualswholoseSSI
eligibility because of receipt of RSDI early
widow/widowersbenefits;
2.3.1.5.2.3 Pickle–IndividualswhocurrentlyreceiveRSDI;
wereeligibletoreceivebothRSDIandSSIor
MandatoryStateSupplement(MSS)inatleast
one (1) month since April 1, 1977; and lost
SSI/MSSeligibilityeither:
GroupOne–asthedirectresultofan
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RSDICOLA;or
GroupTwo–duetoreceiptoforincrease
inRSDI,otherthananRSDICOLA,or
receiptoforincreaseinotherincomeand
wouldagainbeeligibleforSSIexceptfor
theRSDICOLAsreceivedsincethelossof
SSI.
2.3.1.5.2.4 Disabled Widows/Widowers and Disabled
SurvivingDivorcedSpousesUnableToPerform
Any Substantial Gainful Activity –
Widows/Widowerswhobecameineligiblefor
SSI due to the receipt of Social Security
Disabled Widows/Widowers Benefits as long
astheywerereceivingSSIforthemonthprior
tothemonththeybeganreceivingRSDI,they
would continue to be eligible for SSI if the
amountoftheRSDIbenefitwasnotcountedas
income,andtheyarenotentitledtoMedicare
PartA;and
2.3.1.5.2.5 BloodProductLitigationProgram–Individuals
wholoseSSI eligibilitybecauseofsettlement
paymentsundertheSusanWalkerv.Bayer
Corporation settlement and the Ricky Ray
HemophiliaReliefFundActof1998.
2.3.1.5.3 Medicaid Purchase Plan Program – Working individuals age
sixteen (16) through sixty‐four (64) who have a disability as
definedbytheSocialSecurityAdministrationthatcanbuyhealth
coverageofferedbytheLouisianaMedicaidProgram;
2.3.1.5.4 Provisional Medicaid Program – Individuals with a disability as
defined by the Social Security Administration or age sixty‐five
(65)orolder,andwhomeetthefinancialeligibilitycriteriaforSSI,
butarenotreceivingSSI;and
2.3.1.5.5 Agedandrelatedpopulations‐Beneficiarieswhoareagesixty‐
five(65)orolderandnotmembersoftheblind/disabled
populationormembersoftheSection1931Adultpopulation.
2.3.1.6 TransitionalMedicaidProgram–Short‐termcoverageforindividualswholose
Parents and Caretaker Relatives or Family Independence Temporary
Assistance Program (FITAP, administered by DCFS) eligibility because of an
increaseinearnings.
2.3.1.7 Tuberculosis (TB) Infected Individual Program ‐ Individuals whohavebeen
diagnosedas,oraresuspectedof,beinginfectedwithTB.
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2.3.1.8 Adult Group – Individuals age nineteen (19) through sixty‐four (64), not
pregnant, entitles to or enrolled in Medicare Part A or Part B, and not
otherwiseeligiblefortheLouisianaMedicaidProgram.
2.3.1.9 Act421Children’sMedicaidOption–Childrenundertheageofnineteen(19),
who have a disability as defined by the Social Security Administration and
meet the level‐of‐care for a nursing facility, hospital, or Intermediate Care
FacilitiesforIndividualswithIntellectualDisabilities(ICF/IID).
2.3.2 VoluntaryMCOPopulations
The Contractor shall accept Enrollment of the following Louisiana Medicaid Program
populationsandprovideforallSBHS,NEMTservices,andNEAT)services.
2.3.2.1 IfanysuchBeneficiaryvoluntarilyenrollsintheManagedCareProgramforall
otherMedicaidCoveredServices,theContractorshallprovideforallservices
asspecifiedintheServicessection.Thesepopulationsinclude:
2.3.2.1.1 Non‐dually eligible Beneficiaries receiving services through the
following1915(c)HomeandCommunity‐Based(HCBS)Waivers
andanyHCBSWaiver(s)thatreplacesthesecurrentWaivers:
2.3.2.1.1.1 AdultDayHealthCareWaiver(ADHC)–Direct
careinalicensedadultdayhealthcarefacility
forthoseindividualsagetwenty‐two(22)and
older who would otherwise require nursing
facilityservices;
2.3.2.1.1.2 New Opportunities Waiver (NOW) – Services
to individuals age three (3) and older who
wouldotherwiserequireICF/IIDservices;
2.3.2.1.1.3 Children’sChoiceWaiver(CC)–Supplemental
support services to disabled children from
birthtoagetwenty(20)ontheNOWregistry;
2.3.2.1.1.4 Residential Options Waiver (ROW) – Services
to individuals living in the community who
wouldotherwiserequireICF/IIDservices;
2.3.2.1.1.5 Supports Waiver – Services to individuals
eighteen (18) years of age and older with a
developmental disability which manifested
priortoagetwenty‐two(22);and
2.3.2.1.1.6 Community Choices Waiver (CCW) – Services
topersonsagesixty‐five(65)andolderor,
persons age twenty‐two (22) or older with
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adult‐onsetdisabilities,whowouldotherwise
requirenursingfacilityservices.
2.3.2.1.2 Beneficiariesundertheageoftwenty‐one(21),eligibleforthe
LouisianaMedicaidProgramwhoarelistedonOCDD’sRequest
forServicesRegistrywhoareChisholmClassMembers.
2.3.2.2 VoluntaryMCOPopulationsmayelecttoreceiveallotherMedicaidCovered
ServicesthroughtheManagedCareProgramatanytime.
2.3.2.3 Voluntary MCO Populations may return to FFS for all Medicaid Covered
ServicesotherthanSBHSandNEMT/NEAT services effective the earliest
possiblemonththattheadministrativeactioncanbetaken.
2.3.2.4 Voluntary MCO Populations who have previously returned to FFS for all
Medicaid Covered Services other than SBHS and NEMT/NEAT services may
elect to return to the Managed Care Program for other Medicaid Covered
ServicesonlyduringtheopenEnrollmentperiod.
2.3.3 MandatoryMCOPopulationsforSBHSandNEMTservicesonly.
ThefollowingLouisianaMedicaidProgrampopulationsareautomaticallyenrolledinthe
ManagedCareProgramforSBHSandNEMTservicesonly,andreceiveallotherMedicaid
CoveredServicesthroughFFS:
2.3.3.1 BeneficiariesresidinginNursingFacilities(NF);and
2.3.3.2 Beneficiariesundertheageoftwenty‐one(21)residinginICF/IIDs.
2.3.4 MandatoryMCOPopulationsforSBHSandNEMT/NEATservicesonly.
ThefollowingLouisianaMedicaidProgrampopulationsareautomaticallyenrolledinthe
Managed Care Programfor SBHS and NEMT/NEAT services only, and receive all other
MedicaidCoveredServicesthroughFFS:
2.3.4.1 BeneficiarieswhoareenrolledinboththeLouisianaMedicaidProgramand
Medicare(Medicaiddual eligible), except thoseresiding in an institutionas
specifiedinthissection.
2.3.4.2 LaHIPPBeneficiariesexceptthoseresidinginaninstitutionasspecifiedinthis
section.
2.3.5 Mandatory MCO Populations for All MCO Covered Services Except SBHS and CSoC
Services.
The Contractor shall accept Enrollment of children who are functionally eligible and
participateintheCSoCprogramforallservicesasspecifiedintheServicessection,except
SBHSandCSoC services.For thispopulation,PsychiatricResidential TreatmentFacility
(PRTF),TherapeuticGroupHome(TGH),andSUDResidentialservices(ASAMLevels3.1,
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3.2‐wm,3.5 and 3.7) remain theresponsibility ofthe Contractor.TheContractorshall
implementprocedurestocoordinateservicesitprovidestotheEnrolleewiththeservices
the Enrollee receives from the CSoC contractor, including sharing the results of any
identificationand assessment of that Enrollee's needs to prevent duplication of those
activitiesasrequiredby42C.F.R.§438.208(b)(4).
2.3.6 ExcludedPopulations
The following Louisiana Medicaid Program populations cannot participate in the
ManagedCareProgramandreceiveallMedicaidCoveredServicesthroughFFS:
2.3.6.1 Beneficiariesagetwenty‐one(21)andolderresidinginanICF/IID;
2.3.6.2 Beneficiaries enrolled in the Program of All‐Inclusive Care for the Elderly
(PACE),acommunity‐basedalternativetoplacementinanursingfacilitythat
includesacomplete“managedcare”typebenefitcombiningmedical,social
andlong‐termcareservices;
2.3.6.3 RefugeeCashAssistance;
2.3.6.4 RefugeeMedicalAssistance;
2.3.6.5 TakeChargePlus;
2.3.6.6 SpecifiedLowIncomeMedicareBeneficiary(SLMB)only;
2.3.6.7 QualifiedIndividualCategory1(QI‐1);
2.3.6.8 LongTermCare(LTC)Co‐Insurance;
2.3.6.9 QualifiedDisabledWorkingIndividual(QDWI);
2.3.6.10 QualifiedMedicaidBeneficiary(QMB)only;
2.3.6.11 Beneficiarieswithalimitedeligibilityperiodincluding:
2.3.6.11.1 Spend‐DownMedicallyNeedyProgram–Anindividualorfamily
whohasincomeinexcessoftheprescribedincomestandardcan
reduceexcessincomebyincurringmedicaland/orremedialcare
expensestoestablishatemporaryperiodofLouisianaMedicaid
Programcoverage(uptothree[3]months);and
2.3.6.11.2 EmergencyServicesOnly–EmergencyServicesforalienswhodo
not meet Medicaid citizenship/ five (5) year residency
requirements.
2.3.7 ChangestoPopulationGroups
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LDHmayadd,delete,orotherwisechangemandatory,voluntaryopt‐out,voluntaryopt‐
in,andexcludedpopulationgroups.Ifchanged,theContractshallbeamendedandthe
Contractorgivensixty(60)CalendarDays’advancenoticewheneverpossible.
2.3.8 Eligibility,EnrollmentandDisenrollment
TheContractorshallabidebyallEnrollmentandDisenrollmentprocedures.Automatic
AssignmentalgorithmsanddecisionsregardingEnrollmentareatthesolediscretionof
LDH,andtheContractormustabidebythosedecisions.
2.3.9 VoluntarySelectionofMCOforNewEnrollees
2.3.9.1 PotentialEnrolleesshallbegivenanopportunitytochooseanMCOatthetime
ofapplication.OncethePotentialEnrolleeisdeterminedeligible,theirchoice
ofMCOshallbetransmittedtotheEnrollmentBroker.
2.3.9.2 Duringtheninety(90)CalendarDaysfollowingthedateoftheEnrollee’sinitial
EnrollmentintoanMCO,orduringtheninety(90)CalendarDaysfollowingthe
datetheStateorits designeesendstheEnrolleenoticeofthat Enrollment,
whichever is later, the Enrollee shall be allowed to request Disenrollment
without cause by submitting an oral or written request to the Enrollment
Broker.
2.3.9.3 All eligible Enrollees shall be provided the opportunity to request
Disenrollment without cause at least once every twelve (12) months
thereafter.
2.3.9.4 AllEnrolleesshallbegivenanopportunitytochooseanMCOatthestartofa
newMCOcontracteitherthroughtheregularlyscheduledEnrollmentperiod
orspecialEnrollmentperiod.
2.3.10 AssistancewithMedicaidEligibilityRenewal
RenewalsofLouisianaMedicaidProgrameligibilityareconductedannually.Atleastthirty
(30)CalendarDayspriortotherenewaldateasindicatedonthe834file,theContractor
shall provide assistance to Enrollees with eligibility renewals. The Contractor shall
attempttocontacttheEnrolleebymailand/orphonethree(3)timestoencouragetheir
Timelyresponsetotherenewal.TheEnrolleeshouldbeprovidedwithinformationonthe
waystoapply/renew.
2.3.11 Suspensionofand/orLimitsonEnrollments
2.3.11.1 TheContractorshallnotifyLDHofthemaximumnumberofEnrolleesitisable
toenrollandmaintainundertheContractpriortotheinitialEnrollmentand
upon changes. LDH reserves the right to approve or deny the maximum
number of Enrollees to be enrolled in the Contractor based on LDH's
determinationoftheadequacyofitscapacity.
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2.3.11.2 IntheeventtheContractor’sEnrollmentreachesthirty‐fivepercent(35%)of
thetotalEnrollmentintheState,orninety‐fivepercent(95%)ofitscapacity,
atLDH’ssolediscretion,theContractorshallnotreceiveadditionalEnrollees
throughtheAutomaticAssignmentalgorithm.LDHalsohasthesolediscretion
to suspend the Contractor’s Automatic Assignment due to Contract
noncompliance,asfurtherexplainedintheAutomaticAssignmentsection.
2.3.11.3 TheContractormaycontinuetoreceivenewEnrolleesasaresultof:Enrollee
choiceandnewbornEnrollments;automaticreenrollmentswhenanEnrollee
loses and regains eligibility within three (3) months; the needtoensure
continuity of care for the Enrollee; or determination of just cause by LDH.
LDH’sevaluationofantheContractor’sEnrollmentmarketshare will take
placeonacalendarquarterbasis.
2.3.12 ContractorEnrollmentProcedures
2.3.12.1 AcceptanceofAllEnrollees
2.3.12.1.1 TheContractorshallenrollanyBeneficiaryinaMandatoryMCO
Population or Voluntary MCO Population who selects it or is
otherwiseassignedtoit.
2.3.12.1.2 TheContractor shall acceptnew Enrollment ofBeneficiaries in
theorderinwhichtheyaresubmittedbytheEnrollmentBroker
withoutrestrictionasspecifiedbyLDH,uptothelimitssetunder
the Contract with LDH [42 C.F.R. §438.3(d)(1)]. Enrollment is
voluntary,exceptinthecaseofMandatoryMCOPopulationsthat
meettheconditionssetforthin42C.F.R.§438.50(a).
2.3.12.1.3 The Contractor shall not discriminate against Enrollees on the
basisoftheirhealthhistory,healthstatus,needforhealthcare
servicesoradversechangeinhealthstatus;oronthebasisofage,
religiousbelief,sex,gender,sexualorientation,genderidentity,
ordisability.Further,theContractorshallnotuseanypolicyor
practicethathastheeffectofdiscriminatingonthebasisofage,
religious belief, race, color, national origin, sex, sexual
orientation, gender identity, or disability. This applies to
Enrollment,reenrollmentorDisenrollmentfromtheContractor.
TheContractorshallbesubjecttoMonetaryPenaltiesandother
sanctions if it is determined by LDH that the Contractor has
requestedDisenrollmentforanyoftheseprohibitedreasons.
2.3.12.1.4 The Contractor shall comply with all Federal and State laws,
regulations,rules, policies,procedures, andmanuals, theState
Plan,andapplicableWaiversgoverningdirectreimbursementto
EnrolleesforpaymentsmadebythemforMCOCoveredServices
andsuppliesdeliveredduringaperiodofretroactiveeligibility.
2.3.12.2 EffectiveDateofEnrollment
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2.3.12.2.1 TheeffectivedateofinitialEnrollmentwiththeContractorshall
be the date provided on the outbound ANSI ASC X12N 834
Benefit Enrollment & Maintenance electronic transaction file
initiatedbytheEnrollmentBroker.
2.3.12.2.2 AnEnrollee’s effective date of Enrollment with the Contractor
shallbethesameastheEnrollee’seffectivedateofeligibilityfor
the Louisiana Medicaid Program, subject to the following
limitations:
2.3.12.2.2.1 Beneficiaries may be retroactively approved
for the Louisiana Medicaid Program.
Beneficiaries retroactively approved for the
Louisiana Medicaid Program may be
retroactivelyenrolledwiththeContractorfor
aperiodofuptotwelve(12)months.
2.3.12.2.2.2 In cases of retroactive Enrollment, the
effectivedateofEnrollmentmayoccurpriorto
eithertheBeneficiaryortheContractorbeing
notifiedoftheEnrollment.
2.3.12.2.3 The Contractor shall not be liable for the cost of any MCO
Covered Services rendered prior to the effective date of
Enrollment.However,theContractorshallberesponsibleforthe
costsofMCOCoveredServicesrenderedonorafter12:01a.m.
ontheeffectivedateofEnrollment,includingreimbursementto
anEnrolleeforpaymentsalreadymadebytheEnrolleeforMCO
Covered Services rendered during the retroactive Enrollment
period in accordance with the process outlined in the MCO
Manual.
2.3.12.2.4 LDHshallmakemonthlyCapitationPaymentstotheContractor
from the effective date of an Enrollee’s Enrollment. LDH shall
deductfromthemonthlyCapitationPaymentanyFFSclaimspaid
forservicesrenderedduringtheretroactiveEnrollmentperiod.
2.3.12.2.5 Except for cost sharing that does not exceed the cost sharing
amounts in the State Plan, the Contractor shall ensure that
EnrolleesareheldharmlessforthecostofMCOCoveredServices
providedasoftheeffectivedateofEnrollmentwiththe
Contractor.
2.3.12.3 ChangesinDemographicInformationorStatus
2.3.12.3.1 TheContractor shall report to LDH, in the manner andformat
determinedbyLDH,anychangesindemographicinformationor
livingarrangementsforfamiliesorindividualEnrolleeswithinfive
(5) Business Days of discovery, including changes in mailing
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address, residential address, e‐mail address, and telephone
number.
2.3.12.3.2 TheContractorshallsubmitnotificationstoLDH,inthemanner
and format determined by LDH in writing, any other known
changesinstatuswhichmayaffecteligibilityforparticipationin
theManagedCareProgramincluding,butnotlimitedto,death,
admissiontoanICF/IIDforEnrolleesagetwenty‐one(21)and
older,andentryintoinvoluntarycustody/incarceration.
2.3.12.4 NewbornEnrollment
2.3.12.4.1 The Contractor shall contact Enrollees who are expectant
mothersatleastsixty(60)CalendarDayspriortotheexpected
dateofdeliverytoencouragethemotherstochooseaPCPfor
theirnewborns.IntheeventthatthepregnantEnrolleedoesnot
select a PCP, the Contractor shall provide the Enrollee with a
minimumoffourteen(14)CalendarDaysafterbirthtoselecta
PCPpriortoassigningone.
2.3.12.4.2 Newbornsandtheirmothers,totheextentthatthemotheris
eligiblefortheLouisianaMedicaidProgram,shallbeenrolledin
thesameMCOwiththeexceptionofnewbornsplacedfor
adoption, newborns who are born out‐of‐state and are not
Louisiana residents at the time of birth, and newborns and
mothers eligible for the Louisiana Medicaid Program after the
monthofbirth.
2.3.12.4.3 If LDH discovers that a newborn was incorrectly enrolled in a
differentMCOthanitsmotherforthemonthofbirth,LDHshall
immediately:
2.3.12.4.3.1 DisenrollthenewbornfromtheMCOinwhich
thenewbornwasincorrectlyenrolled;
2.3.12.4.3.2 Enroll the newborn in the correct MCO with
thesameeffectivedateaswhenthenewborn
wasenrolledintheincorrectMCO;
2.3.12.4.3.3 Recoup any payments made to the incorrect
MCOforthenewborn;and
2.3.12.4.3.4 MakepaymentsonlytotheMCOinwhichthe
newborniscorrectlyenrolledfortheperiodof
coverage.
2.3.12.4.4 IftheContractordiscoversthatanewbornwasincorrectly
enrolledinadifferentMCOthanitsmotherforthemonthof
birth,theContractorshallnotifyLDHimmediately.
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2.3.12.4.5 The MCO in which the newborn is correctly enrolled shall be
responsibleforthecoverageof,andpaymentfor,MCOCovered
Servicesprovidedtothenewbornforthefullperiodofcoverage.
The MCO in which the newborn was incorrectly enrolled shall
havenoliabilityforthecoverageof,orpaymentfor,anyservices
duringtheperiodofincorrectEnrollment.LDHshallbeliableonly
fortheCapitationPaymenttotheMCOinwhichthenewbornis
correctlyenrolledandmayrecouptheCapitationPaymentfrom
theMCOinwhichthenewbornwasincorrectlyenrolled.
2.3.12.4.6 Fornewbornsdisenrolled,theMCOinwhichthenewbornwas
incorrectlyenrolled shallnot recoverclaimpaymentsfrom the
provider.TheMCOinwhichthenewbornisincorrectlyenrolled
shall seek such claim payments from the MCO in which the
newbornshouldhavebeenenrolledonthedatesofservice.
2.3.12.4.7 TheContractor shall beresponsibleforensuringthathospitals
reportthebirthsofnewbornswithintwenty‐four(24)hoursof
birthforEnrolleesinaccordancewiththeprocessoutlinedinthe
MCOManual.Enrollmentofdeemedeligiblenewbornswhoare
Louisiana residents at the time of birth and who are not
surrenderedpriortohospitaldischargeshallberetroactivetothe
dateofthebirth.
2.3.12.4.8 TheContractorshallrequireitshospitalproviderstoregisterall
births within fifteen (15) Calendar Days through Louisiana
Electronic Event Registration System (LEERS) administered by
LDH/VitalRecordsRegistry.
2.3.12.5 Justice‐InvolvedEnrollees
Alljustice‐involvedEnrolleesreleasingfromincarcerationshallbeenrolledin
accordance with the process outlined in the Justice‐Involved Pre‐Release
EnrollmentProgramManual.
2.3.13 Disenrollment
2.3.13.1 GeneralRequirements
2.3.13.1.1 TheContractor shall, at a minimum, continue to provide MCO
Covered Services and all other services required under this
ContracttoEnrolleesupto12:00a.m.ontheCalendarDayafter
theeffectivedateofDisenrollment.
2.3.13.1.2 TheContractorshalldemonstrateasatisfactorilylowVoluntary
Disenrollment Rate as compared with other MCOs, as
determinedbyLDH.
2.3.13.2 VoluntaryDisenrollmentRequestedbytheEnrollee
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AnEnrolleemayrequestDisenrollmentfromtheContractorasfollows:
2.3.13.2.1 Forcause,atanytime.Thefollowingcircumstancesarecausefor
Disenrollment:
TheContractordoesnot,becauseofmoralorreligiousobjections,cover
theservicetheEnrolleeseeks;
TheEnrolleeneedsrelatedservicestobeperformedatthesametime;not
all related services are available within the Enrollee’s MCO and the
Enrollee’sPCPoranotherproviderdeterminesthatreceivingtheservices
separatelywouldsubjecttheEnrolleetounnecessaryrisk;
TheContractbetweentheContractorandLDHisterminated;
PoorqualityofcarebytheContractorasdeterminedbyLDH;
LackofaccesstoMCOCoveredServicesasdeterminedbyLDH;
The Enrollee’s active specialized behavioral health provider ceases to
contractwiththeContractorforreasonsotherthannon‐compliancewith
theNetworkProviderAgreementorthisContract;or
AnyotherreasondeemedtobevalidbyLDHand/oritsagent.
2.3.13.2.2 Withoutcauseatthefollowingtimes:
Duringtheninety(90)CalendarDaysfollowingthedateoftheEnrollee’s
initialEnrollment withthe Contractoror duringthe ninety(90) Calendar
DaysfollowingthedatetheEnrollmentBrokersendstheBeneficiarynotice
ofthatEnrollment,whicheverislater;
Everytwelve(12)monthsthereafter;
Uponautomaticreenrollmentunder42C.F.R.§438.56(g),ifatemporary
(ninety(90)CalendarDay)lossofLouisianaMedicaidProgrameligibilityhas
causedtheEnrolleetomisstheEnrollmentperiod;
WhenLDHimposestheintermediatesanctionprovisionsspecified in42
C.F.R§438.702(a)(3);or
AfterLDHnotifiestheContractorthatitintendstoterminatetheContract
asprovidedby42C.F.R.§438.722.
2.3.13.3 InvoluntaryDisenrollmentRequestedbytheContractor
2.3.13.3.1 TheContractormayrequestinvoluntaryDisenrollmentofan
EnrolleeiftheEnrollee’sutilizationofservicesconstitutesFraud,
Waste,and/orAbusesuchasmisusingorloaningtheEnrollee’s
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MCOMemberIDCardtoanotherpersontoobtainservices.In
suchcasetheContractorshallreporttheeventtoLDHandMFCU.
2.3.13.3.2 The Contractor shall submit Disenrollment requests to the
EnrollmentBroker,inaformatandmannertobedeterminedby
LDH.
2.3.13.3.3 The Contractor shall ensure that involuntary Disenrollment
documentsaremaintainedinanidentifiableEnrolleerecord.
2.3.13.3.4 The Contractor shall not request Disenrollment because of an
adversechangeinphysicalormentalhealthstatusorbecauseof
the Enrollee’s health diagnosis, utilization of medical services,
diminished mental capacity, pre‐existing medical condition,
refusalofmedicalcareordiagnostictesting,attempttoexercise
his/her rights under the Contractor’s grievance system, or
attempttoexerciseher/herrighttochange,forcause,thePCP
thathe/shehaschosenorbeenassigned.Further,theContractor
shall not request Disenrollment because of an Enrollee’s
uncooperative or disruptive behavior resulting from his or her
special needs, except when his or her continued Enrollment
seriously impairs the Contractor’s ability to furnish services to
either this particular Enrollee or other Enrollees. [42 C.F.R.
§438.56(b)(2)]
2.3.13.3.5 TheContractorshallnotrequestDisenrollmentforreasonsother
thanthosestatedinthisContract.Inaccordancewith42C.F.R.
§438.56(b)(3), LDH shall ensure that the Contractor is not
requesting Disenrollment for other reasons by reviewing and
rendering decisions on all Disenrollment Request Forms
submittedtotheEnrollmentBroker.
2.3.13.3.6 AllDisenrollmentrequestsshallbereviewedonacase‐by‐case
basisandaresubjecttothesolediscretionofLDHoritsdesignee
(EnrollmentBroker).Alldecisionsarefinalandnotsubjecttothe
disputeresolutionprocessbytheContractor.
2.3.13.3.7 WhentheContractor’srequestforinvoluntaryDisenrollmentis
approvedbyLDHinwriting,theContractorshallnotifythe
Enrollee in writing of the requested Disenrollment. The notice
shallinclude:
2.3.13.3.7.1 ThereasonfortheDisenrollment;
2.3.13.3.7.2 TheeffectivedateoftheDisenrollment;
2.3.13.3.7.3 AninstructionthattheEnrolleechooseanew
MCO;and
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2.3.13.3.7.4 AstatementthatiftheEnrolleedisagreeswith
theDisenrollmentdecision,theEnrolleehasa
righttosubmitarequestforaStateFair
Hearing.
2.3.13.3.8 Untilthe Enrollee is Disenrolled by the Enrollment Broker, the
Contractorshallcontinuetoberesponsiblefortheprovisionof
allMCOCoveredServicestotheEnrollee.
2.3.13.4 DisenrollmentEffectiveDate
2.3.13.4.1 TheeffectivedateofDisenrollmentshallbenolaterthanthefirst
(1st) day of the second (2nd) month following the calendar
monthinwhichtherequestforDisenrollmentisfiled.
2.3.13.4.2 If LDH or its designee fails to make a Disenrollment
determinationbythefirst(1st)dayofthesecond(2nd)month
following the month in which the request for Disenrollment is
filed,theDisenrollmentisdeemedapproved.
2.3.13.4.3 LDH,theContractor,andtheEnrollmentBrokershallreconcile
Enrollment/Disenrollment issues at the end of each month
utilizinganagreeduponprocedure.
2.3.14 EnrollmentandDisenrollmentUpdates
2.3.14.1 LDH’sEnrollmentBrokershallnotifytheContractoratspecified timeseach
monthoftheBeneficiariesthatareenrolled,reenrolled,ordisenrolledfrom
the Contractor for the following month. The Contractor shall receive this
notification through the ANSI ASC X12N 834 Benefit Enrollment and
Maintenance electronic transaction file, or in instances of corrections to
closedsegmentsorotherspecialcircumstances,theContractorshallreceive
thisnotificationthroughamanualcorrectionprocessingfile.
2.3.14.2 LDHshalluseitsbesteffortstoensurethattheContractorreceivesTimelyand
accurate Enrollment and Disenrollment information. In the eventof
discrepanciesorirreconcilabledifferencesbetweenLDHandtheContractor
regarding Enrollment, Disenrollment and/or termination, LDH’s decision is
final.
2.3.15 Updates
TheEnrollmentBrokershallmakeavailabletotheContractordailyviaelectronicmedia
(ASC X12N 834 Benefit Enrollment and Maintenance transaction file) updates on
Beneficiaries newly enrolled with the Contractor in the format specified in the MCO
SystemCompanionGuide.TheContractorshallhavewrittenpoliciesandproceduresfor
receiving these updates, incorporating them into its managementinformationsystem
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andensuringthisinformationisavailabletotheirproviders.Policiesandproceduresshall
beavailableduringReadinessReview.
Ininstancesofcorrectionsorupdatestoclosedsegments,theContractorshallreceive
datathroughaweeklymanualcorrectionprocessingfile.
LDHreservestherighttorequiretheContractortoacceptreal‐timeEnrollmentupdates
from the Enrollment Broker upon the implementation of such functionality by the
EnrollmentBroker.
2.3.16 Reconciliation
2.3.16.1 Enrollment
TheContractorisresponsibleformonthlyandquarterlyreconciliationofthe
membership list of Enrollments and Disenrollments received fromthe
Enrollment Brokeragainst its internal records. The Contractor shallprovide
written notification to the Enrollment Broker of any data inconsistencies
withinten(10)CalendarDaysofreceiptofthemonthlyandquarterly
reconciliationdatafile.
2.3.16.2 Payment
The Contractor shall receive a monthly electronic file (ASC X12N 820
Transaction)fromtheFiscalIntermediary(FI)listingallEnrolleesforwhomthe
ContractorreceivedaCapitationPaymentandtheamountreceived. The
Contractorisresponsibleforreconcilingthislistingagainstitsinternalrecords.
ItistheContractor’sresponsibilitytonotifytheFIofanydiscrepancieswithin
sixty(60)CalendarDaysofthefiledate.Lackofcompliancewithreconciliation
requirements shall result in the deduction of a portion of future monthly
payments and/or Monetary Penalties as defined in Attachment G, Table of
MonetaryPenaltiesuntilrequirementsaremet.
Services
2.4.1 MCOCoveredServices
2.4.1.1 TheContractorshallprovideEnrolleesallmedicallynecessaryMCOCovered
ServicesspecifiedinAttachmentC,MCOCoveredServices,asthoseservices
are defined in the State Plan and the MCO Manual. The Contractor shall
possess the expertise and resources to ensure the delivery of quality
healthcareservicestoitsEnrolleesinaccordancewiththisContract and
prevailingmedicalcommunityandnationalstandards.
2.4.1.2 MCOCoveredServicesshallbefurnishedinanamount,duration,andscope
thatis no less than the amount, duration,andscope for the same services
furnishedtoBeneficiariesunderFFS,assetforthin42C.F.R.§440.230,andfor
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Enrolleesundertheageoftwenty‐one(21),assetforthin42C.F.R.Part441,
SubpartB.[42C.F.R.§438.210(a)(2)]
2.4.1.3 The Contractor shall ensure that MCO Covered Services are sufficient in
amount,duration,orscopetoreasonablyachievethepurposeforwhichthe
servicesarefurnished.TheContractorshallnotarbitrarilydenyorreducethe
amount,duration,orscopeofarequiredservicebecauseofdiagnosis,typeof
illness,orconditionoftheEnrollee.[42C.F.R.§438.210(a)(3)]
2.4.1.4 In accordance with 42 C.F.R. §438.210(a)(4), the Contractor may place
appropriatelimitsonaservicethatare:
2.4.1.4.1 OnthebasisofcriteriaappliedundertheStatePlan,suchas
medicalnecessity;or
2.4.1.4.2 Forthepurposeofutilizationcontrol,providedthat:
2.4.1.4.2.1 The services furnished can reasonably be
expectedtoachievetheirpurpose;
2.4.1.4.2.2 TheservicessupportEnrolleeswithongoingor
chronic conditions and are authorized in a
manner that reflects the Enrollee’s ongoing
needforsuchservicesandsupports;and
2.4.1.4.2.3 Family planning services are provided in a
manner that protects and enables the
Enrollee’s freedom to choose the method of
familyplanningtobeusedconsistentwith42
C.F.R.§441.20.
2.4.1.5 TheContractorshallprovideMCOCoveredServicesinaccordancewithLDH’s
definition of medically necessary services (see Glossary), including
quantitative and non‐quantitative treatment limits, as indicated in State
statutes and regulations, the State Plan, and the MCO Manual. [42 C.F.R.
§438.210(a)(5)(i)]
2.4.1.5.1 Apublichealthquarantineorisolationorderorrecommendation
alsoestablishesmedicalnecessityofhealthcareservices.
2.4.1.6 TheContractorshallcovermedicallynecessaryservicesthataddress:
2.4.1.6.1 Theprevention,diagnosisandtreatmentofanEnrollee’sdisease,
condition, and/or disorder that results in health impairments
and/ordisability;
2.4.1.6.2 TheabilityforanEnrolleetoachieveage‐appropriategrowthand
development;and
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2.4.1.6.3 TheabilityforanEnrolleetoattain,maintain,orregainfunctional
capacity.
2.4.1.7 TheContractorshallensurethateachEnrolleehasanongoingsourceofcare
appropriatetotheirneedsasrequiredunder42C.F.R.§438.208(b)(1)andshall
formally designate a PCP as primarily responsible for coordinating services
accessed by the Enrollee, as further described in the Provider Network,
Contracts,andRelatedResponsibilitiessection.
2.4.1.8 The Contractor shall not avoid costs for services covered in its Contract by
referring Enrollees to publicly supported health care resources. [42 C.F.R.
§457.1201(p)]
2.4.1.9 The Contractor shall provide a mechanism to reduce inappropriate and
duplicativeuseofhealthcareservices,including,butnotlimitedto,potentially
preventable hospital emergency department (ED) visits and inpatient
readmissions.
2.4.1.10 TheContractorshallnotconditiontheprovisionofcareorotherwise
discriminate against an Enrollee based on whether or not the Enrollee has
executed an Advance Directive. [42 C.F.R. §438.3(j)(1) and (2); 42 C.F.R.
§489.102(a)(3).]
2.4.1.11 TheContractoranditsprovidersshalldeliverservicesinaculturallycompetent
mannertoallEnrollees,includingthosewithlimitedEnglishproficiencyand
diverseculturalandethnicbackgrounds,disabilities,andregardlessofgender,
sexualorientation,orgenderidentityandprovideforculturalcompetencyand
linguistic needs, including the Enrollee prevalent language(s) and sign
languageinterpretersinaccordancewith42C.F.R.§438.206(c).
2.4.1.12 IntheeventthatLDHdeterminesthattheContractorfailedtoprovideoneor
moreMCOCoveredServices,LDHshalldirecttheContractortoprovidesuch
service. If the Contractor continues to refuse to provide the MCO covered
service(s),LDHshallauthorizetheEnrolleestoobtaintheMCOcoveredservice
fromanothersourceandshallnotifytheContractorinwritingthat the
Contractorshallbechargedtheactualamountofthecostofsuchservice.
2.4.1.12.1 Insuchevent,thechargestotheContractorshallbeobtainedby
LDHintheformofdeductionsfromthenextmonthlyCapitation
Payment made to the Contractor or a future payment as
determinedbyLDH.Withsuchdeductions,LDHshallprovidea
list of the Enrollees for whom payments were deducted, the
natureoftheservice(s)denied,andpaymentsLDHmadeorwill
maketoprovidethemedicallynecessaryMCOCoveredServices.
2.4.1.12.2 Inadditiontothededuction,theContractormaybeassesseda
MonetaryPenaltyperincidentofnon‐compliance(see
AttachmentG,TableofMonetaryPenalties).
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2.4.2 ExcludedServices
2.4.2.1 The following services are available to Enrollees under the State Plan or
applicable Waivers, but are excluded from this Contract and notprovided
throughtheContractor.TheContractorshallinformEnrolleeshowtoaccess
excludedservices,provideallrequiredreferralsandassistinthecoordination
ofschedulingsuchservices.TheContractorshallimplementprocedures to
coordinate the services it provides to the Enrollee with the services the
EnrolleereceivesinFFS.
2.4.2.1.1 Adultdentalserviceswiththeexceptionofsurgicaldental
servicesandEmergencyDentalServices;
2.4.2.1.2 ServicestoindividualsinICF/IIDs;
2.4.2.1.3 Personalcareservicesforthoseagestwenty‐one(21)andolder;
2.4.2.1.4 Nursing facility services, with the exception of post‐acute
rehabilitativecareprovidedat the discretionoftheContractor
whenitiscosteffectivetodosoinplaceofcontinuedinpatient
careasanapprovedinlieuofservice;
2.4.2.1.5 Individualized Education Plan (IEP) services, including physical
therapy, occupational therapy, speech/language therapy,
audiologyandsomepsychologicaltherapy,providedbyaschool
district and billed through the intermediate school district, or
school‐basedservicesfundedwithcertifiedpublicexpenditures
(theseservicesarenotprovidedbyOPHcertifiedschool‐based
healthclinics);
2.4.2.1.6 Allhome&community‐basedWaiverservices;
2.4.2.1.7 Targetedcasemanagementservices;
2.4.2.1.8 ServicesprovidedthroughLDH’sEarlyStepsProgram;and
2.4.2.1.9 Thefollowingexcludeddrugs:
2.4.2.1.9.1 Select agents when used for symptomatic
relief of cough and colds, not including
prescription antihistamine and
antihistamine/decongestant combination
products;
2.4.2.1.9.2 Selectagentswhenusedforanorexia,weight
loss,orweightgain,notincludingorlistat;
2.4.2.1.9.3 Selectagentswhenusedtopromotefertility,
notincludingvaginalprogesteronewhenused
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forhigh‐riskpregnancytopreventpremature
births;
2.4.2.1.9.4 Drug Efficacy Study Implementation (DESI)
drugs;and
2.4.2.1.9.5 Select nonprescription drugs, not including
OTC antihistamines,
antihistamine/decongestant combinations,or
polyethyleneglycol.
2.4.3 ProhibitedServices
ThefollowingservicesarenotMedicaidCoveredServicesandshallnotbeprovidedto
EnrolleesunderthisContract:
2.4.3.1 Electiveabortions(thosenotcoveredinAttachmentC,MCOCoveredServices
andtheMCOManual)andrelatedservices;
2.4.3.2 Experimental/investigational drugs, procedures or equipment, unless
approvedbytheSecretaryofLDHinwriting;
2.4.3.3 Electivecosmeticsurgery;and
2.4.3.4 Assistedreproductivetechnologyfortreatmentofinfertility.
2.4.4 InLieuofServices
2.4.4.1 TheContractormay,atitsoption,coverservicesorsettingsforEnrolleesthat
areinlieuofMCOCoveredServicesifthefollowingconditions are met, as
requiredin42C.F.R.§438.3(e)(2)(i)‐(iii):
2.4.4.1.1 LDH determines that the alternative service or setting is a
medically appropriate and cost effective substitute for the
coveredserviceorsettingundertheStatePlan;
2.4.4.1.2 TheEnrolleeisnotrequiredbytheContractortousethe
alternativeserviceorsetting;and
2.4.4.1.3 Theapprovedinlieuofservicesareauthorizedandidentifiedin
AttachmentD,ActuarialRateCertificationLetter.
2.4.4.2 Theutilizationand actualcost ofinlieuof services istaken intoaccountin
developingthecomponentoftheCapitationRatesthatrepresentstheMCO
CoveredServices,unlessastatuteorregulationexplicitlyrequiresotherwise.
2.4.4.3 The Contractor shall submit all in lieu of services for LDH approval in
accordancewiththeMCOManual.
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2.4.4.4 TheContractorshallhaveaplanforidentifyingandreportingtheutilizationof
inlieuofservicestoLDHinaccordancewiththeMCOManual.Theplanshall
besubmittedtoLDHoritsdesigneeduringReadinessReviewanduponany
subsequentLDHapprovalofadditionalinlieuofservices.
2.4.5 Value‐AddedBenefits
2.4.5.1 As permitted under 42 C.F.R. §438.3(e)(1), the Contractor may offer value‐
addedbenefits(VAB)whicharenotMedicaidCoveredServicesorprohibited
services.Value‐addedbenefitsareprovidedattheContractor’sexpense,are
not included in the Capitation Rate, and shall be identified as value‐added
benefitsinencounterdatainaccordancewiththeMCOManualandtheMCO
SystemCompanionGuide.
2.4.5.2 Ataminimum,theContractorshalloffertheVAB(s)proposedinitsresponse
totheRFPandagreeduponbyLDH,consistentwiththisSection.Additional
VABsmaybeoffered,attheContractor’soption.AllVABsshallbereportedin
accordancewiththeMCOManualandtheMCOSystemCompanionGuide.
2.4.5.3 AttheContractor’sdiscretion,itmayprovideorassistEnrollees with
transportationtoaccessaVAB.EncountersfortransportationrelatedtoVAB
shallbeidentifiedassuch.
2.4.5.4 TheContractormayproposetoaddtoorexpandupontheVAB(s)proposedin
theContractor’sRFPresponseaspre‐approvedinwritingbyLDH.Deletionsor
reductionsto theVAB(s) may beproposedonan annual basis and shall be
submitted to LDH for approval at least six (6) months in advance of the
effectivedateofEnrollmentresultingfromtheEnrollmentperiod.
2.4.5.5 Annually,forthe VAB(s)proposed inthe Contractor’sRFP response,and as
amended,theContractorshall:
2.4.5.5.1 IndicatethePMPMactuarialvalueoftheVAB(s),individuallyand
inaggregate,basedonEnrollmentprojectionsforthe
Contractor’s plan, accompanied by a statement from the
preparing/consultingactuarywhoisamemberoftheAmerican
AcademyofActuariescertifyingtheaccuracyoftheinformation;
and
2.4.5.5.2 IncludeastatementofcommitmenttoprovidetheVAB(s)forthe
year.
2.4.5.6 TheContractorshallbedirectedbyLDHinwritingtoreviseitsproposedPMPM
based on any feedback from LDH, following an independent reviewofany
statementsofactuarialvalueprovidedbytheContractor.
2.4.5.7 The proposed monetary value of the VAB(s) shall be considered a
binding
Contractdeliverable. Ifforany reason,including, butnot limitedto,lackof
Enrollee participation, the aggregated annual PMPM proposed is not
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expendedbytheContractor,LDHreservestherighttorequiretheContractor
to provide an alternate benefit of equal value and/or may conduct a
reconciliationfortheamountunexpended.
2.4.5.8 VABsarenotsubjecttoAppealandStateFairHearingrights.Adenialofthese
benefits shall not be considered an Adverse Benefit Determination for
purposesofEnrolleeGrievancesandAppeals.TheContractorshallsendthe
EnrolleeanotificationletterifaVABisnotapproved.
2.4.6 MoralorReligiousObjections
2.4.6.1 IftheContractorelectsnottoprovide,reimbursefor,orprovidecoverageof,
acounselingorreferralservicebecauseofanobjectiononmoralorreligious
grounds,theContractormustfurnishinformation abouttheservicesthatit
doesnotcover,inaccordancewith42U.S.C.§1396u‐2(b)(3)(B)and42C.F.R.
§438.102(b)(1),bynotifying:
2.4.6.1.1 LDHwithitsProposal,orwheneveritadoptsthepolicyduringthe
termoftheContract;
2.4.6.1.2 Potential Enrollees before and during Enrollment with the
Contractor;
2.4.6.1.3 Enrolleesatleastthirty(30)CalendarDayspriortotheeffective
dateofthepolicywithrespecttoanyparticularservice;and
2.4.6.1.4 EnrolleesthroughtheinclusionoftheinformationintheMember
Handbook.
2.4.6.2 IftheContractorelectsnottoprovide,reimbursefor,orprovidecoverageof
anMCOcoveredservicedescribedinthissectionbecauseofanobjectionon
moralorreligiousgrounds,theContractor’smonthlyCapitationPaymentwill
beadjustedaccordingly.
PopulationHealthandSocialDeterminantsofHealth
TheContractorshallparticipateinandsupportLDH’seffortstoadvancepopulationhealth.
2.5.1 TheContractorshalldevelopaPopulationHealthStrategicPlanalignedwiththeLouisiana
MedicaidManagedCareQualityStrategyandsubmitittoLDHorits designee during
ReadinessReviewandannuallythereafter.Thepopulationhealthstrategyshallinclude:
2.5.1.1 PreventionandwellnessprogramsavailabletoallEnrollees;
2.5.1.2 Preventionandwellnessprogramstargetedtothefollowingspecificissues:
2.5.1.2.1 Reductionofkeycommunicablediseases:HIV,HCV,andsexually
transmittedinfections;
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2.5.1.2.2 Maternalmortalityandmorbidity;
2.5.1.2.3 Substanceusedisorderssuchasopioidusedisorder;
2.5.1.2.4 Mentalhealthconditionssuchasdepressionandanxiety;
2.5.1.2.5 Diabetesmellitus;
2.5.1.2.6 Hypertension;
2.5.1.2.7 Cardiovasculardisease;
2.5.1.2.8 Tobaccocessation;and
2.5.1.2.9 Early childhood health and development, including Adverse
ChildhoodExperiences(ACEs);
2.5.1.3 Plantoaddressprioritysocialdeterminantsofhealth(SDOH),whichinclude
housing,foodinsecurity,physicalsafety,andtransportation;
2.5.1.4 Plan for identification of Enrollees that could benefit from prevention and
wellnessprogramsthroughseveralmechanisms,whichshallinclude,butnot
belimitedto:
2.5.1.4.1 HealthNeedsAssessments;
2.5.1.4.2 Claimsanalysisandriskscoring;
2.5.1.4.3 Providerreferral;and,
2.5.1.4.4 Enrolleeself‐referral.
2.5.1.5 Initiatives to increase Enrollee and Network Provider awarenessof
Contractor’spopulationhealthprograms;
2.5.1.6 Collaborationwithcommunity‐basedorganizationstofacilitatetheprovision
ofservicestoEnrollees;
2.5.1.7 ReferraltoOfficeofPublicHealthprogramsasappropriateincluding,butnot
limited to, the following: Women, Infants, and Children (WIC), Maternal,
Infant,Early ChildhoodHome Visitingfamilycoachingandsupportservices,
theLouisianaEarlyHearingDetectionandInterventionProgram,anddisease
intervention specialists to support partner notification for STD/HIV, viral
hepatitis,andsyphilis;
2.5.1.8 ReferraltoOCDDWaiverservices,EarlyStepsandservicesundertheOfficeof
BehavioralHealth;
2.5.1.9 Description of how the care management program will serve to advance
populationhealthgoals;and
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2.5.1.10 DescriptionofhowtheHealthEquityPlanasdescribedintheHealthEquity
sectionisincorporatedintothepopulationhealthstrategy.
2.5.2 TheContractorshallprovideanannualreporttoLDH,andasrequestedbyLDH,onits
PopulationHealthStrategicPlanimplementation.
2.5.3 CollaborativeWorkonPopulationHealthInitiatives
2.5.3.1 AsrequestedbyLDH,theContractorshallparticipateininitiatives,whichmay
requirecollaborationamongMCOs,todevelop,implementwithinanagreed
upon timeframe, and continually improve reports. Contractorshall support
practiceactivitiesto improvepopulationhealth through case management,
including, but not limited to, creating and maintaining actionable lists of
Enrolleesassignedtopracticesthatidentifythetargetedpatientpopulations
withidentified gapsincareand Enrollees assignedtothe practicewhoare
eithernotreceivingservicesorarereceivingservicesfromdifferentproviders.
2.5.3.2 AsrequestedbyLDH,theContractorshallparticipateininitiatives,whichmay
require collaboration among MCOs, to develop a core set of SDOH,
community‐basedsupportserviceprovision,utilization,andhealthoutcomes
that providers shall submit for inclusion in performance measure reports,
includingagreementonhowthedatamustbesubmittedbyprovidersinorder
tominimizeadministrativeburden.
HealthEquity
TheContractormustparticipatein,andsupport,LDH'seffortstoreducehealthdisparities,address
socialriskfactors,andachievehealthequity.TheContractormustengageavarietyofEnrolleesand
populations to develop and implement a Health Equity Plan designed to address the cultural,
socioeconomic, racial, and regionaldisparitiesinhealthcarethatexistamongtheContractor’s
EnrolleesandcommunitieswithintheState.TheHealthEquityPlanshallbedevelopedinalignment
with the Contractor’s Population Health Strategic Plan, the Louisiana Medicaid Managed Care
QualityStrategy,andtheLDHHealthEquityPlan.
2.6.1 TheContractor’sHealthEquityPlanshallbecomposedofthreemainsections,asfollows:
2.6.1.1 NarrativeoftheHealthEquityPlandevelopmentprocess,including
meaningfulcommunityengagement;
2.6.1.2 Action plan consisting of focus areas, goals within each focus area, specific
measurableobjectiveswithineachgoalthatdefinemetricsandtimelinesthat
indicatesuccess,andmechanismstoclosethereferrallooptoactonidentified
social risk factors. Overall strategies and specific activities to achieve each
measurableobjectivemustinclude,butarenotlimitedto:
2.6.1.2.1 Ensuringthedeliveryofservicesinaculturallyappropriateand
effectivemannertoallEnrolleesbypromotingculturalhumility
atalllevelsoftheContractor’sorganizationandwithNetwork
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Providers,includingpromotingawarenessofimplicitbiasesand
howtheyimpactpolicyandprocesses;
2.6.1.2.2 Engaging diverse families when designing services and
interventions that integrate care and address childhood
adversityandtrauma;
2.6.1.2.3 Obtaining ongoing input from Enrollees who have disparate
outcomestoincorporatetheperspectiveoftheEnrollee;
2.6.1.2.4 Ensuring that each functional area with outward facing
communications tests potential publications with Enrollees for
understandingandconveyanceoftheintendedmessage,aswell
asculturalappropriateness;
2.6.1.2.5 Partnering with community‐based organizations to address
SDOH‐relatedneeds,includingensuringtheactivereferraltoand
follow‐uponidentifiedneedsrelatedtoSDOHby:
2.6.1.2.5.1 Providing validated up‐to‐date community
resourcelistsforEnrolleeandprovideruse;
2.6.1.2.5.2 Sharing health needs assessments and other
sources identifying SDOH needs, subject to
state and federal privacy requirements, with
Network Providers and community health
workers;and
2.6.1.2.5.3 ReimbursingNetworkProvidersforscreening
for SDOH needs and submitting applicable
diagnosiscodes(“Zcodes”)onclaimsincluding
specific reimbursement amounts and
frequencies.
2.6.1.3 Plantoconductculturalresponsivenessandimplicitbiastrainingwithinthe
Contractor’sorganizationandamongNetworkProviders.
2.6.2 HealthEquityPlanTimeline
2.6.2.1 TheContractorshallsubmititsHealthEquityPlantoLDHoritsdesigneeas
partofReadinessReview.
2.6.2.2 TheContractorshallprovideupdatestoLDHonimplementationofitsHealth
EquityPlaninanannualreportofitsprogressonmeetingHealthEquityPlan
objectivesinthepriorcalendaryear.
2.6.3 TransparencyofMCOPerformanceonLDHIncentive‐basedMeasures:
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2.6.3.1 TheContractorshallensure thatdatacollection,datasystems,andanalysis
allow for the identification of disparities by Enrollee characteristics. As
directedbyLDH,theContractorshallstratifyandannuallyreportonquality
measures by race, ethnicity, language, geographic location (urban/rural
parish)and/orbydisabilityinaformatprovidedbyLDH.
2.6.3.2 LDH may publicly share these stratified results, including comparing
performance across MCOs, over time, and to state and other available
benchmarks.
2.6.4 MCOPerformanceWithholdLinkedtoHealthEquity
LDHmaydesignatecertainhealthequityrelatedtasksand/orbenchmarkstobelinkedto
aportionoftheMCOperformancewithholdconsistentwiththewithholdrequirements
inPart4oftheContract.
CareManagement
2.7.1 ComprehensiveCareManagementProgram
The Contractor shall offer a comprehensive care management program to support
Enrollees,regardlessofage,basedonanindividualizedassessmentofcareneeds.Ata
minimum,caremanagementshallincludeboththepopulationsandfunctionsdescribed
below.
2.7.2 HealthNeedsAssessment
2.7.2.1 TheContractorshallattempttoconductEnrolleeHealthNeedsAssessments
(HNA)aspartoftheEnrolleewelcomecalltoidentifyhealthandfunctional
needs of Enrollees, and to identify Enrollees who require short‐term care
coordination or Case Management for medical, behavioral or social needs.
When an Enrollee is a child, the HNA shall be completedby the Enrollee’s
parentorlegalguardian.
2.7.2.2 The Contractor shall develop, implement, and maintain procedures for
completing an initial HNA for each Enrollee, and shall make best efforts to
complete such screening within ninety (90)Calendar Days ofthe Enrollee’s
effectivedateofEnrollment[42C.F.R.§438.208(b)].IftheinitialHNAattempt
is unsuccessful, the Contractor shall attempt to conduct, and document its
efforts to conduct, the HNA on at least three (3) different occasions, at
differenttimesofthedayandondifferentdaysoftheweek.
2.7.2.3 TheContractorshallprovideHNAdatatotheEnrollee’sassignedPCP,andto
LDHasrequested.
2.7.2.4 TheContractor’sHNAshall:
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2.7.2.4.1 Utilize a common survey‐based instrument, which shall be
developedbyLDHasdescribedinPart3:StateResponsibilities;
2.7.2.4.2 BemadeavailabletoEnrolleesinmultipleformatsincludingweb‐
based,print,andtelephone;
2.7.2.4.3 BeconductedwiththeconsentoftheEnrollee;
2.7.2.4.4 IdentifyindividualsforreferraltoCaseManagement,withmore
in‐depthassessmenttooccuraspartofthePOC;
2.7.2.4.5 Screen for needs relevant to priority social determinants of
health as described in the Population Health and Social
DeterminantsofHealthsection;and
2.7.2.4.6 Includedisclosuresofhowinformationwillbeused.
2.7.3 EnrolleeswithSpecialHealthCareNeeds(SHCN)
2.7.3.1 The Contractor shall implement mechanisms to provide each Enrollee
identifiedashavingSHCNwithacomprehensiveassessmentconductedbya
qualifiedhealthcareprofessionaltoidentifyanyongoingspecialconditionsof
theEnrolleethatrequireacourseoftreatmentorregularcaremonitoring.
2.7.3.2 The Contractor shall complete this comprehensive assessment for at least
ninetypercent(90%)ofthoseEnrolleesthattheContractorisabletocontact
andarewillingtoengagewithinninety(90)CalendarDaysofbeingidentified
ashavingSHCN.
2.7.3.3 The Contractor shall offer Case Management to all Enrollees with SHCN
regardlessofinformationgatheredthroughthiscomprehensiveassessmentor
theHNA.
2.7.4 ReferraltoCaseManagement
2.7.4.1 TheContractorshallreceivereferralstoCaseManagementthroughtheHNA,
identificationofindividualswithSHCN,aswellasreferralsources,including,
butnotlimitedto:
2.7.4.1.1 Enrollee services and self‐referral (including Enrollee
Grievances);
2.7.4.1.2 Providers (including primary care, behavioral health and
specialistproviders);and
2.7.4.1.3 Statestaff,includingBHSF,OBH,OAAS,OCDD,OPH,andDCFS.
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2.7.4.2 TheContractorshallprovideguidelinesonhowandinwhatcircumstancesto
referEnrollees forpotentialengagementin CaseManagement in amanner
andformatthatisreadilyaccessibletoproviders.
2.7.4.3 TheContractorshallprovideguidelinestoEnrolleesintheMemberHandbook
onhowandinwhatcircumstancesEnrolleesmayengageinCase
Management.
2.7.4.4 TheContractorshall considerallreferredEnrolleesfor engagementinCase
Management.
2.7.5 TieredCaseManagementBasedonNeed
TheContractor shall implementatieredCase Management program thatprovidesfor
differing levels of Case Management based on an individual Enrollee’s needs. The
ContractorshallengageEnrollees,ortheirparentorlegalguardian,asappropriate,ina
level of Case Management commensurate with their risk score as identified through
predictive modeling, if applicable, combined with the care needs identified in the
Enrollee’sPlanofCare(POC)andHNA,asdescribedbelow.IfrequestedbytheEnrollee,
ortheEnrollee'sparentorlegalguardian,thefrequencyand/ormethodofengagement
may be increased, reduced, or substituted or declined. The Contractor shall retain
documentationofsuchrequests.WheretheEnrollee’sPCPorbehavioralhealthprovider
offers Case Management, the Contractor shall support the provider as the lead case
manageronthemulti‐disciplinarycareteam.
TheContractorshallmaintainthree(3)levelsofCaseManagementandTransitionalCase
Managementforindividualsastheymovebetweencaresettings.
2.7.5.1 IntensiveCaseManagementforHighRiskEnrollees(High)(Tier3)
EnrolleesengagedinintensiveCaseManagementareofthehighestneedand
requirethemostfocusedattentiontosupporttheirclinicalcareneedsandto
addressSDOH.APOCshallbecompletedinpersonwithinthirty(30)Calendar
Daysofidentificationandshallincludeassessmentofthehomeenvironment
andprioritySDOH(seePopulationHealthandSocialDeterminantsofHealth
section).CaseManagementmeetingsshalloccuratleastmonthly,inperson,
intheEnrollee’spreferredsetting,ormoreasrequiredwithintheEnrollee’s
POC,withmonthlyupdatestothePOCandformalinpersonre‐assessment
quarterly. Case Management may integrate community health worker
support.AttestationsofmonthlyupdatestothePOCandcommunicationof
POC to the Enrollee and the Enrollee’s primary care provider shall be
completed. Case managers serving Tier 3 Enrollees shall focus on
implementation of the Enrollee’s POC, preventing institutionalization and
otheradverse outcomes, andsupporting the Enrollee inmeeting hisor her
caregoals,includingself‐management.Behavioralhealthcasemanagersshall
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be the lead whenever there is an Enrollee with primarily behavioral health
needs.
2.7.5.2 CaseManagement(Medium)(Tier2)
EnrolleesengagedinthemediumlevelofCaseManagementaretypicallyof
risingriskandneedfocusedattentiontosupporttheirclinicalcareneedsand
to address SDOH.A POC shall be completed in person within thirty (30)
CalendarDaysofidentificationandincludeassessmentofthehome
environment and priority SDOH (see Population Health and Social
DeterminantsofHealthsection).CaseManagementmeetingsshalloccurat
least monthly, with quarterly updates to the POC and formal in‐person re‐
assessment quarterly. Case Management may integrate community health
worker support. Attestations of quarterly updates to the POC and
communication of POC to the Enrollee and the Enrollee’s primarycare
providershallbecompleted.CasemanagersservingTier2Enrolleesshallfocus
onimplementationoftheEnrollee’sPOC,preventinginstitutionalizationand
otheradverse outcomes, andsupporting the Enrollee inmeeting hisor her
caregoals,includingself‐management.Behavioralhealthcasemanagersshall
be the lead whenever there is an Enrollee with primarily behavioral health
needs.
2.7.5.3 CaseManagement(Low)(Tier1)
EnrolleesengagedinthislevelofCaseManagementareofthelowestlevelof
risk within the Case Management program and typically require support in
carecoordinationandinaddressingSDOH.APOCshallbecompletedinperson
withinninety(90)CalendarDaysofidentificationandincludeassessmentof
thehomeenvironmentandprioritySDOH(seePopulationHealthandSocial
DeterminantsofHealthsection).CaseManagementmeetingsshalloccurat
leastquarterly,ormore as required within the Enrollee’s POC,with annual
updatestothePOCandformalin‐personre‐assessmentannually.Attestations
ofannualupdatestothePOCandcommunicationofPOCtotheEnrolleeand
theEnrollee’sprimarycareprovidershallbecompleted.
2.7.5.4 TransitionalCaseManagement
TheContractorshallimplementprocedurestocoordinatetheservicesthatit
furnishes to the Enrollee between settings of care, including appropriate
discharge planning for short‐term and long‐term hospital and institutional
staysasrequiredby42C.F.R.§438.208(b)(2)(i).TheContractorshallprovide
TransitionalCaseManagementforEnrolleestosupporttransitionsbetween
institutional and community care settings, including, but not limited to,
transitions to/from inpatient hospitals, nursing facilities (not including
members of the DOJ Agreement Target Population), psychiatric residential
treatment facilities (PRTFs), therapeutic group homes (TGHs), ICF/IIDs,
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residentialsubstanceusedisordertreatmentsettings,andincarcerationand
transitionstopermanentsupportivehousing.
TransitionalCaseManagementshallinclude:
2.7.5.4.1 DevelopmentofatransitionPOCincoordinationwiththecare
setting, the Enrollee, and other key members of an Enrollee’s
multi‐disciplinaryteampriortothetransitionwhichisprovided
inwritingtotheEnrolleeupondischarge,includespostdischarge
care appointments and linkages as appropriate, medication
reconciliation, patient education and self‐management
strategies,andaddressesPriorAuthorizationneeds.TheEnrollee
shall be provided the case manager’s name and contact
informationpriortodischarge.
2.7.5.4.2 For Enrollees preparing for discharge from a PRTF, TGH, or
ICF/IID,aftercareservices shallbeinplacethirty(30)Calendar
Dayspriortodischarge.
2.7.5.4.3 EnsuringthatthesettingfromwhichtheEnrolleeistransitioning
is sharing information with the Enrollee’s PCP and behavioral
healthproviders regardingthetreatmentreceived andcontact
information.
2.7.5.4.4 FollowupwithEnrolleeswithinseven(7)CalendarDaysfollowing
discharge/transitiontoensurethatservicesarebeingprovided
as detailed within the Enrollee’s transition POC. The POC shall
identifycircumstancesinwhichthefollow‐upincludesaface‐to‐
facevisit.
2.7.5.4.5 Additionalfollow‐upasdetailedinthedischargeplan.
2.7.5.4.6 Coordination across the multi‐disciplinary team involved in
TransitionalCaseManagementforEnrollees.
2.7.5.4.7 For Enrollees identified as homeless at the time of care
transition, the care management team shall include a housing
specialist,asdescribedintheIndividualPlanofCaresubsection,
onthemulti‐disciplinarycareteam.Housingspecialistsshallalso
be used to ensure Enrollees transitioning from facility to
community are connected to appropriate housing resources,
including, but not limited to, referral of Potential Enrollees to
Contractor’s Permanent Supportive Housing liaison for
application to the Louisiana Permanent Supportive Housing
program.
2.7.6 Case Management for Individuals in DOJ Agreement Target Population (Case 3:18‐cv‐
00608,MiddleDistrictofLouisiana)
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The Contractor shall develop a specialized community Case Management program
consistentwiththeDOJAgreementandLDH‐issuedguidanceforthetargetpopulation
transitioningordivertedfromnursingfacilitylevelofcareusing subcontracted
community case managers who meet the qualifications establishedbyLDH.The
ContractorshallmakeareferraltoacommunityCaseManagementagencywithinone(1)
BusinessDayofreceiptofareferralfromLDH. TheContractorshallmaintainultimate
responsibilityforensuringtheCaseManagementneedsofthetargetpopulationaremet
bycommunity casemanagers and communitycasemanagers satisfactorily completing
requiredactivities.
2.7.7 IndependentEvaluationsforPASRRLevelII
2.7.7.1 TheContractorshallberesponsibleforconductingPASRRLevelIIevaluations
of Enrollees upon referral from LDH. PASRR Level II evaluationsmustbe
performedbyalicensedmentalhealthprofessional(LMHP).Referralsshallbe
basedupontheneedforanindependentevaluationtodeterminetheneed
fornursingfacilityservicesand/ortheneedforspecializedservicestoaddress
mentalhealthissuesbeforetheEnrolleeisinanursingfacility.Thisevaluation
doesnotincludeindividualswithadevelopmentaldisability(DD);thereisa
separatedeterminationprocessoutsideofthisContractforDDevaluations.
2.7.7.2 Inconductingtheevaluation,theContractorshallfollowthecriteriasetforth
in42C.F.R.Part483,SubpartCandshallutilizethePASRRLevelIIstandardized
evaluationformprovidedbyLDH.
2.7.7.3 The Contractor shall maintain appropriate levels of LMHP staff to assure
adequate local geographic coverage for in field face‐to‐face contact with
Enrolleesinneedofsuchevaluations.Thesestaffmustbeadministratively
separatefromstaffperformingutilizationreview.
2.7.7.4 Evaluators may use relevant evaluative data, obtained prior to initiation of
PASRR,ifthedataareconsideredvalidandaccurateandreflectthecurrent
functionalstatusoftheindividual.However,ifnecessarytosupplementand
verifythecurrencyandaccuracyofexistingdata,theevaluatorshallgather
additionalinformationnecessarytoassessproperplacementandtreatment.
2.7.7.5 Inordertocomplywithfederallymandatedtimelines,theContractor shall
submit the completed Level II evaluation report to OBH within four (4)
CalendarDaysofreceiptofthereferralfromOBH.
2.7.7.6 Level II evaluation recommendations shall focus on ensuring theleast
restrictivesettingappropriatewiththeappropriateservices.
2.7.7.7 WhenOBHdeterminesthatnursingfacilityservicesarenotappropriate,the
Contractor shall assist eligible Enrollees to obtain appropriate alternative
behavioralhealthservicesavailableunderthisContract.
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2.7.7.8 IfatanytimetheContractordiscoversthatanEnrolleeresidinginanursing
homewhohasanSMIhasnotreceivedaLevelIIdetermination,theContractor
shallnotifyOBH.
2.7.7.9 TheContractorshalltrackEnrolleesinanursingfacilitywhohavegonethrough
thePASRRprocess,thoseidentifiedwithSMIandthosereceivingspecialized
services,asper42C.F.R.§483.130.
2.7.7.10 TheContractorshalltrackandreportquarterlytoLDHthedeliveryofallPASRR
SBHS as defined and required under 42 C.F.R. §483.120 and the DOJ
Agreement.
2.7.7.11 TheContractorshallreporttoLDHindicatorsrelativetoindividualevaluations
onaquarterlybasiswithinformationavailablebyregion,typeofplacements,
results of recommendations, location of individuals and referral sources as
outlinedintheLDH‐issuedreportingtemplate.
2.7.8 IndividualPlanofCare
2.7.8.1 The Contractor shall develop a comprehensive individualized, person‐
centeredPOCforallEnrolleeswhoarefoundeligibleforCaseManagement.
WhenanEnrolleereceivesservicesfromtheContractoronlyforSBHS,thePOC
shallfocusoncoordinationandintegration,asappropriate.WhenanEnrollee
receivesservicesrequiringaPOCfromLDH,suchasHomeandCommunity
Based Waiver services or services through OPH, the Contractor shall
collaboratewithLDHoritsdesigneeindevelopingthePOC.
2.7.8.2 Development of the POC shall be a person‐centered process led by the
Enrolleeandtheircasemanagerwithsignificantinputfrommembersofthe
Enrollee’sinterdisciplinarycareteam.WhenanEnrolleereceivesSBHSandhas
treatment plans developed through their behavioral health providers, the
ContractorshallworkwiththeEnrollee’sbehavioralhealthprovidersinorder
to incorporate the treatment plans into the Enrollee’s overall POC and to
support the Enrollee and the provider in their efforts to implement the
treatmentplan.
2.7.8.3 ThePOCshallbebasedontheprinciplesofself‐determinationandrecovery,
andshallincludeallmedicallynecessaryservicesidentifiedbytheEnrollee’s
providersaswellasthecarecoordinationandothersupportstobeprovided
bytheContractor.
2.7.8.4 ThePOCshallbereviewedandreviseduponreassessmentoffunctionalneed.
ThePOCrevisionsshalloccuratleastatthefrequencyrequiredintheTiered
Case Management Based on Need section,orwhentheEnrollee’s
circumstancesorneedschangesignificantly,orattherequestoftheEnrollee,
theirparentorlegalguardian,oramemberofthemulti‐disciplinarycareteam.
2.7.9
Multi‐DisciplinaryCareTeam
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2.7.9.1 The Contractor shall identify a multi‐disciplinary care team toserveeach
EnrolleebasedonindividualneedforallEnrolleesinCaseManagementTiers
2and3andTransitionalCaseManagement.TheContractorshallassignlead
case managers based on an Enrollee’s priority care needs, as identified
through the POC. Where behavioral health is an Enrollee’s primary health
issue,thecasemanagershallbeabehavioralhealthcasemanager.Asneeded,
casemanagerswithexpertiseinphysicalorbehavioralhealthcarewillsupport
leadcasemanagerswheretherearesecondarydiagnoses.IftheEnrolleeis
undertheageofsix(6),theleadcasemanagershallhaveexpertiseinearly
childhoodmentalhealthoraccesstoaconsultantwithexpertiseininfantand
earlychildhoodmentalhealth.
2.7.9.2 Physicalandbehavioralhealthcasemanagersshallbeco‐locatedandbasedin
LouisianatoallowforintegrationofCaseManagementforEnrolleeswithboth
physical and behavioral health care needs. The Contractor may request
exceptionsinwritingtothisrequirementforindividualcasemanagers.
2.7.9.3 In addition to the case manager and the Enrollee and their family or
AuthorizedRepresentative,thecareteamshallincludemembersbasedonan
Enrollee’sspecificcareneedsandgoalsidentifiedinthePOC.Theteammay
change over time as the Enrollee’s care needs change. Potentialteam
membersshallinclude,butarenotlimitedto:
2.7.9.3.1 Primarycareprovider;
2.7.9.3.2 Behavioralhealthproviders;
2.7.9.3.3 Specialists;
2.7.9.3.4 Pharmacists;
2.7.9.3.5 Communityhealthworkers;
2.7.9.3.6 Homeandcommunitybasedserviceprovidersandmanagers;
2.7.9.3.7 Housingspecialists,iftheEnrolleeisidentifiedashomeless;and
2.7.9.3.8 Statestaff,includingtransitioncoordinators.
2.7.9.4 TeamsshallmeetatregularintervalsasidentifiedinthePOC,basedonthe
individual’s care needs. When possible, the team shall meet in person but
whennecessary,teammembersmayparticipateinmeetingsviatelephone.At
aminimum,multi‐disciplinarycareteamsshallmeetonamonthlybasisfor
EnrolleesinTier3CaseManagementandonaquarterlybasisforEnrolleesin
Tier2CaseManagement.
2.7.10 CaseManagementPoliciesandProcedures
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The Contractor shall develop, implement, and maintain criteria and protocols for
determiningwhichCaseManagementactivitiesmaybenefitanEnrollee.TheContractor
shallsubmitsuchcriteriaandprotocolstoLDHoritsdesigneeaspartofReadinessReview
and prior to any substantive revisions. Where the Contractor delegates Case
ManagementtoaNetworkProvider,theContractorshallhaveawrittenplaninplacefor
monitoring and oversight of performance under any such agreements, including
provisionsforassessingProvidercomplianceandcorrectiveactionsand/ortermination
asappropriate.
TheContractor shalldevelop,implement, and maintain procedures forproviding Case
Management.CaseManagementproceduresshall:
2.7.10.1 BesubjecttoapprovalbyLDHinwriting;
2.7.10.2 IncludeproceduresforcontactingEnrolleestocompletetheHNAand
comprehensive assessment, including number of contact attempts and
methodsofcontact;
2.7.10.3 IncludeproceduresforacquiringanddocumentingEnrollees’consent(orthe
Enrollee’sfamilyorAuthorizedRepresentative)toreceiveCaseManagement
and for the Contractor to share information about an Enrollee’scarewith
Enrollee’sproviderstopromotecoordinationandintegration;
2.7.10.4 Includeaplandescribinghowmanagementofbehavioralhealthservicesshall
beintegratedintotheoverallcaremanagementoftheEnrolleepopulation;
2.7.10.5 Include criteria and protocols for ensuring appropriate staffing ratios and
caseloads for case managers and other staff involved in care management
activitiesinlinewithindustrypractices;
2.7.10.6 IncludeprocessesfortheContractortomeasuretheeffectivenessandquality
of the Contractor’s Case Management procedures. Such processes shall
include:
2.7.10.6.1 TrackingoffrequencyandtypeofCaseManagementcontact;
2.7.10.6.2 Developingandimplementinginclusioncriteriafordifferenttiers
of Case Management, including how the HNA and
comprehensiveassessmentareutilized;
2.7.10.6.3 Determiningexpectedoutcomesinsubgroupsatdifferenttiers
of Case Management, including an impact analysis of Case
Management on the use of the ED, inpatient admissions, and
follow‐upcare;
2.7.10.6.4 Expected Case Management penetration and target rate of
engagement;
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2.7.10.6.5 Identificationofrelevantmeasurementprocessesoroutcomes;
and
2.7.10.6.6 Useofvalidquantitativemethodstomeasureoutcomesagainst
performancegoals;
2.7.10.7 Include protocols for providing Case Management activities in a variety of
settings,including,butnotlimitedtoanEnrollee’shome,shelter,orothercare
setting;
2.7.10.8 Includecriteriaandprotocolsregardingdocumentationoffollow‐throughwith
identificationandsuccessfullinkagetocommunityresources;
2.7.10.9 Include criteria and protocols for discharging Enrollees from Case
Management;
2.7.10.10 Ensure that the Case Management activities each Enrollee is receiving are
appropriatelydocumented;
2.7.10.11 EnsureregularcontactsbetweenCaseManagementstaff,theEnrollee’sPCP,
the Enrollee’s primary behavioral health provider as applicable, and the
Enrollee;and
2.7.10.12 IncludeaprocessforgraduationfromTiers2or3ofCaseManagementtoa
lower tier, as an Enrollee’s ongoing Case Management needs are reduced
basedontheEnrollee’sPOC.
2.7.11 ReferralsforTobaccoCessationandProblemGaming
2.7.11.1 The HNA shall screen for problem gaming and tobacco usage. The case
manager shall refer Enrollees who screen positive to appropriate Network
Providers offering tobacco cessation treatment and/or problem gaming
treatmentservices,includingtheLouisianaTobaccoQuitline.
2.7.11.2 Information regarding treatment servicesand/orreferraltocare shall be
entered into the Contractor’s systems for the purpose of tracking and
reportingaccordingtovariousdemographics.Tobaccocessationandproblem
gaming reports shall be made available upon LDH request in a format and
frequencyasdeterminedbyLDH.
2.7.12 Women,Infant,andChildren(WIC)ProgramReferral
TheContractorshallberesponsibleforensuringthatcoordinationexistsbetweentheWIC
Program and its Enrollees. Coordination shall include referral of potentially eligible
women,infantsandchildrenandreportingofappropriatemedicalinformationtotheWIC
Program.
2.7.13 OutreachProgramforPregnancyServices
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TheContractorshalldevelopanoutreachprogramtoencouragewomentoseekprenatal
services during the first trimester of pregnancy. This outreach program may utilize
communityandreligiousorganizationsandothercommunitygroupstodevelopoutreach
programsorreferralnetworks,aswellasincludeissuanceofbrochuresand/orperiodic
articlesemphasizingtheimportanceofsuchcaretoallEnrollees.
2.7.14 PermanentSupportiveHousing
2.7.14.1 The Contractor shall support the Permanent Supportive Housing program,
whichisapartnershipbetweenLDHandtheLouisianaHousingAuthority(LHA)
toprovidedeeplyaffordable,community‐integratedhousingpaired with
tenancysupportsthatassisthigh‐riskpersonswithdisabilitiestobesuccessful
tenantsandmaintainstablehousing.
2.7.14.2 ForthePSHProgram,theContractorshall:
2.7.14.2.1 Assist potentially eligible Enrollees in completing the PSH
Programapplication;
2.7.14.2.2 Withinone(1)BusinessDayofreceiptofarequestfrom
designatedLDHPSHProgramstaff,provideaccurateinformation
aboutcurrentandpastServiceAuthorizationsandencountersfor
an Enrollee, particularly for behavioral health services such as
Community Psychiatric Support and Treatment (CPST),
Psychosocial Rehabilitation (PSR), and Assertive Community
Treatment(ACT);
2.7.14.2.3 Ensure Timely Prior Authorization for PSH tenancy and pre‐
tenancysupportsasapplicable;
2.7.14.2.4 EnsurePSHtenancysupportsaredeliveredinaTimelyand
effectivemannerinaccordancewithanappropriatePOC;
2.7.14.2.5 RespondTimelytoserviceproblemsidentifiedbyPSHProgram
management,including,butnotlimitedto,thosethatplacean
Enrollee’s/tenant’shousingorPSHservicesatrisk;and
2.7.14.2.6 Work with PSH Program management to ensure an optimal
network of qualified service providers trained by the LDH PSH
Programstaffordesigneetoprovidetenancysupportsacross
disabilitygroupsandcertifiedtodeliverservicesasdefinedinthe
PSHProviderCertificationRequirements.
2.7.14.3 To ensure effective accomplishment of the responsibilities required in this
section,theContractorshall:
2.7.14.3.1 IdentifyaPSHProgramliaison,subjecttoapprovalbyLDH,to
work with LDH PSH Program staff to ensure effective
performance of contract responsibilities and requirements,
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effective implementation and delivery of PSH services, and to
addressproblemsorissuesthatmayarise;
2.7.14.3.2 AssistwithstatewidetargetedoutreachtoEnrollees/households
whocouldbenefitfromPSH,includingthoseEnrolleeswhoare
leastlikelytoapply.TheContractorshallensureparticipationof
Contractor staff appropriate and sufficient for effective
representation on LDH‐convened PSH outreach committee(s);
and
2.7.14.3.3 DevelopforapprovalbyLDHPSHProgramstaffwrittenpolicies
and procedures necessary to implement the PSH‐related
requirementsofthisContract.InitialversionsofPSHpoliciesand
proceduresshallbesubmittedtoLDHpriortoReadinessReview.
PSH Program staff will work with the Contractor to ensure
consistentpoliciesandproceduresacrossMCOs.
2.7.15 DelegatedCaseManagement
TheContractormaydevelopaprogramtodelegateCaseManagement services to
Providers,includingreimbursementforservicesrendered.Thepurposeofsuchaprogram
istoreimburseforCaseManagementservicesinsettingswhereEnrollees are already
accessing care and to avoid duplication with MCO Case Management services. If a
programisestablished,itshould:
2.7.15.1 Include PCPs, obstetrics and gynecology providers, and behavioral health
providers.
2.7.15.2 Establish minimum provider qualifications for each tier of delegated Case
Managementservices.
2.7.15.3 EstablishcriteriatodistinguishwhenanEnrolleeiseligiblefordelegatedCase
Management versus MCO Case Management. Wherever appropriate, the
ContractorshouldutilizedelegatedCaseManagementforeligibleEnrollees.
2.7.15.4 Establish monitoring and oversight procedures to ensure delegated Case
Management providers are adhering to applicable Case Management
requirementsdescribedinthisContract.
2.7.15.5 Establish a reimbursement rate for an initial assessment and POC
developmentaswellasamonthlyreimbursementrateforeachtierofCase
Managementservices.
2.7.15.6 BeavailabletoEnrolleesthatmeetcriteriaandprovidersthatmeetminimum
qualifications.
ContinuityofCare
2.8.1 ContinuityofCareandCareTransitions
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2.8.1.1 The Contractor shall develop and maintain effective continuity of care and
caretransitionactivitiestoensureacontinuumofcareapproachtoproviding
healthcareservicestoEnrollees.TheContractorshallestablishaprocessto
coordinatethedeliveryofMCOCoveredServicesforwhichitisresponsible
withservicesthatareprovidedthroughFFS,anotherLDHcontractor, or
providedbycommunityandsocialsupportprovidersasrequiredby42C.F.R.
§438.208(b)(2)(iv). The Contractor shall ensure appropriate provider choice
withintheContractor’sprovidernetworkandcoordinationwithout of
Network Providers, as needed for continuity of care. The Contractor shall
engageincontinuityofcareactivitiestoensurethatNetworkProvidersand
ContractorstaffarekeptinformedoftheEnrollees’treatmentneeds,changes,
progressorproblems.TheContractorshallprovidetoLDHoritsdesigneeits
activitiesandprocessesforcontinuityofcarethroughworkflowswithspecific
decisionpointsaspartofReadinessReview.
2.8.1.2 The Contractor’s continuity of care activities shall provide processes to
support effective interactions between Enrollees and providers, and to
identifyandaddressinteractionsthatarenoteffective.TheContractorshall
monitor service delivery through Enrollee surveys, medical and treatment
recordreviews,andexplanationofbenefits(EOBs)toidentifyandovercome
barrierstoprimaryandpreventivecarethatanEnrolleemayencounter.The
ContractorshallimplementaCorrectiveActionPlanwithitsprovidersonan
asneededbasisandasdeterminedbyLDH.
2.8.1.3 TheContractorshallberesponsibleforthecoordinationandcontinuityofcare
ofhealthcareservicesforallEnrolleesconsistentwith42C.F.R.§438.208.In
addition, the Contractor shall be responsible for coordinating with LDH,
includingtheOfficeforCitizenswithDevelopmentalDisabilitiesandtheOffice
ofAgingandAdultServices,toensureintegratedsupportacrossbehavioral
healthservicesandlong‐termsupportsandservices.
2.8.1.4 TheContractorshallimplementcontinuityofcarepoliciesandprocedures,as
approvedbyLDHinwriting,thatmeetorexceedthefollowingrequirements:
2.8.1.4.1 EnsurethateachEnrolleehasanongoingsource ofpreventive
andprimarycareappropriatetotheirneeds;
2.8.1.4.2 Ensure each Enrollee is provided with information on how to
contact the person designated to coordinate the services the
Enrolleeaccesses;
2.8.1.4.3 CoordinatecarebetweennetworkPCPsandspecialists,including
specializedbehavioralhealthproviders;
2.8.1.4.4 Coordinatecareforout‐of‐networkservices,includingspecialty
careservices;
2.8.1.4.5 Coordinate Contractor‐provided services with services the
Enrolleemayreceivefromotherhealthcareproviders;
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2.8.1.4.6 Uponwrittenrequest,sharewith LDH or other health care
entities serving an Enrollee with special health care needs the
resultsandidentificationandassessmentofthatEnrollee’sneeds
topreventduplicationofassessmentactivities;
2.8.1.4.7 Ensure that each provider furnishing services to the Enrollee
maintainsandsharestheEnrollee’shealthrecordinaccordance
withprofessionalstandards;
2.8.1.4.8 Document authorized referrals in its utilization management
system;
2.8.1.4.9 Provide active assistance to Enrollees receiving treatment for
chronic and acute medical conditions or behavioral health
conditionstotransitiontoanotherproviderwhentheircurrent
providerhasterminated participation withtheContractor.The
Contractorshallprovidecontinuationofsuchservicesforupto
ninety (90) Calendar Days or until the Enrollee is reasonably
transferredwithoutinterruptionofcare,whicheverisless;and
2.8.1.4.10 Coordinate with the court system and state child‐serving
agencies with regard to court‐ and agency‐involved youth, to
ensure that appropriate services can be accessed. This may
include,butisnotlimitedto,attendingcourtproceedingsatthe
writtenrequestofLDHwhenthereisaneedtoinformthecourt
ofavailableservicesandlimitations,andparticipatingincross‐
agencystaffing.
2.8.1.4.11 Continue the behavioral health therapeutic classes (including
long‐acting injectable antipsychotics) and other medication
assisted treatment (including buprenorphine/naloxone and
naloxoneproducts)prescribedtotheEnrolleeinamentalhealth
treatmentfacilityforatleastsixty(60)CalendarDaysafterthe
facility discharges the Enrollee, unless the Contractor’s
psychiatrist, in consultation and agreement with the facility's
prescribingphysician,determinesthatthemedicationsare:
2.8.1.4.11.1 Notmedicallynecessary;or
2.8.1.4.11.2 PotentiallyharmfultotheEnrollee.
2.8.2 ContinuityofCareandCareTransitionsforBehavioralHealth
2.8.2.1 ThePCPshallprovideBasicBehavioralHealthServicesandrefertheEnrollee(s)
totheappropriatehealthcarespecialistasdeemednecessaryforSBHS.
2.8.2.2 The Contractor shall establish policies and procedures to facilitate the
integration of physical and behavioral health and to provide for the
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appropriate continuity of care across programs. Principles that guide care
integrationareasfollows:
2.8.2.2.1 Mentalillnessandaddictionarehealthcareissuesandshallbe
integratedintoacomprehensivephysicalandbehavioralhealth
caresystemthatincludesprimarycaresettings;
2.8.2.2.2 Manypeoplesufferfrombothmentalillnessandaddiction.As
careisprovided,bothillnesses shallbeunderstood, identified,
andtreatedasprimaryconditions;
2.8.2.2.3 Thesystemofcareshallbeaccessibleandcomprehensive,and
shallfullyintegrateanarrayofpreventionandtreatmentservices
forallagegroups.Itshallbedesignedtobeevidence‐informed,
responsive to changing needs, and built on a foundation of
continuousqualityimprovement;and
2.8.2.2.4 Itisimportantthatrelevantclinicalinformationisaccessibleto
boththeprimarycareandbehavioralhealthprovidersconsistent
with Federal and State laws, regulations, rules, policies, and
otherapplicablestandardsofmedicalrecordconfidentialityand
theprotectionofpatientprivacy.
2.8.2.3 Thesepoliciesandproceduresshallincludethefollowing:
2.8.2.3.1 Mechanisms for collaborating with OJJ, DCFS, and DOE to
coordinatethedischargeandtransitionofchildrenandyouthin
out‐of‐home placement for the continuance of prescribed
medicationandotherbehavioralhealthservicespriortoreentry
intothecommunity,includingthereferraltonecessaryproviders
oraWAAifindicated;
2.8.2.3.2 MechanismsforcollaboratingwithnursingfacilitiesandICF/IIDs
tocoordinateaftercareplanningpriortodischargeandtransition
ofEnrolleesforthecontinuanceofbehavioralhealthservicesand
medication prior to reentry into the community, including
referraltocommunityproviders;
2.8.2.3.3 Mechanismstorequirecollaborationfromhospitals,residential
facilities,andinpatientfacilitiestocoordinateaftercareplanning
priortodischargeandtransitionofEnrolleesforthecontinuance
ofbehavioralhealthservicesandmedicationpriortoreentryinto
thecommunity, including referral to community providers and
after‐careappointments;and
2.8.2.3.4 MechanismsforcollaboratingwiththeDepartmentof
Corrections and local criminal justice systems in Louisiana to
facilitateaccesstoand/orcontinuationofprescribedmedication
and other behavioral health services for Enrollees, including
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referral to community providers, prior to reentry into the
community including, but not limited to, Enrollees in the
LouisianaMedicaidProgrampre‐releaseprogram.
2.8.2.4 InanyinstancewhentheEnrolleepresentstotheNetworkProvider,including
callingtheContractor’stoll‐freenumberlistedontheMCOMemberIDCard,
and an Enrollee is in need of emergency behavioral health services, the
ContractorshallinstructtheEnrolleetoseekhelpfromthenearestemergency
medical provider. The Contractor shall initiate follow‐up with the Enrollee
within forty‐eight (48) hours for follow‐up to establish that appropriate
serviceswereaccessed.
2.8.2.5 The Contractor shall comply with all post‐stabilization care service
requirementsfoundat42C.F.R.§438.114.
2.8.2.6 TheContractorshallincludedocumentationintheEnrollee’smedicalrecord
thatattemptsaremadetoengagetheEnrollee’scooperationandpermission
to coordinate the Enrollee’s POC with the Enrollee’s behavioral health and
primarycareprovider.
2.8.2.7 TheContractorshallprovideproceduresandcriteriaformakingreferralsand
coordinating care with behavioral health and primary care providers and
agenciesthatwillpromotecontinuityofcare.
2.8.2.8 These procedures shall address Enrollees with co‐occurring medical and
behavioralconditions,includingchildrenwithspecialhealthcareneeds,who
may require services from multiple providers, facilities and agencies and
requirecomplexcoordinationofbenefitsandservices.
2.8.2.9 The Contractor shall provide orarrange for training ofproviders and other
individuals involved in care management activities on identification and
screeningofbehavioralhealthconditionsandreferralprocedures.
2.8.3 TransitioningBetweenMCOsorFFS
2.8.3.1 The Contractor shall provide additional active assistance to Enrollees when
transitioning between MCOs or FFS in accordance with a written policy,
incorporatingtherequirementslistedbelow,thatensurescontinuedaccessto
servicesduringthetransition.
2.8.3.2 ThereceivingMCOshallberesponsibleforactivitiesthatinclude,butarenot
limitedto:
2.8.3.2.1 EnsuringtheEnrolleehasaccesstoservicesconsistentwiththe
access they previously had, and is permitted to retain their
currentproviderforaspecifiedperiodoftimeifthatprovideris
notintheContractor’snetwork;
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2.8.3.2.2 CoordinatingcarewiththerelinquishingMCOsoservicesarenot
interrupted;
2.8.3.2.3 Arranging for continuity of necessary care such as by making
referralstoappropriateprovidersofservicesthatareinnetwork;
2.8.3.2.4 AdheringtotheServiceAuthorizationrequirementsasdescribed
undertheServiceAuthorizationRequirementsforNewEnrollees
section;
2.8.3.2.5 Ifnecessary,initiationoftherequestoftransferfortheEnrollee’s
healthrecordtothereceivingMCOandthenewPCP.Thecostof
reproducing and forwardingthe health record to the receiving
MCOshallbetheresponsibilityoftherelinquishingMCO;and
2.8.3.2.6 AnyothernecessaryproceduresasspecifiedbyLDHinwritingto
ensurecontinuedaccesstoservicestopreventseriousdetriment
totheEnrollee's healthorreducethe riskofhospitalization or
institutionalization.
2.8.3.3 TherelinquishingMCOshallberesponsibleforactivitiesthatinclude,butare
notlimitedto:
2.8.3.3.1 Ensuring Timely notification to the receiving MCO regarding
pertinent information related to any health needs of
transitioningEnrollees.
2.8.3.3.2 FullyandTimelycomplyingwithrequestsforhistoricalutilization
data from the receiving MCO in compliance with Federal and
Statelaws,regulations,rules,policies,procedures,andmanuals.
2.8.3.3.3 Consistent with Federal and State laws, regulations, rules,
policies,procedures, and manuals, allowing the Enrollee'snew
provider(s) to obtain copies of the Enrollee's health record, as
appropriate.
2.8.3.3.4 AnyothernecessaryproceduresasspecifiedbyLDHinwritingto
ensurecontinuedaccesstoservicestopreventseriousdetriment
totheEnrollee's healthorreducethe riskofhospitalization or
institutionalization.
2.8.3.4 IfanEnrollee isto betransferred betweenMCOsbut ishospitalizedatthe
time, the transfer shall be effective on the date of Enrollmentintothe
receiving MCO. However, the relinquishing MCO is responsible for the
Enrollee’shospitalizationuntiltheEnrolleeisdischarged.ThereceivingMCO
isresponsibleforallothercare.
2.8.3.4.1 IntheeventthattherelinquishingMCO’scontractisterminated
priortotheEnrollee’sdischarge,responsibilityfortheremainder
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ofthehospitalizationchargesshallreverttothereceivingMCO,
effective at 12:01 a.m. on the Calendar Day after the
relinquishingMCO’scontractends.LDHwillidentifyandaddress
anyexceptionstothisprovisionintheMCOManual.
2.8.3.5 Specialconsiderationshallbegivento,butnotlimitedto,thefollowing:
2.8.3.5.1 Enrollees with significant conditions or treatments such as
enteralfeedings, oxygen,wound care,and ventilators,medical
supplies, transportation on a scheduled basis, chemotherapy
and/orradiationtherapyorwhoarehospitalizedatthetimeof
transition;
2.8.3.5.2 EnrolleeswhohavereceivedPriorAuthorizationforservicessuch
asscheduledsurgeries,post‐surgicalfollowupvisits,therapiesto
beprovidedaftertransitionorout‐of‐areaspecialtyservices;
2.8.3.5.3 Enrolleeswhohaveconditionsrequiringongoingmonitoringor
screening such as elevated blood lead levels or Enrollees who
werebornprematurely;and
2.8.3.6 Enrolleeswithsignificantmedicalconditionssuchasahigh‐riskpregnancyor
pregnancy within the last thirty (30) Calendar Days, the need fororganor
tissuetransplantation,orchronicillnessresultinginhospitalization.
ProviderNetwork,Contracts,andRelatedResponsibilities
2.9.1 GeneralProviderNetworkRequirements
2.9.1.1 The Contractor shall provide or ensure the provision of all MCO Covered
ServicesspecifiedinthisContractthroughthedevelopmentandmaintenance
of an adequate provider network. Availability and accessibilityofMCO
CoveredServicesshallbeinaccordancewiththeNetworkAdequacystandards
setforthintheapplicablefederalregulationsandthisContract,including,but
not limited to, requirements set forth in Attachment F, Provider Network
Standards.
2.9.1.2 The Contractor shall give assurances to LDH and provide supporting
documentation that demonstrates that it has the capacity to serve the
expectedEnrollmentinaccordancewithLDH’sstandardsforaccesstocare,
includingthestandardsat42C.F.R.§438.68and§438.206andtheaccessto
carestandardsinAttachmentF,ProviderNetworkStandards,duringReadiness
Review,onanannualbasis,andatanytimetherehasbeenaMaterialChange
intheContractor’soperationsthatwouldaffecttheadequacyofcapacityand
services.TheContractor’ssupportingdocumentationshallbeincompliance
withtheMCOManualanddemonstratethatit:
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2.9.1.2.1 Offers an appropriate range of preventive, primary care, and
specialtyservices,includingbehavioralhealthspecialtyservices,
thatisadequatefortheanticipatednumberofEnrollees;and
2.9.1.2.2 Maintains a network of providers that is sufficient in number,
mix, and geographic distribution to meet the needs of the
anticipatednumberofEnrollees.
2.9.1.3 To demonstrate accessibility and availability of MCO Covered Services, the
Contractorshallcomplywithallapplicablereportingrequirements.Achieving
these minimum requirements shall not release the Contractor from the
requirementtoprovideorarrangefortheprovisionofanymedicallynecessary
MCOcoveredservicerequiredbyitsEnrollees,takingintoaccounttheurgency
oftheneedforservices.
2.9.1.4 In assessing network adequacy and compliance with this Contract, the
Contractor shall identify, take into consideration, and separately report on
providerspecialistswithlimitedNetworkProviderAgreements,suchassingle
caseagreements,inaformatspecifiedbyLDH.
2.9.2 AvailabilityandFurnishingofMCOCoveredServices
2.9.2.1 TheContractorshallmaintainandmonitoranetworkofappropriateproviders
thatissufficienttoprovideadequateaccesstoallservicescoveredunderthis
Contract for all Enrollees, including those with limited English proficiency,
physical,cognitive,orbehavioralhealthdisabilities.[42C.F.R.§438.206(b)(1)]
For the purposes of determining network adequacy, the Contractor shall
consideronlythoseproviderswhomeetthefollowingcriteria:
2.9.2.1.1 Physicalhealth providers whohave submitted at leasttwenty‐
five(25)claimsinanofficesettingwithinthepriorsix(6)calendar
months;
2.9.2.1.2 Behavioralhealthproviderswhohavesubmittedatleasttwenty‐
five(25)claimswithinthepriorsix(6)calendarmonths;or
2.9.2.1.3 Any providers who were credentialed within the prior six (6)
calendarmonths,regardlessofclaimsubmissions.
2.9.2.2 TheContractorshallensurethatNetworkProvidersprovidephysicalaccess,
reasonable accommodations, and accessible equipment for Enrollees with
physical,cognitive,orbehavioralhealthdisabilities[42C.F.R.§438.206(c)(3)].
2.9.2.3 Ifthe Contractorisunable to provide thenecessary services toanEnrollee
withintheirnetwork,theContractorshalladequatelyandTimelycoverthese
servicesoutofnetworkfortheEnrolleeforaslongastheContractor’sprovider
network is unable to provide the services. The Contractor shall ensure
coordination with respect to authorization and payment issues in these
circumstances to ensure that the cost to the Enrollee is no greater than it
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would be if the services were furnished within the network [42 C.F.R.
§438.206(b)(4)and(5)].
2.9.2.4 TheContractorshallensureparityindeterminingaccesstoout‐of‐Network
Providers for mental health or substance use disorder benefits that are
comparable to, and applied no more stringently than, the processes,
strategies, evidentiary standards, or other factors in determining access to
out‐of‐NetworkProvidersformedical/surgicalbenefitsinaccordancewith42
C.F.R.§438.910(d)(3).
2.9.3 TimelyAccesstoCare
2.9.3.1 The Contractor shall meet and require its Network Providers to meet LDH
standardsforTimelyaccesstocareandservicesasspecifiedinthisContract,
taking into account the urgency of the need for services [42 C.F.R.
§438.206(c)(1)(i)].
2.9.3.2 The Contractor shall ensure that the Network Providers offer hours of
operationtoitsEnrolleesthatarenolessthanthehoursofoperationoffered
to commercial Enrollees or comparable to FFS, if the provider serves only
Enrollees [42 C.F.R. §438.206(c)(1)(ii)]. The Contractor shall regularly
disseminate appointment standards and procedures to its providers and
EnrolleesandincludethisinformationontheContractor’sproviderwebsite.
The Contractor must include the applicable appointment accessibility
standards from Attachment F, Provider Network Standards,initsNetwork
ProviderAgreements,eitherdirectlyorthroughreferencetotheContractor’s
ProviderManual.
2.9.3.3 TheContractorshallmakeservicesincludedintheContractavailabletwenty‐
four(24)hoursaday,seven(7)daysaweek,whenmedicallynecessary[42
C.F.R.§438.206(c)(1)(iii)].
2.9.3.4 The Contractor shall educate providers on the appointment accessibility
standards of this Contract, evaluate provider compliance with these
standards, and ensure that appointments with qualified providers are
availabletoEnrolleesonaTimelybasis.
2.9.3.5 TheContractorshallestablishmechanismstoensurecompliancewithaccess
requirements by Network Providers and shall monitor Network Providers
regularlytodeterminecomplianceandshalltakecorrectiveactionifthereisa
failuretocomplybyaNetworkProvider[42C.F.R.§438.206(c)(1)].
2.9.3.6 IftheContractororLDHidentifiesoranticipatesthatthenetworkwillnotbe
sufficienttomeetthetimelyaccesstocarestandardsofthisContractforan
MCOCoveredServiceinanylocationorforanypopulationofEnrollees,the
Contractorshallenhanceitsprovidernetworkinordertomeetsuchstandards.
TheContractorshouldnotifyLDHofitsstrategyforenhancingitsnetworkand
itscontingencyplanforconnectingimpactedEnrolleestocare.
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2.9.4 Out‐of‐NetworkProtocols
2.9.4.1 TheContractorshallmaintainandutilizeprotocolstoaddresssituationswhen
theprovidernetworkisunabletoprovideanEnrolleewithappropriateaccess
toMCOCoveredServicesasdefinedinthisContractandtheMCOManual.
TheContractor’sprotocolsshallensure,ataminimum,thefollowing:
2.9.4.1.1 IftheContractorisunabletoprovideaparticularMCOcovered
servicethroughaNetworkProvider,itwillbeadequatelycovered
inaTimelymannerout‐of‐network;
2.9.4.1.2 That the particular service will be provided by a qualified and
clinicallyappropriateprovider;
2.9.4.1.3 Thattheprovidershallbelocatedwithintheshortesttraveltime
oftheEnrollee’sresidence,takingintoaccounttheavailabilityof
publictransportationtothelocation;
2.9.4.1.4 That the provider is licensed by the state of Louisiana or, if
locatedinanotherstate,theproviderislicensedbythatstate;
and
2.9.4.1.5 ThattheproviderislicensedandaccreditedbyanLDHapproved
accreditingorganization,ifrequiredbyLouisianastateorfederal
requirements.
2.9.5 RequestsforExceptionstoAccessRequirements
2.9.5.1 The Contractor shall ensure PCP, OB/GYN, hospital, pharmacy, behavioral
health,andotherservicesidentifiedintheContractandtheMCOManualare
available from Network Providers within the specified distance from the
Enrollee’shome.Exceptions,ifany,tothesedistancestandardsshallbeatthe
discretion of LDH and only considered based on the prevailing community
standard.
2.9.5.2 The Contractor must submit any requests for exceptions for distance or
appointment accessibility standards in writing to LDH for approval. Such
requestsmustbeinaformatspecifiedbyLDHandincludedataonthelocal
providerpopulationavailabletothenon‐Medicaidpopulation.
2.9.5.3 If LDH grants the Contractor an exception to a distance or appointment
accessibilitystandard:
2.9.5.3.1 Theexceptionislimitedtotheidentifiedprovidertypeandparish
orparishesandisgrantedforaperiodofuptoone(1)year,at
whichpointtheContractormaysubmitanewrequest.
2.9.5.3.2 The Contractor shall monitor Enrollee access to the specific
provider type on an ongoing basis and provide the findings to
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LDHaspartofitsNetworkDevelopmentandManagementPlan.
Specifically,theContractorshall:
2.9.5.3.2.1 DescribehowitshallreasonablydeliverMCO
Covered Services to Enrollees who may be
affectedbytheexceptionandhowitwillwork
toincreaseaccesstotheprovidertypeinthe
designatedparishorparishes;and
2.9.5.3.2.2 Monitor, track, and report to LDH on the
deliveryofMCOCoveredServicestoEnrollees
potentiallyaffectedbytheexception.
2.9.5.4 As permitted by Federal and State laws, regulations, rules, policies,
procedures, and manuals, the State Plan, and applicable Waivers,
telemedicinemaybeusedtofacilitateaccesstoMCOCoveredServices by
licensedprofessionals.AnyMCOCoveredServiceprovidedviatelemedicine
mustbemedicallynecessary,andtheprocedureindividualized,specific,and
consistentwithsymptomsorconfirmeddiagnosisofanillnessorinjuryunder
treatment,andnotinexcessoftheEnrollee’sneeds.IftheContractorintends
toutilizetelemedicinetomeetnetworkadequacyrequirements,the
Contractor’stelemedicineutilizationmustbeapprovedbyLDHinwritingfor
thispurpose.TheContractormaynotutilizenationaltelemedicineproviders
except in temporary or emergency situations (e.g., pandemics, natural
disasters)ifapprovedbyLDHinwriting.
2.9.6 OverallNetworkManagement
TheContractorshalldevelopandimplementastrategytomanagetheprovidernetwork
withafocusonTimelyaccesstoservicesforEnrollees,quality, consistent practice
patterns,theprinciplesofrehabilitationandrecoveryforbehavioral health services,
culturalandlinguisticcompetence,andcosteffectiveness.
2.9.6.1 TheContractor’snetworkmanagementstrategyshallincludeataminimum:
2.9.6.1.1 A system for utilizing Network Provider profiling and
benchmarkingdatatoidentifyandmanageOutliers;
2.9.6.1.2 Asystemfor theContractor andNetworkProvidersto identify
andestablishimprovementgoalsandperiodicmeasurementsto
track Network Providers’ progress toward those improvement
goals;and
2.9.6.1.3 Conducting on‐site visits to Network Providers for quality
managementandqualityimprovementpurposes.
2.9.6.2 The Contractor must conduct profiling activities for behavioralhealth
providers and facilities and other provider types as directed by LDH. The
Contractormustdescribethemethodologyitusestoidentifywhichandhow
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manyproviderstoprofileandtoidentifymeasurestouseforprofilingsuch
providers.
2.9.6.3 TheContractorshallusetheresultsofitsproviderprofilingactivitiestoidentify
areasofimprovementforproviders,and/orgroupsofprovidersandestablish
provider‐specific quality improvement goals for priority areas inwhicha
provider(s)doesnotmeetestablishedContractorstandardsorimprovement
goals;
2.9.6.4 TheContractorshallmonitorandenforceaccessandothernetworkstandards
requiredbythisContractandtakeappropriateactionwithproviderswhose
performance is in need of improvement or out of compliance withthis
Contract, including when a provider fails to meet minimum provider
qualificationsorrequirements,orappointmentavailabilitystandards;and
2.9.6.5 The Contractor shall make collected information, monitoring reviews and
findings,Corrective Action Plans and follow‐up relatedtoprovidernetwork
management available to LDH upon request. At LDH’s direction, the
Contractorshallmodifyitsnetworkmanagementstrategy,tools,and
processestocomplywiththeContractandtheMCOManual.
2.9.7 ProviderParticipation
2.9.7.1 Inaccordancewith42C.F.R.§438.602(b)anduponLDHimplementationofa
providermanagementsystem,theContractoranditssubcontractorsshallnot
enterintoaNetworkProviderAgreementwithaprovidertoprovideservices
to Beneficiaries or reimburse a claim containing a provider’s NPIwhen the
provider is not otherwise appropriately screened by and enrolled with the
Stateaccordingtothestandardsunder42C.F.R.Part455,SubpartsBandE.
SuchEnrollmentincludesprovidersthatorder,refer,orfurnishservicesunder
theStatePlanandWaivers.SuchEnrollmentdoesnotobligateprovidersto
participateinFFS.
2.9.7.2 TheContractormayexecuteNetworkProviderAgreementspendingthe
outcomeoftheStatescreening,Enrollment,andre‐validationprocessforup
toonehundredtwenty(120)CalendarDays,butuponnotificationfromthe
State that a provider’s Enrollment has been denied or terminated, or the
expiration of the one hundred twenty (120) Calendar Day period without
Enrollmentoftheprovider,theContractor shall terminate suchNetwork
ProviderimmediatelyandnotifyaffectedEnrolleesinwritingthattheprovider
isnolongerparticipatinginthenetwork.
2.9.7.3 PriortocontractingwithaNetworkProviderand/orpayingaprovider’sclaim,
theContractorshallensurethattheproviderhasavalidNational Provider
Identifier(NPI)Number,whereapplicable,hasavalidlicenseorcertification
toperformservicesintheState,hasnotbeenexcludedorbarr
ed from
participation in Medicare, Medicaid, CHIP, and/or any other government
healthcareprogramandhasobtainedaMedicaidprovidernumberfromLDH.
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2.9.7.4 TheContractorshallcomplyTimelywithallnon‐complianceactionsimposed
by the State on Network Providers, including Enrollment revocation,
termination,andexclusions.
2.9.7.5 For the following qualified providers, the Contractor shall offeraNetwork
ProviderAgreementandalsohaveLDH’swrittenapprovalpriortoterminating
theagreements:
2.9.7.5.1 LouisianaOfficeofPublicHealth(OPH);
2.9.7.5.2 AllOPH‐certifiedSchoolBasedHealthClinics(SBHCs);
2.9.7.5.3 All small rural hospitals meeting the definition in the Rural
HospitalPreservationAct;
2.9.7.5.4 FederallyQualifiedHealthCenters(FQHCs);
2.9.7.5.5 RuralHealthClinics(RHCs)(free‐standingandhospitalbased);
2.9.7.5.6 Clinics and outpatient providers funded under the HRSA
administeredRyanWhiteHIV/AIDSProgram;
2.9.7.5.7 OPH Family Planning clinics and providers, including those
fundedbyTitleXofthePublicHealthServicesAct;
2.9.7.5.8 OpioidTreatmentPrograms;
2.9.7.5.9 All providers approved in writing by the LDH PSH Program to
provide tenancy and pre‐tenancy supports for the Louisiana
PermanentSupportiveHousingprogram;
2.9.7.5.10 LocalGoverningEntities;and
2.9.7.5.11 ProvidersthatareactivelyservingtheContractor’sEnrolleesthat
are eligible under the Act 421 Children’s Medicaid Option,
subjectto42C.F.R.§431.52andexcludingICF/IIDs.
2.9.7.6 IfanyMedicaidproviderrequestsparticipationintheContractor’snetwork,
theContractorshallmakeagoodfaithefforttoexecuteacontract. In the
eventanagreementcannotbereachedandtheproviderdoesnotparticipate
withtheContractor,theContractorhasmetthisrequirement;theContractor
shallmaintaindocumentationdetailingeffortsmade.
2.9.7.7 Notwithstanding therequirementsof thisSection, theContractor maylimit
provider participation to the extent necessary to meet the needs of the
Contractor’sEnrollees.Theseprovisionsalsodonotinterferewithmeasures
establishedbytheContractortocontrolcostsandqualityconsistentwithits
responsibilitiesunderthisContractnordoesitprecludetheContractorfrom
using different reimbursement amounts, which may be greater than the
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publishedFFSRate,fordifferentspecialistsorfordifferentpractitionersinthe
samespecialty[42C.F.R.§438.12(b)].
2.9.7.8 IftheContractordeclinesrequestsofindividualsorgroupsofproviderstobe
included in its provider network, the Contractor shall give the affected
providers written notice of the reason for its decision within fourteen (14)
CalendarDaysofitsdecision[42C.F.R.§438.12(a)(1)].
2.9.8 ExclusionfromParticipation
2.9.8.1 TheContractorshallnotpayclaimstoorexecutecontractswithindividualsor
groups of providers who have been excluded from participation in Federal
healthcareprogramsundereither42U.S.C.§1320a‐7or§1320a‐7a[42C.F.R.
§438.214(d)]orstatefundedhealthcareprograms.TheContractormayaccess
alistofprovidersexcludedfromfederallyfundedhealthcareprogramsusing
thesourcesprovidedintheMCOManual.
2.9.8.2 TheContractorshallnotcontractorshallterminatecontractswithproviders
whohavebeenexcludedfromparticipationintheMedicareand/orMedicaid
program pursuant to 42 U.S.C. §1320a‐7or 42 U.S.C. §1320c‐5 orwhoare
otherwise barred from participation in the Medicaid and/or Medicare
program. This includes providers currently undergoing any of the following
conditionsidentifiedthroughLDHproceedings:
2.9.8.2.1 Revocationoftheprovider’slicense;
2.9.8.2.2 ExclusionfromtheMedicaidprogram;
2.9.8.2.3 TerminationfromtheMedicaidprogram;
2.9.8.2.4 Withholding of Medicaid reimbursement as authorized by the
Department’s Surveillance and Utilization Review Subsystems
(SURS)Rule(LAC50:I.Chapter41);
2.9.8.2.5 ProviderfailstoTimelyrenewitslicense;or
2.9.8.2.6 TheLouisianaAttorneyGeneral’sOfficehasseizedtheassetsof
theserviceprovider.
2.9.8.3 TheContractorshall not enter into any relationship with anyone debarred,
suspendedorotherwiseexcludedfromparticipatinginprocurementactivities
undertheFederalAcquisitionRegulationorfromnon‐procurementactivities
underregulationsissuedunderExecutiveOrders.
2.9.8.4 The Contractor shall not remit payment for services provided under this
ContracttoproviderslocatedoutsideoftheUnitedStates.Theterm“United
States”meansthefifty(50)states,theDistrictofColumbia,and any U.S.
territories.
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2.9.9 OtherEnrollmentandDisenrollmentRequirements
2.9.9.1 TheContractorshallnotdiscriminateintheparticipation,reimbursement,or
indemnificationofanyproviderwhoisactingwithinthescopeofhisorher
license or certification under applicable State laws, rules, and regulations,
solelyonthebasisofthatlicensureorcertification.
2.9.9.2 The Contractor shall establish and follow a documented process for
credentialing and re‐credentialing of Network Providers [42 C.F.R.
§438.12(a)(2)and§438.214].Inaddition,theContractorshallnotdiscriminate
againstparticularprovidersthatservicehigh‐riskpopulationsorspecializein
conditionsthatrequirecostlytreatment[42C.F.R.§438.214(c)].
2.9.9.3 The Contractor shall require that all providers be in compliance with
Americans with Disabilities Act (ADA) requirements and provide access for
Enrolleeswithdisabilities.
2.9.9.4 The Contractor shall require unlicensed staff of entities rendering and
receivingreimbursementforMentalHealthRehabilitation(MHR)servicesto
obtainandsubmitNPInumberstotheContractor,aswellasdocumentation
verifying the unlicensed staff meets all qualifications and requirements for
providing MHR services established by applicable Federal and State laws,
rules, regulations, and the Medicaid Behavioral Health Service Provider
Manual, inclusive of Evidence‐Based Practice (EBP) MHR services, prior to
reimbursingagencies forservicesprovidedbythesestaff.Claimssubmitted
forMHRservicesshallincluderenderingproviderNPIsandotherContractor
required identifiers regardless of whether the rendering staff is licensed or
unlicensed.TheContractorshallconfiguresystemstodenyclaimsforservices
whenrenderingprovidersandNPIsaredenotedonclaimsforservicethathave
notbeencredentialedandapprovedbytheContractor.TheContractorshall
submittheirpoliciesandproceduresassociatedwiththisrequirementtoLDH
oritsdesigneeforapprovalduringReadinessReview.
2.9.9.5 IftheContractorterminatesaNetworkProviderAgreementforcause, the
Contractorshallprovidewrittennoticetotheproviderwithinone(1)Business
Dayofthedecisionbeingmade.Thenoticeshallbesentatleastfifteen(15)
CalendarDayspriortotheeffectivedateofterminationviaelectronicmeans
andwithinone(1)BusinessDayofthedecisionbeingmadeviacertifiedmail.
TheContractorshallnotifyLDHthroughemailpriortoprovidernotification.
TheterminationshallbeimmediateiftheterminationispursuanttoLa.R.S.
46:460.73(B),duetothelossofrequiredlicense,orduetohealthandsafety
concerns.
2.9.9.6 The Contractor shall notify LDH when the Contractor or its subcontractor
terminates a Network Provider Agreement for program integrity‐related
reasonsorotherwiselimitstheabilityofproviderstoparticipate in the
programforprogramintegrityreasons.
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2.9.9.7 TheContractormaynotterminateNetworkProviderAgreementswithout
causeduringtheperiodofforty‐five(45)CalendarDayspriortothestartof
theEnrollmentperiodthroughthelastCalendarDayoftheEnrollmentperiod.
2.9.9.8 IftheContractorterminatesaNetworkProviderAgreementwithout cause,
theContractorshallberesponsibleforthefollowing:
2.9.9.8.1 Identifyingand providingto LDHan accountingof allEnrollees
whohavereceivedservicesfromthe impactedproviderwithin
thepasteighteen(18)monthsby,atminimum,claimsanalysis
andPCPselectionconcurrentlywiththenotificationtoLDH;
2.9.9.8.2 SubmissionofaletterinformingEnrolleesoftheterminationand
theirabilitytochangetheirMCO,ifappropriate,toLDHwithin
five(5)BusinessDaysofnotificationtoLDH;
2.9.9.8.3 Receivingand inputting in the member Enrollment web‐based
system Enrollee Disenrollment requests resulting from the
termination within five (5) Business Days of the receipt of the
request;and
2.9.9.8.4 The administrative cost borne by LDH for Disenrollments
resultingfromthetermination,asinvoicedbyLDH.
2.9.9.9 TheContractorshallreceivewrittenapprovalfromLDHpriortoterminatinga
NetworkProviderAgreementwithoutcausewhentheproviderislocatedina
HealthProfessionalShortageArea(HPSA).
2.9.9.10 WhenaNetworkProviderAgreementisterminated,withcause,the
Contractor shall also provide to LDH its plan to notify the Contractor’s
Enrollees of such change, its strategy to ensureTimelyaccess for Enrollees
throughdifferentin‐networkand/orout‐of‐NetworkProviders,anditsplanfor
ensuringthattherewillbenostoppageorinterruptionofservicestoEnrollees.
2.9.9.11 TheContractorshallnotifyitsEnrolleesofproviderterminationsinaccordance
withtheEnrolleeServicessection.
2.9.9.12 TheContractorshallnotifytheState’sprovidermanagementcontractorofa
NetworkProvider’sterminationbycloseofbusinessonthenextBusinessDay
followingthetermination.
2.9.10 Mainstreaming
2.9.10.1 LDH considers mainstreaming of Enrollees into the broader health delivery
systemtobeimportant.TheContractorshallensurethatallNetworkProviders
acceptEnrolleesfortreatmentandthatNetworkProvidersdonot
intentionally segregate Enrollees in any way from other persons receiving
services.
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2.9.10.2 To ensuremainstreamingof Enrollees,theContractor shalltake affirmative
actiontoconfirmthatEnrolleesareprovidedMCOCoveredServiceswithout
regardtorace,color,creed,sex,genderidentity,religion,age,nationalorigin
ancestry, marital status, sexual preference, health status, income status,
programmembership,orphysical,behavioral,orcognitivedisability,except
wheremedicallyindicated.Examplesofprohibitedpracticesinclude,butare
notlimitedto,thefollowing:
2.9.10.2.1 DenyingornotprovidingtoanEnrolleeanymedicallynecessary
MCOcoveredserviceoravailabilityofafacility;and
2.9.10.2.2 Discriminatory practices with regard to Enrollees such as
separate waiting rooms, separate appointment days, separate
physicallocations,orpreferencetoprivatepayorFFSpatients.
2.9.10.3 WhentheContractorbecomesawareofaNetworkProvider’sfailure to
complywithmainstreaming,theContractorshalldevelopawrittenplanfor
coming into compliance with the Contract requirement for mainstreaming
withtheNetworkProviderwithinthirty(30)CalendarDaysandprovidethe
plantoLDHinwriting.
2.9.10.4 The Contractor shall ensure that providers do not exclude treatment or
placementofEnrolleesforauthorizedbehavioralhealthservicessolelyonthe
basisofStateagency(DCFS,OCDD,orOJJ,etc.)involvementorreferral.
2.9.11 PrimaryCare
ThePCPshallserveastheEnrollee'sinitialandmostimportantpointofinteractionwith
the Contractor's provider network. A PCP shall be an individual physician, nurse
practitioner, or physician assistant who accepts primary responsibilityforthe
management of an Enrollee’s health care. The primary care provider is the Enrollee’s
pointofaccessforpreventivecareoranillnessandmaytreattheEnrolleedirectly,refer
theEnrolleetoaspecialist(secondary/tertiarycare),oradmittheEnrolleetoahospital.
2.9.11.1 PCPSelection
TheContractorshall:
2.9.11.1.1 AlloweachEnrolleetochoosehisor herPCPandotherhealth
careprofessionalstotheextentpossibleandappropriate;
2.9.11.1.2 MakebesteffortstoassistandencourageeachEnrolleetoselect
a PCP. Such best efforts shall include, but not be limited to,
providing interpreter services when necessary to assist the
Enrollee in choosing a PCP, making efforts to contact those
EnrolleeswhohavenotcontactedtheContractorand,inthecase
ofchildreninthecareorcustodyofDCFS,makingeffortsto
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contactthechild’sstatecaseworkerthroughtheLDHappointed
DCFSliaison;and
2.9.11.1.3 AssistEnrolleesinselectingaPCP,withinfifteen(15)Calendar
Days after their effective date of Enrollment, by eliciting
informationonpriorPCPaffiliationsthattheEnrolleemayhave
had and providing the Enrollee with relevant information on
adult or pediatric PCPs in close proximity to the Enrollee,
includingprovidinginformationregardingtheexperienceofthe
PCPintreatingspecialpopulationsifknowntobeapplicable.
2.9.11.2 PCPAutomaticAssignment
2.9.11.2.1 The Contractor is responsible for developing a PCP Automatic
AssignmentmethodologyincollaborationwithLDHtoassignto
aPCPanEnrolleeforwhomtheContractoristheprimarypayor
whentheEnrollee:
2.9.11.2.1.1 DoesnotmakeaPCPselection;
2.9.11.2.1.2 SelectsaPCPwithinthenetworkthathas
reacheditsmaximumphysician/patientratio;
2.9.11.2.1.3 SelectsaPCPwithinthenetworkthathas
restrictions/limitations (e.g. pediatric only
practice);or
2.9.11.2.1.4 DoesnotmakeaselectionofaPCPfora
newbornwithinfourteen(14)CalendarDaysof
birth.
2.9.11.2.2 Inthe event that the Enrollee has not selected a PCP and the
ContractorisunabletoelicitaPCPselectionfromanEnrollee,the
ContractorshallpromptlyassignaPCPtoeachsuchEnrolleeas
described below. The assignment shall be to the most
appropriate PCP in accordance with this Contract, the MCO
Manual, and the Contractor’s approved PCP Automatic
Assignment methodology, as approved by LDH in writing. The
PCP assignment shall be effective no later than fifteen (15)
Calendar Days after the effective date of Enrollment with the
Contractor.Foranewborn,thePCPassignmentshallbeeffective
nolater than the first month of Enrollment subsequent tothe
birthofthechild.
2.9.11.2.3 TheContractor’sPCPAutomaticAssignmentmethodologyshall
besubjecttoLDHapprovalaspartofReadinessReviewand
fifteen(15)CalendarDayspriortoanysubsequentchangesinthe
Contractor’sassignment methodologyunless otherwiseagreed
to in writing by LDH. The Contractor shall make its PCP
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assignment methodology readily available to LDH and via the
Contractor’s website, provider handbook, and Member
Handbookanduponrequest.
2.9.11.3 PCPDesignationforEnrollees
2.9.11.3.1 IfanewEnrolleehasinformedtheEnrollmentBrokerofaPCP
selection,thenameofthePCPrequestedbytheEnrolleewillbe
includedintheEnrolleefilefromtheEnrollmentBrokertothe
Contractor. The Contractor shall confirm the PCP selection
informationreceivedintheEnrolleeFileinawrittennoticetothe
Enrolleewithinten(10)BusinessDaysofreceivingthefile.
2.9.11.3.2 ForanyEnrolleewhohasnotyetselectedorbeenassignedaPCP,
the Contractor shall, within three (3) Business Days after
receivingnotificationthatsuchEnrolleeseekstoorhasobtained
care,inoroutoftheprovidernetwork,contacttheEnrolleeand
assisttheEnrolleeinchoosingaPCP.IftheContractorisunable
toreachtheEnrollee,thentheContractorshallassignaPCPto
suchEnrolleeandaffirmativelynotifytheEnrolleeandthePCPof
theassignmentasrequiredinthisContract.
2.9.11.3.3 Atleastmonthly,theContractorshallsharecompletelistsof
designated Enrollees with PCPs. The Contractor shall have a
process,nottoexceedfifteen(15)BusinessDays,bywhichaPCP
may dispute the Contractor’s assignment policies or the
assignmentofanEnrollee.TheContractorshallsubmititsdispute
processtoLDHoritsdesigneeduringReadinessReview.
2.9.11.3.4 The Contractor shall be responsible for providing to the
Enrollment Broker, information on the number of Enrollees in
eachPCPpanelandremainingcapacityofeachindividualPCPon
aquarterlybasis.TheContractorshallsubmitalistingforeach
PCP, the Enrollees that are designated, via selection or PCP
Automatic Assignment, to that PCP’s panel to LDH weekly as
describedintheMCOManualandtheMCOSystemCompanion
Guide.
2.9.11.3.5 TheContractorshall:
2.9.11.3.5.1 Monitor, on an ongoing basis, the
completeness and accuracy of the PCP
designationsforallEnrollees;
2.9.11.3.5.2 Annually,andatotherfrequenciesspecifiedby
LDH, audit PCP designations for Enrollees to
identifyEnrolleeswith noPCPdesignationor
anincorrectPCPdesignation;
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2.9.11.3.5.3 Takestepstorectifyidentifiederrorsandgaps
in PCP designations, such as through
reconciliationof information providedby the
Enrollee, the PCP, and/or the Contractor’s
records, and facilitation of Enrollee selection
ofaPCP,orassignmentofEnrolleestoPCPs;
2.9.11.3.5.4 Conductroot cause analyses, and implement
activities to maximize proactively the
completeness and accuracy of PCP
designations;
2.9.11.3.5.5 Annually,andatotherfrequenciesspecifiedby
LDH, assess its PCP assignment methodology
by conducting a claims/encounter‐based
analysis utilizing available historical
informationaboutEnrolleeuseofhealthcare
servicestoidentifywhichprovidersand
primarycareservicestheEnrolleesusedover
aperiodoftime,andconsiderprovidersthat
havebilledforevaluationandmanagement
codes,includingthoseforwellnesscare.Based
on this analysis the Contractor shall offer to
change PCPs for Enrollees and shall consider
changestoitsPCPassignmentmethodologyto
improvecareandcasemanagement;and
2.9.11.3.5.6 Annually submit to LDH an Enrollee‐PCP
assignmentreportina formatandfrequency
to be specified by LDH, such report shall
include results of the Contractor’s Enrollee‐
PCP assignment monitoring efforts and the
actions taken by the Contractor in the prior
twelve(12)months.
2.9.11.4 PCPTransfers
TheContractorshall:
2.9.11.4.1 AllowanEnrolleetochangePCPs,atleastonce,duringthefirst
ninety (90) Calendar Days from the Enrollee’s selection of or
assignmenttoaPCPwithoutcauseandshallallowsuchaPCP
transferrequesttogoineffectimmediately;
2.9.11.4.2 AttheEnrollee’srequest,allowtheEnrolleetochangehisorher
PCPwithcauseatanytimeandallowforEnrollmentwiththenew
PCPtobeeffectiveimmediately;
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2.9.11.4.3 Havewritten policies and procedures for allowing Enrollees to
selectanewPCPandprovideinformationtoEnrolleesonoptions
forselectinganewPCP;and
2.9.11.4.4 Definewhatisconsideredascauseinwrittenpoliciestoinclude,
butnotbelimitedto,whenanEnrolleehasmoved,aPCPisnon‐
compliantwithproviderstandardsoristerminatedfromthe
Contractor, or when a PCP change is ordered as part of the
resolutiontoaGrievanceproceeding.
2.9.11.5 PCPResponsibilities
2.9.11.5.1 The Contractor shall ensure that network PCPs fulfill their
responsibilitiesincluding,butnotlimitedto,thefollowing:
2.9.11.5.1.1 Managing and coordinating the medical and
behavioral health care needs of Enrollees to
ensure that all medically necessary services
aremadeavailableinaTimelymanner;
2.9.11.5.1.2 Referring patients to specialists or
subspecialists and hospitals as they are
identified for consultation and diagnostics
according to evidence‐based criteria forsuch
referralsasitisavailable;
2.9.11.5.1.3 Communicatingwithallotherlevelsofmedical
caretocoordinate,andfollowupthecareof
individualpatients;
2.9.11.5.1.4 Providing the coordination necessary for the
referral of patients to specialists or
subspecialists;
2.9.11.5.1.5 Maintaining a medical record of all services
renderedbythePCPandarecordofreferralto
other providers and any documentation
providedbytherenderingprovidertothePCP
forfollowupand/orcoordinationofcare;
2.9.11.5.1.6 Developmentofplansofcaretoaddressrisks
and medical needs and other responsibilities
asdefinedinthissection;
2.9.11.5.1.7 Ensuring that in the process of coordinating
care, each Enrollee's privacy is protected
consistent with the confidentiality
requirements in 45 C.F.R. Parts 160 and 164
and all state statutes. 45 C.F.R. Part 164
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specifically describes the requirements
regarding the privacy of individually
identifiablehealthinformation;
2.9.11.5.1.8 Providing after‐hours availability to patients
whoneedmedicaladvice.Ataminimum,the
PCP office shall have a return call system
staffedandmonitoredinordertoensurethat
the Enrollee is connected to a designated
medicalpractitionerwithinthirty(30)minutes
ofthecall;
2.9.11.5.1.9 Maintaining hospital admitting privileges or
arrangementswithaphysicianwhohas
admitting privileges at a Contractor
participatinghospital;
2.9.11.5.1.10 Working with Contractor case managers to
develop plans of care for Enrollees receiving
casemanagementservices;
2.9.11.5.1.11 Participating in the Contractor’s case
management team, as applicable and
medicallynecessary;and
2.9.11.5.1.12 Conducting screens for common behavioral
issues, including, but not limited to,
depression, anxiety, trauma/ ACEs, and
substance use, early detection, identification
of developmental disorders/delays, social‐
emotional health, and SDOH to determine
whethertheEnrolleeneedsbehavioralhealth
services.
2.9.11.5.2 The Contractor shall seek to contract with adult and pediatric
PCPs that offer extended primary care hours and shall review
adultandpediatricprimarycare,urgentcareandEDutilization
patternsacrossdifferentregionsandparishestoassessaccessto
care.
2.9.11.5.3 Atleastannually,accordingtoaformatspecifiedbyLDH,the
Contractorshall:
2.9.11.5.3.1 Reportonthenumberandpercentageofadult
PCPswithextendedprimarycarehours(nights
and weekends) that are not closed to new
patients;
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2.9.11.5.3.2 Report on the number and percentage of
pediatric PCPs with extended primary care
hours (nights and weekends) that are not
closedtonewpatients;and
2.9.11.5.3.3 Review primary care, urgent care and ED
utilization patterns to identify regions and
parishes that appear to have significant
primary care access constraints for adults or
children.
2.9.12 SpecialtyProviders
2.9.12.1 TheContractorshallensureaccesstospecialtyproviders,asappropriate,for
allEnrollees.TheContractorshallensureaccessstandardsandguidelinesto
specialtyprovidersaremetasspecifiedinthisContract.
2.9.12.2 TheContractor’sprovidernetworkshallincludeparticipatingspecialistswith
pediatric expertise for children/adolescents when the need for pediatric
specialtycareissignificantlydifferentfromtheneedforadultspecialtycare
(e.g.apediatriccardiologist).
2.9.12.3 TheContractorshallensureaccesstoappropriateservicesettingsforEnrollees
needing medically high‐risk perinatal care, including both prenatal and
neonatalcare.
2.9.12.4 TheContractorshallestablishandmaintainaprovidernetworkofphysician
specialiststhatisadequateandreasonableinnumber,inspecialtytype,and
ingeographicdistributiontomeetthemedicalneedsofitsEnrollees(adults
and children) without excessive travel requirements. This meansthat,ata
minimum:
2.9.12.4.1 The Contractor has signed a contract with providers of the
specialty types listed in theMCOManualwhoacceptnew
Enrolleesandareavailableonatleastareferralbasis;and
2.9.12.4.2 The Contractor is in compliance with access and availability
requirementsforthesespecialtytypes.
2.9.12.5 The Contractorshall ensure, at a minimum, the availability of specialistsin
compliancewiththeratio,distance,andappointmenttimerequirementsset
inAttachmentF,ProviderNetworkStandards.
2.9.12.6 The Contractor will be required to provide a higher ratio of specialists per
Enrolleepopulationand/oradditionalspecialisttypes/Enrolleeratiosmaybe
established,ifitisdeterminedbyLDHthattheContractordoesnotmeetthe
accessstandardsspecifiedinAttachmentF,ProviderNetworkStandards.
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2.9.12.7 In accordance with 42 C.F.R. §438.208(c)(4), for Enrollees withSHCN
determined to need a course of treatment or regular monitoring,the
Contractor shall have a mechanism in place to allow Enrollees to directly
accessaspecialistasappropriatefortheEnrollee’sconditionandidentified
needs.
2.9.13 Hospitals
2.9.13.1 TheContractorshallensurethathospitalserviceprovidersutilized by
EnrolleesmeettheconditionsrequiredforparticipationundertheLouisiana
MedicaidProgram.Thisappliestonon‐NetworkProviderswhen
circumstancesallow.
2.9.13.2 TheContractorshallinclude,ataminimum,accesstothefollowing:
2.9.13.2.1 One(1)hospitalthatprovidesEmergencyRoomCare,inpatient,
and outpatient care in each parish in the state, provided the
parishhassuchahospital.
2.9.13.2.2 TheContractormustestablishaccesstooneofthefollowingper
region,at a minimumandtotheextent available, within their
networkofhospitals:
LevelIIIObstetricalservices;
LevelIIINeonatalIntensiveCare(NICU)services;
Pediatricservices;
Traumaservices;
Burnservices;and
AChildren’sHospitalthatmeetstheCMSdefinitionin42
C.F.R.§495.302and§412.23(d).
2.9.14 TertiaryCare
Tertiarycareisdefinedashealthservicesprovidedbyhighlyspecializedproviders,such
asmedicalsub‐specialists;theseservicesfrequentlyrequirecomplextechnologicaland
support facilities. The Contractor shall provide tertiary care services including trauma
centers,burncenters,levelIII(high‐risk)nurseries,rehabilitationfacilities,andmedical
sub‐specialiststwenty‐four(24)hoursperday.IftheContractordoesnothaveafullrange
oftertiarycareservices,theContractorshallhaveaprocessforprovidingsuchservices
includingtransferprotocolsandarrangementswithout‐of‐NetworkProviders.
2.9.15 AccesstoMedicationAssistedTreatment
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2.9.15.1 The Contractor shall ensure that substance use residential providers offer
Medication Assisted Treatment (MAT) onsite or facilitate accesstoMAT
offsite.
2.9.15.2 The Contractor shall report on Enrollee access to MAT in a format and
frequencyspecifiedintheMCOManual.
2.9.15.3 The Contractor shall be responsible for conducting Enrollee outreach and
providereducationandtrainingregardingutilizationofMATtotreatOpioid
UseDisorder.Thisshallinclude,butnotbelimitedto,assistancewithfederal
requirementstobecomeaDrugAddictionTreatmentActof 2000waivered
physiciantoexpandaccesstoMATservices.
2.9.15.4 LDHmaypursueSPAsorWaiverstoexpandthesubstanceuseservicearrayto
include additional American Society of Addiction Medicine (ASAM) criteria
and/orlevelsofcare,orotherpatientplacementassessmenttoolsthatreflect
evidence‐basedclinicaltreatmentguidelines.
2.9.16 DirectAccesstoSpecialistsforHIVPositiveEnrollees
TheContractorshallprovidedirectaccesstoaninfectiousdiseasehealthspecialist(s)in‐
networkforEnrolleesknowntobeHIVpositive.Thisaccessshallbeinadditiontothe
Enrollee’sPCPifthatproviderisnotaninfectiousdiseasespecialist.
2.9.17 DirectAccesstoWomen’sHealthCare
TheContractorshallprovidedirectaccesstoahealthspecialist(s)in‐networkforMCO
CoveredServicesnecessarytoprovidewomen’sroutineandpreventivehealthcareand
gynecologyservices.ThisaccessshallbeinadditiontotheEnrollee’sPCPifthatprovider
isnotawomen’shealthspecialist.
2.9.17.1 TheContractorshalldemonstratethatitsnetworkincludessufficientfamily
planningproviderstoensureTimelyaccesstoMCOCoveredServices.
2.9.17.2 TheContractorshallnotifyandgiveeachEnrollee,includingadolescents,the
opportunity to use their own PCP or utilize any family planningservice
provider for family planning services without requiring a referral or
authorization. Family planning services shall be available to help prevent
unintended or unplanned pregnancies. Family planning services include
examinations, assessments, and traditional contraceptive devices. The
Contractor’s family planning services shall also include preconception and
interconception care services to optimize the Enrollee’s healthentering
pregnancy.The Contractor shallagree tomakeavailableallfamily planning
servicestoEnrolleesasspecifiedinthisContract.
2.9.17.3 Enrollees shall have the freedom to receive family planning services and
relatedsuppliesfromappropriateMedicaidprovidersoutsidetheContractor’s
provider network without any restrictions as specified in 42 C.F.R.
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§431.51(b)(2).Theout‐of‐networkMedicaidenrolledfamilyplanningservices
providershallbilltheContractorandbereimbursednolessthantheFFSrate
ineffectonthedateofservice.Enrolleesshallbeencouragedbythe
Contractor to receive family planning services through the Contractor’s
networkofproviderstoensurecontinuityandcoordinationoftheEnrollee’s
totalcare.NoadditionalreimbursementsshallbemadetotheContractorfor
Enrollees who elect to receive family planning services outsidethe
Contractor’sprovidernetwork.
2.9.17.4 TheContractormayrequirefamilyplanningproviderstosubmitclaims or
reportsinspecifiedformatsbeforereimbursingservices.
2.9.17.5 The Contractor shall maintain the confidentiality of family planning
informationand recordsfor eachEnrollee including thoseunderthe ageof
majority.
2.9.18 PrenatalCareServices
2.9.18.1 TheContractorshallassistallpregnantEnrolleesinchoosingapediatrician,or
otherappropriatePCP,forthecareoftheirnewbornbabiesbefore the
beginningofthelasttrimesterofgestation.TheContractorshallreporttoLDH
onaquarterlybasisthenumberandpercentageofnewbornsforwhichaPCP
hasbeenselectedpriortobirth.
2.9.18.2 IntheeventthatthepregnantEnrolleedoesnotselectapediatrician,orother
appropriatePCP,theContractorshallprovidetheEnrolleewithaminimumof
fourteen(14)CalendarDaysafterbirthtoselectaPCPpriortoassigningone.
2.9.18.3 TheContractorshallensurethatEnrolleeswhoarepregnantbeginreceiving
carewithinthefirsttrimesterorwithinseven(7)CalendarDaysafterenrolling
withtheContractor.TheContractorshallprovideavailable,accessible,and
adequate numbers of prenatal care providers to provide prenatalservices,
includingSBHSthatareincidentaltoapregnancy(inaccordancewith42C.F.R.
Part440SubpartB)toallEnrollees.
2.9.19 OtherServiceProviders
TheContractorshallensuretheavailabilityofmedicalserviceprovidersincluding,butnot
limitedto,ambulanceservices,durablemedicalequipment,orthotics, prosthetics and
certainsupplies,radiology,andlaboratories.
2.9.20 NEMTandNEAT
2.9.20.1 The Contractor shall have sufficient NEMT and NEAT providers, including
wheelchair lift equipped vans, to transport Enrollees to/from medically
necessaryserviceswhennotifiedforty‐eight(48)hoursinadvance.Hospital
dischargesshallbetransportedwithinthreehoursofnotificationbyamedical
facility.
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2.9.20.2 IfanEnrolleerequestsaNetworkProviderwhoislocatedbeyondtheaccess
standards provided in Attachment F, Provider Network Standards, and the
Contractor has an appropriate provider within the access standards who
accepts new patients, it shall not be considered a violation oftheaccess
requirementsfortheContractortogranttheEnrollee’srequest.However,in
suchcases,theEnrolleeshallberesponsiblefortravelarrangementsandcosts
toaccesscarefromthisselectedprovider.
2.9.21 FQHC/RHCClinicServices
2.9.21.1 The Contractor shall offer to contract with all FQHCs and RHCs (both
freestandingandhospital‐based)intheState.
2.9.21.2 See the Provider Reimbursement section for FQHC/RHC reimbursement
requirements.
2.9.22 School‐BasedHealthClinics(SBHCs)
2.9.22.1 SBHC (certified by LDH OPH) services are those Medicaid CoveredServices
providedwithinschoolsettingstoBeneficiariesundertheageoftwenty‐one
(21).
2.9.22.2 TheContractorshallofferacontracttoeachSBHC.TheContractor may
stipulate that the SBHC follow all of the Contractor’s required policies and
procedures.
2.9.23 Laboratory
All laboratory testing sites providing services under this Contract shall have either a
ClinicalLaboratoryImprovementAmendments(CLIA)certificateorWaiverofacertificate
ofregistrationalongwithaCLIAidentificationnumber.
2.9.24 LocalParishHealthClinics
2.9.24.1 The Contractor shall offer a contract to OPH for the provision of personal
healthservicesofferedwithintheparishhealthunits(e.g.immunizations,STI,
familyplanning).
2.9.24.2 TheContractorshallcoordinateitspublichealth‐relatedactivitieswithOPH.
Coordination mechanisms and operational protocols for addressing public
healthissuesshallbenegotiatedwithLDHandreflectLouisianapublichealth
priorities.Thecoordinationofactivitiesrelatedtopublichealthshalltakethe
formofagreementsamongthepartieswhichmayincludepolicymemosor
separate memorandums of understanding signed by OPH, BHSF, and the
Contractor.
2.9.25 SpecializedBehavioralHealthProviders
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2.9.25.1 TheContractorshallensurebehavioralhealthservicesareofferedtoaddress
the needs of youth with serious emotional disorders, adults with Serious
MentalIllness(SMI),Enrolleeswithsubstanceusedisorders,Enrolleeswithco‐
occurring mental health and substance use disorders and other
developmental disorders. This shall include coordination with the Local
GoverningEntities(LGEs)fortheprovisionofMedicaidCoveredServices.
2.9.25.2 The Contractor shall ensure its provider network offers a rangeofBasic
Behavioral Health Services and SBHS as reflected in the MCO Manual and
meetsthenetworkadequacystandardsdefinedinthisContract.Theprovider
network shall be adequate for the anticipated number of Enrolleesforthe
servicearea.
2.9.25.3 The Contractor shall develop its network to meet the needs of Enrollees,
includingbutnotlimitedto, providingassessment to identifyand treat the
behavioralhealth needs of Enrollees with pasthistoryorcurrent displayof
aggression,runawaybehavior,sexualoffenses,orintellectualdisability.
2.9.25.4 The Contractor shall develop, in coordination with LDH and other MCOs, a
systemtoprovidepsychiatricprescribingsupporttoprimarycareproviders.
Such support may be provided through consultation with psychiatrists
regardingpsychiatricprescribingpractices.
2.9.25.5 TheContractorshallendorserealtimeconsultationofprimarycareproviders
with behavioral health professionalsorpsychiatristsforbehavioral health
issuesorconsultationsonmedications.
2.9.25.6 TheContractorshalldesignitsprovidernetworktomaximizetheavailability
of community‐based behavioral health care that reduces utilization of
EmergencyServiceswhenlowercostcommunity‐basedservicesareavailable
and eliminates preventable hospital, nursing home, and other institutional
admissions. The Contractor shall coordinate with other state agencies, as
appropriate, to match services to meet behavioral health needs in the
communitywithservicesandsupportstomeettheEnrollee’sotherneedsin
thecommunity,suchasI/DD.
2.9.25.7 TheContractorshalldesignitsprovidernetworktoincreasetheemerginguse
ofpeersasproviders.Thisincludespeersprovidingservicesforyouth,adults
and parents/families served in community and residential settings, and
certifiedpeersupportspecialistswithOBHapprovedcredentialstoserveas
qualifiedproviders.
2.9.25.8 TheContractorshallensuretheprovidernetworkhasasufficientnumberof
prescribersandotherqualifiedbehavioralhealthserviceproviderstodeliver
servicesduringeveningsandweekends.
2.9.25.9
TheContractorshallhaveafullyoperationalnetworkofbehavioral health
crisisresponseProvidersofferingacompletearrayofcrisisservices,available
twenty‐four(24)hoursperday,seven(7)daysperweek.Crisisservicesshall
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include an on‐call, twenty‐four (24)‐hour crisis hotline, crisis counseling,
mobileandfacilitybasedcrisisinterventionandfollowup,linkagetoongoing
behavioral health management and intervention, and crisis stabilization for
children and adults. Louisiana crisis services will be deliveredintheleast
restrictive setting using approaches that minimize the use of coercive
interventions.ThesecrisisserviceswillallowEnrolleestoreceiveservicesin
the community rather than in EDs when there are no medical or other
contraindicationstodoingso.TheContractorshallmaintainanactiverolein
managingtheprocesstoensureresolutionofbehavioralhealthcrisesinthe
communityandreferraltoandassistancewithplacementinbehavioralhealth
servicesrequiredbytheindividualinneed.
2.9.25.10 TheContractormayalsocoordinatewithcommunityresourcestoexpandthe
crisisresponse.Thecommunity‐basedcrisisresponsesystemmayinclude,but
isnotlimitedto,warmlines,collaborationwithlawenforcement,andother
innovativeapproachestocrisisservicesbeyondthatwhichisestablishedas
reimbursablethroughtheLouisianaMedicaidProgram.TheContractorshall
familiarizeitselfwiththelocalcrisiscollaborativeandworkwithittofacilitate
crisisresolution.
2.9.25.11 The Contractor will work with LDH on strategies to reduce the need for
services delivered in EDs, or the involvement of law enforcement in crisis
response when it can be safely avoided. This includes the use of law
enforcementfortransportation.
2.9.25.12 TheContractorshalleducateEnrolleesontheavailabilityofcrisisservices,and
thestatewidephonenumberforaccessingtheservices.
2.9.25.13 TheContractorshallworkwithLDHandotherentitiesasidentifiedbyLDHto
developarobustcontinuumofbehavioralhealthcrisisresponsesthatincludes
servicesrangingacrossthecrisiscontinuumtoincludethefollowing:
2.9.25.13.1 Crisis prevention and crisis planning by outpatient treatment
providers;
2.9.25.13.2 EarlycrisisinterventionbyoutpatienttreatmentProviders;
2.9.25.13.3 Acutecrisisintervention;
2.9.25.13.4 Crisistreatment(includingalternativestoinpatienttreatment);
and
2.9.25.13.5 Post‐crisissupportsandstrategiestopreventneedforextended
inpatientoradmissiontoothercongregateliving.
2.9.25.14 The Contractor will also be responsible for facilitating or participating in
state/local crisis system of care collaboratives/workgroups with a focus on
carecoordination,reviewofperformancedata,assessmentandremediation
ofgapsandneeds,andothercrisissystemimprovementstrategies
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2.9.25.15 TheContractormustensurethatContractor'sstaffwhohavedirectEnrollee
contactknowthecontinuumofcommunityresourcesforbehavioralhealth
crisisservices,includingcrisislinesandtheappropriatecrisisservicesavailable
withineachregion.
2.9.25.16 TheContractormusttrainContractor'sstaffwhointerfacewiththepublicor
have direct Enrollee contact how to connect (through direct linkages)
Enrolleesinneedofbehavioralhealthcrisisservicestotheappropriatecrisis
services.
2.9.25.17 The Contractor must track and document behavioral health crisiscontacts
fromEnrolleesandensurethatthisinformationissharedassoonaspossible
andnolaterthanthenextBusinessDaywiththeContractorcasemanager,
community case management Provider, Assertive Community Treatment
(ACT)TeamifappropriateorotherbehavioralhealthProviderforappropriate
follow‐up.
2.9.25.18 TheContractorwillperformTimelyauthorization,ifrequired,forcrisisservices
inordertominimizewaittimebeforethoseservicescancommenceandto
assuretheefficientoperationofthecrisissystemofcare.
2.9.25.19 TheContractormustcontractwithallProvidersidentifiedbyLDHaseligibleto
providecrisisservices.Whenthereareinstancesofqualityconcernsthatplace
theprovider’scontractinjeopardy,theContractormustimmediatelynotify
LDHifit isnot willingto contractwitha particularcrisis Providerand must
collaboratewithLDHonnextsteps,whichmustincludeaplantoassureTimely
deliveryofservicesinthegeographicareacoveredbytheProviderofconcern.
2.9.25.20 The Contractor must monitor crisis Providers for compliance with LDH's
standardsandguidanceusingastandardizedprotocolasspecifiedbyLDH.As
directed by LDH, the Contractor must coordinate monitoring activities with
otherContractors.
2.9.25.21 IfshortagesinprovidernetworksufficiencyareidentifiedbyLDH, the
ContractorshallconductoutreacheffortsapprovedbyLDHinwriting,andtake
necessaryactionstoensureEnrolleeaccesstomedicallynecessarybehavioral
healthservices.TheContractorshall execute an ad hoc or single case
agreementwhenaclinicalneedoraspecializedbehavioralhealthserviceis
identifiedforanEnrolleeandaNetworkProviderisnotavailabletomeetthat
particular need. In such cases, all transportation necessary toreceive
medically necessaryservices shall be provided andreimbursed throughthe
Contractor,includingmealsandlodgingasappropriate.
2.9.25.22 TheContractorshallensurethatallplacementsareatthemostappropriate,
leastrestrictive,andmedicallynecessaryleveltotreatthespecialtyneedsof
the Enrollee. The Contractor shall defer to the responsible state agencies
regardingtheappropriatenessofresidentialplacementoptionsforLongTerm
Supports and Services outside of the scope of this Contract.
Institutional
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placementsshouldnotbeviewedassubstitutesforneededbehavioralhealth
treatment.
2.9.25.23 TheContractorshallrequire behavioralhealthproviders toscreenfor basic
medicalissues.
2.9.25.24 The Contractor shall monitor and support development of local provider
capacityforthepurposeofidentifyingandfillinggapsinserviceavailability.
2.9.25.25 The Contractor shall report the number of out‐of‐state placements as
specifiedbyLDH.LDHmayrequiretheContractortotakecorrectiveactionor
employotherremediesfornon‐complianceasauthorizedintheContractNon‐
CompliancesectionintheeventLDHdeterminestheContractor’srateofout‐
of‐stateplacementstobeexcessive.
2.9.25.26 The Contractor shall develop policies and procedures to supportthe
developmentofaworkforceandprovideservicestotheduallydiagnosed,
individuals with a co‐occurring developmental disability and mental health
diagnosis.Thesepoliciesandproceduresshallinclude:
2.9.25.26.1 A plan for how to improve and increase services available for
individuals with behavioral health and developmental
disabilities, including autism spectrum disorders, which
incorporates reducing health disparities and long‐range fiscal
planningto supportthetrainingand fiscal sustainabilityofthe
provisionofsuchservices.ThisshallbesubmittedtoLDHorits
designeeaspartofReadinessReviewforapprovalandannually
thereafter.
2.9.25.26.2 Anannualassessmentofthenumberofprovidersserving
Enrolleeswithbehavioralhealthanddevelopmentaldisabilities
andofwhethertheneedsofthispopulationarebeingmet.This
assessmentshallinclude:thenumberofEnrolleesbeingserved
outofstateduetoalackofappropriateservicesinstate;whether
these providers have waiting lists; and whether access to care
standardsarebeingmetbytheseproviders.
2.9.25.26.3 A database of trainers, consultants, and contractors that
specialize in working with Enrollees with dual diagnosis of
behavioralhealthanddevelopmentaldisabilities.
2.9.25.26.4 Trainingplansandcurriculathataddressdualdiagnosis.Training
ondualdiagnosisshallbeofferedtobehavioralhealthNetwork
Providers who are interested in certification and required for
unlicensed staff working with this population. The training
programandapproachshallbereviewedandsubjecttoapproval
byOBHandOCDD.
2.9.25.26.5 Incentivesforproviderstoattainthecertification.
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2.9.25.27 The Contractor shall contract with at least one (1) psychiatric residential
treatmentfacility(PRTF)withintheStatewiththeabilitytoworkeffectively
withEnrolleeswithdualdiagnosisofdevelopmentaldisabilitiesandbehavioral
health.TheContractor shall have atleastone (1) Therapeutic GroupHome
(TGH)withinthestatewiththeabilitytoworkeffectivelywithEnrolleeswith
dualdiagnosisofdevelopmentaldisabilitiesandbehavioralhealth.
2.9.25.28 TheContractorshallhavecommunityproviders(i.e.psychiatrist,psychologist,
socialworkers, advanced practice registered nurses [APRNs], mental health
rehabilitation [MHR] providers, Wrap‐around agencies [WAAs], etc.) within
theStatewiththeabilitytoeffectivelyworkwithEnrolleeswith a dual
diagnosisofdevelopmentaldisabilitiesandbehavioralhealth.
2.9.25.29 TheContractorshallmaketrainingavailabletolicensedprovidersasneeded
toimproveandincreaseaccesstobehavioralhealthservicesfor this
population.Thetrainingprogramandapproachmustbereviewedandsubject
toapprovalbyOBHandOCDD.
2.9.25.30 Unlicensed staff shall mandatorily complete training that addresses dual
diagnosisandshallreceivecertification.
2.9.26 IndianHealthCareProviders(IHCPs)
2.9.26.1 TheContractorshalldemonstratethattherearesufficientIHCPsparticipating
intheprovidernetworkoftheContractortoensureTimelyaccesstoservices
availableundertheContractfromsuchprovidersforIndianEnrolleeswhoare
eligibletoreceiveservices.
2.9.26.2 The IHCPs,whetherparticipatingintheContractornetworkor not,shallbe
paidforMCOCoveredServicesprovidedtoIndianEnrolleeswhoareeligible
toreceiveservicesfromsuchprovidersasfollows:
2.9.26.2.1 AtaratenegotiatedbetweentheContractorandtheIHCP;or
2.9.26.2.2 Intheabsenceofanegotiatedrate,ataratenotlessthanthe
levelandamountofpaymentthattheContractorwouldmakefor
theservicestoaNetworkProviderwhichisnotanIHCP;and
2.9.26.2.3 MakepaymenttoallIHCPsinitsnetworkinaTimelymanneras
required for payments to practitioners in individual or group
practicesunder42C.F.R.§447.45and§447.46.
2.9.26.3 TheContractorshallpermitanyIndianwhoisenrolledwiththeContractorand
iseligibletoreceiveservicesfromanIHCPprimarycareproviderparticipating
asaNetworkProvider,tochoosethatIHCPashisorherPCP,aslongasthat
providerhascapacitytoprovidetheservices.
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2.9.26.4 TheContractorshallpermitIndianEnrolleestoobtainMCOCoveredServices
fromout‐of‐networkIHCPsfromwhomtheEnrolleeisotherwiseeligibleto
receivesuchservices.
2.9.26.5 WhereTimelyaccesstoMCOCoveredServicescannotbeensuredduetofew
ornoIHCPs,theContractorshallbeconsideredtohavemettherequirement
inparagraph42C.F.R.§438.14(b)(1)if:
2.9.26.5.1 IndianEnrolleesarepermittedbytheContractortoaccessout‐
of‐stateIHCPs;or
2.9.26.5.2 If this circumstance is deemed to be good cause for
Disenrollment from the State’s Managed Care Program in
accordancewith42C.F.R.§438.56(c).
2.9.26.6 TheContractorshallpermitanout‐of‐networkIHCPtoreferanIndianEnrollee
toaNetworkProvider.
2.9.27 NetworkDevelopmentandManagementPlan
2.9.27.1 The Contractor shall develop and maintain a Network Developmentand
ManagementPlanwhichensuresthatMCOCoveredServicesarereasonably
accessible to Enrollees and are provided promptly in accordancewiththe
urgencyofthesituationandtheaccessibilitystandardsinthisContract.
2.9.27.2 TheContractorshallsubmititsNetworkDevelopmentandManagementPlan
inaccordancewiththeMCOManualtoLDHoritsdesigneeduringReadiness
ReviewandasrequestedbyLDH.
2.9.27.3 The Network Development and Management Plan shall include the
Contractor’s process to develop, maintain and monitor an appropriate
providernetworkthatissupportedbywrittenagreementsandissufficientto
provide adequate access to all required services included in the Contract.
Whendesigningthenetworkofproviders,andenteringintoNetworkProvider
Agreements,theContractorshallconsiderthenumberofindividualsenrolled
intheLouisianaMedicaidProgram;theexpectedutilizationof services;the
characteristicsofspecificpopulations includedin thisContract;the number
andtypesof providersrequiredto furnishservices; thenumberofcontract
providers who are not accepting new Enrollees; the geographic location of
providersandEnrollees;distance,andthemeansoftransportationordinarily
usedbyEnrollees;andwhetheraproviderlocationprovidesphysicalaccess
forEnrolleeswithdisabilities.
2.9.28 MaterialChangetoProviderNetwork
2.9.28.1 The Contractor shall provide advance written notice to LDH prior to any
NetworkProviderAgreementterminationthatcausesaMaterialChange in
theContractor’sprovidernetwork,whetherterminatedbytheContractoror
the provider, and such notice shall include the reason(s) for the proposed
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action.ThenotificationshallincludetheContractor’splanstonotifyEnrollees
ofsuchchangeandthestrategytoensureTimelyaccessthroughotherin‐
networkand/orout‐of‐NetworkProviderstopreventstoppageorinterruption
ofservicestotheEnrollee.
2.9.28.2 A MaterialChange for purposes of the Provider Network isdefined as one
whichaffects,orcanreasonablybeforeseentoaffect,theContractor’sability
tomeettheperformanceandnetworkstandardsasdescribedintheContract,
includingbutnotlimited,tothefollowing:
2.9.28.2.1 A termination or non‐renewal of a hospital or residential
treatmentfacility;
2.9.28.2.2 Aterminationornon‐renewalofanOpioidTreatmentProgram;
2.9.28.2.3 A termination or non‐renewal of community health center or
communitymentalhealthcenter;
2.9.28.2.4 Atermination or non‐renewal of a chain pharmacy within the
Contractor’snetwork;
2.9.28.2.5 Achangetoone(1)oftheContractor’sMaterialSubcontractors,
includingitsbehavioralhealthsubcontractor,ifapplicable;
2.9.28.2.6 Any change that would cause more than five percent (5%) of
Enrolleeswithintheparishtochangethelocationwhereservices
arereceivedorrendered;
2.9.28.2.7 A decrease in the total of individual PCPs by more than five
percent(5%);
2.9.28.2.8 Alossofanyparticipatingspecialistwhichmayimpairordenyan
Enrollee’sadequateaccesstoproviders;
2.9.28.2.9 Adecreaseinabehavioralhealthprovidertypebymorethanfive
percent(5%);
2.9.28.2.10 Alossofanyparticipatingbehavioralhealthspecialistwhichmay
impairordenytheEnrollee’sadequateaccesstoproviders;or
2.9.28.2.11 Otheradverse changes to the composition of the Contractor’s
network which result in the Contractor’s inability to meet the
network adequacy and Timelyaccess to care standards of this
ContractorwhichimpairordenyanEnrollee’sadequateaccess
to providers such as capping of patient loads by Network
Providersimpactingavailabilityofqualifiedspecialistsinaregion.
2.9.28.3 TheContractorshallprovideorarrangeformedicallynecessaryMCOCovered
Servicesifthenetworkbecomestemporarilyinsufficientwithinaservicearea.
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2.9.28.4 TheContractorshallsubmitrequiredinformationonMaterialChangestoits
providernetworkinaccordancewiththeMCO Manualinthetimeperiod
specifiedbyLDH.
2.9.29 NetworkProviderAgreementRequirements
2.9.29.1 TheContractorshallenterintowrittenagreementswithproviderstoprovide
MCOCoveredServices.
2.9.29.2 InordertoensurethatEnrolleeshaveaccesstoabroadrangeofhealthcare
providers,andtolimitthepotentialforDisenrollmentduetolackofaccessto
providersorservices,theContractorshallnothaveacontractualarrangement
withanyserviceproviderinwhichtheproviderrepresentsoragreesthatit
shallnotcontractwithanotherMCOorinwhichtheContractorrepresentsor
agreesthatitshallnotcontractwithanotherprovider.TheContractorshall
notadvertiseorotherwiseholditselfoutashavinganexclusiverelationship
withanyserviceprovider.
2.9.29.3 TheContractorshallhavewrittenpoliciesandproceduresforselectionand
retentionofprovidersinaccordancewith42C.F.R.§438.214.
2.9.29.4 The Contractor shall provide LDH or its designee with written provider
credentialing and re‐credentialing policies that are compliant with NCQA
HealthPlanAccreditationstandardsandallapplicableFederalandStatelaws,
regulations, rules, policies, procedures, and manuals as part of Readiness
Reviewandonanannualbasis.
2.9.29.5 The Contractor’s provider selection policies and procedures shall not
discriminate against particular providers that serve high‐risk populations or
specializeinconditionsthatrequirecostlytreatment.
2.9.29.6 The ContractorshallnotincludeinitsNetworkProviderAgreementsanall‐
productsclause,requiringproviderstoparticipateinallproductsofferedby
theContractororitsparentorganization.
2.9.29.7 The Contractor shall inform all providers, at the time they enter into a
contract,abouttheEnrollees’rights,andtheavailabilityofassistance,tofile
GrievancesandAppeals,requestStateFairHearings,andrequestcontinuation
ofbenefitsthattheContractorseekstoreduceorterminateduringanAppeal
orStateFairHearing,iffiledwithintheallowable timeframes,althoughthe
EnrolleemaybeliableforthecostofanycontinuedbenefitswhiletheAppeal
orStateFairHearingispendingifthefinaldecisionisadversetotheEnrollee.
2.9.29.8 TheContractorshallrequirethatprovidersnotbillEnrolleesforMCOCovered
ServicesinanyamountgreaterthanwouldbeowediftheContractorprovided
theservicesdirectly.
2.9.29.9 TheContractorshallrequirethatprovidersofferthesameservicestoEnrollees
asthose offered to individuals not receiving services through the Louisiana
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MedicaidProgram,providedthattheyareMCOCoveredServices.Providers
shall also be required to treat Enrollees equally in terms of scope, quality,
duration, and method of delivery of services, unless specifically limited by
regulation. Providers are not required to accept every Enrollee requesting
service.
2.9.29.10 TheContractorshallrequiretheprovidertoreporttotheContractorlossof
accreditation, suspension, or action taken that could result in loss of
accreditation,inclusiveofalldocumentationfromtheaccreditingbody,within
twenty(24)hoursofreceiptofnotification,ifrequiredtobeaccredited.
2.9.29.11 TheContractorshallrequiretheprovidertoimmediatelyreportcancellation
of any required insurance coverage, licensure, or certificationtothe
Contractor.
2.9.29.11.1 Uponreceiptofthisreport,theContractorshallimmediately
notifytheProviderthatitisprohibitedfromperforminganywork
undertheContractunlessanduntiltheProviderprovideswritten
documentationtotheContractorindicatingthattheProviderhas
reinstated all required insurance coverage, licensure, or
certification.
2.9.29.12 As required by 42 C.F.R. §438.3(k) and §438.230, the Contractor shall be
responsible for overseeing all providers’ performance and shallbeheld
accountable for any function and responsibility that it delegates to any
provider,including,butnotlimitedto:
2.9.29.12.1 AllNetworkProviderAgreementsmustfulfilltherequirements
of42C.F.R.Part438thatareappropriatetotheserviceoractivity
delegatedundertheagreement;
2.9.29.12.2 PriortoexecutingaNetworkProviderAgreement,theContractor
shall evaluate the prospective provider’s qualifications and
abilitytoperformtheactivitiestobedelegated;and
2.9.29.12.3 TheContractor shall develop a template for Network Provider
Agreements that shall be approved by LDH in writing that
specifies the requirements and reporting responsibilities
delegatedtotheproviderandprovidesforrevokingdelegation
or imposing other non‐compliance actions and penalties if the
provider’sperformanceisinadequate.
2.9.29.13 The Contractor shall require providers of personal care services (PCS) and
home health care services to use the State‐contracted electronic visit
verification(EVV)systemasdirectedbyLDH.
2.9.29.14 The Network Provider Agreement shall require providers to provide any
information related to the performance of contract responsibilities as
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requestedbyLDH.TheContractorshallberesponsibleforforwarding the
informationreceivedfromproviderstoLDH.
2.9.29.15 The contractor shall submit all original and amended Network Provider
AgreementtemplatestoLDHforapprovalpriortotheexecutionof the
agreementwithaprovider.
2.9.29.16 AllNetworkProviderAgreementsshallprovidethattheprovidershallcomply,
withinareasonabletime,withanyinformation,recordsordatarequestsfrom
any healthcare oversight agency, including the Louisiana Department of
Justice, MFCU, related to any services provided under this Contract.When
requestedbytheMFCU,theproductionoftheinformation,recordsordata
requestedbytheMFCUshallbedoneatnocosttotheMFCU,andtheprovider
shall not require the MFCU to enter into any contract, agreement or
memorandumofunderstandingtoobtaintherequestedinformation,records
ordata.TheprovidershallagreethatitsNetworkProviderAgreementcreates
for any healthcare oversight agency an enforceable right for which the
healthcare oversight agency can petition the court in the event of non‐
compliancewithaninformation,recordsordatarequest.
2.9.30 CredentialingandRe‐credentialingofProvidersandClinicalStaff
2.9.30.1 TheContractorshallhaveawrittencredentialingandre‐credentialingprocess
that complies with 42 C.F.R. §438.12, §438.206, §438.214, §438.224,
§438.230,§438.602(b)andNCQAHealthPlanAccreditationStandardsforthe
review,credentialingandre‐credentialingoflicensed,independentproviders
andprovidergroupswithwhomitcontractsoremploysandwithwhomitdoes
not contract but with whom it has an independent relationship. An
independent relationship exists when theContractor selects and directs its
Enrolleestoseeaspecificproviderorgroupofproviders.Theseprocedures
shall be submitted to LDH or its designee during Readiness Review, and
subsequentlyanytimeachangeismade,andannuallythereafterbycontract
year.
2.9.30.2 TheContractorshalldevelopandimplementpoliciesandproceduresforthe
acceptanceofnewprovidersscreened,enrolled,andapprovedinwritingby
theState,andterminationorsuspensionofproviderstoensurecompliance
withtheContract.
2.9.30.3 PriortoenteringintoaNetworkProviderAgreement,theContractor shall
ensure that providers have been properly credentialed to ensure provider
facilities,organizations,andstaffmeetallqualificationsandrequirementsfor
participationintheLouisianaMedicaidProgramandasoutlinedintheMCO
Manual.
2.9.30.4 TheContractorshallusetheLouisianaStandardizedCredentialingApplication
Form(see
MCOManual)orCouncilforAffordableQualityHealthcare(CAQH)
standardizedcredentialingform.TheContractormustallowproviderstouse
CAQHifavailablefortheirprovidertype.
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2.9.30.5 The Contractor shall utilize the current NCQA Standards and Guidelines for
HealthPlanAccreditationforthecredentialingandre‐credentialingoflicensed
independent providers and provider groups with whom it contracts or
employsandwhofallwithinitsscopeofauthorityandaction.
2.9.30.6 If the Contractor has or is pursuing NCQA Health Plan Accreditation, those
credentialing policies and procedures shall meet LDH's credentialing
requirements.
2.9.30.7 The Contractor shall completely process credentialing applications from all
provider types within sixty (60) Calendar Days of receipt of a completed
credentialing application, including all necessary documentation and
attachments, and a signed Network Provider Agreement. “Completely
process”meansthattheContractorshall:
2.9.30.7.1 Providewrittenconfirmation,electronicallyorbymail,ofreceipt
totheproviderwithinfive(5)BusinessDaysofreceiptofthe
application;
2.9.30.7.2 Iftheapplicationisdeemedincomplete,sendawrittenrequest
withinthirty(30)CalendarDaysofreceiptoftheapplicationto
theproviderforallmissinginformation;
2.9.30.7.3 Review, approve and load approved applicants to its provider
filesinitsclaimsprocessingsystem;and
2.9.30.7.4 Submit on the weekly electronic Provider Directory to LDH or
LDH’sdesignee;or
2.9.30.7.5 Denytheapplicationandassurethattheproviderisnotusedby
theContractor.
2.9.30.8 The Contractor shall comply with interim credentialing requirements in
accordancewithLa.R.S.46:460.62.
2.9.30.9 IftheContractorhasdelegatedcredentialingtoasubcontractor,thereshallbe
awritten description ofthe delegation ofcredentialing activities withinthe
contract. The Contractor must require that the subcontractor provide
assurance that all licensed medical professionals are credentialed in
accordancewithLDH’scredentialingrequirements.
2.9.30.10 The Contractor shall not delegate credentialing of specialized behavioral
healthprovidersunlessapprovedbyLDHinwritinginadvance.
2.9.30.11 TotheextenttheContractorhasdelegatedcredentialingagreementsinplace
withanydelegatedcredentialingagencyapprovedbyLDHinwriting, the
Contractor shall ensure all providers submitted to the Contractor from the
delegatedcredentialingagentareloadedtoitsproviderfilesandintoitsclaims
processingsystemwithinthirty(30)CalendarDaysofreceipt.
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2.9.30.12 The Contractor shall notify LDH when it denies a provider credentialing
application for program integrity‐related reasons or otherwise limits the
abilityofproviderstoparticipateintheprogramforprogramintegrityreasons.
2.9.30.13 Theprocessofperiodicre‐credentialingshallbecompletedatleastonceevery
three(3)years.
2.9.30.14 The Contractor shall develop and implement policies and procedures for
approval of new providers, and termination or suspension of providers to
assurecompliancewiththeContract.Thepoliciesandprocedures should
include,butarenotlimitedto,theencouragementofapplicable board
certification(s).
2.9.30.15 The Contractor shall develop and implement a mechanism, subjecttoLDH
approval, for reporting quality deficiencies, which result in suspension or
terminationofaNetworkProvider.ThisprocessshallbesubmittedtoLDHor
itsdesigneeaspartofReadinessReviewandannuallythereafter,andpriorto
implementationofrevisions.
2.9.30.16 The Contractor shall designate a credentialing committee that uses a peer
review process to evaluate provider credentialing files (including re‐
credentialing files). The credentialing committee, including the Medical
Director,isresponsibleforcredentialingdecisionsandisrequiredtodocument
itsstepsinthedecisionprocessandmaintainindividualproviderfiles.
2.9.30.17 LDHreservestherighttocontractwithasingleNationalCommitteeforQuality
Assurance(NCQA)‐certifiedCredentialVerificationOrganization(CVO).Ifthis
optionispursued,theContractoranditssubcontractorsshallagreetousethe
CVOforthecredentialingandre‐credentialingofallNetworkProviders.The
Contractor will be given at least ninety (90) Calendar Days’ notice before
implementation of any CVO contract. When LDH implements a CVO, the
Contractorshall:
2.9.30.17.1 AcceptthefinalcredentialingdecisionsoftheCVO.
2.9.30.17.2 Within thirty (30) Calendar Days of receipt of an approved
credentialing decision, load providers in its claims processing
system.
2.9.30.17.3 Provide information to the State’s provider management
contractoronNetworkProviders.
2.9.30.17.4 Participate on the CVO’s Credentialing Committee to evaluate
providercredentialingfiles(includingre‐credentialingfiles)using
a peer review process. The credentialing committee is
responsibleforcredentialingdecisionswhich shallbeaccepted
bytheContractor.
2.9.31 NetworkGuidelinesforProvidersNeedingDCFSLicensing
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It is the Contractor’s responsibility to ensure its providers comply with DCFS licensing
requirements as applicable and can submit proof of compliance upon request. The
ContractorshallfollowcommunicationprotocolsasestablishedbyDCFSifnecessary.
2.9.32 Provider‐EnrolleeCommunicationAnti‐GagClause
2.9.32.1 Subjecttothelimitationsdescribedin42C.F.R.§438.102(a)(2),theContractor
shallnotprohibitorotherwiserestrictahealthcareprovideractingwithinthe
lawfulscopeofpracticefromadvisingoradvocatingonbehalfofanEnrollee,
whoisapatientoftheprovider,regardlessofwhetherbenefitsforsuchcare
ortreatmentareprovidedundertheContract,forthefollowing:
2.9.32.1.1 TheEnrollee’shealthstatus,medicalcare,ortreatmentoptions,
including any alternative treatment that may be self‐
administered;
2.9.32.1.2 Any information the Enrollee needs in order to decide among
relevanttreatmentoptions;
2.9.32.1.3 The risks, benefits and consequences of treatment or non‐
treatment;and
2.9.32.1.4 The Enrollee’s right to participate in decisions regarding their
health care, including, the right to refuse treatment, and to
expresspreferencesaboutfuturetreatmentdecisions.
2.9.32.2 Any Contractor that violates the anti‐gag provisions set forth in 42 C.F.R.
§438.102(a)(1)shallbesubjecttointermediatesanctions.
2.9.32.3 TheContractorshallcomplywiththeprovisionsof42C.F.R.§438.102(a)(1)(ii)
concerning the integrity ofprofessional advice given to Enrollees, including
interference with provider’s advice to Enrollees and information disclosure
requirementsrelatedtophysicianincentiveplans.
2.9.33 PharmacyNetwork,AccessStandards,andReimbursement
2.9.33.1 The Contractor shall provide a pharmacy network that complies with the
requirements of this Contract and the MCO Manual.Ataminimum,the
Contractor’s pharmacy network shall include only licensed and registered
pharmacieswho are appropriatelyscreened byand enrolled withthe State
andthat conform tothe LouisianaBoard ofPharmacyrules concerning the
recordstobemaintainedbyapharmacy.
2.9.33.2 TheContractorshallnotprohibitanypharmacyorpharmacistparticipatingin
the Louisiana Medicaid Program from contracting as a Network Provider
providedthepharmacyorpharmacistislicensedandingoodstandingwith
theLouisianaStateBoardofPharmacyandacceptsthetermsandconditions
ofthecontractofferedtothembytheContractor.
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2.9.33.3 Out‐of‐StatePharmacyProviders
2.9.33.3.1 Ifservicesare provided toan Enrollee whois out‐of‐state, the
Contractorshall require theproviderto enrollinthe Louisiana
MedicaidProgramforthepurposesofsecuringpaymentofthe
claim and finalizing the claim at issue, not for obtaining
continuousandactiveNetworkProviderstatus.TheContractor
may include out‐of‐state pharmacies that supply services not
availablewithinthestateasaNetworkProvider.
2.9.33.4 TheContractorshallhaveanetworkpharmacyauditprogramthatincludes,at
aminimum:
2.9.33.4.1 Random audits to determine provider compliance with the
policies, procedures and limitations outlined in the Network
ProviderAgreementandthisContract.TheContractorshallnot
utilizecontingencyfeebasedpharmacyaudits.
2.9.33.4.2 TheContractorshallsubmittoLDHoritsdesigneethepoliciesof
itsauditprogramforapprovalduringReadinessReview.
2.9.33.5 TheContractorshallensurethatpharmaciessubmittheNPIoftheprescriber
onallpharmacyclaims.TheContractorshalldenyclaimssubmittedwithout
theNPIoftheprescriber.
2.9.33.6 TheContractorshalleducateNetworkProvidersonhowtoaccessthePDLon
their websites. The Contractor shall also provide provider education on
pharmacyclaimsprocessingandpaymentpoliciesandprocedures.
2.9.33.7 In accordance with applicable Federal and State laws, regulations, rules,
policies, procedures, and manuals, the State Plan, and Waivers , the
Contractormaynegotiatetheingredientcostreimbursementinitscontracts
withproviders.However,theContractorshall:
2.9.33.7.1 ReimbursenolessthantheFFSRateonthedateofservicetoall
localpharmaciesasrequiredbyLa.R.S.46:460.36(D);
2.9.33.7.2 Reimburseanystateimposedproviderfeesforpharmacyclaims,
on top of the professional dispensing fee and ingredient cost
reimbursement;
2.9.33.7.3 Updatetheingredientcostsofmedicationsatleastweeklyand
withinthree(3)BusinessDaysofnewratesbeingpostedfrom
thenationaldatabasesourceselectedbytheContractor;
2.9.33.7.4 BaseMaximumAllowableCost(MAC)pricelistsongenericdrugs
withaFDAratingbeginningwithan“A”;
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2.9.33.7.5 Make the drug pricing list available to pharmacies for review,
uponrequest;and
2.9.33.7.6 Afford individual pharmacies a chance to appeal inadequate
reimbursement.
2.9.33.8 TheContractorandtheContractor’sPBMshallnotchargepharmacyproviders
claimsprocessingorproviderEnrollmentfees.ThisSectiondoesnotprohibit
sanctioningpharmacyproviders.
2.9.33.9 PharmacyClaimsDisputeManagement
The Contractor shall maintain an internal claims dispute process to permit
pharmacies to dispute the reimbursement paid for any claim madeforthe
dispensingofadrugasspecifiedintheMCOManual.
2.9.33.10 MailOrder/MailServicePharmacy
TheContractorshallnotrequireitsEnrolleestouseamailservicepharmacy.
Mailordershallnotexceedmorethanonepercent(1%)ofallpharmacy
claims.Enrolleesshallnotbechargedanyamountsaboveapplicablecopays
formailorder(e.g.shippingandhandlingfees).
2.9.33.11 SpecialtyDrugsandSpecialtyPharmacies
2.9.33.11.1 LDHrecognizestheimportanceofprovidingadequateaccessto
specialtydrugstoEnrolleeswhileensuringpropermanagement
ofhandlingandutilization.TheContractorshallcomplywiththe
specialtydrugandspecialtypharmacyrequirementsspecifiedin
theMCOManualandthisContract.
2.9.33.11.2 Aspecialty drugis defined as a prescription drugwhichmeets
twoormoreofthefollowingcriteria:
2.9.33.11.2.1 The drug is not routinely dispensed at a
majorityofretailcommunitypharmaciesdue
to physical or administrative requirements
that limit preparation and/or delivery in the
retail community pharmacy environment.
Suchdrugsmayinclude,butarenotlimitedto,
chemotherapy, radiation drugs, intravenous
therapy drugs, biologic prescription drugs
approvedforusebythefederalFoodandDrug
Administration, and/or drugs that require
physicalfacilitiesnottypicallyfoundinaretail
community pharmacy, such as a ventilation
hoodforpreparation;
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2.9.33.11.2.2 Thedrugisusedtotreatcomplex,chronic,or
raremedicalconditions:
Thatcanbeprogressive;or
That can be debilitating or fatal if left
untreatedorundertreated;or
Forwhichthereisnoknowncure.
2.9.33.11.2.3 The drug requires special handling, storage,
and/or has distribution and/or inventory
limitations;
2.9.33.11.2.4 Thedrughasacomplexdosingregimenor
requiresspecializedadministration;
2.9.33.11.2.5 Any drug that is considered to have limited
distribution by the federal Food and Drug
Administration;
2.9.33.11.2.6 Thedrugrequires:
Complexandextendedpatienteducation
orcounseling;or
Intensivemonitoring;or
Clinicaloversight;and
2.9.33.11.2.7 Thedrughassignificantsideeffectsand/orrisk
profile.
ProviderServicesandSupport
2.10.1 ProviderAdvisoryCouncil
TheContractorshallestablishaProviderAdvisoryCounciltoprovideinputandadviceto
enhance the Contractor’s service delivery, improve provider satisfaction and Enrollee
experience, promote data sharing and value‐based payment strategies, and enable
regularproviderparticipationinclinicalpolicydevelopmentandprovideroperations.
2.10.2 ProviderDirectory
2.10.2.1 TheContractorshallmaintainacompleteandaccurateproviderdirectoryas
requiredintheEnrolleeServicessectiontobeutilizedbyitsNetworkProviders.
2.10.2.2 TheContractorshallmakeavailabletoallPCPsalistingofreferralproviders,
including behavioral health providers, in hard copy if requested. The
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Contractorshallalsomaintainanupdatedelectronic,web‐accessibleversion
ofthereferralproviderlisting.
2.10.3 ProviderRelations
TheContractorshall:
2.10.3.1 EstablishandmaintainaformalproviderrelationsfunctiontorespondTimely
andadequatelytoinquiries,questions,andconcernsfromNetworkProviders;
2.10.3.2 Provide sufficient information and procedural guidelines to all providers in
ordertooperateinfullcompliancewiththisContractandallapplicableFederal
andStatelaws,regulations,rules,policies,procedures,andmanuals,theState
Plan,andWaivers;
2.10.3.3 Providesufficientinformationandproceduralguidelinestoallprovidersthat
addressservicesexcludedorlimitedbytheLouisianaMedicaidProgram;
2.10.3.4 Maintainaprotocolthatfacilitatescommunicationtoandfromprovidersand
the Contractor, and which shall include, but not be limited to,aprovider
newsletter, e‐mail, periodic provider meetings, and updated contact
informationforProviderRelationsrepresentativesthatincludestheirareasof
responsibility;
2.10.3.5 ExceptasotherwiserequiredorauthorizedbyLDHinwritingorbyoperation
oflaw,ensurethatprovidersreceivethirty(30)CalendarDaysadvancenotice
inwritingofpolicyandprocedurechanges,andmaintainaprocesstoprovide
education and training for providers regarding any changes thatmaybe
implemented,priortothepolicyandprocedurechangestakingeffect;
2.10.3.6 Workincollaborationwithproviderstoactivelyimprovethequalityofcare
provided to Enrollees, consistent with the quality improvement goals and
qualitymeasures,andallotherrequirementsofthisContract;
2.10.3.7 HavetrainedproviderrelationsstaffdedicatedtothisContractandavailable
toproviderstoaddressproviderissuesMondaythroughFridayfrom7a.m.to
7p.m.CentralTimeandtohandlenon‐routinePriorAuthorizationrequests
twenty‐four(24)hoursperdayseven(7)daysperweek;
2.10.3.8 Haveaprocessinplacetohandleafter‐hoursinquiriesfromprovidersseeking
toverifyEnrollmentforanEnrolleeinneedofurgentorEmergencyServices.
The Contractorandits providers shall notrequire such verification prior to
providingEmergencyServices;
2.10.3.9 Handle emergent provider issues twenty‐four (24) hours per day seven (7)
daysperweek;
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2.10.3.10 Provideongoingprovidertraining,respondtoproviderinquiriesandprovide
general assistance to providers regarding program operations and
requirements;and
2.10.3.11 Ensureregularlyscheduledvisitstoprovidersites,aswellasadhocvisitsas
circumstances dictate and provide technical assistance, including assistance
on the Contractor’s systems and billing practices. Documentation of these
visitsshallbeprovideduponrequestbyLDHandshallincludesign‐insheets,
agendas, documented follow‐up action items (as appropriate), and any
distributedmaterials.
2.10.4 ProviderToll‐FreeTelephoneLine
2.10.4.1 TheContractorshalloperateaprovidertoll‐freetelephonelinetorespondto
providerquestions,commentsandinquiries.Thetelephonelineshallinclude
the ability for providers to access interpreter services as described in the
EnrolleeServicessection.Thetelephonelineshallhavethecapabilitytotrack
providercallmanagementmetricsandcomplywiththemembercallcenter
performancestandardsoutlinedintheEnrolleeServicessection.
2.10.4.2 TheContractorshalldeveloptelephonelineproceduresthataddressthehiring
and training of personnel, staffing ratios, hours of operation, response
standards,monitoringofcallsviarecordingorothermeans,andcompliance
withthisContract’sstandards.
2.10.4.3 OutsideofBusinessHours,theproviderservicecomponentofthetelephone
lineshall include the capabilityof providing information regarding Business
Hours and instructions for verifying enrollment for any Enrollee with an
emergencyorurgentmedicalcondition.
2.10.5 ProviderWebsite
2.10.5.1 TheContractorshallhaveaproviderwebsite.Theproviderwebsitemaybe
developedonapagewithintheContractor’sexistingwebsite(suchasaportal)
tomeettheserequirements.Requirementsforthewebsitearecontainedin
theMCOManual.
2.10.5.2 TheContractorshallmaintainformsonitsproviderwebsitetoallowsubmittal
of complaints and disputes electronically. In addition, the Contractor shall
provideproviderswithanaddresstosubmitGrievancesandAppealsinwriting
andaphonenumbertosubmitGrievancesandAppealsbytelephone.
2.10.5.3 The Contractor’s provider website shall provide a secure provider portal in
accordancewiththefollowingrequirements:
2.10.5.3.1 TheContractorshallusecurrentstateandfederalstandardsand
procedures(e.g.,HL7,HIPAA,CMS,CPT,ICD‐10,andDSM‐5)for
all provider used systems and maintain a uniform service and
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provider taxonomy for billing and information management
purposes;
2.10.5.3.2 The Contractor shall, with appropriate Enrollee consent, allow
the provider access to Enrollee clinical data including
assessmentsandplansofcareand/orrelevantdatanecessaryto
provideforappropriatecoordinationofcare;
2.10.5.3.3 The Contractor shall grant user‐defined LDH access to and
trainingontheproviderwebsite;and
2.10.5.3.4 TheContractor shall provide a link tothe Medicaid Behavioral
HealthServicesProvider Manualandthe Contractor’sprovider
handbook.
2.10.5.4 The Contractor shall provide, in accordance with national standards,claims
inquiry information to providers and subcontractors via the Contractor’s
website.
2.10.5.5 TheContractorshalldevelopandmaintainmethodstocommunicatepolicies,
proceduresandrelevantinformationtoprovidersthroughitswebsite.
2.10.5.6 TheContractorshallprovideallqualifiedbehavioralhealthserviceproviders
accesstotheMedicaidBehavioralHealthServicesProviderManual,andany
updates,eitherthroughtheContractor’swebsite,orbyprovidingpapercopies
toprovidersuponrequest.
2.10.5.7 The Contractor shall remain compliant with HIPAA privacy and security
requirementswhenprovidinganyEnrolleeeligibilityormemberidentification
informationonthewebsite.
2.10.5.8 TheContractorwebsiteshallbeincompliancewithSection508oftheADA,
andmeetallstandardstheADAsetsforpeoplewithvisualimpairmentsand
disabilitiesthatmakeusabilityaconcern.
2.10.5.9 TheContractorisresponsibleforensuringthatthewebsiteismaintainedwith
accurateandcurrentinformationandiscompliantwithrequirementsofthis
Contract.
2.10.6 ProviderHandbook
2.10.6.1 The Contractor shall develop and maintain a provider handbook which
includesspecificinformationaboutMCOCoveredServices,non‐MCOCovered
Services, and other requirementsoftheContractrelevanttoprovider
responsibilities.
2.10.6.2 The Contractor shall submit to LDH or its designee for approvalaspartof
ReadinessReviewaproviderhandbookspecifictotheManagedCareProgram.
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2.10.6.3 TheContractorshallsubmitanupdatedproviderhandbooktoLDHannually
andasrequestedbyLDH.Requirementsforthehandbookarelocatedinthe
MCOManual.
2.10.6.4 TheContractorshalldistributeaproviderhandbooktoallprovidersatthetime
Network Provider Agreements are executed and annually as the provider
handbookisupdated.
2.10.6.5 The Contractor may choose not to distribute a hard copy of the provider
handbook, provided it submits a written notification to all providers that
explainshowtoobtaintheproviderhandbookfromtheContractor’swebsite.
Thisnotification shallalso detail howthe provider canrequesta hardcopy
fromtheContractoratnochargetotheprovider.Allproviderhandbooksand
bulletins shall be in compliance with applicable Federal and State laws,
regulations,rules,policies,procedures,andmanuals.Theproviderhandbook
shallserveasasourceofinformationregardingMCOCoveredServices,
policies and procedures, laws, regulations, telephone access, and special
requirementstoensureallContractrequirementsaremet.
2.10.6.6 The Contractor shall disseminate bulletins as needed to incorporate any
changestotheproviderhandbook.
2.10.7 ProviderEducationandTraining
2.10.7.1 TheContractorshallprovidetrainingtoallprovidersandtheirstaffregarding
therequirementsoftheContract,includinglimitationsonprovidermarketing,
andidentificationofspecialneedsofEnrollees.TheContractorshallconduct
initial training within thirty (30) Calendar Days of placing a new Network
Provider,orprovidergroup,onactivestatus.TheContractorshallalsoconduct
ongoingtraining,asdeemednecessarybytheContractororLDH,inorderto
ensurecompliancewithprogramstandardsandtheContract.
2.10.7.2 The Contractor shall submit a copy of the Provider Training Manual and
training schedule to LDH or its designee for approval as part of Readiness
Review.AnychangestothemanualshallbesubmittedtoLDHatleastthirty
(30)CalendarDayspriortothescheduledchangeanddisseminationofsuch
change.
2.10.7.3 TheContractorshalldevelopandofferspecializedinitialandongoingtraining
in the areas including, but not limited to, billing procedures and Service
Authorizationrequirements.
2.10.7.4 The Contractorshallprovide prescriber education, training andoutreachto
support the implementation, maintenance, and updating of its behavioral
health pharmacy management activities, including, but not limited to,
educationandtrainingrelativetothePreferredDrugList,PriorAuthorization
requirements,failfirst,step‐therapy,approvedprescribingcaps,andrelevant
Enrollee Appeal, expedited Appeal, and peer‐to‐peer procedures and
protocols. The Contractor shall submit its tentative prescriber
training and
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educationscheduleorplantoLDHoritsdesigneeaspartofReadinessReview
forapproval.
2.10.7.4.1 TheContractormustobtainpriorwrittenapprovalfromLDHfor
all provider materials related to the pharmacy benefit, unless
exemptedbyLDHinwriting.Provider(pharmacyandprescribing)
materialsmustbesubmittedtoLDHforapprovalatleastthirty
(30)CalendarDaysbeforeimplementation,unlesstheContractor
can demonstrate to LDH’s satisfaction that just cause for an
abbreviatedtimeframeexists.
2.10.7.5 TheContractorshallprovidetechnicalassistanceandnetworkdevelopment
training (e.g., billing, behavioral health services and authorization,
linguistic/cultural competency, etc.) for its behavioral health providers,
includingrequiredtrainingsforcertainbehavioralhealthproviders(e.g.Child
andAdolescentNeedsandStrengths[CANS],LevelofCareUtilizationSystem
[LOCUS], OBH standardized training for non‐licensed providers, etc.). The
Contractorshallmaintainrecordsofsuchtrainingincludingcompletiondates,
whichshallbemadeavailabletoLDHuponwrittenrequest.
2.10.7.6 TheContractorshallofferprovidertrainingsonintegratedcareincluding,but
notlimitedto,appropriateutilizationofbasicbehavioralhealthscreensinthe
primary care setting and basic physical health screenings in the behavioral
healthsetting.

2.10.7.7 The Contractor shall ensure that behavioral health providers (i.e.
organizations, practitioners and staff) are trained and/or meet training
requirementsinaccordancewithStatelaws,regulations,rules,policies,and
theMCOManualforMCOCoveredServices.
2.10.7.8 TheContractorshallprovideatleastseven(7)CalendarDaysadvancenotice
ofallProvidertrainingstoLDH,andLDHshallbeinvitedtoattendallprovider
sessions.TheContractorshallmaintainandprovideuponLDHwrittenrequest
allprovidertrainingreportsidentifyingtrainingtopicsprovided,dates,sign‐in
sheets,invited/attendees’lists,andorganizationstrained.
2.10.8 ProviderSatisfactionSurveys
2.10.8.1 The Contractor shall conduct an annual provider survey to assess overall
satisfaction,aswellassatisfactionwiththefollowingfunctions:
2.10.8.1.1 Accesstolinguisticassistance;
2.10.8.1.2 ProviderEnrollment;
2.10.8.1.3 Providercommunication;
2.10.8.1.4 Providereducationandtrainings(includingculturalcompetency
trainings);
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2.10.8.1.5 Resolutiontoprovidercomplaints/disputes;
2.10.8.1.6 Claimsprocessing;
2.10.8.1.7 Claimsreimbursement;
2.10.8.1.8 Network/coordinationofcare;
2.10.8.1.9 Utilization management processes (including medical reviews
and support toward Patient Centered Medical Home
implementation);and
2.10.8.1.10 NEMTservices.
2.10.8.2 TheProviderSatisfactionsurveytoolandmethodologymustbesubmittedto
LDHforapprovalninety(90)CalendarDayspriortoadministration.
2.10.8.3 Allrequiredcomponentsofthesurveytoolmustbeadministeredandresults
must be reported to LDH annually within the provider satisfaction survey
report. Survey response rates shall consider the population size and
demographiccategoryofproviderswithaminimummarginoferrorofplusor
minusfivepercent(5%)andaconfidencelevelofatleastninety‐five(95%).
Thisshallbetheminimumresponseratedforsurveyscompletedandreported
toLDH.
2.10.8.4 TheContractorshallsubmitanannualProviderSatisfactionSurveyReportthat
summarizes the survey methods and findings, includes the raw data in the
format required by LDH, and provides analysis of opportunities for
improvement. Provider Satisfaction Survey Reports are due one hundred
twenty(120)CalendarDaysaftertheendofthecontractyear.
2.10.9 ProviderComplaintSystem
2.10.9.1 DefinitionofProviderComplaint
For the purposes of this subsection, a provider complaint is any verbal or
writtenexpression,originatingfromaprovideranddeliveredtoanyemployee
oftheContractor,voicingdissatisfactionwithapolicy,procedure,paymentor
any other communication or action by the Contractor, including,butnot
limitedto,anadverseaction,excludingrequestofreconsiderationorappeal
forspecificindividualclaims.Itdoesincludegeneralcomplaintsaboutclaim
paymentpolicies.GrievancesandAppealsfiledbyprovidersonbehalfofan
Enrolleeshouldbe documentedandprocessed in accordance with Enrollee
GrievanceandAppealspolicies.
2.10.9.2 TheContractorshallestablishaProviderComplaintSystemtotrackthereceipt
and resolution of provider complaints from in‐network and out‐of‐Network
Providers.
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2.10.9.3 DefinitionofAdverseAction
Forthepurposesofthissubsection,anadverseactionisdefinedas:
Thedenialorlimitedauthorizationofarequestedservice,includingthe
typeorlevelofservice;
The reduction, suspension, or termination of a previously authorized
service;
The failure to provide services in a Timely manner, as defined inthis
section;or
ThefailureoftheMCOtoactwithinthetimeframesprovidedinthis
Contract.
2.10.9.4 Thissystemmustbecapableofidentifyingandtrackingprovidercomplaints
receivedbyphone,inwriting,orinperson.
2.10.9.5 AspartoftheProviderComplaintsystem,theContractorshall:
2.10.9.5.1 Have dedicated provider relations staff for providers to ask
questions,fileaprovidercomplaintandresolveproblems;
2.10.9.5.2 Identifyakeystaffpersonspecificallydesignatedtoreceiveand
processprovidercomplaints;
2.10.9.5.3 Thoroughlyinvestigateeachprovidercomplaintusingapplicable
statutory, regulatory, contractual and Network Provider
Agreement provisions, collecting all pertinent facts from all
parties and applying the Contractor’s written policies and
procedures;and
2.10.9.5.4 Ensure that the Contractor’s executives with the authority to
requirecorrectiveactionareinvolvedintheprovidercomplaint
escalation process. The Contractor shall provide the names,
phonenumbersande‐mailaddressesoftheseexecutivestoLDH
or its designee during Readiness Review and within two (2)
BusinessDaysofanychanges.
2.10.9.6 TheContractorshalldevelopandimplementwrittenpoliciesandprocedures
whichdetailtheoperationoftheProviderComplaintSystemandalignwith
the provider issue resolution requirements in the MCO Manual. The
ContractorshallsubmititsProviderComplaintSystempoliciesandprocedures
toLDHoritsdesigneeforapprovalaspartofReadinessReview.
2.10.9.7 The Contractor shall acknowledge provider complaints within three (3)
BusinessDaysofreceiptandshallresolvecomplaintsand/orcommunicatethe
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resulttotheproviderassoonaspossibleorwithinthirty(30)CalendarDaysof
receipt,whicheverissooner.
2.10.9.8 Thepoliciesandproceduresshallinclude,ataminimum:
2.10.9.8.1 Aprocess to allow providers to file a written complaint and a
descriptionofhowproviderscanfilecomplaintswiththe
Contractorandtheresolutiontime;
2.10.9.8.2 Adescription ofhow and under what circumstances providers
areadvisedthattheymayfileacomplaintwiththeContractor;
2.10.9.8.3 A description of how provider relations staff are trained to
distinguish between a provider complaint and an Enrollee
Grievance or Appeal in which the provider is acting on the
Enrollee’sbehalf;
2.10.9.8.4 A process to allow providers to consolidate complaints of
multiple claims that involve the same or similar payment or
coverageissues,regardlessofthenumberofindividualpatients
orpaymentclaimsareincludedinthebundledcomplaint;
2.10.9.8.5 A process for thoroughly investigating each complaint and for
collecting pertinent facts fromallpartiesduringthe
investigation;
2.10.9.8.6 A description of the methods used to ensure that the
Contractor’s executive staff with the authority to require
correctiveactionareinvolvedinthecomplaintprocess,as
necessary;
2.10.9.8.7 A process for giving providers or their representatives the
opportunitytopresenttheircasesinperson;
2.10.9.8.8 Identification of specific individuals who have authority to
administertheprovidercomplaintprocess;
2.10.9.8.9 Asystemtocapture,track,andreportthestatusandresolution
of all provider complaints, including all associated
documentation,whetherreceivedbytelephone,inperson,orin
writing;and
2.10.9.8.10 AprovisionrequiringtheContractorto report the status ofall
provider complaints and their resolution toLDH on a monthly
basisintheformatrequiredbyLDH.
2.10.9.9 The Contractor shall distribute, or make available in a readily accessible
format, its policies and procedures to in‐Network Providers at the time of
executionoftheNetworkProviderAgreement.TheContractormaydistribute
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a summary of these policies and procedures to providers if the summary
includesinformationabouthowtheprovidermayaccessthefullpoliciesand
proceduresontheContractor’swebsite.Thissummaryshallalsodetailhow
theNetworkProvidercanrequestahardcopyfromtheContractor at no
chargetotheprovider.
2.10.9.10 TheContractorshallnotprohibit,discourage,intimidate,orinanyotherway
takeretaliatoryactionagainstaproviderthatreportsanycomplainttoLDH.
ProviderReimbursement
TheContractorshalladministeraneffective,accurateandefficientclaimsprocessingsystemthat
AdjudicatesproviderclaimsforMCOCoveredServicesthatarefiledwithinthetimeframesspecified
inthis Contract and in compliance with all applicable Federaland State laws, regulations,rules,
policies,procedures,andmanuals.
2.11.1 MinimumReimbursementtoIn‐NetworkProviders
2.11.1.1 The Contractor shall provide reimbursement for MCO Covered Services
providedbyanin‐NetworkProvider.
2.11.1.2 ForMCOCoveredServices,theContractor’srateofreimbursementshallbeno
less than the published FFS Rate in effect on the date of serviceorthatis
containedontheweeklyprocedurefilesenttotheContractorbytheFI,orits
equivalent,unlessmutuallyagreedtobyboththeContractorandtheprovider
intheNetworkProviderAgreement.
2.11.1.3 For inpatient hospital services,theContractorshallhaveasystemwith the
capacity to group claims and reimburse under a Diagnosis Related Groups
(DRG) methodology as defined by LDH within one hundred eighty (180)
CalenderDays,orlongerifdeemedappropriatebyLDH,ofnotificationbyLDH
thatsuchreimbursementmethodologyisrequired.Uponimplementationof
themethodology,theContractor’srateofreimbursementshallbenolessthan
theDRGrateestablishedbyLDH,unlessmutuallyagreedtobyboth the
ContractorandtheproviderintheNetworkProviderAgreement.
2.11.1.4 Forcost‐basedservices,theContractor’srateofreimbursementshallbeno
lessthanthepublishedFFSRateadjustedbythecost‐basedsettlement.
2.11.1.5 For cases eligible for Outlier payments, the Contractor’s rate of
reimbursementshallbenolessthanthepublishedFFSRateplustheadditional
calculatedoutlieramount.
2.11.1.6 ForproviderswithstateEnrollmenteffectivedatesequaltoorlessthanninety
(90)CalendarDayspriortoexecutionoftheContractor’sNetworkProvider
Agreement,reimbursementshallbeprovidedfordatesofservicesonorafter
the state Enrollment effective date. For providers with state Enrollment
effectivedatesgreaterthanninety(90)CalendarDayspriortoexecutionof
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the Contractor’s Network Provider Agreement, reimbursement shall be
providedfordatesofservicesonoraftertheNetworkProviderAgreement
executiondate.In either case,if a providerwould otherwisebeeligible for
reimbursement at an earlier date under La. R.S. 46:460.62, then
reimbursementshallbeprovidedfordatesofserviceonorafterthatdate. 
2.11.2 FQHC/RHCContractingandReimbursement
2.11.2.1 TheContractor shallensurethatits paymentsto Federally Qualified Health
Centers(FQHCs)
andRuralHealthClinics(RHCs)forservicestoEnrolleesare
greaterthanorequaltothepaymentamountsdescribedin42U.S.C.
§1396a(bb).Inordertocomplywiththisrequirement,theContractorshallpay
FQHCsandRHCsatleasttheamountLDHwouldpayforsuchservicesthrough
FFSasdefinedbytheProspectivePaymentSystem(PPS)rateineffectonthe
dateofserviceforeachencounteroranalternativepaymentmethodology
approvedbyLDHinwriting.
2.11.2.2 IftheContractorisunabletocontractwithanFQHCorRHC,theContractoris
notrequiredtoreimbursethatFQHCorRHCwithoutPriorAuthorizationfor
out‐of‐networkservicesunless:
2.11.2.2.1 The medically necessary services are required to treat an
EmergencyMedicalCondition;or
2.11.2.2.2 FQHC/RHC services are not available through at least one (1)
MCOwithinLDH’sestablisheddistancetravelstandards.
2.11.2.2.3 The Contractor may stipulate that reimbursement will be
contingent upon receiving a clean claim and all the medical
informationrequiredtoupdatetheEnrollee’smedicalrecord.
2.11.3 IndianHealthService(IHS)Providers
TheContractorshallreimbursetheIHSproviderattheannualratespublishedbytheIHS
intheFederalRegister.IHSissuesthepaymentratebasedonacalendaryearthatwillbe
effectiveretroactivetoJanuary1ofthatyear.TheContractorshallrecycleclaimsforthe
calendaryeartocapturetheadjustedrate.See42C.F.R.§438.14(c).
2.11.4 ReimbursementtoOut‐of‐NetworkProviders
2.11.4.1 TheContractorshallmakepaymentforcoveredemergencyandpost‐
stabilizationservicesthatarefurnishedtoEnrolleesbyprovidersthathaveno
contractual arrangements with the Contractor for the provision of such
services. The Contractor shall reimburse the provider one hundred percent
(100%)of the FFS RateforEmergency Services. In compliance with Section
6085 of the Deficit Reduction Act (DRA) of 2005, reimbursement by the
Contractor to out‐of‐Network ProvidersfortheprovisionofEmergency
ServicesshallbenomorethantheFFSRate.
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2.11.4.2 For services that do not meet the definition of Emergency Services, the
Contractorshallcompensate,ataminimum,ninetypercent(90%)ofthe
publishedFFSRateineffectonthedateofservicetoout‐of‐NetworkProviders
towhomtheyhavemadeatleastthree(3)documentedattemptstoinclude
intheirnetwork(exceptasnotedinthissectionforFQHCs,RHCsandIHS
providers).TheContractormayrequirePriorAuthorizationforout‐of‐network
services, unless services are required to treat an Emergency Medical
Condition.
2.11.4.3 The Contractor shallnotmake payment forCommunity Psychiatric Support
Treatment (CPST) or Psychosocial Rehabilitation (PSR) services that are
furnishedtoEnrolleesbyprovidersthatareout‐of‐network.TheContractor
maymakepaymentforCPSTorPSRservicesonlytothoseproviderswhoare
credentialedandparticipatingintheprovidernetworkoftheContractorfor
theprovisionofsuchservices,orwhoarelicensedandaccreditedandhavea
singlecaseagreementwiththeContractorforprovisionofsuchservices.
2.11.4.4 TheContractorshallreimburseout‐of‐NetworkProvidersfortheprovisionof
servicesrequiredbytheContinuityofCaresectionatthein‐networkrate,in
accordance with the Minimum Reimbursement to In‐Network Providers
section.
2.11.5 EffectiveDateofPaymentforNewEnrollees
TheContractorisresponsibleforpaymentofMCOCoveredServicesfromanEnrollee’s
effectivedateofEnrollmentwiththeContractor.
2.11.6 ClaimsProcessingRequirements
2.11.6.1 Ata minimum,theContractorshallrunone(1)providerpaymentcycleper
week,onthesamedayeachweek,asdeterminedbytheContractor.
2.11.6.2 The Contractor shall support a CAQH/CORE compliant interface tothe
automatedclearinghouse(ACH)thatallowsproviderstorequestandreceive
electronicfundstransfer(EFT)ofclaimspayments.
2.11.6.3 The Contractor shall encourage its providers to submit and receive claims
informationthroughelectronicdatainterchange(EDI)asanalternativetothe
filingofpaper‐basedclaims.
2.11.6.4 Claims shall be processed in adherence to information exchange and data
managementrequirementsspecifiedinthisContract.
2.11.6.5 The Contractor shall not pay any claim submitted by a provider who is
excludedorsuspendedfromthe Medicare,Medicaid, orCHIPprogramsfor
Fraud,Abuse,orWasteorotherwiseincludedontheDepartmentofHealth
and Human Services Officeof InspectorGeneral exclusions list,
oremploys
someoneonthislist.TheContractorshallnotpayanyclaimsubmittedbya
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providerthatisonpaymentsuspensionand/orwithholdundertheauthority
ofLDHoritsauthorizedagent(s).
2.11.6.6 The Contractor shall inform all Network Providers about Clean Claim
requirements. The Contractor shall make requirements and guidelines for
claimscodingandprocessingthatarespecifictoProvidertypesavailableto
NetworkProviders.TheContractorshallnotifyprovidersninety(90)Calendar
Daysbeforeimplementingchangestoclaimscodingandprocessingguidelines,
or as soon aspossible if directedby LDH pursuant to Federalor State law,
regulation,rule,orpolicytoimplementsuchchangeearlier.
2.11.7 InappropriatePaymentDenials,Delays,orRecoupments
If the Contractor has a pattern, as determined by LDH, of inappropriately denying,
delayingorrecoupingproviderpaymentsforservices,theContractormaybesubjectto
suspensionofnewEnrollments,MonetaryPenaltiesequaltooneandone‐half(1.5)times
the value of the claims inappropriately denied, delayed, or recouped, contract
cancellation, or refusal to contract in a future time period. This applies not only to
situationswhereLDHhasorderedpaymentafterappealbuttosituationswherenoappeal
hasbeenmade(i.e.LDHisknowledgeableaboutthedocumentedinstancesfromother
sources).
2.11.7.1 If the Contractor has a pattern, as determined by LDH, of inappropriately
denying, delaying, or recouping provider payments for services after the
terminationoftheContract,LDHmayimposeMonetaryPenaltiesequaltoone
and one‐half (1.5) times the value of the claims inappropriately denied,
delayed,orrecouped.LDHmay,atitssolediscretion,makeaclaimagainstthe
performancebondordeductfromthewithholdofthefinalpaymenttosatisfy
theMonetaryPenaltiesimposed.
2.11.8 PaymentforEmergencyServicesandPost‐StabilizationServices
2.11.8.1 TheContractorshallreimburseprovidersforEmergencyServices rendered
withoutarequirementforServiceAuthorizationofanykind.
2.11.8.2 The Contractor’s protocol for provision of Emergency Services shall specify
thatEmergencyServicesshallbecoveredwhenfurnishedbyaproviderwith
whomtheContractordoesnothaveaNetworkProviderAgreementorreferral
arrangement.
2.11.8.3 TheContractormaynotlimitwhatconstitutesanEmergencyMedical
Conditiononthebasisofdiagnosesorsymptoms.
2.11.8.4 TheContractorshallnotdenypaymentfortreatmentobtainedundereither
ofthefollowingcircumstances:
2.11.8.4.1 AnEnrolleehadanEmergencyMedicalCondition,includingcases
inwhichtheabsenceofimmediatemedicalattentionwouldnot
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resultinplacingthehealthoftheindividual(or,forapregnant
woman,thehealthofthewomanorherunbornchild)inserious
jeopardy, serious impairment to bodily functions, or serious
dysfunctionofanybodilyorganorpart;or
2.11.8.4.2 ArepresentativeoftheContractorinstructstheEnrolleetoseek
EmergencyServices.
2.11.8.5 The Contractor shall not refuse to cover Emergency Services based on the
emergency room provider, hospital, or fiscal agent’s failure tonotifythe
Enrollee’sPCPortheContractoroftheEnrollee’sscreeningandtreatment
withinten(10)CalendarDaysofpresentationforEmergencyServices.
2.11.8.6 The Contractor shall be financially responsible for Emergency Services,
including transportation, and shall not retroactively deny a claim for
Emergency Services, including transportation, to an emergency provider
becausethecondition,whichappearedtobeanEmergencyMedicalCondition
underthe prudentlaypersonstandard,was subsequentlydeterminedtobe
non‐emergentinnature.
2.11.8.7 TheContractorisfinanciallyresponsibleforpost‐stabilizationcareservices,as
specifiedin42C.F.R.§438.114(e)and§422.113(c),obtainedwithinoroutside
thenetworkthatare:
2.11.8.7.1 Pre‐approved by a Network Provider or other Contractor
representative;or
2.11.8.7.2 Not pre‐approved by a Network Provider or other Contractor
representative,but:
2.11.8.7.2.1 Administered to maintain the Enrollee’s
stabilized condition within one (1) hour of a
requesttotheContractorforpre‐approvalof
furtherpost‐stabilizationcareservices;
2.11.8.7.2.2 Administeredtomaintain,improveorresolve
the Enrollee’s stabilized condition if the
Contractor:
Doesnotrespondtoarequestforpre‐
approvalwithinone(1)hour;
Cannotbecontacted;or
Contractor’s representative and the
treating physician cannot reach an
agreementconcerningtheEnrollee'scare
andanetworkphysician isnot available
for consultation. In this situation, the
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Contractor shall give the treating
physiciantheopportunitytoconsultwith
a network physician and the treating
physicianmaycontinuewithcareof the
patient until a network physician is
reachedoroneofthecriteriaof42C.F.R.
§422.113(c)(3)ismet.
2.11.8.7.2.3 Are for post‐stabilization hospital‐to‐hospital
ambulancetransportationofEnrolleeswitha
behavioralhealthcondition,includinghospital
tobehavioralhealthspecialtyhospital.
2.11.8.8 The attending emergency physician, or the provider actually treating the
Enrollee, is responsible for determining when the Enrollee is sufficiently
stabilizedfortransferordischarge,andthatdeterminationisbindingonthe
Contractor as responsible for coverageandpaymentasper42C.F.R.
§438.114(d). The Contractor’s financial responsibility ends forpost
stabilizationcareservicesithasnotpre‐approvedwhen:
2.11.8.8.1 A network physician with privileges at the treating hospital
assumesresponsibilityfortheEnrollee’scare;
2.11.8.8.2 A network physician assumes responsibility for the Enrollee’s
carethroughtransfer;
2.11.8.8.3 A representative of the Contractor and the treating physician
reachanagreementconcerningtheEnrollee’scare;or
2.11.8.8.4 TheEnrolleeisdischarged.
2.11.9 Non‐PaymentforSpecifiedServices
TheContractorshalldenypaymenttoprovidersfordeliveriesoccurringbeforethirty‐nine
(39)weekswithoutamedicalindication.
2.11.10 ProviderPreventableConditions(PPCs)
2.11.10.1 The Contractor shall deny payment to providers for PPCs that meet the
followingcriteria:
2.11.10.1.1 IsidentifiedintheStatePlan;
2.11.10.1.2 Hasbeen found by theState, based upon a review of medical
literature by qualified professionals, to be reasonably
preventablethroughtheapplicationofproceduressupportedby
evidence‐basedguidelines;
2.11.10.1.3 HasanegativeconsequencefortheBeneficiary;
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2.11.10.1.4 Isauditable;and
2.11.10.1.5 Includes, at a minimum, wrong surgical or other invasive
procedure performed on a patient, surgical or other invasive
procedure performed on the wrong body part, or surgical or
otherinvasiveprocedureperformedonthewrongpatient.
2.11.10.2 TheContractorshallrequireallproviderstoreportPPCsassociatedwithclaims
forpaymentorEnrolleetreatmentsforwhichpaymentwouldotherwisebe
made.PPCsshouldbeidentifiedontheencounterfileviathePresent on
Admission(POA)indicators.
2.11.11 PaymentforNewbornCare
The Contractor shall cover all newborn care rendered within the first month of life
regardlessofwhetherprovidedbythedesignatedPCPoranotherNetworkProvider.The
Contractorshallcompensate,ataminimum,ninetypercent(90%)oftheFFSRateineffect
foreachservicecodedasaprimarycareservicerenderedtoanewbornwithinthirty(30)
CalendarDaysofthe Enrollee’sbirthregardlessofwhether theproviderispartofthe
Contractor’snetwork,butsubjecttothesamerequirementsasaNetworkProvider.
2.11.12 PaymentforHospitalServices
The Contractor is not responsible for reimbursement of graduatemedicaleducation
(GME) payments ordisproportionate share hospital (DSH) payments to providers. The
Contractorshallusetheincreasedhospitalfundsreceivedabovethebaserate(subjectto
riskadjustment)totheFullMedicaidPricing,oranysuccessive payment model, as
detailed in Attachment D, Actuarial Rate Certification Letter, for reimbursement of
inpatientandoutpatienthospitalservicesincompliancewith42C.F.R.§438.6.
2.11.13 PaymentforAmbulanceServices
TheContractorshallusetheincreasedambulanceservicesfundsreceivedabovethebase
rate(subjecttoriskadjustment)totheFullMedicaidPricing,oranysuccessivepayment
model,asdetailedinAttachmentD,ActuarialRateCertificationLetter,forreimbursement
ofambulanceservicesincompliancewith42C.F.R.§438.6.
2.11.14 PaymentforPhysicianServices
TheContractorshallusetheincreasedphysicianservicesfundsreceivedabovethebase
rate(subjecttoriskadjustment)totheFullMedicaidPricing,oranysuccessivepayment
model,asdetailedinAttachmentD,ActuarialRateCertificationLetter,forreimbursement
ofphysicianservicesincompliancewith42C.F.R.§438.6.
2.11.15 Federal Responsibility for Payment for SBHS Provided to Enrollees Participating in
CoordinatedSystemofCare
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2.11.15.1 TheCSoCcontractorshallberesponsibleforpaymenttoenrolledprovidersfor
theprovisionofSBHS,withtheexceptionofPRTF,TGH,andSUDResidential
treatmentservices(ASAM3.1,3.2‐wm,3.5and3.7forchildrenunder21and
Levels3.3and3.7‐wmforyouthaged21),foreachmonthduringwhichthe
Enrolleehasa1915(c)/1915(b)(3)Waiversegmentontheeligibilityfilewitha
begindateonorearlierthanthefirst(1
st
)CalendarDayofthatmonth,orin
theeventthatanEnrolleetransfersbetweenWaiversduringthemonth,but
theprevioussegmentbeganonorearlierthanthefirst(1
st
)CalendarDayof
thatmonth.
2.11.15.2 TheCSoCcontractorshallberesponsibleforpaymenttoenrolledprovidersfor
theprovisionofSBHSthroughthelastdayofthemonthwhichincludesthe
enddateofthe1915(c)/1915(b)(3)segmentontheeligibilityfile.
2.11.15.3 TheContractorshallberesponsibleforpaymenttoenrolledprovidersforthe
provision of SBHS for any month during which the Enrollee has a
1915(c)/1915(b)(3)segmentontheeligibilityfilewithabegindatelaterthan
thefirst(1
st
)CalendarDayofthatmonth.
2.11.15.4 TheContractor shallbe responsibleforpayment ofall PRTF,TGH,andSUD
Residential treatment services (ASAM Levels 3.1, 3.2‐wm, 3.5 and 3.7 for
children under 21 and Levels 3.3 and 3.7‐wm for youth aged 21) for CSoC
enrolledyouth.
2.11.15.5 IfanEnrolleenolongermeetsmedicalnecessitycriteriaforahigherlevelof
care(i.e.,inpatienthospital)thatwasauthorizedbytheCSoCcontractor,and
the Contractor has authorized PRTF, TGH, or SUD Residential treatment
services (ASAM Levels 3.1, 3.2‐wm, 3.5 and 3.7), but is unable to secure
placement, the Contractor shall be responsible for assuming the continued
authorizationof,andpaymentfor,thehigherlevelserviceuntilplacementis
made,regardlessof the Enrollee’sCSoC Enrollmentstatus,unless theChild
and Family Team (CFT) agrees that the Enrollee’s behavioral health and/or
medical condition is stable enough for the Enrollee to be safely discharged
home,andtheCFThasmadeaplantosupporttheEnrolleeandfamilywith
outpatientcareuntilplacementinresidentialtreatmentissecured.
UtilizationManagement
TheContractorshalldevelopautilizationmanagement(UM)programforallMCOCoveredServices
thatfacilitatesthedeliveryofhighquality,cost‐efficient,andeffectivecare.
2.12.1 GeneralRequirements
2.12.1.1 The Contractor shall develop and maintain written program policies and
procedureswithdefinedstructuresandprocessesthatmeetNCQAstandards.
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2.12.1.2 The Contractor shall submit written policies and procedures to LDH or its
designeeforapprovalaspartofReadinessReviewandpriortoanysubstantive
changes.Policiesandproceduresshallinclude,butnotbelimitedto:
2.12.1.2.1 The methodology utilized to evaluate the medical necessity,
appropriateness,efficacy,orefficiencyofhealthcareservices;
2.12.1.2.2 Provisionsforensuringconfidentialityofclinicalinformation;
2.12.1.2.3 ThereportingofFraudandAbuseinformationidentifiedthrough
theprogramtoLDHinaccordancewith42C.F.R.§455.1(a)(1);
2.12.1.2.4 Policies and procedures to maintain, or require providers and
contractors to maintain, an individual health record for each
Enrollee,inaccordancewiththe MCOManual. TheContractor
shallcollectandprovidehealthrecordstoLDHuponrequest;
2.12.1.2.5 Whereapplicable,the requirementthateachEnrollee'srecord
includesinformationneededtoperformutilizationreviews.This
informationmustinclude,atleast,thefollowing:
2.12.1.2.5.1 IdentificationoftheEnrollee;
2.12.1.2.5.2 ThenameoftheEnrollee'sphysician;
2.12.1.2.5.3 Dateofadmission,anddatesofapplicationfor
and authorization of Louisiana Medicaid
Program benefits if application is made after
admission;
2.12.1.2.5.4 ThePOCrequiredunder42C.F.R.§456.80and
§456.180;
2.12.1.2.5.5 Initial and subsequent continued stay review
dates described under 42 C.F.R. §456.128,
§456.133,§456.233and§456.234;
2.12.1.2.5.6 Date of operating room reservation, if
applicable;and
2.12.1.2.5.7 Justification of emergency admission, if
applicable.
2.12.1.3 Alldocumentationand/orrecordsmaintainedbytheContractor,itsmaterial
subcontractors,anditsNetworkProvidersrelatedtoMCOCoveredServices,
charges,operationsandagreementsunderthisContractshallbemaintained
foratleastten(10)calendaryearsafterthelastgood,serviceorsupplyhas
beenprovidedtoanEnrolleeoranauthorizedagentofthestateorfederal
governmentoranyofitsauthorizedagentsunlessthoserecordsaresubject
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toreview,audit,investigationsorsubjecttoanadministrativeorjudicialaction
brought by or on behalf of the state or federal government. Under no
circumstances shall the Contractororanyofitsmaterialsubcontractors
destroyordisposeofanysuchrecords,evenaftertheexpiration of the
mandatoryten(10)yearretentionperiod,withouttheexpresspriorwritten
permissionofLDH.
2.12.1.4 The Contractor shall submit utilization management reportsas specified by
LDH.
2.12.2 UtilizationManagementCommittee
2.12.2.1 TheUMprogramshallincludeaUMCommitteethatintegrateswith other
functional units of the Contractor as appropriate and supports the quality
assessment and performance improvement program (QAPI) Program as
definedintheQualityManagementandQualityImprovementsection.
2.12.2.2 The UM Committee shall provide utilization review and monitoring of UM
activities of both the Contractor and its providers and is directed by the
Contractor’sMedicalDirector.TheUMCommitteeshallconvenenolessthan
quarterlyandshallmakemeetingminutesavailabletoLDHuponrequest.LDH
representatives,asappointedbyLDH,shallbeincludedasmembersoftheUM
Committee,ifrequested.UMCommitteeresponsibilitiesinclude:
2.12.2.2.1 Reviewing,updating,andapprovingpoliciesandproceduresfor
UM that conform to industry standards, including methods,
timelinesandindividualsresponsibleforcompletingeachtask;
2.12.2.2.2 Monitoringthemedicalappropriatenessandnecessityofhealth
careservicesprovidedtoitsEnrollees;
2.12.2.2.3 Monitoringproviders’requestsforPriorAuthorizationofhealth
careservicestoitsEnrollees;
2.12.2.2.4 Monitoring consistent application of Service Authorization
criteria;
2.12.2.2.5 Monitoringover‐andunder‐utilization;
2.12.2.2.6 ReviewofOutliers;and
2.12.2.2.7 Monitoringofhealthrecordreviews.
2.12.3 GeneralServiceAuthorizationRequirements
2.12.3.1 TheContractorshallhaveclearlydelineatedServiceAuthorizationprocedures
forPriorAuthorization,concurrentauthorization,andpostauthorizationthat
complywith42C.F.R.§438.210andanycourt‐orderedrequirementsofLDH.
ForpharmacyServiceAuthorizations,seetheMCOManual.
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2.12.3.2 TheContractormaynotarbitrarilydenyorreducetheamount,duration,or
scope of a required service solely because of diagnosis, type of illness, or
conditionoftheEnrollee.
2.12.3.3 The Contractor must ensure that the services are sufficient in amount,
duration,orscopetoreasonablyachievethepurposeforwhichtheservices
arefurnished.
2.12.3.4 TheContractorshallnotberequiredtopayforaparticularitem orservice
when the provider does not provide requested medical information for
purposesofmakingaServiceAuthorizationdetermination,forthatparticular
itemorservice.
2.12.3.4.1 When the provider fails to provide requested medical
information, the Contractor may at its discretion, or shall as
directedbyLDH,imposefinancialpenaltiesagainsttheprovider
asappropriate.
2.12.3.5 Allcourt‐orderedbehavioralhealthservicesaresubjecttomedicalnecessity
review.Inorderfortheservicetobeeligibleforreimbursement, the
ContractorshalldeterminethattheserviceismedicallynecessaryandanMCO
CoveredService.
2.12.3.6 TheContractorshallmaintainwrittenproceduresincluding,butnotlimitedto,
thefollowing:
2.12.3.6.1 Aprocess for submission and processing of requests for initial
andcontinuingauthorizationsofservices;
2.12.3.6.1.1 The Contractor is responsible for eliciting
pertinenthealthrecordinformationfromthe
treating health care provider(s), as needed
and/oras requested by LDH, for purposes of
makingServiceAuthorizationdeterminations.
2.12.3.6.1.2 The Contractor shall take appropriate action
whenatreatinghealthcareproviderdoesnot
providecompletemedicalhistoryinformation
withintherequestedtimeframe.
2.12.3.6.2 The process to be followed in the event the Contractor
determines the need for additional information not initially
requested;
2.12.3.6.3 The process for conducting peer‐to‐peer reviews of adverse
determinations;
2.12.3.6.4 A process to ensure that authorization requirements of the
Contractorshalleitherbefurnishedtothe healthcareprovider
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withintwenty‐four(24)hoursofarequestfortherequirements
orpostedinaneasilysearchableformat,thatincludesthedate
oflastreview,ontheContractor’swebsite.TheContractorshall
furnishtheserequirementstoProvidersinadditiontothePrior
Authorization information and training that must be furnished
undertheProviderServicesandSupportsection;
2.12.3.6.5 Aprocesstoarrangeforanotherlevelofcareifappropriatewhen
theContractordeniesaServiceAuthorizationrequest;and
2.12.3.6.6 Amechanism by which an Enrollee may submit, verbally or in
writing,aServiceAuthorizationrequest.Thisprocessshallalso
beincludedintheMemberHandbookand incorporatedin the
Grievanceprocedures.
2.12.4 ServiceAuthorizationCriteria
2.12.4.1 TheContractorshallensurethatServiceAuthorizationcriteriaareconsistent
withapplicableFederalandStatelaws,regulations,rules,policies,procedures,
andmanuals,theStatePlan,andWaivers;
2.12.4.2 TheContractorshalluseLDH’sdefinitionofmedicallynecessaryservices;
2.12.4.3 TheContractorshallonlyusecriteriathat:
2.12.4.3.1 Are adopted in consultation with contracted healthcare
providers;
2.12.4.3.2 Areobjectiveandbasedonvalidandreliableclinicalevidenceor
aconsensusofhealthcareprofessionalsintheparticularfield;
2.12.4.3.3 ConsidertheneedsoftheEnrollees;and
2.12.4.3.4 Areupdatedperiodicallyasappropriate.
2.12.4.4 TheContractorshallclearlyidentifythesourceofthecriteriaandinclude:
2.12.4.4.1 Thevendorifthecriteriawerepurchased;
2.12.4.4.2 Theassociation if the criteria are developed/recommended or
endorsedbyanationalorstatehealthcareproviderassociation
orsociety;and/or
2.12.4.4.3 The guideline source if the criteria are based on a published
clinicalpracticeguideline.
2.12.5 ServiceAuthorizationStaffingRequirements
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2.12.5.1 TheContractorshallensurethatcompensationtoindividualsorentitiesthat
conductUMactivitiesisnotstructuredtoprovideincentivesfortheindividual
or entity to deny, limit, or discontinue medically necessary MCO Covered
ServicestoanyEnrolleeinaccordancewith42C.F.R.§438.3(i)and42C.F.R.
§422.208.
2.12.5.2 The Contractor shall ensure that only licensed clinical professionals with
appropriateclinical expertisein the treatmentofan Enrollee’s conditionor
diseaseandtrainingintheuseofanyrequiredassessmentsshalldetermine
Service Authorization request denials or authorize a service in an amount,
durationorscopethatislessthanrequested.
2.12.5.2.1 Theindividualmakingdeterminationsshallattestthatnoadverse
determinationwillbemaderegardinganymedicalprocedureor
serviceoutsideofthescopeoftheindividual’sexpertise.
2.12.5.3 The Contractor shall ensure that staff consistently and correctly apply
authorization criteria and make appropriate determinations, including a
processtoensurestaffperformingbelowacceptablethresholdsoninter‐rater
reliability tests are not permitted to make independent authorization
determinationsuntilsuchtimethatthestaffmembercanberetrained,
monitored, and demonstrate performance that meets or exceeds the
acceptablethreshold;
2.12.5.4 Theindividual(s)makingdeterminationsshallhavenohistoryofdisciplinary
action or sanctions, including loss of staff privileges or participation
restrictions, that have been taken or are pending by any hospital,
governmentalagencyorunit,orregulatorybodythatraiseasubstantial
questionastotheclinicalpeerreviewer’sphysical,mental,orprofessionalor
moralcharacter.
2.12.5.5 TheContractorshallprovidestaffspecificallyassignedto:
2.12.5.5.1 SBHS;and
2.12.5.5.2 PSHtoensureappropriateauthorizationoftenancyservices.
2.12.6 ServiceAuthorizationDeterminationTimingandNotices
2.12.6.1 StandardServiceAuthorization
2.12.6.1.1 The Contractor shall make eighty percent (80%) of standard
Service Authorization determinations within two (2) Business
Daysofobtainingappropriatemedicalinformationthatmaybe
requiredregardingaproposedprocedure,orservicerequiringa
reviewdetermination,withthefollowingexceptions:
2.12.6.1.1.1 The Contractor shall make all inpatient
hospitalServiceAuthorizationswithintwo(2)
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Calendar Days of obtaining appropriate
medicalinformation;and
2.12.6.1.1.2 The Contractor shall make all CPST and PSR
ServiceAuthorizationswithinfive(5)Calendar
Days of obtaining appropriate medical
information.
2.12.6.1.2 AllstandardServiceAuthorizationdeterminationsshallbemade
nolaterthanfourteen(14)CalendarDaysfollowingreceiptofthe
requestforservice.
2.12.6.1.3 TheServiceAuthorizationdeterminationmaybeextendedupto
anadditionalfourteen(14)additionalCalendarDaysif:
2.12.6.1.3.1 The Enrollee, or the provider, requests the
extension;or
2.12.6.1.3.2 TheContractorjustifies(toLDHuponrequest)
aneedforadditionalinformationandhowthe
extensionisintheEnrollee’sinterest.
2.12.6.1.4 TheContractorshallmakeallconcurrentreviewdeterminations
withinone(1)CalendarDayofobtainingtheappropriatemedical
informationthatmayberequired.
2.12.6.2 ExpeditedServiceAuthorization
2.12.6.2.1 Intheeventaproviderindicates,ortheContractordetermines,
that following the standard Service Authorization timeframe
couldseriouslyjeopardizetheEnrollee’slifeorhealthorability
toattain,maintain,orregainmaximumfunction,theContractor
shall make an expedited authorization determination and
providenoticeasexpeditiouslyastheEnrollee’shealthcondition
requires,butnolaterthanseventy‐two(72)hoursafterreceipt
oftherequestforservice.
2.12.6.2.2 The Contractor may extend the seventy‐two (72) hour time
periodbyuptofourteen(14)CalendarDaysiftheEnrollee
requeststheextensionoriftheContractorjustifiestoLDHaneed
for additional information and how the extension is in the
Enrollee’sbestinterest.
2.12.6.3 PostAuthorization
2.12.6.3.1 TheContractorshallmakeretrospectivereviewdeterminations
withinthirty(30)CalendarDaysofobtainingtheresultsofany
appropriatemedicalinformationthatmayberequired,butinno
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instancelaterthanonehundredeighty(180)CalendarDaysfrom
thedateofreceiptofrequestforServiceAuthorization.
2.12.6.3.2 TheContractor shall notsubsequently retract its authorization
afterserviceshavebeenprovidedorreducepaymentforanitem
or service furnished in reliance upon previous Service
Authorizationapproval, unless the approvalwas based upon a
material omission or misrepresentation about the Enrollee’s
healthconditionmadebytheprovider.
2.12.6.3.3 The Contractor shall not use a policy with an effective date
subsequenttotheoriginalServiceAuthorizationrequestdateto
rescinditsPriorAuthorization.
2.12.6.4 NoticesofDeterminations
2.12.6.4.1 ServiceAuthorizationApprovals
2.12.6.4.1.1 ForServiceAuthorizationapprovalforanon‐
emergency admission, procedure or service,
the Contractor shall notify the provider
verbally or as expeditiously as the Enrollee’s
health condition requires but not more than
one (1) Business Day of making the initial
determination and provide written
notification to the provider within two (2)
BusinessDaysofmakingthedetermination.
2.12.6.4.1.2 For Service Authorization approval for
extended stay or additional services, the
Contractorshallnotifytheproviderrendering
theservice,whetherahealthcareprofessional
orfacility orboth,and theEnrolleereceiving
theservice,verballyorasexpeditiouslyasthe
Enrollee’s health condition requires but not
morethanone(1)BusinessDayofmakingthe
initialdeterminationandshallprovidewritten
notification to the provider within two (2)
BusinessDaysofmakingthedetermination.
2.12.6.4.2 AdverseAction
2.12.6.4.2.1 The Contractor shall notify the Enrollee, in
writing using language that is easily
understoodbytheEnrollee,ofdeterminations
to deny a Service Authorization request, to
authorizeaserviceinanamount,duration,or
scopethatislessthanrequested,and/orany
other action as defined in the Enrollee
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Grievances, Appeals and State Fair Hearings
section.ThenoticeofactiontoEnrolleesshall
be consistent with requirements in 42 C.F.R.
§438.404, §438.10 and §438.210, the
MarketingandEducationsectionforEnrollee
written materials, and anyagreements that
the Department may have entered into
relativetothecontentsofEnrolleenoticesof
denialorpartialdenialofservices,regardless
ofwhethersuchagreementsarerelatedto
legalproceedingsorout‐of‐courtsettlements.
2.12.6.4.2.2 The Contractor shall notify the requesting
provider of a determination to deny an
authorizationorreauthorizationrequestorto
authorizeorreauthorizeaserviceinan
amount, duration, or scope that is less than
requested. The Contractor shall provide
writtennotificationtotheproviderrendering
theservice,whetherahealthcareprofessional
orfacilityorboth,withintwo(2)BusinessDays
ofmakingthedetermination.
2.12.6.4.3 InformalReconsideration
2.12.6.4.3.1 AspartoftheContractor’sAppealProcedures,
the Contractor shall include an Informal
Reconsideration process that allows the
Enrollee (or provider/agent on behalf of an
Enrollee)areasonableopportunitytopresent
evidence, and allegations of fact or law, in
personandinwriting.
2.12.6.4.3.2 Inacaseinvolvinganinitialdeterminationora
concurrent review determination, the
Contractor shall provide the Enrollee or a
provideractingonbehalfoftheEnrolleeand
with the Enrollee’s written consent an
opportunity to request an informal
reconsideration of an adverse determination
by the physician or clinical peer making the
adverse determination [42 C.F.R.
§438.402(c)(1)(ii)].
2.12.6.4.3.3 Theinformalreconsiderationshalloccur
withinone(1)BusinessDayofthereceiptof
therequest and shall be conducted between
the provider rendering the service and the
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Contractor’s physician authorized to make
adverse determinations or a clinical peer
designated by the medical director if the
physician who made the adverse
determinationcannotbeavailablewithinone
(1)BusinessDay.
2.12.6.4.3.4 TheInformalReconsiderationdoesnotextend
the thirty (30) Calendar Day required
timeframeforaNoticeofAppealResolution.
2.12.7 ServiceAuthorizationRequirementsforNewEnrollees
2.12.7.1 GeneralRequirements
2.12.7.1.1 The Contractor shall not require Service Authorization for the
continuationofmedicallynecessaryMCOCoveredServicesofa
new Enrollee transitioning into the Contractor, regardless of
whethersuchservicesareprovidedbyanin‐networkorout‐of‐
Network Provider, however, the Contractor may require Prior
Authorizationofservicesbeyondthirty(30)CalendarDays.
2.12.7.1.2 For the first thirty (30) Calendar Days of Enrollment, the
ContractorisprohibitedfromdenyingPriorAuthorizationsolely
onthebasisoftheproviderbeinganout‐of‐NetworkProvider.
2.12.7.2 Pregnancy
2.12.7.2.1 IntheeventanewEnrolleeisinthefirsttrimesterofpregnancy
and is actively receiving medically necessary covered prenatal
careservicesatthetimeofEnrollment,theContractorshallbe
responsible for the costs of continuation of such medically
necessary prenatal care services, including prenatal care,
delivery, and post‐natal, without any form of authorization
neededandwithoutregardtowhethersuchservicesarebeing
providedbyanetworkornon‐NetworkProvideruntilsuchtime
as the Contractor can reasonably transfer the Enrollee to a
NetworkProviderwithoutimpedingservicedeliverythatmight
beharmfultotheEnrollee’shealth.
2.12.7.2.2 IntheeventanewEnrolleeisinhersecondorthirdtrimesterof
pregnancyandisactivelyreceivingmedicallynecessarycovered
prenatalcareservicesatthetimeofEnrollment,theContractor
shall be responsible for providing continued access to the
prenatal care provider (whether network or non‐Network
Provider)forsixty(60)CalendarDayspostpartum,providedthe
Enrollee remains covered through Contractor, or referral to a
safetynetprovideriftheEnrollee’seligibilityterminatesbefore
theendofthepostpartumperiod.
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2.12.7.2.3 In the event a new Enrollee is actively receiving medically
necessaryMCOCoveredServicesotherthanprenatalservicesat
thetimeofEnrollment,theContractorshallberesponsiblefor
thecosts ofcontinuationof suchmedically necessary services,
withoutanyformofauthorizationneededandwithoutregardto
whether such services are being provided by network or non‐
NetworkProviders.TheContractorshallprovidecontinuationof
suchservicesuptoninety(90)CalendarDaysoruntiltheEnrollee
may be reasonably transferred to an in‐Network Provider
withoutdisruption,whicheverisless.TheContractormayrequire
PriorAuthorizationforcontinuationoftheservicesbeyondthirty
(30)CalendarDays;however,theContractorisprohibitedfrom
denyingauthorizationsolelyonthebasisthattheproviderisa
non‐contractprovider.
2.12.7.2.4 TheContractorshallensurethattheEnrolleeisheldharmlessby
theproviderforthecostsoftheabovemedicallynecessaryMCO
CoveredServices.
2.12.7.3 SpecialHealthCareNeeds
2.12.7.3.1 WhereanewEnrolleewithSHCNisactivelyreceivingmedically
necessaryMCOCoveredServicesatthetimeofEnrollment,the
Contractor shall provide continuation/coordination of such
servicesuptoninety(90)CalendarDaysoruntiltheEnrolleemay
be reasonably transferred to a Network Provider without
disruption,whicheverisless. TheContractor mayrequirePrior
Authorizationforcontinuationoftheservicesbeyondthirty(30)
Calendar Days; however, the Contractor is prohibited from
denyingauthorizationsolelyonthebasisthattheproviderisa
non‐contractprovider.
2.12.7.4 MaintenanceMedications
2.12.7.4.1 The Contractor shall submit for approval, a transition of care
program that ensures Enrollees can continue treatment of
maintenance medications for at least sixty (60) Calendar Days
afterEnrollmentwiththeContractororswitchingfromoneplan
to another. The Contractor shall continue any treatment of
antidepressantsandantipsychoticsforatleastsixty(60)Calendar
DaysafterEnrollmentwiththeContractor.Additionally,an
Enrolleethatis,atthetimeofEnrollmentwiththeContractor,
receivingaprescriptiondrugthatisnotonthePDLshallbe
permitted to continue to receive that prescription drug if
medicallynecessaryforatleastsixty(60)CalendarDays.
2.12.7.5 DME,Prosthetics,Orthotics,andCertainSupplies
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2.12.7.5.1 In the event an Enrollee who is newly enrolled with the
Contractor is actively receiving Medicaid covered durable
medicalequipment,prosthetics,orthotics,and certainsupplies
servicesatthetimeofEnrollment,whethersuchserviceswere
provided by another MCO or FFS, the Contractor shall be
responsible for the costs of continuation of these services,
withoutanyformofauthorizationandwithoutregardtowhether
such services are being provided by network or non‐Network
Providers.TheContractorshallprovide continuation of such
servicesforuptoninety(90)CalendarDaysoruntiltheEnrollee
maybereasonablytransferredtoaNetworkProvider(withinthe
timeframe specified in this Contract) without disruption,
whicheverisless.
2.12.7.5.2 The Contractor shall also honor any Prior Authorization for
durable medical equipment, prosthetics, orthotics and certain
supplies services issued while the Enrollee was enrolled in
another MCOor FFS for a periodof ninety (90)CalendarDays
aftertheEnrollee’sEnrollment.
2.12.8 OtherServiceAuthorizationRequirements
2.12.8.1 TheMedicaidExecutiveDirector,inconsultationwiththeMedicaidMedical
Director,mayrequiretheContractortoauthorizeservicesonacase‐by‐case
basis.
2.12.8.2 The Contractor shall not deny continuation of higher‐level services (e.g.,
inpatient hospitalor PRTF) forfailure tomeet medical necessity unless the
Contractorcanprovidetheservicethroughanin‐networkorout‐of‐Network
Provideratalowerlevelofcare.
2.12.8.3 The Contractor shall utilize a common hospital observation policy that is
developedandmaintainedcollectivelybytheMCOswithapprovalbyLDHin
writing.AnyrevisionsshallbereviewedandapprovedbyLDHinwritingatleast
thirty(30)CalendarDayspriortoimplementation.
2.12.8.4 The Contractor shall perform Prior Authorization and concurrent utilization
reviewforadmissionstoinpatientgeneralhospitalsandconcurrentutilization
review for psychiatric admissions to inpatient general hospitals, specialty
psychiatrichospitalsinLouisianaorout‐of‐state,orstatementalhospitals.
2.12.8.5 TheContractorshall ensurethatinitialandconcurrentinpatient psychiatric
hospitalutilizationreviewsarecompletedbyaLicensedMentalHealth
Professional(LMHP)orpsychiatristforeachEnrollee.
2.12.8.6 TheContractorshouldcoordinatethedevelopmentofServiceAuthorization
policies with other MCOs where appropriate to avoid providers receiving
conflictingpoliciesfromdifferentMCOs.
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2.12.8.7 TheContractorshallnotrequireServiceAuthorizationfor:
2.12.8.7.1 EmergencyServicesorpost‐stabilizationservicesasdescribedin
this Section whether provided by an in‐network or out‐of‐
NetworkProvider;
2.12.8.7.2 Non‐emergency inpatient hospital admissions for normal
newborndeliveries;and
2.12.8.7.3 EPSDTscreeningservices.
2.12.9 HealthRecordReview
2.12.9.1 By sampling or other methods and on a regular basis, the Contractor shall
verifythatservicesforwhichreimbursementwasmadewereprovided to
Enrolleesasbilled.
2.12.9.2 TheContractorshallmaintainawrittenstrategyforconductinghealthrecord
reviews,reportingresultsandthecorrectiveactionprocess.Thestrategyshall
beprovidedtoLDHoritsdesigneeforapprovalaspartofReadinessReview
andsixty(60)CalendarDayspriortotheimplementationofanyupdates.The
strategyshallinclude,ataminimum,thefollowing:
2.12.9.2.1 Designatedstafftoperformthisduty;
2.12.9.2.2 Themethodofcaseselection;
2.12.9.2.3 Theanticipatednumberofreviewsbypracticesite;
2.12.9.2.4 ThetooltheContractorshallusetorevieweachsite;
2.12.9.2.5 HowtheContractorshall link the information compiled during
the review to other Contractor functions (e.g. quality
improvement[QI],credentialing,peerreview,etc.);and
2.12.9.2.6 Scheduleofreviewsbyprovidertype.
2.12.9.3 The standards, which shall include all health record documentation
requirementsaddressedintheContract,shallbedistributedtoallproviders.
2.12.9.4 TheContractorshallconductreviewsatallPCPsiteswithfifty(50)ormore
linkedEnrolleesandpracticesiteswhichincludeboth individualofficesand
largegroupfacilities.TheContractorshallrevieweachsiteatleastone(1)time
duringeachtwo(2)yearperiod.
2.12.9.4.1 TheContractorshallreviewareasonablenumberofrecordsat
eachsitetodeterminecompliance.Five(5)toten(10)records
persiteisagenerallyacceptedtarget.Forlargegrouppractices
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(six[6]ormoreprovidersinthegroup),three(3)recordreviews
perprovidershallberequired.
2.12.9.5 The Contractor shall report the results of health record reviews to LDH
quarterlywithanannualsummary.
2.12.10 CSoCRequirements
2.12.10.1 The Contractor shall conduct UM functionsfortheCSoCpopulation. The
Contractorshall:
2.12.10.1.1 ApplyinitialriskscreenforCSoCeligibility;
2.12.10.1.2 Refer calls (via a seamless “warm transfer”) to the contracted
administratoroftheCSoCprogram,whoshallapplyBriefCANS
assessmenttooltoassessforCSoCpresumptiveeligibility;and
2.12.10.1.3 Documentinthechild’shealthrecordwhetherornot(according
toCSoCcontractedadministrator)thechildmetcriteriaforCSoC
presumed eligibility, when the child was referred tothe WAA,
andthedateonwhichtheFreedomofChoice(FOC)wassigned.
2.12.10.2 TheContractorshallalsodocumentinthechild’shealthrecordifthechilddoes
notbecomeenrolledinCSoC,forthereasonsof1)theyouthandfamilyrefuse
CSoCservices,or2)theyouthdoesnotmeetclinicaleligibilitybasedonthe
comprehensiveCANS,or3)foranyotherreason.
2.12.10.3 Foryouthwhoscreenedpositivelyontheinitialriskscreen,butwhodonot
completeEnrollmentinCSoC,theContractorshall offerparticipationinthe
CaseManagementProgram,and/orotherbehavioralhealthservicestomeet
thechildandfamily’spresentingneeds.
2.12.10.4 Upon request, the Contractor shall provide LDH with documentation
supportinghowithasplacedappropriatelimitsonaserviceonthebasisof
medicalnecessityforindividualsdeterminedbyLDHtoneedSBHS.
2.12.11 PRTFRequirements
2.12.11.1 Pre‐screenforPRTF
2.12.11.1.1 When a referring party requests PRTF for an Enrollee, the
Contractorshallperformaninitialscreenuponreceiptofreferral
includingreview of records and current clinical information to
determine whether PRTF is an appropriate level of care, or if
alternate community‐based services could meet the referral
needs. The screen shall be completed within twenty‐four (24)
hoursoftheContractor’s receiptofthereferraland allclinical
information needed and requested by the Contractor to make
thedetermination.
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2.12.11.1.2 Upon completion of the screen, if the PRTF is approved, the
ContractorshallimmediatelynotifytheEnrolleeand/orguardian
and,withconsent,thereferringpartyrequestingPRTFservices
and,withinforty‐eight(48)hours,providewrittennotificationof
the approval. The Contractor shall also then generate a Prior
Authorization for each PRTF admission within forty‐eight (48)
hours of completion of the screen. In consultation with the
Enrollee’s guardian and referring party, the Contractor shall
locateaPRTFproviderappropriatetomeettheEnrollee’sneeds
withavailabilitytoadmittheEnrollee.Giventheneedtolocate
an appropriate PRTF provider with bed availability in a Timely
manner, the Contractor shall maintain near real time bed
utilization/availability for network PRTFs and out‐of‐network
replacements.Whentheinitialscreenresultsinadetermination
thattheEnrolleeisinneedofPRTFcare,theContractorshall
secureadmissiontoanappropriatePRTFfortheEnrolleewithin
the timeframe stated in Attachment F, Provider Network
Standards,incompliancewithaccessandavailabilitystandards
forthislevelofcare.
2.12.11.1.3 If PRTF placement is denied, the Contractor shall immediately
notify the Enrollee and/or guardian and, with consent, the
referringpartyrequestingPRTFservicesand,withinforty‐eight
(48) hours, provide written notification of the denial. The
notification of denial shall include information on alternative
servicesthatmaymeettheEnrollee’sneedstoensurehealthand
safety, including information on available providers of those
services,therightoftheEnrolleetoAppealthedenial,andthe
processtodoso.
2.12.11.1.4 ForyouthpendingreleasefromasecuresettingforwhomaPRTF
isbeing requested, theContractoris required tocompletethe
screen prior to the youth’s release if it is anticipated that the
youthwillbere‐linkedtotheContractorfollowingrelease.
2.12.11.2 CertificationofNeed(CON)forPRTFs
2.12.11.2.1 TheContractorshallcomplywiththerequirementssetforthat
42C.F.R.Part441,SubpartD.
2.12.11.2.2 TheContractorshallensureLMHPsareincludedintheteam
responsibleforcertificationandrecertificationofPRTFservices
inLouisiana.Thisshallincludeaface‐to‐faceassessmentbyan
LMHPoratelephonic/videoconsultationwithanLMHPwhohas
hadaface‐to‐faceinterviewwiththechild/youth,inadditionto
the recommendations of the team specified at 42 C.F.R.
§441.156.
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2.12.11.2.3 TheContractormayuseanLMHP/teamcomposedofContractor
staff or subcontracted LMHPs. To ensure the team has
knowledge ofthe ambulatoryresourcesavailable to the youth
andtheyouth’ssituation, the Contractor shall ensurethat the
teamisassembledbyasubcontractinthechild’s/youth’sparish
of residence or adjacent parish (if not in state custody) or the
child’s/youth’s parish or adjacent parish of responsibility (ifin
statecustody).
2.12.11.2.4 ForyouthpendingreleasefromasecuresettingforwhomaPRTF
isbeingrequested,theContractorisrequiredtocoordinatethe
completionoftheCONpriortotheyouth’sreleaseifitis
anticipatedthattheyouthshallbere‐linkedtotheContractor
followingrelease.
2.12.11.2.5 Recertificationofthestay shalloccur everysixty(60) Calendar
Days.ForthePRTFscreenstobecomplete,theteamshallmeet
andruleoutothercommunitybasedoptions.Thisdoesnotapply
tootherinpatientscreens.
2.12.11.3 Inadditiontothepre‐screenandcertifyingtheneed,theContractorshall:
2.12.11.3.1 BeresponsiblefortrackingtheEnrollee’sauthorizationperiodfor
PRTF stays and providing notification to the Authorized
Representativewhenarecertificationisdue;
2.12.11.3.2 Ensure that PRTF certification, including the independent
certification,areforwardedtotheadmittingfacility;
2.12.11.3.3 Accurately determine admissions and discharges to PRTFs and
performPRTF‐specificeligibilityfunctions;and
2.12.11.3.4 Work with the FI to determine retroactive eligibility and
assignment,whenapplicable.
2.12.12 ClinicalPracticeGuidelinesforBehavioralHealthServices
2.12.12.1 For the purposes of this Section, clinical practice guidelines refer to
educational materials aimed at informing providers of best practices and
evidence‐based standards. Clinical practice guidelines are distinct from
authorization criteria and shall not be used to make coverage, medical
necessity,orreimbursementdeterminations.
2.12.12.2 TheContractorshallhaveclinicalpracticeguidelinesforthebehavioralhealth
conditionslistedbelow:
2.12.12.2.1 Schizophrenia;
2.12.12.2.2 ADHD;
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2.12.12.2.3 AutismSpectrumDisorder;
2.12.12.2.4 Depression;
2.12.12.2.5 GeneralizedAnxietyDisorder;
2.12.12.2.6 Post‐TraumaticStressDisorder;
2.12.12.2.7 SuicidalBehavior;
2.12.12.2.8 OppositionalDefiantDisorder;
2.12.12.2.9 BipolarDisorder;and
2.12.12.2.10 SubstanceUseDisorders.
2.12.12.3 The Contractor should coordinate the development of clinical practice
guidelineswithotherMCOswhereappropriatetoavoidproviders receiving
conflictingguidelinesfromdifferentMCOs.
2.12.12.4 TheContractorshalldisseminatetheclinicalpracticeguidelinestoallaffected
providersand,uponrequest,toEnrolleesandPotentialEnrollees.
2.12.12.5 TheContractorshouldencourageadoptionoftheclinicalpracticeguidelines
byproviders andmeasure compliancewith theguidelines throughprovider
monitoring.
2.12.12.6 TheContractorshouldemployproviderincentivestrategies,suchasfinancial
andnon‐financialincentives,toimprovecompliance.
EnrolleeServices
2.13.1 Enrollees’RightsandResponsibilities
2.13.1.1 The Contractor shall have written policies regarding Enrollee rights and
responsibilities.TheContractorshallcomplywithall applicableFederal and
Statelaws,regulations,rules,policies,procedures,andmanualspertainingto
Enrollee rights and privacy. The Contractor shall further ensure that the
Contractor’semployees,subcontractorsandprovidersconsiderand respect
thoserightswhenprovidingservicestoEnrollees.
2.13.1.2 TherightsaffordedtocurrentEnrolleesaredetailedintheMCOManual.
2.13.1.3 The Contractor shall encourage each Enrollee to be responsible for his/her
ownhealth carebybecominganinformed andactive participant inhis/her
care. Enrollees have the responsibility to cooperate fully with providers in
following mutually acceptable courses of treatment, providing accurate
medicalandpersonalhistories,beingpresentatscheduledappointmentsand
reportingontreatmentprogress,suchasnotifyinghis/herhealthcareprovider
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promptlyifserioussideeffectsandcomplicationsoccur,and/orworseningof
theconditionarises.
2.13.1.4 The Contractor shall inform Enrollees of their responsibilities which shall
include,butarenotlimitedto:
2.13.1.4.1 Informing the Contractor of the loss or theft of their MCO
MemberIDCard;
2.13.1.4.2 PresentingtheirMCOMemberIDCardwhenusinghealthcare
services;
2.13.1.4.3 BeingfamiliarwiththeContractor’sprocedurestothebestofthe
Enrollee'sabilities;
2.13.1.4.4 Callingor contacting the Contractor to obtain information and
havequestionsanswered;
2.13.1.4.5 Providing participating Network Providers with accurate and
completemedicalinformation;
2.13.1.4.6 Askingquestions ofproviders todetermine thepotential risks,
benefits and costs of treatment alternatives and following the
prescribedtreatmentofcarerecommendedbytheprovideror
lettingtheproviderknowthereasonsthetreatmentcannotbe
followed,assoonaspossible;
2.13.1.4.7 Living healthy lifestyles and avoiding behaviors known to be
detrimentaltotheirhealth;
2.13.1.4.8 FollowingtheGrievancesystemestablishedbytheContractorif
theyhaveadisagreementwithaprovider;and
2.13.1.4.9 Makingeveryefforttokeepanyagreeduponappointmentsand
follow‐upappointments,accessingpreventivecareservices,and
contacting the provider in advance if unable to keep the
appointment.
2.13.2 RequiredMaterialsandServices
2.13.2.1 TheContractorshallensurematerialsdonotdiscriminateagainstEnrolleeson
thebasisoftheirhealthhistory,healthstatusorneedforhealthcareservices.
This applies to Enrollment, reenrollment or Disenrollment materials and
processesfromtheContractor.
2.13.2.2 TheContractorshalladheretotherequirementsandproceduresregardingthe
justice‐involved pre‐release population as set forth in the Justice‐Involved
Pre‐ReleaseEnrollmentProgramManual.
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2.13.2.3 TheContractorshalladheretotherequirementsfortheMemberHandbook,
WelcomeMemberNewsletter,MCOMemberIDCard,andProviderDirectory
asspecifiedinthisContract,itsattachments,andinaccordancewith42C.F.R.
§438.10.
2.13.3 WelcomePackets
2.13.3.1 TheContractorshallsendawelcomepackettonewEnrolleeswithinten(10)
BusinessDaysfromthedateofreceiptoftheANSIASCX12834fileidentifying
the new Enrollee. MCO Member ID Cards must be mailed within ten (10)
BusinessDays.
2.13.3.2 When the name of the Authorized Representative for the new Enrollee is
associatedwithtwo(2) ormorenewEnrollees inthesameeligibilitygroup
(seeEligibilityandEnrollmentsection),theContractorisonlyrequiredtosend
one (1) welcome packet. If Enrollees are in different eligibility groups that
equatetodifferentlevelsofcoverage,separatewelcomepacketsforeachtype
ofcoverageshallbesent.
2.13.3.3 Allcontentsofthewelcomepacketareconsideredmembermaterialsand,as
such, shall be reviewed and subject to written approval by LDH prior to
distributionaccordingtotheprovisionsdescribedinthisContract.Contentsof
thewelcomepacketsshallincludethoseitemsspecifiedintheContract.The
welcomepacketshallinclude,butisnotlimitedto:
2.13.3.3.1 AMemberHandbookand/orWelcomeMemberNewsletter;
2.13.3.3.2 TheMCOMemberIDCard(ifnotmailedunderaseparate
mailing);
2.13.3.3.3 If the MCO Member ID Card is mailed separately, a welcome
letter highlighting major program features, details that a card
specifictotheContractorshallbesentviamailseparately,and
contactinformationfortheContractor;and
2.13.3.3.4 Acurrentproviderdirectorywhenspecificallyrequestedbythe
Enrollee(alsomustbeavailableinsearchableformatonline).
2.13.4 WelcomeCalls
2.13.4.1 TheContractorshallmakewelcomecallstonewEnrolleeswithinfourteen(14)
BusinessDaysofthedatetheContractorsendsthewelcomepacket.
2.13.4.2 TheContractorshallreviewPCPassignmentifaPCPAutomaticAssignment
was made and assist the Enrollee in changing the PCP if requested by the
Enrollee.
2.13.4.3 TheContractorshalldevelopandsubmittoLDHforapprovalascript(s),forall
coveredpopulationsasspecifiedintheEligibilityandEnrollmentsectiontobe
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usedduring the welcome callto discuss the followinginformation with the
Enrollee:
2.13.4.3.1 Abriefexplanationoftheprogram;
2.13.4.3.2 StatementthatallEnrolleePHIshall behandledin accordance
withFederalandStateprivacylaws;
2.13.4.3.3 The availability of oral interpretation and written translation
servicesandhowtoobtainthemfreeofcharge;
2.13.4.3.4 Theconceptofthepatient‐centeredmedicalhome,includingthe
importanceoftheEnrollee(s)makingafirstappointmentwithhis
orherPCPforpreventivecarebeforetheEnrolleerequirescare
due to an illness or condition and instructions about changing
PCPs;and
2.13.4.3.5 AdministrationoftheHealthNeedsAssessmentwithafocuson
criteriatoestablishtheappropriatetierofcasemanagementas
describedintheCareManagementsection.
2.13.4.4 TheContractorshallmakethree(3)attemptstocontacttheEnrollee.Ifthe
Contractor discovers that the Enrollee lost or never received the welcome
packet,theContractorshallresendthepacket.
2.13.5 MemberMaterialsandProgramsforCurrentEnrollees
TheContractorshalldevelopanddistributeEnrolleeeducationalmaterials,includingbut
notlimitedto,thefollowing:
2.13.5.1 An Enrollee‐focused website which can be a designated section of the
Contractor’s general informational website, and interactive media content
suchasamobiledeviceapplication,amobileoptimizedwebsite,orinteractive
socialmedia;
2.13.5.2 Bulletinsornewslettersdistributednotlessthantwo(2)timespercalendar
yearthatprovideinformationonpreventivecare,accesstoPCPsandother
providers,andotherinformationthatishelpfultoEnrollees;
2.13.5.3 Literature, including brochures and posters, such as calendars and growth
charts,regardingallhealth or wellness promotion programs offered by the
Contractor. This would also include, but not be limited to, EPSDT outreach
materialsandEnrolleeappointmentandpreventivetestingreminders;
2.13.5.4 Targetedbrochures,postersandpamphletstoaddressissuesassociatedwith
Enrolleeswithchronicdiseasesand/orspecialheathcareneeds;
2.13.5.5 MaterialsfocusedonhealthpromotionprogramsavailabletotheEnrollees;
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2.13.5.6 CommunicationsdetailinghowEnrolleescantakepersonalresponsibilityfor
theirhealthandself‐management;
2.13.5.7 Materials that promote the availability of health education classes for
Enrollees;
2.13.5.8 MaterialsthatprovideeducationforEnrolleeswith,oratriskfor,aspecific
disabilityorillness;
2.13.5.9 Materials that provide education toEnrollees, Enrollees’ families andother
healthcareprovidersaboutearlyinterventionandmanagementstrategiesfor
variousillnessesand/orexacerbationsrelatedtothatdisabilityordisabilities;
2.13.5.10 NotificationtoitsEnrolleesoftheirrighttorequestandobtainthewelcome
packet(includingallitemsnotedinthissectionexceptfortheMCOMember
IDcard)atleastonceayear;
2.13.5.11 NotificationtoitsEnrolleesofanychangethatLDHdefinesassignificantat
leastthirty(30)CalendarDaysbeforetheintendedeffectivedate;and
2.13.5.12 Allmaterialsdistributedmustcomplywiththerelevantguidelinesestablished
byLDHforthesematerialsand/orprograms.
2.13.6 MemberHandbook
2.13.6.1 TheContractorshallprovideeachEnrolleeaMemberHandbook,utilizingthe
State developed model Member Handbook in the Marketing and Member
EducationCompanionGuide,toserveasasummaryofbenefitsandcoverage,
withthewelcomepacket.[42C.F.R.§438.10]
2.13.6.2 Ataminimum,theMemberHandbookshallincludethefollowinginformation,
asapplicabletothecoveredpopulationthatistheaudienceforthehandbook,
thatenablestheEnrolleetounderstandhowtoeffectivelyusetheManaged
CareProgram:
2.13.6.2.1 Tableofcontents;
2.13.6.2.2 Ageneral description about how the Contractor operates, and
detailed descriptions of the following: Enrollee rights and
responsibilities, appropriate utilization of services includingED
for non‐emergent conditions, behavioral health services
available,adescriptionofthePCPselectionprocess,thePCP’s
roleascoordinatorofservices,andanexplanationofhowthe
Enrollee can access LDH’s policy on how to receive continued
servicesduring a termination of theContractor Disenrollment
fromanMCOasrequiredby42C.F.R.§438.62;
2.13.6.2.3 Enrollee’s right to disenroll from the Contractor including
Disenrollmentforcause;
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2.13.6.2.4 Enrollee’srighttoselectandchangePCPsandotherhealthcare
professionalswithintheContractor’sprovidernetworkandhow
todoso;
2.13.6.2.5 Any restrictions on the Enrollee’s freedom of choice among
NetworkProviders;
2.13.6.2.6 Enrollee’s rights and protections, as specified in 42 C.F.R.
§438.100andthisContract;
2.13.6.2.7 The amount, duration, and scope of benefits available to the
Enrollee under this Contract in sufficient detail to ensure that
Enrollees understand the benefits to which they are entitled,
includingspecializedbehavioralhealthbenefitsandinformation
abouthealtheducationandpromotionprograms,includingCare
Management,tobaccocessation,andproblemgaming;
2.13.6.2.8 Procedures for obtaining benefits, including authorization
requirements;
2.13.6.2.9 DescriptiononthepurposeoftheMedicaidIDCardandtheMCO
MemberIDCardandwhybotharenecessaryandhowtouse
them;
2.13.6.2.10 The extent to which, and how, Enrollees may obtain benefits,
including family planning services from out‐of‐Network
Providers.Anexplanationshallbeincludedthatexplainsthatthe
ContractorcannotrequiretheEnrolleetoobtainareferralbefore
choosingafamilyplanningprovider;
2.13.6.2.11 Theextenttowhich,andhow,after‐hours,crisisandemergency
coverageareprovided,including:
2.13.6.2.11.1 What constitutes an Emergency Medical
Condition, Emergency Services, and post‐
stabilization services, as defined in 42 C.F.R.
§438.114(a);
2.13.6.2.11.2 That prior authorization is not required for
EmergencyServices;
2.13.6.2.11.3 The process and procedures for obtaining
EmergencyServices,includinguseofthe911‐
telephonesystemoritslocalequivalent;
2.13.6.2.11.4 Thelocationsofanyemergencysettingsand
other locations at which providers and
hospitalsfurnishEmergencyServicesandpost‐
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stabilization services covered by the
Contractor;and
2.13.6.2.11.5 That,subjecttotheprovisionsof42C.F.R.Part
438,theEnrolleehasarighttouseanyhospital
orothersettingforemergencycare.
2.13.6.2.12 The post‐stabilization care services rules set forth in 42 C.F.R.
§422.113(c);
2.13.6.2.13 Policyonreferralsforspecialtycare,includingSBHSandforother
benefitsnotfurnishedbytheEnrollee’sPCP;
2.13.6.2.14 Howandwheretoaccessanybenefitsthatareavailableunder
theStatePlan,butarenotcoveredundertheContract;
2.13.6.2.15 ThattheEnrolleehastherighttorefusetoundergoanymedical
service,ortreatmentortoacceptanyhealthserviceprovidedby
theContractoriftheEnrolleeobjects(orinthecaseofachild,if
theparentorguardianobjects)onreligiousgrounds;
2.13.6.2.16 ForcounselingorreferralservicesthattheContractordoesnot
coverbecauseofmoralorreligiousobjections,theContractor
shalldirecttheEnrolleetocontacttheEnrollmentBrokerfor
informationonDisenrollmentprocedures;
2.13.6.2.17 Enrollee Grievance, Appeal, and State Fair Hearing procedures
andtimeframes,asdescribedin42C.F.R.Part438,SubpartFand
thisContract;
2.13.6.2.18 Grievance, Appeal, and State Fair Hearing procedures that
includethefollowing:
2.13.6.2.18.1 ForStateFairHearing:
Therighttoahearing;
Themethodforobtainingahearing;and
The rules that govern representation at
thehearing.
2.13.6.2.18.2 TherighttofileGrievancesandAppeals;
2.13.6.2.18.3 Therequirementsandtimeframesforfilinga
GrievanceorAppeal;
2.13.6.2.18.4 The availability of assistance in the filing
process;
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2.13.6.2.18.5 Thetoll‐freenumbersthattheEnrolleecanuse
tofileaGrievanceoranAppealbyphone;
2.13.6.2.18.6 Thefactthat,whenrequestedbytheEnrollee:
BenefitswillcontinueiftheEnrolleefiles
anAppealorarequestforStateFair
Hearing within the timeframes specified
forfiling;and
TheEnrolleemayberequiredtopaythe
costofservicesfurnishedwhilethe
Appealispending,ifthefinaldecisionis
adversetotheEnrollee.
2.13.6.2.18.7 InaStateFairHearing,theDivisionof
Administrative Law shall make the
recommendationtotheSecretaryoftheLDH
whohasfinalauthoritytodeterminewhether
servicesshallbeprovided.
2.13.6.2.19 Advance Directives, as set forth in 42 C.F.R. §438.3(j). A
descriptionofAdvanceDirectiveswhichshallinclude:
2.13.6.2.19.1 The Contractor’s policies related to Advance
Directives;
2.13.6.2.19.2 TheEnrollee’srightsunderStatelaw,including
therighttoacceptorrefusemedical,surgical,
orbehavioralhealthtreatmentandtherightto
formulateAdvanceDirectives;anychangesin
law shall be reflected in the Member
Handbook as soon as possible, but no later
thanninety(90)CalendarDaysafterthe
effectivedateofthechange;
2.13.6.2.19.3 InformationonhowEnrolleescanfile
complaintsaboutthefailuretocomplywithan
Advance Directive with the LDH Health
Standards Section, Louisiana’s Survey and
Certificationagency;and
2.13.6.2.19.4 InformationaboutwhereanEnrolleecanseek
assistance in executing an Advance Directive
andtowhomcopiesshouldbegiven.
2.13.6.2.20 InformationonhowtocalltheMedicaidCustomerServiceUnit
toll‐freehotline,visittheLouisianaMedicaidProgramwebsite,or
visit a regional Louisiana Medicaid Program eligibility office to
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reportanychangestodemographicorotherinformationwhich
mayaffecteligibility;
2.13.6.2.21 Information on how to make, change, and cancel medical
appointments and the importance of canceling and/or
reschedulingratherthanbeinga“noshow”;
2.13.6.2.22 AdescriptionofEnrolleeServicesandthetoll‐freenumber,fax
number,e‐mailaddressandmailingaddresstocontactEnrollee
Services;
2.13.6.2.23 Thetoll‐freetelephonenumberformedicalmanagement;
2.13.6.2.24 Howto obtain emergencyand NEMT, includingtransportation
foranybenefitscarvedoutoftheContractandprovidedbythe
State;
2.13.6.2.25 Information about Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) services and how to access component
servicesifindividualsunderage21entitledtotheEPSDTbenefit
areenrolledwiththeContractor;
2.13.6.2.26 How and where to access any benefits provided by the State,
including EPSDT and dental benefits delivered outside the
Contractor;
2.13.6.2.27 Informationaboutcostsharingonanybenefitscarvedoutofthe
ContractandprovidedbytheState;
2.13.6.2.28 InformationabouttherequirementthatanEnrolleeshallnotify
theContractorimmediatelyifheorshehasaWorker’s
Compensation claim, a pending personal injury or medical
malpractice lawsuit, or has been involved in an automobile
accident;
2.13.6.2.29 Reporting requirements for the Enrollee that has or obtains
anotherhealthinsurancepolicy,includingemployer sponsored
insurance.SuchsituationsshallbereportedtotheContractor;
2.13.6.2.30 Enrollee responsibilities, appropriate and inappropriate
behavior, and any other information deemed essential by the
Contractor or LDH. This shall include a statement that the
EnrolleeisresponsibleforprotectingtheirMCOMemberIDCard
andthatmisuseofthecard,includingloaning,sellingorgivingit
tootherscouldresultinlossoftheEnrollee’sLouisianaMedicaid
Programeligibilityand/orlegalaction;
2.13.6.2.31 Instructions on how to access auxiliary aids and services,
including interpretation and translation in alternative formats
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and languages when needed at no cost to the Enrollee. This
instructionshallbe included inallversionsof the handbookin
EnglishandSpanish;
2.13.6.2.32 Information on the Enrollee’s right to a second opinion in
accordancewith42C.F.R.§438.206(b)(3)atnocostandhowto
obtainit;
2.13.6.2.33 Waystoreportsuspectedprovider Fraudand Abuse including,
butnotlimitedto,usingtheLDHandContractortoll‐free
numbersandwebsiteestablishedforthatpurpose;
2.13.6.2.34 AnyadditionaltextprovidedtotheContractorbyLDHinwriting
ordeemedessentialbytheContractor;
2.13.6.2.35 Thedateofthelastrevision;
2.13.6.2.36 Additionalinformationthatisavailableuponrequest,including
thefollowing:
2.13.6.2.36.1 Informationonthestructureandoperationof
theContractor;
2.13.6.2.36.2 Physicianincentiveplans[42C.F.R.§438.3(i)].
2.13.6.2.36.3 Serviceutilizationpolicies;and
2.13.6.2.36.4 Howtoreportallegedmarketingviolationsto
LDHutilizingthe MarketingComplaintForm,
which can be found in the Procurement
Library.
2.13.6.2.37 InformationregardingSBHS,including,butnotlimitedto:
2.13.6.2.37.1 A description of covered behavioral health
services;
2.13.6.2.37.2 Where and how to access behavioral health
servicesandbehavioralhealthproviders;
2.13.6.2.37.3 General information on the treatment of
behavioralhealthconditionsandtheprinciples
ofadult,family,child,youthandyoungadult
engagement; resilience; strength‐based and
evidence‐based practice; and best/proven
practices;
2.13.6.2.37.4 Description of the family/caregiver or legal
guardian role in the assessment, treatment,
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andsupportforindividualswithanemphasis
onpromotingengagement,resilience,andthe
strengthsofindividualsandfamilies;and
2.13.6.2.37.5 Any limitations involving the provision of
informationforadultpersonswhodonotwant
information shared with family members,
including age(s) of consent for behavioral
healthtreatmentasper42C.F.R.Part2.
2.13.6.2.38 InformationonwhattodoifanEnrolleeisbilled,andunderwhat
circumstancesanEnrolleemaybebilledfornon‐MCOCovered
Services;
2.13.6.3 The informationspecifiedin thisSectionfor theMemberHandbookwill be
consideredtobeprovidediftheContractor:
2.13.6.3.1 MailsaprintedcopyoftheinformationtotheEnrollee’smailing
address;
2.13.6.3.2 ProvidestheinformationbyemailafterobtainingtheEnrollee’s
agreementtoreceivetheinformationbyemail;
2.13.6.3.3 PoststheinformationontheirEnrolleewebsiteandadvisesthe
Enrollee in paper or electronic form that the information is
availableatthespecifiedwebaddress,providedthatEnrollees
with disabilitieswhocannotaccess thisinformation online are
providedauxiliaryaidsandservicesuponrequestatnocost;or
2.13.6.3.4 Provides the information in any other method that can
reasonably be expected to result in the Enrollee receiving the
information.
2.13.6.4 Atleastonceayear,theContractorshallnotifytheEnrolleeoftheiroptionof
receivingeithertheMemberHandbookortheMemberWelcomeNewsletter,
and the Provider directory, in either electronic format or hardcopy, upon
requestfromtheEnrollee.
2.13.6.5 TheContractorshallreviewandupdatetheMemberHandbookatleastonce
ayear.ThehandbookshallbesubmittedtoLDHforapprovalatleastfour(4)
weeks prior to the Enrollment period and upon any changes priortothe
updatedversionbeingmadeavailabletoEnrollees.
2.13.6.6 WelcomeNewsletter
2.13.6.6.1 ShouldtheContractorelectnottoprovideaMemberHandbook
hardcopy atthe time ofsending the welcome packetfor new
Enrollees,theContractorshalldevelopandmaintainaWelcome
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Newsletterthatadherestotherequirementsin42C.F.R.
§438.10.
2.13.6.6.2 TheContractorshallreviewandupdatetheWelcomeNewsletter
atleastonceayear.ThenewslettermustbesubmittedtoLDH
forapprovalatleastfour(4)weekspriortotheEnrollmentperiod
anduponanychangespriortotheupdatedversionbeingmade
availabletoEnrollees.
2.13.6.6.3 At a minimum, each Welcome Newsletter shall include the
followinginformationasitappliestothecoveredpopulationsas
specifiedintheEligibilityandEnrollmentsection:
2.13.6.6.3.1 Right to request an updated Member
Handbook at no cost to the Enrollee.
Notification that the Member Handbook is
available on the Contractor’s website, by
electronicmailorthroughpostalmailingmust
bereferenced;
2.13.6.6.3.2 EnrolleeGrievanceandAppealrights;
2.13.6.6.3.3 Right to access oral interpretation services,
free of charge, and how to access them that
adheres to the requirements in 42 C.F.R.
§438.10(d)(4)and(5);
2.13.6.6.3.4 Contractorservicehoursandavailabilitywith
contactinformationincluding,butnotlimited
to, Enrollee Services, Nurse Line, Behavioral
Health Crisis Line, reporting suspected Fraud
and Abuse, Pharmacy Benefits Manager, and
any subcontractor providing MCO Covered
ServicesorValue‐AddedBenefits;
2.13.6.6.3.5 TobaccoCessationInformationwithawebsite
linktotobaccoeducationandprevention
program;
2.13.6.6.3.6 Information on how to search for providers,
including specialized behavioral health
providers,andhowtoobtain,atnocharge,a
directoryofproviders;
2.13.6.6.3.7 Information regarding the circumstances
underwhichanEnrolleemaybebilledfornon‐
MCOCoveredServices;
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2.13.6.6.3.8 Whattodoincaseofanemergency,
information on proper emergency service
utilization,andtherighttoobtainEmergency
ServicesatanyhospitalorotherEDfacility,in
orout‐of‐network;
2.13.6.6.3.9 Description of Fraud, Waste, and Abuse,
including instruction on how to report
suspectedFraud,Waste,andAbuse;
2.13.6.6.3.10 Right to be treated fairly regardless of race,
religion, gender identity, age, sexual
orientation,andabilitytopay;
2.13.6.6.3.11 Righttorequestamedicalrecordcopyand/or
inspectmedicalrecordsatareasonable,cost‐
basedfeeasspecifiedin45C.F.R.164.524;
2.13.6.6.3.12 Howtoaccessafter‐hourscare;
2.13.6.6.3.13 HowtochangeMCOs;
2.13.6.6.3.14 InstructionsonchangingyourPCP;
2.13.6.6.3.15 Instructionsonwheretofinddetailedlistingof
coveredbenefits;
2.13.6.6.3.16 Identificationofservicesforwhichcopaysare
applicable;
2.13.6.6.3.17 SBHSinformation,includingwhereandhowto
access behavioral health services (including
emergencyorcrisisservices);and
2.13.6.6.3.18 Problem gambling treatment with a website
linktoresources.
2.13.7 MemberIdentification(ID)Cards
2.13.7.1 Enrolleesshallbeissuedataminimumtwo(2)differentMCOMemberIDcards
relatedtotheirEnrollmentintheManagedCareProgram.TheContractormay
opttoprovideEnrolleeswithathirdIDcard,iftheContractorelectstoissuea
separatePharmacyIDCard.
2.13.7.2 AMedicaidIDCardshallbeissuedtoallBeneficiaries,includingEnrollees.This
cardisnotproofofeligibility,butcanbeusedbyproviderstoaccesstheState's
electroniceligibilityverificationsystems.Thesesystemswillcontainthemost
currentinformationavailabletoLDH,includingspecificinformationregarding
Enrollment.TherewillbenoContractor specificinformationprintedon the
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card.The Enrollee mayneed toshow thiscard toaccess Medicaid Covered
ServicesnotincludedintheMCOCoveredServices.
2.13.7.3 TheContractorshalldesignand,upon approvalbyLDHinwriting, produce,
anddistributeMCOMemberIDCards.TheMCOMemberIDCardshallcontain
informationspecifictotheContractorandbeeasilyandreadilydistinguishable
from all other insurance products operated by the Contractor oritsparent
corporation.TheMCOMemberIDCardshallataminimuminclude,butnotbe
limitedto,thefollowinginformationasitappliestothecoveredpopulations
asspecifiedintheEligibilityandEnrollmentsection:
2.13.7.3.1 TheEnrollee'snameanddateofbirth;
2.13.7.3.2 The Enrollee's Unique Identifying number encoded into a
standard2D,QRmachine‐readablebarcodeandprintedwitha
minimum3/4"heightandwidth;
2.13.7.3.3 TheContractor’snameandaddress;
2.13.7.3.4 Instructionsforemergencies;
2.13.7.3.5 ThePCP’snameandtelephonenumbers (includingafter‐hours
number, if different from the PCP’s normal operating hours
number);and
2.13.7.3.6 Thetoll‐freenumber(s)for:
2.13.7.3.6.1 24‐hourNurseLine;
2.13.7.3.6.2 EnrolleeServicesLine;
2.13.7.3.6.3 FilingGrievances;
2.13.7.3.6.4 24‐hourbehavioralhealthcrisisline;
2.13.7.3.6.5 ProviderServicesandPriorAuthorization;and
2.13.7.3.6.6 Reporting Louisiana Medicaid Program Fraud
(1‐800‐488‐2917).
2.13.7.4 TheContractorshallensurethatitssubcontractorscanidentifyEnrolleesina
mannerwhichshallnotresultindiscriminationagainsttheEnrollees,inorder
toprovideorcoordinatetheprovisionofallMCOCoveredServicesand/orVAB
andout‐of‐networkservices.
2.13.7.5 TheContractormayprovidetheMCOMemberIDCardinaseparatemailing
fromthewelcomepacket,howeverthecardshallbesentnolaterthanten
(10)BusinessDaysfromthedateofreceiptoftheANSIASCX12834filefrom
LDH or the Enrollment Broker identifying the new Enrollee. As part of the
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welcomepacketinformation,theContractorshallexplainthepurposeofthe
card,howtousethecard,andhowtouseitintandemwiththeMedicaidID
Card.
2.13.7.6 TheMCOMemberIDCardshallbeissuedwithoutthePCPinformationifno
PCPselectionhasbeenmadeasofthedateofthemailing.
2.13.7.7 OncePCPselectionhasbeenmadebytheEnrolleeorthroughPCPAuto
Assignment,theContractorshallreissuetheMCOMemberIDCardinkeeping
withthetimeguidelinesinthisContract.Aspartofthemailingofthereissued
MCOMemberIDCard,theContractorshallexplainthepurposeofthereissued
card,thechangesbetweenthenewcardandthepreviouscard,andwhatthe
Enrolleeshoulddowiththepreviouscard.
2.13.7.8 The Contractor shall reissue the MCO Member ID Card within ten (10)
CalendarDaysofnoticethatanEnrolleereportsalostorstolencard,thereis
anEnrolleenamechange,thePCPchanges,orforanyotherreasonthatresults
inachangetotheinformationontheMCOMemberIDCard.
2.13.7.9 TheholderoftheMCOMemberIDCardissuedbytheContractorshallbean
EnrolleeorguardianofanEnrollee.IftheContractorhasknowledgeofany
EnrolleepermittingtheuseoftheMCOMemberIDCardbyanyotherperson,
the Contractor shall immediately report this violation to the Louisiana
MedicaidProgramFraudHotlinenumber:1‐800‐488‐2917.
2.13.7.10 PharmacyIDCardRequirements
2.13.7.10.1 TheContractorshallprovideontheMCOMemberIDCard,oron
a separate Pharmacy ID Card, or through other technology,
prescriptionbillinginformationthat:
2.13.7.10.1.1 Complies with the standards set forth in the
National Council for Prescription Drug
Programs Pharmacy ID Card prescription
benefitcardimplementationguideatthetime
ofissuanceofthecardorothertechnology;or
2.13.7.10.1.2 Includes, at a minimum, the following data
elements:
Thenameoridentifyingtrademarkofthe
MCO and the prescription benefit
manager(seeco‐brandingrestrictionsin
theMarketingandEducationsection);
The name and MCO member
identificationnumberoftheEnrollee;
The telephone number that providers
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maycallforpharmacybenefitassistance,
24‐hour Enrollee services and filing
Grievances, Provider services and Prior
Authorization;andreportingFraud;
All electronic transaction routing
informationandothernumbersrequired
bytheContractororitsbenefit
administrator to process a prescription
claimelectronically.
2.13.7.10.1.3 If the Contractor chooses to include the
prescription benefitinformationon the MCO
MemberIDCard,theContractorshallensure
all Enrollees have a card that includes all
necessaryprescriptionbenefitinformation,as
outlinedabove.
2.13.7.10.1.4 IftheContractorchoosestoprovideaseparate
Pharmacy ID Card, the card mailer that
accompanies the card shall include language
thatexplainsthepurposeofthePharmacyID
Card,howtousethecardandhowtouseitin
tandem with the Medicaid ID Card and the
MCO‐MemberIDCard.
2.13.8 ProviderDirectoryforEnrollees
2.13.8.1 TheContractorshalldevelopandmaintainaProviderDirectoryinthree(3)
formats:
2.13.8.1.1 A hard copy directory, a copy of which shall be provided to
EnrolleesandPotentialEnrolleesuponrequest;
2.13.8.1.2 Web‐basedmachinereadableandsearchable, mobile‐enabled,
onlinedirectoryforEnrolleesandthepublic;and
2.13.8.1.3 Electronic file of the directory to be submitted and updated
weekly to the FI, the Enrollment Broker, or other designee as
determinedbyLDH.
2.13.8.2 TheContractorshallsubmittemplatesofitsProviderDirectorytoLDHorits
designeeaspartofReadinessReview.
2.13.8.3 TheContractorshallprovidetheProviderDirectoryinamanneragreeableto
the Enrollee either by mail or by utilizing the Contractor’s website. The
Contractorshalldistributeinformationregardingproviderdirectoriestonew
Enrollees within thirty (30) Calendar Days of receipt of notification of
Enrollment. Such information shall include how to access the Provider
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Directory, including the right to request a hard copy and to contact the
Contractor’s Enrollee services line to inquire regarding a provider’s
participationinthenetwork.EnrolleesreceivingahardcopyoftheProvider
Directory shall be advised that the network may have changed since the
directorywas printedandhow to access current information regarding the
NetworkProviders.
2.13.8.4 The hardcopy directoryforEnrolleesshall berevised withupdatesatleast
quarterly.Insertsmaybeusedtoupdatethehardcopydirectoriesmonthlyto
fulfill requests by Enrollees and Potential Enrollees. The web‐based online
versionshallbeupdatedinrealtime,butnolessthanweekly.
2.13.8.5 TheonlinedirectoryshallbemadereadilyaccessibletoEnrollees.Thismeans
thedirectoryshallhaveaclearlyidentifiablelinkortabandshallnotrequire
anEnrolleeaccountorpolicynumbertoaccessthedirectory.Thedirectory
mustaccommodatethecommunicationneedsofindividualswithdisabilities,
andincludealinktoorinformationregardingavailableassistanceforpersons
withlimitedEnglishproficiency.
2.13.8.6 The Contractor shall include, in both electronic and paper directories, a
customerserviceemailaddress,telephonenumberand/orelectroniclinkthat
individualsmayusetonotifytheContractorofinaccurateProviderDirectory
information.
2.13.8.7 Inaccordancewith42C.F.R.§438.10(h),theProviderDirectoryshallinclude,
butnotbelimitedto:
2.13.8.7.1 Identificationofqualifiedprovidersdividedintospecificprovider
andservice typesandspecializations, includingbut notlimited
to,PCPs,specialists,hospitalPCPgroups,pharmacies,behavioral
health providers, clinic settings, home and community‐based
services, outpatient therapy, residential substance use, youth
residential services, inpatient mental health and residential
substanceuseservices,andFQHCsandRHCsintheservicearea.
This shall include a child serving Provider list that is both
monitoredandfrequentlyupdatedtoensureviableoptionsare
identified and available for OJJ, DCFS and LDOE field staff.
Providersspecializinginservingindividualswithdualdiagnosisof
behavioralhealthanddevelopmentaldisabilitiesshallbeclearly
identified.Providertypes shall bedelineated byparishand zip
code;
2.13.8.7.1.1 ThehardcopyandonlineProviderDirectories
shall not include providers who have
submittednoclaimswithinthesix(6)calendar
months prior to publication, unless the
providerwasnewlycredentialedduringthissix
(6)monthperiod;
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2.13.8.7.2 Names,groupaffiliations,streetaddresses,telephonenumbers,
websiteURLs,specialties,whethertheproviderisacceptingnew
Enrollees, and cultural and linguistic capabilities by current
Network Providers by each provider type specified in this
Contract. Cultural and linguistic capabilities shall include
languagesofferedbytheprovideroraskilledmedicalinterpreter
attheprovider’soffice,andwhethertheproviderhascompleted
cultural competency training. The Provider Directory shall also
indicate whether the provider’s office/facility has
accommodationsforpeoplewithphysicaldisabilities,including
offices,examroom(s)andequipment;
2.13.8.7.3 Noteofpriorauthorizationorreferralrequirementforproviders,
ifapplicable;
2.13.8.7.4 Identification of any restrictions on the Enrollee’s freedom of
choiceamongNetworkProviders;
2.13.8.7.5 Identification of hours of operation including identification of
providerswithnon‐traditionalhours(before8a.m.orafter5
p.m.oranyweekendhours);
2.13.8.7.6 Identification of pharmacies that provide vaccine services and
deliveryservices;
2.13.8.7.7 InstructionsfortheEnrolleetocontacttheContractor’stollfree
Enrollee services telephone line for assistance in finding a
provideroraconvenientpharmacy;and
2.13.8.7.8 Customer service email address, telephone number, and/or
electroniclinkthatindividualsmayusetonotifytheContractor
ofinaccurateProviderDirectoryinformation.
2.13.8.8 LDH reserves the right to request in writing additional data needed for
enhancementstotheprovidersearchfunction.
2.13.8.9 The Contractor shall audit Provider Directory information for accuracy in
accordancewiththisContractandtheMCOSystemCompanionGuideforall
PCPs,OB/GYNs,hospitals,andbehavioralhealthprovidersatleastquarterly,
and audit at least a statistically valid sample size of its Provider Directory
informationonamorefrequent,periodicbasis.Documentationofsuchaudits
shallberetainedandmadeavailabletoLDHuponrequest.
2.13.8.10 LDHreservestherighttoconductperiodicauditstoverifytheaccuracyofthe
Contractor’s Provider Directory data. LDH will utilize full discretion in
determiningtheaudittype,criteria,andmethodology.LDHmaypenalizethe
ContractorforinaccurateProviderDirectoriesusingone(1)ormoreremedies
intheContractNon‐Compliancesectionand
AttachmentG,TableofMonetary
Penalties.
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2.13.9 NoticetoEnrolleesofProviderTermination
2.13.9.1 TheContractorshalldevelopanotificationtemplate,tobeapprovedbyLDH
inwriting,informingEnrolleesofproviderterminations. Thenoticeshallbe
mailedtoeachimpactedEnrollee.
2.13.9.1.1 IftheContractorterminatesaNetworkProviderAgreement
withoutcause,thenotificationshallalsoinformtheEnrolleeof
theirabilitytochangetheirMCOandincludeapre‐paidreturn
envelope.
2.13.9.2 TheContractorshallgive writtennoticeofaprovider’sterminationtoeach
Enrollee who received care from the terminated provider within the last
eighteen(18)months.WhenTimelynoticefromtheproviderisreceivedor
whentheContractorinitiatesthetermination,thenoticetotheEnrolleeshall
beprovidedbythelaterofthirty(30)CalendarDayspriortotheeffectivedate
ofthetermination,orfifteen(15)CalendarDaysafterreceiptorissuanceof
theterminationnotice.
2.13.9.2.1 The Contractor shall also give written notice of a provider’s
terminationtotheStateagency,asappropriate,thathasbeen
involvedinthecareofanimpactedEnrollee.
2.13.9.3 Failureto provide notice prior tothedates of termination shall beallowed
whenthe providerbecomesunable tocarefor Enrolleesdue toillness,the
providerdies,theprovidermovesfromtheserviceareaandfailstonotifythe
Contractor, the provider fails credentialing or is displaced asaresultofa
naturalorman‐madedisaster,orforanyotherreasondeterminedsufficient
by LDH in writing. Under these circumstances, notice shall be issued
immediatelyupontheContractorbecomingawareofthecircumstances.
2.13.10 EnrolleeCallCenter
2.13.10.1 TheContractorshallmaintainatoll‐freeEnrolleeservicecallcenter,physically
located in the United States, with dedicated staff to respond to Enrollee
questionsincluding,butnotlimitedto,suchtopicsas:
2.13.10.1.1 ExplanationofMCOpoliciesandprocedures;
2.13.10.1.2 Priorauthorizations;
2.13.10.1.3 Accessinformation;
2.13.10.1.4 InformationonPCPsorspecialists;
2.13.10.1.5 Referralstoparticipatingspecialists;
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2.13.10.1.6 Resolution of service and/or medical or behavioral health
deliveryproblems;
2.13.10.1.7 Enrolleerightsandresponsibilities;
2.13.10.1.8 CoordinationofsupportservicesavailablethroughtheLouisiana
MedicaidProgramorcommunityorganizations;
2.13.10.1.9 EnrolleeGrievances;and
2.13.10.1.10 InformationonSBHSandProviders.
2.13.10.2 Thetoll‐freenumbermustbestaffedonBusinessDaysbetweenthehoursof
7a.m.and7p.m.CentralTime.
2.13.10.3 Thetoll‐freelineshallhaveanautomatedsystem,availabletwenty‐four(24)‐
hoursaday,seven(7)daysaweek.Thisautomatedsystemshallincludethe
capabilityofprovidingcallerswithoperatinginstructionsonwhattodoincase
ofanemergencyandtheoptiontotalkdirectlytoanurseorotherclinicianor
leaveamessage,includinginstructionsonhowtoleaveamessageandwhen
that message will be returned. The Contractor shall ensure thatthevoice
mailbox has adequate capacity to receive all messages and that Enrollee
servicesstaffreturnallcallsbycloseofbusinessthefollowingBusinessDay.
2.13.10.4 The toll‐free phone line shall be accessible by all Enrollees, regardless of
whether they are calling about physical health or behavioral health. The
Contractormayeitherroutethecalltoanotherentityorconducta“warm
transfer”toanotherentity,buttheContractorshallnotrequireanEnrolleeto
callaseparatenumberregardingbehavioralhealthservices.
2.13.10.5 IftheContractor’snursetriage/nurseadvicelineisseparatefromitsEnrollee
servicesline,thenumberforthenursetriage/nurseadvicelineshallbethe
sameforallEnrollees,regardlessofwhethertheyarecallingaboutphysical
healthorbehavioralhealthservices,andtheContractormayeitherroutecalls
toanotherentityorconduct“warmtransfers,”buttheContractorshallnot
requireanEnrolleetocallaseparatenumber.
2.13.10.6 TheContractorshallhavesufficienttelephonelinestoanswerincomingcalls.
TheContractorshallensuresufficientstaffingtomeetperformancestandards
listedinthisContract.LDHreservestherighttospecifystaffingratioand/or
otherrequirements,ifperformancestandardsarenotmetoritisdetermined
that the call center staffing and/or processes are not sufficient to meet
EnrolleeneedsasdeterminedbyLDH.
2.13.10.7 TheContractorshalldevelopacontingencyplanforhiringcallcenterstaffto
addressoverflowcallsandemailsandtomaintaincallcentera
ccessstandards
setforthforMCOperformance.TheContractorshalldevelopandimplement
aplantosustaincallcenterperformancelevelsinsituationswherethereis
highcall and/ore‐mailvolumeor lowstaff availability.Such situationsmay
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include,butarenotlimitedto,increasesincallvolume,eventsdescribedin
theContinuityofOperationsPlansection,staffparticipatingintraining,staff
illnesses,andvacations.
2.13.10.8 TheContractorshalldeveloptelephonehelplinepoliciesandproceduresthat
address staffing, personnel, hours of operation, access and response
standards,monitoringofcallsviarecordingorothermeans,andcompliance
with standards and emergencies including, but not limited to, hurricane‐
related evacuations. The Contractor shall submit these telephone help line
policiesandprocedures,includingperformancestandards,toLDHforwritten
approval at least thirty (30) Calendar Days prior to implementation of any
policies.Thisshallincludeacapabilitytotrackandreportinformationoneach
call.TheMCO callcentershall havethecapabilityto produce anelectronic
recordtodocumentasynopsisofallcalls.Thetrackingshallincludesufficient
informationtomeetthereportingrequirements.
2.13.10.9 The Contractor shall develop call center quality criteria and protocols to
measure and monitor the accuracy of responses and phone etiquette as it
relatestothetoll‐freetelephoneline.TheContractorshallsubmitcallcenter
qualitycriteriaandprotocolstoLDHforreviewandapprovalannually.
2.13.10.10 TheContractorshallprovidegeneralassistanceandinformationtoindividuals
andtheirfamiliesseekingtounderstandhowtoaccesscare.ForCSoCeligible
Enrollees, the Contractor shall provide information to families about the
specializedservicesandhowtocontacttheCSoCcontractor.
2.13.11 24‐HourBehavioralHealthCrisisLine
2.13.11.1 TheContractorshallmaintainatwenty‐four(24)‐hourtoll‐freecrisisresponse
centertorespondtospecializedbehavioralhealthneeds.Thecallcentermay
becombinedwiththeContractor’stwenty‐four(24)‐hournurselineormaybe
aseparateline,butmustcomplywiththefollowingrequirements:
2.13.11.1.1 Twenty‐four(24)‐hour,seven(7)‐dayaweekaccesstostaff;
2.13.11.1.2 Answeredbyalivevoiceatalltimes;and
2.13.11.1.3 Havesufficienttelephonelinestoanswerincomingcalls.
2.13.11.2 The Contractor shall assist and triage callers who may be in crisis by
effectuating an immediate transfer to a case manager. The call shall be
answeredwithinthirty(30)secondsandonlytransferredviaawarmlinetoan
LMHP. The Contractor shall respect the caller’s privacy during all
communicationsandcalls.
2.13.11.3 TheContractormusthaveanafter‐hourssystemtorouteemergen
tandcrisis
behavioralhealthcallsoutsideofitsEnrolleeserviceshoursofoperationin
ordertoensureindividualsincrisisareabletoaccesscrisisservicesnecessary
tomeettheirneeds.
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2.13.12 TransportationCallCenter
TheContractorortheContractor’sTransportationBrokershallestablishandmaintaina
callcenterlocatedinLouisiana.Thecallcentershallberesponsible for scheduling all
NEMTreservationsanddispatchingof tripsduringthehoursof7:00a.m.to7:00p.m.
CentralTimeonBusinessDays.
2.13.13 AutomatedCallDistribution(ACD)System
The Contractor shall install, operate, and monitor a system forthecustomerservice
telephonecallcenter.Thesystemshall:
2.13.13.1 Effectivelymanageallcallsreceivedandassignincomingcallstoavailablestaff
inanefficientmanner;
2.13.13.2 Transfercallstoothertelephonelines;
2.13.13.3 Provide detailed analysis as required for the reporting requirements, as
specifiedby LDH,including thequantity,lengthand typesofcalls received;
elapsedtimebeforethecallsareanswered;thenumberofcallstransferredor
referred; abandonment rate; wait time; busy rate; response time; and call
volume;
2.13.13.4 Provide a message that notifies callers that the call may be monitored for
qualitycontrolpurposes;
2.13.13.5 Measurethenumberofcallsinthequeue;
2.13.13.6 Measurethelengthoftimecallersareonhold;
2.13.13.7 Measure the total number of calls and average calls handled per
day/week/month;
2.13.13.8 Measuretheaveragehoursofuseperday;
2.13.13.9 Assessthebusiesttimesanddaysbynumberofcalls;
2.13.13.10 Recordcallstoassesswhetheransweredaccurately;
2.13.13.11 Provide a backup telephone system that shall operate in the event of line
trouble,emergencysituationsincludingnaturaldisasters,orotherproblems
sothataccesstothetelephonelinesisnotdisrupted;
2.13.13.12 Provide interactive voice response (IVR) options that are user‐friendly to
EnrolleesandincludeadecisiontreeillustratingIVRsystem;and
2.13.13.13 InformtheEnrolleetodial911ifthereisanemergency.
2.13.14 CallCenterPerformanceStandards
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2.13.14.1 TheContractorshallcomplywiththefollowingrequirements:
2.13.14.1.1 Answerninety‐fivepercent(95%)ofcallswithinthirty(30)
secondsordirectthecalltoanautomaticcallpickupsystemwith
IVRoptions;
2.13.14.1.2 Nomorethanonepercent(1%)ofincomingcallsreceiveabusy
signal;
2.13.14.1.3 Maintainanaverageholdtimeofthree(3)minutesorlessper
call.Hold time,or wait time, forthepurposesof this Contract
includes:1)themeasureoftimeafteracallerhasrequesteda
livepersonthroughtheIVRsystemandbeforeacustomerservice
representativeanswersthecall;plus2)themeasureoftime
whenacustomerservicerepresentativeplacesacalleronhold;
and
2.13.14.1.4 Maintainabandonedrateofcallsofnotmorethanfivepercent
(5%).
2.13.14.2 The Contractor shall conduct ongoing quality assurance to ensure these
standardsaremet.
2.13.14.3 IfLDHdeterminesthatitisnecessarytoconductonsitemonitoring of the
Contractor’sEnrolleecallcenterfunctions,theContractorisresponsibleforall
reasonablecostsincurredbyLDHoritsauthorizedagent(s)relatingtosuch
monitoring.
2.13.15 InterpretationandWrittenTranslationServices
2.13.15.1 Inaccordancewith42C.F.R.§438.10(d)LDHshallprovideonitswebsitethe
prevalentnon‐EnglishlanguagesspokenbyEnrolleesintheState.
2.13.15.2 The Contractor shall make interpretation services, including real‐time oral
interpretationandtheuseofauxiliaryaidssuchasTTY/TDDandAmericanSign
Language (ASL), available free of charge to each Potential Enrollee and
Enrollee. This applies to all non‐English languages and not just those that
Louisianaspecificallyrequires(Spanish).Theseinterpretationservicesshallbe
madeavailabletoNetworkProviderstreatingnon‐EnglishspeakingEnrollees
atnocharge.TheContractormaycoordinatewiththeLouisianaCommission
fortheDeafforAmericanSignLanguageinterpretationservices.
2.13.15.3 TheContractorshallnotifyitsEnrolleesthatinterpretationisavailableforany
language and how to access those services. On materials where this
informationisprovided,thenotationshallbewritteninSpanish.Embedded
videosinAmericanSignLanguageshallbemadeavailableontheMCOwebsite
withpertinentinformationlabeledforEnrolleesthataredeaf,deaf‐blind,or
hardofhearing.
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2.13.15.4 The Contractor shall ensure that translation services are provided for all
writtenmarketingandmembermaterialsforanylanguagethatisspokenasa
primary language for four percent (4%) or more Enrollees, or Potential
EnrolleesofanMCO.Withinninety(90)CalendarDaysofnoticefromLDH,
materials shall be translated and made available. Materials shall be made
availableatnochargeinthatspecificlanguagetoensureareasonablechance
for all Enrollees to understand how to access the MCO and use services
appropriatelyasspecifiedin42C.F.R.§438.10(c)(4)and(5).
2.13.15.5 Written materials shall also be made available in alternative formats upon
request of the Enrollee or Potential Enrollee at no cost. Written materials
criticaltoobtainingservicesshallincludetaglinesintheprevalentnon‐English
languages in the state and large print explaining the availability of written
translation or oral interpretation to understand the information provided,
informationonhowtorequestauxiliaryaidsandservices,andthetoll‐freeand
TTY/TDD telephone number of the Contractor’s Enrollee customer service
unit.Largeprintmeansprintedinaconspicuously‐visiblefontsize.
MarketingandEducation
2.14.1 GeneralGuidelines
2.14.1.1 Marketing,forpurposesofthisContract,isdefinedin42C.F.R.§438.104(a)as
anycommunicationfromanMCOtoaBeneficiarywhoisnotenrolledinthat
MCO thatcanreasonably beinterpretedto influence theBeneficiaryto: 1)
enrollinthatMCO,or2)eithernotenrollin,ordisenrollfrom,anotherMCO.
2.14.1.2 Marketingdiffersfromeducation,whichisdefinedascommunicationwithan
enrolledmemberofanMCOforthepurposeofretainingtheEnrollee,and
improvingthehealthstatusofEnrollees.
2.14.1.3 Marketing and education includes both verbal presentations and written
materials.
2.14.1.4 Marketing materials are produced in any medium and include, butarenot
limitedto,theconceptsofadvertising,publicserviceannouncements,printed
publications, websites, social media, mobile device applications, broadcasts
andelectronicmessagesdesignedtoincreaseawarenessandinterestinthe
MCO. This includes any information that can reasonably be interpreted as
intendedtomarkettheMCOtoPotentialEnrollees.
2.14.1.5 Member materials generally include, but are not limited to, Member
Handbooks, MCO Member ID cards, Provider directories, health education
materials,formletters,massmailings,e‐mails,SMSmessages,Enrolleeletters,
andnewsletters.
2.14.1.6 AllmarketingandeducationguidelinesareapplicabletotheMCO,itsagents,
materialsubcontractors,volunteers,and/orproviders.
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2.14.1.7 Allmarketingandeducationactivitiesshallbeconductedinanorderly,non‐
disruptivemannerandshallnotinterferewiththeprivacyofBeneficiariesor
thegeneralcommunity.
2.14.1.8 TheContractorshallprovideinformationtoEnrolleesandPotentialEnrollees
inamannerandformatthatmaybeeasilyunderstoodandisreadilyaccessible
by such Enrollees and Potential Enrollees [42 C.F.R. §438.10(c)(1)]. All
marketing and member materials and activities shall comply withthe
informationrequirementsin42C.F.R.§438.10andtheLDHrequirementsset
forth in this Contract, the MCO Manual, and the Marketing and Enrollee
EducationCompanionGuide.
2.14.1.9 TheContractorshallmakeitswrittenmaterialsthatarecriticaltoobtaining
services, including provider directories, Enrollee Handbooks, Appeal and
Grievance notices, and denial and termination notices availableinthe
prevalent non‐English languages in the State as required by LDH [42 C.F.R.
§438.10(d)(3)]. The Contractor is responsible for creation, production and
distributionofitsownmarketingandmembermaterialstoitsEnrollees.
2.14.1.10 TheContractorshallnotperformanydirectmarketingtoPotentialEnrollees
inaccordancewith42U.S.C.§1396u‐2(d)(2)and42C.F.R.§438.104.
2.14.1.11 Activitiesinvolvingdistributionandcompletion ofanMCO Enrollment form
duringthecourseofEnrollmentactivitiesisanEnrollmentfunctionandisthe
soleresponsibilityofLDH’sEnrollmentBroker.
2.14.1.12 The Contractor shall ensure that marketing and member materialsare
accurate and do not mislead, confuse, or defraud the Enrollee/Potential
Enrollee or LDH as required by 42 U.S.C. §1396u‐2(d)(2) and 42 C.F.R.
§438.104.
2.14.1.13 The Contractor shall comply with the National Standards for Culturally and
LinguisticallyAppropriateServicesinhealthandhealthcare,asoutlinedbythe
Department of Health and Human Services’ Office of Minority Health,
incorporating the standards found here:
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53.
Additionally,theContractorshallparticipateintheState’seffortstopromote
thedeliveryofservicesinaculturallycompetentmannertoallEnrollees.
2.14.1.14 The Contractor shall develop marketing and member materials that
appropriatelyaddressalltheMCOpopulationsoutlinedintheEligibilityand
EnrollmentsectionoftheContract.
2.14.1.15 Sponsorships and events shall be scheduled throughout the stateina
geographicallyequitablemanner.
2.14.2 ProhibitedMarketingActivities
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The Contractor and its subcontractors are prohibited from engaging in the following
activities:
2.14.2.1 Marketing directlyorindirectly to Beneficiaries, including personscurrently
enrolledinFFSorotherMCOs(includingdirectmailadvertising,“spam”,door‐
to‐door,telephonic,e‐mail,texting,orother“coldcall”marketing
techniques);
2.14.2.2 AssertingthattheContractorisendorsedbyCMS,thefederalor state
governmentorsimilarentity;
2.14.2.3 Distributingplansandmaterialsormakinganystatement(writtenorverbal)
thatLDHdeterminestobeinaccurate,false,confusing,misleadingorintended
todefraudEnrolleesorLDH.Thisincludesstatementswhichmisleadorfalsely
describeMCOCoveredServices,membershiporavailabilityofprovidersand
qualifications and skills of providers, and assertions the recipient of the
communication mustenrollin a specificplan in ordertoobtain ornot lose
benefits;
2.14.2.4 Portrayingcompetitorsorpotentialcompetitorsinanegativemanner;
2.14.2.5 AttachingaLouisianaMedicaidProgramapplicationand/orEnrollmentform
tomarketingmaterialsdistributedtoanyEnrolleenotcurrentlyenrolledwith
theContractor;
2.14.2.6 Assisting with Enrollment or Disenrollment or improperly influencing MCO
selection;
2.14.2.7 UsingthesealoftheState,LDH’sname,logoorotheridentifyingmarksonany
materialsproducedorissued,withoutthepriorwrittenconsentofLDH;
2.14.2.8 Distributingmarketinginformation(writtenorverbal)thatimpliesthatjoining
MCOsoraparticularMCOistheonlymeansofpreservingLouisianaMedicaid
ProgramcoverageorthatMCOsoraparticularMCOistheonlyproviderof
MedicaidCoveredServicesandthatthePotentialEnrolleemustenrollinthe
MCOorMCOstoobtainbenefitsornotlosebenefits;
2.14.2.9 ComparingitsMCOtoanotherorganization/MCObyname;
2.14.2.10 Sponsoring or attending any marketing or community health activities or
eventswithoutnotifyingLDHinwritingwithinthetimeframesspecifiedinthis
Contract;
2.14.2.11 Engaging in any marketing activities, including unsolicited personal contact
withaPotentialEnrollee,atanemployer‐sponsoredenrollmenteventwhere
employeeparticipationismandatedbytheemployer;
2.14.2.12 Marketingordistributingmarketingmaterials,includingMemberHandbooks,
andsolicitingEnrolleesinanyothermanner,inside,attheentranceorwithin
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one hundred (100) feet of check cashing establishments, public assistance
offices, DCFS eligibility offices for the Supplemental Nutrition Assistance
Program(SNAP),FITAP, Health Units,Louisiana MedicaidProgramEligibility
Offices,and/orcertifiedMedicaidApplicationCenterswithoutpriorapproval
fromLDH;
2.14.2.13 ConductingmarketingordistributingmarketingmaterialsinEDs,includingthe
EDwaitingareas,patientroomsortreatmentareas;
2.14.2.14 PurchasingorotherwiseacquiringorusingmailinglistsofBeneficiariesfrom
thirdpartyvendors,includingprovidersandStateoffices;
2.14.2.15 Usingraffleticketsoreventattendanceorsign‐insheetstodevelopmailing
listsofPotentialEnrollees;
2.14.2.16 ChargingEnrolleesforgoodsorservicesdistributedatevents;
2.14.2.17 ChargingEnrolleesafeeforaccessingtheContractor’swebsite;
2.14.2.18 InfluencingEnrollmentinconjunctionwiththesaleorofferingofanyprivate
insuranceorMedicareAdvantagePlan;
2.14.2.19 Usingtermsthatwouldinfluence,mislead,orcauseBeneficiariestocontact
theContractor,ratherthantheEnrollmentBroker,forEnrollment;and
2.14.2.20 Usingtermsinmarketingmaterialssuchas“choose,”“pick,”“join,”etc.unless
themarketingmaterialsincludetheEnrollmentBroker’scontactandmobile
applicationinformation.
2.14.3 AllowableMarketingActivities
2.14.3.1 The Contractor and its subcontractors shall be permitted to perform the
followingactivities:
2.14.3.1.1 Distribute general information through mass media (i.e.
newspapers,magazinesandotherperiodicals,radio,television,
the Internet, public transportation advertising, billboards and
othermediaoutlets)inkeepingwithprohibitionstoplacement
asdetailedinthisContract;
2.14.3.1.2 MaketelephonecallsandhomevisitsonlytoEnrolleescurrently
enrolledintheMCO(Enrolleeeducationandoutreach)forthe
purposeofeducatingthemaboutservicesofferedbyoravailable
throughtheMCO;
2.14.3.1.3 Respondtoverbalorwrittenrequestsforinformationmadeby
Potential Enrollees, in compliance with the response plan
outlinedintheMarketingandEnrolleeEducationPlan(seeMCO
Manual),approvedbyLDHinwritingpriortoresponse;
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2.14.3.1.4 Provide promotional giveaways that exceed $15.00 value to
currentEnrolleesonly;
2.14.3.1.5 Attendororganizeactivitiesthatbenefittheentirecommunity,
such as health fairs or other health education and promotion
activities.NotificationtoLDHmustbemadeoftheactivityand
detailsmustbeprovidedabouttheplannedmarketingactivities;
2.14.3.1.6 Attend activities at a business at the invitation of the entity.
NotificationtoLDHshallbemadeoftheactivityanddetailsshall
beprovidedabouttheplannedmarketingactivities;
2.14.3.1.7 Conduct telephone marketing only during incoming calls from
PotentialEnrollees.TheContractormayreturntelephonecallsto
PotentialEnrolleesonlywhenrequestedtodosobythecaller.
The Contractor shall utilize the response plan outlined in the
Marketing and Member Education Plan (see MCO Manual),
approvedbyLDHinwriting,duringthesecalls;and
2.14.3.1.8 Send plan‐specific materials to Potential Enrollees at the
PotentialEnrollee’srequest.
2.14.3.2 InanyinstancewhereanMCO‐allowableactivityconflictswithaprohibited
activity,theprohibitedactivityguidanceshallprevail.
2.14.4 MarketingandMemberMaterialsApprovalProcess
2.14.4.1 TheContractorshallobtainpriorwrittenapprovalfromLDHforallmarketing
andmembermaterialsforpotentialorcurrentEnrollees.Thisincludes,butis
not limited to, print, television, web, and radio advertisements; Member
Handbooks,MCOMemberIDCardsandproviderdirectories;callscriptsfor
outbound calls or customer service centers; MCO website screen shots;
promotional items; brochures; letters and mass mailings and e‐mailings.
Neither the Contractor nor its subcontractors may distribute any MCO
marketingormembermaterialswithoutpriorLDHconsent.
2.14.4.2 All proposedmaterials shallbesubmittedviaemail toLDH inaformatand
mannerapprovedbyLDHinwriting.
2.14.4.2.1 Materials submitted as part of the original Marketing and
MemberEducationPlanshallbeconsideredapprovedwiththe
approvaloftheplanifthematerialswereinfinaldraftform.
2.14.4.3 TheContractorshallobtainpriorwrittenapprovalbyLDHforall materials
developedbyarecognizedentitythatisnotassociatedwiththeContractor,
suchasagovernmententityoranonprofitorganization,thattheContractor
wishestodistribute.LDHshallonlyconsidermaterialswhensubmittedbythe
Contractor(notsubcontractors).
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2.14.4.4 ReviewProcessforMaterials
2.14.4.4.1 LDHshallreviewthesubmittedmarketingandmembermaterials
and either approve, deny or submit changes in writing within
thirty(30)CalendarDaysfromthedateofsubmission.
2.14.4.4.2 Once member materials are approved in writing by LDH, the
ContractorshallsubmittoLDHanelectronicversionofthefinal
printed product within ten (10) Calendar Days from the print
date, unless otherwise specified by LDH. If LDH requests that
originalprintsbesubmittedinhardcopy,photocopiesmaynot
besubmittedforthefinalproduct.Uponrequest,theContractor
shallprovideadditionaloriginalprintsofthefinalproducttoLDH.
2.14.4.4.3 Prior to modifying any approved member material, the
ContractorshallsubmitforwrittenapprovalbyLDH,adetailed
descriptionoftheproposedmodificationaccompaniedbyadraft
oftheproposedmodification.
2.14.4.4.4 LDHreservestherighttorequiretheContractortodiscontinue
ormodifyanymarketingormembermaterialsafterapproval.
2.14.4.4.5 MCOmaterialsusedforthepurposeofmarketingandeducation,
exceptfortheoriginalMarketingand MemberEducation Plan,
are deemed approved if a response from LDH is not returned
withinthirty(30)CalendarDaysfollowingreceiptofmaterialsby
LDH.
2.14.4.4.6 TheContractorshallreviewallmarketingandmembermaterials
onanannualbasisandrevisematerials,ifnecessary,toreflect
current practices. Any revisions shall be approved by LDH in
writingpriortodistribution.
2.14.5 EventsandActivitiesApprovalProcess
2.14.5.1 The Contractor shall provide written notice to LDH in accordance with the
MCOManualforallmarketingandEnrolleeeducationeventsandactivitiesfor
potential or current Enrollees as well as any community/health education
activitiesthatarefocusedonhealthcarebenefits(healthfairsorotherhealth
educationandpromotionactivities).
2.14.5.2 TheContractorshallobtainpriorwrittenapprovalfromLDHforanypressor
mediaeventsoractivitiesoractivitiesthatitissponsoring.
2.14.5.2.1 Activitiesandeventssubmittedaspartoftheoriginalmarketing
andEnrolleeeducationplanshallbeconsideredapprovedwith
the approval of the plan if the activity or event details are
complete.
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2.14.5.2.2 The Contractor’s sponsorship distribution must be equitable
across all nine (9) Louisiana Medicaid Program geographic
regions. Equitability is assessed through a comparison of
sponsorshipdollarstototalEnrolleeswithinaspecificregion.Ifa
sponsorshipisnotwithintheequitabilityrange,LDHmaydeny
approval.
2.14.5.2.3 To consider denial of approval based on equitability, the
followingcriteriamustallbepresent:
2.14.5.2.3.1 Contractorhassponsoredatleastonepercent
(1%)ofstatewidesponsorships;
2.14.5.2.3.2 Contractorisoverequityrangefortheregion
inquestion;
2.14.5.2.3.3 Contractorisunderequityrangeinatleastone
region;
2.14.5.2.3.4 Aggregated MCOs are over equity range for
theregioninquestion;and
2.14.5.2.3.5 Therehasbeennomajordisasterdeclaration
activeinthepastsix(6)months.
2.14.5.3 ReviewProcessforEventsandActivities
2.14.5.3.1 LDHshallreviewproposedsponsorship,press,ormediaevents
andactivitiesandeitherapproveordenyinwritingwithinseven
(7)CalendarDaysfromthedateofsubmission.
2.14.5.3.2 Inthecasewhereasponsorship,press,ormediaeventoractivity
arisesandapprovalwithintheseven(7)CalendarDaytimeframe
isnotpossibleduetotheproximityoftheeventoractivity,the
Contractor may request an expedited approval in writing. LDH
reservestherighttodenysuchrequests.
2.14.5.3.3 Proposedsponsorship,press,ormediaeventsandactivities,
except for those included in the original MCO marketing and
Enrollee education plan, are deemed approved if a response
from LDH is not returned within seven (7) Calendar Days
followingnoticeofeventtoLDH.
2.14.5.3.4 Anyrevisionstoapproved sponsorship,press,or mediaevents
andactivitiesmustberesubmittedforapprovalbyLDHinwriting
prior to the event or activity in accordance with the MCO
Manual.
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2.14.5.3.5 LDHreservestherighttorequiretheContractortodiscontinue
or modify any marketing or Enrollee education events after
approvalbyLDHinwriting.
2.14.6 MCOProviderMarketing
2.14.6.1 Whenconductinganyformofmarketinginaprovider’soffice,theContractor
shallacquireandkeeponfilethewrittenconsentoftheprovider.
2.14.6.2 The Contractor shall not require its providers to distribute MCO‐prepared
marketingcommunicationstotheirpatients.
2.14.6.3 The Contractor shall not provide incentives or giveaways to providers to
distributemarketingcommunicationstoEnrolleesorPotentialEnrollees.
2.14.6.4 The Contractor shall not conduct Enrollee education or distribute Enrollee
educationmaterialsinprovideroffices,withtheexceptionofhealtheducation
materials(brandedornon‐branded)withtheprovider’sconsent.
2.14.6.5 TheContractorshallnotallowproviderstosolicitEnrollmentorDisenrollment
inanMCO,ordistributeMCO‐specificmaterialsasamarketingactivity.
2.14.6.6 TheContractorshallnotprovideprintedmaterialswithinstructionsdetailing
howtochangeMCOstoEnrolleesofotherMCOstoproviders.
2.14.6.7 The Contractor shall instruct Network Providers regarding the following
communicationrequirements:
2.14.6.7.1 NetworkProviderswhowishtolettheirpatientsknowoftheir
affiliationswithone(1)ormoreMCOsshalllisteachMCOwith
whomtheyhavecontracts;
2.14.6.7.2 Network Providers may display and/or distribute health
educationmaterialsforallcontractedMCOsortheymaychoose
nottodisplayand/ordistributeforanycontractedMCOs.Health
educationmaterialsshalladheretothefollowingguidance:
2.14.6.7.2.1 Healtheducationposterscannotbelarger
than16”x24”;
2.14.6.7.2.2 Children’sbooks,donatedbyMCOs,mustbe
incommonareas;
2.14.6.7.2.3 MaterialsmayincludetheMCO’sname,logo,
phonenumberandwebsite;and
2.14.6.7.2.4 Providersarenotrequiredtodistributeand/or
displayallhealtheducationmaterialsprovided
by each MCO with whom they contract.
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Providerscanchoosewhichitemstodisplayas
long as they distribute items from each
contractedMCOandthatthedistributionand
quantityofitemsdisplayedareequitable;
2.14.6.7.3 Providers may display marketing materials for MCOs provided
thatappropriatenoticeisconspicuouslyandequitablyposted,in
bothsizeofmaterialandtypeset,forallMCOswithwhomthe
providerhasacontract;
2.14.6.7.4 ProvidersmaydisplayMCOparticipationstickers,buttheyshall
displaystickersbyallcontractedMCOsorchoosetonotdisplay
stickersforanycontractedMCOs;
2.14.6.7.5 MCO stickers indicating the provider participates with a
particularMCOcannotbelargerthan5"x7”andmaynotinclude
anythingmorethantheMCOnameand/orlogoorwiththe
statementthatitisacceptedorwelcomedhere;
2.14.6.7.6 Providersmayinformtheirpatientsofthebenefits,servicesand
specialtycareservicesofferedthroughtheMCOsinwhichthey
participate.However,providersshallnotrecommendoneMCO
over another MCO, offer patients incentives for selecting one
MCO over another, assist the patient in deciding to select a
specific MCO in any way, or otherwise intend to influence an
Enrollee’sdecision;and
2.14.6.7.7 The MCO shall not produce branded materials instructing
EnrolleesonhowtochangeaMCO.TheymustuseLDHprovided
or approved materials and shall refer Enrollees directly to the
EnrollmentBrokerforneededassistance.
2.14.7 MCOMarketingRepresentatives
2.14.7.1 All MCO marketing representatives, including subcontractors assigned to
marketing, shall successfully complete a training program about the basic
conceptsoftheLouisianaMedicaidProgram,theManagedCareProgram,and
theEnrollees’rightsandresponsibilitiesrelatingtoEnrollmentinMCOsand
GrievanceandAppealsrightsbeforeengagingindirectmarketingtoPotential
Enrollees.
2.14.7.2 The Contractor shall ensure that all marketing representatives engage in
professional and courteous behavior. The Contractor shall not participate,
encourage,oracceptinappropriatebehaviorbyitsmarketingrepresentatives,
including, but not limited to interference with other MCO presentations or
talkingnegativelyaboutotherMCOs.
2.14.7.3 TheContractorshallnotoffercompensationtoamarketing representative,
includingsalaryincreasesorbonuses,basedsolelyonanoverallincreasein
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MCO Enrollment. Compensation may be based on periodic performance
evaluations which consider Enrollment productivity as one (1) of several
performancefactors.
2.14.7.4 Sign‐onbonusesformarketingrepresentativesareprohibited.
2.14.8 WrittenMaterials
TheContractorshallcomplywiththefollowingrequirementsasitrelatestoallwritten
member materials, regardless of the means of distribution (printed, web, advertising,
directmail,etc.).TheContractorshallalsocomplywiththerequirementsoutlinedin42
C.F.R.§438.10,42U.S.C.§1396u‐2(d)(2)(A)(i),and42U.S.C.§1396u‐2(a)(5):
2.14.8.1 All member materials shall be in a style and reading level that shall
accommodatethereadingskillsofMCOEnrollees.Ingeneral,thewritingshall
beatnohigherthana6.9gradelevel,asdeterminedbyanyoneoftheindices
below,takingintoconsiderationtheneedtoincorporateandexplaincertain
technicalorunfamiliartermstoensureaccuracy:
Flesch–Kincaid;
FryReadabilityIndex;
PROSE The Readability Analyst (software developed by Educational
Activities,Inc.);
GunningFOGIndex;
McLaughlinSMOGIndex;or
OthercomputergeneratedreadabilityindicesacceptedbyLDH.
Allwrittenmaterialsshallbeclearlylegiblewithaminimumfontsizeof
twelve(12)‐point,withtheexceptionofMCOMemberIDCards,andor
otherwiseapprovedbyLDHinwriting.
2.14.8.2 LDHreservestherighttorequireevidencethatwrittenmaterialsforEnrollees
havebeentestedagainstthe6.9gradereading‐levelstandard.
2.14.8.3 IfapersonmakingatestimonialorendorsementforanMCOhasafinancial
interestinthecompany,suchfactshallbedisclosedinthemarketing
materials.
2.14.8.4 The quality of materials used for printed materials shall be, at a minimum,
equaltothematerialsusedforprintedmaterialsfortheMCO’scommercial
plansifapplicable.
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2.14.8.5 TheMCO’sname,mailingaddress(andphysicallocation,ifdifferent),website
andtoll‐freenumbershallbeprominentlydisplayedonatleastone(1)page
withinallmulti‐pagedmarketingmaterials.
2.14.8.6 All multi‐page writtenmember materials shallnotifythe Enrollee thatreal‐
time oral and American Sign Language interpretation is available for any
languageatnoexpensetothemand provideinformationonhowtoaccess
thoseservices;
2.14.8.7 AllwrittenmaterialsrelatedtoMCOandPCPEnrollmentshalladvisePotential
Enrolleestoverifywiththemedicalservicesproviderstheypreferorhavean
existingrelationshipwith,thatsuchmedicalservicesprovidersareNetwork
ProvidersoftheselectedMCOandareavailabletoservetheEnrollee.
2.14.8.8 Alternative forms of communication shall be provided upon request for
personswith visual, hearing,speech,physicalor developmental disabilities.
ThesealternativesshallbeprovidedatnoexpensetotheEnrollee.
2.14.8.9 MarketingmaterialsshallbemadeavailablethroughtheMCO’sentireservice
area. Materials may be customized for specific parishes and populations
withintheMCO’sservicearea.
2.14.8.10 All marketing activities shall provide for equitable distribution of materials
withoutbiastowardoragainstanygroup.
2.14.8.11 Marketing materials shall accurately reflect general information,whichis
applicabletotheaveragePotentialEnrolleeoftheMCO.
2.14.8.12 TheMCOshallincludethefollowinginformationinallmembermaterials:
2.14.8.12.1 Thedateofissue;
2.14.8.12.2 Thedateofrevision;and/or
2.14.8.12.3 Ifthepriorversionsareobsolete.
2.14.8.13 Except as otherwise indicated in the Marketing and Member Education
CompanionGuide,theMCOsmaydeveloptheirownmaterialsthatadhereto
requirementssetforthinthisContractoruseStatedevelopedmodelEnrollee
notices.Statedevelopedmodelnoticesmustbeusedfordenialnoticesand
pharmacylock‐innotices.
2.14.9 Website
2.14.9.1 The Contractor’s website, available in English and Spanish, shall include an
Enrollee‐focusedsectionwhichcanbeadesignatedsectionoftheContractor’s
general informational website, which is interactive and accessible using
mobiledevices,andhasthecapabilityforbidirectionalcommunications,i.e.
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EnrolleescansubmitquestionsandcommentstotheContractorandreceive
responses.
2.14.9.2 The website shall include general and up‐to‐date information about the
ContractorasitrelatestotheManagedCareProgram.Thismaybedeveloped
onapagewithinitsexistingwebsitetomeettheserequirements.
2.14.9.3 TheContractorshallobtainpriorwrittenapprovalfromLDHbeforeupdating
theEnrollee‐facingportionofitswebsite,unlessthenewcontenthasbeen
approvedinwritinginanotherformat.
2.14.9.4 The Contractor shall remain compliant with HIPAA privacy and security
requirements when providing Enrollee eligibility or Enrollee identification
informationonthewebsite.
2.14.9.5 TheContractor’swebsiteshall,ataminimum,beincompliancewithSection
508oftheADA,andmeetallstandardstheADAsetsforpeoplewithvisual
impairmentsanddisabilitiesthatmakeusabilityaconcern.TheContractor’s
websiteshallfollowallwrittenmarketingguidelinesincludedinthisSection.
2.14.9.6 Useofproprietaryitemsthatwouldrequireaspecificbrowserisnotallowed.
2.14.9.7 The Contractor shall provide the following information on its website, and
such information shall be easy to find, navigate, and understand by all
Enrollees:
2.14.9.7.1 ThemostrecentversionoftheEnrolleeHandbook;
2.14.9.7.2 Telephone contact information, including a toll‐free customer
service number prominently displayed and a
TelecommunicationsDevicefortheDeaf(TDD)number;
2.14.9.7.3 AsearchablelistofNetworkProviderswithadesignationofopen
versus closed panels, which shall be updated in real time and
uponchangestothenetwork;
2.14.9.7.4 ThelinktotheEnrollmentBroker’swebsite,mobileapplication,
and toll‐free number for questions about Enrollment and
Disenrollment;
2.14.9.7.5 ThelinktotheLouisianaMedicaidProgramwebsiteandthetoll‐
free number for questions about Louisiana Medicaid Program
eligibility;
2.14.9.7.6 Generalcustomerserviceinformation;
2.14.9.7.7 Updates on emergency situations that may impact the public,
suchastheeventsdescribedintheContinuityofOperationsPlan
section, that would require time sensitive action by Enrollees,
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suchasevacuationfromtheirhomesorcommunitiesorother
preparedness‐related activities. The website shall include
hyperlinks to state and federal emergency preparedness
websites;
2.14.9.7.8 InformationonhowtofileGrievancesandAppeals;and
2.14.9.7.9 InformationspecifictoaccessforSBHS,including,butnotlimited
to:
2.14.9.7.9.1 ThelinktotheLDH‐OBHandCSoCwebsites;
2.14.9.7.9.2 InformationonhowtoaccessSBHS;
2.14.9.7.9.3 Crisisresponseinformationandtoll‐freecrisis
telephonenumbers;
2.14.9.7.9.4 Information regarding community forums,
volunteer activities, and
workgroups/committees that provide
opportunitiesforEnrolleesreceivingservices,
their families/caregivers, providers, and
stakeholderstobecomeinvolved;and
2.14.9.7.9.5 Informationregardingadvocacyorganizations,
including how Enrollees and other
families/caregivers may access advocacy
services.
2.14.10 WebandMobile‐BasedEnrolleeApplications
2.14.10.1 NolaterthantheOperationalStartDate,theContractorshallprovideaweb
or mobile based Enrollee/patient portal that includes the following
informationandfeatures:
2.14.10.1.1 Medical claims information such as lab and imaging results,
medicationsandkeyhealthappointments;
2.14.10.1.2 Social services information and resources, such as housing
supports,foodprograms,etc.;
2.14.10.1.3 Thecapabilityforadditionalhealthinformationtobeenteredby
theEnrollee;
2.14.10.1.4 Consumer‐friendly content that complies with MCO education
guidelines;and
2.14.10.1.5 ToolstohelphigherriskusersaccessState‐basedorplan‐based
resources such as smoking cessation or weight management
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programs. Need will be determined by the MCO health‐risk
assessmentorothertoolsusedforestablishinghigherriskusers.
2.14.10.2 The Contractor shall develop and promote patient engagement tools,
includingmobileapplicationsandsmartphone‐basedsupporttosupplement
existingpregnancyservices.TheContractorshallprovidedetailsofitsplanin
theMCOMarketingandOutreachPlansubmittedtoLDHforwrittenapproval.
2.14.10.3 TheContractorshallprovidereportingandanalyticstohelptheStatemeasure
theeffectivenessofsuchapplications.
2.14.11 MarketingReportingandMonitoring
2.14.11.1 TheContractorshallsubmitanupdatedplanofallanticipatedmarketingand
EnrolleeeducationeffortsforthecomingyeartoLDHinaccordancewiththe
MCOManual.
2.14.11.2 Toensurethefairandconsistentinvestigationofallegedviolations,LDHhas
outlinedthefollowingreportingguidelines:
2.14.11.2.1 TheContractorshallreportallegedmarketingviolationstoLDH
inaccordancewiththeMCOManual.
2.14.11.2.2 Uponwrittenreceiptofallegations,LDHshall:
2.14.11.2.2.1 Acknowledgereceipt,inwriting,withinfive(5)
BusinessDaysfromthedateofreceiptofthe
allegation.
2.14.11.2.2.2 Begin investigation within five (5) Business
Daysfromreceiptoftheallegationand
complete the investigation within thirty (30)
Calendar Days. LDH mayextendthetime for
investigation if there are extenuating
circumstances;
2.14.11.2.2.3 Analyze the findings and take appropriate
action(seeContractNon‐Compliancesection,
foradditionaldetails);and
2.14.11.2.2.4 Notify the complainant after appropriate
actionhasbeentaken.
2.14.11.3 LDHmayimposesanctionsagainsttheContractorformarketingandmember
education violations as outlined in the Contract Non‐Compliance section of
thisContract.
2.14.12 Pharmacy‐RelatedMarketingandEnrolleeEducation
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2.14.12.1 TheContractor, itssubcontractors, including PBMs,and Network Providers,
aresubjecttotheMarketingandEnrolleeEducationrequirementssetforthin
thissection.Thisincludesthereviewandwrittenapprovalofallmarketingand
member materialsincluding, but not limited to, websites and social media,
PharmacyIDCards,callscriptsforoutboundcallsorcustomerservicecenters,
providerdirectories,advertisementanddirectEnrolleemailings.
2.14.12.2 EnrolleesofanMCOshallhavefreeaccesstoanypharmacyparticipatingin
theMCO’snetwork(exceptincaseswheretheEnrolleeisparticipatinginthe
pharmacy/prescriber lock‐in program). Neither the Contractor nor any
subcontractor is allowed to steer Enrollees to certain Network Providers
includingspecialtypharmacies.LDHretainsthediscretiontodenytheuseof
marketing and member material that it deems to promote undue patient
steering,including,butnotlimitedto,Enrolleewebportalsandmobile‐based
Enrolleeapplications.
2.14.12.3 TheMCOisprohibitedfromdisplayingthenamesand/orlogosofco‐branded
PBMs on the MCO Member ID Card. Co‐branded marketing materials that
display the names and/or logos of co‐branded PMBs must include the
followinglanguage:“OtherPharmaciesareAvailableinOurNetwork.”
2.14.12.4 Co‐brandedmarketingmaterialsshallbesubmittedtoLDHbytheMCOfor
approvalinwritingpriortodistribution,inaccordancewiththeprocessesand
timelinesoutlinedinthissection.
2.14.13 MarketingandEducationViolations
2.14.13.1 WheneverLDHdeterminesthattheContractororanyofitsagents,
subcontractors,volunteersorprovidershasengagedinanyunfair,deceptive,
or prohibited marketing or Enrollee education practices in connectionwith
proposing,offering,selling,soliciting,andprovidinganyhealthcareservices,
oneormoreoftheremedialactionsasspecifiedinthisSectionshallapply.
2.14.13.2 Unfair,deceptive,orprohibitedmarketing andEnrolleeeducationpractices
shallinclude,butarenotlimitedto:
2.14.13.2.1 Failuretosecurewrittenapprovalbeforedistributingmarketing
ormembermaterials;
2.14.13.2.2 Failure to secure written approval for events involving
sponsorshipsandmediaevents;
2.14.13.2.3 Engagingin,encouraging,orfacilitatingprohibitedmarketingby
aprovider;
2.14.13.2.4 Directly marketing to Enrollees of another MCO or Potential
Enrollees;
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2.14.13.2.5 Failuretomeettimerequirementsforcommunicationwithnew
Enrollees(distributionofwelcomepackets,welcomecalls);
2.14.13.2.6 Failure to provide interpretation services or make materials
availableinrequiredlanguages;
2.14.13.2.7 Engaging in any of the prohibited marketing and Enrollee
educationpracticesdetailedinthisContract;
2.14.13.2.8 Utilizationofafalse,misleadingoralorwrittenstatement,visual
description,advertisement,orotherrepresentationofanykind
which has the capacity, tendency, or effect of deceiving or
misleadingPotentialEnrollees orEnrollees withrespect toany
health care services, MCO, or health care provider; or the
ManagedCareProgram;
2.14.13.2.9 RepresentationthatanMCOorNetworkProvideroffersany
service,benefit,accesstocare,orchoicewhichitdoesnothave;
2.14.13.2.10 Representation that an MCO or health care provider has any
status, certification, qualification, sponsorship, affiliation,or
licensurewhichitdoesnothave;
2.14.13.2.11 Failuretostateamaterialfactifthefailuredeceivesortendsto
deceive;
2.14.13.2.12 Offeringanykickback,bribe,award,orbenefittoanyBeneficiary
as an inducement to select, or to refrain from selecting any
health care service, MCO, or health care provider, unless the
benefitofferedismedicallynecessaryhealthcareorisamongthe
Value‐Added Benefits that are offered to all Enrollees or
predefinedeligibilitygroups;and
2.14.13.2.13 UseoftheBeneficiary’soranotherperson’sinformationwhichis
confidential, privileged, or which cannot be disclosed to or
obtained by the user without violating a State or Federal
confidentialitylaw,including:
2.14.13.2.13.1 Medicalrecordsinformation;
2.14.13.2.13.2 InformationthatidentifiestheEnrolleeorany
memberofhisorherhouseholdasa
participant of any government sponsored or
mandatedhealthcoverageprogram;and
2.14.13.2.13.3 Useofanydeviceorartificeinadvertisingthe
Contractor or soliciting a Beneficiary which
misrepresents the solicitor’s profession,
status,affiliation,ormission.
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2.14.13.3 TheContractorshallnotadvertise orotherwise holditselfoutas havingan
exclusiverelationshipwithanyserviceprovider.
2.14.13.4 IfLDHdeterminestheContractororitssubcontractorshassteeredPotential
EnrolleestojointheMCO,LDHmayimposeoneormoreofthefollowingnon‐
complianceactions:
2.14.13.4.1 TheEnrollee(s)shallbedisenrolledfromtheMCOattheearliest
effectivedateallowed;
2.14.13.4.2 PMPMs for the months(s) the Enrollee(s) was enrolled in the
MCOwillberecouped;
2.14.13.4.3 TheContractorshallbeassessedanadditionalMonetaryPenalty
per Enrollee (see Attachment G, Table of Monetary Penalties);
and/or
2.14.13.4.4 TheContractorshallsubmitalettertoeachEnrolleenotifyingthe
Enrollee of the imposed sanction and of their right to choose
anotherMCO.
2.14.13.5 IfLDHdeterminestheContractorhasviolatedanyofthemarketing or
educationactivitiesoutlinedintheContract,theContractormaybesubjectto
remedial actions specified in this Section and/or a Monetary Penalty per
violation/incident(seeAttachmentG,TableofMonetaryPenalties).Thetype
ofpenaltyshallbeatthesolediscretionofLDH.
2.14.14 RemedialActionsforMarketingViolations
2.14.14.1 LDH shall notify the Contractor in writing of the determinationofnon‐
compliance,oftheremedialaction(s)thatmustbetaken,andofany other
related conditions such as the length of time the remedial actions shall
continueandthecorrectiveactionsthattheContractorshallperform.
2.14.14.2 LDH may require the Contractor to recall previously authorized marketing
material(s).
2.14.14.3 LDH may suspend Enrollment of new Enrollees to the Contractor for an
amountoftimespecifiedbyLDH.
2.14.14.4 LDHmayrequiretheContractortocontact,inamannerspecifiedbyLDH,each
Enrollee who enrolled during the period while the Contractor was out of
compliance,inordertoexplainthenatureofthenon‐complianceandinform
theEnrolleeofhisorherrighttotransfertoanotherMCO.
2.14.14.5 LDHmayprohibitfuturemarketingactivitiesbytheContractorforanamount
oftimespecifiedbyLDH.
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EnrolleeGrievances,Appeals,andStateFairHearings
2.15.1 GeneralProvisions
2.15.1.1 TheContractorshallestablishandmaintainasystemforreceiving,reviewing,
andresolving Enrollee Grievancesand Appeals. Componentsshallincludea
Grievanceprocess,anAppealProcedure,andaprocesstoaccessaStateFair
Hearing.
2.15.1.2 TheContractorshallensurethatallEnrolleesareinformedofalltheprocesses.
FormswithwhichEnrolleesmayfileGrievancesorAppealsshallbeavailable
throughtheContractor,andshallbeprovideduponrequestoftheEnrollee.
The Contractor shall make all forms readily accessible on the Contractor’s
website.
2.15.1.3 TheContractorshallensurethatalldecisionsonGrievancesandAppealsare
madebyhealthcareprofessionalsinaccordancewithfederalregulations.
2.15.1.4 TheContractorshallreferallEnrolleeswhoaredissatisfiedwiththeContractor
oritsactivitiestotheContractor’sGrievancesystem.
2.15.1.5 TheContractorshallassisttheEnrolleeincompletingformsandfollowingthe
proceduresforfilingaGrievanceorAppealorrequestingaStateFairHearing.
2.15.1.6 Upon request, the Contractor shall provide the Enrollee and his or her
AuthorizedRepresentativetheEnrollee’srecord,includingallmedicalrecords
and any other documents and records considered or relied upon by the
ContractorregardinganAppealorStateFairHearing,includingthe
opportunitybeforeandduringtheAppealorStateFairHearingprocessforthe
Enrollee or an Authorized Representative to examine the record.The
Contractor shall provide such records free of charge and within seven (7)
CalendarDaysofreceiptoftherequest.
2.15.1.7 TheContractoranditssubcontractorsshallmaintainacompleteandaccurate
recordofallGrievancesandAppealsforaperiodofnolessthanten(10)years
followingterminationoftheContract.TheContractorshallmakeGrievance
andAppeal recordsavailable uponrequest byLDH andCMS.The recordof
each Grievance and Appeal shall contain, at a minimum, the information
specifiedin42C.F.R.§438.416(b).
2.15.1.8 The Contractor shall log, track, and trend all Grievances, regardless of the
degree of seriousness or whether the Enrollee expressly requests filing the
concern.
2.15.1.9 TheContractorshallreportonGrievancesandAppealstoLDHinamannerand
formatdeterminedbyLDH.
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2.15.1.10 TheContractorshalldisposeofaGrievanceandresolveeachAppeal, and
providenotice,asexpeditiously asthe Enrollee’shealth condition requires,
withinthetimeframesestablishedherein.
2.15.1.11 AprovidermayfileanAppealorrequestaStateFairHearingonbehalfofthe
EnrolleewiththeEnrollee’swrittenconsent.TheEnrollee'sconsentshallnot
berequiredforproviderAppealsofclaimdenials.
2.15.2 ProcessforGrievances
2.15.2.1 AnEnrollee,orAuthorizedRepresentativeactingontheEnrollee’sbehalf,may
fileaGrievanceorallyorinwritingatanytime.
2.15.2.2 The Contractor’s process for handling Enrollee Grievances shall include
acknowledgementinwritingwithinfive(5)BusinessDaysofreceiptofeach
Grievance.
2.15.2.3 TheContractorshallreviewtheGrievanceandprovidewrittennoticetothe
EnrolleeofthedispositionofaGrievancenolaterthanninety(90)Calendar
DaysfromthedatetheContractorreceivestheGrievance.
2.15.3 ProcessforAppeals
2.15.3.1 SubmissionandProcessingofAppeals
2.15.3.1.1 AnEnrollee,AuthorizedRepresentative,orlegalrepresentative
mayfileanAppealwiththeContractor,orallyorinwriting,within
sixty(60)CalendarDaysfromthedateonthenoticeofAdverse
BenefitDetermination.
2.15.3.1.2 OnceanoralAppealisreceived,theContractorshallinformthe
Enrolleetheyshallreceiveanoticeorwrittenconfirmationofthe
Appeal.Thedateoftheoralfilingshallconstitutedateofreceipt.
2.15.3.1.3 TheContractorshallacknowledgeeachAppealinwritingwithin
five(5)BusinessDaysofreceipt of each Appeal unless the
Enrolleerequestsanexpeditedresolution.
2.15.3.1.4 The Contractor shall provide the Enrollee a reasonable
opportunitytopresentevidenceandallegationsoffactorlaw,in
personaswellasinwriting.
2.15.3.1.5 The Contractor shall provide the Enrollee, the Enrollee’s
Authorized Representative, and the Enrollee’s legal
representative opportunity, before and during the Appeals
process, to examine the Enrollee's case file, including medical
recordsandanyotherdocumentsandrecordsconsideredduring
theAppealsprocess.
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2.15.3.1.6 TheContractorshallincludeaspartiestotheAppeal:
2.15.3.1.6.1 The Enrollee, the Enrollee’s Authorized
Representative, and/or the Enrollee’s legal
representative;or
2.15.3.1.6.2 The legal representative of a deceased
Enrollee'sestate.
2.15.3.2 ContinuationofBenefits
2.15.3.2.1 TheContractor shall continue to provide benefits and services
duringtheAppealifallofthefollowingoccur:
2.15.3.2.1.1 TheforanAppealisfiledTimelyasdefinedin
the Contract in accordance with applicable
Federal and State laws, regulations, rules,
policies, procedures, and manual. As used in
thissection,“Timely”'filingmeansfilingonor
beforethelaterofthefollowing:
Withinten(10)CalendarDaysofthe
ContractormailingthenoticeofAdverse
BenefitDetermination;or
The intended effective date of the
Contractor'sproposedaction.
2.15.3.2.1.2 The Appeal involves the termination,
suspension, or reduction of a previously
authorizedcourseoftreatment;
2.15.3.2.1.3 The services were ordered by an authorized
provider;
2.15.3.2.1.4 The original period covered by the original
authorizationhasnotexpired;and
2.15.3.2.1.5 The Enrollee Timely files for continuation of
benefits.
2.15.3.2.2 If, at the Enrollee's request, the Contractor continues or
reinstatestheEnrollee'sbenefitswhiletheAppealispending,the
benefitsshallbecontinueduntiloneoffollowingoccurs:
2.15.3.2.2.1 TheEnrolleewithdrawstheAppeal;
2.15.3.2.2.2 Ten (10) Calendar Days pass after the
Contractor mails the notice providing the
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resolution of the Appeal adverse to the
Enrollee, unless the Enrollee, within the ten
(10)CalendarDaytimeframe,hasrequesteda
State Fair Hearing with continuation of
benefitsuntilaStateFairHearingdecisionis
reached;
2.15.3.2.2.3 Following a State Fair Hearing, the
administrative law judge issues a hearing
decisionadversetotheEnrollee;or
2.15.3.2.2.4 Thetimeperiodorservicelimitsofapreviously
authorizedservicehasbeenmet.
2.15.3.3 StandardResolutionofAppeals
2.15.3.3.1 Forresolution,anAppealshallbeheardandnoticeofAppeal
resolutionshallbesenttothe Enrolleeandall partiesnolater
than thirty (30) Calendar Days from the date the Contractor
receivestheAppeal.
2.15.3.3.2 Ifadeterminationisnotmadeinaccordancewiththetimeframe
specified, the Enrollee’s request shall be deemed to have
exhaustedtheContractor’sAppealProcedureasofthedateupon
whichafinaldeterminationshouldhavebeenmade.TheEnrollee
maytheninitiateaStateFairHearing.
2.15.3.4 ExpeditedResolutionofAppeals
2.15.3.4.1 TheContractorshallestablishandmaintainanexpeditedreview
process for Appeals, when the Contractor determines (for
Enrollee requests) or indicates (when requesting on the
Enrollee'sbehalforsupportingtheEnrollee'srequest)thattaking
thetimeforastandardresolutioncouldseriouslyjeopardizethe
Enrollee's life, health, or ability to attain, maintain, or regain
maximumfunction.
2.15.3.4.2 TheContractorshallresolveeachexpeditedAppealandprovide
notice to the Enrollee, as quickly as the Enrollee’s health
conditionrequires,withinestablishedtimeframesnottoexceed
seventy‐two(72)hoursaftertheContractorreceivestheAppeal
request,whethertheAppealwasmadeorallyorinwriting.
2.15.3.4.3 The Contractor shall inform the Enrollee of the limited time
availablefortheEnrolleetopresentevidenceandallegationsof
fact or law, in person and in writing, in the case of expedited
resolution,and ensure thattheEnrolleeunderstands anytime
limitsthatapply.
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2.15.3.4.4 IfanEnrolleeasksforanextension,theContractorshalltreatthe
requestasadenial forexpeditedAppeal,immediatelytransfer
theAppealtothetimeframeforstandardresolution,andshallso
notifytheEnrollee.NothinginthissectionrelievestheContractor
ofitsobligationtoresolvetheEnrollee’sAppealasexpeditiously
astheEnrollee's health condition requires, in accordance with
FederalandStatelaws,regulations,rules,policies,procedures,
andmanuals.
2.15.3.4.5 InthecaseofanexpeditedAppealdenial,theContractorshall
provideoralnoticetotheEnrolleebycloseofbusinessontheday
ofresolution andwritten noticeto the Enrolleewithin two (2)
CalendarDaysofthedisposition.
2.15.3.5 NoticeofAppealResolution
2.15.3.5.1 TheContractorshallprovidetheEnrolleewithawrittennoticeof
AppealresolutionusingatemplateapprovedbyLDHinwriting.
2.15.3.5.2 TheContractorshallincludeonthenoticeauniqueidentifying
number,correspondingtothenumberonthenoticeofAdverse
BenefitDeterminationthatgaverisetotheAppeal.
2.15.3.5.3 For Appeals not resolved wholly in favor of the Enrollees, the
notice shall include all information required under 42 C.F.R.
438.408,including,butnotlimitedto,informingtheEnrolleeof
theirrighttoseekaStateFairHearingiftheEnrolleeisnot
satisfiedwiththeContractor’sdecisioninresponsetoanAppeal,
andtheprocessfordoingso.
2.15.4 ProcessforStateFairHearings
2.15.4.1 AnEnrolleeorotherpartytotheAppeal,whohascompletedtheContractor’s
Appeal Procedure, may request a State Fair Hearing within one hundred
twenty (120) Calendar Days after receiving a notice of Appeal resolution
indicatingthattheContractorisupholding,inwholeorinpart,theAdverse
BenefitDetermination,oraftertheContractorfailstoadheretothenoticeand
timingrequirementsapplicabletoAppeals.
2.15.4.2 TheContractorshallattendStateFairHearingsasscheduledandsupplythe
necessarywitnessesandevidentiarymaterials.
2.15.4.3 TheContractorshallsubmitanevidencepackettoLDHandtotheEnrollee,
freeofcharge,withinseven(7)BusinessDaysfromthetimetheContractor
receivesnotificationofthehearing.Theevidencepacketshallbesubmittedto
LDHinaccordancewithanyprehearinginstructions.Theevidencepacketshall
include all necessary documents including the statement of matters (or,
alternatively,thedenialletter)andanymedicalrecordsorotherdocuments
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and/orrecordsconsideredorrelieduponbytheContractorandsupporting
theContractor’sAdverseBenefitDeterminationandAppealresolution.
2.15.4.4 Withintwo(2)BusinessDaysofnotificationoftheStateFairHearingrequest,
the Contractor shall provide the corresponding Notice of Adverse Benefit
DeterminationandtheNoticeofAppealResolutionthatrelatetotheStateFair
HearingrequesttoLDH.
2.15.4.5 The Contractor shall designate an email address for all State Fair Hearing‐
relatedcommunicationsfromLDHandanypartytotheStateFairHearing.
2.15.4.6 The Contractor shall continue the Enrollee’s benefits while theStateFair
Hearing is pending if the Enrollee Timely files for continuation of benefits
withinten(10)CalendarDaysaftertheContractorsendsthenoticeofAppeal
resolutionthatisnotwhollyintheEnrollee’sfavor,inaccordance with 42
C.F.R.§438.420(b).
2.15.4.7 The Contractor shall comply with all terms and conditions set forth in any
ordersandinstructionsissuedbyanadministrativelawjudge.
2.15.4.8 If,attheEnrollee’srequest,theContractorcontinuesorreinstatesthebenefits
whiletheStateFairHearingispending,thebenefitsshallcontinueuntilone
(1)ofthefollowingoccurs:
2.15.4.8.1 TheEnrolleewithdrawstheStateFairHearingrequest;
2.15.4.8.2 TheStateFairHearingofficerissuesahearingdecisionadverse
totheEnrollee.
2.15.4.9 If the Contractor’s action is reversed by the administrative law judge and
services were not furnished while the Appeal was pending, the Contractor
shallauthorizeorprovidethedisputedservicespromptlyandasexpeditiously
astheEnrollee’shealthconditionrequires,butnolaterthanseventy‐two(72)
hours from the date the Contractor receives the notice reversing the
determination.
2.15.4.10 TheContractorshallnotcreatebarrierstoTimelydueprocess.TheContractor
shallbesubjecttopenaltiesifitisdeterminedbyLDHthattheContractorhas
createdbarrierstoTimelydueprocess,and/or,iftenpercent(10%)orhigher
ofdeniedAppealsarereversedorotherwiseresolvedinfavoroftheEnrollee
following a State Fair Hearing within a calendar year. Examplesofcreating
barriersshallinclude,butnotbelimitedto:
2.15.4.10.1 Labeling Grievances as inquiries and funneling them into an
informalreview;
2.15.4.10.2 Failure to inform Enrollees of their rights to file Grievances,
Appeals,andStateFairHearings;
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2.15.4.10.3 FailuretologandprocessGrievancesandAppeals;
2.15.4.10.4 Failure to issue a proper notice including vague or illegible
notices;and
2.15.4.10.5 Failuretoinformofcontinuationofbenefits.
2.15.4.11 The Contractor shall take no punitive action against a provider who either
requests an expedited resolution on behalf of an Enrollee or supports an
Enrollee’sAppeal.
QualityManagementandQualityImprovement
LDH’sMedicaidManagedCareQualityStrategy(“QualityStrategy”)definesanddrivestheoverall
visionforadvancinghealthoutcomesandqualityofcareprovidedtoEnrollees.Itestablishesclear
aims,goals,andobjectivestodriveimprovementsincaredeliveryandtheoutcomesandmetrics
bywhichprogresswillbemeasured.Itarticulatespriorityareasforqualityimprovement,anddetails
thestandardsandmechanismsfordesiredoutcomes,integrationwithpopulationhealthpriorities,
andtheadvancementofhealthequitythroughreductionofhealthdisparities.TheQualityStrategy
isaroadmapbywhichLDHshallusethemanagedcareinfrastructuretofacilitateimprovementin
theclinicalandnon‐clinicaldriversofhealth,incentivizingtheContractortoattainqualitygoalsand
improvehealthoutcomes.
2.16.1 GeneralRequirements
2.16.1.1 TheContractor’squalitymanagementandqualityimprovement(QM/QI)and
Quality Assessment and Performance Improvement (QAPI) programs shall
align with LDH’s priorities, goals and objectives as detailed in the Quality
Strategy.
2.16.1.2 TheContractorshall deliverquality care that enables Enrollees tomaintain
goodhealth,preventpoorhealthoutcomesand,ifnecessary,manage a
chronicillnessordisability.Qualitycarerefersto:
2.16.1.2.1 Clinicalqualityofphysicalhealthcare;
2.16.1.2.2 Clinicalquality of behavioral health care focusing on recovery,
resilienceandrehabilitation;
2.16.1.2.3 Access and availability of primary and specialty care providers
andservices;
2.16.1.2.4 Continuity and coordination of care across settings and care
transitions;and
2.16.1.2.5 Enrolleeexperiencewithrespecttoquality,access,availability,
culturalandlinguisticappropriatenessofservices,andcontinuity
andcoordinationofcare.
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2.16.1.3 TheContractorshallapplytheprinciplesofcontinuousqualityimprovement
(CQI)toallaspectsoftheContractor’sservicedeliverysystemthroughongoing
analysis,evaluationandsystematicenhancementsbasedon:
2.16.1.3.1 Quantitative and qualitative data collection with data‐driven
decision‐making;
2.16.1.3.2 Up‐to‐date evidence‐based practice guidelines consisting of
explicitcriteriadevelopedbyprofessionalsocietiesor,where
evidence‐based practice guidelines do not exist, consensus of
professionalsinthefield;
2.16.1.3.3 Feedback provided by Enrollees and providers in the design,
planning,andimplementationofCQIactivities;
2.16.1.3.4 IssuesidentifiedbytheContractororLDH;and
2.16.1.3.5 QM/QIrequirementsofthisContractappliedtothedeliveryof
bothphysicalhealthservicesandbehavioralhealthservices.
2.16.1.4 The Contractor’s QM/QI organizational and program structure shall comply
withallapplicableprovisionsof42C.F.R.Part438,including,butnotlimited
to,SubpartsDandE.
2.16.1.5 TheContractorshallannuallymeasureandreporttotheStateon its
performance,usingthestandardmeasuresrequiredbytheState,andsubmit
datatotheState,asspecifiedinthissection.
2.16.2 QualityAssessmentandPerformanceImprovement(QAPI)Program
2.16.2.1 TheContractorshallestablishandimplementaQAPIprogram,asrequiredby
thisContractand42C.F.R.§438.330(a)(1).
2.16.2.2 TheQAPI program shall clearlydefine QM/QIstructuresand processes and
assignresponsibilitytoappropriateindividuals.
2.16.2.3 Ataminimum,theQAPIprogramshall:
2.16.2.3.1 Objectivelyandsystematicallymonitorandevaluatethequality
andappropriatenessofcareandservicesandpromoteimproved
patientoutcomesthroughmonitoringandevaluationactivities,
including, but not limited to, improving the Contractor’s
performance on measures specified in Attachment H, Quality
PerformanceMeasures;
2.16.2.3.2 Incorporate improvement strategies and performance
improvementprojectsasdefinedbyLDH;
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2.16.2.3.3 Detectand address underutilization of high value services and
overutilization of low value services, as guided by the Quality
Strategy.TheContractorshallworkcollaborativelywithLDHto
prioritize specific efforts anticipated to improve high quality,
cost‐effectivecareforEnrollees.TheContractorshallimplement
atleastone(1)initiativetoreducelow‐valuecareinatargeted
area through coordination with Network Providers, including
providerandEnrolleeeducationefforts.Withinthefirstyearof
theContract’sOperationalStartDate,theContractorshall
proposeitsinitiativetoreducelow‐valuecareinatargetedarea,
subject to LDH approval in writing, based on feasibility,
thoughtfulness of approach to Enrollee and provider
engagement,consistencywithprioritiesoftheQualityStrategy,
and alignment with nationally validated initiatives and
frameworks.
2.16.2.3.4 Includecollectionandsubmissionofperformancemeasurement
datainaccordancewith42C.F.R.§438.330(c);
2.16.2.3.5 AddressthequalityofMCOCoveredServices,includingphysical
healthandbehavioralhealthservices;
2.16.2.3.6 Includethe Contractor’s plan forimproving thequality ofcare
andpatient safetybased on improvementinhealthoutcomes,
ratherthanprocessorutilizationoutcomes;
2.16.2.3.7 Incorporate applicable reporting and monitoring requirements
andactivities;
2.16.2.3.8 Includemechanismstoassessthequalityandappropriatenessof
carefurnishedtoEnrolleeswithSHCN;
2.16.2.3.9 Include specific mechanisms to assess the quality and
appropriatenessofcareprovidedtoEnrolleesatriskforhealth
disparities due to: race, ethnicity, sex, primary language, and
sexualorientation;
2.16.2.3.10 Include QM/QI activities to improve health care disparities
identifiedthroughdatacollection;
2.16.2.3.11 DetailtheContractor’sProviderSupportPlan;and
2.16.2.3.12 BeevaluatedandupdatedatleastannuallybytheContractor.
2.16.2.4 TheContractorshallusetheresultsofQAPIactivitiestoimprovethequalityof
physicalhealthandbehavioralhealthservicedeliverywithappropriateinput
from Enrollees and providers. The Contractor’s annual QAPI report shall
describe how the Contractor solicited direct input from Enrollees and
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providersandhowtheresultsofQAPIactivitiesimprovedthequalityofservice
delivery.
2.16.2.5 TheContractorshallsubmititsQAPIProgramDescriptiontoLDHforwritten
approvalatleastthirty(30)CalendarDayspriortotheOperationalStartDate,
and at least annually for the duration of the Contract. The QAPI program
descriptionshall include an annual QM/QI Work Plan that addresses issues
identified by the Contractor,LDH, Enrollees, and providers, and how those
issuesaretrackedandresolvedovertime.
2.16.3 QAPIGovernance
2.16.3.1 TheContractor’sgoverningbodyshalloverseeandevaluatetheimpactand
effectivenessoftheQAPIProgram.TheroleoftheContractor’s governing
bodyshallincludeprovidingstrategicdirectiontotheQAPIProgram,aswell
asensuringtheQAPIProgramisincorporatedintotheoperationsthroughout
theContractor.
2.16.3.2 The Contractor shall have sufficient mechanisms in place to solicit QM/QI
feedbackandrecommendationsfrom key stakeholders, Enrollees and their
families/caregivers,andproviders,andusefeedbackandrecommendationsto
improveperformance.
2.16.3.3 The Contractor shall disseminate information about QAPI findings and
improvement actions taken and their effectiveness to LDH and other key
stakeholders as directed by LDH. At LDH’s request, the Contractormaybe
requiredtoconductspecialfocusstudies.
2.16.3.4 TheContractorshallincreasethealignmentofassessmentandtreatmentof
medicalconditionswithbestpracticestandardsthroughpolicies.
2.16.3.5 TheContractorshallconductpeerreviewtoevaluatetheclinicalcompetence
and quality and appropriateness of medical care and services provided to
Enrollees.TheContractor shall provide peerreviewdocumentation toLDH,
uponrequest.
2.16.3.6 The Contractor shall have appropriate staff participate in the LDH Quality
Committee meetings and other quality improvement‐related meetings and
workgroups,asdirectedbyLDH andshallestablishandimplementpoliciesand
proceduresinordertoaddressspecificqualityconcerns.
2.16.4 QAPICommittee
TheContractorshallformaQAPICommitteethatshall
ataminimuminclude:
2.16.4.1 TheContractor’sMedicalDirectorwhomustserveaseitherthechairmanor
co‐chairman;
2.16.4.2 TheContractor’sBehavioralHealthDirector;
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2.16.4.3 Substantialinvolvement ofmedical and behavioral health providers serving
theContractor’sEnrollees;
2.16.4.4 AppropriateContractormedicalandbehavioralhealthstaffrepresentingthe
variousdepartmentsoftheorganization;and
2.16.4.5 AnEnrolleerepresentative(s)and/oradvocate(s).
TheContractorshallprovidetheMedicaidMedicalDirectorwithten(10)CalendarDays
advancenoticeofallregularlyscheduledmeetingsoftheQAPIcommittee.TheMedicaid
MedicalDirector,OBHMedicalDirector,OBHDirectorofQualityManagement,Medicaid
QualityImprovementSectionChief,OCDDClinicalDirector,OAASAssistantSecretary,or
his/herdesignee(s),mayattendtheQAPIcommitteemeetingsathis/heroption.
2.16.5 QAPICommitteeResponsibilities
TheQAPICommitteeshallmeetonatleastaquarterlybasis.Its responsibilities shall
include:
2.16.5.1 DirectandreviewQM/QIactivitiesandtheQAPIProgramoverall;
2.16.5.2 Ensure that QAPI activities take place throughout the Contractor’s
organizationandensurethatprovidersareinvolvedintheQAPIProgram;
2.16.5.3 Review and evaluate results of the QM/QI activities, recommend policy
decisions,andsuggestnewand/orimprovedQM/QIactivities;
2.16.5.4 Create and direct task forces/committees to identify, review, and address
areasofconcernintheprovisionofhealthcareservicestoEnrollees,including
institutingneededactionandensuringthatappropriatefollow‐upoccurs;
2.16.5.5 Designateevaluationandstudydesignprocedures;
2.16.5.6 Review providernetworkperformance, including individualPCP, specialized
behavioral health provider, and practice quality performance measure
profilingtoidentifyandaddresspatterns;
2.16.5.7 Report findings to appropriate executive authority, staff, and departments
withintheContractor’sorganization;
2.16.5.8 DirectandanalyzeperiodicreviewsofEnrollees’serviceutilizationpatterns;
2.16.5.9 Maintainwrittenminutesofallcommitteeandsub‐committeemeetingsand
submit meeting minutes to LDH. A copy of the signed and dated written
minutesforeachmeetingshallbeavailableaftertheminutesareapproved
andshallbeavailableforreviewuponrequestandduringEQROreviewsand
duringNCQAaccreditationreviews;
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2.16.5.10 ReportanevaluationoftheimpactandeffectivenessoftheQAPIprogramto
LDHannually;
2.16.5.11 Ensure that the QAPI committee chair, and/or the appropriate designee,
participatesin LDH’sQualityCommittee meetings andother quality related
meetingsasrequiredbythissectionofthisContract;
2.16.5.12 WorkwithotherContractorstaffandsubcontractorstoestablishpoliciesand
procedurestoaddressspecificqualityconcernsasrequiredbythissectionof
thisContract;and
2.16.5.13 Update provider manuals and other relevant clinical content on a periodic
basisasoftenasdeterminednecessarybythecommitteechairperson.
TheContractorshalltake appropriateaction toaddressservicedelivery,provider,and
otherQM/QIissuesastheyareidentified,including,butnotlimitedto,discussingand
addressingidentifiedqualityofcareconcernsduringregularandadhocQAPICommittee
meetings.
2.16.6 QAPIWorkPlan
The QAPI Committee shall develop and implement a written QAPI plan which
incorporatesthestrategicdirectionprovidedbythegoverningbody.TheQAPIworkplan
shallbesubmittedtoLDHoritsdesigneeaspartofReadinessReview and annually
thereafter,andpriortoimplementationofrevisions.TheQAPIplan,ataminimum,shall:
2.16.6.1 Reflect a coordinated strategy to implement the QAPI Program, including
planning,decisionmaking,interventionandassessmentofresults;
2.16.6.2 Includeprocessesandmetricstoevaluatetheimpactandeffectivenessofthe
QAPIProgram;
2.16.6.3 Includeadescriptionof theContractor staffassignedto theQAPIProgram,
theirspecifictraining,theirorganizationalstructure,andtheirresponsibilities;
2.16.6.4 DescribetheroleofitsprovidersandEnrolleesinprovidinginputtotheQAPI
Program;
2.16.6.5 Be exclusive to the Louisiana Medicaid Program and shall not contain
documentationfromotherstateMedicaidprogramsorproductlinesoperated
bytheContractor;and
2.16.6.6 DescribethemethodsforensuringdatacollectedandreportedtoLDHisvalid,
accurate,andreflectsproviders’adherencetoclinicalpracticeguidelinesas
appropriate.
2.16.7 QAPIReportingRequirements
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2.16.7.1 TheContractorshallsubmitQAPIreportsatleastannuallytoLDHwhich,ata
minimum,shallinclude:
2.16.7.1.1 Qualityimprovement(QI)activities;
2.16.7.1.2 Recommendednewand/orimprovedQIactivities;and
2.16.7.1.3 Resultsoftheevaluationoftheimpactandeffectivenessofthe
QAPIprogram.
2.16.7.2 LDHreservestherighttorequestadditionalreportsasdeemednecessary.LDH
willnotifytheContractorofadditionalrequiredreportsnolessthansixty(60)
CalendarDayspriortotheduedateofthosereports.
2.16.7.3 The Contractor shall provide all reports required under this subsection,
including, but not limited to, ad‐hoc reports and reports for special
populationstoLDHusing thespecificationsandformatapprovedbyLDHin
writing.TheContractorshallsubmitthereportsbasedontheagreedupon
datesestablishedbytheContractorandLDH.
2.16.8 PerformanceMeasures
2.16.8.1 Annually,theContractorshallreportonallHEDISmeasuresdesignatedbyLDH
inAttachmentH,QualityPerformanceMeasures.TheContractorshallcontract
withanNCQA‐certifiedHEDISauditortovalidatetheprocessesof the
Contractor in accordance with NCQA requirements. Audited HEDIS results
shall be submitted to LDH, NCQA and LDH’s EQRO annually according to
NCQA’s data submission timeline for health plans to submit final Medicaid
HEDISresults.
2.16.8.2 LDHhasthesolediscretiontodeterminewhethertheContractor will be
grantedanexceptionfromobtainingaHEDISauditand/orfromsubmittingthe
resultsoftheHEDISaudittoNCQAforeithersomeorallofthequalityand
healthoutcomemeasurements.Ifsuchanexceptionisgrantedinwriting,the
ContractorshallcomplywithallinstructionsanddeadlinesprovidedbyLDH.
2.16.8.3 TheContractorshallreportonadditionalnon‐HEDISperformancemeasures
listedinandasspecifiedinAttachmentH,QualityPerformanceMeasures.
2.16.8.4 Reporting of quality measures shall include stratification of performance
measure results across different populations with attention to geography,
ethnicity,race,anddisabilitystatus.
2.16.8.5 TheContractorshallhaveprocessesinplacetomonitor,self‐report, and
implementCQIonallperformancemeasures.
2.16.8.6 The data shall demonstrate adherence to clinical practice guidelines and
improvementinpatientoutcomes.
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2.16.8.7 TheContractorshallutilizesystems,operations,andperformancemonitoring
toolsand/orautomatedmethodsformonitoring.
2.16.8.8 Thetoolsandreportsshallbeflexibleandadaptabletochangesinthequality
measurementsrequiredbyLDH.
2.16.8.9 The Contractor shall maintain integrity, accuracy, and consistency in data
reported.Uponrequest,theContractorshallsubmittoLDHdetailssufficient
toindependentlyvalidatethedatareported.
2.16.9 IncentiveBasedPerformanceMeasures
2.16.9.1 Incentive Based (IB) performance measures are measures that may affect
PMPMpaymentsandcanbeidentifiedinAttachmentH,QualityPerformance
Measures,annotatedwith“$$”.
2.16.9.2 LDH expressly reserves the right to modify IB performance measures. Any
changesintheIBperformancemeasuresshallrequireanamendmenttothe
ContractandLDHshallnotifyContractorofsuchchangepriortothestartof
themeasurementyear.
2.16.9.3 TheContractor’sannualperformanceonIBperformancemeasuresinrelation
toLDHbenchmarktargetsandtheContractor’spriorperformanceshallaffect
itsability to earn backCapitation Payments related to thequalitywithhold
describedintheFinancialIncentivesforMCOPerformancesection.
2.16.10 PerformanceMeasureMonitoring
2.16.10.1 The Contractor shall submit administrative encounter data to LDH or its
designee upon request in a format that facilitates monitoring of the
Contractor’sperformanceonqualitymeasuresandbenchmarks.
2.16.10.2 During the course of the Contract, the Contractor shall actively participate
withLDHoritsdesigneetoreviewtheresultsofperformancemeasures.
2.16.10.3 Corrective action may be required for performance measures thatdonot
reachtheDepartment’sperformancebenchmark. LDHhasthesolediscretion
todeterminethestandardsbywhichtheContractorshallbesurveyedand
evaluated.
2.16.10.4 LDH may impose Monetary Penalties, sanctions and/or restrict Enrollment
pendingattainmentofacceptablequalityofcare.
2.16.11 PerformanceImprovementProjects
2.16.11.1 The Contractor shall implement an ongoing program of Performance
Improvement Projects (PIPs) that focus on clinical and non‐clin
ical
performancemeasuresasspecifiedin42C.F.R.§438.330.ClinicalPIPsinclude
projects focusing on prevention and care of acute and chronic conditions,
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high‐volume services, high‐risk services, and continuity and coordination of
care; non‐clinical PIPs include projects focusing on availability, accessibility,
low‐valuecare,addressingSDOH,andculturalcompetencyofservices.
2.16.11.2 TheContractorshallperformatleastthree(3)LDH‐approvedPIPsofwhichat
leastonemustbeabehavioralhealthPIP.LDHmayrequiretheContractorto
performuptotwo(2)additionalprojectsforamaximumoffive(5)projects.
2.16.11.3 AtLDH’srequest,priortoinitiationofeachLDH‐directedPIP,theContractor
shallsubmitinwritingaPIPproposal,incompliancewiththeMCOManual,
forwrittenapprovalbyLDHapproval.
2.16.11.4 TheContractorshall,incollaborationwithLDH,identifybenchmarksandset
achievableperformancegoalsforeachofitsPIPs.TheContractorshallidentify
and implement intervention and improvement strategies for achieving the
performancegoalsetforeachPIPandpromotingsustainedimprovements.
2.16.11.5 PIPs shall be designed to achieve, through ongoing measurementsand
intervention, significant improvement sustained over time, with favorable
effectsonhealthoutcomesandEnrollee satisfaction. Each project must
involvethefollowing:
2.16.11.5.1 Measurementofperformanceusingobjectivequalityindicators;
2.16.11.5.2 Implementationofinterventionstoachieveimprovementinthe
accesstoandqualityofcare;
2.16.11.5.3 Evaluationoftheeffectivenessoftheinterventions;and
2.16.11.5.4 Planningand initiation of activities for increasing or sustaining
improvement.
2.16.11.6 LDH,inconsultationwithCMSandotherstakeholders,mayrequirespecific
performancemeasuresandPIPtopics.TheContractorshallreportthestatus
andresultsofeachPIPasspecifiedintheMCOManual.IfCMSspecifiesaPIP,
theContractorshallimplementthisPIP,anditshallcounttowardthestate‐
approvedprojects.
2.16.11.7 TheContractorshallcompleteeachprojectshallwithininareasonabletime
within the performance period to allow the Contractor to utilize aggregate
informationonthesuccessofPIPstodevelopactionplanstoimplementfuture
PIPsthatwillmosteffectivelyimprovequality.
2.16.12 EnrolleeSatisfactionSurveys
2.16.12.1 The Contractor shall conduct annual Consumer Assessment of Healthcare
ProvidersandSubsystems(CAHPS)surveys.
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2.16.12.2 TheContractorshallenterintoanagreementwithavendorthatiscertifiedby
NCQAtoperformCAHPSsurveys.
2.16.12.3 TheContractor’svendorshallperformCAHPSAdultsurveysandCAHPSChild
surveys,includingtheChildrenwithChronicConditionssurveysupplement.
2.16.12.4 SurveyresultsandadescriptionofthesurveyprocessshallbereportedtoLDH
separately for each required CAHPS survey. CAHPS survey results shall be
submittedtoLDH,NCQAandLDH’sEQROannuallyaccordingtoNCQA’sdata
submissiontimelineforhealthplanstosubmitfinalMedicaidCAHPSresults.
2.16.12.5 TheCAHPSsurveyresultsshallbereportedtoLDHoritsdesigneeforeach
survey question. These results may be used by LDH for public reporting.
ResponsesshallbeaggregatedbyLDHoritsdesigneeforreporting.Thesurvey
shallbeadministeredtoastatisticallyvalidrandomsampleofclientswhoare
enrolledintheContractoratthetimeofthesurvey.
2.16.12.6 Thesurveysshallprovidevalidandreliabledataforresults.
2.16.12.7 Analyses shall provide statistical analysis for targeting improvement efforts
andcomparisontonationalandstatebenchmarkstandards.
2.16.12.8 ThemostcurrentCAHPSHealthPlanSurveyforEnrolleesshallbeusedand
include:
2.16.12.8.1 GettingNeededCare;
2.16.12.8.2 GettingCareQuickly;
2.16.12.8.3 HowWellDoctorsCommunicate;
2.16.12.8.4 HealthPlanCustomerService;and
2.16.12.8.5 GlobalRatings.
2.16.13 ExternalReviewandOversightofContractor
2.16.13.1 The Contractor shall fully cooperate with LDH, CMS, LDH’s EQRO and
OutcomesResearchandEvaluationcontractors,andanyotherLDHdesignees
related to reviewing, evaluating, and monitoring of this Contract, the
Contractor,ortheManagedCareProgram.
2.16.13.2 TheContractorshallprovideallinformationrequestedbyLDHand/oritsEQRO
including, but not limited to, quality outcomes, quality improvement
processes, timeliness of, and Enrollee access to, MCO Covered Services,
networkadequacyandNCQAaccreditationstatus.
2.16.13.3 The Contractor shall comply with the EQRO’s requests for information
including,butnotlimitedto,areviewoftheContractor’sQAPI Committee
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meetingminutesandannualmedicalrecordauditstoensurethatitprovides
qualityandaccessiblehealthcaretoContractorEnrollees,inaccordancewith
standards contained in the Contract. Such audits shall allow LDH or its
designee to review individual medical records, identify and collect
managementdataincluding,butnotlimitedto,surveysandotherinformation
concerningtheuseofservicesandthereasonsforDisenrollment.
2.16.13.4 ThestandardsbywhichtheContractorshallbesurveyedandevaluatedbythe
EQROshallbeatthesolediscretionandapprovalofLDH.Ifdeficienciesare
identified, LDH shall determine the remedy or remedies as outlined in the
ContractNon‐Compliancesection.
2.16.13.5 IftheEQROindicatesthatthequalityofcareisnotwithinacceptablelimitsset
forthintheContract,LDHmaypenalizetheContractorinaccordancewiththe
Contract and may immediately terminate all Enrollment activities and
Automatic Assignment until the Contractor attains a satisfactory level of
qualityofcareasdeterminedbytheEQROandLDH.
2.16.13.6 TheContractorshallincludeadescriptionoftheperformanceimprovement
goals,objectives,andactivitiesdevelopedandimplementedinresponsetothe
EQROfindingsintheContractor'sQAPIprogram.
2.16.14 HealthPlanAccreditation
2.16.14.1 IftheContractorisNCQAaccreditedforitsMedicaidproductcoveredbythis
ContractasoftheOperationalStartDate,theContractorshallmaintainfull
NCQAaccreditationthroughoutthetermofthisContract.
2.16.14.2 IftheContractorisnotNCQAaccreditedforitsMedicaidproductcoveredby
thisContractbytheOperationalStartDate,theContractorshallattainsuch
accreditation.
2.16.14.3 TheContractor’sapplicationforNCQAaccreditationshallbesubmittedatthe
earliestpointallowedbytheorganization.TheContractorshallprovideLDH
with a copy of all correspondence with NCQA regarding the application
processandtheaccreditationrequirements.
2.16.14.4 Withinten(10)CalendarDaysofreceiptofthefinalhardcopyNCQA
Accreditationreportforeachaccreditationcycle,theContractorshallprovide
LDHwithacopyofitsfinalaccreditationreportincluding:
2.16.14.4.1 Accreditationstatus,surveytype,andlevel(asapplicable);
2.16.14.4.2 Accreditation results, including recommended actions or
improvements, Corrective Action Plan(s), and summaries of
findings;and
2.16.14.4.3 Expirationdateoftheaccreditation.
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2.16.14.5 TheContractorshallprovideLDHwithupdatesofitsNCQAaccreditationstatus
ifthereareanychangeswithintheaccreditationperiodoruponrequestby
LDH.
2.16.14.6 IftheContractorachievesprovisionalaccreditationstatusfromNCQA:
2.16.14.6.1 LDH may restrict automatic and voluntary Enrollment in the
Contractor’splan;and
2.16.14.6.2 LDHshallrequiretheContractorto initiateaCorrectiveAction
Planwithinthirty(30)CalendarDaysofreceiptoftheFinalReport
fromNCQAandworktoaddressthefindingscontributingtothe
provisionalaccreditationstatus.
2.16.14.7 TheContractor’sfailuretoattainfullNCQAaccreditationunderthisContract
orfailuretomaintainfullNCQAaccreditationatanytimemaybeconsidered
abreachoftheContractandmayresultinterminationoftheContract.
2.16.14.8 IftheContractorsubcontractswithathirdparty(whichiseitherapartofthe
Contractor’sparentorganizationorwhollyindependent)forbehavioralhealth
services, the subcontractor shall be accredited by NCQA as a managed
behavioral health organization, or be working towards receiving full NCQA
accreditationwithintheContractterm.
2.16.15 EnrolleeAdvisoryCouncil
As specified in the MCO Manual, the Contractor shall establish an Enrollee Advisory
Counciltoenhancetheservicedeliverysystem,improveEnrolleeexperience,andallow
participation in providing input on policy and programs. Such Council shall be in
compliancewiththerequirementsintheMCOManual.
2.16.16 ProviderSupportsforQualityImprovement
2.16.16.1 TheContractor shallprovidesupportto providerstailoredto advance state
priorities and ensure providers’ ability to achieve the goals outlined in the
QualityStrategy.Suchsupportsshallassistprovidersinclinicaltransformation
andcareimprovementeffortsataregionalandpracticelevel.
2.16.16.2 AspartoftheContractor’sQAPIPlan,itshalldevelopandmaintainaProvider
SupportPlan,whichshallbeupdatedonanannualbasis.TheProviderSupport
Planshall:
2.16.16.2.1 BedevelopedasacomponentoftheQAPIprogram;provider
supportactivitiesshouldrelatetoimprovementinspecifichealth
outcomes;and
2.16.16.2.2 Include:(a)alistofprovidersupports;(b)howtheContractorwill
provide in‐person, online, and practice‐level and regional
collaborative support opportunities; (c) all planned technical
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support activities including the Contractor’s plan for sharing
relevantdata;(d)metricstoevaluateproviderengagementand
related improvements; and (e) detailed information regarding
how its proposed provider supports activities will advance the
aims,goals,andobjectivesoutlinedwithintheQualityStrategy.
2.16.16.3 The Contractor shall provide quality improvement support to Network
Providersduringtheinitiationandimplementationofqualityandpopulation
healthinterventions,asoutlinedintheQualityStrategyandincoordination
withtheLouisianaMedicaidQualityCommittee,orasotherwisespecifiedby
LDH.
2.16.16.4 TheContractorshallprovideanopportunityforproviders(in‐person,online,
routine/ad‐hoc)toraiselocalchallengesandexchangebestpracticesrelated
to quality and population health interventions, as outlined in the Quality
StrategyandotherLDHtransformationinitiatives.
2.16.16.5 The Contractor shall communicate with the Medicaid Medical Director or
designatedprimarycontactinordertoraiseregionalissuesrelatedtoquality
andpopulationhealthinterventions,asoutlinedintheQualityStrategyandas
otherwisespecifiedbyLDH.
2.16.17 FidelitytoEvidence‐BasedPracticesinBehavioralHealthCare
2.16.17.1 TheContractorshallestablishafidelity‐monitoringplanforEvidencedBased
Practice providers to ensure providers’ adherence to evidence‐based and
evidence‐informedpracticestoensurethecoreelementsoftheintervention
aremaintainedandminimumfidelitystandardsaremet.
2.16.17.2 Aformalfidelity‐monitoringplanshallbesubmittedtoLDHoritsdesigneeas
part of Readiness Review, which demonstrates compliance with the
requirementsforfidelitymonitoringasspecifiedintheMCOManual.
2.16.18 BestPracticesinChildren’sBehavioralHealthResidentialTreatment
The Contractor shall advance initiatives aimed at increased alignment of children’s
behavioral health residential programming with national best practice standards. The
Contractor shall utilize authorization, continued stay review, and discharge planning
protocols that support the implementation of best practices, including family
engagementthroughouttheresidentialtreatmentepisode,proactivedischargeplanning
includingreferral toCSoC(if appropriate)sixty (60)Calendar Daysprior toanticipated
dischargetoahomesetting,andensuringthataftercareprovidershavebeenidentified
thirty(30)CalendarDayspriortodischargesothataftercareservicesbeginimmediately
upon discharge to a home setting. The Contractor shall participate in planning and
implementation of these initiatives with LDH, and collaborate to develop an
implementation monitoring plan and provide assistance to providers in collecting and
reportingonbestpractice‐relatedperformanceindicators.
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2.16.19 AdverseIncidentandQualityofCareConcernsManagementandReporting
2.16.19.1 TheContractorshalldevelopandimplement adverseincidentmanagement
policies and procedures for specialized behavioral health providers, which
enablethe Contractor to identifyand address Enrollee servicegaps;Timely
identify, address, and remediate harms; assess the effectiveness of the
correctiveorremedialactions,andreducerisksofrecurrentharm.
2.16.19.2 TheContractorshallestablishreportingandinvestigationprotocolsforquality
of care concerns, and report such concerns to LDH. The Contractor shall
provide training, on no less than an annual basis, to specialized behavioral
health providers on adverse incident management and reporting
requirements.
2.16.19.3 TheContractorshallrequirespecializedbehavioralhealthproviderstoreport
adverse incidents as specified in the MCO Manual and within the required
timeframe.
2.16.19.4 AsrequestedbyLDH,theContractorshallobtainEnrolleerecordsandother
documentationfromNetworkProviders,andsubmitsuchinformationtoLDH
withintherequestedtimeframe.
2.16.19.5 TheContractorwillensureremedialandcorrectiveactionsrequestedbyLDH
areimplementedTimelyandappropriately.
2.16.20 OutcomeAssessmentforBehavioralHealthServices
2.16.20.1 TheContractorshallassessthetreatmentprogressandeffectivenessofSBHS
for both children and adults using standardized clinical outcome tools and
measures,accordingtotheguidelinesintheMCOManual.
2.16.20.2 The Contractor shall ensure providers and appropriate Contractor staff are
adequatelytrainedand/orcertifiedintheuseofsuchtoolsandsuchtraining
and/orcertificationiscurrent.
2.16.20.3 The Contractor shall be responsibleforcollectionofoutcomedata, data
validationactivities,andreportingtoLDH.
2.16.21 ManagedCareIncentiveProgram
2.16.21.1 LDHmaymakeincentivepaymentsofuptofivepercent(5%),intotal,above
the approved Capitation Payments attributable to the Enrollees or services
coveredbytheApprovedIncentiveArrangements(AIAs)implementedbyLDH.
These incentive payments will support the activities, targets, performance
measures,orquality‐basedoutcomesspecifiedinLDH’sQualityStrategy.
2.16.21.2
EachMCOshallparticipateintheAIAsimplementedbyLDH.AttheMCO’ssole
discretion, a participating MCO may subcontract with one or more third
parties to assist in its achievement of those AIAs. The subcontract should
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includespecificprovisionspertainingtotherightsandobligationsoftheMCO
and such third parties; eligibility for participation; payment amount and
timing; recovery of payments (including the amount, time and
manner/method); and other such terms particular to that AIA as mutually
agreeduponintheContractbetweentheContractorandsuchthirdparty.
2.16.21.3 LDH will, for each AIA to be implemented, specify the activities, targets,
performancemeasures,orquality‐basedoutcomestobeachievedandhow
eachwillbeevaluated.LDHwillonlyimplementAIAthatareconsistentwith
42C.F.R.§438.6(b)(2)andthisSection,including:
2.16.21.3.1 AIAswillbeforafixedperiodoftimeandperformancewillbe
measuredduringtheratingperiodundertheContractinwhich
theAIAisapplied.
2.16.21.3.2 AIAswillnotberenewedautomatically.
2.16.21.3.3 AIAswillbemadeavailabletobothpublicandprivatecontractors
underthesametermsofperformance.
2.16.21.3.4 NeitheranMCO’sparticipationintheMCIP,noranyAIA,willbe
conditioned on the MCO entering into or adhering to an
intergovernmentaltransferagreement.
2.16.21.3.5 AIAsarenecessaryforthespecifiedactivities,targets,
performancemeasures,orquality‐basedoutcomesthatsupport
programinitiativesasspecifiedintheQualityStrategy.
2.16.21.4 EachAIAshalldefinethequalitystrategyobjectives.
2.16.21.5 Foreachmeasurementyear,LDHwillevaluateperformancerelative tothe
specified activities, targets, performance measures, or quality‐based
outcomestobeachievedfortheAIA.LDH’sevaluationwillbebased on
documentation,submittedbytheMCO,reflectingperformance.
2.16.21.6 LDHshallTimelynotifytheContractorregardingachievementforthespecified
activities,targets,performancemeasuresorquality‐basedoutcomesforthe
AIAforthatmeasurementyear.IntheeventLDHfindsadeficiency,LDHwill
notifytheContractorofitsfindings,includingtheportionoftheincentive
payments made attributable to such deficiency. Upon request of the
Contractor, LDH may defer recoupment, and the Contractor and LDH may
confer regarding LDH’s findings, proposed action and opportunity for cure.
UponfinaldeterminationbyLDH,whichshallnotbesubjecttoAppeal,LDH
mayrecoupfromtheContractortheportionoftheincentivepaymentsmade
attributabletoanyuncureddeficiency.AllLDHrecoupmentsmadefromthe
Contractor pursuant to this Section shall be made in accordancewiththe
recoupmenttermsestablishedbyLDH,whichtermsshallbeprovidedtothe
Contractorinwritingatleastthirty(30)CalendarDaysinadvance of LDH
recoupmentfromtheContractor.
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2.16.21.7 TheMCOshallensurethatanysubcontractstheMCOmayhavewithanythird
party to fulfill the obligations under this Section contain provisions clearly
providingfortheMCO’srightofrecoveryinsituationswherebyLDHrecoups
MCIP payments from the MCO. LDH reserves the right to recoup inany
situationwhere CMS disallows federal financial participation related to any
paymentsintheMCIPprogram.AnMCO’sactivitiestorecoversuchpayments
fromitssubcontractor,throughrecoupment,withholdorotherwise,arenot
subject to the prior notification requirement under the Fraud, Waste and
Abuse Preventionsection,oranyothernoticeandreportingobligationset
forthinthisContractunlessotherwiserequiredbythetermsofrecoupment
specifiedbyLDHunderthisSection.
2.16.21.8 AnMCO’sparticipationintheAIAsshallhavenoimpactontheMCO’srights
orobligationsunderthisContract,exceptasitrelatesspecificallytotheMCIP
Program.AnMCO’sparticipationinanAIAdoesnotrepresentabinding
obligationontheMCOtoachievetheapprovedtargetedhealthoutcomes,and
failure to achieve such outcomes shall not be considered a breach of this
Contract.Further,exceptforrecoupmentofMCIPpayments,eitherdirectlyor
viaoffset,nopenaltyshallbeappliedforfailuretoachievetargetedoutcomes.
The aforementioned penalty limitation shall not apply to instances of the
MCO’sfraudulentconduct.Intheeventofaconflictwithothertermsofthis
Contract,theprovisionsofthisSectionandLDH’sMCIPProtocolshallprevail.
2.16.22 QualityMonitoringReviews
TheContractorshallcollaboratewiththeotherMCOstodevelopandimplementaplan
formonitoringastatisticallysignificantsampleofspecializedbehavioralhealthproviders
andfacilitiesacrossservicecategories,whichincorporatesonsitereviewsandmember
interviews,onaquarterlybasis.TheContractorshallsubmittheplantoLDHforapproval
nolaterthansixty(60)CalendarDaysaftertheOperationalStartDateoftheContractand
atleastsixty(60)CalendarDayspriortoanyMaterialChange.TheContractor’s
monitoring plan, monitoring process, and sampling approach shall comply with the
requirementsasspecifiedbyLDHintheMCOManual.
Value‐BasedPayment
2.17.1 Value‐BasedPayment(VBP)Overview
The Contractor shall develop and implement a VBP Strategic Planforachievingthe
performance benchmarks in the MCO Manual and paying providers based on
performance.TheContractor’sVBPstrategyshallpertaintomeasurableoutcomesthat
aremeanttoimprovethehealthofpopulations(betterhealth),enhancetheexperience
ofcareforindividuals(bettercare),effectivelymanageLouisianaMedicaidProgramper
capita care costs (lower costs), and be designed to meet or exceed the VBP withhold
requirementsinthisContract.
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IndevelopingitsVBPStrategicPlan,theContractorshallrefertothisContract,theMCO
ManualandtheAlternativePaymentMethod(APM)FrameworkdevelopedbytheHealth
CarePaymentLearningandActionNetwork(HCP‐LAN).
2.17.2 MinimumVBPThresholdandQualifyingVBPArrangements
AportionoftheContractor’sannualVBPwithholddescribedintheFinancialIncentives
forMCOPerformancesectionshallbetiedtotheContractor’sdemonstrationthatithas
mettheminimumVBPthresholdestablishedasdefinedbyLDHinaccordancewiththis
Contractand theMCO Manual.Unlessotherwise modifiedby LDH,the minimumVBP
thresholdforeachmeasurementyearisasfollows:
2.17.2.1 CY2023
2.17.2.1.1 Contractualarrangements linked to a VBP modelthat includes
oneormoreoftheHCPLANcategoriesidentifiedbyLDHaccount
foratleastfortypercent(40%)oftotalproviderpaymentsinthe
measurementyearandtheContractor’stotalpotentialprovider
incentivepaymentsrelatedtothismeasurementyearexceedsix
(6)milliondollarsintotalproviderpayments;or
2.17.2.1.2 The Contractor’s total potential provider incentive payments
exceedtwelve(12)milliondollarsintotalproviderpayments.
2.17.2.1.3 The Contractor’s VBP models must include at least one new
NetworkProviderAgreementwithacategory3AAPM,category
3BAPMorcategory4APMthatiseffectivenolaterthan
December2023.
2.17.2.1.4 The Contractor must submit an annual report to LDH
demonstrating how its VBP models align with LDH MCO
incentive‐based and other contractual performance measures
and provide initial data‐based assessments to determine the
extent to which providers participated in specific VBP models
maybeperformingdifferentlyontargetedqualitymeasuresthan
providersnotparticipatinginsuchVBPmodels.
2.17.2.2 CY2024
2.17.2.2.1 ContractualarrangementslinkedtoaVBPmodelaccountforat
least fifty percent (50%) of total provider payments in the
measurementyearandtheContractor’stotalpotentialprovider
incentive payments related to this measurement year exceed
seven(7)milliondollarsintotalproviderpayments;or
2.17.2.2.2 The Contractor’s total potential provider incentive payments
exceedfourteen(14)milliondollarsintotalproviderpayments.
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2.17.2.2.3 The Contractor’s VBP models must include at least one new
NetworkProviderAgreementwithacategory3AAPM,andone
newNetworkProviderAgreementwithacategory3BAPMor
category4APMthatiseffectivenolaterthanDecember2024.
2.17.2.2.4 The Contractor must submit an annual report to LDH
demonstrating how its VBP models align with LDH MCO
incentive‐based and other contractual performance measures.
TheContractormustalsoanalyzeVBPandqualityperformance
todeterminetheextenttowhichprovidersparticipatingin
specific VBP models performed differently on targeted quality
measuresthanprovidersnotparticipatinginsuchVBPmodels.
TheContractorshallindicate howit willuse theresultsof this
dataanalysistoimproveitVBPmodelsandprovidersupportfor
CY2025andfutureyears.
2.17.2.3 CY2025andFutureYears
2.17.2.3.1 ContractualarrangementslinkedtoaVBPmodelaccountforat
least sixty percent (60%) of total provider payments, and the
Contractor’stotalpotentialproviderincentivepaymentsexceed
eight(8)milliondollarsintotalproviderpayments,or
2.17.2.3.2 The Contractor’s total potential provider incentive payments
exceedsixteen(16)milliondollarsintotalproviderpayments.
2.17.2.3.3 The Contractor’s VBP models must include at least one new
NetworkProviderAgreementwithacategory3AAPM,onenew
NetworkProviderAgreementwithacategory3BAPM,andone
newNetworkProviderAgreementwithacategory4APMthatis
effectivenolaterthantheendoftheapplicablecalendaryear.
2.17.2.3.4 The Contractor must submit an annual report to LDH
demonstrating how its VBP models align with LDH MCO
incentive‐based and other contractual performance measures.
TheContractormustalsoanalyzeVBPandqualityperformance
todeterminetheextenttowhichprovidersparticipatingin
specific VBP models performed differently on targeted quality
measuresthanprovidersnotparticipatinginsuchVBPmodels.
TheContractorshallindicate howit willuse theresultsof this
dataanalysistoimproveitVBPmodelsandprovidersupportfor
CY2026andfutureyears.
2.17.3 QualifyingVBPArrangements
TheContractormayonlyreportaproviderpaymentmodelasaVBParrangementifthe
followingconditionsaremet:
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2.17.3.1 ThepaymentmodelincludesaCategory2AfoundationalpaymentorCategory
2B pay for reporting as one component of a broader payment model that
includesCategory2Cor3APMsforthesameprovider(s);and/or
2.17.3.2 ThepaymentmodelfallswithinCategories2C,3or4oftheLANAlternative
PaymentModelFramework;and
2.17.3.3 The payment model is linked to applicable incentive‐based measures from
AttachmentH,QualityPerformanceMeasures.
2.17.3.4 VBPmodelsfocusedonPCPsmustincludeatleasttwoincentive‐based
measure from Attachment H, Quality Performance Measures. VBP
arrangementsfocusedonservicesotherthanprimarycaremustutilizeatleast
two applicable measures in Attachment H, Quality Performance Measures,
andthesemeasuresdonotneedtobeidentifiedasincentive‐basedmeasures.
2.17.4 PhysicianIncentivePlans
2.17.4.1 In accordance with 42 C.F.R. §422.208 and §422.210, the Contractor may
operate a Physician Incentive Plan, but specific payment cannotbemade
directlyorindirectlyunderaPhysicianIncentivePlantoaphysician or
physician group as an inducement to reduce or limit medically necessary
servicesfurnishedtoanindividual.
2.17.4.2 TheContractor’sPhysicianIncentivePlansshallbeincompliancewith42C.F.R.
§438.3(i),§422.208and§422.210andtheMCOManual.
2.17.4.3 Anysub‐capitationarrangementwithNetworkProvidersisconsidered a
Physician Incentive Plan and subject to federal requirements and
requirementsofthissection.
2.17.4.4 TheContractorshallreporttoLDHtwiceannuallyonallPhysicianIncentive
Plansitoperates,andthosePhysicianIncentivePlansthatitintendstooperate
withinthenextsix(6)months.TheContractor’sPhysicianIncentivePlanreport
isdueonFebruary1andAugust30ofeachyearandinaccordancewithLDH
instructionsandtemplates.Ineachofthesereports,theContractorshall:
2.17.4.4.1 ProvideawrittenassurancetoLDHthateither:
2.17.4.4.1.1 TheContractorisnotoperatinganyPhysician
Incentive Plans that put physicians and
physiciangroupsat“substantialfinancialrisk”
asdefinedin42C.F.R.§422.208;or
2.17.4.4.1.2 TheContractorisoperatingPhysicianIncentive
Plansthatputphysiciansandphysiciangroups
at“substantialfinancialrisk”asdefinedin42
C.F.R. §422.208 and those plans meet all
applicablefederalrequirements.
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2.17.4.4.2 Report to LDH the following information in sufficient detail to
determine whether each existing and proposed Physician
Incentive Plan complies with the regulatory requirements
including:
2.17.4.4.2.1 Whether services not furnished by the
physician or physician group are covered by
the Physician Incentive Plan. No further
disclosureisrequiredifthePhysicianIncentive
Plandoesnotcoverservicesnotfurnishedby
thephysicianorphysiciangroup;
2.17.4.4.2.2 The type of incentive arrangement (e.g.,
withhold,bonus,capitationarrangement,etc.)
and the percent of withhold or bonus, if
applicable;
2.17.4.4.2.3 If the physician or physician group is at
substantialfinancialrisk,proofthephysicianor
physician group has adequate stop‐loss
protection,includingtheamountandtypeof
stop‐lossprotection;and
2.17.4.4.2.4 An explanation and the results of Enrollee
surveysinaccordancewith42C.F.R.§417.479.
2.17.4.5 TheContractorshallprovidetheinformationspecifiedin42C.F.R.§422.210(b)
regardingitsPhysicianIncentivePlanstoanyEnrolleeuponrequest.
2.17.5 VBPDataSharingandCollaborativeEfforts
2.17.5.1 TheContractorshallworkcollaborativelywithLDH,providers,andwithother
MCOs to develop common measure specifications, address Attribution
challenges, and work to align data collection processes, baseline data, and
reportsforprovidersengagedinVBParrangements.
2.17.5.2 TheContractorshalldedicateresourcesforprovideroutreachandeducation
relatedtoVBPmodels,primarycarepracticetransformation,assistancewith
dataandreportinterpretation,andotheractivitiestosupportprovider'sVBP
readinessandperformanceimprovement.
2.17.5.3 The Contractor shall implement processes to share data and performance
reports with participating VBP providers on a regular basis, no less than
monthly. The Contractor shall consider provider capabilities for accessing,
utilizing and acting on data shared in different formats as well as provider
capabilities to share such data internally. The Contractor shall identify and
incorporate aligned data sharing approaches and policies with providers to
supportVBPmodels,promptlysharedata,andreduceadministrativeburden
onproviders.
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2.17.5.4 The Contractor shall fully participate in LDH‐directed VBP Workgroups and
paymentreforminitiativesimplementedthroughoutthetermoftheContract
designed to pay providers for improving quality and efficiency of care and
simplifyingadministration.TheContractorshallenableproviderstoengagein
VBParrangementsthatallowtheprovidertohavegraduatedopportunitiesfor
earningperformanceincentivepaymentsandtoobtaininterimperformance
payments pending reconciliation based on the Contractor’s final
determinationofqualityandfinancialresultsasapplicabletothemodel.
2.17.5.5 TheContractor’sVBPapproachshallbedesignedtoalignfinancialincentives
forplansandprovidersandbuildsharedcapacitytoimprovecarethroughdata
andcollaboration.
2.17.5.6 TheContractorshallofferinformationandtoolsforproviderstoquerydata
sets,includinginformationandtoolssuchas:
2.17.5.6.1 Timelyandactionabledataregardingcost,utilizationandquality
forattributedEnrolleepopulations;
2.17.5.6.2 Contact, health screening, and health risk information for
attributedEnrollees;
2.17.5.6.3 Identificationofhighutilizersandotherpertinentinformation;
2.17.5.6.4 Real‐timedata related to Admission, Discharge, and Transfers;
and
2.17.5.6.5 Enrolleeregistries.
2.17.5.7 TheContractorshallcomplywithproviderprofilinganddatasharingformats
andfrequencyspecificationsissuedbyLDH.
2.17.5.8 The Contractor’s data sharing policies and agreements with providers shall
addressandcomplywithapplicablefederalandStatedataprivacyandsecurity
requirements.
2.17.5.9 The Contractor shall employ and clearly identify provider network
representativestosupportprovidersthatareengagedinVBParrangements
tobetterunderstandandactondatatoimprovequalityandmanagecostsof
care.
2.17.5.10 TheContractorshallensurethatitreceivesencounterandotherdataneeded
underVBParrangementstomeetitsobligationsunderthisContract.
2.17.6 PreferredVBPArrangements
2.17.6.1 PreferredVBParrangementsareprioritiesforLDHbasedonthepotentialto
improve health care and cost‐efficiency. The Contractor shall indicate in its
VBPStrategicPlanandsubsequentupdatestothePlanwhichofthefollowing
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preferred VBP arrangements it intends to implement and when it will
implementsucharrangementsduringtheContractperiod:
2.17.6.1.1 Maternity‐focusedVBParrangements;
2.17.6.1.2 Modelssupportingphysicalandbehavioralhealthintegration;
2.17.6.1.3 Patient‐centeredmedicalhomemodelsthatarepartofabroader
paymentmodelthatincludesCategory2Cor3APMsandwhich
support the integration of behavioral health, SDOH, and/or
populationswithspecialhealthcareneeds;
2.17.6.1.4 HospitalVBParrangements;and
2.17.6.1.5 OthermodelsasidentifiedbyLDH,including,butnotlimitedto,
VBPmodelsspecificallydesignedtoreducehealthdisparitiesand
improveequity.
2.17.7 EnrolleeAttributioninVBPArrangements
2.17.7.1 VBP models involve Enrollees being clearly attributed to providers for
considerationof quality performance, and insome cases,total costofcare
performance ofthe provider’s attributed population, as defined in the VBP
modelandpaymentarrangements.TheContractorshalldevelopandshareits
AttributionapproachforVBParrangementswithLDHandNetworkProviders
inatransparentandaccessiblemanner.
2.17.7.2 The Contractor shall collaborate with providers engaged in VBP models to
developandmaintainanaccurate,up‐to‐datelistofattributedEnrolleesand
associatedproviders.Atleastmonthly,theContractorshall sharecomplete
listsofattributedEnrolleeswithVBPproviders.Ataminimum,theContractor
shall share performance and claims data for attributed Enrollees with VBP
providersonaquarterlybasis.
2.17.7.3 For a VBP arrangement that includesprimarycare,theContractor shall
attributeEnrolleestothesameproviderwhichhasbeenselected,eitherby
choice or assignment, as the Enrollee’s PCP. The Contractor shall educate
providersonhowtoaccess,utilize,andsharedataonattributedEnrollees.
2.17.8 MechanismsforProviderstoDisputeEnrolleeAttribution
2.17.8.1 TheContractorshallhaveaprocessbywhichaprovidermaydispute the
Contractor’sAttributionofanEnrolleeinrelationtoaVBParrangementasit
relatestothemeasurementoftheprovider’squalityorfinancialperformance
inthemodel.TheContractorshallinformprovidersofsuchdisputeprocess
and must respond to and address provider complaints related to Enrollee
Attributionwithinfifteen(15)CalendarDaysofreceipt.
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2.17.8.2 For Attribution to PCPs, the Contractor shall attribute Enrollees to their
assignedPCP.
2.17.8.3 The Contractor shall consider altering its Attribution and related PCP
assignment when an Enrollee is regularly seeing a different provider for
primarycareservicesthanthePCPtowhichtheEnrolleehasbeenattributed
andwhenanEnrolleehasnotseentheattributedPCPinthepasttwelve(12)
months.
2.17.8.4 TheContractorshallhaveclearmethodsforadjustingitsPCPassignmentand
VBPAttributionmethodologiesbasedondataanalysis,andshallimplement
anyLDH‐directedPCPassignmentandAttributionpoliciesandmethodologies
toensureuniformityacrossMCOs.
2.17.9 FinancialBenchmarks,SharedSavingsCalculations,andRiskMitigation
2.17.9.1 The Contractor’sfinancialbenchmarksin VBPmodels shallincentivize high‐
quality,efficientcare,enableaccountability,andestablishtargetsthatfairly
rewardproviderorganizations.AspartofitsVBPagreements,theContractor
shall not hold providers accountable for meeting a higher target for the
incentive‐basedmeasurethanthetargettowhichLDHholdstheMCOforthe
samemeasureunlesstheproviderisalreadyperformingabovethebenchmark
setbyLDHforMCOperformanceontheincentive‐basedmeasure.
2.17.9.2 The Contractor shall risk‐adjust provider payment rates when feasible and
appropriateinVBPmodelstoreflecttheriskoftheattributedpopulation.
2.17.9.3 The Contractor shall transparently communicate to providers theshared
savingsandrisk‐sharingparametersinvolvedinparticipatinginaVBPmodel,
suchthatproviderscanaccesstheinformationtheyneedtofullycomprehend
theopportunitiesandrisksassociatedwithparticipation.TheContractorshall
clearly articulate when and how it will determine provider financial
performanceandhowitwillsetthetargets.
2.17.9.4 The Contractor shall offer providers in good standing and with prior VBP
experiencewiththeContractortheoptiontoobtainaportionofanticipated
VBP payments prospectively based on interim financial and quality
performanceresultsratherthanwaitingforpotentialpaymentsfromshared
savingscalculationsaftertheendoftheperformanceperiod.
2.17.9.5 TheContractorshallofferprovidersanauditorappealprocessonVBPbudget
andsharedsavingsorsharedriskcalculations.
2.17.9.6 Forsharedriskarrangements,theContractorshallconsiderwhetherandhow
tousestop‐lossorotherriskprotectionsinconsultationwithNetwork
Providers, and consider provider size, financial stability, the potential for
randomvariation inmedicalexpendituresof a population,and a provider’s
VBP experience. The Contractor shall share financial modeling data with
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providers to demonstrate potential changes in provider paymentspriorto
acceptingdownsideriskarrangements.
ClaimsManagement
TheContractorshallensurethatallproviderclaimsareprocessedappropriatelyinaccordance
withthisContractandtheSystemCompanionGuide.TheContractormaybesubjecttoMonetary
Penalties if LDH determines, at its sole discretion, that the Contractor has inappropriately
processedproviderclaimsforservices.Theobligationsoutlinedinthissectionshallsurvivethe
terminationoftheContractforaslongasanyoutstandingobligationsundertheContractremain.
2.18.1 Functionality
2.18.1.1 TheContractorshallmaintainanelectronicclaimsmanagementsystemthat
shall:
2.18.1.1.1 Uniquely identify the attending and billing provider of each
service;
2.18.1.1.2 IdentifythedateofreceiptoftheclaimbytheContractoras
indicatedbythedatestampontheclaim;
2.18.1.1.3 Identify real‐time accurate history with dates of adjudication
results of each claim such as paid, denied, pended, adjusted,
voided, appealed, etc., and follow up information on disputed
claims;
2.18.1.1.4 Identifythedateofpaymentasindicatedonthecheckorother
form of payment, and the number of the check or electronic
fundstransfer(EFT);
2.18.1.1.5 IdentifyalldataelementsasrequiredbyLDHforencounterdata
submissionasstipulatedinthisSectionoftheContractandthe
MCOSystemCompanionGuide;
2.18.1.1.6 Acceptsubmissionofpaper‐basedclaimsandelectronicclaims
byNetworkProviders,andOut‐of‐NetworkProviders;
2.18.1.1.7 Accept submission of paper‐based and electronic adjustments
andvoidtransactions;
2.18.1.1.8 Havecapabilitytopayclaimsat$0.00;and
2.18.1.1.9 ForthepurposeofthisSection,identifymeanstocapture,edit,
andretain.
2.18.1.2 The Contractor shall not derive financial gain from a provider’s use of
electronicclaimsfilingfunctionalityand/orservicesofferedbytheContractor
orathirdparty.However,thisprovisionshallnotbeconstruedtoimplythat
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providersmaynotberesponsibleforpaymentofapplicabletransactionfees
and/orcharges.
2.18.1.3 The Contractor shall assume all costs associated with claims processing,
includingcostsforprocessingand/orreprocessingencounters.
2.18.1.4 TheContractorshallprovideonlineandphone‐basedcapabilitiestoproviders
toobtainclaimprocessingstatusinformation.
2.18.1.5 The Contractor shall support a CAQH/CORE compliant interface tothe
automatedclearinghouse(ACH)thatallowsproviderstorequestandreceive
electronicfundstransfer(EFT)ofclaimspayments.
2.18.1.6 TheContractorshallhaveprocedures,whichshallbesubmittedandapproved
byLDHinwriting priortoimplementation,availabletoproviders inwritten
andwebformfortheacceptanceofclaimsubmissionswhichinclude:
2.18.1.6.1 Theprocessfordocumentingthedateofactualreceiptofnon‐
electronic claims and date and time of receipt of electronic
claims;
2.18.1.6.2 Theprocessforreviewingclaimsforaccuracyandacceptabilityin
accordancewith42C.F.R.§438.242(b)(3);
2.18.1.6.3 Theprocessforpreventionoflossofsuchclaims;and
2.18.1.6.4 Theprocessforreviewingclaimsfordeterminationastowhether
claimsareacceptedascleanclaims.
2.18.1.7 The Contractor shall not employ off‐system or gross adjustmentswhen
processingcorrectionsforpaymenterrors,unlesstheContractorrequestsand
receivespriorwrittenapprovalfromLDH.
2.18.1.8 Forpurposesofnetworkmanagement,theContractorshallnotifyallNetwork
Providers to file claims associated with covered services for its Enrollees
directlywiththeContractor.
2.18.1.9 TheContractorshallmodifyitsclaimsbillingandprocessingprocedurestobe
consistentwithindustrynormswithinthirty(30)CalendarDaysofreceiptofa
requestfromLDH.
2.18.2 ClaimsProcessing
2.18.2.1 TheContractorshallensurethatallproviderclaimsareprocessedaccording
tothefollowingtimeframes:
2.18.2.1.1 Withinfive(5)BusinessDaysofreceiptofaclaim,theContractor
shallperformaninitialscreening,andeitherrejecttheclaim,or
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assignauniquecontrolnumberandenteritintothesystemfor
processingandadjudication;
2.18.2.1.2 Processandpayordeny,asappropriate,atleastninetypercent
(90%)ofallcleanclaimsforeachclaimtype,withinfifteen(15)
CalendarDaysofthedateofreceipt;
2.18.2.1.3 Processandpayordeny, asappropriate,onehundredpercent
(100%) of clean claims for each claim type, within thirty (30)
CalendarDaysofthedateofreceipt;and
2.18.2.1.4 Payordenyall(100%)pendedclaimswithinsixty(60)Calendar
Daysofthedateofreceipt.
2.18.2.2 TheContractormaypendclaimssubmittedbyprovidersthatarethesubject
ofapaymentsuspensionduetoacredibleallegationofFraudinaccordance
with42C.F.R.§455.23forthedurationofthepaymentsuspension.Oncethe
suspensionperiodhasended,theContractorshallAdjudicateanypreviously
pendedclaimsinaccordancewiththetimeframesabove.
2.18.2.3 TheContractorshallnotautomaticallyadjust,down‐code,orpayclaimsata
lowerlevelofservicethanwhatwassubmittedbytheprovider.
2.18.2.4 In accordance with 42CFR § 455.440, allclaimsforpayment foritemsand
services that were ordered or referred shall contain the National Provider
Identifier(NPI)oftheproviderwhoorderedorreferredsuchitemsorservices.
2.18.3 RejectedClaims
2.18.3.1 The Contractor may reject claims because of missing or incomplete
informationrequiredforadjudication.Paperclaimsthatarereceivedbythe
Contractorthatarescreenedandrejectedpriortoscanningshallbereturned
to the provider with a letter notifying them of the rejection. Paper claims
received by the Contractor that are scanned prior to screening and then
rejectedarenotrequiredtoaccompanytherejectionletter.
2.18.3.2 The Contractorshallnotincludea rejected claimonthe Remittance Advice
(RA)becauseitwillnothaveenteredtheclaimsprocessingsystem(exceptfor
pharmacyRAs).
2.18.3.3 In the claims rejectionletter, theContractor shall indicatewhy the claimis
being returned, including all defects or reasons known at the time the
determinationismadeandataminimum,mustincludethefollowing:
2.18.3.3.1 Thedatetheletterwasgenerated;
2.18.3.3.2 TheEnrollee’sname;
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2.18.3.3.3 Provideridentification,ifavailable,suchasproviderIDnumber,
TINorNPI;
2.18.3.3.4 Thedateofeachservice;
2.18.3.3.5 Thepatientaccountnumberassignedbytheprovider;
2.18.3.3.6 Thetotalbilledcharges;
2.18.3.3.7 Thedatetheclaimwasreceived;and
2.18.3.3.8 Thereasonsforrejection.
2.18.4 PendedClaims
Ifaclaimisreceived,butadditionalinformationisrequiredfor adjudication, the
Contractormaypendtheclaimandrequestinwritingallnecessaryinformationinorder
fortheclaimtobeAdjudicatedwithinthetimeframesdescribedabove.Claimsshouldnot
bependedsolelybasedonpredictivemodelingalgorithmtools.
2.18.5 PaymenttoProviders
2.18.5.1 Ata minimum,theContractorshallrunone(1)providerpaymentcycleper
week,onthesamedayeachweek.
2.18.5.2 TheContractorshallencouragethatitsproviders,asanalternativetothefiling
ofpaper‐basedclaims,submitandreceiveclaimsinformationthrough
electronicdatainterchange(EDI).
2.18.5.3 TheContractorshallpayprovidersinterestatarateoftwelvepercent(12%)
perannum,calculateddailyforthefullperiodinwhichapayablecleanclaim
remainsunpaidbeyondthethirty(30)CalendarDaycleanclaimsprocessing
deadline.Interestowedtotheprovidershallbepaidthesamedatethatthe
claim is Adjudicated. Any interest payment should be reported on the
applicable encounter submissions to the FI as defined in the MCO System
CompanionGuide.
2.18.5.4 TheContractorshallnotifyprovidersandLDHwithinfive(5)BusinessDaysof
discoveryofasystemerroror“glitch”thatimpactsreimbursement.
2.18.5.4.1 Thenotificationmustoutlinetheprocessofresolution,including
timeframes,andbepostedontheproviderportalonthe
Contractor’swebpageandsenttoprovidersviaemailand/orfax
blast.
2.18.5.4.2 TheContractorshouldprovideitsprovidercallcenterstaffwith
the relevant information immediately after discovery of the
systemerroror“glitch”inordertoensurethatstaffwillbeable
toproperlyanswerproviderquestions.
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2.18.6 ClaimsReprocessing
IftheContractororLDHoritssubcontractorsorProvidersdiscovererrorsmadebythe
Contractor when a claim was Adjudicated, the Contractor shall make corrections and
reprocesstheclaimwithinfifteen (15)CalendarDaysofdiscoveryornotification,orif
circumstances exist that prevent the Contractor from meeting this time frame, by a
specifieddatesubjecttoLDHwrittenapproval.TheContractorshallpayprovidersinterest
attwelvepercent(12%)perannum,calculateddailyforthefullperiodinwhichapayable
clean claim remains unpaid beyond either the fifteen (15) Calendar Day claims
reprocessingdeadlineorthespecifieddeadlineapprovedbyLDHinwriting,whicheveris
later.TheContractorshallautomaticallyrecycleallimpactedclaimsforallprovidersand
shallnotrequiretheprovidertoresubmittheimpactedclaims.
2.18.7 AdjustmentsandVoids
TheContractormayadjustorvoidincorrectclaimspaymentsinaccordancewiththeMCO
Manual.
2.18.8 TimelyFilingGuidelines
2.18.8.1 TheContractorshallrequireproviderstofileLouisianaMedicaidProgram‐only
claims within three hundred sixty‐five (365) Calendar Days of the date of
service.
2.18.8.2 Electronicsubmissionofpharmacyclaims(reversalsandresubmittals)shallbe
allowed to process electronically within three hundred sixty‐five (365)
CalendarDaysofthedateofservice.
2.18.8.3 The Contractor shall require providers to file claims involvingthirdparty
liability(excluding Medicare)within threehundredsixty‐five (365)Calendar
Daysfromthedateofservice.
2.18.8.4 WhenMedicareistheprimaryinsurer,theContractorshallrequireproviders
to file the claim within one hundred eighty (180) Calendar Daysfrom
Medicare’sEOBofpaymentordenial.
2.18.8.5 LDHwillidentifyandaddressanyexceptionstotheseprovisionsintheMCO
Manual.
2.18.9 ClaimSystemEdits
2.18.9.1 TheContractorshallperformsystemeditsincluding,butnotlimitedto:
2.18.9.1.1 ConfirmingeligibilityoneachEnrollee;
2.18.9.1.2 ValidatingEnrolleename;
2.18.9.1.3 ValidatinguniqueEnrolleeidentificationnumber;
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2.18.9.1.4 Validatingdateofservice–Performsystemeditsforvaliddates
ofservice,andensurethatdatesofservicesarevaliddates,e.g.,
not dates in the future or outside of an Enrollee’s Louisiana
MedicaidProgrameligibilityspan;
2.18.9.1.5 Determination of medical necessity – By a staff of qualified,
medically trained and appropriately licensed personnel,
consistentwithNCQAaccreditationstandards,whoseprimary
dutiesaretoassistinevaluatingclaimsformedicalnecessity;
2.18.9.1.6 CoveredServices–Ensurethatthesystemverifiesthataservice
isacoveredserviceandiseligibleforpayment;
2.18.9.1.7 Prior Authorization – The system shall determine whether a
coveredservicerequiredpriorauthorizationandifso,whether
theContractorgrantedsuchauthorization;
2.18.9.1.8 DuplicateClaims–Thesystemshallinanautomatedmanner,flag
aclaimasbeingexactlythesameasapreviouslysubmittedclaim
or a possible duplicate and either deny or pend the claim as
needed;
2.18.9.1.9 ProviderValidation–Ensure thatthesystemshall approve for
payment only those claims received from qualified providers
eligibletorendertheserviceforwhichtheclaimwassubmitted
and that the provider has not been excluded from receiving
Medicaid payments as stipulated in the Provider Network,
Contracts,andRelatedResponsibilitiessection;and
2.18.9.1.10 QuantityofService–Ensurethatthesystemshallevaluateclaims
forservicesprovidedtoensurethatanyapplicablebenefitlimits
areapplied.
2.18.9.2 The Contractor shall perform post‐payment review on a statistically valid
sampleofclaimstoensureservicesprovidedweremedicallynecessary.
2.18.9.3 TheContractorshallnotifyLDHandprovidersastowhensystemupdateswill
beinproductionandoftheContractor’sprocessfortherecyclingofdenied
claimsthat aredue tosystemupdatedelays. Therecyclingof thesedenied
claimsshallbecompletednolaterthanfifteen(15)CalendarDaysafterthe
systemupdate.
2.18.9.4 ExceptasotherwisespecifiedbyLDHinwriting,theContractorshalluseonly
national standard code sets such as CPT/HCPCS, ICD‐10‐CM, etc. The
Contractorshallalsocomplywithdeadlinesforcommunication,testingand
implementationofcodesetsestablishedbyCMSand/orLDH.
2.18.9.5 The Contractor shallhavethe ability toupdatenational standardcodesets
suchasCPT/HCPCS,ICD‐10‐CM,andmovetofutureversionsasrequiredby
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CMSorLDH.Updatestocodesetsaretobecompletenolaterthanthirty(30)
CalendarDaysafternotification,unlessotherwisedirectedbyLDHinwriting.
Thisincludesannualandotherfeescheduleupdates.
2.18.9.6 In addition to CPT, ICD‐10‐CM, ICD‐10‐PCS and other national coding
standards,theContractorshalluseapplicableHCPCSLevelIIandCategoryII
CPT codes to aid both the Contractor and LDH in evaluating performance
measures.
2.18.9.7 The Contractor shall perform internal audit reviews at least annually to
confirm claim edits are functioning properly and provide LDH with
confirmationofthisprocess.LDHshallbeprovidedtheresultsofinternalaudit
reviewsuponrequest.
2.18.9.8 The Contractor shall employ CMS mandated edits for Louisiana Medicaid
Program and nationally recognized clinical editing standards as outlined
below:
2.18.9.8.1 At a minimum, these edits shall be maintained and updated
annuallyunlessotherwiseappropriateandapplytopractitioners,
outpatienthospitals,andDMEservices.
2.18.9.8.2 Edits shall be based on current industry benchmarks and best
practicesincluding,butnotlimitedto,specialtysocietycriteria,
American Medical Association CPT coding guidelines, and CMS
mandatededitsforLouisianaMedicaidProgram,whichinclude
thequarterlyNationalCorrectCodingInitiative(NCCI)editsorits
successor.
2.18.9.8.3 These edits include, but are not limited to, units of service,
unbundling, mutually exclusive and incidental procedures,
pre/post‐op surgical periods, modifier usage, multiple surgery
reduction,add‐oncodes,cosmetic,andassistantsurgeon.Editing
shallincludetheabilitytoapplyeditstothecurrentclaimaswell
aspaidhistoryclaimswhenapplicable.
2.18.9.8.4 The Contractorshall provide a written attestation to LDH
annually stating that they are adhering to these requirements
andaresubjecttoperiodicrequestsfromLDHforvalidationof
theedits.
2.18.9.9 TheContractorshallimplementCMSmandatededitsandNCCIeditsquarterly
asdirectedbyCMSandadheretoLDHtimelinesfortheupdates
2.18.10 RemittanceAdvices
Inconjunctionwithitspaymentcycles,theContractorshallprovidethat:
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2.18.10.1 EachremittanceadvicegeneratedbytheContractortoaprovidershallcomply
withtheprovisionsofLa.R.S.46:460.71.
2.18.10.2 AdjustmentsandVoidsshallappearontheremittanceadviceunder“Adjusted
orVoidedClaims”eitherasApprovedorDenied.
2.18.10.3 Inaccordancewith42C.F.R.§455.18and§455.19,thefollowingstatements
shallbeincludedoneachremittanceadvicesenttoproviders:
2.18.10.3.1 “Thisistocertifythattheforegoinginformationistrue,accurate,
andcomplete.”
2.18.10.3.2 “IunderstandthatpaymentofthisclaimwillbefromFederaland
State funds, and that any falsification, or concealment of a
materialfact,maybeprosecutedunderFederalandStatelaws.”
2.18.10.4 PharmacyremittanceadvicefromthePBMmustbeissuedasastandalone
remittanceadvice,specifictotheLouisianaMedicaidProgramandseparate
fromotherlinesofbusinessattherequestofthepharmacy.
2.18.10.5 Pharmacy remittance advice shall be submitted in compliance with R.S.
22:1856(C),22:1856(D),and22:1856(E).
2.18.10.6 TheContractorshallsubmitasampleofremittanceadvicesthatweresentto
independent,chainandspecialtypharmaciesbythePBMto LDHpharmacy
staffquarterly.Thissampleshallincludeatleastten(10)remittanceadvices
fromdifferentpharmaciesfromeachpharmacytype(independent,chain,and
specialty).Eachquartershallhavesamplesfromdifferentpharmacies.
2.18.11 SamplingofPaidClaims
2.18.11.1 On a monthly basis, the Contractor shall provide individual explanation of
benefits(EOB)noticestoasamplegroupofEnrollees,notmorethanforty‐five
(45)CalendarDaysfromthedateofpayment,inamannerthatcomplieswith
42 C.F.R. §455.20 and §433.116(e). In easily understood language, the
requirednoticeshallspecify:
2.18.11.1.1 Descriptionoftheservicefurnished;
2.18.11.1.2 Thenameoftheproviderfurnishingtheservice;
2.18.11.1.3 Thedateonwhichtheservicewasfurnished;
2.18.11.1.4 Theamountofthepaymentmadefortheservice;and
2.18.11.1.5 The method for notifying the Contractor of services not
rendered.
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2.18.11.2 TheContractorshallstratifythepaidclaimssampletoensurethatallprovider
types(orspecialties)andallclaimtypesareproportionallyrepresentedinthe
samplepoolfromtheentirerangeofservicesavailableundertheContract.To
the extent that the Contractor or LDH considers a particular specialty (or
provider) to warrant closer scrutiny, the Contractor may over sample the
group.Thepaidclaimssampleshallbeaminimumoftwopercent(2%)ofpaid
claimspermonthtobereportedtoLDHonaquarterlybasis.
2.18.11.3 Thenoticesmaybeprovidedbymail,telephonically,orinperson(e.g.,case
managementon‐sitevisits).
2.18.11.4 TheContractorshalltrackanyresponsesreceivedfromEnrolleesandresolve
the responses according to its established policies and procedures. The
resolutionmaybeeffectedthroughEnrolleeeducation,providereducation,
paymentrecovery,orreferraltoLDH.TheContractorshallusethefeedback
received to modify or enhance the verification of receipt of paid services
samplingmethodology.
2.18.11.5 Withinthree(3)BusinessDaysofreceiptofaresponsefroman Enrollee,
resultsindicatingthatpaidservicesmaynothavebeenreceived shall be
referredtotheContractor’sFraudandAbusedepartmentforreviewandto
theLDHProgramIntegritycontact.
2.18.11.6 Reporting shall include, at a minimum, the total number of notices sent to
Enrollees, total number of services sent for validation, total number of
responses completed, total services requested for validation, number of
servicesvalidated,analysisofinterventionsrelatedtoresolution,andnumber
ofresponsesreferredtoLDHforfurtherreview.
2.18.12 ClaimsDisputeManagement
2.18.12.1 The Contractor shall develop an internal claims dispute processforthose
claimsorgroup ofclaimsthat havebeendeniedorunderpaid.The process
shallbesubmittedaspartofReadinessReviewtoLDHoritsdesignee for
approval.
2.18.12.2 TheContractor’sClaims Disputeprocess shallallow providerstheoptionto
requestbindingarbitrationforclaimsthathavedeniedorunderpaidclaimsor
a group of claims bundled, by a private arbitrator who is certified by a
nationally recognized association that provides training and certification in
alternativedisputeresolution.IftheContractorandtheproviderareunable
toagreeonanassociation,therulesoftheAmericanArbitrationAssociation
shallapply.Thearbitratorshallhaveexperienceandexpertiseinthehealth
carefieldandshallbeselectedaccordingtotherulesofhisorhercertifying
association.ArbitrationconductedpursuanttothisSectionshallbebindingon
allparties.Thearbitratorshallconductahearingandissueafinalrulingwithin
ninety (90) Calendar Days of being selected, unless the Contractor and the
providermutuallyagreetoextendthisdeadline.Allcostsofarbitration,not
includingattorneyfees,shallbesharedequallybytheparties.
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2.18.12.3 The Contractor shall systematicallycapturethestatusandresolution of all
claimdisputesaswellasallassociateddocumentation.
2.18.12.4 TheContractorshallAdjudicatealldisputedclaimstoapaidordeniedstatus
withinthirty(30)BusinessDaysofreceiptofthedisputedclaim.
2.18.12.5 Theprovidershallhaveonehundredeighty(180)CalendarDaysfromthedate
ofdenialtodisputethedeniedclaim.
2.18.13 PaymentRecoupments
2.18.13.1 The Contractor shall provide written prior notification to a provider of its
intenttorecoupanypayment.
2.18.13.2 Thenotificationshallinclude:
2.18.13.2.1 TheEnrollee’sname,dateofbirth,andMedicaididentification
number;
2.18.13.2.2 Thedate(s)ofhealthcareservicesrendered;
2.18.13.2.3 Acompletelistingofthespecificclaimsandamountssubjectto
therecoupment;
2.18.13.2.4 Thespecificreasonsformakingtherecoupmentforeachofthe
claimssubjecttotherecoupment;
2.18.13.2.5 Thedatetherecoupmentisproposedtobeexecuted;
2.18.13.2.6 Themailingaddressorelectronicmailaddresswhereaprovider
maysubmitawrittenresponse;
2.18.13.2.7 When applicable, the date LDH notified the Contractor of the
Enrollee’s Disenrollment via the ASC X12N 834 Benefit
EnrollmentandMaintenanceTransaction;and
2.18.13.2.8 Whenapplicable,theeffectivedateofDisenrollment.
2.18.13.3 Beforetherecoupmentisexecuted,theprovidershallhavesixty(60)Calendar
Daysfromreceiptofwrittennotificationofrecoupmenttosubmitawritten
responsetotheContractorastowhytherecoupmentshouldnotbeputinto
effect on the date specified in the notice. If the provider failstosubmita
writtenresponsewithinthetimeperiodprovided,theContractormayexecute
therecoupmentonthedatespecifiedinthenotice.
2.18.13.4 UponreceiptbytheContractorofawrittenresponseastowhythe
recoupmentshouldnotbeputintoeffect,theContractorshall,withinthirty
(30)CalendarDaysfromthedatethewrittenresponseisreceived,consider
thestatement,includinganypertinent additionalinformationsubmitted by
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theproviderorotherwiseavailabletotheContractor,determinewhetherthe
facts justify recoupment, and provide a written notice of determination to
eachwrittenresponsethatincludestherationaleforthedetermination.
2.18.13.5 IftheContractordeterminesthattherecoupmentisvalid,theprovidershall
remittheamounttotheContractororpermittheContractortodeductthe
amountfromfuturepaymentsduetotheprovider.
2.18.13.6 LDHreservestherighttoreviewandprohibitanyrecoupment.
2.18.13.7 TheContractormustcompleteallreviewsand/orauditsofaproviderclaimno
laterthanone(1)yearafterreceiptofacleanclaim,regardlessofwhetherthe
provider participates in the Contractor's network. This includes an
“automated”review,whichisoneforwhichananalysisofthepaidclaimis
sufficient to determine the existence of an overpayment, whereas no
additionaldocumentationis required tobe submitted fromthe provider to
determinetheexistenceofanoverpayment.
2.18.13.7.1 ThislimitationdoesnotapplyincasesofproviderFraud,Waste,
orAbusethattheContractordidnotdiscoverwithintheone‐(1)‐
year period following receipt of a claim via “complex” review.
(Additional information regarding automated and complex
reviewsmaybefoundintheFraud,WasteandAbusePrevention
section.)
2.18.13.7.2 ThislimitationalsodoesnotapplywhenCMS,OIG,HHS,LLA,the
LouisianaDepartmentofJustice,theGovernmentAccountability
Office (GAO), LDH, and/or any of their designees conclude an
examination,audit,orinspectionofaprovidermorethanone(1)
yearaftertheContractorreceivedtheclaim.
2.18.13.8 ForEnrolleesdisenrolledduetotheinvalidationofaduplicateMedicaidID,
theContractorshallnotrecoverclaimpaymentsundertheretroactivelydis‐
enrolled member’s ID if the remaining, valid ID is also linked tothesame
ContractorfortheretroactiveDisenrollmentperiod.TheContractor shall
identify these duplicate Medicaid IDs for a single Enrollee andresolvethe
duplicationsothathistoriesoftheduplicaterecordsarelinkedormerged.
2.18.13.9 The Contractor shall develop and implement a safeguard for automated
reviewstopreventsubsequentreviewsonaclaimwhenthedenial or
exceptionreasonisthe sameasapreviousdenialorexceptionreason.The
Contractor and its subcontractors shall not recover from a provider via
automatedreviewforaclaimforwhichanautomateddenialwasreversed
subsequenttoproviderdispute,whenthedenialsareforthesamereason.For
suchclaims,theContractorshallensureacomplexreviewandconsideration
oftheclaimhistoryoraudittrail.
2.18.13.10 Attheprovider’srequest,theContractorshallprovideanindependentreview
ofclaimsthatarethesubjectofanadversedeterminationbytheContractor.
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The review shall be provided and conducted in accordance with La. R.S.
46:460.81through460.90.
2.18.13.11 TheContractor shall not recoup simply on the basis of an encounter being
denied.
2.18.14 ClaimsPaymentAccuracyReport
2.18.14.1 Onamonthlybasis,theContractorshallsubmitaclaimspaymentaccuracy
percentagereporttoLDH.Thereportshallbebasedonanauditconductedby
theContractor.Theauditshallbeconductedbyanentityorstaffindependent
of claims management, and shall utilize a randomly selected sample of all
processedandpaidclaimsuponinitialsubmissionineachmonth.Aminimum
sampleconsistingoftwohundred(200)totwohundred‐fifty(250)claimsper
month, based on financial stratification, shall be selected from the entire
population of electronic and paper claims processed or paid upon initial
submission.
2.18.14.2 Theminimumattributestobetestedforeachclaimselectedshallinclude:
2.18.14.2.1 Claimdataiscorrectlyenteredintotheclaimsprocessingsystem;
2.18.14.2.2 Claimisassociatedwiththecorrectprovider;
2.18.14.2.3 Properauthorizationwasobtainedfortheservice;
2.18.14.2.4 Enrolleeeligibilityatprocessingdatewascorrectlyapplied;
2.18.14.2.5 Allowedpaymentamountagreeswithcontractedrate;
2.18.14.2.6 Duplicatepaymentofthesameclaimhasnotoccurred;
2.18.14.2.7 Denialreasonisappliedappropriately;
2.18.14.2.8 Co‐paymentsareconsideredandapplied,ifapplicable;
2.18.14.2.9 Effectofmodifiercodeswerecorrectlyapplied;and
2.18.14.2.10 Propercoding.
2.18.14.3 Theresultsoftestingataminimumshouldbedocumentedtoinclude:
2.18.14.3.1 Resultsforeachattributetestedforeachclaimselected;
2.18.14.3.2 Amount of overpayment or underpayment for each claim
processedorpaidinerror;
2.18.14.3.3 Explanation of the erroneous processing for each claim
processedorpaidinerror;
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2.18.14.3.4 Determinationiftheerroristheresultofakeyingerrororthe
resultoferrorintheconfigurationortablemaintenanceofthe
claimsprocessingsystem;and
2.18.14.3.5 Claimsprocessedorpaidinerrorhavebeencorrected.
2.18.14.4 IftheContractorsubcontractedfortheprovisionofanycoveredservices,and
the subcontractor is responsible for processing claims, then the Contractor
shall submit a claims payment accuracy percentage report for the claims
processedbythesubcontractor.
2.18.15 EncounterData
2.18.15.1 The Contractor’s system shall be able totransmit toand receive electronic
datafromtheLDHFI’ssystemasrequiredfortheappropriatesubmissionof
encounterdata.
2.18.15.2 The Contractor shall create a unique Processor Control Number (PCN) or
GroupnumberfortheLouisianaMedicaidProgramandshallsubmitthePCN
orgroupnumberandtheBankIdentificationNumberwiththeencounter
claimsdatasubmission.
2.18.15.3 Forencounterdatasubmissions,theContractorshall:
2.18.15.3.1 Submitcompleteandaccurateencounterdataatleastmonthly
foralldatesofserviceduringthecontractperiodtoLDHoritsFI,
asdirectedbyLDH;and
2.18.15.3.2 Submit the encounter data in accordance with the encounter
reconciliationschedulepublishedbyLDHoritscontractedreview
organization, including encounters reflecting a zero dollar
amount($0.00)andencountersinwhichtheContractororits
subcontractorhasacapitationarrangement witha provider.If
theContractororitssubcontractedvendor(s),individuallyorin
aggregate,failstosubmitcompleteencounterdataasmeasured
byacomparisonofencounterstocashdisbursementswithina
one percent (1%) error threshold (i.e., encounters are at least
ninety‐nine percent [99%] but no greater than one hundred
percent [100%] of cash disbursements), LDH may impose
MonetaryPenaltiesinaccordancewithAttachmentG,Tableof
Monetary Penalties.LDH,atitssolediscretion,maywaivethe
penaltyifencountersprocessedbysubcontractedvendors(e.g.,
pharmacy,non‐emergencytransportation,vision)fallbelowthe
completion threshold during the transition to a new vendor;
however,thisgraceperiodshallnotexceedninety(90)Calendar
Daysforencountersprocessedbyeithertheexitingvendororthe
newvendor.
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2.18.15.4 TheContractorshallsubmitHIPAAcompliant837encountersforInstitutional,
Professional and Dental, and the NCPDP D.0 format in a batch processing
methodforpharmacyencounters.TheContractorshallbeabletotransmitthis
encounterdatatotheFIthirty(30)CalendarDaysaftertheOperationalStart
Date. Inpatient Hospital services (Institutional encounters indicating Facility
TypeCodeof11,12,18,21or86)areAdjudicatedatthedocumentlevel.All
otherencountersareAdjudicatedatthelinelevel.
2.18.15.5 Aspart of the Readiness Review, the Contractor’ssystem shall be ready to
submit encounter data to the FI according to specifications, including data
elementsandreportingrequirements,intheMCOSystemCompanionGuide.
TheContractor’ssystemshallsubmitsuchencounterdatawithinthirty(30)
Calendar Days of the Operational Start Date.The Contractor shall incur all
costsassociatedwithcertifyingHIPAAtransactionsreadinessthroughathird
partypriortosubmittingencounterdatatotheFI.
2.18.15.6 TheContractorshallprovidetheFIwithcompleteandaccurateencounterdata
foralllevelsofhealthcareservicesprovided,includingallclaimspaid,denied,
adjustedorvoideddirectlybytheContractororindirectlythrough a
subcontractor,regardlessofwhetherthesubcontractor’sagreementhassince
termed.
2.18.15.7 TheContractorshallhavethecapabilitytoconvertallinformationthatenters
itsclaimssystemviahardcopypaperclaimstoelectronicencounterdata,for
submissionintheappropriateHIPAAcompliantformatstoLDH’sFI.
2.18.15.8 TheContractorshallensurethatallencounterdatafromasubcontractoris
incorporatedintofilessubmittedbytheContractortotheFI.TheContractor
shallnotsubmitseparateencounterfilesfromsubcontractors.
2.18.15.9 TheContractorshallensurethelevelofdetailassociatedwithencountersfrom
providerswith whom the Contractor has a capitation arrangementshallbe
equivalent to the level of detail associated with encounters for which the
ContractorreceivedandsettledaFFSclaim.
2.18.15.10 TheContractor shall utilize the MCO System Companion Guide to become
familiarwiththeclaimsdataelementsthatshallbeincludedinencounters.
TheContractorshallretainallrequireddataelementsinclaimshistoryforthe
purposeofcreatingencountersthatarecompatiblewithLDHanditsFI’sbilling
requirements.
2.18.15.11 The Contractor shall adhere to federal and/or LDH payment rulesinthe
definitionandtreatmentofcertaindataelements,suchasunitsofservicethat
are a standard field in the encounter data submissions and will be treated
similarlybyLDHacrossallMCOs.
2.18.15.12 The Contractor shall submit paid, denied, adjusted, and voided claims as
encounterstotheFI.LDHshallestablishtheappropriateidentifierstoindicate
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these claims as encounters, as provided in the MCO System Companion
Guide.
2.18.15.13 The Contractor shall ensure that encounter files contain settled claims,
adjustments,denialsorvoids,including,butnotlimitedto,adjustments
necessitatedbypaymenterrors,processedduringthatpaymentcycle,aswell
asencountersprocessedduringthatpaymentcyclefromproviderswithwhom
theContractorhasacapitationarrangement.
2.18.15.14 TheFIencounter processshall utilize aLDH‐approved versionoftheclaims
processing system (edits and adjudication) to identify valid and invalid
encounterrecordsfromabatchsubmissionbytheContractor.Anysubmission
whichcontainsfatalerrorsthatpreventprocessing,orthatdoesnotsatisfy
definedthresholderrorrates,shallberejectedandreturnedtotheContractor
forcorrectionandresubmissiontotheFIinthenextpaymentcycle.
2.18.15.15 LDHhasauthorizeditsFItoeditMCOencountersusingacommonsetofedit
criteria,thatmightcausedenials,andMCOsshouldresolvedeniedencounters
whenappropriate. Encounterdenialcodesshall be deemed “repairable” or
“non‐repairable”. The Contractor is required to be familiar with the FI edit
codesanddispositionsforthepurposeofrepairingencountersdeniedbythe
FI.AlistofencountereditcodesislocatedintheMCOSystemCompanion
Guide.
2.18.15.16 Inordertomaintainintegrityofprocessing,theContractorshalladdressany
issuesthatpreventprocessingofanencounter.TheContractorshalladdress
ninetypercent(90%)ofreportedrepairableerrorswithinthirty(30)Calendar
Daysand one hundred percent (100%) of reportedrepairable errorswithin
sixty(60)CalendarDaysorwithinanegotiatedtimeframeapprovedbyLDHin
writing.Failuretopromptlyresearchandaddressreported errors,including
submissionofandcompliancewithanacceptableCorrectiveActionPlan,may
resultinMonetaryPenalties.
2.18.15.17 The Contractor CEO, CFO or their designee shall attest to the truthfulness,
accuracy,andcompletenessofallencounterdatasubmitted.
2.18.15.18 The Contractor shall make an adjustment to encounter claims when the
Contractordiscoversthedataisincorrect,nolongervalid,orsomeelementof
theclaimnotidentifiedaspartoftheoriginalclaimneedsto be changed
except as noted otherwise. Incorrect provider numbers, incorrect Enrollee
MedicaidIDnumbers,orincorrectclaimtypescannotbeadjusted.Rather,the
encounterrecord mustbe voided and resubmittedas an original.Allother
adjustmentstoanencounterrecordshallbedoneasanadjustmentrecord.
2.18.15.19 EncounterssubmittedbytheContractormustcontaintheclaimsdata
submittedtotheContractorbytheproviderwithoutalterations,exceptfor
adjustmentsrequiredforclaimsprocessingasprovidedabove.T
otheextent
that the provider submits an adjusted claim to the Contractor to correct
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missingorincompletemedicalinformation,theContractormustthensubmit
thecorrectedclaimtotheFIasanencounter.
2.18.15.20 If LDH or its subcontractors discover errors or a conflict withapreviously
Adjudicatedencounter,theContractorshallberequiredtoadjustorvoidthe
encounterwithinfourteen(14)CalendarDaysofnotificationbyLDH,orif
circumstancesexistthatpreventtheContractorfrommeetingthistimeframe,
byaspecifieddateapprovedbyLDHinwriting.TheContractorshallobtain
priorapprovalfromLDHinwritingforanysubmissiontotheFiscal
Intermediary for numbers greater than one hundred thousand (100,000)
encounters.
2.18.16 ClaimsSummaryReport
TheContractorshallsubmitmonthlyClaimsSummaryReportsofpaidanddeniedclaims
toLDHbyclaimtype.InstructionsareprovidedintheMCOSystemCompanionGuide.
2.18.17 PharmacyClaimsProcessing
2.18.17.1 SystemRequirements
2.18.17.1.1 TheContractorshallhaveanautomatedclaimsandencounter
processing system for pharmacy claims that will support the
requirements of this Contract and ensure the accurate and
Timelyprocessingofclaimsandencounters.TheContractorshall
allow pharmacies to back bill electronically (reversals and
resubmissions)forthreehundredsixty‐five(365)CalendarDays
fromthedateoftheoriginalsubmissionoftheclaim.
2.18.17.1.2 The Contractor shall support electronic submission of claims
usingthemostcurrentHIPAAcomplianttransactionstandard.
2.18.17.1.3 Pharmacy claim edits shall include eligibility, drug coverage,
benefitlimitations,prescriberandprospective/concurrentdrug
utilizationreviewedits.
2.18.17.1.4 The system shall provide for an automated update to the
National Drug Code file including all product, packaging,
prescription and pricing information. The system shall provide
online access to reference file information. The system shall
maintainahistoryofthepricingschedulesandothersignificant
referencedata.Thedrugfileforbothretailandspecialtydrugs,
includingprice,shallbeupdatedwithinthree(3)BusinessDays
ofreceiptofthedrugfile.
2.18.17.1.5 TheContractorshallcomplywiththeclaimshistoryrequirements
inthisSection.
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2.18.17.1.6 The Contractor shall ensure that the manufacturer number,
product number, and package number for the drug dispensed
shallbelistedonallclaims.Thisinformationshallbetakenfrom
theactualpackagefromwhichthedrugisusuallypurchasedbya
provider,fromasupplierwhoseproductsaregenerallyavailable
to all pharmacies and reported in one or more national
compendia.
2.18.17.1.7 Provisions shall be made to maintain permanent history by
servicedateforthoseservicesidentifiedas“once‐in‐a‐lifetime.”
2.18.17.2 PharmacyRebates
The Contractor shall submit all drug encounters, with the exception of
inpatienthospital drugencounters, toLDH oritssubcontractorpursuantto
therequirementsofthissection.LDHoritssubcontractorshallsubmitthese
encounters for federal or supplemental pharmacy rebates from
manufacturers under the authority of the LDH Secretary pursuanttothe
Section2501ofthePatientProtectionandAffordableCareAct(ACA).
2.18.17.3 PharmacyEncountersClaimsSubmission
2.18.17.3.1 The Contractor shall submit a weekly claim‐level detail file of
pharmacy encounters to LDH which includes individual claim‐
leveldetailinformationoneachpharmacyclaimdispensedtoan
Enrolleeincluding,butnotlimitedto,thetotalnumberofmetric
units,dosageform,strengthandpackagesize,andNationalDrug
Code of each covered outpatient drug dispensed to Enrollees.
This weekly submission must comply with encounter data
requirementsofthissection.SeetheMCOSystemCompanion
Guideforacompletelistingofclaimfieldsrequired.
2.18.17.3.2 At the request of LDH or the FI, the Contractor shall submit
pharmacy claims information in an electronic format that is
suitedtoallowforintegrationwiththeState'spharmacyrebate
programaccordingtothescheduleestablishedbyLDHinwriting.
Thepharmacyrebateprocessisaquarterlyprocess,andclaims
informationisusuallyrequiredbeforetheendofthemonththat
followstheendofthequarter.
2.18.17.3.3 The Contractor shall require thatNetworkProviderswhoare
coveredentities,asdefinedbySection340BofthePublicHealth
ServicesAct,utilizethesamecarve‐inorcarve‐outdesignation
for the Contractor’s Enrollees as for FFS. If a covered entity
appears on the Medicaid Exclusion File, LDH will exclude that
provider’sFFSandMCOclaimsfromrebateinvoicing.Claimsfor
FFSandEnrolleesaretreatedidenticallyinregardstoexclusion
fromrebateinvoicing.
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2.18.17.3.4 TheContractorshallutilizeauniqueProcessorControlNumber
(PCN)orGroupNumberfortheLouisianaMedicaidProgram.This
uniquePCNorgroupnumbershallbesubmittedtoLDHbefore
processinganypharmacyclaims.
2.18.17.3.5 Contract pharmacies are not permitted to bill the Louisiana
Medicaid Program for drugs purchased at 340B pricing. This
includesbothFFSandtheMCOs.
2.18.17.3.6 The Contractor shall include billing instructions on how to
identify 340B claims/encounters in their contracts with 340B
providers.
2.18.17.4 DisputedPharmacyEncounterSubmissions
2.18.17.4.1 Atleastquarterly,LDHmayreviewthe Contractor’s pharmacy
encounterclaimsandsendafilebacktotheContractorof
disputed encounters that were identified through the drug
rebateinvoicingprocess.
2.18.17.4.2 Withinsixty(60)CalendarDaysofreceiptofthedisputed
encounterfilefromLDH,theContractorshall,ifneeded,correct
andresubmitanydisputedencountersandsendaresponsefile
toLDHoritsdesigneethatincludes1)correctedandresubmitted
encounters as described in the Rebate Section of the MCO
SystemCompanion Guide, and/or2) a detailed explanationof
whythe disputed encounters could not be corrected including
documentation of all attempts to correct the disputed
encountersatanencounterclaimleveldetail,asdescribedinthe
RebateSectionoftheMCOSystemCompanionGuide.
2.18.17.4.3 The Contractor may be subject to Monetary Penalties in
accordancewithAttachmentG,TableofMonetaryPenalties,for
failuretosubmitweeklypharmacyencounterclaimsfilesand/or
aresponsefiletothedisputedencountersfilewithinsixty(60)
CalendarDaysasdetailedaboveforeachdisputedencounter.
2.18.17.5 UseofaPharmacyBenefitsManager(PBM)
2.18.17.5.1 TheContractorshallutilizeasinglePBMdesignatedbyLDHfor
pharmacyclaimspaymentandadministrativeservices.
2.18.17.5.2 TheContractorshallsubmitaplanforoversightofthePBM’s
performance during Readiness Review to LDH or its designee.
TheplanshallbesubjecttoLDHapprovalandcomplywiththis
ContractandallLDHrequirements;and
2.18.17.6 Withninety(90)CalendarDaysofwrittennoticetotheContractor,LDHmay
carveoutalloutpatientpharmacyservicesfrommanagedcare.
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2.18.18 AuditRequirements
TheContractorshallensurethatitssystemsfacilitatetheauditingofindividualclaims.
Adequateaudittrailsshallbeprovidedthroughoutthesystems.LDHmayrequirethe
Contractor and/or subcontractors, if performing a key internal control, to submit to
financialandperformanceauditsfromoutsidecompaniestoensureboththefinancial
viability of the program and the operational viability, including the policies and
proceduresplacedintooperation.
TheContractorshallberesponsibleforanyadditionalcostsincurredbyLDHassociated
withon‐site audits or other oversight activities that resultwhen required systems are
locatedoutsideofthestateofLouisiana.
2.18.18.1 StateAudits
2.18.18.1.1 TheContractorshallprovidetoStateauditors(includingLLA),or
their designee, upon written request, files for any specified
accountingperiodthatavalidContractexistsinafileformator
audit defined media, magnetic tapes, CD or other media
compatible with LDH and/or State auditor’s facilities.The
ContractorshallprovideinformationnecessarytoassisttheState
auditorsinprocessingorutilizingthefiles.
2.18.18.1.2 If the auditor’s findings point to discrepancies or errors, the
ContractorshallprovideawrittenCorrectiveActionPlantoLDH
withinten(10)BusinessDaysofreceiptofthefinalauditreport.
2.18.18.2 LouisianaLegislativeAuditorAuthority
2.18.18.2.1 TheContractorshallenterintoadatasharingagreement(DSA)
withLLAtoauthorizethesharingofdataandinformation.
2.18.18.2.2 TheContractoragreesandacknowledgesthattheLLAhasthe
authoritypursuanttoLa.R.S.24:51etseq.,subjecttoStateand
Federal laws and privileges protecting the confidentiality of
information,toconductoversightandauditofLDH,includingthe
Managed Care Program. Pursuant to the DSA, LLA may, in
coordinationwithLDHandtheContractor:
2.18.18.2.2.1 Attendquarterlymeetingsbetweenthe
Contractor,LDH,andMFCU;
2.18.18.2.2.2 EvaluatetheeffectivenessoftheContractor’s
programintegrityoutcomes;
2.18.18.2.2.3 Audit,evaluateandinspectthebooks,records,
and contracts related to the performance of
theContractor;and
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2.18.18.2.2.4 Access all audit information relating to the
performance of the Contractor obtained by
LDHrelatedtotheManagedCareProgram.
2.18.18.3 IndependentAuditsofSystems
2.18.18.3.1 TheContractorshallsubmitanindependentSOC2TypeIIsystem
audit.Theauditshallreviewsystemsecurity,systemavailability,
systemconfidentialityandprocessingintegrityfortheLouisiana
Medicaid Program line of business. The audit period shall be
twelve(12)consecutivemonths,aligningwiththeContractor’s
fiscalyear,withnobreaksbetweensubsequentauditperiods.
2.18.18.3.2 TheContractorshallsupplyLDHwithanexactcopyoftheSOC2
TypeIIindependentauditnolaterthansix(6)monthsafterthe
closeoftheContractor’sfiscalyear.
2.18.18.3.3 TheContractorshalldelivertoLDH aCorrectiveActionPlan to
addressdeficienciesidentifiedduringtheauditwithinthirty(30)
BusinessDaysoftheContractor’sreceiptofthefinalauditreport.
2.18.18.3.4 Theseauditrequirementsarealsoapplicabletoany
subcontractors or vendors delegated the responsibility of
adjudicatingclaimsonbehalfoftheContractor.Thecostofthe
auditshallbebornebytheContractororsubcontractor.
2.18.18.4 AuditCoordinationandClaimsReviews
2.18.18.4.1 TheContractorshallcoordinateauditswithLDHasdirectedby
LDH.
2.18.18.4.2 LDHreservestherighttoreviewanyclaimpaidbytheContractor
ordesignee.TheContractorhastherighttocollectorrecoupany
overpayments identified by the Contractor from providers of
serviceinaccordancewithapplicableFederalandStatelaws,
regulations,rules,policies,andprocedures.Ifanoverpaymentis
identifiedbytheStateoritsdesigneeandtheproviderfailsto
remitpaymenttotheState,LDHmayrequiretheContractorto
collectandremittheoverpaymenttoLDH.Failurebythe
Contractor to collect from the provider does not relieve the
ContractorfromremittingtheidentifiedoverpaymenttoLDH.
2.18.18.4.3 The Contractor must complete all reviews and/or audits of a
providerclaimnolaterthanone(1)yearafterreceiptofaclean
claim,regardlessofwhethertheproviderparticipatesinthe
Contractor's network. This includes an “automated” review,
whichisoneforwhichananalysisofthepaidclaimissufficient
todeterminetheexistenceofanoverpayment,whereasno
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additionaldocumentationisrequiredtobesubmittedfromthe
providertodeterminetheexistenceofanoverpayment.
2.18.18.4.3.1 Thislimitationdoesnotapplyincasesof
provider Fraud, Waste, or Abuse that the
Contractordidnotdiscoverwithintheone(1)‐
year period following receipt of a claim via
“complex” review. (Additional information
regarding automated and complex reviews
maybefoundintheFraud,WasteandAbuse
Preventionsection.)
2.18.18.4.3.2 ThislimitationalsodoesnotapplywhenCMS,
OIG,HHS,LLA,theOfficeoftheAttorney
General,GAO,LDH,and/oranyoftheir
designeesconcludeanexamination,audit,or
inspectionofaprovidermorethanone(1)year
aftertheContractorreceivedtheclaim.
2.18.19 LaHIPP
2.18.19.1 The Louisiana Health Insurance PremiumPayment(LaHIPP)programisa
Louisiana Medicaid program that pays all or part of the health insurance
premiumforanemployeeandtheirfamilyif:(a)healthinsuranceisavailable
fromtheirjob(i.e.,EmployerSponsoredInsurance);(b)someoneinthefamily
hascoveragethroughtheLouisianaMedicaidProgram;and(c)itisdetermined
thatitwouldcostlessfortheLouisianaMedicaidProgramtopaythehealth
insurance premium for the person who receives overage through the
Louisiana Medicaid Program than it would be for the Louisiana Medicaid
Programtopaythecostofthesameperson’spermemberpermonthpayment
for physical health coverage through the Enrollee’s MCO or the Enrollee
receivescoveragethroughtheAct421Children’sMedicaidOptionandmeets
thecriteriaspecifictothatprogramforeligibilityinLaHIPP.ThegoalofLaHIPP
istoreducethenumberofuninsuredLouisianacitizensandlowerLouisiana
Medicaid Program spending by establishing a third party resource as the
primarypayeroftheEnrollee’smedicalexpenses.
2.18.19.2 LDH is responsible for determining if an individual qualifies for LaHIPP
participation. LaHIPP is not an eligibility category. LaHIPP participants are
identifiedintheTPLfile.
2.18.19.3 LDHisresponsibleforissuingpaymentforallorpartofLaHIPPparticipants’
healthinsurancepremium.
2.18.19.4 AllLaHIPPparticipantsaremandatorilyenrolledintheManagedCareProgram
for SBHS and NEMT, including NEAT, unless residing in an institution as
specifiedunderSection2.3.
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2.18.19.4.1 LaHIPP participants who receive coverage via the Act 421
Children’s Medicaid Option are mandatorily enrolled in the
ManagedCareProgramforallMedicaidCoveredServices.
2.18.19.5 The Contractor is responsible for payment of LaHIPP participants’ total
member liability (co‐payments, co‐insurance and deductibles) ifthe
participantusesaproviderthatacceptstheinsuranceasprimarypayerand
theLouisianaMedicaidProgramassecondarypayer.Iftheproviderdoesnot
acceptthispaymentarrangement,theparticipantshallberesponsibleforthe
memberliability.TheContractorpaysonlyafterthethirdpartyhasmetthe
legalobligationtopay.TheContractorisalwaysthepayeroflastresort,except
whentheContractorisresponsibleforpaymentasprimarypayerforMedicaid
CoveredServicesnotcoveredbycommercialinsuranceasprimarypayer(e.g.,
mentalhealthandtransportationservices).
2.18.19.6 Theserviceslistedbelowaretypicallynotreimbursedbycommercialhealth
plans.TheContractorshallacceptthefollowingclaimsbilleddirectlyfromthe
providerwithoutrequiringanexplanationofbenefitsfromtheprimarycarrier
andpayasprimarypayer:
2.18.19.6.1 H0018‐TherapeuticGroupHome;
2.18.19.6.2 H0039‐AssertiveCommunityTreatmentperdiem;
2.18.19.6.3 H0045‐CrisisStabilization;
2.18.19.6.4 H2017‐PsychosocialRehabilitationServices;
2.18.19.6.5 H0036‐Communitypsychiatricsupportandtreatment;
2.18.19.6.6 H2033‐Multi‐systemicTherapy;
2.18.19.6.7 H2011‐CrisisInterventionService,per15minutes;
2.18.19.6.8 S9485‐CrisisInterventionMentalHealthServices;
2.18.19.6.9 T1019‐Early and Periodic Screening, Diagnosis and Treatment
(EPSDT)PersonalCareServices(PCS);and
2.18.19.6.10 T1025,T1026,T2002‐PediatricDayHealthCare.
SystemsandTechnicalRequirements
2.19.1 GeneralRequirements
2.19.1.1 TheContractorshallmaintainanautomatedManagementInformationSystem
(MIS),hereinafterreferredtoasSystem,whichacceptsandprocessesprovider
claims,verifieseligibility,collectsandreportsencounterdata,andvalidates
priorauthorizationandpre‐certificationthatcomplieswithLDHandfederal
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reportingrequirements.TheContractorshallensurethatitsSystemmeetsthe
requirementsoftheContract,theMCOManual,andallapplicableapplicable
Federal and State laws, regulations, rules, and policies, including, but not
limited to, Medicaid confidentiality,HIPAA,andAmericanRecovery and
ReinvestmentAct(ARRA)privacyandsecurityrequirements.
2.19.1.2 TheSystemshallprovideinformationonareasincluding,butnotlimitedto,
utilization, claims, Grievances and Appeals, and Disenrollment for reasons
other than loss of Louisiana Medicaid Program eligibility [42 C.F.R.
§438.242(a)].
2.19.1.3 The Contractor shall comply with Section 6504(a) of the PPACA, which
requiresthatstateclaimsprocessingandretrievalsystemsareabletocollect
data elements necessary to enable the mechanized claims processing and
information retrieval systems in operation by the state to meetthe
requirements of Section 1903(r)(1)(F) of the Act [42 C.F.R. §438.242(b)(1);
Section6504(a)oftheACA;Section1903(r)(1)(F)oftheAct].
2.19.1.4 TheContractor’sapplicationsystemsfoundationshallemployarelationaldata
model in its database architecture, which would entail the utilization of a
relational database management system (RDBMS). The Contractor’s
application systems shall support query access using StructuredQuery
Language (SQL). Other standard connector technologies, such as Open
Database Connectivity (ODBC) and/or Object Linking and Embedding (OLE),
aredesirable.
2.19.1.5 The Contractor shall comply with the health IT standards referenced in 45
C.F.R.Part170,SubpartBandtheInteroperabilityStandardsAdvisory(ISA)as
setforthbytheOfficeoftheNationalCoordinatorforHealthIT(ONC).
2.19.1.6 TheContractorshallcomplywiththeCMSInteroperabilityandPatientAccess
for Medicare Advantage Organization and Medicaid Managed Care Plans,
State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities,
Issuesof QualifiedHealthPlanson the Federally‐Facilitated Exchanges, and
HealthCare Providers(referred toasthe "CMSInteroperabilityandPatient
Access final rule") in accordance with timelines established byCMSandas
directedbyLDHthroughtheLDHMCEInteroperabilityCompliancePlan.
2.19.1.7 AllContractorapplications,operatingsoftware,middleware,andnetworking
hardware and software shall be able to interoperate as needed with LDH’s
systemsandshallconformtoapplicablestandardsandspecificationssetby
LDH.
2.19.1.8 If the Contractor uses different Management Systems for physical health
servicesandbehavioralhealthservices,thesesystemsshallbeinteroperable.
Inaddition,theContractorshallhavethecapabilitytointegratedatafromthe
differentsystems.
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2.19.1.9 TheContractor’sSystemshallhave,andmaintain,capacitysufficienttohandle
theworkloadprojectedfortheOperationalStartDateandshallbescalable
andflexiblesothatitcanbeadaptedasneeded,withinnegotiated
timeframes,inresponsetochangesintheContractrequirements.
2.19.1.10 TheContractorshallbecapableoftransmittingalldata,whichisrelevantfor
analyticalpurposes,toLDHonaregularscheduleinXMLformat. Final
determinationofrelevantdatawillbemadebyLDHbasedoncollaboration
between both parties. The schedule for transmission of the datawillbe
establishedbyLDHanddependentontheneedsofLDHrelatedtothedata
beingtransmitted.XMLfilesforthispurposeshallbetransmittedviaSecure
FileTransferProtocol(SFTP)toLDH.Anyotherdataormethodoftransmission
usedforthispurposeshallbeviawrittenagreementbybothparties.
2.19.1.11 The Contractor is responsible for procuring and maintaining hardware and
softwareresourceswhicharesufficienttosuccessfullyperformtheservices
detailedinthisContract.
2.19.1.12 The Contractor shall adhere to Federal and State laws, regulations, rules,
policies, procedures, and guidelines as well as industry standards and best
practicesforsystemsorfunctionsrequiredtosupporttherequirementsofthis
Contract.
2.19.1.13 Unlessexplicitlystatedtothecontrary,theContractorisresponsibleforall
expenses required to obtain access to LDH systems—including systems
maintained by other Contractors including, but not limited to, FI and
EnrollmentBrokerresourcesthatarerelevanttosuccessfulcompletionofthe
requirementsofthisContract.TheContractorisalsoresponsibleforexpenses
requiredfor LDH to obtain accessto theContractor’s systems or resources
whicharerelevanttothesuccessfulcompletionoftherequirementsofthis
Contract. Such expenses are inclusive of hardware, software, network
infrastructureandanylicensingcosts.
2.19.1.14 MCOinterfaceconnectionswiththeStateshallbeestablished,monitored,and
maintainedincompliancewiththeState’sInformationSecurityPolicylocated
at:http://www.doa.la.gov/pages/ots/informationsecurity.aspx.
2.19.1.15 TheContractororitsdesignatedsubcontractorshalltakeallstepsnecessary,
asdeterminedbyLDH,toensurethattheContractor’ssystemsarealwaysable
to interface with LDH IT applications, including the State’s Enterprise
Architecture.
2.19.1.16 AnyconfidentialinformationshallbeencryptedtoFIPS140‐2standardswhen
atrestorintransit.
2.19.1.17 Contractor owned resources shall be compliant with industry standard
physicaland procedural safeguards (NIST SP 800‐114, NIST SP800‐66,NIST
800‐53A, ISO 17788, etc.) for confidentialinformation (HITECH, HIPAA Part
164).
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2.19.1.18 Any Contractor use of flash drives or external hard drives for storage of
LouisianaMedicaidProgramdatashallfirstreceivewrittenapprovalfromLDH
anduponsuchapprovalshalladheretoFIPS140‐2hardwarelevelencryption
standards.
2.19.1.19 The Contractor shall comply with LDH electronic visit verification (EVV)
requirementsforpersonalcareservices(PCS)andhomehealthcareservices.
2.19.1.20 AllContractorutilizedcomputersanddevicesshall:
2.19.1.20.1 Beprotectedbyindustrystandardvirusprotectionsoftware
whichisautomaticallyupdatedonaregularschedule;
2.19.1.20.2 Haveinstalledallsecuritypatcheswhicharerelevanttothe
applicableoperatingsystemandanyothersystemsoftware;and
2.19.1.20.3 Have encryption protection enabled at the Operating System
level.
2.19.1.21 TheContractorshallhave:
2.19.1.21.1 Capabilities of interagency electronic transfer to and from the
participatingStateagencies(LDH‐OBH,DCFS,andOJJ)asneeded
tosupporttheoperationsasdeterminedbyLDH;
2.19.1.21.2 Electronic storage and retrieval of individualized Plans of Care
(POC),treatmentplans,crisisplans,andAdvanceDirectives;
2.19.1.21.3 AnMCODataWarehousethatsupportstheTimelysubmissionof
validdata,including,butnotlimitedto,encounterdata;
2.19.1.21.4 Asecureonlineweb‐basedportalthatallowsprovidersandstate
agencies (DCFS, LDOE, LDH, and OJJ) to submit and receive
responsestoreferralsandpriorauthorizationsforservices;and
2.19.1.21.5 An MIS that regularly (e.g., bi‐weekly) electronically transfers
client/episode‐levelrecipient,assessment,service,andprovider
data as directed by LDH for purposes of state and federal
reporting (e.g., SAMHSA National Outcome Measures [NOM]S,
TreatmentEpisodeDataSets[TEDS])‐,GovernmentPerformance
ReportingandResultsAct[GPRA]),andforadhocreportingas
needed by the State for service quality monitoring and
performanceaccountability.
2.19.2 HIPAAStandardsandCodeSets
2.19.2.1 The System shall be able to transmit, receive and process data in current
HIPAA‐compliantorLDHspecificformatsand/ormethods,including,butnot
limitedto,SecureFileTransferProtocol(SFTP)overasecureconnectionsuch
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as a Virtual Private Network (VPN), that are in use at the start of Systems
ReadinessReviewactivities.Dataelementsandfileformatrequirementsmay
befoundintheMCOSystemCompanionGuide.
2.19.2.2 AllHIPAA‐conformingexchangesofdatabetweenLDH,itscontractors,andthe
Contractorshallbesubjectedtothehighestlevelofcomplianceasmeasured
usinganindustry‐standardHIPAAcompliancechecker.
2.19.2.3 The System shall conform to the following HIPAA‐compliant standards for
informationexchange.Batchtransactiontypesinclude,butarenotlimitedto,
thefollowing:
2.19.2.3.1 ASCX12N834BenefitEnrollmentandMaintenance;
2.19.2.3.2 ASCX12N835ClaimsPaymentRemittanceAdviceTransaction;
2.19.2.3.3 ASCX12N837IInstitutionalClaim/EncounterTransaction;
2.19.2.3.4 ASCX12N837PProfessionalClaim/EncounterTransaction;
2.19.2.3.5 ASCX12N837DDentalClaim/EncounterTransaction;
2.19.2.3.6 ASCX12N270/271Eligibility/BenefitInquiry/Response;
2.19.2.3.7 ASCX12N276ClaimsStatusInquiry;
2.19.2.3.8 ASCX12N277ClaimsStatusResponse;
2.19.2.3.9 ASCX12N278UtilizationReviewInquiry/Response;
2.19.2.3.10 ASC X12N 820 Payroll Deducted and Other Group Premium
PaymentforInsuranceProducts;and
2.19.2.3.11 NCPDPPharmacyClaims.
2.19.2.4 TheContractorshallnotreviseormodifystandardizedformsorformats.
2.19.2.5 Transactiontypesaresubjecttochange,andtheContractorshallcomplywith
applicableFederalandHIPAAstandardsandregulationsastheyoccur.
2.19.2.6 The Contractor shall adhere to national standards and standardized
instructionsanddefinitionsthatareconsistentwithindustrynormsthatare
developedjointlywithLDH.Theseshallinclude,butnotbelimitedto,HIPAA
based standards and Federal safeguard requirements including signature
requirementsdescribedintheCMSStateMedicaidManual.
2.19.3 Connectivity
2.19.3.1 TheContractorshallinterfacewithLDH,theFI,theEnrollmentBroker,andits
tradingpartners.TheContractorshallhavecapacityforrealtimeconnectivity
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toallLDHapprovedsystems.TheContractorshallhavethecapabilitytoallow
andenable authorized LDH personnel tohave real‐time connectivity to the
Contractor’ssystemasremoteconnectionsfromLDHoffices.
2.19.3.2 TheSystemshallconformandadheretothedataanddocumentmanagement
standards of LDH and the FI, inclusive of standard transaction codesets as
outlinedintheMCOSystemCompanionGuide.
2.19.3.3 TheMCO’sSystemsshallutilizemailingaddressstandardsinaccordancewith
theUnitedStatesPostalService.
2.19.3.4 TheContractorshallencourageallhospitals,physicians,andotherproviders
initsnetworktoadoptcertifiedelectronichealthrecordtechnology(CEHRT)
andcomply andattest withits correspondingmeaningfuluse requirements
anddeadlinesasoutlinedbyCMSandtheOfficeoftheNationalCoordinator
(ONC).
2.19.3.5 TheContractorshallrequireallEDsinitsnetworktoexchangeadmitdischarge
transfer(ADT)datawithaHealthInformationExchange(HIE)EDvisitregistry
toaidinidentificationofandcreationofpoliciesaroundhighutilizers,drug
seeking behavior, and Care Management. The visit registry shall consist of
three(3)basicattributes:1)theabilitytocaptureandmatchpatientsbased
ondemographics information,2) the ability to identify the facilityat which
careisbeingsought,and3)atminimum,thechiefcomplaintofthevisit.These
three (3) pieces of information are commonly available through theHealth
LevelSeven (HL7) ADT message standard and in use by most EDadmission
systemsinusetodayacrossthecountry.Thisdatashallbeavailableinreal‐
timeinordertoassistprovidersandsystemswithup‐to‐dateinformationfor
treatingpatientsappropriately.
2.19.3.6 The Contractor shall require all network hospitals to comply withthedata
submissionrequirementsofLa.R.S.40:1173.1through1173.6,including,but
not limited to, syndromic surveillance data under the Sanitary Code ofthe
StateofLouisiana(LAC51:II.105).TheContractorshallencouragetheuseof
HIEswheredirectconnectionstopublichealthreportinginformationsystems
arenotfeasibleorarecostprohibitive.
2.19.3.7 All information, whether data or documentation and reports that contain
references to that information involving or arising out of the Contract, is
owned by LDH. The Contractor is expressly prohibited from sharing or
publishingLDH’sinformationandreportswithoutthepriorwrittenconsentof
LDH. In the event of a dispute regarding the sharing or publishing of
informationandreports,LDH’sdecisiononthismattershallbefinal.
2.19.3.8 TheMedicaidManagementInformationSystem(MMIS)processesclaimsand
payments for Medicaid Covered Services for FFS. LDH shall require the
Contractortocomplywithalltransitionalrequirementsasnecessary ifLDH
contractswithanewFIduringtheContracttermatnocosttoLDHortheFI.
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2.19.3.9 TheContractorshallberesponsibleforallinitialandrecurringcostsrequired
for access to LDH system(s), as well as LDH access to the Contractor’s
system(s).Thesecostsinclude,butarenotlimitedto,hardware, software,
licensing, and authority/permissiontoutilizeanypatents,annual
maintenance,support,andconnectivitywithLDH,theFI,andtheEnrollment
Broker.
2.19.3.10 LDH may require the Contractor to complete an Information Systems
CapabilitiesAssessment(ISCA),whichshallbeprovidedbyLDH.TheISCAshall
be completed and returned to LDH as part of Readiness Review and upon
requestthereafter.
2.19.4 HardwareandSoftware
The Contractor shall maintain hardware and software compatible with current LDH
requirementsinaccordancewiththeMCOManual.
2.19.5 NetworkandBack‐upCapabilities
TheContractorshallhavenetworkandback‐upcapabilitiesinaccordancewiththeMCO
Manual.
2.19.6 ResourceAvailabilityandSystemsChanges
2.19.6.1 ResourceAvailability
TheContractor shall provideSystems HelpDesk services toLDH,itsFI,and
Enrollment Broker staff that have direct access to the data in the MCO’s
Systems.
2.19.6.1.1 TheSystemsHelpDeskshall:
2.19.6.1.1.1 Be available via local and toll‐free telephone
service,andviae‐mailonBusinessDaysfrom
7:00 a.m. to 7:00 p.m., Central Time.Upon
request by LDH, the Contractor shall be
requiredtostaff theSystemsHelpDeskona
State‐designatedholiday,Saturday,orSunday;
2.19.6.1.1.2 Answer questions regarding the Contractor’s
System functions and capabilities; report
recurring programmatic and operation
problems to appropriate staff for follow‐up;
redirect problems or queries that are not
supported by the Systems Help Desk, as
appropriate,viaatelephonetransferorother
agreed upon methodology; and redirect
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problems or queries specific to data access
authorizationtotheappropriateLDHstaff;
2.19.6.1.1.3 Ensureindividualswhoplacecallsafterhours
havetheoptiontoleaveamessage.The
Contractor’s staff shall respond to messages
leftbetweenthehoursof7:00p.m.and7:00
a.m.bynoonthenextBusinessDay;
2.19.6.1.1.4 Ensure recurring problems not specific to
Systems unavailability identified by the
Systems Help Desk are documented and
reportedtoMCOmanagementwithinone(1)
Business Day of recognition so that
deficienciesarepromptlycorrected;and
2.19.6.1.1.5 Haveaservicemanagementsystemthat
provides an automated method to record,
trackandreportallquestionsand/orproblems
reportedtotheSystemsHelpDesk.
2.19.6.2 SystemsQualityAssurancePlan
The Contractor shall ensure that written Systems process and procedure
manuals document and describe all manual and automated system
procedures for its information management processes and information
systems.TheSystemsQualityAssurancePlaninformationsystems
documentationrequirementsmustbesubmittedtoLDHoritsdesigneeaspart
ofReadinessReviewforapproval.Ataminimum,theSystemsQuality
AssurancePlanmustaddressthefollowing:
2.19.6.2.1 TheContractorshalldevelop,prepare,print,maintain,produce,
anddistributetoLDHdistinctSystemsdesignandmanagement
manuals, user manuals and quick reference guides, and any
updates.
2.19.6.2.2 TheContractorshallensuretheSystemsusermanualscontain
informationabout,andinstructionfor,usingapplicableSystems
functionsandaccessingapplicablesystemdata.
2.19.6.2.3 TheContractorshallensurewhenaSystemchangeissubjectto
LDH prior written approval, the Contractor will submit any
necessary revision(s) to the appropriate manuals before
implementingsaidSystemschanges.
2.19.6.2.4 The Contractor shall ensure all aforementioned manuals and
referenceguidesareavailableinprintedformandonline;and
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2.19.6.2.5 The Contractor shall update the electronic version of these
manuals immediately, and update printed versions within ten
(10)BusinessDaysoftheupdatetakingeffect.
2.19.6.2.6 TheContractorshallprovidetoLDHdocumentationdescribingits
SystemsQualityAssurancePlan.
2.19.6.3 SystemsChanges
2.19.6.3.1 TheMCO’sSystemsshallconformtofuturefederaland/orLDH
specificstandardsforencounterdataexchangepriortothe
standard’seffectivedate,unlessotherwisedirectedbyCMSor
LDH.
2.19.6.3.2 Ifasystemupdateand/or changeis necessary,theContractor
shall draft appropriate revisions for the documentation or
manuals,andpresenttoLDHthirty(30)CalendarDayspriorto
implementation, for LDH review and approval.Documentation
revisionsshallbeaccomplishedelectronicallyandshallbemade
availableforDepartmentreviewinaneasilyaccessible,nearreal‐
timemethod.Printedmanualrevisionsshalloccurwithinten(10)
BusinessDaysoftheactualrevision.
2.19.6.3.3 TheContractorshallnotifyLDHstaffofthefollowingchangesto
itsSystemwithinitsspanofcontrolupontheearlierofbeginning
workonthechangesoratleastninety(90)CalendarDaysprior
totheprojecteddateofthechange,unlessotherwisedirectedby
LDH:
2.19.6.3.3.1 Major changes, upgrades, modification or
updates to application or operating software
associatedwiththefollowingcoreproduction
Systems:
Claimsprocessing;
EligibilityandEnrollmentprocessing;
Serviceauthorizationmanagement;
Provider Enrollment and data
management;and
Conversions of core transaction
managementSystems.
2.19.6.3.4 TheContractorshallrespondtoLDHnotificationofSystem
problemsnotresultinginSystemunavailabilityaccordingtothe
followingtimeframes:
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2.19.6.3.4.1 Within five (5) Calendar Days of receiving
notification from LDH, the Contractor shall
respond in writing to notices of system
problems.
2.19.6.3.4.2 Within fifteen (15) Calendar Days, the
correction shall be made or a requirements
analysis and specifications document will be
due.
2.19.6.3.4.3 TheContractorshallcorrectthedeficiencyby
aneffectivedatetobedeterminedbyLDH.
2.19.6.3.4.4 TheContractor’sSystemsshallhaveasystem‐
inherentmechanismforrecordinganychange
toasoftwaremoduleorsubsystem.
2.19.6.3.4.5 The Contractor shall put in place procedures
and measures for safeguarding against
unauthorizedmodificationtotheContractor’s
Systems.
2.19.6.3.5 UnlessotherwiseagreedtoinadvancebyLDH,theContractor
shall not schedule Systems unavailability to perform system
maintenance,repairand/orupgradeactivitiesduringhoursthat
cancompromiseorpreventcriticalbusinessoperations.
2.19.6.3.6 The Contractor shall work with LDH pertaining to any testing
initiativeasrequiredbyLDHandshallprovidesufficientsystem
accesstoallowtestingbyLDHand/oritsFIoftheContractor’s
System.
2.19.7 SystemsRefreshPlan
2.19.7.1 TheContractorshallprovidetoLDHoritsdesigneeaSystemsRefreshPlanas
partofReadinessReviewandsixty(60)CalendarDayspriortoimplementation
ofrevisions.TheplanshalloutlinehowSystemswithintheContractor’sspan
ofcontrolshallbesystematicallyassessedtodeterminetheneedtomodify,
upgrade and/or replace application software, operating hardwareand
software,telecommunicationscapabilities,informationmanagementpolicies
and procedures, and/or systems management policies and procedures in
responsetochangesinbusinessrequirements,technologyobsolescence,staff
turnoverandotherrelevantfactors.
2.19.7.2 ThesystemsrefreshplanshallalsoindicatehowtheContractorshallensure
thattheversionand/orreleaselevelofallofitsSystemscomponents
(application software, operating hardware, and operating software) are
always formally supported by the original equipment manufacturer (OEM),
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software development firm (SDF), or a third party authorized bytheOEM
and/orSDFtosupporttheSystemscomponent.
2.19.8 OtherElectronicDataExchange
2.19.8.1 The Contractor’s system shall scan, house, and retain indexed electronic
imagesofdocumentstobeusedbyEnrolleesandproviderstotransactwith
the Contractor and shall repose them in appropriate database(s)and
documentmanagementsystems(i.e.,MasterPatientIndex)astomaintainthe
logical relationships to certain key data such as Enrollee identification
numbers, provider identification numbers and claim identification
numbers.TheContractorshallensurethatrecordsassociatedwithacommon
event,transactionorcustomerserviceissuehaveacommonindexthatshall
facilitatesearch,retrievalandanalysisofrelatedactivities,suchasinteractions
withaparticularEnrolleeaboutareportedproblem.
2.19.8.2 The Contractor shall implement Optical Character Recognition (OCR)
technology that minimizes manual indexing and automates the retrieval of
scanneddocuments.
2.19.9 ElectronicMessaging
2.19.9.1 The Contractor shall provide a continuously available electronic mail
communicationlink(e‐mailsystem)tofacilitatecommunicationwithLDH.This
e‐mailsystemshallbecapableofattachingandsendingdocumentscreated
using software compatible with LDH's installed version of Microsoft Office
(currently2016)andanysubsequentupgradesasadopted.Thee‐mailsystem
shallalsobecapableofsendinge‐mailblaststoproviders.
2.19.9.2 As needed, the Contractor shall be able to communicate with LDHovera
secureVirtualPrivateNetwork(VPN).
2.19.9.3 The Contractor shall comply with national standards for submitting PHI
electronically and shall set up a secure emailing system that is password
protectedforbothsendingandreceivinganyPHI.
2.19.10 EligibilityandEnrollmentDataExchange
TheContractorshall:
2.19.10.1 Receive,processandupdateEnrollmentfilessentbytheEnrollmentBroker,
andupdateeligibilityandEnrollmentdatabaseswithinthefollowingtimelines:
2.19.10.1.1 Dailyfiles–withintwenty‐four(24)hoursofreceipt;
2.19.10.1.2 Weekly reconciliation files – within three (3) Business Days of
receipt;
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2.19.10.1.3 Quarterlyormonthlyreconciliationfiles–withinfive(5)Business
Daysofreceipt;and
2.19.10.1.4 Special corrections files – within seven (7) Business Days of
receipt;
2.19.10.2 Be capable of uniquely identifying (i.e., Master Patient Index)adistinct
EnrolleeacrossmultiplepopulationsandSystemswithinitsspanofcontrol;
and
2.19.10.3 BeabletoidentifypotentialduplicaterecordsforasingleEnrolleeand,upon
confirmationofsaidduplicaterecordbyLDH,resolvetheduplicationwithin
five(5)BusinessDaysafterreceiptofmanualcorrection,such that the
enrollment, service utilization, and customer interaction histories of the
duplicaterecordsarelinkedormerged.
2.19.11 ProviderEnrollment
2.19.11.1 AttheonsetoftheContractandperiodicallyaschangesarenecessary,LDH
shallfurnishtotheContractoralistofMedicaidprovidertypes,specialty,and
sub‐specialtycodes.InordertocoordinateproviderEnrollmentrecords,the
ContractorshallutilizethepublishedlistofMedicaidprovidertypes,specialty,
andsub‐specialtycodesinallproviderdatacommunicationswithLDHandthe
EnrollmentBroker.TheContractorshallprovidethefollowing:
2.19.11.1.1 AweeklyProviderRegistryFileasdescribedintheMCOSystem
CompanionGuide;
2.19.11.1.2 AweeklyPrimaryCareProviderLinkagefileasdescribedinthe
MCOSystemCompanionGuide;and
2.19.11.1.3 Performance of all federal or state mandated exclusion
background checks on all providers, including owners and
managers.The providers shall perform the same for all their
employeesatleastannually.
2.19.12 InformationSystemsAvailability
TheContractorshall:
2.19.12.1 Not be responsible for the availability and performance of systems and IT
infrastructuretechnologiesoutsideoftheContractor’sspanofcontrol;
2.19.12.2 Allow LDH personnel, agents of the Louisiana Attorney General’s Office,
individualsauthorizedbyLDHinwriting,andCMSdirect,real‐time,read‐only
accesstoitsdataforthepurposeofdataminingandreview.Accessshallbe
granted within thirty (30) Calendar Days of LDH request. Direct, real‐time,
read‐only access can be provided through a SQL based production‐like
reportingenvironmenttobeupdatednolessthanweeklywiththeabilityto
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queryusingMicrosoftSQLServerManagementStudio©,orsimilarenterprise‐
grade technology which shall be subject to LDH approval. This reporting
environmentshallincludealldatafromthesystemsreferencedintheContract
oranyadditionaldatauponLDHrequest.
2.19.12.2.1 Accessshallbeprovided tothe followingContractor (including
subcontractors)systems(thisisnotanexclusivelist):
2.19.12.2.1.1 Priorauthorization;
2.19.12.2.1.2 Claimsprocessing;
2.19.12.2.1.3 Providerportal;
2.19.12.2.1.4 Thirdpartyliability;
2.19.12.2.1.5 Fraud,Waste,andAbuse;
2.19.12.2.1.6 Pharmacybenefitsmanagerpointofsale;
2.19.12.2.1.7 Pharmacy benefits manager prior
authorization;and
2.19.12.2.1.8 Providercontractingandcredentialing.
2.19.12.2.2 TheContractor’ssatisfactionoftherequirementstoprovidethe
direct, real‐time access to LDH personnel shall not constitute
constructivecompliancewithnorrelievetheContractorofany
dutytosatisfyanyotherprovisionofthisContract,including,but
notlimitedto,theContractor’sobligationtoprovideinformation
attherequestofLDH.
2.19.12.3 ProvidetrainingofLDHstaffonhowtousetheContractor’sSystemsanddata
on‐siteattheContractor’slocationuponrequestbyLDH;
2.19.12.4 EnsurethatcriticalEnrolleeandproviderinternetand/ortelephone‐basedIVR
functions and information functions are available to the applicable System
userstwenty‐four(24)hoursaday,seven(7)daysaweekexcept during
periods of scheduled System unavailability agreed upon by LDH and the
Contractor.UnavailabilitycausedbyeventsoutsideoftheContractor’sspan
ofcontrolisoutsideofthescopeofthisrequirement;
2.19.12.5 Ensure that, at a minimum, all other Systemfunctions and information are
availabletotheapplicablesystemusersbetweenthehoursof7:00a.m.and
7:00p.m.,CentralTime,MondaythroughFriday;
2.19.12.6 Ensurethatthesystemsandprocesseswithinitsspanofcontrolassociated
withitsdataexchangeswiththeFIand/orEnrollmentBrokerand its
contractorsareavailableandoperational;
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2.19.12.7 Ensurethatintheeventofapandemic,naturaldisasterorman‐made
emergencyincluding,butnotlimitedto,localizedactsofnature,accidents,
andtechnologicaland/orattack‐relatedemergencies,orothereventswhich
leadstoasignificantdisruptioninoperationsduetostaffabsenceand/orloss
ofutilities,theContractor’scoreeligibility/Enrollmentandclaimsprocessing
systemshallbebackonlinewithinseventy‐two(72)hoursofthefailure’sor
disaster’soccurrence;
2.19.12.8 Notify designated LDH staff via phone and electronic mail within sixty (60)
minutesofdiscoveryofaproblemwithinoroutsidetheContractor’sspanof
controlthatmayjeopardizeorisjeopardizingavailabilityandperformanceof
criticalsystemsfunctionsandtheavailabilityofcriticalinformationasdefined
inthisSection,includinganyproblemsimpactingscheduledexchangesofdata
between the Contractor and LDH, LDH’s FI, or any other state vendors or
systems.Initsnotification,theContractorshallexplainindetailtheimpactto
critical path processes such as Enrollment management and encounter
submissionprocesses;
2.19.12.9 NotifydesignatedLDHstaffviaphoneandelectronicmailwithinfifteen(15)
minutesofdiscoveryofaproblemthatresultsindelaysinreportdistribution
orproblemsinonlineaccesstocriticalsystemsfunctionsandinformation,in
orderfortheapplicableworkactivitiestoberescheduledorhandledbasedon
Systemunavailabilityprotocol;
2.19.12.10 ProvideinformationonSystemunavailabilityevents,aswellasstatusupdates
onproblemresolution,toappropriateLDHstaff.Ataminimum,theseupdates
shallbeprovidedonanhourlybasisuntilresolutionandmadeavailablevia
phoneand/orelectronicmail;
2.19.12.11 Resolveandimplementsystemrestorationwithinsixty(60)minutesofofficial
declarationofunscheduledSystemunavailabilityofcriticalfunctionscaused
by the failure of system and telecommunications technologies within the
Contractor’sspan ofcontrol.UnscheduledSystem unavailability toall other
System functions caused by system and telecommunications technologies
withintheContractor’sspanofcontrolshallberesolved,andtherestoration
ofservicesimplemented,withineight(8)hoursoftheofficialdeclarationof
Systemunavailability;
2.19.12.12 CumulativeSystemsunavailabilitycausedbysystemsand/orISinfrastructure
technologieswithintheContractor’sspanofcontrolshallnotexceedtwelve
(12)hoursduringanycontinuoustwenty(20)BusinessDayperiod;and
2.19.12.13 Within five (5) Business Days of the occurrence of a problem with system
availability,theContractorshallprovideLDHwithfullwrittendocumentation
that includes a Corrective Action Plan describing how the Contractor shall
preventtheproblemfromreoccurring.
2.19.13 OffSiteStorageandRemoteBack‐up
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2.19.13.1 The Contractor shall provide for off‐site storage and a remote back‐up of
operating instructions, procedures, reference files, system documentation,
andoperationalfiles.
2.19.13.2 Thedataback‐uppolicyandproceduresshallinclude,butnotbelimitedto:
2.19.13.2.1 Descriptions of the controls for back‐up processing, including
howfrequentlyback‐upsoccur;
2.19.13.2.2 Documentedback‐upprocedures;
2.19.13.2.3 Thelocationofdata thathasbeenbackedup(off‐siteandon‐
site,asapplicable);
2.19.13.2.4 Identificationanddescriptionofwhatisbeingbackedupaspart
oftheback‐upplan;
2.19.13.2.5 Anychangeinback‐upproceduresinrelationtotheContractor’s
technologychanges;and
2.19.13.2.6 Alistofallback‐upfilestobestoredatremotelocationsandthe
frequencywithwhichthesefilesareupdated.
2.19.14 RecordsRetention
2.19.14.1 TheContractorshallhaveonlineretrievalandaccesstodocumentsandfiles
forauditandreportingpurposesforten(10)yearsfollowingterminationof
the Contract in live systems and an additional four (4) years in archival
systems.Historicalencounterdatasubmissionshallberetainedforaperiod
notlessthanten(10)yearsfollowingterminationoftheContract,following
generally accepted retention guidelines. Services which have a once in a
lifetime indicator (e.g., appendix removal, hysterectomy) are denoted on
LDH’sprocedureformularyfile,andclaimsshallremaininthecurrent/active
claims history that is used in claims editing and are not to be archived or
purged. Online access to claims processing data shall be by theMedicaid
recipientID,providerID,providerNPI,and/orICN(internalcontrolnumber)
toincludepertinentclaimsdataandclaimsstatus.
2.19.14.2 Audittrailsshallbemaintainedonlinefornolessthansix(6)yearsfollowing
terminationoftheContract.
2.19.14.3 The Contractor shall provide access to information in machine‐readable
formatwithinforty‐eight(48)hoursofrequestsforinformationlessthansix
(6)yearsoldandwithinseventy‐two(72)hoursofrequestsforinformation
greaterthansix(6)yearsold.
2.19.14.4 Ifanauditoradministrative,civil,orcriminalinvestigationorprosecutionisin
progressorunresolved,informationshallbekeptinelectronicformuntilall
tasksorproceedingsarecompleted.
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2.19.14.5 UndernocircumstancesshalltheContractordestroyordisposeofanysuch
records,even aftertheexpiration ofthe retention periodsprovidedabove,
withouttheexpresspriorwrittenpermissionofLDH.
2.19.15 InformationSecurityandAccessManagement
TheContractor’ssystemshall:
2.19.15.1 Employ an access management function that restricts access to varying
hierarchical levels of system functionality and information.The access
managementfunctionshall:
2.19.15.1.1 EstablishuniqueaccessidentificationperMCOemployee;
2.19.15.1.2 Restrictaccesstoinformationona“leastprivilege”basis,suchas
userspermittedinquiryprivilegesonlyshallnotbepermittedto
modifyinformation;
2.19.15.1.3 Restrict access to specific system functions and information
based on an individual user profile, including inquiry only
capabilities; globalaccess toall functions shall be restricted to
specifiedstaffjointlyagreedtobyLDHandtheContractor;and
2.19.15.1.4 Restrict unsuccessful attempts to access system functions to
three (3), with a system function that automatically prevents
furtheraccessattemptsandrecordstheseoccurrences.
2.19.15.2 MakeSysteminformationavailabletoLDH,itsdesignees,andotherstateand
federalagenciestoevaluate,throughinspectionsorothermeans,thequality,
appropriatenessandtimelinessofservicesperformed.
2.19.15.3 Containcontrolstomaintaininformationintegrity.Thesecontrolsshallbein
placeatallappropriatepoints ofprocessing.Thecontrolsshall betestedin
periodic and spot audits following a methodology to be developed by the
ContractorandLDH.
2.19.15.4 EnsurethataudittrailsareincorporatedintoallSystemstoallowinformation
onsourcedatafilesanddocumentstobetracedthroughtheprocessingstages
tothepointwheretheinformationisfinallyrecorded.Theaudittrailsshall:
2.19.15.4.1 Containauniquelog‐onorterminalID,thedate,andtimeofany
create/modify/delete action and, if applicable, the ID of the
systemjobthateffectedtheaction;
2.19.15.4.2 Havethedateandidentification“stamp”displayedonanyonline
inquiry;
2.19.15.4.3 Havetheabilitytotracedatafromthefinalplaceofrecording
backtoitssourcedatafileand/ordocument;
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2.19.15.4.4 Be supported by listings, transaction reports, update reports,
transactionlogs,orerrorlogs;and
2.19.15.4.5 Facilitateauditingofindividualrecordsaswellasbatchaudits.
2.19.15.5 Haveinherentfunctionalitythatpreventsthealterationoffinalizedrecords;
2.19.15.6 Provideforthephysicalsafeguardingofitsdataprocessingfacilitiesandthe
systems and information housed therein.The Contractor shall provide LDH
with access to data facilities upon request.The physical security provisions
shallbeineffectforthelifeoftheContract;
2.19.15.7 Restrictperimeteraccessto equipmentsites,processing areas,andstorage
areas through a card key or other comparable system, as well asprovide
accountability control to record access attempts, including attempts of
unauthorizedaccess;
2.19.15.8 Include physical security features designed to safeguard processor sites
throughrequiredprovisionoffireretardantcapabilities,aswellassmokeand
electricalalarms,monitoredbysecuritypersonnel;
2.19.15.9 Put in place procedures, measures and technical security to prohibit
unauthorizedaccesstotheregionsofthedatacommunicationsnetworkinside
oftheContractor’s span ofcontrol.This includes, but is not limitedto,any
providerorEnrolleeserviceapplicationsthataredirectlyaccessibleoverthe
Internet,whichshallbeappropriatelyisolatedtoensureappropriateaccess;
2.19.15.10 EnsurethatremoteaccessusersofitsSystemscanonlyaccesssaidSystems
through two‐factor user authentication and via methods such as Virtual
PrivateNetwork(VPN),whichmustbepriorapprovedbyLDHinwritingaspart
ofReadinessReview;
2.19.15.11 Comply with recognized industry standards governing security of state and
federalautomateddataprocessingsystemsandinformationprocessing.Ata
minimum, the Contractor shall conduct a security risk assessment and
communicatetheresultsinanInformationSecurityPlanprovidedtoLDHor
itsdesigneeduringReadinessReview.Theriskassessmentshallalsobemade
availabletoappropriatefederalagencies;
2.19.15.12 EnsureappropriateprotectionsofsharedPersonallyIdentifiableInformation
(“PII”),inaccordancewith45C.F.R.§155.260;and
2.19.15.13 EnsurethatitssystemisoperatedincompliancewiththeCMS’latestversion
oftheMinimumAcceptableRiskStandardsforExchanges(MARS‐E)Document
Suite,currentlyMARS‐Eversion2.0.
2.19.15.13.1 Multi‐factorauthenticationisaCMSrequirementforallremote
users,privileged accounts,andnon‐privileged accounts. In this
context,“remoteuser”referstostaffaccessingthenetworkfr
om
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offsite,normallywithaclientVPNwiththeabilitytoaccessCMS,
specificallyMedicaiddata.
2.19.15.13.2 A site‐to‐site tunnel is an extension of LDH’s network. For
contractorsthatareutilizingaVPNsite‐to‐sitetunnelandalso
have remote users who access CMS data, the contractor is
responsible for providing and enforcing multi‐factor
authentication.ContractorsthatdonotutilizeaVPNsite‐to‐site
tunnel will be charged for dual authentication licensing and
hardwaretokensasnecessary.Costsassociatedwiththe
purchaseandanyreplacementoflosthardwaretokenswillbe
chargedtothecontractor.
Fraud,Waste,andAbusePrevention
2.20.1 GeneralProvisions
2.20.1.1 TheContractoranditssubcontractorsshallcomplywithallapplicableFederal
andStatelaws,regulations,rules,policies,procedures,andmanualsrelating
toFraud,Abuse,andWasteintheLouisianaMedicaidProgram,including,but
notlimitedto, 42C.F.R.§438.1‐438.608;La.R.S.46:437.1‐437.14;42 C.F.R.
§455.12 – 455.23; LAC 50:I.4101‐4235; and Sections 1128, 1156, and
1902(a)(68)oftheSocialSecurityAct.
2.20.1.2 TheContractComplianceOfficerandCEOorCOOshallmeetinperson,unless
otherwiseapprovedbyLDHinwriting,withLDHandMFCUatLDH’srequest
todiscussFraud,Abuse,Waste,neglectandoverpaymentissues.Forpurposes
of this Section, the Contract Compliance Officer shall serve astheprimary
point of contact for the Contractor on issues related to Fraud, Abuse, and
WastePrevention.
2.20.1.3 TheContractoranditssubcontractorsshallcooperateandassisttheStateand
anystateorfederalagencychargedwiththedutyofidentifying,investigating,
or prosecuting suspected Fraud, Abuse, or Waste. During Business Hours,
CMS,theOIG,HHS,LLA,theOfficeoftheAttorneyGeneral,GAO,LDH,and/or
anyofthedesigneesoftheabove,andasoftenastheymaydeemnecessary
during the Contract period and for a period of ten (10) years following
terminationoftheContractorfromthedateofcompletionofany audit,
whicheverislater,shallhavetherighttoinspect orotherwiseevaluatethe
quality,appropriateness,andtimelinessofservicesprovidedundertheterms
oftheContractandanyotherapplicablerules.MFCUshallbeallowedaccess
totheContractor’splaceofbusinessandtoallLouisianaMedicaidProgram
recordsofanycontractor,subcontractor,orproviderduringBusinessHours,
except under special circumstances determined by the MFCU when after‐
hoursadmissionshallbeallowed.
2.20.1.4 TheContractoranditsprovidersandsubcontractorsshallmakeallprogram
andfinancialrecordsandservicedeliverysitesopentotherepresentativeor
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anydesigneesoftheaboveuponrequest.HHS,OIG,LDH,GAO,LLA,theOffice
oftheAttorneyGeneral,and/orthedesigneesofanyoftheaboveshallhave
Timely and reasonable access and the right to examine and make copies,
excerpts,ortranscriptsofallbooks,documents,papers,andrecordswhichare
directlypertinenttoaspecificprogramforthepurposeofmakingauditsand
examinations,contactandconductprivateinterviewswithContractorclients,
employees,andcontractors,anddoon‐sitereviewsofallmattersrelatingto
servicedeliveryasspecifiedbytheContract.
2.20.1.5 The Contractor and its providers and subcontractors shall provide originals
and/or copies (at no charge) of all records and information requested.
Requestsforinformationshallbecompiledintheformandthelanguage
requested.
2.20.1.6 The Contractor’s employees, consultants, and its subcontractorsandtheir
employees shall cooperate fully and be available in person for interviews,
grandjuryproceedings,pre‐trialconferences,hearings,trials,andinanyother
investigativeorjudicialprocesses.
2.20.1.7 TheContractorshallcertifyallstatements,reportsandclaims,financialand
otherwise,astrue,accurate,andcomplete.TheContractorshallnotsubmit
forpaymentpurposesthoseclaims,statements,orreportswhichitknows,or
has reason to know, are not properly prepared or payable pursuant to
applicableFederalandStatelaws,regulations,rules,policies,procedures,and
manuals,theStatePlan,Waivers,theContract,andtheMCOManual.
2.20.1.8 The Contractor and its subcontractors shall have programs and procedures
pursuantto42C.F.R.§438.608(a)(1)tosafeguardLouisianaMedicaidProgram
fundsagainstunnecessaryorinappropriateuseofMedicaidCoveredServices
andagainstimproperpayments.TheContractorshallhaveinternalcontrols
andpoliciesandproceduresinplacethataredesignedtoprevent,detect,and
reportknownorsuspectedFraud,Waste,andAbuseactivities.
2.20.1.9 TheContractor,aswellasitssubcontractorsandproviders,shallcomplywith
all federal requirements (42 C.F.R. Part 1002) on exclusion anddebarment
screening. Any unallowable funds made to excluded individuals as full or
partial wages and/or benefits shall be refunded to and/or obtained by the
State and/or the Contractor dependent upon the entity that identifies the
paymentofunallowablefundstoexcludedindividuals.
2.20.1.10 The Contractor shall have adequate staffing and resources to investigate
unusualincidentsanddevelopandimplementCorrectiveActionPlanstoassist
theContractorinpreventinganddetectingpotentialFraud,Waste,andAbuse.
Ataminimum,theContractorshallhaveone(1)full‐timeinves
tigator
physicallylocatedwithinLouisianaforeveryfiftythousand(50,000)Enrollees
orfractionthereof.LDHmayapprovewrittenrequestswithdetailed
justification to substitute another SIU position in place of an investigator
position.
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2.20.1.11 ReportingandInvestigatingSuspectedFraudandAbuse
2.20.1.11.1 The Contractor shall have methods for identification,
investigation,andreferralofsuspectedFraudcases(42C.F.R.
§455.13, §455.14, and §455.21) both internally and for its
subcontractors.
2.20.1.11.2 The Contractor shall report all tips, confirmed or suspected
Fraud,Waste,andAbusetoLDHandtheappropriateagencyas
follows:
2.20.1.11.2.1 All tips (regarding any potential billing or
claims issue identified through either
complaintsorinternalreviewreceivedwithin
thepreviousmonth)shallbereportedtoLDH
ProgramIntegritymonthly;
2.20.1.11.2.2 Triage and/or substantiate tips and provide
updatestoMFCUandLDHwhentheconcerns
and/or allegations of any tips are
authenticated;
2.20.1.11.2.3 Suspected Fraud and/or Abuse in the
administration of the program shall be
reportedinwritingtoLDHProgramIntegrity
andMFCUwithinfive(5)BusinessDaysofthe
Contractorbecomingawareoftheissue;
2.20.1.11.2.4 AllconfirmedorsuspectedproviderFraudand
Abuseshallimmediatelybereportedinwriting
toLDHProgramIntegrityandMFCU;and
2.20.1.11.2.5 AllconfirmedorsuspectedEnrolleeFraudand
Abuse shall be reported immediately, in
writing,toLDHProgramIntegrityandlocallaw
enforcement of the Enrollee’s parish of
residence.
2.20.1.11.3 WhenmakingareferralofsuspectedFraud,theContractorshall
utilize the LDH Provider Fraud Referral Form available in the
MCOManual.
2.20.1.11.4 The Contractor shall promptly perform a preliminary
investigation of all incidents of suspected and/or confirmed
FraudandAbuse.Unlesspriorwrittenapprovalisobtainedfrom
the agency to whomthe incidentwas reported, or toanother
agencydesignatedbytheagencythatreceivedthereport,after
reporting Fraud or suspected Fraud and/or suspected Abuse
and/orconfirmedAbuse,theContractorshallnottakeanyofthe
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followingactionsastheyspecificallyrelatetoLouisianaMedicaid
Programclaims:
2.20.1.11.4.1 Contactthesubjectoftheinvestigationabout
anymattersrelatedtotheinvestigation;
2.20.1.11.4.2 Enter into or attempt to negotiate any
settlement or agreement regarding the
incident;or
2.20.1.11.4.3 Acceptanymonetaryorotherthingof
valuableconsiderationofferedbythesubject
of the investigation in connection with the
incident.
2.20.1.11.5 The Contractor shall provide the results of its preliminary
investigationtoLDHortheagencytowhomtheincidentwas
reported, or to another agency designated by the agency that
receivedthereport.
2.20.1.11.6 The Contractor and its subcontractors shall seek to reduce
prospective financial loss to health Fraud, Waste, and Abuse
when fraudulent and/or criminal activity is suspected through
pre‐paymentorpost‐paymentreview,auditorinvestigation.The
Contractor may mitigate loss of funds to Fraud by employing
proceduresincluding,butnotlimitedto,pre‐paymentedits,prior
authorization,medicalnecessityreview,verificationofservices
being rendered as billed, payment withhold in full or in part,
CorrectiveActionPlans,terminationoftheprovideragreement,
orotherremedies.
2.20.1.11.7 TheContractorand/oritssubcontractorsshallsuspendpayment
toaNetworkProviderwhentheStatedeterminesthereisa
credibleallegationofFraud,unlesstheStatedeterminesthereis
cause for not suspending payments to the Network Provider
pending the investigation. The Contractor is responsible for
sending the Network Provider the required notice and appeal
rightsasrequiredby42C.F.R.§455.23.
2.20.1.12 The Contractor and/or subcontractors shall include in all of its provider
agreementsaprovisionrequiring,asaconditionofreceivinganyamountof
Louisiana Medicaid Program payment, that the provider complies with this
SectionoftheContract.
2.20.2 Fraud,Waste,andAbuseCompliancePlan
2.20.2.1 In accordance with 42 C.F.R. §438.608(a), the Contractor and its
subcontractors, to the extent that the subcontractor is delegated
responsibilitybytheContractorforcoverageofservicesandpaymentofclaims
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undertheContractbetweentheContractorandthestate,shallimplementand
maintain a compliance program that includes arrangements or procedures
designedtopreventanddetectFraud,Waste,andAbuse.
2.20.2.2 Inaccordancewith42C.F.R.§438.608(a),thearrangementsandprocedures
ofthecomplianceprogramshallincludeallofthefollowingelements:
2.20.2.2.1 Written policies, procedures, and standards of conduct that
articulate the organization's commitment to comply with all
applicablerequirementsandstandardsundertheContract,and
allapplicableFederalandStaterequirements.
2.20.2.2.2 The designation of a Contract Compliance Officer who is
responsible for developing and implementing policies,
procedures, andpractices designed to ensure compliance with
therequirementsoftheContractandwhoreportsdirectlytothe
ChiefExecutiveOfficerandtheboardofdirectors.
2.20.2.2.3 TheestablishmentofaRegulatoryComplianceCommitteeonthe
BoardofDirectorsandattheseniormanagementlevelcharged
withoverseeingtheorganization'scomplianceprogram andits
compliancewiththerequirementsundertheContract.
2.20.2.2.4 AsystemfortrainingandeducationfortheContractCompliance
Officer, the organization's senior management, and the
organization's employees for the Federal and State standards
andrequirementsundertheContract.
2.20.2.2.4.1 Fraud,WasteandAbuseTrainingshallinclude,
butnotbelimitedto:
Annualtrainingofallemployees;and
New hire training within thirty (30)
Calendar Days of beginning date of
employment.
2.20.2.2.4.2 TheContractorshallrequirenewemployeesto
completeandattesttotrainingmoduleswithin
thirty(30)CalendarDaysofhirerelatedtothe
following in accordance with applicable
FederalandStatelaws,regulations,rules,and
policies:
ContractorCodeofConductTraining;
Privacy and Security – Health Insurance
PortabilityandAccountabilityAct;
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Fraud, Waste, and Abuse identification
andreportingprocedures;
TheFalseClaimsActandemployee
whistleblowerprotections;
Procedures for Timely consistent
exchange of information and
collaborationwithLDH;
Organizational chart including the
Program Integrity Officer and full‐time
programintegrityinvestigator(s);and
Provisions that comply with 42 C.F.R.
§438.608 and 438.610 and all relevant
State and Federal laws, regulations,
policies, procedures, and guidance
(including CMS’ Guidelines for
Constructing a Compliance Program for
Medicaid Managed Care Organizations
and Prepaid Networks) issued by LDH,
HHS, CMS, and OIG, including updates
andamendmentstothesedocumentsor
any such standards established or
adopted by the Stateof Louisiana or its
agencies.
2.20.2.2.5 Effective lines of communication between the Contract
ComplianceOfficerandtheorganization'semployees.
2.20.2.2.6 Enforcement of standards through well‐publicized disciplinary
guidelines.
2.20.2.2.7 Establishmentandimplementationofproceduresandasystem
withdedicatedstaffforroutineinternalmonitoringandauditing
of compliance risks, prompt response to compliance issues as
theyareraised,investigationofpotentialcomplianceproblems
as identified in the course of self‐evaluation and audits,
correction of such problems promptly and thoroughly (or
coordination of suspected criminal acts with law enforcement
agencies) to reduce the potential for recurrence, and ongoing
compliancewiththerequirementsundertheContract.
2.20.2.2.8 ProceduresforpromptnotificationtoLDHwhentheContractor
receives information about changes in an Enrollee’s
circumstancethat may affectthe Enrollee’s eligibilityincluding
changesintheEnrollee’sresidenceanddeathofanEnrollee.
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2.20.2.2.9 ProceduresforpromptnotificationtoLDHwhentheContractor
receivesinformationaboutachangeinaNetworkProvider’s
circumstancesthatmayaffecttheNetworkProvider’seligibility
toparticipateintheprogram.
2.20.2.2.10 Procedures to verify, by sampling or other methods, whether
servicesthathavebeenrepresentedtohavebeendeliveredby
Network Providers were received by Enrollees and the
applicationofsuchverificationonaregularbasis.
2.20.2.2.11 Provision for the Contractor’s suspension of payments to a
NetworkProviderforwhichtheStatedeterminesthereisa
credibleallegationofFraudinaccordancewith42CFR§455.23.
2.20.2.2.12 Proceduresforapromptresponsetodetectedoffensesandfor
development of corrective action initiatives related to the
Contract.
2.20.2.2.13 Protections to ensure that no individual who reports program
integrity related violations or suspected Fraud, Waste, and/or
Abuse is retaliated against by anyone who is employed by or
contractswiththeContractor.TheContractorshallensurethat
theidentityofindividualsreportingviolationsofthecompliance
plan shall be held confidential to the extent possible. Anyone
who believes that he or she has been retaliated against may
reportthisviolationtoLDHand/ortheU.S.OfficeofInspector
General.
2.20.2.2.14 ProceduresforaNetworkProvidertoreporttotheContractor
whenithasreceivedanoverpayment,toreturntheoverpayment
totheContractorwithinsixty(60)CalendarDaysofthedateon
which the overpayment was identified, and to notify the
Contractorinwritingofthereasonfortheoverpayment.
2.20.2.2.15 ProceduresforpromptreportingtotheStateofalloverpayments
identified and recovered, specifying the overpayments due to
potentialFraud.
2.20.2.3 Inadditiontothearrangementsandproceduresspecifiedin42C.F.R.
§438.608(a), the Contractor’s compliance program shall incorporate the
followingrequirements:
2.20.2.3.1 Detection and prevention of Louisiana Medicaid Program
violationsand possible Fraud,Wasteand Abuse overpayments
throughdatamatching,trending,statisticalanalysis,monitoring
serviceand billingpatterns, monitoringclaimsedits,andother
dataminingtechniques.
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2.20.2.3.2 Descriptions of specific controls in place for prevention and
detectionofpotentialorsuspectedFraud,Wasteand,,including:
lists of pre‐payment claims edits, post‐payment claims edits,
post‐payment claims audit projects, data mining and provider
profiling algorithms, and references in provider and member
materials relative to identifying and reporting Fraud to the
Contractorandlawenforcement.
2.20.2.3.3 Provisionsfortheconfidentialreportingofplanviolations,such
asadedicatedtoll‐freehotlinetoreportviolationsandaclearly
designatedindividual,suchastheContractComplianceOfficer,
to receive them. Several independent reporting paths shall be
createdforthereportingofFraudsothatsuchreportscannotbe
divertedbysupervisorsorotherpersonnel.
2.20.2.3.4 Writtenpoliciesandproceduresforconductingbothannounced
and unannounced site visits and field audits on providers to
ensureservicesarerenderedandbilledcorrectly.
2.20.2.4 Effectiveimplementationofawell‐publicizedemailaddressforthededicated
purpose of reporting Fraud. This email address must be made available to
Enrollees,providers,ContractoremployeesandthepublicontheContractor’s
website required under this Contract. The Contractor shall implement
procedurestoreviewcomplaintsfiledintheFraudreportingemailaccountat
leastweekly,andinvestigateandactonsuchcomplaintsaswarranted.The
ContractorshallsubmittoLDHoritsdesigneetheFraud,Waste,andAbuse
CompliancePlanaspartofReadinessReview,annuallythereafter,andupon
updatesormodificationsforwrittenapprovalatleastthirty(30)CalendarDays
inadvanceofmakingthemeffective.LDH,atitssolediscretion,mayrequire
thattheContractormodifyitscomplianceplan.
2.20.3 ProhibitedAffiliations
2.20.3.1 Inaccordancewith42C.F.R.§438.610,theContractoranditssubcontractors
areprohibitedfromknowinglyhavingarelationshipwith:
2.20.3.1.1 Anindividualorentitythatis(orisaffiliatedwithaperson/entity
that is) debarred, suspended, or otherwise excluded from
participating in procurement activities under the Federal
Acquisition Regulation (FAR) or from participating in non‐
procurementactivitiesunderregulationsissuedunderExecutive
Order No. 12549 or under guidelines implementing Executive
OrderNo.12549;or
2.20.3.1.2 Anindividualorentitythatisexcludedfromparticipationinany
Federal health care program under 42 U.S.C. §1320a‐7 and
§1320a‐7a.
Page294of381
2.20.3.2 TheContractorshallnothaveacontractfortheadministration,management,
orprovisionofmedicalservices(ortheestablishmentofpoliciesorprovision
ofoperationalsupportforsuchservices),eitherdirectlyorindirectly,with:
2.20.3.2.1 Anindividualconvictedofcrimesdescribedin42U.S.C.§1320a‐
7(b)(8)(B);
2.20.3.2.2 Any individual or entity that is (or is affiliated with a
person/entity that is) debarred, suspended, or excluded from
participating in procurement activities under the FAR or from
participating in non‐procurement activities under regulation
issued under Executive Order No. 12549 or under guidelines
implementingExecutiveOrderNo.12549;or
2.20.3.2.3 Anyindividualorentitythatisexcludedfromparticipationinany
Federal health care program under 42 U.S.C. §1320a‐7 and
§1320a‐7a.
2.20.3.3 The Contractor is prohibited from employing or contracting, directly or
indirectly,forthefurnishingofhealthcare,utilizationreview,medicalsocial
work,oradministrativeserviceswith:
2.20.3.3.1 Any individual or entity that is (or is affiliated with a
person/entity that is) debarred, suspended, or excluded from
participating in procurement activities under the FAR or from
participating in non‐procurement activities under regulation
issued under Executive Order No. 12549 or under guidelines
implementingExecutiveOrderNo.12549;
2.20.3.3.2 Anyindividualorentitythatisexcludedfromparticipationinany
Federal health care program under 42 U.S.C. §1320a‐7 and
§1320a‐7a;
2.20.3.3.3 Anyindividualorentitythatwould(orisaffiliatedwitha
person/entity that would) provide those services through an
individual or entity debarred, suspended, or excluded from
participating in procurement activities under the FAR or from
participating in non‐procurement activities under regulation
issued under Executive Order No. 12549 or under guidelines
implementingExecutiveOrderNo.12549;or
2.20.3.3.4 Any individual or entity that would provide those services
throughanindividualorentityexcludedfromparticipationinany
Federal health care program under 42 U.S.C. §1320a‐7 and
§1320a‐7a.
2.20.3.4 TheContractorisprohibitedfrombeingcontrolledbyasanctionedindividual
under42U.S.C.§1320a‐7(b)(8).
Page295of381
2.20.3.5 IfLDHfindstheContractorisnotincompliancewith42C.F.R.§438.610(a)and
(b),LDH:
2.20.3.5.1 ShallnotifytheSecretaryoftheU.S.DepartmentofHealthand
HumanServices(HHS)ofthenoncompliance;
2.20.3.5.2 MaycontinueanexistingagreementwiththeContractorunless
theSecretaryofHHSdirectsotherwise;
2.20.3.5.3 Maynotreneworotherwiseextendthedurationofanexisting
agreement with the Contractor unless the Secretary of HHS
providestoLDHandtoCongressawrittenstatementdescribing
compelling reasons that exist for renewing or extending the
agreementdespitetheprohibitedaffiliations;and
2.20.3.5.4 Nothinginthissectionshallbeconstruedtolimitorotherwise
affectanyremediesavailabletotheU.S.under42U.S.C.§1320a‐
7,§1320a‐7a,and§1320a‐7b.
2.20.3.6 The Contractor and its subcontractors shall comply with all applicable
provisionsof42C.F.R.§438.608and§438.610pertainingtodebarmentand/or
suspensionincludingwritten disclosure toLDH of anyprohibitedaffiliation.
TheContractoranditssubcontractorsshallscreenallemployees,contractors,
andNetworkProviderstodeterminewhethertheyhavebeenexcludedfrom
participationinMedicare,Medicaid,theChildren’sHealthInsuranceProgram,
and/oranyfederalhealthcareprograms.Tohelpmakethisdetermination,
theContractorshallconductscreeningstocomplywiththerequirementsset
forthat42C.F.R.§455.436.
2.20.3.7 TheContractoranditssubcontractorsshallconductasearchoftheOIGLEIE,
LouisianaAdverseActionsListSearch,SAM,andotherapplicablesitesasmay
bedeterminedbyLDH,monthlytocaptureexclusionsandreinstatementsthat
have occurred since the previous search. Any and all exclusion information
discovered shall be reported to LDH within three (3) Business Days. Any
individual or entity that employs or contracts with an excluded
provider/individualcannotclaimreimbursementfromtheLouisianaMedicaid
Programforanyitemsorservicesfurnished,authorized,orprescribedbythe
excludedproviderorindividual.Thisisaprohibitedaffiliation.Thisprohibition
appliesevenwhentheLouisianaMedicaidProgrampaymentitselfismadeto
anotherproviderwhoisnotexcluded.[See42U.S.C.§1320a‐7a(a)(6)and42
C.F.R.§1003.102(a)(2).]
2.20.3.8 An individual who is an Affiliate of a prohibited person or entity described
abovecaninclude:
2.20.3.8.1 Adirector,officer,orpartneroftheContractor;
2.20.3.8.2 AsubcontractoroftheContractor;
Page296of381
2.20.3.8.3 Apersonwithanemployment,consultingorotherarrangement
withtheContractorfortheprovisionofitemsandserviceswhich
aresignificantandmaterialtotheContractor’sobligationsunder
thisContract;or
2.20.3.8.4 ANetworkProvider.
2.20.3.9 TheContractorshallnotifyLDHinwritingwithinthree(3)CalendarDaysofthe
timeitreceivesnoticethatactionisbeingtakenagainsttheContractororany
persondefinedaboveorundertheprovisionsof42U.S.C.§1320a‐7(a)or(b)
oranycontractorwhichcouldresultinexclusion,debarment,orsuspensionof
the Contractor or a contractor from the Medicaid or CHIP program, or any
programlistedinExecutiveOrder12549ofFebruary18,1986,whichstates
thatdebarmentorsuspensionofaparticipantinaprogrambyoneagency
shallhavegovernment‐wideeffect.
2.20.3.10 TheContractor,throughitsContractComplianceOfficer,shallattestmonthly
toLDHthatithasscreenedallemployeesandsubcontractorsasspecifiedin
theDebarment/Suspension/Exclusionsectiontocaptureallexclusions.
2.20.3.11 TheContractoranditssubcontractorsshallretainthedata,information,and
documentationspecifiedin42CFR§438.410,foraperiodofnolessthanten
(10)yearsfollowingterminationoftheContract.
2.20.4 PaymentstoExcludedProviders
2.20.4.1 FederalFinancialParticipation(FFP)isnotavailableforservicesdeliveredby
providers excluded by Medicare, Medicaid, or CHIP except for certain
EmergencyServicesasspecifiedin42C.F.R.§1001.1901;and
2.20.4.2 LDHmayrecoverfromtheMCO,viaadeductionfromtheMCO’sCapitation
Payment,anymoneypaidforservicesprovidedbyanexcludedprovider.
2.20.5 Reporting
2.20.5.1 The Contractor and its subcontractors shall be responsible for promptly
reporting suspected Fraud, Abuse, Waste, and neglect information to the
LouisianaOfficeofAttorneyGeneralMFCUandLDHassoonaspracticalafter
discovering suspected incidents,butnolaterthanthree(3)Business Days,
takingpromptcorrectiveactionsandcooperatingwithLDHinitsinvestigation
ofthematter(s).
2.20.5.2 TheContractorshallnotifyLDHwithinthree(3)BusinessDaysofthetimeit
receives notice that action is being taken against the Contractor or
Contractor’semployee, NetworkProvider, subcontractoror subcontractor’s
employee under the provisions of 42 U.S.C. §1320a through 1320b, which
could result in exclusion, debarment, or suspension of the Cont
ractor,
NetworkProvider,orasubcontractorfromtheMedicaidorCHIPprogram,or
anyprogramlistedinExecutiveOrder12549.
Page297of381
2.20.5.3 TheContractorshallreporttoLDH,withinthree(3)BusinessDays,whenithas
discovered that any Contractor employee(s), Network Provider,
subcontractor, or subcontractor’s employee(s) have been excluded,
suspended,ordebarredfromanystateorfederalhealthcarebenefitprogram
viathedesignatedLDHProgramIntegritycontact.
2.20.5.4 Reportingshallinclude,butisnotlimitedto,thefollowing,assetforthat42
C.F.R.§455.17:
2.20.5.4.1 Number of complaints of Fraud, Abuse, Waste, neglect, and
overpaymentsmadetotheContractorthatwarrantpreliminary
investigation(under42C.F.R.§455.14);
2.20.5.4.2 Number of complaints reported to the Contract Compliance
Officer;and
2.20.5.4.3 Foreachcomplaintthatwarrantsfullinvestigationconductedin
accordancewith42C.F.R.§455.15and§455.16,theContractor
shallprovideLDH,ataminimum,thefollowing:
2.20.5.4.3.1 ProviderNameandIDnumber;
2.20.5.4.3.2 Sourceofcomplaint;
2.20.5.4.3.3 Typeofprovider;
2.20.5.4.3.4 Natureofcomplaint;
2.20.5.4.3.5 Approximate amount of dollars involved if
applicable;and
2.20.5.4.3.6 Legal and administrative disposition of the
case and any other information necessary to
describe the activity regarding the
complainant.
2.20.5.5 The Contractor shall report to LDH Program Integrity monthly all audits
performedandoverpaymentsidentifiedandrecoveredbytheContractorand
allofitssubcontractors.[See42C.F.R.§438.608(d)(3).]
2.20.5.6 The Contractor shall report overpayments made by LDH to the Contractor
withinsixty(60)CalendarDaysfromthedatetheoverpaymentwasidentified.
2.20.5.7 TheContractorshallreporttoLDHProgramIntegritymonthlyallunsolicited
provider refunds, which shall include any payments submitted tothe
Contractorand/oritssubcontractorsbyprovidersforoverpaymentsidentified
throughself‐auditand/orself‐disclosure.
2.20.6 RightsofReviewandRecoverybyContractorandLDH
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2.20.6.1 The Contractor and its subcontractorsareresponsibleforinvestigating and
reportingpossibleactsof providerFraud,Abuse,and Wasteforallservices
underthisContract.
2.20.6.2 TheContractoranditssubcontractorsshallhavetherighttoaudit,reviewand
investigateprovidersandEnrolleeswithintheContractor’snetworkforaone
(1)yearperiodfromthedateofpaymentofaclaimvia“automated”review.
Anautomatedreviewisoneforwhichananalysisofthepaidclaims is
sufficient to determine the existence of an overpayment, whereas no
additionaldocumentationis required tobe submitted fromthe provider to
determine the existence of an overpayment. The collected funds from the
Contractor’sautomatedreviewsaretoremainwiththeContractor. The
Contractorshallnotrecoverfromprovidersviaautomatedreviewforclaims
olderthanone(1)yearunlessauthorizedinwritingbyLDH.
2.20.6.3 TheContractoranditssubcontractorsshallhavetherighttoaudit,reviewand
investigateprovidersandEnrolleeswithintheContractor’snetworkforafive
(5)year periodfromthe dateofservice ofa claimvia“complex”review.A
complexreviewisoneforwhichthereviewofmedical,financial,and/orother
records,includingthoseonsite,werenecessarytodeterminetheexistenceof
an improper payment. The collected funds from the Contractor’s complex
reviewsaretoremainwiththeContractor.
2.20.6.4 Allcomplexreviewsshallbecompletedwithinten(10)months(threehundred
(300)CalendarDays)ofthedatethecasewasopenedunlessanextensionis
authorizedbyLDH.Thisreviewperiodisinclusiveofallprovidernotifications,
healthplandocumentreviews,andincludesanyproviderappealorrebuttal
process.
2.20.6.5 The Contractor shall ensure compliance with all requirements ofLa.R.S.
46:460.72‐460.73,includingtherequirementtovoidallclaimsandencounters
associatedwithFraud,Waste,andAbuseforthepurposeofreducingPMPM
rates, thereby returning overpayments to the State. The Contractor shall
comply with the timelines specified in the MCO Manual for voiding such
encounters.
2.20.6.6 LDHoritsdesigneewillnotifytheContractorwhenitisprohibitedfromtaking
any actions to recoup or withhold improperly paid funds alreadypaidor
potentiallyduetoaproviderwhentheissues,servicesorclaimsuponwhich
therecoupmentorwithholdarebasedmeetone(1)ormoreofthefollowing
criteria:
2.20.6.6.1 Theimproperlypaidfundshavealreadybeenrecoveredbythe
StateofLouisiana,eitherbyLouisianaMedicaidProgramdirectly
oraspartofaresolutionofastateorfederalinvestigation,audit,
and/or lawsuit including, but not limited to, False Claims Act
cases;or
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2.20.6.6.2 When the issues, services or claims that are the basis of the
recoupment or withhold are the subject of pending State or
Federalinvestigation,audit,and/orlawsuit.
2.20.6.7 Theprohibitiondescribedintheprecedingsectionshallbelimitedtoaspecific
provider(s),forspecificdates,andforspecificissues,servicesorclaims.Inthe
eventthattheContractorobtainsfundsincaseswhererecovery,recoupment
orwithholdisprohibitedunderthisSection,LDHmayrecoverthefundsfrom
theContractor.
2.20.6.8 Contact with a provider shall be prohibited in instances resulting from
suspectedFraud,whichtheContractorhasidentifiedandsubmittedareferral
ofFraudtoLDH,MFCU,orotherappropriatelawenforcementagency,until
approvedbyLDHinwriting.
2.20.6.9 IftheContractorfailstocollectatleastaportionofanidentifiedrecoveryafter
three hundred sixty‐five (365) Calendar Days from the date LDH approved
proceeding with the recoupment, unless an extension or exception is
authorizedinwriting byLDH,andthe Contractorhasdocumentedrecovery
efforts deemed sufficient by LDH upon review, including formally initiating
collection efforts, LDH or its agent may recover the overpayment from the
ContractorandsaidfundsshallberetainedbytheState.Exceptionreasons
mayinclude,butarenotlimitedto,ContractorcooperationwithLDHorother
government agencies, termination of provider participation withthe
Contractor,ordissolutionoftheprovider’sbusiness.
2.20.6.10 LDHoritsagentshallhavetherighttoaudit,reviewandinvestigateproviders
andEnrolleeswithintheContractor’snetworkvia“complex”or“automated”
review.LDHmayrecoverfromtheContractor,viaadeductionfrom the
Contractor’s Capitation Payment, any provider overpayments identified by
LDHoritsagent,andsaidrecoveredfundsshallberetainedbytheState.The
Contractormay pursuerecovery fromthe providerasaresult oftheState‐
identified overpayment. LDH shall not initiate its own review on the same
claimsforaNetworkProviderwhichhasbeenidentifiedbytheContractoras
underareview approvedbyLDH.LDH shalltrackopen LDHandContractor
reviewstoensureauditcoordination.
2.20.6.11 IntheeventLDHoritsagentinitiatesareviewonaNetworkProvider, a
notification shall be sent to the Contractor Special Investigation Unit (SIU)
designee.TheLDHnotificationoftheintenttoreviewshallincludeprovider
name, NPI, city, and provider type, allegation or issue being reviewed,
procedurecodesorNDCsunderreview,daterangefordatesofserviceunder
review,andamountpaid.TheContractorshallhaveten(10)BusinessDaysto
indicatewhethertheclaimswerecorrectedoradjustedpriortothedateof
thenotificationfromLDH.IftheStatedoesnotreceivearesponsefromthe
Contractor within ten (10) Business Days, the State may proceedwithits
review.
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2.20.6.12 IntheeventtheStateoritsagentinvestigates,reviews,orauditsaprovideror
Enrollee within the Contractor’s Network, the Contractorshall comply with
documentandclaimsrequestsfromtheStatewithinfourteen(14)Calendar
Daysoftherequest,unlessanothertimeperiodisagreedtoinwritingbythe
ContractorandState.
2.20.6.13 LDH shall notify the Contractor and the Network Provider concurrently of
overpaymentsidentifiedbytheStateoritsagents.
2.20.6.14 UpontheconclusionofproviderrebuttalsandAppeals,ifapplicable,theState
oritsagentshallnotifytheContractoroftheoverpayment.The Contractor
shall correct or initiate its own review on the identified encounters within
fourteen(14)CalendarDaysofnotificationfromLDH.TheContractor shall
submitconfirmationthatthecorrectionshavebeencompleted.
2.20.6.15 TheContractoranditssubcontractorsshallenforceLDHdirectivesregarding
sanctionsonMCONetworkProvidersandEnrollees,including,butnotlimited
to,terminationorexclusionfromthenetwork.
2.20.6.16 There shall be no LDH provider improper payment recovery request of the
ContractorapplicableforthedatesofserviceoccurringbeforetheOperational
StartDateorforprovidersforwhichnoMCOrelationshipexisted.
2.20.6.17 TheContractorshallnotremitpaymenttoanyproviderforwhichtheState‐
issuedMedicaidProviderIdentifiernumberhasbeenrevokedorterminated
byLDH.
2.20.6.18 TheContractoranditssubcontractorsshallretainalldata,information,and
documentationspecifiedin42CFR§438.608foraperiodofnolessthanten
(10)yearsfollowingterminationoftheContract.
2.20.7 ProgramIntegrityRequirements
TheContractorshallmeetfollowingrequirements:
2.20.7.1 NotifyLDHuponcontactbyanyinvestigativeauthoritiesconductingFraudand
Abuse investigations, except in situations where investigative authorities
makeitillegaltoprovidesuchnotice.TheContractor,andwhereapplicable
anySubcontractorsorMaterialSubcontractors,shallcooperatefullywiththe
agencies that conduct investigations; full cooperation includes, but is not
limitedto,TimelyexchangeofinformationandstrategiesforaddressingFraud
andAbuse,aswellasallowingpromptdirectaccesstoinformation,freecopies
ofdocuments,andotheravailableinformationrelatedtoprogramviolations,
whilemaintainingtheconfidentialityofanyinvestigation.TheContractorshall
make knowledgeable employees available at no charge to support any
investigation,court,oradministrativeproceeding;
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2.20.7.2 Notify LDH in writing upon receipt of any voluntary provider disclosures
resultinginreceiptofoverpaymentsinexcessof$25,000,evenifthereisno
suspicionoffraudulentactivity;and
2.20.7.3 ReportannuallytoLDH,inaformandformatspecifiedbyLDH,on the
Contractor’s recoveries of overpayments in accordance with 42 C.F.R.
§438.608.
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PART3: STATERESPONSIBILITIES
ContractManagement
BHSFisresponsiblefortheprimaryoversightoftheContract,includingLouisianaMedicaidProgram
policydecision‐makingandContractinterpretation.Asappropriate,BHSFshallprovideclarification
ofContractrequirementsandLousianaMedicaidProgrampolicy,regulationsandproceduresand
shallschedulemeetingsasnecessarywiththeContractor.
3.1.1 ContractAdministrationPersonnel
3.1.1.1 TheContractComplianceOfficer,describedintheAdministration&Contract
Managementsection,shallfacilitate theestablishment andmaintenanceof
direct relationships between the appropriate LDH Business Owners and
Contractoremployeeswithcorrespondingresponsibilitiesforthedurationof
theContract.
3.1.1.2 TheContractComplianceOfficershallintroduceContractoremployeesnewly
placedinapositiontotherelevantLDHBusinessOwners,basedonrolesand
responsibilities,withinfive(5)BusinessDaysoftheplacement.
3.1.2 ContractMonitor
MedicaidExecutiveDirectororhis/herDesignee
LouisianaDepartmentofHealth
BureauofHealthServicesFinancing
628North4thSt.,7thfloor
BatonRouge,LA70802
3.1.3 Notices
AnynoticegiventoapartyundertheContractisdeemedeffective,ifaddressedtothe
ContractMonitorasaddressedabove,upon:(i)delivery,ifhanddelivered;(ii)receiptof
aconfirmedtransmissionbyfacsimileoremailifacopyofthenoticeissentbyanother
meansspecifiedinthisSection;(iii)thethird(3
rd
)BusinessDayafterbeingsentbyU.S.
mail,postagepre‐paid,returnreceiptrequested;or(iv)thenextBusinessDayafterbeing
sentbyanationallyrecognizedovernightexpresscourierwithatrackingsystem.
Eitherpartymaychangeitsaddressfornotificationpurposesbyprovidingwrittennotice
statingthechange,effectivedateofthechangeandsettingforththenewaddressatleast
ten(10)BusinessDayspriortotheeffectivedateofthechangeofaddress.Ifdifferent
representatives are designated after execution of the Contract, notice of the new
Page303of381
representativesshallbegiveninwritingtotheotherpartyandattachedtooriginalsof
theContract.
WheneverLDHisrequiredbythetermsofthisContracttoprovidewrittennoticetothe
Contractor, such notice shall be signed by the Medicaid Executive Director or his/her
designee.
3.1.4 RequiredSubmissions
3.1.4.1 TheContractorshallsubmitdocumentsandinformationinaccordancewith
this Contract and the MCO Manual. LDH shall have the right to approve,
disapprove,orrequiremodificationofthesedocuments,information,andany
procedures,policiesandmaterialsrelatedtotheContractor'sresponsibilities
underthetermsoftheContract.
3.1.4.2 LDHshallreviewreports to determine that they are complete and without
erroraccordingtothereportingrequirementsprovidedintheMCOManual.
Anyreportsfoundtobeincompleteorsubmittedwitherrorsshallbereturned
to the Contractor for correction and resubmission within specified
timeframes.LDHreservestherighttoassessMonetaryPenaltiesforfailureto
complywithreportingrequirements.
3.1.5 ReadinessReview
3.1.5.1 LDHoritsdesigneewillassesstheperformanceoftheselectedMCOspriorto
and after the begin date for operations in accordance with 42 C.F.R.
§438.66(d).LDHexpectstocompletetheReadinessReviewatleastthree(3)
monthspriortotheOperationalStartDate.EachReadinessReviewforentities
thatdidnotcontractwithLDHasanMCOimmediatelypriortotheContract
effectivedateshallbeperformedviaadeskreviewofdocumentsandon‐site
at the Contractor’s Louisiana administrative offices and shall include an
assessmentoftheContractor’sabilityandcapabilitytoperformsatisfactorily
intheareasnotedbelowassetforthin42C.F.R.§438.66(d)(4).Allselected
MCOsmustparticipateinacomprehensiveReadinessReviewifrequiredby
LDH;however,LDHretainsthediscretiontoconductamorelimitedReadiness
Review for existing MCO contractors. LDH or its designee may conduct
additionalReadinessReviewsof theContractorpriortoenrollingadditional
populationsinmanagedcareorpriortoaddingordeletingcoveredservices
fromAttachmentC,MCOCoveredServices.
3.1.5.2 ThescopeoftheContractor’sReadinessReviewmayinclude,butisnotlimited
to,areviewofthefollowingelementsagainsttherequirementsprovidedin
thisContractandtheMCOManual:
3.1.5.2.1 Administrativestaffingandresources,includingkeypersonnel;
3.1.5.2.2 DelegationandoversightofContractorresponsibilities,including
capabilitiesofmaterialsubcontractors;
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3.1.5.2.3 Enrollee and provider communications, including Enrollee
servicescapability;
3.1.5.2.4 GrievanceandAppeals;
3.1.5.2.5 Enrolleeservicesandoutreach,includingmarketingmaterials;
3.1.5.2.6 Provider network management plans and model Network
Provider Agreements, including any provider performance
incentives;
3.1.5.2.7 Programintegrityandcompliance,includingFraud,Waste,and
Abuse;
3.1.5.2.8 Servicedelivery,includingcaremanagementcapabilities,quality
managementandqualityimprovement,andutilizationreview;
3.1.5.2.9 Financial management, including financial reporting and
monitoringandfinancialsolvency;and
3.1.5.2.10 Systemsmanagement,includingclaimsmanagement,encounter
dataandEnrolleeinformationmanagement,and,attherequest
ofLDH,awalk‐throughofanyinformationsystems,interfacing
andreportingcapabilities,andvaliditytestingofencounterdata,
includingITtestingandsecurityassurances.
3.1.5.3 LDHshallnot enrollPotential Enrollees intothe MCO untilLDHdetermines
thattheContractorisreadyandabletoperformitsobligations under the
ContractasdemonstratedduringtheReadinessReview,exceptasprovided
below.
3.1.5.4 LDHshallidentifytotheContractorallareaswheretheContractorisnotready
andabletomeetitsobligationsundertheContractandmay,initsdiscretion:
3.1.5.4.1 AllowtheContractortoproposeaplantoremedyalldeficiencies
priortotheContractOperationalStartDate;
3.1.5.4.2 PostponetheContractOperationalStartDateforanyMCOthat
failstosatisfyallReadinessReviewrequirements;or
3.1.5.4.3 EnrollEnrolleesintotheMCOasoftheContractOperationalStart
Date provided the Contractor and LDH agree on a Corrective
ActionPlantoremedyanydeficiencies.
3.1.5.5 If,foranyreason,theContractordoesnotfullysatisfyLDHthatitisreadyand
able to perform its obligations under the Contract prior to the Contract
Operational Start Date, and LDH does not agree to postpone the Contract
Operational Start Date, or extend the date for full compliance with the
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applicableContractrequirement,thenLDHmayterminatetheContractand
shallbeentitledtorecoverdamagesfromtheContractor.
3.1.5.6 LDHshallsubmittheresultsoftheReadinessReviewtoCMSinorderforCMS
tomakeadeterminationthattheContractorassociatedContractamendment
isapprovedunder42C.F.R.§438.3(a).
3.1.6 OngoingContractMonitoring
LDHshallmonitortheContractor’sperformancetoensuretheContractorisincompliance
with Contract provisions. The Contractor remains responsible for continuously
monitoring the performance of its material subcontractors and providers and their
compliancewithContractprovisions.LDHmaydevelop,basedonitsongoingmonitoring,
apublicperformancedashboarddisplayingtheContractor’sperformance.
3.1.6.1 LDHoritsdesigneeshallcoordinatewiththeContractortoestablishthescope
ofthemonitoringreview,thereviewsite,ifon‐site,relevanttimeframesfor
obtaininginformation,andthecriteriaforreview.
3.1.6.2 LDH or its designee shall monitor the operation of the Contractor for
compliancewiththeprovisionsofthisContract,andallapplicableFederaland
Statelawsandregulations.InspectionmayincludetheContractor'sfacilities,
aswellasauditingand/orreviewofallrecordsdevelopedunderthisContract
including,butnotlimitedto,periodicmedicalaudits,Grievances,Enrollments,
Disenrollments,utilizationandfinancialrecords,reviewofthemanagement
systemsandproceduresdevelopedunderthisContractandanyotherareasor
materialsrelevantorpertainingtothisContract.
3.1.6.3 The Contractor shall provide access to documentation, medical records,
premises,andstaffasdeemednecessarybyLDH.
3.1.6.4 LDHshallprovidetheContractorwiththerighttoreviewandcommentonany
ofthefindingsandrecommendationsresultingfromContractmonitoringand
audits,exceptinthecasesofFraudinvestigationsorcriminalaction.OnceLDH
finalizestheresultsofmonitoringand/ortheauditreport,theContractorshall
complywithallrecommendationsresultingfromthereview.Failuretocomply
with recommendations for improvement may result in Monetary Penalties,
administrativeactions,Enrollmentrestrictions,and/orcontracttermination.
3.1.7 MCOOn‐SiteReviews
Inadditiontotheon‐sitecomponentofReadinessReviewsfortheContractor,LDHorits
designeemayconducton‐sitereviewsatanytimeduringthecourseoftheContractto
monitorContractorperformanceorassesscomplianceofanycontractualrequirement.
3.1.8 RegularContractMonitoringMeetings
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LDH shall assess and communicate feedback on overall plan performance to the
Contractor through routine meetings with Contractor leadership, including but not
limitedto:
3.1.8.1 Monthlyin‐person ortelephonic meetingsbetweenthe Medicaid Executive
Director, Medicaid Deputy Director responsible for the Managed Care
Program,andtheContractor’sCEO.
3.1.8.2 QuarterlyperformancereviewswhereinContractorleadershippresenttoLDH
leadershiponoverallContractorperformancerelativetoLDHgoalsandthe
requirementsoftheContract.Thereviewsshalltakeplacein‐personatLDH
headquarters on a schedule determined by LDH. LDH shall notify the
Contractorofthescheduleandanyformatorcontentrequirementsthirty(30)
CalendarDayspriortothereviewdate.UnlessotherwisespecifiedbyLDHin
writing,in‐personattendanceofthefollowingContractorstaffismandatory:
3.1.8.2.1 ChiefExecutiveOfficer(CEO);
3.1.8.2.2 MedicalDirector;
3.1.8.2.3 BehavioralHealthMedicalDirector;
3.1.8.2.4 ChiefOperatingOfficer(COO);
3.1.8.2.5 ChiefFinancialOfficer(CFO);
3.1.8.2.6 QualityManagementCoordinator;
3.1.8.2.7 ProviderServicesManager;
3.1.8.2.8 CaseManagementAdministrator/Manager;and
3.1.8.2.9 OtherstaffasdesignatedbyLDHbasedoncontent.
3.1.9 ContractorMonitoring
3.1.9.1 LDHshall:
3.1.9.1.1 MonitorcompliancewiththetermsoftheContract;
3.1.9.1.2 Receiveandrespondtoallinquiriesandrequestsmadebythe
ContractorunderthisContract,inthetimeframesspecifiedby
theContract;
3.1.9.1.3 MeetwiththeContractor'srepresentativeonaperiodicoras
neededbasisandresolveissuesthatarise;
3.1.9.1.4 Ensure that LDH staff with appropriate expertise in clinical,
financial, data, systems, marketing, Enrollment, and quality
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management matters, are involved in the Contractor’s QAPI
program;
3.1.9.1.5 EnsurethatappropriatestafffromLDHagenciesareavailableto
assist the Contractor with care and service coordination
activities;
3.1.9.1.6 Makebesteffortstoresolveanyissuesidentifiedeitherbythe
Contractor or LDH that may arise that are applicable to the
Contract;
3.1.9.1.7 InformtheContractorofanydiscretionaryactionbyLDHunder
theprovisionsoftheContract;and
3.1.9.1.8 Reviewandapproveinwriting:

3.1.9.1.8.1 TransitionWorkPlan;
3.1.9.1.8.2 Remedyplan;
3.1.9.1.8.3 Keypersonnelandstaffingplan;
3.1.9.1.8.4 Materialsubcontracts;
3.1.9.1.8.5 Performancereviewpolicies, procedures and
workplan;
3.1.9.1.8.6 PCPAutomaticAssignmentmethodology;
3.1.9.1.8.7 Materialchangeinprovidernetwork;
3.1.9.1.8.8 Providerhandbook;
3.1.9.1.8.9 Providertrainingmanualandschedule;
3.1.9.1.8.10 Tentative prescriber training and education
scheduleorplan;
3.1.9.1.8.11 Utilizationmanagementreports;
3.1.9.1.8.12 Planforlong‐termstaysinEDs;
3.1.9.1.8.13 Press or media events/activities or activities
thatincludesponsorship;
3.1.9.1.8.14 Telephonehelplinepoliciesandprocedures;
3.1.9.1.8.15 Callcenterqualitycriteriaandprotocols;
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3.1.9.1.8.16 Qualitydeficiencieswhichresultinsuspension
or termination of a Network
Provider/subcontractor(s);
3.1.9.1.8.17 QAPIprogramdescription;
3.1.9.1.8.18 Internalclaimsdisputeprocess;
3.1.9.1.8.19 ClaimsPaymentAccuracyPercentageReport;
3.1.9.1.8.20 PharmacyBenefitsManager(PBM);
3.1.9.1.8.21 Correctiveactionplans;
3.1.9.1.8.22 Systemupdateand/orchangerevisions;
3.1.9.1.8.23 SystemsRefreshPlan;
3.1.9.1.8.24 InformationSecurityPlan;
3.1.9.1.8.25 Fraud,Waste,andAbuseCompliancePlan;
3.1.9.1.8.26 VBPStrategicPlan;
3.1.9.1.8.27 TurnoverPlan;
3.1.9.1.8.28 TurnoverResultsreport;
3.1.9.1.8.29 Insurancepolicies;
3.1.9.1.8.30 Reinsuranceagreements;
3.1.9.1.8.31 ContinuityofOperationsPlan;
3.1.9.1.8.32 Requests for exemptions to requirements as
allowedbythisContract;and
3.1.9.1.8.33 Other deliverables and information as
requiredintheContractandMCOManual.
3.1.9.2 IfLDHdeterminesthattheContractorisinviolationofanyofthetermsofthe
Contractstatedherein,atitssolediscretion,itmayapplyone(1)ormoreof
the actions provided in the Contract Non‐Compliance section, including
terminationoftheContract;provided,however,thatLDHshallonlyimpose
those actions that it determines to be reasonable and appropriateforthe
specificviolation(s)identified.
3.1.9.3 LDHshallnotifytheContractor,aspromptlyasispracticable,ofanyproviders
suspended or terminated from participation in the Louisiana Medicaid
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ProgramsothattheContractormaytakeactiontoremovesuchproviderfrom
theirprovidernetwork.
3.1.10 DataSharing
LDHshallshareavailablepublichealthdataonEnrolleeswiththeContractorincluding,
butnotlimitedto,thefollowing:
3.1.10.1 ImmunizationdataforEnrolleesthroughthemonthoftheirtwenty‐first(21st)
birthday;and
3.1.10.2 Vitalrecordsdata.
3.1.11 CoordinationofBenefits
3.1.11.1 LDHoritscontractorshallprovidetheContractorwithallthird‐partyhealth
insuranceinformationonEnrolleeswhenithasverifiedthatthirdpartyhealth
insuranceexists.
3.1.11.2 WhenLDHhasknowledgethatanEnrolleehasbeeninvolvedinanaccidentor
hashadatraumaticeventandaliablethirdpartymightexist,LDHshallnotify
theContractorandprovidetheEnrollee’snameandpertinentinformation.
3.1.11.3 LDH shall develop base CapitationRatesthatarenetofexpected TPL
recoveries,consistentwiththeContractor’sobligationunderthisContract,to
recoverclaimspaidtoproviderswhenathird‐partywastheprimaryinsurer.
3.1.12 Enrollment,Assignment,andDisenrollmentProcess
3.1.12.1 EnrollmentVerification
LDHshallverifyandinformtheContractorofeachEnrollee’seligibility and
EnrollmentstatuswiththeContractorthroughtheState’selectroniceligibility
systemsandthroughtheASCX12N834OutboundEnrollmentfile.
3.1.12.2 Enrollment
LDHshall:
3.1.12.2.1 Maintainsole responsibility fortheEnrollment of Beneficiaries
withtheContractor,asdescribedintheEligibilityandEnrollment
section. LDH shall present all options available to its Enrollees
under theLouisiana Medicaid Program in anunbiasedmanner
andshallinformeachEnrolleeatthetimeofEnrollmentoftheir
righttoterminateEnrollmentatanytime;
3.1.12.2.2 MakeavailabletotheContractoreachBusinessDay,viatheASC
X12N834OutboundDailyEnrollmentfile,informationpertaining
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to all Enrollments, including the Effective Date of Enrollment,
whichshallbeupdatedeachBusinessDay;
3.1.12.2.3 At its discretion, automatically reenroll on a prospective basis
withthe Contractor, Enrollees who were disenrolled from the
Contractor due to loss of eligibility and whose eligibility was
reestablishedbyLDH;
3.1.12.2.4 Atitsdiscretion,automaticallyassignPotentialEnrolleestothe
Contractor based on a methodology defined by LDH; no
Automatic Assignments shall occur once the Contractor’s
Enrollment capacity reaches ninety‐five (95%) or if thirty‐five
(35%)ormoreofthetotalManagedCareProgrameligible
populationisenrolledwiththeContractor;
3.1.12.2.5 Make best efforts to provide the Contractor with the most
current demographic information available to LDH. Such
demographic data shall include, when available to LDH, the
Enrollee’s name, address, Louisiana Medicaid identification
number, date of birth, telephone number, race, gender,
ethnicity,andprimarylanguage;and
3.1.12.2.6 ReviewandrespondtowrittencomplaintsfromtheContractor
abouttheEnrollmentBrokerwithinareasonabletime.LDHmay
requestadditionalinformationfromtheContractorinorderto
performanysuchreview.
3.1.12.3 AutomaticAssignment
3.1.12.3.1 LDH shall auto‐assign Potential Enrollees who do not request
EnrollmentinaspecifiedMCOatthetimeoffinancialapplication
fortheLouisianaMedicaidProgramorthroughthehelpofthe
EnrollmentBroker,orwhocannotbeenrolledintotherequested
MCO for reasons including, but not limited to, the requested
MCOhavingreacheditsEnrollmentcapacitylimitorasaresultof
LDH‐initiated sanctions. As specified in the Eligibility and
Enrollment section,EnrolleeswhofailtoselectanewMCO
duringtheirEnrollmentperiodshallremainenrolledwith their
existing MCO. These Enrollees shall not be subject to the
AutomaticAssignmentprocess.
3.1.12.3.2 Inaccordancewith42C.F.R.§438.54theAutomaticAssignment
methodologyshallseektopreserveexistingProvider‐Beneficiary
Relationships during the previous year and relationships with
providers that have traditionally served Beneficiaries. After
consideration of Provider‐Beneficiary Relationships, the
methodologyshallassignBeneficiaries equitablyamongMCOs,
excludingthosesubjecttotheintermediatesanctiondescribed
in42C.F.R.§438.702(a)(4).
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3.1.12.3.3 IftheContractorisnoncompliantwiththetermsofthisContract,
LDHmayexcludetheContractorfromanyorallcomponentsof
Automatic Assignment until the defect is cured to LDH’s
satisfaction. LDH shall have sole discretion to determine
compliancewithallsuchrequirementsandtodefinetheperiod
ofexclusion.LDHmaymakesuchdeterminationonacase‐by‐
casebasisandfailuretoexcludeanMCOfromAutomatic
Assignment or to take any other punitive action shall not
constituteratificationorapprovalofsuchnoncompliance.
3.1.12.3.4 TheAutomaticAssignmentmethodologyforallpopulationsshall
bebasedonthefollowinghierarchy:
3.1.12.3.4.1 IftheEnrolleehasmadeapriorMCOselection
atthetimeoftheLouisianaMedicaidProgram
application, the Enrollee shall be enrolled in
thatMCO.
3.1.12.3.4.2 IftheEnrolleehasacurrentDCFSsegment,the
Enrollee shall follow the DCFS Automatic
Assignmentprocess.
3.1.12.3.4.3 TheEnrollmentBrokershallseek topreserve
existing Provider‐Beneficiary Relationships. If
the Enrollee has had a relationship in the
previoustwelve(12)monthswithaprovider
assigned to an MCO, the Enrollee shall be
assignedtothatMCO.
IftheproviderisinmultipleMCO
networks, and if the Enrollee has
householdEnrolleesenrolledinanMCO,
theEnrolleewillbeassignedtothatMCO.
IfmultipleMCOlinkagesexistwithinthe
household,theEnrolleeshallbeassigned
to the MCO of the youngest household
Enrollee.
IfthereisnoMCOrelationshipwithinthe
household, the Beneficiary shall be
assigned to the MCO in which the
provider participates with the lowest
AutomaticAssignmentenrollments.
3.1.12.3.4.4 IfMCOassignmentcannotbemadebasedon
existing Provider‐Beneficiary Relationships,
and if the Enrollee has household Enrollees
enrolled in an MCO, the Enrollee shall be
Page312of381
enrolledinthatMCO.IfmultipleMCOlinkages
existwithinthehousehold,theEnrollee shall
be enrolled to the MCO of the youngest
householdEnrollee.
3.1.12.3.4.5 Ifthereisnopreviousproviderrelationship,
the Enrollment Broker shall seek to preserve
priorMCOrelationshipswithinthepastsix(6)
months.IfaMCOrelationshipisidentified,the
Beneficiary shall be assigned to the most
recentMCO.
3.1.12.3.4.6 IfthereisnopreviousMCOrelationship,the
EnrollmentBrokershallusearoundrobin
methodtodeterminetheMCOassignment.
3.1.12.3.4.7 If an MCO’s membership is comprised of
thirty‐five percent (35%) or more of total
statewide membership at the end of any
quarter, the MCO will be removed from the
AutomaticAssignmentroundrobinprocessfor
the following quarter, but Enrollees can
continuetoproactivelyselectthatMCO.
3.1.12.3.4.8 Inaddition,theContractor’squalitymeasures
maybefactoredintothealgorithmfor
Automatic Assignment, at the discretion of
LDH.
3.1.12.3.5 LDHreservestherighttoadjusttheAutomaticAssignment
algorithmtoassignsufficientEnrolleestosupporttheviabilityof
a new MCO. This may include, but is not limited to, the
elimination of MCO linkages established under a previous
contract.
3.1.12.3.6 LDH reserves the right to exclude the Contractor from the
AutomaticAssignmentprocesswithinthree(3)monthspriorto
any termination of the Contract whether initiated by the
Contractor, whether initiated by LDH, or whether at the
expirationoftheContracttermandanyextensions.
3.1.12.4 Disenrollment
3.1.12.4.1 DisenrollmentConditions
LDHshalldisenrollanEnrolleefromtheMCOandheorsheshallno
longerbeeligibleforservicesundertheMCOfollowing:
3.1.12.4.1.1 LossofLouisianaMedicaidProgrameligibility;
Page313of381
3.1.12.4.1.2 Completion of the Enrollee’s voluntary
Disenrollmentrequest;
3.1.12.4.1.3 LDHapprovalinwritingofarequestbythe
Contractorforinvoluntarytermination;or
3.1.12.4.1.4 Loss of eligibility for the Managed Care
Program.
3.1.12.4.2 Exceptasotherwise providedunder Federal lawor Waiver, an
Enrolleemaydisenrollvoluntarily:
3.1.12.4.2.1 Forcause,atanytime,inaccordancewith42
C.F.R.§438.56(d);
3.1.12.4.2.2 Without cause when the Contractor
repeatedly fails to meet substantive
requirementsin Sections1903(m) or1932 of
theSocialSecurityActor42C.F.R.§438;and
3.1.12.4.2.3 Without cause, at any time during an
Enrollmentperiod.
3.1.12.4.3 DisenrollmentInformation
LDHshall:
3.1.12.4.3.1 Make available to the Contractor each
BusinessDay,viatheASCX12N834Outbound
Enrollment File, information pertaining to all
Disenrollments,includingtheeffectivedateof
Disenrollment and the Disenrollment reason
code;and
3.1.12.4.3.2 Provide the Contractor with information
related to the reason for voluntary
Disenrollment as received from Enrollees via
the State’s Enrollment Broker, on a monthly
basis.
3.1.12.5 EnrollmentBroker
LDHoritsdesigneeshall:
3.1.12.5.1 DevelopgenericmaterialstoassistEnrolleesinchoosingwhether
toenrollintheMCO.SaidmaterialsshallpresenttheMCOinan
unbiased manner to Potential Enrollees. LDH may collaborate
withtheContractorindevelopingMCO‐specificmaterials;
Page314of381
3.1.12.5.2 PresenttheMCO inanunbiasedmannertoEnrolleeswhoare
newlyeligibleformanagedcareorseekingtotransferfromone
MCO to another MCO. Such presentation(s) shall ensure that
Enrolleesareinformedpriortoenrollmentofthefollowing:
3.1.12.5.2.1 The nature of the requirements of
participation in an MCO, including but not
limitedto:
UseofNetworkProviders;
Maintenance of existing relationships
withNetworkProviders;and
TheimportanceofPrimaryCare;
3.1.12.5.2.2 ThenatureoftheContractor'sdeliverysystem,
including,butnotlimitedtotheProvider
Network,abilitytoaccommodatenon‐English‐
speaking Enrollees, referral system, and
requirements and rules which Enrollees shall
followonceenrolledintheContractor;and
3.1.12.5.2.3 OrientationandotherEnrolleeservicesmade
availablebytheContractor.
3.1.12.5.3 Enroll,disenroll,andprocesstransferrequestsofEnrolleesinthe
Contractor, including completion of LDH’s Enrollment and
Disenrollment forms, except Enrollment forms for newborn
Enrollees;
3.1.12.5.4 EnsurethatEnrolleesareinformedatthetimeofEnrollmentor
transferoftheirrighttoterminatetheirEnrollmentvoluntarilyat
anytime,unlessotherwiseprovidedbyFederallaworWaiver;
3.1.12.5.5 BeknowledgeableabouttheContractor’spolicies,services,and
procedures;
3.1.12.5.6 At its discretion, develop and implement processes and
standards to measure and improve the performance of the
EnrollmentBrokerstaff;and
3.1.12.5.7 Include all contracted MCOs in all LDH‐sponsored Enrollment
activities.
3.1.13 Marketing
3.1.13.1 LDH shall monitor the Contractor’s marketing activities and distribution of
relatedmaterials.
Page315of381
3.1.13.2 Withinthirty(30)CalendarDaysofreceiptofmarketingmaterialsubmittedby
theContractor in compliance withthe Enrollee ServicesandMarketingand
Educationsection,LDHshalltakeoneofthefollowingactions:
3.1.13.2.1 Approveordisapprovethemarketingmaterial;
3.1.13.2.2 Requiremodificationtothemarketingmaterial;or
3.1.13.2.3 NotifytheContractorthatLDHrequiresanadditionalten(10)
Business Days from the date of such notification to take the
actionsdescribedabove.
3.1.13.3 TheContractorshallcomplywithanysuchLDHaction.
3.1.13.4 LDH’sfailuretotakeanyoftheactionsdescribedabovewithin thirty (30)
Calendar Days after receipt of the Contractor’s marketing material shall be
deemedtoconstituteapprovalofsaidmarketingmaterial.
3.1.13.5 IfLDHhasnotifiedtheContractorthatanadditionalten(10)BusinessDaysis
required,LDH’sfailuretotakeapprove,disapprove,orrequiremodificationin
writingofthemarketingmaterialbytheendofthisten(10)Business Day
periodshallbedeemedtoconstituteapprovalofthemarketingmaterial,
3.1.13.6 LDH’s failure to respond within ten (10) Business Days of receipt of
modificationstomarketingmaterialssubmittedtoLDHpursuanttotheabove
shallbedeemedtoconstituteapprovalofthemarketingmaterial.
3.1.14 AdditionalEnrolleeGroupsandCoveredServices
LDHmay:
3.1.14.1 Add,deleteorotherwisechangemandatory,voluntaryopt‐out,voluntaryopt‐
inandexcludedpopulationgroupstotheContract,withsixty(60)Calendar
DaysadvancenoticetotheContractor,whenpossible;
3.1.14.2 Developandimplementthenecessaryprocessesandproceduresrequiredto
implementEnrollmentofadditionalEnrolleegroups,as furtherspecifiedby
LDH;
3.1.14.3 Amend Medicaid Covered Services and modify the Contractor’s covered
servicesrequired,includingaddingcoveredservicesconsistentwiththeState
Plan,Waiverorotherrequiredstateauthorities;
3.1.14.4 Developreimbursementrate(s)thataccountfortheabovechangestoEnrollee
groupsorcoveredservicesconsistentwithstateandfederalauthorities as
applicable;and
3.1.14.5 Develop,incooperationwiththeContractor,animplementationstrategyfor
providingservicestoEnrollees.
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3.1.15 HealthNeedsAssessmentInstrument(HNA)
3.1.15.1 LDHshallprovidetheContractorwiththeHNAinstrument,whichshallinclude
theminimumnecessarysetofquestionstoidentifyanEnrolleeaspotentially
requiring case management support. The HNA will aim to identify physical,
behavioralandSDOHriskfactors.TherequiredHNAmaynotbemodified,but
therewillbeoptionalscreeningdomainsthattheMCOsmayadd,subjectto
LDHapproval.
3.1.15.2 HNAquestionsshallinclude:
3.1.15.2.1 Enrollee demographics, personal health history, including
chronic conditions and previous and current treatment for
physical and behavioral health care needs, and self‐perceived
healthstatus;
3.1.15.2.2 Questions to identify Enrollees’ needs for culturally and
linguistically appropriate services including, but not limited to,
hearingandvisionimpairmentandlanguagepreference;
3.1.15.2.3 QuestionstoidentifytheEnrollee’shealthconcernsandgoals;
3.1.15.2.4 Questionstoidentifypotentialgapsincare;and
3.1.15.2.5 Questions to identify Enrollees’ health‐related social needs,
including housing, food insecurity, physical safety, and
transportation.
ContractNon‐Compliance
WhenLDHidentifiesthattheContractorisnotcompliantwiththetermsofthecontract,LDHmay
pursueadministrativeactions,CorrectiveActionPlans,MonetaryPenalties,intermediatesanctions,
and/orcontracttermination.
3.2.1 AdministrativeActions
3.2.1.1 Administrativeactions exclude MonetaryPenalties,Corrective ActionPlans,
intermediate sanctions and Contract termination and include, but are not
limitedto:
3.2.1.1.1 Awarningthroughwrittennoticeorconsultation;
3.2.1.1.2 Education requirement regarding program policies and
procedures;
3.2.1.1.3 ReviewoftheContractor’sbusinessprocesses;
3.2.1.1.4 ReferraltotheLouisianaDepartmentofInsurancefor
investigation;
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3.2.1.1.5 Referralforreviewbyappropriateprofessionalorganizations;
3.2.1.1.6 Referral to the Office of the Attorney General for Fraud
investigation;and/or
3.2.1.1.7 Exclusion from Automatic Assignment – LDH may exclude the
Contractor from any or all components of the Automatic
Assignment process described in the State Responsibilities,
Contract Management section for the duration of the
noncompliance.Duringthisperiodofexclusion,Enrolleesshallbe
automatically assigned under the terms of the State
Responsibilities,ContractManagementsectionasiftheexcluded
MCO were not a participant in the assignment process. Upon
determining that the noncompliance has been satisfactorily
curedandthethirty(30)CalendarDayminimumexclusionperiod
has lapsed, LDH shall return the Contractor to the Automatic
Assignmentprocessbutshallnottakeanyactiontoreturnthe
Contractortothepositionitwouldhavebeeninhaditnotbeen
excluded.
3.2.2 CorrectiveActionPlans
3.2.2.1 LDHmayrequiretheContractortodevelopaCorrectiveActionPlan(CAP)that
includesthestepstobetakenbytheContractortoobtaincompliancewiththe
termsoftheContract.ACAPisnotrequiredbeforeLDHmaypursue the
applicationofanyothernon‐complianceactionauthorizedintheContract.
3.2.2.2 LDHshallapproveandmonitorimplementationoftheCAPthroughavailable
reportingresources,on‐siteevaluations,orrequestedstatusreports.
3.2.2.3 The CAP shall include a timeframe for anticipated compliance and a date
certainforthecorrectionofthenon‐compliance.
3.2.2.4 LDH may impose Monetary Penalties if the terms of the CAP are not met.
Monetary Penalties shall continue until satisfactory correction of the non‐
compliancehasbeenmadeasdeterminedbyLDH.
3.2.3 MonetaryPenalties
3.2.3.1 GeneralInformation
3.2.3.1.1 Failure to comply with the requirements and performance
standardssetforthinthisContractmayresultintheassessment
ofaMonetaryPenaltyperincidentand/orperCalendarDayof
non‐compliance. Determinations of non‐compliance may be
based on findings from a review of deliverables, Enrollee or
provider complaints, or any other reliable source at the sole
discretionofLDH.
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3.2.3.1.2 ThepurposeofestablishingandimposingMonetaryPenaltiesis
toprovideameansforLDHtoobtaintheservicesandlevelof
performancerequiredforsuccessfuloperationoftheContract.
LDH’sfailuretoassessMonetaryPenaltiesinoneormoreofthe
particularinstancesdescribedhereinshallnotwaivetherightof
LDHtoassessMonetaryPenaltiesoractualdamagesinthe
future.
3.2.3.1.3 For purposes of this section, violations involving individual,
unrelatedactsshallnotbeconsideredasarisingoutofthesame
action.
3.2.3.1.4 AttachmentG,TableofMonetaryPenaltiesspecifiespermissible
MonetaryPenaltiesforcertainviolationsoftheContract.Forany
violationnotexplicitlydescribedinthetable,LDHmayimposea
Monetary Penalty of up to five thousand dollars ($5,000) per
occurrenceand/orperCalendarDay.
3.2.3.1.5 LDH may, at its sole discretion, make a claim against the
performancebondtosatisfyMonetaryPenaltiesimposedafter
contracttermination.
3.2.3.2 NoticesofActionandMonetaryPenalty
3.2.3.2.1 LDH may first notify the Contractor of incidents of non‐
complianceandofLDH’sauthoritytoimposeaMonetaryPenalty
viaaNoticeofAction(NOA).TheNOAwillincludethebasisand
nature of the violation, the relevant contract sections and/or
provisionsoflaw,thedeadlinetocuretheviolation,ifapplicable,
andthemethodologyforcalculationofanyMonetaryPenaltyif
the violation is not cured by the established deadline, if
applicable.
3.2.3.2.2 MonetaryPenalties maybe assessed againstthe Contractor at
the sole discretion of LDH, regardless of whether an NOA is
issued. LDH will notify the Contractor of the assessment of
MonetaryPenaltiesviaaNoticeofMonetaryPenalty(NOMP).
3.2.3.2.3 LDHmayrequire theContractorto provideawritten response
withadetailedexplanationofthereasonsfortheviolation,the
Contractor’s assessment or diagnosis of the cause, and
Contractor’s plan to address or cure the deficiency within the
timeframesetforthintheNOAorNOMP.
3.2.3.2.4 Repeateddeficienciesortherepeatedfailuretoresolveanysuch
deficienciesmayentitleLDHtopursueanyotherremedy
providedintheContractoranyotherappropriateremedyLDH
mayhaveatlaw.
Page319of381
3.2.3.2.5 Atanytimeandatitssolediscretion,LDHmayimposeorpursue
oneormoreremediesforeachitemofnoncomplianceandwill
determineappropriateremediesonacase‐by‐casebasis.
3.2.4 IntermediateSanctions
3.2.4.1 ActsorFailurestoActSubjecttoIntermediateSanctions
Pursuant to 42 C.F.R. §438.700, LDH may impose on the Contractor
intermediatesanctionsifitdeterminesthattheContractor:
3.2.4.1.1 Fails substantially to provide medically necessary services that
the Contractor is required to provide, under law or under the
Contract,toanEnrolleecoveredundertheContract;
3.2.4.1.2 ImposesonEnrolleespremiumsorchargesthatareinexcessof
the premiums or charges permitted under the Managed Care
Program;
3.2.4.1.3 ActstodiscriminateamongEnrolleesonthebasisoftheirhealth
statusorneedforhealthcareservices.Thisincludestermination
of Enrollment, refusal to reenroll an Enrollee, except as
permittedintheEligibilityandEnrollmentsection,oranypractice
thatwouldreasonablybeexpectedtodiscourageEnrollmentby
Beneficiaries whose medical condition or history indicates
probableneedforsubstantialfuturemedicalservices;
3.2.4.1.4 MisrepresentsorfalsifiesinformationthatitfurnishestoCMSor
toLDH;
3.2.4.1.5 Misrepresents or falsifies information that it furnishes to an
Enrollee,PotentialEnrollee,orahealthcareprovider;
3.2.4.1.6 Fails to comply with the requirements for physician incentive
plans,assetforthin42C.F.R.§438.3(i),§422.208,and§422.210;
3.2.4.1.7 Distributes directly, or indirectly through any agent or
independentcontractor,marketingmaterialsthathavenotbeen
approvedbyLDHinwritingorthatcontainfalseormaterially
misleadinginformation;or
3.2.4.1.8 Violates any of the other applicable requirements of 42 U.S.C.
§1396b(m), §1396d(t)(3), or §1396u‐2 and any implementing
regulations.
3.2.4.2 OtherMisconductSubjecttoIntermediateSanctions
LDHalsomayimposesanctionsagainsttheContractorifitfinds anyof the
followingnon‐exclusiveactions/occurrences:
Page320of381
3.2.4.2.1 TheContractorhasfailedtocorrectdeficienciesinitsdeliveryof
serviceafterhavingreceivedwrittennoticeofthesedeficiencies
fromLDH;
3.2.4.2.2 TheContractorhasbeenexcludedfromparticipationinMedicare
because of fraudulent or abusive practices pursuant to the
Medicare‐Medicaid Anti‐Fraud and Abuse Amendments, Public
Law95‐142;
3.2.4.2.3 TheContractororanyofitsowners,officersordirectorshasbeen
convicted of a criminal offense relating to performance of the
Contract with LDH or of fraudulent billing practices or of
negligentpracticeresultingindeathorinjurytotheContractor’s
Enrollee;
3.2.4.2.4 TheContractor has presented, or has caused to be presented,
anyfalseorfraudulentclaimforservicesorhassubmitted,orhas
causedtobesubmitted,falseinformationtobefurnishedtothe
StateortheSecretaryofthefederalDepartmentofHealthand
HumanServices;
3.2.4.2.5 TheContractorhasengagedina practice of charging and
acceptingpayment(inwholeorpart)fromEnrolleesforservices
forwhichaPMPMpaymentwasmadebyLDH;
3.2.4.2.6 TheContractorhasrebatedoracceptedafeeorportionoffeeor
chargeforapatientreferral;
3.2.4.2.7 TheContractorhasfailedtorepayormakearrangementsforthe
repayment ofidentifiedoverpayments or otherwiseerroneous
payments;
3.2.4.2.8 TheContractorhasfailedtokeepormakeavailablefor
inspection, audit or copying, such records regarding payments
claimedforprovidingservices;
3.2.4.2.9 TheContractorhasfailedtofurnishanyinformationrequested
byLDHregardingpaymentsforprovidinggoodsorservices;
3.2.4.2.10 TheContractorhasmade,orcausedtobemade,anyfalse
statementorrepresentationofamaterialfacttoLDHorCMSin
connectionwiththeadministrationoftheContract;or
3.2.4.2.11 TheContractor has furnished goods or services to an Enrollee
which at the sole discretion of LDH, and based on competent
medical judgment and evaluation are determined to be 1)
insufficientforhisorherneeds,2)harmfultotheEnrollee,or3)
ofgrosslyinferiorquality.
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3.2.4.3 SanctionTypes
ThetypesofintermediatesanctionsthatLDHmayimposeontheContractor
shallbeinaccordancewithAct(42U.S.C.§1396u‐2)and42C.F.R.§438.702
through§438.708andmayincludeanyofthefollowing:
3.2.4.3.1 Civil Monetary Penalties in the amounts specified in 42 C.F.R.
§438.704;
3.2.4.3.2 AppointmentoftemporarymanagementforanMCOasprovided
in42C.F.R.§438.706;
3.2.4.3.3 Granting Enrollees the right to terminate Enrollment without
cause and notifying the affected Enrollees of their right to
disenroll;
3.2.4.3.4 Suspension of all new Enrollments, including Automatic
Assignment,aftertheeffectivedateofthesanctionandfora
timeperioddeterminedbyLDH;
3.2.4.3.5 SuspensionofpaymentforEnrolleesenrolledaftertheeffective
dateofthesanction anduntilCMSor LDHis satisfiedthat the
reasonforimpositionofthesanctionnolongerexistsandisnot
likelytorecur;and
3.2.4.3.6 AdditionalsanctionsallowedunderStatelaws,regulations,rules,
and policies that address areas of noncompliance described
above.
3.2.4.3.7 LDHmayrequiretheContractortodevelopaCorrectiveAction
Plan,asdescribedinthissection,toaddressareasofnon‐
compliancesubjecttointermediatesanctions.
3.2.4.3.8 Except as provided in this section, before imposing any
intermediate sanctions, LDH shall give the Contractor Timely
writtennoticethatexplainsthebasisandnatureofthesanction
andanyotherdueprocessprotections.
3.2.4.4 NoticetoCMS
LDHshallgivetheCMSRegionalOfficewrittennoticewheneveritimposesor
lifts an intermediate sanction for one of the violations listed in 42 C.F.R.
§438.700,specifyingtheaffectedMCO,thekindofsanction,andthereason
forLDH’sdecisiontoimposeorliftasanction. Noticewillbegivennolater
thanthirty(30)CalendarDaysafterLDHimposesorliftsthesanction.
3.2.5 DisputesandAppeals
Page322of381
3.2.5.1 IfLDHchoosestonotifytheContractorofincidentsofnon‐complianceandof
LDH’sauthoritytoimposeaMonetaryPenaltyorotheradministrativeaction
viaaNOApriortoassessingthepenaltyoraction,theContractormaydispute
infractionscontainedwithintheNOAthroughthefollowingprocess:
3.2.5.1.1 Withinfourteen(14)CalendarDaysafterreceiptoftheNOA,the
ContractorshallsubmititsdisputeoftheNOAdirectlytothe
Medicaid Deputy Director or his/her designee in writing via e‐
mail;thissubmissionshallincludeallarguments,materials,data,
andinformationnecessarytoresolvethedispute.
3.2.5.1.2 TheContractorshallwaiveanydisputeorargumentnotraised
withinfourteen(14)CalendarDaysofreceivingtheNOA.The
Contractorshallalsowaivetherighttouseanymaterials,data,
and/or information not contained in or accompanying the
Contractor’s submission submitted within the fourteen (14)
CalendarDaysfollowingitsreceiptoftheNOAinanysubsequent
NOMP issued should the Contractor fail to demonstrate
complianceasstatedintheNOA.
3.2.5.1.3 TheMedicaidDeputyDirectororhis/herdesigneewilldecidethe
dispute,reducethedecisiontowriting,andprovideacopytothe
Contractor.Thiswrittendecisionwillbefinal.
3.2.5.2 ToappealtheassessmentofaMonetaryPenaltyorintermediatesanction:
3.2.5.2.1 Withinseven(7)BusinessDaysofreceiptoftheNOMP,the
ContractorshallsubmititsappealinwritingtotheMedicaid
Deputy Director or his/her designee.LDHwillissueawritten
decisionwithinfifteen(15)BusinessDaysoftheappeal.
3.2.5.2.2 Withinfive(5)BusinessDaysofreceiptofLDH’swrittendecision,
theContractormayrequestreconsiderationofthedecisionin
writing to the Medicaid Executive Director. The Medicaid
ExecutiveDirectorshallissueawrittenopinionwithinthirty(30)
CalendarDays.NofurtherappealstoLDHshallbeallowed.
3.2.6 PaymentofMonetaryPenaltiesandIntermediateSanctions
3.2.6.1 MonetaryPenaltiesorintermediatesanctionsassessedbyLDHthatcannotbe
collectedthroughthecapitatedpaymentdeductionspecifiedinthePayment
andFinancialProvisions,ReturnofFundssectionshallbedueandpayableto
LDHwithinthirty(30)CalendarDaysaftertheContractor’sreceipt of the
noticeofMonetaryPenaltiesorsanctions.
3.2.6.2 TheassessmentofMonetaryPenaltiesorintermediatesanctionsshallnotbe
halted by the disputes and appeals process. In the event an appeal by the
ContractorresultsinadecisioninfavoroftheContractor,thepenalty/sanction
amountspecifiedinthedecisionshallbereturnedtotheContractor.
Page323of381
3.2.6.3 LDH has the right to recovery of any amounts overpaid as the result of
deceptive practices by the Contractor and/or its subcontractors, and may
considertrebleddamages,civilpenalties,and/orotherremedialmeasures.
3.2.6.4 AMonetaryPenaltyorsanctionmaybeappliedtoallknownAffiliates,
subsidiaries and parents of the Contractor, provided that each decision to
includeanAffiliateismadeonacase‐by‐casebasisaftergivingdueregardto
allrelevantfactsandcircumstances.Theviolation,failure,orinadequacyof
performance may be imputed to a person with whom the Contractoris
affiliatedwhensuchconductwasaccomplishedwithinthecourseofhisofficial
duty or was effectuated by him with the knowledge or approval of such
person.
3.2.7 TerminationofMCOContract
3.2.7.1 NothinginthisSectionshalllimitLDH’srighttoterminatetheContractorto
pursueanyotherlegalorequitableremedies.
3.2.7.2 Pursuantto42C.F.R.§438.708,LDHmayterminatetheContractandenroll
thatContractor’sEnrolleesinotherMCOsorprovidetheirbenefitsthrough
otheroptionsincludedintheStatePlanifLDH,atitssolediscretion,
determines that the Contractor has failed to: (1) carry out the substantive
termsoftheContract,or(2)meetapplicablerequirementsin42 U.S.C.
§1396b(m),§1396d(t),or§1396u‐2.
3.2.7.3 LDH shall provide the Contractor with a Timely written Notice of Intent to
Terminate(Notice)thatstatesthenatureandbasisoftheterminationandpre‐
terminationhearingrights.
3.2.7.4 Theterminationshallbeeffectivenolessthanthirty(30)CalendarDaysfrom
the date of the Notice of Intent to Terminate. The Contractor may, at the
discretionofLDH,beallowedtocorrectthedeficiencieswithinthethirty(30)
CalendarDay notice period, unlessotherprovisions inthis Section demand
otherwise,priortotheissuanceofaNoticeofTermination.
3.2.7.5 Inaccordancewith42C.F.R.§438.710,LDHshallconductapre‐termination
hearingasoutlinedintheNoticeofIntenttoTerminatetoprovide the
Contractortheopportunitytocontestthenatureandbasisofthesanction.
3.2.7.6 The Contractor shall receive a written notice of the outcome ofthepre‐
terminationhearing,ifapplicable,indicatingdecisionreversaloraffirmation.
3.2.7.7 ThedecisionbytheLDHUndersecretaryshallbefinalandtheAdministrative
Procedure Act, La. R.S. 49:950, et seq., does not apply. The Notice of
Terminationwillstatetheeffectivedateoftermination.
3.2.7.8 LDHshallnotifytheEnrolleesenrolledintheContractorinwriting,consistent
with42C.F.R.§438.710and§438.722,oftheaffirmingterminationdecision
Page324of381
andoftheiroptionsforreceivingMedicaidCoveredServicesandtheirrightto
disenrollimmediatelywithoutcause.
3.2.8 PaymentofOutstandingMoniesorCollectionsfromMCO
TheContractorshallbepaidforanyoutstandingmoniesduelessanyassessedMonetary
Penaltiesorsanctions.IfMonetaryPenaltiesexceedmoniesdue,collectionmaybemade
fromtheContractorFidelityBond,PerformanceBond,Retainage,ErrorsandOmissions
Insurance,oranyinsurancepolicyorpoliciesrequiredunderthisContract.Therightsand
remediesprovidedinthisclauseshallnotbeexclusiveandareinadditiontoanyother
rightsandremediesprovidedbylaworunderthisContract.
3.2.9 ProviderSanctions
NothingcontainedhereinshallprohibitLDHfromimposingsanctions,including,butnot
limitedto,civilMonetaryPenalties,licenserevocation,andLouisianaMedicaidProgram
termination,uponahealthcareproviderforitsviolationsofFederalorStatelaw,rule,or
regulations.
3.2.10 IndependentAssurances
3.2.10.1 When required by LDH, the Contractor shall provide a quality control plan,
such as third party Quality Assurance (QA), Independent Verification and
Validation(IV&V),andotherinternalproject/programreviewsandaudits.
3.2.10.2 TheseauditsshallrequiretheContractortoprovideanyassistance,records
access,informationsystemaccess,staffaccess,andspaceaccesstotheparty
selectedtoperformtheindependentaudit.Theauditfirmwillsubmittothe
Departmentand/orContractorafinalreportoncontrolsplacedinoperations
fortheprojectandincludesadetaileddescriptionoftheauditfirm’stestsof
theoperatingeffectivenessofcontrols.
3.2.10.3 TheContractorshallsupplytheLDHwithanexactcopyofthereportwithin
thirty(30)CalendarDaysofcompletion.WhenrequiredbyLDH,suchaudits
maybeperformedannuallyduringthetermoftheContract.TheContractor
shallagreetoimplementrecommendationsassuggestedbytheauditswithin
three(3)monthsofreportissuanceatnocosttotheState.Thecostofthe
auditistobebornebytheContractor.
Page325of381
PART4: PAYMENTANDFINANCIALPROVISIONS
CapitatedPayments
4.1.1 LDHshallmakemonthlyCapitationPaymentstoeachMCObasedonitsEnrollmentfor
themonth.
4.1.2 EnrollmentforthemonthisdeterminedbythetotalnumberofEnrolleeslinkedtothe
MCOasofthefirst(1
st
)CalendarDayofthemonth,withCapitationPaymentsdueinthe
followingmonth.Foragegroupassignmentpurposes,ageshallbedeterminedasofthe
first(1
st
)CalendarDayofthemonthforwhichthepaymentisintended.
4.1.3 LDH may make Capitation Payments on a lump sum basis when administratively
necessary.
MaternityKickPayments
4.2.1 LDHshallprovidetheContractorwithaone‐timesupplementallumpsumpaymentfor
eachobstetricaldelivery.ThismaternityKickPaymentisintendedtocoverthecostof
prenatalcare,thedeliveryevent,postpartumcare,anduncomplicatednewbornhospital
costs.
4.2.2 MaternityKickPaymentsmaybedifferentiatedbetweenearlyelectivedeliveryevents
(deliveriesoccurringbeforethirty‐nine(39)weekswithoutamedicalindication)andall
otherdeliveryevents.TheamountofmaternityKickPaymentsshallbedeterminedby
LDH’sactuary.
4.2.3 Onlyone(1)maternityKickPaymentshallbemadeperdeliveryevent.Multiplebirths
duringthesamedeliveryshallresultinone(1)maternityKickPaymentbeingpaid.The
maternity Kick Payment shall be paid for both live and still births. A maternity Kick
Paymentshallnotbepaidforabortionsorspontaneousabortions(asdefinedinState
law).
4.2.4 The maternity Kick Payment shall be paid to the Contractor uponsubmissionof
satisfactoryevidenceoftheoccurrenceofaqualifyingdelivery.
MCOPaymentSchedule
4.3.1 CapitatedpaymentsandmaternityKickPaymentsshallbemadeinaccordancewiththe
payment schedule established by LDH and published on the Fiscal Intermediary (FI)
website.
4.3.2 LDHreservestherighttodeferremittanceofthemonthlyCapitationPaymentscheduled
forJuneuntilthefirst(1
st
)paymentcycleinJulytocomplywithStatefiscalpoliciesand
procedures.
4.3.3 Any incentive payments made by LDH shall be made in accordance withthetimeline
establishedinApprovedIncentiveArrangementsandtheMCIPprotocol.
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FinancialIncentivesforMCOPerformance
4.4.1 MCOPerformanceWithholdAmount
4.4.1.1 LDHmaywithholdaportionoftheContractor’smonthlyCapitationPayments
to incentivize quality, health outcomes, value‐based payments, and health
equity.Thewithholdamountwillbeequaltotwopercent(2%)ofthemonthly
Capitation Payments for integrated physical and behavioral healthforall
Enrollees, exclusive of maternity Kick Payments, payments underthe
Managed Care Incentive Program, and the Full Medicaid Pricing (FMP)
componentofthemonthlyCapitationPayments.
4.4.1.2 Half of the total withhold amount (i.e., one percent (1.0%) of the monthly
CapitationPayments)shallbeconsideredthequalitywithholdandappliedto
incentivizequalityandhealthoutcomesforEnrollees.Theremaininghalfof
thetotalwithholdamount(i.e.,onepercent(1.0%)ofthemonthlyCapitation
Payment as described in 4.4.1.1.) shall be divided and allocated in equal
proportiontotheValueBasedPayment(i.e.,one‐halfpercent(0.5%)ofthe
applicable monthly Capitation Payment) and Health Equity (i.e.,one‐half
percent (0.5%) of the applicable monthly Capitation Payment) withholds,
respectively.TheValue‐BasedPayment(VBP)withholdisappliedtoincentivize
theContractor’suseandexpansionofVBParrangementswithproviders.The
HealthEquitywithholdisappliedtoincentivizetheContractor’shealthequity
strategies.
4.4.1.3 NointerestshallbeduetotheContractoronanysumswithheldorretained
underthisSection.
4.4.1.4 Thewithholdarrangementisforafixedperiodoftimeandperformanceis
measuredduringtheratingperiodunderthecontractinwhichthewithhold
arrangement is applied. Withhold arrangements shall not be renewed
automatically.Withholdarrangementsareavailabletobothpublicandprivate
contractorsunderthesametermsofperformance.Participationinwithhold
arrangementsisnotconditionedontheContractorenteringintooradhering
tointergovernmentaltransferagreements.
4.4.1.5 The withhold arrangement is necessary for the specified activities, targets,
performance measures, or quality‐based outcomes that support program
initiativesasspecifiedintheState'squalitystrategyunder42C.F.R.§438.340.
4.4.1.6 TheprovisionsofthisSectionmaybeinvokedaloneorinconjunctionwithany
other remedy or adjustment otherwise allowed under this Contract. LDH
reservestherighttoassessMonetaryPenaltiesforfailuretomeetdeliverables
asrequiredunderthisSection.
4.4.2 EarningtheQualityandHealthOutcomesWithhold
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4.4.2.1 For each Measurement Year, the Contractor may earn back the quality
withholdfortheMeasurementYearbasedonitsperformancerelative to
incentive‐basedmeasuresandtargetsasestablishedbyLDH.
4.4.2.2 Performancemeasuredescriptionsandtargetsforincentivebasedmeasures
willbespecifiedinAttachmentH,QualityPerformanceMeasures,priortothe
startoftheMeasurementYear.Incentive‐Based(IB)measuresareidentified
inAttachmentH,QualityPerformanceMeasures,annotatedwith“$$.”
4.4.2.3 Targets for Healthcare Effectiveness Data and Information Set (HEDIS®)
incentive‐based measure scores will be equal to or above the National
CommitteeforQualityAssurance(NCQA)QualityCompassMedicaidNational
50
th
percentile [All Lines of Business (LOBs) (Excluding Preferred Provider
Organizations(PPOs)andExclusiveProviderOrganizations(EPOs))]valuesfor
thepriorMeasurementYear.
4.4.2.4 TargetsforHEDIS®incentive‐basedmeasurescoreswithoutaNCQAQuality
Compass Medicaid National 50th percentile [All Lines of Business (LOBs)
(Excluding Preferred Provider Organizations (PPOs) and Exclusive Provider
Organizations(EPOs))]valuewillbeequaltothebestperformancereported
toLDHbyanyMCOforthepriormeasurementyear.
4.4.2.5 IfNCQAmakeschangestoanyofthemeasuresselectedbyLDH,such that
validcomparisontopriorMeasurementYearswillnotbepossible,orifitis
determined that a measure is not reasonably attainable, LDH, atitssole
discretion, may elect to eliminate the measure from incentive eligibility,
changetheaffectedmeasuretobereportingonly,orreplaceitwithanother
measure.
4.4.2.6 Targets for non‐HEDIS incentive‐based measures shall be equal to the best
performancereportedtoLDHbyanyMCOforthepriorMeasurementYear.
4.4.2.7 LDHshalldeterminetheamountofthequalitywithholdearnedbackbythe
Contractor based on the Contractor’s performance on the incentive‐based
measures.
4.4.2.8 Allincentive‐based measuresshallbe weighted equally for purposes ofthe
Contractorearningback thequality withhold,unless otherwisespecifiedby
LDHpriortotheMeasurementYear.
4.4.2.9 Toearnbackthefullwithholdamountassociatedwitheachincentive‐based
measure,ContractorperformancemusteithermeettheLDH‐specifiedtarget
for that measure or improve over the Contractor’s performance for that
measure for the prior Measurement Year by at least two (2) points (2.0
withoutanyrounding).IftheContractordidnotreportdataforaparticular
measure in accordance with LDH requirements for the prior Measurement
Year,or ifcomparable data isnot availableforany specificincentive‐based
measure in the prior Measurement Year, as determined by LDH, the
Contractorshallmeetthetargettoearnthewithholdforthismeasure.
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4.4.2.10 IftheContractorsubmitsitsHEDIS results to NCQA per the timelines and
specifications as required in the Quality Management and Quality
Improvementsection,alongwithproofofsubmissiontoLDH,LDHshallrefund
uptofive(5)monthsoftheContractor’sestimatedwithheldfundsforquality
and health outcomes for the Measurement Year for which the results are
reported,providedthattheunauditedresultsindicatethattheContractoris
meetingor exceeding the benchmarkor performance improvementtargets
formorethanhalfoftheincentive‐basedmeasures.
4.4.2.11 Non‐HEDIS incentive‐based measure scores shall be calculated byLDHand
comparedtotargetsestablishedbyLDH.
4.4.2.12 For all measures, the Contractor’s results shall be validated by LDH’s
contracted External Quality Review Organization (EQRO) and outcomes
research&evaluationcontractor.
4.4.2.13 No later thantheend ofthecalendar yearofthe reporting year,LDHshall
notifytheContractoroftheamountofitsqualitywithholdearnedbackand
refundtheamountwithinthirty(30)CalendarDaysofsuchnotice.
4.4.2.14 LDHshallretaintheamountofthequalitywithholdnotearnedbackbythe
Contractor.
4.4.3 EarningtheVBPWithhold
ForeachContractyear,theContractormayearnbacktheVBPwithholdbasedonmeeting
the VBP reporting and performance requirements and targets as established by this
ContractandasdescribedintheValue‐BasedPaymentsection.
4.4.3.1 The MCO may earn back the VBP withhold amount for submitting VBP
deliverablesandmeetingVBPtargetsspecifiedbyLDHasdemonstratedwithin
theMCO’sreporteduseofVBPconsistentwithpaymentmodelsthatinclude
categories2A,2C,3and/or4oftheLearningActionNetwork(LAN)Alternative
Payment Models (APM) Framework and aligned with the incentive‐based
measuresspecifiedinAttachmentH,QualityPerformanceMeasures.
4.4.3.2 ToearnbackthefullVBPwithholdamountrelatedtoperformance,theMCO
shall:
4.4.3.2.1 Annually,onorbeforeAugust30,submittoLDHawrittenVBP
mid‐yearreportdescribingtheimplementationandstatusofits
VBP use and evidence that each VBP model includes financial
incentivesforproviderslinkedtoatleasttwooftheMCO
incentive‐basedmeasuresinAttachmentH,QualityPerformance
Measures,orotherAttachmentH,Quality Performance
Measures,measuresfornon‐primarycareVBParrangements.As
part of its VBP agreements, the MCO shall not hold providers
accountableformeetingahighertargetfortheincentive‐based
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measure than the target to which LDH holds the MCO for the
samemeasureunlesstheproviderisalreadyperformingabove
thebenchmarksetbyLDHforMCOperformanceonthe
incentive‐basedmeasure.
4.4.3.2.1.1 If an MCO implements a VBP arrangement
withprimarycareproviders,theVBP
arrangement must include at least two
measures from Attachment H, Quality
PerformanceMeasures,oneofwhichmustbe
anincentive‐basedmeasure,inorderforthe
MCO to report the primary care VBP in its
Attachment E, APM Strategic Plan
Requirements and Reporting Template
reporting.
4.4.3.2.1.2 IfanMCOimplementsaVBParrangementfor
services other than primary care, the MCO
must include at least any two applicable
incentive‐basedmeasuresfromAttachmentH,
Quality Performance Measures,intheVBP
arrangement,in order for the MCO to count
thenon‐primarycareVBPinitsAttachmentE,
APM Strategic Plan Requirements and
ReportingTemplatereporting.Iftherearenot
atleasttwoapplicablemeasuresin
AttachmentH,QualityPerformanceMeasures,
theMCOmustjustifyitsrationaleforselecting
differentVBPmeasuresandmustseek
approvalfromLDHtoincludetheVBP
arrangement in its Attachment E, APM
Strategic Plan Requirements and Reporting
Template,reporting.
4.4.3.2.1.3 To increase simplification and consistency in
provider performance data reporting, the
MCOmustuseperformancemeasure
specifications in its VBP arrangements that
alignwiththeLDHspecificationsformeasures
inAttachmentH,Quality Performance
Measures when the MCO is utilizing any
measure included in Attachment H, Quality
PerformanceMeasures.
4.4.3.2.1.4 If LDH determines that the mid‐year report
demonstrates an increase in VBP use by the
MCO,alignmentwithperformancemeasures
inAttachmentH,Quality Performance
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Measures, and is consistent with LDH
specifications,LDHwillrefundanyVBP‐related
amounts withheld for the calendar year
through June of that year. The VBP withhold
amounts shall not be refunded for late
submissions.
4.4.3.2.2 Annually,onorbeforeMarch15submittoLDHareportonits
VBPuseforthepriorCalendarYearasspecifiedinAttachmentE,
APMStrategicPlanRequirementsandReportingTemplate,anda
VBP year‐end report. In reporting its VBP use and provider
payments,theMCOshallusea“dateofpayment”approachto
completeAttachmentE,APM StrategicPlan Requirementsand
Reporting Template.IftheMCOdidnotmeettheVBPtargets
identifiedin4.4.3.2.4,4.4.3.2.5,4.4.3.2.6below,ifapplicable,the
MCOshalldescribewhytheVBPtargetswerenotmet.
4.4.3.2.3 IfLDHdeterminesthattheMCO’suseofrecognizedVBPmodels
meetsthefollowingVBPtargetsineachspecificCYasdescribed
below,LDHwillrefundanyremainingamountswithheldforVBP.
Recognized VBP arrangements exclude LAN APM category 2B
(payforreporting)modelsandVBPmodelsthatdonothavea
linktoatleasttwooftheapplicableMCOperformancemeasures
inAttachmentH, Quality PerformanceMeasures, asdefinedin
4.4.3.2.1above.
4.4.3.2.4 CY2023
4.4.3.2.4.1 MCO contractual arrangements linked to a
VBP model that includes one or moreof the
HCPLANcategoriesidentifiedbyLDHaccount
foratleastfortypercent(40%)oftotal
provider payments in the measurement year
and the Contractor’s total potential provider
incentive payments related to this
measurement year exceed six (6) million
dollars in total provider payments, OR the
Contractor’stotalpotentialproviderincentive
paymentsexceedtwelve(12)milliondollarsin
totalproviderpayments.
4.4.3.2.4.2 TheContractor’sVBPmodelsmustincludeat
least one new provider contract with a
category3AAPM,category3BAPMor
category4APMthatiseffectivenolaterthan
December2023.
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4.4.3.2.4.3 TheContractormustsubmitanannualreport
demonstratinghowitsVBPmodelsalignwith
LDH MCO incentive‐based and other
contractual performance measures and
provide initial data‐based assessments to
determine the extent to which providers
participated in specific VBP models may be
performing differently on targeted quality
measures than providers not participating in
suchVBPmodels.
4.4.3.2.5 CY2024
4.4.3.2.5.1 Contractual arrangements linked to a VBP
modelaccountforatleastfiftypercent(50%)
of total provider payments in the
measurementyearandtheContractor’stotal
potentialproviderincentivepaymentsrelated
to this measurement year exceed seven (7)
million dollars in total provider payments, or
the Contractor’s total potential provider
incentive payments exceed fourteen (14)
milliondollarsintotalproviderpayments.
4.4.3.2.5.2 TheContractor’sVBPmodelsmustincludeat
least one new provider contract with a
category3AAPM,andonenewprovider
contractwithacategory3BAPMorcategory4
APMthatiseffectivenolaterthanDecember
2024.
4.4.3.2.5.3 TheContractormustsubmitanannualreport
demonstratinghowitsVBPmodelsalignwith
LDH MCO incentive‐based and other
contractualperformancemeasures.
4.4.3.2.5.4 TheContractormustanalyzeVBPandquality
performancetodeterminetheextenttowhich
providersparticipatinginspecificVBPmodels
performed differently on targeted quality
measures than providers not participating in
suchVBPmodels.TheContractorshall
indicatehowitwillusetheresultsofthisdata
analysistoimproveitVBPmodelsandprovider
supportforCY2025andfutureyears.
4.4.3.2.6 CY2025andFutureYears
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4.4.3.2.6.1 Contractual arrangements linked to a VBP
modelaccountforatleastsixtypercent(60%)
of total provider payments, and the
Contractor’stotalpotentialproviderincentive
payments exceed eight (8) million dollars in
total provider payments, or the Contractor’s
total potential provider incentive payments
exceed sixteen (16) million dollars in total
providerpayments.
4.4.3.2.6.2 TheContractor’sVBPmodelsmustincludeat
least one new provider contract with a
category3AAPM,onenewprovidercontract
withacategory3BAPM,andonenewprovider
contractwithacategory4APMthatis
effective no later than the end of the
applicablecalendaryear.
4.4.3.2.6.3 TheContractormustsubmitanannualreport
demonstratinghowitsVBPmodelsalignwith
LDH MCO incentive‐based and other
contractualperformancemeasures.
4.4.3.2.6.4 TheContractormustanalyzeVBPandquality
performancetodeterminetheextenttowhich
providersparticipatinginspecificVBPmodels
performed differently on targeted quality
measures than providers not participating in
suchVBPmodels.TheContractorshall
indicatehowitwillusetheresultsofthisdata
analysistoimproveitVBPmodelsandprovider
supportforCY2025andfutureyears.
4.4.3.2.7 LDH may refund to the MCO some of the remaining amounts
withheldfor VBPduringthe calendaryear iftheMCOpartially
meets the VBP targets in 4.4.3.2.4, 4.4.3.2.5, 4.4.3.2.6, if
applicableanddescribestoLDH’ssatisfactionwhytheMCOdid
notfullymeettheVBPtargets.
4.4.3.2.8 LDHshallretaintheamountoftheVBPwithholdnotearnedback
bytheMCO.
4.4.4 EarningHealthEquityWithhold
ForeachContractyear,theContractormayearnbacktheHealthEquitywithholdbased
onitsreportingandperformancerelativetohealthequityrequirementsasestablishedby
thisContractandLDHasdescribedintheHealthEquitysection.
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4.4.4.1 The MCO may earn back the health equity withhold amount for the
developmentand the submission of health equity deliverables specified by
LDHintheHealthEquitysection:
4.4.4.1.1 The MCO must develop a multi‐year Health Equity Plan and
submit the finalized plan thirty (30) Calendar Days after the
OperationalStartDate.TheContractor’sHealthEquityPlanmust
include:
4.4.4.1.1.1 Stratify MCO results on certain quality
measurestoidentify/addressdisparities.
4.4.4.1.1.2 Include staff/provider training requirements
relatedtoequity,beyondCLASrequirements.
4.4.4.1.1.3 Include social needs/equity questions in
Health Needs Assessment and develop
mechanismstoclosethereferrallooptoacton
identifiedsocialriskfactors.
4.4.4.1.1.4 Engage a variety of Enrollees/populations in
theMCO’shealthequityapproach.
4.4.4.1.2 TheMCOmustsubmitupdatestotheHealthEquityPlantwice
peryearbyJuly31
st
andDecember31
st
.
4.4.4.1.2.1 Themid‐yearreportmustincludeastatus
update on progress made on health equity
strategiessubmittedwiththeinitialplan.
4.4.4.1.2.2 The annual report submitted to LDH by
December31
st
mustdemonstrateprogresson
meetingHealthEquitymilestonesandgoalsas
outlinedinSection2.7ofthecontract.
4.4.4.2 LDHshallretaintheamountoftheHealthEquitywithholdnotearnedbackby
theContractor.
4.4.5 OtherRequirementsRelatedtoQualityandVBPWithholds
4.4.5.1 If,inthefinaldeterminationofMCOperformancerelativetoQuality and
Health Outcomes, VBP and Health Equity incentives, the MCO’s unearned
withhold amount exceeds its withhold balance held in escrow by LDH, the
MCOisresponsibleforremittingpaymentforthebalancetoLDHwithinthirty
(30)CalendarDaysfollowingnotificationtotheMCObyLDHunlessotherwise
authorizedinwritingbyLDH.LDH,atitsdiscretion,reservestherighttocollect
amountsduebywithholdingandapplyingallbalancesduetoLDHtofuture
payments.
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4.4.5.2 IftheMCOisunabletoachievespecifiedmilestonesrequiredtoearnbackthe
withhold,solelyduetoanearlyterminationforconvenience,LDHshallrefund
theremainderoftheamountwithheld.
4.4.5.3 All MCOs contracted with LDH shall utilize the collectively agreed upon
common format and frequency for provider‐specific profile reports on the
incentive‐based quality measures identified in Attachment H, Quality
PerformanceMeasures.Theprofileformatshallbereviewedannuallybythe
MCOs.AnyrevisionsshallbereviewedandapprovedbyLDHatleastthirty(30)
CalendarDayspriortoimplementation.
4.4.5.4 TheMCOshalldistributeprovider‐specificprofilereportstoprovidersusing
thecommonformatandfrequencyeffectivethefirstquarterofcalendaryear
X,asapprovedbyLDHinwriting.
4.4.5.5 NointerestshallbeduetotheMCOonanysumswithheldorretainedunder
thisSection.
4.4.5.6 Thewithholdarrangementisforafixedperiodoftimeandperformanceis
measuredduringtheratingperiodunderthecontractinwhichthewithhold
arrangementisapplied.Withholdarrangementsareavailabletobothpublic
andprivatecontractorsunderthesametermsofperformance.Participation
in withhold arrangements is not conditioned on the MCO entering into or
adheringtointergovernmentaltransferagreements.
4.4.5.7 The withhold arrangement is necessary for the specified activities, targets,
performance measures, or quality‐based outcomes that support program
initiativesasspecifiedintheState'squalitystrategyunder42C.F.R.§438.340.
4.4.5.8 TheprovisionsofthisSectionmaybeinvokedaloneorinconjunctionwithany
other remedy or adjustment otherwise allowed under this Contract. LDH
reservestherighttoassessMonetaryPenaltiesforfailuretomeetdeliverables
asrequiredunderthissection.
MedicalLossRatio
4.5.1 InaccordancewiththeMCO Financial Reporting Guide and 42 C.F.R. §438.8, the
ContractorshallprovideanannualMedicalLossRatio(MLR)reportfollowingtheendof
theMLRreportingyear.
4.5.2 TheMLRshallbereportedintheaggregate,unlessLDHrequiresseparatereportingand
separateMLRcalculationsforspecificpopulations.
4.5.3 IftheaggregateMLRortheMLRforanyspecificpopulationislessthaneighty‐fivepercent
(85%),theContractorshallrefundLDHthedifference.Anyunpaid balances after the
refundisdue shallbesubjecttointerestatthe currentFederalfundsrates plusthree
percent(3%)ortenpercent(10%)annually,whicheverishigher.
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4.5.4 LDHmayrequestMLRreportingthatdistinguishesphysicalandbasicbehavioralhealth
fromspecializedbehavioralhealth.
4.5.5 TheContractoranditssubcontractorsshallretainMLRreportsforaperiodofnolessthan
ten(10)yearsfollowingterminationoftheContract.
PaymentAdjustments
4.6.1 IntheeventthatanerroneouspaymentismadetotheContractor,LDHshallreconcile
the error by adjusting the Contractor’s next monthly CapitationPaymentorfuture
CapitationPaymentsonascheduledeterminedbyLDHinconsultationwiththeFI.
4.6.2 RetrospectiveadjustmentstopriorCapitationPaymentsmayoccurwhenitisdetermined
thatanEnrollee’saidcategoryand/ortypecasewaschangedandtheEnrolleeremains
MCOeligible.
4.6.3 IfanEnrolleeismovingfromanaidcategoryand/ortypecasethatiseligibleformanaged
caretoanaidcategoryand/ortypecasethatisnoteligibleformanagedcare,theprevious
Capitation Payments for excluded months will be recouped from the Contractor. The
Contractorshallinitiaterecoupmentsofpaymentstoproviderswithinsixty(60)Calendar
DaysaftertheendofthemonthinwhichLDHnotifiestheContractorofthechange.The
Contractorshallinstructtheprovidertoresubmittheclaim(s)toFFS(ifapplicable).
4.6.4 In cases of a retroactive effective date for Medicare EnrollmentofanEnrollee,the
Contractorshallrecouppaymentsmadetotheprovidersin accordancewiththePost‐
PaymentRecoveriessectionofthisContract.TheContractorshallinitiaterecoupments
withinsixty(60)CalendarDaysaftertheendofthemonthinwhichLDHnotifiesthe
ContractorofMedicareEnrollment.TheContractorshallinstructtheprovidertoresubmit
theclaim(s)toMedicare.
4.6.5 CapitationPaymentsreceivedfromLDHforadeceasedEnrolleeafterthemonthofdeath
andforanincarceratedEnrolleethemonthafterenteringinvoluntarycustodyshallbe
recoupedbyLDH.
4.6.6 For Enrollees who are disenrolled due to the invalidation of a duplicate Medicaid ID
Number, the Contractor shall not recover claim payments under the retroactively dis‐
enrolled Medicaid ID Number if the remaining valid Medicaid ID Number is linked to
anotherMCO.TheContractorshallsubrogatetheamountofthepaidclaim(s)totheMCO
thatisresponsiblefortheclaim(s)forthedatesofservice.
4.6.7 TheentiremonthlyCapitationPaymentshallbepaidforthemonthofbirth,monthof
death,andmonthofentryintoinvoluntarycustody. CapitationPayments shall notbe
proratedtoadjustforpartialmontheligibilityasthishasbeenfactoredintotheactuarial
rates.
RiskSharing
4.7.1 TheContractorshallagreetoaccept,aspaymentinfull,themonthlyCapitationPayment
andmaternityKickPaymentestablishedbyLDHpursuanttotheContract,andshallnot
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seekadditionalpaymentfromanEnrollee,orLDH,foranyunpaidcostexceptasallowed
bytheCostSharingrequirementsofthisSection.
4.7.2 TheContractorshall assumeonehundred percent(100%)liabilityforanyexpenditure
abovethemonthlyCapitationPaymentandmaternityKickPayment.
4.7.3 LDH will maintain a risk corridor for Hepatitis C‐related pharmacy, physician, and
laboratorycosts.Theparametersofthisriskcorridorandprocessforreconciliationand
paymentswillbespecifiedintheFinancialReportingGuide.
4.7.3.1 TheContractorwillbefullyatriskforgainsorlosseslessthanorequalto1%
oftheaggregateHepatitisC‐relatedmedicalcomponentoftherisk‐adjusted
capitationpayment.
4.7.3.2 TheContractorandLDHwillshareriskforgainsandlossesgreaterthan1%of
the aggregate Hepatitis C‐related medical component of the risk‐adjusted
capitationpayment.
4.7.3.2.1 TheContractorshareofriskwillbe1%.
4.7.3.2.2 TheLDHshareoftheriskwillbe99%.
4.7.4 ZolgensmaRiskPoolArrangement
Theamountoftheriskpool,ifapplicable,willbedeterminedbytheprojectedZolgensma
costs incorporated into annual capitation rates as described in the rate certification.
MaximumallowablecostperclaimwillbebasedonFFSreimbursement (wholesale
acquisition cost plus professional dispensing fee). LDH will redistribute funds among
MCOsbasedontheactualZolgensmacosts,netofTPL.TheContractorshallfollowFFS
clinical criteria for Zolgensma. The Zolgensma risk pool will besettledfollowingthe
conclusionoftheannualcontractperiod.
DeterminationofCapitationRates
4.8.1 LDHshalldevelopactuariallysoundCapitationRatesinaccordancewith42C.F.R.§438.4
through §438.7 and all applicable CMS rules and regulations. LDH shall not use a
competitivebiddingprocesstodeveloptheCapitationRates.LDHshalldevelopCapitation
RatesthatwillbeofferedtoMCOs.TheCapitationRatesarenotnegotiable.
4.8.2 CapitationRatesshallbesetusingencounterdata,financialdata,andsupplementalad
hocdataand analyses appropriatefordeterminingactuarially soundCapitationRates.
Fiscalperiodsofthebasedatashallbedeterminedbasedupon thedatasources,rate
periods,andpurposesforwhichthedataisusedwithappropriateadjustments,including
thefollowing:
4.8.2.1 Utilizationtrendandtheexpectedimpactofmanagedcareontheutilization
ofthevarioustypesofservicesappliedtovaryingsourcesofdata,including
managedcaresavingsassumptionsandmanagedcareefficiencyadjustments.
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4.8.2.2 Unit cost trend and assumptions regarding managed care pricing and
payments.
4.8.2.3 ThirdPartyLiability(TPL)recoveries.
4.8.2.4 The expected cost of MCO administration and overhead, includingbutnot
limitedtopremiumtaxes.
4.8.3 AdditionalfactorsdeterminingtheCapitationRateforanEnrolleemayinclude:1)age;2)
gender;3)LouisianaMedicaidProgramcategoryofassistance;4)thegeographiclocation
oftheEnrollee’sresidence;and5)MedicareEnrollment.
4.8.4 The Contractor shall be paid in accordance with the Capitation Rates specified in
AttachmentD,ActuarialRateCertificationLetter,ofthisContract.
4.8.5 Theratesshallbereviewedandmaybeperiodicallyadjusted.AnyadjustedCapitation
Ratesshallbeactuariallysound,consistentwithrequirementssetforthin42C.F.R.§438.4
through§438.7,andwillrequireanamendmenttotheContract.
4.8.6 LDHreservestherighttoadjusttheCapitationRatesinthefollowinginstances:
4.8.6.1 ChangestoMCOCoveredServicesincludedintheCapitationRates;
4.8.6.2 ChangestoLouisianaMedicaidProgrampopulationgroupseligibletoenrollin
anMCO;
4.8.6.3 Legislativeappropriationsandbudgetaryconstraints;or
4.8.6.4 ChangesinFederalrequirements.
4.8.7 TheContractorshallprovide,inwriting,anyinformationrequestedbyLDHtoassistinthe
determination of Capitation Rates. LDH shall give the Contractor reasonable time to
respondtotherequestandfullcooperationbytheContractorisrequired.LDHshallmake
thefinaldeterminationastowhatisconsideredreasonabletime.
4.8.8 LDH shall utilize MCO overpayment and recovery data in calculating future Capitation
Ratesper42C.F.R.§438.608(d)(4).
RiskAdjustment
4.9.1 CapitationPaymentsforintegratedphysicalandbehavioralhealthshallberisk‐adjusted
asdeemedappropriatebyLDH.
4.9.1.1 LDHshallanalyzetheriskprofileofEnrolleesineachMCOusinganationalrisk
adjustmentmodelspecifiedbytheState.
4.9.1.2 EachEnrolleeshallbeassignedtoriskcategoriesbasedonfactorsappropriate
for the risk adjustment model. This information and the relative cost
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associatedwitheachriskcategoryreflectstheanticipatedutilizationofhealth
careservicesrelativetotheoverallpopulation.
4.9.1.2.1 TherelativecostsshallbedevelopedusingLouisianaspecific
historicaldatafromFFSclaimsandencounterdataasdetermined
appropriate.
4.9.1.3 TherelevantportionsoftheContractor’sproposedbaseCapitationRatesshall
beriskadjustedbasedontheContractor’sriskscorethatreflectstheexpected
health care expenditures associated with its Enrollees relativetothe
applicabletotalLouisianaMedicaidProgrampopulation.
4.9.1.4 When practical, LDH shall notifytheContractorinadvanceofany major
revision to the risk adjustment methodology that differs from the
methodologyusedforthepriorriskadjustmentupdate.TheContractorshall
begivenfourteen(14)CalendarDaysfromthedateofthenoticetoprovide
inputontheproposedchanges.LDHshallconsiderthefeedbackreceivedfrom
the Contractor when implementing changes to the risk adjustment
methodology,buthasfinaldecision‐makingauthority.
4.9.2 CertainCapitationPaymentsmaynotberisk‐adjustedbasedonconsiderationsofhow
suchpaymentsweredevelopedandtheavailabilityofriskadjustmentdata.
ReturnofFunds
4.10.1 AllamountsowedbytheContractortoLDH,asidentifiedthroughroutineorinvestigative
reviewsofrecordsorauditsconductedbyLDHorotherStateorFederalagency,aswell
asMonetaryPenaltiesleviedagainsttheContractorforContractnon‐compliance,maybe
deductedfromthemonthlyCapitationPaymentuponnotificationbyLDH.
4.10.2 AmountsthatexceedorcannototherwisebecollectedthroughtheCapitationPayment
deduction shall be due and payable to LDH no later than thirty (30) Calendar Days
followingnotificationtotheContractorbyLDH,unlessotherwiseauthorizedinwritingby
LDH.LDHreservestherighttoaccrueandcollectinterestonunpaidbalancesbeginning
thirty(30)CalendarDaysfromthedateofinitialnotification.Anyunpaidbalancesthat
remainaftertherefundisdueshallbesubjecttointerestatthecurrentFederalfunds
rateplusthreepercent(3%)ortenpercent(10%)annually,whicheverishigher.
4.10.3 TheContractorshallreimburseLDHforanyFederaldisallowancesorsanctionsimposed
onLDHasaresultoftheContractor’sfailuretoabidebythetermsoftheContract.The
ContractorshallbesubjecttoanyadditionalconditionsorrestrictionsplacedonLDHby
HHSasaresultofthedisallowance.Instructionsforreturningoffundsshallbeprovided
bywrittennotice.
OtherPaymentTerms
4.11.1 TheContractorshallmakepaymentstoitsprovidersasstipulatedintheContract.
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4.11.2 TheContractorshallnotassignitsrighttoreceivepaymenttoanyotherentitywithout
writtenconsentofLDH.Noticeofanysuchassignmentortransfer shall be promptly
furnishedtotheDivisionofAdministration,OfficeofStateProcurement.
4.11.3 PaymentforitemsorservicesprovidedunderthisContractwillnotbemadetoanyentity
locatedoutsideoftheUnitedStates.
4.11.4 The Contractor shall agree to accept payments as specified in this Section and have
written policies and procedures for receiving and processing payments and
adjustments.Anychargesorexpensesimposedbyfinancialinstitutionsfortransfersor
relatedactionsshallbebornebytheContractor.
4.11.5 ShouldanypartofthescopeofworkunderthisContractrelatetoastateprogramthatis
nolongerauthorizedbylaw(e.g.,whichhasbeenvacatedbyacourtoflaw,orforwhich
CMShaswithdrawnfederalauthority,orwhichisthesubjectofalegislativerepeal),the
Contractormustdonoworkonthatpartaftertheeffectivedateofthelossofprogram
authority.Thestatemustadjustcapitationratestoremovecoststhatarespecifictoany
program or activity that is no longer authorized by law. If the Contractor works on a
programoractivitynolongerauthorizedbylawafterthedatethelegalauthorityforthe
workends,theContractorwillnotbepaidforthatwork.IfthestatepaidtheContractor
inadvancetoworkonano‐longer‐authorizedprogramoractivityandunderthetermsof
thiscontracttheworkwastobeperformedafterthedatethelegalauthorityended,the
payment for that work should be returned to the state. However,iftheContractor
workedonaprogramoractivitypriortothedatelegalauthorityendedforthatprogram
oractivity,andthestateincludedthecostofperformingthatworkinitspaymentstothe
Contractor,theContractormaykeepthepaymentforthatworkevenifthepaymentwas
madeafterthedatetheprogramoractivitylostlegalauthority.
CostSharing
4.12.1 TheContractoranditssubcontractorsarenotrequiredtoimposeanyCopaymentsorCost
SharingrequirementsonEnrollees.
4.12.2 TheContractoranditssubcontractorsmayimposeCostSharingon Enrollees in
accordancewith42C.F.R.§447.50through§447.82providedthatitdoesnotexceedCost
SharingamountsintheStatePlan.TheCopaymenttiersintheStatePlanshallbebased
onthetotalamountreimbursedtothepharmacyfortheclaim.
4.12.3 The Contractor shall ensure Cost Sharing incurred by all individuals in the Louisiana
MedicaidProgramhouseholddoesnotexceedanaggregatelimitoffivepercent(5%)of
thehousehold’sincomeappliedonaquarterlyormonthlybasisasinstructedbyLDH.
4.12.4 LDHreservestherighttoamendCostSharingrequirements.
4.12.5 TheContractoranditssubcontractorsmaynot:
4.12.5.1 Deny services to an Enrollee who is eligible for services because of the
Enrollee’sinabilitytopaytheCostSharing.
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4.12.5.2 Restrict Enrollees’ access to neededdrugsandrelatedpharmaceutical
productsbyrequiringEnrolleestousemail‐orderpharmacyproviders.
4.12.5.3 ImposeCopaymentsforservicesspecifiedintheMCOManual.
ThirdPartyLiability
4.13.1 GeneralTPLInformation
4.13.1.1 PursuanttoFederalandStatelaw,theLouisianaMedicaidProgramisintended
tobethepayeroflastresort.Thismeansallotherliablethirdpartiesmust
meettheirlegalobligationtopayclaimsbeforetheContractorpaysforthe
careofanEnrollee.
4.13.1.2 TheContractorshalltakereasonablemeasurestodetermineTPL.
4.13.1.3 TheContractorshallcoordinatebenefitsinaccordancewith42C.F.R.Part433,
SubpartDandLa.R.S.46:460.71,sothatcostsforservicesotherwisepayable
bytheContractorarecostavoidedorrecoveredfromaliablethirdparty.The
two methods used are cost avoidance and post‐payment recovery. The
ContractorshallusethesemethodsinaccordancewithFederalandStatelaws,
regulations,rules,policies,procedures,andmanuals,andtheStatePlan.
4.13.1.4 EstablishingTPLtakesplacewhentheContractorreceivesconfirmationthat
anotherpartyis,bylaw, contract,oragreement,legallyresponsibleforthe
paymentofaclaimforahealthcareitemorservicedeliveredtoanEnrollee.
4.13.1.5 IftheprobableexistenceofTPLcannotbeestablished, theContractorshall
Adjudicatetheclaim.TheContractorshallthenutilizepost‐paymentrecovery
ifTPLislaterdeterminedtoexist.
4.13.1.6 TheContractormayutilizesubcontractors to comply with coordination of
benefit (COB) efforts for servicesprovided pursuant to this Contract. If the
ContractorintendstosubcontractforCOBTPLservicesorwithasubrogation
vendortoperformitsaccident/trauma‐relatedrecoveries,theContractorshall
notify LDH of the vendor and provide a copy of the contract to LDH or its
designee during Readiness Reviews. The Contractor shall notify LDH of any
subsequentchangestoitsvendorandprovideacopyofthecontractnolater
thanthirty(30)CalendarDayspriortotheeffectivedateofthe contract.
FailuretocomplymayresultinMonetaryPenaltiesbeingassessedagainstthe
Contractor.
4.13.1.7 FortheeligibleLouisianaMedicaidProgrampopulationthatisduallyenrolled
inMedicare,Medicaid‐coveredSBHSthatarenotcoveredbyMedicareshall
bepaidbytheContractorastheprimarypayer.Forduallyeligibleindividuals,
Medicare“crossover”claims(claimsforservicesthatarecoveredbyMedicare
as the primary payer) are excluded from coverage under the Capitation
Payments.TheseservicesshallbeadministeredseparatelybytheFIfromthe
servicescoveredundertheCapitationPaymentseffectiveunderthisContract.
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In the event that a dually eligible Enrollee’s Medicare benefits have been
exhaustedasofthedateofserviceonwhichaMedicarecoveredbehavioral
healthservicewasprovided,LouisianaMedicaidProgramshallbeconsidered
primary.Claimsforthoseservicesshallnolongerbeconsidered“crossover”
claims,andtheContractorshallberesponsibleforpayment.
4.13.1.8 TheContractorshallupdateitssystemwithTPLrecordssentdailyfromLDH
(oritsdesignee)withinone(1)BusinessDayofreceipt.TheContractorshall
reconcileitssystemwithTPLreconciliationfilessentweeklyfromLDHwithin
one(1)BusinessDayofreceipt.IfanEnrolleeisunabletoaccessservicesor
treatmentuntilanupdateismade,theContractorshallverifyandupdateits
systemwithin four(4)Business Hoursofreceipt ofanupdaterequest.This
includesupdatesoncoverage,includingremovalofcoveragethatexistedprior
to the Enrollee’s linkage to the Contractor that impacts current provider
adjudication orEnrolleeservice access. Such updates shall be submitted to
LDHand/oritsdesigneeinthemannerspecifiedintheMCOManual.
4.13.1.9 TheContractorshallreviewresponsefilessentdailyfromLDH(oritsdesignee)
andrejectedrecordsshallbecorrectedandcompletedwithinfive(5)Business
Days.TheContractorshallensureitsrecordsreconciletotheTPLreconciliation
filesreceivedweeklyfromLDHoritsdesignee.Failuretocomplymayresultin
Monetary Penalties in accordance with Attachment G, Table of Monetary
Penalties.
4.13.1.10 TPLDataExchange
4.13.1.10.1 TheContractorshall:
4.13.1.10.1.1 Receive, process, and update all records
includedinTPLfilessentbyLDHorits
designee.
4.13.1.10.1.2 Update its TPL databases within one (1)
BusinessDayofreceiptofsaidfiles.
4.13.1.10.1.3 TransmittoLDHoritsdesignee,intheformats
and methods specified by LDH, TPL files the
Contractororitssubcontractordiscoversthat
havenototherwisebeenprovidedbyLDHor
itsdesignee.
4.13.2 CostAvoidanceandPayandChase
4.13.2.1 TheContractorshallcost‐avoidaclaimifitestablishestheprobableexistence
of a liable third party other health insurance at the time the claim is filed,
exceptforthe“payandchase”claimsidentifiedintheMCOManual.
4.13.2.2 The Contractor shall “pay and chase” the full amount allowed under its
paymentschedulefortheclaimandthenseekreimbursementfromtheTPL
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insurer.TheContractorshall,withinsixty(60)CalendarDaysaftertheendof
thecalendarmonthinwhichthepaymentwasmade(orwithinsixty (60)
CalendarDaysaftertheendofthecalendarmonththeContractorlearnsof
theexistenceofaliablethirdparty),pursuerecoveryfromsaidthirdpartyfor
anylegalliability.
4.13.2.3 TheContractorshall“waitandsee”onclaimsforaservicethatisprovidedto
anindividualonwhosebehalfchildsupportenforcementisbeingcarriedout
bythestateTitleIV‐Dagency.“Waitandsee”isdefinedaspaymentofaclaim
onlyafterdocumentationissubmittedtotheContractordemonstratingthat
onehundred(100)CalendarDayshaveelapsedsincetheproviderbilledthe
responsiblethirdpartyandtheproviderhasnotreceivedpaymentforsuch
services.
Post‐PaymentRecoveries
4.14.1 Post‐paymentrecoveryisnecessaryincaseswheretheContractorhasnotestablished
theprobableexistenceofTPLatthetimeserviceswererendered or paid for. The
Contractorshalladheretothefollowingrequirementsforpost‐paymentrecovery:
4.14.1.1 Initiaterecoveryofreimbursementwithinsixty(60)CalendarDaysafterthe
endofthecalendarmonthinwhichitlearnsoftheexistenceoftheliablethird
party.
4.14.1.2 Not perform post‐payment recoveryforTPLfrom providers for claimswith
datesofservice(DOS)olderthanten(10)months,exceptwhentheprimary
carrieristraditionalMedicare,Tricare,orChampus.
4.14.1.3 IftheliablethirdpartyistraditionalMedicare,TricareorChampus,andmore
thanten(10)monthshavepassedsincetheDOS,theContractorshallrecover
fromtheprovider.
4.14.1.4 Allowproviderssixty(60)CalendarDaysfromthedatestampoftherecovery
letter to refute the recovery with a one‐time thirty (30) Calendar Day
extensionattheprovider’srequest.
4.14.1.5 Referpayandchaseclaimsdirectlytotheliablethirdparties.
4.14.1.6 ReferPointofSale(POS)pharmacyclaimsdirectlytothecarrier.
4.14.1.7 TheContractorshallinitiateanautomaticrecoupmentattheexpirationofthe
sixty(60)CalendarDaytimeperiodifanextensionrequestisnotreceivedfrom
theproviderandattheexpirationoftheninety(90)CalendarDaytimeperiod
ifanextensionisrequestedbytheprovideriftheproviderhasnotremitted
thepaymenttotheContractor
4.14.1.8 TheContractorshallvoidencountersforclaimsforwhichthefull Louisiana
MedicaidProgrampaidamountisbeingrecouped.Forrecoupmentsforwhich
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thefullLouisianaMedicaidProgrampaidamountisnotbeingrecouped,the
Contractorshallsubmitadjustedencountersfortheclaims.
4.14.1.9 TheContractorshallidentifythe existence ofpotential TPLtopayforMCO
CoveredServicesthroughtheuseoftraumacodeeditsinaccordancewith42
C.F.R.§433.138(e).
4.14.1.10 TheContractorshallberequiredtoseekreimbursementinaccident/trauma
related cases when claims in the aggregate equal or exceed five hundred
dollars ($500.00) as required by the State Plan and Federal Medicaid
guidelinesandmayseekreimbursementwhenclaimsintheaggregateareless
thanfivehundreddollars($500.00).Failuretoseekreimbursementmayresult
in Monetary Penalties as specified in Attachment G, Table of Monetary
Penalties.
4.14.1.11 TheContractor shallnotify LDH whensubpoenas duces tecumare received
andreporttheresultingrecoveriestoLDH.
4.14.1.12 TheamountofanyrecoveriescollectedbytheContractoroutsideoftheclaims
processing system shall be treatedbytheContractorasoffsetstomedical
expensesforthepurposesofreporting.
4.14.1.13 PriortoacceptingaTPLsettlementonaccident/trauma‐relatedclaimsequal
toorgreaterthantwenty‐fivethousanddollars($25,000.00),theContractor
shallobtainapprovalfromLDHinwriting.
4.14.1.14 Upon receipt of a subpoena duces tecum, the Contractor shall produce
documents responsive to said subpoena by the date of return indicated
therein(orshallcontactthepartywhocausedissuanceofthesubpoena,in
ordertorequestadditionaltimetorespond)iftheproductionisauthorized
underLa.R.S.13:3715.1.Uponreceiptofarequestforrecordsnotsentvia
subpoena,theContractorshallreleasePHIoraresponseexplainingwhyPHI
cannot be released to the individual or entity making the request, within
fifteen(15)CalendarDaysofreceiptoftherequestandawritten
authorization, as set forth in La. R.S. 40:1165.1(A)(2)(c). The Contractor is
solely responsible for any sanctions and costs imposed by a court of
competentjurisdictionforfailuretocomplywiththerequirementsofLa.R.S.
40:1165.1(A)(2)(c)orforfailuretorespondTimelytoasubpoenaducestecum.
Additionally,LDHmayimposesanctionsagainsttheContractorforfailureto
properlyorTimelyrespondtorequestsforPHI.
4.14.1.15 AllrecordsrequestsreceivedbytheContractorshallbeinvestigatedbythe
Contractor(oritsvendor)forpossibleTPLrecoveries,resultinginissuanceof
alienstatement(ornoticeoflackthereof)totherequestingparty,asprovided
forinLa.R.S.46:446.
4.14.1.16 When the Contractor has actual knowledge that an insurer or other risk
bearingentityofanEnrolleehasfiledforbankruptcyandtheproviderfilesa
claimforreimbursementwiththeContractorwithdatesofservicepriortothe
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datetheinsurerorotherriskbearingentityfiledbankruptcy,theContractor
shall reimburse the provider with the Louisiana Medicaid Program as the
primaryinsureronlyiftheEnrolleewasenrolledwiththeContractoratthe
timetheservicewasprovidedandtheproviderhasnotbeenpaid. The
Contractor shall seek reimbursement as a creditor in the bankruptcy
proceeding or from a liable third party. If the provider files a claim for
reimbursementwiththeContractorwithdatesofserviceafterthedatethe
insurerorotherriskbearingentityfiledforChapter11bankruptcy,theinsurer
orotherriskbearingentityshallcontinuetobetheprimaryinsurer. If the
provider files a claim for reimbursement with the Contractor withdatesof
serviceafterthedatetheinsurerorotherriskbearingentityfiledforChapter
7bankruptcy,theLouisianaMedicaidProgramshallbetheprimaryinsurer.
4.14.2 DistributionofTPLRecoveries
4.14.2.1 TheContractormayretainuptoonehundred(100%)ofitsTPLrecoveriesifall
ofthefollowingconditionsexist:
4.14.2.1.1 TotalTPLrecoveriesreceiveddonotexceedthetotalamountof
theContractor’sfinancialliabilityfortheEnrollee.
4.14.2.1.2 TherearenopaymentsmadebyLDHrelatedtoFFS,reinsurance,
oradministrativecosts(e.g.,lienfiling)fortheEnrollee.
4.14.2.1.3 SuchrecoveryisnotprohibitedbyStateorFederallaw.
4.14.2.1.4 LDH shall utilize the TPL recovery data in calculating future
CapitationRates.
4.14.3 TPLReportingRequirements
4.14.3.1 TheContractorshallprovideTPLinformationtoLDHinaformatandmedium
describedintheMCOManualandshallcooperateinanymannernecessary,
asrequestedbyLDH,withLDHand/oritsdesignee.
4.14.3.2 TheContractorshallincludetheTPLrecoveriesandclaimsinformationinthe
encounter data submitted to LDH, including any retrospective findings via
encounteradjustmentsorvoids.
4.14.3.3 UpontherequestofLDH,theContractorshallprovideinformation not
includedinencounterdatasubmissionsthatmaybenecessaryfor the
administrationofTPLactivity.Theinformationshallbeprovidedwithinthirty
(30)CalendarDaysofLDH’srequest.Suchinformationmayinclude,butisnot
limitedto,EnrolleeMedicalRecordsfortheexpresspurposeofaliablethird
partytodetermineliabilityfortheservicesrendered.
4.14.3.4 UpontherequestofLDH,theContractorshalldemonstratethatreasonable
efforthasbeenmadetoseek,collect,and/orreportTPLandre
coveries.LDH
shallhavethesoleresponsibilityfordeterminingwhetherornotreasonable
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effortshavebeendemonstrated.Saiddeterminationshalltakeintoaccount
reasonable industry standards and practices. Failure to seek
reimbursement/recovery may result in Monetary Penalties as set forth in
AttachmentG,TableofMonetaryPenalties.
4.14.3.5 TheContractorshallsubmitanannualreportofallhealthinsurancecollections
forEnrolleespluscopiesofanyForm1099sreceivedfromhealthinsurance
companiesforthatperiodoftime.
4.14.4 LDHRighttoConductIdentificationandPursuitofTPL
4.14.4.1 LDH may invoke its right to pursue TPL recoveries if the Contractorfailsto
recoverreimbursementfromtheliablethirdpartytothelimitoflegalliability
withinthreehundredsixty‐five(365)CalendarDaysfromdate(s)ofserviceof
theclaims(s).
4.14.4.2 IfLDHdeterminesthattheContractorisnotactivelyengagedincostavoidance
activities,theContractormaybesubjecttoMonetaryPenaltiesassetforthin
AttachmentG,TableofMonetaryPenalties.
CoordinationofBenefits
4.15.1 OtherCoverageInformation
TheContractorshallprovide TPLinformationitor itssubcontractor discoversforeach
EnrolleethatisnotincludedinthereconciliationfilesreceivedweeklyfromtheFI.The
ContractorshallsubmitaTPLfilesentdailyreportingverifiedadditionsandupdatesof
TPL information in a format and medium specified by LDH in the MCO Manual. The
Contractorshall reviewresponsefiles sentdailyfrom the FIandcorrectandresubmit
rejectedrecordsuntiltherecordiscorrectlyreportedonTPLreconciliationfilesreceived
weeklyfromtheFI.

4.15.2 ReportingandTracking
TheContractor’ssystemshallidentifyandtrackpotentialTPLrecoveries.Thesystemshall
produce reports indicating open receivables, closed receivables, amounts collected,
amountswrittenoff,andamountsavoided.ThesereportsshallbemadeavailabletoLDH
uponrequest.
FinancialDisclosuresforPharmacyServices
TheContractorshalldiscloseallfinancialtermsandarrangementsforremunerationofanykindthat
applybetweenthe Contractororthe Contractor’sPBMsubcontractorand anyprescriptiondrug
wholesaler, manufacturer or labeler, including, without limitation, formulary management,
educational support, claims processing, pharmacy network fees, drugproductsalesorpricing
agreements,datasalesfees,andanyotherfees.TheClaimsManagementsectionofthisContract
providesthatLDHorStateauditorsmayauditsuchinformationatanytime.LDHagreestomaintain
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the confidentiality of information disclosed by the Contractor pursuant to the Contract, to the
extentthatsuchinformationisconfidentialunderStateorFederallaw.
BondRequirements
4.17.1 PerformanceBond
4.17.1.1 TheContractorshallestablishandmaintainaperformancebondfortheentire
termoftheContractandcontinuetomaintainthebondforatleastfifteen(15)
months following the termination date of this Contract or as long as the
Contractor has Contract‐related outstanding liabilities of at least fifty
thousanddollars($50,000.00),whicheverislater,toguarantee:(1)payment
oftheContractor'sobligationstoLDHand(2)performancebytheContractor
ofitsobligationsunderthisContract(42C.F.R.§438.116).
4.17.1.2 The bond shall be obtained from an agent appearing on the United States
DepartmentofTreasury’slistofapprovedsureties.Thebondshallbemade
payabletotheStateofLouisiana.TheContractanddatesofperformanceshall
bespecifiedinthebond.
4.17.1.3 The initial amount of the bond shall be equal to fifty million dollars
($50,000,000). The initial bond shall be submitted to LDH within ten (10)
Calendar Days of Contract approval in writing by the Office of State
Procurement.
4.17.1.4 ThebondamountshallbereevaluatedandadjustedfollowingtheEnrollment
process,whichincludestheperiodduringwhichEnrolleescanchangeMCOs
withoutcause.Theadjustedamountshallbeequaltofiftypercent(50%)of
thetotalCapitationPayment,exclusiveofmaternityKickPayments,paidto
theContractorforthemonthfollowingtheendoftheprocess.Theadjusted
bondshallbesubmittedtoLDHwithinsixty(60)CalendarDaysofnotification
totheContractoroftheadjustedamount.
4.17.1.5 All bonds newly submitted to LDH shall be original and have theraised
embossedsealonthebondandonthePowerofAttorneypage.Continuation
certificatesmaybesubmittedforrenewedbonds.TheContractorshallretain
aphotocopyofthebond.
4.17.1.6 Any performance bond furnished shall be written by a surety or insurance
company currently on the U.S. Department of the Treasury Financial
Management Service list of approved bonding companies that is published
annually in the Federal Register, or by a Louisiana domiciled insurance
companywithatleastanA‐ratinginthelatestprintingoftheA.M.Best'sKey
Rating Guide to write individual bonds up to ten percent (10%) of
policyholders'surplusasshownintheA.M.Best'sKeyRatingGuideorbyan
insurancecompanythatiseitherdomiciledinLouisianaorownedbyLouisiana
residents and is licensed to write surety bonds. No surety or insurance
company shall write a performance bond whichisin excess of the amount
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indicatedasapprovedbytheU.S.DepartmentoftheTreasuryFinancial
ManagementServicelistorbyaLouisianadomiciledinsurancecompanywith
anA‐ratingbyA.M.Bestuptoalimitoftenpercent(10%)ofpolicyholders'
surplusasshownbyA.M.Best;companiesauthorizedbythisParagraphwho
are not on the treasury list shall not write a performance bond when the
penaltyexceedsfifteenpercent(15%)ofitscapitalandsurplus,suchcapital
and surplus being the amount by which the company's assets exceed its
liabilities as reflected by the most recent financial statements filed by the
companywiththeDepartmentofInsurance.Inaddition,anyperformance
bond furnished shall be written by a surety or insurance company that is
currentlylicensedtodobusinessintheStateofLouisiana.
4.17.2 FidelityBond
4.17.2.1 TheContractorshallsecureandmaintain,duringthetermoftheContract,a
blanketfidelitybondonallpersonnelinitsemployment.
4.17.2.2 Thebondshallinclude,butnotbelimitedto,coverageforlossessustained
throughanyfraudulentordishonestactoractscommittedbyanyemployees
oftheContractoranditssubcontractors.
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PART5: TURNOVERREQUIREMENTS
GeneralTurnoverRequirements
UponterminationoftheContract,theContractorshall:
5.1.1 ComplywithalltermsandconditionsstipulatedintheContract,includingbutnotlimited
to:
5.1.1.1 ContinuationofMCOCoveredServicestoEnrolleesuntiltheeffectivedateof
termination;and
5.1.1.2 Compliance with all requirements that survive termination of the Contract
(e.g., provider reimbursement, encounter submissions, report submissions,
recordretentionrequirements,andotherrequirementswithspecificdatesor
timeperiodsthatextendbeyondtheeffectivedateoftermination)untilthe
applicabledateor at theend oftheapplicabletimeperiod specifiedin the
ContractandtheMCOManual;
5.1.2 Promptly supply all information necessary for the reimbursement of any outstanding
claims;
5.1.3 ProvideallreasonablynecessaryassistancetoLDHintransitioningEnrolleesoutofthe
Contractor’splanuponterminationoftheContractortotheextentspecifiedinthenotice
oftermination.Suchassistanceshallinclude,butbenotlimitedto,forwardingmedical
andotherrecords;facilitationandschedulingofmedicallynecessaryappointmentsfor
care and services; and identification of Enrollees with SHCN including those that are
chronicallyill,highrisk,hospitalizedorpregnant;and
5.1.4 Identify and maintain sufficient key personnel and support staff based in Louisiana to
support all required Contract functions while any outstanding obligations under the
Contractremain.TheContractor’stransitionteamshallassistwithEnrolleetransitionsto
anewMCOandensurethesharingofdocumentationsuchasactivepriorauthorizations,
currentassessmentsandPOCs,andothernecessaryinformationtosupportcontinuityof
care,particularlyforEnrolleeswithSHCN.
TurnoverPlan
5.2.1 UponwrittennotificationofterminationoftheContractbyeitherparty,theContractor
shallsubmitaTurnoverPlanwithinthirty(30)CalendarDaysfromthedateofnotification,
unlessotherappropriatetimeframeshavebeenmutuallyagreeduponbybothparties.If
the Contract is not terminated by written notification, the Contractor shall submit a
Turnover Plan six (6) months prior to the end of the Contract period, including any
extensionstosuchperiod.
5.2.2 TheTurnoverPlanshall:
5.2.2.1 BeapprovedbyLDH;
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5.2.2.2 Detail the approach to ensure an efficient turnover that complies with all
ContractrequirementswhileminimizingdisruptiontoEnrolleesandproviders.
Ataminimum,theTurnoverPlanshallspecificallyaddressthefollowing:
5.2.2.2.1 Staffingplanandretentionstrategies;
5.2.2.2.2 Continuityofcare;
5.2.2.2.3 Enrolleesupportandcommunicationstrategies;
5.2.2.2.4 Providernetworkandaccesstocarestandards;
5.2.2.2.5 Providersupportandcommunicationstrategies;
5.2.2.2.6 Claims management, including provider payments and
recoupments;
5.2.2.2.7 Reportingofdeliverablesdueaftercontracttermination;and
5.2.2.2.8 Monitoringandqualityassuranceprocesses;
5.2.2.3 Include a detailed work plan, in Excel format, that includes the proposed
schedule,activities,resources,anddependenciesassociatedwiththeturnover
tasks,includingtasksthatextendbeyondterminationoftheContract;
5.2.2.4 AddresstheturnoverofrecordsandinformationmaintainedbytheContractor
toeitherLDHorathirdpartydesignatedbyLDH;
5.2.2.5 DescribetheContractor’sapproachforthetransferofallrecords,data,and
operationalsupportinformation,asapplicable,toeitherLDHorathirdparty
designatedbyLDH;Includeanitemizationofallrecords,data,andoperational
support information (in broad categories) that will be transferred and the
scheduleforcompletion.Theproposed transferscheduleshouldbephased
andalignaround theeffective dateoftermination (e.g.,sixty(60) Calendar
Days prior, thirty (30) Calendar Days prior, day of termination, thirty (30)
CalendarDaysafter,etc.;and
5.2.2.6 Include copies of all relevant Enrollee and MCO Covered Services data,
documentation,andotherpertinentinformationnecessary,asdeterminedby
LDH,forLDHorasubsequentMCOtoassumetheoperationalactivities
successfully. This includes, but is not limited to, correspondence,
documentationofongoingoutstandingissues,andotheroperationssupport
documentation.
TransferofData
5.3.1 TheContractorshalltransferalldataregardingtheprovisionofcoveredservicestoLDH
orathirdparty,atthesolediscretionofLDHandasdirectedbyLDH.Alltransferreddata
mustbetransferredincompliancewithHIPAA.
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5.3.2 Allrequired transfersof dataand informationspecified inthisContractshall bemade
electronically, unless otherwise directed by LDH, and accordingtotheformatand
scheduleapprovedbyLDH.
5.3.3 AlldatareceivedshallbeverifiedbyLDHorthesubsequentMCO.IfLDHdeterminesthat
notallofthedataregardingtheprovisionofcoveredserviceswastransferredtoLDHor
thesubsequentMCO,asrequired,orthedatawasnottransferredinaHIPAAcompliant
manner, LDH reserves the right to hire an independent contractortoassistLDHin
obtaining and transferring all the required data and to ensure that all the data was
transferred in a HIPAA compliant manner. The Contractor shall be responsible for
paymentof allreasonable costsincurred byLDH forany suchservices providedbyan
independentcontractor.
Post‐TurnoverServices
5.4.1 Thirty(30)CalendarDaysfollowingturnoverofoperations,theContractorshallprovide
LDHwithaTurnoverResultsreportdocumentingthecompletionandresultsofeachstep
oftheTurnoverPlan.Turnovershallnotbeconsideredcompleteuntilthisdocumenthas
beenapprovedbyLDH.
5.4.2 IftheContractordoesnotprovidetherequireddataandreference tables,
documentation,and/orotherpertinentinformationnecessaryforLDHorthesubsequent
MCO to assume the operational activities successfully, the Contractoragreesto
reimburse LDH for all reasonable costs, including, but not limited to, transportation,
lodging,andsubsistenceforallstateandfederalrepresentatives,ortheiragents,tocarry
outtheirinspection,audit,review,analysis,reproductionandtransferfunctionsatthe
location(s)ofsuchrecords.
5.4.3 TheContractorshallalsopayanyandalladditionalcostsincurredbyLDHthatarethe
result of the Contractor’s failure to provide the required records, data, and/or
documentationwithinthetimeframesagreedtointheTurnoverPlan.LDHmay,atits
solediscretion,deductfromthewithholdofthefinalpaymenttosatisfytheadditional
costsincurred.
5.4.4 TheContractorshallmaintainalldataandrecordsrelatedtoEnrolleesandprovidersfor
ten(10)yearsafterthedateoffinalpaymentundertheContractoruntiltheresolution
ofalllitigation,claims,financialmanagementrevieworauditpertainingtotheContract,
whicheverislonger.UndernocircumstancesshalltheContractororanyofitsmaterial
subcontractorsdestroyordisposeofanysuchrecords,evenaftertheexpirationofthe
mandatoryten(10)yearretentionperiod,withouttheexpresspriorwrittenpermission
ofLDH.
5.4.5 TheContractoragreestorepayanyvalid,undisputedauditexceptionstakenbyLDHin
anyauditoftheContract.LDHmay,atitssolediscretion,deductfromthewithholdofthe
finalpaymentforreimbursementofanyamountsduerelatedtotheauditexception.
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PART6: TERMSANDCONDITIONS
GeneralTerms
6.1.1 TheOperationalStartDateisanticipatedto beJuly1,2022.LDHreservestherightto
revisetheanticipatedOperationalStartDateandshallprovidetheContractorsixty(60)
CalendarDays’priornoticeofsuchchange.TheContractorshallsuccessfullycompletea
ReadinessReview asspecified intheContractTransition andReadinesssectionofthis
ContractpriortotheOperationalStartDate.
6.1.2 ThetermoftheContractshallbethirty‐six(36)monthsfromtheOperationalStartDate
unlessterminatedpriortothatdateinaccordancewithStateorFederallawortermsof
theContract.WithallproperapprovalsandconcurrenceoftheContractor,LDHmayalso
exerciseanoptiontoextendtheContractforuptotwenty‐four(24)additionalmonthsat
thesamerates,terms,andconditionsoftheinitialterm,inclusive of any and all
amendments. Prior to the extension of the Contract beyond the initial thirty‐six (36)
monthterm,approval bytheJointLegislativeCommitteeontheBudget (JLCB)and/or
otherapprovalrequiredbylawshallbeobtained.WrittenevidenceofJLCBapprovalshall
besubmitted,alongwith thecontractamendmenttothe Officeof StateProcurement
(OSP)toextendcontracttermsbeyondtheinitialthirty‐six(36)monthterm.Thetotal
term of the Contract, with extensions, shall not exceed sixty (60)months.The
continuation of the Contract is contingent upon the appropriation of funds by the
legislaturetofulfilltherequirementsoftheContract.
6.1.3 TheContractshallnotbevalid,norshallLDHbeboundbytheContract,untilithasfirst
beenexecutedbytheheadoftheusingagency,orhisdesignee,andtheContractorand
hasbeenapprovedinwritingbyCMSandthedirectorofOSP.
6.1.4 TheContractorshallcomply,tothesatisfactionofLDH,with:(1)allrequirementssetforth
inthisContract;(2)allprovisionsofStateandFederallaws,rules,regulations,policies,
andprocedures,theStatePlan,andWaiversapplicabletotheManagedCareProgram;
and(3)theMCOManual.
6.1.5 TheContractorshallcomplywithallsettlementagreements,orders,and/orjudgements
renderedbyacourtofcompetentjurisdiction,including,butnotlimitedto,thosethat
arisefromA.J. v.LDH (Case3:19‐CV‐00324), Chisholmv.Phillips(Case2:97‐cv‐03274),
and United States v. State of Louisiana (DOJ Agreement, Case‐3:18‐cv‐00608), and
subsequent implementation plans in accordance with the Contract, theMCO Manual,
andasdirectedbyLDH.LDHreservestherighttoassessMonetaryPenaltiesforfailureto
meetthisrequirement.
6.1.6 LDH reserves the right to provide written clarification for non‐material changes of
Contractrequirementswheneverdeemednecessary,atanypointintheContractperiod,
toensuretheproperandefficientadministrationoftheManagedCareProgram.Such
clarificationsshallbeimplementedbytheContractorandshallnotrequireanamendment
totheContract.
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6.1.7 LDH,atitsdiscretion,mayissuecorrespondencetoinformtheContractorofchangesin
Louisiana Medicaid Program policies and procedures which may affect the Contract.
Unless otherwise specified in the Louisiana Medicaid Program correspondence, the
Contractorshallbegivensixty(60)CalendarDaystoimplementsuchchanges.
Amendments
6.2.1 NoamendmentshallbevaliduntilexecutedbyallpartiesandapprovedinwritingbyOSP
in accordance with La. R.S. 39:1595.1. Any amendment to the Contract may require
approvalofCMSpriortotheamendmentimplementation.
6.2.2 LDH,initssolediscretion,maypursueanamendmenttotheContractatanytime.Prior
tosubmissionoftheamendmentfortherequisiteapproval(s),LDHmaysolicitfeedback
fromtheContractorontheproposedamendmentlanguage.However,LDHretainsfinal
decision‐makingauthorityonthelanguagethatwillultimatelybesubmittedtoCMSand
OSPforreviewandapproval.
6.2.3 UnlessotherwisespecifiedbyLDH,theContractorshallimplementallprovisionsofan
amendmentnolaterthansixty(60)CalendarDaysfromthedatetheContractorreceives
thefullyexecutedamendment.
6.2.4 ShouldtheContractorrefusetoacceptanamendment,itmaysubmitawrittenrequest
toLDHtoterminatetheContractwithaneffectivedateofatleastsixty(60)CalendarDays
fromthedateofLDH’sreceiptofthewrittenrequest.LDHshallhavesolediscretionto
approve or deny the request for termination and to impose such conditions on the
grantingofanapprovalasitmaydeemappropriate.
6.2.5 LDHmayterminatetheContractiftheContractorfailstoexecuteanamendmentwithin
ten(10)CalendarDaysofdelivery.
6.2.6 IftheContractisterminatedinaccordancewith6.2.4or6.2.5, at a minimum, the
requirements set forth in Part 5: Turnover Requirements and the Bond Requirements
sectionshallapply.
RateAdjustments
6.3.1 The Capitation Rates identified in this Contract shall be in effect during the periods
identified in the rate certifications posted on LDH’s website. CapitationRatesmaybe
adjustedduringthetermoftheContractbasedonLDHandactuarialanalysis,subjectto
CMSreviewandapproval.
6.3.2 Adjustments to the Capitation Rate(s) shall be implemented through a written
amendmenttotheContract.
ReferencestoLaws,Rules,orRegulations
AllreferencesinthisContracttoanylaw,rule,orregulationshallbedeemedtorefertothelaw,
rule,orregulationineffectatthetimeoftheissuanceofthisContractorastheymaybehereafter
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amended.Throughouttheterm oftheContract, including anyextension(s),theContractorshall
complywiththelaws,rules,andregulationsineffectatthattime.
ApplicableLawsandRegulations
TheContractoragreestocomplywithallapplicableFederalandStatelaws,regulations,andrules,
including,butnotlimitedto:
6.5.1 Constitutionalprovisionsregardingdueprocessandequalprotection.
6.5.2 Code of Federal Regulations (C.F.R.), Title 42, Chapter IV, Subchapter C (Medical
AssistancePrograms).
6.5.3 Provisionsrelatingtomanagedcarein42U.S.C.§1396u‐2.
6.5.4 Allapplicablestandards,orders,orregulationsissuedpursuanttotheCleanAirAct,as
amended(42U.S.C.§7401,etseq.),regulationsissuedpursuantthereto;theCleanWater
Act,asamended(33U.S.C.§1251,etseq.),andregulationsissuedpursuantthereto;and
thePro‐ChildrenActof1994(20U.S.C.§6081,etseq.)andregulationsissuedpursuant
thereto.
6.5.5 The Balanced Budget Act of 1997, as amended (P.L. 105‐33), and regulations issued
pursuantthereto;andtheBalancedBudgetRefinementActof1999,asamended(P.L.
106‐113),andregulationsissuedpursuantthereto.
6.5.6 Section 1128 of the Social Security Act (42 U.S.C. §1320a‐7) and regulations issued
pursuant thereto, relating to exclusion of certain individuals and entities from
participationinMedicareandtheLouisianaMedicaidProgram.
6.5.7 Section 1156 of the Social Security Act (42 U.S.C. §1320c‐5) and regulations issued
pursuantthereto.
6.5.8 The Drug Free Workplace Act of 1988, as amended (41 U.S.C. §8101, et seq.), and
regulationsissuedpursuantthereto.
6.5.9 TheByrdAnti‐LobbyingAmendment(31U.S.C.§1352)andregulationsissuedpursuant
thereto,whichprovidethattheContractoranditsSubcontractor(s)shallfiletherequired
certification.Eachtiercertifiestothetierabove,thatitwillnotandhasnotusedFederal
appropriatedfundstopayany personororganizationforinfluencingorattemptingto
influence an officer or employee of any agency, a member of Congress, officer or
employeeofCongress,oranemployeeofamemberofCongressin connection with
obtainingany Federalcontract,grantoranyotherawardcoveredby 31U.S.C. §1352.
Each tier must also disclose any lobbying with non‐Federal fundsthattakesplacein
connectionwithobtaininganyFederalaward.Suchdisclosuresareforwardedfromtier‐
to‐tieruptothenon‐Federalaward.
6.5.10 ThePaulWellstoneandPeteDomeniciMentalHealthParityandAddictionEquityActof
2008(P.L.110‐343)andregulationspursuantthereto,whichrequirecoverageformental
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health and substance use disorders to be no more restrictive than the coverage that
generallyisavailableformedical/surgicalconditions.
CivilRightsCompliance
TheContractoragreestoabidebythefollowingrequirements,asapplicable:
6.6.1 Section1557ofthePatientProtectionandAffordableCareAct(42U.S.C.§18116)and
regulationsissuedpursuantthereto;TitleVIoftheCivilRightsActof1964,asamended
(42U.S.C.§2000d,etseq.),andregulationsissuedpursuantthereto;TitleVIIoftheCivil
Rights Act of 1964, as amended (42 U.S.C. §2000e, et seq.), and regulations issued
pursuantthereto;TitleIXoftheEducationAmendmentsof1972(20U.S.C.§1681,etseq.)
andregulationsissuedpursuantthereto;theAgeDiscriminationActof1975,asamended
(42U.S.C.§6101,etseq.),andregulationsissuedpursuantthereto;Section504ofthe
RehabilitationActof1973,asamended(29U.S.C.§794),andregulationsissuedpursuant
thereto;Section508oftheRehabilitationActof1973(29U.S.C.§794d)andregulations
issued pursuant thereto; the Americans with Disabilities Act of1990, as amended (42
U.S.C. §12101, et seq.), and regulations issued pursuant thereto;theVietnamEra
Veterans’ReadjustmentAssistanceActof1974(38U.S.C.§4212)andregulationsissued
pursuantthereto;theFairHousingActof1968(42U.S.C.§3601,etseq.)andregulations
issuedpursuantthereto;andFederalExecutiveOrder11246.
6.6.2 TheContractoragreesnottodiscriminateinitsemploymentpractices,andwillrender
servicesunderthisContractwithoutregardtorace,color,religion,sex,sexualorientation,
nationalorigin,genderidentity,veteranstatus,politicalaffiliation,disability,orageinany
matterrelatingtoemployment.
6.6.3 TheContractoragreesthatnoperson,onthegroundsofthesefactors,shallbeexcluded
fromparticipationin,orbedeniedbenefitsoftheContractor’sprogram,orbeotherwise
subjectedtodiscriminationintheperformanceofthisContract.TheContractorshallnot
use any policy or practice, including its employment practices, that has the effect of
discriminatingonthesefactors.AnyactofdiscriminationcommittedbytheContractor,
orfailuretocomplywiththesestatutoryobligations,whenapplicable,asdeterminedby
LDHinitssolediscretion,shallbegroundsforterminationofthisContract.
6.6.4 In all hiring or employment made possible by or resulting from this Contract, the
Contractorshalltakeaffirmativeactiontoensurethatapplicantsareemployedandthat
employeesaretreated duringemploymentinaccordancewithall applicablestateand
Federallawsregardingemploymentofpersonnel.
6.6.5 This requirement shall apply to, but not be limited to, the following: employment,
upgrading, demotion, transfer, recruitment or recruitment advertising, layoff,
termination, rates of pay or other forms of compensation, and selection for training
including apprenticeship. The Contractor further agrees to give public notice in
conspicuousplacesavailabletoemployeesandapplicantsforemploymentsettingforth
theprovisionsofthisSection.Allsolicitationsoradvertisementsforemployeesshallstate
thatallqualifiedapplicantswillreceiveconsiderationforemploymentwithoutregardto
disability,age,race,color,religion,sex,nationalorigin,orsexualorientation.Allinquiries
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made to the Contractor concerning employment shall be answered without regard to
handicap,age,race,color,religion,sex,nationalorigingenderidentity,veteranstatus,
political affiliation, or sexual orientation. All responses to inquiries made to the
Contractor concerning employment made possible as a result of this Contract shall
conformtoFederal,State,andlocalregulations.
6.6.6 TheContractorshallpostnoticesofnon‐discriminationinconspicuousplaces,available
toallemployeesandapplicants.ThisprovisionshallbeincludedinallNetworkProvider
Agreementsandsubcontracts.
PaymentofPremiumTaxes
TheContractorshallberesponsibleforpaymentofallpremiumtaxesassessedontheCapitation
PaymentstotheLouisianaDepartmentofInsuranceaccordingtothescheduleestablishedinLa.
R.S.22:845.
ConfidentialityofInformation
6.8.1 Allfinancial,statistical,personal,technicalandotherdataandinformationrelatingtothe
State'soperationwhicharedesignatedconfidentialbytheStateandmadeavailableto
the Contractor in order to carry out this Contract, or which become available to the
Contractor in carrying out this Contract, shall be protected bytheContractorfrom
unauthorizeduseanddisclosurethroughtheobservanceofthesameormoreeffective
requirementsasareapplicabletotheState.Theidentificationofallsuchconfidentialdata
andinformationaswellastheState'sproceduralrequirementsforprotectionofsuchdata
andinformationfromunauthorizeduseanddisclosureshallbeprovidedbytheStatein
writingtotheContractor.IfthemethodsandproceduresemployedbytheContractorfor
theprotectionoftheContractor'sdataandinformationaredeemedbytheStatetobe
adequatefortheprotectionoftheState'sconfidentialinformation,suchmethodsand
proceduresmaybeused,withthewrittenconsentoftheState,tocarryouttheintentof
this paragraph. The Contractor shall not be required under the provisions of this
paragraph to keep confidential any data or information which is or becomes publicly
available, is independently developed by the Contractor outsidethescopeofthe
Contract,orislawfullyobtainedfreeofrestrictionfromathirdpartyhavingtherightto
furnishsuchconfidentialdataorinformation.
6.8.2 Under no circumstance shall the Contractor discuss and/orrelease informationtothe
mediaconcerningthisContractwithoutpriorexpresswrittenapprovalofLDH.
ConflictofInterest
6.9.1 TheContractoracknowledgesthatChapter15ofTitle42oftheLouisianaRevisedStatutes
(La.R.S.42:1101etseq.,CodeofGovernmentalEthics)appliestotheContractorinthe
performanceofservicescalledforinthisContract.TheContractoragreestoimmediately
notifytheStateifpotentialviolationsoftheCodeofGovernmentalEthicsariseatany
timeduringthetermofthisContract.
6.9.2 TheContractorshallcomplywiththeprohibitionssetforthin42U.S.C.§1396a(a)(4)(C).
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6.9.3 Neither the Contractor nor any Material Subcontractor shall, for the duration of the
Contract,haveanyinterestthatwillconflictorappearstoconflict,asdeterminedbyLDH,
with the performance of services under the Contract, or that may be otherwise
anticompetitive. Without limiting the generality of the foregoing, LDH requires that
neither the Contractor nor any material subcontractor have any financial, legal,
contractual,orotherbusinessinterestinanyentityperformingEnrollmentfunctionsfor
theManagedCareProgram.
WarrantyofRemovalofConflictofInterest
TheContractorwarrantsthatit,itsofficers,anditsemployeeshavenointerestandshallnotacquire
anyinterest,directorindirect,whichconflictsinanymannerordegreewiththeperformanceof
services hereunder. The Contractor shall inquire of its officers and employees concerning such
conflictsatleastquarterly,andshallinformLDHofanypotentialoractualconflict(s)withinone(1)
BusinessDayofdiscovery.TheContractorwarrantsthatitshallremoveanyconflictofinterestprior
tosigningtheContractandduringthetermoftheContract.
ContractControversies
AnyclaimorcontroversyarisingoutoftheContractshallberesolvedbytheprovisionsofLa.R.S.
39:1672.2‐1672.4.
ContractLanguageInterpretation
The Contractor and LDH agree that in the event of a disagreementregarding,arisingoutof,or
related to, Contract language interpretation, LDH’s interpretation of the Contract language in
disputeshallcontrolandgovern.
InterpretationDisputeResolutionProcedure
6.13.1 TheContractormayrequestthatLDHprovideadeterminationwith respect to the
applicationofanyprovisionofthisContractrequiredforproper performance of the
servicesunderthisContract.Anysuchrequestmustbesubmitted in writing to the
MedicaidDeputyDirectorforProgramOperationsandCompliance.
6.13.2 IftheContractordoesnotagreewiththeinterpretationprovidedbytheMedicaidDeputy
Director,theContractormayrequestreconsideration.Therequestforreconsideration
mustbesubmittedinwritingtotheMedicaidExecutiveDirector and include an
explanation of about the reason for the disagreement. The deadline for requesting
reconsiderationistwenty‐one(21)CalendarDaysafterreceiptoftheresponsefromthe
MedicaidDeputyDirector.
6.13.3 TheoptiontodisputeaninterpretationdoesnotapplytolanguageintheContractthatis
basedonFederalorStatelaws,regulations,policies,procedures,ormanuals,theState
Plan,orWaivers.
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6.13.4 TheMedicaidExecutiveDirectorwillrenderhisorherfinaldecisionbaseduponwritten
submissions from the Contractor and the Medicaid Deputy Director for Program
Operations and Compliance, unless, at the sole discretion of the Medicaid Executive
Director,theMedicaidExecutiveDirectorallowsoralpresentationsbytheContractorand
theMedicaidDeputyDirectororhis/herdesignee.Ifsuchapresentationisallowed,the
informationpresentedshallbeconsideredinrenderingthedecision.
6.13.5 TheMedicaidExecutiveDirectorshallreducehisorherdecisiontowritingandprovidea
copytotheContractor.ThewrittendecisionoftheMedicaidExecutiveDirectorshallbe
thefinaldecisionofLDH.
6.13.6 PendingfinaldeterminationofanydisputeoveraLDHdecision,theContractorshall
proceed diligently with the performance of the Contract and in accordance with the
directionofLDH.
CooperationwithOtherContractors
In the event that LDH has entered into, or enters into, agreementswithothercontractorsfor
additionalworkrelatedtotheservicesrenderedunderthisContract,including,butnotlimitedto,
FIandEnrollmentBrokerservices,theContractoragreestocooperate fully with such other
contractors.TheContractorshallnotcommitanyactthatwillinterferewiththeperformanceof
workbyanyotherLDHcontractor.
Copyrights
IfanycopyrightablematerialisdevelopedinthecourseoforunderthisContract,LDHshallreceive
a royalty free, and shall have a non‐exclusive, and irrevocable right to reproduce, publish, or
otherwiseusetheworkforLDHpurposes.
CorporationRequirements
IftheContractorisacorporation,thefollowingrequirementshallbemetpriortoexecutionofthe
Contract:
6.16.1 IftheContractorisaforprofitcorporationwhosestockisnot publicly traded, the
ContractormustfileaDisclosureofOwnershipformwiththeLouisianaSecretaryofState.
6.16.2 IftheContractorisacorporationnotincorporatedunderthelawsoftheStateof
Louisiana,theContractorshallobtainaCertificateofAuthority from the Louisiana
SecretaryofState.,inaccordancewithLa.R.S.12:301,etseq.
6.16.3 TheContractor’slegalcounselshallprovidewrittenassurancetoLDHthattheContractor
isnot prohibited by its articles of incorporation, bylaws, or the laws under which it is
incorporatedfromperformingtheservicesrequiredundertheContract.
6.16.4 SecureandattachtotheContractaformalBoardResolutionindicatingthesignatoryto
theContractisacorporaterepresentativeandauthorizedtosignsaidContract.
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Debarment/Suspension/Exclusion
6.17.1 The Contractor agrees to comply with all applicable provisions of 2 C.F.R. Part 376,
pertainingtononprocurement debarment and/or suspension, and42 C.F.R. §438.610,
pertainingtoprohibitedaffiliations.
6.17.2 The Contractor shall screen all directors, officers, partners, persons with beneficial
ownershipoffivepercent(5%)ormore,Subcontractors,NetworkProviders,andpersons
withanemployment,consulting,orotherarrangementwiththeContractortodetermine
whethertheyhavebeenexcludedfromparticipationinMedicare,Medicaid,CHIP,and/or
anyotherFederalhealthcareprograms.
6.17.3 The Contractor shall conduct such screenings monthly to capture exclusions and
reinstatementsthathaveoccurredsincethelastsearch,andanyexclusioninformation
discoveredshouldbeimmediatelyreportedtoLDH.

6.17.4 Anyindividualorentitythatemploysorsubcontractswithanexcludedprovidercannot
claim reimbursement from the Louisiana Medicaid Program for anyitemsorservices
furnished,authorized,or prescribed bythe excluded provider.Thisprohibition applies
evenwhentheLouisianaMedicaidProgrampaymentitselfismadetoanotherprovider
who is not excluded; for example, a pharmacy that fills a prescription written by an
excluded doctor for a Beneficiary cannot claim reimbursement fromtheLouisiana
MedicaidProgramforthatprescription.CivilMonetaryPenaltiesmaybeimposedagainst
Providerswho employor enterintoprovideragreementswith excluded individuals or
entitiestoprovideitemsorservicestoEnrollees.See42U.S.C.§1320a‐7and§1320a‐7a
and42C.F.R.§1003.140(a)(2).
EmployeeEducationaboutFalseClaimsRecovery
IfannualpaymentstotheContractorequalfivemilliondollars($5,000,000)ormoreinaccordance
with42U.S.C.§1396a(a)(68)andregulationsissuedpursuantthereto,theContractormust:
6.18.1 Establish writtenpolicies forall employeesofthe Contractor (including management),
andofanySubcontractororagentoftheContractor,thatprovidedetailedinformation
about the False Claims Act established under 31 U.S.C. §§3729 through 3733,
administrative remedies for false claims and statements established under 31 U.S.C.
Chapter38,anyStatelawspertainingtocivilorcriminal penaltiesforfalseclaims and
statements,andwhistleblowerprotectionsundersuchlaws,withrespecttotheroleof
suchlawsinpreventinganddetecting Fraud,Waste,andAbuseinFederalhealthcare
programs(asdefinedin42U.S.C.§1320a‐7b(f)).
6.18.2 Include as part of such written policies, detailed provisions regarding the Contractor’s
policiesandproceduresfordetectingandpreventingFraud,Waste,andAbuse.
6.18.3 IncludeinanyemployeehandbookfortheContractor,aspecificdiscussionofthelaws
describedin6.18.1,therightsofemployeestobeprotectedaswhistleblowers,andthe
Contractor’s policies and procedures for detecting and preventing Fraud, Waste, and
Abuse.
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EntireContractandOrderofPrecedence
6.19.1 ThisContractandanyamendmentsthereof,includingtheRFPandanyaddendaissued
thereto,theproposalsubmittedbytheContractor,andanyattachments,appendices,and
exhibitsspecificallyincorporatedthereinbyreference,constitutetheentireagreement
betweenthepartieswithrespecttothesubjectmatter.
6.19.2 ThisContractshall,totheextentpossible,beconstruedtogiveeffecttoallprovisions
contained therein. However, in the event of any inconsistency or conflict among the
documentelementsofthisContract,suchinconsistencyorconflictshallberesolvedby
givingprecedencetothefollowingdocumentsinthefollowingorder:
6.19.2.1 ThebodyoftheContractwithexhibitsandattachments,excludingtheRFPand
theContractor’sproposal.
6.19.2.2 TheRFPandanyaddendaandappendices.
6.19.2.3 TheMCOManual.
6.19.2.4 TheProposalsubmittedbytheContractorinresponsetotheRFP.
GoverningLawandVenue
ThisContractshallbegovernedbyandinterpretedinaccordancewiththelawsoftheStateof
Louisiana,exceptitsconflictoflawsprovisions.Anyadministrativeproceeding,actionatlaw,suitin
equity,orjudicialproceedingfortheenforcementofthisContractoranyprovisionthereofshallbe
institutedonlyintheadministrativetribunalsandcourtsoftheStateofLouisiana.Specifically,any
statecourtsuitshallbefiledinthe19thJudicialDistrictCourtforEastBatonRougeParishasthe
exclusivevenueforsame,andanyFederalsuitshallbefiledintheU.S.DistrictCourtfortheMiddle
DistrictofLouisianaastheexclusivevenueforsame.ThisSectionshallnotbeconstruedasgranting
arightorcauseofactiontotheContractorinanyoftheaforementionedCourts.
AttorneyFees
In the event LDH should prevail in any legal action arising out of the performance or non‐
performance of the Contract, the Contractor shall pay, in additiontoanypenaltiesordamages
awarded,allexpensesofsuchactionincluding,butnotlimitedto,reasonableattorneyfeesand
costs.Theterm“legalaction”shallbedeemedtoincludeadministrativeproceedingsofallkinds,as
wellasallactionsatlaworequity.
The Contractor is prohibited from expending funds received fromLDHunderthisContractto
dispute, appeal, or take legal action arising out of the performance or non‐performance of the
Contract.
Page360of381
ConfidentialityofPatientandEnrolleeRecords–HIPAA
TheContractorshallcomplywiththeHealthInsurancePortabilityandAccountabilityActof1996
(HIPAA),asamendedbytheHealthInformationTechnologyforEconomicandClinicalHealthActof
2009(theHITECHAct)andtherulesandregulationspromulgatedthereunder(45C.F.R.Parts160,
162, and 164). The Contractor shall ensure compliance with all HIPAA requirements across all
systemsandservicesrelatedtothisContract,includingtransaction,commonidentifier,andprivacy
andsecuritystandards,bytheeffectivedateofthoserulesandregulations.TheContractorshall
protect the privacy and confidentiality of medical records and any and all other health and
EnrollmentinformationrelatingtoEnrolleesorPotentialEnrollees,whichisprovidedtoorobtained
byorthroughtheContractor’sperformanceunderthisContract,whetherverbal,written,electronic
file,orotherwise,asrequiredbyapplicableprovisionsof45C.F.R.Parts160and164(theHIPAA
PrivacyRule)andotherStateandFederallaws,orthisContract.Nothingstatedhereinshallprohibit
thedisclosureofinformationinsummary,statistical,orotherformthatdoesnotidentifyparticular
individuals.
HIPAABusinessAssociateProvisions
Asa“businessassociate”ofLDH,asthattermisdefinedintheHIPAAPrivacyRule,theContractor
shallcomplywiththeHIPAABusinessAssociateprovisionsfoundinSection43oftheLDHStandard
ContractForm(CF‐1),whichisAttachmentItotheRFP.
ConfidentialityofPatientandEnrolleeRecords–SubstanceUseTreatmentRecords
TheContractorshall comply with the requirements of42 U.S.C. §290dd‐2 and its implementing
regulations, 42 C.F.R. Part 2. The Contractor shall strictly maintain the confidentiality of patient
records of drug, alcohol, and other drug treatment programs in addition to treatment and
assessmentforpathologicalorcompulsivegambling.
The Contractor shall ensure that every Enrollee treated by a providerthatisacoveredPart2
Program,asdefinedin42C.F.R.§2.11,isofferedtheopportunitytosignaconsentformforthe
disclosureofsubstanceusetreatmentinformationtotheEnrollee’sPCPforthepurposeofhealth
careintegrationinaccordancewith42C.F.R.Part2,SubpartC.
TheContractorshallhavetheabilitytotrackprovidercompliancewithofferingconsentformsfor
EnrolleesreceivingsubstanceuseservicesfromPart2Programs,includingthenumberofEnrollees
receivingsubstanceuseservicesbyeachproviderandthenumberofconsentformsofferedand
signed.TheContractorshallreportthisinformationtoLDHuponrequest.
Whensubstanceuseinformationissubjecttotherequirementsof42C.F.R.Part2,anydisclosure
ofthatinformationwithoutthewrittenconsentofthepatientshallcomplywith42C.F.R.Part2and
shallbeaccompaniedbyastatementnotifyingtherecipientoftheprohibitionagainstre‐disclosure.
TheContractor shalldevelop policies andprocedureswhichoutlineHIPAA requirements and 42
C.F.R.Part2requirementsforthepurposeofhealthcareintegration.Thesepoliciesandprocedures
shalloutlineinstancesinwhich42C.F.R.Part2requirementsoverrideHIPAArequirements.
Page361of381
The Contractor shall educate contracted Network Providers on protocols for requesting and
receivingpatientrecordsinaccordancewith45C.F.R.Parts160and164(HIPAA)and42C.F.R.Part
2.
6.24.1 HIPAADisclosureProcess

6.24.1.1 The Contractor shall protect confidential information and documents in
accordancewith42U.S.C.§671(a)(8),42U.S.C.§5106a,42U.S.C.§290dd‐2,
45C.F.R.§1355.21,45C.F.R.§205.50,45C.F.R.§1355.30,42C.F.R.Part2,La.
R.S.46:56,and45C.F.R.Parts160and164,asapplicable.TheContractorshall
discloseinwritinganyuseordisclosureofPHIotherthanaspermittedbythe
Contract within three (3) Calendar Days of becoming aware of the use or
disclosure.
6.24.1.2 The Contractorisrequiredtosubmitincident reportsaffectingProviders or
EnrolleesreceivingservicestoLDHwithaCAPandtimelinesfor
implementation of correction for approval by LDH within ten (10) Business
DaysoftheContractor’s discoveryofanyHIPAA breaches,asdefinedat45
C.F.R.§164.402.Theincidentreportshallinclude,ataminimum:
6.24.1.2.1 Dateofdiscovery.
6.24.1.2.2 Dateordaterangeofviolation/potentialviolation.
6.24.1.2.3 Causeoftheincidentincludingsequenceandmechanisms.
6.24.1.2.4 NumberofunauthorizedindividualswhoviewedPHI.
6.24.1.2.5 NumberofaffectedindividualswhosePHIwascompromised.
6.24.1.2.6 Stepstakentocorrectthisincidenttodate,andplannedstepsto
correctincident.
6.24.1.2.7 Steps taken to prevent reoccurrence from happening in the
future.
6.24.1.2.8 Steps taken to mitigate any harmful effects caused by the
unauthorizeddisclosure.
6.24.1.2.9 Any training or other corrective action targeted to the
Contractor.
6.24.1.2.10 PlansfornotificationofCMS/HHS.
6.24.1.2.11 Notificationplantoindividuals.
6.24.1.2.12 Ariskassessmentwhichincludesthefollowing:
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6.24.1.2.12.1 The nature and extent of the PHI involved,
including the types of identifiers and the
likelihoodofre‐identification.
6.24.1.2.12.2 TheunauthorizedpersonwhousedthePHIor
towhomthedisclosurewasmade.
6.24.1.2.12.3 Whether the PHI was actually acquired or
viewed.
6.24.1.2.12.4 The extent to which the risk to the PHI has
beenmitigated.
ReleaseofRecords
The Contractor shall release Medical Records upon request by Enrollees or their Authorized
Representatives,asmaybedirectedbyauthorizedpersonnelofLDH,appropriateagenciesofthe
StateofLouisiana,orFederalagencies.ReleaseofMedicalrecords shall be consistentwith the
provisionsofconfidentialityassetforthinthisContract.Theownershipandprocedureforrelease
ofMedicalRecordsshallbecontrolledbytheStateandFederallawandregulations,includingbut
notlimitedto,La.R.S.40:1165.1,La.R.S.13:3734,andLa.C.E.art.510and45C.F.R.Parts160and
164(HIPAAPrivacyRule)andsubjecttoreasonablecharges.TheContractorshallnotchargeLDHor
itsdesigneeforanycopiesofMedicalRecordsrequested.
Security
6.26.1 Contractor’spersonnelshallcomplywithallsecurityregulationsineffectattheState’s
premises and externally for materials and property belonging to the State or to the
project.Wherespecialsecurityprecautionsarewarranted(e.g.,correctionalfacilities),
theStateshallprovidesuchprocedurestotheContractor,accordingly.
6.26.2 TheContractorshallcomplywiththeOfficeofTechnologyServices’InformationSecurity
Policyathttp://www.doa.la.gov/Pages/ots/InformationSecurity.aspx.
6.26.3 CybersecurityTraining
6.26.3.1 In accordance with La. R.S. 42:1267(B)(3) and the State of Louisiana’s
InformationSecurityPolicy,iftheContractor,anyofitsemployees,agents,or
subcontractorswillhaveaccesstoStategovernmentinformationtechnology
assets, the Contractor’s employees, agents, or subcontractors with such
access must complete cybersecurity training annually, and the Contractor
mustpresentevidenceof such compliance annually anduponrequest. The
ContractormayusethecybersecuritytrainingcourseofferedbytheLouisiana
Department of State Civil Service without additional cost or may use any
alternatecourseapprovedinwritingbytheOfficeofTechnologyServices.
6.26.3.2 For purposes of this Section, “access to State government information
technology assets” means the possession of credentials, equipment, or
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authorizationtoaccesstheinternalworkingsofStateinformationtechnology
systems or networks. Examples would include but not be limited to State‐
issuedlaptops,VPNcredentialstoaccesstheStatenetwork,badgingtoaccess
theState’stelecommunicationsclosetsorsystems,orpermissionstomaintain
ormodifyITsystemsusedbytheState.Finaldeterminationofscopeinclusions
orexclusionsrelativetoaccesstoStategovernmentinformationtechnology
assetswillbemadebytheOfficeofTechnologyServices.
SafeguardingInformation
TheContractorshallestablishwrittensafeguardsthatrestricttheuseanddisclosureofinformation
concerningEnrolleesorPotentialEnrolleestopurposesdirectlyconnectedwiththeperformanceof
thisContract.TheContractor'swrittensafeguardsshall:
6.27.1 BecomparabletothoseimposedupontheLDHby42C.F.R.Part431,SubpartF,andLa.
R.S.46:56;
6.27.2 State that the Contractor will identify and comply with any stricter state or Federal
confidentiality standards which apply to specific types of information or information
obtainedfromoutsidesources;
6.27.3 RequireawrittenauthorizationfromtheEnrolleeorPotentialEnrolleebeforedisclosure
of information about him or her under circumstances requiring such authorization
pursuantto45C.F.R.§164.508;
6.27.4 Notprohibitthereleaseofstatisticaloraggregatedatawhichcannotbetracedbackto
particularindividuals;and
6.27.5 Specifyappropriatepersonnelactionstosanctionviolators.
HomelandSecurityConsiderations
6.28.1 TheContractorshallperformallservicesunderthisContractwithintheUnitedStates.The
term “United States” includes the fifty (50) states, the District of Columbia, and U.S.
territories.Inaddition,theContractorwillnothireanyindividualtoperformanyservices
underthisContractifthatindividualisrequiredtohaveaworkvisaapprovedbytheU.S.
DepartmentofHomelandSecurityandsuchindividualhasnotmetthisrequirement.
6.28.2 IftheContractorperformsservices,orusesservices,inviolation of the foregoing
paragraph,theContractorshallbeinmaterialbreachofthisContractandshallbeliable
toLDHforanycosts,fees,damages,claims,orexpensesitmayincur.LDHmayimpose
any sanction, up to and including termination for cause, for violation of this section.
Additionally, the Contractor shall be required to hold harmless and indemnify LDH
pursuanttotheindemnificationprovisionsofthisContract.
6.28.3 TheprohibitionsinthisSectionshallalsoapplytoanyandallagentsandSubcontractors
oftheContractortoperformanyservicesunderthisContract.
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SafetyPrecautions
LDHassumesnoresponsibilitywithrespecttoaccidents,illnessesorclaimsarisingoutofanyactivity
performedunderthisContract.TheContractorshalltakenecessarystepstoinsureorprotectits
Enrollees,itself,itspersonnel,Providers,andanySubcontractor.TheContractoragreestocomply,
and ensure that all of its Subcontractors comply, with all applicable local, State, and Federal
occupationalandsafetylaws,rules,andregulations.
LicensesandPermits
6.30.1 TheContractorshallsecureandmaintainalllicensesandpermits,andpayinspectionfees
requiredtodotheworkinaccordancewiththisContract.
6.30.2 The Contractor shall secure and maintain an active license or certificate of authority
issuedbytheLouisianaDepartmentofInsurancetooperateasaMedicaidriskbearing
“prepaidentity”pursuanttoLa.R.S.22:1016.
SolvencyRequirement
TheContractorshallcomplywithallLouisianaDepartmentofInsuranceapplicablestandards.The
Contractor shall meet solvency standards as specified in 42 C.F.R. §438.116 and Title 22 of the
LouisianaRevisedStatutes.
InsuranceRequirements
6.32.1 The Contractor shall purchase and maintain for the term of the Contract, insurance
againstclaimsforinjuriestopersonsordamagestopropertythatmayarisefromorin
connectionwiththeperformanceoftheworkhereunderbytheContractor,itsagents,
representatives, employees, Providers, or Subcontractors. The Contractor shall not
commenceworkunderthisContractuntilithasobtained,atitsowncostandexpense,all
insurancerequiredherein.
6.32.1.1 The Contractor shall not allow any Subcontractor to commence work on a
subcontract until all insurance required for the Subcontractor has been
obtainedandapproved.
6.32.1.2 MinimumScopeandLimitsofInsuranceforWorkers’Compensation
6.32.1.2.1 Employers Liability is included with a minimum limit of one
million dollars ($1,000,000) per accident/per disease/per
employee.Ifworkistobeperformedoverwaterandinvolves
maritimeexposure,applicable Longshore andHarborWorkers’
CompensationAct(33U.S.C.§901,etseq.),MerchantMarineAct
of1920(46U.S.C.§30104),orothermaritimelawcoverageshall
beincluded.
6.32.1.3 CommercialGeneralLiability
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6.32.1.3.1 CommercialGeneral Liability insurance, includingPersonaland
Advertising Injury Liability and Products and Completed
Operations Liability coverage, shall have a minimum limit per
occurrenceof twomilliondollars ($2,000,000)and aminimum
generalannualaggregateoffourmilliondollars($4,000,000).The
Insurance Services Office (ISO) Commercial General Liability
occurrencecoverageformCG0001(currentformapprovedfor
use in Louisiana), or equivalent, shall be used in the policy.
Claims‐madeformisunacceptable.
6.32.1.3.2 TheContractorshallmaintain,duringthetermoftheContract,
Commercial General Liability Insurance to protect the
Contractor,LDH,andanySubcontractorduringtheperformance
ofworkcoveredbytheContractfromclaimsordamagesfor
personalinjury,includingaccidentaldeath,aswellasfromclaims
forproperty damages,which may arisefrom operations under
theContract,whethersuchoperationsbebytheContractoror
byaSubcontractor,orbyanyonedirectlyorindirectlyemployed
byeither,orinsuchamannerastoimposeliabilitytoLDH.
6.32.1.4 ProfessionalLiability(ErrorsandOmissions)
6.32.1.4.1 ProfessionalLiability(Error&Omissions)insurance,whichcovers
theprofessionalerrors,acts,oromissionsoftheContractor,shall
haveaminimum limitof threemillion dollars($3,000,000)per
claim. Claims‐made coverage is acceptable. The date of the
inceptionofthepolicyshallbenolaterthanthefirstdateofthe
anticipated workunder thisContract. Itshall providecoverage
forthedurationofthisContractandshallhaveanexpirationdate
noearlierthanthirty(30)CalendarDaysaftertheanticipated
termination date of the Contract. The policy shall provide an
extendedreportingperiodofnotlessthanthirty‐six(36)months,
withfullreinstatementoflimits,fromtheexpirationdateofthe
policy,ifthepolicyisnotrenewed.
6.32.1.5 AutomobileLiability
6.32.1.5.1 AutomobileLiabilityInsuranceshallhaveaminimumcombined
singlelimitperaccidentofonemilliondollars($1,000,000).ISO
formnumberCA0001(currentformapprovedforusein
Louisiana), or equivalent, shall be used in the policy. This
insurance shall include third‐party bodily injury and property
damageliabilityforowned,hired,andnon‐ownedautomobiles.
6.32.2 CyberLiability
6.32.2.1 Cyberliabilityinsurance,includingfirst‐partycosts,duetoanelectronicbreach
thatcompromisestheState’sconfidentialdatashallhaveaminimumlimitper
occurrence of five million dollars ($5,000,000). Claims‐made coverage is
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acceptable.Thedateoftheinceptionofthepolicyshallbenolaterthanthe
firstdateoftheanticipatedworkunderthisContract.Itshallprovidecoverage
forthedurationofthisContractandshallhaveanexpirationdatenoearlier
thanthirty(30)CalendarDaysaftertheanticipatedterminationdateofthe
Contract. The policy shall provide an extended reporting period of not less
thanthirty‐six(36)monthsfromtheexpirationdateofthepolicy,ifthepolicy
isnotrenewed.Thepolicyshallnotbecancelledforanyreason,exceptnon‐
paymentofpremium.
6.32.3 DeductiblesandSelf‐InsuredRetentions
Anydeductiblesorself‐insuredretentionsshallbedeclaredtoandacceptedbyLDH.
The
Contractorshallberesponsibleforalldeductiblesandself‐insuredretentions.
6.32.4 OtherInsuranceProvisions
6.32.4.1 CommercialGeneralLiability,AutomobileLiability,andCyberLiabilitypolicies
shallcontain,orbeendorsedtocontain,thefollowingprovisions:
6.32.4.1.1 LDH, its officers, agents, employees, and volunteers shall be
named as an additional insured as regards negligence by the
Contractor.ISOFormsCG2010(forongoingwork)ANDCG2037
(for completed work) (current forms approved for use in
Louisiana), or equivalents, shall be used when applicable. The
coverage shall contain no special limitations on the scope of
protectionaffordedtoLDH.
6.32.4.1.2 TheContractor’sinsuranceshallbeprimarywithrespecttoLDH,
its officers, agents, employees, and volunteers for any and all
losses that occur under the Contract. Any insurance or self‐
insurance maintained by LDH shall be in excess and non‐
contributoryoftheContractor’sinsurance.
6.32.4.2 Workers’Compensation andEmployersLiabilitypoliciesshallcontain,orbe
endorsedtocontain,thefollowingprovision:
6.32.4.2.1 Tothefullestextentallowedbylaw,theinsurershallagreeto
waiveallrightsofsubrogationagainstLDH,itsofficers,agents,
employees, and volunteers for losses arising from work
performedbytheContractorforLDH.
6.32.4.3 Allpoliciesshallcontain,orbeendorsedtocontain,thefollowingprovisions:
6.32.4.3.1 All policies must be endorsed to require thirty (30) Calendar
Days’ written notice of cancellation to LDH. Ten (10) Calendar
Days’ written notice of cancellation is acceptable for non‐
payment of premium.
Notifications shall comply with the
standard cancellation provisions in the Contractor’s policy. In
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addition, the Contractor is required to notify LDH of policy
cancellationsorreductionsinlimits.
6.32.4.3.2 Theacceptanceofthecompletedwork,payment,failureofLDH
torequire proofofcompliance, or LDH’s acceptance of a non‐
compliant certificate of insurance shall not release the
Contractorfromtheobligationsoftheinsurancerequirementsor
indemnificationagreement.
6.32.4.3.3 The insurer issuing the policies shall have no recourse against
LDHforpaymentofpremiumsorforassessmentsunderanyform
ofthepolicies.
6.32.4.3.4 AnyfailureoftheContractortocomplywithreportingprovisions
of the policy shall not affect coverage provided to LDH, its
officers,agents,employees,andvolunteers.
6.32.5 AcceptabilityofInsurers
6.32.5.1 Allrequiredinsuranceshallbeprovidedbyacompanyorcompanieslawfully
authorizedtodobusinessintheStateofLouisiana.Insuranceshallbeplaced
with insurers with an A.M. Best's rating of A‐:VI or higher. This rating
requirementmaybewaivedforWorkers’Compensationcoverageonly.
6.32.5.2 If,atanytime,aninsurerissuinganysuchpolicydoesnotmeettheminimum
A.M.Bestrating,theContractorshallobtainapolicywithaninsurerthatmeets
theminimumA.M.Bestratingandshallsubmitanothercertificate of
insurancewithinthirty(30)CalendarDaysofdiscoveryornotificationthatthe
insurerdoesnotmeettheminimumrating.
6.32.6 VerificationofCoverage
6.32.6.1 ContractorshallfurnishLDHwithcertificatesofinsurancereflectingproofof
requiredcoverage.Thecertificatesofinsuranceforeachinsurancepolicyare
tobesignedbyapersonauthorizedbythatinsurertobindcoverageonits
behalf.ThecertificatesofinsurancearetobereceivedandapprovedbyLDH
beforeworkcommencesanduponanyrenewaloftheContractorinsurance
policyrenewalthereafter.
6.32.6.2 TheCertificateHoldershallbelistedasfollows:
StateofLouisiana
Louisiana Department of Health, Bureau of Health Services Financing, Its Officers,
Agents,Employees,andVolunteers
628 4thStreet,BatonRouge,Louisiana70802
Contractnumber,tobedetermined
6.32.6.3 Inadditiontothecertificatesofinsurance,theContractorshall submitthe
declarations page and the cancellation provision for each insurance policy.
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LDH reserves the right to request complete certified copies of all required
insurancepoliciesatanytime.
6.32.6.4 Upon failure of the Contractor to furnish, deliver, and maintain required
insurance,thisContract,attheelectionofLDH,maybeterminated.Failureof
theContractortopurchaseand/ormaintainanyrequiredinsuranceshallnot
relievetheContractorfromanyliabilityorindemnificationundertheContract.
6.32.7 Subcontractors
Contractor shall include all Subcontractorsasinsuredsunderits policies OR shall be
responsibleforverifyingandmaintainingthecertificatesofinsuranceprovidedbyeach
Subcontractor.TheContractorshallrequirethatanyandallSubcontractors,whichare
notprotectedundertheMCO'sowninsurancepolicies,takeandmaintaininsuranceof
thesamenatureandinthesameamountsasrequiredoftheContractororinareduced
amountifapprovedbyLDHatitssolediscretion.Subcontractorsshallbesubjecttoallof
the requirements stated herein. The Contractor shall furnish LDH with each
Subcontractor’scertificatesofinsuranceuponrequest.
6.32.7.1 AdditionalRequirementsforTransportationBroker
6.32.7.1.1 CommercialGeneralLiability
IftheContractorelectstocontractwithaTransportationBroker,
theContractorshallrequireitsTransportationBrokertomaintain,
during the life of the contract between the Contractor and the
Transportation Broker, Commercial General Liability Insurance,
with a minimum limit per occurrence of one million dollars
($1,000,000) and a minimum general aggregate of two million
dollars ($2,000,000), to protect the Contractor, LDH, the
Transportation Broker and any Subcontractor or provider during
theperformanceofworkcoveredbytheContractorthecontract
betweentheContractorandtheTransportationBrokerfromclaims
ordamagesforpersonalinjury,includingaccidentaldeath,aswell
asfromclaimsforpropertydamages,whichmayarisefrom
operations under the Contract or the contract between the
Contractor and the Transportation Broker, whether such
operationsbebytheContractororbytheTransportationBroker,
Subcontractor, or provider, or by anyone directly or indirectly
employedbythem,or insuchamanneras toimposeliabilityto
LDH.
6.32.7.1.2 AutomobileLiability
IftheContractorelectstocontractwitha
TransportationBroker, the Contractorshallrequire
itsTransportationBrokertomaintain,duringthelife
of the contract between the Contractor and the
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Transportation Broker, Automobile Liability
Insurance to protect the Contractor, LDH, the
Transportation Broker and any Subcontractor or
providerduringtheperformanceofworkcoveredby
theContractorthecontractbetweentheContractor
and the Transportation Broker that shall have a
minimumcombinedsinglelimitperaccidentofone
milliondollars($1,000,000).ISOformnumberCA00
01(currentformapprovedforuseinLouisiana),or
equivalent,shallbeusedinthepolicy.Thisinsurance
shall include third‐party bodily injury and property
damage liability for owned, hired and non‐owned
automobiles.
6.32.7.2 AdditionalRequirementsforNEMT/NEATProviders
6.32.7.2.1 CommercialGeneralLiability
IftheContractorelectstocontractwitha
TransportationBroker,TheContractorshallrequire
its Transportation Broker to require their
NEMT/NEATProviderstomaintain,duringthelifeof
theprovideragreementbetweentheTransportation
Brokerand theNEMT/NEAT Providers,Commercial
GeneralLiabilityInsurance,withaminimumlimitof
one hundred thousand dollars ($100,000) on the
businessentity,toprotecttheContractor,LDH,the
TransportationBroker,andtheNEMT/NEAT
Providersduring the performanceof work covered
bytheContractortheprovideragreementfrom
claims or damages for personal injury, including
accidentaldeath,aswellasfromclaimsforproperty
damages, which may arise from operations under
the Contract or the provider agreement, whether
suchoperationsbebytheTransportationBroker,the
NEMT/NEAT Providers, or by anyone directly or
indirectlyemployedbyeitherofthem,orinsucha
mannerastoimposeliabilitytoLDH.
6.32.7.2.2 AutomobileLiability
IftheContractorelectstocontractwithaTransportationBroker,theContractor
shall require its Transportation Broker to require their NEMT/NEAT Providers to
maintain,duringthe life ofthe provider agreement between theTransportation
brokerandtheNEMT/NEATProviders,AutomobileLiabilityInsurancetoprotectthe
Contractor,LDH,theTransportationBroker,andtheNEMT/NEATProvidersduring
theperformanceofworkcoveredbytheContractortheprovideragreementthat
shallhavecoverageoftwenty‐fivethousanddollars($25,000)forbodilyinjuryper
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person, fifty thousand dollars ($50,000) per accident, and twenty‐five thousand
dollars($25,000)forpropertydamagesforNEMTProviderstravelingin‐stateand
onemilliondollars($1,000,000)forNEATProviders.
6.32.7.3 Workers’CompensationIndemnity
IntheeventtheContractorisnotrequiredtoprovideorelectsnottoprovide
workers’ compensation coverage, the parties hereby agree that the
Contractor,itsowners,agentsandemployeeswillhavenocauseofaction
against,andwillnotassertaclaimagainst,theStateofLouisiana, its
departments,agencies,agentsoremployeesasanemployer,whether
pursuanttotheLouisianaWorkersCompensationLaw,La.R.S.23:1020.1,et
seq.orotherwise,underanycircumstance.Thepartiesalsoherebyagreethat
theStateofLouisiana,itsdepartments,agencies,agents,andemployeesshall
innocircumstancebe,orconsideredas,theemployerorstatutoryemployer
oftheContractor,itsowners,agents,andemployees.Theparties further
agreethattheContractorisawhollyindependentcontractorandisexclusively
responsibleforitsemployees,owners,andagents.Contractorherebyagrees
to protect, defend, indemnify, and hold the State of Louisiana,its
departments, agencies, agents and employees harmless from any such
assertionorclaimthatmayarisefromtheperformanceofthisContract.
DutytoDefend
Uponnoticeofanyclaim,demand,suit,orcauseofactionagainsttheState,allegedtoariseoutof
orberelatedtothisContract,Contractorshallinvestigate,handle,respondto,providedefensefor,
anddefendatitssoleexpense,eveniftheclaim,demand,suit,orcauseofactionisgroundless,
false,orfraudulent.TheStatemay,butisnotrequiredto,consultwithorassisttheContractor,but
thisassistanceshallnotaffecttheContractor’sobligations,duties,andresponsibilitiesunderthis
section.ContractorshallobtaintheState’swrittenconsentbeforeenteringintoanysettlementor
dismissal.
LiabilityandIndemnification
6.34.1 ContractorLiability
Contractorshallbeliablewithoutlimitationforanyandallinjury,death,damage,loss,
destruction, damages, costs, fines, penalties, judgments, forfeitures, assessments,
expenses(includingattorneyfees),obligations,andotherliabilitiesofeverynameand
description,whichmayoccurorinanywayariseoutofanyactoromissionofContractor,
itsowners,partners,officers,directors,agents,employees,agents,orsubcontractors.
6.34.2 ForceMajeure
6.34.2.1 It is understood and agreed that neither party can foresee the exigencies
beyondthecontrolofeachpartywhicharisebyreasonofanActofGodor
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forcemajeure;therefore,neitherpartyshallbeliableforanydelayorfailure
in performance beyond its control resulting from an Act of God or force
majeure.TheStateshalldeterminewhetheradelayorfailureresultsfroman
ActofGodorforcemajeurebasedonitsreviewofallfactsandcircumstances.
6.34.2.2 The Contractor shall, however, beresponsibleforthedevelopment and
implementation of a Continuity of Operations Plan as specified in the
ContinuityofOperations Plansection of thisContract.Notwithstanding the
preceding, as long as this Contract remains in full force and effect, the
Contractor shall be liable for the MCO Covered Services required to be
providedorarrangedforinaccordancewiththisContractandtheContractor’s
approvedContinuityofOperationsPlan.
6.34.3 Indemnification
6.34.3.1 Contractor shall fully indemnify and hold harmless the State, without
limitation,foranyandallinjury,death,damage,loss,destruction,damages,
costs, fines, penalties, judgments, forfeitures, assessments, expenses
(includingattorneyfees),obligations,andotherliabilitiesofeverynameand
description,thatmayoccurorinanywayariseoutofanyactoromissionof
Contractor, its owners, partners, officers, directors, employees, or
subcontractors,including,butnotlimitedto:
6.34.3.1.1 SanctionsonNetworkProvidersandEnrollees,including,butnot
limited to, termination or exclusion from the Network, in
accordance with provisions in the Fraud, Waste, and Abuse
PreventionSection.
6.34.3.1.2 Publication, translation, reproduction, delivery, performance,
use,ordispositionofanydataprocessedunderthisContractina
manner not authorized by the Contract or by Federal or State
lawsorregulations.
6.34.3.1.3 FailuretocomplywithapplicableFederalorStatelaws,including,
butnotlimitedto,Medicaidlawsandregulations,laborlaws,and
minimumwagelaws.
6.34.3.1.4 Noncompliancewithanyjudgment,settlement,courtorder,or
consentdecree,forwhichtheresponsibilityforcompliancehas
beendelegatedtotheContractorbyLDH.
6.34.3.1.5 FailuretoproviderecordstoLDHinaccordancewiththepublic
records’ request requirements in the Administration and
ContractManagementsection.
6.34.3.2 The Contractor shall not indemnify for the portion of any loss or damage
arisingfromtheState’sactorfailuretoact.

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6.34.4 IntellectualPropertyIndemnification
6.34.4.1 Contractor shall fully indemnify and hold harmless the State, without
limitation, from and against any and all damages, costs, fines, penalties,
judgments, forfeitures, assessments, expenses (including attorney fees),
obligations,andotherliabilitiesofeverynameanddescriptionthatmaybe
assessedagainsttheStateinanyactionforinfringementofanyintellectual
propertyright,includingbutnotlimitedto,trademark,trade‐secret,copyright,
andpatentrights.
6.34.4.2 Whenadisputeorclaimarisesrelativetoarealoranticipatedinfringement,
the Contractor, at its sole expense, shall submit information and
documentation,includingformalpatentattorneyopinions,asrequiredbythe
State.
6.34.4.3 If the use of the product, material, service, or any component thereof is
enjoinedforanyreasonoriftheContractorbelievesthatitmaybeenjoined,
the Contractor, while ensuring appropriate migration and implementation,
dataintegrity, andminimal delaysof performance,shallatitssoleexpense
andinthefollowingorderofprecedence:(i)obtainfortheStatetherightto
continue using such product, material, service, or component thereof; (ii)
modify the product, material, service, or component thereof so that it
becomesanon‐infringingproduct,material,orserviceofatleastequalquality
andperformance; (iii) replace the product,material, service, orcomponent
thereofsothatitbecomesanon‐infringingproduct,material,orserviceofat
least equal quality and performance; or, (iv) provide the Statemonetary
compensation for all payments made under the Contract related to the
infringingproduct,material,service,orcomponent,plusforallcostsincurred
toprocureandimplementanon‐infringingproduct,material,orserviceofat
leastequalqualityandperformance.Untilthisobligationhasbeensatisfied,
theContractorremainsindefault.
TheContractorshallnotbeobligatedtoindemnifythatportionofaclaimor
disputebasedupontheState’sunauthorized:i)modificationoralterationof
theproduct,materialorservice;ii)useoftheproduct,materialorservicein
combinationwithotherproductsnotfurnishedbyContractor;or,iii)useof
the product, material or service in other than the specified operating
conditionsandenvironment.
6.34.5 LimitationsofLiability
The Contractor shall not be liable for incidental, indirect, special, or consequential
damages,unlessotherwisespecificallyenumeratedherein,orinaresultingtaskorderor
purchaseordermutuallyagreeduponbetweentheparties.Innocircumstanceshallthe
Statebeliableforincidental,indirect,special,orconsequentialdamages;lostprofits;lost
revenue;orlostinstitutionaloperatingsavings.
6.34.6 OtherRemedies
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IftheContractorfailstoperforminaccordancewiththetermsand conditions of this
Contract,orifanylienorclaimfordamages,penalties,costsandthelikeisassertedbyor
againsttheState,then,uponnoticetotheContractor,theStatemaypursueallremedies
available to it at law or equity, including retaining monies from amounts due the
ContractorandproceedingagainstanysuretyoftheContractor.
ActualDamages
6.35.1 TheContractormaybeliableforactualdamages,liabilities,costs,andexpensesofevery
typeordescriptionthatmaybeincurredbytheStatetotheextentcausedbyContractor’s
violationofthisContract,including,butnotlimitedto:
6.35.1.1 All amounts for which the State may be liable in an action or claim for
damages,whetherthroughasettlementorthroughajudgmentofacourtof
competentjurisdiction.;
6.35.1.2 All fines, Monetary Penalties, or disallowances whether civil or criminal,
imposedbyHHSorbyanyotherfederalorstategovernmentagency,andall
other costs and expenses necessitated by compliance with any order or
mandateofsuchagency.
6.35.1.3 All costs and expenses, legal and otherwise, incurred in connection with
6.36.1.1and6.36.1.2above,including,butnotlimitedto,attorney’sfees.
6.35.1.4 All costsandexpensesincurredfor theprovision ofremedial orrestorative
servicestoindividualswhoseinformationwasaffectedbytheviolationorto
otheraffectedparties.
6.35.1.5 All costs and expenses that the State maybe required to incur inorderto
procureanothercontractortocompleteanyworkthatContractorperformed
inanon‐compliantmannerorfailedtocompletesuccessfullyinaccordance
withthetermsoftheContract.Forpurposesoftheprecedingsentence,“costs
andexpensesthattheStatemayberequiredtoincur”meanseither(a)the
final amount as determined by mutual written agreement of the parties
followinganegotiationofsuchcostsandexpenses,or,intheeventthatthe
partiesarenotabletoreachsuchagreement(b)thefinallyjudiciallyawarded
amount,ifany,bywhichthereasonablefeesthattheStateisrequiredtopay,
andactuallypays,toanalternativeserviceprovidertoperformtheterminated
Services (or any portion(s) of suchterminatedservices)notperformed by
Contractorasoftheeffectivedateofterminationofsuchservicesexceedsthe
feesthattheStatewouldotherwisehavepaidtoContractorpursuanttothis
Contracttoperformsuchservices.
HoldHarmlessastoEnrollees
6.36.1 NotwithstandingStatePlanapprovedcostsharing,theContractorherebyagreesnotto
bill,charge, collecta deposit from,seek costsharing orother formsofcompensation,
remunerationorreimbursementfrom,orhave recourseagainst,Enrollees, orpersons
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actingontheirbehalf,forMCOCoveredServicesthatarerenderedtosuchEnrolleesby
theContractoranditsSubcontractors.
6.36.2 TheContractorfurtheragreesthattheEnrolleeshallnotbeheldliableforpaymentfor
covered services furnished under a Network Provider agreement, referral, or other
arrangement,totheextentthatthosepaymentswouldbeinexcessoftheamountthat
theEnrolleewouldoweiftheContractorprovidedtheservicedirectly.TheContractor
agreesthatthisprovisionisapplicableinallcircumstancesincluding,butnotlimitedto,
non‐paymentbytheContractorandinsolvencyoftheContractor.
6.36.3 TheContractorfurtheragreesthattheEnrolleeshallnotbeheldliableforthecostsofany
andallservicesprovidedbyaproviderwhoseserviceisnotcoveredbytheContractoror
whodoesnotobtainTimelyapprovalorrequiredprior‐authorization.
6.36.4 TheContractorfurtheragreesthatthisprovisionshallbeconstruedtobeforthebenefit
of the Enrollees, and that this provision supersedes any oral or written contrary
agreement now existing or hereafter entered into between the Contractor and its
Enrollees,orpersonsactingontheirbehalf.
LossofFederalFinancialParticipation(FFP)
TheContractorherebyagreestobeliableforanylossofFFPsufferedbyLDHduetotheContractor's,
Providers’oritsSubcontractors'actionsorinactions,including,butnotlimitedto,failuretoperform
theservicesasrequiredunderthisContract.PaymentsprovidedforunderthisContractshallbe
deniedfornewEnrolleeswhen,andforsolongas,paymentforthoseEnrolleesisdeniedbyCMSin
accordancewiththerequirementsin42C.F.R.§438.730.CMSmaydenypaymenttotheStatefor
newEnrolleesifitsdeterminationisnotTimelycontestedbytheContractor.
Interest
InterestgeneratedthroughinvestmentsmadebytheContractorshall be the property of the
ContractorandshallbeusedattheContractor’sdiscretion.
MisuseofSymbols,Emblems,orNamesinReferencetoMedicaid
TheContractormaynotuse,inconnectionwithanyitemconstitutinganadvertisement,solicitation,
circular,book,pamphlet or othercommunication,ora broadcast,telecast, orotherproduction,
alone or with other words, letters, symbols or emblems the words “Louisiana Medicaid” or
“LouisianaDepartmentofHealth”or“DepartmentofHealth”
or“LDH”or“BureauofHealthServices
Financing”unlesspriorwrittenapprovalisobtainedfromLDH.Specificwrittenauthorizationfrom
LDHisrequiredtoreproduce,reprint,ordistributeanyLDHform,application,orpublicationfora
fee.Stateandlocalgovernmentsareexemptfromthisprohibition.Adisclaimerthataccompanies
theinappropriateuseofprogramorLDHtermsdoesnotprovideadefense.Eachpieceofmailor
informationconstitutesaviolation.
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NationalProviderIdentifier(NPI)
The HIPAA Standard Unique Health Identifier regulations (45 C.F.R. Part 162) require that all
CoveredEntitiesmustusetheidentifierobtainedfromtheNationalPlanandProviderEnumeration
System(NPPES).
Non‐WaiverofBreach
ThefailureofLDHatanytimetorequireperformancebytheContractorofanyprovisionofthis
Contract,orthecontinuedpaymentoftheContractorbyLDH,shallinnowayaffecttherightofLDH
toenforceanyprovisionofthisContract;norshallthewaiverofanybreachofanyprovisionthereof
betakenorheldtobeawaiverofanypriororsubsequentbreachofsuchprovisionorasawaiver
oftheprovisionitself.NoprovisionofthisContractshallbewaived,modified,ordeletedexceptby
thewrittenagreementofthepartiesandapprovalofCMS,ifapplicable.
PoliticalActivity
6.42.1 Noneofthefunds,materials,property,orservicesprovideddirectlyorindirectlyunder
thisContractshallbeusedforanypartisanpoliticalactivity,ortofurthertheelectionor
defeatofanycandidateforpublicoffice,orotherwiseinviolationoftheprovisionsofthe
HatchActof1939,asamended(5U.S.C.§1501,etseq.),andregulationsissuedpursuant
thereto.
6.42.2 Additionally,nofundsprovidedhereinshallbeusedtourgeanyelectortovoteforor
againstanycandidateorpropositiononanelectionballotnorshallsuchfundsbeusedto
lobbyfororagainstanypropositionormatterhavingtheeffectoflawbeingconsidered
bytheLegislatureoranylocalgoverningauthority.Thisprovisionshallnotpreventthe
normaldisseminationoffactualinformationrelativetoaproposition or any election
ballot or a proposition or matter having the effect of law being considered by the
Legislatureoranylocalgoverningauthority.
ProhibitedPayments
Paymentforthefollowingshallnotbemade:
6.43.1 Organtransplants,unlesstheStatePlanhaswrittenstandardsthatprovideforsimilarly
situatedindividualstobetreatedalikeandforanyrestrictiononfacilitiesorpractitioners
tobeconsistentwiththeaccessibilityofhighqualitycaretoEnrollees.
6.43.2 Non‐EmergencyServicesprovidedbyorunderthedirectionofanexcludedindividual.
6.43.3 Any amount expended for which funds may be not used under the Assisted Suicide
FundingRestrictionActof1997(42U.S.C.§14401,etseq.).
6.43.4 Any amount expended for roads, bridges, stadiums, or any other item or service not
coveredundertheStatePlan.
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6.43.5 AnyamountexpendedforhomehealthcareservicesunlesstheContractorensuresthat
theprovidermeetstheappropriatesuretybondrequirements.
OfferofGratuities
BysigningthisContract,theContractorsignifiesthatnomemberof,oradelegateof,Congress,nor
any elected or appointed official or employee of the State of Louisiana, the Government
Accountability Office, HHS, CMS, or any other Federal agency has or shall benefit financially or
materially from this Contract. This Contract may be terminated ifLDHdetermines,initssole
discretionthatgratuitiesofanykindwereofferedto,orreceivedby,anyofficialsoremployeesof
theState,itsagents,oremployees.
RecordOwnership
6.45.1 Allrecords,reports,documentsandothermaterialdeliveredortransmittedtoContractor
byLDHshallremainthepropertyofLDH,andshallbereturnedbyContractortoLDH,at
Contractor'sexpense,atterminationofthisContract.
6.45.2 All records, reports, documents, or other material related to this Contract and/or
obtained or prepared by the Contractor in connection with the performance of the
servicescontractedforhereinshallbecomethepropertyoftheState.
6.45.2.1 UponterminationofthisContractforanyreason,theContractorshallreturn
ordestroy,asdirectedbyLDHinwriting,withinthirty(30)CalendarDaysof
the effective date of termination, all PHI received from LDH, or createdor
receivedbytheContractoronbehalfofLDH.Thisprovisionshallalsoapplyto
PHIthatisinthepossessionofSubcontractorsoragentsoftheContractor.The
ContractorshallnotretainanycopiesofPHI.
6.45.2.2 IntheeventthattheContractordeterminesthatreturningordestroyingPHI
isnotfeasible,theContractorshallprovidetoLDHnotification of the
conditions,withinthirty(30)CalendarDaysoftheeffectivedate of
termination of the Contract, that make return or destruction not feasible.
UponamutualdeterminationthatreturnordestructionofPHIisnotfeasible,
theContractorshallextendtheprotectionsoftheContracttosuchPHIand
limitfurtherusesanddisclosuresofsuchPHItothosepurposesthatmakethe
returnordestructionnotfeasible,forsolongastheContractormaintainssuch
PHI.IfLDHdoesnotagreewiththeContractorthatthereturnordestruction
ofPHIisnotfeasible,theContractorshallreturn or destroy the PHIwithin
thirty(30)CalendarDaysofnotificationofLDH’sdetermination.
6.45.3 Allotherrecords,reports,documents,orothermaterialshall,uponrequest,bereturned
bytheContractortotheState,attheContractor’sexpense,atterminationorexpiration
oftheContract.
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UseofData
LDHshallhaveunlimitedrightstouse,disclose,orduplicate,foranypurpose,allinformationand
datadeveloped,derived,documented,orfurnishedbytheContractorresultingfromthisContract.
RecordRetention
6.47.1 TheContractorshallretain,andrequiresubcontractorstoretain,asapplicable,financial
records,supportingdocuments,statisticalrecords,andallotherrecordspertinenttoan
award,including,butnotlimitedtoEnrolleeGrievanceandAppealrecordsin42C.F.R.
§438.416,basedatain42C.F.R.§438.5(c),MLRreportsin42C.F.R.§438.8(k),andthe
data,information,anddocumentationspecifiedin42C.F.R.§§438.604,438.606,438.608,
and438.610,shallberetainedforaperiodoften(10)yearsfromthedateofsubmission
ofthefinalexpenditurereport.Theonlyexceptionsarethefollowing:
6.47.1.1 Ifanylitigation,claim,financialmanagementreview,orauditisstartedbefore
theexpirationoftheten(10)yearperiod,therecordsshallberetaineduntil
alllitigation,claims,orauditfindingsinvolvingtherecordshavebeenresolved
andfinalactiontaken;
6.47.1.2 RecordsforrealpropertyandequipmentacquiredwithFederalfundsshallbe
retainedforten(10)yearsafterfinaldisposition;
6.47.1.3 WhenrecordsaretransferredtoormaintainedbyLDH,theten(10) year
retentionrequirementisnotapplicabletotheContractor;and
6.47.1.4 Indirectcostrateproposals,costallocationsplans,etc.,asspecifiedin45C.F.R.
§75.361(f).
6.47.2 UndernocircumstancesshalltheContractororanyofitsMaterialSubcontractorsdestroy
ordisposeofanysuchrecords,evenaftertheexpirationofthemandatoryten(10)year
retentionperiod,withouttheexpresspriorwrittenpermissionofLDH.
ReportingChanges
TheContractorshallimmediatelynotifyLDHofanyofthefollowing:
6.48.1 Changeinbusinessaddress,telephonenumber,facsimilenumber,ande‐mailaddress;
6.48.2 Changeincorporatestatusornature;
6.48.3 Changeinbusinesslocation;
6.48.4 Changeinsolvency;
6.48.5 Changeincorporateofficers,executiveemployees,orcorporatestructure;
6.48.6 Changeinownership,includingbutnotlimitedtothenewowner’slegalname,business
address,telephonenumber,facsimilenumber,ande‐mailaddress;
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6.48.7 Changeinincorporationstatus;
6.48.8 ChangeinFederalemployeeidentificationnumberorFederaltaxidentificationnumber;
and/or
6.48.9 ChangeinContractorlitigationhistory,currentlitigation,auditsandothergovernment
investigationsbothinLouisianaandinotherstatesrelatedtothedeliveryofmanaged
carebenefits.
RighttoAudit
6.49.1 LLA,LDH,internalauditorsoftheDivisionofAdministration,CMS,OIG,theComptroller
General, and their designees may, at any time, inspect and audit any records or
documentsof theContractor,orits subcontractors,and may,atanytime,inspectthe
premises,physicalfacilities,andequipmentwhereMedicaid‐relatedactivitiesorworkis
conducted.
6.49.2 Therighttoauditunderthissectionexistsforten(10)yearsfromthefinaldateofthe
contracttermorfromthedateofcompletionofanyaudit,whicheverislater.
6.49.3 RecordsshallbemadeavailableduringBusinessHoursforthispurpose.
Severability
IfanyprovisionofthisContractisdeclaredorfoundtobeillegal, unenforceable, or void by a
judgmentororderofacourtofcompetentjurisdiction,thenbothLDHandtheContractorshallbe
relievedofallobligationsarisingundersuchprovision.IftheremainderofthisContractiscapable
ofperformance,itshallnotbeaffectedbysuchdeclarationorfindingandshallbefullyperformed.
In addition, if the laws or regulations governing this Contract should be amended or judicially
interpretedastorenderthefulfillmentoftheContractimpossibleoreconomicallyinfeasible,both
LDHandtheContractorwillbedischargedfromfurtherobligationscreatedunderthetermsofthe
Contract.
SoftwareReportingRequirement
AllreportssubmittedtoLDHbytheContractorshallbeinaformataccessibleandmodifiablebythe
standard MicrosoftOffice Suiteof products, Version 2007or later,orinaformatacceptedand
approvedbyLDH.
Termination
6.52.1 TerminationforConvenience
LDHmayterminatethisContractatanytimewithoutpenaltybygivingsixty(60)Calendar
Days’writtennoticetotheContractorofsuchterminationornegotiatinganeffectivedate
with the Contractor. The Contractor shall be entitled to payment for deliverables in
progress,totheextentworkhasbeenperformedsatisfactorily.
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6.52.2 TerminationDuetoSeriousThreattoHealthofEnrollees
LDHmayterminatethisContractimmediatelyifLDHdetermines,initssolediscretion,
thatactionsbytheContractor,itsSubcontractor(s),orProvider(s)poseaseriousthreat
tothehealthofitsEnrollees.
6.52.3 TerminationforInsolvency,Bankruptcy,orInstabilityofFunds
6.52.3.1 TheContractor'sinsolvencyorthefilingofapetitioninbankruptcy by or
againsttheContractor shallconstitute groundsforterminationforcause.If
LDH determines, in its sole discretion, that the Contractor has become
financially unstable, LDH shall immediately terminate this Contract upon
writtennoticetotheContractoreffectivethecloseofbusinessonthedate
specifiedinsuchnotice.
6.52.3.2 TheContractorshallcovercontinuationofservicestoEnrolleesforanyperiod
forwhichpaymenthasbeenmade,aswellasforinpatientadmissionsupuntil
discharge.
6.52.4 TerminationforOwnershipViolations
TheContractorissubjecttoterminationforcause,unlesstheContractorcandemonstrate
changesofownershiporcontrol,when:
6.52.4.1 ApersonwithadirectorindirectownershipinterestintheContractor:
6.52.4.1.1 Hasbeenconvictedofacriminaloffenseunder42U.S.C.§1320a‐
7(a),(b)(1)or(3),inaccordancewith42C.F.R.§1002.203.
6.52.4.1.2 HashadcivilMonetaryPenaltiesorassessmentsimposedunder
42U.S.C.§1320a‐7a.
6.52.4.1.3 HasbeenexcludedfromparticipationinMedicareoranystate
healthcareprogram.
6.52.4.2 AnyindividualwhoisanAffiliateoranofficer(iftheContractorisorganizedas
acorporation),orwhoisapartner(ifitisorganizedasapartnership),orwho
is an agent or a managing employee, is under temporary management as
definedintheContractNon‐Compliancesection.
6.52.4.3 TheContractorhasadirectorindirectsubstantialcontractual relationship
withanexcludedindividualorentity.
6.52.5 TerminationforNon‐AppropriationofFunds
6.52.5.1 ThecontinuationofthisContractshallbecontingentupontheappropriation
offundsbythelegislaturetofulfillthe requirementsofthe Contract.Ifthe
legislature fails to appropriate sufficient monies to provide for the
continuationoftheContract,orifsuchappropriationisreducedbytheveto
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oftheGovernororbyanymeansprovidedintheappropriationsactofTitle39
oftheLouisianaRevisedStatutesof1950topreventthetotalappropriation
fortheyearfromexceedingrevenuesforthatyear,orforanyother lawful
purpose,andtheeffectofsuchreductionistoprovideinsufficientmoniesfor
thecontinuationoftheContract,theContractshallterminatewithoutpenalty
onthedateofthebeginningofthefirstfiscalyearforwhichfundshavenot
beenappropriated.
6.52.6 TerminationforUnavailabilityofFederalFunds
6.52.6.1 ThecontinuationofthisContractshallbecontingentupontheavailabilityof
Federal funds to fulfill the requirements of the Contract. If Federal funds
becomeunavailableduringthetermofthisContract,LDHmayterminatethe
Contractwithoutpenalty.Availabilityoffundsshallbedeterminedsolelyby
LDH.LDHshallnotifytheContractoroftheunavailabilityofFederalfundsin
writingandthedateuponwhichtheContractshallterminate.
6.52.7 TerminationoftheContractforCause
6.52.7.1 Exceptasotherwiseprovidedforherein,LDHmayterminatetheContractfor
cause based upon the failure of the Contractor to comply with the terms
and/or conditions of the Contract; provided LDH shall give the Contractor
writtennoticespecifyingtheContractor’sfailure.Ifwithinthirty(30)Calendar
Daysafterreceiptofsuchnotice,theContractorshallnothave either
correctedsuchfailureor,inthecaseoffailurethatcannotbe corrected in
thirty(30)CalendarDays,beguningoodfaithtocorrectsaidfailure and
thereafterproceededdiligentlytocompletesuchcorrection,thenLDHmay,at
itsoption,placetheContractorindefaultandtheContractshallterminateon
thedatespecifiedinsuchnotice.Failuretoperformwithinthetimeagreed
uponintheContractmayconstitutedefaultandmayresultinterminationof
theContract.
6.52.7.2 TheContractormayexerciseanyrightsavailabletoitunderLouisianalawto
terminate for cause upon thefailure of LDH to comply with the termsand
conditionsofthecontractprovidedthattheContractorshallgiveLDHwritten
noticespecifyingLDHsfailureandareasonableopportunityforLDHtocure
thedefect.
6.52.8 TheContractorhasthedutytofullycooperatewiththeStateandprovide anyand all
requestedinformation,documentation,etc.atitsearliestconveniencetotheStatewhen
requested. This applies even if the contract is terminated and/oralawsuitisfiled.
Specifically,theContractordoesnothavetherighttolimitorimpedetheState’srightto
auditortowithholdState‐owneddocuments.
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Headings
Headingstosectionsareincludedforthepurposeofconvenientreferenceandshallhavenoforce
oreffectupontheconstructionorinterpretationofanyprovisionoftheContract.
WithholdinginLastMonthofPayment;OffsetsAgainstFuturePaymentsUnderaNew
Contract
For the last month of the Contract, LDH shall withhold seventy‐fivepercent(75%)ofthefinal
paymenttotheContractorforamaximumofonehundredeighty(180)CalendarDaysfromthedue
dateofsuchamount.LDHmayretainandoffsetthiswithholdiftheContractordoesnotfulfillits
contractualobligations,someofwhichmayextendpastthetermoftheContract,including,butnot
limitedto,payingLDHanyoutstandingMonetaryPenaltiesandsanctionsassessedduringtheterm
oftheContract,payingLDHanyMonetaryPenaltiesandsanctionsassessedafterthetermofthe
Contract for any Contractor noncompliance that occurred during the term of the Contract, or
repayingLDHforpaymentsmadeonbehalfofineligibleEnrollees.
ShouldLDHidentifyContractornon‐compliancewithanysurvivingprovisionsoftheContractafter
terminationorexpirationoftheContractandContractorandLDHhaveenteredintoanewcontract
for MCO services, LDH may offset any such Monetary Penalties and sanctions against future
paymentstoContractor.PenaltiesforContractornoncompliancethatoccurredpartiallyduringthe
termoftheContractandpartiallyduringthetermofthenewcontractforMCOservicesshallbe
assessedinaccordancewiththetermsoftheContractfortheentiretyofthenoncompliance.Any
notice requirements by LDH, and Contractor dispute rights relating to the Monetary Penalties
and/orpaymentoffsets,shallbeinaccordancewiththetermsoftheContract.
Hudson/VeteransInitiativeReporting
DuringthetermoftheContractandatexpiration,theContractorwillberequiredtoreportVeteran‐
Owned and Service‐Connected Disabled Veteran‐Owned and Hudson Initiative small
entrepreneurshipsubcontractorparticipationandthedollaramountofeach.