Specifications include, but are not limited to: Provider Network Development. The Contractor must develop and implement written policies and procedures for the selection and retention of providers as detailed in 42 CFR 438.214; and must ensure the network of providers is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of members in the service area as detailed in 42 CFR 438.207(b). The Contractor’s policies and procedures must include a process for receiving requests for initial services and continuing authorization of services, per 42 CFR 438.214(b)(1) and a process for credentialing and re-credentialing of providers who have signed contracts or participation agreements with the Contractor, per 42 CFR 438.214(b)(2). The Contractor’s policies and procedures must include a requirement that providers disclose to the Contractor information about criminal convictions for anyone who has ownership or control interest in the provider, or is an agent or managing employee of the provider, as detailed in 42 CFR 455.106, The Contractor must disclose to IDHW information of owners, individuals or corporations, as defined in 42 CFR 455.104(b), who own five percent (5%) or more in a provider entity, as detailed in 42 CFR 455.104(a)(2). The Contractor must submit this information to IDHW at the time it executes a contract with the IDHW and within thirty-five (35) calendar days after any change in ownership of the Contractor per Section 1124(a)(2)(A) of the Social Security Act; section 1903(m)(2)(A)(viii) of the Social Security Act; and 42 CFR 438.608(c)(2), 455.100 – 103, and 455.104(c)(3). Contractor must provide information on all managing employees of the disclosing entity (provider) including name, address, date of birth, Social Security Number or other tax identification number as defined in 42 CFR 455.101 and 42 CFR 455.104(b)(4). The address for corporate entities must include as applicable, primary business address, every business location, and P.O. Box address per 42 CFR 438.604(a)(6); 438.606; 455.104(b)(1)(i); 438.230; 438.608(c)(2); 455.104(b)(1)(ii); and 455.104(b)(1)(iii). The Contractor must provide information on all Subcontractors in which a provider has direct or indirect ownership of five percent (5%) or more as detailed in 42 CFR 455.104(b)(2). The Contractor must list ownership of any Subcontractor with whom this provider has had business transactions totaling more than twenty-five thousand dollars ($25,000) during the previous twelve (12) month period, per 42 CFR 455.105. The Contractor must list persons that are related to each other (spouses, parents, children, or siblings). The Contractor must identify persons with criminal offenses related to the person's involvement in any program under Medicare, Medicaid, or Title XX, per 42 CFR 455.100 and 42 CFR 455.106. IDHW will review the ownership and control disclosures submitted by the Contractor and any of its Subcontractors in compliance with regulations in 42 CFR 438.602(c) and 438.608(c). Information System Data Exchange IDHW will designate where data will be sent and received and reserves the right to change the entity and manner in which data is sent and received at any time during this Contract. The Contractor must successfully complete EDI testing and be authorized by IDHW’s current MMIS Contractor to submit production EDI transactions before the Services Start Date and as a condition for meeting readiness review. The Contractor must demonstrate ability to send and receive member data, provider data, process claims, send encounter data to all MMIS vendors as designated by IDHW at no additional cost to the State. The Contractor must also complete EDI testing with the contractor for IDHW’s new MMIS as implementation of that new system is completed, as needed, at no additional cost to the state. Service Start Date and Monitoring The Contractor must not start providing services until it receives written approval from IDHW indicating that all readiness testing requirements have been met. The Contractor must provide the following information to IDHW daily for the first month after services begin, and weekly during the second and third months after services begin and then at the frequency specified in Appendix E – Reports Matrix. Call center activity, for both member and provider lines, including call volume (total calls received), total calls answered, abandonment rate, and average speed to answer; Grievance and appeals filed with the Contractor by members and providers; Prior Authorization requests, approvals, denials, and pended requests; and Claim information including claims received, approved, and denied.
