3.1.1 Contractor shall provide eligible clients with insurance case management and premium assistance for an individual policy coveringthe eligible referred client from DPH. 3.1.2 Contractor shall oversee initial and renewal enrollment process. 3.1.3 Contractor shall followupwitheachclientto obtainthe necessaryinformationfordecisions regardinginsurance options. 3.1.4 Contractor shall manage andmaintain eachactive client on service: 3.1.4.1 Communicate and make pertinent client eligibility information accessible for DPH upon approval or denial. 3.1.4.2 Contractor shall monitor client information and documentation andclientfollow-up. 3.1.4.3 Contractor shall ensure fairness with eligibility determinations and establish a grievance procedure when a client is deemed ineligible or becomes inactive in accordance with program eligibility. 3.1.4.4 Contractor shall review internal processes and data to ensure program productivity, quality of service and customer satisfaction, and to identify and remedy program challenges. 3.1.4.5 Contractor shall conduct periodic audit of client records to evaluate program adherence and quality of service provided to patients. Determine the quality of service provided to clients and identify and overcome any present andfuture program challenges. 3.1.4.6 Contractor shall utilize an evaluation process to ensure a highly trained staff, concise policies and procedures, data integrity, and qualityassurance. 3.1.4.7 Contractor shall provide a written audit and review report to DPH upon request. 3.1.5 Contractor shall monitor the assistance provided for each client and assure expenses do not exceed the annual cap for premium assistance and approved out of pocket expenses for FDA approved indicated treatmentsof the diagnosis. 3.1.5.1 The annual cap for premium assistance for the Bleeding Disorders Assistance program is $15,000 and out of pocket is $10,000. 3.1.5.2 The annual cap for premium assistance for the Sickle Cell Program is $7,500 and out of pocket is $8,000. 3.1.6 Contractor shall provide all labor, materials, supervision, equipment, supplies, and reports necessary to effectuate the terms and requirements establish by the contract for a set fee for medical insurance case management services. 3.1.7 Contractor shall submit a client detailed and total report of all actual cost of premium assistance for the prior month's charges to include client premiums paid, out of pocket cost paid, case management fee and/or program administrativeservice fee. 3.1.8 Contractor shall provide accurate outcome data to assist the state of South Carolina in analyzing the success of the program by sending DPH quarterly reports regarding the provision of medical insurance case management services performed relevant to contract specifics. 3.1.9 Contractor shall submitquarterly reportsdetailingindividual premiums andoutof pocket assistancepaidfor eachclient. 3.1.10 Contractor shall communicate and meetwithCYSHCN program staff monthly or as needed.
