Fillable Printable Form 439
Fillable Printable Form 439
Form 439
AHCCCS CONTRACTOR OPERATIONS MANUAL
C
HAPTER
400
-
O
PERATIONS
Page 439 - 1 of 6
439 – MATERIAL CHANGES: PROVIDER NETWORK AND BUSINESS OPERATIONS
EFFECTIVE DATE: 10/01/15, 07/01/16
REVISION DATE: 04/21/16
STAFF RESPONSIBLE FOR POLICY: DHCM OPERATIONS
I. PURPOSE
This Policy applies to Acute Care,
ALTCS/EPD, CRS, DCS/CMDP (CMDP), DES/DDD
(DDD), and RBHA Contractors. This Policy establishes guidelines for AHCCCS
Cont ractors regardi ng the id entificat ion and ass essment o f material ch anges to a Con tractor’s
provider network and business operations and the approval process for such changes.
II. DEFINITIONS
A
DMINISTRATIVE
SERVICES SUBCONTRACTS
An agreement that delegates any of the requirements of the
contract with AHCCCS, including, but not limited to the
following:
a. Claims processing, including pharmacy claims,
b. Credentialing, including
those for only primary source
verification (i.e. Credential Verification Organization),
c. Management Service Agreements,
d.
Service Level Agreements with any Division or
Subsidiary of a corporate parent owner,
e. DDD acute care subcontractors,
Providers are not Administrative Services Subcontractors.
D
ELEGATED
A
GREEMENT
A type of subcontract agreement with a qualified organization
or person to perform one or more functions required to be
performed by the Contractor pursuant to this contract.
G
EOGRAPHICAL
S
ERVICE
AREA (GSA)
An area designated by AHCCCS within which a Contractor of
record provides, directly or through subcontract, covered
health car e serv ices to a mem ber en rol led wi th th at C on tract or
of record, as defined in 9 A.A.C. 22, Article 1.
M
ANAGEMENT
S
ERVICES
AGREEMENT (MSA)
A type of subcontract with an entity in which the owner of the
Contractor delegates some or all of the comprehensive
management and administrative services necessary for the
operation of the Contractor.
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M
ATERIAL
C
HANGE TO
BUSINESS OPERATIONS
Any change in overall operations that affects, or can
reasonably be foreseen to affect, the Contractor’s ability to
meet the performance standards as required in contract
including, but not limited to, any change that would impact or
is likely to impact more than 5% of total membership and/or
provider network in a specific GSA.
M
ATERIAL
C
HANGE TO
THE
PROVIDER NETWORK
Any change that affects, or can reasonably be foreseen to
affect, th e Contractors’ ability to meet the performance and/o r
provider network standards as required in contract including,
but not limited to, any change that would cause or is likely to
cause more than 5% of the members in a GSA to change the
location where services are received or rendered.
P
ROVIDER
G
ROUP
Two or more health care professionals who practice their
profession at a common location (whether or not they share
facilities, supporting staff, or equipment).
III. POLICY
The Contractor must have efficient and effective business operations and provider networks
to ensure that performance and provider network standards are met to support an individual’s
needs as well as the needs of the membership as a whole [42 CFR 438.207]. Changes to
business operations or to the provider network must be evaluated for the impact to members
and providers. Implementation must be planned to ensure continuity of care to members.
AHCCCS-initiated changes, such as changes in reimbursement methodologies (e.g. APR-
DRG) or changes to reference tables impacting claims payment, and Industry-initiated
changes, such as CPT/Diagnosis code changes, are excluded from these Policy requirements.
A. IDENTIFYING A PROVIDER NETWORK AND/OR BUSINESS OPERATIONS MATERIAL
CHANGE
1. The Contractor is responsible for evaluating all business operational and provider
network changes, including unexpected or significant changes, and determining
whether those changes are material changes to the provider network or business
operations.
2. For changes impacting members and/or providers regarding the provider network
and/or business operations the Contractor must:
a. Establish criteria and/or methodology for determining the impact of the change to
members and providers.
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b. Evaluate the impact of the change to its membership and provider network, by
GSA and as a whole, utilizing the established criteria and/or methodology
established under III (A)(2)(a.) above.
c. Determine, based on the evaluation results, if the change meets the definition of a
material change as outlined in this Policy and determine if it complies with
Contract and Policy requirements.
d. Maintain documentation of evaluation of all provider network and business
operations changes.
3. Provider Network changes may include, but are not limited to, changes in services,
GSA, payments or eligibility of a new population. Changes may also include the
addition or change in:
a. Pharmacy Benefit Manager (PBM),
b. Dental Benefit Manager,
c. Transportation Vendor,
d. Provider Contracts (e.g. Hospital, Nursing Facility, assisting living facility,
primary care or specialty providers),
e. Lab Contracts,
f. Crisis Services Vendor, and
g. Any other delegated agreements.
4. Business Operations changes may include, but are not limited to, policy, process, and
protocol, such as prior authorization or retrospective review. Changes may also
include the addition or change in:
a. PBM,
b. Dental Benefit Manager,
c. Transportation vendor,
d. Claims Processing system,
e. System changes and upgrades,
f. Member ID Card vendor,
g. Call center system,
h. MSA, and
i. Any other Administrative Services Subcontract.
5. AHCCCS may request and review documentation of established methodology,
criteria, and evaluation results for all provider network and business operations
changes.
6. For all changes which have a member impact, the Contractor is required to provide
member notification as stipulated in ACOM Policy 404.
7. The Contractor must request in writing, prior approval of a material change to the
provider network and/or business operations in accordance with this Policy.
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a. A material change in the provider network and/or business operations requires a
30 day advance written notice from the Contractor to members and providers [42
CFR 438.10(f)(4)]. In the event unforeseen circumstances prevent the Contractor
from providing 30 days advance written notice to members and providers, the
Contractor shall notify AHCCCS within one business day of identifying the
material change to the provider network for AHCCCS determination of
notification requirements.
b. Additionally, when appropriate, the Contractor must make a good faith effort to
give written notice to enrollees within 15 days after receipt or issuance of a
provider termination notice, to each member who received their primary care
from, or is seen on a regular basis by, the terminated provider [42 CFR
438.10(f)(5)].
8. A material change to operati ons may also constitute a material change to the provider
network.
B. CONTRACTOR REPORTING REQUIREMENTS
1. The Contractor must request, in writing, prior approval of a material change to the
provider network or business operations as specified in Contract, Section F,
Attachment F3, Contractor Chart of Deliverables and RBHA Contract, Exhibit-9,
Deliverables. A request for approval shall include a detailed description of the
proposed change and all requirements outlined above and summarized in Attachment
A, Provider Network/Business Operations Material Change Plan Checklist.
2. The Contractor must request prior approval, in writing, of a material change that
involves major system changes and upgrades to the Contractor’s information system
that affects claims processing, payment or other major business component as
specified in Contract, Section F, Attachment F3, Contractor Chart of Deliverabl es and
RBHA Contract, Exhibit-9, Deliverables. A request for approval must include a
system change plan that includes a timeline, milestones and outlines adequate testing
to be completed before implementation.
3. In the event of an unexpected change that is likely to cause or may reasonably be
foreseen to cause a material change to the provider network and/or business
operations, the Contract or must submit written notification to A HCCCS no later than
one business day of the Contractor becoming aware of the unexpected change.
Notification must be submitted as specified in Contract, Section F, Attachment F3,
Contractor Chart of Deliverables and RBHA Contract, Exhibit-9, Deliverables. The
Contractor shall include t he information known at the time of the notice and complete
follow-up information regarding the change shall be provided no later than 10
business days after initial notification.
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4. AHCCCS will review and respond to the Contractor within 30 days of the
submission. Incomplete submissions will not be approved and additional information
may be requested. The approval process will be expedited for emergency situations.
5. The Contractor may be required to provide periodic updates on the status of the
change or implementation.
6. The Contractor may be required to conduct meetings with providers and/or members
to provide general information, technical assistance or address issues related to
changes to business operations, changes in policy, reimbursement matters, prior
authorizations and other matters as identified or requested by AHCCCS.
IV. REFERENCES
• Acute Care Contract, Section D
• ALTCS/EPD Contract, Section D
• CRS Contract, Section D
• DCS/CMDP Contract, Section D
• DES/DDD Contract, Section D
• Contract, Section F, Attachment F3, Contractor Chart of Deliverables
• RBHA Contract, Scope of Work
• RBHA Contract, Exhibit-9, Deliverables
• Attachment A, Provider Network/Business Operations Material Change Plan Checklist
• 9 A.A.C. 22, Article 1
• 42 CFR 438.10(f)(4)
• 42 CFR 438.10(f)(5)
• 42 CFR 438.207
• ACOM Policy 404
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ATTACHMENT A, PROVIDER NET W ORK AND/OR BUSINESS OPERATIONS CHANGES PLAN
CHECKLIST
SEE THE ACOM WEBPAGE FOR ATTACHMENT A OF THIS POLICY
