|
19. Health Plan shall provide to Provider required information on the grievance and appeal system (42 C.F.R. §
<br />438.414 and 42 C.F.R. § 438.10(g)(1)). This information shall include the toll -free numbers to file oral
<br />Grievances and Appeals, the availability of assistance in filing a Grievance or Appeal, including informing
<br />the Enrollee about Ombuds services and how to access these services, the Member's right to request
<br />continuation of Medicaid benefits during an appeal or hearing and, if the Health Plan's Adverse Benefit
<br />Determination is upheld, that the Member may be responsible to pay for the cost of the benefits received for
<br />the first sixty (60) calendar days after the appeal or hearing request was received, the Member's right to file
<br />Grievances and Appeals and their requirements and timeframes for filing, the Member's right to a hearing,
<br />how to obtain a hearing, and representation rules at a hearing. The Provider may file a Grievance or request
<br />an adjudicative proceeding on behalf of a Member. Health Plan and Provider shall retain as applicable,
<br />Member Grievance and Appeal records pursuant to 42 CFR § 438.416, base data pursuant to 42 CFR §
<br />438.5(c), Medicaid Loss Ration reports pursuant to 42 CFR § 438.8(k), and the data, information, and
<br />documentation specified in 42 CFR § 438.605, 438.606, 438.608, and 438.610 for a period of no less than
<br />ten (10) years.
<br />20. Provider shall have and maintain insurance appropriate to the services to be performed and shall make
<br />copies of Provider's Certificates of Insurance available to Health Plan if requested.
<br />21. If Provider is at financial risk, as defined in the Washington Medicaid Contract, Health Plan will establish,
<br />enforce and monitor solvency requirements, and Provider shall comply with such requirements.
<br />22. As applicable, Members have the right to self -refer for certain services to participating or nonparticipating
<br />local health departments and participating or nonparticipating family planning clinics paid through separate
<br />arrangements with the state of Washington. The services to which Members may self -refer are: 1 - family
<br />planning services and supplies, and sexually transmitted disease screening and treatment services provided
<br />at participating or non -participating providers, including but not limited to family planning agencies, such
<br />as Planned Parenthood, 2 — immunizations, sexually -transmitted disease screening and follow up, HIV
<br />screening, tuberculosis screening and follow up, and family planning services through and if provided by a
<br />local health department, 3 — immunizations, sexually transmitted disease screening, family planning and
<br />behavioral health services through and if provided by a school -based health center, 4 - all services received
<br />by American Indian or Alaska Native Members at an IHCP, and 5 — crisis response services, including
<br />crisis intervention, crisis respite, investigation and detention services; and evaluation and treatment services.
<br />Self -referrals can also be made for assessment and intake for behavioral health services.
<br />23, Provider shall disclose the following to Health Plan upon contract execution, upon request during the re-
<br />validation of enrollment process, and within thirty-five (35) business days after any change in ownership of
<br />Provider: the name and address of any person (individual or corporation) with an ownership or control
<br />interest in Provider; if Provider is a corporate entity, the disclosure must include primary business address,
<br />every business location, and P.O. Box address; if Provider has corporate ownership, the tax identification
<br />number of the corporate owner(s); if Provider is an individual, date of birth and Social Security Number; if
<br />Provider has a 5 percent ownership interest in any of its subcontractors, the tax identification number of the
<br />subcontractor(s); whether any person with an ownership or control interest in Provider is related by
<br />marriage or blood as a spouse, parent, child, or sibling to any other person with an ownership or control
<br />interest in Provider; if Provider has a 5 percent ownership interest in any of its subcontractors, whether any
<br />person with an ownership or control interest in such subcontractor is related by marriage or blood as a
<br />spouse, parent, child, or sibling to any other person with an ownership or control interest in Provider; and
<br />whether any person with an ownership or control interest in Provider also has an ownership or control
<br />interest in any Managed Care entity.
<br />24. As applicable, Provider shall ensure interpreter services are provided free of charge for Enrollees and
<br />Potential Enrollees with a primary language other than English or those who are Deaf, DeafBlind, or Hard
<br />of Hearing. This includes oral interpretation, Sign Language (SL), and the use of Auxiliary Aids and
<br />Services as defined in this Contract (42 C.F.R. 438.10(d)(4)). Interpreter services, provided by certified
<br />interpreters, shall be provided for all interactions between such Enrollees or Potential Enrollees and Health
<br />Plan, or Provider, or any of its providers, including but not limited to customer service, all interactions with
<br />any provider for any covered service, Emergency Services and all steps necessary to file Grievances and
<br />Appeals including requests for Independent Review of Health Plan decisions.
<br />MHWPROV22.3 MHWHA/Revised Jan 2024 Page 24 of 25
<br />
|