Exhibit 4 Provider Network Provider Contract Requirements ICS must develop, implement, and maintain a comprehensive provider network that assures access to primary and specialty health related care that meets the access, quality, and CMS credentialing standards. The provider services delivery network for the ICS shall have the size and resources necessary to assure comprehensive services to members throughout its designated service area without perceptible disruption of service. The primary care physicians shall be an integral part of the health care delivery system and should be informed of all services. The ICS medical director shall be responsible for the medical management of all members. Physician and hospital services rendered to members must be rendered by ICS participating network providers that the ICS has credentialed in compliance with CMS credentialing standards, except for ICS approved out-of-network or emergency services. All primary care physicians serving members must sign contracts with the ICS prior to serving the members. Provider Directory The ICS network provider directory shall identify all service sites, hospitals, specialists, and ancillary network providers. The directory shall include location addresses and telephone numbers for all providers and will be updated monthly. Any lists of ICS network providers made available to members shall be arranged alphabetically, showing the network provider s name and specialty and, separately, by specialty, in alphabetical order. Exhibit 4 Provider Network 8-22 1
Provider Access Standards 1) Travel Time. a) Primary care services must be available within 30 minutes driving time of the member s residence. b) In-network specialty physician services, ancillary services, and specialty hospital services must be available within 60 minutes driving time from the member s residence. c) With sufficient justification, if primary care, specialty care, or ancillary services are not obtainable due to a limitation of ICS network providers, such as in rural areas, a request may be made to CMS to waive driving times. d) Hospital services must be provided within 60 minutes driving time from the member's residence. 2) Timely Treatment. a) Routine well-child care in which there is no significant medical problem or concern (e.g., child health services per the American Academy of Pediatrics (AAP) periodicity schedule for immunizations) must be provided within 4 weeks of the request for services by the member or the parent or guardian. b) Routine symptomatic care, in which there is a medical concern, but for which there is no urgent or emergency condition, is to be provided within 2 weeks. c) Specialty evaluation and treatment for a member's condition is to be provided within 30 days of the request for services by the primary care physician. d) Urgent care must be provided to the member within 24 hours. e) Emergency care must be provided in accordance with state and federal laws. Access to emergency services must be without prior authorization even if the emergency services provider does not have a contractual relationship with the entity. The ICS will be responsible to provide for all emergency services. Emergency services must include: 1. The screening or evaluation and all medically necessary emergency services when a member is referred by the ICS representative to the emergency room. 2. The screening or evaluation, when an absence of clinical emergency is determined by the member's presenting symptoms are of sufficient severity (including severe pain) such that a prudent lay person, who possesses an average knowledge of Exhibit 4 Provider Network 8-22 2
health and medicine, could reasonably expect the absence of immediate medical attention to result in an emergency medical condition. 3. Both the screening or evaluation and stabilization services when a clinical emergency is determined. 4. Continued emergency services until the member can be safely discharged or transferred. 5. Post-stabilization services which are pre-authorized by the ICS or were not pre-authorized, but the ICS failed to respond to request for pre-authorization within one hour, or could not be contacted. Post-stabilization services remain covered until the ICS contacts the emergency room and takes responsibility for the member. f) Care for medical emergencies is to be provided to the member and ICS shall approve such claims without prior authorization. g) The ICS must provide access to health care services on a 24-hour, 7-day-aweek basis. The ICS must provide for after-hours access. The after-hours access does not include an answering machine or answering service unless it results in a prompt callback by someone who is licensed to render an appropriate clinical decision within a time appropriate to the situation but not to exceed 60 minutes. The caller must be connected to either the primary care physician, someone who can contact him, or her, or someone who can render a clinical decision on his/her behalf. The after hours coverage must be accessible using the medical office's daytime phone number. ICS will establish a mechanism that monitors the duration between the call and the response. h) The ICS network physician providers will comply with the in-office waiting time standard of 45 minutes. Provision of Care Outside the ICS Network. Policies shall be developed for the provision of medical services to members requiring referrals to out-of-network qualified specialty care providers to address the unique medical needs of the member if the care cannot be provided within the ICS. Financial arrangements for the provision of these services shall be agreed to prior to these services being rendered. Emergency services, including screening, examination, and evaluation provided to members outside the network by a service provider who does not have a contract with the ICS shall be reasonably reimbursed by the CMS fiscal agent based on the Medicaid rate. If the member must access services outside the ICS service area, the ICS must treat any CMS credentialed provider from that outside area as an in-network provider. Exhibit 4 Provider Network 8-22 3
Delivery System Requirements a) Treatment of children with complex conditions requires a multidisciplinary team approach and the resources of pediatric specialists and sub-specialists. The primary care physician will coordinate care and have acknowledged expertise and experience in the management of the complex condition specific to the child. Health care providers included in the ICS must have demonstrated experience in providing services to children with special health care needs. In order to provide a comprehensive continuum of care for members, the ICS will develop a team approach that includes a mechanism for family input. b) The ICS must establish a delivery system that demonstrates that members physician and hospital services will be predominantly rendered by ICS participating network providers. The ICS is also expected to provide ancillary benefits using in-network providers. c) The ICS will ensure that executed contracts with all in-network providers are in place. The ICS will be required to provide the appropriate array of comprehensive and pediatric specialty health care services in the closest proximity to the member s residence. The member or member's family may request care be provided by other in-network providers. d) Health care services that are provided outside the network must be coordinated by the ICS. Staff and Physicians. a) The ICS shall ensure that all ICS network providers, whether they are employees, agents, subcontractors or anyone acting for or on behalf of the ICS, are licensed under applicable state law or regulations b) The ICS will contract with sufficient numbers and types of service providers to ensure access to all covered services prior to contract execution and will maintain sufficient numbers and types of service providers to ensure access to all covered services for the duration of the contract. c) In the event a member develops a need for a covered service that cannot be fulfilled within the existing network, the ICS will be required to use an out-ofnetwork service provider who meets CMS credentialing criteria or is a CMS credentialed service provider for non-emergency services. d) The ICS will establish criteria permitting physicians in other specialties to serve as primary care physicians in the ICS (e.g., infectious disease specialists for HIV-infected persons). The ICS will identify the physician specialties eligible to serve as primary care physicians in the ICS (e.g., pediatric cardiologist). e) The ICS will immediately act to terminate any ICS network provider from participation (and, if such ICS network provider is a primary care physician, reassign his or her member panel to other primary care physicians) upon Exhibit 4 Provider Network 8-22 4
notification from CMS that the ICS network provider has been terminated or suspended from participation in the CMS program due to quality of care issues or has been charged or convicted of Medicare or Medicaid fraud or other professional or criminal conduct. Similarly, the ICS will notify CMS of the practice restrictions or termination of any ICS network provider because of the quality of care issues discovered by the ICS quality improvement process. f) The ICS must notify the Department within 10 days of any changes to the composition of the ICS provider network that affects the ICS s ability to make available all covered services in a timely manner. The ICS must have procedures to address changes in its network that negatively affect access to care. A copy of these procedures will be provided to the Department with the notification of change. Changes in ICS provider network composition that the Department determines to negatively affect members access to covered services may be grounds for contract termination. g) The ICS will assure that primary care physicians have an active CMS caseload in accordance with the requirements of the Department. Primary Care Physicians. The primary care physician shall be a pediatrician or a family practice physician with board certification or pending board certification. Specialty Coverage. a) The ICS will use sub-boarded pediatric specialists where appropriate. b) The ICS shall include ancillary health professionals (e.g., home health services, nursing services, social workers, speech therapists, respiratory therapists, physical therapists, occupational therapists) with experience in dealing with children with special health care needs and their families. ICS network providers should be recruited who demonstrate understanding, sensitivity, knowledge, and skills needed to work collaboratively with families and children with special health care needs. Ancillary health professionals and all non-physician ICS network providers who serve Title XXI members must agree to abide by the standards of the Department. All non-physician ICS network providers who serve members must agree to abide by the standards shown below. 1) Employ staff that have received and continue to receive specialized training, education, and licensure or certification. 2) Have measurable criteria to demonstrate quality assurance monitoring and continuous quality improvement activities. 3) Demonstrate the capacity to provide services based upon identified patient care need specific to the service provider s scope of practice. Exhibit 4 Provider Network 8-22 5
4) Define the geographical area they will serve. 5) Demonstrate sensitivity, respect, support, and education to families, as appropriate. 6) Function as responsive partners with the CMS area office and the ICS. Provider Termination For providers serving Title XXI members, termination procedures must comply with the following: a) The ICS shall comply with all state and federal laws regarding provider termination. b) The ICS shall notify enrollees in accordance with the provisions of the Contract resulting from this ITN regarding provider termination. c) In a case in which a patient's health is subject to imminent danger or a physician's ability to practice medicine is effectively impaired by an action by the Board of Medicine or other governmental agency, notice to both the provider and the Department shall be immediate. d) The ICS shall notify the provider, the Department, and members in active care at least sixty (60) calendar days before the effective date of the suspension or termination of a provider from the network. If the termination was for "cause", the ICS shall provide to the Department the reasons for termination. Facility Standards. Facilities used for primary and secondary care services for the CMS population shall meet applicable accreditation and licensure requirements and meet facility regulations specified by the Agency for Health Care Administration. The ICS must ensure the utilization of existing CMS approved cardiac facilities, RPICC centers, hematology and oncology centers, and craniofacial centers for services rendered to all members. Additionally, the ICS must ensure utilization of existing transplant centers designated by the Agency for Health Care Administration. The ICS must also ensure that members have access and referral to CMS approved centers of excellence for unique and complicated care. Independent laboratory testing sites providing services under this contract must be certified in accordance with Public Law 100-578, the Clinical Laboratory Improvement Amendments of 1988 (CLIA). The laboratory may provide only those specific laboratory test specialties and subspecialties covered by its CLIA certification. Independent laboratory testing sites must also comply with Part I, Chapter 483, Florida Statutes. Exhibit 4 Provider Network 8-22 6
Regional Perinatal Intensive Care Centers. Regional Perinatal Intensive Care Centers (RPICC) are statutorily authorized facilities that are required for the tertiary care of CMS children. The ICS must have a minimum of one RPICC in the system's network of service providers. The CMS Program Office will provide in writing a listing of authorized RPICCs to the ICS. Provider Handbook The ICS shall issue a provider handbook to all providers at the time the provider credentialing is complete. The ICS may choose not to distribute the provider handbook via surface mail, provided it submits a written notification to all providers that explains how to obtain the handbook from the Health Plan s website. This notification shall also detail how the provider can request a hard copy from the ICS at no charge. The ICS shall keep all provider handbooks and bulletins up to date and in compliance with state and federal laws. The provider handbook shall serve as a source of information regarding ICS covered services, policies and procedures, statutes, regulations, telephone access and special requirements to ensure all Contract requirements are met. At a minimum, the provider handbook shall include the following information: (1) Description of the ICS program; (2) Covered Services; (3) Emergency service responsibilities; (4) Child Health Check-Up program services and standards; (5) Policies and procedures that cover the provider complaint system. This information shall include, but not be limited to, specific instructions regarding how to contact the ICS to file a provider complaint, including complaints about claims issues, and which individual(s) has authority to review a provider complaint; (6) Required procedural steps in the enrollee grievance process, including the address, telephone number, and office hours of the grievance staff; the enrollee s right to request continuation of benefits while utilizing the grievance system. The ICS shall specify telephone numbers to call to present a complaint, grievance, or appeal. Each telephone number shall be toll-free within the caller s geographic area and provide reasonable access to the ICS without undue delays; (7) Medical necessity standards and practice protocols, including guidelines pertaining to the treatment of chronic and complex conditions; Exhibit 4 Provider Network 8-22 7
(8) PCP responsibilities; (9) Other provider or subcontractor responsibilities; (10) Prior authorization and referral procedures, including required forms; (11) Medical record standards; (12) Claims submission information; (13) Protocols for submitting encounter data; if applicable (14) A summary of the ICS s cultural competency plan and how to get a full copy at no cost to the provider; and (15) Enrollee rights and responsibilities. Toll-Free Provider Help Line a). The ICS shall operate a toll-free telephone help line to respond to provider questions, comments, and inquiries. b) The ICS 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 other means, and compliance with ICS standards. c.) The help line shall be staffed twenty-four hours a day, seven days a week (24/7) to respond to prior authorization requests. This help line shall have staff to respond to provider questions in all other areas, including the provider complaint system, provider responsibilities, etc., between the hours of 8 a.m. and 7 p.m. in the provider s time zone, Monday through Friday, excluding state holidays. d) The ICS s call center systems shall have the capability to track call management metrics identified in Exhibit 15- Information Management and Systems. e) The ICS shall ensure that after regular business hours, the provider services line (not the prior authorization line) is answered by an automated system with the capability to provide callers with information about operating hours and instructions about how to verify enrollment for an enrollee with an emergency or urgent medical condition. This requirement shall not be construed to mean that the provider must obtain verification before providing emergency services and care. Exhibit 4 Provider Network 8-22 8