CurrentBlue Cross Blue Shield - North DakotaPolicy N/A

1915(i) Conflict of Interest Requirements

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Governs federal and North Dakota-specific conflict of interest standards for 1915(i) care coordination and supportive service providers, Human Service Zone eligibility staff, and members receiving 1915(i) services.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

Policy1915(i) Conflict of Interest Requirements

Policy CodePolicy N/A

Change TypeNo material changes identified

Effective DateN/A

Next Review DateN/A

Key ActionProviders must document and maintain written conflict-of-interest standards and policies and inform members of their rights, including options to choose or change providers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2conflict-of-interest exemptions described

5explicit conflict triggers

6 monthsexemption duration

yeswritten standards required

Conflict-of-Interest Coverage Criteria

Conflict of interest standards and exceptions

Standards and allowable exceptions for who may provide care coordination versus other 1915(i) services to the same member.

Process when other qualified providers exist: When other qualified or culturally specific providers exist, the care coordination agency must send service referrals through Therap in order of member choice; Therap denials serve as documented denials; accepting agencies must be identified on the plan of care; lack of response within two business days may be treated as a denial.

Documentation accepted to demonstrate lack of other willing and qualified providers: Documentation may include Therap referral denials, screenshots showing no response, SComms indicating inability to serve, or evidence that an accepting agency failed to start services within five business days (counts as denial).

Agency separation and staffing requirements: Care coordination agencies that provide both care coordination and other 1915(i) services must document different individual providers and supervisors for care coordination versus other services on the plan of care and implement conflict of interest protections.

Restriction on individual providers employed by multiple agencies: An individual provider affiliated with multiple agencies cannot provide care coordination for a member under one agency and provide other 1915(i) services for the same member under a different agency if that individual is employed by both agencies for those roles.

Human Service Zone role: Human Service Zone performs independent evaluation of eligibility and must meet the same conflict-free standards (not related, financially responsible, or empowered to make decisions for the member).

WHODAS administration: WHODAS for 1915(i) eligibility or redetermination cannot be administered by the same person providing care coordination or supportive services; it may be administered by another employee of the care coordination agency only if that person meets conflict-free criteria.

Conflict of Interest Coverage Criteria

Standards and operational expectations for conflict-free care coordination and when exemptions apply.

Agencies must maintain written conflict-of-interest standards and written policy ensuring independence between individual providers and supervisors who provide care coordination and those who provide other 1915(i) services to the same member.

Exemption duration and re-evaluation: Approved conflict-of-interest exemptions last six (6) months; at that time the care coordinator must reassess availability of other willing and qualified providers and end the exemption if other providers can serve the member.

Provider Responsibilities and Operational Requirements

Prior Authorization

Prior authorization required when applicable

If applicable, providers must obtain prior service authorization before delivering services.

Documentation Required

Document conflict-of-interest policies; member notification and exemption process

Providers must maintain written conflict-of-interest standards and policies ensuring independence between care coordination staff and providers/supervisors of other 1915(i) services; care coordinators must inform members of their right to choose/change providers and document dispute resolution and free choice on the Plan of Care. Exemptions for a provider to perform both roles may be requested when the provider is the only willing and qualified option (see examples); approved exemptions last six months and must be reassessed at expiration.

Maintain written conflict-of-interest standards and policy ensuring independence of individual providers and supervisors for care coordination and other 1915(i) services (chunk 15).
Care coordinator must inform member of right to choose and change providers, provide dispute resolution form, and document member acknowledgement of free choice on the Plan of Care (chunk 19).
Examples of 'only willing and qualified' situations that may justify an exemption: sole provider in county, sole language-capable provider, sole youth-serving provider, or sole provider matching service preferences, provided no inappropriate legal history exists between provider and member (chunk 19).
If an exemption is approved it lasts six (6) months; the care coordinator must reassess availability of other willing and qualified providers at that time (chunk 20).
Email information about agency translation services to nd1915(i)@nd.gov to be listed; translation services do not substitute for having agency staff who speak the member's language for exemption purposes (chunk 19).

Key Definitions

Care coordinator

DefinitionCare coordinator - the professional responsible for plan of care development and coordinating access to needed services.

Primary responsibilitiesPerforms assessments, develops the Plan of Care, and coordinates access to needed supports and services for Medicaid members.

Independence requirementMust be independent from providers of other 1915(i) services to the same member unless an approved exemption applies.

Care coordination

DefinitionCare coordination - performing assessments and developing a Plan of Care for a Medicaid member, carried out by a care coordinator.

Key activitiesConducts assessments, identifies needed services, develops and documents the Plan of Care, and coordinates referrals and service access.

DocumentationPlan of Care must record member notification of rights and any selections or acknowledgements related to provider choice.

Conflict of interest

DefinitionConflict of interest - the expectation that care coordinators are independent or separate from providers of other 1915(i) services to the same member.

Employer-based separationIndependence is determined at the employing legal entity level; care coordinators cannot have an interest in or be employed by a provider of other 1915(i) services to the same member unless an exemption applies.

Policy requirementAgencies must maintain written conflict-of-interest standards and policies to ensure independence between care coordination staff and other 1915(i) service providers.

Cultural background

DefinitionCultural background - a shared set of beliefs, practices, traditions, and values inherited from the ancestry of a social group; for 1915(i) a specific group must be identified (e.g., a particular tribe).

RelevanceMay justify an exemption when the only willing and qualified provider shares the member's language or cultural background and no other suitable providers exist.

Documentation noteCultural or language-based exemptions require demonstration of provider availability and that service staff (not just translation services) meet the language/cultural need while remaining separate roles.

Separately employed / EIN

DefinitionSeparately employed / EIN - means employed by a legal entity with a separate Employer Identification Number (EIN).

ImplicationConflict-of-interest determinations use the employing legal entity (EIN) to establish whether staff are separate; same EIN indicates same employer unless an exemption applies.

Employer interestCare coordinators cannot have a financial interest in or be employed by providers of other 1915(i) services to the same member absent an approved exemption.

Only willing and qualified provider

DefinitionOnly willing and qualified provider - a provider who is the sole willing and qualified option for the member in a given circumstance (county, language, youth services, or matching service preferences).

ExamplesSole supportive service provider in the member's county; only provider offering services in the member's language in the county; only provider currently serving youth in the county; only provider matching requested service preferences (e.g., female peer support specialist).

LimitationMust have no pre-existing legal impediment or inappropriate legal history with the member to qualify for exemption consideration.

Exemption duration

DurationApproved conflict-of-interest exemptions last six (6) months.

Renewal requirementAt six months the care coordinator must reassess availability of other willing and qualified providers and end the exemption if suitable providers exist.

Process noteThe care coordinator must repeat the exemption process to demonstrate continued lack of other willing and qualified providers before renewal or continuation is allowed.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

Policy1915(i) Conflict of Interest Requirements

Policy CodePolicy N/A

Change TypeNo material changes identified

Effective DateN/A

Next Review DateN/A

Key ActionProviders must document and maintain written conflict-of-interest standards and policies and inform members of their rights, including options to choose or change providers.

SourceLink

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1915(i) Conflict of Interest Requirements

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - North Dakota policy alerts

Know when Blue Cross Blue Shield - North Dakota releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Conflict-of-Interest Coverage Criteria

Conflict of interest standards and exceptions

Standards and allowable exceptions for who may provide care coordination versus other 1915(i) services to the same member.

Conflict of Interest Coverage Criteria

Standards and operational expectations for conflict-free care coordination and when exemptions apply.

Provider Responsibilities and Operational Requirements

Prior Authorization

Prior authorization required when applicable

If applicable, providers must obtain prior service authorization before delivering services.

Documentation Required

Document conflict-of-interest policies; member notification and exemption process

Maintain written conflict-of-interest standards and policy ensuring independence of individual providers and supervisors for care coordination and other 1915(i) services (chunk 15).
Care coordinator must inform member of right to choose and change providers, provide dispute resolution form, and document member acknowledgement of free choice on the Plan of Care (chunk 19).
Examples of 'only willing and qualified' situations that may justify an exemption: sole provider in county, sole language-capable provider, sole youth-serving provider, or sole provider matching service preferences, provided no inappropriate legal history exists between provider and member (chunk 19).
If an exemption is approved it lasts six (6) months; the care coordinator must reassess availability of other willing and qualified providers at that time (chunk 20).
Email information about agency translation services to nd1915(i)@nd.gov to be listed; translation services do not substitute for having agency staff who speak the member's language for exemption purposes (chunk 19).

Key Definitions

Care coordinator

DefinitionCare coordinator - the professional responsible for plan of care development and coordinating access to needed services.

Primary responsibilitiesPerforms assessments, develops the Plan of Care, and coordinates access to needed supports and services for Medicaid members.

Independence requirementMust be independent from providers of other 1915(i) services to the same member unless an approved exemption applies.

Care coordination

DefinitionCare coordination - performing assessments and developing a Plan of Care for a Medicaid member, carried out by a care coordinator.

Key activitiesConducts assessments, identifies needed services, develops and documents the Plan of Care, and coordinates referrals and service access.

DocumentationPlan of Care must record member notification of rights and any selections or acknowledgements related to provider choice.

Conflict of interest

DefinitionConflict of interest - the expectation that care coordinators are independent or separate from providers of other 1915(i) services to the same member.

Policy requirementAgencies must maintain written conflict-of-interest standards and policies to ensure independence between care coordination staff and other 1915(i) service providers.

Cultural background

RelevanceMay justify an exemption when the only willing and qualified provider shares the member's language or cultural background and no other suitable providers exist.

Separately employed / EIN

DefinitionSeparately employed / EIN - means employed by a legal entity with a separate Employer Identification Number (EIN).

ImplicationConflict-of-interest determinations use the employing legal entity (EIN) to establish whether staff are separate; same EIN indicates same employer unless an exemption applies.

Employer interestCare coordinators cannot have a financial interest in or be employed by providers of other 1915(i) services to the same member absent an approved exemption.

Only willing and qualified provider

LimitationMust have no pre-existing legal impediment or inappropriate legal history with the member to qualify for exemption consideration.

Exemption duration

DurationApproved conflict-of-interest exemptions last six (6) months.

Renewal requirementAt six months the care coordinator must reassess availability of other willing and qualified providers and end the exemption if suitable providers exist.

Process noteThe care coordinator must repeat the exemption process to demonstrate continued lack of other willing and qualified providers before renewal or continuation is allowed.