2017-21 Contract Between State of Rhode Island Executive Office of Health and Human Services and UnitedHealthcare of New England for Medicaid Managed Care Services (Table of Contents & Attachments)
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This document is the contract between the Rhode Island Executive Office of Health and Human Services and UnitedHealthcare of New England for Medicaid managed care services (2017-21) and includes the table of contents and attachments for program standards, enrollment, provider networks, service access, reporting, grievances, payments, and other operational provisions. It governs the managed care relationship and operational requirements for the plan under the contract.
No material clinical or coverage changes in this revision.
Coverage, Benefits, and Program Scope
In-Plan Services and Care Coordination
Sections describe the comprehensive benefit package, care management, coordination with out-of-plan services, and new in-plan services.
Provider Networks
Provider network requirements including network composition, contracting with certified accountable entities, PCPs, behavioral health, FQHCs/RHCs, and network change processes are listed in the Table of Contents.
Grievance and Appeals
Grievance and appeals processes, adverse benefit determinations, expedited appeals, and continuation of benefits are covered in the grievances and appeals sections.
TOC: Disclosures and Program Integrity
Listed contract subsections relevant to disclosure and program integrity (TOC).
Scope (TOC)
This excerpt does not contain clinical coverage rules; it lists contractual sections related to integrity, payments, and administrative obligations.
Attachment schedules (referenced)
The contract includes multiple attachments listing in-plan benefits, in-lieu of services, out-of-plan benefits, non-covered services, EPSDT schedules, specialty program schedules, and other operational attachments.
Adverse benefit determination criteria (definition only)
Definitions related to adverse benefit determinations identify scenarios that would be treated as denials or limitations subject to appeal/grievance processes.
ONE of
- Denial or limited authorization of a requested service (including medical necessity, appropriateness, setting, or effectiveness).
- Reduction, suspension, or termination of a previously authorized service.
- Denial, in whole or in part, of payment for a service.
- Failure to provide services in a timely manner, as defined by the State.
- Failure of the Contractor to act within the timeframes in 42 C.F.R §438.408(b)(1) and (2) for standard grievance/appeal resolution.
- For residents of rural areas with only one MCO, denial of a request to obtain out-of-network services under 42 C.F.R. §438.52(b)(2)(ii).
- Denial of a member's request to dispute a financial liability (cost sharing, copayments, premiums, deductibles, coinsurance, other liabilities).
Coverage-related definitions
Definitions that establish coverage categories and related federal references used elsewhere in the Agreement.
Excluded Services Reference
Where coverage exclusions are referenced:
Coding, Claims, and Regulatory Citations
| Operational Data Reporting, Encounter Data Reporting, All Payer Claims Database referenced (coding/claims data topics) |
| No codes listed |
| No codes listed |
| No codes listed |
| No codes listed |
| No codes listed |
| No codes listed |
| Payments to subcontractors and providers; Liability for Payment; Payments for FQHCs/RHCs and capitation-related payment topics referenced in TOC |
| No codes listed |
| No codes listed |
| HIPAA | Health Insurance Portability and Accountability Act of 1996 (description and applicability referenced) |
| 42 U.S.C. §1396d(r) | Statutory authority for EPSDT (Early and Periodic Screening, Diagnosis and Treatment). |
| 42 C.F.R. §438.2 | Regulatory reference for enrollee encounter data and comprehensive risk contract definitions. |
| 42 C.F.R. §440.70 | Regulatory definition referenced for Home Health Services |
| 42 C.F.R. §438.14 | Citation used in the definition of 'Indian' and 'Indian Healthcare Provider' |
| No codes listed |
| Prescription drug coverage and prescription drugs are defined (no specific NDC or formulary codes listed in this excerpt). |
Prior Authorization, Authorization Definitions, and Provider Obligations
Prior authorization and utilization management topics are listed in TOC; consult sections for requirements
Table of contents identifies prior authorization and utilization management topics (e.g., Utilization Review and Quality Assurance, Operational Data Reporting, Encounter Data Reporting) under Medical Management and Quality Assurance and Operational Data Reporting; providers should consult the referenced sections for specific prior authorization and UM rules and workflows.
- See Medical Management and Quality Assurance (2.12) for Utilization Review and Quality Assurance details and processes.
- Refer to Operational Data Reporting and Encounter Data Reporting (2.13) for reporting requirements tied to utilization management.
TOC — administrative sections shown; no authorization rules in excerpt
This excerpt contains only table of contents listings for administrative chapters (payments, records retention, compliance, program integrity) and does not include operational or prior authorization rules; providers must refer to the full contract sections cited in the TOC for obligations and procedures.
- TOC entries shown include Payments to and from Plans (2.15), Records Retention (2.17), and Compliance (2.18).
- No authorization rules are present in these TOC excerpts; consult the full text of each numbered section for requirements.
Table of Contents — no authorization content in this excerpt; consult full sections
Table of contents pages shown list many headings but do not include substantive authorization content; providers should consult the full Agreement (the numbered sections referenced) for specific authorization, prior authorization, and denial procedures.
- TOC entries enumerate headings (e.g., Audited Financial Reports, Records Retention) but do not define clinical or prior authorization rules.
- Providers must open the referenced sections (Article II and related subsections) to find applicable authorization policy.
TOC entries only; no authorization rules present here
TOC entries in this window are placeholders listing section titles without authorization rules. Providers should refer to the full contract subsections named in the TOC to find any procedural or authorization requirements.
- Examples of listed TOC items include Records Retention (2.17) and Compliance (2.18).
- No prior authorization or denial procedures are provided in these TOC lines.
Compliance TOC lists disclosures and prohibited affiliations; see full text for obligations
Compliance TOC entries (2.18.01–2.18.11) list contractor and provider compliance obligations—such as disclosures, prohibited affiliations, and adherence to state and federal regulations—but do not include prior authorization rules in this excerpt. Providers must review the full compliance sections for disclosure and affiliation obligations.
- Compliance topics shown include Prohibited Affiliations and Disclosure of Ownership and Control Interest.
- No authorization or clinical prior authorization rules are included in the compliance TOC here; see the full 2.18 text for provider obligations.
Procedures and disclosures (TOC) are listed; consult sections for required actions
Table of contents lists procedures and disclosure-related TOC entries for contractor/provider associations and required disclosures (ownership, control interests, business transactions, persons convicted of crimes); the excerpt does not include the procedural text—providers should consult the named sections for disclosure procedures.
- TOC entries include: Procedure for Contractor Associating with Prohibited Affiliations and Disclosure by Providers (ownership, business transactions, persons convicted of crimes).
- Providers must follow the detailed procedures in the full contract sections referenced in the TOC.
TOC-only content; no authorization rules provided here
This TOC-only excerpt reiterates headings for compliance and program integrity without providing rules. Providers should not assume procedural details from the TOC—refer to the full Agreement sections named in the TOC for requirements.
- TOC headings shown include Disclosure by Providers and Program Integrity subsections.
- Full contractual language contains the operative requirements; TOC entries are not sufficient for compliance.
Program integrity and contract obligations listed in TOC; consult full section for requirements
Program integrity and contract obligations are listed in the TOC (Program Integrity, Fraud Prevention Program, Investigations, Overpayments, Recoupment, Provider Terminations); providers must review the full Program Integrity section for obligations, reporting, audits, overpayment recovery, and cooperation requirements.
- TOC entries show Program Integrity subsections: Fraud Prevention Program; Engagement with EOHHS' Office of Program Integrity; Overpayments; Recoupment; Suspension of Payment; Provider Terminations.
- Providers should follow the full Program Integrity provisions for audit, reporting, recoupment, and cooperation obligations.
Adverse Benefit Determination — definition and examples (42 C.F.R. §438.400)
An 'Adverse Benefit Determination' is defined per 42 C.F.R. §438.400 and includes denial or limited authorization of a requested service; reduction, suspension, or termination of a previously authorized service; denial of payment; failures to provide timely services or to meet grievance/appeal timeframes; denials of out-of-network requests for certain rural residents; and denial of disputes over member financial liability.
- Examples enumerated include: denial/limited authorization based on medical necessity or appropriateness; reduction/suspension/termination of authorized services; denial of payment.
- Also includes: failure to provide timely services as defined by the State; Contractor failure to meet §438.408 timeframes; denial to obtain out-of-network services for rural residents (per §438.52); denial of a member's request to dispute financial liability.
Adverse Benefit Determination — provider-facing summary of denial events
The definition lists specific acts that constitute adverse benefit determinations, including failures to act within grievance/appeal timeframes and denials related to medical necessity, setting, or appropriateness; providers should recognize these actions as potential denials subject to appeals.
- Includes denial, limitation, reduction, suspension, termination, payment denial, timeliness failures, and financial liability dispute denials.
- Providers must follow appeals and grievance processes when these determinations occur (see full grievances/appeals sections).
Covered Services — definition and reference to Article II
'Covered Services' are defined as the medical (primary and acute), behavioral healthcare, long-term care services and supports and benefit packages described in Article II; providers should reference Article II to determine which services require authorization or are covered.
- Covered Services refers to the full set of benefits described in ARTICLE II: HEALTH PLAN PROGRAM STANDARDS.
- Providers must consult Article II for details on coverage scope and any authorization requirements.
Enrollee Encounter Data — definition and reporting pointer
'Enrollee encounter data' is defined per 42 C.F.R. §438.2 as information relating to the receipt of any item or service by the enrollee under this contract; providers must submit encounter/claims data per the referenced reporting sections.
- Encounter data is governed by 42 C.F.R. §438.2 and is tied to Operational Data Reporting and Encounter Data Reporting (see 2.13).
- Providers should follow the Encounter Data Reporting requirements in section 2.13 for submission formats and timelines.
Home Care Services — authorization context and covered elements
Home Care Services are defined as services provided under a physician‑authorized home care plan and include nursing, therapies, laboratory services, private duty nursing when medically required, personal care, and incidental homemaking (only when personal care is also needed); respite, relief care, and day care are excluded.
- Covered components include full-time, part-time, or intermittent licensed nursing or home health aide care; PT/OT/respiratory/speech therapy as authorized by a physician.
- Homemaking services are covered only when the member also needs personal care; respite, relief care, and day care are not included.
Home Health Services — defined by 42 C.F.R. §440.70
Home Health Services are those services defined by federal regulation at 42 C.F.R. §440.70; providers should follow the federal definition and the Agreement when determining coverage and authorization needs.
- The Agreement adopts the 42 C.F.R. §440.70 definition for Home Health Services.
- Providers must apply the federal regulatory standard and any plan procedures when seeking authorization.
Medical necessity — definition and EPSDT inclusion for under‑21 members
'Medical necessity' is defined to include services required for prevention, diagnosis, cure, or treatment and, for members under 21, EPSDT services per 42 U.S.C. §1396d(r); a service is medically necessary if it meets any of seven listed situations (life‑threatening, treat injury/illness, achieve function, maternity care, prevent serious disease, prevent impairment, support growth/development).
- EPSDT services are specifically included for members under age 21 per Section 1905(r) of the Social Security Act.
- Seven situations are enumerated where services are considered medically necessary (e.g., life‑threatening conditions; treat illness; achieve functional capacity).
Definition of Pre-authorization / Prior Authorization / Precertification — plan determination of medical necessity
Pre-authorization / Prior Authorization / Precertification is defined as the health plan's determination that a proposed service, treatment plan, prescription drug, or durable medical equipment is medically necessary to meet the member's needs; providers should follow the plan's authorization process for services requiring pre‑authorization.
- This term specifies that authorization is the plan's medical necessity determination for services, drugs, DME, or treatment plans.
- Providers must obtain pre-authorization where the plan requires it, per the applicable service-specific sections in the Agreement.
Key Definitions and Terms
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