2017-21 Contract Between the State of Rhode Island Executive Office of Health and Human Services and Neighborhood Health Plan of Rhode Island for Medicaid Managed Care Services
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This document is the contract between the Rhode Island Executive Office of Health and Human Services and Neighborhood Health Plan of Rhode Island governing Medicaid managed care services (2017-21 contract, attachments and program standards) and applies to the parties to that contract.
Coverage and Program Topics (Table of Contents)
inv-01: Table of contents for coverage and program sections
This part of the contract contains table-of-contents entries that identify sections addressing coverage, services, and program requirements. The TOC entries list topics and locations but do not themselves state coverage rules or medical necessity criteria.
ALL of the following
TOC entries (examples)
- Member enrollment and disenrollment (sections 2.04–2.05) including assignment, automatic re-assignment, enrollment procedures, change in status, and services for new members.
- In‑plan services and Description of Comprehensive Benefit Package (Article II, section 2.06) including care management, care coordination, second opinion, in‑plan service arrangements.
- Coordination with out‑of‑plan services and enrollee/provider communication (Article II TOC entries).
inv-02: Table of contents topics (no coverage rules present)
Topics listed in these TOC excerpts include grievance/appeals, compliance reporting, financial and records topics, and other program sections; the TOC lists headings and page references only.
ALL of the following
Sample TOC topic groups
- Grievance and Appeals (general, adverse benefit determination, health plan grievance and appeals process, expedited resolution of appeals, continuation of benefits).
- Compliance and reporting (HIPAA requirements, certification of data, RIte Share reporting, All Payer Claims Database, Patient Protection and Affordable Care Act).
- Financial, audit, and records retention topics (financial data reporting; audited financial reports; audits; periodic financial audit; records retention; operational data reports; medical records).
inv-03: Administrative table of contents — no coverage criteria
Administrative contract TOC entries are shown here; they enumerate administrative and compliance subsections without providing coverage decisions or clinical criteria.
ALL of the following
- Records Retention (2.17) and related operational/medical records reporting items listed in the TOC.
- Compliance chapter headings (2.18) including general requirements, SUPPORT Act compliance, prohibited affiliations, procedures for associating with prohibited affiliations, and contractor disclosure obligations.
- Contractor disclosure headings (disclosure of ownership/control interest) are listed as administrative obligations in the TOC.
inv-04: No coverage criteria in TOC
This excerpt reiterates TOC headings and confirms that TOC lines list topics without stating coverage stances or medical necessity rules.
ALL of the following
- Compliance TOC items (2.18.05–2.18.08 and related subsections) listing provider disclosure topics: ownership/control, business transactions, persons convicted of crimes, and disclosures made by providers to the contractor.
- TOC entries reference page numbers for compliance subsections but do not include the substantive compliance language or enforcement details.
inv-05: Compliance chapter TOC
The Compliance chapter TOC enumerates subsections that cover contractor and provider compliance obligations; full requirements are located in the referenced sections.
ALL of the following
- Compliance chapter headings (2.18.01–2.18.11) including general requirements, Compliance with H.R.6 (SUPPORT Act), prohibited affiliations, procedures for contractor associations with prohibited affiliations, and multiple disclosure requirements for contractors and providers.
- TOC lines also reference program integrity and link to Article II/III sections for enforcement and contract-level obligations.
inv-06: Referenced contract sections (TOC only)
These TOC entries identify contract sections that impose obligations on the contractor (program integrity, provider disclosures) rather than clinical coverage rules.
ALL of the following
- Contractor obligations appear in the TOC under Program Integrity (2.19) and include general requirements, a Fraud Prevention Program, engagement with EOHHS' Office of Program Integrity, cooperation with other agencies, program integrity staff, provider site audits, fraud/waste/abuse compliance plans, and investigation/reporting processes.
- Provider disclosure obligations are listed under compliance subsections (2.18.05–2.18.11) and cover disclosure of ownership/control interest, business transactions, persons convicted of crimes, and disclosures made by providers to the contractor.
inv-07: Contractor and Provider Program Integrity / Disclosure Obligations
TOC entries for Program Integrity and related contract terms enumerate the program elements and enforcement mechanisms the contractor must maintain; the TOC lists topics, not full requirements.
ALL of the following
- Program Integrity (Article II/2.19) TOC items include: Fraud Prevention Program; engagement with EOHHS Office of Program Integrity; cooperation with other agencies; program integrity staff; provider site audits; fraud, waste and abuse compliance plan; plan requirements; investigation and reporting of fraud, waste and abuse; overpayments; recoupment; suspension of payment; credible allegations of fraud; and provider terminations.
- Payment and contract terms (Article III TOC lines) including contract administration, contract officers, liaisons, notice requirements, interpretations and disputes, and payment provisions are listed as administrative sections in the TOC.
inv-08: Program Integrity and Contract Terms (TOC)
Program Integrity TOC entries identify subsections that govern contractor and provider obligations related to program integrity, audits, and enforcement.
ALL of the following
- Program Integrity subsections (2.19.05–2.19.14) listed in the TOC include program integrity staff, provider site audits, fraud/waste/abuse compliance plan and plan requirements, investigation and reporting of fraud/waste/abuse, overpayments, recoupment, suspension of payment, credible allegation of fraud, and provider terminations.
- These TOC lines indicate the scope of program integrity oversight and remedies, but the TOC does not contain the substantive program rules or procedures.
inv-09: Coverage-related definitions
Definitions in Article I that affect coverage and authorization are listed here in the TOC and definition entries; these definitions inform medical necessity and authorization processes.
ALL of the following
- Post‑Stabilization Care Services (1.103): defined consistent with 42 C.F.R. §438.114 as covered services related to an emergency medical condition provided after an enrollee is stabilized to maintain the stabilized condition or, in certain circumstances, to improve or resolve the enrollee's condition.
- Pre‑authorization / Prior Authorization / Precertification (1.105): defined as a health plan's determination that a proposed health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary to meet the needs of the member.
- Medical Necessity / Medically Necessary Service (definition referenced in Article I): includes services required for prevention, diagnosis, cure, or treatment; for members under 21 includes EPSDT services (1905(r)).
Billing, Codes and Regulatory References
| No billing or clinical codes present in this chunk; document is a table of contents. |
| Attachments include Schedule of In-Plan Benefits, Schedule of In Lieu of, Out-of-Plan, Non-Covered Services and EPSDT periodicity schedule; specific codes not provided in this excerpt. |
| 42 C.F.R. §440.70 | Reference defining Home Health Services |
| 1905(r) | EPSDT services inclusion for members under 21 within medical necessity |
Provider Requirements, Appeals, and Program Integrity (TOC & Definitions)
Follow TOC grievance & appeals headings (Grievance, Adverse Determination, Expedited Appeals, Continuation, External Review)
TOC headings identify the grievance and appeal framework providers must follow, including: General grievance and appeals procedures; Adverse Benefit Determination; Health Plan Grievance and Appeals Process; Expedited Resolution of Appeals; Continuation of Benefits; and State Fair Hearing and External Appeal (Medical Review Process).
- Grievance and Appeals — General; Adverse Benefit Determination; Health Plan Grievance and Appeals Process (2.14.01–2.14.03) [[see cited TOC entries]]
- Expedited Resolution of Appeals (2.14.04) and Continuation of Benefits (2.14.05)
- State Fair Hearing and External Appeal (Medical Review Process) referenced (2.14.06 / related TOC lines)
Comply with HIPAA and the contract grievance/appeal processes referenced in the TOC
TOC entries require provider compliance with referenced legal and administrative processes, including HIPAA requirements and the full grievance/appeals workflow (adverse determinations, expedited resolution, continuation of benefits, and State fair hearing/external appeal). Providers must follow these processes as specified by the plan/contract.
- Health Insurance Portability and Accountability Act (HIPAA) requirements are listed in the TOC (2.13.10).
- Grievance and appeals processes referenced include adverse benefit determination, expedited resolution, continuation of benefits, State fair hearing and external appeal (TOC entries).
Adhere to TOC financial, records retention, and reporting requirements
TOC lists financial, records, and compliance topics that govern provider obligations; providers must be aware these sections cover Financial Data Reporting, Audited Financial Reports, Audits, Periodic Financial Audit, Records Retention, Operational Data Reports, and Medical Records.
- Financial reporting sections: Financial Benchmarks; Financial Data Reporting; Audited Financial Reports; Audit; Periodic Financial Audit (2.16.x).
- Records Retention and Medical Records requirements (2.17.01–2.17.03) appear in the TOC and apply to providers and contractors.
Observe Compliance & Disclosures TOC requirements (prohibited affiliations, ownership disclosures)
TOC entries require compliance with disclosure and affiliation rules; providers should note the contract's Compliance & Disclosures chapter which lists prohibited affiliations and disclosure obligations for contractors and providers.
- Compliance chapter headings include General Requirements and Prohibited Affiliations (2.18.01–2.18.04).
- Disclosure and contractor ownership/control interest headings are listed (2.18.05 and related subsections).
Provide required ownership/control and business disclosures to the contractor per TOC
Providers are required to make disclosures to the Contractor as shown in the TOC (sections listing provider disclosure obligations and contractor ownership/control interest). Follow the contract subsections for specific reporting and disclosure obligations.
- Disclosure of the Contractor's Ownership and Control Interest (2.18.05).
- Disclosure by Providers: Ownership and Control; Business Transactions; Persons Convicted of Crimes; and Disclosures Made by Providers to the Contractor (2.18.06–2.18.09).
Comply with provider disclosure and program integrity TOC obligations
The TOC lists provider disclosure and program integrity topics; providers must comply with reporting and program integrity obligations referenced (disclosures, fraud prevention, and cooperation with oversight).
- Program Integrity and Fraud Prevention Program headings are in the TOC (2.19.01–2.19.02).
- Engagement with EOHHS Office of Program Integrity and cooperation with other agencies are TOC items providers should expect in program integrity requirements.
Prepare to meet Program Integrity obligations: fraud reporting, overpayments, recoupment, suspension, terminations
TOC program integrity entries list specific actions and obligations (investigation/reporting of fraud, overpayments, recoveries, recoupment, suspension of payment, credible allegation of fraud, and provider terminations) that providers must follow when applicable.
- Investigation and Reporting of Fraud, Waste and Abuse (2.19.09–2.19.10).
- Overpayments, Recoupment, Suspension of Payment, Credible Allegation of Fraud, and Provider Terminations (2.19.10–2.19.14).
Follow TOC payment and financial sections for billing and payment obligations
TOC includes payment and financial sections providers should reference for billing/payment obligations: Payments (capitation, fee-for-service), payments to subcontractors/providers, and payment-related liabilities are listed; providers must follow payment terms and related contract sections.
- Payment-related TOC items include Capitation, Fee-For-Service, Payments to Subcontractors and Providers, and Payment-related liabilities (see Article III TOC lines).
- Providers should review the contract payment sections for billing and payment procedures referenced in the TOC.
Recognize Adverse Benefit Determination triggers (denials, reductions, suspensions, payment denials, untimely actions)
The contract defines 'Adverse Benefit Determination' broadly; providers should recognize denials, limited authorizations, reductions, suspensions, terminations, payment denials, untimely actions, network access exceptions for rural areas, and disputes over financial liability as adverse determinations that trigger appeal rights and processes.
- Adverse Benefit Determination includes denial or limited authorization based on medical necessity, reduction/suspension/termination of authorized service, denial of payment, failure to provide timely service, failure to act within 42 C.F.R. §438.408(b) timeframes, rural access denials, and disputes about financial liability.
Provide and stabilize Emergency Medical Conditions per 42 C.F.R. §438.114
Emergency medical condition is defined per 42 C.F.R. §438.114; providers must treat and stabilize conditions manifesting acute symptoms that a prudent layperson would consider life‑threatening, risking serious impairment to bodily functions, or serious dysfunction of an organ or part.
- Emergency Medical Condition criteria: acute symptoms of sufficient severity that absence of immediate attention could place health in serious jeopardy, cause serious impairment to bodily functions, or serious dysfunction of any organ or part.
Emergency Services are covered to evaluate/stabilize emergencies; check Attachment D for excluded services
The contract defines 'Emergency Services' per 42 C.F.R. §438.114 as covered inpatient and outpatient services furnished by qualified providers and needed to evaluate or stabilize an emergency medical condition; Attachment D lists excluded (noncovered) services.
- Emergency Services: covered services needed to evaluate or stabilize an emergency medical condition and furnished by a qualified provider.
- Excluded Services are referenced to Attachment D (Schedule of NonCovered Services) and may affect coverage/authorization.
Deliver Home Care Services under a physician-authorized plan; note included services and exclusions
Home Care Services are defined as services provided under a physician‑authorized home care plan and include nursing (full/part-time/intermittent), therapies (PT/OT/respiratory/speech), lab services, private duty nursing, personal care, and incidental homemaking when personal care is needed; respite, relief, and day care are excluded.
- Home care includes skilled nursing, home health aide services, therapies, laboratory services, private duty nursing for higher-skilled needs, personal care (hygiene, dressing, feeding, transfers), and homemaking tasks incidental to health needs.
- Home care expressly excludes respite care, relief care, and day care.
Develop an Intensive Care Management Plan collaboratively to address identified member risks
The Intensive Care Management Plan is a written plan developed collaboratively with the member (and family/guardian with consent), PCP, and other providers to delineate Intensive Care Activities addressing key risks identified during enrollment.
- Plan developed with member, family (with written consent), guardian or adult caretaker, PCP, and other involved providers.
- Purpose: delineate Intensive Care Activities to address key risk issues identified during enrollment.
Base care planning and authorization on the Intensive Care Plan and Medical Necessity (EPSDT included for <21)
Care planning and medical necessity context: the document references Intensive Care Management Plans and defines Medical Necessity (including EPSDT for members under 21), which providers must use when proposing services and obtaining authorizations.
- Medical Necessity includes criteria such as response to life‑threatening conditions, treatment of injury/illness, achieving community-standard function, maternity care, preventing serious disease, treating conditions that cause impairment, and achieving/maintaining/regaining functional capacity.
- For members under 21, Medical Necessity explicitly includes EPSDT services per Section 1905(r).
Request pre-authorization when the plan requires it; pre-authorization confirms medical necessity
Pre-authorization (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 member needs; providers must seek pre-authorization when required by the plan.
- Pre-authorization is the plan’s medical necessity determination for proposed services, treatment plans, prescription drugs, or durable medical equipment.
- Providers must request prior authorization where the plan requires it under contract procedures.
Contract Definitions (Selected Terms from Article I)
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