Contract Management Philosophy The Contractor shall develop and implement policies and procedures to ensure that all Medically Necessary Services are provided to Enrollees based on their individual needs and consistent with Appendix A and B. Such policies and procedures, including any updates to existing policies and procedures, shall be submitted to the Commonwealth for review upon request. The Contractor shall manage all aspects of its ICO line of business consistent with a data driven management philosophy, where decisions are made utilizing available data. Such data shall come from multiple sources including, claims and encounter data, authorization data, medical record reviews, Enrollee input, Provider surveys, clinical outcomes data, Appeals, Grievances, sanctions and corrective action plans. The Contractor shall use data analysis and reports for management purposes for Network Management, Utilization Management, Care Management, Quality Management, and customer service responsibilities under this Contract. C. Contract Management The Contractor must employ a qualified individual to serve as the contract manager of its Capitated Financial Alignment Model. The contract manager must be primarily dedicated to the Contractor’s program and be authorized and empowered to represent the Contractor in all matters pertaining to the Contractor’s program. The contract manager must act as liaison between the Contractor, CMS, and EOHHS, and has responsibilities that include but, are not limited to, the following: Ensure the Contractor’s compliance with the terms of the Contract, including securing and coordinating resources necessary for such compliance; Implement all action plans, strategies, and timelines, including but not limited to those described in the Contractor’s response to the Request for Responses (RFR) and approved by CMS and EOHHS; Oversee all activities by the Contractor and its First Tier, Downstream and Related Entities, including but not limited to coordinating with the Contractor’s quality management director, medical director, and behavioral health clinician;
Contract Management Philosophy The Contractor shall develop and implement policies and procedures to ensure that all Medically Necessary Services are provided to Enrollees based on their individual needs and consistent with Appendix A and B. Such policies and procedures, including any updates to existing policies and procedures, shall be submitted to the Commonwealth for review upon request. The Contractor shall manage all aspects of its ICO line of business consistent with a data driven management philosophy, where decisions are made utilizing available data. Such data shall come from multiple sources including, claims and encounter data, authorization data, medical record reviews, Enrollee input, Provider surveys, clinical outcomes data, Appeals, Grievances, sanctions and corrective action plans. The Contractor shall use data analysis and reports for management purposes for Network Management, Utilization Management, Care Management, Quality Management, and customer service responsibilities under this Contract. C. Contract Management The Contractor must employ a qualified individual to serve as the contract manager of its Capitated Financial Alignment Model. The contract manager must be primarily dedicated to the Contractor’s program and be authorized and empowered to represent the Contractor in all matters pertaining to the Contractor’s program. The contract manager must act as liaison between the Contractor, CMS, and EOHHS, and has responsibilities that include but, are not limited to, the following: Ensure the Contractor’s compliance with the terms of the Contract, including securing and coordinating resources necessary for such compliance; Implement all action plans, strategies, and timelines, including but not limited to those described in the Contractor’s response to the Request for Responses (RFR) and approved by CMS and EOHHS; Oversee all activities by the Contractor and its First Tier, Downstream and Related Entities, including but not limited to coordinating with the Contractor’s quality management director, medical director, and behavioral health clinician;