2021-350-EMS-E-WellCare Health Plans of NC Inc-Medicaid managed care

Browse Search

Page 17 of 48 activities; ii) maintain the confidentiality of a Covered Persons information and records pursuant to the Agreement; and iii) allow the Company to use facility’s performance data. 6 Long Term Services and Supports (“LTSS”) and Home and Community-Based Services (“HCBS”) Providers. If Provider or a Contracted Provider is a provider of LTSS and/or HCBS services, the following provisions apply. 6.1 Definition. LTSS generally includes assistance with daily self-care activities (e.g., walking, toileting, bathing, and dressing) and activities that support an independent lifestyle (e.g., food preparation, transportation, and managing medications). The broad category of LTSS also includes care and service coordination for people who live in their own home, a residential setting, a nursing facility, or other institutional setting. Home and community-based services (“HCBS”) are a subset of LTSS that functions outside of institutional care to maximize independence in the community. Long-term care (“LTC”) is another subset of LTSS which provides benefits as specified through the SMMC LTC Program. 6.2 HCBS Waiver Authorization. Provider shall not provide HCBS Covered Services to Covered Person without the required HCBS waiver authorization. 6.3 Conditions for Reimbursement. No payment shall be made to the Provider unless the Provider has strictly conformed to the policies and procedures of the HCBS Waiver Program, including but not limited to not providing HCBS Covered Services without prior authorization of WellCare. For the purposes of this Exhibit, “HCBS Waiver Program” shall mean any special Medicaid program operated under a waiver approved by the Centers for Medicare and Medicaid Services which allows the provision of a special package of approved services to Covered Person. 6.4 Acknowledgement. WellCare acknowledges that Provider is a provider of LTSS and is not necessarily a provider of medical or health care services. Nothing in this Agreement is intended to require Provider to provide medical or health care services that Provider does not routinely provide, but woul d not prohibit providers from offering these services, as appropriate. 6.5 Notification Requirements. Provider or the applicable Contracted Provider shall provide the following notifications to WellCare, via written notice or via telephone contact at a numbe r to be provided by WellCare, within the following time frames: 6.5.1 Provider or the applicable Contracted Provider shall notify WellCare of a Covered Person’s visit to urgent care or the emergency department of any hospital, or of a Covered Person’s hospitali zation, within twenty-four (24) hours of becoming aware of such visit or hospitalization. 6.5.2 Provider or the applicable Contracted Provider shall notify WellCare of any change to the designated/assigned services being provided under a Covered Person’s plan of care and/or service plan, within 24 hours of becoming aware of such change. 6.5.3 Provider or the applicable Contracted Provider shall notify WellCare if a Covered Person misses an appointment with Provider, within 24 hours of becoming aware of such missed appointment. 6.5.4 Provider or the applicable Contracted Provider shall notify WellCare of any change in a Covered Person’s medical or behavioral health condition, within 24 hours of becoming aware of such change. (Examples of changes in condition are set forth in the Provider Manual.) 6.5.5 Provider or the applicable Contracted Provider shall notify WellCare of any safety issue identified by Provider or Contracted Provider or its agent or subcontractor, within 24 hours of the identification of such safety issue. (Examples of safety issues are set forth in the Provider Manual.) DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210