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

Browse Search

Page 28 of 48 6.2 Termination. The Agreement sets forth the basis for termination of the Agreement by either party and the related notice requirements. Notwithstanding anything in the Agreement or this Attachment to the contrary, WellCare may immediately terminate the Agreement or this Attachment and a Participating Provider’s participation thereunder upon: (1) a confirmed finding of fraud, waste or abuse by the NC DHHS or the North Carolina Department of Justice Medicaid Investigations Division, or (2) failure of the Part icipating Provider to maintain enrollment as a Medicaid provider. (Sections VII, G(1)(d) and G(1)(f)(i)). 6.3 Insolvency. If the Agreement or this Attachment terminates as a result of WellCare’s or Payor’s insolvency, Participating Provider will cooperate in the transition of administrative duties and records and ensure the continuation of care when inpatient care is on-going in accordance with the requirements of the Agreement, this Attachment and the State Contract. If WellCare or Payor provides for or arranges for the delivery of health care services on a prepaid basis, Participating Provider will continue inpatient care until the patient is ready for discharge. (Section VII, G(1)(e)). 7. Covered Person Services. 7.1 Covered Person Billing. Participating Provider shall not bill any Medicaid Managed Care Covered Person for Covered Services, except for specified coinsurance, copayments, and applicable deductibles. Participating Provider is responsible for collecting applicable deductibles, copayments, coinsurance and fees for non-Covered Services. This provision does not prohibit a Participating Provider and Covered Person from agreeing to continue non-Covered Services at the Covered Person’s own expense, as long as the Participating Provider has notified the Covered Person in advance that a Payor may not cover or continue to cover specific services and the Covered Person to receive the services (Section VII, G(1)(h)). 7.2 Provider Accessibility. Participating Provider shall provide call coverage or other back-up to provide service in accordance with WellCare’s standards for provider accessibility addressed set forth herein, in the Provider Manual and/or in the State Contract. (Section VII, G(1)(i)). Participating Provider agrees to meet the NC DHHS standards for timely access to care and services, taking into account the urgency of need for services. (Section V, D(1)(d)(ii)). Participating Provider shall provide physical access, reasonable accommod ations, including parking, exam and waiting rooms, and accessible equipment for Medicaid Covered Persons with physical or mental disabilities. (Section V, (1)(d)(vi)). 7.3 Eligibility Verification. WellCare or Payor shall provide a mechanism that allows Participating Provider to verify Covered Person eligibility, based on current information held by WellCare or Payor, as applicable, before rendering Covered Services. (Section VII, G(1)(j)). 7.4 Covered Person Appeals and Grievances. Participating Provider shall cooperate with Covered Person in regard to Covered Person appeals and grievance procedures. (Section VII, G(1)(l)). Participating Provider has the right to file a grievance or appeal. WellCare’s internal appeal processes must be completed before seeking other legal or administrative remedies under state or federal law. (Section V, D(2)(c)(xi)). 7.5 Appointment Wait Times. Participating Provider shall cooperate with WellCare to ensure that appointment wait times for Covered Persons do not exceed the requirements set forth below, to the extent applicable. (Section VII, F. Table 3). (a) If Participating Provider is a PCP providing preventative care services, appointment wait time shall not exceed thirty (30) calendar days for adults (21 years of age and older) and children ages six (6) months to twenty (20) years of age, and fourteen (14) calendar days for children less than six (6) months of age. (b) If Participating Provider is a PCP providing urgent care services, appointment wait time shall not exceed twenty-four (24) hours. DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210