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

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Page 32 of 48 15. Advanced Medical Homes. To the extent Participating Provider is an Advanced Medical Home (AMH), Participating Provider shall comply with NC DHHS’ Advanced Medical Home Program, including the requirements set forth below. (Section VII, G(1)(v)). 15.1 Identified as PCP. Participating Provider shall accept Covered Persons and be listed as a PCP in WellCare’s Covered Person-facing materials for the purpose of providing care to Covered Persons and managing their health care needs. 15.2 Care Coordination Services. Participating Provider shall provide primary care and patient care coordination services to each Covered Person, in accordance with WellCare policies. (Section VII, G(1)(v)(i)) 15.3 Primary Care Coverage. Participating Provider shall provide or arrange for primary care coverage for services, consultation or referral, and treatment for emergency medical conditions, twenty -four (24) hours per day, seven (7) days per week. Automatic referral to the hospital emergency department for services does not satisfy this requirement. 15.4 Minimum Office Hours. Participating Provider shall provide direct patient care a minimum of 30 office hours per week. 15.5 Preventive Services. Participating Provider shall provide preventive services, in accordance with Section VII. Attachment M. Table 1: Required Preventive Services of the State Contract as set forth on Attachment A: Medicaid, Appendix A to Schedule A, Governmental Program Requirements to the Agreement. 15.6 Unified Medical Record. Participating Provider shall maintain a unified patient medical record for each Covered Person following the WellCare’s medical record documentation guidelines. 15.7 Referrals. Participating Provider shall promptly arrange referrals for Medically Necessary health care services that are not provided directly and document referrals for specialty care in the medical record. 15.8 Medical Record Transfer. Participating Provider shall transfer the Covered Person medical record to the receiving provider upon the change of PCP at the request of the new PCP or WellCare (if applicable) and as authorized by the Covered Person within thirty (30) days of the date of the request, free of charge. 15.9 Appointments. Participating Provider shall authorize care for the Covered Person or provide care for the Covered Person based on the standards of appointment availability as defined by the WellCare’s network adequacy standards. 15.10 Second Opinion. Participating Provider shall refer for a second opinion as requested by the Covered Person, based on NC DHHS guidelines and WellCare standards. 15.11 Utilization Management. 15.11.1. Participating Provider shall review and use Covered Person utilization and cost reports provided by WellCare for the purpose of AMH level utilization mana gement and advise WellCare of errors, omissions, or discrepancies if they are discovered. 15.11.2. Prepaid Health Plans utilizes only North Carolina Medicaid’s Clinical Coverage Policies for utilization management/clinical guidelines and other Department-approved utilization management/clinical guidelines. 15.12 Enrollment Report. Participating Provider shall review and use the monthly enrollment report provided by WellCare for the purpose of participating in WellCare or practice-based population health or care management activities. (Section VII, M(2)) DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210