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<br /> <br /> Page 33 of 48 <br /> <br />15.13 Advanced Medical Home Tier 3 Standard Terms and Conditions. If Provider or a Contracted <br />Provider is a Tier 3 Advanced Medical Home (“AMH”) Participating Provider, the Agreement must include <br />provisions that outline the AMH Tier 3 care management model and requirements consistent with the State Contract <br />as set forth below. (Section VII, M(2 - 4 (a-e)) <br /> <br />(a) (The AMH has primary responsibility for care management, and when the Prepaid Health <br />Plan (“PHP”) and AMH offer the same or similar disease management programs, the PHP will defer to the AMH <br />program when the member’s AMH is contracted as an Tier 3 AMH (“AMH3” or “AMH Level 3”) except where the <br />AMH is not performing to the operational or quality levels contractually required; and <br /> <br />(b) The PHP’s disease management and care coordination program shall coordinate and work <br />with the member’s Advanced Medical Home’s care coordination when the member’s AMH is contracted as a Tier 3 <br />AMH. <br /> <br />Unless otherwise specified, any required element may be performed either by the Tier 3 AMH practice itself <br />or by a clinically-integrated network (“CIN”) with which the practice has a contractual agreement that contains <br />equivalent contract requirements. The WellCare shall maintain a contractual relationship with the AMH (not the <br />CIN). <br /> <br />15.13.1. Tier 3 AMH practices must be able to risk stratify all empaneled patients. <br /> <br />(a) The Tier 3 AMH practice must ensure that assignment lists transmitted to the practice by the <br />WellCare are reconciled with the practice's panel list and up to date in the clinical system of record. <br /> <br />(b) The Tier 3 AMH practice must use a consistent method to assign and adjust risk status for <br />each assigned patient. <br /> <br />(c) The Tier 3 AMH practice must use a consistent method to combine risk scoring information <br />received from the WellCare with clinical information to score and stratify the patient panel. <br /> <br />(d) The Tier 3 AMH practice must, to the greatest extent possible, ensure that the method is <br />consistent with the Contract of identifying "priority populations" for care management. <br /> <br />(e) The Tier 3 AMH practice must ensure that the whole care team understands the basis of the <br />practice's risk scoring methodology (even if this involves only clinician judgment at the practice-level) and that the <br />methodology is applied consistently. <br /> <br />(f) The Tier 3 AMH practice must define the process and frequency of risk score review and <br />validation. <br /> <br />15.13.2. Tier 3 AMH practices must be able to define the process and frequency of risk score review and <br />validation. <br /> <br />(a) The Tier 3 AMH practice must use its risk stratification method to identify patients who may <br />benefit from care management. <br /> <br />(b) The Tier 3 AMH practice must perform a Comprehensive Assessment (as defined below) on <br />each patient identified as a priority for care management to determine care needs. The Comprehensive Assessment <br />can be performed as part of a clinician visit, or separately by a team led by a clinician with a minimum credential of <br />RN or LCSW. The Comprehensive Assessment must include at a minimum: <br /> <br />i) Patients immediate care needs and current services; <br />DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210