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

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Page 43 of 48 (b) Nursing Facility (c) Adult Care Home (d) Inpatient behavioral health services (e) Facility-based crisis services for children (f) Facility-based crisis services for adults (g) ADATC (Section V, D(2)(c)(xiv)). 27. Claim Submission. Participating Provider will not submit claim or encounter data for services covered by Medicaid managed care and WellCare directly to the NC DHHS. (Section V, D(2)(c)(xviii)). 28. Provider Preventable Conditions. Participating Provider will comply with 42 C.F.R. § 438.3(g), which, at a minimun, means non-payment of provider-preventable conditions as well as appropriate reporting, as required by WellCare. (Section V, D(2)(d)(ii)). 29. Program Integrity. Participating Provider: (a) will have compliance plans that meet the requirements of 42 C.F.R. § 438.608 and policies and procedures that meet the requirements of the Deficit Reduction Act of 2005; (b) will have policies and procedures that recognize and accept Medicaid as “the payer of last resort”; and (c) is prohibited from billing Covered Persons for Covered Services any amount greater than would be owed if the Participating Provider provided the service directly as provided in 42 C.F.R. §§ 438.3(k) and 438.230(c)(1)-(2). (Section V, D(2)(f); Section V, J(2)(b)(iii)(c)). 30. No Auto-Enrollment in Other Products. WellCare will not require individual practitioners, as a condition of contracting with it, to agree to participate or accept other products offered by the WellCare nor will WellCare automatically enroll the provider in any other product offered by it. This requirement does not apply to facility providers. (Section V, D(2)(c) (viii)) 31. Grievance and Appeals. WellCare shall handle appeals and grievances raised by Provider in connection with the Medicaid Product promptly, consistently, fairly, and in compliance with state and federal law and Department requirements, through an appeals and grievance system that is distin ct from that offered to Covered Persons. Such appeals and grievance system, additional information about which is set forth in the Provider Manual, shall meet the requirements set forth below: (a) Grievances. WellCare will have a process in place to receive and resolve complaints or disputes with Provider, in a timely manner, where remedial action is not requested. WellCare will accept and resolve Provider’s grievances regarding WellCare that are referred from the Department. WellCare will make available to Provider a method for submitting grievances through WellCare’s provider portal. (b) Appeals. WellCare will offer Provider appeal rights as described in the State Contract and Provider Manual. WellCare will provide written notice of Provider’s right to appeal along with any notice of a decision giving rise to Provider’s right to appeal. WellCare will make available to Provider a method for submitting appeals through WellCare’s provider portal. WellCare will accept a written request for an appeal from Provider within thirty (30) calendar days of the date on which (i) Provider received written notice from WellCare of the decision giving rise to the right to appeal; or (ii) WellCare should have taken a required action and failed to take such actions. WellCare will acknowledge receipt of each appeal request within five (5) calendar days of receipt of the request, and will extend such timeframe by thirty (30) calendar days if Provider’s request is for an appeal for good cause shown, as determined by WellCare. WellCare will consider the voluminous nature of required evidence/supporting documentation, and the appeal of an adverse quality decision, as good cause reasons to extend such timeframe. Provider shall exhaust WellCare’s internal appeals process before seeking recourse under any other process permitted by contract or law. DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210