Provider Payment

2.10.1. Payment to Medicaid Covered Service Providers 2.10.1.1. The Contractor shall:

2.10.1.1.1. Process clean claims from providers of Medicaid covered services (e.g., NFs, LTSS, community behavioral health) within fourteen (14) days of receipt of the clean claim. This does not apply to LTC pharmacies within a NF.

2.10.1.1.2. Pay home health and EDCD waiver service providers no lower than the current FFS Medicaid rate or a different negotiated rate as mutually agreed to by the provider and the Contractor.

2.10.1.1.3. Pay NFs no less than the Medicaid rate for Medicaid covered days. DMAS will publish Medicaid rates by nursing home based on the most recent settled rates inflated to the Contract period and adjusted for changes in case mix. During the Demonstration, DMAS may modify the NF reimbursement methodology so that facility rates will be adjusted by acuity using Resource Utilization Groups. Contractor must be able to accommodate the new

payment methodology, unless an alternate reimbursement methodology is agreed upon by contracted NFs. The Contractor shall meet these requirements during the Demonstration.

2.10.1.1.4. .

2.10.1.2. The Contractor shall notify DMAS and CMS 45 days in advance of any proposal to modify claims operations and processing that shall include relocation of any claims processing operations. Any expenses incurred by DMAS and CMS or its contractors to adapt to the Contractor’s claims processing operational changes (including but not limited to costs for site visits) shall be borne by the Contractor.

2.10.1.3. The Contractor must make available to providers an electronic means of submitting claims. In addition, the Contractor shall make every effort to assure at least sixty (60%) percent of claims received from providers are submitted electronically.

2.10.1.4. The Contractor must pay interest charges on claims in compliance with requirements set forth in § 38.2-4306.1 of the Code of Virginia.

Specifically, interest upon the claim proceeds paid to the subscriber, claimant, or assignee entitled thereto shall be computed daily at the legal rate of interest from the date of thirty calendar days from the Contractor‘s receipt of proof of loss to the date of claim payment. "Proof of loss" means the date on which the Contractor has received all necessary documentation reasonably required by the Contractor to make a determination of benefit coverage. This shall also apply to retroactive denials or adjustments of a claim or portion of a claim not in accordance with this agreement. This requirement does not apply to claims for which payment has been or will be made directly to health care providers pursuant to a negotiated

reimbursement arrangement requiring uniform or periodic interim

payments to be applied against the managed care organization's obligation on such claims.

2.10.1.5. To the extent the Governor and/or General Assembly implement a

specified rate increase for Medicaid specific nursing facility, home health, or HCBS waiver service providers, and as identified by DMAS, and these rate adjustments are incorporated into the Demonstration capitation

payment rates during the Contract period, where required by DMAS and/or regulation, the Contractor is required to increase its reimbursement to

providers at the same percentage as Medicaid’s increase as reflected in the revised fee-for- service fees under the Medicaid fee schedule, beginning on the effective date of the rate adjustment, unless otherwise agreed to by DMAS. The DMAS shall make every reasonable effort to provide at least 90 days advance notice of such increases. The Contractor shall provide written notice to providers in a format determined by the Contractor advising of the rate adjustment and when it shall be effective. A facsimile notice is an acceptable format. A copy of such notification shall be

provided to DMAS 60 days before the Contractor‘s mailing of such notice or as soon as practicable if DMAS provides less than ninety (90) day notice to the Contractor.

2.10.1.6. Under 1932 (b) of the SSA the Contractor must establish an internal grievance procedure by which providers under contract may challenge the Contractor‘s decisions including, but not limited to, the denial of payment for services.

2.10.2. FQHCs Reimbursements

2.10.2.1. The Contractor shall ensure that its payments to FQHCs for services to Enrollees are no less than the sum of:

2.10.2.1.1. The level and amount of payment that the Contractor would make for such services if the services had been furnished by an entity providing similar services that was not a FQHC, and

2.10.2.1.2. The difference between 80% of the Medicare FFS rate for that FQHC and the Medicaid PPS amount for that FQHC, where the Medicaid PPS amount exceeds 80% of the Medicare rate.

2.10.3. Out of Network Reimbursement Rules.

2.10.3.1. The Contractor must reimburse an out-of-network Provider of emergent or Urgent Care, as defined by 42 C.F.R. § 424.101 and 42 C.F.R. § 405.400 respectively, at the prevailing Medicare or Medicaid FFS payment levels for that service.

2.10.3.2. Contractors may authorize other out-of-network services to promote access to and continuity of care. For services that are part of the traditional

Medicare benefit package, prevailing Medicare Advantage policy will apply, under which Contractors shall pay Out of Network providers the amount that would have been paid by Medicare and/or DMAS if the Enrollee was not enrolled in the Demonstration, but rather enrolled in Medicare and the State’s Medicaid program, regardless of the setting and type of care for authorized out-of-network services..

2.10.4. Primary Care Payment Rates

2.10.4.1. As directed by the DMAS, the Contractor shall set payment rates for primary care services provided by eligible providers in accordance with Section 1202 of the ACA and 42 U.S.C. § 1396a(13)(C), and all applicable federal and state laws, regulations, rules, and policies related to the

implementation of such requirement. Notwithstanding the generality of the foregoing, the Contractor shall, in accordance with 42 C.F.R. §

438.6(c)(5)(vi), for payments for primary care services in calendar year 2014 furnished to Enrollees under 42 C.F.R. Part 447, subpart G:

2.10.4.1.1. Make payments to those specified physicians (whether directly or through a capitated arrangement) at least equal to the amounts set forth and required under 42 C.F.R. Part 447, subpart G; and 2.10.4.1.2. Provide documentation to the DMAS, sufficient to enable

Department to ensure that Provider payments are made as required by this Section 2.10.4.