Alabama Medicaid Provider Enrollment

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4.10 Refer for a second opinion as defined by Patient 1 st policy.4.11 Review and use all enrollee utilization and cost reports provided by the Patient 1 st Program for the purpose of practice levelutilization management and advise the Agency of errors, omissions, or discrepancies. Review and use the monthlyenrollment report as required by Patient 1 st policy.4.12 Participate with Agency utilization management, quality assessment, complaint and grievance, and administrative programs.4.13 Provide the Agency, its duly authorized representatives and appropriate Federal Agency representatives unlimited access(including on site inspections and review) to all records relating to the provision of services under this agreement as requiredby Medicaid policy and 42 C.F.R. 431.107.4.14 Maintain reasonable standards of professional conduct and provide care in conformity with generally accepted medicalpractice following national and regional clinical practice guidelines or guidelines approved by the Patient 1 st AdvisoryGroup.4.15 Notify the Agency of any and all changes to information provided on the initial application for participation. If suchchanges are not reported within 30 days of change, future participation may be limited.4.16 Give written notice of termination of this agreement, within 15 days after receipt of the termination notice, to each enrolleewho received his or her primary care from, or was seen on a regular basis by, the PMP.4.17 Refrain from discriminating against individuals eligible to enroll on the basis of health status or the need for health careservices.4.18 Refrain from discriminating against individuals eligible to enroll on the basis of race, color, or national origin and willrefrain from using any policy or practice that has the effect of discriminating on the basis of race, color, or national origin.4.19 Comply with all Federal and State laws and regulations including Title VI of the Civil Rights Act of 1964, Title IX of theEducation of Amendments of 1972 (regarding education programs and activities), the Age Discrimination Act of 1975, theRehabilitation Act of 1973, and the Americans with Disabilities Act.4.20 Make oral interpretation services available free of charge to each potential enrollee and enrollee. This requirement appliesto all non-English languages.4.21 Receive prior approval from the Agency of any Patient 1 st specific materials prior to distribution. Materials shall not makeany assertion or statement (whether written or oral) that the recipient must enroll with the PMP in order to obtain benefits orin order not to lose benefits. Materials shall not make any assertion or statement that the PMP is endorsed by CMS, theFederal or State government or similar entity.4.22 Refrain from door-to-door, telephonic or other ‘cold-call’ marketing or engaging in marketing activities that could mislead,confuse, or defraud Medicaid Recipients, or misrepresent the PMP, its marketing representatives, or the Agency.4.23 Refrain from knowingly engaging in a relationship with the following:o an individual who is debarred, suspended or otherwise excluded from participating in procurement activities under theFederal Acquisition Regulation or from participating in non-procurement activities under regulations issued underExecutive Order No. 12549 or under guidelines implementing Executive Order No. 12549;o an individual who is an affiliate, as defined in the Federal Acquisition Regulation.Note: The relationship is described as follows:o As a director, officer, partner of the PMP,o A person with beneficial ownership of more than five percent (5%) or more of the PMP’s equity; or,o A person with an employment, consulting or other arrangement with the PMP for the provision of items and servicesthat are significant and material to the PMP’s contractual obligation with the Agency.4.24 Retain records in accordance with requirements of 45 C.F.R. 74 (3 years after the final payment is made and all pendingmatters closed, plus additional time if an audit, litigation, or other legal action involving the records is started before theoriginal 3 year period ends.)4.25 Provide the Agency within 30 days notice of PMP disenrollment or change in practice site. This will allow for an orderlyreassignment of enrollees. Failure to provide 30 days notice may preclude future participation and/or result in recoupmentof case management fees.V. Functions and Duties of the AgencyThe Agency agrees to do the following:Patient 1st 6 Revised September 2009
5.1 List the PMP’s name by specialty as a primary medical provider in the Patient 1 st Program. The PMP has the ability todesignate whether he wants it to be listed.5.2 Pay the PMP on a fee-for-service basis in accordance with the Medicaid fee schedule and billing guidelines. Any monthlymanagement/coordination fee paid in addition to the fee-for service Medicaid payments will be paid per member per month,subject to the maximum number of enrollees under paragraph 7.1.A. The amount of the management/coordination fee, ifany, may be adjusted according to practice and performance parameters as defined by the Agency. Changes will be made ona quarterly basis.5.3 Provide the PMP with a monthly list of enrollees who have selected him or have been assigned to him for the purpose ofmanaging their health care needs.5.4 Provide training and technical assistance regarding the Patient 1 st Program.5.5 Provide the PMP with periodic utilization and cost reports.5.6 Gather and analyze data relating to service utilization by enrollees to determine whether PMPs are within acceptable Patient1 st comparison parameters.5.7 Publish the Alabama Medicaid Provider Manual, specifically Chapter 39 and the Medicaid General and Special Bulletins onthe Agency’s website at http://www.medicaid.alabama.gov. All such policies, procedures, Medicaid provider bulletins andmanuals are incorporated into this agreement by reference.5.8 Provide an ongoing quality assurance program to evaluate the quality of health care services rendered to enrollees.5.9 Provide program education to all enrollees during eligibility reviews or within a reasonable timeframe.5.10 Provide potential enrollees and enrollees with information that contains program information including enrollee rights andprotections, program advantages, enrollee responsibilities, complaint and grievance instructions as specified in 42 CFR438.10 The information will also be published on the Agency’s website at http://www.medicaid.alabama.gov.5.11 Notify enrollees that oral interpretation is available for any language and written material is available in prevalent languagesand how to access these services.5.12 Provide written materials that use easily understood language and format. Written material will be available in alternativeformats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visuallylimited or have limited reading proficiency.5.13 Inform enrollees and potential enrollees that information is available in alternative formats and how to access those formats.VI. Case Management FeeThe monthly case management fee will be automatically paid to the PMP on the 1 st checkwrite of each month. The monthly casemanagement fee will be determined by the components of care delineated in Attachment B of the contract. The components andthe corresponding dollar amounts are also included in Attachment B of this agreement. By initialing the optional component,the PMP is agreeing to provide this service. All other components are contractually required and these services must beprovided to be considered for enrollment in the Patient 1 st Program. Verification of the PMP’s ability/willingness to providethe services will be accomplished through the regular Medicaid enrollment process, the complaints and grievances process andindividual Agency verification. A monthly enrollment summary report will indicate the individual amount of case managementfee being paid for that month.Case management fees are not subject to third party liability requirements as specified in 42 CFR 434.6(a)(9).VII. General Terms and Conditions7.1 Recipient Enrollment and DisenrollmentA. Recipient Enrollment1. The PMP must accept individuals in the order in which they apply without restriction up to the limits set by theagreement. The PMP may specify a limit on the number of enrollees on the Patient 1 st Application for Participationsubject to the following terms and conditions:• Maximum enrollment is set at 1200 enrollees per physician unless otherwise approved by the Agency. Anadditional 400 enrollees per physician extender (up to 2) will be allowed.• The PMP may set enrollment criteria on the Application, but must accept recipients who meet the enrollmentcriteria up to the limit specified.Patient 1st 7 Revised September 2009
Page 1 and 2: Alabama MedicaidProvider Enrollment
Page 3 and 4: Section II (continued)Admitting Pri
Page 5: the primary care provider. If not p
Page 9 and 10: In order to amend this agreement, t
Page 11 and 12: ALABAMA MEDICAID AGENCYAttachment B
Page 13 and 14: ALABAMA MEDICAID AGENCYAttachment D
Page 15: I certify that, to the best of my k

Alabama Medicaid Provider Enrollment

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