Ssl.doas.state.ga.us



#SERVICEQUESTIONSECTIONANSWER1Radiology ServicesPrior authorization of radiology services is not specifically mentioned in the Scope of Work, but metrics are provided. Is prior authorization of radiology services to be included?Procurement Library: Transaction Numbers Master List Draft 123014Yes, radiology services are included.2Certified Mail ServicesFinal member notices are to be sent certified mail for the specified waiver services. What other notices must be sent certified mail? For instance GAPP, ABA, CIS?Attachment K, Requirements and Scope of Work, Section B.5d.3.iv.d. All Waiver Programs: Communications (page 59)All final notices to members, including any notice with hearing rights or that requires a member to take action, must be sent certified mail.3Additional Services for ASDOn July 7, 2014, CMCS issued an Informational Bulletin to provide information on approaches available under Medicaid for providing services to individuals with Autism Spectrum Disorder (ASD). Are additional services that will require prior authorization anticipated in response to this bulletin? If so, can anticipated volumes be provided?Procurement Library: Transaction Numbers Master List Draft 123014The MMURS vendor must comply with any federally mandated programmatic changes as well as any programmatic changes initiated by the Department. 4SURS ServicesThe current medical management contract includes Program Integrity activities, specifically SURS member studies and SURS peer reviews. These activities are not specified in Attachment J, State Contract for Medical Management and Utilization Review Services. Are those activities to be excluded?Attachment J, State ContractSURS (Surveillance and Utilization Review Services) is not within the scope of services for this RFP.5Review of Pre-payment Provider types What other Program Integrity pre-pay provider types besides Dental will be expected to be reviewed and what are the volumes experienced in the past fiscal year?Attachment K, Requirements and Scope of Work, Medical Claims Review/Clinical Documentation Section B.5.a.4.c.1.ix (page 43)Review of pre-payment provider types is not within the scope of services for this RFP. Please disregard the reference to “Dental Pre-Payment Providers.”6Hospital Utilization ReviewsReviews of Hospital UR Plans volumes are not included in the Review Count Spreadsheet. Does DCH intend to continue to have the vendor conduct the annual review of hospital UR plans?Procurement Library: Transaction Numbers Master List Draft 123014Yes, the MMURS vendor will be required to conduct reviews of hospital utilization review plans. The plans are required to be submitted every 2 years per Part 2 Hospital Services Manual. 7Public Records RequestsAttachment A section 2.1.12.1 requires a redacted version of the proposal be submitted.Should a redacted copy be submitted together with the electronic proposal?Attachment A, State Entity eRFP, Section 2.1.12.1 (page 9)No; however, the vendor should be prepared to submit its proposed redacted proposal and affidavit in accordance with the Georgia Open Records Act upon request by DCH. 8Administrative ReviewsPlease provide the volume in most recent fiscal year for the Second Level (Administrative Review/Reconsideration) reviews.Attachment K, Requirements and Scope of Work, Section B.8.b. Administrative Reviews and Hearings (page 64)The volume for second level reviews was approximately 115 in SFY15.9Performance GuaranteesAttachment J indicates all pre-certifications/prior approvals/level of care determinations have a 3-day turn-around time. This is different from the turn-around times in the current DCH Program Policy for some review types, for example: Katie Beckett (30 business days); DME (30 calendar days); GAPP (30 calendar days); emergency ambulance (5 calendar days); oral/maxillary surgery (10 business days). Does DCH intend on varying turn-around time by review type in the future contract? If so, please specify turn-around times by review type.Attachment J, State Contract, Exhibit 4 Performance Guarantees/Liquidated Damages 9.a. (page 152)Attachment J, Item 9.a, requires the vendor to complete 95% of all Pre-Certifications, Prior Authorizations, and Level of Care Determinations within the timeframes stated in the Contract. In addition, 100% of the Level of Care Determinations shall be processed no later than three (3) Business days after the required timeframes. 10Public ReportingCan DCH describe or provide an example of a report that is typically requested by the legislature? Attachment K, Requirements and Scope of Work, Section 11.b Monitoring and Reporting>Public ReportingFrequent requests include utilization and cost, for example, number of members within a program, number of services received, number of denials by category, and reasons for denials.11Public ReportingAlso, what is the typical annual volume of these ad hoc reports?Attachment K, Requirements and Scope of Work, Section 11.b Monitoring and Reporting>Public ReportingTypical annual volume is around 9 requests per year; however, the MMURS vendor must be capable of supporting increases in volume.12Planning and ImplementationPlease describe the number and types of data exchanges required to support the work.Attachment K, Requirements and Scope of Work, Section B.1.fAll data exchanges must be HIPAA compliant. DCH expects CMS to update its data exchange requirements soon, and expects the MMURS vendor to be compliant with any new standards as well.Exchange of data will occur with the following: External partners, including DBHDD and its ASOData from and to CMOsLink with Fiscal Agent (MMIS)Connection with DHS, including DFACS and Division of Aging Services Or any other external vendors or partners identified by DCH.13Planning and ImplementationPlease describe the type of data to be exchanged and the nature of the secure messaging i.e. email, web service, etc.Attachment K, Requirements and Scope of Work, Section B.1.gAll member data, services data, clinical data, utilization, member eligibility, and cost.Secure messaging must comply with the requirements of the contract, HIPAA, and BAA.14Planning and ImplementationRecognizing that differences exist between vendor systems, please describe the data transition expectations. Is the information regarding enrollment and application data stored as an image? Is it an actual data table?Attachment K, Requirements and Scope of Work, Section B.1.a.1The MMURS vendor will coordinate with the existing vendor to receive historic information (at least 3 prior fiscal years) as further described in the RFP. Additional information will be provided after contract award.15Maintenance of an Information SystemRegarding the use of existing forms, is an acceptable alternative one that exactly replicates all of the questions and data points required, but presents the questions in a way that incorporates parent–child question relationships? Such a method avoids confusion and improves satisfaction for the user or preparer by asking only the questions relevant to the application or assessment by bypassing all unnecessary questions.Attachment K, Requirements and Scope of Work, Sections B.2.a, B.2.bDCH welcomes, encourages, and will review any suggested alternatives to existing forms or electronic submission, and improvement and simplification of procedures.16Medical Review PortalPlease expand on the requirement for “a drop down of inquiry types”. What are some examples of inquiries? And what sorts of responses will the successful contractor be required to make? Fax, Phone, Email, Other?Attachment K, Requirements and Scope of Work, Section B.2.f.11The drop down should provide category of service, waiver type, PA type, and any other categories identified by DCH. Examples of inquiries include submitting a prior authorization request, requesting status of review, etc. Responses would include providing status of review, etc.The inquiries are online only. The MMURS vendor must be able to receive, track, manage and respond to all inquiries within the online system.17Utilization ReviewReview of suspended claims. Are these claims transferred to the successful vendor as part of the identified file transfer processes or is there another method to identify / access these review items?Attachment K, Requirements and Scope of Work, Section B.5.c.1The MMURS vendor will be provided reports and automated weekly claim files by the GAMMIS vendor. The MMURS vendor will have access to the GAMMIS and can make review decisions in the MMIS panel for suspense locations (deny or approve claims) in the panel.18Utilization ReviewAs it relates to otherwise non-eligible members, how are they tracked in GAMMIS? Are they included in the member feeds? Are they to be issued temporary ID’s by the agency? Attachment K, Requirements and Scope of Work, Section B.5.c.2Members denied eligibility or “closed” are known to GAMMIS and issued an ID. Members and their IDs are included in the member feeds. New and pending applications are NOT included in the member feeds. The vendor must be able to issue temporary IDs for those members that submit (whether level of care request or other) simultaneously with applications for Medicaid and then marry up the individual with the GAMMIS assigned Medicaid ID Number once it is issued. 19GeneralPlease provide the historical annual cost saving for the past 3 years.GeneralThis information is not available.20GeneralWhat specific priorities is the Department looking to achieve the quickest regarding “Transforming Medical Management and Utilization Review process to maximize efficiency, consistency and outcomes”? How will the Department measure “efficiency and outcomes” and how does this relate to the proposal scoring?Attachment A, State Entity eRFP, Section 1.1b Goals The RFP outlines DCH’s goals in general. Offeror may propose information within its proposal to meet these goals.The areas to be scored have been identified within the Mandatory Scored Worksheet. Please refer to Section 6 of Attachment A, State Entity eRFP, for the scoring process.21GeneralDoes the Department anticipate any future changes to the program that would impact the annual volume? If so, what specifically?Attachment A, State Entity eRFP, Attachment K, Requirements and Scope of WorkThe MMURS vendor must be capable of ramping up or scaling down as needed to accommodate fluctuations in volume. The Department reserves the right to implement programmatic changes as needed to comply with regulations and MMURS vendor must comply with all such changes.22GeneralIn order to expedite processes and procedure, will the Department consider mandating that all providers use the portal? Provider portalYes, all providers must use the web portal via secure logon.23Bidders ConferenceIs the Department offering a bidders conference?Attachment A, State Entity eRFP, Section 2.1.4No. Please see Attachment A, State Entity eRFP, Section 1.4 Schedule of Events.24Reciprocal Preference LawPlease describe how this preference will be applied to the proposal scoring. Attachment A, State Entity eRFP, Section 6.5If another state provides a preference for companies based within the state, then Georgia will apply that preference against those companies when bidding in the State of Georgia against a Georgia company. If no out-of-state companies bidding on this RFP enjoy a preference within their home state, then no preference will be applied.25GeneralPlease identify the incumbent Contractor and current pricing per the Cost Proposal. GeneralAlliant/GMCF is GA’s current contractor. To request public records, please submit a request to openrecordrequests@dch.. 26Scope of WorkIs the Scope of Work consistent with the previous scope? If not, what will change in the new contract?Attachment K, Requirements and Scope of WorkNo, the Scope of Work is not identical. For example, there are certain services within the current contract that are not included within the RFP such as prepayment reviews and nurse aide training program and registry.The RFP and contract outline the requirements for the resulting contract award.27GeneralPlease provide further information concerning the extent to which the current system meets this expectation. Attachment A, State Entity eRFP, Section 1.1.bRefer to the RFP for the Department’s requirements regarding the new system.28GeneralDoes DCH anticipate that FFS members will access this system and use it to track their requests?Attachment A, State Entity eRFP, Section 1.o, DCH does not anticipate that FFS members will access this system and use it to track their requests.29GeneralDoes the Contractor conduct review of prisoner utilization?Attachment A, State Entity eRFP, Section 1.o, the Contractor does not conduct review of prisoner utilization; however, DCH may consider including this in the future. 30Letter of CreditIs a bond acceptable in lieu of a Letter of Credit?Attachment A, State Entity eRFP, Section 3.3No, a bond is not acceptable in lieu of a letter of credit. Please refer to Attachment A, State Entity eRFP, Section 3.2.31Additional Scored WorksheetPlease confirm that there is no Additional Scored Information worksheet for this procurement Attachment A, State Entity eRFP, Section 6.2.2Confirmed. There is no Additional Scored Worksheet.32GaHINWhat is the DCH supplier-hosted entity-owned repository, i.e., the Contractor’s system?Attachment E, Question #27The DCH supplier--hosted entity-owned repository refers to a data repository that is owned by a participating entity (hospital or provider group for example) but hosted /supported by a third party vendor.33Care CoordinationWhat does care coordination mean in the context of the scope of work?Attachment K, Requirements and Scope of Work “Care coordination” in the context of scope of work can include CMOs, hospitals, nursing facilities, discharge planners or any other entity with whom DCH partners. The goal of coordinated care is to make sure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. Care coordination consists of the following:Numerous participants are typically involved in care coordination;Coordination is necessary when participants are dependent upon each other to carry out disparate activities in a patient's care;In order to carry out these activities in a coordinated way, each participant needs adequate knowledge about their own and others' roles, and available resources;In order to manage all required patient care activities, participants rely on exchange of information; andIntegration of care activities has the goal of facilitating appropriate delivery of health care services.Care coordination encompasses a variety of care management methods - from case to disease management - that aim to improve the quality of care provided to patients with chronic illness while decreasing avoidable costs associated with their delivery...care coordination is viewed by its practitioners (mostly specially trained nurse case managers) as a method for decreasing the fragmentation of health delivery sites and, through better planning and monitoring of patient care plans, ending the confusion and uncertainty that often attend care for patients with complicated illnesses or multiple medical problems. Care coordination also is a means to increase the likelihood that patients with chronic illness will achieve recommended care and adhere to best practices for specific illnesses and conditions. Finally, care coordination is a collaborative and team approach that recognizes the importance of keeping the attending physicians informed while enhancing information sharing and communication among providers so as to maintain a fabric of continuity. “Coordination” is the middle ground in integrated care, and entails the development of formal structures and mechanisms to bridge the gap between providers and institutions, as well as work around system weaknesses and barriers, without fundamentally changing these systems?per se. A variety of techniques are employed, including uniform assessment procedures, care management, joint care planning, team care, standardized guidelines and protocols, and common clinical and service records.34Bidder’s LibraryIs the Bidder’s Library that Attachment A references the same as the Supplier’s Library in Attachment K? If so, materials that Attachment K references in this item are not in the Bidder’s Library, e.g., current forms (B.2.b)Attachment A, State Entity eRFP, Section 1.1 and Attachment K, Requirements and Scope of Work, Section B.2.bYes, both the “Bidder’s Library” and the “Supplier’s Library” refer to the website with the information file provided by DCH to Offerors. DCH will update the Library to include example forms.35StaffingPlease clarify the second sentence.Attachment K, Requirements and Scope of Work, Section B.1.bAll required staff must be hired and trained prior to the Operational Start Date. 36Planning and ImplementationPlease provide examples of outcomes. Attachment K, Requirements and Scope of Work, Section B.1.nExamples include quality metrics, timeframes, effectiveness and efficiency, reduced denial rates for level of care, etc. Suppliers should include additional examples from their experience. 37FrameworkDoes DCH have an Enterprise Data Management framework and if so please provide a brief overview relative to this procurement or refer prospective bidders to a document if available.Attachment K, Requirements and Scope of Work, Section B.1.cYes, please refer to attached document titled “DCH Medicaid Data Management Strategy.” DCH will post this document to the Supplier’s Library.38HostingThe Attachment states that the Contractor must host the system within its base office location. Does “base office” mean corporate office or Georgia office?Attachment K, Requirements and Scope of Work, Section B.2.cKey staff must be located in a Georgia office; however, the system may be hosted in any secure location within the United States.39Medical Review PortalPlease clarify “seamless.”Attachment K, Requirements and Scope of Work, Section B.2.f.1Seamless means without interruption.40DatabasePlease provide information about the format and media the existing Contractor could use for this information.Attachment K, Requirements and Scope of Work, Section B.2.hThe MMURS vendor will coordinate with DCH and the existing vendor to transfer historic information that is not housed within GAMMIS. The MMURS vendor will interface with GAMMIS to access other information which is in XML e-File format.41GaHINPlease provide additional information on how GaHIN will support medical review, specifically if DCH anticipates that some pre-certifications or prior-authorizations will be auto-authorized. Attachment K, Requirements and Scope of Work, Section B.2.jAt this time, the Department does not anticipate auto-authorizations of pre-certification or prior-authorizations involving GaHIN.42Level of Care DeterminationsPlease clarify the graphic on page 24 of Attachment K that shows the Contractor submitting Waiver Level of Care review requests to the ASO (which Attachment K.B.2.l.7.i.a does not address) given that the Scope of Work includes conducting Level of Care determinations.Attachment A, State Entity eRFP, Section 1.1.b and Attachment K, Requirements and Scope of Work, Section B.2.lLevel of care determinations must be made available to operating agencies such as the Division of Aging Services, Department of Behavioral Health and Developmental Disabilities, and their contractors.43GAMMIS Data ExchangePlease define “outlier.” For example, does the term refer to day or cost outliers relative to a DRG system?Attachment K, Requirements and Scope of Work, Section B.2.m.8-10“Outlier” is related to an algorithm formula for cost analysis of inpatient claims that post edit 4399 relative to a DRG payment system. The outlier policy and formula is outlined in the Hospital Services Manual, Appendix J.44GaHINWhat is the status of GaHIN in terms of provider participation and support for medical review? For example, what percentage of hospitals and physicians current participate? Attachment K, Requirements and Scope of Work, Section B.2.o23 hospitals and 6,303 providers currently participate in GaHIN.45Utilization ReviewThe third paragraph indicates that the Contractor will evaluate all requests and make recommendations. What would the responsibilities of the Contractor be in the context of auto-authorization of review requests, which contribute significantly to reduction of administrative burden but which typically do not entail discussion with the provider?Attachment K, Requirements and Scope of Work, Section B.5As stated in Section B.5, the MMURS vendor must review all requests and make recommendations.46Utilization ReviewAre pre-certification numbers distinct in format and/or content from denial numbers? Please provide examples of these numbers.Attachment K, Requirements and Scope of Work, Section B.5.a.1.iiNo. Each PA and pre-cert that the MMURS vendor receives will be assigned an alphanumeric identifier. This number remains the same through final disposition.47Utilization ReviewPlease confirm that beneficiaries will submit pre-certification requests directly to the Contractor. If so, how does the process work if the Contractor requires additional information, especially clinical information?Attachment K, Requirements and Scope of Work, Section B.5.a.1.xNo, this refers to pre-certifications received for dually-eligible members. Additional information can be obtained from the provider.48Utilization ReviewThis item suggests a provider could change the request after the Contractor denied it. If so, does this change invalidate the denial or constitute a reconsideration request or appeal? How does the change affect the member’s appeal rights? How does the Contractor report changes to DCH?Attachment K, Requirements and Scope of Work, Section B.5.a.3.viiiAfter the request has been denied, a user must submit a new request. Please refer to Attachment K, Section B.8 for appeal rights. For approved requests, the system must allow a user to make changes (units, etc.), for example, as services may change.49Utilization ReviewCan the user withdraw the request after the Contractor denied it? If so, does that cancel the denial, and what is the affect on the member’s appeal rights? How does the Contractor report withdrawn requests to DCH? Attachment K, Requirements and Scope of Work, Section B.5.a.3.xviiiAfter a request is denied, the request cannot be withdrawn. The vendor must be able to maintain, track and report the denied requests. Please refer to Attachment K, Section B.8, for appeal rights. Pending requests may be withdrawn. The vendor must be able to track withdrawn requests.50Utilization ReviewHow does the responsibility to review outpatient psychiatric services for members <21 relate to the ASO?Attachment K, Requirements and Scope of Work, Section B.5.a.4If member is receiving services through DBHDD (ASO), then vendor must coordinate information shared with DBHDD (ASO).51Level of Care DeterminationsPlease provide additional information on the level of care determinations and annual reviews, a)Are they the same activity? b)What are the timeframes for annual reviews? c)Are they conducted onsite?If the team conducting the Professional Review served the member in the facility how is the Professional Review independent? Attachment K, Requirements and Scope of Work, Section B.5.a.4The level of care determination is performed as an initial request. The determination is then reviewed during the annual review process.Annual reviews are conducted at a minimum once a calendar year but may be required to be conducted more frequently for certain individuals depending on need.No.The review must be performed collaboratively with the facility that provided the care. 52Plan of CareIs there an opportunity for the individual to participate in the development of the Plan of Care?Attachment K, Requirements and Scope of Work, Section B.4.d.3.ii.a.3.ii.eYes, there is an opportunity for the individual to participate in the development of the Plan of Care.53SurveysPlease provide additional information about the member survey:a)Please provide the sample size, confidence level, margin of error, and response rate.b)What instrument and process does the current Contractor use for the member survey?How are results reported to DCH?Attachment K, Requirements and Scope of Work, Section B.4.3.3.ii.f.1The entire waiver population is surveyed. The response rate varies dependent on members’ participation.Quality of Life survey is utilized; however, the vendor may propose an alternate instrument for DCH consideration.An annual written report of the findings is submitted to DCH.54SurveysPlease provide additional information about the survey of families:a)What does DCH consider the “family” for survey purposes in terms of the individual(s) actually responding?b)Please provide the sample size, confidence level, margin of error, and response rate.c)What instrument and process does the current Contractor use for the member survey?How are results reported to DCH?Attachment K, Requirements and Scope of Work, Section B.4.d.3.iii.gFamily refers to the parent, legal guardian or responsible adult. The entire population is surveyed. The response rate varies dependent on members’ participation.Quality of Life survey is utilized; however, the vendor may propose an alternate instrument for DCH consideration.An annual written report of the findings is submitted to DCH.55Data ModelDoes the DCH Data Model include all the elements listed throughout the RFP Attachments?How does the Data Model represent elements like the corrective action plan (Item 10 on page 61), i.e., as an attachment to the record, as a set of data elements with defined values, or as free text?Attachment K, Requirements and Scope of Work, Section B.6Not at this time; however, the Department is moving towards being able to capture all data elements.For the vendor’s data model, it may be necessary in certain situations to capture “free text”; however, wherever possible, responses should be aggregated into commonly used categories. 56Administrative Reviews and HearingsWhat does “Favors” mean?Attachment K, Requirements and Scope of Work, Section B.8.aMedical necessity review of denied covered medical service(s).57Administrative Reviews and HearingsDoes “approve or deny the request” refer to the actual reconsideration determination or does it just relate to accepting the request? That is, does approving the request result in overturning the initial denial?Attachment K, Requirements and Scope of Work, Section B.8.a.1.iiiIt refers to the actual reconsideration determination of the denied initial decision. Yes, the reconsideration request may result in overturning the initial denial.58Administrative Reviews and HearingsIs the Administrative Review discussed in this section the same as the Favors Review?Attachment K, Requirements and Scope of Work, Section B.o, this section concerns the second level review (DCH) of denial of an initial determination. 59StaffingAcknowledging that the current RFP will result in efficiencies through improved information systems support, please provide the current staffing levels for Attachment I Cost Proposal categories.Attachment K, Requirements and Scope of Work, Section B.12Required staff positions are outlined in Attachment K, Section B.12. The vendor is required to provide sufficient staff to successfully perform requirements. Vendor must complete Attachment I based on the staffing level it proposes to meet all requirements.60Cost ProposalPlease confirm that bidders should fully load proposed rates for these categories.Attachment I, Cost ProposalPlease complete Attachment I in accordance with the instructions.61Cost ProposalCost elements are for each annual period. How do these amounts relate to Contractor payments, e.g., does DCH break the annual amounts into 12 equivalent amounts and reimburse the Contractor on a monthly basis?Attachment I, Cost ProposalYes, the vendor will provide an itemized invoice on a monthly basis for DCH review.62PortalWill the web portal be a requirement for all users, or will they also be able to submit via fax/email, etc.? The answer could substantially impact staffing patterns, depending on the number of users submitting via the web portal vs. those submitting via other methods. Attachment K, Requirements and Scope of Work, Section B.5.d.3.i (page 47)Yes, all providers must use the web portal via secure logon.63GAMMISCan the state provide the expected file format for sending data to GAMMIS?Attachment K, Requirements and Scope of Work, Section B.5.d.3.iii(page 47)The MMURS vendor’s decisions would come to GAMMIS via e-file via XML. Prior Authorization files and outlier decisions come to GAMMIS in XML format. The MMURS vendor will have access via interface to the GAMMIS and will be able to make decisions within the GAMMIS panel for suspense locations (deny or approve the suspended claim).64SystemPlease confirm that requests for Level of Care Determinations and Prior Authorization requests will be submitted via an electronic form in the Contractor’s system rather than using a document upload feature to submit forms? Other than ‘age’ what relevant factors must the contractor report? Attachment K, Requirements and Scope of Work, Section B.5.d.3.i (page 47)The Contractor’s system must have an electronic form; however, to support the requests, the Contractor’s system must also have the ability to upload relevant clinical data such as nurse’s notes, hospital discharge summaries, doctor’s notes, etc.Contractor should be prepared to report clinical data such as diagnoses, member demographics, outcome of determinations and other information as requested by DCH.65SystemCan document requests be built into the system as an option to communicate “Further Documentation Requested” to the requestor? Attachment K, Requirements and Scope of Work, Section B.5.d.3.i.c(page 47)No, the request for further documentation is sent to the members and their families who do not have access to the system. However, tracking of the request must be built into the Contractor’s system.66Certified MailDo any notices have to go via certified mail? Can notices be placed in the web system?Attachment K, Requirements and Scope of Work, Section B.5.d.3.i.f(page 48)Yes, please refer to the Department’s response to Question #2. Tracking of the request must be built into the Contractor’s system.67Deeming/Katie Beckett Level of Care ReviewHow many hearings occur per month/year, etc.? Are DCH attorneys involved in these hearings, if the parent/caregiver enlists an attorney?Attachment K, Requirements and Scope of Work, Section B.5.d.3.i.h(page 48)The average number of Katie Beckett cases is approximately 10 per month. DCH attorneys are involved in all hearings.68Deeming/Katie Beckett Level of Care ReviewIs Level of Care Determination update based on a new evaluation each year? Attachment K, Requirements and Scope of Work, Section B.5.d.3.i.i(page 48)Yes, the Level of Care Determination update is based on a new evaluation each year.69Deeming/Katie Beckett Level of Care ReviewPlease provide additional information about the cost-effectiveness studies in terms of content, timing, and use in the utilization management program. Would the analysis be based on claims submitted to GAMMIS, since authorizations may not equal actual costs? Will GAMMIS provide claims data routinely in order to properly conduct the cost-effectiveness study?Attachment K, Requirements and Scope of Work, Section B.5.d.3.i.k(page 48)Analyses of cost effectiveness for Katie Beckett program is based on clinical information submitted during the eligibility process. The MMURS vendor must review this information for validity.GAMMIS can provide claims data on a routine basis.70Independent Care Waiver Program (ICWP)Is there a wait list?Attachment K, Requirements and Scope of Work, Section B.5.d.3.ii.a (page 48)Yes, there is a wait list.71Independent Care Waiver Program (ICWP)How are requests received, e.g., fax, email, through a web portal? Who submits them (provider, family, etc.)?Attachment K, Requirements and Scope of Work, Section B.5.d.3.ii.a.1 (page 48)ICWP requests to be on the waiting list for the waiver may be submitted via fax, email, telephone or mail. These requests originate from members, families and providers. The web portal may not be used to submit these requests.72Independent Care Waiver Program (ICWP)How are denial notices issued, US mail, Certified mail, and/or Notice through the web system?Attachment K, Requirements and Scope of Work, Section B.5.d.3.ii.a.2.i(page 48)Certified Mail.73Independent Care Waiver Program (ICWP)What is the requirement for other attendees at the face-to-face assessment? Attachment K, Requirements and Scope of Work, Section 3.ii.a.3.i(page 48)Any individual in attendance should be able to provide relevant information as authorized by the member.74Independent Care Waiver Program (ICWP)Should this be “within 10 business days” as opposed to “in 10 business days?” Attachment K, Requirements and Scope of Work, Section B.5.d.3.ii.a.3.i (page 49)Yes, within 10 business days.75Independent Care Waiver Program (ICWP)What method is acceptable for notification to the member: Phone call; mail/certified mail? Should both the Member and legal representative if there is one receive notices? If the latter, can DCH please provide an estimate for costing purposes of the number of members with a legal representative?Attachment K, Requirements and Scope of Work, Section B.5.d.3.ii.a.3.ii.a(page 49)By mail unless otherwise indicated by the member or the member’s authorized representative.Both member and legal representative should be notified as rmation concerning number of legal representatives is not readily available.76Independent Care Waiver Program (ICWP)Please clarify if the case manager is an employee of the Contractor or another entity. Attachment K, Requirements and Scope of Work, SectionB.5.d.3.ii.a.3.vi(page 49)The case manager is a private enrolled provider with DCH and not an employee of the MMURS vendor.77Independent Care Waiver Program (ICWP)What does “with the case manager and Provider” mean in operational terms, i.e., does the case manager and provider have to co-sign the certified letter? Attachment K, Requirements and Scope of Work, Section B.5.d.3.ii.a.3.ix (page 49)The case manager and provider would initiate the process through the MMURS vendor. The case manager and provider do not co-sign the certified letter. ................
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