PIHP CSoC Louisiana Request For Proposals . - Department Of Health

PIHP CSoC Louisiana Request for Proposals COORDINATED SYSTEM OF CARE OFFICE OF BEHAVIORAL HEALTH RFP # 305PUR-LDHRFP-CSOC-2017-OBH Proposal Due Date/Time: July 20, 2018 4 p.m CT Release Date: June 20, 2018

TABLE OF CONTENTS GLOSSARY . 1 GLOSSARY OF ACRONYMS . 22 1. GENERAL INFORMATION . 25 1.1. 1.2. 1.3. 1.4. 1.5. BACKGROUND . 25 PURPOSE . 25 GOALS OF THE CSOC . 26 INVITATION TO PROPOSE . 26 RFP ADDENDA . 27 2. ADMINISTRATIVE INFORMATION . 28 2.1. 2.2. 2.3. 2.4. RFP COORDINATOR . 28 PROPOSER INQUIRIES. 28 PRE-PROPOSAL CONFERENCE . 28 SCHEDULE OF EVENTS . 28 3. SCOPE OF WORK . 30 3.1. 3.2. 3.3. 3.4. 3.5. 3.6. 3.7. 3.8. CSOC PROJECT OVERVIEW. 30 GENERAL CONTRACTOR REQUIREMENTS . 31 CMS WAIVER AUTHORITIES . 32 M ANAGEMENT OF SERVICES FOR CSOC MEMBERS . 32 SUBCONTRACTING INFORMATION . 33 COMPLIANCE WITH COURT ORDERED SETTLEMENTS . 34 RESOURCES AVAILABLE TO CONTRACTOR . 34 TERM OF CONTRACT . 34 4. STAFF REQUIREMENTS AND SUPPORT SERVICES . 36 4.1. 4.2. 4.3. 4.4. GENERAL REQUIREMENTS . 36 KEY STAFF POSITIONS . 37 WRITTEN POLICIES, PROCEDURES, AND JOB DESCRIPTIONS. 45 STAFF TRAINING AND MEETING ATTENDANCE . 45 5. CONTRACTOR REIMBURSEMENT. 47 5.1. 5.2. 5.3. 5.4. 5.5. 5.6. 5.7. 5.8. 5.9. 5.10. 5.11. PAYMENT TERMS . 47 CONTRACTOR PAYMENT SCHEDULE. 47 DETERMINATION OF CONTRACTOR RATES . 48 ANNUAL ACTUARIAL STUDY . 48 PAYMENT FOR MEDICAID ELIGIBLE CHILDREN ENROLLED IN CSOC . 49 PAYMENT ADJUSTMENTS . 49 RISK SHARING . 50 MEDICAL LOSS RATIO . 50 RETURN OF FUNDS . 50 THIRD PARTY LIABILITY . 51 RESPONSIBILITY FOR PAYMENT FOR SPECIALIZED BEHAVIORAL HEALTH SERVICES PROVIDED TO COORDINATED SYSTEM OF CARE (CSOC) RECIPIENTS . 53 6. COVERED BENEFITS AND SERVICES . 55 6.1. 6.2. GENERAL PROVISIONS . 55 1915(C) CHILDREN’S CSOC SERIOUS EMOTIONAL DISTURBANCE (SED) HOME AND COMMUNITYBASED WAIVER . 56 1915(B)(3) SERVICES FOR CHILDREN AND YOUTH WHO ARE FUNCTIONALLY ELIGIBLE FOR CSOC . 56 CHANGES TO CHILDREN/YOUTH SERVICES CONTINGENT ON CMS APPROVAL . 57 6.3. 6.4. i

6.5. 6.6. 6.8. COVERAGE AND PAYMENT FOR POST-STABILIZATION SERVICES . 57 PRIOR AUTHORIZATION AND CONCURRENT UTILIZATION REVIEW FOR INPATIENT PSYCHIATRIC HOSPITALIZATION FOR CHILDREN/YOUTH . 57 PROCEDURE FOR SERVICES DETERMINED MEDICALLY NECESSARY UNDER EPSDT BY A CHILD AND FAMILY TEAM BUT NOT IN MEDICAID STATE PLAN . 57 SERVICES FOR CO-OCCURRING BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES . 58 7. MEMBER SERVICES . 59 7.1. 7.2. 7.3. 7.4. 7.5. 7.6. 7.7. 7.8. 7.9. 7.10. 7.11. 7.12. 7.13. 7.14. 7.15. GENERAL REQUIREMENTS . 59 M ARKETING AND EDUCATIONAL M ATERIALS APPROVAL PROCESS. 60 REVIEW PROCESS FOR MATERIALS . 60 REVIEW PROCESS FOR EVENTS AND ACTIVITIES . 60 MEMBER EDUCATION PLAN . 61 WRITTEN M ATERIALS GUIDELINES . 61 CONTRACTOR WEBSITE GUIDELINES . 62 MEMBER COMMUNICATION/EDUCATION REQUIRED MATERIALS AND SERVICES. 64 MEMBER HANDBOOK. 65 PROVIDER DIRECTORY FOR MEMBERS . 68 MEMBER SERVICE AND CALL CENTER STAFF . 69 AUTOMATED CALL DISTRIBUTION (ACD) SYSTEM . 71 MEMBERS’ RIGHTS AND RESPONSIBILITIES . 72 NOTICE TO MEMBERS OF PROVIDER TERMINATION AND CHANGES . 75 ORAL AND WRITTEN INTERPRETATION SERVICES . 76 8. PROVIDER NETWORK REQUIREMENTS. 77 8.1. 8.2. 8.3. 8.4. 8.5. 8.6. 8.7. 8.8. 8.9. 8.10. GENERAL PROVIDER NETWORK REQUIREMENTS . 77 NETWORK DEVELOPMENT AND M ANAGEMENT PLAN . 80 NETWORK STANDARDS AND GUIDELINES . 84 OTHER NETWORK REPORTS . 86 PROVIDER ENROLLMENT . 87 M ATERIAL CHANGE TO PROVIDER NETWORK . 88 CREDENTIALING AND RE-CREDENTIALING OF PROVIDERS . 90 NETWORK PROVIDER AGREEMENTS . 93 PROVIDER-MEMBER COMMUNICATION ANTI-GAG CLAUSE . 96 M AINSTREAMING . 97 9. CARE AND UTILIZATION MANAGEMENT . 98 9.1. 9.2. 9.3. 9.4. 9.5. 9.6. 9.7. 9.8. 9.9. 9.10. 9.11. 9.12. CARE M ANAGEMENT REQUIREMENTS . 98 CARE COORDINATION, CONTINUITY OF CARE, AND CARE TRANSITION. 99 CARE M ANAGEMENT POLICIES AND PROCEDURES . 104 UTILIZATION M ANAGEMENT . 104 SERVICE AUTHORIZATION . 107 UTILIZATION M ANAGEMENT (UM) COMMITTEE . 107 UTILIZATION M ANAGEMENT (UM) REPORTS . 108 TIMING OF SERVICE AUTHORIZATION DECISIONS . 108 DOCUMENTATION FOR SERVICE AUTHORIZATION . 111 COURT-ORDERED ASSESSMENT, TREATMENT, AND PLACEMENT WHICH CHALLENGE MEDICAL NECESSITY DETERMINATION AND DEFENSIBLE LENGTHS OF STAY . 111 PROVIDER UTILIZATION AND QUALITY PROFILING . 111 PROVIDER UTILIZATION AND QUALITY PROFILE REPORTING REQUIREMENTS . 112 10. PROVIDER PAYMENTS . 113 10.1. 10.2. 10.3. 10.4. GENERAL PROVISIONS . 113 MINIMUM REIMBURSEMENT TO CONTRACTED PROVIDERS . 113 REIMBURSEMENT TO NON-CONTRACTED PROVIDERS . 113 FQHC CONTRACTING AND REIMBURSEMENT . 113 6.7. ii

10.5. 10.6. 10.7. 10.8. EFFECTIVE DATE OF ELIGIBILITY FOR NEW MEMBERS. 114 CLAIMS PROCESSING REQUIREMENTS (PROVIDER PAYMENTS) . 114 INAPPROPRIATE PAYMENT DENIALS . 115 PAYMENT FOR EMERGENCY SERVICES AND POST-STABILIZATION SERVICES . 116 11. PROVIDER SERVICES . 117 11.1. 11.2. 11.3. 11.4. 11.5. 11.6. PROVIDER RELATIONS . 117 PROVIDER TOLL-FREE TELEPHONE LINE . 117 PROVIDER WEBSITE . 118 PROVIDER HANDBOOK . 119 PROVIDER EDUCATION AND TRAINING . 121 PROVIDER COMPLAINT SYSTEM . 122 12. ENROLLMENT . 124 12.1. 12.2. ENROLLMENT OF CHILDREN AND YOUTH FOR CSOC . 124 CONTRACTOR ENROLLMENT PROCEDURES . 125 13. GRIEVANCE AND APPEAL SYSTEM . 127 13.1. 13.2. 13.3. 13.4. 13.5. 13.6. 13.7. ADVERSE BENEFIT DETERMINATIONS, GRIEVANCE AND APPEAL PROCEDURES . 127 APPLICABLE DEFINITIONS. 128 NOTICE OF ADVERSE BENEFIT DETERMINATION. 128 HANDLING OF GRIEVANCES AND APPEALS . 131 PROHIBITION AGAINST PUNITIVE ACTION . 136 CONTINUATION OF BENEFITS . 137 GRIEVANCE/APPEAL/STATE FAIR HEARING RECORDS AND REPORTS . 138 14. QUALITY MANAGEMENT . 139 14.1. 14.2. 14.3. 14.4. 14.5. 14.6. 14.7. 14.8. QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM . 139 QAPI COMMITTEE . 140 CSOC OUTCOME EVALUATION . 142 MEDICAID HOME AND COMMUNITY-BASED WAIVERS . 142 PERFORMANCE IMPROVEMENT PROJECTS . 144 PROVIDER MONITORING. 145 MEMBER SATISFACTION SURVEYS . 146 QUALITY REVIEWS . 146 15. PROGRAM INTEGRITY .147 15.1. 15.2 15.3. 15.4. 15.5. 15.6. FRAUD, WASTE AND ABUSE PREVENTION . 147 CONTRACTOR PROHIBITED RELATIONSHIPS . 152 CRIMINAL BACKGROUND CHECKS AND INFORMATION ON PERSONS CONVICTED OF CRIMES. 154 EXCLUDED PROVIDERS. 154 PROGRAM INTEGRITY REPORTING AND INVESTIGATING SUSPECTED FRAUD AND ABUSE . 154 RIGHT TO REVIEW AND RECOVERY BY CONTRACTOR AND LDH . 157 16. SYSTEMS AND TECHNICAL REQUIREMENTS . 159 16.1 16.2 16.3 16.4 16.5 16.6 16.7 16.8 16.9 16.10 GENERAL REQUIREMENTS . 159 INTERFACE REQUIREMENTS WITH WAAS . 161 HIPAA STANDARDS AND CODE SETS . 161 CONNECTIVITY . 162 INFORMATION SYSTEMS DOCUMENTATION REQUIREMENTS . 163 SYSTEMS CHANGES . 164 ELECTRONIC MESSAGING . 165 ELIGIBILITY AND ENROLLMENT DATA EXCHANGE. 165 INFORMATION SYSTEMS AVAILABILITY . 166 CONTINGENCY PLAN . 167 iii

16.11 16.12 16.13 OFF SITE STORAGE, REMOTE BACK-UP, AND RETRIEVAL . 168 RECORDS RETENTION . 168 INFORMATION SECURITY AND ACCESS M ANAGEMENT . 169 17. CLAIMS MANAGEMENT . 171 17.1. THE CONTRACTOR WILL IMPLEMENT AND MAINTAIN A COMPREHENSIVE CLAIMS PROCESSING SYSTEM 17.2. 17.3. 17.4. 17.5. 17.6. 17.7. 17.8. 17.9. 17.10. CAPABLE OF PAYING CLAIMS IN ACCORDANCE WITH STATE AND FEDERAL REQUIREMENTS AND IN TERMS OF THE CONTRACT. . 171 FUNCTIONALITY. 171 CLAIMS PROCESSING . 173 SAMPLING OF PAID CLAIMS . 174 REMITTANCE ADVICES. 175 ENCOUNTER DATA . 175 ADHERENCE TO KEY CLAIMS M ANAGEMENT STANDARDS . 177 NATIONAL PROVIDER IDENTIFIER (NPI) . 178 CLAIMS DISPUTE MANAGEMENT . 178 CLAIMS PAYMENT ACCURACY REPORT . 178 18. AUDITS, RECORDS, AND REPORTS . 180 18.1. 18.2. 18.3. 18.4. 18.5. 18.6. 18.7. 18.8. 18.9. 18.10. 18.11. 18.12. 18.13. 18.14. 18.15. REPORTING. 180 OWNERSHIP DISCLOSURE. 181 OTHER REPORTING REQUIREMENTS IN THIS RFP . 181 ENCOUNTER DATA . 181 FINANCIAL REPORTING . 181 REPORT ERRORS . 183 SUBMISSION TIMEFRAMES . 183 AD HOC REPORTS. 183 COURT-ORDERED REPORTING . 183 TRANSPARENCY REPORT . 184 AUDIT REQUIREMENTS . 184 STATE AUDITS . 184 INDEPENDENT AUDIT OF SYSTEMS . 184 AUDIT COORDINATION AND CLAIMS REVIEWS . 185 BEHAVIORAL HEALTH RECORDS . 185 19. CONTRACT COMPLIANCE AND MONITORING . 188 19.1. 19.2. 19.3. 19.4. 19.5. 19.6. 19.7. 19.8. CONTACT PERSONNEL . 188 CONTRACT MONITOR. 188 NOTIFICATION TO CONTRACTOR OF POLICIES AND PROCEDURES . 188 CONTRACTOR CONTRACT AND INFORMATION CHANGES . 188 REQUIRED SUBMISSIONS . 189 ONGOING CONTRACT MONITORING . 189 PERFORMANCE ASSESSMENT . 189 MONITORING REPORTS. 189 20. REMEDIATION . 190 20.1. 20.2. 20.3. 20.4. 20.5. 20.6. 20.7. 20.8. NON-COMPLIANCE ACTIONS GENERALLY. 190 ADMINISTRATIVE ACTIONS . 191 CORRECTIVE ACTION PLANS (CAPS). 191 MONETARY PENALTIES. 192 SANCTIONS STATUTORILY ENFORCED BY 42 CFR §438 SUBPART I . 194 TERMINATION OF CONTRACT GENERALLY . 195 TERMINATION OF CONTRACT DUE TO SERIOUS THREAT TO HEALTH OF MEMBERS . 195 TERMINATION OF CONTRACT FOR CONTRACTOR INSOLVENCY, BANKRUPTCY, OR INSTABILITY OF FUNDS . . 195 PROVIDER SANCTIONS . 196 20.9. iv

20.10. NON-WAIVER OF BREACH . 196 21. TRANSITION REQUIREMENTS . 197 21.1. 21.2. 21.3. 21.4. 21.5. 21.6. 21.7. 21.8. 21.9. 21.10. INTRODUCTION . 197 GENERAL REQUIREMENTS . 197 IMPLEMENTATION PLAN . 197 GENERAL TRANSITION REQUIREMENTS . 198 TRANSITION PLAN . 198 TRANSITION SERVICES . 200 MEMBER AND PROVIDER SERVICES TRANSITION . 201 TRANSFER OF DATA . 202 POST-TRANSITION SERVICES . 203 TRANSITION DELIVERABLES. 204 22. PROPOSALS . 205 22.1. 22.2. 22.3. 22.4. 22.5. 22.6. 22.7. 22.8. 22.9. 22.10. 22.11. 22.12. 22.13. 22.14. 22.15. 22.16. 22.17. 22.18. GENERAL INFORMATION . 205 CONTACT AFTER SOLICITATION . 205 CODE OF ETHICS . 206 REJECTION AND CANCELLATION . 206 CONTRACT AWARD AND EXECUTION . 206 ASSIGNMENTS. 207 DETERMINATION OF RESPONSIBILITY . 207 PROPOSAL AND CONTRACT PREPARATION COSTS . 210 ERRORS AND OMISSIONS. 210 OWNERSHIP OF PROPOSAL. 210 PROCUREMENT LIBRARY/RESOURCES AVAILABLE TO PROPOSER . 210 PROPOSAL SUBMISSION . 210 CONFIDENTIAL INFORMATION, TRADE SECRETS,

PIHP CSoC Louisiana Request for Proposals. COORDINATED SYSTEM OF CARE . OFFICE OF BEHAVIORAL HEALTH . RFP # 305PUR-LDHRFP-CSOC-2017-OBH . Proposal Due Date/Time: July 20, 2018 4 p.m CT