OMB NO:0938-0935
--------- REGULATORY REQUIREMENTS THROUGH POLICIES, STANDARDS & MANUALS
(These provisions must be included in provider procedures, standards or manuals, etc.)
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CMS REGULATION - 42 CFR 422 |
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Permanent “out of area members to receive benefits in continuation area 422.54(b) |
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Prohibition against discrimination based on health status 422.110(a) |
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Pay for emergency and urgently needed care consistent with provisions 422.112(a)(9); 422.100(b) |
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Pay for renal dialysis for those temporarily out of service area 422.100(b)(1)(iv) |
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Direct access to mammography screening and influenza vaccinations 422.100(g)(1) |
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No copay for influenza and pneumoccocal vaccines 422.100(g)(2) |
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Agreements with providers to demonstrate “adequate” access. Network must be sufficient to provide access to covered services 422.112(a)(1) |
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Direct access to in-network women’s health specialist for routine and preventive services 422.112(a)(3) |
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Services available 24 hrs/day, 7 days/week 422.112(a)(7) |
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Suspension or termination of plan-contracted providers 422.204 |
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Safeguard privacy and maintain records accurately and timely 422.118 |
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Adhere to CMS marketing provisions 422.80(a), (b), (c) |
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Ensure services are provided in culturally competent manner 422.112(a)(8) |
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Conduct a health assessment of all new enrollees within 90 days of the effective date of enrollment 422.112(b)(4) |
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Document in a prominent place in medial record if individual has executed Advance directive 422.128(b)(1)(ii)(E) |
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Provide covered benefits in a manner consistent with professionally-recognized standards of health care 422.504(a)(3)(iii) |
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Payment and incentive arrangements specified between MAO, providers, first tier, & downstream entities be specified in all contract(s) 422.504 |
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Subject to laws applicable to federal funds 422.504(h) |
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Disclose to CMS all information necessary to (1) administer & evaluate the program (2) establish and facilitate a process for current and prospective beneficiaries to exercise choice in obtaining Medicare services 422.64: 422.504(a)(4): 422.504(f)(2) |
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Must make good faith effort to notify all affected members of the termination of a provider contract within 30 days of notice of termination by plan or provider 422.111(e) |
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Submission medical records and certify completeness and truthfulness 422.504(a)(8); 422.504(d)-(e); 422.504(i)(3)-(4);422.504 (l)(3) |
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Comply with medical policy, QM and MM. MAO must develop such standards in consultation with contracting providers 422.202(b); 422.504(a)(5) |
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Disclose to CMS quality & performance indicators for plan benefits re: disenrollment rates for benes enrolled in the plan for the previous two years 422.504(f)(2)(iv)(A) |
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Disclose to CMS quality & performance indicators for the benefits under the plan regarding enrollee satisfaction 422.504(f)(2)(iv)(B) |
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Disclose to CMS quality & performance indicators for the benefits under the plan regarding health outcomes 422.504(f)(2)(iv)(C) |
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Notify provider in writing of reason for denial, suspension & termination 422.204(c)(1) |
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Provide 60 days notice (terminating contract without cause) 422.204(c)(4) |
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Comply with Civil Rights Act, ADA, Age Discrimination Act, federal funds laws 422.504(h)(1) |
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Prohibits MAO, first tier & downstream entities from employing or contracting with individuals excluded from participation in Medicare under section 1128 or 1128A of the SSA 422.752(a)(8) |
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Adhere to appeals/grievance procedures 422.562(a) |
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Matrix2.doc (Policies & Procedures)
Revised: 1-18-2007
page
File Type | application/msword |
File Title | --------- |
Author | HCFA Software Control |
Last Modified By | CMS |
File Modified | 2007-01-19 |
File Created | 2007-01-19 |