Oregon Mental Health


Enrollee selection of plan

"IV.  Enrollment and Disenrollment
A.  Enrollment
1 ...DHS shall sign on such individuals with the contractor selected by the individual… Contractor shall have an open Enrollment period at all times, during which contractor shall accept, without restriction, all eligible individuals in the order in which they apply and are signed on with Contractor by DHS…"  Oregon Mental Health Contract, page 4.

Auto-enrollment process

"IV.  Enrollment and Disenrollment
A.  Enrollment
1 ...If an eligible individual does not select a contractor, DHS may, pursuant to OAR 410-141-0060, Oregon Health Plan Managed Care Enrollment Requirements, elect to assign the person to a contractor selected by DHS…"  Oregon Mental Health Contract, page 4.

Service coverage, limits, and exclusions

"G. OMAP Member Rights...
2.  Contractor shall assure that OMAP Members receive information on the rights specified in OAR 410-141-0320, Oregon Health Plan Prepaid Health Member Rights and Responsibilities. Contractor shall give particular attention to the following rights:

a.  The right to receive Covered Services...

h.  The right to refer oneself directly to the Contractor for Covered Services without first having to gain authorization from another provider;

i.  The right to have access to Covered Services which at least equals access available to other persons served by the contractor...

n.  The right to receive, within 30 calendar days of Enrollment, written materials describing at least the following topics: …benefits available..."  Oregon Mental Health Contract, pages 28-29.

Emergency care

"G.  OMAP Member Rights...
2.  Contractor shall assure that OMAP Members receive information on the rights specified in the OAR 410-141-0320, Oregon Health Plan Prepaid Health Member Rights and Responsibilities. Contractor shall give particular attention to the following rights: ...

n.  The right to receive, within 30 calendar days of Enrollment, written materials describing at least the following topics: … how to access Covered Services, what to do in an Emergency Situation…"  Oregon Mental Health Contract, page 29.

Participating provider

"G.  OMAP Member Rights...
2.  Contractor shall assure that OMAP Members receive information on the rights specified in the OAR 410-141-0320, Oregon Health Plan Prepaid Health Member Rights and Responsibilities.  Contractor shall give particular attention to the following rights: ...
g.  The right to have an opportunity to select an appropriate Mental Health Practitioner and service site from within the Contractor's participating Provider Panel…"  Oregon Mental Health Contract, pages 28-29.

" 5.  As described in OAR 410-141-0280 (2) (e), Contractor shall provide written notice to affected OMAP Members of any significant changes in program or service sites that impacts OMAP Members' ability to access care or services from the Contractors providers.  Such notice will be provided to the division and the OMAP Members at least 14 days prior to the effective date of that change."  Oregon Mental Health Contract, page 36.

Other

"b.  Preventive and Early Intervention Services...
(d)  Contractor shall have mechanisms to inform its OMAP Members, Family Members, Health care professionals, and the community about its preventive and Psychoeducational programs."  Oregon Mental Health Contract, page 13

"F.  Informational Materials and Education of OMAP Members
Contractor shall develop or provide informational materials and educational programs as described in OAR 410-141-0280, Oregon Health Plan Prepaid Health plan Information Requirements and OAR 410-141-0300, Oregon Health Plan Prepaid Health Plan Member Education. These materials and programs shall be tailored the backgrounds and special needs of OMAP Members…"  Oregon  Mental Health Contract, page 27.

"G.  OMAP Member Rights...
2.  Contract shall assure that OMAP Members receive information on the rights specified in OAR 410-141-0320, Oregon Health Plan Prepaid Health Plan Members Rights and Responsibilities. Contract shall give particular attention to the following rights: ...

b.  The right to be actively involved in the development of Treatment Plans if Covered Services are to be provided and to have parents to be involved in such Treatment Planning consistent with OAR 309-032-0950 through 309-032-1080, Standards for Community Treatment Services for Children;

c.  The right to consent to Treatment and refuse Covered Services;

d.  The right to be informed as required in ORS 127.703, Required Policies Regarding Mental Health Treatment Rights Information; Declaration for Mental Health Treatment;

e.  The right to gain access to his or her own records, unless access is restricted in accordance with ORS 179.505 or other applicable law…

i.  The right to have access to Covered services which at least equals access available to other persons served by Contractor;

j.  The right to receive a Notice of Action when a service, benefit, Request for Service Authorization or request for Claim Payment is denied; or Notice of Intended Action prior to termination, suspension or reduction of a benefit or service as described in Exhibit G, Oregon Health Plan Mental Health Services Complaint and Hearings Process...

m.  The right to request Continuation of Benefit until a decision in a hearing is rendered. The OMAP member may be required to repay any benefits continued if the issue is resolved in favor of the contractor...

o.  The right to have written materials explained in a manner which is understandable; and

p.  The right to access protective services as described in ors 430.735 through 430.765, Abuse Reporting for Mentally Ill and OAR 309-040-0200 through 309-040-0290, Abuse Reporting and Protective Services in Community Programs and Community Facilities."  Oregon Mental Health Contract, pages 28-30.

Prior-authorization procedures

"G.  OMAP Member Rights...
2.  Contractor shall assure that OMAP Members receive information on the rights specified in the OAR 410-141-0320, Oregon Health Plan Prepaid Health Member Rights and Responsibilities. Contractor shall give particular attention to the following rights: ...
h.  The right to refer oneself to Contractor for Covered Services without first having to gain authorization from another provider…"  Oregon Mental Health Contract, pages 28-29.

Grievances and complaints procedures

"4. Client Notices...
Contractor shall make available in all clinics frequented by OMAP Members information provided by Division concerning client notices, complaints and hearings."  Oregon Mental Health Contract, page 10.

"F.  Information Materials and Education of OMAP Members...
Contractor shall offer member orientation that includes information on the contractor's Grievance and Complaint process.

G.  OMAP Member Rights...
2.  Contract shall assure that OMAP Members receive information on the rights specified in OAR 410-141-0320, Oregon Health Plan Prepaid Health Plan Members Rights and Responsibilities. Contract shall give particular attention to the following rights: …

k.  The right to make a Complaint or request a hearing as described in Exhibit G, Oregon Health Plan Mental Health Services Complaint and Hearings Process;

l.  The right to request an Expedited Hearing if the OMAP Member feels the mental health problem is urgent or emergent and cannot wait for the normal hearing process...

n.  The right to receive, within 30 calendar days of Enrollment, written materials describing at least the following topics: …how to make a Complaint…"  Oregon Mental Health Contract, pages 27-29.

"Oregon Health Plan Mental Health Services Client Notices, Complaint and Hearing Process...
2.  Hearing Process
Contractor shall have the following responsibilities in resolving disagreements with OMAP Members and/or OMAP Member Representatives: ...
D. Have a method of informing OMAP members about compliant and MHDDSD Hearings procedures. Information provided to OMAP Members shall include the following:

(1)  written material, or alternative forms as required by the OMAP Member's special need, describing these processes;

(2)  Assurance that clinical information related to the Complaint or MHDDSD Hearing issue will be kept confidential except to the extent that sharing of such information between Contractor and Division, and other persons authorized by the OMAP Member, is necessary to resolve the issue;

(3)  Availability of Complaint forms, Notice of Hearing Rights (MHDDSD-OHP-0505-3/98), Notice of Complaint Process (MHDDSD-OHP-0504-3/98), and Administrative Hearing Request Forms (AFS 443) in all offices; and

(4)  Assurance that Contractor and its Participating Providers will take no retaliatory action against the OMAP Member for making a Complaint or requesting a MHDDSD Hearing."  Oregon Mental Health System, pages G1-G3.

Confidentiaility policies

"G.  OMAP Members Rights...
2.  Contractor shall assure that OMAP Members receive information on the rights specified in the OAR 410-141-0320, Oregon Health Plan Prepaid Health Plan Member Rights and Responsibilities.  Contractor shall give particular attention to the following rights: ...

f.  The right to have Clinical Records Kept confident consistent with laws listed in OAR 410-141-0180, Oregon Health Plan Prepaid Health Plan Recordkeeping and OAR 309-032-0950 through 309-032-1080, Standards for Community Treatment Services for Children"  Oregon Mental Health Contract, page 28.

Physician incentive agreements

"Practitioner Incentive Plans...
3.  Contractor shall provide to any OMAP Member who request it the following information:
a.  Whether the Contractor uses a practitioner incentive plan that affects the use of referral services;

b.  The type of incentive arrangement;

c.  Whether Stop Loss Protection is provided; and

d.  If a survey is required to ensure access to services is not being denied based on the practitioner incentive plan, a summary of the survey results."  Oregon Mental Health Contract, page I1.

Plan disenrollment for loss of coverage or eligibility

"IV.  Enrollment and Disenrollment...
B.  Disenrollment
1.  An individual is no longer an OMAP member eligible for Covered Services under this Agreement as of the effective date of the OMAP Member's Disenrollment from Contractor, and as of that date, Contractor is no longer required to provide services to such individual under this Agreement."  Oregon Mental Health Contract, pages 4-5.

Plan disenrollment for cause

"IV. Enrollment and Disenrollment...
B.  Disenrollment...
2.  An OMAP Member may be disenrolled from Contractor in the accordance with OAR 410-141-0080, Oregon Health Plan Disenrollment from Prepaid Health Plans.  Contractor or the Psychiatric Security Review Board (PSRB) may request Disenrollment of an OMAP Member under the jurisdiction of PSRB. Division shall approve Disenrollment request of Contractor or PSRB for OMSP Members under PSRB jurisdiction."  Oregon Mental Health Contract, pages 4-5.

"B.  Secondary Payer Status and Retroactive Disenrollment...
If OMAP determines that the OMAP Member has sufficient third party resources, DHS may disenroll the OMAP Member in accordance with OAR 410-141-0080, Oregon Health Plan Disenrollment from Prepaid Health Plans.  The effective date of disenrollment shall be the first of the month after OMAP makes such a determination unless OMAP specifies a retroactive effective date of disenrollment pursuant to OAR 410-141-0080 (3), except that such date shall not exceed 18 months.  When an OMAP Member is retroactively disenrolled, Division through OMAP shall recoup all Capitation Payment from the date of disenrollment."  Oregon Mental Health Contract, page 45.

Protections against plan disenrollment

"10.  Contractor shall not deny Covered Services to, or request Disenrollment of, an OMAP Member based on disruptive or abusive behavior resulting from symptoms of a mental disorder or from another disability…"  Oregon Mental Health Contract, page 25.

Care coordination/case management

"3.  Mental Health Services Which Are Not Covered Services
Contractor shall assist its OMAP Members in gaining access to certain mental health services that are not Covered Services and that are provided under separate contract with the Division and/or OMAP.  Services which are not Covered Services include, but are not limited to, the following: ...
m.  Extended care services for OMAP Members 18 years of age and older including Extended Care Management…" Oregon Mental Health Contract, page 9.

"2.  Components of the Delivery Services
a.  Services Coordination...
(2)  Contractor shall mange all Covered Services for its OMAP Members and shall help OMAP Members gain access to needed mental health, physical health, and social support services which are Not Covered Services. Contractor shall identify barriers to such access and help remove barriers if possible…"  Oregon Mental Health Contract, page 12.

"f.  Acute Inpatient Hospital Psychiatric Care...
(4)  Contractor shall coordinate admissions to and discharges from Acute Inpatient Hospital Psychiatric Care for OMAP Members in the care and custody of the State Office for Services to Children and Families (SOSCF) or Oregon Youth Authority (OYA) with such OMAP Member's SOSCF or OYA case manager...
3.  Integration and Coordination
a.  Mental Health Services Which Are Not Covered Services
Contractor shall coordinate services for each OMAP Member who requires services from agencies providing mental health services which are not covered services. These services include, but are not limited to, those listed in section V, Statement of work, Subsection A, Benefit Package, item 3, Mental Health Services Which Are Not Covered Services."  Oregon Mental Health Contract, pages 16-17.

"(5)  Contractor shall work with the ECMU, COT Representative or OCS Team in managing admissions to and discharge from LTPC for OMAP Members who require such care at Oregon State Hospital or Eastern Oregon Psychiatric Center...
(b)  Contractor shall also work with the OSH-GTS Interdisciplinary Team assigned to the OMAP Member in managing Discharges from long term Geropsychiatric Care.

(6)  Contractor shall assure that any involuntary treatment provided under this contract is provided in accordance with administrative rule and statute and shall coordinate with the CHMP director in assuring that all statutory requirements are met…"  Oregon Mental Health Contract, pages 21-22.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...

Case Management: Services provided to OMAP Members who require assistance to ensure access to benefits and services from Local, Regional and/or State Allied Agencies or other Services Providers. Services provided may include: advocating for the OMAP Member's treatment needs; providing assistance in obtaining entitlements based on mental and emotional Disability; referring OMAP Members to needed services or supports; accessing housing or residential programs; coordinating services including educational or vocational activities; and establishing alternatives to inpatient hospital services...

Traditional Service:  A Medically Appropriate mental health service defined in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for per capita costs, October 1997 through September 1998. Traditional Services are those services that have historically been used to treat mental disorders and include services for which Fee-For-Service billing categories exist.

For OMAP Members under 21 years of age Traditional Services include the following: …Clinical Services Coordination; Case Management…For OMAP Members 21 years of age and older Traditional Services include the following: …Case Management…"  Oregon Mental Health Contract, Appendix K, pages K1-K2, K 21-K22.

Family therapy

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules (OARs)...
Family Therapy:  Planned treatment actively involving the immediate or extended Family to remediate significant impairments to functioning that are related to a mental disorder diagnosed on Axis I or II of a DSM IV multi-axial Diagnosis and identified by the Mental Health Assessment.  Family Therapy is individualized to meet specific goals and Measurable Objectives in the Treatment Plan.  The intended outcome of Family Therapy for a child is to achieve and maintain the best possible, developmentally appropriate level of functioning.  The intended outcome of Family Therapy for an Adult is to manage, reduce or resolve the identified mental health problem thereby allowing the adult to function more independently and competently in daily life...

Traditional Service:  A Medically Appropriate mental health service defined in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for per capita costs, October 1997 through September 1998. Traditional Services are those services that have historically been used to treat mental disorders and include services for which Fee-For-Service billing categories exist. For OMAP Members under 21 years of age Traditional Services include the following: …Family Therapy…For OMAP Members 21 years of age and older Traditional Services include the following: …Family Therapy…"  Oregon Mental Health Contract, Appendix K, pages K, K8-K9, K21-K22.

Individual therapy

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Individual Therapy:  Planned treatment to remediate significant impairments in functioning that are the results of a principal mental or emotional disorder diagnosed in Axis I or II of a DSM-IV multi-axial Diagnosis and identified by a mental health Assessment.  Therapy is individualized to meet specific goals and Measurable Objectives in the Treatment Plan.  The intended outcome of Individual Therapy for a child is to achieve and maintain the best possible, Developmentally appropriate, level of functioning.  The intended outcome of individual Therapy for an Adult is the management, reduction or resolution of identified mental health problems thereby allowing the client to function more independently and competently in daily life...

Traditional Service:  A Medically Appropriate mental health service defined in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for per capita costs, October 1997 through September 1998.  Traditional Services are those services that have historically been used to treat mental disorders and include services for which Fee-For-Service billing categories exist. For OMAP Members under 21 years of age Traditional Services include the following: …Individual Therapy…For OMAP Members 21 years of age and older Traditional Services include the following: …Individual Therapy…"  Oregon Mental Health Contract, Appendix K, pages K1, K-10-K-11,  K21-K22.

Group therapy

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Group Therapy:  Planned treatment to remediate significant impairment in the functioning that are the result of the result of a Principal mental or emotional disorder diagnosed on Axis I or II of a DSM-IV multi-axial Diagnosis and identified by a mental health Assessment.  Group Therapy is the treatment of three or more unrelated persons with similar therapeutic issues. It is individualized to meet specific goals and Measurable Objectives in the Treatment Plan.  The intended outcome of Group Therapy for a child is to achieve and maintain the best possible, developmentally appropriate, level of functioning. The intended outcome of Group Therapy for an adult is to manage, to reduce or resolve the identified mental health problems thereby allowing the client to function more independently and competently in daily life...

Traditional Service:  A Medically Appropriate mental health service defined in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for per capita costs, October 1997 through September 1998.  Traditional Services are those services that have historically been used to treat mental disorders and include services for which Fee-For-Service billing categories exist. For OMAP Members under 21 years of age Traditional Services include the following: …Group Therapy…For OMAP Members 21 years of age and older Traditional Services include the following:  Interpreter Services…Group Therapy…"  Oregon Mental Health Contract, Appendix K, pages K1, K10, K21-K 22.

Inpatient services for persons under 21

"f.  Acute Inpatient Hospital  Psychiatric Care
(1)  Contractor shall maintain agreements with local and regional hospitals to ensure provisions of emergency and non emergency hospitalization for OMAP Members with mental disorders which require Acute Inpatient Psychiatric Care...

(2)  Contractor shall cover the cost of Acute Inpatient Psychiatric Care for OMAP Members who do not meet the criteria for Long Term Psychiatric Care."  Oregon Mental Health Contract, page 16.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
JCAHO Psychiatric Residential Program:  A program which provides non-emergency inpatient (residential) psychiatric services for children under age 21 in residential facilities which are licensed by SOSCF and accredited by the JCAHO.  These programs must meet DARTS standards regarding staffing credentials and staffing patterns, the integration of education and treatment, and Family focused, community based treatment."  Oregon Mental Health Contract, Appendix K, pages K1, K11.

Long-term residential

"3.  Mental Health Services Which Are Not Covered Services
Contractor shall assist its OMAP Members in gaining access to certain mental health services that are not Covered Services and that are provided under separate contract with the Division and/or OMAP. Services which are not Covered Services include, but are not limited to, the following: ...

f.  Residential/Medical Youth Care Residential Center for OMAP Members under 21 years of age;

h.  JCAHO Psychiatric Residential Programs for OMAP Members under 21 years of age (except for those services included in the intensive Treatment Services Pilot Project)...

k.  Long Term Psychiatric Care in a state or other approved psychiatric hospital for OMAP Members 21 years of age or older...

o.  Other Residential Services for OMAP Members 21 years of age or older provided in Residential Care facilities, Residential Treatment Facilities and Residential Treatment Homes…"  Oregon Mental Health Contract, pages 8-9.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...Long Term Psychiatric Care or Long Term Hospitalization: Inpatient psychiatric services delivered in an Oregon State Operated Hospital after Usual and Customary care has been provided in an acute inpatient Hospital Psychiatric Care setting or JCAHO Residential Psychiatric Treatment Center for children under age 18 and the individuals continues to require a hospital level of care."  Oregon Mental Health Contract, Appendix K, pages K1, K12.

Medication management

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Extended Medication Adjustment:  Regulation and adjustment of medicines lasting more than 21 to 28 days due to significant complications arising from severe side effects of Medicines...

Medication Management:  Services delivered by a licensed registered nurse or physician related to the prescribing, dispensing, administration and management of Medication as described in the Treatment Plan...

Traditional Services:  A Medically Appropriate mental health service defined in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for per Capita Costs, October 1997 through September 1998.  Traditional services are those services that have historically been used to treat mental disorders and include services for which Medicaid Fee-For Service billing categories exist.  For OMAP Members under 21 years of age Traditional Services include the following…Medication Management…For OMAP Members 21 years of age and older Traditional Services include the following:  Medication Management…"  Oregon Mental Health Contract, Appendix K, pages K1, K8, K13, K21-K22.

Partial day treatment programs

"3.  Mental Health Services Which Are Not Covered Services
Contractor shall assist its OMAP Members in gaining access to certain mental health services that are not Covered Services and that are provided under separate contract with the Division and or OMAP.  Services which are not Covered Services include, but are not limited to the following: ...

c.  DARTS Psychiatric Day Treatment for OMAP Members under 21 years of age (except for those services included in the Intensive Treatment Pilot Project)…"  Oregon Mental Health Contract, page 8.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...

Day and Residential Treatment Services (DARTS) Psychiatric Day Treatment: Community based day or residential treatment services for children in psychiatric treatment setting which confirm to state-approved standards."  Oregon Mental Health Contract, Appendix K, pages K1, K6.

Prescribed drugs

"3.  Mental Health Services Which Are Not Covered Services
Contractor shall assist its OMAP Members in gaining access to certain mental health services that are not Covered Services and that are provided under separate contract with the Division and or OMAP.  Services which are not Covered Services include, but are not limited to the following: ...
b.  Medication…"  Oregon Mental Health Contract, page 8.

Preventive health services

"b.  Preventive and Early Intervention Services
(1)  Contractor shall establish and conduct preventive mental health and psychoeducational programs to decrease the incidence, prevalence and residual effects of mental disorders in selected are of the OMAP Member population.

(a)  Contractor shall have screening mechanisms to determine the presence and the prevalence of mental disorders in its OMAP Membership.

(b)  Contractor shall adopt program with the participation of Health Care Professionals, OMAP Members, Family Members, and Local and/or Regional Allied Agencies.

(c)  Contractor shall assure that such programs are appropriate to the age, gender, socioeconomic status, ethnicity, clinical history, and risk characteristics of OMAP Membership.

(d)  Contractor shall have mechanism to inform its OMAP Members, Family Members, Health Care Professionals, and the community about its preventive and its psychoeducational programs.

(e)  Contractor shall have mechanism to monitor the use of its preventive and psychoeducational Programs and assess their impact on the OMAP Membership and the community.

(f)  Contractor shall take action to improve the appropriate use of preventive and psychoeducational programs."  Oregon Mental Health Contract, page 13.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Prevention: Services provided to stop, lessen or ameliorate the occurrence of mental disorders."  Oregon Mental Health Contract, Appendix K, pages K1, K17.

Referrals

"2.  Components of the Delivery Services
a.  Services Coordination...
(2)  Contractor shall manage all Covered Services for its OMAP Members and shall help OMAP Members gain access to needed mental health, physical health, and social support services which are Not Covered Services. Contractor shall identify barriers to such access and help remove barriers if possible…"  Oregon Mental Health Contract, page 12.

Screening, assessment and diagnosis

"3.  Mental Health Services Which Are Not Covered Services
Contractor shall assist its OMAP Members in gaining access to certain mental health services that are not Covered Services and that are provided under separate contract with the Division and/or OMAP.  Services which are not Covered Services include, but are not limited to, the following: …

l.  Preadmission Screening and Resident Review(PASRR) for OMAP Members seeking admission to a Nursing Home…"  Oregon Mental Health Contract, page 9.

"b.  Preventive and Early Intervention Services...
(a)  Contractor shall have screening mechanisms to determine the presence and the prevalence of mental disorders in its OMAP Membership."  Oregon Mental Health Contract, page 13.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...

Evaluation:  A Psychiatric or Psychological Assessment used to determine the need for mental health services. The evaluation includes the collection and analysis of pertinent biopsychosocial information through interview observation, and Psychological and neuropsychological testing . The Evaluation concludes with a five axes Diagnosis of a DSM IV multiaxial Diagnosis, prognosis for rehabilitation, and treatment recommendations...

Traditional Services: A Medically Appropriate mental health service defined in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for per Capita Costs, October 1997 through September 1998.  Traditional services are those services that have historically been used to treat mental disorders and include services for which Medicaid Fee-For Service billing categories exist.  For OMAP Members under 21 years of age Traditional Services include the following…Assessment and Evaluation…For OMAP Members 21 years of age and older Traditional Services include the following:  Assessment and Evaluation…" Oregon Mental Health Contract, Appendix K, pages K1, K8, K21-K22.

Short-term residential (includes hospital)

"3.  Mental Health Services Which Are Not Covered Services
Contractor shall assist its OMAP Members in gaining access to certain mental health services that are not Covered Services and that are provided under separate contract with the Division and/or OMAP. Services which are not Covered Services include, but are not limited to, the following: …

h.  JCAHO Psychiatric Residential Programs for OMAP Members under 21 years of age (except for those services included in the Intensive Treatment Services Pilot Project)...

o.  Other Residential Services for OMAP Members 21 years of age and older provided In Residential Care Facilities, Residential Treatment Facilities and Residential Treatment Homes…"  Oregon Mental Health Contract, page 9.

"f.  Acute Inpatient Hospital  Psychiatric Care
(1)  Contractor shall maintain agreements with local and regional hospitals to ensure provisions of emergency and non emergency hospitalization for OMAP Members with mental disorders which require Acute Inpatient Psychiatric Care...

(2)  Contractor shall cover the cost of Acute Inpatient Psychiatric Care for OMAP Members who do not meet the criteria for Long Term Psychiatric Care."  Oregon Mental Health Contract, page 16.

Transportation

"V.  Statement of Work...
2. Provision of Covered Services …
d.  Contractor's obligation to pay for Emergency Services that are received from non- Participating Providers limited to Covered Services that are needed immediately…

(2)  Contractor is responsible for arranging for transportation and transfer of the OMAP Member to the Contractor's care when it can be done without harmful consequences…

3.  Mental Health Services Which Are Not Covered Services
Contractor shall assist its OMAP Members in gaining access to certain Mental Health Services that are not Covered Services and that are provided under separate contract with the division and/or OMAP. Services which are not Covered Services include, but are not limited to, the following:
  a. Medical Transportation…"  Oregon Mental Health Contract, pages 7-8.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...

Medical Transportation:  A service provided to Medicaid-eligible persons pursuant to rules (410-136-0020 et. Seq.) promulgated by the OMAP and published in its Medical Transportation Services Guide."  Oregon Mental Health Contract, Appendix K, pages K1, K12.

Other

"3.  Mental Health Services Which Are Not Covered Services
Contractor shall assist its OMAP Members in gaining access to certain mental health services that are not Covered Services and that are provided under separate contract with the Division and/or OMAP.  Services which are not Covered Services include, but are not limited to, the following:

a.  Medical Transportation;

b.  Medication;

c.  DARTS Psychiatric Day Treatment for OMAP Members under 21 years of age (except for those services included in the Intensive Treatment Services Pilot Project);

d.  Treatment Foster care reimbursed under BA code 030 for OMAP Members under 21 years of age;

e.  Therapeutic Group Home for OMAP Members under 21 years of age;

f.  Residential/Medical Youth Care Residential Center for OMAP Members under 21 years of age;

g.  Behavioral Rehabilitative Services that are financed through Medicaid and regulated by SOSCF and OYA;

h.  JCAHO Psychiatric Residential Programs for OMAP Members under 21 years of age (except for those services included in the Intensive Treatment Services Pilot Project);

i.  Child and Adolescent Treatment Services (CATS) at the Oregon State Hospital (OSH) (except for those services included in the Intensive Treatment Services Pilot Project);

j.  Investigation of OMAP Members for civil commitment;

k.  Long Term Psychiatric Care in a state or other approved Psychiatric hospital for OMAP Members 21 years of age and older;

l.  Preadmission Screening and Resident Review(PASRR) for OMAP Members seeking admission to a Nursing Home;

m.  Extended care services for OMAP Members 18 years of age and older including Extended Care Management, Enhanced Care Services provided in SDSD licensed facilities, '365' projects, Psychiatric Vocational Projects, PASSAGES Projects, and other services  developed as less  restrictive alternatives to Long Term Psychiatric Care at an Oregon State Hospital;

n.  Personal Care in Adult Foster Homes for OMAP Members 21 years of age and older;

o.  Other Residential Services for OMAP Members 21 years of age and older provided In Residential Care Facilities, Residential Treatment Facilities and Residential Treatment Homes;

p.  Services provided to persons while in custody of a correctional facility or jail;

q.  Abuse investigations and protective services as described in OAR 309-040-0200 through 309-040-0390, Abuse Reporting and Protective Services in Community Facility, and ORS 430.735 through ORS 430.765, Abuse Reporting for the Mentally Ill; and

r.  Personal Care Services as described in OAR 411-34-000."  Oregon Mental Health Contract, pages 8-10.

"c.  Rehabilitative Treatment Services
(1)  Contractor shall establish and make available services for OMAP Members who have non- urgent or non-Emergency needs for Covered Services.

(2)  Contractor shall establish written policies and procedures that ensure Covered Services which are Rehabilitative are provided within Medically Appropriate time frames...

e.  Involuntary Psychiatric Care
(1)  Contractor shall make reasonable effort to provide Covered Services on a voluntary basis and consistent with current Declaration for Mental Health Treatment in lieu of involuntary treatment.

(2)  Contractor shall have written policies and procedures describing the appropriate use of Emergency Psychiatric Holds and alternatives to Involuntary Psychiatric Care to assure such holds are only used when a less restrictive voluntary service will not meet the Medically Appropriate needs of the OMAP Member and the behavior of the OMAP Member meets legal standards for the use of an Emergency Psychiatric Hold.

(3)  Contractor shall only use psychiatric in-patient facilities and non in-patient facilities certified by the Division under OAR 309-33-0500, Standard for the approval of Facilities that provide Care, Custody and treatment to committed persons or to persons in Custody or on Diversion, to provide Emergency Psychiatric Holds.

(4)  Contractor shall comply with ORS Chapter 426, OAR 309-200-0000 through 309-200-0150, and OAR 309-205-0000 through 309-205-0050 for involuntary civil commitment of those OMAP Members who are civilly committed under ORS 426.130.

(5)  Contractor shall administer Medication to OMAP Members held or civilly committed under ORS Chapter 426, regardless of setting, only as permitted by applicable statute and administrative rule. Contractor shall not transfer civilly committed OMAP Members to a state hospital for the sole purpose of obtaining authorization to administer Medication on an involuntary basis."  Oregon Mental Health Contract, pages 14-15.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Flexible Service: A service that is an alternative or addition to a Traditional Service that is as likely or more likely to effectively treat the mental disorder as documented in the OMAP Member's Clinical Record. Flexible Services include, but are not limited to: Respite Care, Partial Hospitalization, Subacute Psychiatric Care, Family Support Services, Parent Psychosocial Skills Development, Peer Counseling, and other nontraditional services identified...

Geropsychiatric Treatment Service: Four units at Oregon State Hospital Serving frail elderly persons with mental disorders, head trauma, advanced dementia, and/or concurrent medical conditions who cannot be served in community programs...

Group Skills Development:  An individualized program of interventions designed to meet specific goals and objectives in an OMAP Member's Treatment Plan and to remediate significant impairments in an OMAP Member's functioning that are the result of a principal mental or emotional disorder…

Rehabilitative Services: Rehabilitative Services are any Medically Appropriate remedial services for the maximum reduction of a mental disability and attainment by the covered individual of his/her beat possible functional level...

Traditional Services:  A Medically Appropriate mental health service defined in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for per Capita Costs, October 1997 through September 1998.  Traditional services are those services that have historically been used to treat mental disorders and include services for which Medicaid Fee-For Service billing categories exist.  For OMAP Members under 21 years of age Traditional Services include the following...Multi Family Treatment Group; Individual Skills Development and Group Skills Development; Intensive Treatment, Structure and Support...For OMAP Members 21 years of age and older Traditional Services include the following: …Consultation…Daily Structure and Support; Individual and Group Skills Training…Covered Services provided in a variety of residential settings."  Oregon Mental Health Contract, Appendix K, pages K1, K9, K19, K21-K22.

Urgent care: Coverage

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...

Traditional Service:  A Medically Appropriate mental health service defined in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for per capita costs, October 1997 through September 1998.  Traditional Services are those services that have historically been used to treat mental disorders and include services for which Fee-For-Service billing categories exist.  For OMAP Members under 21 years of age Traditional Services include the following: …24-hour Urgent and Emergency Response; and Acute Inpatient Hospital Psychiatric Care.  For OMAP Members 21 years of age and older Traditional Services include the following: …24-hour Urgent and Emergency Response; and Acute Inpatient Hospital Psychiatric Care...

Twenty-four Hour Urgent and Emergency Services: Services available 24 hours per day for persons experiencing an acute mental or emotional disturbance potentially endangering their health or safety or that of others, but not necessarily creating a sufficient cause for civil commitment as set forth in OAR 309-033-0200 through 309-033-0340."  Oregon Mental Health Contract, Appendix K, pages K1, K21-22.

Urgent care: Definition

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Urgent Care:  Care which is necessary within 48 hours to prevent a serious deterioration In an OMAP Member's mental health.

Urgent Situation:  A situation requiring attention within 48 hours to prevent a serious deterioration in an OMAP Member's mental health."  Oregon Mental Health Contract, Appendix K, pages K1, K22.

Emergency care: Coverage

"V.  Statement of Work...
2.  Provisions of Covered Services…
d.  Contractor's obligation to pay for Emergency Services that are received from non Participating providers is limited to Covered Services that are needed immediately and the time required to reach  Contractor or a participating Provider (or alternatives authorized by Contractor) would have meant substantial risk to the OMAP Member's health or safety or the health or the safety of another.

(1)  Covered Services following the provision of Emergency Services are considered to be Emergency Services as long as transfer of the OMAP Member to the Contractor or a Participating Provider or the designated alternative is precluded because of risk to the OMAP Member's health or safety or that of another because transfer would be unreasonable, given the distance involved in the transfer and the nature of the mental health condition...

e.  Contractor shall pay for emergency screening if condition was determined to be non- emergent, but presenting condition met prudent layperson definition…"  Oregon Mental Health Contract, page 7.

"d.  24 Hour Urgent and Emergency Response System
(1)  Contractor shall provide Covered mental health Emergency Services that are needed immediately, or appear to be needed immediately by a prudent layperson...

(2)  Contractor shall establish, consistent with OAR 410-141-0140, Oregon Health Plan Prepaid Health Plan Emergency and Urgent Care Medical Services, an Urgent and Emergency Response System that operates 24 hours per day, 7 days per week.

(3)  Contractor shall have, and adhere to, written policies and procedures that ensure its Emergency Response System provides an immediate, initial and/or limited duration response consisting of: a telephone or face-to-face screening to determine the nature of the situation and the person's immediate need for Covered Services; Capacity to conduct the elements of a mental health Assessment that are needed to determine the interventions necessary to begin the crisis situation; development of a written initial service plan at the conclusion of the mental health Assessment; provisions of Covered Services and/or Outreach needed to address the Urgent or Emergency situation; and linkage with the public sector crisis services, such as pre commitment."  Oregon Mental Health Contract, pages 14-15.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Emergency Service: Covered Services that are needed immediately or appear to be needed immediately because of an injury, sudden illness that would have meant risk of permanent damage to the OMAP Member's health…

Traditional Service:  A Medically Appropriate mental health service defined in Attachment 1, State of Oregon, Oregon Health Plan Service Categories for per capita costs, October 1997 through September 1998.  Traditional Services are those services that have historically been used to treat mental disorders and include services for which Fee-For-Service billing categories exist.  For OMAP Members under 21 years of age Traditional Services include the following: …24-hour Urgent and Emergency Response; and Acute Inpatient Hospital Psychiatric Care. For OMAP Members 21 years of age and older Traditional Services include the following: …24-hour Urgent and Emergency Response; and Acute Inpatient Hospital Psychiatric Care...

Twenty-four Hour Urgent and Emergency Services:  Services available 24 hours per day for persons experiencing an acute mental or emotional disturbance potentially endangering their health or safety or that of others, but not necessarily creating a sufficient cause for civil commitment as set forth in OAR 309-033-0200 through 309-033-0340."  Oregon Mental Health Contract, pages K1, K7, K 21-K 22.

Emergency care: Definition

"V. Statement of Work...
2.  Provision of Covered Services…
d.  Contractor's obligation to pay for Emergency Services that are received from non Participating providers is limited to Covered Services that are needed immediately and the time required to reach a Contractor or a participating Provider (or alternatives authorized by Contractor) would have meant substantial risk to the OMAP Member's health or safety or the health or the safety of another...

e. Contractor shall pay for emergency screening if condition was determined to be non- emergent, but presenting condition met prudent layperson definition…"  Oregon Mental Health Contract, page 7.

"d.  24 Hour Urgent and Emergency Response System
(1) Contractor shall provide Covered mental health Emergency Services that are needed immediately, or appear to be needed immediately by a prudent layperson, because of a sudden mental health condition, or exacerbation of a mental health condition…"  Oregon Mental Health Contract, page 14.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Emergency Situation: A mental Health condition, manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in
(1) serious jeopardy to the health of the OMAP Member,

(2) serious impairment of bodily function, or

(3) serious dysfunction of any bodily part or part."  Oregon Mental Health Contract, Appendix K, pages K1, K7.

Coverage for urgent and emergency services out-of-plan

"V.  Statement of work
A.  Benefit Package...
2.  Provisions of Covered Services…
d.  Contractor's obligation to pay for Emergency Services that are received from non-participating Providers is limited to Covered Services that are needed immediately and the time required to reach Contractor or a Participating Provider (or alternatives authorized by a Contractor) would have meant substantial risk to the OMAP Member's health or safety or the health or safety of another.

(1)  Covered services following the provision of Emergency Services are considered to be Emergency Services as long as transfer of the OMAP Member to the contractor or a Participating Provider or the designated alternative is precluded because of risk to the OMAP /member's health or safety or that of another because transfer would be unreasonable, given the distance involved in the transfer and the nature of the mental health condition.

(2)  Contractor is responsible for arranging for transportation and transfer of the OMAP Member to Contractor's care when it can be done without harmful consequences."  Oregon Mental Health Contract, pages 6-7.

"9.  Contractor shall assure that identified Covered Service needs of an OMAP Member are met during transfer from one hospital or practitioner to another regardless of whether the practitioners or hospitals are participating providers…"  Oregon Mental Health Contract, page 25.

General coverage rule

"5.  Utilization Management...
b.  Contractor may adopt Treatment Parameters or Utilization Guidelines which result in limitations being placed on covered Services; however, Contractor shall assure that a Medically Appropriate level of Covered Service is provided based on the needs of the OMAP Members regardless of limits specified in any such Treatment Parameters or Utilization Guidelines."  Oregon Mental Health Contract, page 10.

"d. 24 Hour Urgent and Emergency Response System
(1)  ...Contractor is responsible to pay all necessary mental Health Emergency services which are medically appropriate , until the emergency is stabilized, to non participating mental health practitioners or licensed facilities."  Oregon Mental Health Contract, page 14.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Covered Services:  Services included in the Capitation Payment paid to the Contractor under this Agreement with respect to an OMAP Member under this Agreement whenever services are Medically Appropriate for the OMAP Member…"  Oregon Mental Health Contract, Appendix K, pages K1, K5.

Medical necessity standard

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Appropriate: The extent to which a particular procedure, treatment, test, or service is documented to be effective, clearly indicated, not excessive, adequate in quantity, and provided in the setting best suited to the needs of the OMAP Member...

Medically Appropriate: Services and Supplies which are required for prevention(including preventing a relapse), Diagnosis and treatment of  mental disorders and which are Appropriate and consistent with the Diagnosis; consistent with treating the symptoms of a mental illness or treatment of a mental disorder; appropriate with regard to standards of good practice and generally recognized by the relevant scientific community as effective; not solely for the convenience of the OMAP Member or provider of the service or supply; and the most cost effective of the alternative levels of Covered Services or supplies which can be safely and effectively provided to the OMAP Member in the Contractor's judgement."  Oregon Mental Health Contract, Appendix K, pages K1,  K12.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...

Medically Appropriate: Services and Supplies which are required for prevention(including preventing a relapse), Diagnosis and treatment of  mental disorders and which are Appropriate and consistent with the Diagnosis; consistent with treating the symptoms of a mental illness or treatment of a mental disorder; appropriate with regard to standards of good practice and generally recognized by the relevant scientific community as effective; not solely for the convenience of the OMAP Member or provider of the service or supply; and the most cost effective of the alternative levels of Covered Services or supplies which can be safely and effectively provided to the OMAP Member in the Contractor's judgement."  Oregon Mental Health Contract,Appendix K, pages K1, K12.

Children in foster care or out-of-home placement

"3.  Mental Health Services Which Are Not Covered Services
Contractor shall assist its OMAP Members in gaining access to certain mental health services that are not Covered Services and that are provided under separate contract with the Division and or OMAP.  Services which are not Covered Services include, but are not limited to the following: ...

d. Treatment Foster Care reimbursed under BA code 030 for OMAP Members under 21 years of age…"  Oregon Mental Health Contract, page 8.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...

Treatment Foster Care:  A program of rehabilitation as prescribed in the Treatment Plan and provided in the child's foster home.  Skill development activities are delivered on an individual basis and are designed to promote skill development in areas identified in the Treatment Plan.  The service requires the use of Treatment Foster Care in coordination with other mental health interventions to reduce symptoms associated with the child's mental or emotional disorder and to provide a structured, Therapeutic environment.  The service is intended to reduce the need for future services, increase the child's potential to remain in the community, restore the child's best possible functional level, and to allow the child to be maintained in a least restrictive setting."  Oregon Mental Health Contract, Appendix K, pages K1, K22.

Hospitals and other institutions

"f.  Acute Inpatient Psychiatric Care
Contractor shall maintain agreements with local and regional hospitals to ensure provisions of emergency and non emergency hospitalization for OMAP Members with mental disorders which require Acute Inpatient Hospital Psychiatric Care.  If Contractor uses hospitals other than those under contract with the Division, then the Contractor shall assure that the hospitals selected comply with OAR 309-032-0850 through OAR 309-032-0890, standards for Regional Acute Care Facilities for Adults."  Oregon Mental Health Contract, page 16.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...

Mental Health Organization (MHO):  A prepaid Health Plan Under Contract with Division to provide Covered Services under the OHP Medicaid Demonstration Project and Children's Health Insurance Program.  MHOs can be FCHPs, CMHPs or private MHOs or combinations thereof...

Residential/Medical Youth Care Residential Care Residential Center: A facility providing treatment under a physician approved plan to children and adolescents(ages 3 through 20) with mental or emotional disorder as identified in a mental health Assessment. These children and adolescents are placed by OYA and SOSCF in cooperation with the county mental health authority.  Adolescents receiving this service have a DSM-IV, Axis I Diagnosis and reside in a SOSCF licensed youth care center.  This service includes an Appropriate mix and intensity of individual and group therapies and skills Development to reduce or eliminate the symptoms of the disorder and restore the individual's ability to function, to the best possible level, in home, school and community settings...

Residential Treatment Facility:  A facility that is operated to provide supervision, care and treatment on a 24-hour basis for six or more residents consistent with ORS 443.400 through ORS 443.455.

Residential Treatment Home:  A home that is operated to provide supervision, care and treatment on a 24-hour basis for five or fewer residents consistent with ORS 443.400 through ORS 443.455...
State Hospital:  State-operated psychiatric hospitals including Oregon State Hospital in Salem and Portland, and Eastern Oregon Psychiatric Center in Pendleton."  Oregon Mental Health Contract, Appendix K, pages K1, K13, K19-K20.

Mental health and substance abuse providers

"C. Delivery System Capacity
1. Contractor shall maintain a Provider Panel sufficient to ensure adequate Capacity and expertise to provide timely and Appropriate access to Covered Services across the age span from child to older adult...

c.  Contractor shall assure that OMAP Members have a choice of providers within Contractors; Provider Panel consistent with Section 1932(a)(1)(2)(3) of title XIX of the social security act and Section (1)(b) of OAR 410-141-0120, Oregon Health Plan Prepaid Health Provisions of Health Care Services; Section (2)(c) of OAR 410-141-0320, Oregon Health Plan Prepaid Health Member Rights and Responsibilities; and Section (1)(a) of OAR 410-141-0160, Oregon Health Plan Prepaid Health Plan Continuity of Care.

d. Contractor shall assure OMAP Members have access, as Medically Appropriate, to psychiatrists, other licensed mental health practitioners."  Oregon Mental Health Contract, page 23.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Mental Health Practitioner: Persons with current and appropriate licensure, certification, or accreditation in a mental health profession, which include but not limited to: psychiatrists, psychologists, registered psychiatric nurses, QMHAs, and QMHPs...

Qualified Mental Health Associate (QMHA): A person delivering services under the direct supervision of a QMHP and meeting the following minimum qualifications as documented by the Contractor: A bachelor's degree in behavioral sciences field; or a combination of at least three years, relevant work, education, training or experience; and has the competencies necessary to communicate effectively; understand mental health assessment, treatment and terminology and to apply the concepts; and provide psychosocial Skills Development and to implement interventions prescribed on a Treatment Plan within their scope of practice.

Qualified Mental Health Professional(QMHP): a LMP or any other person meeting the following minimum qualifications as documented by the Contractor: graduate degree In psychology; bachelor's degree in nursing and licensed by the State of Oregon; graduate degree in social work; graduate degree in behavioral science field; graduate degree in recreational, art, or music therapy; or bachelor's degree in occupational therapy and licensed by the State of Oregon; and whose education and experience demonstrates the competencies to identify precipitating events; gather histories of mental and physical disabilities, alcohol and drug use, past mental health services and criminal justice contacts; assess Family, social and work relationships; conduct a mental status examination; document a multiaxial DSM Diagnosis; write and supervise a treatment plan; conduct a Comprehensive Mental Health Assessment; and provide Individual Therapy, Family Therapy and/or Group Therapy within their scope of training."  Oregon Mental Health Contract, Appendix K, pages K1, K13, K18.

Primary care providers

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Primary Care Practitioner(PCP):  A general practice physician, Family physician, general internist, pediatrician, or gynecologist who is responsible for providing and coordinating the OMAP Member's health care services. This person authorizes referrals to specialists and payment is contingent upon these authorizations."  Oregon Mental Health Contract, Appendix K, pages K1, K17.

Hospitals and other institutions

"g.  Medicare payers and Providers
Contractor shall coordinate with Medicare payers and providers as Medically Appropriate to coordinate the care and benefits of OMAP Members who are eligible for both Medicare and Medicaid.

h.  OMAP Members in Extended Care Settings
Contractor shall coordinate with the ECMU of Division and extended care service providers to integrate services for OMAP Members in Extended Care Programs.  ECMU shall determine, after collaborating with Contractor and the Extended Care Program, when OMAP Member is ready for discharge from the extended care program. Contractor shall ensure that such OMAP member receives Covered Services following discharge to ensure timely discharge."  Oregon Mental Health Contract, pages 18-19.

Mental health and substance abuse providers

"b.  Preventive and Early Intervention Services...
(b)  Contractor shall adopt program with the participation of Health Care Professionals, OMAP Members, Family Members, and Local and/or Regional Allied Agencies."  Oregon Mental Health Contract, page 13.

"f. Chemical Dependency Providers
Contractor shall coordinate with Chemical Dependency Providers as Medically Appropriate and within laws governing confidentiality and shall provide technical assistance to help assure that OMAP Members with dual diagnosis are identified and referred to treatment. Contractor shall work with FCHPs and Chemical Dependency Providers certified by the Office of Alcohol and Drug Abuse Programs (OADAP) to develop the capacity to provide Appropriate services to dually diagnosed OMAP Members so the needs of such persons can be better met."  Oregon Mental Health Contract, page 18.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Community Coordinating Committee:  A committee composed of representatives from the Local Community Mental Health Program, State Office for Services to Children and Families, Juvenile Court, local educational district, and Oregon State Hospital, Children and Adolescent Treatment (CATS) program. The Committee performs the intake functions to assure the child's need for Long Term Psychiatric Care at the CATS Program...

Community Mental Health Program (CMHP): The organization of all services for persons with mental or emotional disorders and developmental disabilities operated by, or contractually affiliated with, a LMHA, operated in a specific geographic area of the state under an intergovernmental agreement or direct contract with Division."  Oregon Mental Health Contract, Appendix K, pages K1, K4.

Role of primary care providers

"e. Physical Health Care Providers
Contractor shall coordinate with physical health care providers and Fully Capitated Health Plans as follows:
(1)  Consult and communicate with OMAP Member's physical health provider as Medically Appropriate and within laws governing confidentiality as specified in OAR 410-141-0180, Oregon Health Plan Prepaid Health Plan Recordkeeping.

(2)  Consult with, and provide technical assistance to, physical health care providers in the Service Area to help assure that mental disorders are identified early so that intervention and prevention strategies can begin as soon as possible.

(3)  Develop and implement methods of coordinating with FCHPs in order to assure access and appropriate coordination of services delivered to mutual OMAP Members, particularly OMAP Members with exceptional service needs.  Such coordination shall be conducted within laws governing confidentiality."  Oregon Mental Health Contract, page 18.

Service areas defined

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Service Area:  The geographic area in which the MHO is responsible for delivering Covered Services under this Agreement."  Oregon Mental Health Contract, Appendix K, pages K1, K20.

Plan analysis of service area needs

"5. Utilization Management...
B. Delivery System Configuration
1. Needs Assessment
a. Contractor shall develop a mechanism for determining the service demand and unique service needs of its OMAP Members based on, but not limited to, factors such as:

  (1)  Profiles of the Service Area such as: age, gender, ethnicity, and socioeconomic indicators;

  (2)  Social indicators such as: unemployment rates, divorce rate, single parent household rate, homelessness rate, immigration, seasonal or transient residents, education levels, teenage pregnancy rates, and income and poverty levels; and

  (3)  Incidence of selected behaviors such as: attempted and completed suicide rates; rates of incarcerated persons with mental illness by type of crime; alcohol and drug usage (including arrest)by age, gender and ethnicity; alcohol and drug related deaths; alcohol and drug related motor vehicle accidents and fatalities; driving under the influence of intoxicants; reported domestic violence activity; child and elder abuse investigations; nursing facility resident to resident abuse rates; diagnosis; school dropout rates; foster care density; and crime rates by type of crime, age, gender and ethnicity.

b.  In accordance with findings of the needs assessment, Contractor shall, on an ongoing basis, adjust its delivery system configuration and capacity to assure an adequate range and intensity of Covered Service options.  These Covered Services options shall assure that individualized Covered services in the least restrictive treatment settings are provided. Contractor shall also assure timely and appropriate access to Covered Services to OMAP Members.

c.  Contractor shall coordinate its needs assessment and service delivery planning system planning effort with organized planning efforts carried out by the Local Mental Health Authorities of its services area."  Oregon Mental Health Contract, pages 11-12.

Utilization review process

"5.  Utilization Management
a.  Contractor shall have written utilization Management policies, procedures and criteria for covered services. These Utilization Management Procedures shall be consistent with appropriate Utilization control requirements of CFR part 456.

b.  Contractor may adopt Treatment Parameters or Utilization Guidelines which result In limitations being placed on Covered Services; however, Contractor shall assure that a Medically Appropriate level of Covered Services is provided based on the needs of the OMAP Member regardless of limits specified in any such Treatment Parameters or Utilization Guidelines.

c.  If Contractor adopts Treatment Parameters or Utilization Guidelines, Contractor shall provide copies of such existing Treatment Parameters and Utilization Guidelines to Division as of the effective date of this Agreement; within 45 days of change or adoption; and within 30 calendar days of Division's request.

d.  If the Contractor adopts Treatment Parameters and Utilization Guidelines, Contractor shall establish an appeal process which allows for an independent clinical review of the decision by one or more QMHPs who were not involved in the original Utilization management decision. Contractor may use its complaint process for resolving utilization management appeals.

 (1)  The appeal process of Contractor shall afford those persons requesting Covered Services an expeditious method of reviewing Utilization Management decisions.

(2)  Contractor shall have written policies and procedures for its Utilization Management appeal process, notify organizations, agencies and health care professionals requesting Covered Services of such process, and, upon request, provide a copy of written Utilization Management appeal policies and procedures.

(3)  Contractor shall maintain records of all Utilization Management appeals made and shall document all review decisions in writing.  Records of utilization's Management appeals and decisions shall be made available, within limits of laws or rules governing confidentiality, to the person appealing the original Utilizational Management decision."  Oregon Mental Health Contract, pages 10-11.

Prior authorization prohibited for certain procedures

"G.  OMAP Member Rights...
2.  Contractor shall assure that OMAP Members receive information on the rights specified in the OAR 410-141-0320, Oregon Health Plan Prepaid Health Member Rights and Responsibilities. Contractor shall give particular attention to the following rights: ...
h.  The right to refer oneself to Contractor for Covered Services without first having to gain authorization from another provider…"  Oregon Mental Health Contract, pages 28-29.

Reviewers clinically competent

"5. Utilization Management...
d. If the Contractor adopts Treatment Parameters and Utilization Guidelines, Contractor shall establish an appeal process which allows for an independent clinical review of the decision by one or more QMHPs who were not involved in the original Utilization management decision…"  Oregon Mental Health Contract, page 10.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...

Medicaid Authorization Specials(MAS): A QMHP designated at the county or regional level to determine the rehabilitative mental needs of children in state custody referred for certain residential programs or OMAP Members under age 18 requiring services which are not Covered Services."  Oregon Mental Health Contract, Appendix K, pages K1, K12.

Time limits for prior authorization

"5.  Utilization Management...
(1)  The appeal process of Contractor shall afford those persons requesting Covered Services an expeditious method of reviewing Utilization Management decisions."  Oregon Mental Health Contract, pages 10-11.

24-hour telephone access for prior authorization

"d.  24 hour urgent and Emergency Response System...
(2)  Contractor shall establish, consistent with OAR 410-141-0140, Oregon Health Plan Prepaid Health Plan Emergency and Urgent Care Medical Services, an Urgent and Emergency system that operates 24 hours per day, 7 days per week."  Oregon Mental Health Contract, page 14.

Required to use review or authorization for mental health and substance abuse

"i.  Long Term Psychiatric Care (LTPC)
(1)  If Contractor believes that an OMAP Member is Appropriate for LTPC, Contractor shall request a LTPC determination from the applicable Division. The Division staff member shall render a determination within three working days of receiving a completed request if the OMAP Member is 18 or more years of age or within seven working days of receiving a completed request if the OMAP Member is under age 18."  Oregon Mental Health Contract, page 19.

Services for persons whose primary language is not English

"4.  Contractor shall have a method of responding to telephone calls from non-English speaking OMAP Members and shall make available to these OMAP Member, interpreters capable of effectively receiving, interpreting and translating routine and clinical information."  Oregon Mental Health Contract, page 25.

Services for persons with speech, language, hearing, or vision related disabilities

"5.  Contractor shall have a method of responding to telephone calls from non-English speaking OMAP Members and shall make available to these OMAP Members, TDD services and sign language or oral interpreters capable of effectively receiving, interpreting and translating routine and clinical information.

6.  Contractor shall make reasonable Accommodations to administrative practices and services approaches to ensure service access and continuity of Care for OMAP Members with Disabling Conditions."  Oregon Mental Health Contract, page 25.

Cultural competence defined

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Culturally Competent: The Capacity to provide services in an effective manner that is sensitive to the culture, race, ethnicity, language and other differences of an individual. Such Services may include, but are not limited to, use of bilingual and bicultural staff, provisions of services in culturally appropriate settings, and use of bicultural paraprofessionals as intermediaries with professional staff."  Oregon Mental Health Contract, Appendix K, pages K1, K 5.

Emergency care

"2.  In access and continuity of care standards specified in the rules above in Subsection D.1, Contractor shall establish standards for access to Covered Services and Continuity of Care which at a minimum include the following:

a.  For Emergency Services, Contractor shall assure that 98% it's OMAP Members receive an initial face-to-face or telephone screening within 15 minutes of contact to determine the nature and the urgency of the situation.

b.  For Emergency Services, Contractor shall assure that 100% of it's OMAP Members receive timely Covered Services within time frames identified by the Urgent and emergency response screening or within 24 hours of contact, whichever is shorter…"  Oregon Mental Health Contract, page 24.

Medically necessary/acute care adult visits

"2.  In addition to access and continuity of care standards specified in the rules above in Subsection D.1, Contractor shall establish standards for access to Covered Services and Continuity of Care which at a minimum include the following: ...

d. For non-Urgent and non-Emergency services, Contractor shall assure that 95% of its OMAP Members wait no more than two calendar weeks following a request Covered Services for an intake, Assessment, and initiation of Covered Services.

e. For post-hospital appointments, Contractor shall assure that 95% of its OMAP Members wait no more than one calendar week for an appointment following discharge or that such OMAP Members receive follow-up appointments within a Medically Appropriate period of time."  Oregon Mental Health Contract, page 24.

Medically necessary/acute care pediatric visits

"2.  In addition to access and continuity of care standards specified in the rules above in Subsection D.1, Contractor shall establish standards for access to Covered Services and Continuity of Care which at a minimum include the following: ...

d.  For non-Urgent and non-Emergency services, Contractor shall assure that 95% of its OMAP Members wait no more than two calendar weeks following a request Covered Services for an intake, Assessment, and initiation of Covered Services.

e.  For post-hospital appointments, Contractor shall assure that 95% of its OMAP Members wait no more than one calendar week for an appointment following discharge or that such OMAP Members receive follow-up appointments within a Medically Appropriate period of time."  Oregon Mental Health Contract, page 24.

Urgent care

"2.  In addition to access and continuity of care standards specified in the rules above in Subsection D.1, Contractor shall establish standards for access to Covered Services and Continuity of Care which at a minimum include the following:

a.  For Urgent Services…Contractor shall assure that 98% it's OMAP Members receive an initial face-to-face or telephone screening within 15 minutes of contact to determine the nature and the urgency of the situation…

c.  For Urgent Services, Contractor shall assure that 95% of its OMAP Members receive timely services within time frames identified by the urgent and emergency response screening or within 48 hours of request, whichever is shorter."  Oregon Mental Health Contract, page 24.

For other benefits or services

"2.  In addition to access and continuity of care standards specified in the rules above in Subsection D.1, Contractor shall establish standards for access to Covered Services and Continuity of Care which at a minimum include the following: ...

g.  For routine travel time from the OMAP Member residence to the participating Provider, Contractor shall assure that 95% of its OMAP Members spend no more than the community standard."  Oregon Mental Health Contract, pages 24-25.

Anticipated need for health care

"IV.  Enrollment and Disenrollment
A.  Enrollment...
Contractor shall not discriminate in coverage or Enrollment against any eligible individual an the basis of…need for Covered Services…"  Oregon Mental Health Contract, page 4.

Disability

"IV.  Enrollment and Disenrollment
A.  Enrollment...
Contractor shall not discriminate in coverage or Enrollment against any eligible individual on the basis of…other Disabling Conditions."  Oregon Mental Health Contract, page 4.

Mental health status

"IV.  Enrollment and Disenrollment
A.  Enrollment...
Contractor shall not discriminate in coverage or Enrollment against any eligible individual on the basis of Mental health status…"  Oregon Mental Health Contract, page 4.

Other

"XXII.  Non Discrimination
Contractor shall comply Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1973, Part V of the Rehabilitation Act of 1973 as amended, The Americans with disabilities Act (ADA) of 1990, and all amendments to those Acts and all regulations promulgated thereunder. Contractor shall also comply with all applicable requirements of state civil rights and rehabilitation statutes and rules."  Oregon Mental Health Contract, page 49.

Child welfare

"f.  Acute Inpatient Hospital Psychiatric Care...
(4) Contractor shall coordinate admissions to and discharges from Acute Inpatient Hospital Psychiatric Care for OMAP Members in the  care custody of the state office for Services to Children and Families (SOSCF)…"  Oregon Mental Health Contract, page 16.

State/local mental health

"B.  Delivery System Configuration...
c.  Contractor shall coordinate its needs assessment and service delivery system planing efforts carried out by the Local Mental Health Authorities of its Service Area.

2.  Components of the Delivery System
a.  Services Coordination
(1) Contractor shall have written policies and procedures that ensure the provisions of Services Coordination for this OMAP Members with unique needs or requiring services from more than one Local and/or Regional Allied Agency.  Such policies and procedures shall be specific to these agencies."  Oregon Mental Health Contract, pages 11-12.

"3. Integration and Coordination...
b. Local Mental Health Authority (LMHA)/ Community Mental Health Program (CMHP)
Contractor shall establish working relationship with the LMHA and CMHP operating in the service area for the purpose of maintaining a comprehensive and coordinated crisis response and mental health services, including Civil Commitment and protective services/abuse investigations processes.

c.  Community Emergency Service Agencies
Contractor shall coordinate, consult, communicate with, and provide technical assistance to, Community Emergency Services to promote appropriate responses to, and assure Appropriate services for, OMAP Members experiencing a mental health crisis.

d.  Local and/or Regional Allied Agencies
Contractor shall have a mechanism for Multi-Disciplinary team service planning and Service Coordination for OMAP Members requiring service from more than one publicly funded agency or service provider."  Oregon Mental Health Contract, page 17.

Internal QA system

"E. Quality Assurance/Quality Improvement (QA/QI) Requirements
1.  QA/QI system
Contractor and its subcontractors shall have a planned, systematic and ongoing process for monitoring, evaluating , and improving the quality and Appropriateness of Covered Services provided to OMAP Members.

a.  Behavioral Health Accreditation Standards of the National Committee for Quality Assurance (NCQA).
This process shall be consistent with the following 1997 Behavioral Health Accreditation Standards of the NCQA...

b.  Division's Guide to Quality Assurance and to Quality Improvement.
The process shall be consistent with the Division's Guide to Quality Assurance and Quality Improvement.

c.  Stakeholder Input
Contractor shall have a formal and ongoing for gathering and considering information from Stakeholders…"  Oregon Mental Health Contract, page 26.

External review of plan's performance

"M.  Research, Evaluation and Monitoring
3. Contractor, or opts subcontractors, shall cooperate with its Division by providing access to records and facilities for the purpose of an external independent review of the quality of service provided under this agreement…"  Oregon Mental Health Contract, page 34.

"XXX.  Agreement Compliance and Quality Assurance Monitoring
A. Division shall conduct Agreement compliance and QA monitoring related to this Agreement . Contractor and its subcontractors shall cooperate in such monitorings and the Contractor shall notify its subcontractors and Participating Providers of such monitorings, related instructions and requests for information.

B.  Division shall provide Contractor 30 calendar days written notice of any action or cooperation by Contractor as specified in D. below...

C.  Notice of monitorings shall include the date the monitoring shall occur, names of individuals conducting the monitoring, and instructions and requests for information.

D.  Monitoring procedures may include, but are not limited to, the following:
1.  Entry and inspection of any facility used in the delivery of Covered Services;

2.  A request for Submission to the Division of copies of documents, or access to such documents during a site visit, as needed to verify compliance with this agreement or state and federal laws, rules and regulations;

3. The completion by Contractor of self assessment checklist or presite visit questionnaires recording the degree of compliance with the degree of compliance or noncompliance with specific agreements or rule requirements; and

4.  Conduct of interviews with, and administration of questionnaires to, Contractor staff,  Participating Providers, Health Care Professional, Local and /or Regional Allied Agencies, and Consumers knowledgeable of service operations.

E.  Contractor shall Cooperate with Divisions in the development of a corrective action plan to bring Contractors performance in compliance with this Agreement or state and federal laws, rules and regulations.

F.  Division shall make available to Contractor a written report of its findings and conclusions within 60 calendar days of the completion the monitoring."  Oregon Mental Health Contract, pages 53-54.

Corrective action plan

"E.  Quality Assurance/Quality Improvement(QA/QI) Requirements...
2.  Quality Improvement Work Plan
Contractor shall develop and submit to Division a written Quality Improvement Work plan within 30 days of the effective dates of this agreement.  Contractor shall obtain Division approval of such plan within three calendar months following the effective dates of this agreement.

a.  Contractor shall develop and monitor progress toward measurable Objectives, Indicators, and Benchmarks in the following domains: Access to Services; Quality of services; Integration and Coordination of Services; Prevention, Education, and Outreach; and Outcomes.

b.  Contractor shall work with Division to identify at least three activities to measure compliance with the applicable terms and requirements of this Agreement.

c.  Contractor shall submit a Quality Improvement workplan report describing process towards objectives and benchmarks 30 days after the termination of this agreement."  Oregon Mental Health Contract, pages 26-27.

"Contractor shall cooperate with Division in the development of a corrective action plan to bring Contractor performance in compliance with this Agreement or state and federal laws, rules and regulations."  Oregon Mental Health Contract, page 54.

Linkage between performance measures and service duties

"E.  Quality Assurance/Quality Improvement(QA/QI) Requirements...
3.  Measurable Objectives and Benchmarks
Contractor shall develop and monitor progress toward Measurable Objectives and Benchmarks in the above mentioned domains.  Contractor shall demonstrate that findings are used to improve access and remove barriers to Covered Services; improve Capacity to provide Covered Services in a timely manner; improve the quality of care provided and the coordination of benefits, and strengthen and expand prevention, Early Intervention and Education Services."  Oregon Mental Health Contract, page 27.

Access data

"K.  Reports
1.  Participating provider Listing and Capacity Report
Contractor shall submit to Division, one calendar month following the effective date of this agreement, the Mental Health Services Practitioner Report, as described in Exhibit A...

"MENTAL HEALTH SERVICES PRACTITIONER REPORT
1.  Contractor shall complete the Mental Health Services Practitioner Report and submit the report on a computer diskette using a spreadsheet format...

2.  Contractor shall list the name of each employed or contracted Health Care Professional providing Covered Services sorted by degree or license. Contractor shall include those employed persons whose duties may be administrative if such persons are responsible for oversight of clinical or Case Management activities; however, the amount of time recorded for such persons shall be limited to the proportion of time spent conducting clinical oversight or Case Management activities.

a.  Contractor shall indicate whether the Health Care Professional is a QMHP or QMHA as defined in Exhibit K, Definitions.

b.  Contractor shall list the specialty of each Health Care Professional.

c.  For employed Health Care Professionals, Contractor shall indicate the average number of hours worked each week over the last three months for Contractor..."  Oregon Mental Health Contract, Appendix A, page A1.

Complaints and grievances

"K. Reports...
2.  Complaint Log
a.  Contractor shall submit to Division, within 60 calendar days following the end of each calendar quarter, the Health Plan Compliant Log, included in Exhibit B.

b.  Contractor shall work with Division to establish a method to collect and analyze data concerning complaints and develop a method for the Contractors to integrate the information in Quality Improvement process."  Oregon Mental Health Contract, page 32.

"HEALTH PLAN COMPLAINT LOG
1.  Contractor shall collect information concerning OMAP Member Complaints filed with Contractor, its subcontractors, and its Participating Providers.

2.  Contractor shall complete and submit the Health Plan Complaint Log on a quarterly basis within 60 calendar days of the end of the calendar quarter...

3.  Contractor shall send these reports to Office of Mental Health Services Community Services…"  Oregon Mental Health Contract, Appendix B, page B1.

Encounter data

"L.  Data Systems
1.  Encounter Data
Contractor shall submit accurate and complete Encounter Data to Division through OMAP pursuant to Exhibit D, Encounter Minimum Data Set Requirements.  Contractor shall use the DSM-IV Multi Axial classification system inclusive of Axes I, II and V."  Oregon Mental Health Contract, page 33.

"ENCOUNTER MINIMUM DATA SET REQUIREMENTS
1.  General Provisions:
a.  Contractor shall submit data concerning OMAP Member Encounters as described in this Exhibit and using submission requirements established by OMAP.

b.  OMAP shall process Encounter data through the Medicaid Management  Information System(MMIS).  OMAP shall 'pend' all Encounters that cannot be processed because of missing or erroneous data...

c.  Timeliness
(1)  Contractor shall submit Encounter data to OMAP at least once per calendar month...

(3)  Contractor shall submit all corrections to pended Encounters to OMAP within 63 calendar days of the date that OMAP mails Contractor a notice that the Encounters were pended.

(4)  Contractor shall submit Encounter data for Covered Services known to have been provided to OMAP Members.  Contractor shall submit such Encounters regardless of the reimbursement method used, claim payment status (the claim was denied), placement on the Prioritized List of Health Services, or Third Party Resource Status.

d. Data Transmission and Format: ...
(2)  Contractor shall submit all data In a format approved by Division and OMAP.

(3)  Contractor may have another entity submit Encounter data on it's behalf, however, Contractor shall request approval of such arrangement from the Technical/ Encounter Data Services Subunit, Program Operations Unit, OMAP...

e.  Testing of Data Submission
(1)  Contractor shall work with Technical/Encounter Data Services Subunit, Programs Operation Unit, OMAP to test data submission and resubmission for each Encounter data format...

(3)  Contractor shall work with Division and OMAP in developing and testing the Encounter Data System to assure reporting of accurate data.

2.  Data Set Requirements...
b. Contractor shall submit the following identifying information for all Encounters:
(1) Contractor' OMAP Prepaid Health Plan Provider Number

(2) OMAP Member Name

(3) Medicaid Recipient Number, also known as the OMAP Prime Number.

c. For outpatient mental health Encounters, in addition to the identifying information listed in subsection 2.b., Contractor shall submit the following information…"  Oregon Mental Health Contract, Appendix D, pages D1-D2.

Financial data

"2.  Financial Records
Contractor shall maintain complete and legible financial records pertinent to Covered Services delivered and Capitation payments received. Such records shall be maintained in accordance with accounting principles approved by the American Institute of Certified Public Accountants, Generally Accepted Accounting Principles (GAAP), and/or other acceptable accounting guidelines. Financial records shall be retained for at least three years after final payment is made under this agreement or until all pending matters are resolved, whichever period is longer. Contractor shall maintain an appropriate record system for services to enroll members and retain records in accordance with 45 CFR part 74, unless otherwise specified in applicable Oregon Revised Statutes or Oregon Administrative Rules…

K.  Reports...
4.  Financial and Utilization Reports
Contractor shall submit to Division, monthly, quarterly, and yearly financial reports specified in Exhibit C, Solvency Plan and Financial Reporting."  Oregon Mental Health Contract,  pages 31-32.

"SOLVENCY PLAN AND FINANCIAL REPORTING...
4.  Contractor shall provide Third Party Resource collection information, using Report C2, Current OMAP Members with Third Party Resources (Quarterly Report), on a quarterly basis within 60 calendar days of the end of each calendar quarter...

5.  Contractor shall provide financial information, using Report C3, Quarterly Balance Sheet of MHO Contractor's Corporate Activity, on a quarterly basis within 60 days of the end of each calendar quarter...

6.  Contractor shall provide financial information, using Report C4, MHO Contractor's Quarterly Statement of Revenue, Expenses and Net Worth, on a quarterly basis within 60 calendar days of the end of each calendar quarter...

7.  Contractor shall also submit, within 180 days of the Contractors fiscal year, an annual audited financial statement that provides information reflected on Reports C3 and C4, and sets forth statements of opinion from an independent accounting firm about the Contractor financial statements based on its audit and about the assumptions and methods used in determining loss reserve, actuarial liabilities and related items...

8.  Contractor shall send these reports to Office of Mental Health Services Community Services…"  Oregon Mental Health Contract, Appendix C, page C2.

General authorization

"3.  Government Access to Records
Contractor shall provide Division, HCFA, the Comptroller General of the United States, the Oregon Secretary of State, OMAP and all their duty authorized representatives the right of access to facilities and to financial (including all accompanying billing records), clinical, and personnel records and other books, documents, papers, plans and writings of Contractor that are pertinent to this Agreement to perform examination and audits and make excerpts and transcripts. Contractor shall retain and keep accessible all such financial, clinical and personnel records and books, documents, papers, plans, and writings for a minimum of three(3) years, or such longer period as may be required by applicable law, following final payment and termination of this agreement, or until the conclusion any audit, controversy or litigation arising out of or related to the agreement, whichever date is later. Contractor shall upon request and without charge, provide a suitable work area and copying capabilities to facilitate such a review or an audit."  Oregon Mental Health Contract, pages 31-32.

"M.  Research, Evaluation and Monitoring
3.  Contractor, or its subcontractors, shall cooperate with its Division by providing access to records and facilities for the purpose of an external independent review of the quality of service provided under this Agreement…"  Oregon Mental Health Contract, page 34.

Utilization data

"SOLVENCY PLAN AND FINANCIAL REPORTING...
3. Contractor shall provide Utilization information, using Report C1, Mental Health Utilization Overview, on a monthly  basis within 90 calendar days of the end of each month...
8. Contractor shall send these reports to the Office of Mental Health Services Community Services…"  Oregon Mental Health Contract, Appendix C, page C2.

"DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Mental Health Information System(MHIS): The information system of the Division that includes the CPMS for community based services and the Oregon Patient/Resident Care System for inpatient and acute services. It provides a statewide registry and contractor registry for tracking service Utilization and contractor Capacity."  Oregon Mental Health Contract, Appendix K, pages K1, K13.

Other

"K.  Reports...
3.  QA Reports
Contractor shall negotiate with Division to identify and agree upon activities to be reported...

5.  Practitioner Incentive Plans
Contractor shall submit to Division information necessary to comply with Sections 4204(a) and 4731 of OBRA of 1990 that concern practitioner incentive plans, if applicable.  Such information shall be provided using repots specified in Exhibit I, Practitioner Incentive Plans.

6.  Abuse Reporting and Protective Services
For adult OMAP Members, Contractors and Participating Providers shall comply with all Protective Services, investigation , and reporting requirements described in OAR 309-040-0290, Abuse Reporting and Protective Services In Community Programs and Community Facilities and ORS 430.735 through 430.765, Abuse Reporting for Mentally Ill.

7.  Key Personnel
Contractor shall submit to Division, within thirty days following the effective date of this Agreement, and immediately following any changes, the names and contacts of the following key personnel: Contract Liaison, Quality Assurance/Improvement Liaison, Complaint and Hearing Liaison, and Long Term Psychiatric Care Liaison.

L.  Data Systems...
2.  Client Process Monitoring System
Contractor shall submit accurate, timely and complete Client Process Monitoring System (CPMS) data to Division pursuant to Exhibit E.

3.  Oregon Patient/Resident Care System
Contractor shall submit accurate, timely and complete Oregon Patient/Resident Care System (OP/RCS) data to Division pursuant to Exhibit E."  Oregon Mental Health Contract, pages 32-33.

"3.  Contractor's report shall include the following data elements:
a. Name of MHO
b. Report Date
c. County, or counties, to which this report applies"  Oregon Mental Health Contract, Appendix A, page A1.

"SOLVENCY PLAN AND FINANCIAL REPORTING...
4.  Contractor shall provide Third Party Resource collection information, using Report C2, Current OMAP Members with Third Party Resources (Quarterly Report), on a quarterly basis within 60 calendar days of the end of each calendar quarter…

8. Contractor shall send these reports to Office of Mental Health Services Community Services…"  Oregon Mental Health Contract, Appendix C, page C2.

"PREVENTION/DETECTION OF FRAUD AND ABUSE
Contractor shall have in place internal controls, policies or procedures capable of preventing and detecting fraud and abuse activities as they relate to the Oregon Health Plan. This may include operational policies and controls in areas such as complaint and grievance resolution, provider credentialing and contracting, provider and staff education, and corrective action plans to prevent potential fraud and abuse activities…If Contractor is also a Medicaid Contractor, the fraud and abuse policies established by Contractor to meet HCFA standards shall be deemed sufficient to meet the Divisions requirements for fraud and abuse prevention and monitoring...

6.  An incident with any of the referral characteristics listed above should be refereed to the MFCU, and other incident found to have characteristics which indicate fraud or abuse which Contractor has verified should also be refereed. Contractor may also refer cases of fraud and abuse to the MFCU...

8.  Incidents of verified or suspected fraud or abuse by an OMAP Member should be reported to the Adult and Family Services (AFS) Fraud Unit.

9.  Contractor shall promptly report all fraud and abuse as requires in this section."  Oregon Mental Health Contract, Exhibit J, pages J1-J2.

Hospitalization for mental illness

"OREGON PATIENT/RESIDENT CARE SYSTEM
The Oregon Patient/Resident Care System (OP/RCS) contains information on all consumers served at any of the three state psychiatric hospitals, two developmental disability training centers and nine psychiatric Acute Care facilities.

1.  Contractor shall cooperate with Division in establishing the electronic means to enter OP/RCS data at the hospital or facility providing Acute Inpatient Psychiatric Care services under this Agreement...

2.  Contractors or its subcontractors shall electronically submit, within 12 hours of admission to Acute Inpatient Hospital Psychiatric Care, OP/RCS information for Acute Inpatient Hospital Psychiatric Care services provided to adults as indicated in the following table…" Oregon Mental Health Contract, Exhibit F, pages F1-F2.

Other

"CLIENT PROCESS MONITORING SYSTEM
The Process Monitoring System(CPMS) tracks community-based treatment services for persons with mental illness, persons with developmental disabilities, and persons with substance abuse problems…This information allows the Division to manage publicly funded mental health services, respond to legislative inquiries, and demonstrate cost effectiveness under the federal requirement for the OHP Medicaid Demonstration Project and Children's Health Program.
1.  General Provisions:
a.  Contractor shall submit CPMS data for OMAP Members receiving Covered Services who meet one or more of the following conditions:
(1)  The OMAP Member is functionally impaired, as defined below, or would be at such risk for such impairment without Medication or support services.

(a)  Functional impairment shall be determined by the DSM-IV, Axis 5 Global Level of Level of Functioning (GAF) for adults and CGAS.

(b)  A GAF score of 1-60 shall result in an OMAP Member who is an adult or adolescent 18 or more years of age being  registered in the CPMS.

(c)  A CGAS score of 1-50 shall result in an OMAP Member who is a child or adolescent under 18 years of age being registered in the CPMS.

(2)  The OMAP Member has had nine or more mental health Encounters within 60 calendar days.

(3)  The OMAP Member is civilly committed to the custody of the Division under ORS 426.130."  Oregon Mental Health Contract, Exhibit E, page E1.

Reinsurance

"Solvency Plan and Financial Reporting...
1. Contractor shall protect itself against excessive loss by either self-insuring or by obtaining stop-loss protection from a private insurer in an amount sufficient to cover estimated risk for the duration of this agreement. Contractor shall provide proof of such coverage to Division within 30 days following the start of this Agreement."  Oregon Mental Health Contract, Exhibit C, page C1.

Reserve

"I.  Financial Risk, Management and Solvency...
Contractor shall maintain sound financial management consistent with OAR 410-141-0340, Oregon Health Plan Prepaid Health Plan Financial Solvency and shall maintain protection against Insolvency, as specified   in Exhibit C, Solvency Plan and Financial Reporting. If Contractor expects to change any elements of the solvency plan or solvency protection arrangements, Contractor shall provide written advance notice to Division at least 60 calendar days before the proposed effective date of change…" Oregon Mental Health Contract, page 30.

"SOLVENCY PLAN AND FINANCIAL REPORTING...
2.  Restrictive Reserve Fund
a. Contractor shall maintain a Restricted Reserve Fund balance equal to $250,000 and provide evidence of the required restricted reserve account balance to Division within 60 calendar days of the end of each calendar quarter. Contractor shall identify where and by whom the restricted account is held.

b.  If Contractor subcontractor any work to be performed under this Agreement using a capitated reimbursement arrangement, Contractor may choose to require it's subcontractor to maintain a Restricted Reserve Fund for its portion of the risk assumed or may maintain a Restricted Reserve Fund for all risk assumed under this Agreement. Regardless of the choice made, Contractor shall assure that the Combined total Restricted Reserve Fund balance meets the requirements of this Agreement.

c.  If the Restricted Reserve Fund is held in a combined account or pool with other entities, Contractor…shall provide a statement from the pool or account manager that the Restricted Reserve Fund is available to the Contractor, or its subcontractor as applicable, and has not been obligated elsewhere.

d.  If Contractor shall use its Restricted Reserve Fund to finance Covered Services, Contractor shall provide advance written notice to Division of the amount to be withdrawn, the reason for withdrawal, when and how the Restricted Reserve Fund will be replenished, and steps to be taken to avoid the need for future Restricted Reserve Fund withdrawals.

e.  Contractor shall provide Division access to its Restricted Reserve Fund if Insolvency occurs."  Oregon Mental Health Contract, Exhibit C, page C1.

MIS requirements

"5.  Other Systems
Contractor shall have automated capacity adequate to track changes to and errors in the Enrollment listing; track utilization Management activities; coordinate benefits with other payers; collect funds from other payers; and track claims received, adjudicated and paid."  Oregon Mental Health Contract, page 34.

Internal grievance process

"H.  Complaints and MHDDSD Hearing Process
Contractor shall submit to the Division for review and approval, by the effective date of this Agreement, written Grievance and Complaints procedure for accepting, processing and responding to all Complaints from Family Members, Local and/or Regional Allied Agencies, and OMAP Members. Contractor shall also submit the Member Complaint Form and Notice of Denial letter to the Division for review and approval.

Contractor shall include on its complaint form places for the OMAP Member or OMAP Member representative to indicate a request for benefit continuation when a Notice of Intended Action has been issued, a request for an expedited process, and the reason for an expedited request. The complaint form shall also provide notice that any benefits continued may have to be paid by the OAP Member if the issue is resolved in the favor of the contractor. Contractor shall also handle OMAP Member complaints consistent with Exhibit G, Oregon Health Plan Mental Health Services Complaint and Hearing Process."  Oregon Mental Health Contract, page 30.

"OREGON HEALTH PLAN MENTAL HEALTH SERVICES CLIENT NOTICES, COMPLAINT AND HEARING PROCESS
1.  Client Notices
a.  Contractor shall issue a written Notice of Action or Notice of Intended Action, in a form meeting the OMAP Member's special needs, to the OMAP Member or OMAP Member Representative, each time a service or benefit will be terminated, suspended or reduced, or each time the request for service authorization or request for claim payment is denied...

b.  A Notice of Action or Notice of Intended Action shall inform the OMAP Member of the following: ...

c. The OMAP Member or OMAP Member Representative who files a complaint or requests a hearing concerning a termination, suspension or reduction in services, shall receive a written decision from the MHO that denied the service...

f. Contractor shall make available in all clinics frequented by OMAP Members information concerning client notices, complaints and hearing processes.

2. Hearing Process
Contractor shall have the following responsibilities in resolving disagreement with OMAP Members and/or OMAP Member Representatives:

a.  Have written procedures for accepting, documenting, processing, analyzing, resolving and responding to all complaints made and MHDDSD Hearings requested by OMAP Members or OMAP Members Representatives

b.  Designate staff members to handle Complaints received and MHDDSD Hearings requested by OMAP Members or OMAP Members or OMAP Members Representatives...

c.  Have a method of informing its participating providers of the Complaint and MHDDSD Hearings procedures, monitoring Participating Providers compliance with such procedures, and taking corrective action to assure Participating Providers compliance with procedures and reporting requirements.

d.  Have a method of informing OMAP Members about Complaint and MHDDSD Hearings procedures...

g.  Have a provision for reviewing the internal Complaint and MHDDSD Hearings processes.

h.  Retain the following documents regarding Complaints and MHDDSD Hearings in a central location: ...

i. Afford OMAP Members or OMAP Member Representatives the full use of the complaint and MHDDSD Hearing procedures without penalty.

j. Cooperate with Division and/or DHR and the OMAP Member or OMAP Member Representative in seeking a remedy to Complaint and MHDDSD Hearing issues...

k. Cooperate in the MHDDSD Hearing process and make available…all persons with relevant information and all pertinent files and Clinical Records.

l.  Continue benefits until a decisions rendered about the Complaint or MHDDSD Hearing issue when an OMAP Member Representative files a Complaint or requests a MHDDSD Hearing before the effective date of intended action and requests a MHDDSD Hearing before the effective data of intended action and requests that benefits be continued...

3. Procedures for complaints...
c. The Complaint shall be handled as described below when the OMAP Member or OMAP Member Representative has made a complaint but has not requested a MHDDSD Hearing about the Complaint issue...

d. The Complaint shall be handled as described below when the OMAP Member or OMAP Member Representative has made a Complaint and requested a MHDDSD Hearing before receiving a decision about the Complaint issue...

4.  Procedure for MHDDSD Hearings
a.  If the MHDDSD Hearing issue involves a Notice of Action, Notice of Intended Action or a decision about a complaint, the OMAP Member or OMAP Member Representative must request a hearing with the Division within 45 days of the date of the Notice of Intended Action or written decision regarding a Complaint...

b. Upon receipt of the Administrative Hearing Request (form AFS 443), the receiver shall forward it and any documentation related to the MHDDSD Hearing issue to the Division Representative and AFSD Hearings Unit.

c.  The Division Representative shall review the Administrative Hearing Request, documentation related to the MHDDSD Hearing issue, and computer records to determine whether the claimant or the person for whom the request is being made is an OMAP Member; whether the hearing request was timely…"  Oregon Mental Health Contract, Exhibit G, page G1-G7.

Expedited grievance process

"G. OMAP Member Rights...
2. Contractor shall assure that OMAP Members receive information on the rights specified in the OAR 410-141-0320, Oregon Health Plan Prepaid Health Member Rights and Responsibilities. Contractor shall give particular attention to the following rights: ...
l. The right to request an Expedited Hearing if the OMAP Member feels the mental health problem is urgent or emergent and cannot wait for the normal hearing process…"  Oregon Mental Health Contract, pages 28-29.

"H.  Complaints and MHDDSD Hearing Process...
Contractor shall include on its complaint form places for the OMAP Member or OMAP Member representative to indicate a request for benefit continuation when a Notice of Intended Action has been issued, a request for an expedited process, and the reason for an expedited request..."  Oregon Mental Health Contract, page 30.

"OREGON HEALTH PLAN MENTAL HEALTH SERVICES CLIENT NOTICES, COMPLAINT AND HEARING PROCESS...
b. A Notice of Action or Notice of Intended Action shall inform the OMAP Member of the following: ...
(4)  The method by which the OMAP Member may obtain a hearing; or in the event the OMAP Member feels the mental health problem cannot wait for the normal hearing process, how to request an Expedited Hearing...

3. Procedure for Complaints...
(2)  The OMAP Member is only entitled to an expedited Complaint if the mental status of the OMAP Member meets the definition of an Emergency Situation or Urgent Situation and the situation cannot wait to be addressed within the time frames associated with a regular Complaint.

(3) If the OMAP Member's situation is consistent with criteria described above in Section(2), the OMAP Member or OMAP Member Representative may request an expedited Complaint process by indicating such in place provided on the Complaint form and then why a decision is needed right away...

5. Expedited Complaints and MHDDSD Hearings
a. An OMAP Member is entitled to an expedited Complaint or MHDDSD Hearing if the mental status of the OMAP Member meets the definition of an Emergency Situation or Urgent Situation and the situation cannot wait to be addressed within the time frames associated with a regular Complaint or MHDDSD Hearing. The OMAP Member or OMAP Member Representative must request an expedited Complaint or MHDDSD Hearing and provide information justifying such a request.

b.  Upon receipt of an expedited Complaint or MHDDSD Hearing request, the Contractor Representative…shall immediately notify other payors with an interest in the issue and begin collecting relevant documents. Any delay in receipt of records shall extend the time period for making a decision about the need for an expedited resolution. The extension shall equal the delay in receiving records.

c.  The Contractor Representative shall forward, as soon as available, the information collected to the Contractor Clinical Director and MHDDSD Medical Director, or designees of the said directors...

d.  The Contractor Clinical Director and the MHDDSD Medical Director, or designees of said directors shall, within two working days of receiving Clinical Records, review documentation received to determine if mental status of he OMAP Members meets the definition of Emergency Situation or Urgent Situation.  The Contractor Clinical Director and MHDDSD Medical Director shall discuss their findings and attempt to come to an agreement. If agreement cannot be reached, the decision of the MHDDSD Medical Director shall be final...

g. If an expedited Complaint or MHDDSD Hearing has been granted, the following shall occur:
(1)  For an expedited Complaint, the Contractor Representative shall convene a Complaint review group to address the Complaint within five working days of the receipt of the expedited Complaint.

(2)  For an expedited MHDDSD Hearing, the AFSD Hearing officer or the MHDDSD Hearing officer shall conduct the MHDDSD Hearing as described In Sections (2) and (3) of OAR 461-025-0315, Expedited Hearings and all parties to the expedited MHDDSD Hearing issue shall prepare for the MHDDSD Hearing."  Oregon Mental Health Contract, Exhibit G, pages G1, G4, G10-G11.

External appeal to state

"OREGON HEALTH PLAN MENTAL HEALTH SERVICES CLIENT NOTICES, COMPLAINT AND HEARING PROCESS
1.  Client Notices...
b. A Notice of Action or Notice of Intended Action shall inform the OMAP Member of the following: ...
(3) The OMAP Member's right to file a complaint with the Contractor and request an Administrative Hearing with the Division...
(4) Procedures for MHDDSD Hearings...

2. Hearing Process
Contractor shall have the following responsibilities in resolving disagreement with OMAP Members and/or OMAP Member Representatives: ...
i. Afford OMAP Members or OMAP Member Representatives the full use of the complaint and MHDDSD Hearing procedures without penalty.

j. Cooperate with Division and/or DHR and the OMAP Member or OMAP Member Representative in seeking a remedy to Complaint and MHDDSD Hearing issues...

k. Cooperate in the MHDDSD Hearing process and make available…all persons with relevant information and all pertinent files and Clinical Records.

l.  Continue benefits until a decisions rendered about the Complaint or MHDDSD Hearing issue when an OMAP Member Representative files a Complaint or requests a MHDDSD Hearing before the effective date of intended action and requests a MHDDSD Hearing before the effective data of intended action and requests that benefits be continued...

4.  Procedure For MHDDSD Hearings...
a.  If the MHDDSD Hearing issue involves a Notice of Action, Notice of Intended Action or a decision about a complaint, the OMAP Member or OMAP Member Representative must request a hearing with the Division within 45 days of the date of the Notice of Intended Action or written decision regarding a Complaint...

b.  Upon request of the Administrative Hearings Request (form AFS 443), the receiver shall forward it and any documentation related to the MHDDSD Hearing issue to the Division Representative and AFSD Hearings Unit.

c.  The Division Representative shall review the Administrative Hearings Request, documentation related to the MHDDSD Hearing related issue, and computer records to determine whether the claimant or the person for whom the request is being made is an OMAP Member; whether the hearing request was timely (requested within 45 calendar days of the Notice of Action, Notice of Intended Action or a decision about a Complaint; and whether continuation has been requested…"  Oregon Mental Health Contract, Exhibit G, page G1, G7.

Provider selection standards

"V.  Statement of Work
A.  Benefit Package...
1.  Flexible Services...
b. If the provider rendering a Flexible Service is not licensed or certified by a state board or licensing agency, or employs personnel to provide the service who do not meet the definition for Qualified Mental Health Associate (QMHA) or Qualified Mental Health Professional (QMHP) as described in Exhibit K, Definitions, Contractor shall insure such provider meets criteria described in item 1.a. (2) of Section V, Statement of Work, Subsection N, Credentialing Process."  Oregon Mental Health Contract, page 6.

"f. Acute Inpatient Psychiatric Care
(1) ...If Contractor uses hospitals other than those under contract with Division, then Contractor shall assure that the hospitals selected comply with OAR309-032-0850 through OAR 309-032-0890, Standards for Regional Acute Care Facilities for Adults."  Oregon Mental Health Contract, page 16.

"N. Credentialing Process
Contractor shall have policies and procedures for collecting evidence of credentials and screening the credentials of providers, programs and facilities used to deliver Covered  Services. These policies and procedures shall be consistent with OAR 410-141-0120, Oregon Health Plan Prepaid Health Plan Provision of Health Care Services and shall include validating possession of in force licenses or certificates if any are required under any federal, state, or local law, rule, or regulation to deliver Covered Services in the State of Oregon. These policies and procedures shall also include collecting of proof of liability insurance and evidence of hospital privileges of physicians rendering services in an Acute Inpatient Hospital Psychiatric Care setting.

A.  If participating Providers are not required to be licensed or certified by a state of Oregon board or licensing agency, then Contractor shall either:
(1)  Ensure such participating providers meet the definitions for QMHA or QMHP as described in Exhibit K, Definitions and provide services under the supervision of a Licensed Medical Practitioner (LMP) as defined in Exhibit K, Definitions; or

(2)  For participating Providers not meeting either the QMHP or QMHA definition, Contractor shall document and certify that the person's education, experience, competence, and supervision are adequate to permit the person to perform his or her specific assigned duties.

b.  Contractor shall ensure that all programs operated directly or by subcontract are accredited by nationally recognized organizations … and/or are certified under OAR 309-012-0130 et. Seq. or licensed under OAR chapter 443 by the state of Oregon to deliver specified services...

c.  Contractor shall assure that all facilities used to deliver Covered Services, either directly or through subcontract, are certified or licensed as described in Section V, Statement of Work, Subsection N, Credentialling Process, Item 1.b. by the state of Oregon to deliver specified services…safe and adequately staffed for Covered Services provided.

d.  Contractor shall periodically check to ensure that participating Providers and programs are credentialed as specified above."  Oregon Mental Health Contract, pages 35-36.

Stop-loss insurance for providers

"O.  Delegation of Activities...
6.  Contractor shall notify Division in writing of work under this Agreement to be subcontracted.  Contractor shall ensure that all subcontracts meet the requirements described below...

g.  In cases where the subcontractor has assumed any Risk covered under this Agreement, contain a provision that the subcontractor must protect itself against loss by either self-insuring or providing proof of Reinsurance…"  Oregon Mental Health Contract, pages 37- 38.

"Practitioner Incentive Plans...
6.  Contractor shall ensure that all practitioners and practitioner groups determined to be at substantial financial risk have either aggregate or per OMAP Member Stop Loss Protection in accordance with the following requirements:
a.  if aggregate Stop Loss Protection is provided, Contractor shall cover 90 percent of referral service costs (beyond allocated amounts) that exceed 25 percent of potential earnings of the practitioner or practitioner group; or

b. if per patient Stop Loss Protection is provided, Contractor shall provide Stop Loss Coverage based on patient size as reflected in the following table:

Patient Panel Size...Per Patient Stop Loss Limit
Less than 1,000...  $10,000
1,000 to 10,000...$30,000
10,001 to 25,001...$200,000
More than 25,000(No Pooling)...No Specification
More than 25,000(Pooling)...$200,000"  Oregon Mental Health Contract, page I3.

Prohibition on plan delegation of liability to subcontractor

"O.  Delegation of Activities
Contractor is responsible for the quality of care and services provided under the terms and requirements of this Agreement.  Subject to the provisions of this section, Contractor may subcontract any or all of the work to be performed under this Agreement.  No subcontract shall terminate or limit Contractor's legal responsibilities to Division for the timely and effective performance of its duties and responsibilities under this Agreement." Oregon Mental Health Contract, page 37.

Restrictions on physician incentive agreements

"K.  Reports...
5.  Practitioner Incentive Plans
Contractor shall submit to Divisions information necessary to comply with Sections 4204(a) and 4731 of OBRA of 1990 that concern practitioner incentive plans, if applicable. Such information shall be provided using reports specified in Exhibit I, Practitioner Incentive Plans."  Oregon Mental Health Contract, pages 32-33.

"PRACTITIONER INCENTIVE PLANS
1.  Contractor shall comply with all requirements of this Exhibit to ensure compliance with s 4204 (a) and 4731 of the OMNIBUS Reconciliation Act of 1990 that concern practitioner incentive plans. The purpose of this act is to ensure that OMAP Members are not being denied access to Medically Appropriate referral services based on financial incentives. Contractor shall not set into place any financial incentives which reduce or limit provisions of Covered Services to OMAP Members as specified in this Agreement.

2.  Contractor shall comply and submit to Division Report I 1: Practitioner Incentive Plan Disclosure, under the following circumstances: ...

3.  Contractor shall provide to any OMAP Member who requests it the following information: ...

4.  If Contractor practitioner incentive plans meet the definitions appearing in Report I 1: Practitioner Incentive Plan Disclosure, Contractor shall complete and submit to Division, as of the effective date of this Agreement and at least 45 calendar days before the effective date of changes to the practitioner incentive plans, Report I 2: Practitioner Incentive Plan Detail. Division shall use information reported to determine whether Contractor incentive arrangements place the practitioner or practitioner group at risk for amounts beyond a specified threshold.

a.  Risk threshold means the maximum risk to which a practitioner or a practitioner group may be exposed under a practitioner incentive plan without being at substantial financial risk. It applies to incentive arrangements involving referral services. The specified risk threshold is set at 25 percent of potential earnings of the practitioner or practitioner group.

b.  Substantial financial risk applies to those practitioners and practitioner groups with patient panel size 25,001 OMAP Members or a patient panel size of more than 25,000 OMAO Members as a result of pooling OMAP Members...

c.  An arrangement shall be determined as causing substantial financial risk under the following circumstances:
(1)  Withholds are  greater than 25 percent of the maximum anticipated total incentive payments (salary, Fee-For Service payments, Capitation Payments, returned withhold and bonuses);

(2)  Withholds less than 25 percent of potential payments if the practitioner or practitioner group is potentially liable for amounts exceeding 25 percent of potential payments;

(3)  Bonus that are greater than 33 percent of potential payments minus the bonus;

(4)  Withholds plus bonuses if this sum equals more than 25 percent of potential payments.  The threshold bonus percentage for a particular withhold percentage may be calculated using this formula: ...

(5)  For Capitation arrangements, if the difference between the maximum possible payments is more than 25 percent of the maximum possible payments; or the maximum and minimum possible payments are not clearly explained in the practitioner's or  practitioner group's contract; and

(6)  Any other incentive arrangements that have a potential to hold a practitioner or practitioner group liable for more than 25 percent of potential payments.

5.  If Contractor is found to have referral incentive arrangements which place its practitioners or practitioner groups at substantial financial risk, Contractor shall conduct a survey of OMAP Members to address satisfaction with the quality of services provided and degree of access to the services...

6.  Contractor shall ensure that all practitioner groups determine to be at substantial financial risk have either aggregate or per OMAP Member Stop Loss Protection in accordance with the following requirements: ...

7.  HCFA may impose a penalty of up to $25,00 in addition to or in lieu of other remedies available under law if HCFA determines that Contractor either misinterpreted or falsified information furnished to Division or an OMAP Member…"  Oregon Mental Health Contract, Exhibit I, pages I1-I3.

Restrictions on provider communications with enrollees

"V. Statement of Work...
2.  Provision of Covered Services…
g.  Contractor may not prohibit or otherwise limit or restrict a mental health care professional (acting within the scope practice) from advising an OMAP Member about their mental health care status or about medical care or treatment, regardless of the whether the Contractor provides benefits for the particular type of care or treatment."  Oregon Mental Health Contract, page 8.

Scope of duties delegated to subcontractors

"O.  Delegation of Activities...
Subject to the provisions of this section, Contractor may subcontract any or all of the work to be performed under this Agreement...

2.  Contractor shall have a written Agreement that specifies the delegated activities and reporting responsibilities of the subcontractor. Contractor shall notify the Division in writing of subcontractor and activities to be delegated.

3.  The following requirements of the MHO Agreement may not be delegated:
a.  Oversight and Monitoring of QA/QI Activities;

b.  Adjudication of Final Appeals in a Member Complaint and Grievance Process; and

c. Service Delivery Needs Assessment

4.  Contractor's agreement with the subcontractor shall provide for the revocation of the delegation or imposition of other sanctions if the performance of the subcontractor is inadequate to meet the requirements of the MHO Agreement...

6.  Contractor shall notify Division in writing of work in this agreement to be subcontracted. Contractor shall ensure that all subcontracts meet requirements described below and shall incorporate portions of this Agreement, as applicable, based on the scope of work to be subcontracted.
a.  Be in writing and incorporate each applicable requirement of this Agreement...

b.  Clearly identify the work to be performed by the subcontractor and what of that work, if any, the subcontractor may further subcontract.

c.  Ensure that the requirements of 42 CFR part 434 that are appropriate to the services or activity required under the subcontract are fulfilled.

d.  Contain a provision that the subcontractor shall not bill, charge, seek compensation, remuneration or reimbursement from, or have recourse against Division or any OMAP Member for Covered Services provided during the period for which Capitation payments were made by the Division through OMAP to Contractor with respect to said OMAP Member, even if Contractor becomes insolvent.

e.  Contain a provision that the subcontractor shall continue to provide Covered Services during periods of Contractor Insolvency or cessation of operations through the period for which Capitations payment were made to the contractor.

f.  Contain a  provision requiring the subcontractor to follow OAR 410-141--0420-, Billing and Payment Under the Oregon Health Plan, when submitting Fee-For-Service claims for Oregon Health Plan services provided to OMAP members that are not Covered Services.

g.  In cases where the subcontractor has assumed any Risk covered under this Agreement, contain a provision that the subcontractor has to protect itself against loss by either self-insuring or providing proof of Reinsurance and by maintaining a Restricted Reserve Fund as described in Exhibit C, Solvency Plan and Financial Reporting.

h.  If Contractor chooses to delegate the Complaints and Grievance process, Contractor shall require the subcontractor to have a written policies and procedures for accepting, processing and responding to all Complaints and Grievances...

i.  Contain a provision that data used for analysis of delivery system Capacity, Consumer satisfaction, and financial solvency, and Encounter, client process monitoring, and Acute Inpatient Psychiatric Care admission data submission must be provided to Contractor within time frames sufficient to allow Contractor to meet reporting requirements described in Exhibit A...

j. Contain a provision that requires the subcontractor to have a planned, systematic and ongoing process for monitoring, evaluating and improving the quality and Appropriateness of Covered Services provided to OMAP Members.

k.  Contain a provision that requires the subcontractor to participate in QA and QI activities of Contractor, or those of the Division if requested to do so.

l.  Contain a provision that requires the subcontractor to provide access to records and facilities as described in OAR 410-141-0180, Oregon Health Plan Prepaid Health Plan Recordkeeping...

m.  Contain a provision that requires the subcontractor to cooperate withal  processes and procedures of abuse reporting, investigations, and protective services…"  Oregon Mental Health Contract, pages 37-39.

Adjustment in payment

"E.  Settlement of Accounts...
Division through OMAP shall have no obligation to make any payments to Contractor for any period(s) during which Contractor substantially fails to carry out the terms of this Agreement. Any payments received by Contractor from Division through OMAP for such periods, and any other payments received by the Contractor from Division through OMAP to which Contractor is not entitled under the terms of this Agreement, shall be considered an overpayment and shall be recovered from Contractor.  Any Capitation Payment received by Contractor which are considered an overpayment may be offset by any future payments to which Contractor will be entitled under OMAP or Division rules for any Covered Services provided by Contractor."  Oregon Mental Health Contract, pages 41-43.

Liquidated/exemplary damages

"Practitioner Incentive Plans...
7.  HCFA may impose a penalty of up to $25,000 in addition to or in lieu of other remedies available under law if HCFA determines that the contractor either misrepresented or falsified information furnished to Division or an OMAP Member…"  Oregon Mental Health Contract, Exhibit I, page I 3.

Termination

"B.  This Agreement may be terminated under any of the following conditions: ...
2.  Division may also terminate this Agreement effective upon delivery of written notice to Contractor, or at such later date as may be established by Division, as set forth elsewhere in this Agreement, or under any of the following conditions: ...

b.  If federal or state regulations or guidelines or HCFA waiver terms are modified, changed or interpreted in such a way that the services are no longer allowable or appropriate for purchase under this Agreement or are no longer eligible for the funding proposed for payments under this Agreement.

c.  If any license, registration or certificate required by law or regulation to be held by the Contractor or Contractors subcontractors or Participating Providers to provide Covered Services is for any reason denied, revoked, or not renewed.

d.  If Division determines that the health or welfare of OMAP Members is in jeopardy should this Agreement continue.

e.  If Contractor fails to provide services called for by this Agreement; fails to perform any other provisions of this Agreement within the time specified or any extension thereof; or fails to pursue the work of this Agreement in accordance with its terms; and such failure continues for ten(10) calendar days, or such longer period as Division may authorize, after Contractor's receipt of written notice thereof.

f.  If Contractor fails to perform or otherwise comply with any provision contained in Section V, Statement of Work.

g.  If a Contractor is a fully Capitated Health Plan(FCHP) and no longer provides services under the OHP Medicaid Demonstration Project in all of the countries listed in Part I, Section III.B., Service Area, pursuant to its FCHP service Area, pursuant to its FCHP service agreement with the Office of Medical Assistance Programs(OMAP).

h.  If Contractor is a County Government (or a group of counties acting through a lead county under ORS Chapter 190…and no longer operates or contracts for CMHPs…" Oregon Mental Health Contract, pages 55-56.

Withholding of capitation

"L. Data Systems...
4.  Failure to Comply with Data Submission Requirements
Contractor's failure to submit data in accordance with Exhibits D through F shall be considered noncompliance with the terms of this Agreement and shall be grounds for withholding Capitation Payments…"  Oregon Mental Health Contract, page 33.

"VII. Consideration
A.  Payment Types and Rates
In  consideration of all work to be performed by Contractor under this Agreement, Division through OMAP shall pay Contractor a monthly Capitation Payment for each OMAP Member…Where the date of an OMAP Member's Enrollment or Disenrollment is during mid-month, the Capitation Payment for that OMAP Member shall be prorated. The Division may withhold payment for new enrollees when, and for so long as, Division determines the Contractor meets the circumstances cited in 42 CFR 434.67…"  Oregon Mental Health Contract, pages 40-41.

Other

"G.  Remedies Short of Termination
Whenever Division, in its sole judgement, determines that Contractor is out of compliance with this Agreement, Division may, at its discretion take Remedial Action. Division shall issue a notice of intended Remedial Action which provides, in non-Emergency situations, at least 30 calendar days notice prior to the effective date of Remedial Action, and in Emergency Situations, at least seven(7) calendar days notice prior to the effective date of Remedial Action. Contractor may request an Administrative review concerning the Notice of Intended Remedial Action and may also request suspension of the Remedial Action until a decision is reached through the  administrative review process.  To receive suspension of the intended Remedial Action, Contractor must request an administrative review before the effective date of the intended Remedial Action and include a request to suspend the intended Remedial Action. If the intended Remedial Action is suspended and a decision is reached in favor of Division, Division may impose the Remedial Action retroactively to effective date stated in the Notice of Intended Remedial Action."  Oregon Mental Health Contract, pages 43-44.

Premium includes all covered services

"VII. Consideration...
B.  Payment in Full
The Consideration listed in Exhibit L plus any Reimbursement for LTPC described in Section VII.F. below is the total consideration payable to Contractor for all work under this Agreement."  Oregon Mental Health Contract, pages 40-41.

Fee-for-service for some or all covered services

"D. Timing of Capitation Payment...
All Fee-For-Service(FFS) claims must be billed by Contractor, its subcontractor, or its Participating Providers directly in accordance with OAR 410-141-0420, Billing and Payment Under the Oregon Health Plan. Billing providers must be enrolled with OMAP in order to receive payment. Contractor shall not submit any FFS claims for any Covered Services provided to OMAP Members."  Oregon Mental Health Contract, page 42.

"F.  Long Term Psychiatric Care
1.  Compensation
Division shall use one of the methods  listed below to reimburse Contractor for Acute Inpatient Hospital Psychiatric Care or other inpatient services costs for OMAP Members determined by Division or the clinical Reviewer to be Appropriate for LTPC…
a.  Division shall reimburse Contractor for actual costs incurred; or

b.  If Contractor has a declining daily rate of reimbursement arrangement with the hospital for Acute Inpatient Hospital Psychiatric Care as stipulated by the contract, Division shall reimburse Contractor at the daily rate negotiated with the hospital for the provision of LTPC services or the daily rate paid to the hospital on the last day the OMAP Member is Appropriate for Acute Inpatient Hospital Psychiatric Care;

In no case shall the reimbursement by the Division under Section VII, Consideration, Section F, Long Term Psychiatric Care, Subsection F.1.a. or F.1.b. of compensation be greater than $800 per day."  Oregon Mental Health Contract, page 43.

"E.  In the event of termination of this Agreement, the following provisions apply: ...
3.  All terminations shall include a final accounting of Capitation Payments received and OMAP Members enrolled during the month in which termination is effective and shall be accomplished as follows: ...

b.  Responsibility for Claims…
Contractor shall promptly notify Division through OMAP of any outstanding claims for which Division may owe, or be liable for, a Fee-For-Service payment, which are known to Contractor at the time of termination or when such new claims incurred prior to termination are received…" Oregon Mental Health Contract, page 58.

Withholding of payments

"L. Data Systems...
4.  Failure to Comply with Data Submission Requirements
Contractor's failure to submit data in accordance with Exhibits D through F shall be considered noncompliance with the terms of this Agreement and shall be grounds for withholding Capitation Payments…"  Oregon Mental Health Contract, page 33.

"VII. Consideration
A.  Payment Types and Rates
In  consideration of all work to be performed by Contractor under this Agreement, Division through OMAP shall pay Contractor a monthly Capitation Payment for each OMAP Member…Where the date of an OMAP Member's Enrollment or Disenrollment is during mid-month, the Capitation Payment for that OMAP Member shall be prorated. The Division may withhold payment for new enrollees when, and for so long as, Division determines the Contractor meets the circumstances cited in 42 CFR 434.67…"  Oregon Mental Health Contract, pages 40-41.

State delegation of third party liability collection

"X.  Third Party Resources
A.  Notice to Health Insurance Group
Contractor shall notify the Health Insurance Group, Third Party Recovery Unit, Adult and Family Services Division(ASDF) within thirty(30) calendar days from the time that Contractor learns that an OMAP Member might have other health insurance...

B.  Secondary Payor Status and Retroactive Disenrollment
Contractor is secondary payor when the OMAP Member is covered by another health insurance policy...

C. Collection of Third Party Resources
Contractor may require OMAP Members to cooperate in securing payment from the Third Party Resources (TPR), including liability insurance, but may not require OMAP Members to file a claim other than for personal injury protection coverage. To the extent permitted by law, Contractor shall make a reasonable effort to identify and pursue such TPR without regard to any Capitation Payments received by Contractor under this Agreement. Contractor shall have a system for obtaining timely assignment of the rights to Recovery or the assignment of lien rights from the OMAP Member and/or provider as necessary to effectively pursue TPR claims.  If Contractor is unable to gain cooperation from the OMAP Member in pursuing the TPR, Contractor shall notify the AFSD's Third Party Recovery Unit of the OMAP Member's refusal to cooperate...

E.  Claims Processing
Contractor may not refuse payment on Valid Claims based solely Contractor's belief that there may be potential TPR, absent documentation of potential TPR. If a Provider cannot obtain recovery from the TPR, Contractor shall not delay payment to the provider.

F.  Accounting For Third Party Collections
Contractor shall be responsible for maintaining records in such a manner so as to ensure that all monies collected from TPR on behalf of OMAP Members may be identified and reported to Division in accordance with Exhibit C, Solvency Plan and Financial Reporting. Contractor shall also keep records third party recovery efforts that are not successful. Contractor shall make these records available for audit and review consistent with the provisions of this Agreement.

G. Third Party Recoveries
Contractor shall pursue third party recovery during this Agreement period pursuant to the requirements of this Agreement, federal and state law, rules and regulations.  The Capitation rate(s) in this Agreement are based, in part, on projected third party recoveries. Contractor's failure to submit third party recovery data and/or pursue recoverable third party recovery obligation during this Agreement may create a claim for reimbursement to the extent required by federal law."  Oregon Mental Health Contract, pages 44-46.

"SOLVENCY PLAN AND FINANCIAL REPORTING...
4 ...Contractor shall make reasonable efforts to identify and pursue such Third Party Resource without regard to any capitation payments. Contractor shall keep records of such efforts, successful or unsuccessful, to ensure accuracy of such reports and make reports and make records available for audit and review upon request."  Oregon Mental Health Contract, page C2.

Actuarial sound capitation rates

"VII.  Consideration
A.  Payment Types and Rates...
Division shall provide upon Contractor request and availability documents produced by the Actuarial firm which document and describe the rate development process…

C.  Changes in Payment Rates
The Capitation Payment may be changed by amendment to this Agreement pursuant to XXXI, Amendments and Termination, of this Agreement, except that changes in Covered Services in response to revisions in the Prioritized List of Health Services by the HSC that would have an actuarial impact, as determined by Division, on Contractors projected costs greater than 1% or in response to action by the Oregon Legislative Assembly shall be made as follows…" Oregon Mental Health Contract, pages 40-41.

Time lines for payment to network providers

"V. Statement of Work...
2.  Provisions of Covered Services...
C.  Contractor shall provide all Covered Services to OMAP Members but may require, except in an emergency, that OMAP Members obtain such services from Contractor or provider affiliated with Contractor. Contractor shall adjudicate Valid Claims within 45 calendar days of receipt…"  Oregon Mental Health Contract, pages 6-7.

Cost sharing

"V. Statement of Work...
2.  Provision of Covered Services...
C.  Contractor shall provide all Covered Services to OMAP Members but may require, except in an emergency, that OMAP Members obtain such covered services from Contractor or providers affiliated with Contractor…Contractor shall ensure that neither Division nor the OMAP Member receiving services is held liable for any costs or charges related to Covered Services rendered to an OMAP Member whether in an Emergency or otherwise."  Oregon Mental Health Contract, pages 6-7.

"d.  Contain a provision that the subcontractor shall not bill, charge, seek compensation, remuneration or reimbursement from, or have recourse against Division or any OMAP Member for Covered Services provided during the period for which Capitation Payments were made by the Division through OMAP to Contractor with respect to said OMAP Member, even if contractor becomes insolvent."  Oregon Mental Health Contract, page 38.