DMC-ODS Readines Review FY2017/18

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CMS requires that California demonstrate that they meet all of the following criteria in the following table in order to implement DMC-ODS services through County PIHPs.
California Drug Medi-Cal Organized Delivery System Implementation
Functional Area
Operation Activities for Assessment
Action Steps
QI Notes
1. Administration Operations Interagency Coordination Stakeholder Engagement Plan functions:
  • 1.1 Hiring plan including job descriptions
  • 1.2 Building readiness including work space and accessibility
  • 1.3 System capacity to report member service calls and issues daily during the transition period
  • 1.4 Training schedule and materials prepared
1.1 Hiring Plan & Job Description 1.2 Building Readiness – Including Workspace and accessibility 1.3 System Capacity / Member Service Calls 1.4 Training Schedule
2. Enrollment-Related Functions Enrollment and Disenrollment Beneficiary Support system Enrollment Systems Outreach Enrollee Information Marketing Fraud and Abuse Plan functions:
  • 2.1 Member materials developed and approved by the state
  • 2.2 Call center scripts developed and approved and staff trained on benefits
  • 2.3 Call center contingency plans developed
  • 2.4 Compliance officer hired and employee fraud prevention and notification materials signed
2.1 Materials 2.2 Call Center 2.4 Compliance Plan
3. Member Services Member Handbook and Enrollee Information MCO Outreach, Scheduling, and Transportation Enrollee Services and Supports Plan functions:
  • 3.1 Develop member handbook and get approved by the state
  • 3.2 Continuously updated provider directory for call center staff to reference
3.2 MCBH Welcoming Packet MCBH Provider List
4. Service Provision Utilization Management Service Delivery Service Planning Plan functions:
  • 4.1 Practice guidelines developed and approved for use by the state
4.1 Service Provision
5. Access Provider Network Adequacy Access and Availability Access for People with Disabilities or Other Special Needs MCO Contracts with Network Providers Plan functions:
  • 5.1 Plans do provider outreach to enroll providers and provide assistance through the credentialing process
  • 5.2 Work with providers to ensure appropriate and accurate information collected during credentialing process to ensure provider directory is accurate and can include information like cultural competency, disability accessibility and open panels
  • 5.3 P&Ps developed on provider credentialing process and ability for credentialing committee to meet more frequently if necessary
  • 5.4 Single case agreement process developed to handle out of network providers
5.1 Provider List 5.2 / 5.3 Credentialing Process 5.4 Single Case Agreement 5.5 Contracted Provider Boilerplate  
6. Continuity and Coordination of Care Develop and Monitor Care Coordination Plan to Facilitate Successful Transitions Between Levels of SUD Care Plan function:
  • 6.1 Develop care coordination plans between various levels of care utilizing the ASAM criteria
  • 6.2 Provide training to all providers in ASAM criteria and care coordination systems
  • 6.3 Execute MOU with all Medi-Cal MCPs in the plan’s county of operation
  • 6.4 Ensure systems are in place to follow continuity of care procedures outlined in contract and by the state to ensure claims and services are not denied for the incorrect reasons
6.1 Care Coordination Plans 6.2 Provider Training 6.3 Execute MOU with Medi-Cal MCP 6.4
7. Grievance, Appeal, and Fair Hearing Process General Requirements Enrollee Reporting of Grievances and Appeals Handling of Grievances and Appeals Monitoring of Grievances and Appeals Plan functions:
  • 7.1 Training, of call center and other enrollee facing staff to recognize when an issue is a grievance or appeal and when it should be referred to other staff at the plan to handle
  • 7.2 Tracking allowing all staff to track when a grievance or appeal is filed with internal notifications for processing
  • 7.3 Implement state specific reporting mechanism
7.1 7.2
8. Quality Elements of State Quality Strategy MCO Structural and Operational Standards Quality Assessment and Performance Improvement External Quality Reviews Plan functions:
  • 8.1 Quality management plan developed and staff trained on the management plan
  • 8.2 P&Ps created related to the quality systems in place
  • 8.3 Performance Improvement projects developed and committees set up to measure any improvements as they relate to the new benefits
8.1
9. Systems General MMIS Operations Payment Systems Eligibility and Enrollment Third Party Liability (TPL) MCO information Systems, including Provider Payment Systems See finance and encounter data.
  • 9.1 Provide status of system readiness based on testing

10. Program Integrity State Administrative Structure, Communication, and Reporting Finance, Data, and Systems Assurance General Contractor Oversight and Reporting Provider Screening and Enrollment Plan functions:
  • 10.1 Develop systems to track and collect program integrity issues
  • 10.2 Hire compliance officer, and train staff on identification of fraud and abuse as it relates to the new benefits
  • 10.3 Develop reporting structure for the state when issues are identified
  • 10.4 Develop plan to report any collection of over-payment to the systems process
10.1 & 10.4MCHB Policy 108(pg 11, line 393) 10.2 & 10.3 MCBH Policy 108 (pg 12, line 419)
11. Finance General Financial Oversight Payments to Providers Third Party Liability (TPL) and Coordination of Benefits Plan functions:
  • 11.1 Test claims payment functions and have working P&Ps on timely payment of claims
  • 11.2 If necessary, train staff on other areas of TPL to ensure appropriate billing of third parties