19-159 Contract Status Validation Needed by March 15, 2019, for Hospital Directed Payment Programs

Date: 02/27/19

Updated step-by-step instructions provided to validate contract status for the 2017–2018 state fiscal year

The Department of Health Care Services (DHCS) implemented the state fiscal year (SFY) 2017–2018 Designated Public Hospital (DPH) Enhanced Payment Program (EPP) and Private Hospital Direct Payment Program (PHDP).

The DPH EPP and PHDP provide supplemental reimbursement to participating hospitals based on the actual utilization of qualifying services for eligible members covered under managed care organizations (MCOs), as reflected in Medi-Cal claims encounters reported to DHCS.

California Health & Wellness Plan (CHWP) has received first pass detail files from DHCS for SFY 2017–2018 Phase 1 (July 1, 2017–December 31, 2017). Hospitals have also received first pass files directly from DHCS and were asked to report the contract status for each line of their SFY 2017–2018 Phase 1 Detail File.

Note: First pass files are preliminary and may be missing service lines. DHCS will send a second pass file, which will be the final pass file (to be completed at a later date) that will reflect all encounters received by December 31, 2018.

INSTRUCTIONS

You should have received a file from DHCS to use in the contracting status review. To validate contract status, providers are required to do the following:                     

1     Retrieve the file sent directly from DHCS to confirm contract status.

2     Do not add or delete any service lines.

3     Hospitals shall complete the file they received from DHCS with “Contract Status” under the “Hospital_Contract_Status” column.

4     Acceptable values for contract status are:

-        C – Contracted

-        H – Hospital to hospital

-        N – Not contracted

5     To be deemed contracted, agreements must meet the DHCS requirements. See below for contract definition and demonstrable “unbroken contracting path.”

6     When sending files, please use the following file naming convention and change the date to the date you are sending us the file. Safeguard all transmitted protected health information (PHI) by only sending through secured channels in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

-        Private hospitals: PHDP_Contract_Date sent back to CHWP_Hospital 

         Name.

         Example: PDHP_Contract_YYYYMMDD_Smith Medical Center

-        Public hospitals: EPP_Contract_Date sent back to CHWP_Hospital Name.

Example: EPP_Contract_YYYYMMDD_Doe Medical Center

7     Fee-for-service (FFS) hospitals must return their completed files to CHWP no later than March 15, 2019. Files must be submitted to both Teresa.L.Bailey@Centene.com and Marisela.D.Lorray@HealthNet.com.

8     Please note that these files have encounters for all Medi-Cal members, including full and partial dual members. Please leave the file format and type as it was received and complete the information for all of the encounters and encounter lines in the file. Note that it is our understanding that the encounters for members who have Medicare (full or partial duals) may not qualify for directed payments.

9    Once files have been completed with both the Hospital Contract Statuses and the Plan Contract Statuses included, files will be sent to capitated providers, capitated hospitals and service-rendering hospitals for use in reconciliation when needed.

In addition to completing and returning the file with confirmation of contract status, CHWP will also require providers to attest to the accuracy of the reported contract data. A separate attestation form will be provided.

Lastly, DHCS will be collecting contract documents via a random sampling process to validate the reported contract status data. In the event any of your contracts are selected, you will need to submit supporting contract data to CHWP within 48 hours of our request.

We appreciate your attention to this matter and your cooperation in completing the necessary data timely so that we may submit the contract data files to DHCS by March 15, 2019, for the second pass.

CONTRACT DEFINTION AND CONTRACTING PATH

PHDP and EPP Contract Definition

Agreement MUST:	Agreement MUST NOT:
Cover one or more defined non-excluded populations of Medi-Cal beneficiaries	Be limited to a single patient only
Cover a defined set of one or more non-excluded hospital services	Be limited to treatment of a single case or instance only
Specify rates of payment or include a defined methodology for calculating specific rates of payment	Permit payment to be negotiated on a per-patient or single instance of service basis
Be for a term of at least 120 days, be signed and dated, and be effective for the dates of service	Expressly permit the provider to select on a case-by-case basis whether to provide services covered in the agreement to a patient covered by the agreement

Furthermore, for delegated arrangements (if applicable):

• There must be a demonstrable “unbroken contracting path” between the plan and the provider for:

-        The service rendered; and

-        The member receiving the service; and

-        The applicable dates of service.

“Unbroken contracting path” means a sequence of contracts (as defined) linking the plan and a direct subcontractor, or a series of subcontractors, to the provider.

 

 

 

For more information about the directed payments program, visit www.dhcs.ca.gov/services/Pages/DirectedPymts.aspx.

ADDITIONAL INFORMATION

If you have questions regarding the information contained in this update, contact both Teresa.L.Bailey@Centene.com and Marisela.D.Lorray@HealthNet.com. For all other questions, contact CHWP at 1-877-658-0305.