514I.7 - ADMINISTRATIVE CONTRACTOR.
514I.7 ADMINISTRATIVE CONTRACTOR. 1. An administrative contractor shall be selected by the hawk-i board through a request for proposals process. 2. The administrative contractor shall do all of the following: a. Determine individual eligibility for program enrollment based upon review of completed applications and supporting documentation. The administrative contractor shall not enroll a child who has group health coverage. b. Enroll qualifying children in the program with maintenance of a supporting eligibility file or database. c. Forward names of children who appear to be eligible for medical assistance to the department of human services for follow-up and retain identifying data on children who are referred. d. Monitor and assess the medical and dental care provided through or by participating insurers as well as complaints and grievances. e. Verify and forward to the department participating insurers' payment requests. f. Develop and issue appropriate approval, denial, and cancellation notifications to inform applicants and enrollees of the status of the applicant's or enrollee's eligibility to participate in the program. Additionally, the administrative contractor shall process applications, including verifications and mailing of approvals and denials, within ten working days of receipt of the application, unless the application cannot be processed within this period for a reason that is beyond the control of the administrative contractor. g. Create and maintain eligibility files that are compatible with the data system of the department including, but not limited to, data regarding beneficiaries, enrollment dates, disenrollments, and annual financial redeterminations. h. Provide electronic access to the administrative contractor's database to the department. i. Provide periodic reports to the department for administrative oversight and monitoring of federal requirements. j. Perform annual financial reviews of eligibility for each beneficiary. k. Receive completed applications and verifications at a central location. l. Collect and track monthly family premiums to assure that payments are current. m. Notify each participating insurer of new program enrollees who are enrolled by the administrative contractor in that participating insurer's plan. n. Verify the number of program enrollees with each participating insurer for determination of the amount of premiums to be paid to each participating insurer. o. Maintain data for the purpose of quality assurance reports as required by rule of the board.
Section History: Recent Form 98 Acts, ch 1196, §8, 16; 99 Acts, ch 208, §39; 2003 Acts, ch 108, §131; 2003 Acts, ch 124, §9, 10; 2008 Acts, ch 1188, §10; 2009 Acts, ch 118, §34