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 or any child who has dropped coverage in the previous six months, unless the coverage was involuntarily lost or unless the reason for dropping coverage is allowed by rule of the board.
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 or other public health insurance coverage to local department of human services offices or other appropriate person or agency for follow up and retain the identifying data on children who are referred.
d. Monitor and assess the medical 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. Make program applications available through the mail and through local sites, as determined by the department, including, but not limited to, schools, local health departments, local department of human services offices, and other locations.
i. Provide electronic access to the administrative contractor's database to the department.
j. Provide periodic reports to the department for administrative oversight and monitoring of federal requirements.
k. Perform annual financial reviews of eligibility for each beneficiary.
l. Receive completed applications and verifications at a central location.
m. Collect and track monthly family premiums to assure that payments are current.
n. Notify each participating insurer of new program enrollees who are enrolled by the administrative contractor in that participating insurer's plan.
o. Verify the number of program enrollees with each participating insurer for determination of the amount of premiums to be paid to each participating insurer.
p. Maintain data for the purpose of quality assurance reports as required by rule of the board.
98 Acts, ch 1196, §8, 16; 99 Acts, ch 208, §39
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