FIDE-SNP APPENDIX D.pdf

Appendix D: Provider Letter of Intent Form

EOHHS Medicaid Managed Care Fully Integrated Dual Special Needs Plan Program

APPENDIX D

Provider Letter of Intent Form

Rhode Island Executive Office of Health and Human Services

3 West Road │ Virks Building │ Cranston, RI 02920

Medicaid Managed Care Fully Integrated Dual Special Needs Plan Program

The following is the mandated format for the Rhode Island EOHHS Medicaid Managed Care Fully

Integrated Dual Special Needs Plan Program Procurement Letter of Intent (LOI) as required for a

Managed Care Organization Bidder to submit as part of its QLV response to demonstrate its ability to establish a geographically robust and culturally diverse Provider Network. It is to be used to show a Provider’s intention to enter into a contract with a Bidder.

Bidder Instructions

• Please fill out the shaded boxes with identifying information, no alterations or changes are permitted, except for shaded areas which identify the Bidder.

• Only completed LOIs will be acceptable evidence of a Bidder's proposed network.

• Supply LOI Form, with your information included, to proposed Provider and once completed and signed, submit as a part of your Bid Submission Package.

Provider Instructions

• Please fill out all applicable fields of the LOI, sign and return to the Bidder.

• Do not send completed LOIs to Rhode Island EOHHS.

• If you have multiple sites that offer identical services, only one LOI should be signed, with additional service site information (items 1 to 6) attached to the LOI.

• If services differ between sites, a separate LOI must be obtained for each service site.

• If a representative signs an LOI on behalf of a provider, evidence of authority for the representative must be available upon request.

Medicaid Managed Care Fully Integrated Dual Special Needs Plan Program

Please do not sign this Letter of Intent unless you seriously intend to enter into negotiations with the health plan mentioned below.

No alterations or changes are permitted, except for shaded areas which identify the Bidder. This letter is subject to verification by the Executive Office of Health and Human Services (EOHHS).

The Provider signing below is willing to enter into contract negotiations with the Bidder, named below, to provide covered services to Rhode Island Medicaid members enrolled with the Bidder if they are awarded an EOHHS Medicaid Managed Care Fully Integrated Dual Special Needs Plan Program contract beginning January 1, 2028, and if an acceptable agreement can be reached between the Provider and Bidder.

Signing this Letter of Intent does not obligate the Provider to sign a contract with Bidder, however, please do not sign this non-binding Letter of Intent unless you seriously intend to enter into negotiations with the above-mentioned health plan.

The following information is furnished by the Bidder:

Bidder Name

Address

City State Zip Code

Contact Person

Telephone Email

The following information is furnished by the provider:

EOHHS Provider Identification Number

Provider Name

Address (where services will be provided)

City State Zip Code

Telephone Email

Please check here if Additional Service Site information is attached to the Letter of Intent

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Provider Type – Please check all that apply.

Primary Care Provider Pediatric Adult

Physician – Specialist (specify)

Hospital

Urgent Care Facility

Pharmacy

Laboratory

Medical Imaging

Medically Necessary Transportation

Nursing Facility

Therapy (specify)

Behavioral Health Provider (specify)

Durable Medical Equipment

Home Health Agency

Assisted Living Facility

Adult Day Care Center

Community Based LTSS Agency (specify)

Other (specify)

Languages spoken by the Provider (other than English)

Spanish Portuguese French Haitian Chinese Khmer

Other (specify)

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Name of Hospital(s) where Provider has admitting privileges (if applicable)

Notice to Providers

This is not a contract. This Letter of Intent will be used by EOHHS in its bid evaluation and contract award process. You should only sign this Letter of Intent if you intend to enter into contract negotiations with Bidder should they receive a contract award.

If you are signing on behalf of a physician, please provide evidence of your authority to do so.

Do not return completed Letter of Intent to EOHHS. Completed Letter of Intent needs to be returned to the Bidder.

Provider Signature Date

Printed Name of Signatory Title

Letter of Intent Addendum Additional Service Sites

EOHHS Provider Identification Number

Provider Name

Address (where services will be provided)

City State Zip Code