Exhibit 10.4
AMENDED AND RESTATED
CONTRACT BETWEEN
THE GEORGIA DEPARTMENT OF COMMUNITY
HEALTH
and
AMERIGROUP GEORGIA MANAGED CARE
COMPANY, INC.
for
PROVISION OF SERVICES TO
GEORGIA FAMILIES
Contract No.: 0652
Amendment 3
May 1, 2008

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TABLE OF CONTENTS

         
1.0 SCOPE OF SERVICE
    1    
1.1 BACKGROUND
    1    
1.2.1 Medicaid
    2    
1.2.2 PeachCare for Kids
    3    
1.2.3 Exclusions
    3    
1.3 SERVICE REGIONS
    4    
1.4 DEFINITIONS
    4    
1.5 ACRONYMS
    19  
 
       
2.0 DCH RESPONSIBILITIES
    22    
2.1 GENERAL PROVISIONS
    22    
2.2 LEGAL COMPLIANCE
    22    
2.3 ELIGIBILITY AND ENROLLMENT
    22    
2.4 DISENROLLMENT
    24    
2.5 MEMBER SERVICES AND MARKETING
    25    
2.6 COVERED SERVICES & SPECIAL COVERAGE PROVISIONS
    25    
2.7 NETWORK
    25    
2.8 QUALITY MONITORING
    26    
2.9 COORDINATION WITH CONTRACTOR’S KEY STAFF
    27    
2.10 FORMAT STANDARDS
    27    
2.11 FINANCIAL MANAGEMENT
    27    
2.12 INFORMATION SYSTEMS
    27    
2.13 READINESS OR ANNUAL REVIEW
    28  
 
       
3.0 GENERAL CONTRACTOR RESPONSIBILITIES
    29  
 
       
4.0 SPECIFIC CONTRACTOR RESPONSIBILITIES
    30  

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4.1 ENROLLMENT
    30    
4.1.1 Enrollment Procedures
    30    
4.1.2 Selection of a Primary Care Provider (PCP)
    30    
4.1.3 Newborn Enrollment
    31    
4.1.4 Reporting Requirements
    32    
4.2 DISENROLLMENT
    32    
4.2.1 Disenrollment Initiated by the Member
    32    
4.2.2 Disenrollment Initiated by the Contractor
    33    
4.2.3 Acceptable Reasons for Disenrollment Investigation Requests by Contractor
    33    
4.2.4 Unacceptable Reasons for Disenrollment Requests by Contractor
    34    
4.3 MEMBER SERVICES
    35    
4.3.1 General Provisions
    35    
4.3.2 Requirements for Written Materials
    35    
4.3.3 Member Handbook Requirements
    36    
4.3.4 Member Rights
    39    
4.3.5 Provider Directory
    40    
4.3.6 Member Identification (ID) Card
    40    
4.3.7 Toll-free Member Services Line
    41    
4.3.8 Internet Presence/Web Site
    42    
4.3.9 Cultural Competency
    43    
4.3.10 Translation Services
    44    
4.3.11 Reporting Requirements
    44    
4.4 MARKETING
    44    
4.4.1 Prohibited Activities
    44    
4.4.2 Allowable Activities
    44    
4.4.3 State Approval of Materials
    45    
4.4.4 Provider Marketing Materials
    45    
4.5 COVERED BENEFITS AND SERVICES
    46    

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4.5.1 Included Services
    46    
4.5.2 Individuals with Disabilities Education Act (IDEA) Services
    48    
4.5.3 Enhanced Services
    49    
4.5.4 Medical Necessity
    49    
4.5.5 Experimental, Investigational or Cosmetic Procedures
    50    
4.5.6 Moral or Religious Objections
    50    
4.6 SPECIAL COVERAGE PROVISIONS
    50    
4.6.1 Emergency Services
    50    
4.6.2 Post-Stabilization Services
    52    
4.6.3 Urgent Care Services
    54    
4.6.4 Family Planning Services
    54    
4.6.5 Sterilizations, Hysterectomies and Abortions
    55    
4.6.6 Pharmacy
    56    
4.6.7 Immunizations
    57    
4.6.8 Transportation
    57    
4.6.9 Perinatal Services
    57    
4.6.10 Parenting Education
    58    
4.6.11 Mental Health and Substance Abuse
    59    
4.6.12 Advance Directives
    59    
4.6.13 Foster Care Forensic Exam
    60    
4.6.14 Laboratory Services
    60    
4.6.15 Member Cost-Sharing
    60    
4.7 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM:
HEALTH CHECK
    60    
4.7.1 General Provisions
    60    
4.7.2 Outreach and Informing
    61    
4.7.3 Screening
    62    
4.7.4 Tracking
    63    

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4.7.5 Diagnostic and Treatment Services
    64    
4.7.6 Reporting Requirements
    64    
4.8 PROVIDER NETWORK
    64    
4.8.1 General Provisions
    64    
4.8.2 Primary Care Providers (PCPs)
    66    
4.8.3 Direct Access
    69    
4.8.4 Pharmacies
    69    
4.8.5 Hospitals
    69    
4.8.6 Laboratories
    70    
4.8.7 Mental Health/Substance Abuse
    70    
4.8.8 Federally Qualified Health Centers (FQHCs)
    70    
4.8.10 Family Planning Clinics
    71    
4.8.11 Nurse Practitioners Certified (NP-Cs) and Certified Nurse Midwives (CNMs)
    71    
4.8.13 Geographic Access Requirements
    72    
4.8.14 Waiting Maximums and Appointment Requirements
    73    
4.8.15 Credentialing
    74    
4.8.16 Mainstreaming
    75    
4.8.17 Coordination Requirements
    75    
4.8.18 Network Changes
    75    
4.8.19 Out-of-Network Providers
    76    
4.8.21 Reporting Requirements
    77    
4.9 PROVIDER SERVICES
    78    
4.9.1 General Provisions
    78    
4.9.2 Provider Handbooks
    78    
4.9.3 Education and Training
    79    
4.9.4 Provider Relations
    80    
4.9.5 Toll-free Provider Services Telephone Line
    80    
4.9.6 Internet Presence/Web Site
    81    

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4.9.7 Provider Complaint System
    82    
4.9.8 Reporting Requirements
    84    
4.10 PROVIDER CONTRACTS AND PAYMENTS
    85    
4.10.1 Provider Contracts
    85    
4.10.2 Provider Termination
    89    
4.10.3 Provider Insurance
    89    
4.10.4 Provider Payment
    90    
4.10.5 Reporting Requirements
    92    
4.11 UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES
    93    
4.11.1 Utilization Management
    93    
4.11.2 Prior Authorization and Pre-Certification
    94    
4.11.3 Referral Requirements
    95    
4.11.4 Transition of Members
    96    
4.11.5 Court-Ordered Evaluations and Services
    98    
4.11.6 Second Opinions
    98    
4.11.7 Care Coordination and Case Management
    98    
4.11.8 Disease Management
    100    
4.11.9 Discharge Planning
    100    
4.11.10 Reporting Requirements
    101    
4.12 QUALITY IMPROVEMENT
    101    
4.12.1 General Provisions
    101  
 
       
4.12.2 QUALITY STRATEGIC PLAN REQUIREMENTS
    101  
 
       
4.12.3 REPORTING REQUIREMENTS
    102    
4.12.4 Quality Assessment Performance Improvement (QAPI) Program
    103    
4.12.5 Performance Improvement Projects
    104    
4.12.6 Practice Guidelines
    106    

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4.12.7 Focused Studies
    107    
4.12.7.1 Focus Studies:
    107    
4.12.8 Patient Safety Plan
    107    
4.12.9 Performance Incentives
    108    
4.12.9.1 Incentive Arrangement
    108    
4.12.10 External Quality Review
    108    
4.12.11 Reporting Requirements
    108    
4.13 FRAUD AND ABUSE
    108    
4.13.1 Program Integrity
    108    
4.13.2 Compliance Plan
    109    
4.13.3 Coordination with DCH and Other Agencies
    110    
4.13.4 Reporting Requirements
    111    
4.14 INTERNAL GRIEVANCE SYSTEM
    111    
4.14.1 General Requirements
    111    
4.14.2 Grievance Process
    113    
4.14.3 Proposed Action
    114    
4.14.4 Administrative Review Process
    116    
4.14.5 Notice of Adverse Action
    117    
4.14.7 Continuation of Benefits while the Contractor Appeal and Administrative
Law Hearing are Pending
    119    
4.14.8 Reporting Requirements
    120    
4.15 ADMINISTRATION AND MANAGEMENT
    121    
4.15.1 General Provisions
    121    
4.15.2 Place of Business and Hours of Operation
    121    
4.15.3 Training
    121    
4.15.4 Data Certification
    122    
4.15.5 Implementation Plan
    122    
4.16 CLAIMS MANAGEMENT
    122    

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4.16.1 General Provisions
    123    
4.16.2 Other Considerations
    125    
4.16.4 Reporting Requirements
    126    
4.17 INFORMATION MANAGEMENT AND SYSTEMS
    127    
4.17.1 General Provisions
    127    
4.17.2 Global System Architecture and Design Requirements
    128    
4.17.3 Data and Document Management Requirements by Major Information Type
    131    
4.17.4 System and Data Integration Requirements
    131    
4.17.5 System Access Management and Information Accessibility Requirements
    131    
4.17.6 Systems Availability and Performance Requirements
    132    
4.17.7 System User and Technical Support Requirements
    135    
4.17.8 System Change Management Requirements
    137    
4.17.9 System Security and Information Confidentiality and Privacy Requirements
    137    
4.17.10 Information Management Process and Information Systems Documentation
Requirements
    138    
4.17.11 Reporting Requirements
    139    
4.18 REPORTING REQUIREMENTS
    139    
4.18.1 General Procedures
    139    
4.18.2 Weekly Reporting
    140    
4.18.3 Monthly Reporting
    140    
4.18.4 Quarterly Reporting
    143    
4.18.5 Annual Reports
    147    
4.18.6 Ad Hoc Reports
    149    
4.18.6.5 Contractor Notifications
    152  
 
       
5.0 DELIVERABLES
    152    
5.1 CONFIDENTIALITY
    152    
5.2 NOTICE OF DISAPPROVAL
    152    
5.3 RESUBMISSION WITH CORRECTIONS
    152    

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5.4 NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION
    153    
5.5 DCH FAILS TO RESPOND
    153    
5.6 REPRESENTATIONS
    153    
5.7 CONTRACT DELIVERABLES
    153    
5.8 CONTRACT REPORTS
    156  
 
       
6.0 TERM OF CONTRACT
    158  
 
       
7.0 PAYMENT FOR SERVICES
    158  
 
       
8.0 FINANCIAL MANAGEMENT
    161    
8.1 GENERAL PROVISIONS
    161    
8.2 SOLVENCY AND RESERVES STANDARDS
    161    
8.3 REINSURANCE
    161    
8.4 THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS
    162    
8.4.2 Cost Avoidance
    162    
8.4.3 Compliance
    163    
8.5 PHYSICIAN INCENTIVE PLAN
    163    
8.6 REPORTING REQUIREMENTS
    164  
 
       
9.0 PAYMENT OF TAXES
    167  
 
       
10.0 RELATIONSHIP OF PARTIES
    167  
 
       
11.0 INSPECTION OF WORK
    168  
 
       
12.0 STATE PROPERTY
    168  
 
       
13.0 OWNERSHIP AND USE OF DATA/ UPGRADES
    168    
13.1 OWNERSHIP AND USE OF DATA
    168    
13.2 SOFTWARE AND OTHER UPGRADES
    169  
 
       
14.0 CONTRACTOR STAFFING
    169  

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14.1 STAFFING ASSIGNMENTS AND CREDENTIALS
    169    
14.2 STAFFING CHANGES
    171    
14.3 CONTRACTOR’S FAILURE TO COMPLY
    171  
 
       
15.0 CRIMINAL BACKGROUND CHECKS
    172  
 
       
16.0 SUBCONTRACTS
    172    
16.1 USE OF SUBCONTRACTORS
    172    
16.2 COST OR PRICING BY SUBCONTRACTORS
    173  
 
       
17.0 LICENSE, CERTIFICATE, PERMIT REQUIREMENT
    173  
 
       
18.0 RISK OR LOSS AND REPRESENTATIONS
    174  
 
       
19.0 PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES
    174  
 
       
20.0 RECORDS REQUIREMENTS
    174    
20.1 GENERAL PROVISIONS
    174    
20.2 RECORDS RETENTION REQUIREMENTS
    175    
20.3 ACCESS TO RECORDS
    175    
20.4 MEDICAL RECORD REQUESTS
    175  
 
       
21.0 CONFIDENTIALITY REQUIREMENTS
    176    
21.1 GENERAL CONFIDENTIALITY REQUIREMENTS
    176    
21.2 HIPAA COMPLIANCE
    176  
 
       
22.0 TERMINATION OF CONTRACT
    176    
22.1 GENERAL PROCEDURES
    176    
22.2 TERMINATION BY DEFAULT
    177    
22.3 TERMINATION FOR CONVENIENCE
    177    
22.4 TERMINATION FOR INSOLVENCY OR BANKRUPTCY
    177    
22.5 TERMINATION FOR INSUFFICIENT FUNDING
    178    
22.6 TERMINATION PROCEDURES
    178  

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22.7 TERMINATION CLAIMS
    180  
 
       
23.0 LIQUIDATED DAMAGES
    181    
23.1 GENERAL PROVISIONS
    181    
23.2 CATEGORY 1
    181    
23.3 CATEGORY 2
    181    
23.4 CATEGORY 3
    182    
23.5 CATEGORY 4
    184    
23.6 OTHER REMEDIES
    186    
23.7 NOTICE OF REMEDIES
    187  
 
       
24.0 INDEMNIFICATION
    187  
 
       
25.0 INSURANCE
    188    
25.1 INSURANCE OF CONTRACTOR
    188    
27.0 COMPLIANCE WITH ALL LAWS
    190    
27.1 NON-DISCRIMINATION
    190    
27.2 DELIVERY OF SERVICE AND OTHER FEDERAL LAWS
    190    
27.3 COST OF COMPLIANCE WITH APPLICABLE LAWS
    191    
27.4 GENERAL COMPLIANCE
    191  
 
       
28.0 CONFLICT RESOLUTION
    192  
 
       
29.0 CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE
    192  
 
       
30.0 NOTICE
    193  
 
       
31.0 MISCELLANEOUS
    193    
31.1 CHOICE OF LAW OR VENUE
    193    
31.2 ATTORNEY’S FEES
    193    
31.3 SURVIVABILITY
    194    
31.4 DRUG-FREE WORKPLACE
    194  

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31.5 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER
MATTERS
    194    
31.6 WAIVER
    194    
31.7 FORCE MAJEURE
    194    
31.8 BINDING
    194    
31.9 TIME IS OF THE ESSENCE
    195    
31.10 AUTHORITY
    195    
31.11 ETHICS IN PUBLIC CONTRACTING
    195    
31.12 CONTRACT LANGUAGE INTERPRETATION
    195    
31.13 ASSESSMENT OF FEES
    195    
31.14 COOPERATION WITH OTHER CONTRACTORS
    195    
31.15 SECTION TITLES NOT CONTROLLING
    196    
31.16 LIMITATION OF LIABILITY/EXCEPTIONS
    196    
31.17 COOPERATION WITH AUDITS
    196    
31.18 HOMELAND SECURITY CONSIDERATIONS
    196    
31.19 PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED
    197    
31.20 OWNERSHIP AND FINANCIAL DISCLOSURE
    197  
 
       
32.0 AMENDMENT IN WRITING
    198  
 
       
33.0 CONTRACT ASSIGNMENT
    198  
 
       
34.0 SEVERABILITY
    198  
 
       
35.0 COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT
ORGANIZATIONS (O.C.G.A. § 50-20-1 ET SEQ.)
    198  
 
       
36.0 ENTIRE AGREEMENT
    199  
 
       
ATTACHMENT A
    201    
DRUG FREE WORKPLACE CERTIFICATE
    201  
 
       
ATTACHMENT B
    203  

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CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER
RESPONSIBILITY MATTERS
    203  
 
       
ATTACHMENT C
    205    
NONPROFIT ORGANIZATION DISCLOSURE FORM
    205  
 
       
ATTACHMENT D
    206    
CONFIDENTIALITY STATEMENT
    206  
 
       
ATTACHMENT E
    207    
BUSINESS ASSOCIATE AGREEMENT
    207  
 
       
ATTACHMENT F
    212    
VENDOR LOBBYLIST DISCLOSURE AND REGISTRATION CERTIFICATION FORM
    212  
 
       
ATTACHMENT G
    214    
PAYMENT BOND AND
    214    
IRREVOCABLE LETTER OF CREDIT
    214  
 
       
ATTACHMENT H
    216    
CAPITATION PAYMENT
    216    
NOTICE OF YOUR RIGHT TO A HEARING
    218  
 
       
ATTACHMENT J
    219    
MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS
    219  
 
       
ATTACHMENT K
    220    
APPLICABLE CO-PAYMENTS
    220  
 
       
ATTACHMENT L
    221    
INFORMATION MANAGEMENT AND SYSTEMS
    221  

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     THIS AMENDED AND RESTATED CONTRACT, with an effective date of July 1, 2008
(hereinafter referred to as the “Effective Date”), is made and entered into by
and between the Georgia Department of Community Health (hereinafter referred to
as “DCH” or the “Department”) and Amerigroup Georgia Managed Care Company, Inc.
(hereinafter referred to as the “Contractor”).
     WHEREAS, DCH is responsible for Health Care policy, purchasing, planning
and regulation pursuant to the Official Code of Georgia Annotated (O.C.G.A.) §
31-5A-4 et. seq.;
     WHEREAS, DCH is the single State agency designated to administer medical
assistance in Georgia under Title XIX of the Social Security Act of 1935, as
amended, and O.C.G.A. §§ 49-4-140 et seq.(the “Medicaid Program”), and is
charged with ensuring the appropriate delivery of Health Care services to
Medicaid recipients and PeachCare for Kids Members;
     WHEREAS, DCH caused Request for Proposals Number 41900-001-0000000027
(hereinafter the “RFP”) to be issued through Department of Administrative
Service(s) (DOAS), which is expressly incorporated as if completely restated
herein;
     WHEREAS, DCH received from Contractor a proposal in response to the RFP,
“Contractor’s Proposal,” which is expressly incorporated as if completely
restated herein;
     WHEREAS, DCH accepted Contractor’s Proposal and entered into a contract
with Contractor on July 18, 2005, for the provision of various services for the
Department; and
     WHEREAS, DCH and Contractor now wish to amend and restate the Contract in
its entirety
     NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises, covenants
and agreements contained herein, and other good and valuable consideration, the
receipt and sufficiency of which are hereby acknowledged, the Department and the
Contractor (each individually a “Party” and collectively the “Parties”) hereby
agree as follows:

1.0   SCOPE OF SERVICE   1.0.1   The State of Georgia is implementing reforms to
the Medicaid and PeachCare for Kids programs. These reforms will focus on
system-wide improvements in performance and quality, will consolidate fragmented
systems of care, and will prevent currently unsustainable trend rates in
Medicaid and PeachCare for Kids expenditures. The reforms will be implemented
through a management of care approach to achieve the greatest value for the most
efficient use of resources.   1.0.2   The Contractor shall assist the State of
Georgia in this endeavor through the following tasks, obligations, and
responsibilities.   1.1   BACKGROUND   1.1.1   In 2003, the Georgia Department
of Community Health (DCH) identified unsustainable Medicaid growth and projected
that without a change to the system, Medicaid would require

Page 1 of 233

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    50 percent of all new State revenue by 2008. In addition, Medicaid
utilization was driving more than 35 percent of total growth each year. For that
reason, DCH decided to employ a management of care approach to organize its
fragmented system of care, enhance access, achieve budget predictability,
explore possible cost containment opportunities and focus on system-wide
performance improvements. Furthermore, DCH believed that managed care could
continuously and incrementally improve the quality of healthcare and services
provided to patients and improve efficiency by utilizing both human and material
resources more effectively and more efficiently. The DCH Division of Managed
Care and Quality submitted a State Plan Amendment in 2004 to implement a
full-risk mandatory Medicaid Managed Care program called Georgia Families.  
1.1.2   Effective June 1, 2006 the state of Georgia implemented Georgia Families
(GF), a managed care program through which health care services are delivered to
members of Medicaid and PeachCare for Kids™. The intent of this program is to:

  1.   Offer care coordination to members     2.   Enhance access to health care
services     3.   Achieve budget predictability as well as cost containment    
4.   Create system-wide performance improvements     5.   Continually and
incrementally improve the quality of health care and services provided to
members     6.   Improve efficiency at all levels

1.1.3   The GF program is designed to:

  1.1.3.1   Improve the Health Care status of the Member population;     1.1.3.2
  Establish a “Provider Home” for Members through its use of assigned Primary
Care Providers (PCPs);     1.1.3.3   Establish a climate of contractual
accountability among the state, the care management organizations and the health
care providers;     1.1.3.4   Slow the rate of expenditure growth in the
Medicaid program; and     1.1.3.5   Expand and strengthen a sense of Member
responsibility that leads to more appropriate utilization of health care
services.

1.2   ELIGIBILITY FOR GEORGIA FAMILIES

1.2.1   Medicaid

  1.2.1.1   The following Medicaid eligibility categories are required to enroll
in GF.

  1.2.1.1.1   Low Income Families — Adults and children who meet the standards
of the old AFDC (Aid to Families with Dependent Children) program.

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  1.2.1.1.2   Transitional Medicaid — Former Low-Income Medicaid (LIM) families
who are no longer eligible for LIM because their earned income exceeds the
income limit.     1.2.1.1.3   Pregnant Women (Right from the Start Medicaid —
RSM) — Pregnant women with family income at or below two hundred percent (200%)
of the federal poverty level who receive Medicaid through the RSM program.    
1.2.1.1.4   Children (Right from the Start Medicaid — RSM) — Children less than
nineteen (19) years of age whose family income is at or below the appropriate
percentage of the federal poverty level for their age and family.     1.2.1.1.5
  Children (newborn) — A child born to a woman who is eligible for Medicaid on
the day the child is born.     1.2.1.1.6   Women Eligible Due to Breast and
Cervical Cancer — Women less than sixty-five (65) years of age who have been
screened through Title XV Center for Disease Control (CDC) screening and have
been diagnosed with breast or cervical cancer.     1.2.1.1.7   Refugees — Those
individuals who have the required INS documentation showing they meet a status
in one of these groups: refugees, asylees, Cuban parolees/Haitian entrants,
Amerasians or human trafficking victims.

1.2.2   PeachCare for Kids

  1.2.2.1   PeachCare for Kids — The State Children’s Health Insurance Program
(SCHIP) in Georgia. Children less than nineteen (19) years of age who have
family income that is less than two hundred thirty-five percent (235%) of the
federal poverty level, who are not eligible for Medicaid or any other health
insurance program, and who cannot be covered by the State Health Benefit Plan.

1.2.3   Exclusions

  1.2.3.1   The following recipients are excluded from Enrollment in GF, even if
the recipient is otherwise eligible for GF per section 1.2.1 and section 1.2.2.

  1.2.3.1.1   Recipients eligible for Medicare;     1.2.3.1.2   Recipients that
are Members of a Federally Recognized Indian Tribe;

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  1.2.3.1.3   Recipients that are enrolled in fee-for-service Medicaid through
Supplemental Security Income prior to enrollment in GF. Members that are already
enrolled in a CMO through GF will remain in that CMO until the disenrollment is
completed through the normal monthly process.     1.2.3.1.4   Children less than
twenty-one (21) years of age who are in foster care or other out-of-home
placement;     1.2.3.1.5   Medicaid children enrolled in the Children’s Medical
Services program administered by the Georgia Division of Public Health;    
1.2.3.1.6   Children less than twenty-one (21) years of age who are receiving
foster care or other adoption assistance under Title IV-E of the Social Security
Act (NOTE: Foster Children in “Relative” placement remain within the Georgia
Families program);     1.2.3.1.7   Children enrolled in the Georgia Pediatric
Program (GAPP);     1.2.3.1.8   Recipients enrolled under group health plans for
which DCH provides payment for premiums, deductibles, coinsurance and other cost
sharing, pursuant to Section 1906 of the Social Security Act.     1.2.3.1.9  
Individuals enrolled in a Hospice category of aid.

1.3   SERVICE REGIONS   1.3.1   For the purposes of coordination and planning,
DCH has divided the State, by county, into six (6) Service Regions. See
Attachment J for a listing of the counties in each Service Region.   1.3.2  
Members will choose or will be assigned to a Care Management Organization
(CMO) plan that is operating in the Service Region in which they reside.   1.4  
DEFINITIONS

Whenever capitalized in this Contract, the following terms have the respective
meaning set forth below, unless the context clearly requires otherwise.
Abandoned Call: A call in which the caller elects a valid option and is either
not permitted access to that option or disconnects from the system.
Abuse: Provider practices that are inconsistent with sound fiscal, business, or
medical practices, and result in unnecessary cost to the Medicaid program, or in
reimbursement for services that are not medically necessary or that fail to meet
professionally recognized standards for Health Care. It also includes Member
practices that result in unnecessary cost to the Medicaid program.

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Administrative Law Hearing: The appeal process administered by the State in
accordance with O.C.G.A. § 49-4-153 and as required by federal law, available to
Members and Providers after they exhaust the Contractor’s Grievance System and
Complaint Process.
Administrative Review: means the formal reconsideration, as a result of the
proper and timely submission of a provider or member’s request, by an Office or
Unit of the Division, which has proposed an adverse action.
Administrative Service(s): The contractual obligations of the Contractor that
include but may not be limited to utilization management, credentialing
providers, network management, quality improvement, marketing, enrollment,
member services, claims payment, management information systems, financial
management, and reporting.
Action: The denial or limited authorization of a requested service, including
the type or level of service; the reduction, suspension, or termination of a
previously authorized service; the denial, in whole or part of payment for a
service; the failure to provide services in a timely manner; or the failure of
the CMO to act within the time frames provided in 42 CFR 438.408(b).
Advance Directives: A written instruction, such as a living will or durable
power of attorney for Health Care, recognized under State law (whether statutory
or as recognized by the courts of the State), relating to the provision of
Health Care when the individual is incapacitated.
After-Hours: Provider office/visitation hours that extends beyond the normal
business hours of a provider, which are Monday-Friday 9-5:30 and may extend to
Saturday hours.
Agent: An entity that contracts with the State of Georgia to perform
administrative functions, including but not limited to: fiscal agent activities;
outreach, eligibility, and Enrollment activities; Systems and technical support;
etc.
Appeal: A request for review of an action, as “action” is defined in 438.400.
Assess: Means the process used to examine and determine the level of quality or
the progress toward improvement of quality and/or performance related to
Contractor service delivery systems.
At Risk: Any service for which the Provider agrees to accept responsibility to
provide, or arrange for, in exchange for the Capitation payment and Obstetrical:
Delivery Payments.
Authoritative Host: A system that contains the master or “authoritative” data
for a particular data type, e.g. Member, Provider, CMO, etc. The Authoritative
Host may feed data from its master data files to other systems in real time or
in batch mode. Data in an Authoritative Host is expected to be up-to-date and
reliable.
Authorized Representative: A person authorized by the Member in writing to make
health-related decisions on behalf of a Member, including, but not limited to
Enrollment and Disenrollment decisions, filing Appeals and Grievances with the
Contractor, and choice of a Primary Care

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Physician (PCP). The authorized representative is either the Parent or Legal
Guardian for a child. For an adult this person is either the legal guardian
(guardianship action), health care or other person that has power of attorney,
or another signed HIPAA compliant document indicating who can make decisions on
behalf of the member.
Automatic Assignment (or Auto-Assignment): The Enrollment of an eligible person,
for whom Enrollment is mandatory, in a CMO plan chosen by DCH or its Agent. Also
the assignment of a new Member to a PCP chosen by the CMO Plan, pursuant to the
provisions of this Contract.
Benefits: The Health Care services set forth in this Contract, for which the
Contractor has agreed to provide, arrange, and be held fiscally responsible.
Blocked Call: A call that cannot be connected immediately because no circuit is
available at the time the call arrives or the telephone system is programmed to
block calls from entering the queue when the queue backs up beyond a defined
threshold.
Calendar Days: All seven days of the week.
Capitation: A Contractual agreement through which a Contractor agrees to provide
specified Health Care services to Members for a fixed amount per month.
Capitation Payment: A payment, fixed in advance, that DCH makes to a Contractor
for each Member covered under a Contract for the provision of medical services
and assigned to the Contractor. This payment is made regardless of whether the
Member receives Covered Services or Benefits during the period covered by the
payment.
Capitation Rate: The fixed monthly amount that the Contractor is prepaid by DCH
for each Member assigned to the Contractor to ensure that Covered Services and
Benefits under this Contract are provided.
Capitated Service: Any Covered Service for which the Contractor receives an
actuarially sound Capitation Payment.
Care Coordination: A set of Member-centered, goal-oriented, culturally relevant,
and logical steps to assure that a Member receives needed services in a
supportive, effective, efficient, timely, and cost-effective manner. Care
Coordination is also referred to as Care Management.
Care Management Organization (CMO): an entity organized for the purpose of
providing Health Care, has a Health Maintenance Organization Certificate of
Authority granted by the State of Georgia, which contracts with Providers, and
furnishes Health Care services on a prepaid, capitated basis to Members in a
designated Service Region.
Centers for Medicare & Medicaid Services (CMS): The Agency within the U.S.
Department of Health and Human Services with responsibility for the Medicare,
Medicaid and the State Children’s Health Insurance Program.

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Certified Nurse Midwife (CNM): A registered professional nurse who is legally
authorized under State law to practice as a nurse-midwife, and has completed a
program of study and clinical experience for nurse-midwives or equivalent.
Chronic Condition: Any ongoing physical, behavioral, or cognitive disorder,
including chronic illnesses, impairments and disabilities. There is an expected
duration of at least twelve (12) months with resulting functional limitations,
reliance on compensatory mechanisms (medications, special diet, assistive
device, etc) and service use or need beyond that which is normally considered
routine.
Claim: A bill for services, a line item of services, or all services for one
recipient within a bill.
Claims Administrator: The entity engaged by DCH to provide Administrative
Service(s) to the CMO Plans in connection with processing and adjudicating
risk-based payment, and recording health benefit encounter Claims for Members.
Clean Claim: A claim received by the CMO for adjudication, in a nationally
accepted format in compliance with standard coding guidelines, which requires no
further information, adjustment, or alteration by the Provider of the services
in order to be processed and paid by the CMO. The following exceptions apply to
this definition: i. A Claim for payment of expenses incurred during a period of
time for which premiums are delinquent; ii. A Claim for which Fraud is
suspected; and iii. A Claim for which a Third Party Resource should be
responsible.
Cold-Call Marketing: Any unsolicited personal contact by the CMO Plan, with a
potential Member, for the purposes of marketing.
Completion/Implementation Timeframe: The date or time period projected for a
project goal or objective to be met, for progress to be demonstrated or for a
proven intervention to be established as the standard of care for the
Contractor.
Condition: A disease, illness, injury, disorder, of biological, cognitive, or
psychological basis for which evaluation, monitoring and/or treatment are
indicated.
Consecutive Enrollment Period: The consecutive twelve (12) month period
beginning on the first day of Enrollment or the date the notice is sent,
whichever is later. For Members that use their option to change CMO plans
without cause during the first ninety (90) Calendar Days of Enrollment, the
twelve-month consecutive Enrollment period will commence when the Member enrolls
in the new CMO plan. This is not to be construed as a guarantee of eligibility
during the consecutive Enrollment period.
Contested Claim: A Claim that is denied because the Claim is an ineligible
Claim, the Claim submission is incomplete, the coding or other required
information to be submitted is incorrect, the amount Claimed is in dispute, or
the Claim requires special treatment.
Contract: The written agreement between the State and the Contractor; comprised
of the Contract, any addenda, appendices, attachments, or amendments thereto.

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Contract Award: The date upon which DCH issues the Apparent Successful Offeror
Letters.
Contract Execution: The date upon which all parties have signed the Contract.
Contractor: The Care Management Organization with a valid Certificate of
Authority in Georgia that contracts hereunder with the State for the provision
of comprehensive Health Care services to Members on a prepaid, capitated basis.
Contractor’s Representative: The individual legally empowered to bind the
Contractor, using his/her signature block, including his/her title. This
individual will be considered the Contractor’s Representative during the life of
any Contract entered into with the State unless amended in writing.
Co-payment: The part of the cost-sharing requirement for Members in which a
fixed monetary amount is paid for certain services/items received from the
Contractor’s Providers.
Core Services: Covered services for both the Rural Health Centers (RHC) and
Federally Qualified Health Centers (FQHC) programs defined as follows: Physician
services, including required physician supervision of Physician Assistants
(Pas), Nurse Practitioners (NPs), and Certified Nurse Midwives (CNMs); Services
and supplies furnished as incident to physician professional services; Services
of PAs, NPs and CNMs; Services of clinical psychologists and clinical social
workers (when providing diagnosis and treatment of mental illness); Services and
supplies furnished as incident to professional services provided by PAs, NPs,
CNMs, clinical psychologists, and clinical social workers; Visiting nurse
services on a part time or intermittent basis to homebound patients (limited to
areas in which there is a designated shortage of home health agencies).
Corrective Action Plan: The detailed written plan required by DCH to correct or
resolve a deficiency or event causing the assessment of a liquidated damage or
sanction against the CMO.
Corrective Action Preventive Action (CAPA): CAPA focuses on the systematic
investigation of discrepancies (failures and/or deviations) in an attempt to
prevent their reoccurrence. To ensure that corrective and preventive actions are
effective, the systematic investigation of the failure incidence is pivotal in
identifying the corrective and preventive actions undertaken.
Cost Avoidance: A method of paying Claims in which the Provider is not
reimbursed until the Provider has demonstrated that all available health
insurance has been exhausted.
Covered Services: Those Medically Necessary Health Care services provided to
Members, the payment or indemnification of which is covered under this Contract.
Credentialing: The Contractor’s determination as to the qualifications and
ascribed privileges of a specific Provider to render specific Health Care
services.
Critical Access Hospital (CAH): Critical access hospital’ means a hospital that
meets the requirements of the federal Centers for Medicare and Medicaid Services
to be designated as a critical access hospital and that is recognized by the
Department of Community Health as a critical access hospital for purposes of
Medicaid.

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Cultural Competency: A set of interpersonal skills that allow individuals to
increase their understanding, appreciation, acceptance, and respect for cultural
differences and similarities within, among and between groups and the
sensitivity to know how these differences influence relationships with Members.
This requires a willingness and ability to draw on community-based values,
traditions and customs, to devise strategies to better meet culturally diverse
Member needs, and to work with knowledgeable persons of and from the community
in developing focused interactions, communications, and other supports.
Deliverable: A document, manual or report submitted to DCH by the Contractor to
fulfill requirements of this Contract.
Department of Community Health (DCH): The Agency in the State of Georgia
responsible for oversight and administration of the Medicaid program, the
PeachCare for Kids program, and the State Health Benefits Plan (SHBP).
Department of Insurance (DOI): The Agency in the State of Georgia responsible
for licensing, overseeing, regulating, and certifying insuring entities.
Diagnostic Related Group (DRG): Any of the payment categories that are used to
classify patients and especially Medicare patients for the purpose of
reimbursing hospitals for each case in a given category with a fixed fee
regardless of the actual costs incurred and that are based especially on the
principal diagnosis, surgical procedure used, age of patient, and expected
length of stay in the hospital.
Diagnostic Services: Any medical procedures or supplies recommended by a
physician or other licensed medical practitioner, within the scope of his or her
practice under State law, to enable him or her to identify the existence, nature
or extent of illness, injury, or other health deviation in a Member.
Discharge: Point at which Member is formally released from hospital, by treating
physician, an authorized member of physician’s staff or by the Member after they
have indicated, in writing, their decision to leave the hospital contrary to the
advice of their treating physician.
Disenrollment: The removal of a Member from participation in the Contractor’s
plan, but not necessarily from the Medicaid or PeachCare for Kids program.
Documented Attempt: A bona fide, or good faith, attempt to contract with a
Provider. Such attempts may include written correspondence that outlines
contracted negotiations between the parties, including rate and contract terms
disclosure, as well as documented verbal conversations, to include date and time
and parties involved.
Durable Medical Equipment (DME): Equipment, including assistive technology,
which: a) can withstand repeated use; b) is used to service a health or
functional purpose; c) is ordered by a qualified practitioner to address an
illness, injury or disability; and d) is appropriate for use in the home, work
place, or school.

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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program: A Title
XIX mandated program that covers screening and Diagnostic Services to determine
physical and mental deficiencies in Members less than 21 years of age, and
Health Care, treatment, and other measures to correct or ameliorate any
deficiencies and Chronic Conditions discovered.
Emergency Medical Condition: A medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) that a prudent
layperson, who possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in
placing the health of the individual (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy, serious
impairments of bodily functions, or serious dysfunction of any bodily organ or
part. An Emergency Medical Condition shall not be defined on the basis of lists
of diagnoses or symptoms.
Emergency Services: Covered inpatient and outpatient services furnished by a
qualified Provider that are needed to evaluate or stabilize an Emergency Medical
Condition that is found to exist using the prudent layperson standard.
Encounter: A distinct set of health care services provided to a Medicaid or
PeachCare for Kids Member enrolled with a Contractor on the dates that the
services were delivered.
Encounter Data: Health Care Encounter Data include: (i) All data captured during
the course of a single Health Care encounter that specify the diagnoses,
comorbidities, procedures (therapeutic, rehabilitative, maintenance, or
palliative), pharmaceuticals, medical devices and equipment associated with the
Member receiving services during the Encounter; (ii) The identification of the
Member receiving and the Provider(s) delivering the Health Care services during
the single Encounter; and, (iii) A unique, i.e. unduplicated, identifier for the
single Encounter.
Enrollee: See Member.
Enrollment: The process by which an individual eligible for Medicaid or
PeachCare for Kids applies (whether voluntary or mandatory) to utilize the
Contractor’s plan in lieu of fee for service and such application is approved by
DCH or its Agent.
Enrollment Broker: The entity engaged by DCH to assist in outreach, education
and Enrollment activities associated with the GF program.
Enrollment Period: The twelve (12) month period commencing on the effective date
of Enrollment.
Evaluate: The process used to examine and determine the level of quality or the
progress toward improvement of quality and/or performance related to Contractor
service delivery systems.
External Quality Review (EQR): The analysis and evaluation by an external
quality review organization of aggregated information on quality, timeliness,
and access to the Health Care services that a CMO or its Subcontractors furnish
to Members and to DCH.

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External Quality Review Organization (EQRO): An organization that meets the
competence and independence requirements set forth in 42 CFR 438.354 and
performs external quality review, and other related activities.
Federal Financial Participation (FFP): The funding contribution that the federal
government makes to the Georgia Medicaid and PeachCare for Kids programs.
Federally Qualified Health Center (FQHC): An entity that provides outpatient
health programs pursuant to Section 1905(l) (2) (B) of the Social Security Act.
Fee-for-Service (FFS): A method of reimbursement based on payment for specific
services rendered to a Member.
Financial Relationship: A direct or indirect ownership or investment interest
(including and option or non vested interest) in any entity. This direct or
indirect interest may be in the form of equity, debt, or other means and
includes any indirect ownership or investment interest no matter how many levels
removed from a direct interest, or a compensation arrangement with an entity.
Fraud: An intentional deception or misrepresentation made by a person with the
knowledge that the deception could result in some unauthorized benefit or
financial gain to him/herself or some other person. It includes any act that
constitutes Fraud under applicable federal or State law.
Grievance: An expression of dissatisfaction about any matter other than an
action. Possible subjects for grievances include, but are not limited to, the
quality of care or services provided or aspects of interpersonal relationships
such as rudeness of a provider or employee, or failure to respect the enrollee’s
rights.
Grievance System: The overall system that includes Grievances and Appeals at the
Contractor level and access to the State Fair Hearing process (the State’s
Administrative Law Review).
Georgia Technology Authority (GTA): The state agency that manages the state’s
information technology (IT) infrastructure i.e. data center, network and
telecommunications services and security, establishes policies, standards and
guidelines for state IT, promotes an enterprise approach to state IT, and
develops and manages the state portal.
Health Care: Health Care means care, services, or supplies related to the health
of an individual. Health Care includes, but is not limited to, the following:
(i) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or
palliative care, and counseling, service, assessment, or procedure with respect
to the physical or mental Condition, or functional status, of an individual or
that affects the structure or function of the body; and (ii) Sale or dispensing
of a drug, device, equipment, or other item in accordance with a prescription.
Health Care Professional: A physician or other Health Care Professional,
including but not limited to podiatrists, optometrists, chiropractors,
psychologists, dentists, physician’s assistants, physical or occupational
therapists and therapists assistants, speech-language pathologists,
audiologists, registered or licensed practical nurses (including nurse
practitioners, clinical nurse specialist,

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certified registered nurse anesthetists, and certified nurse midwives), licensed
certified social workers, registered respiratory therapists, and certified
respiratory therapy technicians licensed in the State of Georgia.
Health Check: The State of Georgia’s Early and Periodic Screening, Diagnostic,
and Treatment program pursuant to Title XIX of the Social Security Act.
Health Insurance Portability and Accountability Act (HIPAA): A law enacted in
1996 by the Congress of the United States. When referenced in this Contract it
includes all related rules, regulations and procedures.
Health Maintenance Organization: As used in Section 8.6 a Health Maintenance
Organization is an entity, that is organized for the purpose of providing Health
Care and has a Health Maintenance Organization Certificate of Authority granted
by the State of Georgia, which contracts with Providers and furnishes Health
Care services on a prepaid, capitated basis to Members in a designated Service
Region.
Historical Provider Relationship: A Provider who has been the main source of
Medicaid or PeachCare for Kids services for the Member during the previous year
(decided on by the most recent provider on the member’s claim history).
Immediately: Within twenty-four (24) hours.
In-Network Provider: A Provider that has entered into a Provider Contract with
the Contractor to provide services.
Incentive Arrangement: Any mechanism under which a Contractor may receive
additional funds over and above the Capitation rates, for exceeding targets
specified in the Contract.
Incurred-But-Not-Reported (IBNR): Estimate of unpaid Claims liability, includes
received but unpaid Claims.
Information: i. Structured Data: Data that adhere to specific properties and
Validation criteria that is stored as fields in database records. Structured
queries can be created and run against structured data, where specific data can
be used as criteria for querying a larger data set; ii. Document: Information
that does not meet the definition of structured data includes text, files,
spreadsheets, electronic messages and images of forms and pictures.
Information System/Systems: A combination of computing hardware and software
that is used in: (a) the capture, storage, manipulation, movement, control,
display, interchange and/or transmission of information, i.e. structured data
(which may include digitized audio and video) and documents; and/or (b) the
processing of such information for the purposes of enabling and/or facilitating
a business process or related transaction.
Insolvent: Unable to meet or discharge financial liabilities.

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Limited-English-Proficient Population: Individuals with a primary language other
than English who must communicate in that language if the individual is to have
an equal opportunity to participate effectively in, and benefit from, any aid,
service or benefit provided by the health Provider.
Mandatory Enrollment: The process whereby an individual eligible for Medicaid or
PeachCare for Kids is required to enroll in a Contractor’s plan, unless
otherwise exempted or excluded, to receive covered Medicaid or PeachCare for
Kids services.
Marketing: Any communication from a CMO plan to any Medicaid or PeachCare for
Kids eligible individual that can reasonably be interpreted as intended to
influence the individual to enroll in that particular CMO plan, or not enroll in
or disenroll from another CMO plan.
Marketing Materials: Materials that are produced in any medium, by or on behalf
of a CMO, and can reasonably be interpreted as intended to market to any
Medicaid or PeachCare for Kids eligible individual.
Measurable: applies to a Contractor objective and means the ability to determine
definitively whether, or not the objective has been met, or whether progress has
been made toward a positive outcome.
Medicaid: The joint federal/state program of medical assistance established by
Title XIX of the Social Security Act, which in Georgia is administered by DCH.
Medicaid Eligible: An individual eligible to receive services under the Medicaid
Program but not necessarily enrolled in the Medicaid Program.
Medicaid Management Information System (MMIS): Computerized system used for the
processing, collecting, analysis and reporting of Information needed to support
Medicaid and SCHIP functions. The MMIS consists of all required subsystems as
specified in the State Medicaid Manual.
Medical Director: The licensed physician designated by the Contractor to
exercise general supervision over the provision of health service Benefits by
the Contractor.
Medical Records: The complete, comprehensive records of a Member including, but
not limited to, x-rays, laboratory tests, results, examinations and notes,
accessible at the site of the Member’s participating Primary Care physician or
Provider, that document all medical services received by the Member, including
inpatient, ambulatory, ancillary, and emergency care, prepared in accordance
with all applicable DCH rules and regulations, and signed by the medical
professional rendering the services.
Medical Screening: An examination: i. provided on hospital property, and
provided for that patient for whom it is requested or required, ii. performed
within the capabilities of the hospital’s

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emergency room (ER) (including ancillary services routinely available to its ER)
iii. the purpose of which is to determine if the patient has an Emergency
Medical Condition, and iv. performed by a physician (M.D. or D.O.) and/or by a
nurse practitioner, or physician assistant as permitted by State statutes and
regulations and hospital bylaws.
Medically Necessary Services: Those services that meet the definition found in
Section 4.5.
Member: A Medicaid or PeachCare for Kids recipient who is currently enrolled in
a CMO plan.
Methodology: Means the planned process, steps, activities or actions taken by a
Contractor to achieve a goal or objective, or to progress toward a positive
outcome.
Monitoring: Means the process of observing, evaluating, analyzing and conducting
follow-up activities.
National Committee for Quality Assurance (NCQA): An organization that sets
standards, and evaluates and accredits health plans and other managed care
organizations.
Net Capitation Payment: The Capitation Payment made by DCH to Contractor less
any quality assessment fee made by Contractor to DCH. This payment amount also
excludes a payment to a Contractor for obstetrical or other medical services
that are on a per occurrence basis rather than a per member basis.
Non-Emergency Transportation (NET): A ride, or reimbursement for a ride,
provided so that a Member with no other transportation resources can receive
services from a medical provider. NET does not include transportation provided
on an emergency basis, such as trips to the emergency room in life threatening
situations.
Non-Institutional Claims: Claims submitted by a medical Provider other than a
hospital, nursing facility, or intermediate care facility/mentally retarded
(ICF/MR).
Nurse Practitioner Certified (NP-C): A registered professional nurse who is
licensed by the State of Georgia and meets the advanced educational and clinical
practice requirements beyond the two or four years of basic nursing education
required of all registered nurses.
Objective: Means a measurable step, generally in a series of progressive steps,
to achieve a goal.
Obstetrical Delivery Payment: A payment, fixed in advance, that DCH makes to a
Contractor for each birth of a child to a Member. The Contractor is responsible
for all medical services related to the delivery of the Member’s child.
Out-of-Network Provider: A Provider of services that does not have a Provider
contract with the Contractor.
PeachCare for Kids: The State of Georgia’s State Children’s Health Insurance
Program established pursuant to Title XXI of the Social Security Act.

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Performance Improvement Project (PIP): Means a planned process of data
gathering, evaluation and analysis to determine interventions or activities that
are projected to have a positive outcome. A PIP includes measuring the impact of
the interventions or activities toward improving the quality of care and service
delivery.
Pharmacy Benefit Manager (PBM): An entity responsible for the provision and
administration of pharmacy benefit management services including but not limited
to claims processing and maintenance of associated systems and related
processes.
Physician Assistant (PA) — A trained, licensed individual who performs tasks
that might otherwise be performed by physicians or under the direction of a
supervising physician.
Physician Incentive Plan: Any compensation arrangement between a Contractor and
a physician or physician group that may directly have the effect of reducing or
limiting services furnished to Members.
Post-Stabilization Services: Covered Services, related to an Emergency Medical
Condition that are provided after a member is stabilized in order to maintain
the stabilized condition or to improve or resolve the member’s condition.
Potential Enrollee: See Potential Member.
Potential Member: A Medicaid or SCHIP recipient who is subject to mandatory
Enrollment in a care management program but is not yet the Member of a specific
CMO plan.
Pre-Certification: Review conducted prior to a Member’s admission, stay or other
service or course of treatment in a hospital or other facility.
Prevalent Non-English Language: A language other than English, spoken by a
significant number or percentage of potential Members and Members in the State.
Preventive Services: Services provided by a physician or other licensed health
practitioner within the scope of his or her practice under State law to: prevent
disease, disability, and other health Conditions or their progression; treat
potential secondary Conditions before they happen or at an early remediable
stage; prolong life; and promote physical and mental health and efficiency.
Primary Care: All Health Care services and laboratory services, including
periodic examinations, preventive Health Care and counseling, immunizations,
diagnosis and treatment of illness or injury, coordination of overall medical
care, record maintenance, and initiation of Referrals to specialty Providers
described in this Contract, and for maintaining continuity of patient care.
These services are customarily furnished by or through a general practitioner,
family physician, internal medicine physician, obstetrician/gynecologist, or
pediatrician, and may be furnished by a nurse practitioner to the extent the
furnishing of those services is legally authorized in the State in which the
practitioner furnishes them.

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Primary Care Provider (PCP): A licensed medical doctor (MD) or doctor of
osteopathy (DO) or certain other licensed medical practitioner who, within the
scope of practice and in accordance with State certification/licensure
requirements, standards, and practices, is responsible for providing all
required Primary Care services to Members. A PCP shall include general/family
practitioners, pediatricians, internists, physician’s assistants, CNMs or NP-Cs,
provided that the practitioner is able and willing to carry out all PCP
responsibilities in accordance with these Contract provisions and licensure
requirements.
Prior Authorization: (also known as “pre-authorization” or “prior approval”).
Authorization granted in advance of the rendering of a service after appropriate
medical review.
Proposed Action: The proposal of an action for the denial or limited
authorization of a requested service, including the type or level of service;
the reduction, suspension, or termination of a previously authorized service;
the denial, in whole or part of payment for a service; the failure to provide
services in a timely manner; or the failure of the CMO to act within the time
frames provided in 42 CFR 438.408(b).
Prospective Payment System (PPS): A method of reimbursement in which Medicare
payment is made based on a predetermined, fixed amount. The payment amount for a
particular service is derived based on the classification system of that service
(for example, DRGs for inpatient hospital services). CMS uses separate PPSs for
reimbursement to acute inpatient hospitals, home health agencies, hospice,
hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation
facilities, long-term care hospitals, and skilled nursing facilities.
Provider: Any physician, hospital, facility, or other Health Care Professional
who is licensed or otherwise authorized to provide Health Care services in the
State or jurisdiction in which they are furnished.
Provider Complaint: A written expression by a Provider, which indicates
dissatisfaction or dispute with the Contractor’s policies, procedures, or any
aspect of a Contractor’s administrative functions, including a Proposed Action.
Provider Contract: Any written contract between the Contractor and a Provider
that requires the Provider to perform specific parts of the Contractor’s
obligations for the provision of Health Care services under this Contract.
Quality: The degree to which a CMO increases the likelihood of desired health
outcomes of its Members through its structural and operational characteristics,
and through the provision of health services that are consistent with current
professional knowledge.
Referral: A request by a PCP for a Member to be evaluated and/or treated by a
different physician, usually a specialist.
Referral Services: Those Health Care services provided by a health professional
other than the Primary Care Provider and which are ordered and approved by the
Primary Care Provider or the Contractor.

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Reinsurance: An agreement whereby the Contractor transfers risk or liability for
losses, in whole or in part, sustained under this Contract. A reinsurance
agreement may also exist at the Provider level.
(Claims) Reprocessing: Upon determination of the need to correct the outcome of
one or more claims processing transactions, the subsequent attempt to process a
single claim or batch of claims.
Remedy: The State’s means to enforce the terms of the Contract through
performance guarantees and other actions.
Risk Contract: A Contract under which the Contractor assumes financial risk for
the cost of the services covered under the Contract, and may incur a loss if the
cost of providing services exceeds the payments made by DCH to the Contractor
for services covered under the Contract.
Routine Care: Treatment of a Condition that would have no adverse effects if not
treated within twenty-four (24) hours or could be treated in a less acute
setting (e.g., physicians office) or by the patient.
Rural Health Clinic (RHC): A clinic certified to receive special Medicare and
Medicaid reimbursement. The purpose of the RHC program is improving access to
primary care in underserved rural areas. RHCs are required to use a team
approach of physicians and midlevel practitioners (nurse practitioners,
physician assistants, and certified nurse midwives) to provide services. The
clinic must be staffed at least 50% of the time with a midlevel practitioner.
RHCs may also provide other health care services, such as mental health or
vision services, but reimbursement for those services may not be based on their
allowable costs.
Rural Health Services: Medical services provided to rural sparsely populated
areas isolated from large metropolitan counties.
Scope of Services: Those specific Health Care services for which a Provider has
been credentialed, by the plan, to provide to Members.
Service Authorization: A Member’s request for the provision of a service.
Service Region: A geographic area comprised of those counties where the
Contractor is responsible for providing adequate access to services and
Providers.
Short Term: A period of thirty (30) Calendar Days or less.
Significant Traditional Providers: Those Providers that provided the top eighty
percent (80%) of Medicaid encounters for the GMC-eligible population in the base
year of 2004.
Span of Control: Information systems and telecommunications capabilities that
the CMO itself operates or for which it is otherwise legally responsible
according to the terms and Conditions of this Contract. The CMO span of control
also includes Systems and telecommunications capabilities outsourced by the CMO.

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Stabilized: With respect to an emergency medical condition; that no material
deterioration of the condition is likely, within reasonable medical probability,
to result from or occur during the transfer of the individual from a facility,
or , with respect to a woman in labor, the woman has delivered (including the
placenta).
State: The State of Georgia.
State Children’s Health Insurance Program (SCHIP): A joint federal-state Health
Care program for targeted, low-income children, established pursuant to Title
XXI of the Social Security Act. Georgia’s SCHIP program is called PeachCare for
Kids.
State Fair Hearing: See Administrative Law Hearing
Subcontract: Any written contract between the Contractor and a third party,
including a Provider, to perform a specified part of the Contractor’s
obligations under this Contract.
Subcontractor: Any third party who has a written Contract with the Contractor to
perform a specified part of the Contractor’s obligations under this Contract.
Subcontractor Payments: Any amounts the Contractor pays a Provider or
Subcontractor for services they furnish directly, plus amounts paid for
administration and amounts paid (in whole or in part) based on use and costs of
Referral Services (such as Withhold amounts, bonuses based on Referral levels,
and any other compensation to the physician or physician group to influence the
use for Referral Services). Bonuses and other compensation that are not based on
Referral levels (such as bonuses based solely on quality of care furnished,
patient satisfaction, and participation on committees) are not considered
payments for purposes of Physician Incentive Plans.
System Access Device: A device used to access System functions; can be any one
of the following devices if it and the System are so configured: i. Workstation
(stationary or mobile computing device) ii. Network computer/“winterm” device,
iii. “Point of Sale” device, iv. Phone, v. Multi-function communication and
computing device, e.g. PDA.
System Unavailability: Failure of the system to provide a designated user access
based on service level agreements or software/hardware problems within the
contractors span of control.
System Function Response Time: Based on the specific sub function being
performed,
Record Search Time-the time elapsed after the search command is entered until
the list of matching records begins to appear on the monitor.
Record Retrieval Time-the time elapsed after the retrieve command is entered
until the record data begin to appear on the monitor.
Print Initiation Time- the elapsed time from the command to print a screen or
report until it appears in the appropriate queue.
On-line Claims Adjudication Response Time- the elapsed time from the receipt of
the transaction by the Contractor from the Provider and/or switch vendor until
the Contractor hands-off a response to the Provider and/or switch vendor.

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Systems: See Information Systems.
Telecommunication Device for the Deaf (TDD): Special telephony devices with
keyboard attachments for use by individuals with hearing impairments who are
unable to use conventional phones.
Third Party Resource: Any person, institution, corporation, insurance company,
public, private or governmental entity who is or may be liable in Contract,
tort, or otherwise by law or equity to pay all or part of the medical cost of
injury, disease or disability of an applicant for or recipient of medical
assistance.
Urgent Care: Medically Necessary treatment for an injury, illness, or another
type of Condition (usually not life threatening) which should be treated within
twenty-four (24) hours.
Utilization: The rate patterns of service usage or types of service occurring
within a specified time.
Utilization Management (UM): A service performed by the Contractor which seeks
to assure that Covered Services provided to Members are in accordance with, and
appropriate under, the standards and requirements established by the Contractor,
or a similar program developed, established or administered by DCH.
Utilization Review (UR): Evaluation of the clinical necessity, appropriateness,
efficacy, or efficiency of Health Care services, procedures or settings, and
ambulatory review, prospective review, concurrent review, second opinions, care
management, discharge planning, or retrospective review.
Validation: The review of information, data, and procedures to determine the
extent to which they are accurate, reliable, free from bias and in accord with
standards for data collection and analysis.
Week: The traditional seven-day week, Sunday through Saturday.
Withhold: A percentage of payments or set dollar amounts that a Contractor
deducts from a practitioner’s service fee, Capitation, or salary payment, and
that may or may not be returned to the physician, depending on specific
predetermined factors.
Working Days: Monday through Friday but shall not include Saturdays, Sundays, or
State and Federal Holidays.
Work Week: The traditional work week, Monday through Friday.

1.5   ACRONYMS

AFDC — Aid to Families with Dependent Children

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AICPA — American Institute of Certified Public Accountants
CAH — Critical Access Hospital
CAP — Corrective Action Plan
CAPA — Corrective Action Preventive Action
CDC — Centers for Disease Control
CFR — Code of Federal Regulations
CMO — Care Management Organization
CMS — Centers for Medicare & Medicaid Services
CNM — Certified Nurse Midwives
CSB — Community Service Boards
DCH — Department of Community Health
DME — Durable Medical Equipment
DOI — Department of Insurance
EB — Enrollment Broker
EPSDT — Early and Periodic Screening, Diagnostic, and Treatment
EQR — External Quality Review
EQRO — External Quality Review Organization
EVS — Eligibility Verification System
FFS — Fee-for-Service
FQHC — Federally Qualified Health Center
GF — Georgia Families
GTA — Georgia Technology Authority
HHS — US Department of Health and Human Services

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HIPAA — Health Insurance Portability and Accountability Act
HMO — Health Management Organization
IBNR — Incurred-But-Not-Reported
INS — U.S. Immigration and Naturalization Services
LIM — Low-Income Medicaid
MMIS — Medicaid Management Information System
NAIC — National Association of Insurance Commissioners
NCQA — National Committee for Quality Assurance
NET — Non-Emergency Transportation
NP-C — Certified Nurse Practitioners
NPI — National Provider Identifier
PA — Physician Assistant
PBM — Pharmacy Benefit Manager
PCP — Primary Care Provider
PPS — Prospective Payment System
QAPI — Quality Assessment Performance Improvement
RHC — Rural Health Clinic
RSM — Right from the Start Medicaid
SCHIP — State Children’s Health Insurance Program
SSA — Social Security Act
TANF — Temporary Assistance for Needy Families
TDD — Telecommunication Device for the Deaf
UM — Utilization Management

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UPIN — Unique Physician Identifier Number
UR — Utilization Review

2.0   DCH RESPONSIBILITIES   2.1   GENERAL PROVISIONS   2.1.1   DCH is
responsible for administering the GF program. The agency will administer
Contracts, monitor Contractor performance, and provide oversight in all aspects
of the Contractor operations.   2.2   LEGAL COMPLIANCE   2.2.1   DCH will comply
with, and will monitor the Contractor’s compliance with, all applicable State
and federal laws and regulations.   2.3   ELIGIBILITY AND ENROLLMENT

2.3.1   The State of Georgia has the sole authority for determining eligibility
for the Medicaid program and whether Medicaid beneficiaries are eligible for
Enrollment in GF. DCH or its Agent will determine eligibility for PeachCare for
Kids and will collect applicable premiums. DCH or its agent will continue
responsibility for the electronic eligibility verification system (EVS).   2.3.2
  DCH or its Agent will review the Medicaid Management Information System
(MMIS) file daily and send written notification and information within two
(2) Business Days to all Members who are determined eligible for GF. A Member
shall have thirty (30) Calendar Days to select a CMO plan and a PCP. Each Family
Head of Household shall have thirty (30) Calendar Days to select one (1) CMO
plan for the entire Family and PCP for each member. DCH or its Agent will issue
a monthly notice of all Enrollments to the CMO plan.   2.3.3   If the Member
does not choose a CMO plan within thirty (30) Calendar Days of being deemed
eligible for GF, DCH or its Agent will Auto-Assign the individual to a CMO plan
using the following algorithm:

  2.3.3.1   If an immediate family member(s) of the Member is already enrolled
in one CMO plan, the Member will be Auto-Assigned to that plan;     2.3.3.2   If
there are no immediate family members already enrolled and the Member has a
Historical Provider Relationship with a Provider, the Member will be
Auto-Assigned to the CMO plan where the Provider is contracted;

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  2.3.3.3   If the Member does not have a Historical Provider Relationship with
a Provider in any CMO plan, or the Provider contracts with all plans, the Member
will be Auto-Assigned to the CMO plan that has the lowest capitated rates in the
Service Region.

2.3.4   Enrollment, whether chosen or Auto-Assigned, will be effective at
12:01 a.m. on the first (1st) Calendar Day of the month following the Member
selection or Auto-Assignment, for those Members assigned on or between the first
(1st) and twenty-fourth (24th) Calendar Day of the month. For those Members
assigned on or between the twenty-fifth (25th) and thirty-first (31st) Calendar
Day of the month, Enrollment will be effective at 12:01 a.m. on the first (1st)
Calendar Day of the second (2nd) month after assignment.   2.3.5   In the
future, at a date to be determined by DCH, DCH or its Agent may include quality
measures in the Auto-Assignment algorithm. Members will be Auto-Assigned to
those plans that have higher scores on quality measures to be defined by DCH.
This factor will be applied after determining that there are no Historical
Provider Relationships, but prior to utilizing the lowest Capitation rates
criteria.   2.3.6   In the Atlanta Service Region, DCH will limit enrollment in
a single plan to no more than forty percent (40%) of total GF eligible lives in
the Service Region. Members will not be Auto-Assigned to a CMO plan unless a
family member is enrolled in the CMO plan or a Historical Provider Relationship
exists with a Provider that does not participate in any other CMO plan in the
Atlanta Service Region. DCH may, at its sole discretion, elect to modify this
threshold for reasons it deems necessary and proper.   2.3.7   In the five
(5) Service Regions other than Atlanta DCH will limit Enrollment in a single
plan to no more than sixty-five percent (65%) of total GF eligible lives in the
Service Region. Members will not be Auto-Assigned to a CMO plan unless a family
member is enrolled in the CMO plan or a Historical Provider Relationship exists
with a Provider that does not participate in any other CMO plan in the Service
Region. Enrollment limits will be figured once per quarter at the beginning of
each quarter.   2.3.8   DCH or its Agent will have five (5) Business Days to
notify Members and the CMO plan of the Auto-Assignment. Notice to the Member
will be made in writing and sent via surface mail. Notice to the CMO plan will
be made via file transfer.   2.3.9   DCH or its Agent will be responsible for
the consecutive Enrollment period and re-Enrollment functions.   2.3.10  
Conditioned on continued eligibility, all Members will be enrolled in a CMO plan
for a period of twelve (12) consecutive months. This consecutive Enrollment
period will commence on the first (1st) day of Enrollment or upon the date the
notice is sent, whichever is later. If a Member disenrolls from one CMO plan and
enrolls in a

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    different CMO plan, consecutive Enrollment period will begin on the
effective date of Enrollment in the second (2nd) CMO plan.   2.3.11   DCH or its
Agent will automatically enroll a Member into the CMO plan in which he or she
was most recently enrolled if the Member has a temporary loss of eligibility,
defined as less than sixty (60) Calendar Days. In this circumstance, the
consecutive Enrollment period will continue as though there has been no break in
eligibility, keeping the original twelve (12) month period.   2.3.12   DCH or
its Agent will notify Members at least once every twelve (12) months, and at
least sixty (60) Calendar Days prior to the date upon which the consecutive
Enrollment period ends (the annual Enrollment opportunity), that they have the
opportunity to switch CMO plans. Members who do not make a choice will be deemed
to have chosen to remain with their current CMO plan.   2.3.13   In the event a
temporary loss of eligibility has caused the Member to miss the annual
Enrollment opportunity, DCH or its Agent will enroll the Member in the CMO plan
in which he or she was enrolled prior to the loss of eligibility. The member
will receive a new 60-calendar day notification period beginning the first day
of the next month.   2.3.14   In accordance with current operations, the State
will issue a Medicaid number to a newborn upon notification from the hospital,
or other authorized Medicaid provider.   2.3.15   Upon notification from a CMO
plan that a Member is an expectant mother, DCH or its Agent shall mail a newborn
enrollment packet to the expectant mother. This packet shall include information
that the newborn will be Auto-Assigned to the mother’s CMO plan and that she
may, if she wants, select a PCP for her newborn prior to the birth by contacting
her CMO plan. The mother shall have ninety (90) Calendar Days from the day a
Medicaid number was assigned to her newborn to choose a different CMO plan.  
2.4   DISENROLLMENT   2.4.1   DCH or its Agent will process all CMO plan
Disenrollments. This includes Disenrollments due to non-payment of the PeachCare
for Kids premiums, loss of eligibility for GF due to other reasons, and all
Disenrollment requests Members or CMO plans submit via telephone, surface mail,
internet, facsimile, and in person.   2.4.2   DCH or its Agent will make final
determinations about granting Disenrollment requests and will notify the CMO
plan via file transfer and the Member via surface mail of any Disenrollment
decision within five (5) Calendar Days of making the final determination   2.4.3
  Whether requested by the Member or the Contractor the following are the
Disenrollment timeframes:

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  2.4.3.1   If the Disenrollment request is received by DCH or its agent on or
before the managed care monthly process on the twenty-fourth (24th) Calendar Day
of the month, the Disenrollment will be effective at midnight the first (1st)
day of the month following the month in which the request was filed; and    
2.4.3.2   If the Disenrollment request is received by DCH or its agent after the
managed care monthly process on the twenty-fourth (24th) Calendar Day of the
month, the Disenrollment will be effective at midnight the first (1st) day of
the second (2nd) month following the month in which the request was filed.    
2.4.3.3   If a Member is hospitalized in an inpatient facility on the first day
of the month their Disenrollment is to be effective, the Member will remain
enrolled until the month following their discharge from the inpatient facility.

2.4.4   When Disenrollment is necessary due to a change in eligibility category,
or eligibility for GF, the Member will be disenrolled according to the
timeframes identified in Section 2.4.3.   2.4.5   When disenrollment is
necessary because a Member loses Medicaid or PeachCare for Kids eligibility (for
example, he or she has died, been incarcerated, or moved out-of-state)
disenrollment shall be immediate.   2.5   MEMBER SERVICES AND MARKETING   2.5.1
  DCH will provide to the Contractor its methodology for identifying the
prevalent non-English languages spoken. For the purposes of this Section,
prevalent means a non-English language spoken by a significant number or
percentage of Medicaid and PeachCare for Kids eligible individuals in the State.
  2.5.2   DCH will review and prior approve all marketing materials.   2.6  
COVERED SERVICES & SPECIAL COVERAGE PROVISIONS   2.6.1   DCH will use submitted
Encounter Data, and other data sources, to determine Contractor compliance with
federal requirements that eligible Members under the age of twenty-one (21)
receive periodic screens and preventive/well child visits in accordance with the
specified periodicity schedule. DCH will use the participant ratio as calculated
using the CMS 416 methodology for measuring the Contractor’s performance.   2.7
  NETWORK

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2.7.1   DCH will provide to the Contractor up-to-date changes to the State’s
list of excluded Providers, as well as any additional information that will
affect the Contractor’s Provider network.   2.7.2   DCH will consider all
Contractors’ requests to waive network geographic access requirements in rural
areas. All such requests shall be submitted in writing.   2.7.3   DCH will
provide the State’s Provider Credentialing policies to the Contractor upon
execution of this Contract.   2.8   QUALITY MONITORING   2.8.1   DCH will have a
written strategy that the contractor fully cooperates with DCH’s Quality
Monitoring reviews by providing at a minimum information for review that
supports it’s compliance with the items being monitored. In accordance with 42
CFR 438.204, this strategy will, at a minimum, monitor:

  2.8.1.1   The availability of services;     2.8.1.2   The adequacy of the
Contractor’s capacity and services;     2.8.1.3   The Contractor’s coordination
and continuity of care for Members;     2.8.1.4   The coverage and authorization
of services;     2.8.1.5   The Contractor’s policies and procedures for
selection and retention of Providers;     2.8.1.6   The Contractor’s compliance
with Member information requirements in accordance with 42 CFR 438.10;    
2.8.1.7   The Contractor’s compliance with State and federal privacy laws and
regulations relative to Member’s confidentiality;     2.8.1.8   The Contractor’s
compliance with Member Enrollment and Disenrollment requirements and
limitations;     2.8.1.9   The Contractor’s Grievance System;     2.8.1.10   The
Contractor’s oversight of all Subcontractor relationships and delegations;    
2.8.1.11   The Contractor’s adoption of practice guidelines, including the
dissemination of the guidelines to Providers and Providers’ application of them;
    2.8.1.12   The Contractor’s quality assessment and performance improvement
program; and

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  2.8.1.13   The Contractor’s health information systems.     2.8.1.14   The
Contractor shall respond to requests for information within stipulated time
frame.

2.9   COORDINATION WITH CONTRACTOR’S KEY STAFF   2.9.1   DCH will make diligent
good faith efforts to facilitate effective and continuous communication and
coordination with the Contractor in all areas of GF operations.   2.9.2  
Specifically, DCH will designate individuals within the department who will
serve as a liaison to the corresponding individual on the Contractor’s staff,
including:

  2.9.2.1   A program integrity staff Member;     2.9.2.2   A quality oversight
staff Member;     2.9.2.3   A Grievance System staff Member who will also ensure
that the State Administrative Law Hearing process is consistent with the Rules
of the Office of the State Administrative Hearings Chapter 616-1-2 and with any
other applicable rule, regulation, or procedure whether State or federal;    
2.9.2.4   An information systems coordinator; and     2.9.2.5   A vendor
management staff Member.  

2.10   FORMAT STANDARDS   2.10.1   DCH will provide to the Contractor its
standards for formatting all Reports requested of the Contractor. DCH will
require that all Reports be submitted electronically.   2.11   FINANCIAL
MANAGEMENT   2.11.1   In order to facilitate the Contractor’s efforts in using
Cost Avoidance processes to ensure that primary payments from the liable third
party are identified and collected to offset medical expenses; DCH will include
information about known Third Party Resources on the electronic Enrollment data
given to the Contractor.   2.11.2   DCH will monitor Contractor compliance with
federal and State physician incentive plan rules and regulations.   2.12  
INFORMATION SYSTEMS   2.12.1   DCH will supply the following information to the
Contractor:

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  2.12.1.1   Application and database design and development requirements
(standards) that are specific to the State of Georgia.     2.12.1.2   Networking
and data communications requirements (standards) that are specific to the State
of Georgia.     2.12.1.3   Specific information for integrity controls and audit
trail requirements.     2.12.1.4   State web portal (Georgia.gov) integration
standards and design guidelines.     2.12.1.5   Specifications for data files to
be transmitted by the Contractor to DCH and/or its agents.     2.12.1.6  
Specifications for point-to-point, uni-directional or bi-directional interfaces
between Contractor and DCH systems.

2.13   READINESS OR ANNUAL REVIEW   2.13.1   DCH will conduct a readiness review
of each new CMO at least 30 days prior to Enrollment of Medicaid and/or
PeachCare for Kids™ recipients in the CMO plan and an annual review of each
existing CMO plan. The readiness and financial review will include, one (1) or
more as needed as determined by DCH on-site review. DCH will conduct the reviews
to provide assurances that the Contractor is able and prepared to perform all
administrative functions and is providing for high quality of services to
Members.   2.13.2   Specifically, DCH’s review will document the status of the
Contractor with respect to meeting program standards set forth in this Contract,
as well as any goals established by the Contractor. A multidisciplinary team
appointed by DCH will conduct the readiness and annual review. The scope of the
reviews will include, but not be limited to, review and/or verification of:

  2.13.2.1   Network Provider composition and access;     2.13.2.2   Staff;    
2.13.2.3   Marketing materials;     2.13.2.4   Content of Provider agreements;  
  2.13.2.5   EPSDT plan;     2.13.2.6   Member services capability;

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  2.13.2.7   Comprehensiveness of quality and Utilization Management strategies;
    2.13.2.8   Policies and procedures for the Grievance System and Complaint
System;     2.13.2.9   Financial solvency;     2.13.2.10   Contractor litigation
history, current litigation, audits and other government investigations both in
Georgia and in other states; and     2.13.2.11   Information systems’ Claims
payment system performance and interfacing capabilities.

2.13.3   The readiness review may assess the Contractor’s ability to meet any
requirements set forth in this Contract and the documents referenced herein.  
2.13.4   Members may not be enrolled in a CMO plan until DCH has determined that
the Contractor is capable of meeting these standards. A Contractor’s failure to
pass the readiness review 30 days prior to the beginning of service delivery may
result in immediate Contract termination. Contractor’s failure to pass the
annual review may result in corrective action and pending contract termination.
  2.13.5   DCH will provide the Contractor with a summary of the findings as
well as areas requiring remedial action.   3.0   GENERAL CONTRACTOR
RESPONSIBILITIES   3.1   The Contractor shall immediately notify DCH of any of
the following:   3.1.1   Change in business address, telephone number, facsimile
number, and e-mail address;   3.1.2   Change in corporate status or nature;  
3.1.3   Change in business location;   3.1.4   Change in solvency;   3.1.5  
Change in corporate officers, executive employees, or corporate structure;  
3.1.6   Change in ownership, including but not limited to the new owner’s legal
name, business address, telephone number, facsimile number, and e-mail address;
  3.1.7   Change in incorporation status; or   3.1.8   Change in federal
employee identification number or federal tax identification number.

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3.1.9   Change in CMO litigation history, current litigation, audits and other
government investigations both in Georgia and in other states.   3.2   The
Contractor shall not make any changes to any of the requirements herein, without
explicit written approval from Commissioner of DCH, or his or her designee.  
4.0   SPECIFIC CONTRACTOR RESPONSIBILITIES       The Contractor shall complete
the following actions, tasks, obligations, and responsibilities:   4.1  
ENROLLMENT   4.1.1   Enrollment Procedures

  4.1.1.1   DCH or its Agent is responsible for Enrollment, including
auto-assignment of a CMO plan; Disenrollment; education; and outreach
activities. The Contractor shall coordinate with DCH and its Agent as necessary
for all Enrollment and Disenrollment functions.     4.1.1.2   DCH or its Agent
will make every effort to ensure that recipients ineligible for Enrollment in GF
are not enrolled in GF. However, to ensure that such recipients are not enrolled
in GF, the Contractor shall assist DCH or its Agent in the identification of
recipients that are ineligible for Enrollment in GF, as discussed in
Section 1.2.3, should such recipients inadvertently become enrolled in GF.    
4.1.1.3   The Contractor shall assist DCH or its Agent in the identification of
recipients that become ineligible for Medicaid (for example, those who have
died, been incarcerated, or moved out-of-state).     4.1.1.4   The Contractor
shall accept all individuals for enrollment without restrictions. The Contractor
shall not discriminate against individuals on the basis of religion, gender,
race, color, or national origin, and will not use any policy or practice that
has the effect of discriminating on the basis of religion, gender, race, color,
or national origin or on the basis of health, health status, pre-existing
Condition, or need for Health Care services.

4.1.2   Selection of a Primary Care Provider (PCP)

  4.1.2.1   At the time of plan selection, Members, with counseling and
assistance from DCH or its Agent, will choose an In-Network PCP. If a Member
fails to select a PCP, or if the Member has been Auto-Assigned to the CMO plan,
the Contractor shall Auto-Assign Members to a PCP based on the following
algorithm:

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  4.1.2.1.1   Assignment shall be made to a Provider with whom, based on FFS
Claims history, the Member has a Historical Provider Relationship, provided that
the geographic access requirements in 4.8.13 are met;     4.1.2.1.2   If there
is no Historical Provider Relationship the Member shall be Auto-Assigned to a
Provider who is the assigned PCP for an immediate family member enrolled in the
CMO plan, if the Provider is an appropriate Provider based on the age and gender
of the Member;     4.1.2.1.3   If other immediate family members do not have an
assigned PCP, Auto-Assignment shall be made to a Provider with whom a family
member has a Historical Provider Relationship; if the Provider is an appropriate
Provider based on the age and gender of the Member;     4.1.2.1.4   If there is
no Member or immediate family member historical usage Members shall be
Auto-Assigned to a PCP, using an algorithm developed by the Contractor, based on
the age and sex of the Member, and geographic proximity.

  4.1.2.2   PCP assignment shall be effective immediately. The Contractor shall
notify the Member via surface mail of their Auto-Assigned PCP within ten
(10) Calendar Days of Auto-Assignment.     4.1.2.3   The Contractor shall submit
its PCP Auto-Assignment Policies and Procedures to DCH for review and approval
within sixty (60) Calendar Days of Contract Award and as updated thereafter.

4.1.3   Newborn Enrollment

  4.1.3.1   All newborns shall be Auto-Assigned by DCH or its Agent to the
mother’s CMO plan.     4.1.3.2   The Contractor shall be responsible for
notifying DCH or its Agent of any Members who are expectant mothers at least
sixty (60) Calendar Days prior to the expected date of delivery. The Contractor
shall be responsible for notifying DCH or its Agent of newborns born to enrolled
members that do not appear on a monthly roster within 60 days of birth.    
4.1.3.3   The Contractor shall provide assistance to any expectant mother who
contacts them wishing to make a PCP selection for her newborn and record that
selection.     4.1.3.4   Within twenty-four (24) hours of the birth, the
Contractor shall ensure the submission of a newborn notification form to DCH or
its agent. If the mother has made a PCP selection, this information shall be
included in the newborn

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      notification form. If the mother has not made a PCP selection, the
Contractor shall Auto-Assign the newborn to a PCP within thirty (30) days of the
birth. Auto-Assignment shall be made using the algorithm described in
Section 4.1.2.1. Notice of the PCP Auto-Assignment shall be mailed to the mother
within twenty-four (24) hours.

4.1.4   Reporting Requirements

  4.1.4.1   The Contractor shall submit to DCH weekly Member Information Reports
as described in Section 4.18.2.1.     4.1.4.2   The Contractor shall submit to
DCH monthly Eligibility and Enrollment Reconciliation Reports as described in
Section 4.18.3.2.

4.2   DISENROLLMENT   4.2.1   Disenrollment Initiated by the Member

  4.2.1.1   A Member may request Disenrollment from a CMO plan without cause
during the ninety (90) Calendar Days following the date of the Member’s initial
Enrollment with the CMO plan or the date DCH or its Agent sends the Member
notice of the Enrollment, whichever is later. A Member may request Disenrollment
without cause every twelve (12) months thereafter.     4.2.1.2   A Member may
request Disenrollment from a CMO plan for cause at any time. The following
constitutes cause for Disenrollment by the Member:     4.2.1.2.1   The Member
moves out of the CMO plan’s Service Region;     4.2.1.2.2   The CMO plan does
not, because of moral or religious objections, provide the Covered Service the
Member seeks;     4.2.1.2.3   The Member needs related services to be performed
at the same time and not all related services are available within the network.
The Member’s Provider or another Provider have determined that receiving service
separately would subject the Member to unnecessary risk;     4.2.1.2.4   The
Member requests to be assigned to the same CMO plan as family members; and    
4.2.1.2.5   The Member’s Medicaid eligibility category changes to a category
ineligible for GF, and/or the Member otherwise becomes ineligible to participate
in GF.     4.2.1.2.6   Other reasons, per 42 CFR 438.56(d)(2), include, but are
not limited to, poor quality of care, lack of access to services covered under
the

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      Contract, or lack of Providers experienced in dealing with the Member’s
Health Care needs. (DCH or its Agent shall make determination of these reasons.)

  4.2.1.3   The Contractor shall provide assistance to Members seeking to
disenroll. This assistance shall consist of providing the forms to the Member
and referring the Member to DCH or its Agent who will make Disenrollment
determinations.

4.2.2   Disenrollment Initiated by the Contractor

  4.2.2.1   The Contractor shall complete all Disenrollment paperwork for
Members it is seeking to disenroll.     4.2.2.2   The Contractor shall notify
DCH or its Agent upon identification of a Member who it knows or believes meets
the criteria for Disenrollment, as defined in Section 4.2.3.1.     4.2.2.3  
Prior to requesting Disenrollment of a Member for reasons described in
Sections 4.2.3.1.1, 4.2.3.1.2, and 4.2.3.1.3 the Contractor shall document at
least three (3) interventions over a period of ninety (90) Calendar Days that
occurred through treatment, case management, and Care Coordination to resolve
any difficulty leading to the request. The Contractor shall provide at least one
(1) written warning to the Member, certified return receipt requested, regarding
implications of his or her actions. DCH recommends that this notice be delivered
within ten (10) Business Days of the Member’s action.     4.2.2.4   If the
Member has demonstrated abusive or threatening behavior as defined by DCH, only
one (1) written attempt to resolve the difficulty is required.     4.2.2.5   The
Contractor shall cite to DCH or its Agent at least one (1) acceptable reason for
Disenrollment outlined in Section 4.2.3 before requesting Disenrollment of the
Member.     4.2.2.6   The Contractor shall submit Disenrollment requests to DCH
or its Agent and the Contractor shall honor all Disenrollment determinations
made by DCH or its Agent. DCH’s decision on the matter shall be final,
conclusive and not subject to appeal.

4.2.3   Acceptable Reasons for Disenrollment Investigation Requests by
Contractor

  4.2.3.1   The Contractor may request Disenrollment if:

  4.2.3.1.1   The Member demonstrates a pattern of disruptive or abusive
behavior that could be construed as non-compliant and is not caused by a
presenting illness;

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  4.2.3.1.2   The Member’s Utilization of services is Fraudulent or abusive;    
4.2.3.1.3   The Member has moved out of the Service Region;     4.2.3.1.4   The
Member is placed in a long-term care nursing facility, State institution, or
intermediate care facility for the mentally retarded;     4.2.3.1.5   The
Member’s Medicaid eligibility category changes to a category ineligible for GF,
and/or the Member otherwise becomes ineligible to participate in GF.
Disenrollments due to Member eligibility will follow the normal monthly process
as described in Section 2.4.3. Disenrollments will be processed as of the date
that the member eligibility category actually changes and will not be made
retroactive, regardless of the effective date of the new eligibility category.
Note exception when SSI members are hospitalized.     4.2.3.1.6   The Member has
any other condition as so defined by DCH; or     4.2.3.1.7   The Member has
died, been incarcerated, or moved out of State, thereby making them ineligible
for Medicaid.

4.2.4   Unacceptable Reasons for Disenrollment Requests by Contractor

  4.2.4.1   The Contractor shall not request Disenrollment of a Member for
discriminating reasons, including:

  4.2.4.1.1   Adverse changes in a Member’s health status;     4.2.4.1.2  
Missed appointments;     4.2.4.1.3   Utilization of medical services;    
4.2.4.1.4   Diminished mental capacity;     4.2.4.1.5   Pre-existing medical
condition;     4.2.4.1.6   Uncooperative or disruptive behavior resulting from
his or her special needs; or     4.2.4.1.7   Lack of compliance with the
treating physician’s plan of care.

  4.2.4.2   The Contractor shall not request Disenrollment because of the
Member’s attempt to exercise his or her rights under the Grievance System.

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  4.2.4.3   The request of one PCP to have a Member assigned to a different
Provider shall not be sufficient cause for the Contractor to request that the
Member be disenrolled from the plan. Rather, the Contractor shall utilize its
PCP assignment process to assign the Member to a different and available PCP.

4.3   MEMBER SERVICES   4.3.1   General Provisions

  4.3.1.1   The Contractor shall ensure that Members are aware of their rights
and responsibilities, the role of PCPs, how to obtain care, what to do in an
emergency or urgent medical situation, how to request a Grievance, Appeal, or
Administrative Law Hearings, and how to report suspected Fraud and Abuse. The
Contractor shall convey this information via written materials and via
telephone, internet, and face-to-face communications that allow the Members to
submit questions and receive responses from the Contractor.

4.3.2   Requirements for Written Materials

  4.3.2.1   The Contractor shall make all written materials available in
alternative formats and in a manner that takes into consideration the Member’s
special needs, including those who are visually impaired or have limited reading
proficiency. The Contractor shall notify all Members and Potential Members that
information is available in alternative formats and how to access those formats.
    4.3.2.2   The Contractor shall make all written information available in
English, Spanish and all other prevalent non-English languages, as defined by
DCH. For the purposes of this Contract, prevalent means a non-English language
spoken by a significant number or percentage of Medicaid and PeachCare for Kids
eligible individuals in the State.     4.3.2.3   All written materials
distributed to Members shall include a language block, printed in Spanish and
all other prevalent non-English languages, that informs the Member that the
document contains important information and directs the Member to call the
Contractor to request the document in an alternative language or to have it
orally translated.     4.3.2.4   All written materials shall be worded such that
they are understandable to a person who reads at the fifth (5th) grade level.
Suggested reference materials to determine whether this requirement is being met
are:

  4.3.2.4.1   Fry Readability Index;

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  4.3.2.4.2   PROSE The Readability Analyst (software developed by Education
Activities, Inc.);     4.3.2.4.3   Gunning FOG Index;     4.3.2.4.4   McLaughlin
SMOG Index;     4.3.2.4.5   The Flesch-Kincaid Index; or     4.3.2.4.6   Other
word processing software approved by DCH.

  4.3.2.5   The Contractor shall provide written notice to DCH of any changes to
any written materials provided to the Members. Written notice shall be provided
at least thirty (30) Calendar Days before the effective date of the change.    
4.3.2.6   All written materials, including information for the Web site, must be
submitted to DCH for approval before being distributed.

4.3.3   Member Handbook Requirements

  4.3.3.1   The Contractor shall mail to all newly enrolled Members a Member
Handbook within ten (10) Calendar Days of receiving the notice of enrollment
from DCH or its Agent. The Contractor shall mail to all enrolled Members a
Member Handbook at least annually thereafter.     4.3.3.2   Pursuant to the
requirements set forth in 42 CFR 438.10, the Member Handbook shall include, but
not be limited to:

  4.3.3.2.1   A table of contents;     4.3.3.2.2   Information about the roles
and responsibilities of the Member (this information to be supplied by DCH);    
4.3.3.2.3   Information about the role of the PCP;     4.3.3.2.4   Information
about choosing a PCP;     4.3.3.2.5   Information about what to do when family
size changes;     4.3.3.2.6   Appointment procedures;     4.3.3.2.7  
Information on Benefits and services, including a description of all available
GF Benefits and services;

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  4.3.3.2.8   Information on how to access services, including Health Check
services, non-emergency transportation (NET) services, and maternity and family
planning services;     4.3.3.2.9   An explanation of any service limitations or
exclusions from coverage;     4.3.3.2.10   A notice stating that the Contractor
shall be liable only for those services authorized by the Contractor;    
4.3.3.2.11   Information on where and how Members may access Benefits not
available from or not covered by the Contractor;     4.3.3.2.12   The Medical
Necessity definition used in determining whether services will be covered;    
4.3.3.2.13   A description of all pre-certification, prior authorization or
other requirements for treatments and services;     4.3.3.2.14   The policy on
Referrals for specialty care and for other Covered Services not furnished by the
Member’s PCP;     4.3.3.2.15   Information on how to obtain services when the
Member is out of the Service Region and for after-hours coverage;     4.3.3.2.16
  Cost-sharing;     4.3.3.2.17   The geographic boundaries of the Service
Regions;     4.3.3.2.18   Notice of all appropriate mailing addresses and
telephone numbers to be utilized by Members seeking information or
authorization, including an inclusion of the Contractor’s toll-free telephone
line and Web site;     4.3.3.2.19   A description of Utilization Review policies
and procedures used by the Contractor;     4.3.3.2.20   A description of Member
rights and responsibilities as described in Section 4.3.4;     4.3.3.2.21   The
policies and procedures for Disenrollment;     4.3.3.2.22   Information on
Advance Directives;     4.3.3.2.23   A statement that additional information,
including information on the structure and operation of the CMO plan and
physician incentive plans, shall be made available upon request;

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  4.3.3.2.24   Information on the extent to which, and how, after-hours and
emergency coverage are provided, including the following:

  i.   What constitutes an Urgent and Emergency Medical Condition, Emergency
Services, and Post-Stabilization Services;     ii.   The fact that Prior
Authorization is not required for Emergency Services;     iii.   The process and
procedures for obtaining Emergency Services, including the use of the 911
telephone systems or its local equivalent;     iv.   The locations of any
emergency settings and other locations at which Providers and hospitals furnish
Emergency Services and Post-Stabilization Services covered herein; and     v.  
The fact that a Member has a right to use any hospital or other setting for
Emergency Services;

  4.3.3.2.25   Information on the Grievance Systems policies and procedures, as
described in Section 4.14 of this Contract. This description must include the
following:

  i.   The right to file a Grievance and Appeal with the Contractor;     ii.  
The requirements and timeframes for filing a Grievance or Appeal with the
Contractor;     iii.   The availability of assistance in filing a Grievance or
Appeal with the Contractor;     iv.   The toll-free numbers that the Member can
use to file a Grievance or an Appeal with the Contractor by phone;     v.   The
right to a State Administrative Law Hearing, the method for obtaining a hearing,
and the rules that govern representation at the hearing;     vi.   Notice that
if the Member files an Appeal or a request for a State Administrative Law
Hearing within the timeframes specified for filing, the Member may be required
to pay the cost of services furnished while the Appeal is pending, if the final
decision is adverse to the Member; and

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  vii.   Any Appeal rights that the State chooses to make available to Providers
to challenge the failure of the Contractor to cover a service.

  4.3.3.3   The Contractor shall submit to DCH for review and approval any
changes and edits to the Member Handbook at least thirty (30) Calendar Days
before the effective date of change.

4.3.4   Member Rights

  4.3.4.1   The Contractor shall have written policies and procedures regarding
the rights of Members and shall comply with any applicable federal and State
laws and regulations that pertain to Member rights. These rights shall be
included in the Member Handbook. At a minimum, said policies and procedures
shall specify the Member’s right to:

  4.3.4.1.1   Receive information pursuant to 42 CFR 438.10;     4.3.4.1.2   Be
treated with respect and with due consideration for the Member’s dignity and
privacy;     4.3.4.1.3   Have all records and medical and personal information
remain confidential;     4.3.4.1.4   Receive information on available treatment
options and alternatives, presented in a manner appropriate to the Member’s
Condition and ability to understand;     4.3.4.1.5   Participate in decisions
regarding his or her Health Care, including the right to refuse treatment;    
4.3.4.1.6   Be free from any form of restraint or seclusion as a means of
coercion, discipline, convenience or retaliation, as specified in other federal
regulations on the use of restraints and seclusion;     4.3.4.1.7   Request and
receive a copy of his or her Medical Records pursuant to 45 CFR 160 and 164,
subparts A and E, and request to amend or correct the record as specified in 45
CFR 164.524 and 164.526;     4.3.4.1.8   Be furnished Health Care services in
accordance with 42 CFR 438.206 through 438.210;     4.3.4.1.9   Freely exercise
his or her rights, including those related to filing a Grievance or Appeal, and
that the exercise of these rights will not adversely affect the way the Member
is treated;

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  4.3.4.1.10   Not be held liable for the Contractor’s debts in the event of
insolvency; not be held liable for the Covered Services provided to the Member
for which DCH does not pay the Contractor; not be held liable for Covered
Services provided to the Member for which DCH or the CMO plan does not pay the
Health Care Provider that furnishes the services; and not be held liable for
payments of Covered Services furnished under a contract, Referral, or other
arrangement to the extent that those payments are in excess of amount the Member
would owe if the Contractor provided the services directly; and     4.3.4.1.11  
Only be responsible for cost sharing in accordance with 42 CFR 447.50 through 42
CFR 447.60 and Attachment K of this Contract.

4.3.5   Provider Directory

  4.3.5.1   The Contractor shall mail via surface mail a Provider Directory to
all new Members within ten (10) Calendar Days of receiving the notice of
Enrollment from DCH or the State’s Agent.     4.3.5.2   The Provider Directory
shall include names, locations, office hours, telephone numbers of, and
non-English languages spoken by, current Contracted Providers. This includes, at
a minimum, information on PCPs, specialists, dentists, pharmacists, FQHCs and
RHCs, mental health and substance abuse Providers, and hospitals. The Provider
Directory shall also identify Providers that are not accepting new patients.    
4.3.5.3   The Contractor shall submit the Provider Directory to DCH for review
and prior approval within sixty (60) Calendar Days of Contract Award and as
updated thereafter.     4.3.5.4   The Contractor shall up-date and amend the
Provider Directory on its Web site within five (5) Business Days of any changes,
produce and distribute quarterly up-dates to all Members, and re-print the
Provider Directory and distribute to all Members at least once per year.    
4.3.5.5   At least once per month, the Contractor shall submit to DCH and its
Agent any changes and edits to the Provider Directory. Such changes shall be
submitted electronically in a format to be determined by DCH.     4.3.5.6   The
Contractor shall post on its website a searchable list of all providers with
which the care management organization has contracted. At a minimum, this list
shall be searchable by provider name, specialty, and location.

4.3.6   Member Identification (ID) Card

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  4.3.6.1   The Contractor shall mail via surface mail a Member ID Card to all
new Members according to the following timeframes:

  4.3.6.1.1   Within ten (10) Calendar Days of receiving the notice of
Enrollment from DCH or the Agent for Members who have selected a CMO plan and a
PCP;     4.3.6.1.2   Within ten (10) Calendar Days of PCP assignment or
selection for Members that are Auto-Assigned to the CMO plan.

  4.3.6.2   The Member ID Card must, at a minimum, include the following
information:

  4.3.6.2.1   The Member’s name;     4.3.6.2.2   The Member’s Medicaid or
PeachCare for Kids identification number;     4.3.6.2.3   The PCP’s name,
address, and telephone numbers (including after-hours number if different from
business hours number);     4.3.6.2.4   The name and telephone number(s) of the
Contractor;     4.3.6.2.5   The Contractor’s twenty-four (24) hour, seven
(7) day a week toll-free Member services telephone number;     4.3.6.2.6  
Instructions for emergencies; and     4.3.6.2.7   Includes minimum or
instructions to facilitate the submission of a claim by a provider.

  4.3.6.3   The Contractor shall reissue the Member ID Card within ten
(10) Calendar Days of notice if a Member reports a lost card, there is a Member
name change, the PCP changes, or for any other reason that results in a change
to the information disclosed on the Member ID Card.     4.3.6.4   The Contractor
shall submit a front and back sample Member ID Card to DCH for review and
approval within sixty (60) Calendar Days of Contract Award and as updated
thereafter.

4.3.7   Toll-free Member Services Line

  4.3.7.1   The Contractor shall operate a toll-free telephone line to respond
to Member questions, comments and inquiries.     4.3.7.2   The Contractor shall
develop Telephone Line Policies and Procedures that address staffing, personnel,
hours of operation, access and response standards,

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      monitoring of calls via recording or other means, and compliance with
standards.     4.3.7.3   The Contractor shall submit these Telephone Line
Policies and Procedures, including performance standards pursuant to
Section 4.3.7.7, to DCH for review and approval within sixty (60) Calendar Days
of Contract Award and as updated thereafter.     4.3.7.4   The telephone line
shall handle calls from non-English speaking callers, as well as calls from
Members who are hearing impaired.     4.3.7.5   The Contractor’s call center
systems shall have the capability to track call management metrics identified in
Attachment L.     4.3.7.6   The telephone line shall be fully staffed between
the hours of 7:00 a.m. and 7:00 p.m. EST, Monday through Friday, excluding State
holidays. The telephone line staff shall be trained to accurately respond to
Member questions in all areas, including, but not limited to, Covered Services,
the provider network, and non-emergency transportation (NET).     4.3.7.7   The
Contractor shall develop performance standards and monitor Telephone Line
performance by recording calls and employing other monitoring activities. At a
minimum, the standards shall require that, on a monthly basis, eighty percent
(80%) of calls are answered by a person within thirty (30) seconds, the Blocked
Call rate does not exceed one percent (1%), and the rate of Abandoned Calls does
not exceed five percent (5%).     4.3.7.8   The Contractor shall have an
automated system available between the hours of 7:00 p.m. and 7:00 a.m. EST
Monday through Friday and at all hours on weekends and holidays. This automated
system must provide callers with operating instructions on what to do in case of
an emergency and shall include, at a minimum, a voice mailbox for callers to
leave messages. The Contractor shall ensure that the voice mailbox has adequate
capacity to receive all messages. A Contractor’s Representative shall return
messages on the next Business Day.     4.3.7.9   The Contractor shall develop
Call Center Quality Criteria and Protocols to measure and monitor the accuracy
of responses and phone etiquette as it relates to the Toll-free Telephone Line.
The Contractor shall submit the Call Center Quality Criteria and Protocols to
DCH for review and approval within sixty (60) Calendar Days of Contract Award
and annually with updates thereafter.

4.3.8   Internet Presence/Web Site

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  4.3.8.1   The Contractor shall provide general and up-to-date information
about the CMO plan’s program, its Provider network, its customer services, and
its Grievance and Appeals Systems on its Web site.     4.3.8.2   The Contractor
shall maintain a Member portal that allows Members to access a searchable
Provider Directory that shall be updated within five (5) Business Days upon
changes to the Provider network.     4.3.8.3   The Web site must have the
capability for Members to submit questions and comments to the Contractor and
for members to receive responses.     4.3.8.4   The Web site must comply with
the marketing policies and procedures and with requirements for written
materials described in this Contract and must be consistent with applicable
State and federal laws.     4.3.8.5   In addition to the specific requirements
outlined above, the Contractor’s Web site shall be functionally equivalent, with
respect to functions described in this Contract, to the Web site maintained by
the State’s Medicaid fiscal agent (www.ghp.georgia.gov).     4.3.8.6   The
Contractor shall submit Web site screenshots to DCH for review and approval
within sixty (60) Calendar Days of Contract Award and as updated thereafter.

4.3.9   Cultural Competency

  4.3.9.1   In accordance with 42 CFR 438.206, the Contractor shall have a
comprehensive written Cultural Competency Plan describing how the Contractor
will ensure that services are provided in a culturally competent manner to all
Members, including those with limited English proficiency. The Cultural
Competency Plan must describe how the Providers, individuals and systems within
the CMO plan will effectively provide services to people of all cultures, races,
ethnic backgrounds and religions in a manner that recognizes values, affirms and
respects the worth of the individual Members and protects and preserves the
dignity of each.     4.3.9.2   The Contractor shall submit the Cultural
Competency Plan to DCH for review and approval within sixty (60) Calendar Days
of Contract Award and as updated thereafter.     4.3.9.3   The Contractor may
distribute a summary of the Cultural Competency Plan to the In-Network Providers
if the summary includes information on how the Provider may access the full
Cultural Competency Plan on the Web site. This summary shall also detail how the
Provider can request a hard copy from the CMO at no charge to the Provider.

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4.3.10   Translation Services

  4.3.10.1   The Contractor is required to provide oral translation services of
information to any Member who speaks any non-English language regardless of
whether a Member speaks a language that meets the threshold of a Prevalent
Non-English Language. The Contractor is required to notify its Members of the
availability of oral interpretation services and to inform them of how to access
oral interpretation services. There shall be no charge to the Member for
translation services.

4.3.11   Reporting Requirements

  4.3.11.1   The Contractor shall submit monthly Telephone and Internet Activity
Reports to DCH as described in Section 4.18.3.1.

4.4   MARKETING

4.4.1   Prohibited Activities

  4.4.1.1   The Contractor is prohibited from engaging in the following
activities:

  4.4.1.1.1   Directly or indirectly engaging in door-to-door, telephone, or
other Cold-Call Marketing activities to Potential Members;     4.4.1.1.2  
Offering any favors, inducements or gifts, promotions, and/or other insurance
products that are designed to induce Enrollment in the Contractor’s plan, and
that are not health related and/or worth more than $10.00 cash;     4.4.1.1.3  
Distributing information, plans and materials that contain statements that DCH
determines are inaccurate, false, or misleading. Statements considered false or
misleading include, but are not limited to, any assertion or statement (whether
written or oral) that the recipient must enroll in the Contractor’s plan in
order to obtain Benefits or in order to not lose Benefits or that the
Contractor’s plan is endorsed by the federal or State government, or similar
entity; and     4.4.1.1.4   Distributing information or materials that,
according to DCH, mislead or falsely describe the Contractor’s Provider network,
the participation or availability of network Providers, the qualifications and
skills of network Providers (including their bilingual skills); or the hours and
location of network services.

4.4.2   Allowable Activities

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  4.4.2.1   The Contractor shall be permitted to perform the following marketing
activities:

  4.4.2.1.1   Distribute general information through mass media (i.e.
newspapers, magazines and other periodicals, radio, television, the Internet,
public transportation advertising, and other media outlets);     4.4.2.1.2  
Make telephone calls, mailings and home visits only to Members currently
enrolled in the Contractor’s plan, for the sole purpose of educating them about
services offered by or available through the Contractor;     4.4.2.1.3  
Distribute brochures and display posters at Provider offices and clinics that
inform patients that the clinic or Provider is part of the CMO plan’s Provider
network, provided that all CMO plans in which the Provider participates have an
equal opportunity to be represented; and     4.4.2.1.4   Attend activities that
benefit the entire community such as health fairs or other health education and
promotion activities.

  4.4.2.2   If the Contractor performs an allowable activity, the Contractor
shall conduct these activities in the entire Service Region as defined by this
Contract.     4.4.2.3   All materials shall comply with the information
requirements in 42 CFR 438.10 and detailed in Section 4.3.2 of this Contract.

4.4.3   State Approval of Materials

      The Contractor shall submit a detailed description of its Marketing Plan
and copies of all Marketing Materials (written and oral) it or its
Subcontractors plan to distribute to DCH for review and approval within sixty
(60) Calendar Days of Contract Award and as updated thereafter.     4.4.3.1  
This requirement includes, but is not limited to posters, brochures, Web sites,
and any materials that contain statements regarding the benefit package and
Provider network-related materials. Neither the Contractor nor its
Subcontractors shall distribute any marketing materials without prior, written
approval from DCH.     4.4.3.2   The Contractor shall submit any changes to
previously approved marketing materials and receive approval from DCH of the
changes before distribution.

4.4.4   Provider Marketing Materials

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  4.4.4.1   The Contractor shall collect from its Providers any Marketing
Materials they intend to distribute and submit these to DCH for review and
approval prior to distribution.

4.5   COVERED BENEFITS AND SERVICES   4.5.1   Included Services

  4.5.1.1   The Contractor shall at a minimum provide Medically Necessary
services and Benefits as outlined below, and pursuant to the Georgia State
Medicaid Plan, and the Georgia Medicaid Policies and Procedures Manual. Such
Medically Necessary services shall be furnished in an amount, duration, and
scope that is no less than the amount, duration, and scope for the same services
furnished to recipients under Fee-for-Service Medicaid. The Contractor may not
arbitrarily deny or reduce the amount, duration or scope of a required service
solely because of the diagnosis, type of illness or Condition.     4.5.1.2  

      SERVICE   COVERAGE LIMITATIONS
Ambulatory Surgical Services
   
 
   
Audiology Services
  Not covered for Members age 21 and older. Available under EPSDT as part of a
written service plan.
 
   
Childbirth Education Services
   
 
   
Dental Services
  Preventive, diagnostic and treatment services provided to Members under age
21. Emergency Services only for Members age 21 and older.
 
   
Durable Medical Equipment
   
 
   
Early and Periodic Screening, Diagnostic, and Treatment Services
   
 
   
Emergency Transportation Services
   
 
   
Emergency Services
   
 
   
Family Planning Services and Supplies
   
 
   
Federally Qualified Health Center Services
  Ambulatory services such as dental services are subject to any limitations
applicable to the specific ambulatory service.
 
   
Home Health Services
  Not covered: social services, chore services, meals on wheels, audiology
services.  
Hospice Services
  Available to Members certified as

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      SERVICE   COVERAGE LIMITATIONS
 
  being terminally ill and having a medical prognosis of life expectancy of six
(6) months or less.
 
   
Inpatient Hospital Services
  Psychiatric hospitalizations are covered for a maximum of 30 days per
treatment episode
 
   
Laboratory and Radiological Services
  Not covered: portable X-ray services; services provided in facilities not
meeting the definition of an independent laboratory or X-ray facility; services
or procedures referred to another testing facility; services furnished by a
State or public laboratory; services or procedures performed by a facility not
certified to perform them.
 
   
Mental Health Services
  Community Mental Health Rehabilitation services are only available as part of
a written service plan.
Nurse Midwife Services
   
 
   
Nurse Practitioner Services
   
 
   
Nursing Facility Services
  Not covered: Long-term nursing facility (over 30 Consecutive Days)
 
   
Obstetrical Services
   
 
   
Occupational Therapy Services
  These services are covered for children under age 21 as medically necessary.

Services for adults 21 and older are covered when medically necessary for short
term rehabilitation.
 
   
Optometric Services
  Not covered for Members age 21 and older: routine refractive services and
optical devices.
 
   
Orthotic and Prosthetic Services
  Not covered for Members age 21 and older: orthopedic shoes and supportive
devices for the feet which are not an integral part of a leg brace; hearing aids
and accessories.
 
   
Oral Surgery
   
 
   
Outpatient Hospital Services
   

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      SERVICE   COVERAGE LIMITATIONS
Pharmacy Services
  Not covered: certain outpatient drugs pursuant to Section 1927(d) of the
Social Security Act. Additionally, certain over the counter (OTC) drugs must be
included, pursuant to the Georgia State Policies and Procedures Manual.
 
   
Physical Therapy Services
  These services are covered for children under age 21 as medically necessary.

Services for adults 21 and older are covered when medically necessary for short
term rehabilitation.
 
   
Physician Services
   
 
   
Podiatric Services
  Not covered: services for flatfoot; subluxation; routine foot care, supportive
devices; vitamin B-12 injections.
 
   
Pregnancy-Related Services
   
 
   
Private Duty Nursing Services
   
 
   
Rural Health Clinic Services
   
 
   
Speech Therapy Services
  These services are covered for children under age 21 as medically necessary.

Services for adults 21 and older are covered when medically necessary for short
term rehabilitation.
 
   
Substance Abuse Treatment Services (Inpatient)
  Substance abuse treatment, inpatient and rehabilitative, are covered as part
of a written service plan.
 
   
Swing Bed Services
   
 
   
Targeted Case Management
  Covered for pregnant women under age 21 and other pregnant women at risk for
adverse outcomes; infants and toddlers with established risk for developmental
delay.
 
   
Transplants
  Not covered for Members age 21 and older: heart, lung and heart/lung
transplants.

4.5.2   Individuals with Disabilities Education Act (IDEA) Services

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  4.5.2.1   For Members up to and including age three (3), the Contractor shall
be responsible for Medically Necessary IDEA services provided pursuant to an
Individualized Family Service Plan (IFSP) or Individualized Service Plan (IEP).
    4.5.2.2   For Members age four (4) and older, the Contractor shall not be
responsible for Medically Necessary IDEA services provided pursuant to an IEP or
IFSP. Such services shall remain in FFS Medicaid.

  4.5.2.2.1   The Contractor shall be responsible for all other Medically
Necessary covered services.

4.5.3   Enhanced Services

  4.5.3.1   In addition to the Covered Services provided above, the Contractor
shall do the following:

  4.5.3.1.1   Place strong emphasis on programs to enhance the general health
and well-being of Members;     4.5.3.1.2   Make health promotion materials
available to Members;     4.5.3.1.3   Participate in community-sponsored health
fairs; and     4.5.3.1.4   Provide education to Members, families and other
Health Care Providers about early intervention and management strategies for
various illnesses.

  4.5.3.2   The Contractor shall not charge a Member for participating in health
education services that are defined as either enhanced or Covered Services.

4.5.4   Medical Necessity

  4.5.4.1   Based upon generally accepted medical practices in light of
Conditions at the time of treatment, Medically Necessary services are those that
are:

  4.5.4.1.1   Appropriate and consistent with the diagnosis of the treating
Provider and the omission of which could adversely affect the eligible Member’s
medical Condition;     4.5.4.1.2   Compatible with the standards of acceptable
medical practice in the community;     4.5.4.1.3   Provided in a safe,
appropriate, and cost-effective setting given the nature of the diagnosis and
the severity of the symptoms;

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  4.5.4.1.4   Not provided solely for the convenience of the Member or the
convenience of the Health Care Provider or hospital; and     4.5.4.1.5   Not
primarily custodial care unless custodial care is a covered service or benefit
under the Members evidence of coverage.

  4.5.4.2   There must be no other effective and more conservative or
substantially less costly treatment, service and setting available.     4.5.4.3
  For children under 21, the Contractor is required to provide medically
necessary services to correct or ameliorate physical and behavioral health
disorders, a defect, or a condition identified in as EPSDT (Health Check)
screening, regardless whether those services are included in the State Plan, but
are otherwise allowed pursuant to 1905 (a) of the Social Security Act. See
Diagnostic and Treatment, Section 4.7.5.2.

4.5.5   Experimental, Investigational or Cosmetic Procedures

  4.5.5.1   Pursuant to the Georgia State Medicaid Plan and the Georgia Medicaid
Policies and Procedures Manual, in no instance shall the Contractor cover
experimental, investigational or cosmetic procedures.

4.5.6   Moral or Religious Objections

  4.5.6.1   The Contractor is required to provide and reimburse for all Covered
Services. If, during the course of the Contract period, pursuant to 42 CFR
438.102, the Contractor elects not to provide, reimburse for, or provide
coverage of a counseling or Referral service because of an objection on moral or
religious grounds, the Contractor shall notify:

  4.5.6.1.1   DCH within one hundred and twenty (120) Calendar Days prior to
adopting the policy with respect to any service;     4.5.6.1.2   Members within
ninety (90) Calendar Days after adopting the policy with respect to any service;
and     4.5.6.1.3   Members and Potential Members before and during Enrollment.

  4.5.6.2.   The Contractor acknowledges that such objection will be grounds for
recalculation of rates paid to the Contractor.

4.6   SPECIAL COVERAGE PROVISIONS

4.6.1   Emergency Services

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  4.6.1.1   Emergency Services shall be available twenty-four (24) hours a day,
seven (7) Days a week to treat an Emergency Medical Condition.     4.6.1.2   An
Emergency Medical Condition shall not be defined or limited based on a list of
diagnoses or symptoms. An Emergency Medical Condition is a medical or mental
health Condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in the following:

  4.6.1.2.1   Placing the physical or mental health of the individual (or, with
respect to a pregnant woman, the health of the woman or her unborn child) in
serious jeopardy;     4.6.1.2.2   Serious impairment to bodily functions;    
4.6.1.2.3   Serious dysfunction of any bodily organ or part;     4.6.1.2.4  
Serious harm to self or others due to an alcohol or drug abuse emergency;    
4.6.1.2.5   Injury to self or bodily harm to others; or     4.6.1.2.6   With
respect to a pregnant woman having contractions: (i) that there is adequate time
to effect a safe transfer to another hospital before delivery, or (ii) that
transfer may pose a threat to the health or safety of the woman or the unborn
child.

  4.6.1.3   The Contractor shall provide payment for Emergency Services when
furnished by a qualified Provider, regardless of whether that Provider is in the
Contractor’s network. These services shall not be subject to prior authorization
requirements. The Contractor shall be required to pay for all Emergency Services
that are Medically Necessary until the Member is stabilized. The Contractor
shall also pay for any screening examination services conducted to determine
whether an Emergency Medical Condition exists.     4.6.1.4   The Contractor
shall base coverage decisions for Emergency Services on the severity of the
symptoms at the time of presentation and shall cover Emergency Services when the
presenting symptoms are of sufficient severity to constitute an Emergency
Medical Condition in the judgment of a prudent layperson.     4.6.1.5   The
attending emergency room physician, or the Provider actually treating the
Member, is responsible for determining when the Member is sufficiently
stabilized for transfer or discharge, and that determination is binding on the

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      Contractor, who shall be responsible for coverage and payment. The
Contractor, however, may establish arrangements with a hospital whereby the
Contractor may send one of its own physicians with appropriate emergency room
privileges to assume the attending physician’s responsibilities to stabilize,
treat, and transfer the Member, provided that such arrangement does not delay
the provision of Emergency Services.     4.6.1.6   The Contractor shall not
retroactively deny a Claim for an emergency screening examination because the
Condition, which appeared to be an Emergency Medical Condition under the prudent
layperson standard, turned out to be non-emergency in nature. If an emergency
screening examination leads to a clinical determination by the examining
physician that an actual Emergency Medical Condition does not exist, then the
determining factor for payment liability shall be whether the Member had acute
symptoms of sufficient severity at the time of presentation. In this case, the
Contractor shall pay for all screening and care services provided. Payment shall
be at either the rate negotiated under the Provider Contract, or the rate paid
by DCH under the Fee for Service Medicaid program.     4.6.1.7   The Contractor
may establish guidelines and timelines for submittal of notification regarding
provision of emergency services, but, the Contractor shall not refuse to cover
an Emergency Service based on the emergency room Provider, hospital, or fiscal
agent’s failure to notify the Member’s PCP, CMO plan representative, or DCH of
the Member’s screening and treatment within said timeframes.     4.6.1.8   When
a representative of the Contractor instructs the Member to seek Emergency
Services the Contractor shall be responsible for payment for the Medical
Screening examination and for other Medically Necessary Emergency Services,
without regard to whether the Condition meets the prudent layperson standard.  
  4.6.1.9   The Member who has an Emergency Medical Condition shall not be held
liable for payment of subsequent screening and treatment needed to diagnose the
specific Condition or stabilize the patient.     4.6.1.10   Once the Member’s
Condition is stabilized, the Contractor may require Pre-Certification for
hospital admission or Prior Authorization for follow-up care.

4.6.2   Post-Stabilization Services

  4.6.2.1   The Contractor shall be responsible for providing Post-Stabilization
care services twenty-four (24) hours a day, seven (7) days a week, both
inpatient and outpatient, related to an Emergency Medical Condition, that are
provided after a Member is stabilized in order to maintain the stabilized
Condition, or,

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      pursuant to 42 CFR 438.114(e), to improve or resolve the Member’s
Condition.     4.6.2.2   The Contractor shall be responsible for payment for
Post-Stabilization Services that are Prior Authorized or Pre-Certified by an
In-Network Provider or organization representative, regardless of whether they
are provided within or outside the Contractor’s network of Providers.    
4.6.2.3   The Contractor is financially responsible for Post-Stabilization
Services obtained from any Provider, regardless of whether they are within or
outside the Contractor’s Provider network that are administered to maintain the
Member’s stabilized Condition for one (1) hour while awaiting response on a
Pre-Certification or Prior Authorization request.     4.6.2.4   The Contractor
is financially responsible for Post-Stabilization Services obtained from any
Provider, regardless of whether they are within or outside the Contractor’s
Provider network, that are not prior authorized by a CMO plan Provider or
organization representative but are administered to maintain, improve or resolve
the Member’s stabilized Condition if:

  4.6.2.4.1   The Contractor does not respond to the Provider’s request for
pre-certification or prior authorization within one (1) hour;     4.6.2.4.2  
The Contractor cannot be contacted; or     4.6.2.4.3   The Contractor’s
Representative and the attending physician cannot reach an agreement concerning
the Member’s care and a CMO plan physician is not available for consultation. In
this situation the Contractor shall give the treating physician the opportunity
to consult with an In-Network physician and the treating physician may continue
with care of the Member until a CMO plan physician is reached or one of the
criteria in Section 4.6.2.5 are met.

  4.6.2.5   The Contractor’s financial responsibility for Post-Stabilization
Services it has not approved will end when:

  4.6.2.5.1   An In-Network Provider with privileges at the treating hospital
assumes responsibility for the Member’s care;     4.6.2.5.2   An In-Network
Provider assumes responsibility for the Member’s care through transfer;    
4.6.2.5.3   The Contractor’s Representative and the treating physician reach an
agreement concerning the Member’s care; or     4.6.2.5.4   The Member is
discharged.

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  4.6.2.6   In the event the Member receives Post-Stabilization Services from a
Provider outside the Contractor’s network, the Contractor is prohibited from
charging the Member more than he or she would be charged if he or she had
obtained the services through an In-Network Provider.

4.6.3   Urgent Care Services

  4.6.3.1   The Contractor shall provide Urgent Care services as necessary. Such
services shall not be subject to Prior Authorization or Pre-Certification.

4.6.4   Family Planning Services

  4.6.4.1   The Contractor shall provide access to family planning services
within the network. In meeting this obligation, the Contractor shall make a
reasonable effort to contract with all family planning clinics, including those
funded by Title X of the Public Health Services Act, for the provision of family
planning services. The Contractor shall verify its efforts to contract with
Title X Clinics by maintaining records of communication. The Contractor shall
not limit Members’ freedom of choice for family planning services to In-Network
Providers and the Contractor shall cover services provided by any qualified
Provider regardless of whether the Provider is In-Network. The Contractor shall
not require a Referral if a Member chooses to receive family planning services
and supplies from outside of the network.     4.6.4.2   The Contractor shall
inform Members of the availability of family planning services and must provide
services to Members wishing to prevent pregnancies, plan the number of
pregnancies, plan the spacing between pregnancies, or obtain confirmation of
pregnancy.     4.6.4.3   Family planning services and supplies include at a
minimum:

  4.6.4.3.1   Education and counseling necessary to make informed choices and
understand contraceptive methods;     4.6.4.3.2   Initial and annual complete
physical examinations;     4.6.4.3.3   Follow-up, brief and comprehensive
visits;     4.6.4.3.4   Pregnancy testing;     4.6.4.3.5   Contraceptive
supplies and follow-up care;     4.6.4.3.6   Diagnosis and treatment of sexually
transmitted diseases; and     4.6.4.3.7   Infertility assessment.

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  4.6.4.4   The Contractor shall furnish all services on a voluntary and
confidential basis, even if the Member is less than eighteen (18) years of age.

4.6.5   Sterilizations, Hysterectomies and Abortions

  4.6.5.1   In compliance with federal regulations, the Contractor shall cover
sterilizations and hysterectomies, only if all of the following requirements are
met:

  4.6.5.1.1   The Member is at least twenty-one (21) years of age at the time
consent is obtained;     4.6.5.1.2   The Member is mentally competent;    
4.6.5.1.3   The Member voluntarily gives informed consent in accordance with the
State Policies and Procedures for Family Planning Clinic Services. This includes
the completion of all applicable documentation;     4.6.5.1.4   At least thirty
(30) Calendar Days, but not more than one hundred and eighty (180) Calendar
Days, have passed between the date of informed consent and the date of
sterilization, except in the case of premature delivery or emergency abdominal
surgery. A Member may consent to be sterilized at the time of premature delivery
or emergency abdominal surgery, if at least seventy-two (72) hours have passed
since informed consent for sterilization was signed. In the case of premature
delivery, the informed consent must have been given at least thirty
(30) Calendar Days before the expected date of delivery (the expected date of
delivery must be provided on the consent form);     4.6.5.1.5   An interpreter
is provided when language barriers exist. Arrangements are to be made to
effectively communicate the required information to a Member who is visually
impaired, hearing impaired or otherwise disabled; and     4.6.5.1.6   The Member
is not institutionalized in a correctional facility, mental hospital or other
rehabilitative facility.

  4.6.5.2   A hysterectomy shall be considered a Covered Service only if the
following additional requirements are met:

  4.6.5.2.1   The Member must be informed orally and in writing that the
hysterectomy will render the individual permanently incapable of reproducing
(this is not applicable if the individual was sterile prior to the hysterectomy
or in the case of an emergency hysterectomy); and

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  4.6.5.2.2   The Member must sign and date a “Patient’s Acknowledgement of
Prior Receipt of Hysterectomy Information” form prior to the Hysterectomy.
Informed consent must be obtained regardless of diagnosis or age.

  4.6.5.3   Regardless of whether the requirements listed above are met, a
hysterectomy shall not be covered under the following circumstances:

  4.6.5.3.1   If it is performed solely for the purpose of rendering a Member
permanently incapable of reproducing;     4.6.5.3.2   If there is more than one
(1) purpose for performing the hysterectomy, but the primary purpose was to
render the Member permanently incapable of reproducing; or     4.6.5.3.3   If it
is performed for the purpose of cancer prophylaxis.

  4.6.5.4   Abortions or abortion-related services performed for family planning
purposes are not Covered Services. Abortions are Covered Services if a Provider
certifies that the abortion is medically necessary to save the life of the
mother or if pregnancy is the result of rape or incest. The Contractor shall
cover treatment of medical complications occurring as a result of an elective
abortion and treatments for spontaneous, incomplete, or threatened abortions and
for ectopic pregnancies.     4.6.5.5   The Contractor shall maintain
documentation of all sterilizations, hysterectomies and abortions and provide
documentation to DCH upon the request of DCH.

4.6.6   Pharmacy

  4.6.6.1   The Contractor shall provide pharmacy services either directly or
through a Pharmacy Benefits Manager (PBM). The Contractor or its PBM may
establish a drug formulary if the following minimum requirements are met:

  4.6.6.1.1   Drugs from each specific therapeutic drug class are included and
are sufficient in amount, duration, and scope to meet Members’ medical needs;  
  4.6.6.1.2   The only excluded drug categories are those permitted under
section 1927(d) of the Social Security Act;     4.6.6.1.3   A Pharmacy &
Therapeutics Committee that advises and/or recommends formulary decisions; and

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  4.6.6.1.4   Over-the-counter medications specified in the Georgia State
Medicaid Plan are included in the formulary.

  4.6.6.2   The Contractor shall provide the formulary to DCH upon the request
of DCH.     4.6.6.3   If the Contractor chooses to implement a mail-order
pharmacy program, any such program must be accordance with State and federal
law.

4.6.7   Immunizations

  4.6.7.1   The Contractor shall provide all Members under twenty-one (21) years
of age with all vaccines and immunizations in accordance with the Advisory
Committee on Immunization Practices (ACIP) guidelines.     4.6.7.2   The
Contractor shall ensure that all Providers use vaccines which have been made
available, free of cost, under the Vaccine for Children (VFC) program for
Medicaid children eighteen (18) years old and younger. Immunizations shall be
given in conjunction with Well-Child/Health Check care.     4.6.7.3   The
Contractor shall provide all adult immunizations specified in the Georgia
Medicaid Policies and Procedures Manual.     4.6.7.4   The Contractor shall
report all immunizations to the Georgia Registry of Immunization Transactions
and Services (GRITS) in a format to be determined by DCH.

4.6.8   Transportation

  4.6.8.1   The Contractor shall provide emergency transportation and shall not
retroactively deny a Claim for emergency transportation to an emergency Provider
because the Condition, which appeared to be an Emergency Medical Condition under
the prudent layperson standard, turned out to be non-emergency in nature.    
4.6.8.2   The Contractor is not responsible for providing non-emergency
transportation (NET) but the Contractor shall coordinate with the NET vendors
for services required by Members.

4.6.9   Perinatal Services

  4.6.9.1   The Contractor shall ensure that appropriate perinatal care is
provided to women and newborn Members. The Contractor shall have adequate
capacity such that any new Member who is pregnant is able to have an initial
visit with her Provider within fourteen (14) Calendar Days of Enrollment. The
Contractor shall have in place a system that provides, at a minimum, the
following services:

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  4.6.9.1.1   Pregnancy planning and perinatal health promotion and education
for reproductive-age women;     4.6.9.1.2   Perinatal risk assessment of
non-pregnant women, pregnant and post-partum women, and newborns and children up
to five (5) months of age;     4.6.9.1.3   Childbirth education classes to all
pregnant Members and their chosen partner. Through these classes, expectant
parents shall be encouraged to prepare themselves physically, emotionally, and
intellectually for the childbirth experience. The classes shall be offered at
times convenient to the population served, in locations that are accessible,
convenient and comfortable. Classes shall be offered in languages spoken by the
Members.     4.6.9.1.4   Access to appropriate levels of care based on risk
assessment, including emergency care;     4.6.9.1.5   Transfer and care of
pregnant women, newborns, and infants to tertiary care facilities when
necessary;     4.6.9.1.6   Availability and accessibility of OB/GYNs,
anesthesiologists, and neonatologists capable of dealing with complicated
perinatal problems; and     4.6.9.1.7   Availability and accessibility of
appropriate outpatient and inpatient facilities capable of dealing with
complicated perinatal problems.

  4.6.9.2   The Contractor shall provide inpatient care and professional
services relating to labor and delivery for its pregnant/delivering Members, and
neonatal care for its newborn Members at the time of delivery and for up to
forty-eight (48) hours following an uncomplicated vaginal delivery and
ninety-six (96) hours following an uncomplicated Caesarean delivery.

4.6.10   Parenting Education

  4.6.10.1   In addition to individual parent education and anticipatory
guidance to parents and guardians at preventive pediatric visits and Health
Check screens, the Contractor shall offer or arrange for parenting skills
education to expectant and new parents, at no cost to the Member.     4.6.10.2  
The Contractor agrees to create effective ways to deliver this education,
whether through classes, as a component of post-partum home visiting, or other
such means. The educational efforts shall include topics such as bathing,
feeding (including breast feeding), injury prevention, sleeping,

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      illness, when to call the doctor, when to use the emergency room, etc. The
classes shall be offered at times convenient to the population served, and in
locations that are accessible, convenient and comfortable. Convenience will be
determined by DCH. Classes shall be offered in languages spoken by the Members.

4.6.11   Mental Health and Substance Abuse

  4.6.11.1   The Contractor shall have written Mental Health and Substance Abuse
Policies and Procedures that explain how they will arrange or provide for
covered mental health and substance abuse services. Such policies and procedures
shall include Advance Directives. The Contractor shall assure timely delivery of
mental health and substance abuse services and coordination with other acute
care services.     4.6.11.2   Mental Health and Substance Abuse Policies and
Procedures shall be submitted to DCH for approval within sixty (60) Calendar
Days of Contract Award and as updated thereafter.     4.6.11.3   The Contractor
shall permit Members to self-refer to an In-Network Provider for an initial
mental health or substance abuse visit but prior authorization may be required
for subsequent visits.

4.6.12   Advance Directives

  4.6.12.1   In compliance with 42 CFR 438.6 (i) (1)-(2) and 42 CFR 422.128, the
Contractor shall maintain written policies and procedures for Advance
Directives, including mental health advance directives. Such Advance Directives
shall be included in each Member’s medical record. The Contractor shall provide
these policies to all Members eighteen (18) years of age and older and shall
advise Members of:

  4.6.12.1.1   Their rights under the law of the State of Georgia, including the
right to accept or refuse medical or surgical treatment and the right to
formulate Advance Directives; and     4.6.12.1.2   The Contractor’s written
policies respecting the implementation of those rights, including a statement of
any limitation regarding the implementation of Advance Directives as a matter of
conscience.

  4.6.12.2   The information must include a description of State law and must
reflect changes in State laws as soon as possible, but no later than ninety
(90) Calendar Days after the effective change.

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  4.6.12.3   The Contractor’s information must inform Members that complaints
may be filed with the State’s Survey and Certification Agency.     4.6.12.4  
The Contractor shall educate its staff about its policies and procedures on
Advance Directives, situations in which Advance Directives may be of benefit to
Members, and their responsibility to educate Members about this tool and assist
them to make use of it.     4.6.12.5   The Contractor shall educate Members
about their ability to direct their care using this mechanism and shall
specifically designate which staff Members and/or network Providers are
responsible for providing this education.

4.6.13   Foster Care Forensic Exam

  4.6.13.1   The Contractor shall provide a forensic examination to a Member
that is less than eighteen (18) years of age that is placed outside the home in
State custody. Such exam shall be in accordance with State law and regulations.

4.6.14   Laboratory Services

  4.6.14.1   The Contractor shall require all network laboratories to
automatically report the Glomerular Filtration Rate (GFR) on any serum
creatinine tests ordered by In-Network Providers.

4.6.15   Member Cost-Sharing

  4.6.15.1   The Contractor shall ensure that Providers collect Member
co-payments as specified in Attachment K.

4.7   EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM:
HEALTH CHECK

4.7.1   General Provisions

  4.7.1.1   The Contractor shall provide EPSDT services (called Health Check
services) to Medicaid children less than twenty-one (21) years of age and
PeachCare for Kids children less than age nineteen (19) years of age (hereafter
referred to as Health Check eligible children), in compliance with all
requirements found below.     4.7.1.2   The Contractor shall comply with
sections 1902(a)(43) and 1905(a)(4)(B) and 1905(r) of the Social Security Act
and federal regulations at 42 CFR 441.50 that require EPSDT services to include
outreach and informing, screening, tracking, and, diagnostic and treatment
services. The Contractor shall comply

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      with all Health Check requirements pursuant to the Georgia Medicaid
Policies and Procedures Manual.

  4.7.1.3   The Contractor shall develop an EPSDT Plan that includes written
policies and procedures for conducting outreach, informing, tracking, and
follow-up to ensure compliance with the Health Check periodicity schedules. The
EPSDT Plan shall emphasize outreach and compliance monitoring for children and
adolescents (young adults), taking into account the multi-lingual,
multi-cultural nature of the GF population, as well as other unique
characteristics of this population. The plan shall include procedures for
follow-up of missed appointments, including missed Referral appointments for
problems identified through Health Check screens and exams. The plan shall also
include procedures for referral, tracking and follow up for annual dental
examinations and visits. The Contractor shall submit its EPSDT Plan to DCH for
review and approval within sixty (60) Calendar Days of Contract Award and as
updated thereafter.

4.7.2   Outreach and Informing

  4.7.2.1   The Contractor’s Health Check outreach and informing process shall
include:

  4.7.2.1.1   The importance of preventive care;     4.7.2.1.2   The periodicity
schedule and the depth and breadth of services;     4.7.2.1.3   How and where to
access services, including necessary transportation and scheduling services; and
    4.7.2.1.4   A statement that services are provided without cost.

  4.7.2.2   The Contractor shall inform its newly enrolled families with Health
Check eligible children about the Health Check program within sixty
(60) Calendar Days of Enrollment with the plan. This requirement includes
informing pregnant women and new mothers, either before or within seven (7) days
after the birth of their children, that Health Check services are available.    
4.7.2.3   The Contractor shall provide written notification to its families with
Health Check eligible children when appropriate periodic assessments or needed
services are due. The Contractor shall coordinate appointments for care. The
Contractor shall follow up with families with Health Check eligible children
that have failed to access Health Check screens and services after one hundred
and twenty (120) Calendar Days of Enrollment in the CMO plan.     4.7.2.4   The
Contractor shall provide to each PCP, on a monthly basis, a list of the PCP’s
Health Check eligible children that have not had an encounter during the initial
one hundred and twenty (120) Calendar Days of CMO plan

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      Enrollment, and/or are not in compliance with the Health Check periodicity
schedule. The Contractor and/or the PCP shall contact the Members’ parents or
guardians to schedule an appointment.

  4.7.2.5   Informing may be oral (on the telephone, face-to-face, or
films/tapes) or written and may be done by Contractor personnel or Health Care
Providers. All outreach and informing shall be documented and shall be conducted
in non-technical language at or below a fifth (5th) grade reading level. The
Contractor shall use accepted methods for informing persons who are blind or
deaf, or cannot read or understand the English language, in accordance with
Section 4.3.2 of this Contract.     4.7.2.6   The Contractor may provide
nominal, non-cash incentives (valued $10 or less) to Members to motivate
compliance with periodicity schedules.

4.7.3   Screening

  4.7.3.1   The Contractor is responsible for periodic screens in accordance
with the State’s periodicity schedule. Such screens must include all of the
following:

  4.7.3.1.1   A comprehensive health and developmental history;     4.7.3.1.2  
Developmental assessment, including mental, emotional, and behavioral health
development;     4.7.3.1.3   Measurements (including head circumference for
infants);     4.7.3.1.4   An assessment of nutritional status;     4.7.3.1.5   A
comprehensive unclothed physical exam;     4.7.3.1.6   Immunizations according
to the Advisory Committee of Immunization Practices (ACIP);     4.7.3.1.7  
Certain laboratory tests (including the federally required blood lead
screening);     4.7.3.1.8   Anticipatory guidance and health education;    
4.7.3.1.9   Vision screening;     4.7.3.1.10   Tuberculosis and lead risk
screening;     4.7.3.1.11   Hearing screening; and     4.7.3.1.12   Dental and
oral health assessment.

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  4.7.3.2   Lead screening is a required component of a Health Check screen and
the Contractor shall implement a screening program for the presence of lead
toxicity. The screening program shall consist of two (2) parts: verbal risk
assessment (from thirty-six (36) to seventy-two (72) months of age), and blood
lead screening. Regardless of risk, the Contractor shall provide for a blood
lead screening test for all Health Check eligible children at twelve (12) and
twenty-four (24) months of age. Children between twenty-four (24) months of age
and seventy-two (72) months of age should receive a blood lead screening test if
there is no record of a previous test.     4.7.3.3   The Contractor shall have a
lead case management program for Health Check eligibles and their households
when there is a positive blood lead test equal to or greater than ten
(10) micrograms per deciliter. The lead case management program shall include
education, a written case management plan that includes all necessary referrals,
coordination with other specific agencies, and aggressive pursuit of
non-compliance with follow-up tests and appointments.     4.7.3.4   The
Contractor shall have procedures for Referral to and follow up with oral health
professionals, including annual dental examinations and services by an oral
health professional.     4.7.3.5   The Contractor shall provide inter-periodic
screens, which are screens that occur between the complete periodic screens and
are Medically Necessary to determine the existence of suspected physical or
mental illnesses or Conditions. This includes at a minimum vision, hearing and
dental services.     4.7.3.6   The Contractor shall provide Referrals for
further diagnostic and/or treatment services to correct or ameliorate defects,
and physical and mental illnesses and Conditions discovered by the Health Check
screens. Referral and follow up may be made to the Provider conducting the
screening or to another Provider, as appropriate.     4.7.3.7   The Contractor
shall provide an initial health and screening visit to all newly enrolled GF
Health Check eligible children within ninety (90) Calendar Days and within
twenty-four (24) hours of birth to all newborns.     4.7.3.8   Minimum
Contractor compliance with the Health Check screening requirements, including
blood lead screening and annual dental examinations and services, is an eighty
percent (80%) screening rate, using the methodology prescribed by CMS to
determine the screening rate.

4.7.4   Tracking

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  4.7.4.1   The Contractor shall establish a tracking system that provides
information on compliance with Health Check requirements. This system shall
track, at a minimum, the following areas:

  4.7.4.1.1   Initial newborn Health Check visit occurring in the hospital;    
4.7.4.1.2   Periodic and preventive/well child screens and visits as prescribed
by the periodicity schedule;     4.7.4.1.3   Diagnostic and treatment services,
including Referrals;     4.7.4.1.4   Immunizations, lead, tuberculosis and
dental services; and     4.7.4.1.5   A reminder/notification system.

  4.7.4.2   All information generated and maintained in the tracking system
shall be consistent with Encounter Data requirements as specified elsewhere
herein.

4.7.5   Diagnostic and Treatment Services

  4.7.5.1   If a suspected problem is detected by a screening examination as
described above, the child shall be evaluated as necessary for further
diagnosis. This diagnosis is used to determine treatment needs.     4.7.5.2  
Health Check requires coverage for all follow-up diagnostic and treatment
services deemed Medically Necessary to ameliorate or correct a problem
discovered during a Health Check screen. Such Medically Necessary diagnostic and
treatment services must be provided regardless of whether such services are
covered by the State Medicaid Plan, as long as they are Medicaid-Covered
Services as defined in Title XIX of the Social Security Act. The Contractor
shall provide Medically Necessary, Medicaid-covered diagnostic and treatment
services, either directly or by Referral.

4.7.6   Reporting Requirements

  4.7.6.1   The Contractor shall submit to DCH quarterly Health Check Reports as
described in Section 4.18.4.1. The Contractor shall report Health Check visits
in accordance with the appropriate codes specified in the appropriate Provider
Handbooks.

4.8   PROVIDER NETWORK

4.8.1   General Provisions

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  4.8.1.1   The Contractor is solely responsible for providing a network of
physicians, pharmacies, hospitals, and other health care Providers through whom
it provides the items and services included in Covered Services.     4.8.1.2  
The Contractor shall ensure that its network of Providers is adequate to assure
access to all Covered Services, and that all Providers are appropriately
credentialed, maintain current licenses, and have appropriate locations to
provide the Covered Services.     4.8.1.3   The Contractor shall notify DCH
sixty (60) days in advance when a decision is made to close network enrollment
for new provider contracts and also notify DCH when network enrollment is
reopened. The Contractor must notify DCH sixty (60) days prior to closing a
provider panel.     4.8.1.4   The Contractor shall not include any Providers who
have been excluded from participation by the Department of Health and Human
Services, Office of Inspector General, or who are on the State’s list of
excluded Providers. The Contractor is responsible for routinely checking the
exclusions list and shall immediately terminate any Provider found to be
excluded and notify the Member per the requirements outlined in this Contract.  
  4.8.1.5   The Contractor shall require that each Provider have a unique
physician identifier number (UPIN). Effective May 23, 2007, in accordance with
45 CFR 160.103, the Contractor shall require that each Provider have a national
Provider identifier (NPI).     4.8.1.6   The Contractor shall have written
Selection and Retention Policies and Procedures. These policies shall be
submitted to DCH for review and approval within sixty (60) Calendar Days of
Contract Award and as updated thereafter. In selecting and retaining Providers
in its network the Contractor shall consider the following:

  4.8.1.6.1   The anticipated GF Enrollment;     4.8.1.6.2   The expected
Utilization of services, taking into consideration the characteristics and
Health Care needs of its Members;     4.8.1.6.3   The numbers and types (in
terms of training, experience and specialization) of Providers required to
furnish the Covered Services;     4.8.1.6.4   The numbers of network Providers
who are not accepting new GF patients; and     4.8.1.6.5   The geographic
location of Providers and Members, considering distance, travel time, the means
of transportation ordinarily used by

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      Members, and whether the location provides physical access for Members
with disabilities.

  4.8.1.7   If the Contractor declines to include individual Providers or groups
of Providers in its network, the Contractor shall give the affected Providers
written notice of the reason(s) for the decision. These provisions shall not be
construed to:

  4.8.1.7.1   Require the Contractor to contract with Providers beyond the
number necessary to meet the needs of its Members;     4.8.1.7.2   Preclude the
Contractor from establishing measures that are designed to maintain quality of
services and control costs and are consistent with its responsibilities to
Members.

  4.8.1.8   The Contractor shall ensure that all network Providers have
knowingly and willfully agreed to participate in the Contractor’s network. The
Contractor shall be prohibited from acquiring established networks without
contacting each individual Provider to ensure knowledge of the requirements of
this Contract and the Provider’s complete understanding and agreement to fulfill
all terms of the Provider Contract, as outlined in section 4.10. DCH reserves
the right to confirm and validate, through both the collection of information
and documentation from the Contractor and on-site visits to network Providers,
the existence of a direct relationship between the Contractor and the network
Providers.     4.8.1.9   The Contractor shall submit an up-dated version of the
Provider Network Listing spreadsheet for all requested Provider types (as
outlined under Required Attachments in 5.1.2.8 in the RFP), and include any
Provider Letters of Intent or executed Signature Pages of Provider Contracts not
previously submitted (as part of the RFP response) to DCH within sixty
(60) Calendar Days of Contract Award and as updated thereafter.     4.8.1.10  
The Contractor shall submit a final copy of the Provider Network Listing
spreadsheet for all requested Provider types (as outlined under Required
Attachments in 5.1.2.8 in the RFP), Signature Pages for all Provider Contracts,
and written acknowledgements from all Providers part of a PHO, IPA, or other
network stating that they know they are in the CMO’s network, know they are
accepting Medicaid patients, and that they are accepting the terms and
conditions. These shall all be submitted to DCH ninety (90) Calendar Days prior
to establishment of the Contractor in that Service Region.

4.8.2   Primary Care Providers (PCPs)

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  4.8.2.1   The Contractor shall offer its Members freedom of choice in
selecting a PCP. The Contractor shall have written PCP Selection Policies and
Procedures describing how Members select their PCP.     4.8.2.2   The Contractor
shall submit these PCP Selection Policies and Procedures policies to DCH for
review and approval within sixty (60) Calendar Days of Contract Award and as
updated thereafter.     4.8.2.3   PCP assignment policies shall be in accordance
with Section 4.1.2 of this Contract.     4.8.2.4   The Contractor may require
that Members are assigned to the same PCP for a period of up to six (6) months.
In the event the Contractor requires that Members are assigned to the same PCP
for a period of six (6) months or less, the following exceptions shall be made:

  4.8.2.4.1   Members shall be allowed to change PCPs without cause during the
first ninety (90) Calendar Days following PCP selection;     4.8.2.4.2   Members
shall be allowed to change PCPs with cause at anytime. The following constitute
cause for change:

  4.8.2.4.2.1   The PCP no longer meets the geographic access standards as
defined in Section 4.8.14;     4.8.2.4.2.2   The PCP does not, because of moral
or religious objections, provide the Covered Service(s) the Member seeks; and  
  4.8.2.4.2.3   The Member requests to be assigned to the same PCP as other
family members.

  4.8.2.4.3   Members shall be allowed to change PCPs every six (6) months.

  4.8.2.5   The PCP is responsible for supervising, coordinating, and providing
all Primary Care to each assigned Member. In addition, the PCP is responsible
for coordinating and/or initiating Referrals for specialty care (both in and out
of network), maintaining continuity of each Member’s Health Care and maintaining
the Member’s Medical Record, which includes documentation of all services
provided by the PCP as well as any specialty services. The Contractor shall
require that PCPs fulfill these responsibilities for all Members.     4.8.2.6  
The Contractor shall include in its network as PCPs the following:

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  4.8.2.6.1   Physicians who routinely provide Primary Care services in the
areas of:

  4.8.2.6.1.1   Family Practice;     4.8.2.6.1.2   General Practice;    
4.8.2.6.1.3   Pediatrics; or     4.8.2.6.1.4   Internal Medicine.

  4.8.2.6.2   Nurse Practitioners Certified (NP-C) specializing in:

  4.8.2.6.2.1   Family Practice; or     4.8.2.6.2.2   Pediatrics.

  4.8.2.7   NP-Cs in independent practice must also have a current collaborative
agreement with a licensed physician who has hospital admitting privileges.    
4.8.2.8   FQHCs and RHCs may be included as PCPs. The Contractor shall maintain
an accurate list of all Providers rendering care at these facilities.    
4.8.2.9   Primary Care Public Health Department Clinics and Primary Care
Hospital Outpatient Clinics may be included as PCPs if they agree to the
requirements of the PCP role, including the following conditions:

  4.8.2.9.1   The practice must routinely deliver Primary Care as defined by the
majority of the practice devoted to providing continuing comprehensive and
coordinated medical care to a population undifferentiated by disease or organ
system. If deemed necessary, a Medical Record audit of the practice will be
performed. Any exceptions to this requirement will be considered on a
case-by-case basis.     4.8.2.9.2   Any Referrals for specialty care to other
Providers of the same practice may be reviewed for appropriateness.

  4.8.2.10   Physician’s assistants (PAs) may participate as a PCP as a Member
of a physician’s practice.     4.8.2.11   The Contractor may allow female
Members to select a gynecologist or obstetrician-gynecologist (OB-GYN) as their
Primary Care Provider.     4.8.2.12   The Contractor may allow Members with
Chronic Conditions to select a specialist with whom he or she has an on-going
relationship to serve as a PCP.

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4.8.3   Direct Access

  4.8.3.1   The Contractor shall provide female Members with direct in-network
access to a women’s health specialist for covered care necessary to provide her
routine and preventive Health Care services. This is in addition to the Member’s
designated source of Primary Care if that Provider is not a women’s health
specialist.     4.8.3.2   The Contractor shall have a process in place that
ensures that Members determined to need a course of treatment or regular care
monitoring have direct access to a specialist as appropriate for the Member’s
condition and identified needs. The Medical Director shall be responsible for
over-seeing this process.     4.8.3.3   The Contractor shall ensure that Members
who are determined to need a course of treatment or regular care monitoring have
a treatment plan. This treatment plan shall be developed by the Member’s PCP
with Member participation, and in consultation with any specialists caring for
the Member. This treatment plan shall be approved in a timely manner by the
Medical Director and in accord with any applicable State quality assurance and
utilization review standards.

4.8.4   Pharmacies

  4.8.4.1   The Contractor shall maintain a comprehensive Provider network of
pharmacies that ensures pharmacies are available and accessible to all Members.

4.8.5   Hospitals

  4.8.5.1   The Contractor shall have a comprehensive Provider network of
hospitals such that they are available and accessible to all Members. This
includes, but is not limited to tertiary care facilities and facilities with
neo-natal, intensive care, burn, and trauma units.     4.8.5.2   The Contractor
shall include in its network Critical Access Hospitals (CAHs) that are located
in its Service Region.     4.8.5.3   The Contractor shall maintain copies of all
letters and other correspondence related to its efforts to include CAHs in its
network. This documentation shall be provided to DCH upon request.     4.8.5.4  
A critical access hospital must provide notice to a care management organization
and the Department of Community Health of any alleged

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      breaches in its contract by such care management organization (Title 33 of
the Official Code of Georgia Annotated as amended pursuant to HB 1234).

4.8.6   Laboratories

  4.8.6.1   The Contractor shall maintain a comprehensive Provider network of
laboratories that ensures laboratories are accessible to all Members. The
Contractor shall ensure that all laboratory testing sites providing services
under this contract have either a clinical laboratory (CLIA) certificate or a
waiver of a certificate of registration, along with a CLIA number, pursuant to
42 CFR 493.3.

4.8.7   Mental Health/Substance Abuse

  4.8.7.1   The Contractor shall include in its network Core Service Providers
(CSP’s) that meet the requirements of the Department of Human Resources and are
located in its Service Region, provided they agree to the Contractor’s terms and
conditions as well as rates; and presuming they meet the credentialing
requirements established by the Contractor for that provider type.     4.8.7.2  
The Contractor shall maintain copies of all letters and other correspondence
related to the inclusion of CSP’s in its network. This documentation shall be
provided to DCH upon request.

4.8.8   Federally Qualified Health Centers (FQHCs)

  4.8.8.1   The Contractor shall include in its Provider network all FQHCs in
its Service Region based on PPS rates.     4.8.8.2   The Contractor shall
maintain copies of all letters and other correspondence related to its efforts
to include FQHCs in its network. This documentation shall be provided to DCH
upon request.     4.8.8.3   The FQHC must agree to provide those primary care
services typically included as part of a physician’s medical practice, as
described in §901 of State Medicaid Manual Part II for FQHC (the Manual).
Services and supplies deemed necessary for the provision of a Core services as
described in §901.2 of the Manual are considered part of the FQHC service. In
addition, an FQHC can provide other ambulatory services of the following state
Medicaid Program, once enrolled in the programs:

  4.8.8.1.1   Health Check (COS 600),     4.8.8.1.2   Mental Health (COS 440),  
  4.8.8.1.3   Dental Services (COS 450 and 460),     4.8.8.1.4   Refractive
Vision Care services (COS 470),     4.8.8.1.5   Podiatry (COS 550),

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  4.8.8.1.6   Pregnancy Related services (COS 730), and

4.8.9   Rural Health Clinics (RHCs)

  4.8.9.1   The Contractor shall include in its Provider network all RHCs in its
Service Region based on PPS rates.     4.8.9.2   The Contractor shall maintain
copies of all letters and other correspondence related to its efforts to include
FQHCs and RHCs in its network. This documentation shall be provided to DCH upon
request.     4.8.9.3   The RHC must agree to provide those primary care services
typically included as part of a physician’s medical practice, as described in
§901 of State Medicaid Manual Part II for RHC (the Manual). Services and
supplies deemed necessary for the provision of a Core services as described in
§901.2 of the Manual are considered part of the RHC service. In addition, an RHC
can provide other ambulatory services of the following state Medicaid Program,
once enrolled in the programs:

  4.8.9.3.1   Health Check (COS 600),     4.8.9.3.2   Mental Health (COS 440),  
  4.8.9.3.3   Dental Services (COS 450 and 460),     4.8.9.3.4   Refractive
Vision Care services (COS 470),     4.8.9.3.5   Podiatry (COS 550),    
4.8.9.3.6   Pregnancy Related services (COS 730), and     4.8.9.3.7   Perinatal
Case Management (COS 761).

4.8.10   Family Planning Clinics

  4.8.11.1   The Contractor shall make a reasonable effort to subcontract with
all family planning clinics, including those funded by Title X of the Public
Health Services Act.     4.8.11.2   The Contractor shall maintain copies of all
letters and other correspondence related to its efforts to include Title X
Clinics in its network. This documentation shall be provided to DCH upon
request.

4.8.11   Nurse Practitioners Certified (NP-Cs) and Certified Nurse Midwives
(CNMs)

  4.8.11.1   The Contractor shall ensure that Members have appropriate access to
NP-Cs and CNMs, through either Provider contracts or Referrals. This provision
shall in no way be interpreted as requiring the Contractor to provide any
services that are not Covered Services.

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4.8.12   Dental Practitioners

  4.8.12.1   The Contractor shall not deny any dentist from participating in the
Medicaid and PeachCare for Kids dental program administered by such care
management organization if:

  4.8.12.1.1   If such dentist has obtained a license to practice in this state
and is an enrolled provider who has met all of the requirements of the
Department of Community Health for participation in the Medicaid and PeachCare
for Kids program; and     4.8.12.1.2   If licensed dentist will provide dental
services to members pursuant to a state or federally funded educational loan
forgiveness program that requires such services; provided, however, each care
management organization shall be required to offer dentists wishing to
participate through such loan forgiveness programs the same contract terms
offered to other dentists in the service region who participate in the care
management organization’s Medicaid and PeachCare for Kids dental programs;    
4.8.12.1.3   If the geographic area in which the dentist intends to practice has
been designated as having a dental professional shortage as determined by the
Department of Community Health, which may be based on the designation of the
Health Resources and Services Administration of the United States Department of
Health and Human Services; 4.8.12.1.4 The Contractor much establish to the
satisfaction of the Department of Community Health that a sufficient number of
general dentists and specialists have contracted with the care management
organization to provide covered dental services to members in the geographic
region.     4.8.12.1.4   The Contractor may only decline to contract with a
dentist who has had his or her license to practice dentistry sanctioned in any
manner or fails to meet the credentialing criteria established by the care
management organization. Any dentist denied on this basis shall be entitled to a
hearing before an administrative law judge as set forth in subsection (e) of
Code Section 49-4-153.

4.8.13   Geographic Access Requirements

  4.8.13.1   In addition to maintaining in its network a sufficient number of
Providers to provide all services to its Members, the Contractor shall meet the
following geographic access standards for all Members:

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              Urban   Rural
PCPs
  Two (2) within eight (8) miles   Two (2) within fifteen (15) miles
 
       
Specialists
  One (1) within thirty (30) minutes or thirty (30) miles   One within
forty-five (45) minutes or forty-five (45) miles
 
       
Dental Providers
  One (1) within thirty (30) minutes or thirty (30) miles   One within
forty-five (45) minutes or forty-five (45) miles
 
       
Hospitals
  One (1) within thirty (30) minutes or thirty (30) miles   One within
forty-five (45) minutes or forty-five (45) miles
 
       
Mental Health Providers
  One (1) within thirty (30) minutes or thirty (30) miles   One within
forty-five (45) minutes or forty-five (45) miles
 
       
Pharmacies
  One (1) twenty-four (24) hours a day, seven (7) days a week within fifteen
(15) minutes or fifteen (15) miles   One (1) twenty-four (24) hours a day (or
has an after hours emergency phone number and pharmacist on call), seven (7)
days a week within thirty (30) minutes or thirty (30) miles

  4.8.13.2   All travel times are maximums for the amount of time it takes a
Member, using usual travel means in a direct route to travel from their home to
the Provider. DCH recognizes that transportation with NET vendors may not always
follow direct routes due to multiple passengers.

4.8.14   Waiting Maximums and Appointment Requirements

  4.8.14.1   The Contractor shall require that all network Providers offer hours
of operation that are no less than the hours of operation offered to commercial
and Fee-for-Service patients. The Contractor shall encourage its PCPs to offer
After-Hours office care in the evenings and on weekends.     4.8.14.2   The
Contractor shall have in its network the capacity to ensure that waiting times
for appointments do not exceed the following:

     
PCPs (routine visits)
  21 Calendar Days
PCP (adult sick visit)
  72 hours
PCP (pediatric sick visit)
  24 hours
Specialist
  30 Calendar Days
Non-emergency hospital stays
  30 Calendar Days
Mental health Providers
  14 Calendar Days

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Urgent Care Providers
  24 hours
Emergency Providers
  Immediately (24 hours a day, 7 days a week) and without prior authorization

  4.8.14.3   The Contractor shall provide adequate capacity for initial visits
for pregnant women within fourteen (14) Calendar Days and visits for Health
Check eligible children within ninety (90) Calendar Days of Enrollment into the
CMO plan.     4.8.14.4   The Contractor shall take corrective action if there is
a failure to comply with these waiting times.

4.8.15   Credentialing

  4.8.15.1   The Contractor shall maintain written policies and procedures for
the Credentialing and Re-Credentialing of network Providers, using standards
established by National Committee Quality Assurance (NCQA), Joint Commission on
Accreditation Healthcare Organization (JCAHO), or American Accreditation
Healthcare Commission/URAC. At a minimum, the Contractor shall require that each
Provider be credentialed in accordance with State law. The Contractor may impose
more stringent Credentialing criteria than the State requires. The Contractor
shall Credential all completed applications packets within 120 calendar days of
receipt.       4.8.15.2   Credentialing policies and procedures shall include:
the verification of the existence and maintenance of credentials, licenses,
certificates, and insurance coverage of each Provider from a primary source; a
methodology and process for Re-Credentialing Providers; a description of the
initial quality assessment of private practitioner offices and other patient
care settings; and procedures for disciplinary action, such as reducing,
suspending, or terminating Provider privileges.     4.8.15.3   Upon the request
of DCH, The Contractor shall make available all licenses, insurance
certificates, and other documents of network Providers. The Contractor shall
also make available to DCH each quarter the total number of provider
applications by date that have been received, credentialed, and approved. These
reports should be catalogued date in such a way to allow age tracking of each
provider application submitted and the specific reason code for applications
delayed beyond 120 days.     4.8.15.4   The newly awarded Contractor shall
submit its Provider Credentialing and re-Credentialing Policies and Procedures
to DCH within sixty (60) Calendar Days of Contract Award and as updated
thereafter. Existing Contractors shall submit its Provider Credentialing and
re-Credentialing Policies and Procedures to DCH quarterly.

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4.8.16   Mainstreaming

  4.8.16.1   The Contractor shall encourage that all In-Network Providers accept
Members for treatment, unless they have a full panel (2500 members) and are
accepting no new GF or commercial patients. The Contractor shall ensure that
In-Network Providers do not intentionally segregate Members in any way from
other persons receiving services.     4.8.16.2   The Contractor shall ensure
that Members are provided services without regard to race, color, creed, sex,
religion, age, national origin, ancestry, marital status, sexual preference,
health status, income status, or physical or mental disability.

4.8.17   Coordination Requirements

  4.8.17.1   The Contractor shall coordinate with all divisions within DCH, as
well as with other State agencies, and with other CMO plans operating within the
same Service Region.     4.8.17.2   The Contractor shall also coordinate with
local education agencies in the Referral and provision of children’s
intervention services provided through the school to ensure Medical Necessity
and prevent duplication of services.     4.8.17.3   The Contractor shall
coordinate the services furnished to its Members with the service the Member
receives outside the CMO plan, including services received through any other
managed care entity.     4.8.17.4   The Contractor shall coordinate with all NET
vendors.     4.8.17.5   DCH strongly encourages the Contractor to Contract with
Providers of essential community services who would normally Contract with the
State as well as other public agencies and with non-profit organizations that
have maintained a historical base in the community.     4.8.17.6   The
Contractor shall implement procedures to ensure that in the process of
coordinating care each Member’s privacy is protected consistent with the
confidentiality requirements in 45 CFR 160 and 45 CFR 164.

4.8.18   Network Changes

  4.8.18.1   The Contractor shall notify DCH within seven (7) Business Days of
any significant changes to the Provider network or, if applicable, to any
Subcontractors’ Provider network. A significant change is defined as:

  4.8.18.1.1   A decrease in the total number of PCPs by more than five percent
(5%);

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  4.8.18.1.2   A loss of all Providers in a specific specialty where another
Provider in that specialty is not available within sixty (60) miles;    
4.8.18.1.3   A loss of a hospital in an area where another contracted hospital
of equal service ability is not available within thirty (30) miles; or    
4.8.18.1.4   Other adverse changes to the composition of the network, which
impair or deny the Members’ adequate access to In-Network Providers.

  4.8.18.2   The Contractor shall have procedures to address changes in the
health plan Provider network that negatively affect the ability of Members to
access services, including access to a culturally diverse Provider network.
Significant changes in network composition that negatively impact Member access
to services may be grounds for Contract termination or State determined
remedies.     4.8.18.3   If a PCP ceases participation in the Contractor’s
Provider network the Contractor shall send written notice to the Members who
have chosen the Provider as their PCP. This notice shall be issued no less than
thirty (30) Calendar Days prior to the effective date of the termination and no
more than ten (10) Calendar Days after receipt or issuance of the termination
notice.     4.8.18.4   If a Member is in a prior authorized ongoing course of
treatment with any other participating Provider who becomes unavailable to
continue to provide services, the Contractor shall notify the Member in writing
within ten (10) Calendar Days from the date the Contractor becomes aware of such
unavailability.     4.8.18.5   These requirements to provide notice prior to the
effective dates of termination shall be waived in instances where a Provider
becomes physically unable to care for Members due to illness, a Provider dies,
the Provider moves from the Service Region and fails to notify the Contractor,
or when a Provider fails Credentialing. Under these circumstances, notice shall
be issued immediately upon the Contractor becoming aware of the circumstances.

4.8.19   Out-of-Network Providers

  4.8.19.1   If the Contractor’s network is unable to provide Medically
Necessary Covered Services to a particular Member, the Contractor shall
adequately and timely cover these services Out-of-Network for the Member. The
Contractor must inform the Out-of Network Provider that the member cannot be
balance billed.

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  4.8.19.2   The Contractor shall coordinate with Out-of-Network Providers
regarding payment. For payment to Out-of-Network, or non-participating
Providers, the following guidelines apply:

  4.8.19.2.1   If the Contractor offers the service through an In-Network
Provider(s), and the Member chooses to access the service (i.e., it is not an
emergency) from an Out-of-Network Provider, the Contractor is not responsible
for payment.     4.8.19.2.2   If the service is not available from an In-Network
Provider, but the Contractor has three (3) Documented Attempts to contract with
the Provider, the Contractor is not required to pay more than Medicaid FFS rates
for the applicable service, less ten percent (10%).     4.8.19.2.3   If the
service is available from an In-Network Provider, but the service meets the
Emergency Medical Condition standard, and the Contractor has three
(3) Documented Attempts to contract with the Provider, the Contractor is not
required to pay more than Medicaid FFS rates for the applicable service, less
ten percent (10%).     4.8.19.2.4   If the service is not available from an
In-Network Provider and the Member requires the service and is referred for
treatment to an Out-of-Network Provider, the payment amount is a matter between
the CMO and the Out-of-Network Provider.

  4.8.19.3   In the event that needed services are not available from an
In-Network Provider and the Member must receive services from an Out-of-Network
Provider, the Contractor must ensure that the Member is not charged more than it
would have if the services were furnished within the network.

4.8.20   Shriners Hospitals for Children

  4.8.20.1   The Contractor shall comply with the responsibilities outlined in
the “Memorandum of Understanding for the PeachCare Partnership Program” executed
on February 18, 2008.     4.8.20.2   The Contractor shall cooperate with DCH in
making any updates or revisions to the Memorandum, as necessary.

4.8.21   Reporting Requirements

  4.8.21.1   The Contractor shall submit to DCH Provider Network Adequacy and
Capacity Reports, as described in Section 4.18.6.2.     4.8.21.2   The
Contractor shall submit to DCH quarterly Timely Access Reports as described in
Section 4.18.4.2.

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4.9   PROVIDER SERVICES

4.9.1   General Provisions

  4.9.1.1   The Contractor shall provide information to all Providers about GF
in order to operate in full compliance with the GF Contract and all applicable
federal and State regulations.     4.9.1.2   The Contractor shall monitor
Provider knowledge and understanding of Provider requirements, and take
corrective actions to ensure compliance with such requirements.     4.9.1.3  
The Contractor shall submit to DCH for review and prior approval all materials
and information to be distributed and/or made available.     4.9.1.4   All
Provider Handbooks and bulletins must be in compliance with State and federal
laws.

4.9.2   Provider Handbooks

  4.9.2.1   The Contractor shall issue a Provider Handbook to all network
Providers at the time the Provider Contract is signed. The Contractor may choose
not to distribute the Provider Handbook via mail, provided it submits a written
notification to all Providers that explains how to obtain the Provider Handbook
from the CMO’s Web site. This notification shall also detail how the Provider
can request a hard copy from the CMO at no charge to the Provider. All Provider
Handbooks and bulletins shall be in compliance with State and federal laws. The
Provider Handbook shall serve as a source of information regarding GF Covered
Services, policies and procedures, statutes, regulations, telephone access and
special requirements to ensure all Contract requirements are being met. At a
minimum, the Provider Handbook shall include the following information:

  4.9.2.1.1   Description of the GF;     4.9.2.1.2   Covered Services;    
4.9.2.1.3   Emergency Service responsibilities;     4.9.2.1.4   Health
Check/EPSDT program services and standards;     4.9.2.1.5   Policies and
procedures of the Provider complaint system;

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  4.9.2.1.6   Information on the Member Grievance System, including the Member’s
right to a State Administrative Law Hearing, the timeframes and requirements,
the availability of assistance in filing, the toll-free numbers and the Member’s
right to request continuation of Benefits while utilizing the Grievance System;
    4.9.2.1.7   Medical Necessity standards and practice guidelines;    
4.9.2.1.8   Practice protocols, including guidelines pertaining to the treatment
of chronic and complex Conditions;     4.9.2.1.9   PCP responsibilities;    
4.9.2.1.10   Other Provider or Subcontractor responsibilities;     4.9.2.1.11  
Prior Authorization, Pre-Certification, and Referral procedures;     4.9.2.1.12
  Protocol for Encounter Data element reporting/records;     4.9.2.1.13  
Medical Records standard;     4.9.2.1.14   Claims submission protocols and
standards, including instructions and all information necessary for a clean or
complete Claim;     4.9.2.1.15   Payment policies;     4.9.2.1.16   The
Contractor’s Cultural Competency Plan; and     4.9.2.1.17   Member rights and
responsibilities.

  4.9.2.2   The Contractor shall disseminate bulletins as needed to incorporate
any needed changes to the Provider Handbook.     4.9.2.3   The Contractor shall
submit the Provider Handbook to DCH for review and approval within sixty
(60) Calendar Days of Contract Award and as updated thereafter. Any updates or
revisions shall be submitted to DCH for review and approval at least 30 days
prior to distribution.

4.9.3   Education and Training

  4.9.3.1   The Contractor shall provide training to all Providers and their
staff regarding the requirements of the Contract and special needs of Members.
The Contractor shall conduct initial training within thirty (30) Calendar Days
of placing a newly Contracted Provider on active status. The Contractor shall
also conduct ongoing training as deemed necessary by the Contractor or DCH in
order to ensure compliance with program standards and the GF Contract.

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  4.9.3.2   The Contractor shall submit the Provider Training Manual and
Training Schedule to DCH for review and approval within sixty (60) Calendar Days
of Contract Award and as updated thereafter.     4.9.3.3   The Contractor shall
submit the Provider Rep Field Visit Report as described in Section 4.18.4.13.

4.9.4   Provider Relations

  4.9.4.1   The Contractor shall establish and maintain a formal Provider
relations function to timely and adequately respond to inquiries, questions and
concerns from network Providers. The Contractor shall implement policies
addressing the compliance of Providers with the requirements of GF, institute a
mechanism for Provider dispute resolution and execute a formal system of
terminating Providers from the network.     4.9.4.2   The Contractor shall
provide for a Provider Relations Liaison to carry out the Provider relations
functions. There shall be at least one (1) Provider Relations Liaison in each
Service Region.

4.9.5   Toll-free Provider Services Telephone Line

  4.9.5.1   The Contractor shall operate a toll-free telephone line to respond
to Provider questions, comments and inquiries.     4.9.5.2   The Contractor
shall develop Telephone line Policies and Procedures that address staffing,
personnel, hours of operation, access and response standards, monitoring of
calls via recording or other means, and compliance with standards.     4.9.5.3  
The Contractor shall submit these Telephone line Policies and Procedures,
including performance standards, to DCH for review and approval within sixty
(60) Calendar Days of Contract Award and as updated thereafter.     4.9.5.4  
The Contractor’s call center systems shall have the capability to track call
management metrics identified in Attachment L.     4.9.5.5   Pursuant to OCGA
30-20A-7.1, the telephone line shall be staffed twenty-four (24) hours a day,
seven (7) days a week to respond to Prior Authorization and Pre-certification
requests. This telephone line shall have staff to respond to Provider questions
in all other areas, including the Provider complaint system, Provider
responsibilities, etc. between the hours of 7:00am and 7:00pm EST Monday through
Friday, excluding State holidays.

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  4.9.5.6   The Contractor shall develop performance standards and monitor
Telephone Line performance by recording calls and employing other monitoring
activities. At a minimum, the standards shall require that, on a monthly basis,
eighty percent (80%) of calls are answered by a person within thirty
(30) seconds, the Blocked Call rate does not exceed one percent (1%), and the
rate of Abandoned Calls does not exceed five percent (5%).     4.9.5.7   The
Contractor shall insure that after regular business hours the non-Prior
Authorization/Pre-certification line is answered by an automated system with the
capability to provide callers with operating hour’s information and instructions
on how to verify Enrollment for a Member with an Emergency or Urgent Medical
Condition. The requirement that the Contractor shall provide information to
Providers on how to verify Enrollment for a Member with an Emergency or Urgent
Medical Condition shall not be construed to mean that the Provider must obtain
verification before providing Emergency Services.     4.9.5.8   The Contractor
shall develop Call Center Quality Criteria and Protocols to measure and monitor
the accuracy of responses and phone etiquette as it relates to the Toll-free
Telephone Line. The Contractor shall submit the Call Center Quality Criteria and
Protocols to DCH for review and approval within sixty (60) Calendar Days of
Contract Award and as updated thereafter.

4.9.6 Internet Presence/Web Site

  4.9.6.1   The Contractor shall dedicate a section of its Web Site to Provider
services and provide at a minimum, the capability for Providers to make
inquiries and receive responses through the Medicaid fiscal agent Web Site,
(www.ghp.georgia.gov).     4.9.6.2   In addition to the specific requirements
outlined above, the Contractor’s Web Site shall be functionally equivalent, with
respect to functions described in this Contract, to the Web Site maintained by
the State’s Medicaid fiscal agent (www.ghp.georgia.gov).     4.9.6.3   The
Contractor shall submit Web site screenshots to DCH for review and approval
sixty (60) Calendar Days prior to Contract Award and quarterly thereafter and as
updated.     4.9.6.4   The Contractor shall maintain a website that allows
providers to submit, process, edit (only if original submission is in an
electronic format), rebill, and adjudicate claims electronically. To the extent
a provider has the capability; each care management organization shall submit
payments to providers electronically and submit remittance advices to providers
electronically within one business day of when payment is made. To the extent
that any of these functions involve covered transactions under 45 C.F.R.
Section 162.900, et

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      seq., then those transactions also shall be conducted in accordance with
applicable federal requirements.

  4.9.6.5   The Contractor shall post on its website a searchable list of all
providers with which the care management organization has contracted. At a
minimum, this list shall be searchable by provider name, specialty, and
location. At a minimum, the list shall be updated once each month.

4.9.7   Provider Complaint System

  4.9.7.1   The Contractor shall establish a Provider Complaint system that
permits a Provider to dispute the Contractor’s policies, procedures, or any
aspect of a Contractor’s administrative functions.     4.9.7.2   The Contractor
shall submit its Provider Complaint System Policies and Procedures to DCH for
review and approval quarterly and annually and as updated thereafter.    
4.9.7.3   The Contractor shall include its Provider Complaint System Policies
and Procedures in its Provider Handbook that is distributed to all network
Providers. This information shall include, but not be limited to, specific
instructions regarding how to contact the Contractor’s Provider services to file
a Provider complaint and which individual(s) have the authority to review a
Provider complaint.     4.9.7.4   The Contractor shall distribute the Provider
Complaint System Policies and Procedures to Out-of-Network Providers with the
remittance advice of the processed Claim. The Contractor may distribute a
summary of these Policies and Procedures if the summary includes information on
how the Provider may access the full Policies and Procedures on the Web site.
This summary shall also detail how the Provider can request a hard copy from the
CMO at no charge to the Provider.     4.9.7.5   As a part of the Provider
Complaint System, the Contractor shall:

  4.9.7.5.1   Allow Providers thirty (30) Calendar Days to file a written
complaint;     4.9.7.5.2   Allow providers to consolidate complaints or appeals
of multiple claims that involve the same or similar payment or coverage issues,
regardless of the number of individual patients or payment claims included in
the bundled complaint or appeal.

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  4.9.7.5.3   Allow a provider that has exhausted the care management
organization ´s internal appeals process related to a denied or underpaid claim
or group of claims bundled for appeal the option either to pursue the
administrative review process described in subsection (e) of Code
Section 49-4-153(e) or to select binding arbitration by a private arbitrator who
is certified by a nationally recognized association that provides training and
certification in alternative dispute resolution. If the care management
organization and the provider are unable to agree on an association, the rules
of the American Arbitration Association shall apply. The arbitrator shall have
experience and expertise in the health care field and shall be selected
according to the rules of his or her certifying association. Arbitration
conducted pursuant to this Code section shall be binding on the parties. The
arbitrator shall conduct a hearing and issue a final ruling within 90 days of
being selected, unless the care management organization and the provider
mutually agree to extend this deadline. All costs of arbitration, not including
attorney ´s fees, shall be shared equally by the parties.     4.9.7.5.4   For
all claims that are initially denied or underpaid by a care management
organization but eventually determined or agreed to have been owed by the care
management organization to a provider of health care services, the care
management organization shall pay, in addition to the amount determined to be
owed, interest of 20 percent per annum, calculated from 15 days after the date
the claim was submitted. A care management organization shall pay all interest
required to be paid under this provision or Code Section 33-24-59.5
automatically and simultaneously whenever payment is made for the claim giving
rise to the interest payment.     4.9.7.5.5   All interest payments shall be
accurately identified on the associated remittance advice submitted by the care
management organization to the provider.     4.9.7.5.6   Require that the reason
for the complaint is clearly documented;     4.9.7.5.7   Require that Providers
exhaust the Contractor’s internal Provider Complaint process prior to requesting
an Administrative Law Hearing (State Fair Hearing);     4.9.7.5.8   Have
dedicated staff for Providers to contact via telephone, electronic mail, or in
person, to ask questions, file a Provider Complaint and resolve problems;    
4.9.7.5.9   Identify a staff person specifically designated to receive and
process Provider Complaints;

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  4.9.7.5.10   Thoroughly investigate each GF Provider Complaint using
applicable statutory, regulatory, and Contractual provisions, collecting all
pertinent facts from all parties and applying the Contractor’s written policies
and procedures; and     4.9.7.5.11   Ensure that CMO plan executives with the
authority to require corrective action are involved in the Provider Complaint
process.

  4.9.7.6   In the event the outcome of the review of the Provider Complaint is
adverse to the Provider, the Contractor shall provide a written Notice of
Adverse Action to the Provider. The Notice of Adverse Action shall state that
Providers may request an Administrative Law Hearing in accordance with OCGA §
49-4-153, OCGA § 50-13-13 and OCGA § 50-13-15.     4.9.7.7   The Contractor
shall notify the Providers that a request for an Administrative Law Hearing must
include the following information:

  4.9.7.7.1   A clear expression by the Provider that he/she wishes to present
his/her case to an Administrative Law Judge;     4.9.7.7.2   Identification of
the Action being appealed and the issues that will be addressed at the hearing;
    4.9.7.7.3   A specific statement of why the Provider believes the
Contractor’s Action is wrong; and     4.9.7.7.4   A statement of the relief
sought.

  4.9.7.8   DCH has delegated its statutory authority to receive hearing
requests to the Contractor. The Contractor shall include with the Notice of
Adverse Action the Contractor’s address where a Provider’s request for an
Administrative Law Hearing should be sent in accordance with OCGA § 49-4-153(e).

Amerigroup Georgia Managed Care Company, Inc.
303 Perimeter Center North
Suite 400
Atlanta, GA 30346

4.9.8   Reporting Requirements

  4.9.8.1   The Contractor shall submit to DCH monthly Telephone and Internet
Activity Reports as described in Section 4.18.3.1.

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  4.9.8.2   The Contractor shall submit to DCH quarterly Provider Complaints
Reports as described in 4.18.4.3.

4.10   PROVIDER CONTRACTS AND PAYMENTS

4.10.1   Provider Contracts

  4.10.1.1   The Contractor shall comply with all DCH procedures for contract
review and approval submission. Memoranda of Agreement (MOA) shall not be
permitted. Letters of Intent shall only be permitted in accordance with
Section 4.8.1.9.     4.10.1.2   The Contractor shall submit to DCH for review
and approval a model for each type of Provider Contract within sixty
(60) Calendar Days of Contract Award and as updated thereafter.     4.10.1.3  
Any significant changes to the model Provider Contract shall be submitted to DCH
for review and approval no later than thirty (30) Calendar Days prior to the
Enrollment of Members into the CMO plan.     4.10.1.4   Upon request, the
Contractor shall provide DCH with free copies of all executed Provider
Contracts.     4.10.1.5   The Contractor shall not require providers to
participate or accept other plans or products offered by the care management
organization unrelated to providing care to members, nor reduce the funding
available for members as a result of payment of such penalties.. Any care
management organization which violates this prohibition shall be subject to a
penalty of $1,000.00 per violation.     4.10.1.6   The Contractor shall not
enter into any exclusive contract agreements with providers than exclude other
health care providers from contract agreements for network participation.    
4.10.1.7   Health care providers may not, as a condition of contracting with a
CMO, require the CMO to contract with or not contract with another health care
provider. A provider who violates this probation will be subject to a $1,000 per
violation penalty.     4.10.1.8   If a provider has complied with all of DCH’s
published procedures for verifying a patient’s eligibility for Medicaid benefits
through the established common verification process, DCH must reimburse the
provider for all covered services provided to the patient within the 72 hours
following the verification, if such services are denied by a CMO or DCH because
the patient is not enrolled as shown in the verification process. DCH would be
able to

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      pursue a case of action against a person who had contributed to the
incorrect verification.

  4.10.1.9   In addition to addressing the CMO plan licensure requirements, the
Contractor’s Provider Contracts shall:

  4.10.1.9.1   Prohibit the Provider from seeking payment from the Member for
any Covered Services provided to the Member within the terms of the Contract and
require the Provider to look solely to the Contractor for compensation for
services rendered, with the exception of nominal cost sharing pursuant to the
Georgia State Medicaid Plan, the Georgia State Medicaid Policies and Procedures
Manual, and the GF Contract;     4.10.1.9.2   Require the Provider to cooperate
with the Contractor’s quality improvement and Utilization Review and management
activities;     4.10.1.9.3   Include provisions for the immediate transfer to
another PCP or Contractor if the Member’s health or safety is in jeopardy;    
4.10.1.9.4   Not prohibit a Provider from discussing treatment or non-treatment
options with Members that may not reflect the Contractor’s position or may not
be covered by the Contractor;     4.10.1.9.5   Not prohibit a Provider from
acting within the lawful scope of practice, from advising or advocating on
behalf of a Member for the Member’s health status, medical care, or treatment or
non-treatment options, including any alternative treatments that might be
self-administered;     4.10.1.9.6   Not prohibit a Provider from advocating on
behalf of the Member in any Grievance System or Utilization Review process, or
individual authorization process to obtain necessary Health Care services;    
4.10.1.9.7   Require Providers to meet appointment waiting time standards
pursuant to Section 4.8.15.2 of this Contract;     4.10.1.9.8   Provide for
continuity of treatment in the event a Provider’s participation terminates
during the course of a Member’s treatment by that Provider;     4.10.1.9.9  
Prohibit discrimination with respect to participation, reimbursement, or
indemnification of any Provider who is acting within the scope of his or her
license or certification

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      under applicable State law, solely based on such license or certification.
This provision should not be construed as any willing provider law, as it does
not prohibit Contractors from limiting Provider participation to the extent
necessary to meet the needs of the Members. Additionally, this provision shall
not preclude the Contractor from using different reimbursement amounts for
different specialties or for different practitioners in the same specialty. This
provision also does not interfere with measures established by the Contractor
that are designed to maintain Quality and control costs;

  4.10.1.9.10   Prohibit discrimination against Providers serving high-risk
populations or those that specialize in Conditions requiring costly treatments;
    4.10.1.9.11   Specify that CMS and DCH will have the right to inspect,
evaluate, and audit any pertinent books, financial records, documents, papers,
and records of any Provider involving financial transactions related to the GF
Contract;     4.10.1.9.12   Specify Covered Services and populations;    
4.10.1.9.13   Require Provider submission of complete and timely Encounter Data,
pursuant to Section 4.17.4.2 of the GF Contract;     4.10.1.9.14   Include the
definition and standards for Medical Necessity, pursuant to the definition in
Section 4.5.4 of this Contract;     4.10.1.9.15   Specify rates of payment. The
Contractor ensures that Providers will accept such payment as payment in full
for Covered Services provided to Members, as deemed Medically Necessary and
appropriate under the Contractor’s Quality Improvement and Utilization
Management program, less any applicable Member cost sharing pursuant to the GF
Contract;     4.10.1.9.16   Provide for timely payment to all Providers for
Covered Services to Members.  Pursuant to O.C.G.A. 33-24-59.5(b) (1) once a
clean claim has been received, the CMO(s) will have 15 Business Days within
which to process and either transmit funds for payment electronically for the
claim or mail a letter or notice denying it, in whole or in part giving the
reasons for such denial.     4.10.1.9.17   Specify acceptable billing and coding
requirements;

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  4.10.1.9.18   Require that Providers comply with the Contractor’s Cultural
Competency plan;     4.10.1.9.19   Require that any marketing materials
developed and distributed by Providers be submitted to the Contractor to submit
to DCH for approval;     4.10.1.9.20   Specify that in the case of newborns the
Contractor shall be responsible for any payment owed to Providers for services
rendered prior to the newborn’s Enrollment with the Contractor;     4.10.1.9.21
  Specify that the Contractor shall not be responsible for any payments owed to
Providers for services rendered prior to a Member’s Enrollment with the
Contractor, even if the services fell within the established period of
retroactive eligibility;     4.10.1.9.22   Comply with 42 CFR 434 and 42 CFR
438.6;     4.10.1.9.23   Require Providers to collect Member co-payments as
specified in Attachment K;     4.10.1.9.24   Not employ or subcontract with
individuals on the State or Federal Exclusions list;     4.10.1.9.25   Prohibit
Providers from making Referrals for designated health services to Health Care
entities with which the Provider or a Member of the Provider’s family has a
Financial Relationship.     4.10.1.9.26   Require Providers of transitioning
Members to cooperate in all respects with Providers of other CMO plans to assure
maximum health outcomes for Members;     4.10.1.9.27   Not require that
Providers sign exclusive Provider Contracts with the Contractor if the Provider
is an STP, CAH, FQHC, or RHC;     4.10.1.9.28   Contain a provision stating that
in the event DCH is due funds from a Provider; who has exhausted or waived the
administrative review process, if applicable, the Contractor shall reduce
payment by one hundred percent (100%) to that Provider until such time as the
amount owed to DCH is recovered; and     4.10.1.9.29   Contain a provision
giving notice that the Contractor’s negotiated rates with Providers shall be
adjusted in the event

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      the Commissioner of DCH directs the Contractor to make such adjustments in
order to reflect budgetary changes to the Medical Assistance program.

4.10.2   Provider Termination

  4.10.2.1   The Contractor shall comply with all State and federal laws
regarding Provider termination. In its Provider Contracts the Contractor shall:

  4.10.2.1.1   Specify that in addition to any other right to terminate the
Provider Contract, and notwithstanding any other provision of this Contract, DCH
may request Provider termination immediately, or the Contractor may immediately
terminate on its own, a Provider’s participation under the Provider Contract if
a Provider fails to abide by the terms and conditions of the Provider Contract,
as determined by DCH, or, in the sole discretion of DCH, fails to come into
compliance within fifteen (15) Calendar Days after a receipt of notice from the
Contractor specifying such failure and requesting such Provider to abide by the
terms and conditions hereof;     4.10.2.1.2   Specify that any Provider whose
participation is terminated under the Provider Contract for any reason shall
utilize the applicable appeals procedures outlined in the Provider Contract. No
additional or separate right of appeal to DCH or the Contractor is created as a
result of the Contractor’s act of terminating, or decision to terminate any
Provider under this Contract. Notwithstanding the termination of the Provider
Contract with respect to any particular Provider, this Contract shall remain in
full force and effect with respect to all other Providers;

  4.10.2.2   The Contractor shall notify DCH at least forty-five (45) Calendar
Days prior to the effective date of the suspension, termination, or withdrawal
of a Provider from participation in the Contractor’s network. If the termination
was “for cause” the Contractor shall provide to DCH the reasons for termination;
and     4.10.2.3   The Contractor shall notify the Members pursuant to
Section 4.8.19 of this Contract.

4.10.3   Provider Insurance

  4.10.3.1   The Contractor shall require each Provider (with the exception of
4.10.3.2 below, and FQHCs that are section 330 grantees) to maintain, throughout
the terms of the Contract, at its own expense, professional and comprehensive
general liability, and medical malpractice, insurance. Such comprehensive
general liability policy of insurance shall provide coverage in an amount
established by the Contractor pursuant to its written Contract with the

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      Provider. Such professional liability policy of insurance shall provide a
minimum coverage in the amount of one million dollars ($1,000,000) per
occurrence, and three million dollars ($3,000,000) annual aggregate. Providers
may be allowed to self-insure if the Provider establishes an appropriate
actuarially determined reserve. DCH reserves the right to waive this requirement
if necessary for business need.     4.10.3.2   The Contractor shall require
allied mental health professionals to maintain, throughout the terms of the
Contract, professional and comprehensive general liability, and medical
malpractice, insurance. Such comprehensive general liability policy of insurance
shall provide coverage in an amount established by the Contractor pursuant to
its written Contract with Provider. Such professional liability policy of
insurance shall provide a minimum coverage in the amount of one million dollars
($1,000,000) per occurrence, and one million dollars ($1,000,000) annual
aggregate. These providers may also be allowed to self insure if the Provider
establishes an appropriate actuarially determined reserve.     4.10.3.3   In the
event any such insurance is proposed to be reduced, terminated or canceled for
any reason, the Contractor shall provide to DCH and Department of Insurance
(DOI) at least thirty (30) Calendar Days prior written notice of such reduction,
termination or cancellation. Prior to the reduction, expiration and/or
cancellation of any insurance policy required hereunder, the Contractor shall
require the Provider to secure replacement coverage upon the same terms and
provisions so as to ensure no lapse in coverage, and shall furnish DCH and DOI
with a Certificate of Insurance indicating the receipt of the required coverage
at the request of DCH or DOI.     4.10.3.4   The Contractor shall require
Providers to maintain insurance coverage (including, if necessary, extended
coverage or tail insurance) sufficient to insure against claims arising at any
time during the term of the GF Contract, even though asserted after the
termination of the GF Contract. DCH or DOI, at its discretion, may request that
the Contractor immediately terminate the Provider from participation in the
program upon the Provider’s failure to abide by these provisions. The provisions
of this Section shall survive the expiration or termination of the GF Contract
for any reason.

4.10.4   Provider Payment

  4.10.4.1   With the exceptions noted below, the Contractor shall negotiate
rates with Providers and such rates shall be specified in the Provider Contract.
DCH prefers that Contractors pay Providers on a Fee for Service basis, however
if the Contractor does enter into a capitated arrangement with Providers, the
Contractor shall continue to require all Providers to submit detailed Encounter
Data, including those Providers that may be paid a Capitation Payment.

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  4.10.4.2   The Contractor shall be responsible for issuing an IRS Form
(1099) in accordance with all federal laws, regulations and guidelines.    
4.10.4.3   When the Contractor negotiates a contract with a Critical Access
Hospital (CAH), pursuant to Section 4.8.6 of the GF Contract, the Contractor
shall pay the CAH a payment rate based on 101% allowable costs incurred by the
CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so
directed by the State of Georgia’s Appropriations Act.

  4.10.4.3.1   A critical access hospital must provide notice to a care
management organization and the Department of Community Health of any alleged
breaches in its contract by such care management organization.     4.10.4.3.2  
If a critical access hospital satisfies the requirement of Title 33 of the
Official Code of Georgia Annotated (HB1234), and if the Department of Community
Health concludes, after notice and hearing, that a care management organization
has substantively and repeatedly breached a term of its contract with a critical
access hospital, the department is authorized to require the care management
organization to pay damages to the critical access hospital in an amount not to
exceed three times the amount owed. Notwithstanding the foregoing, nothing in
Title 33 of the Official Code of Georgia Annotated (HB1234) shall be interpreted
to limit the authority of the Department of Community Health to establish
additional penalties or fines against a care management organization for failure
to comply with the contract between a care management organization and the
Department of Community Health.

  4.10.4.4   When the Contractor negotiates a contract with a FQHC and/or a RHC,
as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security
Act, the Contractor shall, at minimum, pay the PPS rates for Core Services and
other ambulatory services per encounter. The rates are established as described
in §1001.1 of the Manual. At Contractor’s discretion, it may pay more than the
PPS rate for these services.

  4.10.4.4.1   Payment Reports must consist of all covered service claim types
each month, inclusive of all of the below claims data:

  •   Early and Periodic Screening, Diagnosis and Treatment     •   Physician
Services     •   Office Visits     •   Laboratory Diagnostics     •   Radiology
Diagnostics     •   Obstetrical Services

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  •   Family Planning Services     •   Injectable Drugs and Immunizations     •
  Visiting Nurse Services     •   Newborn Hearing Screening     •   Hospitals  
  •   Nursing Homes     •   Other Clinics     •   Residential     •   Dental
Services     •   Mental Health Clinic Services     •   Refractive Services     •
  Pharmaceutical Services     •   Psychology Services     •   Podiatry Services
    •   Pediatric Preventive Health Screening/Newborn Metabolic     •   Supplies
incident to core services

(SEE DCH MEDICIAD MANUAL FOR ADDITIONAL INFORMATION ON FQHCs AND RHCs
REQUIREMENTS:
https://www.ghp.georgia.gov/wps/output/en_US/public/Provider/MedicaidManuals/01_2008_RHC_v2.pdf
https://www.ghp.georgia.gov/wps/output/en_US/public/Provider/MedicaidManuals/01_2008_FQHC_manual_v2.pdf

  4.10.4.5   Upon receipt of notice from DCH that it is due funds from a
Provider, who has exhausted or waived the administrative review process, if
applicable, the Contractor shall reduce payment to the Provider for all claims
submitted by that Provider by one hundred percent (100%), or such other amount
as DCH may elect, until such time as the amount owed to DCH is recovered. The
Contractor shall promptly remit any such funds recovered to DCH in the manner
specified by DCH. To that end, the Contractor’s Provider Contracts shall contain
a provision giving notice of this obligation to the Provider, such that the
Provider’s execution of the Contract shall constitute agreement with the
Contractor’s obligation to DCH.     4.10.4.6   The Contractor shall adjust its
negotiated rates with Providers to reflect budgetary changes to the Medical
Assistance program, as directed by the Commissioner of DCH; to the extent, such
adjustments can be made within funds appropriated to DCH and available for
payment to the Contractor. The Contractor’s Provider Contracts shall contain a
provision giving notice of this obligation to the Provider, such that the
Provider’s execution of the Contract shall constitute agreement with the
Contractor’s obligation to DCH.

4.10.5   Reporting Requirements

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  4.10.5.1   The Contractor shall submit a monthly FQHC and RHC Reports as
described in Section 4.18.4.4.

4.11   UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES

4.11.1   Utilization Management

  4.11.1.1   The Contractor shall provide assistance to Members and Providers to
ensure the appropriate Utilization of resources, using the following program
components: Prior Authorization and Pre-Certification, prospective review,
concurrent review, retrospective review, ambulatory review, second opinion,
discharge planning and case management. Specifically, the Contractor shall have
written Utilization Management Policies and Procedures that:

  4.11.1.1.1   Include protocols and criteria for evaluating Medical Necessity,
authorizing services, and detecting and addressing over-Utilization and
under-Utilization. Such protocols and criteria shall comply with federal and
State laws and regulations.     4.11.1.1.2   Address which services require PCP
Referral; which services require Prior-Authorization and how requests for
initial and continuing services are processed, and which services will be
subject to concurrent, retrospective or prospective review.     4.11.1.1.3  
Describe mechanisms in place that ensure consistent application of review
criteria for authorization decisions.     4.11.1.1.4   Require that all Medical
Necessity determinations be made in accordance with DCH’s Medical Necessity
definition as stated in Section 4.5.4.

  4.11.1.2   The Contractor shall submit the Utilization Management Policies and
Procedures to DCH for review and prior approval within quarterly and as changed.
    4.11.1.3   Network Providers may participate in Utilization Review
activities in their own Service Region to the extent that there is not a
conflict of interest. The Utilization Management Policies and Procedures shall
define when such a conflict may exist and shall describe the remedy.    
4.11.1.4   The Contractor shall have a Utilization Management Committee
comprised of network Providers within each Service Region. The Contractor may
have one (1) independent Utilization Management Committee for all of the Service

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      Regions in which it is operating, if there is representation from each
Service Region on the Committee. The Utilization Management committee is
accountable to the Medical Director and governing body of the Contractor. The
Utilization Management Committee shall meet on a regular basis and maintain
records of activities, findings, recommendations, and actions. Reports of these
activities shall be made available to DCH upon request.

  4.11.1.5   The Contractor, and any delegated Utilization Review agent, shall
not permit or provide compensation or anything of value to its employees,
agents, or contractors based on:

  4.11.1.5.1   Either a percentage of the amount by which a Claim is reduced for
payment or the number of Claims or the cost of services for which the person has
denied authorization or payment; or     4.11.1.5.2   Any other method that
encourages the rendering of a Proposed Action.

4.11.2   Prior Authorization and Pre-Certification

  4.11.2.1   The Contractor shall not require Prior Authorization or
Pre-Certification for Emergency Services, Post-Stabilization Services, or Urgent
Care services, as described in Section 4.6.1, 4.6.2, and 4.6.3.     4.11.2.2  
The Contractor shall require Prior Authorization and/or Pre-Certification for
all non-emergent and non-urgent inpatient admissions except for normal newborn
deliveries.     4.11.2.3   The Contractor may require Prior Authorization and/or
Pre-Certification for all non-emergent, Out-of-Network services.     4.11.2.4  
Prior Authorization and Pre-Certification shall be conducted by a currently
licensed, registered or certified Health Care Professional who is appropriately
trained in the principles, procedures and standards of Utilization Review.    
4.11.2.5   The Contractor shall notify the Provider of Prior Authorization
determinations in accordance with the following timeframes:

  4.11.2.5.1   Standard Service Authorizations. Prior Authorization decisions
for non-urgent services shall be made within fourteen (14) Calendar Days of
receipt of the request for services. An extension may be granted for an
additional fourteen (14) Calendar Days if the Member or the Provider requests an
extension, or if the Contractor justifies to DCH a need for additional
information and the extension is in the Member’s interest.

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  4.11.2.5.2   Expedited Service Authorizations. In the event a Provider
indicates, or the Contractor determines, that following the standard timeframe
could seriously jeopardize the Member’s life or health the Contractor shall make
an expedited authorization determination and provide notice within twenty-four
(24) hours. The Contractor may extend the twenty-four (24) hour period for up to
five (5) Business Days if the Member or the Provider requests an extension, or
if the Contractor justifies to DCH a need for additional information and the
extension is in the Member’s interest.     4.11.2.5.3   Authorization for
services that have been delivered. Determinations for authorization involving
health care services that have been delivered shall be made within thirty
(30) Calendar Days of receipt of the necessary information.

  4.11.2.6   The Contractor’s policies and procedures for authorization shall
include consulting with the requesting Provider when appropriate.

4.11.3 Referral Requirements

  4.11.3.1   The Contractor may require that Members obtain a Referral from
their PCP prior to accessing non-emergency specialized services.     4.11.3.2  
In the Utilization Management Policies and Procedures discussed in Section
4.11.1.1, the Contractor shall address:

  4.11.3.2.1   When a Referral from the Member’s PCP is required;     4.11.3.2.2
  How a Member obtains a Referral to an In-Network Provider or an Out-of-Network
Provider when there is no Provider within the Contractor’s network that has the
appropriate training or expertise to meet the particular health needs of the
Member;     4.11.3.2.3   How a Member with a Condition which requires on-going
care from a specialist may request a standing Referral; and     4.11.3.2.4   How
a Member with a life-threatening Condition or disease, which requires
specialized medical care over a prolonged period of time, may request and obtain
access to a specialty care center.

  4.11.3.3   The Contractor shall prohibit Providers from making Referrals for
designated health services to Health Care entities with which the Provider or a
Member of the Provider’s family has a Financial Relationship.     4.11.3.4   DCH
strongly encourages the Contractor to develop electronic, web-based Referral
processes and systems. In the event a Referral is made via the

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      telephone, the Contractor shall ensure that the Contractor, the Provider
and DCH maintain Referral data, including the final decision, in a data file
that can be accessed electronically.

  4.11.3.5   In conjunction with the other Utilization Management policies, the
Contractor shall submit the Referral processes to DCH for review and approval.

4.11.4   Transition of Members

  4.11.4.1   Procedures that are scheduled to occur after their new CMO
effective date, but that have been authorized by either DCH or the patients
original CMO prior to their new CMO effective date will be covered by the
patients new CMO for 30 days, this will include:

  4.11.4.1.1   Members that are in ongoing treatment or that are receiving
medication that has been covered by DCH or another CMO prior to their new CMO
effective date will be covered by the new CMO for at least 30 days to allow time
for clinical review, and if necessary transition of care. The CMO will not be
obligated to cover services beyond 30 days, even if the DCH authorization was
for a period greater than 30 days.     4.11.4.1.2   Members who are otherwise
engaged with programs operated by the State Department of Human Resources; child
protective agency; mental health program; or children’s medical services. 

  4.11.4.2   Inpatient Care

  4.11.4.2.1   Members enrolled in a CMO that are hospitalized in an inpatient
facility will remain the responsibility of that CMO until they are discharged
from the facility, even if they change to a different CMO, or they become
eligible for coverage under FFS Medicaid during their inpatient stay.    
4.11.4.2.2   Inpatient care for newborns born on or after their mother’s
effective date will be the responsibility of the mother’s assigned CMO.    
4.11.4.2.3   Members that become eligible and enrolled in SSI after the date of
an inpatient hospitalization shall remain the responsibility of the CMO until
they are discharged from inpatient hospital care. These members will remain the
responsibility of the CMO for all covered services, even if the start date for
SSI eligibility is made retroactive to a date prior to the hospitalization.

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  4.11.4.2.4   The CMO will continue to receive capitation payment for every
month that the member continues to be hospitalized and will be responsible for
all medical claims during the period that they are receiving capitation. At
discharge, and upon notice of such discharge, DCH will reassign the member to
FFS or the new CMO following the normal monthly process.     4.11.4.2.5   Upon
notification that a hospitalized member will be transitioning to a new CMO, or
to FFS Medicaid, the current CMO will work with the new CMO or FFS Medicaid to
ensure that coordination of care and appropriate discharge planning occurs.

  4.11.4.3   When relinquishing Members, the Contractor shall cooperate with the
receiving CMO plan regarding the course of on-going care with a specialist or
other Provider.     4.11.4.4   Contractors must identify and facilitate
coordination of care for all Georgia Families members during changes or
transitions between Contractors, as well as transitions to FFS Medicaid. Members
with special circumstances (such as those listed below) may require additional
or distinctive assistance during a period of transition. Policies or protocols
must be developed to address these situations. Special circumstances include
members designated as having “special health care needs”, as well as members who
have:

  4.11.4.4.1   Medical conditions or circumstances such as:

  4.11.4.4.1.1   Pregnancy (especially women who are high risk and in third
trimester, or are within 30 days of their anticipated delivery date)    
4.11.4.4.1.2   Major organ or tissue transplantation services which are in
process, or have been authorized     4.11.4.4.1.3   Chronic illness, which has
placed the member in a high-risk category and/or resulted in hospitalization or
placement in nursing, or other, facilities, and/or     4.11.4.4.1.4  
Significant medical conditions, (e.g., diabetes, hypertension, pain control or
orthopedics) that require ongoing care of specialist appointments.

  4.11.4.4.2   Members who are in treatment such as:

  4.11.4.4.2.1   Chemotherapy and/or radiation therapy, or     4.11.4.4.2.2  
Dialysis.

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  4.11.4.4.3   Members with ongoing needs such as:

  4.11.4.4.3.1   Durable medical equipment including ventilators and other
respiratory assistance equipment     4.11.4.4.3.2   Home health services    
4.11.4.4.3.3   Medically necessary transportation on a scheduled basis    
4.11.4.4.3.4   Prescription medications, and/or     4.11.4.4.3.5   Other
services not indicated in the State Plan, but covered by Title XIX for Early and
Periodic Screening, Diagnosis and Treatment eligible members.

  4.11.4.4.4   Members who are currently hospitalized.

4.11.5   Court-Ordered Evaluations and Services

  4.11.5.1   In the event a Member requires Medicaid-covered services ordered by
a State or federal court, the Contractor shall fully comply with all court
orders while maintaining appropriate Utilization Management practices.

4.11.6   Second Opinions

  4.11.6.1   The Contractor shall provide for a second opinion in any situation
when there is a question concerning a diagnosis or the options for surgery or
other treatment of a health Condition when requested by any Member of the Health
Care team, a Member, parent(s) and/or guardian (s), or a social worker
exercising a custodial responsibility.     4.11.6.2   The second opinion must be
provided by a qualified Health Care Professional within the network, or the
Contractor shall arrange for the Member to obtain one outside the Provider
network.     4.11.6.3   The second opinion shall be provided at no cost to the
Member.

4.11.7   Care Coordination and Case Management

  4.11.7.1   The Contractor shall be responsible for the Care Coordination/Case
Management of all Members and shall make special effort to identify Members who
have the greatest need for Care Coordination, including those who have
catastrophic, or other high-cost or high-risk Conditions.

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  4.11.7.2   The Contractor’s Care Coordination system shall emphasize
prevention, continuity of care, and coordination of care. The system will
advocate for, and link Members to, services as necessary across Providers and
settings. Care Coordination functions include:

  4.11.7.2.1   Early identification of Members who have or may have special
needs;     4.11.7.2.2   Assessment of a Member’s risk factors;     4.11.7.2.3  
Development of a plan of care;     4.11.7.2.4   Referrals and assistance to
ensure timely access to Providers;     4.11.7.2.5   Coordination of care
actively linking the Member to Providers, medical services, residential, social
and other support services where needed;     4.11.7.2.6   Monitoring;    
4.11.7.2.7   Continuity of care; and     4.11.7.2.8   Follow-up and
documentation.

  4.11.7.3   The Contractor shall develop and implement a Care Coordination and
case management system to ensure:

  4.11.7.3.1   Timely access and delivery of Health Care and services required
by Members;

  4.11.7.3.2   Continuity of Members’ care; and     4.11.7.3.3   Coordination
and integration of Members’ care.

  4.11.7.4   These policies shall include, at a minimum, the following elements:

  4.11.7.4.1   The provision of an individual needs assessment and diagnostic
assessment; the development of an individual treatment plan, as necessary, based
on the needs assessment; the establishment of treatment objectives; the
monitoring of outcomes; and a process to ensure that treatment plans are revised
as necessary. These procedures must be designed to accommodate the specific
cultural and linguistic needs of the Contractor’s Members;

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  4.11.7.4.2   A strategy to ensure that all Members and/or authorized family
members or guardians are involved in treatment planning     4.11.7.4.3  
Procedures and criteria for making Referrals to specialists and subspecialists;
    4.11.7.4.4   Procedures and criteria for maintaining care plans and Referral
Services when the Member changes PCPs; and     4.11.7.4.5   Capacity to
implement, when indicated, case management functions such as individual needs
assessment, including establishing treatment objectives, treatment follow-up,
monitoring of outcomes, or revision of treatment plan.

  4.11.7.5   The Contractor shall submit the Care Coordination and Case
Management Policies and Procedures to DCH for review and approval within ninety
(90) Calendar Days of Contract Award and as updated thereafter.

4.11.8   Disease Management

  4.11.8.1   The Contractor shall develop disease management programs for
individuals with Chronic Conditions.     4.11.8.2   The Contractor shall have
disease management programs for Members with diabetes and asthma.     4.11.8.3  
In addition, the Contractor shall develop programs for at least two
(2) additional Conditions to be chosen from the following list:

  4.11.8.3.1   Perinatal case management;     4.11.8.3.2   Obesity;    
4.11.8.3.3   Hypertension;     4.11.8.3.4   Sickle cell disease; or    
4.11.8.3.5   HIV/AIDS.

4.11.9 Discharge Planning

  4.11.9.1   The Contractor shall maintain and operate a formalized
discharge-planning program that includes a comprehensive evaluation of the
Member’s health needs and identification of the services and supplies required
to facilitate appropriate care following discharge from an institutional
clinical setting.

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4.11.10   Reporting Requirements

  4.11.10.1   The Contractor shall submit Utilization Management Reports to DCH
as described in Sections 4.18.3.6 and 4.18.4.5.     4.11.10.2   The Contractor
shall submit monthly Prior Authorization and Pre-Certification Reports to DCH as
described in Section 4.18.3.3.

4.12   QUALITY IMPROVEMENT

4.12.1   General Provisions

  4.12.1.1   The Contractor shall provide for the delivery of Quality care with
the primary goal of improving the health status of Members and, where the
Member’s Condition is not amenable to improvement, maintain the Member’s current
health status by implementing measures to prevent any further decline in
Condition or deterioration of health status. This shall include the
identification of Members at risk of developing Conditions, the implementation
of appropriate interventions and designation of adequate resources to support
the intervention(s).     4.12.1.2   The Contractor shall seek input from, and
work with, Members, Providers and community resources and agencies to actively
improve the Quality of care provided to Members.     4.12.1.3   The Contractor
shall establish a multi-disciplinary Quality Oversight Committee to oversee all
Quality functions and activities. This committee shall meet at least quarterly,
but more often if warranted.

4.12.2   Quality Strategic Plan Requirements

  4.12.2.1   The Contractor shall support and comply with Georgia Families
Quality Strategic Plan. The Quality Strategic Plan is designed to improve the
Quality of Care and Service rendered to GF members (as defined in Title 42 of
the Code of Federal Regulations (42 CFR) 431.300 et seq. (Safeguarding
Information on Applicants and Recipients); 42 CFR 438.200 et seq. (Quality
Assessment and Performance Improvement Including Health Information Systems),
and 45 CFR Part 164 (HIPAA Privacy Requirements).     4.12.2.2   The GF Quality
Strategic Plan promotes improvement in the quality of care provided to enrolled
members through established processes. DCH Managed Care & Quality staff’
oversight of the Contractor includes:

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  4.12.2.2.1   Monitoring and evaluating the Contractor’s service delivery
system and provider network, as well as its own processes for quality management
and performance improvement;     4.12.2.2.2   Implementing action plans and
activities to correct deficiencies and/or increase the quality of care provided
to enrolled members,     4.12.2.2.3   Initiating performance improvement
projects to address trends identified through monitoring activities, reviews of
complaints and allegations of abuse, provider credentialing and profiling,
utilization management reviews, etc.;     4.12.2.2.4   Monitoring compliance
with Federal, State and Georgia Families requirements;     4.12.2.2.5   Ensuring
the Contractor’s coordination with State registries;     4.12.2.2.6   Ensuring
Contractor executive and management staff participation in the quality
management and performance improvement processes;     4.12.2.2.7   Ensure that
the development and implementation of quality management and performance
improvement activities include contracted provider participation and information
provided by members, their families and guardians, and     4.12.2.2.8  
Identifying the Contractor’s best practices for performance and quality
improvement.

4.12.3   Reporting Requirements

Contractors must submit the following data reports as indicated.

          REPORT   DUE DATE   REPORTS DIRECTED TO:
Performance Improvement Project Proposal(s)
  Annually by March 31   Georgia Families/Quality Management Unit
 
       
Quality Assurance Performance Improvement Plan
  Annually by March 31   Georgia Families/Quality Management Unit
 
       
Quality Assurance Performance Improvement Program Evaluation
  Annually by March 31   Georgia Families/Quality Management Unit
 
       
Performance Improvement Project Baseline Report
  By March 31 following initial year of study   Georgia Families/Quality
Management Unit

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          REPORT   DUE DATE   REPORTS DIRECTED TO:
Performance Improvement Project Final Evaluation Report (including any new QM/PI
activities implemented as a result of the project)
  Annually by March 31   Georgia Families/Quality Management Unit
 
       
Corrective Action Preventive Action Plan for deficiencies noted in:
1. An Operations Field Review
2. A Focused Review
3. QM/PI Plan
4. Performance related to Quality Measures
  30 days after receipt of notice to submit a Corrective Action Preventive
Action Plan (CAP) unless otherwise stated.   Georgia Families/Quality Management
Unit
 
       
Quarterly QM Reports
  45 days after end of quarter   Georgia Families/Quality Management Unit
 
       
Performance Measures Report
  Annually by March 31   Georgia Families/Quality Management Unit

If an extension of time is needed to complete a report, the Contractor may
submit a request in writing to the Georgia Families/ Quality Management

4.12.4   Quality Assessment Performance Improvement (QAPI) Program

  4.12.4.1   The Contractor shall have in place an ongoing QAPI program
consistent with 42 CFR 438.240.     4.12.4.2   The Contractor’s QAPI program
shall be based on the latest available research in the area of Quality assurance
and at a minimum must include:

  4.12.4.2.1   A method of monitoring, analysis, evaluation and improvement of
the delivery, Quality and appropriateness of Health Care furnished to all
Members (including under and over Utilization of services), including those with
special Health Care needs;     4.12.4.2.2   Written policies and procedures for
Quality assessment, Utilization Management and continuous Quality improvement
that are periodically assessed for efficacy;     4.12.4.2.3   A health
information system sufficient to support the collection, integration, tracking,
analysis and reporting of data;     4.12.4.2.4   Designated staff with expertise
in Quality assessment, Utilization Management and continuous Quality
improvement;     4.12.4.2.5   Reports that are evaluated, indicated
recommendations that are implemented, and feedback provided to Providers and
Members;

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  4.12.4.2.6   A methodology and process for conducting and maintaining Provider
profiling;     4.12.4.2.7   Quarterly Reports to the Contractor’s
multi-disciplinary Quality oversight committee and DCH on results, conclusions,
recommendations and implemented system changes;     4.12.4.2.8   Annual
performance improvement projects (PIPs) that focus on clinical and non-clinical
areas; and     4.12.4.2.9   Annual Reports on performance improvement projects
and a process for evaluation of the impact and assessment of the Contractor’s
QAPI program.

  4.12.4.3   The Contractor’s QAPI Program Plan must be submitted to DCH for
review and approval within ninety (90) Calendar Days of Contract Award and as
updated thereafter.     4.12.4.4   The Contractor shall submit any changes to
its QAPI Program Plan to DCH for review and prior approval sixty (60) Calendar
Days prior to implementation of the change.     4.12.4.5   Upon the request of
DCH, the Contractor shall provide any information and documents related to the
implementation of the QAPI program.

4.12.5   Performance Improvement Projects

  4.12.5.1   As part of its QAPI program the Contractor shall conduct clinical
and non-clinical performance improvement projects in accordance with DCH and
federal protocols. In designing its performance improvement projects, the
Contractor shall:

  4.12.5.1.1   Show that the selected area of study is based on a demonstration
of need and is expected to achieve measurable benefit to the Member (rationale);
    4.12.5.1.2   Establish clear, defined and measurable goals and objectives
that the Contractor shall achieve in each year of the project;     4.12.5.1.3  
Measure performance using Quality indicators that are objective, measurable,
clearly defined and that allow tracking of performance and improvement over
time;     4.12.5.1.4   Implement interventions designed to achieve Quality
improvements;

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  4.12.5.1.5   Evaluate the effectiveness of the interventions;     4.12.5.1.6  
Establish standardized performance measures (such as HEDIS or another similarly
standardized product);     4.12.5.1.7   Plan and initiate activities for
increasing or sustaining improvement; and     4.12.5.1.8   Document the data
collection methodology used (including sources) and steps taken to assure data
is valid and reliable.

  4.12.5.2   Each performance improvement project must be completed in a period
determined by DCH, to allow information on the success of the project in the
aggregate to produce new information on Quality of care each year.     4.12.5.3
  The Contractor shall perform the following required clinical performance
improvement projects, ongoing for the duration of the GF Contract period:

  4.12.5.3.1   One (1) in the area of Health Check screens;     4.12.5.3.2   One
(1) in the area of immunizations; and     4.12.5.3.3   One (1) in the area of
blood lead screens.     4.12.5.3.4   One (1) in the area of detection of chronic
kidney disease.

  4.12.5.4   The Contractor shall perform one (1) optional clinical performance
improvement project from the following areas:

  4.12.5.4.1   Coordination/continuity of care;     4.12.5.4.2   Chronic care
management;     4.12.5.4.3   High volume Conditions; or     4.12.5.4.4   High
risk Conditions.

  4.12.5.5   The Contractor shall perform the following required non-clinical
performance improvement projects:

  4.12.5.5.1   One (1) in the area of Member satisfaction; and     4.12.5.5.2  
One (1) in the area of Provider satisfaction.

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  4.12.5.6   The Contractor shall perform one (1) optional non-clinical
performance improvement project from the following areas:

  4.12.5.6.1   Cultural competence;     4.12.5.6.2   Appeals/Grievance/Provider
Complaints;     4.12.5.6.3   Access/service capacity; or     4.12.5.6.4  
Appointment availability.

  4.12.5.7   The Contractor shall submit its Proposed Performance Improvement
Projects to DCH for review and prior approval within ninety (90) Calendar Days
of Contract Award and as updated thereafter.     4.12.5.8   The Contractor shall
meet the established goals and objectives, as determined by DCH, for its
performance improvement projects. The Contractor shall submit to DCH any and all
data necessary to enable DCH to measure the Contractor’s performance under this
Section.

4.12.6   Practice Guidelines

  4.12.6.1   The Contractor shall adopt a minimum of three (3) evidence-based
clinical practice guidelines, one of which shall be for chronic kidney disease.
Such guidelines shall:

  4.12.6.1.1   Be based on the health needs and opportunities for improvement
identified as part of the QAPI program;     4.12.6.1.2   Be based on valid and
reliable clinical evidence or a consensus of Health Care Professionals in the
particular field;     4.12.6.1.3   Consider the needs of the Members;    
4.12.6.1.4   Be adopted in consultation with network Providers; and    
4.12.6.1.5   Be reviewed and updated periodically as appropriate.

  4.12.6.2   The Contractor shall submit the Practice Guidelines, which shall
include a methodology for measuring and assessing compliance, to DCH for review
and prior approval as part of the QAPI program plan within ninety (90) Calendar
Days of Contract Award and as updated thereafter.     4.12.6.3   The Contractor
shall disseminate the guidelines to all affected Providers and, upon request, to
Members.

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  4.12.6.4   The Contractor shall ensure that decisions for Utilization
Management, Member education, coverage of services, and other areas to which the
guidelines apply are consistent with the guidelines.     4.12.6.5   In order to
ensure consistent application of the guidelines the Contractor shall encourage
Providers to utilize the guidelines, and shall measure compliance with the
guidelines, until ninety percent (90%) or more of the Providers are consistently
in compliance. The Contractor may use Provider incentive strategies to improve
Provider compliance with guidelines.

4.12.7   Focused Studies

  4.12.7.1   Focus Studies are State required studies that examine a specific
aspect of health care (such as prenatal care) for a defined point in time. These
projects are usually based on information extracted from medical records or
Contractor administrative data such as enrollment files and encounter/claims
data. Steps to be taken by Contractor when conducting focus studies are:

  •   Selecting the Study Topic(s)     •   Defining the Study Question(s)     •
  Selecting the Study Indicator(s)     •   Identifying a representative and
generalizable study population     •   Documenting sound sampling techniques
utilized (if applicable)     •   Collecting reliable data     •   Analyzing data
and interpreting study results

  4.12.7.2   The Contractor shall also perform a minimum of two (2) focused
studies each year, commencing with the second (2nd) year of operations. One
(1) study shall focus on preventive care services.     4.12.7.3   The Contractor
shall submit to DCH for approval the areas in which it will conduct focused
studies on the first (1st) day of the third (3rd) quarter annually. Due to
federal reporting requirements (e.g., Quality Strategic Plan and EQRO), the year
for Focus Studies is defined as October 1 – September 30 therefore the 1st day
of the 3rd quarter is April 1.

4.12.8   Patient Safety Plan

  4.12.8.1   The Contractor shall have a structured Patient Safety Plan to
address concerns or complaints regarding clinical care. This plan must include
written policies and procedures for processing of Member complaints regarding
the care they received. Such policies and procedures shall include:

  4.12.8.1.1   A system of classifying complaints according to severity;

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  4.12.8.1.2   A review by the Medical Director and a mechanism for determining
which incidents will be forwarded to Peer Review and Credentials Committees; and

  4.12.8.1.3   A summary of incident(s), including the final disposition,
included in the Provider profile.

  4.12.8.2   The Contractor shall submit the Patient Safety Plan to DCH for
review and approval within ninety (90) Calendar Days of the Contract Award and
as updated thereafter.

4.12.9   Performance Incentives

  4.12.9.1   The Contractor may be eligible for Performance Incentives as
described in Section 7.0. All Incentives must comply with the federal managed
care Incentive Arrangement requirements pursuant to 42 CFR 438.6 and the State
Medicaid Manual 2089.3.

4.12.10   External Quality Review

  4.12.10.1   DCH will contract with an External Quality Review Organization
(EQRO) to conduct annual, external, independent reviews of the Quality outcomes,
timeliness of, and access to, the services covered in this Contract. The
Contractor shall collaborate with DCH’s EQRO to develop studies, surveys and
other analytic activities to assess the Quality of care and services provided to
Members and to identify opportunities for CMO plan improvement. To facilitate
this process the Contractor shall supply data, including but not limited to
Claims data and Medical Records, to the EQRO.

4.12.11   Reporting Requirements

  4.12.11.1   The Contractor’s Quality Oversight Committee shall submit Quality
Oversight Committee Reports to DCH as described in Section 4.18.4.6.    
4.12.11.2   The Contractor shall submit Performance Improvement Project Reports
as described in Section 4.18.5.1     4.12.11.3   The Contractor shall submit
annual Focused Studies Reports to DCH as described in Section 4.18.5.2.    
4.12.11.4   The Contractor shall submit annual Patient Safety Plan Reports to
DCH as described in Section 4.18.5.3.

4.13   FRAUD AND ABUSE   4.13.1   Program Integrity

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  4.13.1.1   The Contractor shall have a Program Integrity Program, including a
mandatory compliance plan, designed to guard against Fraud and Abuse. This
Program Integrity Program shall include policies, procedures, and standards of
conduct for the prevention, detection, reporting, and corrective action for
suspected cases of Fraud and Abuse in the administration and delivery of
services under this Contract.     4.13.1.2   The Contractor shall submit its
Program Integrity Policies and Procedures, which include the compliance plan and
pharmacy lock-in program described below, to DCH for approval within sixty
(60) Calendar Days of Contract Award and as updated thereafter.

4.13.2   Compliance Plan

  4.13.2.1   The Contractor’s compliance plan shall include, at a minimum, the
following:

  4.13.2.1.1   The designation of a Compliance Officer who is accountable to the
Contractor’s senior management and is responsible for ensuring that policies to
establish effective lines of communication between the Compliance Officer and
the Contractor’s staff, and between the Compliance Officer and DCH staff, are
followed;     4.13.2.1.2   Provision for internal monitoring and auditing of
reported Fraud and Abuse violations, including specific methodologies for such
monitoring and auditing;     4.13.2.1.3   Policies to ensure that all officers,
directors, managers and employees know and understand the provisions of the
Contractor’s Fraud and Abuse compliance plan;     4.13.2.1.4   Policies to
establish a compliance committee that periodically meets and reviews Fraud and
Abuse compliance issues;     4.13.2.1.5   Policies to ensure that any individual
who reports CMO plan violations or suspected Fraud and Abuse will not be
retaliated against;     4.13.2.1.6   Polices of enforcement of standards through
well-publicized disciplinary standards;     4.13.2.1.7   Provision of a data
system, resources and staff to perform the Fraud and Abuse and other compliance
responsibilities;     4.13.2.1.8   Procedures for the detection of Fraud and
Abuse that includes, at a minimum, the following:

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  4.13.2.1.8.1   Claims edits     4.13.2.1.8.2   Post-processing review of
Claims;     4.13.2.1.8.3   Provider profiling and Credentialing;    
4.13.2.1.8.4   Quality Control; and     4.13.2.1.8.5   Utilization Management.

  4.13.2.1.9   Written standards for organizational conduct;

  4.13.2.1.10   Effective training and education for the Compliance Officer and
the organization’s employees, management, board Members, and Subcontractors;    
4.13.2.1.11   Inclusion of information about Fraud and Abuse identification and
reporting in Provider and Member materials;     4.13.2.1.12   Provisions for the
investigation, corrective action and follow-up of any suspected Fraud and Abuse
reports; and     4.13.2.1.13   Procedures for reporting suspected Fraud and
Abuse cases to the State Program Integrity Unit, including timelines and use of
State approved forms.

  4.13.2.2   As part of the Program Integrity Program, the Contractor shall
implement a pharmacy lock-in program. The policies, procedures and criteria for
establishing a lock-in program shall be submitted to DCH for review and approval
as part of the Program Integrity Policies and Procedures discussed in
Section 4.13.1.2. The pharmacy lock-in program shall:

  4.13.2.2.1   Allow Members to change pharmacies for good cause, as determined
by the Contractor after discussion with the Provider(s) and the pharmacist.
Valid reasons for change should include recipient relocation or the pharmacy
does not provide the prescribed drug;     4.13.2.2.2   Provide Case management
and education reinforcement of appropriate medication use;     4.13.2.2.3  
Annually assess the need for lock-in for each Member; and     4.13.2.2.4  
Require that the Contractor’s Compliance Officer report on the program on a
quarterly basis to DCH.     4.13.2.2.5   A member will not be allowed to
transfer to another pharmacy, PCP, or CMO while enrolled in their existing CMO’s
pharmacy lock-in program.

4.13.3   Coordination with DCH and Other Agencies

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  4.13.3.1   The Contractor shall cooperate and assist any State or federal
agency charged with the duty of identifying, investigating, or prosecuting
suspected Fraud and Abuse cases, including permitting access to the Contractor’s
place of business during normal business hours, providing requested information,
permitting access to personnel, financial and Medical Records, and providing
internal reports of investigative, corrective and legal actions taken relative
to the suspected case of Fraud and Abuse.     4.13.3.2   The Contractor’s
Compliance Officer shall work closely, including attending quarterly meetings,
with DCH’s program integrity staff to ensure that the activities of one entity
do not interfere with an ongoing investigation being conducted by the other
entity.     4.13.3.3   The Contractor shall inform DCH immediately about known
or suspected cases and it shall not investigate or resolve the suspicion without
making DCH aware of, and if appropriate involved in, the investigation, as
determined by DCH.

4.13.4   Reporting Requirements

  4.13.4.1   The Contractor shall submit a Fraud and Abuse Report, as described
in Section 4.18.4.7 to DCH on a monthly basis. This Report shall include
information on the pharmacy lock-in program described in Section 4.13.2.2.

4.14   INTERNAL GRIEVANCE SYSTEM   4.14.1   General Requirements

  4.14.1.1   The Contractor’s Grievance System shall include a Grievance
process, an Administrative Review process and access to the State’s
Administrative Law Hearing (State Fair Hearing) system. The Contractor’s
Grievance System is an internal process that shall be exhausted by the Member
prior to accessing an Administrative Law Hearing.     4.14.1.2   The Contractor
shall develop written Grievance System Policies and Procedures that detail the
operation of the Grievance System. The Contractor’s policies and procedures
shall be available in the Member’s primary language. The Grievance System
Policies and Procedures shall be submitted to DCH for review and approval within
sixty (60) Calendar Days of Contract Award and as updated thereafter.    
4.14.1.3   The Contractor shall process each Grievance and Administrative Review
using applicable State and federal statutory, regulatory, and GF Contractual

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      provisions, and the Contractor’s written policies and procedures.
Pertinent facts from all parties must be collected during the investigation.

  4.14.1.4   The Contractor shall give Members any reasonable assistance in
completing forms and taking other procedural steps for both Grievances and
Administrative Reviews. This includes, but is not limited to, providing
interpreter services and toll-free numbers that have adequate TTD and
interpreter capability.     4.14.1.5   The Contractor shall acknowledge receipt
of each filed Grievance and Administrative Review in writing within ten
(10) Business Days of receipt. The Contractor shall have procedures in place to
notify all Members in their primary language of Grievance and Appeal
resolutions.     4.14.1.6   The Contractor shall ensure that the individuals who
make decisions on Grievances and Administrative Reviews were not involved in any
previous level of review or decision-making; and are Health Care Professionals
who have the appropriate clinical expertise, as determined by DCH, in treating
the Member’s Condition or disease if deciding any of the following:

  4.14.1.6.1   An Appeal of a denial that is based on lack of Medical Necessity;
    4.14.1.6.2   A Grievance regarding denial of expedited resolutions of an
Administrative Review; and     4.14.1.6.3   Any Grievance or Administrative
Review that involves clinical issues.

  4.14.1.7   DCH also allows a state review on behalf of PeachCare for
Kids members.  If the member or parent believes that a denied service should be
covered, the parent must send a written request for review to the Care
Management Organization (CMO) in which the affected child is enrolled. The CMO
will conduct its review process in accordance with Section 4.14.4 of the
contract.     4.14.1.8   If the decision of the CMO review maintains the denial
of service, a letter will be sent to the parent detailing the reason for denial.
If the parent elects to dispute the decision, the parent will have the option of
having the decision reviewed by the Formal Appeals Committee. The request should
be sent to:

Department of Community Health
PeachCare for Kids
Administrative Review Request
2 Peachtree Street, NW, 39th floor
Atlanta, GA 30303-3159

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  4.14.1.9   The decision of the Formal Grievance Committee will be the final
recourse available to the member. In reference to the Formal Grievance level,
the State assures:

  4.14.1.9.1   Enrollees receive timely written notice of any documentation that
includes the reasons for the determination, an explanation of applicable rights
to review, the standard and expedited time frames for review, the manner in
which a review can be requested, and the circumstances under which enrollment
may continue, pending review.     4.14.1.9.2   Enrollees have the opportunity
for an independent, external review of a delay, denial, reduction, suspension,
termination of health services, failure to approve, or provide payment for
health services in a timely manner. The independent review is available at the
Formal Grievance level.     4.14.1.9.3   Decisions are written when reviewed by
DCH and the Formal Grievance Committee.     4.14.1.9.4   Enrollees have the
opportunity to represent themselves or have representatives in the process at
the Formal Grievance level.     4.14.1.9.5   Enrollees have the opportunity to
timely review their files and other applicable information relevant to the
review of the decision. While this is assured at each level of review, members
will be notified of the timeframes for the appeals process once an appeal is
file with the Formal Grievance Committee.     4.14.1.9.6   Enrollees have the
opportunity to fully participate in the review process, whether the review is
conducted in person or in writing.     4.14.1.9.7   Reviews that are not
expedited due to an enrollee’s medical condition will be completed within 90
calendar days of the date of a request is made.     4.14.1.9.8   Reviews that
are expedited due to an enrollee’s medical condition shall be completed within
72 hours of the receipt of the request.

4.14.2   Grievance Process

  4.14.2.1   A Member or Member’s Authorized Representative may file a Grievance
to the Contractor either orally or in writing. A Grievance may be filed about
any matter other than a Proposed Action. A Provider cannot file a Grievance on
behalf of a Member.     4.14.2.2   The Contractor shall ensure that the
individuals who make decisions on Grievances that involve clinical issues or
denial of an expedited review of an Administrative Review are Health Care
Professionals who have the appropriate clinical expertise, as determined by DCH,
in treating the

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      Member’s Condition or disease and who were not involved in any previous
level of review or decision-making.

  4.14.2.3   The Contractor shall provide written notice of the disposition of
the Grievance as expeditiously as the Member’s health Condition requires but
must be completed within ninety (90) days but shall not exceed ninety
(90) Calendar Days of the filing date.

4.14.3   Proposed Action

  4.14.3.1   All Proposed Actions shall be made by a physician, or other peer
review consultant, who has appropriate clinical expertise in treating the
Member’s Condition or disease.     4.14.3.2   In the event of a Proposed Action,
the Contractor shall notify the Member in writing. The Contractor shall also
provide written notice of a Proposed Action to the Provider. This notice must
meet the language and format requirements in accordance with Section 4.3.2 of
this Contract and be sent in accordance with the timeframes described in
Section 4.14.3.4.     4.14.3.3   The notice of Proposed Action must contain the
following:

  4.14.3.3.1   The Action the Contractor has taken or intends to take, including
the service or procedure that is subject to the Action.     4.14.3.3.2  
Additional information, if any, that could alter the decision.     4.14.3.3.3  
The specific reason used as the basis of the action.     4.14.3.3.4   The
reasons for the Action must have a factual basis and legal/policy basis.    
4.14.3.3.5   The Member’s right to file an Administrative Review through the
Contractor’s internal Grievance System as described in Section 4.14.    
4.14.3.3.6   The Provider’s right to file a Provider Complaint as described in
Section 4.9.7;     4.14.3.3.7   The requirement that a Member exhaust the
contractor’s internal Administrative Review Process;     4.14.3.3.8   The
circumstances under which expedited review is available and how to request it;
and     4.14.3.3.9   The Member’s right to have Benefits continue pending
resolution of the Administrative Review with the Contractor, Member instructions

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      on how to request that Benefits be continued, and the circumstances under
which the Member may be required to pay the costs of these services.

  4.14.3.4   The Contractor shall mail the Notice of Proposed Action within the
following timeframes:

  4.14.3.4.1   For termination, suspension, or reduction of previously
authorized Covered Services at least ten (10) Calendar Days before the date of
Proposed Action or not later than the date of Proposed Action in the event of
one of the following exceptions:

  4.14.3.4.1.1   The Contractor has factual information confirming the death of
a Member.     4.14.3.4.1.2   The Contractor receives a clear written statement
signed by the Member that he or she no longer wishes services or gives
information that requires termination or reduction of services and indicates
that he or she understands that this must be the result of supplying that
information.     4.14.3.4.1.3   The Member’s whereabouts are unknown and the
post office returns Contractor mail directed to the Member indicating no
forwarding address (refer to 42 CFR 431.231(d) for procedures if the Member’s
whereabouts become known).     4.14.3.4.1.4   The Member’s Provider prescribes a
change in the level of medical care.     4.14.3.4.1.5   The date of action will
occur in less than ten (days), in accordance with § 483.12(a) (5) (ii), which
provides exceptions to the 30 days notice requirements of § 483.12(a) (5) (i).  
  4.14.3.4.1.6   The Contractor may shorten the period of advance notice to five
(5) Calendar Days before date of action if the Contractor has facts indicating
that action should be taken because of probable Member Fraud and the facts have
been verified, if possible, through secondary sources.

  4.14.3.4.2   For denial of payment, at the time of any Proposed Action
affecting the Claim.     4.14.3.4.3   For standard Service Authorization
decisions that deny or limit services, within the timeframes required in
Section 4.11.2.5.

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  4.14.3.4.4   If the Contractor extends the timeframe for the decision and
issuance of notice of Proposed Action according to Section 4.11.2.5, the
Contractor shall give the Member written notice of the reasons for the decision
to extend Grievance if he or she disagrees with that decision. The Contractor
shall issue and carry out its determination as expeditiously as the Member’s
health requires and no later than the date the extension expires.     4.14.3.4.5
  For authorization decisions not reached within the timeframes required in
Section 4.11.2.5 for either standard or expedited Service Authorizations, Notice
of Proposed Action shall be mailed on the date the timeframe expires, as this
constitutes a denial and is thus a Proposed Action.

4.14.4   Administrative Review Process

  4.14.4.1   An Administrative Review is the request for review of a “Proposed
Action”. The Member, the Member’s Authorized Representative, or the Provider
acting on behalf of the Member with the Member’s written consent, may file an
Administrative Review either orally or in writing. Unless the Member or Provider
requests expedited review, the Member, the Member’s Authorized Representative,
or the Provider acting on behalf of the Member with the Member’s written
consent, must follow an oral filing with a written, signed, request for
Administrative Review.     4.14.4.2   The Member, the Member’s Authorized
Representative, or the Provider acting on behalf of the Member with the Member’s
written consent, may file an Administrative Review with the Contractor within
thirty (30) Calendar Days from the date of the notice of Proposed Action.    
4.14.4.3   Administrative Reviews shall be filed directly with the Contractor,
or its delegated representatives. The Contractor may delegate this authority to
an Administrative Review committee, but the delegation must be in writing.    
4.14.4.4   The Contractor shall ensure that the individuals who make decisions
on Administrative Reviews are individuals who were not involved in any previous
level of review or decision-making; and who are Health Care Professionals who
have the appropriate clinical expertise in treating the Member’s Condition or
disease if deciding any of the following:

  4.14.4.4.1   An Administrative Review of a denial that is based on lack of
Medical Necessity.     4.14.4.4.2   An Administrative Review that involves
clinical issues.

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  4.14.4.5   The Administrative Review process shall provide the Member, the
Member’s Authorized Representative, or the Provider acting on behalf of the
Member with the Member’s written consent, a reasonable opportunity to present
evidence and allegations of fact or law, in person, as well as in writing. The
Contractor shall inform the Member of the limited time available to provide this
in case of expedited review.     4.14.4.6   The Administrative Review process
must provide the Member, the Member’s Authorized Representative, or the Provider
acting on behalf of the Member with the Member’s written consent, opportunity,
before and during the Administrative Review process, to examine the Member’s
case file, including Medical Records, and any other documents and records
considered during the Administrative Review process.     4.14.4.7   The
Administrative Review process must include as parties to the Administrative
Review the Member, the Member’s Authorized Representative, the Provider acting
on behalf of the Member with the Member’s written consent, or the legal
representative of a deceased Member’s estate.     4.14.4.8   The Contractor
shall resolve each Administrative Review and provide written notice of the
resolution, as expeditiously as the Member’s health Condition requires but shall
not exceed forty-five (45) Calendar Days from the date the Contractor receives
the Administrative Review. For expedited reviews and notice to affected parties,
the Contractor has no longer than three (3) working days or as expeditiously as
the Member’s physical or mental health condition requires, whichever is sooner.
If the Contractor denies a Member’s request for expedited review, it must
transfer the Administrative Review to the timeframe for standard resolution
specified herein and must make reasonable efforts to give the Member prompt oral
notice of the denial, and follow up within two (2) Calendar Days with a written
notice. The Contractor shall also make reasonable efforts to provide oral notice
for resolution of an expedited review of an Administrative Review.     4.14.4.9
  The Contractor may extend the timeframe for standard or expedited resolution
of the Administrative Review by up to fourteen (14) Calendar Days if the Member,
Member’s Authorized Representative, or the Provider acting on behalf of the
Member with the Member’s written consent, requests the extension or the
Contractor demonstrates (to the satisfaction of DCH, upon its request) that
there is need for additional information and how the delay is in the Member’s
interest. If the Contractor extends the timeframe, it must, for any extension
not requested by the Member, give the Member written notice of the reason for
the delay.

4.14.5   Notice of Adverse Action

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  4.14.5.1   If the Contractor upholds the Proposed Action in response to a
Grievance or Administrative Review filed by the Member, the Contractor shall
issue a Notice of Adverse Action within the timeframes described in
Section 4.14.4.8 and 4.14.4.9.     4.14.5.2   The Notice of Adverse Action shall
meet the language and format requirements as specified in 4.3 and include the
following:

  4.14.5.2.1   The results and date of the adverse Action including the service
or procedure that is subject to the Action.     4.14.5.2.2   Additional
information, if any, that could alter the decision.     4.14.5.2.3   The
specific reason used as the basis of the action.;     4.14.5.2.4   The right to
request a State Administrative Law Hearing within thirty (30) Calendar Days. The
time for filing will begin when the filing is date stamped;     4.14.5.2.5   The
right to continue to receive Benefits pending a State Administrative Law
Hearing;     4.14.5.2.6   How to request the continuation of Benefits;    
4.14.5.2.7   Information explaining that the Member may be liable for the cost
of any continued Benefits if the Contractor’s action is upheld in a State
Administrative Law Hearing.     4.14.5.2.8   Circumstances under which expedited
resolution is available and how to request it; and

4.14.6   Administrative Law Hearing

  4.14.6.1   The State will maintain an independent Administrative Law Hearing
process as defined in the Georgia Administrative Procedure Act O.C.G.A.
§49-4-153) and as required by federal law, 42 CFR 431.200. The Administrative
Law Hearing process shall provide Members an opportunity for a hearing before an
impartial Administrative Law Judge. The Contractor shall comply with decisions
reached as a result of the Administrative Law Hearing process.     4.14.6.2  
The Contractor is responsible for providing counsel to represent its interests.
DCH is not a party to case and will only provide counsel to represent its own
interests.

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  4.14.6.3   A Member or Member’s Authorized Representative may request in
writing an Administrative Law Hearing within thirty (30) Calendar Days of the
date the Notice of Adverse Action is mailed by the Contractor. The parties to
the Administrative Law Hearing shall include the Contractor as well as the
Member, Member’s Authorized Representative, or representative of a deceased
Member’s estate. A Provider cannot request an Administrative Law Hearing on
behalf of a Member. DCH reserves the right to intervene on behalf of the
interest of either party.     4.14.6.4   The hearing request and a copy of the
adverse action letter must be received by the Department within 30 days or less
from the date that the notice of action was mailed.     4.14.6.5   A Member may
request a Continuation of Benefits as described in Section 4.14.7 while an
Administrative Law Hearing is pending.     4.14.6.6   The Contractor shall make
available any records and any witnesses at its own expense in conjunction with a
request pursuant to an Administrative Law Hearing.

4.14.7   Continuation of Benefits while the Contractor Appeal and Administrative
Law Hearing are Pending

  4.14.7.1   As used in this Section, “timely” filing means filing on or before
the later of the following:

  4.14.7.1.1   Within ten (10) Calendar Days of the Contractor mailing the
Notice of Adverse Action.     4.14.7.1.2   The intended effective date of the
Contractor’s Proposed Action.

  4.14.7.2   The Contractor shall continue the Member’s Benefits if the Member
or the Member’s Authorized Representative files the Appeal timely; the Appeal
involves the termination, suspension, or reduction of a previously authorized
course of treatment; the services were ordered by an authorized Provider; the
original period covered by the original authorization has not expired; and the
Member requests extension of the Benefits.     4.14.7.3   If, at the Member’s
request, the Contractor continues or reinstates the Member’s benefit while the
Appeal or Administrative Law Hearing is pending, the Benefits must be continued
until one of the following occurs:

  4.14.7.3.1   The Member withdraws the Appeal or request for the Administrative
Law Hearing.

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  4.14.7.3.2   Ten (10) Calendar Day pass after the Contractor mails the Notice
of Adverse Action, unless the Member, within the ten (10) Calendar Day
timeframe, has requested an Administrative Law Hearing with continuation of
Benefits until an Administrative Law Hearing decision is reached.     4.14.7.3.3
  An Administrative Law Judge issues a hearing decision adverse to the Member.  
  4.14.7.3.4   The time period or service limits of a previously authorized
service has been met.

  4.14.7.4   If the final resolution of Appeal is adverse to the Member, that
is, upholds the Contractor action, the Contractor may recover from the Member
the cost of the services furnished to the Member while the Appeal is pending, to
the extent that they were furnished solely because of the requirements of this
Section.     4.14.7.5   If the Contractor or the Administrative Law Judge
reverses a decision to deny, limit, or delay services that were not furnished
while the Appeal was pending, the Contractor shall authorize or provide this
disputed services promptly, and as expeditiously as the Member’s health
condition requires.     4.14.7.6   If the Contractor or the Administrative Law
Judge reverses a decision to deny authorization of services, and the Member
received the disputed services while the Appeal was pending, the Contractor
shall pay for those services.

4.14.8   Reporting Requirements

  4.14.8.1   The Contractor shall log and track all Grievances, Proposed
Actions, Appeals and Administrative Law Hearing requests, as described in
Section 4.18.4.8.     4.14.8.2   The Contractor shall maintain records of
Grievances, whether received verbally or in writing, that include a short, dated
summary of the problems, name of the grievant, date of the Grievance, date of
the decision, and the disposition.     4.14.8.3   The Contractor shall maintain
records of Appeals, whether received verbally or in writing, that include a
short, date summary of the issues, name of the appellant, date of Appeal, date
of decision, and the resolution.     4.14.8.4   DCH may publicly disclose
summary information regarding the nature of Grievances and Appeals and related
dispositions or resolutions in consumer information materials.

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  4.14.8.5   The Contractor shall submit quarterly Grievance System Reports to
DCH as described in Section 4.18.4.8.1.

4.15   ADMINISTRATION AND MANAGEMENT   4.15.1   General Provisions

  4.15.1.1   The Contractor shall be responsible for the administration and
management of all requirements of this Contract. All costs related to the
administration and management of this Contract shall be the responsibility of
the Contractor.

4.15.2   Place of Business and Hours of Operation

  4.15.2.1   The Contractor shall maintain a central business office within the
Service Region in which it is operating. If the Contractor is operating in more
than one (1) Service Region, there must be one (1) central business office and
an additional office in each Service Region. If a Contractor is operating in two
(2) or more contiguous Service Regions, the Contractor may establish one
(1) central business office for all Service Regions. This business office must
be centrally located within the contiguous Service Regions and in a location
accessible for foot and vehicle traffic. The Contractor may establish more than
one (1) business office within a Service Region, but must designate one (1) of
the offices as the central business office.     4.15.2.2   All documentation
must reflect the address of the location identified as the legal, duly licensed,
central business office. This business office must be open at least between the
hours of 8:30 a.m. and 5:30 p.m. EST, Monday through Friday. The Contractor
shall ensure that the office(s) are adequately staffed to ensure that Members
and Providers receive prompt and accurate responses to inquiries.     4.15.2.3  
The Contractor shall ensure that all business offices and all staff that perform
functions and duties, related to this Contract are located within the United
States.     4.15.2.4   The Contractor shall provide live access, through its
telephone hot line as described in Section 4.3.7 and Section 4.9.5. The
Contractor shall provide access twenty-four (24) hours a day, seven (7) days per
week to its Web site.

4.15.3   Training

  4.15.3.1   The Contractor shall conduct on-going training for its entire
staff, in all departments, to ensure appropriate functioning in all areas and to
ensure that staff is aware of all programmatic changes.

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  4.15.3.2   The Contractor shall submit a staff-training plan to DCH for review
and approval within ninety (90) days of Contract Award and as updated
thereafter.     4.15.3.3   The Contractor designated staff are required to
attend DCH in-service training quarterly and annually. DCH will determine the
type and scope of the training.

4.15.4   Data Certification

  4.15.4.1   The Contractor shall certify all data pursuant to 42 CFR 438.606.
The data that must be certified include, but are not limited to, Enrollment
information, Encounter Data, and other information required by the State and
contained in Contracts, proposals and related documents. The data must be
certified by one of the following: the Contractor’s Chief Executive Officer, the
Contractor’s Chief Financial Officer, or an individual who has delegated
authority to sign for, and who Reports directly to the Contractor’s Chief
Executive Officer or Chief Financial Officer. The certification must attest,
based on best knowledge, information, and belief, as follows:

  4.15.4.1.1   To the accuracy, completeness and truthfulness of the data.    
4.15.4.1.2   To the accuracy, completeness and truthfulness of the documents
specified by the State.

  4.15.4.2   The Contractor shall submit the certification concurrently with the
certified data.

4.15.5   Implementation Plan

  4.15.5.1   The Contractor shall develop an Implementation Plan that details
the procedures and activities that will be accomplished during the period
between the awarding of this Contract and the start date of GF. This
Implementation Plan shall have established deadlines and timeframes for the
implementation activities and shall include coordination and cooperation with
DCH and its representatives during all phases.     4.15.5.2   The Contractor
shall submit its Implementation Plan to DCH for DCH’s review and approval within
thirty (30) Calendar Days of Contract Award. Implementation of the Contract
shall not commence prior to DCH approval.     4.15.5.3   The Contractor will not
receive any additional payment to cover start up or implementation costs.

4.16   CLAIMS MANAGEMENT

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4.16.1   General Provisions

  4.16.1.1   The Contractor shall utilize the same time frames and deadlines for
submission, processing, payment, denial, adjudication, and appeal of Medicaid
claims as the time frames and deadlines that the Department of Community Health
uses on claims its pays directly. The Contractor shall administer an effective,
accurate and efficient Claims processing function that adjudicates and settles
Provider Claims for Covered Services that are filed within the time frames
specified by the Depatment of Community Health (see Part I. Policy and
Procedures for Medicaid/PeachCare for Kids Manual) and in compliance with all
applicable State and federal laws, rules and regulations.     4.16.1.2   The
Contractor shall maintain a Claims management system that can identify date of
receipt (the date the Contractor receives the Claim as indicated by the
date-stamp), real-time-accurate history of actions taken on each Provider Claim
(i.e. paid, denied, suspended, Appealed, etc.), and date of payment (the date of
the check or other form of payment).     4.16.1.3   At a minimum, the Contractor
shall run one (1) Provider payment cycle per week, on the same day each week, as
determined by the Department of Community Health.     4.16.1.4   The Contractor
shall support an Automated Clearinghouse (ACH) mechanism that allows Providers
to request and receive electronic funds transfer (EFT) of Claims payments.    
4.16.1.5   The Contractor shall encourage that its Providers, as an alternative
to the filing of paper-based Claims, submit and receive Claims information
through electronic data interchange (EDI), i.e. electronic Claims. Electronic
Claims must be processed in adherence to information exchange and data
management requirements specified in Section 4.17. As part of this Electronic
Claims Management (ECM) function, the Contractor shall also provide on-line and
phone-based capabilities to obtain Claims processing status information.    
4.16.1.6   The Contractor shall generate Explanation of Benefits and Remittance
Advices in accordance with State standards for formatting, content and
timeliness.     4.16.1.7   The Contractor shall not pay any Claim submitted by a
Provider who is excluded or suspended from the Medicare, Medicaid or SCHIP
programs for Fraud, abuse or waste or otherwise included on the Department of
Health and Human Services Office of Inspector General exclusions list, or
employs someone on this list. The Contractor shall not pay any Claim submitted
by a Provider that is on payment hold under the authority of DCH or its
Agent(s).

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  4.16.1.8   Not later than the fifteenth (15th) business day after the receipt
of a Provider Claim that does not meet Clean Claim requirements, the Contractor
shall suspend the Claim and request in writing (notification via e-mail, the CMO
plan Web Site/Provider Portal or an interim Explanation of Benefits satisfies
this requirement) all outstanding information such that the Claim can be deemed
clean. Upon receipt of all the requested information from the Provider, the CMO
plan shall complete processing of the Claim within fifteen (15) Business Days.  
  4.16.1.9   If a provider submits a claim to a responsible health organization
for services rendered within 72 hours after the provider verifies the
eligibility of the patient with that responsible health organization, the
responsible health organization shall reimburse the provider in an amount equal
to the amount to which the provider would have been entitled if the patient had
been enrolled as shown in the eligibility verification process. After resolving
the provider’s claim, if the responsible health organization made payment for a
patient for whom it was not responsible, then the responsible health
organization may pursue a cause of action against any person who was responsible
for payment of the services at the time they were provided but may not recover
any payment made to the provider.     4.16.1.10   The Contract shall not apply
any penalty for failure to file claims in a timely manner, for failure to obtain
prior authorization, or for the provider not being a participating provider in
the person’s network, and the amount of reimbursement shall be that person’s
applicable rate for the service if the provider is under contract with that
person or the rate paid by the Department of Community Health for the same type
of claim that it pays directly if the provider is not under contract with that
person.     4.16.1.11   The Contractor shall inform all network Providers about
the information required to submit a Clean Claim as a provision within the
Contractor/Provider Contract. The Contractor shall make available to network
Providers Claims coding and processing guidelines for the applicable Provider
type. The Contractor shall notify Providers ninety (90) Calendar Days before
implementing changes to Claims coding and processing guidelines.     4.16.1.12  
The Contractor shall assume all costs associated with Claim processing,
including the cost of reprocessing/resubmission, due to processing errors caused
by the Contractor or to the design of systems within the Contractor’s span of
control.     4.16.1.13   In addition to the specific Web site requirements
outlined above, the Contractor’s Web site shall be functionally equivalent to
the Web site maintained by the State’s Medicaid fiscal agent.

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4.16.2   Other Considerations

  4.16.2.1   An adjustment to a paid Claim shall not be counted as a Claim for
the purposes of reporting.     4.16.2.2   Electronic Claims shall be treated as
identical to paper-based Claims for the purposes of reporting.

4.16.3   Encounter Data Submission Requirements

  4.16.3.1   The Georgia Families program utilizes encounter data to determine
the adequacy of medical services and to evaluate the quality of care rendered to
members. DCH will use the following requirements to establish the standards for
the submission of data and to measure the compliance of the Contractor to
provide timely and accurate information. Encounter data from the Contractor also
allows DCH to budget available resources, set contractor capitation rates,
monitor utilization, follow public health trends and detect potential fraud.
Most importantly, it allows the Division of Managed Care and Quality to make
recommendations that can lead to the improvement of healthcare outcomes.    
4.16.3.1   The Contractor shall work with all contracted providers to implement
standardized billing requirements to enhance the quality and accuracy of the
billing data submitted to the health plan.     4.16.3.2   The Contractor shall
instruct contracted providers that the Georgia State Medicaid ID number is
mandatory, and must be documented in record. The Contractor will emphasize to
providers the need for a unique GA Medicaid number for each practice location.  
  4.16.3.3   The Contractor shall submit to Fiscal Agent weekly cycles of data
files. All identified errors shall be submitted to the Contractor from the
Fiscal Agent each week. The Contractor shall clean up and resubmit the corrected
file to the Fiscal Agent within seven (7) Business Days of receipt.     4.16.3.4
  The Contractor is required to submit 100% of Critical Data Elements such as
state Medicaid ID numbers, NPI numbers, SSN numbers, Member Name, and DOB. These
items must match the states eligibility and provider file.     4.16.3.5   The
Contractor submitted claims must consistently include:

      4.16.3.5.1 1- patient name         4.16.3.5.2 2- date of birth        
4.16.3.5.3 3- place of service         4.16.3.5.4 4- date of service        
4.16.3.5.5 5- type of service

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      4.16.3.5.6 6- units of service         4.16.3.5.7 7- diagnosis-primary &
secondary         4.16.3.5.8 8- treating provider         4.16.3.5.9 9- NPI
number

  4.16.3.5.10   10- Medicaid Number     4.16.3.5.11   11- facility code    
4.16.3.5.12   12- a unique TCN     4.16.3.5.13   13- all additionally required
CMS 1500 or UB 04 codes.     4.16.3.5.14   14 – CMO Paid Amount

  4.16.3.6   For each submission of claims per 4.16.3.5, Contractor must provide
the following Cash Disbursements data elements:

  1.   Provider/Payee Number     2.   Name     3.   address     4.   city     5.
  state     6.   zip     7.   check date     8.   check number     9.   check
amount     10.   check code( ie. eft, paper check, etc)

Contractor will assist DCH in reconciliation of Cash Disbursement check amounts
totals to CMO Paid Amount totals for submitted claims.

  4.16.3.7   The Contractor shall maintain an Encounter Error Rate of <5% weekly
as monitored by the Fiscal Agent and DCH.  The Encounter Error Rate is the
occurrence of a single error in any Transaction Control Number (TCN) or
encounter claim counts as an error for that encounter (this is regardless of how
many other errors are detected in the TCN.)      4.16.3.8   The Contractors
failure to comply with defined standard(s) will be subject to a corrective
action plan (CAP) and may be liable for liquidated damages (LD’s).

4.16.4   Reporting Requirements

  4.16.4.1   The Contractor shall submit Claims Processing Reports to DCH as
described in section 4.18.3.5.1.

4.16.5   Emergency Health Care Services

  4.16.5.1   The Contractor shall not deny or inappropriately reduce payment to
a provider of emergency health care services for any evaluation, diagnostic
testing, or

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      treatment provided to a recipient of medical assistance for an emergency
condition; or

  4.16.5.2   Make payment for emergency health care services contingent on the
recipient or provider of emergency health care services providing any
notification, either before or after receiving emergency health care services.  
  4.16.5.3   In processing claims for emergency health care services, a care
management organization shall consider, at the time that a claim is submitted,
at least the following criteria:

  4.16.5.3.1   The age of the patient;     4.16.5.3.2   The time and day of the
week the patient presented for services;     4.16.5.3.3   The severity and
nature of the presenting symptoms;     4.16.5.3.4   The patient’s initial and
final diagnosis; and     4.16.5.3.5   Any other criteria prescribed by the
Department of Community Health, including criteria specific to patients under
18 years of age.

  4.16.5.4   The Contractor shall configure or program its automated claims
processing system to consider at least the conditions and criteria described in
this subsection for claims presented for emergency health care services.    
4.16.5.5   If a provider that has not entered into a contract with a care
management organization provides emergency health care services or
post-stabilization services to that care management organization’s member, the
care management organization shall reimburse the non contracted provider for
such emergency health care services and post-stabilization services at a rate
equal to the rate paid by the Department of Community Health for Medicaid claims
that it reimburses directly.

4.17   INFORMATION MANAGEMENT AND SYSTEMS   4.17.1   General Provisions

  4.17.1.1   The Contractor shall have Information management processes and
Information Systems (hereafter referred to as Systems) that enable it to meet GF
requirements, State and federal reporting requirements, all other Contract
requirements and any other applicable State and federal laws, rules and
regulations including HIPAA.     4.17.1.2   The Contractor is responsible for
maintaining a system that shall possess capacity sufficient to handle the
workload projected for the start of the program and will be scaleable and
flexible enough to adapt as needed, within negotiated timeframes, in response to
program or Enrollment changes.

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  4.17.1.3   The Contractor shall provide a Web-accessible system hereafter
referred to as the DCH Portal that designated DCH and other state agency
resources can use to access Quality and performance management information as
well as other system functions and information as described throughout this
Contract. Access to the DCH Portal shall be managed as described in section
4.17.5.     4.17.1.4   The Contractor shall attend DCH’s Systems Work Group
meetings as scheduled by DCH. The Systems Work Group will meet on a designated
schedule as agreed to by DCH, its agents and every Contractor.     4.17.1.5  
The Contractor shall provide a continuously available electronic mail
communication link (E-mail system) with the State. This system shall be:

  4.17.1.5.1   Available from the workstations of the designated Contractor
contacts; and     4.17.1.5.2   Capable of attaching and sending documents
created using software products other than Contractor systems, including the
State’s currently installed version of Microsoft Office and any subsequent
upgrades as adopted.

  4.17.1.6   By no later than the 30th of April of each year, the Contractor
will provide DCH with an annual progress/status report of the Contractor’s
system refresh plan for the upcoming State fiscal year. The plan will outline
how Systems within the Contractor’s Span of Control will be systematically
assessed to determine the need to modify, upgrade and/or replace application
software, operating hardware and software, telecommunications capabilities,
information management policies and procedures, and/or systems management
policies and procedures in response to changes in business requirements,
technology obsolescence, staff turnover and other relevant factors. The systems
refresh plan will also indicate how the Contractor will insure that the version
and/or release level of all of its System components (application software,
operating hardware, operating software) are always formally supported by the
original equipment manufacturer (OEM), software development firm (SDF) or a
third party authorized by the OEM and/or SDF to support the System component.  
  4.17.1.7   The Contractor is responsible for all costs associated with the
Contractors system refresh plan.

4.17.2   Global System Architecture and Design Requirements

  4.17.2.1   The Contractor shall comply with federal and State policies,
standards and regulations in the design, development and/or modification of the
Systems it will employ to meet the aforementioned requirements and in the
management of Information contained in those Systems. Additionally, the
Contractor shall

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      adhere to DCH and State-specific system and data architecture preferences
as indicated in this Contract.

  4.17.2.2   The Contractor’s Systems shall:

  4.17.2.2.1   Employ a relational data model in the architecture of its
databases and relational database management system (RDBMS) to operate and
maintain them;     4.17.2.2.2   Be SQL and ODBC compliant;     4.17.2.2.3  
Adhere to Internet Engineering Task Force/Internet Engineering Standards Group
standards for data communications, including TCP and IP for data transport;    
4.17.2.2.4   Conform to standard code sets detailed in Attachment L;    
4.17.2.2.5   Contain controls to maintain information integrity. These controls
shall be in place at all appropriate points of processing. The controls shall be
tested in periodic and spot audits following a methodology to be developed
jointly and mutually agreed upon by the Contractor and DCH; and     4.17.2.2.7  
Partner with the State in the development of future standard code sets, not
specific to HIPAA or other federal effort and will conform to such standards as
stipulated by DCH.

  4.17.2.3   Where Web services are used in the engineering of applications, the
Contractor’s Systems shall conform to World Wide Web Consortium (W3C) standards
such as XML, UDDI, WSDL and SOAP so as to facilitate integration of these
Systems with DCH and other State systems that adhere to a service-oriented
architecture.     4.17.2.4   Audit trails shall be incorporated into all Systems
to allow information on source data files and documents to be traced through the
processing stages to the point where the Information is finally recorded. The
audit trails shall:

  4.17.2.4.1   Contain a unique log-on or terminal ID, the date, and time of any
create/modify/delete action and, if applicable, the ID of the system job that
effected the action;     4.17.2.4.2   Have the date and identification “stamp”
displayed on any on-line inquiry;

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  4.17.2.4.3   Have the ability to trace data from the final place of recording
back to its source data file and/or document shall also exist;     4.17.2.4.4  
Be supported by listings, transaction Reports, update Reports, transaction logs,
or error logs;     4.17.2.4.5   Facilitate auditing of individual Claim records
as well as batch audits; and     4.17.2.4.6   Be maintained for seven (7) years
in either live and/or archival systems. The duration of the retention period may
be extended at the discretion of and as indicated to the Contractor by the State
as needed for ongoing audits or other purposes.

  4.17.2.5   The Contractor shall house indexed images of documents used by
Members and Providers to transact with the Contractor in the appropriate
database(s) and document management systems to maintain the logical
relationships between certain documents and certain data.     4.17.2.6   The
Contractor shall institute processes to insure the validity and completeness of
the data it submits to DCH. At its discretion, DCH will conduct general data
validity and completeness audits using industry-accepted statistical sampling
methods. Data elements that will be audited include but are not limited to:
Member ID, date of service, Provider ID, category and sub category (if
applicable) of service, diagnosis codes, procedure codes, revenue codes, date of
Claim processing, and date of Claim payment.     4.17.2.7   Where a System is
herein required to, or otherwise supports, the applicable batch or on-line
transaction type, the system shall comply with HIPAA-standard transaction code
sets as specified in Attachment L.     4.17.2.8   The Contractor System(s) shall
conform to HIPAA standards for information exchange.     4.17.2.9   The layout
and other applicable characteristics of the pages of Contractor Web sites shall
be compliant with Federal “section 508 standards” and Web Content Accessibility
Guidelines developed and published by the Web Accessibility Initiative.    
4.17.2.10   Contractor Systems shall conform to any applicable Application,
Information and Data, Middleware and Integration, Computing Environment and
Platform, Network and Transport, and Security and Privacy policy and standard
issued by GTA as stipulated in the appropriate policy/standard. These policies
and standards can be accessed at:
http://gta.georgia.gov/00/channel_modifieddate/0,2096,1070969_6947051,00.html

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4.17.3   Data and Document Management Requirements by Major Information Type

  4.17.3.1   In order to meet programmatic, reporting and management
requirements, the Contractor’s systems shall serve as either the Authoritative
Host of key data and documents or the host of valid, replicated data and
documents from other systems. Attachment L lays out the requirements for
managing (capturing, storing and maintaining) data and documents for the major
information types and subtypes associated with the aforementioned programmatic,
reporting and management requirements.

4.17.4   System and Data Integration Requirements

  4.17.4.1   All of the Contractor’s applications, operating software,
middleware, and networking hardware and software shall be able to interface with
the State’s systems and will conform to standards and specifications set by the
Georgia Technology Authority and the agency that owns the system. These
standards and specifications are detailed in Attachment L.

  4.17.4.2   The Contractor’s System(s) shall be able to transmit and receive
transaction data to and from the MMIS as required for the appropriate processing
of Claims and any other transaction that may be performed by either System.    
    The Contractor shall generate encounter data files no less than weekly (or
at a frequency defined by DCH) from its claims management system(s) and/or other
sources. The files will contain settled Claims and Claim adjustments and
encounters from Providers with whom the Contractor has a capitation arrangement
for the most recent month for which all such transactions were completed. The
Contractor will provide these files electronically to DCH and/or its designated
agent in adherence to the procedure and format indicated in Attachment L.      
  The Contractor’s System(s) shall be capable of generating all required files
in the prescribed formats (as referenced in Attachment L) for upload into state
Systems used specifically for program integrity and compliance purposes.

  4.17.4.3   The Contractor’s System(s) shall possess mailing address
standardization functionality in accordance with US Postal Service conventions.

4.17.5   System Access Management and Information Accessibility Requirements

  4.17.5.1   The Contractor’s System shall employ an access management function
that restricts access to varying hierarchical levels of system functionality and
Information. The access management function shall:

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  4.17.5.1.1   Restrict access to Information on a “need to know” basis, e.g.
users permitted inquiry privileges only will not be permitted to modify
information;     4.17.5.1.2   Restrict access to specific system functions and
information based on an individual user profile, including inquiry only
capabilities; global access to all functions will be restricted to specified
staff jointly agreed to by DCH and the Contractor; and     4.17.5.1.3   Restrict
attempts to access system functions to three (3), with a system function that
automatically prevents further access attempts and records these occurrences.  
  4.17.5.1.4   At a minimum, follow the GTA Security Standard and Access
Management protocols.

  4.17.5.2   The Contractor shall make System Information available to duly
Authorized Representatives of DCH and other State and federal agencies to
evaluate, through inspections or other means, the quality, appropriateness and
timeliness of services performed.     4.17.5.3   The Contractor shall have
procedures to provide for prompt electronic transfer of System Information upon
request to In-Network or Out-of-Network Providers for the medical management of
the Member in adherence to HIPAA and other applicable requirements.     4.17.5.4
  All Information, whether data or documents, and reports that contain or make
references to said Information, involving or arising out of this Contract are
owned by DCH. The Contractor is expressly prohibited from sharing or publishing
DCH information and reports without the prior written consent of DCH. In the
event of a dispute regarding the sharing or publishing of information and
reports, DCH’s decision on this matter shall be final and not subject to change.

4.17.6   Systems Availability and Performance Requirements

  4.17.6.1   The Contractor will ensure that Member and Provider portal and/or
phone-based functions and information, such as confirmation of CMO Enrollment
(CCE) and electronic claims management (ECM), Member services and Provider
services, are available to the applicable System users twenty-four (24) hours a
day, seven (7) Days a week, except during periods of scheduled System
Unavailability agreed upon by DCH and the Contractor. Unavailability caused by
events outside of a Contractor’s span of control is outside of the scope of this
requirement.

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  4.17.6.2   The Contractor shall ensure that at a minimum, all other System
functions and Information are available to the applicable system users between
the hours of 7:00 a.m. and 7:00 p.m. Monday through Friday.

  4.17.6.3   The Contractor shall ensure that the average response time that is
controllable by the Contractor is no greater than the requirements set forth
below, between 7:00 am and 7:00 pm, Monday through Friday for all applicable
system functions except a) during periods of scheduled downtime, b) during
periods of unscheduled unavailability caused by systems and telecommunications
technology outside of the Contractor’s span of control or c) for Member and
Provider portal and phone-based functions such as CCE and ECM that are expected
to be available twenty-four (24) hours a day, seven (7) days a week:

  4.17.6.3.1   Record Search Time – The response time shall be within three
(3) seconds for ninety-eight percent (98%) of the record searches as measured
from a representative sample of DCH System Access Devices, as monitored by the
Contractor;     4.17.6.3.2   Record Retrieval Time – The response time will be
within three (3) seconds for ninety-eight percent (98%) of the records retrieved
as measured from a representative sample of DCH System Access Devices;    
4.17.6.3.3   On-line Adjudication Response Time – The response time will be
within five (5) seconds ninety-nine percent (99%) of the time as measured from a
representative sample of user System Access Devices.

  4.17.6.4   The Contractor shall develop an automated method of monitoring the
CCE and ECM functions on at least a thirty (30) minute basis twenty-four
(24) hours a day, seven (7) Days per week. The monitoring method shall
separately monitor for availability and performance/response time each component
of the CCE and ECM systems, such as the voice response system, the PC software
response, direct line use, the swipe box method and ECM on-line pharmacy system.

  4.17.6.5   Upon discovery of any problem within its Span of Control that may
jeopardize System availability and performance as defined in this Section of the
Contract, the Contractor shall notify the DCH, Managed Care & Quality, Director
of Contract Management in person, via phone, electronic mail and/or surface
mail.     4.17.6.6   The Contractor shall deliver notification as soon as
possible but no later than 7:00 pm if the problem occurs during the business day
and no later than 9:00 am the following business day if the problem occurs after
7:00 pm.

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  4.17.6.7   Where the operational problem results in delays in report
distribution or problems in on-line access during the business day, the
Contractor shall notify the DCH, Managed Care & Quality, Director of Contract
Management within fifteen (15) minutes of discovery of the problem, in order for
the applicable work activities to be rescheduled or be handled based on System
Unavailability protocols.     4.17.6.8   The Contractor shall provide to the
DCH, Managed Care & Quality, Director of Contract Management information on
System Unavailability events, as well as status updates on problem resolution.
These up-dates shall be provided on an hourly basis and made available via
electronic mail, telephone and the Contractor’s Web Site/DCH Portal.    
4.17.6.9   Unscheduled System Unavailability of CCE and ECM functions, caused by
the failure of systems and telecommunications technologies within the
Contractor’s Span of Control will be resolved, and the restoration of services
implemented, within thirty (30) minutes of the official declaration of System
Unavailability. Unscheduled System Unavailability to all other Contractor System
functions caused by systems and telecommunications technologies within the
Contractor’s Span of Control shall be resolved, and the restoration of services
implemented, within four (4) hours of the official declaration of System
Unavailability.     4.17.6.10   Cumulative System Unavailability caused by
systems and telecommunications technologies within the Contractor’s span of
control shall not exceed one (1) hour during any continuous five (5) Day period.
    4.17.6.11   The Contractor shall not be responsible for the availability and
performance of systems and telecommunications technologies outside of the
Contractor’s Span of Control. Contractor is obligated to work with identified
vendors to resolve and report system availability and performance issues.
Reference Section 23.5.1.5 - Liquidated Damages)     4.17.6.12   Full written
documentation that includes a Corrective Action Plan with a set time frame for
resolution must be submitted to DCH by close of business the same day, that
describes what caused the problem, how the problem will be prevented from
occurring again, shall be delivered within five (5) Business Days of the
problem’s occurrence.     4.17.6.13   Regardless of the architecture of its
Systems, the Contractor shall develop and be continually ready to invoke a
business continuity and disaster recovery (BC-DR) plan that at a minimum
addresses the following scenarios: (a) the central computer installation and
resident software are destroyed or damaged, (b) System interruption or failure
resulting from network, operating hardware,

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      software, or operational errors that compromises the integrity of
transactions that are active in a live system at the time of the outage, (c)
System interruption or failure resulting from network, operating hardware,
software or operational errors that compromises the integrity of data maintained
in a live or archival system, (d) System interruption or failure resulting from
network, operating hardware, software or operational errors that does not
compromise the integrity of transactions or data maintained in a live or
archival system but does prevent access to the System, i.e. causes unscheduled
System Unavailability.     4.17.6.14   The Contractor shall periodically, but no
less than annually, test its BC-DR plan through simulated disasters and lower
level failures in order to demonstrate to the State that it can restore System
functions per the standards outlined elsewhere in this Contract. The Contractor
will prepare a report of the results of these tests and present to DCH staff
within five (5) business days of test completion.     4.17.6.15   In the event
that the Contractor fails to demonstrate in the tests of its BC-DR plan that it
can restore system functions per the standards outlined in this Contract, the
Contractor shall be required to submit to the State a Corrective Action Plan
that describes how the failure will be resolved. The Corrective Action Plan will
be delivered within five (5) Business Days of the conclusion of the test.    
4.17.6.16   The Contractor shall submit System Availability and Performance
Report to DCH as described in section 4.18.3.4.1

4.17.7   System User and Technical Support Requirements

  4.17.7.1   Beginning sixty (60) Calendar Days prior to the scheduled start of
operations, the Contractor shall provide Systems Help Desk (SHD) services to all
DCH staff and the other agencies that may have direct access to Contractor
systems.     4.17.7.2   The SHD shall be available via local and toll free
telephone service and via e-mail from 7 a.m. to 7 p.m. EST Monday through
Friday, with the exception of State holidays. Upon State request, the Contractor
shall staff the SHD on a State holiday, Saturday, or Sunday at the Contractor’s
expense.     4.17.7.3   SHD staff shall answer user questions regarding
Contractor System functions and capabilities; report recurring programmatic and
operational problems to appropriate Contractor or DCH staff for follow-up;
redirect problems or queries that are not supported by the SHD, as appropriate,
via a telephone transfer or other agreed upon methodology; and redirect problems
or queries specific to data access authorization to the appropriate State login
account administrator.

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  4.17.7.4   The Contractor shall submit to DCH for review and approval its SHD
Standards. At a minimum, these standards shall require that between the hours of
7 a.m. and 7 p.m. EST ninety percent (90%) of calls are answered by the fourth
(4th) ring, the call abandonment rate is five percent (5%) or less, the average
hold time is two (2) minutes or less, and the blocked call rate does not exceed
one percent (1%).     4.17.7.5   Individuals who place calls to the SHD between
the hours of 7 p.m. and 7 a.m. EST shall be able to leave a message. The
Contractor’s SHD shall respond to messages by noon the following Business Day.  
  4.17.7.6   Recurring problems not specific to System Unavailability identified
by the SHD shall be documented and reported to Contractor management within one
(1) Business Day of recognition so that deficiencies are promptly corrected.    
4.17.7.7   Additionally, the Contractor shall have an IT service management
system that provides an automated method to record, track, and report on all
questions and/or problems reported to the SHD. The service management system
shall:

  4.17.7.7.1   Assign a unique number to each recorded incident;     4.17.7.7.2
  Create State defined extract files that contain summary information on all
problems/issues received during a specified time frame;     4.17.7.7.3  
Escalate problems based on their priority and the length of time they have been
outstanding;     4.17.7.7.4   Perform key word searches that are not limited to
certain fields and allow for searches on all fields in the database;    
4.17.7.7.5   Notify support personnel when a problem is assigned to them and
re-notify support personnel when an assigned problem has escalated to a higher
priority;     4.17.7.7.6   List all problems assigned to a support person or
group;     4.17.7.7.7   Perform searches for duplicate problems when a new
problem is entered;     4.17.7.7.8   Allow for entry of at least five hundred
(500) characters of free form text to describe problems and resolutions; and    
4.17.7.7.9   Generate Reports that identify categories of problems encountered,
length of time for resolution, and any other State-defined criteria.

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  4.17.7.8   The Contractor’s call center systems shall have the capability to
track call management metrics identified in Attachment L.

4.17.8   System Change Management Requirements

  4.17.8.1   The Contractor shall absorb the cost of routine maintenance,
inclusive of defect correction, System changes required to effect changes in
State and federal statute and regulations, and production control activities, of
all Systems within its Span of control.     4.17.8.2   The Contractor shall
provide DCH, prior written notice of non-routine System changes excluding
changes prompted by events described in Section 4.17.6 and including proposed
corrections to known system defects, within ten (10) Calendar Days of the
projected date of the change. As directed by the state, the Contractor shall
discuss the proposed change in the Systems Work Group.     4.17.8.3   The
Contractor shall respond to State reports of System problems not resulting in
System Unavailability according to the following timeframes:

  4.17.8.3.1   Within five (5) Calendar Days of receipt, the Contractor shall
respond in writing to notices of system problems.     4.17.8.3.2   Within
fifteen (15) Calendar Days, the correction will be made or a Requirements
Analysis and Specifications document will be due.     4.17.8.3.3   The
Contractor will correct the deficiency by an effective date to be determined by
DCH.     4.17.8.3.4   Contractor systems will have a system-inherent mechanism
for recording any change to a software module or subsystem.

  4.17.8.4   The Contractor shall put in place procedures and measures for
safeguarding the State from unauthorized modifications to Contractor Systems.  
  4.17.8.5   Unless otherwise agreed to in advance by DCH as part of the
activities described in Section 4.17.8.3, scheduled System Unavailability to
perform System maintenance, repair and/or upgrade activities shall take place
between 11 p.m. on a Saturday and 6 a.m. on the following Sunday.

4.17.9   System Security and Information Confidentiality and Privacy
Requirements

  4.17.9.1   The Contractor shall provide for the physical safeguarding of its
data processing facilities and the systems and information housed therein. The
Contractor shall provide DCH with access to data facilities upon DCH

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      request. The physical security provisions shall be in effect for the life
of this Contract.

  4.17.9.2   The Contractor shall restrict perimeter access to equipment sites,
processing areas, and storage areas through a card key or other comparable
system, as well as provide accountability control to record access attempts,
including attempts of unauthorized access.     4.17.9.3   The Contractor shall
include physical security features designed to safeguard processor site(s)
through required provision of fire retardant capabilities, as well as smoke and
electrical alarms, monitored by security personnel.     4.17.9.4   The
Contractor shall ensure that the operation of all of its systems is performed in
accordance with State and federal regulations and guidelines related to security
and confidentiality and meet all privacy and security requirements of HIPAA
regulations. Relevant publications are included in Attachment L.     4.17.9.5  
The Contractor will put in place procedures, measures and technical security to
prohibit unauthorized access to the regions of the data communications network
inside of a Contractor’s Span of Control.     4.17.9.6   The Contractor shall
ensure compliance with:

  4.17.9.6.1   42 CFR Part 431 Subpart F (confidentiality of information
concerning applicants and Members of public medical assistance programs);    
4.17.9.6.2   42 CFR Part 2 (confidentiality of alcohol and drug abuse records);
and     4.17.9.6.3   Special confidentiality provisions related to people with
HIV/AIDS and mental illness.

  4.17.9.7   The Contractor shall provide its Members with a privacy notice as
required by HIPAA. The Contractor shall provide the State with a copy of its
Privacy Notice for its filing.

4.17.10   Information Management Process and Information Systems Documentation
Requirements

  4.17.10.1   The Contractor shall ensure that written System Process and
Procedure Manuals document and describe all manual and automated system
procedures for its information management processes and information systems.

  4.17.10.2   The Contractor shall develop, prepare, print, maintain, produce,
and distribute distinct System Design and Management Manuals, User Manuals and

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      Quick/Reference Guides, and any updates thereafter, for DCH and other
agency staff that use the DCH Portal.

  4.17.10.3   The System User Manuals shall contain information about, and
instructions for, using applicable System functions and accessing applicable
system data.     4.17.10.4   When a System change is subject to State sign off,
the Contractor shall draft revisions to the appropriate manuals prior to State
sign off the change.     4.17.10.5   All of the aforementioned manuals and
reference guides shall be available in printed form and on-line via the DCH
Portal. The manuals will be published in accordance to the applicable DCH and/or
Georgia Technology Authority (GTA) standard.     4.17.10.6   Updates to the
electronic version of these manuals shall occur in real time; updates to the
printed version of these manuals shall occur within ten (10) Business Days of
the update taking effect.

4.17.11   Reporting Requirements

  4.17.11.1   The Contractor shall submit a monthly Systems Availability and
Performance Report to DCH as described in Section 4.18.3.4.

4.18   REPORTING REQUIREMENTS   4.18.1   General Procedures

  4.18.1.1   The Contractor shall comply with all the reporting requirements
established by this Contract. The Contractor shall create Reports using the
formats, including electronic formats, instructions, and timetables as specified
by DCH, at no cost to DCH. Changes to the format must be approved by DCH prior
to implementation. The Contractor shall transmit and receive all transactions
and code sets required by the HIPAA regulations in accordance with Section 21.2.
The Contractor’s failure to submit the Reports as specified may result in the
assessment of liquidated damages as described in Section 23.0.

  4.18.1.1.1   The Contractor shall submit the Deliverables and Reports for DCH
review and approval according to the following timelines, unless otherwise
indicated.

  4.18.1.1.1.1   Annual Reports shall be submitted within thirty (30) Calendar
Days following the twelfth (12th) month Members are enrolled in the CMO plan;

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  4.18.1.1.1.2   Quarterly Reports shall be submitted by April 30, July 30,
October 30, and January 30, for the quarter immediately preceding the due date;
    4.18.1.1.1.3   Monthly Reports shall be submitted within fifteen
(15) Calendar Days of the end of each month; and     4.18.1.1.1.4   Weekly
Reports shall be submitted on the same day of each week, as determined by DCH.

  4.18.1.2   For reports required by DOI and DCH, the Contractor shall submit
such reports according to the DOI schedule of due dates, unless otherwise
indicated. While such schedule may be duplicated in this Contract, should the
DOI schedule of due dates be amended at a future date, the due dates in this
Contract shall automatically change to the new DOI due dates.     4.18.1.3   The
Contractor shall, upon request of DCH, generate any additional data or reports
at no additional cost to DCH within a time period prescribed by DCH. The
Contractor’s responsibility shall be limited to data in its possession.

4.18.2   Weekly Reporting

  4.18.2.1   Member Information Report

  4.18.2.1.1   Pursuant to Section 4.1.4.1 the Contractor shall submit a Member
Information Report. The report shall include information on the Members that
change addresses or move outside the Service Region. The Contractor shall also
report any information that may affect the Member’s eligibility for GF
including, but not limited to, changes in income or employment, family size, or
incarceration. The minimum data elements that will be required for this report
are described in Attachment L.

  4.18.2.2   Member Data Conflict Report

  4.18.2.2.1   Pursuant to Section 5.8, the Contractor shall submit a Member
Data Conflict Report. The report shall include data conflicts that may affect
the Member’s eligibility for Georgia Families including, but not limited to,
name changes, date of birth, duplicate records, social security number or
gender.

4.18.3   Monthly Reporting

  4.18.3.1   Telephone and Internet Activity Report

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  4.18.3.1.1   This information may be submitted as a summary report, in a
format to be determined by DCH. The Contractor shall maintain, and make
available at the request of DCH, any and all supporting documentation. Each
Telephone and Internet Activity Report shall include the following information:

  i.   Call volume;     ii.   E-mail volume;     iii.   Average call length;    
iv.   Average hold time;     v.   Abandoned Call rate;     vi.   Accuracy rate
based on CMO’s Call Center Quality Criteria and Protocols;     vii.   Content of
call or email and resolution; and     viii.   Blocked Call rate.

  4.18.3.2   Eligibility and Enrollment Reconciliation Report

  4.18.3.2.1   Pursuant to Section 4.1.4.2 the Contractor shall submit an
Eligibility and Enrollment Reconciliation Report that reconciles eligibility
data to the Contractor’s Enrollment records. The written report shall verify
that the Contractor has an Enrollment record for all Members that are eligible
for Enrollment in the CMO plan.

  4.18.3.3   Prior Authorization and Pre-Certification Report

  4.18.3.3.1   Pursuant to Section 4.11.10.2 the Contractor shall submit Prior
Authorization and Pre-Certification Reports that summarize all requests in the
preceding month for Prior Authorization and Pre-Certification. The Report shall
include, at a minimum, the following information:

  i.   Total number of completed requests for Standard Service Authorizations;  
  ii.   Total number of completed requests for Expedited Service Authorizations;
    iii.   Percent of completed requests within timeliness standards by type of
service;     iv.   Total number of completed requests authorized by type of
service;     v.   Total number or completed requests denied by type of service;
and     vi.   Percent of completed requests denied by type of service;

4.18.3.4   System Availability and Performance Report

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  4.18.3.4.1   Pursuant to Section 4.17.6.16 the Contractor shall submit a
System Availability and Performance Report that shall report the following
information:

  i.   Record Search Time     ii.   Record Retrieval Time     iii.   Screen Edit
Time     iv.   New Screen/Page Time     v.   Print Initiation Time     vi.  
Confirmation of CMO Enrollment Response Time     vii.   Online Claims
Adjudication Response Time

  4.18.3.5   Claims Processing Report

  4.18.3.5.1   Pursuant to Section 4.16.4 the Contractor shall submit a Claims
Processing Report that documents the claims processing activities for the
following claim types:

      i            Physicians         ii            Institutional        
iii            Professional         iiii            Pharmacy        
iiv            Dental         iv            Vision        
ivi            Behavioral

  4.18.3.5.2.1   Number and dollar value of Claims processed by Provider type
and processing status (adjudicated and paid, adjudicated and not paid,
suspended, appealed, denied);     4.18.3.5.2.2   Aging of Claims: number, dollar
value and status of Claims filed in most recent and prior months (defined as six
(6) months previous) by Provider type and processing status; and    
4.18.3.5.2.3   Cumulative percentage for the current fiscal year of Clean Claims
processed and paid within thirty (30) calendar and ninety (90) Calendar Days of
receipt.

  4.18.3.6   Utilization Management Report

  4.18.3.6.1   Pursuant to Section 4.11.10.1, the Contractor shall submit a
Utilization Management Report on Utilization patterns and aggregate trend
analysis. The monthly Utilization Management Report shall be based on
authorization data and will contain specific elements specified by DCH such that
all CMOs are reporting a common data set.

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4.18.4   Quarterly Reporting

  4.18.4.1   EPSDT Report

  4.18.4.1.1   Pursuant to Section 4.7.6.1 the Contractor shall submit an EPSDT
Report for Medicaid Members and PeachCare for Kids Members that identifies at a
minimum the following:

  i.   Number of Health Check eligible Members;     ii.   Number of live births;
    iii.   Number of initial newborn visits within twenty-four (24) hours of
birth;     iv.   Number of Members who received all scheduled EPSDT screenings
in accordance with the periodicity schedule;     v.   Number of Members who
received dental examinations services by an oral health professional;     vi.  
Number of Members that received an initial health visit and screening within
ninety (90) Calendar Days of Enrollment;     vii.   Number of diagnostic and
treatment services, including Referrals; and     viii.   Number and rate of
blood lead screening.

  4.18.4.1.2   Reports shall capture Medicaid Members and PeachCare for Kids
Members separately.     4.18.4.1.3   DCH, at its sole discretion, may add
additional data to the EPSDT Report if DCH determines that it is necessary for
monitoring purposes.

  4.18.4.2   Timely Access Report

  4.18.4.2.1   Pursuant to Section 4.8.19.2 the Contractor shall submit Timely
Access Reports that monitor the time lapsed between a Member’s initial request
for an office appointment and the date of the appointment. These data for the
Timely Access Reports may be collected using statistical sampling methods
(including periodic Member and/or Provider surveys). The report shall include:

  i.   Total number of appointment requests;     ii.   Total number of requests
that meet the waiting time standards;     iii.   Total number of requests that
exceed the waiting time standards; and     iv.   Average waiting time for those
requests that exceed the waiting time standards. Information for items iii and
iv shall be provided for each provider type/class.

  4.18.4.3   Provider Complaints Report

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  4.18.4.3.1   Pursuant to Section 4.9.8.2 the Contractor shall submit a
Provider Complaints Report that includes, at a minimum, the following:

  i.   Number of complaints by type;     ii.   Type of assistance provided; and
    iii.   Administrative disposition of the case.

  4.18.4.4   FQHC and RHC Report

  4.18.4.4.1   Pursuant to 4.10.5.1 the Contractor shall submit monthly FQHC and
RHC Payment Reports that identify Contractor payments made to each FQHC and RHC
for each Covered Service provided to Members.

  4.18.4.5   Utilization Management Report

  4.18.4.5.1   Utilization Management Reports must include an analysis of data
and identification of opportunities for improvement and follow up of the
effectiveness of the intervention. Utilization data is to be reported separately
based on both authorization (report based on authorization data shall be
submitted monthly pursuant to Section 4.18.3.6.1) and claim data. The reports
shall include, at a minimum, the following data: Specific data elements are
defined with DCH such that all CMOs are reporting a common data set.

  4.18.4.5.1.1   Number of UM cases handled, by type;     4.18.4.5.1.2   Number
of denials (medical/dental/behavioral health/pharmaceutical);     4.18.4.5.1.3  
Number of appeals;     4.18.4.5.1.4   Monitoring of at least four (4) types of
utilization data for over-utilization and under-utilization. This should be
measured against an established threshold (length of stay, unplanned
readmissions, procedure rates, member complaints, etc.)

  4.18.4.5.2   Pursuant to Section 4.11.10.1, the Contractor shall submit a
Utilization Management Report on Utilization patterns and aggregate trend
analysis. The Contractor shall also submit individual physician profiles to DCH,
as requested. These Reports should provide to DCH analysis and interpretation of
Utilization patterns, including but not limited to, high volume services, high
risk services, services driving cost increases, including prescription drug
utilization; Fraud and Abuse trends; and Quality and disease management. The
Contractor shall provide ad hoc Reports pursuant to the requests of DCH. The

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      Contractor shall submit its proposed reporting mechanism, including but
not limited to focus of study, data sources to DCH for approval.     4.18.4.5.3
  The Contractor shall select three (3) of the following elements to monitor in
its physician profiles. Each element should be measured against an established
threshold.

  4.18.4.5.3.1   Member access (encounters per member per year, new patient
visit within 6 months, ER use per member per year, etc.)     4.18.4.5.3.2  
Preventive care (EPSDT rates, breast cancer screening rates, immunizations,
etc.)     4.18.4.5.3.3   Disease management (asthma ER/IP encounters, HBA1C
rates, etc.)     4.18.4.5.3.4   Pharmacy utilization (generics, asthma
medications, etc.)

  4.18.4.6   Quality Oversight Committee Report

  4.18.4.6.1   Pursuant to Section 4.12.11.1 the Contractor shall submit a
Quality Oversight Committee Report that shall include a summary of results,
conclusions, recommendations and implemented system changes for the QAPI
program.

  4.18.4.7   Fraud and Abuse Report

  4.18.4.7.1   Pursuant to Section 4.13.4.1 the Contractor shall submit a Fraud
and Abuse Report, which shall include, at a minimum, the following:

  i.   Source of complaint;     ii.   Alleged persons or entities involved;    
iii.   Nature of complaint;     iv.   Approximate dollars involved;     v.  
Date of the complaint;     vi.   Disciplinary action imposed;     vii.  
Administrative disposition of the case;     viii.   Investigative activities,
corrective actions, prevention efforts, and results; and

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  ix.   Trending and analysis as it applies to: Utilization Management; Claims
management; post-processing review of Claims; and Provider profiling.

  4.18.4.8   Grievance System Report

  4.18.4.8.1   Pursuant to Section 4.14.8.5 the Contractor shall submit a
summary of Grievance, Appeals and Administrative Law Hearing requests. The
report shall, at a minimum, include the following:

  i.   Number of complaints by type;     ii.   Type of assistance provided; and
    iii.   Administrative disposition of the case.

  4.18.4.9   Cost Avoidance Report

  4.18.4.9.1   Pursuant to Section 8.6.1 the Contractor shall submit a Cost
Avoidance Report that identifies all cost-avoided claims for Members with third
party coverage from private insurance carriers and other responsible third
parties.

  4.18.4.10   Medical Loss Ratio Report

  4.18.4.10.1   Pursuant to Section 8.6.2, the Contractor shall submit monthly,
a Medical Loss Ratio report that captures medical expenses relative to
capitation payments received on a cumulative year to date basis. In addition,
the Medical Loss Ratio report shall be submitted by May 15, August 15,
November 15 and February 15 for the quarter immediately preceding the due date.
The Medical Loss Ratio report shall include:

  4.18.4.10.1.1   Capitation payments received;     4.18.4.10.1.2   Medical
expenses by provider grouping including, but not limited to:

  4.18.4.10.1.2.1   Direct payments to Providers for covered medical services;  
  4.18.4.10.1.2.2   Capitated payments to providers; and     4.18.4.10.1.2.3  
Payments to subcontractors for covered benefits and services.

  4.18.4.10.1.3   An Estimate of incurred but not reported IBNR expenses;

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  4.18.4.10.1.4   Actuarial certification that the report, including the
estimate of IBNR, has been reviewed for accuracy; and     4.18.4.10.1.5  
Supporting claims lag tables by claim type.

  4.18.4.11   Independent Audit and Income Statement

  4.18.4.11.1   The Contractor shall submit to DOI:

  4.18.4.11.1.1   A quarterly report on the form prescribed by the National
Association of Insurance Commissioners (NAIC) for Health Maintenance
Organizations (HMOs)pursuant to Section 8.6.6; and     4.18.4.11.1.2   A
quarterly income statement on the form prescribed by the NAIC for HMOs pursuant
to Section 8.6.6.

  4.18.4.12   Subcontractor Agreement Report

  4.18.4.12.1   Pursuant to Section 16.0, the Contractor shall submit a
Subcontractor Agreement Report. The Subcontractor Agreement Report shall
include:

  i.   All signed agreements for services provided (direct or indirect) to or on
behalf of the Contractor’s assigned membership or contracted providers that
includes:

  •   Name of Subcontractor     •   Services provided by Subcontractor     •  
Terms of the subcontracted agreement     •   Subcontractor contact information

  ii.   Monitoring schedule (at lest twice per year)     iii.   Monitoring
results

4.18.4.13   Provider Rep Field Visit Report

  4.18.4.13.1   The Contractor shall submit the Provider Rep Field Visit Report
(4.9.3) quarterly, and on an as-needed-basis, according to the guidelines
outlined in section 4.9.3.1 and 4.9.3.2. The purpose of this report is to show
that the CMOs conduct training within thirty (30) Calendar Days of placing a
newly Contracted Provider on active status. The contractor shall also conduct
ongoing training as deemed necessary by the Contractor or DCH in order to ensure
compliance with program standard and the GHF Contract.

4.18.5   Annual Reports

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  4.18.5.1   Performance Improvement Projects Reports

  4.18.5.1.1   Pursuant to Section 4.12.5 the Contractor shall submit a
Performance Improvement Projects Report that includes the study design,
analysis, status and results on performance improvement projects. Status Reports
on Performance Improvement Projects may be requested more frequently by DCH.

  4.18.5.2   Focused Studies Report

  4.18.5.2.1   Pursuant to Section 4.12.7.3 the Contractor shall, by April 1,
submit the Focus Studies proposal that includes study topics, study questions,
study indicators, and the study population for each of the two required focused
studies to DCH for approval. The Contractor shall submit annual Reports on the
focused studies, which includes analysis and results, no later than the March
31.

  4.18.5.3   Patient Safety Reports

  4.18.5.3.1   Pursuant to Section 4.12.8 the Contractor shall submit a Patient
Safety Report that includes, at a minimum, the following:

  i.   A system of classifying complaints according to severity;     ii.  
Review by Medical Director and mechanism for determining which incidents will be
forwarded to Peer Review and Credentials Committees; and     iii.   Summary of
incident(s) included in Provider Profile.

  4.18.5.4   Systems Refresh Plan

  4.18.5.4.1   Pursuant to Section 4.17.1.6 the Contractor shall submit to DCH a
Systems Refresh Plan no later than April 30 of each contract year.

  4.18.5.5   Independent Audit and Income Statement

  4.18.5.5.1   The Contractor shall submit to DOI:

  ii.   An annual report on the form prescribed by the National Association of
Insurance Commissioners (NAIC) for Health Maintenance Organizations
(HMO) pursuant to Section 8.6.6;     iii.   An annual income statement pursuant
to Section 8.6.6; and

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  iv.   An annual audit of its business transactions pursuant to Section 8.6.6.

  4.18.5.6   “SAS 70” Report

  4.18.5.6.1   Pursuant to Section 8.6.4, the Contractor shall submit to DCH an
annual SAS 70 Report conducted by an independent auditing firm.     4.18.5.6.2  
SAS 70 reports shall be due May 15 of each year and apply to the preceding
twelve (12) month period April through March.

  4.18.5.7   Disclosure of Information on Annual Business Transactions

  4.18.5.7.1   Pursuant to Section 8.6.5, the Contractor shall submit to DCH, in
a format specified by DCH, an annual Disclosure of Information on Annual
Business Transactions.

4.18.6   Ad Hoc Reports

  4.18.6.1   State Quality Monitoring Reports

  4.18.6.1.1   Pursuant to section 2.8.1 the Contractor shall report, upon
request by DCH, information to support the State’s Quality Monitoring Functions
in accordance with 42 CFR 438.204. These Reports shall include information on:

  4.18.6.1.1.1   The availability of services;     4.18.6.1.1.2   The adequacy
of the Contractor’s capacity and services;     4.18.6.1.1.3   The Contractor’s
coordination and continuity of care for Members;     4.18.6.1.1.4   The coverage
and authorization of services;     4.18.6.1.1.5   The Contractor’s policies and
procedures for selection and retention of Providers;     4.18.6.1.1.6   The
Contractor’s compliance with Member information requirements in accordance with
42CFR 438.10;     4.18.6.1.1.7   The Contractor’s compliance with 45 CFR
relative to Member’s confidentiality;     4.18.6.1.1.8   The Contractor’s
compliance with Member Enrollment and Disenrollment requirements and
limitations;     4.18.6.1.1.9   The Contractor’s Grievance System;    
4.18.6.1.1.10   The Contractor’s oversight of all subcontractual relationships
and delegations therein;     4.18.6.1.1.11   The Contractor’s adoption of
practice guidelines, including the dissemination of the guidelines to Providers
and Provider’s application of them;

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  4.18.6.1.1.12   The Contractor’s quality assessment and performance
improvement program; and     4.18.6.1.1.13   The Contractor’s health information
systems.

  4.18.6.2   Monthly Provider Network Adequacy and Capacity Report

  4.18.6.2.1   Pursuant to Section 4.8.15.2 the Contractor shall submit a
Provider Network Adequacy and Capacity Report monthly that demonstrates that the
Contractor offers an appropriate range of preventive, Primary Care and specialty
services that is adequate for the anticipated number of Members for the service
area and that its network of Providers is sufficient in number, mix and
geographic distribution to meet the needs of the anticipated number of Members
in the service area.     4.18.6.2.2   This Provider Network Adequacy and
Capacity Report shall list all Providers enrolled in the Contractor’s Provider
network, including but not limited to, physicians, hospitals, FQHC/RHCs, home
health agencies, pharmacies, Durable Medical Equipment vendors, behavioral
health specialists, ambulance vendors, and dentists. Each Provider shall be
identified by a unique identifying Provider number as specified in
Section 4.8.1.5. This unique identifier shall appear on all Encounter Data
transmittals. In addition to the listing, the Provider Network Adequacy and
Capacity Report shall identify:

  i.   Provider additions and deletions from the preceding month;     ii.   All
OB/GYN Providers participating in the Contractor’s network, and those with open
panels; and     iii.   List of Primary Care Providers with open panels.

  4.18.6.2.3   The Reports shall be submitted to DCH at the following times:

  i.   Sixty (60) Calendar Days after Contract Award and monthly thereafter;    
ii.   Upon DCH request;     iii.   Upon Enrollment of a new population in the
Contractor’s plan; and     iv.   Any time there has been a significant change in
the Contractor’s operations that would affect adequate capacity

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      and services. A significant change is defined as any of the following:

  –   A decrease in the total number of PCPs by more than five percent (5%);    
–   A loss of Providers in a specific specialty where another Provider in that
specialty is not available within sixty (60) miles; or     –   A loss of a
hospital in an area where another CMO plan hospital of equal service ability is
not available within thirty (30) miles; or     –   Other adverse changes to the
composition of the network, which impair or deny the Members’ adequate access to
CMO plan Providers.

  4.18.6.3   Third Party Liability and Coordination of Benefits Report

  4.18.6.3.1   Pursuant to Section 8.6.3, the Contractor shall submit a Third
Party Liability and Coordination of Benefits Report that includes any Third
Party Resources available to a Member discovered by the Contractor, in addition
to those provided to the Contractor by DCH pursuant to Section 2.11.1, within
ten (10) Business Days of verification of such information. The Contractor shall
report any known changes to such resources in the same manner.

  4.18.6.4   Hospital Statistical and Reimbursement Report

  4.18.6.4.1   The Contractor shall provide a Hospital Statistical and
Reimbursement Report (HS&R) to a hospital provider upon request by the hospital
or DCH using the same format that is used by DCH in completing HS&R reports
within 30 days or receipt of such request.     4.18.6.4.2   Contractor will
provide DCH with a quarterly report due fifteen (15) days after the end of the
quarter, indicating all HS&R reports requested, the requesting hospital, date
requested by hospital and date provided to hospital.     4.18.6.4.3   Contractor
must provide the HS&R report to the requesting hospital within thirty (30) days
of request. If delinquent in providing the HS&R Report, Contractor is subject to
a $1,000 per day starting on the thirty-first day after the request and
continuing until the report is provided. Payment of the penalty will be to DCH
to be deposited in the Indigent Care Trust Fund. Contractor shall not reduce the
funding available for health care services for Members as a result of payment of
such penalties.

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  4.18.6.5   Contractor Notifications

  4.18.6.5.1   Pursuant to Section 5.8 the Contractor shall submit a Contractor
Notifications Report that includes all DCH requested updated information within
10 days of verification; subsequently a quarterly summary must be provided that
includes but is not limited to:

  i.   Relationship of Parties     ii.   Criminal Background     iii.  
Confidentiality Requirements     iv.   Insurance Coverage     v.   Payment Bond
& Letter of Credit     vi.   Compliance with Federal Laws     vii.   Conflict of
Interest and Contractor Independence     viii.   Drug Free Workplace     ix.  
Business Associate Agreement     x.   System Status     xi.   Key staff or
Senior Level Management     xii.   Current Corporate and Local Organization
Chart

5.0   DELIVERABLES   5.1   CONFIDENTIALITY   5.1.1   The Contractor shall ensure
that any Deliverables that contain information about individuals that is
protected by confidentiality and privacy laws shall be prominently marked as
“CONFIDENTIAL” and submitted to DCH in a manner that ensures that unauthorized
individuals do not have access to the information. The Contractor shall not make
public such reports. Failure to ensure confidentiality may result in sanctions
and liquidated damages as described in Section 23.   5.2   NOTICE OF DISAPPROVAL
  5.2.1   DCH will provide written notice of disapproval of a Deliverable to the
Contractor within fourteen (14) Calendar Days of submission if it is
disapproved. DCH may, at its sole discretion, elect to review a deliverable
longer than 14 calendar days.   5.2.2   The notice of disapproval shall state
the reasons for disapproval as specifically as is reasonably necessary and the
nature and extent of the corrections required for meeting the Contract
requirements.   5.3   RESUBMISSION WITH CORRECTIONS

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5.3.1   Within fourteen (14) Calendar Days of receipt of a notice of
disapproval, the Contractor shall make the corrections and resubmit the
Deliverable.   5.4   NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION   5.4.1  
Within thirty (30) Calendar Days following resubmission of any disapproved
Deliverable, DCH will give written notice to the Contractor of approval,
Conditional approval or disapproval.   5.5   DCH FAILS TO RESPOND   5.5.1   In
the event that DCH fails to respond to a Contractor’s resubmission within the
applicable time period, the Contractor may either:

  5.5.1.1   Notify DCH in writing that it intends to proceed with subsequent
work unless DCH provides written notice of disapproval within fourteen
(14) Calendar Days from the date DCH receives the Contractor’s notice.    
5.5.1.2   Notify DCH that it intends to delay subsequent work until DCH responds
in writing to the resubmission.

5.6   REPRESENTATIONS   5.6.1   By submitting a Deliverable or report, the
Contractor represents that to the best of its knowledge, it has performed the
associated tasks in a manner that will, in concert with other tasks, meet the
objectives stated or referred to in the Contract.   5.6.2   By approving a
Deliverable or report, DCH represents only that it has reviewed the Deliverable
or report and detected no errors or omissions of sufficient gravity to defeat or
substantially threaten the attainment of those objectives and to warrant the
Withholding or denial of payment for the work completed. DCH’S acceptance of a
Deliverable or report does not discharge any of the Contractor’s Contractual
obligations with respect to that Deliverable or report.   5.7   CONTRACT
DELIVERABLES

                  Contract     Deliverable   Section   Due Date
PCP Auto-assignment Policies
    4.1.2.3     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Member Handbook
    4.3.3.5     Within 60 Calendar Days of Contract Award and as updated
thereafter.

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                  Contract     Deliverable   Section   Due Date
Provider Directory
    4.3.5.3     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Sample Member ID card
    4.3.6.4     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Telephone Hotline Policies and
    4.3.7.3     Within 60 Calendar
Procedures (Member and Provider)
    4.9.6     Days of Contract Award and as updated thereafter.
Call Center Quality Criteria and Protocols
    4.3.7.9
4.9.5.8     Within 60 Calendar Days of Contract Award and as updated thereafter.
Web site Screenshots
    4.3.8.5
4.9.6     Within 60 Calendar Days of Contract Award and as updated thereafter.
Cultural Competency Plan
    4.3.9.3     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Marketing Plan and Materials
    4.4.3.1     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Provider Marketing Materials
    4.4.4.1     Within 60 Calendar Days of Contract Award and as updated
thereafter.
MH/SA Policies and Procedures
    4.6.10     Within 60 Calendar Days of Contract Award and as updated
thereafter.
EPSDT policies and procedures
    4.7.1.3     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Provider Selection and Retention Policies and Procedures
    4.8.1.5     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Provider Network Listing spreadsheet for all requested Provider types and
Provider Letters of Intent or executed Signature Pages of Provider Contracts not
previously submitted as part of the RFP response
    4.8.1.7     Within 60 Calendar Days of Contract Award and as updated
thereafter.

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                  Contract     Deliverable   Section   Due Date
Final Provider Network Listing spreadsheet for all requested Provider types,
Signature Pages for all Providers, and written acknowledgements from all
Providers part of a PPO, IPO, or other network stating they know they are in the
Contractor’s network, know they are accepting Medicaid patients, and are
accepting the terms and conditions of the Provider Contract.
    4.8.1.8     Within 90 Calendar Days of Contract Award and as updated
thereafter.
PCP Selection Policies and Procedures
    4.8.2.2     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Credentialing and Re-Credentialing Policies and Procedures
    4.8.13.4     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Provider Handbook
    4.9.2.4     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Provider Training Manuals
    4.9.3.2     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Provider Complaint System Policies and Procedures
    4.9.7.2     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Utilization Management Policies and Procedures
    4.11.1.2     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Care Coordination and Case Management Policies and Procedures
    4.11.8.3     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Quality Assessment and Performance Improvement Plan
    4.12.2.3     Within 90 Calendar Days of Contract Award and as updated
thereafter.
Proposed Performance Improvement
Projects
    4.12.3.7     Within 90 Calendar Days of Contract Award and as updated
thereafter.
Practice Guidelines
    4.12.4.2     Within 90 Calendar Days of Contract Award and as updated
thereafter.
Focused Studies
    4.12.5.2     1st day of the 4th Quarter of the 1st year

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                  Contract     Deliverable   Section   Due Date
Patient Safety Plan
    4.12.6.2     Within 90 Calendar Days of Contract Award and as updated
thereafter.
Program Integrity Policies and Procedures
    4.13.1.2     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Grievance System Policies and Procedures
    4.14.1.2     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Staff Training Plan
    4.15.3.2     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Implementation Plan
    4.15.5.2     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Payment Schedule
    4.16.1.4     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Business Continuity Plan
    4.17     Within 60 Calendar Days of Contract Award and as updated
thereafter.
System Users Manuals and Guides
    4.17     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Information Management Policies and Procedures
    4.17     Within 60 Calendar Days of Contract Award and as updated
thereafter.
Subcontractor Agreements
    16.1     Within 60 Calendar Days of Contract Award and as updated
thereafter.

5.8   CONTRACT REPORTS

                  Contract     Report   Section   Due Date
Member Information Report
    4.18.2.1     Weekly
Member Data Conflict Report
    4.18.2.2     Weekly
Telephone and Internet Activity Report
    4.18.3.1     Monthly
Eligibility and Enrollment Reconciliation Report
    4.18.3.2     Monthly

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                  Contract     Report   Section   Due Date
Prior Authorization and Pre-Certification Report
    4.18.3.3     Monthly
Claims Processing Report
    4.18.3.4     Monthly
System Availability and Performance Report
    4.18.3.5     Monthly
Utilization Management Report
    4.18.3.6     Monthly
Medical Loss Ratio Report
    4.18.4.10     Quarterly
Inpatient Expense Report
    8.0     Monthly
Physicians Expense Report
    8.0     Monthly
Pharmacy Expense Report
    8.0     Monthly
Outpatient Expense Report
    8.0     Monthly
Specialty Physician Expense
Report
    8.0     Monthly
Utilization by Age Report
    8.0     Monthly
Enrollment Report
    8.0     Monthly
Large Claims Report
    8.0     Monthly
Claims Expense by Size Report
    8.0     Monthly
GME Payments Report
    8.0     Monthly
EPSDT Report
    4.18.4.1     Quarterly
Timely Access Report
    4.18.4.2     Quarterly
Provider Complaints Report
    4.18.4.3     Quarterly
FQHC & RHC Report
    4.18.4.4     Quarterly
Utilization Management Report
    4.18.4.5     Quarterly
Quality Oversight Committee
Report
    4.18.4.6     Quarterly
Contractor Information Report
    14.0     Quarterly
Subcontractor Information
Report
    16.0     Quarterly
Fraud and Abuse Report
    4.18.4.7     Monthly
Grievance System Report
    4.18.4.8     Quarterly
Cost Avoidance and Post Payment Recovery Report
    4.18.4.9     Quarterly
Independent Audit and Income Statement
    4.18.4.11     Quarterly
Hospital Statistical and Reimbursement Report
    4.18.6.4     Quarterly
Subcontractor Agreement Report
    4.18.4.12     Quarterly
Performance Improvement
Projects Report
    4.18.5.1     Annually
Focused Studies Report
    4.18.5.2     Annually
Patient Safety Report
    4.18.5.3     Annually
System Refresh Plan
    4.48.5.4     Annually
Independent Audit and Income Statement
    4.18.5.5     Annually
“SAS 70” Report
    4.18.5.6     Annually

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                  Contract     Report   Section   Due Date
Disclosure of Information on Annual Business Transactions
    4.18.5.7     Annually
State Quality Monitoring Report
    4.18.6.1     Upon request by DCH
Provider Network Adequacy and Capacity Report
    4.18.6.2     Sixty Days after Contract Award; Quarterly; and Any time there
is a significant change. Monthly or any time there is a significant change.
Third Party Liability and Coordination of Benefits Report
    4.18.6.1.3     Within 10 Days of verification
Contractor Notifications
    4.18.6.5     Within 10 Days of verifications Quarterly summary report
Hospital Statistical and Reimbursement Report
    4.18.6.4     Upon request by Hospital Provider or DCH within 30 days of
receipt of the request

6.0   TERM OF CONTRACT   6.1   This Contract shall begin on July 15, 2005 and
shall continue until the close of the then current State fiscal year unless
renewed as hereinafter provided. DCH is hereby granted six (6) options to renew
this Contract for an additional term of up to one (1) State fiscal year, which
shall begin on July 1, and end at midnight on June 30, of the following year,
each upon the same terms, Conditions and Contractor’s price in effect at the
time of the renewal. The option shall be exercisable solely and exclusively by
DCH. As to each term, the Contract shall be terminated absolutely at the close
of the then current State fiscal year without further obligation by DCH.   7.0  
PAYMENT FOR SERVICES   7.1   GENERAL PROVISIONS

  7.1.1   DCH will compensate the Contractor a prepaid, per member per month
capitation rate for each GF Member enrolled in the Contractor’s plan (See
Attachment H).The number of enrolled Members in each rate cell category will be
determined by the records maintained in the Medicaid Member Information System
(MMIS) maintained by DCH’s fiscal agent. The monthly compensation will be the
final negotiated rate for each rate cell multiplied by the number of enrolled
Members in each rate cell category. The Contractor must provide to DCH, and keep
current, its tax identification number, billing address, and other contact
information. Pursuant to the terms of this Contract, should DCH assess
liquidated damages or other remedies or actions for noncompliance or deficiency
with the terms of this Contract, such amount

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      shall be withheld from the prepaid, monthly compensation for the following
month, and for continuous consecutive months thereafter until such noncompliance
or deficiency is corrected.     7.1.2   The relevant Deliverables shall be
mailed to the Project Leader named in the Notice provision of this Contract.    
7.1.3   The total of all payments made by DCH to Contractor under this Contract
shall not exceed the per Member per month Capitation payments agreed to under
Attachment H, which has been provided for through the use of State or federal
grants or other funds. With the exception of payments provided to the Contractor
in accordance with Section 7.2 on Performance Incentives, DCH will have no
responsibility for payment beyond that amount. Also as specified in
Section 7.2.2 the total of all payments to the Contract will not exceed one
hundred and five percent (105%) of the Capitation payment pursuant to 42 CFR
438.6 (hereinafter the “maximum funds”). It is expressly understood that the
total amount of payment to the Contractor will not exceed the maximum funds
provided above, unless Contractor has obtained prior written approval, in the
form of a Contract amendment, authorizing an increase in the total payment.
Additionally, the Contractor agrees that DCH will not pay or otherwise
compensate the Contractor for any work that it performs in excess of the Maximum
Funds.

7.2   Performance Incentives   7.2.1   The Contractor may be eligible for
financial performance incentives subject to availability of funding. In order to
be eligible for the financial performance incentives described below the
Contractor must be fully compliant in all areas of the Contract. All incentives
must comply with the federal managed care Incentive Arrangement requirements
pursuant to 42 CFR 438.6 and the State Medicaid Manual 2089.3.   7.2.2   The
total of all payments paid to the Contractor under this Contract shall not
exceed one hundred and five percent (105%) of the Capitation payment pursuant to
42 CFR 438.6.   7.2.3   The amount of financial performance incentive and
allocation methodology is developed solely by DCH.

  7.2.3.1   Health Check Screening Initiative

  7.2.3.1.1   The Contractor could become eligible for a performance incentive
payment if the Contractor’s performance exceeds the minimum compliance standard
for Health Check visits.

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  7.2.3.1.2   The payment to the Contractor, if any, shall depend upon the
percentage of Health Check well-child visits and screens achieved by the
Contractor in excess of the minimum required compliance standard of eighty
percent (80%). Payment shall be based on information obtained from Encounter
Data.

  7.2.3.2   Blood Lead Screening Test Incentive

  7.2.3.2.1   Pursuant to the requirements outlined in Section 4.7.3.2, the
Contractor may be eligible for a performance incentive payment if the
Contractor’s performance exceeds the minimum compliance standard for blood lead
screening tests provided to children age nine (9) months to thirty (30) months
of age.     7.2.3.2.2   The payment to the Contractor, if any, shall depend upon
the percentage of lead screening blood tests performed per unduplicated child
during the Contract period, in excess of the minimum required compliance
standard of eighty percent (80%) blood lead screening for children age nine
(9) months to thirty (30) months of age. Payment shall be based on information
obtained from Encounter Data.

  7.2.3.3   Dental Visits Incentive

  7.2.3.3.1   The Contractor may be eligible for financial performance
incentives if the Contractor’s performance exceeds the minimum compliance
standard for the provision of children’s dental services, as specified in
Section 4.7.3.8, and as reported in Encounter Data. Dental services mean any
dental service that is reported using a dental HCPC code or an ADA dental Claim
form.     7.2.3.3.2   The payment to the Contractor, if any, shall be based on
the percentage or number of visits achieved by the Contractor in excess of the
minimum compliance standard of an eighty percent (80%) rate of Health Check
eligible children receiving visits.

  7.2.3.4   Newborn Enrollment Notification Incentive

  7.2.3.4.1   Pursuant to the requirements outlined in Section 4.1.3, the
Contractor may be eligible for financial incentive payments based on the
Contractor’s compliance with newborn Enrollment notification to DCH. Minimum
Contractor compliance with newborn Enrollment notification is

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      notification to DCH within twenty-four (24) hours of the birth of each
newborn.     7.2.3.4.2   The payment to the Contractor, if any, shall depend
upon the number of newborn Enrollment notifications received by DCH within the
first twelve (12) hours of the birth of the newborn.

  7.2.3.5   EPSDT Tracking and Notices for Missed Appointments and Referrals

  7.2.3.5.1   Pursuant to the requirements outlined in Section 4.7 the
Contractor may be eligible for incentive payments based on the Contractor’s
follow-up, in the form of a telephone call or second (2nd) notice, to Health
Check eligible Members who have received an initial notice of missed screens.

8.0   FINANCIAL MANAGEMENT   8.1   GENERAL PROVISIONS   8.1.1   The Contractor
shall be responsible for the sound financial management of the CMO plan.   8.2  
SOLVENCY AND RESERVES STANDARDS   8.2.1   The Contractor shall establish and
maintain such net worth, working capital and financial reserves as required
pursuant to O.C.G.A. § 33-21.   8.2.2   The Contractor shall provide assurances
to the State that its provision against the risk of insolvency is adequate such
that its Members shall not be liable for its debts in the event of insolvency.  
8.2.3   As part of its accounting and budgeting function, the Contractor shall
establish an actuarially sound process for estimating and tracking incurred but
not reported costs. As part of its reserving process, the Contractor shall
conduct annual reviews to assess its reserving methodology and make adjustments
as necessary.   8.3   REINSURANCE   8.3.1   DCH will not administer a
Reinsurance program funded from capitation payment Withholding.   8.3.2   In
addition to basic financial measures required by State law and discussed in
section 8.2.1 and section 26, the Contractor shall meet financial viability
standards. The Contractor shall maintain net equity (assets minus liability)
equal to at least one (1) month’s capitation payments under this Contract. In
addition, the Contractor shall

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    maintain a current ratio (current assets/current liabilities) of greater
than or equal to 1.0.

8.3.3   In the event the Contractor does not meet the minimum financial
viability standards outlined in 8.3.2, the Contractor shall obtain Reinsurance
that meets all DOI requirements. While commercial Reinsurance is not required,
DCH recommends that Contractors obtain commercial Reinsurance rather than
self-insuring. The Contractor may not obtain a reinsurance policy from an
offshore company; the insurance carrier, the insurance carrier’s agents and the
insurance carrier’s subsidiaries must be domestic.   8.4   THIRD PARTY LIABILITY
AND COORDINATION OF BENEFITS   8.4.1   Third party liability refers to any other
health insurance plan or carrier (e.g., individual, group, employer-related,
self-insured or self-funded, or commercial carrier, automobile insurance and
worker’s compensation) or program, that is, or may be, liable to pay all or part
of the Health Care expenses of the Member.

  8.4.1.1   Pursuant to Section 1902(a)(25) of the Social Security Act and 42
CFR 433 Subpart D, DCH hereby authorizes the Contractor as its agent to identify
and cost avoid Claims for all CMO plan Members, including PeachCare for Kids
Members.     8.4.1.2   The Contractor shall make reasonable efforts to determine
the legal liability of third parties to pay for services furnished to CMO plan
Members. To the extent permitted by State and federal law, the Contractor shall
use Cost Avoidance processes to ensure that primary payments from the liable
third party are identified, as specified below.     8.4.1.3   If the Contractor
is unsuccessful in obtaining necessary cooperation from a Member to identify
potential Third Party Resources after sixty (60) Calendar Days of such efforts,
the Contractor may inform DCH, in a format to be determined by DCH, that efforts
have been unsuccessful.

8.4.2   Cost Avoidance

  8.4.2.1   The Contractor shall cost avoid all Claims or services that are
subject to payment from a third party health insurance carrier, and may deny a
service to a Member if the Contractor is assured that the third party health
insurance carrier will provide the service, with the exception of those
situations described below section 8.4.2.2. However, if a third party health
insurance carrier requires the Member to pay any cost-sharing amounts (e.g.,
co-payment, coinsurance, deductible), the Contractor shall pay the cost sharing
amounts. The Contractor’s liability for such cost sharing amounts shall not
exceed the amount the Contractor would have paid under the Contractor’s payment
schedule for the service.

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  8.4.2.2   Further, the Contractor shall not withhold payment for services
provided to a Member if third party liability, or the amount of third party
liability, cannot be determined, or if payment will not be available within
sixty (60) Calendar Days.

  8.4.2.3   The requirement of Cost Avoidance applies to all Covered Services
except Claims for labor and delivery, including inpatient hospital care and
postpartum care, prenatal services, preventive pediatric services, and services
provided to a dependent covered by health insurance pursuant to a court order.
For these services, the Contractor shall ensure that services are provided
without regard to insurance payment issues and must provide the service first.
The Contractor shall then coordinate with DCH or it agent to enable DCH to
recover payment from the potentially liable third party.

  8.4.2.4   If the Contractor determines that third party liability exists for
part or all of the services rendered, the Contractor shall:

  8.4.2.4.1   Notify Providers and supply third party liability data to a
Provider whose Claim is denied for payment due to third party liability; and    
8.4.2.4.2   Pay the Provider only the amount, if any, by which the Provider’s
allowable Claim exceeds the amount of third party liability.

8.4.3   Compliance

  8.4.3.1   DCH may determine whether the Contractor complies with this Section
by inspecting source documents for timeliness of billing and accounting for
third party payments.

8.5   PHYSICIAN INCENTIVE PLAN   8.5.1   The Contractor may establish physician
incentive plans pursuant to federal and State regulations, including 42 CFR
422.208 and 422.210, and 42 CFR 438.6.   8.5.2   The Contractor shall disclose
any and all such arrangements to DCH, and upon request, to Members. Such
disclosure shall include:

  8.5.2.1   Whether services not furnished by the physician or group are covered
by the incentive plan;     8.5.2.2   The type of Incentive Arrangement;    
8.5.2.3   The percent of Withhold or bonus; and,     8.5.2.4   The panel size
and if patients are pooled, the method used.

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8.5.3   Upon request, the Contractor shall report adequate information specified
by the regulations to DCH in order that DCH will adequately monitor the CMO
plan.   8.5.4   If the Contractor’s physician incentive plan includes services
not furnished by the physician/group, the Contractor shall: (1) ensure adequate
stop loss protection to individual physicians, and must provide to DCH proof of
such stop loss coverage, including the amount and type of stop loss; and
(2) conduct annual Member surveys, with results disclosed to DCH, and to
Members, upon request.   8.5.5   Such physician incentive plans may not provide
for payment, directly or indirectly, to either a physician or physician group as
an inducement to reduce or limit medically necessary services furnished to an
individual.   8.6   REPORTING REQUIREMENTS   8.6.1   The Contractor shall submit
to DCH quarterly Cost Avoidance Reports as described in Section 4.18.4.9.  
8.6.2   The Contractor shall submit to DCH quarterly Medical Loss Ratio Reports
that detail direct medical expenditures for Members and premiums paid by the
Contractor, as described in Section 4.18.4.10.   8.6.3   The Contractor shall
submit to DCH Third Party Liability and Coordination of Benefits Reports within
ten (10) Business Days of verification of available Third Party Resources to a
Member, as described in Section 4.18.6.3. The Contractor shall report any known
changes to such resources in the same manner.   8.6.4   The Contractor, at its
sole expense, shall submit by May 15 (or a later date if approved by DCH) of
each year a “Report on Controls Placed in Operation and Tests of Operating
Effectiveness”, meeting all standards and requirements of the AICPA’s SAS 70,
for the Contractor’s operations performed for DCH under the GF Contract.

  8.6.4.1   Statement on Auditing Standards Number 70 (SAS 70), Reports on the
Processing of Transactions by Service Organizations, is an auditing standard
developed by the American Institute of Certified Public Accountants (AICPA). The
completion of the SAS 70 process represents that a service organization has been
through an in-depth audit of their control objectives and control activities,
which include controls over information technology and related processes. A Type
II report not only includes the service organization’s description of controls,
but also includes detailed testing of the service organization’s controls over a
period of time. The Type II SAS 70 should be for a period no less than nine
months. The control objectives to be included in the scope of the SAS 70 must be
approved by the Georgia Department of Community Health (DCH) before the SAS 70
process is commenced.

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  8.6.4.2   The audit shall be conducted by an independent auditing firm, which
has prior SAS 70 audit experience. The auditor must meet all AICPA standards for
independence. The selection of, and contract with the independent auditor shall
be subject to the approval of DCH and the State Auditor. Since such audits are
not intended to fully satisfy all auditing requirements of DCH, the State
Auditor reserves the right to fully and completely audit at their discretion the
Contractor’s operation, including all aspects, which will have effect upon the
DCH account, either on an interim audit basis or at the end of the State’s
fiscal year. DCH also reserves the right to designate other auditors or
reviewers to examine the Contractor’s operations and records for monitoring
and/or stewardship purposes.     8.6.4.3   The independent auditing firm shall
simultaneously deliver identical reports of its findings and recommendations to
the Contractor and DCH within forty-five (45) Calendar Days after the close of
each review period. The audit shall be conducted and the report shall be
prepared in accordance with generally accepted auditing standards for such
audits as defined in the publications of the AICPA, entitled “Statements on
Auditing Standards” (SAS). In particular, both the “Statements on Auditing
Standards Number 70-Reports on the Processing of Transactions by Service
Organizations” and the AICPA Audit Guide, “Audit Guide of
Service-Center-Produced Records” are to be used.     8.6.4.4   The Contractor
shall respond to the audit findings and recommendations within thirty
(30) Calendar Days of receipt of the audit and shall submit an acceptable
proposed corrective action to DCH. The Contractor shall implement the corrective
action plan within forty (40) Calendar Days of its approval by DCH.

8.6.5   The Contractor shall submit to DCH a “Disclosure of Information on
Annual Business Transactions”. This report must include:

  8.6.5.1   Definition of A Party in Interest – As defined in section 1318(b) of
the Public Health Service Act, a party in interest is:

  8.6.5.1.1   Any director, officer, partner, or employee responsible for
management or administration of an HMO; any person who is directly or indirectly
the beneficial owner of more than five percent (5%) of the equity of the HMO;
any person who is the beneficial owner of a mortgage, deed of trust, note, or
other interest secured by, and valuing more than five percent (5%) of the HMO;
or, in the case of an HMO organized as a nonprofit corporation, an incorporator
or Member of such corporation under applicable State corporation law;

  8.6.5.1.2   Any organization in which a person described in section 8.6.5.1.1
is director, officer or partner; has directly or indirectly a beneficial

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      interest of more than five percent (5%) of the equity of the HMO; or has a
mortgage, deed of trust, note, or other interest valuing more than five percent
(5%) of the assets of the HMO;

  8.6.5.1.3   Any person directly or indirectly controlling, controlled by, or
under common control with a HMO; or     8.6.5.1.4   Any spouse, child, or parent
of an individual described in sections 8.6.5.1.1, Section 8.6.5.1.2, or
Section 8.6.5.1.3.

  8.6.5.2   Types of Transactions Which Must Be Disclosed – Business
transactions which must be disclosed include:

  8.6.5.2.1   Any sale, exchange or lease of any property between the HMO and a
party in interest;     8.6.5.2.2   Any lending of money or other extension of
credit between the HMO and a party in interest; and     8.6.5.2.3   Any
furnishing for consideration of goods, services (including management services)
or facilities between the HMO and the party in interest. This does not include
salaries paid to employees for services provided in the normal course of their
employment;

  8.6.5.3   The information which must be disclosed in the transactions listed
in Section 8.6.5.2 between an HMO and a party of interest includes:

  8.6.5.3.1   The name of the party in interest for each transaction;    
8.6.5.3.2   A description of each transaction and the quantity or units
involved;     8.6.5.3.3   The accrued dollar value of each transaction during
the fiscal year; and     8.6.5.3.4   Justification of the reasonableness of each
transaction.

8.6.6   The Contractor shall submit all necessary reports, documentation, to DOI
as required by State law, which may include, but is not limited to the
following:

  8.6.6.1   Pursuant to State law and regulations, an annual report on the form
prescribed by the National Association of Insurance Commissioners (NAIC) for
HMOs, on or before March 1 of each calendar year.

  8.6.6.2   An annual income statement detailing the Contractor’s fourth quarter
and year to date earned revenue and incurred expenses as a result of this
Contract on or before March 1 of each year. This annual income statement shall
be accompanied by a Medical Loss Ratio report for the corresponding period and

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      a reconciliation of the Medical Loss Ratio report to the annual NAIC
filing on an accrual basis.     8.6.6.3   Pursuant to state law and regulations,
a quarterly report on the form prescribed by the NAIC for HMOs filed on or
before May 15 for the first quarter of the year, August 15 for the second
quarter of the year, and November 15, for the third quarter of the year.    
8.6.6.4   A quarterly income statement detailing the Contractor’s quarterly and
year to date earned revenue and incurred expenses because of this contract filed
on or before May 15, for the first quarter of the year, August 15, for the
second quarter of the year, and November 15, for the third quarter of the year.
Each quarterly income statement shall be accompanied by a Medical Loss Ratio
report for the corresponding period and reconciliation of the Medical Loss Ratio
report to the quarterly NAIC filing on an accrual basis.     8.6.6.5   An annual
independent audit of its business transactions to be performed by a licensed and
certified public accountant, in accordance with National Association of
Insurance Commissioners Annual Statement Instructions regarding the Annual
Audited Financial Report, including but not limited to the financial
transactions made under this contract.

9.0   PAYMENT OF TAXES   9.1   Contractor will forthwith pay all taxes lawfully
imposed upon it with respect to this Contract or any product delivered in
accordance herewith. DCH makes no representation whatsoever as to the liability
or exemption from liability of Contractor to any tax imposed by any governmental
entity.   9.2   The Contractor shall remit the Quality Assessment fee, as
provided for in O.C.G.A. §31-8-170 et seq., in the manner prescribed by DCH.  
10.0   RELATIONSHIP OF PARTIES   10.1   Neither Party is an agent, employee, or
servant of the other. It is expressly agreed that the Contractor and any
Subcontractors and agent, officers, and employees of the Contractor or any
Subcontractor in the performance of this Contract shall act as independent
contractors and not as officers or employees of DCH. The parties acknowledge,
and agree, that the Contractor, its agent, employees, and servants shall in no
way hold themselves out as agent, employees, or servants of DCH. It is further
expressly agreed that this Contract shall not be construed as a partnership or
joint venture between the Contractor or any Subcontractor and DCH.

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11.0   INSPECTION OF WORK   11.1   DCH, the State Contractor, the Department of
Health and Human Services, the General Accounting Office, the Comptroller
General of the United States, if applicable, or their Authorized
Representatives, shall have the right to enter into the premises of the
Contractor and/or all Subcontractors, or such other places where duties under
this Contract are being performed for DCH, to inspect, monitor or otherwise
evaluate the services or any work performed pursuant to this Contract. All
inspections and evaluations of work being performed shall be conducted with
prior notice and during normal business hours. All inspections and evaluations
shall be performed in such a manner as will not unduly delay work.   12.0  
STATE PROPERTY   12.1   The Contractor agrees that any papers, materials and
other documents that are produced or that result, directly or indirectly, from
or in connection with the Contractor’s provision of the services under this
Contract shall be the property of DCH upon creation of such documents, for
whatever use that DCH deems appropriate, and the Contractor further agrees to
execute any and all documents, or to take any additional actions that may be
necessary in the future to effectuate this provision fully. In particular, if
the work product or services include the taking of photographs or videotapes of
individuals, the Contractor shall obtain the consent from such individuals
authorizing the use by DCH of such photographs, videotapes, and names in
conjunction with such use. Contractor shall also obtain necessary releases from
such individuals, releasing DCH from any and all Claims or demands arising from
such use.   12.2   The Contractor shall be responsible for the proper custody
and care of any State-owned property furnished for the Contractor’s use in
connection with the performance of this Contract. The Contractor will also
reimburse DCH for its loss or damage, normal wear and tear excepted, while such
property is in the Contractor’s custody or use.   13.0   OWNERSHIP AND USE OF
DATA/ UPGRADES   13.1   OWNERSHIP AND USE OF DATA   13.1.1   All data created
from information, documents, messages (verbal or electronic), Reports, or
meetings involving or arising out of this Contract is owned by DCH, hereafter
referred to as DCH Data. The Contractor shall make all data available to DCH,
who will also provide it to CMS upon request. The Contractor is expressly
prohibited from sharing or publishing DCH Data or any information relating to
Medicaid data without the prior written consent of DCH. In the event of a
dispute

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    regarding what is or is not DCH Data, DCH’s decision on this matter shall be
final and not subject to Appeal.   13.2   SOFTWARE AND OTHER UPGRADES   13.2.1  
The Parties also understand and agree that any upgrades or enhancements to
software programs, hardware, or other equipment, whether electronic or physical,
shall be made at the Contractor’s expense only, unless the upgrade or
enhancement is made at DCH’s request and solely for DCH’s use. Any upgrades or
enhancements requested by and made for DCH’s sole use shall become DCH’s
property without exception or limitation. The Contractor agrees that it will
facilitate DCH’s use of such upgrade or enhancement and cooperate in the
transfer of ownership, installation, and operation by DCH.   14.0   CONTRACTOR
STAFFING   14.1   STAFFING ASSIGNMENTS AND CREDENTIALS   14.1.1   The Contractor
warrants and represents that all persons, including independent Contractors and
consultants assigned by it to perform this Contract, shall be employees or
formal agents of the Contractor and shall have the credentials necessary (i.e.,
licensed, and bonded, as required) to perform the work required herein. The
Contractor shall include a similar provision in any contract with any
Subcontractor selected to perform work hereunder. The Contractor also agrees
that DCH may approve or disapprove the Contractor’s Subcontractors or its staff
assigned to this Contract prior to the proposed staff assignment. DCH’s decision
on this matter shall not be subject to Appeal.   14.1.1.1   The contractor shall
insure that all personnel involved in activities that involve clinical or
medical decision making have a valid, active and unrestricted license to
practice. On at staff have a decision making least an annual current license
have a valid, basis the CMO and that is in good active and its subcontractors
standing and will unrestricted will verify that provide a list to license to DCH
of licensed staff and current licensure status.   14.1.2   In addition, the
Contractor warrants that all persons assigned by it to perform work under this
Contract shall be employees or authorized Subcontractors of the Contractor and
shall be fully qualified, as required in the RFP and specified in the
Contractor’s proposal and in this Contract, to perform the services required
herein. Personnel commitments made in the Contractor’s proposal shall not be
changed unless approved by DCH in writing. Staffing will include the named
individuals at the levels of effort proposed.   14.1.3   The Contractor shall
provide and maintain sufficient qualified personnel and staffing to enable the
Deliverables to be provided in accordance with the RFP, the Contractor’s
proposal and this Contract. The Contractor shall submit to DCH a

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    detailed staffing plan, including the employees and management for all CMO
functions.   14.1.4   At a minimum, the Contractor shall provide the following
staff:

  14.1.4.1   An Executive Administrator who is a full-time administrator with
clear authority over the general administration and implementation of the
requirements detailed in this Contract.     14.1.4.2   A Medical Director who is
a licensed physician in the State of Georgia. The Medical Director shall be
actively involved in all major clinical program components of the CMO plan,
shall be responsible for the sufficiency and supervision of the Provider
network, and shall ensure compliance with federal, State and local reporting
laws on communicable diseases, child abuse, neglect, etc.     14.1.4.3   A
Quality Improvement/Utilization Director.     14.1.4.4   A Chief Financial
Officer who oversees all budget and accounting systems.     14.1.4.5   An
Information Management and Systems Director and a complement of technical
analysts and business analysts as needed to maintain the operations of
Contractor Systems and to address System issues in accordance with the terms of
this contract.     14.1.4.6   A Pharmacist who is licensed in the State of
Georgia;     14.1.4.7   A Dental Consultant who is a licensed dentist in the
State of Georgia.     14.1.4.8   A Mental Health Coordinator who is a licensed
mental health professional in the State of Georgia.     14.1.4.9   A Member
Services Director.     14.1.4.10   A Provider Services Director.     14.1.4.11  
A Provider Relations Liaison.     14.1.4.12   A Grievance/Complaint Coordinator.
    14.1.4.13   Compliance Officer.     14.1.4.14   A Prior
Authorization/Pre-Certification Coordinator who is a physician, registered
nurse, or physician’s assistant licensed in the State of Georgia.

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  14.1.4.15   Sufficient staff in all departments, including but not limited to,
Member services, Provider services, and prior authorization and concurrent
review services to ensure appropriate functioning in all areas.

14.1.5   The Contractor shall conduct on-going training of staff in all
departments to ensure appropriate functioning in all areas.   14.1.6   The
Contractor shall comply with all staffing/personnel obligations set out in the
RFP and this Contract, including but not limited to those pertaining to
security, health, and safety issues.   14.2   STAFFING CHANGES   14.2.1   The
Contractor shall notify DCH in the event of any changes to key staff, including
the Executive Administrator, Medical Director, Quality Improvement/Utilization
Director, Management Information Systems Director, and Chief Financial Officer.
The Contractor shall replace any of the key staff with a person of equivalent
experience, knowledge and talent.   14.2.2   DCH also may require the removal or
reassignment of any Contractor employee or Subcontractor employee that DCH deems
to be unacceptable. DCH’s decision on this matter shall not be subject to
Appeal. Notwithstanding the above provisions, the Parties acknowledge and agree
that the Contractor may terminate any of its employees designated to perform
work or services under this Contract, as permitted by applicable law. In the
event of Contractor termination of any key staff identified in 14.1.4, the
Contractor shall provide DCH with immediate notice of the termination, the
reason(s) for the termination, and an action plan for replacing the discharged
employee.   14.2.3   The Contractor must submit to DCH quarterly the Contractor
Information Report that includes but is not limited to the Contractor’s local
staff information as well as local and corporate organizational charts.   14.3  
CONTRACTOR’S FAILURE TO COMPLY   14.3.1   Should the Contractor at any time: 1)
refuse or neglect to supply adequate and competent supervision; 2) refuse or
fail to provide sufficient and properly skilled personnel, equipment, or
materials of the proper quality or quantity; 3) fail to provide the services in
accordance with the timeframes, schedule or dates set forth in this Contract; or
4) fail in the performance of any term or condition contained in this Contract,
DCH may (in addition to any other contractual, legal or equitable remedies)
proceed to take any one or more of the following actions after five (5) Calendar
Days written notice to the Contractor:

  14.3.1.1   Withhold any monies then or next due to the Contractor;

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  14.3.1.2   Obtain the services or their equivalent from a third party, pay the
third party for same, and Withhold the amount so paid to third party from any
money then or thereafter due to the Contractor; or     14.3.1.3   Withhold
monies in the amount of any damage caused by any deficiency or delay in the
services.

15.0   CRIMINAL BACKGROUND CHECKS   15.1   The Contractor shall, upon request,
provide DCH with a resume or satisfactory criminal background check or both of
any Members of its staff or a Subcontractor’s staff assigned to or proposed to
be assigned to any aspect of the performance of this Contract.   16.0  
SUBCONTRACTS   16.1   USE OF SUBCONTRACTORS   16.1.1   The Contractor will not
subcontract or permit anyone other than Contractor personnel to perform any of
the work, services, or other performances required of the Contractor under this
Contract, or assign any of its rights or obligations hereunder, without the
prior written consent of DCH. Prior to hiring or entering into an agreement with
any Subcontractor, any and all Subcontractors shall be approved by DCH. DCH
reserves the right to inspect all subcontract agreements at any time during the
Contract period. Upon request from DCH, the Contractor shall provide in writing
the names of all proposed or actual Subcontractors. The Contractor is solely
accountable for all functions and responsibilities contemplated and required by
this Contract, whether the Contractor performs the work directly or through a
Subcontractor.   16.1.2   All contracts between the Contractor and
Subcontractors must be in writing and must specify the activities and
responsibilities delegated to the Subcontractor. The contracts must also include
provisions for revoking delegation or imposing other sanctions if the
Subcontractor’s performance is inadequate.   16.1.3   All contracts must ensure
that the Contractor evaluates the prospective Subcontractor’s ability to perform
the activities to be delegated; monitors the Subcontractor’s performance on an
ongoing basis and subjects it to formal review according to a periodic schedule
established by DCH and consistent with industry standards or State laws and
regulations; and identifies deficiencies or areas for improvement and that
corrective action is taken.   16.1.4   The Contractor shall give DCH immediate
notice in writing by registered mail or certified mail of any action or suit
filed by any Subcontractor and prompt notice of

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    any Claim made against the Contractor by any Subcontractor or vendor that,
in the opinion of Contractor, may result in litigation related in any way to
this Contract.   16.1.5   All Subcontractors must fulfill the requirements of 42
CFR 438.6 as appropriate.   16.1.6   All Provider contracts shall comply with
the requirements and provisions as set forth in Section 4.10 of this Contract.  
16.1.6   The Contractor shall submit a Subcontractor Information Report to
include, but is not limited to: Subcontractor name, services provided, effective
date of the subcontracted agreement.   16.2   COST OR PRICING BY SUBCONTRACTORS
  16.2.1   The Contractor shall submit, or shall require any Subcontractors
hereunder to submit, cost or pricing data for any subcontract to this Contract
prior to award. The Contractor shall also certify that the information submitted
by the Subcontractor is, to the best of their knowledge and belief, accurate,
complete and current as of the date of agreement, or the date of the negotiated
price of the subcontract to the Contract or amendment to the Contract. The
Contractor shall insert the substance of this Section in each subcontract
hereunder.   16.2.2   If DCH determines that any price, including profit or fee
negotiated in connection with this Contract, or any cost reimbursable under this
Contract was increased by any significant sum because of the inaccurate cost or
pricing data, then such price and cost shall be reduced accordingly and this
Contract and the subcontract shall be modified in writing to reflect such
reduction.   17.0   LICENSE, CERTIFICATE, PERMIT REQUIREMENT   17.1   The
Contractor warrants that it is qualified to do business in the State and is not
prohibited by its articles of incorporation, bylaws or the law of the State
under which it is incorporated from performing the services under this Contract.
The Contractor shall have and maintain a Certificate of Authority pursuant to
O.C.G.A. §33-21, and shall obtain and maintain in good standing any
Georgia-licenses, certificates and permits, whether State or federal, that are
required prior to and during the performance of work under this Contract. Loss
of the licenses certificates and permits, and Certificate of Authority for
health maintenance organizations shall be cause for termination of the Contract
pursuant to Section 22 of this Contract. In the event the Certificate of
Authority, or any other license or permit is canceled, revoked, suspended or
expires during the term of this Contract, the Contractor shall inform the State
immediately and cease all activities under this Contract, until further
instruction from DCH. The Contractor agrees to provide DCH with certified copies
of all licenses, certificates and permits necessary upon request.

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17.2   The Contractor shall be accredited by the National Committee for Quality
Assurance (NCQA) for MCO, URAC (Health Plan accreditation), Accreditation
Association for Ambulatory Health Care (AAAHC) for MCO, or Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) for MCO, or shall be actively
seeking and working towards such accreditation. The Contractor shall provide to
DCH upon request any and all documents related to achieving such accreditation
and DCH shall monitor the Contractor’s progress towards accreditation. DCH may
require that the Contractor achieve such accreditation by year three of this
Contract.   18.0   RISK OR LOSS AND REPRESENTATIONS   18.1   DCH takes no title
to any of the Contractor’s goods used in providing the services and/or
Deliverables hereunder and the Contractor shall bear all risk of loss for any
goods used in performing work pursuant to this Contract.   18.2   The Parties
agree that DCH may reasonably rely upon the representations and certifications
made by the Contractor, including those made by the Contractor in the
Contractor’s response to the RFP and this Contract, without first making an
independent investigation or verification.   18.3   The Parties also agree that
DCH may reasonably rely upon any audit report, summary, analysis, certification,
review, or work product that the Contractor produces in accordance with its
duties under this Contract, without first making an independent investigation or
verification.   19.0   PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES   19.1
  The Contractor, in the performance of this Contract, shall not offer or give,
directly or indirectly, to any employee or agent of the State, any gift, money
or anything of value, or any promise, obligation, or contract for future reward
or compensation at any time during the term of this Contract, and shall comply
with the disclosure requirements set forth in O.C.G.A. § 45-1-6.   19.2   The
Contractor also states and warrants that it has complied with all disclosure and
registration requirements for vendor lobbyists as set forth in O.C.G.A. §
21-5-1, et. seq. and all other applicable law, including but not limited to
registering with the State Ethics Commission. In addition, the Contractor states
and warrants that no federal money has been used for any lobbying of State
officials, as required under applicable federal law. For the purposes of this
Contract, vendor lobbyists are those who lobby State officials on behalf of
businesses that seek a contract to sell goods or services to the State or oppose
such contract.   20.0   RECORDS REQUIREMENTS   20.1   GENERAL PROVISIONS

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20.1.1   The Contractor agrees to maintain books, records, documents, and other
evidence pertaining to the costs and expenses of this Contract to the extent and
in such detail as will properly reflect all costs for which payment is made
under the provisions of this Contract and/or any document that is a part of this
Contract by reference or inclusion. The Contractor’s accounting procedures and
practices shall conform to generally accepted accounting principles, and the
costs properly applicable to the Contract shall be readily ascertainable.   20.2
  RECORDS RETENTION REQUIREMENTS   20.2.1   The Contractor shall preserve and
make available all of its records pertaining to the performance under this
Contract for a period of seven (7) years from the date of final payment under
this Contract, and for such period, if any, as is required by applicable statute
or by any other section of this Contract. If the Contract is completely or
partially terminated, the records relating to the work terminated shall be
preserved and made available for period of seven (7) years from the date of
termination or of any resulting final settlement. Records that relate to
Appeals, litigation, or the settlements of Claims arising out of the performance
of this Contract, or costs and expenses of any such agreements as to which
exception has been taken by the State Contractor or any of his duly Authorized
Representatives, shall be retained by Contractor until such Appeals, litigation,
Claims or exceptions have been disposed of.   20.3   ACCESS TO RECORDS   20.3.1
  The State and federal standards for audits of DCH agents, contractors, and
programs are applicable to this section and are incorporated by reference into
this Contract as though fully set out herein.   20.3.2   Pursuant to the
requirements of 42 CFR 434.6(a) (5) and 42 CFR 434.38, the Contractor shall make
all of its books, documents, papers, Provider records, Medical Records,
financial records, data, surveys and computer databases available for
examination and audit by DCH, the State Attorney General, the State Health Care
Fraud Control Unit, the State Department of Audits, or authorized State or
federal personnel. Any records requested hereunder shall be produced immediately
for on-site review or sent to the requesting authority by mail within fourteen
(14) Calendar Days following a request. All records shall be provided at the
sole cost and expense of the Contractor. DCH shall have unlimited rights to use,
disclose, and duplicate all information and data in any way relating to this
Contract in accordance with applicable State and federal laws and regulations.  
20.4   MEDICAL RECORD REQUESTS   20.4.1   The Contractor shall ensure a copy of
the Member’s Medical Record is made available, without charge, upon the written
request of the Member or Authorized Representative within fourteen (14) Calendar
Days of the receipt of the written request.

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20.4.2   The Contractor shall ensure that Medical Records are furnished at no
cost to a new PCP, Out-of-Network Provider or other specialist, upon Member’s
request, no later than fourteen (14) Calendar Days following the written
request.   21.0   CONFIDENTIALITY REQUIREMENTS   21.1   GENERAL CONFIDENTIALITY
REQUIREMENTS   21.1.1   The Contractor shall treat all information, including
Medical Records and any other health and Enrollment information that identifies
a particular Member or that is obtained or viewed by it or through its staff and
Subcontractors performance under this Contract as confidential information,
consistent with the confidentiality requirements of 45 CFR parts 160 and 164.
The Contractor shall not use any information so obtained in any manner, except
as may be necessary for the proper discharge of its obligations. Employees or
authorized Subcontractors of the Contractor who have a reasonable need to know
such information for purposes of performing their duties under this Contract
shall use personal or patient information, provided such employees and/or
Subcontractors have first signed an appropriate non-disclosure agreement that
has been approved and maintained by DCH. The Contractor shall remove any person
from performance of services hereunder upon notice that DCH reasonably believes
that such person has failed to comply with the confidentiality obligations of
this Contract. The Contractor shall replace such removed personnel in accordance
with the staffing requirements of this Contract. DCH, the Georgia Attorney
General, federal officials as authorized by federal law or regulations, or the
Authorized Representatives of these parties shall have access to all
confidential information in accordance with the requirements of State and
federal laws and regulations.   21.2   HIPAA COMPLIANCE   21.2.1   The
Contractor shall assist DCH in its efforts to comply with the Health Insurance
Portability and Accountability Act of 1996 (“HIPAA”) and its amendments, rules,
procedures, and regulations. To that end, the Contractor shall cooperate and
abide by any requirements mandated by HIPAA or any other applicable laws. The
Contractor acknowledges that HIPAA may require the Contractor and DCH to sign a
business associate agreement or other documents for compliance purposes,
including but not limited to a business associate agreement. The Contractor
shall cooperate with DCH on these matters, sign whatever documents may be
required for HIPAA compliance, and bide by their terms and conditions.   22.0  
TERMINATION OF CONTRACT   22.1   GENERAL PROCEDURES

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22.1.1   This Contract may terminate, or may be terminated, by DCH for any or
all of the following reasons:

  22.1.1.1   Default by the Contractor, upon thirty (30) Calendar Days notice;  
  22.1.1.2   Convenience of DCH, upon thirty (30) Calendar Days notice;    
22.1.1.3   Immediately, in the event of insolvency, Contract breach, or
declaration of bankruptcy by the Contractor; or     22.1.1.4   Immediately, when
sufficient appropriated funds no longer exist for the payment of DCH’s
obligation under this Contract.

22.2   TERMINATION BY DEFAULT   22.2.1   In the event DCH determines that the
Contractor has defaulted by failing to carry out the substantive terms of this
Contract or failing to meet the applicable requirements in 1932 and 1903(m) of
the Social Security Act, DCH may terminate the Contract in addition to or in
lieu of any other remedies set out in this Contract or available by law.  
22.2.2   Prior to the termination of this Contract, DCH will:

  22.2.2.1   Provide written notice of the intent to terminate at least thirty
(30) Calendar Days prior to the termination date, the reason for the
termination, and the time and place of a hearing to give the Contractor an
opportunity to Appeal the determination and/or cure the default;     22.2.2.2  
Provide written notice of the decision affirming or reversing the proposed
termination of the Contract, and for an affirming decision, the effective date
of the termination; and     22.2.2.3   For an affirming decision, give Members
or the Contractor notice of the termination and information consistent with 42
CFR 438.10 on their options for receiving Medicaid services following the
effective date of termination.

22.3   TERMINATION FOR CONVENIENCE   22.3.1   DCH may terminate this Contract
for convenience and without cause upon thirty (30) Calendar Days written notice.
Termination for convenience shall not be a breach of the Contract by DCH. The
Contractor shall be entitled to receive, and shall be limited to, just and
equitable compensation for any satisfactory authorized work performed as of the
termination date Availability of funds shall be determined solely by DCH.   22.4
  TERMINATION FOR INSOLVENCY OR BANKRUPTCY

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22.4.1   The Contractor’s insolvency, or the Contractor’s filing of a petition
in bankruptcy, shall constitute grounds for termination for cause. In the event
of the filing of a petition in bankruptcy, the Contractor shall immediately
advise DCH. If DCH reasonably determines that the Contractor’s financial
condition is not sufficient to allow the Contractor to provide the services as
described herein in the manner required by DCH, DCH may terminate this Contract
in whole or in part, immediately or in stages. The Contractor’s financial
condition shall be presumed not sufficient to allow the Contractor to provide
the services described herein, in the manner required by DCH if the Contractor
cannot demonstrate to DCH’s satisfaction that the Contractor has risk reserves
and a minimum net worth sufficient to meet the statutory standards for licensed
health care plans. The Contractor shall cover continuation of services to
Members for the duration of period for which payment has been made, as well as
for inpatient admissions up to discharge.   22.5   TERMINATION FOR INSUFFICIENT
FUNDING   22.5.1   In the event that federal and/or State funds to finance this
Contract become unavailable, DCH may terminate the Contract in writing with
thirty (30) Calendar Days notice to the Contractor. The Contractor shall be
entitled to receive, and shall be limited to, just and equitable compensation
for any satisfactory authorized work performed as of the termination date.
Availability of funds shall be determined solely by DCH.   22.6   TERMINATION
PROCEDURES   22.6.1   DCH will issue a written notice of termination to the
Contractor by certified mail, return receipt requested, or in person with proof
of delivery. The notice of termination shall cite the provision of this Contract
giving the right to terminate, the circumstances giving rise to termination, and
the date on which such termination shall become effective. Termination shall be
effective at 11:59 p.m. EST on the termination date.   22.6.2   Upon receipt of
notice of termination or on the date specified in the notice of termination and
as directed by DCH, the Contractor shall:

  22.6.2.1   Stop work under the Contract on the date and to the extent
specified in the notice of termination;     22.6.2.2   Place no further orders
or Subcontract for materials, services, or facilities, except as may be
necessary for completion of such portion of the work under the Contract as is
not terminated     22.6.2.3   Terminate all orders and Subcontracts to the
extent that they relate to the performance of work terminated by the notice of
termination;

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  22.6.2.4   Assign to DCH, in the manner and to the extent directed by the
Contract Administrator, all of the right, title, and interest of Contractor
under the orders or subcontracts so terminated, in which case DCH will have the
right, at its discretion, to settle or pay any or all Claims arising out of the
termination of such orders and Subcontracts;     22.6.2.5   With the approval of
the Contract Administrator, settle all outstanding liabilities and all Claims
arising out of such termination or orders and subcontracts, the cost of which
would be reimbursable in whole or in part, in accordance with the provisions of
the Contract;     22.6.2.6   Complete the performance of such part of the work
as shall not have been terminated by the notice of termination;     22.6.2.7  
Take such action as may be necessary, or as the Contract Administrator may
direct, for the protection and preservation of any and all property or
information related to the Contract that is in the possession of Contractor and
in which DCH has or may acquire an interest;     22.6.2.8   Promptly make
available to DCH, or another CMO plan acting on behalf of DCH, any and all
records, whether medical or financial, related to the Contractor’s activities
undertaken pursuant to this Contractor. Such records shall be provided at no
expense to DCH;     22.6.2.9   Promptly supply all information necessary to DCH,
or another CMO plan acting on behalf of DCH, for reimbursement of any
outstanding Claims at the time of termination; and     22.6.2.10   Submit a
termination plan to DCH for review and approval that includes the following
terms:

  22.6.2.10.1   Maintain Claims processing functions as necessary for ten (10)
consecutive months in order to complete adjudication of all Claims;    
22.6.2.10.2   Comply with all duties and/or obligations incurred prior to the
actual termination date of the Contract, including but not limited to, the
Appeal process as described in Section 4.14;     22.6.2.10.3   File all Reports
concerning the Contractor’s operations during the term of the Contract in the
manner described in this Contract;     22.6.2.10.4   Ensure the efficient and
orderly transition of Members from coverage under this Contract to coverage
under any new arrangement developed by DCH in accordance with procedures set
forth in Section 4.11.4;

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  22.6.2.10.5   Maintain the financial requirements, and insurance set forth in
this Contract until DCH provides the Contractor written notice that all
continuing obligations of this Contract have been fulfilled; and     22.6.2.10.6
  Submit Reports to DCH every thirty (30) Calendar Days detailing the
Contractor’s progress in completing its continuing obligations under this
Contract until completion.

22.6.3   Upon completion of these continuing obligations, the Contractor shall
submit a final report to DCH describing how the Contractor has completed its
continuing obligations. DCH will advise, within twenty (20) Calendar Days of
receipt of this report, if all of the Contractor’s obligations are discharged.
If DCH finds that the final report does not evidence that the Contractor has
fulfilled its continuing obligations, then DCH will require the Contractor to
submit a revised final report to DCH for approval.   22.7   TERMINATION CLAIMS  
22.7.1   After receipt of a notice of termination, the Contractor shall submit
to the Contract Administrator any termination claim in the form, and with the
certification prescribed by, the Contract Administrator. Such claim shall be
submitted promptly but in no event later than ten (10) months from the effective
date of termination. Upon failure of the Contractor to submit its termination
claim within the time allowed, the Contract Administrator may, subject to any
review required by the State procedures in effect as of the date of execution of
the Contract, determine, on the basis of information available, the amount, if
any, due to the Contractor by reason of the termination and shall thereupon
cause to be paid to the Contractor the amount so determined.   22.7.2   Upon
receipt of notice of termination, the Contractor shall have no entitlement to
receive any amount for lost revenues or anticipated profits or for expenditures
associated with this Contract or any other contract. Upon termination, the
Contractor shall be paid in accordance with the following:

  22.7.2.1   At the Contract price(s) for completed Deliverables and/or services
delivered to and accepted by DCH; and/or     22.7.2.2   At a price mutually
agreed upon by the Contractor and DCH for partially completed Deliverables
and/or services.

22.7.3   In the event the Contractor and DCH fail to agree in whole or in part
as to the amounts with respect to costs to be paid to the Contractor in
connection with the total or partial termination of work pursuant to this
article, DCH will determine, on the basis of information available, the amount,
if any, due to the Contractor by reason of termination and shall pay to the
Contractor the amount so determined.

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23.0   LIQUIDATED DAMAGES   23.1   GENERAL PROVISIONS   23.1.1   In the event
the Contractor fails to meet the terms, conditions, or requirements of this
Contract and financial damages are difficult or impossible to ascertain exactly,
the Contractor agrees that DCH may assess liquidated damages, not penalties,
against the Contractor for the deficiencies. The Parties further acknowledge and
agree that the specified liquidated damages are reasonable and the result of a
good faith effort by the Parties to estimate the actual harm caused by the
Contractor’s breach. The Contractor’s failure to meet the requirements in this
Contract will be divided into four (4) categories of events.   23.1.2  
Notwithstanding any sanction or liquidated damages imposed upon the Contractor
other than Contract termination, the Contractor shall continue to provide all
Covered Services and care management.   23.2   CATEGORY 1   23.2.1   Liquidated
damages up to $100,000 per violation may be imposed for Category 1 events. For
Category 1 events, the Contractor shall submit a written corrective action plan
to DCH for review and approval prior to implementing the corrective action.
Category 1 events are monitored by DCH to determine compliance and shall include
and constitute the following:

  23.2.1.1   Acts that discriminate among Members on the basis of their health
status or need for health care services; and     23.2.1.2   Misrepresentation of
actions or falsification of information furnished to CMS or the State.    
23.2.1.3   Failure to implement requirements stated in the Contractor’s
proposal, the RFP, this Contract, or other material failures in the Contractor’s
duties.     23.2.1.4   Failure to participate in a readiness and/or annual
review.     23.2.1.5   Failure to provide an adequate provider network of
physicians, pharmacies, hospitals, and other specified health care Providers in
order to assure member access to all Covered Services.

23.3   CATEGORY 2   23.3.1   Liquidated damages up to $25,000 per violation may
be imposed for the Category 2 events. For Category 2 events, the Contractor
shall submit a written corrective action plan to DCH for review and approval
prior to implementing the corrective action.

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    Category 2 events are monitored by DCH to determine compliance and include
the following:

  23.3.1.1   Substantial failure to provide medically necessary services that
the Contractor is required to provide under law, or under this Contract, to a
Member covered under this Contract;     23.3.1.2   Misrepresentation or
falsification of information furnished to a Member, Potential Member, or health
care Provider;     23.3.1.3   Failure to comply with the requirements for
physician incentive plans, as set forth in 42 CFR 422.208 and 422.210;    
23.3.1.4   Distribution directly, or indirectly, through any Agent or
independent contractor, marketing materials that have not been approved by the
State or that contain false or materially misleading information;     23.3.1.5  
Violation of any other applicable requirements of section 1903(m) or 1932 of the
Social Security Act and any implementing regulations;     23.3.1.6   Failure of
the Contractor to assume full operation of its duties under this Contract in
accordance with the transition timeframes specified herein;     23.3.1.7  
Imposition of premiums or charges on Members that are in excess of the premiums
or charges permitted under the Medicaid program (the State will deduct the
amount of the overcharge and return it to the affected Member).     23.3.1.8  
Failure to resolve Member Appeals and Grievances within the timeframes specified
in this Contract;     23.3.1.9   Failure to ensure client confidentiality in
accordance with 45 CFR 160 and 45 CFR 164; and an incident of noncompliance will
be assessed as per member and/or per HIPAA regulatory violation.     23.3.1.10  
Violation of a subcontracting requirement in the Contract.     23.3.1.11  
Failure to enhance provider rates in accordance with the legislative mandates of
Georgia House Bill 990.

23.4   CATEGORY 3   23.4.1   Liquidated damages up to $5,000.00 per day may be
imposed for Category 3 events. For Category 3 events, a written corrective
action plan may be required and corrective action must be taken. In the case of
Category 3 events, if corrective action is taken within four (4) Business Days,
then liquidated damages may be waived at the

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    discretion of DCH. Category 3 events are monitored by DCH to determine
compliance and shall include the following:

  23.4.1.1   Failure to submit required Reports and Deliverables in the
timeframes prescribed in Section 4.18 and Section 5.7;     23.4.1.2   Submission
of incorrect or deficient Deliverables or Reports as determined by DCH;    
23.4.1.3   Failure to comply with the Claims processing standards as follows:

  23.4.1.3.1   Failure to process and finalize to a paid or denied status
ninety-seven percent (97%) of all Clean Claims within fifteen (15) Business Days
during a fiscal year;     23.4.1.3.2   Failure to pay Providers interest at an
eighteen percent (18%) annual rate, calculated daily for the full period during
which a clean, unduplicated Claim is not adjudicated within the claims
processing deadlines. For all claims that are initially denied or underpaid by a
Contractor but eventually determined or agreed to have been owed by the
Contractor to a provider of health care services, the Contractor shall pay, in
addition to the amount determined to be owed, interest of 20 percent per annum,
calculated from 15 days after the date the claim was submitted. A Contractor
shall pay all interest required to be paid under this provision or Code
Section 33-24-59.5 automatically and simultaneously whenever payment is made for
the claim giving rise to the interest payment. All interest payments shall be
accurately identified on the associated remittance advice submitted by the
Contractor to the provider. A Contractor shall not be responsible for the
penalty described in this subsection if the health care provider submits a claim
containing a material omission or inaccuracy in any of the data elements
required for a complete standard health care claim form as prescribed under 45
C.F.R. Part 162 for electronic claims, a CMS Form 1500 for nonelectronic claims,
or any claim prescribed by the Department of Community Health.     23.4.1.3.3  
 

  23.4.1.4   Failure to comply with the EPSDT initial health visit and screening
requirements for Health Check eligibles within sixty (60) Calendar Days as
described in Section 4.7.     23.4.1.5   Failure to comply with the EPSDT
periodicity schedule for eighty percent (80%) of Health Check eligibles as
described Section 4.7.

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  23.4.1.6   Failure to provide an initial visit within fourteen (14) Calendar
Days for all newly enrolled women who are pregnant in accordance with
Sections 4.6.9.1 and 4.8.13.4.     23.4.1.7   Failure to comply with the Notice
of Proposed Action and Notice of Adverse Action requirements as described in
Sections 4.14.3 and 4.14.5.     23.4.1.8   Failure to comply with any corrective
action plans as required by DCH.     23.4.1.9   Failure to seek, collect and/or
report third party information as described in Section 8.4.     23.4.1.10  
Failure to comply with the Contractor staffing requirements as described in
Section 14.3.     23.4.1.11   Failure of Contractor to issue written notice to
Members upon Provider’s notice of termination in the Contractor’s plan as
described in Sections 4.8.17.3 and 4.8.17.4.     23.4.1.12   Failure to comply
with federal law regarding sterilizations, hysterectomies, and abortions and as
described in Section 4.6.5.     23.4.1.13   Failure to submit acceptable member
and provider directed materials or documents in a timely manner, i.e., member
and provider directories, handbooks, policies and procedures.

23.5   CATEGORY 4   23.5.1   Liquidated damages as specified below may be
imposed for Category 4 events. Imposition of liquidated damages will not relieve
the Contractor from submitting and implementing corrective action plans or
corrective action as determined by DCH. Category 4 events are monitored by DCH
to determine compliance and include the following:

  23.5.1.1   Failure to implement the business continuity-disaster recovery
(BC-DR) plan as follows:

  23.5.1.1.1   Implementation of the (BC-DR) plan exceeds the proposed time by
two (2) or less Calendar Days: five thousand dollars ($5,000) per day up to day
2;     23.5.1.1.2   Implementation of the (BC-DR) plan exceeds the proposed time
by more than (2) and up to five (5) Calendar Days: ten thousand dollars
($10,000) per each day beginning with Day 3 and up to Day 5;

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  23.5.1.1.3   Implementation of the (BC-DR) plan exceeds the proposed time by
more than five (5) and up to ten (10) Calendar Days, twenty-five thousand
dollars ($25,000) per day beginning with Day 6 and up to Day 10; and    
23.5.1.1.4   Implementation of the (BC-DR) plan exceeds the proposed time by
more than ten (10) Calendar Days: fifty thousand dollars ($50,000) per each day
beginning with Day 11.

  23.5.1.2   Unscheduled System Unavailability (other than CCE and ECM functions
described below) occurring during a continuous five (5) Business Day period, may
be assessed as follows:

  23.5.1.2.1   Greater than or equal to two (2) and less than twelve (12) hours
cumulative: up to one hundred twenty-five dollars ($125) for each thirty (30)
minutes or portions thereof;     23.5.1.2.2   Greater than or equal to twelve
(12) and less than twenty-four (24) hours cumulative: up to two hundred fifty
dollars ($250) for each thirty (30) minutes or portions thereof; and    
23.5.1.2.3   Greater than or equal to twenty-four (24) hours cumulative: up to
five hundred dollars ($500) for each thirty (30) minutes or portions thereof up
to a maximum of twenty-five thousand dollars ($25,000) per occurrence.

  23.5.1.3   Confirmation of CMO Enrollment (CCE) or Electronic Claims
Management (ECM) system downtime. In any calendar week, penalties may be
assessed as follows for downtime outside the State’s control of any component of
the CCE and ECM systems, such as the voice response system and PC software
response system:

  23.5.1.3.1   Less than twelve (12) hours cumulative: up to two hundred fifty
dollars ($250) for each thirty (30) minutes or portions thereof;     23.5.1.3.2
  Greater than or equal to twelve (12) and less than twenty-four (24) hours
cumulative: up to five hundred ($500) for each thirty (30) minutes or portions
thereof; and     23.5.1.3.3   Greater than or equal to twenty-four (24) hours
cumulative: up to one thousand dollars ($1,000) for each thirty (30) minutes or
portions thereof up to a maximum of fifty thousand dollars ($50,000) per
occurrence.

  23.5.1.4   Failure to make available to the state and/or its agent readable,
valid extracts of Encounter Information for a specific month within fifteen
(15) Calendar

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      Days of the close of the month: five hundred dollars ($500) per day. After
fifteen (15) Calendar Days of the close of the month: two thousand dollars
($2000) per day.

  23.5.1.5   Failure to correct a system problem not resulting in System
Unavailability within the allowed timeframe, where failure to complete was not
due to the action or inaction on the part of DCH as documented in writing by the
Contractor:

  23.5.1.5.1   One (1) to fifteen (15) Calendar Days late: two hundred and fifty
dollars ($250) per Calendar Day for Days 1 through 15;     23.5.1.5.2   Sixteen
(16) to thirty (30) Calendar Days late: five hundred dollars ($500) per Calendar
Day for Days 16 through 30; and     23.5.1.5.3   More than thirty (30) Calendar
Days late: one thousand dollars ($1,000) per Calendar Day for Days 31 and
beyond.

  23.5.1.6   Failure to meet the Telephone Hotline performance standards:

  23.5.1.6.1   $1,000.00 for each percentage point that is below the target
answer rate of eighty percent (80%) in thirty (30) seconds;     23.5.1.6.2  
$1,000.00 for each percentage point that is above the target of a one percent
(1%) Blocked Call rate; and     23.5.1.6.3   $1,000.00 for each percentage point
that is above the target of a five percent (5%) Abandoned Call rate.

23.6   OTHER REMEDIES   23.6.1   In addition other liquidated damages described
above for Category 1-4 events, DCH may impose the following other remedies:

  23.6.1.1   Appointment of temporary management of the Contractor as provided
in 42 CFR 438.706, if DCH finds that the Contractor has repeatedly failed to
meet substantive requirements in section 1903 (m) or section 1932 of the Social
Security Act;     23.6.1.2   Granting Members the right to terminate Enrollment
without cause and notifying the affected Members of their right to disenroll;  
  23.6.1.3   Suspension of all new Enrollment, including default Enrollment,
after the effective date of remedies;

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  23.6.1.4   Suspension of payment to the Contractor for Members enrolled after
the effective date of the remedies and until CMS or DCH is satisfied that the
reason for imposition of the remedies no longer exists and is not likely to
occur;     23.6.1.5   Termination of the Contract if the Contractor fails to
carry out the substantive terms of the Contract or fails to meet the applicable
requirements in 1932 and 1903(m) of the Social Security Act;     23.6.1.6  
Civil Monetary Fines in accordance with 42 CFR 438.704; and     23.6.1.7  
Additional remedies allowed under State statute or State regulation that address
areas of non-compliance specified in 42 CFR 438.700.

23.7   NOTICE OF REMEDIES   23.7.1   Prior to the imposition of either
liquidated damages or other remedies, DCH will issue a written notice of
remedies that will include the following:

  23.7.1.1   A citation to the law, regulation or Contract provision that has
been violated;     23.7.1.2   The remedies to be applied and the date the
remedies will be imposed;     23.7.1.3   The basis for DCH’s determination that
the remedies should be imposed;     23.7.1.4   Request for a corrective action
plan, if applicable; and     23.7.1.5   The time frame and procedure for the
Contractor to dispute DCH’s determination. A Contractor’s dispute of a
liquidated damage or remedies shall not stay the effective date of the proposed
liquidated damage or remedies.

24.0   INDEMNIFICATION   24.1   The Contractor hereby releases and agrees to
indemnify and hold harmless DCH, the State of Georgia and its departments,
agencies and instrumentalities (including the State Tort Claims Trust Fund, the
State Authority Liability Trust Fund, The State Employee Broad Form Liability
Funds, the State Insurance and Hazard Reserve Fund, and other self-insured
funds, all such funds hereinafter collectively referred to as the “Funds”) from
and against any and all claims, demands, liabilities, losses, costs or expenses,
and attorneys’ fees, caused by, growing out of, or arising from this Contract,
due to any act or omission on the part of the Contractor, its agents, employees,
customers, invitees, licensees or others working at the direction of the
Contractor or on its behalf, or due to any breach of this Contract by the
Contractor, or due to the application or violation of any pertinent federal,
State or local law, rule or regulation. This indemnification extends to the
successors and assigns of the

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    Contractor, and this indemnification survives the termination of the
Contract and the dissolution or, to the extent allowed by the law, the
bankruptcy of the Contractor.   25.0   INSURANCE   25.1   INSURANCE OF
CONTRACTOR   25.1.1   The Contractor shall, at a minimum, prior to the
commencement of work, procure the insurance policies identified below at the
Contractor’s own cost and expense and shall furnish DCH with proof of coverage
at least in the amounts indicated. It shall be the responsibility of the
Contractor to require any Subcontractor to secure the same insurance coverage as
prescribed herein for the Contractor, and to obtain a certificate evidencing
that such insurance is in effect. In the event that any such insurance is
proposed to be reduced, terminated or cancelled for any reason, the Contractor
shall Provider to DCH at least thirty (30) Calendar Days written notice. Prior
to the reduction, expiration and/or cancellation of any insurance policy
required hereunder, the Contractor shall secure replacement coverage upon the
same terms and provisions to ensure no lapse in coverage, and shall furnish, at
the request of DCH, a certificate of insurance indicating the required
coverage’s. The Contractor shall maintain insurance coverage sufficient to
insure against claims arising at any time during the term of the Contract. The
provisions of this Section shall survive the expiration or termination of this
Contract for any reason. In addition, the Contractor shall indemnify and hold
harmless DCH and the State from any liability arising out of the Contractor’s or
its Subcontractor’s untimely failure in securing adequate insurance coverage as
prescribed herein:

  25.1.1.1   Workers’ Compensation Insurance, the policy (ies) to insure the
statutory limits established by the General Assembly of the State of Georgia.
The Workers’ Compensation Policy must include Coverage B – Employer’s Liability
Limits of:

  25.1.1.1   Bodily injury by accident: five hundred thousand dollars ($500,000)
each accident;     25.1.1.2   Bodily Injury by Disease: five hundred thousand
dollars ($ 500,000) each employee; and     25.1.1.3   One million dollars ($
1,000,000) policy limits.

  25.1.1.2   The Contractor shall require all Subcontractors performing work
under this Contract to obtain an insurance certificate showing proof of Worker’s
Compensation Coverage.     25.1.1.3   The Contractor shall have commercial
general liability policy (ies) as follows:

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  25.1.1.3.1   Combined single limits of one million dollars ($1,000,000) per
person and three million dollars ($3,000,000) per occurrence;     25.1.1.3.2  
On an “occurrence” basis; and     25.1.1.3.3   Liability for property damage in
the amount of three million dollars ($3,000,000) including contents coverage for
all records maintained pursuant to this Contract.

26.0   PAYMENT BOND & IRREVOCABLE LETTER OF CREDIT

     
Section 26.1
  Within five (5) Business Days of Contract Execution, Contractor shall obtain
and maintain in force and effect an irrevocable letter of credit in the amount
representing one half of one month’s Net Capitation Payment associated with the
actual GCS lives in the Atlanta and Central Service Regions enrolled in
Contractor’s plan. On or before July 2 each following year, Contractor shall
modify the amount of the irrevocable letter of credit currently in force and
effect to equal one-half of the average of the Net Capitation Payments paid to
the Contractor for the months of January, February and March. If at any time
during the year, the actual GCS lives enrolled in Contractor’s plan increases or
decreases by more than twenty-five percent, DCH, at it sole discretion, may
increase or decrease the amount required for the irrevocable letter of credit.
 
   
 
  DCH may, at its discretion, redeem Contractor’s irrevocable letter of credit
in the amount(s) of actual damages suffered by DCH if DCH determines that the
Contractor is (1) unable to perform any of the terms and conditions of the
Contract or if (2) the Contractor is terminated by default or bankruptcy or
material breach that is not cured within the time specified by DCH, or under
both conditions described at one (1) and two (2).
 
   
 
  With regard to the irrevocable letter of credit, DCH may recoup payments from
the Contractor for liabilities or obligations arising from any act, event,
omission or condition which occurred or existed subsequent to the effective date
of the Contract and which is identified in a survey, review, or audit conducted
or assigned by DCH.
 
   
Section 26.2
  DCH may also, at its discretion, redeem Contractor’s irrevocable letter of
credit in the amount(s) of actual damages suffered by DCH if DCH determines that
the Contractor is (1) unable to perform any of the terms and conditions of the
Contract or if (2) the Contractor is terminated by default or bankruptcy or
material breach that is not

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  cured within the time specified by DCH, or under both conditions described at
one (1) and two (2).
 
   
Section 26.3
  During the Contract period, Contractor shall obtain and maintain a payment
bond from an entity licensed to do business in the State of Georgia and
acceptable to DCH with sufficient financial strength and creditworthiness to
assume the payment obligations of Contractor in the event of a default in
payment arising from bankruptcy, insolvency, or other cause. Said bond shall be
delivered to DCH within five (5) Business Days of Contract Execution and shall
be in the amount of Five Million Dollars ($5,000,000.00). On or before July 2,
of each following year, Contractor shall modify the amount of the bond to equal
the average of the Net Capitation Payments paid to the Contractor for the months
of January, February and March.
 
   
 
  If at any time during the year, the actual GCS lives enrolled in Contractor’s
plan increases or decreases by more than twenty-five percent, DCH, at it sole
discretion, may increase or decrease the amount required for the bond.

27.0 COMPLIANCE WITH ALL LAWS
27.1 NON-DISCRIMINATION

27.1.1   The Contractor agrees to comply with applicable federal and State laws,
rules and regulations, and the State’s policy relative to nondiscrimination in
employment practices because of political affiliation, religion, race, color,
sex, physical handicap, age, or national origin including, but not limited to,
Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education
Amendments of 1972 as amended; the Age Discrimination Act of 1975, as amended;
Equal Employment Opportunity (45 CFR 74 Appendix A (1), Executive Order 11246
and 11375) and the Americans with Disability Act of 1993 (including but not
limited to 28 C.F.R. § 35.100 et seq.). Nondiscrimination in employment
practices is applicable to employees for employment, promotions, dismissal and
other elements affecting employment.

27.2   DELIVERY OF SERVICE AND OTHER FEDERAL LAWS   27.2.1   The Contractor
agrees that all work done as part of this Contract will comply fully with
applicable administrative and other requirements established by applicable
federal and State laws and regulations and guidelines, including but not limited
to section 1902(a)(7) of the Social Security Act and DCH Medicaid and PeachCare
for Kids Policies and Procedures manuals, and assumes responsibility for full
compliance with all such applicable laws, regulations, and guidelines, and
agrees to fully reimburse DCH for any loss of funds or resources or overpayment
resulting from non-compliance by Contractor, its staff, agents or
Subcontractors, as revealed in

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    subsequent audits. The provisions of the Fair Labor Standards Act of 1938
(29 U.S.C. § 201 et seq.) and the rules and regulations as promulgated by the
United States Department of Labor in Title XXIX of the Code of Federal
Regulations are applicable to this Contract. Contractor shall agree to conform
with such federal laws as affect the delivery of services under this Contract
including but not limited to the Titles VI, VII, XIX, XXI of the Social Security
Act, the Federal Rehabilitation Act of 1973, the Davis Bacon Act (40 U.S.C. §
276a et seq.), the Copeland Anti-Kickback Act (40 U.S.C. § 276c), the Clean Air
Act (42 U.S.C. 7401 et seq.) and the Federal Water Pollution Control Act as
Amended (33 U.S.C. 1251 et seq.); the Byrd Anti-Lobbying Amendment (31 U.S.C.
1352); and Debarment and Suspension (45 CFR 74 Appendix A (8) and Executive
Order 12549 and 12689); the Contractor shall agree to conform to such
requirements or regulations as the United States Department of Health and Human
Services may issue from time to time. Authority to implement federal
requirements or regulations will be given to the Contractor by DCH in the form
of a Contract amendment.   27.2.2   The Contractor shall include notice of
grantor agency requirements and regulations pertaining to reporting and patient
rights under any contracts involving research, developmental, experimental or
demonstration work with respect to any discovery or invention which arises or is
developed in the course of or under such contract, and of grantor agency
requirements and regulations pertaining to copyrights and rights in data.  
27.2.3   The Contractor shall recognize mandatory standards and policies
relating to energy efficiency, which are contained in the State energy
conservation plan issues in compliance with the Energy Policy and Conservation
Act (Pub. L. 94-165).   27.3   COST OF COMPLIANCE WITH APPLICABLE LAWS   27.3.1
  The Contractor agrees that it will bear any and all costs (including but not
limited to attorneys’ fees, accounting fees, research costs, or consultant
costs) related to, arising from, or caused by compliance with any and all laws,
such as but not limited to federal and State statutes, case law, precedent,
regulations, policies, and procedures. In the event of a disagreement on this
matter, DCH’s determination on this matter shall be conclusive and not subject
to Appeal.   27.4   GENERAL COMPLIANCE   27.4.1   Additionally, the Contractor
agrees to comply and abide by all laws, rules, regulations, statutes, policies,
or procedures that may govern the Contract, the Deliverables in the Contract, or
either party’s responsibilities. To the extent that applicable laws, rules,
regulations, statutes, policies, or procedures require the Contractor to take
action or inaction, any costs, expenses, or fees associated with that action or
inaction shall be borne and paid by the Contractor solely.

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28.0   CONFLICT RESOLUTION   28.1   Any dispute concerning a question of fact or
obligation related to or arising from this Contract that is not disposed of by
mutual agreement shall be decided by the Contract Administrator who shall reduce
his or her decision to writing and mail or otherwise furnish a copy to the
Contractor. The written decision of the Contract Administrator shall be final
and conclusive, unless the Contractor mails or otherwise furnishes a written
Appeal to the Commissioner of DCH within ten (10) Calendar Days from the date of
receipt of such decision. The decision of the Commissioner or a duly Authorized
Representative for the determination of such Appeal shall be final and
conclusive. In connection with any Appeal proceeding under this provision, the
Contractor shall be afforded an opportunity to be heard and to offer evidence in
support of its Appeal. Pending a final decision of a dispute hereunder, the
Contractor shall proceed diligently with the performance of the Contract.   29.0
  CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE   29.1   No official or
employee of the State of Georgia or the federal government who exercises any
functions or responsibilities in the review or approval of the undertaking or
carrying out of the GF program shall, prior to the completion of the project,
voluntarily acquire any personal interest, direct or indirect, in this Contract
or the proposed Contract.   29.2   The Contractor covenants that it presently
has no interest and shall not acquire any interest, direct or indirect, that
would conflict in any material manner or degree with, or have a material adverse
effect on the performance of its services hereunder. The Contractor further
covenants that in the performance of the Contract no person having any such
interest shall be employed.   29.3   All of the parties hereby certify that the
provisions of O.C.G.A. §45-10-20 through §45-10-28, which prohibit and regulate
certain transactions between State officials and employees and the State of
Georgia, have not been violated and will not be violated in any respect
throughout the term.   29.4   In addition, it shall be the responsibility of the
Contractor to maintain independence and to establish necessary policies and
procedures to assist the Contractor in determining if the actual Contractors
performing work under this Contract have any impairments to their independence.
To that end, the Contractor shall submit a written plan to DCH within five (5)
Business Days of Contract Award in which it outlines its Impartiality and
Independence Policies and Procedures relating to how it monitors and enforces
Contractor and Subcontractor impartiality and independence. The Contractor
further agrees to take all necessary actions to eliminate threats to
impartiality and independence, including but not limited to reassigning,
removing, or terminating Contractors or Subcontractors.

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30.0   NOTICE   30.1   All notices under this Contract shall be deemed duly
given upon delivery, if delivered by hand, or three (3) Calendar Days after
posting, if sent by registered or certified mail, return receipt requested, to a
party hereto at the addresses set forth below or to such other address as a
party may designate by notice pursuant hereto.

For DCH:
Contract Administration:
CMO Name and Address
(404) XXX-XXXX – Phone
(404) XXX-XXXX – Fax
E-mail address: XXXX
Project Leader:
Name
Georgia Department of Community Health
2 Peachtree Street, NW – 36th Floor
Atlanta, GA 30303-3159
(404) XXX-XXXX – Phone
(404) XXX-XXXX – Fax
E-mail address: XXXX

30.2   It shall be the responsibility of the Contractor to inform the Contract
Administrator of any change in address in writing no later than five
(5) Business Days after the change.   31.0   MISCELLANEOUS   31.1   CHOICE OF
LAW OR VENUE   31.1.1   This Contract shall be governed in all respects by the
laws of the State of Georgia. Any lawsuit or other action brought against DCH,
the State based upon, or arising from this Contract shall be brought in a court
or other forum of competent jurisdiction in Fulton County in the State of
Georgia.   31.2   ATTORNEY’S FEES   31.2.1   In the event that either party
deems it necessary to take legal action to enforce any provision of this
Contract, and in the event DCH prevails, the Contractor agrees to

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    pay all expenses of such action including reasonable attorney’s fees and
costs at all stages of litigation as awarded by the court, a lawful tribunal,
hearing officer or administrative law judge. If the Contractor prevails in any
such action, the court or hearing officer, at its discretion, may award costs
and reasonable attorney’s fees to the Contractor. The term legal action shall be
deemed to include administrative proceedings of all kinds, as well as all
actions at law or equity.   31.3   SURVIVABILITY   31.3.1   The terms,
provisions, representations and warranties contained in this Contract shall
survive the delivery or provision of all services or Deliverables hereunder.  
31.4   DRUG-FREE WORKPLACE   31.4.1   The Contractor shall certify to DCH that a
drug-free workplace shall be provided for the Contractor’s employees during the
performance of this Contract as required by the “Drug-Free Workplace Act”,
O.C.G.A. § 50-24-1, et seq. and applicable federal law. The Contractor will
secure from any Subcontractor hired to work in a drug-free workplace such
similar certification. Any false certification by the Contractor or violation of
such certification, or failure to carry out the requirements set forth in the
code, may result in the Contractor being suspended, terminated or debarred from
the performance of this Contract.   31.5   CERTIFICATION REGARDING DEBARMENT,
SUSPENSION, PROPOSED DEBARMENT AND OTHER MATTERS   31.5.1   The Contractor
certifies that it is not presently debarred, suspended, proposed for debarment
or declared ineligible for award of contracts by any federal or State agency.  
31.6   WAIVER   31.6.1   The waiver by DCH of any breach of any provision
contained in this Contract shall not be deemed to be a waiver of such provision
on any subsequent breach of the same or any other provision contained in this
Contract and shall not establish a course of performance between the parties
contradictory to the terms hereof.   31.7   FORCE MAJEURE   31.7.1   Neither
party to this Contract shall be responsible for delays or failures in
performance resulting from acts beyond the control of such party. Such acts
shall include, but not be limited to, acts of God, strikes, riots, lockouts,
acts of war, epidemics, fire, earthquakes, or other disasters.   31.8   BINDING

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31.8.1   This Contract and all of its terms, conditions, requirements, and
amendments shall be binding on DCH, the Contractor, and their respective
successors and permitted assigns.   31.9   TIME IS OF THE ESSENCE   31.9.1  
Time is of the essence in this Contract. Any reference to “Days” shall be deemed
Calendar Days unless otherwise specifically stated.   31.10   AUTHORITY  
31.10.1   DCH has full power and authority to enter into this Contract, and the
person acting on behalf of and signing for the Contractor has full authority to
enter into this Contract, and the person signing on behalf of the Contractor has
been properly authorized and empowered to enter into this Contract on behalf of
the Contractor and to bind the Contractor to the terms of this Contract. Each
party further acknowledges that it has had the opportunity to consult with
and/or retain legal counsel of its choice, read this Contract, understands this
Contract, and agrees to be bound by it.   31.11   ETHICS IN PUBLIC CONTRACTING  
31.11.1   The Contractor understands, states, and certifies that it made its
proposal to the RFP without collusion or fraud and that it did not offer or
receive any kickbacks or other inducements from any other Contractor, supplier,
manufacturer, or Subcontractor in connection with its proposal to the RFP.  
31.12   CONTRACT LANGUAGE INTERPRETATION   31.12.1   The Contractor and DCH
agree that in the event of a disagreement regarding, arising out of, or related
to, Contract language interpretation, DCH’s interpretation of the Contract
language in dispute shall control and govern. DCH’s interpretation of the
Contract language in dispute shall not be subject to Appeal under any
circumstance.   31.13   ASSESSMENT OF FEES   31.13.1   The Contractor and DCH
agree that DCH may elect to deduct any assessed fees from payments due or owing
to the Contractor or direct the Contractor to make payment directly to DCH for
any and all assessed fees. The choice is solely and strictly DCH’s choice.  
31.14   COOPERATION WITH OTHER CONTRACTORS   31.14.1   In the event that DCH has
entered into, or enters into, agreements with other contractors for additional
work related to the services rendered hereunder, the Contractor agrees to
cooperate fully with such other contractors. The Contractor shall

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    not commit any act that will interfere with the performance of work by any
other contractor.   31.14.2   Additionally, if DCH eventually awards this
Contract to another contractor, the Contractor agrees that it will not engage in
any behavior or inaction that prevents or hinders the work related to the
services contracted for in this Contract. In fact, the Contractor agrees to
submit a written turnover plan and/or transition plan to DCH within thirty
(30) Days of receiving the Department’s intent to terminate letter. The Parties
agree that the Contractor has not successfully met this obligation until the
Department accepts its turnover plan and/or transition plan.   31.14.3   The
Contractor’s failure to cooperate and comply with this provision, shall be
sufficient grounds for DCH to halt all payments due or owing to the Contractor
until it becomes compliant with this or any other contract provision. DCH’s
determination on the matter shall be conclusive and not subject to Appeal.  
31.15   SECTION TITLES NOT CONTROLLING   31.15.1   The Section titles used in
this Contract are for reference purposes only and shall not be deemed a part of
this Contract.   31.16   LIMITATION OF LIABILITY/EXCEPTIONS   31.16.1   Nothing
in this Contract shall limit the Contractor’s indemnification liability or civil
liability arising from, based on, or related to claims brought by DCH or any
third party or any claims brought against DCH or the State by a third party or
the Contractor.   31.17   COOPERATION WITH AUDITS   31.17.1   The Contractor
agrees to assist and cooperate with the Department in any and all matters and
activities related to or arising out of any audit or review, whether federal,
private, or internal in nature, at no cost to the Department.   31.17.2   The
parties also agree that the Contractor shall be solely responsible for any costs
it incurs for any audit related inquiries or matters. Moreover, the Contractor
may not charge or collect any fees or compensation from DCH for any matter,
activity, or inquiry related to, arising out of, or based on an audit or review.
  31.18   HOMELAND SECURITY CONSIDERATIONS   31.18.1   The Contractor shall
perform the services to be provided under this Contract entirely within the
boundaries of the United States. In addition, the Contractor will not hire any
individual to perform any services under this Contract if that individual is
required to have a work visa approved by the U.S. Department of Homeland
Security and such individual has not met this requirement.

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31.18.2   If the Contractor performs services, or uses services, in violation of
the foregoing paragraph, the Contractor shall be in material breach of this
Contract and shall be liable to the Department for any costs, fees, damages,
claims, or expenses it may incur. Additionally, the Contractor shall be required
to hold harmless and indemnify DCH pursuant to the indemnification provisions of
this Contract.   31.18.3   The prohibitions in this Section shall also apply to
any and all agents and Subcontractors used by the Contractor to perform any
services under this Contract.   31.19   PROHIBITED AFFILIATIONS WITH INDIVIDUALS
DEBARRED AND SUSPENDED   31.19.1   The Contractor shall not knowingly have a
relationship with an individual, or an affiliate of an individual, who is
debarred, suspended, or otherwise excluded from participating in procurement
activities under the Federal Acquisition Regulation or from participating in
non-procurement activities under regulations issued under Executive Order
No. 12549 or under guidelines implementing Executive Order No. 12549. For the
purposes of this Section, a “relationship” is described as follows:

  31.19.1.1   A director, officer or partner of the Contractor;     31.19.1.2  
A person with beneficial ownership of five percent (5%) or more of the
Contractor entity; and     31.19.1.3   A person with an employment, consulting
or other arrangement with the Contractor’s obligations under its Contract with
the State.

31.20   OWNERSHIP AND FINANCIAL DISCLOSURE   31.20.1   The Contractor shall
disclose financial statements for each person or corporation with an ownership
or control interest of five percent (5%) or more in the Contractor’s entity for
the prior twelve (12) month period. For the purposes of this Section, a person
or corporation with an ownership or control interest shall mean a person or
corporation:

  31.20.1.1   That owns directly or indirectly five percent (5%) or more of the
Contractor’s capital or stock or received five percent (5%) or more of its
profits;     31.20.1.2   That has an interest in any mortgage, deed of trust,
note, or other obligation secured in whole or in part by the Contractor or by
its property or assets, and that interest is equal to or exceeds five percent
(5%) of the total property and assets of the Contractor; and

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  31.20.1.3   That is an officer or director of the Contractor (if it is
organized as a corporation) or is a partner in the Contractor’s organization (if
it is organized as a partnership).

32.0   AMENDMENT IN WRITING   32.1   No amendment, waiver, termination or
discharge of this Contract, or any of the terms or provisions hereof, shall be
binding upon either party unless confirmed in writing. None of the Solicitation
Documents may be modified or amended, except by writing executed by both
parties. Additionally, CMS approval may be required before any such amendment is
effective. DCH will determine, in its sole discretion, when such CMS approval is
required. Any agreement of the parties to amend, modify, eliminate or otherwise
change any part of this Contract shall not affect any other part of this
Contract, and the remainder of this Contract shall continue to be of full force
and effect as set out herein.   33.0   CONTRACT ASSIGNMENT   33.1   Contractor
shall not assign this Contract, in whole or in part, without the prior written
consent of DCH, and any attempted assignment not in accordance herewith shall be
null and void and of no force or effect.   34.0   SEVERABILITY   34.1   Any
section, subsection, paragraph, term, condition, provision, or other part of
this Contract that is judged, held, found or declared to be voidable, void,
invalid, illegal or otherwise not fully enforceable shall not affect any other
part of this Contract, and the remainder of this Contract shall continue to be
of full force and effect as set out herein.   35.0   COMPLIANCE WITH AUDITING
AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS (O.C.G.A. § 50-20-1 ET
SEQ.)   35.1   The Contractor agrees to comply at all times with the provisions
of the Federal Single Audit Act (hereinafter called the Act) as amended from
time to time, all applicable implementing regulations, including but not limited
to any disclosure requirements imposed upon non-profit organizations by the
Georgia Department of Audits as a result of the Act, and to make complete
restitution to DCH of any payments found to be improper under the provisions of
the Act by the Georgia Department of Audits, the Georgia Attorney General’s
Office or any of their respective employees, agents, or assigns.

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36.0   ENTIRE AGREEMENT   36.1   This Contract constitutes the entire agreement
between the parties with respect to the subject matter hereof and supersedes all
prior negotiations, representations or contracts. No written or oral agreements,
representatives, statements, negotiations, understandings, or discussions that
are not set out, referenced, or specifically incorporated in this Contract shall
in any way be binding or of effect between the parties.

(Signatures on following page)
SIGNATURE PAGE
     IN WITNESS WHEREOF, the parties state and affirm that, they are duly
authorized to bind the respected entities designated below as of the day and
year indicated.
GEORGIA DEPARTMENT OF COMMUNITY HEALTH

         
/S/ Rhonda Medows MD
  8/20/08          
XXX, Commissioner
  Date    
 
       
DOAS STATE PURCHASING REPRESENTATIVE
       
 
       
 
Anne Maize
 
 
Date    
 
       
AMERIGROUP Georgia Care Management Company, Inc
       
CONTRACTOR NAME
       

             
BY:
  /S/ Melvin Lindsey
 
Signature   5/29/08
 
Date    

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/S/ Melvin Lindsey
   
 
Print/Type Name
   
 
   
CEO
   
 
TITLE
 
 
 AFFIX CORPORATE SEAL HERE
 
  (Corporations without a seal, attach a
 
  Certificate of Corporate Resolution)

         
ATTEST:
  /S/ Stanley F. Baldwin
 
**SIGNATURE    
 
       
 
  Corporate Secretary
 
TITLE    

 

*   Must be President, Vice President, CEO or other authorized officer
  **   Must be Corporate Secretary

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ATTACHMENT A
DRUG FREE WORKPLACE CERTIFICATE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
GRANTEES OTHER THAN INDIVIDUALS
By signing and/or submitting this application or grant agreement, the grantee is
providing the certification set out below.
This certification is required by regulations implementing the Drug-Free
Workplace Act of 1988, 45 CFR Part 76, Subpart F. The regulations, published in
the January 31, 1989 Federal Register, require certification by grantees that
they will maintain a drug-free workplace. The certification set out below is a
material representation of fact upon which reliance will be placed when HHS
makes a determination regarding the award of the grant. False certification or
violation of the certification shall be grounds for suspension of payments,
suspension or termination of grants, or government-wide suspension or debarment.
The grantee certifies that it will provide a drug-free workplace by:

1.   Publishing a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession or use of a controlled substance is
prohibited in the grantee’s workplace and specifying the actions that will be
taken against employees for violation of such prohibition;   2.   Establishing a
drug-free awareness program to inform employees about:

  a)   The dangers of drug abuse in the workplace;     b)   The grantee’s policy
of maintaining a drug-free workplace;     c)   Any available drug counseling,
rehabilitation, and employee assistance programs; and     d)   The penalties
that may be imposed upon employees for drug abuse violations occurring in the
workplace;

3.   Making it a requirement that each employee who will be engaged in the
performance of the grant be given a copy of the statement required by paragraph
1;   4.   Notifying the employee in the statement required by paragraph 1 that,
as a Condition of employment under the grant, the employee will:

  a)   Abide by the terms of the statement; and     b)   Notify the employer of
any criminal drug statute conviction for a violation occurring in the workplace
no later than five Days after such conviction;

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5.   Notifying the agency within ten Days after receiving notice under
subparagraph 4. b) from an employee or otherwise receiving actual notice of such
conviction;   6.   Taking one of the following actions, within 30 Days of
receiving notice under subparagraph 4. b), with respect to any employee who is
so convicted;

  a)   Taking appropriate personnel action against such an employee, up to and
including termination; or     b)   Requiring such employee to participate
satisfactorily in a drug abuse assistance or rehabilitation program approved for
such purposes by a federal, State, or local health, law enforcement, or other
appropriate agency;

7.   Making a good faith effort to continue to maintain a drug-free workplace
through implementation of paragraphs 1, 2, 3, 4, 5, and 6.

             
 
 
 
Contractor        
 
           
 
 
 
Signature  
 
Date    

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ATTACHMENT B
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED
DEBARMENT, AND OTHER RESPONSIBILITY MATTERS
(GEORGIA DEPARTMENT OF COMMUNITY HEALTH LOGO) [w71300w7130001.gif]
     Federal Acquisition Regulation 52.209-5, Certification Regarding Debarment,
Suspension, Proposed Debarment, and Other Responsibility Matters (March 1996)

(a)   (1) The Contractor certifies, to the best of its knowledge and belief,
that—

  (i)   The Contractor and/or any of its Principals—

  A.   Are o are not o presently debarred, suspended, proposed for debarment, or
declared ineligible for award of Contracts by any Federal agency;     B.   Have
o have not o within a three-year period preceding this offer, been convicted of
or had a civil judgment rendered against them for: commission of Fraud or
criminal offense in connection with obtaining, attempting to obtain, or
performing a public (federal, State, or local) Contract or subcontract;
violation of federal or State antitrust statutes relating to the submission of
offers; or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, evasion, or receiving stolen
property; and     C.   Are o are not o presently indicted for, or otherwise
criminally or civilly charged by a governmental entity with commission of any of
the offenses enumerated in subdivision (a) (1) (i) (B) of this provision.

  (ii)   The Contractor has o has not o within a three-year period preceding
this offer, had one or more Contracts terminated for default by any federal
agency.     (2)   “Principals,” for purposes of this certification, means
officers, directors, owners, partners, and, persons having primary management or
supervisory responsibilities within a business entity (e.g., general manager,
plant manager, head of a subsidiary, division, or business segment; and similar
positions).

This certification concerns a matter within the jurisdiction of an Agency of the
United States and the making of a false, fictitious, or Fraudulent certification
may render the maker subject to prosecution under 18 U.S.C. § 1001.

(b)   The Contractor shall provide immediate written notice to the Contracting
Officer if, at any time prior to Contract Award, the Contractor learns that its
certification was erroneous when submitted or has become erroneous by reason of
changed circumstances.

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(c)   A certification that if any of the items in paragraph (a) of this
provision exist will not necessarily result in Withholding of an award under
this solicitation. However, the certification will be considered in connection
with a determination of the Contractor’s responsibility. Failure of the
Contractor to furnish a certification or provide such additional information as
requested by the Contracting Officer may render the Contractor non-responsible.
  (d)   Nothing contained in the foregoing shall be construed to require
establishment of a system of records in order to render, in good faith, the
certification required by paragraph (a) of this provision. The knowledge and
information of a Contractor is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.   (e)
  The certification in paragraph (a) of this provision is a material
representation of fact upon which reliance was placed when making award. If it
is later determined that the Contractor knowingly rendered an erroneous
certification, in addition to other remedies available to the Government, the
Contracting Officer may terminate the Contract resulting from this solicitation
for default.

                          Contractor:            
 
                   
 
  By:                
 
     
 
           
 
     
 
Signature      
 
Date    
 
                   
 
     
 
Name and Title            

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ATTACHMENT C
GEORGIA DEPARTMENT OF COMMUNITY HEALTH
NONPROFIT ORGANIZATION DISCLOSURE FORM
Notice to all DCH Contractors: Pursuant to Georgia law, nonprofit organizations
that receive funds from a State organization must comply with audit requirements
as specified in O.C.G.A. § 50-20-1 et seq. (hereinafter “the Act”) to ensure
appropriate use of public funds. “Nonprofit Organization” means any corporation,
trust, association, cooperative, or other organization that is operated
primarily for scientific, educational, service, charitable, or similar purposes
in the public interest; is not organized primarily for profit; and uses its net
proceeds to maintain, improve or expand its operations. The term nonprofit
organization includes nonprofit institutions of higher education and hospitals.
For financial reporting purposes, guidelines issued by the American Institute of
Certified Public Accountants should be followed in determining nonprofit status.
The Department of Community Health (DCH) must report Contracts with nonprofit
organizations to the Department of Audits and must ensure compliance with the
other requirements of the Act. Prior to execution of any Contract, the potential
Contractor shall complete this form disclosing its corporate status to DCH. This
form must be returned, along with proof of corporate status, to: Name, Director,
Contract and Procurement Administration, Georgia Department of Community Health,
35th Floor, 2 Peachtree Street, N.W., Atlanta, Georgia 30303-3159.
Acceptable proof of corporate status includes, but is not limited to, the
following documentation:

•   Financial statements for the previous year;   •   Employee list;   •  
Employee salaries;   •   Employees’ reimbursable expenses; and   •   Corrective
action plans.

Entities that meet the definition of nonprofit organization provided above and
are subject the requirements of the Act will be contacted by DCH for further
information.

         
COMPANY NAME:
       
 
 
 
   

         
ADDRESS:
       
 
 
 
   

                                 
PHONE:
          FAX:                              
 
                            CORPORATE STATUS: (check one)   For Profit       
                     Non-Profit                      

I, the undersigned duly Authorized Representative of                        
                                         do hereby attest that the above
information is true and correct to the best of my knowledge.

             
 
           
 
Signature
     
 
Date    

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ATTACHMENT D
STATE OF GEORGIA
THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH
2 PEACHTREE STREET, N.W.
ATLANTA, GEORGIA 30303-3159
CONFIDENTIALITY STATEMENT
FOR SAFEGUARDING INFORMATION
I, the undersigned, understand, and by my signature agree to comply with Federal
and State requirements (References: 42 CFR 431.300 – 431.306. Chapter 350-5 of
Rules of Georgia Department of Community Health) regarding the safeguarding of
Medicaid information in my possession, including but not limited to information
which is electronically obtained from the Medicaid Management Information System
(MMIS) while performing Contractual services with the Department of Community
Health, its Agents or Contractors.
Individual’s Name: (typed or printed):                                         
                                         
Signature:                                                               Date:
                                                             
Telephone No.:                                                              

         
Company or Agency Name and Address:
       
 
 
 
   
 
       
 
 
 
   
 
       
 
 
 
   

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ATTACHMENT E
BUSINESS ASSOCIATE AGREEMENT
     This Business Associate Agreement (hereinafter referred to as “Agreement”),
effective this                      day of                     ,
                    is made and entered into by and between the Georgia
Department of Community Health (hereinafter referred to as “DCH”) and
                                                              (hereinafter
referred to as “Contractor”) as Amendment No.            
                             to Contract No.
                                         between DCH and Contractor dated
                                         (“Contract”).
     WHEREAS, DCH is required by the Health Insurance Portability and
Accountability Act of 1996, Public Law 104-191 (“HIPAA”), to enter into a
Business Associate Agreement with certain entities that provide functions,
activities, or services involving the use of Protected Health Information
(“PHI”);
     WHEREAS, Contractor, under Contract No.
                                          (hereinafter referred to as
“Contract”), may provide functions, activities, or services involving the use of
PHI;
     NOW, THEREFORE, for and in consideration of the mutual promises, covenants
and agreements contained herein, and other good and valuable consideration, the
receipt and sufficiency of which are hereby acknowledged, DCH and Contractor
(each individually a “Party” and collectively the “Parties”) hereby agree as
follows:

1.   Terms used, but not otherwise defined, in this Agreement shall have the
same meaning as those terms in the Privacy Rule, published as the Standards for
Privacy of Individually Identifiable Health Information in 45 CFR Parts 160 and
164 (“Privacy Rule”):   2.   Except as limited in this Agreement, Contractor may
use or disclose PHI only to extent necessary to meet its responsibilities as set
forth in the Contract provided that such use or disclosure would not violate the
Privacy Rule if done by DCH.   3.   Unless otherwise required by Law, Contractor
agrees:

  A.   That it will not request, create, receive, use or disclose PHI other than
as permitted or required by this Agreement or as required by law.     B.   To
establish, maintain and use appropriate safeguards to prevent use or disclosure
of the PHI other than as provided for by this Agreement.

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  C.   To mitigate, to the extent practicable, any harmful effect that is known
to Contractor of a use or disclosure of PHI by Contractor in violation of the
requirements of this Agreement.     D.   That its Agents or Subcontractors are
subject to the same obligations that apply to Contractor under this Agreement
and Contractor agrees to ensure that its Agents or Subcontractors comply with
the Conditions, restrictions, prohibitions and other limitations regarding the
request for, creation, receipt, use or disclosure of PHI, that are applicable to
Contractor under this Agreement.     E.   To report to DCH any use or disclosure
of PHI that is not provided for by this Agreement of which it becomes aware.
Contractor agrees to make such report to DCH in writing in such form as DCH may
require within twenty-four (24) hours after Contractor becomes aware.     F.  
To make any amendment(s) to PHI in a Designated Record Set that DCH directs or
agrees to pursuant to 45 CFR 164.526 at the request of DCH or an Individual,
within five (5) Business Days after request of DCH or of the Individual.
Contractor also agrees to provide DCH with written confirmation of the amendment
in such format and within such time as DCH may require.     G.   To provide
access to PHI in a Designated Record Set, to DCH upon request, within five
(5) Business Days after such request, or, as directed by DCH, to an Individual.
Contractor also agrees to provide DCH with written confirmation that access has
been granted in such format and within such time as DCH may require.     H.   To
give DCH, the Secretary of the U.S. Department of Health and Human Services (the
“Secretary”) or their designees access to Contractor’s books and records and
policies, practices or procedures relating to the use and disclosure of PHI for
or on behalf of DCH within five (5) Business Days after DCH, the Secretary or
their designees request such access or otherwise as DCH, the Secretary or their
designees may require. Contractor also agrees to make such information available
for review, inspection and copying by DCH, the Secretary or their designees
during normal business hours at the location or locations where such information
is maintained or to otherwise provide such information to DCH, the Secretary or
their designees in such form, format or manner as DCH, the Secretary or their
designees may require.     I.   To document all disclosures of PHI and
information related to such disclosures as would be required for DCH to respond
to a request by an Individual or by the Secretary for an accounting of
disclosures of PHI in accordance with the requirements of the Privacy Rule.    
J.   To provide to DCH or to an Individual, information collected in accordance
with Section 3. I. of this Agreement, above, to permit DCH to respond to a
request by an Individual for an accounting of disclosures of PHI as provided in
the Privacy Rule.

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4.   Unless otherwise required by Law, DCH agrees:       That it will notify
Contractor of any new limitation in DCH’s Notice of Privacy Practices in
accordance with the provisions of the Privacy Rule if, and to the extent that,
DCH determines in the exercise of its sole discretion that such limitation will
affect Contractor’s use or disclosure of PHI.       That it will notify
Contractor of any change in, or revocation of, permission by an Individual for
DCH to use or disclose PHI to the extent that DCH determines in the exercise of
its sole discretion that such change or revocation will affect Contractor’s use
or disclosure of PHI.       That it will notify Contractor of any restriction
regarding its use or disclosure of PHI that DCH has agreed to in accordance with
the Privacy Rule if, and to the extent that, DCH determines in the exercise of
its sole discretion that such restriction will affect Contractor’s use or
disclosure of PHI.   5.   The Term of this Agreement shall be effective as of
                                         , and shall terminate when all of the
PHI provided by DCH to Contractor, or created or received by Contractor on
behalf of DCH, is destroyed or returned to DCH, or, if it is infeasible to
return or destroy PHI, protections are extended to such information, in
accordance with the termination provisions in this Section.

  A.   Termination for Cause. Upon DCH’s knowledge of a material breach by
Contractor, DCH will either:

  (1)   Provide an opportunity for Contractor to cure the breach or end the
violation, and terminate this Agreement if Contractor does not cure the breach
or end the violation within the time specified by DCH;     (2)   Immediately
terminate this Agreement if Contractor has breached a material term of this
Agreement and cure is not possible; or     (3)   If neither termination nor cure
is feasible, DCH will report the violation to the Secretary.

  B.   Effect of Termination.         Except as provided in paragraph (A.)
(2) of this Section, upon termination of this Agreement, for any reason,
Contractor shall return or destroy all PHI received from DCH, or created or
received by Contractor on behalf of DCH. This provision shall apply to PHI that
is in the possession of Subcontractors or Agents of Contractor. Neither
Contractor nor its Agents nor Subcontractors shall retain copies of the PHI.

  (1)   In the event that Contractor determines that returning or destroying the
PHI is not feasible, Contractor shall send DCH detailed written notice of the
specific

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      reasons why it believes such return or destruction not feasible and the
factual basis for such determination, including the existence of any Conditions
or circumstances, which make such return or disclosure infeasible. If DCH
determines, in the exercise of its sole discretion, that the return or
destruction of such PHI is not feasible, Contractor agrees that it will limit
its further use or disclosure of PHI only to those purposes DCH may, in the
exercise of its sole discretion, deem to be in the public interest or necessary
for the protection of such PHI, and will take such additional action as DCH may
require for the protection of patient privacy or the safeguarding, security and
protection of such PHI.

  (2)   If neither termination nor cure is feasible, DCH will report the
violation to the Secretary.     (3)   Section 5. B. of this Agreement, regarding
the effect of termination or expiration, shall survive the termination of this
Agreement.

  C.   Conflicting Termination Provisions.         In the event of conflicting
termination provisions or requirements, with respect to PHI, the termination
provisions of Section 5 in this Business Associate Agreement shall control,
supercede, and control those in the underlying Contract.

6.   Interpretation. Any ambiguity in this Agreement shall be resolved to permit
DCH to comply with applicable Medicaid laws, rules and regulations, and the
Privacy Rule, and any rules, regulations, requirements, rulings,
interpretations, procedures or other actions related thereto that are
promulgated, issued or taken by or on behalf of the Secretary; provided that
applicable Medicaid laws, rules and regulations and the laws of the State of
Georgia shall supercede the Privacy Rule if, and to the extent that, they impose
additional requirements, have requirements that are more stringent than or have
been interpreted to provide greater protection of patient privacy or the
security or safeguarding of PHI than those of HIPAA and its Privacy Rule.   7.  
All other terms and Conditions contained in the Contract and any amendment
thereto, not amended by this Amendment, shall remain in full force and effect.

Signatures on following page

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SIGNATURE PAGE
Individual’s Name: (typed or printed):                                         
                    
*Signature:                                                               Date:
                                                             
Title:                                             &n bsp;                   
                                     

         
Telephone No.:                     
  Fax No.                                             
 
       
Company or Agency Name and Address:
       
 
 
 
   
 
       
 
 
 
   
 
       
 
 
 
   

 

*   Must be President, Vice President, CEO or other authorized officer
  **   Must be Corporate Secretary

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ATTACHMENT F
VENDOR LOBBYLIST DISCLOSURE AND REGISTRATION
CERTIFICATION FORM
(GEORGIA DEPARTMENT OF COMMUNITY HEALTH LOGO) [w71300w7130001.gif]
Pursuant to Executive Order Number 10.01.03.01 (the “Order”), which was signed
by Governor Sonny Perdue on October 1, 2003, Contractors with the State are
required to complete this form. The Order requires “Vendor Lobbyists,” defined
as those who lobby State officials on behalf of businesses that seek a Contract
to sell goods or services to the State or those who oppose such a Contract, to
certify that they have registered with the State Ethics Commission and filed the
disclosures required by Article 4 of Chapter 5 of Title 21 of the Official Code
of Georgia Annotated. Consequently, every vendor desiring to enter into a
Contract with the State must complete this certification form. False,
incomplete, or untimely registration, disclosure, or certification shall be
grounds for termination of the award and Contract and may cause recoupment or
refund actions against Contractor.
In order to be in compliance with Executive Order Number 10.01.03.01, please
complete this Certification Form by designating only one of the following:

     
o
  Contractor does not have any lobbyist employed, retained, or affiliated with
the Contractor who is seeking or opposing Contracts for it or its clients.
Consequently, Contractor has not registered anyone with the State Ethics
Commission as required by Executive Order Number 10.01.03.01 and any of its
related rules, regulations, policies, or laws.
 
   
o
  Contractor does have lobbyist(s) employed, retained, or affiliated with the
Contractor who are seeking or opposing Contracts for it or its clients. The
lobbyists are:
 
   
 
   
 
   
 
   
 
   
 
   
 
   
 
  Contractor states, represents, warrants, and certifies that it has registered
the above named lobbyists with the State Ethics Commission as required by
Executive Order Number 10.01.03.01 and any of its related rules, regulations,
policies, or laws.

Signatures on the following page

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SIGNATURE PAGE

         
 
Contractor Date
 
 
   
 
       
 
       
Signature
  Title of Signatory    

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ATTACHMENT G
PAYMENT BOND AND
IRREVOCABLE LETTER OF CREDIT
Signatures on the following page

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SIGNATURE PAGE
     Signed and sealed this      day of                                         
in the presence of:

         
 
 
 
   
Seal
       
 
  Witness   Contractor
 
       
 
 
 
   
 
  Title    
 
       
 
 
 
   
Seal
       
 
  Witness   Surety
 
       

          By:                                                              
          Title                                                              
          COUNTERSIGNED
           By:                                                            
                       

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ATTACHMENT H
CAPITATION PAYMENT
On the Following Page

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ATTACHMENT I
(GEORGIA DEPARTMENT OF COMMUNITY HEALTH LOGO) [w71300w7130002.gif]
NOTICE OF YOUR RIGHT TO A HEARING
You have the right to a hearing regarding this decision. To have a hearing, you
must ask for one in writing. Your request for a hearing, along with a copy of
the adverse action letter, must be received within thirty (30) days of the date
of the letter. Please mail your request for a hearing to:
[NAME, ADDRESS, FAX NUMBER FOR MANAGED CARE ORGANIZATION:]
 
 
 
 
     The Office of State Administrative Hearings will notify you of the time,
place and date of your hearing. An Administrative Law Judge will hold the
hearing. In the hearing, you may speak for yourself or let a friend or family
member to speak for you. You also may ask a lawyer to represent you. You may be
able to obtain legal help at no cost. If you desire an attorney to help you, you
may call one of the following telephone numbers:

          Georgia Legal Services Program   Georgia Advocacy Office  
1-800-498-9469
  1-800-537-2329  
(Statewide legal services, EXCEPT
  (Statewide advocacy for persons  
for the counties served by Atlanta
  with disabilities or mental  
illness)
     
Legal Aid)
   

Atlanta Legal Aid
404-377-0701 (Dekalb/Gwinnett Counties)
770-528-2565 (Cobb County)
404-524-5811 (Fulton County)
404-669-0233 (South. Fulton/Clayton County)
678-376-4545 (Gwinnett County)
You may also ask for free mediation services after you have filed a Request for
Hearing by calling (404) 657-2800. Mediation is another way to solve problems
before going to a hearing.
If the problem cannot be solved during mediation, you still have the right to a
hearing.

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ATTACHMENT J
MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS

                      Atlanta   Central   East   North   SE   SW
Barrow
  Baldwin   Burke   Banks   Appling   Atkinson
Bartow
  Bibb   Columbia   Catoosa   Bacon   Baker
Butts
  Bleckley   Emanuel   Chattooga   Brantley   Ben Hill
Carroll
  Chattahoochee   Glascock   Clarke   Bryan   Berrien
Cherokee
  Crawford   Greene   Dade   Bulloch   Brooks
Clayton
  Crisp   Hancock   Dawson   Camden   Calhoun
Cobb
  Dodge   Jefferson   Elbert   Candler   Clay
Coweta
  Dooly   Jenkins   Fannin   Charlton   Clinch
DeKalb
  Harris   Lincoln   Floyd   Chatham   Coffee
Douglas
  Heard   McDuffie   Franklin   Effingham   Colquitt
Fayette
  Houston   Putnam   Gilmer   Evans   Cook
Forsyth
  Jones   Richmond   Gordon   Glynn   Decatur
Fulton
  Lamar   Screven   Habersham   Jeff Davis   Dougherty
Gwinnett
  Laurens   Taliaferro   Hall   Liberty   Early
Haralson
  Macon   Warren   Hart   Long   Echols
Henry
  Marion   Washington   Jackson   McIntosh   Grady
Jasper
  Meriwether   Wilkes   Lumpkin   Montgomery   Irwin
Newton
  Monroe       Madison   Pierce   Lanier
Paulding
  Muscogee       Morgan   Tattnall   Lee
Pickens
  Peach       Murray   Toombs   Lowndes
Rockdale
  Pike       Oconee   Ware   Miller
Spalding
  Pulaski       Oglethorpe   Wayne   Mitchell
Walton
  Talbot       Polk       Quitman
 
  Taylor       Rabun       Randolph
 
  Telfair       Stephens       Seminole
 
  Treutlen       Towns       Schley
 
  Troup       Union       Stewart
 
  Twiggs       Walker       Sumter
 
  Upson       White       Terrell
 
  Wheeler       Whitfield       Thomas
 
  Wilcox               Tift
 
  Wilkinson               Turner
 
  Johnson               Webster
 
                  Worth

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ATTACHMENT K
APPLICABLE CO-PAYMENTS
Children under age twenty-one (21), pregnant women, nursing facility residents
and Hospice care Members are exempted from co-payments.
There are no co-payments for family planning services and for emergency services
except as defined below.
Services can not be denied to anyone based on the inability to pay these
co-payments.

              Service   Additional Exceptions   Co-Pay Amount Ambulatory
Surgical Centers       A $3 co-payment to be deducted from the surgical
procedure code billed. In the case of multiple surgical procedures, only one $3
amount will be deducted per date of service.
 
            FQHC/RHCs       A $2 co-payment on all FQHC and RHC.
 
            Outpatient       A $3 member co-payment is required on all
non-emergency outpatient hospital visits
 
            Inpatient   Members who are admitted from an emergency department or
following the receipt of urgent care or are transferred from a different
hospital, from a skilled nursing facility, or from another health facility are
exempted from the inpatient co-payment.   A co-payment of $12.50 will be imposed
on hospital inpatient services
 
            Emergency Department       A $6 co-payment will be imposed if the
Condition is not an Emergency Medical Condition
 
            Oral Maxiofacial Surgery       A $2 Member co-payment will be
imposed on all evaluation and management procedure codes (99201 – 99499) billed
by oral surgeons.
 
           
Prescription Drugs
      Drug Cost:   Co-pay Amount
 
      <$10.01    $ .50
 
      $10.01 — $25.00    $1.00
 
      $25.01 — $50.00    $2.00
 
      >$50.01    $3.00

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ATTACHMENT L
INFORMATION MANAGEMENT AND SYSTEMS

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